Breaking Down the Initial Evaluation, Part 4: Movement Assessment

 

The previous posts discussed static postural assessment. I never solely conduct a static postural assessment and establish my diagnosis. We, as physical therapists, are movement experts and therefore, while I can utilize a static postural assessment to guide my clinical evaluation, I am more interested in seeing how my client moves. More importantly, I am interested in how they move in weight bearing positions because we often are required to do so in our daily lives. I utilize the SFMA primarily and add in other movement patterns depending on the client’s sport (running assessment if there is a running component to their sport/activity, for example). A basic run-down of the SFMA is that it uses 7 top-tier movement patterns starting with the cervical spine to the overhead deep squat and single leg balance. Each top-tier pattern can be broken down into its component tests to determine whether the dysfunction is soft tissue, joint, or stability/motor control related.

I won’t be going over the entire SFMA top-tier screen in detail– if you want to know more, please attend a live SFMA weekend course – but I will be picking some of the clinical highlights from select movement patterns to help guide your clinical decision making and localizing the source of the pain more efficiently in an evaluation.

A big “principle” in the SFMA is if the client can’t perform the movement in standing, change the stability requirements and re-assess. If reducing the stability requirements for that particular movement increases ROM, then the primary deficit is in motor control/motor recruitment. For example, for cervical flexion, if the client is unable to touch their chin to their chest in standing, but is able to in supine, there can’t be a joint mobility problem because they can perform the movement when their cervical musculature is on slack – therefore, it must be over recruitment of cervical musculature when in weight bearing. Since utilizing the SFMA, I’ve begun to realize that I need to further test to distinguish what is causing a ROM deficit – is it a true joint hypomobility or is it more of a stability motor control deficit. Many patients may appear to have a lack of ROM, but if tested further, you may find that they just don’t know how to control their range. If you’ve further tested by eliminating body parts or reducing stability requirements and the client still has decreased range, then biomechanical assessment is warranted to determine the cause of joint hypomobility.

The first movement I’d like to review is the multi-segmental flexion. The client essentially locks out their knees (feet together, for consistency in every position besides single leg balance and overhead squat) and bends forward and tries to touch their toes. Most people who can’t reach their toes automatically assume they have tight hamstrings. However, this may not be the case. When I see someone perform this movement and they can’t touch their toes, I re-assess them after they have activated their core – I place a foam roller in between their legs and ask them to squeeze it hard and repeat the motion. If they gain more range with this modification, it tells me they have a weak core and their hamstrings are, more or less, “holding on for dear life” for stability. If they don’t gain more range, then it’s a possibility that they have tight hamstrings. **A neat trick in the clinic is you can differentiate which side is tight by unweighting each side and repeating the motion – unweight by flexing the knee on the side you are trying to put on slack.

The second movement pattern is multi-segmental extension. One of the criteria for this movement to be scored “functional” is that the ASIS have to translate anteriorly and clear the toes. I’ve found that when it doesn’t, there is an extension deficit at the hip. I further assess this with a “step up with opposite knee march to 90°”. With this follow-up test, I can determine if the client achieves hip extension through lumbar compensation. Either way, I would assess joint mobility of the hip in prone and sitting to conclude if it is a joint/soft tissue dysfunction or stability/motor control dysfunction.

Single leg balance is something I work on with a majority of my clients with low back and lower extremity diagnoses. One point that the SFMA makes about this pattern is that difficulty with single leg balance is not always a proprioception deficit – in fact they make a point to say that until you have ruled out all other possibilities (ankle ROM, vestibular, visual, core, hip stability etc…) you can’t be certain it’s a proprioception deficit. I tend to agree, as I have found that hip and core weakness are more common culprits (again, hips and core….). In the breakouts, one that I have tended to gravitate towards automatically is differentiating hip weakness and core weakness. Half kneeling on an airex pad loads both the hips and the spine while quadruped “bird dog” loads only the hips. By performing these two quick assessments, you will be able to tease out if the hips or the core require more neuromuscular re-education. **Side bar – I know that the core is still required to activate in quadruped, however the differentiation is that the spine is not loaded in this position, and therefore the stability requirements are different. Half kneeling is more demanding and loads the spine more than quadruped.**

With athletes, in addition to the SFMA top tier tests and their breakout components, I always like to add a jumping and/or running component to the evaluation. Most sports will have a jumping or running aspect and watching a client jump on and off a box to see how they land as well as how they run and how their body is moving during dynamic movements is vital. Golf will be a special topic discussed later in the future because it does not fit this rule, it is rather an exception, of having a jump or run aspect – it is mostly rotation and there are separate tests you can do for golfers.

This concludes the first topic series on the initial evaluation. Everything from here on out will build off of the information presented in these previous 4 posts as well as provide new, additional insight. The next planned topic series will discuss the Overhead Athlete. I hope you guys enjoyed this first topic series. Please comment below if you have any suggestions of topics to cover. Thanks, again.

2 thoughts on “Breaking Down the Initial Evaluation, Part 4: Movement Assessment

  1. Notyouraveragephysio,

    I am loving your post so far and agree with the importance of posture before diving further into the evaluation process. I have not been able to take the SFMA course yet so I am unfamiliar with some of the concepts you bring up in this post. Would you mind explaining in more detail the lack of extension and how the step up concept provides you with more feedback? Thanks a lot.

    Like

    1. Hey Dr. HaleyBailey,

      Thank you for your comment and question. The step up test that you are referring to actually isn’t part of the SFMA – it’s a test that I started to use after noticing that many of my clients would perform a step up with increased posterior trunk lean. The purpose of the “step up with opposite knee march to 90*” is multi-layered. First, the non-stance pelvis will be posteriorly rotated in relation to the stance side. This will put the stance pelvis in “relative” anterior tilt. Second, unilateral hip extension is required to maintain balance. What I started to notice is that if the client lacks either core stability or hip/glute activation, they will start to extend from their lumbar spine (compensation due to the relative anterior tilt of the stance side) in order to complete the motion. Therefore, functional weight bearing hip extension is lacking – they may have it passively or even in prone, but lack it in standing. I would also follow up with a biomechanical test of the hip joint in sitting and prone to make sure they don’t have any femoral ante or retro-version/torsion that would cause decreased hip extension.

      Hope that helps

      #NotYourAveragePhysio

      Like

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