Why you can stop worrying about stiffness…
Welcome to our next newsletter. Thanks for all the feedback on our Pain and the Brain Series. This newsletter is slightly less academically demanding and is the first of three, attempting to dispel the myths around muscle and joint tightness. The first two newsletters will explore the reasoning why stiffness/tightness is often irrelevant for pain and the last one will discuss times where stiffness and mobility might be relevant for pain and injury.
“It is not by muscle, speed, or physical dexterity that great things are achieved, but by reflection, force of character, and judgment…”
– Marcus Tullius Cicero
The keen reader will have noted a great deal of reference in our recent newsletters regarding how the brain uses muscular tension as a protective system. Therefore, I’m sure you now realise that this is not a random event but a well evolved survival strategy. We explored this in our newsletters on Knee Pain, Back Pain, Why am I still in Pain and Expectation and Pain.
Muscle and joint tightness can be viewed as two things:
1. Actual or perceived joint and muscle stiffness. Stiffness is a mechanical concept that describes how much force it takes to move a joint or structure. Stiffer materials or joints require more force to lengthen or move.
2. Mobility refers to your entire range of motion. Some people call having a decreased range of motion being stiff. We shouldn’t use the term stiffness this way. View a lack of range of motion as limitation in your mobility. This would show up whether you can touch your toes, reach your hand behind your back or do a backbend. Your mobility is very dependent on genetics which influences the blend of collagen that make up your anatomy.
As an aside, ‘tightness’ is a pretty meaningless term. It often gets used to mean you both feel stiff and you feel like your mobility is restricted. I’m using it pretty generically to mean either stiffness or to denote a restriction in joint mobility. When it’s important I will try to be more specific.
Traditional physiotherapy has often blamed ‘tight’ muscles as a cause of pain. Indeed, I have lost count of the amount of patients I have met over the years that were told ‘tight hamstrings’ account for their back pain. Let’s look at some of those theories and then see how they are probably irrelevant when it comes to pain. Again, we are doing this in two parts. Part one focuses on the sensory aspects of this stiffness and mobility and part two focuses on the mechanical aspects of stiffness and mobility. Both parts pretty much tell us to not worry about it too much. Stiffness and mobility restrictions get way too much blame in the pain world.
No such thing as ‘Tight Muscles’…it’s 1970’s nonsense…
You might see me put ‘tight’ into quotes. This is because a muscle can feel tight or stiff but it isn’t truly lacking mobility nor is it objectively stiff. Very simply, we can’t always trust what we feel. Especially when we have pain. Pain corrupts how we perceive our body which we investigated in our Pain and the Brain Series. That’s why people in pain at many joints (spine, knee, neck) will report greater perceptions of stiffness but this does NOT line up with their actual measured stiffness as explored by Professor Lorimer Moseley et al., in their paper ‘Feeling stiffness in the back: a protective perceptual inference in chronic back pain.‘ We see that people with neck pain report stiffness but they aren’t objectively tighter than those who aren’t in pain (source).
This is pretty common – we can’t always trust what we feel when we have pain. People with knee pain will report a feeling of instability but their objective measures of instability/laxity don’t correlate with their perceptions which is eloquently discussed in this paper that looked at knee arthritis. This is also true for the perception of swelling. According to the paper ‘But it Feels Swollen!’, ‘actual’ swelling doesn’t correlate with perceived swelling in those with knee pain…
It almost feels like we don’t have means of communicating when something is kind of sore or bothersome and so we just feel it as ‘tight’. Again, this isn’t weird. Our perceptions aren’t always a good indication of what is really going on. Blazevich et al., showed that when people undergo a long term stretching regime their mobility or range or motion does not increase and we won’t see a change in how stiff the joint is, yet the subjects claim greater mobility. Supporting this finding, the scientific paper ‘Effects of 6 weeks of constant stretching’, shows that while a person may report feeling ‘less stiff’ (remember placebo plays a huge role here) there is no objective change in actual range of motion.
Many researchers suggest that the perception of ‘feeling stiff’ is really just one way that a sense of unease, discomfort, fatigue, pain or sensitivity show up. We, as clinicians, can amplify this if we don’t consider our comments carefully and frame our communications with consideration. For example, if you are in pain and some well meaning therapist tells you something is tight (i.e whilst grabbing your traps the therapist says ‘these are the tightest traps I’ve ever felt’) and that’s causing your pain. It’s highly likely you will fall down the rabbit hole of spending a lot of time trying to ‘fix’ an assumed tightness/stiffness problem that was never really a problem in the first place. We might be ‘pathologizing’ a normal sensation and this can set you up to fail because all of your ‘fixes’ (i.e stretching, foam rolling, massage, manipulation) are chasing the wrong target.
Movement is a Nutrient…
I know I said I was going easy on you but with anything human, you cannot ignore neurology. We have extensively covered how stiffness and pain work together in our newsletter ‘Why does my back still hurt?’, which I would encourage you to read if you have not. You should now understand that stiffness occurs with pain but isn’t actually the cause of pain. Thus, as elegantly outlined in the paper ‘trunk stabilization in patients with low back pain’, we see greater spine stiffness in those with pain. Consequently, the authors suggest that your hard wired survival orientated central nervous system both causes the pain and the perception of stiffness as a defensive strategy. This is seen in some of the experimentally induced pain research where in those people who tend to catastrophize (invent unfounded worst case scenarios) they find greater muscle stiffness as investigated in the paper ‘Pain catastrophizing changes spinal control.’
A simple example is knee osteoarthritis which we covered in depth in our recent newsletter ‘Why does my knee still hurt?’. When someone has knee osteoarthritis they will have stiffness in the morning. This is part of the condition. They might also have pain. Both pain and stiffness are caused by the process of knee osteoarthritis and it’s your protective neurological machinery that’s driving all of this. Pain and stiffness are just correlated. It’s not the stiffness causing the pain.
Fear of ‘stiffness’ can create what’s called ‘fear-avoidance.’ We do less because we are scared, thus our world gets far smaller, we get more deconditioned, therefore we get more injuries which feeds the cycle of negative behaviour. You might have low back pain, be sensitive to spine flexion and be fearful of spine flexion. Maybe you have been told some nonsense like your discs wear out when you bend your spine or for the rest of your life you need to brace your spine and avoid flexion to protect it. As I have probably told you as a patient, ‘movement is a nutrient’ and this is supported by such studies as ‘Mechanical loading positively influences the lumbar disc’ and ‘Muscle Adaptations in High-Volume Road Cyclists’. For chronic cases (definition of chronicity is more than 2 months of intermittent pain) ‘avoidance’ is pretty horrible advice (there are some exceptions where we want to avoid flexion temporarily in the acute stage of disc based pain) and it’s this type of advice that has messed up a lot of people.
With ‘fear-avoidance’, the lack of movement in chronic patients is now helping to perpetuate pain because the spine loves to move and you are denying the spine healthy activity. The primary stimulus for the ongoing pain maintenance is often the bad advice you have been given. I keep hearing ‘I’ve been told it’s my stiff muscles’, ‘It’s my core strength’, ‘My disc might slip again..’… (all are nonsense by the way, ‘core strength’ has been debunked as a ‘thing’ for over a decade). The beliefs, fears and worries patients have about their back can cause them to stop doing healthy things like moving their backs thoughtlessly, fearlessly and confidently. So the muscle and joint stiffness was initially a side effect of pain and the beliefs you had but now it is helping to promote the pain problem.
The solution here isn’t foam rolling your spine, excessive stretching in a yoga class or a massage to “loosen” something. No, the solution would be to develop a healthy view of your spine, your pain problem and start to feel confident again in what you are capable of through education and movement . As patients of our clinic know, that’s what we promote – cognitive confidence through education and movement and that why we get such good results with the chronic cases no one else wants to see.
So you’re not the ‘bendiest/best*’ in the Yoga class…?
*Rest assured the smug hypermobile individual at the front of the class is probably doing more harm than good!
Because pain and stiffness perception are often linked when you are in pain you might start to think that the perception of stiffness is the important problem. It’s easy to catastrophize based on nonsense cultural messages like ‘being flexible means your healthy’ and the rather tiresome, ‘bendiest in the yoga class is the best’, despite hypermobile patients presenting daily at our practice in agony. As humans, we have the ability to take innocuous sensations and really turn them into something concerning that can lead to suffering and disability. Sadly, I see with the perception of stiffness in clinic far too regularly.
If you are a human you will feel stiffness and you will feel pain. These things are unavoidable. If you have been told that they are problematic then you might think that you always need to ‘fix’ these things. Patients then become hyper-vigilant and begin manically foam rolling, rubbing stuff, stretching and looking for some release whilst relentlessly scrutinising every sensation both imagined and real!
Unfortunately, many health professionals have ‘pathologized’ normal body sensations and for a subset of us this can really create suffering. It’s like hearing something drip at night. You want to go to sleep but you just start worrying and thinking about the dripping sound. It’s just water dripping. It’s going down the drain. It’s nothing. But if you keep thinking about then that is all you hear and you can not sleep. Like trying to sleep….the more you try to sleep and the more you think about your need to sleep the harder it is to sleep.
Perhaps have been told your IT band is tight and needs to be released or stretched. Or some tendon is tight or your hip flexors are tight and are tugging on your pelvis and causing back pain etc etc. These things don’t really exist and aren’t problems. However if you start to poke your IT band it might feel tender and it might feel stiff or if you keep excessively stretching hip flexors then it’s quite likely you will damage a joint in your spine. You can’t stretch out connective tissue. That’s not how we work. Again, the problem here is that we are taking a normal sensation and turning it into a problem. Don’t do that.
So what is the solution here?
Is it OK to stretch, mobilize, foam roll and get a massage?
If you have tried these approaches and they are successful for you, then great. Keep doing them. But, if you’ve tried them and you are still suffering or if you need to foam roll 20 minutes before and after you do anything then maybe it’s time to wean off that self care. Re-evaluate what that stiffness really means. Is it really a problem that is causing you suffering? Did someone just tell you it was a problem and now you spend half your life trying ‘release’ something. Can you view the sensation of stiffness non-judgmentally and just say ‘hey, this movement feels stiff. Interesting. But that isn’t inherently problematic or pathological. It is what it is and it’s not something that needs fixing’.
This isn’t always easy. You are just accepting these sensations and trying not to amplify them. The interesting thing is that sometimes when we do this they actually become less of an issue and we might not even notice them. You give up on trying to ‘fix something’ that actually doesn’t need fixing and then you get comfortable with yourself.
It is quite regular to hear a triathlete/runner/cyclist to worrying about taping/foam rolling/orthotics. My response when I worked in professional sport was that we have to use all ‘crutches’ we can as it’s the sportsman’s/woman’s/other’s job to perform, it’s not about health. In practice with amateur’s, my view is to the contrary. If people feel the need to foam roll, use orthotics or need to tape knees etc then they simply are not moving well enough for the demand of the sport and have clear ‘negative beliefs’ about how their body is performing. It’s time to take a step back, discuss the issues and aim to create enough robustness physiologically and psychologically so that they can cope.
We know this will resonate with many of you as we have gotten to know your concerns well and thus, how to support you. Remember, pain is always much more complex than just being ‘mechanical’…there is a human involved! You are not a machine, you don’t suffer from ‘wear and tear’, you are a cellular organism that responds to use by creating more robust cells. Lack of use means lack of cellular response…
As experienced clinicians, our job is to get a deeper understanding of your overall clinical picture. The more we get to know you, the more useful we are clinically. This is why patients describe a superior experience with the increasing number of highly qualified, state registered high street professionals. We learn from you, that is in reality how we enhance our clinical skills by ‘doing and reflecting’. The rich long term feedback we get from working with you over potentially years means we benefit from considerable growth in our clinical abilities. So thank you for your constructive feedback, you make us good at our job!
Part two of this series will look to dispel the myths behind stiff joints causing altered postures and proposed negative mechanical loading. Part three will look at when stiffness and mobility might be relevant for pain.