Too Little or Too Much?
A few years ago, I was contacted by a writer for Elle, a fashion magazine, who was seeking my “expert opinion” for a piece she was preparing. Hard to believe, but she didn’t seem to be interested in getting my take on the latest trends in menswear! Rather, she was intent on learning about my experiences with patients who had been injured practicing, of all things, yoga.
Because most of us think of yoga as a gentle form of stretching, it may be surprising to hear that I have treated many patients over the years for yoga-related ailments. In some cases, folks have caused themselves acute injuries – usually your generic sprains and strains – by being too aggressive when attempting certain poses. In other instances, individuals have created, over time, a more chronic condition associated with excessive mobility of joints, particularly those in the spine. Such problems are not limited to those practicing yoga; anyone (can you say “runner”?) who regularly engages in efforts to maximize flexibility can be susceptible to injuries of this nature.
Most of us are conditioned to believe that we are not flexible enough. It is a rare runner indeed who comes to me complaining of being “too loose.” Perhaps the most frequent comment I hear is some variation of “my hamstrings are too tight.” (Most, in fact, have sufficient length of these muscles – they are mistaking fatigue and soreness for inflexibility.) A fair number of runners take this perceived need to improve their lower extremity flexibility a step further, believing that they also need to “Gumbify” the spine, particularly the lumbar, or low back, segments. So they embark on a program of exercises, not unlike those found in yoga, that they hope will permit them to put their head on their straightened knees, arch back far enough to touch their heels with the back of their head, and twist around enough to qualify for the starring role in Exorcist VIII.
There are several problems with this extremity-to-spine extrapolation. First of all, the structures most affected by lower extremity stretching are the muscles (hamstrings, quads, and calves primarily), while it is the joint capsules and ligaments that are mostly lengthened when performing spinal stretching. If the goal of these exercises is to achieve what would be considered “normal” flexibility and length of muscles, tendons, and ligaments, there really wouldn’t be any problem. Moreover, if muscles are stretched gradually over time beyond this accepted range, there really is no downside from a physiologic or biomechanical standpoint. Joint capsules and ligaments, however, are a different story.
All joints, like muscles, have a typical range of motion and degree of mobility. We are all generally familiar with conditions in which a joint becomes stiff and limited (hypomobile), the result of injury or disease (e.g., arthritis). The treatments for this – heat, ultrasound, manual therapies such as joint mobilization/manipulation, passive stretching – have been with us for eons and are generally accepted. At the same time, most people are less aware, conceptually, of conditions that involve too much movement of a joint (hypermobility).
Actually, almost everyone is familiar with at least one example of hypermobility. This would be the one that occurs at the shoulder, most often as a result of a dislocation of the ball from the socket. If the ligaments and capsule that contain the ball in the socket do not heal properly after such an event, the shoulder can become chronically unstable, with a partial or full dislocation occurring with some level of frequency from simply moving the shoulder in a particular direction.
Similarly, in the spine we often see conditions in which one or more segments become hypermobile or unstable, either secondary to trauma or excessive repetitive end-range movement, such as would occur with aggressive stretching. The lumbar spinal joints and especially the sacroiliac region (the upper tailbone and pelvis) are designed for stability, not mobility. Upset that balance and you have a recipe for trouble. Over the past few years, in fact, researchers have shown that this condition is the primary source of lumbar spine pain. In these cases, the emphasis of therapeutic intervention is to train the trunk muscles to stabilize the spine – not to stretch it.
Do not misinterpret this information to conclude that yoga, or stretching in general, is bad for you. The message here is that any stretching of the spine, or any joint for that matter, should be done gently and within its natural limits. In any case, the so-called “no pain, no gain” principle should be discarded completely. If a stretching movement causes increased pain when performed repetitively, it should not be done to “work through it.” You may be creating a long-term problem for yourself.