The following is a guest post by Justin Kompf.
The joint by joint approach to training was conceived by physical therapist Gray Cook and strength coach Mike Boyle and first introduced to us in 2007 on T-nation. Since its inception this theory has birthed a whole host of correct exercises that most personal trainers have bought into using. My concern is what if the premise that the joint by joint approach is built on is flawed? If the premise is flawed we really need to examine the value that corrective exercise brings to the table. Is it better than exercise in general? And then there’s the big question, if the joint by joint approach is flawed or if trainers are reading into it too much (spotting dysfunction where it doesn’t exist) then wouldn’t our time as trainers be better spent returning to training with less of an emphasis on corrective exercises?
At this point in the game I’m sure most people are familiar with the joint by joint theory. Picture the body as a stack of joints that alternate as either mobile or stable. Here’s how it stacks up (no pun intended):
Ankle: Mobile
Knee: Stable
Hips: Stabile
Low back: Stable
Thoracic spine: Mobile
Scapula: Stable
Shoulder: Mobile
If a mobile joint like the ankle became too stable it would result in sloppy knee movement and so on. Immobile hips would lead to a mobile lumbar spine which would eventually lead to low back pain.
Loss of mobility –> aberrant movement of a stable joint –> pain
I’m assuming this theory is alluding to regional interdependence which is the concept that “seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with the patient’s primary complaint” (11). According to this, dysfunction in one area may cause pain in another which sounds a lot like the joint by joint approach.
Clinical research left unanswered questions and exceptions that didn’t mesh with some of the principles that the joint by joint approach is based on. I also saw a lack of criticism directed towards the joint by joint hypothesis. It seemed like plenty of trainers base their training and the exercises they do off this idea without truly examining it. Below are some points from the original T-nation article I thought deserved some attention.
“Injuries relate closely to proper joint function, or more appropriately, to joint dysfunction. Problems at one joint usually show up as pain in the joint above or below” AND “poor T-spine mobility, cervical pain.”
There are suggestions that, “poor mobility in the upper thoracic spine was a predictor for neck and shoulder pain” (9). One study found that people with neck pain had a greater upper thoracic angle and concluded that, “a person with a greater upper thoracic angle may be more likely to develop neck pain” (9).
Unfortunately it is difficult to determine causality because these subjects were already in pain. It is entirely possible that the pain was causing the change in thoracic trunk angle. We’ve seen that experimentally induced pain can alter trunk muscle activity which makes it hard to say that poor posture leads to pain rather than pain leads to different postures (13).The only true way to test this would to conduct a longitudinal study on pain free people with different thoracic spine angles to see who would develop pain over time.
The quote from the article demonstrates a far too simplistic view on pain and still falls under the umbrella of structuralism as a cause for pain. Going by this theory one would predict that a person with kyphosis lacks the ability to get into spinal extension. If you connected the dots you would come to the conclusion that this would lead to pain. Contrary to the above study, which was flawed because participants were already in pain, we find that this is not the case.
In one study the authors found that, “a number of individuals with normal posture were found to have significant pain, whereas some individuals with more severe postural deviations in the thoracic-cervical-shoulder region were found to have minimal pain.” (8)
“The primary illustration is in the low back. It’s clear we need core stability, and it’s also obvious many people suffer from back pain. The intriguing part lies in the theory behind low back pain- the new theory of the cause: loss of hip mobility.” AND “if somebody comes to you with a hip mobility issue- if he or she has lost hip mobility- the complaint will generally be one of low back pain.”
Trying to pinpoint an exact mechanical reason for low back pain is a bit far-fetched. Low back pain is one of the most frequent medical complaints in the United States. In fact 80 percent of people will experience low back pain at some point in their life (7). So all we can really say is that if you are a human you will probably experience back pain. (Nick’s article here covers a variety of the evidence refuting much of the conventional wisdom surrounding the cause of low back pain.)
Blaming it on posture, lack of core stability or poor movement just doesn’t hold up. Central sensitization seems like a more believable reason for low back pain compared to structural or biomechanical issues.
There is a lack of strong evidence that treating the hip can result in decreased low back pain. Evidence does however support the fact that general exercise is just as good for treating back pain as other options (1). Many of the studies look at rotational hip motion rather than hip flexion as seen in the squat and as alluded to in the joint by joint approach article. That being said evidence does support that lack of hip rotation is correlated with back pain (11).
However, this may only be applicable to certain subgroups of people with low back pain and cannot be used as a general statement for all people with low back pain. One study looked at the characteristics of people with non specific low back pain and found that a group of individuals presented with, “higher fear avoidance, sensory pain, anxiety, depression, disability, and response to pain provocation test. This group demonstrated a greater likelihood of having allodynia (pain in response to non noxious stimuli) and was judged to have a dominant psychosocial component to presentation” (19). Being able to subgroup people with low back pain is important. Some people might have mechanical issues where application of the joint by joint theory could be applicable but others might have underlying psychosocial issues.
From my own experience (I realize anecdotal evidence isn’t too valid) I can recall two clients that I had, one with chronic back pain and the other with no back pain. The person with chronic back pain had excellent hip mobility with no problems doing a deep body weight squat. The other individual with no pain had a hip replacement surgery and it was physically impossible for her to get parallel on her squat.
Contradictory to some of the rotational studies was a study that found that there was no significant difference in hip mobility aside from left hip flexion (p=.011) when comparing symptomatic to asymptomatic patients. It should be noted that right hip flexion approached significance (p= -.074). The validity of this study should be called into question however, because measurements were far off from the standard measurements obtained from the American Academy of Orthopedic Surgeons and other sources and once again they were looking at people already in pain and we know that pain changes movement(12).
“The lumbar spine is even more interesting. This is clearly a series of joints in need of stability, as evidenced by all the research in the area of core stability.”
Core stability and its relationship to low back pain is a far stretch. Not to neglect the value of core strength as it is usually a staple in most training programs. However, with such low levels of abdominal activity during most tasks it would seem unlikely that lack of strength would be a cause for concern. Strengthening the abdominal muscles “does not seem to improve the pain level or disability in CLBP patients,” and “There is no evidence that reduced trunk muscle strength or endurance will predispose the individual to LBP.” (1)
Clearly a stable and ‘neutral’ back is a better option than a flexed lumbar spine when picking up heavy loads however the notion that greater ‘core stability’ will protect someone from low back pain is a poorly evidenced one.
“There’s a huge prevalence of restricted dorsiflexion in people who present with knee problems, whether MCL or ACL.”
If we’re looking at the kinematics of non contact ACL injuries from landing, “one possible mechanism may be that excessive knee internal rotation in conjunction with knee valgus at the time of landing leads to ACL injuries.” (2)
So what about restricted ankle range of motion?
In the review portion of studies on ground reaction forces and ankle range of motion the authors of “Ankle Dorsiflexion Range of Motion and Landing Biomechanics” state that, “ restricted dorsiflexion ROM may increase ACL loading and injury risk via association with less knee-flexion displacement, greater knee-valgus displacement, and greater ground reaction forces during landing” (4).
Stiff landing mechanics that result in greater posterior ground forces are associated with “greater knee valgus displacement and moment” (4). Ankle ROM restrictions may play a contributing factor in the ‘stiff’ landing.
In the aforementioned study that looked at how ground reaction forces, knee and hip flexion correlated with ankle range of motion, the experimenters hypothesized that, “greater passive ankle-dorsiflexion ROM was associated with greater knee-flexion displacement and smaller ground reaction forces during landing. These biomechanical factors are considered risk factors for ACL injury, the findings indicate that techniques designed to increase plantar-flexor extensibility and dorsiflexion ROM may attenuate ACL injury risk by placing the lower extremity in a position consistent with reduced ACL loading, thus decreasing the forces the lower extremity must absorb after ground contact.” (4).
The authors recommend that ankle dorsiflexion range of motion screening to identify those at risk for ACL injuries.
Although it was close to significance some of the results of their study conflicted with their hypothesis that restricted ankle range of motion correlated with knee valgus displacement. The authors saw some correlation between risk factors and straight leg passive dorsiflexion range of motion but no correlation between bent leg passive dorsiflexion range of motion to any biomechanical risk factors.
The main goal of preventative programs is “on neuromuscular control of the knee.” (3) Success has been seen in programs that incorporate a focus on acceleration and direction change mechanics, proprioceptive training programs, and plyometric programs with a focus on soft landing (3).
To support the theory that ankle restrictions can at least lead to aberrant knee movement, at least in the form of medial knee displacement one study found that, “activation of the gastrocnemius was 42% greater in the MKD (medial knee displacement) group than in the control group during the descending phase of the no–heel-lift condition. The gastrocnemius is one of the primary muscles that eccentrically resists ankle dorsiflexion.”The authors theorized that “increased gastrocnemius activation may have resulted in a larger internal ankle plantar-flexion moment and increased posterior ankle stiffness” (5).
Although it might be important it certainly isn’t first on the list of ‘dysfunctions’ that lead to ACL injuries. When it comes to limited ankle ROM and its predictive validity for ACL injuries, “little data exist regarding the feasibility and effectiveness of screening the ‘at-risk’ population.” (4).
“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.”
The effects of foam rolling have been shown to increase range of motion. One study found a 4.3% increase in range of motion after using a massage roller (6).
Not to discount the statement because one can certainly use that increased range of motion as a window to more benefits from exercise. Although we have a decent of idea of what foam rolling can do I don’t think we’ve come to a consensus on why it does what it does. One of my favorite explanations is that it’s just a change in sensation that allows for greater range of motion.
So I agree that you will see stiffness return the following day because of the transient nature of foam rolling but I do not believe stiffness is returning because stability wasn’t installed somewhere in the kinetic chain.
Note from Nick: It’s important to note here that the burden of proof is solely on the party(s) making the claim(s), not on those who reject the claims. So, if you’re thinking, “well, in this (above) part of the article, Justin hasn’t provided any objective evidence, he’s just sharing why he doesn’t “believe” the claim, so he’s not providing any evidence to support his position.” Keep in mind that he doesn’t have to provide any objective evidence to reject any claims made because the burden of proof is not on him – it’s on the claimers who provided zero objective evidence in support of the claims made (in the original t-nation article) to meet any sort of burden of proof. Not to mention, many of the claims made have been falsified in the research, as demonstrated by the references Justin has provided.
So, in shot, make sure you don’t fall for the fallacy of switching the burden or proof onto Justin, and that you don’t forget the basic rules of logic summarized perfectly (in the image below) by the late Christopher Hitchens…
“Often the scapula is stuck in the wrong position.”
What is the right position? Often times an anteriorly tilted and internally rotated scapula is blamed as the culprit for impingement of the subacromial space. This might be more relevant in dynamically, however, in a recent review on scapular position to determine if it had an effect on subacromial impingement syndrome the authors concluded that, “Non-surgical treatment involving rehabilitation of the scapula to an idealised normal posture is currently not supported by the available literature” (10).
For this statement I feel that giving criteria for what the wrong position is would have been helpful and a great clarifier.
The TAKE AWAY
The joint by joint approach did bring a nice way of thinking to the table and I’m in agreement that joints should move the way they were proposed to move in this thought process. I also believe the authors have done a lot to bring about progress in the fitness industry. Problems arise with some of the broad and generalized assumptions that were made especially when trying to connect the dots on causes of pain.
The implications garnered from this idea have lead to the creation of an infinite amount of mobility drills that have been adopted by trainers and therapist alike sometimes to the point where no training effect is elicited because we deem clients too dysfunctional do exercise. We end up giving them an endless supply of corrective exercises rather than working around their limitations to create a training effect.
We need to question the benefits of these mobilization drills we give our clients based off of the joint by joint concept. Does the time spent on corrective exercise make more of a difference than the time we could have spend exercising?
To quote Dr. Eyal Lederman:
“The winner in the competition-in-adaptation, is ultimately the one most practiced, that is, the default PSB state/behavior of the individual.” (14)
COMMON QUESTIONS
I wanted to conclude this section by addressing some common questions that usually arise with this topic.
“So what do you mean when you say corrective exercise?”
When I think corrective exercise, I’m not thinking about things that are addressed with good coaching, nor am I thinking of simply using basic exercise regressions. When I think “corrective exercise” I’m referring to special exercises coaches prescribe after an assessment procedure in attempt to “fix” (i.e. correct) what they deem are specific “dysfunctions” displayed by the client.
Now, I’m not completely discounting corrective exercise – it has it’s place. My main concern and message is its overuse where simply basic exercise training concepts would be more effective, not to mention the lack of evidence that supports many of claims that drive corrective exercise prsecription. I also have concerns on the lack of definable lines that we can draw on where and what “dysfunction” actually is. The problem is if there isn’t a real problem and trainers spend time addressing this “boogeyman” problem that doesn’t exist.
“Are you saying posture doesn’t matter?”
That’s a great question and up until six months ago I probably would have said yes it does matter. Now I was only saying this because other people were telling me it was so. I should have looked at the pain free kyphotic client that I had that was deadlifting over four hundred pounds to see that there are no cookie cutter rules for pain, posture, and performance.
Pain is multifactoral, posture can certainly have its part in subgroups of people but as a predictive tool for pain it is a poor one. I’ve gone through rebuttals on this topic and would like to quote Gary Fryer as I think he sums it up quite nicely;
“The causes of spinal pain are unclear, but pain is multifactorial, and an overemphasis of any one aspect, such as mechanical factors, is inappropriate”… “ The literature does not, however, demonstrate that postural factors have no influence on pain.” (15)
Furthermore, in cases where postural deviation becomes extremely severe, as with elderly people we see increased risk of falls and fractures, decreased physical performance, lower quality of life and worse health (16).
However, even if you do improve posture there is no guarantee that it will have a pain reducing effect or a performance enhancing effect. In one study the authors urged the readers to acknowledge that posture doesn’t follow any set patterns. In their study they used taping to improve thoracic kyposis to determine if it would allow the shoulder to get increased pain free motion. Their postural improvement intervention, “despite a mean improvement, had a detrimental effect on shoulder range of motion in both groups” (17).
Posture may play a part, and it might matter, just not as much as we make it out to.
“If posture doesn’t matter, why are so many people talking about it?”
Another good question and I wish I had a good answer. Perhaps it’s because it gives us something to do? It creates a problem that needs to be fixed. Maybe we think our ability to identify postural deviations makes us sound smarter to prospective clients?
That being said I don’t believe visual assessment and diagnosis of a client is something that personal trainers should be doing because I have doubts on it reliability as test. For example, in one study twenty-eight chiropractors, physical therapists, physiatrists, rheumatologists, and orthopedic surgeons were asked to evaluate cervical and lumbar lordosis of photographed subjects. They concluded that, “intrarate reliability of the visual assessment of cervical and lumbar lordosis was statistically fair, whereas interrater reliability was poor” (18). If these professionals cannot identify posture then what makes personal trainers think they can?
Are you saying form doesn’t matter?
Of course not! I would certainly not ignore medial knee displacement or a flexed lumbar deadlift. Remember biomechanics do play a part.
Medial knee displacement is a biomechanical risk factor for ACL injuries and also tells me that the person either has poor neuromuscular control (they’ve never done a squat before) or there is some weakness in the hip muscles which needs to be addressed in training.
As for lumbar flexion under load, Stuart Mcgill states in his book, Ultimate Back and Fitness, that, “not only is the spine much stronger and better able to bear compressive loads in a neutral position but dangerous shear forces are also minimized” (Mcgill 88).
That being said, is the guy doing rounded back deadlifts going to hurt himself for sure? I think the outcome of that question is so variable it is impossible to predict. Sure he’s more likely to and should certainly be corrected but he might be adapted to that movement pattern and this “chronic overloading often results in adaptation and expansion of the physiological range” (14)
What should we do instead?
There’s so much more to talk about with endless information out there for the reader to study (myself included) and I’m sure I’ve left quite a few questions unanswered simply because when it comes to this topic no rules are carved in stone.
I question how much of an impact corrective exercise makes. It can have its place, for example, in the warm up as movement prep or during rest periods. Just to make it clear, I do not believe these drills are obsolete or useless I just believe an overemphasis can be detrimental just in the sense that time spent on these drills could be spent as time training.
I recommend working within the client’s current capabilities, giving them exercises they can do. My best guess is that this will help them improve quicker than three sets of ten quadruped rocking with hip internal rotation and t spine extension while practicing diaphragmatic breathing (I’m sure that one exist somewhere!). Give it a try, see if you can progress a client without or minimally touching on corrective exercise, as Nick covers in this video:
Author Bio:
Justin Kompf is a certified personal trainer and certified strength and conditioning specialist through the National Strength and Conditioning Association. He graduated from the State University of New York in 2012 with a bachelor’s degree in Kinesiology. He is currently an adjunct professor, teaching personal training classes at Cortland as well as the strength coach for Cortland athletics. Justin blogs for bloodandiron315.com and has been featured on STACK.com, thePTDC.com, elitefts.com, Gaglionestrength.com, and Tonygentilcore.com He can be contacted at justin.kompf90@gmail.com for questions.
REFERENCES
(1) The myth of core stability
(2) Muscle Activity Response to External Moment During Single-Leg Drop Landing in Young Basketball Players: The Importance of Biceps Femoris in Reducing Internal Rotation of Knee During Landing
(3) Etiology and prevention of non contact ACL injuries
(4) Ankle dorsiflexion range of motion and landing biomechanics
(5) Neuromuscular Characteristics of Individuals Displaying Excessive Medial Knee Displacement
(6) Roller massager application to the hamstring increases sit and reach range of motion within five to ten seconds without performance impairments.
(7) https://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=3
(8) Incidences of common postural abnormalities in the cervical, shoulder, and thoracic regions and their associations with pain in two age groups of healthy subjects.
(9) Relationship between sagittal postures of thoracic and cervical spine, presence of neck pain, neck pain severity, and disability.
(10) Non-surgical treatment involving rehabilitation of the scapula to an idealised normal posture is currently not supported by the available literature
(11) The Hips influence on low back pain: a distal link to proximal problem
(12) Ranges of active hip motion in low back pain patients and apparently healthy controls
(13) Experimental muscle pain changes feedforward postural responses of the trunk muscles
(14)Quote from: The fall of the postural structural biomechanical model
(15) Is postural- structural-biomechanical model, within manual therapies, viable?: A JBMT debate
(16) Age- related hyperkyphosis: its causes, consequences, and management
(17) Subacromial Impingement Syndrome: The Effect of Changing Posture on Shoulder Range of Movement
(18) Reliability of the visual assessment of cervical and lumbar lordosis: how good are we?
(19) A Process of Subgroup Identification in Non‐specific Low Back Pain Using a Standard Clinical Examination and Cluster Analysis
Not cited extra reading for fun
https://www.ncbi.nlm.nih.gov/pubmed/15144357
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597839/
Scapular positioning assessment: is side to side comparison clinically acceptable
Here’s another review that was brought to my attention written by Bret Contreras and Greg Lehman give that a read as well if you want more information on the topic https://www.thebodymechanic.ca/2012/05/29/exceptions-to-the-exceptional-joint-by-joint-approach/
