Is Stretching All Its Cracked Up to Be?

For those that don’t know, there is a hot debate going on in the rehab, sports medicine, and sports performance community.  The debate centers on the topic “to stretch or not to stretch?”  Pause for a second here and you’ll probably ask yourself just why the heck is this so important.  You’ll then follow that thought with “duh, we all should stretch more.” Well, we hate to be the bearer of bad news but the answer isn’t that simple.

What prompted this blog was a recent interview we did on ESPN Radio Chicago 1000 AM with Dr. Brian Cole, MD and Steve Kashul.  In the months following the interview, I’ve received some “interesting” responses and commentary. Click here to listen to the podcast of that interview (http://ec.libsyn.com/p/2/d/6/2d61d8317e9ea2ed/10-12SMW.mp3?d13a76d516d9dec20c3d276ce028ed5089ab1ce3dae902ea1d01c08f31d5ce58a53c&c_id=6278029). The interview takes place about 19 minutes into the episode and lasts about 10 minutes. In a 10 minute segment, it’s really hard to get into any depth about why you should or shouldn’t do something.  A blog is a better venue to explain your ideas. 

Somewhere over the past 30+ years the stretching myth has infiltrated into the realms of rehab, sports medicine and sports performance training without much scientific basis.  Blanket stretching recommendations were given to athletes and non-athletes without clear concise standards. If you go to a gym, to an athletic field, or onto a bike/running path you’ll see athletes stretching prior to and after exercise. Some athletes don’t have a clue why or what they are stretching, but are doing so because that’s what they were told to do years ago by a coach, athletic trainer, physical therapist, chiropractor, doctor, etc. It’s time to take a hard look at the sacred cow of stretching.  This will be an unbiased view so please lock your trays in the upright position and buckle your safety belts.

The Case Against Stretching 

The research in favor of static stretching is underwhelming.  Contradictory findings abound (10). We are defining stretching in this blog as a static hold with the intent of elongation of the soft tissues (muscles, tendons, ligaments, and fascia) that is held for set length of time (ex. 2-3 sets of a static stretch for 30 seconds).  We are not talking about a dynamic warm-up, mobility training, movement prep, ballistic or explosive maneuvers.

1). Increased Risk for Injury: Several studies indicate that stretching before exercise/athletic competition actually increases the risk for injury.  One study even showed that 24 hours later performance was impaired (2). Counterproductive don’t you think?  Athletes and exercisers want to reduce the chance for injury and increase the chance for exceptional performance, not increase the risk for injury and impair sports performance.

It is well known that stretching can improve range of motion, but is improving range of motion always a good thing?  In some cases muscle stiffness and limited range is a protective phenomenon; therefore, attempts to push through the barrier with static stretching to improve flexibility and improve range of motion may impair the body’s adaptation (muscle and joint stiffness) leading to injury (8).

An example of this occurs in this video https://www.youtube.com/watch?v=m3gsYKUJ1TE. A colleague, Dr. Kathy Dooley, assesses core stability and hamstring length.  At first glance, it appears that the subject has limited hamstring flexibility/length; however, when challenged with a core stability task (holding a kettlebell and cued to activate the abdominal musculature) you find an immediate improvement in hip mobility.  The purpose of this video is to show that core stability issues often masquerade around as hamstring flexibility problems. These are the people that walk around saying, “My hamstrings are always so tight and I don’t know why because I stretch and stretch them all the time.”  Maybe then the apparent loss of flexibility and length is a protective phenomenon and maybe attempting to stretch through that barrier increases the risk of injury by reducing the protective tone.  To add insult to injury, stretching will then be used in rehab of the hamstring injury further reducing the protective tension and also at the risk of the core stability issue not being addressed adequately.  This scenario sets the stage for future injury and this cycle is repeated over and over again.

Keep stretching that hamstring when it doesn't need it and this may happen

Keep stretching that hamstring when it doesn’t need it and this may happen

Rather than stretch, a phased in warm-up prior to the activity is still advised to assist in performance and reduce injury risk (12, 16). The phased in warm up should include progressive cardiovascular training, dynamic movement prep (mobility not flexibility work and yes there is a difference), muscular activation and/or strengthening exercises, and sports specific training.

My own personal routine prior to running includes walking, then jogging, then running for a total of 10-15 minutes, followed by foam rolling (quads, calves, hamstrings, groin, mid back, chest, latts – takes about 3-5 minutes), followed by mobility work (ankle, hips and mid back – takes about 3-5 minutes, followed by activation exercises for the glutes, tib anterior, intrinsic muscles of the feet, extensor hallucis brevis, core musculature, and neck musculature (takes about 3-5 minutes).  This 20-30 minute pre-run routine has kept me healthy after a rough injury filled 3 year stretch.  This 20-30 minute routine has also helped drop my running times in the 5k, 10k, 10 mile and half marathon distances. Another way to avoid injury is strength training. Strength training has repeatedly shown to decrease the incidence of injury and re-injury in select conditions including hamstring injuries (14, 15).

2). Poor Performance: Studies have shown that athletic performance measures such as speed (sprinting time), vertical jump, lateral agility and change of direction activities can be impaired immediately following rigorous static stretching (2, 3, 4, 5, 6).  The impairment from static stretching may even last for a period of 24 hours following a bout of static stretching (2).   The impairment produced by static stretching can be offset if the athlete resumes a phased in, progressive warm up following the bout of stretching (2, 4).  Studies indicate that a progressive warm up and/or a bout of dynamic stretching (dynamic movements/movement prep) is indicated to improve performance (3).  So out with the old (static stretching) and in with the new (dynamic movement/mobility training/movement prep).

3). Tissue Lengthening?:  Another misconception is that stretching lengthens soft tissues (namely muscle).  The perceived lengthening is actually greater neurological tolerance.  The nervous system adapts to the imposed demands of the stretch and adjusts accordingly so we effectively can tolerate greater range of motion with the stretch without actual tissue lengthening. An example of neurological tolerance occurred when I first sprained my ankle years ago. The pain was sharp and rated 8/10.  The same type of ankle sprain 20 years later was rated a 3/10.  We all perceive pain at the same threshold, but our tolerance and ability to adapt change.  The multiple sprains over the past 20 years caused a neurological adaptation to pain.  A similar concept occurs with stretching.  The tolerance to the stretch goes up (neurological adaptation), but the tissue does not remain lengthened.

The book that started this whole idea for me about nervous system sensitivity, testing the nervous system and neural mobilization

The book that started this whole idea for me about nervous system sensitivity, testing the nervous system and neural mobilization.  Stretching is a neural process.

4). Time:  Length a stretch is held doesn’t matter as much as you think.  So, holding a stretch for 60 seconds vs. 30 seconds  doesn’t necessarily make a difference  According to one of the articles listed below, a stretch should be held at least 15 seconds, but holding the stretch longer than 30 seconds did not seem to show any further benefit.

The way to permanently deform tissues and cause actual long term lengthening of the tissues is to hold the tissue in an elongated position for hours or more on end.  Braces (teeth) in a child permanently elongate and deform the tissues.  Braces are worn 24/7 for months to years to achieve the elongation/deformation. Likewise, patients wear plantar fasciitis (misnamed and misunderstood…read here for more info http://thecfim.com/truth-plantar-fasciitis) night splints which hold the tissue in an elongated state overnight (6-8 hours). This is a very tedious and uncomfortable process; however, long term static elongation does work, but not in the traditional sense of the 30-60 second stretch.  You must also be careful to permanently deform/elongate tissue without a justified and measurable reason.

Night Splint for Plantar Fasciosis: Most of the time this is not needed for the condition, but the point here is if you are really trying to lengthen soft tissues an occasional 30-60 second stretch is not enough to do it.

Night Splint for Plantar Fasciosis: Most of the time this is not needed for the condition, but the point here is if you are really trying to lengthen soft tissues an occasional 30-60 second stretch is not enough to do it. Long term tissue elongtation/deformation takes an application of force over time.

5). Long Term Benefits:  The long term benefits of routine stretches recedes within days following cessation of a stretching program, meaning that the improved flexibility only lasts as long as you keep stretching. Other tools such as strength training have gains that last weeks to months after the program has been concluded.  So the moral of the story here is that the mobility gains are neurological. Neurological gains occur and go away very quickly.

The body's physical and neural adaptations to strength training are longer lasting than that of stretching.

The body’s physical and neural adaptations to strength training are longer lasting than that of stretching.

6). No Difference:  Several studies have shown that other risk factors reduce the injury risk.  One modifiable risk factor is general fitness (1, 8).  General fitness in military recruits reduced the rate of injury (1).  Control (non stretch) and intervention (stretch) groups had similar rates of injury in the study, but the more fit group showed decreased injury rates.  The study indicates that general fitness mattered more than the decision to stretch or not to stretch.

7. Muscle Imbalance:  Static Stretching of specific muscle groups may create a muscular imbalance.  For example, hamstring stretching and quadriceps stretching may effect the strength ratio between the two muscles (9).  Theoretically, muscular imbalance could contribute to many of the sports medicine and orthopedic injuries we see potentially including ACL injuries.

8). Post Exercise Recovery: Stretching may not assist in flushing metabolic byproducts of exercise (blood lactate) (13). So stretching after a hard workout may not help you accelerate your rate of recovery.

The Case For Stretching – Should You Throw the Baby Out With the Bathwater?

If you’ve read the above comments, you’ve come to the realization that a strong case can be made against stretching; however, their is a case for stretching and we shouldn’t throw the baby out with the bathwater.

1. Sports Specificity:  Specific sports and performance may actually benefit from improve range of motion. Examples would include gymnastics, dancing, or diving (7).  Flexibility is an inherent part of those sports. Sports of long duration at lower intensity (cycling, running, swimming) may not see the benefit from increased flexibility or range of motion.  Caution should be taken with increasing flexibility in gymnastics, dancing or diving.  These athletes are prone to laxity.  Attempts to further increase flexibility and mobility could theoretically increase injury risk by reduction of protective tone.  We often find these athletes need more stability than mobility.

2. Post Surgical Rehabilitation: There may be a role for static stretching in the post surgical patient. Injuries and surgery impairs a patient’s normal motor patterns.  In other words, the way they move prior to and after surgery is completely screwed up.  The goal of rehab is to reduce pain and restore normal movement patterns including the ability to crawl, walk, turn over in bed, squat, lunge or just lift their arm overhead.  Static stretching can be used to reduce pain, improve range of motion and assist in injury or surgery recovery; however, the patient should be transitioned from static stretching into other activities as soon as they can tolerate it.  As discussed in the radio clip, there are alternative methods available like ART (Active Release Techniques http://www.activerelease.com/), FAKTR (Functional and Kinetic Treatment with Rehab http://www.faktr.com/), and functional rehab that may be a better fit.

3.  Psychological: Let’s face it, we are creatures of habit.  Stretching can be so ingrained in a rehab professional’s (doctor, chiropractor, physical therapist, athletic trainer, strength and conditioning coach, etc.) or patient’s mind that no matter what the evidence is they will not stop.  Positive expectation leads to positive performance.  Sometimes the mind is so powerful that believing in something (aka stretching) will make it work even with the evidence available that contradicts its efficacy.  For those that absolutely must stretch, your performance or your flexibility could improve simply because you believe it so.  Please be aware that short term benefits of stretching still place you susceptible to long term injury.

Summary

Confused yet?  Please no nasty emails if your bubble has been burst or your head is spinning.

1.  The decision to stretch or not to stretch is not as simple as you think.  Contact your rehab professional (doctor, chiropractic, physical therapist, athletic trainer, strength and conditioning coach, etc.) to discuss this and tailor a program (if needed) to fit your needs. If you need some help and are in the greater Chicagoland area, call us at 708-532-2346.

2.  There is more credible evidence against static stretching than there is for static stretching; however, we should not completely eliminate static stretching.

3.  Always warm up and always cool down! Static stretching is optional and at your discretion.

4. If you do choose to stretch make sure it is never right before an explosive event or activity (sprinting, jumping, change of direction, etc.).

5. Stretching can be used as part of a phased in cool down, in a sports specific training program, or in injury/post surgical rehabilitation.

6. The benefits of stretching are short lived so either you must stretch often and don’t stop, stretch longer (hours, days, months to deform/elongate tissues), strength train (longer performance gains) or find out what’s really going on prior to stretching anything (best solution of the group).

References

1. http://www.ncbi.nlm.nih.gov/pubmed/10694106

2. http://www.ncbi.nlm.nih.gov/pubmed/23615481

3. http://www.ncbi.nlm.nih.gov/pubmed/21904235

4. http://www.ncbi.nlm.nih.gov/pubmed/18768355

5. http://www.ncbi.nlm.nih.gov/pubmed/19127179

6. http://www.ncbi.nlm.nih.gov/pubmed/19855346

7. http://www.ncbi.nlm.nih.gov/pubmed/16130528

8. http://www.ncbi.nlm.nih.gov/pubmed/15495679

9. http://www.ncbi.nlm.nih.gov/pubmed/21672027

10. http://www.ncbi.nlm.nih.gov/pubmed/15233597

11. http://www.ncbi.nlm.nih.gov/pubmed/10593217

12. http://www.ncbi.nlm.nih.gov/pubmed/16679062

13. http://www.ncbi.nlm.nih.gov/pubmed/23256711

14. http://www.ncbi.nlm.nih.gov/pubmed/21825112

15. http://www.ncbi.nlm.nih.gov/pubmed/23269328

16. http://www.ncbi.nlm.nih.gov/pubmed/22812375

**** Dr. Konstantine “Dino” B. Pappas, DC, MS, ATC, CSCS, CKTP, cert MDT is the author of this article.  Dr. Dino works out of The Center for Integrated Medicine, LLC.  The Center for Integrated Medicine, LLC (CIM) is an innovative health and wellness clinic offering comprehensive conservative care to south and southwest suburbs of Chicago.  CIM focuses on evidence based, conservative neuromusculoskeletal care (evaluation and treatment of nerve, muscle, bone, joint, and soft tissue injuries) and evidence based, conservative internal medicine.  CIM offers niche based care in integrated medicine, sports medicine, orthopedics, rehabilitation, women’s health, pregnancy care, and pediatrics. CIM also offers custom lab testing, acupuncture and comprehensive nutritional analysis.  Dr. Dino focuses on sports medicine, orthopedic injuries and rehabilitation.  He enjoys working with athletes of all shapes and sizes at all skill levels from professional to recreational with particular interest in endurance athletes (running, biking, swimming and triathletes), throwing/overhead athletes (baseball, softball, volleyball, tennis, swimmers), and athletes in contact sports (football, rugby, lacrosse, soccer, basketball). He can be reached at drdinopappas@gmail.com.  To schedule an appointment, please contact 708-532-CFIM (2346). ***

*** Dr. Kathy Dooley is a mentor and a colleague. We first met Dr. Dooley in the anatomy lab at Logan College of Chiropractic in September 2006. Her passion for helping people was evident back then and continues today. Dr. Dooley is a woman of many talents and those include as an anatomy instructor for several major medical and allied health institutions, as a practicing chiropractor in the state of New York, as a traveling instructor teaching NeuroKinetic Therapy (a novel diagnostic method that uses muscle testing, assessment of motor patterns, and integration of brain, pain and movement science – http://neurokinetictherapy.com/), as an acupuncturist and a student (she continuously strives to learn, grow and be better). She has spent endless hours dedicated towards her craft with elite level certifications with the Motion Palpation Institute (MPI), Selective Functional Movement Assessment (SFMA), Strong First (SFG), Russian Kettlebell Challenge (RKC), NeuroKinetic Therapy (NKT), and as a Certified Kettlebell Functional Movement Specialist (CK-FMS). Perhaps, her best quality is the zeal for life she exudes. She can be reached at drkathydooley@gmail.com.  Check out her website at http://www.drdooleynoted.com/background/ and make sure to watch her informative and inspiring YouTube videos at https://www.youtube.com/user/drkathydooley?feature=watch).

Be Sociable, Share!

Leave a Reply

Looking for something?

Use the form below to search the site:

Still not finding what you're looking for? Drop a comment on a post or contact us so we can take care of it!

Visit our friends!

A few highly recommended friends...