Wednesday 10 September 2008
Elbow.
Current status:
Mid-Feb 2008: Tweaked elbow (golfer's elbow, join of the tendon inside my forearm to the bony spur at my elbow) bouldering indoors. Elbow felt fine afterwards and kept climbing.
Feb - March 2008: Continued climbing but a mild pain started to build up. Eased off climbing in proportion to pain, but pain continued and worsened.
April - May 2008: Realised (far too late) that I was getting properly injured and eased off climbing a lot more. Pain stayed at a constant level.
June - July 2008: Mostly rested for six weeks until mid-July, started therapeutic exercises.
July - Sept 2008: Eased back into climbing at up to 50% of my usual physical limit. Pain still present and initially no better than before rest. Slowly pain seems to alleviated a little but still prominent and variable.
Physio recommendations:
Physio 1:
- Any climbing usage is likely to re-damage it and slow down or inhibit healing.
- Taking 3 months total rest would likely be a good way to let it heal.
- Intensity of climbing is not so relevant, even gentle use is damaging.
- Recommends icing after any exercise.
- Recommends regular massage with ibuprofen gel.
- Recommends use of an epiclasp restraint below injury site.
- Therapies listed below are all useful although eccentric exercises should be mild.
Physio 2:
- Climbing at up to 50% will be fine for my elbow and possibly beneficial in conjunction with other therapies.
- It will take several months to regain a good level of strength.
- Total rest is not necessary providing I am disciplined.
- Ibuprofen is not recommended for long-term healing.
- There may be some issues with my shoulder / back that should be treated.
- Therapies listed below are all useful.
- Recommends taping and being cautious with epiclasp usage.
Physio 3:
- Climbing at up to 50% will be fine for my elbow and possibly beneficial in conjunction with other therapies.
- It will take several months to regain a good level of strength.
- Total rest would actually be less recommended due to loss in strength and dangers of building back up from scratch.
- If pain is prominent I should drop the level I'm climbing at rather than stop.
- If iced water feels better than icing, I should stick with ice water.
- Ibuprofen does inhibit the healing process (reduces white blood cells).
- Recommends taping across the injury site.
- Therapies listed below are useful.
Other sources (e.g. Dave Mac's writing etc):
- Iced water recommended.
- Ibuprofen not recommended.
- Therapeutic exercises all recommended.
Current therapeutic practices:
1. Ice water bath 2 x 30 minutes daily.
2. Eccentric wrist curls 2 x 3 sets x 10 reps, 5 days per week.
3. Reverse wrist raises 2 x 2 sets x 20 reps, 5 days per week.
4. Press-ups 2 x 20 reps, 5 days per week and/or after climbing.
5. Massage and stretching 2 x 10 minutes daily.
6. Massage before and after climbing.
7. Ice after climbing (or ice water if ice does not alleviate pain).
8. Climb only up to 50% of physical limit and avoid anything further.
(Note that I probably do half as much of the therapeutic practices as is recommended)
In my actual experience:
Good (i.e. less pain):
- Iced water
- Massage
- Eccentric exercises then massage
- Taping across elbow
- Random days when I wake up and it feels fine
Indifferent:
- Climbing steadily (more tender to pressure later in climbing session but reduced to normal within a day)
- Epiclasp below injury site
- Taking ibuprofen when climbing (reduces pain but reduces healing)
Bad (i.e. more pain):
- Sleeping on it funny and waking up with random pain
- Any obviously harder pulling
- Strenuous gardening / DIY
- Regular icing i.e. ice pack
Finally...
What I've done in the last couple of months is monitor the pain and what I can do on the elbow carefully (those being the only - and vague - indications I have of what is going on), and to seek as much advice as possible from different sources. I take all that advice, mix it all together, see what comes out as the average, and then tally that against my physical instinct and what it actually feels like. That more people have said "keep going" than have said "rest completely", I'm not taking that as gospel nor as a carte blanche to climb lots - I realise that caution and discipline are essential. Based on this I am going to keep climbing at a low level, perhaps reducing the level a bit, but making sure that I rest as much as possible and do the therapeutic practices as much as possible.
I'm not sure how you find the time to climb, it must take half your day to do all the therapeutic practices. Fingers crossed it's sorting itself out. x
ReplyDeleteWell....I'm not doing much climbing at the moment.
ReplyDeleteAnd I'm not doing as much of the exercises and shit as I should :P.
Physio 1 seems to be treating it as an acute injury, which it's not.
ReplyDeletePhysios 2 and 3 seem to be in agreement with each other and also what I've picked up from both experience and research.
Other stuff:
1) Total rest means the new tissue heals less strong and knitted together, exercise and massage (across the tendon not down it) makes it stronger and better formed (Dave Mac).
2) Careful not to do too much therapeutic stuff! Strength stuff 5 times per week sounds a lot, as does massage twice a day (but as you point out, you're probably not doing it that often anyway). Useful guideline is as long as they're not causing you any ill effects it's fine, but I reckon if they're making your elbow tender (which they do for me), every one or two days is fine. Remember it's rehabilitation and maintenance, not strength training as such, so more isn't necessarily better. Stuff like the iced water bath is fine twice a day as it's passive not active.
3) If you ask physios questions, try not to put answers into their mouths. I find if I say to them 'how often should I do this', they'll answer more honestly than 'is it okay if I do this every day'. They don't know for sure what's best, so if you load a question they'll just tend to agree with you. In general they'll just say to do whatever doesn't hurt. But it's often hard to tell what's really hurting in our desperation to get better and keep climbing, it's very hard to be totally objective. The proof being that we often don't realise our arms are hurting when we initially hurt them, can be months before we think 'maybe this is something I ought to get seen to'!
4) For me personally, I find ice makes it worse (as does cold camping), heat/iced water bath helps. NSAIDS make no difference (and stopped on Dave Mac's advice). Taping helps if it suddenly starts hurting again, but hinders if i'm starting to feel stronger again. Find the taping miles better than the clasp (which I didn't like). Eccentric wrist curls - my jury's still out on that one, as not been doing them long enough or frequenly enough or with enough weight. The theory seems sound, and sort of helps, but any strength stuff makes my muscles/tendons feel tender so it's hard to tell. I find press ups hurt my elbow, AND my rotator cuff! Can't do them at all at the moment, despite my various injuries being the best they have in years (apart from the last 2 weeks). When my injuries were worse, I was doing press ups every day for 6 months to fix an unrealted injury with no problems. Haven't quite worked out the logic there.
5) Have you tried swimming? I find it a good indicator of my level of recovery. I find it very hard to tell the difference between normal pump / post climbing muscle/tendon stiffness, and injury pain. So I use swimming instead - if I can swim without pain, it's just stiffness, it's swimming hurts it's more serious and need to reduce climbing intensity for 2 weeks (I find 2's a good number).
6) Important to remember low intensity climbing is part of the rehabilitation rather than for you to abuse to get routes done, but doesn't mean it can't be fun and useful rather than frustrating. Try different styles - Dawes type dynamic climbing, footwork stuff, slopers (meant to be better for injuries than crimps, but not always), local endurance, yoga for flexibility. This is what I was pondering on on Saturday and mentioned on voicemail. My footwork improve no end the second time I hurt my elbow (the second time I hurt it - mid 2005 - light climbing was great for it, the first time I hurt it (autumn 2004) light climbing very bad, despite injury sites being very close together) which has help me lots in the long run - I climb harder now than a couple of years ago, despite being less strong. You rely a lot on strength for your climbing, so if you can change your style a little to a less intensive method you're less likely to hurt it again in future.
7) Don't get a steroid injection. Can offer temporary relief but weakens the joint.
All just my thoughts from an experience and research perspective, certainly not gospel or professional! :)
Sarah (can't remember my password)
(Clearly I could remember my password (I had to as I couldn't work out how to post as a guest), but forgot to take that bit off when I did!)
ReplyDeleteThanks for your comments, I will reply properly when my brain is working.
ReplyDeleteIn reply (your comments definitely appreciated):
ReplyDeletePhysio 1 knows how long it's been going on for but I agree he does seem to be treating it as acute. He is more of a sports physio.
Physios 2 and 3 are climbing physios and have tended to correlate on most things. One of them refers to some of the same research that you do.
1) Yes, understood. I have asked P2 and P3 about massage directions. P2 says across the area, P3 says it doesn't really matter as long as I get exactly the right spot.
2) The rehabilitation exercises - 2 times daily for 5 days was what was recommended in the Australian physio article that Ru linked on UKB, that's what I'm following. I haven't noticed any worsening when I do them regularly (a rarity!).
3) Yes, agreed, I have been careful with that. The only time I've tried to "guide" the physios towards an answer was when I was asking P2 and P3 about total rest - I made it clear I'd be prepared to rest, I wasn't averse to it, and would be quite accepting of their advice to rest. I wanted to "encourage" them about the resting idea to make totally sure that if they said I didn't need total rest, that was their best advice and I had not influenced them to allow me to keep climbing, but had given them a clear opportunity to tell me to rest (they didn't).
4) I've recently been recommended cold/hot alternations by P2, using packs. I've only done it a few times but has found it has made a noticable difference to the pain-to-touch straight away. I found the ice bath helpful BUT I didn't get that red blood rush to the area that I'd heard I should get.
5) Good idea, I intend to do more of it.
6) Very good points. Yes I should keep away of easy climbing as part of rehabilitation rather than a carte blanche to bumble around whenever. I still tend to get a bit carried away (not to the point of tweaking, I do keep aware of it). I entirely agree about working on other aspects of climbing, and thanks for the encouragement in that direction. I did intend to do that - work on footwork, balance, and in particular gear placing and smoothness, but it hasn't worked quite like that. Because I'm rusty and out of practise I've tended to fall back on sloppy panicking more than I should!! I need to be more dilligent about that and use the time well...
4) You might well not get the red blood rush for an elbow, as it's deeper tissue than a finger (which is what the cold bath's most often recommended for). According to MacLeod (and research), the cold bath is meant to reach deeper tissues than the hot/cold (therefore better for the elbow), but if you find hot cold better I guess go with that, don't know. I find it hard to fit either in to my day, practically. Should try harder.
ReplyDelete