Mobility Matters – Identifying The Cause Rather Than The Symptom

By Dr. Jennifer Reiner

In the last ten years, the term mobility within the fitness and sports performance community has been pushed to the forefront.  Foam rollers, slant boards, rolling sticks, baseballs, and other torture devices are a mainstay in gyms to improve flexibility and mobility.  As a chiropractor that works primarily with athletes and the active population, I feel the hierarchy of movement begins here.  In school, we spend years understanding the basis of joint movement, how to assess it, and ways to improve upon it.  I hope to provide a little insight from a clinical chiropractic perspective on mobility and perhaps give you a few exercises to add to the toolbox.

A wide variety of philosophies and therefore treatment and assessment protocols exist in the chiropractic profession.  While some are deeply rooted in the older chiropractic philosophy of maintenance care and wellness, others focus on rehabilitating neuromusculoskeletal problems.  To provide a little background into my methodologies and techniques, I graduated from chiropractic school with a focus on sport related injuries.  This led me to a series of seminars, specifically Active Release Technique and Graston.  I spent a three-month internship with the University of Miami and later moved to San Diego to work with the University of California San Diego’s athletic training staff.  A few years of Active Release and manipulations on 300 pound offensive linemen and 6’9” basketball players took its toll on my 5’3,” 115 pound frame.  If I continued at this rate, I knew my career would be short-lived.  It was time to treat smarter, not harder.

I began questioning the soft tissue techniques I utilized as well as my own abilities.  Common areas, such as the IT band or hip flexors, would be resistant to repeated treatments using Graston and Active Release.  I blamed the athlete’s mechanics, the sport, or a previous injury for the recurring issue.  Bottom line, my hands and body were taking a beating only to achieve temporary improvement in the athlete’s condition.  Around this time I returned to my roots of exercise science and obtained my Certified Strength and Conditioning Specialist certification.  A plethora of information related to functional movement and corrective exercise existed opening my eyes to many physical therapists, strength coaches, researchers, and other like-minded chiropractors.  Gray Cook, Mike Boyle, Craig Liebenson, Greg Rose, Stewart McGill, and Mike Reinold are just a few whose research, articles, seminars, and philosophies I took interest in.  I believe my “aha” moment came during the FMS/SMFA (Functional Movement Screen/Selective Functional Movement Assessment) seminar when the discussion began on joint mobility and stability.  Finally, objective findings coinciding with our understanding of biomechanics, to effectively provide a rationale for repetitive soft tissue and joint tightness, pain, and/or injury.  It wasn’t so much my treatment techniques that were in question, but rather the assessment.  Evaluating movement in relation to mobility and stability would be the guiding factor as to which area was the weakest link.  As such, treatment directed towards the cause utilizing objective evidence rather than symptoms, would produce long-lasting, efficient, and effective results.

Whether the FMS/SFMA is your evaluation tool or another, mobility limitations must be considered before progressing to motor control problems.  For those unfamiliar with the joint-by-joint approach described by Gray Cook and Mike Boyle, each segment of the body is viewed by its role in providing mobility or stability.  To begin, our ankle, hip, thoracic spine, and glenohumeral joint should be mobile while the knee, lower back, cervical spine, and scapulae should be stable.

The hips can be tricky, however, as this region serves both a mobility and stability purpose.  Based on these patterns, it is no wonder that disrupting the sequence creates compensation elsewhere.  For example, clinicians (me included) can get caught up at the site of the patient’s symptoms.  Insidious onset of anterior knee pain is a great example.  If orthopedic tests fail to reveal instability, compromises in range of motion, meniscal problems, etc., we often categorize the issue as patellofemoral pain, tendonitis, and so forth.  These diagnoses are more of the symptom rather than the cause.  Typical treatment including ultrasound, myofascial release, rest, and non-steroidal anti-inflammatories may provide short-term relief, but often the same issue rears its ugly head a short time later, perhaps even worse.  Well it is time to take a step back both figuratively and literally to view the areas above and below the site of complaint.  It is time to include an assessment of the fundamental movement patterns our patients and athletes are utilizing in their every day activities.  Sure, standard orthopedic tests, isolated muscle strength, and range of motion are integral to each examination, but often these do not provide the rationale for the cause of injury.  A movement screen can provide foreshadowing of a potential problem to come.  Utilizing this information begins to tell the story of the mechanical breakdown producing the dysfunction.

After performing a movement screen or assessment and evaluating your results, addressing joint mobility limitations and/or soft tissue extensibility problems is the first step in treatment.  Let’s get back to the basics, if the range of motion at a particular joint is significantly lacking, the motor control of the muscles surrounding the joint will also be compromised.  Unfortunately, you cannot exercise yourself out of poor movement patterns.  The system must be reset at the most basic of levels.  The lack of mobility may be due to several factors including a poorly managed injury, posture, stress, or inefficient stabilization.  Over time, our body detects the lack of movement and begins to compensate by making up for it elsewhere.  This is our innate ability for survival.  Compensation, however, was designed for short-term management…. i.e. running away from a pack of wolves.  Nowadays, however, when our bodies begin to signal signs of distress by way of pain, tightness, and discomfort, we run for the nearest bottle of Ibuprofen.  Silencing the alarm system leads to ongoing distress at the joint or soft tissue priming us for that disc rupture, ACL tear, meniscal derangement, rotator cuff injury, and the list goes on.

As babies, we are born with ample mobility throughout our spine and extremities.  Personally, I think God was doing us a favor (being a woman that is) providing substantial movement to be able to twist, turn, flex, and extend during the birthing process.  Mobility provides the platform by which we build our stability.   The developmental process involves movement milestones beginning with the mobility of the hips and shoulders and progresses to rolling patterns and core stability.  Therefore, we must address mobility before expecting a new level of motor control in order to overcome movement dysfunctions.

Generally speaking, many of the mobilizations/manipulations I perform are directed towards the ankles, hips, thoracic spine, and glenohumeral joint.  As such, the videos below are examples of a few exercises commonly prescribed to patients.

Whether you are a “top down” or “bottom up” believer, I’m sure we can all agree that limited dorsiflexion of the ankle can produce a number of issues up the kinetic chain.  Many athletes I treat present with low back, hip, knee, and/or ankle issues that relate to the limited mobility of the talocrural joint.  This is a modified hinge, synovial joint, comprised of the talus and distal tibia and fibula.  While the articular geometry of the ankle limits the amount of inversion and eversion, the mobility lies primarily in the sagittal plane (plantarflexion and dorsiflexion).  Dorsiflexion in the non-weight-bearing position is 20 degrees and plantarflexion is 50 degrees.  Perhaps a more functional measurement, closed chain dorsiflexion, is standard at 43 degrees with the knee flexed and 36 degrees with the knee extended (Reischi, Noceti-DeWit).

For many individuals, especially those who have played sports, an ankle sprain is as common as a winter cold.  Left untreated, scar tissue forms around the joint and soft tissues impeding dorsiflexion, an imperative component to shock absorption in running and jumping and in fundamental movements such as squatting and lunging.  Rather than strengthening the supporting musculature and improving the proprioception of the foot and ankle, patients subscribe to heavy taping and ankle braces.  In his book, Movement, Gray Cook reports a direct connection between the stiffness of a basketball shoe and the amount of taping and bracing that correlates with the high incidence of patella-femoral syndrome in basketball players.  Therefore, improving the movement within the sagittal plane improves knee tracking creating less stress at the knee, hip and lower back.  Soft tissue extensibility and joint mobility techniques are both essential for improving ankle mobility.  The video below includes stretches directed towards the flexibility of the lower leg musculature and ankle mobilization techniques directed toward the joint.

For patients presenting with lower back pain, the hip and thoracic spine must be considered.  The lumbar spine is wedged between these two generally stiff joints and is forced to make up for the insufficiency of mobility.  Increased movement at the discs creates shearing forces and aberrant movement at the facet joints.  It comes as no surprise that some of most common spinal regions for disc pathologies and degenerative changes is in the lumbar spine. The body’s natural response to excessive movement at the joint level is to tighten down the surrounding soft tissue, particularly the musculature.  If poor trunk stability is added to the equation, low back symptoms are inevitable.  Here we begin to tap into the cause of chronic mechanical lower back pain and stiffness.  It’s no wonder repetitive manipulation or soft tissue mobilization of the lumbar spine fails to solve the root of the problem.  These treatments are simply addressing the symptoms.   The hip joint is designed for multiplanar movement, as it is a multiaxial ball-and-socket joint.  In a society of chronic desk sitters, many people lack mobility in hip extension, abduction, and external rotation.  Again, where the hips do not move, the low back will.  So, provide that foundational mobility to protect the stability of the lumbosacral spine.  Here are several hip stretches and mobility exercises to improve upon these commonly restricted movements.

According to the U.S. Department of Labor, Occupational Safety and Health Administration (OSHA), repetitive strain injuries are the nations most common and costly occupational health problem, affecting hundreds of thousands of American workers and costing more than $20 billion a year in workers compensation.  The typical workstation is not ergonomically designed, and even when it is, a conscious effort in correct sitting posture is not at the top of most people’s list.  Poor sitting habits are considered a repetitive stress injury.  Although the amount of stress is minimal (literally the weight of ones head, upper extremities, and torso), the repetition or duration, in this instance, is extreme.  Insistent flexion stress to the spine causes deformation of the supportive anatomy that holds us upright.  This phenomenon is known as creep, a condition where passive, supportive structures such as ligaments and joint structures are stretched.  As a result, the mobility of our spine becomes more limited and the supportive musculature cannot function properly.  Compromising the movement of the thoracic spine only increases the stress to the adjacent joints and tissues.  As previously mentioned with the lack of hip mobility and subsequent stress added to the lumbar spine, the cervical spine suffers a similar fate.  Clinically, in the cervical spine, the most frequent degenerative changes and disc pathologies occur at the mid to lower cervical spine as a result of increased shearing and movement.  Thoracic flexion should measure 20 – 45, extension 25 – 45 degrees, lateral flexion 20 – 40 degrees, and rotation 35 -50 degrees.  Compared to other joints, this is a wide range for accepted movement, so erring towards the higher number is to our benefit.  To quote Mike Boyle on thoracic mobility, “almost no one has enough, and it’s hard to get too much.”  From a chiropractic perspective, I feel joint manipulation is very effective here, particularly at the cervicothoracic and thoracolumbar junction.  Daily mobilization and stretching techniques are just as important and can easily be given to patients/clients for homework.  In fact, most of my patients, whether they are coming in for a shoulder, neck, or lower back problem, will receive a home exercise program including thoracic mobility.

Because shoulder mobility is closely tied to thoracic mobility, I will address the glenohumeral joint here as well.   The shoulder could easily be a whole other article so, to keep it short we’ll discuss it in relation to the thoracic spine.  Before beginning to consider the movement of the shoulder, we must look at the posture and movement of the thoracic spine.  Patients with poor thoracic extension often present with impingement (secondary) issues.  In essence, improving your thoracic spine mobility will also improve shoulder mechanics.  For example, try flexing the shoulder while sitting in a slouched posture and you will experience limited motion and possibly discomfort or pain as you raise the arm.  Conversely, forward shoulder flexion with an extended thoracic spine clears the subacromial space allowing the glenohumeral joint to move freely.  Once this is established, we can move distal to the scapula stabilizers and the glenohumeral joint when considering movement dysfunctions and other pathologies.  Below are some of my favorite thoracic mobility exercises that also benefit the shoulder.

Sometimes clients may reach a plateau in their flexibility and mobility or they complain of pain (not the typical discomfort felt during a stretch).  If this is the case, be sure to refer to a clinician who is licensed to evaluate musculoskeletal conditions.   There are a variety of pathologies, which affect bone, joint, and soft tissue that can underlie movement restrictions and/or produce pain.  There are also a variety of manual techniques to mobilize soft tissue and joints such as Active Release Technique, Instrument Assisted Soft Tissue Mobilization Techniques (IASTM), belt mobilization, and manipulation/adjustments that will go beyond self-mobility work.  These can often break through soft tissue barriers including scar tissue and capsular restrictions, which can be resistant to stretching, foam rolling, and the like.

Most importantly, and the answer to my issue of repetitive “tightness,” consider your evaluation process when clients/patients complain of persistent IT band issues or chronic lower back stiffness.  Stop blaming his/her exercise regime or work environment and look deeper into their movement patterns.  Evaluating fundamental movements may actually reveal joint mobility issues or underlying stability problems away from their site of complaint. Your hands and client will thank you when you find the cause of the tightness and offer a solution to their problem rather than continuing to treat their symptoms.

Cook, Gray. Athletic Body in Balance. Champaign: Human Kinetics. 2003.

Cook, Gray. Movement. Lee Burton, Kyle Kiesel, Dr. Greg Rose, and Milo Bryant. Santa
Cruz: On Target Publications. 2010.

Magee, David J. Orthopedic Physical Assessment. 4th Edition. Philidelphia: Saunders.
2002.

Reischl, Stephen F.  Noceti-DeWit , Lisa M., Current Concepts of Orthopaedic Physical
Therapy. The Foot and Ankle:  Physical Therapy Patient Manageemnt Utilizing Current
Evidence. Orthopaedic Section, APTA, Inc. 2006.

Sahrmann, Shirley.  Diagnosis and Treatment of Movement Impairment Syndromes. St.
Louis: Mosby. 2002.

Dr. Jennifer Reiner is the chiropractor for Water and Sports Physical Therapy and Fitness Quest 10 in San Diego, California.  She obtained a Bachelor’s of Science Degree in Exercise Science from the University of Florida and went on to pursue a Doctor of Chiropractic degree from Palmer College of Chiropractic West.  As a member of the Palmer West Sports Council, Dr. Reiner focused her studies on sports injuries and rehabilitation.  She is also a Certified Strength and Conditioning Specialist (CSCS) by the National Strength and Conditioning Association.

She spent five years as the official chiropractor for the University of California San Diego, providing care to a variety of sports including swimming, soccer, volleyball, track and field, tennis, and basketball.  Dr. Reiner is certified in Graston Technique as well as Active Release Technique (ART).  She also holds certifications in FMS (Functional Movement Screen), SFMA (Selective Functional Movement Assessment), TRX suspension training, and K-laser therapy.

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