[ research report ]

KYUNG-MI PARK, PT, MS1 • HEON-SEOCK CYNN, PT, PhD1 • SUNG-DAE CHOUNG, PT, BSc2

Musculoskeletal Predictors of Movement

Quality for the Forward Step-down Test
in Asymptomatic Women

V
isual observation of lower extremity movement patterns observational lower extremity movement-
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during various tasks is a common way to assess dynamic pattern tests should be adequate to sup-
port their use in clinical practice.
function and alignment in the clinical setting.7,19 Functional
The forward step-down (FSD) is a
movements, such as the lunge, step-up, step-down, single- functional task requiring stair descent,
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

leg press, bilateral squat, and balance
and reach, are frequently used to assess
movement quality of the lower extremi-
ties.2,5,19,20,22 Authors of previous studies
have reported moderate to good interrater
reliability for visual assessment of move-
TTSTUDY DESIGN: Cross-sectional.
TTOBJECTIVE: To investigate the interrater reli-
Journal of Orthopaedic & Sports Physical Therapy®
ment quality during a single-limb mini-
squat in healthy individuals (κ = 0.92)1
and a lateral step-down in healthy sub-
jects (κ = 0.59)25 and in those with patel-
lofemoral pain syndrome (κ = 0.67).25
Thus, the interrater reliability of these
were assessed by independent t tests.
TTRESULTS: The kappa coefficient and percent
which involves weight-bearing stress
at various knee flexion angles as well
as dynamic muscular control. Poor me-
chanics during an FSD task could place
abnormal stresses on the knee at both the
tibiofemoral and patellofemoral joints.18
Accordingly, the FSD task could be per-
formed either as a screening tool18 or as
an exercise for knee rehabilitation.8,31,32

Loudon et al18 used the FSD task as a

ability of movement-quality ratings for the forward
step-down (FSD) test and to compare hip muscle
strength and lower extremity joint range of mo-
tion and muscle flexibility among asymptomatic
women with different levels of movement quality.
TTBACKGROUND: The interrater reliability of
the FSD test has not yet been investigated. Ad-
ditionally, it is not known whether differences in
musculoskeletal measures exist among individuals
with different levels of movement quality during
the FSD test.
TTMETHODS: Two physical therapists assessed
movement quality during the FSD test in 26
a­symptomatic women (mean  SD age, 22.7 
0.9 years). Hip muscle strength and lower extrem-
ity joint range of motion and muscle flexibility were
also assessed. The interrater reliability of the FSD
test was estimated by using the kappa coefficient
and percent agreement. Differences in musculo­
skeletal measures based on movement quality
agreement for rating the quality of movement on
the FSD test were 0.80 (95% confidence interval:
0.57, 1.00) and 85%, respectively. The subjects
with moderate movement quality had significantly
less strength of the hip abductors, less knee flexion
range of motion measured in prone (quadriceps
flexibility), and less hip adduction range of motion
measured in sidelying (iliotibial band/tensor fascia
latae flexibility) compared to those with good
movement quality.
TTCONCLUSION: There was good agreement
for the rating of movement quality during the
FSD test, and there were physical attributes that
distinguished those with moderate from those
with good quality of movement. J Orthop Sports
Phys Ther 2013;43(7):504-510. Epub 11 June 2013.
doi:10.2519/jospt.2013.4073
TTKEY WORDS: abductors, hip, knee, reliability,
strength
screening tool to determine level of func-
tion and reported moderate to high in-
trarater reliability (intraclass correlation
coefficient model 3,1 = 0.94) in individu-
als with patellofemoral pain syndrome.
However, no studies have investigated
the interrater reliability of the FSD task
in healthy individuals, which is needed
to determine how suitable the test is for
clinical practice and screening for risk of
injuries.
An exaggerated dynamic knee valgus
during weight-bearing tasks can result
from many factors, including a lack of
muscular strength and flexibility.23,24 Dur-
ing weight-bearing tasks requiring knee
flexion, the hip abductors and external
rotators act eccentrically both to stabi-

1
Applied Kinesiology and Ergonomic Technology Laboratory, Department of Physical Therapy, The Graduate School, Yonsei University, Wonju, Gangwon-do, South Korea.
2
Department of Physical Therapy, The Graduate School, Yonsei University, Wonju, Gangwon-do, South Korea. The protocol for this study was approved by the Yonsei University
Wonju Campus Human Studies Committee. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial
interest in the subject matter or materials discussed in the article. Address correspondence to Dr Heon-Seock Cynn, Department of Physical Therapy, Yonsei University,
1 Yonseidae-gil, Wonju-si, Gangwon-do, South Korea. E-mail: cynn@yonsei.ac.kr t Copyright ©2013 Journal of Orthopaedic & Sports Physical Therapy ®

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 lize the pelvis in the frontal plane and to
control motion of the femur in the fron-
tal and transverse planes.16,24 Weakness
of these muscles can lead to excessive
hip adduction and hip internal rotation
during weight-bearing activities12 and,
consequently, to excessive knee valgus
alignment.13,24
Other potential factors can also lead
to poor lower extremity function during
weight-bearing tasks. Limited quadriceps
flexibility may limit knee flexion and re-
sult in greater ipsilateral hip adduction,
whereas limited iliotibial band/tensor
fascia latae (ITB/TFL) flexibility may
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lead to ipsilateral pelvic rotation in the
transverse plane, along with hip internal
rotation15,21 and tibial external rotation,
inducing knee valgus alignment.17 De-
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
creased hamstring and gastrocnemius
muscle flexibility may contribute to ab-
duction and external rotation of the tib-
ia, also facilitating dynamic knee valgus
alignment.3,17
The aims of this study were (1) to
investigate the interrater reliability of
the movement-quality ratings for the
FSD test and (2) to compare hip muscle
Journal of Orthopaedic & Sports Physical Therapy®
strength and lower extremity joint range
of motion and muscle flexibility among
asymptomatic women with different
levels of movement quality on the FSD
test. We hypothesized that (1) interrater
reliability of the movement-quality rat-
ings for the FSD would be high and (2)
women with lower levels of movement
quality would have less hip abductor and
external rotator muscle strength, greater
hip internal rotation range of motion,
and decreased flexibility of the ITB/TFL.
Women were selected for the study based
on a higher incidence of patellofemoral
joint pain in this population.4
METHODS
Subjects
T
wenty-six asymptomatic female
subjects were recruited from the
Department of Physical Therapy at
Yonsei University. All subjects had not
participated in regular strength training
journal of orthopaedic & sports physical therapy  |  volume 43  |  number 7  |  july 2013  |  505
43-07 Park.indd 505
or in a stretching program for at least 3
months prior to the study. The average
 SD age, height, and body mass of the
subjects were 22.7  0.9 years, 161.5 
4.2 cm, and 54.0  3.9 kg, respectively.
Subjects were included if they were pain
free and had no musculoskeletal or neu-
rological injuries in the lower extremities
or lumbar spine within the 6 months pri-
or to the study. Subjects were excluded if
they had undergone surgery for the lower
extremities or lumbar spine during the
6 months preceding the study, had any
balance impairments secondary to a ves-
tibular or neurological disorder, or used
medications that could cause dizziness
or loss of balance. All subjects read and
signed an informed-consent form prior
to participation. The protocol for the
study was approved by the Yonsei Uni-
versity Wonju Campus Human Studies
Committee.
The number of subjects in the study
was determined by calculating the ef-
fect size, based on previously published
data25 on the difference in ankle dorsiflex-
ion range of motion measured with knee
extension between subjects with different
levels of movement quality during the lat-
eral step-down test. With an effect size
of 1.26, power analysis indicated that a
total sample size of 18 participants was
required to achieve a significance level of
.05 and a power of 0.8.
Procedures
Two examiners participated in data col-
lection. One examiner had 2 years of
clinical experience in the field of applied
kinesiology and musculoskeletal physi-
cal therapy. The other examiner had
more than 6 years of clinical experience
in musculoskeletal physical therapy. Be-
fore data collection, the 2 examiners had
a 5-hour training session on the methods
to be used in the study. For reliability ex-
amination of the FSD test, the examin-
ers discussed the operational definition
and practiced scoring and classifying
subjects in 3 categories (good, moderate,
and poor), based on movement quality.
For musculoskeletal measurements (hip
muscle strength and lower extremity joint
range of motion and muscle flexibility),
the 2 examiners determined the testing
position and methods to detect end range
of movement, and standardized all pro-
cedures. Following this training session,
pilot testing was performed on 5 healthy
volunteers and final modifications of the
testing procedures were made.
The 2 examiners assessed the move-
ment quality of the FSD test simulta-
neously on each subject to establish
interrater reliability. Following the
FSD test, each examiner completed the
musculoskeletal measurements of the
subjects. The average value of the 2 exam-
iners was used for statistical analysis. The
data-collection session lasted approxi-
mately 40 minutes for each subject. The
order of musculoskeletal measurements
was randomly determined by drawing a
sealed envelope from a box, to account
for any potential effects of measurement
order. All testing was performed on the
dominant limb of each subject, defined
as the limb used to kick a ball.10
FSD Test
The FSD test used in this study was a
modification of the test used by Piva et
al22 (FIGURE). Prior to performing the test,
the tibial tuberosity of the tested limb and
the vertical front edge of the step, just
under the second toe of the tested limb,
were marked with a 1-cm red sticker to
facilitate visualization. Next, the height of
the step was adjusted so that each partici-
pant achieved 60° of knee flexion during
the test. If the heel of the nontested limb
did not contact the floor when the knee
of the tested limb was bent to 60°, wood
blocks were placed on the step to ensure
that the knee of the tested limb reached
60° of flexion when the heel of the non-
tested limb touched the floor.
For testing, the subject stood on a
20-cm step, with the foot of the tested
limb close to the edge of the step and the
nontested limb positioned in front of the
step, with the knee straight and the ankle
at maximum dorsiflexion. Subjects were
asked to keep their trunk straight, hands
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 [ research report
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Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
FIGURE. (A) Start and (B) end positions for the forward step-down test.
on their waist, and to bend the knee on
the tested side until the heel of the non-
tested limb touched the floor. The sub-
jects were asked not to apply any weight
on the heel of the nontested limb once it
Journal of Orthopaedic & Sports Physical Therapy®
reached the floor and to immediately re-
extend the knee of the tested limb to re-
turn to the starting position. The subjects
performed 5 consecutive FSD movements
after 3 minutes of familiarization. After
the 5 consecutive trials were completed,
each examiner rated the performance of
the subject across all 5 repetitions of the
FSD. Standing 3 m directly in front of
and facing the subject, both examiners
scored the test simultaneously, based on
the following 5 criteria:
1. Arm strategy: if the subject used an
arm strategy to recover balance, 1
point was given. Because subjects were
instructed to keep their hands on their
waist, removing their hands from their
waist was interpreted as a strategy to
recover balance.
2. Trunk movement: if the subject leaned
the trunk to either side, interpreted as
recovering balance, 1 point was given.
3. Pelvic plane: if 1 side of the pelvis was
rotated in the transverse plane or el-
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43-07 Park.indd 506
evated in the frontal plane compared
with the other side, 1 point was given.
4. Knee position: if the knee of the tested
limb moved medially in the frontal
plane and the tibial tuberosity crossed
an imaginary vertical line positioned
directly over the second toe of the
tested foot, 1 point was given. If the
knee moved medially and the tibial tu-
berosity crossed an imaginary vertical
line positioned directly over the me-
dial border of the tested foot, 2 points
were given.
5. Maintenance of a steady unilateral
stance: if the subject had to support
body weight on the nontested limb, or
the foot of the tested limb moved dur-
ing testing, 1 point was given.
A total score of 0 or 1 was classified as
good movement quality, a total score of 2
or 3 was classified as moderate movement
quality, and a total score of 4 or more was
classified as poor movement quality. Each
examiner rated the performance of the
test individually for each subject. No dis-
cussion was allowed between the examin-
ers during the performance and scoring
of the test. The raters’ scores of the FSD
test were used for the calculation of inter-
]
rater reliability.
Immediately after testing, the 2 exam-
iners compared their ratings to determine
if they agreed on the good, moderate, or
poor classification. Consensus was re-
quired to assign each subject to a single
category for the analysis comparing
musculoskeletal measurements between
groups of different movement quality. If
consensus was not present between the 2
raters, the subjects were asked to repeat 5
additional FSD movements to finalize the
classification. Only 4 of 26 subjects were
rated differently between the 2 examiners
and needed to repeat the test.
Strength Testing
Strength testing of the hip abductors
and external rotators was performed
with a handheld dynamometer (Lafay-
ette Manual Muscle Testing System; La-
fayette Instrument Company, Lafayette,
IN), as described by Piva et al,22 who re-
ported intraclass correlation coefficients
of 0.85 and 0.79, respectively, for inter-
rater reliability. Muscle strength was re-
corded in kilograms and normalized by
dividing the raw score by the participant’s
body mass. Each trial was performed for
3 seconds, with 1 minute of rest between
trials. Each subject was allowed 2 repeti-
tions for practice, and the results of the
3 subsequent repetitions were averaged
and recorded.
Hip Abduction Strength Hip abduction
muscle strength was measured in the
sidelying position, with the subject ly-
ing on the nontested side. The subject’s
tested hip was in approximately 30° of
abduction and 5° of extension, and the
iliac crest of the tested side was manu-
ally stabilized by the examiner. The sub-
ject performed isometric hip abduction
against the resistance of the handheld
dynamometer, which was placed just
proximal to the lateral malleolus.
Hip External Rotation Strength Hip
external rotation muscle strength was
tested with the subject prone on the
table, the tested knee flexed to 90°, and
the hip in neutral. The nontested limb
was positioned with the hip in the neu-
6/19/2013 1:09:05 PM
 tral position and full knee extension. The
examiner manually fixed the subject’s
pelvis with 1 hand. The subject exerted
an isometric action of the hip external
rotators against the resistance of the
handheld dynamometer, positioned just
proximal to the medial malleolus of the
tested limb.
Range-of-Motion Testing
Hip external and internal rotation, ad-
duction, flexion, as well as knee flexion
range of motion were measured with
a fluid-filled inclinometer (MIE Medi-
cal Research Ltd, Leeds, UK).29 Ankle
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dorsiflexion range of motion was mea-
sured with a universal goniometer in 1°
increments. Intraclass correlation coef-
ficients for interrater reliability of these
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
range-of-motion measurements have
been reported to be higher than 0.82.22,26
For this study, 1 examiner performed the
measurements while the other examiner
read and recorded the values. The incli-
nometer was first zeroed on a fixed verti-
cal reference prior to the measurements.
Two practice repetitions were performed
to ensure that the subject was relaxed
Journal of Orthopaedic & Sports Physical Therapy®
and comfortable. Data are the average of
3 measurements, taken with 5 seconds
between trials.
Hip External Rotation Hip external ro-
tation was measured with the subject in
a prone position. The knee of the tested
limb was flexed to 90°, and the nontested
hip was abducted about 30°, so that the
hip motion on the tested side would not
be obstructed. The starting position for
measuring hip rotation was determined
by positioning the tested tibia perpen-
dicular to the support surface. The in-
clinometer was positioned on the distal
third of the fibula. The examiner manu-
ally fixed the subject’s pelvis at neutral
with 1 hand, then moved the tested limb
through passive hip external rotation.
End range of motion was defined as the
point at which the lower shank could no
longer be moved without pelvic rotation.
Hip Internal Rotation Hip internal ro-
tation was determined in the same way
as the measurement of hip external rota-
journal of orthopaedic & sports physical therapy  |  volume 43  |  number 7  |  july 2013  |  507
43-07 Park.indd 507
tion, except that the tested hip was inter-
nally rotated.
Knee Flexion in Prone (Quadriceps Flex-
ibility) The examiner manually fixed the
subject’s pelvis in neutral with 1 hand
to avoid anterior tilting of the pelvis or
extension of the lumbar spine. The incli-
nometer was placed over the distal half
of the anterior border of the tibia. The
knee on the tested side was then pas-
sively flexed to end range of motion. The
measurement was taken when the lum-
bar spine or pelvis first began to move
or when the end range of motion was
achieved. The opposite limb remained
flat on the table.
Hip Adduction in the Sidelying Posi-
tion (ITB/TFL Flexibility) Hip adduc-
tion was examined using the Ober test.16
The subject was positioned lying on the
side, with the tested limb in the superior
position and the knee flexed at 90°. The
nontested limb was slightly flexed at the
hip and knee to maintain stability on the
table. The examiner manually fixed the
subject’s pelvis in neutral with 1 hand and
grasped just below the knee of the tested
side with the other hand. The inclinom-
eter was placed over the distal portion of
the tested thigh. The examiner moved the
tested thigh first in flexion, then through
abduction combined with extension, un-
til the hip was positioned in midrange hip
abduction with neutral flexion/extension.
From this position, the thigh was allowed
to drop toward the table until the thigh
stopped, at which point the inclinometer
value was recorded.
Hip Flexion in the Supine Position (Ham-
string Flexibility) The subject was placed
in the supine position with the knee of
the tested limb in full extension. The
nontested limb remained flat on the table
to avoid posterior pelvic tilt. The exam-
iner lifted the tested limb in hip flexion,
while maintaining the knee in full exten-
sion. The inclinometer was placed on the
distal half of the anterior border of the
tibia. The measurement was taken when
no further motion occurred or when the
examiner noted any change in the posi-
tion of the pelvis.
Ankle Dorsiflexion With the Knee Ex-
tended (Gastrocnemius Flexibility) The
subject was positioned in the prone posi-
tion, feet over the edge of the table. The
foot of the tested ankle was maintained in
subtalar joint neutral, with the examiner
palpating the medial and lateral aspects
of the head of the talus. Dorsiflexion was
measured as the angle formed by the line
from the head of the fibula to the tip of
the lateral malleolus and the lateral mid-
line of the foot, using the border of the
rearfoot/calcaneus.
Statistical Analysis
Kappa coefficients and percent agree-
ment between examiners were used as
estimates of interrater reliability for the
rating of the quality of movement on the
FSD test. Kappa values of 0.20 or less
were considered poor, 0.21 to 0.40 fair,
0.41 to 0.60 moderate, and greater than
0.60 good.30 All of the continuous vari-
ables were found to approximate a nor-
mal distribution (Kolmogorov-Smirnov
Z test, P>.05). Independent t tests were
used to identify differences in demo-
graphic variables (age, height, and body
mass), as well as in the musculoskeletal
measurements between subjects with
good and moderate movement quality
on the FSD test. The alpha level was set
at .05. All statistical analyses were per-
formed using PASW Statistics 18 (SPSS
Inc, Chicago, IL).
RESULTS
T
he examiners rated the move-
ment quality on the FSD test as
good for 11 subjects, moderate for 14
subjects, and poor for 1 subject. The kap-
pa coefficient (95% confidence interval)
and percent agreement for the interrater
reliability of rating the quality of move-
ment for the FSD test were 0.80 (0.57,
1.00) and 85%, respectively. The results
of the independent t tests (excluding
the subject with the poor rating) assess-
ing the differences in demographics and
musculoskeletal measurements between
the good and moderate groups are sum-
6/19/2013 1:09:07 PM
 [ research report ]
marized in TABLE 1. Significantly less hip
abductor strength, knee flexion range of Subject Characteristics for Groups  
TABLE 1
motion in the prone position, and hip ad- Based on Quality of Movement*
duction range of motion in the sidelying
position were found in the subjects with Moderate
moderate movement quality compared to Good (n = 11) (n = 14) Poor (n = 1) P Value
those with good movement quality. The Age, y 22.5  0.8 22.6  0.8 25.0 .580
frequency of movement deviations for Height, cm 161.6  4.3 161.7  4.2 158.0 .964

each group, as rated by raters 1 and 2, is Body mass, kg 52.4  3.7 55.3  3.6 50.0 .063

summarized in TABLE 2. Hip abduction strength, % body mass 9.4  2.5 7.0  2.5 6.7 .024†
Hip external rotation strength, % body mass 11.7  2.3 11.5  3.9 13.1 .915

DISCUSSION Hip external rotation ROM, deg 52.2  6.7 53.0  9.1 31.0 .814
Hip internal rotation ROM, deg 42.9  8.7 45.2  6.8 67.3 .474

T
he purposes of this study were Knee flexion ROM, deg 148.2  7.9 141.2  4.9 133.7 .013†

to investigate the interrater reliabil- Hip adduction ROM, deg 10.7  4.8 6.4  2.7 0.8 .010†
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Hip flexion ROM, deg 61.0  7.7 61.6  12.0 55.7 .873
ity of assessing movement quality
Ankle dorsiflexion ROM, deg 6.6  4.1 5.3  2.7 6.0 .374
of the lower extremity during the FSD
test and to compare the musculoskeletal Abbreviation: ROM, range of motion.
*Values are mean  SD.
characteristics between asymptomatic †
Significantly different between good and moderate groups (P<.05), independent t test.
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

women with different levels of movement

quality. The primary findings were that
the kappa coefficient and percent agree-
Frequency of Movement Deviation for  
ment of the FSD test were high, and that TABLE 2
Groups Based on Quality of Movement
the subjects with moderate movement
quality had significantly less hip abduc-
Arm Strategy Trunk Alignment Pelvis Plane Knee Position Steady Stance
tor strength and quadriceps and ITB/
Rater 1
TFL flexibility compared to those with
Good (n = 11) 0 5 1 1 2
good movement quality.
Journal of Orthopaedic & Sports Physical Therapy®

The interrater reliability of the clas-
sification system for rating movement
quality during the FSD test in our inves-
tigation (κ = 0.80; agreement, 85%) was
similar to that previously reported by
Piva et al22 (κ = 0.67; agreement, 80%),
who used the same classification system
during a lateral step-down test in patients
with patellofemoral pain syndrome. In
contrast, previous studies reported bet-
ter interrater reliability for movement
quality assessed during functional tasks.
Ageberg et al1 reported high interrater
reliability (κ>0.90; agreement, 96%) for
the visual assessment of mediolateral
knee motion during a single-limb mini-
squat. Similarly, Ekegren et al11 reported
high intrarater reliability (κ = 0.75-0.85;
agreement, 88%-90%) for visual ratings
of dynamic knee valgus during a drop
jump performed by healthy participants.
These differences in interrater reliability
can be partially explained by the classi-
fication criteria. These authors1,11 used a
Moderate (n = 14) 0 10
Poor (n = 1) 0 1
Rater 2
Good (n = 11) 0 6
Moderate (n = 14) 0 9
Poor (n = 1) 0 1
classification system solely based on the
frontal plane position of the knee relative
to the foot. In contrast, the classification
system used in this study is more com-
prehensive and requires the simultaneous
evaluation of arm strategy, trunk, pelvis,
knee alignment, and balance. This great-
er number of scoring criteria might have
increased the probability of disagreement
between raters.
In this study, the examiners rated
the movement quality on the FSD test
as good for 11 subjects and moderate for
14 subjects. In addition, 1 subject (3.8%)
was considered to have poor movement
quality during the FSD. Chmielewski et
al5 reported that 11.5% of uninjured sub-
12 5 7
1 1 1
1 1 1
12 6 7
1 1 1
jects who performed a lateral step-down
task had a poor movement rating. It is
possible that the greater the number of
deviations during the FSD, the greater
the potential risk of limited performance
and injury.
Previous studies have established
an association between hip abductor
weakness and altered movement pat-
tern during dynamic activities.6,9,14,26,28
Our findings are consistent with these
studies, as we found that subjects with
a moderate movement quality during
the FSD showed relatively lower hip ab-
duction strength than those with good
movement quality. Hip abduction mus-
culature provides pelvis and stance limb

508  |  july 2013  |  volume 43  |  number 7  |  journal of orthopaedic & sports physical therapy

43-07 Park.indd 508 6/19/2013 1:09:08 PM

 stability by eccentric control during
weight-bearing activities.12,16 Weakness
of the hip abductors can lead to excessive
femoral adduction, a contralateral pelvic
drop, or both during weight-bearing ac-
tivities.24 This, in turn, can alter hip and
knee joint mechanics.24 The 2 movement
alterations more likely to occur as a result
of weaker hip abductors are changes in
trunk alignment and pelvic plane motion,
which were the most frequent movement
deviations noted in our sample (TABLE
2). Leaning the trunk laterally over the
stance leg shifts the center of mass over
the hip joint center, thereby reducing the
Downloaded from www.jospt.org at on May 1, 2023. For personal use only. No other uses without permission.
internal abduction moment demand on
the weak muscles.21 In addition, elevat-
ing the contralateral pelvis is a common
compensation strategy for reducing the
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
demand on the hip abductors, as it moves
the ground reaction force vector closer to
the hip joint center.23
In this study, strength of the hip ex-
ternal rotators was not reduced in those
with moderate quality of movement,
suggesting that the trunk lean and pelvic
rotation exhibited in the moderate group
during the FSD test were not caused by
Journal of Orthopaedic & Sports Physical Therapy®
weak hip external rotators.
Our findings showed that there was
no significant difference in hip external
and internal rotation range of motion
between the groups with good and mod-
erate quality of movement. Rabin and
Kozol25 investigated hip external and
internal rotation range of motion during
the lateral step-down test in healthy fe-
males and reported no significant differ-
ence between groups with different levels
of movement quality. In contrast to our
findings, Sigward et al27 demonstrated
decreased hip external rotation range of
motion among subjects with greater me-
dial displacement of the knee during the
drop-land task. The difference between
our findings and those of Sigward et al27
may be due to differences in the function-
al task used in the 2 studies (drop landing
versus FSD).
The subjects with moderate move-
ment quality had relatively lower quad-
riceps flexibility compared to those with
journal of orthopaedic & sports physical therapy  |  volume 43  |  number 7  |  july 2013  |  509
43-07 Park.indd 509
good movement quality. As the knee only
needed to be flexed to 60° during the FSD
test, it is not clear how reduced flexibility
could be associated with poor quality of
movement. Our data also indicated that
individuals with moderate movement
quality had less ITB/TFL flexibility. De-
creased muscle flexibility of the ITB/TFL
may lead to ipsilateral rotation of the pel-
vis in the transverse plane, internal rota-
tion of the hip,15,21 and external rotation of
the tibia, thus facilitating dynamic knee
valgus alignment.17 Finally, our study
found no difference in hamstring and
gastrocnemius flexibility between sub-
jects with good and moderate quality of
movement on the FSD, suggesting that
hamstring and gastrocnemius flexibility
may not be responsible for the movement
deviation observed in a­symptomatic
women exhibiting moderate quality of
movement during the FSD test.
Our study has some limitations. First,
the findings are limited to asymptomatic
women, which limits the generalizability
of the results to other populations, in-
cluding asymptomatic males or patients
with a knee disorder. Second, because the
subjects of this study were recruited from
the Department of Physical Therapy, we
cannot rule out subject bias, as these
individuals could have had knowledge
of good and bad movement patterns.
However, we provided consistent verbal
instruction to each subject to reduce this
bias. Third, because the functional move-
ment test was performed first and the
musculoskeletal measurements second,
the potential for examiner bias during
the musculoskeletal measurements can-
not be excluded. Fourth, we examined
reliability using a categorical distribution
(good, moderate, and poor) and not each
movement deviation, which could have
affected reliability ratings. Although the
frequency distribution was similar be-
tween raters, it does not guarantee that
for each trial the raters observed the same
movement deviation. Fifth, a cause-and-
effect relationship between movement
pattern and noted strength and flexibil-
ity differences between groups cannot be
assumed, given the cross-sectional de-
sign of the study. Finally, the validity of
using movement quality on the FSD test
to predict those at greater risk of injuries
is unknown.
CONCLUSION
A
ssessment of movement quality
on the FSD test had good interrater
reliability. Asymptomatic women
with moderate movement quality during
the FSD test exhibited less hip abduction
strength and decreased quadriceps and
ITB/TFL flexibility compared to those
with good movement quality. t
KEY POINTS
FINDINGS: Assessment of movement qual-
ity on the FSD test had good interrater
reliability. Asymptomatic women with
moderate movement quality during the
FSD test exhibited less hip abduction
strength and decreased quadriceps and
ITB/TFL flexibility compared to those
with good movement quality.
IMPLICATIONS: Clinicians should consider
assessment of hip abductor strength and
flexibility of the quadriceps and ITB/
TFL when individuals demonstrate poor
quality of movement on the FSD test.
CAUTION: The results of this study are
limited to asymptomatic women.
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mechanical measures of neuromuscular jospt.2010.3337
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510  |  july 2013  |  volume 43  |  number 7  |  journal of orthopaedic & sports physical therapy

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