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This course introduces the Overhead Squat Assessment (OHSA). A dynamic movement assessment that can be used to quickly identify reliable signs correlated with movement impairment and compensation patterns.

Overhead Squat Assessment: Introduction

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Course Summary: Introduction to the Overhead Squat Assessment (OHSA)

All fitness, performance, and physical rehabilitation programs should start with a movement assessment. The goal of assessment is to refine exercise and technique recommendations, with the intent of improving client or patient outcomes. From the perspective of decision theory, the goal of an assessment is to differentiate client or patient populations into subgroups that achieve optimal outcomes from different intervention plans.

Introduction to the Overhead Squat Assessment (OHSA):

This course introduces a dynamic movement assessment (a.k.a. dynamic postural assessment), known as the Overhead Squat Assessment (OHSA). This assessment is also referenced as the OSA, OHSA, squat assessment, and overhead squat in various publications. Further, it is similar to the deep squat assessment of the Functional Movement Screen. With this assessment, a professional can quickly identify reliable signs correlated with movement impairments, including altered shoulder mobility, scapula dyskinesis, altered core strength, hip mobility, knee joint alignment, and/or ankle mobility. Note, additional assessments can be added to measure improvements (continuous interval measures), measure range of motion (ROM), identify altered recruitment patterns, muscle imbalances (muscle overactivity or muscle under-activity), loss of muscle strength, or increased joint stiffness (e.g. 

goniometry, muscle length tests, manual muscle testing

This course includes unique content only available from the 

. Unlike other education companies that also teach a squat assessment, including the National Academy of Sports Medicine (NASM), the American Council on Exercise (ACE), and the Functional Movement Screen (FMS), the Brookbush Institute provides an evidence-based analysis of muscle imbalances and joint dyskinesis. But perhaps most importantly, the 

 is the first company to teach a methodology that includes assessment using a reference model and a preset group of reliable "signs of dysfunction," analysis of the impairments implied by those signs (including altered muscle activity, altered muscle length, and joint dyskinesis), development of an evidence-based and integrated approach to address the analyzed signs, and promotion of immediate post-intervention reassessment to determine the efficacy of the approach. The development of this process was a purposeful attempt to address a weakness in the industry exhibited by other professional education organizations, that is, the relationship between assessment and effective technique selection. This course is an introduction to a clear methodology for the implementation of this dynamic assessment for use by all sports medicine professionals (personal trainers, fitness instructors, physical therapists, massage therapists, chiropractors, occupational therapists, athletic trainers, occupational therapists, osteopaths, acupuncturists, etc.).

Webinar: Introduction to the Overhead Squat Assessment

Study Guide: Introduction to the Overhead Squat Assessment

Set up and Ideal Alignment (with Video Lecture)

Signs of Dysfunction (with Video Lecture)

5 Steps for Analyzing Signs of Dysfunction (with Video Lecture)

Prioritizing Multiple Assessed Signs of Dysfunction (with Video Lecture)

Overhead Squat Assessment: Signs of Dysfunction

Overhead Squat Assessment: Sign Clusters and Compensation Patterns

Identify the excessive joint actions that correlate with the sign(s) of dysfunction.

List muscles responsible for that joint action ("short" muscles).

List the muscles responsible for the opposing joint action ("long" muscles).

Although no one can see muscle activity or length, anyone can see motion (i.e. joint actions). Joint actions can then be used to infer muscle length and activity, and potentially the behavior of other structures (joint, fascia, nerves). For example, you cannot see "tight hip flexors," but you can see excessive hip flexion.

It is important to create a systematic method for listing the altered muscle lengths correlated with the signs of dysfunction and excessive joint actions. Our recommendation is to use a "solutions table" like the one below. Initially, it may be necessary to review functional anatomy when building these tables. If you have taken our "

" courses, you may recognize how important it is to practice listing muscles by joint action. Although these tables may be challenging to complete the first time, repetition will lead to memorization of each sign, the excessive joint actions, and the muscles responsible for that joint action and the opposing joint action. Because there are only 10 potential signs, and many of the signs include the same excessive joint actions, it will not take long to commit the "solutions tables" to memory. These patterns will look very similar to the predictive models of postural dysfunction discussed in future courses on 

Generally, muscles implicated as short are also overactive, and the opposing muscles are long and underactive

 We can use these tables to build a corrective/therapeutic exercise plan.

Using additional resources, a more comprehensive and accurate analysis can be constructed, and various interventions can be compared to identify the techniques and intervention plans resulting in the best possible outcomes. The Brookbush Institute has continued to refine analyses and recommendations through years of testing in an outcome-driven practice and the systematic review of all peer-reviewed and published research. These analyses can be reviewed in the additional OHSA courses.

Course Summary Webinar: Overhead Squat Assessment: Introduction

Brookbush Institute Overhead Squat Assessment: Introduction Course Study Guide

Study Guide: Overhead Squat Assessment: Introduction

Why Assess?

 The act of assessing. Determining the size, value, or importance of a measure.

: The goal of an assessment is to differentiate patient/client populations into subgroups that achieve optimal outcomes from different intervention plans.

In most cases, the results of an assessment are compared to normative data or an optimal range. If the individual exhibits values within an optimal range then it is assumed that the assessed parameter is unlikely to contribute to dysfunction. If the values fall outside of an optimal range, it is assumed that this parameter has a certain probability of contributing to dysfunction. For example, deviations noted during the 

 are compared to an average range of ideal joint and bone alignment. Research has demonstrated that the deviations from ideal alignment assessed during an OHSA are correlated with dysfunction and pain, and addressing these signs is a reliable method for improving dysfunction and pain.

"Clear" the Patient/Client for Intervention:

 Tests, assessments, and evaluations used to determine if a patient/client's issue may improve with the interventions available to the assessing practitioner (based on the practitioner's scope of practice, skills, and willingness to treat the individual).

For example, many special tests used in orthopedic medicine assist in diagnosing the likelihood of a pathological condition. The treatment of pathologies is beyond the scope of practice of a movement professional. Further, some issues are optimally treated by professionals with more experience with a particular client/patient population. For example, the Ottowa Ankle and Foot Signs are a cluster of signs that, when positive, imply that referral for imaging is needed to determine whether a fracture is present. If fracture is a possible source of a patient's complaints, then manual therapy, physical interventions, and exercises are contraindicated.

These are tests, assessments, and evaluations used to stratify risk or deter a professional from addressing certain tissues, motions, or using a particular technique.

 may imply the presence of a rotator cuff tear. This may imply that specific exercises with the intent of strengthening rotator cuff muscles are contraindicated during the acute phase of injury. However, physical rehabilitation focused on improving cervical spine, thoracic spine, and scapular motion may still be the ideal treatment option.

These are tests, assessments, and evaluations used to assist the professional in determining which techniques, modalities, and exercises will best address a client/patient's complaints or desired goals. This category of assessment should likely comprise the majority of a movement professional's initial evaluation, as well as re-assessments.

For example, the Overhead Squat Assessment (OHSA) aids in identifying addressable signs correlated with movement impairment, symptoms, or dysfunction. Further, these signs imply a set of techniques that are reliably effective for reducing the presence of these signs, as well as improving a patient's impairments, symptoms, or dysfunctions.

Note: An assessment or a particular assessment result may fall into more than one category. For example, although goniometry is an assessment most often used to 

, if a particular 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 

 to resume rehab activities. Further, that same patient may return to the human movement professional with a list of 

The Difference Between a Good Assessment and a Bad Assessment:

Good tests, assessments, and evaluations are relevant, valid, reliable, and accurate.

 The quality or state of being closely connected or appropriate.

Each test, assessment, and evaluation used by the human movement professional should be chosen because the data from that assessment will aid in optimizing an intervention plan to address the patient's complaints or goals. The OHSA may be particularly relevant for movement professionals because it allows for a relatively quick assessment of the whole body, the identified signs have a relatively strong correlation with the most common orthopedic dysfunctions, and analysis of these signs implies a set of reliably effective techniques.

 Validity refers to whether something measures what it purports to be measuring. Specifically, "face validity" refers to whether it is possible that the test measures what it appears to measure.

The OHSA is a valid measure when used to identify deviations from optimal motion. It would not be a valid measure of orthopedic pathological conditions.

 Reliability refers to the ability of a test or assessment to consistently produce accurate results time after time, regardless of who is performing the assessment. 

Some studies have demonstrated that the signs of OHSA may be reliably identified when repeated by the same professional, or when assessed by two different professionals (1-5).

Accuracy is a measure of how well a test identifies true positives and true negatives. It is calculated as the proportion of individuals correctly identified by the test results.

The accuracy of the OHSA is determined by the ability of the test to identify individuals exhibiting a sign of dysfunction, as well as the ability of the test to differentiate between individuals exhibiting a sign of dysfunction, and those who exhibit normal variations in motion (1).

If the results from an assessment do not have a chance of altering the client/patient's intervention plan, do not use it. If the intervention plan will not be altered by either a positive or negative assessment, then it is a waste of time. Although this assertion may seem self-evident, many professionals learn 100s of assessments during their education and include dozens of assessments in their evaluation process. However, many of these same professionals have not considered the effects of each individual assessment on their intervention selection. Every assessment included in a movement professional's evaluation and re-assessment strategy should have the potential to refine intervention selection in a way that will improve outcomes.

 If a practitioner does not intend to perform any manual therapy, corrective exercise, or modalities with the intent of improving movement quality, then there is no reason to perform the Overhead Squat Assessment (OHSA). Note, that this is why the OHSA courses are mandatory for the Brookbush Institute's Human Movement Specialist (HMS) and Integrated Manual Therapist (IMT) certifications but are not mandatory for the Certified Personal Trainer (CPT) certification.

 Performing a Single-leg Squat Assessment (SLSA) after performing an Overhead Squat Assessment (OHSA) does not provide additional information. Further, the SLSA is far more likely to add contradicting information and reduce the reliability of intervention planning.

 Performing shoulder impingement syndrome (SIS) special tests may not be necessary because they lack the specificity to differentiate between SIS and other common shoulder pathologies (e.g. labrum tear, rotator cuff tear, acromioclavicular joint pain, etc.). The diagnosis of SIS does not aid in differentiating patient groups (and improving intervention selection), because all common shoulder pathologies are likely to result in positive findings for SIS special tests. A more efficient evaluation would remove the SIS special tests and replace them with assessments to "rule out" other common shoulder pathologies.

Why the Overhead Squat Assessment (OHSA)?

This assessment is designed to highlight deviations from ideal motion with the intent of informing intervention selection. This dynamic movement assessment is particularly well-designed for quickly assessing multiple body segments and highlighting altered movement 

 that may incorporate multiple joints, muscles, fascia, and/or neural structures. This category of assessments is different from most assessments, which attempt to identify dysfunction of a single structure or joint. For example, although a 

manual muscle test for the gluteus medius

, which is a sign implying altered alignment of the 

The OHSA is similar to a static postural assessment (e.g. Plumb Line Assessment). Both assessments are designed to highlight deviations from an ideal alignment of bones and joints. However, the OHSA could be considered a progression of the Plumb Line Assessment. Unlike the plumb line assessment, the OHSA is dynamic, functional (related to sit-to-stand transfer, squatting, and jumping), and requires an individual to test the full range of motion (ROM) of several joints, which likely results in the OHSA being a more sensitive assessment. The increased sensitivity of this assessment increases the reliability of certain signs that may be barely perceptible during a static posture assessment.

The Overhead Squat Assessment (OHSA) is NOT a Diagnostic Test

The OHSA is not designed to be a valid measure of joint or muscle pathological conditions, and it is not designed with the intent of aiding in differential diagnosis. Unlike special tests (e.g. 

, etc.) that are used to aid in determining the likelihood of pathological conditions, the OHSA is a movement assessment designed to highlight common "signs of dysfunction." Research has correlated these signs of dysfunction with many common orthopedic pathological conditions; however, it cannot be said that these signs are those conditions. If an OHSA results in signs that imply the presence of an orthopedic pathological condition (e.g., excruciating pain, abnormal balance issues, unique presentation, etc.), then additional testing or referral to an appropriate medical professional is recommended. Further, if the results from a subjective evaluation, special test, or diagnostic assessment imply that a physician consultation or imaging may be required to confirm or reject the possibility of a pathological condition, the OHSA may be contraindicated.

Recommended Use of the Overhead Squat Assessment (OHSA)

The Brookbush Institute recommends that the OHSA is one of several assessments used in a systematic approach to patient/client assessment and reassessment. Because this assessment is not intended to "clear patients for physical interventions" and is not designed to "highlight contraindications" (as discussed above), it is recommended that patients with complaints of pain or dysfunction are first assessed via subjective examination, diagnostic testing, and/or 

 (if these assessments are within the scope of practice of the professional). Because the OHSA challenges the dynamic flexibility and neuromuscular control of many of the large joints of the human body, it is recommended that the OHSA is the first movement assessment performed. The evaluation of the human body as a system of joints provides information regarding patterns of compensation and may imply relationships between joints and dysfunction that would be missed if assessed individually (e.g., asymmetrical ankle mobility contributing to low back pain). Following the OHSA, additional assessments can be added for measuring improvement (e.g. a continuous interval measure), and/or specific movement impairments (e.g. 

Clear for Activity and/or Identify Contraindications:

 Subjective examination, physical activity readiness questionnaire (PAR-Q), diagnostic testing, and/or special tests

Measuring Improvement and Specific Impairments:

Goniometry, muscle length tests, manual muscle testing

Necessary Prior Knowledge

 The OHSA is not a complicated assessment; however, analysis of the signs of dysfunction requires significant functional anatomy knowledge. It is recommended that before continuing with the 

 courses, an individual has passed, or could pass, all 22 courses in the "

" category. More functional anatomy knowledge will result in more accurate and thorough analysis and more sophisticated and effective intervention plans.

 Some experience with corrective/therapeutic exercise and/or manual therapy is also recommended. As mentioned above, this assessment is designed to highlight signs of dysfunction that are deviations from optimal alignment. The intent of identifying these signs is to address them with corrective interventions.

 The OHSA may be the most elegant assessment for identifying signs that can be matched to reliable intervention plans. That is, this assessment is particularly helpful for refining exercise selection for routines designed to enhance the quality of human movement.

 A dynamic movement assessment that combines end-range shoulder flexion with a squat (sit-to-stand transfer).

 An abnormality or impairment. A deviation from optimal.

Arthro- and osteo-kinematic alignment maintained by myofascial activity and length, as a result of sensation, integration, and activation by the nervous system - both statically and dynamically. For example, "good form" is an example of an ideal posture for a given exercise.

Evidence-based Definition of Ideal Posture/Alignment:

 A mean range of segment alignment (bone, joint, muscle, nerve) that is absent of signs correlated with dysfunction, pain, or an increased risk of injury.

For a more comprehensive review of movement science and concepts, we recommend the following course:

Lesson 22: Introduction to Human Movement Science

Set-up and Ideal Alignment: Overhead Head Squat Assessment (OHSA) Video 1

 to indicate the objective of the assessment or the signs you are attempting to identify. We do not want the client/patient attempting to "fix" their alignment.

Ask your patient/client to stand with feet hip-width apart.

Because a patient/client may assume a range of comfortable foot positions, it may be necessary to cue and manually adjust foot position so that the OHSA is started with the ideal foot position (or as close to the ideal foot position as can be achieved).

Ask your patient/client to reach "straight up over their head" with "elbows locked".

Ask your patient to "sit down" and "stand up" as many times as necessary to assess for the "signs of dysfunction".

For those who do not know how to squat or may be at risk of falls, this can be done with a chair, and thought of as a "sit-to-stand transfer assessment".

For advanced exercises and athletes who may "know what a squat should look like", it may be helpful to have them close their eyes, reducing visual input and their ability to self-correct

 It is tempting to start noting every "deviation" based on a personal frame-of-reference of squat form. The only signs that have been correlated with dysfunction and successful intervention are the signs discussed below. Adding additional signs to the assessment, however well-intentioned, may serve to invalidate the assessment, reduce assessment reliability, or reduce the relative efficacy of the implied interventions.

As mentioned above, this assessment is designed to highlight deviations from ideal motion with the intent of informing intervention selection. It may be helpful to review the definition (discussed above) of 

Evidence-based Ideal Posture/Alignment Definition:

The ideal alignment described here is similar to what may be anticipated during a static postural assessment or gait assessment. However, additional details have been added to aid in differentiating between ideal motion and the deviations discussed below.

 Ideal alignment includes feet parallel (2nd metatarsal and toe pointing forward), hip width, and the medial longitudinal arch maintained. That is, the 2nd metatarsals (center of the foot) are parallel, in alignment with the hip joints which are inferior to the anterior superior iliac spine (ASIS), and significant inferior motion of the navicular tubercle is not observed.

Although the neck of the femur extends the greater trochanter laterally and gives the appearance that the hip joints extend to the lateral thigh, the hip joints are only about 7" apart (6). This is about the same width as the ASIS, and the hip joints are in fact, just inferior and in near alignment with the ASIS. Because the hip joints cannot be palpated, the ASIS are used as the reference for hip width.

 The knees should maintain alignment with the hip joint and ankle joint. If optimal foot position is maintained, the anterior and posterior motion of the patella during the squat should align with the 2nd and 3rd metatarsals.

 Ideal alignment includes an optimal lumbar curve, ASIS just inferior to the level of the posterior superior iliac spine (PSIS) (within 2 cm), and the right and left iliac crest level.

During the lateral view of the OHSA, the intersection of the mid-axillary line, and a line between the ASIS and PSIS should be near 90º.

 The tibia and the mid-axillary line should maintain near-parallel alignment during a squat.

 Ideal alignment includes depression and retraction of the scapula. Shoulder flexion should be achieved via upward rotation and posterior tipping of the scapula.

 Ideal alignment is maintaining the arms in alignment with the torso with elbows at terminal extension. That is, 180º of shoulder flexion should be maintained.

Set-up and Ideal Alignment: Overhead Squat Assessment (OHSA) Video 1

Signs of Dysfunction: Overhead Squat Assessment (OHSA) Video 2

It is important to adhere to the pre-determined signs of dysfunction below for several reasons:

Intertester and intratester reliability are dependent on consistent observations by all assessors.

Research has demonstrated that the signs, or comparable assessment findings, are correlated with dysfunction, pain, and/or increased risk of injury.

The pre-dertminied signs observed during the OHSA imply a reliably effective set of techniques (an integrated intervention plan).

Although additional alignment issues may be observed, they may not have a correlation with pain, dysfunction, or an increased risk of injury.

Additional observations may not correlate with an intervention plan that is reliably effective.

Excessive lordosis (Anterior pelvic tilt)

Note: Each sign is discussed in detail in the additional courses:

Printable PDF of the Movement Assessment Template:

5 Steps for Analyzing Signs of Dysfunction: Overhead Squat Assessment (OHSA) Video 3

Understanding movement impairment starts with analyzing the most common signs of dysfunction and compensatory patterns. Each of the visually observable signs of dysfunction that is assessed during the overhead squat assessment (OHSA) is correlated with joint actions that are occurring excessively. For example, 

 = excessive ankle eversion. Based on these joint actions, relative changes in muscle length and activity may be inferred. The final step is a refinement of the description of inferred changes via a systematic review of relevant research. This final step is separate from the steps below and was performed by the Brookbush Institute, and covered in additional 

Using additional resources, a more comprehensive and accurate analysis can be constructed, and various interventions can be compared to identify the techniques and intervention plans resulting in the best possible outcomes. The Brookbush Institute has continued to refine analyses and recommendations through years of testing in an outcome-driven practice and the systematic review of all peer-reviewed and published research. These analyses are covered in the additional OHSA courses.

Prioritizing Multiple Assessed Signs of Dysfunction: Overhead Squat Assessment (OHSA) Video 4

As mentioned above, the Brookbush Institute recommends the OHSA as the first movement assessment performed. That is, the OHSA should follow a subjective assessment, a physical activity readiness questionnaire, and/or special tests if necessary, but precede additional movement assessments. The OHSA often implies the movement pattern that should be addressed, refining the selection of additional movement assessments for the involved joints.

 For example, a patient/client complains of "low back pain" and exhibits an 

 on the OHSA. An Excessive Forward Lean implies a loss of dorsiflexion and/or hip joint impairment, which may then be assessed using joint-specific assessments (e.g., goniometry, muscle length tests, manual muscle testing, and passive accessory motion examination).

 For example, a patient/client "feels weak during push-off," and a prior assessment by a medical professional noted a decrease in hip internal rotation range of motion (ROM). During the OHSA you identify that the patient exhibits the sign "

", implying that a lack of hip internal rotation and "weak push-off" may be correlated with a lower extremity compensation pattern.

 For example, a college athlete continues to get sidelined by nagging soreness in the left ankle, right knee, right hip, lower back, and neck. During the OHSA, you note the individual exhibits an asymmetrical weight shift, excessive forward lean, and arms falling. You start with the 

During an Overhead Squat Assessment (OHSA), most individuals exhibit multiple signs of dysfunction, and often, signs present asymmetrically from right to left. To ensure that the resulting intervention plans are reliable and effective, it is important to develop a systematic approach to selecting which sign you will focus on.

Heuristic for Prioritizing Multiple Assessed Signs

 A sign obstructing the individual from performing activities of daily living, recreation, or sport. This is often the sign most strongly correlated with patients' symptoms or complaints.

A sign that presents in different magnitudes on the left and right sides.

Most often, a "worst dysfunction" is hard to determine, but occasionally, a patient/client will present with an "obvious worst.

 If presented with multiple, bilateral dysfunctions (not asymmetrical), it is generally best practice to begin corrective interventions with the foot/ankle complex and progress up the body. 

 Clinical experience (and some research) suggests dysfunction "spreads" up from the lower extremity, faster than it "spreads" down from the upper extremity.

Clinical experience suggests it is more effective to address only the number of signs that can be comprehensively addressed during a single session (e.g. release, mobilize, lengthen, activate, integrate, and home exercise). Choosing just 1 or 2 techniques per dysfunction to attempt to address multiple dysfunctions during a single session is unlikely to result in optimal outcomes (e.g., "Jack of all trades and master of none"). If a sign is addressed with an effective intervention strategy, then improvement of that sign should be noted during reassessment, and using the prioritization filter (heuristic) discussed below will imply the "next" most important sign, which can then be addressed comprehensively.

Case Study

No obstruction, no asymmetry, and no worst dysfunction. 

Case Study: Overhead Squat Assessment, Prioritization, Analysis, and Corrective Intervention

Post, Eric G., et al. "The reliability and discriminative ability of the overhead squat test for observational screening of medial knee displacement." Journal of Sport Rehabilitation 26.1 (2017).

Rabin, A., & Kozol, Z. (2017). Utility of the overhead squat and forward arm squat in screening for limited ankle dorsiflexion. The Journal of Strength & Conditioning Research, 31(5), 1251-1258.

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.

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.

Overhead Squat Assessment: Introduction

Related Courses: