Art of Prevention
Our mission is to decrease the prevalence of preventable injuries and athletes therein optimizing performance by decreasing the time that our athletes spend benched due to injury. We are going to distill information and practices from experts in the field of injury prevention. High level coaches and top performing athletes. We believe this information should be accessible to everyone so that we can reduce the rates of preventable injuries.
Art of Prevention
Managing Climbers' Elbows: Pain Relief and Injury Prevention with Dr.Tyler Nelson DC
What is the best way to "treat" a painful elbow? We promise you'll leave this episode with actionable insights and strategies to manage and prevent elbow pain, especially tailored for rock climbers and those engaged in overhead activities. Tyler Nelson returns to reveal the fascinating intricacies of elbow discomfort, covering everything from golfer's and tennis elbow to medial epicondalgia and epicondylosis. Through this episode, you'll gain a deeper understanding of the muscles and tendons contributing to pain and learn why proper education and programming can often be more effective than traditional hands-on treatments.
For climbers struggling with elbow pain, we discuss personalized exercise routines, the importance of modifying climbing session volumes, and the benefits of incorporating consistent off-wall warm-ups. Tyler shares invaluable strategies tailored to individual schedules and needs, helping you continue your beloved activities without worsening symptoms. We also explore the psychological impact of injury testing and the importance of adjusting load and activity levels rather than focusing solely on getting stronger. Discover how the right balance of rest and activity can aid recovery and prevent future injuries.
Finally, we dive into the benefits of climbing-specific exercises like isometrics and the creative "donut challenge" approach to rehabilitation. We address the multifaceted contributors to elbow pain, including diet, lifestyle, and stress factors, offering practical advice on balancing activity and rest. This episode is packed with empowering strategies to help you manage elbow pain confidently and know when to seek professional help. Join us for an enlightening discussion that promises to enhance your climbing experience and overall well-being.
I highly recommend following Tyler on Instagram
@C4HP
and be sure to check out his website for courses and information from him and his team:
https://www.camp4humanperformance.com/
If you have listened to this podcast for any length of time you know that strength training is crucial for runners. However a major obstacle for many runners is not know what to do once they get to the weight room. This PDF seeks to change that. It will arm you with the tools you need to effectively strength train to get the most out of your runs.
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Hello everyone and welcome yet again to the Art of Prevention podcast.
Speaker 1:Today I have another very special guest coming back for round two is Tyler Nelson, and today we are going to dive into a very pertinent topic for many rock climbers, as well as many people that do overhead activities and athletic endeavors, and this pain or discomfort in this region affects somewhere between 7 and 13% of rock climbers, and this region that we're talking about today is the elbow.
Speaker 1:So we're going to be talking about your golfer's elbow, your tennis elbow, your medial epicondalgia, your epicondylosis all those different things we're going to dive into today with Tyler. Now, tyler has a very significant background in the treatment of elbow pain as well as climbing injuries, and over the past couple of years he's treated literally thousands of rock climbers, and today he's going to impart some wisdom on us about rehabilitation as well as giving us good understanding of elbow injuries. So, tyler, thank you so much for taking time out of your day to sit down and talk to us about elbow pain, and I guess we'll get into it. So, tyler, what are some of the common structures involved with elbow pain and how does this happen? Like, why is it that climbers specifically get so much elbow pain?
Speaker 2:yeah, thanks, uh, for having me back. Nice to see you again. It's interesting treated thousands of climbers, you know I think about like people think about treatment and they think about about hands on things or interventions applied to patients, right, which I do none of, and so like it's kind of funny. I feel like my job is mostly like an educator, which, for people listening and people that you know like maybe don't understand all the nuance there's, that's really probably the most important part of rehab, which is pretty hard to do in a clinical setting because of the kind of barriers let's say that actual treatment like gets in the way of, because a lot of people feel, especially with elbow pain, that there's something particular that needs to happen to them that's gonna make it it go way faster, which is one of the barriers to, like you know, um, people getting better in a lot of ways. So it's kind of as a side note, like I don't do a lot of treating climbers. I do a ton of consulting and rehab programming things. You know like, um, it sounds like you have a case that maybe we'll talk about later as well that you did recently I, I think, with the elbow.
Speaker 2:The original question was tissues. Is that right? Which tissues are involved?
Speaker 1:Yeah, I mean, I think a lot of people would have elbow pain and be like Tyler, what's wrong with me? Like, why am I having this pain? Can we tack it down to a specific structure, or is it more of like, maybe the structure itself doesn't matter and the thing that matters most is, like, what we're going to do about it. Right, so?
Speaker 2:but I know that you have a really good like anatomy background.
Speaker 1:So I think a lot of people would be psyched to know, like what are some of the common structures of the elbow?
Speaker 2:and like those that can get affected.
Speaker 2:So like diagnosing. You know, elbow pain that doesn't have any acute known cause can be called golfer's elbow, tennis elbow. Even people use the term climber's elbow, which is a nondescript kind of front-sided elbow pain, where golfers is on the inside, tennis is on the outside and the classic symptoms of tennis or golfer's elbow is like a hot kind of acute, sharp pain. It's not like the dull, achy, throbbing kind of pain. That's probably more muscular, and so the science is not that confident that we understand where the pain comes from and it's definitely not a single source.
Speaker 2:But the muscle is something that gets overlooked a lot in terms of actually creating that pain. So, like, on the inside of the elbow, there's a bunch of muscles that attach to a common flexor tendon and so the trick there is there's a lot of muscles that attach there and they do different things slightly at the elbow, and so same thing at the outside of the elbow. You know, there's multiple muscles that converge on a single tendon, or a confluence of tendons that seems to be the source of irritation on both sides of the elbow. The golfer's elbow or the climber's elbow is more front-sided elbow pain, which would incorporate either the bicep tendon or the climber's elbow is more front-sided elbow pain, which would incorporate either the bicep tendon or the brachialis tendon. So those are a little bit more.
Speaker 1:There's just two tendons that live there, kind of thing and as far as naming things go, I've always had like a I've always hated the naming of elbow pain because people come in and they're like oh, you know, I'm a tennis player but I have pain on the outside of my elbow and that would be like golfer's elbow.
Speaker 1:And I always tell people golfers can get tennis elbow and tennis players can get golfer's elbow. So for me I usually just like to call it like medial or lateral elbow pain. So for those of you listening, just so that we don't get too like anatomically dense, we can say like if you just look down at the palm of your hand and then you go to your elbow, if you're looking at your palm, then the inside of the elbow is the medial side and then the outside of your elbow, on the outside of your body, is lateral. And then for the climbers elbow that would be right in the crease, so right in the center of the elbow. Elbow that would be right in the crease, so right in the center of the elbow. Um, to me I usually just like to go like medial or lateral elbow pain with my like descriptors um, because I never want somebody that's like oh, I'm a climber, why do I have golfer's elbow. You know, it's not like you're sneaking out and playing golf or anything like that.
Speaker 2:it's one of those things brings up an interesting point where the the research would suggest that tennis elbow or golfer's elbow or what we're calling climber's elbow, is not a sports injury.
Speaker 2:Where, if you look at achilles tendonitis what they call achilles tendonitis or what I would most of the time clinicians would say tendinopathy is a better term for like non-identifiable or diffuse pain at a tendon or a joint, and so tendinopathy is a vague term.
Speaker 2:It's a latin term that just means painful tendon, like in and around a tissue, which is a more appropriate term. But elbow pain is incredibly common in the general public so it's easier for athletes to think about medial and or lateral or front side elbow pain as a repetitive stress injury. So pretty much anything that humans do that has a high repetitive nature, that has some intensity to it, but it doesn't have to be really intense, but it just has to be highly repetitive, have a ton of elbow pain in general, and so one of the things I think that's important for climbers to understand that, because everyone wants to blame something for why they have a pain, complaint right, and one of the mistakes I think happens in the rehabilitation world is we start to blame mechanical things with the individual and then it just goes down the rabbit hole of structuralism and all that which has been shown time and time again to not be helpful or fruitful in a rehab context. So it's not a sports injury, you know.
Speaker 1:that doesn't mean that sports aren't contributing, because they definitely are, but it is a stress, repetitive stress, injury, injury yeah, for me personally, I know I started to get a little bit of, not when I was solely climbing, but actually when I was like volunteer setting at the gym and doing a bunch of repetitive, like rotation of the wrench or using the drill, a bunch and things like that. And then it's like wasn't necessarily like associated with the sport, but just the repetitive utilization of the elbow and a lot of the musculature, not to get, not to go back to mechanistic, you know, thinking or anything like that, but really just using a lot of those muscles around the elbow, would you say.
Speaker 2:That's like a pattern that you commonly see definitely I have tons of route setters that are clients.
Speaker 2:The problem with being, you know, with our demographic, with rock climbers, is they're active and they love to do outdoor stuff, and so a lot of rock climbers like to lift weights, like to finger train, like to mountain bike, like to ice climb, like. They just do a lot of things that require the similar kind of repetitive stress with the elbow and season to season we just like accumulate a whole bunch of fatigue that at some point creates a degenerative tendon. You know it is. The is the real hallmark of like if we took a histology sample that presents with a pain complaint, right, right, the important thing for, and I think for people to understand there is, if you have a repetitive stress, injury stuff is not less stressful, right, where giving athletes more things to do technically is more things to recover from, and so a lot of the prescriptions that are overly targeted at tissues in the rehab setting I think don't work well, because it's just another thing that athletes have to recover from.
Speaker 1:It's one of those things are where, if we don't do that education piece that you were talking about, it's like okay, so if we just have an athlete that comes in and they're climbing and or setting ice climbing, throw a pickleball in the mix, mix all these different things where that are just adding stress to the elbow articulation. If we don't give them education as far as modification of that stress and we just give them stuff to do, even if it's like well-intentioned loading exercises, then they may not get better because we're not altering the things that caused or potentially caused that elbow pain in the first place. Is that kind of what you're saying?
Speaker 2:Yeah, and that's why, like I, don't do treatments anymore, because the science if you compare any of the non-surgical treatments and surgical treatments to a placebo, they are not any better. And you know there's only been one study done on tennis elbow where they actually did a placebo that they are not any better. And you know there's only been one study done on tennis elbow where they actually did a placebo and the results were the same. The only difference was two weeks out, people that had surgery had more pain and so like. Typically in the very high percent range.
Speaker 2:It, like this, is not a debilitating, life-changing kind of injury. The timeline for elbow pain to go away is like three months, which is like it's a good amount of, it's a good enough time to annoy the hell out of people where they feel like they're wasting time. They need to go see someone else because someone else has a better therapy that they're going to get right. And this does not mean also that therapies can't be helpful, because they can. But if the only intervention that an athlete is getting is a passive therapy but they're not getting the education, they're not getting the training structure, evaluation, they're not talking about diet, not progressively overloading, they're essentially just like spending money.
Speaker 1:They're not really going to see good progress based on what the science would tell us now, when you do, when you are doing an online consult with somebody that is having elbow pain, what does some of that education and advice look like for that individual?
Speaker 2:so yeah, it depends that's a good question it depends a ton obviously on the individual and that's where like writing, like generalized rehab programs is hard. You know, if you like put out a do this for elbow pain, that's going to fix your elbow pain. It's usually an exercise or a group of exercises, which I think misses the point, because then people put way too much value on the exercise and they don't actually learn that it's not the exercise or it's not a single thing. They have to think about all of their things to help better manage themselves and their training load right, because this is a loading kind of problem. But when it comes to the individual, I like to have someone describe to me what their normal week looks like, because I kind of have a fixed, everyone has kind of a fixed schedule per week. You know, we do a certain amount of climbing days, we do some extra training, we do these things right, and so I say, okay, you know what does that normally look like for you? And then we're just going to start dropping things, you're going to start eliminating the things that have the least amount of importance for the individual.
Speaker 2:If I'm personally not someone that likes to stretch, it's not a comfortable thing for me because I'm very tight, so it's never been something that I've like incorporated.
Speaker 2:Some people love to stretch, so if there's someone that like does yoga and they stretch all the time, I would say having people not do the things that they really like to do is not a good strategy. So I can't because I don't like to stretch, doesn't that doesn't mean that stretching would not be helpful, because stretching can be helpful for elbow pain. It's just not something that I do, and so you don't have to stretch to get your symptoms to go away. But if you like stretching, you're probably okay to continue stretching. You just have to like modify the total volume and the frequency of those things. And so the most important thing I would say about customization is really understanding what the person likes to do. You know, because if we give people exercises that they don't like to do or that are not comfortable for them or that are novel, the science would suggest they're probably not helping people because they're not going to do them anyways, but they're just like not going to have the same response. You know that you would if you did something you enjoyed.
Speaker 1:Now what about if that individual is doing an activity that they love doing, let's say board training or something like that but it has an effect of provocation of their symptoms. So you know, if we go back to like you know what a lot of research has shown us about tendons and tendon loading, tendons sometimes respond really favorably to those like static, heavy, longer duration isometrics and then they can sometimes get aggravated with really dynamic movements like board training. And somebody is like Tyler I really love getting on the training boards, I really feel like it's helping me with my climbing and it's really fun for me. But every time I do a kilter board session or a moon board session my elbow feels like shit. How would you educate that person or modify those loads to make it so that they can still do it but they're not having that increase in discomfort or provocation of their symptoms?
Speaker 2:Yeah, I usually will have people warm up off the wall before, just like as a standard kind of intervention. You know, warming up off the wall, doing pulling movements, pushing movements, movements, dumbbell movements, finger boarding, gives the athlete something that's more consistent that they can replicate session after session so they know that they're doing they as they. I think about it as they change the expectation of the exercise, of the session. Whereas if you go into a board climbing session and you warm up climbing easy problems, then you climb some hard board problems. Let's say you do 15 total things and then your elbows pissed the next day. What was the reason that your elbow was pissed? Was it a certain problem? Was it the total number of problems? Was it the direction, the times? Under tension, it's just harder to feel. It's harder for the athletes to feel like they have control over it in that setting, whereas if they do a 20 to 30 minute something off the wall that's easily reproduced, they can do it and then make an assessment how they feel and then they can do the same thing the next time. So you can just make it more regular and that should and does, from my experience, help people know that. Oh, these things were fine. My elbow feels fine. I'm going to do those the next time and it should also be fine because of that.
Speaker 2:And then with the board climbing, you definitely have to reduce the volume. You know someone, you mentioned the kilter board. The kilter board you can do the most volume on just because the holds are comfortable, you know. So it doesn't mean that board climbing is a bad idea. Um, when someone has elbow pain, it just means that you have to eliminate some of the variety. So I like the idea of, like you know, doing the wall crawl stuff there where you're doing the slow, controlled climbing. If the wall is steeper, if it's at like 30 to 40 degrees, if the athletes can tolerate that, you can just have them climb up at like a ladder. I find works really well because it still scratches that itch that climbers have to load on a wall. But it's considerably safer in that context for not provoking symptoms and that's a good like starting point.
Speaker 1:Do you still educate people on the latency of like tendon pain or like elbow pain? So a lot of times people go into a session they'll do their warm-up like, yeah, you know, it was a little tweaky or I felt a little bit of symptoms when I was warming up. Then it went away and I felt really good during my session. However, then I just did like a really big session and then the next morning my elbow was really pissed off do you see that?
Speaker 2:and that's. That's the classic story.
Speaker 2:Oh yeah, everyone that I talk to does that with elbow pain. Because climbers are so strong they can have really bad elbow pain. And though elbow pain is not commonly like seen on an ultrasound you know imaging or MRI Most people that have tendonitis you won't find anything on diagnostic imaging. It's not until it's very advanced that you see it. So climbers are so strong that it usually is not a sport limiter, it's a power limiter. So they won't have that like extra effort, they won't have that.
Speaker 2:I feel really confident on the wall with my climbing right now. They will lose power and so absolutely they need to focus on frequency more than volume. So they can still have sessions, but those sessions have to be, you know, on, let's say, on average, 50% less volume per session. So it's more a focus on recovery than it is about the session.
Speaker 2:So that's where sitting down and talking to someone what does your normal week look like? That doesn't look the same person to person, and so you have to better understand the person to really give them advice. That makes sense, because if I don't understand you and I say, okay, you're going to load twice a week, and they're like I'm a professional climber, I load five days a week, you're like, oh, that's not good advice for them. But if it's someone that climbs twice a week and you're like we're going to climb twice a week, they're like I do that already, like that's probably too much or you need to cut their session in half, right, so you have to just like it's a bit of working. You know like the training program's got to be flexible in that sense yeah, I completely agree.
Speaker 1:It's got to be very much individualized to that person. Um, and I think incorporation of things that that person likes is is so crucial. You can't just give it like a cookie cutter approach or you know, a lot of times people come in and they've they've done the like. Oh, I did a, a generalized program for, like, reducing elbow pain and didn't really work and things like that. Um, but, like you said, a lot of times they're just adding stuff onto what they're already doing.
Speaker 1:Um, as far as like, measuring and tracking, this is something that I always have my climbers start doing if they come into me to see me with an injury. But what's some of the advice that you give as far as like variables to measure and variables to track? Because one thing that's really tough about climbing, in my opinion, is there are so many different variables at play Steepness of the wall, intensity of the session, types of holds, um, how hard somebody's trying restoration. In between goes sport climbing, bouldering, trad climbing, etc. So, when you're talking with some of your athletes, what are some of the things that you tell them?
Speaker 2:I need you to like, literally write this down or track this and measure this and see how your elbow responds I usually have people track the intensity of, like the definitely the warm-up things, because those are more weight lifting and have them track the intensity and the sets and the reps of the lifting stuff, because that gives them a general sense of how much they've done and what they should be able to tolerate and how we can adjust the loads up and down.
Speaker 2:In terms of, like testing, medial and lateral, or golfers or I guess what we call climbers, elbow pain I don't I'm not actually a big fan of doing, like you know, initial injury force testing. I don't think that makes a ton of sense because, unless the athlete already has a history of testing it. But if you take someone with a pain complaint, you're like, okay, pull as hard as you can. Like a ton of sense unless the athlete already has a history of testing it. But if you take someone with a pain complaint, you're like, okay, pull as hard as you can. Like, what do you expect to find? Like, it's definitely going to be lower.
Speaker 1:Right.
Speaker 2:Like why are we surprised that the force is lower? They're like, oh my God, it's 25% lower. You're like, yeah, your elbow hurts. Like what the hell did you expect to happen? That doesn't really mean anything to me and all it means is that they're not confident pulling really hard, which is I already knew that.
Speaker 2:They already knew that the downside of doing that that's been studied, like in the knee, is when people, you know, anchor someone to a number that's really small or anchor them to the idea that they're really weak, like they feel really weak, they feel more fragile than they really are. Right, their tendon's not really that hurt, but it feels like that. And if I give someone, ooh, it's 50% less than the other side. Now they got to walk away thinking that their elbow's totally in trouble and they're 50% weaker. So I think, in terms of getting better, you do not have to document the number. It's very, I think, insurance billable, but I don't bill any insurance, so I don't really have to worry about that. But that's probably a big reason why it's done.
Speaker 2:But the science would say it doesn't really matter all that much if I measure someone and then remeasure them for them to get better, because the science also says that you don't have to get stronger literally to make your elbow pain go away. Most climbers that we talk to are strong as hell already. Like they don't need to get stronger, they need to do less stuff, right? So one of the one of the like um, one of the documented and reported or discussed things in the paper about the problems with strength training is the assumption that athletes need to get exponentially stronger to get better, because all that does is make them do more stuff. But this is a repetitive stress injury. They're already really strong, so the narrative that accompanies I need to get stronger just makes them do more things and will also halt recovery, you know. So it's like I hope I'm not going off on a tangent, but that like those are important, like met, I think, things to consider for people that have pain complaints at the elbow or anywhere.
Speaker 1:Really no, I think that's a good point, because a lot of times it's like we really want to climb. So if it's like, oh yeah, I heard nick say that strength training is great, so and it's going to help relieve my elbow pain, so I'm just going to keep climbing, but I'm just going to also start strength training and I'm just going to add even more stuff in where it's like we really need to modify the climbing load. Potentially input some of the strength training as a warmup or as part of your routine, or sub out if you're climbing like too many climbing sessions in a week and sub out one of those climbing sessions for a strength training session. Would you agree with that kind of modification?
Speaker 2:yeah, yeah, I mean, I would maybe add does the person like strength training right?
Speaker 2:because, like I. I don't like the narrative that you have to strength train to be healthy and you have to strength train. That's not true either. Like there's no, I mean, evidence supports that strength training is a good idea and there's good ramifications for your health. But there's lots of people that don't strength train. They live long, healthy lives. So the fact to say that you have to do it, I think, is not reasonable either.
Speaker 2:Like before I got on the call with you, I talked to someone just recently who has been going to physio. It was for a risk complaint, but the same would apply for an elbow, for it's been over a year and he's had lots of things done for his elbow and he really likes the strength train. But he was told that he probably shouldn't strength train, right, and so in his case, I asked him. I said, well, do you actually? I mean, I think strength training works well because it is a good way to build confidence in athletes, it's easy to track, it has, you know, influence on the connective tissue, which is productive for creating stiffness, which is good for practice, whatever. And do you like doing it? And he's like, yeah, I love strength training. Great for him, it will work well.
Speaker 2:But I have other clients that are like, no, I don't really like it. And some female clients are like I don't really like strength training, I don't like the atmosphere. The gym I go to I say, cool, we don't have to strength train. I will create some form of strength training in your warm-up routine. That should be a good enough stimulus to help you, and so that's another thing that clients also is helpful for them to understand. There's not like a for sure you have to do this or for sure don't do that.
Speaker 1:That doesn't exist for pain complaints Awesome. Now we've talked about subtracting things, but oftentimes we see people subtract everything. So what is a reasonable time period to rest? So let's say, tyler, I come to you as a client and I'm like, yeah, man, I just had this like great bouldering session and the next day my elbow felt atrocious, like is there a reasonable time period for total rest and how long is that rest period?
Speaker 2:Yeah, if it was like maybe that's a first pain complaint you know, never had elbow pain before, they just felt it pretty sharply I'd say, take two or three days off, go back and load and see how it feels. For someone that has a chronic pain complaint and they've been fighting through it and go on trips and still train and whatnot, like it's okay to take two, three weeks off and do other things Beyond. That is not reasonable. And so that's another thing that this particular client did. Is he this whole time, this three month time period which is the last stint of doing rehab, he was not loading his fingers like a rock climber and so the whole time he's like, well, can I load my fingers? And they're like, yeah, we'll get to that.
Speaker 2:But within a three month time period he was not cleared to like load his fingers on a fingerboard, right, like I would say that's a mistake. Like I have my athletes load, like, continue loading on a fingerboard. The risk of loading on a fingerboard with elbow pain I would say is zero. You know you're not going to hurt your elbow doing that, but it gives a climber something that looks and feels like climbing, that they already have some value, you know with. They already have a relationship with most climbers and that's a really good starting point. And so doing nothing is not good, not because it doesn't help things settle down, because it does. Doing nothing isn't good because it doesn't keep the capacity of all the other healthy stuff, of which there's way more.
Speaker 1:Now, when we are loading on something like a fingerboard, we know that pain is not necessarily related to structural damage. But if we are loading on something like a fingerboard, should we load with pain? Should we load up to the threshold before we have pain? Should we load completely non-painful? Can you give us a little bit of guidance as far as that? So the relationship between loading and discomfort or pain generation you'd expect a personal thing.
Speaker 2:You know, when I talk to some people and they're really fearful of hurting and they've had this for a long time and their fear avoidance is much higher, I tend to not say, hey, you should work at a three out of 10 pain because that's probably not going to work for them. Where someone else that you know has a different you know expectation like I know I can work with some pain it's probably fine. Then they're probably okay. I think in general you also do not have to have a little bit of pain to know that you're loading it properly or it's going to get better. So that's another narrative that I hear regularly.
Speaker 2:When talking to people they say and I don't know why they hear this, but they've heard that you should feel two out of 10 pain complaint with rehab. That's not true. I don't know who the hell made that term up, but that's not reported as like a significant documented number. Like you do not, you could do nothing and the pain will go away. It's actually hard not to heal with elbow pain.
Speaker 2:The difference is like how confident is the individual for doing something like rock climbing, which has a whole bunch of variety and volume to it, you know. So I think the pain I like the idea of people not having pain when they exercise. That's the whole point that they're talking to you and me like they're sick of hurting. So saying you should feel two out of three pain, I think just makes them expect to hurt every time. So I usually like giving. That's why I like isometric loading, which we can talk about, is it gives people the sense of having more control when they're loading, which is the easiest way to like work back into having some confidence, and it's been shown to have some benefit on reducing pain. So it's kind of hard, the pain thing, because it's definitely not a representation that tissues are injured or a direct relationship. But it's not always necessary to find it to get better either.
Speaker 1:Yeah, I'd love to start talking a little bit about isometrics and like loading strategies, because I find they can be really helpful in, like the modification of pain but also instilling confidence in the ability to load tissues in a non-painful manner. So, like, I literally just got, you know, finished up with a client in person and they had discomfort with like a pull-up motion, but then I put them at that you know, about 120 degrees, 120 degrees of the elbow and then I had them do like. Then I had them do a really heavy isometric, pulling basically as hard as they could, and with the pull-up motion they had discomfort, but with the heavy isometric they had no discomfort during and then no discomfort afterwards. Is that what?
Speaker 2:you mean by?
Speaker 1:incorporating some isometrics and things like that, yeah, and.
Speaker 2:I mean that's another important reason why understanding climbers is important. For, like healthcare, you know a healthcare provider that works with climbers. You know I will talk with a lot of people that will go to a healthcare provider that is not a climber, doesn't know climbing, and they get really bad advice Because you and I know, like I know, how strong climbers are. Like, a pull-up is not that hard for 90% of my clients. So that means pull-up is maybe 60% of someone's max at their body weight, which means that, like, most climbers can hang with one arm without a whole lot of problem. And so if I, if I know that going into it, I can say, okay, well, we're going to start on a bar and I'm going to have you at a joint angle that puts the muscle in a really good spot to generate force and I'm going to have you load.
Speaker 2:I know that that's not that heavy and it's pretty familiar to them and they're like oh yeah, I do pull-ups, I like doing pull-ups, I like fingerboarding and that it just a really like good entry level loading position and exercise for them, because it's very good for the tendon because it will get enough load but it's very comfortable for the individual. And so the isometrics also have been shown to reduce pain, but they're not like better per se than other types of muscle contractions either, which is important for people to understand. Some people like that love doing weighted pull-ups and they have a progression that they're going through and they have following a plan and they have pain at the top. I'll have them keep doing their weighted pull-ups. They'll just do like three quarters of the range of motion. Same thing with the bench press.
Speaker 2:It's pretty common to get those tight joint angles where people have pain. Just modify the range of motion. Sometimes for individuals that works well, and so again, it's got to be like you have to hear what the person's saying and what they really are doing and what they expect and then just make modifications because either one of those can work well uh, I feel like this might be a great spot to talk about the origin of the the donut challenge oh yeah, that it kind of was elbow pain yeah so I was chatting with.
Speaker 2:Uh, oh yeah that it kind of was elbow pain.
Speaker 1:Yeah. So I was chatting with uh oh, go ahead. Well, I mean, I've just listened to like a shitload of your conversations that you've had with people, and so I heard this story about you working with a high level climber and you're like all right, well, let's do some, let's try some isometrics and see if we can load this thing without pain. And they're doing a one-arm hang at 90 degrees and they're like, dude, I could, I could eat a donut doing this, you know. So tell me a little bit more about that's that story yeah, so I've.
Speaker 2:I've been doing that kind of stuff for climbers since I was right out of school. Like it just made sense to me as like a intervention for elbow pain, just because it's like, it does look like climbing. It's easy to modify the position so you can get a chin up, a neutral, a regular, you can get some rotation at the elbow and it's an easy way to overload the tendon and you know, therapeutic and a good progression. And so one of my clients back in the day he's still a client, but he's not a kid anymore, he was a youth climber. He's like in college he was 22 but a really strong climber and just rehabbed his elbow and we were doing the isometric stuff and he came back for a follow-up and he was like dude, look how strong I've got with this.
Speaker 2:And he was like a friend relation, friendly enough relationship, where he was talking smack to me like dude, there's no way you could hold it. I was like, dude, I totally could hold that longer than you. And then someone mentioned like I think I said, like I could hold it, I could eat a donut and do this with one arm. And so that's. And he's like let's go buy donuts. And so we walked to the store next door and bought donuts, and that was that was the start of the donut walk-off.
Speaker 1:Nice and I feel like that might be a good segue. You mentioned that there are many contextual factors, many variables that can contribute to pain or like elbow pain specifically, and one of the things that you mentioned was like diet. So while it's like super fun to talk about donuts and stuff, but like what are some of the dietary factors that can be contributors to pain onset in the elbow or in?
Speaker 2:any. Oh, I would. I would say donuts probably help people feel better because they have, because it makes people happy, um. But I mean not diet in the sense of like we want to go down the diet rabbit hole. That's not something I would consider my expertise I obviously took biochemistry and know a good enough about it but that's not something I lose sleep over, is like like dietary modifications or management other than just like getting in your basic macronutrients, like I think one of the highlights that I tell people is just make sure you're getting enough protein.
Speaker 2:Like the thing that's hard to get enough of is protein. It's easy to get enough carbs. It's easy to get enough fat. In our modern diet it's hard to get enough protein. So, like more like the dietary intake is just making sure they're getting enough calories first of all and then sure they're getting enough protein. I don't the science that's been done on like supplementing collagen is not promising for like tendon complaints. You know, um, now in 2024, the studies that have been done and tried to replicate are not great. So if people want to do that, I think there's no downside with doing that either. You're just like spending money and you're gonna put it out of your system, but I don't. There's not convincing evidence that it has to be done, um, especially for I mean, the science is just not good on elbow pain period, which is interesting because it is so common, but the science is not that good just like with what to do and things to do. There's not been that much money put into it.
Speaker 1:Yeah, I mean in my clinical experience, like sometimes people come in with elbow pain and you know I use like a variety of techniques and sometimes it's like it feels like it's the easiest thing to treat in the world. But then in other instances you do have this recalcitrance where it lingers for quite a bit of time. And then there is that small subgroup of the population that has lingering symptomology for much longer than that average duration of discomfort, like that average like three months, and then it'll probably get better, kind of thing.
Speaker 2:Yeah, I think in the general, in the general population, genetic factors I mean all in all the population genetic factors are a big deal.
Speaker 2:Two factors that are hugely important are general health of an individual and smoking like you're, I think, I read, two to three times more likely to get tendonitis in your elbow if you're a smoker, and there's obviously other you know health ramifications with that.
Speaker 2:So like general systemic vulnerability is is different between people too, which is hard to like teach people or educate people on, but that definitely is something that we people or educate people on, but that definitely is something that we have less control over.
Speaker 2:But the things that we have the most control over, and like social stress, like anxiety and job fear and all that kind of stuff, I usually tell clients like the easiest things to manage are the physical stresses, the physical stressors. So like we're going to modify the physical things as best we can, but it's up to you to try and manage because I'm not a psychologist try and manage other stressors in your life because they definitely will impact your total systemic vulnerability to like having any sort of pain complaint, and those are the things that are actually way harder to manage for the individual than is doing less reps, doing more frequency, you know like. Increase your protein intake, get on a regular sleeping schedule. You know those are all things that the individual needs to take upon themselves to help get better as quickly as they can, because there's still no magic bullet for making this go away faster, which is kind of sold as like an exercise thing, which is not not the case.
Speaker 1:Yeah, and I think it's especially tricky when you know it's like I need you to manage your stress and they're like rock climbing is how I manage stress. You know there's that meme of like you know I have to go and climb plastic holds or else like I'm going to mentally combust, you know, know, um. So that can always be a really big challenge, I think, for a lot of my clients, because they're like dude, like rock climbing is my means by which I manage my job stress or my life stress, um, and then do you tell them to more like, modify or like. I think one thing that's really nice is like having like people that have other physical activities that they can do, like go for a run or maybe try a yoga session, or do you give any advice along those lines as far as like doing something?
Speaker 2:else that is physical yeah, of course I try and keep people climbing as much as I can. To kind of meet them in the middle there say, okay, that's fine to do a little bit of climbing, but we need to take this total amount, we need to start chopping it down a little bit. But having other types of activities that they love is great, you know, um, ones that preferably don't have a lot of upper extremity pushing and pulling. You know, I think one of the common things that I see with the injuries which I think pertains probably more to finger injuries than elbow injuries is people, if they can't climb really intense as much as they want, they do more strength training, which still is like in the case of, like the finger injuries, just a lot of bar grabbing, a lot of different kinds of stress, which isn't really less stressful overall. But I think the elbow is a little bit, you know, is definitely can tolerate more stuff there, so it's less a problem there.
Speaker 2:But in a long answer to the question is, yeah, having other things to do to satisfy your time is necessary, because none of the things that we prescribe. People are fixing the elbow, the body is going to. People are fixing the elbow, the body is going to take care of the elbow as best it can, as long as we give it what it needs. But in a bio, in a biological sense, it needs some form of stimulation to make a change, and so that's our job to give you an amount of stimulation to the tissue that will create the adaptation. But the rest is up to the, you know, bodies. Um, that's, that's the body's job, and it would do a great job at taking care of things, you know. But you have to be patient. It's just not.
Speaker 1:You can't make it happen faster, you know, and the having patience for it is the hardest thing for athletes and what are some of the ways in which we can so just mechanistically and like in the ultra practical sense, like what are? What are some of the ways in which we can so just mechanistically and like in the ultra practical sense, like what are? What are some of the advice that you give people to stimulate the tissues of the elbow? Because there are some things that you know, we get taught, like when we're in school, like using the Thera bar or something like that, which is likely not enough load, or maybe the wrong type of load to totally stimulate the tissues. But then you know one thing that I get asked about, which I don't necessarily prescribe all the time, is just like dead hangs from a bar, you know. So there are a lot of different ways in which we can stimulate these tissues. What are some of your go-tos for trying to improve capacity in the tissues of the elbow?
Speaker 2:Yeah, I would say, technically any of those can work and they all could be a symptom provoker. It really just depends on the person and that's what I don't like about the narrative or the selling of this exercise for this pain complaint. That's the only gripe I have. But I don't dislike exercises or tools at all. It really is most climbers at least my bias with my population. They're ridiculously strong. Like using something that's really low intensity to try and manage a tenant complaint for them does not make sense, but for an elderly lady that has elbow pain it's probably pretty intense. And so it really just depends on the person and their tolerance level.
Speaker 2:You know, even things like gentle mobilization, like and stretching of the tissue, self stretching, massage, like those things can be helpful, but they're really just different ways of getting some sort of nerve signal activation to the tissue and blood flow to the tissue, which is a good starting point.
Speaker 2:But for most people mobilization and stretching and massage therapy is not enough stimulation, enough physical intensity to modify the tendon, to make it stiffer, to where it should be able to go back and start grabbing things fast, like on a climbing wall. And so if I only take the approach of I'm going to do low intensity stuff because I'm fearful of it, that doesn't. There's a big gap that needs to be filled there between climbing, which is pretty intense, and something very low intensity down here. This needs to be filled in and that's where you can do isometric on a pull-up bar, you can do partial range of motion. You can use the wrist wrench for inside elbow pain. You can use the wrist wrench in reverse for outside elbow pain. You can do reverse wrist curl. Isometrics like progress, those into full range of motion, like honestly, I think the exercises are just means by which we can get some form of stimulation to the tissue, but they're not better or worse for getting the tissue to get better. I don't know if that sounded confusing, yeah what is the saying Like?
Speaker 1:there's like nine ways to skin a cat or whatever. There are multiple ways in which we can input an appropriate level of stimulus to try and reach the outcome desired, which is desensitizing the tissue but also improving some of the tissue properties. Is that what you're trying to say?
Speaker 2:More or less like. It can be done in lots of different ways. Honestly, if someone is really like time crunched and they don't want to do a bunch of rehab stuff, they could just use a fingerboard and just do some isometrics on a pull-up bar and climb at a lower frequency and that's enough for most people. Because even when you're loading on a fingerboard, if you're doing a half grip on a fingerboard, your wrist is an extension. So if you have tennis elbow, you're definitely getting stimulus to the lateral elbow. If, because you're doing this, you're still getting stimulus to the flexor side of the elbow, if you're doing a pull-up bar, too, you're getting the medial or like cubital space in the elbow and so like it can be that simple. The confusing part that clients have is you look on Instagram in the world and you just see so many things and you're just like, oh my God, I want to do all the things, but that is absolutely not the best approach. It's more confusing.
Speaker 1:Let's say I'm a client that gives you a call. I know that you've seen this probably a hundred times, Tyler. I've had this elbow pain for four or five, six months. What are the biggest issues that you see with what they're trying to do to fix their elbow problem?
Speaker 2:most of the time people try and add in lots of stuff. Instead of subtracting things, they just try and add in new things that they've seen people do or people have told them to do. It does not mean that those things are bad, it just means that they're not addressing the primary problem, which is the muscles are just fatigued. That's probably the most common. The other one I would guess is probably they've reduced the climbing intensity as the sole intervention. They're like well, I don't, I've climbed less intense things, but because they're climbing less intense thing, they're doing just as much or more volume, which is counterproductive. That will that will definitely keep the tendon reactive. And that's usually the two biggest, like I guess, culprits that I would see people do.
Speaker 1:Now you mentioned that, by and large, like most elbow complaints will go away within approximately three months. What's a time duration for conservative management in your opinion that is appropriate before you move on to orthobiologics or a surgical approach, things like that? Do you think that there is a place for those kinds of interventions, such as PRP, stem cell cortisone injections and then potentially surgery? I know for a lot of people it's like dude, I can't freaking climb, and it's been a year and I've been trying to work on all these things.
Speaker 2:Yeah, for sure. I've had clients use Volterrin which I prescribe relatively common. It's not a prescription, you can buy it over the counter, it's a topical but it's a steroid. I've definitely had clients get steroid injections before a trip. I talked to a supplier yesterday that is going to Kalymnos in a month and his pain is under control and then he'll go on a climbing trip and go hard and it'll come back and it's just been kind of wobbly, which is not uncommon for those pain complaints to come back. And so for him before his trip we're going to kind of hold off and put that, leave that in our back pocket as an option so he can go enjoy his trip.
Speaker 2:Because if you, if you stop the pain for a short period of time and then you go on a trip and you climb hard on it, the long-term consequences if you get like a steroid injection on the tendon are not huge. Like you definitely don't want to do multiple steroid injections on the tendon, it definitely will, you know, degrade the tendon. But that also gets kind of overhyped, you know, um steroid injections or the risk thereof, it's definitely not a sustainable thing to do it a lot. But you know, like once in a short case, it's probably okay. Um, the prp and stem cell stuff is just so new. It's really just like. So we last, yeah, yeah, the, the, the tendo seal, I think, is like the most promising biologic that's been made, and they are they would admittedly say they're still like in the trial phases of learning what the hell is going on with it. So they're incredibly new.
Speaker 2:Uh, the prp injection the science is terrible. Um, you know it's, the idea makes sense and it's very easy to sell, I think, because it sounds very organic and natural. And how could you not want your own body's platelets to like patch up injured tendon? But that's very mechanistic in its approach, which kind of slaps the understanding of how pain really works in the face, because that's not how pain really works in the face, because that's not how pain really works. Right, your pain is not represent, your pain is not a direct representation of some like seeing tear in your tendon. Some cases that will happen, but that's not the common case of tendonitis. So those are all really really, really new and the science would say they're a waste of money for most people. But I've had people have them and so there, there's a big, there's a big. I mean it's the patient's preference, it's their choice. Obviously it's not my choice. My choice and your choice is to have a really good understanding of what the science says about these things and then I'll let the client make that choice.
Speaker 2:Most of the clients that I've had that have decided to do prp injections have seen short-term relief but no long-term relief, you know, and it's expensive. So if it's not a problem and someone wants to try it, that's up to them to try. Um surgery, like the inertial procedure, is like they go in there and they would take a piece of the tendon out, they do a release and you would. You would reserve the inertial procedure for people that have diagnosed like tears, like legit, like 50% tears in the tendon and they would do that. The long-term outcomes it's no different than placebo. So if they want it done, that's okay. If they don't want to get done, that's okay. Long-term, as far as we know, they're the same. So most people would probably say no, I don't want to do that.
Speaker 2:But I think those are the majority of the more interventional procedures for tendons. I guess the denervation the denervation actually has the most promising outcomes, I guess where they essentially they just like, inhibit or they use a radial frequency and they essentially stop the sensory like inhibit. Or they use a radial frequency and they essentially stop the sensory innervation to the location. So in that case it would be, you know, the branches of the radial nerve that go to the common extensor tendon if we're talking about elbow, or the nerve that goes to the common flexor tendon. So it's called a radial frequency nerve ablation, which sounds really dramatic but the nerves grow, grow back. But it also is one of those things that pain is not a direct like reflection of a tissue sending a signal. So it doesn't mean that everyone that gets that has no pain. It just means that in some dosage they just can't get sensation from that area so they might have less pain you know, but we could do a whole.
Speaker 2:You could do a whole podcast on that stuff because it's super interesting, um, but I think the very last one, maybe that we didn't mention was shockwave. Have you guys been exposed to that in school, you're?
Speaker 1:done with school now right I'm a little bit out of school, you know.
Speaker 2:I'm like five years out um, I will say like or did you learn about that in school, though, is what I meant. I know you're out of school, but like you didn't learn about that in school no, but I I have had experience.
Speaker 1:Like my last office had a shockwave machine and, like me, I've had like really good experiences with using it on some recalcitrant cases, especially like tendinopathies or like this is like an off-label like thing for it.
Speaker 1:But, um, I have a hip labral tear. So I had like chronic pain in my right side hip for years, in spite of all conservative means by which I tried to treat it, and then I shockwave the hell out of it like eight times and then my hip feels much, much better, which is not something that people even advertise it for. However, I think I probably had some tendinopathic alterations in some of those proximal tendons. That was more of the lasting contributors, contributors for my pain in my hip. So, like, I'm super familiar with shockwave and I've used it a couple times on a couple of different things and I've had really good results. But I know that the research is quite equivocal or not necessarily saying like you know. It's like what you said we don't really know, like what the best treatment is for elbow pain. Sometimes it might be helpful, sometimes it's not. But I'm really curious as to what your opinion is on shockwave for elbow pain.
Speaker 2:I think I know what you're going to say, but I mean, if there, I think if there's calcification, it probably is the best indication and that's what the science says is it is good at calcified tendon tendinopathic.
Speaker 2:You know symptoms, but that's just not something that happens at the elbow. So it's like not common to have a calcific tendinopathy at the elbow. It's super common in the shoulder and it can happen elsewhere. And for that shockwave has, you know, had some like some success in in managing it because it really will break up the tissue in the hopes that the tissue will like get inflamed and sore and heal and it won't be as stiff like from tissues pulling. Because if you had like a rope with a, you know a rock tied in the middle and you're yanking at both ends, like the part that's attached is going to be the part that has trouble, you know, tolerating load, and so the science on elbow pin is just it's not good because there's not a lot of calcification that happens, but that doesn't mean it's not helpful elsewhere. But in general it's like a kidney stone, you know, kind of device that's meant to break things up, which is kind of savage to think about.
Speaker 1:I totally agree. Well, and then, like you know, if we were doing this podcast 20 years ago or 25 years ago, then we'd we'd be taking instruments and trying to break up these tissues, just like with a piece of rebar or something you know.
Speaker 2:Yeah, the friction massage stuff is still around, surprisingly, I think. I think for like a massage therapist, if it's because, again, elbow pain is like most of the symptom is probably muscular pain and it is a big trigger points are in fact a contributor, and so self-massage is definitely the best thing people can do. And so self-massage is definitely the best thing people can do. But that doesn't mean you want to use the arm aid and just like just badger your arm with it relentlessly, because more is not better. But a little bit of symptom relief with those is probably OK.
Speaker 2:The cross-friction stuff, if you're a massage therapist and you're like hands are sore as hell from doing this all day, like using tools and going over the skin kind of makes sense, you know, but like trying to dig at a connective tissue bundle to make it heal better, the science on that is, you know, definitely not good and not suggested anymore. But for muscle stuff it's probably fine. But again, it's kind of like a, an individual preference. I personally do not like massage because I get so sore afterwards, so I never get like a an individual preference. I personally do not like massage because I get so sore afterwards, so I never get like a therapeutic benefit from it. Some people will really like it. So again, that's kind of like a is you know, people ask me about things like is that something you normally do?
Speaker 2:and they're like, yeah, I do it all the time, they're probably fine to keep doing that. But if they're not doing it and say, well, do well, do I need to do this? Like no, you don't have to do that.
Speaker 1:Like take a big deep breath, like there's not stuff that you're missing out on by just like doing your normal routine, because the outcomes will be the same for most people in all of those settings mechanistic narratives surrounding manual care have really changed in the last five to 10 years from that tissue-based model to more of what we were talking about, where it's like it's a, it's a neurophysiological input to the tissues. Like if you have an irritated tissue, we can do an input, whether that's manual therapy, with hands-on with an instrument or with a set of needles or whatever and that input can help reduce pain and discomfort. And potentially, what are your thoughts on the whole? Like opening a window of opportunity for then loading. So we know that sometimes manual therapy like some people are like oh, this is like all you, you need is just I just need to rub the heck out of this thing or stab it with a needle.
Speaker 1:But then, you know, sometimes we don't get lasting changes. But in some instances it can be something that gives people an opportunity, with a good pain decrease, to then load those tissues appropriately to facilitate adaptation. What are your thoughts there? I know you're doing more remote work, but me as a practitioner, I see people you know a lot more face to face, so I will incorporate some manual therapy in order to decrease their symptoms. And then I'm really lucky, I'm in a gym space. So then we go into the gym and then we do loading procedures there.
Speaker 2:I think that's fine. I don't think there's any downside with doing that. I think from a patient coming into the office standpoint, that's kind of like it's almost forced in some way, not that like you're doing that. Like that's how I felt in my clinic is like people come in to see you and they like expect this, this, this and this, and then you got to like at the same same time try and teach them about stuff and then do some exercise. But then you like run through half your visit and you're like, oh shit, now I only have like 30 minutes. The science would say it's not better, like it's not better one or the other. You know, it really is kind of a personal preference thing, I think for the individual, where if people like that great for me I've learned over my life, now that I'm 42, I'm not a very touchy person like I don't. I just like that's just not something that I'm used to. Maybe my mom didn't hug me when I was little.
Speaker 1:You're not a touchy-feely guy, tyler. No, that's just not my personality, so I would like.
Speaker 2:So I think the people probably that want to do consults with me are like people that like just tell me like that's kind of how I am, just like tell me what I need to do and I will do it and it'll be fine, right? Some people want to be nurtured a little bit more. I think it probably is just a patient preference thing, you know, but arguably both would respond well to complaints, as long as the athlete that comes in still gets the things to do in their way. Where a lot of my time is spent talking. But then it's about customized programming for the individual, where in a clinic you just don't have time for that, right, so it's like extra time that you have to make yeah, I, I totally agree.
Speaker 1:I'm I'm super lucky with my setup, that I spend a shitload of time with people, um, but it's also like not super practical for like every single dirtbag climber to come and see me. That's like one of those things where there are pros and cons.
Speaker 2:Well, it's interesting, like just the general rehab model. I talk to so many PTs that have great intentions and they're knowledgeable and smart and their job is just like they're just overworked. They don't have the physical time to sit and spend with their clients like they know is necessary and they end up hating their job and end up leaving and doing other stuff. You know, same thing in the Cairo world is. You know, people that try to stay up to date with modern rehab science know that what we've been talking about is the approach and the direction, but that's really hard to do and make a lot.
Speaker 2:Make, make money right it's hard to like make money when you know, with the general public, like I'm really lucky and grateful that my population is really easy to work with. They're strong, they're healthy, they're super reliant, they're super like confident, they do what they're told and they get better. Muchiant, they're super like confident they do what they're told and they get better, much better than the general public does you know so it's like, my bias is definitely towards that demographic, which you know makes it a little bit easier on me.
Speaker 1:I'm the exact same way. I mean, I did a phone call with one of my friends and he was. I went to chiro school with him and he called me up and he's telling me about this patient that he had with this finger pain and it was like a diagnosed annular pulley tear. So I'm like, all right, what's kind of stuff you're doing with them and stuff. And he's like, oh, they've got a ton of fear, avoidance, and it's been months and they're not getting better. We've been doing some loading things and it just hasn't really been working. Like huh'm like huh. So we get to talking and then later on it's like, oh, but actually this person is, their occupation is driving a truck and they have raging uncontrolled diabetes and they smoke a pack a day. And I'm like, dude, kudos to you, that's an uphill battle.
Speaker 1:And I'm sorry but you're doing a great job and it's going to be really tough. That's just the way it's going to. Be sorry, but you're you're doing a great job and it's going to be really tough.
Speaker 2:That's just the way it's going to be yeah, yeah, yeah, I mean even in for that case, like it's probably not that big of a deal like an a2 pulley injury.
Speaker 2:For someone it's a big deal because they have symptoms and pain, but management is, you know, in that case you could splint someone's finger and it would be fine for a couple weeks, you know, even a month, and they would get full range motion, be fine. It's much harder, probably, for a climber, because they're like I want to get back to, like, pulling on monos again, you know. So it's like they probably have an easier job there than than you and I do, with a pulley rupture in that case, which is funny yeah and they're like, oh, I've got a 10 sleep trip coming up, okay, well, I've got a.
Speaker 1:I would love to get some of your advice. I had a climbing athlete do a consult with me and I gave them advice as far as how to manage this and the decreasing in the symptoms and also the like getting back to climbing has gone really well. So I'd love to tell you some of the advice that I gave them. But then what I'd really like to pick your brain on is how, what advice should I give that client that will keep this from coming back again? So this client's based out of Lake Tahoe.
Speaker 1:They're really into bouldering over the summer but they had this progressive onset of elbow pain and discomfort and it was really limiting their climbing sessions.
Speaker 1:So they would go out for a climbing session really big like social contribution there.
Speaker 1:So it's like really important to them to be able to go out to the boulders. But whenever they were climbing for these long sessions, like the next day, they would really feel an exacerbation of their symptoms and it would really mess with their ability to go out and do that like partake in that social endeavor. So I gave them some advice as far as heavy hangs and actually some like hangs and coordination isometrics on the boulders and like working on that on their projects and then really tracking attempts and making sure they're resting appropriately in between attempts. Then slowly work into slower controlled movements and then, as that became more palatable for the elbow, then working into those more like dynamics type of movements. And the last time I checked in with this person they were doing quite a bit better. It barely ever bothered them and they were back to climbing at almost their full level, as previous. And they were back to climbing at almost their full level, as previous. But now it's like, if I were to call that person up, what would be your advice for them to keep this?
Speaker 2:elbow issue from ever coming back again. I mean, the likelihood that it comes back again at some point is pretty high and that's not like a real concern, you know. Know, once the science that's been done on tendons shows that when people have a persistent pain complaint and there is some degenerative changes to the tendon, it will maybe will stay like that. So that does not mean that and which is important to teach people just because your pain goes away and you're back to normal climbing doesn't mean that you can just go back to doing whatever the hell you want and not think that there's consequences, because there is. And so the preventative side there is. Like they need to be thoughtful about their training program. They need to have some sort of periodized structure where they're doing more volume of climbing getting close to the season or in the season, but at some point they got to back off and they need to go through a strength training phase and rebuild the capacity of their tissues again and then repeat that process, do a bunch of climbing and then back off.
Speaker 2:How long they can have that climbing phase is a very individual thing.
Speaker 2:Maybe it's a month, maybe it's eight weeks, but it's definitely not three months at your limit because that will you know, that's a pretty high dosage, right, and everyone gets hurt doing that. So they got to back off. So they have to learn for themselves the amount of volume they can take per week and per, let's say, season until they need to back off in general, because giving them like blanket statement advice, do this thing forever and you won't get hurt is not true, obviously. And do these things and you're not going to get hurt that's not true. There's no evidence for that. And so it's a mix of, like strength training and climbing, but the frequency and volume of each change, based on the proximity to the climbing season, which is not as easy, answer, right, not like a oh, this for sure, do this and it'll never come back. That's where the, the deep learning, really is the solution. But this individual's got to give a damn and they got to like learn and care and apply it to themselves or have a coach that helps them do that.
Speaker 1:Right, that's another thing that we do yeah, and they've got to listen to their body. Do the right dietary things, uh. Intake enough protein, maybe with a donut right and?
Speaker 2:sometimes shit just happens. Sometimes you just get hurt. You know the only jokingly, the only way you I tell people that if you, if you don't ever want to get hurt again, just stop trying hard, right, like all you have to do is just like climb boulders that are like pretty easy for you and keep the volume low and you really won't get hurt. But most climbers are, they want to try hard and they have goals and they want to like to push themselves right. So if you're doing that, there's always the random chance that something's going to get hurt. But I think think we have way more control I know clients have. We have way more control over injuries than we think we do. But it just requires people to really, you know, pay attention to it.
Speaker 1:Yeah, being cognizant of some of those variables that we talked about previously, such as load intensity, how your body responds to specific loads and intensities, etc. And.
Speaker 2:I think the dosage, the like, the range of like one to 1.5 grams per kilogram body weight protein per day is like the athletic range I personally find for me, the higher the protein content, the less sore and injured I get. So like I have a lot of my clients if they're not getting the higher end of that range of protein, I have them start there and your body just needs those basic building blocks. And most athletes are just active. They're just doing a lot of stuff. They definitely need that recovery.
Speaker 1:And I think that with climbers, especially climbers that are, you know, doing the kind of travel lifestyle, it's hard to carry around that much protein in a mini fridge.
Speaker 2:It's super inconvenient, for sure. Sure, that's when supplements are great, like I use I've used fizzy vantage for years, their whey protein supplement. Those things are very well researched, very like, legit, very helpful. There's very few questions about protein supplements and they have ones, for you know vegans as well, and so like that's just the easiest, that's the lowest hanging fruit, I think, from like a rehab standpoint, is making sure you're getting that in and then making sure you're modifying your life, not just your climbing, to make sure that your body is going to get better and it's like hard not to heal. Your body's just too damn good at getting better yeah, I I agree with that.
Speaker 1:Just like you know, I don't really give like super sophisticated nutrition advice, but I also find that I don't really need to a lot of times, because a lot of times, if I just ask about the basics like, what does your hydration look like? Are you getting? I typically recommend like 1.6 to 2.0 grams per kilogram of body weight per day, are you getting in this? Are you getting in the proper amount of macronutrients? And a lot of times it's like oh yeah, like uh, my, my protein intake is like a quarter of that, because I have like one egg in the morning with a piece of bread and it's like, okay, well, low-hanging fruit here we need to really improve like the intake of the building blocks of connective tissues, which is protein, the cool thing about the supplement is they just mix it with water and then you get like eight ounces of water too, like.
Speaker 2:So just like have gets twice a day. You just get like there's a couple glasses of water and then you know probably 50 grams of protein. That's like great, you know, per day.
Speaker 1:A place to start it sounds like you need to do a collaboration with uh gnarly and work on a protein donut oh, that would be sick, huh, I well, I've taken, I've.
Speaker 2:I like gnarly's protein, I like fizzy vantage protein, gnarly's protein. It's interesting, theirs is two scoops, or fizzy advantages is one, I'm not sure why. Um, but my wife actually has a different brand of protein which I like the flavor of the best, like a vanilla bean. So I eat, I eat hers at night, and then I have the fizzy vantage. One office I actually work right next to gnarly.
Speaker 1:They're cool that's why I was like dude. They're really cool. Facilitate that man get it.
Speaker 2:That would be pretty sick. Yeah, I wonder what I mean. Yeah, like a sprinkled donut, like protein flavor, that would be pretty tight yeah, all right, tyler.
Speaker 1:Thank you so much for sitting down with me now. I always end these podcasts with one. You know what is your ounce of prevention as far as preventing elbow pain from happening in rock climbers council prevention.
Speaker 2:I don't know if I understand. The question sounds like.
Speaker 1:So we've been we've been talking for about an hour and 15 minutes and we've talked about a lot of different things. We've talked about load management. We've talked about different treatment options, dietary things a ton of different stuff. If we could distill this down into one ounce of actionable advice for somebody that's listening to this kind of sum everything up Like what would you say to?
Speaker 2:somebody who doesn't want to get out of pain.
Speaker 2:Don't new things in you have pain. Don't add a bunch of new stuff in you don't. There's not things you're not doing that's gonna make it go away. You have to think about your normal week and you gotta start reducing the total amount of stress to the elbow, because the elbow is repetitively stressed. Make sure you like recover really good. You need your recover to be optimized sleeping habits, hygiene, eight hours, you know, eight hours a day, same time of the day, etc. Make sure you're getting plenty of calories and don't stop climbing. You just have to modify the stuff that you're doing, you know, and be patient, like, and most of the time when people do that, their elbow pain will go away. Right, and don't assume that there's like some magic thing that you can do that's going to make it stay away forever, because that thing doesn't exist awesome, I think.
Speaker 1:I think having that understanding and the educational piece is like one of the things that even if you do get like a flare-up in elbow pain, then it's like, oh well, yeah, it's not the end of the things. That even if you do get like a flare up in elbow pain, then it's like oh well, yeah, it's not the end of the world, I just need to do these things. And then it's like really not a big deal.
Speaker 2:For sure. I think the most important thing for like me clinically going to pyro school is, like you know, you'll learn so much about spinal pain, but I personally have had like a lot of spinal pain in my life, but I know how not scary and not like physically concerning it really is, and that to me is such a sense of comfort, because when you have pain, just like I know that it's an inconvenience but I know it's not the end of the world, and so having that confidence and knowing that is amazing, and so that's really what I like to do with my clients is really try and instill in them a sense of like control and confidence and have them educate themselves about it Right, and that is amazing, for, for, for patients.
Speaker 1:Awesome. Well, thank you so much again, tyler, and I'm excited for the next one already.
Speaker 2:Yeah, thanks for having me, man. We'll think of something cool.
Speaker 1:Yeah, I hope that you enjoyed this episode of the Art of Prevention podcast. If you did enjoy and or benefit from some of the information in this podcast, please be sure to like, subscribe and share this podcast, or please give us a five-star review on any platform that you find podcasts. One thing to note that this podcast is for education and entertainment purposes only. No patient is formed, and if you are having any difficulty, pain, discomfort, etc. With any of the movements or ideas described within this podcast, please seek the help of a qualified and board-certified medical professional, such as your medical doctor or a sports chiropractor, physical therapist, etc.