ACSM'S Health & Fitness Journal:
COLUMNS: Clinical Applications
Movement Patterns That May Predict Problems for Your Clients
Hanaki-Martin, Saori Ph.D., ATC; Swank, Ann M. Ph.D., FACSM, C.S.C.S., ACSM-CES, ACSM C-PD
Saori Hanaki-Martin, Ph.D., ATC, is a biomechanist and a certified athletic trainer. Her research interests includebiomechanics related to sports performance and sports injury, which align with her personal interest in competing in triathlons and running recreationally. She currently teaches as an assistant professor at Transylvania University in Lexington, KY.
Ann M. Swank, Ph.D., FACSM, C.S.C.S., ACSM-CES, ACSM C-PD, is a professor of exercise physiology, co-chair of the Health and Sport Science Department, and director of the Exercise Physiology Laboratory at the University of Louisville. Her research interests are exercise testing and prescription for special populations, with an emphasis on chronic heart failure. She is ACSM Program Director certified, ACSM Clinical Exercise SpecialistSM certified, and a fellow of ACSM.
Disclosure: The authors declare no conflicts of interest and do not have any financial disclosures.
Past Clinical Application columns have addressed helping clients stay with their exercise program. Strategies such as periodizing the exercise program and adding planned recovery time have been presented. Adding variety such as including metabolic resistance training and separating training into 3 10-minute sessions instead of 30 minutes also has been discussed. The purpose of presenting many different strategies for staying with an exercise program is the fact that what works for one individual may not be effective for another. With the presentation of multiple ideas, perhaps a patient will find the one that works for him or her. With this column, injury prevention is addressed through an assessment of movement patterns that may predict injury. Some simple screening tests are presented that can be done with minimal invasiveness that can help the clinician possibly prevent injury.
SOME SIMPLE SCREENING TESTS; WHAT SHOULD THE CLINICIAN LOOK FOR
More than 80% of musculoskeletal injuries among adults are related to physical activity, with 70% occurring in the lower extremity (10). The interdependency of the mechanics of the lower extremity joints (2) is known as the kinetic chain. As an example of this interdependency, excessive pronation of the foot (flatfoot) is likely a factor related to many leg, knee, and low back pathologies (3,13). The excessive pronation of the foot may cause the leg to internally rotate, resulting in knee valgus position, causing the pelvis to tilt anteriorly and laterally, ultimately affecting lumbar function (1,13). This mechanical sequencing affects the working length of the muscles, changing the effectiveness of force production capability (1). In addition, altered joint positions lead to increased load applied to static joint structures like ligaments and joint capsules (13,17). Another foot type, the more rigid supinated foot (“high-arched” foot) is associated with impact-related injuries like stress fractures as the impact attenuation capability is reduced because of reduced flexibility in the foot (12,17).
One reliable method of identifying foot types that may predispose individuals to injury is the arch ratio (9,17). The lower ratio (≤0.275) is considered “flat arch,” and individuals with this foot type would benefit from “motion control” shoes that include more arch support (5). A high-arch foot type (ratio, ≥0.356) would benefit from shoes that provide additional cushioning (7).
Weakness in the gluteus medius muscle can be assessed by the single-leg squat (2,18). Viewed in the frontal plane, the clinician can assess the vertical alignment of the hip, knee, and the ankle joints during the single leg squat. An individual who exhibits the knocked knee position (knee valgus with hip adduction and internal rotation) possibly accompanied with Trendelenburg sign (nonstanding side pelvic drop) may benefit from corrective exercises to strengthen the hip abductors to prevent potential injuries specifically related to the knee joint (19). A possible underlying mechanism for weakness in the gluteus medius muscle is the likely inability of maintaining appropriate pelvic position resulting in the misalignment of body weight force to the knee and ankle and an increased risk for conditions like patella-femoral pain syndrome (anterior knee pain) (2). Poor positioning of the pelvis can result from other factors including any imbalances in the strength and/or flexibility of structures that are connected to the pelvis (the abdominal, back, hip flexor, and hamstring muscles, the ligaments, and joint capsules). The postulate that positioning of the pelvis has an influence on the function of the lower extremity is well accepted (18); however, there still is controversy (8). The research has not yet identified how much imbalance is too much.
Another relatively new method of assessing the dynamic function of the body to predict injury is functional movement screening (FMS) (6). FMS includes seven dynamic movement tasks that are scored individually using a three-point scale; 3 being the most functionally sound (the composite score is 21). An individual scoring a perfect 21 would be less likely to suffer an injury while someone scoring below 21 may be more likely. The intervention to potentially prevent injury would be specific for the test in which the individual did not score well. For example, an individual with a low score on shoulder mobility may benefit from shoulder flexibility training. High intratester and intertester reliabilities have been reported for this screening method, even among novice testers (16). Studies of NFL football players have identified the preseason composite score of 14 as the cutoff for increased injury prevalence during the season (11,15). However, the cutoff value for heightened injury risk seems to be dependent on the population tested (4,14,15).
Some biomechanical characteristics have been identified to have association with certain musculoskeletal injuries, and clinicians can perform screening tests to recognize these characteristics. The complexity in human body movements will continue to be a challenge in identifying clear mechanical features that have causal effects on injuries.
The next series of Clinical Application columns will begin to address exercise prescription for special populations, with an emphasis of identifying some specific exercise strategies that will be beneficial for all clients and patients but particularly relevant for the special population addressed. The first column will address the addition of martial art to exercise programs for intellectually disabled individuals, specifically Down syndrome. Balance and strength are two critical components for quality of life for an individual with Down syndrome, and an appropriately designed martial art program may be just the ticket.
1. Azegami M, Yanagihash R, Miyoshi K, Akahane K, Ohira M, Sadoyama T. Effects of multi-joint angle changes on EMG activity and force of lower extremity muscles during maximum isometric leg press exercises. J Phys Ther Sci. 2007; 19 (1): 65–72.
2. Barwick A, Smith J, Chuter V. The relationship between foot motion and lumbopelvic-hip function: A review of the literature. Foot 2012; 22 (3): 224–31.
3. Bird AR, Payne CB. Foot function and low back pain. Foot 1999; 9 (4): 175–80.
4. Bushman TT, Grier T, Canham-Chevak M, Anderson MK, Waajid M, Jones BH. Injury risk associated with functional movement screening in the United States Army. Med. Sci. Sports Exerc. 2012; 44: 842.
5. Cheung RTH, Ng GYF. Motion control shoe delays fatigue of shank muscles in runners with overpronating feet. Am. J. Sports Med. 2010; 38 (3): 486–91.
6. Cook G. Baseline Sports-Fitness Testing, in High Performance Sports Conditioning. In: Foran B, editor. Champaign: Human Kinetics; 2001.
7. Fong DTP, Hong YL, Li JX. Cushioning and lateral stability functions of cloth sport shoes. Sports Biomech. 2007; 6 (3): 407–17.
8. Herrington L. Assessment of the degree of pelvic tilt within a normal asymptomatic population. Manual Ther. 2011; 16 (6): 646–8.
9. Hillstrom HJ, Son JS, Kraszewski AP, et al. Foot type biomechanics part 1: Structure and function of the asymptomatic foot. Gait Posture. 2013; 37 (3): 445–51.
10. Hootman JM, Macera CA, Ainsworth BE, Addy CL, Martin M, Blair SN. Epidemiology of musculoskeletal injuries among sedentary and physically active adults. Med. Sci. Sports Exerc. 2002; 34 (5): 838–44.
11. Kiesel K, Plisky PJ, Voight ML. Can serious injury in professional football be predicted by a preseason functional movement screen? N. Am. J Sports Phys. Ther. 2007; 2 (3): 147–58.
12. Kirby KA. Biomechanics of the normal and abnormal foot. J. Am. Podiatr. Med. Assoc. 2000; 90 (1): 30–4.
13. Kosashvili Y, Fridman T, Backstein D, Safir O, Bar Ziv Y. The correlation between pes planus and anterior knee or intermittent low back pain. Foot Ankle Int. 2008; 29 (9): 910–3.
14. Lisman P, O’Connor FG, Deuster PA, Knapik JJ. Functional movement screen and aerobic fitness predict injuries in military training. Med. Sci. Sports Exerc. 2013; 45 (4): 636–43.
15. O’Connor FG, Deuster PA, Davis J, Pappas CG, Knapik JJ. Functional movement screening: predicting injuries in officer candidates. Med. Sci. Sports Exerc. 2011; 43 (12): 2224–30.
16. Teyhen DS, Shaffer SW, Lorenson CL, et al. The functional movement screen: A reliability study. J. Orthop. Sports Phys. Ther. 2012; 42 (6): 530–40.
17. Williams DS, McClay IS, Hamill J. Arch structure and injury patterns in runners. Clin. Biomech. 2001; 16 (4): 341–7.
18. Willson JD, Dougherty CP, Ireland ML, Davis IM. Core stability and its relationship to lower extremity function and injury. J. Am. Acad. Orthop. Surg. 2005; 13 (5): 316–25.
19. Zifchock RA, et al. Side-to-side differences in overuse running injury susceptibility: A retrospective study. Hum. Mov. Sci. 2008; 27 (6): 888–902.
© 2013 American College of Sports Medicine.
What does "Remember me" mean?
By checking this box, you'll stay logged in until you logout. You'll get easier access to your articles, collections,
media, and all your other content, even if you close your browser or shut down your
To protect your most sensitive data and activities (like changing your password),
we'll ask you to re-enter your password when you access these services.
What if I'm on a computer that I share with others?
If you're using a public computer or you share this computer with others, we recommend
that you uncheck the "Remember me" box.
Data is temporarily unavailable. Please try again soon.
Readers Of this Article Also Read