THE JOINT-BY-JOINT APPROACH

Michael Boyle

Excerpted with permission from Advances in Functional Training:
Training Techniques for Coaches, Personal Trainers and Athletes

If you are not yet familiar with the joint-by-joint theory, be prepared to take a quantum leap in thought process. My good friend, physical therapist Gray Cook has a gift for simplifying complex topics. In a conversation about the effect of training on the body, Gray produced one of the most lucid ideas I have ever heard.

We were discussing the findings of his Functional Movement Screen (FMS), the needs of the different joints of the body and how the function of the joints relate to training. One beauty of the FMS is it allows us to distinguish between issues of stability and those of mobility; Gray’s thoughts led me to realize the future of training may be a joint-by-joint approach, rather than a movement-based approach.

His analysis of the body is a straightforward one. In his mind, the body is a just a stack of joints. Each joint or series of joints has a specific function and is prone to predictable levels of dysfunction. As a result, each joint has particular training needs.

This joint-by-joint idea has really taken on a life of its own, one I certainly didn’t envision. It seems like everyone’s familiar with it; it’s become so common knowledge people fail to reference Gray Cook or me as the developers of the idea.

The table in the next column looks at the body on a joint-by-joint basis from the bottom up.

The first thing you should notice is the joints alternate between mobility and stability. The ankle needs increased mobility, and the knee needs increased stability. As we move up the body, it becomes apparent the hip needs mobility. And so the process goes up the chain –a basic, alternating series of joints.

Joint — Primary Need

Ankle — Mobility (sagittal)

Knee — Stability

Hip — Mobility (multi-planar)

Lumbar Spine — Stability

Thoracic Spine — Mobility

Scapula — Stability

Gleno-humeral — Mobility

Over the past 20 years, we have progressed from the approach of training by body part to a more intelligent approach of training by movement pattern. In fact, the phrase movements, not muscles has almost become an overused one, and frankly, that’s progress. Most good coaches and trainers have given up on the old chest-shoulder-triceps method and moved to push-pull, hip-extend, knee-extend programs.

Still, the movement-not-muscles philosophy probably should have gone a step further. Injuries relate closely to proper joint function, or more appropriately, to joint dysfunction. Problems at one joint usually show up as pain in the joint above or below.

The primary illustration is in the lower back. It’s clear we need core stability, and it’s also obvious many people suffer from back pain. The intriguing part lies in the theory behind low back pain–the new theory of the cause: loss of hip mobility.

Loss of function in the joint below–in the case of the lumbar spine, it’s the hips–seems to affect the joint or joints above. In other words, if the hips can’t move, the lumbar spine will. The problem is the hips are designed for mobility, and the lumbar spine for stability. When the intended mobile joint becomes immobile, the stable joint is forced to move as compensation, becoming less stable and subsequently painful.
The Process is Simple

Lose ankle mobility, get knee pain

Lose hip mobility, get low back pain

Lose thoracic mobility, get neck and shoulder pain, or low back pain

Looking at the body on a joint-by-joint basis beginning with the ankle, this makes sense.

The ankle is a joint that should be mobile and when it becomes immobile, the knee, a joint that should be stable, becomes unstable; the hip is a joint that should be mobile and it becomes immobile, and this works its way up the body. The lumbar spine should be stable; it becomes mobile, and so on, right on up through the chain.

Now take this idea a step further. What’s the primary loss with an injury or with lack of use? Ankles lose mobility; knees lose stability; hips lose mobility. You have to teach your clients and patient these joints have a specific mobility or stability need, and when they’re not using them much or are using them improperly, that immobility is more than likely going to cause a problem elsewhere in the body.

If somebody comes to you with a hip mobility issue–if he or she has lost hip mobility–the complaint will generally be one of low back pain. The person won’t come to you complaining of a hip problem. This is why we suggest looking at the joints above and looking at the joints below, and the fix is usually increasing the mobility of the nearby joint.

These are the results of joint dysfunction: Poor ankle mobility equals knee pain; poor hip mobility equals low back pain; poor T-spine mobility, cervical pain.

An immobile ankle causes the stress of landing to be transferred to the joint above, the knee. In fact, there is a direct connection between the stiffness of the basketball shoe and the amount of taping and bracing that correlates with the high incidence of patella-femoral syndrome in basketball players. Our desire to protect the unstable ankle came with a high cost. We have found many of our athletes with knee pain have corresponding ankle mobility issues. Many times this follows an ankle sprain and subsequent bracing and taping.

The exception to the rule seems to be at the hip. The hip can be both immobile and unstable, resulting in knee pain from the instability–a weak hip will allow internal rotation and adduction of the femur–or back pain from the immobility.

How a joint can be both immobile and unstable is an interesting question.

Weakness of the hip in either flexion or extension causes compensatory action at the lumbar spine, while weakness in abduction, or, more accurately, prevention of adduction, causes stress at the knee.

Poor psoas and iliacus strength or activation will cause patterns of lumbar flexion as a substitute for hip flexion. Poor strength or low activation of the glutes will cause a compensatory extension pattern of the lumbar spine to replace the motion of hip extension.

This fuels a vicious cycle. As the spine moves to compensate for the lack of strength and mobility of the hip, the hip loses more mobility. Lack of strength at the hip leads to immobility, and immobility in turn leads to compensatory motion at the spine. The end result is a kind of conundrum, a joint that needs both strength and mobility in multiple planes.

Your athletes, clients and patients must learn to move from the hips, not from the lumbar spine. Most people with lower back pain or hamstring strains have poor hip or lumbo-pelvic mechanics and as a result must extend or flex the lumbar spine to make up for movement unavailable through the hip.

The lumbar spine is even more interesting. This is clearly a series of joints in need of stability, as evidenced by all the research in the area of core stability. The biggest mistake we have made in training over the last 10 years is an active attempt to increase the static and active range of motion of an area that requires stability.

Most, if not all, of the many rotary exercises done for the lumbar spine were misdirected. Physical therapist Shirley Sahrmann in Diagnosis and Treatment of Movement Impairment Syndromes and James Porterfield and Carl DeRosa in Mechanical Low Back Pain: Perspectives in Functional Anatomy all indicate attempting to increase lumbar spine range of motion is not recommended and is potentially dangerous. Our lack of understanding of thoracic mobility caused us to try to gain lumbar rotary range of motion, and this was a huge mistake.

The thoracic spine is the area about which we know the least. Many physical therapists recommend increasing thoracic mobility, though few have exercises designed specifically for it. The approach seems to be ìWe know you need it, but we’re not sure how to get it.î Over the next few years, we will see an increase in exercises designed to increase thoracic mobility. A leader in the field, Sahrmann was early to advocate the development of thoracic mobility and the limitation of lumbar mobility.

The gleno-humeral joint is similar to the hip. The gleno-humeral joint is designed for mobility and therefore needs to be trained for stability. The need for stability in the gleno-humeral joint presents a great case for exercises like stability ball and BOSU pushups, as well as unilateral dumbbell work.

In the book Ultra-Prevention, a nutrition book, authors Mark Hyman and Mark Liponis describe our current method of reaction to injury perfectly. Their analogy is simple: Our response to injury is like hearing the smoke detector go off and running to pull out the battery. The pain, like the sound, is a warning of some other problem. Icing a sore knee without examining the ankle or hip is like pulling the battery out of the smoke detector. The relief is short-lived.

Excerpted with permission from Michael Boyle
Advances in Functional Training by Michael Boyle

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