At least that’s the sort of sentiment my Twitter feed has been full of this week. So, rather than trying to share my thoughts on stretching with only 140 characters, I thought it would make an interesting blog post…
Last year (2013) Danish researchers Lauersen et.al. published a meta analysis? in BJSM, which has gone-on to gain some traction amongst the wider sporting community.
Here’s the Abstract:
The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials
Physical activity is important in both prevention and treatment of many common diseases, but sports injuries can pose serious problems.
To determine whether physical activity exercises can reduce sports injuries and perform stratified analyses of strength training, stretching, proprioception and combinations of these, and provide separate acute and overuse injury estimates.
Material and methods:
PubMed, EMBASE, Web of Science and SPORTDiscus were searched and yielded 3462 results. Two independent authors selected relevant randomised, controlled trials and quality assessments were conducted by all authors of this paper using the Cochrane collaboration domain-based quality assessment tool. Twelve studies that neglected to account for clustering effects were adjusted. Quantitative analyses were performed in STATA V.12 and sensitivity analysed by intention-to-treat. Heterogeneity (I2) and publication bias (Harbord’s small-study effects) were formally tested.
25 trials, including 26610 participants with 3464 injuries, were analysed. The overall effect estimate on injury prevention was heterogeneous. Stratified exposure analyses proved no beneficial effect for stretching (RR 0.963 (0.846–1.095)), whereas studies with multiple exposures (RR 0.655 (0.520–0.826)), proprioception training (RR 0.550 (0.347–0.869)), and strength training (RR 0.315 (0.207–0.480)) showed a tendency towards increasing effect. Both acute injuries (RR 0.647 (0.502– 0.836)) and overuse injuries (RR 0.527 (0.373–0.746)) could be reduced by physical activity programmes. Intention-to-treat sensitivity analyses consistently revealed even more robust effect estimates.
Despite a few outlying studies, consistently favourable estimates were obtained for all injury prevention measures except for stretching. Strength training reduced sports injuries to less than 1/3 and overuse injuries could be almost halved.
With a conclusion like that, I’m not surprised to hear many of those who have never really gotten on with stretching using this review to vindicate their often vocal anti-stretching standpoint.
Let’s Take a Closer Look
I’ve said it before; in the fitness industry we are often culprits of two mistakes:
1: Trying to polarise our stance on any given subject, and applying this across the board with our advice.
2: Reading research abstracts and jumping to conclusions, in lieu of reading and understanding the full text.
I do include myself in this… I think I’m getting better!
With that in mind, let’s take a closer look at the review and understand a bit more about the data involved. There are some key details to consider that aren’t addressed in the abstract.
Targeted Strength Training & Specific Outcomes
In this review, strength training was shown to reduce acute injuries down to one third, and overuse injuries down to one half. That’s great. There’s no arguing with that!
But, the question has to be: “what kind of strength training?” and “for which injuries?“.
When you dig into the data pooled from the 25 studies used for this review, you can see that half of the studies using strength training as an intervention focused only on hamstring strengthening, and only looked at changes in hamstring injury occurrence, rather than overall rate of injury occurrence.
Understanding that different types of injury occur across the body through differing mechanisms; this type of specificity will fall short of telling us the full story about the efficacy of strengthening regimes.
Multiple Training Methods
Eleven studies included in this review investigated the efficacy of multi-faceted programs incorporating multiple training methods. Typically (with a few exceptions) these looked at occurrence rate of all injuries or lower limb injuries in general as their outcome measure.
This is where research gets really tough, as different types of exercise/method will be more or less effective in helping to prevent any given type of injury. The scope is just so wide!
Being specific about the measure (i.e. type of injury) allows us to look at the effect of a specific intervention. Take the Gilchrist et.al. paper for example, which was used as one of the sources for this particular review, in the ‘Multi’ category. In their study, they wanted to see whether a simple on-field alternative warm-up routine can reduce non-contact Anterior Cruciate Ligament (ACL) injuries in collegiate female soccer players.
Their warm-up protocol focused on neuromuscular control exercises. Neuromuscular control is an accepted factor in non-contact ACL injury. It was observed that non-contact ACL injury rate among athletes performing their warm-up was 3.3 times less than in the control group. The specificity of this link between intervention and measured outcome enables strong conclusions to be made.
In comparison, this meta-analysis leaves a number of question marks in my mind when we consider how specific exercises will help target specific types of injury. We need to appreciate the demands/risks of the sport each athlete is engaging in, their injury history, and create their program accordingly.
What About Stretching?
So, back to the title of this article… Many of the articles, tweets etc that ensued as a result of the publication of this meta-analysis were focused on the loose conclusion that “Stretching Doesn’t Work” to prevent injury.
Of the 25 studies included in the review, only three specifically investigated the efficacy of stretching as a form of injury prevention.
In each of these 3 studies, the intervention was various forms of static stretching, rather than dynamic stretching pre-exercise. Thus it comes as no surprise to me that little benefit was experienced.
What to Make of All This?
Firstly, as ever, don’t be too quick to jump on the bandwagon. Be smart: check out the source and its data, not just the headline or the abstract!
Have a healthy cynicism about anybody touting method x, y, or z as being the “best” or indeed “of no use” for the prevention of injury in general terms.
We should be probably be speaking instead in terms of specific injuries, and types of injury commonly sustained by specific types of athlete.
- ITB Syndrome in Triathletes
- Groin Injuries in Soccer Players
- ACL injuries in Netball Players
For Runners & Triathletes?
Firstly, none of the papers reviewed in this meta analysis were looking at a running or triathlon population specifically. This is important to remember.
We know that in runners and triathletes, many (not all) of the injuries we see are overuse in nature and often come as a result of muscular imbalance, poor stability, and inadequate strength-endurance in certain areas. These factors create compensatory movement patterns, muscle activity and postures. Some muscles increase in tone (get tighter) and others become positionally weak as posture changes.
As runners and triathletes, we engage in highly repetitive movement patterns. Unlike many of the multi-directional sport (soccer, basketball, etc…) athletes from the studies in this review. In my experience, we’re more likely to build and reinforce overuse patterns and get ‘tight’ accordingly.
As an example of where daily habits become part of the picture, these imbalances are sometimes exacerbated by sitting for extended periods of time frequently.
Is stretching on it’s own enough to fix/prevent this. Nope! But it’s normally part of the big picture.
Muscles get ‘tight’ when they have a stimulus to do so. Perhaps it’s protective, perhaps it’s as a direct result of weakness or fatigue, or simply due to postural adaptation. Identifying these imbalances and dysfunctions is an important start, then correction usually combines strengthening, stretching, mobilising, improving neuromuscular control, movement pattern re-education etc…
In my opinion – and it does come down to opinion because the research isn’t conclusive yet – a multi-faceted program based on demands for the sport is the way to go for any given athlete’s injury prevention needs. Whoever is designing the program needs to understand the demands of the sport, common injury patterns associated, and of course the history of the specific athlete in question.
30 Day Challenge
This post was never meant to be a plug for our 30 Day Challenge, but it’s lent itself rather well to being just that. So I’m rolling with it!
I’m advocating a multi-faceted approach to injury prevention in runners and triathletes, combining elements of stretching, strengthening, balance/proprioception, technique, etc… All targeted in such a way to hit the commonly troublesome areas in this type of athlete.
Putting my money where my mouth is: Here’s our 30 Day Challenge – Check it out!
great post and great review of the research (thanks for digging). The research is always hard to pull from because they are using a linear treatment or prevention program for a multi-faceted problem. Stretching can also mean lots of things: dynamic, static, mobilization, and/or yoga. I really appreciate the multi-model approach you use. It offers offers balance and an incredible amount of novel stimulus to the body.
Thanks again for sharing
James – sorry for calling you Dave! My mistake!
A great and important review and necessary qualification to a bold statement on stretching. Since embracing both endurance running and the last 7 years, triathlon, my philosophy has progressed to a similar conclusion to your own, (partly down to experience and in part to following your site for the last two years). To keep the body in balance requires stimulus from different perspectives so the variation of exercise, stretching, static and dynamic and recovery and rest gives individuals the best chance of staying injury free.
Great post. I agree with several of the points you made. All too often, I see people jumping on a band-wagon (don’t Stretch, don’t Roll) based on incomplete information. Saying that “Stretching Does Not Work” is definitely an ‘Opinion’ (one based on a very limited set of data) and is not a ‘Fact’. As the rebuttal mentioned, most injuries involve muscular imbalances, stability issues, and inadequate strength-endurance in certain areas of the body. This article also did not take into consideration the importance of tissue-remodeling, kinetic chain relationships, and a variety of neurological factors. There were a multitude of factors that were not adequately considered, and whose role would greatly affect the results of this study.
As the rebuttal mentioned, you cannot take one type of potential injury and extrapolate those conclusions across all other types of potential injuries. So I agree, stretching alone will not prevent injuries from occurring. This is a common discussion I have with many of my patients. But the final solution varies. I tell the injured Yoga teacher to start weight training, the injured weight-lifter to start stretching, and both groups to start doing more aerobic exercises to increase their ATP production. Of course, this is just my own ‘opinion’ based on a combination of my personal, clinical, and educational experiences.
As a nearly 50yo I have employed your multifaceted approach and have finally experienced a significant period without the aches and pains that historically have forced me into periods of rest. When running, I have increased my warm up time to a 10 minute brisk walk, and followed this up with 20sec stretches applied to each muscle group (approx 2 min in total), before starting my run of 2 – 4 km. My run ends with some walking and another round of stretches, totaling 4-5 minutes. Three days a week I have worked on increasing my strength through my hips, and abs and my balance in 15 minute sessions. I am aware I am not doing the distances of your target audience or aiming for a marathon, but this regime keeps me feeling fit and energetic and my weight and mind healthy. I feel so much stronger and confident since following your advice, I run without feeling the need to guard, I have no more ITBS pain, no hip pain, no pain behind my patellar and no piriformis pain. Amazing. I am spreading the word. A very big thank you from me.
Theres never any mention of eyesight, and how that affects the body,s biomechanics its a massive player I have found in sports injuries. Also the answer is appropriate stretching is the answer, having worked with a number of Triathletes.
I while heartily agree. Neuro muscular science is fascinating . We link locally with an optician and encourage clients to get eyes checked through our assessments
James you talk a whole lot of sense. I was looking at some of the protocols on some tests utter nonsense, in fact they had me smiling some years ago.Got something that would interest you pm me, privately.
As a clinical trials biostatistician, I certainly commend you for this post. All very excellent points and very clear exposition. Very helpful, as are just about all of your posts!
Thanks Robert! I appreciate the support 🙂
Did you see this really unhelpful article.? I put myself in people’s shoes that come across these articles, that in my opinion people only look at the title. They then get confused. I agree with a lot said here, and I do believe in kelly starrett has some very valid training methods . I however don’t agree however on how this article is written . It’s not helpful ..and attacks prevention methods to injury. Why can’t bloggers write about solutions? https://www.t-nation.com/training/4-most-useless-rehab-methods . From my experience different people dependant on sport, age and ability respond to different methods . I look at the problem and the bigger picture of bad habits and postural weakness and then take action from there. Seems to yield very well for me, and our clientele.
Ps. Very good blog James very well put !
Great article, thank you. I’d love to know more about strength training as I’ve just reduced mine from a week to 0. I found I’d be stiff for days afterwards and this seemed to cause me injuries. If it’s so good for you how can I know what intensity to do and how to do it correctly? Thanks!
Hi Shannon, thanks for the comment.
Glad to hear you enjoyed the article.
This webinar may be of interest to you: http://www.kinetic-revolution.com/strength-training-for-runners-exclusive-webinar/
James, I don’t know how I am just now coming across your blog/website or this article but it is great! The pretext had me hooked because its absolutely true…I’m guilty myself! Thank you for taking the time to actually research one of these studies and share it with us!
Maybe a very silly question but what’s divides stretching from strength training?
Is there’s some point at which they merge or cross over. Could different people categorise an exercise differently? Observing and doing are often different.
I’m thinking of TaiChi, Chi Gung and even some styles of yoga. Maybe any martial art but I’m sure you can think of other examples along these lines.
Hi james,very good blog post.