We often have excuses for not getting some exercise in every day. If you’ve ever needed a kick in the butt to get you out the door, maybe these stories will inspire you (or shame you into getting some exercise!)
Recently, 2 new records were made in the 60m dash…
First, we have Julie Hawkins – 102 years old, setting the 60m record at 24.79 (she is the runner in Lane 1, wearing red)
Second, we have Orville Rogers – 100 years old, setting the 60m record at 19.13 (he is the runner in blue, with the bright yellow shoes)
Alternatively, you could be inspired by that guy in the green. That is Edward Cox, 90 years old and he ran the 60m in 16.77 seconds!
Here is a pic of the two centenarians:
As clinicians, we all want to help people. It feels good to help people. We do what we can to accomplish that goal.
Patellofemoral Pain Syndroms (PFPS) is known as “runner’s knee”. Knee pain is by far the most common location of pain for distance runners and PFPS is by far the most common type of knee pain in runners. In other words, we see it often.
There are many, well researched, effective ways to treat PFPS including quad, gluteal and core strengthening. There are many systematic reviews covering this (see here, here, here and here). Training errors also play a large role in developing this pain and shoe choice has a large role as well (see here).
However, I don’t want to explore all of that in this brief blog post. I only want to talk about taping for PFPS. If it is true that, as clinicians, we want to do what we can to help patients, why not do some taping as well? After all, taping helps reduce pain as well as alter the patellofemoral joint mechanics, so of course we should. Or…..does it?
McConnell taping is used ostensibly to change the patellar medial glide, medial tilt, anterior tilt or rotation. Most studies have been performed in non-weight bearing (here, here and here), which obviously is not practical. Even then, the results are mixed as to whether taping makes any difference as to the patellar positioning. More recently, a better study was published comparing the patellar positioning whilst in 0°, 20° and 40° of weight bearing knee flexion (patellar position was evaluated by MRI). Three different conditions were used – no taping, McConnell taping and Kinesiotaping. Patellar positioning was the same in all three condition, In other words – taping with Kinesiotape of rigid McConnell tape DOES NOT alter the position of the patella in any positional sense, or with contact area.
A 2015 recent systematic review concluded, “The findings of this review demonstrate that there is currently inadequate evidence for the effect of McConnell taping on biomechanics and muscle activation in individuals with anterior knee pain. This necessitates the questioning of the routine use of patellar taping in clinical practice.”
I often hear the argument – “OK, fine. It doesn’t change the biomechanics, but at least it helps reduce pain.” Well…does it? This 2012 Cochrane review would argue “No”. They concluded, “A meta-analysis of the visual analogue scale (VAS) pain data (scale 0 to 10: worst pain), measured in different ways, from four trials (data from 161 knees), found no statistically or clinically significant difference between taping and non taping in pain at the end of the treatment programmes”
However, let’s pretend that you don’t want to believe that meta analysis. In other words, let’s pretend for a minute that taping actually DID reduce pain; My question is, “Why would you take a runner with PFPS, and try to mask their pain when they run?” I suppose there is a situation where the runner/patient has really, really important race that they are adamant about running. However, for everyday training, I would argue that they are doing themselves a disservice by continuing to run without changing their listening to their body, even if you already have them changing training habits, changing footwear or performing rehab exercises.
The title of this blog post is fake news. Very fake news. Nobody loves to run more than I do and by the time you have read this, you’re going to love running too. You’re going to get tired of how much running you will do. This blog post will Make Running Great Again.
OK, on to the evidence…
“Injury” can be summed up in a simple sentence: The load applied to a tissue has exceed the capacity of that tissue to withstand that load.
Stand in front of a speeding bus, and the load that the bus imparts on you will exceed the capacity of many bones and ligaments to withstand that load. There is a not so lovely example of a traumatic injury.
Non-traumatic injuries can occur as well. For example – we’ve been told that if you run enough miles in your life and your knees will degenerate. It’s a small load, but done enough times, the cumulative load will exceed the capacity of the cartilage in your knee and the cartilage will break down. Sounds reasonable, right? Fortunately, it’s not reality. At least, it’s not the total reality, if you’re smart about your training. If you agree with the statement that running will cause your knees to degenerate, you’re forgetting that we are adaptive, living beings. We are not mechanical. Mechanical models and biologic models are quite different. Let me explain:
If you drive your car around enough, the parts in the car break down through wear and tear. The parts do not adapt to the load being applied to them and they weaken and break down. That is the mechanical model.
Humans, on the other hand, are biologic. We adapt. If you go to the gym and lift weights, do your biceps wear down? No, they get stronger. If you are at risk of osteoporosis, you are told to increase your bone density by doing some weight bearing activities. Doctors know that bones adapt by increasing density to become stronger. This is the biologic model.
Because we are in the biologic model, we need to put an addendum on the end of the definition of an injury. It should read: The load applied to a tissue has exceed the capacity of that tissue to withstand that load. However, the capacity of the tissue will increase if the load approaches, but does not exceed the tissue’s tolerance.
So, why do doctors and many people not have the same attitude about knees and cartilage? Cartilage CAN adapt too! When it comes to the shape and healing, cartilage is much less adaptive than other tissues in the body, but it can certainly change is composition in a positive, healthy way.
For example, we know that when mechanical loading is taken away or diminished, cartilage becomes unhealthy. It actually becomes thinner [1,2,3,4]. Research also shows that cartilage thickness increases with increasing physical activity in children [5,6] but maybe not in adults . This is a bit conflicting, since it has been shown that knee cartilage is thicker in marathon runners compared to non-runners , although this was an observational study, so maybe those runners were running because they had thicker, healthier cartilage to begin with? This is the problem with this type of research.
However, that is with respect to cartilage thickness…
There is more to cartilage health than thickness. Cartilage composition is also important. Without getting too much into the detail of cartilage, it is made of cells called chondrocytes with an extracellular matrix. Within the extracellular matrix are glycosaminoglycans (GAGs) which contribute to the strength of the cartilage and also attract water in the cartilage. Van Ginkle et al., found that after only a 10 week “start to run” program, there was a significant increase in GAG content in the knee cartilage in the runners when compared to a similar group of subjects that didn’t run during that 10 weeks. They found this by taking MRI’s at the beginning and end of the 10 weeks. Tiderius et al., also found higher GAG content in runners compared to non-runners, and several animal model studies also support this [9, 10, 11, 12]. Therefore, it would seem that running positively alters the composition of the knee cartilage, despite the evidence being inconclusive when measuring thickness of cartilage in runners compared to non-runners.
In addition, a recent meta-analysis (pooled data from previous research papers) found that runners have a 50% less chance of ever undergoing knee surgery due to arthritis . We also need to take into account that one of the biggest modifiable risk factors for developing arthritis in the knee is being overweight – even more so than the non-modifiable risk factor of genetics . So if a high BMI is a big risk factor for developing knee arthritis, and running is a way to exercise to reduce BMI, and we know running improves the composition of cartilage, wouldn’t it be logical to run? One could argue that other, less mechanically stressful forms of exercise could do the same thing, but the mechanism thought to improve the composition of cartilage is the compressive, load bearing mechanism . You just don’t get that with swimming or biking.
Runners often tell me they can’t run because they feel pain in their knees. Again, this is often due to the application of the load. They are running in a manner that loads the knee excessively, or their training methods were poorly applied and the tissue didn’t have time to adapt. There are ways to remedy these problems.
In conclusion, research thus far has generally shown no negative association between long term distance running and knee arthritis, despite widespread public opinion that “running is bad for your knees.” Don’t believe the fake news 😉
I was recently approached by Kristian Manietta and Peter Lever – owners and hosts of trispecific.com and the Fat Black Podcast. They had seen my video online regarding Prescribing Running Shoes and read other posts on my blog and thought it would be worthwhile to interview me on running injuries, biomechanics and prescribing running shoes. I was (and still am) flattered. The Fat Black Podcast is a popular podcast with 20,000 downloads per episode.
The podcast can be found here (click on the pic):
Speaking to 20,000 people can be a bit unnerving. Speaking to 20,000 people when you have a pre-rehearsed speech will be hard enough however, speaking to 20,000 people when you’re getting asked questions and you can’t anticipate questions would be even more difficult.
That being said, I did make a couple mistakes:
1) At the 15:00 minute mark, the Brian Noehren study showed increased hip adduction did correlate with more patellofemoral pain I know the study inside and out and I don’t know why said “less”.
2) I got into many details and got sidetracked by my own ramblings quite often. I guess the issue is really about focusing on training errors as well as looking at the whole individual and not just biomechanics, shoes, stress levels, hormones, antibiotics, diet or other things that can be taken singularly and not as part of a larger picture
3) If the question comes down to whether or not giving a motion control shoe to someone who you deem is overpronating, or they have flat feet will affect injury rates, we need to just look at a few studies. The answer according to a few studies on that is “no”. Knapik et al. (2014) reviewed 3 studies of about 6,000 military recruits assigned shoes based on their foot type, like whether they has high arched or low arched feet, while they had a control group were assigned stability shoes regardless of their foot type. They found there were no differences in injuries between the two groups. Ryan did another similar study in 2011 and looked at women training for a half marathon and found the same thing, which was assigning a shoe based on the shape of your foot has no affect of injury. So then this year, Laurent Malisoux released a study where they found that motion control shoes did, in fact reduce injury in those with flat feet. The unfortunate part about that study is that 18% dropped out of the study in the group given neutral shoes and 31% dropped out in the MC group. We aren’t told WHY they dropped out. Why did 31% of the people who were given motion control shoes drop out when only 18% who were given neutral shoes drop out. Really? Almost double the amount of people drop out when they’re given MC shoes and we aren’t told why, and when they drop out, they aren’t included in the statistics at the end of the study, so they concluded that motion control shoes reduced injury. That seems strange to me when 31% of those people mysteriously dropped out of the study.
In the end, I still firmly believe that our bodies are amazing and are capable of adapting to the various loads we place on them. Most injuries in running are overuse injuries (unless you fall, roll your ankle or get hit by a bus). That basically means that the load is exceeding the capacity of the body to withstand that load. There are two ways to deal with that: 1) reduce the load and 2) increase the capacity of the body to take that load
Reduce the Load: this is in the form of offloading for a while to let the body adapt and/or reducing the load in terms of altering your training pace, spreading the load out more during the week, altering some biomechanics or maybe altering the shoes
Increase the capacity of the body to take that load: This would include GRADUALLY increasing training and giving the body time to make the necessary adaptations by increasing bone density, ligament strength, tendon stiffness, muscle strength etc. In addition I believe heavy resistance training is beneficial for tissue strength and hormonal factors.
Staying current on healthcare research is no easy task:
1) There are many hours of reading that go into it.
2) Summarizing all the evidence is also difficult.
3) Explaining it to patients in a manner they can understand is the final hurdle (the last part is a skill I wish my car mechanic and my IT guy would pick up on.)
These 3 problems haunt every healthcare provider who wishes to provide the best care for their patients. As a result of the problems listed above, I have made a few attempts to summarize current literature of a handful of different topics in the form of easy to understand videos.
When patients mention a certain topic, or we need to explain a detailed topic, we can direct them to these videos which makes all our lives easier.
I put some of these videos out on social media and some have become pretty popular (the shoe prescription one is averaging 2.5K views per week).
My Twitter feed (@runningreform) has attracted the attention of some leading biomechanics researchers and tendon researchers and other authorities. As a result, The British Journal of Sports Medicine approached me and asked me to write a blog post for them with a collection of some of those videos. BJSM has promoted @runningreform quite a bit on Twitter, so I’m assuming they feel the content of these videos is accurate as far as the best available research evidence. To say I’m honoured is an understatement.
Anyway, here is a link to the blog post:
This question came to us via Facebook. The response is a bit too long for FB, so here is the response…
“Beyond developing a strong core, which exercises are most effective for strengthening an injury-prone lower back?
BTW, it has been awhile, but out of sight is not out of mind! Always grateful for the excellent, expert care you have given… Straightening out my sideways…to keep me in the classroom and gym!”
Great question. The ideas of “core stability” and a “strong core” have been widely misinterpreted and abused and thus have come under great scrutiny lately (see here, here and here). I think the idea of “the core” is highly misunderstood and is confusing for many people for a number of reasons:
First of all, how do we define “the core”. Does it include the gluteal muscles, the diaphragm (a very important muscle for lifting), multifidus, the psoas and other hip flexors, the hamstrings (they do attach to the pelvis)? There are many different interpretations.
It has been misinterpreted that “pulling in the belly”, bracing before movement and/or doing a lot of sit ups and variations of the plank will create “core stability”. I think this has succeeded in making people think they need to become more rigid and stiff when they move, which would be detrimental.
Many trainers and fitness gurus have taken to training abdominal and low back muscles individually instead of as a group.
So back to your question regarding which exercises are most effective for an injury prone back…
Unfortunately, it’s a seemingly simple question without a simple answer, other than the answer of, “Whatever is appropriate for you.” I hope this doesn’t seem like a cop out answer. Let me explain.
There is no one cause of low back pain. It may be biomechanical irritation, spinal stenosis, discs, arthritis, referral from another organ, muscular, cognitive and many others. The appropriate exercise rests on what the source is. For example, in someone with pain from a disc, we generally want to avoid compression initially. Therefore, exercises which cause a lot of compression such as deadlifts may not be a good idea for those people. On the other hand, many people have great fear about their low back pain despite an absence of significant structural pathology. Those people need to be taught that hurt does not equal harm and they need more cognitive therapy where we reassure them that they will be OK and gradually expose them to more and more spinal loading as they realize they won’t get hurt. Ultimately, this may include a lot of deadlifting. In other words, exercises that will be great for one group may not be for another. Some people have poor control and/or mobility with rotation, some people have poor control with sagittal plane movements. Some people are exposed to heavy squatting when they can’t control a squat properly because they have really bad mobility in their ankles. The causes are multifactorial.
My point is, we are all individuals needing individual evaluation and then we need to address these issues. Often it’s biomechanically based, but it is also very often cognitively based.
Patients sometimes get upset when we talk about cognitive issues with low back pain. We must understand that this doesn’t mean patients are “making it up”. I frequently hear from patients that they have been told by another healthcare provider that they should avoid certain exercises or activities because they basically were deemed to have a fragile spine. This ultimately does more harm than good. It has been shown over and over again that “catastrophizing” a patient’s pain ends up causing the patient to actually feel more pain (here, here, here and here).
Essentially, the spine can be thought of as a movement system in 3 dimensions. Within that system are a variety of mechanisms that control intra-abdominal pressure, timing, mobility and stability. What we want to avoid is the idea that the back is fragile, or that you need to be rigid and stiff in order to avoid flare-ups.
I think the key is variety; Do a variety of different exercises and challenge your body in different ways.
Tendon pain is not as straight forward as Dr. Google tries to make it. While I understand most bloggers, friends and relatives have degrees from the Google School of Medicine, more often than not, well intentioned recommendations for managing tendon pain are inappropriate for patients.
If your buddy had a pair of glasses that helped his vision, I doubt you would assume that those same glasses would be appropriate for you. However, when it comes to treating low back pain, Achilles pain, hamstring tears, tennis elbow, shoulder pain, etc, etc…many people assume that the rehab exercises that helped their cousin will certainly help them.
Unfortunately, it doesn’t work that way. Many patients then question us when we recommend stopping the stretching, foam rolling or exercises that they have been doing for 6 months without success.
Let’s take lateral hip pain as an example. Dr. Google will typically recommend the following two interventions:
Unfortunately, the gluteus medius and gluteus minimus tendons get very compressed by the bone underneath it and thus, the tendon has a hard time healing. The role that compression plays in tendon pain cannot be understated. However, many patients don’t know the detailed anatomy (and they shouldn’t have to) so they have a hard time understanding what we mean when we talk about compression.
In an effort to improve patient education (and make life easier for me) I made a 5 minute video for patients to watch to help them understand WHY we recommend some of the exercises we do and WHY they should avoid others.
This post is just a few brief thoughts on a very complicated topic. I understand it’s not very sexy to make a post saying, “it depends”, but this is not a black and white issue. Those people that have made it appear black and white are deluding themselves, or are just not up to date on the research.
The impetus for this post is a few different runners who have presented to my office for calf pain. When I watch them run, their heels never touch the ground…ever. When I asked them if they were trying to run with a forefoot strike, they give me different answers, but are usually themed around the idea that, “that’s the way my coach told me to run” or, “I read on Runner’s World that heel striking is bad.” Oh boy…here we go.
Unfortunately, some coaches are part of the problem (the black and white problem). They apparently tell all their clients (or if it’s a high school coach they tell the whole team) that heel striking is bad and forefoot is good and they wanted everyone to avoid heel striking. There is very little that can be said in absolute terms when it comes to running form debates, but apparently some coaches feel that everyone should run with a forefoot strike (FFS as opposed to a rearfoot strike (RFS) or however the runner feels comfortable). While it is generally thought that a FFS will lessen the forces on the knee, those forces cannot just go away – they have to go somewhere and in the case of FFS, they tend to move to the calf muscles. In these runners, that would likely mean that the FFS is contributing to the calf pain.
Below, I have listed some papers that have shown that a FFS is generally not more economical, does not necessarily result in a lower loading rate, does not generally lead to lower injuries and results in higher loads to the posterior calf and Achilles (moves the load).
FFS is not usually more economical – papers found here, here and here
FFS does not usually result in lower loading rate – here
Forefoot strike vs heelstrike does not change injury rates –here
FFS results in higher loads on the posterior calf muscles (gastroc and soleus) and the Achilles tendon – here and here
Notice that I said “generally” not more economical, and “not necessarily” result in lower loading rate. I am using vague terms becasue in those studies, the MEAN result and the AVERAGE result showed that a FFS is not more economical or results in lower loading rate. There were individuals in those studies where a FFS did result in better economy and lower loading rates, but for the most part, it didn’t. But that’s the point – we’re all individuals, and to make sweeping recommendations for EVERYONE is ridiculous.
If you’re still reading and are hungry for more on this topic of individuality, I wrote another piece on the individuality of running shoe selection last year. If you’re STILL hungry for more info and you want to read more, I posted this piece on cadence and ground contact times – more on the loading rates in the comments section of the post.
It’s much easier to present evidence to someone who has no opinion vs. someone who already has preconceived ideas. Such is the case with stretching. For decades, the dogma has been that stretching is good for you. In some cases this is true, however when put to the test in research, stretching not only falls short of its intentions, it can be detrimental. I don’t mean to sound dramatic with that statement. Stretching is not catastrophic. It merely has the potential to be detrimental, so I think you should be aware before you stretch.
Keep in mind that when I mention stretching in this post, I am referring to static stretching (i.e. stretch and hold), not dynamic stretching (i.e. rhythmically moving a joint through its range of motion). So, without further ado, here we go…
Stretching: Injury Prevention and Athletic Performance
For the past 15 years, we have known that stretching prior to exercise does not prevent injury. The British Journal of Sports Medicine published a lengthy review of the topic in 1999 and concluded, “The basic science literature supports the epidemiologic evidence that stretching before exercise does not reduce the risk of injury.” Since then, many other papers concluded that stretching does not prevent injury. Those published in reputable medical journals include these ones in 2000, 2001, 2002, 2003, 2008, 2011, 2013 and there are quite a few other studies.
With all those studies and reviews pointing out that static stretching doesn’t reduce injuries, I have to throw out a small caveat. There are a couple studies (Small in 2008 and McHugh in 2010) that found that static stretching does not reduce overall injuries, but may reduce muscle strains. There was also this 2010 study that showed stretching “does not appreciably reduce all-injury risk but probably reduces the risk of some injuries” See if you can wrap your head around that ambiguous statement! (full text is available on the link I provided).
However, when weighing all the research, we can safely state that the overwhelming evidence shows that stretching prior to exercise does not reduce injury.
At this point, some zealots may wish to continue stretching before exercise. After all, “What’s the harm?” The harm comes in the form of a significant reduction in performance. What exactly do I mean by that? Well, static stretching has been shown to (at least temporarily)
reduce balance, reaction, and movement times (2004)
Some people argue that the reduction in performance is dose dependent. In other words, if you don’t hold the stretch too long, the degradation in performance won’t be too bad. Studies are mixed on that thought: This 2014 study found that no change was present in jump performance with a 30 second stretch hold, but jump performance was reduced with a 60 second hold time. This 2006 study found that strength output was reduced with a 30 second stretch hold, but was worse following a 60 second hold. Contrary to those studies, this 2006 study found that there was a similar reduction in strength output regardless of whether the stretch was 15 seconds or 30 seconds. Therefore, whether the detrimental effects are dose dependent is still up for debate. Lastly, this 2014 study found that 30m sprint performance was reduced even 24 hours after static stretching.
So if stretching before exercise is a bad idea, why stretch at all? I can think of 3 other reasons why people stretch and hold:
1. Stretching as Treatment for an Already Injured Tissue.
I hear this on a daily basis – New patients present to my clinic reporting for a muscle/tendon injury and soo they started “stretching the #$&@ out of it.” I would argue that your body is trying to mend the torn tissue, and you stretching it is disrupting that process. It’s like being married to a spouse who is in a bad mood – you just have to let them be – pestering them about their mood will not help!
Unfortunately, the research is sorely lacking on this. To my knowledge, there has been only one study where injured patients were split into two groups – one told to stretch and the other not. This was on hamstring injuries and the group who was put in the “more intensive stretching program” resulted in better mobility and earlier return to play (contrary to my views on stretching an injured muscle). However, I don’t have the full text of that study, so I don’t know what the differences between the treatments were in each group or any other details.
Contrary to that study and contrary to conventional public beliefs, the medical literature OPINION is firmly against aggressively stretching an acute muscle strain or tendon injury. For example:
American Journal of Sports Medicine, 2005 Muscle Injuries: Biology and Treatment: “We also instruct the athlete to move very carefully for the first 3 to 7 days after the injury to prevent the injured muscle from stretching.”
ISRN Orthopedics 2012 Treatment of Skeletal Muscle Injury: A Review: “…early mobilization also has disadvantages. The scar that is formed will be larger, and reruptures will be more common. Therefore, rest is advised during the first 3 to 7 days to allow the scar tissue to gain strength. Subsequently, mobilization within the pain free limits is initiated.”
Best Practice and Research Clinical Rheumatology 2007 Muscle Injuries – Optimizing Recovery: “We also instruct the athlete to take things very carefully for the first 3–7 days after the injury to prevent the injured muscle from stretching in any way.”
If you suffer from limited mobility in a particular range of motion (ROM), you may want to stretch the tissues that are limiting that motion. However, as outlined above, there may be concurrent detrimental aspects to stretch and hold. Methods other than static stretching can be employed to increase ROM. For example,
Myofascial Release Therapies: A review of the literature performed in 2014 , found that myofascial release therapies (Active Release Technique – ART is highlighted in the paper) are effective at increasing ROM and flexibility WITHOUT the concurrent detrimental aspects of force production or performance that are typically seen with static stretching. I spoke with one of the authors of the study (Darin Padua, PhD, ATC) and he stated that even though the paper was just published, there have been several new and better studies published since they submitted their article and it being accepted and published.
Strengthening: One thing that most people don’t realize – stretching does not change the structure of a muscle or tendon. It is thought that the increased ROM seen with stretching is mostly neurologic tolerance. Strengthening does actually change the structure of a muscle and tendon. As such, strengthening (eccentric strengthening in particular) has been shown to improve ROM and/or flexibility just as much, if not better than static stretching (2004, 2007, 2008, 2009, 2009, 2012 ). Eccentric strengthening will not only give the benefit of increasing flexibility and ROM, but also potentially give the added benefit of injury protection and improved performance.
2. General Health Benefits.
Some people just want to be more flexible. I get that. However, stretching to increase ROM in a joint/muscle/tendon that already has adequate mobility is going down a path that I’m not sure I would want to go down. There is convincing evidence that HYPERmobility (too much ROM) is a greater risk for injury than HYPOmobility (too little ROM). For example,
This 2014 study looked at over 800 women participating in a variety of physical activities over 100 weeks and found there was significantly more injuries in the women who had greater ROM’s
This 2012 study on English Premiere League soccer players found that hypermobile athletes had a higher incidence of injuries and were more likely to experience at least 1 injury, a reinjury, and a severe injury compared with non-hypermobile athletes.
A 2010 review paper pooled the data from 18 papers and concluded that general hypermobility resulted in a near 5 fold increased risk of knee injuries for athletes participating in contact sports .
So you’re a dancer or a gymnast who needs better flexibility? Fine, just be cautious… This 2013 study found hypermobility in certain joints increases injury risk and that, “Young dancers (less than10 years of age) should not be exposed to overload (especially of the back) or extensive stretching exercises.” That same study referenced another study that found, “joint hypermobility required by many dance styles may increase the risk of tendinopathy.”
Am I saying activities like Yoga and Pilates are bad for you? No, I’m not saying that. They is a great deal more to those practices than just the stretching aspect. There is an inherent component of novel movements, body control, movement variability, balance and coordination that are paramount in those practices. So hold the hate mail. I’m not saying Yoga and Pilates are bad.
Summary/Take Home Points
Does this mean that static stretching should NEVER be done? No, I’m not saying that. The main take home points are the following
Static stretching for injury prevention has not been proven; in fact it has been overwhelmingly proven NOT to help
Static stretching results in reduced power output and performance (at least temporarily
Generalized stretching just for the sake of stretching is unwarranted and potentially increases risk of injury if there is too much mobility
If you have limited ROM/flexibility, stretching is fine, but be aware there are equally beneficial methods in the form of manual myofascial release (such as ART) or with eccentric strengthening.
I am a firm advocate of movement screening with the SFMA. The SFMA is a series of movements developed by an advisory committee of orthopedists, chiropractors, physical therapists and athletic trainers. They developed 7 simple movements that everyone should be able to perform. If you cannot perform them, the evaluator can break the movement down into its individual parts in order to discover the reason for the faulty movement. AT THAT POINT, you can start a program to address any ROM/flexibility deficits you may have. However, stretching just for the sake of stretching, I feel is a poorly thought out plan.
I first wrote about the pitfalls of static stretching 3 years ago and was surprised back then at how popular opinion hadn’t caught up with evidence. Here we are 3 years later and the London Marathon website still says, “stretching can help protect your body from the impact of running on the road, while reducing muscle soreness and the risk of injury to muscles, joints and tendons.” Ironically, it is on their page titled “The Perfect Warm-Up“. It seems that though stretching is the modern day equivalent to Bilbo Baggins and the One Ring. It keeps calling out to people and making them do things they shouldn’t be doing and they just can’t stop themselves.
Tendinopathy (pain or pathology of a tendon) is a complex topic. Contrary to public opinion, it is relatively poorly understood by both healthcare providers and researchers alike. When you get into the specifics of the cellular aspects of tendon pain and healing, you need to understand substances that have pro and anti-inflammatory effects, for example TNF∝, interleukin, substance P, neurotransmitters such as glutamate (frankly, I have a poor understanding of those things as well) and other factors such as neural and vascular ingrowth and fibrotic development. There are also non-cellular factors that need to be considered such as central and peripheral sensitization. In addition, non-synaptic intercellular signalling is poorly understood. The fact is, understanding the biology, physiology and anatomy of tendinopathy is in its infancy.
With all these cellular and neural pathways to consider, it is easy to understand why researchers and clinicians don’t fully understand tendon healing or what even causes pain to be felt in tendons. As such, many clinicians turn to the simple solution of recommending some pain relievers or administration of an injection. However, more recent research is showing that these solutions may do more harm than good. For example…
The Use of Non-Steroidal Anti-Inflammatory Drugs (NSAID’s, such as Motrin, Ibuprofen etc)..
As I outlined above, there are many cellular factors involved in tendon healing. These require certain “signalling” processes along with “migration” of other cells to the repair site. It has been found in these two studies here and here, that Celebrex and Ibuprofen both inhibit these cellular processes from occurring which may, in part, account why tendon healing is impaired.
Contrary to the negative studies I just listed, there is a potential benefit to taking non-steroidal anti-inflammatory (NSAID) meds such as Ibuprofen and that is reduction in adhesion formation and improved range of motion (here and here). Some tendons in the body require the tendon to be able to glide freely relative to it’s sheath or surrounding soft tissues. Any restrictions in motion could potentially be harmful (although manual soft tissue techniques such as Active Release Techniques may remedy this). NSAIDs have been shown to reduce adhesion formation, thus improve the gliding ability of the tendon relative to its surroundings. The tendon in question needs to be considered in this case. For example, the Achilles or patellar tendons do not need to glide through a sheath or surrounding soft tissues like the flexor tendons of the wrist do. However, the Achilles and patellar tendons are subjected to much higher loads, so full tendon healing strength is a priority. Since NSAID’s appear to reduce healing strength, administration of NSAIDs for these tendons is questionable.
Use of Steroid Injections…
A 2013 study showed the use of corticosteroid injections in patients with “tennis elbow” resulted in better immediate improvements compared to placebo, however the patients who had the steroid injection were significantly worse off 6 months later and 1 year later. There were also more recurrences in the steroid injection group.
At the risk of being boring and listing many other studies just like the one above, let me just note a 2010 study that looked at 41 different published trials on the use of steroid injections for tendinopathy. This review paper showed that there is “consistent findings between many high-quality randomised controlled trials that corticosteroid injections reduced pain in the short term compared with other interventions, but this effect was reversed at intermediate and long terms.” In other words, people feel better for a while after a steroid injection, but later, they are typically worse off than patients who did not get a steroid injection for a tendinopathy.
In our clinic, we heavily rely on mechanotherapy for patients with tendinopathy. If you are unfamiliar with mechanotherapy, it is simply the use of mechanical loading on a tendon in order to stimulate cellular responses and structural changes. For example, if you lift weights, your muscles will grow. This is an example of a mechanical loading process, stimulating cellular responses which cause structural change. Weight bearing exercises are another example in that they stimulate bone growth. Conversely, if you are sedentary, there is no mechanical stimulation and muscles and bones will weaken. The same can be said for tendons. If you stimulate the tendon in the proper manner, tendon cells (tenocytes) will be stimulated through a process of cellular signalling that I won’t get into in this post. If you are interested in the cellular processes, please read this article.
What is well established, is that mechanotherapy, if done properly, has the best available evidence for treating tendinopathy for the long term. The words “if done properly” are not there by accident. Too little mechanical load doesn’t stimulate the tendon enough, whereas too much mechanical load may exceed the tissue tolerance and worsen the condition. One must find the “Goldilocks” phenomenon – not too little and not too much mechanical load. In addition, certain area of the tendons will respond better to certain types of loads. For example, utilizing eccentric drops with end ROM dorsiflexion on an insertional Achilles tendinopathy causes compression of the tendon at the end ROM dorsiflexion and will likely make the condition worse. Read more about the role of compressive loads and how it aggravates tendons here.
The “art” of therapy is designing a program for each individual patient, based on the tendon that is injured, the location of the pain within the tendon (musculotendinous, mid-portion or insertional), the age of the patient, the patient’s beliefs about their tendinopathy and how to manage it, the goals of the patient, the biomechanics of the patient, the motivation of the patient, the compliance of the patient and quite a few other factors that will get boring if I list them all.
In summary, the biologic and therapeutic understanding of tendinopathy is poor. That being said, utilizing medications that alter the healing process is a bit of a shot in the dark, since we don’t fully understand how they affect tendons, but we know there are significant detrimental alterations. For the better long term prognosis, however, I believe it is more prudent to progressively load the tendon and examine the patient’s biomechanics and training load/frequency.