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The Joint By Joint Approach

The joint by joint approach, as described by Cook (2010), is a way to conceptualize the body as a stack of joints that alternate between needing mobility and stability, that have specific predictable types of dysfunction. Joint pain is usually accompanied by either dysfunction in the above or below joints mobility or stability. This is due to changes in mobility force a stable joint to move, as a compensation, which leads to altered transfer of forces and pain. Two joint areas that could benefit from added mobility are the ankle and the thoracic spine.

The ankle joint or talocrural articulation is located between the distal ends of the tibia and the fibula and the superior part of the talus, and is classified as a hinge type synovial joint (Moore, Dalley, & Agur, 2014). The tibula and fibula meet at a bracket shaped socket called a mortise. The talus fits snugly in the mortise, forming the joint articulation. Basically, the ankle is where the lower leg meets the foot. The ankle can dorsiflex or plantarflex. Dorsiflexion is raising the foot upwards and is performed by muscles in the anterior compartment of the leg (tibialis anterior, extensor hallucis longus and extensor digitorum longus). Plantar flexion is moving the foot downwards and is performed by the muscles in the posterior compartment (gastrocnemius, soleus, plantaris and posterior tibialis) (Moore et al., 2014).

The ankle is frequently injured and could benefit from increased mobility and flexibility. The ankle becomes stiff during the aging process. Negative age related changes include an increased passive resistance of the elastic tissue in opposing muscles, tendons, and articular structures, weakened agonist muscles for the dorsiflexors and plantar flexors, and diminished proprioception (Vandervoort, 1999). This may lead to tripping and falling, which could lead to further disability. to damaging. Tightness in the gastrocnemius and soleus (triceps surae) can lead to the bodies center of mass to shift forward. This causes overactivation of the thoracolumbar paraspinals, which increases stress on the lumbar spine, eventually causing chronic low back pain (Page, Frank, & Lardner, 2010) Injuries can occur in both plantarflexion and dorsiflexion. Tightness in the gastrocnemius and soleus (triceps surae) can lead to the bodies center of mass to shift forward. This causes overactivation of the thoracolumbar paraspinals, which increases stress on the lumbar spine, eventually causing chronic low back pain. Plantarflexion is associated more with acute injuries. During plantarflexion the ankle is unstable because the trochlea of the talus is narrow posteriorly and, therefore, lies relatively loosely within the mortise (Moore et al., 2014). During weightbearing movement if the foot is twisted the lateral ligament is usually sprained. The lateral ligament is injured because it is far weaker than the medial ligament, and is the ligament that resists inversion at the ankle joint. During normal dorsiflexion the shin moves forward, relative to the foots position. Altered dorsiflexion can impact the knees and feet. Decreased dorsiflexion is associated with greater knee valgus during squatting and landing tasks, which may increase the risk for ACL injury risk (Fong, Blackburn, Norcross, Mcgrath, & Padua, 2011). Foot issues are also associated with poor dorsiflexion. Plantar fasciitis is an inflammatory condition of the plantar aponeurosis of the foot that causes heel pain. During limited ankle dorsiflexion (less than 10°) excessive pronation of the foot of occurs to compensate, which increases the tensile load on the plantar region, which contributes to the pathology (Riddle, Pulisic, Pidcoe, & Johnson, 2003). Immobile ankles can lead to acute injuries and dysfunction in the joints above and below.

There are a couple of ways to screen ankle mobility. One way is through muscle length testing. Tightness in the triceps surae can limit ankle motion and cause immobility. To test these, a clinician should stand facing their client who is lying supine with one leg flexed and resting, while the leg being tested is extended with the foot hanging over the tables edge (Tunnell, 1998). The clinician should have a hook position with his hand and hold the calcaneus of the tested leg. The clinician should then distract the calcaneus downward until all the slack is taken up or no movement is observed. Then the clinician should rest their thumb on the client’s foot. While maintaining calcaneal distraction, the clinician lightly gives pressure to the forefoot in the movement in direction, while keeping the subtalar joint as immobile as possible (Page et al., 2010). The triceps surae in normal length allows for the foot to be in 0°of dorsiflexion. If the triceps surae is dorsiflexion is less. To differentiate between the gastrocenemius and soleus tightness, the clinician should flex the patient’s knee while palpating the heel and pressure on the forefoot. If the range of motion increases the shortness is from the gastrocnemius, and if there is no change in range of motion, the source is the soleus (Page et al., 2010).

The thoracic spine is complex region of the body. It is located between the lumbar vertebrae and cervical vertebrae, and is composed of 12 vertebrae that provide for attachments of the ribs (Moore et al., 2014). Generally, each thoracic vertebrae that are shaped like a heart and are relatively broad. Each verterbrae gets progressively thicker through the descending spinal column. The thoracic spine typically has a kyphotic curve between 20-50°. The main motion of the thoracic spine is rotation, but it can also extend and laterally flex. These movements are performed by the primarily by the muscles of the erector spinae group. The primary role of the thoracic spine is to provide stability, due to the support system it creates with the ribs to protect internal organs, but it is highly mobile. The thoracic spine tends to get stiff and immobile due to poor posture and bad habits.

Immobility in the thoracic spine can cause issues with posture, upper limb movement, lower limb movement and breathing. Thoraicic mobility decreases with age and also sitting electronics usage which increase axial load on the vertebrae (Edmondston et al., 2011). This increases pain and can affect the rest of the body. Kyphosis increases as immobility increases. A kyphotic posture can misalign the spine, which can cause pain all throughout the spinal column (Hinman, 2004). Increased kyphotic posture is correlated with loss of shoulder function. Since the scapula is attaches to upper back, healthy thoracic spine positioning dictates the function of the shoulder. People with more erect postures and less kyphotic postures have greater shoulder range of motion (Barrett, Keeffe, Sullivan, Mccreesh, & Lewis, 2016). The lower body is also affected by poor thoracic mobility. Increases in kyphosis leads to increased lumbar spine lordosis and an anterior pelvic tilt changes the forces on the lower limb, which may lead an increase in falls among the eledery (Ishikawa et al., 2017). Lastly poor thoracic mobility can affect breathing. Many muscles attach the thoracic cage that are involved in normal respiration. An impairment in the strength and coordination in these muscles can lead to shallower breathing, decreased air exchange, and increased respiratory rates (Ekstrum, Black, & Paschal, 2009). Poor thoracic mobility negatively impacts the rest of the bodies function.

The passive physiological intervertebral motion (PPIM) test has been shown to be a reliable indicator of the middle thoracic spine (Brismace et al., 2006). The test isolates movement in each spinal segment, and the evaluator judges both the quality and quantity of movement. In the test the client sits with their thoracic spine passively extended, while side bending towards the clinician and rotating the opposite side away from the clinician. The clinician uses their thumb to detect the movement at the T6-T7 segment. To perform PPIM motion tests, the clinician passively moves the spine in each direction, the spinal segment is palpated, and a judgment is made with respect to the amount of motion and end feel produced at that segment (Brismace et al., 2006). If there is little movement there is most likely a mobility issue.


Barrett, E., Keeffe, M., Sullivan, K., Mccreesh, K., & Lewis, J. (2016). Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Manual Therapy, 25, 38-46.

Brismace, J., Gipson, D., Ivie, D., Lopez, A., Moore, M., Matthijs, O., . . . Sizer, P. (2006). Interrater reliability of a Passive Physiological Intervertebral Motion test in the mid-thoracic spine. Journal of Manipulative and Physiological Therapeutics, 29(5), 368-373.

Cook, G. (2010, October 02). Expanding on the joint-by-joint approach. Retrieved from

Edmondston, S., Waller, R., Vallin, P., Holthe, A., Noebauer, A., & King, E. (2011). Thoracic spine extension mobility in young adults: Influence of subject position and spinal curvature. Journal of Orthopaedic & Sports Physical Therapy, 41(4), 266-273.

Ekstrum, J. A., Black, L. L., & Paschal, K. A. (2009). Effects of a thoracic mobility and respiratory exercise program on pulmonary function and functional capacity in older adults. Physical & Occupational Therapy In Geriatrics, 27(4), 310-327.

Fong, C., Blackburn, J. T., Norcross, M. F., Mcgrath, M., & Padua, D. A. (2011). Ankle-dorsiflexion range of motion and landing biomechanics. Journal of Athletic Training, 46(1), 5-10.

Hinman, M. (2004). Comparison of thoracic kyphosis and postural stiffness in younger and older women. The Spine Journal, 4(4), 413-417.

Ishikawa, Y., Miyakoshi, N., Hongo, M., Kasukawa, Y., Kudo, D., & Shimada, Y. (2017). Relationships among spinal mobility and sagittal alignment of spine and lower extremity to quality of life and risk of falls. Gait & Posture, 53, 98-103.

Moore, K. L., Dalley, A. F., & Agur, A. M. (2014). Clinically oriented anatomy (7th ed.). Baltimore, MD: Lippincott, Williams & Wilkins.

Riddle, D. L., Pulisic, M., Pidcoe, P., & Johnson, R. E. (2003). Risk factors for plantar fasciitis: A matched case-control study. The Journal of Bone and Joint Surgery-American Volume, 85(5), 872-877.

Tunnell, P. W. (1998). Muscle length assessment of tightness-prone muscles. Journal of Bodywork and Movement Therapies, 2(1), 21-27.

Vandervoort, A. A. (1999). Ankle mobility and postural stability. Physiotherapy Theory and Practice, 15(2), 91-103.