Ep 89 - Tennis Elbow and Golfer's Elbow with Dr. Joe Muscolino

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0:02:18.5 Darren Buford: Welcome to The ABMP podcast. My name is Darren Buford, I'm the editor-in-chief at massage and bodywork magazine and Senior Director of communications for ABMP.

0:02:27.0 KC: And I'm Kristen Coverly, licensed massage therapists and ABMP's Director of Professional Education. This podcast is created in conjunction with today's ABMP CE socials event featuring Dr. Joe Muscolino's new course Assessing and Treating Tennis and Golfers Elbow, join us for an interactive learning experience, including a live Q&A session with Dr. Muscolino. Learn more at ABMP.com/CE-socials.

0:02:53.9 DB: Our guest today is Dr. Joe Muscolino. Dr. Musculino has been a manual and movement therapy educator for more than 30 years. He is the author of the muscular system manual, the muscle and bone palpation manual with trigger points, referral patterns and stretching and kinesiology. He teaches continuing education workshops around the world, including a certification in clinical orthopedic manual therapy, and has created learned muscles continuing education, a video streaming subscription service for manual and movement professionals with seven new video lessons added each week. And he has created muscle anatomy master class, the most comprehensive and detailed muscle anatomy online class in the world, with each muscle taught and five distinct video lessons, visit learnmuscles.com, for more information. Hello, Dr. Joe and Hello Kristen.

0:03:45.6 Dr. Joe Muscolino: Hey there folk, pleasure to be here.

0:03:47.9 KC: We're so happy to have you back for your second ABMP podcast visit, and really, especially this one will be fun to talk about in conjunction with our ABMP CE socials event and your new course. The course covers the causes, anatomy and treatments of both conditions. On this podcast, we really wanna dive in and talk about how these conditions impact clients and their daily lives. So let's start though with a brief summary of the conditions, in case we've got some people who aren't quite familiar, so talking about tennis elbow, that's the layman's term, it's also known as lateral elbow tendinopathy, lateral epicondylitis and lateral epicondylosis, and also golfers elbow, known as medial elbow tendinopathy, medial epicondylitis and medial epicondylosis. That's a lot of words, but these are two conditions that can affect people for a lot of different reasons, right, Dr. Joe, not just playing tennis and golf.

0:04:41.8 DM: Yes, certainly a lot can be said about this, so I'm going to try to simplify the idea. And that is that both tennis elbow and golfers elbow, first of all, are not conditions of the elbow joint, they're pain at... Near the elbow joint, but they're of proximal attachments for muscles that function across the wrist and the finger joints. Tennis elbows out on the lateral side at the lateral epicondyle of humerus. Golfer elbow is over on the medial side of the epicondyle of humerus, attaching it to the lateral epicondyle, there are four muscles that can join their tendons together, they are the extensor carpi radialis Revis, the extensor digitorum, the extensor digiti minimi, and the extensor carpi ulnaris and all four of them can join their tendons together to attach onto the lateral epicondyle of humerus, because in days past, there was really never any diagnosis or assessment made until an x-ray was done, soft tissue never being seen, would never show anything until the X-ray got to the point where the periosteum lining of the lateral epicondyle was literally lifted away and or inflamed, so that swelling went between the body of the bone and the periosteum and they could see that small little space, and they named it for the bone and they called it lateral epicondylitis.

0:06:09.9 DM: Iitis means inflammation of, and right there, that creates an issue for us manual therapists because it takes the responsibility of the problem away from soft tissue, and it makes it act like it's a bone problem, really before it's ever a periosteal bone inflammation problem. It's a tendinitis of that common extensor tendon of those four muscles that are in the posterior superficial compartment of the forearm. But even more than that, and that's why it can also be called a tendinopathy, lateral elbow tendinopathy, but even before it's a common tendon, it's common muscle belly. I go in cadaver labs all the time, teaching cadaver labs, etcetera. And you always see the bellies of those forearm muscles melding and blending together before they become a tendon. Now, if you're saying that it's a tendon problem because there's too much pull on the tendon, where is the pull coming from? It is coming from the muscle bellies. From, as Leon Chaitow would say, use, overuse, misuse, abuse. It's an overuse syndrome of those muscles. So I'd like to propose, first of all, but it's not the common extensor belly tendon, I mean a tendon it's the common extensor belly tendon. And I'd like to propose that it's first a muscular problem, then it's a tendon problem, then it's a periosteum bone problem.

0:07:44.0 DM: So those different names, lateral epicondylitis implies the inflammation of the periosteum. Then they realized that when the problem becomes chronic after around sixish months or so, six to 12 months, gradually inflammation goes away and it becomes more a degradation of the fascia tissue of the tendon going there. Then they say, 'Oh well, we should call it lateral epicondylosis.' Osis is a generic condition of. So then you have an 'itis' for the beginning acute stage and 'osis' for later. And now that they're saying, "Well, lateral elbow tendinopathy I like more, because it encompasses the 'itis' and 'osis' and although it still skips the muscle aspect of it." And just to briefly say on the medial side, it's five muscles into the medial epicondyle of the humerus. They're all muscles in the anterior compartment of the forearm. It's the common flexor tendon or common flexor belly tendon and it's the three muscles of the wrist flexor group, flexor carpi radialis, palmaris longus, flexor carpi ulnaris and the pronator teres, they're superficial. And one level deeper, flexor digitorum superficialis.

0:09:00.1 DM: So that everything I said for the lateral side can be said for the medial side as far as the naming and the general idea, there is not a perfect mirror symmetry though. As the article that we had, whenever that came out in ABMP's journal, talks about there, and we can talk about the causes and all a little bit, but that's a nutshell of the conditions, the naming, etcetera.

0:09:25.5 DB: And Dr. Joe, how often do you typically work with clients who are experiencing one of these conditions?

0:09:30.3 DM: I'm a chiropractic physician, a very soft tissue oriented chiropractic physician. I would say number one is neck, number two is low back pelvis sacroiliac. Number three is probably mid-back. But when you start getting into peripheral joints, I would say that most likely, tennis golfer's elbow will probably be the most common peripheral joint condition that I treat. Because they clearly are not only going to occur with people who play tennis and play golf. They are extremely common, I treat them very often.

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0:10:45.3 KC: Can you tell us about that you mentioned is not only from just playing tennis and golf, what other daily activities tend to have this result?

0:10:52.8 DM: So if we really just, you know, I'm a great believer that if we just kind of go back to mechanics, biomechanics things can be figured out. If we're saying that golfer's elbow is caused by wrist flexor group, flexor digitorum superficialis and pronator teres. Then any joint action we do of those, which would be anything that flexes the hand at the wrist, anything that flexes fingers, to the five flexor digitorum superficialis at the metacarpophalangeal and proximal interphalangeal joints, but basically generically flexing the fingers. And any pronation of the forearm at the radioulnar joints would place a stress on this musculature, therefore, this tendinous tissue, therefore the medial epicondyle. So anything where we're flexing fingers. That's every time you grip any object.

0:11:47.3 DM: So that could be anything from opening the refrigerator to opening your door, to holding your steering wheel, to holding a cell mobile phone to a pencil, a pen. There's this myth that you have to have bad form in tennis to get tennis elbow, which is not true. Certainly if you're hitting a backhand and you do break the wrist, so to speak. You let the wrist actually go from a neutral anatomic position into a position of extension, that it will puts way more stress on this musculature tendon lateral epicondyle, but even if you have perfect form, you hit that ball with the backhand and to stop the ball hitting the racket from collapsing your hand at the wrist into flexion, which is what would happen with the backhand shot requires an isometric contraction of extensors, which is a physical stress to that tissue, just like a concentric contraction would be. So you have that and then you look at the leverage force from the racket strings all the way to your hand, and you say, 'My goodness, that's just a tremendous force'. So that's one way. And that's why it's called tennis elbow with backhands in tennis. But frankly, a forehand in tennis, a serve tennis could get it, or a golfer or anything, because...

0:13:05.8 DM: When you grip an object with your fingers, there are two major muscles that will engage and they are flexor digitorum superficialis and flexor digitorum profundus, and they're in the anterior compartment. And the superficialis is part of golfers elbow, hence gripping at a golfing club could give you golfer's elbow in the medial site or for that matter, a forehand in tennis or serve, as I said, or gripping the racket, or gripping anything. But when you grip an object, and anyone that's at home right now, you can look at this right now, if you find your... So I always say for people to find the epicondyle is they flex their arm with their shoulder joint 90 degrees, they flex their elbow joint 90 degrees, they put their thumb and their middle finger on each side of the upper arm, and they go down until they feel the bumps. Those are the epicondyles. Then their middle finger is on the lateral epicondyle and if they simply immediately internally rotate their arm and their neck, they could see their middle finger there. Then just to make it easier, maybe you wanna put a different finger pad there and then you drop immediately distal and you're on the common extensor belly tendon area of tennis elbow and just palpate it and feel it. And if you extend the hand with the wrist, you can certainly feel that engaged.

0:14:22.5 DM: If you extend fingers or finger joints, to keep it simple, you can feel engaged but if you make a fist, you'll also feel engaged and yet that's a flexion activity of the anterior compartment. Why? The flexors digitorum superficialis and profundus, they also cross the wrist anteriorly. They should when you flex the fingers to grip, make the hands go into the flexion at the wrist joint, but that would make your fist very weak. And if you wanna try it, try flexing your hand with your wrist as much as you can and now make a fist, and you won't be able to have a strong fist. So the point is that you have to stabilize the wrist joint with wrist extensors. So that means that you can get tennis elbow from extension activities and flexion activities. And name anything you do with your hand at your wrist, your fingers at the finger joints, a let alone supination or the lateral epicondylitis pronation and you can get golfer's or tennis elbow, or both.

0:15:23.9 KC: Listeners, Dr. Joe and Darren both have experience with both conditions, not kidding, and we're going to talk about what it's like for them as clients. Let's start with Darren. Please share your story. How has this journey unfolded for you?

0:15:37.6 DB: Oh boy. Yeah, I got a story. So in October 2015, while I was playing golf, I felt what could only be described as a tear or a rip while playing golf in my right arm and it was golfer's elbow on the right arm. I knew so little about what had happened that I actually... I think I was on hole 16 or 17 of 18, so I was almost done. I knew so little about what had happened other than this hurt. I actually finished the round but then I was a little scared, like clients can be, and don't necessarily wanna know what had happened even though something did happen. I didn't do anything at first. All of this was the end of the golfing season, so I knew I wasn't gonna be golfing for a while. I didn't immediately go get it checked out but after about two months or so, when this was still hurting, and I mean hurting to the point of just opening a door handle, that twist, I noticed it wasn't getting better, so I had a routine visit with my primary care physician. She suggested I seek out a facility where I could get a cortisone shot. So I got one, I felt incredible, obviously, and then the instructions from the clinic where I got the cortisone shot which was, "Go live your life again and then come back, if this comes up."

0:17:02.7 DB: Well, I played golf again and it came back again. So at this point, once the cortisone had worn off, they encouraged me to get another cortisone shot. Again, it felt great, started playing golf. This time, I didn't quite make it to the same length of time, probably half the time, that the cortisone shot worked. After this worn off, I started with an ortho clinic that specialized in PRP injections. Now, this was... For us in Colorado at the time, this was early. PRP injections hadn't become quite as popular yet, so it was relegated in the clinic to this back office, I'm not kidding you, and it was barely an office. There was a physician there who was administering them and we went through the process. And after the PRP injection, I was encouraged to go through a 10-week cycle of physical therapy. I did but there was little or no progress.

0:18:06.6 DB: It was around this time that I started also working with a massage therapist just to ease the pain so I would feel better and this massage therapist suggested a different PRP-specific clinic in Boulder, Colorado, which is... I wasn't living at Boulder at that time but very close to where I live now. And at this point, I... This is a PRP-specific clinic that I went to and a golfer, who I was a friend with, suggested a physical therapy clinic that specialized in sports-specific injuries. So now, all of a sudden, I felt like I was on a path. I got a PRP shot in my right arm and then the physical therapy started. This time, I recovered but of course, I started playing golf again.

0:18:52.1 DB: Now, my right arm is fine but in 2018, my left arm, golfer's elbow this time with twinges of tennis elbow occasionally, although that is very minor. So what did I do? I got a PRP injection and started again with physical therapy but the recovery has been really, really slow, and this has been about six months. After the end of the six months, the physical therapist... This is probably... This is March. I think everything ended about January, where they suggested that they felt that I had gotten to 80% of recovery and are encouraging me to go get another PRP shot. So this system, what I wanted to bring to the conversation today, it's incredibly frustrating and I don't feel like I necessarily have a guiding liaison for me through this process. There isn't a person I continue to check in with. I wanna golf again but honestly, at the most base level, what I really wanna do is be able to work out again. I wanna be able to lift weights, do push-ups, do yoga. All of my general health has been relegated to aerobics, like hiking, snowboarding, running, anything that doesn't involve...

0:20:05.1 DB: My arms. So, that's kind of my general story. I would sign it, just like they do the anonymous letters. I'd sign it frustrated is how I would sign this. And really, what I'm looking for is just guidance and help. And this is probably a story for a lot of listeners of just the miscommunication between providers. Nobody's communicating to each other other than me. And so, I am responsible each time for repeating the story. They pick up the story and then everybody brings their expertise, like they're gonna solve the problem, but nobody has further communication, checking in with the PRP clinic, or the primary care physician, or the physical therapy, or a manual therapist. So, I'm the one doing that. And again, it leaves me super frustrated 'cause I just want some guidance and somebody to talk me through it, that's probably half the battle here.

0:20:53.2 KC: Sounds like you need a healthcare advocate who will really be that person for you to be your sounding board, but also to communicate and create a strategy moving forward.

0:21:02.4 DB: That's right.

0:21:02.7 KC: Rather than just bouncing around trying your best as a client. And I think that's important for us to remember as massage therapists because we can find ourselves in that role sometimes for our own clients who come to us in pain or injury. And they may be looking for us to take on some of those responsibilities and help guide them. Dr. Joe, what do you feel? What are your thoughts about hearing Darren's story?

0:21:25.5 DM: Oh goodness. So first, I'm glad we have three hours for this, right?

[laughter]

0:21:31.0 DM: So, to Frustrated in Colorado, thank you very much for your story. You know there are so many levels at which we can approach that story depending on how we want to look at it. One level would be looking at the different modes of treatment in the different worlds that are out there. There's an old saying, if all you have is a hammer, everything looks like a nail. So, had you gone to a surgeon, they might have wanted to go in and cut and debride the area. If you go to someone that does regenerative therapy, PRP, stem cell injections, what they're gonna say is you need an injection. If you went to a massage therapist that's sloppy, they would say, "I'll look at these trigger points in these muscles that when they are tight or taut in tender bands, pulling on the tendon, and increase the pulling on the tendon, tensile force, irritation, use, overuse, blah, blah, blah."

0:22:24.1 DM: And if you go to a regular allopathic medical doctor, the odds are it would go toward cortisone, which went for your oral anti-inflammatories, you would be told to go, stop using your upper extremity for a month or six months. And maybe if you go to a "Typical physical therapist," physiotherapist for anybody outside the United States for that term, then there's a very good chance you would have been given strengthening exercises that would be... If they worked, would be great, but also run the risk of over-stressing an area that's already over-stressed. So, there's all these different approaches. And first to your point, Chris and I have thought about that idea, but a health advocate is the problem, is that that health advocate would have to be open-minded to be able to say, "I see the value in each and every one of these approaches."

0:23:21.1 DM: And maybe in your... And let me advise you as to the pros and the cons for each one. And maybe in your case, it's clear that this path might be better for you, or maybe it's a 50-50. And you wanna try this path. And if it doesn't work to go into that path." So first of all, it requires that profession to be there. Now, we're here in the world of manual therapy. I am a firm believer that whether someone wants to employ massage, not from an orthopedic medical, what are the other terms? And every other English-speaking country, remedial massage where you remedy a specific condition. In other words, we're not looking to work on conditions but you're looking for, touch relaxation, central nervous system relaxation, all those other great benefits.

0:24:10.8 DM: Even if you don't want to do orthopedic massage, clinical orthopedic massage, however they call it, it still behooves you to understand what the mechanics of a condition are, what all of the choices are, what the medical doctor benefit, etcetera, because you are probably going... You might be the only person with whom that client actually speaks about stuff and feels, will listen to them for more than three minutes before they're being pushed out the door. I'm not trying to be too mean toward every other profession, but so many professions, including my profession of chiropractic is you're in, you're out so often. And then, if you are doing orthopedic work, to understand that maybe your clinical orthopedic manual therapy will not cure... Cure is a very good word, but help every one of everything, so maybe they should be given some alternatives or at least layout. Here are the possibilities.

0:25:09.9 KC: Dr. Joe, let's talk about your story. Both tennis and golfer's elbow, is that right?

0:25:15.1 DM: Yes, and bilaterally. So, I'm gonna say that first, I've been a manual therapy physician since 1985. And if you take clinical school a year or two before that. So, I've put a lot of stress through my elbows, but you can do something as perfectly as it can be done, but if you do a lot of it, maybe it will catch up with you. Well, that didn't catch up with me for a good, I don't know, at least 10, 15 years, because the first thing that happened to me was, well, I was playing tennis. And I was playing tennis two, three times a week. And I played for a few hours at a time and I usually play singles. And I hit a lot of balls. And the the first time I ever had any discomfort was tennis elbow on my right side. I'm right-handed, but that really didn't really stop me.

0:26:04.1 DM: It just kinda gave me a low grade kind of irritation. And I could kind of keep it at bay. I love playing tennis. If someone had told me back then "You can't play tennis." I would have said, "Who am I?" It was my identity. It was my exercise. It was my everything. I couldn't have imagined it. But it was when I bought a piece of property to have a house. And it would have six acres of woods. And I with a couple of friends single-handedly cleared about three acres. And I got what I called jokingly, when I told my tennis buddies I had to stop playing for a while, chain saw elbow, because I was holding a chain saw, gripping it with my right hand, which meant the grip I talked about. And there's movements at the elbow and at the wrist and the hand, and the darn thing is vibrating...

0:26:53.7 DM: All the time through, and then I'm lifting up logs and putting them into piles, that's when I really first got it and I really got it badly; I had to stop playing tennis, I had to stop doing... Holding a gallon of orange juice or a half gallon of milk or something was painful, everything, I couldn't grip steering wheels hard anymore I had to hold them gently, which was probably a good lesson. There's no reason to grip a pen or a steering wheel hard, so I kind of... Babied it and got along with it and iced it some and took it easy, and it did gradually get better and I went back to tennis, so I did great until I decided to write a book. Well actually, I had a hardwood cherry... Now here's stupidity at it's optimal amount. I was mousing with my right hand and I had the mouse far in on the desk and it was a hardwood cherry desk, and if you look at the posture you're at when your mouse seemed far in, the inside of your elbow, your medial epicondyle is rubbing on the wood. I actually gave myself golfer's elbow by physical irritation.

0:28:06.6 DM: Forget all the fancy kinematic chain things of muscles and playing tennis or anything else for any tennis manual therapy, I got it from rubbing my medial epicondyle and inflaming it. And I should know, I did this writing a book on Kinesiology. So sometimes we are so blind to our own, and then I gave that time and I got over it and I was fine, and then I really got them all really bad from... You can see this for sure looking at visuals, holding my cell phone in my left hand, gripping with my fingers gave me golfer's elbow, gripping with my fingers gave me tennis elbow on my left side. Not my tennis racket side, not my dominant side in manual therapy. Not the mousing side there.

0:29:02.1 DM: I got it from constantly gripping my cell phone with my left hand for stabilization as my right hand would type away. And I realized that one day sitting with my phone in my hand and saying, "Why is my elbow hurting so much?" And looking at my phone. So I took it easy, I had manual therapy, I had all those things but nothing really helped me at that point. It got so bad until I got some PRP injections and they really did the trick for me, and then I was smarter about everything after that. And I've just been really careful since then, but if I were to suddenly play like I played pickleball nowadays, that's a sign of my age right there. And I can feel my right tennis and golfer's elbow, so I got bilateral both. I can feel it on the right side there. If I suddenly play and I haven't played for a while that start and stop seasonal is a real dangerous thing for people, so that's kind of a nutshell of it. I've kept it at bay. It doesn't bother me when I treat patients, it doesn't bother me when I'm doing workshops, it doesn't bother me when I'm at the computer, but I'm careful about these things and I don't grip anything hard anymore.

0:30:17.8 DB: Dr. Joe you're totally right, I have pretty much been nodding my head in agreement for everything we've been talking about the last 20 minutes. I absolutely... While golf may have been the trigger and clearly was the first trigger, I also drive a manual car. I also grip the steering wheel like a death grip on the steering wheel and in Colorado when we have crazy blizzards sometimes we call it white knuckle driving around here sometimes, I absolutely caught myself doing the same thing with my phone. Holding it with a bent elbow at a certain degree and using, with my left hand using it with my right.

0:30:56.9 DB: And occasionally potentially sitting just like you mentioned at a desk, all of those had been triggers for me as well. The one saving grace probably with golf, if I'm ever able to play again which I'm hoping I am, golf does have vibrational deadeners in the grips so I can go to a club fitter who is aware of my condition, the grips can change, the clubs can change, all of that can help, and then I have occasionally worn armbands as well on my left or right arm depending. Now all of those have helped but just like Dr. Joe mentioned, if you give me a little I'm gonna go a mile. If you give me an inch I'm gonna go mile and all of a sudden it wasn't just I'm gonna try to golf nine holes, all of a sudden I'm playing three and four times a week. And hopefully I have learned my lesson there, if I get to pick up a club and play again that I won't go back and be stupid like that. I'm hoping that I'm slower in my approach here.

0:31:54.8 DM: It really comes down if we do say that this is an overuse injury, multifactorial also points to multifactorial, when someone says, "What is causing this?" Well, what are... What things are causing it is basically to take a step back and say let me look at the biomechanics. Now, frankly, I don't know a lot of people who'd did what I did, literally physically irritated it. But short of that it's typically any contraction whether it's isometrics, concentric or eccentric of any wrist or finger muscles or pronators or supinators at the radioulnar joints, if you just stop, and our viewers are manual therapists they should understand the mechanics here, and just stop and say "Anything I do that does that. Oh, this does that, does that, does that, does... How can I try to lessen it? Do I have to grip the steering wheel so hard? Can I let my hands rest in my lap and hold it gently? Can I put it on auto drive when you're on a highway if it's safe to do it." My wife is always big saying "Use dictation programs at the computer instead of typing and mousing so much." And I agree except that I do technical writing and they don't usually do well with the technical terms. But for other people, other types of writing, just hello emails, those types of things.

0:33:16.8 DM: Or when you have your digital device, do you have to hold it? Can you put it in a stand in front of you? There's some... The bands, by the way, the armbands, they act, whether it's proximal up by the elbow or distal down by the wrist, they act like a retinaculum to hold down the muscular tendons, myofascial tissue, so it doesn't bowstring away and have to work any harder than it needs to to create the movement it needs. So those decrease the stress, but the biggest thing is A: When you think you're better, you're not necessarily better, the symptoms are simply under the radar, and I have an analogy I always like with patients, the picture a glass on a counter, and when the glass is empty, you are one hundred percent healthy. But you put a little water in the glass and that water represents objective subject... Objective, bad health, right? Whatever it's gonna be. And the water stays in the glass, so you never feel anything subjectively, and the water builds up in the glass, now it's halfway. But if someone says, "How are you feeling, now?" "I'm feeling great" "How are you feeling, Joe?" "I feel great.

0:34:24.0 DM: "Okay, but your glass is now half empty, you're getting closer and now the water is right up at the edge, but you still feel fine. Then one day you do one little thing, the straw that breaks the proverbial camel's back and some water spills on the table and you go, "Ouch... I have a problem now." Well, your problem began two months, six months, two years, eight years ago. Then they... Someone mops up a little bit of water and you say, "I'm better. Thank you, this is great." And then you go out and do what you did, and the water spills right over again.

0:34:57.9 DM: So that's a matter of you... You have to mop up the water that spilled, and you have to lower the water level in the glass far enough that you... You're never gonna empty it all the way, we'll never bring our bodies back to being totally pristine. There's some remnant of almost every structure issue we've ever had, let alone functionally how our nervous system reacts, but you wanna lower the level enough that you have the room in there to add a little water when you decide to play little longer this Saturday, and then it will drop back down because you're good to it after that. Maybe you go and you have some massage once a week, once a month, once every two weeks, maybe you do some of your own, if you can reach this area or maybe you ice it, maybe you moist, heat it and stretch it gently. Maybe you rest, whatever. But the idea is don't count on what you feel is necessarily representative of the objective circumstance there.

0:35:52.3 KC: I wanna thank both Doctor Joe and Darren for sharing your stories. I think the takeaway for me here, and I think a lot of listeners too, is that I'm gonna examine everything I do...

[laughter]

0:36:01.8 KC: With gripping inflection and extension, and really see if I can make some changes now so that I don't also have a tennis and golfer's elbow story to share in the future. So thank you both for being so candid about your experiences and talking this through from beginning to where we are today.

0:36:18.7 DM: You're very welcome, thank you.

0:36:20.2 DB: I wanna thank our guest today, Doctor Joe Muscolino. Listeners, find out more information about Doctor Joe at learnmuscles.com. And listeners, if you like what you heard today and you're not already an ABMP member, be sure to check out more info about ABMP at ABMP.com/more. We know we have listeners around the world, and ABMP offers a wide variety of membership levels no matter where you're located. To learn more, visit ABMP.com/more.

0:36:46.5 KC: Thanks so much for joining us today. Dr. Joe and I look forward to seeing you online at today's ABMP CE socials event, ABMP.com/CE-socials.