The Elbow Episode
In this episode of the Unreal Results podcast, I explore the various challenges of treating elbow pain, using a specific case study with one of my throwing athletes. As always, I emphasize using a holistic assessment that considers visceral and central nervous system influences rather than just focusing solely on any dysfunction located at the elbow joint. I firmly believe by using this approach you will have more effective and lasting results by aligning treatment with the body's protective patterns and shifting patients into a parasympathetic state.
Resources Mentioned In This Episode:
Episode 16: Why The Shoulder Comes Last
Considering the viscera as a source of musculoskeletal pain and dysfunction is a great way to ensure a more true whole-body approach to care, however, it can be a bit overwhelming on where to start, which is exactly why I created the Visceral Referral Cheat Sheet. This FREE download will help you to learn the most common visceral referral patterns affecting the musculoskeletal system. Download it at www.unrealresultspod.com
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Anna Hartman: Hey there, and welcome. I'm Anna Hartman, and this is Unreal Results, a podcast where I help you get better outcomes and gain the confidence that you can help anyone, even the most complex cases. Join me as I teach about the influence of the visceral organs and the nervous system on movement, pain, and injuries, all while shifting the paradigm of what whole body assessment and treatment really looks like.
I'm glad you're here. Let's dive in.
Hi, hi, welcome to another episode of the Unreal Results podcast. Here we are again, same background, same shirt, because it's the same day. The last podcast was pretty quick, so I'm going to go ahead and record another one. Um, what a different life it is having someone help you edit. You can just record more and not have so much work to do.
So shout out, Joe. Thank you for your help. Um, what I want to talk about today, I want to talk about the elbow. Um, elbow is a unique, unique joint, uh, in, in my world. Um, obviously I have athletes that use their elbow and have elbow pain and have elbow issues, elbow injuries. And so it does come up, but I want to talk about how I would treat it.
I, I, I touched on it a little bit on the podcast episode. Why you never, why the, why the shoulder comes last is the name of it. I'll link it in the show notes because the upper extremity in general always comes last, meaning that when it comes to treatment, there is almost always a visceral referral or central nervous system referral driving some of the dysfunction, driving.
Some of the pain and so you want to make sure you really identify what that is before you just drive dive into treatment in that joint. So specifically here talking about the elbow, like somebody like today, someone came to me with elbow pain, a thrower, um, and. Even though the elbow felt like orthopedically, like, dang, things are like jammed up in here.
I want to get in there. I know I want to do some manual therapy. I know that like something doesn't feel right with the joints, but you gotta be patient and sort of let the body take you there because when you let the body take you there, then it becomes way easier to treat. The elbow can be very challenging to treat from a manual step, manual therapy standpoint.
And so you want to set yourself up in a. in a position or set yourself up for success. And the way you're going to have success with the elbow is unlayering all the other stuff that, that got it there in the first place. So, um, the interest that one of the interesting things about the elbow is even though we have some very strong visceral referrals to the shoulder, And to the hand, there's actually no true visceral referral to the elbow joint.
So the elbow joint is sort of at the mercy of everybody else, which, um, makes sense given where it is anatomically, right? It's in the middle. So it kind of makes sense that it's sort of at mercy of the hand and wrist and the Um, but there's no direct referral pattern to the elbow, meaning, for example, when somebody tells me they have shoulder pain, I instantly think liver, gallbladder, or lungs, like it's one of those, usually always the liver, especially if it's the right shoulder.
If someone's telling me they have hand or wrist pain, I'm thinking thoracic organs, but also still could be. liver, hand, I mean, sorry, liver or like upper abdominal organs, but most of the time if it's hand, it's thoracic organs. And, um, The elbow though, there's not like necessarily one specific organ. If I, if I were to base it, this is, this, so, so those last ones, the shoulder and the hand things, not only are those the world according to Anna and what she's experienced, but that's the world according to the Barral Institute.
That's what I learned within the Barral Institute and since I've been practicing their work, it's pretty much consistently what I've seen in my patients. Now, the elbow consistently what I've seen in my patients is that there is always a neural component to it and there's usually always an underlying central nervous system component to it.
Sometimes there's a visceral piece, sometimes it's just straight up central nervous system. In the case today, the athlete I worked with today, it was straight up central nervous system. So, um, that's, that's where we had to start. The only way I knew that I had to start there is that I used the LTAP and it directed me there.
But in absence of having the LTAP, I would, if it's an elbow, I would always start at the nervous system, ideally the central nervous system, and then kind of work your way through the periphery. Um, but, so, you know, given, given the person and the situation, that means you might be doing work on their cervical spine, you might be doing work on their brachial plexus, you might be working on different fascial containers between their neck and their armpit, you might be doing something in their cranium and their jaw, like in their sacrum and tailbone, like Anywhere along the spine could have created some sort of nervous system tension that results in things being out of balance around the elbow and either creating elbow pain or creating a mechanical structural sort of joint incongruency that is then leading to the pain.
For what it's worth, for what it's worth, the patient I saw today, she didn't actually have any pain. She just felt like she couldn't get her elbow all the way extended in her throwing position. And it was messing up her throwing mechanic enough that she was getting frustrated and like, you know, was like talking to her coach being like, I don't understand what I can't get there.
She tried all these manual therapy things on herself. And it was like, I'm missing something. I need to see somebody. So, um, not necessarily any pain, but she was like, her carrying angle was really off and she couldn't get in a position to throw the javelin well. And, um, what it was changing as a, her whole mechanic through her shoulder, her trunk and her hip.
And so being a professional, she just knew like, this is not right. This is off. I love that she stopped herself and it was investigating how to fix this elbow piece of it because the throw she showed me, had she continued to throw on that like that, she probably would end up with a shoulder problem, to be honest, or even like an oblique strain.
Um, so I'm, I'm glad that I saw her, but, um, so her elbow presented as a very large carrying angle and then could not reach full extension and it almost gave the appearance and the feeling like she had some sort of like loose body, um, with a hard end feel into elbow extension and our electron process.
But luckily this is where like having experience is helpful. I've felt many baseball players with actual loose bodies, bone spurs. in their olecranon fossa around their olecranon process. And I, so I knew with my own hands when I felt that on her and I'm like, it does have that jammed up feeling, but it's not bone spur and it's not loose bodies.
Like I felt that before this feels different. It just feels like it almost to me just felt like the. The ulna was just like slightly off kilter, like not congruent with the humerus. And so it couldn't actually like lock into the olecranon fossa. And then with that said, when I was checking supination and pronation, she was very limited in supination, but it felt like she was very limited in supination because of like the positioning of the radius.
And so It's, I always think like, well, what would I do if I didn't have this lens of view where I know I can't just start at the elbow and then, um, it's always interesting to see how, as you peel back the layers, how it changes. So when I treat it, you know, her body directed me to her central nervous system, I treat it up in her cranium and then.
down between her cranium and her sacrum and then we rechecked things and then it was apparent, more apparent, I was able to finally get a more true upper And limb neural tension test on her and she did have some nerve tension there. So then I was able to follow that nerve route and find that she had, um, some real tightness in her clavicular pectoral fascia underneath her collarbone and then, um, around the spiral groove that the radial nerve goes through.
And so I did treatment all in those areas and then when I rechecked her. Elbow her carrying angle had already decreased her extension was almost full without that hard blocking feeling at the olecranon anymore and we were just kind of left over with Still a little bit of more of a carry angle than the other side and some real tension into supination and so Traditional sports medicine would have me stretching the crap out of like stretching supination and extension, just like stretching it or doing a ton of like deep tissue around that area.
My lens of view is like, no, I'm going to do this like skin lift technique around where the radius or sorry, the radial nerve. goes, and then I'm going to, um, instead of stretching or manual therapy or mobilizing her elbow in the direction that the direct, like, stretch direction, the direction that she's limited, right, instead of focusing on extension and focusing on supination, I'm going to focus on pronation.
inflection and freeing up then inflection, pronation, and supination. And as I did that, and as I loaded the, the other opposite is traditionally when you do joint MOBS in traditional sports medicine, you do distraction of the joint. In an osteopathic standpoint, you tend to move into compression a little bit more of the joint.
And so as I did that, pretty soon her The, the tightness that I was feeling in her brachial radialis, which was clearly messing up the radius, but then increasing that carry angle, it slowly started to let go. And that's when I also just felt this whole like fascial line all the way back up to that clavicular pectoral fascia.
And so we just sort of like met the body where it was at and just like stretched it already in the direction that. She could go through an ease right remember she was very limited in supination not pronation pronation was good But pronation was the best way I could get to actually then stretch the brachioradialis out so we did that and That cleared up a lot of the extension and improve the carry angle.
But then I was like, okay, now I feel like it's just truly more lacking supination from maybe the flexor bundle. So I did a little light cupping around the medial epicondyle. And then I went into flexion and I loaded the ulna in towards proximal, towards the elbow, inflection, and then compress the ulna and the radius together.
And then as I was there, the whole, like, forearms sort of shifted, I gotta think, yep, it shifted laterally, and I just kind of followed it. So that's a technique called induction. You load the tissues, and then as the tissues, you respond, you follow them where they're going. So it was this big feeling of, um.
Translation. So, the, the majority of the forum was translating laterally, but that means the lacrinon was going medially, if that makes sense, and I just did that and followed it, and then just kept rechecking flexion and supination, flexion, and pronation, and really clearing that up in sort of any way it went easy, I would just follow it there and then recheck the resistance.
And the more I followed into the direction of ease, the less resistance she was showing me in the other direction. And then finally, like, extended all the way, never. And I felt like, Oh, finally that olecranon feels like it's like sinking into the fossa, locking out and no more tension. And I was like, okay, I think that's it.
And then she got off the table and checked her position. And she was like, Oh, that feels like my normal arm again. That feels like my normal arm slot position for my throw. And she's like, I feel so much more expansive. Throughout her side and across her trunk, and it was just like really cool to see so Yeah, it was a cool case, but I think it was just like again a reminder that the elbow Can be tricky, but it's especially tricky when you're starting at the elbow so the key is to The key is to feel it, not feel it, the key is to search and, and figure out, is it a visceral thing or a central nervous system or peripheral nervous system thing, and treat those things first, and then keep checking in with the orthopedics of the elbow and see if it's changing, but once you get Once you treat the other stuff, it usually makes the elbow part to go pretty quickly.
Um, the other sort of indication, like when I was speaking to her about like what she was feeling in her body, um, and how I knew it was neural, uh, before I even really assessed her to figure out where the body was, uh, taking me is she just felt like in general, her, her arm was like a lot, her like movement was a lot slower.
Like it felt like, um, felt like she couldn't get the speed on it. So sometimes my baseball players will say that they're, uh, it feels like they have a dead arm. Um, Another term people will use is they'll feel like their limb is heavy. I tend to get the heavy word usually with the lower extremity. So usually with the upper extremity it is like dead arm or slow, like, it doesn't feel as fast.
So that's what she was saying too. And so what happens is when we do have some sort of nerve tension, in our nervous system, our central nervous system, or our peripheral nervous system. The limbs especially will resist full ranges of motion because it is It's like the body is afraid to overstretch the nerve and damage the nerve.
So the muscles neurologically stiffen up to prevent it. And so what that feels like is this like heaviness or this like resistance that you're moving through. And. Those are some key words that I hear sometimes when people are describing what they're feeling that starts to make me think, Hmm, this might be nerve.
Versus there's something wrong with the muscle or there's something wrong with the joint. So that was sort of like a little like tell that she had too that I was like, oh, yeah. I think this is gonna be a nervous system. Even though when I tested her ulnar, her upper nerve, Limb tension test. I couldn't actually get a good test.
I couldn't get a good test because the congruency of her elbow was off so much like I couldn't actually get to the spot where I was like testing the nerves and Had a different I didn't feel the nerve resistance. I didn't feel the muscle resistance. I just couldn't get past this like structural thing in her elbow, which in that moment, I could have easily been like, Oh, your elbow's jacked up.
Let's just do a bunch of men meal, you know, therapy and mobilizations around it. It was true, right? Her elbow. joint congruency was off, but it was getting pulled off by just different muscular tensions because of this protective pattern. So you have to sometimes be patient and realize when an assessment test that you're using is not a good test because of the situation, which is nice then to have other tests that are going to give you similar information.
So I didn't have to only rely on the upper nerve. upper limb neural tension test, because the LTAP has a way of telling me if there's a central nervous system or peripheral nervous system tension as well. And so I was able to quickly differentiate that it was central nervous system, treat the central nervous system.
And then when I Once I treated the central nervous system, then when I went to retest the orthopedics, which I include the ulnar nerve tension test as an orthopedic test, I was like, okay, there's the peripheral nerve entrapment piece too. That was there. I thought it would be there based on her story, based on her subjective information.
But I couldn't, I didn't have a good test for it. It was a faulty test because of the elbow joint. You know, this is why it's valuable to have multiple ways to test out things in the body, and especially something like the LTAP that, um, can direct you sort of where to start first. So you don't get distracted by incongruent elbow joint mechanics.
Um, man, when I was talking through that, I, that was like, I have one more thing to say about this. That's really profound. And I totally lost it. So, I think that's it. A real quick, another quick 20 minute episode, but like, fun case and just a reminder that elbows don't have a visceral referral, like a specific pain referral, but are very much at the mercy of the viscera and the central nervous system and the peripheral nervous system.
So if you have elbow pain, if you have elbow problems, elbow joint incongruencies, right? Like some jammed up elbow joints. Don't just hover, like don't just get like blinders on and focus on the elbow. Like take a step back, take a moment to see. Oh, I remembered I was going to say, take a moment to see where the body is directing you and go from there.
The thing I remembered is one of the cool things, not just her in this case, but in general using the LTAP is when you, you know, the whole point of the LTAP is listening to the body. So the body can direct you. where to do treatment. Typically, that is where the body is protecting the most important thing.
It is typically locating the protection pattern. And when you can locate the protection pattern, you can figure out what the body's protecting and treat that. You instantly take them out of a sympathetic Threat protection pattern and instantly move them into a parasympathetic rest, relaxation and recovery.
And that is exactly what she felt in her body and what I witnessed with her on the table. As soon as I treated that central nervous system piece, she got real sleepy. And she said, Oh, I'm sorry, I'm yawning. All of a sudden, I got really tired. It's not you. I'm sorry. I didn't realize I was so tired. And I just laughed.
I was like, no, it actually is me. Um, it's you and me. Like, it's the treatment. I, I was like, this is great. I love that you are yawning. Like, uh, there was a lot of deep breath. There was a lot of yawning and this is her nervous system like resetting itself and shifting into that parasympathetic state. And the more she did that, every time I would recheck her elbow, the better the mobility was.
And this is just, again, the indication That I did a good job of figuring out where the body was protecting and shifting her in that nervous system state means that then the last little bit of manual therapy I did do on the elbow joint, she is more than likely going to keep that new range of motion because we, we, Improved it.
We got it there in a relaxed, relaxed, restful state. And that is so important. And that's actually why it's so, one of the reasons why it's so important to have something like the LTAP to figure out where the body is protecting, because it fundamentally changes the nervous system into a more self healing, healing, recovery, restoration mode, which is why the results are better and why Treatments stick and You don't have to repeat treatments All the time.
So. That was the other really cool part of her case I think is like, again, worthwhile. If you find yourself forcing things, If you're starting to feel a lot of tension in your body when you're working on someone. We Probably because you're being met with tension from theirs because you're trying to force something because you're trying to do treatment not where the body actually wants you to do treatment away from the area that the body thinks is most important that it's protecting and So we want to figure out where that is and treat there And so it's a constant dance of working with the body right working with the body not on the body There is a very distinct difference between the two So hopefully this episode was helpful for you, insightful.
Next time you have an elbow thing come up in your clinic or your athletic training room, look elsewhere and see what happens. Have a great day.