Flexibility: What the Research is Finding, and Missing

Charlie Hoolihan, CSCS*D, NASM, CES/PESPelican Athletic Club Personal Training Director

Charlie@thepac.com

Goals of Flexibility To improve motion. To improve length tension

relationship in muscles and joints. To improve neural stretch response. To improve postural alignment. To improve function.

Let’s see!– Breathe!– Slump rotation/good posture rotation– Close eyes and notice where your weight is

absorbed through foot.– Foot Circles – 20 inside/20 outside/20 point/flex.– Walk around room. Notice change– Get partner and touch toes. – Reassess– Find a chair/table/or stage– Tri-plane hip flexor stretch one side only– Walk and notice difference. Finish other side.– Grid Foam roll volunteers.

No stretching!!Releasing hamstrings. (Egsocue/Carey) Foam roll for posture.

• Above photo – dog for 2:00, above right, spinal twist for 1:00 each side then cats and dogs (cat at right) for 20 reps.

Hip Flexors – (Gray/Wolf/Parracino)

Left: Sagital plane – lean slightly to stimulate muscles from foot to fingers. Middle: Rotate toward back leg with slight leg. Right: Rotate towards support side with slight lean.

Overhead squat (Cook, Carey et. al.)

Foam roll – upper back, piriformis, IT band

Rotation lunges with opposite transverse reaches (Gray/Wolf/Parracino)

Right: front rotation; Left: Reverse rotation

What is optimal range of motion?

Range of motion is life• Hip extension/flexion, spinal rotation/extension/flexion,

knee flexion/extension, shoulder abduction/adduction, dorsi/plantar flexion, etc. All before hitting the ground.

• The association between flexibility and running economy in sub-elite male distance runners: CRAIB, MITCHELL W.; MITCHELL, VICKI A.; FIELDS, KARL B.; COOPER, THERESA R.; HOPEWELL, REGINA; MORGAN, DON W. Department of Exercise and Sport Science, The University of North Carolina at Greensboro, Greensboro, NC Medicine & Science in Sports & Exercise:Volume 33(5) Supplement 1May 2001p S23.

• Although speculative, these results suggest that inflexibility in certain areas of the musculoskeletal system may enhance running economy in sub-elite male runners by increasing storage and return of elastic energy and minimizing the need for muscle-stabilizing activity

• Study comparing the hip extension ROM of sprinters and distance runners found that sprinters had more ROM in hip extension than distance runners.

Going through these ROMs without ground force.

What functional ROM’s here?

You never know when you need the extra ROM. (Active or Passive)

Even regular guys work extreme ROMs

To achieve goals we must:

Understand the purpose and stretch to an ideal end range of motion of a real life motion. Understand that active and passive motion are

two different things.

Understand the muscles systems required to get to the End range of motion.

Understand what may be interfering with the end ranges. Tightness or weakness

Utilize an variety of techniques achieve goals.

What about research

There is research that says some forms of stretching are: Ineffective and a waste of time. Increases the chance of injury. Decreases strength and power. That static stretching is superior to PNF That PNF is superior to static stretching That stretching should be active. That stretching should be passive.

AAAAAAAAAGH!!!

• Thacker et al: Impact of Stretching on Sports Injury Risk. MSSE– “There is not sufficient evidence to endorse or

discontinue routine pre or post-event stretching to prevent injury among competitive or recreational athletes.”

Common Sense When we stretch it feels good. Animals stretch and seem to like it. Yoga and other eastern movement

modalities have been practiced for thousands of years.

People who have limited ranges of motion get injured or are in pain. Maybe the research is not quite

measuring the right movements. Maybe the stretches are too isolated.

Research on research

• Test-Retest Reliability of 20 Flexibility Measures in Adults: O'Neill, Cian M.; Donncha, Ciaran Mac. University of Limerick, Limerick, Ireland. Medicine & Science in Sports & Exercise:Volume 39(5) SupplementMay 2007p S344

– The purpose of this study was to examine the reliability of 20 joint flexibility measures in a

healthy adult population. – Concluded only 12/20 for males and 8/20 for females

were reliable.• The Effects of Hamstring Stretching on Range of Motion: A

Systematic Literature Review. Decoster, Cleland, Altieri, Russell. Journal of Orthopaedic & Sports Physical Therapy. Volume 35 • Number 6 • June 2005.

– Found flaws in 78% of 20 methodological proceedings making it difficult to identify effective hamstring stretching modalities.

Conflicting Research?

• AN EXAMINATION OF FLEXIBILITY AND RUNNING ECONOMY IN FEMALE COLLEGIATE TRACK ATHLETES. Beaudoin, C M.1; Blum, J Whatley1 1University of Southern Maine, Gorham, ME

– Results suggest that subjects with greater trunk rotation were more economical than subjects with less trunk rotation. Results support general beliefs that improved flexibility is desirable for enhanced running economy.

• The Association Between Flexibility and Running Economy in Sub Elite Male Distance Runners: Craib, Mitchell, Mitchell, Fields, Cooper, Hopewell, Morgan. UNC Greensboro. MSSE, Vol 35. Supplement, May 2001.

– Although speculative, these results suggest that inflexibility in certain areas of the musculoskeltal system may enhance running economy in sub elite male runners by increasing storage and return of elastic energy and minimizing the need for muscle stabilizing activity

• Study comparing the hip extension in sprinters and ld runners found that sprinters had more ROM in hip extension than distance runners.

Neuromuscular variable may produce some answers as measuring tools improve.

• Neural Aspects of Muscle Stretching: Nathalie Guissard and Jacques Duchateau Laboratory of Applied Biology and Research Unit in Neurophysiology, Universite´ Libre de Bruxelles, Brussels, Belgium.Exerc. Sport Sci. Rev., Vol. 34, No. 4, pp. 154Y158, 2006

– Conducted 30 stretching sessions and measured the neural responses and found that neural input was reduced and flexibility increased.

– Considered the possibility that stretching reduced the afferent feedback via the muscle spindles and reduced their sensitivity and increased the compliance of the passive elastic components of the muscle tendon unit.

• Proprioceptors may be the key component in the conflicting research – Gray – At least six different kinds of proprioceptors with different neuromuscular functions at

different locations in the joints, tendons, muscles and ligaments. They measure and report to the brain about length/tension relationships, velocity, force, end ranges of motion, types of motion etc.

• And if proprioceptors don’t recognize a motion. They will shut things down and this is when injury occurs.

Posture and alignment variable

The effects of pelvic position and stretching technique on hamstring flexibility: Sullivan, Dejula, Worrell. Krannert Graduate School of Physical Therapy. University of Indianapolis. MSSE. Vol 24, Number 12, 1992

Study specified that anterior pelvic tilt (right) was more effective than posterior tilt (left). But also notice thoracic flexion vs. extension as well.

Multidimensional variableA Comparison of 2 Rehabiliation Programs in the Treatment of

Acute Hamstring Strains. Sherry and Best. Journal of Orthopaedic Sports Therapy. 2004; 34:116; 116-125.

Compared traditional static stretching, isolated progressive hamstring resistance exercise and icing (STST) with a program of progressive agility and trunk stabilization exercises and icing. (PATS)

Results – Return to sports STST – 37.4 days; PATS, 22.2 days

Results – Re-injury rate 2 weeks after – STST, 54%; PATS, 0%

1 year after – STST, 70%; PATS, 7.7%

Myofacial Release. Foam roll

Multi-plane static stretching. Hip flexor stretch.

Passive joint alignment. Foot circles, dog/spinal twist/cat-dog

Active multi-plane dynamic warm-ups. Lunge matrix

NOTE: Because flexibility research is extremely fluid and somewhat contradictory right now, it behooves us to continue to stay abreast of current research and examine the research protocols.

Answers may be found in mixed modalities

Myofascia Release Myofascia - Connective tissue that consists

partly of endomysium, epymysium and perimysium that bundle the muscles and muscle fibers. It creates the linked muscle systems that are involved in motion by compartmentalizing, maintaining structural integrity and helping to define muscle motion and resisting mechanical stressors.

Multi-plane Static Stretching

Most end ranges of movement exist in three planes of motion.

Most injuries occur in the frontal and transverse planes.

Most static stretching protocols occur in sagital plane.

End ranges of motion in frontal and transverse planes involve distal deceleration before a proximal acceleration.

Hence it makes sense to stretch in all three planes of movement that are relative to the motions that are being prepared for.

Passive Alignment Techniques

Mostly gravity based Allows for bilateral

alignment patterns Some are passive Some are somewhat active Some isometric

contractions. Can be done post-workout to

undo stressors placed on joints.

Can be done at home for therapeutic purposes.

Active Multi-plane warm-up techniques

Tri-plane movements Similar to tri-plane

static stretching Dynamic and

progressive Can also morph into

loaded workout phases

Strengthen weak muscles schools of “flexibilty”

• Muscle Activation Therapy (Roskopf)– Symetrical ranges of motion.– Strengthen isolated weak muscles through :06 isometric

contraction.• Muscle Energy Therapy (Chaitow)

– Origin school of thought• Isometric, concentric, eccentric and isolytic exercises

• Proprioceptive Neuromuscular Facilitation (PNF)– Reciprocal inhibition. Contract antogonist of muscle that is being

stretched. 6-10 seconds. Then move to new position.

• Active Isolation Stretching (Mattes/Wharton)– Reciprocal Inhibition.– Stretch isolated muscles with a :02 stretch to avoid myotatic reflex at the

:03 mark.

Multi-Directional Movement Mechanics considerations.

Because athletic and functional movements are multi-directional and need multi-directional flexibility

Posterior and Anterior Linked systems Superficial large muscle groups (Anatomy Trains)

Rotation and deep support. These groups, especially deep muscle groups, are most often under-trained and under-stretched. (Anatomy Trains)

Frontal and Transverse Plane Systems (Anatomy Trains)

• Color of Text

More Muscles in motion(Yoga Anatomy)

Foot alignment must be considered in flexibility. (Rolf)

Multi-plane multi movement joints

(Boyle/Cook) Foot flexibility and mobility. Increase dorsiflexion. Internal rotation.

Pelvis hip flexors and extensors. Abductors and adductors. Balance and alignment.

Thoracic spine mobility. Shoulder girdle mobility.

Strength, weaknesses and tightness in hip musculature can be critical. (Rolf)

15 lower body muscles attach at hip

Even subtle differences in hip orientation.Sciatic nerve is entrapped in both excessive anterior and posterior tilts.(Rothbart)

Entrapment and outlet syndromes tip of the iceberg (musculosketal atlas)

Can isolated single plane stretches help these muscle groups?

(Musculoskeltal Atlas)

Or these? (Musculoskeltal Atlas)

17 muscles attach to scapula

Day to day life determines flexibility patterns

• Restrictions are developed over time.• Posture is controlled by beer and TV.• Muscles and muscle patterns move bones• One stretch session cannot fix• (Carey)

Time under tensionHow long to stretch?

• Research and “experts” 3 seconds to 30 minutes• Undoing a lifetime of posture or repetitive

movement.• How long are you in the position of limited range

of motion?• How long do you repeat a certain range of

motion? • Muscles and Muscle movement control joint

motion.

Lower body release, lengthening and alignment.

Make sure thoracic spine is right – upper back roll.***

Create sensation of proper foot strike – foot circles

Improve dorsiflexion – heel drop and calf roll. Increase ROM in hip flexors – tri-plane hip

flexor stretch.*****Important to swimmers for length of stroke

and injury reduction.

10 minutes of Myfacial release

Upper back roll. Piriformis/TFL/ITB Hamstrings. Calves/Tibiali/Peroneals. Quads/Adductors.

Foam roll – upper back, piriformis, IT band

Preparing to squat

Left: Air bench – hold for :30 focus on foot placement, equilateral muscle activation in quadriceps and adductors – especially medial, driving to heel. Right: Heel drop – line all joints up so head rests on heels. Hold for 1:00 – (Egoscue/Carey)

Hip Flexors – (Gray/Wolf/Parracino)

Left: Sagital plane – lean slightly to stimulate muscles from foot to fingers. Middle: Rotate toward back leg with slight leg. Right: Rotate towards support side with slight lean.

Releasing hamstrings with no stretch. (Egsocue/Carey)

• Above photo – dog for 2:00, above right, spinal twist for 1:00 each side then cats and dogs (cat at right) for 20 reps.

Stimulate hamstring length with movement (Egoscue/Carey)

From left: Track start initial position, track start triangle position, hamstring extension finish position. The start position is a 90 degree knee bend tapping the wall. There is a small ball between knees to encourage alignment. Alternate foot positions to stimulate all three hamstring bands - Egoscue

Hamstrings – (Gray/Wolf/Parracino)

Left: Bend from hips into stretch. Middle: Rotate towards support leg. Rotate away from support leg. In all stretches, keep foot in dorsi-flexion. Option to turn foot in or rotate from side to side.

Passive Healthy and aligned hip flexion (Egoscue/Carey)

Passive hip stabilizationUnilateral and bilateral.

(Egoscue/Carey)

Promote bilateral symmetry from AB and AD ductors (Egoscue/Carey)

Internal and external rotation in femur and pelvis (Egoscue/Carey/Gray)

Extension, alignment and the true nature of abdominals. (Gray/Wolf/Parracino/Carey)

Lateral lunges with overhead opposite reach (Gray/Wolf/Parracino

Land with whole foot on lunge. Shift balance. Stretch into overhead. Lateral support group is fired and ready

Rotation lunges with opposite transverse reaches (Gray/Wolf/Parracino)

Right: front rotation; Left: Reverse rotation

Thoracic Spine position – (Resistance Training Systems)

The only point of attachment for the arms (Rolf)

Elevated or upright posture opens up chest cavity. The heart and aorta have ample room to deliver blood and oxygen to the body. The lungs can expand to full capacity. 

An extreme example of how a slouched posture can compress heart, lungs, aorta and interfere with proper cardiovascular activity.  

Another extreme example but compression can also occur in the lower organs like stomach, liver, spleen, uterus

 

Proper Thoracic extension goes beyond arthrokinetic issues and into cardiovascular efficiency

Lymphatic system and hip flexors

• Diaphragm stimulates the natural pumping action of lymphatic system.– Heart transplant study. Lymphatic system efficiency is

increased by up to 700% via exercise.

• Psoas and QL are attached to the diaphragm via fascia.

• Restrictions in the thoracic spine, restricts breathing which restricts lymphatic circulation.– (Principles of Manual Therapy)

Upper body alignment guidelines Upright thoracic cage Alignment of Deltoids Activation of rotator cuff Scapular mobility and placement Rotational component Compound movements Relate upper body reaction to abdominals

and lower body.

Stretch/release anteriorStrengthen posterior

Upper back roll, lat (see below), pec and shoulder roll with small ball Wall clock Lateral Oblique stretch on wall Mock Shoulder press Arm circles and elbow/scap squeeze

Make sure upper back muscles are strong.

Pec and lat stretches on wall, doors or corners. Cross chest stretch contraindicated unless stuck in the hallelujah position.

• Pectoral and lat releases (Soleway,Lang)

Thoracic activation linked to lower body

Plus wall clocks and leans(Egoscue/Carey)

Doorway and countertop stretches

(Egoscue/Carey)

Wall Clocks – (Egoscue/Carey)

TYLs -Strengthen

Scapular activation for :06 – work on strengthening muscles to bring scapula closer to midline with ‘T’, rotated down and closer with ‘Y’ and down with ‘L’. Two or three six count reps per exercise.One hand width guideline.

Shoulder extensions with lunge – (Gray Cook)

Shoulder flexions with lunges – (Gray Cook)

Select BibliographyMuscles: Testing and FunctionMuscles: Testing and Function. Kendall, McCreary & . Kendall, McCreary & Provance. (Lippincott, Williams & Wilkins)Provance. (Lippincott, Williams & Wilkins)Pain FreePain Free – Pete Egoscue and Roger Gittens – Pete Egoscue and Roger GittensThe Pain Free ProgramThe Pain Free Program – Anthony Carey – Anthony CareyAAnatomy Trainsnatomy Trains. Thomas W. Meyer. . Thomas W. Meyer. Janda Compendium,Janda Compendium, Vladimir Janda. ( Vladimir Janda. (www.optp.com)www.optp.com)Athletic Body in Balance. Athletic Body in Balance. Gray CookGray CookBody Therapy: Small Ball Release Body Routine. Body Therapy: Small Ball Release Body Routine. Cheryl Soleway, PTCheryl Soleway, PTExplain Pain.Explain Pain. Butler, Moseley Butler, Moseley7-Steps to a Pain-Free Life.7-Steps to a Pain-Free Life. McKenzie McKenzieChi Running.Chi Running. Danny Dreyer Danny DreyerDiagnosis and Treatment of Movement Impairment Diagnosis and Treatment of Movement Impairment Syndromes,Syndromes, SA. Sahrmann. SA. Sahrmann.Musculoskeltal Atlas – Musculoskeltal Atlas – www.depts.washington.edu/msatlaswww.depts.washington.edu/msatlas

Select BibliographyRolfing: Ada RolfRolfing: Ada RolfActive Isolated Stretching: Active Isolated Stretching: Wharton, Random HouseWharton, Random HousePrinciples of Manual Therapy:Principles of Manual Therapy: Greenman. Lippencott, Greenman. Lippencott, Wilkins and Williams. Wilkins and Williams. The Trigger Point Therapy Workbook.The Trigger Point Therapy Workbook. Davies, Davies Davies, Davies and Simmons. New Harbinger Communications.and Simmons. New Harbinger Communications.

Selected Bibliography (web sites and coursework)

Chek Institute – Chek Institute – www.chekinstitute.com

Scientific abodominal training courseScientific abodominal training course..

Egoscue Method – Egoscue Method – www.egoscue.com

PAS course.PAS course.

Anthony Carey – Anthony Carey – www.anthonycareyinc.com

Movement by Design course.Movement by Design course.

Corrective Exercise DVDsCorrective Exercise DVDs

Functional Design Systems (Gary Gray) Functional Design Systems (Gary Gray) www.functionaldesign.com

Chain Reaction SeminarsChain Reaction Seminars

Functional Video Digest – 48 DVDsFunctional Video Digest – 48 DVDs

PT on the Net. PT on the Net. www.ptonthenet.comwww.ptonthenet.com

Selected Bibliography (web sites and coursework)

Chuck WolfChuck Wolf

Flexibility Highways DVD, one day seminar and IDEA Flexibility Highways DVD, one day seminar and IDEA workshops.workshops.

www.3dhumanmotion.comwww.3dhumanmotion.com

Muscle Activation Technique (MAT) Muscle Activation Technique (MAT) www.muscleactivation.com

Three weekend MAT Jumpstart CoursesThree weekend MAT Jumpstart Courses

Assessment and Exercise DVDAssessment and Exercise DVD

Resistance Training Systems Resistance Training Systems www.resistancetrainingsystems.com

CertificationsCertifications

Gray Cook – www.functionalmovement.com

One and two day seminars.

Lenny Parracino – www.kineticconditioning.net