Gray Cook: Expanding on the Joint-by-Joint Approach, Part 3 of 3
Movement: Functional Movement Systems
Gray Cook, Expanding on the Joint-by-Joint Approach, Part 3 of 3
If you did not yet see the first two parts, click here to start at the beginning.
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 in-correctly 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 lub.
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 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.
This was part three, excerpted from Appendix 2 of Gray’s book, Movement.