Is he wasting his time?
Physical therapy, musculoskeletal rehabilitation, fitness training, and even orthopedic medicine are awash in bad advice and bad science that fuels common practices with no proof of efficacy or effectiveness. Yet these practices continue, almost unchecked, for various reasons. Many practitioners just don’t know their ideas and beliefs are outdated. Some are just willfully ignorant and stuck in their ways. Some may know what they’re doing doesn’t work, but they don’t know what to replace it with and so continue as they have before. And some bad apples knowingly sell snake oil to hopeful consumers just looking for relief from pain or improved performance.
Consumers can often rely on the internet for decent advice in most areas, but when it comes to healthcare the internet is largely to blame for the popularity and perpetuation of numerous bogus treatments. When enough people laud the healing power of arnica cream, you start to believe it (even though it’s almost impossible that it has any notable physical effect)
What’s wrong with perpetuating and selling these misconceptions to patients and clients? At best, the patient merely wastes their time and money on trivialities that aren’t really helping them achieve their goals. At worst, these ideas convince the patient that they are fragile and perpetually reliant upon another person to keep them healthy. And that is no small thing. How can you live the life you want without an internal locus of control?
In the next several posts, I will discuss some outdated ideas that are very common in the realm of physical medicine and rehabilitation. I want you to be as informed as you can be as a healthcare consumer. There are many well-intentioned pitfalls out there. Beware.
The first item on the agenda is one of the biggest controversies out there…
Is stretching important for preventing injury?
In a few words: not really. Certainly not as important as we tend to think.
“But,” you ask, “if it’s not good for preventing injury, why does everyone say to do it?” Indeed, flexibility makes up one of the five aspects of physical fitness according to the American College of Sports Medicine (ACSM), and their latest position statement recommends performing a stretching routine 2-3 days a week.
Within the body of the statement the ACSM cites many studies of how stretching may improve flexibility, but only one study that stretching may improve any meaningful measure, in this case postural stability. Even this one study showing a benefit is refuted by other studies showing no benefit. The paragraph concludes with a damning statement: “No consistent link has been shown between regular flexibility exercise and a reduction of musculotendinous injuries, prevention of low back pain, or [delayed onset muscle soreness].”
Thus, this position statement nicely illustrates the crux of the problem. Namely,
Stretching may improve flexibility but flexibility itself is rarely someone’s end goal.
There is little doubt that frequent stretching can improve flexibility, but unless you pursue an activity with extreme ranges of motion like dancing, martial arts, or gymnastics having flexibility isn’t really all that important. Most of us stretch not to be flexible but because we believe it will prevent future injuries. Unfortunately, after many decades of testing, this all-important benefit has not been conclusively demonstrated.
That’s because most injuries have nothing to do with muscles being too “tight”. Most injuries are overuse injuries, injuries involving sudden over-stretching of ligaments, bone injuries, or injuries from contact, etc. and having “loose” muscles just won’t prevent those injuries.
Surely stretching could mitigate the risk of muscle strains? It seems logical that having longer, suppler muscles would prevent muscle strain injuries but even this idea is flawed. Most muscle injuries don’t happen when they’re stretched to the extreme. They happen with strong contractions in mid-ranges, so, again, stretching wouldn’t help that. And yet, some studies have shown that a warm-up including stretching resulted in fewer muscle strains. However, because stretching was only part of the warm-up it’s impossible to say if it was stretching that had the effect in particular or just the warm-up in general.
Additionally, stretching hasn’t been shown to prevent tendinopathy (tendon pain). In fact, in one study it increased the risk of developing patellar tendon pain in pain-free individuals if they had pre-existing signs of tendon abnormalities. And, stretching before or after activity doesn’t prevent, shorten the duration, or lessen the intensity of muscle soreness. Lastly, stretching only results in a transient reduction in feelings of “tightness” or “tension”, but even gaining range of motion does not always make that feeling go away.
So, with all this evidence against any significant benefit of stretching for the average Joe, why should you stretch at all?
Stretch because you like to. Because you use that time to unwind, or it helps you mentally prepare for your upcoming activity. Or, because you require extreme ranges of motion for your sport or activity. Other than those reasons, there isn’t a great argument for recommending stretching as a regular part of your routine. It has been studied time and again and there just isn’t much convincing evidence that it’s useful for anything other than increasing range of motion. Even then, we’re not sure of the frequency, intensity, duration, or mode of stretching that is best.
What should you do instead to prevent injury?
Do a warm-up that resembles the activity you’re about to do, but at a lower intensity. Walk briskly then jog before you run. Lift light weights before you lift heavy weights. Toss a ball softly before throwing hard. It’s pretty simple.
And the best advice? Build resilience by getting strong through a full range of motion. Simply being stronger throughout your range of motion is enough to begin to reduce the risk of injury. And strengthening a muscle at its end-range has been shown to increase flexibility, in some cases faster than static stretching. So take your strengthening exercises through the fullest range that you can control. Over time you will start to gain flexibility while building strength. That’s a much better bang for your buck than just static stretching.
Here are some ideas for “strengthening and lengthening” muscles that we commonly feel are “tight”
Hamstrings: Stiff-legged or “Romanian” deadlift
Keep slight arch in your back. Your back doesn’t bend during this exercise. Instead the forward bend is happening at the hips and the hips only. Keep your shoulder blades back throughout the exercise. You can allow your knees to bend slightly, but allow the tension to be felt in your hamstrings. Lower slowly, then squeeze your but as you stand all the way back up.
Calves: Single leg calf raises off a step
Lower your heel slowly all the way down as far as it goes. If it’s too difficult to raise yourself back up with one leg then do it with two, but lower with one.
Hip flexors and quadriceps: Rear foot elevated split squat or “Bulgarian” split squat
Make sure to step far enough away from the bench to feel a stretch in the front of your hip when you go down. Lower yourself slowly and as you do push your back foot into the bench help control your lowering. Push through both feet to stand back up. Make sure your torso stays upright. Try not to lean forward.
Groin: Lateral lunges
Take a big enough step to the side that you feel a stretch in your groin as you lower. Lower slowly, thinking about sitting your butt back as if there were a chair behind you.
Latissimus dorsi, “Lats”: Dumbbell pullover
Brace your abs and press your low back into the bench. Don’t let it come up as I did in the video (yikes!). If you find it hard to keep you back flat you can place your feet on a box or the bench rather than the floor. As usual, lower the weight in a slow, controlled manner.
Pectoralis major and minor: Dumbbell fly
Brace your abs and press your low back into the bench. If you find it hard to keep you back flat you can place your feet on a box or the bench rather than the floor. Lower the weights in a direction that gives you a good stretch. For most that will be mostly out to the side but slightly in an overhead direction, kind of like a shallow “Y”. If the weights are too heavy to raise back up, bend your elbows first then press the weights back up as I did in the last two repetitions.