Overhead Squat Assessment: Signs of Dysfunction

By Brent Brookbush DPT, PT, COMT, MS, PES, CES, CSCS, H/FS

For an introduction to the Overhead Squat Assessment (OHSA) including intent, validity, reliability, signs of dysfunction, analysis and set-up please review:

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.

Printable PDF of the Movement Assessment Template (including the OHSA):

Feet Flatten:

Feet Flatten = Excessive Eversion

Note: This compensation pattern is often driven by a lack of dorsiflexion

Short/Over-activeLong/Under-active
Evertors:

Invertors:

Plantar Flexors:

Dorsiflexors:

Research

  • 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

Short/Over-activeLong/Under-active
Tibial External Rotators

Tibial Internal Rotators:

Plantar Flexors:

Dorsiflexors:

Special notes:

Research:

  • 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

Short/Over-activeLong/Under-active
Tibial External Rotators

Tibial Internal Rotators:

Femoral Internal Rotators

Femoral External Rotators

Special notes:

Research:

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

If this dysfunction is driven by ankle dysfunction, it may be necessary to add Plantar Flexor and Evertor: Release and Lengthening and Tibialis Posterior Activation

Short/OveractiveInhibited Agonists
Synergists of External Rotation:

Agonists of External Rotation:

Evertors:

Invertors:

Special notes:

  1. This is a tricky dysfunction to analyze.  Although it is tempting to label the hip dysfunction as "excessive abduction", this would imply the ineffective practice of inhibiting an under-active gluteus medius and activating the commonly over-active adductors.  Practice and other clues offered by various research studies has lead to the hypothesis that synergistic dominance of the external rotators of the hip in conjunction with relatively under-active glute complex drive hip dysfunction for this sign.
  2. Experience has also shown that if correcting this dysfunction results in “Knees Bow In”, this is an improvement.  This sign is our first “compensations within a compensation.”  If the “Knees Bow In” on reassessment treat the dysfunction as such and use the corrective strategy implied by the table “Knees Bow In.”

Research:

  • 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".

Short/OveractiveLong/Underactive
Hip Flexors:

Hip Extensors

Plantar Flexors:

Dorsiflexors:

Special notes:

  1. In this dysfunction we find our first "long/over-active" muscles (those marked with an"*").  Generally, as is the case above, this pairing of maladaptive length and activity is a sign of the muscle(s) becoming synergistically dominant for an inhibited prime mover.  These muscles should not be stretched, activated or strengthened, however, release techniques may be effective for improving function.
  2. The “Tibial Internal Rotator Activation” is added as a means of increasing semitendinosus and semimembranosus activity.

Research:

  • 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.

Short/OveractiveLong/Underactive
Hip Flexors:

Hip Extensors:

Lumbar Extensors:

Trunk Flexors:

Special notes:

  • In this dysfunction we find "long/over-active" muscles (those marked with an "*").  Generally, as is the case above, this pairing of maladaptive length and activity is a sign of the muscle(s) becoming synergistically dominant for an inhibited prime mover.  These muscles should not be stretched, activated or strengthened, however, release techniques may be effective for improving function.
  • Tibial Internal Rotator Activation” is added as a means of increasing semitendinosus and semimembranosus activity.
  • The recruitment of trunk musculature is likely best explained by the relative activity of muscular synergies known as “subsystems (slings).”  Although TVA Activation is often the focus of routines for Lumbo Pelvic Hip Complex Dysfunction (LPHCD), it is likely recruited in conjunction with all of muscles of the Intrinsic Stabilization Subsystem.
  • The anterior trunk musculature could also be grouped and referred to as the Anterior Oblique Subsystem.

Research:

  • 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

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).

Short/OveractiveLong/Underactive
Shoulder Internal Rotators:

Shoulder External Rotators

  • Special notes:In this dysfunction we find "long/over-active" muscles (those marked with an "*").  Generally, as is the case above, this pairing of maladaptive length and activity is a sign of the muscle(s) becoming synergistically dominant for an inhibited prime mover.  These muscles should not be stretched, activated or strengthened, however, release techniques may be effective for improving function.
  • It is very rare that shoulder dysfunction presents without scapula and thoracic spine dysfunction.  Most often a corrective strategy would include many of the techniques recommended in the graph below “Shoulders Elevate

Research:

  • 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:

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.

Short/OveractiveLong/Underactive
Downward Rotators:

Upward Rotators:

Anterior Tippers

Posterior Tippers

Special notes:

  1. This dysfunction is most often paired with shoulder dysfunction (graph above).
  2. The Upper Trapezius fall on both sides of the graph (another strange occurrence). Based on research correlating muscle activity and shoulder girdle dysfunction is likely best to treat the Upper Trapezius as short/over-active (release and lengthen)

Research:

  • 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."

These common clusters may be described by the Predictive Models of Movement Impairment discussed in the articles below:

Bibliography:

  1. Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary McIntyre Rodgers, William Anthony Romani, Muscles: Testing and Function with Posture and Pain: Fifth Edition © 2005 Lippincott Williams & Wilkins
  2. Phillip Page, Clare FrankRobert Lardner
    Assessments used by human movement professionals can be divided into three broad categories:

    • "Clear" the Patient/Client for Intervention - These are tests, assessments and evaluations used to determine if a patient/client's issue may improve given the assessing professional's scope, skills, abilities and willingness to treat that individual.

      • For example, many of the special tests used in orthopedic medicine assist in determining the level of pathology or likelihood of a particular diagnosis. Certain issues and diagnoses are beyond the scope of the human movement professional, and are better treated by diagnostic professionals in the medical community (physicians, podiatrists, surgeons, etc.). A Calf Squeeze (Thompson) Test is one example, in which a positive sign may indicate a rupture of the Achilles tendon that may be better treated via surgical intervention.



    • Highlight Contraindications - Tests, assessments and evaluations used to stratify risk or preclude a professional from addressing certain tissues, motions or using a particular technique.

      • For example, the Vertebral Artery Test (VBI) is often used to determine if high velocity thrust mobilizations (manipulations) are safe for a patient with cervical dysfunction.



    • Refine Exercise/Intervention Selection: Tests, assessments and evaluations used to assist the professional in determining which techniques, modalities and exercises will best address a patient/client's complaints or desired goals.

      • Most movement assessments fall into this category. For example, a positive Ely's Test may indicate a need to release and/or lengthen the rectus femoris.




    Note: An assessment, or assessment result, may fall into more than one category. For example, although goniometry is an assessment most often used to Refine Exercise/Intervention Selection, if a range of motion is significantly altered, with an abnormal end-feel, and/or causes the patient or client/pain, the individual may need to be referred to a physician for further testing and Clearance to resume rehab activities.  Further, that same patient may return to the human movement professional with a list of Contraindicated Activities from the physician. - "When in doubt, refer out!"">Assessment
    and Treatment of Muscle Imbalance: The Janda Approach 
    © 2010 Benchmark Physical Therapy, Inc., Clare C. Frank, and Robert Lardner
  3. Janda V.
    Assessments used by human movement professionals can be divided into three broad categories:

    • "Clear" the Patient/Client for Intervention - These are tests, assessments and evaluations used to determine if a patient/client's issue may improve given the assessing professional's scope, skills, abilities and willingness to treat that individual.

      • For example, many of the special tests used in orthopedic medicine assist in determining the level of pathology or likelihood of a particular diagnosis. Certain issues and diagnoses are beyond the scope of the human movement professional, and are better treated by diagnostic professionals in the medical community (physicians, podiatrists, surgeons, etc.). A Calf Squeeze (Thompson) Test is one example, in which a positive sign may indicate a rupture of the Achilles tendon that may be better treated via surgical intervention.



    • Highlight Contraindications - Tests, assessments and evaluations used to stratify risk or preclude a professional from addressing certain tissues, motions or using a particular technique.

      • For example, the Vertebral Artery Test (VBI) is often used to determine if high velocity thrust mobilizations (manipulations) are safe for a patient with cervical dysfunction.



    • Refine Exercise/Intervention Selection: Tests, assessments and evaluations used to assist the professional in determining which techniques, modalities and exercises will best address a patient/client's complaints or desired goals.

      • Most movement assessments fall into this category. For example, a positive Ely's Test may indicate a need to release and/or lengthen the rectus femoris.




    Note: An assessment, or assessment result, may fall into more than one category. For example, although goniometry is an assessment most often used to Refine Exercise/Intervention Selection, if a range of motion is significantly altered, with an abnormal end-feel, and/or causes the patient or client/pain, the individual may need to be referred to a physician for further testing and Clearance to resume rehab activities.  Further, that same patient may return to the human movement professional with a list of Contraindicated Activities from the physician. - "When in doubt, refer out!"">Evaluation
    of Muscle Imbalances. In: Leibenson C, Rehabilitation of the Spine: Second Edition © 2007 Williams and Wilkens: Chapter Ten, pg. 204 – 225
  4. Shirley A Sahrmann, Diagnoses and Treatment of Movement Impairment Syndromes, © 2002 Mosby Inc.
  5. David G. Simons, Janet Travell, Lois S. Simons, Travell & Simmons’ Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body: Second Edition, © 1999 Williams and Wilkens
  6. Cynthia C. Norkin, D. Joyce White, Measurement of Joint Motion: A Guide to
     

    1. Cynthia C. Norkin, D. Joyce White. Measurement of Joint Motion: A Guide to Goniometry 3rd Edition. Copyright (C) 2003 by F.A. Davis Company

    ">Goniometry
    – Third Edition. © 2003 by F.A. Davis Company
  7. Carolyn Richardson, Paul Hodges, Julie Hides.  Therapeutic Exercise for Lumbo Pelvic Stabilization – A Motor Control Approach for the Treatment and Prevention of Low Back Pain: 2nd Edition (c) Elsevier Limited, 2004
  8. Vleeming, Mooney, Stoeckart.  Movement, Stability & Lumbopelvic Pain: Integration of Research and Therapy.  (c) 2007 Elsevier, Limited
  9. Craig Leibenson.  Rehabilitation of the Spine: A Practitioner’s Manual – Second Edition (c) 2007 Lippencott Williams & Wilkins
  10. Dr. Mike Clark & Scott Lucette, “NASM Essentials of Corrective Exercise Training” © 2011 Lippincott Williams & Wilkins
  11. Donald A. Neumann, “Kinesiology of the Musculoskeletal System: Foundations of Rehabilitation – 2nd Edition” © 2012 Mosby, Inc.

    ">Regional Interdependence

  12. Sueki, D. G., Cleland, J. A., & Wainner, R. S. (2013). A Wainner RS, Flynn TW, Whitman JM. Spinal and extremity manipulation: the basic skill set for physical therapists. San Antonio (TX): Manipulations, Inc; 2001

  13. ">regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. Journal of Manual & Manipulative Therapy, 21(2), 90-102.

  14. Wainner RS, Flynn TW, Whitman JM. Spinal and extremity manipulation: the basic skill set for physical therapists. San Antonio (TX): Manipulations, Inc; 2001

    • Feet Flatten

  15. Basmajian JV, Stecko G. The role of muscles in arch support of the foot. J Bone Joint Surg 1963;45A: 1184-90
  16. Mizel MS, Temple HT, Scranton PE II, Gellman RE, Hecht PJ, Horton GA, et al. Role of the peroneal tendons in the production of the deformed

    foot with posterior tibial tendon deficiency.

  17. Dyal CM, Feder J, Deland JT, Thompson FM. Pes planus in patients with posterior tibial tendon insufficiency: asymptomatic versus symptomatic

    foot. Foot Ankle Int 1997;18: 85-8.

  18. Pohl MB, Rabbito M, Ferber R. The role of tibialis posterior fatigue on foot kinematics during walking. Journal of Foot and Ankle Research 2010 3:6
  19. Mosier SM, Pomeroy G, Manoli A II. Pathoanatomy and aetiology of posterior tibial tendon dysfunction. Clin Orthop Rel Res 1999;365:12-22.

  20. Kulig K, Lederhaus E, Reischl S, Arya S, Bashfor G. Effect of Eccentric Exercise Program for Early Tibialis Posterior Tendinopathy Foot & Ankle International September 2009 vol. 30 no. 9 877-885
  21. 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

  22. 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.

  23. Kwon O, Yun M, and Lee W. (2014). Correlation between intrinsic patellofemoral pain syndrome in young adults and lower extremity biomechanics. J. Phys. Ther. Sci. 26: 961-964
  24. 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

  25. 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.
  26. 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.
  27. 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
  28. 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
  29. Noehren B, Hamill J, Davis I. Prospective Evidence for a Hip Etiology in Patellofemoral Pain. Medicine & Science in Sports & Exercise. 2013;45(6):1120–1124.
  30. 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.
  31. 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.
  32. 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
  33. 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
  34. 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.
  35. 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

  36. 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
  37. Snyder, K. R., Earl, J. E., O’Connor, K. M., & Ebersole, K. T. (2009). Resistance training is accompanied by increases in hip strength and changes in lower extremity biomechanics during running. Clinical Biomechanics, 24(1), 26-34

    • Knee Bows Out

  38. Sharma, L., Song, J., Felson, D. T., Shamiyeh, E., & Dunlop, D. D. (2001). The role of knee alignment in disease progression and functional decline in knee osteoarthritis. Jama, 286(2), 188-195.
  39. Brouwer, G. M., Van Tol, A. W., Bergink, A. P., Belo, J. N., Bernsen, R. M. D., Reijman, M., … & Bierma‐Zeinstra, S. M. A. (2007). Association between valgus and varus alignment and the development and progression of radiographic osteoarthritis of the knee. Arthritis & Rheumatism, 56(4), 1204-1211.

  40. 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.
  41. Andrews, M., Noyes, F. R., Hewett, T. E., & Andriacchi, T. P. (1996). Lower limb alignment and foot angle are related to stance phase knee adduction in normal subjects: a critical analysis of the reliability of gait analysis data. Journal of orthopaedic research, 14(2), 289-295.
  42. 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.

  43. 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
  44. 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]
  45. Ellison, JB., Rose, S., Sahrmann, S. (1990). Patterns of Hip Rotation Range of Motion: A Comparison Between Healthy Subjects and Patients with Low Back Pain. Phys Ther 1990. 70: 537-541
  46. Schache, A. G., Blanch, P. D., & Murphy, A. T. (2000). Relation of anterior pelvic tilt during running to clinical and kinematic measures of hip extension. British journal of sports medicine, 34(4), 279-283.

    • Low Back Pain Altered Recruitment

  47. 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
  48. Cooper, N., Scavo, K., Strickland, K., Tipayamongkol, N., Nicholson, J., Bewyer, D., Sluka, K. Prevalence of gluteus medius weakness in people with chronic low back pain compared to healthy controls. J Euro Spine. 26 May 2015
  49. Hungerford, B., Gilleard, W., Hodges, P. (2003) Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac jugular). (Etymology Online)">joint pain. Spine 28(14), 1593-1600
  50. O’Sullivan, P. B., Beales, D. J., Beetham, J. A., Cripps, J., Graf, F., Lin, I. B., … & Avery, A. (2002). Altered motor control strategies in subjects with sacroiliac joint pain during the active straight-leg-raise test. Spine27(1), E1-E8
  51. Lewis CL, Sahrmann. 2005 Timing of muscle activation during prone hip extension. Abstract. J Orhop Sports Phys Ther 35(1): A56.

    • Exercise Low Back Pain

  52. Sihawong, R., Janwantanakul, P., Jiamjarasrasi, W. (2014) A prospective, cluster-randomized controlled trial of exercise program to prevent low back pain in office workers. European Spine Journal 23:786-793
  53. 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
  54. Oh, J. S., Cynn, H. S., Won, J. H., Kwon, O. Y., & Yi, C. H. (2007). Effects of performing an abdominal
    The "drawing-in" maneuver is a common cue used during exercise and rehabilitation programs.
    ">drawing-in maneuver during prone hip extension exercises on hip and back extensor muscle activity and amount of anterior pelvic tilt. journal of orthopaedic & sports physical therapy, 37(6), 320-324.

  55. 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.

  56. Hides, J. A., Jull, G. A., & Richardson, C. A. (2001). Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine, 26(11), e243-e248

    • Excessive Forward Lean

  57. 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
  58. Bullock-Saxton, J. E. (1994). Local sensation changes and altered hip muscle function following severe ankle sprain. Physical therapy74(1), 17-28

    • As well as studies 32 and 34
    • Arms Fall

  59. Scovazzo, M.L., Browne, A., Pink, M., Jobe, F.W., and Kerrigan, J.  (1991).  The painful shoulder during freestyle swimming: An electromyographic cinematographic analysis of twelve muscles. The American Journal of Sports Medicine. 19(6).  577-582 
  60. José Miota Ibarra, Hong-You Ge, Chao Wang, Vicente Martínez Vizcaíno, Thomas Graven-Nielsen, Lars Arendt-Nielsen. Latent Myofascial Trigger Points are Associated With an Increased Antagonistic Muscle Activity During Agonist Muscle Contraction. The Journal of Pain, Volume 12, Issue 12, December 2011, Pages 1282–1288
  61. Boone, D. C., Azen, S. P., Lin, C. M., Spence, C., Baron, C., & Lee, L. (1978). Reliability of
     

    1. Cynthia C. Norkin, D. Joyce White. Measurement of Joint Motion: A Guide to Goniometry 3rd Edition. Copyright (C) 2003 by F.A. Davis Company

    ">goniometric
    measurements. Physical Therapy, 58(11), 1355-1360.
  62. Rothstein, J. M., Miller, P. J., & Roettger, R. F. (1983).
     

    1. Cynthia C. Norkin, D. Joyce White. Measurement of Joint Motion: A Guide to Goniometry 3rd Edition. Copyright (C) 2003 by F.A. Davis Company

    ">Goniometric
    reliability in a clinical setting. Physical Therapy, 63(10), 1611-1615.
  63. Mullaney MJ, McHugh MP, Johnson CP, Tyler TF. (2010). Reliability of shoulder range of motion comparing
     

    1. Cynthia C. Norkin, D. Joyce White. Measurement of Joint Motion: A Guide to Goniometry 3rd Edition. Copyright (C) 2003 by F.A. Davis Company

    ">goniometer
    to a digital level. Physiotherapy Theory & Practice. 26(5): 327-333.
  64. Riddle DL, Rothstein JM, Lamb RL. (1987).
     

    1. Cynthia C. Norkin, D. Joyce White. Measurement of Joint Motion: A Guide to Goniometry 3rd Edition. Copyright (C) 2003 by F.A. Davis Company

    ">Goniometric
    reliability in a clinical setting. Physical Therapy. 67(5): 668-673.
  65. Dougherty J, Walmsley S, and Osmotherly PG. (2014). Passive range of movement of the shoulder: a standardized method for measurement and
    Assessments used by human movement professionals can be divided into three broad categories:

    • "Clear" the Patient/Client for Intervention - These are tests, assessments and evaluations used to determine if a patient/client's issue may improve given the assessing professional's scope, skills, abilities and willingness to treat that individual.

      • For example, many of the special tests used in orthopedic medicine assist in determining the level of pathology or likelihood of a particular diagnosis. Certain issues and diagnoses are beyond the scope of the human movement professional, and are better treated by diagnostic professionals in the medical community (physicians, podiatrists, surgeons, etc.). A Calf Squeeze (Thompson) Test is one example, in which a positive sign may indicate a rupture of the Achilles tendon that may be better treated via surgical intervention.



    • Highlight Contraindications - Tests, assessments and evaluations used to stratify risk or preclude a professional from addressing certain tissues, motions or using a particular technique.

      • For example, the Vertebral Artery Test (VBI) is often used to determine if high velocity thrust mobilizations (manipulations) are safe for a patient with cervical dysfunction.



    • Refine Exercise/Intervention Selection: Tests, assessments and evaluations used to assist the professional in determining which techniques, modalities and exercises will best address a patient/client's complaints or desired goals.

      • Most movement assessments fall into this category. For example, a positive Ely's Test may indicate a need to release and/or lengthen the rectus femoris.




    Note: An assessment, or assessment result, may fall into more than one category. For example, although goniometry is an assessment most often used to Refine Exercise/Intervention Selection, if a range of motion is significantly altered, with an abnormal end-feel, and/or causes the patient or client/pain, the individual may need to be referred to a physician for further testing and Clearance to resume rehab activities.  Further, that same patient may return to the human movement professional with a list of Contraindicated Activities from the physician. - "When in doubt, refer out!"">assessment
    of intrarater reliability. Journal of Manipulative and Phsyiological Therapeutics. 38(3): 218-224.

    • Shoulders Elevate

  66. 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
  67. 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
  68. 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

  69. 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
  70. 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
  71. 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.

  72. 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.

  73. 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

  74. Souza, T. R., Pinto, R. Z., Trede, R. G., Kirkwood, R. N., & Fonseca, S. T. (2010). Temporal couplings between rearfoot–shank complex and hip jugular). (Etymology Online)">joint during walking. Clinical biomechanics25(7), 745-748‘
  75. Ayhan, C., Camci, E., & Baltaci, G. (2015). Distal radius fractures result in alterations in scapular kinematics: A three-dimensional motion analysis. Clinical Biomechanics.
  76. 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
  77. 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.
  78. 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
  79. 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.

  80. 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
  81. 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
  82. 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
  83. 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.

  84. 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.

  85. 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 for a given exercise.

    © 2017 Brent Brookbush
    ">posture and tibial translation. Clinical Biomechanics, 17(4), 286-290.

  86. Mauntel, T. C., Post, E. G., Padua, D. A., & Bell, D. R. (2015). Sex differences during an overhead squat
    Assessments used by human movement professionals can be divided into three broad categories:


    Note: An assessment, or assessment result, may fall into more than one category. For example, although goniometry is an assessment most often used to Refine Exercise/Intervention Selection, if a range of motion is significantly altered, with an abnormal end-feel, and/or causes the patient or client/pain, the individual may need to be referred to a physician for further testing and Clearance to resume rehab activities.  Further, that same patient may return to the human movement professional with a list of Contraindicated Activities from the physician. - "When in doubt, refer out!"
    ">assessment. Journal of applied biomechanics, 31(4), 244-249.

  87. Noda, T., & Verscheure, S. (2009). Individual
     


    1. Cynthia C. Norkin, D. Joyce White. Measurement of Joint Motion: A Guide to Goniometry 3rd Edition. Copyright (C) 2003 by F.A. Davis Company

    ">goniometric measurements correlated with observations of the deep overhead squat. Athletic Training and Sports Health Care, 1(3), 114-119.

  88. 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.

  89. 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 –