I initially started working in the restaurant industry because of Chef Wylie Dufresne. I was introduced to him by his previous Pastry Chef, Sam Mason.
One night when I shook Wylie’s hand, I noticed his tennis elbow brace and demonstrated a move that helps unload the tension in the elbow by mobilizing a joint. We have been friends ever since.
As a physical therapist, I am always watching how people move. As they walk down the street, bend over, get up out of chairs, go down stairs and hold things in their hands. I watch body mechanics and observe their anatomy. Some people are blessed and fit looking who seem to have strong and supple bodies for what life brings us. Others are deconditioned or flat out overweight with poor body mechanics and difficulty in minimal existence. It is a variable world and a reason why healthcare practitioners are in business and the weight loss industry is a billion dollar industry.
So when I sit at a bar where some of my clients work, I watch the manual labor involved in bartending. Their skill is generating a new interesting drink and then the execution of that drink. It is a mentally challenging and physically laborious task. I watch the number of bottles picked up and poured, the prep of the garnishes, and then the preparation of the blend. It is sometimes a simple spoon stir and other times an aggressive shake, complete with a vertically oriented arm motion. It is impressive and at the same time disturbing because in my eyes, I see a potential repetitive use injury.
Elbows are the intermediate joint in between the shoulder and the wrist. Elbows can become painful in the service industry because the muscles that attach there are actually muscles that control the wrist and hand. The most common injury would be tennis elbow or lateral epicondylitis.
To the layperson, that is an overuse, repetitive stress injury of the tendons on the outside of the elbow. The condition causes significant pain on the outside of the elbow, difficulty and pain with gripping or holding anything in their hand, and pain and swelling on the outside of the elbow.
Another injury that can occur is a nerve entrapment in the elbow. In the bar industry, the motion required to ‘massage’ the ice is with the arm elevated overhead with the elbow bent. The hand is also required to hold onto the smooth metal of the mixer. This can make the task even more difficult as bartenders are dealing with liquids which means things can be slippery and the mixer is typically a set circumference with a top and bottom that needs to stay together and stay in your hands.
The ulnar nerve is a nerve that travels from the neck to the pinky side of the finger. There are a couple of places along its path where the nerve can get entrapped, or impinged. In bartenders, the most likely area would be the cubital tunnel, an area behind the elbow where the nerve travels through a tunnel of tissue under the bony prominence on the inside of the elbow. It is a small area without a lot of soft tissue to protect it.
This nerve is easily aggravated because of its location and how superficially it exists. When the elbow is bent, the nerve gets stretched over the bone and can get irritated. It can also slip out from under the bone and be further irritated. When you hit your ‘funny bone’ (the bone under which the ulnar nerve sits), you get a ‘shock-like’ feeling or tingling that shoots down into the pinky finger. It also means that something as simple as leaning on your elbow and sleeping with your arm bent can aggravate this nerve.
Bartenders lean across countertops engaging in conversation with us. They also aggressively bend their elbows and pump them with the elbow fully bent to blend drinks. Sometimes they shake the mixer in front of the body; sometimes they have 2 mixers going at the same time over each shoulder! Pouring the drinks requires the elbow to be bent and the hand to be turned over which can also stress the elbow. Picking up a heavy bottle, a wide bottle, the bucket of ice and even serving food can all stress the elbow further. Bottom line, there is a lot in the service industry that can potentially cause this problem.
Physical therapy can help reduce the irritation in the nerve by using modalities like kinesiology tape, ultrasound and soft tissue massage to the surrounding soft tissues. We show you the appropriate exercises to strengthen the area. Activities that aggravate must be avoided, which can be detrimental to a bartender. It means minimizing the use of the hand and arm and making sure to minimize the amount of time the nerve is stretched or the elbow is bent.
Conservative care can typically resolve the nerve compression and entrapment but sometimes surgery is required. When this occurs, a procedure called an ulnar nerve transposition will be performed. This involves moving the nerve to a more suitable place where it is not pinched or irritated by the bony prominence it sits under. Recovery takes 3-6 months and physical therapy starts 2-4 weeks post-surgery.
Whether you do physical therapy to avoid surgery or after you’ve had surgery, your care involves reducing the inflammation, pain and swelling and increasing strength and endurance of the muscles. Prognosis depends on severity, type of surgery and the patient’s general health. Either way, your physical therapist will get you back behind the bar and back to life without complaints. Hopefully your customers will want drinks that are stirred, not shaken.
To learn more about ActiveCare Physical Therapy, please visit their website or call 212.777.4374.