Overview of Elbow Tendon Injuries

Pain near the bony medial (inside) or lateral (outside) epicondyles of the elbow is an exceedingly common ailment among serious climbers. In most cases the onset of pain is very gradual as a schedule of frequent climbing produces microscopic injury that fails to repair before the tendon is subjected to additional strain. A tendinosis cycle develops and amplifies as breakdown exceeds repair and the extent of microtraumas accumulate over many weeks and months. In the early stage of tendinosis, pain is dull and may be felt only after a day of climbing; however pain experienced in the course of everyday activities such as opening a door or washing your hair is a sign of advanced tendinosis. The hallmark of tendinosis is its gradual onset and lack of inflammation and visible swelling.

A similar, yet less common and often misdiagnosed injury is tendinitis. The suffix “itis” means inflammation, and the term tendinitis should be reserved for acute tendon injury accompanied by inflammation and palpable swelling. In climbing, tendinitis occurs most often near the medial epicondyle as the tendon is injured during a maximal one-arm pull on a small hold or in performing advance training exercises without adequate warm-up or training experience.

A third, more subtle class of tendon injury is paratenonitis (formerly termed tenosynovitis and tenovaginitis), an inflammation and degeneration of the outer layers of the tendon and the synovial lined tendon sheath. Paratenonitis can develop in the tendons of the arms and fingers and in concert with either tendinosis or tendinitis.

Regardless of which tendon ailment you possess, the one commonality is the extremely slow rate of healing. Unlike muscles which possess abundant blood flow and a relatively rapid rate of healing, blood flow to the rope-like collagenous tendons is poor and laying down new collagen make take 100 days or more. Exacerbating these slow-healing injuries is the tendency of enthusiastic climbers to rush back into training and climbing prematurely. Worse yet researchers have discovered that an enduring tendinosis cycle often leads to collagen repair with an abnormal structure and composition, thus making the repaired tendon less able to withstand tensile stress and more vulnerable to further injury. Following acute injury, the strength of a repaired tendon can remain as much as 30 percent lower than normal for months or even years.

In severe, chronic cases of elbow tendinitis or tendinosis, surgery may offer the only lasting remedy. The most popular procedure is to simply excise the diseased tissue from the tendon, then reattach healthy tendon to the bone. Eighty-five to 90 percent of patients recuperate in three months, 10 to 12 percent have improvement but some pain during exercise, and only 2 to 3 percent have no improvement.

So what causes tendinopathy?

While this question has yet to be fully elucidated, the leading cause of sports-related tendinopathy is likely a homeostasis perturbation in which collagen degeneration exceeds collagen synthesis over an extended period of time. Among beginning climbers this can develop simply by climbing (and specific training) too much, too soon, or perhaps, due to poor biomechanics. Advanced climbers must navigate an injury mine field as the stress of high-intensity and high-volume training/climbing is compounded by frequent dynamic moves in which tendons repeatedly store and release energy (dynamic moves, campus training, and such). Read more about the latest science and nutritional interventions to combat tendinopathy here.

Over the next two months I’ll provide detailed coverage of the two most common elbow injuries.