*Please note that this piece of writing is not to serve as a diagnostic tool for your specific physical complaints. If you have pain or symptoms you wish to have corrected, please contact a trusted healthcare professional*
Why you should work out with a physical therapist:
Body wisdom and knowledge of pathology - snapping triceps syndrome
Physical therapists have extensive knowledge of human anatomy and movement science. In fact, those basics make up the majority of the profession’s academic curriculum. Exercise is our modality of choice when assisting people with pain, impairment, dysfuction, and/or fitness/wellness needs. As expects of anatomy, movement, and exercise with longer times spent with our patients and clients (appointments are often 45 to 90 min per treatment), we, as physical therapists, recognize what others in the healthcare and fitness industries might miss.
As an exercise advocate, yoga instructor, and fitness junky, I have visited many gyms, trialing innumerable class types, meeting instructors, and experiencing and witnessing many dynamics and interactions (environment + exercise + client + instructor). It is common for trainers to push their clients, with the idea of greater strength gains (or weight loss or whatever the goal might be) are enhanced with high intensity exercise. At the same time, however, I see clients sacrifice postural integrity and inherent body wisdom (i.e. something doesn’t feel right, but the client does it anyway thinking they are ‘pushing’ themselves). How well do trainers recognize when a "push" is appropriate? - if a popping sound, fatigue, or soreness is normal or abnormal?
An example of this would be snapping triceps syndrome and ulnar nerve dislocation. I have these physical issues myself and modify my form during exercise. In classes, trainers often try to “correct” me; I educate them after class to explain why I modify like I do. I have not yet met a trainer that has familiarity with ulnar nerve dislocation or snapping triceps syndrome.
The ulnar nerve runs from the lower neck -> brachial plexus -> back posterior upper arm/triceps region -> cubital tunnel of the elbow -> lateral forearm -> Guyon’s tunnel (or canal) of the wrist. The ulnar nerve is superficial in the cubital tunnel (medial posterior elbow), making it easy to both palpate and irritate. When you bump your “funny bone”, this is the nerve that you hit, reproducing that dull, tooth-like ache. The ulnar nerve can impede function when neural tension exists somewhere along its path (neck down to the wrist), causing paresthesia (typically in the medial palm and fingers), pain at neck, elbow, and/or hand, tightness along the neural pathway, and even muscle weakness longer term (usually noted in grip differences). Pain might be deferred for a few hours or until the following day, making aggravating movements and involved structures difficult to isolate as the source of pain. The nerve can also create dysfunction when the cubital tunnel of the elbow is shallow or the retinaculum that holds the nerve in place is lax or insufficient, allowing the nerve to dislocate (also referred to as luxtion or subluxation) during movement. The dislocation of the nerve typically occurs at 70-90 degrees of flexion, can be palpated, and is not uncommon (approx. 16% of the population https://www.ncbi.nlm.nih.gov/pubmed/1139823/). Depending on pain, level of inflammation (ie ulnar neuritis) and functional impairment, formal rehabilitation may be necessary or surgical movement (i.e. transposition) of the nerve or nearby structures can relieve symptoms.
Snapping triceps syndrome is rare and has to do with the shape of the medial triceps insertion; others consider snapping triceps to result from differences in elbow alignment and the shape of distal musculature. There is a palpable ‘snap’ at approx. 115 deg elbow flexion (after the ulnar nerve displacement at 70-90 deg) (Vanhees et al. 2010 https://onlinelibrary.wiley.com/doi/full/10.1111/j.1758-5740.2009.00033.x ). Movements that can recreate these snaps, both ulnar nerve and triceps, include push ups, overhead work, skull crushers, and lowering into yoga’s chaturanga. The snap can be annoying to painful (at the elbow and radiating immediately or later into the pinkie/ring fingers), depending on inflammation present in triceps, ulnar nerve, and surrounding ligaments.
There are many ways these symptoms can be managed and minimized, including self-treatment such as wearing an elbow compression sleeve to limit movement of the ulnar nerve to modifying your range of motion in aggravating movements, such as staying away from/shy of recreating the distinguishing snaps (ex. not doing a full range push up). These self-treatment ideas are intuitive and relate to body wisdom that most people possess. If something doesn’t feel right, recreates pain, or some other issue, don’t do it, regardless of what your trainer recommends (remember that depending on your trainer, they might not have the anatomical knowledge to know when to modify a movement or to “push” you). Doing full range push-ups with snapping triceps or ulnar nerve dislocation can lead to pain, ulnar neuritis, or worse. If symptoms don’t improve with changes in movement, worsen, or cause significant impairment, a full examination by a movement professional (physical therapist) is recommended to isolate the source of your impairment (ex. with the ulnar nerve – is it actually dislocating out of the cubital tunnel or are your symptoms from somewhere else along the nerve’s pathway? Or related to another structure entirely?)
Exercise is medicine, and form is extremely important in managing musculoskeletal and neuromuscular symptoms and systems. Physical therapists can help you maximize your exercise potential, if that is a goal of yours, while accommodating the unique anatomical needs of your body.
For more information or to workout with me, email me, Dr. Allison Mitch, PT (DPT) at firstname.lastname@example.org
*Please do not copy this material. All writing is copyright protected*
Resources and additional reading on elbow pathology (UCL, ulnar nerve, snapping triceps, overhead athletes, etc)