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<p>NASM’s Essentials of</p><p>Corrective Exercise Training</p><p>Micheal A. Clark, DPT, MS, PES, CES</p><p>Chief Executive Officer</p><p>National Academy of Sports Medicine</p><p>Mesa, AZ</p><p>Scott C. Lucett, MS, PES, CES, NASM—CPT</p><p>Director of Education</p><p>National Academy of Sports Medicine</p><p>Mesa, AZ</p><p>NASM_FM.indd iNASM_FM.indd i 7/5/2010 8:47:30 PM7/5/2010 8:47:30 PM</p><p>Acquisitions Editor: Emily Lupash</p><p>Product Manager: Andrea Klingler</p><p>Marketing Manager: Christen Murphy</p><p>Designer: Teresa Mallon</p><p>Compositor: SPi Technologies</p><p>First Edition</p><p>Copyright © 2011 Lippincott Williams & Wilkins, a Wolters Kluwer business</p><p>351 West Camden Street Two Commerce Square</p><p>Baltimore, MD 21201 2001 Market Street</p><p>Philadelphia, PA 19103</p><p>Printed in China</p><p>All rights reserved. This book is protected by copyright. No part of this book may be reproduced</p><p>or transmitted in any form or by any means, including as photocopies or scanned-in or other</p><p>electronic copies, or utilized by any information storage and retrieval system without written</p><p>permission from the copyright owner, except for brief quotations embodied in critical articles</p><p>and reviews. Materials appearing in this book prepared by individuals as part of their offi cial</p><p>duties as U.S. government employees are not covered by the above-mentioned copyright. To</p><p>request permission, please contact Lippincott Williams & Wilkins at Two Commerce Square,</p><p>2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via website</p><p>at lww.com (products and services).</p><p>Library of Congress Cataloging-in-Publication Data</p><p>NASM essentials of corrective exercise training/[edited by] Micheal A. Clark, Scott C. Lucett.</p><p>— 1st ed.</p><p>p. ; cm.</p><p>Other title: Essentials of corrective exercise training</p><p>Includes bibliographical references and index.</p><p>ISBN 978-0-7817-6802-3 (alk. paper)</p><p>1. Exercise therapy. I. Clark, Micheal. II. Lucett, Scott. III. National Academy of Sports</p><p>Medicine. IV. Title: Essentials of corrective exercise training.</p><p>[DNLM: 1. Athletic Injuries—rehabilitation. 2. Athletic Injuries—diagnosis. 3. Athletic</p><p>Injuries—prevention & control. 4. Exercise Movement Techniques. 5. Exercise Therapy—</p><p>methods. 6. Sports Medicine. QT 261 N255 2011]</p><p>RM725.N373 2011</p><p>615.8’2—dc22</p><p>2010023998</p><p>DISCLAIMER</p><p>Care has been taken to confirm the accuracy of the information present and to describe gener-</p><p>ally accepted practices. However, the authors, editors, and publisher are not responsible for</p><p>errors or omissions or for any consequences from application of the information in this book</p><p>and make no warranty, expressed or implied, with respect to the currency, completeness, or</p><p>accuracy of the contents of the publication. Application of this information in a particular situa-</p><p>tion remains the professional responsibility of the practitioner; the clinical treatments described</p><p>and recommended may not be considered absolute and universal recommendations.</p><p>The authors, editors, and publisher have exerted every effort to ensure that drug selection</p><p>and dosage set forth in this text are in accordance with the current recommendations and prac-</p><p>tice at the time of publication. However, in view of ongoing research, changes in government</p><p>regulations, and the constant fl ow of information relating to drug therapy and drug reactions,</p><p>the reader is urged to check the package insert for each drug for any change in indications and</p><p>dosage and for added warnings and precautions. This is particularly important when the recom-</p><p>mended agent is a new or infrequently employed drug.</p><p>Some drugs and medical devices presented in this publication have Food and Drug Admin-</p><p>istration (FDA) clearance for limited use in restricted research settings. It is the responsibility</p><p>of the health care provider to ascertain the FDA status of each drug or device planned for use</p><p>in their clinical practice.</p><p>To purchase additional copies of this book, call our customer service department at</p><p>(800) 638-3030 or fax orders to (301) 223-2320. International customers should call</p><p>(301) 223-2300.</p><p>Visit Lippincott Williams & Wilkins on the Internet: http://www.lww.com. Lippincott</p><p>Williams & Wilkins customer service representatives are available from 8:30 am to 6:00 pm, EST.</p><p>9 8 7 6 5 4 3 2 1</p><p>NASM_FM.indd iiNASM_FM.indd ii 7/5/2010 8:47:31 PM7/5/2010 8:47:31 PM</p><p>http://www.lww.com</p><p>NASM’s Essentials of Corrective Exercise Training Mission</p><p>To provide health and fitness professionals with the best evidence-based</p><p>injury prevention education, systems, and solutions</p><p>NASM_FM.indd iiiNASM_FM.indd iii 7/5/2010 8:47:31 PM7/5/2010 8:47:31 PM</p><p>THE following code of ethics is designed to assist certifi ed and non-certified</p><p>members of the National Academy of Sports Medicine (NASM) to uphold (both</p><p>as individuals and as an industry) the highest levels of professional and ethical</p><p>conduct. This Code of Ethics refl ects the level of commitment and integrity</p><p>necessary to ensure that all NASM members provide the highest level of ser-</p><p>vice and respect for all colleagues, allied professionals and the general public.</p><p>Professionalism</p><p>Each certifi ed or non-certifi ed member must provide optimal professional ser-</p><p>vice and demonstrate excellent client care in his/her practice. Each member</p><p>shall:</p><p>1. Abide fully by the NASM Code of Ethics.</p><p>2. Conduct themselves in a manner that merits the respect of the public,</p><p>other colleagues and NASM.</p><p>3. Treat each colleague and/or client with the utmost respect and dignity.</p><p>4. Not make false or derogatory assumptions concerning the practices of col-</p><p>leagues and/or clients.</p><p>5. Use appropriate professional communication in all verbal, non-verbal and</p><p>written transactions.</p><p>6. Provide and maintain an environment that ensures client safety that, at</p><p>minimum, requires that the certifi ed or non-certifi ed member:</p><p>a. Shall not diagnose or treat illness or injury (except for basic fi rst aid)</p><p>unless the certifi ed or non-certifi ed member is legally licensed to do so</p><p>and is working in that capacity, at that time.</p><p>b. Shall not train clients with a diagnosed health condition unless the cer-</p><p>tifi ed or non-certifi ed member has been specifi cally trained to do so,</p><p>is following procedures prescribed and supervised by a valid licensed</p><p>medical professional, or unless the certifi ed or non-certifi ed member is</p><p>legally licensed to do so and is working in that capacity at that time.</p><p>c. Shall not begin to train a client prior to receiving and reviewing a current</p><p>health-history questionnaire signed by the client.</p><p>d. Shall hold a CPR certifi cation at all times.</p><p>7. Refer the client to the appropriate medical practitioner when, at mini-</p><p>mum, the certifi ed or non-certifi ed member:</p><p>a. Becomes aware of any change in the client’s health status or medication</p><p>b. Becomes aware of an undiagnosed illness, injury or risk factor</p><p>c. Becomes aware of any unusual client pain and/or discomfort during the</p><p>course the training session that warrants professional care after the ses-</p><p>sion has been discontinued and assessed</p><p>National Academy of Sports Medicine</p><p>Code of Ethics</p><p>NASM_FM.indd ivNASM_FM.indd iv 7/5/2010 8:47:31 PM7/5/2010 8:47:31 PM</p><p>8. Refer the client to other healthcare profes-</p><p>sionals when nutritional and supplemental</p><p>advice is requested unless the certifi ed or</p><p>non-certifi ed member has been specifi cally</p><p>trained to do so or holds a credential to do</p><p>so and is acting in that capacity at the time.</p><p>9. Maintain a level of personal hygiene appro-</p><p>priate for a health and fitness setting.</p><p>10. Wear clothing that is clean, modest and pro-</p><p>fessional.</p><p>11. If certifi ed, remain in good standing and</p><p>maintain current certifi cation status by</p><p>acquiring all necessary continuing-education</p><p>requirements (see NASM Recertifi cation</p><p>Information).</p><p>Confi dentiality</p><p>Each certifi ed and non-certifi ed member shall</p><p>respect the confi dentiality of all client informa-</p><p>tion. In his/her professional role, the certifi ed or</p><p>non-certifi ed member:</p><p>1. Protect the client’s confi dentiality</p><p>The starting</p><p>point for a lift, the proper posture, the ability (or inability) to develop tension</p><p>when reacting or correcting a movement are all impacted by the length of the</p><p>muscle when stimulated. Just as the position of one joint can drastically affect</p><p>other joints, a change in joint angle can affect the tension produced by mus-</p><p>cles that surround the joint. If muscle length is altered as a result of misalign-</p><p>ment (i.e., poor posture), then tension development will be reduced and the</p><p>muscle will be unable to generate proper force for effi cient movement. With</p><p>movement at one joint being interdependent on movement or preparation for</p><p>movement of other joints, any dysfunction in the chain of events producing</p><p>movement will have direct effects elsewhere (2,10).</p><p>FORCE-VELOCITY CURVE AND FORCE-COUPLE RELATIONSHIPS</p><p>The force-velocity curve refers to the relationship of a muscle’s ability to pro-</p><p>duce tension at differing shortening velocities. This hyperbolic relationship</p><p>shows that as the velocity of a concentric contraction increases, the devel-</p><p>oped tension decreases (Figure 2-11). The velocity of shortening appears to be</p><p>related to the maximum rate at which the cross-bridges can cycle and be infl u-</p><p>enced by the external load (17). Conversely, with eccentric muscle action, as</p><p>the velocity of muscle action increases, the ability to develop force increases.</p><p>This is believed to be the result of the use of the elastic component of the con-</p><p>nective tissue surrounding and within the muscle (1,4–6,16–18).</p><p>Muscles produce a force that is transmitted to bones through elastic and con-</p><p>nective tissues (tendons). Because muscles are recruited as groups, many</p><p>muscles will transmit force onto their respective bones, creating movement</p><p>at the joints (1,5,8). This synergistic action of muscles to produce movement</p><p>around a joint is also known as a force-couple (1,5,8). Muscles in a force-</p><p>couple provide divergent tension to the bone or bones to which they attach.</p><p>Because each muscle has different attachment sites and lever systems, the</p><p>tension at different angles creates a different force on that joint. The motion</p><p>that results from these forces depends on the structure of the joint, the intrin-</p><p>sic properties of each fi ber, and the collective pull of each muscle involved</p><p>(Figure 2-12).</p><p>Force-velocity curve:</p><p>the relationship of</p><p>a muscle’s ability to</p><p>produce tension at</p><p>differing shortening</p><p>velocities.</p><p>Force-couple: the</p><p>synergistic action of</p><p>muscles to produce</p><p>movement around a</p><p>joint.</p><p>Figure 2.10 Length-tension relationships.</p><p>F</p><p>or</p><p>ce</p><p>Sarcomere length</p><p>Resting length</p><p>Figure 2.11 Force-velocity curves.</p><p>Concentric</p><p>contraction</p><p>Eccentric</p><p>contraction</p><p>M</p><p>us</p><p>cl</p><p>e</p><p>fo</p><p>rc</p><p>e</p><p>Velocity of contraction</p><p>NASM_Chap02.indd 19NASM_Chap02.indd 19 7/5/2010 9:42:24 PM7/5/2010 9:42:24 PM</p><p>20 CHAPTER 2</p><p>Figure 2.12 Force-couple relationships.</p><p>Upper</p><p>trapezius</p><p>Serratus</p><p>anterior</p><p>Middle</p><p>trapezius</p><p>Lower</p><p>trapezius</p><p>Figure 2.13 Effi cient human movement.</p><p>Optimal</p><p>neuromuscular control</p><p>Normal length-</p><p>tension relationships</p><p>Normal force-</p><p>couple relationships</p><p>Optimal sensorimotor</p><p>integration</p><p>Optimal neuromuscular</p><p>efficiency</p><p>Optimal tissue</p><p>recovery</p><p>Normal joint</p><p>arthrokinematics</p><p>In reality, however, every movement we produce must involve all muscle</p><p>actions (eccentric, isometric, concentric) and functions (agonists, synergists,</p><p>stabilizers, and antagonists) to ensure proper joint motion as well as minimize</p><p>NASM_Chap02.indd 20NASM_Chap02.indd 20 7/5/2010 9:42:25 PM7/5/2010 9:42:25 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 21</p><p>unwanted motion. Therefore, all muscles working together for the production</p><p>of proper movement are working in a force-couple (1,5,8). Proper force-couple</p><p>relationships are needed so that the HMS moves in the desired manner. This</p><p>can only happen if the muscles are at the optimal length-tension relationships</p><p>and the joints have proper arthrokinematics (or joint motion). Collectively,</p><p>optimal length-tension relationships, force-couple relationships, and arthro-</p><p>kinematics produce ideal sensorimotor integration and ultimately proper and</p><p>effi cient movement (2,3) (Figure 2-13).</p><p>Muscular Leverage and Arthrokinematics</p><p>The amount of force that the human movement system can produce depends</p><p>not only on motor unit recruitment and muscle size but also on the lever sys-</p><p>tem of the joint (1,4). A lever system is composed of some force ( muscles),</p><p>a resistance (load to be moved), lever arms (bones), and a fulcrum (the</p><p>pivot point). Three classes of levers are present in the body (Figure 2-14).</p><p>A fi rst class lever has the fulcrum between the force/effort(E) and the load/</p><p>resistance(R). A second class lever has the load between the force and the</p><p>fulcrum. Third class levers, the most common in the body, have the pull</p><p>between the load and the fulcrum.</p><p>E</p><p>E</p><p>E</p><p>R</p><p>R</p><p>R</p><p>ER R</p><p>E</p><p>R</p><p>F</p><p>E</p><p>F FF</p><p>F</p><p>F</p><p>Figure 2.14 Levers.</p><p>NASM_Chap02.indd 21NASM_Chap02.indd 21 7/5/2010 9:42:29 PM7/5/2010 9:42:29 PM</p><p>22 CHAPTER 2</p><p>In the HMS, the bones act as lever arms that move a load from the</p><p>force applied by the muscles. This movement around an axis can be termed</p><p>rotary motion and implies that the levers (bones) rotate around the axis (joints)</p><p>(4,5,9). This “turning” effect of the joint is often referred to as torque (10,19).</p><p>In resistance training, torque (distance from the load to the center of the</p><p>axis of rotation X the force) is applied so we can move our joints. Because the</p><p>neuromuscular system is ultimately responsible for manipulating force, the</p><p>amount of leverage the HMS will have (for any given movement) depends on</p><p>the leverage of the muscles in relation to the resistance. The difference between</p><p>the distance that the weight is from the center of the joint, the muscle’s attach-</p><p>ment and it’s line of pull (direction through which tension is applied through</p><p>the tendon) will determine the effi ciency with which the muscles manipulate</p><p>the movement (1,4,5,9). Because we cannot alter the attachment sites or the line</p><p>of pull of our muscles through the tendon, the easiest way to alter the amount</p><p>of torque generated at a joint is to move the resistance. In other words, the</p><p>closer the weight is to the point of rotation (the joint), the less torque it creates</p><p>(Figure 2-15). The farther away the weight is from the point of rotation, the more</p><p>torque it creates.</p><p>For example, to hold a dumbbell straight out to the side at arm’s length</p><p>(shoulder abduction), the weight may be approximately 24 inches from the</p><p>center of the shoulder joint. The prime mover for shoulder abduction is the</p><p>deltoid muscle. Let’s say its attachment is approximately two inches from</p><p>the joint center. That is a disparity of 22 inches (or roughly 12 times the</p><p>difference). If the weight is moved closer to the joint center, let’s say to the</p><p>Rotary motion: move-</p><p>ment of the bones</p><p>around the joints.</p><p>Torque: a force that</p><p>produces rotation.</p><p>Common unit of</p><p>torque is the newton-</p><p>meter or N·m.</p><p>Figure 2.15 Load and torque relationship.</p><p>U</p><p>pp</p><p>er</p><p>e</p><p>xt</p><p>re</p><p>m</p><p>ity</p><p>w</p><p>ei</p><p>gh</p><p>t (</p><p>w</p><p>)</p><p>Shoulder abduction angle (degrees)</p><p>0 30 60 90 120 150 180</p><p>Abductor muscle force</p><p>Compression load on joint</p><p>NASM_Chap02.indd 22NASM_Chap02.indd 22 7/5/2010 9:42:30 PM7/5/2010 9:42:30 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 23</p><p>elbow, the resistance is only approximately 12 inches from the joint center.</p><p>Now the difference is only 10 inches or fi ve times greater. Essentially, the</p><p>torque required to hold the weight was reduced by half. Many people per-</p><p>forming side lateral raises with dumbbells (laterally raising dumbbells to</p><p>the side) do this inadvertently by fl exing their elbow, bringing the weight</p><p>closer to the shoulder joint and effectively reducing the required torque.</p><p>Health and fi tness professionals can use this principle as a regression for</p><p>exercises that are too demanding, reducing the torque placed on the HMS,</p><p>or as a progression to increase the torque and place a greater</p><p>demand on</p><p>the HMS.</p><p>FUNCTIONAL ANATOMY</p><p>Traditionally, anatomy has been taught in isolated, fragmented components.</p><p>The traditional approach mapped the body, provided simplistic answers about</p><p>the structures, and categorized each component. Looking at each muscle as an</p><p>isolated structure fails to answer complex questions, such as “How does the</p><p>human movement system function as an integrated system?” Or even more</p><p>simply, “What do our muscles do when we move?” The everyday functioning</p><p>of the human body is an integrated and multidimensional system, not a series</p><p>of isolated, independent pieces. During the last 25 years, traditional training</p><p>has focused on training specifi c body parts, often in single, fi xed planes of</p><p>motion. The new paradigm is to present anatomy from a functional, integrated</p><p>perspective. The health and fi tness professional armed with a thorough under-</p><p>standing of functional anatomy will be better equipped to select exercises and</p><p>design programs.</p><p>Although muscles have the ability to dominate a certain plane of motion,</p><p>the central nervous system optimizes the selection of muscle synergies</p><p>(1,20–25), not simply the selection of individual muscles. The central nervous</p><p>system coordinates deceleration, stabilization, and acceleration at every joint</p><p>in the HMS in all three planes of motion. Muscles must also react proprio-</p><p>ceptively to gravity, momentum, ground reaction forces, and forces created</p><p>by other functioning muscles. Depending on the load, the direction of resis-</p><p>tance, body position, and the movement being performed, muscles will par-</p><p>ticipate as an agonist, antagonist, synergist, or stabilizer. Although they may</p><p>have different characteristics, all muscles work in concert with one another</p><p>to produce effi cient motion (1,23,24,26,27). Agonists are muscles that act as</p><p>prime movers. For example, the gluteus maximus is the prime mover for hip</p><p>extension. Antagonists are muscles that act in direct opposition to prime mov-</p><p>ers. For example, the psoas (hip fl exor) is antagonistic to the gluteus maximus.</p><p>Synergists are muscles that assist prime movers during functional movement</p><p>patterns. For example, the hamstring complex and the erector spinae are syn-</p><p>ergists to the gluteus maximus during hip extension. Stabilizer muscles sup-</p><p>port or stabilize the body while the prime movers and the synergists perform</p><p>the movement patterns. For example, the transversus abdominus, internal</p><p>oblique, multifi dus, and deep erector spinae muscles stabilize the lumbo-</p><p>pelvic-hip complex (LPHC) during functional movements while the prime</p><p>movers and synergists perform functional activities.</p><p>Agonists: muscles that</p><p>act as prime movers.</p><p>Antagonists: muscles</p><p>that act in direct oppo-</p><p>sition to prime movers.</p><p>Synergists: muscles</p><p>that assist prime mov-</p><p>ers during functional</p><p>movement patterns.</p><p>Stabilizers: muscles</p><p>that support or</p><p>stabilize the body</p><p>while the prime mov-</p><p>ers and the synergists</p><p>perform the movement</p><p>patterns.</p><p>NASM_Chap02.indd 23NASM_Chap02.indd 23 7/5/2010 9:42:31 PM7/5/2010 9:42:31 PM</p><p>24 CHAPTER 2</p><p>Traditional training has focused almost exclusively on uniplanar, concen-</p><p>tric force production. But this is a shortsighted approach as muscles function</p><p>synergistically in force-couples to produce force, reduce force, and dynami-</p><p>cally stabilize the entire HMS; they function in integrated groups to provide</p><p>control during functional movements (5,8,9,28). Realizing this allows one to</p><p>view muscles functioning in all planes of motion throughout the full spectrum</p><p>of muscle action (eccentric, concentric, isometric).</p><p>Current Concepts in Functional Anatomy</p><p>It has been proposed that there are two distinct, yet interdependent, muscular</p><p>systems that enable our bodies to maintain proper stabilization and ensure effi -</p><p>cient distribution of forces for the production of movement (28–30). Muscles</p><p>that are located more centrally to the spine provide intersegmental stability</p><p>(support from vertebra to vertebra), whereas the more lateral muscles support</p><p>the spine as a whole (30). Bergmark (28) categorized these different systems in</p><p>relation to the trunk into local and global muscular systems.</p><p>JOINT SUPPORT SYSTEM</p><p>The Local Muscular System (Stabilization System)</p><p>The local musculature system consists of muscles that are predominantly</p><p>involved in joint support or stabilization (3,28–31) (Figure 2-16). It is impor-</p><p>tant to note, however, that joint support systems are not confi ned to the spine</p><p>and are evident in peripheral joints as well. Joint support systems consist of</p><p>muscles that are not movement specifi c, rather they provide stability to allow</p><p>movement of a joint. They are usually located in close proximity to the joint</p><p>with a broad spectrum of attachments to the joint’s passive elements that</p><p>make them ideal for increasing joint stiffness and stability (3,31). A common</p><p>example of a peripheral joint support system is the rotator cuff that provides</p><p>dynamic stabilization for the humeral head in relation to the glenoid fossa</p><p>(32–35). Other joint support systems include the posterior fi bers of the gluteus</p><p>medius and the external rotators of the hip that provide pelvofemoral stabi-</p><p>lization (1,36–39) and the oblique fi bers of the vastus medialis that provides</p><p>patellar stabilization at the knee (1,40,41).</p><p>The joint support system of the core or LPHC includes muscles that either</p><p>originate or insert (or both) into the lumbar spine (28,31). The major muscles</p><p>include the transversus abdominis, multifi dus, internal oblique, diaphragm,</p><p>and the muscles of the pelvic fl oor (13,28,30,31).</p><p>THE GLOBAL MUSCULAR SYSTEMS (MOVEMENT SYSTEMS)</p><p>The global muscular systems are responsible predominantly for movement and</p><p>consist of more superfi cial musculature that originate from the pelvis to the</p><p>rib cage, the lower extremities, or both (1,23,24,28,30,31,42) (Figure 2-17).</p><p>Some of these major muscles include the rectus abdominis, external obliques,</p><p>erector spinae, hamstring complex, gluteus maximus, latissimus dorsi, adduc-</p><p>tors, quadriceps, and gastrocnemius. The movement system muscles are pre-</p><p>dominantly larger and associated with movements of the trunk and limbs that</p><p>equalize external loads placed on the body. These muscles are also important</p><p>in transferring and absorbing forces from the upper and lower extremities</p><p>Local musculature</p><p>system: muscles that</p><p>are predominantly</p><p>involved in joint sup-</p><p>port or stabilization.</p><p>Global muscular sys-</p><p>tems: muscles respon-</p><p>sible predominantly for</p><p>movement and consist-</p><p>ing of more superfi cial</p><p>musculature that origi-</p><p>nates from the pelvis to</p><p>the rib cage, the lower</p><p>extremities, or both.</p><p>NASM_Chap02.indd 24NASM_Chap02.indd 24 7/5/2010 9:42:31 PM7/5/2010 9:42:31 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 25</p><p>to the pelvis. The movement system muscles have been broken down and</p><p>described as force-couples working in four distinct subsystems (1,29,43,44):</p><p>the deep longitudinal, posterior oblique, ante-</p><p>rior oblique, and lateral subsystems. This dis-</p><p>tinction allows for an easier description and</p><p>review of functional anatomy. It is crucial for</p><p>health and fi tness professionals to think of</p><p>these subsystems operating as an integrated</p><p>functional unit. Remember, the central ner-</p><p>vous system optimizes the selection of muscle</p><p>synergies, not isolated muscles (23,24,45,46).</p><p>The Deep Longitudinal Subsystem (DLS)</p><p>The major soft tissue contributors to the</p><p>deep longitudinal subsystem are the erector</p><p>spinae, thoracolumbar fascia, sacrotuberous</p><p>ligament biceps femoris, and peroneus longus</p><p>(Figure 2-18). Some experts suggest that the</p><p>DLS provides a longitudinal means of recip-</p><p>rocal force transmission from the trunk to</p><p>the ground (13,23,24,43,44). As illustrated in</p><p>Figure 2-18, the long head of the biceps femoris</p><p>attaches in part to the sacrotuberous ligament</p><p>at the ischium. The sacrotuberous ligament in</p><p>turn attaches from the ischium to the sacrum.</p><p>The erector spinae attach from the sacrum and</p><p>Figure</p><p>2.16 Local muscular system. Figure 2.17 Global muscular system.</p><p>Figure 2.18 Deep longitudinal sub-system.</p><p>Sacrotuberous</p><p>ligament</p><p>Biceps</p><p>femoris</p><p>Tibialis</p><p>anterior</p><p>Peroneus</p><p>longus</p><p>NASM_Chap02.indd 25NASM_Chap02.indd 25 7/5/2010 9:42:31 PM7/5/2010 9:42:31 PM</p><p>26 CHAPTER 2</p><p>ilium up the ribs to the cervical spine. Thus, activation of the biceps femoris</p><p>increases tension in the sacrotuberous ligament, which in turn transmits force</p><p>across the sacrum, stabilizing the sacroiliac joint, then up the trunk through</p><p>the erector spinae (43,44) (Figure 2-18).</p><p>As illustrated in Figure 2-18, this transference of force is apparent during</p><p>normal gait. Before heel strike, the biceps femoris activates to eccentrically</p><p>decelerate hip fl exion and knee extension. Just after heel strike, the biceps</p><p>femoris is further loaded through the lower leg via posterior movement of the</p><p>fi bula. This tension from the lower leg, up through the biceps femoris, into the</p><p>sacrotuberous ligament, and up the erector spinae creates a force that assists</p><p>in stabilizing the sacroiliac joint (SIJ) (12).</p><p>Another force-couple not often mentio ned in this subsystem consists</p><p>of the superfi cial erector spinae, the psoas, and the intrinsic core stabilizers</p><p>(transverses abdominus, multifi dus). Although the erector spinae and psoas</p><p>create lumbar extension and an anterior shear force at L4 through S1, dur-</p><p>ing functional movements the local muscular system provides intersegmen-</p><p>tal stabilization and a posterior shear force (29,31,43,44,47,48). Dysfunction</p><p>in any of these structures can lead to SIJ instability and low-back pain</p><p>(LBP) (44).</p><p>The Posterior Oblique Subsystem (POS)</p><p>The posterior oblique subsystem</p><p>works synergistically with the DLS.</p><p>As illustrated in Figure 2-19, both</p><p>the gluteus maximus and latissimus</p><p>dorsi have attachments to the thora-</p><p>columbar fascia, which connects to</p><p>the sacrum, whose fi bers run per-</p><p>pendicular to the SIJ. Thus, when the</p><p>contralateral gluteus maximus and</p><p>latissimus dorsi contract, a stabiliz-</p><p>ing force is transmitted across the SIJ</p><p>(force closure) (44). Just before heel</p><p>strike, the latissimus dorsi and the</p><p>contralateral gluteus maximus are</p><p>eccentrically loaded. At heel strike,</p><p>each muscle accelerates its respective</p><p>limb (through its concentric action)</p><p>and creates tension across the tho-</p><p>racolumbar fascia. This tension also</p><p>assists in stabilizing the SIJ. Thus,</p><p>when an individual walks or runs,</p><p>the POS transfers forces that are sum-</p><p>mated from the muscle’s transverse</p><p>plane orientation to propulsion in the Figure 2.19 Posterior oblique sub-system.</p><p>Sacrotuberous</p><p>ligament</p><p>Sacroiliac</p><p>joint</p><p>Biceps</p><p>femoris</p><p>Iliotibial</p><p>tract</p><p>Latissimus</p><p>dorsi</p><p>Thoracolumbar</p><p>fascia</p><p>Gluteus</p><p>maximus</p><p>Gluteus</p><p>medius</p><p>NASM_Chap02.indd 26NASM_Chap02.indd 26 7/5/2010 9:42:35 PM7/5/2010 9:42:35 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 27</p><p>sagittal plane. The POS is also of prime importance for rotational activities</p><p>such as swinging a golf club or a baseball bat, or throwing a ball (29,43,47).</p><p>Dysfunction of any structure in the POS can lead to SIJ instability and LBP.</p><p>The weakening of the gluteus maximus, the latissimus dorsi, or both can</p><p>lead to increased tension in the hamstring complex—a factor in recurrent</p><p>hamstring strains (42,44,47). If performed in isolation, squats for the gluteus</p><p>maximus and pulldowns/pull-ups for the latissimus dorsi will not adequately</p><p>prepare the POS to perform optimally during functional activities.</p><p>The Anterior Oblique Subsystem (AOS)</p><p>The anterior oblique subsystem (Figure 2-20) is similar to</p><p>the POS in that it also functions in a transverse plane ori-</p><p>entation, mostly in the anterior portion of the body. The</p><p>prime contributors are the internal and external oblique</p><p>muscles, the adductor complex, and hip external rotators.</p><p>Electromyography of these AOS muscles show that they aid</p><p>in pelvic stability and rotation as well as contributing to leg</p><p>swing (11,12,14). The AOS is also a factor in the stabilization</p><p>of the SIJ (48).</p><p>When we walk, our pelvis rotates in the transverse</p><p>plane to create a swinging motion for the legs (43). The</p><p>POS (posteriorly) and the AOS (anteriorly) contribute to this</p><p>rotation. Knowing the fi ber arrangements of the muscles</p><p>involved (latissimus dorsi, gluteus maximus, internal and</p><p>external obliques, adductors, and hip rotators) emphasizes</p><p>this point. The AOS is also necessary for functional activi-</p><p>ties involving the trunk and upper and lower extremities.</p><p>The obliques, in concert with the adductor complex, not</p><p>only produce rotational and fl exion movements, but are also</p><p>instrumental in stabilizing the lumbo-pelvic-hip complex</p><p>(29,48).</p><p>The Lateral Subsystem (LS)</p><p>The lateral subsystem is composed of the gluteus medius, tensor fascia latae,</p><p>adductor complex, and the quadratus lumborum, all of which participate in</p><p>frontal plane (13) and pelvofemoral stability (10,49). Figure 2-21 shows how</p><p>the ipsilateral gluteus medius, tensor fascia latae, and adductors combine with</p><p>the contralateral quadratus lumborum to control the pelvis and femur in the</p><p>frontal plane during single leg functional movements such as in gait, lunges, or</p><p>stair climbing (42). Dysfunction in the LS is evident during increased subtalar</p><p>joint pronation in conjunction with increased tibial and femoral adduction</p><p>and internal rotation during functional activities (10). Unwanted frontal plane</p><p>movement is characterized by decreased strength and decreased neuromuscu-</p><p>lar control in the LS (10,49–51).</p><p>External</p><p>obliques</p><p>Adductors</p><p>Figure 2.20 Anterior oblique sub-system.</p><p>NASM_Chap02.indd 27NASM_Chap02.indd 27 7/5/2010 9:42:37 PM7/5/2010 9:42:37 PM</p><p>28 CHAPTER 2</p><p>The descriptions of these four systems have been simplifi ed, but real-</p><p>ize that the human body simultaneously coordinates these subsystems during</p><p>activity. Each system individually and collectively contributes to the produc-</p><p>tion of effi cient movement by accelerating, decelerating, and dynamically sta-</p><p>bilizing the HMS during motion.</p><p>Functional Anatomy of the Major Muscles</p><p>The traditional, simplistic explanation of skeletal muscles is that they work</p><p>concentrically and predominantly in one plane of motion. However, muscles</p><p>should be viewed as functioning in all planes of motion, throughout the full</p><p>muscle action spectrum. The following section lists attachments and innerva-</p><p>tions as well as the isolated and integrated functions of the major muscles of</p><p>the human movement system (1,6,52).</p><p>Figure 2.21 Lateral sub-system.</p><p>Adductors</p><p>(adductor magnus)</p><p>Gluteus</p><p>medius</p><p>Tensor</p><p>fascia latae</p><p>Quadratus</p><p>lumborum</p><p>Adductors</p><p>NASM_Chap02.indd 28NASM_Chap02.indd 28 7/5/2010 9:42:38 PM7/5/2010 9:42:38 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 29</p><p>LEG COMPLEX</p><p>ANTERIOR TIBIALIS</p><p>ORIGIN</p><p>Lateral condyle and proximal two-thirds of the lateral surface of the tibia•</p><p>INSERTION</p><p>Medial and plantar aspects of the medial cuneiform and the base of •</p><p>the fi rst metatarsal</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Ankle dorsifl exion and inversion•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Ankle plantar fl exion and eversion•</p><p>Isometric Action</p><p>Stabilizes the arch of the foot•</p><p>INNERVATION</p><p>Deep peroneal nerve•</p><p>POSTERIOR TIBIALIS</p><p>ORIGIN</p><p>Proximal two-thirds of posterior surface of the tibia and fi bula•</p><p>INSERTION</p><p>Every tarsal bone (navicular, cuneiform, cuboid) but the talus plus the •</p><p>bases of the second through the fourth metatarsal bones. The main</p><p>insertion is on the navicular tuberosity and the medial cuneiform bone</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Ankle plantar fl exion and inversion of the foot•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Ankle dorsifl exion and eversion•</p><p>Isometric Action</p><p>Stabilizes the arch of the foot•</p><p>INNERVATION</p><p>Tibial nerve•</p><p>SOLEUS</p><p>ORIGIN</p><p>Posterior surface of the fi bular head and proximal one-third of its shaft •</p><p>and from the posterior side of the tibia</p><p>INSERTION</p><p>Calcaneus via the Achilles tendon•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates</p><p>plantar fl exion•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates ankle dorsifl exion•</p><p>Isometric Action</p><p>Stabilizes the foot and ankle complex•</p><p>INNERVATION</p><p>Tibial nerve•</p><p>NASM_Chap02.indd 29NASM_Chap02.indd 29 7/5/2010 9:42:39 PM7/5/2010 9:42:39 PM</p><p>30 CHAPTER 2</p><p>GASTROCNEMIUS</p><p>ORIGIN</p><p>Posterior aspect of the lateral and medial femoral condyles•</p><p>INSERTION</p><p>Calcaneus via the Achilles tendon•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates plantar fl exion•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates ankle dorsifl exion•</p><p>Isometric Action</p><p>Isometrically stabilizes the foot and ankle complex•</p><p>INNERVATION</p><p>Tibial nerve•</p><p>PERONEUS LONGUS</p><p>ORIGIN</p><p>Lateral condyle of tibia, head and proximal two-thirds of the lateral •</p><p>surface of the fi bula</p><p>INSERTION</p><p>Lateral surface of the medial cuneiform and lateral side of the base of •</p><p>the fi rst metatarsal</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Plantar fl exes and everts the foot•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates ankle dorsifl exion and inversion•</p><p>Isometric Action</p><p>Stabilizes the foot and ankle complex•</p><p>INNERVATION</p><p>Superfi cial peroneal nerve•</p><p>BICEPS FEMORIS-LONG HEAD</p><p>ORIGIN</p><p>Ischial tuberosity of the pelvis, part of the sacrotuberous ligament•</p><p>INSERTION</p><p>Head of the fi bula•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates knee fl exion and hip extension, tibial external rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates knee extension, hip fl exion, and tibial internal rotation•</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex and knee•</p><p>INNERVATION</p><p>Tibial nerve•</p><p>NASM_Chap02.indd 30NASM_Chap02.indd 30 7/5/2010 9:42:41 PM7/5/2010 9:42:41 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 31</p><p>BICEPS FEMORIS-SHORT HEAD</p><p>ORIGIN</p><p>Lower one-third of the posterior aspect of the femur•</p><p>INSERTION</p><p>Head of the fi bula•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates knee fl exion and tibial external rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates knee extension and tibial internal rotation•</p><p>Isometric Action</p><p>Stabilizes the knee•</p><p>INNERVATION</p><p>Common peroneal nerve•</p><p>SEMIMEMBRANOSUS</p><p>ORIGIN</p><p>Ischial tuberosity of the pelvis•</p><p>INSERTION</p><p>Posterior aspect of the medial tibial condyle of the tibia•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates knee fl exion, hip extension and tibial internal rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates knee extension, hip fl exion and tibial external rotation•</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex and knee•</p><p>INNERVATION</p><p>Tibial nerve•</p><p>SEMITENDINOSUS</p><p>ORIGIN</p><p>Ischial tuberosity of the pelvis and part of the sacrotuberous ligament•</p><p>INSERTION</p><p>Proximal aspect of the medial tibial condyle of the tibia (pes anserine)•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates knee fl exion, hip extension and tibial internal rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates knee extension, hip fl exion and tibial external rotation•</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex and knee•</p><p>INNERVATION</p><p>Tibial nerve•</p><p>NASM_Chap02.indd 31NASM_Chap02.indd 31 7/5/2010 9:42:43 PM7/5/2010 9:42:43 PM</p><p>32 CHAPTER 2</p><p>VASTUS LATERALIS</p><p>ORIGIN</p><p>Anterior and inferior border of the greater trochanter, lateral region of •</p><p>the gluteal tuberosity, lateral lip of the linea aspera of the femur</p><p>INSERTION</p><p>Base of patella and tibial tuberosity of the tibia•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates knee extension•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates knee fl exion•</p><p>Isometric Action</p><p>Stabilizes the knee•</p><p>INNERVATION</p><p>Femoral nerve•</p><p>VASTUS MEDIALIS</p><p>ORIGIN</p><p>Lower region of intertrochanteric line, medial lip of linea aspera, prox-•</p><p>imal medial supracondylar line of the femur</p><p>INSERTION</p><p>Base of patella, tibial tuberosity of the tibia•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates knee extension•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates knee fl exion•</p><p>Isometric Action</p><p>Stabilizes the knee•</p><p>INNERVATION</p><p>Femoral nerve•</p><p>VASTUS INTERMEDIUS</p><p>ORIGIN</p><p>Anterior-lateral regions of the upper two-thirds of the femur•</p><p>INSERTION</p><p>Base of patella, tibial tuberosity of the tibia•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates knee extension•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates knee fl exion•</p><p>Isometric Action</p><p>Stabilizes the knee•</p><p>INNERVATION</p><p>Femoral nerve•</p><p>NASM_Chap02.indd 32NASM_Chap02.indd 32 7/5/2010 9:42:45 PM7/5/2010 9:42:45 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 33</p><p>RECTUS FEMORIS</p><p>ORIGIN</p><p>Anterior-inferior iliac spine of the pelvis•</p><p>INSERTION</p><p>Base of patella, tibial tuberosity of the tibia•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates knee extension and hip fl exion•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates knee fl exion and hip extension•</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex and knee•</p><p>INNERVATION</p><p>Femoral nerve•</p><p>HIP COMPLEX</p><p>ADDUCTOR LONGUS</p><p>ORIGIN</p><p>Anterior surface of the inferior pubic ramus of the pelvis•</p><p>INSERTION</p><p>Proximal one-third of the linea aspera of the femur•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates hip adduction, fl exion and internal rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates hip abduction, extension and external rotation•</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex•</p><p>INNERVATION</p><p>Obturator nerve•</p><p>ADDUCTOR MAGNUS, ANTERIOR FIBERS</p><p>ORIGIN</p><p>Ischial ramus of the pelvis•</p><p>INSERTION</p><p>Linea aspera of the femur•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates hip adduction, fl exion and internal rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates hip abduction, extension and external rotation•</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex•</p><p>INNERVATION</p><p>Obturator nerve•</p><p>NASM_Chap02.indd 33NASM_Chap02.indd 33 7/5/2010 9:42:46 PM7/5/2010 9:42:46 PM</p><p>34 CHAPTER 2</p><p>ADDUCTOR MAGNUS, POSTERIOR FIBERS</p><p>ORIGIN</p><p>Ischial tuberosity of the pelvis•</p><p>INSERTION</p><p>Adductor tubercle on femur•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates hip adduction, extension and external rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates hip abduction, fl exion and internal rotation•</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex•</p><p>INNERVATION</p><p>Sciatic nerve•</p><p>ADDUCTOR BREVIS</p><p>ORIGIN</p><p>Anterior surface of the inferior pubic ramus of the pelvis•</p><p>INSERTION</p><p>Proximal one-third of the linea aspera of the femur•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates hip adduction, fl exion and internal rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates hip abduction, extension and external rotation•</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex•</p><p>INNERVATION</p><p>Obturator nerve•</p><p>GRACILIS</p><p>ORIGIN</p><p>Anterior aspect of lower body of pubis•</p><p>INSERTION</p><p>Proximal medial surface of the tibia (pes anserine)•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates hip adduction, fl exion and internal rotation; assists in •</p><p>tibial internal rotation</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates hip abduction, extension and external rotation•</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex and knee•</p><p>INNERVATION</p><p>Obturator nerve•</p><p>NASM_Chap02.indd 34NASM_Chap02.indd 34 7/5/2010 9:42:50 PM7/5/2010 9:42:50 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 35</p><p>PECTINEUS</p><p>ORIGIN</p><p>Pectineal line on the superior pubic ramus of the pelvis•</p><p>INSERTION</p><p>Pectineal line on the posterior surface of the upper femur•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates hip adduction, fl exion and internal rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates hip abduction, extension and external rotation•</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex•</p><p>INNERVATION</p><p>Obturator nerve•</p><p>GLUTEUS MEDIUS, ANTERIOR FIBERS</p><p>ORIGIN</p><p>Outer surface of the ilium•</p><p>INSERTION</p><p>Lateral surface of the greater trochanter on the femur•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates hip abduction and internal rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates hip adduction and external rotation•</p><p>Isometric</p><p>Action</p><p>Dynamically stabilizes the lumbo-pelvic-hip complex•</p><p>INNERVATION</p><p>Superior gluteal nerve•</p><p>GLUTEUS MEDIUS, POSTERIOR FIBERS</p><p>ORIGIN</p><p>Outer surface of the ilium•</p><p>INSERTION</p><p>Lateral surface of the greater trochanter on the femur•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates hip abduction and external rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates hip adduction and internal rotation•</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex•</p><p>INNERVATION</p><p>Superior gluteal nerve•</p><p>NASM_Chap02.indd 35NASM_Chap02.indd 35 7/5/2010 9:42:52 PM7/5/2010 9:42:52 PM</p><p>36 CHAPTER 2</p><p>GLUTEUS MINIMUS</p><p>ORIGIN</p><p>Ilium between the anterior and inferior gluteal line•</p><p>INSERTION</p><p>Greater trochanter of the femur•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates hip abduction, fl exion, and internal rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates frontal plane hip adduction, extension, and external rota-•</p><p>tion</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex•</p><p>INNERVATION</p><p>Superior gluteal nerve•</p><p>TENSOR FASCIA LATAE</p><p>ORIGIN</p><p>Outer surface of the iliac crest just posterior to the anterior-superior •</p><p>iliac spine of the pelvis</p><p>INSERTION</p><p>Proximal one-third of the iliotibial band•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates hip fl exion, abduction and internal rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates hip extension, adduction and external rotation•</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex•</p><p>INNERVATION</p><p>Superior gluteal nerve•</p><p>GLUTEUS MAXIMUS</p><p>ORIGIN</p><p>Outer ilium, posterior side of sacrum and coccyx and part of the •</p><p>sacrotuberous and posterior sacroiliac ligament</p><p>INSERTION</p><p>Gluteal tuberosity of the femur and iliotibial tract•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates hip extension and external rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates hip fl exion, internal rotation, and tibial internal rotation •</p><p>via the iliotibial band</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex•</p><p>INNERVATION</p><p>Inferior gluteal nerve•</p><p>NASM_Chap02.indd 36NASM_Chap02.indd 36 7/5/2010 9:42:53 PM7/5/2010 9:42:53 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 37</p><p>PSOAS</p><p>ORIGIN</p><p>Transverse processes and lateral bodies of the last thoracic and all •</p><p>lumbar vertebrae including intervertebral discs</p><p>INSERTION</p><p>Lesser trochanter of the femur•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates hip fl exion and external rotation, extends and rotates lum-•</p><p>bar spine</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates hip internal rotation and decelerates hip extension•</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex•</p><p>INNERVATION</p><p>Spinal nerve branches of L2-L4•</p><p>SARTORIUS</p><p>ORIGIN</p><p>Anterior-superior iliac spine of the pelvis•</p><p>INSERTION</p><p>Proximal medial surface of the tibia•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates hip fl exion, external rotation and abduction, accelerates •</p><p>knee fl exion and internal rotation</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates hip extension, external rotation, knee extension and exter-•</p><p>nal rotation</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex and knee•</p><p>INNERVATION</p><p>Femoral nerve•</p><p>PIRIFORMIS</p><p>ORIGIN</p><p>Anterior surface of the sacrum•</p><p>INSERTION</p><p>The greater trochanter of the femur•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Accelerates hip external rotation, abduction and extension•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates hip internal rotation, adduction and fl exion•</p><p>Isometric Action</p><p>Stabilizes the hip and sacroiliac joints•</p><p>INNERVATION</p><p>Sciatic nerve•</p><p>NASM_Chap02.indd 37NASM_Chap02.indd 37 7/5/2010 9:42:55 PM7/5/2010 9:42:55 PM</p><p>38 CHAPTER 2</p><p>ABDOMINAL MUSCULATURE</p><p>RECTUS ABDOMINIS</p><p>ORIGIN</p><p>Pubic symphysis of the pelvis•</p><p>INSERTION</p><p>Ribs 5-7•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Spinal fl exion, lateral fl exion and rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Spinal extension, lateral fl exion and rotation•</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex•</p><p>INNERVATION</p><p>Intercostal nerve T7-T12•</p><p>EXTERNAL OBLIQUE</p><p>ORIGIN</p><p>External surface of ribs 4-12•</p><p>INSERTION</p><p>Anterior iliac crest of the pelvis, linea alba and contralateral rectus •</p><p>sheaths</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Spinal fl exion, lateral fl exion and contralateral rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Spinal extension, lateral fl exion and rotation•</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex•</p><p>INNERVATION</p><p>Intercostal nerves (T8-T12), iliohypogastric (L1), ilioinguinal (L1)•</p><p>INTERNAL OBLIQUE</p><p>ORIGIN</p><p>Anterior two-thirds of the iliac crest of the pelvis and thoracolumbar •</p><p>fascia</p><p>INSERTION</p><p>Ribs 9-12, linea alba and contralateral rectus sheaths•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Spinal fl exion (bilateral), lateral fl exion and ipsilateral rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Spinal extension, rotation and lateral fl exion•</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex•</p><p>INNERVATION</p><p>Intercostal nerves (T8-T12), iliohypogastric (L1), ilioinguinal (L1)•</p><p>NASM_Chap02.indd 38NASM_Chap02.indd 38 7/5/2010 9:42:57 PM7/5/2010 9:42:57 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 39</p><p>TRANSVERSE ABDOMINIS</p><p>ORIGIN</p><p>Ribs 7-12, anterior two-thirds of the iliac crest of the pelvis and thora-•</p><p>columbar fascia</p><p>INSERTION</p><p>Lineae alba and contralateral rectus sheaths•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Increases intra-abdominal pressure. Supports the abdominal viscera.•</p><p>INTEGRATED FUNCTION</p><p>Isometric Action</p><p>Synergistically with the internal oblique, multifi dus and deep erector •</p><p>spinae to stabilize the lumbo-pelvic-hip complex</p><p>INNERVATION</p><p>Intercostal nerves (T7-T12), iliohypogastric (L1), ilioinguinal (L1)•</p><p>DIAPHRAGM</p><p>ORIGIN</p><p>Costal part: inner surfaces of the cartilages and adjacent bony regions •</p><p>of ribs 6-12. Sternal part: posterior side of the xiphoid process. Crural</p><p>(lumbar) part: (1) two aponeurotic arches covering the external sur-</p><p>faces of the quadratus lumborum and psoas major; (2) right and left</p><p>crus, originating from the bodies of L1-L3 and their intervertebral discs</p><p>INSERTION</p><p>Central tendon•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Pulls the central tendon inferiorly, increasing the volume in the tho-•</p><p>racic cavity</p><p>INTEGRATED FUNCTION</p><p>Isometric Action</p><p>Stabilization of the lumbo-pelvic-hip complex•</p><p>INNERVATION</p><p>Phrenic nerve (C3-C5)•</p><p>BACK MUSCULATURE SUPERFICIAL ERECTOR SPINAE</p><p>ORIGIN</p><p>Common origin: iliac crest of the pelvis, sacrum, spinous and trans-•</p><p>verse processes of T1-L5</p><p>ILIOCOSTALIS: LUMBORUM DIVISION</p><p>ORIGIN</p><p>Common origin•</p><p>INSERTION</p><p>Inferior border of ribs 7-12•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Spinal extension, rotation and lateral fl exion•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Spinal fl exion, rotation and lateral fl exion•</p><p>Isometric Action</p><p>Stabilizes the spine during functional movements•</p><p>INNERVATION</p><p>Dorsal rami of thoracic and lumbar nerves•</p><p>NASM_Chap02.indd 39NASM_Chap02.indd 39 7/5/2010 9:42:59 PM7/5/2010 9:42:59 PM</p><p>40 CHAPTER 2</p><p>ILIOCOSTALIS: THORACIS DIVISION</p><p>ORIGIN</p><p>Common origin•</p><p>INSERTION</p><p>Superior border of ribs 1-6•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Spinal extension, rotation and lateral fl exion•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Spinal fl exion, rotation and lateral fl exion•</p><p>Isometric Action</p><p>Stabilizes the spine during functional movements•</p><p>INNERVATION</p><p>Dorsal rami of thoracic nerves•</p><p>ILIOCOSTALIS: CERVICUS DIVISION</p><p>ORIGIN</p><p>Common origin•</p><p>INSERTION</p><p>Transverse process of C4-C6•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Spinal extension, rotation and lateral fl exion•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Spinal fl exion, rotation and lateral fl exion.•</p><p>Isometric Action</p><p>Stabilizes the spine during functional movements•</p><p>INNERVATION</p><p>Dorsal rami of thoracic nerves•</p><p>LONGISSIMUS: THORACIS DIVISION</p><p>ORIGIN</p><p>Common origin•</p><p>INSERTION</p><p>Transverse process T1-T12; Ribs 2-12•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Spinal extension, rotation and lateral fl exion•</p><p>INTEGRATED FUNCTION</p><p>Eccentric</p><p>Action</p><p>Spinal fl exion, rotation and lateral fl exion•</p><p>Isometric Action</p><p>Stabilizes the spine during functional movements•</p><p>INNERVATION</p><p>Dorsal rami of thoracic and lumbar nerves•</p><p>NASM_Chap02.indd 40NASM_Chap02.indd 40 7/5/2010 9:43:02 PM7/5/2010 9:43:02 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 41</p><p>LONGISSIMUS: CERVICUS DIVISION</p><p>ORIGIN</p><p>Common origin•</p><p>INSERTION</p><p>Transverse process of C6-C2•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Spinal extension, rotation and lateral fl exion•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Spinal fl exion, rotation and lateral fl exion•</p><p>Isometric Action</p><p>Stabilizes the spine during functional movements•</p><p>INNERVATION</p><p>Dorsal rami of cervical nerves•</p><p>LONGISSIMUS: CAPITIS DIVISION</p><p>ORIGIN</p><p>Common origin•</p><p>INSERTION</p><p>Mastoid process of the skull•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Spinal extension, rotation and lateral fl exion•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Spinal fl exion, rotation and lateral fl exion•</p><p>Isometric Action</p><p>Stabilizes the spine during functional movements•</p><p>INNERVATION</p><p>Dorsal rami of cervical nerves•</p><p>SPINALIS: THORACIS DIVISION</p><p>ORIGIN</p><p>Common origin•</p><p>INSERTION</p><p>Spinous process of T7-T4•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Spinal extension, rotation and lateral fl exion•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Spinal fl exion, rotation and lateral fl exion•</p><p>Isometric Action</p><p>Stabilizes the spine during functional movements•</p><p>INNERVATION</p><p>Dorsal rami of thoracic nerves•</p><p>NASM_Chap02.indd 41NASM_Chap02.indd 41 7/5/2010 9:43:05 PM7/5/2010 9:43:05 PM</p><p>42 CHAPTER 2</p><p>SPINALIS: CERVICUS DIVISION</p><p>ORIGIN</p><p>Common origin•</p><p>INSERTION</p><p>Spinous process of C3-C2•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Spinal extension, rotation and lateral fl exion•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Spinal fl exion, rotation and lateral fl exion•</p><p>Isometric Action</p><p>Stabilizes the spine during functional movements•</p><p>INNERVATION</p><p>Dorsal rami of cervical nerves•</p><p>SPINALIS: CAPITIS DIVISION</p><p>ORIGIN</p><p>Common origin•</p><p>INSERTION</p><p>Between the superior and inferior nuchal lines on occipital bone of the •</p><p>skull</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Spinal extension, rotation and lateral fl exion•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Spinal fl exion, rotation and lateral fl exion•</p><p>Isometric Action</p><p>Stabilizes the spine during functional movements•</p><p>INNERVATION</p><p>Dorsal rami of cervical nerves•</p><p>QUADRATUS LUMBORUM</p><p>ORIGIN</p><p>Iliac crest of the pelvis•</p><p>INSERTION</p><p>12th rib, transverse processes L2-L5•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Spinal lateral fl exion•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates contralateral lateral spinal fl exion•</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex•</p><p>INNERVATION</p><p>Spinal nerves (T12-L3)•</p><p>NASM_Chap02.indd 42NASM_Chap02.indd 42 7/5/2010 9:43:07 PM7/5/2010 9:43:07 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 43</p><p>TRANSVERSOSPINALIS: THORACIS DIVISION</p><p>ORIGIN</p><p>Transverse process T12-T7•</p><p>INSERTION</p><p>Spinous process T4-C6•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Produces spinal extension and lateral fl exion; extension and •</p><p>contralateral rotation of the head</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates lateral fl exion of the spine, fl exion and contralateral •</p><p>rotation of the head</p><p>Isometric Action</p><p>Stabilizes the spine•</p><p>INNERVATION</p><p>Dorsal rami C1-T6 spinal nerves•</p><p>TRANSVERSOSPINALIS: CERVICIS DIVISION</p><p>ORIGIN</p><p>Transverse process T6-C4•</p><p>INSERTION</p><p>Spinous process C5-C2•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Produces spinal extension and lateral fl exion; extension and contralat-•</p><p>eral rotation of the head</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates lateral fl exion of the spine, fl exion and contralateral rota-•</p><p>tion of the head</p><p>Isometric Action</p><p>Stabilizes the spine•</p><p>INNERVATION</p><p>Dorsal rami C1-T6 spinal nerves•</p><p>TRANSVERSOSPINALIS: CAPITUS DIVISION</p><p>ORIGIN</p><p>Transverse process T6-C7•</p><p>Articular process C6-C4•</p><p>INSERTION</p><p>Nuchal line of occipital bone of the skull•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Produces spinal extension and lateral fl exion; extension and contralat-•</p><p>eral rotation of the head</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Decelerates lateral fl exion of the spine, fl exion and contralateral rota-•</p><p>tion of the head</p><p>Isometric Action</p><p>Stabilizes the spine•</p><p>INNERVATION</p><p>Dorsal rami C1-T6 spinal nerves•</p><p>NASM_Chap02.indd 43NASM_Chap02.indd 43 7/5/2010 9:43:09 PM7/5/2010 9:43:09 PM</p><p>44 CHAPTER 2</p><p>MULTIFIDUS</p><p>ORIGIN</p><p>Posterior aspect of the sacrum; Processes of the lumbar, thoracic and •</p><p>cervical spine</p><p>INSERTION</p><p>Spinous processes 1 to 4 segments above the origin•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Spinal extension and contralateral rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Spinal fl exion and rotation•</p><p>Isometric Action</p><p>Stabilizes the spine•</p><p>INNERVATION</p><p>Corresponding spinal nerves•</p><p>SHOULDER MUSCULATURE</p><p>LATISSIMUS DORSI</p><p>ORIGIN</p><p>Spinous processes of T7-T12; Iliac crest of the pelvis; Thoracolumbar •</p><p>fascia; Ribs 9-12</p><p>INSERTION</p><p>Inferior angle of the scapula; Intertubecular groove of the humerus•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Shoulder extension, adduction and internal rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Shoulder fl exion, abduction and external rotation and spinal fl exion•</p><p>Isometric Action</p><p>Stabilizes the lumbo-pelvic-hip complex and shoulder•</p><p>INNERVATION</p><p>Thoracodorsal nerve (C6-C8)•</p><p>SERRATUS ANTERIOR</p><p>ORIGIN</p><p>Ribs 4-12•</p><p>INSERTION</p><p>Medial border of the scapula•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Scapular protraction•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Scapular retraction•</p><p>Isometric Action</p><p>Stabilizes the scapula•</p><p>INNERVATION</p><p>Long thoracic nerve (C5-C7)•</p><p>NASM_Chap02.indd 44NASM_Chap02.indd 44 7/5/2010 9:43:12 PM7/5/2010 9:43:12 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 45</p><p>RHOMBOIDS</p><p>ORIGIN</p><p>Spinous processes of C7-T5•</p><p>INSERTION</p><p>Medial border of the scapula•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Produces scapular retraction and downward rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Scapular protraction and upward rotation•</p><p>Isometric Action</p><p>Stabilizes the scapula•</p><p>INNERVATION</p><p>Dorsal scapular nerve (C4-C5)•</p><p>LOWER TRAPEZIUS</p><p>ORIGIN</p><p>Spinous processes of T6-T12•</p><p>INSERTION</p><p>Spine of the scapula•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Scapular depression•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Scapular elevation•</p><p>Isometric Action</p><p>Stabilizes the scapula•</p><p>INNERVATION</p><p>Cranial nerve XI, ventral rami C2-C4•</p><p>MIDDLE TRAPEZIUS</p><p>ORIGIN</p><p>Spinous processes of T1-T5•</p><p>INSERTION</p><p>Acromion process of the scapula; Superior aspect of the spine of the •</p><p>scapula</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Scapular retraction•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Scapular protraction and elevation•</p><p>Isometric Action</p><p>Stabilizes scapula•</p><p>INNERVATION</p><p>Cranial nerve XI, ventral rami C2-C4•</p><p>NASM_Chap02.indd 45NASM_Chap02.indd 45 7/5/2010 9:43:14 PM7/5/2010 9:43:14 PM</p><p>46 CHAPTER 2</p><p>UPPER TRAPEZIUS</p><p>ORIGIN</p><p>External occipital protuberance of the skull; Spinous process of C7•</p><p>INSERTION</p><p>Lateral third of the clavicle; Acromion process of the scapula•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Cervical extension, lateral fl exion and rotation; scapular elevation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Cervical fl exion, lateral fl exion, rotation, scapular depression•</p><p>Isometric Action</p><p>Stabilizes the cervical spine and scapula, stabilizes the medial border •</p><p>of the scapula creating a stable base for the prime movers during scap-</p><p>ular abduction and upward rotation</p><p>INNERVATION</p><p>Cranial nerve XI, ventral rami C2-C4•</p><p>LEVATOR SCAPULAE</p><p>ORIGIN</p><p>Transverse processes of C1-C4•</p><p>INSERTION</p><p>Superior vertebral border of the scapulae•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Cervical extension, lateral fl exion and ipsilateral rotation when the •</p><p>scapulae is anchored; Assists in elevation and downward rotation of</p><p>the scapulae</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Cervical fl exion, contralateral cervical rotation, lateral fl exion, scapu-•</p><p>lar depression and upward rotation when the neck is stabilized</p><p>Isometric Action</p><p>Stabilizes the cervical spine and scapulae•</p><p>INNERVATION</p><p>Ventral rami C3-C4, dorsal of subscapular nerve•</p><p>PECTORALIS MAJOR</p><p>ORIGIN</p><p>Anterior surface of the clavicle; Anterior surface of the sternum, carti-•</p><p>lage of ribs 1-7</p><p>INSERTION</p><p>Greater tubercle of the humerus•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Shoulder fl exion (clavicular fi bers), horizontal adduction and internal •</p><p>rotation</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Shoulder extension horizontal abduction and external rotation•</p><p>Isometric Action</p><p>Stabilizes the shoulder girdle•</p><p>INNERVATION</p><p>Medial and lateral pectoral nerve (C5-C7)•</p><p>NASM_Chap02.indd 46NASM_Chap02.indd 46 7/5/2010 9:43:16 PM7/5/2010 9:43:16 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 47</p><p>PECTORALIS MINOR</p><p>ORIGIN</p><p>Ribs 3-5•</p><p>INSERTION</p><p>Coracoid process of the scapula•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Protracts the scapula•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Scapular retraction•</p><p>Isometric Action</p><p>Stabilizes the shoulder girdle•</p><p>INNERVATION</p><p>Medial pectoral nerve (C6-T1)•</p><p>ANTERIOR DELTOID</p><p>ORIGIN</p><p>Lateral third of the clavicle•</p><p>INSERTION</p><p>Deltoid tuberosity of the humerus•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Shoulder fl exion and internal rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Shoulder extension and external rotation•</p><p>Isometric Action</p><p>Stabilizes the shoulder girdle•</p><p>INNERVATION</p><p>Axillary nerve (C5-C6)•</p><p>MEDIAL DELTOID</p><p>ORIGIN</p><p>Acromion process of the scapula•</p><p>INSERTION</p><p>Deltoid tuberosity of the humerus•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Shoulder abduction•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Shoulder adduction•</p><p>Isometric Action</p><p>Stabilizes the shoulder girdle•</p><p>INNERVATION</p><p>Axillary nerve (C5-C6)•</p><p>NASM_Chap02.indd 47NASM_Chap02.indd 47 7/5/2010 9:43:18 PM7/5/2010 9:43:18 PM</p><p>48 CHAPTER 2</p><p>POSTERIOR DELTOID</p><p>ORIGIN</p><p>Spine of the scapula•</p><p>INSERTION</p><p>Deltoid tuberosity of the humerus•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Shoulder extension and external rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Shoulder fl exion and internal rotation•</p><p>Isometric Action</p><p>Stabilizes the shoulder girdle•</p><p>INNERVATION</p><p>Axillary nerve (C5-C6)•</p><p>TERES MINOR</p><p>ORIGIN</p><p>Lateral border of the scapula•</p><p>INSERTION</p><p>Greater tubercle of the humerus•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Shoulder external rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Shoulder internal rotation•</p><p>Isometric Action</p><p>Stabilizes the shoulder girdle•</p><p>INNERVATION</p><p>Axillary nerve (C5-C6)•</p><p>INFRASPINATUS</p><p>ORIGIN</p><p>Infraspinous fossa of the scapula•</p><p>INSERTION</p><p>Middle facet of the greater tubercle of the humerus•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Shoulder external rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Shoulder internal rotation•</p><p>Isometric Action</p><p>Stabilizes the shoulder girdle•</p><p>INNERVATION</p><p>Suprascapular nerve (C5-C6)•</p><p>NASM_Chap02.indd 48NASM_Chap02.indd 48 7/5/2010 9:43:21 PM7/5/2010 9:43:21 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 49</p><p>SUBSCAPULARIS</p><p>ORIGIN</p><p>Subscapular fossa of the scapula•</p><p>INSERTION</p><p>Lesser tubercle of the humerus•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Shoulder internal rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Shoulder external rotation•</p><p>Isometric Action</p><p>Stabilizes the shoulder girdle•</p><p>INNERVATION</p><p>Upper and lower subscapular nerve (C5-C6)•</p><p>SUPRASPINATUS</p><p>ORIGIN</p><p>Supraspinous fossa of the scapula•</p><p>INSERTION</p><p>Superior facet of the greater tubercle of the humerus•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Abduction of the arm•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Adduction of the arm•</p><p>Isometric Action</p><p>Stabilizes the shoulder girdle•</p><p>INNERVATION</p><p>Suprascapular nerve (C5-C6)•</p><p>TERES MAJOR</p><p>ORIGIN</p><p>Inferior angle of the scapula•</p><p>INSERTION</p><p>Lesser tubercle of the humerus•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Shoulder internal rotation, adduction and extension•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Shoulder external rotation, abduction and fl exion•</p><p>Isometric Action</p><p>Stabilizes the shoulder girdle•</p><p>INNERVATION</p><p>Lower subscapular nerve•</p><p>NASM_Chap02.indd 49NASM_Chap02.indd 49 7/5/2010 9:43:23 PM7/5/2010 9:43:23 PM</p><p>50 CHAPTER 2</p><p>ARM MUSCULATURE</p><p>BICEPS BRACHII</p><p>ORIGIN</p><p>Short head: Corocoid process; Long head: Tubercle above glenoid cav-•</p><p>ity on the humerus</p><p>INSERTION</p><p>Radial tuberosity of the radius•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Elbow fl exion, supination of the radioulnar joint, shoulder fl exion•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Elbow extension, pronation of the radioulnar joint, shoulder extension•</p><p>Isometric Action</p><p>Stabilizes the elbow and shoulder girdle•</p><p>INNERVATION</p><p>Musculocutaneous nerve•</p><p>TRICEPS BRACHII</p><p>ORIGIN</p><p>Long head: Infraglenoid tubercle of the scapula; Short head: Posterior •</p><p>humerus; Medial head: posterior humerus</p><p>INSERTION</p><p>Olecranon process of the ulna•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Elbow extension, shoulder extension•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Elbow fl exion, shoulder fl exion•</p><p>Isometric Action</p><p>Stabilizes the elbow and shoulder girdle•</p><p>INNERVATION</p><p>Radial nerve•</p><p>BRACHIALIS</p><p>ORIGIN</p><p>Humerus•</p><p>INSERTION</p><p>Coronoid process of ulna•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Flexes elbow•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Elbow extension•</p><p>Isometric Action</p><p>Stabilizes the elbow•</p><p>INNERVATION</p><p>Musculocutaneous, radial nerve•</p><p>NASM_Chap02.indd 50NASM_Chap02.indd 50 7/5/2010 9:43:25 PM7/5/2010 9:43:25 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 51</p><p>ANCONEUS</p><p>ORIGIN</p><p>Lateral epicondyle of humerus•</p><p>INSERTION</p><p>Olecranon process, posterior ulna•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Extends elbow•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Elbow fl exion•</p><p>Isometric Action</p><p>Stabilizes the elbow•</p><p>INNERVATION</p><p>Radial nerve•</p><p>BRACHIORADIALIS</p><p>ORIGIN</p><p>Lateral supracondylar ridge of humerus•</p><p>INSERTION</p><p>Styloid process of radius•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Flexes elbow•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Elbow extension•</p><p>Isometric Action</p><p>Stabilizes the elbow•</p><p>INNERVATION</p><p>Radial nerve•</p><p>PRONATOR QUADRATUS</p><p>ORIGIN</p><p>Distal ulna•</p><p>INSERTION</p><p>Distal radius•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Pronates forearm•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Forearm supination•</p><p>Isometric Action</p><p>Stabilizes distal radioulnar joint•</p><p>INNERVATION</p><p>Anterior interosseus nerve•</p><p>NASM_Chap02.indd 51NASM_Chap02.indd 51 7/5/2010 9:43:27 PM7/5/2010 9:43:27 PM</p><p>52 CHAPTER 2</p><p>PRONATOR TERES</p><p>ORIGIN</p><p>Medial epicondyle of humerus, coronoid process of ulna•</p><p>INSERTION</p><p>Radius•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Pronates forearm•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Forearm supination•</p><p>Isometric Action</p><p>Stabilizes proximal radioulnar joint and elbow•</p><p>INNERVATION</p><p>Median nerve•</p><p>SUPINATOR</p><p>ORIGIN</p><p>Lateral epicondyle of humerus•</p><p>INSERTION</p><p>Radius•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Supinates forearm•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Forearm pronation•</p><p>Isometric Action</p><p>Stabilizes proximal radioulnar joint and elbow•</p><p>INNERVATION</p><p>Radial nerve•</p><p>NECK MUSCULATURE</p><p>STERNOCLEIDOMASTOID</p><p>ORIGIN</p><p>Sternal head: Top of Maubrium of the sternum; Clavicular head: •</p><p>Medial one-third of the clavicle</p><p>INSERTION</p><p>Mastoid process, lateral superior nuchal line of the occiput of the skull•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Cervical fl exion, rotation and lateral fl exion•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Cervical extension, rotation and lateral fl exion•</p><p>Isometric Action</p><p>Stabilizes the cervical spine and acromioclavicular joint•</p><p>INNERVATION</p><p>Cranial nerve XI•</p><p>NASM_Chap02.indd 52NASM_Chap02.indd 52 7/5/2010 9:43:28 PM7/5/2010 9:43:28 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 53</p><p>SCALENES</p><p>ORIGIN</p><p>Transverse processes of C3-C7•</p><p>INSERTION</p><p>First and second ribs•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Cervical fl exion, rotation and lateral fl exion; Assists rib elevation dur-•</p><p>ing inhalation</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Cervical extension, rotation and lateral fl exion•</p><p>Isometric Action</p><p>Stabilizes the cervical spine•</p><p>INNERVATION</p><p>Ventral rami (C3-C7)•</p><p>LONGUS COLLI</p><p>ORIGIN</p><p>Anterior portion of T1-T3•</p><p>INSERTION</p><p>Anterior and lateral C1•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Cervical fl exion, lateral fl exion and ipsilateral rotation•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Cervical extension, lateral fl exion and contralateral rotation•</p><p>Isometric Action</p><p>Stabilizes the cervical spine•</p><p>INNERVATION</p><p>Ventral rami (C2-C8)•</p><p>LONGUS CAPITUS</p><p>ORIGIN</p><p>Transverse processes of C3-C6•</p><p>INSERTION</p><p>Inferior occipital bone•</p><p>ISOLATED FUNCTION</p><p>Concentric Action</p><p>Cervical fl exion and lateral fl exion•</p><p>INTEGRATED FUNCTION</p><p>Eccentric Action</p><p>Cervical extension•</p><p>Isometric Action</p><p>Stabilizes the cervical spine•</p><p>INNERVATION</p><p>Ventral rami (C1-C3)•</p><p>NASM_Chap02.indd 53NASM_Chap02.indd 53 7/5/2010 9:43:30 PM7/5/2010 9:43:30 PM</p><p>54 CHAPTER 2</p><p>A review of the actions within this section of pertinent skeletal muscles</p><p>should make it clear that muscles function in all three planes of motion (sagit-</p><p>tal, frontal, and transverse) using the entire spectrum of muscle actions (eccen-</p><p>tric, isometric, and concentric). In addition, the previous section shows which</p><p>muscles work synergistically with each other to produce force, stabilize the</p><p>body, reduce force, or all three.</p><p>Corrective exercise programs become more specifi c when there is a</p><p>broader understanding of functional anatomy. A limited understanding of the</p><p>synergistic functions of the HMS in all three planes of motion can lead to</p><p>a lack of functional performance, the potential of developing muscle imbal-</p><p>ances, and injury.</p><p>MOTOR BEHAVIOR</p><p>The functional anatomy and biomechanics portions of this chapter present</p><p>information about how the different parts of the HMS operate as a synergistic,</p><p>integrated functional unit in all three planes of motion. This is accomplished</p><p>and retained using the concept of motor behavior. Motor behavior is the HMS</p><p>response to internal and external environmental stimuli. The study of motor</p><p>behavior examines the manner by which the nervous, skeletal, and muscular</p><p>systems interact to produce skilled movement using sensory information from</p><p>internal and external environments.</p><p>Motor behavior is the collective study of motor control, motor learning,</p><p>and motor development (13,53) (Figure 2-22). Motor control is the study of pos-</p><p>ture and movements with the involved structures and mechanisms used by the</p><p>central nervous system to assimilate and integrate sensory information with</p><p>previous experiences (45,46). Motor control is concerned with what central</p><p>nervous system structures are involved with motor behavior to produce move-</p><p>ment (46). Motor learning is the utilization of these processes through practice</p><p>and experience, leading to a relatively permanent change in one’s capacity to</p><p>produce skilled movements (21). Finally, motor development is defi ned as the</p><p>change in motor behavior over time throughout one’s lifespan (54). For the</p><p>purposes of this text we will confine this section to a brief discussion of motor</p><p>control and motor learning.</p><p>Motor behavior: the</p><p>human movement</p><p>systems response to</p><p>internal and external</p><p>environmental stimuli.</p><p>Sensory information:</p><p>the data that the central</p><p>nervous system receives</p><p>from sensory recep-</p><p>tors to determine such</p><p>things as the body’s</p><p>position in space and</p><p>limb orientation, as well</p><p>as information about</p><p>the environment, tem-</p><p>perature, texture, etc.</p><p>Motor learning: the</p><p>utilization of these pro-</p><p>cesses through practice</p><p>and experience leading</p><p>to a relatively perma-</p><p>nent change in one’s</p><p>capacity to produce</p><p>skilled movements.</p><p>Motor control: the</p><p>study of posture and</p><p>movements with the</p><p>involved structures</p><p>and mechanisms used</p><p>by the central nervous</p><p>system to assimilate</p><p>and integrate sensory</p><p>information with previ-</p><p>ous experiences. Motor behavior</p><p>Motor learning Motor developmentMotor control</p><p>Figure 2.22 Components of motor behavior.</p><p>NASM_Chap02.indd 54NASM_Chap02.indd 54 7/5/2010 9:43:32 PM7/5/2010 9:43:32 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 55</p><p>Motor Control</p><p>To move in an organized and effi cient manner, the HMS must exhibit precise con-</p><p>trol over its collective segments. This segmental control is an integrated process</p><p>involving neural, skeletal, and muscular components to produce appropriate</p><p>motor responses. This process (and the study of these movements) is known as</p><p>motor control and focuses on the involved structures and mechanisms used by</p><p>the central nervous system to integrate internal and external sensory informa-</p><p>tion with previous experiences to produce a skilled motor response. Essentially,</p><p>motor control is concerned with the neural structures that are involved with</p><p>motor behavior and how they produce movement (13,23,24,46).</p><p>One of the most important concepts in motor control and motor learning</p><p>is how the central nervous system incorporates the information it receives to</p><p>produce, refi ne, manipulate, and remember a movement pattern. The best</p><p>place to start is with sensory information followed by proprioception, muscle</p><p>synergies, and sensorimotor integration.</p><p>SENSORY INFORMATION</p><p>Sensory information is the data that the central nervous system receives from</p><p>sensory receptors to determine such things as the body’s position in space</p><p>and limb orientation as well as information about the environment, tempera-</p><p>ture, texture, and so forth (45,46). This information allows the central nervous</p><p>system to monitor the internal and external environments to modify motor</p><p>behavior using adjustments ranging from simple refl exes to intricate move-</p><p>ment patterns.</p><p>Sensory information is essential in protecting the body from harm. It also</p><p>provides feedback about movement to acquire and refi ne new skills through</p><p>sensory sensations and perceptions. A sensation is a process by which sensory</p><p>information is received by the receptor and transferred either to the spinal</p><p>cord for refl exive motor behavior, to higher cortical areas for processing, or</p><p>both (45,46). Perception is the integration of sensory information with past</p><p>experiences or memories (55).</p><p>The body uses sensory information in three ways:</p><p>Sensory information provides information about the body’s spatial orienta-•</p><p>tion to the environment and itself before, during, and after movement.</p><p>It assists in planning and manipulating movement action plans. This may •</p><p>occur at the spinal level in the form of a refl ex or at the cerebellum, where</p><p>actual performance is compared.</p><p>Sensory information facilitates learning new skills as well as relearning •</p><p>existing movement patterns that may have become dysfunctional (45,46).</p><p>PROPRIOCEPTION</p><p>Proprioception is one form of sensory (afferent) information that uses</p><p>mechanoreceptors (from cutaneous, muscle, tendon, and joint receptors) to</p><p>provide information about static and dynamic positions, movements, and sen-</p><p>sations related to muscle force and movement (45). Lephart (53) defi nes prop-</p><p>rioception as the cumulative neural input from sensory afferents to the central</p><p>nervous system. This vital information ensures optimum motor behavior and</p><p>Perceptions: the inte-</p><p>gration of sensory</p><p>information with</p><p>past experiences or</p><p>memories.</p><p>Sensations: a process</p><p>by which sensory infor-</p><p>mation is received by</p><p>the receptor and trans-</p><p>ferred either to the</p><p>spinal cord for refl exive</p><p>motor behavior, to</p><p>higher cortical areas for</p><p>processing, or both.</p><p>Proprioception: the</p><p>cumulative neural</p><p>input from sensory</p><p>afferents to the central</p><p>nervous system.</p><p>Motor development:</p><p>the change in motor</p><p>behavior over time</p><p>throughout one’s</p><p>lifespan.</p><p>NASM_Chap02.indd 55NASM_Chap02.indd 55 7/5/2010 9:43:33 PM7/5/2010 9:43:33 PM</p><p>56 CHAPTER 2</p><p>neuromuscular effi ciency (21,56). This afferent information is delivered to dif-</p><p>ferent levels of motor control within the central nervous system to use in</p><p>monitoring and manipulating movement (53).</p><p>Proprioception is altered after injury (57–59). With many of the receptors</p><p>being located in and around joints, any joint injury will likely also damage prop-</p><p>rioceptive components</p><p>that could be compromised for some time after an injury.</p><p>When one considers the 85% of our population that experiences LBP, or the</p><p>estimated 80,000 to 100,000+ anterior cruciate ligament (ACL) injuries annu-</p><p>ally, or the more than two million ankle sprains, individuals may have altered</p><p>proprioception as a result of past injuries. A thorough rehabilitation program</p><p>after a musculoskeletal injury will normally contain a proprioceptive compo-</p><p>nent. Much of our movement is supported by the global muscular system, rein-</p><p>forcing the need for core and balance training to enhance one’s proprioceptive</p><p>capabilities, increase postural control, and decrease tissue overload (51,60,61).</p><p>Rationale for Training in Unstable, Yet Controllable Environments</p><p>By placing the body in a multisensory environment (unstable, yet controllable), the brain</p><p>is able to learn how to manipulate the musculoskeletal system to produce the movement</p><p>with the right amount of force at the right time. If the structures of the brain are never</p><p>challenged, they will never be forced to adapt and improve in their functional capabilities.</p><p>GETTING YOUR FACTS STRAIGHT</p><p>MUSCLE SYNERGIES</p><p>One of the most important concepts in motor control is that the central ner-</p><p>vous system recruits muscles in groups or synergies (1,21,26). This simplifi es</p><p>movement by allowing muscles to operate as a functional unit (1,5). Through</p><p>practice of proper movement patterns and technique, these synergies become</p><p>more fl uent and automated (Table 2-4).</p><p>SENSORIMOTOR INTEGRATION</p><p>Sensorimotor integration is the ability of the central nervous system to gather</p><p>and interpret sensory information to execute the proper motor response</p><p>(23,24,46,52,62). Sensorimotor integration is only as effective as the quality</p><p>of the incoming sensory information (21,63). An individual who trains with</p><p>improper form delivers improper sensory information to the central nervous</p><p>system, which can lead to movement compensation and potential injury. Thus,</p><p>programs need to be designed to train and to reinforce correct technique. For</p><p>example, the individual who consistently performs a squat with an arched</p><p>lower back and adducted femur will alter the length-tension relationships of</p><p>muscles, force-couple relationships, and arthrokinematics. This can ultimately</p><p>lead to back, knee, and hamstring problems (51,64–68).</p><p>Motor Learning</p><p>Motor learning is the integration of these motor control processes through</p><p>practice and experience, leading to a relatively permanent change in the</p><p>capacity to produce skilled movements (21,46). At its most basic, the study</p><p>Sensorimotor integra-</p><p>tion: the ability of the</p><p>central nervous system</p><p>to gather and interpret</p><p>sensory information</p><p>to execute the proper</p><p>motor response.</p><p>NASM_Chap02.indd 56NASM_Chap02.indd 56 7/5/2010 9:43:33 PM7/5/2010 9:43:33 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 57</p><p>of motor learning looks at how movements are learned and retained for</p><p>future use. Proper practice and experience will lead to a permanent change</p><p>in an individual’s ability to perform skilled movements effectively. For this to</p><p>occur, feedback is necessary to ensure optimal development of these skilled</p><p>movements.</p><p>FEEDBACK</p><p>Feedback is the utilization of sensory information and sensorimotor integra-</p><p>tion to aid in the development of permanent neural representations of motor</p><p>Feedback: the uti-</p><p>lization of sensory</p><p>information and sen-</p><p>sorimotor integration</p><p>to aid in the develop-</p><p>ment of permanent</p><p>neural representations</p><p>of motor patterns for</p><p>effi cient movement.</p><p>Table 2.4 MUSCLE SYNERGIES</p><p>Bench Press</p><p>Prime Mover Pectoralis major</p><p>Synergists</p><p>Anterior deltoid</p><p>Triceps</p><p>Stabilizers</p><p>Rotator cuff</p><p>Biceps</p><p>Squats</p><p>Prime Mover</p><p>Quadriceps</p><p>Gluteus maximus</p><p>Synergists</p><p>Hamstrings complex</p><p>Adductor magnus</p><p>Gastrocnemius/soleus complex</p><p>Posterior tibialis</p><p>Stabilizers</p><p>Lower extremity musculature</p><p>� Flexor hallucis longus</p><p>� Posterior tibialis</p><p>� Anterior tibialis</p><p>� Soleus</p><p>� Gastrocnemius</p><p>Lumbo-pelvic-hip complex</p><p>� Adductor longus</p><p>� Adductor brevis</p><p>� Transverse abdominus</p><p>� Gluteus medius</p><p>Scapular stabilizes</p><p>� Trapezius</p><p>� Rhomboids</p><p>Cervical stabilizers</p><p>NASM_Chap02.indd 57NASM_Chap02.indd 57 7/5/2010 9:43:33 PM7/5/2010 9:43:33 PM</p><p>58 CHAPTER 2</p><p>patterns for effi cient movement. This is achieved through internal (or sensory)</p><p>feedback and external (or augmented) feedback (13,46,62).</p><p>Internal (or sensory) feedback is the process by which sensory informa-</p><p>tion is used by the body via length-tension relationships, force-couple rela-</p><p>tionships, and arthrokinematics to monitor movement and the environment.</p><p>Internal feedback acts as a guide, steering the human movement system to the</p><p>proper force, speed, and amplitude of movement patterns. Proper form during</p><p>movement ensures that the incoming internal (sensory) feedback is the correct</p><p>information, allowing for optimal sensorimotor integration for ideal structural</p><p>and functional effi ciency (21).</p><p>External (or augmented) feedback is information provided by some exter-</p><p>nal source, for example, a health and fi tness professional, videotape, mirror, or</p><p>heart rate monitor. This information is used to supplement internal feedback</p><p>(46,62). External feedback provides another source of information that allows</p><p>for the individual to associate the outcome of the achieved movement pattern</p><p>(“good” or “bad”) with what is felt internally.</p><p>Two major forms of external feedback are knowledge of results and knowl-</p><p>edge of performance (21). Knowledge of results is used after the completion of</p><p>a movement to inform individuals about the outcome of their performance.</p><p>This can come from the health and fi tness professional, the client, or some</p><p>technological means. The health and fi tness professional might inform indi-</p><p>viduals that their squats were “good” and ask clients whether they could “feel”</p><p>or “see” their form. By getting clients involved with knowledge of results, they</p><p>increase their own awareness and augment their impressions with multiple</p><p>forms of feedback. This can be done after each repetition, after a few repeti-</p><p>tions, or once the set is completed. As individuals become more familiar with</p><p>the desired movement technique, knowledge of results from the health and</p><p>fi tness professional should be given less frequently. This improves neuromus-</p><p>cular effi ciency (62).</p><p>Knowledge of performance provides information about the quality of</p><p>the movement. An example would be noticing that, during a squat, the indi-</p><p>vidual’s feet were externally rotated, the femurs were excessively adduct-</p><p>ing, and then asking whether the individual felt or saw anything different</p><p>about those repetitions. Or, to get individuals to absorb the shock of land-</p><p>ing from a jump (and not landing with extended knees which places the</p><p>ACL in a precarious position), telling them to listen to the impact and land</p><p>quietly, effectively teaching the individual to absorb the shock of landing.</p><p>These examples get the client involved in his or her own sensory process.</p><p>Such feedback should be given less frequently as the client becomes more</p><p>profi cient (62).</p><p>These forms of external feedback identify performance errors. This</p><p>feedback is also an important component in motivation. Further, feedback</p><p>gives the client supplemental sensory input to help create an awareness of</p><p>the desired action (21). It is important to state, however, that a client must not</p><p>become too dependent on external feedback, especially from the health and</p><p>fitness professional, as this may detract from the individual’s own responsive-</p><p>ness to internal sensory input (21,46). This could alter sensorimotor integra-</p><p>tion and affect the learning by the client and the ultimate performance of new</p><p>and skilled movement.</p><p>Internal (or sensory)</p><p>feedback: the process</p><p>by which sensory infor-</p><p>mation is used by the</p><p>body via length-tension</p><p>relationships, force-</p><p>couple relationships,</p><p>and arthrokinematics</p><p>to monitor movement</p><p>and the environment.</p><p>External (or</p><p>augmented) feedback:</p><p>information provided</p><p>by some external</p><p>source, for example, a</p><p>health and fi tness pro-</p><p>fessional, videotape,</p><p>mirror, or heart rate</p><p>monitor.</p><p>Knowledge of results:</p><p>used after the comple-</p><p>tion of a movement</p><p>to inform individuals</p><p>about the outcome of</p><p>their performance.</p><p>Knowledge of perfor-</p><p>mance: provides infor-</p><p>mation about the quality</p><p>of the movement.</p><p>NASM_Chap02.indd 58NASM_Chap02.indd 58 7/5/2010 9:43:33 PM7/5/2010 9:43:33 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 59</p><p>SUMMARY • In summary, each component of the HMS is interdependent.</p><p>However, the HMS must work interdependently to gather information from</p><p>internal and external environments to create, learn, and refi ne movements (or</p><p>motor behavior) through proprioception, sensorimotor integration, and mus-</p><p>cle synergies to create effi cient movement (motor control). Then, repeated</p><p>practice and incorporating internal and external feedback allows this effi cient</p><p>movement to be reproduced (motor learning).</p><p>References</p><p>1. Newmann D. Kinesiology of the Musculoskeletal Sys-</p><p>tem; Foundations for Physical Rehabilitation. St. Louis,</p><p>MO: Mosby; 2002.</p><p>2. Sahrmann S. Diagnosis and Treatment of Movement</p><p>Impairment Syndromes. St. Louis, MO: Mosby; 2002.</p><p>3. Panjabi MM. The stabilizing system of the spine. Part I.</p><p>Function, dysfunction, adaptation, and enhancement. J</p><p>Spinal Disord 1992;5:383–89; discussion 397.</p><p>4. Hamill J, Knutzen KM. Biomechanical Basis of Human</p><p>Movement. 2nd ed. Philadelphia, PA: Lippincott</p><p>Williams & Wilkins, 2003.</p><p>5. Levangle PK, Norkin CC. Joint Structure and Function:</p><p>A Comprehensive Analysis. 3rd ed. Philadelphia, PA:</p><p>FA Davis Company; 2001.</p><p>6. Watkins J. Structure and Function of the Musculoskel-</p><p>etal System. Champaign, IL: Human Kinetics; 1999.</p><p>7. Nordin M, Frankel VH. Basic Biomechanics of the</p><p>Musculoskeletal System. 3rd ed. Philadelphia, PA:</p><p>Lippincott Williams & Wilkins; 2001.</p><p>8. Kendall FP, McCreary EK, Provance PG. Muscles Test-</p><p>ing and Function with Posture and Pain. 5th ed. Balti-</p><p>more, MD: Lippincott Williams & Wilkins; 2005.</p><p>9. Luttgens K, Hamilton N. Kinesiology: Scientifi c Basis of</p><p>Human Motion. 9th ed. Dubuque, IA: Brown & Bench-</p><p>mark Publishers; 1997.</p><p>10. Powers CM. The infl uence of altered lower-extremity</p><p>kinematics on patellofemoral joint dysfunction: a</p><p>theoretical perspective. J Orthop Sports Phys Ther</p><p>2003;33:639–46.</p><p>11. Inman VT, Ralston HJ, Todd F. Human Walking. Balti-</p><p>more, MD: Williams & Wilkins; 1981.</p><p>12. Innes KA. The Effect of Gait on Extremity Evaluation.</p><p>In: Hammer WI, ed. 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Edgerton VR, Wolf SL, Levendowski DJ, Roy RR.</p><p>Theoretical basis for patterning EMG amplitudes</p><p>to assess muscle dysfunction. Med Sci Sports Exerc</p><p>1996;28:744–51.</p><p>27. Lieber RL. Skeletal Muscle Structure and Func-</p><p>tion: Implications for Rehabilitation. Baltimore, MD:</p><p>Lippincott Williams & Wilkins; 2002.</p><p>28. Bergmark A. Stability of the lumbar spine. A</p><p>study in mechanical engineering. Acta Ortho Scand</p><p>1989;230(Suppl):20–4.</p><p>29. Mooney V. Sacroiliac Joint Dysfunction. In: Vleeming</p><p>A, Mooney V, Dorman T, Snijders C, Stoeckart R, eds.</p><p>Movement, Stability and Low Back Pain. London, UK:</p><p>Churchill Livingstone; 1997: 37–52.</p><p>30. Crisco JJ, Panjabi MM. The intersegmental and mul-</p><p>tisegmental muscles of the spine: a biomechanical</p><p>model comparing lateral stabilizing potential. Spine</p><p>1991;7:793–9.</p><p>31. Richardson C, Jull G, Hodges P, Hides J. Therapeutic</p><p>Exercise for Spinal Segmental Stabilization in Low</p><p>Back Pain. London, UK: Churchill Livingstone; 1999.</p><p>32. Culham LC, Peat M. Functional anatomy of the shoul-</p><p>der complex. J Ortho Sports Phys Ther 1993;18:342–50.</p><p>NASM_Chap02.indd 59NASM_Chap02.indd 59 7/5/2010 9:43:33 PM7/5/2010 9:43:33 PM</p><p>60 CHAPTER 2</p><p>33. Wilk KE, Reinold MM, Dugas JR, Arrigo CA, Moser</p><p>MW, Andrews JR. Current concepts in the recogni-</p><p>tion and treatment of superior labral (SLAP) lesions. J</p><p>Orthop Sports Phys Ther 2005;35:273–91.</p><p>34. Millett PJ, Wilcox RB 3rd, O’Holleran JD, Warner JJ.</p><p>Rehabilitation of the rotator cuff: an evaluation-based</p><p>approach. J Am Acad Orthop Surg 2006;14:599–609.</p><p>35. Kibler WB, Chandler TJ, Shapiro R, Conuel M. Muscle</p><p>activation in coupled scapulohumeral motions in</p><p>the high performance tennis serve. Br J Sports Med</p><p>2007;41:745–9.</p><p>36. Gottschalk F, Kourosh S, Leveau B. The functional</p><p>anatomy of tensor fascia latae and gluteus medius and</p><p>minimus. J Anat 1989;166:179–89.</p><p>37. Anderson FC, Pandy MG. Individual muscle contri-</p><p>butions to support in normal walking. Gait Posture</p><p>2003;17:159–69.</p><p>38. Hossain M, Nokes LD. A model of dynamic sacro-iliac</p><p>joint instability from malrecruitment of gluteus maxi-</p><p>mus and biceps femoris muscles resulting in low back</p><p>pain. Med Hypotheses 2005;65:278–81.</p><p>39. Liu MQ, Anderson FC, Pandy MG, Delp SL. Muscles</p><p>that support the body also modulate forward progres-</p><p>sion during walking. J Biomech 2006;39:2623–30.</p><p>40. Lieb FJ, Perry J. Quadriceps function. J Bone Joint Surg</p><p>1971;50A:1535–48.</p><p>41. Toumi H, Poumarat G, Benjamin M, Best T, F’Guyer</p><p>S, Fairclough J. New insights into the function of the</p><p>vastus medialis with clinical implications. Med Sci</p><p>Sports Exerc 2007;39:1153–9.</p><p>42. Lee D. Instability of the Sacroiliac Joint and the</p><p>Consequences for Gait. In: Vleeming A, Mooney V,</p><p>Dorman T, Snijders C, Stoeckart R, eds. Movement,</p><p>Stability and Low Back Pain. London, UK: Churchill</p><p>Livingstone; 1997: 231-234.</p><p>43. Gracovetsky SA. Linking the Spinal Engine With</p><p>the Legs: A Theory of Human Gait. In: Vleeming A,</p><p>Mooney V, Dorman T, Snijders C, Stoeckart R, eds.</p><p>Movement, Stability and Low Back Pain. London, UK:</p><p>Churchill Livingstone; 1997: 243-252.</p><p>44. Vleeming A, Snijders CJ, Stoeckart R, Mens JMA.</p><p>The Role of the Sacroiliac Joints in Coupling Between</p><p>Spine, Pelvis, Legs and Arms. In: Vleeming A, Mooney</p><p>V, Dorman T, Snijders C, Stoeckart R, eds. Movement,</p><p>Stability and Low Back Pain. London, UK: Churchill</p><p>Livingstone; 1997: 53-72.</p><p>45. Newton RA. Neural Systems Underlying Motor Control.</p><p>In: Montgomery PC, Connoly BH, eds. Motor Control</p><p>and Physical Therapy: Theoretical Framework and Prac-</p><p>tical Applications. Hixson, TN: Chattanooga Group; 1991.</p><p>46. Rose DJ. A Multi-level Approach to the Study of</p><p>in conver-</p><p>sations, advertisements and any other arena,</p><p>unless otherwise agreed upon by the client</p><p>in writing, or due to medical and/or legal</p><p>necessity.</p><p>2. Protect the interest of clients who are minors</p><p>by law, or who are unable to give voluntary</p><p>consent by securing the legal permission of</p><p>the appropriate third party or guardian.</p><p>3. Store and dispose of client records in secure</p><p>manner.</p><p>Legal and Ethical</p><p>Each certifi ed or non-certifi ed member must</p><p>comply with all legal requirements within the</p><p>applicable jurisdiction. In his/her professional</p><p>role, the certifi ed or non-certifi ed member must:</p><p>1. Obey all local, state, providence and/or</p><p>federal laws.</p><p>2. Accept complete responsibility for his/her</p><p>actions.</p><p>3. Maintain accurate and truthful records.</p><p>4. Respect and uphold all existing publishing</p><p>and copyright laws.</p><p>Business Practice</p><p>Each certifi ed or non-certifi ed member must</p><p>practice with honesty, integrity and lawfulness.</p><p>In his/her professional role, the certifi ed or non-</p><p>certifi ed member shall:</p><p>1. Maintain adequate liability insurance.</p><p>2. Maintain adequate and truthful progress</p><p>notes for each client.</p><p>3. Accurately and truthfully inform the public</p><p>of services rendered.</p><p>4. Honestly and truthfully represent all profes-</p><p>sional qualifi cations and affi liations.</p><p>5. Advertise in a manner that is honest, dig-</p><p>nified and representative of services that</p><p>can be delivered without the use of pro-</p><p>vocative and/or sexual language and/or</p><p>pictures.</p><p>6. Maintain accurate fi nancial, contract,</p><p>appointment and tax records including origi-</p><p>nal receipts for a minimum of four years.</p><p>7. Comply with all local, state, federal</p><p>or providence laws regarding sexual</p><p>harassment.</p><p>NASM expects each member to uphold the Code</p><p>of Ethics in its entirety. Failure to comply with</p><p>the NASM Code of Ethics may result in disci-</p><p>plinary actions including but not limited to sus-</p><p>pension or termination of membership and/or</p><p>certifi cation. All members are obligated to report</p><p>any unethical behavior or violation of the Code</p><p>of Ethics by other NASM members.</p><p>NASM_FM.indd vNASM_FM.indd v 7/5/2010 8:47:31 PM7/5/2010 8:47:31 PM</p><p>THE NASM Corrective Exercise Continuum has been a facet in both the fitness</p><p>and sports performance training arenas for years and as such, has benefi ted</p><p>many professionals and top-notch athletes along the way. From top-level train-</p><p>ers, executives owning and managing professional teams, to the athletes them-</p><p>selves, the reach of the Corrective Exercise Continuum is beyond compare as</p><p>noted by the following friends of NASM, who have been instrumental in the</p><p>success of the best performance and injury prevention training system in the</p><p>fi eld.</p><p>“NASM OPT-Training is a huge benefit. It has a cumulative effect on your body.</p><p>If your body is more receptive every night, it’s going to help you over the long</p><p>term.”</p><p>—Steve Nash, Phoenix Suns, Two-Time NBA MVP</p><p>“NASM’s Corrective Exercise Training course is by far the best continuing educa-</p><p>tion I have taken. The systematic process, the redefining of preventative care, and</p><p>the hands-on focus has allowed me to do my job better.”</p><p>—Fred Tedeschi, Head Athletic Trainer, Chicago Bulls</p><p>“I felt like I didn’t have the competitive edge to make a lasting impact in the per-</p><p>sonal training industry. I would struggle to see what other trainers were doing</p><p>and what I wasn’t doing. I finally realized that the one major thing that NASM</p><p>offered, that most other certifications didn’t offer, was Corrective Exercise as well</p><p>as Optimum Performance Training. Keep up the great work NASM as you continue</p><p>to lead the fitness industry and change the lives of many for years to come!”</p><p>—Ralph Arellanes, NASM CPT, CES, Personal Trainer, New Mexico</p><p>“The health and wellness of professional athletes has an intangible value—sickness</p><p>or injury can devastate an organization, team, and athlete. As a medical profes-</p><p>sional, I understand the importance of keeping each athlete healthy and I rely</p><p>on the best science and techniques to do just that. NASM’s unique program-</p><p>ming model and integrated training techniques exemplify their commitment to</p><p>cutting-edge performance training methods. Too often we dedicate our resources</p><p>to rehabilitating an athlete and neglect to focus on injury prevention, but NASM’s</p><p>programs combine the latest science, research and clinical applications available</p><p>to help athletes reduce injuries and reach their performance potential. NASM’s</p><p>evidence-based approach systematically progresses athletes through a solid foun-</p><p>dation punctuated with preventative measures and works to ensure a physically</p><p>sound athlete throughout their career.”</p><p>—Dr. Thomas Carter, Team Physician, Phoenix Suns and Emeritus</p><p>Head of Orthopedic Surgery, Arizona State University</p><p>Preface</p><p>NASM_FM.indd viNASM_FM.indd vi 7/5/2010 8:47:31 PM7/5/2010 8:47:31 PM</p><p>“I feel like I’m contributing. As long as I feel like that, I’ll keep playing . . . I feel</p><p>like I found the fountain of youth.”</p><p>—Grant Hill, Phoenix Suns</p><p>“As an athletic trainer with the Chicago Cubs, I applied the information and prin-</p><p>ciples from NASM’s Sports Performance and Corrective Exercise programs with</p><p>great results. These courses made me an even better athletic trainer and the players</p><p>respected me even more.”</p><p>—Esteban Melendez, MS, ATC, LAT, NASM PES, CES, Florida</p><p>“NASM has given me more avenues to explore what a player is going through.</p><p>Watching his movements, seeing what he’s lacking, then assessing and stretching</p><p>the asymmetries in players. The more you have in your toolbox, the better you’ll</p><p>be professionally, and the better you’ll be for your players.”</p><p>—Ben Potenziano, ATC, CES. Strength and Conditioning Coach, San Francisco Giants</p><p>“NASM has been an unparalleled education provider to myself and my staff. They</p><p>have helped us provide our athletes with the best possible training and corrective</p><p>strategies to keep them on the court.”</p><p>—Aaron Nelson, Head Athletic Trainer, Phoenix Suns</p><p>“I had been a trainer and in the business for approximately 13 years and carried</p><p>three other certifications . . . They were helpful, but I knew I needed something</p><p>to augment and enhance my knowledge . . . NASM provided this. Because of the</p><p>educational opportunities and leadership provided by NASM, I have been greatly</p><p>enhanced as a trainer, simply because it is effective and builds upon itself.”</p><p>—Dan Cordell, NASM CPT, PES, CES, Georgia</p><p>“I’ve obtained numerous certifications from nationally recognized organizations,</p><p>but NASM is simply the best. NASM has given me scientific, progressive knowl-</p><p>edge that I apply to all of my client programs.”</p><p>—Patrick Murphy, NASM CPT, CES, PES</p><p>NASM_FM.indd viiNASM_FM.indd vii 7/5/2010 8:47:31 PM7/5/2010 8:47:31 PM</p><p>I applaud you on your dedication to helping athletes achieve the height of</p><p>their physical skill, and thank you for entrusting the National Academy of</p><p>Sports Medicine (NASM) with your education. By following the techniques in</p><p>this book, NASM’s Essentials of Corrective Exercise Training, you will gain the</p><p>information, insight, and inspiration you need to change the world as a health</p><p>and fitness professional.</p><p>Since 1987, NASM has been the leading authority in certifi cation, continu-</p><p>ing education, solutions and tools for health and fitness, sports performance</p><p>and sports medicine professionals. Our systematic and scientifi c approach to</p><p>both fitness and performance continues to raise the bar as the “gold standard”</p><p>in the industry. Today, we serve as the global authority in more than 80 coun-</p><p>tries, serving more than 100,000 members! Tomorrow, our possibilities are</p><p>endless.</p><p>The health and fitness and sports performance industries are prime for</p><p>a convergence of the latest science with cutting-edge technological solutions</p><p>for maximizing the human potential. With the advances in research and</p><p>application techniques, exercise and sports performance training will shift</p><p>upward, drawing on traditional approaches</p><p>Motor</p><p>Control and Learning. Needham Heights, MA: Allyn &</p><p>Bacon; 1997.</p><p>47. Porterfi eld JA, DeRosa C. Mechanical Low Back Pain.</p><p>Philadelphia, PA: WB Saunders; 1991.</p><p>48. Snijders CJ, Vleeming A, Stoeckart R, Mens JMA,</p><p>Kleinrensink GJ. Biomechanics of the Interface</p><p>Between Spine and Pelvis in Different Postures.</p><p>In: Vleeming A, Mooney V, Dorman T, Snijders C,</p><p>Stoeckart R, eds. Movement, Stability and Low Back</p><p>Pain. London, UK: Churchill Livingstone; 1997:</p><p>103-114.</p><p>49. Fredericson M, Cookingham CL, Chaudhari AM,</p><p>Dowdell BC, Oestreicher N, Sahrmann SA. Hip abduc-</p><p>tor weakness in distance runners with iliotibial band</p><p>syndrome. Clin J Sport Med 2000;10:169–75.</p><p>50. Ireland ML, Wilson JD, Ballantyne BT, Davis IM. Hip</p><p>strength in females with and without patellofemoral</p><p>pain. J Orthop Sports Phys Ther 2003;33:671–6.</p><p>51. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR.</p><p>The effect of neuromuscular training on the incidence</p><p>of knee injury in female athletes. A prospective study.</p><p>Am J Sports Med 1999;27:699–706.</p><p>52. Seeley RR, Stephans TD, Tate P. Anatomy and Physiol-</p><p>ogy. 6th ed. Boston, MA: McGraw-Hill; 2003.</p><p>53. Lephart SM, Fu FH. Proprioception and Neuromuscu-</p><p>lar Control in Joint Stability. Champaign, IL: Human</p><p>Kinetics; 2000.</p><p>54. Gabbard C. Lifelong Motor Development. San Fran-</p><p>cisco, CA: Pearson Benjamin Cummings; 2008.</p><p>55. Sage GH. Introduction to Motor Behavior: A Neu-</p><p>ropsychological Approach. 3rd ed. Dubuque, IA: WC</p><p>Brown; 1984.</p><p>56. Ghez C. The Control of Movement. In: Kandel E,</p><p>Schwartz J, Jessel T, eds. Principles of Neuroscience.</p><p>New York, NY: Elsevier Science; 1991: 653-673.</p><p>57. Brown CN, Mynark R. Balance defi cits in recreational</p><p>athletes with chronic ankle instability. J Athl Train</p><p>2007;42:367–73.</p><p>58. Solomonow M, Barratta R, Zhou BH. The synergis-</p><p>tic action of the anterior cruciate ligament and thigh</p><p>muscles in maintaining joint stability. Am J Sports Med</p><p>1987;15:207–13.</p><p>59. Uremović M, Cvijetić S, Pasić MB, Serić V, Vidrih B,</p><p>Demarin V. Impairment of proprioception after whip-</p><p>lash injury. Coll Antropol 2007;31:823–7.</p><p>60. Paterno MV, Myer GD, Ford KR, Hewett TE. Neu-</p><p>romuscular training improves single-limb stability</p><p>in young female athletes. J Orthop Sports Phys Ther</p><p>2004;34:305–16.</p><p>61. Chmielewski TL, Hurd WJ, Rudolph KS, Axe MJ,</p><p>Snyder-Mackler L. Perturbation training improves</p><p>knee kinematics and reduces muscle co-contraction</p><p>after complete unilateral anterior cruciate ligament</p><p>rupture. Phys Ther 2005;85:740–9.</p><p>62. Swinnen SP. Information Feedback for Motor Skill</p><p>Learning: A Review. In: Zelaznik HN, ed. Advances in</p><p>Motor Learning and Control. Champaign, IL: Human</p><p>Kinetics; 1996: 37-43.</p><p>63. Biedert RM. Contribution of the Three Levels of</p><p>Nervous System Motor Control: Spinal Cord, Lower</p><p>Brain, Cerebral Cortex. In: Lephart SM, Fu FH, eds.</p><p>Proprioception and Neuromuscular Control in Joint</p><p>Stability. Champaign, IL: Human Kinetics; 2000:</p><p>23-30.</p><p>64. Ford KR, Myer GD, Hewett TE. Valgus knee motion</p><p>during landing in high school female and male basket-</p><p>ball players. Med Sci Sports Exerc 2003;35:1745–50.</p><p>NASM_Chap02.indd 60NASM_Chap02.indd 60 7/5/2010 9:43:33 PM7/5/2010 9:43:33 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 61</p><p>65. Nadler SF, Malanga GA, Bartoli LA, Feinberg JH,</p><p>Prybicien M, Deprince M. Hip muscle imbalance and</p><p>low back pain in athletes: infl uence of core strength-</p><p>ening. Med Sci Sports Exerc 2002;34:9–16.</p><p>66. Nadler SF, Malanga GA, Feinberg JH, Rubanni M,</p><p>Moley P, Foye P. Functional performance defi cits in</p><p>athletes with previous lower extremity injury. Clin J</p><p>Sport Med 2002;12:73–8.</p><p>67. Bullock-Saxton JE. Local sensation changes and altered</p><p>hip muscle function following severe ankle sprain.</p><p>Phys Ther 1994;74:17–28.</p><p>68. Knapik JJ, Bauman CL, Jones BH, Harris JM, Vaughan</p><p>L. Preseason strength and fl exibility imbalances asso-</p><p>ciated with athletic injuries in female collegiate ath-</p><p>letes. Am J Sports Med 1991;19:76–81.</p><p>NASM_Chap02.indd 61NASM_Chap02.indd 61 7/5/2010 9:43:33 PM7/5/2010 9:43:33 PM</p><p>62</p><p>INTRODUCTION</p><p>AS reviewed in the previous chapter, the human movement system (HMS)</p><p>is a very complex, well-orchestrated system of interrelated and interdepen-</p><p>dent myofascial, neuromuscular, and articular components. The functional</p><p>integration of each system allows for optimal neuromuscular effi ciency dur-</p><p>ing functional activities (Figure 3-1). Optimal alignment and functioning of</p><p>all components (and segments of each component) result in optimum length-</p><p>tension relationships, force-couple relationships, precise arthrokinematics</p><p>(path of instantaneous center of rotation), and neuromuscular control (1–3).</p><p>Optimum alignment and functioning of each component of the HMS depends</p><p>on the structural and functional integrity of each of its interdependent sys-</p><p>tems. This structural alignment is known as posture. Posture is the indepen-</p><p>dent and interdependent alignment (static posture) and function (transitional</p><p>and dynamic posture) of all components of the HMS at any given moment,</p><p>and is controlled by the central nervous system (4). Assessments for these dif-</p><p>ferent forms of posture will be covered in later chapters.</p><p>C H A P T E R 3</p><p>OBJECTIVES Upon completion of this chapter, you will be able to:</p><p>Explain the importance that proper posture ➤</p><p>has on movement.</p><p>Understand and explain common causes for ➤</p><p>movement dysfunction.</p><p>Understand and explain common human ➤</p><p>movement system dysfunctions and potential</p><p>causes for each.</p><p>An Evidence-Based</p><p>Approach to</p><p>Understanding Human</p><p>Movement Impairments</p><p>Neuromuscular effi -</p><p>ciency: the ability of the</p><p>neuromuscular system</p><p>to allow agonist, antag-</p><p>onists, synergists, and</p><p>stabilizers to work syn-</p><p>ergistically to produce,</p><p>reduce, and dynamically</p><p>stabilize the HMS in all</p><p>three planes of motion.</p><p>Posture: the indepen-</p><p>dent and interdepen-</p><p>dent alignment (static</p><p>posture) and func-</p><p>tion (transitional and</p><p>dynamic posture) of all</p><p>components of the HMS</p><p>at any given moment,</p><p>controlled by the cen-</p><p>tral nervous system.</p><p>NASM_Chap03.indd 62NASM_Chap03.indd 62 7/5/2010 9:44:11 PM7/5/2010 9:44:11 PM</p><p>AN EVIDENCE-BASED APPROACH TO UNDERSTANDING HUMAN MOVEMENT IMPAIRMENTS 63</p><p>Effi ciency and longevity of the HMS requires integration of all systems.</p><p>Structural effi ciency is the alignment of each segment of the HMS, which allows</p><p>posture to be balanced in relation to one’s center of gravity. This enables</p><p>individuals to maintain their center of gravity over their constantly changing</p><p>base of support during functional movements. Functional effi ciency is the abil-</p><p>ity of the neuromuscular system to recruit correct muscle synergies, at the</p><p>right time, with the appropriate amount of force to perform functional tasks</p><p>with the least amount of energy and stress on the HMS. This helps prevent</p><p>overtraining and the development of movement impairment syndromes.</p><p>HUMAN MOVEMENT SYSTEM IMPAIRMENT</p><p>Impairment or injury to the HMS rarely involves one structure. Because</p><p>the HMS is an integrated system, impairment in one system leads to com-</p><p>pensations and adaptations in other systems. As outlined in Figure 3-2, if</p><p>Figure 3.1 Optimal neuromuscular effi ciency.</p><p>Figure 3.2 Human movement impairment.</p><p>Structural effi ciency:</p><p>the alignment of each</p><p>segment of the HMS,</p><p>which allows posture</p><p>to be balanced in rela-</p><p>tion to one’s center of</p><p>gravity.</p><p>Functional effi ciency:</p><p>the ability of the neu-</p><p>romuscular system to</p><p>recruit correct muscle</p><p>synergies, at the right</p><p>time, with the appro-</p><p>priate amount of force</p><p>to perform functional</p><p>tasks with the least</p><p>amount of energy and</p><p>stress on the HMS.</p><p>NASM_Chap03.indd 63NASM_Chap03.indd 63 7/5/2010 9:44:11 PM7/5/2010 9:44:11 PM</p><p>64 CHAPTER 3</p><p>one component in the HMS is out of alignment (muscle tightness, muscle</p><p>weakness, altered joint arthrokinematics), it creates predictable patterns of tis-</p><p>sue overload and dysfunction, which leads to decreased neuromuscular con-</p><p>trol and microtrauma,</p><p>and initiates the cumulative injury cycle (Figure 3-3). The</p><p>cumulative injury cycle causes decreased performance, myofascial adhesions</p><p>(which further alter length-tension relationships and joint arthrokinematics),</p><p>and eventually injury (5).</p><p>These predictable patterns of dysfunction are referred to as movement</p><p>impairment syndromes. Movement impairment syndromes refer to the state in</p><p>which the structural integrity of the HMS is compromised because the com-</p><p>ponents are out of alignment (1). This places abnormal distorting forces on the</p><p>structures in the HMS that are above and below the dysfunctional segment. If</p><p>one segment in the HMS is out of alignment, then other movement segments</p><p>have to compensate in attempts to balance the weight distribution of the dys-</p><p>functional segment. For example, if the gluteus medius is underactive, then the</p><p>tensor fascia latae (TFL) may become synergistically dominant to produce the</p><p>necessary force to accomplish frontal plane stability of the lumbo-pelvic-hip</p><p>complex (LPHC). An overactive TFL can lead to tightness in the iliotibial band</p><p>(ITB) and lead to patellofemoral joint pain, ITB tendonitis, and low-back pain</p><p>(1,6–9). To avoid movement impairment syndromes and the chain reactions that</p><p>one misaligned segment creates, the health and fi tness professional must empha-</p><p>size optimum static, transitional, and dynamic postural control to maintain the</p><p>structural integrity of the HMS during functional activities. Optimum move-</p><p>ment system balance and alignment helps prevent movement impairment syn-</p><p>dromes and provides optimal shock absorption, weight acceptance, and transfer</p><p>of force during functional movements.</p><p>Cumulative injury</p><p>cycle: a cycle whereby</p><p>an injury will induce</p><p>infl ammation, muscle</p><p>spasm, adhesion,</p><p>altered neuromuscular</p><p>control, and muscle</p><p>imbalances.</p><p>Movement impair-</p><p>ment syndromes: refer</p><p>to the state in which</p><p>the structural integrity</p><p>of the HMS is compro-</p><p>mised because the</p><p>components are out of</p><p>alignment.</p><p>Figure 3.3 Cumulative injury cycle.</p><p>NASM_Chap03.indd 64NASM_Chap03.indd 64 7/5/2010 9:44:12 PM7/5/2010 9:44:12 PM</p><p>AN EVIDENCE-BASED APPROACH TO UNDERSTANDING HUMAN MOVEMENT IMPAIRMENTS 65</p><p>STATIC MALALIGNMENTS</p><p>Static malalignments may alter normal</p><p>length-tension relationships. Common</p><p>static malalignments include joint hypo-</p><p>mobility and myofascial adhesions that</p><p>lead to or can be caused by poor static pos-</p><p>ture. Joint dysfunction (hypomobility) is</p><p>one of the most common causes of pain in</p><p>an individual (10,11). Once a joint has lost</p><p>its normal arthrokinematics, the muscles</p><p>around that joint may spasm and tighten</p><p>in an attempt to minimize the stress at</p><p>the involved segment (10,11). Certain</p><p>muscles become tight (alters the length-</p><p>tension relationship) or overactive (alters</p><p>force- couple relationships) to prevent</p><p>movement and further injury. This pro-</p><p>cess initiates the cumulative injury cycle.</p><p>Therefore, a joint dysfunction causes</p><p>altered length-tension relationships. This</p><p>alters normal force-couple relationships,</p><p>which alters normal movement patterns</p><p>and leads to structural and functional</p><p>ineffi ciency (1,5,10–12) (Figure 3-4).</p><p>ALTERED MUSCLE RECRUITMENT</p><p>Static malalignments (altered</p><p>length-tension relationships</p><p>resulting from poor static pos-</p><p>ture, joint dysfunction, and</p><p>myofascial adhesions) may lead</p><p>to altered muscle recruitment</p><p>patterns (altered force-couple</p><p>relationships). This is caused</p><p>by altered reciprocal inhibition.</p><p>Altered reciprocal inhibi-</p><p>tion is the process by which a</p><p>tight muscle (short, overactive,</p><p>myofascial adhesions) causes</p><p>decreased neural drive, and</p><p>therefore optimal recruitment</p><p>of its functional antagonist (1).</p><p>This process alters the normal</p><p>force-couple relationships that</p><p>should be present at all seg-</p><p>ments throughout the HMS.</p><p>Furthermore, altered reciprocal</p><p>Altered reciprocal</p><p>inhibition: the process</p><p>whereby a tight mus-</p><p>cle (short, overactive,</p><p>myofascial adhesions)</p><p>causes decreased neu-</p><p>ral drive, and there-</p><p>fore optimal recruit-</p><p>ment of its functional</p><p>antagonist.</p><p>Figure 3.4 Joint dysfunction.</p><p>Figure 3.5 Altered reciprocal inhibition and synergistic</p><p>dominance.</p><p>Erector</p><p>spinae</p><p>Iliopsoas</p><p>Rectus</p><p>femoris</p><p>NASM_Chap03.indd 65NASM_Chap03.indd 65 7/5/2010 9:44:13 PM7/5/2010 9:44:13 PM</p><p>66 CHAPTER 3</p><p>inhibition can lead to synergistic dominance, which is the process in which a</p><p>synergist compensates for a prime mover to maintain force production (1,13).</p><p>For example, a tight psoas decreases the neural drive and therefore opti-</p><p>mal recruitment of the gluteus maximus. This altered recruitment and force</p><p>production of the gluteus maximus (prime mover for hip extension), leads to</p><p>compensation and substitution by the synergists (hamstrings) and stabilizers</p><p>(erector spinae) (Figure 3-5). This can potentially lead to hamstring strains and</p><p>low back pain. In another example, if a client has a weak gluteus medius, then</p><p>synergists (tensor fascia latae, adductor complex, and quadratus lumborum)</p><p>become synergistically dominant to compensate for the weakness (6). This</p><p>altered muscle recruitment pattern further alters static alignment (alters nor-</p><p>mal joint alignment and normal length-tension relationships around the joint</p><p>to which the muscles attach) and leads to injury.</p><p>DYNAMIC MALALIGNMENTS</p><p>Several authors have described common movement impairment syndromes</p><p>(dynamic malalignment) that are caused by static malalignments and altered</p><p>muscle recruitment patterns (1,10,14). The most common movement impairment</p><p>syndromes include the lower extremity movement impairment syndrome and the</p><p>upper extremity movement impairment syndrome.</p><p>Individuals with a lower extremity movement impairment syndrome are</p><p>usually characterized by excessive foot pronation (fl at feet), increased knee val-</p><p>gus (tibia internally rotated and femur internally rotated and adducted or knock-</p><p>kneed), and increased movement at the</p><p>LPHC (extension or fl exion) during func-</p><p>tional movements (Figure 3-6; Table 3-1).</p><p>Potentially tightened or overactive muscles</p><p>may include the peroneals, lateral gastroc-</p><p>nemius, soleus, iliotibial band, lateral ham-</p><p>string complex, adductor complex, and</p><p>psoas. Potentially weakened or inhibited</p><p>muscles may include the posterior tibialis,</p><p>fl exor digitorum longus, fl exor hallucis lon-</p><p>gus, anterior tibialis, vastus medialis, pes</p><p>anserine complex (sartorius, gracilis, semi-</p><p>tendinosus), gluteus medius, hip exter-</p><p>nal rotators, gluteus maximus, and local</p><p>stabilizers of the LPHC. Potential joint dys-</p><p>functions may include the fi rst metatar-</p><p>sophalangeal joint, subtalar joint, talocrural</p><p>joint, proximal tibiofi bular joint, sacroiliac</p><p>joint, and lumbar facet joints. Individu-</p><p>als who present with the lower extremity</p><p>movement impairment syndrome typi-</p><p>cally exhibit predictable patterns of injury</p><p>including plantar fasciitis, posterior tibialis</p><p>tendinitis (shin splints), anterior knee pain,</p><p>and low-back pain (1,10,14).</p><p>Synergistic domi-</p><p>nance: the process</p><p>by which a synergist</p><p>compensates for a</p><p>prime mover to main-</p><p>tain force production.</p><p>Upper extremity</p><p>movement impair-</p><p>ment syndrome:</p><p>usually characterized</p><p>as having rounded</p><p>shoulders and a for-</p><p>ward head posture or</p><p>improper scapulotho-</p><p>racic or glenohumeral</p><p>kinematics during</p><p>functional movements.</p><p>Figure 3.6 Lower extremity movement</p><p>impairment syndrome.</p><p>Misalignment</p><p>of hips</p><p>Misalignment</p><p>of knees</p><p>Pronated/</p><p>flat foot</p><p>Hyperextends</p><p>Grinds</p><p>meniscus</p><p>Low back</p><p>pain</p><p>Lower extremity</p><p>movement impair-</p><p>ment syndrome:</p><p>usually characterized</p><p>by excessive foot</p><p>pronation (fl at feet),</p><p>increased knee valgus</p><p>(tibia internally rotated</p><p>and femur internally</p><p>rotated and adducted</p><p>or knock-kneed), and</p><p>increased movement</p><p>at the LPHC (extension</p><p>or fl exion) during func-</p><p>tional movements.</p><p>NASM_Chap03.indd 66NASM_Chap03.indd 66 7/5/2010 9:44:16 PM7/5/2010 9:44:16 PM</p><p>AN EVIDENCE-BASED APPROACH TO UNDERSTANDING HUMAN MOVEMENT IMPAIRMENTS 67</p><p>Table 3.1 LOWER EXTREMITY MOVEMENT</p><p>IMPAIRMENT SYNDROME</p><p>Tight or Overactive</p><p>Muscles</p><p>Weak or Underactive Muscles Common Joint</p><p>Dysfunction</p><p>Possible Injuries</p><p>Peroneals</p><p>Lateral gastrocnemius</p><p>Soleus</p><p>Iliotibial band</p><p>Lateral hamstring complex</p><p>Adductor complex</p><p>Psoas</p><p>Posterior tibialis</p><p>Flexor digitorum longus</p><p>Flexor hallucis longus</p><p>Anterior tibialis</p><p>Vastus medialis</p><p>Pes anserine complex</p><p>Gracilis</p><p>Sartorius</p><p>Semitendinosus</p><p>Gluteus medius</p><p>Hip external rotators</p><p>Gluteus maximus</p><p>Local stabilizers of the LPHC</p><p>First metatarsopha-</p><p>langeal joint</p><p>Subtalar joint</p><p>Talocrural joint</p><p>Proximal tibiofi bular</p><p>joint</p><p>Sacroiliac joint</p><p>Lumbar facet joints</p><p>Plantar fasciitis</p><p>Posterior tibialis</p><p>tendinitis</p><p>Anterior knee pain</p><p>Low-back pain</p><p>Individuals with the upper extremity movement impairment syndrome</p><p>are usually characterized as having rounded shoulders and a forward head</p><p>posture or improper scapulothoracic or glenohumeral kinematics during</p><p>functional movements (Figure 3-7; Table 3-2). This pattern is common in</p><p>individuals who sit for extended periods of time or who develop pattern</p><p>overload (e.g., throwing, continual bench pressing, and swimming). Poten-</p><p>tially tightened or overactive muscles include</p><p>the pectoralis major, pectoralis minor, anterior</p><p>deltoid, subscapularis, latissimus dorsi, leva-</p><p>tor scapulae, upper trapezius, teres major, ster-</p><p>nocleidomastoid, scalenes, and rectus capitis.</p><p>Potentially weakened or inhibited muscles usu-</p><p>ally include the rhomboids, lower trapezius,</p><p>posterior deltoid, teres minor, infraspinatus,</p><p>serratus anterior, longus coli, and longus capi-</p><p>tis. Potential joint dysfunctions may include the</p><p>sternoclavicular joint, acromioclavicular joint,</p><p>and thoracic and cervical facet joints.</p><p>Individuals who present with the upper</p><p>extremity movement impairment syndrome</p><p>typically exhibit predictable patterns of injury</p><p>including rotator cuff impingement, shoulder</p><p>instability, biceps tendinitis, thoracic outlet syn-</p><p>drome, and headaches (1,10).</p><p>Assessing an individual for these impair-</p><p>ment syndromes will be covered in further detail</p><p>in later chapters.</p><p>Overactive/tight</p><p>Pectoralis major</p><p>and minor</p><p>Inhibited/weak</p><p>Deep neck flexors</p><p>Inhibited/weak</p><p>Serratus anterior</p><p>Lower trapezius</p><p>Overactive/tight</p><p>Upper trapezius</p><p>Levator scapula</p><p>Figure 3.7 Upper extremity movement impairment syndrome.</p><p>NASM_Chap03.indd 67NASM_Chap03.indd 67 7/5/2010 9:44:17 PM7/5/2010 9:44:17 PM</p><p>68 CHAPTER 3</p><p>Table 3.2 UPPER EXTREMITY MOVEMENT IMPAIRMENT SYNDROME</p><p>Tight/Overactive</p><p>Muscles</p><p>Weak/Underactive</p><p>Muscles</p><p>Common Joint Dysfunction Possible Injuries</p><p>Pectoralis major Rhomboids Sternoclavicular joint Rotator cuff impingement</p><p>Pectoralis minor Lower trapezius Acromioclavicular joint Shoulder instability</p><p>Anterior deltoid Posterior deltoid Thoracic and cervical facet joints Biceps tendinitis</p><p>Subscapularis Teres minor Thoracic outlet syndrome</p><p>Latissimus dorsi Infraspinatus Headaches</p><p>Levator scapulae Serratus anterior</p><p>Upper trapezius</p><p>Teres major</p><p>Sternocleidomastoid</p><p>Scalenes</p><p>Rectus capitis</p><p>Longus coli and</p><p>longus capitis</p><p>EVIDENCE-BASED REVIEW OF COMMON SEGMENTAL MOVEMENT</p><p>SYSTEM IMPAIRMENTS</p><p>Foot and Ankle</p><p>SCIENTIFIC REVIEW</p><p>The ankle is the most commonly injured joint in both sports and daily life (15).</p><p>Several authors have found that control at the hip is vital for maintaining control</p><p>at the ankle (16–19). It has also been demonstrated that proximal factors such as</p><p>LPHC muscle weakness, in particular in the frontal and transverse planes, con-</p><p>tribute to altered lower extremity alignment, leading to increased foot pronation</p><p>(9,20,21) (Figure 3-8). If the hip lacks dynamic stability in the frontal and trans-</p><p>verse planes during functional weight-bearing activities, the femur may adduct</p><p>and internally rotate, whereas the tibia may externally rotate and the foot goes</p><p>into excessive pronation (9,20). These static malalignments (altered length-ten-</p><p>sion relationships and joint arthrokinematics), abnormal muscle activation pat-</p><p>terns, and dynamic malalignments can alter neuromuscular control and can</p><p>lead to plantar fasciitis (22,23), patellofemoral pain (9,24–34), ITB tendonitis</p><p>(35), and increased risk of anterior cruciate ligament (ACL) tears (36–50).</p><p>STATIC MALALIGNMENTS (ALTERED LENGTH-TENSION</p><p>RELATIONSHIPS OR ALTERED JOINT ARTHROKINEMATICS)</p><p>Common static malalignments of the foot and ankle include hyperpronation of</p><p>the foot (9,20,51,52), which may result from overactivity of the peroneals and</p><p>lateral gastrocnemius, underactivity of the anterior and posterior tibialis, and</p><p>decreased joint motion of the fi rst metatarsophalangeal (MTP) joint and talus</p><p>(decreased posterior glide). It has been reported that there is decreased ankle</p><p>NASM_Chap03.indd 68NASM_Chap03.indd 68 7/5/2010 9:44:17 PM7/5/2010 9:44:17 PM</p><p>AN EVIDENCE-BASED APPROACH TO UNDERSTANDING HUMAN MOVEMENT IMPAIRMENTS 69</p><p>Figure 3.8 Effects of weak LPHC on lower extremity.</p><p>A B</p><p>+</p><p>Normal Abnormal</p><p>dorsifl exion after an ankle sprain (53,54). It is hypothesized that decreased</p><p>posterior glide of the talus can decrease dorsifl exion at the ankle (55). Denegar</p><p>et al. (56) found decreased posterior glide of the talus in subjects with a his-</p><p>tory of lateral ankle sprains. Green et al. (57) found a more rapid restoration of</p><p>dorsifl exion and normalization of gait in patients with ankle sprains who were</p><p>treated with manual posterior glide of the talus.</p><p>ABNORMAL MUSCLE ACTIVATION PATTERNS</p><p>(ALTERED FORCE-COUPLE RELATIONSHIPS)</p><p>It has been demonstrated that subjects with unilateral chronic ankle sprains</p><p>had weaker ipsilateral hip abduction strength (17,19) and increased postural</p><p>sway (58,59). It has also been demonstrated that subjects with increased pos-</p><p>tural sway had up to seven times more ankle sprains than those subjects with</p><p>better postural sway scores (60,61). Furthermore, fatigue in the knee and hip</p><p>musculature (sagittal and frontal planes) creates even greater postural sway</p><p>(62,63). Cerny (64) found that weakness and decreased postural stability in</p><p>the stabilizing muscles of the LPHC, such as the gluteus medius, may pro-</p><p>duce deviations in subtalar joint motion during gait (Figure 3-8). Foot place-</p><p>ment depends on hip abduction and adduction moments generated during the</p><p>swing phase of gait, and subsequent subtalar joint inversion moments occur in</p><p>response to medial foot placement errors secondary to overactivity of the hip</p><p>NASM_Chap03.indd 69NASM_Chap03.indd 69 7/5/2010 9:44:18 PM7/5/2010 9:44:18 PM</p><p>70 CHAPTER 3</p><p>adductors (16). This has led to the determination through research that proxi-</p><p>mal stability and strength defi cits at the hip can lead to ankle injuries (65).</p><p>DYNAMIC MALALIGNMENT</p><p>It has been shown that excessive pronation of the foot during weight-bearing</p><p>causes altered alignment of the tibia, femur, and pelvic girdle (Figure 3-5) and</p><p>can lead to internal rotation stresses at the lower extremity and pelvis, which</p><p>may lead to increased strain on soft tissues (Achilles’ tendon, plantar fascia,</p><p>patella tendon, ITB, etc.) and compressive forces on the joints (subtalar joint,</p><p>patellofemoral joint, tibiofemoral joint, iliofemoral joint, and sacroiliac joint),</p><p>which can become symptomatic (9,51). The LPHC alignment has been shown</p><p>by Khamis and Yizhar (66) to be directly affected by bilateral hyperpronation</p><p>of the feet. Hyperpronation of the feet induced an anterior pelvic tilt of the</p><p>LPHC. The addition of two to three degrees of foot pronation led to a 20 to</p><p>30% increase in pelvic alignment while standing and a 50 to 75% increase in</p><p>anterior pelvic tilting during walking (66). Because an anterior pelvic tilt has</p><p>been correlated with increased lumbar curvature, the change in foot alignment</p><p>might also infl uence lumbar spine position (67). Furthermore, an asymmetric</p><p>change in foot alignment (as might occur from a unilateral ankle sprain) may</p><p>cause asymmetric lower extremity, pelvic, and lumbar alignment, which might</p><p>enhance symptoms or dysfunction.</p><p>Hip and Knee</p><p>SCIENTIFIC</p><p>REVIEW</p><p>Knee injuries account for greater than 50% of injuries in college and high</p><p>school (25,26) athletes, and among lower extremity injuries, the knee is one of</p><p>the most commonly injured segments of the HMS. Two of the more common</p><p>diagnoses resulting from physical activity are patellofemoral pain (PFP) and</p><p>ACL sprains or tears. Both PFP and ACL injuries are public health concerns</p><p>costing $2.5 billion annually for ACL injuries (38). Most knee injuries occur</p><p>during noncontact deceleration in the frontal and transverse planes (43,68). It</p><p>has also been shown that static malalignments, abnormal muscle activation</p><p>patterns, and dynamic malalignments alter neuromuscular control and can</p><p>lead to PFP (14,24), ACL injury (47,69–74), and ITB tendonitis (35).</p><p>STATIC MALALIGNMENTS (ALTERED LENGTH-TENSION</p><p>RELATIONSHIPS AND JOINT ARTHROKINEMATICS)</p><p>Static malalignments can lead to increased PFP and knee injury. Common</p><p>static malalignments include hyperpronation of the foot (9,20,51,52), increased</p><p>Q angle (a 10-degree shift in Q-angle increased patellofemoral contact forces</p><p>by 45%) (75) (Figure 3-9), anterior pelvic tilt (66), and decreased fl exibility of</p><p>the quadriceps, hamstring complex, and iliotibial band (21,22,27).</p><p>ABNORMAL MUSCLE ACTIVATION PATTERNS</p><p>(ALTERED FORCE-COUPLE RELATIONSHIPS)</p><p>Abnormal muscle activation patterns can lead to PFP, ACL injury, and other</p><p>knee injuries. Abnormal contraction intensity and onset timing of the vas-</p><p>tus medialis obliquus (VMO) and vastus lateralis have been demonstrated in</p><p>NASM_Chap03.indd 70NASM_Chap03.indd 70 7/5/2010 9:44:18 PM7/5/2010 9:44:18 PM</p><p>AN EVIDENCE-BASED APPROACH TO UNDERSTANDING HUMAN MOVEMENT IMPAIRMENTS 71</p><p>subjects with PFP (76). Ireland et al. have demonstrated 26% less hip abduction</p><p>strength and 36% decreased strength of the hip external rotators in subjects</p><p>with PFP, leading to increased femoral adduction and internal rotation (24).</p><p>Other researchers have also demonstrated decreased hip abduction strength</p><p>in subjects with PFP (77–79). Fredericson et al. (35) found that long-distance</p><p>runners with ITB syndrome had weaker hip abduction strength on the affected</p><p>leg, and also demonstrated that their symptoms were alleviated with a suc-</p><p>cessful return to running after undergoing a hip abductor strengthening pro-</p><p>gram. Heinert et al. (80) found that hip abductor weakness infl uenced knee</p><p>abduction (femoral adduction or internal rotation and tibial external rotation)</p><p>during the stance phase of running. Lawrence et al. (81) demonstrated that</p><p>individuals with decreased hip external rotation strength had increased verti-</p><p>cal ground reaction forces during landing, which is a potential predictor of PFP</p><p>and ACL injury. Research has also demonstrated increased adductor activity</p><p>and decreased dorsifl exion in subjects demonstrating increased dynamic knee</p><p>valgus (82) and decreased neuromuscular control of core musculature (83,84).</p><p>DYNAMIC MALALIGNMENTS</p><p>Dynamic malalignments may occur during movement as a result of poor neu-</p><p>romuscular control and dynamic stability of the trunk and lower extremi-</p><p>ties (14,70,84,85). Static malalignments (altered length-tension relationships</p><p>and altered joint arthrokinematics) and abnormal muscle activation patterns</p><p>Patella</p><p>ASIS</p><p>Q angle</p><p>Figure 3.9 Q-Angle.</p><p>HIP PAIN</p><p>From faulty</p><p>hip alignment</p><p>KNEE PAIN</p><p>From excesssive</p><p>lower leg rotation</p><p>LOW BACK PAIN</p><p>From faulty mechanics</p><p>originating at the foot</p><p>FOOT PAIN</p><p>From ankle joint</p><p>laxity, plantar</p><p>fasciitis, bunions</p><p>Figure 3.10 Effects of excessive knee valgus.</p><p>NASM_Chap03.indd 71NASM_Chap03.indd 71 7/5/2010 9:44:19 PM7/5/2010 9:44:19 PM</p><p>72 CHAPTER 3</p><p>(altered force-couple relationships) of the LPHC compromise dynamic stability</p><p>of the lower extremity and result in dynamic malalignments in the lower</p><p>extremity (83,84). There is a consistent description of this dynamic malalign-</p><p>ment (multisegmental HMS impairment) as a combination of contralateral</p><p>pelvic drop, femoral adduction and internal rotation, tibia external rotation,</p><p>and hyperpronation (9,14,70,73,85–92) (Figure 3-6). McLean et al. (93) have</p><p>shown that an increase in knee valgus angle could increase ACL loading by</p><p>approximately 100% (Figure 3-10). This multisegmental dynamic malalign-</p><p>ment (movement impairment syndrome) has been shown to alter force pro-</p><p>duction (94), proprioception (95), coordination (96), and landing mechanics</p><p>(97). Defi cits in neuromuscular control of the LPHC may lead to uncontrolled</p><p>trunk displacement during functional movements, which in turn may place</p><p>the lower extremity in a valgus position, increase knee abduction motion and</p><p>torque (femoral adduction or internal rotation and tibial external rotation</p><p>occurring during knee fl exion), and result in increased patellofemoral contact</p><p>pressure (75,98), knee ligament strain, and ACL injury (70,85).</p><p>Low Back</p><p>SCIENTIFIC REVIEW</p><p>Back injuries can be costly to both the individual and the health-care system.</p><p>Previous studies have found a high incidence of low-back pain (LBP) in sports</p><p>(99–101). For example, 85% of male gymnasts, 80% of weightlifters, 69% of</p><p>wrestlers, 58% of soccer players, 50% of tennis players, 30% of golfers, and</p><p>60 to 80% of the general population were reported to have LBP (102–104). It</p><p>is estimated that the annual costs attributable to LBP in the United States is</p><p>greater than $26 billion per year (105). Individuals who have LBP are signifi -</p><p>cantly more likely to have additional low-back injuries, which can predispose</p><p>the individual to future osteoarthritis and long-term disability (106). It has</p><p>been demonstrated that static malalignments</p><p>(altered length-tension relationships or altered</p><p>joint arthrokinematics), abnormal muscle</p><p>activation patterns (altered force-couple rela-</p><p>tionships), and dynamic malalignments (move-</p><p>ment system impairments) can lead to LBP.</p><p>STATIC MALALIGNMENTS (ALTERED</p><p>LENGTH-TENSION RELATIONSHIPS OR</p><p>ALTERED JOINT ARTHROKINEMATICS)</p><p>Optimal muscle performance is determined</p><p>by the posture (length-tension) of the LPHC</p><p>during functional activities (107–110). If the</p><p>neutral lordotic curve of the lumbar spine is</p><p>not maintained (i.e., low-back arches, low-</p><p>back rounds, or excessive lean forward), the</p><p>activation (107) and the relative moment arm</p><p>of the muscle fi bers decreases (109,110). Verte-</p><p>bral disk injuries occur when the outer fi brous</p><p>structure of the disk (annulus fi brosis) fails, Figure 3.11 Intervertebral disk injury.</p><p>NASM_Chap03.indd 72NASM_Chap03.indd 72 7/5/2010 9:44:19 PM7/5/2010 9:44:19 PM</p><p>AN EVIDENCE-BASED APPROACH TO UNDERSTANDING HUMAN MOVEMENT IMPAIRMENTS 73</p><p>allowing the internal contents of the disk (nucleus pulposus) to be extruded</p><p>and irritate nerves exiting the intervertebral foramen ( Figure 3-11).</p><p>The exact mechanism underlying injury to the intervertebral disk is unclear,</p><p>but it is generally proposed that it is caused by a combination of motion with</p><p>compressive loading. Increases in disk pressures and stresses are infl uenced by</p><p>the kinematics of the lumbar spine (13,111,112). Disk pressure increases with</p><p>lumbar fl exion (13,111,112) and a decrease in lordosis (e.g., low-back rounding)</p><p>during the performance of activities (161,163). In addition, a combination of</p><p>motions about the lumbar spine have been demonstrated to increase the strain</p><p>placed on the disks, and include fl exion with lateral bending</p><p>(112). This combination of motions may generate an axial</p><p>torque that Drake et al. (113) demonstrated to increase the</p><p>initiation of disk herniation. Lu et al. (114) combined all of</p><p>these factors and were able to demonstrate that compression</p><p>combined with bending and twisting moments about the</p><p>disk contributed to earlier degeneration in saturated inter-</p><p>vertebral disks. Pelvic asymmetry (iliac rotation asymmetry</p><p>or sacroiliac joint asymmetry) (Figure 3-12) has been shown</p><p>to alter movement of the HMS in standing (115) and sitting</p><p>(116). Pelvic asymmetry alters static posture of the entire</p><p>LPHC, which alters normal arthrokinematics (coupling</p><p>movement of the spine) (117–119). These changes in trunk</p><p>kinematics were linked to nonspecifi c LBP (120). It has also</p><p>been demonstrated that hip rotation asymmetry, in particu-</p><p>lar decreased hip internal rotation range of motion, is present</p><p>in clients with sacroiliac joint dysfunction (121).</p><p>ABNORMAL MUSCLE ACTIVATION PATTERNS</p><p>(ALTERED FORCE-COUPLE RELATIONSHIPS)</p><p>Because the LPHC musculature plays a critical role in sta-</p><p>bilizing this complex, insuffi ciency of any of the muscu-</p><p>lature may induce biomechanical dysfunction and altered</p><p>force-couple relationships (122). Subjects with LBP have</p><p>been reported to demonstrate impaired postural con-</p><p>trol (123–125), delayed muscle relaxation (126,127), and</p><p>abnormal muscle recruitment patterns (128), notably the</p><p>transverse abdominus and multifi dus activation is dimin-</p><p>ished in patients with LBP (129,130). A similar delay in</p><p>activation of the internal oblique, multifi dus, and gluteus</p><p>maximus was observed on the symptomatic side of indi-</p><p>viduals with sacroiliac joint pain (131). Hides et al. (132)</p><p>demonstrated that multifi dus atrophy was present in cli-</p><p>ents even in the absence of continued LBP. Further, Iwai</p><p>et al. (133) demonstrated that trunk extensor strength was</p><p>correlated with LBP in collegiate wrestlers. Nadler et al.</p><p>(134) demonstrated that a bilateral imbalance in isometric</p><p>strength of the hip extensors was related to the develop-</p><p>ment of LBP. The loads, forces, and movements that occur</p><p>about the lumbar spine are controlled by a considerable Figure 3.12 Pelvic asymmetry.</p><p>NASM_Chap03.indd 73NASM_Chap03.indd 73 7/5/2010 9:44:20 PM7/5/2010 9:44:20 PM</p><p>74 CHAPTER 3</p><p>number of ligaments and muscles. The ligaments that surround the spine</p><p>limit intersegmental motion, maintaining the integrity of the lumbar spine.</p><p>These ligaments may fail when proper motion cannot be created, proper</p><p>posture cannot be maintained, or excessive motion cannot be resisted by</p><p>the surrounding musculature (107–110). Therefore, decreasing the ability</p><p>of local and global stabilizing muscles to produce adequate force can lead</p><p>to ligamentous injury (Figure 3-13).</p><p>DYNAMIC MALALIGNMENTS</p><p>Decreased core neuromuscular control may contribute to increased valgus</p><p>positioning of the lower extremity, which can lead to increased risk of knee</p><p>injuries (84,135). Several studies have demonstrated that training of the trunk</p><p>musculature may increase the control of hip adduction and internal rota-</p><p>tion during functional activities and prevent dynamic malalignments and the</p><p>potential injuries that arise from this impaired movement pattern (136–138).</p><p>Shoulder</p><p>SCIENTIFIC REVIEW</p><p>Shoulder pain is reported to occur in up to 21% of the general population (139,140)</p><p>with 40% persisting for at least one year (141) at an estimated annual cost of $39</p><p>billion (142). Shoulder impingement is the most prevalent diagnosis, account-</p><p>ing for 40 to 65% of reported shoulder pain (143), while traumatic shoulder dis-</p><p>locations account for an additional 15 to 25% of shoulder pain (144–146). The</p><p>persistent nature of shoulder pain may be the result of degenerative changes to</p><p>the shoulder’s capsuloligamentous structures, articular cartilage, and tendons</p><p>Figure 3.13 Local and global stabilizers.</p><p>P</p><p>NASM_Chap03.indd 74NASM_Chap03.indd 74 7/5/2010 9:44:21 PM7/5/2010 9:44:21 PM</p><p>AN EVIDENCE-BASED APPROACH TO UNDERSTANDING HUMAN MOVEMENT IMPAIRMENTS 75</p><p>as the result of altered shoulder mechanics. As many as 70% of individuals</p><p>with shoulder dislocations experience recurrent instability within two years</p><p>(146) and are at risk of developing glenohumeral osteoarthritis secondary to the</p><p>increased motion at the glenohumeral joint (147,148). Degenerative changes</p><p>may also affect the rotator cuff by weakening the tendons with time through</p><p>intrinsic and extrinsic risk factors (142,149–151), such as repetitive overhead</p><p>use (>60° of shoulder elevation), increased loads raised above shoulder height</p><p>(152), and forward head and rounded shoulder posture (153), as well as altered</p><p>scapular kinematics and muscle activity (154,155). Those factors are theorized</p><p>to overload the shoulder muscles, especially the rotator cuff, which can lead to</p><p>shoulder pain and dysfunction. Given the cost, rate of occurrence, and diffi cult</p><p>resolution of shoulder pain, preventive exercise solutions that address these</p><p>factors are essential in preventing shoulder injuries. It has been demonstrated</p><p>that static malalignments (altered length-tension relationships or altered joint</p><p>arthrokinematics), abnormal muscle activation patterns (altered force-couple</p><p>relationships), and dynamic malalignments (movement system impairments)</p><p>can lead to shoulder impairments (154–158).</p><p>STATIC MALALIGNMENTS (ALTERED LENGTH-TENSION</p><p>RELATIONSHIPS OR ALTERED JOINT ARTHROKINEMATICS)</p><p>It has been demonstrated that posterior glenohumeral capsular contracture</p><p>can alter normal glenohumeral kinematics, resulting in increased anterior and</p><p>superior migration of the humeral head during shoulder fl exion and signifi -</p><p>cantly limiting shoulder internal rotation (159,160). It is also theorized that</p><p>rounded shoulders (forward shoulder posture) (Figure 3-7) alters the normal</p><p>length-tension relationship and joint kinematic balance of the shoulder com-</p><p>plex (161). Any kinematic mechanism that reduces the subacromial space dur-</p><p>ing humeral elevation will likely predispose an individual to impingement of</p><p>the rotator cuff (162–164).</p><p>ABNORMAL MUSCLE ACTIVATION</p><p>PATTERNS (ALTERED FORCE-COUPLE</p><p>RELATIONSHIPS)</p><p>Rounded shoulder posture lengthens the rhom-</p><p>boids and lower trapezius musculature and</p><p>shortens the serratus anterior, which alters the</p><p>normal scapulothoracic force-couple relation-</p><p>ship. This altered posture and muscle recruit-</p><p>ment pattern would cause the scapula to remain</p><p>forward-tipped and internally rotated relative</p><p>to the elevating humerus, forcing the acromion</p><p>and humerus to approximate and narrow the</p><p>subacromial space (161,165,166) (Figure 3-14).</p><p>Furthermore, a rounded shoulder posture may</p><p>lead to decreased rotator cuff activation, which</p><p>would decrease stabilization and lead to com-</p><p>pression of the humeral head in the glenoid</p><p>fossa (155,166).Figure 3.14 Shoulder impingement.</p><p>Supraspinatus</p><p>tendonAcromion</p><p>Clavicle</p><p>Scapula</p><p>Humerus</p><p>Subacromial</p><p>bursa</p><p>NASM_Chap03.indd 75NASM_Chap03.indd 75 7/5/2010 9:44:22 PM7/5/2010 9:44:22 PM</p><p>76 CHAPTER 3</p><p>DYNAMIC MALALIGNMENTS</p><p>There is a sequential muscle activation and force development pattern that is</p><p>initiated from the ground to the core and through the extremities that has been</p><p>demonstrated during kicking, running, and throwing and with a tennis serve</p><p>(167–169). It has been demonstrated that approximately 85% of the muscle</p><p>activation required to slow the forward-moving arm while throwing comes</p><p>from the core and the scapulothoracic stabilizers (170). It has also been shown</p><p>that maximal rotator cuff activation can be increased by 23 to 24% if the scap-</p><p>ula is stabilized by the core musculature and the scapulothoracic stabilizers</p><p>(trapezius, rhomboids, serratus anterior) (171). A recent study demonstrated a</p><p>signifi cant decrease in shoulder internal rotation (9.5 degrees), total shoulder</p><p>motion (10.7 degrees), and elbow extension (3.2 degrees) immediately after</p><p>pitching a baseball in the dominant shoulder. These changes continued to exist</p><p>24 hours after pitching (172). Altered static posture, muscle imbalances, and</p><p>muscle weakness in the lower extremity, LPHC, or upper extremity can lead</p><p>to dynamic malalignments.</p><p>SUMMARY • The HMS consists of the myofascial system, articular system, and</p><p>neural system. Each system functions synergistically. Dysfunction in any system</p><p>alters length-tension relationships, force-couple relationships, and joint kinemat-</p><p>ics, leading to movement impairment syndromes. The health and fi tness pro-</p><p>fessional must understand these concepts and the importance of maintaining</p><p>proper structural and functional effi ciency during training, reconditioning, and</p><p>rehabilitation. The health and fi tness professional must also be capable of per-</p><p>forming a comprehensive HMS assessment before initiating a training program.</p><p>1. Sahrmann SA. Diagnosis and Treatment of Move-</p><p>ment Impairment Syndromes. St. Louis, MO: Mosby;</p><p>2002.</p><p>2. Panjabi MM. 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Ineffi cient muscular</p><p>stabilization of the lumbar spine associated with low</p><p>back pain. A motor control evaluation of transversus</p><p>abdominis. Spine 1996;21:2640–50.</p><p>131. Hungerford BP, Gilleard WP, Hodges, PP. Evidence</p><p>of altered lumbopelvic muscle recruitment in the</p><p>presence of sacroiliac joint pain. Spine 2003;28:</p><p>1593–600.</p><p>132. Hides JA, Richardson CA, Jull GA. Multifi dus muscle</p><p>recovery is not automatic after resolution of acute,</p><p>fi rst-episode low back pain. Spine 1996;21:2763–9.</p><p>133. Iwai K, Nakazato K, Irie K, Fujimoto H, Nakajima</p><p>H. Trunk muscle strength and disability level of low</p><p>back pain in collegiate wrestlers. Med Sci Sports Exerc</p><p>2004;36:1296–300.</p><p>134. Nadler SF, Malanga GA, Feinberg JH, Prybicien M,</p><p>Stitik TP, DePrince M. Relationship between hip</p><p>muscle imbalance and occurrence of</p><p>low back</p><p>pain in collegiate athletes: a prospective study. Am</p><p>J Phys Med Rehabil 2001;80:572–7.</p><p>135. Leetun DT, Ireland ML, Willson JD, Ballantyne BT,</p><p>Davis IM. Core stability measures as risk factors for</p><p>lower extremity injury in athletes. Med Sci Sports</p><p>Exerc 2004;36:926–34.</p><p>136. Myer GD, Ford KR, Brent JL, Hewett TE. The effects</p><p>of plyometric vs. dynamic stabilization and balance</p><p>training on power, balance, and landing force in</p><p>female athletes. J Strength Cond Res 2006;20:345–53.</p><p>137. Myer GD, Ford KR, Palumbo JP, Hewett TE. Neuro-</p><p>muscular training improves performance and lower-</p><p>extremity biomechanics in female athletes. J Strength</p><p>Cond Res 2005;19:51–60.</p><p>138. Paterno MV, Myer GD, Ford KR, Hewett TE. Neu-</p><p>romuscular training improves single-limb stability</p><p>in young female athletes. J Orthop Sports Phys Ther</p><p>2004;34:305–16.</p><p>139. Bongers PM. The cost of shoulder pain at work. BMJ</p><p>2001;322:64–5.</p><p>140. Urwin M, Symmons D, Allison T, et al. Estimating</p><p>the burden of musculoskeletal disorders in the com-</p><p>munity: the comparative prevalence of symptoms at</p><p>different anatomical sites, and the relation to social</p><p>deprivation. Ann Rheum Dis 1998;57:649–55.</p><p>141. Van der Heijden G. Shoulder disorders: a state of the</p><p>art review. Baillieres Best Pract Res Clin Rheumatol</p><p>1999;13:287–309.</p><p>142. Johnson M, Crosley K, O’Neil M, Al Zakwani I.</p><p>Estimates of direct health care expenditures among</p><p>individuals with shoulder dysfunction in the United</p><p>States. J Orthop Sports Phys Ther 2005;35:A4–PL8.</p><p>143. van der Windt DA, Koes BW, Boeke AJ, Deville</p><p>W, De Jong BA, Bouter LM. Shoulder disorders in</p><p>general practice: prognostic indicators of outcome.</p><p>Br J Gen Pract 1996;46:519–23.</p><p>144. Matsen FA III, Thomas SC, Rockwood CA Jr. Ante-</p><p>rior Glenohumeral Instability. In: Rockwood CA Jr,</p><p>Matsen FA III, eds. The Shoulder, Vol 1. Philadelphia,</p><p>PA: WB Saunders; 1990. p 526–622.</p><p>145. Dobson CC, Cordasco FA. Anterior glenohumeral</p><p>joint dislocations. Orthop Clin North Am</p><p>2008;39(4):507–18, vii.</p><p>146. Blasier RB, Guldberg RE, Rothman ED. Anterior</p><p>shoulder instability: contributions of rotator cuff</p><p>forces and the capsular ligaments in a cadaver model.</p><p>J Shoulder Elbow Surg 1992;1:140–50.</p><p>147. Buscayret F, Edwards TB, Szabo I, Adeleine P,</p><p>Coudane H, Walch G. Glenohumeral arthrosis in</p><p>anterior instability before and after surgical interven-</p><p>tion. Am J Sports Med 2004;32:1165–72.</p><p>148. Cameron ML, Kocher MS, Briggs KK, Horan MP,</p><p>Hawkins RJ. The prevalence of glenohumeral</p><p>osteoarthrosis in unstable shoulders. Am J Sports Med</p><p>2003;31:53–5.</p><p>NASM_Chap03.indd 80NASM_Chap03.indd 80 7/5/2010 9:44:23 PM7/5/2010 9:44:23 PM</p><p>AN EVIDENCE-BASED APPROACH TO UNDERSTANDING HUMAN MOVEMENT IMPAIRMENTS 81</p><p>149. Bigliani LU, Levine WN. Subacromial impingement</p><p>syndrome. J Bone Joint Surg Am 1997;79:1854–68.</p><p>150. Yamaguchi K, Ditsios K, Middleton WD, Hildebolt</p><p>CF, Galatz LM, Teefey SA. The demographic and</p><p>morphological features of rotator cuff disease. A</p><p>comparison of asymptomatic and symptomatic shoul-</p><p>ders. J Bone Joint Surg Am 2006;88:1699–704.</p><p>151. Yamaguchi K, Sher JS, Andersen WK, et al.</p><p>Glenohumeral motion in patients with rotator cuff</p><p>tears: a comparison of asymptomatic and symptom-</p><p>atic shoulders. J Shoulder Elbow Surg 2000;9:6–11.</p><p>152. NIOSH. Shoulder Musculoskeletal Disorders: Evid-</p><p>ance for Work Readiness. In: Bernard, ed. Muscu-</p><p>loskeletal disorders (MSD’s) and workplace factors:</p><p>a Critical Review of Epidemiologic Evidence for</p><p>Work-related Musculoskeletal Disorders of the</p><p>Neck, Upper Extremity, and Low Back. Cincinnati,</p><p>OH: Centers for Disease Control and Prevention,</p><p>1997:122–95.</p><p>153. Szeto GPY, Straker L, Raine S. A fi eld comparison of</p><p>neck and shoulder postures in symptomatic and asymp-</p><p>tomatic offi ce workers. Appl Ergon 2002;33:75–84.</p><p>154. Thigpen CA, Padua DA, Karas SG. Comparison of</p><p>scapular kinematics between individuals with and</p><p>without multidirectional shoulder instability. J Athl</p><p>Train 2005;40.</p><p>155. Thigpen CA, Padua DA, Xu N, Karas SG. Compari-</p><p>son of serratus anterior and upper trapezius muscle</p><p>activation between subjects with and without multi-</p><p>directional shoulder instability. J Orthop Sports Phys</p><p>Ther 2005;35:A80–PL22.</p><p>156. Yamaguchi T, Ishii K, Yamanaka M, Yasuda K. Acute</p><p>effect of static stretching on power output during</p><p>concentric dynamic constant external resistance leg</p><p>extension. J Strength Cond Res 2006;20:804–10.</p><p>157. Schmitt L, Snyder-Mackler L. Role of scapular stabi-</p><p>lizers in etiology and treatment of impingement syn-</p><p>drome. J Orthop Sports Phys Ther 1999;29:31–8.</p><p>158. Mesiter K. Injuries to the shoulder in the throwing</p><p>athlete. Part 1: biomechanics/pathophysiology/clas-</p><p>sifi cation of injury. Am J Sports Med 2000;28:265–75.</p><p>159. Tyler TF, Nicholas SJ, Roy T, Gleim GW. Quantifi ca-</p><p>tion of posterior capsule tightness and motion loss</p><p>in patients with shoulder impingement. Am J Sports</p><p>Med 2000;28:668–73.</p><p>160. Harryman DT, Sidles JA, Clark JM, McQuade KJ,</p><p>Gibb TD, Matsen FA. Translation of the humeral</p><p>head on the glenoid with passive glenohumeral</p><p>motion. J Bone Joint Surg Am 1990;72:1334–43.</p><p>161. Hebert LJ, Moffet H, McFadyen BJ, Dionne CE.</p><p>Scapular behavior in shoulder impingement</p><p>syndrome. Arch Phys Med Rehabil 2002;83:60–9.</p><p>162. Fu FH, Harner CD, Klein AH. Shoulder impingement</p><p>syndrome. A critical review. Clin Orthop Relat Res</p><p>1991:162–73.</p><p>163. Michener LA, McClure PW, Karduna AR. Anatomi-</p><p>cal and biomechanical mechanisms of subacromial</p><p>impingement syndrome. Clin Biomech (Bristol, Avon)</p><p>2003;18:369–79.</p><p>164. Gohlke F, Barthel T, Gandorfer A. The infl uence of</p><p>variations of the coracoacromial arch on the develop-</p><p>ment of rotator cuff tears. Arch Orthop Trauma Surg</p><p>1993;113:28–32.</p><p>165. Cools AM, Witvrouw EE, Declercq GA,</p><p>Vanderstrateten GG, Cambier DC. Scapular muscle</p><p>recruitment patterns: trapezius muscle latency with</p><p>and without impingement symptoms. Am J Sports</p><p>Med 2003;31:542–9.</p><p>166. Halder AM, Halder CG, Zhao KD, O’Driscoll SW,</p><p>Morrey BF, An KN. Dynamic inferior stabilizers</p><p>of the shoulder joint. Clin Biomech (Bristol, Avon)</p><p>2001;16:138–43.</p><p>167. Putnam C. Sequential motions of body segments</p><p>in striking and throwing skills: descriptions and</p><p>explanations. J Biomech 1993;26(Suppl 1):125–35.</p><p>168. Kibler W, Chandler T, Livingston B, Roetert E.</p><p>Shoulder range of motion in elite tennis players.</p><p>Effect of age and years of tournament play. Am J</p><p>Sports Med 1996;24:279–85.</p><p>169. Hirashima M, Kadota H, Sakurai S, Kudo K, Ohtsuki</p><p>T. Sequential muscle activity and its functional role</p><p>in the upper extremity and trunk during overarm</p><p>throwing. J Sports Sci 2002;20:301–10.</p><p>170. Happee R, Van der Helm FC. The control of shoulder</p><p>muscles during goal directed movements, an inverse</p><p>dynamic analysis. J Biomech 1995;28:1179–91.</p><p>171. Kebaetse M, McClure P, Pratt NA. Thoracic position</p><p>effect on shoulder range of motion, strength, and</p><p>three-dimensional scapular kinematics. Arch Phys</p><p>Med Rehabil 1999;80:945–50.</p><p>172. Reinold MM, Wilk KE, Macrina LC, et al. Changes</p><p>in shoulder and elbow passive range of motion after</p><p>pitching in professional baseball players. Am J Sports</p><p>Med 2008;36:523–7.</p><p>NASM_Chap03.indd 81NASM_Chap03.indd 81 7/5/2010 9:44:23 PM7/5/2010 9:44:23 PM</p><p>SECTION 2 ASSESSING FOR HUMAN</p><p>MOVEMENT DYSFUNCTION</p><p>CHAPTER 4: Health Risk Appraisal</p><p>CHAPTER 5: Static Postural</p><p>Assessments</p><p>CHAPTER 6: Movement Assessments</p><p>CHAPTER 7: Range of Motion</p><p>Assessments</p><p>CHAPTER 8: Strength Assessments</p><p>NASM_Chap04.indd 82NASM_Chap04.indd 82 7/5/2010 8:49:36 PM7/5/2010 8:49:36 PM</p><p>83</p><p>INTRODUCTION</p><p>ASSESSMENTS are crucial in the design of a safe, individualized corrective exercise</p><p>program. The fi rst step in the assessment process is to perform a health risk</p><p>appraisal on your client. The subjective information obtained in the health</p><p>risk appraisal can offer insight into the individual’s past, present, and, per-</p><p>haps, future. The assessment will also provide the health and fi tness profes-</p><p>sional any potential “red fl ags” that may need to be taken into account before</p><p>starting a program. Some of the key pieces of information to obtain from a</p><p>health risk appraisal include one’s physical readiness for activity, general life-</p><p>style information, and medical history.</p><p>READINESS FOR ACTIVITY</p><p>Gathering personal background information about an individual can be very</p><p>valuable in gaining an understanding of the individual’s physical condition</p><p>and can also provide insights into what types of imbalances they may exhibit.</p><p>One of the easiest methods of gathering this information is through the Physi-</p><p>cal Activity Readiness Questionnaire (PAR-Q) (Figure 4-1), which was designed</p><p>to help determine whether a person is ready to undertake low-to-moderate-</p><p>to-high activity levels (1). Furthermore, it aids in identifying people for whom</p><p>Health Risk</p><p>Appraisal</p><p>OBJECTIVES Upon completion of this chapter, you will be able to:</p><p>Explain the components and function of a ➤</p><p>health appraisal.</p><p>Ask appropriate general and medical ➤</p><p>questions to gather subjective information</p><p>from clients.</p><p>Recognize potential “red fl ags” that may need ➤</p><p>to be considered when designing a corrective</p><p>exercise program.</p><p>C H A P T E R 4</p><p>NASM_Chap04.indd 83NASM_Chap04.indd 83 7/5/2010 8:49:37 PM7/5/2010 8:49:37 PM</p><p>84 CHAPTER 4</p><p>certain activities may not be appropriate or who may need further medical</p><p>attention.</p><p>The PAR-Q is directed toward detecting any possible cardiorespiratory</p><p>dysfunction, such as coronary heart disease, and is a good beginning point for</p><p>gathering personal background information concerning one’s cardiorespira-</p><p>tory function. However, it is only one component of a thorough corrective</p><p>exercise assessment. Although this information is extremely important, ask-</p><p>ing other questions can provide additional information about an individual.</p><p>This includes questions about an individual’s general lifestyle and medical</p><p>history.</p><p>GENERAL LIFESTYLE INFORMATION</p><p>Asking some very basic questions concerning an individual’s history or per-</p><p>sonal background can provide a wealth of information. Two important areas</p><p>to understand include one’s occupation and lifestyle.</p><p>Occupation</p><p>Knowing a client’s occupation can provide the health and fi tness professional</p><p>with insight into what his or her movement capacity is and what kinds of</p><p>movement patterns are performed throughout the day. Examples of typical</p><p>questions are shown in Figure 4-2.</p><p>By obtaining this information, a health and fi tness professional can begin</p><p>to recognize important clues about the structure and, ultimately, the function of</p><p>a client. Each question provides relevant information about one’s structure.</p><p>Figure 4.1 Sample physical activity readiness questionnaire (PAR-Q).</p><p>Questions Yes No</p><p>1</p><p>2</p><p>3</p><p>4</p><p>5</p><p>6</p><p>7</p><p>Has your doctor ever said that you have a heart condition and that</p><p>you should only perform physical activity recommended by a doctor?</p><p>Do you have a bone or joint problem that could be made worse by a</p><p>change in your physical activity?</p><p>Do you feel pain in your chest when you perform physical activity?</p><p>Do you lose your balance because of dizziness or do you ever</p><p>lose consciousness?</p><p>Is your doctor currently prescribing any medication for your blood</p><p>pressure or for a heart condition?</p><p>In the past month, have you had chest pain when you were not</p><p>performing any physical activity?</p><p>Do you know of any other reason why you should not engage in</p><p>physical activity?</p><p>If you have answered “Yes” to one or more of the above questions, consult your physician</p><p>before engaging in physical activity. Tell your physician which questions you answered</p><p>“Yes” to. After a medical evaluation, seek advice from your physician on what type of</p><p>activity is suitable for your current condition.</p><p>NASM_Chap04.indd 84NASM_Chap04.indd 84 7/5/2010 8:49:37 PM7/5/2010 8:49:37 PM</p><p>HEALTH RISK APPRAISAL 85</p><p>EXTENDED PERIODS OF SITTING</p><p>This is a very important question that provides a lot of information. First, if</p><p>an individual is sitting a large portion of the day, his or her hips are fl exed for</p><p>prolonged periods of time. This, in turn, can lead to tight hip fl exors that can</p><p>cause postural imbalances within the kinetic chain. Second, if an individual</p><p>is sitting for prolonged periods of time, especially at a computer, there is a</p><p>tendency for the shoulders and cervical spine to fatigue under the constant</p><p>infl uence of gravity. This often leads to a postural imbalance of rounding of</p><p>the shoulders and a forward head.</p><p>REPETITIVE MOVEMENTS</p><p>Repetitive movements can create a pattern overload to muscles and joints that</p><p>may lead to tissue trauma and eventually kinetic chain dysfunction (2). This</p><p>can be seen in jobs that require a lot of overhead work such as construction</p><p>and painting. Working with the arms overhead for long periods may lead to</p><p>shoulder soreness that could be the result of tightness in the latissimus dorsi</p><p>and pectorals and weakness in the rotator cuff. This imbalance does not allow</p><p>for proper shoulder motion or stabilization during activity which can lead to</p><p>shoulder and neck pain.</p><p>DRESS SHOES</p><p>Wearing shoes with a heel puts the ankle complex in a plantarfl exed position for</p><p>extended periods. This can lead to tightness in the gastrocnemius and soleus,</p><p>causing postural imbalance, such as overpronation at the foot and ankle com-</p><p>plex (fl attening of the arch of the foot) which can lead to foot and ankle injury.</p><p>MENTAL STRESS</p><p>Mental stress or anxiety can lead to a dysfunctional breathing pattern that can</p><p>further lead to postural distortion and kinetic chain dysfunction (3,4).</p><p>Questions Yes No</p><p>1</p><p>2</p><p>3</p><p>5</p><p>What is your current occupation?</p><p>Does your occupation cause you anxiety (mental stress)?</p><p>Does your occupation require extended periods of sitting?</p><p>Does your occupation require extended periods of repetative</p><p>movements? (If yes, please explain.)</p><p>4 Does your occupation require you to wear shoes with a heel (dress</p><p>shoes)?</p><p>Figure 4.2 Sample questions: client occupation.</p><p>NASM_Chap04.indd 85NASM_Chap04.indd 85 7/5/2010 8:49:37 PM7/5/2010 8:49:37 PM</p><p>86 CHAPTER 4</p><p>Lifestyle</p><p>Questions pertaining to an individual’s lifestyle will refl ect what an individual</p><p>does in his or her free time. This is generally known as their recreation or hob-</p><p>bies. Examples of typical questions are shown in Figure 4-3.</p><p>Figure 4.3 Sample questions: client’s lifestyle.</p><p>Questions Yes No</p><p>2 Do you have any hobbies (reading, gardening, working on cars, etc.)?</p><p>(If yes, please explain.)</p><p>1 Do you partake in any recreational activities (golf, tennis, skiing, etc.)?</p><p>(If yes, please explain.)</p><p>RECREATION</p><p>Recreation, in the context of an assessment, refers to an individual’s physical</p><p>activities outside of the work environment. By fi nding out what recreational</p><p>activities an individual performs, a health and fi tness professional can better</p><p>design a program to fi t these needs. This information also provides insight on</p><p>the types of stresses being placed on one’s structure that can lead to muscle</p><p>imbalances. For example, many people like to golf, ski, play tennis, or engage in</p><p>a variety of other sporting activities in their spare time. Proper program strate-</p><p>gies must be incorporated to ensure that individuals are trained in a manner</p><p>that optimizes the effi ciency of the human movement system while addressing</p><p>potential muscles imbalances that may be a result of their activity.</p><p>HOBBIES</p><p>Hobbies, in the context of an assessment, refer to activities that an individual</p><p>may partake in regularly, but are not necessarily athletic in nature. Examples</p><p>include gardening, working on cars, reading, watching television, and play-</p><p>ing video games. In many of these cases, the individual must maintain a par-</p><p>ticular posture for an extended period of time, leading to potential muscle</p><p>imbalances.</p><p>MEDICAL HISTORY</p><p>The medical history (Figure 4-4) is absolutely crucial. Not only does it provide</p><p>information about any life-threatening chronic diseases (such</p><p>while embracing new ideologies</p><p>for enhancing the abilities of gym enthusiast and athletes alike. These indus-</p><p>try shifts will continue to provide unlimited opportunities for you as an elite</p><p>NASM professional.</p><p>Today’s gym member and athlete have an increasingly high level of expec-</p><p>tations. They demand the best and the brightest who can provide unparalleled</p><p>results. To meet these expectations and better deliver quality, innovation, and</p><p>evidence-based performance enhancement solutions to the world, NASM has</p><p>developed new and exciting solutions with best-in-class partners from the edu-</p><p>cation, healthcare, sports and entertainment, and technology industries. With</p><p>the help of our best-in-class partnerships—and top professionals like you—we</p><p>will continue to live up to the expectations placed upon us and strive to raise</p><p>the bar in our pursuit of excellence!</p><p>Innovation is important in performance and the new NASM refl ects</p><p>our ability to stay ground-breaking in an ever evolving world. Amidst all of</p><p>the change, we will always stay true to our mission and values: delivering</p><p>evidence-based solutions driven by excellence, innovation and results. This is</p><p>essential to our long-term success as a company, and to your individual career</p><p>success as a health and fitness professional.</p><p>Scientific research and techniques also continue to advance and, as a</p><p>result, you must remain on the cutting edge in order to remain competitive.</p><p>The NASM education continuum—certifi cation, specializations, continuing</p><p>Letter from the CEO</p><p>NASM_FM.indd viiiNASM_FM.indd viii 7/5/2010 8:47:31 PM7/5/2010 8:47:31 PM</p><p>and higher education—is based on a foundation of comprehensive, scientifi c</p><p>research supported by leading institutes and universities. As a result, NASM</p><p>offers scientifically-validated education, evidence-based solutions and user-</p><p>friendly tools that can be applied immediately.</p><p>The tools and solutions in the Corrective Exercise Continuum is an inno-</p><p>vative, systemic approach, used by thousands of health and fitness and sports</p><p>performance professionals worldwide to help decrease the risk of injury and</p><p>maximize results. NASM’s techniques work, creating a dramatic difference in</p><p>training programs and their results.</p><p>One of the most infl uential people of the twentieth century told us “a life</p><p>is not important except for the impact it has on other lives.”1 For us as health</p><p>and fitness professionals in the twenty-fi rst century, the truth behind this wis-</p><p>dom has never been greater.</p><p>There is no quick fix to a healthy lifestyle. However, NASM’s education,</p><p>solutions, and tools can positively impact behavior by allowing the masses to</p><p>participate in practical, customized, evidence-based exercise.</p><p>The future of fitness and sports performance is upon us all, and there is</p><p>much work to be done. With that, I welcome you to the NASM community</p><p>of health and fitness professionals. If you ever need assistance from one of</p><p>our subject matter experts, or simply want to learn more about our new part-</p><p>nerships and evidence-based health and fitness solutions, please call us at</p><p>800-460-NASM or visit us online at www.nasm.org.</p><p>We look forward to working with you to impact the performance world.</p><p>Now let’s go out together and empower our athletes to achieve their potential!</p><p>Micheal A. Clark, DPT, MS, PT, PES, CES</p><p>CEO</p><p>1. Jackie Robinson, Hall of Fame baseball player and civil rights leader (1919–1972)</p><p>NASM_FM.indd ixNASM_FM.indd ix 7/5/2010 8:47:31 PM7/5/2010 8:47:31 PM</p><p>BASED upon feedback from past students and health and professionals, this</p><p>new textbook includes several new updates in comparison to the previous cor-</p><p>rective exercise materials:</p><p>1. The Corrective Exercise Continuum. The NASM OPT model™ has</p><p>been simplified to include the most commonly used phases of training for</p><p>health and fitness as well as sports performance goals. One of the phases</p><p>of training that is no longer included in the updated version of the OPT™</p><p>model is Corrective Exercise Training. Corrective Exercise Training would</p><p>be used for individuals who posses muscle imbalances or who’ve come off</p><p>an injury and prepares that individual to enter into the OPT model™. This</p><p>form of training is covered exclusively in this book and introduces the</p><p>health and fitness professional to the Corrective Exercise Continuum, a</p><p>system of training that uses corrective exercise strategies to help improve</p><p>muscle imbalance, movement capabilities and decrease the risk of injury.</p><p>2. Additional Content Areas. This textbook includes several new chapters</p><p>not included in the previous corrective exercise materials. These addi-</p><p>tional chapter topics will assist in creating a more well-round health and</p><p>fitness professional and thus creating more value in you as a professional.</p><p>These additional chapters include:</p><p>The Rationale for Corrective Exercise Training•</p><p>Health Risk Assessments•</p><p>Static Postural Assessments•</p><p>Range of Motion Assessments (Goniometric Assessments)•</p><p>Strength Assessments (Manual Muscle Testing)•</p><p>Corrective Strategies for the Cervical Spine, Elbow and Wrist•</p><p>3. Updated Chapter Content. All of the chapter topics in this textbook have</p><p>been updated to include new information and the most up to date research</p><p>provided and reviewed by some of the most well respected professionals in</p><p>the industry. Some of the new content update highlights include:</p><p>A. A variety of both transitional and dynamic movement assessments</p><p>B. Updated content for all components of the Corrective Exercise Continuum</p><p>Inhibitory techniques•</p><p>Lengthening techniques•</p><p>Activation techniques•</p><p>Integration techniques•</p><p>C. Advanced corrective exercise applications</p><p>Neuromuscular stretching•</p><p>Positional isometrics•</p><p>New Content</p><p>NASM_FM.indd xNASM_FM.indd x 7/5/2010 8:47:31 PM7/5/2010 8:47:31 PM</p><p>D. More than 100 corrective exercise techniques in the categories of</p><p>self-myofascial release, static stretching, neuromuscular stretching, iso-</p><p>lated strength training, positional isometrics, and integrated dynamic</p><p>movements.</p><p>E. Step-by-step assessment and corrective exercise strategies for common</p><p>movement impairments seen in each segment of the body:</p><p>Foot and ankle complex•</p><p>Knee•</p><p>Lumbo-pelvic-hip complex•</p><p>Shoulder, elbow, and wrist•</p><p>Cervical spine•</p><p>4. Glossary. We’ve included a Glossary to include a number of important</p><p>terms and defi nitions. We’ve also included an index for easy navigation</p><p>when searching for topics, concepts or programming strategies.</p><p>5. Appendix. We’ve also included an Appendix that includes example</p><p>corrective exercise programs for common impairments seen in each seg-</p><p>ment of the body as well as a guide to common myofascial dysfunction.</p><p>New Pedagoligical Features</p><p>The new textbook comes with a variety of new educational features.</p><p>These features include:</p><p>New illustrations•</p><p>Updated tables•</p><p>New anatomical images•</p><p>Sidebars to emphasize key terms and concepts•</p><p>Updated photos•</p><p>Sample programs•</p><p>Additional Resources</p><p>NASM Essentials of Corrective Exercise Training includes additional</p><p>resources for students and instructors that are available on the book’s</p><p>companion website at thePoint.lww.com/NASMCES.</p><p>PowerPoint lecture outlines•</p><p>Image Bank•</p><p>Test Bank•</p><p>Quiz Bank•</p><p>Lab Activities•</p><p>NASM_FM.indd xiNASM_FM.indd xi 7/5/2010 8:47:31 PM7/5/2010 8:47:31 PM</p><p>http://www.lww.com/NASMCES</p><p>Objectives open each chapter</p><p>and present learning goals to</p><p>help you focus on and retain</p><p>the crucial topics discussed.</p><p>NASM Essentials of Corrective Exercise Training was created and developed by the National Academy</p><p>of Sports Medicine to introduce health and fi tness professionals to NASM’s proprietary Corrective</p><p>Exercise Continuum, a system of training that uses corrective exercise strategies to help improve mus-</p><p>cle imbalances and movement effi ciency to decrease the risk of injury. Please take a few moments to</p><p>look through this User’s Guide, which will introduce you to the tools and features that will enhance</p><p>your</p><p>as coronary heart</p><p>disease, high blood pressure, and diabetes), it also provides information about</p><p>the structure and function of the individual by uncovering important informa-</p><p>tion such as past injuries, surgeries, imbalances, and chronic conditions.</p><p>NASM_Chap04.indd 86NASM_Chap04.indd 86 7/5/2010 8:49:38 PM7/5/2010 8:49:38 PM</p><p>HEALTH RISK APPRAISAL 87</p><p>Past Injuries</p><p>Inquiring about an individual’s past injuries can illuminate possible</p><p>dysfunctions. One of the best predictors of future injuries is past injury. There</p><p>is a vast array of research that has demonstrated past injuries affect the func-</p><p>tioning of the human movement system (5–46). Beyond the risk of suffer-</p><p>ing the same injury again or compensating for an incompletely rehabilitated</p><p>injury leading to another (possibly more serious) injury, a prior injury can also</p><p>have effects up and down the kinetic chain:</p><p>1. Ankle Sprains</p><p>Ankle sprains have been shown to decrease the neural control to the</p><p>gluteus medius and gluteus maximus muscles. This, in turn, can lead to</p><p>poor control of the lower extremities during many functional activities,</p><p>which can eventually lead to injury (5–8).</p><p>2. Knee Injuries Involving Ligaments</p><p>Knee injury can cause a decrease in the neural control to muscles that</p><p>stabilize the patellofemoral and tibiofemoral joints and lead to further</p><p>injury. Noncontact knee injuries are often the result of ankle or hip</p><p>dysfunctions. The knee is caught between the ankle and the hip. If the</p><p>ankle or hip joint begins to function improperly this results in altered</p><p>movement and force distribution of the knee. Over time, this can lead</p><p>to further injury (9–25).</p><p>3. Low-Back Injuries</p><p>Low-back injuries can cause decreased neural control to stabilizing</p><p>muscles of the core, resulting in poor stabilization of the spine. This can</p><p>further lead to dysfunction in upper and lower extremities (26–33).</p><p>Figure 4.4 Sample questions: client’s medical history.</p><p>Questions Yes No</p><p>1</p><p>2</p><p>3</p><p>4</p><p>Have you ever had any pain or injuries (ankle, knee, hip, back,</p><p>shoulder, etc.)? (If yes, please explain.)</p><p>Are you currently taking any medication? (If yes, please explain.)</p><p>Have you ever had any surgeries? (If yes, please explain.)</p><p>Has a medical doctor ever diagnosed you with a chronic disease, such</p><p>as coronary heart disease, coronary artery disease, hypertension (high</p><p>blood pressure), high cholesterol or diabetes? (If yes, please explain.)</p><p>NASM_Chap04.indd 87NASM_Chap04.indd 87 7/5/2010 8:49:38 PM7/5/2010 8:49:38 PM</p><p>88 CHAPTER 4</p><p>4. Shoulder Injuries</p><p>Shoulder injuries cause altered neural control of the rotator cuff mus-</p><p>cles, which can lead to instability of the shoulder joint during func-</p><p>tional activities (34–42).</p><p>5. Other Injuries</p><p>Injuries that result from human movement system imbalances include</p><p>repetitive hamstring complex strains, groin strains, patellar tendonitis</p><p>(jumper’s knee), plantar fasciitis (pain in the arch of the foot), posterior</p><p>tibialis tendonitis (shin splints), biceps tendonitis (shoulder pain), and</p><p>headaches.</p><p>All of the aforementioned past injuries should be taken into consideration</p><p>while assessing individuals, as the mentioned imbalances will manifest over</p><p>time, unless proper care has been given. However, at best, individuals can</p><p>recall only half their injury history, mostly the severe injuries. So a close exam-</p><p>ination of imbalances through further assessments performed by the health</p><p>and fi tness professional can turn up areas of potential risks.</p><p>Past Surgeries</p><p>Surgical procedures create trauma for the body and may have similar effects</p><p>to those of an injury. They can create dysfunction, unless properly rehabili-</p><p>tated. Some common surgical procedures include the following:</p><p>Foot and ankle surgery•</p><p>Knee surgery•</p><p>Back surgery•</p><p>Shoulder surgery•</p><p>Cesarean section for birth (cutting through the abdominal wall to deliver a •</p><p>baby)</p><p>Appendectomy (cutting through the abdominal wall to remove the •</p><p>appendix)</p><p>In each case, surgery will cause pain and infl ammation that can alter</p><p>neural control to the affected muscles and joints if not rehabilitated properly</p><p>(43,44).</p><p>Chronic Conditions</p><p>Numerous governmental, health-care organizations, professional medical</p><p>societies, social organizations, and even special interest groups point out that</p><p>chronic medical conditions will cost ever-increasing amounts of public and</p><p>private money for ongoing, and sometimes lifetime, treatment. Routine care</p><p>and care of complications from chronic conditions such as hypertension,</p><p>hyperlipidemia, obesity, osteoarthritis, cardiopulmonary diseases, and diabe-</p><p>tes may well become the greatest expense a nation can endure. It should not</p><p>be surprising that many of these conditions have a lifestyle component that</p><p>has some infl uence on the development of the disease, and in many cases the</p><p>condition begins with the sedentary child, meaning the focus on prevention</p><p>of chronic diseases needs to start maybe even as early as elementary school.</p><p>NASM_Chap04.indd 88NASM_Chap04.indd 88 7/5/2010 8:49:38 PM7/5/2010 8:49:38 PM</p><p>HEALTH RISK APPRAISAL 89</p><p>The American College of Sports Medicine has begun an Exercise Is Medicine</p><p>initiative in an attempt to raise awareness in the medical community of the</p><p>physician’s obligation to prescribe and encourage an active lifestyle in all his</p><p>or her patients. It is estimated that more than 75% of the American adult pop-</p><p>ulation does not partake, on a daily basis, in 30 minutes of low-to- moderate</p><p>physical activity (45). The risk of chronic disease goes up signifi cantly in</p><p>individuals who are not as physically active as this minimal standard (45,46).</p><p>In all likelihood, the health and fi tness professional will work not only with</p><p>relatively healthy clients, but also with clients with any number of chronic</p><p>diseases such as:</p><p>Cardiovascular disease, coronary artery disease, congenital heart disease, •</p><p>valvular disorders, or congestive heart failure</p><p>Hypertension (high blood pressure)•</p><p>High cholesterol or other blood lipid disorders•</p><p>Stroke or peripheral artery disease•</p><p>Lung or breathing problems from smoking, asthma, obstructive pulmonary •</p><p>diseases, or exposure to infl ammatory stimuli</p><p>Obesity in children or adults•</p><p>Type 1 or type 2 diabetes mellitus•</p><p>Cancer•</p><p>Medications</p><p>Some individuals may be under the care of a medical professional and may be</p><p>required to use any one of a variety of medications. It is not the role of a health</p><p>and fi tness professional to administer, prescribe, or educate on the usage and</p><p>effects of any of these medications.</p><p>The purpose of this section is to briefl y outline some of the primary classes</p><p>of drugs and their proposed physiologic effects (Tables 4-1 and 4-2). The tables</p><p>are merely intended to present a simplistic overview of medications. They</p><p>are not intended to serve as conclusive evidence regarding the medications</p><p>Table 4.1 COMMON MEDICATIONS BY CLASSIFICATION</p><p>Medication Basic Function</p><p>Beta-Blockers (ß-Blockers) Generally used as antihypertensive (high blood pressure); may also be</p><p>prescribed for arrhythmias (irregular heart rate)</p><p>Calcium Channel Blockers Generally prescribed for hypertension and angina (chest pain)</p><p>Nitrates Generally prescribed for hypertension, congestive heart failure</p><p>Diuretics Generally prescribed for hypertension, congestive heart failure, and</p><p>peripheral edema</p><p>Bronchodilators Generally prescribed to correct or prevent bronchial smooth muscle</p><p>constrictor in individuals with asthma or other pulmonary diseases</p><p>Vasodilators Used in the treatment of hypertension and congestive heart failure</p><p>Antidepressants Use in the treatment of various psychiatric and emotional disorders</p><p>NASM_Chap04.indd 89NASM_Chap04.indd 89 7/5/2010 8:49:38 PM7/5/2010 8:49:38 PM</p><p>90 CHAPTER 4</p><p>or their effects. For more complete information about medications, contact a</p><p>health-care provider or refer to the Physician’s Desk Reference.</p><p>SUMMARY • A health and fitness professional’s primary responsibility</p><p>is to</p><p>safely and effectively guide clients to successful attainment of their goals. To</p><p>do so requires a comprehensive understanding of an individual’s background</p><p>as well as his or her physical capabilities and desires. A health risk appraisal is</p><p>the fi rst step in gathering this information about clients to design an individu-</p><p>alized corrective exercise program. A corrective exercise program is only as</p><p>good as the assessment process, making all aspects of the assessment process</p><p>crucial to ensure the program is safe and specifi c to meet the client’s needs.</p><p>1. Thomas S, Reading J, Shephard R. Revision of the</p><p>Physical Activity Readiness Questionnaire (PAR-Q).</p><p>Can J Sport Sci 1992;17:338–45.</p><p>2. Bachrach RM. The relationship of low back pain to</p><p>psoas insuffi ciency. J Orthop Med 1991;13:34–40.</p><p>3. Janda V. Muscles and Motor Control in Cervicogenic</p><p>Disorders In: Grant R, ed. Physical Therapy of the</p><p>Cervical and Thoracic Spine. Edinburgh: Churchill</p><p>Livingstone; 1988:182–99.</p><p>4. Leahy PM. Active Release Techniques: Logical Soft</p><p>Tissue Treatment. In: Hammer WI, ed. Functional Soft</p><p>Tissue Examination and Treatment by Manual Methods.</p><p>Gaithersburg, MD: Aspen Publishers, Inc; 1999:</p><p>549–60.</p><p>5. Bullock-Saxton JE. Local sensation changes and altered</p><p>hip muscle function following severe ankle sprain.</p><p>Phys Ther 1994;74:17–28; discussion 28–31.</p><p>6. Guskiewicz K, Perrin D. Effect of orthotics on postural</p><p>sway following inversion ankle sprain. J Orthop Sports</p><p>Phys Ther 1996;23:326–31.</p><p>7. Nitz A, Dobner J, Kersey D. Nerve injury and grades</p><p>II and III ankle sprains. Am J Sports Med 1985;13:</p><p>177–82.</p><p>8. Wilkerson G, Nitz A. Dynamic ankle stability:</p><p>mechanical and neuromuscular interrelationships.</p><p>J Sport Rehab 1994;3:43–57.</p><p>9. Barrack R, Lund P, Skinner H. Knee proprioception</p><p>revisited. J Sport Rehab 1994;3:18–42.</p><p>10. Beard D, Kyberd P, O’Connor J, Fergusson C. Refl ex</p><p>hamstring contraction latency in ACL defi ciency.</p><p>J Orthop Res 1994;12:219–28.</p><p>11. Boyd I. The histological structure of the receptors in</p><p>the knee joint of the cat correlated with their physi-</p><p>ological response. J Physiol 1954;124:476–88.</p><p>12. Corrigan J, Cashman W, Brady M. Proprioception</p><p>in the cruciate defi cient knee. J Bone Joint Surg Br</p><p>1992;74B:247–50.</p><p>13. DeCarlo M, Klootwyk T, Shelbourne D. ACL sur-</p><p>gery and accelerated rehabilitation. J Sport Rehab</p><p>1997;6:144–56.</p><p>References</p><p>Table 4.2 EFFECTS OF MEDICATION ON HEART RATE AND BLOOD PRESSURE</p><p>Medication Heart Rate Blood Pressure</p><p>Beta-Blockers (ß-Blockers) ↓ ↓</p><p>Calcium Channel Blockers ↑</p><p>↔ or ↓</p><p>↓</p><p>Nitrates ↑</p><p>↔</p><p>↔</p><p>↓</p><p>Diuretics ↔ ↔</p><p>↓</p><p>Bronchodilators ↔ ↔</p><p>Vasodilators ↑</p><p>↔ or ↓</p><p>↓</p><p>Antidepressants ↑ or ↔ ↔ or ↓</p><p>↓, decrease; ↑, increase; ↔, no effect.</p><p>NASM_Chap04.indd 90NASM_Chap04.indd 90 7/5/2010 8:49:38 PM7/5/2010 8:49:38 PM</p><p>HEALTH RISK APPRAISAL 91</p><p>14. Ekholm J, Eklund G, Skoglund S. On the refl ex</p><p>effects from knee joint of the cat. Acta Physiol Scand</p><p>1960;50:167–74.</p><p>15. Feagin J. The syndrome of the torn ACL. Orthop Clin</p><p>North Am 1979;10:81–90.</p><p>16. Fredericson M, Cookingham CL, Chaudhari AM,</p><p>Dowdell BC, Oestreicher N, Sahrmann SA. Hip abduc-</p><p>tor weakness in distance runners with iliotibial band</p><p>syndrome. Clin J Sport Med 2000;10:169–75.</p><p>17. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR.</p><p>The effect of neuromuscular training on the incidence</p><p>of knee injury in female athletes. A prospective study.</p><p>Am J Sports Med 1999;27:699–706.</p><p>18. Ireland ML, Willson JD, Ballantyne BT, Davis IM. Hip</p><p>strength in females with and without patellofemoral</p><p>pain. J Orthop Sports Phys Ther 2003;33:671–6.</p><p>19. Irrgang J, Harner C. Recent advances in ACL rehabili-</p><p>tation: clinical factors. J Sport Rehab 1997;6:111–24.</p><p>20. Irrgang J, Whitney S, Cox E. Balance and propriocep-</p><p>tive training for rehabilitation of the lower extremity.</p><p>J Sport Rehab 1994;3:68–83.</p><p>21. Johansson H. Role of knee ligaments in proprioception</p><p>and regulation of muscle stiffness. J Electromyogr Kine-</p><p>siol 1991;1:158–79.</p><p>22. Johansson H, Sjolander P, Sojka P. A sensory role</p><p>for the cruciate ligaments. Clin Orthop Relat Res</p><p>1991;268:161–78.</p><p>23. Johansson H, Sjölander P, Sojka P. Receptors in the</p><p>knee joint ligaments and their role in the biomechan-</p><p>ics of the joint. Crit Rev Biomed Eng 1991;18:341–68.</p><p>24. Nyland J, Smith S, Beickman K, Armsey T, Caborn D.</p><p>Frontal plane knee angle affects dynamic postural con-</p><p>trol strategy during unilateral stance. Med Sci Sports</p><p>Exerc 2002;34:1150–7.</p><p>25. Powers C. The infl uence of altered lower-extremity</p><p>kinematics on patellofemoral joint dysfunction: a</p><p>theoretical perspective. J Orthop Sports Phys Ther</p><p>2003;33:639–46.</p><p>26. Bullock-Saxton JE, Janda V, Bullock MI. Refl ex activa-</p><p>tion of gluteal muscles in walking. An approach to</p><p>restoration of muscle function for patients with low-</p><p>back pain. Spine 1993;18:704–8.</p><p>27. Hodges P, Richardson C, Jull G. Evaluation of the</p><p>relationship between laboratory and clinical tests of</p><p>transversus abdominis function. Physiother Res Int</p><p>1996;1:30–40.</p><p>28. Hodges PW, Richardson CA. Ineffi cient muscular</p><p>stabilization of the lumbar spine associated with low</p><p>back pain. A motor control evaluation of transversus</p><p>abdominis. Spine 1996;21:2640–50.</p><p>29. Hodges PW, Richardson CA. Contraction of the</p><p>abdominal muscles associated with movement of the</p><p>lower limb. Phys Ther 1997;77:132–42; discussion</p><p>142–4.</p><p>30. Janda V. Muscles and Motor Control in Low Back</p><p>Pain: Assessment and Management. In: Twomey L,</p><p>ed. Physical Therapy of the Low Back. New York, NY:</p><p>Churchill Livingstone;1987.</p><p>31. Lewit K. Muscular and articular factors in movement</p><p>restriction. Manual Med 1985;1:83–5.</p><p>32. O’Sullivan P, Twomey L, Allison G, Sinclair J, Miller</p><p>K, Knox J. Altered patterns of abdominal muscle acti-</p><p>vation in patients with chronic low back pain. Aust J</p><p>Physiother 1997;43:91–8.</p><p>33. Richardson C, Jull G, Toppenberg R, Comerford M.</p><p>Techniques for active lumbar stabilization for spinal</p><p>protection. Aust J Physiother 1992;38:105–12.</p><p>34. Broström L-Å, Kronberg M, Nemeth G. Muscle activ-</p><p>ity during shoulder dislocation. Acta Orthop Scand</p><p>1989;60:639–41.</p><p>35. Glousman R. Electromyographic analysis and its</p><p>role in the athletic shoulder. Clin Orthop Relat Res</p><p>1993;288:27–34.</p><p>36. Glousman R, Jobe F, Tibone J, Moynes D, Antonelli</p><p>D, Perry J. Dynamic electromyographic analysis of the</p><p>throwing shoulder with glenohumeral instability.</p><p>J Bone Joint Surg Am 1988;70A:220–6.</p><p>37. Hanson ED, Leigh S, Mynark RG. Acute effects of</p><p>heavy- and light-load squat exercise on the kinetic</p><p>measures of vertical jumping. J Strength Cond Res</p><p>2007;21:1012–7.</p><p>38. Howell S, Kraft T. The role of the supraspinatus and</p><p>infraspinatus muscles in glenohumeral kinematics</p><p>of anterior shoulder instability. Clin Orthop Relat Res</p><p>1991;263:128–34.</p><p>39. Kedgley A, Mackenzie G, Ferreira L, Johnson J,</p><p>Faber K. In vitro kinematics of the shoulder follow-</p><p>ing rotator cuff injury. Clin Biomech (Bristol, Avon)</p><p>2007;22:1068–73.</p><p>40. Kronberg M, Broström L-Å, Nemeth G. Differences in</p><p>shoulder muscle activity between patients with gen-</p><p>eralized joint laxity and normal controls. Clin Orthop</p><p>Relat Res 1991;269:181–92.</p><p>41. Yanagawa T, Goodwin C, Shelburne K, Giphart J,</p><p>Torry M, Pandy M. Contributions of the individual</p><p>muscles of the shoulder to glenohumeral joint stability</p><p>during abduction. J Biomech Eng 2008;130:21–4.</p><p>42. Yasojima T, Kizuka T, Noguchi H, Shiraki H, Mukai N,</p><p>Miyanaga Y. Differences in EMG activity in scapular</p><p>plane abduction under variable arm positions and</p><p>loading conditions. Med Sci Sports Exerc 2008;40:</p><p>716–21.</p><p>43. Graven-Nielsen T, Mense S. The peripheral apparatus</p><p>of muscle pain: evidence from animal and human</p><p>studies. Clin J Pain 2001;17:2–10.</p><p>44. Mense S, Simons D. Muscle Pain. Understanding its</p><p>Nature, Diagnosis, and Treatment. Philadelphia, PA:</p><p>Williams & Wilkins;2001.</p><p>45. Lambert E, Bohlmann I, Cowling K. Physical activity</p><p>for health: understanding the epidemiological evi-</p><p>dence for risk benefi ts.</p><p>Int J Sports Med 2001;1:1–15.</p><p>46. Pate R, Pratt M, Blair S, et al. Physical activity and</p><p>public health: a recommendation from the Centers for</p><p>Disease Control and Prevention and the American Col-</p><p>lege of Sports Medicine. JAMA 1995;273:402–7.</p><p>NASM_Chap04.indd 91NASM_Chap04.indd 91 7/5/2010 8:49:38 PM7/5/2010 8:49:38 PM</p><p>92</p><p>OBJECTIVES Upon completion of this chapter, you will be able to:</p><p>Defi ne the function of a static postural ➤</p><p>assessment.</p><p>Describe the kinetic chain implications for ➤</p><p>static postural alignment.</p><p>Discuss the avenues through which static ➤</p><p>postural alignment may alter over time.</p><p>Discuss the implications for existing postural ➤</p><p>distortions.</p><p>Perform a static postural assessment. ➤</p><p>Static Postural</p><p>Assessments</p><p>INTRODUCTION</p><p>POSTURAL assessments have been a tool available to clinicians across the ages.</p><p>Before the availability of data-driven technologies, postural assessments were</p><p>a critical component of any evaluation. As the limitations of some of these</p><p>data-driven technologies to provide kinetic chain–related information are</p><p>being realized, postural assessments and functional movement assessments</p><p>are being given greater credence (1–3). The renaissance of these qualitative</p><p>assessments has then posed the diffi culty of quantifying qualitative infor-</p><p>mation in an attempt to provide objective and measurable baselines. In this</p><p>new age of evidence-based medicine, there has been little time to allow for</p><p>the applied clinical research to objectively evaluate these qualitative tech-</p><p>niques. Therefore, there is limited clinical research and subsequently limited</p><p>evidence-based research on the effi cacy of postural assessments.</p><p>POSTURE</p><p>Posture can be thought of as static or dynamic. Static posture, or how</p><p>individuals physically present themselves in stance, could be considered the</p><p>base from which an individual moves. It is refl ected in the alignment of the</p><p>body (Figure 5-1). It provides the foundation or the platform from which</p><p>Static posture: how</p><p>individuals physically</p><p>present themselves in</p><p>stance. It is refl ected in</p><p>the alignment of the</p><p>body.</p><p>C H A P T E R 5</p><p>NASM_Chap05.indd 92NASM_Chap05.indd 92 7/5/2010 8:50:08 PM7/5/2010 8:50:08 PM</p><p>STATIC POSTURAL ASSESSMENTS 93</p><p>the extremities function. As with any structure, a weak foundation leads to</p><p>secondary problems elsewhere in the system. For instance, the shifting foun-</p><p>dation of a house may not be noticed until the cracks appear in the walls or</p><p>problems occur at the roof.</p><p>Dynamic posture is refl ective of how an individual is able to maintain</p><p>posture while performing functional tasks. This will be covered in further</p><p>Figure 5.1 Static posture.</p><p>Dynamic posture: how</p><p>an individual is able to</p><p>maintain posture while</p><p>performing functional</p><p>tasks.</p><p>NASM_Chap05.indd 93NASM_Chap05.indd 93 7/5/2010 8:50:09 PM7/5/2010 8:50:09 PM</p><p>94 CHAPTER 5</p><p>detail in chapter six. For the sake of this chapter, we will be focusing on static</p><p>postural assessments.</p><p>IMPORTANCE OF POSTURE AS IT RELATES TO INJURY</p><p>The use of a static postural assessment has been the basis for identifying</p><p>muscle imbalances. The assessment may not be able to specifi cally identify</p><p>whether a problem is structural (or biomechanical) in nature or whether it</p><p>is derived from the development of poor muscular recruitment patterns with</p><p>resultant muscle imbalances. However, a static postural assessment provides</p><p>excellent indicators of problem areas that must be further evaluated to clarify</p><p>the problems at hand. This allows for intervention at the level of the causative</p><p>factor rather than simply treating the symptomatic complaints. For instance,</p><p>it is easy to add a bit more plaster to a crack in the wall, sand it out, and</p><p>paint over it. However, if the weakened and shifted foundation of the house</p><p>is left as is, the visible cracks in the wall will return, accompanied by per-</p><p>haps larger cracks in the wall and problems with the ceiling. At some point,</p><p>the “patch and go” approach no longer works, forcing a larger intervention,</p><p>perhaps a renovation or reconstruction. The same is true within the body. We</p><p>can continue to treat the symptomatic complaints using anti-infl ammatory</p><p>medications, modifi cation of activities, or simply pushing through the pain,</p><p>all leading to further dysfunction adding layer upon layer of structural and</p><p>neuromuscular adaptations. However, if we return to looking for the causative</p><p>factors of the infl ammation, discomfort, or poor performance, we will more</p><p>likely be successful in selecting the most effective intervention to alleviate the</p><p>dysfunction and provide the pain-free functional outcomes we seek for our</p><p>clients. Beginning with a static postural assessment is a fundamental step to</p><p>achieve this goal-oriented outcome.</p><p>MUSCLE IMBALANCE</p><p>There may be several causative factors for changes in joint alignment, includ-</p><p>ing quality and function of myofascial tissue, and alterations in muscle-tendon</p><p>function. Whatever the reason, the body will continually adapt in an attempt</p><p>to produce the functional outcome that is requested by the system. Unfor-</p><p>tunately, this adaptability will lead to imbalances and eventually to imbal-</p><p>ances that move beyond a dysfunction and into tissue damage and pathology.</p><p>Along the continuum of the adaptation, the muscle-tendon units will shorten</p><p>or lengthen as the stressors demand. This can result in the stabilizing mus-</p><p>cles being less effi cient to stabilize joints as they are pulled out of optimal</p><p>alignment (4–7).</p><p>Muscle imbalance is a condition in which there is a lack of balance between</p><p>certain types of muscles. This tendency appears to be fairly systematic. It seems</p><p>that certain muscles are prone to shortening (tightness), whereas other muscles</p><p>are susceptible to lengthening and weakness (inhibition) (8, 9). The combina-</p><p>tion of tight and weak muscles can alter normal movement patterns (10, 11).</p><p>This results in an alteration of the biomechanics of joints leading to degenera-</p><p>tion. Table 5-1 lists the muscles prone to shortening and lengthening.</p><p>Myofascial: the</p><p>connective tissue in</p><p>and around muscles</p><p>and tendons.</p><p>Muscle imbalance:</p><p>alteration in the</p><p>functional relation-</p><p>ship between pairs or</p><p>groups of muscles.</p><p>NASM_Chap05.indd 94NASM_Chap05.indd 94 7/5/2010 8:50:10 PM7/5/2010 8:50:10 PM</p><p>STATIC POSTURAL ASSESSMENTS 95</p><p>HOW DO ALTERATIONS IN STATIC POSTURE OCCUR?</p><p>The main factors that cause postural imbalance include the following:</p><p>1. Habitual movement patterns</p><p>2. Altered movement patterns from repetitive movement</p><p>3. Altered movement patterns from injury</p><p>4. Altered movement patterns from surgery</p><p>5. Altered movement patterns from incompletely rehabilitated injuries</p><p>Habitual Movement Patterns</p><p>It is essential for the health and fi tness professional to have an understand-</p><p>ing of posture and the importance it has in our daily lives. It is even more</p><p>important to realize what effects posture has on a daily basis. Individuals may</p><p>have developed some poor postural habits without even realizing it. Many</p><p>individuals carry overstuffed briefcases on just one side of their body, which</p><p>chronically overloads it. Frequently the body does not readjust itself to neutral</p><p>Table 5.1 MUSCLES PRONE TO SHORTENING AND LENGTHENING</p><p>Typically Shortened Muscles Typically Lengthened Muscles</p><p>Gastrocnemius Anterior tibialis</p><p>Soleus Posterior tibialis</p><p>Adductors Vastus medialis oblique (VMO)</p><p>Hamstring complex Gluteus maximus/medius</p><p>Psoas Transverse abdominus</p><p>Tensor fascia latae Internal oblique</p><p>Rectus femoris Multifi dus</p><p>Piriformis Serratus anterior</p><p>Quadratus lumborum Middle/lower trapezius</p><p>Erector spinae Rhomboids</p><p>Pectoralis major/minor Teres minor</p><p>Latissimus dorsi Infraspinatus</p><p>Teres major Posterior deltoid</p><p>Upper trapezius Deep cervical fl exors</p><p>Levator scapulae</p><p>Sternocleidomastoid</p><p>Scalenes</p><p>Adapted from Janda V. Muscles and Motor Control in Low Back Pain: Assessment and</p><p>Management. In: Twomey LT, ed. Physical Therapy of the</p><p>Low Back. Edinburgh: Churchill</p><p>Livingstone; 1987:253–78.</p><p>NASM_Chap05.indd 95NASM_Chap05.indd 95 7/5/2010 8:50:10 PM7/5/2010 8:50:10 PM</p><p>96 CHAPTER 5</p><p>positioning and continues to move in this imbalanced position, even when not</p><p>loaded. The same may be true for those who do a lot of driving. Chronic use of</p><p>the right lower extremity without awareness of trying to maintain symmetry</p><p>causes the body to shift to the right and promote external rotation of the left</p><p>lower extremity. Workstations both at home and at the offi ce frequently con-</p><p>tribute to neck and arm dysfunction. Positioning of the computer monitor, the</p><p>keyboard, and the chair may all create an environment for the development of</p><p>postural deviations (Figure 5-2).</p><p>Altered Movement Patterns from Repetitive Movement</p><p>Repetition of movement as in chronic overuse or injury can lead to a change</p><p>in the elasticity of the muscle (12). Poor posture and a lack of daily movement</p><p>are also considered a contributing factor (13). Muscle that is repeatedly placed</p><p>in a shortened position, such as the iliopsoas complex during sitting, will even-</p><p>tually adapt and tend to remain short (10,14). Stress and chronic fatigue may</p><p>also result in muscle imbalances (15,16).</p><p>Repetitive movements can cause imbalances by placing demands on</p><p>certain muscle groups more predominantly. This is evident when looking at</p><p>many athletes such as swimmers, runners, and tennis players. Swimmers often</p><p>exhibit overemphasized pectoral muscles in relation to the scapular retractors,</p><p>giving them a rounded shoulder posture (17) (Figure 5-3).</p><p>Figure 5.2 Habitual patterns.</p><p>Pectoralis</p><p>Deltoid</p><p>Latissimus</p><p>dorsi</p><p>Figure 5.3 Overused muscles on swimmers.</p><p>Repetitive movement also affects everyday people such as a construction</p><p>worker who is hammering with the same hand day in and day out (Figure 5-4).</p><p>Waiters and waitresses often carry large trays with the same arm, much the</p><p>same as a mother carries her child on the same hip.</p><p>Postural imbalances are also seen in the gym with people who focus on</p><p>certain muscle groups more so than others. This is evident in individuals who</p><p>overemphasize chest, shoulder, and biceps work (Figure 5-5). This often results in</p><p>rounded shoulders, a forward head, and internal rotation at the shoulder joint.</p><p>NASM_Chap05.indd 96NASM_Chap05.indd 96 7/5/2010 8:50:10 PM7/5/2010 8:50:10 PM</p><p>STATIC POSTURAL ASSESSMENTS 97</p><p>Altered Movement Patterns from Injury</p><p>Acute injury may result in chronic muscle imbalances. An individual may</p><p>assume adaptive postures to avoid pain or to create function. Oftentimes, even</p><p>after the pain has subsided and motion restrictions or strength has returned,</p><p>the individual may not change his or her adaptive movement strategies unless</p><p>reminded to return to a more normal motor pattern. It is those mild yet repeti-</p><p>tive ankle sprains, or the occasional sore back, that continues to promote mod-</p><p>ifi ed motion. The changing movement patterns alter loads across the joints</p><p>and alter recruitment strategies of muscles, all leading to muscular imbalances</p><p>refl ected in postural changes.</p><p>Injury may also result in tissue that becomes restricted ( hypomobility).</p><p>Immobilizations through splinting or self-immobilization as a result of pain</p><p>may allow tissue to shorten. Without restoring mobility, the reciprocal mus-</p><p>cles are lengthened, creating weakness. Muscles that are too short and tight</p><p>are then functionally paired with muscles that are lengthened and weak,</p><p>disrupting the neuromuscular balance in the interdependent relationship.</p><p>Postural changes caused by the muscle imbalances become evident.</p><p>Altered Movement Patterns from Surgery</p><p>Even the best of surgeries results in scar tissue. Scar mobility is often an</p><p>overlooked aspect of the rehabilitation paradigm. Lack of mobility alters the</p><p>tissue alignment and pulls on the fascia, affecting joints and muscle func-</p><p>tion. There may have been some compensatory altered movement patterns</p><p>used for functional mobility before the surgery or shortly after the surgical</p><p>Hypomobility:</p><p>restricted motion.</p><p>Infraspinatus</p><p>Deltoid</p><p>Upper</p><p>trapezius</p><p>Sternocleidomastoid</p><p>Figure 5.4 Overused muscles on construction</p><p>workers.</p><p>Pectoralis</p><p>Deltoid</p><p>Tricep</p><p>Figure 5.5 Overused muscles on gym members.</p><p>NASM_Chap05.indd 97NASM_Chap05.indd 97 7/5/2010 8:50:12 PM7/5/2010 8:50:12 PM</p><p>98 CHAPTER 5</p><p>intervention. Balanced movement must be actively restored, or resultant</p><p>muscle imbalances and postural changes will develop.</p><p>Altered Movement Patterns from Incompletely</p><p>Rehabilitated Injuries</p><p>In these days of a limited number of visits for insurance-covered rehabilita-</p><p>tion, many clients may have initiated a rehabilitative intervention after an</p><p>injury, but have been discharged before return to their required functional</p><p>level. They then continue on their own well-intended programs that may be</p><p>overlooking the imbalances that were never resolved. Or they may simply</p><p>discontinue rehabilitation and be willing to live within their current limita-</p><p>tions. In either case, the body will adapt to the available mobility and stability,</p><p>creating compensatory movement patterns that are eventually refl ective in</p><p>postural imbalance.</p><p>By knowing what can cause improper postural habits, the health and fi t-</p><p>ness professional can begin to properly address the client’s needs. As a com-</p><p>mon denominator, improper posture usually results from or leads to muscle</p><p>imbalances (4, 5, 10, 14, 15, 18–22). The health and fi tness professional’s job</p><p>is to identify those muscle imbalances, identify the causative agents, and insti-</p><p>tute a comprehensive corrective exercise program. A postural assessment is</p><p>the fi rst step in assessing the client’s status.</p><p>COMMON DISTORTIONAL PATTERNS</p><p>How an individual presents himself or herself in static stance is, in a sense, a</p><p>road map of how the body has been used over time. Twists and turns in what</p><p>should otherwise be a fairly erect and cylindrical structure are evidence of</p><p>compensatory movement patterns. Something is not working as well as the</p><p>body requires it to work; therefore, it has called on other structures or muscle</p><p>groups to “jump in and help” (synergistic dominance). Most structures and</p><p>muscle groups in the body have very defi ned functional roles. Although they</p><p>may be appropriately used to create more than one movement, for instance</p><p>the quadriceps may fl ex the hip (rectus femoris) or extend the knee; how-</p><p>ever, when asked to provide rotational stability at the knee, the quadriceps</p><p>may be hypertrophied from the overtaxing use and result in symptomatic</p><p>complaints of infrapatellar tendonitis, anterior knee pain, or patellofemoral</p><p>dysfunction. Hips shifted off of midline may indicate load-bearing habits to</p><p>one side and may be refl ective of imbalances in the pelvis as a result of car-</p><p>rying a heavy briefcase. Or those driving may develop fatigue and tightness</p><p>in the right leg.</p><p>What is interesting is that the body has a tendency to compensate in</p><p>particular patterns or by particular relationships between muscles. These pat-</p><p>terns were studied and described by Janda (19) in the early 1970s. Florence</p><p>and Henry Kendall similarly studied these patterns and took an alternative</p><p>approach of addressing these postural deviations through the relationship</p><p>of agonist–antagonist muscle groups. Their work was continued by one of</p><p>Florence Kendall’s students, Shirley Sahrmann (23).</p><p>NASM_Chap05.indd 98NASM_Chap05.indd 98 7/5/2010 8:50:15 PM7/5/2010 8:50:15 PM</p><p>STATIC POSTURAL ASSESSMENTS 99</p><p>JANDA’S POSTURAL DISTORTION SYNDROMES</p><p>Janda identifi ed three basic compensatory patterns (19). This is not to say</p><p>that other compensations do not occur. He simply suggested that there was a</p><p>cascading effect of alterations or deviations in static posture that would more</p><p>likely than not present themselves in a particular pattern. The three postural</p><p>distortion patterns to be assessed during a static postural assessment include</p><p>the lower crossed syndrome,</p><p>upper crossed syndrome, and pronation distortion</p><p>syndrome. These three static postural distortion syndromes can translate into</p><p>the lower and upper extremity movement impairment syndromes discussed</p><p>in chapter three during functional movement. Assessments for the movement</p><p>impairment syndromes will be done through the use of movement assess-</p><p>ments discussed in the next chapter.</p><p>Lower Crossed Syndrome</p><p>An individual with lower crossed syndrome is characterized by increased lum-</p><p>bar lordosis and an anterior pelvic tilt (Figure 5-6). There are common muscles</p><p>that are too tight and others that are too weak. The</p><p>muscles that may be tight include the gastrocne-</p><p>mius, soleus, adductor complex, hip fl exor complex</p><p>(psoas, rectus femoris, tensor fascia latae), latissi-</p><p>mus dorsi, and the erector spinae (Table 5-2). The</p><p>muscles that are commonly weak or lengthened</p><p>include the posterior tibialis, anterior tibialis, glu-</p><p>teus maximus, gluteus medius, transverse abdomi-</p><p>nus, and internal oblique (Table 5-2). The pattern of</p><p>tightness and weakness indicative of lower crossed</p><p>syndrome causes predictable patterns of joint dys-</p><p>functions, movement imbalances, and injury pat-</p><p>terns. Associated joint dysfunctions include the</p><p>subtalar joint, tibiofemoral joint, iliofemoral joint,</p><p>sacroiliac joint, and lumbar facet joints. Common</p><p>movement dysfunctions include decreased stabili-</p><p>zation of the lumbar spine during functional move-</p><p>ments. This is characterized by excessive lumbar lor-</p><p>dosis with squatting, lunging, or overhead pressing.</p><p>Lower crossed syn-</p><p>drome: a postural</p><p>distortion syndrome</p><p>characterized by an</p><p>anterior tilt to the pel-</p><p>vis and lower-extremity</p><p>muscle imbalances.</p><p>Upper crossed syn-</p><p>drome: a postural</p><p>distortion syndrome</p><p>characterized by a</p><p>forward head and</p><p>rounded shoulders</p><p>with upper-extremity</p><p>muscle imbalances.</p><p>Pronation distortion</p><p>syndrome: a postural</p><p>distortion syndrome</p><p>characterized by foot</p><p>pronation and lower-</p><p>extremity muscle</p><p>imbalances.</p><p>Figure 5.6 Lower crossed</p><p>syndrome.</p><p>Table 5.2 LOWER CROSSED SYNDROME SUMMARY</p><p>Short Muscles Lengthened Muscles Altered Joint Mechanics Possible Injuries</p><p>Gastrocnemius Anterior tibialis Increased: Hamstring complex strain</p><p>Soleus Posterior tibialis Lumbar extension Anterior knee pain</p><p>Hip fl exor complex Gluteus maximus Low-back pain</p><p>Adductors Gluteus medius Decreased:</p><p>Latissimus dorsi Transversus abdominis Hip extension</p><p>Erector spinae Internal oblique</p><p>NASM_Chap05.indd 99NASM_Chap05.indd 99 7/5/2010 8:50:15 PM7/5/2010 8:50:15 PM</p><p>100 CHAPTER 5</p><p>Table 5.3 UPPER CROSS SYNDROME SUMMARY</p><p>Short Muscles Lengthened Muscles Altered Joint Mechanics Possible Injuries</p><p>Upper trapezius Deep cervical fl exors Increased: Headaches</p><p>Levator scapulae Serratus anterior Cervical extension Biceps tendonitis</p><p>Sternocleidomastoid Rhomboids Scapular protraction/elevation Rotator cuff impingement</p><p>Scalenes Mid-trapezius Thoracic outlet syndrome</p><p>Latissimus dorsi Lower trapezius Decreased:</p><p>Teres major Teres minor Shoulder extension</p><p>Subscapularis Infraspinatus Shoulder external rotation</p><p>Pectoralis major/minor</p><p>Common injury patterns include hamstring complex strains, anterior knee</p><p>pain, and low-back pain (5,10,14).</p><p>Upper Crossed Syndrome</p><p>Individuals with upper crossed syndrome are characterized by rounded</p><p>shoulders and a forward head posture (Figure 5-7). This pattern is common in</p><p>individuals who sit a lot or who develop pattern overload from one- dimensional</p><p>training protocols. Functionally tightened muscles include the pectoralis major,</p><p>pectoralis minor, subscapularis, latissimus dorsi, levator scapulae, upper tra-</p><p>pezius, teres major, sternocleidomastoid, and scalenes (Table 5-3). Function-</p><p>ally weakened or lengthened muscles include the rhomboids, lower trapezius,</p><p>teres minor, infraspinatus, serratus anterior, and deep cervical fl exors (Table</p><p>5-3). Potential joint dysfunctions include the sternoclavicular joint, acromio-</p><p>clavicular joint, and thoracic and cervical facet joints. Potential injury pat-</p><p>terns include rotator cuff impingement, shoulder instability, biceps tendinitis,</p><p>thoracic outlet syndrome, and headaches (5,10,14).</p><p>Pronation Distortion Syndrome</p><p>Individuals with pronation distortion syndrome are characterized by exces-</p><p>sive foot pronation (fl at feet), knee fl exion, internal rotation, and adduction</p><p>(“knock-kneed”) (Figure 5-8). Functionally tightened muscles include the</p><p>peroneals, gastrocnemius, soleus, iliotibial band, hamstring complex, adduc-</p><p>tor complex, and psoas (Table 5-4). Functionally weakened or inhibited areas</p><p>include the posterior tibialis, anterior tibialis, vastus medialis, gluteus medius,</p><p>gluteus maximus, and hip external rotators (Table 5-4). Potential joint dys-</p><p>functions include the fi rst metatarsophalangeal joint, subtalar joint, talocru-</p><p>ral joint, sacroiliac joint, and lumbar facet joints. Individuals with pronation</p><p>distortion syndrome develop predictable patterns of injury, including plantar</p><p>fasciitis, posterior tibialis tendinitis (shin splints), patellar tendonitis, and low-</p><p>back pain (24–26).</p><p>Figure 5.7 Upper</p><p>crossed syndrome.</p><p>Figure 5.8 Pronation</p><p>distortion syndrome.</p><p>NASM_Chap05.indd 100NASM_Chap05.indd 100 7/5/2010 8:50:15 PM7/5/2010 8:50:15 PM</p><p>STATIC POSTURAL ASSESSMENTS 101</p><p>Table 5.4 PRONATION DISTORTION SYNDROME SUMMARY</p><p>Short Muscles Lengthened Muscles Altered Joint Mechanics Possible Injuries</p><p>Gastrocnemius Anterior tibialis Increased: Plantar fascitis</p><p>Soleus Posterior tibialis Knee adduction Posterior tibialis tendonitis</p><p>(shin splints)</p><p>Peroneals Vastus medialis Knee internal rotation Patellar tendonitis</p><p>Adductors Gluteus medius/maximus Foot pronation Low-back pain</p><p>Iliotibial band Hip external rotators Foot external rotation</p><p>Hip fl exor complex Decreased:</p><p>Biceps femoris (short</p><p>head)</p><p>Ankle dorsifl exion</p><p>Ankle inversion</p><p>SYSTEMATIC APPROACH TO ASSESS STATIC POSTURE</p><p>Static postural assessments require a strong visual observation skill from the practitioner.</p><p>This can be developed with time and practice. It requires a systematic approach. Common-</p><p>ly, static postural assessments begin at the feet and travel upward toward the head. We are</p><p>bipedal in nature, and our feet interact with the external environment with every step we</p><p>take. Often, alterations or deviations observed in the lower part of the body are then re-</p><p>fl ected in compensatory alterations or deviations farther up the kinetic chain. Many of these</p><p>compensations can be identifi ed through a comprehensive static postural assessment.</p><p>KINETIC CHAIN CHECKPOINTS ➤</p><p>Postural assessments require observation of the kinetic chain (human movement system).</p><p>To structure this observation, NASM has devised the use of kinetic chain checkpoints to</p><p>allow the health and fi tness professional to systematically view the body statically and</p><p>during motion (which will be reviewed in the next chapter). The kinetic chain checkpoints</p><p>refer to major joint regions of the body including the following:</p><p>1. Foot and ankle</p><p>2. Knee</p><p>3. Lumbo-pelvic-hip complex (LPHC)</p><p>4. Shoulders</p><p>5. Head/cervical spine</p><p>ANTERIOR VIEW</p><p>Foot/ankles: straight and parallel, not fl attened or externally rotated•</p><p>Knees: in line with toes, not adducted or abducted•</p><p>LPHC: pelvis level with both anterior superior iliac spines in same transverse plane•</p><p>Shoulders: level, not elevated or rounded•</p><p>Head: neutral position, not tilted or rotated•</p><p>Note: An imaginary line should begin midway between the heels, extending upward</p><p>between the lower extremities, through the midline of the pelvis and through the trunk</p><p>and skull.</p><p>Continued on page 102</p><p>(Text continues on page 103)</p><p>NASM_Chap05.indd 101NASM_Chap05.indd 101 7/5/2010 8:50:16 PM7/5/2010 8:50:16 PM</p><p>102 CHAPTER 5</p><p>Kinetic Chain Checkpoints, Anterior View</p><p>LATERAL VIEW</p><p>Foot/ankle: neutral position, leg vertical at right angle to sole of foot•</p><p>Knees: neutral position, not fl exed or hyperextended•</p><p>LPHC: pelvis in neutral position, not anteriorly (lumbar extension)</p><p>or posteriorly rotated •</p><p>(lumbar fl exion)</p><p>Shoulders: normal kyphotic curve, not excessively rounded•</p><p>Head: neutral position, not in excessive extension (“jutting” forward)•</p><p>Note: An imaginary line should run slightly anterior to the lateral malleolus, through the</p><p>middle of the femur, center of the shoulder, and middle of the ear.</p><p>Kinetic Chain Checkpoints, Lateral View</p><p>NASM_Chap05.indd 102NASM_Chap05.indd 102 7/5/2010 8:50:16 PM7/5/2010 8:50:16 PM</p><p>STATIC POSTURAL ASSESSMENTS 103</p><p>POSTERIOR VIEW</p><p>Foot/ankle: heels are straight and parallel, not overly pronated•</p><p>Knees: neutral position, not adducted or abducted•</p><p>LPHC: pelvis level with both posterior superior iliac spines in same transverse plane•</p><p>Shoulders/scapulae: level, not elevated or protracted (medial borders essentially parallel •</p><p>and approximately 3 to 4 inches apart)</p><p>Head: neutral position neither tilted nor rotated•</p><p>Note: An imaginary line should begin midway between the heels, extending upward between</p><p>the lower extremities, through the midline of the pelvis and through the spine and skull.</p><p>Kinetic Chain Checkpoints, Posterior View</p><p>SUMMARY • A static postural assessment is a simple yet effective tool to</p><p>quickly “size up” your client. Consider yourself a detective looking for struc-</p><p>tural deviations within a kinetic chain as well as for symmetry from the</p><p>right to left side of the body. Alterations in structure will lead to or could be</p><p>caused by muscle imbalances. Many muscle imbalances can be inferred sim-</p><p>ply from the deviations noted in the static postural assessment. Using a static</p><p>postural assessment on an initial evaluation of your client will give you a “big</p><p>picture” view of how that individual uses his or her body day in and day out.</p><p>Consider the body as a road map. Movement patterns commonly used will</p><p>be expressed in the alignment the body naturally assumes. Identifying these</p><p>static deviations and asymmetries in conjunction with those identifi ed in the</p><p>dynamic postural assessment (see chapter six, Movement Assessments) will</p><p>provide the clues as to how an individual uses his or her body biomechani-</p><p>cally. Knowing that and understanding how interconnected all the body sys-</p><p>tems are, the health and fi tness professional can begin to identify what other</p><p>components have been affected by the altered alignment. How have these</p><p>alterations distorted the feedback from the proprioceptors? How has the</p><p>altered alignment affected the function of the soft tissue? Has the fascia been</p><p>NASM_Chap05.indd 103NASM_Chap05.indd 103 7/5/2010 8:50:17 PM7/5/2010 8:50:17 PM</p><p>104 CHAPTER 5</p><p>overloaded? Have compensatory muscle imbalances been generated creat-</p><p>ing altered length-tension relationships, altered force production, synergistic</p><p>dominance, and altered reciprocal inhibition relationships? How have these</p><p>changes affected the entire kinetic chain and overall coordination of move-</p><p>ment within the limbs and between the limbs and the trunk? What further</p><p>questions will you need to ask your clients about their day-to-day postural</p><p>habits (how they stand, sit, and carry packages, briefcases, or babies)? Do you</p><p>need to dig further into prior injuries, surgeries, or “minor” aches and pains</p><p>that with time may have altered their freedom of movement? Do they appear</p><p>to fall neatly into one of the more common postural disorders or do they have</p><p>combined compensations leading to further complexities in biomechanical</p><p>and neuromuscular loading? The static postural assessment is the fi rst step in</p><p>assessing the biomechanical and neuromuscular pieces of the puzzle neces-</p><p>sary to create a program for functional rebalancing for your client.</p><p>References</p><p>1. Bell DR, Padua DA. Infl uence of ankle dorsifl exion</p><p>range of motion and lower leg muscle activation on</p><p>knee valgus during a double legged squat. J Athl Train</p><p>2007;42:S-84.</p><p>2. Padua DA, Marshall SW, Boling MC, Thigpen CA,</p><p>Garrett WE, Beutler AI. The landing error scoring sys-</p><p>tem (LESS) is a valid and reliable clinical assessment</p><p>tool of jump-landing biomechanics: the JUMP-ACL</p><p>study. Am J Sports Med 2009;37(10):1996–2002.</p><p>3. Vesci BJ, Padua DA, Bell DR, Strickland LJ, Guskiewicz</p><p>KM, Hirth CJ. Infl uence of hip muscle strength, fl ex-</p><p>ibility of hip and ankle musculature, and hip muscle</p><p>activation on dynamic knee valgus motion during a</p><p>double-legged squat. J Athl Train 2007;42:S-83.</p><p>4. Lewit K. Muscular and articular factors in movement</p><p>restriction. Manual Med 1985;1:83–5.</p><p>5. Janda V. Muscle Strength in Relation to Muscle</p><p>Length, Pain and Muscle Imbalance. In: Harms-</p><p>Rindahl K, ed. Muscle Strength. New York, NY:</p><p>Churchill Livingstone; 1993:83–91.</p><p>6. Beimborn DS, Morrissey MC. A review of literature</p><p>related to trunk muscle performance. Spine</p><p>1988;13:655–70.</p><p>7. Liebenson C. Active muscular relaxation techniques.</p><p>Part II: clinical application. J Manipulative Physiol Ther</p><p>1990;13(1):2–6.</p><p>8. Janda V. On the concept of postural muscles and pos-</p><p>ture in man. Aust J Physiother 1983;29(3):83–4.</p><p>9. Janda V. Muscle Function Testing. London: Butter-</p><p>worths; 1983.</p><p>10. Liebenson C. Integrating Rehabilitation into Chiro-</p><p>practic Practice (Blending Active and Passive Care). In:</p><p>Liebenson C, ed. Rehabilitation of the Spine. Baltimore,</p><p>MD: Williams & Wilkins;1996:13–44.</p><p>11. Edgerton VR, Wolf S, Roy RR. Theoretical basis for</p><p>patterning EMG amplitudes to assess muscle dysfunc-</p><p>tion. Med Sci Sports Exerc 1996;28(6):744–51.</p><p>12. Leahy PM. Improved treatments for carpal tunnel</p><p>syndrome. Chiro Sports Med 1995;9:6–9.</p><p>13. Guyer B, Ellers B. Childhood injuries in the United</p><p>States: mortality, morbidity, and cost. Am J Dis Child</p><p>1990;144:649–52.</p><p>14. Hammer WI. Muscle Imbalance and Post-facilitation</p><p>Stretch. In: Hammer WI, ed. Functional Soft Tissue</p><p>Examination and Treatment by Manual Methods. 2nd ed.</p><p>Gaithersburg, MD: Aspen Publishers, Inc; 1999:415–46.</p><p>15. Chaitow L. Cranial Manipulation Theory and Prac-</p><p>tice: Osseous and Soft Tissue Approaches. London:</p><p>Churchill Livingstone; 1999.</p><p>16. Timmons B. Behavioral and Psychological Approaches to</p><p>Breathing Disorders. New York, NY: Plenum Press; 1994.</p><p>17. Hammer WI. The shoulder. In: Hammer WI, ed.</p><p>Functional Soft Tissue Examination and Treatment by</p><p>Manual Methods. 2nd ed. Gaithersburg, MD: Aspen</p><p>Publishers, Inc; 1999:35–136.</p><p>18. Lewitt K. Manipulation in Rehabilitation of the Loco-</p><p>motor System. London: Butterworths; 1993.</p><p>19. Janda V. Muscles and Motor Control in Cervicogenic</p><p>Disorders. In: Grant R, ed. Physical Therapy of the</p><p>Cervical and Thoracic Spine. St. Louis, MO: Churchill</p><p>Livingstone; 2002:182–99.</p><p>20. Hodges PW. Motor control of the trunk. In: Grieve GP, ed.</p><p>Modern Manual Therapy of the Vertebral Column. 3rd</p><p>ed. New York, NY: Churchill Livingstone; 2004:119–40.</p><p>21. Spring H, Illi U, Kunz H, Rothlin K, Schneider W,</p><p>Tritschler T. Stretching and Strengthening Exercises.</p><p>New York, NY: Theime Medicals Publishers, Inc; 1991.</p><p>22. Sarhmann S. Posture and muscle imbalance: faulty</p><p>lumbopelvic alignment and associated musculoskel-</p><p>etal pain syndromes. Orthop Div Rev Can Phys Ther</p><p>1992;12:13–20.</p><p>23. Sahrmann S. Diagnosis and Treatment of Movement</p><p>Impairment Syndromes. St. Louis, MO: Mosby; 2002.</p><p>24. Irving DB, Cook JL, Young MA, Menz HB. Obesity</p><p>and pronated foot type may increase the risk of</p><p>chronic plantar heel pain: a matched case-control</p><p>study. BMC Musculoskelet Disord 2007;8:41.</p><p>25. Kaufman KR, Brodine SK, Shaffer RA, Johnson CW,</p><p>Cullison TR. The effect of foot structure and range of</p><p>motion on musculoskeletal overuse injuries.</p><p>Am J Sports Med 1999;27:585–93.</p><p>26. Moen MH, Tol JL, Weir A, Steunebrink M, De Winter</p><p>TC. Medial tibial stress syndrome: a critical review.</p><p>Sports Med 2009;39:523–46.</p><p>NASM_Chap05.indd 104NASM_Chap05.indd 104 7/5/2010 8:50:18 PM7/5/2010 8:50:18 PM</p><p>105</p><p>C H A P T E R 6</p><p>Movement</p><p>Assessments</p><p>OBJECTIVES Upon completion of this chapter, you will be able to:</p><p>Explain the rationale for performing move- ➤</p><p>ment assessments.</p><p>Understand the difference between transi- ➤</p><p>tional and dynamic movement assessments.</p><p>Determine potential muscle imbalances based ➤</p><p>on certain movement compensations.</p><p>Design a corrective exercise strategy to ➤</p><p>improve movement impairments.</p><p>OBJECTIVES Upon completion of this chapter, you will be able to:</p><p>Explain the rationale for performing ➤</p><p>movement assessments.</p><p>Understand the difference between transi- ➤</p><p>tional and dynamic movement assessments.</p><p>Determine potential muscle imbalances based ➤</p><p>on certain movement compensations.</p><p>Design a corrective exercise strategy to ➤</p><p>improve movement impairments.</p><p>Movement</p><p>Assessments</p><p>INTRODUCTION</p><p>MOVEMENT is the means by which we are able to perform all activities, ranging</p><p>from those necessary for daily living to job tasks and recreational enjoyment. Our</p><p>ability to move is one of the most important aspects of our existence. Recognizing</p><p>optimal movement requires a thorough understanding and application of human</p><p>movement science, specifi cally functional anatomy, kinesiology, biomechanics,</p><p>physiology, and motor control. Understanding normal movement allows identi-</p><p>fi cation of abnormal movement, which can indicate possible muscle imbalances</p><p>and corrective strategies. This chapter will review the rationale for movement</p><p>assessments, present how to perform movement assessments, and discuss how</p><p>to correlate the fi ndings of these assessments to possible muscle imbalances.</p><p>THE SCIENTIFIC RATIONALE FOR MOVEMENT ASSESSMENTS</p><p>Movement assessments, based on sound human movement science, are the</p><p>cornerstone of a comprehensive and integrated assessment process (1,2).</p><p>Other assessments in this integrated approach include those for both muscle</p><p>length (goniometric assessment) and muscle strength (manual muscle testing),</p><p>which will be reviewed in later chapters (1,2).</p><p>Movement represents the integrated functioning of many systems within the</p><p>human body, primarily the muscular, skeletal, and nervous systems (1–3). These</p><p>NASM_Chap06.indd 105NASM_Chap06.indd 105 7/5/2010 8:51:13 PM7/5/2010 8:51:13 PM</p><p>106 CHAPTER 6</p><p>systems form an interdependent triad that, when operating correctly, allows for</p><p>optimal structural alignment, neuromuscular control (coordination), and move-</p><p>ment (4). Each of these outcomes is important to establishing normal length-</p><p>tension relationships, which ensure proper length and strength of each muscle</p><p>around a joint (1,5,6). This is known as muscle balance (Figures 6-1, 6-2).</p><p>As mentioned in previous chapters, muscle balance is essential for optimal</p><p>recruitment of force-couples to maintain precise joint motion and ultimately</p><p>decrease excessive stress placed on the body (1–3,6). All of this translates</p><p>into the effi cient transfer of forces to accelerate, decelerate, and stabilize the</p><p>interconnected joints of the body, and is the source from which the term</p><p>Figure 6.2 Muscle imbalance.Figure 6.1 Muscle balance.</p><p>kinetic chain is derived. “Kinetic” denotes the force transference from the ner-</p><p>vous system to the muscular and skeletal systems as well as from joint to</p><p>joint, and “chain” refers to the interconnected linkage of all joints in the body.</p><p>Essentially, the kinetic chain can be considered the human movement system</p><p>(HMS).</p><p>However, as mentioned in chapter three, for many reasons such as repeti-</p><p>tive stress, impact trauma, disease, and sedentary lifestyle, dysfunction can</p><p>occur in one or more of these systems (1,2,6,7). When this occurs, muscle</p><p>balance, muscle recruitment, and joint motion are altered, leading to changes</p><p>in structural alignment, neuromuscular control (coordination), and movement</p><p>patterns of the HMS (1–4, 8–10). The result is a HMS impairment and, ulti-</p><p>mately, injury (1–6, 8–11). When HMS impairments exist, there are muscles</p><p>that are overactive and muscles that are underactive around a joint (Table 6-1)</p><p>(1–3,6,9,10). The terms “overactive” and “underactive” are used in this text to</p><p>refer to the activity level of a muscle relative to another muscle or muscle group,</p><p>not necessarily to its own normal functional capacity. Any muscle, whether</p><p>in a shortened or lengthened state, can be underactive or weak because of</p><p>altered length-tension relationships or altered reciprocal inhibition (chapter</p><p>three) (10). This results in an altered recruitment strategy and ultimately an</p><p>altered movement pattern (1,2,6,7,10,11). Alterations in muscle activity will</p><p>Kinetic chain: “kinetic”</p><p>denotes the force</p><p>transference from the</p><p>nervous system to the</p><p>muscular and skel-</p><p>etal systems as well as</p><p>from joint to joint, and</p><p>“chain” refers to the</p><p>interconnected linkage</p><p>of all joints in the body.</p><p>Muscle balance: estab-</p><p>lishing normal length-</p><p>tension relationships,</p><p>which ensure proper</p><p>length and strength of</p><p>each muscle around a</p><p>joint.</p><p>NASM_Chap06.indd 106NASM_Chap06.indd 106 7/5/2010 8:51:13 PM7/5/2010 8:51:13 PM</p><p>MOVEMENT ASSESSMENTS 107</p><p>change the biomechanical motion of the joint and lead to increased stress on</p><p>the tissues of the joint, and eventual injury (1–4,6,9,10).</p><p>A movement assessment allows a health and fi tness professional to observe</p><p>for HMS impairments including muscle imbalances (length and strength defi -</p><p>cits) and altered recruitment strategies (2). This information can then be corre-</p><p>lated to subjective fi ndings and isolated assessments such as goniometric and</p><p>manual muscle testing. Collectively, this data will produce a more compre-</p><p>hensive representation of the client or patient and thus a more individualized</p><p>corrective exercise strategy.</p><p>TYPES OF MOVEMENT ASSESSMENTS</p><p>Movement assessments can be categorized into two types: transitional assessments</p><p>and dynamic assessments. Transitional movement assessments are assessments</p><p>that involve movement without a change in one’s base of support. This would</p><p>include movements such as squatting, pressing, pushing, pulling, and balanc-</p><p>ing. Dynamic movement assessments are assessments that involve movement</p><p>with a change in one’s base of support. This would include movements such</p><p>as walking and jumping.</p><p>Because posture is a dynamic quality, these observations can show pos-</p><p>tural distortions and potential overactive and underactive muscles in a natu-</p><p>rally dynamic setting. Both types of assessments place a different demand on</p><p>the HMS, so performing both transitional and dynamic assessments can help</p><p>provide a better observation of one’s functional status.</p><p>Transitional movement</p><p>assessments: assessments</p><p>that involve movement</p><p>without a change in one’s</p><p>base of support.</p><p>Dynamic movement</p><p>assessments: assess-</p><p>ments that involve</p><p>movement with a</p><p>change in one’s base of</p><p>support.</p><p>Table 6.1 TYPICAL OVERACTIVE AND UNDERACTIVE MUSCLES</p><p>Typically Overactive Muscles Typically Underactive Muscles</p><p>Gastrocnemius Anterior tibialis</p><p>Soleus Posterior tibialis</p><p>Adductors Vastus medialis oblique (VMO)</p><p>Hamstring complex Gluteus maximus/medius</p><p>Psoas Transverse abdominus</p><p>Tensor fascia latae Internal oblique</p><p>Rectus femoris Multifi dus</p><p>Piriformis Serratus anterior</p><p>Quadratus lumborum Middle/lower trapezius</p><p>Erector spinae Rhomboids</p><p>Pectoralis major/minor Teres minor</p><p>Latissimus dorsi Infraspinatus</p><p>Teres major Posterior deltoid</p><p>Upper trapezius Deep cervical fl exors</p><p>Levator scapulae</p><p>Sternocleidomastoid</p><p>Scalenes</p><p>NASM_Chap06.indd 107NASM_Chap06.indd 107 7/5/2010 8:51:14 PM7/5/2010 8:51:14 PM</p><p>108 CHAPTER 6</p><p>KINETIC CHAIN CHECKPOINTS</p><p>Movement assessments require observation of the kinetic chain (HMS). To</p><p>structure this observation, NASM has devised the use of kinetic chain check-</p><p>points to allow the health and fi tness professional to systematically view the</p><p>body during motion. The kinetic chain checkpoints refer to major joint regions</p><p>of the body including the:</p><p>1. Foot and ankle</p><p>2. Knee</p><p>3. Lumbo-pelvic-hip complex (LPHC)</p><p>4. Shoulders and head/cervical spine (upper body)</p><p>Each joint region has a specifi c biomechanical motion that it produces</p><p>based on its structure and function (12) as well as</p><p>the joints above and below it</p><p>(8). When that specifi c motion deviates from its normal path, it is considered a</p><p>compensation and can be used to presume possible HMS impairments (muscle</p><p>imbalance) (1,6,7,9–11).</p><p>TRANSITIONAL MOVEMENT ASSESSMENTS</p><p>As stated earlier, transitional movement assessments are assessments in which movement</p><p>is occurring without a change in one’s base of support. The transitional movement assess-</p><p>ments that will be covered in this chapter include the:</p><p>1. Overhead squat</p><p>2. Single-leg squat</p><p>3. Push-up</p><p>4. Standing cable row</p><p>5. Standing overhead dumbbell press</p><p>6. Star balance excursion</p><p>7. Upper extremity assessments</p><p>OVERHEAD SQUAT ASSESSMENT ➤</p><p>PURPOSE</p><p>This is designed to assess dynamic fl exibility, core strength, balance, and overall neuro-</p><p>muscular control. There is evidence to support the use of transitional movement assess-</p><p>ments such as the overhead squat assessment (13–17). This assessment appears to be a</p><p>reliable and valid measure of lower extremity movement patterns when standard pro-</p><p>tocols are applied. The overhead squat assessment has also been shown to refl ect lower</p><p>extremity movement patterns during jump landing tasks (14). Knee valgus during the</p><p>overhead squat test is infl uenced by decreased hip abductor and hip external rotation</p><p>strength (15), increased hip adductor activity (16), and restricted ankle dorsifl exion (16,17).</p><p>These results suggest that the movement impairments observed during this transitional</p><p>movement assessment may be the result of alterations in available joint motion, muscle</p><p>activation, and overall neuromuscular control that can point toward people with an el-</p><p>evated injury risk (16,17).</p><p>(Text continues on page 139)</p><p>NASM_Chap06.indd 108NASM_Chap06.indd 108 7/5/2010 8:51:14 PM7/5/2010 8:51:14 PM</p><p>MOVEMENT ASSESSMENTS 109</p><p>PROCEDURE</p><p>1. The individual stands with the feet shoulder-width apart and pointed straight ahead.</p><p>The foot and ankle complex should be in a neutral position. It is suggested that the as-</p><p>sessment is performed with the shoes off to better view the foot and ankle complex.</p><p>2. Have individual raise his or her arms overhead, with elbows fully extended. The upper</p><p>arm should bisect the torso.</p><p>Anterior Lateral Posterior</p><p>Overhead Squat Position</p><p>1. Instruct the individual to squat to roughly the height of a chair seat and return to the</p><p>starting position.</p><p>2. Repeat the movement for 5 repetitions, observing from each position (anterior, lateral,</p><p>and posterior).</p><p>Anterior Lateral Posterior</p><p>Overhead Squat Movement</p><p>Position</p><p>Movement</p><p>Continued on page 110</p><p>NASM_Chap06.indd 109NASM_Chap06.indd 109 7/5/2010 8:51:15 PM7/5/2010 8:51:15 PM</p><p>110 CHAPTER 6</p><p>1. View feet, ankles, and knees from the front. The feet should remain straight with the</p><p>knees tracking in line with the foot (second and third toes).</p><p>2. View the LPHC, shoulder, and cervical complex from the side. The tibia should remain in</p><p>line with the torso while the arms also stay in line with the torso.</p><p>3. View the foot and ankle complex and the LPHC from behind. The foot and ankle com-</p><p>plex will demonstrate slight pronation, but the arch of the foot will remain visible. The</p><p>feet should also remain straight while the heels stay in contact with the ground. The</p><p>LPHC should not shift from side to side.</p><p>Anterior Lateral Posterior</p><p>Overhead Squat Views</p><p>1. Feet:</p><p>a. Do the feet fl atten and/or turn out?</p><p>2. Knees:</p><p>a. Do the knees move inward (adduct and internally rotate)?</p><p>b. Do the knees move outward (abduct and externally rotate)?</p><p>Feet Flatten Feet Turn Out Knees Move Inward Knees Move Outward</p><p>Overhead Squat Compensations, Anterior View</p><p>Views</p><p>Compensations:</p><p>Anterior View</p><p>NASM_Chap06.indd 110NASM_Chap06.indd 110 7/5/2010 8:51:18 PM7/5/2010 8:51:18 PM</p><p>MOVEMENT ASSESSMENTS 111</p><p>1. LPHC:</p><p>a. Does the low back arch (excessive spinal extension)?</p><p>b. Does the low back round (excessive spinal fl exion)?</p><p>c. Does the torso lean forward excessively?</p><p>2. Shoulder:</p><p>a. Do the arms fall forward?</p><p>Low Back Arches Low Back Rounds Excessive Forward Lean Arms Fall Forward</p><p>Overhead Squat Compensations, Lateral View</p><p>1. Feet:</p><p>a. Do the feet fl atten (excessive pronation)?</p><p>b. Do the heels rise off the fl oor?</p><p>2. LPHC:</p><p>a. Is there an asymmetric weight shift?</p><p>Feet Flatten Heels Rise Off Floor Asymmetric Weight Shift</p><p>Overhead Squat Compensations, Posterior View</p><p>Compensations:</p><p>Lateral View</p><p>Compensations:</p><p>Posterior View</p><p>Continued on page 112</p><p>NASM_Chap06.indd 111NASM_Chap06.indd 111 7/5/2010 8:51:21 PM7/5/2010 8:51:21 PM</p><p>112 CHAPTER 6</p><p>When performing the assessment, record all of your fi ndings. You can then refer to</p><p>the table below to determine potential overactive and underactive muscles that will</p><p>need to be addressed through corrective fl exibility and strengthening techniques</p><p>to improve the individual’s quality of movement, decreasing the risk for injury and</p><p>improving overall performance.</p><p>OVERHEAD SQUAT OBSERVATIONAL FINDINGS</p><p>View Checkpoints Movement Observation Right - Y Left - Y</p><p>Anterior</p><p>Feet</p><p>Turn out</p><p>Flatten</p><p>Knees Move inward</p><p>Lateral</p><p>LPHC</p><p>Excessive forward lean</p><p>Low back arches</p><p>Shoulder complex Arms fall forward</p><p>Posterior</p><p>Feet Flatten</p><p>LPHC Asymmetric weight shift</p><p>MOVEMENT COMPENSATIONS FOR THE OVERHEAD SQUAT ASSESSMENT</p><p>View Checkpoint Compensation Probable</p><p>Overactive</p><p>Muscles</p><p>Probable</p><p>Underactive Muscles</p><p>Possible Injuries</p><p>Anterior</p><p>Feet</p><p>Turns Out Soleus</p><p>Lat. Gastroc-</p><p>nemius</p><p>Biceps Femoris</p><p>(short head)</p><p>Tensor Fascia</p><p>Latae (TFL)</p><p>Med. Gastrocnemius</p><p>Med. Hamstring</p><p>Gluteus</p><p>Medius/Maximus</p><p>Gracilis</p><p>Popliteus</p><p>Sartorius</p><p>Plantar fasciitis</p><p>Achilles</p><p>tendinopathy</p><p>Medial tibial stress</p><p>syndrome</p><p>Ankle sprains</p><p>Patellar</p><p>Tedinopathy</p><p>(jumper’s knee)Flatten Peroneal</p><p>Complex</p><p>Lat.</p><p>Gastrocnemius</p><p>Biceps Femoris</p><p>TFL</p><p>Anterior Tibialis</p><p>Posterior Tibialis</p><p>Med. Gastrocnemius</p><p>Gluteus Medius</p><p>Knees</p><p>Move Inward</p><p>(Valgus)</p><p>Adductor</p><p>Complex</p><p>Biceps Femoris</p><p>(short head)</p><p>TFL</p><p>Lat Gastroc-</p><p>nemius</p><p>Vastus Lateralis</p><p>Med. Hamstring</p><p>Med. Gastrocnemius</p><p>Gluteus Medius/</p><p>Maximus</p><p>Vastus Medialis Oblique</p><p>(VMO)</p><p>Anterior Tibialis</p><p>Posterior Tibialis</p><p>Patellar</p><p>tendinopathy</p><p>(jumpers knee)</p><p>Patellofemoral</p><p>Syndrome</p><p>ACL Injury</p><p>IT band tendonitis</p><p>Move Outward Piriformis</p><p>Biceps Femoris</p><p>TFL/Gluteus</p><p>Minimus</p><p>Adductors Complex</p><p>Med. Hamstring</p><p>Gluteus Maximus</p><p>NASM_Chap06.indd 112NASM_Chap06.indd 112 7/5/2010 8:51:23 PM7/5/2010 8:51:23 PM</p><p>MOVEMENT ASSESSMENTS 113</p><p>Continued on page 114</p><p>Lateral</p><p>LPHC</p><p>Excessive</p><p>Forward</p><p>Lean</p><p>Soleus</p><p>Gastrocnemius</p><p>Hip Flexor</p><p>Complex</p><p>Piriformis</p><p>Abdominal Com-</p><p>plex ( rectus</p><p>abdominus,</p><p>external oblique)</p><p>Anterior Tibialis</p><p>Gluteus Maximus</p><p>Erector Spinae</p><p>Intrinsic Core Stabilizers</p><p>(transverse abdomi-</p><p>nis, multifi dus, trans-</p><p>versospinalis, internal</p><p>oblique, pelvic fl oor</p><p>muscles)</p><p>Hamstring, quad &</p><p>groin strain</p><p>Low back pain</p><p>Low Back</p><p>Arches</p><p>Hip Flexor</p><p>Complex</p><p>Erector Spinae</p><p>Latissimus Dorsi</p><p>Gluteus Maximus</p><p>Hamstrings</p><p>Intrinsic Core Stabilizers</p><p>Low Back</p><p>Rounds</p><p>Hamstrings</p><p>Adductor Magnus</p><p>Rectus</p><p>Abdominis</p><p>External</p><p>Obliques</p><p>Gluteus Maximus</p><p>Erector Spinae</p><p>Intrinsic Core Stabilizers</p><p>Hip Flexor Complex</p><p>Latissimus Dorsi</p><p>Shoulders</p><p>Arms Fall</p><p>Forward</p><p>Latissimus Dorsi</p><p>Pectoralis Major/</p><p>Minor</p><p>Coracobrachialis</p><p>Teres Major</p><p>Mid/Lower Trapezius</p><p>Rhomboids</p><p>Posterior Deltoid</p><p>Rotator Cuff</p><p>Headaches</p><p>Biceps tendonitis</p><p>Shoulder injuries</p><p>Posterior</p><p>Foot</p><p>Foot Flattens Peroneal Complex</p><p>Lat. Gastrocnemius</p><p>Biceps Femoris</p><p>(short head)</p><p>TFL</p><p>Anterior Tibialis</p><p>Posterior Tibialis</p><p>Med. Gastrocnemius</p><p>Gluteus Medius</p><p>Plantar fascitis</p><p>Achilles</p><p>tendinopathy</p><p>Medial tibial stress</p><p>syndrome</p><p>Ankle sprains</p><p>Patellar Tedinopathy</p><p>(jumper’s knee)</p><p>Heel of Foot</p><p>Rises</p><p>Soleus Anterior Tibialis</p><p>LPHC</p><p>Asymmetrical</p><p>Weight Shift</p><p>Adductor Complex</p><p>TFL (same side</p><p>of shift)</p><p>Gastrocnemius/</p><p>soleus</p><p>Piriformis</p><p>Bicep Femoris</p><p>Gluteus Medius</p><p>(opposite side</p><p>of shift)</p><p>Gluteus Medius, (same</p><p>side of shift)</p><p>Anterior Tibialis</p><p>Adductor Complex</p><p>(opposite side of shift)</p><p>Hamstring,</p><p>Quad &</p><p>Groin strain</p><p>Low back pain</p><p>SI joint pain</p><p>View Checkpoint Compensation Probable</p><p>Overactive</p><p>Muscles</p><p>Probable Underactive</p><p>Muscles</p><p>Possible Injuries</p><p>MOVEMENT COMPENSATIONS FOR THE OVERHEAD SQUAT ASSESSMENT (CONTINUED)</p><p>NASM_Chap06.indd 113NASM_Chap06.indd 113 7/5/2010 8:51:23 PM7/5/2010 8:51:23 PM</p><p>114 CHAPTER 6</p><p>MODIFICATIONS TO THE OVERHEAD SQUAT ASSESSMENT</p><p>There are a couple of modifi cations to the overhead squat assessment that the health</p><p>and fi tness professional can make to gain a clearer picture of the possible overactive and</p><p>underactive muscles. These include elevating the individual’s heels or performing the over-</p><p>head squat assessment with the hands on the hips.</p><p>Elevating the heels does two primary things. First, it places the foot and ankle complex in</p><p>plantarfl exion, which decreases the stretch (or extensibility) required from the plantarfl exor</p><p>muscles (gastrocnemius and soleus). This is important because deviation through the foot</p><p>and ankle complex can cause many of the devia-</p><p>tions to the kinetic chain, especially the feet,</p><p>knees, and LPHC. Second, it alters the client’s</p><p>center of gravity (CoG) by decreasing the base</p><p>of support (less or shorter contact surface of</p><p>the foot on the ground) and shifting the CoG</p><p>forward. When the CoG is moved forward, it</p><p>allows the individual to sit more upright or lean</p><p>back more. This is also important because with</p><p>less forward lean there will be less hip fl exion</p><p>needed and less emphasis placed on the LPHC.</p><p>In all, this modifi cation allows the health and</p><p>fi tness professional to see the infl uence the foot</p><p>and ankle has on the individual’s deviations. For</p><p>example, if an individual’s knees move inward</p><p>during the overhead squat assessment, but the</p><p>compensation is then corrected after elevating</p><p>the heels, then the primary region that mostly</p><p>likely needs to be addressed is the foot and ankle</p><p>complex. If the knees still move inward after the</p><p>heels are elevated, then the primary region that</p><p>most likely needs to be addressed is the hip.</p><p>Placing the hands on the hips directly removes the stretch placed on the latissimus dorsi,</p><p>pectoralis major and minor, and coracobrachialis and requires less demand from the intrinsic</p><p>core stabilizers. This allows the health and fi tness professional to see the infl uence the upper</p><p>body has on the individual’s compensations. For example, if an individual’s low back arches</p><p>during the overhead squat assessment, but the compensation is then corrected when perform-</p><p>ing the squat with the hands on the hips, then the primary regions that most likely need to be</p><p>addressed are the latissimus dorsi and pectoral muscles. If the compensation still exists with the</p><p>hands on the hips, then the primary regions that most likely need to be stretched include the hip</p><p>fl exors and the regions that need to be strengthened are the hips and intrinsic core stabilizers.</p><p>SINGLE-LEG SQUAT ASSESSMENT ➤</p><p>PURPOSE</p><p>This transitional movement assessment also assesses dynamic fl exibility, core strength,</p><p>balance, and overall neuromuscular control. There is evidence to support the use of the</p><p>single-leg squat as a transitional movement assessment (13). This assessment also appears</p><p>to be a reliable and valid measure of lower extremity movement patterns when standard</p><p>application protocols are applied. Knee valgus has been shown to be infl uenced by de-</p><p>creased hip abductor and hip external rotation strength (15), increased hip adductor activ-</p><p>ity (16), and restricted ankle dorsifl exion (16,17). These results suggest that the movement</p><p>impairments observed during this transitional movement assessment may be the result of</p><p>alterations in available joint motion, muscle activation, and overall neuromuscular control.</p><p>Elevating Heels</p><p>Hands on Hips</p><p>Heels Elevated Hands on Hips</p><p>Overhead Squat Assessment Modifi cations</p><p>NASM_Chap06.indd 114NASM_Chap06.indd 114 7/5/2010 8:51:23 PM7/5/2010 8:51:23 PM</p><p>MOVEMENT ASSESSMENTS 115</p><p>PROCEDURE</p><p>1. The individual should stand with hands on the hips and eyes focused on an object</p><p>straight ahead.</p><p>2. Foot should be pointed straight ahead and the foot, ankle, knee, and the LPHC should</p><p>be in a neutral position.</p><p>Single-Leg Squat Assessment, Position</p><p>1. Have the individual squat to a comfortable level and return to the starting position.</p><p>2. Perform up to 5 repetitions before switching sides.</p><p>1. View the knee, LPHC, and shoulders from the front. The knee should track in line with</p><p>the foot (second and third toes). The LPHC and shoulders should remain level and face</p><p>straight ahead.</p><p>Single-Leg Squat Assessment, Movement</p><p>Position</p><p>Movement</p><p>Views</p><p>Continued on page 116</p><p>NASM_Chap06.indd 115NASM_Chap06.indd 115 7/5/2010 8:51:25 PM7/5/2010 8:51:25 PM</p><p>116 CHAPTER 6</p><p>1. Knee:</p><p>a. Does the knee move inward (adduct and internally rotate)?</p><p>2. LPHC:</p><p>a. Does the hip hike?</p><p>b. Does the hip drop?</p><p>c. Does the torso rotate inward?</p><p>d. Does the torso rotate outward?</p><p>Torso Rotates Inward Torso Rotates Outward</p><p>Knee Moves Inward Hip Hikes Hip Drops</p><p>Single-Leg Squat Assessment, Compensations</p><p>Like the overhead squat assessment, record your fi ndings. You can then refer to the table</p><p>to determine potential overactive and underactive muscles that will need to be addressed</p><p>through corrective fl exibility and strengthening techniques to improve the individual’s</p><p>quality of movement, decreasing the risk for injury and improving overall performance.</p><p>Compensations</p><p>NASM_Chap06.indd 116NASM_Chap06.indd 116 7/5/2010 8:51:26 PM7/5/2010 8:51:26 PM</p><p>MOVEMENT ASSESSMENTS 117</p><p>SINGLE-LEG SQUAT OBSERVATIONAL FINDINGS</p><p>View Checkpoints Movement</p><p>Observation</p><p>Right - Y Left - Y</p><p>Anterior</p><p>Knees Move inward</p><p>LPHC</p><p>Hip hikes</p><p>Hip drops</p><p>Inward rotation</p><p>Outward rotation</p><p>MOVEMENT COMPENSATIONS FOR THE SINGLE-LEG SQUAT ASSESSMENT</p><p>View Checkpoint Compensation Probable Overactive</p><p>Muscles</p><p>Probable Underactive</p><p>Muscles</p><p>Anterior</p><p>Knee</p><p>Move Inward</p><p>(Valgus)</p><p>Adductor Complex</p><p>Bicep Femoris (short</p><p>head)</p><p>TFL</p><p>Lat. Gastrocnemius</p><p>Vastus Lateralis</p><p>Med. Hamstring</p><p>Med. Gastrocnemius</p><p>Gluteus Medius/ Maximus</p><p>VMO</p><p>LPHC</p><p>Hip Hike Quadratus Lumborum</p><p>(opposite side of</p><p>stance leg)</p><p>TFL/ Gluteus Mini-</p><p>mus (same side as</p><p>stance leg)</p><p>Adductor Complex (same</p><p>side as stance leg)</p><p>Gluteus Medius (same</p><p>side)</p><p>Hip Drop Adductor Complex</p><p>(same side as stance</p><p>leg)</p><p>Gluteus Medius (same side</p><p>as stance leg)</p><p>Quadratrus Lumborum</p><p>(same side as stance leg)</p><p>Upper</p><p>Body</p><p>Inward Trunk</p><p>Rotation</p><p>Internal Oblique</p><p>(same side as stance</p><p>leg)</p><p>External Oblique</p><p>(opposite side of</p><p>stance leg)</p><p>TFL (same side)</p><p>Adductor complex</p><p>(same side as stance</p><p>leg)</p><p>Internal Oblique ( opposite</p><p>side of stance leg)</p><p>External Oblique (same</p><p>side as stance leg)</p><p>Gluteus Medius/ Maximus</p><p>Outward</p><p>Trunk Rota-</p><p>tion</p><p>Internal Oblique</p><p>(opposite side of</p><p>stance leg)</p><p>External Oblique</p><p>(same side as stance</p><p>leg)</p><p>Piriformis (same side</p><p>as stance leg)</p><p>Internal Oblique (same</p><p>side)</p><p>External Oblique ( opposite</p><p>side of stance leg)</p><p>Adductor Complex (oppo-</p><p>site side of stance leg)</p><p>Gluteus Medius/ Maximus</p><p>Continued on page 118</p><p>NASM_Chap06.indd 117NASM_Chap06.indd 117 7/5/2010 8:51:28 PM7/5/2010 8:51:28 PM</p><p>118 CHAPTER 6</p><p>PUSHING ASSESSMENT: PUSH-UPS ➤</p><p>PURPOSE</p><p>The push-up assessment is related to pushing activities and evaluates the function of the</p><p>LPHC and the scapular and cervical spine stabilizers.</p><p>PROCEDURE</p><p>1. Instruct the individual to assume a prone position with hands roughly shoulder-width</p><p>apart and knees fully extended. A modifi ed version of the push-up can also be used</p><p>depending on the capabilities of the individual.</p><p>Modifi ed Position</p><p>Start Finish</p><p>Push-Ups Assessment, Position</p><p>1. Instruct the individual to push against the fl oor, displacing the thorax backward until</p><p>the scapulae are in a position of protraction.</p><p>2. The individual should move slowly and consistently as most faults will not be exhibited</p><p>until the individual is fatigued. A 2-0-2 speed per repetition is</p><p>recommended (two sec-</p><p>onds up, zero-second hold, two seconds down).</p><p>3. Perform 10 repetitions.</p><p>1. View the knees, LPHC, shoulders, and cervical spine from the side. The body should lift</p><p>as one functional unit.</p><p>Position</p><p>Movement</p><p>Views</p><p>NASM_Chap06.indd 118NASM_Chap06.indd 118 7/5/2010 8:51:28 PM7/5/2010 8:51:28 PM</p><p>MOVEMENT ASSESSMENTS 119</p><p>1. LPHC:</p><p>a. Does the low back sag?</p><p>b. Does the low back round?</p><p>2. Shoulders:</p><p>a. Do the shoulders elevate?</p><p>b. Does the scapulae wing (lift away from the rib cage)?</p><p>3. Head/cervical spine:</p><p>a. Does the cervical spine hyperextend?</p><p>Low Back Sags</p><p>Cervical Spine Hyperextends</p><p>Low Back Rounds</p><p>Shoulders Elevate Scapulae Wings</p><p>Push-Ups Assessment, Compensations</p><p>Record your fi ndings. You can then refer to the table on the following page to determine</p><p>potential overactive and underactive muscles that will need to be addressed through</p><p>corrective fl exibility and strengthening techniques to improve the individual’s quality of</p><p>movement, decreasing the risk for injury and improving overall performance.</p><p>Compensations</p><p>Continued on page 120</p><p>NASM_Chap06.indd 119NASM_Chap06.indd 119 7/5/2010 8:51:30 PM7/5/2010 8:51:30 PM</p><p>120 CHAPTER 6</p><p>PUSH-UP OBSERVATIONAL FINDINGS</p><p>Checkpoints Movement Observation Yes</p><p>LPHC</p><p>Low back sags</p><p>Low back rounds</p><p>Shoulders</p><p>Shoulders elevate</p><p>Scapular winging</p><p>Head/Cervical Spine Hyperextension</p><p>MOVEMENT COMPENSATIONS FOR THE PUSH-UP ASSESSMENT</p><p>Checkpoint Compensation Probable Overactive</p><p>Muscles</p><p>Probable</p><p>Underactive Muscles</p><p>LPHC</p><p>Low Back Sags Erector Spinae</p><p>Hip Flexors</p><p>Instrinsic Core Stabilizers</p><p>Gluteus Maximus</p><p>Low Back Rounds Rectus Abdominus</p><p>External Obliques</p><p>Instrinsic Core Stabilizers</p><p>Shoulders</p><p>Shoulders Elevate Upper Trapezius</p><p>Levator Scapulae</p><p>Sternocleidomastoid</p><p>Mid and Lower Trapezius</p><p>Scapular Winging Pectoralis Minor Serratus Anterior</p><p>Mid and Lower Trapezius</p><p>Cervical</p><p>Spine</p><p>Hyperextension Upper Trapezius</p><p>Sternocliedomastoid</p><p>Levator Scapulae</p><p>Deep Cervical Flexors</p><p>PUSHING ASSESSMENT OPTION</p><p>If a standard or modifi ed push-up is too diffi cult for the individual, pushing assessments can</p><p>also be done in a standing position using cables or tubing or seated using a machine.</p><p>PULLING ASSESSMENT: STANDING ROWS ➤</p><p>PURPOSE</p><p>The standing row assessment is related to pulling activities and evaluates the function of</p><p>the LPHC and the scapular and cervical spine stabilizers.</p><p>PROCEDURE</p><p>1. Instruct the individual to stand in a staggered stance with the toes pointing forward.</p><p>1. Viewing from the side, instruct the individual to pull handles toward the body and</p><p>return to the starting position. Like the pushing assessment, the lumbar and cervical</p><p>spines should remain neutral while the shoulders stay level.</p><p>2. Perform 10 repetitions in a controlled fashion using a 2-0-2 tempo.</p><p>Position</p><p>Movement</p><p>NASM_Chap06.indd 120NASM_Chap06.indd 120 7/5/2010 8:51:33 PM7/5/2010 8:51:33 PM</p><p>MOVEMENT ASSESSMENTS 121</p><p>Start Finish</p><p>Standing Row Assessment, Position</p><p>1. Low back:</p><p>a. Does the low back arch?</p><p>2. Shoulders:</p><p>a. Do the shoulders elevate?</p><p>3. Head:</p><p>a. Does the head migrate forward?</p><p>Low Back Arches Shoulders Elevate Head Forward</p><p>Standing Row Assessment, Compensations</p><p>Record your fi ndings. You can then refer to the table on the following page to determine</p><p>potential overactive and underactive muscles that will need to be addressed through</p><p>corrective fl exibility and strengthening techniques to improve the individual’s quality of</p><p>movement, decreasing the risk for injury and improving overall performance.</p><p>Compensations</p><p>Continued on page 122</p><p>NASM_Chap06.indd 121NASM_Chap06.indd 121 7/5/2010 8:51:33 PM7/5/2010 8:51:33 PM</p><p>122 CHAPTER 6</p><p>STANDING ROW OBSERVATIONAL FINDINGS</p><p>Checkpoints Movement Observation Yes</p><p>LPHC Low back arches</p><p>Shoulders Shoulders elevates</p><p>Head Head migrates forward</p><p>MOVEMENT COMPENSATIONS FOR THE STANDING ROW ASSESSMENT</p><p>Checkpoint Compensation Probable</p><p>Overactive Muscles</p><p>Probable</p><p>Underactive Muscles</p><p>LPHC Low Back Arches Hip Flexors, Erector</p><p>Spinae</p><p>Intrinsic Core</p><p>Stabilizers</p><p>Shoulders Shoulder Elevation Upper Trapezius,</p><p>Sternocleido-</p><p>mastoid, Levator</p><p>Scapulae</p><p>Mid and Lower</p><p>Trapezius</p><p>Head Head Migrates</p><p>Forward</p><p>Upper Trapezius,</p><p>Sternocleido-</p><p>mastoid, Levator</p><p>Scapulae</p><p>Deep Cervical Flexors</p><p>PULLING ASSESSMENT OPTION</p><p>Like the pushing assessment, the pulling assessment can also be performed on a machine,</p><p>depending on the individual’s physical capabilities.</p><p>PRESSING ASSESSMENT: STANDING OVERHEAD DUMBBELL PRESS ➤</p><p>PURPOSE</p><p>The pressing assessment is related to everyday pressing activities and evaluates the</p><p>function of the LPHC, scapular stabilizers, and cervical spine stabilizers as well as shoulder</p><p>range of motion.</p><p>PROCEDURE</p><p>1. Instruct the individual to stand with feet shoulder-width apart and toes pointing</p><p>forward.</p><p>2. Choose a dumbbell weight at which the individual can perform 10 repetitions</p><p>comfortably.</p><p>Position</p><p>NASM_Chap06.indd 122NASM_Chap06.indd 122 7/5/2010 8:51:35 PM7/5/2010 8:51:35 PM</p><p>MOVEMENT ASSESSMENTS 123</p><p>Standing Overhead Dumbbell Press Assessment, Position</p><p>1. Viewing from the anterior and lateral positions, instruct the individual to press the</p><p>dumbbells overhead and return to the starting position. The lumbar and cervical spines</p><p>should remain neutral while the shoulders stay level and the arms bisect the ears.</p><p>2. Perform 10 repetitions in a controlled fashion using a 2-0-2 tempo.</p><p>Standing Overhead Dumbbell Press Assessment, Movement</p><p>1. Low back:</p><p>a. Does the low back arch?</p><p>2. Shoulders:</p><p>a. Do the shoulders elevate?</p><p>b. Do the arms migrate forward?</p><p>c. Do the elbows fl ex?</p><p>3. Head:</p><p>a. Does the head migrate forward?</p><p>Movement</p><p>Compensations</p><p>Continued on page 124</p><p>NASM_Chap06.indd 123NASM_Chap06.indd 123 7/5/2010 8:51:35 PM7/5/2010 8:51:35 PM</p><p>124 CHAPTER 6</p><p>Elbows Flex Head Forward</p><p>Low Back Arches Shoulders Elevate Arms Fall Forward</p><p>Standing Overhead Dumbbell Press Assessment, Compensations</p><p>Record your fi ndings. You can then refer to the table on the following page to determine</p><p>potential overactive and underactive muscles that will need to be addressed through</p><p>corrective fl exibility and strengthening techniques to improve the individual’s quality of</p><p>movement, decreasing the risk for injury and overall improving performance.</p><p>OVERHEAD PRESS OBSERVATIONAL FINDINGS</p><p>Checkpoints Movement Observation Yes</p><p>LPHC Low back arches</p><p>Shoulders</p><p>Shoulders elevates</p><p>Arms migrate forward</p><p>Elbows fl ex</p><p>Head Head migrates forward</p><p>NASM_Chap06.indd 124NASM_Chap06.indd 124 7/5/2010 8:51:36 PM7/5/2010 8:51:36 PM</p><p>MOVEMENT ASSESSMENTS 125</p><p>MOVEMENT COMPENSATIONS FOR THE OVERHEAD PRESS ASSESSMENT</p><p>Checkpoint Compensation Probable Overactive Muscles Probable Underactive</p><p>Muscles</p><p>LPHC</p><p>Low Back Arches Hip Flexors</p><p>Erector Spinae</p><p>Latissimus Dorsi</p><p>Intrinsic Core</p><p>Stabilizers</p><p>Gluteus Maximus</p><p>Shoulders</p><p>Shoulder Elevation Upper Trapezius, Sternocleido-</p><p>Mastoid, Levator Scapulae</p><p>Mid and Lower</p><p>Trapezius</p><p>Arms Migrate Forward Latissimus Dorsi</p><p>Pectorals</p><p>Rotator Cuff</p><p>Mid and Lower Trapezius</p><p>Elbows Flex Latissimus Dorsi</p><p>Pectorals</p><p>Biceps Brachii</p><p>Rotator Cuff</p><p>Mid and Lower</p><p>Trapezius</p><p>Head</p><p>Head Migrates</p><p>Forward</p><p>Upper Trapezius,</p><p>Sternocleidomastoid,</p><p>Levator Scapulae</p><p>Deep Cervical Flexors</p><p>STAR BALANCE EXCURSION TEST ➤</p><p>PURPOSE</p><p>This assessment measures multiplanar balance and neuromuscular effi ciency of the testing</p><p>leg during closed-chain functional movements (18–20).</p><p>PROCEDURE</p><p>1. The individual is instructed to stand on the testing leg.</p><p>2. This individual is instructed to squat down as far as he or she can control with the knee</p><p>aligned in a neutral position (balance threshold).</p><p>Star Balance Excursion Test, Position</p><p>Position</p><p>Balance threshold:</p><p>the distance one can</p><p>squat down on one leg</p><p>while keeping the knee</p><p>aligned in a neutral</p><p>position (in line with</p><p>the second and third</p><p>toes).</p><p>Continued on page 126</p><p>NASM_Chap06.indd 125NASM_Chap06.indd 125 7/5/2010 8:51:38</p><p>learning experience.</p><p>User’s Guide</p><p>OBJECTIVES Upon completion of this chapter, you will be able to:</p><p>Identify the importance of achieving optimal</p><p>range of motion in human movement.</p><p>Explain how the integrated function of the</p><p>muscular, skeletal, and nervous systems collec-tively infl uences the ability to move through a full range of motion.</p><p>Discuss how a goniometer and an inclinometer</p><p>can be used to measure joint range of motion and why it is important for the health and fit-ness professional to develop skill in taking these measures.</p><p>Discuss the various components of a goniom-</p><p>eter and specifi cally explain how to use this instrument to measure joint range of motion.</p><p>Demonstrate the ability to measure joint range</p><p>of motion at the foot, knee, hip, and shoulder joints.</p><p>Explain how optimal range of motion at these</p><p>joints correlates to the overhead squat and single-leg squat assessments.</p><p>For each joint movement identifi ed, discuss</p><p>the muscles being assessed, the antago-nist muscles, positioning of the client, the execution of the goniometric measurement, common errors in measurement, and the movement compensations to look for.</p><p>Range of Motion</p><p>Assessments</p><p>C H A P T E R 7</p><p>NASM_FM.indd xiiNASM_FM.indd xii 7/5/2010 8:47:31 PM7/5/2010 8:47:31 PM</p><p>Sidebars, set in the margins,</p><p>highlight the defi nitions of</p><p>key terms that are presented</p><p>in the chapter. The key terms</p><p>are bolded throughout the</p><p>chapter for easy reference.</p><p>Getting Your Facts Straight</p><p>boxes emphasize key concepts</p><p>and fi ndings from current</p><p>research.</p><p>212 CHAPTER 10</p><p>In other words, although a muscle may not be as resistant to being stretched (allowing for better extensibility), it still maintains the rate of increase in stiff-ness in response to stimuli (the ability to respond to a stretch force).Neurologically, static stretching of neuromyofascial tissue to the end ROM appears to decrease motor neuron excitability, possibly through the inhibitory effects from the Golgi tendon</p><p>organs (autogenic inhibition)</p><p>as well as possible contri-</p><p>butions from the Renshaw</p><p>recurrent loop ( recurrent</p><p>inhibition) (6). Recurrent</p><p>inhibition is a feedback</p><p>circuit that can decrease</p><p>the excitability of motor</p><p>neurons via the interneu-</p><p>ron called the Renshaw cell</p><p>(11) (Figure 10-2). Collec-</p><p>tively, these may decrease</p><p>the responsiveness of the</p><p>stretch refl ex (Figure 10-3)</p><p>and increase the tolerance a</p><p>person has to stretch and thus</p><p>allow for increased ROM.</p><p>In general, it is thought that static stretching of 20 to 30 seconds causes an acute viscoelastic stress relaxation response, allowing for an immediate increase in ROM. Long-term, the increases in maximal joint ROM may be caused by increased tolerance to stretch and not necessarily changes in the viscoelastic properties of myofascial tissue (5,12) or a possible increase in mus-cle mass and added sarcomeres in series (4).In practice, static stretching is characterized by (1 2):</p><p>Recurrent inhibition:</p><p>a feedback circuit</p><p>that can decrease</p><p>the excitability of</p><p>motor neurons via the</p><p>interneuron called the</p><p>Renshaw cell.</p><p>Stretch refl ex: a muscle</p><p>contraction in response</p><p>to stretching within the</p><p>muscle.</p><p>Motor neuron</p><p>Renshaw cell</p><p>(inhibitory interneuron)</p><p>Axon</p><p>Internode</p><p>Figure 10.2 Renshaw cells and recurrent inhibition.</p><p>ECNEICS TNEMEVOM NAMUH OT NOITCUDORTNI</p><p>17</p><p>the muscles must decelerate or reduce the forces acting on the body (or force</p><p>reduction). This is a critical aspect of all forms of movement because the</p><p>weight of the body must be decelerated and then stabilized to properly accel-</p><p>erate during movement.</p><p>Gravity and Its Effect on Movement</p><p>Gravity is a constant downward-directed force that we are infl uenced by every second of</p><p>every day. This increases the eccentric demand that our muscles are placed under, which</p><p>must therefore be trained for accordingly, making the eccentric action of training just as</p><p>important (if not more important) as the concentric action.</p><p>GETTING YOUR FACTS STRAIGHT</p><p>Table 2.3 MUSCLE ACTION SPECTRUM</p><p>Concentric Developing tension while a muscle is shortening; when</p><p>developed tension overcomes resistive force</p><p>Eccentric Developing tension while a muscle is lengthening; when</p><p>resistive force overcomes developed tension</p><p>Isometric When the contractile force is equal to the resistive force</p><p>NASM_FM.indd xiiiNASM_FM.indd xiii 7/5/2010 8:47:32 PM7/5/2010 8:47:32 PM</p><p>Movement Assessment</p><p>sections discuss the purpose</p><p>and procedures of various</p><p>techniques that can be used</p><p>in corrective exercise.</p><p>High-quality, four-color</p><p>photographs and artwork</p><p>throughout the text help</p><p>to draw attention to</p><p>important concepts in a</p><p>visually stimulating and</p><p>intriguing manner. They</p><p>help to clarify the text and</p><p>are particularly helpful for</p><p>visual learners.</p><p>Anterior</p><p>Lateral</p><p>Posterior</p><p>Overhead Squat Views</p><p>1. Feet:</p><p>a. Do the feet fl atten and/or turn out?2. Knees:</p><p>a. Do the knees move inward (adduct and internally rotate)?b. Do the knees move outward (abduct and externally rotate)?</p><p>Feet Flatten Feet Turn Out Knees Move Inward Knees Move Outward</p><p>Overhead Squat Compensations, Anterior View</p><p>Compensations:</p><p>Anterior View</p><p>Student Resources</p><p>Inside the front cover of your textbook, you’ll fi nd your personal access code. Use it to</p><p>log on to http://thePoint.lww.com/NASMCES—the companion website for this textbook.</p><p>On the website, you can access various supplemental materials available to help enhance</p><p>and further your learning. These assets include the fully searchable online text, a quiz</p><p>bank, and lab activities.</p><p>NASM_FM.indd xivNASM_FM.indd xiv 7/5/2010 8:47:32 PM7/5/2010 8:47:32 PM</p><p>http://thePoint.lww.com/NASMCES</p><p>Photography:</p><p>Ben Bercovici</p><p>President</p><p>In Sync Productions</p><p>Calabasas, CA</p><p>Anton Polygalov</p><p>Photographer</p><p>In Sync Productions</p><p>Calabasas, CA</p><p>Models:</p><p>Joey Metz</p><p>Monica Munson</p><p>Allie Shira</p><p>Cameron Klippsten</p><p>Zack Miller</p><p>Paul Terek</p><p>Photo Shoot Sites:</p><p>National Academy of Sports Medicine Headquarters</p><p>26632 Agoura Rd</p><p>Calabasas, CA 91302</p><p>Acknowledgments</p><p>NASM_FM.indd xvNASM_FM.indd xv 7/5/2010 8:47:33 PM7/5/2010 8:47:33 PM</p><p>Micheal A. Clark, DPT, MS, PES, CES</p><p>CEO</p><p>National Academy of Sports Medicine</p><p>Calabasas, CA</p><p>Scott C. Lucett, MS, PES, CES, NASM – CPT</p><p>Director of Education</p><p>National Academy of Sports Medicine</p><p>Mesa, AZ</p><p>Cathleen N. Brown, PhD, ATC</p><p>University of Georgia</p><p>Department of Kinesiology</p><p>Athens, GA</p><p>Chuck Thigpen, PhD, PT, ATC</p><p>Assistant Professor</p><p>Department of Athletic Training & Physical Therapy</p><p>Brooks College of Health</p><p>University of North Florida</p><p>Jacksonville, FL</p><p>Marjorie A. King, PhD, ATC, PT</p><p>Director of Graduate Athletic Training Education</p><p>Plymouth State University</p><p>Plymouth, NH</p><p>William Prentice, PhD, PT, ATC, FNATA</p><p>Associate Professor</p><p>Coordinator, Sports Medicine Program</p><p>Department of Exercise and Sports Science</p><p>University of North Carolina at Chapel Hill</p><p>Chapel Hill, NC</p><p>Kim D. Christensen, DC, DACRB, CSCS, CES, PES</p><p>Peacehealth Medical Group</p><p>Chiropractic Physician</p><p>Longview, WA</p><p>Jeffrey Tucker, DC</p><p>Diplomate American Chiropractic Rehabilitation Board</p><p>Certified in Chiropractic Spinal Trauma</p><p>Post Graduate Rehab Instructor</p><p>NASM Instructor</p><p>Private Practice</p><p>Los Angeles, CA</p><p>Russell D. Fiore, MEd, ATC</p><p>Head Athletic Trainer</p><p>Brown University</p><p>Providence, RI</p><p>Gregory D. Myer, PhD, CSCS</p><p>Sports Biomechanist</p><p>Cincinnati Children’s Hospital Medical Center</p><p>Cincinnati, OH</p><p>Melanie McGrath, PhD, ATC</p><p>Assistant Professor</p><p>Health, Physical Education, & Recreation Department</p><p>Program Director</p><p>Athletic Training Education Program</p><p>University of Nebraska at Omaha</p><p>Omaha, NE</p><p>Lindsay J. DiStefano, PhD, ATC, PES</p><p>Assistant Professor</p><p>University of Connecticut</p><p>Storrs, CT</p><p>Michael Rosenberg, MEd, PT, ATC-L, PES, CES</p><p>Lead Physical Therapist</p><p>Presbyterian Rehabilitation Center</p><p>Charlotte, NC</p><p>Contributors</p><p>NASM_FM.indd xviNASM_FM.indd xvi 7/5/2010 8:47:33 PM7/5/2010 8:47:33 PM</p><p>Reviewers</p><p>George J. Davies, DPT, MEd, PT, SCS, ATC, LAT, CSCS, FAPTA</p><p>Professor – Physical Therapy</p><p>Armstrong Atlantic</p><p>PM7/5/2010 8:51:38 PM</p><p>126 CHAPTER 6</p><p>1. The individual is then to reach with the opposite leg in the sagittal, frontal, and</p><p>transverse planes while trying to maintain balance and keeping the knee in line with the</p><p>second and third toes of the balance foot. The health and fi tness professional assesses</p><p>in which plane of motion the individual has the least amount of control (i.e., cannot</p><p>maintain balance or knee moves inward). This can help in determining which plane(s) of</p><p>motion may need to be emphasized in the individual’s corrective exercise strategy.</p><p>Sagittal Plane Frontal Plane Transverse Plane</p><p>Star Balance Excursion Test, Movement</p><p>UPPER EXTREMITY TRANSITIONAL ASSESSMENTS ➤</p><p>PURPOSE</p><p>The upper extremity transitional assessments are used to determine any specifi c move-</p><p>ment defi cits in the shoulder complex. These assessments include the:</p><p>Horizontal abduction test•</p><p>Rotation test•</p><p>Shoulder fl exion test•</p><p>PROCEDURE</p><p>All three tests are performed with the client standing with heels, buttocks, shoulders, and</p><p>head against a wall (the low back should be held in a neutral lumbar position).</p><p>1. For the horizontal abduction test, raise both arms straight out in front to 90 degrees of</p><p>fl exion with the thumbs up. Keeping the elbows extended, horizontally abduct the arms</p><p>back toward the wall. Properly performed, the back of the hands will touch the wall with</p><p>no movement compensations.</p><p>2. For the rotation test, abduct the shoulders to 90 degrees and bend the elbows to 90</p><p>degrees. With each humerus parallel to the fl oor, internally rotate the palms toward</p><p>the fl oor then externally rotate the arms back toward the wall. The goal is to internally</p><p>rotate the humerus until the palms of the hands and the forearms are within 20 degrees</p><p>of the wall, then to externally rotate the humerus to touch the back of the hands against</p><p>the wall with no movement compensations in either direction.</p><p>3. The shoulder fl exion test begins as described above. The elbows are extended with</p><p>thumbs up, then the straight arms are extended straight up toward the wall. The goal</p><p>is to touch the thumbs against the wall with no compensatory movements such as</p><p>shrugging or increasing lumbar lordosis.</p><p>Movement</p><p>Position</p><p>Movement</p><p>NASM_Chap06.indd 126NASM_Chap06.indd 126 7/5/2010 8:51:39 PM7/5/2010 8:51:39 PM</p><p>MOVEMENT ASSESSMENTS 127</p><p>Upper Extremity Transitional Assessments, Movement</p><p>Rotation Test</p><p>Shoulder Flexion Test</p><p>Abduction Test</p><p>Continued on page 128</p><p>NASM_Chap06.indd 127NASM_Chap06.indd 127 7/5/2010 8:51:40 PM7/5/2010 8:51:40 PM</p><p>128 CHAPTER 6</p><p>1. Horizontal abduction test:</p><p>a. Do the shoulders elevate?</p><p>b. Do the shoulders protract?</p><p>c. Do the elbows fl ex?</p><p>2. Rotation test:</p><p>a. Do the shoulders elevate (internal rotation)?</p><p>b. Do the shoulders protract (internal rotation)?</p><p>c. Are the hands far from the wall (internal and external rotation)?</p><p>3. Shoulder fl exion test:</p><p>a. Do the shoulders elevate?</p><p>b. Does the low back arch?</p><p>c. Do the elbows fl ex?</p><p>Elbows Flex</p><p>Shoulders Elevate Shoulders Protract</p><p>Upper Extremity Transitional Assessments, Compensations</p><p>Horizontal Abduction Test Compensations</p><p>Compensations</p><p>NASM_Chap06.indd 128NASM_Chap06.indd 128 7/5/2010 8:51:42 PM7/5/2010 8:51:42 PM</p><p>MOVEMENT ASSESSMENTS 129</p><p>Rotation Test Compensations</p><p>Shoulders Elevate Shoulders Protract</p><p>Hands Far from Wall, Internal Rotation Hands Far from Wall, External Rotation</p><p>Shoulders Elevate Low Back Arches Elbows Flex</p><p>Shoulder Flexion Test Compensations</p><p>You can then refer to the table on the following page to determine potential overactive</p><p>and underactive muscles that will need to be addressed through corrective fl exibility and</p><p>strengthening techniques to improve the individual’s quality of movement, decreasing the</p><p>risk for injury and overall improving performance.</p><p>Continued on page 130</p><p>NASM_Chap06.indd 129NASM_Chap06.indd 129 7/5/2010 8:51:44 PM7/5/2010 8:51:44 PM</p><p>130 CHAPTER 6</p><p>UPPER EXTREMITY TRANSITIONAL ASSESSMENT SOLUTIONS TABLE</p><p>Probable Compensations for the Horizontal Abduction Test</p><p>Compensation Potential Meaning</p><p>Elbows consistently fl ex even when</p><p>properly shown or told not to</p><p>Overactive biceps brachii (long head)</p><p>Underactive triceps brachii (long head) and rotator cuff</p><p>Shoulder protracts (humeral head</p><p>moves forward and upward)</p><p>Overactive pectoralis major/minor and hypomobile posterior capsule</p><p>Underactive rotator cuff, rhomboids, and middle/lower trapezius</p><p>Shoulders elevate Overactive upper trapezius and levator scapulae</p><p>Underactive rotator cuff, rhomboids, and middle/lower trapezius</p><p>Probable Compensations for the Rotation Test</p><p>Compensation Potential Meaning</p><p>Internal Rotation</p><p>Hands are far from wall Overactive teres minor and infraspinatus and hypomobile posterior</p><p>capsule</p><p>Underactive subscapularis and teres major</p><p>Shoulder protracts (humeral head</p><p>moves forward and upward)</p><p>Overactive pectoralis major/minor and hypomobile posterior capsule</p><p>Underactive rotator cuff, rhomboids, and middle/lower trapezius</p><p>Shoulders elevate Overactive upper trapezius and levator scapulae</p><p>Underactive rotator cuff, rhomboids, and middle/lower trapezius</p><p>External Rotation</p><p>Hands are far from wall Overactive subscapularis, pectoralis major, teres major, and</p><p>latissimus dorsi</p><p>Underactive teres minor and infraspinatus</p><p>Probable Compensations for the Standing Shoulder Flexion Test</p><p>Compensation Potential Meaning</p><p>Elbows fl ex Overactive biceps brachii (long head), latissimus dorsi, teres major,</p><p>and pectoralis major</p><p>Underactive triceps brachii (long head) and rotator cuff</p><p>Shoulders elevate Overactive upper trapezius and levator scapulae</p><p>Underactive rotator cuff, rhomboids, and middle/lower trapezius</p><p>Low back arches off the wall Overactive erector spinae, latissimus dorsi and pectoralis major/minor</p><p>Underactive rotator cuff, rhomboids, and middle/lower trapezius</p><p>DYNAMIC POSTURAL ASSESSMENTS ➤</p><p>As stated earlier in the chapter, dynamic movement assessments are assessments in which</p><p>movement is occurring with a change in one’s base of support. The dynamic movement</p><p>assessments that will be covered in this chapter include:</p><p>1. Gait</p><p>2. Landing error scoring system (LESS) test</p><p>3. Tuck jump test</p><p>4. Davies test</p><p>NASM_Chap06.indd 130NASM_Chap06.indd 130 7/5/2010 8:51:49 PM7/5/2010 8:51:49 PM</p><p>MOVEMENT ASSESSMENTS 131</p><p>GAIT: TREADMILL WALKING ➤</p><p>PURPOSE</p><p>To assess one’s dynamic posture during ambulation.</p><p>PROCEDURE</p><p>1. Have the individual walk on a treadmill at a comfortable pace at a 0-degree incline.</p><p>1. From an anterior view, observe the feet and knees. The feet should remain straight with</p><p>the knees in line with the toes. From a lateral view, observe the low back, shoulders, and</p><p>head. The low back should maintain a neutral lordotic curve. The shoulders and head</p><p>should also be in neutral alignment. From a posterior view, observe the feet and LPHC.</p><p>The feet should remain straight and the LPHC should remain level.</p><p>Posterior</p><p>Anterior Lateral</p><p>Gait: Treadmill Walking Assessment, Views</p><p>Movement</p><p>Views</p><p>Continued on page 132</p><p>NASM_Chap06.indd 131NASM_Chap06.indd 131 7/5/2010 8:51:49 PM7/5/2010 8:51:49 PM</p><p>132 CHAPTER 6</p><p>1. Feet:</p><p>a. Do the feet fl atten and/or turn out</p><p>2. Knees:</p><p>a. Do the knees move inward?</p><p>Feet Flatten/Knees Move Inward</p><p>Gait: Treadmill Walking Assessment Compensations, Anterior View</p><p>1. LPHC:</p><p>a. Does the low back arch?</p><p>2. Shoulders and head:</p><p>a. Do the shoulders round?</p><p>b. Does the head migrate forward?</p><p>Low Back Arches Shoulders Round</p><p>Gait: Treadmill Walking Assessment Compensations, Lateral View</p><p>Compensations:</p><p>Anterior View</p><p>Compensations:</p><p>Lateral View</p><p>NASM_Chap06.indd 132NASM_Chap06.indd 132 7/5/2010 8:51:53 PM7/5/2010 8:51:53 PM</p><p>MOVEMENT ASSESSMENTS 133</p><p>Head Forward</p><p>Gait: Treadmill Walking Assessment Compensations, Lateral View</p><p>1. Feet:</p><p>a. Do the feet fl atten and/or turn out?</p><p>2. LPHC:</p><p>a. Is there excessive pelvic rotation?</p><p>b. Do the hips hike?</p><p>Feet Flatten and/or Turn Out Excessive Pelvic Rotation Hip</p><p>Hikes</p><p>Gait: Treadmill Walking Assessment Compensations, Posterior View</p><p>When performing the assessment, record all of your fi ndings. You can then refer to the</p><p>table on the following page to determine potential overactive and underactive muscles</p><p>that will need to be addressed through corrective fl exibility and strengthening techniques</p><p>to improve the individual’s quality of movement, decreasing the risk for injury and improv-</p><p>ing overall performance.</p><p>Compensations:</p><p>Posterior View</p><p>Continued on page 134</p><p>NASM_Chap06.indd 133NASM_Chap06.indd 133 7/5/2010 8:51:57 PM7/5/2010 8:51:57 PM</p><p>134 CHAPTER 6</p><p>GAIT OBSERVATIONAL FINDINGS</p><p>Checkpoints Movement Observation Yes</p><p>Feet</p><p>Flatten</p><p>Turn out</p><p>Knees Move inward</p><p>LPHC</p><p>Low back arches</p><p>Excessive rotation</p><p>Hip hikes</p><p>Shoulders Rounded</p><p>Head Forward</p><p>MOVEMENT COMPENSATIONS FOR THE GAIT ASSESSMENT</p><p>Checkpoint Compensation Probable Overactive Muscles Probable Underactive Muscles</p><p>Feet</p><p>Flatten Peroneal Complex</p><p>Lat. Gastrocnemius</p><p>Biceps Femoris (short head)</p><p>TFL</p><p>Anterior Tibialis</p><p>Posterior Tibialis</p><p>Med. Gastrocnemius</p><p>Gluteus Medius</p><p>Turn Out Soleus</p><p>Lat. Gastrocnemius</p><p>Biceps Femoris (short head)</p><p>TFL</p><p>Med. Gastrocnemius</p><p>Med. Hamstring</p><p>Gluteus Medius/Maximus</p><p>Gracilis</p><p>Sartorius</p><p>Popliteus</p><p>Knees</p><p>Move Inward</p><p>(Valgus)</p><p>Adductor Complex</p><p>Biceps Femoris (short head)</p><p>TFL</p><p>Lat Gastrocnemius</p><p>Vastus Lateralis</p><p>Med. Hamstring</p><p>Med. Gastrocnemius</p><p>Gluteus Medius/Maximus</p><p>Vastus Medialis Oblique</p><p>Anterior Tibialis</p><p>Posterior Tibialis</p><p>LPHC</p><p>Low Back Arches Hip Flexor Complex</p><p>Erector Spinae</p><p>Latissimus Dorsi</p><p>Gluteus Maximus</p><p>Intrinsic Core Stabilizers</p><p>Hamstrings</p><p>Excessive Rotation External Obliques</p><p>Adductor Complex</p><p>Hamstrings</p><p>Gluteus Maximus and Medius</p><p>Intrinsic Core Stabilizers</p><p>Hip Hike Quadratus Lumborum (opposite side</p><p>of stance leg)</p><p>TFL/Gluteus Minimus (same side as</p><p>stance leg)</p><p>Adductor Complex (same side</p><p>as stance leg)</p><p>Gluteus Medius (same side as</p><p>stance leg)</p><p>Shoulders Rounded Pectorals</p><p>Latissimus Dorsi</p><p>Mid and Lower Trapezius</p><p>Rotator Cuff</p><p>Head</p><p>Forward Upper Trapezius</p><p>Levator Scapulae</p><p>Sternocliedomastoid</p><p>Deep Cervical Flexors</p><p>NASM_Chap06.indd 134NASM_Chap06.indd 134 7/5/2010 8:51:59 PM7/5/2010 8:51:59 PM</p><p>MOVEMENT ASSESSMENTS 135</p><p>LANDING ERROR SCORING SYSTEM (LESS) TEST ➤</p><p>PURPOSE</p><p>The LESS test is a clinical dynamic movement assessment tool for identifying improper</p><p>movement patterns during the jump landing tasks (21,22). This test evaluates landing tech-</p><p>nique based on nine jump landing concepts using 13 different yes or no questions.</p><p>PROCEDURE</p><p>1. The individual stands on a 30-cm (12-inch) box. A target line is drawn on the fl oor at a</p><p>distance of half the individual’s height.</p><p>1. The individual is instructed to “jump forward from the box with both feet so that you</p><p>land with both feet just after the line” and “as soon as you land, jump up for maximum</p><p>height and land back down.”</p><p>Start Jump Land Jump</p><p>Landing Error Scoring System (LESS) Test</p><p>2. The individual views a demonstration performed by the health and fi tness professional,</p><p>then gets the opportunity to practice.</p><p>3. Ideally, video cameras are place 10 feet in front and to the right of the landing area.</p><p>4. Three trials are performed.</p><p>5. The videos are evaluated as follows:</p><p>a. Knee fl exion angle at initial contact >30 degrees; 0 = yes, 1 = no</p><p>b. Knee valgus at initial contact, knees over midfoot; 0 = yes, 1 = no</p><p>c. Trunk fl exion angle at contact; 0 = trunk is fl exed, 1 = not fl exed</p><p>d. Lateral trunk fl exion at contact; 0 = trunk is vertical, 1 = not vertical</p><p>e. Ankle plantar fl exion at contact; 0 = toe to heel, 1 = no</p><p>f. Foot position at initial contact, toes > 30 degrees external rotation; 0 = no, 1 = yes</p><p>g. Foot position at initial contact, toes > 30 degrees internal rotation; 0 = no, 1 = yes</p><p>h. Stance width at initial contact < shoulder width; 0 = no, 1 = yes</p><p>i. Stance width at initial contact > shoulder width; 0 = no, 1 = yes</p><p>j. Initial foot contact symmetric; 0 = yes, 1 = no</p><p>Position</p><p>Movement</p><p>Continued on page 136</p><p>NASM_Chap06.indd 135NASM_Chap06.indd 135 7/5/2010 8:52:00 PM7/5/2010 8:52:00 PM</p><p>136 CHAPTER 6</p><p>k. Knee fl exion displacement (knee position before jumping), > 45 degrees; 0 = yes, 1 = no</p><p>l. Knee valgus displacement (knee position before jumping), knee inside great toe;</p><p>0 = no, 1 = yes</p><p>m. Trunk fl exion at maximal knee angle, trunk fl exed more than at initial contact;</p><p>0 = yes, 1 = no</p><p>n. Hip fl exion angle at initial contact, hips fl exed; 0 = yes, 1 = no</p><p>o. Hip fl exion at maximal knee angle, hips fl exed more than at initial contact; 0 = yes,</p><p>1 = no</p><p>p. Joint displacement, sagittal plane; 0 = soft, 1 = average, 2 = stiff</p><p>q. Overall impression; 0 = excellent, 1 = average, 2 = poor</p><p>6. A higher LESS score indicates a greater number of landing errors committed and there-</p><p>fore a higher risk for injury.</p><p>Although the above process for the LESS test will provide the health and fi tness profession-</p><p>al with the most comprehensive analysis of one’s functional status, this assessment may be</p><p>diffi cult to perform in some settings in which video cameras are not an option. In this case,</p><p>a modifi ed version of this assessment can be used to assess some of the primary compen-</p><p>sations that can be indicators of potential injury. In the modifi ed version, the health and</p><p>fi tness professional would view the individual from an anterior view. The primary compen-</p><p>sations to look for would include the:</p><p>1. Foot position:</p><p>a. Foot position at initial contact, toes > 30 degrees external rotation; 0 = no, 1 = yes</p><p>2. Knee position:</p><p>a. Knee valgus at initial contact, knees over midfoot; 0 = yes, 1 = no</p><p>b. Knee valgus displacement, knee inside great toe; 0 = no, 1 = yes</p><p>If these compensations are present, the professional can use Table 6-1 to determine</p><p>potential muscle imbalances that should be addressed through a corrective exercise</p><p>program.</p><p>TUCK JUMP TEST ➤</p><p>PURPOSE</p><p>The tuck jump exercise may be useful to the health and fi tness professional for the iden-</p><p>tifi cation of lower extremity technical fl aws during a plyometric activity (23,24). The tuck</p><p>jump requires a high effort level from the individual. Initially, the individual may place most</p><p>of his or her cognitive efforts solely on the performance of this diffi cult jump. The health</p><p>and fi tness professional may readily identify potential defi cits especially during the fi rst</p><p>few repetitions (23,24).</p><p>PROCEDURE</p><p>1. The individual performs repeated tuck jumps for 10 seconds (see the fi gure on</p><p>opposite page), which allows the health and fi tness professional to visually grade the</p><p>outlined criteria (23). To further improve the accuracy of the assessment, a standard</p><p>two-dimensional camera in the frontal and sagittal planes may be used to assist the</p><p>health and fi tness professional.</p><p>2. The individual’s techniques are subjectively rated as either having an apparent defi cit</p><p>(checked) or not. The movement defi cits to be evaluated are listed on the following page.</p><p>3. The defi cits are then tallied for the fi nal assessment score. Indicators of fl awed tech-</p><p>niques should be noted for each individual and should be the focus of feedback during</p><p>subsequent training sessions (23).</p><p>4. The individual’s baseline performance can be compared with repeated assessments</p><p>performed at the midpoint and conclusion of training protocols to objectively track</p><p>improvement with jumping and landing technique.</p><p>Movement</p><p>NASM_Chap06.indd 136NASM_Chap06.indd 136 7/5/2010 8:52:01 PM7/5/2010 8:52:01 PM</p><p>MOVEMENT ASSESSMENTS 137</p><p>Start Jump Land and Repeat</p><p>Tuck Jump Test</p><p>5. Empirical laboratory evidence suggests that individuals who do not improve their</p><p>scores, or who demonstrate six or more fl awed techniques, should be targeted for</p><p>further technique training (23).</p><p>TUCK JUMP ASSESSMENT OBSERVATIONS</p><p>Tuck Jump Assessment Pre Mid Post Comments</p><p>Knee and Thigh Motion</p><p>1. Lower extremity valgus at landing</p><p>2. Thighs do not reach parallel (peak of jump)</p><p>3. Thighs not equal side-to-side</p><p>(during fl ight)</p><p>Foot Position During Landing</p><p>4. Foot placement not shoulder width apart</p><p>5. Foot placement not parallel (front to back)</p><p>6. Foot contact timing not equal</p><p>7. Excessive landing contact noise</p><p>Plyometric Technique</p><p>8. Pause between jumps</p><p>9. Technique declines prior to 10 seconds</p><p>10. Does not land in same footprint (excessive</p><p>in-fl ight motion)</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>Total_____</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>Total_____</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>Total_____</p><p>Continued on page 138</p><p>NASM_Chap06.indd 137NASM_Chap06.indd 137 7/5/2010 8:52:01 PM7/5/2010 8:52:01 PM</p><p>138 CHAPTER 6</p><p>UPPER EXTREMITY DAVIES TEST ➤</p><p>PURPOSE</p><p>This assessment measures upper extremity agility and stabilization. This assessment may</p><p>not be suitable for individuals who lack shoulder stability.</p><p>PROCEDURE</p><p>1. Place two pieces of tape on the fl oor, 36 inches apart.</p><p>2. Have individual assume a push-up position, with one hand on each piece of tape.</p><p>Upper Extremity Davies Test, Position</p><p>1. Instruct individual to quickly move the right hand to touch the left hand.</p><p>2. Perform alternating touching on each side for 15 seconds.</p><p>3. Repeat for three trials.</p><p>4. Record the number of lines touched by both hands.</p><p>5. Reassess in the future to measure improvement of number of touches and improve-</p><p>ments in movement effi ciency.</p><p>Upper Extremity Davies Test, Movement</p><p>Position</p><p>Movement</p><p>NASM_Chap06.indd 138NASM_Chap06.indd 138 7/5/2010 8:52:04 PM7/5/2010 8:52:04 PM</p><p>MOVEMENT ASSESSMENTS 139</p><p>CHECKLIST FOR THE DAVIES TEST</p><p>Distance of</p><p>Points</p><p>Trial Number Time Repetitions</p><p>Performed</p><p>36 inches One 15 seconds</p><p>36 inches Two 15 seconds</p><p>36 inches Three 15 seconds</p><p>WHEN NOT TO PERFORM THE LESS, TUCK JUMP,</p><p>AND DAVIES TESTS</p><p>Although very helpful in uncovering movement deficien-</p><p>cies, these dynamic movement assessments may not be</p><p>appropriate for all populations. This is one reason why</p><p>subjective assessments, static posture, and transitional</p><p>movement assessments are important to perform before</p><p>dynamic assessments as these assessments can be used</p><p>to qualify one’s ability to perform these assessments.</p><p>For example, if an individual has difficulty performing</p><p>the single-leg squat assessment, then the LESS and tuck</p><p>jump tests may not be appropriate for that individual.</p><p>Or, if an individual exhibits poor scapular stability</p><p>during the push-up assessment, then the Davies test</p><p>should be discouraged. In these examples, the tran-</p><p>sitional movement assessments should provide all of</p><p>the answers necessary to begin developing a corrective</p><p>exercise strategy.</p><p>ASSESSMENT IMPLEMENTATION OPTIONS</p><p>Movement assessments are a key component in determining movement</p><p>efficiency and potential risks for injury. These assessments, along with previ-</p><p>ous and future assessments covered in this textbook, can help in designing a</p><p>specific corrective exercise program to enhance one’s functionality and overall</p><p>performance, thus decreasing the risk for injury. We reviewed a number of</p><p>example movement assessments in this chapter, and although all of them can</p><p>provide valuable information about your client, time is of the essence. So it</p><p>will be important to maximize your time by choosing assessments that will</p><p>provide you with the most amount of information in the least amount of time.</p><p>If time becomes an issue, the primary movement assessments that should be</p><p>performed in the assessment process are the overhead squat and the single-leg</p><p>squat. These assessments will provide you with the most information about</p><p>your client’s functional status in a relatively short time. The remaining assess-</p><p>ments (push-up, standing cable row, overhead dumbbell press, star excursion,</p><p>upper extremity, gait, LESS test, tuck jump, and Davies test) could be viewed</p><p>as secondary assessments and performed if time allowed.</p><p>A second option to consider is that all of the assessments covered in this</p><p>chapter can become one’s first workout. From this fi rst workout, the health and</p><p>fitness professional can obtain the necessary information about the individual.</p><p>The client will think he or she is getting a workout, but you as the health and</p><p>fitness professional are obtaining valuable information about the client’s struc-</p><p>tural integrity to help design and implement a corrective exercise program</p><p>specific to the needs of that client. It’s important to remember that depending</p><p>on one’s physical capabilities, not all assessments will be appropriate for all</p><p>clients, so only choose assessments that the individual can perform safely.</p><p>NASM_Chap06.indd 139NASM_Chap06.indd 139 7/5/2010 8:52:07 PM7/5/2010 8:52:07 PM</p><p>140 CHAPTER 6</p><p>Third, using these movement assessments could be a way to help build</p><p>your client base. Offering 30- to 45-minute “assessment sessions” that take</p><p>individuals through these assessments and a customized corrective exercise</p><p>program based on the assessment fi ndings can be a way to help generate rev-</p><p>enue as well as to potentially have individuals working with you long term.</p><p>SUMMARY • Movement assessments are the cornerstone of an integrated</p><p>assessment process (1,2). They allow the health and fi tness professional to</p><p>observe the length-tension relationships, force-couple relationships, and joint</p><p>motions of the entire kinetic chain.</p><p>With a thorough understanding of human movement science and the use</p><p>of the kinetic chain checkpoints to systematically detect compensation in joint</p><p>motion, inferences as to HMS impairments can be made (1–3,9,10). This data</p><p>can then be correlated to other assessments such as goniometric measure-</p><p>ments and manual muscle testing so that a comprehensive corrective strategy</p><p>can be developed.</p><p>References</p><p>1. Sahrmann SA. Diagnosis and Treatment of Movement</p><p>Impairment Syndromes. St. Louis, MO: Mosby; 2002.</p><p>2. Liebenson C. Integrated Rehabilitation Into Chiro-</p><p>practic Practice (blending active and passive care). In:</p><p>Liebenson C, ed. Rehabilitation of the Spine. Balti-</p><p>more, MD: Williams & Wilkins; 1996:13–43.</p><p>3. Comerford MJ, Mottram SL. Movement and stability</p><p>dysfunction—contemporary developments. Man Ther</p><p>2001;6(1):15–26.</p><p>4. Panjabi MM. The stabilizing system of the spine. Part</p><p>I: function, dysfunction, adaptation, and enhance-</p><p>ment. J Spinal Disord 1992;5(4):383–9.</p><p>5. Kendall FP, McCreary EK, Provance PG, Rodgers</p><p>MM, Romani WA. Muscles Testing and Function with</p><p>Posture and Pain. 5th ed. Baltimore, MD: Lippincott</p><p>Williams & Wilkins; 2005.</p><p>6. Janda V. Evaluation of Muscle Imbalances. In:</p><p>Liebenson C, ed. Rehabilitation of the Spine. Balti-</p><p>more, MD: Williams & Wilkins; 1996:97–112.</p><p>7. Sahrmann SA. Posture and muscle imbalance. Faulty</p><p>lumbar pelvic alignments. Phys Ther 1987;67:1840–4.</p><p>8. Powers CM. The infl uence of altered lower-extremity</p><p>kinematics on patellofemoral joint dysfunction: a</p><p>theoretical perspective. J Orthop Sports Phys Ther</p><p>2003;33(11):639–46.</p><p>9. Janda V. Muscles and Motor Control in Low Back</p><p>Pain: Assessment and Management. In: Twomey LT,</p><p>ed. Physical Therapy of the Low Back. Edinburgh:</p><p>Churchill Livingstone; 1987:253–78.</p><p>10. Janda V. Muscle Strength in Relation to Muscle</p><p>Length, Pain, and Muscle Imbalance. In: Harms-</p><p>Ringdahl, ed. International Perspectives in Physical</p><p>Therapy VIII. Edinburgh: Churchill Livingstone;</p><p>1993:83–91.</p><p>11. Edgerton VR, Wolf SL, Levendowski DJ, Roy RR.</p><p>Theoretical basis for patterning EMG amplitudes</p><p>to assess muscle dysfunction. Med Sci Sports Exerc</p><p>1996;28(6):744–51.</p><p>12. Neumann DA. Kinesiology of the Musculoskeletal</p><p>System: Foundations for Physical Rehabilitation. St.</p><p>Louis, MO: Mosby; 2002.</p><p>13. Zeller B, McCrory J, Kibler W, Uhl T. Differences in</p><p>kinematics and electromyographic activity between</p><p>men and women during the single-legged squat. Am J</p><p>Sports Med 2003;31:449–56.</p><p>14. Buckley BD, Thigpen CA, Joyce CJ, Bohres SM, Padua</p><p>DA. Knee and hip kinematics during a double leg</p><p>squat predict knee and hip kinematics at initial con-</p><p>tact of a jump landing task. J Athl Train 2007;42:S-81.</p><p>15. Ireland ML, Willson JD, Ballantyne BT, Davis IM. Hip</p><p>strength in females with and without patellofemoral</p><p>pain. J Orthop Sports Phys Ther 2003;33:671–6.</p><p>16. Vesci BJ, Padua DA, Bell DR, Strickland LJ, Guskiewicz</p><p>KM, Hirth CJ. Infl uence of hip muscle strength, fl ex-</p><p>ibility of hip and ankle musculature, and hip muscle</p><p>activation on dynamic knee valgus motion during a</p><p>double-legged squat. J Athl Train 2007;42:S-83.</p><p>17. Bell DR, Padua DA. Infl uence of ankle dorsifl exion</p><p>range of motion and lower leg muscle activation on</p><p>knee valgus during a double legged squat. J Athl Train</p><p>2007;42:S-84.</p><p>18. Herrington L, Hatcher J, Hatcher A, McNicholas M. A</p><p>comparison of star excursion balance test reach dis-</p><p>tances between ACL defi cient patients and asymptom-</p><p>atic controls. Knee 2009;16(2):149–52.</p><p>19. McKeon PO, Ingersoll CD, Kerrigan DC, Saliba E,</p><p>Bennett BC, Hertel J. Balance training improves func-</p><p>tion and postural control in those with chronic ankle</p><p>instability. Med Sci Sports Exerc 2008;40(10):1810–9.</p><p>20. Plisky PJ, Rauh MJ, Kaminski TW, Underwood FB.</p><p>Star excursion balance test as a predictor of lower</p><p>extremity injury in high school basketball players.</p><p>J Orthop Sports Phys Ther 2006;36(12):911–9.</p><p>21. DiStefano LJ, Padua DA, DiStefano MJ, Marshall SW.</p><p>Infl uence of age, sex, technique, and exercise program</p><p>on movement patterns after anterior cruciate ligament</p><p>NASM_Chap06.indd 140NASM_Chap06.indd 140 7/5/2010 8:52:07 PM7/5/2010 8:52:07 PM</p><p>MOVEMENT ASSESSMENTS 141</p><p>injury prevention in youth soccer players. Am J Sports</p><p>Med 2009;37(3):495–505.</p><p>22. Padua DA, Marshall SW, Boling MC, Thigpen CA,</p><p>Garrett WE, Beutler AI. The landing error scoring sys-</p><p>tem (LESS) is a valid and reliable clinical assessment</p><p>tool of jump-landing biomechanics: the JUMP-ACL</p><p>study. Am J Sports Med 2009;37(10):1996-2002.</p><p>23. Myer GD, Ford KR, Hewett TE. Tuck jump assessment</p><p>for reducing anterior cruciate ligament injury risk.</p><p>Athl Ther Today 2008;13(5):39–44.</p><p>24. Myer GD, Ford KR, Hewett TE. Rationale and clini-</p><p>cal techniques for anterior cruciate ligament injury</p><p>prevention among female athletes. J Athl Train</p><p>2004;39(4):352–364.</p><p>NASM_Chap06.indd 141NASM_Chap06.indd 141 7/5/2010 8:52:07 PM7/5/2010 8:52:07 PM</p><p>142</p><p>OBJECTIVES Upon completion of this chapter, you will be able to:</p><p>Identify the importance of achieving optimal ➤</p><p>range of motion in human movement.</p><p>Explain how the integrated function of the ➤</p><p>muscular, skeletal, and nervous systems collec-</p><p>tively infl uences the ability to move through a</p><p>full range of motion.</p><p>Discuss how a goniometer and an inclinometer ➤</p><p>can be used to measure joint range of motion</p><p>and why it is important for the health and fit-</p><p>ness professional to develop skill in taking</p><p>these measures.</p><p>Discuss the various components of a goniom- ➤</p><p>eter and specifi cally explain how to use this</p><p>instrument to measure joint range of motion.</p><p>Demonstrate the ability to measure joint range ➤</p><p>of motion at the foot, knee, hip, and shoulder</p><p>joints.</p><p>Explain how optimal range of motion at these ➤</p><p>joints correlates to the overhead squat and</p><p>single-leg squat assessments.</p><p>For each joint movement identifi ed, discuss ➤</p><p>the muscles being assessed, the antago-</p><p>nist muscles, positioning of the client, the</p><p>execution of the goniometric measurement,</p><p>common errors in measurement, and the</p><p>movement compensations to look for.</p><p>Range of Motion</p><p>Assessments</p><p>INTRODUCTION</p><p>OPTIMAL human movement requires optimum range of motion (ROM) at each</p><p>joint. The ability to identify proper and altered joint motion and muscle</p><p>lengths, correlate them to movement dysfunctions, and develop a method-</p><p>ological strategy is vital for all health and fitness professionals to develop safe</p><p>and effective corrective strategies for their clients. This chapter is intended to</p><p>guide the health and fitness professional in the assessment of joint ROM and</p><p>muscle length by using goniometric measurement.</p><p>C H A P T E R 7</p><p>NASM_Chap07.indd 142NASM_Chap07.indd 142 7/5/2010 8:52:37 PM7/5/2010 8:52:37 PM</p><p>RANGE OF MOTION ASSESSMENTS 143</p><p>THE SCIENTIFIC RATIONALE FOR GONIOMETRIC MEASUREMENT</p><p>Goniometric measurement is a major component of a comprehensive and</p><p>integrated assessment process (1–3). Other assessments in this integrated</p><p>approach include movement assessments and muscle strength (manual mus-</p><p>cle testing) (1,2).</p><p>The movement of a joint through its biomechanical ROM represents the</p><p>integrated functioning of the HMS (1,2,4). When operating correctly, this sys-</p><p>tem allows for optimal structural alignment, optimal neuromuscular control</p><p>(coordination), and optimal ROM to occur at each joint (5). This is essential to</p><p>help ensure proper length and strength of each muscle as well as optimal joint</p><p>ROM (1,6,7).</p><p>Precise neuromuscular control of ROM at each joint</p><p>will ultimately decrease excessive stress placed on the</p><p>body (1,2,4,8). Herein lies the importance of assessing</p><p>joint ROM. If one joint lacks proper ROM, then adja-</p><p>cent joints and tissues (above and/or below) must move</p><p>more to compensate for the dysfunctional joint ROM.</p><p>For example, if clients possess less than adequate ankle</p><p>dorsifl exion, they may be at greater risk of injury to the</p><p>knee (9,10), hip, or low back.</p><p>In all, each joint must exhibit proper ROM for the</p><p>effi cient transference of forces to accelerate, decelerate,</p><p>and stabilize the interconnected joints of the body and</p><p>produce optimal human movement.</p><p>The concept of human movement system impair-</p><p>ment is important to understand because it is essentially</p><p>what is being assessed with goniometric measurements.</p><p>As mentioned in chapter three, human movement system</p><p>impairments are an alteration in the ability of the muscu-</p><p>lar, nervous, and skeletal systems to function interdepen-</p><p>dently and effectively to perform their functional tasks</p><p>(8,11). Some muscles will become overactive, shortened,</p><p>and restrict joint motion whereas other muscles will</p><p>become underactive, lengthened, and not promote joint</p><p>motion (1,2,4,7,11,12). A noted decrease in the ROM of</p><p>a joint may signify overactive muscles, underactive mus-</p><p>cles, and/or altered arthrokinematics (3).</p><p>RANGE OF MOTION</p><p>Range of motion is the amount of motion available at a</p><p>specifi c joint. To understand ROM measurement a com-</p><p>plete understanding of the starting position is crucial. In</p><p>all motions except rotations, the body is in the anatomic</p><p>position (Figure 7-1). In this position, the body is at rest</p><p>at 0 degrees of fl exion, extension, abduction, and adduc-</p><p>tion. The ROM is affected by the type of motion applied</p><p>(passive or active).</p><p>Range of motion: the</p><p>amount of motion</p><p>available at a specifi c</p><p>joint.</p><p>Figure 7.1 Anatomic position.</p><p>NASM_Chap07.indd 143NASM_Chap07.indd 143 7/5/2010 8:52:37 PM7/5/2010 8:52:37 PM</p><p>144 CHAPTER 7</p><p>Passive range of motion is the amount obtained by the examiner without</p><p>any assistance by the client. In most normal subjects, passive ROM is slightly</p><p>greater than active ROM. Passive ROM provides information regarding joint-</p><p>play motion and physiologic end-feel to the movement. This helps create an</p><p>objective look at the articular surfaces of the joint as well as tissue extensibil-</p><p>ity of both contractile and noncontractile tissues.</p><p>Active range of motion refers to the amount of motion obtained solely</p><p>through voluntary contraction from the client. Active ROM can be determined</p><p>through the use of movement assessments such as the overhead squat assess-</p><p>ment. Information provided here includes muscular strength, neuromuscular</p><p>control, painful arcs, and overall functional abilities. Comparisons of passive</p><p>and active ROM provide a complete objective assessment of the articulations</p><p>and the soft tissue that envelops and moves it.</p><p>PHYSIOLOGIC END-FEEL</p><p>Some joints are constructed so that the joint capsule is the limiting factor</p><p>in movement, whereas other joints rely solely on ligamentous structures for</p><p>stability (Figure 7-2). The extent of passive ROM</p><p>is limited by the uniqueness</p><p>of the structure being evaluated. For example, a soft end-feel may acknowl-</p><p>edge the presence of edema. A fi rm end-feel may describe increased muscu-</p><p>lar tonicity or a normal ligamentous structure. This information is important</p><p>because it describes the integrity of the structures being evaluated. Initiat-</p><p>ing a training program that fails to correct mechanical movement fl aws and</p><p>Passive range of</p><p>motion: the amount</p><p>obtained by the exam-</p><p>iner without any assis-</p><p>tance by the client.</p><p>Active range of motion:</p><p>the amount of motion</p><p>obtained solely</p><p>through voluntary</p><p>contraction from the</p><p>client.</p><p>Synovial fluid:</p><p>lubricates the joint</p><p>Muscle</p><p>Tendon:</p><p>joins muscle to bone</p><p>enabling movement</p><p>Synovial membrane:</p><p>produces synovial fluid</p><p>Ligament:</p><p>joins bone to bone</p><p>Hyaline cartilage:</p><p>reduces friction, acts as</p><p>shock absorber</p><p>Fibrous joint</p><p>capsule</p><p>Figure 7.2 Joint stability.</p><p>NASM_Chap07.indd 144NASM_Chap07.indd 144 7/5/2010 8:52:38 PM7/5/2010 8:52:38 PM</p><p>RANGE OF MOTION ASSESSMENTS 145</p><p>neuromuscular effi ciency will create further dysfunction, and ultimately</p><p>further injury. Cookson and Kent (13) described physiologic and pathologic</p><p>(abnormal) end-feels (Table 7-1).</p><p>TECHNIQUES AND PROCEDURES</p><p>Competency and profi ciency in goniometric assessment requires the examiner</p><p>to acquire the following knowledge and skills to produce reliable and valid</p><p>measurements.</p><p>Knowledge of:</p><p>1. Recommended testing position</p><p>2. Alternative testing position</p><p>3. Anatomic bony landmarks</p><p>4. Normal end-feels</p><p>5. Instrument alignment</p><p>6. Stabilization techniques required</p><p>7. Joint structure and function</p><p>Required skills:</p><p>1. Move a part through the appropriate range of motion</p><p>2. Position and stabilize correctly</p><p>3. Palpate the appropriate bony landmarks</p><p>4. Align the goniometer correctly</p><p>5. Determine the end-feel of the ROM when performing passive ROM</p><p>6. Read the measurement correctly</p><p>7. Record the measurement correctly</p><p>Table 7.1 PATHOLOGIC (ABNORMAL) END-FEEL</p><p>End-Feel Description Examples</p><p>Soft Occurs later or earlier in the motion than</p><p>is normal, or in a joint which usually</p><p>has a fi rm or hard end-feel</p><p>Soft tissue edema</p><p>Synovitis</p><p>Firm Occurs later or earlier in the motion than</p><p>is normal, or in a joint that usually has</p><p>a hard or soft end-feel</p><p>Increased muscle tone</p><p>Capsular, ligamentous, or</p><p>muscular shortening</p><p>Hard Occurs later or earlier in the motion than</p><p>is normal, or in a joint that normally</p><p>has a soft or fi rm end-feel</p><p>Chondromalacia</p><p>Osteoarthritis</p><p>Loose bodies in joint space</p><p>Fracture</p><p>Empty No real end-feel because end of motion</p><p>is never reached owing to pain,</p><p>muscular guarding, or disruption in</p><p>ligamentous integrity</p><p>Acute joint infl ammation</p><p>Bursitis</p><p>Abscess</p><p>Fracture</p><p>NASM_Chap07.indd 145NASM_Chap07.indd 145 7/5/2010 8:52:40 PM7/5/2010 8:52:40 PM</p><p>146 CHAPTER 7</p><p>Testing Reliability and Validity</p><p>Objective information gained through goniometric assessment must be both reliable and</p><p>valid. Reliability refers to the amount of agreement between successive measurements.</p><p>The higher the agreement of the values, the higher the reliability. Two types of reliability</p><p>are important in goniometry. These are intratester and intertester reliability. Intratester</p><p>reliability refers to the amount of agreement between goniometric values obtained by the</p><p>same tester. Intertester reliability refers to the amount of agreement between goniomet-</p><p>ric values obtained by different testers. Validity of joint motion assessment refl ects how</p><p>closely the measurement represents the actual angle or total available ROM. An evaluation</p><p>that truly represents either the actual joint angle or available ROM is valid. Two successive</p><p>recordings may be reliable, but not always valid. Reliability and validity are each enhanced</p><p>when assessments (intertester and intratester) are performed using identical applications</p><p>and procedures.</p><p>GETTING YOUR FACTS STRAIGHT</p><p>Positioning</p><p>Positioning is an important part of goniometry. Proper positioning aligns the</p><p>joints in a zero starting position and helps to increase reliability and validity</p><p>of measurements. Positioning affects the amount of tension involving tissues</p><p>that surround a joint before adjusting ROM assessment.</p><p>Stabilization</p><p>The proximal joint structures must be properly stabilized before the goniomet-</p><p>ric assessments. Without correct stabilization, the measurement’s reliability</p><p>and validity are decreased. This stabilization is often applied by the examiner,</p><p>or through proper positioning and subject awareness and self-stabilization.</p><p>THE USE OF GONIOMETRIC MEASUREMENTS</p><p>Various devices for assessing joint ROM have been designed to accommodate</p><p>variations in the size of the joints and the complexity of movements in articu-</p><p>lations that involve more than one joint (14–16). Of these devices, the simplest</p><p>and most widely used is the goniometer (Figure 7-3). The goniometer is one</p><p>tool by which joint motion is measured (3). The use of goniometric measure-</p><p>ments enables health and fitness professionals to objectively determine the</p><p>available ROM at each particular joint. However,</p><p>accurate measurement of the joint ROM takes</p><p>some practice on the part of the health and fit-</p><p>ness professional. By passively moving a client’s</p><p>joint to an end-range (point of no further motion</p><p>or point of compensatory motion of that joint),</p><p>the available motion a client has can be com-</p><p>pared with normative ROM data to determine the</p><p>amount of restriction if any at that joint. Table 7-2</p><p>lists normal active joint ROM.</p><p>Body</p><p>Movement</p><p>arm</p><p>Stabilization</p><p>armAxis</p><p>Short end</p><p>Long end</p><p>Figure 7.3 Goniometer.</p><p>NASM_Chap07.indd 146NASM_Chap07.indd 146 7/5/2010 8:52:40 PM7/5/2010 8:52:40 PM</p><p>RANGE OF MOTION ASSESSMENTS 147</p><p>Goniometric measurements can be highly effective in helping determine</p><p>the cause and extent of restriction in joint ROM (3). This is especially true</p><p>when an active ROM assessment such as an overhead squat or single-leg squat</p><p>is performed before goniometric measurements (1,3). Furthermore, move-</p><p>ment assessments and goniometric measurements should precede testing for</p><p>muscle strength (manual muscle testing) to determine available ROM at the</p><p>joint being tested (3). The use of goniometric measurements also provides the</p><p>health and fitness professional with objective, reliable, and valid data neces-</p><p>sary to develop an evidence-based corrective strategy (3).</p><p>Table 7.2 SUMMARY OF NORMAL JOINT END RANGES OF MOTION</p><p>Joint Action Degrees of Motion</p><p>Shoulder</p><p>Flexion 160 degrees</p><p>Extension 50 degrees</p><p>Abduction 180 degrees</p><p>Internal rotation 45 degrees</p><p>External rotation 90 degrees</p><p>Elbow</p><p>Flexion 160 degrees</p><p>Extension 0 degrees</p><p>Forearm</p><p>Pronation 90 degrees</p><p>Supination 90 degrees</p><p>Wrist</p><p>Flexion 90 degrees</p><p>Extension 70 degrees</p><p>Radial deviation 20 degrees</p><p>Ulnar deviation 30 degrees</p><p>Hip</p><p>Flexion 120 degrees</p><p>Extension 0–10 degrees</p><p>Abduction 40 degrees</p><p>Adduction 15 degrees</p><p>Internal rotation 45 degrees</p><p>External rotation 45 degrees</p><p>Knee</p><p>Flexion 140 degrees</p><p>Extension (hip neutral) 0 degrees</p><p>Extension (hip fl exed) 20 degrees</p><p>Ankle</p><p>Plantarfl exion 45 degrees</p><p>Dorsifl exion 20 degrees</p><p>Foot</p><p>Inversion 30 degrees</p><p>Eversion 10 degrees</p><p>American Academy of Orthopaedic Surgeons. Joint Motion: Method of Measuring and Record-</p><p>ing. Chicago, IL: AAOS; 1983.</p><p>NASM_Chap07.indd 147NASM_Chap07.indd 147 7/5/2010 8:52:40 PM7/5/2010 8:52:40 PM</p><p>148 CHAPTER 7</p><p>A goniometer is essentially a large protractor with measurements in degrees.</p><p>Goniometers come in different shapes and sizes, and are made of a variety of</p><p>materials. However, they all adhere to the same basic design. A typical design</p><p>for a goniometer includes a body, axis, stabilization arm, and movement arm.</p><p>The body represents the arc of measurement. The goniometer in Figure 7-3 •</p><p>shows the measurement recorded in degrees of a circle (0–360 degrees).</p><p>The • axis (A) is the center of the goniometer and is the part that will be</p><p>placed on the imaginary joint line</p><p>(or axis of rotation for the joint).</p><p>The • stabilization arm (SA) is a structural part of the goniometer that is</p><p>attached to the body. This part of the goniometer will be placed on the sta-</p><p>ble, nonmoving limb or bony segment that forms the joint being measured.</p><p>The • movement arm (MA) is the only moving component of the goniometer.</p><p>It is placed on the moving limb of the joint being measure to provide the</p><p>measurement reading.</p><p>For ease of measurement, the body, axis, and stabilizing arm should be</p><p>placed directly on the client’s joint and stable, nonmoving limb (or closest to</p><p>the client’s body), and the movement arm of the goniometer should remain</p><p>on the outside, unimpeded and able to move freely. Reading the measurement</p><p>on the goniometer will come from either the short end of the movement arm</p><p>or the long end of the movement arm. The short end is considered the area</p><p>from the axis to the bottom of the movement arm. The long end is consid-</p><p>ered the area from the axis upward toward the “ruler” looking section of the</p><p>movement arm.</p><p>By aligning the two arms parallel to the longitudinal axis of the two seg-</p><p>ments involved in motion about a specifi c joint, it is possible to obtain rela-</p><p>tively accurate measures of ROM.</p><p>In some cases, the health and fitness professional may use an inclinom-</p><p>eter instead of a goniometer. (Figure 7-4). An inclinometer is a more precise</p><p>measuring instrument with high reliability that has most often been used in</p><p>research settings. Inclinometers are affordable and can easily be used to accu-</p><p>rately measure ROM of all joints of the body from complex movements of the</p><p>spine to simpler movements of the large joints of the extremities and the small</p><p>joints of fi ngers and toes (17,18).</p><p>Figure 7.4 Inclinometer.</p><p>(Text continues on page 164)</p><p>NASM_Chap07.indd 148NASM_Chap07.indd 148 7/5/2010 8:52:40 PM7/5/2010 8:52:40 PM</p><p>RANGE OF MOTION ASSESSMENTS 149</p><p>NASM SELECTED GONIOMETRIC MEASUREMENTS</p><p>There are many joints in the body and most all are able to be measured goniometrically.</p><p>However, NASM has only chosen a select number of joints to be measured. The following</p><p>measurements were selected because of their overall importance to optimal human move-</p><p>ment as well as their ability to correlate to the movement assessments. This following list is</p><p>by no means intended to be exhaustive. Rather, its intent is to be very practical and used as</p><p>part of an integrated assessment process.</p><p>LOWER EXTREMITY ➤</p><p>FOOT AND ANKLE COMPLEX</p><p>Dorsifl exion•</p><p>KNEE</p><p>Extension (90-degree hip/90-degree knee position)•</p><p>HIP COMPLEX</p><p>Flexion (bent knee)•</p><p>Abduction•</p><p>Internal rotation•</p><p>External rotation•</p><p>Extension•</p><p>UPPER EXTREMITY ➤</p><p>SHOULDER COMPLEX</p><p>Shoulder fl exion•</p><p>Glenohumeral internal rotation•</p><p>Glenohumeral external rotation•</p><p>FOOT AND ANKLE COMPLEX ➤</p><p>DORSIFLEXION</p><p>1. Joint motion being assessed:</p><p>a. Dorsifl exion of talocrural joint</p><p>2. Muscles being assessed:</p><p>a. Gastrocnemius and soleus</p><p>b. Posterior tibialis, peroneus longus, peroneus brevis, fl exor hallucis longus, fl exor</p><p>digitorum longus, plantaris</p><p>3. Antagonists potentially underactive if ROM is limited:</p><p>a. Anterior tibialis</p><p>b. Extensor digitorum longus, extensor digitorum brevis, extensor hallucis longus,</p><p>peroneus tertius</p><p>4. Normal Value (22): 20 degrees</p><p>The client is positioned supine with knee fully extended. The ankle is positioned in subtalar</p><p>neutral (0 degrees of inversion and eversion at the subtalar joint). Pinch the talar neck with</p><p>the thumb and index fi nger. Passively invert, then evert the foot until equal pressure is</p><p>noted at the thumb and index fi nger. The foot will appear to be slightly inverted because it</p><p>is in a nonweight-bearing position.</p><p>Positioning</p><p>Continued on page 150</p><p>NASM_Chap07.indd 149NASM_Chap07.indd 149 7/5/2010 8:52:41 PM7/5/2010 8:52:41 PM</p><p>150 CHAPTER 7</p><p>Dorsifl exion Assessment, Position</p><p>Place the goniometer as follows:</p><p>A• : Directly below the lateral malleolus near the base of the foot.</p><p>SA• : Lateral aspect of fi bula.</p><p>MA• : Midline of fi fth metatarsal.</p><p>Holding the plantar surface of the client’s foot (just below the metatarsophalangeal joints,</p><p>or “ball” of the foot), place the subtalar joint in neutral and guide the client as he or she</p><p>actively dorsifl exes the ankle while passively assisting the path of motion to the point of</p><p>fi rst resistance or compensation. The primary compensations to look for are eversion of the</p><p>ankle complex and/or fl exing of the knee during dorsifl exion. Have the client hold the posi-</p><p>tion and record measurement. Measurement is read at the long end of the movement arm</p><p>on the upper red number between 0 and 20.</p><p>Dorsifl exion Assessment, Measurement</p><p>Execution</p><p>NASM_Chap07.indd 150NASM_Chap07.indd 150 7/5/2010 8:52:41 PM7/5/2010 8:52:41 PM</p><p>RANGE OF MOTION ASSESSMENTS 151</p><p>Common errors that can occur during this measurement that must be avoided include</p><p>failure of the health and fitness professional to maintain a subtalar neutral position.</p><p>This measurement is typically restricted in a person who demonstrates foot compensations</p><p>(turning outward, fl attening, or heels rising) and/or an excessive forward lean during an</p><p>overhead squat assessment. Functional activities such as squatting into an average chair</p><p>(the depth for an overhead squat assessment) and running require 20 degrees of dorsifl ex-</p><p>ion at the ankle, while normal walking requires up to approximately 15 degrees (19,20). A</p><p>lack of dorsifl exion in the ankle has been shown to lead to knee injury (10).</p><p>KNEE ➤</p><p>EXTENSION (90 DEGREES OF HIP FLEXION, 90 DEGREES OF KNEE FLEXION)</p><p>1. Joint motion being assessed:</p><p>a. Extension of the tibiofemoral joint</p><p>b. Flexion of iliofemoral joint</p><p>2. Muscles being assessed:</p><p>a. Hamstring complex, gastrocnemius, neural tissue (sciatic nerve)</p><p>3. Antagonists potentially underactive if ROM is limited:</p><p>a. Hip fl exor complex</p><p>b. Quadriceps complex</p><p>4. Normal Value (22): 20 degrees</p><p>Client is positioned supine with the hip fl exed at 90 degrees and knee fl exed at 90 degrees.</p><p>Hip is in neutral (0 degrees of rotation, abduction, and adduction).</p><p>Knee Extension Assessment, Position</p><p>Place the goniometer as follows:</p><p>A• : Center the goniometer at the lateral joint line of the tibiofemoral joint.</p><p>SA• : Lateral midline of the femur.</p><p>MA• : Lateral midline of the fi bula.</p><p>Holding the client’s lower leg with one hand and his or her thigh with the other hand,</p><p>passively extend the knee until the fi rst restriction or compensation. The primary</p><p>Common Errors</p><p>Human Movement</p><p>System Impairment</p><p>Positioning</p><p>Execution</p><p>Continued on page 152</p><p>NASM_Chap07.indd 151NASM_Chap07.indd 151 7/5/2010 8:52:42 PM7/5/2010 8:52:42 PM</p><p>152 CHAPTER 7</p><p>compensations to look for will be posterior tilting of the pelvis or hip extension. Have the</p><p>client hold the position and record measurement. Measurement will be read from the short</p><p>end of the movement arm on the middle black numbers.</p><p>Knee Extension Assessment, Measurement</p><p>Common errors that can occur during this measurement that must be avoided include</p><p>failure of the health and fitness professional to maintain a neutral hip or thigh position or</p><p>moving the client into position too slowly, and an inability to see compensations.</p><p>This measurement may be restricted in a person who demonstrates feet turned out (ex-</p><p>ternally rotated), feet fl attening, knee moving inward (short head of biceps femoris), knees</p><p>moving outward (long head of biceps femoris), or low back rounding during the overhead</p><p>squat or single-leg squat assessments.</p><p>HIP COMPLEX ➤</p><p>HIP FLEXION (BENT KNEE)</p><p>1. Joint motion being assessed:</p><p>a. Flexion of iliofemoral joint</p><p>2. Muscles being assessed:</p><p>a. Gluteus maximus, adductor magnus, upper portion of hamstring complex</p><p>b. NOTE: If client reports a pinching sensation in the front of the hip during this assess-</p><p>ment, the psoas and/or rectus femoris may be overactive.</p><p>3. Antagonists potentially underactive if ROM is limited:</p><p>a. Hip fl exor complex</p><p>b. Hip extensor</p><p>complex (gluteus maximus)</p><p>4. Normal Value (22): 120 degrees</p><p>The client is positioned supine with the knee fully fl exed, and the hip is in neutral (0 de-</p><p>grees of abduction, adduction, and rotation). The knee is fl exed to shorten the hamstring</p><p>complex, which may have a limiting effect on hip fl exion.</p><p>Common Errors</p><p>Human Movement</p><p>System Impairment</p><p>Positioning</p><p>NASM_Chap07.indd 152NASM_Chap07.indd 152 7/5/2010 8:52:43 PM7/5/2010 8:52:43 PM</p><p>RANGE OF MOTION ASSESSMENTS 153</p><p>Hip Flexion (Bent Knee) Assessment, Position</p><p>Place the goniometer as follows:</p><p>A• : Center the goniometer at the lateral thigh using the greater trochanter as a reference.</p><p>SA• : Lateral midline of the pelvis and midaxillary line of the trunk.</p><p>MA• : Lateral midline of the femur.</p><p>Holding the client’s knee (tibial tuberosity), passively fl ex the hip to the point of fi rst</p><p>restriction or compensation. The primary compensation to look for is a posterior titling of</p><p>the pelvis, lifting of the contralateral leg off the table, or abduction of the femur. Have the</p><p>client hold the position and record measurement. Measurement is read at the short end of</p><p>the movement arm on the middle black numbers.</p><p>Hip Flexion (Bent Knee) Assessment, Measurement</p><p>Execution</p><p>Continued on page 154</p><p>NASM_Chap07.indd 153NASM_Chap07.indd 153 7/5/2010 8:52:44 PM7/5/2010 8:52:44 PM</p><p>154 CHAPTER 7</p><p>Common errors that can occur during this measurement that must be avoided include</p><p>failure of the health and fitness professional to maintain a neutral hip or thigh position or</p><p>moving the client into position too slowly, and an inability to see compensations.</p><p>This measurement may be restricted in a person who demonstrates rounding of the low</p><p>back during the overhead squat assessment. Sitting into a chair with an average seat</p><p>height (the depth of an overhead squat) requires approximately 112 degrees of bent knee</p><p>hip fl exion, and squatting is said to require approximately 115 degrees (21).</p><p>HIP ABDUCTION</p><p>1. Joint motion being assessed:</p><p>a. Abduction of iliofemoral joint</p><p>2. Muscles and ligaments being assessed:</p><p>a. Adductor complex, pubofemoral ligament, iliofemoral ligament, medial hip capsule</p><p>b. Medial hamstring complex</p><p>3. Antagonists potentially underactive if ROM is limited:</p><p>a. Gluteus medius, gluteus minimus, tensor fascia latae (TFL), sartorius</p><p>b. Biceps femoris</p><p>4. Normal Value (22): 40 degrees</p><p>The client is positioned supine with the knee extended. The hip is in neutral (0 degrees of</p><p>rotation, fl exion, and extension).</p><p>Hip Abduction Assessment, Positioning</p><p>Place the goniometer as follows:</p><p>A• : Center the goniometer at the ASIS (anterior superior iliac spine) of the extremity being</p><p>measured.</p><p>SA• : Imaginary line connecting one ASIS to the other ASIS.</p><p>MA• : Anterior midline of the femur, referencing the patellar midline.</p><p>Common Errors</p><p>Human Movement</p><p>System Impairment</p><p>Positioning</p><p>Execution</p><p>NASM_Chap07.indd 154NASM_Chap07.indd 154 7/5/2010 8:52:45 PM7/5/2010 8:52:45 PM</p><p>RANGE OF MOTION ASSESSMENTS 155</p><p>Holding the client’s lower leg, passively abduct the leg until the fi rst restriction or</p><p>compensation. The primary compensations to look for are motion in the opposite ASIS or</p><p>lateral fl exion of spine (or hip hike on the side of measurement). Have the client hold the</p><p>position and record measurement. Measurement is read from the short end of the move-</p><p>ment arm on the top red numbers between 0 and 40 degrees.</p><p>Hip Abduction Assessment, Measurement</p><p>Common errors that can occur during this measurement that must be avoided include</p><p>failure of the health and fitness professional to maintain a neutral hip or thigh position or</p><p>moving the client into position too slowly, and an inability to see compensations.</p><p>This measurement may be restricted in a person who demonstrates knees moving inward</p><p>or an asymmetric weight shift during the overhead squat or single-leg squat assessments.</p><p>HIP INTERNAL ROTATION</p><p>1. Joint motion being assessed:</p><p>a. Internal rotation of iliofemoral joint</p><p>2. Muscles and ligaments being assessed:</p><p>a. Piriformis and hip external rotators (gemellus superior, gemellus inferior, obturator</p><p>externus, obturator internus, quadratus femoris), adductor magnus (oblique fi bers),</p><p>ischiofemoral ligament</p><p>b. Gluteus medius (posterior fi bers), gluteus maximus</p><p>3. Antagonists potentially underactive if ROM is limited:</p><p>a. Adductor magnus (longitudinal fi bers), TFL, gluteus minimus, gluteus medius (ante-</p><p>rior fi bers), adductor longus, adductor brevis, pectineus, gracilis, medial hamstring</p><p>complex</p><p>4. Normal Value (22): 45 degrees</p><p>The client is positioned supine with the hip fl exed to 90 degrees and 0 degrees of abduc-</p><p>tion and adduction. The knee is also fl exed to 90 degrees.</p><p>Common Errors</p><p>Human Movement</p><p>System Impairment</p><p>Positioning</p><p>Continued on page 156</p><p>NASM_Chap07.indd 155NASM_Chap07.indd 155 7/5/2010 8:52:46 PM7/5/2010 8:52:46 PM</p><p>156 CHAPTER 7</p><p>Hip Internal Rotation Assessment, Positioning</p><p>Place the goniometer as follows:</p><p>A• : Center the goniometer over the anterior aspect of the patella.</p><p>SA• : Parallel to an imaginary line down the center of the body.</p><p>MA• : Anterior midline of the lower leg, referencing the tibial tuberosity.</p><p>Holding the client’s lower leg with one hand and the thigh with the other hand, passively</p><p>rotate the femur internally until the fi rst restriction or compensation. The primary com-</p><p>pensation to look for is a hip hike (lateral fl exion of spine) on the side of the measurement.</p><p>Have the client hold the position and record measurement. Measurement is read from the</p><p>long end of the movement arm on the middle black numbers.</p><p>Hip Internal Rotation Assessment, Measurement</p><p>Execution</p><p>NASM_Chap07.indd 156NASM_Chap07.indd 156 7/5/2010 8:52:47 PM7/5/2010 8:52:47 PM</p><p>RANGE OF MOTION ASSESSMENTS 157</p><p>Common errors that can occur during this measurement that must be avoided include</p><p>failure of the health and fitness professional to maintain a neutral hip or thigh position,</p><p>moving the client into position too slowly, and an inability to see compensations or</p><p>improper alignment of the stabilization arm.</p><p>This measurement may be restricted in a person who demonstrates knees moving inward</p><p>or outward or asymmetric weight shift during the overhead squat or single-leg squat</p><p>assessments.</p><p>HIP EXTERNAL ROTATION</p><p>1. Joint motion being assessed:</p><p>a. External rotation of iliofemoral joint</p><p>2. Muscles and ligaments being assessed:</p><p>a. Adductor magnus (longitudinal fi bers), iliofemoral ligament, pubofemoral ligament</p><p>b. TFL, gluteus minimus, gluteus medius (anterior fi bers)</p><p>3. Antagonists potentially underactive if ROM is limited:</p><p>a. Piriformis and hip external rotators (gemellus superior, gemellus inferior, obturator</p><p>externus, obturator internus, quadratus femoris), adductor magnus (oblique fi bers)</p><p>b. Gluteus medius (posterior fi bers), gluteus maximus</p><p>4. Normal Value (22): 45 degrees</p><p>The client is positioned supine with the hip fl exed to 90 degrees and 0 degrees of</p><p>abduction and adduction. The knee is also fl exed to 90 degrees.</p><p>Hip External Rotation Assessment, Position</p><p>Place the goniometer as follows:</p><p>A• : Center the goniometer over the anterior aspect of the patella.</p><p>SA• : Parallel to an imaginary line down the center of the body.</p><p>MA• : Anterior midline of the lower leg, referencing the tibial tuberosity.</p><p>Common Errors</p><p>Human Movement</p><p>System Impairment</p><p>Positioning</p><p>Execution</p><p>Continued on page 158</p><p>NASM_Chap07.indd 157NASM_Chap07.indd 157 7/5/2010 8:52:48 PM7/5/2010 8:52:48 PM</p><p>158 CHAPTER 7</p><p>Holding the client’s lower leg with one hand and the thigh with the other hand, passively</p><p>rotate the femur externally until the fi rst restriction or compensation. The primary com-</p><p>pensation to look for is motion in the opposite ASIS. Have the client hold the position and</p><p>record measurement. Measurement is read from the long end of the movement arm on</p><p>the middle black numbers.</p><p>Hip External Rotation Assessment, Measurement</p><p>Common errors that can occur during this measurement that must be avoided include</p><p>failure of the health and fitness professional to maintain a neutral hip or thigh position,</p><p>moving the client into position too slowly, and inability to see compensations or improper</p><p>alignment of the stabilization arm.</p><p>This measurement may be restricted in a person who demonstrates the knees mov-</p><p>ing inward or asymmetric weight shift during the overhead squat or single-leg squat</p><p>assessments.</p><p>HIP EXTENSION</p><p>1. Joint motion being assessed:</p><p>a. Extension of iliofemoral joint</p><p>2. Muscles and tissues being assessed:</p><p>a. Psoas, iliacus, rectus femoris, TFL, sartorius</p><p>b. Adductor complex, anterior hip capsule</p><p>3. Antagonists potentially underactive if ROM is limited:</p><p>a. Gluteus maximus, gluteus medius (posterior fi bers)</p><p>b. Hamstring complex, adductor magnus</p><p>4. Normal Value (22): 0–10 degrees</p><p>The client is positioned supine with the pelvis off the table. The opposite hip is fl exed to</p><p>assist in fl attening the low back against the table and rotating the pelvis posteriorly. The</p><p>knee of the test leg should be fl exed to almost 90 degrees.</p><p>Common Errors</p><p>Human Movement</p><p>System Impairment</p><p>Positioning</p><p>NASM_Chap07.indd 158NASM_Chap07.indd 158 7/5/2010 8:52:49 PM7/5/2010 8:52:49 PM</p><p>RANGE OF MOTION ASSESSMENTS 159</p><p>Hip Extension Assessment, Position</p><p>Place the goniometer as follows:</p><p>A• : Center the goniometer at the greater trochanter.</p><p>SA• : Lateral midline line of the trunk.</p><p>MA• : Lateral midline of the femur, referencing the lateral condyle.</p><p>Holding the client’s thigh, passively allow the hip to extend until fi rst restriction or com-</p><p>pensation. The primary compensation to look for is anterior tilting of the pelvis or low back</p><p>arching off the table. Have the client hold the position and record measurement. Measure-</p><p>ment is read at the short end of the movement arm on the middle black numbers.</p><p>Hip Extension Assessment, Measurement</p><p>Execution</p><p>Continued on page 160</p><p>NASM_Chap07.indd 159NASM_Chap07.indd 159 7/5/2010 8:52:50 PM7/5/2010 8:52:50 PM</p><p>160 CHAPTER 7</p><p>Many muscles can be implicated in this assessment and can be identifi ed by the compen-</p><p>sation noted at the hip and knee. Listed below are the possible scenarios for each muscle:</p><p>If the • psoas is the primary restriction the pelvis rotates anteriorly (low back begins to arch),</p><p>the thigh stays in a neutral position, and the knee remains fl exed.</p><p>If the • rectus femoris is the primary restriction, the pelvis rotates anteriorly, the thigh</p><p>remains neutral, and the knee extends.</p><p>If the • tensor fascia latae is the primary restriction, the pelvis rotates anteriorly, the thigh</p><p>abducts and internally rotates, and the knee extends via tension through the iliotibial</p><p>band.</p><p>If the • sartorius is the primary restriction, the pelvis rotates anteriorly, the thigh abducts</p><p>and externally rotates, and the knee remains fl exed.</p><p>If the • adductor complex is the primary restriction, the pelvis rotates anteriorly, the thigh</p><p>adducts, and the knee remains fl exed.</p><p>Common errors that can occur during this measurement that must be avoided include failure</p><p>of the health and fitness professional to maintain a neutral hip or thigh position (thigh tends to</p><p>abduct) or moving the client into position too slowly, and an inability to see compensations.</p><p>This measurement may be restricted in a person who demonstrates arching of the low</p><p>back or excessive forward lean during the overhead squat or single-leg squat assessments.</p><p>SHOULDER COMPLEX ➤</p><p>SHOULDER FLEXION</p><p>1. Joint motion being assessed:</p><p>a. Flexion of shoulder complex</p><p>2. Muscles being assessed:</p><p>a. Latissimus dorsi, teres major, teres minor, infraspinatus, subscapularis, pectoralis</p><p>major (lower fi bers), triceps (long head)</p><p>3. Antagonists potentially underactive if ROM is limited:</p><p>a. Anterior deltoid, pectoralis major (upper fi bers, clavicular fi bers), middle deltoid</p><p>b. Lower and middle trapezius, rhomboids</p><p>4. Normal Value (22): 160 degrees</p><p>The client is positioned supine with shoulder in neutral (0 degrees of abduction, adduction, and</p><p>rotation).</p><p>Shoulder Flexion Assessment, Position</p><p>Variations</p><p>Common Errors</p><p>Human Movement</p><p>System Impairment</p><p>Positioning</p><p>NASM_Chap07.indd 160NASM_Chap07.indd 160 7/5/2010 8:52:52 PM7/5/2010 8:52:52 PM</p><p>RANGE OF MOTION ASSESSMENTS 161</p><p>Place the goniometer as follows:</p><p>A• : Center the goniometer at the lateral shoulder, 1 inch distal to the acromion process.</p><p>SA• : Midaxillary line of the upper thorax.</p><p>MA• : Lateral midline of the humerus, referencing the lateral epicondyle of the humerus.</p><p>Holding the client’s arm in external rotation, place the thumb on the lateral border of the</p><p>scapula and passively fl ex the shoulder until excessive scapular movement is felt or the</p><p>fi rst resistance barrier is noted. Have the client hold the position and record measure-</p><p>ment. Measurement is read at the long end of the measurement arm on the middle black</p><p>numbers.</p><p>Shoulder Flexion Assessment, Measurement</p><p>Common errors that can occur during this measurement that must be avoided include</p><p>failure of the health and fitness professional to maintain a neutral shoulder position or</p><p>moving the client into position too slowly, and an inability to see or feel compensations.</p><p>This measurement may be restricted in a person who demonstrates arching of the low</p><p>back or arms falling forward during the overhead squat assessment or shows restrictions in</p><p>the shoulder fl exion wall test.</p><p>GLENOHUMERAL JOINT INTERNAL ROTATION</p><p>1. Joint motion being assessed:</p><p>a. Internal rotation of glenohumeral joint</p><p>2. Muscles being assessed:</p><p>a. Infraspinatus, teres minor, posterior glenohumeral joint capsule</p><p>3. Antagonists potentially underactive if ROM is limited:</p><p>a. Subscapularis, teres major, pectoralis major, latissimus dorsi, anterior deltoid</p><p>4. Normal Value (22): 45 degrees</p><p>The client is positioned supine with the humerus abducted at 90 degrees and the elbow</p><p>fl exed at 90 degrees. The forearm is in also at 0 degrees of supination and pronation so</p><p>that the palmar surface of the hand faces the ground during the measurement. The hu-</p><p>merus can be supported by a towel to maintain a level position aligned with the acromion.</p><p>Place the palm or heel of one hand on the client’s anterior shoulder.</p><p>Execution</p><p>Common Errors</p><p>Human Movement</p><p>System Impairment</p><p>Positioning</p><p>Continued on page 162</p><p>NASM_Chap07.indd 161NASM_Chap07.indd 161 7/5/2010 8:52:52 PM7/5/2010 8:52:52 PM</p><p>162 CHAPTER 7</p><p>Glenohumeral Joint Internal Rotation, Position</p><p>Place the goniometer as follows:</p><p>A• : Center the goniometer at the olecranon process of the elbow.</p><p>SA• : Align the arm to be perpendicular to the fl oor.</p><p>MA• : Align the arm with the lateral midline of the ulna, referencing the ulnar styloid and</p><p>olecranon process.</p><p>Holding the client’s arm, passively lower the humerus by applying downward pressure un-</p><p>til the fi rst resistance barrier or compensation is noted. The primary compensation to look</p><p>for is an upward migration of the humeral head into the hand over the anterior shoulder.</p><p>Have the client hold the position and record measurement. Measurement is read at the</p><p>long end of the measurement arm on the middle black numbers.</p><p>Glenohumeral Joint Internal Rotation, Measurement</p><p>Execution</p><p>NASM_Chap07.indd 162NASM_Chap07.indd 162 7/5/2010 8:52:53 PM7/5/2010 8:52:53 PM</p><p>RANGE OF MOTION ASSESSMENTS 163</p><p>Common errors that can occur during this measurement that must be avoided include</p><p>failure of the health and fitness professional to maintain a neutral shoulder position,</p><p>moving the client into position too slowly, and an inability to see compensations.</p><p>This measurement may be restricted in a person who demonstrates arms falling forward dur-</p><p>ing the overhead squat assessment or shows restrictions in the shoulder rotation wall test.</p><p>GLENOHUMERAL JOINT EXTERNAL ROTATION</p><p>1. Joint motion being assessed:</p><p>a. External rotation of glenohumeral joint</p><p>2. Muscles and tissues being</p><p>assessed:</p><p>a. Subscapularis, latissimus dorsi, teres major, pectoralis major, anterior deltoid, ante-</p><p>rior glenohumeral joint capsule</p><p>3. Antagonists potentially underactive if ROM is limited:</p><p>a. Infraspinatus, teres minor</p><p>4. Normal Value (22): 90 degrees</p><p>The client is positioned supine with the humerus abducted at 90 degrees and the elbow</p><p>fl exed at 90 degrees. The elbow is also at 0 degrees of supination and pronation so that the</p><p>palmar surface of the hand faces the ceiling during the measurement. The humerus is sup-</p><p>ported by a towel to maintain a level position aligned with the acromion process. Place the</p><p>palm or heel of one hand on the client’s anterior shoulder.</p><p>Glenohumeral Joint External Rotation, Position</p><p>Place the goniometer as follows:</p><p>A• : Center the goniometer at the olecranon process of the elbow.</p><p>SA• : Align the arm to be perpendicular to the fl oor.</p><p>MA• : Align the arm with the lateral midline of the ulna, referencing the ulnar styloid and</p><p>olecranon process.</p><p>Holding the client’s arm, passively lower the humerus into external rotation until the fi rst</p><p>resistance barrier or compensation is noted. The primary compensation to look for is an</p><p>upward migration of the humeral head into the hand over the anterior shoulder. Have the</p><p>Common Errors</p><p>Human Movement</p><p>System Impairment</p><p>Positioning</p><p>Execution</p><p>Continued on page 164</p><p>NASM_Chap07.indd 163NASM_Chap07.indd 163 7/5/2010 8:52:55 PM7/5/2010 8:52:55 PM</p><p>164 CHAPTER 7</p><p>client hold the position and record measurement. Measurement is read at the long end of</p><p>the measurement arm on the middle black numbers.</p><p>Glenohumeral Joint External Rotation, Measurement</p><p>Common errors that can occur during this measurement that must be avoided include fail-</p><p>ure of the health and fitness professional to maintain a neutral shoulder position, moving</p><p>the client into position too slowly, and an inability to see or feel compensations.</p><p>This measurement may be restricted in a person who demonstrates arms falling forward</p><p>during the overhead squat assessment or shows restrictions in the shoulder rotation wall</p><p>test.</p><p>Common Errors</p><p>Human Movement</p><p>System Impairment</p><p>SUMMARY • Measuring joint ROM is an important part in an integrated assess-</p><p>ment process. Using ROM assessments through the use of a goniometer or incli-</p><p>nometer can help in confi rming suspected reasons for movement compensa-</p><p>tions seen in the movement assessments. ROM assessments, in conjunction with</p><p>movement and muscle strength assessments, can also help pinpoint specifi c</p><p>regions of the body that must be addressed to assist the health and fitness pro-</p><p>fessional in designing an individualized corrective exercise program that meets</p><p>the needs of the client.</p><p>References</p><p>1. Sahrmann SA. Diagnosis and Treatment of Movement</p><p>Impairment Syndromes. St. Louis, MO: Mosby; 2002.</p><p>2. Liebenson C. Integrated Rehabilitation Into Chiro-</p><p>practic Practice (blending active and passive care).</p><p>In: Liebenson C, ed. Rehabilitation of the Spine.</p><p>Baltimore, MD: Williams & Wilkins; 1996:</p><p>13–43.</p><p>3. Norkin CC, White DJ. Measurement of Joint Motion:</p><p>A Guide to Goniometry. 3rd ed. Philadelphia, PA: FA</p><p>Davis; 2003.</p><p>4. Comerford MJ, Mottram SL. Movement and stability</p><p>dysfunction—contemporary developments. Man Ther</p><p>2001;6(1):15–26.</p><p>5. Panjabi MM. The stabilizing system of the spine. Part</p><p>I: function, dysfunction, adaptation, and enhance-</p><p>ment. J Spinal Disord 1992;5(4):383–9.</p><p>6. McCreary EK, Provance PG, Rogers MM, Rumani</p><p>WA. Muscles: Testing and Function with Posture and</p><p>Pain. 5th ed. Philadelphia, PA: Lippincott Williams &</p><p>Wilkins; 2005.</p><p>NASM_Chap07.indd 164NASM_Chap07.indd 164 7/5/2010 8:52:56 PM7/5/2010 8:52:56 PM</p><p>RANGE OF MOTION ASSESSMENTS 165</p><p>7. Janda V. Evaluation of Muscle Imbalances. In:</p><p>Liebenson C, ed. Rehabilitation of the Spine.</p><p>Baltimore, MD: Williams & Wilkins; 1996:97–112.</p><p>8. Sahrmann SA. Posture and muscle imbalance: faulty</p><p>lumbar-pelvic alignments. Phys Ther 1987;67:1840–4.</p><p>9. Lun V, Meeuwisse WH, Stergiou P, Stefanyshyn D.</p><p>Relation between running injury and static lower limb</p><p>alignment in recreational runners. Br J Sports Med</p><p>2004;38(5):576–80.</p><p>10. Powers CM. The infl uence of altered lower-extremity</p><p>kinematics on patellofemoral joint dysfunction: a</p><p>theoretical perspective. J Orthop Sports Phys Ther</p><p>2003;33(11):639–46.</p><p>11. Janda V. Muscle Strength in Relation to Muscle</p><p>Length, Pain, and Muscle Imbalance. In: Harms-</p><p>Ringdahl K, ed. International Perspectives in Physical</p><p>Therapy 8. Edinburgh: Churchill Livingstone; 1993:</p><p>83–91.</p><p>12. Janda V. Muscles and Motor Control in Low Back</p><p>Pain: Assessment and Management. In: Twomey LT,</p><p>ed. Physical Therapy of the Low Back. Edinburgh:</p><p>Churchill Livingstone; 1987:253–78.</p><p>13. Cookson JC, Kent BE. Orthopedic manual therapy—an</p><p>overview: part I. Phys Ther 1979;59:136–46.</p><p>14. American Academy of Orthopaedic Surgeons. Joint</p><p>Motion: Method of Measuring and Recording.</p><p>Chicago, IL: AAOS; 1983.</p><p>15. Kersey R. Measurement of joint motion: a guide to</p><p>goniometry. Athl Ther Today 2005;10(1):42.</p><p>16. American Medical Association. Guidelines to the</p><p>Evaluation to Permanent Impairment. 3rd ed. Chicago,</p><p>IL: AMA; 1988.</p><p>17. Clapis P, Davis SM, Davis RO. Reliability of inclinome-</p><p>ter and goniometric measurements of hip fl exor length</p><p>used during the Thomas test. J Orthop Sports Phys Ther</p><p>2006;36(1):135–41.</p><p>18. Mullaney M, Johnson C, Banz J. Reliability of active</p><p>shoulder range of motion comparing a goniometer to a</p><p>digital level. J Orthop Sports Phys Ther 2006;36(1):A80.</p><p>19. McPoil TG, Cornwall MW. Applied Sports Mechanics</p><p>in Rehabilitation Running. In: Zachazeweski JE, Magee</p><p>DJ, Quillen WS, eds. Athletic Injuries and Rehabilita-</p><p>tion. Philadelphia, PA: WB Saunders; 1996.</p><p>20. Ostrosky KM. A comparison of gait characteristics in</p><p>young and old subjects. Phys Ther 1994;74(7):637–44.</p><p>21. Magee DJ. Orthopedic Physical Assessment. 4th ed.</p><p>Philadelphia, PA: WB Saunders; 2002.</p><p>22. Greene WB, Heckman JD. American Academy of</p><p>Orthopedic Surgeons. The Clinical Measurement of</p><p>Joint Motion. Chicago, IL: AAOS; 1994.</p><p>23. Greene BL, Wolf SL. Upper extremity joint movement:</p><p>comparison of two measurement devices. Arch Phys</p><p>Med Rehabil 1989;70:288–90.</p><p>NASM_Chap07.indd 165NASM_Chap07.indd 165 7/5/2010 8:52:57 PM7/5/2010 8:52:57 PM</p><p>166</p><p>OBJECTIVES Upon completion of this chapter, you will be able to:</p><p>Explain the rationale for performing move- ➤</p><p>ment assessments.</p><p>Understand the difference between transi- ➤</p><p>tional and dynamic movement assessments.</p><p>Determine potential muscle imbalances based ➤</p><p>on certain movement compensations.</p><p>Design a corrective exercise strategy to ➤</p><p>improve movement impairments.</p><p>C H A P T E R 8</p><p>OBJECTIVES Upon completion of this chapter, you will be able to:</p><p>Understand the rationale for the use of manual ➤</p><p>muscle testing in an integrated assessment</p><p>process.</p><p>Demonstrate proper execution of manual ➤</p><p>muscle tests on select muscle groups.</p><p>Interpret the fi ndings seen in select manual ➤</p><p>muscle tests.</p><p>Determine proper corrective exercise strate- ➤</p><p>gies based on the fi ndings of an integrated</p><p>assessment process.</p><p>Strength</p><p>Assessments</p><p>INTRODUCTION</p><p>TO achieve optimal movement, muscles must be properly activated by the</p><p>nervous system. The ability of the neuromuscular system to produce internal</p><p>tension to overcome an external force is a simple defi nition of strength (1). Thus,</p><p>the ability of the nervous system to recruit and activate muscles dictates muscle</p><p>strength. Understanding muscle strength and how to assess it entails a compre-</p><p>hensive knowledge of human movement science, specifi cally functional anat-</p><p>omy, kinesiology, biomechanics, physiology, and motor control. The ability to</p><p>identify accurate muscle strength is an important assessment tool for the health</p><p>and fi tness professional to develop a safe and effective corrective strategy for</p><p>his or her clients. This chapter is intended to guide the health and fi tness profes-</p><p>sional in the assessment of muscle strength through the use of manual muscle</p><p>testing (MMT). It should be noted that one must be a qualifi ed health and fi tness</p><p>professional (i.e., a licensed professional) to apply MMT techniques on clients.</p><p>THE SCIENTIFIC RATIONALE FOR MANUAL MUSCLE TESTING</p><p>Manual muscle testing (MMT) is a major component of a comprehensive and</p><p>integrated assessment process (2–4). It involves the testing of muscle strength,</p><p>which can provide an indication of neuromuscular recruitment, as well as the</p><p>capability of the muscle to function during movement and provide stability (3).</p><p>Strength: the ability</p><p>of the neuromuscular</p><p>system to produce</p><p>internal tension to</p><p>overcome an external</p><p>force.</p><p>NASM_Chap08.indd Sec1:166NASM_Chap08.indd Sec1:166 7/5/2010 8:53:40 PM7/5/2010 8:53:40 PM</p><p>STRENGTH ASSESSMENTS 167</p><p>Although other methods of evaluating muscle function</p><p>exist that are more objective and reliable than MMT,</p><p>such as isokinetic testing (Figure 8-1) or handheld dyna-</p><p>mometry, MMT provides an opportunity to assess mus-</p><p>cle function with low cost and little diffi culty (3,5).</p><p>As mentioned in earlier chapters, each muscle must</p><p>exhibit normal strength with proper neuromuscular con-</p><p>trol to effectively accelerate, decelerate, and stabilize the</p><p>interconnected joints of the body and produce optimal</p><p>human movement. Optimal muscle strength and recruit-</p><p>ment can only be achieved through the integrated functioning of the skeletal,</p><p>muscular, and nervous systems (chapter two) (1,2,6,7). When operating cor-</p><p>rectly, these three systems allow for optimal structural alignment, neuromuscu-</p><p>lar control (coordination and recruitment), and range of motion to occur at each</p><p>joint (1,2,6,7). Coordination of these systems is essential to help ensure proper</p><p>muscle balance and strength of each muscle (1–4,7,8).</p><p>However, for many reasons, such as repetitive stress, impact trauma, disease, and</p><p>sedentary lifestyles, impairment to the human movement system can occur (2,3,8).</p><p>When impairment of the human movement system occurs, muscle balance, muscle</p><p>recruitment, and joint motion are altered (chapter three) (1,3,8,9). This impairment</p><p>affects the ability of the muscular, nervous, and skeletal systems to function inter-</p><p>dependently and effectively perform their functional tasks, which may ultimately</p><p>result in injury (1,8–11). For example, research has demonstrated that weakness of</p><p>hip abductors (i.e., gluteus medius) is associated with patellofemoral pain (10,11), ili-</p><p>otibial band (IT-band) syndrome (12), and overall lower extremity injury (13). Weak-</p><p>ness of the gluteus medius, which is</p><p>the primary frontal plane stabilizer</p><p>of the femur, is also associated with</p><p>overactivity (or synergistic domi-</p><p>nance) of the tensor fascia lata (TFL)</p><p>(2). The TFL attaches to the IT-band</p><p>and onto the lateral aspect of the tibia</p><p>via the IT-band. When overactive,</p><p>the TFL can cause increased tension</p><p>throughout the IT-band and lateral</p><p>knee (IT-band syndrome) (Figure 8-2).</p><p>Also, the TFL can cause external rota-</p><p>tion of the tibia, placing increased</p><p>stress on the tibiofemoral and patel-</p><p>lofemoral joints, which may result in</p><p>patellofemoral pain (14). The concept</p><p>of human movement system impair-</p><p>ment is important because it is what</p><p>the health and fi tness professional is</p><p>helping to identify with MMT.</p><p>THE NASM USE OF MANUAL MUSCLE TESTING</p><p>MMT is an assessment process used to test the recruitment capacity and con-</p><p>traction quality of individual muscles or movements (15). Although many</p><p>Isokinetic testing:</p><p>muscle strength test-</p><p>ing performed with a</p><p>specialized apparatus</p><p>that provides variable</p><p>resistance to a move-</p><p>ment, so that no mat-</p><p>ter how much effort is</p><p>exerted, the movement</p><p>takes place at a con-</p><p>stant speed. Such test-</p><p>ing is used to assess</p><p>and improve muscular</p><p>strength and endur-</p><p>ance, especially after</p><p>injury.</p><p>IT-band syndrome:</p><p>continual rubbing of</p><p>the IT band over the</p><p>lateral femoral epicon-</p><p>dyle leading to the area</p><p>becoming infl amed.</p><p>Dynamometry: the</p><p>process of measuring</p><p>forces at work using a</p><p>handheld instrument</p><p>(dynamometer) that</p><p>measures the force of</p><p>muscular contraction.</p><p>Figure 8.1 Isokinetic testing.</p><p>Iliotibial (IT)</p><p>band</p><p>Site of IT-band</p><p>pain and inflammation</p><p>Tensor</p><p>fascia latae</p><p>Gluteus</p><p>medius</p><p>and</p><p>maximus</p><p>Figure 8.2 IT-band syndrome.</p><p>NASM_Chap08.indd Sec1:167NASM_Chap08.indd Sec1:167 7/5/2010 8:53:40 PM7/5/2010 8:53:40 PM</p><p>168 CHAPTER 8</p><p>motions are the result of more than one muscle working, emphasis can be</p><p>placed on a particular muscle through proper positioning (3).</p><p>The premise behind MMT is to place the desired muscle in a position that</p><p>will induce resistance against it. This can be done with gravity or manual pres-</p><p>sure and through concentric or isometric muscle actions (3). The isometric</p><p>MMT process has been termed a break test and is said to be the most common</p><p>and easiest to perform (3). An isometric test is easier to perform and theoreti-</p><p>cally should be more reliable than a concentric test because confounding fac-</p><p>tors, such as speed of contraction and varying resistance in different positions</p><p>and directions, are removed (15).</p><p>The ability of the client to withstand various levels of resistance will ren-</p><p>der a specifi c grade, usually numerical, on a 0 to 5 scale (Table 8-1) (3).</p><p>Although a variety of methods and grading systems exist for MMT, NASM</p><p>has chosen to use a two-step isometric MMT process graded with a simple</p><p>3-point grading system (Table 8-2), as suggested by Kendall and colleagues (1).</p><p>More extensive grading systems are recommended when the purpose of the</p><p>MMT is to determine prognosis versus diagnosis or evaluation (3). The numeri-</p><p>cal grade of 3 represents a client who maintains good structural alignment and</p><p>holds the end-range position against the assessor’s pressure, which indicates a</p><p>pure isometric contraction is present (15). A grade of 2 represents a client with</p><p>good overall strength, but with compensations from other muscles or failure</p><p>to maintain the isometric contraction. This will be evident by alteration of the</p><p>body or limb position that occurs with increased pressure from the assessor. A</p><p>grade of 1 indicates little to no ability of the client to withstand or resist pressure</p><p>from the assessor.</p><p>The two-step process to assess muscle strength is used to help the health</p><p>and fi tness professional evaluate the possible cause of muscle weakness in a</p><p>client, which will direct corrective exercise strategies. Muscle weakness can</p><p>be attributable to several factors, but the most common factors in a healthy</p><p>individual are atrophy or inhibition (16). An inhibited muscle always produces</p><p>less counterpressure than requested by an examiner (15).</p><p>Step one of the NASM MMT process includes the following (Table 8-3):</p><p>Place the joint in the desired position for the specifi c muscle to be tested.•</p><p>Ask the client to hold that position while applying pressure against the •</p><p>limb directly in the line of pull for the desired muscle.</p><p>The pressure applied should be done in a ramping-up manner versus •</p><p>quickly applying maximum force.</p><p>The client must hold that position and not allow the assessor to “break” •</p><p>the hold. This should be held for 4 seconds.</p><p>Break test: at the end</p><p>of available range, or</p><p>at a point in the range</p><p>where the muscle is</p><p>most challenged, the</p><p>client is asked to hold</p><p>that position and not</p><p>allow the examiner to</p><p>“break” the hold with</p><p>manual resistance.</p><p>Table 8.1 MANUAL MUSCLE TESTING 6-POINT GRADING SYSTEM</p><p>Numerical Score Level of Strength</p><p>5 Normal</p><p>4 Good</p><p>3 Fair</p><p>2 Poor</p><p>1 Trace activity</p><p>0 No activity</p><p>NASM_Chap08.indd Sec1:168NASM_Chap08.indd Sec1:168 7/5/2010 8:53:42 PM7/5/2010 8:53:42 PM</p><p>STRENGTH ASSESSMENTS 169</p><p>Determine and grade the client’s level of strength.•</p><p>If the muscle tests normal with no compensation or movement, then the •</p><p>muscle is considered strong.</p><p>If the position breaks (muscle assumes an eccentric contraction) or if com-•</p><p>pensations</p><p>State University</p><p>Sports Physical Therapist - Coastal Therapy</p><p>Savannah, GA</p><p>and</p><p>Professor Emeritus</p><p>UW-LaCrosse</p><p>Sports Physical Therapist and Consultant</p><p>Sports Physical Therapy Residency Program</p><p>Gundersen Lutheran Sports Medicine</p><p>LaCrosse, WI</p><p>Darin A. Padua, PhD, ATC</p><p>Associate Professor</p><p>Director, Sports Medicine Research Laboratory</p><p>Department of Exercise and Sport Science</p><p>University of North Carolina at Chapel Hill</p><p>Chapel Hill, NC</p><p>NASM_FM.indd xviiNASM_FM.indd xvii 7/5/2010 8:47:33 PM7/5/2010 8:47:33 PM</p><p>Table of Contents</p><p>SECTION 1 Introduction to Corrective Exercise Training 1</p><p>CHAPTER 1 The Rationale for Corrective Exercises 2</p><p>Scott C. Lucett</p><p>CHAPTER 2 Introduction to Human Movement Science 8</p><p>Micheal A. Clark, Scott C. Lucett</p><p>CHAPTER 3 An Evidence-Based Approach to Understanding</p><p>Human Movement Impairments 62</p><p>Micheal A. Clark</p><p>SECTION 2 Assessing for Human Movement Dysfunction 82</p><p>CHAPTER 4 Health Risk Appraisal 83</p><p>Scott C. Lucett</p><p>CHAPTER 5 Static Postural Assessments 92</p><p>Marjorie A. King</p><p>CHAPTER 6 Movement Assessments 105</p><p>Micheal A. Clark, Scott C. Lucett</p><p>CHAPTER 7 Range of Motion Assessments 142</p><p>William Prentice</p><p>CHAPTER 8 Strength Assessments 166</p><p>Lindsay Distefano</p><p>SECTION 3 The Corrective Exercise Continuum 196</p><p>CHAPTER 9 Inhibitory Techniques: Self-Myofascial</p><p>Release 197</p><p>Russell D. Fiore</p><p>CHAPTER 10 Lengthening Techniques 210</p><p>Melanie McGrath</p><p>CHAPTER 11 Activation and Integration Techniques 230</p><p>Michael Rosenberg</p><p>SECTION 4 Corrective Exercise Strategies 251</p><p>CHAPTER 12 Corrective Strategies for Foot and Ankle</p><p>Impairments 252</p><p>Cathleen N. Brown</p><p>NASM_FM.indd xviiiNASM_FM.indd xviii 7/5/2010 8:47:34 PM7/5/2010 8:47:34 PM</p><p>CHAPTER 13 Corrective Strategies for Knee</p><p>Impairments 267</p><p>Gregory D. Myer</p><p>CHAPTER 14 Corrective Strategies for Lumbo-Pelvic-Hip</p><p>Impairments 290</p><p>Kim D. Christensen, Jeff Tucker</p><p>CHAPTER 15 Corrective Strategies for Shoulder, Elbow and</p><p>Wrist Impairments 316</p><p>Chuck Thigpen</p><p>CHAPTER 16 Corrective Strategies for Cervical Spine</p><p>Impairments 351</p><p>Kim D. Christensen, Jeff Tucker</p><p>APPENDIX A Sample Corrective Exercise Program</p><p>Strategies 369</p><p>APPENDIX B A Guide to Common Myofascial</p><p>Dysfunction 382</p><p>GLOSSARY 388</p><p>INDEX 405</p><p>NASM_FM.indd xixNASM_FM.indd xix 7/5/2010 8:47:34 PM7/5/2010 8:47:34 PM</p><p>NASM_FM.indd xxNASM_FM.indd xx 7/5/2010 8:47:34 PM7/5/2010 8:47:34 PM</p><p>INTRODUCTION TO</p><p>CORRECTIVE EXERCISE</p><p>TRAINING</p><p>CHAPTER 1: The Rationale for</p><p>Corrective Exercises</p><p>CHAPTER 2: Introduction to Human</p><p>Movement Science</p><p>CHAPTER 3: An Evidence-</p><p>Based Approach to</p><p>Understanding Human</p><p>Movement Impairments</p><p>SECTION 1</p><p>NASM_Chap01.indd 1NASM_Chap01.indd 1 7/5/2010 8:45:28 PM7/5/2010 8:45:28 PM</p><p>2</p><p>OBJECTIVES Upon completion of this chapter, you will be able to:</p><p>Understand the state of today’s typical client. ➤</p><p>Be familiar with injury rates of today and ➤</p><p>rationalize the need for corrective exercise.</p><p>Understand and describe the Corrective ➤</p><p>Exercise Continuum.</p><p>The Rationale for</p><p>Corrective Exercises</p><p>INTRODUCTION</p><p>FROM the mid-1980s to the present, the wealth of technology and automation</p><p>in the United States has begun to take a toll on public health. The work</p><p>and home environments are inundated with automation, personal comput-</p><p>ers, cell phones, and other technology that are more prevalent today than</p><p>ever before. Housekeepers, gardeners, remote controls, and video games</p><p>now run a household. People are less active and are no longer spending as</p><p>much of their free time engaged in physical activity (1). Physical education</p><p>and after-school sports programs are being cut from school budgets, fur-</p><p>ther decreasing the amount of physical activity in children’s lives. Today,</p><p>approximately one third (33.8%) of adults are estimated to be obese (2).</p><p>This also carries over to the adolescent population, with 18% of adolescents</p><p>and teenagers considered overweight (3). This new environment is produc-</p><p>ing more inactive, less healthy, and nonfunctional people (4) who are more</p><p>prone to injury.</p><p>RATIONALE FOR CORRECTIVE EXERCISE</p><p>Research suggests that musculoskeletal pain is more common now than it was</p><p>40 years ago (5). This lends support to the concept that decreased activity may</p><p>lead to muscular dysfunction and, ultimately, injury.</p><p>C H A P T E R 1</p><p>NASM_Chap01.indd 2NASM_Chap01.indd 2 7/5/2010 8:45:29 PM7/5/2010 8:45:29 PM</p><p>THE RATIONALE FOR CORRECTIVE EXERCISES 3</p><p>Foot and Ankle Injuries</p><p>In the general population, plantar fasciitis accounted for more than 1 million</p><p>ambulatory care (doctor) visits per year (6). Ankle sprains are reported to be</p><p>the most common sports-related injury (7). Individuals who suffer a lateral</p><p>ankle sprain are at risk for developing chronic ankle instability (8). It has</p><p>also been shown that individuals may experience hip weakness after an ankle</p><p>sprain (9).</p><p>Low-Back Pain</p><p>Low-back pain is one of the major forms of musculoskeletal degeneration seen</p><p>in the adult population, affecting nearly 80% of all adults (10, 11). Research</p><p>has shown low-back pain to be predominant among workers in enclosed</p><p>workspaces (such as offi ces) (12, 13), as well as in people engaged in manual</p><p>labor (farming) (14), in people who sit for periods greater than 3 hours (13),</p><p>and in people who have altered lumbar lordosis (curve in the lumbar spine)</p><p>(15). More than one third of all work-related injuries involve the trunk, and of</p><p>these, more than 60% involve the low back (16). These work-related injuries</p><p>cost workers approximately 9 days per back episode or, combined, more than</p><p>39 million days of restricted activity. It has been estimated that the annual</p><p>costs attributable to low-back pain in the United States are greater than $26</p><p>billion (16). In addition, 6 to 15% of athletes experience low-back pain in a</p><p>given year (17, 18).</p><p>Knee Injuries</p><p>The incidence of knee injuries is also a concern. An estimated 80,000 to</p><p>100,000 anterior cruciate ligament (ACL) injuries occur annually in the gen-</p><p>eral U.S. population. Approximately 70 to 75% of these are noncontact inju-</p><p>ries (19–25). In addition, ACL injuries have a strong correlation to acquiring</p><p>arthritis in the affected knee (26). Most ACL injuries occur between 15 and 25</p><p>years of age (19). This comes as no surprise when considering the lack of activ-</p><p>ity and increased obesity occurring in this age group owing to the abundance</p><p>of automation and technology, combined with a lack of mandatory physical</p><p>education in schools (4).</p><p>Shoulder Injuries</p><p>Shoulder pain is reported to occur in up to 21% of the general population (27,</p><p>28), with 40% persisting for at least 1 year (29) at an estimated annual cost</p><p>of $39 billion (30). Shoulder impingement is the most prevalent diagnosis,</p><p>accounting for 40 to 65% of reported shoulder pain. The persistent nature</p><p>of shoulder pain may be the result of degenerative changes to the shoulder’s</p><p>capsuloligamentous structures, articular cartilage, and tendons as the result of</p><p>altered shoulder mechanics.</p><p>With this growing population of untrained or undertrained individuals, it</p><p>is important to ensure that all components of their bodies are properly prepared</p><p>for the stress that will be placed on them both inside and outside of the gym.</p><p>NASM_Chap01.indd 3NASM_Chap01.indd 3 7/5/2010 8:45:29 PM7/5/2010 8:45:29 PM</p><p>4 CHAPTER 1</p><p>Unfortunately, many training programs for conditioning the musculoskeletal</p><p>system often neglect proper training guidelines and do not address potential</p><p>muscle imbalances one may possess from a sedentary lifestyle. This can result</p><p>in a weakened structure and lead to injury.</p><p>Simply put, the extent to which we condition our musculoskeletal system</p><p>directly infl uences our risk of injury. The less conditioned our musculoskeletal</p><p>systems are, the higher the risk of injury (31). Therefore, as our daily lives</p><p>include less physical activity, the less prepared we are to partake in recre-</p><p>ational and leisure activities such as resistance training, weekend sports, or</p><p>simply playing</p><p>are observed, move to step two.</p><p>Step two involves the same process as step one, but involves lengthening</p><p>of the muscle by placing the muscle in a midrange position. The reason for</p><p>this second step involves simple joint mechanics. If muscles are shortening on</p><p>one side of the joint, then muscles on the opposing side must be lengthening.</p><p>If these lengthening muscles do not have the proper extensibility (ability to</p><p>elongate), they will limit the functional capacity of the opposing muscle group</p><p>(in this case the muscles being tested in the shortened position). This has been</p><p>noted by several authors (2,3,7) and is known as altered reciprocal inhibition.</p><p>It is important to note that although tight muscles may be the cause of a mus-</p><p>cle’s weakness in a shortened position, restrictions in skin, neural tissue, or</p><p>articular ligaments and tissues can also result in muscle inhibition (15).</p><p>Overactivity of a shortened muscle will reciprocally inhibit its functional</p><p>antagonist (2,3,8). This inhibition can lead to a false reading that a muscle is</p><p>weak when in fact the strength impression is purely a factor of joint position. If</p><p>the muscle tests normal (strong) in the midrange, then there is either a muscle</p><p>length issue on the opposing side of the joint or possibly a joint restriction (15).</p><p>In this situation, the health and fi tness professional can easily assess muscle</p><p>length through goniometric measurement, address the muscle with appropriate</p><p>fl exibility techniques (inhibit and lengthen), and retest the muscle strength.</p><p>An example of this can be seen in a weak or underactive gluteus medius.</p><p>If the adductor complex is overactive and restricting proper hip abduction,</p><p>extension, and external rotation, the gluteus medius will be limited (inhibited)</p><p>in its functional ability. This will often lead to overactivity (synergistic domi-</p><p>nance) of the TFL (2,9). When the adductor complex (and TFL, if necessary)</p><p>is addressed with proper fl exibility and the strength of the gluteus medius is</p><p>Table 8.2 NASM 3-POINT GRADING SYSTEM</p><p>Numerical Score Level of Strength</p><p>3 Normal</p><p>2 Compensates (uses other muscles)</p><p>1 Weak (little to no activity)</p><p>Table 8.3 NASM 2-STEP MANUAL MUSCLE TESTING PROCESS</p><p>Step 1 Step 2</p><p>Place muscle in shortened position, or to point of joint •</p><p>compensation.</p><p>Ask client to hold that position while applying pressure.•</p><p>Gradually increase pressure.•</p><p>Client’s strength is graded•</p><p>If client can hold the position without compensation, •</p><p>then the muscle is noted as strong.</p><p>If the muscle is weak or compensates, move to step 2.•</p><p>Place muscle in midrange position and retest •</p><p>strength.</p><p>If muscle strength is normal in midrange, •</p><p>there may be opposing muscle overactivity or</p><p>joint hypomobility—inhibit and lengthen.</p><p>If the muscle is weak or compensates in mid-•</p><p>range position, the muscle is likely weak—</p><p>reactivate and reintegrate.</p><p>NASM_Chap08.indd Sec1:169NASM_Chap08.indd Sec1:169 7/5/2010 8:53:42 PM7/5/2010 8:53:42 PM</p><p>170 CHAPTER 8</p><p>regained, then the underlying problem may not be true muscle weakness, but</p><p>altered reciprocal inhibition caused by an antagonist muscle group (adductors</p><p>and TFL). If the muscle still tests weak or compensates in the midrange posi-</p><p>tion, then it is likely that true muscle weakness exists. In this case, the health</p><p>and fi tness professional should reactivate the muscle and then reintegrate it</p><p>back into its functional synergy.</p><p>NASM SELECTED MANUAL MUSCLE TESTS</p><p>There are many muscles in the body that can be evaluated with MMT. However,</p><p>NASM has only chosen a select number of muscles to be tested (Table 8-4).</p><p>The following muscles were selected because of their overall importance to</p><p>optimal human movement, as well as their ability to correlate to the move-</p><p>ment assessments and goniometric measurements. The following list is by no</p><p>means intended to be exhaustive. Rather, its intent is to be very practical and</p><p>used in an integrated assessment process. Refer to chapter two of this textbook</p><p>for details on muscle location and integrated function.</p><p>Any MMT has limitations with variability and subjectivity. The health and</p><p>fi tness professional should remember that MMT only measures the force pro-</p><p>duced during a specifi c isometric movement in a specifi c position. To improve</p><p>reliability and safety, as well as reduce errors with an MMT assessment, the</p><p>following guidelines should be followed:</p><p>The same health and fi tness professional should be used with a single •</p><p>client to reduce intertester variability.</p><p>Do not test a muscle in a fully lengthened position because it can lead to •</p><p>overstretching and injury.</p><p>Ensure proper position of the joint before performing the test.•</p><p>Ensure proper stabilization to minimize compensations.•</p><p>Establish a time (4 seconds) for the client to hold the isometric muscle contraction.•</p><p>Table 8.4 NASM SELECTED MANUAL MUSCLE TESTS</p><p>Lower Extremity Trunk Upper Extremity and</p><p>Cervical Spine</p><p>Foot/Ankle</p><p>Anterior tibialis•</p><p>Posterior tibialis•</p><p>Knee</p><p>Medial hamstring complex•</p><p>Biceps femoris•</p><p>Hip</p><p>Iliopsoas•</p><p>Tensor fascia lata•</p><p>Sartorius•</p><p>Adductor complex•</p><p>Gracilis•</p><p>Adductor magnus•</p><p>Gluteus medius•</p><p>Hip external rotators•</p><p>Gluteus maximus•</p><p>Rectus abdominis•</p><p>Oblique abdomi-•</p><p>nals</p><p>Latissimus dorsi•</p><p>Shoulder external rotators•</p><p>Shoulder internal rotators•</p><p>Rhomboids•</p><p>Lower trapezius•</p><p>Serratus anterior•</p><p>Anterior neck fl exors•</p><p>Anterolateral neck fl exors•</p><p>Posterolateral neck •</p><p>extensors</p><p>NASM_Chap08.indd Sec1:170NASM_Chap08.indd Sec1:170 7/5/2010 8:53:42 PM7/5/2010 8:53:42 PM</p><p>STRENGTH ASSESSMENTS 171</p><p>Continued on page 172</p><p>Provide gradual increases in pressure at a constant speed.•</p><p>Manual resistance should be applied at a 90-degree angle to the primary •</p><p>axis of a body part (17).</p><p>Both the client and health and fi tness professional should be in comfort-•</p><p>able and stable positions.</p><p>MANUAL MUSCLE TESTS</p><p>FOOT AND ANKLE COMPLEX ➤</p><p>ANTERIOR TIBIALIS</p><p>1. Joint position being tested:</p><p>a. Dorsifl exion and inversion of ankle</p><p>2. Muscles being assessed:</p><p>a. Anterior tibialis (prime mover)</p><p>b. Extensor digitorum longus, extensor hallucis longus, peroneus tertius (synergists)</p><p>3. Potentially overactive muscles if strength is limited:</p><p>a. Gastrocnemius, soleus, peroneus longus, peroneus brevis</p><p>Client is supine with knee extended. Place ankle in dorsifl exion and inversion.</p><p>• Support the posterior lower leg just above the ankle.</p><p>Instruct client to “hold” the position.•</p><p>Apply gradual and increasing pressure to the medial dorsal surface of the foot in the •</p><p>direction of plantarfl exion and eversion.</p><p>Look for compensations of the toes extending or foot everting.•</p><p>Grade client’s strength: 3 = normal, 2 = compensates, 1 = weak.•</p><p>If graded 1 or 2, take client’s foot or ankle into a midrange and retest.•</p><p>Anterior Tibialis Assessment, Execution</p><p>Positioning</p><p>Execution</p><p>(Text continues on page 195)</p><p>NASM_Chap08.indd Sec1:171NASM_Chap08.indd Sec1:171 7/5/2010 8:53:42 PM7/5/2010 8:53:42 PM</p><p>172 CHAPTER 8</p><p>This muscle may be weak in a person who demonstrates fl attening of the feet (excessive prona-</p><p>tion) during the overhead squat assessment. It may also appear weak at the end-range if there</p><p>is limited dorsifl exion measured by goniometric measurement, which can be caused by overac-</p><p>tivity in the gastrocnemius or soleus, as well as the peroneus longus and peroneus brevis.</p><p>POSTERIOR TIBIALIS</p><p>1. Joint position being tested:</p><p>a. Plantarfl exion and inversion of ankle</p><p>2. Muscles being assessed:</p><p>a. Posterior tibialis</p><p>b. Anterior tibialis, fl exor digitorum longus, fl exor hallucis longus, soleus, extensor hal-</p><p>lucis longus</p><p>3. Potentially overactive muscles if strength is limited:</p><p>a. Peroneus longus, brevis and tertius, extensor digitorum longus and brevis</p><p>b. Lateral gastrocnemius</p><p>Client is supine with knee extended. Place ankle in plantarfl exion and inversion.</p><p>• Support the posterior lower leg just above the ankle.</p><p>Instruct client to “hold” the position.•</p><p>Apply gradual and increasing</p><p>on the playground.</p><p>THE FUTURE</p><p>There is a general inability to meet the needs of today’s client and athlete. The</p><p>health and fi tness industry has only recently recognized the trend toward non-</p><p>functional living. Health and fi tness professionals are now noticing a decrease</p><p>in the physical functionality of their clients and athletes and are beginning to</p><p>address it.</p><p>This is a new state of training, in which the client has been physically</p><p>molded by furniture, gravity, and inactivity. The continual decrease in every-</p><p>day activity has contributed to many of the postural defi ciencies seen in peo-</p><p>ple (32). Today’s client is not ready to begin physical activity at the same level</p><p>that a typical client could 20 years ago. Therefore, today’s training programs</p><p>cannot stay the same as programs of the past.</p><p>The new mindset in fi tness should cater to creating programs that address</p><p>functional capacity as part of a safe program designed especially for each indi-</p><p>vidual person. In other words, training programs must consider each person,</p><p>their environment, and the tasks that will be performed. It will also be impor-</p><p>tant to address any potential muscle imbalances and movement defi ciencies</p><p>that one may possess to improve function and decrease the risk of injury. This</p><p>is best achieved by introducing an integrated approach to program design. It</p><p>is on this premise that the National Academy of Sports Medicine (NASM) pres-</p><p>ents the rationale for the Corrective Exercise Continuum and its importance to</p><p>integrate into today’s exercise programs.</p><p>THE CORRECTIVE EXERCISE CONTINUUM</p><p>Corrective exercise is a term used to describe the systematic process of iden-</p><p>tifying a neuromusculoskeletal dysfunction, developing a plan of action and</p><p>implementing an integrated corrective strategy. This process requires knowl-</p><p>edge and application of an integrated assessment process, corrective program</p><p>design, and exercise technique. Collectively, the three-step process is to:</p><p>1. Identify the problem (integrated assessment)</p><p>2. Solve the problem (corrective program design)</p><p>3. Implement the solution (exercise technique)</p><p>Solving the identifi ed neuromusculoskeletal problems will require a</p><p>systematic plan. This plan is known as the Corrective Exercise Continuum</p><p>Corrective exercise: a</p><p>term used to describe</p><p>the systematic pro-</p><p>cess of identifying a</p><p>neuromusculoskeletal</p><p>dysfunction, develop-</p><p>ing a plan of action,</p><p>and implementing an</p><p>integrated corrective</p><p>strategy.</p><p>Corrective Exercise</p><p>Continuum: the</p><p>systematic program-</p><p>ming process used to</p><p>address neuromuscu-</p><p>loskeletal dysfunction</p><p>through the use of</p><p>inhibitory, lengthening,</p><p>activation, and integra-</p><p>tion techniques.</p><p>NASM_Chap01.indd 4NASM_Chap01.indd 4 7/5/2010 8:45:29 PM7/5/2010 8:45:29 PM</p><p>THE RATIONALE FOR CORRECTIVE EXERCISES 5</p><p>(Figure 1-1) and will specifi cally outline the necessary steps needed to properly</p><p>structure a corrective exercise program.</p><p>The Corrective Exercise Continuum includes four primary phases (Figure</p><p>1-1). The fi rst phase is the Inhibit phase using inhibitory techniques. Inhibi-</p><p>tory techniques are used to release tension or decrease activity of overactive</p><p>neuromyofascial tissues in the body. This can be accomplished through the</p><p>use of self-myofascial release techniques (e.g., foam roller). This phase will</p><p>be covered in more detail in chapter nine of the textbook. The second phase</p><p>is the Lengthen phase using lengthening techniques. Lengthening techniques</p><p>are used to increase the extensibility, length, and range of motion (ROM) of</p><p>neuromyofascial tissues in the body. This can be accomplished through the use</p><p>of static stretching and neuromuscular stretching. This phase will be covered</p><p>in more detail in chapter ten of the textbook. The third phase is the Activate</p><p>phase using activation techniques. Activation techniques are used to reedu-</p><p>cate or increase activation of underactive tissues. This can be accomplished</p><p>through the use of isolated strengthening exercises and positional isometric</p><p>techniques. This phase will be covered in more detail in chapter eleven of the</p><p>textbook. The fourth and fi nal phase is the Integrate phase using integration</p><p>techniques. Integration techniques are used to retrain the collective synergistic</p><p>function of all muscles through functionally progressive movements through</p><p>the use of integrated dynamic movements. This will be covered in more detail</p><p>in chapter eleven of the textbook.</p><p>Before implementing the Corrective Exercise Continuum, an integrated</p><p>assessment process must be done to determine dysfunction and ultimately</p><p>the design of the corrective exercise program. This assessment process should</p><p>include (but not be limited to) movement assessments, range of motion assess-</p><p>ments, and muscle strength assessments. This integrated assessment process</p><p>will help in determining which tissues need to be inhibited and lengthened</p><p>and which tissues need to be activated and strengthening through the use</p><p>of the Corrective Exercise Continuum. These assessments will be covered in</p><p>greater detail in the Assessment section of this textbook.</p><p>Inhibitory techniques:</p><p>corrective exercise tech-</p><p>niques used to release</p><p>tension or decrease</p><p>activity of overactive</p><p>neuromyofascial tissues</p><p>in the body.</p><p>Lengthening tech-</p><p>nique: corrective exer-</p><p>cise techniques used to</p><p>increase the extensibil-</p><p>ity, length, and range</p><p>of motion (ROM) of</p><p>neuromyofascial tis-</p><p>sues in the body.</p><p>Activation techniques:</p><p>corrective exercise</p><p>techniques used to</p><p>reeducate or increase</p><p>activation of underac-</p><p>tive tissues.</p><p>Integration techniques:</p><p>corrective exercise</p><p>techniques used to</p><p>retrain the collective</p><p>synergistic function</p><p>of all muscles through</p><p>functionally progres-</p><p>sive movements.</p><p>Figure 1.1 The corrective exercise continuum.</p><p>Inhibit Lengthen Activate Integrate</p><p>Inhibitory</p><p>techniques</p><p>Self-</p><p>myofascial</p><p>release</p><p>Lengthening</p><p>techniques</p><p>Activation</p><p>techniques</p><p>Integration</p><p>techniques</p><p>Positional</p><p>isometrics</p><p>Isolated</p><p>strengthening</p><p>Static</p><p>stretching Integrated</p><p>dynamic</p><p>movementNeuromuscular</p><p>stretching</p><p>Corrective exercise continuum</p><p>NASM_Chap01.indd 5NASM_Chap01.indd 5 7/5/2010 8:45:29 PM7/5/2010 8:45:29 PM</p><p>6 CHAPTER 1</p><p>SUMMARY • Today, more people work in offi ces, have longer work hours,</p><p>use better technology and automation, and are required to move less on a</p><p>daily basis. This new environment produces more inactive and nonfunctional</p><p>people and leads to dysfunction and increased incidents of injury including</p><p>low-back pain, knee injuries, and other musculoskeletal injuries.</p><p>In working with today’s typical client and athlete, who more than likely</p><p>possesses muscle imbalances, health and fi tness professionals must take spe-</p><p>cial consideration when designing programs. An integrated approach should</p><p>be used to create safe programs that consider the functional capacity for each</p><p>individual person. They must address factors such as appropriate forms of</p><p>fl exibility, increasing strength and neuromuscular control, training in different</p><p>types of environments (stable to unstable), and training in different planes of</p><p>motion. These are the basis for the use of corrective exercise and NASM’s Cor-</p><p>rective Exercise Continuum model. All of the phases included in the model</p><p>have been specifically designed to follow biomechanical, physiologic, and</p><p>functional principles of the human movement system. They should provide an</p><p>easy-to-follow systematic process that will help improve muscle imbalances,</p><p>minimize injury, and maximize results.</p><p>References</p><p>1. Centers for Disease Control and Prevention. Preva-</p><p>lence of physical activity, including lifestyle activities</p><p>among adults—United States, 2000–2001. Morbid</p><p>Mortal Wkly Rep 2003;52:764–9.</p><p>2. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Preva-</p><p>lence and trends in obesity among US adults, 1999–</p><p>2008. JAMA 2010;303:235–41. Epub 2010 Jan 13.</p><p>3. Ogden CL, Carroll MD, Curtin LR, Lamb MM,</p><p>Flegal KM. Prevalence of high body mass index in</p><p>US children and adolescents,</p><p>2007–2008. JAMA</p><p>2010;303:242–9. Epub 2010 Jan 13.</p><p>4. Centers for Disease Control and Prevention. The bur-</p><p>den of obesity in the United States: a problem of mas-</p><p>sive proportions. Chronic Dis Notes Rep 2005;17:4–9.</p><p>5. Harkness EF, Macfarlane GJ, Silman AJ, McBeth J.</p><p>Is musculoskeletal pain more common now than</p><p>40 years ago?: two population-based cross-sectional</p><p>studies. Rheumatology (Oxford) 2005;44:890–5.</p><p>6. Riddle DL, Schappert SM. Volume of ambulatory care</p><p>visits and patterns of care for patients diagnosed with</p><p>plantar fasciitis: a national study of medical doctors.</p><p>Foot Ankle Int 2004;25:303–10.</p><p>7. McKay GD, Goldie PA, Payne WR, Oakes BW. Ankle</p><p>injuries in basketball: injury rate and risk factors. Br J</p><p>Sports Med 2001;35:103–8.</p><p>8. Garrick JG. The frequency of injury, mechanism of</p><p>injury, and epidemiology of ankle sprains. Am J Sports</p><p>Med 1977;5:241–2.</p><p>9. Hosea TM, Carrey CC, Harrer MF. The gender issue:</p><p>epidemiology of knee and ankle injuries in high school</p><p>and college players. Clin Orthop Relat Res 2000;372:45–9.</p><p>10. Walker BF, Muller R, Grant WD. Low back pain in</p><p>Australian adults: prevalence and associated disability.</p><p>J Manipulative Physiol Ther 2004;27:238–44.</p><p>11. Cassidy JD, Carroll LJ, Cote P. The Saskatchewan</p><p>health and back pain survey. The prevalence of low</p><p>back pain and related disability in Saskatchewan</p><p>adults. Spine 1998;23:1860–6.</p><p>12. Volinn E. The epidemiology of low back pain in the</p><p>rest of the world. A review of surveys in low- and</p><p>middle-income countries. Spine 1997;22:1747–54.</p><p>13. Omokhodion FO, Sanya AO. Risk factors for low</p><p>back pain among offi ce workers in Ibadan, Southwest</p><p>Nigeria. Occup Med (Lond) 2003;53:287–9.</p><p>14. Omokhodion FO. Low back pain in a rural commu-</p><p>nity in South West Nigeria. West Afr J Med 2002;</p><p>21:87–90.</p><p>15. Tsuji T, Matsuyama Y, Sato K, Hasegawa Y, Yimin</p><p>Y, Iwata H. Epidemiology of low back pain in the</p><p>elderly: correlation with lumbar lordosis. J Orthop Sci</p><p>2001;6:307–11.</p><p>16. Luo X, Pietrobon R, Sun SX, Liu GG, Hey L. Esti-</p><p>mates and patterns of direct health care expenditures</p><p>among individuals with back pain in the United</p><p>States. Spine 2004;29:79–86.</p><p>17. Nadler SF, Malanga GA, DePrince M, Stitik TP,</p><p>Feinberg JH. The relationship between lower extrem-</p><p>ity injury, low back pain, and hip muscle strength in</p><p>male and female collegiate athletes. Clin J Sport Med</p><p>2000;10:89–97.</p><p>18. Nadler SF, Malanga GA, Feinberg JH, Rubanni M,</p><p>Moley P, Foye P. Functional performance defi cits in</p><p>athletes with previous lower extremity injury. Clin J</p><p>Sport Med 2002;12:73–8.</p><p>19. Griffi n LY, Agel J, Albohm MJ, et al. Noncontact ante-</p><p>rior cruciate ligament injuries: risk factors and pre-</p><p>vention strategies. J Am Acad Orthop Surg 2000;8:</p><p>141–50.</p><p>20. Noyes FR, Mooar PA, Matthews DS, Butler DL. The</p><p>symptomatic anterior cruciate defi cient knee. Part I:</p><p>the long-term functional disability in athletically active</p><p>individuals. J Bone Joint Surg Am 1983;65:154–62.</p><p>NASM_Chap01.indd 6NASM_Chap01.indd 6 7/5/2010 8:45:30 PM7/5/2010 8:45:30 PM</p><p>THE RATIONALE FOR CORRECTIVE EXERCISES 7</p><p>21. Arendt E, Dick R. Knee injury patterns among men</p><p>and women in collegiate basketball and soccer.</p><p>NCAA data and review of literature. Am J Sports Med</p><p>1995;23:694–701.</p><p>22. Arendt EA, Agel J, Dick R. Anterior cruciate ligament</p><p>injury patterns among collegiate men and women.</p><p>J Athl Train 1999;34:86–92.</p><p>23. Boden BP, Dean GS, Feagin JA, Garrett WE. Mecha-</p><p>nisms of anterior cruciate ligament injury. Orthopedics</p><p>2000;23:573–8.</p><p>24. Engstrom B, Johansson C, Tornkvist H. Soccer inju-</p><p>ries among elite female players. Am J Sports Med</p><p>1991;19:372–5.</p><p>25. Ireland ML, Wall C. Epidemiology and comparison of</p><p>knee injuries in elite male and female United States</p><p>basketball athletes. Med Sci Sports Exerc 1990;22:S82.</p><p>26. Hill CL, Seo GS, Gale D, Totterman S, Gale ME,</p><p>Felson DT. Cruciate ligament integrity in osteoarthritis</p><p>of the knee. Arthritis Rheum 2005;52:3:794–9.</p><p>27. Bongers PM. The cost of shoulder pain at work. BMJ</p><p>2001;322:64–5.</p><p>28. Urwin M, Symmons D, Allison T, et al. Estimating</p><p>the burden of musculoskeletal disorders in the com-</p><p>munity: the comparative prevalence of symptoms at</p><p>different anatomical sites, and the relation to social</p><p>deprivation. Ann Rheum Dis 1998;57:649–55.</p><p>29. Van der Heijden G. Shoulder disorders: a state of the</p><p>art review. Baillieres Best Pract Res Clin Rheumatol</p><p>1999;13:287–309.</p><p>30. Johnson M, Crosley K, O’Neil M, Al Zakwani I.</p><p>Estimates of direct health care expenditures among</p><p>individuals with shoulder dysfunction in the United</p><p>States. J Orthop Sports Phys Ther 2005;35:A4–PL8.</p><p>31. Barr KP, Griggs M, Cadby T. Lumbar stabilization:</p><p>core concepts and current literature, part 1. Am J Phys</p><p>Med Rehabil 2005;84:473–80.</p><p>32. Hammer WI. Chapter 12. Muscle Imbalance and</p><p>Postfacilitation Stretch. In: Hammer WI, ed. Func-</p><p>tional Soft Tissue Examination and Treatment by</p><p>Manual Methods. 2nd ed. Gaithersburg, MD: Aspen</p><p>Publishers; 1999:415–446.</p><p>NASM_Chap01.indd 7NASM_Chap01.indd 7 7/5/2010 8:45:30 PM7/5/2010 8:45:30 PM</p><p>8</p><p>C H A P T E R 2</p><p>OBJECTIVES Upon completion of this chapter, you will be able to:</p><p>Explain functional anatomy as it relates to ➤</p><p>corrective exercise training.</p><p>Explain the concept of functional multiplanar ➤</p><p>biomechanics.</p><p>Explain the concepts of motor learning and ➤</p><p>motor control as they relate to corrective</p><p>exercise training.</p><p>Introduction to Human</p><p>Movement Science</p><p>INTRODUCTION</p><p>HUMAN movement science is the study of how the human movement system</p><p>(HMS) functions in an interdependent, interrelated scheme. The HMS consists</p><p>of the muscular system (functional anatomy), the skeletal system (functional</p><p>biomechanics), and the nervous system (motor behavior) (1–3). Although</p><p>they appear separate, each system and its components must collaborate to</p><p>form interdependent links. In turn, this entire interdependent system must</p><p>be aware of its relationship to internal and external environments while gath-</p><p>ering necessary information to produce the appropriate movement patterns.</p><p>This process ensures optimum functioning of the HMS and optimum human</p><p>movement. This chapter will review the pertinent aspects of each component</p><p>of the HMS as it relates to function and human movement (Figure 2-1).</p><p>BIOMECHANICS</p><p>Biomechanics applies the principles of physics to quantitatively study how</p><p>forces interact within a living body (4–7). For purposes of this text, the spe-</p><p>cifi c focus will be on the motions that the HMS produces (kinematics) and the</p><p>forces (kinetics) that act on it. This includes basic understanding of anatomic</p><p>terminology, planes of motion, joint motions, muscle action, force-couples,</p><p>leverage, and basic muscle mechanics.</p><p>Biomechanics: a study</p><p>that uses principles of</p><p>physics to quantitatively</p><p>study how forces inter-</p><p>act within a living body.</p><p>C H A P T E R 2</p><p>NASM_Chap02.indd 8NASM_Chap02.indd 8 7/5/2010 9:41:55 PM7/5/2010 9:41:55 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 9</p><p>ANATOMIC TERMINOLOGY</p><p>All professions have language that is specifi c to their needs. The health and</p><p>fi tness professional needs to understand the basic anatomic terminology for</p><p>effective communication.</p><p>Planes of Motion and Axes, and Combined Joint Motions</p><p>Human movement occurs in three dimensions and is universally discussed</p><p>in a system of planes and axes (Figure 2-2). Three imaginary planes are posi-</p><p>tioned through the body at right angles so they intersect at the body’s center</p><p>of mass. These planes are termed the sagittal, frontal, and transverse planes.</p><p>Movement is said to occur predominantly in a specifi c plane when that move-</p><p>ment occurs along or parallel to the plane. Although movements can be domi-</p><p>nant in one plane, no motion occurs strictly in one plane of motion. Movement</p><p>in a plane occurs around an axis running perpendicular to that plane—much</p><p>like the axle that a car wheel revolves around. This is known as joint motion.</p><p>Joint motions are termed for</p><p>their action in each of the three planes of motion</p><p>(Table 2-1).</p><p>THE SAGITTAL PLANE</p><p>The sagittal plane bisects the body into right and left halves. Sagittal plane</p><p>motion occurs around a frontal axis (4,5,8). Movements in the sagittal plane</p><p>include fl exion and extension (Figure 2-3). Flexion occurs when the relative</p><p>angle between two adjacent segments decreases (5,9). Extension occurs when</p><p>the relative angle between two adjacent segments increases (5,9) (Table 2-1).</p><p>Flexion and extension occur in many joints in the body including vertebral,</p><p>shoulder, elbow, wrist, hip, knee, foot, and hand. The ankle is unique and</p><p>includes special terms for movement in the sagittal plane. “Flexion” is more</p><p>accurately termed dorsifl exion and “extension” is referred to as plantarfl exion</p><p>(4,5,9). Examples of predominantly sagittal plane movements include biceps</p><p>curls, triceps pushdowns, squats, front lunges, calf raises, walking, running,</p><p>and climbing stairs (Table 2-1).</p><p>Figure 2.1 Components of the human movement system.</p><p>Human movement</p><p>system</p><p>Nervous system Muscular systemSkeletal system</p><p>NASM_Chap02.indd 9NASM_Chap02.indd 9 7/5/2010 9:41:55 PM7/5/2010 9:41:55 PM</p><p>10 CHAPTER 2</p><p>THE FRONTAL PLANE</p><p>The frontal plane bisects the body into front and back halves with frontal</p><p>plane motion occurring around an anterior-posterior axis (4,5,9). Movements</p><p>in the frontal plane include abduction and adduction of the limbs (relative</p><p>to the trunk), lateral fl exion in the spine, and eversion and inversion of the</p><p>foot and ankle complex (Figure 2-4) (4,5,8,9). Abduction is a movement away</p><p>Figure 2.2 Planes of motion.</p><p>Longitudinal</p><p>axis</p><p>Coronal</p><p>axis Anterior-posterior</p><p>axis</p><p>Sagittal</p><p>plane</p><p>Transverse</p><p>plane</p><p>Frontal</p><p>plane</p><p>NASM_Chap02.indd 10NASM_Chap02.indd 10 7/5/2010 9:41:56 PM7/5/2010 9:41:56 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 11</p><p>Table 2.1 EXAMPLES OF PLANES OF MOTION, MOTIONS, AND AXES</p><p>Plane Motion Axis Example</p><p>Sagittal</p><p>Flexion/Extension Coronal • Bicep curls</p><p>• Tricep pushdowns</p><p>• Squats</p><p>• Front lunges</p><p>• Calf raises</p><p>• Walking</p><p>• Running</p><p>• Vertical jumping</p><p>• Climbing stairs</p><p>Frontal</p><p>Adduction/Abduction Anterior-Posterior • Lateral shoulder raises</p><p>Lateral Flexion • Side lunges</p><p>Eversion/Inversion • Side shuffl ing</p><p>Transverse</p><p>Internal/External Rotation Longitudinal • Cable rotations</p><p>Left/Right Spinal Rotation • Transverse plane</p><p>lunges</p><p>Horizontal Add/Abduction • Throwing</p><p>• Golfi ng</p><p>• Swinging a bat</p><p>from the midline of the body or, similar to extension, an increase in the angle</p><p>between two adjoining segments only in the frontal plane (4,5,8,9). Adduction</p><p>is a movement of the segment toward the midline of the body or, like fl exion,</p><p>a decrease in the angle between two adjoining segments only in the frontal</p><p>plane (4,5,8,9). Lateral fl exion is the bending of the spine (cervical, thoracic,</p><p>lumbar) from side to side or simply side-bending (4,5). Eversion and inversion</p><p>relate specifi cally to the movement of the calcaneus and tarsals in the frontal</p><p>plane during functional movements of pronation and supination (discussed</p><p>later) (4,5,8,9). Examples of frontal plane movements include lateral shoulder</p><p>raises, side lunges, and side shuffl ing (Table 2-1).</p><p>THE TRANSVERSE PLANE</p><p>The transverse plane bisects the body to create upper and lower halves. Trans-</p><p>verse plane motion occurs around a longitudinal or a vertical axis (4,5,8). Move-</p><p>ments in the transverse plane include internal rotation and external rotation</p><p>for the limbs, right and left rotation for the head and trunk, and radioulnar</p><p>pronation and supination (4,5,8) (Figure 2-5). The transverse plane motions of</p><p>the foot are termed abduction (toes pointing outward, externally rotated) and</p><p>adduction (toes pointing inward, internally rotated) (5). Examples of trans-</p><p>verse plane movements include cable rotations, turning lunges, throwing a</p><p>ball, and swinging a bat (Table 2-1).</p><p>NASM_Chap02.indd 11NASM_Chap02.indd 11 7/5/2010 9:41:56 PM7/5/2010 9:41:56 PM</p><p>12 CHAPTER 2</p><p>Figure 2.3A Shoulder fl exion Figure 2.3B Shoulder</p><p>extension</p><p>Figure 2.3C Hip fl exion</p><p>Figure 2.3E Spinal fl exion Figure 2.3F Spinal extension Figure 2.3G Elbow fl exion</p><p>Figure 2.3H Elbow extension Figure 2.3I Dorsifl exion Figure 2.3J Plantarfl exion</p><p>Figure 2.3D Hip extension</p><p>NASM_Chap02.indd 12NASM_Chap02.indd 12 7/5/2010 9:41:56 PM7/5/2010 9:41:56 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 13</p><p>COMBINED JOINT MOTIONS</p><p>During movement, the body must maintain its center of gravity aligned over</p><p>a constantly changing base of support. If a change in alignment occurs at one</p><p>joint, changes in alignment of other joints must occur. For example, when</p><p>individuals stand and turn their patella inward, then outward, you will notice</p><p>obligatory effects from the subtalar joint to the pelvis. When the patella is</p><p>turned inward (tibial and femoral internal rotation), pronation occurs at the</p><p>subtalar joint (Figure 2-6). When the patella is turned outward (tibial and</p><p>femoral external rotation), subtalar joint supination occurs (Figure 2-6).</p><p>Even though a joint has a predominant plane of movement, all freely</p><p>moveable joints can display some movement in all three planes of motion.</p><p>Functional multiplanar biomechanics of the subtalar joint can be simplifi ed</p><p>into pronation and supination (10). In reality, subtalar pronation with obliga-</p><p>tory tibial and femoral internal rotation is a multiplanar, synchronized joint</p><p>motion that occurs with eccentric muscle function. Thus, subtalar supination</p><p>Figure 2.4A Shoulder abduction Figure 2.4B Shoulder adduction Figure 2.4C Hip adduction</p><p>Figure 2.4D Hip abduction Figure 2.4E Eversion Figure 2.4F Inversion</p><p>NASM_Chap02.indd 13NASM_Chap02.indd 13 7/5/2010 9:41:59 PM7/5/2010 9:41:59 PM</p><p>14 CHAPTER 2</p><p>Figure 2.5A Spinal rotation Figure 2.5B Shoulder internal rotation Figure 2.5C Shoulder external rotation</p><p>Figure 2.5D Hip internal</p><p>rotation</p><p>Figure 2.5E Hip external</p><p>rotation</p><p>Figure 2.5F Radioulnar</p><p>supination</p><p>Figure 2.5G Radioulnar</p><p>pronation</p><p>with obligatory tibial and femoral external rotation is also a multiplanar,</p><p>synchronized joint motion that occurs with concentric muscle function</p><p>(Table 2-2).</p><p>The gait cycle will be used to briefl y describe functional biomechanics to</p><p>show the interdependence of joint and muscle actions on each other (11,12).</p><p>During the initial contact phase of gait, the subtalar joint pronates creating</p><p>obligatory internal rotation of the tibia, femur, and pelvis. At mid-stance, the</p><p>subtalar joint supinates leading to obligatory external rotation of the tibia,</p><p>femur, and pelvis (Figure 2-7). The health and fi tness professional should</p><p>remember that these linkages are bidirectional: pelvic motion can create</p><p>lower extremity motion and lower extremity motion can create pelvic motion</p><p>(Figure 2-8) (10,13).</p><p>Poor control of subtalar joint pronation along with tibial and femoral inter-</p><p>nal rotation decreases the ability to eccentrically decelerate multisegmental</p><p>NASM_Chap02.indd 14NASM_Chap02.indd 14 7/5/2010 9:42:07 PM7/5/2010 9:42:07 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 15</p><p>Figure 2.6 Lower extremity supination and pronation.</p><p>Tibial and femoral</p><p>internal rotation</p><p>Pronation Supination</p><p>Subtalar</p><p>pronation</p><p>Tibial and</p><p>femoral</p><p>supination</p><p>Subtalar</p><p>supination</p><p>Table 2.2 FUNCTIONAL BIOMECHANICS</p><p>During Pronation</p><p>The foot Dorsifl exes, everts, abducts</p><p>The ankle Dorsifl exes, everts, abducts</p><p>The knee Flexes, adducts, internally rotates</p><p>The hip Flexes, adducts, internally rotates</p><p>During Supination</p><p>The foot Plantarfl exes, inverts, adducts</p><p>The ankle Plantarfl exes, inverts, adducts</p><p>The knee Extends, abducts, externally rotates</p><p>The hip Extends, abducts, externally rotates</p><p>motion that can lead to muscle imbalances, joint dysfunction, and injury.</p><p>Poor production of subtalar joint supination along with tibial and femoral</p><p>external rotation decreases the ability of the human movement system to</p><p>concentrically produce the appropriate</p><p>force for push-off that can lead to syn-</p><p>ergistic dominance (which will be explained in greater detail in chapter 3).</p><p>NASM_Chap02.indd 15NASM_Chap02.indd 15 7/5/2010 9:42:22 PM7/5/2010 9:42:22 PM</p><p>16 CHAPTER 2</p><p>During functional movement patterns, almost every muscle</p><p>has the same synergistic function: to eccentrically decelerate</p><p>pronation or to concentrically accelerate supination. When</p><p>an articular structure is out of alignment, abnormal distort-</p><p>ing forces are placed on the articular surfaces. Poor align-</p><p>ment also changes the mechanical function of muscle and</p><p>force-couple relationships of all of the muscles that cross</p><p>that joint. This leads to altered movement patterns, altered</p><p>reciprocal inhibition, synergistic dominance, and ultimately,</p><p>decreased neuromuscular effi ciency; these concepts will be</p><p>developed throughout this book.</p><p>Muscle Actions</p><p>Muscles produce tension through a variety of means to effec-</p><p>tively manipulate gravity, ground reaction forces, momen-</p><p>tum, and external resistance. There are three different muscle</p><p>actions: eccentric, isometric, and concentric (Table 2-3).</p><p>ECCENTRIC</p><p>An eccentric action occurs when a muscle develops tension</p><p>while lengthening; the muscle lengthens because the con-</p><p>tractile force is less than the resistive force. The overall ten-</p><p>sion within the muscle is less than the external forces trying</p><p>to lengthen the muscle. During resistance training, an eccen-</p><p>tric muscle action is also known as “a negative.” This occurs</p><p>during the lowering phase of any resistance exercise. During</p><p>integrated resistance training, the eccentric action exerted</p><p>by the muscle(s) prevents the weight/resistance/implement</p><p>from accelerating in an uncontrolled manner downward as a</p><p>result of gravitational force.</p><p>In all activities, muscles work as much eccentrically as</p><p>they do concentrically or isometrically (14,15). Eccentrically,</p><p>Figure 2.7 Supination and pronation during gait.</p><p>Contact Midstance Propulsion</p><p>Figure 2.8 Pronations effect on the entire</p><p>kinetic chain.</p><p>Tibial and femoral</p><p>internal rotation</p><p>Subtalar</p><p>pronation</p><p>NASM_Chap02.indd 16NASM_Chap02.indd 16 7/5/2010 9:42:23 PM7/5/2010 9:42:23 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 17</p><p>the muscles must decelerate or reduce the forces acting on the body (or force</p><p>reduction). This is a critical aspect of all forms of movement because the</p><p>weight of the body must be decelerated and then stabilized to properly accel-</p><p>erate during movement.</p><p>Gravity and Its Effect on Movement</p><p>Gravity is a constant downward-directed force that we are infl uenced by every second of</p><p>every day. This increases the eccentric demand that our muscles are placed under, which</p><p>must therefore be trained for accordingly, making the eccentric action of training just as</p><p>important (if not more important) as the concentric action.</p><p>GETTING YOUR FACTS STRAIGHT</p><p>ISOMETRIC</p><p>An isometric muscle action occurs</p><p>when the contractile force is equal</p><p>to the resistive force, leading to no</p><p>visible change in the muscle length</p><p>(5,9). As the muscle shortens, elastic</p><p>components of the muscle lengthen.</p><p>The muscle is shortening; however,</p><p>there is no movement of the joint.</p><p>In all activities, isometric</p><p>actions dynamically stabilize the</p><p>body. This can be seen when stabiliz-</p><p>ers isometrically contract to restrict</p><p>a limb from moving in an unwanted</p><p>direction. For example, when walk-</p><p>ing, the hip adductors and abduc-</p><p>tors will dynamically stabilize the</p><p>leg and pelvis from excessive move-</p><p>ments in the frontal and transverse</p><p>planes (Figure 2-9) (4,9,15).</p><p>CONCENTRIC</p><p>A concentric muscle action occurs</p><p>when the contractile force is greater</p><p>than the resistive force, resulting in</p><p>Table 2.3 MUSCLE ACTION SPECTRUM</p><p>Concentric Developing tension while a muscle is shortening; when</p><p>developed tension overcomes resistive force</p><p>Eccentric Developing tension while a muscle is lengthening; when</p><p>resistive force overcomes developed tension</p><p>Isometric When the contractile force is equal to the resistive force</p><p>Figure 2.9 Dynamic stabilization.</p><p>Adductors</p><p>Gluteus</p><p>medius</p><p>Quadratus</p><p>lumborum</p><p>NASM_Chap02.indd 17NASM_Chap02.indd 17 7/5/2010 9:42:24 PM7/5/2010 9:42:24 PM</p><p>18 CHAPTER 2</p><p>shortening of the muscle and visible joint movement. This is referred to as the</p><p>“positive” during integrated resistance training (5,11). All movements require</p><p>concentric muscle actions.</p><p>Muscular Force</p><p>A force is defi ned as the interaction between two entities or bodies that result in</p><p>either the acceleration or deceleration of an object (1,4,5,7). Forces are character-</p><p>ized by both magnitude (how strong) and direction (which way they are moving)</p><p>(1,5). The HMS manipulates variable forces from a multitude of directions to effec-</p><p>tively produce movement. As such, the health and fi tness professional must gain</p><p>an understanding of some of the more pertinent mechanical factors that affect</p><p>force development that the HMS must deal with and how motion is affected.</p><p>Forces and Their Effect on the HMS</p><p>Every time one takes a step, gravity and momentum forces the body down onto the</p><p>ground. The ground then exerts an opposite and equal force back onto the body up</p><p>through the foot. This is known as ground reaction force (1). Ground reaction force places</p><p>further stresses through the HMS. Not only do we have gravity pushing us downward, but</p><p>also we have ground reaction force pushing from below back up through the body. As the</p><p>speed and amplitude of movement increases so does the ground reaction force (2). While</p><p>walking, ground reaction force can be 1 to 1.5 times one’s body weight (3), 2 to 5 times</p><p>one’s body weight during running (3) and 4 to 11 times one’s body weight when jumping</p><p>(4). This is important for a health and fi tness professional to note when designing a proper</p><p>program. Think of a 150-pound person who goes jogging or a person walking up and</p><p>down stairs. They must withstand approximately 300 to 600 pounds of force on one leg,</p><p>each and every step, in an unstable, unpredictable environment. Thus, a program must be</p><p>designed to help individuals be able to control themselves (decelerate and dynamically</p><p>stabilize) against these forces and decrease their risk of injury.</p><p>1. Hamill J, Knutzen JM. Biomechanical Basis of Human Movement. Baltimore, MD: Williams & Wilkins; 1995.</p><p>2. Voloshin A. The infl uence of walking speed on dynamic loading on the human musculoskeletal system.</p><p>Med Sci Sports Exerc 2000;32:1156–9.</p><p>3. Brett GA, Whalen RT. Prediction of human gait parameters from temporal measures of foot-ground</p><p>contact. Med Sci Sports Exerc 1997;29:540–7.</p><p>4. Witzke KA, Snow CM. Effects of plyometric jumping on bone mass in adolescent girls. Med Sci Sports</p><p>Exerc 2000;32:1051–7.</p><p>GETTING YOUR FACTS STRAIGHT</p><p>LENGTH-TENSION RELATIONSHIPS</p><p>Length-tension relationship refers to the resting length of a muscle and the</p><p>tension the muscle can produce at this resting length (1,6,16,17). There is an</p><p>optimal muscle length at which the actin and myosin fi laments in the sarcom-</p><p>ere have the greatest degree of overlap (Figure 2-10). The thick myosin fi lament</p><p>is able to make the maximal amount of connections with active sites on the</p><p>thin actin fi lament, leading to maximal tension development of that muscle.</p><p>When the muscle is stimulated at lengths greater than or less than this optimal</p><p>length, the resulting tension is less because there are fewer interactions of the</p><p>myosin cross-bridges and actin active sites (1,5,6,16-18).</p><p>Force: an infl uence</p><p>applied by one object</p><p>to another, which</p><p>results in an accelera-</p><p>tion or deceleration of</p><p>the second object.</p><p>Length-tension rela-</p><p>tionship: the resting</p><p>length of a muscle and</p><p>the tension the muscle</p><p>can produce at this</p><p>resting length.</p><p>NASM_Chap02.indd 18NASM_Chap02.indd 18 7/5/2010 9:42:24 PM7/5/2010 9:42:24 PM</p><p>INTRODUCTION TO HUMAN MOVEMENT SCIENCE 19</p><p>This concept is important to the health and fi tness professional and coin-</p><p>cides with the previously discussed concept of joint alignment.</p>
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NASM Essentials Of Corrective Exercise Training - Anatomia (2024)
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