Part 1 of this series explored the causes and initial treatment strategies for Lateral Epicondylitis. Part 2 is a short piece designed to share exercises for Phase 2 and Phase 3 of the recovery process - building rotator cuff strength and improving core stability and endurance while strengthening wrist and elbow flexors and extensors.
Phase 2: Rotator Cuff Strength
The rotator cuff musculature represents an area of the shoulder that is frequently weak and underdeveloped. This can contribute to deficits in strength or stability at the shoulder joint, which anatomically is already one of the most unstable joints in the body. This issue becomes more serious when compounded by an imbalance created by the much more powerful superficial muscles that cross the shoulder joint and/or attach to the upper humerus. The idea is to strengthen and stabilize the weak joints in the kinetic chain (specifically at the shoulder in this case) in order to reduce the increased compensatory forces placed on the ECRB tendon.
Exercise 8: Allan Press Progressions
- Goal: To temporarily take the place of shoulder presses in order to correct the imbalance between the rotator cuff muscles and the anterior deltoid.
- Step 1 - 180 degrees of flexion at the shoulder.
- Step 2 - Client lowers the weights until the upper arms are parallel to the floor.
- Step 3 - Client horizontally adducts the weights toward the midline.
- Step 4 - The client horizontally abducts the arms back to the starting position of Step 3.
- Step 5 - The client presses the weight overhead. Step 6 - The client slowly lowers the weights down toward the starting position and then repeats steps 1-6.
- Note: The client can double or triple up the repetitions of step 3, 4 and 6 in order to better correct the imbalance.
Exercise 9: Window Washers
- Goal: To mobilize the shoulder in the frontal plane. Note: This exercise is effective at exposing wrist and elbow dominance as well as upper trap facilitation. Use it as a corrective exercise teaching tool.
- Procedure: Client holds tubing handle in one hand and externally rotates the shoulder on the same side while the elbow is bent 45 to 50 degrees. With the other hand, the tube is secured at the belt line (on the opposite ASIS.)
Exercise 10 (no picture): You Tell Me!
- Goal: This is the time where you get to be creative. Ask yourself what exercises you can create using tubing that will be safe, effective and train the rotator cuff as both a stabilizer and a prime mover in a multi-planar fashion that is specific to the client’s everyday needs, without contradicting or exceeding any joint or tissue limitations they may still have.
Exercise 11 (no picture): New ROM Isometric Holds Progression
- Goal: To improve the strength at the new end point in joint range of motion that has been created by increased flexibility in the shoulder.
- Procedure: Sub maximal resistance on table. This can be done with the arm in different positions but should be specific to the positions that were used to increase ROM by the Phase 1 stretching protocol. Then progress to standing resisted pushes and eventually one leg resisted pushes, both with core activation of TVA.
Exercise 12: Allan Arm Wrestlers
- Goal: The last step in improving dynamic rotator cuff strength in a single joint movement, when no pain is present.
- Procedure: The trainer provides resistance to both concentric and eccentric portions of the movement. The client kneels with his/her elbow on the apex of the stability ball. The client proceeds to internally and externally rotate at the shoulder with little or no pressure applied by the elbow down into the ball. Cue is: “Relax the hand and hover the elbow.”
Phase 3: Improving Core Stability and Endurance While Strengthening Wrist and Elbow Flexors and Extensors
Core Stability and Endurance Isolation Progression:
- TVA breathing exercises in all body positions relevant to client’s lifestyle demands.
- Supine neural training of TVA and lower abdominal activation and coordination using palpation, cueing, feedback devices and exercise modification.
- TVA training (i.e., plank progressions and supermans, etc.)
- Lower abdominal strength and hypertrophy exercises.
- Isolated oblique work to alleviate any ipsi or contra-lateral imbalances.
Functional Strengthening of Wrist and Elbow Extensors
- What was the mechanism of injury? Is it sport or work/life related?
- What are the top five associated activities in the client’s life that could negatively affect the elbow?
- What is it about these five activities that are causing stress on the wrist extensor?
- Are there alternative ways to perform these tasks while not exacerbating the issue? Can we re-teach the faulty motor patterns?
- Is it an issue of a faulty kinetic chain handoff (i.e., late tennis backhand where the wrist is forced to do all of the work)?
- Is there an imbalance between flexor and extensor strength at the elbow and wrist joints?
- What creative ways can I think of to strengthen the arms while providing a core challenge that is related to my client’s functional demands (i.e., tennis player with racket and tubing)?
Note: Because function is specific to each individual client, it is more beneficial for this portion of the article to provide a list of questions that, when answered correctly, will provide a road map leading to a great functional program for core, wrist and elbow musculature.
In closing, remember that everyone who comes to you for training has a completely different set of issues you’ll need to address. Inevitably there will come a time where you need to do some thinking on your own. I believe that in order to find the answer to a problem, we must first know the question. In other words, never stop asking yourself "why?"
Photography by Dr. Jeff Goodman and Enza Gitto.
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