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Fundamentals of the Thoracic Spine

The thoracic spine refers to the area of the spine where our ribs attach, and includes vertebrae T1 through T12. The thoracic spine is a common focal point for mobility training and for good reason. It is the area of the spine that is most suited for variable movement, as the vertebrae are shaped in a way that encourages not only flexion and extension, but also lateral flexion as well as rotation. We have freedom to move in all three planes of motion at the thoracic spine. However, while it is important to have adequate mobility throughout the thoracic spine, there are also a handful of just as important yet less talked about functional anatomy concepts when it comes to the thoracic spine.

Through personal and clinical experience, I have noticed that there are a couple other additional fundamental functions we want to restore and maintain when it comes to thoracic spine function. In addition to ensuring multi-planar mobility, the ability to both coil and store elastic energy through the connection in the thoracolumbar fascia, as well as the ability to stabilize the ribcage as a stable platform for the scapula in order to ensure optimal arm mechanics are also paramount. In this article, we will expand our understanding of each of these fundamental elements and some practical movement sequences to start working on improving them.

Fundamental 1 – Multiplanar Mobility

Understanding the basic anatomy of the thoracic spine is a great place to start when understanding why we need mobility in this area. Take a look below:

Vertebrae comparison.jpg

As you can see, there are a few distinguishing features that differentiate thoracic vertebrae from the lumbar vertebrae and even cervical vertebrae. Namely the size of the vertebral body and the orientation of the facet joints. Due to this anatomical structure, the thoracic spine is more well suited overall mobility, specifically lateral and rotational movements, and thus contributes greatly to rotational movements throughout the body.

One large issue that plagues our society today is just a general lack of movement, and the thoracic spine and ribcage are an area that can get really sticky really quickly. This has implications not only for traditional strength training, but more importantly it greatly impacts our breathing, and consequently our neck and hip health. I very seldom see clients with chronic neck/shoulder/low back pain who don’t also have mobility issues in their T-spines as well. The thoracic spine is meant to move, and when we don’t move well or often through the thoracic spine, our shoulders, necks, and low backs often pay the price.

When we utilize different exercises to improve mobility in the thoracic spine and ribcage, the best way is to mobilize it in a multidirectional fashion. This means that we need to move not only through the flexion-extension (front-to-back) continuum, but also add in lateral flexion and rotation into the mix. We also want to appreciate how the thoracic spine’s ability to move is affected by breath. You will get a lot more bang for your buck by incorporating intentional breath work with your mobility drills. Below are a few of my favorites.

Try performing this sequence of drills a couple of times through and notice how your upper back, neck, and breathing feel afterwards. Chances are good that everything will feel lighter, looser, and more connected.

Fundamental 2 – Elastic Energy and the Posterior Spiral Kinetic Chain

Another important function of the thoracic spine is the thoracolumbar fascia and its involvement in rotational movements. Gait is one, but we can also include things like throwing, punching, climbing, rowing, as well as hip focused movements like kicking, jumping, and other athletic maneuvers. Taking a closer look at the thoracolumbar fascia, we can see that it serves as a crossroads for many different kinetic chains and muscle groups.

Many muscles run through and feed into the thoracolumbar fascia.

By virtue of its orientation on the back side of the body and connection to these groups of muscles, we can see that the thoracolumbar fascia connects the upper torso to the hips, and helps to generate rotational power through our midline. Since we are talking specifically about the thoracic spine in this article, I want to illustrate how important the coiling/storing of elastic energy function is for upper body movements.

Loading of the thoracolumbar fascia is also super important for maintaining normal breathing mechanics, ribcage stability, and scapular control, which are all critical for pressing strength movements. The health of your shoulders over your training career also largely depends on how well can you can control rotational forces through your thoracolumbar fascia and thoracic spine. The ribcage is the foundation for your scapula (shoulder blades), and the scapula are the foundation for your humerus (ball-socket-arm articulation). It stands to reason that the TL fascia has the capacity to create issues in your shoulder, elbows, and wrists if not properly managed. Below are a few of my favorite drills that focus on the coiling and loading through the posterior spiral kinetic chain.

Tenet 3: The Ribcage as a Platform for the Shoulders

Some of you may have heard of the idea of “proximal stability for distal mobility.” What this basically means in a nutshell is that in order to express strength in the parts of your body further away from the center (arms and legs primarily), you need adequate stability from the centralized areas of the body. This is why core stability and function are so important. The limiting factor for strength in our arms and legs strength will almost always be the core. In the case of the thoracic spine, in order to fully express functional strength in our arms, we need the requisite stability in the ribcage. The thorax serves as the stable platform or foundation for the shoulders to work off of.

In the world of strength and conditioning, there is an idiom that goes something like, “You can’t shoot a cannon from a canoe.” This is in direct reference to the idea that you need a stable foundation in order to get most out of your extremities. If your midline and axial skeleton are not stable, you will have all kinds of energy leaks and have a hard time transferring strength from your lower body to your upper body and vice versa. This has huge implications from a performance standpoint, particularly with things like running, throwing, striking, etc.

Once we have mobility restored (flexion, extension, lateral flexion, AND rotation), and have learned how to get the thoracic spine participating in rotational movements, the final step in ensuring optimal shoulder health and function is learning how to load the shoulder. Smooth, well-articulating movement through the shoulder complex with significant load requires optimal function of the ribcage as a platform, upward rotation of the scapula on the ribcage, and rotational stability of the ball-and-socket joint via the rotator cuff. Because it requires all of these things integrating together, heavy pressing is a great litmus test for shoulder function.

So how do we learn how to brace and set the ribcage properly to facilitate better shoulder mechanics? Use drills that focus on ribcage-pelvis alignment, scapulo-thoracic joint articulation, and maintaining congruence of ball-in-socket alignment. Below I’ve outlined a simple example sequence that does each of these things.

Wrapping Up

The thoracic spine is one of the most important areas of the body when it comes to [re]establishing and maintaining overall movement quality. Thoracic spine function has huge carryover to other areas of the body. Lack of functional capacity in the thoracic spine is one of the most common limiting factors for most people.

When training to improve thoracic spine function, we want to focus on three key areas: multiplanar mobility, rotational coiling and storing of elastic energy through the connection in the thoracolumbar fascia, as well as the ability to stabilize the entire thorax as a stable platform for the scapula in order to ensure optimal arm mechanics, and proper bracing for upper body strength exercises. There are many exercises and protocols we can use to improve each of these. If you’re looking for a missing link to improving your overall movement capacity and athleticism, exploring additional ways to train the thoracic spine can be a great option.

Global-Local-Global Assessment

No matter what your movement practice is (pumping iron, crossfit, calisthenics, yoga, etc.), every movement practice should have a means of assessing where you at currently, and have ways of tracking improvements over time. If you don’t include this component into your training or movement practice, how do you know if you are improving the way you want? How do you choose which exercises to use? How do you know how to design or structure a program that is conducive to hitting your goals? If you are a professional working with clients, how do you know which therapeutic intervention or training modality is most appropriate to address a client’s symptoms or goals?

Assessments are meant to give us an idea of what is not functioning optimally, what is comprising said function, and how we can get a big picture idea of how those pieces fit together in order to create a corrective and preventative strategy to restore function and optimize movement.

One key element of how I like to assess clients is to use a global-local-global approach in our movement assessment. This is one of the key tenets from a technique I utilize regularly in my practice, Dynamic Neuromuscular Assessment (DNA). Straight from the DNA manual, “When we notice an imbalance in the integration of the movement, we can then start looking at the components of that movement. Local assessment is looking at the individual pieces that would combine into the greater movement. When the dysfunctional component is corrected, then the global movement is reevaluated.”

We’ve all heard the expression, “a chain is only as strong as its weakest link,” and that idea certainly applies to human movement. Whatever global movement we do, we need to understand what the components make up those global movements, what is the function of each of those components, and what is impairing that function, ultimately creating a weak link in the chain.

Here’s a simple example:

A client comes in getting elbow pain throwing a baseball. The global movement is throwing a baseball. Some necessary pieces involved in throwing a baseball might be:

  • rotational mobility of the thoracic spine

  • scapular control

  • eccentric lengthening of the lats to decelerate the arm

  • and/or coordinated timing of pronation/supination in the forearm

  • Muscles/soft tissues of the thorax, shoulder, arm, & hand

If any of these “local” components are not functioning properly, the global movement will be compromised. Let’s say there is limited mobility in the thoracic spine, which is causing the scapula and rotator cuff muscles to compensate, and through biomechanical inefficiency, the pain shows up at the elbow. If we correct the client’s inability to rotate through the thoracic spine, the weak link in the global movement has been fixed, and chances are good that the elbow pain will resolve as a result.

No matter what techniques or strategies you use to assess movement, utilizing a global-local-global approach, is the best possible approach for restoring movement to the fullest capacity, and getting the best outcomes for relieving pain and restoring functional movement.

What is Missing from Most Assessment Strategies?

Many of you out there, particularly fitness professionals, might be familiar with the Functional Movement Screen (FMS), created and popularized by Gray Cook. FMS has become one of the gold standards for screening movement within the training space, but even Gray himself would be the first to tell you that there are absolutely shortcomings with it. The FMS is a great example of how we would assess movement at the “global” level. Unfortunately, an assessment like this does not necessarily give us enough information as far as what is causing those global movements to not function properly. We need to dig deeper.

One of the common shortcomings I’ve seen and experienced firsthand throughout the years with different movement assessment techniques is that they more or less end up just boiling down to, “Can you do this?” To which the proposed solution is often, “If not, practice it until you can.” This is a tedious and unpredictable solution. Unfortunately, most fitness professionals simply don’t have the knowledge or skills to assess movement much deeper than their own subjective idea of a movement should “look like.”

Another pitfall with most movement assessment strategies is that they often lack the tools to assess movements at a local level. This is where something like manual muscle testing can really become a powerful tool in your arsenal as a movement professional. We can specifically assess the function of individual muscles, joints, connective tissues, reflexes, etc.

In the example I previously mentioned (baseball pitcher), I could have my client throw a baseball, and I could then utilize muscle testing to assess whether or not that movement is functional for them. If not, the nervous system will compensate and this will show up in a muscle test, either creating a hypertonic (locking up) response, or an inhibitory (shutting muscles off) response. I could then assess where the aberrant nervous system response is coming from, whether it is structural (lats, shoulder ligaments), physiological (pancreas and spleen are related to lats), or an emotional memory/experience (remembering the pain and associated psychological stress from an old wrist injury). Once I fix the dysfunctional component, the global action of throwing a baseball should greatly improve because we normalized the weak links the body was compensating around. We would then want to test the limits to which his nervous system and structure can tolerate load, volume, etc.

This leads me into my next point: most movement assessment strategies also lack the tools to assess how physiology and emotions affect motor output, not just structure. In the above example, I just named just a few potential things that most techniques would not even think to look at that might be affecting the motor output of the muscles involved in throwing.

What Should a Good Movement Assessment Include?

I contend that every good assessment should have a few objectives. Primarily, a good assessment is a fantastic opportunity to establish trust and connection between the professional and the client. This includes getting a better understanding of who the person is, what makes them tick, what sort of lifestyle they live, what their goals are, and what those goals mean to them. Essentially, every assessment needs to start with clarifying for both the professional as well as the client WHY they are there in the first place. If you don’t start with why, the goals become blurry, and the pathway to achieving those goals gets even blurrier. We also want to get a thorough injury history and a better understanding of past traumatic experiences (physical and emotional).

On the movement side of the equation, a good assessment should look at:

  • Joint Mobility

  • Soft tissue quality

  • Fundamental movement patterns

  • Neurological Reflexes

When we look at joint mobility, we want to assess both passive and active, and note any discrepancy between the two. All of our joints generally have normal ranges that should be accessible. Often times passive mobility range of motion exceeds active, which is indicative that instability is more likely the cause of limited mobility, rather than structural limitations in the joint itself. Distinguishing between passive and active mobility in a joint’s range of motion is important for deciding whether to aggressively mobilize the joint (structural problem) or creating more stability in a synergistic area, thereby decreasing the protective tension and muscular guarding around the joint.

As far as tissue quality is concerned, we mostly want to make note of tissues and different muscles that are too high tone and too low tone. Based on research done by Dr. Jose Palomar, the creator of a therapeutic technique called Proprioceptive Deep Tendon Reflex (P-DTR), we have an incredibly thorough understanding on how the nervous system creates compensation patterns. Muscles having too high or too low of tone are indicative that the muscles themselves are part of a larger compensation pattern, and many muscles can be involved in any given pattern. Muscle tone is directly related to muscle function. Palpation and tissue quality can be a simple and effective means of following the breadcrumbs to the source of the dysfunction, and can be used as a before and after measurement for changes in nervous system compensation.

In the context of strength training, I there are several foundational movements that I like to help clients improve: breathing, getting up, walking, squatting, hinging, pressing, and pulling. In my practice, I often times also look at sport-specific or activity-specific movements. Whatever I am working with a client to improve, I’m always cognizant of the fundamental kinetic chains that ALL human bodies utilize. Working with athletes, we can get very specific with movements we want to assess. However, before getting too specific, we want ensure all of the basic kinetic chains are functioning independently and that they are functioning relative to each other.

Before we can throw a baseball, we need to have good balance between our anterior and posterior spiral kinetic chains (posterior – wind up; anterior – follow through & release). Before we can have good functional balance of our anterior and posterior spiral kinetic chains, we need to have proper axial stability through our lateral and deep longitudinal kinetic chains. In order to create proper axial stability, our intrinsic core and breathing structures need to be functioning optimally. The layering of these kinetic chains and building functional strength in a way that focuses on integration of these kinetic chains is the best way to restore and maintain function, minimize injury risk, and improve performance-based metrics like strength, speed, power, and endurance.

One other piece probably relatively unique to how I like to assess clients is to also take a look at basic neurological reflexes to make sure the body is integrating multiple systems, not just the musculo-skeletal system. This includes things like visual reflexes, labyrinthine reflex, head-on-neck reflex, joint position, nociceptive withdrawal reflex, and other peripheral receptor-based processing. It’s all important.

Wrapping Up

There are many ways to assess movement. However, if you are looking for the most optimal way to assess all of the potential factors that affect motor output, muscular function, and ultimately movement and athletic performance and injury risk, you need to have many different tools in your toolbox.

I’m a huge advocate for movement professionals expanding their knowledge and toolbox to enable them to assess with a global-local-global strategy. This requires knowledge in many different areas, and requires techniques and unique skill sets to be able to do. The traditional ways in which we have thought of pain, nervous system influence, and movement are being pushed to new frontiers as integrative techniques like DNA, P-DTR, and others are making new discoveries and new ways to open up healing for clients.

If you’d like to learn more about some the techniques I utilize, please feel free to reach out with questions!

Hip Mobility

When it comes to mobility training, the hips and shoulders are often primary areas of focus. There’s good reason for that: they are the only ball-and-socket joints in the body, and thus are primed for mobility by design. So when our hips are not moving well, it should be cause for concern. For most of us, the ability to adequately use our hips leaves a lot left to be desired, and unfortunately a lack of adequate movement in the hip joint can be a precursor to lower back pain, knee pain, and increased susceptibility to injury, particularly during athletic endeavors.

In order to most effectively improve and maintain mobility in our hips, we need to understand some basic hip anatomy, some of the potential reasons our hips tend to lose mobility, and then have some tools in our back pocket to be able to directly address what is causing our lack of hip mobility. I am of the opinion that mobility training has become way too complicated over the years, particularly with the age of social media. You don’t need hundreds of different exercises to improve hip function. More important than having hundreds of tools to address immobile hips is the skillful and appropriate application of these tools based on thorough understanding. It’s not the tool, it’s effectively you can use that tool. The purpose of today’s article is to breakdown some of the primary factors that affect the mobility of our hips, whether structural, functional, or otherwise, and ultimately how to effectively improve and maintain the health of our hips through a combination of exercises, drills, and training protocols.

Anatomy of the Hip Joint

The hip joint is made up of two primary articulating structures, the acetabulum (socket) and the head of the femur (ball). The acetabulum is a conglomerate of the bones of the pelvis:  the ilium, ischium, and pubis. Depending on how our bones develop over our lifetime (combination of genetics and lifestyle), the anatomy of our hip sockets can vary from person. Some peoples’ hip sockets are shallow while others’ are deeper. Some face more forward while others might be positioned more laterally.

In addition to having individual variation between people in regards to hip socket anatomy, we also see a ton of variation between individuals in regards to the head (ball) and neck of the femur. See the pictures below to get a better visual of all of these potential anatomical variations within the hips.

The shallowness or depth of the acetabulum leaves more or less room for movement in the hip.

The shallowness or depth of the acetabulum leaves more or less room for movement in the hip.

Notice how the different angles of the neck of the femur can affect force transmission through the pelvis.

Notice how the different angles of the neck of the femur can affect force transmission through the pelvis.

Notice the variation between femurs: length, torsion, neck angle, size of the femoral head, etc.

Notice the variation between femurs: length, torsion, neck angle, size of the femoral head, etc.

We can clearly see that structure alone can have a huge impact on the movement capacity of our hips. Some of us naturally have better mobility in our hips than others. Some of us are better suited to squat deeply than others. Some of us might be more suited for deadlifting. Some might prefer a narrower stance while others might benefit more from a wider stance. Some of us need to work diligently and regularly on mobility in order to maintain it, while some have naturally mobile joints.

Utilizing a combination of passive and active mobility screens, as well as a myriad of different exercises and drills can help to provide an idea of what is most affecting our hip function,  whether positively or negatively.

Assessing Hip Mobility

There are two primary ways to categorize mobility in the context of an assessment. Passive mobility is range of motion assessed manually by the therapist, where the client is completely relaxed. Active mobility is assessed by asking the client to move through specified ranges of motion via their own voluntary muscular effort. There is almost always a discrepancy between the two. Just because the joints have structural capacity for range of motion does not inherently mean that we also have the muscular control and strength to effectively utilize that range of motion.

Passive mobility gives the therapist or practitioner a lot of information about whether or not the immobility is coming from structural or tissue limitations. If I take someone’s hip through passive range of motion assessments, I can feel if the ligaments, tendons, capsule, or bone on bone contact is what is creating the limitation in mobility, or if it feels like guarding and protective muscular tension is more likely the culprit.

Active mobility gives the therapist or practitioner information about how the client is able to create motion in the hips via their own ability to control muscular output. Structure does not always dictate function. While hardware can be physically manipulated to potentially improve mobility, neurological outputs are not as easy to manipulate to create predictable change. Motor control is the key to active mobility and owning your range of motion, and motor control can be compromised for any number of complex reasons. This is where deeper assessment skills are helpful.

In addition to assessing the hip joint directly, we also need to take into account how other areas of the body can potentially be affecting the hip. Often times a restriction in the hip, like any other joint, is simply a compensatory response to dysfunction (usually instability) somewhere else. Typically, the core/pelvis and the ankle/foot all play large roles in hip function.

Dean Somerset made a video that went viral (as viral as a video can go in the health and fitness industry at least), providing a good visual demonstration of how a lack of stability leads to compressed joints as compensation. Check it out here:

If we go back to the question I posed earlier, whether hip mobility is coming from a structural/anatomical limitation or if it is simply compensation for lack of stability elsewhere, giving the above protocol a shot might help illuminate this for you.

Hip mobility is a direct product of how stable your pelvis is, and how well your feet can provide your hips feedback during closed chain movements. The chances are high that your hips will move well and maintain good mobility if you have the requisite core/pelvic stability, functional and strong feet, and train your hips through various ranges of motion regularly.

Once you’ve got an idea of whether your hip dysfunction is mostly coming from lack of actual joint mobility, imbalanced muscular tension, or from a weak link somewhere else in the body, there are no shortage of hip mobility drills, programs, progressions, and sequences you can utilize to start restoring the mobility in your hips.

Putting it All Together

With a better understanding of what our hip mobility can be affected by, it’s time to put that knowledge to good use and start the process of improving and maintaining functional and mobile hips for the long-haul.

Since there are literally hundreds if not thousands of potentially helpful exercises to improve hip mobility, rather than overwhelm you, I want to share just a few of my favorite go-to drills that I have used to great effect in helping restore clients’ hip function.

First, it is a good idea to have a movement that teaches the functional relationship between the lumbo-pelvic complex and the hip. As we’ve already shown, an unstable pelvis will almost always lock up the hip joint. I have three favorites to address this issue: Deadbugs, Birddogs, and Quadruped Rocking. Each of these exercises puts particular emphasis on maintaining isometric stability (preventing movement) through the lumbar area.

  • We are relying on our hip flexors controlling the hip joint.
  • Focus on feeling the motion exclusively through the hip joint.
  • Adjust the difficulty by shortening the leg by flexing or extending the knee.
  • Make sure you don’t need to hold your breath to accomplish pelvic stability.

  • This movement is essentially an inverted deadbug.

  • We are relying on our hip extensors controlling the hip joint.
  • Without feedback from the floor, the lower back is more susceptible to unwanted movement.
  • Try and minimize the shifting of your weight side to side; stay centered.

  • Great regression of the squat pattern.
  • The goal is to learn how to brace the core while accessing end-range closed-chain hip flexion.
  • 4 points of contact with the floor allows for good amount of tactile feedback.
  • If you can do these perfectly, but can’t squat standing, then your feet are likely the issue, not your core.

After we ensure we are able to differentiate between lumbar movement and hip movement, the next step is to start working on drills that are helpful for teaching us to feel the connection between our feet and our hips. In order to do that, we need to focus mostly on closed-chain (feet in contact with the floor) exercises.

  • Combines rotational stability of the lumbo-pelvic complex with multiplanar motion through the hip.
  • Focus should be on maintaining a neutrally grounded foot position throughout.
  • These are a great regression for the single-leg RDL.

  • Rotational resistance also provides tactile feedback to help orient and integrate rotation through the ankle/foot, knee, hip, and lumbo-pelvic complex.
  • This should feel really stable and fluid before attempting to load a single-leg RDL pattern.

  • This is a helpful drill to integrate the hip, knee, and foot together through all three planes of motion.
  • The goal is to minimize rotation through the spine, and promote most of the rotation through the hip.
  • The foot should be springy; don’t allow excessive unwanted movement, but don’t let the foot go rigid.

Conclusion

Hip mobility is an interesting topic. While there is no shortage of other considerations, exercises, and theorizing we could talk about in regards to hip mobility, I like keeping things simple. If your hip mobility is less than adequate, consider not only the tissues in the hip itself, but also the stability of the core and pelvis, as well as the functionality and loading capacity of the feet. If you are clicking on all cylinders as far as those things are concerned, your immobility hips will be a thing of the past.

The Function of the Knee

Outside of the lower back, the knee is one of the most common areas of the body we experience injuries and chronic pain. For professional athletes, more games are missed and money lost on knee injuries than almost any other type of injury. For recreational movers like you and I, it is just as common for knee issues to prevent us from staying on top of our fitness and physical activities. Understanding why we as humans commonly experience back pain makes sense: the lower back is essentially the crossroads of the body; tons of muscles, tissues, and kinetic chains feed through the lumbo-pelvic complex. It stands to reason that the low back has a large potential for things to go awry. But when it comes to the knee, why do so many of us experience symptoms and pain?

Anatomically, the knee is unfortunately predisposed to acute, sports-related injuries. The way the knee joint is set up structurally, I contend that a large part of what makes it so susceptible to injury is that it does not have many ways of compensating. Biomechanically, the knee is often at the mercy of how the foot and/or hip joints move and function. Core stability originates from the trunk and pelvis, ensuring optimal movement and loading through the hip joint, while closed-chain interaction with the ground starts with our feet, ensuring optimal movement and load through the ankles. The knee joint is situated right in the middle of the action as far as lower extremity movements go, and thus needs the capacity to dissipate, transmit, and tolerate large forces generated from the core and feet to keep everything communicating and functioning optimally.

Common acute knee injuries:

  • MCL/LCL/ACL/PCL sprains/tears
  • Meniscus-related issues
  • Hamstring strains

Common chronic knee symptoms:

  • Patellar tendonitis
  • Quad tendonitis
  • Popliteal pain
  • Patellar tracking issues

No matter the issue we might be dealing with in our knees, there are a few key concepts to understand in our attempts to better facilitate our treatments and training strategies. Understanding the 3 major roles the knee joint plays in movement gives a ton of insight into how to keep our knees healthy. They are:

  • screw-home mechanism and rotational stability
  • patellar tracking in relation to quad balance and ITB activity
  • transmission of GRF through the fibula/biceps femoris

Without further ado, let’s dive in!

The Screw-Home Mechanism

As I mentioned previously, we often associate the knee with flexion and extension, movements that predominantly occur in the sagittal (front to back movements) plane. What often goes underappreciated is how much rotation occurs at the knee, and what role that rotation plays in the function of our lower-extremity kinetic chains.

This is a good visual demonstration of how the knee locks and unlocks in rotation as it goes through flexion-extension moments:

When the knee is fully extended (straight), the femur rotates internally relative to the tibia, and the tibia rotates externally relative to the femur.

When flexion is initiated at the knee, the femur rotates externally relative to the tibia, and the tibia rotates internally relative to the femur.

In gait, the external rotation of the tibia is coupled with supination of the foot and external rotation of the hip. The inverse is also true, whereby the internal rotation of the tibia is coupled with pronation of the foot and internal rotation of the hip. If any of these joint motions are not fully accessible, it could potentially lead to excessive motion at the other joints, increasing mechanical stress and creating symptoms. In order to fully understand and resolve our knee symptoms, we need to make sure that each of these coupled movements at the foot, knee, and hip are integrated well. Below are a couple examples of how these ideas might manifest as knee pain:

An immobile navicular bone in the foot is preventing full pronation in the foot. A lack of adequate pronation then leads to increased subtalar inversion, which shifts the talus position medially. The talus shifting medially then neurologically inhibits all the muscles in the lower extremity moving laterally. Decreased muscle strength of the glute medius, TFL, and other abductors then destabilizes the hip leading to an aggressive knee valgus, and the medial knee becomes painful. Our symptoms are at the knee, but in order to restore them we need to retrace the origins of the dysfunction and improve mobility and joint-loading capacity at the navicular bone.

OR

An unstable SI joint stuck in anterior torsion. This decreases the hip joint’s available external rotation. A lack of hip external rotation then becomes compensated for by increased external rotation of the tibia. Excessive external rotation of the tibia then leads to an imbalance between the lateral and medial hamstrings over time. The lateral hamstrings have more mechanical stress on them, and over time we start to get pain in the posterior lateral knee.

There are numerous potential ways in which any one person can compensate around dysfunction. The above are some hypothetical examples. The primary point is that rotation does in fact occur at the knee, and it is greatly affected by our both feet and our hips. In order to optimize our knee function, it is imperative that we consider rotational stability and how things are functioning above and below at the hip and foot respectively. Ensuring optimal stability at the pelvis and movement through the hip, as well as stability of the foot and movement in the ankle will allow the knee to stay within its optimal parameters for movement, reducing the likelihood of symptoms.

Patellar Tracking

The patella being one of the primary structures involved in knee mechanics, it is important to have an understanding of the role the patella plays in movement, as well as what muscles are involved in those movements.

IMG_2561.PNG

The patella is a sesamoid bone. We have just a few sesamoid bones in the entire body, the others are located in the flexor hallucis brevis muscle on the bottom of the foot. What characterizes a sesamoid bone is that it is embedded within the tendon. Sesamoid bones essentially act like pulleys, allowing for increased mechanical advantage and improve a tendon’s ability to transmit forces.

Our patella is the largest sesamoid bone in the body, and it is primarily acted upon by some very large and powerful muscles, the quadriceps. Optimized knee mechanics require balanced patellar tracking, and balanced patellar tracking is ultimately determined by balance in the quadriceps. We have 4 quad muscles (hence, “quads”), and each function just a bit differently. Take a look at them below.

 

 

Going clockwise from upper left:   Vastus Lateralis (outer quad), Vastus Medialis (inner quad), Vastus Intermedius (middle quad), and Rectus Femoris (two-joint quad, crossing both the knee and the hip).

 


Vastus Lateralis (Outer Quad)Vastus Medialis (Inner Quad)Vastus Intermedius (Middle Quad)Rectus Femoris (notice how it crosses the knee AND hip joints)

Common sense would tell us that if the lateral quad muscle fibers pull with too much tension relative to the medial quad fibers, the patella will track more laterally; the opposite is also true. We definitely want to make sure that our vastus lateralis and vastus medialis are working in harmony in order to keep our patellar tracking optimized.

However, what I find to be far more of a common problem in patellar tracking is the rectus femoris. The rectus femoris is the muscle you feel pulling tight when you the all-too common kneeling hip flexor stretch. It is the most superficial quad muscle, and has the most direct impact on patellar function due to uniqueness among the quads. As you might notice on the picture above, the rectus femoris crosses both the knee joint through the quad tendon, patella, and patellar tendon attaching on the tibia, but it also crosses the hip joint attaching on the ASIS. Because the muscle crosses two joints, the rectus femoris is both a hip flexor and a knee extensor. This makes it more susceptible to unwanted compensation.

Patellar tendonitis is perhaps the most common knee condition I treat regularly. It is sometimes also referred to as “Jumper’s Knee.” It is often characterized by a sharp pain occurring just below the patella during activities like squatting, walking up or down stairs, lunging, or other activities involving knee bending. The rectus femoris muscle is usually our prime suspect when it comes to patellar pain. Taking into account that the muscle crosses two joints, it is often important to appreciate the rectus femoris’ role on the hip, not just the knee. As I’ve mentioned several times already, the knee is often at the mercy of what is occuring at the hip and the feet. This is another piece to that puzzle. Appreciating the functional relationship between the hip flexors and knee extensors is the key to maintaining normal patellar tracking and patellar tendon health.

Shock Absorption & Dissipation of Ground Reaction Forces

When we’re talking about movements and functions of the knee, our conversations are usually focused on the previous two ideas we’ve covered. Far less understood is the role the knee plays in shock absorption and transfer of kinetic energy via ground reaction forces. What does all this mean? Keep reading to find out.

The knee actually has 4 bones associated with it. Most of us know of the femur (leg bone), tibia (shin bone), and patella (knee cap), but what we often fail to appreciate is the role the fibula (outer lower leg bone) plays in knee mechanics.

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The fibula has two primary roles within the knee joint. First, the distal end helps to form the talocrural (true ankle) joint, while the proximal end provides additional stability for the knee joint and helps to transmit force from the lateral foot through the lateral hamstrings and into the pelvis. We are mostly focused on the proximal portion and how it helps to transmit force through the lower extremity.

As part of the deep longitudinal subsystem, the tibiofibular joint is incredibly important for providing the knee with additional stability for activities like running and jumping that require a lot of force to be transferring through multiple joints in sequence. In gait, as we heel strike, the energy upon contacting the ground is sent through the heel, then the ankle, then the fibula and knee joint, through the hamstrings, and into the pelvis. If we lose our ability to respond to load in the tibio-fibular joint, then we are likely to experience knee symptoms, chronic hamstring tightness/irritation, and dysfunctional compensation further upstream or downstream in the hips or ankles.

Take a quick glance at the feathery connective tissue between the fibula and tibia. Notice the oblique direction of the interosseous membrane. This tissue plays a significant role in shock absorption in the lower leg.

Wrapping Up

The knee is a more complex joint than most of us give it credit for. Symptoms in the knee are incredibly common, and we need to have better ways of understanding, assessing, and correcting dysfunctions in the knee.

Often times we must consider the function of the joints above and below the knee, as well as how the muscles acting on the knee are functioning. We must appreciate that the knee joint has several important roles, and that each must be working optimally to minimize our risk of injury. The knee plays an important role by providing:

  • Rotational stability in athletic movements
  • Optimized tracking of our patella
  • Absorption and dissipation of ground reaction forces in athletic movement

Make sure that you are assessing the knee through several different lenses, understanding there are more functions in the knee than just flexion and extension. As we work our way up through the body, we are going to take a closer look at the hips and what the most important factors are when it comes to hip function and movement.

The Ankle and the Pronation-Supination Continuum

In this next installment of our foot series, we are going to be taking a look at the anatomy of the ankle, the biomechanics of the ankle with particular emphasis on the talus and rearfoot tripod (yes, we have another tripod in the foot!), and the role these structures play in our ability to supinate, pronate, and ultimately integrate our feet with the rest of the body.

Anatomy of the Ankle

First, let’s review the anatomy of the ankle. The ankle is comprised of two primary joints, the subtalar joint and the talocrural joint. Just briefly watch a few seconds of the video below to get a visual of the structures involved.

What is important to notice when it comes to these two joints is that they have one key component in common: the talus. The talus is a very unique bone in the body in that it has no muscular attachments, and because of this, it provides a very specific type of proprioceptive feedback to the rest of the body. The talus serves as a gyroscope of sorts. Check this out:

Pretty crazy right? What this means is that ankle function is of utmost importance. If our talus is malpositioned or unstable, it will adversely affect how muscles not only in the lower extremity, but throughout the entire body function. In order to restore and maintain optimal position and movement of the talus, we need to make sure to have adequate control through the pronation-supination continuum. We need to ensure that not only do the talocrural and subtalar joints of the ankle function well, but also ensure that the midfoot integrates with the ankle as well.

The Second [Less Often Talked About] Foot Tripod

In a previous article [CLICK HERE], we went over the forefoot tripod, and the role it plays in foot function. What we didn’t talk about is that there is technically another tripod within the foot. The two are intrinsically linked together. The three points in the rearfoot tripod are the:

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If you read the previous foot tripod article, you might remember that we briefly talked about the importance of these joints and how to mobilize them. The ability to respond to load in these joints has a drastic effect on the talus and vice versa. Because we know the talus has large-scale effects on proprioceptive input and neuromuscular control, maintaining optimal foot function must involve the integration of the forefoot tripod, rearfoot tripod, and ankle joints. This is what will ultimately allow for the fluid control of pronation and supination in the foot and ankle.


Supination vs Pronation

When we are talking about pronation and supination, we mostly associate these joint motions with walking gait. Pronation and supination allow the foot to have the dynamic stability required for shock absorption, as well as allow for the storing and releasing of kinetic energy through the lower extremities. The feet are highly involved in the Deep Longitudinal, Lateral, Anterior and Posterior Spiral kinetic chains. It at all starts with the feet.

One simple way to think about supination is to liken it to inversion, or simply the foot pointing down-and-in. We mostly utilize the foot in a supinated position in gait when we are pushing off and extending through the hips. Pronation is simply the opposite; liken it to eversion, or the foot turning out and up.

Our conversation around ankle mobility is most often centered around the idea of restoring dorsiflexion, which is primarily motion happening at the talocrural joint. Adequate ankle dorsiflexion is an important component for deep squats and activities like olympic lifting. However, as important as talocrural joint-focused ankle mobility is, we need to also appreciate the importance of subtalar joint function. I don’t think we talk enough about the rotational and lateral motions that also occur at the ankle when it comes to performance.

Chronic instability or lack of mobility in the subtalar joint will often lead to issues like knee pain and hip immobility. This has implications with almost any athletic endeavor.

In the case of the feet and ankles, my clinical experience has shown me that no matter what type of athlete you are, whether you are a weightlifter or runner, skier or cyclist, crossfitter or yogi, the feet and ankles are almost always in need of improvement. We usually get drastic improvements in strength, flexibility, power and overall athletic performance when we restore and maintain optimal foot and ankle function.


Integrating the Feet & Ankles

My usual approach foot and ankle integration is focused on simplicity. What will give us the most bang for our buck with our self-administered corrective protocols?

Focusing on restoring mobility in the requisite joints, and make sure that those joints have the ability to appropriately respond to load is a good place to start. I showed you a few drills in my Foot Tripod article that focused on three key joints of the foot tripod; here they are again in case you missed them:

Typically, if the joints feel stiff and achy while performing these drills, chances are that they need improvement. Doing them regularly and prior to any lower body training days will help to slowly progress the function of the joints over time.

Once we’ve mobilized the foot, the next step is to focus on integrating the foot and ankle with the knee, hip, and spine. There are many ways to do this depending on what your training goals are. However, I am of the opinion that the absolute best way to integrate the feet with the rest of the body is incredibly simple. The magic exercise that makes this happen that almost everyone needs to do more of is…..

…WALKING!!

Yes, you read that right. Walking is one of the most under-appreciated and under-utilized forms of exercise out there. Granted, not everyone’s gait pattern is a thing of beauty, but even then I recommend more walking for improved overall function. More minimal the footwear the better. Chances are high that if we ensure the feet and ankles are functioning well, and we then integrate our feet and ankles with our walking gait through copious amounts of walking, we will be well on our way to functioning and feeling a lot better. Sometimes it is that simple.

In order to further help integrate your walking gait, here are a handful of drills that can also help:

Rolling Patterns: Sequential rotation of the legs, hips, spine, and shoulders is incredibly important for walking gait. One of the primary problems that shows up in gait is a lack of rotation happening through the hips and thoracic spine. Rolling patterns are a great way to work on improving sequential rotation throughout the body, particularly because we can do so without loading the joints which helps to minimize compensation. I consider this to be a regression of walking. This drills does not allow you to use your large prime mover type muscles like your quads, lats, hamstrings, etc. and so you are forced to use your deeper stabilizing muscles predominantly.

Slow Gait Walking: With any exercise, one way to really make sure you are owning it and able to do it properly is by slowing it down. Slowing things down forces you to recognize and work through suboptimal compensation strategies. Performing a skill more slowly forces you own each phase or aspect of that skill.

By that logic, walking incredibly slowly will make it apparent to you where you might need to improve stability, or joint response, or load capacity. By slowing down, you can pay more attention to the areas that need improvement, and then incorporate additional drills that can improve upon and reintegrate the pieces that are not functioning optimally.

If rolling patterns and slow, gait-mechanics-focused walking are feeling good, go walk! Walk your dog! Walk to work! Walk a handful of miles a week at least. It’s one the simplest and most effective ways of improving overall biomechanical function.

Wrapping Up

The feet and ankles are one the most important key areas in the body when it comes to restoring and maintaining full-body biomechanical efficiency and movement capacity. The more efficiently we move and larger capacity we have for good movement, the smaller our chances are in regards to sustaining injuries, struggling with chronic pain, and greater our overall performance.

Hopefully this article gave you guys some good insights and understanding as well as some useful tools to help facilitate better function in your feet and ankles! Stay tuned, we’re just getting started. Over the coming weeks and months, I will be continuing to write articles like this going through every area of the body.