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Functional Assessments
in Athletes
James T. Kurtz, DC DACBSP, DACRB, CSCS, CES, PES
• Diplomate of American Chiropractic Board of
Sports Physicians
• Diplomate of American Chiropractic Rehabilitation
Board
• Certified Strength and Conditioning Specialist
• Corrective Exercise Specialist
• Performance Enhancement Specialist
Purpose of Functional
Assessments
• “Great clinicians perform
assessments to uncover the
cause of pain, then work to
eliminate the cause first,
followed by an intervention to
reduce the risk of reoccurrence
and enhance the robustness of
the patient.” - Stu McGill, Phd
• Every system in the body
requires movement for optimal
function and performance. We
are looking at how the body
moves.
Biomechanical Assessments
• Detect MSK abnormalities
that put athlete at risk of injury
• Virtually any athletic task can
become a test
• Provides feedback regarding
kinetic chain dysfunctions and
clue to compensatory
patterns i.e. joint dysfunction,
pain, soft tissue dysfunction
• Prevent injuries?
• Aid in development of a
comprehensive rehab plan
• Look at motor control,
flexibility, strength,
proprioception
• Elimination of intrinsic
faults prior to coaching
technique, training, or
rehab
• Assess progress
Assessment
• What are you going to
assess?
• What type of athlete are
you going to assess?
• What functions are most
important to their sport,
activity, or position?
• What are of major
importance? What are of
minor importance?
Micro vs Macro Tissue Injuries
• Macro: Positive ortho tests and imaging
• Micro: Negative ortho tests and imaging,
edema?
• Assessment tools need to be sensitive and
specific enough to detect micro tissue injury.
• History, palpation
Fascia
• Definition: all
collagenous fibrous
connective tissues
that can be seen as
elements of a body-
wide tensional force
transmission network
(First Fascia Research
Congress)
A whole body,
continuous, 3-D,
viscoelastic matrix of
structural support.
Anatomy Trains by Thomas Myers
Regional Interdependence
Wainner, Whitman, Cleland, Flynn. Regional interdependence.Journal of Ortho Sports
Physical Therapy 2007 37(11):658-660.
• The concept that seemingly unrelated
impairments in a remote anatomical region may
contribute to or be associated with the patient’s
primary complaint.
• When challenged the human body will always
sacrifice quality over quantity of movement.
Mobility-Stability Continuum
• Michael Boyle and Gray Cook
- Joint-by-joint training theory
or Mobility Stability Continuum
• Ankles, knees, hips, lumbar
spine, thoracic spine, cervical
spine, TMJ
• Joints with greatest natural
ROM = mobile
• Joints with limited ROM in at
least one plane = stable
All joints are multi-plane in
nature, but for stability/mobility, if
there is one primary motion, then
it is considered stable.
Mobility and Stability must
coexist to create efficient
movement in the human body.
They usually occur naturally.
Mobility-Stablity Model
Sitting is the new smoking
Mobility-Stability Model Compensation and incorrect body mechanics caused by
inadequate mobility and stability can produce poor efficiency,
require more energy, and increase the chance of dysfunction.
Hips Core T-spine
Sloppy
Stiff Stiff
Poor mobility can force stable segments to become mobile
segments. i.e. limited hip ROM can cause lumbar spine to become
unstable. The L-spine will sacrifice stability to obtain more motion.
This abnormal motion in the lumbar spine can be one of the primary
reasons for disc and facet injuries in the lower back.
Clinical Audit
Process
1. CC (chief complaint)
2. AI (activity intolerance)
3. MS (mechanical
sensitivity)
4. AMC (abnormal motor
control)
5. Re-set and/or training
6. Reassessment
Hip Hinge
Combined flexion and
compression is the quickest way
to injure the disc.
Adams MA, Hutton WC. Gradual disc prolapse. Spine
1985; 10:524-31.
Wade KR, Robertson PA, Thambyah A, Broom ND.
How healthy discs herniate: a biomechanical and
micro structural study investigating the combined
effects of compression rate and flexion. Spine 2014
Jun 1;39(13):1018-28.
Spinal Hinging
• The amount of recovery between
episodes of spinal hinging, also,
plays a role in whether load
exceeds tissue tolerance. When
tissue tolerance is exceeded, injury
occurs to the internal lamellae of
the annulus of the lumbar disc and
progresses outward.
• Inner layers of annulus are free of
nociceptive neurons. Pain is not
felt until compromise reaches well-
innervated/vascularized outer
layers of the disc or the resultant
disc bulge produces mechanical
pressure on the nerve roots.
Hip Hinge Genetics largely determine how
often and how much of this activity
can be tolerated before injury
occurs.
Battié MC, Videman T, Levälahti E, Kaprio J. Genetic and
environmental effects of disc degeneration by phenotype
and spinal level: a multivariate study. Spine (Phil PA
1976).2008 Dec 1;33(25):2801-8.
Videman T, Gibbons LE, Kaprio J, Battié MC.Challenging
the cumulative model:positive effects of greater body mass
on disc deneration.Spine J.2010 Jan;10(1):26-31.
In disc patients, often see tendency
to hinge excessively in the lumbar
spine vs the hips with forward
bending activity.
> 5 degree asymmetry, predictor of injury.
Malliaras, Pl, Cook, J.C., Kent, P. 2006. Reduced ankle dorsiflexion range may increase risk of patellar tendon injury
among volleyball players. Journal of Science and Medicine in Sports, 9, 304 - 309.
Fong, C.M. et al. 2011. Ankle dorsiflexion ROM and landing mechanics. Journal of Athletic Training. 46, 5.
Macrum, E, et al. 2012. Effects of limiting ankle dorsiflexion ROM on lower extremity kinematics and muscle-activation
patterns during a squat. Journal of Sport Rehabilitation, 21, 144.
Ankle Dorsiflexion Test
Overhead
Squat Test
Overhead
Squat Test
Overhead
Squat Test
Single Leg Squat Test
• Pass = 3, Pain = 0
• Can’t squat to 30 deg
knee flexion (1)
• Knee valgus (med to gr
toe)(1)
• Lumbar spine flexion (2)
• Anterior patellar shear (2)
• Trendelenberg sign (2)
• Hyperpronation (2)
Knee Valgus
• Dysfunctional movement
mechanics —> joint
stress and soft tissues of
kinetic chain
• Excessive rear foot
eversion and hip adduction
are risk factors for
patellofemoral joint pain
Barton, C. J., Levinger, P., et al 2012. The
relationship between rearfoot, tibial, and hip
kinematics in individuals with patellofemoral pain
syndrome. Clinical Biomechanics, 27, 702-705.
Single Leg Bridge
• Pelvic drop or rotation (1)
• Can’t maintain full hip
extension (2)
• Thighs don’t remain
parallel (2)
Side Bridge Endurance Test
• Mean endurance times for
healthy men and women =
84.5 s
• According to McGill,
asymmetry of > 15s could be
predictor of LBP.
McGill SM, Childs A, Liebenson C.Endurance times
for stabilization exercises:clinical targets for testing
and training from a normal database.Arch Phys Med
Rehabil 1999;80:941-944.
Flexor Endurance Test
• Normative data for men and
women = 134 secs
McGill, S.M. et al. (2010) Comparison of two
methods to quantify torso flexion
endurance. Occupational Ergonometrics, 9:
55-61.
Back Extensor Test • Normative data for men and
women = 173 secs
Biering-Sorenson,F.(1984) Physical
measurements as risk factors for low back
trouble over a one year period. Spine, 9: 106-
119.
• Teenagers with LBP have
stronger flexors and weaker
extensors compared to controls
Bernard, J.D., Boudokhane, S., et al. 2013.
Isokinetic trunk muscle performance in pre-teens
and teens with and without back pain. Annuals
of Physical and Rehabilitation Medicine, 57(1),
38-54.
Prone Plank Endurance Test
• Test duration should equal 100 secs
for both men and women
Strand S, Hjelm J, Shoepe T, Fajardo M, Norms for an
isometric muscle endurance test, J Human Kinetics.2014
Mar27;40:93-102.
Van Dillen, L.R., Bloom, N.J. et al, 2008 Hip
Rotation ROM in people with and without LBP
who participate in rotation-related sports. Physical
Therapy in Sports, 9, 72-81.
Hip Rotation
Side-to-side asymmetry
prevalent in those with LBP in
rotational sports
Hanging Scapular Clocks
Ida Portal
Kneeling Chop
Single Leg RDL
Pallof Press
Bear
Bird Dog
Hip Abduction Test
Single Leg Balance
Hamstring to quadricep
strength ratio has been shown to
be predictive of ACL injury in
female athletes.
Quad/Ham Ratio
Myer, G. D., Ford, K. R., et al 2009. The
relationship of hamstring and quadriceps
strength to ACL injury in female athletes.
Clinical Journal of Sport Medicine, 19, 3-8.
ER: IR ratio is predictive of in-
season shoulder injury in
baseball pitchers.
Shoulder Rotation
Strength Ratio
Byrum, L. R., Bushnell, B. D., et al. 2010.
Pre-season shoulder strength
measurements in professional baseball
pitchers identifying players at risk for
injury. The American Journal of Sports
Medicine, 38, 1375 - 1382.
• Predicting, preventing, and rehabilitating
hamstring injuries.
• Test-re-test reliability higher for bilateral
testing compared to unilateral testing.
• Athletes with a hamstring strain in the
previous 12 months still show a significant
weakness on the injured limb, despite
“successful” rehabilitation.
• Nordbord test has good reliability and is
able to identify those who have suffered
previous hamstring injury within a 12
month time period.
Opar et al. A novel device using the nordic hamstring exercise
to assess eccentric knee flexor strength: A reliability and retrospective
injury study.J ortho sports phys thera 2013;43(a):636-640.
Nordic Hamstring Exercise
Hamstring Strengthening
• A substantial portion of
hamstring strain injuries in
running occur in the long
head of biceps femoris.
• Nordics have been found to
reduce hamstring strain
injuries
• The Nordic exercise, highest
eccentric EMG of any of the
10 exercises tested.