Should you be flexible enough to touch your toes?

Tegan Taylor: I actually want to ask you, Norman…I can’t see you, are you standing or sitting? 

Norman Swan: I’m sitting. 

Tegan Taylor: Could you stand up for a second? I’m going to do the same thing. 

Norman Swan: Okay, I’ll take the microphone with me. I am standing up with a microphone in my hand like a sports commentator. Yeah, carry on.

Tegan Taylor: You’re going to need at least one hand for this, because we’re gonna see if we can touch our toes.

Norman Swan: Oh, well, that’s easy, yeah I can. 

Tegan Taylor: Is it easy? Okay, let’s go. One, two, three…

Norman Swan: …and back up. 

Tegan Taylor: Can you put your hands flat on the ground? Wait, can I put my hands flat on the ground? Oh my gosh!

Norman Swan: Listen, I’m just getting to touching my toes…

Tegan Taylor: But you can, hey?

Norman Swan: No, that’s too a step too far, but I can touch my toes. 

Tegan Taylor: So can I. Okay, we’re allowed to sit down again now. 

Norman Swan: Okay, I’m sitting again. I couldn’t do that six months ago, by the way.

Tegan Taylor: Interesting. Do you think this has to do with your Pilates habit? 

Norman Swan: Yep, absolutely. 

Tegan Taylor: I’m very looking forward to having this chat today, because of course we are talking about not just toe touching but flexibility in general here on What’s That Rash? today.

Norman Swan: Which is the podcast where we answer the health questions that simply everyone is asking.

Tegan Taylor: This week’s question comes from Jeff, who says, ‘Longtime listener, first time emailer.’ Hi Jeff. ‘My question,’ Jeff writes, ‘is about flexibility and its impact on health. I’ve been very stiff for most of my life. I’ve never been able to bend down and touch my toes, which I suspect might be related to my X-shaped legs and the way I walk…’

Norman Swan: ‘X-shaped legs’?

Tegan Taylor: He says he walks a bit like a duck. ‘Anyway,’ Jeff writes, ‘I have recently added stretching as part of my exercise routine and set a target to be able to touch my toes in 100 days. My question is, I know flexibility is important to your health, but is being able to touch your toes a good measurement of your flexibility? Between touching your toes and doing a middle split, which one is better suffering in improving your flexibility?’

Norman Swan: What’s a middle split? 

Tegan Taylor: I didn’t really think about this but our producer, Shelby Traynor, is a trained…well, has been a competitive dancer, and she started talking about middle splits versus straddle, so I had to go and do some searching. 

Norman Swan: Is this the one where you spread your legs to the side?

Tegan Taylor: Right. A straddle is where both of your legs are sticking out to the sides, and a middle split is where you’re in that but you’ve rolled over your pelvis so that actually your tailbone is facing back, like your chest could be on the floor. Shelby, have I got that right? 

Shelby Traynor: You have, yes. 

Norman Swan: Can you do it, Shelby?

Shelby Traynor: No. I think there was probably a period of a week when I was competitive dancing full time where I could do a middle split.

Norman Swan: So this is a real…to use a dad joke, this is a real stretch for Jeff, to be talking about a middle split.

Tegan Taylor: I thought I was the one that threw around dad jokes here, Norman. 

Norman Swan: I had a holiday for a few weeks while you did them. 

Tegan Taylor: Well, I want to pick up first of all on something that Jeff has said in his email, which he says, ‘I know that flexibility is important to your health.’ I want to dig into that a little bit today, because I feel like it’s good for your health, but I don’t know what the evidence says.

Norman Swan: So ‘health’ is a big word here that implies that it’s good for maybe your heart and your blood vessels, or your weight, or maybe your muscle strength. ‘Flexibility’ and ‘mobility’ we need to unpick as well. So let’s move through it, and we will get to those elements later. But I think health is probably not at the top of the list in terms of the benefits of flexibility.

Tegan Taylor: Well, I don’t think it’s a bad thing for us to start with some definitions. I think people have a sense of what flexibility might be. Can you touch your toes? Can you do a split? Mobility is something that I hear exercise folks talk about a lot, but they’re not really exactly the same thing.

Norman Swan: The simplest way to look at mobility is your ability to move freely and easily through life, and flexibility, in some senses, is a component of that. 

Tegan Taylor: So, flexibility, we’re usually talking about soft tissues, I think about my muscles being flexible or my tendons. Is that right?

Norman Swan: Yeah. So it’s your muscles, your ligaments, your tendons and other soft tissues that surround the muscles that go around each joint in your body, and if they are shortened and tight, then you just don’t get a full range of motion out of that joint, or necessarily get the full range of power out of the muscles that power that joint.

Tegan Taylor: We’re hearing Jeff talking about touching his toes. We’ll talk in a little while about how we can influence our flexibility, but there does seem to be a genetic component here. Some people are just bendy, some people just seem so much more bendy than others.

Norman Swan: Yeah, they’ve studied contortionists, you know, people who can put themselves into a shoe box. They’ve studied ballerinas. So there is a genetic component to it, they’ve found genes that actually do predict whether or not you are flexible in that situation, small studies. There’s a medical condition, a genetic condition called Ehlers-Danlos Syndrome, which comes in various forms but it’s hypermobility of the joints and looseness around the ligaments and tendons, which create all sorts of problems for people with the various forms of Ehlers-Danlos. And there’s gender; males are less flexible than females, and we’re not talking about psychology here.

Tegan Taylor: Well, I wanted to interrogate that a little bit because I have mentioned (probably more times than is cool) rock climbing, and I know when I’m climbing with my mates, who are all blokes, they are all stronger than me, by orders of magnitude, and I feel like I suck. But there are some things that I can do that they can’t do. I can put my leg up higher than they can sometimes. And I’ve wondered whether it’s because of my body’s mechanics and a sex-based thing, or whether it’s because I do yoga and they don’t. I did gymnastics as a kid, and they didn’t. How much of it is almost like cultural, culturally gender based, and how much is actually about my physiology or their physiology? 

Norman Swan: Well, the basic physiology would say that it looks as though oestrogen does make your tissues more flexible, and your pelvis is a different shape to a male pelvis, which would partly explain how you can lift your legs to a higher level than they can. And you’ve also trained yourself over the years to have stretched, flexible muscles and tendons. 

Tegan Taylor: So it’s a bit of both. 

Norman Swan: It’s a bit of both. But gender is pretty solid in all this. 

Tegan Taylor: So we’ve got some underlying genetics, as you’ve just mentioned, but there also is…like you say, if you stretch it, it’s stretchier. Let’s talk about what we know in terms of promoting flexibility, because everyone’s got their own patented ‘this will make you more flexible’ routine. Are there some flexibility routines that are better than others?

Norman Swan: Well, people argue about this ’til the cows come home, and it depends on what you’re looking for, and there are a lot of myths about flexibility and stretching. So what is known? And we can refer people back to one of our early What’s That Rash? which was on delayed onset muscle soreness, where stretching makes no difference to delayed onset muscle soreness after a period of exercise. 

Tegan Taylor: It feels like it does, though. 

Norman Swan: It feels great when you do it, but the studies have been done, it makes no difference at all to delayed onset muscle soreness.

Tegan Taylor: I know that we researched and recorded and have published, but I still don’t know if I believe it.

Norman Swan: God, why do I bother! Anyway, there’s also very little evidence that stretching prevents injury.

Tegan Taylor: Well, static stretching can be linked to injury, if I’m not mistaken, in certain sports.

Norman Swan: Ah, well, there is a theory with a little bit of evidence attached to it, that if you stretch without strengthening your muscles, you may actually expose your joints more to injury because they are more flexible and go through a wider range of movement without necessarily the muscle strength around the joint to protect it. So in theory…there’s not a lot of evidence to back this up…but in theory, stretching, independent of muscle strengthening exercise, could actually increase the risk of injury. There’s very little evidence that it actually reduces injury. So a group of experts got together on all this (and we’ll put a link to that in our show notes) to actually look at all the evidence for and against stretching. And the evidence is not great, apart from that stretching increases your range of motion, and presumably, by implication, makes you more mobile.

Tegan Taylor: So that really speaks to Jeff’s question, that Jeff’s getting up every morning, 100 days, wants to be able to touch his toes. Amazing. What I’m hearing from you is that stretching like that might get him there, but it might not necessarily be good for him once he gets there. 

Norman Swan: I mean, if you can touch your toes with straight legs, you are more flexible by definition. It’s likely that you will walk more easily because the muscles that you are stretching in order to be able to touch your toes and the tendons and ligaments and so on, are the ones that you need for smooth walking. So it’s quite likely that your walking improves with that stretching. But some people stretch in order to improve their athletic performance, and that kind of stretching has got a particular name because you asked earlier about whether one kind of stretching is better than others. 

So the basic kind of stretch is the static stretch, which most of us would know about. You know, you get your leg up on the table and you lean into it, feel the stretch at the back, and you do it for maybe five breaths, 10 or 30 seconds, and you usually do it after exercise. The other one is called dynamic stretching, which has got less evidence attached to it, which are really you’re stretching while you move your muscles. So let’s say you’re doing an ankle stretch and you’re doing it on a stair, you’re moving down to stretch your gastrocnemius, your calf muscles, and then you’re lifting it up, and that does a stretch as well as muscle movement.

Tegan Taylor: So you are doing like a calf raise, it’s controlled, it’s warming up the muscle and also moving it past the point that you probably would go into in your exercise.

Norman Swan: That’s right, on the way down, and that’s an example of a dynamic stretch. The other one is PNF, proprioceptive neuromuscular facilitation.

Tegan Taylor: I mean, if it’s got the word ‘proprioceptive’ in it, and it’s got an acronym, that says to me that this is the science one, right?

Norman Swan: They’ve all had some studies. So a PNF is…imagine you do a straight leg raise…it’s got to be done with a therapist, or somebody who knows what they’re doing…you do a straight leg raise, and then the resistance, the isometric exercise, is not contracting your hamstrings but your quadriceps, so you’re trying to actually stretch the leg even more against resistance.

Tegan Taylor: My quads are hurting even thinking about doing this exercise.

Norman Swan: Well, I was doing it as I was talking, and I thought, oh my god, can I talk and do this at the same time?

Tegan Taylor: Okay, this sounds like the type of yoga that I do where you get into a position that’s quite a deep position, but you’re holding it very actively, you’re not just sort of collapsing into it. It’s not so much about stretching as it is about holding yourself in quite an uncomfortable position, often.

Norman Swan: And understanding where your joint is in space, which is what the proprioception is all about. So the interesting evidence on this PNF stretching, proprioceptive neuromuscular facilitation, is that if you do it before sport or exercise, you actually reduce performance, but if you do it after exercise, subsequent performance goes up.

Tegan Taylor: Is it because you’re perhaps tiring the muscle out before you’re then trying to get it to perform?

Norman Swan: Possibly. Look, as with all these things, people try to find reasons for something that they actually haven’t got a clue why it works, but there’s consistent evidence that PNF stretching before you actually exercise reduces the performance, whereas it improves power to muscle ratios after exercise and the next time you do it. And the other thing about stretching here and athletic performance or muscle performance, is that if you stretch and you increase the range of motion, your muscles and ligaments lengthen over time a little bit, and therefore the muscles are contracting over a larger distance, and therefore give you more power, whereas if you are tight and it’s a little bit bent (I’m being simplistic here), the muscles aren’t getting the full chance to contract properly. So there is a performance benefit to stretching over a period of time, but it involves hard work. Some people would say that if you’re really trying to get that done, it’s four minutes a muscle.

Tegan Taylor: That’s such a long time

Norman Swan: This is not an easy solution.

Tegan Taylor: So we sort of brushed past it at the beginning, this assumption that being flexible is good for your health, and what I’m hearing you say is there’s certain types of stretching that perhaps seems to be very good for your sports performance, depending on your sport. What about overall health?

Norman Swan: So it’s not a replacement for muscle strengthening exercises, but it will…in theory, it could enhance the benefits of muscle strengthening exercises. So what you want as you get older are larger, stronger muscles. Stretching itself probably does not have a significant effect on what’s called muscle hypertrophy. It may have a little but not a lot. It probably facilitates the process of muscle strengthening, because you’re able to move the joint against resistance through a larger arc.

Tegan Taylor: So what you mean by that is the stretching alone isn’t going to make your muscles bigger, but it might make your exercise to make your muscles bigger more effective.

Norman Swan: That’s right. And then in terms of health, there is this tantalising suggestion that it may improve your cardiovascular health. 

Tegan Taylor: Why? How?

Norman Swan: Well, it may stress the vascular system and reduce…because you’re stretching all the soft tissue, so imagine you’re doing a hamstring stretch, it’s not just the tendons, the ligaments and the muscles, it’s the arteries that you’re stretching as well, so that you might get more flexible arteries, which means your blood pressure will go down, and that’s a healthier situation to be in. Not really proven, but there’s no evidence that it does you any harm. 

Tegan Taylor: The other thing I’d add to that is quality of life, especially if we’re talking about getting older, I’m thinking about stability, like wanting to avoid falls, and having a good range of motion is important for that. And also you want to be able to tie your shoes, you want to be able to wash yourself in the shower, a base level of flexibility is required for those sorts of self-care tasks.

Norman Swan: Yes, absolutely. And the more flexible you are, the greater, in theory, your ability is to recover if you trip over, particularly if you’re associating it with muscle strengthening exercises. If you’re stiff, you just don’t have the error margin, if you like, when you get into strife.

Tegan Taylor: So you mentioned before, Norman, that you could touch your toes now, but you couldn’t have done it six months ago. What are you doing differently?

Norman Swan: I’m going to Pilates twice a week, and I’m being put through a series of exercises which strengthen muscles, improve mobility and improve balance, and part of that is showing that you are flexible, and you start off each day or finish it off with a roll down and a roll back up.

Tegan Taylor: Did you set out to change your flexibility? Was that part of what you were hoping to get out of doing Pilates?

Norman Swan: I just wanted my whole body…I’ve been unco for my whole life, and I just wanted to be less unco and less stiff. And, by the way, there’s not a lot of evidence that some of the static stretching is any better than getting one of those rough rollers and rolling your muscle along one of those rollers.

Tegan Taylor: Oh, when you said a roll down and a roll up, I thought you meant like a bend down into a forward fold and…

Norman Swan: No, no, that is exactly what I’m talking about. 

Tegan Taylor: Oh, so you’re saying you do a physical bend over, roll down, and then roll back up again, and also you use a foam roller.

Norman Swan: I don’t like using a foam roller, so I prefer the actual physical stretching. But the evidence would suggest that a foam roller is pretty good for the sort of benefits that you get out of stretching, which is about function.

Tegan Taylor: So we’re saying static stretching can make someone perhaps more prone to injury. You should still be warming up before you exercise though.

Norman Swan: There’s no evidence that stretching before exercise as part of a warm up routine prevents injury or improves performance, and as I just said earlier, there’s some evidence that it reduces performance. So if what you’re doing with a warm-up is actually match appropriate exercise for that sport, that’s a different matter from should I be stretching before exercise? And the answer would be from the evidence; no.

Tegan Taylor: Okay, all right, cool. So if you’re listening to this, like, oh my gosh, Norman, Tegan, you’re so smart, I’m completely convinced, I want to improve my flexibility for my health, I want to do it in an evidence-based way…what do I actually do?

Norman Swan: Well, the recommendation from the American College of Sports Medicine (which we’ll have a link to in our show notes) suggests that for people who are not doing elite sport, stretches, yoga, tai chi (they don’t mention Pilates, but I will), for all major muscle tendon groups, that’s your neck, your shoulders, your chest, your trunk, the lower back, the hips, legs and ankles, at least two to three times a week…and if you don’t know how to do that, I’m sure there are YouTubes that will help you, or maybe you check in with a physiotherapist for a couple of sessions, just so that you get taught how to do it, and that you should spend about a minute on each stretching exercise. So you know, if you can hold a particular stretch for 15 seconds only, repeat it three times, but ideally extend that and extend that so it’s for about a minute. So it takes a while to get done. 

Tegan Taylor: So not just chucking my heel out in front of me and bending over and thinking that’s stretching my hamstrings and then go for a run. 

Norman Swan: That’s my technique. But no.

Tegan Taylor: Well, Jeff, I hope that has helped you with your X-shaped legs and your ambition to touch your toes. Do let us know how you get on.

Norman Swan: And we just cannot help you with a middle split, you’re on your own on that one. Just make sure there’s a health professional there nearby to help you out of it.

Tegan Taylor: Yeah, or a phone nearby so you can dial triple-zero if you stretch too far.

Norman Swan: Yeah, don’t phone us, we’ll phone you.

Tegan Taylor: Well, Jeff emailed us at thatrash@abc.net.au, and it’s where you can send your emails as well if you’ve got a question that you would like us to tackle, and it’s also where you can send your feedback to us. 

Norman Swan: And we’ve had a lot of feedback on our No Poo What’s That Rash?.

Tegan Taylor: Yeah, No Poo, if you haven’t listened to it, it is not about being constipated, it’s about shampoo, and people eschewing shampoo and conditioner. Quite a few people have already taken this…we’re obviously behind the times, Norman.

Norman Swan: We are, we are. So David writes, ‘I’ve listened to the argument that frequent shampooing may strip the scalp of useful organisms and oils. Upon hearing the Glover’s…’ He’s mentioning Richard Glover, who used to present the Drive show on ABC Radio Sydney, ‘…approach to hair care, perhaps a year or two ago, I’ve adopted his approach and used no hair products.’ He just does a water wash as part of a daily shower, and his hair, he says, ‘is no worse or easier to handle as I go about my day, and there’s been no complaints from others.’ 

Tegan Taylor: And I should point out, the David in question is one of our colleagues, and we have verified that it’s fine. We’re not just taking his word for it, people in the office have gone, ‘Yes, correct, it’s fine, David, you can continue with this.’

Norman Swan: They just stop breathing as they go by. No, no.

Tegan Taylor: Another from Helen, not our colleague, saying, ‘Everything old is new again.’ Norman, do you remember this? Helen says, ‘An episode of the Health Report broadcast 30 years ago on the 2nd of October, 1995,’ (Helen, how do you know this?), ‘included a discussion on this topic with Dr Norman Swan interviewing Australian dermatologist Dr Hugh Molloy, who also has published an excellent book titled Good Skin with a foreword by Dr Norman Swan.’ Do you remember any of this, Norman?

Norman Swan: It was one of the most popular Health Reports we have ever done in the 40-year history of the Health Report, our sister podcast. And Hugh Molloy, like many dermatologists, eschewed soap of any kind. He also talked about how you shouldn’t have a doona because doonas make you sweat and are bad for your skin. 

Tegan Taylor: I love a cuddly doona. 

Norman Swan: So there was a whole radical process, and there were lots of our colleagues in Radio National who actually changed their lives thanks to Hugh Molloy. So a very, very popular Health Report. And as Helen correctly said, it sounds like Dr Swan may not have followed the good doctor’s advice.

Tegan Taylor: Getting called out here. Well, Helen has followed it…

Norman Swan: Do as I broadcast, but not as I say.

Tegan Taylor: Helen says, ‘As recommended by Dr Malloy, I use conditioner to wash my hair and Sorbolene and glycerine cream to wash my skin.’ And then she signs off, as if she needed to specify this, ‘A very appreciative, long-term listener.’ Helen, you’ve been listening to the Health Report for…I’m not going to say longer than I’ve been alive, I’m not going to lie to people like that, but longer than our producer, Shelby Traynor, has been alive. 

Norman Swan: Remember I was only 12 at the time, let’s just clarify that.

Tegan Taylor: Indeed, indeed, of course. Well, thank you so much, Helen, David and anyone who’s ever sent us an email, thatrash@abc.net.au, send us a line, I want to hear about it. I want to see your middle split. And we’ll catch you again next week. 

Norman Swan: Yeah, give us a video of your middle split. We really want to clarify that one. See you next week. 

Tegan Taylor: See you then.