Managing Injuries: What About Stretching, Mobility, and Core?
By: Mark Doherty
Tags: Mobility, Core, Injury, Stretching, Powerlifting

What’s the fun in discussing pain and injury without modalities like stretching, joint mobilizations, and core stability exercises? It’s clear that modalities of this nature are quite popular in fitness and strength sports, including powerlifting, and used as interventions for a myriad of reasons; some justified, others probably not so much.

Experiencing knee pain? Stretch your quads. Hip “mobility” problems? Place a band around your hip in a pigeon pose and let the magic happen. Back pain? “Stabilize” your “core” with bird dogs and you’ll be good as new. Given the fascination with this stuff, it must work, right? I guess that depends on a few things such as how we define these terms, and what we mean by “work.” Efficacy if defined as the ability to produce and intended or desired result. So when we’re asking if something like stretching “works” for knee pain, we’re referring to the efficacy of that intervention.

Pain is currently defined by the International Association of Pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage,” and the result of varying degrees of biological, psychological, and socio-environmental factors(1).

Injury is harder to define and classify without specific context, for reasons we’ve covered in previous posts and articles. For those reasons I’ll be using my particular case of cervical radiculopathy, which can certainly be classified as an injury — persistent pain that interrupted my sleep for a number of consecutive weeks, and has since caused me to significantly modify training in the presence of ongoing symptoms — to create context.

Cervical radiculopathy is a common clinical scenario and typically presents with unilateral neck pain, arm pain, or both. Patients may also present with neurologic signs such as sensory or motor deficits. It is important to differentiate cervical radiculopathy from other items on the differential diagnosis including peripheral nerve entrapment syndromes and shoulder pathology. Most cases of cervical radiculopathy are self-limited and may be managed conservatively in the absence of progressive neurologic symptoms or other concerning symptoms such as osseous lesions, etc. There are several options for conservative management, but there is little evidence to suggest that any of these interventions substantially alter the natural history of the disease(2).

In early October I started to notice a slight weakness in my left arm after months of persistent neck and arm pain. Strangely, once the pain subsided the weakness progressively worsened to the point where I couldn’t bench press as little as 45% of 1RM for a single repetition. In the last month I’ve made considerable progress, my most recent injury PR of 80% of 1RM for a paused single. I have posted the highlights on Instagram, but what about behind the scenes, surely I’ve been doing some special stretches or “mobility” exercises, right? In order to answer those questions, we need a more detailed picture of what we’re looking at, which is why I’m going to use myself and the injury I’m currently managing as an example in this article to talk about why I choose to use, or discard, certain modalities.

We must consider the models we use to view the human body from a pain and injury standpoint. Manual and physical therapists, as well as coaches and health & fitness professionals alike often use a postural-structural-biomechanical (PSB) model to ascertain the causes of various musculoskeletal conditions. Even NASM and other personal training certifications shove Janda’s upper and lower cross down your throat and set you loose to fix posture with corrective exercises. It is believed that postural deviations, body asymmetries and pathomechanics are the predisposing/maintaining factors for many musculoskeletal conditions. The PSB model also plays an important role in clinical assessment and management, including the choice of manual techniques and the exercise prescribed. However, the most important question is consistently being ignored — can a person’s physical shape/posture/structure/biomechanics be the cause of their pain?(3) What about their injury?

The study referenced and quoted above found that:

Asymmetries and imperfections are normal variation — not a pathology. Neuromuscular and motor control variations are normal. The body has surplus capacity to tolerate such variation without loss to normal function or development of symptomatic conditions. Pathomechanics do not determine symptomatology. There is no relationship between pre-existing PSB factors and back pain.

Yet many coaches and clinicians still view pain and injury from a postural-structural-biomechanical perspective, disregarding the complexity of the lived human experience(4) and contextual factors associated with pain(5). The oversimplification of complex problems have us missing the mark, leading to the use, or likely overuse, of modalities that address these problems in the short term rather than long term(3).

Clearly there are biological factors at play in my case, I have been experiencing significant weakness in my left arm for over three months. And, given that I lift weights for sport, biomechanics and training load certainly factor into this. But viewing cervical radiculopathy strictly through a PSB lens assumes nerve root compression or dysfunction while not addressing the many factors influencing the problem, leading to inappropriate solutions, or rather, non-solutions.

Non-solutions for example, would be passive in nature—traction, spinal manipulation, stretching, ect. Several studies have examined the efficaciousness of cervical traction in isolation or in combination with an exercise regimen (6, 7, 8). These studies generally do not support a widespread role for cervical traction as most randomized control trials show similar results in patients who did and did not receive cervical traction, particularly when using validated outcome instruments(9).

Recently, Gross et al. performed a Cochrane review examining the effect of manipulation and mobilization as a treatment modality for neck pain. These authors generally found that the literature in this area was of low to very low quality. They showed improved immediate pain with manipulation compared to immobilization and that repeated manipulations might provide some benefit However, these authors were able to find no benefit for manipulation at short-term and intermediate follow-up. Additionally, when manipulation was compared to mobilization and physical therapy, there were no differences in outcome at immediate, short-term, and intermediate follow-up(10).

A 2017 Review on stretching for the prevention of contractures, Contractures being a common complication of neurological and non‐neurological conditions characterised by a reduction in joint mobility found that “There was high‐quality evidence that stretch did not have clinically important effects on joint mobility in people with or without neurological conditions if performed for less than seven months.”(11). A deep dive into the literature doesn’t turn up much support for the use of stretching to reduce injury risk or improve performance either (12, 13, 14, 15, 16).

Another favorite amongst coaches and clinicians that I consider a non-solution is random and even carefully chosen “core stability” exercises that, in reality, have no bearing on the actual issue at hand. We make gaping assumptions about spinal alignment and pain, and implement a variety of different strategies and exercises to improve said alignment. But do these strategies and exercises have efficacy or are we just committing post hoc ergo propter hoc? A 2011 study titled, The Myth of Core Stability (17), concluded that:

Weak trunk muscles, weak abdominals and imbalances between trunk muscles groups are not pathological, just a normal variation.

The division of the trunk into core and global muscle systems is a reductionist fantasy, which serves only to promote CS.

Weak or dysfunctional abdominal muscles will not lead to back pain .

Tensing the trunk muscles is unlikely to provide any protection against back pain or reduce the recurrence of back pain.

Core stability exercises are no more effective than, and will not prevent injury more than, any other forms of exercise.

Core stability exercises are no better than other forms of exercise in reducing chronic lower back pain.

Any therapeutic influence is related to the exercise effects rather than CS issues.

While you can and certainly should train your trunk muscles, the traditional idea of “core stability” should be discarded. A 2019 prospective study looking at impaired “core stability” as a risk factor for the development of lower extremity overuse injuries identified measures for dynamic postural control, trunk muscle strength, and trunk muscle endurance as significant risk factors for the development of overuse injuries after statistical model building. However, core neuromuscular control and proprioception and functional movement might not allow clinicians to identify patients at risk(18). Yeah, because doing a plank or single leg bridge tells you jack shit about how an athlete resists forces in a changing dynamic environment. Not to mention, a study in 2018 comparing trunk muscle activity in a 6RM barbell back squat vs a prone bridge (plank) concluded that squatting resulted in greater erector spinae activation, but similar rectus abdominis and oblique external activation as the prone bridge. Therefore, it is suggested that high-intensity squats be utilized by athletes rather than isometric low intensity “core” exercises (19). Looks like I’ll be skipping McGills “Big 3” for the real deal — squat, bench press, and deadlift.

We have plenty of evidence supporting the benefits of general exercise for various musculoskeletal conditions, and that’s exactly what I’ve been doing, no manipulations or special exercises needed. Just finding the right dosage of volume and intensity in the exercise affected by my injury — the bench press — that I could work with and gradually progress over the last few months. Due to the decrease in overall volume and intensity, I’ve added in a variety of upper body exercises, especially exercises that target my neck, shoulders, and arms in different ways, employing varying loading protocols — high reps, low reps, AMRAP, ect. On top of the fact that the human body has a tendency to heal itself and adapt to its environment under the right conditions, as long as I remain positive, embrace uncertainty, and continue training both hard and smart, the natural course is upward. I just have to keep my eyes on the prize, keep it simple, and not get discouraged along the way.