How then shall we stretch?

In the previous installment I was a stretching snob and offered much criticism regarding five common stretches. So here are a few alternatives. Please keep in mind that the suggested movements are not fitting for all people at all times. They are based on the typical stress imposed on our bodies and the typical response to movement. 

But we're not all typical. If you try these and feel pain or inordinate discomfort, 1.) your are performing the stretch wrong, 2.) stretching correctly but too aggressively, or 3.) the stretch simply is not good for you.

1. Instead of Neck Circles...Try cervical retraction and thoracic extension.

With cervical retraction, the lower cervical vertebrae are extending (moving backward) while the upper cervical vertebrae flex (move forward). This counteracts the typical slumped posture where the lower vertebrae are forward with the upper segments extended.  

You can also try thoracic extension stretches, which definitely reduce the strain placed on the neck by moving the mid- to upper back into a more upright position. Be sure to keep the head neutral (horizontal relative to the trunk).

[For all the videos, please excuse my less-than-polished commentary ; ) ]



2. Instead of Ankle Alphabets...Try ankle multiplanar stretches and some light balance work.  

For tight ankles, try something that will actually stretch the tissue you intend to be stretched. If you claim to have "weak ankles," make some single leg balance/reach type activities a part of every warm-up. 



3. Instead of toe touches...Try kneeling hip flexor/lower back stretches or prone press ups. 

Give your lower back and hips some much needed relief from all the forward bending. For the hamstrings try to hip hinge while keeping the knee extended and lower back neutral. 



4. Instead of the High Five Pec Stretch...try the "W" or low doorway stretches. 

Having the elbow well below shoulder level minimizes the risk of soft tissue impingement and does not promote more laxity of the anterior shoulder capsule. You may also want to consider thoracic mobility (see above) and the internal rotation "sleeper" stretch. 

5. Instead of Shoulder Circles...try push ups, yoga-push ups, shoulder elevation at wall and shoulder abduction with thoracic side bend.

Try to perform all of these while keeping the lower back neutral and the shoulder blades in proper position.



Many of the best dynamic warm-up movements provide a moderate stretch to many of the tissues involved above plus some dynamic movement with balance and control. While these do little to increase the flexibility of tight tissues, they do serve as a time efficient and much more effective warm up to physical activity. A few of my favorites are:



This list is not meant to be comprehensive, but certainly let me know if there any that I missed. Or if your shoulders did fine since the first grade with arm circles, well then, keep doing arm circles.

Top 5 Stretches to AVOID

Stretching is like dark leafy green vegetables. Some people love them. The other 99% of us feel that stretching is time consuming, mildly uncomfortable, and boring. But people who are healthy stretch. Because stretching is good for you. Right?

See this commentary [ Link: Stretching The Truth ] of what stretching does and does not accomplish.

While stretching is highly over-rated as a prelude to more vigorous exercise, it's often worthwhile in the context of physical rehab. Stretching may also serve as a simple and effective means of counteracting the daily demands we place on our bodies.

But not all stretches are created equal. Some are a waste of time and others may actually put you at increased injury risk. We've all seen and likely performed such ill-advised stretching.

I'll readily concede that there may be instances where some of these stretches may by warranted for select individuals. But here are the Top 5 stretches that most individuals should probably avoid:





Image: Dr. Gustav Zander's hip and abdominal stretching
machine circa 1880



Top 5 Stretches to Avoid:

1. Neck Circles

Neck circles are your grandfather's answer to every condition above the shoulders. Cervical disc herniation? Central canal spinal stenosis? Suboccipital muscle spasms? Whiplash? Give it some neck circles.  

It's easy to visualize how neck circles can be harmful when performed in less than ideal posture. But even in good posture, the 3 and 9 o'clock positions can be awfully hard on your neck.


2. Ankle Alphabets

This is where you are supposed to trace each letter of the alphabet with your toes. While I'm sure AAs have never caused an ankle or foot injury, neither have they helped other than possibly providing circulation to the area. There are far more specific and effective ways to strengthen and stretch the ankle, foot, and lower leg.

If your physical therapist, athletic trainer, or personal trainer has you do AAs, what they are really telling you is that you should move your ankle around while they complete their notes or something.


3. Toe Touches

Ah, toe touches. THE classic stretch, standing or seated on the ground, where the lower back and hips both bend (flex) forward. So after you had your lumbar spine and hips flexed while sitting all day at work or in class, while driving to the gym or athletic field, and while putting on your socks and shoes, you're going to stretch the back and hips into a MORE forward bent position?

There are some instances where forward bending of the spine is warranted. But far more often than not, such excessive forward bending causes problems. There are better ways to stretch the lower back and hamstrings.

4. Shoulder Circles

This is the one where a person puts the sore arm out to the side and grinds away. Despite what every gym teacher believed in the1980s, this movement is a poor choice for healthy shoulders much less sensitive ones. Sorry Mr. Waller.

Raising your arm up and back in a palms-down position compromises the space occupied by the rotator cuff tendons, subacromial bursa, and other soft tissues. Shoulder Circles cause these structures to get caught on or pinched between the humerus and shoulder blade.



5. High Five Pec Stretch

Most athletes who throw, hit, and serve with an overhead movement naturally acquire some degree of laxity or looseness in the front aspect of the shoulder joint. The rest of us desk jockeys and weekend warriors chronically sit with the shoulder blades tilted forward and the humerus seated forward in the socket of the shoulder blade. The High Five Pec Stretch is a great way to take both of these problems from bad to worse.

For healthy shoulders that enable you to do something that's worthy of an actual high five, avoid the High Five Pec Stretch.


Stay tuned for appropriate alternatives to these Bottom 5!

Why CUSTOM Orthotics?

Did a guy at Foot Locker or the Dr. Scholls machine at Walmart say that you need a certain insert? Do these gel inserts and other off-the-shelf varieties really accomplish much the same at half the cost of a custom orthotic?

These are good questions. My informal on-line search reveals a lack of quality advice on this topic. Those who manufacture and sell off-the-shelf inserts portray their product as pure nirvana for any and every foot condition. On the other hand, many medical professionals promote custom orthotics as if they are the only treatment option.

Not every person with a foot issue needs a custom orthotic (or an orthotic at all). Some will do perfectly fine in the right off-the-shelf insert while others clearly need custom inserts. And the Dr. Scholl's (and other) gel liners? If that's all it takes to clear up your chronic leg or foot problems, consider yourself fortunate.

Which type of insert is best for you? First a disclaimer!

Everyone has a unique set of circumstances. Some of the more obvious variables to consider include foot structure, movement quality (strength, flexibility, etc), and activity level. But there are an equal number of soft variables. What kind of shoes do you wear and are you willing to wear? How compliant will you be with instructions regarding orthotics, exercises, and a slow return to desired activities? How sensitive is your foot (really your entire being) to change?

Given the disclaimer, here are a few important considerations regarding off-the-shelf versus custom orthotics.

1. Soft off-the-shelf inserts:


There is a reason why most off-the-shelf inserts are made of gel or other squishy material: they will hurt people far less often than a more rigid off-the-shelf insert. The problem with gel inserts is that the treatment effect is minimal. While almost everyone will tolerate a gel or soft foamy insert, very few will see actual change in terms of pain and functional ability.

Take plantar fasciitis, for example. This problem is not due to ground pressure into the foot, but from abnormal strain ACROSS the length of the foot. The chronic pain, inflammation, and degenerative changes are caused by the PF being pulled apart and/or twisted, not from being pressed into. This is why squishy shoes, gel heel cups, and soft cushioning inserts rarely provide long-term relief.


2. Rigid off-the-shelf inserts:

Rigid inserts have greater potential for providing support and relief as compared to gel inserts. They stiffen the shoe and help the entire leg function with improved leverage. The problem with off-the-shelf rigid inserts is that they are constructed according to the average, most probable foot. So if your foot is a little wider or narrower, higher or lower in the arches, or the proportions and contours vary from the norm, the insert will often cause more grief than relief. This is an issue because it's those without "average" feet who have the most problems.

An easy way to see if you can get by with a rigid off-the-shelf insert rather than a rigid custom orthotic is to simply stand in them. Place them on the ground and then in your shoes. Walk around for 5 or 10 minutes if you can. If you feel contoured support but no ridges, abrupt creases, or edges, then it's probably worth the time and cost to give them a try.

3. Rigid custom orthotics:

These are constructed from a foam impression or a plaster cast that enables the clinician to capture the exact width, length, contour, and proportion of the feet. This allows for improved tolerance to a fairly rigid device. The clinician can also more easily identify high-pressure areas and perform various custom accommodations. Do you need a little or lot more arch fill than the norm? Do you need a metatarsal pad just proximal to (but not on) the a neuroma? Custom orthotics leave out any guesswork as to where various modifications should be placed.

It's important to keep in mind that orthotics are not magic. All inserts are most helpful when used in conjunction with other treatments that can help alleviate swelling and inflammation, improve strength, mobility, and gait pattern, and a skilled eye that can help you "marry" the appropriate orthotic to the right footwear.

No pain - no gain - no motivational cliche

"No pain - no gain" is a half-truth.

"Pain is weakness leaving the body," is dead wrong.

Suffering an injury when you're on the brink of a major challenge or p.r. is like picking Mr. Peppermint when you've just cleared the Molasses Swamp. But maybe if we combine the two oft quoted but false sayings we'll come out with something semi useful.

"Pain is weakness leaving the body - no gain." Or something like that.

While I don't often seriously utter motivational quotes, this mish-mash may be on target. What people are usually trying to convey is the value of toughening up mentally and physically. They're reminding us that there's no reward without intention, grit, and usually plain old suffering.

And it's the regular and disciplined practice of intention and grit that helps mold who you are, what you do, and how you respond to life above and beyond the gym or athletic field.

No, really, check THIS out. Also this.

[And yet all good things can easily be taken to unhealthy extremes. I believe there is more to living than the mechanical and biological...]

Compared to everyday existence, purposeful exercise is physically uncomfortable and mentally irritating. But those are some of the things we need most in our relatively comfortable society.

Name something that...

provides genuine physical and mental benefits
with a regular opportunity to take on challenge and risk
in a relatively safe but real environment
with parameters that you do realistically have some degree of control over?

Now how do you obtain the full dose of physical activity while minimizing the risk?

1. Smart programming. Study up so you know what you're doing or find someone who does.

2. Let gradual, process-focused progression be your guide. When we want results yesterday, we miss the value and built-in safety mechanisms of the ride.We do too much too soon and something suffers.

3. Watch the extremes: dead lifting your body weight for many reps with ease = good. Dead lifting triple body weight for one rep = risk. 5 K for faster time = good. Completing five marathons - risk.
Risk is fine if you're aware of what you're getting into.

4. Smart programming: Some degree of variety helps hold your interest and keeps you from over-training any one area or component of fitness. But too much variety never allows you to know where you stand in terms of truly facing limits. Doing too much at once often leaves you spinning your wheels due to incompatible goals (like improving both strength and running endurance). Think in terms of months and years not days and weeks. Set a goal and stick with it for a while. 

You don't have to destroy yourself with effort and injury in order to enjoy the plethora of "gain" associated with physical activity. The process need not require much time or expense. But the practice of discipline is a must, and that's never easy. Feeding your system relatively controlled doses of discomfort is absolutely good for us on a number of levels. The key is discovering the zone where you actually find joy in it.

"No hurries. No short-cuts."

Dead lifts for rehabilitation

"Wait, don't dead lifts cause injury? Like, people get injured doing them?"

Yes. People absolutely hurt their lower back doing dead lifts. We'll get to that. But first is the claim that dead lifts are a critical component of rehabilitation. Please consider reading this as a prelude:

You'll hurt your back (not) doing dead lifts!

From that essay:

Dead lifts accomplish what no machine, training device, or supplement can. They teach the brain to dial in the correct movement pattern for functional lifting. Picking things up is a part of life, unless you can find a way to hamstring curl your suitcase through the airport or leg press a new TV up the stairs. 

As a physical therapist, I've never tried documenting dead lifts as medically necessary. Medical doctors, insurers, and other third party payers would understandably raise an eyebrow. So instead, many patients under my care have something like this listed as one of their long-term goals:

Patient will demonstrate a proper neutral spine hip hinge pattern [shhh...a deadlift!] as a means to return to their basic self care, household tasks, and fitness/wellness activities without exacerbation of pain.

Take Quay as a case study to illustrate the point.

Quay himself in a cool display of extension overload!

Quay was seventeen when he first came to the office for treatment of severe and chronic lower back pain, demonstrating signs and symptoms of both flexion (too much bending) and extension (too much arching) overload. The pain increased when he sat and especially worsened when he extended his spine as in serving and spiking a volleyball.

With poor hip, abdominal, and lower back strength, his discs and vertebrae were taking the brunt of it. How else do you explain the MRI which revealed various degenerative changes? In the words of a local orthopedist, "He has the back of a 50-year old."

The problem was that Quay was not 50. He had plans to play volleyball and work and do things. He was not content with the "sit around and do as little as possible" route to long-term spinal...health.

So we began with some light hands-on work and wimpy core stabilization exercises. The pain remained off and on for some time, I believe primarily due to the fact that he was playing volleyball through a fairly significant injury. But the frequency and intensity of his pain slowly improved.

Quay began with dead lift variations in the clinic before he even realized it. He acquired knowledge of his limits, and sufficient strength and stability to tolerate some decent resistance training. After discharge from formal physical therapy, I had him pulling up the barbell within a partial range of motion. Not long after that, he managed to dead lift 150 pounds off the ground with nary an issue.

As of today, Quay is playing volleyball, jumping higher than ever, hitting, sprinting and lifting with much less pain. His brain has learned to "turn on" the stabilizing muscles when he moves, and he has developed adequate strength levels to effectively decrease the wear and tear on his back.

Quay is working consistently and I do keep pushing him to get even stronger. I'm certain that getting to the point where he can easily lift his body weight (say, ~ 200 pound dead lift) off the ground would be a realistic and fruitful goal.

Given his history, I would not encourage Quay to be a power lifter. Besides, nobody ever claimed it was necessarily healthy to test the absolute most you can lift for one repetition, especially in the dead lift. But I know equally well that the process of building strength and stability through dead lifting variation holds tremendous value for individuals who expect to do more than take it easy for the rest of their life.


 - - - - -

personal records in the rain (and other nonsense)

What did the neighbors think upon seeing a few of us running down Grantham road today? We're crazy. That's what I think, in the comfort of my own home or vehicle, when judging some poor soul wearing shorts and running out in the November rain. 

Addicted.
Obsessed.
Slave.
Would it really hurt you to take a day off?

Maybe nobody else gives it nearly this much thought. Of course this lack of grace toward the fanatical exercise guild says more about my own issues (and my day job). How obvious it is when examining others.

Thirty minutes later it's still raining. Grey dusk and colder temperatures are also upon us. The crown of my head is buried into the exterior hatch of the old Subaru because my shoulders are made waste and my hands keep slipping off the bumper.

Inching down Bonny Lane at some pathetic fraction of one mile per hour, every step is a grinding effort of literal and figurative hardheadedness. Each foot placement is a gamble as to whether or not the coefficient of friction of wet shoes and macadam is sufficient to withstand the applied force.

I'm trying desperately not to fail in an effort to match the epic Car Push that occurred last week (completed by two of my proteges nonetheless). Another neighbor pulls behind me. From the corner of my eye I notice that it's Jack from down the street. Nice guy. Usually waves or says hello to the kids. So I put my head down and dig. Jack patiently waits for the Subaru to clear a few cars parked along the side of the road before pulling around us.

And so I made it, joined the Cul De Sac Car Push Club at (possible) further expense to my reputation as an upright neighbor and proper 37 year-old. At least my doctor is pleased with the top notch blood profiles.

But sprinting and car pushing in the rain is far from the end of the nonsense.

A few weeks ago my friend Matt walked down Bonny Lane with a weighted barbell sustained high over his head. I Farmer Walked two heavy dumbbells as our kids biked circles around us. There have been thousands of tuck jumps and a few Tony Little Gazelle carries on that road.

Neither is the ridiculousness limited to the outdoors. Just two days ago I noticed bloodshot eyes after doing heavy dead lifts with a lifting belt notched too tight. Breaking the blood vessels in your corneas, that can't be a good thing...

I want to tell my neighbors that we're...not as bad as it looks. I want to explain how this sprinting and car push nonsense truly happens less than once per week, and we only train three days per week. The conditioning must happen on Friday because of tight family and work schedules. Friday comes but once per week, and this is actually something that we enjoy. Yes it's miserable but also rewarding. Training day is like when a dog who sees his master move toward the door with a leash.

"Who wants to go for a walk!"

That's the rhythm your body feels when it's time. And if we don't get some decent conditioning done on Friday, we'll be set back for...  ...

'Doh...

...That sets us back in terms of recovery for a heavy lifting day. Dead lifts will suffer. And we simply can't have that.

So never mind. I will simply smile and wave and thank my kind neighbors for tolerating the crazies. And I'm thankful for the fellow obsessives (including a few of those very neighbors) who join me, follow me, lead me.

And that's why you see us sprinting and pushing the car on a wet dreary Friday.
 

an open letter to the coach

Dear Coach,

Your commitment to the team is great. You genuinely want to help each athlete mature and develop to their highest potential. It's for good reason that you hope they are likewise committed to the sport and to you.

You don't want to see your investment depreciate during the off season, wasting five months finding trouble, losing interest, or sitting around becoming Call Of Duty champions. You want them to continue developing their skill, physical conditioning, and competitive drive. This is where I take issue.

There are patterns that I notice. I love sports and athletics, but not having a horse in the race gives me an advantage in perspective. I'll cut to the chase here. Why all the structured distance running in the off season? 

Running is better than nothing. It may even be the best thing for a few athletes. But when you actually evaluate the demands of the sport, and match that against the strengths and weaknesses of an individual, you will often find that running is far from the best use of their time.

I recently had a client ask what I thought of this typical soccer, basketball, lacrosse, field hockey, etc off-season training "strength and conditioning" workout.

- - - - -
10-15min Warm-up

10 minutes run at 60-70% MAS or around 75-85% HRmax

1 circuit of BW exercises - 15 reps each of air squats, split jumps, skater hops, and calf raises

10 minutes run

1 circuit of BW exercises

10 minutes run

1 circuit of BW exercises

STRETCH and COOL DOWN

 - - - - - -

This is someone's idea of a strength training? My response, for this athlete, was "Why?" I never said it was easy. Even if the sport in question is cross country or other endurance events, this is a fairly useless thing to trudge through during the off season.

Granted, most sports require running. Sports (and positions) vary greatly in the amount of endurance, power, and top speed that they demand. But even soccer players (ugh, especially soccer players) would do well to invest a three- or six month chunk of time toward developing peak speed and strength.

Focus on refining your weak points and movement patterns, pushing your body to new limits in jumping higher, sprinting faster, and actually moving some weight, not simply more more more distance running.

Do you imagine that a wiry teenager is going to become clunky and slow by devoting 6 months to building total body power and a little size?

This does not mean being lazy. This does not mean taking up hardcore Crossfit or Powerlifting as a competitive level. It does mean shifting the focus and priority for just a few months. It means giving the mind and body a chance to adapt to different yet complementary stimuli. What you get is a physically and mentally refreshed beast of an athlete in the new season.

No athlete can (or should) need to maintain peak endurance and stamina year 'round. Where strength, power, and size take months and years to develop, an active and motivated young adult can easily recover high level endurance abilities in two to three weeks.

What sport-specific test would convince you of this? The timed mile? A soccer player who trains appropriately with a power and speed emphasis can easily break the 6 minute mark with just a few weeks of endurance work.

Again, we're talking about a well designed strength and conditioning program involving plyometrics and total body resistance and conditioning with free weights, not group Boot Camp or sitting on various resistance machines mindlessly churning out 3 sets of 10.

See what happens when you give motivated, devoted athletes some structured training with a break from intense endurance work. You'll get a bigger, faster, more powerful version of the person you knew, with some newfound confidence to tear it up.