Gray Cook – Expanding on the Joint By Joint Approach

The following is an excerpt from Gray Cook’s Movement book.   The original conversation between Mike Boyle and me regarding the joint-by-joint approach to training was more about the thought process than about physiological facts and absolutes.  This has been the topic of lots of discussion, but here is the pearl: Our modern bodies have started developing tendencies. Those of us who are sedentary, as well as those of us who are active, seem to migrate to a group of similar mobility and stability problems.  Of course you will find exceptions, but the more you work in exercise and rehabilitation, the more you will see these common tendencies, patterns and problems. A quick summary looks goes like this—

1. The foot has a tendency toward sloppiness and therefore could benefit from greater amounts of stability and motor control. We can blame poor footwear, weak feet and exercises that neglect the foot, but the point is that the majority of our feet could be more stable.
2. The ankle has a tendency toward stiffness and therefore could benefit from greater amounts of mobility and flexibility. This is particularly evident in the common tendency toward dorsiflexion limitation.
3. The knee has a tendency toward sloppiness and therefore could benefit from greater amounts of stability and motor control. This tendency usually predates knee injuries and degeneration that actually make it become stiff.
4. The hip has a tendency toward stiffness and therefore could benefit from greater amounts of mobility and flexibility. This is particularly evident on range-of-motion testing for extension, medial and lateral rotation.
5. The lumbar and sacral region has a tendency toward sloppiness and therefore could benefit from greater amounts of stability and motor control. This region sits at the crossroads of mechanical stress, and lack of motor control is often replaced with generalized stiffness as a survival strategy.
6. The thoracic region has a tendency toward stiffness and therefore could benefit from greater amounts of mobility and flexibility. The architecture of this region is designed for support, but poor postural habits can promote stiffness.
7. The middle and lower cervical regions have a tendency toward sloppiness and therefore could benefit from greater amounts of stability and motor control.
8. The upper cervical region has a tendency toward stiffness and therefore could benefit from greater amounts of mobility and flexibility.
9. The shoulder scapular region has a tendency toward sloppiness and therefore could benefit from greater amounts of stability and motor control. Scapular substitution represents this problem and is a common theme in shoulder rehabilitation.
10. The shoulder joint has a tendency toward stiffness and therefore could benefit from greater amounts of mobility and flexibility.

Note how stiffness and sloppiness alternate. Of course, trauma and structural problems can break the cycle, but it is a present and observable phenomenon producing many common movement pattern problems. It also represents the rule in orthopedics evaluation of always assessing joints above and below a problem region. It would be illogical to expect to improve knee stability in the presence of ankle and hip mobility restrictions.  Likewise, it would be impractical to assume that a recent improvement in hip mobility would not return to stiffness if improved stability were not also created in the lumbar and knee regions. Chronic sloppiness would always be more convenient to use than new mobility.

When Mike and I first discussed this layering of opposites, he did a great job of developing the topic to discuss a more comprehensive approach to exercise program design. The point in the joint-by-joint approach is not so much the 10 Commandments of Mobility and Stability: Make the ankle mobile. Make the knee stable. Make the hip mobile. Make the low back stable. We’ll find a person every now and then whose ankle has too much mobility or who’s sloppy in the hip. We use the words mobility or stability to implicate a segment of the body that should be moving better or have more control. The whole point is to practice with a systemic approach to clear the joints above and below the one with the problem. I was interviewed on this topic after it became popular, and many of my comments regarding the joint-by-joint discussion have been transcribed for you here. When we talk about the ankle, we’re talking about the ankle joint, the inverters, the everters, the dorsiflexors, the plantar flexors and all of the other stabilizers that control that ankle. We’re not just talking about a joint—we’re talking about a complex. Same thing with the knee; same thing with the hip; same thing with the back, the T-spine, and so on up the chain. When you’re about to do knee stability training or lumbar stabilization and you take the classic kinesiology approach of training all the muscles around the knee or all the muscles around the core, you’re going to make a mistake nine times out of ten. You’re assuming when you train the knee that the ankle and hip are contributing like they should, as much as they should. That’s hardly ever the case. It’s the same is true with lumbar stability.

Some of the people producing lumbar stability research today are very well intentioned about the muscles they want us to fire and the muscles on which they want us to focus our exercises. I don’t have a problem with stability research or stability suggestions. All I ask is that the authors use a qualifying statement in front of their core stabilization talks: These statements about stability have been made assuming that you know how to clear the hips and clear the T-spine and other regions where mobility will actually compromise stability. These regions should be considered as potential reasons for loss of stability and compensation behavior. Logically we must make sure these areas are mobile, because if the hips and T-spine aren’t mobile, the lumbar stability we create is synthetic. It is not real. We develop enough stability and strength to do a side plank, but we don’t authentically stabilize in natural environments. The central point of the joint-by-joint discussion is to assure we’re working on what we think we’re working on.

Most of us make the mistake by assuming sloppy knee, stiff ankle, stiff T-spine without considering the potential problems above and below. What would be a reason for the T-spine to become stiff? Probably there’s a lack of stability somewhere else. Often if you don’t have the necessary core stability, the T-spine will get stiff and this also works in reverse. If the T-spine is too stiff, the core stability will be compromised. It can work either way. It’s not about finding what came first, the chicken or the egg—you have to catch both or you can’t manage either. The takeaway from a joint-by-joint discussion is this: Instead of trying to memorize how everything is supposed to be in a perfect world, ask yourself these questions—

• I’m getting ready to train mobility or stability in this segment.
• I either want this segment to move better or I want this segment to be more stable.
• Have I truly cleared the joints above and below that can compound the problem?

 

Reviewing the Joints

I often start at the discussion at the foot, where I defer to Todd Wright and Gary Gray. They have great perspective and discussion with respect to the foot. People have always tried to pull me into a top-down or bottom-up argument, but I’m not committed either way. Problems can come from either place and be corrected by either approach. The real question is what do you see. Here is an example. Let’s say we do the movement screen and we learn that the active straight-leg raise, shoulder mobility, pushup and rotary stability patterns are great, but in standing, the squat, hurdle steps and lunges are bad. You need to consider the foot. This is because everything was going great until you asked the foot to contribute. It does not imply a foot problem; it simply suggests that perceptions and behaviors are compromised when the foot hits the ground. Here’s what I want people to know: The brain and its information pathways work two ways. We’re not just sending information down the spinal cord out to the hands and feet. We’re also uptaking information through the hands and feet. If the feet are sloppy and the grip is off, not only will the person not activate the right muscles, but he or she is not even up taking the right sensory information. Let me say that again. If there are any mobility or stability compromises between the foot and the brain, it’s like standing on two garden hoses wondering where all the water is.

The information pathway is broken two ways… up and down. The foot is no longer a sensory organ because any information that foot could collect in its normal alignment has to be compromised. The foot has to pronate even more because of a stiff ankle, or maybe the foot has to fire too much throughout the plantar flexors because of a sloppy knee. The other reason we’ve got to clean up these issue is it’s not just motor pathway down; it’s sensory pathway up. The foot will keep flattening out to grab as much sensation as possible because the brain knows there is a problem. It’s hoping more information will help. If you’ve got bad shoulder positioning in a push or pull movement, you’re going to do things with your grip that aren’t as authentic as they could be. Let’s look back at the foot. The foot needs to be mobile, but it’s inherently set up to be mobile. Look how many bones, how many joints are in the foot.

There’s movement all over the place unless there’s arthritis. The muscular role in that foot should be that of stability, and that’s why we have all those intrinsic muscles. These are muscles that dwell within the foot, within the arch of the foot. Then we get to the ankle. It’s a boney, stable joint. You’re never going to see many people over-dorsiflex or over-plantar flex. But since people know of inversion or eversion sprains or strain, they think the ankle must be trained for stability. Most of the time, the patient with the rolled ankle will also have restricted dorsiflexion, unless the person stepped on a foot or had a contact injury. There’s a huge prevalence of restricted dorsiflexion in people who present with knee problems, whether MCL or ACL. When a client can squat to parallel, we often leave that last 10 degrees of dorsiflexion on the table, thinking it’s no big deal. We want the foot to be stable, but that doesn’t mean the foot has to be stiff.

We want a mobile foot to be instantaneously stable at contact and push-off, but also to be relaxed enough to accommodate great range of motion. The foot has to be adaptable, but it also has to be instantaneously stable. The ankle has to have freedom of movement. You can’t have ankle restrictions. The ankle also has to be stable, but one of the major problems we see is lack of dorsiflexion.  Is it our footwear? Is it the way we train? It’s all that. The muscles attaching around the ankle have great leverage and strength, but the mobility provides the best overall function to utilize the potential strength and power in the ankle. We need that inherent reflex stability in the foot. We need to have a clear ankle when it comes to plantar flexion and dorsiflexion. Knees are simple hinge joints. They’re supposed to flex and extend, and when they rotate too much or move valgus or varus too much, we start seeing problems with the knee. Does the knee need to be mobile? Yes, but once it’s mobile, it needs to be stable enough to stay inside the proper plane of movement where its functional attributes are possible and practical.

The rotating joints are the ankle and hip. The ankle doesn’t just hinge, and the hip doesn’t just move in one plane. The knee is more of a hinge joint. What we want to see at the knee is once we have the mobility, we need stability. What are the common problems we see at the hip? Can we see a sloppy hip? Can we see a dislocating hip? Absolutely. But in general, we see a lot more hips that don’t have the full authentic mobility.

• Common problems in the foot: People give up their stability.
• Common problems in the ankle: People give up their mobility.
• Common problems in the knee: People give up their stability.
• Common problems in the hip: People give up their mobility.
• Now we’re at the low back: People give up their stability.

So once again, these aren’t the 10 Commandments, but they’re common tendencies when injury, poor training, unilateral dominance, one-dimensional training, a lack of training or an excess of training occur.  These are common defaults the body will go to; they’re not absolutes. Ribs, vertebrae and lots of muscle and fascia crisscrossing the front and back of the thorax cause thoracic stiffness. We don’t inherently have a lot of mobility there, but we need all we can get. However, stiffness isn’t just something we need to get rid of. Stiffness is there for a reason.  Biological mechanisms that move very well in childhood will develop stiffness following an injury or following repetitive bad mechanics over time. If the body doesn’t stabilize correctly, it will figure out another way to get stability: it’s called stiffness.

If you find tight hamstrings or a tight T-spine and you just hit the foam roller, you may change mobility, but you will see the stiffness return the following day. Mobility efforts without reinstalling stability somewhere else simply don’t last. Those hamstrings were tight for a reason. That T-spine is stiff for a reason. If you don’t also backfill some of that new motion with reflex muscular integrity and motor control, you’re going to have a problem. Usually we see tight hamstrings on people who don’t extend their hips well. They don’t use their glutes well, and so the poor hamstrings get double-time. The hamstrings get too much use, and they fatigue—a fatigued muscle and a tight muscle look very much the same. It’s all just protection. Most T-spine mobility problems occur in people who also don’t have full range-of-motion core stability and strength. We may see a tight T-spine on a person who can side plank or front plank for an hour, but who don’t have great core stability through a full shoulder turn in the golf swing. This may be a stiffness developed as a protection. As we get up in the thoracic spine, we’d like to have mobility.

In the scapulothoracic complex, there is only one boney connection of the scapula to the entire axial skeleton (rib cage or vertebra) and that’s at the sternoclavicular (SC) joint. This is where the top end of the collar bone and sternum meet. The acromioclavicular (AC) joint and the SC joint are at each end of the collarbone connecting the shoulder girdle to the rest of the body. But that poor scapula is floating on the rib cage, held in place mostly by muscles and by two joints that aren’t much bigger than the joints in the index finger. That scapulothoracic area needs stability. Does that mean we don’t have to get rid of some trigger points in the upper trap first? No. But often that scapula is stuck in the wrong position. We think it’s stable, but instead it’s just not mobile. It doesn’t mean it’s stable where it ought to be.  Sometimes we loosen that scapula up to make it more stable. We foam roll the upper back, do a little bit of stretching of the teres major, stick a little ball in the armpit, stretch that out, and reset the scapula. Then we train it for authentic stability, but only when mobility is acceptable. Once again, we see tight traps, and we think the last thing we need to do to those shoulders is add stability, thinking instead we need to do mobility work.  Maybe you get the scapula back where it belongs, but if you want to see if it’s stable, watch the person deadlift and see if the exact same scapular position can be maintained throughout a deadlift. No? Then the individual has no stability.

The deadlift represents distraction, and plank and pushups represent compression. The stable shoulder must be able to manage both situations. At the glenohumeral joint we look for mobility. But certainly you can think of a person who dislocated a shoulder. Once you see the dislocation, you may think everybody needs to stabilize their glenohumeral joint, but if you actually go around and measure glenohumeral range of motion, you might start to feel different. In past shoulder training, we’d work on the rotator cuff and try to strengthen it. Then we got better and realized the shoulder needed a stable base. That base was the scapula. How can you make the scapula stable if the T-spine is stiff? The scapula may be moving around incorrectly or too much when the shoulders don’t turn right. I’ve seen many golfers try this. They don’t have T-spine mobility for rotation, so to get a good shoulder turn on a golf swing, they protract one shoulder, retract the other, and it looks like they’re turning their spines. They’re not. They’re just destabilizing both shoulders and in doing so, they’re really losing a lot of good contact and connection with the club. We can take this a few steps further.

Past the glenohumeral joint, we were back on the T-spine, we go up into the mid-neck, the vertebrae from maybe seven up to two. Most people need more stability there. They need their curve back, and they need good stability. Most people in the computer age, in the driving age, are stiff in their suboccipital region, the joints between the base of the skull and C-2. That’s why so many people with their teeth together can barely touch the chin to the chest or do 45 degrees of rotation without using the rest of the neck.  They’re very tight in the suboccipital region from many bad posture habits and from tension.  They overuse the middle components of the neck, which are usually where we see degenerative changes. Where do we see degenerative changes in the spine most? In the mid-neck and in the low back, areas that need to be more stable. Once these areas are degenerated, they become stiff, Many people don’t understand that the stiffness is the body’s attempt to stop the sloppiness. We usually see quite a bit of degeneration in the knees. That doesn’t mean we don’t have it in the hips and ankles, but in the knees it just seems to be compounded. These are areas that could probably use better stability, and better alignment, better everything.

We can follow this out into the elbow and hands, but it gets complicated there because we’ve got injuries to consider. The elbow is more than just one joint, too; there are a lot of things going on there. When we get into the hands and all the manipulative things people do, one of the first things I always do is look for full wrist extension and flexion. Without that, the other mechanics all the way up the chain are compromised: elbow, shoulder, scapula, T-spine and neck. In our Secrets of the Shoulder DVD, Brett Jones and I discussed all the neurons in the brain dedicated to the hand. These exceed all the neurons dedicated to the entire arm, scapula, and even the same-side leg. There is a large amount of brain area dedicated to the effective management of the hand. When there are restrictions, compensations and problems in the hand, a person will nearly contort the whole body to accommodate it. Because sensory information is so important, because foot information is so important, because hand information is so important, a person will sacrifice other parts of the body. This is to make sure to get a good perspective with grip, with stride and step, and the way the foot connects, and with the way vision interacts. The whole purpose of the joint-by-joint concept is to realize generalities. It’s a mobility stacked on a stability, stacked on mobility.

The examples are there to make you think above and below the area you’re working on and in the things you’re asking for. That’s why, in a strange sense, the joint-by-joint is simply another way to make people appreciate whole movement patterns outside of the movement screen. Once you get it, if you decide to go on through the rest of your life without using movement screen, it won’t bother me a bit. It’s simply a tool. Once you get the perspective, that’s fine. What happens, though, is this tool sets a great baseline and sometimes protects us from our subjectivity. A doc can get really good at calling fractures, but we still appreciate him shooting the X-ray. It’s very easy without an X-ray to get about 85-percent accuracy on a fracture, and anyone who’s done sports medicine for a long time gets a sense of a sprain or a fracture in a joint. But, you’d always want to have that X-ray. I have a pretty good perspective on how a person moves, but I want to revisit the baseline because if I improve the movement in some way, I don’t just want my subjective information to say that. I want to know I followed a joint-by-joint perspective, and have something to show for it. We often see somebody focus on core stability. They hammer the side plank, they hammer another core exercise. The core stability is better, and I won’t argue that. But now you’ve jacked up the upper trapezius, threw the neck out of alignment, and the hip basically doesn’t move any better than it did before the side plank. The side plank fired the core, didn’t fix the hip, and jacked up the shoulder and the neck. That’s what? One step forward, two steps back? That’s the problem we get into with the Kinesiology 101 approach.

We find a movement error and we want to fix it. We map the major movers in that area. We exercise them concentrically, and think we did something. We didn’t. Honestly, we leave so much on the table in rehab, we can’t throw stones at anyone in strength conditioning. The number one risk factor for a future injury is a previous injury. That pretty much means there are a lot of chiropractors, physical therapists and athletic trainers discharging people, or giving them a clean bill of health when patients say they feel fine. That’s great, I am glad they feel fine. If the doctor releases an NFL player to play, the strength coach might agree that the medical problem is resolved. However, being well and being ready to play in the NFL are two different things. The movement screen and other functional testing demonstrate risk factors, and the best strength coaches watch these risk factors constantly.  The guy might have an asymmetrical lunge. He’s pain-free; nobody’s arguing that. But we as clinicians in the musculoskeletal fields discharge people feeling fine, but who are still moving poorly. We send them back to their personal trainers, back to their strength coaches, back to their yoga instructors. Now we’ve got an entire fitness industry trying to deal with issues that should have either been cleaned up in the rehab situation or at least forecasted, meaning clinicians need to be ready to have another conversation. “Insurance isn’t going to pay me to treat you anymore, you’ve got no back pain and you feel fine, but you don’t squat well. When you lunge on the left side, it looks great.

When you lunge on the right side is very unstable. I want to get you hooked up with a trainer who gets it, but here’s the deal. “You’ve got to get your lunge patterns symmetrical and get your squat pattern back. I know you want to lose weight and get back in the gym but you need to move well before you move more. I know you want to get fit again. I know you want to play golf in the spring. These are the fastest ways to get you there.” That’s what I talk about in our movement training workshops when to get people working together. The top risk factor for an injury is a previous injury. That is an insult to anybody who’s treating injuries, because it means we leave risk factors on the table. It does not mean we need to fix all these problems, but we can use our professional network to give our patients options. When we peel the onion, guess what we find these risk factors are? It isn’t strength. It isn’t even flexibility. It’s left-right asymmetries. Not mobility asymmetries or stability asymmetries—movement asymmetries. Break these down. Figure out what’s causing them: dorsiflexion restriction, poor spine mechanics, whatever. Fix it, but recheck the movement pattern. If the movement pattern didn’t change, you think you fixed it, but you didn’t. Keep working, keep tweaking it. When the movement pattern changes, you’ve done your job.

Motor control

Motor control is the ability to balance and move through space and range of motion. People call it stability; we’re going to call it motor control. It’s not strength. It’s just can you balance on one foot? Can you control a deep squat? Can you lunge narrow without losing your balance? Asymmetries and motor control are the two underlying things that aren’t addressed in rehabilitation. I want the entire fitness and conditioning community to learn from the mistakes we make.  Just because a person feels fine doesn’t mean he or she is not at risk for an injury, and it doesn’t mean the person is not going to butcher the great exercise program you designed. It’s not because it’s a bad exercise program.

Your clients are going to try to move around things because they can’t move through the things. Joint-by-joint is an excellent template to get you past that entry-level thinking that Kinesiology 101 is going to save the day. It makes you consider joints above and below, but if you really want another way to check yourself, look at the whole patterns of movement. Movement, once we get through the mechanics, is still a behavioral entity that largely goes unaddressed. Really, when we train people and we’re working on functional training, we’re working on conditioning, training or changing movement behavior. To take joint-by-joint a little bit deeper, don’t only focus on the segment in which you think you found a problem. Realize this: Until you clear everything above or below, it cannot be a singular problem.