CES_CH1

MovementAssessments

Corrective Exercise Specialist

National Academy of Sports Medicine

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IntroductionMovement is the means by which we are able to perform all

activities, ranging from those necessary for daily living to job tasksand recreational enjoyment. Our ability to move is one of the most

important aspects of our existence. Recognizing optimum movement requiresa thorough understanding and application of Human Movement Science,specifically, functional anatomy, kinesiology, biomechanics, physiology, and motorcontrol. Understanding normal movement allows identification of abnormalmovement which can indicate possible muscle imbalances and correctivestrategies. This module will review the rationale for movement assessments,how to perform the Overhead Squat and Single Leg Squat movementassessments, and discuss how to correlate the findings of these assessments topossible muscle imbalances.

The Scientific Rationale for MovementAssessments

Movement assessments based upon sound Human Movement Science(functional anatomy, kinesiology, biomechanics, physiology, and motor control)are the cornerstone of a comprehensive and integrated assessment process. 1,2

Other assessments in this integrated approach include those for both muscle

length (goniometric assessment) and muscle strength (manual muscletesting).1,2

Movement represents the integrated functioning of many systems withinthe human body, primarily the muscular, articular, and nervous systems, asshown in Figure 1.1-3 These systems form an interdependent triad which, whenoperating correctly, allows for optimum structural alignment, neuromuscularcontrol (coordination), and movement. 4 Each of these outcomes is importantto establishing normal length-tension relationships, which ensure proper lengthand strength of each muscle around a joint.1,5,6 This is known as muscle balance.

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Muscle balance is essential for optimal recruitment of force-couples tomaintain precise joint motion and ultimately decrease excessive stress placedon the body.1-3,6 All of this translates into the efficient transfer of forces toaccelerate, decelerate, and stabilize the interconnected joints of the body, andis the source of the term kinetic chain is derived. "Kinetic" denotes the forcetransference from the nervous system to the muscular and articular systemsas well as from joint to joint, while "chain" refers to the interconnected linkageof all joints in the body. Essentially, the kinetic chain can also be considered thehuman movement system (Figure 1).

Figure 1:Human Movement System

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However, for many reasons such as repetitive stress, impact trauma,disease and, sedentary lifestyle, dysfunction can occur in one or more of thesesystems.1,2,6,7 When this happens, muscle balance, muscle recruitment, and jointmotion are altered leading to changes in structural alignment, neuromuscularcontrol (coordination), and movement patterns of the human movementsystem.1-5, 8-10 The result is a human movement system impairment and,ultimately, injury (Figure 2).1-6, 8-11

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Figure 2:Human Movement System Impairment

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The concept of human movement system impairment is importantbecause it is what is ultimately being evaluated with a movement assessment.A human movement system impairment is an alteration in the muscular,nervous and articular systems to function interdependently and effectively toperform there functional tasks.7,10 This includes alterations in:

❑ Length-tension Relationships: A change in the resting length of the muscles surrounding the joint.

❑ Force-couple Relationships: The ability of the muscles around a joint to be activated by the nervous system at the right time, with the appropriate amount of force.

❑ Arthrokinematics: The ability of a joint to move through its biomechanical range of motion.

When a human movement system impairment exists, there are musclesthat are overactive and muscles that are underactive around a joint (Table 1).1-

3,6,9,10 The terms "overactive" and "underactive" are used in this text to refer tothe activity level of a muscle relative to another muscle or muscle group, notnecessarily to its own normal functional capacity. Any muscle, whether in ashortened or lengthened state, can be underactive or weak.10 Underactivemuscles exhibit less than optimal force production capabilities. This results in

an altered recruitment strategy and ultimately an altered movementpattern.1,2,6,7,10,11 Alterations in muscle activity will change the biomechanicalmotion of the joint and lead to increased stress on the tissues of the joint, andeventual injury.1-4,6,9,10

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Table 1:Human Movement System Impairment

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A movement assessment allows a Health and Fitness Professional toobserve human movement system impairments including muscle imbalances(length and strength deficits), and altered recruitment strategies.2 Thisinformation can then be correlated to subjective findings and isolatedassessments such as goniometric and manual muscle testing. Collectively, thisdata will produce a more comprehensive representation of the client orpatient.

NASM Rationale for Overhead Squatand Single-leg Squat Assessments

NASM uses two primary movement assessments, the Overhead Squat(OHS) and the Single-leg Squat (SLS). The OHS assessment is a two-leggedsquat performed with the arms held overhead (Figure 3). This movementassessment was selected because it assesses total body structural alignment,dynamic flexibility, and neuromuscular control from a bilateral standingposture. Squatting requires optimal motion in the ankles, knees, and hips.Having the arms elevated overhead stresses the musculature surrounding theshoulder complex and increases the demand placed upon the core stabilizingmuscles.12

To perform the OHS correctly without compensation in structuralalignment (proper joint motions), one must demonstrate optimal and bilaterallysymmetrical dynamic range of motion at each involved joint (length-tensionrelationships) and optimal force-couple relationships (proper recruitmentstrategies). Based upon principles of Human Movement Science (functionalanatomy, kinesiology, biomechanics, physiology, and motor control), musclesknown to be prone to overactivity and underactivity, goniometric and manualmuscle testing data, we can surmise what may be overactive, underactive,and/or restricted from the movement compensation(s) seen during the OHSassessment.

Essentially, the OHS will provide an overall view of a client's length-tensionrelationships, force-couple relationships, and joint motion abilities. The OHSalso assesses a functionally applicable movement (the squatting motion) usedin everyday activities.

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Figure 3:Overhead Squat

The SLS assessment was selected because it assesses lower body dynamicflexibility and neuromuscular control as well as balance from a unilateralstanding position (Figure 4). The SLS provides a greater challenge to thelumbo-pelvic-hip complex as the base of support for the body has beenreduced. This forces the core and the proprioception mechanisms to workharder than when squatting on two legs. The SLS also assesses functionallyapplicable movements (squatting and balancing) used in everyday activities.

Figure 4:Single-Leg Squat

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Kinetic Chain Checkpoints Movement assessments require observation of the kinetic chain. To

structure this observation, NASM has devised the use of Kinetic ChainCheckpoints to allow the Health and Fitness Professional to systematicallyview the body during motion. The Kinetic Chain Checkpoints refer to majorjoint regions of the body and include:

1. Foot/Ankle2. Knee3. Lumbo-Pelvic-Hip Complex (LPHC)4. Shoulder and cervical spine (Upper Body)

Each joint region has specific biomechanical motion that it produces basedupon its structure and function as well as the joints above and below it.8,13

When that specific motion deviates from its normal path, it is considered acompensation and can be used to presume possible human movement systemimpairments (muscle imbalance).1,6,7,9-12

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Overhead Squat Assessment

Performing the OHS assessment is accurately achieved by following threesteps:

1. Set-up--how to position the client for best results and observation.2. Procedure--what the Health and Fitness Professional and client

must do to accurately perform the assessment.3. Observation--what the Health and Fitness Professional should be

looking for throughout the assessment.

Set-upSet-up for the OHS entails placing the client's feet straight ahead,

approximately hip- to shoulder-width apart with arms raised above their headas shown in Figure 5.

Figure 5:Set-up position for OHS

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ObservationThe observation for the OHS will be specific to each view and involve

observing Kinetic Chain Checkpoints for given movement compensations. Asa reference point for your observation, Figure 6 demonstrates what an "ideal"OHS should look like.

Figure 6:Ideal OHS, anterior / Ideal OHS, lateral

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ProcedureThe OHS assessment consists of performing a series of squats (5 per

view) with the hands raised overhead. The hands will remain overhead for theduration of observation for each view and the client should squat to a depthof the average chair-seat height. The OHS will be observed from 3 differentviews, anterior, lateral, and posterior.

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Anterior ViewThe observation will begin by viewing the client squatting for 5 repetitions

from the anterior view. From this vantage point, the Health and FitnessProfessional will be observing two main checkpoints, the feet and knees, forspecific compensations shown in Table 2.

Figure 7:Kinetic Chain Checkpointsfor the Anterior View

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Table 2:Kinetic Chain Compensations for the Anterior View

*Note: The TFL is implicated as being overactive in both the knee movinginward and outward, which may seem to be a contradicting statement. The TFLis a major abductor of the femur and is noted as being overactive when thegluteus medius and/or maximus are underactive.1,13,14 In this case, combinedwith the underactivity of the adductor complex, the movement deviation isdifferent.Thus it can be implicated in either scenario. Likewise, the underactivityof the gluteus medius and/or maximus is also shown in both cases. The gluteusmedius and/or maximus have been shown to be prone to underactivity and

when underactive lead to synergistic dominance or overactivity of othermuscles.1,9,14 Overactivity (synergistic dominance) of the TFL, piriformis, andbiceps femoris can all stem from or lead to underactivity of the gluteusmedius/maximus because they are each a functional synergists to the glutealcomplex.1,9,14

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Feet:Turn OutThe feet should be aligned straight ahead, meaning that the second

metatarsals of each foot should be parallel to one another as if standing onsnow skis. When compensating, the feet will display a few positional deviations,one being that they will turn out, or externally rotate, relative to their startingposition. Figure 8 demonstrates ideal foot alignment and what "feet turnedout" typically looks like.

Figure 8:Ideal / Feet Turn Out

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When this compensation is noted, it is generally the collective motion ofthe foot/ankle and lower leg, as they are all connected. Therefore, thedisplacement of the foot will more than likely be a result of altered lower legmotion/alignment.Table 2 lists the probable structures that could be overactiveand underactive. The soleus, lateral gastrocnemius, biceps femoris, and TFL allattach to the lower leg and have the ability to produce external rotation of thelower leg.13,14 If overactive, each and/or all of these muscles can lend to theproduction of this compensation.

In conjunction, the medial gastrocnemius, medial hamstrings, popliteus, andgracilis produce internal rotation of the tibia (and counter the list of overactivemuscles) to help maintain normal tibial position. If underactive, they will beineffective and allow the tibia to externally rotate leading to the compensationof the feet turning out. The gluteus medius and/or maximus muscles are alsoimplicated in underactivity and when they are the TFL and biceps femoris oftenbecome synergistically dominant.1,14

Knees: Move InwardDuring movement the knees should remain in line with the second/third

metatarsal of the foot. When compensating, the tibial tuberosity will eithermove inside the first metatarsal of the foot or outside the fourth metatarsal ofthe foot. Figure 9 demonstrates ideal knee alignment and what the kneesmoving inward will typically look like.

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This compensation consists of the femoral adduction (internal rotation)and/or tibial abduction (external rotation). Table 2 lists the probable structuresthat could be overactive and underactive. The adductor complex, bicepsfemoris (short head),TFL and lateral gastrocnemius all affect either the femurand/or the lower leg, and when overactive can cause this altered knee position.14 In conjunction, the medial hamstrings (particularly at the knee), gracilis,popliteus, medial gastrocnemius, and the gluteus medius and/or maximus aremuscles that when underactive will allow the femur to adduct (internallyrotate) and/or lower leg to abduct (externally rotate).14

Figure 9:Ideal / Knees Move Inward

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The biceps femoris (short head),TFL, and lateral gastrocnemius each crossthe knee joint (tibiofemoral joint) laterally. When overactive compared to themedial structures, they laterally pull the femur and lower leg closer together inthe frontal and transverse planes.14 Without adequate medial support, the kneeis virtually pushed inward resulting in the "Move Inward" compensation.

Knees: Move OutwardFigure 10 demonstrates ideal knee alignment and what the knees moving

outward will typically look like.

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Figure 10:Ideal / Knees Move Outward

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This compensation consists of the femoral abduction (external rotation)and/or tibial adduction (internal rotation). Table 2 lists the probable structuresthat could be overactive and underactive. The bicep femoris (long head),piriformis,TFL, gluteus minimus and medius all have an effect on the femur andwhen overactive can cause this altered knee position.14 In conjunction, theadductor complex, medial hamstrings and the gluteus medius and/or maximusare muscles that when underactive will allow the femur to abduct and/or lowerleg to adduct.14

Lateral ViewFollowing the completion of the anterior view, the client will turn to

his/her left so that the Health and Fitness Professional will next be observingthe right side of the client. The client will again squat for the desired numberof repetitions. From the lateral view, the Health and Fitness Professional willbe observing two main checkpoints, the LPHC and upper body, for specificcompensations shown in Table 3.

Figure 11:Lateral View

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LPHC: Excessive Forward LeanDuring the descent into the squat, the trunk line (imaginary line running

from the greater trochanter through the humeral head) should remain parallelto the lower leg line (imaginary line running from the lateral maleous through

the lateral tibial condyle). Figure 12 demonstrates ideal trunk alignment andwhat a forward trunk lean would typically look like.

Table 3:Lateral View

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Figure 12:Ideal / Excessive Forward Lean

This compensation involves primarily the LPHC and ankle complex and isevident by the excessive inclination of the trunk line relative to the lower legline. Table 3 lists the probable overactive and underactive muscles involved.The soleus, gastrocnemius and/or the hip flexor muscles are typicallyoveractive and help produce this compensation. To perform the squat properly,both the ankle and hip complexes must work/move together to flex andextend the ankle, knee, and hip structures.15 If the ankle lacks dorsiflexionduring the descent (overactive calf musculature) then more hip flexion will berequired (overactive hip flexors).

In conjunction, the anterior tibialis, gluteus maximus and erector spinaemuscles may be underactive. In an underactive state, the anterior tibialis willnot be as capable of assisting in pulling the tibia forward over the foot to createproper dorsiflexion. The underactivity of the gluteus maximus and/or erectorspinae will not be able to effectively decelerate the trunk and hip from flexingand further allow the trunk to continue forward.

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Figure 13:Ideal / Low Back Arches

LPHC: Low Back ArchesFigure 13 demonstrates ideal low back alignment and what a low back

arching would typically look like

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This compensation involves anterior rotation of the pelvis and extensionof the lumbar spine. It has also been termed lower or pelvic crossedsyndrome.6 Table 3 lists the probable overactive and underactive musclesinvolved. The hip flexor muscles, erector spinae and latissimus dorsi musclesare typically overactive and help produce this compensation. When activated,

each of these muscle groups is capable of anteriorly rotating the pelvis and/orextending the lumbar spine.9,10,13 In conjunction, the intrinsic core stabilizers(transverse abdominis, multifidus, internal oblique, transversospinalis, and pelvicfloor muscles) and gluteus maximus are typically underactive.9,12,14 Thesemuscle groups help to counter the pelvic and lumbar spine motions and whenunderactive cannot provide sufficient stabilization to overcome thiscompensation.

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LPHC: Low Back RoundsFigure 14 demonstrates ideal low back alignment and what a low back

rounding would typically look like.

Figure 14:Ideal / Low Back Rounding

This compensation involves posterior rotation of the pelvis and flexion ofthe lumbar spine. Table 3 lists the probable overactive and underactive musclesinvolved. The hamstring muscles, adductor magnus and abdominal muscles aretypically overactive and produce this compensation. When activated, each of

these muscle groups is capable of posteriorly rotating the pelvis and/or flexingthe lumbar spine.13 In conjunction, the intrinsic core stabilizers(transverseabdominis, multifidus, transversospinalis, internal oblique, and pelvic floormuscles) erector spinae, and gluteus maximus are typically underactive. Thesemuscle groups help to counter the pelvic and lumbar spine motions and whenunderactive cannot provide sufficient stabilization to overcome thiscompensation.

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Upper Body:Arms Fall ForwardDuring the OHS, the arms should remain over the head in an elbow

extended position. Figure 15 demonstrates what arms falling forward wouldtypically look like.

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Figure 15:Ideal / Arms Fall Forward

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This compensation is characterized by extension of the shoulder and/orflexion of the elbow especially during the descent. Table 3 lists the probableoveractive and underactive muscles involved. When contracted, the latissimusdorsi, pectoralis major and minor and/or the coracobrachialis muscles will pullthe shoulder into extension and/or create elbow flexion when the arms are inan overhead position. In conjunction, the middle and lower trapezius,rhomboid, posterior deltoid, and rotator cuff muscles function to providestabilization to the scapula and shoulder girdle preventing it from fallingforward. When these muscles are underactive they cannot counter the pull ofthe overactive muscles and the arms will fall forward and/or the elbows willflex.

Posterior ViewFollowing the completion of the lateral view, the client will again turn to

their left so that the Health and Fitness Professional will be observing the clientfrom the posterior view. The client will again squat for the desired number ofrepetitions. From the lateral view, the Health and Fitness Professional will beobserving two main checkpoints, the feet and LPHC, for specificcompensations shown in Table 4.

Figure 16:OHS, Posterior View

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Table 4:Kinetic Chain Compensations for the Posterior View

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Feet: FlattenDuring the descent of the squat, the foot/ankle complex will demonstrate

slight pronation, but the arch of the foot will remain visible. Pronation is acombined motion consisting of dorsiflexion (primarily in the talocrural joint),eversion and abduction (primarily in the subtalar joint and transverse tarsaljoints).13 Figure 17 demonstrates ideal foot alignment and what flattening feetwould typically look like.

Figure 17:Ideal / Feet Flatten

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This compensation more technically refers to the increased frontal plane(eversion) and transverse plane motion (abduction) of the foot/ankle thatresults in a collapsing of the medial and longitudinal arches of the foot (or, over-pronation). Table 4 lists the probable overactive and underactive musclesinvolved. When contracting or overactive, the peroneal complex and lateralgastrocnemius are both capable of causing the foot/ankle to evert and/orabduct. The biceps femoris (short head) and TFL can also cause the lower legto abduct which can perpetuate eversion of the foot/ankle.14

In conjunction, the anterior tibialis and posterior tibialis arguably have thegreatest effect on the arch of the foot. This is especially true of the posteriortibialis with its multiple and diverse attachment sites. When underactive thesemuscles cannot provide the necessary plantar support for the foot duringpronation. Also in an underactive state, the medial gastrocnemius, medialhamstrings and gluteus medius cannot counter the eversion of the foot/ankleand abduction of the lower leg which can further perpetuate thiscompensation.

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Feet: Heel RiseDuring the descent of the squat the ankle must produce adequate

dorsiflexion to allow the tibia to move forward over the foot (in primarily thesagittal plane) to effectively control the center of gravity to remain in anoptimal upright squat position. Figure 18 demonstrates ideal foot alignmentand what heels rising would typically look like.

Figure 18:Ideal / Heels Rise

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This compensation consists of the inability of the talocrural joint to moveoptimally through a full range of motion. Table 4 lists the probable overactiveand underactive muscles. It has been previously stated that the talocrural jointfunctions primarily in the sagittal plane.13 This, combined with a bent knee duringthe squat, would dictate that when overactive the soleus muscle would be themost restrictive muscle. In conjunction, the anterior tibialis when underactivewould assist in a decreased ability to move the tibia forward over the foot. Ifthe knees continue to travel forward, this will in essence pull the heels up.

This compensation is often seen in individuals who lack dorsiflexion and are"knee" squatters - meaning that they squat primarily from the knee and ankle,not the hip and ankle. A knee squatter will try to maintain an upright or evenvertical trunk while bending the knee to lower the body into a squat position.When asked to keep their feet flat on the ground, they will often demonstrateexcessive forward lean and/or other foot compensations.

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LPHC:Asymmetrical Weight ShiftOne of the purposes of performing a two-legged squat is to note the

symmetrical motion of each side of the body. If one side is limited in motionand/or strength it will create an asymmetrical movement pattern most notablethrough the LPHC. Figure 19 demonstrates ideal LPHC alignment and what anasymmetrical weight shift would typically look like.

Figure 19:Ideal / Asymmetrical Weight Shift

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This compensation is perhaps the most complicated and can result from anumber of situations. Table 4 simplistically lists the probable overactive andunderactive muscles involved. When an asymmetrical shift occurs to the right,the LPHC will demonstrate adduction on the right side (femur and pelvis movecloser together) and abduction on the left side (femur and pelvis move fartherapart). In this case, the right adductor complex and left TFL and piriformis areoveractive and essentially pulling the LPHC into an asymmetrical position. Inconjunction, the right gluteus medius and left adductor complex are consideredunderactive as they are unable to counter the asymmetrical shift and thus allowit to occur.

Other possible contributors to an asymmetrical shift include asymmetricaloveractivity or restriction in the foot/ankle complex. If one foot/ankle is morerestricted than the other it typically will not allow that lower leg to moveforward (dorsiflexion) appropriately and result in asymmetrical motion fromthe feet up. Also, often time there will be an asymmetrical restriction in the hipflexor and hip extensor complexes. For example, the right hip flexor complexand left hip extensors may be more overactive and this can result in anasymmetrical rotation of each ilium (the right side rotating anteriorly and leftside rotating posteriorly).14 With each ilium having different degrees of flexionand extension (due to asymmetrical rotation) and the squat requiring flexionand extension as primary motions, this can lead to an asymmetrical shift.

OHS SummaryTable 5 provides an overall summary of Tables 2-4 with a list of possible

injuries that can typically occur with each compensation. However, it isimportant to remember that the kinetic chain is an interconnected system inwhich each joint can dramatically affect all of the others. In this case, eachcompensation could in essence lead to any of the mentioned injuries.

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Table 5:OHS Movement Assessment Compensations

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Modifications to the Overhead SquatAssessment

There are a couple of modifications to the OHS assessment that theHealth and Fitness Professional can make to gain a clearer picture of thepossible overactive and underactive muscles. These include elevating the heelsof the client as shown in Figure 20 and 21 and performing the OHS assessmentwith the hands on the hips as seen in Figure 22 and 23.

Figure 22:OHS Assessment,Hands on hips

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Figure 23:OHS Assessment,Hands on hips squatting

Figure 21:Heels Elevated Squat

Figure 20:Heels Elevated Set Up

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Elevating the heels does two primary things. First, it places the foot/anklecomplex in plantarflexion which decreases the stretch (or, extensibility)required from the plantarflexor muscles (gastrocnemius and soleus). This isimportant because deviation through the foot/ankle complex can cause manyof the deviations to the kinetic chain especially the feet, knees, and LPHC.Second, it alters the client's center of gravity (CoG) by decreasing the base ofsupport (less/shorter contact surface of the foot on the ground) and shiftingthe CoG forward. When the CoG is moved forward it allows the client to sitmore upright or lean back more. This is also important because with lessforward lean there will be less hip flexion needed and less emphasis placed onthe LPHC. In all, this modification allows the Health and Fitness Professional tosee the influence the foot/ankle has on the client's deviations.

Placing the hands on the hips directly removes the stretch placed on thelatissimus dorsi, pectoralis major/minor and coracobrachialis and requires lessdemand from the intrinsic core stabilizers. This allows the Health and FitnessProfessional to see the influence the upper body has on the client'scompensations.

Interpreting the Findings of a ModifiedOverhead Squat

When using the modified versions of the OHS assessment, it is importantto understand what the findings reveal about the client's movement. After anOHS has been performed, the modified versions can be used to clarify or helppin-point specific areas to focus on by process of elimination. For example, aclient may demonstrate any of the listed compensations (Table 5), particularlyto the feet, knees, and LPHC. Then, when he/she performs the OHS withelevated heels the squat dramatically improves and looks close to ideal. Thisfinding points to the strong possibility that the foot/ankle may be the primaryregion to focus the corrective strategy on because when removed from themovement (heels elevated) the squat is executed more efficiently.

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Conversely, if the squat does not make any significant change when theheels are elevated, this would suggest the high probability that the LPHC is theprimary region to target a corrective strategy because the removal of thefoot/ankle variable did not make a difference. Since squat mechanics aredictated primarily by hip and ankle motion, the lack of effect from thefoot/ankle leaves us with the LPHC as the likely problem.15

Using the other modification (hands down), we can use the same processof elimination. For example, if a client demonstrates any of the listedcompensations (Table 5) which improves when he/she performs the squat withhands on hips the squat, it can be deduced that the upper extremity has amajor influence on the deviation(s) seen. Often, this involves the overactivityof the latissimus dorsi as it is the only upper extremity muscle that attaches tothe pelvis (LPHC), as well as underactivity of the lower trapezius and scapulastabilizers.

If, on the other hand, the squat does not improve or gets worse with thehands down, it can be assumed that the upper body has little effect on thedeviations. The compensations may reveal weak core stabilizing muscles, whichhelp maintain stability in the trunk. This often manifests by clients becomingmore unstable through the trunk during the squat with hands down. This canresult from the overactivity (synergistic dominance) in the latissimus dorsicompensating for a weak core.

Single-Leg Squat Assessment

The SLS assessment will be performed in the same manner as the OHSassessment by following three steps:

1. Set-up-how to position the client for best results and observation.2. Procedure-what the Health and Fitness Professional and client must

do to accurately perform the assessment.3. Observation-what the Health and Fitness Professional should be

looking for throughout the assessment.

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Set-upSet-up for the SLS entails placing the client's feet straight ahead,

approximately hip- to shoulder-width apart with hands on hips. Then he/shewill be asked to accept weight onto the right and/or left foot as shown in Figure24.

Figure 24:Set up for Single Leg Squat

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ProcedureThe SLS assessment consists of performing 3 squats with the hands placed

on hips. The client should squat to a depth that is comfortable. The SLS willbe observed from the anterior view as shown in Figure 25.

Figure 25:Anterior View, Single LegSquat

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ObservationThe observation for the SLS will be specific to the anterior view and

involve observing Kinetic Chain Checkpoints for given movementcompensations. As a reference point for your observation, Figure 25demonstrates what an "ideal" SLS should look like.

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Table 6:Kinetic Chain Compensations for the anterior view of the SLS

Anterior ViewThe observation will begin by viewing the client squatting three times from

the anterior view. From this vantage point, the Health and Fitness Professionalwill be observing three main checkpoints (the feet, knees, and LPHC) forspecific compensations shown in Table 6. The foot and knee compensations willbe identical to the OHS and the reader is referred back to this section. TheLPHC, however, is slightly different and will be addressed here.

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LPHC: Hip HikeDuring the SLS, the pelvis should remain level in the frontal plane.

Commonly in the SLS the client will present with a hip hike. Figure 27demonstrates what an ideal hip position should be and what a hip hike wouldtypically look like.

This compensation consists of the opposite hip hiking up. Table 6 lists theprobable overactive and underactive muscles. The gluteus medius is theprimary frontal plane stabilizer of the hip. When it is underactive, the TFL,adductor, as well as the opposite quadratus lumborum (QL) becomeoveractive.1 It is this overactivity in the QL and the underactivity of the gluteusmedius that produces the hip hike.14

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Figure 27:Ideal / Hip Hike

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LPHC: Hip DropSimilar to (but opposite of) a hip hike is the hip drop. Figure 28

demonstrates what an ideal hip position should be and what a hip drop wouldtypically look like.

Figure 28:Ideal / Hip Drop

This compensation consists of the hip dropping. Table 6 lists the probableoveractive and underactive muscles. As was the case with the hip hike, thegluteus medius is underactive. In this compensation, however, the adductorcomplex is the main overactive muscle group; its overactivity and the

underactivity of the gluteus medius produces the hip drop.14

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Upper Body: Inward Trunk RotationAs previously stated, during the SLS, the hip, knee, and foot should stay in

line with one another. Similarly, the trunk should remain in a neutral andforward facing position. Another common deviation in the SLS is rotationthrough the trunk. Figure 28 demonstrates what an ideal trunk position shouldbe and what an inward trunk rotation would typically look like.

Figure 29:Ideal / Inward Trunk Rotation

This compensation is characterized by a rotation of the trunk or torsotoward the stance leg (internal rotation). It can be seen with or without foot,knee, and LPHC compensation. Table 6 lists the overactive and underactivemuscles. Due to the lack of frontal plane stabilization of the pelvis and leg, thekinetic chain uses transverse plane stabilizers to compensate. The same sideinternal oblique and opposite side external oblique muscles are overactive inconjunction with the adductor complex and the TFL, all of which work toproduce internal rotation. When the muscles that produce external rotationare underactive, there is an internal rotational compensation seen through thetrunk relative to the stance leg.

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Upper Body: Outward Trunk RotationSimilar to (but opposite of) the inward trunk rotation is the outward trunk

rotation. Figure 29 demonstrates what an ideal trunk position should be andwhat an outward trunk rotation would typically look like.

Figure 30:Ideal SLS / Outward Trunk Rotation

This compensation is characterized by a rotation of the trunk or torsoaway from the stance leg (external rotation). This compensation can also be

seen with or without foot, knee, and LPHC compensation as is usually lesscommon than the inward rotation. Table 6 lists the overactive and underactivemuscles. Again, due to the lack of frontal plane stabilization of the pelvis andleg, the kinetic chain uses the transverse plane stabilizers to compensate. Inthis compensation, the same side external oblique and the opposite sideinternal oblique muscles are overactive in conjunction with the same sidepiriformis, all of which work to produce external rotation. When the musclesthat produce internal rotation are underactive, there is an external rotationalcompensation seen through the trunk relative to the stance leg.

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Correlating to the Overhead Squat andSingle-Leg Squat

Both the OHS and the SLS are used to observe the movement abilities ofa client. They each follow the same Kinetic Chain Checkpoints and look forvery similar compensations. Together, the OHS and SLS are used to help theHealth and Fitness Professional establish a better view of a client's functionalanatomy. The use of the SLS is important to help confirm findings in the OHSas well as expose weaknesses not as readily visible in the two-legged stance ofthe OHS. For example, looking at the feet, a client whose feet flatten duringthe OHS will typically demonstrate a flattened foot in the SLS. However,sometimes the foot will present with a much better arch in a SLS, but there willbe more compensation at the knee, hip, or trunk. This finding indicates that thehip (gluteus medius/maximus) may be the weaker link, not really the foot.

In another example, looking at the knees, a client whose knees moveinward in an OHS will typically demonstrate the same compensation whenperforming the SLS. Conversely, a client's whose knees move outward in anOHS may often demonstrate knees moving inward in the SLS. Though themovement pattern is different it still confirms that the weak link may lie in thegluteus medius/maximus, but the TFL (and short head of the biceps femoris)may be the primary overactive muscles instead of the piriformis.

Looking at the LPHC and/or trunk, a client who demonstrates anasymmetrical shift in the OHS will typically show some asymmetrical motionin the SLS. This may be greater knee compensation, hip compensation, and/ortrunk rotation on one side versus the other.

There will also be times that the OHS and the SLS do not seem to concur.This is why there needs to be an integrated assessment process to allow theHealth and Fitness Professional dig deeper into the cause of muscle imbalances.

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Conclusion Movement assessments are the cornerstone of an integrated assessment

process.1,2 They allow the Health and Fitness Professional to observe thelength-tension relationships, force-couple relationships, and joint motions ofthe entire kinetic chain. NASM uses two primary movement assessments, theOverhead Squat and the Single-Leg Squat.

With a thorough understanding of Human Movement Science and the useof the Kinetic Chain Checkpoints to systematically detect compensation injoint motion, inferences as to human movement system impairments can bemade.1-3,6,7,9,10,12,14 This data can then be correlated to other assessments suchas goniometric measurements and manual muscle testing in order for acomprehensive corrective strategy to be developed.

It is vital, however, to point out that movement assessments are only partof a comprehensive assessment process. Movement assessments should beused to detect deviations in the functional anatomy of a client and to lead theHealth and Fitness Professional to specific areas of the body that need to beaddressed in further detail. Other assessments such as goniometricmeasurement and manual muscle testing must be used to confirm or refute thefindings of a movement assessment to ensure the optimal corrective strategyis developed.1,2

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APPENDIX A

46


REFERENCES

References1. Sahrmann SA. Diagnosis and treatment of movement impairment

syndromes. St. Louis: Mosby, Inc.; 2002.

2. Liebenson C. Integrated rehabilitation into chiropractic practice (blendingactive and passive care). In: Liebenson C, editor. Rehabilitation of the spine.Baltimore:Williams & Wilkins; 1996. p. 13-43

3. Comerford MJ, Mottram SL. Movement and stability dysfunction–contemporary developments. Man Ther. 2001; 6(1): 15-2

4. Panjabi MM. The stabilizing system of the spine. Part I: Function,dysfunction, adaptation, and enhancement. J Spinal Disord. 1992; 5(4): 383-9

5. Kendall FP, McCreary EK, Provance PG, Rodgers MM, Romani WA. Musclestesting and function with posture and pain. 5th edition. Baltimore, MA:Lippincott Williams & Wilkins; 2005

6. Janda V. Evaluation of muscle imbalances. In: Liebenson C, editor.Rehabilitation of the spine. Baltimore, MA:Williams & Wilkins; 1996. pp. 97-112.

7. Sahrmann SA. Posture and muscle imbalance. Faulty lumbar pelvicalignments. Phys Ther 1987;67:1840-4.

8. Powers CM. The influence of altered lower-extremity kinematics onpatellofemoral joint dysfunction: a theoretical perspective. J Orthop SportsPhys Ther 2003;33(11):639-46.

9. Janda V. Muscles and motor control in low back pain: assessment andmanagement. In: Twomey LT editor. Physical therapy of the low back.Edinburgh: Churchill Livingstone; 1987. pp 253-278.

10. Janda V. Muscle strength in relation to muscle length, pain, and muscleimbalance. In: International perspectives in physical therapy VIII. Edinburgh:Churchill Livingstone; 1993. pp. 83-91.

11. Edgerton VR, Wolf SL, Levendowski DJ, Roy RR. Theoretical basis forpatterning EMG amplitudes to assess muscle dysfunction. Med Sci SportsExerc 1996;28(6):744-51.

12. Richardson C, Hides J. Closed chain segmental control. In: Richardson C,Hodges P, Hides J. editors. Therapeutic exercise for lumbopelvicstabilization.A motor control approach for the treatment and preventionof low back pain. Edinburgh: Churchill Livingstone; 2004. pp 221-32.

13. Neumann DA. Kinesiology of the musculoskeletal system: Foundations forphysical rehabilitation. St. Louis: Mosby; 2002.

14.Vasilyeva LF, Lewit K. Diagnosis of muscular dysfunction by inspection. In:Liebenson C, editor. Rehabilitation of the spine. Baltimore, MA:Williams &Wilkins; 1996. pp. 113-42.

15. Fry AC, Smith JC, Schilling BK. Effect of knee position on hip and kneetorques during the barbell squat. J Strength Cond Res 2003;17(4):629–633.

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