Beautiful Becca ‘Boarding’

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Eagerly anticipating next season?

Winter is here for sure. Perhaps you’re being asked what you’d like for Christmas? Maybe you feel a hint of optimism with news of the roll out of a vaccine. Wake-boarders, wake-skaters, wake -surfers, wake-foilers and water skiers might be eagerly anticipating an early start to next season to make up for lost time.

Whether you’re investing in a gorgeous new board, a new impact vest or a beautiful new super-soft wetsuit. Loch Lomond Wakeboard are worth checking out for all sorts of fun activities and equipment items.

Whatever your ‘Wake-ing’ dream is for next season. New equipment? New wetsuit? More time spent on the Loch? Trying out a new activity? …

…nobody wants it ruined by elbow ‘Wake-Ache’

More commonly known as ‘golfer’s elbow’, medial epicondylitis (ep-ih’-con-dil-i’-tis) affects people who repeatedly apply a grip during their activity. Loads of people get it whether or not they play golf. Wake based activities are prime contributors to this elbow pain.

Let’s ditch the golfer’s elbow name and simply call it ‘wake-ache’. Repeatedly gripping a handle under tension can lead to your elbow causing you excruciating pain. It can affect either of your arms because wake-boarding can involve the tension being put on either.

What is it?

It’s a painful condition of the elbow, particularly the knobbly bit nearest to your body if you were standing with your arms close to your side. Elbows bent and palms facing upwards.  Roughly the point on the inside of your elbow that’s about level with the lowest rib you can feel.

The medical name of medial epicondylitis is given because it affects the medial epicondyle of the humerus bone. Each humerus (upper arm bone) has 2 condyles and 2 epicondyles- ‘Condyles’ are the knobbly bony bits at the elbow joint end. The ‘epicondyles’ are the outer sides of these knobbly condyles.

Medial Epicondylitis

A condition that ends in an ‘itis’ means there is inflammation of some sort. ‘Epicondylitis’ means that there is inflammation of the tendon attaching the muscle to the epicondyle. However, research has shown that contrary to previous thinking, inflammation is generally not a component of many hand and wrist conditions such as lateral (tennis elbow) and medial epicondylitis (golfers’ elbow) (Fairweather & Mari , 2005). In actual fact, a more correct term would be epicondyl-‘osis’ (‘osis’ meaning disease or pathological process, or a non-inflammatory process, generally suggesting degeneration of the tendon due to overuse/repetitive action).

It’s caused by irritation of the common flexor tendon at the medial epicondyle of the humerus. It could also be the result of factors such as injury, direct trauma, ageing/ degenerative change, overuse or joint disease. The flexor muscles of the forearm are the ones that are involved in bending the wrist in such a way that the palm of the hand and fingers come up towards the inside soft bit of the arm. These flexor muscles join together to form a common flexor tendon and this attaches to the medial epicondyle. it’s is the irritation to that tendon that causes the pain on the inside of the elbow.

Who gets it?

Anyone can get it from repeated gripping actions such as mountain biking or even opening a jar.

With wake sports, gripping a handle under tension is involved, and possibly some jarring or snapping of the rope. This puts the common flexor tendon at risk of injury or overuse. It’s hard not to want to push through the pain when it’s a short season like we have in Scotland, however repeated overuse can lead to much more pain in the long run.

Signs and Symptoms

The main symptoms are tenderness and discomfort on the inside of the elbow, with pain that gets worse with movement or during a full stretch. Sometimes, but not always, there is swelling at the area too. You might feel weakness and the ability to grip fully due to the pain.

Healing time

It takes patience!

Average healing time for tendinitis ranges from a few days to 6 weeks and for tendinosis between 3 and 6 months because degenerated tendons take over 100 days to produce new collagen. (Khan et al 2000). Causes

Irritation

There a lovely quote on the subject of irritation by Harry Emerson Fosdick

“The most extraordinary thing about the oyster is this. Irritation gets into his shell. He does not like them. But when he cannot get rid of them he uses the irritation to do the loveliest thing an oyster ever has the chance to do. If there are irritations in our lives today, there is only one prescription: make a pearl. It may have to be a pearl of patience, but…make a pearl.

However, there is nothing lovely like a pearl produced here. Wake ache is a very painful and debilitation condition and without proper intervention it can seriously impact on normal day to day activities as simple as opening a jar, gripping a handle, holding the steering wheel or bicycle handlebars, or wringing out a cloth.

While it might get you off doing the housework or the dishes for a while, you’re going to want it sorted so you can get back out on the water.

What’s affected?

Muscles, tendons, ligaments, bones, joints, fascia, skin……and, importantly, mood!

While it presents as a physical condition if long term pain is involved or there is restriction of activities or a sport that is enjoyed, then mood will very likely and very understandably be affected too

Massage Therapy to treat elbow ‘wake-ache’

First of all, a full consultation with the client takes place. Assessment of range of active, passive and resisted movement will be carried out to ascertain where there is pain and/or restricted range of movement. In addition to the affected joint, the joints above and below are assessed.

Range of Movement and level of pain are ideal for assessing progress however it’s very useful for the client to tell the therapist what normal day to day activities are affected – for example –  ‘ I can’t grip the rope handle without pain’ or putting on my wetsuit hurts my elbow’. These are good measures for assessing progress in a meaningful way.

Treatment Plan

An important stage in rehabilitation is for the client and therapist to discuss and agree a treatment plan and timescale and to confirm what good progress or a target would look like – for example, in 6 weeks to be riding the wake with less pain.

Goals need to be realistic, measurable and achievable. If a condition has been present for 2 years, it’s probably not going to be fully resolved in 2 treatments. Additionally, clients need to be totally honest in regards to the exercise and rest regime they can invest in their rehabilitation. With best intentions, they may think they can do the required rehab but life takes over sometimes.

Rome wasn’t built in a day.

Techniques applied

Massage treatment could include the use of heat to help release muscles before fascial and trigger point work. The fascia is the outer sheath that surrounds the muscles and trigger points are areas within the muscle that are normally characterised by the fact they refer pain to another part of the body.

Medical Acupuncture (Dry Needling) hot stones or warm bamboo sticks could also be used during treatment.

Fascial work such as cross hand strokes to put the tissue on a stretch could be used as could myofascial spreading, traction, soft tissue technique (pin and stretch), trigger point therapy, deep tissue massage, cross fibre friction and muscle energy techniques. The use of cold therapy could be soothing at the point of insertion of the tendon onto the epicondyle.

There are a lot of valuable tools in the massage therapist’s bag and it depends on each unique situation as to what techniques are most appropriate.

The areas of the body being treated

The body is complicated. Muscles and structures don’t work in isolation so they have an effect on other parts of the body. A client might wonder why for a sore arm, the therapist is treating their neck. It’s  is up to the therapist to explain to the client why the other areas are important in the treatment (a lot of arm pain actually comes from the neck). Pain and tension in one area can cause pain and tension in other areas.

In the case of elbow wake-ache, treatment would include the forearm flexors and extensors, the hand and fingers, the muscles of the upper arm and the muscles responsible for turning the arm – palm up/ palm down. It may also very likely include treatment of the shoulder area, upper back, pec muscles and neck muscles. Even if the other arm was showing no pain, it may also be treated if appropriate.

Re-assessment

Following treatment and reassessment of the Range of Movement and level of discomfort, the therapist and the client should agree a treatment plan which would include follow up visits but may also include some exercises or self-care for the client to do before returning.

Self care

Rest is vital in recovery. This is not what the enthusiastic wakeboarder/ surfer/ skater/ water-skier wants to hear. Mood can be negatively affected when activity is curtailed. It’s perhaps a time to think about doing an alternative exercise temporarily during the rehab phase to alleviate boredom and maintain fitness. This could include activities which either have no impact on the forearm or can be adapted to avoid or lessen strain such as switching temporarily from wakeboarding to wake-surfing where there is less time spent actually holding the rope handle, open water swimming or possibly looking at stretching classes such as Pilates or yoga.

‘Look…No hands!’

Relaxation is fundamental in promoting a feeling of wellbeing and allowing the body to recover. A holistic approach incorporation soothing massage techniques into a remedial massage treatment is also helpful.

Use of warmth

A warmed pad or warm hot water bottle wrapped in a soft towel can be soothing. Gentle pin and stretch techniques applied by the client to their own arm after demonstration by the therapist can be useful if done properly.

If you’re fed up being unable to grip the rope handle and are suffering from elbow ‘wake ache’, Massage Therapy may help to alleviate discomfort and get you back out on the water when the time comes.

In the meantime, use this time out to rest and recover.

Resources

Jing Advanced Massage Training in Brighton have produced some helpful self-care resources which can be downloaded

Helpful visualisations for pain relief (something to try if you’re lying awake in pain and the rest of the world seems to be sleeping)

Catastrophising (avoiding the ‘I’ll never ride again again’ mind-set)

References

Fairweather, R., & Mari, M. S. (2005). Massage Fusion: The Jing Method for the Treatment of Chronic Pain. Edinburgh: Handspring.

Finando, D., & Finando, S. (2005). Trigger Point Therapy for Myofascial Pain. Vermont: Healing Arts Press

Salvo, S.G. (2018). Mosby’s Pathology for Massage Therapists 4^th Edition. St Louis, Missouri: Elsevier Inc