Reducing the Need for Replacement Surgeries

By Dale G. Alexander, LMT, MA, PhD

Reducing the Need for Replacement Surgeries

By Dale G. Alexander, LMT, MA, PhD

As massage therapists, we have an opportunity to incite curiosity and realistic hope into our nation's aging population. The progressions of hip, knee and shoulder degeneration are encroaching upon the quality of life of so many that the general public is reaching out to our professions to assist them.1

Certainly, many clients come to us with pain and reduced range of motion associated with these joints. According to a physician who reviewed this article, Dr. Daniel Herlihy D.O., his clinical experience suggests that clients often present with the signs of these degenerations as young as their early 40s.2

The essential question is whether each of us has the skill sets to screen for early indicators that these joints may be progressing toward degeneration. The following are my time tested screenings for the shoulder, hip and knee. Following these descriptions will be a discussion of anatomical relationships that contribute to the degeneration of these joints.

Screening the Shoulder

For the shoulder, have the client seated. Passively move the compromised arm and shoulder into abduction guiding their arm over their head, as you feel for ease of the humeral head gliding under the shelf of the acromion.

If the range feels restricted, tremors or abruptly stops, this may be an indication that a degenerative process has begun. Encouraging your client to schedule a more formal orthopedic evaluation may serve to preserve future quality of life.

Screening the Hip

For the hip, have the client lie on their side with their bottom leg and thigh extended. Place your foot on the table with your knee bent to 90 degrees and lift the top thigh and leg of the symptomatic hip, balancing it on your thigh. Grasping just above the ankle, passively lift the leg into abduction.

As you guide the hip joint into internal rotation palpate the greater trochanter and feel for the range and quality of the movement through both of your hands. Most commonly, if someone's hip joint has started down the path of degeneration, you will feel not just a restriction to motion, but also an abrupt stop to the motion. In my experience, this lack of internal rotation has been my most reliable indicator that degenerative progression, especially if my best efforts to mobilize the joint are minimally effective.3

Screening the Knee

Evaluating knees is trickier because degeneration can create either an advancing immobility to flexing and extending normally, or the joint can become destabilized to the point where a client reports that it feels as if the knee is going to give out on them with increasing regularity. In both cases if the client doesn't exhibit improvement, it is best to encourage seeking further medical evaluation.

Functioning as part of your clients' early detection team is a golden key to preserving their quality of life even if you treat them only once. You touched them; you cared enough to express concern; trust that the seed was planted. This will serve our professions to do so.

Understanding the Link Between the Hip, Knee & Shoulder

Osteopathy has long held that there exists a lateral fascial integration: from the latissimus dorsi's attachment to the humerus downward throughout the torso via the sacroiliac joints, blending into the lateral hamstrings, then into the peroneal muscle group descending along the lateral ankle and crossing across the foot to the base of the first metatarsal and the medial cuneiform bones.4 This one construct gives us a fascial linkage between the three joints that most commonly need to be replaced.1

Empirical observations within my clinical practice of thousands of clients has evidenced the discovery that the shoulder has a tendency to slip forward in its socket while the femoral head slips posterior in relationship to the acetabulum. Naturally, their myofascial structures spring into protective contraction and spasm. As these protective contractions become chronic their tension reduces adequate blood flow to the joints leading to compression, congestion, degeneration, reduced range of motion, and ischemic pain.5

My speculation is that nature evolved this flexibility in the shoulders and hips as a survival edge when we fall from any degree of height activating the subcortical reflex to "tuck and roll." Additional righting reflexes can be activated by falling, whiplash, and impact injuries of all varieties. One that I commonly find in clients with these progressions was described by Thomas Hanna PhD as the Lateral Trauma Reflex.6

Let's recognize the simple fact that the femur at its proximal end forms the hip joint with the acetabulum while the condyles of its distal end interface with the plateau's of the tibia to form the knee joint. When the head of the femur slips posterior, it also twists to some degree. This twist is communicated down its length distorting the tracking of the interfacing surfaces of the knee joint.

Again, compression, congestion, protective contraction, and friction, provoke inflammatory cycles that result in loss of coordinated motion, range of motion, instability, and eventually ischemic pain. Therefore, it is no surprise that the number of knee replacement surgeries is approximately double the number of hip replacements each year.7

What is remarkable is how adaptable our bodies are to these structural distortions providing us at least some degree of ongoing function for decades until the joint cartilages thin to the dreaded diagnostic statement that you have a joint that is "bone on bone."

Ironically, little orthopedic attention or screening is given to how the degeneration of these joints contribute to arthritic progressions within the axial skeleton, especially the low back. If you have a client with chronic low back pain, please do these screenings. You may be surprised just how often one or more will exhibit signs of degeneration.8

Another overlooked variable is that our feet, legs, thighs, hips and pelvis are designed to bear weight. The axial spine is not. It functions as a relay team passing the baton of the forces of movement and weight bearing through the spaces of their joints in the cross-crawl pattern of walking.4

The next article of this series will explore the more intrinsic relationships of anatomy and physiology that I have clinically correlated to contribute to the progression of degeneration within these joints. Reflect for a moment, our quality of life really does depend upon the normal functioning of our hips, knees and shoulders.


  1. Premier Orthopaedics Blog. Most Common Types of Joint Replacement Surgery. Premier Orthopaedics, 26 Feb 2015.
  2. Nordin M, Frankel VF, et al. Basic Biomechanics of the Musculoskeletal System, 2nd Edition. Philadelphia : Lippincott, Williams & Wilkins, 1989.
  3. Richard MacDonald D.O., tutorial Muscle Energy Technique practicum 1988-90 and during his Functional Anatomy courses taught through the Upledger Institute.
  4. Alexander DG. Freeing the Heart: Protection of the Hip and Shoulder Joints. Massage Today, June, 2013;13(6).
  5. Thomas Hanna Ph.D., course notes and personal sessions with him 1988-90.
  6. Hanna T. Somatics: Reawakening The Mind's Control Of Movement, Flexibility, And Health. Cambridge: Da Capo Press, 1988.
  7. NCHS Data Brief. Hospitalization for Total Hip Replacement Among Inpatients Aged 45 and Over. Centers for Disease Control and Prevention, Feb 2015;186.
  8. Alexander DG. A New Model for Low Back Pain & Dysfunction. Massage Today, August 2013;13(8).