Shooter’s elbow is a bit of a made up term. If it hurts on the outside of your elbow, then it’s the same as tennis elbow (lateral epicondylitis) and if it hurts on the inside of your elbow it’s golfers elbow (medial epicondylitis). I don’t know if any of my friends play tennis, and only a few of them golf; but as a competitive pistol shooter most of my friends shoot, and a lot of them get tendinitis of either their wrist flexors or extensors. So I think the term “shooter’s elbow” works just fine.
Before I go further I want to give Steve Anderson of AndersonShooting.com credit for making this blog happen. A while back I was listening to his podcast and he was talking about his elbow pain and all the advice and treatments he was getting. I thought not only is this something I could help him with, but it’s something I could help him with over the phone. So I contacted him, told him I was a shooter myself (12th at Nationals even), a physical therapist, and more importantly Rob Leatham’s physical therapist. So Steve tried out some home exercises I recommended, said they worked great, and he was kind enough to talk about how well they worked in his podcast. He later messaged me saying people had been contacting him about what to do but said he didn’t want to give away my secrets. I told him no worries, I’ll give them away. Hence this blog.
Shooter’s elbow is tendinitis, however even that name is contentious. The “itis” in tendinitis implies inflammation which biopsies reveal is NOT present. This makes tendinitis a misnomer. More modern terms are tendinosis and tendinopathy. I have actually heard people refer to tennis elbow as lateral epicondylopathy, but correct or not “epicondylopathy” is a ridiculous word and I’m not going to use it. As for the rest of those names, I use them interchangeably and I lament having to waste yet another paragraph on semantics trying to avoid sounding either like an elitist or an uneducated fool. Since the vast majority of the people I know who get tendinitis of the elbow are pistol shooters, this blog is for them. However Rob Leatham told me his elbow got sore from breaking the action open on his sporting clays shotgun, so the condition is not only limited to pistol shooters. Tennis players, golfers, and people who get the condition for no apparent reason at all can still learn a lot from this blog as the principles and techniques of treatment are identical as I draw upon tendinitis research from all sports.
Where to start… I’ve written a fair amount on tendinitis before, and I think I have posted links to my 2006 paper on the brianenos.com forums on how I treated tendinitis some years back. Since then, there has been more research that has led me to change my treatment protocol, as well as how I like to track my research. Papers become dated so I started cataloging research which I made public in a table on my older website. I was able to save the table which I still really like, but it doesn’t work so well with my newer WordPress site so I have not been able to update it since 2011. In the meantime I’ll have to be content with this blog.
Before going further it’s worth noting that shooter’s elbow is a self-limiting condition. That means if you do absolutely nothing at all, it will eventually go away. The problem is it often takes as long as 18 months to just go away, and often goes away for no apparent reason. So, anyone who suffers from shooter’s elbow will swear by whatever they did (or didn’t do) when they got relief, regardless of if it helped or not. The good news is that almost nothing you can do will make it worse except let your doctor give you a cortisone shot. People like cortisone shots because they do make the pain go away in the short-term, and if you are lucky it stays away. However in the mid- and long-term, people who have cortisone shots often relapse, shown by this study where a group of people who have cortisone are consistently worse off than if they did nothing. So my first bit of advice for shooters elbow is DON’T GET A CORTISONE SHOT, EVER! If it hurts, think of it more as an annoyance rather than a debilitation. If you do your exercises properly it won’t hurt very much, for long anyway.
So what has changed since my 2006 paper? One thing that changed was in 2010 I got medial epicondylitis in both my elbows. I had a motorcycle crash in 2010, straining ligaments in both wrists in the process. The ligament strain took about 8 months to heal but I could still shoot just fine, so long as I taped both wrists. However due to the wrist strain I wasn’t doing any weight training. My elbows were fine at first but after several months of shooting high volumes, the continued gripping and shock absorption gradually got to both arms. I felt it coming on, but at first there was little I could do about it; the wrist curl exercises I liked were too much for my wrists. Finally the wrists healed but by then my tendinitis was severe. I could finally start my standard eccentric exercises but they didn’t work as well as they did back when I was a golfer. I took short times off from shooting and finally a month off, only to have it feel worse when I returned. Finally I just thought screw it, kept shooting, started lifting weights regular, and as my strength increased it felt a lot better. So that’s part of my advice now: just keep shooting and don’t think of it as a big deal because resting it doesn’t help anyway.
My experience of not resting turns out to have been backed up by research as I later came across this study that found taking time off from your sport does nothing to help recovery. So, you may as well continue to train. My personal experience is that every time I took a few days off from shooting and came back to it I would feel some increase in pain (and this happened with my USPSA pistol, my sporting clays shotgun, my air rifle and air pistol). Each one had somewhat different muscle actions or stressed the elbow from a slightly different angle. I took great notes at this time and found that if I missed several days of pistol shooting (live fire or dry fire) and came back to it, it would hurt more. However, after shooting 2-3 days in a row it would be pain free. If I transitioned to another type of firearm, it would hurt again. So while it’s anecdotal, I tell all my shooting friends and patients with tendinitis to continue to handle their gun either in live fire or dry fire at least 10-15 minutes daily just to keep the tendons used to the stress.
In my earlier paper I cited studies saying eccentric exercise worked but concentric did not. However a newer paper found that regular (concentric and eccentric) heavy lifting did more to improve recovery from tendinitis than did eccentric only exercise. This is advantageous for a number of reasons. First concentric/eccentric exercise is more intuitive and simpler to perform than eccentric-only exercise. Regular weight training is more efficient; you can work both arms at once with regular lifting, but for eccentric you can only do one at a time. Last, you never have to decide when to discontinue eccentric exercise and start regular weight training (which is what most people do when they workout) because you are doing it all along. So with research being a bit conflicting, I used both ways for a while. After finding that the combination concentric/ eccentric exercise worked as well or better than eccentric alone, I finally retired my eccentric-only method. If any of that eccentric/concentric talk is confusing, in this video I demo the difference:
In my original paper, I said I would do some ultrasound and soft tissue mobilization after the exercise to help make the patient feel better in the short-term. I don’t do either anymore as I don’t think they add much (if anything) to the healing process. Plus, I notice once a person does their exercises they usually feel better in the short term anyway. Generally they do a set of an exercise that works the injured tendon and it hurts a little. If they have good form I move up the weight and they do another set and it hurts a little, but often less than the first set. If they had good form on the second set I move up the weight again and usually they tell me the heaviest set feels the best. They are generally no worse as a result and often report feeling just as good as when they got the ultrasound and massage. After 2-3 days of this the exercises hardly hurt at all, in spite of the fact that I am increasing their weights every visit until they cannot get 15 good reps. That’s the sweet spot for training: where you are training to failure on the 3rd set. The exercises I recommend now are these:
- Dumbbell Curls
- Reverse Grip Lying Triceps Extensions
- Wrist Curls
- Reverse Wrist Curls
The video talks about me doing 3 sets (easy-medium-hard) of 15 reps on each set, which is what I do for patients. If the person gets 15 reps with a full range of motion, pain or not, I ALWAYS increase the weight an increment for the second set. If they get 15 reps with full range of motion then, again, I ALWAYS move the weight up for the third set. If the person gets full range of motion on the 3rd set, then the next day I have them start out with their medium weight before and move up from there. I want to quickly (over a 2-3 days) get them to where they are unable to get all 15 reps on the third set. Only then do I stop increasing the weight until their strength progresses. In my experience 3 times per week works, but 7 days per week works a lot faster. My starting weights are almost never less than 5 lbs. On rare occasions I have worked people up to as much as 50 lb for the dumbbell curls and wrist curls and to 30 lb in the reverse wrist curls and triceps extensions. The idea is you want to make gripping a pistol easy in comparison. I think an adjustable dumbbell set is ideal for home use with the ability to change weights from 5 to at least 30 lb.
Since adopting the above protocol the treatment has always worked. However, I do tell people that I see two kinds of responses, both great but the first obviously better. The first is that the pain goes away completely in a few weeks (maybe 3-6) the person is a lot stronger and able to do everything without pain. The second common response is that the pain gets 90% better in 3-6 weeks. Strength and activity are fully restored, but there is still a little nagging pain (maybe a 1-2/10 with activity) that can last as long as 6 months. While the second is the worst case, if I tell people about it from the start they all agree it’s still a good outcome. As a therapist I have driven myself nuts trying to get rid of that last bit of pain, but now I tell people that it’s normal and to just stick with their exercises. Once strength has been restored and plateaus, I tell my patients they can reduce their training frequency to just 2-3 times a week. Eventually they will notice they haven’t had any pain in a while and their elbow is no longer tender to the touch.
Lastly, I want to give a word about safety. Over the internet I can’t properly diagnose anyone so for all I know a person’s elbow pain could be from bone cancer. However, greater than 90% of people I see with elbow pain have either medial or lateral epicondylitis, so the odds are with you. I find the pain decreasing rapidly with daily exercise to be so consistent that if it does not work I start to question my diagnosis. So if pain increases a bit from one day to the next that’s not a big deal. If it’s getting worse week after week, that’s a red flag you should consider getting checked by a physician. A common method of grading appropriate exercise and activity is to limit the weights you use and the amount of sporting activity (in this case shooting) to that which causes 5/10 pain or less. There is no research that says greater pain is too much, and in fact many of the successful studies told people with Achilles tendinitis to keep running so long as pain was not “debilitating”. A 5/10 on a pain scale might be overly cautious, but I think it’s a reasonable guideline. If I find any other bit of research that changes my advice I’ll be sure to blog about it here.
[5-17-16 UPDATE] So endorsement makes me feel especially good. For most people when you cure their shooter’s elbow, you help them with their hobby. However if you are a professional shooter, you’re helping them with their lively hood. Plus it’s cool to pick up an endorsement by a National Champion. For those who don’t shoot IPSC, this is Shannon Smith, and when Rob texted me saying Shannon was having elbow pain, I knew exactly who he was talking about. Shannon’s case is one that I would describe as a ‘worst case scenario’ as was mine when I had it. As described above, a best case scenario, the person is often 100% healed in 3-6 weeks. Worst case, they are A LOT healed in 3-6 weeks, a LOT stronger but will still have some lingering pain that takes some weeks or months to fully go away. Anyway here’s what Shannon had to say:
I have thanked you personally but wanted to leave a comment on your blog for the benefit of others. I am a National Champion pistol shooter, full time competitor and instructor and thought I was going to have to give up shooting last year due to shooters elbow. To the point I didn’t have grip strength to put a tub of sour cream in the fridge. One thing I noticed is everyone has the ‘fix’. Just trying to help I’m sure but everyone had a different remedy and swore by it. I tried compression (as an avid crossfitter I had high hopes for that), motrin, Jamesons (that was pretty decent), ice, heat, deep massage at chiro, some magnet bs thing, nothing worked.
Was talking to Rob Leatham at Nationals in Oct of last year about it and he referred me to you. Of course you said you had ‘the’ fix…just like everyone did. But I was seriously wondering if I would be able to compete at the top levels of the game again and was willing to try anything and everything.
After talking with Chad and viewing all the videos I went to work. Couldn’t even do a 3lb dumbell, started with a can of soup. It was extremely painful. I kept a journal of every days workouts. I hit it every day as heavy as I could. Started at the beginning of Oct. 2015. Within 2 weeks I was up to 15lbs. Journal note Oct 21 “Still painful, may be slightly better, may also be wishful thinking” / Nov 5 “Definitely felt better shot 3 matches in 2 days” / I suck at keeping journals and stopped on Nov 29 with 25lbs on all 4 exercises and the note “Convinced it’s not placebo, shit is definitely working”.
It is now the end of April 2016. The pain isn’t 100% gone if I’m looking for it, but it’s 98% gone and I don’t notice it while shooting. I’ve been pretty consistent staying with the exercises 2-3 days per week. Normally along with my regular workout schedule. Weight training, pull ups, rowing, no pain on any of it! I can say without a doubt doing as Chad said saved my career. All the tricks I was trying and all it took was a few months of pain, sweat, and hard work! Imagine that.
As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.
Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.