dynamic movement screening - sports motion, inc

Cont

Dynamic Movem

A functionobserving and ass

www.physical
ents
ent Screening al guide to essing movement

-solutions.co.uk

http://www.physical-solutions.co.uk/

2

Introduction p3

Interpreting Movement p5

Screening Classifications p7

Posture Evaluation p11

Gait Analysis p15

The Dynamic Movement Screens p18

General Screening Analysis p37

Specific Screening Analysis p39

Linking Findings Together p56

The Next Step p57

Physical Solutions Screening Form p58

Table of Contents

Screen Introd Historicand gamovemand strattempnothingtell the At the “sportsof assein termdistanc An altedown acan beable todevelopatternreactioonly arby the but in ssquat tthan a In realifunctiothe basbreak drehab chosen The teability control

3

ing Functional Movement Patterns

uction

ally, when evaluating a client beyond the cursory glance at their static posture it, most objective measurements have been based on single plane isolated ents. How far can you flex the shoulder? Can you touch your toes? Flexibility ength assessment was performed on an examination couch usually with an t to isolate the muscle. Although useful, given that fundamentally the body knows of muscles but only movement patterns, the information gained may not always

full picture.

other end of the spectrum, attempting to analyze a person while they are in motion” or a physical “skills” activity is a very difficult and complex task. This sort ssment understandably tends to be over-simplified and carried out and recorded s of quantitative performance. What is your best time? What is your best e? What is your best score?

rnative and complimentary approach to traditional assessment lies in breaking nd observing movement in common patterns that are fundamental to life. We come familiar with observing and testing movement in this way and we are better appreciate the asymmetries and imbalances that may exist and contribute to the pment of poor performance and chronic overuse injuries. These movement s reflect the way the body truly functions in life in relation to gravity, ground n forces and momentum. They are “foundation” or “primary” movements. Not e the joints and muscles working as a continuous system but they are controlled neuromuscular system to ensure kinetic chain integration…it can sound complex implistic terms this is all that they were designed to do. Therefore a single leg est tells us much more about the ability of the hip abductor's true functional ability side lying, resisted hip abduction, graded 1-5 ever would.

ty a movement screen could be any functional exercise or a component of a nal exercise. While appearing daunting at first, once you have mastered using ic movement screens the options open to you are endless and allow you to own movement, identify the dysfunction and apply an appropriate exercise or

strategy. You will also have a quick FUNCTIONAL test available to monitor your intervention’s progress.

sts will be graded by the comparison between the left and right sides and the to perform the entire movement successfully. An appreciation of the quality and of the movement will also be noted.

4

Ultimately, by testing with purpose and with an aim to form a strategy to improve movement quality, you can expect to not only decrease injuries but improve the base of flexibility and stability upon which strength and power can be built to improve performance. What follows is a simple battery of tests that are designed to give the assessor a clear impression of the functional movement qualities of their client. They are designed to highlight both strengths and weaknesses within the kinetic chain and to reveal potential faults and compensations. The tests are:

• Easily reproducible • Need minimal equipment • Based on primal foundation movement sequences • Applicable to all age groups and levels of fitness/ability

Variations of the tests outlined are already in use within the rehab and fitness industry and it is clear that movement screening will become commonplace within these fields. A great deal of credit needs to be given to innovative corrective exercise professionals such as Gray Cook and Gary Gray who have taken an understanding of movement screening to new levels. What am I looking for? Our approach to screening is all about asking and answering physical questions via movement:

• Can they hold the start position? Can they make the finish position? How do they make these transitions? What is their strategy?

• Have they the flexibility to make the shape? • Have they the stability to get there? • Do they show the correct timing of the movement sequence and can they

reproduce this? • Are areas of regional inflexibility exposed by the movement demand? • Are areas of regional weakness exposed by the movement demand? • Do we see compensations elsewhere in the movement sequence due to these

faults? • Do we see static postural observations revealing dynamic movement

consequences? • And perhaps, above all, are these findings symmetrical or asymmetrical?

Straight away you may be thinking this seems a long list and a big call…how can this process be made more accessible?

5

How do I interpret the movements? Answer these questions with exactly what you see and not what you assume you will see.

• When performing the screen give a minimal demonstration and use minimal language…don’t dictate how they should move, observe how they do move.

• Stand back and observe the global movement first. Get a feel for how the whole kinetic chain is working and the sequence and timing it uses to achieve the movement.

• Think in terms of movement success, failure and quality as well as expected range.

• Does the gross movement start and end from a position of stability? • Am I seeing comparable symmetry between left and right and upper and lower?

With any gross movement the whole is the sum of many parts. Hence screening can be a remarkably accurate tool but it is not an exact quantitative science. We are not taking precise goniometric measurements and we are not comparing isometric and myographic readings. But we are making quality observations. The big picture is made up of individual scenes. Stand back, look at the whole movement and get comfortable with trusting what you see. Think in terms of movement and think in your own language…

• “The left side seems to struggle with the pattern” • “The whole leg seems out of synch” • “That looks wooden from the hips up” • “That looks so smooth and easy” • “Something just isn’t right”

The last one is the big one and it’s the one that functional therapists, trainers and educators have been chewing over for years! You want to find out exactly what that something is…and usually quick. Sit back first and pat yourself on the back because you’ve recognized and recorded that something isn’t right…you’ve already got further than most in terms of true functional assessment. Don’t dive into the temptation to over analyze the movement screen that revealed this to you but carry on with the sequence of screens that you are comfortable with. The “something” will be revealed, proved or disproved with this more expansive approach. Repeating and revisiting screens you have already done may help you with this process. With experience in watching other people screen and doing your own screening with clients and colleagues, you will get a sense of what a full range and correctly performed individual screening movement looks like. You will develop an understanding of the benchmark shapes and capabilities and deviations away from this benchmark will be easier to recognize. Guidelines to help you will follow in this article.

6

You already have a powerful tool in your understanding of recognizing movement dysfunction. If, for example, the squat just doesn’t look right and your history taking and knowledge of the client’s physical health leaves you with no concerns, then you may proceed with a squat facilitation program based around corrective exercises with confidence (Gray Cook has done some excellent work in this area). If you perceive weaknesses in other more “global” issues such as balance, stability, timing or just plain lunges etc, then again you have some great places to start building your function-specific training program safe in the knowledge that you are addressing client-specific needs. The screening movements themselves are stand-alone tests of primary movement pattern ability or what can be termed foundation movements. If a client does not show us great ability at these foundation movements, then they are already starting from a point of disadvantage. You can ask and answer a simple question such as “Can they perform the movement?” You can ask and interpret a much more difficult question such as “How do they perform the movement?” Your initial findings may be in “generalist” but very useful terms. If we take the specific components mentioned before, stability, flexibility, balance and strength, you will start to see familiar presentations emerge. The following table is included only as a guide to help you with these observations and the “classification” examples are Physical Solutions' way of giving this simple recording structure. They are not definitive!!!

The dominant movement characteristics seen when performing dynamic movement screens

Classification

Large range-of-movement, loose but not fluent. Occasional loss of balance, screens not performed reliably with same ranges or symmetry. Loss of trunk control at end-ranges. Sacrificing stability for mobility (flexibility).

Flexi-unstable

Large range-of-movement, loose, rhythmical, well-timed. No loss of balance, screens symmetrical and reproducible. Good trunk mobility and control at end-ranges. Efficient stability and mobility (flexibility).

Flexi-stable

Poor range but can maintain balance within this range. Wooden, not expansive patterns. Fixed trunk postures, screens reproducible. Excessive limb movement at end-range. Great sagital ability but poor performance if transverse plane (rotation) is enforced. Rigid and un-functional stability at the expense of mobility.

Stabi-inflexible

Movement patterns are “shutdown” and un-expansive. Protective, poor range and frequent loss of balance. Avoids end-range. Poor movement “excursion”. Slow tempo. Poor flexibility and poor stability.

Unflexstable

7

Clearly we would like to see our athletes and clients screen “Flexi-stable” and on the other end of the scale the screening process actually gives you an opportunity to see how the “Unflexstable” client starts from a position of major disadvantage. The classifications can also give us some insight into movement dysfunction when we cross-reference them with balance and “strength”.

• Employ a balance challenge such as the Single Leg Wall Touch or Balance Reach to a Flexi-unstable and you may see end-range failure…they can get to an impressively flexible end-range but they can’t “bring it back home” and recover it reliably. At end-range (point of transformation) the movement chain will give the impression that it progressively collapses or cannot re-gird itself.

• The Stabi-inflexible is also in trouble at the end-range of his balance tests but for different reasons. He doesn’t have the range of the flexi-unstable and he comes to a more abrupt failure at his end-range. He literally “falls off” the movement screen as his foot is pulled off the stance position by pushing past his flexibility barrier (the movement failure is often seen distally at the foot/ankle)…he has no where else to go without pulling himself outside his base of support and outside it’s recoverable axis.

• The Unflexstable approaches balance with a protective strategy. He shuts down in both range and speed and tends to move in a piecemeal or “staccato” fashion with poor timing. The movement screen fails early with a predictive or almost “pre-prepared” dab of the free foot/hand.

• The Flexi-stable “gets there and comes back”. His screens have great range and timing and if they can improve they do so quickly with repetition.

Functional strength is difficult to quantify but possible to observe, especially when cross-referenced with the flexibility/stability classifications.

• The Flexi-unstable may show great muscle strength tests on the examination couch and isotonic installation, especially of the peripheral groups…quads, hams, lats etc. Their central instability and availability of “unstable” range betray this potential strength as the movement screen collapses or fails from proximal to distal. This is best seen in the lunges and squats as the movement begins to fail at mid-range. Observe it as a past half-way instability failure down into what would be an impressive range.

• The Stabi-inflexible is often a strong/athlete in every sense. Their problems lie in expression of their available strength. They lift the weights, they can super set the reps but they can’t transfer this into performance. Their times, distances and scores are disappointing. They do not reach a clearly obvious potential. The dynamic movement screens reveal this as a mechanical restriction of available force/strength. The squat is restricted, cannot be fully loaded and is unreliable at its disappointing end-range…they are down on their standing jump test and get beaten in the air at football!!

• The Unflexstable submits to gravity. Total body pronation may dominate what lunge and squat range they have. They will try and assist with compensations and trick movements such as hands on knees with lunges, sagital weight shifts in squats and increasing their base size unnecessarily.

8

• The Flexi-stable, if conditioned and trained well, is totally in control of their own body weight, mass and momentum. Timing and range of lunges and squats are reliably reproducible. The point of transformation in screens is easily recovered and reversed. Their strength is unrestricted in its physical expression.

The above classifications are a convenient way to clarify what you are observing as you interpret movement screens as a whole. However, an even deeper understanding of movement characteristics is possible.

Going into more depth It’s relatively easy to see the big picture but it can seem harder to break it down further. Any gross movement is a sequence of individual contributing regional movements meshed together with perfect range, timing, force and control…something commonly termed the “kinetic chain” performing at its coordinated optimum. It is possible to use the movement screens to assess how these individual segments of movement perform in a dynamic sense as opposed to standard isolated muscle group/joint length-tension and strength testing. From studying the screens and experience you will get a feeling of what should happen at a segmental level and from screening your client you will see what actually happens. Your attention is now brought to individual body segments, joints and even muscle groups as you observe them performing their role within the total movement screen. Are they contributing to the movement’s success or failure? This is one of the most contentious issues within movement screening studies. Some may argue that it is not possible to accurately interpret regional movement with dynamic screening at all. Some almost see this skill as an art form as they interpret the subtle nuances of a movement as a critic analyzes a masterpiece. At Physical Solutions we follow what is primarily a very conventional approach. Read around the literature, study the work of the trailblazers in this field, go to the lectures and then screen a few thousand people and you will notice something….patterns of dysfunction. The body is a remarkable machine but sadly no more remarkable than your modern automobile in terms of unreliability. The early Rover K series engine was known for blowing head-gaskets. It was a great engine but it just blew them. Bad news for owners but great news for mechanics because they know where to look first when one comes spluttering into the garage. The body also has its favored weaknesses and faults…they may have developed for different reasons but they are the same faults. By example, tight external hip rotators may have been caused by hours of clerical posture or hours of poor sprint training…two vastly different causes but exactly the same effect. The late Vladimir Janda’s studies of muscle imbalances recognized distinct anatomical regional syndromes of dysfunction highlighting the classic “length-tension”, inhibition and over activity patterns around the pelvic girdle and the shoulder girdles. It is not within the scope of this text to take on this huge topic but generally accepted examples can be seen throughout the body and come in distinct patterns such as:

• Tight and over active agonists inhibit their sister antagonists. • Inefficient proximal stabilizers fail to support their distal “effectors”.

9

• A lack of range in one segment will cause a compensation in another. • You lose what you don’t use…regional weakness, loss of transverse plane

stability. • You abuse what you overuse…pattern overload and plane dominance. • Stability, flexibility, balance and strength are interdependent upon each other. A

fault in one will be at the cost of another. The individual movement screens highlight different kinetic chain segmental contributions and possible dysfunctions. In many, if not most of the cases that you recognize, the screening movement is clearly faulty and there will be regional dysfunctions that follow the probable patterns listed above. Things are beginning to slot together now. We almost come to a cross-roads at this stage of summarizing approaches to movement screening:

• Do we go for a global movement “can they do it, can’t they do it” approach to our screening procedure? This effectively “pass or fail” system gives us clear parameters to act upon and its very strength is its simplicity.

• Or do we delve deeper into the nature and quality of each of the movement

screens and take on the challenge of interpreting the wealth of information that they can provide? It is difficult to make this decision without understanding the challenge.

Interpreting the results If you are new to dynamic movement screening a good strategy is to perform a test and simply make notes on the following observations Observations

• Note the overall quality of movement from in front, side-on and behind. • Note the symmetry of movement. • Note the point of transformation from descending to ascending or one direction to

the other direction. Start to observe more detail in specific regions

• What is happening at the head and neck? • What is happening at the shoulders and arms? • What is happening at the spine and pelvis/hips? • What is happening at the knees? • What is happening at the feet?

At this stage do not attempt to interpret the results; subsequent tests may confirm or disprove an imbalance in a particular region. When you have built up an overall picture from a variety of tests sit down and compare the notes and observations. These will invariable show the same problems continually resurface i.e. the head is protracted with

10

the squat and lunge, the right hip cannot extend with an anterior lunge or single leg overhead reach, there is poor trunk stability on inline lunge and step over chair. The more tests you use the more you will begin to see the client’s chosen movement strategy. If one or two areas are continually a problem, then fundamentally, these areas are worth tackling first with your corrective exercise strategy. It is quite likely that you will have identified familiar patterns of dysfunction. Various experts in the field have named and commented on these dysfunctions. Gary Gray uses the term ‘big rocks’ for these classic findings and, for example, one of his quotes is ‘if in doubt get the hips out’ as he muses on the common patterns found in the lumbo-pelvic complex. Vladimir Janda fired up the muscle imbalance field with his recognition of upper crossed, lower crossed and layer postural imbalances. Your corrective strategy can then be quickly re-assessed for success by repeating the screens. We believe this approach is ultimately more effective at understanding movement dysfunctions than simply following a “cookbook” approach i.e. ‘the knee deviates in therefore strengthen the glut med’. At Physical Solutions, when asking our clients to perform movement screens, we follow a procedure of describing the movement with minimum cueing and also a purposefully basic demonstration. Initially we are trying to ascertain what the client’s chosen movement strategy is. If necessary we will then add more basic prompts to guide the client towards the correct movement. We do not want to dictate to them how to perform the movement as we are trying to assess how they would truly utilize this movement within their own functional parameters. If any screen produces pain or reproduces painful symptoms, other than end-range discomfort, then consider the screen to have failed and take appropriate referral measures if indicated. We have purposefully repeated a basic method of movement observation as it becomes good practice to adopt a methodical approach that can become almost second nature after repeating many client screens. HOWEVER, ALL DYNAMIC MOVEMENT SCREENING IS UNDERPINNED BY: Static Posture Evaluation Prior to looking at a client’s dynamic movement a static posture evaluation should be performed. This should be both in terms of casual observation of seated posture, movement transitions and standing posture as you meet/interview/review the client and also a standard evaluation in standing. It is best to observe the client with as little clothing as acceptable and with shoes removed. The static posture is a cue as to what you may expect to see in a dynamic movement. We take our static postural build and trends into our dynamic movement. Alignment, symmetry, muscle groups, tension, flaccidity, compensations etc…all can be observed, both in their static and dynamic state. In terms of human function, to simply hold a standing posture is a clear function of the kinetic chain…the ability to bipedal stand is a unique reflection of homo sapien loco motor ability …”I stand therefore I am”. To simply

stand I need great balance, anti-gravity strength, coordinated antagonist/agonist co-contraction etc. It is as dynamic as it is static. We call it static posture for obvious reasons but we can be confident that it will reveal to us dynamic evaluation “cues”.

Norris (2000)

For optimal alignment in a static standing position imagine a plumb line hanging down from above the head, ideally a line would takethe following course through the body: • Ear lobe • Through bodies of cervical vertebrae • Tip of shoulder/acromion • Split chest in half • Through center of lumbar spine • Just behind hip joint • Anterior section of knee • Just anterior to the ankle joint

11

12

Ask the client to stand in their natural position with the feet level but slightly apart; stress that this is the position they should feel most comfortable in. They should not try to maintain a posture that they think is correct or what they think you want to see. From here the assessor can note any potential imbalances or asymmetry between the left and right of the body. It is worthwhile looking at the client from behind, the side and in front and from a distance. Make notes as you observe the gross structural landmarks.

Head

Deviated, Forward head (protruding chin)

Shoulder/arms/hands

Protracted or pointing in an anterior direction, palms pointing backward/forward, whole arm internally rotated, asymmetry.

Shoulder Blade

Winging i.e. lifted of the chest wall, protracted or elevated towards the outside of the back

Spine

Kyphotic, lordotic, sway back. Scoliosis.

Hip/pelvis

Anteriorly/posterior tilted, retracted on one side, torsion. Lateral shift.

Knee

Adducted, internally rotated, valgus, varus, recurvatum

Feet

Flattened, externally rotated, pronated, supinated

Postural Classifications

Norr It woreco“cuesum Lord • C• T

al

• H• C Swa • C• T

o

13

Lordotic Kyphotic Swayback Loss of spinal curves

is, (2000)

uld be fair to say that these common postural types are associated with gnizable patterns of dysfunction and muscle imbalance. These patterns are only a ”…do not take them as a “given” at this stage. There follows a very generalized mary of these possible dysfunctions:

otic Posture

lassic arched or ‘hollow back’ posture. he pelvis is tilted forward with probable lengthening and weakness of the bdominals and gluteals and shortening and tightening of the hip flexors and

umbar extensors. amstrings may be over-active and inefficient through full range. ompensatory upper imbalances are common (so called Kypho-lordotic posture).

y Back

lassic ‘slouched’ posture. he hip joint is pushed forward so that the greater trochanter lies anterior to the line f gravity.

14

• Lengthening of the hip flexors, but often inefficient over-activity as the body effectively hangs on the hip ligaments, anterior structures and eccentrically “excitable” hip flexors..

• Over-active rectus abdominus. • Inhibited gluteals. Kyphotic Posture • Round shouldered or curved back. • There is tightness in the pectorals and anterior shoulder structures and lengthening

in the lower trapezius and serratus anterior. • Compensatory forward head posture and short, dominant upper cervical

extensors. The static assessment has now started to bring attention to muscle groups. Think of these observations in terms of what “overlays” the body structure. Your attention is now drawn to muscle bulks, shapes, obvious increases and decreases in resting tone and visual landmarks. Symmetry…if there are two are they where they should be, do they look equal? Is the soft tissue hollow where it should be rounded or vice versa? As with many “physical” observations there are common findings that can be often noted and can commonly be systematic in their presentation but, again, do not take them as a “given”. Postural Morphology Common findings in anatomical ascending order:

Flat, hypotonic feet (pronated) or “fired up” rigid feet (supinated). Clawed toes. Over-active prominent peroneals. Prominent visually tight Achilles Tendon. Hypertrophied Tib. Anterior. Over-developed and bulbous vastus medialis. Visible Ilio Tibial Band. Hypertrophy and bulky distal half of the hamstrings. Often correlates with inhibited flaccid gluteals with uneven gluteal creases. Hollowing at the upper lateral gluteals (glute med. atrophy) Low lumbar paravertebral asymmetry. Multifidi wasting. Uneven lumbar skin creases. Prominent hinge point crease. Blowing of the lateral abdominal wall. Over active upper rectus. Lateral flaccidity. Prominent elevated low rib cage. Lower traps and rhomboid insufficiency and lack of bulk. Scapula winging, asymmetry. Upper traps convex, overactive, bulk. Levator notch. Upper cervical extensor bow-stringing tension. Pectoral hypertrophy, banding. Nipple level asymmetry. Prominent sterno-cleido-mastoids. Assymetrical head carriage. Deltoid flattening and angularity. Bicep increased tone. Chin to neck angle reduced.

15

These postural “cues” give a strong marker for areas of interest that we will be observing closely with the dynamic movement screens. They are, in a sense, predictive and as was mentioned previously, the findings and implications of a static postural evaluation may be reflected in dynamic movement performance. However, it cannot be emphasized enough that these are not recipes of definitive “cause and effect”. The whole point of movement screening is to accurately assess a client’s individual structural and movement characteristics. The following basic examples are simply guidelines only:

Postural Observation Potential Dynamic Implication Rigid high arched foot (supinated) Poor shock absorption and harsh

loading in lunges. Balance issues. Lack of “release” of the lower limb.

Visually tight Achilles and prominent soleus bulk

Restricted functional dorsi-flexion. Restricting squat and posterior lunge ability…limb “bale out”.

Gluteal flaccidity or wasting Poor lower limb pronation control…medial collapse on squat and lunges. Pelvic instability on step testing.

Lumbar extensor over-activity Retained lordosis during movement. Inability to get “through” hip extension…loss of ROM. Inhibited ineffective abdominal stability.

Anterior medially rotated gleno-humeral joint with low trapezius wasting.

Poor overhead raise range. Elevation of the scapulae early in movement cycle…poor timing.

Forward head posture and thoracic kyphosis

Poor wall rotation range, single leg stance instability in the transverse plane.

These are only six examples. Many of these presentations of weakness, restriction and over-activity will correspond to recognized postural dysfunctions and overload patterns. Some may be injury-specific or compensatory. However, none are definitive. Evaluation of Gait No movement screen would be complete without an observation of gait…..our most fundamental movement pattern.

Free joint mobility and appropriate muscle force increases walking efficiency. As the body moves forward, one limb typically provides support while the other limb is

16

advanced in preparation for its role as the support limb. The gait cycle (GC) in its simplest form is comprised of stance and swing phases.

To analyze gait without the use of motion analysis and slow motion video can appear a daunting prospect. The body will rapidly compensate for pathologies in order to achieve motion and do so in the most energy-efficient manner. To simply ask the client to walk a few steps up and down and expect to diagnose an abnormality is wishful thinking.

First, ensure the client is wearing the minimum amount of clothes necessary and view them with both shoes on and shoes off. You will need a decent amount of space so that the client can walk for 15-20 feet before the need to turn. Have them walk up and down a few times before you attempt to analyze their gait. This will enable them to relax into their normal gait pattern and prevent the cat walk poseur.

Fundamentally within a gait cycle, muscle function is designed to eccentrically control the rate of pronation throughout the limb and assist in absorption of the ground reaction forces, before stabilizing lengthening and re-loading into supination prior to the concentrically driven toe-off. How successfully is your client achieving this process?

Before you dive into specific areas get a general feel on how they choose to move. Do they look smooth and coordinated? Do they dominate in one particular plane i.e. excessive frontal plane motion or a lack of movement in the transverse plane? Is there an obvious limp? Are they heavy walkers or light on their feet? These obvious characteristics may be all you are able to see, in which case appreciate that the rest of the dynamic movement screen will break down movement patterns into more manageable units and ‘sniff out’ imbalances. However you can start to refine your analysis by focusing in on specific regions as seen with the static postural screen. In ascending order:

Foot and ankle

Do the feet flatten? Do they turn out? Does the foot slap down? Do they heel-lift early?

Knees Genu varum? Genu valgus? Does the knee hyperextend?

Lumbo-pelvic Asymmetry? Increased lordosis? “Blown” abdominals? Hip hikes? Trendlenburg?

shoulder Protracted? Elevated? Symmetrical? head Forward head posture? Tilted?

Many of the above observations have been discussed in the static postural screen however it is worth highlighting what may be seen with specific muscle weakness.

• Uncompensated calf weakness results in diminished mid stance control of the forwardly rotating tibia. Calf hypomobility/tightness or over-activity, curtails tibial advancement early through mid stance, the observation is often knee hyperextension. Other compensatory maneuvers include reducing step speed and step length.

17

• With mild pre-tibial weakness, foot slap occurs at heel strike. With more extensive dorsiflexion weakness, foot drop and toe drag are observed during swing phase. Compensation is achieved through circumduction of the ipsilateral limb, increased ipsilateral knee and hip flexion and possibly hip hiking to “clear” the weak side. Each of these tendencies assists in swing-phase toe clearance. Of these compensations, circumduction is the most energy-efficient and most commonly observed technique for dorsiflexor insufficiency. Note this exact same pattern of compensation can occur due to structural lack of dorsi-flexion/eversion.

• Quadriceps weakness diminishes knee control and deficits in stance are most pronounced. External forces tend to hyperflex the knee and a variety of compensations are employed to preserve stability in weight bearing. Apparent quadriceps weakness may often be attributable to poor lumbo-pelvic stability.

• Hip abductor weakness results in pelvic instability during stance. External forces (i.e., torso mass and momentum) lead to frontal plane rotation about the ipsilateral hip joint. This tilt is normally resisted by eccentric contraction of ipsilateral hip abductors (i.e., gluteus medius, minimus). Shifting the torso over the ipsilateral hip joint in mid stance (Trendelenburg gait) minimizes the force required by the hip abductors.

• Excessive anterior pelvic tilt with poor shock absorption at heel strike can implicate gluteal weakness, lower abdominal weakness and poor core control. This can be retained throughout the gait cycle.

Analyzing gait is potentially a difficult task but, as with all of movement screens, through repeated observations certain common patterns will emerge. Because gait is so fundamentally significant, it makes it the most natural movement screen and can potentially give us information regarding the client’s further movement characteristics.

18

The Physical Solutions Dynamic Movement Screens Note: We suggest referring to the accompanying video library for visual presentations of each of the following movements (videos in the library are identified using the same name as each movement section name). Squat with overhead raise The squat is a classic fundamental primal movement and a good place to start. The addition to the basic squat is to ask the client to concurrently lift the arms fully overhead while performing the movement. This will begin to highlight upper extremity dysfunction and possible faults in the relationship between upper and lower extremity. Squat characteristics

• Symmetrical movement pattern. • Load to unload throughout the chain. • Creates a dichotomy at the lumbo-pelvic junction. • Control of center-of-gravity over a stable base in the sagital plane. • Requires flexibility in the upper and lower extremities while maintaining proximal

stability.

Starting position End-range position Description of basic instruction:

• Feet approximately shoulder-width apart. • Hands wide grasp stick; keep arms/elbows straight throughout movement. • Descend as far as possible keeping heels on ground and return.

Already you may have gained a wealth of useful information; they may look great; smooth movement with no imbalances or asymmetries. While maintaining the arms vertically above the head they are able to descend fully onto their haunches, showing correct spinal posture with the feet straight ahead and heels on the ground. If not, make notes from the following observations Observations

• Note the overall quality and range-of-movement from in front, side-on and behind.

• Note the symmetry of movement. • Note the point of transformation from descending to ascending. • Note the degree of stability with which the movement is performed

19

Start to observe more detail in specific regions

• What is happening at the head and neck? • What is happening the shoulders and arms? • What is happening at the spine and pelvis/hips? • What is happening at the knees? • What is happening at the feet?

Anterior lunge with overhead reach The lunge is another fundamental primal movement. Various tests will be based around the lunge but altered in direction and with the use of additional components, in order to highlight various movement chains and expose segmental dysfunction. Lunge characteristics

• Dynamic load to unload with weight transfer. • Can be biased towards any plane. • Challenges lumbo-pelvic stability and flexibility. • Requires strength and stability in the lower extremity. • Overhead reach requires flexibility in the anterior sling system.

Description of basic instruction:

• Simple forward lunge just over normal stride length. • As lunge is carried out, raise stick overhead with straight arms to end-range. • It is not necessary to touch-down rear knee. • Immediately push out of the lunge and return to standing with the stick lowered. • Repeat alternates.

Observations • Note the overall quality and range-of-movement from in front, side-on and

behind. • Note the symmetry of movement. • Note the point of transformation from descending to ascending. • Note the degree of stability with which the movement is performed.



Posterior lunge with overhead reach Foot position with the posterior lunge can give some indication of any potential restrictions in two of the ‘big rocks’: the ilio-psoas and calf muscle groups. Both are eccentrically loaded during the test and any tightness can be highlighted. The influence of these upon the whole anterior sling system is also challenged. Lunge characteristics

• Dynamic load to unload with weight transfer. • Can be biased towards any plane. • Challenges lumbo-pelvic stability and flexibility. • Requires strength and stability in the lower extremity. • Overhead reach requires flexibility in the anterior sling system.

Description of basic instr

•••• Simple backward•••• As lunge is carrie•••• It is not necessary

be on ground. •••• Immediately push•••• Repeat alternates

uction: lunge just over normad out, raise stick overh to touch-down rear k

out of the lunge and r.

20

l stride length. ead with straight arms to end-range. nee but encourage whole of rear foot to

eturn to standing with the stick lowered.

21

Observations


• Note the symmetry of movement. • Note the point of transformation from descending to ascending. • Note the degree of stability with which the movement is performed.



Repeat on other side Inline lunge (with stick held along spine) With the inline lunge we are now pre-positioning the feet within a narrow base in order to expose pelvic and lower extremity dysfunctions. The stick serves the added purpose off maintaining a neutral position in the spine. This position will also test the ability to internally rotate at the hip joints. Inline characteristics

• Narrow base specifically challenges frontal plane stability • Internal rotation at the hip joints • Challenges lumbo-pelvic stability and flexibility • Maintain rear foot alignment on return from lunge

Start position End-range position

22

Description of basic instruction: • Feet “in-line” on a line marker. • Feet far enough apart to allow rear knee to touch behind front heel on lunge. • (Observe if rear foot can maintain this position even before lunge) • Stick in contact with back of skull, spine and between glutes; arms ext./int.

rotation to hold stick. • Keep spine vertical and in contact with stick as lunge is performed…prompt knee

to fall behind front heel and to touch floor. • Immediately return from lunge to in-line stance.

Observations





Repeat on other side Squat with rotation line touch This is an essential functional movement in terms of compound “anti-gravity” loading of the whole body with an emphasis on the transverse plane. It replicates generalized lifting technique with a multiple challenge to flexibility and chain loading. Squat/rotate characteristics

• Asymmetrical squat pattern. • Ability to internally rotate at the “lead” hip joint and load the external rotators. • Ability to release and pronate the trail leg. • Spinal coupled rotation and flexion with a thoracic rotation emphasis. • Full protracted loading of shoulder girdle. • Load to unload throughout the chain in an asymmetrical pattern.

23

Starting position End-range position Description of basic instruction:

• Feet shoulder-width apart, line bisects middle of feet (instep). • Prompt to touch line at side of foot with opposite hand. • Prompt to keep feet flat on floor and not to be rotated. • Observe initial strategy. • If necessary, prompt to deep bend knees as movement is carried out.

Observations





Repeat on other side Balance Reach /multidirectional leg reach From a single leg balance, the opposite leg is reached out to barely toe-touch in multi-directions (if the reach leg is planted onto the floor the test becomes a lunge). A simple star pattern can be placed on the floor with the use of masking tape. The test indicates the ability of a single leg to load when driven in multiple directions and the counter-reaction of the upper chain to this load. It can indicate deficits throughout the lower extremity chain.

Balance reach characteristics

• Ability to control center-of-gravity over a modified small base. • Ability to load throughout all the joints in the lower extremity. • In particular, demonstrates the loading strategy at the knee joint. • Initiates and challenges chain stability reaction in multiple planes. • Isolates stance lumbo-pelvic stability.

Starting position Vector point touches Description of basic instruction:

• Single foot stance in middle p• Reach with elevated foot alon

feather-touch it down onto lin• Allow arms etc to help balanc• Encourage greater range as s

Observations

• Note the overall quality and rabehind.

• Note the symmetry of movem• Note the point of transformati• Note the degree of stability w

Start to observe more detail in speci

• What is happening at the hea• What is happening the should• What is happening at the spin• What is happening at the kne• What is happening at the feet

Repeat on other side

24

oint of star if used. g selected line (or plane if not using star) and just

e/floor and then immediately return to start position. e reaction. creen progresses.

nge-of-movement from in front, side-on and

ent. on from descending to ascending. ith which the movement is performed.

fic regions d and neck? ers and arms? e and pelvis/hips? es? ?

25

Balance reach /multidirectional hand reach From a single leg balance stance, the opposite hand is required to touch-down in multi-directions. A simple star pattern can be placed on the floor with the use of masking tape. This test will require a significantly greater degree of loading through the hip joint and will test the ability of the hip to load and unload in all directions. Balance reach with hand characteristics

• Ability to load in flexion through the hip in multiple directions when the hand is used as the drive force.

• Ability to recover into full chain extension and back to starting posture. • Control and recovery of center-of-gravity direction and center-of-mass height

over a modified small base. • Posterior chain/sling flexibility. • Particularly requires accurate sequencing for success.


• Single foot stance in middle point of star if used. • Reach with opposite hand to stance foot along selected line (or plane if not using

star) and just feather-touch it down onto line/floor and then immediately return to start position.

• Allow arm and leg counter-balance etc to help balance reaction. • Observe initial strategy; may be necessary to prompt knee and hip flexion. • Encourage greater range as screen progresses.

Observations



26

Start to observe more detail in specific regions • What is happening at the head and neck? • What is happening the shoulders and arms? • What is happening at the spine and pelvis/hips? • What is happening at the knees? • What is happening at the feet?

Repeat on other side Multidirectional lunge Using the star pattern on the floor, the client will be asked to lunge along each vector and return with the foot of the lunge leg facing forward (the test can be repeated with the foot of the lunge leg turning out along the line of the vector). The test highlights the ability of the lower extremity to load and unload in a lunge pattern in multiple directions. Multidirectional lunge characteristics

• Tri-plane lunge ability. • Highlights flexibility and strength throughout the lower extremity during a

functional primal movement. • Ability to control transfer of their center-of-gravity outside the base of support,

recapture and return. • Opportunity to challenge force absorption and force production movement

strategy. Description of basic instruction:

• A more “freestyle” lunge screen in multi-directions. • Stance foot remains fixed and oriented forwards. • Lines and lead foot strike position will dictate certain lunge criteria i.e. posterior

diagonal lunge with foot fall following line would create external rotation at both hips (see second picture above) but lateral lunge with foot fall remaining oriented anterior and bisecting line would dictate lead hip is internally rotated (see first picture above).

• Multiple planar challenges are possible.

27

Observations





Repeat on other side Hip internal and external rotation The ability to rotate into internal and external rotation at the hip is vital in order to function optimally at the highest level. Unfortunately this motion is often restricted leading to compensations elsewhere in the chain. Various tests can be used to highlight dysfunction: the first is a test of restricted movement and the second is a test of motion AND control of that motion. Hip internal and external characteristics

• Tests the amount of hip rotation in a weight bearing position. • Highlights the ability of the lower extremity to pronate and supinate at each joint. • Highlights the kinetic chain reaction above and beneath the hip joint once its

range has been “used up”. Test 1

28


• Start with feet shoulder-width apart facing forward. • Lift one foot and maintain single leg stance. • Keeping the stance leg facing forward, rotate around that hip to toe-touch with

the opposite leg at the extreme of internal rotation and then external rotation. Test 2 Stand in single leg stance with the opposite knee flexed to 90 degrees at the hip and knee. A dowel rod can be held across the back at the level of the PSIS’s. Rotate the elevated leg around the stance leg to maximal internal rotation and then to external rotation. Observations

• Note the overall quality of movement from in front, side-on and behind. • Note the symmetry of movement. • Note the point of transformation from rotation to return. • Note the degree of stability with which the movement is performed.




29

Step-over test This test looks at the ability to stabilize through the lumbo-pelvic area in single leg stance while the opposite leg is taken through a tri-plane movement pattern. A challenge to functional dynamic stability highlighting the oblique sling systems. Step-over characteristics

• Single leg balance. • Stance lumbo-pelvic stability. • Lead leg open chain flexibility.


• Item chosen for step-over should be approximately height of client's knee joint…i.e. chair, stool, stacked steps etc.

• Stance foot is one foot's distance to the side of the center of object. • Other foot to be lifted over the object without touching it and feather-touched

down in front of it, then immediately lifted and returned to feather-touch behind. • Movement continually repeated.

Observations


• Note the symmetry of movement. • Note the point of transformation from touch-down to return. • Note the degree of stability with which the movement is performed.




Wall rotation variations

This is an easily reproducible test that can reveal the ability of the entire body to both supinate and pronate from the ground up throughout the chain. In this case the total body supination/pronation is driven primarily via the transverse plane. The test is initially performed in bilateral stance then repeated in single leg stance.

Wall rotation characteristics

• Ground up supination/pronation throughout the chain. • Total body compound rotation range-of-movement. • Momentum capture and recovery in single leg stance. • Dynamic balance.

Bilateral stance Single leg stance Description of basic instruction:

• 1) Stand heels against wall, then measure off and stand one fwall.

• Feet hip-width apart. • Arms bent 90 degrees at elbows, index fingers pointed. • Rotate around, keeping elbows by side, to touch wall with both• Repeat on opposite side. • 2) Set up as above then stand on one leg. • Rotate around to touch wall with left hand at chest height and

to touch wall with right hand. (i.e. internal and external rotationhip.

• To further challenge balance and momentum capture ask the each rotation 3 times in succession without dabbing down the

30

oot's distance from

index fingers.

then rotate around about the stance

client to perform elevated foot.

31

Observations • Note the overall quality and range-of-movement from in front, side-on and

behind. • Note the symmetry of movement. • Note the point of transformation from touch to return. • Note the degree of stability with which the movement is performed.




Postural wall hold

This test is used to identify dysfunctions and limitations in the upper extremity. While maintaining a neutral spine and pelvic position imbalances and range-of-movement limitations can be exposed above. With the wall as a reference point, symmetry is easy to compare and compensation easy to see.

Postural wall hold characteristics

• Pectoral, latissimus and shoulder girdle/joint range-of-movement. • Shoulder girdle orientation under load. • Spinal reaction to upper chain loading and vice-versa. • Stability compensations.


• Again, stand one foot's distance away from the wall. • Sit back against the wall, slightly flex knees, engage head, scapulae and pelvis

against wall.

32

• Move both arms flat against the wall and into a crucifix position with elbows bent to 90 degrees, fingers spread wide, back of hands against wall.

• Return back to starting position. • Elevate both arms overhead, thumbs interlinked, elbows straight, try and get

backs of hands flat to wall. Observations


• Note the symmetry of movement. • Note the body posture at spine, shoulders and neck/head as the full range is

reached and held. • Note the degree of stability with which the movement is performed.




Overhead posterior reach This movement performed from a single leg stance will examine the flexibility throughout the entire anterior chain/sling system. In particular, it will identify any restrictions in the hip flexor and the lumbo-pelvic reaction to any limitation. Post O/H reach characteristics

• Sagital plane restrictions in the anterior sling system. • Ability to load through the anterior sling system; in particular control of hip

extension via the hip flexor. • Posterior drive of mass and momentum.

Description of basic instruction: • Measure off and stand 2 foot's distance from wall. • Stand on one leg. • Reach back and overhead with opposite straight arm to touch wall behind and

then return to single leg stance. • Repeat 3 times off each leg.

Observations


• Note the symmetry of movement. • Note the point of transformation at touch to recover. • Note the degree of stability with which the movement is performed.



Repeat on other side Compo These abody fleto co-leintegrattype of

With the following additional screens, Physical Solutions uses a measure tape permanently affixed to wall and floor. This is a great tool and can be used for many purposes such as height records, vertical and horizontal jump measuring and other flexibility criteria.

33

und Flexibility

re two examples of a great technique to assess and compare functional total xibility. Functional flexibility is a reflection of the ability of linked muscle groups ngthen…total chain or sling, flexibility. Sport and athletic function requires ed rather than isolated end-range flexibility and stability, hence the value of this screen.

34

Lateral Compound Flexibility Description of basic instruction:

• Outside foot at right angle to floor tape, foot also flat to floor. • Lateral reach and lunge along the tape line and to the wall tape. • Just touch the tape. • Client must not lean against wall but must be able to “get there and come back”. • Work outside foot along tape until threshold is found and recorded. • Compare left distance with right.

Observations


• Note the symmetry of foot positioning. • Note the quality of the point of transformation at touch to recover. • Note the degree of stability with which the movement is performed.

Anterior Compound Flexibility Another total flexibility screen that is observable in terms of quality and also definitively measurable. The posterior and upper muscular chains/slings are targeted in this case.

35


• Anterior and posterior feet are aligned on the floor tape. • Above example is left foot back, right hand touch to tape. Same side hand touch

can also be assessed. • Just touch the tape. • Client must not lean against wall but must be able to “get there and come back”. • Work rear foot along tape until threshold is found and recorded. • The distance recording is taken from the tip of the big toe. • (a further recording can be the distance between both big toe tips…i.e. full

stabilized stride). • Compare left distances with right.

Observations


• Note the symmetry of foot positioning. • Note the quality of the point of transformation at touch to recover. • Note the degree of stability with which the movement is performed.

Push-up with rotation The push-up is a traditional exercise but can be used to assess scapular and shoulder girdle stability with a symmetrical upper limb activity and also with integration of lumbo-pelvic stability in the sagital plane. It places the upper extremities in a closed chain position which will expose potential scapular winging (instability) and dysfunction. The subsequent rotation will require additional control through a single shoulder girdle and test trunk stability in the transverse plane. The ability to load into this position is vital for full upper chain loading. Push-up with rotation characteristics

• Closed chain symmetrical shoulder motion. • Sagital plane trunk stability. • Transverse plane trunk stability. • Anterior shoulder and chest flexibility.

(If the client is unable to maintain a full push-up position, perform a push-up from all fours.)

36

Description of basic instruction

• Place one hand against the wall then measure out 4 hand widths along the floor tape.

• Assume a push-up position. • Perform one push-up then rotate towards the outside hand lifting this up and

round to touch the wall tape overhead. • Return to start position. • Turn to the opposite direction and repeat on this side.

Observations


• Note the symmetry of movement. • Note the point of transformation at touch to recover. • Note the degree of stability with which the movement is performed.



37

Analysis of the screens The screens demonstrated will provide a comprehensive analysis of the client's chosen movement patterns for a variety of functional movements and others that will target specific ‘big rocks’ where deficits are commonly seen. At first it may seem bewildering to identify dysfunctions particularly when you bear in mind there may be multiple problems. At this stage, step back and work through the following list making notes of what you see or feel. These are the broad observations not the specifics of each test. Start and finish positions ‘If you start from a poor posture you will finish in poor posture’ is a well-known quote used by many educators. Use the start position to identify the client’s adopted choice of static posture. Have they succumbed to gravity? Does the head protrude forward? Are they kyphotic in the spine? Which way does the pelvis tilt? Are the knees straight and level? What are the feet doing? Conversely, they may stand straight and balanced. The starting position will give you a good indication of what to expect with the movement screens and how successful they may well be, i.e. with a flexed kyphotic spine we may see decreased rotation evident on the wall rotation test. Again, at this stage, you do not need to try to interpret the findings but be aware of them and see if they are born out with the subsequent tests. It is no coincidence that we tend to associate the best athletes with a good base posture; this is their foundation for movement. Symmetry of movement An obvious comparison can be made between the right and left sides at all stages of the movement sequence. Simple comparison of symmetry can be most revealing. For example, often an old injury or operation may be responsible for a restriction in the chain or a compensation else where in the chain i.e. following an ankle sprain the client failed to regain full motion in the sub-talar joint and subsequently is unable to pronate effectively on that affected side. This process highlights the importance of obtaining a full past medical history although it is often the case that they only recall an old injury when prompted by your observations. Conversely, asymmetry can be a great indicator of potential for injury and an equally great lead into reasons for poor athletic performance. Do they have the flexibility? Simply put… ‘can they make the shape required’ …this will be a common observation; the client will struggle to obtain the shape or position demanded by the screen due to flexibility issues within the chain. Again, simply make a note of the observations and see if a pattern develops with further testing e.g. during the squat the foot turns out and this is seen again on the rear foot with a posterior/backward lunge.

38

Do they have the stability? Simply put… ‘do they have the control of the motion required’ …again you may well find the client is unable to hold a position or there is an obvious loss of motion form. i.e. the knee drives in or out with a lunge or the pelvis drops on single leg balance tests. Stability throughout the chain can only come from having a stable base. Proximal stability supports and enhances distal mobility, so weakness observations may give us an indication of the ‘core control’ of the client. This also extends to hip stability, which is tested with balance reach and lunge tests. Weakness in this essential ‘powerhouse’ of the body will have a knock on effect not only to the rest of the lower extremity but also to the shoulder and arm. Timing All efficient movement patterns have a relative timing. This is the correct sequencing of the components that make up that movement pattern and involves complex interplay between the articular, muscular and neural systems. Proprioceptive input from the vast network of receptors feeds into the system to ensure a coordinated smooth pattern of movement that starts and finishes at the correct time. Individual segments within the whole sequence can be mal-timed or even absent. In crude observational terms you have two extremes… are you dealing with a ‘motor moron’ who has a poor appreciation of efficient movement or does the client have the graceful movement sequences of a high level athlete? Compensations This is one of the most revealing aspects of dynamic movement screening and one of the most difficult to observe with other forms of musculo-skeletal assessment. In general terms the body will do everything possible to achieve the desired movement required. Therefore, to adjust for a deficit in one part of the chain, other areas in the body will compensate in order to get the movement done. A simple example would be the lumbar spine hyper extending on a posterior overhead reach to compensate for a tight hip flexor and an inability to extend the hip. A more subtle example would be observing a lack of ability to load the right shoulder girdle into protracted reach with an internal rotation wall touch and recognizing the left foot's inability to get out of pronation as setting up a pronatory “hold” on total body rotation loading above it as a potential contributing cause. At this stage you already have a wealth of information and, even if you go no further, you have plenty of places to start improving your client’s ability.

• Can I improve their posture? • They are not symmetrical and the old ankle injury needs addressing. • They are weak throughout the left side. • There is tightness in the calf, hip, shoulder. • Their balance and coordination is poor.

39

You could begin to address these deficits with a program and be reassured you are justified via movement analysis. Simply retest at intervals to note any improvement or need for program review. However, as you become proficient in this process, further information can be obtained from the individual screens. It may be necessary to become comfortable in your ability to regionalize rather than globalize your observations of the individual screen

Further specific findings Squat to overhead

• Is the test performed with symmetry? • Can they load evenly through the ankle, knee and hip joints? • Look for the spinal angle mirroring the tibial angle. • Can they maintain the arms overhead throughout the sequence? • Does the pelvis remain stable throughout? • Do the feet turn out or heels lift up?

This is a closed chain symmetrical test that can identify deficits throughout the kinetic chain. From the bottom up, the flexibility of the calf muscles are assessed. Can they fully dorsiflex the ankle joint while keeping the heels down and toes forward? Restriction in this muscle group may cause the heels to lift up and turn out; the foot may also pronate excessively in order to decrease the amount of muscle length needed. A block or restriction in any of lower extremity joints will be identified by a ‘glitch ‘in the movement or inability to fully load. This may simply be an old injury, bony block, arthritic joint and therefore require further investigation or referral to the appropriate source. The pelvis is caught in a dichotomy: can it maintain a neutral position or is it pulled anteriorly by tight erector spinae and a weak core? Does it tuck under too early or too far, at the late stage into posterior tilt, possibly suggesting short and dominant gluteals or hamstrings?

40

Moving up the chain, the shoulders and arms may well get dragged forward during the movement. As the pelvis tilts back, the latissimus muscle will be put on stretch and, if shortened, will pull the arms forward and into internal rotation. A protruding head posture may be seen as a result of prolonged poor posture coupled with upper crossed syndrome muscle imbalance. Poor tibial excursion, hips “over-flexing” to compensate, creating a strikingly horizontal spinal angle. Terrible form shown by a “stabi-inflexible” professional football player! Picture 3 shows a student at her end-range!…“all locked up with no place to go”. Anterior lunge with overhead reach

• Can they load smoothly and with control through the ankle, knee and hip joints? • Can they perform the lunge and return to the starting position without loss of

balance? • Are they able to elevate the arms above the head with the required relative

timing? • Does the pelvis remain in a neutral position as the lower extremity loads and the

arms elevate? As the weight is transferred forward onto the lunge leg any restrictions in the ankle, knee or hip joints will be exposed. Distance reached can also be compared between right and left legs to ascertain any deficits. The back foot is allowed to rise onto the toes but the front lunge leg should remain straight ahead, heel down allowing ankle dorsi-flexion. The front knee should drift slightly into medial deviation as it releases into pronation. Hip weakness or poor proximal stability may cause excessive medial deviation of the front knee joint well inside the foot and an inability to return to the upright position with control. Gluteal/piriformis dominance or ilio-tibial band tightness may cause the opposite lateral deviation of the front knee. If there is inadequate flexibility around the pelvis caused by hip flexor, adductor, piriformis or hamstring tightness the pelvis may pull into excessive anterior or posterior rotation; further tests can specifically examine which of these may be the limiting factor.

41

Driving the arms above the head limits the ability of the hip to load and will increase the amount of control required at the knee joint. Furthermore it will lengthen the hip flexors exposing tightness in this muscle group. Throughout this the pelvis must maintain a neutral position enhancing proximal stability. With overhead arm elevation, flexibility in and around the shoulder complex and potential reactive spinal compensations will be assessed. Excessive pelvic anterior shear due to tight or dominant lats and pecs firing up the thoraco-lumbar fascia can be seen with this screen. Further examination with the postural wall hold may well clarify this. Great ranges and form but loss of anterior stability as the front leg collapses excessively to the inside by this “flexi-instable” elite youth footballer. Posterior lunge with overhead reach

• Can they lunge backwards with simultaneous elevation of the arms overhead? • Do they have the flexibility and control to load evenly through the calf? • Do they have the flexibility in the hip flexor and stability in the core to maintain a

neutral pelvis? Posterior lunge with overhead reach will offer a chance to observe the ability to load through the back leg calf and then gauge the reaction of the anterior chain to this load. As the leg is driven backward the toes load first before the calf controls the descent of the heel and dorsi-flexion at the ankle joint. If there is restriction in this group the foot may well turn out as the body attempts to compensate for this. A tight or dominant hip-flexor may also cause the whole leg to “bale out” to external rotation as it is placed behind. The calf group and the hip flexors are closely allied. If there is restriction in one group, the other group is also often found to be tight. This test requires adequate flexibility in both and again this may be confirmed by squat to overhead and posterior overhead reach.

42

Similar observations as made with the posterior overhead reach can be made and similar pelvic and shoulder girdle flexibility/stability issues will be observed as in the anterior lunge with overhead reach. A semi-pro footballer shows us how a lower limb type screen can reveal upper limb dysfunction as he is forced into neck flexion, poking chin and upper limb lack of range and distortion. On the right a great example of rear foot “bale out”. Inline lunge (with stick held along spine)

• Can they maintain the vertical spine angle? • Can they descend fully and return to the start position without compensation or

rear foot bale-out? • Closely observe frontal plane stability.

Similar observations can be made to the anterior lunge screen, however this in-line screen presents more of a targeted challenge to stability and segmental alignment as the narrow base foot stance and spinal posture are pre-positioned. Restrictions around the hip and poor core control may see a forward lean of the trunk or an obvious increase in lumbar lordosis when compared with stick position…the pelvis being pulled into anterior shear. Poor ability to control the center-of-gravity over the narrow base will show as instability in the frontal plane and excessive frontal plane pelvic drift. Gluteal weakness may be exposed by excessive medial drift of the front knee, with the floor line being a good marker to gauge this by. Simply holding the start position with sufficient stride distance will be difficult if there is calf or hip-flexor shortening/dominance and in this case return from the lunge will be accompanied by a “baling out” of the rear leg, with the foot being pulled obliquely from the line. An excessive poking chin/forward head posture can also be seen against the stick as a marker.

43

Complete loss of spinal angle with the flexion seen mainly at the hips. The anterior view shows a medial “collapse” of the front leg. The whole screen displays a functional instability. ? Multi-directional lunge Similar criteria to above are observed but can be further challenged in all planes of movement. It is particularly useful to repeat the lunges on alternate legs to seek out asymmetries. Of special note is the ability to perform anterior lunges apparently easily but to struggle with the transverse plane vectors, a classic general finding in poorly conditioned or balanced athletes. A good example of asymmetry in the lead leg on a simple anterior lunge in a very strong athlete. Balance reach/multidirectional leg reach

• Can they control single leg stance? • Can they control displacement of the center-of-gravity smoothly and with control? • Highlights the preferred pronatory loading pattern of the stance leg. • Specifically, can they pronate in all three planes at the knee joint?

The start position of single leg stance with hands on hips is a simple challenge of balance ability and control of the pelvis, further highlighting gluteal or core weakness.

44

With the opposite leg reaching along the following vectors • Anterior • Antero-medial • Medial • Posterior-medial • Posterior • Posterior-lateral

The loading or ability to pronate throughout the lower extremity is assessed. Touch-down distance reached can be compared between the two sides. A tight or restricted calf muscle will limit dorsiflexion on the stance leg. The ability of the sub-talar joint to ‘unlock’ and pronate will be assessed, particularly with the antero-medial and medial balance reach. A rigid supinated foot will appear unstable when asked to pronate and the client may well lose balance or have restricted touch-down reach (excursion). The ability of the knee to load in all three planes is assessed. Following meniscal or ligament disruption, pronation of the knee with an antero-medial balance reach test is often limited or poorly controlled and can highlight a possible weakness that may be exposed in more dynamic activity/sport. Finally, hip control is assessed and we may see the pelvis dropping, as with a Trendlenburg sign or the trunk tilting over the stance leg, as with a reverse Trendlenburg. Single leg stance screens are always an indicator of the ability to control motion at the core and pelvis. A national elite tennis player shows us how he has fantastic range and the strength and athletic ability to “get there” on both sides but observe the asymmetry, pronatory collapse and stability compensations off the right leg. Range at the expense of stability…an injury indicator at all levels.

45

Link this screen with this athlete's previous multi-directional lunge shots. Note how his right leg instability creates a subtle trunk asymmetry and distortion and the need to look down for feed-back this time. The right leg falls into internal rotation and the pelvis tilts to the left. A great example of how screens can “talk” to each other in revealing dysfunction. A young footballer is comparing his medial anterior reach by toe-touch sliding weights along the vectors. He will get a visual appreciation of range. Balance reach/multidirectional hand reach

• Can they control single leg stance? • With hand reach, do they need to counter balance with the non-stance leg? • Are they able to reach in multiple directions smoothly and under control without

loss of balance?

The start position of single leg stance with hands on hips is a simple challenge of balance ability and control of the pelvis, further highlighting gluteal or core weakness.

With the opposite hand reaching along the following vectors

• Anterior • Antero-medial • Medial • Posterior-medial • Posterior • Antero-lateral • Lateral

46

The loading, or ability to pronate and supinate, throughout the lower extremity is assessed in particularly at the hip joint. Touch-down distance reached can be compared between the two sides. This test provides an opportunity to assess the ability to load through the hip in all 3 planes and the eccentric control of the calf, hamstring and back musculature. As the client reaches forward at the hip joint the whole of the posterior chain must decelerate the motion, stabilize and then be able to return the body to the upright position. Training of these muscle groups in this particular way is severely neglected in regular gym programs and hip weakness will commonly be identified by these tests. Poor eccentric loading control as the center-of-gravity is displaced forward may lead the client to lose balance or be unable to return to the start position. The upper limb reach also examines the protraction/retraction shoulder girdle ranges. For example, with a lateral reach off left leg stance, full right shoulder girdle protraction is required. This is a great test of posterior spiral chain (X-factor) ability as the left gluteals and right lat. dorsi. Load into their full movement coupling relationship. Both photos taken without moving the camera show an obvious asymmetry. The image on the left shows a comfortable flexion of the right knee, a good range along the antero-medial vector and an efficient spinal posture. The image on the left reveals a significantly reduced range, the left knee braced higher into extension, a corresponding kyphotic curve within the spine reflected in an alteration in head carriage and most surprisingly, a need to stabilize on the left leg with the left forearm against the thigh. This was a very interesting case and with further screening, subjective history and traditional testing it was found that he had extreme instability around the left hip and lumbo-pelvis. Hip internal and external rotation

• Do they have the ability to internally and externally rotate at the hip joint with the leg in a closed chain stance position?

• Do they have the ability to control, capture and recover this motion? • Can the foot provide adequate pronation and supination to set up the reaction

above?

47

A number of the movement screens will explore the ability to rotate at the hip joints. This is a common area where dysfunction can occur and, due to the importance of this region for efficient function, it needs to be examined closely and multi-dimensionally. This screen will drive rotation from the ground up. The ability of the foot to pronate and supinate will be assessed. A persistently supinated foot is a poor shock absorber and makes it more difficult to load throughout the entire chain into the correct pronation. Conversely a persistently over-pronated foot has “no where else to go” and is an equally poor shock absorber and can “hold off” the whole lower limb's ability to get out into force producing supination . Limited internal rotation at the hip is a common finding and these clients will often have tight hip flexors and may demonstrate this by walking in external rotation. Internal rotation is an important part of pronation and loading at the hip joint. With this limited, the client will be unable to take advantage of the strength and power derived from the hip in dynamic function and is at an increased risk of injury and compensation elsewhere in the chain. With the opposite leg flexed to 90 degrees and used as a marker, we can now see the ability of the hip to control loading into internal rotation. This will highlight the ability of the external rotators to eccentrically lengthen. Again, in function, these are a major source of dynamic stability and power production and are often weak but go un-noticed. On the opposite end of the movement chain, this screen will also highlight external rotation at the hip as the opposite leg rotates outward. Control of this motion is via the anterior short adductor/hip flexor complex and again, this motion is often deficient but goes un-noticed. A young footballer shows us he has great external rotation about his right hip but very restricted internal rotation. In the toe-touch test he shows us his compensation strategy of “baling” the right foot out into external rotation and employing excessive femoral adduction and trunk leaning in order to “get there”. On further testing and manual examination it transpires that this was a case of lack of pelvic/gluteal stability and not structural lack of range-of-movement.

48

Step-Over Test

• “Pylon” balance on stance side. • Lower limb pronation and supination patterns. • 3D pelvic stability, control of pelvis orientation. • Minimal trunk lean.

We are looking for an adaptable single leg stance base with a pelvis that raises, swivels and drops appropriately in all 3 planes of movement. The stance foot should pronate on the posterior touch-down with the tibia and knee following this movement and releasing to the inside medially. Conversely, on anterior touch-down, the stance foot should supinate, taking the tibia and knee with it to the outside laterally. Joint restrictions and bio-mechanical faults may be exposed by a restriction in these patterns. The hip is driven by these movements into external rotation with posterior touch-down and internal rotation with anterior touch-down. A tight or dominant stance side gluteal group may restrict the int. rotation with compensations seen as excessive knee flexion and a tendency to lean back to make touch-down. Weak stance side gluteals may show as an inability to elevate the opposite side of the pelvis and clear it during step-over. Excessive weakness or a lack of stability at the stance lumbo-pelvis may cause a noticeable trunk lean in the frontal plane over the stance leg (the reverse Trendelenberg Sign). A strong controlled lumbo-pelvis/core sees the trunk elongating on the stance side, keeping more vertical and keeping the center-of-gravity over the stance leg. Indications of the efficiency of the oblique slings, ipsilateral hip adductors, contra-lateral quadratus lumborum can also be noted in terms of pelvis frontal plane elevation control. Difficulty in clearing the step-over leg may reveal hip muscular/articular restriction. Note, a tight/dominant hip-flexor on the stance side may restrict pelvic extension and anterior touch-down ability on the opposite step-over side. In terms of balance ability, it is expected that most clients should achieve 3 continuous cycles of this screen without needing to dab the foot or stabilize. Further challenge the client and his progress with this screen by asking for more distance on the touch-downs. Some client’s movement strategy with this screen will be to use trunk forward/backward counter-balance. Modify their approach by prompting to keep the trunk vertical throughout the movement…this often reveals compensations and weaknesses that were hidden.

49

Two entirely different strategies to achieve the same screen…both equally dysfunctional. On the left a shocking combination of stance pronatory collapse, pelvic instability and compensations due to lack of range in an “unflexstable” client. On the right a rigid lumbo-pelvic strategy produces almost a reverse Trendelenberg. Both of these clients exhibited poor balance skills and an inability to complete this screen successfully. Wall rotation variations

• Which segments contribute most to rotation and which contribute least? • Compare supination mechanics on one side of the body to pronation mechanics

on the other. • Test transverse plane single leg stance balance…a cornerstone of athletic

function. • Observe if foot mechanics assists or holds-back the chain above. • Observe if any spinal rotational hypomobility influences the lower chain.

Is the actual range there to perform the screen? The upper spine and pelvis should show disassociation, with the shoulders overtaking the pelvis in terms of relative rotation. The arms should not need to excessively reach to make the wall. Do any of these segments show restriction or, conversely, does the thoracic spine show hyper-mobility? Observe how the “lead” rotation side girds into total chain supination to provide the foundation to rotate around. Expect the “trail” side to release into pronation at foot/ankle/knee/hip. Does the lead side fail and stay in pronation and does the trail side fail and remain held in supination. This is another screen that can help highlight hip dysfunction especially in terms of internal and external rotation. Single leg stance balance control in this transverse plane is often neglected in assessment, yet it is an essential component of athletic function and a cornerstone of many sporting techniques (throwing, hitting, kicking etc). Look at the above supination/pronation mechanics in terms of momentum control. Expect to see a slight decrease in rotation range in single leg stance but this should not be excessive…the

50

contribution of the hip is reduced as its muscle groups have to co-contract to maintain a stable core. Always carefully assess and expect high standards with the internal rotation single leg stance wall touch…it cannot be stressed enough how important dynamic internal rotation loading and unloading at the hip and lumbo-pelvis is to successful athletic function. Our “unflexstable” client shows us how he tears his knees, hips and ankles apart with marked knee hyper-extension, and almost total lack of lumbo-pelvic disassociation. Our rigid client also shows us a range asymmetry on that same right side as he can’t get “round” that right hip. Postural Wall Hold

• Can they complete the full range required? • Does the spine arch into compensation? • Palpate for tightness. • Pain as an indicator of end-range.

Inability to complete the full range of external shoulder rotation with abduction could indicate tight or dominant pectoral group, anterior\rotator cuff restriction or a capsular pattern of restricted motion. Old, or current, sub-acromial impingements may also be exposed.

51

A hypo-mobile thoracic kyphosis will significantly restrict range of both arm positions. Palpation of the tension within the pectorals and lats in relation to thoracic position will help distinguish this. A protruding head posture at end-range may be seen as a result of prolonged poor posture coupled with upper crossed syndrome muscle imbalance. This is a useful screen to expose tightness in the thoraco-lumbar fascia and over-active dominant lumbar extensors. Potential core weakness may also be indicated. In both arm positions, the lumbar spine may fire into, or be “dragged” into, excessive lordosis, with the wall providing a reference point to gauge this by. This screen can induce pain responses at end-range. This may be indicative of conditions such as shoulder impingement or facet impaction in the lumbar spine…appropriate measures or referral should be taken. No range, no way!! Note how the lumbar spine is also forced into lordosis Overhead posterior reach

• Can they control single leg stance with posterior weight displacement? • Have they got the flexibility in the anterior sling system to load overhead

throughout the chain? • Are they restricted in the hip flexor limiting hip extension? • Are they excessively loading in the lumbar spine?

This is another pattern that is neglected in training but often required in sport, i.e. overhead tennis serve, volleyball spike or catching a ball overhead. From single leg stance the center-of-gravity is displaced posteriorly as the client reaches backwards overhead. The anterior sling system is now required to have the flexibility to allow this motion and secondly to have eccentric control of this motion.

52

The most common restriction is seen in the hip flexors; tightness within this muscle group will restrict the ability of the hip to extend, which, in turn, throws the required motion further up the chain to the lumbar spine. Continual hyperextension at these joints can lead to symptoms of low back pain and potentially stress fractures in the younger athlete. This movement will also test the ability to extend through the thoracic spine. Sedentary activity often leads to a flexed rounded posture and loss of extension is common. Tri-plane motion of the thoracic spine is vital for efficient balance and is essential to pre-load and ‘switch on’ the abdominals. In order to efficiently utilize the abdominals they must be lengthened first in order to load eccentrically before unloading concentrically. If, with the above test, the hip, thoracic spine and shoulder have sufficient flexibility then control of this motion will be demonstrated with smoothly “timed” total body extension via eccentric action of the hip flexors and abdominals. ‘Switching on’ the abdominals with this action is a key component of athletic function. Our semi-pro footballer is forced to send that head poking even further forward and blows his chest but he can get “through” his hip flexor and his stance leg is comfortably flexed. The spinal and lumbo-pelvic rigidity has carried through three screens now with this client. He can’t get through his hip flexor at all. His flexible calf allows him to make the dorsi-flexion/tibial angle to get there but you can see it his knee that is taking the flexion “hit” as very little else contributes to his total body extension.

53

Squat with rotation line touch

• Can they get through the loaded internal rotation of the lead leg? • Does the trail leg release into pronation? • Do they employ a successful hip flexion strategy or do they overcompensate with

spinal flexion? • Does the whole spine couple into spinal rotation? • Can the shoulder be fully loaded under the head? • The feet should tilt on a longitudinal axis but should show no torsion about a

vertical axis. It has often been stated that flexion-rotation is the cause of back injury which is surprising when considering it is a perfect example of total kinetic chain function and is so common-place in all dynamic function. The fact that it is neglected in both terms of assessment, training and rehab is even more surprising. This test is easily reproducible and can reveal information on a client's movement selection and potential movement dysfunction. An initial “straight knee”, hip dominant flexion can reveal how the client is unhappy with coupling true flexion and rotation together…an un-effective protective strategy. The movement will show poor relative timing. Poor range and release of the hips will demand that the spine compensate and contribute “too much” to the whole screening pattern…it is this that puts the spine at risk. Spinal hypo-mobility and, in particular, loss of thoracic rotation, will lead to poor range. The knees are now at risk of torsional stress in order to compensate to “get there”. In this case to complete the screen the feet release into rotation or are dragged off the testing line. In the picture on left, his center-of-gravity stays well within his base and the movement is completed successfully with a strong neutral spinal posture. On the right, the range is similar but he has to outwardly rotate the whole right leg with the left lower leg driven inwards. To make the movement, the spine compensates into right side-bending and increased flexion, especially in the thoracic area.

54

Push-up with rotation

• Can they maintain a neutral spine while performing a push-up? • Is there winging of one or both scapulae? • Is the head excessively flexed or extended? • Are they able to smoothly rotate to open up one arm while maintaining correct

alignment? • Do restrictions in the anterior chest prevent them from opening up fully? This is a difficult but valid test, more frequently used in athletic populations. If clients do not have the control to open up to full rotation without collapsing assess them purely on the push-up and the many variations there-of. Simple leg extension from quadruped can be observed with similar criteria to the “push-up with rotation”. The push-up will require sagital plane trunk stability while performing a symmetrical upper limb exercise. Weakness of the posterior chest wall may result in the scapula appearing to wing or fan out. This may be a unilateral or bilateral finding. The trunk should be maintained in a neutral and stable position throughout the test. Inability to maintain this may result in the back dropping into extension/lordosis, with possible low lumbar impingement type discomfort. Conversely, the client may adopt a position with the hips “jack-knifed” higher in the air to avoid stabilizing through a weak core or enforced by overactive hip-flexors. As they rotate through the trunk and open up one arm, a high degree of stability is required in the single arm now in contact with the ground. Poor proprioceptive control in the shoulder joint will be exposed. Tightness through the anterior shoulder joint and chest wall, or pectoral dominance, may prevent full rotation and the ability to touch the wall tape.

An example of scapula winging, with the medial border of the scapula elevated bilaterally but clearly worse on the right side. This young gymnast had extreme gleno-humeral hyper-mobility and had suffered recurrent dislocations.

55

The same gymnast displays a great example of what gleno-humeral hyper-mobility looks like in a functional test. Performing an overhead posterior reach…no need to flex at the knee, no need to open out the hip flexor, no need to even employ spinal extension….compare with the two previous examples of overhead reach and you now see 3 different strategies for the same reproducible movement.

56

Linking Screens and Findings Together Inline Lunge Wall Internal Rotation Plain Squat Client: 50 year old ex-international equestrian competitor. History of equestrian falls and an old low back injury. Still competing at high level. Current problem is right, low grade, medial knee pain. Inline Lunge: Note right leg forward collapse medially (follow clothing lines). Whole of right side “compresses” with right side forward as lumbo-pelvic stability is lost. Also note head position pulled into flexion. Wall Internal Rotation: Loss of control; can get to the wall but struggles to stabilize on return. Uses a strategy of reaching back into excessive lumbar extension. Plain squat: Performed without overhead raise. This time the findings are not subtle at all. Right knee collapses to the “inside” (medially). Pelvis distorts into a frontal plane tilt, lower on the right. Ankle follows knee into excessive pronation at end-range squat. It was performed pain-free until final 10% of range (mild medial knee pain) and on transition to rising the knee deviated further inwards momentarily. On joint and muscle testing, there are no abnormalities at the foot/ankle and calf lengths are even. The screens suggest a possible weakness in the right gluteal group and loss of control of femoral movement in all three planes during dynamic weight bearing. The screens also show how this dysfunction manifests itself within the movement chain, with the right knee effectively “taking the hit” through no real fault of its own. Clinical testing of the right knee showed chronic medial laxity. Further functional testing and subsequent exercises did reveal reduced stability around the right hip and a clear functional strength asymmetry between right and left gluteal groups. There was no obvious structural problem with the right hip. Rehabilitation and treatment directed at this knee is unlikely to succeed unless the hip muscular imbalance and stability weakness is attended to. In this case the primary cause of the imbalance was not clear, although her previous history of falls and a tendency to sit “strong” on one side of the saddle when schooling horses as a young woman was cited. It is likely that her previous low back injury may also have inhibited this right gluteal group.

57

The Next Step This manual has summarized an approach to dynamic movement screening. Initially the assessment is approached in terms of movement only and the reaction and interventions that are decided upon from this screening process will also be in terms of correcting and improving this movement. Going deeper into the specific analysis, it was seen how accurate assessment of more isolated chains of movement, muscle groups and segmental body areas can be made and, again, exercise interventions can be ascertained from interpreting these findings. Once familiar with the screening process and comfortable with observing movement on these terms, it is easy to see that Gary Gray’s often used phrase “the test is the exercise and the exercise is the test” is indeed true. Any movement could be considered a screen, especially if the analysis of this movement follows the previous guidelines. It is not within the scope of this text to fully outline these interventions. We all have our own skills and professional specialties in exercise technique, applications and program design. We have performance-based training, postural techniques and rehabilitation skills. Some may be proponents of one type of stretching technique, others may favor another, etc. Essentially it doesn’t matter as movement screening is a process of movement dysfunction assessment and the subsequent corrective exercises that stem from this assessment do not have to be strictly protocol driven. This sort of assessment helps you to write the menu but it’s up to you to choose the recipes. The potential ingredients could be:

• Facilitate and strengthen weak and inhibited muscle groups. • Stretch and down-regulate over-active and short muscle groups. • Correct muscular asymmetries and imbalances. • Shift length tension relationships. • Postural correction. • Postural and dynamic stability training. • Neuro-motor training, Sensor-motor training. • Correcting faults in relative timing and movement sequencing. • 3 dimensional dynamic flexibility. • Specific foundation flexibility/stability/strength requirements.

Recognizing where all of the above fit into a relevant client-specific training or rehabilitation program is made much easier with prior screening of functional movement patterns.

Dynamic Movement Screen_____________________________

NAME: DATE:

Movement Screen Pass Inc. Fail Comments/Asymmetry Squat with overhead raise

Inline Lunge

R leg forward: L Leg forward:

Anterior Lunge Overhead Reach


Posterior Lunge Overhead reach


Squat Rotation Line Touch

To Right: To Left:

Postural Wall Hold...Crucifix and Overhead

Crucifix 90/90: Overhead:

Wall Touch Rotations

R + L Bilat: R stance Int: Ext: L stance Int: Ext:

Overhead Posterior Reach

Right: Left:

Hip Int/Ext Rotation in Stance

Test 1: Right: Left: Test 2: Right: Left:

Push-up (with rotation?)

Step-over

Right: Left:

Balance multidirectional reach…foot

Right stance: Left stance:

Balance multi-directional reach…hand


Multidirectional lunges


Lateral compound flexibility

To Right: To Left:

Anterior compound flexibility


dynamic movement screening - sports motion, inc

Documents