Elbow pain when squatting: the low bar, bent wrists, the inner elbow and the nerve, and swaps

What a squat asks of the elbows, and what no study has measuredEmerging evidence

In a back squat the bar rests on your upper back and your hands only stop it rolling. In a high-bar squat it sits on the top of the trapezius just below the neck; in a low-bar squat it sits a few centimetres lower, along the spine of the shoulder blade and over the back of the shoulders. Holding a low bar asks the shoulders to turn out and pull back, with the elbows bent behind the bar.

A review of lab studies found the low bar leans the trunk further forward with more hip bend, while the high bar keeps you more upright, and the low bar usually lifts the most; one study of 12 trained men found the opposite angle pattern and no difference in muscle activity. None of these studies, nor the newest one, measured the arms, and one that measured grip width reported no result for it. No study has measured the elbows, wrists or shoulders in a back squat, counted elbow pain from squats or tested a grip against it. So the map below comes from coaching sources and our squat guide (labelled), elbow tendon and nerve research, lifting surveys and NHS pages.

Sources 1, 2, 3, 4, 5, 6

Who gets itEmerging evidence

The elbow is one of the five commonest injured sites across the weight-training sports: 11% of injuries in 101 Oceania powerlifters and, with the upper arm, 8.0% across powerlifting reports. Upper limb injuries, the elbow among them, were commoner in powerlifters over 40. But no review ties an elbow injury to the squat: the squat injuries reported were leg muscle and tendon ruptures and neck and foot fractures.

In the population, tennis elbow affects 1.3% of adults and golfer's elbow 0.4%, both most often from 45 to 54, and weightlifting is among the activities named for golfer's elbow. In our reading, elbow pain from squats is mostly a low-bar complaint, often a few weeks after switching to the low bar, adding squat days or narrowing the grip, in lifters with stiff shoulders. No study gives the share of each cause.

Sources 7, 8, 9, 10, 11, 12, 13

The inner elbow, the nerve and the low-bar hold: our readingEmerging evidence

Golfer's elbow causes pain and tenderness on the inside of the elbow that may spread down the forearm, with difficulty gripping. The ulnar nerve runs behind the same bump. In cadaver studies with no load, bending the elbow fully shrank the nerve's tunnel by 30% to 41% and stretched the nerve most behind the inner bump, and bending the elbow or bending the wrist back each stretched the nerve by 15% or more.

A low-bar hold bends the elbows and bends the wrists back, so it combines both positions. That this strains the nerve, and that this is why some lifters' fingers tingle under a low bar, is our reading: nobody has measured the nerve, or the elbow, under a loaded bar. UK hand surgeons say symptoms are often brought on by leaning on the elbow or holding it bent.

Sources 14, 15, 16, 17, 18

The outside, the front and the back of the elbowEmerging evidence

Tennis elbow on the outer bump is about three times as common as golfer's elbow. Biceps tendon pain at the front of the elbow hurts most turning the palm up against resistance, and it and small partial tears are treated without surgery first. A sudden pop with bruising and a bulge is a torn biceps tendon, which is rare and usually comes from deadlifts or curls rather than squats, and is best repaired early. A soft swelling on the point of the elbow is usually bursitis from pressure or knocks, and it usually settles with simple care.

Sources 12, 19, 20, 21, 22, 23

Shoulder mobility and the low bar: the evidence is mixedMixed evidence

Coaches link elbow pain under a low bar to shoulders that won't turn out far enough, so the hands and elbows take over. The evidence on lifters' shoulders is mixed: 15 male powerlifters had less outward rotation than controls, more so the elite lifters; 12 female powerlifters didn't differ; and 60 recreational weight trainers had more outward rotation than people who didn't train. No study links any shoulder range to bar position, grip width or elbow pain. Shoulder mobility and outward rotation strength work are reasonable and low-cost, not proven fixes.

Sources 24, 25, 26

When a scan or test helpsEmerging evidence

Not for golfer's or tennis elbow: they are diagnosed from your story and an examination, with an ultrasound or magnetic resonance imaging (MRI) scan only when the diagnosis is unsure. Nerve tests matter for tingling that keeps coming back or is constant, a weak or clumsy hand, or wasting of the hand muscles, because surgery's chief aim is to prevent the weakness and wasting of severe untreated cases. A suspected biceps tear needs prompt assessment, and a hot, swollen bursa may need fluid drawn off to test for infection.

Sources 27, 18, 28, 22, 29

How it usually goesEmerging evidence

NHS inform says many new elbow problems or flare-ups begin to settle within 6 weeks, and the NHS says tennis elbow usually gets better after resting the arm for a few weeks but can last longer. In trials of tennis elbow, 83% to 90% had improved at a year with wait and see. Golfer's elbow is less studied, and surgery is considered only after 6 to 12 months of other care. About half of 24 people with ulnar nerve symptoms improved over a year without treatment, partly from changing arm postures. Most injured powerlifters keep training with changes. No one can promise a date.

Sources 30, 31, 32, 33, 27, 34, 35

The high bar and the swaps still train the legsEmerging evidence

Both bar positions build the legs: in 12 trained men, muscle activity didn't differ between them, and the newest study suggests choosing the combination that is most comfortable. A safety squat bar, held by handles in front, cut the 3-repetition maximum by 11.3% and kept the trunk more upright in 12 powerlifters, cut the 1-repetition maximum by about 5% with similar knee demand in 15 men, and worked the legs about as hard at the same relative load in 32 men. The front squat worked the muscles as well as the back squat with less knee compression in 15 trained adults.

Sources 4, 5, 36, 37, 38, 39

That a safety bar spares the elbows is our readingEmerging evidence

The safety bar studies measured the trunk and legs, not the arms. One paper's introduction says a safety bar puts less force on the shoulder and elbow, citing a study whose summary reports no shoulder or elbow measure, and another says it suits people with shoulder or elbow problems, citing coaching articles. So the safety bar sparing your elbows is our reading: your hands hold handles in front instead of a bar behind you. It is still the usual swap.

Sources 36, 6, 40

Tennis elbow: wait and see does well, and a steroid injection does worseStrong evidence

In 185 people, 83% had improved at a year with wait and see, 91% with physiotherapy and 69% with a steroid injection. In 198 people, 90% had improved at a year with wait and see, and most injection successes later relapsed. In 165 adults, 83% had recovered at a year after a steroid injection against 96% after a placebo injection, with relapses in 54% against 12%.

Sources 32, 33, 41

Loading helps elbow tendons, but the golfer's elbow trials are fewEmerging evidence

In 81 adults with long-lasting tennis elbow, 3 months of daily home forearm loading helped more than waiting (72% against 44% had at least a 30% pain reduction), and in 120 adults slow lowering helped a little more than lifting. For golfer's elbow, eccentric (slow lowering) exercise eased pain in 5 small studies (143 people), but certainty is low, and an earlier review found no exercise trial of golfer's elbow alone, so the advice is borrowed from tennis elbow. A UK review puts a break from the aggravating load first, then graduated strengthening. In one trial, most people gave up heavy slow training because it flared their pain, so build up slowly.

Sources 42, 43, 44, 45, 27, 46

The ulnar nerve: change the positions firstEmerging evidence

A Cochrane review of 15 trials (970 people) found that, in mild cases, information on movements or positions to avoid may reduce discomfort, and that when surgery is needed, the type of operation matters little. About half of 24 untreated people improved over a year, and reviews report improvement in 60% to 95% of people treated without surgery. UK hand surgeons say avoiding the positions that bring it on may cure early cases.

Sources 47, 34, 18, 13

Straps and braces: short-term help at mostEmerging evidence

In a small placebo-controlled trial (31 people), a forearm strap eased tennis elbow pain for 2 to 12 weeks, and across 17 trials physiotherapy did better than a strap over the long term. The NHS suggests trying a forearm strap or brace from a pharmacy. No study has tested wrist wraps for squat elbow pain.

Sources 48, 49, 31

Your squat for now (written steps)

Our 3D figure can't show your grip, your wrists or your elbows. These steps come from our squat guide, coaching sources and the studies on this page; no trial has tested a change to the squat for elbow pain, and each step names its source or says it is our suggestion.

• 1. Bar: high, on the muscle of your upper back just below your neck, never on the bones of your neck (our squat guide). Both bar positions build the legs.
• 2. Grip width: coaches disagree. Our squat guide says widen your grip if a low bar hurts your wrists or elbows; some coaches teach as narrow a grip as your shoulders allow, with the thumbs alongside the bar. No study has tested grip width, and both sides agree on the main point: your back, not your hands, carries the bar. While it's sore, use the width at which your wrists stay straight and your elbows can point down (our suggestion).
• 3. Hands and wrists: the bar in the heel of the palm, not the fingers, with your wrists straight in line with your forearms (coaching sources and our squat guide).
• 4. Elbows: down and slightly back rather than driven up behind you (coaching advice; nobody has measured it).
• 5. Load: about half your old working weight, 2 or 3 reps in reserve, and one fewer low-bar day a week for now (editorial).
• 6. Swaps: a safety squat bar, a front squat with crossed arms or straps, a hands-free front squat, a goblet squat (if holding the weight close doesn't bring on tingling) or the leg press (the studies above; sparing the elbows is our reading).
• 7. With tingling in the ring and little fingers: no long holds with the elbow deeply bent, in or out of the gym, and a straighter elbow at night, as UK hand surgeons suggest.

Sources 2, 4, 55, 36, 39, 18

Today and everyday life (written steps)

These come from the NHS unless they say our suggestion.

• 1. A heat pack or a pack of frozen peas wrapped in a tea towel, and painkillers such as paracetamol or ibuprofen, can ease elbow and arm pain for a couple of days (the NHS).
• 2. For tennis elbow, the NHS suggests trying a forearm strap or brace; it may ease pain while you wear it.
• 3. Avoid a steroid injection for tennis elbow: it left fewer people recovered at a year than a placebo injection.
• 4. Grip and carry lightly, with your elbow close to straight, while it settles, and don't lean on the point of your elbow at a desk or in the car (our suggestion).
• 5. Powerlifting: the low bar comes back last, with fewer low-bar days at first; train with the high bar or a safety bar meanwhile. Gripping sports such as climbing, racket sports and golf build back over weeks once the forearm work is easy (our suggestion).

Sources 56, 31, 41