FORM FOLLOWS FUNCTION
By Chuck Wolf, MS
From the pioneer days of fitness and sport performance, weight rooms, health clubs,
and gymnasiums have been the sight of wondrous feats. As the fitness and sports
enhancement industry has ventured ever closer in alliance with the rehabilitation sector,
more people make the commitment to performance enhancement.
Performance enhancement becomes relative terminology to the performing individual.
Whether an elite or developmental athlete, weekend warrior, recreational sports
enthusiast, dancer, rehabilitating patient, or housewife, all must perform with enhanced
capabilities to meet daily challenges of life. With our desires to excel, millions of people
seek health clubs, corporate and community fitness centers, rehabilitation centers,
strength and conditioning specialists, and personal trainers. Each goal is individual, yet
possesses a similar theme – peak performance. At each of these facilities, marvelous
work is accomplished to assist the performer to meet those goals. Volumes of research
verify new techniques, equipment, and protocols to benefit greater outcomes. But
through these endeavors, we invariably forget one important component: incorporating
true function into our processes.
Traditional Methods of Training
Isolated Movements
The kinetic chain is characterized as the deceleration at one joint and the acceleration
at the next joint in the chain. Too many exercises are isolated and not integrated into
the kinetic chain. For example, a leg extension exercise isolates the knee joint and
breaks the kinetic chain. The isolation of the knee joint from the subtalar, ankle, and hip
joints reduces functional movement. Additionally, joint isolation increases torque and
injury vulnerability to that joint. The chain is only as strong as its weakest link, and there
are moments when joint isolation is required. I am not advocating elimination of joint
isolation movements; rather, include integrated movements that require full kinetic chain
recruitment and synchronization resulting in eventual improved function.
Functional movement involves the synchronization of the opening and closing of the
kinetic chain. The issue is not performing open kinetic chain or closed kinetic chain
activities, but to incorporate both forms of movement into an exercise for the sole
purpose to enhance movement. Function needs to include actions requiring force
reduction, stabilization (balance), and force production. Additionally, functional
movement necessitates the involvement of the entire kinetic chain, not the breaking of
the chain thereby reducing the functional effectiveness of the movement.
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Movements are Primarily Force Production in Nature
The exercises in most strength and conditioning programs require force production
movements and not force reduction activities. We hear trainers reminding their
performers to “do the negatives” or “don’t forget the eccentric contraction” during a
session. Yes, the eccentric phase of contraction is important but is done in isolation,
not integrated into complex movements. Movement along the transverse plane is
performed perpendicular to gravity, requires pronation (eccentric or pre-load) or
deceleration along the rotational path, and supination (concentric or afterload) along the
functional, rotational path. In the transverse plane, the transition from deceleration or
force reduction to acceleration or force production must go through stabilization or
balance. Isolated, non-integrated movements do not require the performer to move
through the entire kinetic chain stabilization phase.
Isolated Movements Do Not Promote Stabilization/Balance
Balance is related to agility and coordination. The connotation of balance is a passive
mode by which we maintain a position. However, balance is a dynamic coordination of
intricate sensitivities recruiting our visual, vestibular, musculoskeletal systems and
kinesthetic awareness. Gary Gray, PT, and Vern Gambetta, MA, describe functional
balance as “the control of one’s center of gravity, body angles, and unstable equilibrium.
It is the interplay of imbalance and balance with the body.” In basic terms, as
performers move, they are in a constant state of losing balance and attempting to regain
it. Gray and Gambetta continue to characterize balance as “Inner Zone” balance - the
body’s own weight and center of gravity - and “Outer Zone” balance - how far outside
you can reach or stand and still regain your balance or position. Isolated movements do
not promote balance, particularly if the position does not recruit action originating in the
subtalar joint. To create balance, the performer must go through subtalar neutral. If this
component is not integrated into the exercise movement, it is not truly functional. To
have balance, the performer must possess the ability to create motion with pronation,
and this cannot be attained without passing through the subtalar neutral position.
Movements Are Not Tri-Planar
The majority of excellent training programs are performed on the sagittal and frontal
planes, yet neglect the transverse plane –the functional plane. Living in the real world
requires three dimensions. The truly functional movements and activities of daily living
center around the transverse plane; however, most of the exercise selections
concentrate on the sagittal and frontal plane: i.e. curls, abdominal curls, isolated leg
exercises. I am not suggesting trainers, strength and conditioning coaches, or
therapists disavow exercises from those planes, but to incorporate the transverse plane
into the training program. The incorporation of the transverse plane into exercise
involves curvilinear movement and rotation. Most sagittal and frontal plane actions are
curvilinear but not rotational. In the transverse plane the upright position is
perpendicular to gravity and must allow the performer to engage through force reduction
(pronation), stabilization (balance through the subtalar neutral position), and force
production (supination). The transverse plane actions include open and closed chain
movements. Pronation (pre-loading or eccentric loading) and supination (after-loading
or concentric loading) occur through the rotational segments of the subtalar joint, knee,
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and hip. Additionally, trainers, therapists, and coaches break the kinetic chain by
having the performer seated during many activities, thereby breaking the kinetic chain.
Functional Training
Functional Balance
Functional balance plays an integral role in performance. Performance suffers without
functional balance. The enhancement of functional balance must include actions that
require force reduction, stabilization, and force production. The rebounding athlete,
rotating dancer, gymnast, and cyclist constantly adjust their functional balance to
perform and to have a keen awareness of their body in motion and space. Balance
goes beyond standing on one foot or with feet close together. Rather, it recruits the
nervous and visual systems, and proprioception while in motion.
Balance requires the stabilization musculature from the subtalar joint, the gluteals,
abdominals, erector spinae, up through the cervical spine. The performer must
challenge each of those systems through manipulation of body angles, visual changes,
cervical rotation, intrinsic and extrinsic weight adjustments. Each subtle adjustment and
the combination of these adjustments will lead the performer to increased kinesthesia
and enhanced functional balance. When these adjustments are combined with dynamic
activity, the environment is created to require the performer to slow, stop, or change
direction thereby needing to reduce force in one direction, stabilize, and produce force
in another direction. By performing these activities in the transverse plane, the
individual must now recruit ankle, knee, and hip stabilizers while pronating and then
supinating during rotation. Subtalar and ankle stabilizers, strong hip stabilizers and
internal and external obliques work in tandem to decrease the rotational forces when a
performer must suddenly stop and pivot. This can assist the stability of the hip to knee
relationship and thereby work to prevent the hip from continuing to rotate while the knee
and ankle are fixed and the foot planted. This form of training appears to produce
positive effects in reducing risk of ankle and knee injuries.
When functional, transverse plane activities are utilized, the performer is not only
gaining strength and function, but also recruiting the use of the visual, vestibular, and
somatic senses required for optimal performance. Functional training should include
change of body angle, closing one or both eyes, and cervical rotation to challenge the
visual, vestibular, and proprioception systems to enhance balance and kinesthesia.
These systems function at higher acuity in the transverse plane.
Functional Activity Programming
The article is not suggesting the abandonment of a myriad of program designs, training
techniques, or theories that have positive results. The message in this article is to
consider incorporating these concepts to create truly functional programs that can
enhance power, strength, performance, balance, reduce risk of injury, and improve
quality of life. The same concepts apply in the rehabilitation setting, athletic
environment, preventive program, or working with the senior population. The body
innately functions the same whether recovering from injury, attempting to gain greater
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function, or improve overall function and performance. A major component during the
injury recovery process is to regain strength, stability, and proprioception. The above
principles can be applied as part of a rehabilitation program with moderation and
toleration. The movements do not have to be as large or dynamic in the rehabilitation or
frail populations; however, the goal of strength, stabilization, and function are all relative
to the performer we are working with.
Functional, efficient training activities should consider the following issues:
 Include integrated open and closed chain movements
 Analyze the planes of movement and be sure to encompass tri-planar
movements
 Engage in functional core stabilization exercise. Integrate the subtalar, knee, hip,
and thoracic regions in a weight bearing position to be considered truly
functional.
 Challenge the performer’s balance by constantly adjusting the center of gravity
and/or body angles.
 Challenge the vestibular, visual, and proprioceptor systems.
 Apply specificity to the performer’s activity and life style.
Our industry is not an exact science. Many of the best theories and protocols are
derived from the exchange of ideas. We must be open to rational change to expand our
horizons and the care for the all the performers we come in contact with and affect.
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References
 Gray, Gary W. Chain Reaction Festival, Wynn Marketing, 1996
 Gray, Gary W. Lower Extremity Functional Profile, Wynn Marketing, 1995
 “Restoring the Balance”, G. Metz, T & C, April, ‘99
 “The Agony of the Feet”, M. Forgrave, T & C, December’ 99
 “Hyperpronation and ACL Injury: How Strong is the Link”, P. Edwards, Jr., M.D.,
Biomechanics, October’97
 “Force and Function”, V. Gambetta, T & C, July/August, ’99
 “Twists and Turns”, D. Cipriani, T & C, December, ’99
 “Functional Balance”, G. Gray and V. Gambetta, www
 “Following the functional Path”, G. Gray and V. Gambetta, www
 “Hip Stability Influences Lower Extremity Kinematics, R. Hruska, PT, Biomechanics,
June, ‘98
 “Forefoot Focus”, M. Pryce, MD, Biomechanics, June’98
 “Foot Pathology Takes an Abductory Twist”, S. Gershman, DPM, Biomechanics,
June’98
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A 3-Dimensional Joint By Joint Approach to Movement
By
Chuck Wolf, MS, FAFS
Human Motion Associates
Orlando, Florida
There is a concept permeating the fitness, sports performance, and rehabilitation
industries describing movement within the body as a series of alternating joint levels of
mobility-stability-mobility patterns. I agree with the idea of trying to provide a
systematized arrangement of movement, however, this gives the connotation that this
approach looks at motion in one dimension, when in reality, every muscle and every
joint works in three planes of motion. In fact, there must be adequate range of motion in
all three planes to allow efficient, economical, and successful chain reaction of
synchronized movement.
Before commencing upon this task, there must be a concept that sets the premise for
our discussion. Movement is described as the relationship of bone segments that
comprise the joints. When discussing motion of the extremities, we must look at the
position of the distal bone in relation to the proximal bone. For example, in figure 1, we
see the open chain position of hip adduction with the femur medial to the ilium. In
figure 1.2, we also see the closed chain, integrated position of hip adduction, even
though the foot is not moving in space as in the open chain action. In both pictures, the
femur, the distal bone, is medial or adducted to the proximal bone, the ilium.
Fig. 1.1
Fig. 1.2
In both photos above, the distal segment (femur) is medial to the proximal segment (ilium).
In the spine, however, the description spinal movement is the proximal bone in relation
to the distal bone. In figure 2.1, we see rotation of the cervical spine to the left with the
chin somewhat over the left shoulder. The proximal segments of the cervical spine are
rotated left further than the distal cervical segmental levels. When viewing the
integrated action as shown in Fig. 2.2, there is still left cervical rotation even though the
body is rotated right, the proximal cervical segments are left of the distal segments. Our
discussion will begin at the foot, move through the subtalar joint, and proceed up the
chain to the cervical spine.
Fig. 2.1
Fig. 2.2
In Fig. 2.2, the lower segment of the cervical spine and thoracic spine are rotated right. However, the
proximal segments are relative left to the distal segments, therefore, this is still left cervical rotation.
The Foot
One of the most fascinating and complex structures in the body is the foot, yet, is mostly
overlooked by the fitness industry. Comprised of 24 muscles, 26 bones, and 33 joints,
the foot is the conduit that interfaces with the ground and sets the platform for the body
to react. The foot is categorized into three regions, the forefoot, mid-foot, and rearfoot.
The forefoot consists of the toes (phalanges) and long bones (metatarsals). Each of 2-5
phalanges has three bones and two joints, while the great toe has two bones and one
joint and metatarsals.
The mid-foot includes the 3 cuneiforms (medial, intermediate, and lateral), the navicular
on the medial column, and the cuboid on the lateral column. These five bones form the
mid-foot arch and must be mobile to absorb forces during the “collapsing” of the arch
during pronation.
The calcaneus (heel) and talus make up the rearfoot. The calcaneus has a concave
surface on the superior aspect and the talus is convex at the inferior surface. The union
of the calcaneus and talus form the subtalar joint, an extremely important joint that sets
the environment for successful tri-plane motion.
When describing the action of the rearfoot, I often use the analogy of the bicyclist riding
their bike. Imagine the cyclist riding along and start to lose their balance, the bike falls
to the right while the tires turn outward to the left. In our analogy, the tires and bike are
the calcaneus, while the rider is the talus. The “rider”/talus wears a long helmet called
the tibia, in other words, the tibia sits atop the talus. As the bike falls to the right, the
tires turn outward, similar to the left foot hitting the ground and causing the calcaneus to
evert (heel “falls” right, while the bottom of the heel turns outward). With the foot on the
ground during the landing phase of gait, the medial column of the foot, composed of the
union of the talus and navicular forming the talo-navicular joint, fall medially toward the
ground. Based upon the axis of motion, the talo-navicular and subtalar joints primary
motions are eversion-inversion in the frontal plane. This motion allows the tibia to move
further forward in the sagittal plane and dorsiflex at the ankle, while also internally
rotating in the transverse plane.
Helmet =
tibia
Rider =
talus
Tires =
calcaneus
Tibia internally rotates,
similar to helmet
rotated to right
Equivalent to calcaneus
eversion of
left foot
Most texts discuss the sagittal plane of the ankle, which in the strict isolated sense, the
talocrural joint (ankle) is strictly a sagittal plane mover. However, when the foot loads
upon hitting the ground, the ankle dorsiflexes in the sagittal plane, the calcaneus everts
causing the subtalar joint to evert in the frontal plane, the tibia internally rotates in the
transverse plane. This reaction then causes the mid-foot to evert in the frontal plane.
The forefoot abducts in relation to the mid and rearfoot due to the description of motion
as the distal bone in relation to the proximal bone segments. Because the rearfoot and
mid-foot move further and faster in the frontal plane than the forefoot, the metatarsals
and phalanges are lateral to the proximal segments, therefore, are abducted to the
rearfoot.
As a review, when the foot hits the ground in the pronation phase, the lower extremity is
eccentrically loaded by virtue of:
✦Calcaneal eversion
✦Ankle dorsiflexion
✦Tibial internal rotation
✦Forefoot abduction
These motions clearly show the foot and ankle complex is moving in three planes of
motion. It is agreed that we want mobility in the foot during the pronation phase
allowing absorption of forces. Yet, as ambulation takes place and the hip moves over
the foot, the opposing swing leg will drive the opposing hip forward which will invert the
calcaneus, plantar flex the ankle, externally rotate the tibia, and adduct the forefoot of
the stance leg.
Fig. 3
In the above Fig. 3 photo sequence, notice the left leg and foot. The leg is relatively externally rotated
and foot inverted. As the foot hits the ground, the foot pronates, which enhances relative dorsiflexion,
tibial internal rotation, and forefoot abduction. As the hip moves over the foot, the heel rises off the
ground, foot inverts and “locks” up the mid-foot, enabling the foot to be a cantilever to propel relative
ankle plantar flexion, extension for the metatarsals, forefoot adduction, tibial external rotation, and hip
extension.
In motion, the ankle joint moves primarily in the sagittal plane, however, it needs some
degree of frontal plane action, but not to the point that it creates too much mobility to
increase risk of ankle injuries. This concept will be very important as it is critical for the
foot and ankle to undergo these actions to create an environment for successful knee
and hip function.
The Knee
Books describe knee motion primarily in the sagittal plane as it flexes and extends.
Health and sports performance professionals frequently preach the knee must be stable
in side to side or frontal plane motion. Rarely, however, do we preach that the knee
must move in the frontal and transverse planes when the knee flexes and decelerates
movement. For years, numerous articles have been written stating the knee must track
over the 2nd and 3rd metatarsals when doing a lunge or a squat. If this is the case,
then why does nearly every athletic movement requiring deceleration and change of
direction cause the knee to move medially to the foot and hip as shown in Fig. 4?
Fig. 4
Notice how the hitter’s left knee is medial to the left foot. This allows the hip to eccentrically load as he
drives off his left foot in preparation to run.
As the foot moves through pronation (calcaneal eversion, dorsiflexion, tibial internal
rotation, and forefoot abduction), the tibia internally rotates on the talus. For example,
perform a lunge and place your hand on your tibial line as you do the lunge. If you are
doing a successful lunge, notice the calcaneus everting, ankle dorsiflexing, and tibia
turning inward as the knee flexes. Using the concepts of movement, the tibia is
internally rotated to the femur, therefore, the distal bone (tibia) in relation to the proximal
bone (femur) will place the knee into internal rotation in the transverse plane. Likewise,
if we view the distal end of the tibia in relation to the distal end of the femur, you will
notice the tibia is lateral to the femur, therefore is described as abducted in the frontal
plane. This often can be confusing because people see the knee toward the mid-line
and say the knee is adducted, but by the principles of movement, the distal bone is
abducted to the proximal bone, thereby putting the knee into knee abduction.
I often have said the knee is the dumbest joint in the body because it is highly
influenced by the foot motion and position, as well as that of the hip. Consequently, I
am not overly concerned that the knee may move medially to the foot, HOWEVER, I am
very concerned of WHY the knee may move and react the way it does. If a client does
a lunge or a squat and they cannot return to the starting position without a smooth
transition, then I have major concerns of why that may be the case. We must look at
foot function as well as hip function to make the knee successful.
To review, I agree the knee should be fairly mobile in the sagittal plane, but also must
have some degree of transverse plane and frontal plane mobility. We must raise a
cautionary eye to how smooth, efficient, and successful the transition is from loading the
knee, how much control is demonstrated when moving through the frontal plane and
returning to the start position. If the movement is looking uncontrolled and sloppy, then
we must do strengthening and corrective exercise to stabilize that action. But never
should there be such stability at the knee that no frontal or transverse plane motion
occur.
The actions that promote successful knee function are:
✦Knee flexion in the sagittal plane.
✦Knee abduction in the frontal plane by the tibia being abducted (lateral) to the femur.
✦Knee internal rotation as a resulting tibial internal rotation of the tibia in relation to the
femur.
The Hip
One of the most mobile regions of the body is the hip complex, the other is the thoracic
spine. A myriad of dysfunctions can develop when the hip is immobile in one or more
planes of motion. Among them are knee pain, sacroiliac pain, low back pain, even
shoulder discomfort.
Starting from the foot reaction, as the foot pronates, we learned the calcaneus everts,
ankle dorsiflexes, tibia internally rotates, and forefoot abducts. As the tibia internally
rotates, the knee flexes in the sagittal plane, abducts in the frontal plane, and internally
rotates in the transverse plane. As the femur reacts to the other motions below it, the
forward motion of the femur will result in hip flexion in the sagittal plane.
Simultaneously, as the knee abducts, the femur is “pulled” medially causing hip
adduction because the distal bone (femur) is now medial to the proximal bone (ilium).
The alignment of the femur in relation to the ilium and knee cause the femur to internally
rotate in relation to the ilium when loading the hip. Considering the gluteal complex,
especially the gluteus maximus, is attached at the greater trochanter, gluteal line, and
posterior superior iliac spine, the gluteal tissue is eccentrically loaded as the hip flexes,
adducts, and internally rotates. View Fig. 5 and notice the relationship of the bone
segments to load the hip in all three planes of motion during this frontal plane lunge with
opposite lateral reach.
Fig. 5
During the gait cycle, all the above actions occur on the weight bearing side as a person
ambulates forward. Attention must be brought to the motions of the non-weight bearing
side as the leg swings through to the next step. For consistency, let us consider the
above description on the left side and the right leg is about to swing through during the
gait cycle. Referring to Fig. 6, just prior to the right heel lifting off the ground, the pelvis
is rotated to the right. As the heel lifts off the ground, the pelvis starts to rotate left,
creating a relative externally rotated right hip, as the ilium is rotated left further than the
femur. Or to say it another way, the femur is rotated right (externally rotated) to the
ilium in the transverse plane. As the right leg is beginning to swing forward, the right hip
is lower than the left and slightly medial to the right leg. Therefore, since the right leg is
lateral to the ilium, the right hip is abducted during this swing phase. Additionally, the
leg is extended to the hip, hence, the hip is extended in the sagittal plane. All these
actions are critical for shock absorption, force production, and force transmission during
the efficient and economical gait cycle. As importantly, however, these actions are
critical in reducing overuse issues, especially in commonly injured areas such as the
lumbar spine.
Fig. 6
As a review, the weight bearing hip will move in three planes of motion and undergo
loading or deceleration during the following actions for successful movement:
✦Hip flexion in the sagittal plane
✦Hip adduction in the frontal plane
✦Hip Internal rotation in the transverse plane
The extended, non-weight bearing hip at heel off is:
✦Hip extended in the sagittal plane
✦Hip abducted in the frontal plane
✦Hip Externally rotated in the transverse plane
The Lumbar Spine
The lumbar spine is the nemesis of all fitness and health professionals! Arguably, the
low back accounts for more missed work days, industrial injuries, and approximately
80% of the population will suffer from low muscular back pain at some point in their
lives. Prior to embarking upon a description of the lumbar spine movements, there must
be a foundational concept explained relating to back movement.
Movements of the joints of the extremities has been described as the distal bone in
relation to the proximal bone. However, in the spine, it is the opposite. Spinal motion is
described as the proximal bone to the distal bone.
Referring back to figure 2, the left picture shows left cervical rotation because the
proximal segment is rotated further to the left than the segments below it. However, the
right photograph still demonstrates left cervical rotation because the proximal cervical
segments are still further left than the distal vertebra below. This position shows the
body is rotated right, however, by our foundational concept, this translates to left
cervical rotation.
The entire spine can be difficult to visualize 3-dimensionally, but with careful and
deliberate thought, this can be achieved and the professional will be able to assist their
client into a successful movement environment. When thinking about the segmental
position, you must think how motion is affected from the bottom up as well as top down.
I often imagine the spine as a spiral staircase that has a vertical, rotational, and lateral
components to it. However, this must be thought of as the body moves and is impacted
by the pelvis and arm motion. We will view the lumbar spine from the position in gait
with the left foot and right arm forward just prior to the right heel elevating off the
ground.
As the left leg swings forward, it “pulls” the left hip forward. As the left foot hits the
ground and the foot pronates, the reaction causes the leg to internally rotate, and as our
foundational concept dictates, we now have internal rotation of the left hip as the distal
bone, femur, is internally rotated on the pelvis. Concomitantly, the pelvis turns to the
right, therefore, as the pelvis is turned right, the sacrum is on a right obliquity as well.
The sacral facets of S-1 “carry” the fifth lumbar facets to the right, the fourth follows and
so on up the lumbar spine. Keeping in mind the right arm is forward with the
contralateral reach, the thoracic spine is rotating left due to the right arm and shoulder
are forward causing the thoracic spine to be driven toward the left. There will become a
transition point when the lumbar spine rotates less to the right at each segment the
further upward toward the thoracic spine, and the thoracic spine will move less to the left
as it moves downward toward the lumbar spine.Hence, there is an imaginary rotational
line from the right extended leg and hip that goes from the low right quadrant of the
body up and toward the left shoulder that is extended backward. The extension and
rotation causes these two endpoints to be furthest from each other and allows the
abdominals in the front to be eccentrically loaded from the right up the left. I call this the
Flexibility Highways Anterior X-Factor. Additionally, however, the left gluteal complex is
lengthened by way of the left hip is flexed and internally rotated. When viewing the right
latissimus dorsi and posterior shoulder girdle, the right posterior side is eccentrically
loaded from the lower posterior left hip up through the upper posterior right shoulder.
These structures are connected via the lumbar fascia forming the Flexibility Highways
Posterior X-Factor. In this orientation, the lumbar spine is extended and rotated to the
pelvis in the sagittal and transverse planes.
As the hip moves forward over the left foot during the mid-stance phase of gait, the right
hip will drop a bit causing the left to be higher. The body will strive to keep the head and
eyes level, similar to a bobble head doll. If you tilt the body on a bobble head doll, the
head will tilt to stay level. This accommodation must be made through the spine.
Therefore, the lumbar spine will laterally flex to the right. If this did not occur, the torso
would lean to the opposite side of the higher hip, in this case, to the right. This frontal
plane reaction allows the body to remain relatively upright and stable. Examine the
photo in Fig. 7 and think what position the vertebral segments are in three planes of
motion.
Fig. 7
As a review, the spine reacts to the gait stride in the following tri-plane motions
(assuming left foot in stride cycle):
✦Spinal flexion at left heel strike in the sagittal plane. Spinal extension in relation to an
extended hip in the sagittal plane as the right foot swings through during the gait cycle.
✦Spinal rotation to the right, in the transverse plane, at right heel strike and mid-stance.
✦Lateral flexion to the left in the frontal plane during right leg swing phase.
The Shoulder Girdle Complex
Most often shoulder function connotes the shoulder joint absent of the shoulder girdle.
In fact, many healthcare and fitness professionals advise their clients to train their
shoulder joint to be stable. I agree with this logic to a point, as we want to have a stable
shoulder joint, especially for those that participate in athletics such as baseball/softball,
tennis, golf, javelin throwers, and volleyball players, just to name a few. In reality, all
people need a degree of stability in the shoulder joint. However, there are other issues
that affect shoulder function that needs to be reviewed.
The shoulder is the most mobile joint in the body and is dependent upon a mobile
scapula. The scapula has 19 muscles that attach to it and each one must be strong
enough to withstand eccentric forces to allow the scapula to glide upon the ribs in all
three planes of motion. Scapular motion is necessary to create an environment for the
shoulder joint to be successful. Many shoulder joint impingement issues are a result of
the scapula not gliding properly and not allowing the greater trochanter to be clear from
the acromion process, especially during shoulder abduction moments. Impingement is
often the result of the lack of scapular motion or timing of the scapula moving while the
humerus abducts causing a pinching of the supraspinatus tendon. This is one example
of a common shoulder injury, however, this article is not to discuss the myriad of
shoulder injuries, but to address the relationship of the scapula to the shoulder, as the
scapular reactions are a result of body movements.
There is a saying I often use when relating to shoulder function, ‘where the scapula
goes, the humerus will follow.’ In other words, humeral motion is greatly affected by
scapular reaction. Likewise, the scapula is affected by humeral actions. However, if we
step back from the shoulder girdle complex and globally observe how the implications
the body has upon the scapula, we will quickly sense the scapula is dependent upon
thoracic spine movement. If we delve deeper from a global perspective, the thoracic
spine is greatly impacted my motion of the lumbar spine, which is impacted by hip
motion. The hips, as we have observed, has a tremendous dependency upon foot
function. Therefore, the scapula is a “floating” bone that is influenced by body motions.
There is a distinct relationship of the hips upon the scapula that must be explored. With
this understanding, the fitness and healthcare professional will then be able to create an
environment for shoulder joint success based upon the status of the shoulder girdle.
The scapula and shoulder girdle move in three planes of motion. Scapular reaction is
typically an unconscious response to gravity, body position and angles, and segmental
mobility. There is an important relationship between pelvic mobility and scapula
motions. In the sagittal plane, when there is adequate hip extension, the scapula will
depress and slightly retract. You can explore this by standing in a neutral, bilateral
stance. Drive your hips forward, which creates a relative hip extension to the legs and
spine. You will notice that spine extends backward and the scapula depress and retract
(see Fig. 8). This reaction is due to the change of body position and angles that has
allowed the scapula to react to gravitational forces pulling it downward. Next, keep the
arms relaxed, flex the spine forward to allow the hips to flex. Notice the scapula
elevated and protracted, again, a response to body angles and gravity.
Fig. 8
Fig. 9
Extrapolate how a person’s body angle and position changes and affects the scapula
when they either have to reach into a cabinet that is overhead. They extend at the hip
to allow the lumbar and thoracic spine to extend, creating an environment for the
scapula to depress, “clear” the acromion process in the sagittal plane, and shoulder joint
to flex to accomplish the task. Likewise, if that same person now picks something up
from the ground, the hips, lumbar and thoracic spines will flex causing the scapula to
elevate and protract to allow the humerus to successfully move.
Another example can be seen in bowling. As the bowler approaches their shot, they
flex at the hip and spine, allowing the scapula to elevate and retract while the shoulder
joint extends. None of the above actions can be achieved efficiently, effectively, and
safely without these synergistic responses. Now try any of the above movements and
not allow the hips or spine to naturally move and feel the affect upon the shoulder joint.
You will notice the shoulder is not successful in the task and often feels a “jamming”
sensation. Over many repetitions or years of dysfunction, this will lead to injury.
In the frontal plane, the same side hip that adducts/abducts will cause the scapula of the
corresponding side to adduct/abduct (see Fig. 10). To state it another way, the opposite
side hip that adducts, will cause the opposite scapula to abduct. Of course, on the
same side, the opposite joint that abducts will have an adduction moment on the
opposite side.
Fig. 10
I have observed many throwing injuries of the shoulder complex due to the lack of
motion in the transverse plane. A key relationship exists between the opposite hip and
shoulder during throwing-like actions, i.e. throwing, golfing, tennis swing, hitting,
racquetball, to name a few. It is very important for the opposite hip to be able to attain a
good range of motion during external rotation to allow the opposite shoulder to
externally rotate. When the action occurs, the torso typically turns away from the
opposite hip and toward the side of the affected shoulder joint. For example, when a
right handed thrower is in the act of throwing, the body turns into the right hand and
away from the left hip. This causes the right scapula to retract as it glides along the
ribs. This is a very necessary action to create “clearance” of the sub-acromial space
and reduce risk of impingement. I have seen numerous cases of lack of motion in the
opposite hip and/or opposite shoulder through external rotation that has not allowed the
shoulder to be clear of the acromion process during the throwing-like motion.
Likewise, I have evaluated many posterior shoulder issues that was a result of the lack
of the client to be able to obtain adequate internal rotation of the opposite hip which
does not allow the leg, hip, and torso to decelerate the arm follow through, thereby,
relying upon the posterior shoulder musculature to decelerate the arm action. If there is
not enough left hip internal rotation, for the right handed thrower, the scapula will not be
in a position of success in protraction and cause improper arm slot positioning during
the deceleration phase of throwing or other actions such as the follow through in golf, or
a follow through for a boxing motion.
Base upon the above description we can, therefore, describe the transverse plane
relationship of the hip through the torso to the shoulder girdle, especially the scapula, as
follows:
Figs. 11 & 12 show how the opposite hip must externally rotate to allow the scapula to
be mobile and retract, which will create successful shoulder joint external rotation.
Likewise, however, the same side hip must be able to attain adequate internal rotation
to allow the same side shoulder to externally rotate. In throwing motions, this is the
load-up phase. The release point will demonstrate the body moving into internal
rotation of the opposite hip and external rotation of the same side hip to allow
protraction of the scapula and internal rotation of the opposite side shoulder joint.
Fig.11
Fig.12
It becomes very apparent there must be mobility of various joint segments to allow the
reactions to transpire, yet stability to control and decelerate all these reactions that
occur simultaneously. In these examples, I have seen people that are either very well
developed in the latissimus dorsi that does not allow good rotation through the thoracic
spine. In these cases, they are too stable and not mobile enough to accommodate the
necessary transverse and frontal plane actions required for rotary activities. Yet there
are a myriad of maladies that can limit motion creating instability in other areas of the
body.
To review the shoulder complex movement relationships:
✦In the sagittal plane, the same side hip that flexes will enhance scapular elevation and
slight retraction to allow shoulder joint extension. Likewise, the same side hip that
extends creates an environment for the scapula to depress, retract and enhance
shoulder joint flexion.
✦In the frontal plane, the same side hip that adducts/abducts will cause the scapula of
the corresponding side to adduct/abduct.
✦In the transverse plane, the opposite side hip that externally rotates will cause the
opposite scapula to glide on the ribs and retract allowing the opposite side shoulder joint
to externally rotate. At the same time, the same side hip will internally rotate to allow
the same side scapula to retract and shoulder joint to externally rotate. The opposite
holds true for opposite hip/scapula/shoulder joint during the opposite motions.
Cervical Spine
Thus far the discussion of movement has had an impact upon joints and structures
above and below the specified region. The cervical spine presents a slightly different
perspective as the majority of its motion is often a result of actions that impact the
cervical spine from motions that occur below it. The cervical spine often can liken itself
to the bobble-head doll as it is impacted by body positions, angles, and motions that
have a relative impact upon the C-spine.
The cervical spine is unique in that the lower portion from C3-C7 should maintain its
inherent lordosis in order to serve as a shock absorber from forces generated from the
regions of the body below it. The upper cervical spine, the cervico-occiptal and C-1 do
not have the ample tri-plane motion as the remaining segments possess, therefore, in
order to preserve the upper cervical spine integrity and health, the lower cervical region
requires its tri-plane motion.
The orientation of the cervical vertebra have an alignment that places each segment
approximately 45 degree angular articulation to each other. When the cervical spine
flexes, there is a gliding forward or opening of the proximal cervical segment upon the
distal segments. Conversely, there is a closing of these segments upon return (relative
extension) to the more neutral position or into extension. Therefore it can be viewed as
not only flexion/extension, but also a gliding translation over a center of rotation as
these motions occur. The upper cervical spine typically is conducive for flexion and
extension, limited lateral flexion, and limited rotation. The lower cervical spine has more
tri-plane actions, in fact, these actions require motion in all three planes simultaneously
for successful movement. For example, cervical rotation to the right will cause the
transverse processes of the c-spine to turn to the right. Concomitantly, there is a slight
lateral flexion to the right in the frontal plane, and extension of the transverse process as
well. Therefore, motion must occur in all three planes to allow a successful and efficient
movement to occur. This does not consider the posterior translation required during this
action.
Periodically a client presents with a straight or flexed cervical spine. The fitness and
health industry has addressed this in an isolated manner. If we step back for a moment
to analyze the impact the body has upon the cervical spine, we will quickly notice that
the posture of the body has affected the cervical spine. Assuming the cause is more
soft tissue related than degenerative joint disease of the cervical region, the majority of
cases that present with a flat cervical spine has a flexed thoracic spine and lumbar
spine. If we view further distally, the pelvis typically is in a posterior tilted position.
To functionally improve the cervical spine, the lumbar spine must have a relatively
extended position so the lordosis is gained in this region which will allow the thoracic
spine to gain some degree of extension. This will create an environment for the cervical
spine to be in a lordotic position to allow proper motion to occur.
A strategy that I have found successful is to have the client stand in a staggered stance
and drive the hips forward. This allows the extended hip to tilt anteriorly and the lumbar
spine will extend in relation to the hip, thoracic spine will extend, scapula will retract
along with the shoulder girdle, head will retract, and the cervical spine will be in an
environment to re-gain its lordosis. Next, have the client reach the same side arm or the
extended hip posteriorly. This retracts the scapula and enhances postural alignment.
To review the cervical region, the following concepts should be considered:
✦Movement involves all three planes of motion
✦When movement occurs, there is a translation of the vertebral segments over the
center of rotation.
✦Make sure adequate motion exists within the thoracic spine for successful cervical
movement.
Concluding Remarks
Understanding human motion is a complex synergy of tri-plane segmental actions to
accomplish a specific task. The reaction to those segmental motions are necessary for
efficient and economical results. To fully assist our clients, the health and fitness
professional needs to develop strategies that address the problem, not the symptom
that the client possesses. Our industries do a marvelous job at addressing the “what”,
“when”, and “how” for program design. For instance, if a client has a knee problem, our
industry inherently thinks that we are going to address the knee problem (what), by
doing certain exercises, either with machines, or body weight (how), and will plan this
approach in a certain sequence of events (when). However, our industry does not
address the “why” of the problem. In order words, if a client has an injury issue,
particularly if an overuse problem, the sight of the injury is not the problem, it is the
symptom. The problem is typically a joint level or two levels above or below the
problem and the symptom is the site of the discomfort.
We must step back and learn how the body body moves through a three dimensional
approach and look at movement from a global perspective, not just a local one. When
this paradigm is embraced, program design will take an entirely different approach, and
then, we will be creating a truly personalized exercise prescription that addresses the
limitations, compensations, and idiosyncrasies of our clients.
Take the time, be persistent, and good luck! It will payoff in the long run, and ultimately,
it will have great impact upon the lives of those we serve.
References
Carlsoo, Sven, How Man Moves, 1972, London, William Heinemann Ltd.
Clark, M.A., “Integrated Flexibility Training”, Thousand Oaks, Ca., National Academy of Sports Medicine, 2001
Dykyj, Daria, Ph.D., “Anatomy of Motion”, Clinics in Podiatric Medicine and Surgery, July 1988, Vol. 5, No. 3
Gray, Gary, P.T., “Pronation and Supination”, Wynn Marketing, Adrian, Michigan, 2001
www.wynnmarketing.com,
Gray, Gary, P.T., “Functional Biomechanics: Pure Definitions”, Wynn Marketing, Adrian, Michigan, 2001
www.wynnmarketing.com,
Inman, Verne, Human Walking, Williams & Wilkins, 1981
Katch, Frank, Katch, Victor L., McArdle, William D., Exercise Physiology: Energy, Nutrition, and Human
Performance, 1986, Philadelphia, Lea & Febiger
Masson, Dr. Robert, Neurospine Institute, Ocoee, FL. www.Neurospineinstitute.org
Powers, Scott K. & Howley, Edward T., Exercise Physiology: Theory and Application to Fitness and
Performance, 1990, Dubuque, Iowa, Wm. C. Brown Publishers
Schamberger, Wolf, The Malalignment Syndrome, Churchill Livingstone, 2002
Simon, Sheldon, MD, Mann, Roger, MD, Hagy, John, O.R.E., Larsen, Loren, MD, “Role of the Posterior Calf
Muscles in Normal Gait”, Journal of Bone and Joint Surgery, June 1978, Vol. 60-A, No. 4
Prestige Cervical Core Education Course, Medtronics, 2007
Calcaneal Eversion: A Subtle, But Important
Motion
by Chuck Wolf, MS, FAFS
The subtle, intricate actions of human movement are the individual links that compose the chain of human motion.
Nothing is more important than the need for calcaneal eversion to set the entire chain reaction into motion by
loading the muscles of the foot, calf, knee, leg, and hip. Without calcaneal eversion, inefficient motion occurs and
overuse can soon follow.
In gait, the foot lands on the lateral aspect of the calcaneus as gravity and ground reaction forces cause the heel to
turn laterally, or more accurately, eversion. Along with gravity, ground and reaction forces the eccentric control of
the anterior tibialis, peroneals, and the extensors of the toes lower the foot to the ground. As the calcaneus everts, the
subtalar joint abducts, the ankle dorsiflexes, and tibia internally rotates, thereby creating a tri-planar motion at the
ankle. The anatomical structure of the ankle complex makes the ankle, which dorsiflexes and plantar flexes in the
sagittal plane, a perfect complement to the subtalar joint which functions in the frontal and transverse planes. The
posterior calf group, especially the posterior tibialis, lengthens to decelerate and control these actions. As the
calcaneus everts during pronation of closed chain activities, the midtarsal joints invert, abduct, and dorsiflex in
relation to the subtalar joint and rearfoot to allow proper absorption of forces through the foot. When the tibia moves
over the foot, the soleus decelerates tibial motion in the sagittal plane and the gastrocnemius helps control tibial
rotation in the transverse plane. The chain reactions that follow are knee flexion and abduction, hip flexion and
internal rotation which absorb the forces of the body and gravity. The eccentric tri-plane actions of the calf,
quadriceps, and hip musculature must load to control these forces before any effective actions can transpire.
Therefore, based upon these principles, in order to recruit the gluteals in three planes of motion, the foot must go
through pronation which creates the eccentric loading of the entire chain. This stores energy and enhances the
muscle’s ability to successfully supinate and accelerate propulsion and explosiveness. No matter what stage of life
or activity that is pursued, the subtle calcaneal eversion sets the environment for efficient movement that is energy
efficient and reduces risk of injury.
The fitness professional should become familiar with these functional actions, as inefficient actions of the foot, i.e.
flat or high arched feet, can inhibit the foot’s ability to attain the proper loading and ultimately limit the person’s
ability to have a strong propulsive unloading or supination.