Medial elbow pain is an injury that we see quite often in rock climbers – in fact; it's so common that we even have our very own name for it: Climber's Elbow.

If you feel the little bone on the inside of your Elbow, that is what's called the Medial Epicondyle, and it's where the majority of the muscles that flex your fingers and wrist start.

Climber's Elbow (also known as Golfer's Elbow for the highbrow among us) occurs when this tendon becomes overloaded, and tendinopathy develops, causing a dull pain that is relatively localised right near that Medial Epicondyle bone.

It typically feels like a dull aching pain when you warm up as you start climbing and can generally feel okay during the session but will often be quite painful the night after or the next day following a climbing session.

Good question - tendinopathy (also sometimes referred to as tendonitis) is a repetitive strain injury that occurs when a tendon is overloaded and unable to tolerate training. As a result, the tendon enters a reactive state where it becomes painful and has impaired healing/recovery.

The most common cause of Tendinopathies like Climber's Elbow is a result of sudden increases in load whilst training, and subsequently, the tendon can't keep up. In climbing, this typically looks like: A sudden increase in our training - i.e. an increased number of sessions per week, longer session durations, or increased session intensity, OR…

In both of these situations, the root cause is the same - the tendon, which was strong enough to manage the previous average level of training load, can't keep up with the sudden increase in load.

This causes the tendon to go into a reactive state in which it becomes irritated and is unable to strengthen in response to the training stimulus—resulting in chronic, aching pain in the tendon.

As climbers, we train our forearm flexor muscles far more than we train our extensors muscles. Our forearm flexor muscles are what we use to hold onto the wall and grip with, while the extensors have only an accessory role in raising the wrist while climbing.

Over time this can lead to a muscular imbalance in the forearms that increases the susceptibility of the flexor tendons to becoming overloaded.

Another great question. Well - understanding everything we have spoken about so far, treatment of Climber's Elbow involves three key components:

Load management is the biggest key to healing your medial elbow pain. Right now, your tendons are overloaded, and so they are in a reactive state where they are unable to cope with the load and can't get more robust in response to your training.

So the most crucial step, and if you take nothing more away from this article, is: we need to decrease the load that the tendon is under to a level that it can tolerate.

Don't worry; this doesn't mean you need to stop climbing! It's the opposite - if you rest from climbing altogether, the strength of your tendons will slowly decrease during your time off, and then when you start up again they will be even weaker (and less able to cope with the load) than they are now.

So it would be best if you kept climbing to get your tendons stronger, but at a level that they can cope. But how do you know where that level is you ask?

Well, fortunately, it's quite simple!

You need to monitor your symptoms closely. If you experience an increase in pain immediately after or the next day after climbing, then the tendon has not coped with the load - it's as simple as that.  If the tendon has become more painful after a session, look for ways to decrease your next training session's load a little.

The suggestion here would be to attempt easier climbs (i.e. only climbs you can flash), climbing fewer days per week, or doing shorter sessions with less time on the wall.

When you go climbing at this slightly lower training load, if the pain doesn't increase after the session or the next day, then the tendon has coped with the load and will get stronger in response to your training!

Over time by staying in this "green zone" of training load, your tendon will continue to strengthen, and you will be able to slowly increase the training load back up to your normal levels again.

The second essential component of your recovery is to start a simple two exercise strengthening program to increase the load that the tendon can tolerate and balance out any muscular imbalances in the forearms.

To strengthen the flexor tendons, we are going to use wrist curls (see below)

Focus on a long slow downwards portion of the movement – this will emphasise strengthening the painful tendon that we are trying to target.

Try 2x sets of 10 long slow reps. These should be at a weight that is close to pain-free, with any discomfort settling immediately after you stop the exercise.

To strengthen the extensor muscles of the forearm and even out any muscular imbalance, we are going to turn our wrists now over and do wrist extension curls. This time we are trying to strengthen the muscles, so there is no need to focus on the downwards part of the movement, so aim for 2x sets of 15-20 reps.

Complete both of these exercises 3-5 times per week (see below)

Use a massage ball (or convince a close friend to help you out) and get deep into all the muscles of your forearm to try to release any built-up tension. It's important to note that this is mostly for symptom management rather than treating the root cause of the problem, and is, therefore, more of a supplementary component to your recovery.

However, reducing the tension in the forearms and providing some immediate relief can be very useful in helping the tendinopathy to settle down initially.

Stretching of the forearms is also great, but don't push it early on in your recovery as stretching will pull on the tendon - adding more load to it and contributing to keeping the tendon stirred up. Once your elbow pain starts to subside, then it's a good idea to get into the habit of gently stretching your forearms throughout the day.

Through following all the advice above, your pain should slowly start to settle as your tendons begin to strengthen and become better able to cope with your training load.

At this point, you can slowly start to ramp your climbing back up.

Continue to pay close attention to how the tendon feels, using the same system of monitoring as before (looking for any increase in pain after climbing or the next day). Eventually, your tendon will be strong enough to cope with a full training load, and you will be able to climb pain-free again!

Once the Elbow is pain-free, I recommend that you continue the restrengthening program for six weeks past that point. After that, continue the exercises as part of your antagonist program once or twice per week to help maintain a healthy forearm flexor/extensor balance.

Happy climbing!

Riley Hoare
Physiotherapist (DPT)

If this article has been helpful or if you have any further questions, please feel free to reach out to Riley at sydneyclimbingphysio@gmail.com