Today we’re going to talk about one of the most thought provoking and influential approaches to understanding the human body – the joint-by-joint concept. Now, before we start I want to make it known that this concept is not new or of my own creation. Physical therapist Gray Cook and strength coach Mike Boyle shaped this concept based on their observations and history working with athletes. They have written extensively on it in the past and I definitely recommend checking out their expanded writings on the topic (Click Here). Their simple and straightforward concept is a game changer when it comes to how we as coaches, medical practitioners and athletes view the human body. As a doctor of physical therapy, this philosophy has influenced the way I approach and treat my athletes. The joint-by-joint concept is an idea I would like to share with you. We will also discuss how it relates to the squat.
Human movement is extremely complex. It is so complex that it lends itself to the illustration of a symphony orchestra composed of hundreds of simultaneous and intricate muscle actions. Some muscles create movement while others stabilizing and hinder movement. Just as an orchestra changes tempo and shapes its sound in a united manner, our body must move and flow in a united manner as well.
Each joint in the body tends to have a specific function and purpose that is required for efficient movement to take place. In this stacked series of joints emerges a tendency for alternating series of mobile joints moving on top of stable joints. With an appreciation of what each joint requires we can then ‘connect the dots’ in our understanding of how the body works together to produce efficient movement.
First let’s define two terms that describe the way our body functions.
-Mobility: describes the ability of the joint complex to move freely in an unrestricted manner through full range-of-motion. In basic terminology this is our ability to move at a certain segment.
-Stability: describes the ability of a joint complex to maintain position while motion takes place somewhere else. This is simply the ability to control the motion at a certain segment. Stability can also be synonymous with the term motor control.
Let’s look at a simple breakdown of the primary needs associated to each joint in the Joint-By-Joint Concept.
-Foot = Stability
-Ankle = Mobility
-Knee = Stability
-Hip = Mobility
-Lumbar Spine = Stability
-Thoracic Spine = Mobility
-Scapula = Stability
-Shoulder = Mobility
These labels are based off of common tendencies, patterns and problems that we as practitioners have found over time. What we see is that athletes who develop injuries have similar mobility and stability problems. The overwhelming consensus in practical experience shows us that when the body is unable to adequately demonstrate mobility and stability at certain parts of the body, movement breakdown occurs and injury ensues. Let me explain.
- The foot is an area of the body that could benefit from increased stability and motor control due to its tendency to become unstable during movement. A recent article published in the British Journal of Sports Medicine compared the stability our ‘core’ provides to our lower back to the role of the smaller muscles of our foot that work to maintain the same type of motor control during movement (2). This control inevitably creates the stability of the foot for which all human movement such as squatting is based upon. While proper shoe wear does play an important part in the performance and injury processes, there is no denying we could all benefit from increased stability of the foot. When the foot has a stability problem it will directly affect the ankle joint.
- The ankle is an area of the body that would benefit from increased mobility and flexibility. Inherently we see many athletic injuries that occur when the ankle develops stiffness and looses flexibility – particularly in the movement of dorsiflexion (the movement of the knee moving forward over the toe during the deepest portion of the squat). The tendency for the ankle joint complex to become immobile then affects the role of the joint directly above (the knee) and the area below (the foot).
- The knee joint is an area of the body would benefit from increased stability. Obviously the knee needs to be mobile when we squat in order to reach a solid bottom position. Unfortunately the problem we see is that athletes who develop pain tend to have unstable knees, especially when they squat. When we squat, jump, run and cut, we need to be able to control the knee. The knee must stay in proper alignment (stability) to avoid injury. Many injuries occur because the knee tends to bow in instead of staying aligned over the foot.
- The hip joint is an area of the body that shows a tendency to benefit from increased mobility due to its tendency to become immobile and stiff. If the hip loses its mobility it will affect the role of the joint complex directly above (the low back) and the below (the knee). What we’ve come to find is that the all too common ‘low back pain’ is caused by a lack of hip mobility (1). For this reason, it wouldn’t matter how much strength and stability work you perform on the ‘core’ – if the hip mobility is never addressed, no change in pain will occur.
- The low back (lumbar spine) is a joint complex that requires stability. Very often, we see that the low back looses stability. When this happens our body develops compensations that lead to stiffness, decreased power production and eventual pain. When looking at squats a stable low back in a necessity, otherwise you risk injury. Food for thought: ensuring this stability is more than just performing planks and endless sit ups. Strength is not the same as stability. A strong core and stable spine prevents excessive movement.
- The mid to upper back (thoracic spine) is a joint complex that requires mobility. This area of the body is inherently very stable due to the support it helps create with the ribs for our vital organs. However, we all could benefit from increasing our available mobility and flexibility to this region. For most people, the thoracic spine stiffens due to excessive sitting all day at work playing on the computer and smart phone. The majority of Americans have crappy posture. As a result of this crappy posture, it limits ability to perform high level movements, such as the overhead squat and snatch/jerk. Not to mention, poor posture/inflexible thoracic spine raises the risk of shoulder impingements and other shoulder injuries.
The process goes on and on up the body, in a simple alternating pattern. Stable joints stacked on top of mobile joints. When a mobile joint becomes immobile, the stable joint above or below will give up its stability and move as compensation. This is how injury occurs in our body. The simple format of the joint-by-joint approach allows us to understand the body to a deeper extent.
Recently we have seen a substantial shift in the way athletes are trained and rehabilitated after injury. In years past the paradigm of training and rehabilitation was to concentrate solely on one part of the body. We essentially viewed the body through a microscope. Fueled by the golden era of bodybuilding and the desire to look like Arnold Schwarzenegger, athletes would enter a workout to train their “back and biceps” or “chest and triceps.” This mindset was predicated in the though process that a stronger and bigger muscle would lead to increased performance. Athletes who injured their back would go to a physical therapist and perform hours of ‘core’ work while lying on a bed. Rarely would a therapist make the connection that limited ankle mobility could have a potential connection to the lack in core stability. However, eventually a more intelligent approaching the athlete started to appear. The mantra ‘train movements not muscles’ started to penetrate throughout the sport training and rehabilitation world.
Today athletes enter a training session to work on explosive movement through the power clean and back squat. A physical therapist will now spend a large majority of the time helping an injured patient with back pain recover through teaching core stability principles over a variety of movement patterns such as the squat or lunge. We now have the connection to realize that in order to address an injured area of the body we need to also assess the joint above and below the site of pain. We as a society are starting to see that the missing link between optimal performance and injury is in the way we move as a whole. We are finally putting away the microscope and looking through the looking glass of movement.
Recently I was working with a CrossFit athlete who was complaining of knee pain – one of the most common injuries to an athlete in any sport. She could run without pain. She could jump rope without pain. However, she could not squat with a barbell, snatch or perform pistol squats without pain.
During our first meeting, I asked her to perform two simple bodyweight movements – a deep bodyweight squat and a pistol squat to full depth. Instantly I observed a theoretical ‘crack’ in her movement foundation. Simply put, she could not squat with good technique. During her bodyweight squat, she turned her toes out excessively and allowed her knees to roll in slightly at the bottom position. Her pistol squat was even worse as she was unable to even pass a parallel hip depth position without her knee collapsing inwards.
Straight off the bat this athlete had a movement issue that was causing her pain. By applying the joint-by-joint concept to this broken movement pattern we were able to uncover a few problems that were all connected.
- Stiff ankles
- Unstable knees
- Immobile hips
The combination of these deficits led to knee pain. The most important aspect of the joint-by-joint approach is that it allows us to expand our view of how we approach the body. Given this CrossFit athlete had knee pain, many coaches and trainers may approach this injury by focusing solely on the knee itself. The doctor would hand out some pain medication and tell her to rest. Next a therapist would prescribe a barrage of barrage of Foam rolling, stretching, and icing the knee. Does this sound familiar to you?
Even if we acknowledged there was an instability issue at the knee and started some stability training, the effects would be short lived. The stability we would create wouldn’t be real whenever she needed to squat, clean or snatch again. Until the immobility of the ankles and hips are addressed (the joints directly above and below) the knee will never fully stabilize in real world situations. Gray Cook wrote, “It’s not about finding what came first, the chicken or the egg—you have to catch both or you can’t manage either.”
Let’s return to our analogy from the start of this lecture. Movement in the body is synonymous with a skilled orchestra with dozens of musicians playing in a coordinated and synchronous fashion. Our usual response to pain is like telling the violins to stop playing because they sound bad. The pain, just like the poor sounding instruments, is our warning that something isn’t working correctly. Taking pain medication and placing ice on the knee because it hurts before ever examining the hip and ankle is just like silencing a section of the orchestra that is playing out of tune. In the end, you didn’t fix the issue. The musician’s instruments are still out of tune. You just covered it up and stopped their playing for the time being.
By acknowledging each joint complex has its own specific role, we can use a systematic approach to understanding how movement breaks down and injuries occur. In doing so, we can rid ourselves of pain but also maximize our potential to move and perform at the highest level possible. I challenge you to look at the big picture. When dealing with pain, look at the joint above and below. You may be surprised what you find.
Until next time,
- Roach SM, San Juan JG, Suprak DN, et al. Passive hip range of motion is reduced in active subjects with chronic low back pain compared to controls. Int J Sports Phys Ther. 2015 Feb; 10(1): 13-20
- McKeon PO, Hertel J, Bramble D, & Davi I. The foot core system: a new paradigm for understanding intrinsic foot muscle function. BJSM. (2014) Mar 21.