Validity of FMS 1

Validity Testing of the Functional Movement Screen in Adolescent Athletes

Julia Villani, LAT, ATC

University of Utah

Abstract

Objective: Assessment of functional movements in athletes can help to assess athletes risk of

injury. The purpose of this study is to examine the use of the Functional Movement Screen

assessment tool as a predictor of injury in secondary school athletes. It is hypothesized that the

cut off score to predict injury will be lower than the score of 14, a standard score used in the

adult population, due to differences in musculoskeletal maturation. Methods: A correlational

study design will be used. Both male and female athletes, ages 13-18, from football, soccer, cross

country, and volleyball will be tested during the pre-season using the Gray-Cook standard FMS

protocol. Injury data will be collected throughout the regular season on the screened participants.

Data analysis will include a Pearson's correlation, and a receiver operator characteristics curve to

determine a cutoff score that maximize both sensitivity and specificity of total FMS scores.

Likelihood ratios will be calculated to determine how much a subject's total FMS score

influenced the posttest probability of becoming injured. Results: It is anticipated that biological

maturation, determined by anthropometric measurements, will have an effect on the proper cut

off score to accurately predict injury.

 Validity of FMS 2

Introduction

Sports participation at the high school level has increasingly gained popularity over the

years. It is estimated that participation has grown from 4.0 million participants in 1971-72 to 7.7

million in 2011-12.1 While this increase in sports participation has a positive effect on adolescent

obesity there is also an increased risk of injury. The overall rate for high school sports from a

2011-12 survey indicated an injury incidence rate of 1.8 per 1000 athletic exposures.1 These

injuries often withhold individuals from athletic participation, however many of them could be

preventable.

Injury prevention is a cornerstone of athletic training and the constant advancement of

this domain is essential to the profession. A biomechanical assessment of human movement is a

key component of prevention, as it helps us to understand how the body functions normally, and

more importantly, aids in identification of dysfunctional movements. Functional movement can

be defined as the ability to perform fundamental movement patterns with accuracy and efficiency

by maintaining stability and mobility throughout the kinetic chain.2 When an individual is unable

to maintain proper dynamic control, additional stress is imposed on each joint, thereby placing

individuals at an increased risk for injury.3-5

One common biomechanical assessment tool, the Functional Movement Screening

(FMS), consists of 7 individual tests that assess mobility, stability, dynamic balance and

coordination. Testing only requires FMS equipment and 10-15 minutes to determine if an athlete

many need further evaluation. Research has shown that the FMS is a useful tool to predict injury

risk.6 This has been accomplished by studying normative FMS scores as well has the correlation

between score and rate of injury.5,7 Research has shown that the average FMS composite score is

15.7 on a scale of 21 in a young, healthy population, ages 18-40.7 A score of 14 or lower has
 Validity of FMS 3

shown that athletes are at a 4.7 times higher risk for injury.6

A meta-analysis of several inter and intrarater reliability studies has found a moderate to

good level of reliability for FMS testers regardless of testing experience.8 While shown to be

reliable, the validity of the FMS is in question. The basis upon which the FMS is score is not a

clearly defined as other predictive tests that measure objective markers such as joint laxity, range

of motion, or strength. Instead, the FMS creators state its objective purpose is to determine

whether the athlete has the essential movements needed to participate in sports activities with a

decreased risk of injury.3,9 This is based off the assumption that the FMS tests movements that

are necessary in all sports, and no test specialization is required. Previous studies have shown

that on average the FMS only has a sensitivity of 54% in an adult population, which discredits

the use of FMS as an assessment tool.9 However, currently, there is no data on the validity of the

FMS in the adolescent population. It is possible that due to differences in maturation in

adolescents compared to adult, the validity of the FMS may be different.

The biological age of adolescent athletes need to be taken into consideration with

assessing their functional abilities. Musculoskeletal development affects an athlete's motor

control, coordination, flexibility and strength, all component necessary to perform functional

movements properly. If a biologically immature athlete has dysfunction movements does this put

them at a greater risk for injury as it would in a biologically mature athlete? Two studies

identified normative FMS values, showing that adults 18-40 averaged a score of 15.7 while

adolescent ages 10-17 only average a score of 14.59.10,11 It is possible that while an adolescent

athlete may exhibit dysfunctional movement it could be due to musculoskeletal immaturity and

be unrelated to their risk of injury. The purpose of this study is to determine if the FMS is a valid

assessment tool for predicting injury in high school athletes. It is hypothesized that average FMS
 Validity of FMS 4

scores will be correlated with the biological age of the athletes. In addition, the commonly used

cut off score of 14 to predict injury will not be appropriate to predict risk of injury for the

adolescent population due to musculoskeletal immaturity.

The FMS could be an efficient and effective tool for high school athletic trainers to

improve their preventative care of athlete. Athlete trainers in the secondary school setting are

often lack the time and resources to dedicate to individualized prevention assessments. Should

the FMS prove a valid tool it would give athletic trainers at the secondary school setting an

opportunity to implement a prevention assessment. Ultimately, with the establishment of an

effective tool to identify injury risk, athletic trainers can then progress to developing prevention

programs. By advancing the knowledge of injury risk screening, there is a potential to improve

functional movement abilities and decrease incidence of injury in the adolescent population.

Methods

A correlational research design will be used to determine if there is a relationship

between FMS scores and injuries sustained throughout the regular season. The participants will

be assessed by an athletic trainer during pre-season training sessions using the Functional

Movement Screen kit. Throughout the regular season data will be collected on any injuries

sustained by the study participants.

Participants

A convenience sampling method will be used to obtain participants. Subjects will be

athletes, 13 to 18 years old, participating in fall sports including football, volleyball, girls

soccer, and girls and boys cross country from Canyon School District high schools; Jordan

High School and Corner Canyon High School. Inclusion criteria includes the athlete's academic
 Validity of FMS 5

eligibility as well as a sports physical. Pre-season sport meetings will be used to inform the

athletes and parents about the study and provide them with the documentation required if they

are willing to participate. Exclusion criteria includes athletes that are not medically cleared by a

pre-participation physical

FMS Protocol

The FMS equipment that will be used for testing includes a wooden pole, 1 inch in

diameter, as well as a wooden board, dimensions 2x4x48. The scoring for the FMS tests ranges

from 0 to 3. A score of 3 is given when the athlete is able to perform a movement without an

deficiencies. A 2 is given if any athlete performs a movement either with deficiencies or a

modified position. A score of 1 is given if the athlete is unable to perform a movement, and a 0 is

given if the athlete experiences pain with the movement. The majority of the tests in the FMS

examine both the right and left sides, and it is important that both sides are scored. The lower

score of the two sides is recorded and is counted toward the total.

Three FMS tests have additional clearing screens that are graded as positive or negative

only considering pain. If a person has a positive clearing test, then the score will be zero for the

associated test.

Overhead Squat

The individual assumes the starting position by placing his/her feet approximately

shoulder width apart and the feet aligned in the sagittal plane. The individual then adjusts their

hands on the dowel to assume a 90-degree angle of the elbows with the dowel overhead. Next,

the dowel is pressed overhead with the shoulders flexed and abducted, and the elbows extended,
 Validity of FMS 6

so that the dowel is directly overhead. The individual is then instructed to descend as far as they

can into a squat position while maintaining an upright torso, keeping the heels and the dowel in

position. Hold the descended position for a count of one, and then return to the starting position.

As many as three repetitions may be performed. If the criteria for a score of 3 is not achieved,

the athlete is then asked to perform the test with a 2x6 block under the heels.3

Hurdle Step

The individual assumes the starting position by first placing the feet together and aligning

the toes touching the base of the hurdle. The hurdle is then adjusted to the height of the athletes

tibial tuberosity. The dowel is grasped with both hands and positioned behind the neck and

across the shoulders. The individual is then asked to maintain an upright posture and step over

the hurdle, raising the foot toward the shin, and maintaining alignment between the foot, knee,

and hip, and touch their heel to the floor (without accepting weight) while maintaining the stance

leg in an extended position. The moving leg is then returned to the starting position. The hurdle

step should be performed slowly and as many as three times bilaterally. If one repetition is

completed bilaterally meeting the criteria provide, a 3is given.3

In-line Lunge

The tester attains the individuals tibia length, by either measuring it from the floor to the

tibial tuberosity or acquiring it from the height of the string during the hurdle step test. The

individual is then asked to place the end of their heel on the end of the board or a tape measure

taped to the floor. The previous tibial measurement is then applied from the end of the toes of the
 Validity of FMS 7

foot on the board and a mark is made. The dowel is placed behind the back touching the head,

thoracic spine, and middle of the buttocks. The hand opposite to the front foot should be the hand

grasping the dowel at the cervical spine. The other hand grasps the dowel at the lumbar spine.3

Shoulder Mobility

The tester first determines the hand length by measuring the distance from the distal wrist

crease to the tip of the third digit in inches. The individual is then instructed to make a fist with

each hand, placing the thumb inside of the fist. They are then asked to assume a maximally

adducted, extended, and internally rotated position with on shoulder and a maximally abducted,

flexed, and externally rotated position with the other. During the test, the hands should remain in

a fist and the fists should be place on the back in one smooth motion. The tester then measures

the distance between the two closest bony prominences. Perform the test as many as three times

bilaterally.12

Active Straight-Leg Raise

The individual first assumes the starting position by lying supine with the arms in

anatomical position, legs over the 2 6 board, and head flat on the floor. The tester then

identifies the midpoint between the anterior superior iliac spine, and the midpoint of the patella

of the leg on the floor, and a dowel is placed at this position, perpendicular to the ground. Next

the individual is instructed to slowly lift the test leg with a dorsiflexed ankle and an extended

knee. During the test the opposite knee (the down leg) must remain in contact with the ground

and the toes pointed upward, and the head in contact with the floor. Once the end range position

is achieved, note the position of the upward ankle relative to the nonmoving limb. If the
 Validity of FMS 8

malleolus does not pass the dowel, move the dowel to equal with the malleolus of the test leg,

and score per the criteria.12

Trunk Stability Push-up

The individual assumes a prone position with the feet together. The hands are placed

shoulder width apart at the appropriate position per the described criteria. During this test, men

and women have different starting arm positions. Men begin with their thumbs at the top of the

forehead, while women begin with their thumbs at chin level. The knees are fully extended and

the ankles dorsiflexed. The individual is asked to perform one pushup in this position. The body

should be lifted as a unit; no lag (or arch) should occur in the lumbar spine when performing

the movement. If the individual cannot perform a pushup in this position, the thumbs are moved

to the next easiest position, chin level for males, shoulder level for females, and the pushup is

attempted again. The trunk stability pushup can be performed a maximum of three times.12

Rotator Stability

The individual assumes the starting position in quadruped, their shoulders and hips at 90

degree angles, relative to the torso, with the 2 6 board between their hands and knees. The

knees are positioned at 90 degrees and the ankles should be dorsiflexed. The individual then

flexes the shoulder and extends the same side hip and knee. The leg and hand are only raised

enough to clear the floor by approximately 6 inches. The same shoulder is then extended and the

knee flexed enough for the elbow and knee to touch. This is performed bilaterally, for up to three

attempts each side. If the individual cannot complete this maneuver (score a 3), they are then

instructed perform a diagonal pattern using the opposite shoulder and hip in the same manner as
 Validity of FMS 9

described for the previous test. They are also allowed three attempts at this test.12

Procedures

Descriptive data; height, weight, age, sport, and previous injury will be collected prior to

testing procedures. Anthropometric measurement equations included three somatic dimensions

(height, sitting height, and leg length) to categorize athletes by biological age. This is a non-

invasive method proven to accurately assess years to peak height velocity, a maturational

benchmark.13 The FMS assessments will be performed during pre-season workout sessions

including weight training and conditioning. Participants will be removed from a session for 10-

15 minutes to complete the assessment. Previous research has shown that FMS scores are

unaffected by athletes exertional levels, therefore the participants can be tested throughout the

training session.15 The participants will be read the instructions for each of the FMS movements.

Three trails will be performed for each exercise and scoring protocol described above will be

used to assess the participants. All testing will be done by the Jordan High School athletic

trainer, who has two years of experience assessing athletes. In addition, a video recorded will be

used to review the tests and verify accurate scoring.

Throughout the season, injuries will be recorded through the athletic training staff, using

the electronic medical record system, Heatheathlete. The data collected regarding the injury will

include; mechanism of injury (contact or non-contract), and diagnosis. The timeline for the

collection of data will proceed through the regular season; playoffs will not be included in the

study.
 Validity of FMS 10

Statistical Analysis

Following the data collection, all participants will be identified, and assigned a number

for confidentiality. This data will then be analyzed using SPSS, including a Pearson's correlation

between composite score and whether an injury was sustained. In addition, a receiver operator

characteristics (ROC) curve will be used to determine a cutoff score that maximize both

sensitivity and specificity of total FMS scores. Likelihood ratios will be calculated to determine

how much a subject's total FMS score influenced the posttest probability of becoming injured.
 Validity of FMS 11

References

1. Comstock RD Collins CL Corlette JD Fletcher EN. National high school sportsrelated

injury surveillance study 201112 school year. Columbus, OH: Nationwide Children's

Hospital; 2012. Available at http://www.nationwidechildrens.org/cirp-rio-study-

reports/2011-12HighSchoolRIOSummaryReport.pdf.

2. Mills J, Taunton J, Mills W. Original research: The effect of a 10-week training regimen

on lumbo-pelvic stability and athletic performance in female athletes: A randomized-

controlled trial. Physical Therapy In Sport [serial online]. January 1, 2005;6:60-66.

3. Cook G, Burton L, Hoogenboom B, Voight M. Functional movement screening: the use

of fundamental movements as an assessment of function - part 1. International Journal

Of Sports Physical Therapy [serial online]. June 2014;9(3):396-409.

4. Mitchell U, Johnson A, Adamson B. Relationship between functional movement screen

scores, core strength, posture, and body mass index in school children in moldova.

Journal Of Strength & Conditioning Research (Lippincott Williams & Wilkins) [serial

online]. May 2015;29(5):1172-1179.

5. Kiesel K, Plisky P, Voight M. Can Serious injury in professional football be predicted by

a preseason functional movement screen?. North American Journal Of Sports Physical

Therapy: NAJSPT [serial online]. August 2007;2(3):147-158.

6. Letafatkar A, Hadadnezhad M, Shojaedin S, Mohamadi E. Relationship between

functional movement screening score and history of injury. International Journal Of

Sports Physical Therapy [serial online]. February 2014;9(1):21-27.

7. Schneiders A, Davidsson A, Hrman E, Sullivan S. Functional movement screen

normative values in a young, active population. International Journal Of Sports Physical

 Validity of FMS 12

Therapy [serial online]. June 2011;6(2):75-82.

8. Cuchna J, Hoch M, Hoch J. Literature review: The interrater and intrarater reliability of

the functional movement screen: A systematic review with meta-analysis. Physical

Therapy In Sport [serial online]. May 1, 2016;19:57-65.

9. Beardsley C, Contreras B. The Functional Movement Screen: A Review. Strength &

Conditioning Journal (Lippincott Williams & Wilkins) [serial online]. October

2014;36(5):72.

10. Schneiders A, Davidsson , Hrman E, Sullivan S. Functional movement screen

normative values in a young, active population. International Journal Of Sports Physical

Therapy [serial online]. June 2011;6(2):75-82.

11. Abraham A, Sannasi R, Nair R. Normative values for the functional movement screen

in adolescent school aged children. International Journal Of Sports Physical Therapy

[serial online]. February 2015;10(1):29-36.

12. Cook G, Burton L, Hoogenboom B, Voight M. Functional movement screening: the use

of fundamental movements as an assessment of function-part 2. International Journal Of

Sports Physical Therapy [serial online]. August 2014;9(4):549-563.

13. Mirwald R, Baxter-Jones A, Bailey D, Beunen G. An assessment of maturity from

anthropometric measurements. Medicine & Science In Sports & Exercise [serial online].

April 2002;34(4):689-694.

14. Clifton D, Harrison B, Hertel J, Hart J. Relationship between functional assessments and

exercise-related changes during static balance. Journal Of Strength & Conditioning

Research (Lippincott Williams & Wilkins) [serial online]. April 2013;27(4):966-972.

15. Bardenett S, Micca J, DeNoyelles J, Miller S, Jenk D, Brooks G. Functional movement

 Validity of FMS 13

screen normative values and validity in high school athletes: can the fms be used as a

predictor of injury?. International Journal Of Sports Physical Therapy [serial online].

June 2015;10(3):303-308.