FMS

1. See discussions, stats, and author profiles for this publication at: http://www.researchgate.net/publication/267753155
Relationship between functional movement
screening score and history of injury and
identifying the predictive value of the FMS for
injury
ARTICLE in INTERNATIONAL JOURNAL OF INJURY CONTROL AND SAFETY PROMOTION · DECEMBER 2014
Impact Factor: 0.67 · DOI: 10.1080/17457300.2013.833942 · Source: PubMed
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4 AUTHORS, INCLUDING:
Amir Letafatkar
Kharazmi University
9 PUBLICATIONS 7 CITATIONS
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Available from: Amir Letafatkar
Retrieved on: 06 November 2015

2. The International Journal of Sports Physical Therapy | Volume 9, Number 1 | February 2014 | Page 21
ABSTRACT
Background and Aim: The Functional Movement Screen (FMSTM
) is a screening instrument that evaluates selective
fundamental movement patterns. The main aim of this study was to investigate the relationship between the FMSTM
score and history of injury, and attempt to determine which active students are prone to injury.
Methods: One hundred physically active (50 females and 50 males) students, between 18 and 25 years of age, with no
recent (<6 weeks) history of musculoskeletal injury were recruited. All participants performed the FMSTM
and were
scored using the previously established standardized FMSTM
criteria. The chi square, independent t-test, one-way analy-
sis of variance, and POSTHOC Bonferroni tests were used for data analysis with a preset alpha value of p<0.05.
Results: Of the 100 subjects, 35 suffered an acute lower extremity (ankle=20, knee=15) injury in practice or compe-
tition. An odds ratio was calculated at 4.70, meaning that an athlete had an approximately 4.7 times greater chance of
suffering a lower extremity injury during a regular competitive season if they scored less than 17 on the FMSTM
. There
were statistical differences between the pre-season FMSTM
scores of the injured and non-injured groups, the ankle
injury, knee injury, and non-injured groups, and also between contact injury, non-contact injury, and non-injured
groups.
Discussion and Conclusion: This cross-sectional study provides FMSTM
reference values for physically active stu-
dents, which will assist in the interpretation of individual scores when screening athletes for musculoskeletal injury
and performance factors. More research is still necessary before implementing the FMSTM
into a pre-participation
physical examination (PPE) for athletics, but due to the low cost and its simplicity to implement, it should be consid-
ered by clinicians and researchers in the future.
Level of Evidence: 2B
Key words: Athletic performance, Functional Movement ScreenTM
, injury risk, physically active students, pre-participation
screening
IJSPT ORIGINAL RESEARCH
RELATIONSHIP BETWEEN FUNCTIONAL MOVEMENT
SCREENING SCORE AND HISTORY OF INJURY
Amir Letafatkar1
Malihe Hadadnezhad1
Sadredin Shojaedin1
Elham Mohamadi2
1
Health and Sport Medicine, Department of Sport Medicine,
Kharazmi University, Tehran, Iran
2
Health and Sport Medicine, Department of Sport Medicine,
University of Tehran, Tehran, Iran
CORRESPONDING AUTHOR
Amir Letafatkar
Health and Sport Medicine, Department of
Sport Medicine, Kharazmi University,
Tehran-Mirdamad Street, Physical Education
Faculty, South Razan Street, Tehran, Iran
15875-4398
Telephone: 22269545-6
Khletafatkar@ut.ac.ir; letafatkaramir@yahoo.
com

3. The International Journal of Sports Physical Therapy | Volume 9, Number 1 | February 2014 | Page 22
INTRODUCTION
Athletics has always carried an inherent risk for
injuries. Large numbers of participants in sport
can result in a high number of injuries. Determin-
ing an individual’s ability to participate in sport-
ing events requires careful evaluation of the rigors
and demands on the athlete within his/her desig-
nated sport.1
One of the primary responsibilities of
the sports medicine staff at all levels of athletics is
to attempt to prevent injury.2
Several authors have
evaluated risk factors that contribute to overall injury
rates in athletics such as previous injury, body mass
index, muscle flexibility, and biomechanics during
athletic movements. Intrinsic risk factors include:
agonist/antagonist muscle ratios for strength and
endurance, structural musculoskeletal abnormali-
ties, neuromuscular control, core weakness, contra-
lateral muscular imbalances.1-3
Most research in this
area has investigated these factors individually, but
recently attention has been directed at the multifac-
torial influence of several risk factors. The potential
to screen athletes for risk of injury during a pre-
participation physical examination (PPE) could be
extremely helpful and important. One instrument
that may be useful for these purposes is the Func-
tional Movement ScreenTM
(FMSTM
).2,3
The FMSTM
is designed to evaluate a variety of func-
tional movements that are proposed to be necessary
to participate in higher-level functions such as sport
or recreation. The FMSTM
requires the ability to move
through up to three planes of movement during the
assessment movements. The FMSTM
is assessed by
means of qualitative and quantitative information
regarding specialized motions related to functional
activities. The tests are often utilized for assessing
the athlete’s pain, muscle strength, lower extremity
joint stability in multiple planes of movement, mus-
cle flexibility, balance, and proprioception.4
The FMSTM
is comprised of a series of movements
designed to assess the quality of fundamental move-
ment patterns and presumably identify an individu-
al’s functional limitations or asymmetries. Previous
small studies have demonstrated that low FMSTM
scores (≤14) may associated with serious injury in
American football players and that FMSTM
scores can
be improved following a standardized intervention.2,5
In addition, a large interventional study in firefight-
ers suggested that FMSTM
assessment followed by an
eight week program designed to enhance functional
movement reduced time lost to injury by 62% when
compared with historical injury rates.6
The assess-
ment of fundamental movements is an attempt to
pinpoint deficient areas of mobility and stability that
may be overlooked in the asymptomatic active pop-
ulation. The difficulty in preventing injury seems
to be directly related to the inability to consistently
determine those athletes who are predisposed to
injuries. Meeuwisse suggested that unless specific
markers are identified for each individual, deter-
mining who is predisposed to injuries would be very
difficult.7
Numerous sports medicine professionals
have suggested the need for specific assessment
techniques that utilize a more functional approach
in order to identify movement deficits.7-10
The FMSTM
may be included in the pre-placement/
PPE or be used as a stand-alone assessment tech-
nique utilized to determine deficits that may be
overlooked during the traditional medical and per-
formance evaluations.12
In many cases, muscle flexi-
bility and strength imbalances may not be identified
during the traditional assessment methods. These
problems, previously acknowledged as significant
risk factors, can be identified using the FMSTM
.2
This
movement-based assessment serves to pinpoint
functional deficits (or biomarkers) related to pro-
prioceptive, mobility, and stability weaknesses.7-11
Therefore, the main aim of this study was to exam-
ine the relationship between FMSTM
score with his-
tory of injury, and attempt to determine which active
students are prone to injury.
METHODS
Subjects
The study employed a prospective cross-sectional
design and a reliability component. A convenience
sample of one hundred physically active students
(50 females and 50 males), weight 69.44±5.84 kg,
height 172.69±7.26 cm, and age 22.56±2.99 years
who participated in soccer, handball, and basketball
for at least for 5 years were recruited from a tertiary
student population. Subjects were included in the
study if they participated in sports at a competitive
or recreational level regularly (>1.5 h/week) in a
sport for at least 3 years. Exclusion criteria included

4. The International Journal of Sports Physical Therapy | Volume 9, Number 1 | February 2014 | Page 23
the use of a mobility aid or a prophylactic device (e.g.
knee brace) or if they had reported a recent (within
the past 6 weeks) musculoskeletal or head injury
that was likely to affect their motor performance
on the FMSTM
. Also, subjects with known physical
impairments were excluded. The University of Teh-
ran Human Ethics Committee approved the study
and written informed consent was obtained from all
subjects prior to data collection. The subjects were
required to read and sign consent forms approved
by The University of Kharazmi Institutional Review
Board.
Instrumentation
Instruments utilized included the FMSTM
Kit which
includes a measuring device, hurdle step, stretch
bands, measuring stick necessary for the deep squat,
hurdle step, in-line lunge, shoulder mobility, active
straight leg raise, trunk stability push up, rotary sta-
bility tests.
Data Collection Procedures
The data were collected by two members of the
research team, both physical therapists. A pilot
study was conducted with 20 participants in order
to achieve a reliable level of agreement between the
two test raters, which resulted in Kappa values >.80
for all tests that comprise the FMSTM
.
The average inter-tester reliability between tester
was high for FMSTM
tests (ICC =.877-.932).
The FMSTM
, developed by Cook and Burton, was
used in the study. The subjects tested in the study
were evaluated on the FMSTM
using the standard 0-3
ordinal system. A score of 3 was given for perform-
ing the specific movement perfectly, a 2 was given
when the movement was completed with some
compensatory movements observed, a score of 1
was given when the subject could not complete the
movement, and a score of 0 was given if pain was
present during the movement. The FMSTM
includes
seven movement tests: the deep squat, hurdle step,
in-line lunge, shoulder mobility, active straight leg
raise, trunk stability push-up, and rotary stability
tests.
The composite score for all seven movements of
the FMSTM
was recorded and then compared with
the injury documentation and tracking of the lower
extremity that occurred throughout the season,
which was achieved by the teams’ specific athletic
trainer and sports medicine staff. The injury docu-
mentation was completed after each team exposure,
where an exposure was considered one athlete per
practice or game (based on the time of session/
practice/game). Any acute lower extremity injury
that occurred and kept the athlete out of participa-
tion for one or more full consecutive exposures was
counted as an injury. If an athlete suffered multiple
or repeated acute injuries during the competition
season, only the first injury incident was included in
this analysis. Therefore, an athlete could not appear
more than once in the “injured” group’s analysis.
Data analysis
To determine if there was a significant difference in
FMSTM
scores between athletes that were injured and
athletes that were not injured during the regular com-
petitive seasons, independent t-tests were performed.
To determine if there was a significant difference
between sports, body parts of injured subjects, and
mechanism of injury, one-way analyses of variance
were used. To determine cut-off scores, a receiver-
operator characteristic (ROC) curve was used to plot
sensitivity (true positives) versus 1-specificity (false
positives) for the screening test.A
A 2x2 contingency
table was produced in order to dichotomize the
athletes that suffered an injury and those who did
not, as well as those who were above or below the
specified cutoff score. From the table, odds ratios,
likelihood ratios, sensitivity and specificity were
calculated. Chi-square tests were used to evaluate
if there were any significant differences between
males and females in the distribution of scores for
the different tests. The Intra-class Correlation Coef-
ficient (ICC model 3,1) was used to establish the
inter-rater reliability for the FMSTM
composite score,
A
Receiver operator characteristic curves are a plot of false
positives against true positives for all cut-off values. The area
under the curve of a perfect test is 1.0 and that of a useless test,
no better than tossing a coin, is 0.5. Many clinical tests are
used to confirm or refute the presence of a disease or further
the diagnostic process. Ideally such tests correctly identify all
patients with the disease, and similarly correctly identify all
patients who are disease free. In other words, a perfect test is
never positive in a patient who is disease free and is never
negative in a patient who is in fact diseased. Most clinical tests
fall short of this ideal.

5. The International Journal of Sports Physical Therapy | Volume 9, Number 1 | February 2014 | Page 24
and the unweighted Kappa statistic was used to
establish the inter-rater reliability measurement for
each item. The inter-rater reliability data were inter-
preted according to the categories defined by Landis
and Koch. A Kappa value over 86% represents excel-
lent agreement. All calculations were performed
using SPSS (version 16.0) and the a priori level of
significance was set at p ≤ 0.05.
RESULTS
One hundred subjects participated in the study, 50
females and 50 males. Table 1 presents the subject’s
demographic information. Table 2 presents the inter-
rater reliability results for the individual FMSTM
tests,
with levels of agreement ranging from substantial
to excellent. The inter-rater reliability (ICC) of the
composite score for both testers was .92, which indi-
cates excellent reliability.
The composite mean scores on the FMSTM
for
females, males and the entire sample were 16.3±1.2,
16.9±1.9, and 16.7±1.8 respectively. These scores
are presented in Table 3.
Differences observed between males and females in
trunk stability push-up, the rotary stability, active
SLR, and shoulder mobility tests were significant.
There were significant differences between football,
handball, and basketball sport groups. Basketball
players had lower scores in all seven FMSTM
tests.
For all subjects, a cut-off score of 17 was used that
maximized sensitivity (0.645) and specificity (0.780).
These findings resulted in a positive likelihood ratio
(Sensitivity/1--Specificity) of 2.46 and a negative
likelihood ratio (1-Sensitivity/Specificity) of 0.621
(Table 4). An overall odds ratio was calculated at
4.70, meaning that an athlete has an approximately
4.7 time greater chance of suffering a lower extrem-
ity injury during a regular season by scoring less
than 17 on the FMS™. By using the cut-off score of 17
Table 1. Demographic characteristics of subjects.
Table 2. Inter-rater reliability of individual FMSTM
tests.
Table 3. FMSTM
individual test scores for males and
females.
Table 4. Odds Ratio and Sensitivity/Specificity
calculations by FMS Scores.

6. The International Journal of Sports Physical Therapy | Volume 9, Number 1 | February 2014 | Page 25
a 2×2 contingency table was created to dichotomize
the subjects by their FMS™ score and injury status
after the regular competitive season (Table 5).
Therewasastatisticallysignificantdifferencebetween
the pre-season FMSTM
scores of the injured and the
non-injured groups (t100
=3.60; p=.005).
A one-way ANOVA revealed a statistically signifi-
cant difference between the ankle injury group,
knee injury group, and no injury group (F2,99
= 3.43;
p=.030). The Bonfferoni post hoc testing demon-
strated that the differences existed between the
ankle injury group and no injury group (p=.021), as
well as between the knee injury group and no injury
group (P=.030); but not between the ankle injury
group and knee injury group (p=.101).
The one-way ANOVA did reveal statistically signifi-
cant differences between the groups with a contact
injury, non-contact injury or no injury (F2,99
=2.11;
p=0.010). The Bonfferoni post hoc testing demon-
strated that differences existed between the non-
contact injury and no injury groups (p=.032), as
well as between the contact injury and no injury
groups (p=.013); but not between the contact and
non-contact injury groups (p=.217).
DISCUSSION
This study was designed to determine if a battery of
functional assessment tests relating to athletic per-
formance could be used to predict lower extremity
injury risk in a select group of subjects. Because of
compensations which may occur along the kinetic
chain during movements, isolation of individual
body parts may be necessary to determine if the sub-
ject is at, above, or below average in a certain area.
The most difficult challenge will be to determine
which tests are the most appropriate to use during
the screening process.
The composite score for all seven components of the
FMSTM
test was recorded and then compared with
the injury documentation and tracking of the lower
extremity injuries that occurred throughout the sea-
son by the teams’ specific athletic trainer and sports
medicine staff. The mean composite score reported
in this study is lower than that reported for a group
of professional male football players2
. It might be
expected that professional football players score
better than the average athlete due to their inten-
sive training regimens, however, in a subsequent
study on a similar cohort the mean pre-intervention
composite score was 11.8 for “lineman” and non-
lineman.5
The difference may relate to the cohort
studied, the specific training regimens undertaken
by each team or familiarity with the FMSTM
testing
procedures. Cowen14
studied male and female fire-
fighters whose mean baseline FMSTM
score was also
lower than the current study at 13.25. In the latter
two studies the composite FMSTM
score significantly
increased following an exercise-based intervention.
Based on this study, males were on average better
on the trunk stability push-up and the rotary stabil-
ity tests than females, and females performed bet-
ter on the active straight leg raise and the shoulder
mobility items. The trunk stability push-up is associ-
ated with upper body strength and stability (includ-
ing core stability in the sagittal plane), the rotary
stability test with transverse plane (rotational) core
stability, the active straight leg raise with flexibility
in the hamstring muscles, and the shoulder mobil-
ity test with range of motion in the shoulder com-
plex and thoracic spine.12
The sex differential finding
was supported by Kibler et al in a study that investi-
gated 2107 athletes from a variety of sports inclusive
of junior high to college levels.13
The rotary stabil-
ity test demands trunk stability in the sagittal and
transverse planes during asymmetric movement of
the upper and lower extremities.12
The FMSTM
train-
ing manual comments that it is difficult to obtain a
score of 3 (only 1 subject did so in the present study)
but it is included to capture elite performance. The
authors believe that the proper and perfect imple-
mentation of this test is not applicable for all, and
maybe only some professional athletes are able to
perform this test without error. The rotary stability
test does however provide the potential to measure
change following a specific exercise-training pro-
gram targeted at asymmetric or multi-planar trunk
stability.
Table 5. 2x2 Contingency Table for FMSTM
score data

7. The International Journal of Sports Physical Therapy | Volume 9, Number 1 | February 2014 | Page 26
In this study 27% of the participants had a score of
14 or less which might indicate a potentially higher
risk of injury. This is in comparison to the 22% of the
professional football players in the Kiesel et al study2
and 89% in the subsequent study by Kiesel et al5
who
scored below a 14 and were statistically deemed to
be more likely to be injured. The cutoff score of 14
was determined in a study on 46 professional football
players but, because of the small sample size and the
fact that the target group didn’t represent a general
athletic population, the authors of the current study
suggest that this cutoff value should be used with cau-
tion. Further studies need to be conducted on other
athletic and occupational groups before determining
a substantiated cutoff value.6,15,16
Preliminary studies with the FMSTM
have attempted
to examine risk of injury in a small number of NFL
football players.2,13
Kiesel et al retrospectively ana-
lyzed the relationship between FMSTM
scores for
National Football League (NFL) football players and
the likelihood of serious injury.2
FMS scores were
obtained before the start of the season for 46 NFL
players, and a score of ≤14 was found to positively
predict serious injury with a specificity of 0.91 and
sensitivity of 0.54; the odds of sustaining a serious
injury was 11.7 times higher in those with an FMS
score ≤14 compared with those with a score >14.
Kiesel et al also noted lower scores among those who
had been injured compared to those without injury.2
In the present study, when the authors compared
entry FMSTM
scores by no injury versus any injury,
the scores were the same and the odds ratio for sus-
taining a serious injury was 2.0; the sensitivity and
specificity were 0.67 and 0.90, respectively. Inter-
estingly, two groups have reported that FMSTM
did
not predict injury: one study was with 60 marathon
runners17
and another was on 112 basketball play-
ers.18
Hoover et al.17
reported 8.3% sensitivity and
94.5% specificity for marathon runners, whereas
Sorenson’s18
data yielded a sensitivity and specific-
ity of 53.8% and 52.3%, respectively, for basketball
players. The low sensitivity is problematic because
sensitivity above 50% is desirable so those predis-
posed to injury can be identified early and poten-
tially rehabilitated before injury. Although some
reports of specificity are high, this is in large part
explained by the small proportion of the cohort with
scores ≤14.2,4,6,17-19
The current study displays the need for additional
research of this nature to be conducted. Athletics
has transformed into a business at the collegiate
and professional levels. There seem to be unlimited
possibilities as far as pre-season screening tests and
collection of injury data in multiple sports at the col-
legiate and professional level.
CONCLUSION
The results of the current study demonstrated that
pre-season FMSTM
scores show a relationship with
injury in Kharazmi University athletes. Furthermore,
those who scored less than 17 on the FMS were 4.7
times more likely to sustain an injury of the lower
extremity. More research is still necessary before
implementing the FMSTM
into a PPE for athletics,
but due to the low cost and simplicity of implemen-
tation, it should be considered as a screening tool
by clinicians and researchers in the future. As more
evidence becomes available on the FMSTM
, it could
be an effective tool to use when screening athletes
and determining potential risk for injury.
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