Does the anatomy you learned help you understand movement?
For most of us, the answer is a clear ‘no’. Why is that? If we are trying to improve our client’s life, shouldn’t we understand how they move outside the clinic, getting on with life? This series aims to enhance the visual clarity of real-life movement. This instalment offers another tool for appreciating what happens when we move.
In the last two articles, we explored the relationships between movement direction, joint and muscle orientation. Although the orientation of each overlaps, muscles and joints are rarely taught together in one reference or one class. Seeing how movement and anatomy blend together makes anatomy much easier to learn because we can understand it. Once we understand anatomy, rather than rote memorisation of actions, we can appreciate the broader context in which it operates, because musculoskeletal anatomy only makes sense when placed alongside movement.
We have already explored some of the problems with textbook anatomy – the way that it teaches concentric actions, often emphasises the movement of the ‘insertion’ toward the ‘origin’, and that it separates the body into systems which are taught in different classes or different chapters with little reference between them.
One common issue in current remedial approaches, in both bodywork and many movement modalities, is that we have developed assessment and therapeutic interventions based on our understanding of anatomy. I have written about this before; we have tried to understand movement through the lens of anatomy and by dissecting the body into individual parts. This reductionist approach has created useful orthopaedic assessments and remedial exercises that analyse separate areas, but many are based on a limited anatomical model that emphasises open-chain, isolated movement.
Now, don’t burn those books yet. Orthopaedic-style assessments are useful and necessary, but they only give part of the overall picture of a client’s everyday movement strategy. That fact should be obvious; we don’t reach for a glass with only elbow and shoulder movement. Try it now as you sit in the chair (presumably), reach for that cocktail glass (or coffee mug if it’s not yet 10 am).
What happened? Did you feel your weight shift in the chair? Did your spine flex or extend, and did it rotate? What else were you aware of? You may be scratching your head and thinking, what is he talking about? Trust me with this process.
Insert tensegrity Image – Legend – Accepting the body from a tensegrity point of view requires a new model of the anatomy of movement. Normal real-life movement is complex and changes tissue across the whole structure – some tissues adapt more than others, but each will alter to some degree.
If we all know the ideas behind the body’s tensegrity (fig. 1) – that everything is connected, that if one part changes, the whole thing changes tension – then we should appreciate that every tissue, to some degree, will contribute to everyday, real-life movement. We explored full body reaction to movement in the first of this series. When we made a large sagittal-plane movement, most joints flexed and extended. Similarly, they adducted, abducted, or side-flexed during frontal-plane movement, and rotated during transverse-plane movement.
Real-life movement does not occur on a single plane; it combines all three, but understanding these principles deepens your understanding of movement. Real-life movement uses contributions from a series of joints and tissues. Real-life movements, such as those Owen explores in the ‘Squat’ article in this issue, are therefore compound movements, in contrast to single-joint orthopaedic assessments.
The difference between single-joint and compound movement is important because the goal of any good therapist should not be to improve their client’s performance of leg abduction or internal rotation of the glenohumeral joint. Our ultimate goal should be to improve the client’s real-world performance and success; our clients use real-life, compound, complex movements.
Many therapists think that ‘assess, treat, and reassess’ is the formula for success. And thankfully it can be. But is the goal to help every client pass the Thomas Test? If the Thomas Test assesses the length and any change in length of the hip flexors, is the Thomas Test position a good example of when the client will want the hip flexors to lengthen as they walk to their car? I would suggest not.
Insert images of: a. Thomas Test. b. toe-off position
2 – a. The orthopaedic test known as the Thomas test uses a body position to measure, and sometimes stretch, the hip flexors.
b. In contrast to the spinal and knee flexion position used for the Thomas test, the most common real-life position in which we lengthen the hip flexors is in walking when the spine and knee are both extended.
In the Thomas Test position (fig. 2), the client is passive, the lumbar spine is flexed, the knee is flexed, and the ankle is passive. During gait, the hip flexors should allow the hip to extend when the body is working against gravity, the lumbar spine and the knee are extended, and the ankle is active. The real-life activity and the test position are almost complete opposites.
The problem with complex movement is that they are complex. Standard orthopaedic tests aim to simplify that complexity by removing variables, and therein lies both their strength and their weakness. By isolating the joint and tissues, the therapist gains information about what is going on at that joint. The therapist can measure its range of motion, assess its end-feel, and test its tissue strength. But what do we know about its ability when weight-bearing? What about the client’s ability to coordinate movement when other challenged areas of their body are also working? And, if we find an area that appears challenged in any one of those measurements, how do we retrain the client’s proprioception, coordination, and motor control to integrate any changes that might have occurred during the treatment session?
Instead of the Thomas Test, let’s do a simple but exaggerated movement we have done before. Stand in a comfortable position with your feet roughly hip-width apart, bring your right hand in front of your face, and watch your hand as you move it around and behind you as far as you can comfortably go. Pause at the end of the movement and feel what has happened through your body.
3 – Insert photo of rotation exercise
Starting from a comfortable standing position, look at your right palm and keep looking at it as you take your hand back and around as far as you can comfortably turn. Pause at the end of the movement and note what movements have happened through your body. Also note the angle to which your hand moved (do this by mentally marking a point just beyond your hand – a doorway or bookshelf, for example). Return to neutral and then repeat the exercise but without letting your left foot pronate – did you get as far? Can you achieve the first range of movement? What happens when you try?
Just as with the reach for the cocktail glass above, your whole system reacted and contributed to the movement. If you turned to the right, your spine will have rotated to the right and maybe extended a little; your right hip internally rotated while your left probably externally rotated; your knees had the same reactions as your hips; and your left foot pronated while your right foot supinated. All of this happened unless you have an issue in any of those areas or if you deliberately prevented them from happening.
The whole-body tensegrity model implies that the whole body should react during movement, but few schools of thought really give us the tools to describe how and why each portion of the body reacts in certain ways. It is not easy to develop the understanding needed to predict what happens through a body as it moves, but we have already explored one of the main principles – movement in a predominant plane will cause a matching response through the joints.
Remember: movement in the sagittal plane leads to flexion and extension; movement in the frontal plane causes side flexion, abduction, and adduction; and movement in the transverse plane leads to rotation. Of course, it won’t always be that easy, as few movements are single-plane, but understanding this now makes real-life movement much easier.
What is ‘real-life movement’? Well, it is what we do every time we move, but unlike orthopaedic assessments and many remedial exercises, it involves many joints and tissues.
Let’s revisit the hand-watching rotation exercise. Repeat the movement, and this time note how far you turn. Come back to the centre and then repeat once more but without letting your left foot pronate. What happened? Did you go as far? Can you try and reach the same position as you reached the first time? What do you feel in your body if you do?
Most people will experience a reduced range of hand movement in this position when they cannot pronate the left foot, but why is that? In real-life movement, the body doesn’t move with single-joint strategies; it uses contributions from a sequence of joints. As the tensegrity idea would predict, most everyday movements move the whole body. Real-life actions are compound movements; they use a little bit of range from several tissues.
This brings us to the first Principle for this article:
Principle One – the body uses a series of joints and tissues to achieve an overall range of movement. Real-life movements are compound actions that use a series of ranges of motion at numerous joints.
It can be very useful to differentiate between a global range of movement and a local range of motion. In our movement experience, the rotational reach of the hand had an overall range of movement from the right hand to the left foot, and each part of the body in between contributed to that global range.
We then removed one range of motion, pronation of the left foot, and it reduced the overall range of movement. Without pronation of the left foot, our right-hand reach decreased, but most of us can compensate for that loss.
Try the movement for the last time. While still preventing your left foot from pronating, can you achieve the same overall range you got in the first, uninhibited movement?
Most of us can get very close to it, but what was the cost? Did you feel compression at the back of your right shoulder, a stretch at the front, compression in your spine, a twist in your ribs, torsion through your pelvis, or a twist in your knee? There are no right answers; there is only your body’s response, but most people have felt at least one of those sensations. Where we felt the sensation is probably where we moved ‘too much ’; these are the common areas of compensation for the range that was lost due to the inhibited foot.
To put it another way, reduced pronation limited overall range of movement, which the body compensated for by trying to increase range of motion in other tissues. Now, imagine you are a client; where are you likely to report a problem to your therapist? Will you tell me about your quiet, unmoving foot that you are probably unaware of, or complain about spinal compression, shoulder strain, or knee twisting?
Principle Two – Any reduced range of motion (single joint) can reduce the overall range of movement (real-life, compound). Any reduced range of movement can be compensated for by increasing the range of motion in another joint.
With these principles in place, we can now get to the crux of the matter. Clients do not always complain about the actual cause of their symptoms; they often complain about the compensating areas. We have known that for a long time, and the idea of treating the cause, not the symptoms, has been taught by every school I have encountered. With tensegrity anatomy and a strong understanding of functional anatomy, we can flesh out the story and get better at finding those areas of greater interest.
When taught properly, functional anatomy shows how the system responds to movement. To appreciate real-life movement, we need to be comfortable in that world of variables and acknowledge that there may be many reasons our imaginary left foot does not pronate. It could be because of its environment; the shoe might be restrictive or an orthotic is in place. The client may have had a previous history and relearned a movement pattern to avoid aggravating the area, but never returned to normal once the problem eased.
Many factors could prevent the left foot from pronating during our sample movement, but an orthopaedic test performed with the client supine and relaxed might not show any restriction. We require information from numerous sources to build a full and proper screening of our clients – we need a full verbal history, we need our senses to alert to non-verbal clues, we need a battery of orthopaedic tests, but we also need the skills to observe full body movements, especially in the performance of meaningful tasks.
Summary
Real-life movement uses contributions from a number of tissues to achieve an overall range of movement, it is never only one joint. If one joint in the series does not contribute enough range of motion, the overall range of movement will decrease, or another area will compensate by contributing more. It is often the area of compensation that feels the extra strain rather than the site of restriction.
There are many reasons why a joint might not move, and these may not show up during an orthopaedic screen as they may relate to motor control habits or environmental differences.
In our next instalment we will further develop our understanding of movement by clarifying and refining our vocabulary.
