My PT/MD told me that I'm not flexible enough and I that I should "just keep stretching."
This is a common statement that my patients tell me when they describe failed physical therapy and medical experiences from their past. In most cases they come to me frustrated and jaded - desperate for answers and skeptical about the rehabilitation field as a whole.
I don't blame them.
If pain relief was as simple as improving flexibility, I'd have been unemployed years ago. In my experience, pain is more complex and simply stretching a muscle(s) is only a small part of the equation for relief. In most cases, the problem causing their pain involves multiple body segments - more than just the "sore muscle" that caught their attention. A good rehab plan will address those segments and get them back to their lives faster than the "6-8 weeks" that was tossed out at their doctor's appointment when they inquired.
Here are three real-life examples.
(Also don't miss the self-assessment tool at the bottom!)
None of these cases involved dogs. I just think this photo is adorable.
Case #1: Soccer Sidelined
A patient came to me with a 3-month history of "hamstring tendonitis." The injury began while on vacation and he first noticed it after walking a great deal during the trip. After being referred by his PCP, he had seen another PT for about 2 months. During that time, he had followed instructions and stopped playing soccer and in doing so, had missed the chance to try out for another soccer team. While he had been diligent with his home exercises, the pain had not resolved - and during most PT treatments, it felt worse. Most physical therapy sessions had involved the other physical therapist aggressively stretching his hamstrings and the patient had been told that he "wasn't flexible enough".
When he came to see me he rated his pain at 4/10 with walking and an 8/10 with running or bending/kicking that leg. He was unable to play soccer, and struggled to get through the day without having to sit down.
Upon evaluation, it became clear that he had alignment issues in the hips and low back. This altered the movement pattern of his pelvis with bending, and increased the stretch on the affected hamstring with hip motion. Upon further inquiry, he noted that the week before vacation, he had stepped on a hole with that leg while practicing and had "tweaked the ankle." This had caused a bone in the ankle to stop moving appropriately - artificially lengthening his leg and leading to the hip and low back changes noted. In that first session, correction of the ankle & the alignment/motion in the pelvis and low back left him with an even "pull" in both hamstrings during bending - basically, the pain was gone with movement. He walked out without pain, but was told to do the follow up exercises and hold on soccer initially.
In several more sessions, physical therapy was able to restore strength to that side and address the fear of re-injury that had kept him out of sport. He still has "tight hamstrings" by traditional standards, but they are evenly tight - so it's not an issue. 5 sessions of PT and he's back to playing soccer - without sharp hamstring pain.
Case #2: "Running wrong"
A woman came to me for physical therapy after rest and medication had failed to alleviate her right ankle pain while running. She was a long-time distance athlete and had not changed her training dramatically in the past 6 months, but had begun to notice the pain "gradually increasing" when she trained. After several weeks of suffering, she had seen her MD and was told that she had achilles tendonitis on that side "because she was a runner" and had likely been "running wrong" on that foot. (Please appreciate the SMH moment I had when I heard this). He had prescribed her Motrin, more calf stretching and a mandatory break in her running. She followed his advice, stretching 3 times a day, but when she returned to running as prescribed at the 4 week mark, the pain was worse - and occurred earlier in the run.
Upon evaluation, the patient noted that her initial pain had begun about 2 months after she took a new job - one that required her to drive a longer distance (55 minutes each way). She had no history of a fall/trauma and was in great shape otherwise. She complained that "no matter how much she stretched the right calf, the leg was always tight." Objective assessment showed no variation in calf strength or flexibility, though the patient did have increased tenderness in the right calf. There was no swelling in the achilles and ankle stretching did not reproduce her pain. When hip/low back motion was assessed, there was stiffness on the left side. With muscle testing, her right (same side as the ankle) hip muscles were weak - testing at about 75% of the opposite side. Palpation showed significant tightness in those same muscles on the right.
In that session her alignment was corrected, soft-tissue work was done on the hip muscles that were tight, and she was sent home with several exercises to address the hip weakness. Not one second of her treatment was spent on the right calf.
She came back the following week, and tested equally strong on the right and left at her hips. (Meaning her weakness was from inhibition and not atrophy) There was no tenderness in the right calf and she noted that the sensation of tightness in that leg had "alleviated completely." She now felt "even" when she stretched her right and left calf muscles.
She was told to go running the next day and at her 3rd session, she reported "no achilles pain." She did not need any additional sessions and has since return to training and running marathons.
Her diagnosis? Hip/low back postural/movement dysfunction likely brought on by her new commute. She didn't have "tight calves" so no amount of calf stretching would have helped!
Case #3: Aggravated aerialist
A patient came to me with complaint of some mild low back pain and frustration over a sudden loss of flexibility in her middle split. She noted that she felt like it might be a "hip strain" as the amount of groin/leg pain that she felt with stretching forward was significant enough to cause her to stop. She had tried "stretching more" and was foam rolling those muscles 3-4 times a day. They always felt tight but neither activity provided relief and she felt like she was losing ground in her training. This condition had been bothering her for over 2 months when she decided to seek help from PT.
Upon assessment, the patient had alignment and segmental (joint) movement dysfunction in the pelvis & low back. There was less mobility in the lumbar vertebra and an overall stiffness through the low back muscles. She had tenderness in the gluteals on the right side and weakness in that hip. She also had a rib alignment issue on that side and some tightness through the latissimus dorsi.
During the session, the patient's hip alignment, low back alignment and rib mobility were corrected. Deep tissue work was performed on the right gluteals and the right latissimus dorsi. Joint glides were done on the low back to improve motion. At the end of the session, the patient was able to "pancake" again in her straddle split. This was the first time she had done so in over two months without pain!
Upon follow up via email, it was clear that the corrections lasted and the patient required no follow up sessions.
Okay, so those cases seem like some kind of voodoo magic. What key points are you trying to get across?
The moral of the story? Stretching has immense value, and as such - shouldn't be avoided in any complete fitness routine. That said, it isn't a magic pill and can't fix all of your ailments. Stretching works when the problem is a loss of muscular extensibility. It doesn't when the problem is more complex and involves joints and areas beyond the muscle being targeted. If you're struggling with pain/long-term tightness that isn't going away, some key "red flags" that it's not likely a flexibility problem (so stretching alone won't likely solve it) include:
You were diagnosed with a sprain/strain/muscle pull on one side WITHOUT a history of trauma.
The pain is ONLY on one side (even though you run, play and hang on both).
There is no noticeable change in your flexibility despite several weeks of consistent stretching.
The pain/tightness is temporarily alleviated by foam rolling/self-myofascial release, but then returns in a day (or less once) you train/are active again.
So, this is a topic that could fill another post, but the long and short of this blog entry: