Over the past several years, the trend in the health and fitness industry has been toward injury prevention and movement screening. Gray Cook and Lee Burton have given us the FMS. More recently, the Y-Balance test has emerged as another tool to assess asymmetry in the upper and lower quarter.
I am currently FMS certified and planning to attend the SFMA course next month in Durham. I routinely incorporate the FMS in both our rehab and sports performance work at the APC. I like many things about the screening exam. It provides a consistent tool to assess baseline movement and record asymmetry on a simple 4 point scale scale. It also has been shown to have good intra and inter-rater reliability. Click here for a recent study published in the Journal or Orthopaedic & Sports Physical Therapy.
For those unfamiliar with the screen, it is 7 tests scored on a 0-3 scale as follows:
- 0 = pain
- 1 = unable to perform the movement pattern (or perform with marked dysfunction)
- 2 = performs the movement with a mild compensation
- 3 = performs the movement correctly
I would say on average, most of the athletes I screen score between a 12 and 15. My highest score was a 19 (9 year old gymnast) and my lowest was a 9 (NFL lineman). As screeners, we are charged with uncovering asymmetry and faulty movement patterns. What do you see in the following picture?
Clearly, the dowel is not level, thus we score it a 2. She also had some ER in the right leg when stepping over the hurdle. She was a symmetrical 2 on the hurdle step test. This is a Division I soccer player who scored 17 on the exam.
Most of the movements seem straightforward. However, many question what the rotary stability test measures with respect to the ideal 3 score (ipsilateral movement)? It assesses an unnatural movement pattern to be sure. This athlete failed miserably on the ipsilateral pattern but scored a solid 2 with the contralateral pattern.
I have yet to test someone who can score a legitimate 3. I have seen some get a 3 on one side and 2 on the other (asymmetrical and a red flag in FMS land). As one who naturally questions things, I find myself questioning how many are truly capable of scoring a 3.
As I continue to evolve as a clinician and strength coach, I always question the real “why” and “how” behind everything. My biggest questions remaining about the FMS itself are:
1) Can athletes learn to beat the test without truly cleaning up imbalances? In other words, how does cueing and familiarity change performance on the screen?
2) Does asymmetry and/or scores at or below 14 on the FMS really predict increased injury risk?
3) Should it be used as a final tool to clear injured athletes for return to sport based on scoring?
These are some of the big questions I find myself wrestling with and searching for answers to on a daily basis right now. I recently had a 15 year old female reach the 6 month mark of her ACL rehab. Her single leg squat was symmetrical. Her timed hop and cross-over hop tests were even. Her single leg broad hop was 95% of the uninvolved side. She had no swelling and excellent graft stability. Her only lingering issue was that she did not have full flexion in her knee.
Here is the conundrum. Her FMS score was a 12. She got a 1 on the deep squat and a 1 on her trunk stability push-up. All other scores were symmetrical 2’s. Her deep squat was limited by some residual stiffness in knee flexion as she did no PT prior to surgery and did not start PT until 3 weeks post-op and had already developed a flexion contracture.
In addition to her FMS scores, I looked at Y-Balance scores and she had only one true asymmetry out of the three reaching directions (defined as greater than a 4 cm difference). We are testing some new software in our cliic that takes all of this data into account and then spits out a risk factor for injury. According to the software, my patient was at moderately increased risk for injury.
Hmmm….. Does that mean she can not return to soccer training? Should we wait until she gets a 2 or 3 on the deep squat? Some would say yes. While I agree that we need to get her deep squat better, I am not sure if I would classify her as at moderately increased risk for injury. I think the jury is still out on that one. I believe we have to look at everything. She is currently continuing work with our sports staff to increase mobility, strength and movement patterns as she transitions back to soccer specific training/technical work.
Her gait, single leg stability, single leg strength and deceleration mechanics are solid. Should this score on the FMS be considered strong enough to hold her back from return to sport? Is she more likely to get hurt with her score of 12? Well, I am not the only one wondering these things.
In a recent study by Staurt McGill in the Journal of Strength & Conditioning Research, he looked at FMS scoring. He and the other authors also applied some other scoring to it with three groups (two receiving an intervention and one control group). He essentially finds that the scores may provide a momentary picture of one’s movement, but that further work needs to be done to determine how to more effectively administer the test, interpret results and generate more reliable test scores. Click here to read the abstract.
The authors in this study point out a few key things we must keep in mind:
- It is not perfectly clear what tasks should be graded when trying to predict injury risk
- Task performance can be impacted by coaching or feedback thus making it difficult to rank movement quality over multiple testing sessions
- Need to draw the distinction between what athlete “can do” and what they “choose to do” (habitual or fall back strategies)
I think the neural contributions to movement cannot be understated. People will tend to draw on natural feed forward mechanisms of movement. Their inherent patterns may be flawed. These patterns can certainly be impacted by flexibility, joint mobility, weakness and prior injury. I think as we move forward, we must continue to study how screening is linked with exercise prescription and evaluation of the efficacy of said exercises.
We must continue to question how we measure the quality of movement. We need to critically evaluate how we use assessments to drive our rehab, training and corrective exercise selections. Does the FMS truly predict injury across all populations? Should low scores keep athletes off the field? Finally, we must try to determine if and how our re-assessments measure the efficacy of our exercise interventions.
In the meantime, I will continue to use the FMS and other screening tools to gather as much information as I can about how my athletes move. The integration of this information and influence in my decision making as well as communications with my clientele that continue to require careful consideration. I look forward to learning more and seeking the answers to many of these questions moving forward.