Arm pump or exercise associated arm pump (EAAP), is possibly one of the biggest mysteries in sports like motocross. There are mountains of misconceptions surrounding arm pump about why it happens and what needs to be done to cure. It is a painful and often dangerous condition that often limits athletic performance. Despite a high prevalence of EAAP, surprisingly little research exists to explain the possible causes. Even more, most doctors haven’t heard of arm pump, whereas 100% of athletes know what it is. Most agree that arm pump is a painful, involuntary contraction of muscles in the forearm during and immediately after exercise. Many feel that it’s related to grip strength and holding on too tight. The pain is often isolated to the forearm, whereas the rest of the body often feels fine. Athletes usually have to slow down or stop activity because of arm pump. When arm pump occurs, it’s often a sign there are many dots needing to be connected.

A recent interview with Zach Osborne explains it pretty well. “Symptoms vary from person to person and it’s rare for two people to have the exact same symptoms. Is it mental, physical or a bit of both? In my experience a bit of both. Surprisingly the mental side is not always provoked by high pressure or even by the same circumstances at two different times. Often times it’s a thought as simple as “don’t get arm pump” and suddenly you have arm pump. I’ve found things that helped the symptoms but never one thing that was a sure way to rid myself of it. With arm pump it’s so personal as to what helps and how it happens. If it works for you it may not work for the next guy and if it is placebo, who cares? With this condition, if it helps then go with it. From my experience massage is often relieving but can also make it worse if done too aggressively. A diet high in nitric oxide which increases the oxygen in your blood helped me tremendously. Having beet juice throughout the day during a race or practice often helped or at least delayed my symptoms. Occasionally rolling the muscle with a device made for such helped but again could worsen if done even slightly too hard. Basically it’s to each’s own as to what works for arm pump. Devices and gimmicks sometimes do work but again it’s very individual as to what or does not help.”

Historical perspective

Arm pump was probably first described in sports around the 1980’s. No one has ever documented the exact prevalence. Accordingly, the possibility of arm pump is a common concern to active individuals, particularly those competing and participating in motocross and bicycle events. Other sports that have a high prevalence of arm pump are skiing, wake-boarding, rock climbing, gymnastics, wheelchair athletes, hockey, mixed martial arts and rowing.

Although many agree what arm pump is, the exact reason why it often occurs during exercise continues to elude athletes, trainers, and doctors alike. Understanding the cause of the arm pump is most important, versus depending on a surgery to correct it. Forearm pain during exercise can be other things besides arm pump: carpal tunnel syndrome, arthritis, cubital tunnel syndrome (tennis elbow), ganglion cysts, scar tissue, neck and shoulder pain, and fractures. Diagnosis of arm pump is initially made from a classical symptom history of pain in the forearm, loss of grip strength, and altered sensation in the hands.

The Zach Osborne Decision

I have been helping Zach Osborne with his training, nutrition, and well-being since he was 16 years old. Arm pump has been an issue for every one of those years. We have always tried to avoid it. Arm pump has traditionally affected Zach more in the 1st moto than in the second. Just like everybody else Zach tries hard in practice to elicit his arm pump, but it is nothing like racing and so he usually has problems the 1st moto; if he is going to have problems with arm pump. It’s crazy that sometimes the arm pump never comes. Many things work with his arm pump including bike set up, doing pump up exercises in the morning employing smaller bars which he did find helpful.

The turning point for Zach considering doing something about his arm pump was at the Glen Helen Two-stroke championship. It was a perfect setup to cause the worst possible arm pump. Zach had a different bike, with different bars, different suspension and the track was not like the national track. After the first moto, Zach’s arm pump was so bad that the strength his grip strength was decreased by more than 50%. His forearms, top and bottom were so hard that he could barely stand the pain. And he had sustained numbness in his fingers.

So after some soul searching and a long talk, Zach and I both agreed that undergoing arm pump surgery would be the best way going forwards. We have been contemplating this issue for many years, and for Zach, the timing seemed right.

I have been researching hand surgeons for a while and I was looking for someone who could possibly perform Zach’s surgery with smaller incisions than the huge zipper like incisions that most everyone gets. So after doing an extensive search for orthopedic surgeons who specialize in hand surgery, I finally found a surgeon who specializes in minimally invasive endoscopic fascial release. Fascial release is a fancy term for arm pump surgery. Endoscopic surgery involves the assistance of a camera to actually cut the fascia and is usually less invasive. Traditional arm pump surgeryCR scar 1 involves a long open excision of the forearms and the complete exposure of the flexor and extensor compartments. Incisions are then made to release of fascia so the muscle cannot create a large compartmental pressure as usually happens. The examples of the scars are numerous, and many times these cases of arm pump just return.knarly arm pump pic

Why minimally invasive surgery and why not go with what has been proven to already work? As an anesthesiologist, I see hundreds of different types of surgeries, ranging from brain to foot surgery. I have seen the progression of minimally invasive surgery techniques for some time now, and I work with an orthopedic surgeon in Las Vegas (Dr. James Vahey) who performs minimally invasive carpal tunnel surgery. I insisted on a minimally invasive surgery as the way to go for many reasons. Minimally invasive surgery is overall less risky, meaning that it has less chance of nerve and blood vessel damage. Healing and recovery are often quicker after minimally invasive endoscopic surgery. The scar left from the surgery is about an inch long on each arm versus the tradition zipper like scar often seen. And we knew Zach would be able to get back to riding sooner if he had minimally invasive surgery versus a large incision surgery.

Through talking with Dr. Vahey and educating myself on minimally invasive forearm surgery, I came across an orthopedic surgeon named Tyson Cobb M.D. I gave his office a call and spoke with Dr. Cobb about Zach. Often speaking doctor to doctor cuts through a lot of red tape and he knew immediately what we were trying to accomplish. We spoke a little about the process and it all sounded legitimate and I knew that it would work. I then spoke with Zach about having this type of surgery and explained the risks, benefits, and alternatives. Zach agreed that it would be worth going to Quad cities Iowa and meeting Dr. Cobb for a consultation. Just after the Santa Clara supercross where Zach won his heat race and nearly the main event, Zach traveled to Quad cities where he met Dr. Cobb. After a physical therapy session in attempt to replicate the arm pump, Zach met with Dr. Cobb again and they agreed to proceed with the surgery.

Zach’s surgery went great, he was under the knife for a little under an hour and recovered quite well. Zach said that he could feel a difference right away.  Dr. Cobb used a camera guided knife to cut the fascia in the top and bottom of each forearm. Zach described the experience as pretty streamlined and he was super pumped (no pun intended) about the fact that he only had small incisions in each arm. In fact, he only had one small incision on each arm instead of several. The next day Zach felt fine and he went home after he checked in with Dr. Cobb.zach arm pic 2016

After the surgery, it was quite impressive that Zach already had nearly doubled his grip strength. We were both just blown away! However, there was more work to do. It was important to maintain range of motion, decrease inflammation and make sure there was absolutely no infection. Simple range of motion exercises were employed to help prevent a seroma. A seroma is a collection of bloody fluid where the surgery was performed. In order to keep the inflammation down, we used dietary, medical, mechanical and psychological methods. In the dietary category, Zach made sure that he stayed tight on his ketogenic diet, limiting carbohydrates and using MCT (medium chain triglycerides) and avocado oil whenever possible. Curcumin supplements were taken with every meal as well as putting it on his food. Zach made sure that he kept his fish oil at 3 to 5 grams a day. He also takes 2 grams of vitamin C twice daily. For medications, he simply used ibuprofen of Aleve every 4 to 6 hours for 3 days and then stopped. On the mechanical side of things, he used ice intermittently, used a cryotherapy chamber about 2 times a week. And he was careful to always keep some form of light compression on the forearms. On the psychological side, he performed Wim Hof breathing techniques where he basically breathed rhythmically for 30 to 40 breaths and then held his breath for 2 to 3 minutes at a time. During the breath holds, he enters a state of brief meditation.

After one week of recovery, Zach wanted to try his “new arms” out. Up to now, Dr. Cobb insisted on light activity, range of motion, and compression for 7 days. After the week was up, Zach decided to test his arms out on a mountain bike ride. His arms felt great and this was a great first sign.

The next step would be on the motorcycle. Zach went out 3 days later and hopped on the supercross track. His arms were still a bit sore from the surgery and there was a bit of swelling. He rode a descent session and came back with a smile on his face. He noted zero arm pump, but even more he felt an improvement on his grip strength while on the bike. So far so good.

Post-operative day 14. Zach went to the supercross track for a full day of riding and testing. He kept riding throughout the day waiting for the arm pump to arrive. It never came. He was able to ride the bike freely and without limitations. He couldn’t even remember the last time he felt like this.

Las Vegas supercross (2016)

This race was to be the real test to know if Zach made the right investment in his arms or not. Zach went into Las Vegas riding very well. Zach qualified well as usual. So not much different. Then the rain came down hard and flooded the track. Zach would have trouble in his heat race and had to qualify from the LCQ. The track was muddy, rough, unpredictable; a perfect recipe to elicit arm pump. In the main event, Zach got a horrible start, about 18th. As the race progressed, it got so bad that the main event was cut to 12 laps. Zach worked his way up from 18th to 2nd by the end of the race. He was able to ride to the upper limits of his ability and was about 3 seconds faster a lap than anyone else on the track near the end of the race. That’s when we knew the investment was worth it.

Should you have arm pump surgery?

Many athletes may assume that they should have arm pump surgery based on Zach’s success. I think it is important to try everything including relaxation techniques on the motorcycle, invest in bike setup, improve grip strength, and many other things. If you do decide to go for surgery, I would advise to really research the options and just don’t go to the first surgeon that says he or she can help you. As I said before, who you choose to help you for any surgery is very important. Remember, this is an elective surgery at the end of the day. You have to think about if the surgery doesn’t go exactly as planned, are you prepared to work with that person to make it right? Getting surgery is serious business and the risks, benefits, and alternatives need to be thought out beforehand. Having a person or close friend who is familiar with the medical landscape can be invaluable and save a lot of time and hassle.

Lastly, arm pump surgery is an investment. Whether or not you should have this procedure is a very personal choice. I would suggest that unless your career depends on it, I would advise against it. Remember, all racing ends one day and the surgery stays with you for life.

 

Update – since the writing of this article, Zach has won an AMA 250 Supercross Championship and ironically he came from a last place start to take it in the very last turn, with no arm pump!