Victory Friday | Issue 133
Orthopedic Insights: Unstable Old Guys: Signs of Instability in Older Populations • Basic Upper Cervical Mobility • Hip Mobility Side Doors • Old Guys’ Tight Hamstring Cure.
“Stability is not the absence of change, but the ability to adapt and remain steady amid it.” ~ unknown
Victory Friday is a weekly digest of reflections, insights, and tools from the world of functional manual and performance medicine. It is a free weekly publication. To support Victory Friday with a paid subscription, click below:
(In)Stability is the theme of this week’s Victory Friday: how it often masquerades as stubborn stiffness and tightness, or hides its true cause in adjacent “side door” tissues. Even as we age — and feel (or act) increasingly stiff — we can still harbor significant joint instability.
The good news? Targeted stabilization work can cut through the paradox, delivering lasting improvements in mobility, strength, pain relief, and function.
What I’m Into: Unstable Old Guys: Signs of Instability in Older Populations. When an orthopedist thinks about a typical “instability client” — a person with passive tissue (joint or ligament) hyper mobility, or active core stability deficits — it’s easy to jump to an image of:
• young
• athletic
• female
Hypermobile body types, super-”bendy” and in activities like ballet and gymnastics.
But what about old guys?
They seem to be the opposite, don’t they?
• old (> 40)
• (less) athletic, but still active
• male
Yet old guys1 are among the biggest sufferers of orthopedic instability and the issues that come with it:
• chronic pain
• weakness
• repetitive injury and functional limitation
Can older populations — particularly men — experience problematic orthopedic instability?
Absolutely.
Yet the instability often goes unrecognized for a couple of reasons:
First, most instability issues in older populations are isolated to a single joint, or a few joints: the spine, the shoulders, or the hips.
Most orthopedists are taught about the Beighton Index: a measure of systemic hypermobility found throughout the body from head to toe, used to screen for instability.
Yet few older clients will ever test so highly — and pervasive — under that index. Instead, their instability is more subtle: isolated to one (or a few) joint systems.
Secondly, old guy instability is shrouded in a murky mess of “stiffness and tightness”. This sore-stiffness ranges from run-of-the-mill orthopedic hypo-mobility — stiff myofascial and joint tissue that is increasingly common in most older clients — to more focal, painful and problematic tightness.
One example: chronic hip and hamstring tension: caused not because the hamstring is tight, but because the hip is unstable. (see this week’s Victory, below)
Signs of Clinical Instability in Older Populations. If you’re wondering if your client or you (as a fellow old guy) have instability masked as something else, here are some possible signs:
• “Too mobile”. Old guys (and gals) may not present as true hypermobile, but they often present as…more mobile than they should be.
Unless they perform specific life-long activities that demand full range of motion, if and older client presents with “really good” mobility, they are likely hypermobile and succeptible to instability issues.
Excessive mobility metrics for older clients include:
• cervical rotation: >80 degrees
• cervical sidebending: >50 degrees
• lumbar extension: >45 degrees (able to look to the ceiling or behind them)
• hip flexion: >130 degrees
• shoulder flexion: >180 degrees
Notably: some complementary motions — including lumbar flexion or hip extension — might be significantly (if not profoundly) tighter: either because the hypermobility is unidirectional, or the instability is significant enough to create compensatory (protective) stiffness that “locks up” this motion.
Which leads us to…
• Chronic stiffness. The paradox of instability is how it can cause chronic stiffness. This was covered in a previous Victory Friday2:
Instability creates stiffness and tension for two potential reasons:
• muscles overwork to stabilize a joint. They get stiff and tight as a result of the excessive (or inefficient) work.
• a nervous (or vascular) system under strain will create myofascial tension around sensitive areas to protect them.
• Easy come, easy go. This is the real hallmark of instability. When you treat an “old guy” — who should be stubbornly and densely stiff — yet a modest amount of hands-on treatment creates a rapid restoration of motion…that seldom lasts very long — days or hours — before “re-stiffening”3.
But the good news? Instability in older populations is…
• Highly responsive to stabilization exercise. Also noted in a previous Victory Friday, targeted stability exercise has immediate and significant improvement in not just strength, but system mobility and overall function4.
Takeaways. Once again…don’t discriminate against the old guys! Just as all old guys with diastatis aren't just weak and flabby (but instead have covert stiffness)5, what appears — and often feels — like stiffness and tightness may actually be chronic instability.
If stiff and tightness complaints are stubborn to stretching, if hands-on work creates rapid changes that never seem to stick, and if that part (or other parts) of the body are “too mobile”, try some stability work!
Cool Exercises I Like. Basic Upper Cervical Mobility. I like to post fancy, innovative exercises here at Victory Friday.
But I also like to share the very best ones. Even if they seem (or actually are) pretty basic.
I treat a lot of headache and neck pain. And this exercise, while basic, is the most impactful home exercise I prescribe.
A lot happens at the upper cervical spine. It contains:
• the initial passage of the entire spinal cord, leaving the cranium
• upper cervical and occipital nerves
• suboccipital muscles, containing direct connections to the dura mater of the spinal cord
As such, compression of the upper cervical spine can cause a lot of problems, including:
• headaches
• neck pain and mobility loss (namely: rotation)
and, most notably (yet least recognized):
• neuro-fascial tension and pain anywhere else in the body
As such, maintaining an open and mobile upper cervical space may not only relieve and prevent headache pain and neck stiffness, it is often a key to problem-solving stubborn issues…anywhere below the neck!
My favorite quick-and-dirty upper cervical opener is the retraction exercise:
• In sitting, with finger pressure:
• In supine, against a pillow or small bolster:
In each, there is active and/or passive anterior to posterior glide of the head on the upper spinal segments. This stretches open that crucial upper cervical space!
Simple as it may be, it’s a key tool in the maintenance of a healthy upper neck, and a clutch pain reliever for cervicogenic headache.
Joe’s Articles. Hip Mobility Side Doors. This is actually a re-post from Issue 87 a year ago, but highly relevant to our instability theme this week: how “side door” tissue restrictions can cause persistent mobility loss in “primary” motions. And how side-door strategies — massaging and stretching to these adjacent tissues — can sustainably unlock motion.
From iRunFar.com:
Side-Door Strategies for Improving Hip Mobility
TL;DR:
Core Idea: Traditional hip stretches (focusing on flexion/extension) often plateau; “side-door” approaches target deep, short muscles (rotators, abductors, adductors) around the hip “ball-in-socket” to restore full mobility for running.
Why It Matters: Stiff deep hip tissues limit the femur’s ball movement, causing big restrictions in stride, pain, or injury (even if asymptomatic). These short muscles are hard to stretch due to poor torque.
Key Techniques (using balls/foam roller for self-massage):
Lateral Hip/Pelvis: U-shaped massage around greater trochanter (glutes & deep rotators) with up/down, side-to-side, and rotational motions.
Posterior Hip: Target the “trough” behind greater trochanter with a firm ball for deep rotators/ligaments.
Adductors (Medial Thigh): Foam roll side-to-side, with added hip rotation/flexion.
Prescription & Tips: Pre-test mobility (e.g., hip flexion/extension, pigeon pose); work small areas for a few minutes, reassess; follow with hip strengthening (bridges, clamshells, etc.) to stabilize new range and avoid injury.
Benefits: Improves cardinal running motions + rotation/abduction; can help related issues like knee, ankle, foot, or low-back pain.
Victory Friday. Old Guys’ Tight Hamstring Cure. This is a blast from my Fellowship year.
As I took over the caseload of the departing Fellow, I got to adopt a cadre of new (to me) clients. One of them was a man in his late 60s. A retiree to northern Colorado, who — like most Coloradans — was highly-active, loved hiking and played golf frequently.
Yet his golf was increasingly painful — and limited to a power golf cart — due to chronic posterior thigh pain.
“My hamstrings are just so tight!”, he told me. Hamstring stretching and massage work helped, but the tightness and pain always returned.
Initial hamstring straight leg raise mobility testing: about 50 degrees.
Pretty darn tight, and painful.
So I investigated the side doors of his hip and hamstring: the medial and lateral thigh and hip. They were dense and restricted.
I mobilized these soft tissues. With about ten minutes of massage work to the inner thigh and lateral hip?
Straight leg raise: 100 degrees!
100 degree is a lot in an “old guy”.
Huh.
“Too much, too easy”, I thought.
That was the first time I’d ever considered an older (otherwise “stiff”) man could have true joint instability.
Freeing tissues around the hip joint — the adductors and lateral hip muscles — freed the straight leg raise.
His hamstring pain and tightness was likely a reaction — both myofascial (hamstring overuse) and neuofascial (sciatic nerve tension) — to project an unstable hip joint.
We then performed isolated three-dimensional hip stabilization. This not only maintained his motion through the end of the session, but it resulted in sustained mobility improvement and pain relief.
He might’ve stuck to the golf cart, but he was quickly back to golf 18 holes with much less pain.
Takeaways. Don’t Let Looks (and Age) Deceive. Older clients can have clinical instability! Look for the signs, and apply focused stability for sustained improvement in mobility, strength, pain relief and function!
Issue 133 is a wrap!
Help people move, function and feel better: please share this publication!
Thanks for reading, and have a great weekend!
Older women are also suceptible to tissue instability, but since women of all ages are expected to have greater tissue extensibility, they are less “shocking” that older men to show signs of instability.
Issue 95: You’re Stiff Because You’re Unstable. A neuromuscular stability deficit can cause real motion loss and increased “stiffness” (higher tone and resistance, and discomfort and soreness with movement). This occurs for at least two reasons: uncoordinated muscle activation causes over-activation (“tug of war”) and increased myosfacial tension; inefficient motion places tension or strain on the nervous system, which increases tone/tension to protect itself.
Issue 105: Three (More) Signs of Joint Instability (vs “Stiffness”). Precise stability muscle activation is key for full, pain-free joint movement and prevention of excessive and recurrent muscle stiffness. Signs of instability include rapid (but reversible) mobility gains from minimal mobilization, immediate motion improvements after stability exercises alone, and dramatic strength/performance boosts within days from targeted training.
See Footnote #3.
Issue 123: Men’s (Fascial) Health. ¹ This perspective reframes common age-related men’s health issues—diastasis recti, nocturia, and erectile dysfunction—not primarily as inevitable degeneration, weakness, or prostate-driven problems, but as potential consequences of accumulated fascial stiffness and restricted tissue mobility