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Starting Strength in the Real World

Elbow Tendonitis: How It Occurs and What to Do About It

by Jordan Burnett, SSC | March 17, 2020

elbow position in the squat

Elbow tendonitis is one of the most common and pervasive injuries that serious lifters can experience at some point during their career. It can be debilitating, turning very strong and mentally tough individuals into weeping puddles of inflammation and sadness. It can stop even seasoned trainees in their tracks, preventing them from progressing for long periods of time if not addressed correctly. Some decide to try and push through the pain without any change in technique or training protocol, only serving to make the problem worse over time and only resulting in missed reps, or even bagged training sessions due to the degree of pain they’re experiencing. 

Others recognize their pain is getting worse and opt to completely avoid movements that they’ve identified as the culprit for long periods of time, in hopes that a layoff will make the inflammation heal. To their dismay, they find that once they return to those movements, the pain returns in earnest, just as bad as it was before. I was the former, and it was not a good time. I pushed myself unnecessarily hard to hit bigger numbers, telling myself that the pain would be worth the PR. That is, until it hurt so bad that I couldn’t even make it through my warmups. Don’t be like me. Address the problem NOW and save yourself some heartache down the road. Do not fall into the trap of missing training or completely avoiding movement patterns. An injury like this must be trained through in order to make it heal effectively. Take it from me, layoffs do not work. 

What is elbow tendonitis, and how does it occur? 

This topic has been covered ad nauseum, so I’ll keep it brief. The most common forms of elbow pain are medial and lateral epicondylitis, often referred to as Golfer’s and Tennis elbow, respectively. They are overuse injuries and present as the inflammation of either the flexor or extensor tendons of the forearm that originate at the distal end of the humerus. You might be one of the unfortunate souls that has both. The pain often radiates up into the bicep or down into the forearm. If you’re experiencing bicep pain and can’t pinpoint exactly where it’s coming from, it’s fairly likely that it’s the early stages of elbow tendonitis. 

The most common cause of elbow tendonitis is some combination of grip position, upper back position, or elbow position in the low-bar squat. Essentially this causes undue pressure to be put on the elbow joint due to the hands pushing forward into the bar combined with the external rotation/excessive extension of the shoulder joint. Nick Delgadillo wrote a fantastic article detailing exactly how this occurs and how to correct it. If you’re experiencing elbow tendonitis, this is the first change that must be made – immediately. This is best done under an experienced coach who can guide you through the correct grip and elbow position. 

This can be a particularly challenging change for a lifter that is deep into their novice linear progression (LP). When handling very heavy weights, fight or flight kicks in and the grip and elbow position are usually quickly forgotten about, in favor of a more useful cue that prevents the lifter from getting buried at the bottom of the squat. How we address the tendonitis issue at this point is dependent on how far along the lifter is in the LP and how bad the pain is. Ideally, he is able to implement the coach’s changes to the grip and execute it flawlessly right away, but rarely does this actually happen in practice. Very often we have to reset the squat to a more manageable load so that there is room in the lifter’s brain to make the grip and elbow position the primary focus. The rest of the movement pattern can take care of itself more or less on autopilot due to the lighter load. 

This does not mean that if the lifter is squatting 315x5x3, he reduces the weight to 135. It needs to be as heavy as possible while allowing the lifter to perform the movement correctly, the goal being to work back up over time to heavier weights, but this time with a more solid grip that doesn’t put as much pressure on the elbows. If the lifter is only a month or two into the LP, it can often be fixed without a drastic reset, because the weight is still relatively light enough to focus on the grip position. 

Another option is to use a light day in the middle of the week to focus exclusively on correcting this issue. Pause squats and tempo squats work very well here. Due to the increased time under the bar, the lifter has more time to feel out the correct position for the elbows with a lighter weight. This often transfers very well to the heavier days on Monday and Friday. All of this will depend on where the lifter is in terms of programming and the level of pain. Again, this is where a coach comes in handy. 

Inflammation and eccentric loading 

Even though the squat grip is most likely the cause of elbow tendonitis, it is often felt the most during the pressing movements – particularly the bench press. This makes sense, because where the elbow joint plays a passive role in the squat, it plays a very active role in the bench press. The bottom position of the bench press is the bane of many lifters who suffer from elbow tendonitis. If the squat is the root cause of the problem, the bench press is the thing that gets affected first. 

Even after taking corrective measures with the squat grip, as anyone who’s had tendonitis knows, it does not go away overnight. It might take several weeks to heal properly. How do we continue to train the upper body while managing the pain? Enter the tempo bench press. The following protocol was introduced to us by Will Morris as part of a pain and rehab seminar in Wichita Falls. 

Let’s take a moment to review the Stress/Recovery/Adaptation cycle. A stress is introduced to an organism, and if it’s an appropriate dose of stress, the organism will recover from that stress and adapt to it. This philosophy applies not only to getting stronger, but to healing injuries as well. Just like everything else, elbow tendonitis needs to be presented with a stress that it is able to recover from and adapt to in order to heal effectively. Will explained that a 3-1-2 tempo was a good middle ground between loading the elbow joint and managing pain. The stress comes from the time under tension and the eccentric loading, which has been shown to positively affect inflammation (if not pain) over time, and the pain is managed by the pronounced concentric portion, which has been shown to alleviate pain (if not inflammation). Thus we achieve improvements in both. 

If changing the squat grip does not immediately provide some relief for the lifter, the tempo bench can be used in conjunction to further mitigate pain while continuing to train. The press is removed and the tempo bench is done every session, adding a little weight each time, for roughly two weeks. This works very well to decrease elbow pain. By the end of those two weeks, most lifters report their pain to have decreased to a much more manageable level. Why do we remove the press? Because the loads of a heavy press could potentially have the same effect on the pain as the bench press, and doing the press for a tempo would necessitate lightening the load to such a degree that it would not be enough stress to elicit any kind of meaningful adaptation. If the pain still persists after two to three weeks of tempo benching, there is another option. 

Pin Firing 

Good ol’ pin firing. This method was devised by Rip, and comes from his experience in the horse business. I know nothing about horses, but essentially it was a method by which they introduced more inflammation to an already inflamed tendon, causing the body to heal the original source of inflammation along with it. We apply this concept with the use of chin-ups. Chin-ups have a tendency to really piss off the elbows if they are already inflamed. This approach will vary slightly depending on how many chins you can do, or if you can’t do them at all. The goal is to hit a very high volume of chins in a single session using many sets with very few reps per set. If our theoretical lifter can do a set of 10, he should do 3-4 reps per set, for anywhere from 10 to 15 sets. If one can only a set of 5 reps, do 10 to 15 singles. The goal should be to increase the number of total reps by a little bit each session. 

Regardless of how many chins you can do, the concept is the same. It’s important to note: this method is extremely painful – we are actively trying to increase the inflammation. Naturally, it’s going to hurt. By the end of the session, you might be questioning your reason for existing and asking your god why hath he forsaken thee. Keep doing it anyway. After doing this protocol two times per week, after a couple of weeks you’ll find that the pain is either greatly lessened or gone altogether. This was the protocol I used to remedy my elbow tendonitis, and it works extremely well if you can tolerate the pain. For those that either cannot do a single bodyweight chin-up and for those that can do very few chin-ups (less than 5 reps), assisted chin-ups with a band work well here. Adjust the band tension as necessary, but be sure not to add more assistance than you need to get your chin over the bar. 

There is a systematic and logical approach to deal with this injury and rehab it effectively. If you are one of those suffering from elbow tendonitis: Fix It Now. Even if it is mild and it’s not preventing you from getting your work done, it will get worse if left unaddressed. If the pain is bad, don’t panic or become dejected. Correct the cause, and start the rehab.The healing process takes time and patience, but it will get better if you apply these principles correctly.

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