SCW Corrective Exercise and Coaching Proper Movement

Course developed by Fabio Comana, MA., MS for SCW

Fabio Comana, M.A., M.S.,

NASM CPT, CES & PES; NSCA CSCS; ACE-CPT & HC; ACSM EP-C; USAW1; CISSN

SDSU and NASM faculty, scientific advisor for OrangeTheory Fitness, Core Health and Fitness,
and Caloric Responsibility; and Educational Instructor for SCW. Previously, with ACE, he was
the original creator of ACE’s IFT™ model and their live educational workshops. Prior
experiences include Division I collegiate head coach and strength-conditioning coach;
opening/managing clubs for Club One, and president of Genesis Wellness Consulting. He is a
national and international presenter; media spokesperson and accomplished author.

Welcome to the Course

Greetings and thank you for enrolling in this course. As exercise-related injuries continue to
increase in fitness, there is a greater need today than ever for fitness professionals to recognize
movement dysfunction, implement corrective techniques and then coach proper form. This
requires an understanding of the relationship of stability and mobility throughout the kinetic
chain and how they function in exercise and movement. Through this course, you will learn how
to conduct and interpret key movement screens and then implement a corrective exercise
program to restore the body’s proper biological design. Additionally, you will also learn how to
effectively coach the five primary movement patterns as a pre-requisite to any exercise so that
they can be performed safely and effectively, and without the risk of injury.

Learning Objectives:
1. Describe the roles of stability and mobility throughout the entire kinetic chain
2. Explain how movement dysfunction occurs when either stability or mobility is lacking.
3. Identify common movement dysfunctions often witnessed in various exercises using
movement screens.
4. Implement corrective exercise techniques to promote movement efficiency.
5. Develop specific unloaded and loaded movements and exercises that improve or maintain
kinetic chain stability and mobility.

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 Module 1: Introduction

A fundamental trait we all share is the ‘need to move.’ In fact, for almost all species, survival is
predicated upon this ability – to find food, water, shelter and even a mate. This notion is
supported by an endless volume of research effectively demonstrating how movement, physical
activity and exercise that can all extend longevity (1). Essentially, individuals who move more
often increase their longevity potential whereas sedentary individuals experience rapid
deteriorations in their overall well-being and will ultimately cease to exist.

However, it is also important to recognize that not all movement is equal. Apart from the obvious
benefits of frequency, intensity, duration (time) and type (i.e., FITT), it is the quality of
movement that merits serious consideration given the number of people who suffer from chronic
or overuse injuries. It is estimated that approximately 100 million Americans suffer from some
form of chronic injury and pain, a figure that exceeds the combined number of individuals
diagnosed with diabetes, heart disease and cancer combined (2). These chronic injuries are most
often attributed to habitually bad or awkward postures, poor movement mechanics or training
methods, structural abnormalities, or specific muscular weaknesses or imbalances, and incur
costs estimated to range between $560-and-$635 billion annually (3).

So, while the reasons for participating in movement, activity or exercise are varied, a consistent
theme is the need to move efficiently, to avoid injury and dysfunction. The focus of this course
therefore is to (a) identify existing movement dysfunction(s) using movement screens, (b) to
correct this dysfunction via corrective exercise techniques, and (c) to understand how to coach
proper mechanics that promote safe and efficient movement anytime one performs their ADLs or
exercise.

References:
1. Centers for Disease Control and Prevention, (2018). Morbidity and Mortality Weekly Reports
(MMWR). Retrieved Dec 2018.
2. National Academy of Sciences, (2017).
3. American Academy of Pain Medicine, (2017). AAPM Facts and Figures on Pain.
http://www.painmed.org/patientcenter/facts_on_pain.aspx. Retrieved Dec 2018.

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 Module 2: Functional Design

Efficient movement requires appropriate levels of stability while simultaneously possessing

appropriate levels of mobility.
• Stability can be defined as the ability to maintain or control joint position or movement. A
building or a body is considered stable when it does not move (e.g., seated, static standing
positions), but because humans need to move, a better definition is the ability to control
movement. To understand this concept, first recognize that the body has the capacity to
generate tremendous speeds and forces (e.g., throwing a baseball), but those forces also need
to be decelerated rapidly at end-ranges to avoid injury to joints or tissue. Think of a glass
door being slammed forcefully – this might shatter the glass, but a door fitted with a spring or
hydraulic closer can absorb those forces and decelerate its momentum to save the glass. In a
similar fashion, the body’s elastic tissue offers resistance and a braking effect as it becomes
lengthened, much like a rubber band. The ability to control movement especially when it
needs to be slowed, is a critical component of stability.
• Mobility goes by many definitions, one being the ability of a segment or joint to possess
uninhibited range-of-motion (ROM). This course will explore this concept of mobility in
greater detail and will discuss the idea that it is more than simply muscle extensibility or the
measure of flexibility at a joint. It is the cumulative effects of the neuromuscular (i.e.,
coordination of nerve-muscle action) and fascial systems, coupled with joint design and
structure (i.e., passive structures) that function collectively to promote efficient movement.

Figure 2-1: The roles of stability and mobility in the body

Although every joint and segment contain properties of both stability and mobility, they tend to
favor one over the other based upon their unique design and function (refer to Figure 2-2
presented below). Regardless, what is important to appreciate is that stability should never

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compromise mobility and vice versa because too much of one property can negatively impact the
other. For example, a common issue with the glenohumeral joint may be inadequate stability
when performing specific movements because of the high degree of mobility the joint offers
given its anatomical structure.

Figure 2-2 presents a simplified approach to understanding the relationship between stability and
mobility throughout the human body. Using gait (walking) as an example, during the latter stages
of the leg swing instant (phase) the foot moves into a supinated position (i.e., rolling weight to
the outer edge of the foot) in preparation for heel strike. Upon making ground contact with the
outside of the heel, the calcaneus (heel bone) moves inward (inversion) which moves the many
bones of the foot closer together. Like how the individual sections of a bridge are tightly packed
together to create stiffness, rigidity and stability, calcaneal inversion moves the bones closer to
create stability to accept the load (i.e., body weight) being transferred into that lead foot (1).

FYI – the load transferred into the lead foot is greater than the person’s body weight because the
limb is being accelerated towards the floor by gravity (load might be two times body weight).

After the heel strike instant, as the forefoot lowers towards the floor, the foot moves back
towards pronation (calcaneal
eversion) to create mobility
between the bones and to allow
soft tissue within the arches of
the foot (i.e., longitudinal arches,
medial arch) to absorb the impact
or reactive forces from the
ground. As gait continues, the
foot moves towards the
propulsion instants (i.e., heel-off,
toe-off), moving back towards
supination to create a rigid
platform from which the body is

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propelled. To experience this firsthand, attempt to perform a standing calf-raise exercise. The
natural movement of the foot is to move into a supinated position as the heel lifts off the floor to
provide stiffness or rigidity for the push movement. Pronate the foot and repeat the movement –
notice how uncomfortable and unstable it feels.

What this variety of movements mean is that the foot, with 26 bones and 33 joints, functions
both as a rigid lever during heel strike and heel/toe-off, but also acts as a mobile adaptor to
absorb the impact forces. However, the key instants of heel strike and heel/toe-off during
walking, and the rigid platform needed when performing movements from a static position (e.g.,
squat) all require stability, helping identify the key role of this segment as stable.

The various movements of the foot during gait are made possible by movements occurring at the
ankle which is comprised of various joints. Using the analogy of a horse, a saddle and a rider
where the calcaneus represents the horse, the talus bone represents the saddle and the tibia
represents the rider, we gai a better understanding their individual movements. In the same way
that a rider moves forwards and backwards in a saddle (i.e., sagittal plane movement between the
rider and saddle), dorsi- and plantarflexion occur at the articulation between the tibia and talus
(talocrural joint). However, a loosely fastened saddle will slide around the belly of the horse and
this represents the movements of supination and pronation which occurs at the articulation
between the talus and calcaneus (sub-talar joint). There is also movement within the ankle to
permit small amounts of inversion and eversion which will not be discussed. This series of three-
dimensional movement qualifies the ankle as a mobile joint.

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The knee functions primarily in the sagittal plane, permitting flexion and extension during
walking while simultaneously controlling (minimizing) movement into the other planes (e.g.,
valgus – inward knee collapse; varus – outward knee collapse) which aid in preventing knee
injury or harm. This control of the plane of movement qualifies the knee as stable.

Within the hips, every step tilts the individual pelvic bones forward (anterior tilt) and backwards
(posterior tilt); every single-leg stance position shifts the hips laterally in the frontal plane to
preserve balance and avoid falling over; and with every step, as the trailing limb swings forward
the hips rotate medially (i.e., in the direction of the opposite limb). For example, as the left leg
swings forward, the hips rotate towards the right. This series of three-dimensional movement
qualifies the hips as mobile.

As demonstrated, an alternating pattern of stability and mobility exists through the kinetic chain
and when continuing upwards it is the lumbar spine that favors stability whereas the thoracic
spine favors mobility:
• The lumbar spine is comprised of big vertebrae that support of the mass of the entire upper
extremity. This region demonstrates a good amount of sagittal plane movement (i.e.,
flexion/extension), but only provides small amounts of movement in the other planes (i.e.,
lateral flexion, rotation).

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• The thoracic spine can be deceiving because the rib-cage gives the impression of limited
movement, but each individual rib coupled with costal cartilage have significant
independence in movement.

Your Turn…. Assume a hunched-over position like an older person demonstrating excessive
thoracic kyphosis. From this position, attempt to raise one arm overhead – notice the inability to
fully extend the elbow? Next, continue trying to extend the elbow, but now extend the spine –
notice how the elbow moves into full extension. The raises the question to how the thoracic spine
affects movement of the elbow joint? The answer lies with the need for the scapulae to tilt
backwards 20-to-40 degrees during this movement to facilitate an overhead arm position.
However, with excessive thoracic kyphosis, the ribcage impedes posterior scapulae tilt, therefore
limiting arm movement overhead, but as the thoracic spine extends, adequate space develops to
permit this posterior tilt.

SIDEBAR
This idea that movement of the arm involves a distant segment (i.e., thoracic spine) introduces an
important concept for all health-fitness practitioners to remember, that being that …. Movement is
an integrated and interconnected approach, rather than an isolated process. This becomes
important when examining movement dysfunction and pain. Traditional practices often
identify the location of dysfunction or pain as the location of the cause, when in fact the
location of dysfunction or pain may simply be the site of manifestation and not the actual
cause.
SIDEBAR

Table 2-1 provides a summary of what is illustrated in Figure 2-2. Considering the alternating
pattern of stability and mobility throughout the kinetic chain, if the thoracic spine is mobile and
the glenohumeral joint is mobile, then there must be a stable segment between these two
segments. This is the scapulothoracic segment or the region where the scapulae articulate with
the ribcage and involves several joints (e.g., sternoclavicular, acromion), hence the term region
or segment rather than joint. Although the scapulae move in 10 different directions, they must
retain a stable articulation with the ribcage because they serve as the platform for humeral action
(e.g., push or press movement, pull movements). In the same way that the ground provides a

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platform to the feet for push movements (e.g., squatting), the scapulae provides a platform to the
humerus for upper extremity movements. Whereas the feet have three points of contact with the
floor (i.e., heel, first metatarsal joint, 4th/5th metatarsal joints) to provide a balanced platform, the
humerus only has one point of contact with the shoulder blade and its location is in an offset
position and not in the middle of the scapulae – this increases the challenge of achieving
shoulder stability. Furthermore, the scapulae only affix to the axial skeleton via the clavicle, a
thin S-shaped bone that offers minimal support. Subsequently, the scapulae rely upon 17
different parascapular muscles to provide stability. The 10 different scapulae movements
include:
• Upward and downward rotation.
• Protraction and retraction.
• Elevation and depression.
• Abduction (movement away from spine) and adduction (movement towards spine).
• Anterior and posterior tilting.

Table 2-1: Summary of the stability-mobility relationship throughout the kinetic chain.

Body Segment Stability Mobility

Foot X
Ankle X
Knee X
Hips X
Lumbar Spine X
Thoracic Spine X
Scapulothoracic segment X
Glenohumeral X
Elbow X
Wrist X

What happens then when the body needs to move, but is perhaps lacking stability, or worse yet,
mobility? Using the analogy of living in an apartment complex and making a cake, the easiest
thing to do if you lack an ingredient is to simply borrow from your neighbor. Similarly, if the
body lacks mobility at a segment, one common compensation is to borrow movement from its

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neighbor. In this case, the neighbor or segment favors stability which subsequently becomes less
stable. This increases that segment’s potential for injury. Examining this concept more closely:
• As a society who sits for prolonged periods hunched over phones and computers, the body
loses hip and thoracic mobility which compromises stability within the lumber spine.
• As a society who enjoy wearing shoes with elevated heels and sitting, the body loses ankle
and hip mobility which compromises stability at the knee.
• As a society who sits hunched over, yet thrives on performing overhead movements (e.g.,
popular exercises today – American KB swings, clean-and-press), the body demands
glenohumeral mobility, but lacks thoracic mobility which compromises stability within the
scapulothoracic region.

FYI …. Experts estimate that up to 80% of the population will experience back pain at some
time in their lives (2). Low-back pain costs Americans at least $50 billion in health care costs
each year and if lost wages and decreased productivity are included, that figure exceeds $100
billion annually (3-4).

To cite examples, examine the illustrations presented in Figure 2-5. In the first movement
(bilateral glute or shoulder-bridge), the hips are raised higher than in the second illustration
(single-leg) movement, but why – this has nothing to do with the strength of the glutes which are
potentially the strongest muscles in the body and consider also that the person’s body weight is
directed mostly into the shoulders)? If the individual was asked where they experienced muscle
tension, the low back might be referenced, which elicits the question of why when this is
supposed to be a glute exercise?

The first movement involves hyperextension in the low back,

essentially borrowing movement from the lumber spine
rather than solely from the hips which compromises lumbar
stability. The second movement with a leg positioned at 90-
degrees of hip flexion posteriorly rotates the hips to flatten
the lumbar spine. This prevents lumbar spine movement,
therefore keeping the spine in a more neutral position. This

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same effect can be accomplished by engaging the abdominals prior to performing a bilateral
bridge.

Takeaway: Cue clients to engage their abdominals to stabilize the lumbar spine prior to lifting
the hips off the floor.

In Figure 2-6, the traditional birddog movement requires the individual to extend the hips in the
sagittal plane while simultaneously flexing the shoulders in the sagittal plane. However, what is
often observed are compensations when performing the movement, one of which involves an
increase in lumbar lordosis. As the hips extends, a lack in hip mobility will force anterior tilting
within the hips, thereby increasing lordosis within the lumbar
spine.

By using a dowel placed along the spine (hips, thoracic spine,

back of head), any change in lordotic curvature can be easily
assessed.

Takeaway: Engage the lumbar stabilizers or ensure adequate

hip mobility before performing this movement.

A similar dysfunction is also observed in many individuals during squatting. The initiation of a
good squat involves a hip-hinge (anterior hip tilt) to push the hips backwards, but that should be
corrected immediately to return the spine to neutral. However, what often occurs is that this
increased lumbar lordotic is maintained throughout the entire squat movement. Recognize that a
very small 2° increase in lumbar lordosis (i.e., hyperextension) from neutral position can elevate
the compressive forces placed upon the posterior annulus of the discs by 16% – merits serious
consideration when coaching squats to avoid a potential low back injury (5).

Another compensation that often occurs is movement of a segment into another plane. Using the
birddog movement again, another or different compensation observed might be rotation of the
hips and the foot as the hip extends. Here, the foot does not point to the floor, but points out to

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the side. This introduces unwanted torque into the spine. Another example would be to observe
the ankles during the squat. As the body is lowered towards the floor, the tibia is supposed to
translate forward, but a limitation in ankle dorsiflexion at the talocrural joint might necessitate
movement at the sub-talar joint where it normally falls into pronation.

This can be observed by an inward collapse of the ankles (i.e.,

medial malleoli), possibly coupled with some slight foot eversion.

Takeaway: Ankle mobility is necessary to promote good

squatting technique that maintains stable feet.

The consequence of these compensations are dyskinesis or abnormal (dysfunctional) movement

and abnormal forces being placed upon joints. This alters the mechanical function of the
involved muscles, ultimately compromising neuromuscular coordination or efficiency (i.e., how
the nervous control system controls muscle action). Over time, the potential for chronic injury
may become inevitable.
To summarize… What happens when the stability-mobility relationship becomes altered?
1. Potentially compromised stability to facilitate mobility (e.g., shoulder bridge, lumber spine
during Olympic squats).
2. Movement into other planes (e.g., birddog hip rotation, foot pronation during the lowering
phase of squats).

Physiological and Kinesiological Concepts

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This course examines dysfunctional movement, but in order to fully understand the
consequences of dyskinesis, one must first understand some of the physiological and
kinesiological alterations associated with muscle imbalance.

The Length-Tension Curve

This relationship explains how sarcomere length influences the force-generating capacity of the
muscle. As illustrated below, when the sarcomere is positioned at its normal resting length (i.e.,
100% on the x-axis), it generates a near maximal amount of force. However, a small pre-stretch of
the sarcomere by about 20% optimally orientates the myosin and actin proteins to generate the
greatest amount of force. Continued sarcomere lengthening beyond this point results in a
progressive reduction in force-generating capacity due to inadequate overlap of myosin and actin.
Muscle elasticity (i.e., elastin fibers) permits muscles to be functionally stretched to around 167%
of resting length, yet still generate force, but they will ultimately experience a 'critical failure
threshold' when they reach approximately 250% of resting length where the muscle suffers the
risk of tearing (6).

Figure 2-8: The length-tension relationship of the sarcomere

• Shortening below resting length = excessive contractile protein overlap and reduced force.
• Slight stretching beyond 100% = optimal orientation between contractile proteins and
optimal force.
• Stretching beyond optimal range = reduced binding opportunities and reduced force.

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On the flip side, when the muscle is positioned in a shortened position (e.g., forwarded rounded
shoulders, hip flexors while seated), the force-generating capacity of the muscle is greatly
reduced due to excessive sarcomere overlap where mysoin and actin are bunched too close
together.

Can these muscle properties change can how would this affect the force-generating capacity of
the muscle? The answer is yes, but this change is based upon the stimulus placed upon the
muscle and the subsequent biological adaptation(s) it undergoes. Prolonged immobilization, lack
of use, aging, trauma or any other events that position the muscle(s) in passively shortened
positions for sustained periods (e.g., hip flexors when seated) provide the necessary stimulus.
The biological adaptation of this shortened position is a loss of sarcomere number in series (i.e.,
end-to-end) rather quickly (e.g., 2-to-4 week period, a condition known as adaptive shortening).
For example, the hip flexors can undergo adaptive shortening when held in passively, shortened
positions. The biological adaptation is an attempt to become stronger in this new position (i.e.,
the 'new normal'). This is accomplished by removing sarcomeres which shifts the length-tension
(LT) curve left (refer to the illustration below). For example, think of a muscle that is 12' long
that contains 100,000 sarcomeres – normal resting length (blue shaded area). Now, imagine
compressing those sarcomeres into 9" of space - the normal curve demonstrates a significant loss
of muscle tension at the new length (i.e., observe the force production of the red line between the
dashed black lines). By removing sarcomeres (e.g., reducing 100,000 to 60,000) the curve shifts
left and now demonstrates greater force-generating capacity in the shortened position (observe
the blue curve between the dashed black lines).

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 Figure 2-9: The leftward shift in the length-tension curve.

As a practitioner, this muscle change represents the development of dysfunction as it presents an

alteration in posture (e.g., anterior pelvic tilt due to tight hip flexors) that needs to be corrected.
By simply re-positioning the pelvis into its normal position (i.e., blue band), the muscle is
weaker than a healthy muscle - observe the force-generating capacity of the blue curve as passes
through the blue band versus the healthy muscle. What this means in application is that by
simply stretching a tight muscle, it might allow the joint to move to a neutral, functional position,
but the action of the muscle at the joint is weakened, compromising movement which could
increase the potential for injury. In other words, the stretch is merely a band aid over an
underlying issue – a structural or architectural change within the muscle where sarcomeres were
removed. Corrective exercise will take time and implies returning the muscle to a normal number
of sarcomeres.

What happens at the opposite side of joint (i.e., the antagonist muscle)? This biological
adaptation is the addition of sarcomeres in series as illustrated below. Here the antagonist is
lengthened, thus adapts to become stronger in the lengthened position, but is also now weakened
when the joint and muscle is moved to the normal position (i.e., blue band).

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 Figure 2-10: The rightward shift in the length-tension curve

Muscle Imbalance
All muscles require innervation to act, whether it be to excitatory to initiate a contraction or
inhibitory to allow action within the opposing muscle (i.e., the antagonist on the opposite side of
the joint). A tight muscle triggers a lowering of the irritability threshold within the nerve
innervating that tight muscle. What this means is that a smaller stimulus can now trigger an
action potential (AP) in that muscle, resulting in over-activity of that tight muscle – defined as
Hypertonicity. During normal movement, a desired action of a muscle at a joint is normally
accompanied by a small inhibitory action of the opposing muscle to initiate movement – defined
as Reciprocal Inhibition. But, with hypertonicity, the desired action of the antagonist or muscle
opposite the tight muscle is interfered with. For example, the action of the gluteus maximus to
produce hip extension is interfered by an overactive hip flexor. This is demonstrated in the
graphic presented below.

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Figure 2-11: The process of hypertonicity and synergistic dominance associated with muscle imbalances

But, because the movement is necessary, the body resorts to seeking help from any other muscle
who normally supports movement at that joint. This assistant muscle, a synergist, now becomes
the dominant muscle responsible for generating force and producing movement – defined as
Synergistic Dominance.
The problem with synergistic dominance is the over-reliance on a different muscle to produce a
desired movement, leading to muscle overuse and an increased potential for injury. For
example, a tight hip flexor interferes with the action of the gluteus maximus in hip extension,
therefore relying upon the hamstrings to provide most of this action. This overuses the
hamstrings which could become tight and problematic. Simply stretching the hamstrings is not
the solution, but this is merely a band aid over the problem. The issue here lies with correcting
the imbalance between the hip flexors and the glutes (the hip extensors) which, in turn, will
resolve over-activity within the hamstrings.

Causes of muscle imbalance need to be identified. They are generally classified as correctable
when connected to lifestyle choices or things within our control, or non-correctable when they
are generally considered beyond our control (e.g., congenital, trauma, structural).
To summarize, the outcome of an altered muscle length-tension curves that produce
hypertonicity (smaller neural stimulus to generate an AP) and reciprocal inhibition, resulting in
synergistic dominance.

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Muscle imbalance between agonists and antagonists will change how the body moves, a term
called dyskinesis or dysfunctional movement (i.e., muscle dysfunction equals dyskinesis).
Panjabi’s Model of Movement describes how efficient movement requires the coordinated action
of four subsystems (7):
1. Neural control system (NCS).
2. Active system (muscles) – responsible for approximately 47% of movement at, or across a
joint.
3. Passive system (structures like joint bones, ligaments, tendons, skin) – responsible for
approximately 13% of movement at, or across a joint (skin = 3%; structures = 10%).
4. Passively-active system (myofascial tissue) - responsible for approximately 40-to-44% of
movement at, or across a joint.
As a simplified analogy, think of the NCS
as software and the active system as
hardware. Within a computer, each
influence, and are influenced by the other.
In other words, if one is corrupted or
damaged it affects the functionality of the
other. In this case, muscle (hardware) and
its altered structure affects the NCS
(software). Collectively, both interfere
with normal movement or kinematics.

Figure 2-12: Panjabi’s model of movement

Think how these software and hardware changes affect movement efficiency at a joint (i.e.,
control of movement or joint stability). Now think how this same consequence might affect
actions at adjacent joints (e.g., think how forward rounded shoulders affect movement at the
glenohumeral joint). For example, a tight pectoralis muscle will reciprocally inhibit the shoulder
extensors (e.g., posterior deltoids) and require movement from the scapulae and rhomboids to
open a door (i.e., horizontal extension).

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These alterations will affect each of the primary responsibilities that muscles serve in the body;
force production, support, absorbing reactive forces, and decelerating movement, and are
summarized in Table 2-2.

Table 2-2: The effects of muscle imbalance and dysfunction upon muscle function
Muscle Functions Immediate Effects Long-term Outcome

Generate force and movement. Reduced force production and Overuse and repetitive motion =
dysfunctional movement injury
Provide support within the Weaker muscles – reduced Increased potential for injury
inelastic components. capacity
Absorb reactive forces. Less able to absorb and harness Less efficient movement and
energy overuse = injury
Provide deceleration and Less capable of slowing down Increased injury potential at end-
stability at / across joints. movement ROM

What should practitioners do when individuals present with postural distortions or muscle
imbalances when it comes to exercise? Ideally, the person would recognize the importance of
participating in a corrective exercise program to restore normal muscle balance and function
before participating in any loaded (resistance training) programs to reduce the potential for a
chronic or overuse-type injury. What should a practitioner do when individual present with
postural distortion or muscle imbalance (e.g., lifestyle choices, exercise training)? Figure 2-13
provides a brief overview of a corrective exercise approach that will become the focus of
discussion later in this course.

Figure 2-13: A basic overview of the corrective exercise approach

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Force-Couple Relationships
Muscles rarely ever work in isolation, but function as integrated groups. They provide opposing,
directional or contralateral (opposite sides) pulls to achieve balanced movement in three planes
of motion. These coordinated actions of muscles are called force-couples. To help understand
this concept, imagine muscle actions that differ by direction, magnitude and timing and the
subsequent effects. As illustrated below, examine how direction, magnitude and timing influence
the net force.

Figure 2-14: The effects of direction, magnitude and timing on muscle action

Looking more closely at the muscles spanning the hips. Muscle balance between these muscles
help attain neutral position, but also help promote normal movement. By contrast, muscle
imbalances that produce adaptive shortening and lengthening create abnormal positioning or
movement (dyskinesis). Neutral pelvic position is maintained by opposing force-couples. As
illustrated, the hip flexors (HF) and rectus abdominis (RA), with their opposing pulls, stabilize
the anterior portion of the pelvis while standing. Similarly, the erector spinae (ES) and
hamstrings (H), with their opposing pulls, stabilize the posterior portion of the pelvis while
standing. During movement however, the HF pull downward on the anterior, superior pelvis
while the ES pull upward on the posterior, superior pelvis – they collectively create an anterior
pelvic tilt. The RA pulls upwards upon the anterior, inferior pelvis while the H pull downward on
the posterior, inferior pelvis – they collectively create a posterior pelvic tilt.

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 Figure 2-15: Force couples maintaining and moving the hips

The pelvis undergoes a continuous process of anterior and posterior tilting during walking (i.e.,
opposing force-couples). As the right foot swings forward, the hip moves into flexion requiring
action of the HF and ES to contract while the RA and H relax. As the hips move over the support
or stance leg into hip extension, this requires action of the RA and H while the HF and ES relax.

In another scenario, examine the muscles spanning the shoulder joint and the action of arm
abduction. From a position with the arm at the side, the action of the deltoid muscle is an upward
pull to elevate the humerus and if acting alone, it would result in impingement under the
acromion (AC) process. Therefore, normal motion is achieved by the collective actions of the
rotator cuff muscles first acting with their respective pulls to draw the head closer into the socket
(glenoid fossa) to create more congruency and stability within the joint as they change the
orientation of the humerus (i.e., create 10-to-15 degrees of arm abduction). This new directional
pull of the deltoids creates normal humeral rotation with a low risk of impingement against the
AC process.

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 As illustrated, this initial
action of the rotator cuffs
draws the humeral head
inward to provide more
congruency (contact)
between the two surfaces
(i.e., humeral head and
glenoid fossa) which better
stabilizes and controls
movement at the joint.
Figure 2-16: Force couples acting at the glenohumeral joint

The collective timing and directional pulls of all muscles at the joint ultimately allows the
humeral head to spin upon its own axis (called instantaneous center of rotation or ICR) rather
than glide upwards where it would become impinged. A key reason why this is force couple
relationship is needed is because of the discrepancy between the size of the humeral head and the
size of the glenoid fossa where the head is almost three times larger than the fossa – think of a
golf ball sitting on a tee which is quite unstable. As mentioned, if the deltoids acted alone,
humeral impingement against the AC joint would happen almost immediately due to the upward
glide of the humeral head, much like how a marble rolls across a flat plate. However, it is the
actions of the rotator cuffs to not only draw the ball tighter into the socket (i.e., more
congruency), but their overall downward pull counteracts any upward glide by the deltoids.

Closing Remarks
Now that key physiological and kinesiological concepts have been reviewed, it provides the
reader with a greater understanding of the underlying changes occurring with muscle imbalance
and movement dysfunction. This understanding also contributes to the rationale of how and why
corrective exercise is needed to restore proper mechanics, stability and mobility, all of which are
covered in subsequent modules.

21
References:
1. Gray G, Gray D, and Tiberio D, (2017). The Chain Reaction. Adrian, MI., The Gray Institute.
2. Rubin Dl, (2007). Epidemiology and Risk Factors for Spine Pain. Neurologic Clinics, 25(2):353-371.
3. In Project Briefs: Back Pain Patient Outcomes Assessment Team (BOAT). In MEDTEP Update, Vol.
1 Issue 1, Agency for Health Care Policy and Research, Rockville, MD.
4. Katz JN, (2006). Lumbar disc disorders and low-back pain: socioeconomic factors and consequences
[review]. The Journal of Bone and Joint Surgery American Volume, 88(suppl 2): 21-24.
5. Adams MA, and Dolan P, (1995). Forces acting on the lumbar spine. In: Lumbar Spine Disorders:
Current Concepts. Aspden RM, and porter RW (Eds.). Singapore: World Scientific Publishing.
6. Pocari JP, Bryant CX, and Comana F, (2015). Exercise Physiology. Philadephia, PA. The F.A. Davis
Company.
7. Hoffman J, and Gabel P, (2013). Expanding Panjabi’s stability model to express movement: A
theoretical model. Medical Hypotheses, 80: 692-697.

Image Credits:
1. Figure 2-2: Image courtesy of Creative Commons Attribution 2.1 Japan license. BodyParts3D, © The
Database Center for Life Science licensed under CC Attribution-Share Alike 2.1 Japan.
2. Figure 2-3: Image courtesy of Ada S. Ballin, with permission to use under public domain.
3. Figure 2-4: Image courtesy of BodyParts3D is made by DBCLS - Polygondata is from BodyParts3D,
CC BY-SA 2.1 jp.
4. Figure 2-15: Image courtesy of BodyParts3D, © The Database Center for Life Science licensed
under CC Attribution-Share Alike 2.1 Japan. (Google translate)
5. Figure 2-16: Image courtesy of AidMyRotatorCuff.com.

Notes Section

22
23
 Module 3: Postural Assessment (Brief Overview)

Introduction
The Posture Committee of the American Academy of Orthopedic Surgeons defines posture as
the ‘relative arrangement of the parts of the body’ and ‘good posture as the state of muscular
and skeletal balance which protects the supporting structures of the body against injury or
progressive deformity, irrespective of attitude (e.g., standing lying, squatting)’ (1).

Given the propensity that humans have towards poor posture, some initial emphasis placed upon
evaluating postural alignment is always a good idea. However, what is important to consider is
that while postural assessments examine skeletal alignment and passive range of motion (ROM)
or flexibility assessments can reveal muscle extensibility limitations, they generally fail to
identify the presence of any existing faulty neural control or dysfunctional movements. This
requires active movement in the form of a movement screen. Screens generally challenge
individuals (with no recognized pathologies) to perform basic movements and evaluate that
person’s ability to demonstrate appropriate levels of stability and mobility throughout entire
kinetic chain. This is an equally important element for injury prevention screening as it is as a
rehabilitation component.

Postural Assessment
Some initial focus that evaluates skeletal alignment can provide insight into the probability of
whether an individual demonstrates appropriate levels of stability and mobility during
movement. This section on assessing static posture is provided for your benefit and will only be
briefly reviewed.

When assessing static posture, a simple guideline to follow subscribes to the right-angle rule, a
model that demonstrates how the human body represents itself in vertical alignment across four
joints; the three main weight-bearing joints (i.e., ankles, knees, hips) and the shoulder joint, a
minor weight-bearing joint. This process divides the body into two hemispheres as illustrated in
the figure below while observing symmetry between the joints in all three planes of motion
(frontal or coronal, sagittal and transverse). This implies a state in the frontal plane wherein the

24
two hemispheres are equally divided and in the sagittal plane where the anterior and posterior
surfaces appear in balance. A body is in good postural position when the body parts are
symmetrically balanced around the body’s line of gravity. The body’s line of gravity represents
the intersection of the mid-frontal and mid-sagittal planes.

Although this model helps identify postural compensations and

potential muscles imbalances, it is also important to recognize
that some limitations exist which may not be correctable:
• Postural deviations attributed to congenital issues (e.g.,
scoliosis, polio, birth defects).
• Postural deviations attributed to pathologies (e.g.,
rheumatoid arthritis).
• Postural deviations attributed to structural issues (e.g.,
tibial or femoral torsion, femoral anteversion).
• Postural deviations attributed to trauma-type events
(e.g., surgery, injury, amputations).

Figure 3-1: The right-angle role

When viewed from the front, an imaginary or actual plumbline should divide the two
hemispheres equally – passing equidistant between the feet and ankles, intersecting the pubis,
umbilicus, sternum, manubrium, mandible (chin), maxilla (face) and frontal bone (forehead).
When viewed from the side, an imaginary or actual plumbline should divide the front and back
equally – passing immediately anterior to the lateral malleolus, the anterior ⅓ of the knee, the
greater trochanter, acromio-clavicular (A-C) joint, and pass slightly anterior to the mastoid
process of temporal bone (i.e., pass just behind the ear lobe). But, because this is often
impractical to conduct given how people frequently shift weight and move about when standing
statically, practitioners should train their eyes to quickly identify (a) notable misalignments that
stand out and (b) the more frequent misalignments.

25
These generally include:
• General asymmetry between hemispheres.
• Foot and ankle position – ankle supination or pronation.
• Valgus (knock-knees) or varus (bow-legged) knee position.
• Internally or externally rotated femurs.
• Anterior or posterior pelvic tilt or a lateral hip shift or tilt.
• Excessive thoracic kyphosis (rounded shoulders shoulders).
• Protracted scapulae and internally rotated arms, and head forward position.

Given the high probability of postural shifting and adjustments or unnatural postural stances
attributed to conscious awareness associated with an assessment being performed, any
observations made should be done quickly and ideally, without the person’s conscious
awareness. Furthermore, documenting identified misalignments in front of the individual might
become a source of unwanted anxiety on the part of that individual, therefore aim to make the
observations as subtly as possible. Document noted misalignments after the assessment as they
provide the rationale for corrective exercise and serve as a means of re-evaluation of a program.
Lastly, the cause behind any observed postural misalignments needs to be determined – are they
attributed to correctable causes (e.g., awkward postures, poor exercise technique,
biomechanically unsound repetitive motions) or to non-correctable causes.

References:
1. American Academy of Orthopedic Surgeons (1947). Posture and its relationship to orthopedic
disabilities.

Image Credits:
• Figure 3-1: Image courtesy of Mikael Häggström, svg by Mariana Ruiz Villarreal, Public Domain.

26
 Module 4: Movement Screens

Introduction
Active movement is an excellent method for evaluating the effects that muscle imbalance and
poor posture have upon neural control or functional movement. As indicated previously,
movement screens generally challenge individuals with no recognized pathologies to perform
basic movements that serve as a basis for evaluating levels of stability and mobility at, or across
segments throughout the entire kinetic chain. Although movement screens are suitable for almost
every individual, regardless of conditioning level (e.g., new exerciser, experienced athlete),
several factors should always be considered when selecting a specific movement:
• The movement(s) performed evaluates the functional capacity desired.
• The movement needs to be skill- and conditioning-level appropriate for the individual.
• The movement needs to be specific to the individual’s needs.
• The movement needs to be unloaded (i.e., no external resistance) and performed without pain
or significant discomfort.

What is the movement screen looking to identify?

• Losses of stability and / or mobility.
• Altered neuromuscular coordination – compensated movement.
• Asymmetries.

They may be indicative of overactive (i.e., tight, hypertonic) muscles and underactive (i.e.,
weakened, latent) muscles. Any indication of muscle imbalance or dysfunctional; movement
(dyskinesis) merits the implementation of a corrective exercise program as a pre-requisite to any
training.

Figure 4-1: The need for corrective exercise

27
Humans perform many diverse movements that can be collectively categorized into primary
movement patterns (1). Within the lower extremity, all movement can be categorized into bend-
and-lift patterns (e.g., bending down to pick up objects, squatting, deadlifts) and single-leg
patterns (e.g., stepping, lunging).

Within the upper extremity, all

movement can be categorized into
push patterns (e.g., shoulder press,
chest press) in any plane and pull
patterns (e.g., pull-up, pulling on a
door handle) in any plane.

Figure 4-2: The primary movement patterns

While these lower and upper extremity patterns can be isolated by location (i.e., upper-lower
extremity), spiral or rotational patterns involve more integrated and coordinated actions of both
extremities.

Because the brain stores information on movement patterns rather than exercises, practitioners
should not only initially emphasize coaching proper movement form rather than exercise
technique, but any selected screen(s) should evaluate one’s efficiency of performing these
primary patterns (2). In the interest of time, this course will only assess two problematic
movements – the bend-and-lift pattern and the overhead reach or press pattern (and collectively
combined into the overhead squat). However, any movement can essentially be used to screen
functional versus dysfunctional movement if a practitioner understands the objective behind the
pattern or exercise (i.e., desired joint movements, etc.) and the role(s) of the involved segments
(i.e., stability, mobility) throughout the entire kinetic chain. To assist in performing a screen, one
suggestion is to follow the M.O.V.E. acronym:
• Movement (M): Identify the desired movements at the specific joint(s). For example, sagittal
plane extension of the hips.

28
• Observe (O): Instruct the individual to perform the movement and observe the quality of
movement performed.
• Validate (V): Analyze the individual’s ability to perform the desired movement (i.e.,
function versus dysfunctional) and identify potential causes and reasons for any observed
dysfunction (e.g., loss of stability in lumbar spine to promote hip extension)
• Educate (E): Provide various forms of feedback and interventions to correct, reinforce, and
help correct / self-correct (e.g., kinesthetic, visual and verbal cues, feedback). This includes
corrective exercises to restore appropriate levels of stability and mobility, and to correct
existing faulty neural pathways (i.e., neuromuscular coordination)

Figure 4-3: The M.O.V.E. acronym for performing movement screens

As a quick example, examine the seated leg extension. The desired movement is sagittal plane
hip flexion coupled with knee extension. To perform this quick screen, have the individual sit
towards front edge of a seat or table-top, sitting up straight and avoiding contact with backrest.
Ask the individual to slowly extend one leg and note the degree of difficulty in performing such
a movement – it may help to position the ankle in plantarflexion to avoid any calf muscle
limitations. Observe for the presence of any trunk flexion or drooping as the leg extends. Return
to the starting position, but now tilt the pelvis anteriorly (moving into greater lumbar lordosis)
and while holding this position, repeat the leg extension movement. Notice any difference – why
(validate)? This basic movement assesses hamstring function which should occur without any
lumbar involvement (i.e., active hamstring mobility without any low-back compensation). A
person’s ability to maintain lumbar position (i.e., no spinal flexion) during both movements
indicates adequate lumbar stability and flexibility within the hamstrings. However, the inability

29
to maintain normal lumbar lordosis (i.e., demonstrates spinal flexion) or struggles to extend the
leg during the anterior pelvic tilt movement might indicate some lumbar stability limitation or
hamstrings tightness.

Revisiting the birddog movement;

• Movement: What planes and joint movements are desired? (hint: sagittal plane hip and knee
extension, sagittal plane shoulder flexion).
• Observe: Is the movement functional or dysfunctional? Observe any pronounced lumbar
hyperextension during extremity movement? Observe hip and spinal rotation during the hip
extension movement? Observe any contralateral (opposite) shoulder reaction to the extended
hip (i.e., does that shoulder move to parallel with the floor, and is it influenced by the
opposing hip)?

Figure 4-4: Using the M.O.V.E. acronym on the birddog movement

• Validate: If compensations were noted, determine the cause(s). For example, is the increased
lordosis observed during hip extension due to a lack of core stabilization or a lack of hip
mobility causing the anterior pelvic tilt, or both?
• Educate: Once the causes are determined, the practitioner needs to (a) implement corrective
exercise interventions or break down the movement, and instruct the individual segments in
isolation (i.e., segmented or parts) prior to coaching integrated (whole) movements.

30
Movement Screens
As mentioned, almost any movement pattern can evaluate movement efficiency, but this course
will examine three in detail; one lower extremity screen – the bend-and-lift, one upper extremity
screen – the overhead press, plus one integrated upper and lower extremity screen – the overhead
squat. These screens collectively cover many of the functional activities of daily living
performed by individuals and serves as a basis of movement for many exercises.
• The bend-and-lift screen observes an individual’s ability to properly lower their extremity
towards the floor to lift an object. It focuses upon preservation of structural alignment,
dynamic flexibility, and neuromuscular control throughout the movement.
• The overhead arm reach screen observes an individual’s ability to properly raise their arms
into the overhead position to perform a press or a reach movement. It focuses upon
preservation of structural alignment, dynamic flexibility, and neuromuscular control
throughout the movement.
• The overhead squat screen evaluates total-body structural alignment, dynamic flexibility,
and neuromuscular control from a bilateral standing postural position. Although the squat
component requires optimal motion in the ankles, knees, and hips, the overhead arm position
stresses the needed for stability and mobility within the musculature surrounding the shoulder
complex and within the core region.

Practitioners should develop and/or utilize a scoring matrix to quantify the individual’s
performance and progression. Numbered, color-based or letter grading (e.g., A+, B-) systems all
offer opportunities to score baseline measures and monitor progression over time. As an
example, a numbering system could score individuals as follows:
• Score = 1. The individual experiences pain or significant discomfort while performing the
movement – this usually justifies a medical referral.
• Score = 2. The individual is unable to perform or complete the movement.
• Score = 3. The individual performs the movement, but he or she does so with observed
compensation or dysfunction.
• Score = 4. The individual successfully performs several repetitions (e.g., 2-to-3) with near
perfect or flawless technique.

31
A color-based scoring system for example assigns colors to reflect the quality of the movement
performed. One simple example could utilize the colors of red, yellow and green (Table 4-1):

Table 4-1: A color-based scoring rubric for movement screens.

Color Red Yellow Green

Movement Unable to perform the Movement completed with Several repetitions

Quality screen or experiences pain some observed degree of performed with flawless
or significant discomfort dysfunction. technique.
during the movement –
ideally requires medical
referral.

The Bend-and-lift Screen (1-7)

This screen is ideally performed without shoes to enable greater accuracy in observing potential
limitations in the ankles and feet. While shoes are probably more realistic, they do make it more
difficult to make some of the critical observations.
1. Equipment:
• Two, 2-to-4-foot dowels, broomsticks or small objects to simulate heavy dumbbells or
kettlebells (e.g., tennis balls).
2. Instructions:
• Stand with feet shoulder-width apart, arms hanging freely at sides.
• Place the dowels or small objects on the floor to the immediate outside of each foot at a
height no greater than 8-to-12” off the floor.
• Perform series of controlled, bend-and-lift movements (i.e., squatting), to pick the objects
up off the floor, pausing momentarily in lowered position, before returning to a full, erect
standing position – provide a cue that the objects are very heavy to elicit a squat or
deadlift movement.
• Repeat, performing a series of controlled repetitions until all necessary observations have
been made.
• Consider some practice trials for familiarization, but remember not to cue good or proper
technique, because the purpose is to observe natural movement.

32
 • An alternative option for the depth of bend can be to the height of a seat or toilet seat –
place a chair or bench behind the individual.
3. Key Screening Cues:
• Consider disguising the movement screen if necessary. For example, describe the
movement as a warm-up.
• Communicate to the individual that the objects being lifted are very heavy – this ensures
a deadlift-type movement that aligns with the screen objective.
• Demonstrate the movement using as many repetitions as needed for the individual to
understand what needs to be performed, but do NOT cue how to perform the movement
correctly.
• Repetitions should be performed at controlled tempos to allow for accurate assessment.
4. Movement (M):
• Bilateral movement where symmetry is preserved.
• Movement should preserve foot stability (i.e., no movement), include adequate ankle
mobility to allow the tibia to fall forward, knee stability where the knee moves in the
sagittal plane and remains orientated over the 2nd and 3rd toe, adequate hip mobility to
move into deep hip flexion, and an appropriate level of lumbar stability to preserve a
neutral lumbar spine.
5. Observations (O):

Table 4-2: Frontal view observations

Frontal View

1st repetition: • Observe the ability to preserve a stable foot (i.e. no evidence of pronation or
supination, eversion or inversion – best viewed by observing the medial foot and
medial ankles, or from behind).
2nd repetition: • Observe the alignment of the knees over the 2nd and 3rd toes.
3rd repetition: • Observe the overall symmetry of the entire body over the base of support (i.e., no
evidence of any lateral shift or rotation as the body lowers and rises).

33
 Figure 4-5: Dysfunctional movement at the foot, ankle and knee

Table 4-3: Sagittal view observations

Sagittal View

1st repetition: • Observe whether the heels remain in contact with the floor throughout the
movement.
2nd repetition: • Observe whether the downward movement is initiated by pushing the hips
backwards (glute dominant – ideal*) or by first driving the knees forward (quad
dominant – not ideal).
3rd repetition: • Observe whether the body attains a near parallel position between the tibia and
the torso in the lowered position (i.e., figure-4 position – ideal;) or whether the
body attains the T-configuration (not ideal) in the lowered position where the
tibia remains perpendicular to the floor and the torso moves towards parallel
with the floor.
4th repetition: • Observe the ability to preserve a near neutral spine throughout the movement.
• The use of a dowel to evaluate neutral spine alignment should preserve three
points of contact (back of the head, thoracic spine and sacrum).
• In the lowered position, a flattened-to-neutral spine is acceptable whereas
significantly increased lordosis, spinal rounding or extended head positions are
not considered ideal.

* Quad dominant squats rely heavily upon the quadriceps, often force knee hyperextension and do not
involve the hamstrings which help stabilize the knee.

34
 Figure 4-6: Bend-and-lift movement screen

6. Validate (V):
It is now time to determine the cause(s) of any observed dysfunction. This addresses the ‘why’ or
‘why’s’ for each compensated movement witnessed.

35
 Table 4-4: Movement compensations and possible causes (frontal view)
Compensation Possible Causes – Frontal View

Foot pronation (eversion) Possible lack of ankle mobility, forcing some ankle joint compromise as it
or supination (inversion) moves into different planes (e.g., pronation – evidenced by a foot collapse) –
leads to muscle imbalances.

Knees collapse inward or Usually attributed to an ankle mobility deficiency (i.e., pronation collapses the
fall outward*. knees inward) or hip musculature imbalance (i.e., adductors versus abductors).

Asymmetrical body shift Muscle imbalance (weaknesses) and instability – correctable, or limb length
discrepancies – non-correctable.

* To determine the cause of knee instability, repeat with screen, but elevate the heels two-to-three inches
off floor using any platform (e.g., weight plate) to reduce the amount of ankle dorsiflexion required to
squat. If the individual now demonstrates aligned knees over the 2nd and 3rd toes, the cause would appear
to be in the ankle (i.e., lack of ankle mobility). However, if the knee misalignment remains, then suspect
dysfunction within the hip musculature (e.g., imbalance between the hip abductors and adductors).

Table 4-5: Movement compensations and possible causes (sagittal view)

Compensation Possible Causes – Sagittal View

Heels lifting off the floor. Possible lack of ankle mobility, forcing some ankle joint compromise as it lifts
the heels off the floor.

Quad or glute dominant. Possible knee instability or more likely due to a lack of proper coaching and
cueing – requires instruction on how to hip hinge and engage the posterior
muscles to bend.

T-position or Figure-4 • Lack of ankle mobility preventing the tibia from dorsiflexing forward
position. during the lowering phase of the bend-and-lift.
• Excessive tightness within the hip flexors, coupled with weakness in low
back extensors that fail to preserve torso position (i.e., parallel to tibia).
• Existing belief (coaching/cueing) where the knees should not move
forward towards the toes.

Spinal position – neutral to • Increased lordosis may indicate lack of adequate core stability.
slightly flattened. • Increased rounding may indicate a lack of adequate control within the
lumbar and thoracic extensors.

Table 4-6 provides an example of a worksheet that can be used when an individual performs the
bend-and-lift screen.

36
 Table 4-6: The bend-and-lift worksheet
Bend-and-lift Screen
Pain or discomfort Yes □ No □ Able to perform screen? Yes □ No □
Front View Side View
Foot stability (ankle alignment) Yes □ No □ Heels rise off floor Yes □ No □
Knee alignment Yes □ No □ Glute dominant Yes □ No □
Hip alignment Yes □ No □ Trunk-tibia alignment (Figure-4) Yes □ No □
Spinal alignment (3 contact points) Yes □ No □
Overall Quantitative Score: Notes*:

* In the notes section, practitioners may indicate any discrepancies between the left and right side.

37
The Overhead Reach Screen (2-3,5-7)
This screen can be performed up against a wall or with the individual standing freely. The
possible advantage of the wall is that it offers the practitioner a reference point to observe
movement within the spine throughout the overhead reach
1. Equipment:
• None needed.
2. Instructions:
• If using a wall, instruct the individual to rest against the wall naturally. Ideally this makes
three points of contact (i.e., sacrum, shoulders and head), but does not require the heels to
contact the wall – the heels could be spaced up to about three inches from the wall.
• Instruct the individual to relax their arms at their sides.
• Observe postural alignment of shoulder blades and the back of head – do they make
contact; are the shoulders rounded or positioned flat against the wall?
• Any observed postural misalignments (e.g., less than three points of contact, no head
contact, arms internally rotated, shoulders rounded) merit consideration of corrective
exercise.
• To perform the screen, ask the individual to slowly raise both arms simultaneously to an
overhead position, aiming to touch the wall or reach 180 degrees overhead.
• Slowly return to the starting position and repeat.
3. Key Screening Cues:
• Consider disguising the movement screen if necessary. For example, describe the
movement as a warm-up.
• Demonstrate the movement using as many repetitions as needed for the individual to
understand what needs to be performed, but do NOT cue how to perform the movement
correctly.
• Repetitions should be performed at controlled tempos to allow for accurate assessment.
4. Movement (M):
• Bilateral movement where symmetry is preserved.
• Movement should preserve three points of contact – lumbar stability (i.e., no movement)
and appropriate thoracic mobility to preserve lumbar spine position. The arms should

38
 move overhead to almost 180° and move only in sagittal plane; no evidence of humeral
rotation where palms may rotate to face inward in the overhead position, full elbow
extension, and no excessive elevation of the scapulae evidenced by shrugging.
5. Observations (O):

Table 4-7: Frontal view observations

Frontal View

1st repetition: Observe whether the arms move and appear symmetrical.
2nd repetition: Observe whether the arms remain in the sagittal plane or move into different planes.
3rd repetition: Observe for any excessive trap activity – do the scapulae appear to be shrugged when
the arms are in the overhead position?
• Can the individual shrug with arms in the overhead position?

Figure 4-7: Front view of the overhead reach screen

Table 4-8: Sagittal view observations

Sagittal View

1st repetition: Observe movement of the spine (3-points of contact):

• Is there any increase in lumbar lordosis?
• Does the chest appear to elevate and roll backwards?
2nd repetition: Observe whether the arms reach an overhead position (think 170-to-180°).
3rd repetition: Observe whether the elbows demonstrate good extension.

39
 Figure 4-8: Side view of the overhead reach screen

6. Validate (V):
It is now time to determine the cause(s) of any observed dysfunction. This addresses the ‘why’ or
‘why’s’ for each compensated movement witnessed.

Table 4-9: Movement compensations and possible causes (frontal view)

Compensation Possible Causes – Frontal View

Symmetrical movement Imbalance between the two extremities

overhead

Movement into different Possible overactivity (tightness) in latissimus and pectoralis muscle groups
planes

Excessive scapular Possible overactivity (tightness) in the upper trapezius muscles, perhaps
elevation coupled with underactive (weakened) lower trapezius muscle groups.

Table 4-10: Movement compensations and possible causes (sagittal view)

Compensation Possible Causes – Sagittal View

Preservation of spinal Possible indication of inadequate thoracic mobility or lumber stability

position

Overhead arm reach Possible indication of inadequate thoracic or glenohumeral mobility or

insufficient scapulohumeral rhythm

Elbow extension Possible indication of tightness within the coracobrachialis muscle

40
 Table 4-11 provides an example of a worksheet that can be used when an individual performs the
overhead reach screen.

Table 4-11: The overhead reach worksheet

Overhead Reach Screen
Pain or discomfort Yes □ No □ Able to perform screen? Yes □ No □
Front View Side View
Symmetrical arm movement Yes □ No □ Maintains neutral spine position Yes □ No □
Movement into different planes Yes □ No □ Arms reach near 180° Yes □ No □
Scapular elevation Yes □ No □ Elbow extension Yes □ No □
Overall Quantitative Score: Notes*:

* In the notes section, practitioners may indicate any discrepancies between the left and right side.

41
The Overhead Squat Screen (2,4, 8)
This screen is essentially the combination of the two previous screens (bend-and-lift + overhead
reach) and evaluates total-body structural alignment, dynamic flexibility, and neuromuscular
control from a bilateral standing postural position. However, it is important to recognize that it
may be too advanced for many individuals, especially those who are de-conditioned or present
with postural misalignments and or muscle imbalances.

Much like the bend-and-lift screen, this screen is best performed without shoes to enable greater
accuracy in observing potential limitations in the ankles and feet. While shoes are probably more
realistic, they do make it more difficult to make some of the critical observations.
1. Equipment:
• Two, 2-to-4-foot dowels, broomsticks or small objects to simulate heavy dumbbells or
kettlebells (e.g., tennis balls).
• Optional platform (two-to-three inches).
2. Instructions:
• As the individual stands with feet shoulder-width apart, they need to raise their arms into
the overhead position with the arms moving overhead at shoulder width or a little wider –
make the same assessments as the person moves to the starting position as would be
made in performing the overhead reach.
• While maintaining this overhead position, instruct the individual to slowly squat to a
height equivalent of a seat, pausing briefly before returning to the starting position.
• Repeat the movement until all necessary observations can be made in both planes.
3. Key Screening Cues:
• Realistically, this screen is harder to disguise as a warm-up or otherwise than the
previous screens discussed, but it is important to always consider the perspective of the
individual being screened.
• Follow the same screening cues discussed previously.
4. Movement (M):
• This bilateral compound movement should follow the same objectives of both preceding
screens.

42
 5. Observations (O):
• From both perspectives (frontal view, sagittal view) make the same assessments outlined
in the bend-and-lift screen (Tables 4-2, 4-3), with the addition of a few more
observations:

Table 4-12: Frontal and sagittal plane observations

Frontal View

1st repetition: Observe arm symmetry during the lowering phase.

2nd repetition: Observe the arm plane of movement during the lowering phase.

Sagittal View

1st repetition: Observe the alignment of the arms with the torso – do the arms remain aligned or fall
forward no more than 20º?
2nd repetition: Observe the ability to maintain a neutral spine.

Figure 4-9: The overhead squat screen

43
 6. Validate (V):
It is now time to determine the cause(s) of any observed dysfunction. This addresses the ‘why’ or
‘why’s’ for each compensated movement witnessed.

Table 4-13: Movement compensations and possible causes (frontal view)

Compensations Possible Causes – Frontal View

Arm symmetry Refer to Table 4-9.

Plane of motion Refer to Table 4-9.

Compensations Possible Causes – Sagittal View

Figure-4 position Refer to Table 4-5.

Arm-torso alignment* Arms falling forward might indicate possible overactivity (tightness) in the
latissimus and pectoralis muscles and possible underactivity (weakness) in key
posterior shoulder muscles – lower and mid trapezius, rhomboids and posterior
deltoids.
Neutral spine Inability to preserve a neural or slightly-flattened spine might indicate possible
overactivity (tightness) within the thoracic extensors and underactivity (weakness)
in the core (lumbar) stabilizers.

* Placing hands upon the hips and repeating the screen removes much of the stretch tension placed into
the latissimus and pectoralis muscles, while simultaneously demanding less from the core stabilizers that
oppose the actions of tight latissimus muscles – they increase lumbar lordosis when tight. If the
compensations improve in this position, then suspect tightness within the latissimus and pectoralis muscle
groups. If the compensation remains, then suspect tightness in the lumbopelvic hip complex (LPHC)
muscles (e.g., hip flexors) and weakness within the core stabilizers.

Closing Remarks
While the overhead squat screen serves as an excellent tool to assesses overall levels of stability
and mobility, and neuromuscular coordination throughout the entire kinetic chain, it might be too
advanced for most individuals. Screens should always be tailored to the individual’s unique and
specific needs, they should be skill- and conditioning-level appropriate and should be performed
in the absence of pain or significant discomfort.

44
References:
1. Pocari JP, Bryant CX, and Comana F, (2015). Exercise Physiology. Philadelphia, PA. The F.A. Davis
Company.
2. Clark MA, Lucett SC, and Sutton BG, (2014). NASM’s Essential of Corrective Exercise Training (1st
ed. revised). Burlington, MA. Jones and Bartlett Learning.
3. Gray G, Gray D, and Tiberio D, (2017). The Chain Reaction. Adrian, MI. The Gray Institute.
4. McGill EA, and Montel IN, (eds.) (2017). NASM Essentials of Personal Fitness Training (5th ed.).
Burlington, MA. Jones and Bartlett Learning.
5. Kendall FP, McCreary EK, Provance PG, Rodgers MM, and Romani WA, (2005). Muscles: Testing
and Function with Posture and Pain (5th ed.). Baltimore, MD. Lippincott, Williams and Wilkins.
6. Sahrmann, SA (2002). Diagnosis and treatment of movement impairment syndromes. St. Louis, MO.
Mosby.
7. Bryant CX, Merrill S, and Green DJ, (2014). ACE Personal Trainer Manual. San Diego, CA.
American Council on Exercise.
8. Macrum E, Bell DR, Boling M, Lewek M, and Padua DA (2012). Effect of limiting ankle-
dorsiflexion range of motion on lower extremity kinematics and muscle-activation patterns during a
squat. Journal of Sports Rehabilitation, 21:144-150.

Notes Section

45
 Module 5: Programming Overview

Introduction
Program design can be as unique as an individual’s finger print. Although contemporary models
exist that follow a systematic approach to program design (e.g., NASM’s Optimum Performance
Training™ – OPT™, ACE’s Integrated Fitness Training™ – IFT™), they essentially subscribe to
similar premises proposed in earlier models created by the likes of Mel Siff, Yuri
Verkhoshansky, Tudor Bompa and Leo Matveyev (1-3). One premise is that programming
should be movement-centric, implying that developing movement efficiency or quality should
precede movement quantity. This is illustrated below in the three key pillars of all programming
and training

Training the body to move

efficiently should always be priority
number one. Survival as a species is
dependent upon moving repeatedly
and efficiently, and it should avoid
the plagues of chronic injury
associated with overuse or poor
mechanics.
Figure 5-1: the three pillars of training

Movement requires muscle action, which in turn, requires fuel. Subsequently metabolic
conditioning is a critical foundational pre-requisite to attaining a successful outcome of muscle
conditioning, whether it be for hypertrophy, strength or power.

Another premise is that unloaded training (e.g., bodyweight resistance for stabilization and
endurance) serves as a foundational pre-requisite to loaded training (e.g., external resistance for
hypertrophy and strength) which culminates in exploded training (e.g., power, the combination
of strength and speed).

46
This is illustrated below as the synergistic relationship between the two primary principles of
training; namely the principles of overload and specificity:
• Overload: Adaptations occur when a system (e.g., muscular) is exposed to stressors (e.g.,
volume, intensity) that are greater than those to which that the system is accustomed. For
example, for a muscle to become stronger, it must be exposed to heavier loads (i.e., generate
greater forces) than what it is accustomed to performing.
• Specificity: Adaptations are in direct response to the type of overload imposed. This is also
referred to as the SAID Principle (Specific Adaptations to Imposed Demands). For example,
a runner will adapt to become a better runner from run-training than from training in a pool
or on a bicycle.

Applying these two principles into a training model creates three distinct training phases, each
with unique goals and objectives. The Fundamental phase is intended to onboard and introduce
individuals to a regimen of regular activity. It is more experiential- than outcome-driven where
positive experiences and self-efficacy are emphasized for adherence purposes. It is in this stage
that the individual participates in a corrective exercise program to restore appropriate levels of
stability and mobility throughout the kinetic chain. It is also possible that some isolated muscle
strengthening (muscle stability) in a stable or supported environment (e.g., chair, selectorized
machine) may be needed during this phase to prepare the body for the subsequent phase where
unsupported movement and activity occur.

47
 Figure 5-2: A systematic programming model overview

The Foundational phase of training introduces more traditional exercise workouts, but it should
initially emphasize movement quality over movement quantity. During this phase, coaching and
cueing proper movement of the primary patterns is essentially before the individual participates
in unloaded or volume-based (i.e., higher repetitions and time, lower loads) resistance training
targeting muscle endurance. Another goal of this phase is to build a solid aerobic base derived
off aerobic efficiency where the individual undertakes training to improve fuel utilization (i.e.,
fat utilization as a fuel). Goals during this phase are primarily health-driven, but they do include
some general fitness outcomes. It may also include improving one’s capacity to perform some
activities of daily living (ADLs) safely and effectively*

The Functional phase of training is the phase that is perhaps most familiar considering the use of
resistance and cardiovascular training in both traditional and non-traditional formats (e.g.,
hypertrophy training, HIIT, circuits, hiking). The goals here are purely outcome driven with
some emphasis placed upon health (e.g., reducing blood pressure), but focused more upon fitness
(e.g., recreational pursuits – hiking, physical fitness – fitness enthusiasts, aesthetics) or
performance outcomes (e.g., occupational fitness – firefighters, sports performance – athletes).
Muscle hypertrophy, strength and power (sub-maximal or maximal) are emphasized through
resistance training, and aerobic improvements, anaerobic endurance or capacity and anerobic
power are emphasized through cardiorespiratory training. Additionally, in this phase, a heavy

48
emphasis is placed upon training the skill-related parameters of fitness to optimize functional
specificity. The skill-related parameters include:
• Power.
• Agility.
• Reactivity.
• Coordination.
• Speed – acceleration and quickness.
• Balance – mostly dynamic.

* Technically, ADLs qualifies as functional, but given the focus on stabilization and endurance
to improve ADL’s initially, it is categorized under foundational. For example, although balance
training is a skill-related parameter of fitness and very functional in its application, core
activation and static balance are addressed during this foundational phase of training.

Upon closer examination of NASM’s OPT and ACE’s IFT, not only are they similar in design,
but also mirror the three training phases identified in this model, as illustrated in Table 5-1 (4,5)

Table 5-1: The similarities between various training models

Fundamental Foundational Functional
NASM OPT Stabilization endurance Strength endurance Power
Hypertrophy
Strength
ACE IFT Stability and Mobility Movement Performance
Load

Corrective Exercise
Corrective exercise falls within the Fundamental phase and is merited when postural
misalignments or dyskinesis (dysfunctional movement) is noted. There are many systematic
approaches to restoring appropriate levels of stability and mobility, and one could argue that all
are probably equally effective. This course however, will follow a simple, easy-to-follow,
systematic approach that is similar in design to the model created for NASM’s Corrective
Exercise Training (6). Briefly, this four-stage system adheres to the principles of movement
efficiency defined by Panjabi in his movement model (7).

49
 It first addresses mobility, beginning with
myofascial techniques (actively-passive
system) before addressing muscle
lengthening (flexibility of the active
system) – may include joint mobilization
techniques (e.g., SI joint mobilization) to
help mobilize the passive systems. The
mobility sequence is followed by
activation of the underactive or weakened
antagonistic muscles to improve stability
and some basic muscle strength.

Figure 5-3: Panjabi’s model of movement

The sequence ultimately shifts from addressing problematic segments in isolation towards
integrated movements that incorporate the entire kinetic chain. They are first performed in an
unloaded format (e.g., bodyweight) before external loads and forces (e.g., resistance training) are
introduced. The next two modules will address corrective exercise (Fundamental phase) and
movement coaching (Foundational phase).

Figure 5-4: A sequence for corrective exercise

50
References:
1. Verkhoshansky YV, and Siff M, (2009). Supertraining (6th ed.). Translated by Yessis M, (2009).
Verkhoshansky.com
2. Bompa T, and Buzzichelli C, (2015). Periodization training for sports (3rd ed.). Champaign, IL.
Human Kinetics.
3. Matveyev L, (1981). Fundamentals of sports training. Moscow, Russia. Progress Publishers.
4. McGill EA, and Montel IN, (eds.) (2017). NASM Essentials of Personal Fitness Training (5th ed.).
Burlington, MA. Jones and Bartlett Learning.
5. Bryant CX, Merrill S, and Green DJ, (2014). ACE Personal Trainer Manual. San Diego, CA.
American Council on Exercise.
6. Clark MA, Lucett SC, and Sutton BG, (2014). NASM’s Essential of Corrective Exercise Training (1st
ed. revised). Burlington, MA. Jones and Bartlett Learning.
7. Hoffman J, and Gabel P, (2013). Expanding Panjabi’s stability model to express movement: A
theoretical model. Medical Hypotheses, 80: 692-697.

51
 Module 6: Fundamental Phase

Introduction
Applying these two principles into a training model creates three distinct training phases, each
with unique goals and objectives. The Fundamental phase is intended to onboard and introduce
individuals to a regimen of regular activity. It is more experiential- than outcome-driven where
positive experiences and self-efficacy are emphasized for adherence purposes. It is in this stage
that the individual participates in a corrective exercise program to restore appropriate levels of
stability and mobility throughout the kinetic chain. It is also possible that some isolated muscle
strengthening (muscle stability) in a stable or supported environment (e.g., chair, selectorized
machine) may be needed during this phase to prepare the body for the subsequent phase where
unsupported movement and activity occur.

Figure 6-1: A sequence for corrective exercise

However, perhaps the most important component of a corrective approach lies not with the
exercises, but with lifestyle changes to remove or reduce any precipitating factors of muscle
imbalance, postural misalignments and movement dysfunction. As part of the assessment
process, all potential correctable causes should be identified so that the intervention process
includes both corrective exercises and changes wherever possible to (a) administrative controls
(i.e., how the individual does things) and, (b) engineering controls (i.e., the layout of the physical
environment).

Mobility: Myofascial Techniques (Actively-passive System)

52
Before discussing myofascial techniques, it might be helpful to gain a deeper understanding of
the body’s myofascial architecture. We often envision our fascia as a seamless sheath of tissue
located beneath the skin that envelopes and contains the entire body. While this is not untrue of
the body’s superficial fascia, the truth is that fascia is a multi-dimensional, continuous layer of
tissue (i.e., no interruption) that forms a web of densely woven, incredibly tough connective
tissue that is everywhere. It is under the skin (fascia superficialis) and embedded within and
surrounding every muscle, bone, nerve, blood vessel and organ (fascia profunda) (1). Much like
the fibers of a grapefruit that extend from the skin to the core, the body's fascia extends from the
skin to the bone.

Resembles cotton candy and composed of multiple tendrils

formed from connective tissue (i.e., collagen, elastin), all
immersed in a watery medium which provides its structure
(2). More recently, when examining living fascia, researchers
discovered that water runs inside the individual tendrils and
it is this movement of water that realigns the fascial tendrils.
Figure 6-2: The fascial network

A. Fascial Architecture
Like muscle tissue, fascial tissue contains connective tissue (collagen, elastin), ground substance
(matrix) and fibroblasts (connective tissue-producing cells). The liquid portion* of the matrix
contains mostly water and sugar molecules, plus one important compound – hyaluronic acid
(HA), a sugar molecule polymer that helps hold water. While viscous in nature, HA allows for
flow and movement of the fascial compounds, but this amount of flow improves with increased
motion and hydration. HA is important because with proper hydration and with HA holding
more water, the individual fascial membranes glide over each other, permitting smooth, almost
effortless conformational changes in tissue. By contrast, when tissue becomes dehydrated, the
HA becomes more viscous and gliding doesn’t happen. Tissue will then experience greater levels
of friction and resistance to any movement. An analogy to help explain this concept of gliding
involves sheets of paper. When the paper sheets are aligned in parallel, they glide effortlessly
over each other, much like what the fascial membranes do when the HA is hydrated. By contrast,

53
when the sheets of paper become crumpled (i.e., dehydrated HA), movement encounters lots of
friction.

* The non-liquid portion of fascia contains lymphocytes, nerve endings, and capillaries

To help explain the roles of fascial tissue, it might be best to describe it by location. One region
is located under the skin – the superficial fascia (fascia superficialis), and the other region is
embedded deeper within, and around, muscle and other connective tissue (e.g., tendons) – the
deep fascia (fascia profunda). These regions are depicted in the illustration presented below. The
fascial arrangement of the tendrils (tendril scaffolding) within each region or membranes is not
cleanly organized into rows and columns, but appears rather as a densely, interconnected
(woven) pattern. As mentioned previously, the fluid between the tendrils is the ground substance
(matrix) that contains the HA, but it is the water located inside each tendril that is critical to
movement. Movement of this water produces tendril realignment (e.g., stretching, compressing,
gliding) within the matrix.

Figure 6-3: The superficial and deep fascia tissue

Another analogy for understanding the role of HA and water is to examine the sponge. When
dried, it is brittle, hard and resists movement or conformation shape changes, yet when wet, it is
elastic, resilient and more moveable, thereby facilitating movement or conformation shape

54
changes. Tissue dehydration is akin to tendril or fiber aggregation whereas tissue hydration is
akin to tendril gliding.

These fascial tendrils are arranged in a polyhedron-type shape as illustrated below, offering
properties of both ‘tension and integrity’ or a term called ‘tensegrity’. Tensegrity is defined as
the physical capacity of a structure to offer support against compressive forces (integrity)
coupled with the capacity to offer support against lengthening (e.g., tensioning, elasticity). This
property of fascia maintains the body in equilibrium via a balance of tension and elasticity.
Appropriate tension within tissue and the tendrils provides support, while an appropriate amount
of elasticity within tissue and the tendrils provides.

B. Science and Research

Watch the Video: https://www.youtube.com/watch?v=qSXpX4wyoY8.

This video offers insight (for the first time with good quality reproduction by Dr. Jean Claude
Guimberteau) into the living fascial tissue which has forever changed our understanding of how
the fascial tissue functions and is remodeled. This understanding of water movement within the
tendrils has shifted our perspective and the applications on how we go about implementing
fascial techniques like foam rolling. The video demonstrates how fascial techniques depend two
important factors; tissue hydration and the inclusion of movement (rhythmic preferred) to
remodel all the fascial layers. Movement is essential because passive process (e.g., traditional
foam rolling with no muscle action) may not adequately target or realign the deeper fascia (i.e.,
fascia profunda).

It is also important to understand Davis’s Law which states that soft tissue models itself along
lines of stress. What this essentially means is that any repetitive movements, any awkward
positions or perhaps even poor posture will result in the inelastic collagen fibers layering
themselves in such a way to reduce stress and protect tissue in that region (i.e., develop an
adhesion or knot). This collagen binding reduces gliding between layers, which subsequently
reduces movement. Movement, but more specifically, movement in different planes realigns
these tendrils and helps remove adhesions. So, hydration is NOT enough! Movement, more

55
specifically movement in different planes and varying by tempo (i.e., slow-dynamic to unloaded,
moderately-ballistic) improves mobility.

Try This … As a demonstration of how fascia works, perform an overhead reach with your right arm. Do
you experience what might be described as some tightness in the posterior capsule of the shoulder? Why
would that happen if it is the anterior portion of the shoulder compartment that is being stretched?
Perhaps it is the fascial membrane layers in the posterior segment that are not gliding, resembling the
crumpled sheets of paper. Think to the takeaway here if you were trying to improve shoulder mobility or
movement. Would you simply focus upon the anterior compartment or does the posterior compartment
also merit attention?

How do fascial techniques work? The theory behind how myofascial techniques work subscribe
to two theories (3):
(1) Neurophysiological Effect: Compression or distraction (decompression) triggers tissue
relaxation via autogenic and reciprocal inhibition, and reduced pain perception. Both are
attributed to altered afferent nerve stimulation to the brain which produces altered efferent motor
effects. More specifically, compression into a muscular region increases tension in that region
which then activates the Golgi Tendon Organs (GTO) that are inhibitory in nature. For example,
compression into the quadriceps with some active movement of that targeted muscle activates
GTOs in the quadriceps, which (a) relaxes the quadriceps, (b) produces relaxation within the
hamstrings, and (c) also relaxes contralateral quadriceps. While studies have demonstrated this
contralateral (i.e., opposing limb) effect, the process by which this happens is not fully
understood although what is proposed is a more global neurophysiological response whereby the
body experiences greater parasympathetic dominance and enhanced stretch tolerance (4).
(2) Mechanical Effect: These same techniques provide mechanical energy which moves fluid
and alters the viscoelastic properties within the tissue by stimulating fluid changes (trixotropy or
improved flow as fluid becomes less viscous due to applied stress and shear). This technique is
also believed to reduce fascial inflammation which also promotes more movement.

Before we discuss the actual techniques employed to improve movement, it is also important to
recognize that there are contraindications to participating in fascial techniques. Examples include
individuals with peripheral vascular diseases or other peripheral diseases (e.g., lesions), a current

56
or a history of deep vein thrombosis (DVT), osteoporosis, hypertension (i.e., due to possible
breath holding during administration) and pregnancy (i.e., due to positional reasons).

C. Applications of Myofascial Techniques

Fascial Techniques (FT) can be self-administered or performed under assisted-practice using
devices that manipulate the skin, muscle, myofascia, and tendons via direct compression or even
decompression or distraction (e.g., cupping) modalities. Researchers have demonstrated how FT
improves movement efficiency and flexibility; how FT reduces injury and plays a significant role
of injury prevention and rehabilitation; and how FT is believed to improve cardiovascular blood
flow (1-3). Prior to exercise, FT has been shown to improve flexibility without any performance
decrement when techniques on one region were performed for less than 2-minutes. Post-exercise,
FT reduces the duration of onset of peak muscle soreness attributed or DOMS when performed
for longer periods (i.e., longer than 2-minutes). DOMS peaks earlier with FT (e.g., 24 hours)
versus when none is performed (e.g., 48 hours). The explanation here is that FT creates pressure
to push larger metabolites out of cells and improves one’s pressure pain threshold (PPT).
However, FT coupled with some static or dynamic stretching produces greater results than stand-
alone fascial techniques.

Practical Fascial Technique (FT) Applications:

The goal is to generate a mechanical force that produces hydrostatic pressure that will move
water and metabolites, and to realign the tendrils.
(1) Need 30-to-120 seconds to remove adhesions (ideally 90-to-120 seconds).
(2) Need active muscle contraction to reach the deep fascia. Active motion is more effective than
passive motion because it triggers reciprocal inhibition (GTO) and stimulates greater
myofascial realignment by moving water (muscle action = mechanical force or hydrostatic
pressure).
(3) Need 3-dimensional movement to optimally realign tendrils.
(4) Roller densities show little-to-no differences – the choice should be directed by an
individual’s threshold to discomfort (i.e., pressure pain thresholds or PPT).
(5) Cadence of movement appears to have little effect upon outcome(s).

57
(6) Ridged surfaces show improvements versus smooth surfaces as they create greater surface
deformation of tissue (i.e., both compression and decompression).
(7) Vibration (20-to-50 Hz) may increase tolerance to pain and help move fluid through fascial
tendrils, but localized tissue vibration has a greater effect than whole body vibration.

Lastly, research by Robert Schleip has created a belief that too much tissue compression or strain
may be pose a temporary problem (2). Prolonged compression over three-minutes can force
water out of the localized region, and with the removal of the compression, that region may
experience a larger of fluid that can reduce movement temporary, a concept he termed ‘super-
compensation.’

FYI… Interestingly, the superficial fascia is a proprioceptive system as it contains six-to-10

times the density of sensory nerve receptors versus regular muscle – this almost rivals the
receptor density of the retina in the eye. What this implies is that this tissue is highly reactive to
any mechanical force that is sufficiently strong enough to trigger a conformational shape change
within this connective tissue (e.g., foam rolling). This will be revisited later when fascial
techniques are discussed.

D. Practicum Portion
• Compare technique differences between traditional calf foam rolling and calf myofascial
techniques.
• Identify five primary regions to target with myofascial techniques and provide your rationale
for making these decisions.

Table 6-1: Worksheet for targeted regions for myofascial release

Target Regions Rationale

1.
2.
3.
4.
5.

58
59
Mobility: Muscle Lengthening (Active System)
Stretching is an activity that provides numerous benefits, but it is arguably something that is
neglected by many people. These benefits are not only physiological, but they include many
psycho-emotional benefits as well (e.g., reduced stress, anxiety). While numerous benefits exist,
there are also unsupported claims related to stretching that lack scientific evidence. Briefly:
• Some believe that stretching before exercise can help prevent injury, but there is little science
to support that notion, nor does it reduce post-exercise muscle soreness (7-8).
• Some believe that stretching before exercise reduces strength and power output, but research
demonstrates that short-duration static stretching held under 30-to-45 seconds do not
decrease muscular power, but it may reduce strength (delayed motor unit recruitment).
However, stretches totaling longer than 60-seconds on a muscle group do appear to reduce
performance on strength-, power-, and speed-dependent tasks (9).

A. Proprioceptors
The process of lengthening tissue includes significant involvement from the neural system given
the role that specific proprioceptors play, and the effects of autogenic and reciprocal inhibition.
Prior to discussing stretching applications, a brief neurophysiology review is suggested to
understand the roles of the nervous and muscle systems in elongating muscle tissue. Briefly,
these muscle receptors are located within the muscle itself or within the tendons at the ends of
the muscle and sense physical changes occurring within the muscle (e.g., tension, lengthening)
• Muscle Spindles (MS) are sensitive to change of length and rate of change of length of
muscles. The MS is rapid acting (i.e., responds immediately) and is excitatory in nature (i.e.,
activates a response). They become activated when the amount of stretch or rate of stretch
exceeds what is currently set as a threshold for that muscle (this threshold changes as
flexibility improves). The basic mechanism of action is as follows:
o If a muscle stretch or rate of stretching exceeds the MS stretch threshold, the sensory
neurons wrapped around the MS relay information towards spine.
o This triggers a reflex action whereby the sensory neurons connect with motor (effector)
neurons to trigger a reflexive muscle contraction to resist further stretching.

60
Think About It… Think of a doctor tapping under your knee when seated. The force rapidly indents the
patella tendon, shifting the patella downwards quickly which in turn pulls on the quadriceps tendon and
lengthens the quadriceps muscle, eliciting a MS response.

• Golgi Tendon Organs (GTO) are sensitive to tension within the muscle (e.g., stretching,
loading). The GTO are located at the proximal end of muscle in the tendinous attachment to
the muscle fiber. They connect with approximately five-to-25 muscle fibers, are slow-acting,
taking seven-to-10 seconds to respond and are inhibitory in nature (i.e., trigger reflexive
responses to inhibit muscle and neural activity). They protect against excessive loading (i.e.,
increased muscle tension) which can be introduced through heavy loads (resistance) or
muscle stretching.

B. Research and Science

Muscle is comprised of two key protein structures; elastin which is elastic in nature (i.e., think
bungy cords) and collagen which is inelastic in nature (i.e., think rope). The ability to flex your
elbow and stretch muscles in the posterior compartment (e.g., triceps) is possible because of the
presence of elastin. Essentially, this protein is pliable and can always be stretched. The stress-
strain curve illustrated below demonstrates this component where with some force (load), the
tissue undergoes elastic deformation because of elastin. However, at the yield point, the elastin
can elongate no more and any further lengthening of the muscle must be derived from collagen.
The strain placed upon collagen slowly pulls the collagen fibers apart (known as creep). The
removal of the strain (pull force) leaves the inelastic tissue temporarily deformed, a condition
referred to as plastic deformation (think squeezing toothpaste in a tube which remains deformed
after you stop squeezing the tube). Creep can continue with prolonged strain (i.e., holding
stretches for longer durations, performing up to four repetitions) until a threshold point. Any
excessive stretching may tear (known as the failure point).

61
 Recommendations for static
stretching are up to four
repetitions with each stretch
held between 15-and-60
seconds (first seven-to-ten
seconds of a stretch removes
neural interference and does
not constitute lengthening of
muscle tissue).
Figure 6-4: The elastic and inelastic properties of muscle tissue

C. Applications of Muscle Lengthening – Neurological Principles

First examine a traditional static (passive) stretch which introduces a sustained, low-force stretch
to slowly increase muscle length. The illustration presents the sequence of neural events
occurring during the application of a static stretch.
1. The muscle is stretched to the point of tension which elicits an immediate low-grade muscle
spindle (MS) response. This excitatory response temporarily increases muscle tension in that
very muscle.
2. Because the stretch is pushed no further than the point of tension, that low-grade muscle
response quickly decreases within the first five seconds as stretch duration progresses (MS
desensitization).
3. After seven-to-ten seconds, that muscle tension activates a GTO response which is inhibitory
in nature.
4. This GTO activity inhibits MS activity, subsequently relaxing the muscle which can now be
stretched.
5. This concept of GTO inhibition overriding MS activity is called Autogenic Inhibition.

62
 Figure 6-5: The process of autogenic inhibition

Think About It … How many ways can you stretch a muscle?

• First, recognize whether it is mono-articulate (crosses one
joint) or bi-articulate (crosses two joints).

Next, think to the planes of motion for elongation – do

you know your origins and insertions? Examine
directions one, two and three – how would you apply
these into practice

If one investigates the practice of performing low-intensity, more rhythmic movements involving
the opposing muscles at a joint, a different neurological principle is elicited. The action here is
one where the muscle on one side of the joint (agonist) is activated which simultaneously and
briefly inhibits the muscle on the opposite side of the joint (antagonist) to promote greater
extensibility (movement, not flexibility) of the agonist. Movement in the opposite direction
simply reverses this effect. An example of this pattern would be the action of swinging a leg
back and forth in preparation for a run. In the past this was erroneously referred to as dynamic
stretching, but if you consider how the end-ranges of these movements are only usually held for
brief moments, an insufficient amount of time to evoke any autogenic inhibition or creep, it is
now more aptly referred to as dynamic movement, movement preparation or neuromuscular

63
potentiation. This neurological principle is called reciprocal inhibition which adheres to the
notion that when a muscle (agonist) is activated, the neural system transmits a simultaneous
impulse to the opposite muscle (antagonist) to temporarily inhibit its activity. This enables
greater movement at, or across the joints and this effect is immediately reversed when the limb
moves in the opposite direction (i.e., reciprocal movement). This process basically follows the
below-mentioned sequence:
1. Low-grade muscle action in a muscle (e.g., antagonist) at a less-than-50% intensity of
maximal force production.
2. This activity immediately reduces muscle tonicity (activity) within the agonist (opposite
muscle) to facilitate movement (i.e., the muscle requiring extensibility).
3. This can easily be attained through one set of five-to-10 repetitions performed at a controlled
tempo.

Figure 6-6: The process of reciprocal inhibition

Unlike static stretching and autogenic inhibition which turn off neural activity, reciprocal
inhibition functions to prepare and coordinate nerve and muscle activity, hence is an effective
modality to use before exercise. Static stretching can also be incorporated before exercise, but it
should be followed by some reciprocal inhibition to turn the neuromuscular coordination back on
(i.e., neuromuscular potentiation).

Table 6-2 provides a summary of performing static stretching which subscribes to autogenic
inhibition. Proprioceptive Neuromuscular Facilitation (PNF), another corrective exercise

64
technique for lengthening tissue that will be discussed next that subscribes to both autogenic
inhibition and reciprocal inhibition.

Table 6-2: Static (passive) stretching summary

Principle Static Stretching

Neurological Principle Autogenic Inhibition

Variables 2-to-4 reps x 10-to-30 seconds
Notes • Differentiate between mono-articulate and bi-articulate muscles –
control joint movement.
• After ~5 sec of tension, muscles do experience small amounts of
decreased localized blood flow (ischemia, lactate accumulation) – may
increase fatigue and discomfort.
Demo Passive straight leg raise (hamstrings)

D. Practicum Portion
• Identify five muscle groups that generally appear problematic and demonstrate how you
would perform static stretches on each one (hint – think of positions people adopt throughout
their days).

Table 6-3: Worksheet for targeted regions for static stretching

Target Regions Rationale

1.
2.
3.
4.
5.

E. Proprioceptive Neuromuscular Facilitation (PNF)

Pioneered in the 1940’s by Henry Kabat, it was originally created to treat neuromuscular
conditions (e.g., polio, MS) as it is not only a stretching technique, but also considered a muscle

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strengthening technique. It is generally performed as a partner-assisted modality and includes a
variety of different techniques (contraction, stretching) incorporating both autogenic inhibition
and reciprocal inhibition (10).

The names identifying the type of stretching intervention is defined by the muscle actions
performed – for example:
• Hold implies an isometric contraction of the targeted (lengthened) muscle at its end-range or
motion (end-ROM).
• Relax implies a conscious relaxation of the targeted (lengthened) muscle.
• Contract implies an active concentric contraction of the targeted (lengthened) muscle.
• Antagonist contraction implies an active contraction within the opposing muscle to the
targeted muscle being lengthened.

F. PNF Applications – some examples:

• Hold-relax (simplest modality) involves passive movement of the targeted muscle to it
near-end -ROM. The individual then performs a low-grade (≤ 50% max effort) isometric
contraction which is held up to 15-seconds after which the individual consciously relaxes
(passive stretch) that muscle which is then immediately pushed push deeper into the
stretch and held for an additional 20-to-30 seconds, then repeat 2-to-3 times. This
modality relies upon autogenic inhibition.
• Contract-relax is very similar, except for the contraction phase. Here, the individual
performs a concentric contraction over that timeframe (up to 15-second) rather than an
isometric contraction, followed by the relaxation phase, then repeats 2-to-3 times.
• This modality also relies upon autogenic inhibition, but it is more challenging to
administer.
• Hold-relax-antagonist contract begins much like the hold-relax described above with
an isometric contraction, but it is coupled with only a brief relaxation (e.g., 3-to-6
seconds) before the individual contracts the antagonistic (opposing) muscles to try to
actively move deeper into the stretch. The person then holds this position briefly (e.g., up
to 10-seconds), after which he or she relaxes into a passive stretch for 20-to-30 seconds,
then repeats 2-to-3 times. For example, following the isometric contraction and brief

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 relaxation of the hamstrings, the individual actively tries to move their leg deeper into the
stretch by actively contracting the hip flexors and quadriceps before entering the
relaxation phase (also known as reciprocal relaxation). This is perhaps one of the more
effective PNF techniques and incorporates autogenic inhibition and reciprocal inhibition
into the modality.

G. Practicum Portion
• Using the Table 6-4, perform the PNF stretches instructed on the identified muscles.
While administering each stretch, identify differences in outcomes (i.e., efficacy) and the
degree of challenge in performing each modality.

Table 6-4: Worksheet for different PNF stretches

PNF Stretch Targeted Muscle

1. Hold-relax Quadriceps
2. Hold-relax Latissimus
3. Contract-relax Pectoralis Group
4. Contract-relax Triceps
5. Hold-relax-antagonist contract Hamstrings
6. Hold-relax-antagonist contract Calf muscles

Stability: Muscle Activation (Active System)

Following the mobility interventions (i.e., myofascial techniques and muscle lengthening), the
attention should shift to focus upon the opposing muscles at the joint or segment which tend to
be underactive and weak.

An important point to remember here is that the stabilization properties of a muscle are related
more to the type I muscle fibers than the type II fibers. Type I fibers are more aerobic in nature
and therefore capable of sustaining lower-intensity, longer duration contractions, explaining their
denomination as ‘tonic’ fibers. Type II fibers by comparison, are more anaerobic in nature and
therefore incapable of sustaining lower-intensity, longer duration contractions, explaining their

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denomination as ‘phasic’ fibers (i.e., work in brief burst to provide higher-intensity forces). It is
the type I fibers that provide the stabilizing properties to the body. Therefore, it is these fibers
that need to be activated and not the type II fibers.

Much like with stretching, a variety of muscle activation techniques exist, and many are arguably
effective. However, in this course we will address a simple muscle activation technique called
Positional Isometrics (11). Following the mobilization techniques and as the names implies, this
technique builds kinesthetic awareness of ideal joint or segment position, then activates that
muscle or group of muscles with a low-grade isometric contraction that progresses systematically
over time with an increase in the volume of work performed. Kinesthetic awareness can be
improved using a variety of different tactics:
• Visual cueing and awareness of position (e.g., demonstrating proper position of how to move
from a head-forward position to an ideal position).
• Tactile cueing whereby some device or surface is used to increase awareness via physical
sensations (e.g., sitting against the wall and retracting the scapulae to feel them positioned
flat).
• Auditory cueing where the practitioner provides verbal cueing to help the individual actively
position the joint or segment in the desired position (e.g., cueing the individual to keep
externally rotating their arms until ideal position is reached).
• Spatial cueing where the practitioner uses any device (e.g., dowel, hand) to cue the individual
to align the joint or segment until the two structures (e.g., hand and shoulder blades) become
congruent, but do not actually touch (e.g., retracting the scapulae until the shoulder blades
align parallel with the hand, but do not touch).

The volume progression when performing positional isometrics can be manipulated by

increasing the duration of each contraction (e.g., increasing from 5-seconds to 15-seconds) or by
increasing the number of repetitions performed. Many of the programming principles are listed
in Table 6-5.

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Table 6-5: Programming variables for positional isometrics
Variable Instructions

Training frequency Dose-related, but ideally performed 1-to-2 times daily

Joint position Positioned in neutral or ideal position
Duration of each repetition Begin with a 5-second hold, build progressively
Sets and reps Begin with 1 set x 5-repetions, progress to 2ot-3 sets x 10 repetitions
Tempo Slow and controlled (especially during the relaxation phase), and allow a
few seconds recovery between repetitions
Intensity Low-grade contractions between 25-and-50% of maximal force capacity

A. Practicum Portion
• Using the Table 6-6, perform the positional isometric exercises on the identified joints or
segments. While administering each exercise, experiment with the different cueing
techniques to identify which might works best in your own interventions.

Table 6-6: Worksheet for positional isometric exercises

Joint or Segment Cueing Technique Used (fill in)

1. Head-forward position (hint: cervical extensors)

2. Thoracic kyphosis (rounded upper back)
3. Protracted scapulae
4. Internally-rotated arms
5. Anterior pelvic tilt
6. Pronated feet

Core Stabilization – An Area of Focus for Stability

The core region, a component of the lumbopelvic hip complex (LPHC) has 3-dimensional depth
and tri-planar functional roles. It is comprised of three distinctly different sections with most

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muscles hidden beneath the musculature that people typically train (12-14). Each section will be
briefly reviewed with respect to its anatomy and functional roles.

Figure 6-7: the uniquely different layers of the core region

1. Deep, innermost layer is comprised of vertebral bones, discs, spinal ligaments running
along the front, sides and back of spinal column and small muscle groups spanning each
individual vertebra – the rotatores, interspinali, and intertransversarii. They are generally
considered too small to contribute individually to movement or to offer much spinal support,
but they do offer some segmental mobility and stability and collectively can help stabilize the
spine at end-ROM (e.g., in full flexion, the sum of the individual muscles under tension can
support the spine). These muscles are located in very close proximity to the spine and are
rich in sensory nerve endings to provide continuous feedback to the brain regarding spinal
loading and position.
2. The core unit (middle, local muscles) comprise the fascia encircling the lower regions of
the spine and part of pelvic floor (e.g., linea alba, thoracolumbar fascia), and various muscle
groups. While no universal agreement exists on which exact muscles comprise the core, think
of a theoretical box covering the area between the diaphragm and the sacroiliac joint / pelvic
floor, with muscles enclosing the back, front and sides:
• Transverse abdominis (TVA).
• Multifidi and quadratus lumborum.
• Deep fibers of the internal oblique.
• Diaphragm and pelvic floor musculature.

Their primary roles are to provide stability to the LPHC region during production, transfer
and control of force and motion to the extremities. This implies controlling integrated

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 movement of the trunk and hips together rather than as two individual segments. This
requires a combination of effective motor control, reflexive function, and some stabilization
and endurance. Given the general orientation of the fibers of the TVA, contraction reduces
the diameter of the core region which places the spine into traction (elongation), much like
how squeezing a water balloon in the middle elongates the ends. In theory, this is believed to
reduce the compressive forces on the vertebral discs by up to 40% (15). This concept is
termed hoop tension or increasing intra-abdominal pressure (IAP) which serves to increases
lumbar stiffness to build traction between lumbar vertebra and reduce joint and disk
compression.
Like how a belt works to hold up pants, it
tightens against a rigid structure (e.g., the
sacrum.). I the same way, the multifidi contract
to stiffen the spine, a term called
thoracolumbar fascial gain so that the
contracting TVA draws the abdominal region
in towards the spine to create the hoop tension.
Figure 6-8: The hoop tension effect of the core muscles

In healthy individuals (i.e., no low-back pain) the core muscles function reflexively in
response to anticipated or voluntary / involuntary loading, reacting within 40-to-100m sec of
sensory stimulation. However, delayed or poor TVA activation occurs in individuals
suffering from low back pain (LBP) or with a history of LBP which indicates some neural
control deficit (13,16). This delayed TVA activation inadequately stabilizes the lumbar spine
during loading and movement of the LPHC and increases the injury potential in that region.
It is speculated that de-conditioned individuals who spend many hours seated using
supported devices (e.g. back rests) may also demonstrate similar neural deficits. Individuals
who lack appropriate TVA function have no option but to rely upon synergistic muscles to
provide a stabilizing role (e.g., rectus abdominis). This alters muscle roles in the region and
increases the potential for compromised movement and function.
• The outermost or global unit consists of the larger, more powerful muscles spanning many
vertebrae and the hips, ribcage and shoulder girdle. It includes the rectus abdominis, erector

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 spinae, external and internal obliques, iliopsoas and latissimus dorsi. Although they do offer
some structural support, their primary purpose is to generate force for movement of the trunk
and the LPHC.

A. Practical Application and Activation of the Core Muscles.

The core muscles do not generally act in isolation because they are an integral component of the
entire LPHC, serving to coordinate force production and transfer between extremities through
the hips and trunk. However, for individuals experiencing neural control deficits and poor core
control, some isolated muscle activation is needed to re-engage this reflexive motor response –
serves as the foundational step to developing the ability to co-contract both regions in synchrony
when maximal stabilization of the spine is
needed, a term called bracing (16).

The image illustrates the difference in spinal

support between local versus global
activation. Much like how standing with a
wider base of support to achieve greater
stability, co-contraction of both units
provides greater levels of support, an event
that should happen temporarily during heavy spinal loading (e.g., squatting).
Figure 6-9: The benefits of co-contraction to support the spine

The sequential process for developing lumbar and LPHC stability is to first activate and stabilize
the local muscles, then transition into a more global approach through statically, and ultimately
dynamically controlled movements and exercises. During this fundamental phase, local core
activation and stabilization are addressed in preparation for the Foundational phase where
unsupported movement patterns, operating off both static and dynamic bases of support, are
emphasized.

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 Figure 6-10: A systematic approach for developing LPHC control

Remember however:
• Tonic muscle fibers (e.g., local muscles) function more in the capacity as stabilizers because
they possess higher concentrations of type I fibers (tonic) and are therefore best trained using
volume in unstable surfaces and environments. The progression through this model will
move from stable to unstable surfaces or environments.
• Phasic muscle fibers (e.g., global muscles) function more in the capacity as mobilizers
because they possess higher concentrations of type II fibers (tonic) and are therefore best
trained using load in stable surfaces and environments.

Practical: Core Activation – Muscle Kinesthesia (awareness):

Supine (bent-knee) Hovering Marches:
• This pattern is designed to help the individual develop core muscle kinesthesia.
• Instruct the individual to lie supine on a firm surface with a bent-knee position and place a
BP cuff under the lumbar spine – inflate to a pressure where cuff bladder pushes lightly
against the lumbar spine.
• Lift one foot two inches of the floor and hold this position throughout the repetitions (i.e.,
hovering above the floor).
• Lowly lift the opposite foot two inches off the floor (both feet now raised off the floor) and
perform a series of slow, controlled marches with that second foot. Neither foot should ever
touch the floor and should always remain raised. March the second foot by lifting it 12-
inches off the floor before returning to the starting position (i.e., hovering).
• Perform 5-to-10 slow repetitions and repeat with the other side.

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• Throughout the movement, the needle of the BP cuff should demonstrate little-to-no
movement as the lumbar spine remains stable (use as a biofeedback device – individual
watches the gauge).

Figure 6-11: Supine (bent-knee) Hovering Marches

Practical: Core Activation – Exercise #1

Drawing-in / Centering or Hollowing (muscle action):
• This sequence of movements is designed to engage the lumbar stabilizers in a stable
environment during extremity movement.
• Instruct the individual to lie supine on a firm surface with a bent-knee position and place a
BP cuff under the lumbar spine – inflate to a pressure where cuff bladder pushes lightly
against the lumbar spine. Throughout all movements, the BP cuff needle should demonstrate
little-to-no movement as the lumbar spine remains stable (use as a biofeedback device –
individual watches the gauge).
• Complete the sequence of movements listed, performing 1-to-2 sets of 10 repetitions for each
movement in a slow, controlled manner. At the end-ROM for each movement, hold the
position for 1-to-2 seconds to training the core musculature as stabilizers.
o Movement #1: Pelvic floor contractions (‘kegels’) following a gentle expiration (end-
tidal volume) – kegel contraction stops the flow of urine.
o Movement #2: TVA contraction (drawing belly button towards spine) at end-tidal
volume.

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 o Movement #3: Combination of both contractions and add a 10-second breath count out
loud while breathing normally – ensures normal diaphragmatic function in breathing
while simultaneously resisting the effect of the TVA contraction pushing abdominal
contents upwards (i.e., hoop tension).
o Movement #4: Introduce small lower extremity patterns sliding the hell and marching
the legs off the floor, but DO NOT movement to positions greater than 90° of hip flexion
– this rotates the pelvis posteriorly and flattens the back against the floor, removing the
need for core stabilization.
§ Progress from short-lever (bent elbow) to long lever (extended elbow).
§ Progress from unilateral (one arm moving) to bilateral (two arms moving)
§ Progress from sagittal plane to 3-dimensional, asymmetrical movements in all planes.
o Movement #5: Introduce small upper extremity patterns moving the arms overhead to
touch the floor.
§ Progress from a touch-touch with heel firmly placed on floor to a slow, controlled
heel slide to extend the knee.
§ Progress from unilateral (one leg moving) to bilateral (two legs moving)
§ Progress foot marches from a one-to-two-inch hover towards 12” foot lifts off the
floor
§ Progress from the sagittal plane to 3-dimensional, asymmetrical movements in all
planes.
o Movement #6: multi-dimensional movements simultaneously in both extremities, but
perform slow, controlled movements.

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Practical: Core Stabilization – Exercise #1
Rocking Birddog (Quadruped)
• This sequence of exercises is designed to condition the core stabilizers in a more unstable
environment during extremity movement.
• Instruct the individual to assume a quadruped position (six points of contact – two feet, two
knees, two hands) on a firm, but comfortable surface with the hands positioned under the
shoulders and the knees positioned under the hips.
• Follow the core activation sequence outlined previously (i.e., kegel and TVA) and maintain
this muscle engagement throughout the exercise.
• Place a yoga block or similar stable device on the lower portion of the lumbar spine where it
rests unsupported.
• Complete the sequence of movements listed, performing 1-to-2 sets of 10 repetitions for each
movement in a slow, controlled manner. At the end-ROM for each movement, hold the
position for 1-to-2 seconds to training the core musculature as stabilizers.
o Movement #1: Reduce points of contact from six to two-to-three (i.e., one foot, one
knee, one hand) by slowly lifting a hand, knee and foot 1-to-2 inches off the floor. Hold
position briefly while maintaining balanced position of the yoga block or similar device.
o Movement #2: Slowly introduce a rocking movement, shifting the body’s center of mass
backwards towards the heel and forwards towards the hand while maintaining the
balanced position of the yoga block or similar device.
o Movement #3: Incorporate multi-dimensional movements simultaneously in both
extremities (slow, controlled movements) while rocking backwards and forwards, and
preserving the balanced position of the yoga block or similar device.

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 Figure 6-12: Rocking birddog (quadruped)
Scapular Stabilization – An Area of Focus for Stability
While protracted scapulae are a common occurrence (i.e., upper cross syndrome) and relatively
easy to address, it is the winged scapula that presents a significant challenge. Unlike the
protracted scapula where the medial border protrudes outwards (i.e., scapular abduction away
from the spine), the winged scapula displays this condition coupled with an anterior tilt where
the inferior angle also protrudes outward, resulting in a highly dysfunctional shoulder. This can
be quickly assessed via observation of scapular position when a person stands in a relaxed state
with the arms positioned by their sides. The winged scapula is evidenced by noticeably visible
protrusion of the inferior angle and medial borders rather than a flattened scapular that lies
against the ribcage*.

Figure 6-13: Demonstration of winged and packed scapulae

* Because females have narrower torsos, slight forward-rounding in the scapulae is considered normal
versus men, who have wider torsos. Men should demonstrate a more flattened scapular position – this
position can be observed by running the hands over both scapulae.

The winged scapula should be addressed and rectified before participating in upper extremity
movements to avoid potential injury. To do so, follow the corrective exercise approach outlined
in this section:
• Mobilization: Myofascial techniques – using a massage ball (ideally) and active muscle and
joint movement, introduce some scapular mobility within the anterior and posterior shoulder

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 compartments. One exercise example is to apply pressure over the pectoralis minor region
(i.e., area under the lateral portion of the clavicle) while performing a series of arm
movements (e.g., I-formation, Y-formation, reverse pec flyes, snow-angels).
• Mobilization: Lengthening – The anterior scapula muscles that pull the scapula into an
anterior tilt (e.g., pectoralis minor) are in need lengthening. To facilitate this process, utilize a
ball or prop that can be firmly positioned against the inferior angle while the individual lies
supine on a firm surface. This position creates posterior tilting in the scapulae to rectify the
anterior tilt (assisted by gravity). After several minutes lying in this position, perform
stretching techniques on those anterior shoulder muscles.
• Stabilization: Activation with Shoulder Packing – The goal or objective is to activate the
inferior and medial muscles to hold the scapulae in a flattened or more flattened position.
This involves coaching the individual to perform the following muscle action sequence,
starting first in an open kinetic-chain environment:
o Movement #1: Stabilize the lumbar section by drawing-in – this minimizes any lumbar
involvement in the exercise.
o Movement #2: Retract the scapulae, envisioning them moving along the backside of the
ribcage towards each other. A common mistake made is to extend the thoracic spine (i.e.,
move the chest forward) rather than move the scapulae. This simply collapses the
scapulae onto the ribcage and is NOT an acceptable position because they are not stable.
The scapulae need to move towards a flattened or near-flattened position without any
ribcage movement.
o Movement #3: Depress the scapulae – envision holding heavy kettlebells in each hand.
This corrects normal scapular elevation that frequently accompanies scapular retraction.

Did You Know… The open-kinetic chain environment is one in which the object or surface against
which a person pushes or pulls moves (e.g., barbell bench press, seated row), whereas a closed kinetic-
chain environment is one in which the object or surface against which a person pushes, or pulls does not
move, but the person moves (e.g., squat, push-up).

o Movement #4: Unloaded, open kinetic-chain exercises. With a retracted and depressed
scapular position, perform a series of movements in all three planes while maintaining a
stable (i.e., no movement) scapular position. Two basic rules here:

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 § As the arms move through the multiple planes (e.g., sagittal plane push/pull), avoid
any full elbow extension because this may trigger scapular protraction.
§ Play below shoulder height to avoid upward rotation of the scapulae.
o Movement #5: Loaded, open kinetic-chain exercises. Repeat movement #4, but
introduce light resistance (e.g., elastic, cable).
o Movement #6: Closed kinetic chain exercises: Start standing, positioned approximately
two feet in front of a wall. With packed scapulae, arms at the sides, but bent to 90° at the
elbows, slowly shuffle towards the wall until the hands are firmly placed against the wall.
Next, slowly shuffle the feet backwards as the body assumes a forward lean position,
loading weight into the hands and shoulders – the scapular must NOT move, but remain
stable as should the LPHC (i.e., remain rigid with no hip sagging or hiking). At this point
repeat the same patterns from movements #4 and #5 while changing hand positions on
the wall (e.g., wide, narrow, internally/externally rotated) – moving the body forwards
and backwards (sagittal plane), sides shifts (frontal plane) and dipping one shoulder
(transverse plane). This position will ultimately move towards the floor to become a
push-up, performed with the scapulae in a more stable position.

Figure 6-14: Open- and closed kinetic-chain movement

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Closing Remarks
The approach to corrective exercise is not complicated. While this course presents a sequence
that addresses mobility prior to stability, recognize that many sequences exist that will most
likely attain the same outcome. However, is important to recognize is that some causes of muscle
imbalance, postural misalignments and movement dysfunction are non-correctable, yet every
practitioner should always strive to make improvements where, and whenever possible. Also
recognize that many of the correctable causes are attributed to choices people make voluntarily
and perform repeatedly. Subsequently, all interventions should comprise both corrective exercise
and lifestyle changes that address administrative and engineering controls.

Restoring appropriate levels of stability and mobility back into the body is dose-related. Thirty
minutes of corrective exercise can never undo 10-to-15 hours of bad posture, awkward positions,
or poorly executed movement patterns. There must be conscious awareness to all precipitating
factors coupled with real intention to bring about change.

References:
1. Myers T, (2014). Anatomy trains (3rd ed.). London, England. Churchill Livingstone Elsevier.
2. Schleip R, and Bayer J, (2017). Fascial Fitness. Nutborne, Chichester, UK. Lotus Publishing.
3. Cheatham SW, and Stull KR, (2018). Roller massage: A commentary on clinical standards and survey
of physical therapy professionals – Part 1. The International Journal of Sports Physical Therapy,
13(4):763-772.
4. Cheatham SW, and Kolber MR (2018). Does roller massage with a foam roll change pressure pain
threshold of the ipsilateral lower extremity antagonist and contralateral muscle groups? An
exploratory study. Journal of sports Rehabilitation, 27:165-169.
5. Cheatham SW, and Stull KR, (2018). Comparison of three different density type foam rollers on knee
range of motion and pressure pain threshold: A randomized controlled trial. The International Journal
of Sports Physical Therapy, 13(3):474-482.
6. Cheatham SW, and Stull KR, (2017). Comparison of foam rolling session with active joint motion
and with joint motion: A randomized controlled trial. Journal of Bodywork and Movement Therapies,
22:707-712.
7. Callaghan MJ, and Suff C, (2009). Does stretching before exercise help prevent injury? Emergency
Medicine Journal, 26(8):614.
8. Arrol B, (2003). Review: Stretching before or after exercise does not prevent muscle soreness or
reduce risk of injury, Evidence-Based Medicine, 8(2):52-54.
9. Shrier I, and McHugh M (2012). Does static stretching reduce maximal muscle performance? Clinical
Journal of Sport Medicine, 22(5):450-451.
10. Zaffagnini S, Raggi F, at al., (2016). General Prevention Principles of Injuries. In Mayr HO and
Zaffagnini S, Prevention of injuries and overuse in sports: Directory for physicians, physiotherapists,
sport scientists and coaches. Springer. ISBN 978-3-662-47706-9.

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11. Clark MA, Lucett SC, and Sutton BG, (2014). NASM’s Essential of Corrective Exercise Training (1st
ed. revised). Burlington, MA. Jones and Bartlett Learning.
12. Arokoski JP, Valta T, Airaksinene O and Kanpaanpaa M, (2001). Back and abdominal muscle
function during stabilization exercises. Archives of Physical Medicine and Rehabilitation, 82:1089-
1098.
13. McGill SM, (2007). Low back disorders: Evidence-based prevention and rehabilitation (2nd ed.).
Champaign, IL. Human Kinetics.
14. Golding LA, and Golding SM, (2003). Fitness professionals guide to musculoskeletal anatomy and
human movement. Monterey, CA. Healthy Learning.
15. Hodges PW, and Richardson CA, (1996). Inefficient stabilization of the lumbar spine associated with
LBP: A motor control evaluation of the TVA. Spine, 21:2640-2650.
16. McGill S, (2004). Ultimate Back Fitness and Performance. Waterloo, ON. Wabuno Publishers.

Image Credits:
1. Figure 6-9: Image courtesy of J Marchn - modified from File:718 Vertebra.jpg, under CC BY-SA 3.0.
2. Figure 6-16: Image courtesy of Henry Vandyke Carter – Henry Gray (1918) Anatomy of the Human
Body: Gray's Anatomy, Plate 241, Public Domain.
3. Figure 6-18: Image courtesy of Ada S. Ballin, with permission to use under public domain.

Notes Section

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82
 Module 7: Foundational Phase

Introduction
In this phase, the final piece of the corrective exercise paradigm – integrated movement is
addressed. After sectional stability and mobility have been established, the practitioner’s focus
should shift to instructing and coaching the primary movement patterns, the foundation to
teaching all exercises.

Sensory-motor integration refers to the process of receiving information through any sensory
system, organizing and processing this information, and eliciting the appropriate motor
responses. What this essentially means is that the sensory and motor systems are communicating
and coordinating with each other effectively to produce efficient movement. It is the initial three
phases of the corrective exercise model that re-establish the functional relationships between the
different systems in Panjabi’s movement model (e.g., active, neural control) and restore proper
sensory control. It is now this last phase that emphasizes motor control, to close the sensory-
motor integration loop.

The Primary Movement Patterns

Before discussing each of the five primary movement patterns, it might be helpful to briefly
review two laws in physics that influence movement, namely Newton’s first and third laws
• His first law focuses upon inertia and how an object at rest tends to remain at rest whereas an
object in motions remains in motion. What this essentially means is that it requires more
effort to overcome inertia and initiate movement than it is to maintain motion. As an
example, think of pushing a car – it is harder to get the car moving than it is to keep it in
motion. Within the human body think to the joints – joints that provide stability (e.g., lumbar
spine, knees) have greater congruency between the joint surfaces (i.e., packed closer
together) and requires more force and experience more shear in overcoming inertia*. A more
mobile joint by comparison is less congruent which therefore requires less force and

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 experiences less shear in overcoming inertia. What this means is that to preserve the integrity
of the body’s joints, a good idea is to try initiate movement through mobile, rather than stable
joints.

* To experience shear, firmly place your palms against each other and try to slide the hands in opposite
directions while pressing firmly – this is an example of shear. Now think how this impacts your joints –
good or bad?

Try This … Perform a standing, medicine ball trunk rotation. For option one, keep the ankles and hips
firmly planted and rotate the trunk to either side. Notice the stress in the knees and low back as those
segments experience shear forces. Option two is to initiate the movement by pivoting at the ankles and
hips (i.e., mobile joints), then continuing to rotate the trunk. Notice how much less shear is experienced in
the knees and lumbar spine.

• His third law focuses upon reactive forces (i.e., ‘for every action there is an opposite and
equal reaction’). In practice, think of the arm or elbow driving backwards and the reactive
effect upon the humeral head driving forward. How does the body stabilize against these
reactive forces? This will be discussed in this module.

Bend-and-lift Pattern (1-5)

The squat, an exercise derived from the bend-and-lift pattern, is a popular lower extremity
exercise that is usually poorly performed and often cited as a source of knee or back pain. So,
prior to coaching the bend-and-lift pattern, it might be helpful to review some misconceptions
surrounding the squat. To this day, we still hear certain squat rules echoed over and over
throughout gyms and health clubs by many fitness professionals that often sound contradictory.
While some rules emerged through research, the origins of others may lie in folklore and myth.
The squat is one such example, where we hear an endless list of cues – ‘keep the knees behind
the toes’, ‘align your knees over your second toe’, ‘open your stance’, ‘keep your head up’ and
many more. Which are trusted as evidence-based and which present as more myth-than-fact?
Furthermore, then watching fitness professionals squat, oftentimes they are (a) many are
incapable of squatting correctly on account of inadequate levels of mobility or stability
throughout their own kinetic chain (e.g., ankle mobility), (b) they fail to follow their own rules

84
and resort to compensated movement (dyskinesis), or (c) they are much in need of an update in
their knowledge and understanding of proper form given some updated research on human
movement. With that said, let’s examine some of these common rules.

A. Keep your Knees Behind your Toes

Fry and colleagues examined squats where the knees moved or were restricted from moving
forward. As expected, when forward knee movement was restricted, the shear forces and torques
at the knee were reduced versus squats where the knees could move forward. However, the
researchers also noticed significantly greater amounts of shear forces and torque in the hips and
lumbar spine when squats did not allow the knees to move forward. The ramifications here are
serious given the fact that the lumbar spine is more susceptible to injury. In other words, a more
forward leaning position of the trunk because of a vertical tibia (i.e., not allowing the knees to
move forward) generates greater shear forces between the individual vertebrae in the spine (e.g.,
L5-S1, L5-L4, L4-L3, etc.) during the rising or upward phase (i.e., spinal extension).

Interestingly, shear forces at knee involve anterior-posterior movement of bones at the joint that
affect the cruciate ligaments most notably.
• The ACL begins to experience anterior shear forces starting at a 15° knee bend, experiences
greatest anterior shear forces at a 30° knee bend, and then diminishes after a 60° knee bend.
• The PCL begins to experience posterior shear forces at a 30° knee bend, experiences greatest
posterior shear forces at a 60° knee bend, and then diminishes after a 90° knee bend.

Takeaways: The squat should allow the knees to move forward. It should be initiated by first driving the
hips backwards (hinging) which helps eccentrically load the gluteus maximus, helps initiate an isometric
contraction within the hamstrings to help unload the ACL. Because the knees only begin to translate
forward at about 15-to-30° of hip flexion, this creates more of a hinge movement at the knee which may
reduce potential shear forces in the knee.

B. Keep Knee Aligned over 2nd and/or 3rd Toes

As discussed previously, the talocrural joint between the fibula, tibia and talus produce plantar
flexion and extension whereas the sub-talar joint between the talus and calcaneus produces

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pronation and supination. However, when the talocrural joint lacks mobility, the sub-talar joint
contributes, thereby compromising stability. This often drives the knees inwards, increasing
stress lines along the ACL. This is perhaps the biggest issue in the squat – limited ankle mobility.
• Be sure not to confuse normal slight foot eversion of upto 8-to-10° in the standing position
with eversion and pronation – normal foot position is feet parallel to 8-to-10° of eversion.
• Knees collapsing inward is perhaps the consequence and not the cause of the problem. As
illustrated in the movement screens module, examine the limitations in the ankles and hips as
potential causes.

C. Open or Widen your Stance:

A wide squat-stance is one where the feet are generally placed between 150-to-200% of shoulder
width (i.e., up to 2x wider than shoulders), a stance often assumed when performing deep squats.
Outward rotation of the legs and feet often accompanying the deep squat increases
patellofemoral (15%) and tibiofemoral compressive forces (16%) versus narrow stance (85-to-
120% of shoulder width), although the narrow stance requires more forward tibial translation and
ankle mobility (6). The more a person rotates outward (e.g., 15-to-30° outward rotation), the
greater the engagement from the adductors and the belief that the squat becomes more powerful,
but this position should never compromise good form. But, any limitations in adductor
extensibility becomes an issue during the deep phase as the muscles are lengthened, causing
valgus knee collapse (inward knee collapse). Additionally, excessive external femoral rotation
(i.e., beyond 30-to-40°) changes hip position by tilting the pelvis anteriorly to accommodate the
external femoral rotation, changing lumbar spine alignment*.

* Remember, that for every 2° of lumbar hyperextension beyond neutral, the compressive forces on the
posterior annulus increases by an average of 16% (7).

Try This… While standing, externally rotate the thighs and notice the tension build up in the low back.

D. Maintain the Head-up Position:

The head-up position is most probably a bad myth propagated in gyms. On one side, a head
down position by as little as 4½° from neutral increases spinal flexibility, which in turn can

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increase posterior spinal compression and decrease balance. By contrast, a head-up position is
believed to help maintain balance and shift weight into the heels, but the reality is that this is
usually a consequence of inadequate hip flexor and / or ankle mobility that creates the forward
trunk lean that necessitates a head-up position to avoid falling. This position extends the thoracic
spine and the compressive forces along the entire spine.

Coaching the Bend-and-Lift Pattern:

The functional exercise that mimics the bend-and-lift pattern is the deadlift rather than the squat
because of the arm position (i.e., at sides when people bend to pick up objects). In the traditional
squat, the barbell is placed behind the neck which requires thoracic and shoulder mobility to do
so, without which the lumbar spine is exposed to potential compromise. Therefore, one should
earn the right to squat which is determined via the overhead reach screen to assess thoracic
mobility and lumbar stability. In other words, can the individual abduct and externally rotate the
arms without excessive lumbar lordosis? Considering this challenge to many, the sequence for
teaching usually starts with the bend-and-lift (deadlift), followed by the front squat, and only
permitting the Olympic squat when adequate thoracic mobility exists.

Another important consideration when instructing the bend-and-lift pattern pertains to the hip
hinge to initiate the lowering phase. The hip hinge involves an anterior pelvic tilt to drive the
hips backwards in order to load the posterior chain (e.g., glutes, hamstrings). What is important
to teach is that the hips must move backwards in the absence of any forward-head movement
(i.e., little-to-no forward head movement) in order to preserve the body’s and barbell’s center of
mass (COM) inside the body’s base of support. However, immediately following the hinge, the
lumbar spine, now positioned in increased lordosis which increases compressive forces within
the lumbar spine, requires correction. To do so, it necessitates a small pelvic rounding or
posterior tilt created by contracting the rectus abdominis to return the spine to a neutral position
before starting the lowering movement.

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 Figure 7-1: The hip hinge versus the squat hinge

Shift Forward: With feet placed firmly, shift

forward until heels start to lift off the floor - shifts
tibia forward to, and possibly beyond the knees.
Brace: Co-contraction of both local and global
trunk muscles to maximally stabilize lumber spine
(i.e., prevent increases in lordosis from neutral).

Figure 7-2: Sequence for coaching the Figure-4 position

Torso Hinge: While holding the bracing contraction, move the entire trunk to a more vertical
orientation. DO NOT confuse this movement with hyper-extension of the lumbar spine that
occurs when the movement originates from the head and thoracic spine (i.e., chest rotating
upwards). The entire trunk must move as one unit.
Lower: Sink deeper into the bend-and-lift position which shifts the orientation of the torso and
tibia as they being to move towards a more parallel position.

Repeat the cycle as needed, but always be conscious of (a) foot stability and knee alignment (i.e.,
do not lower if foot stability and knee alignment is lost), (b) quadriceps burn from a prolonged
squatting position, and (c) maintaining neutral-head position with eyes up to preserve balance.

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 The instructional and coaching sequences for each segment of the bend-and-lift pattern are
provided in Table 7-1 and require an appropriate investment of time and perfect repetitions.

Table 7-1: The coaching cues to properly instruct the bend-and-lift pattern
Coaching Cue or Segment Notes

Foot Position:
• 3-points of contact (neutral sub-talar position).
• Foot orientation (parallel, to 8-to-10° eversion).

Pelvic Position:
• Neutral (unloaded).
• Slight posterior (loaded) to preserve COM.

Abdominal Bracing:
• Co-contraction of local and global units to
increase lumbar stability.

Mini Hip Hinge: Use a dowel, face wall to master movement.

• Anterior tilt to load the posterior chain with
little-to-no forward-head movement.
• Pelvic correction – rectus abdominis.
• Spinal alignment (dowel + 3-points of contact)

Lowering Phase: Ankle mobility or hip imbalance issue?

• Foot position – no movement (e.g., pronation).
• Knee alignment – over 2nd -to-3rd toe.
• Spinal alignment – 3-points of contact

Tibial-torso Orientation: Tibial translation – correction sequence outlined below

• Figure-4 v. T-formation

Head Position:
• Aligned with thoracic spine and sacrum.

Rising Phase:
• Hips and shoulder rising together – avoid hyper-
extension, torque and shear forces.

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Single-leg Pattern (8-10)
Single-leg patterns require weight transference over the stance-leg (e.g., walking). During this
loading instant, individuals shift weight over the stance-leg while simultaneously preserving
optimal alignment between the hip, knee and foot – think about the forces acting upon the knee if
the foot remains firmly placed, but the hip shifts significantly sideways? A lateral hip shift of
one-to-two inches coupled by a small hip tilt (~ 4-5°) is considered normal during walking. The
stability of the knee is maintained by the collaborative actions of the stance-side gluteal group
(gluteus medius) and adductor group, plus the contralateral (opposite) quadratus lumborum.
• The gluteus medius needs to eccentrically decelerate lateral hip shifts to preserve postural
alignment, yet individuals train this muscle as a concentric accelerator.
• The adductor group help preserve the angle between the pelvis and femur via isometric
muscle action, yet individuals train this muscle as a concentric accelerator.
• The quadratus lumborum contracts concentrically to keep that opposing hip from tilting
(dropping) by stabilizing the ribcage while pulling upwards on the hips, yet individuals train
this muscle group in the opposite manner (i.e., anchor the hips and laterally flex the trunk).

Figure 7-3: Collaborative muscle action to stabilize hip lateral shifting

To coach these movement patterns, follow the sequence outlined below and use this same muscle
action sequence when performing the side-lunge discussed later.
• Step One: Hip-hinge 10-to-15° at the hips to engage the hip abductors (e.g., left side).
• Step Two: Heel raise – Slowly raise the right heel three inches off the floor.

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• Step Three: Toe-off – Slowly raise the entire foot three inches off the floor, while
controlling and minimizing hip adduction (lateral hip shift).
• Step Four: Double extension – Stand upright by extending at the hip and the knee.
• Step Five: Add drivers – leg swing under the stable hip and hip drive over the stance-leg.

Figure 7-4: The single-leg pattern sequence

The lunge is considered a dynamic movement whereas the single-leg squat is considered a static
movement where the individual’s base of support (BOS) does not move. However, in the lunge,
once the raised leg moves into position and accepts the weight of the body (i.e., completion of
weight transference), it has essentially now become a single-leg squat movement which means
that all the mechanics discussed in the bend-and-lift pattern apply. Yet, what is often witnessed
in lunge exercises are movements that would never be taught, nor allowed in squatting, so why
are they accepted?
• Overstepping (i.e., large lunge step) places the hips into an anterior tilt before any lowering
movement occurs – this eliminates the possibility of performing a hip hinge.

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• The lowering phase is initiated by dropping the hips towards the floor, forcing the femur to
shear over the front of the tibia rather than beginning with a hip hinge.
• Due to the anterior pelvic tilt, the individual attempts to orientate the trunk more vertically
which can only occur through the lumbar spine, consequently increasing lumbar lordosis
beyond neutral.
• Overstepping during the lateral or side lunge creates an orientation between the foot, knee
and hip (ASIS) that is not stacked (i.e., aligned vertically) as they are coached in the squat.
The knee and hips are generally aligned inside of the foot and not stacked vertically – this
destabilizes the knee and increases the valgus stress (inward forces) acting on the knee.
• In the forward-lunge movement, individuals stress actions of the quadriceps and glutes when
rising, whereas it is the action of the hamstrings extending the knee that is critical to helping
stabilize the knee by preventing hyper-extension as the person rises.

Try This … Assume a half-kneeling position with the right leg positioned as the leading leg. Place a hand
upon the hamstrings under that leading leg. Next, return to the standing position but focus upon
contracting the hamstrings to help pull the knee backwards as the body rises. That muscle engagement
within the hamstrings helps stabilize the knee. This is contrary to what many believe – that being that the
hamstrings function as a knee flexor. They are knee flexors when functioning in open kinetic-chain
exercises (e.g., lying/seated leg curls), but when performing functional movements (e.g., step-up,
deadlifts), they function as knee extenders.

• In the side-lunge movement, individuals stress the concentric actions of the gluteus medius
pushing the body sideways, whereas it is the eccentric deceleration of slowing down side
movement by the gluteus medius muscles that should be the emphasized. The same can be
said for any side-walking or side-lunging exercises with rubber bands placed around the legs
or ankle. Emphasize the eccentric movements of both legs rather than the concentric
movements.

Table 7-2 provides important cues to teach during the lunge patterns that help instruct proper
execution of the lunge-type movements.

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 Table 7-2: Coaching cues for lunging
Coaching Cue or Segment Notes

Stepping:
• Avoid overstepping – once weight transference
is completed, the pelvis should be in a neutral
position.

Hip Hinge:
• Initiate with anterior pelvic tilt followed by
pelvic correction.
• On the side-lunge, this movement precedes the
later shift.

Lowering and Shifting Movements:

• Forward lunge – drop into figure-4 position with
some forward trunk inclination.
• Side-lunge – shift until foot, ankle and ASIS are
stacked, then then drop to figure-4 position.

Figure 7-5: Side and forward lunge pattern

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Push and Pull Movements (8-10)
Consider the Newton’s first law, and the functional design of the scapula-thoracic (stable)
segment and the glenohumeral (mobile) joint. This sufficiently illustrates how and where the two
upper extremity movements occur.
• Initiate movement through the glenohumeral joint.
• Maintain stability within the scapulo-thoracic segment or permit movement only after the
more mobile joint has overcome inertia.

Spiral and Rotational Patterns (8-10)

Whether performed segmentally (e.g., sitting trunk rotation) or as an integrated movement (e.g.,
full body swinging a gold club), consider Newton’s first law and the functional design of the
entire kinetic-chain.
Transverse plane or spiral patterns (i.e., diagonal – combination of multiple planes) should
initiate movement through the mobile joints (i.e., hips, ankles, thoracic spine) whenever possible,
while preserving stability at other segments or introducing movement at the stable joints once
inertia is overcome.

To coach this movement pattern, follow the sequence outlined below:

• Step One: Start in a staggered-stance position (i.e., walking step position) with the right leg
forward, feet at hip-width position. Extend both arms diagonally across the front of the body
to the right side above shoulder height (palms touching).
• Step Two: Initiate the locomotor – the hip hinge (hip flexion) with triple flexion (i.e., flexing
at hips, knees, ankles) and the hip drive (hip extension) with triple extension (i.e., extending
at hips, knees, ankles), but moving only in the sagittal plane as the arms (extended) chop
diagonally across the body.
• Step Three: Weight transference – At full extension with arms positioned high, shift weight
to the leading leg; at full flexion with arms positioned low, shift weight into the trailing leg.
• Step Four: Introduce ankle rotation (i.e., foot pivot before it accepts weight) and hip rotation
while keeping the trunk aligned with the hips and spine in a neutral position (i.e., dowel

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 along the spine preserving the 3-points of contact). The middle of the knee should reman
aligned between the 2nd and 3rd toes.
• Step Five: In the raised and lowered positions, following hip and ankle rotation, allow the
trunk to rotate to an end-ROM while preserving spinal orientation (i.e., neutral spine).

Key Movement Mechanics – Gender Differences and Knee Instability

Structural differences in the knee between men and women predispose females to a greater
probability for suffering knee injuries (9-10).
• A wider pelvis in females coupled with shorter limb-length produces an increased Q-angle of
approximately 18° in females versus 12-to-13° in males – this compromises the joint-angle
for loading.
• Females possess smaller bones, ligaments and muscles which translates to less surface area
for attachment and distribution of loading forces (i.e., less stability and strength).
• Females possess a narrower intracondylar notch, the space between the two condyles of the
femur located at the distal or lower end of that bone. It is through this notch that the anterior
cruciate ligament (ACL) and posterior cruciate ligaments (PCL) pass. This increases the
‘shearing’ effect on the ligaments as the two bones (femur, tibia) rotate against each other
resulting in more ligamentous fraying and weakening.
• Females also exhibit as smaller, and more rounded tibial plateau upon which the femur rests
which decreases knee stability.
• Hormones like relaxin relaxes ligaments, especially within the pelvic region (peaks 14 days
prior to ovulation) create greater joint laxity.

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 Figure 7-6: Key structural components of the knee

Considering these structural and physiological differences, there is ample rationale for investing
time and effort into optimally stabilizing the knee, and hip-ankle function in females who are
interested in performing dynamic lower extremity movements (e.g., jump-landing, multiplanar
movements). Live by a simple cue – always teach an individual to land before teaching them
how to jump.

Previous modules also described how a healthy function at the hips and the ankles helps promote
stability to the knees. Consider the action of these hip muscles and the position of the ankle when
striving to improve knee stability.
• The role of the hamstrings functioning as a knee extender in the sagittal plane to help unload
the ACL by preserving stability at the knee by virtue of the hamstring attachment on the
backside of the tibia and fibula. The takeaway here is to emphasize this muscle action during
any closed kinetic-chain knee extension movements (sagittal plane).
• The role of the gluteus medius functioning as an eccentric decelerator in frontal plane
loading. The takeaway here is to emphasize this muscle action during any side-lunging or
side-stepping movements (frontal plane).

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• The role of the gluteus maximus functioning to decelerate internal femoral rotation that
occurs as the foot loads with each step. The takeaway here is to emphasize this muscle action
during any rotational stepping movements (transverse plane).
• The position of the subtalar joint at the ankle (pronation / supination) impacts the position of
the knee (i.e., valgus / varus stress). The takeaway here is to achieve a stable foot position
that permit three points of contact (heel, 1st and 4th / 5th metatarsal contact) and a neutral sub-
talar position.

Key Movement Mechanics – The Upper Extremity Mechanics

Learn by doing to understand key kinesiological factors that should influence exercise selection
for the upper extremity and how the exercises are instructed.

A. Internal Humeral Rotation:

• While standing, internally rotate the arms so that the palms face the thighs. Abduct the arms
in the frontal plane until the first point of resistance and note the position of the arms at this
end-ROM (e.g., 90° out to the side). Return to the starting position, but now externally rotate
the arms and repeat the same movement – notice how the arms move to a complete 180° of
movement – why is there a difference?

Figure 7-7: Arm abduction differences between internal and external humeral rotation

As the arms internally rotate, the greater tubercle of the humerus rotates forward and as it
abducts, it becomes impinged under the acromion (AC) process, compressing that space

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 (sub-acromial space) which is usually quite small (~ 5-to-10 mm of space). Continued
movement in this internally-rotated position irritates the bursa, a fluid-filled sac located in
this space that normally acts as a cushion between the bones. The irritation swells the bursa
(i.e., bursitis), restricting normal blood flow to two tendons passing through this region
(supraspinatus tendon – a rotator cuff muscle, and the tendon of the long head of the biceps
muscle), leading to impingement syndrome and pain.
• Implications for Movement: Given the popularity of upright rows, cleans and snatches –
exercises all involving arm abduction with internal rotation, start by first performing a simple
arm abduction movement screen in the internally-rotated position to determine the
individual’s end-ROM (there is never a one-size-fits-all because the sub-acromial space
varies from person-to-person). Once determined, teach these movements to stop before the
end-ROM to preserve the integrity of the shoulder and prevent bursitis and impingement.

Figure 7-8: anatomical structures of the shoulder girdle

B. Plane of the Scapulae:

• While standing, abduct the arms in the frontal plane (i.e., to the sides) – this is also called the
3 and 9 o’clock positions. Feel the weight in the arms. Next, abduct the arms into the
scapular plane (moving lightly forward of the frontal plane by no more than 30° – also called
the 4 and 8 o’clock positions. Feel the weight in the arms – this plane should feel a little
lighter or less restricted although it is the same arm and same length lever – why the
difference then? Review the anatomy of the shoulder, in particular, the coracoacromial arch.
In the 3 and 9 o’clock position, the greater tubercle is more congruent with the bony

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 structures of the scapular then in the 4 and 8 o’clock positions where the greater tubercle
passes through the highest portion of this arch, experiencing less friction.
• Implications for Movement: When taking the arms to 90° or overhead (e.g., shoulder press,
lat pull downs), move in the plane of the scapulae (scaption plane, 4 and 8 o’clock position)
to preserve the integrity of the shoulder capsule. In other words, position the elbows in front
of the mid-line of the body (mid-axillary line) when performing overhead movements (e.g.,
shoulder press, lat pull downs).

Figure 7-9: Moving in the scaption plane

C. Anterior Shoulder Capsule Stabilization – Part One

• The three heads of the deltoid muscle offer anterior, middle and posterior containment of the
shoulder in the lowered position. However, this changes as the arm abducts and moves
overhead. To demonstrate this, place a thumb on the outer ⅓ of the clavicle and wrap the
hand around the shoulder capsule near the top of the humerus to place the index and middle
finger just behind the midline of the arm. The thumb- and finger-spread essentially cover the
anterior deltoid muscle (spanning the origin and insertion points).
• Now, recall previous discussion on Newton’s third law (i.e., equal reaction for every action).
If the elbow moves backwards, the reactive force would drive the humeral head forward
(shear force), but in the lowered position (i.e., arms at sides), it is contained by this strong
anterior deltoid muscle.
• Next, while keeping the fingers on the shoulder, perform an overhead raise movement and
notice how the orientation of the thumb and fingers change – they rotate backwards, losing
that function as an anterior compartment stabilizer.

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 Figure 7-10: The orientation change of the anterior deltoid in overhead movements

• Implications for Movement: When performing overhead movements, arm abduction

coupled with external humeral rotation equals a loss of the anterior containment role of
the anterior deltoid, passing that role to the smaller subscapularis muscle and the passive
structures (shoulder labrum) – this increases the potential for injury. Subsequently, this
position should be minimized by changing the arm movement into the 4 and 8 o’clock
position. An alternate option is to engage the latissimus muscle when overhead. This
muscle wraps from behind the arm to the front side of the shoulder (insertion point) and
can act as an anterior compartment stabilizer when stretched out (i.e., overhead arm
position). In other words, during the shoulder press, engage the lats as the arms move
upwards into the overhead position and when returning the arms back to shoulder height.
• This same applies to the Olympic squat when a barbell is placed behind the head. Not
only is there a thoracic mobility challenge with this position, but the arm position in
holding the bar (i.e., abducted, externally rotated) places increased shear forces upon the
anterior shoulder compartment.

D. Anterior Shoulder Capsule Stabilization – Part Two

• Considering Newton’s third law once again, examine the stress placed upon the long head
of the biceps running through the bicipital groove when the arm is abducted, and the
elbow falls behind the midline of the torso (e.g., pec flyes exercise). As illustrated, the
long head runs through the bicipital groove under a fibrous sheath crossing it (transverse
humeral ligament). As the arms fall backwards, this fibrous sheath pulls tighter,
restricting blood flow to that region of the muscle and its tendon, potentially increasing
the risk for developing tendonitis.

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 • Implications for Movement: Certain exercises (e.g., pec flyes, incline biceps curls)
involving horizontal extension where the arms are widespread and moving backwards
might merit consideration given how they might aggravate the long head of the biceps.
When performing this movement, restrict the range to where the elbows align with the
midline of the body and no further.
• Think also to a classic pectoralis stretch where the individual places the arm into a door
jam, then drives the torso forward to stretch the chest muscles. This places that same
stress upon the sheath which raises the potential for harm. An alternative option is to
assume a similar position in the door jam, but one where the elbow aligns with the
midline of the torso. Slowly rotate the body outwards to stretch the chest while
preserving the alignment of the elbow and the midline of the torso.

Figure 7-11: The fibrous sheath spanning the bicipital groove

Closing Remarks
Following corrective exercise and the restoration of stability and mobility throughout the kinetic-
chain, unloaded integrated movement happens next. Progressing individuals through the
associative stage of learning and into the autonomous stage is important when teaching the
movement patterns as they serve as the foundation to teaching any exercise. What the

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practitioner needs to understand is how to help their clients, patients or athletes recognize how
each of these primary movements apply to the variety of exercises each performs when
physically active or exercising.

References:
1. Fry AC, Smith JC and Schilling BK, (2003). Effect of knee position on hip and knees torques during
the barbell squat. Journal of Strength and Conditioning Research, 17:629-633.
2. Abelbeck KG, (2002). Biomechanical model and evaluation of a linear motion squat type exercise.
Journal of Strength and Conditioning Research, 16:516-524.
3. Caterisano A, Moss RF, Pellinger TK, Woodruff K, Lewis VC, Booth W, and Khadra T, (2002). The
effect of back squat depth on the EMG activity of 4 superficial hip and thigh muscles. Journal of
Strength and Conditioning Research, 16(3):428-432.
4. Cook G and Jones B, (2007). Secrets of the Hip and Knee. www.functionalmovement.com
5. Escamilla RF, (2001). Knee biomechanics of the dynamic squat exercise. Medicine and Science in
Sports and Exercise, 33:127-141.
6. Escamilla RF, Fleisig GS, Lowry TM, Barrentine WS, and Andrews JR, (2001). A three-dimensional
biomechanical analysis of the squat during varying stance widths. Medicine and Science in Sports and
exercise, 33:994-998.
7. Adams MA, and Dolan P, (1995). Forces acting on the lumbar spine. In: Lumbar Spine Disorders:
Current Concepts. Aspden RM, and porter RW (Eds.). Singapore: World Scientific Publishing.
8. McGill EA, and Montel IN, (eds.) (2017). NASM Essentials of Personal Fitness Training (5th ed.).
Jones and Bartlett Learning, Burlington, MA.
9. Bryant CX, Merrill S, and Green DJ, (2014). ACE Personal Trainer Manual, American Council on
Exercise, San Diego, CA.
10. Clark MA, Lucett SC, and Sutton BG, (2014). NASM’s Essential of Corrective Exercise Training (1st
ed. revised). Jones and Bartlett Learning, Burlington, MA.

Image Credits
1. Figure 7-5: Image courtesy of BodyParts3D, made by DBCLS – Polygondata under CC BY-SA 2.1
2. Figure 7-9: Image courtesy of OpenStax College - Anatomy & Physiology, Connexions Web site,
under CC BY-SA 4.0. Image is a work of the National Institutes of Health, part of the United States
Department of Health and Human Services, in the public domain.
3. Figure 7-11: Image courtesy of Lady of Hats Mariana Ruiz Villarreal, released into the public domain
by its author.
4. Figure 7-14: Image courtesy of Grant, John Charles Boileua, released into the public domain by its
author. Image courtesy of GNU Free Documentation License, Version 1.2 or any later version
published by the Free Software Foundation licensed under Creative Commons Attribution-Share
Alike 3.0 Unported.

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 Notes Section

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