Let's Focus on Movement Instead of 'Structure'


We have been made to believe that the following statements are a huge factor when it comes to pain and injury...

"There's a bone spur on your X-ray" 

"One of your legs is longer than the other"

"Your knee hurts due to aging and overuse"

...even though research has proven that these things don't matter. Let's take them one at a time...

1. one third of asymptomatic (without pain) individuals have a bone spur on X-ray. 75% of pain-free adults have arthritis of the shoulder joint on X-ray - this would suggest "arthritis" is not nearly as bad as we think! It really is just a word to describe the normal progression of our tissue as adults. It does not equal pain or dysfunction!!

2. 90% of people have a leg length discrepancy, with an average difference of half a centimeter. Studies show that this inequality is not significant for the majority of people until the difference is 2 centimeters, and even then many people will have no symptoms!

3. whenever someone tells me that "getting old sucks" or their knee hurts because they are getting old and have done a lot of activity, I ask them "How old is your other knee, the one that doesn't hurt?" Yep, it's the same age. Simply being older has almost nothing to do with your issue!

So if all the things we hear all the time kinda don't matter, what should we focus on?

Look, we can't do anything about getting older, and we can't do anything about diagnostic tests showing signs that we used our joints. In fact, it would be actually be more abnormal if you had a totally clean X-ray or MRI, because if the majority of people have a test result that shows "wear and tear" and their joints don't hurt, "wear and tear" is not the problem! If we fix the movement of the people with or without "wear and tear" they both get better and feel better! Movement is key.

We also should stop worrying about scoliosis, kyphosis, and other "shape" differences that are also just totally normal and are non-predictive of pain. Most research suggests that structural appearance has no bearing on symptoms, but rather a complex mechanism involving hereditary, psychological, and social factors is much more important than mechanical factors when considering why we are in pain. 

On top of those factors - the ones the research has shown to prove -  is the movement factor. If you have smoother and easier movement into a greater range, you typically have less pain. Think about this: if you see someone limping, hobbling, bent over, moving slow, would you likely assume something is wrong or something hurts them?? On the other hand, if you see LeBron James sprint down the court effortlessly and throw down an alley-oop full force, would it even cross your mind that anything was possibly bothering him as he did that?

Treatment based on making you move more like LeBron than the other guy would make more logical sense then, right? We aren't trying to make you a pro athlete, rather move smoother, easier, and further than you are now. It's much less important that you sit perfectly straight at your computer chair during the work day!

Technically speaking, the old bent over person could have no pain at all, and LeBron could be suffering immensely as he dominates his opponent. Thats what makes figuring all of this stuff out so hard, and why you are constantly bombarded with opposing viewpoints and contradicting exercise advice. But, if we look at the most likely scenario for which one is in pain and which isn't, I think it's fair to say we would rather move like LeBron.

But how do we get there?

If your therapist or trainer is spending a lot of time on static stretching - fire them. This is not the way to train efficient movement because you aren't moving! Plus the effects are proven not to last.

If you are in pain and the things you are working on aren't helping immediately when you do them - do something else. If it is good for you, your body will respond by feeling better and moving better right away.

Whether you are working with a professional or trying to work on yourself, choose exercises that work on coordinating the body in some type of pattern that resembles normal movement (most often involving the whole body and not just one piece of it), OR be sure that whatever movement you are doing (or the person is doing to you) is making you move better immediately afterward. How else can you possibly know if you are wasting your time or not? 

If you aren't constantly being retested to measure whether or not the treatment you are using is working, there is no way to know which part of it is working (or if it is working at all). If you do 6 exercises, and only check to see how you feel again after you finish all 6, isn't it quite possible that 4 made you better and 2 made you worse? Could one of them have made you a whole lot better, and the other 5 done absolutely nothing?

This is the paradigm shift that the leaders in PT and rehab are moving to employ. All of you as patients need to be proactive to make it happen though, because you will all get better faster if you do. Find someone who is constantly rechecking to see if what they are doing is working, or demand that whoever you are working with keep rechecking you. The more we all take responsibility for ourselves, the better the outcomes will be. The idea that someone can go to therapy for 6 months and feel no different needs to be stricken from our thoughts and minds, because it simply makes no sense and should never be the case. 

As a nice little bonus, the structural component (one shoulder is higher than the other, one foot sticks out to the side) will often take care of itself if the movement efficiency is improved. So even though the goal shouldn't be to "fix the rotation of the pelvis", the pelvis will often line up for you once everything is working as it should be!

Austin Misiura, DPT, OCS, CSCS is a Board Certified Orthopedic Physical Therapist and owner of Pure Physical Therapy in partnership with MSP Athletics in Miami, FL