Elbow Injuries

I have been working with International Brazilian Jiu Jitsu Federation for the last 14 years covering tournaments in the entire Western region of the United States. I have been privileged to have the opportunity, and over the years, I have seen a lot of injuries. My day is only busy when someone gets hurt or has been hurt and they are looking for information on how to manage their problem are. One of the most common areas that I get questions about is the elbow. It’s also the area of the body that is most frequently injured in competition (roughly 20% of the injuries we see). But the injuries are not always directly related to competition but also to training. This article will discuss elbow injuries, how to manage them, and how to prevent them.

Armbar

An armbar, or armlock, is one of the most basic jiu-jitsu maneuvers, and usually one of the first submissions taught to you in class. It’s a submission attempt whereby the opponent wraps their legs around your armpit and neck from the front side while holding your arm between their legs in a hyperextended position. The lever arm is increased by grabbing the wrist and driving the hips up toward the ceiling. It can cause pain at any part of the elbow, but most commonly the pain is the medial (inside) part of the elbow.

Gripping Activities 

With the nature of the sport, gripping is a necessity to performance. Many successful jiu-jitsu practitioners discuss the importance of grip strength. Having good strength here may prevent your opponent or training partner from getting away from you. Gripping requires strength in your forearm and wrist flexors (muscles of the inside of the elbow), but also requires your wrist extensors (muscles on the outside of the elbow). It is also a normal human activity in which we grasp, push, and pull with for everyday undertakings.

Anatomy

Bones

The bone of the elbow consist of the humerus (upper arm bone) and the radius and ulna (forearm bones). These three bones also make up three joints in the elbow. All of these bones are considered long bones which means they can be used to provide leverage in the case when you get caught in an armlock. The motion that happens among these bones can be significant enough to affect all the way down into your wrist.

Ligaments

The ligaments hold the bones together along with the joint capsule. These two structures often blend together seamlessly. These structures are known as static restraints, meaning that they provide stability when no motion is happening. The ligaments of the elbow are primarily on the inside and outside of the elbow. On the outside, you have the radial collateral ligament (RCL) and the annular ligament. This annular ligament wraps around the radial head to allow you to turn your palm up and down like you are waving. The RCL provides stability to any forces that would push laterally (outwardly). The biggest ligament, and arguably the most important, is the ulnar collateral ligament (UCL). This ligament connects the humerus and ulna together and is very broad and long when compared to the RCL. It prevents force moving medially. This is the area of the elbow that is particularly vulnerable to armlocks and even Americana armlocks.

Muscles

When armlocks occurs, it can also damage the muscular complex around the elbow. Flexion and extension (bending and extending) of the elbow after an armlock is often quite painful if damage happens but can also affect pronation and supination (turning palm down and palm up). When there is damage to the muscle or tendon complex, it can generate a muscle strain/pull or tendinopathy. These muscles create and can control motion at the elbow. These are known as dynamic restraints which means they provide stability when motion is occurring. When an armlock is applied, the muscle that are affected will likely be the biceps brachii, pronator teres, or other wrist flexors. This can also be dependent on the hand position and what is going on at the shoulder during the attack. For instance, if you are placed in a position where you shoulder is also extended behind you, a large amount of tension is placed through the long head of the biceps at the shoulder as it is being tensioned down at the elbow by the attack (shown right). Gripping activities or wrist extension will affect the extensor carpi radialis longus and brevis and extensor digitorum (wrist extensors). These are affected by overtraining or profound changes in your training schedule.

Mechanism of Injury

There are two primary mechanisms for elbow injuries in jiu-jitsu: the armlock and tendinopathy injuries due to unaccustomed activities/overtraining. Besides direct trauma, the tendon injuries happen from multiple causes. In men, it is frequent to see tendon injuries at the lateral elbow which is commonly referred to as “tennis elbow.” This can be due to muscle tightness in the elbow, wrist or hand, a recent change in training schedule, work ergonomics, or typing on a computer.

With the armlock, if your opponent is able to take the arm into the position of elbow extension and your thumb facing straight upward, then there is a risk of damage to the elbow joint capsule and elbow flexors (biceps brachii, brachialis, and brachioradialis). If your opponent moves your elbow into extension and then turns your palm upward, it makes it harder to finish the submission but does stress the medial (inside) part of the elbow. Then there is risk of damage at the UCL and pronator teres muscle. Lastly, if your opponent moves your elbow into extension and then turns your palm down, it also is harder to finish the submission and stresses the lateral (outside) part of the elbow. Then there is risk of damage at the RCL and lateral elbow muscles.

With such a submission, and the long lever force that is generated, there is an inherent potential for both fractures and dislocations. A dislocation can be more obvious because of the large deformity that usually exists, while a fracture can be less obvious. The only way you will know a fracture is to seek a physician consult for imaging study. The rule of thumb for fractures is when in doubt, go get it looked at. For both of these situations, medical intervention should be received for proper injury management to be certain there is no nerve damage or laxity (increased motion) into the elbow joint.

Management

If the serious injuries, like dislocation and fracture, have been ruled out, then the injury can likely be managed conservatively. The worst thing you can do is ignore the injury. Most of these elbow injuries can be managed conservatively with four simple steps. It is best to implement these steps immediately and progressively, and if your problem exists without improvement beyond 7-10 days, then seek medical attention or your nearest physical therapy specialist for a thorough assessment. This may include assessing the pin levels and even using wearable body sensors.

1.  Control the pain and inflammation – Training should be halted here, or significantly modified, until these are under control. This can be achieved simply by applying ice to the area. Inflammation control is important because it creates muscle inhibition (makes muscles harder to function appropriately). Although inflammation is a necessary role for the body to heal correctly, excessive amounts are thought to prolong the recovery time. So early intervention is the best intervention here!! With ice, you can apply it to the injured area for 15-20 minutes only. Any longer than that and you risk making the inflammation worst. (This is a shout out to everyone who keeps ice on for an hour. Don’t do it!) If the elbow injury is severe enough, using a sling or elbow strap may be necessary for a short time to remove additional stresses to the injured elbow to reduce the pain and inflammation.

2.  Restore range of motion and increase muscle activation – Training should still be halted or modified here, but you should be attending class and work on the psychological part of your training. Mindfulness and meditation can be extremely beneficial here. It will also build team camaraderie. Range of motion can be achieved by simple range of motion movements by flexing and extending the elbow and also turning your palm up and down at the wrist repeatedly throughout the day. You do want to work within your comfort zone but know that bending and extending will be the most uncomfortable to start. So, go slow! If the movements produce big spikes in pain again, then you are likely going too far and need to back off. As your range of motion improves, then using a light hand weight or light resistance band to perform the same motions will work well. Proprioception, or joint position sense, is also imperative to retrain at this point. This can be achieved by assuming a push up position and holding for thirty seconds to one minute. You can take some of the load away by going onto your knees or doing this push up position on the wall. If it is painful, then it is likely too soon to do this. This needs to be done repeatedly throughout the day, working up to one to two minutes at a time.

For those that have lateral elbow pain with gripping, stretching the wrist flexors and hand muscles are very important. The wrist flexors get tight from the activities we do daily plus grabbing in jiu-jitsu. Wrist flexor stretches can be done by simply grasping your fingers with your opposite hand and pulling back while your elbow is straight. Another stretch that works great for this is called a lumbrical stretch. First make a hook grip with your fingers, use your opposite hand to extend your fingers over your big knuckles. You should feel this stretching into the palm of your hand. Hold for at least 30 seconds.

3.  Increase your strength and endurance – Training can start here but still be careful with who you train with and make them aware of your injury. The elbow muscles need to function appropriately to provide muscular stability and control to the injured elbow. If there is still inflammation, this can inhibit muscles from working, and then they must be retrained. Or they may not reactivate. Running can offer cardiovascular benefits, but muscular endurance of the elbow can be trained with loading activities (push-ups, hand walking, and pull-ups to name a few). Strengthening of the elbow can be achieved by progressing the resistance bands and hand weights to improve elbow flexion and extension strength and endurance. Don’t forget about pronation and supination. This can also be achieved by doing more big movement activities like push up variations which require more force production. But remember, never sacrifice QUALITY of movement for quantity. We often will recommend repeated movements for time rather than a number of reps. This way the focus is on the quality. Start slow and controlled and progress to faster but always use correct technique.

For those that have lateral elbow pain with gripping, strengthening the wrist extensors with resistance bands and hand weights work well. Usually doing reps of 15-20 of #1-5 bands works well to address both strength and endurance of the lateral elbow muscles. You can also use a dowel with a weighted rope to address the strength in this area. And if you have one available, doing battle ropes up and down work great for the entire shoulder complex and wrist extensors with an overhand grip. Do this for 30 seconds to one minute and you will feel these muscles working.

4.  Increase your functional performance – At this point, you should be feeling great and have already been back to rolling and training. The light is at the end of the tunnel, but you are not quite there yet! This stage is the longest and the easiest for people to stop because they are feeling much better. You need to continue to address overall strength with complex movement activities like plyo push-ups, burpees, and plyo-ball exercises. You can progress from two arm activities to one handed loading activities, which will also challenge your core muscles. It is very important to continue working the proprioceptive of training with faster movements on your hands and dynamic stabilization activities. The more stable you are, the more efficient you will move.

A delay in treatment often leads to extended healing times and lost time with training and rolling. So get treatment right away to achieve the best outcome. If your injury does not progressively improve, you will need to seek intervention consult with a sports/orthopedic physician and/or physical therapist to properly rehabilitate this injury. Improper management of your injury will increase your risk of future injury. So finding a specialist to tend to your injury is very important in the long run. The specialist will be able to work with you and guide you toward the best outcome to match your goals.

Risk Reduction – Prevention

We know that the number one predictor for injury in jiu-jitsu is a previous injury. As mentioned previously, the ligaments and capsule are static restraints and the muscles and tendons are dynamic restraints. When both function as

Right elbow radiography. Open and closed position

required, good stability, motion, and strength at the joint can occur. However, if one or all of these structures are damaged in some way or do not function properly, then there is an increased risk to the joint and therefore for that athlete. Ligament laxity/damage can lead to an impaired joint motion, whether if it moves too much or not enough. This is where strength training and proprioceptive training are very important to continue. The same elements described in “Management” can be applied, particularly steps three and four. If you implement these into your training regimen, then you should see a significant reduction in your own risk of injury and less down time when you do get injured. Also, seeing a movement specialist to identify potential risk factors can be even more beneficial to look for these and then address them.

Conclusion

When it comes to jiu-jitsu, elbow injuries are the most commonly seen in competition. This information cannot necessarily be extrapolated to everyone who trains, but the rate is higher than everywhere else in the body. After an elbow injury, it’s possible to get back quickly by incorporating early intervention strategies for the injury, which often leads to better and faster outcomes. Strength training to regain muscle function and proprioceptive training to controlthe elbow are necessary for recovery. If not, you increase your risk of injury. When exercising, always stay in control. Start slow and progress to quicker movements. Remember that recovery is also an important part of functional performance so listen to your body. If you are feeling tired, then take a rest recovery day. And if your elbow injury is not progressing as it should, seek consult from your physical therapy specialist and/or physician to help get you on track and back to the mats as fast as possible. He/she will be able to give you quick recommendations and intervention after a thorough assessment to get you back quickly. Stay healthy… and see you on the mats!!!