By Dave Gerbarg, DPT, CSCS, TPI
Testing is not the same as assessing. Screening is essential for sports injury management and risk assessment in athletes of all ages. It should be performed by a licensed and trained individual to ensure reliability. Patients can tell when structure is lacking and therapists are testing rather than assessing. This is an important distinction. Screening guides intervention to improve outcomes for patients and mitigate injury risk.
I operate a private outpatient physical therapy and sport prevention facility. My time is precious to me and to my patients, which means screening first to save time later. The tools I use include: general health screens, neuromuscular screens, outcome measures, and movement screens. If you are not screening, how are you narrowing your gaze? If you narrow too rapidly, things are missed.
The doctor of physical therapy education prepared me to perform every test and measure, and I could recite the psychometrics of each and correlating clinical prediction rules with ease. When thrust into the fast-paced outpatient therapy arena, precious time was wasted on measurement without proper screening. I was not prepared for real-world assessment.
The Selective Functional Movement Assessment (SFMA) was first introduced by Gray Cook, one of the godfathers of functional training, in his book, Movement, in 2010. Since publication, movement screening has exploded in popularity among physical therapists, personal trainers, and sports skills coaches. It has been adapted to meet the needs of personal trainers as the watered-down Functional Movement Screen (FMS) and golf professionals as the Titleist Performance Institute (TPI) screen. Researchers have supported efficacy in identification of injury risk of elite athletes, firefighters, and military—with limited support for young and amateur athletes. However, the SFMA is widely used in physical therapy assessments to determine causes of movement dysfunction and guidance for intervention.
How the Screens Differ
The SFMA incorporates many movement pattern tests regularly utilized by physical therapists. The tool provides structure to assessment, while requiring the observational skills and critical thinking of physical therapists.
The FMS has seven parts to look at the primary functional movements and to identify common impairments. These parts include the deep squat, in-line lunge, straight leg raise, hurdle step, shoulder mobility, push-up, and rotational stability.
In my practice, the FMS, SFMA, and TPI are all used to identify movement dysfunction in athletes. Developmental pattern, motor learning, and neuromuscular principles apply to both assessment and intervention. The goals of intervention are correct asymmetries to reduce pain, improve functional mobility, guide strength and mobility interventions, and improve athletic performance.
Titleist teamed up with Functional Movement Systems and Greg Rose, DC, to develop the Titleist Performance Institute, located in Carlsbad, Calif. The screen incorporates parts of the SFMA that correlate with the golf swing and golf-related injuries. The tool is used by healthcare providers, golf professionals, and personal trainers.
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Ball Dynamics International LLC
Cardon Rehabilitation & Medical Equipment Ltd
Core Energy Fitness
Fitter International Inc
General Physiotherapy Inc
Kinesio Holding Corp
Mad Dogg Athletics
N-K Therapy Products
NZ Manufacturing Inc
Power Systems Inc
Straight Arrow Products
Spirit Medical Systems
Trigger Point Performance Inc
Movement dysfunction is common. Work and lifestyle factors in today’s sedentary culture have caused an increase in postural and movement dysfunctions. Many of these issues go unidentified and untreated, leading to injury when participating in athletics. My experience is that lower-extremity and lumbar overuse injuries are often directly related to hip and thoracic mobility restriction, foot and ankle instability, or hip weakness (or all three). The truth is that these are often easily preventable.
Children do not have the same opportunities for play, and sport-specificity is happening at younger ages. Variability in movement is stunted at an earlier age as a result, and movement dysfunctions may be related to this. When children are participating in a single sport or activity at a young age, they are only subjected to the stresses of the given sport. They develop asymmetries in the kinetic chain, joint mobility restrictions, muscular imbalances, and then motor pattern dysfunction. A therapist is often only sought out after an athlete experiences pain or performance is impaired. Getting these young athletes in the clinic early for education can help reduce injury risk.
Early identification of movement dysfunctions or the respective risk factors is critical to athlete development. We utilize the SFMA and FMS screens with all of our teams to guide training programming and stretching/mobility routines with great success. Our athletes are anecdotally injured at a much lower rate with the implementation of pre-season and mid-season screening and education.
As mentioned earlier, the SFMA, FMS, and TPI screens are great tools for global movement assessment that guides intervention. The healthcare provider must understand and apply knowledge of the biomechanics of the sport, athlete demographics, and history to the findings. The result is a better awareness to approach mitigation of injury risk.
Video analysis technology is essential for today’s practitioner. The Hudl Technique (http://www.hudl.com/) app for smartphones is an excellent way to record and annotate video. A golf-specific version of the app is also available. Go Pro continues to dominate the action camera market, and is a great option for shooting video analysis, given the endless options for mounting and high resolution. To display your analysis on the big screen, the Apple TV is a great option.
Goniometers and inclinometers are still the primary measurement tools for physical therapists. The bubble inclinometer from Baseline is sharp and reliable. Using the gyroscope in your phone works as well, with the Tiltmeter (apple app store).
A wide variety of facility-based assessment technologies have been engineered especially for the physical therapy clinic. For example BTE, Hanover, Md, manufactures the Eccentron, an eccentric resistance strength trainer that includes onboard objective measures and results tracking. Likewise, BTE offers the PrimusRS multi-joint testing, orthopedic rehab, neuromuscular re-education, and advanced musculoskeletal athletic training of the upper and lower extremities and the core. Spirit Medical Systems Group, Nestle Road, Jonesboro, Ark, also offers rehabilitation treadmills, rehabilitation steppers, and rehabilitation bikes with instrumented decks.
Strategies for intervention of movement dysfunction run the gamut. Therapists should utilize a functional approach, with focus on the demands of a given sport in correlation with findings from the screen.
Proper warm-up following screening is important prior to intervention. Many athletes with knee pain prefer lower-impact work on an elliptical. Those with hip impingement or labral injuries should avoid excessive cycling, and will warm up on an elliptical as well. We use the ProForm Smart Strider. It remains quiet and has iFit compatibility for regulars.
The deep squat examines lower kinetic chain mobility, thoracic mobility, shoulder mobility, and hip stability primarily. When an athlete has excessive forward lean, this is commonly impaired hip stability. Variable resistance using TheraBand tubing from The Hygienic Corporation, Akron, Ohio, for assisted deep squat is an early intervention strategy. By providing assistance and allowing adequate posterior sway of the pelvis, an athlete can properly engage the posterior chain musculature. TheraBand mini bands are great for increasing lateral hip stability with variable resistance. An additional source of therapeutic latex bands and tubing, fitness balls and discs is Warminster, Pa-based Stretchwell Inc.
Functional hip stability is the goal. Athletes who score poorly on the deep squat, in-line lunge, hurdle step, or SL balance tests in your screens may have stability dysfunction. Neuromuscular deficits rapidly improve with minimal intervention. This often requires gluteal activation, and intervention can simply be supine bridging. However, for most athletes, the ultimate goal is functional hip stability. This means single-leg (SL) or some variation of single-leg strength. SL deadlifts using York kettlebells improves eccentric HS strength with hip stability. SL reaches and lunges on the Balance Disc from Trimax is great for SL dynamic balance. A wide variety of balance discs is also available from Minneapolis-headquartered OPTP. Another provider of balance and stability boards and stability discs is Fitter International Inc, Calgary, Alberta, Canada.
The shoulder complex is generally unstable, and is observed in upper quarter screening. Stability issues can result in subacromial impingement, RC tears, or labral tears—all common in the overhead athlete. With baseball, lacrosse, swimming, and volleyball athletes, I use KT Tape for lower trapezius excitation and postural awareness to increase joint space with overhead movement. The tape works well in water and can be applied with minimal education.
Many athletes present with navicular drop and excessive subtalar eversion that impacts their ability to adequately squat to depth. SOLE orthotics are a great OTC option to control navicular drop, while providing excellent calcaneal support to reduce eversion. At loading response of gait, landing, or SL stance, these OTC orthotics control tibial internal rotation at the foot. PTP
Dave Gerbarg, DPT, CSCS, TPI, is president of One Nine Sports Medicine and Physical Therapy in Solana Beach, Calif. His practice includes expertise in sports injury rehabilitation, sports injury prevention, rotational power development, and athlete counseling. For more information, contact [email protected].
Dallinga JM, Benjaminse A, Lemmink K. Which screening tools can predict injury to the lower extremities in team sports? Sports Medicine. 2012;42(9):791-815.