One of the best changes I ever added to my assessments, thought process, and training methods was incorporating the “joint by joint approach” invented by physical therapist Gray Cook and strength coach Mike Boyle. When working with new clients and especially those with injuries or chronic pain it can be very difficult to know where to start, what to look for, and more importantly what to do to restore pain free movement. I was never taught this concept at any point in my first 5-6 years of personal training and I completed many advanced courses in rehabilitation and worked with many experienced therapists and specialists. I used to rely on postural corrections based around muscle imbalances and would drill down to specific areas with isolated exercises and stretches. While I had some success doing this I regularly would get very frustrated with poor results with transferring isolated exercises to full body movement. Then one day I read the book Movement by Gray Cook and came across the joint by joint approach something clicked in my mind that helped me join the dots together with what I had been doing. Everything seemed to make a lot of sense looking at the body in this way and enabled me to make some big changes that worked much better than anything I had been using previously. In this article, I will explain how I use this method right now and why I believe everyone should be taught this concept.
The first thing I will say about this is as much as I use it all the time and feel it helps in a big way it is not absolutely correct all the time. There are always exceptions to the rule and things that go against the flow so you have to be able to use methods like this as a guide only and not as the only way.
If you have worked within the health and fitness industry or work with injury and rehabilitation for a long period of time you will know that there is nothing absolute with any methods or research. What works for one person may be a huge problem for another. There are no templates for you to follow, only better ways to navigate through all the possibilities to find what the source/s of the problem are to enable you to find the most effective correction for that specific person.
Postural observation assessments give clues as to where something is not ideally aligned and the muscles in this region could be responsible for dysfunction and pain. There are also medical imaging tests like x-ray, MRI, CT scans, and ultrasounds that can help determine the degree of damage to a specific area of the body if there is an injury. But what these tests cannot tell you is why the body is aligned like this in the first place.
Secondly these tests don’t show you how the body creates movement, for these tests are completed while you are perfectly still. The postures people adopt while moving is often much different to when they are standing or lying still.
The obvious solution to the problem of finding out how the body moves is to complete basic movement assessments which can help reveal things you might have missed on a static assessment or from imaging results. However, this is where it can get messy and leave you even more confused for not everything adds up to what you see on postural assessments or explains how a muscle become weak or tight.
Also when you consider that there is often multiple joints and multiple muscle groups all firing at the same time how do you know which one is at fault? Is it weakness, or is it stiffness?
The body is very good at compensating to avoid pain or protect joints from compression which often hides the real problem making it very difficult to pinpoint what is causing these movement dysfunctions. Sometimes these dysfunctions may not even be causing pain, but the way the person moves is inefficient and awkward and likely to create pain in the future if not corrected.
This is where the joint by joint approach helps to narrow down your exercise selection to enable the body to move efficiently and free or dysfunction and pain by targeting an area of the body with a specific function that it is designed to do. Basically it simplifies what can be overwhelmingly complicated.
Human movement in itself is extremely complex. There are hundreds of simultaneous and intricate muscle actions used to complete patterns like walking or throwing a ball. Some muscles create movement while others stabilizing and hinder movement. To know which one is doing what at exactly the right time is impossible to determine as these muscle interactions happen within milliseconds. This is why I don’t like drilling down to specific muscles too much, or blaming a single muscle for a problem like I did at the start for I know that it will only take me so far.
Each joint in the body tends to have a specific function and purpose that is required for efficient movement to take place.
When you look at a stacked series of joints you begin to see a pattern forming where each there is a constant series of a mobile joint moving on top of stable joint. 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.
The best part is it guides you on what may be the most effective exercise at restoring a problem with a movement pattern that is painful or dysfunctional.
To understand the joint by joint approach you need to have a good understanding of the two main functions specific to each joint. These are mobility and stability.
Mobility: describes the ability of the joint complex to move freely in an unrestricted manner through full range-of-motion. In basic language this is our ability to move at a certain segment. (See the article about mobility versus flexibility for more detail on this).
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 is often referred to as motor control. (See the article what stability really means for more detail on this)
The process of rotating between mobility and stability goes on and on up the body in a simple alternating pattern. Stable joints stacked on top of mobile joints.
The Most Important Concept You Need To Remember
Now this is where it gets interesting for 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.
If I have a knee problem then I will look at the mobility of the hips and ankles as a potential source of the problem. If I find something stiff at either of these joints I know I will need to include some mobility work and investigate further as to why either of these areas become stiff.
How do you know if it is the lack of mobility that creates instability and not the other way around? Most of the time stiffness precedes weakness which is due to the way the muscles are designed with tonic versus phasic muscle groups. This fits the majority of people, however you cannot assume that it is always the case as several times I find that people with hypermobile joints it is the other way around. It is the weakness and instability causing the stiffness, but this is the exception to the rule but always a reminder to never assume. You must always test to be sure.
In simple terms tonic system muscles are prone to tightness or shortness and are more concerned with stability, posture, and working for long periods. They are made up mostly of slow twitch fibres and are easily facilitated with constant repetitive movements.
On the other side is the phasic system muscles who are prone to weakness or inhibition and more concerned with fast and powerful movements. They are predominately fast twitch muscle fibres and require specific movement to keep them functional.
The tonic muscles by way of their design begin to develop a method of overworking and dominating all movements and in essence “shut down” or “steal” the phasic muscles workload completely. This creates an imbalance within the body as muscles not capable to perform various movements continue to work developing trigger points and tightness, while at the same time other muscles are becoming weaker due to lack of work. The longer this stays this way the further the imbalance becomes and inevitably reaches a point of chronic pain.
This is known as muscle inhibition.
A good example of this in action is where people try to strengthen the core to improve lumbar spine stability and rehabilitate an injured back. It is pointless trying to strengthen the core if the hips remain immobile for the minute you try to bend over and do not have adequate flexibility in the posterior chain your body will instantly sacrifice any strength in the core to complete the movement.
This is where the core may have great strength in floor exercises or positions that do not demand you to bend, but all of this strength is useless when you need it the most if mobility is an issue. This is due to the fact your hips are too stiff to allow your spine to remain in the safest position. The body must use the spine to complete the range of movement for the hips are unable to do so.
If you were working on a plan of improving hip mobility first and then stabilizing and strengthening you would make much better progress and go a long way to resolving the imbalances.
However, like I said earlier this is not always the case with every person and sometimes weakness can occur first and the hips are one of the joints where this happens. The only way to be sure is to run a series of tests and look closely at how each joint moves on its own and during an integrated movement.
To explain this further, let’s take a closer look at the role each joint must play to help you understand why each joint is more concerned with either mobility or stability.
The Role Of The Feet – Stability
Out of all the joints in the joint by joint discussion I would say this is the most unique in that there is no joint preceding it. Meaning you cannot blame a joint apart from the ankle for creating its weakness. To understand what I mean compare how difficult it is to walk or run on sand, compared to a more stable surface like concrete or asphalt. It is much easier to run and walk faster on a hard and stable surface than the sand for it is easier for our feet to create the stability needed to create motion.
The feet is an area of the body I have discussed in great detail many times and more recently I wrote an article about how they very easily cause weakness at the glutes that could be the catalyst for injuries in the lower limbs and back.
For any movement you do standing up, neural signalling begins at the feet as they are the first part of the body to feel the ground and tell the system what to do. They tell the brain where you are, if you are balanced enough to move yet and basically instigate movement before it even begins. The better the feet and ankles are functioning, the better the signal, the more effective it will be in providing stability providing a stable base for the body to move.
Unfortunately, a most people have very weak feet due to inactivity and modern footwear.
Watch the video below to see an example of how weak feet create problems up the chain.
Our feet and ankles are meant to withstand incredibly high forces and should provide more in terms of shock absorption than perhaps any other body part. Unfortunately, we begin to gradually lose this ability once we start wearing shoes. Over time, the feet, ankles, and toes become inhibited. And as we expose our feet to some trendy shoes with all types of padding and support, this only make matters worse and exacerbates the lazy and weak feet muscles.
With regards to the joint by joint approach you could actually include the big toe on its own in that it actually needs a high degree of mobility. During movements like walking and running, your big toe flexes as your foot pushes off the ground. This flexion creates tension in the plantar fascia, the connective tissue on the sole of your foot.
If your big toe is unable to do this for it has become rigid then you can set off a chain reaction of compensation leading to stiffness and weakness.
To read more about the feet read the articles below
•Exercise solutions for weak feet
•Big toe mobility and function is everything
The Role Of The Ankle Joint – Mobility
Many sporting injuries occur when the ankle develops stiffness and loses flexibility – particularly in the movement of dorsiflexion.
Sometimes ankle immobility can be caused by a sprain or a traumatic accident that was not rehabilitated correctly leaving the ligaments and tendons weakened and forcing the body to use stiffness to protect the joint from more damage. Other times it can be due to weakness at the feet placing the ankle in a terrible position, once again forcing the body to adopt stiffness as a protective mechanism. In this case it can be difficult to make any changes as the underlying problem is really the feet, but on an assessment what you see is the loss of mobility at the ankle.
The movement of the knee moving forward over the toe during the deepest portion of the squat requires a high degree of ankle mobility to do this. The tendency for the ankle joint to become stiff and immobile greatly affects the function and stability of the joint directly above being the knee and the area below being the foot.
The loss of dorsiflexion in the squat can greatly affect the strength of the quadriceps for they will be unable to function due to the poor position they are placed in. This disrupts the timing between the knee movement arm and the hip movement arm which you can read more about in the article – Why your knees must go over your toes when you squat
Dorsiflexion is something we all tend to take for granted in daily life and in sport and trust me you can ask the people with walking impairments how hard it is to walk when your foot does not do this. Every time you squat, lunge, and move your legs for almost any daily activity you require it.
It is vital you continually work on your mobility and also why it features so heavily in our knee pain programs, even though the joint itself has no pain.
You can read more about the ankle in this article – How to improve your ankle mobility
The Role Of The Knee Joint – Stability
Obviously the knee needs to have some degree of mobility such as knee flexion but this joint is very limited in its ability to rotate. Ligaments like the ACL, PCL, MCL are exposed to tremendous pain and problems whenever they are forced into a twisting action or bent sideways, known as valgus or varus, and lastly if they hyper-extend.
This is often the source of the dreaded ACL tear seen in many sports and is known as a career ending injury for it is so destructive to the knee joint.
This injury is much more common with female athletes often due to instability and weakness with the muscles supporting the knee but also due to poor hip mobility and anatomical posture.
Watch the video below to see an example of this.
The knee joint is more or less a hinge, it cannot twist and rotate all that much by itself, and it cannot bend the other way either. While it needs to maintain some degree of mobility it is more concerned with stability to prevent the dangers of twisting and rotating that will ruin the integrity of the ligaments and tendons holding it together.
To prevent being placed into poor positions and maintain good stability the knee requires the joints of the foot/ankle and the hip to provide the rotational movements seen with twisting and turning actions in sports.
To read more about knee stability read the articles below.
•How to strengthen the VMO and get rid of knee pain
•What are ACL tears more common with female athletes?
This brings us to the next joint and arguably the most confusing.
The Role Of The Hip Joint – Mobility
The hip joint is an interesting area of the body in that it 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 phenomenon.
My thoughts are that at first it develops stiffness from inactivity, sitting too much, repetitive actions and poorly executed movements, then eventually develops weakness leading to instability. Like we have seen already with the other joints stiffness is a by-product of instability and a necessary compensation of the body to protect itself from further damage.
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.
Generally speaking the hips 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 back injuries like bulging discs and sacroiliac joint pain is often caused by a lack of hip mobility. This is another example of where core strength is irrelevant for it doesn’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 for the underlying source of the problem is still at large which is exactly what I discussed earlier.
In addition to the mobility restriction, weakness develops later on if it is left unattended for a long period which is where I often see “butt gripping”. This is a compensation by the body to protect itself and is an inferior alternative to stability which can be really difficult to get rid of once it is set in. The body is forced to using this strategy as its last way of protecting itself from catastrophic injuries to either the hip or lower back.
Unfortunately, it robs the glutes and the lower limbs of any strength and only serves to create more problems in the long term leading to injuries like piriformis syndrome.
Great articles to read with more information about the hip are shown below.
•Are tight hips the cause of your back or knee pain?
•10 ways to improve hip mobility
•How butt gripping ruins stability
The Role Of The Lumbar Spine – Stability
This part of the body usually attracts a stack of attention as this is an area of the body that is often injured. Statistics show that 9 out of 10 adults now experience back pain at some point in their life, and only colds and flu beat low back problems for Doctor visits!
As a result many people are prescribed core exercises to make it stronger in the belief that it will go away when their core muscles are stronger. In some ways this is correct, as the lumbar spine is very much like the knee joint in that it has very limited ability to move with rotation and is more concerned with stability than mobility.
However, this is only part of the puzzle for in order to gain stability and strength it is relying on the hips and the thoracic region to provide the rotational movements and ability to position the body correctly avoid being placed in extreme positions of flexion or extension. Failure to address any mobility restrictions below (hips) and above (thoracic) will make any strengthening pointless. In addition to this is movement skills, as many people have good mobility but move so poorly that they always use their spine to instead of their hips.
Strengthening the core is where people make a big mistake is by using exercises to create motion such as a sit-up or using exercises to train the abdominal muscles in the same way you would use bicep curls to make a bicep stronger.
The way we train the core muscles, should line up with the structure of the lumbar spine, and avoid excessive lumbar flexion, extension, and especially rotation. Any repetitive exercise that encourages too much movement at the lumbar spine, will create instability at a part of the body that is especially designed for stability.
How do you generate stability?
To do this correctly you need to understand that this is created by small stabilizing muscles known as the Inner Unit, working together with large prime mover muscles that operate like a series of complex chains and systems to provide stiffness on a greater scale. This known as the Outer Unit.
True core strength requires the use of both.
Watch the video below to see more.
The inner unit is incorporated in almost every movement of the human body and these muscles are comprised of the diaphragm, TVA, pelvic floor and multifidus. These muscles do not attach to bones that can move you as that is not their purpose. They act as an isometric or dynamic stabilizer for movement, transfer force from one extremity to another, or initiate movement itself.
The role of the inner unit is to stabilize the spine. That’s it.
Their work is what you would classify as low level activity needed for long periods of time. They are also known as “feed-forward” muscles in that they react quicker than any other muscle group, to prepare the body for movement.
The outer unit comprises of the large prime mover muscles that are more concerned with moving your arms and legs. However they are unique in that they are also designed in a way to move but at the same time provide stability via use of what are called myofascial slings and co-ordinate the correct sequence of movements.
The main thing to understand here is that the weakness in this area will often be due to stiffness at the hips or thoracic spine forcing the lumbar spine to sacrifice its stability. If you fail to address these factors first you will not change all that much.
Great articles to read on this topic are shown below.
The Role Of The Thoracic Spine – Mobility
This is another really interesting area of the body and unlike the lumbar spine that is associated with pain and many types of injuries this region often remains pain free!
The vertebrae of each part of the spine is designed differently. Some parts are designed for rotation such as the cervical spine and thoracic spine but the lumbar spine as we just discussed is not and can only provide extension and flexion. This is why stiffness in the hips or thoracic spine can create massive problems in the lower back as it may be forced into rotation.
The main function of the thoracic spine is to hold the rib cage, and protect the heart and lungs. It also provides 2 critical movements.
1.Extension of the rib cage in order to lift our arms overhead.
2.Rotation of the trunk for movements like walking, throwing a ball etc.
For most people, the thoracic spine stiffens due to poor posture developed from excessive sitting all day at work playing on the computer and smart phone. This poor posture is known as kyphosis and is extremely common in modern society. Apart from the fact that it looks terrible the bigger concern is the damage this posture creates to the health of the body.
Recent estimates showed that at least 77% of the world’s population has their own mobile phone and many studies have been conducted to study the correlation between using mobile phones for texting and both, neck and shoulder pain. See journal results for more information on this.
The main thing to understand about this joint in relation to the joint by joint approach is that stiffness or a lack of mobility with the thoracic spine can do several things.
1.It can force the lumbar spine to try and rotate to make up for loss of motion with twisting movements.
2.It exposes the shoulder to instability as it attempts to find lost mobility by sacrificing its integrity.
3.Neck stability is also compromised at the cervical spine.
Stiffness in this area is so common due to the high amount of people with poor postural habits and the fact we sit so much. Finding ways to keep this region of the body mobile gives your body every chance of maintaining stability at joints that are commonly injured such as the lower back, neck, and shoulder.
Any time I complete an assessment for any of those injuries I am always looking for stiffness in the thoracic spine. As I mentioned at the start this part of the body very rarely has pain itself so nobody bothers to look there, but make no mistake about it, the thoracic spine can play a big part in creating the weakness and pain at other joints if it remains stiff and immobile.
Great articles to read about this are shown below.
•How the thoracic spine creates pain elsewhere
The Role Of The Scapula & Shoulder – Stability & Mobility
This part of the body is slightly different to the others in for there is more movement possible at the shoulder joint than at any other joint in the body and research shows that it has over 1,600 positions it can obtain! Unfortunately, this dynamic mobility with extreme ranges of movement comes at a price and exposes the joint to lack of stability. While it is certainly a joint that has a lot of mobility its main weakness is always to do with stability whenever we talk about the health of the shoulder.
Where it gets messy is when we talk about the scapula as this is arguably a separate joint but in reality it works in tandem with the shoulder. The scapula often develops massive problems when it loses mobility and the shoulder suffers as the end result by sacrificing its stability leading to injuries like shoulder impingement, rotator cuff tears, and bursitis. Poor scapula function is often seen with winging gets its name from its appearance, a wing-like resemblance, due to the medial border of the scapula sticking straight out from the back.
To sum this up it really is a combination of both stability and mobility.
Poor scapula stability is also proven to be a major contributor with elbow pain.
Scapula dysfunction is a massive problem for the elbow for when the scapula does not sit or move as it is designed to, the arm bone has little chance of being in the right position to move. If the arm bone rotates inward the forearm will have problems.
These problems have to do with how well the forearm rotates into a hand-down position known as pronation and the hand-up position known as supination. We use these actions all the time in daily life and most people think that these movements are only performed by the forearm itself. Little do they know, that it is the scapula that is driving this compensatory movement.
To maintain stability of the scapula and the shoulder joint there are a lot of muscles needed to function correctly to ensure this happens. A combination of the rotator cuff muscles, and work from muscles like serratus anterior, lower trapezius and the upper trapezius ensure this works as intended.
In Even Oscar’s book “Corrective Exercise Solutions For Common Shoulder & Hip Injuries” , a must read, he provides a table of what happens when stability muscles are inhibited.
If you are not 100% with anatomy this might be a bit confusing but this shows how the stabilizer muscles to the left that are labelled as inhibited, will recruit the larger more powerful muscles who are not able to provide stability of the joint.
This leads to instability and where all the problems lie.
Great articles to read with tons of information are shown below.
•The top 5 exercises to correct a winged scapula
•Why the upper trapezius needs to be strengthened
•How good is the external rotation exercise for the rotator cuff?
The Role Of The Cervical Spine – Stability
The last joint is the cervical spine otherwise known as the neck. This is very much like the lumbar spine in that it is more concerned with stability than mobility, although it does have more movement than the lumbar spine.
When you look at a human skeleton you can clearly see how your bones are all stacked upon each other to create stability at your joints. Gravity basically compresses your bones to lock everything into place so you do not fall apart like a bag of bones. The one area that is different to all the others is clavicle (more commonly known as the collarbone) at the front of the shoulder.
The clavicle appears to be the only thing holding up your shoulder as it is not stacked upon other bones vertically like the spine and the lower limbs. The only way it can create stability to hold itself in good position is via use of multiple muscles, tendons, and ligaments.
The clavicle and the scapula appears to be floating in space as neither is connected or stacked upon other bones!
Two of the main muscles that hold these bones in place, LEVATOR SCAPULA and the TRAPEZIUS attach to the neck and the base of the skull.
This explains why dysfunctional movement at the shoulder can easily lead to neck pain and headaches. The levator scapula is often the muscle that people feel neck pain with as it is easily overloaded when weakness is present in other muscles.
Once again poor posture leads to all types of problems with the cervical spine.
As the laws of physics dictate, the further away from the body a weight gets, the more the effective weight is – the heavier it feels and the harder muscles must work to hold it. It takes just an inch of forward head posture to increase the effective weight that the neck muscles and ligaments must support by 10 pounds.
There are a number of muscles responsible for this but if we were to focus on muscles around the head and neck to begin with you would find there are those muscles that are weak, and muscles that are tight.
Most people concentrate all their efforts on trying to stretch and lengthen the tight muscles but I have found this to be very ineffective over the longer term, for the muscles will continue to revert back to what they were doing, until the weakened muscles are strengthened.
Trying to strengthen these muscles while they are short and tight is often very difficult to do and for some people can even create more pain. Using a combination of mobilizing and strengthening exercises I have found to be the most effective way to correct this problem but it takes a bit of trial and error to find the right type of exercises for each person.
Great articles to read about neck stability are shown below.
•Why you should stop stretching your neck
•How to fix forward head posture
Do You Need More Help?
If you currently have back pain, knee pain, hip pain or shoulder pain there are special reports and videos you can download to help guide you on the path to better health.
Go to the ONLINE SHOP to see more.
I included the picture of the back pain program below.
Summary
While it seems like a lot of information that I have covered and that it would be impossible to remember everything the main thing to take away from the joint-by-joint method is these three things.
•Do I need 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 assessed the joints above and below that can compound the problem?
If you keep it to this simple methodology it will help you make better choices in terms of exercise selection and finding out what is truly going on. It makes a complicated topic seem a lot easier to manage and gets you working on what you really needed straight away.
Sure, this is not 100% perfect but nothing is in when talking about health. There are only more logical directions than others and this is definitely one of those.
About The Author
Nick Jack is owner of No Regrets Personal Training and has over 20 years’ experience as a qualified Personal Trainer, Level 2 Rehabilitation trainer, CHEK practitioner, and Level 2 Sports conditioning Coach. Based in Melbourne Australia he specializes in providing solutions to injury and health problems for people of all ages using the latest methods of assessing movement and corrective exercise.
References
•Functional Anatomy of the Pelvis and the Sacroiliac Joint – By John Gibbons
•Movement – By Gray Cook
•Corrective Exercise Solutions – by Evan Osar
•Back Pain Mechanic – by Dr Stuart McGill
•Diagnosis & Treatment Of Movement Impairment Syndromes – By Shirley Sahrman
•Low Back Disorders – by Dr Stuart McGill
•Ultimate Back Fitness & Performance – by Dr Stuart McGill
•Anatomy Trains – by Thomas Meyers
•Motor Learning and Performance – By Richard A Schmidt and Timothy D Lee
•Assessment & Treatment Of Muscle Imbalance – By Vladimir Janda
•How To Eat, Move & Be Healthy by Paul Chek
•Scientific Core Conditioning Correspondence Course – By Paul Chek