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Question for elliott, discussion subject...

Posted by A Manoli II MD on 4/01/05 at 21:22 (172397)

i found your thread on stretching interesting. you are very good at researching the literature. have you EVER found a scientific article that shows that stretching (any musculotendinous unit, take your pick) actually makes the unit LONGER? How does one actually measure such a thing accurately, anyway?

my friend, Dr. Bruce Sangeorzan, U Washington, Harborview Med Ctr, Seattle, once told me that Saxena wrote one that showed that the effects were minimal and short-lasting. I haven't found that report, and no other one in looking for a number of years.

we know that the tensile strength of a normal achilles tendon approaches that of steel. what is all this stretching really DOING? there is no doubt that people often feel better, but pulling a muscle longer, temporarily, may be the only thing happening. i doubt that any tendon or dense fascia is actually getting LONGER with stretching.

am2

Re: Question for elliott, discussion subject...

Dr. Z on 4/01/05 at 22:22 (172408)

It has always been my understanding that you can't strength the plantar fascia except if you cut the structure and that leads to other biomechanical problems.

Re: Dr Manoli re stretching

Julie on 4/02/05 at 01:35 (172416)

Dr Manoli, my understanding, as yours, is that tendons do not stretch. What I suspect is that when we talk about 'lengthening' a tendon what we really mean is restoring a tightened/shortened structure to its natural/optimum length. The achilles, for instance, can shorten with the wearing of high heels, with adverse effects on the feet not to mention the lower back, but can be improved with different shoes and correct exercise.

Muscles stretch, however, and if a muscle can be stretched, i.e. lengthened, the stress on the tendon that attaches it to the bone is reduced and range of movement improved. If the gastrocnemius is stretched, the knock-on effect is less stress on the achilles - and the plantar fascia.

The benefits of stretching are definitely 'short-lasting'. Any benefits will be maintained only if stretching is continued, regularly and forever. If a trial took a group of people and had them stretch for, say, eight weeks, the results would probably show a benefit from the stretching, but if the people didn't understand that they had to go on stretching once the trial was over, their muscles would soon lose any effect from that eight weeks of effort.
.

Re: Dr Manoli re stretching

Julie on 4/02/05 at 02:34 (172421)

I should add that what I've said isn't an opinion, but the evidence of my work with yoga students of all ages, who over the years have greatly improved their mobility and body use through simple, effective exercises, many of them non-weightbearing, that are appropriate for most people. Of course many factors affect outcome, including age and genetic makeup, but my observation over 20 years of teaching has been that most people, if they are willing to persevere, will improve, even men whose hamstrings have drastically shortened from years of impact exercise without stretching. When muscles are at optimum length, stress on the joints is reduced, and posture, alignment, and body use generally, improve. I have also had a few students with PF who got better quickly doing nothing but the simple foot yoga exercises.
.

Re: Question for elliott, discussion subject...

Julie on 4/02/05 at 12:16 (172428)

Dr Z, I think you meant 'lengthen' the plantar fascia, didn't you?

This might be a good opportunity for you to explain why and how you think the plantar fascia stretch (which is a misnomer as it does not really 'stretch' the fascia) works. What do you think it is actually doing, if it is not stretching the plantar fascia? I'm not casting doubt on the exercise: I like it too, but it would be good to hear your analysis of it.
.

Re: Question for elliott, discussion subject...

Dr. Z on 4/02/05 at 14:32 (172435)

Julie,

Both Strengthing and lenghtening could be used. I did mean lengthening. What I think is going on is that by performing petrissage ( spelling) this means milking the tissue you increase circulation, stimulation of venous return which helps heal the intrinic tendons, In addition you can strengthen the muscles, tendon such as the Flexor digitorium brevis with this technique. I am still amazed at the improvement that happens with this technique.

Re: Question for elliott, discussion subject...

Ed Davis, DPM on 4/02/05 at 16:43 (172449)

To all:
How do we explain the mechanism by which the hormone Relaxin allows the pelvis to sperad druing pregancy to open the birth canal?
Ed

Re: Question for elliott, discussion subject...

Ed Davis, DPM on 4/02/05 at 16:46 (172450)

Relaxin: A hormone produced during pregnancy that facilitates the birth process by causing a softening and lengthening of the cervix and the pubic symphysis (the place where the pubic bones come together). Relaxin also inhibits contractions of the uterus and may play a role in timing of delivery. Relaxin works by simultaneously cutting collagen production and increasing collagen breakdown.

A synthetic form of relaxin has been reported to be useful in treating scleroderma (a connective tissue disease that causes the skin to become tight and thick), improving the skin condition, mobility, and function.

The above is from Websters New World Medical Dictionary.
Ed

Re: Question for elliott, discussion subject...

elliott on 4/03/05 at 17:38 (172509)

Dr. am2,

A search of the literature suggests as you said, that if anything, the effects are minimal and short-lasting.

Here, I believe, is the Saxena article to which you referred:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1783755

There are numerous others, much of the research coming from Japan:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15713305

http://jap.physiology.org/cgi/content/abstract/92/2/595

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12952631

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12171150

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12169823

http://www.topracket.com/Badmintology/Research/Stretching.php

http://jap.physiology.org/cgi/content/abstract/91/5/2035

http://www.ms-se.com/pt/re/msse/fulltext.00005768-200205001-00855.htm;jsessionid=CQWmpXg6Fb16WUEBEWzbUy2IJSpHCntwmGgEb8mV5FAEm37tfDN1!-1860688455!-949856031!9001!-1?index=31&results=1&count=10&searchid=1&nav=search

Do rabbits count?

http://journal.ajsm.org/cgi/content/abstract/18/3/300?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=taylor&fulltext=muscle-tendon+units&searchid=1112509436520_3363&stored_search=&FIRSTINDEX=0&sortspec=relevance&journalcode=amjsports

How about horses?

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15767316

It was once explained to me that if one fails the single-heel rise test, it is a possible indication of a slack, elongated posterior tendon that needs to be tightened, e.g., through a Kidner procedure. Would this imply a permanent elongation?

elliott

Re: Question for elliott, discussion subject...

A Manoli, II MD on 4/06/05 at 22:48 (172739)

thanks, everyone. the last article listed, just before the rabbits, was very interesting. the tolerance issue may be very important, as julie implies. it'll take a little time to look at all these, and i really appreciate the efforts. it's certainly an important topic, with a lot of ritual and anecdotal 'stuff.'

is viscoelastic muscle 'creep' really 'stretching? guess it depends on definitions.

elliott: if a posterior tibial tendon is elongated, it is permanently stretched. however, it cannot simply be reconstructed by advancing it with a kidner-like procedure. the problem is that the tendon no longer has a tendon-like microstructure....it has become fibrocartilage with mucinous degeneration and micro clefts. it will just stretch out again. clinically, soft tissue procedures alone have experienced very high failure rates and the best success has been with combined soft tissue work and bone osteotomies.

Mosier SM, Pomeroy G, Manoli A 2nd.
Pathoanatomy and etiology of posterior tibial tendon dysfunction.
Clin Orthop Relat Res. 1999 Aug;(365):12-22. Review.

Mosier SM, Lucas DR, Pomeroy G, Manoli A 2nd.
Pathology of the posterior tibial tendon in posterior tibial tendon insufficiency.
Foot Ankle Int. 1998 Aug;19(8):520-4.

Mosier-LaClair S, Pomeroy G, Manoli A 2nd.
Operative treatment of the difficult stage 2 adult acquired flatfoot deformity.
Foot Ankle Clin. 2001 Mar;6(1):95-119. Review.

Mosier-LaClair S, Pomeroy G, Manoli A 2nd.
Intermediate follow-up on the double osteotomy and tendon transfer procedure for stage II posterior tibial tendon insufficiency.
Foot Ankle Int. 2001 Apr;22(4):283-91.

Pomeroy GC, Pike RH, Beals TC, Manoli A 2nd.
Acquired flatfoot in adults due to dysfunction of the posterior tibial tendon.
J Bone Joint Surg Am. 1999 Aug;81(8):1173-82. Review.

thanks, again

am2

Re: Question for elliott, discussion subject...

elliott on 4/07/05 at 09:15 (172746)

Dr. Manoli,

Talk about coincidence: all the references you supplied contain yourself as an author. :-) Thanks; I appreciate the explanation.

elliott