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The Joint By Joint Approach: Functional Body Organization

As we look at the human body joint by joint from the foot all the way up to the skull we see a pattern of alternating stable and mobile joints that allow us to be strong but still fluid in movement. This assessment of function based on this organization has been called the Joint-by-Joint approach first popularized by Mike Boyle and Gray Cook.

Joint by joint approach by Mike Boyle and Gray Cook

This Joint-by-Joint approach can serve as an extremely useful guide in analyzing movement patterns and treating painful or dysfunctional body regions.**


Joint-by-Joint Approach: alternating stability and mobility

Foot: Stability

Ankle: Mobility

Knee: Stability

Hip: Mobility

Lumbar spine: Stability

Thoracic spine: Mobility

Scapulothoracic joint: Stability

Glenohumeral joint: Mobility

Lower cervical spine: stability

Upper cervical spine: mobility

Elbow: Stability

Wrist: Mobility

Hand: Stability


Let's analyze a few of these joints and see how we may use this joint-by-joint approach in training or manual therapy. If a joint is painful or dysfunctional simply look above and below to see if those joints are doing their job.


FEET vs ANKLES vs KNEES

The feet SHOULD be one of the most stable parts of our body. They are the foundation we walk on, squat on, deadlift on, jump off, land on etc. Due to overly cushioned footwear, a lack of training, and an overall lack of physical activity the feet become weak and are not able to stabilize the weight of our body the way they should.


The knees are similar to the foot in that they SHOULD be a major point of stability in the lower extremity. The surface area of the tibiofemoral joint is actually the largest articulating surface in the human body. If that isn't a joint made for stability then I don't know what is... For many of the same above reasons, the knees become weak. Lack of training, carrying excess weight, overall physical inactivity, etc cause knee instability and a host of other issues develop. Patellofemoral joint dysfunction, knee osteoarthritis (OA), non-contact ligament injuries, etc.


The ankles SHOULD have a huge accessible range of motion; plantar/dorsiflexion, eversion/inversion, abduction/adduction which give the illusion of circumduction when combined. Due to instability above and below the ankle joint, the ankle is now tasked with stiffening up to make up for a lack of stability in the foot and knee. The ankle does this job poorly and now the entire kinetic chain of the lower extremity is dysfunctional.


A once mobile joint has become stiff, and the stable joints are now loose.


THE FIX*


STABILIZE the feet and the knees. Try barefoot foot strengthening exercises like small foot or three point anchoring. Incorporate some balance training barefoot before every workout to strengthen the stabilizers of the foot. Opt for a less cushioned shoe most of the time so your feet get strong again. Build up all the muscle groups around the knee, the adductors, and abductors (connection to knee via the TFL), quadriceps, and hamstrings. Learn to balance in all planes of movement with a variety of single leg strength training exercises as well. Try SKATER SQUATS as an advanced exercise to accomplish this task and more.


MOBILIZE the ankles. Use active mobilization exercises like ankle alphabets, static stretching into dorsiflexion (most commonly limited range), and incorporate full range of motion squat and lunge variations that require a large range of motion at the ankles. Use manual therapies like extremity manipulations to get the joints of the ankles moving and a variety of stretching techniques like PIR, PFS, CRAC, etc to lengthen muscles around the joint that may be guarding against full ROM.


HIPS vs LUMBAR SPINE vs THORACIC SPINE

The lumbar spine is actually designed to be a very stable structure. We have a large amount of muscle and tissue surrounding the lumbar spine (6 core muscles, spinal erectors, deep spinal stabilizers, thoracolumbar fascia, QLs, etc) , the vertebral body's are largest here, and there (normally) is a very small amount of intersegmental motion. Yet, many people have a very hard time stabilizing their lumbar spine and actually end up hyper-mobile due to compensations made from stiffness above and below where we should have mobility.


The thoracic spine SHOULD actually move, a lot! Every single breath you take (if breathing properly) expands and the ribcage in 360 degrees thus moving the thoracic spine via rib-spine articulations. However, postural issues, physical inactivity, and improper breathing (chest breathers) all stiffen the thoracic spine.


The hips SHOULD be quite mobile. As a true ball and socket joint the hip has access to a very large range of motion in circumduction, flexion/extension, internal/external rotation, abduction and adduction. However, due to physical inactivity, desk jobs, and way too much sitting, unless we frequently access the hip's vast range of motion we lose it and the hips stiffen.


So, the lumbar spine attempts to do the job of having mobility because of stiff hips and a stiff thoracic spine eventually developing spinal pain disorders from segmental joint dysfunction, myofascial trigger points, degenerative osteoarthritis (the body trying to make something stable when it moves too much), herniations, and overall core deconditioning.


THE FIX*


STABILIZE the lumbar spine. Use specific core stabilization exercises and overall strength training. Teach neutral spine and abdominal bracing, get the lumbar spine strong with strength training of the lower body in closed chain movements like squats and deadlifts, and enable the lumbar spine to remain neutral as other body parts are moving using heavy carries, unilateral loaded exercises, and multidirectional plyometrics.

MOBILIZE the hips and thoracic spine. Use manual therapy interventions (spinal/extremity manipulation, soft tissue therapies at target tissues) and active care like self stretching and self mobilizations for the hips into all ranges of motion and the thoracic spine into extension and rotation. Try THE WORLD's GREATEST STRETCH to accomplish both of these tasks at once.


This sounds simple... but not simple as low back pain is a multifactorial condition with numerous etiologies. This is just a starting strategy from a manual therapy/exercise prescription perspective.


SHOULDER BLADES vs GLENOHUMERAL JOINT vs LOWER CERVICAL SPINE


Pain and dysfunction at the shoulder (glenohumeral) joint is one of the most common orthopedic complaints from regular gym goers, weekend warriors, couch potatoes, and elite athletes alike. Modern lifestyles, a lack of physical activity, looking down at laptops and cellphones, lazy-boy recliners (basically all the stuff we like) coupled with improper exercise prescription just destroys the relationship between our scapula, lower cervical spine, and glenohumeral joint. Here's what should be happening.


The scapulothoracic joint (not a true joint, but a muscular joint anchoring the scapula to the posterior thoracic wall) SHOULD be stable. Forward head postures, excessive thoracic kyphosis, and upper crossed syndrome cause a weakening of muscles that stabilize the scapula (serratus anterior, middle and lower trapezius) and malpositioning of the scapula at rest from tight and short muscles (upper trap and pecs namely). The rotator cuff muscles are ALL anchored to the scapula and function to secure the head of the humerus while the entire arm moves through a big range of motion. If the scapula is dysfunctional, how can any of the SITS muscles of the rotator cuff do their job?


The lower cervical spine SHOULD be stable. Due to all the same reasons listed above, we lose stability in the lower cervical spine and a large range of motion (primarily in the sagittal plane) takes over. Muscles that should stabilize the lower cervical spine get weak (longus colli/capitis) and our body has to over-react by tightening other muscles in the neck to make up for the dysfunction. Upper traps, SCM, suboccipitals, etc all attempt to stabilize and reposition the cervical spine to be stable and functional. See classic upper crossed syndrome below.

So, the glenohumeral joint tries to make up for this lack of motion with even more motion than it already has accessible without the help of proper scapula control, stability, and movement. The rotator cuff muscles get annoyed (insert tendinopathy and tears) the long head biceps tendon attempts to pick up the slack and gets overused (enter biceps tendinopathy), and then the body responds and says okay now nobody move, and the glenohumeral joint begins to stiffen with joint dysfunction, myofascial trigger points, possibly a frozen shoulder presentation, etc. It is a slippery slope and a cause/effect that is not just at the shoulder.


THE FIX*


STABILIZE the lower cervical spine and scapula. Use strength training to get weak muscles strong! Try deep neck flexor exercises and McGill's curl up (from McGill's big 3). Try serratus push-ups to strengthen the serratus anterior and bent over Y's, T's, W's, I's, A's and whatever other letters you'd like for the middle and lower trapezius. Work on stabilizing the rotator cuff muscles by training their function (not action) in a variety of crawls, carries, and plank variations.

MOBILIZE whatever is limiting full active and passive range of motion at the glenohumeral joint with manual therapies (extremity manipulation, stretching modalities, IASTM, etc) and mobilize the compensations at the cervical and upper thoracic spine with spinal manipulation, PIR, pin and stretch, etc to the upper traps, SCM, scalenes, suboccipitals, etc.


Final Notes

This article is meant to be a guide in assessing movement and painful disorders. This is not the end all be all but a very useful strategy in developing a treatment plan to get people out of pain, moving better, and performing better. As always, seek out the help of a qualified professional to help move you to your goals!


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*All painful or dysfunctional joints can have a multitude of etiologies; the FIX presented is simply a method of analyzing a joint and applying exercise and manual therapy interventions.

**This is intended as a guide for insidious onset pain presentations thought to be related to dysfunctional movement systems or as an aide with movement screens. In the case of trauma, red flags, etc this would not necessarily apply.


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