Two of the most difficult areas of the body to try and restore stability and function to when injured are the shoulder and the elbow. The shoulder is such an amazing joint in that it has an incredible amount of mobility and is able to perform some incredibly powerful and dynamic movements. But this awesome mobility comes at a cost, as the stability of the shoulder can be very easily compromised. And when this happens is when injury and pain takes over. Funnily enough, the problems seen with the shoulder and elbow are closely related to the same dysfunction and instability being driven by the scapula. Unfortunately, this is an area often missed with typical treatments for the elbow, as people are fixated on trying to remove the pain. Trying to treat the elbow without addressing the underlying cause is pointless, and in this article, I will explain exactly how you can begin correcting your elbow problem at the source instead of treating symptoms.

There are two types of elbow pain and they are often referred to as "tennis elbow" and "golfers elbow". (The official terms are lateral epicondylitis and medial epicondylitis).

It must be pointed out that only 5% of people suffering from tennis elbow or golfers elbow relate the injury to tennis or golf! Almost all of the people I have worked with for this injury over the past 16 years have never played either of these sports in their life!

Most of the treatments for elbow pain focus on treating the area in pain with massage, anti-inflammatory medication, cortisone injections, and lastly surgery. Many people are instructed to wear a strap on the forearm, and it is tightened enough so that when the person contracts their wrist extensor muscles, he or she does not fully contract the muscles. This reduces the muscles from over-working and helps to manage the problem. Notice how I said, “it helps to manage the problem”, it does not solve the problem.

Once again we see most of the treatments for this injury more concerned with trying to remove pain, instead of treating the source of the pain. Instead of asking how to get rid of the pain, I find it is better to ask.

1. Why is the pain there in the first place?
2. Why are the forearm muscles over-working?
3. If there is tightness, there is always a weakness, so where is it?

If we go back to the tennis players it is interesting to note that this injury is prevalent among amateurs, but is almost non-existent among professionals. And what is the biggest difference between amateurs and pros? Technique and movement efficiency. It is nothing to do with the size or strength of their muscles.

It is everything to do with how they move and this gives you clues as to where you need to look for treating and preventing this injury. Poor posture, poor leg drive, lack of core control, hitting the ball too late, and incorrect grips are some of the main reasons behind injuries in these sports. This is the main reason why strength training is critical for these sports, and it would help so many amateur sportspeople enjoy their game and remain injury-free if they were to use a corrective program in combination with playing.

You can read more about the specifics of training for golf and tennis players below.

• Strength training secrets for golf
• Strength training for tennis

While we know this injury is seen in these sports we must remember that they represent only 5% of the population that suffers from elbow pain! In this article, I want to spend time focusing on the people who do not play golf or tennis and explain how you can easily develop this painful problem from poor postural and movement habits.

Elbow & Forearm Problems Are On the Rise & This Is Why

Firstly how prevalent is elbow pain and why do I feel it is on the rise?

This year I have spoken to more people about elbow, wrist, and neck problems than I have in the past 10 years, and this is saying something considering the gym has been closed for almost 7 months! Just this past week alone, which was the first week back in the gym I saw 6 people with shoulder and scapula problems!

Here are some statistics from an interesting study examining the prevalence of neck and upper extremity repetitive stress injury among workers in Lagos, Nigeria. (click here to read the full study).

The chart below shows the twelve-month prevalence of upper extremity RSI. One hundred and forty-one (79%) of the respondents had complaints of musculoskeletal discomfort in at least one of the regions of the upper extremity. Sixty-seven (37.43%) were male respondents and 74 (41.57%) were female respondents, representing 72.8% and 86.2% of the total male and female respondents respectively. One hundred and twenty (67.8%) had complaints during or after work, while fifty-seven (32.2%) did not have any work-related complaints in the past twelve months.

The highest prevalence of upper extremity RSI were found for Neck 119 (66.8%) and shoulder 107 (60.1%), followed by Hand 58 (32.6%), upper arm 57 (32.0%), lower arm 56 (31.5%), wrist 50 (28.1%), and elbow 40 (22.5%).

You might be thinking, "hang on a minute the elbow shows the lowest totals". What you will soon see is that the neck and shoulder problems start first and the elbow eventually follows. It is just a matter of time.

Shoulder, neck, and elbow injuries have been on the rise for some time as more people are working longer and longer hours behind a computer with poor postural habits. This year has seen this problem accelerate at an even faster rate due to Covid-19 lock-downs and people being forced to work at home with makeshift offices and working areas that are far from suitable.

Any small problem with the shoulder and neck has rapidly developed into a big problem and this is something I have covered in great detail in several articles earlier this year (see how to stay healthy when working from home).

Once you add on top of that, the use of poor training techniques, and ignorance to quality movement, chronic pain is the result. And once it sets in it can be very difficult to get rid of.

Another interesting fact is the incidence of these injuries is much higher in females than males. In my two-part series on kyphosis and the dowagers hump I published earlier this year I discussed in great detail why problems with the shoulder were much more prevalent among the female population. This has a lot to do with lack of muscle and strength and the fact that females have a lot more laxity within the joints. With the older adult osteoporosis is something to consider but you must not fall into the trap of thinking younger people are not vulnerable.

If you look at the chart below you will that it is the younger age group of females that show the highest rate of shoulder injuries. This age group would not have had time to develop a dowagers hump or be exposed to muscle loss from sarcopenia as seen with older adults, yet they are the most prevalent age group with shoulder pain.

This is a classic example of weakness and poor movement causing instability and nothing to do with getting old. This age group is also the one most obsessed with mobile phones.

The Scapula Is The Key

Scapula dysfunction is a massive problem for the elbow for when the scapula does not sit or move as it is designed to, the arm bone has little chance of being in the right position to move. If the arm bone rotates inward the forearm will have problems.

These problems have to do with how well the forearm rotates into a hand-down position known as pronation and the hand-up position known as supination. We use these actions all the time in daily life and most people think that these movements are only performed by the forearm itself. Little do they know, that it is the scapula that is driving this compensatory movement.

The winged scapula is something I am seeing all the time lately and this dysfunction causes a stack of trouble with the shoulder and the neck. The term winged scapula gets its name from its appearance, a wing-like resemblance, due to the medial border of the scapula sticking straight out from the back. (See picture below)

Weakness with the serratus anterior and excessive tightness with the rhomboids, levator scapula, and middle traps is evident in these cases. Many people can present with this winging of the scapula and have no pain whatsoever.

But....

It won't take much to bring on pain and it could occur at the shoulder, neck, and of course the elbow!

You can read more about this in the article - Top 5 exercises to correct a winged scapula

The Forearm Is a Slave to the Shoulder

If the upper arm bone (humerus) rotates inward then the forearm will also rotate inwards too much. The muscles responsible for this rotation will as a result end up short and tight from never being used, while the muscles responsible for the opposing action will become lengthened and end up in pain from being overused.

Your forearm should rotate 80-90 degrees in both directions (with palm up or palm down). If your elbow is resting on a table your wrist bones should be able to lie flat. When forearm rotation is compromised is when begin to see elbow pain begins.

The muscles that bend and straighten the wrist have their origins at the elbow. When their function is changed in some way you will create the tennis elbow or golfers elbow. The tennis elbow pain refers to the lateral part of the elbow and the golfers elbow refers to the medial part of the elbow.

This is where many of the treatments try to focus on these areas that are in pain. However, while they may be in pain it is interesting to note where these muscles are located and you will see they are perfectly positioned to prevent rotation of the forearm.

Remember we said that if the arm bone rotates inward too much, then the forearm will have no choice but work over-time to resist this and rotate in the opposite direction for you to complete your daily tasks effectively. This is why we will often say the elbow is the slave to the shoulder.

What causes the shoulder to rotate inwards?

Many things can contribute to this, such as working on computers endlessly, lack of stretching with the pecs and lats, poor thoracic mobility, and poor training techniques with poor postural awareness.

If you play sports then technique in your sport is important and things like leg drive and trunk rotation become very important. This is why it is so important to continually be working on your posture and movement skills. There is too much information on all these topics to include in this article so I suggest reading the following articles listed below that you feel relate to your needs if you want to know more.

Each one of these articles will provide several exercise examples to try to rectify your problem.

• Workstation set up and ergonomics
• Posture correction workout
• Mobility and flexibility
• Why lack of thoracic mobility creates dysfunction to other joints
• Rotational power & leg drive to prevent tennis injuries

Now that we understand the reasons behind elbow pain what can you do about it? As usual, this is a combination of many things and not limited to just one or two exercises. If the scapula is so important it makes sense to start there.

I will go into detail about each part of this process but you can watch the full video below of me going through this below.

Wall Slides & Serratus Anterior 

The secret to restoring scapula function is to teach movement mechanics that force the right muscles to the right job at the right time. This is the purpose of the wall slides exercise and it does an amazing job of restoring these muscles during an overhead movement. Of all the exercises to use for scapula control, the wall slides would be my favourite.

There are 3 key concepts specific to ALL shoulder injuries and dysfunction that must be addressed if you want any chance of succeeding in correcting your problems. These relate to relearning movement patterns that coordinate and sequence ideal and optimal movement mechanics.

These 3 key concepts specific to the shoulder are:

1. Optimal Thoracic extension and mobility
2. Posterior tilt of the scapula
3. Upward rotation of the scapula

The wall slides drill to address the 2nd and 3rd problem very effectively. See the two videos below of two versions I might try.

Using trigger point release for teres major and infraspinatus is also very useful in this stage as these muscles can inhibit the serratus anterior from working. Click here to see the video of the drill I like to use between sets of the wall slides to prevent this from happening.

Once you have established great control of the scapula you can begin improving the strength of the serratus anterior and the use of push-ups, cable push, and various other exercises are excellent for doing this.

You will find this article a great resource for doing this - 10 ways to strengthen serratus anterior

Next thing we still need to address is thoracic mobility, and to do this I will use a series of mobility and trigger point drills before the wall slides. That way I achieve all 3 of the key shoulder concepts I need all at once.

The spine is the structure from which all our limbs are supported. When the main structure has problems, the limbs will be put into positions that expose them to potential strain and injury. Rigidity in the thoracic spine will ruin any attempt you make to improve scapula stability so you must address any dysfunction here.

Once again there is no simple solution here or just one way to do this. Sometimes I will use drills that focus more on extension and other times I will focus more on rotation. It can vary a lot from person to person, so I will use a combination of drills and eventually find the one or two that give the greatest effect and use them ALL THE TIME! Often the person with a winged scapula will find the rotation drills the hardest and you may find they even have an excessive thoracic extension so I will avoid these exercises.

The videos below give you several ideas for improving thoracic mobility.

Now that you have begun working on scapula function, thoracic mobility, and strengthening of serratus anterior you still need to address the problems that exist at the forearm.

Forearm & Elbow Specific Exercises

The compensation caused by the weakness and over-use that was forced upon these small muscles will constantly create pain in the elbow and to correct it you will need some isolated exercises that involve a combination of stretching and strengthening. I have included a shortened video for you to see these exercises in action, which you will see below.

I will always start with the forearm stretching release before attempting to strengthen as tight muscles always dominate over weak ones.

Starting with the simple wall stretch to test extension and flexion is a simple way to see just how tight they are. But the real effect will be to find out how much stiffness you have with pronation or supination of the wrist. To do this stretch effectively you will need a partner to help you and it will look very much like a "Chinese burn" that we used to do as kids in the playground as seen in the screenshot from the video of how to do this below.

It can be a great way to weaken the forearms from overworking and help to position the arm correctly. It is very important that you keep your scapula and posture during this exercise or your body will continue to compensate as I explain in the video a few times. Make sure you only try to rotate the wrist to the point of a nice stretch and not pain.

In addition to the various stretches I use for the forearms I follow up with some strange-looking strengthening exercises that are arguably stretching in their own right. Once again the big problem is with the rotation of the wrist with either pronation or supination. The reason for this in case you forgot is that the forearm is trying to rotate against the inward rotation of the arm bone from poor shoulder stability.

For the next exercise, you will need a hammer! Don't worry you are not going to bash your arm with it but you are going to use it as a small dumbbell. This exercise lengthens the pronators teres and quadratus and the supinators of the forearm as it constantly switches from one side to the next. All these muscles are often the ones causing the elbow pain when they become short and tight.

Once again you must be sure your scapula is set right and the shoulder is stable before starting the movement to avoid the compensation kicking in. Gently rotate your arm and avoid the temptation for the wrist and hand to do the work as this will take some concentration and control.

You will see this exercise at the 3:23 mark of the video above.

The third exercise to do this involves your partner again. This time you will need a stick to complete this exercise and it is a slightly more advanced version of the hammer exercise as it is standing up and more unstable. This also requires some reflex stability to react to the stimulus provided by the partner so it is difficult to remain in control as you were with the previous exercise. This is an important step to make to ensure your body is capable of handling the demands it will face in the "real world".

This should take 15-30 seconds to perform one rotation and your goal is to improve the range of motion without losing control of the scapula and shoulder. In the video below you will see Nathan lose this position as his body tries to compensate around the stick moving.

You will see this exercise at the 4:47 mark of the video above.

Another useful way to strengthen the elbow is via the use of vibration tools, which is found to be a great way to restore the muscle balance around the forearm muscles. In Vladimir Janda's book "Assessment and Treatment of Muscle Imbalance" he made note of several useful tools for doing this being Bodyblade and the Flexbar.

Researchers noted that oscillatory exercises (vibration), activated phasic muscles like the serratus anterior at higher levels than antagonistic tonic muscles. This proved to be a useful addition in the process of trying to restore muscle balance to weakened muscles that were usually inhibited by the overworking tonic muscles.

Do Elbow Braces & Straps Work?

Lastly, the use of elbow braces and taping is a very popular strategy used by therapists to reduce the inflammation and pain in the elbow. These have been shown to reduce the elevated forearm activity during grip testing with patients suffering from tennis elbow and can be an effective way to manage the inflammation until you resolve the underlying cause. On its own these braces will never be the long-term solution to your problem, but if used in combination with the various things listed in this article they can be an invaluable tool to helping you.

Putting It All Together

As you can see the shoulder and elbow can be very difficult to work with as there are so many moving parts and pieces to consider. To give you a template of a workout, for this reason, is impossible as the only way to determine what to do is to assess your body first and let the tests dictate what to do.

Two people with identical symptoms may need completely opposing programs. One may need stacks of mobility where the other may be the strengthening exercises that are of more importance.

To help you out with this process we created a detailed shoulder pain report that provides all the tests and exercises in a step-by-step format so you can finally get rid of your problems for good. To see more about what is included in this detailed report click here and to download instantly click the image below. 

Summary

Even when you do everything we have listed here in this article it will seem like nothing is working for the first few weeks. The compensation will take considerable time to change and for your body to adapt to the changes you are trying to make. You have to remain very patient and consistent with the tedious mobility and stability drills to make any lasting changes. Also avoiding anything that aggravates the problem is very important, and this is another reason why shoulders can be so hard to get on top of quickly.

We constantly keep using our arms to do things like put a t-shirt on or move something in the backyard that stirs up all the existing inflammation. It is so hard to stop using your arm all the time and allow the body to heal itself. The use of computers is a huge problem and spending time to address your ergonomic set-up is vital.

And if you are lucky enough that you do not have elbow pain, all the things we have discussed in this article are good to do so you NEVER get it. For trusting me when I say this is a condition you do not want for it is so hard to get rid of once it sets its hooks into you.

For more ideas and information on specific topics I may not have covered in detail be sure to check out our INDEX PAGE on the website that has over 300 of our best articles. These are all sorted into categories for quick reference so you can find what you are after more easily. You can also subscribe to our FREE fortnightly newsletter by clicking here.

If you do need specific help with your exercise program please feel free to reach out to me for help and we can set you up with your individualised program.

About The Author

Nick Jack is owner of No Regrets Personal Training and has over 15 years’ experience as a qualified Personal Trainer, Level 2 Rehabilitation trainer, CHEK practitioner, and Level 2 Sports conditioning Coach. Based in Melbourne Australia he specialises in providing solutions to injury and health problems for people of all ages using the latest methods of assessing movement and corrective exercise. He has worked with professional athletes in Golf, Tennis, Basketball and Football but is known throughout the local community more for his work with injury prevention and rehabilitation.  Having participated at high level in many sports himself and also recovering from several serious injuries he has spent considerable time developing detailed assessments and programs to cater for injury and pain.

References

• Movement - By Gray Cook
• Shoulder & Scapula Injuries in Athletes - By Chris Mallac
• Corrective Exercise Solutions for the Hip & Shoulder - by Evan Osar
• Diagnosis & Treatment Of Movement Impairment Syndromes - By Shirley Sahrman
• Fixing Shoulder & Elbow Pain - By Rick Olderman
• Low Back Disorders - by Stuart McGill
• Back Pain Mechanic – by Stuart McGill
• Anatomy Trains - by Thomas Meyers
• Motor Learning and Performance - By Richard A Schmidt and Timothy D Lee
• Assessment & Treatment Of Muscle Imbalance - By Vladimir Janda
• Scientific Core Conditioning Correspondence Course - By Paul Chek
• Scientific Back Training – By Paul Chek