We’ve helped a lot of people with tennis elbow conditions over the years, both in treatment and in preventing reoccurrence. That said, my journey through this condition has been humbling. Studying and treating tennis elbow and carpal tunnel syndrome have been my two greatest single teachers regarding grip strength training mechanics and how to properly approach hand exercise for sports, music, the workplace, computers/digital & hobby. It is a subject that is close to my heart.

I hope you find today’s blog to be eye-opening. Our hands are more at risk now than ever. Which means so are our elbows…

In Parts 1 & Part 2 of ‘Understanding Hand Exercise and Grip Strength’ series, we went over the 18 muscles of the hand. In Part 3, we learned about the Kinetic Chain of Grip. We are building a strong base to truly understand our hands, our grip, proper hand exercise, and general health principles.

Today’s Part 4 The Cause of Tennis Elbow Examined and next week’s Part 5 Grip Dilemmas at the Elbow are two of the most important sections of these entire teachings. They are doozies! They WILL affect hand exercise and grip strength training programs around the world. When we examine the cause of tennis elbow, we relate grip mechanics to elbow mechanics… and open up a whole new can of worms.

Before you begin, please also be super-comfortable with Part 3 The Kinetic Chain of Grip. If you understand Part 3, Part 4 and Part 5 will be much easier to process, possibly even be obvious.

Share this blog with EVERYONE you know who depends on, trains or treats hands and elbows. TE is that prevalent of a problem with nearly everyone. It is an imbalance that develops subtly. If you are not currently suffering, I can nearly guarantee you have some weakness and imbalance at the lateral elbow, unless you are already knowledgeable of proper training.

In other words, everyone could benefit greatly as of TODAY from understanding tennis elbow, especially if you are grip-dependent in your work, sport, musical pursuit, or hobby.

Sound over-hyped? Unless you are already in our inner circle, this will be brand new information to most of you regardless of how advanced or accomplished you are within your healthcare or fitness field.

Unfortunately, tennis elbow (TE) is not historically a very sexy subject and thus has not been dug into deeply. The mainstream health term for tennis elbow is lateral epicondylitis, where ‘-itis’ means inflammation at the lateral epicondyle, the bony protuberance at the outside of your elbow, the far end of the upper arm bone (the humerus). Hmm.  Even less sexy.

I remember seeing TE cases when I first started in private practice. To me, these were nearly nuisance cases. Not the least bit exciting. ‘Your elbow hurts? It’s inflamed? You overdid it? Ice it, rest it, and suck it up‘ was basically my approach. My success rate, not surprisingly, was low. I became more and more interested as I smartened up.

I began to dig deep as I saw the huge prevalence of tennis elbow cases, especially in sports and music (and eventually in the workplace). In honor of those first poor TE patients of mine, I’d like to entice everyone to do the same thing. Dig deep and understand the relationship between grip and tennis elbow. It will affect you. It already has.

Once you dig deeply into tennis elbow, it will be much easier to explore all grip dilemmas at the elbow.

Is Tennis Elbow (TE) Caused By One Muscle?

If you read articles about the ’cause’ of TE, you will see that inflammation of the extensor carpi radialis brevis (ECRB) tendon is often the focus. It’s a fancy name but the ECRB is simply one of the muscles that aids in extending your wrist backward.

Even though grip activities are always cited as high-risk factors for TE, grip itself is never examined closely as a suspected cause. That has always seemed odd to me. It’s as if there is no awareness that the finger extensor muscles attach at the lateral epicondyle. The theme remains the same to this day. Have a Google search if you wish. I’ll wait.

Grip Activities Common Cause of Tennis Elbow (Lateral Epicondylitis)

My hesitation with the ‘one muscle cause of tennis elbow’ theory is two-fold.

Firstly, there are five muscles that attach at the lateral epicondyle, not one. Three of these muscles are indeed wrist extensors (one being the ECRB muscle), but two are finger extensors.  These five muscles attach to the lateral epicondyle via the common extensor tendon. TE occurs when the common extensor tendon is overused, breaks down and becomes unstable.

It is difficult to conceive that the common extensor tendon (made from 5 muscles) itself is perfectly stable except for the ECRB muscle, yet this has been the thinking for at least the last 30 years. The finger extensor muscles are never suspected as causative (of TE). This is because health and fitness experts are not familiar with the key concept of the kinetic chain of grip (covered in Part 3).

Common Extensor Tendon Weakness – Core Cause of Tennis Elbow

The second misgiving I have with ‘one muscle causes TE’ is that most therapists and trainers actually DO train the wrist extensor muscles. Wrist muscles are popular and quite easy to train. Therapists and trainers, in general, are aware of the importance of wrist muscle strength and balance. No serious tennis player, hockey player or golfer omits wrist muscle training, yet these athletes DO develop TE.

This over-simplification of the cause, diagnosis, and treatment of TE lead the ‘old me’ to initially ignore TE’s importance and diversity. Years later, after much experimentation, feedback and study, I know that TE is a debilitating cry from the body for balance and understanding, not just an inflammatory inconvenience. Old ideas remain as dogma while TE prevalence continues to rise.

But if the ‘one muscle causes TE’ theory isn’t the real cause, what then is?

In studying grip and upper extremity mechanics specifically for over 25 years, I believe strongly that the prevalence of modern TE or lateral epicondylitis is due to:
a) a ripening of the baby boomer generation who have been repetitively gripping for a lifetime and are now focusing on retirement grip sports, music pursuits, and other grip-related hobbies,
b) the prevalence of our electronic-age daily repetitive finger motions (i.e gaming, computers, cell phones, etc.)
c) continued poor understanding and training of grip and hand muscles.

Dental Grip

Smartphone Grip

Hobbies Grip

Current grip training ideas focus on ‘squeeze-only’ exercises where finger extensor muscles contract statically to support finger flexor muscles. This ‘squeeze-only’ approach creates static, weak finger extensor tendons that attach at the lateral epicondyle, via the common extensor tendon.

Additionally, when other muscles are trained in fitness (wrists, biceps, triceps, shoulders, back, chest, legs, etc.) a weight is almost always being held via a ‘clenched hand,’ further training these finger extensor muscles statically… further leading to weakness and overuse at the lateral epicondyle… and further leading to TE.

Grip Only

Clenched Grip

Clenched Grip Kettlebell

We must stabilize all five muscles of the common extensor tendon that attach at the lateral epicondyle if we expect to see TE go away and stay away. And we must maintain the strength and balance of the 18 hand muscles. Only then will we see elbow performance potential and stability maximized.

The examination of the cause of tennis elbow may seem somewhat complicated at this point. I’ve likely muddied the waters for most, but the solution for general elbow health is simple.

Next, we examine further – likely for the first time – why repetitive gripping, poor understanding and poor grip training have been the root cause of an array of elbow health and performance problems, including TE.

Continue to our next blog, ‘Part 5 – The Grip Dilemmas at the Elbow,’ and the picture will become much more clear. Plus, we’ll show you some simple training that anyone can do (and understand!) to treat and prevent TE and other elbow problems. Thanks for reading!

Link to Next Blog: Understanding Hand Exercise & Grip Strength – (Part 5) The Grip Dilemma at the Elbow

Dr. Terry Zachary is an advocate for proper and complete hand exercise & grip strength training in sports, music, the workplace, modern computer, electronics/gaming/esports, therapy/rehab/wellness, and hobby. Dr. Zachary discovered that repetitive gripping imbalances have gone under the radar as a cause of muscle imbalance, weakness, poor blood flow, and poor lymph drainage for over 5 decades. He developed Handmaster Plus to provide the world with fast, easy and complete hand training to create maximum strength, balance, performance, and overall health. The result is healthy, stable fingers, thumbs, wrists, carpal tunnels, forearms, and elbows… and healthier lives.

Dr. Zachary can be reached at terry@doczac.com. For information on Handmaster Plus, visit www.handmasterplus.com

In Parts 1 & Part 2 of ‘Understanding Hand Exercise and Grip Strength’ educational series, we went over the 18 muscles of the hand. This is such key information as a starting point.

9 muscles open the hand and 9 muscles close at hand. It sounds so simple, but now you ALSO realize that these muscles have great reach, not only within the hand but to the fingers, thumb, wrist, carpal tunnel, forearm, and elbow. The veil is off. Hand strength and grip training is no small subject. It relates to everything that happens to the mid and lower arm… and maybe even further.

Now let’s shed some clear and bright light on another new and vital grip concept that you will likely have little idea of, yet utilize every day. It is referred to as the ‘kinetic chain of grip,’ or in other words,‘the sequence of muscle contractions that occur in order to grip something, grab something, or move the fingers and thumb to perform various actions.’ It is how your hands work. And, once you know it, you will wonder how you as an individual or we as a health- and fitness-conscious world ever trained the hands as we did.

‘The kinetic chain of grip’ refers to the cooperative contraction of distinct muscle groups to produce a final desired action of grip. In order for grip to occur, the body, in its wisdom, must stabilize its base so as to connect ‘the peripheral with the proximal.’ In simpler terms, it would appear to do no good to grip a baseball with the fingers and thumb alone if the wrist were not stabilized. The ball, fingers, and thumb would simply just hang there. That picture makes sense to most people… especially pitchers (lol).

Now the slightly tricky part…

What would happen if the finger and thumb extensor muscles are also not providing stabilization, meaning… not contracting? What would happen to the ball then? Would the player have control of it?

Baseball Grip Illustrated – Kinetic Chain

Try it. Go grab a ball, or tennis racquet, or pen or keyboard and feel what happens when you grip them or use your fingers. Feel the ‘back of your hand’ where your finger extensor tendons are. Review ‘Part 2 (The 9 Muscles That Open the Hand)’ here. Are they contracting? The answer is a resounding ‘yes.’ They have to be. Otherwise the hand would fall limp.

One might say that this doesn’t make sense because finger extensor muscles and tendons are supposed to open the hand not close it? Right?

Right! The finger extensor muscles DO contract to open the hand… but they ALSO contract ‘in cooperation with the finger flexor muscles‘ in a supportive role when gripping and grasping, as in sports, music, computers, gaming, workplace and hobby. The finger extensor and finger flexor muscles are constantly in a ‘cooperative co-contraction’ when gripping.

This is what is meant by the ‘kinetic chain of grip.’ The finger extensor muscles contract cooperatively to support the finger flexor muscles… i.e. to grip. It is a kinetic chain. And the kinetic chain of grip can be shown clearly on surface electromyography (sEMG). In fact, it is how we discovered the clear consistent evidence of the kinetic chain of grip. To this day, we have done dozens of sEMG pattern tests in doing our grip research. The images are consistent, revealing and super-interesting.

Hand muscle fire pattern of dental hygienist

The above sEMG signal above shows the sEMG pattern of a dental hygienist while doing a teeth cleaning. Did you ever think that a dental hygienists has a tough physical job? Probably not. You were likely thinking other thoughts while having your teeth cleaned – lol! But dentists, dental hygienists and dental assistants do have a difficult physical job, as do many repetitive grip professionals and workers. In fact, dental hygienists have one of the most demanding physical jobs of any profession.

For real!… as my daughter says.

And one of the main reasons is because of the constant presence of the kinetic chain of grip.

Notice the green signal that indicates the contraction of the finger extensor muscles on the sEMG chart above. The red is the finger flexor muscle signal. When the hygienist is cleaning teeth, BOTH the finger extensor AND flexor flexor muscles are contracting… the whole time… otherwise the hygienist would drop their dental cleaning tool.

Notice the intensity of the green finger extensor muscle pattern. This might surprise many people. It is a huge burden on the entire profession, and we will explain why in more detail in later posts in this series. Indeed, much more to cover on workplace injuries to to repetitive gripping later.

The baseball catcher sEMG below shows the detailed pattern of both finger extensor (green) muscle pattern contraction in support of the finger flexor (red) muscle pattern when the catcher provides a target for the baseball pitch (spike on left of the graph) and when the catcher catches the pitch (red and green simultaneous spikes near right of graph).

Baseball catcher muscle pattern – target & catch

Again the intensity of the finger EXTENSOR muscle signal (green) might surprise you. Most would expect the finger FLEXOR muscle signal (red) to be strong, because historically athletes think of grip only and use ‘squeeze-only’ training devices to prepare for sports.

Muscle fire pattern – Guitar (fret hand)

There is little difference in the study of the kinetic chain of grip in music. The above sEMG pattern depicts the pattern of the finger extensor muscles (green) versus the finger flexor muscles (red) when viewing a guitar player’s fret hand. Note the intensity once again of the green signal that represents the finger extensor muscles, or ‘support muscles’ in the kinetic chain of grip.

These patterns surprise experts and lay people alike. The finger extensor AND flexor muscles contract together in cooperation in order to grip. Indeed, the finger extensor muscle fire pattern is almost always very intense in grip activities.

In summary, the kinetic chain of grip refers to the fundamental concept that the finger extensor muscles contract to support the finger flexor muscles in any grip, grasp or finger action. And as well, the thumb extensor and abductor muscles contract to support thumb flexion muscle actions (more on the thumb later).

It makes sense that, if the finger extensor muscles are not contracted, the finger flexor muscles would simply fall contracted limply towards the ground. It is a rather simple complex, though not at all well known. I often compare cooperative grip contraction (‘the kinetic chain of grip’) to pairs figure skating. We are watching the female skater eloquently complete all of the thrilling tricks, but the partner skater is working well and hard in support to equally create the outcomes we are dazzled by.

The finger extensor muscles are the vital motor for grip. If one expects advanced strength, stamina, and grip performance, finger extensor muscles must be trained properly through their full range of motion. When an athlete’s, musician’s or worker’s grip fatigues it is a more clear indication of poor finger extensor muscle training than finger flexor muscle training. In other words, it is an indication of a kinetic chain that is broken.

Finger extensor muscles must be trained properly by all who depend on grip.

Now that we understand the kinetic chain of grip, we complicate matters a lot. We are a repetitive grip society. We must start to understand where these mechanical problems of the fingers, thumbs, hand, wrist, carpal tunnel, and elbow come from. We must also be prepared to change our training approaches to correct these very debilitating and costly problems.

One of the most common of those problems is tennis elbow or lateral epicondylitis. It is the eye-opening topic of Part 4. But do we understand tennis elbow? Are we approaching tennis elbow exercises and training properly? Thanks for reading!

Next:
Understanding Hand Exercise & Grip Strength – (Part 4) Discussing Tennis Elbow Cause and Treatment

Dr. Terry Zachary is an advocate for proper and complete hand exercise & grip strength training in sports, music, the workplace, modern computer, electronics/gaming/esports, therapy/rehab/wellness, and hobby. Dr. Zachary discovered that repetitive gripping imbalances have gone under the radar as a cause of muscle imbalance, weakness, poor blood flow, and poor lymph drainage for over 5 decades. He developed Handmaster Plus to provide the world with fast, easy and complete hand training to create maximum strength, balance, performance, and overall health. The result is healthy, stable fingers, thumbs, wrists, carpal tunnels, forearms, and elbows… and healthier lives.

Dr. Zachary can be reached at terry@doczac.com. For information on Handmaster Plus, visit www.handmasterplus.com