Knee, back, and shoulder pain has been an ever increasing problem in this country over the past few decades. From 1996 to 2006, there has been a 49% increase in the number of arthroscopic knee procedures performed in the United States, with the 2006 total at nearly 1 million surgeries. An outpatient ACL procedure including MRI’s, readings, and physical therapy will cost the system (patient + health care) about $30,000-$40,000 a pop. That’s a $40 million cost per year in outpatient knee surgeries alone assuming the numbers haven’t increased since 2006. And if you think that number is big, hold on tight for the cost of back care. Duke researchers estimated in 2006 that medical treatment of back pain costs our country $25 billion annually with another $25 billion lost to workers compensation costs and time away from work. Given these numbers, it’s no surprise that as of now 80% of all Americans will experience some type of back pain in their lives.
Orthopedic problems, coupled with the costs associated with the rise in obesity, represent a huge weight that is crushing our health care system. And I’m certainly a part of it since I accounted for three of those outpatient knee operations from 1996-2006. Not only are orthopedic procedures costly to the country, but they also press the pause button on your life. After you get past the period of missing work and being laid up in a drugged state on the couch for a few weeks, you must start the months (or years) long road back to recovery. It can be a depressing and frustrating experience, especially when you go through it multiple times. And as much as I might complain about the woes of knee problems, back pain is much more common and can be much more fickle. Fusion surgery is often unsuccessful and symptoms can persist for decades, limiting activity and causing daily pain that can materially change the way you experience life.
The best thing you can possibly do in the case of orthopedic issues is use preventative care. Just as eating healthy today will help prevent diabetes and metabolic syndrome down the road, taking a proactive approach to fixing your body now will save you many years of orthopedic pain down the road. Trying to gain a full understanding of how to maintain healthy joints can be daunting, but luckily there’s a simple approach outlined by strength coach Mike Boyle to make things a bit clearer.
The Joint by Joint Approach
Coach Boyle recently developed an excellent system of analyzing the movement of the body called the joint by joint approach. In this, Boyle discusses the different training needs and demands on the various joints in our body. As it turns out, our body has an elegant way of arranging itself in order to maximize performance and minimize risk of injury. The arrangement involves joints that alternately are built for mobility and stability as you move up the body, as shown below
- Ankle – Mobility
- Knee – Stability
- Hip – Mobility
- Lumbar (lower) Spine – Stability
- Thoracic (upper) Spine – Mobility
- Scapula (shoulder blade) – Stability
- Glenohumeral (shoulder) – Mobility
Essentially, any joint that is built for a high level of injury free articulations and a large range of motion is a joint where you want mobility. With the hip, we have the capacity for abduction/adduction (taking the leg away from the body and bringing it back), internal/external rotation (the way you turn the leg out and point the toe in a triangle pose in yoga), and flexion/extension (bringing the knee up to the chest and lowering it back down). All of this motion is possible because the joint is a ball and socket design, very similar to the shoulder.
All three of these hip articulations can be combined into thousands of different movements, which become the cornerstone of any athletic pursuit. This is all normal and necessary motion for the hip in order to keep it healthy. The knee, on the other hand, is basically a hinge joint that is built only to flex and extend. Adduction/abduction or rotation of any kind places dangerous force on the joint that will land you in an orthopedist’s office and typically result in one of those 1 million knee procedures each year. Just as the knee is built for stability below the hip, the lumbar spine is built for stability above the hip. The lower back is safest and strongest in a small amount of extension, as shown below.
In this position, the bones and vertebral discs sit correctly on top of each other and do not experience any shear or torsion force that could damage them. However, any flexion of the lower back (rounding over) or excessive twisting can put the lumbar spine in a very compromised position that can result in acute or chronic injury. The big concept to understand here is that mobility in the hip allows for stability in the knee and lumbar spine. If your hips are tight and immobile, any type of movement you do in sport, lifting, or daily life will force you to compensate for that immobility by contorting your knees and lower back in an unsafe way. For this reason, anyone who says squatting or deadlifting hurts their knees and back is almost guaranteed to be an individual with tight hips. Being able to squat and deadlift while keeping the knees and low back in a strong, stable position is as much an expression as it is a developer of hip strength and mobility.
This concept of using mobility joints (hip/ankle) to protect stability joints (knee/lower back) continues to be applied in the upper body. Going from the lumbar spine to the thoracic spine, we see much more of a safe range of flexion, extension, and rotation in the upper back compared to the lower back. You can see a great example in this short video from Chris Mills, who runs Surf Strength Coach:
You can see how much rotational range of motion is possible with a healthy upper back. This exercise is a great way to warm up for rotational sports and an upper body lifting day. It will also give you a good kinesthetic sense of how to develop rotation in your upper back while leaving the lower back stable. Sitting atop and to the outside of the thoracic spine are the scapulae, the shoulder blades which need to be very stable in order to provide our shoulders (the glenohumeral joint) with a large amount of mobility.
The trade off for providing all of this mobility to the shoulder is that the scapulae rely mostly on muscle attachments and only have a single bony attachment to the rest of the body, which is through a ligament at the clavicle. The problem that develops is that these stabilizing muscles like the rotator cuff and trapezius often become some combination of weak and loose or tight and strong, throwing the normal function of the scapulae way out of whack. If the shoulder blades aren’t stabilized the right way, it can spell bad news for the shoulder considering all of the high force applications of the arm and shoulder, such as throwing a fastball, bench pressing, carrying a couch, or knocking somebody out in a fight. The importance of scapular stability is made pretty clear in the quote, “It doesn’t matter how big of a cannon you have if you’re shooting it out of a canoe.”
Long story short, the proper functioning of the upper body relies heavily on rotational mobility in the upper back and strong stabilization in the scapulae, which both allow for a healthy range of motion in the shoulder as well as a stable lower back.
Novak Djokovic: The Joint by Joint Approach in Motion
Coach Boyle makes a very strong case in his joint by joint approach that having the right mix of mobility and stability is crucial for athletic performance and joint health. His conclusions are borne out repeatedly when you look at the positioning of athletes and lifters who are able to consistently avoid injury despite the huge physical demands of their sport. Since I’m a big tennis fan, I’ve noticed lately how well Novak Djokovic exemplifies the concept of having both mobility and stability in the right places. Take a close look at the following pictures with the joint by joint approach in mind and see if you notice any patterns.
Let’s get one thing straight right off that bat: Novak is a freak. His flexibility and body control at high speed is as elite as you can get. Most of us would break a sweat and probably pop some soft tissue trying to get into those positions statically, much less on a full sprint during a tennis match. Despite the fact that we’ll probably never come close to Novak’s level of movement, that doesn’t mean we can’t learn a lot from his positioning.
If you look at all of the pictures and compare them with the joint by joint approach, you’ll notice that everything is spot on. Starting with the lower body, notice how similarly oriented his knees and lower back are in every picture despite very different body positions. These are the stability joints that best transfer force and protect against injury when they’re able to remain stable and resist excess motion. Contrast that with the positioning of his ankles and hips, which show a huge range of quality motion. The upper body is no different. The third picture shows some excellent detail of the rotation that’s possible in the upper back while maintaining a stable lower back. Additionally in that photo, you can see how Novak’s scapulae are locked down tight against his upper back, allowing his shoulders to move through a safe range of motion.
How Does This Apply to You?
Djokovic is an extreme example because most of us will never be in those positions, but the lesson is still the same. If Novak has better knee and lower back stability on a full sprint slide than you do simply getting off the couch, then we have a big problem. If you can’t go through your daily life while remaining stable in the knees, lower back, and scapulae, then you’ll have problems someday if you don’t already. The good news is that if you’re having issues with one of these joints, you probably have to look no further than the joint above or below it and realize you have some big mobility gaps to fill there.
How do you go about it? Well, a number of strategies are available and it’s a lot more complicated that just saying ‘lift weights and stretch’. I actually think this subject is so crucial to lifting, athletic performance, and overall joint health that I’ll be spending the next few months breaking down different pieces of it. In the next blog post, I’ll talk about the typical posture that most desk bound and sedentary people find themselves in, including some initial methods for gaining more mobility and stability in the right places. Stay tuned.