Elbow pain with squatting is a very common symptom we see here at Myomuv. It is frustrating because not only does an upper extremity body part limit you from training a lower body dominant movement, but it also limits activities with gripping, pushing, and pulling.
The first step in treating and managing elbow pain with squatting is an accurate diagnosis to see what structures are involved. The rehab will not just focus on the symptom generators or site of pain but knowing what is involved will give us the most clarity and efficiency in addressing the issue.
This will be a multi part series because there are so many different topics to discuss and consider. This LEARN will cover potential diagnosis as well as activity modifications to implement to address elbow pain.
POTENTIAL DIAGNOSIS
Cubital Tunnel Syndrome and Neuralgia
The ulnar nerve innervates flexor muscles of the anterior forearm and intrinsic muscles of the hand. You may notice both motor (muscle weakness) and sensory changes (numbness/tingling) if the ulnar nerve has been compromised. The ulnar nerve passess through a small tunnel in the elbow called the cubital tunnel. With positions that require a lot of elbow flexion like squatting, the ulnar nerve is susceptible to compression and irritation.
Medial Epicondylagia or Golfers Elbow
The medial epicondyle is the common origin of the flexor and pronator muscles of the forearm. Tendon pain from the attachment to the muscles that insert onto the medial epicondyle can occur from overload and overuse related issues. During a squat if you lack adequate shoulder range of motion and your forearms are not vertical you will have to compensate with excessive wrist extension. Your wrist flexor muscles are working to overcome the force of the loaded barbell while your wrist is in excessive wrist extension from your rack positioning. This continuous eccentric orientation of the forearm flexors will result in aggravation and irritation to the tendon resulting in medial elbow pain. You will also have excessive sustained contraction of the pronator muscle groups because of the lack of shoulder external rotation. To try to the grip the bar with the entire hand and get good thumb and total forearm activation this places alot of stress and strain on that muscle/tendon group.
Tricep Tendinopathy
A condition where repetitive and overly compressive forces are placed on the tricep tendon that connects the tricep muscle to the elbow. Symptoms can include pain in the back side of the elbow and pain with elbow extension under resistance. Tendons under go two types of force:
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Tensile Force: This is when two forces are pulling in opposite directions. In the case of the triceps the tendon is being pulled in one direction by the action of the muscle and another direction by the action of the external load.
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Compressive Force: This occurs when the tendon is compressed against the bone as you move. This is where the triceps tendon gets compressed by the olecranon (elbow) as you bend the elbow to end ranges.
When tendon pathology is present we want to use controlled loading strategies with TENSILE FORCE to treat while avoiding positions that use COMPRESSIVE FORCE on the tendon; like with squatting.
Radial Neuralgia
The radial innervates the extensor muscles of the forearm and the triceps. As the nerve travels down the back side of the arm it passes through the radial tunnel on the lateral elbow. Just like with cubital tunnel syndrome, this nerve can get compressed and irritated. If you have pain on the lateral aspect of the elbow (palm will be upward for orientation) and pain with resisted elbow extension and resisted pronation (turning palm downward).
Once we have assessed and ruled in and ruled out these pathologies we then have to develop a precise action plan to get you OUT OF PAIN. There are several strategies to modify your position, technique, and training as we also begin reconditioning and addressing the root cause of your squat related elbow pain.
ACTIVITY MODIFICATIONS
Elbow pain can be further exacerbated by the squat because of:
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Technique: How are your hands and upper arm positioned and what you using as the shelf for the bar?
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Mobility: How mobile are the wrists and shoulders?
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Frequency: How many times per week are you squatting?
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Load: More weight on the bar results in more stress applied to the elbow.
I am not implying to stop squatting all together, however it is best to modify these 5 areas to get your pain free and healthy elbow back! The following images and discussions will detail just that.
1) WRIST POSITION
The most common cause of squatters elbow is poor shoulder mobility into external rotation and opening up the anterior chest/shoulder. Future LEARNS will address exercises to address those issues. What we see with inadequate shoulder mobility is a wrist hyper extension compensation. Instead of the bar force being equally supported by the shoulder, spine, ribcage, elbow, and wrist; this places abnormal stress and strain on the elbow joint.
2) THUMB POSITION
Like most techniques when it comes to stabilizing and lifting heavy things, a closed grip is needed. The lower picture on the right shows an open grip. The likely cause of this is poor forearm rotation and shoulder mobility. In this position the thumb is working overtime to stabilize the bar and the pronator muscle group is held in constant contraction. The results is an overuse related tendon pain at the medial elbow called medial epicondylagia or “golfers elbow”. Pronation is moving the forearm to a position of having the palm facing downward. Th attachment of that muscle group is at the media condyle of the forearm via the pronator tendon.
3) GRIP WIDTH
Altering the grip width can be the most challenging modification because it may limit how tight or stable you can keep your upper back during the lift. We never want to fix one issue and potentially cause another issue. So this typically is not my first modification unless I am working with an experienced squatter. But due to a pec mobility issue you will see someone use a more narrow grip. By placing the hands further apart you can see how the elbow goes from more flexion to more extension which will decrease elbow pain and discomfort.
4) BAR POSITION
The low bar position shown in the lower picture on the right demands more shoulder mobility. Powerlifters and big squatters will use this position because most people are stronger here by getting more hip and posterior chain engagement. The trade off is more elbow stress. Sometimes just moving to a more high bar position and using the upper traps as the shelf can decrease the strain on the elbow and shoulder joint.
5) BAR CHOICE
The quickest fix is changing the equipment all together. The squat safety bar has endless utility for training modifications. You can see how this bar requires significantly less shoulder mobility. The buffalo bar on the left is designed with a natural curve to also decrease stress and demand on the shoulder/elbow.
Part 2 will be out soon! Expect part 2 to really dive deep into root causes of elbow pain and exercises to address your limitations alongside loading strategies to those irritated tissues!
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