Get ready for an awesome case study. Last week I had a junior elite gymnast travel out to get an evaluation, and it turned out to be a fantastic 2 hour eval and treat. Both her and her mom were great, and after they gave me permission to write-up a case study about her. I wanted to share this case because there were some VERY important training concepts related to flexibility methods and injuries that the gymnastics community can really benefit from thinking about. I will explain more, but remember you can see/hear this entire 2 hour mobility lecture live at our two Gymnastics rEvolution Seminars coming up. We were able to get her “inflexible” shoulders, hips, and splits better quickly without stretching at all. The left is a few before shots, the right after (more below)
Here is the short background story. This gymnast’s mother contacted me saying that her daughter has missed a ton of practice/competition time over a few years due to struggling with many different injuries. She has always had “tight hips” and “tight shoulders” which significantly decreases her performance. She aggressively stretches every day and often has to sit in her splits for minutes before they slowly creep lower to the ground. Despite all of her dedication to daily stretching, she continues to be very frustrated with her split mobility, leap angles, jumps, Tkachevs, and Yurchenko. In the last year she has been dealing with
- Shoulder pain in both sides but left greater than right
- Right sided hamstring and high buttock pain (ischial apophysitis that was borderline hamstring being pulled off from bone) – second biggest current complaint
- Right sided Osgood Schlatter’s Disease and knee pain
- A now healed right sided tibial stress fracture
- Right sided Sever’s Disease and heel pain – this was her biggest current complaint
So from her eval, here is the most important concept about her limited hip flexibility people need to consider.
She Had Significant Amounts of Hip Tone Causing Limited Split Motion and Poor Squatting
This was the biggest thing that stuck out, as her hips were extremely limited for extending and rotating outwards on both sides. She had more than enough hamstring mobility in the other direction. Here are the pre-test picture of her right leg split (painful and less mobile side), overhead squat, and two hip extending mobility tests.
For such an incredible gymnast, I was shocked to see how much hip mobility she was lacking. Here’s where things got interesting. After this I first educated her on
- Pain science concepts like perceived threat/danger alarms, how having lots of passive range with no active control is not a good situation, and how the nervous system may be subconsciously trying to protect her hips from danger. I then linked this to how aggressive stretching may be causing her brain to backfire and keep the brakes on her hip mobility.
- We then talked about how unfortunately even though she sees some gains by sitting in a split for a while, the stretching effects of increased motion are short-lived. We discussed how reducing threat, gaining the motion with consistency rather than intensity, and building the new motion into a useful pattern for the brain may be the best long term solution.
- I taught her how to breathe correctly (find more on this here). I explained how being chronically in a stressed sympathetic state and breathing poorly can cause increased muscle tone. I explained that proper breathing can not only help with her mobility, but also her routine endurance and her ability to recover better following a hard practice. (find more here and here). We focused on 15 rounds of nasal breathing with diaphragm/rib movement and full exhalation.
- After this we did these 2 hip motor control drills aimed at isolating her hip into extension while using the proper breathing on both sides.
Note, we did no stretching and I did not do any manual therapy on her hips. Here were the post test pictures,
Her jaw literally dropped. She was also pretty happy she could do a split without her right buttock being painful and squat with significantly less heel pain. Although we were all pumped, I told her this was unfortunately only a brain trick that would last probably only a few hours. For this to “stick” she needed to progress into a pattern her brain thought was useful, teach her nervous system how to use the motion during skills, and continue to remind her brain of the new motion.
Following this, I then gave her this pattern assisted leap drill on both sides (only left shown) to teach her brain about the new motion, and help her learn control in her full range.
Then we did this tall kneeling bend back drill to teach about spreading the bend and using her hip extension fully (first rep wrong with lower back dominated, then second rep correct)
Finally, I taught her how to squat properly using posterior chain vs being forward using her ankle/knee joints as the dominate area (still have a little work to do)
Why Does This All Matter?
This is where it all comes together for a concept I feel gymnastics needs to progress their thinking about. She had been stretching like crazy, and seeing no long term improvements. I think this situation occurs commonly in gymnastics due to people being under the impression that stretching works by physically deforming and elongating muscle tissue. Some research has suggested that only small amounts of mechanical effects may be seen temporarily in the tissues that leads to range of motion increases with bouts of static stretching (research here and here). There also may some mechanical changes with more aggressive techniques over 8 weeks to change muscle architecture (research here). But, the excessive time/intensity, possible ware and tear, and questionable functional application of this is why I don’t take this avenue with the gymnasts I coach or treat as patients. There is some good support for the use of proper eccentric training to increase tissue length via adding sarcomeres in series (find article and more research studies here).
The more current ideas support that increases in range with certain mobility approaches may come from neurological changes like a decreased stretch reflex onset, tone reduction, stretch modulation, adaptation of nociceptive sensors, and a reduced threat level occurring with the movement over time (research here and here). I do think short term neuroplastic changes can become bioplastic changes in the tissues if the range is used appropriately over time. However, the concepts from some current stretching research, thoughts about increased tissue tone from a stressed sympathetic state, poor breathing patterns, and aggressive stretching triggering threat in the nervous system are reasons I feel she and many other gymnasts do not see long-term improvements from aggressive passive stretching. In her case, working on some of the motor control aspects to her mobility and thinking neurologically lead to notable changes pretty fast. To continue to see improvements, I feel she needs to take the new range and gain control of it in a non threatening, functionally useful pattern, so her nervous system accepts it.
It’s not always about more stretching. As in her case, more aggressive stretching may actually cause the nervous system to backfire, guarding the motion in response to threat. It may also cause injury if you don’t know why your stretching in the first place, or don’t have an understanding about the mechanical/neurological effects stretching has. Her right leg split was actually limited by her back legs hip tone, and not by her front leg hamstring length. Unfortunately, I think her continued aggressive hip stretching was causing her hamstring to become injured where it attached to the bone. I also think this hip tone, along with some other issues above/below her hips (coming in part 2 next week), caused her to not be able to land in a proper squat to load her posterior chain, creating her knee and heel pain during high force impacts.
Concluding Thoughts
On a parting note, I do think proper stretching and other mobility work is needed for gymnasts. Our gymnasts do a dynamic mobility warm up every day, and there are times I use some neurally focused stretches. Along with this, I have worked with gymnasts that need adjunctive manual therapy or soft tissue work to help see changes in motion. Some people don’t have such a great response to these exercise inputs I gave to this gymnast (but remember they are just temporary brain tricks for now). With that said I strongly feel that the overall concepts behind her case are things we really need to address in gymnastics. This is especially when it comes to hip injuries and shoulder injuries.
We need to make sure we know the physiology and rationale behind why we chose certain mobility techniques so we don’t injury someone. We also need to make sure we have shown in a movement assessment it is what they need, and that we teach them how to control their new range as they get it. As I will talk about in Part 2, she had a notable overhead mobility issue and shoulder pain, but it wasn’t due to her shoulders being tight. For now, I really hope everyone takes this post as a professional/educational piece, not me looking to set fires in the sport of gymnastics. I just want to help progress our methods to be effective, help boost performance, and reduce injury risk.
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