This article is includes a video, table with analysis and intervention recommendations, and relevant research for each of the 8 commonly noted signs during the OHSA.
- Feet flatten
- Feet turn-out
- Knees bow-in
- Knees bow-out
- Excessive lordosis (Anterior pelvic tilt)
- Excessive forward lean
- Arms fall
- Shoulder girdle elevation
Printable PDF of the Movement Assessment Template (including the OHSA):
Feet Flatten = Excessive Eversion
Note: This compensation pattern is often driven by a lack of dorsiflexion
- Feet flatten has been correlated with tibialis posterior dysfunction (14-18), and selective activation/exercise for the tibialis posterior has been shown to have a positive effect on foot/ankle and lower extremity kinematics (19-20). Although these studies did not use the OHSA as an outcome measure, description of the sign”eversion/pronation” in these studies is similar to the description of the sign “feet flatten” used for the OHSA. Most of these studies referred to the “Navicular Drop Test”, which may be used as an objective interval measure in conjunction with the OHSA to monitor progress. In a study by Trimble et al. this sign, assessed with a lower extremity posture test was found to be a better indicator of tibial translation than recurvatum or thigh foot angle (84).
Feet Turn Out
Feet Turn Out = Tibial External Rotation
Note: This compensation pattern is often driven by a lack of dorsiflexion
|Tibial External Rotators||Tibial Internal Rotators:|
- Feet Turn Out - Only two studies have correlated feet turn-out with dysfunction. In a study by Winslow et al., feet turn out was correlated with a positive “Ober’s Test” (tensor fascia latae restriction/over-active) and knee pain (21), and in a study by Andrew et al., feet turn out was correlated with a functional varus and linked to knee osteoarthritis (40). However, other studies have shown a correlation between an increase in biceps femoris activity (a strong tibial external rotator) and knee dysfunction/pain (22, 23). In an interesting study by Hasegawa et al., biceps femoris stretching resulted in a relative increase in vastus medialis activity (23); this may be evidence that conservative treatment (exercise/manual therapy) may improve this impairment. It is worth noting, tibial external rotation may also be a component of “Knees Bow In” (functional valgus), as femoral internal rotation can be viewed as relative tibial external rotation.
Knees Bow In
Knees Bow In = Tibial External Rotation & Femoral Internal Rotation
Note: This compensation pattern may be driven by ankle or hip dysfunction. If this dysfunction is driven by ankle dysfunction, it may be necessary to add Plantar Flexor and Evertor: Release and Lengthening and Tibialis Anterior Activation
|Tibial External Rotators||Tibial Internal Rotators:|
|Femoral Internal Rotators||Femoral External Rotators|
Knees Bow In (functional valgus) – Research has correlated a functional valgus with a decrease in gluteus maximus and medius activity, sacroiliac joint dysfunction, excessive hip internal rotation and adduction, a loss of dorsiflexion, and excessive pronation (20, 24-33, 87-88). Studies have also correlated this sign of dysfunction with increased risk of anterior cruciate ligament (ACL) injury and patello-femoral pain (ACL) (24, 27, 28). Several studies have also noted the effectiveness of specific exercise intervention for correcting this dysfunction (20, 35-36). Although the OHSA is not used by name in any of these studies, in many of them, a squat or depth jump (LESS test) was used as to assess to measure the presence as knees bow in (referred to this sign as a “functional valgus” or “medial knee displacement”) (20, 24, 28 – 34)
Knees Bow Out
Knees Bow Out = Femoral External Rotation & Ankle Eversion
|Synergists of External Rotation:||Agonists of External Rotation:|
- Knees Bow Out (functional varus) – In a study by Noda et al., this sign correlated with reduced ankle dorsiflexion and hip internal rotation using goniometric assessment (86). Further, there are several studies showing a correlation between functional varus (measured via gait or imaging) and knee osteoarthritis (37-39). Further, one study correlated an increase in varus loads on the knee with increased feet turn out and feet flatten during gait (40). One study showed that gait retraining (a conservative, exercise based approach) was effective for reducing a functional varus (41).
Excessive Forward Lean
Excessive Forward Lean = Hip Flexion & Lack of Dorsiflexion
Note: Relative to movement analysis, a "lack of dorsiflexion" is the same as "excessive plantar flexion".
|Hip Flexors:||Hip Extensors||
- Excessive Forward Lean – Two studies have shown a relationship between dorsiflexion restriction and excessive trunk flexion during squatting (and additional changes in kinematics) (32, 56). Two additional studies have demonstrated a decrease in gluteus maximus strength and activity related to ankle dysfunction (34, 57), which may partially explain the inability to maintain upright posture. Clinically, addressing dorsiflexion range of motion and addressing gluteus medius and gluteus maximus activity and strength have consistently resulted in positive outcomes.
Anterior Pelvic Tilt (Excessive Lordosis)
Anterior Pelvic Tilt (Excessive Lordosis) = Hip Flexion & Lumbar Extension
Note: The pelvis is not a joint; it is a bone whose position is influenced by lumbosacral joints and hip joints.
|Hip Flexors:||Hip Extensors:|
|Lumbar Extensors:||Trunk Flexors:|
- Anterior Pelvic Tilt (excessive lordosis) – This is an interesting sign relative to available research. Although it is not possible to find a single study that correlates all factors related to this sign, for example – an increase in lumbar lordosis, with a loss of hip range of motion, with an Anterior pelvic tilt, with altered motor control and low back pain – there are numerous studies that correlate 2 or more of these signs/symptoms (42-50). The strongest correlations likely exist between an Anterior pelvic tilt, low back pain and a loss of hip extension and internal rotation, and a relative reduction in transverse abdominis, multifidus, gluteus medius and gluteus maximus activity (42 – 50, 82). In one study by Cholewicki et al., a correlation was made between altered motor control and future low back pain (42); a rare study that implies dysfunction precedes pain! Several studies have shown that exercise is effective in the treatment of low back pain (and presumably an Anterior pelvic tilt) (51-55), especially long-term (55).
Arms Fall Forward = Shoulder Internal Rotation
Note: The muscles that cause the shoulders to internally rotate in static standing posture are the same muscles that would cause extension/adduction of the arms from an overhead position (180° of Flexion/Abduction).
|Shoulder Internal Rotators:||Shoulder External Rotators|
- Arms Fall – Although this sign would seem to indicate over-activity (or a loss of extensibility) of shoulder extensors, it is important that analysis of this sign considers extensors only from 180° of shoulder flexion, as performed during the OHSA. With some analysis and review of anatomy, the list of muscles generated could be summarized as “all shoulder internal rotators and the “posterior deltoid“. This list of muscles, has the added benefit of agreement with various texts that note “excessive internal rotation” in static posture in those exhibiting upper body postural dysfunctions (1-4, 9-10). Research has confirmed a portion of this list, as an increase in subscapularis and posterior deltoid activity has been observed in those experiencing shoulder pain (58, 59). However, there may be any easier method of validating this sign on the OHSA. “Arms fall” is nothing more than an inability to maintain 180° of shoulder flexion, and shoulder flexion goniometry has been shown to be a very reliable assessment (60-64). Although the OHSA may not be a good measure of progress due to the binary nature of assessment results; shoulder flexion goniometry may be used in conjunction with the OHSA as an objective interval measure to monitor progress. There is a gap in the research regarding this sign. There is no single study that correlates the sign “Arms Fall” with common shoulder pathologies (like shoulder impingement syndrome (SIS)), and further, no study that correlates how specific interventions may improve the sign “Arms Fall”. However, pain during end range shoulder flexion (as performed in the OHSA) is perhaps the most common complaint among those exhibiting symptoms of SIS, and there is a significant amount of research on external rotator activation (a commonly used intervention to treat SIS), and various studies have demonstrated that exercise is effective for the treatment of SIS (70 – 72).
Shoulders Elevate = Scapula Downward Rotation + Anterior Tipping
Note: The observable elevation of the shoulder girdle is actually the superior angle elevating around a fixed glenoid fossa - in essence, relative downward rotation.
|Downward Rotators:||Upward Rotators:|
|Anterior Tippers||Posterior Tippers|
- Scapula Elevate – This sign, like the sign above (Arms Fall), must be considered relative to functional anatomy. Although it may be presumed that “elevation” of the scapula is observed, closer examination will reveal this motion is actually elevation of the superior angle of the scapula around a relatively fixed glenoid fossa, in conjunction with sagittal plane motion of the scapula over the top portion of the rib cage. The resulting excessive joint actions are relative downward rotation and anterior tipping of the scapula. Once this discrepancy between observation and analysis is solved for, this sign is presumably valid based on agreement with research relative to shoulder dysfunction. Research by Lawrence et al., demonstrated relative downward rotation and an increase in anterior tipping of the scapula in those with shoulder pain (65). Further, research by Scavozzo et al found that swimmers with symptoms of shoulder impingement exhibited less than half the normal activity of the serratus anterior (an upward rotator and posterior tipper of the scapula) during the pull-through phase of stroke (58). An indirect relationship may also exist between this sign and a thoracic kyphosis, as a thoracic kyphosis has been correlated with shoulder impingement syndrome (66), and shoulder impingement syndrome with scapular dyskinesis (58, 65, 67 – 69). There is a significant amount of research to refine and support the use of scapular mobility techniques, serratus anterior activation and trapezius activation, and as mentioned above, exercise has been shown to be effective for the treatment of SIS (70 – 72).
The Next Step:
The next step in understanding the Overhead Squat Assessment is the recognition of "Clusters of Signs", also known as "Compensation Patterns."
- Upper Body Dysfunction
- Lumbo Pelvic Hip Complex Dysfunction
- Lower Leg Dysfunction
- Sacroiliac Joint Dysfunction
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- Feet Flatten
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- Bell, D. R., Oates, D. C., Clark, M. A., & Padua, D. A. (2013). Two-and 3-dimensional knee valgus are reduced after an exercise intervention in young adults with demonstrable valgus during squatting. Journal of athletic training,48(4), 442-449
- Feet Turn Out
- Winslow, J., & Yoder, E. (1995). Patellofemoral pain in female ballet dancers: correlation with iliotibial band tightness and tibial external rotation. Journal of Orthopaedic & Sports Physical Therapy, 22(1), 18-21.
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- Hasegawa, K. T., Hori, S., Tsujita, J., & Dawson, M. L. (2001). Effects of Stretching Exercises on Vastus Medialis and Vastus Lateralis.Medicine & Science in Sports & Exercise, 33(5), S10
- Knees Bow In
- Hewett, T. E., Myer, G. D., Ford, K. R., Heidt, R. S., Colosimo, A. J., McLean, S. G., & Succop, P. (2005). Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes A prospective study. The American journal of sports medicine, 33(4), 492-501.
- Dos Reis, A. C., Correa, J. C. F., Bley, A. S., Rabelo, N. D. D. A., Fukuda, T. Y., & Lucareli, P. R. G. (2015). Kinematic and Kinetic Analysis of the Single-Leg Triple Hop Test in Women With and Without Patellofemoral Pain. journal of orthopaedic & sports physical therapy, 45(10), 799-807.
- Noehren, B., Scholz, J., Davis, I. (2011) The effects of real-time gait retraining on hip kinematics, pain, and function in subjects with patellofemoral pain syndrome. Br Journal of Sports Medicine. 45:691-696
- Ireland, ML., Wilson, JD., Ballantyne, BT., Davis, IM. (2003). Hip Strength in Females With and Without Patellofemoral Pain. J Orthop Sports Phys Ther 2003. 33: 671-676
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- Smith, J. A., Popovich, J. M., & Kulig, K. (2014). The influence of hip strength on lower limb, pelvis, and trunk kinematics and coordination patterns during walking and hopping in healthy women. Journal of Orthopaedic & Sports Physical Therapy, (Early Access), 1-23.
- Mauntel, T., Begalle, R., Cram, T., Frank, B., Hirth, C., Blackburn, T., & Padua, D. (2013). The effects of lower extremity muscle activation and passive range of motion on single leg squat performance. Journal Of Strength And Conditioning Research / National Strength & Conditioning Association, 27(7), 1813-1823.
- Padua, D. A., Bell, D. R., & Clark, M. A. (2012). Neuromuscular characteristics of individuals displaying excessive medial knee displacement. Journal of athletic training, 47(5), 525
- Macrum et al. Effect of limiting ankle-dorsiflexion range of motion on lower extremity kinematics and muscle-activation patterns during a squat. Journal of Sport Rehabilitation, 2012, 21, Pg 144-150
- Souza, T. R., Pinto, R. Z., Trede, R. G., Kirkwood, R. N., & Fonseca, S. T. (2010). Temporal couplings between rearfoot–shank complex and hip joint during walking. Clinical biomechanics, 25(7), 745-748.
- Franettovich, S. M., Honeywill, C. O. N. O. R., Wyndow, N., Crossley, K. M., & Creaby, M. W. (2014). Neuromotor control of gluteal muscles in runners with achilles tendinopathy. Medicine and science in sports and exercise,46(3), 594-599.
- Exercise Helps Functional Valgus
- Ramskov, D., Barton, C., Nielsen, R. O., & Rasmussen, S. (2015). High Eccentric Hip Abduction Strength Reduces the Risk of Developing Patellofemoral Pain Among Novice Runners Initiating a Self-Structured Running Program: A 1-Year Observational Study. journal of orthopaedic & sports physical therapy, 45(3), 153-161
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- Knee Bows Out
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- Foroughi, N., Smith, R., & Vanwanseele, B. (2009). The association of external knee adduction moment with biomechanical variables in osteoarthritis: a systematic review. The Knee, 16(5), 303-309.
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- Barrios, J. A., Crossley, K. M., & Davis, I. S. (2010). Gait retraining to reduce the knee adduction moment through real-time visual feedback of dynamic knee alignment. Journal of biomechanics, 43(11), 2208-2213.
- Anterior Pelvic Tilt
- Cholewicki, J., Silfies, S., Shah, R., Greene, H., Reeves, N. Alvi, K., Goldberg, B. (2005). Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine. 30(23), 2614-2620
- Tateuchi, H., Taniguchi, M., Mori, N., Ichihashi, N. Balance of hip and trunk muscle activity is associated with increased anterior pelvic tilt during prone hip extension (2013) Journal of Electromyography and Kinesiology 22 (3). 391-397]
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- Low Back Pain Altered Recruitment
- Hodges, P., Richardson, C. (1996). Inefficient Muscular Stabilization of the Lumbar Spine Associated With Low Back Pain: A Motor Control Evaluation of Transverse Abdominis. Spine, 21(22), 2640-2650
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- Exercise Low Back Pain
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- Okubo, Y., Kaneoka, K., Imai, A., Shiina, I., Tatsumura, M., Izumi, S., & Miyakawa, S. (2010). Electromyographic analysis of transversus abdominis and lumbar multifidus using wire electrodes during lumbar stabilization exercises. Journal of Orthopaedic & Sports Physical Therapy, 40(11), 743-750
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- Hides, J. A., Richardson, C. A., & Jull, G. A. (1996). Multifidus Muscle Recovery Is Not Automatic After Resolution of Acute, First‐Episode Low Back Pain.Spine, 21(23), 2763-2769.
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- Excessive Forward Lean
- Bell DR, Padua DA. Influence of ankle dorsiflexion range of motion and lower leg muscle activation on knee vagus during a double legged squat. J Athl Train 2007; 42 S84
- Bullock-Saxton, J. E. (1994). Local sensation changes and altered hip muscle function following severe ankle sprain. Physical therapy, 74(1), 17-28
- As well as studies 32 and 34
- Arms Fall
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- Shoulders Elevate
- Lawrence, R. L., Braman, J. P., Laprade, R. F., & Ludewig, P. M. (2014). Comparison of 3-dimensional shoulder complex kinematics in individuals with and without shoulder pain, part 1: sternoclavicular, acromioclavicular, and scapulothoracic joints. journal of orthopaedic & sports physical therapy, 44(9), 636-A8
- Otoshi, K., Takegami, M., Sekiguchi, M., Onishi, Y., Yamazaki, S., Otani, K., Shishido, H., Shinichi, K., Shinichi, K. (2014). Association between kyphosis and subacromial impingement syndrome: LOHAS study. Journal of Shoulder and Elbow Surgery. 23. e300-e307
- Ludewig P.M., Cook, T.M. (2000) Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement.
Physical Therapy. 80 (3) 276-291
- Cools, A.M., Witvrouw, E.E., Declercq, G.A., Danneels, L.A., Cambier, D.C. (2003) Scapular muscle recruitment patterns: Trapezius muscle latency with and without impingement symptoms. The American Journal of Sports Medicine 31(4). 542-549
- Fayad F, Roby-Brami A, Yazbeck C, Hanneton S, Lefevre-Colau MM, Gautheron V, Poiraudeau S, Revel M. (2008). “Three-dimensional scapular kinematics and scapulohumeral rhythm in patients with glenohumeral osteoarthritis or frozen shoulder.” 2008 Jbiomech, 41(2): 326-332
- Michener, L. A., Walsworth, M. K., & Burnet, E. N. (2004). Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. Journal of hand therapy, 17(2), 152-164.
- Bang, M. D., & Deyle, G. D. (2000). Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. Journal of Orthopaedic & Sports Physical Therapy, 30(3), 126-137.
- Senbursa, G., Baltacı, G., & Atay, A. (2007). Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: a prospective, randomized clinical trial. Knee surgery, sports traumatology, arthroscopy, 15(7), 915-921.
- and 58
- Regional Interdependence
- Souza, T. R., Pinto, R. Z., Trede, R. G., Kirkwood, R. N., & Fonseca, S. T. (2010). Temporal couplings between rearfoot–shank complex and hip joint during walking. Clinical biomechanics, 25(7), 745-748‘
- Ayhan, C., Camci, E., & Baltaci, G. (2015). Distal radius fractures result in alterations in scapular kinematics: A three-dimensional motion analysis. Clinical Biomechanics.
- Day, J. M., Bush, H., Nitz, A. J., & Uhl, T. L. (2015). Scapular Muscle Performance in Individuals With Lateral Epicondylalgia. Journal of Orthopaedic & Sports Physical Therapy, (Early Access), 1-35
- Helgadottir, H., Kristjansson, E., Einarsson, E., Karduna, A., & Jonsson, H. (2011). Altered activity of the serratus anterior during unilateral arm elevation in patients with cervical disorders. Journal of electromyography and kinesiology,21(6), 947-953.
- Kwon JW, Son SM, Lee NK. (2015). Changes in upper-extremity muscle activities due to head position in subjects with a forward head posture and rounded shoulders. J Phys Ther Sci. 27: 1739-1742
- Thigpen CA, Padua DA, Michener LA, Guskiewicz K, Giuliani C, Keener JD, Stergiou N. (2010). Head and shoulder posture affect scapular mechanics and muscle activity in overhead tasks. Journal of Electromyography and Kinesiology. 20: 701-709.
- Reliability and additional research
- Zeller B, McCrorr J, Kibler W, Uhl T. Differences in kinematics and electromygraphic activity between men and women during single-legged squat. Am J Sport Med 2003; 31:182-99
- Buckley BD, Thigpen CA, Joyce CJ, Bohres SM Padua DA. Knee and hip kinematics during a double leg squat predict knee and hip kinematics at initial contact of a jump landing task. J athl Train 2007;42:S81
- Vesci BJ, PAdua DA, Bell DR Strickland LJ, Guskiewicz KM, Hirth CJ. Influence of hip muscle strength, flexibility of hip and ankle musculature, and hip muscle activation on dynamic knee valgus motion during a double-legged squat. J Athl Train 2007; 42:S83
- Matthew Shirey, D. P. T., Matthew Hurlbutt, D. P. T., Nicole Johansen, D. P. T., Gregory, W. K., Wilkinson, S. G., & Hoover, D. L. The influence of core musculature engagement on hip and knee kinematics in women during a single leg squat. Int J Sports Phys Ther. 2012 Feb; 7(1): 1–12.
- Gribble, P. A., & Robinson, R. H. (2009). Alterations in knee kinematics and dynamic stability associated with chronic ankle instability. Journal of Athletic Training, 44(4), 350-355.
- Trimble, M. H., Bishop, M. D., Buckley, B. D., Fields, L. C., & Rozea, G. D. (2002). The relationship between clinical measurements of lower extremity posture and tibial translation. Clinical Biomechanics, 17(4), 286-290.
- Mauntel, T. C., Post, E. G., Padua, D. A., & Bell, D. R. (2015). Sex differences during an overhead squat assessment. Journal of applied biomechanics, 31(4), 244-249.
- Noda, T., & Verscheure, S. (2009). Individual goniometric measurements correlated with observations of the deep overhead squat. Athletic Training and Sports Health Care, 1(3), 114-119.
- Bell, D. R., Padua, D. A., & Clark, M. A. (2008). Muscle strength and flexibility characteristics of people displaying excessive medial knee displacement. Archives of physical medicine and rehabilitation, 89(7), 1323-1328.
- Bell, D. R., Vesci, B. J., DiStefano, L. J., Guskiewicz, K. M., Hirth, C. J., & Padua, D. A. (2012). Muscle activity and flexibility in individuals with medial knee displacement during the overhead squat. Athletic Training and Sports Health Care, 4(3), 117-125.
© 2017 Brent Brookbush
Questions, comments, and criticisms are welcomed and encouraged –