Functional Movement Screen and Ankle Stability Mary A.

Dunyak Meredith College

Table of Contents ABSTRACT...iii LIST OF FIGURESiv CHAPTERS I. II. III. IV. REVIEW OF LITERATURE..1 METHODS11 RESULTS..21 DISCUSSION24

REFERENCES..30 APPENDIX A INFORMED CONSENT..34 APPENDIX B BESS SCRIPT..36

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Abstract Injuries occur in the ankle joint more often in any other joint in the body (Fong et al., 2007), and those injuries often lead to chronic symptoms of residual instability (Yeung et al., 1994). The Functional Movement Screen (FMS) has advertised itself as a tool to identify an individuals risk of injury. The purpose of this research was to identify any potential relationships between the FMS and a measure of ankle stability, to see if the FMS could be a valid tool for predicting ankle injury. The researcher investigated the screen as a whole, individual movements, gender differences, and differences in those with past injury. Sixty individuals participated in this study. Each participant took part of an FMS, performing only the movements that require the ankle joint. They then took the Balance Error Scoring System (BESS) test as the measure of ankle stability. Bivariate correlations were used to analyze the results. This study concludes that the FMS may not be the best form of an ankle injury screen. Since the FMS is often performed in sport performance or physical therapy settings, this research may provide insight to the usefulness of this screen in those settings.

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List of Figures Figure 3.1 Relationship between FMS score and BESS score......21 Figure 3.2 Relationship between FMS score and BESS score in Previously Injured Participants 22 Figure 3.3 Relationship between FMS score and BESS score in Female Participants..23 Figure 3.4 Relationship between Active Straight Leg Raise and BESS scores in Female Participants.23 Figure 3.5 Relationship between In-Line Lunge Score and BESS score in Male Participants.23

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Review of Literature Ankle sprains occur more often in sports than any other injury (Fong, Hong, Chan, Yung & Chan, 2007). Over one-third of injuries occur in the ankle joint, and ankle sprains are estimated to account for 50% to 76% of all ankle injuries (Fong et al., 2007; Garrick & Requa, 1988). In terms of collegiate sports, the Injury Surveillance System predicts that around 11,000 ankle sprains occur per year in NCAA athletics alone (Hootman, Dick & Agel, 2007). Not only are ankle sprains extremely prevalent, but they are also difficult to fully heal from. It has been well documented that a previous ankle injury increases the risk of future ankle injury (Chan, Ding, & Mroczek, 2011; Freeman, Dean & Hanham, 1965; Yeung, Chan, So, & Yuan, 1994). Since ankle injuries are so dominant in athletics, being able to identify an individuals risk for one would prove to be extremely useful in preventing injuries and enhancing health. The Functional Movement Screen (FMS) has introduced itself as a tool for predicting the risk of injury in an individual. It does so by observing stability, range of motion, and asymmetries across the individuals body (Cook, Burton, & Hoogenboom, 2006a; Cook, Burton, & Hoogenboom, 2006b). Theoretically, this tool could be potentially useful in identifying ankle injury risk. Muscular imbalances have been shown to have a positive relationship with ankle injury rates (Riegger, 1988; Willems et al., 2005). However, there is no current research that supports that the FMS shows validity in identifying ankle injuries. The researcher has organized this review in order that the reader better understands the complexity of measuring ankle stability. An anatomical overview of the ankle joint is presented first, followed by how the researcher defines the term ankle instability and what predisposes an individual for ankle instability. Furthermore, several modes to measure ankle stability are discussed, followed by a description about the functional movement screen. Anatomical Overview 1

Anatomy of the ankle. The ankle itself is a very complex anatomical structure. The ankle complex is located at the intersection of the tibia, fibula, and the talus bones, and is comprised of the talocrucial joint, the subtalar joint, and the distal tibiofibular syndesmosis (Hertel, 2002). There are eight ligaments and six muscles that cross the ankle joint (Riegger, 1988). Its range features multiple movements (dorsiflexion, plantarflexion, internal rotation, external rotation, abduction, and adduction), that occur in the frontal, sagittal, and transverse planes (Riegger, 1988). Anatomy of sprains. A sprain of the ankle occurs when the ligaments surrounding the joint stretch or tear (Glasgow, Jackson, & Jamieson, 1980). The most common occurring sprain of the ankle is a lateral ankle sprain (Hertel, 2002). A lateral ankle sprain occurs when the sprain affects either the anterior talofibular ligament, the calcaneofibular ligament, or the posterior talofibular ligament (Glasgow et al., 1980). The etiology involves extreme plantarflexion and inversion in the ankle, although plantarflexion has been more indicative of injury than inversion (Wright, Neptune, van den Bogert, & Nigg, 2000). Medial ankle sprains are also possible, and occur under extreme dorsiflexion and eversion of the ankle (Wolfe, Uhl, Mattacola, & McCluskey, 2001). However, the medial ligaments of the ankle have been found to be stronger than the lateral ligaments (Riegger, 1988). This increases stability of the medial ankle joint and thus decreases the risk of sprain. Defining Ankle Instability There are two different types of ankle instability noted in research. Functional instability describes a deficit in neuromuscular control or proprioception, whereas mechanical instability is associated with structural inefficiencies of the joint (Hertel, 2002). When these symptoms occur over a period of time, they are considered to be chronic. Although ankle instability is very

common amongst people, there is no universally accepted definition of an unstable ankle (Kaminski, & Hartsell, 2002). Previous research studies have developed a variety of definitions for various types of ankle instability. Hertel (2002) defined lateral ankle instability as the existence of an unstable ankle due to lateral ligamentous damage caused by excessive supination or inversion of the rearfoot (p. 365). Hertel (2002) further defined chronic lateral ankle instability as the occurrence of repetitive bouts of lateral ankle instability, resulting in numerous ankle sprains (p. 365). Tropp, Odenrick and Gillquist (1985), defined functional instability as a recurrent sprain or a feeling of giving way of the ankle (p. 180) whereas Hansen, Damholt, and Termansen (1979) defined functional instability as a feeling of insecurity and a tendency for the foot to give way (p. 700). Lee, Lin, and Huang (2006), added that a person could not have had any previous fracture to the bones surrounding the ankle joint in order to be considered functionally instable. Each definition includes attributes of both mechanical and functional instability, because it is believed that feelings of instability involve a combination of both (Hertel, 2002). Based on the above, for the purpose of this study ankle instability will be defined as repetitive bouts of unsteadiness in the ankle joint due to a sprain in the ankle or a feeling of giving way. Risk Factors for Ankle Instability There are two classifications of risk factors for injuries. Extrinsic variables describe the outside-the-body characteristics that could affect injury such as environment or weather (Beynnon et al., 2001). Intrinsic variables describe risk factors associated with the body, such as size, joint position, or proprioception (Beynnon et al., 2001).

Muscular weaknesses and imbalances have been attributed to symptoms of chronic ankle instability. It was found that weakness in the pronator or evertor muscle groups can lead to symptoms of ankle instability (Kaminski & Hartsell, 2002). In addition, the ligamentous structures in the lateral side of the ankle joint are naturally weaker than the medial side (Riegger, 1988), which has been attributed to the high level of lateral ankle sprains. Similarly, it was found that those with stronger dorsiflexors were more prone to ankle sprains (Willems et al., 2005). Ankle sprains are believed to be the greatest risk factor in functional instability of the ankle (Yeung et al., 1994). It has been suggested that up to 73% of ankle sprains will result in some form of functional ankle stability symptom (Yeung et al., 1994). It is also estimated that 20% people who suffer an ankle sprain with develop chronic symptoms of ankle instability (Chan et al., 2011). It has been theorized that a ligament injury can cause partial deafferentation of nerve fibers, which slows down the central nervous systems reaction to sudden instability in the joint (Freeman et al., 1965). As a result, the body would not be able to stabilize the joint quick enough, which leads to the feelings of instability (Freeman et al., 1965). This permanent damage resulting from an ankle sprain could explain the relationship between functional instability as a residual symptom of an ankle sprain. Measuring Ankle Stability Force plates. Force plates have shown to be a strong measure ankle stability, and can be used in a variety of ways. During a single-leg stance, they can show where a participants center of balance is, and how that changes throughout the time in balance. Using this technique, Tropp and colleagues (1985) found that those with functionally stable ankles had a more stable center of pressure in comparison to those with functionally unstable ankles. Similarly, Ross,

Guskiewicz, Gross, & Yu (2009) used force plates to time how long it took for a persons ankle to reach a stable position while remaining stationary in a single-leg stance, as well as jumping single-leg. Both of these studies found that those with stable ankles reached a stable position much faster than those who had functional ankle instability. McGuine, Greene, Best, & Leverson (2000) measured postural sway in basketball players using a force plate, and found a positive relationship between the amount of postural sway in an individual and their susceptibility to ankle injuries. Ross, Guskiewicz, & Yu (2005) had their subjects perform a single leg jump test on a force plate, with the landing on their unstable ankle. They observed how long it took for their subjects to stabilize themselves in both the anterior/posterior direction and the medial/lateral directions. They found that those who had functional ankle instability took longer to stabilize their bodies. On top of that, they suggested that using a single-leg jump-landing test would not only measure stability, but also show jump landing patterns (Ross et al., 2005). The authors of this study found that observing an individuals jump landing pattern could help them discover and correct poor mechanics prior to returning to activity which could also decrease risk of future injury. Force plates are extremely useful tools in measuring the stability of an ankle, due to the accurate measures that researchers can obtain of a persons postural sway and center of gravity in certain moments. However, force plates are expensive and are often out of a research budget. Self-Reported questionnaires. Self-reports from individuals have also been noted to show patterns in ankle instability. This type of measurement is less expensive and does not require a lot of the researchers time.

The Foot and Ankle Ability Measure (FAAM), is a questionnaire that uses a Likert scale to show how effortlessly the subjects perform activities of daily living and sports-related activities (Carcia, Martin, & Drouin, 2008). Carcia and colleagues (2008) found that this tool is valid in showing ankle instability in individuals. A potential limitation of questionnaires involves different individuals perceptions of instability. Each subject will perceive their symptoms differently in comparison to each other; even though two subjects may be experience the same symptoms, one will perceive their symptoms as worse than the other. These differences in perception could potentially cause error in the data. Balance tests. There are several balance protocols that have been followed while measuring ankle stability. The star excursion balance test is a measure of dynamic stability, and involves the subject balancing on one leg while reaching the other leg as far as possible in eight different directions (Olmsted, Carcia, Hertel, & Shultz, 2002). Research has found that patients cannot reach their leg as far of a distance while standing on an ankle that is considered to be chronically unstable (Olmsted et al., 2002). The Balance Error Scoring System (BESS), which has traditionally been used for concussion testing, has recently shown to be a valid measure of ankle stability (Bell, Guskiewicz, Clark & Padua, 2011). Docherty and colleagues (2006) were the first study to demonstrate that the BESS can identify ankle instability in an individual. They selected half of their participants with history of ankle injury and ankle instability, and half with no previous ankle dysfunctions. They found that those with a history of instability scored higher on the BESS test, showing that the BESS can identify ankle instabilities (Docherty et al., 2006).

While using a simple balance test may not give the specifics that force plates can provide, they have shown to be just as accurate in measuring ankle stability. They are also extremely cost efficient and do not require much equipment. Functional Movement Screen (FMS) The Functional Movement Screen (FMS) was formally introduced in 2006 (Cook et al., 2006a). It is a screen that observes the participant performing seven common movement patterns, and looks for movement deficiencies which could identify a potential injury risk. More specifically, it looks at the bodys stability, flexibility, and asymmetries throughout the movements. It implies that the best way to identify potential injury risks is through a screen that involves movement, since injuries generally occur while the body is in motion. Development of inefficient movement patterns. It is stated by Cook and colleagues that poor movement patterns commonly arise through either cognitive programming of poor movement patterns or through compensation after injury (2006a). It has been found that as movements are repeated by the body, the central nervous system adapts and stores the movement in memory (Lephart, Pincivero, Giraldo, & Fu, 1997). Over time, this allows the movements to be performed without consciousness command. In laymans terms, the body learns the movement pattern and does not have to actively think about performing it. Cognitive programming of a movement becomes an issue when the movement is learned incorrectly (Cook et al., 2006a). Considering previous injuries, research has theorized that proprioceptive deficits are observed in previously injured joints (Freeman et al., 1965). Proprioception, which refers to the bodys sensation of joint movement and joint position in space (Lephart et al., 1997), affects the

bodys kinetic linkage. Therefore, it has been concluded that an alteration in a joints proprioception can affect the bodys kinetic linkage of certain movements (Cook et al., 2006a). FMS and fixing movement errors. Cook and colleagues (2006a) believe that the best approach to detecting movement errors was to isolate movements that require proximal-to-distal movement activation. The seven tests within the FMS involve movements that are functional in everyday motion and sport, but all target different potential movement deficiencies. Therefore, the result of a FMS can show which specific movement deficiency the participant has. Narrowing down and identifying the movement deficiency can help therapists and coaches correct the movement inefficiencies. Validity and reliability of the FMS. To date, there has been no formal review of the FMS and its validity or its reliability. This could be attributed to the fact that the FMS is a relatively new tool, and few studies have attempted to identify its validity. Research has shown mixed results in the validity of the FMS since its introduction. Kiesel, Plisky, and Voight (2007) found that NFL players who scored a 15 or greater (out of 21) on their FMS spend significantly less time on the injured reserve in comparison to those who scored a 14 or less. Similarly, Chorba, Chorba, Bouillon, Overmyer and Landis (2010) found that female athletes who scored a 14 or below on their FMS displayed a four-fold injury risk increase in comparison to those who scored a 15 or higher. This has led to the implication that the higher the FMS score is, the lower the injury risk is (Cook et al., 2006a). However, OConnor et al. (2011) found that those who scored a score of 18 on their FMS were more likely to be injured than those who scored a 17. This study was the first to find a negative relationship between the score of the FMS and the individuals injury risk.

Intrarater reliability has found to be strong in several studies. Smith, Chimera, Wright, and Warren (2013) concluded good intra-rater reliability in their study with their intraclass correlation coefficients ranging from 0.81-0.91 for their participants. There are several other studies that confirm a strong intra-rater reliability of the FMS (Gribble, Brigle, Pietrosimone, Pfile, & Webster, 2013; Shultz, Anderson, Matheson, Marcello, & Besier, 2013). Only Teyhen et al. (2012) found only moderate to good intra-rater reliability. Research in FMS and Ankle Stability To date, there have been no studies that have exclusively examined ankle stability and the FMS. Research has focused on injury risk as a whole rather than the identification of specific injury sites on the body. To the researchers knowledge, there is no current research on the FMS and its ability to identify a specific injury. The prevalence and role of ankle injuries has already been extensively discussed. The large role that the ankle plays in athletics and activities of daily living, on top of its anatomy, causes it to be a commonly injured site on the body. Despite the occurrence of these injuries, research is still unsure of a true definition of a stable versus unstable ankle and what the best corrective and preventative measures are. The Functional Movement Screen is a potentially valid tool in identifying risks of injuries. Ankle sprains occur while the body is in motion, which is the methodology behind the FMS. Furthermore, the FMS looks at the bodys asymmetries meaning it could potentially identify a weaker or unstable side of the body. Being able to identify a relationship between the FMS and ankle stability would provide extremely useful in lowering the prevalence of ankle injuries and improving health. Therefore, the purpose of this study is to determine whether or

not the FMS is a valid tool in measuring a persons ankle stability, using the BESS as a valid way to measure ankle stability.

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Methods The purpose of this study was to examine whether or not the functional movement screen (FMS) could be a valid tool in predicting potential ankle injury. Since ankle injuries are so prevalent, being able to identify validity in this could prove extremely helpful in enhancing health of those who are at risk. The researcher set out to answer the following questions: 1) Is there a relationship between total FMS score and ankle stability? 2) Is there a relationship between each of the four FMS movements and ankle stability? 3) Is the relationship between total FMS score and ankle stability different in participants who have previously suffered injuries? 4) Does the relationship between total FMS score and ankle stability differ by gender? Subjects The participants from this study feature 60 young adults, male and female, between the ages of 18 and 25. They were asked personally by the experimenter if they would be willing to donate 10-15 minutes of their time for the research. There was no requirement for their level of physical activity in order to participate. Prior to the start, they signed an informed consent that was approved by an Institutional Review Board (Appendix A). Instruments and Test Equipment For the purpose of performing the FMS screen, a FMS kit was used. The FMS kit included a measuring board, the measuring dowel, and the hurdle complex. For the Balance Error Scoring System (BESS), a 20" x 16.4" x 2.5" Airex foam pad was used. For recording the time of each stance, an iPhone stopwatch was used. Measures

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Data was recorded by the experimenter throughout the stance. The experimenter chose to crease a Microsoft Excel spreadsheet for the purpose of entering data. Each FMS movement was scored on a scale of 0-3, which was recorded after each movement was complete. For the bilateral movements, each side was recorded and then the lower of the two sides was denoted the final score for that movement. At the conclusion of the FMS, the scores for the four movements were summed to give the participants total FMS score. There was a formula utilized in the spreadsheet to do the calculations. The maximum score that a participant could achieve on the FMS was a 12. Each BESS stance was recorded separately. Once the twenty second testing period began, the experimenter would count each time the participant had an error in balance. At the conclusion of each twenty second period, the experimenter would record the number of errors that the participant had. At the conclusion of all six stances, the total number of errors would be calculated to represent the total BESS score. This total was calculated via a formula inserted into the spreadsheet. Procedures The testing began once the participant signed the informed consent. The participants were asked to remove their shoes prior to being tested in order to eliminate any extra stability. Each testing session lasted 10-15 minutes, of which the participants were informed of prior. Prior to the start of the functional movement screen, the experimenter will ask the participant about any previous lower extremity joint injuries. In order for an injury to be considered, it would have had to have been diagnosed by a doctor, and have occurred in either the hip, knee, or ankle joint. The researcher will note the joint, side, and severity of the injury.

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Functional movement screen (FMS). The measurement for the FMS was based off of the guidelines outlined by Cook and colleagues (2006a). For the purpose of this study, only four of the seven movements were performed. It has been noted in the past that performing part of the screen is just as predictive of injury as performing the full screen (OConnor, Deuster, Davis, Pappas, & Knapik, 2011). Since this study was focused on the ankle joint, the four movements used were the ones that utilized the ankle joint: the deep squat, the hurdle step, the in line lunge, and the active straight leg raise. Each movement of the FMS was scored on a scale of 0-3. A score of three indicated that the movement was performed correctly. A score of two specified that the movement was successfully performed, but done so incorrectly. An incorrect movement pattern meant that the subject was compensating in some form, and therefore not performing the movement as efficiently as possible. A score of one meant that the participant could not complete the movement. This could happen under several circumstances, such as the participant loosing balance or being unable to get into the position necessary to score. A score of zero was only given when the participant experienced pain throughout the movement. At the conclusion of the FMS, each movement score will be added together to get the participants total FMS score. For the purpose of this study, the maximum score that an individual could receive on their FMS was 12. The experimenters job while giving the test was to make sure the participant knew what movement to do without being coached into perform it correctly. This was important in ensuring that the participant performed the movement how they would do it naturally, rather than the correct way. The experimenter also used partial demonstration of the movement rather than completely demonstrating the movement. While scoring a subject whose movement was

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between scores, it was suggested to score the participant the lower of the two scores. When scoring a bilateral movement, the experimenter scored each side separately, and took the lower of the two sides for the total score for that movement. Deep squat. The first movement that was performed was the deep squat. The participant began standing with their feet shoulder-width apart. The subject held the dowel across the top of their head so that their elbows formed a ninety-degree angle. On a cue by the experimenter, the participant pressed the dowel up so that their elbows were extended, squatted as deeply as possible, and then returned to the start position. The purpose of this movement was to look at the closed kinetic chain movement of ankle dorsiflexion, knee flexion, hip flexion, thoracic spine extension, and shoulder flexion and abduction. Specifically at the ankle joint, the ankles range of motion in dorsiflexion was tested. There are several parts of the movement that the experimenter must look at. The dowel must remain above the participants feet the entire time; dowel movement in the sagittal plane will reduce the score. The participants femur should also drop below horizontal. The participants knees should also stay aligned above the feet. The absence of any of these cues will result in a lower score. The participant got three attempts to complete this movement, and the highest of the three scores was counted. If the participant performed the movement correctly, they received a score of three. If the experimenter found any error with the movement pattern, the next step was to have the participant perform the deep squat in the heel raised position. Here, they stood with their heels raised on the edge of the board, but their forefoot still on the ground. They will, again, repeat the movement. If the participant performed the movement correctly with their heels raised, then

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they were awarded a score of two. If the movement still had errors to it, then they were awarded a one. If the participant felt pain at any point during the test, then they were awarded a zero. Hurdle step. The hurdle step is the first of the bilateral movements. Prior to the beginning of the hurdle step, the experimenter determined where the subjects tibial tuberosity is, and measured its height from the ground using the dowel. The experimenter then would set up the equipment so that the hurdle was aligned with the height of the tibial tuberosity. The subject started behind the board, with their toes right up against the board. The dowel was placed across the shoulders behind the neck, with the subject lightly holding onto it. The participant then stepped over the hurdle without touching it, lightly tapped their heel on the ground in front of it, and then returned to the starting position. The leg that was stepping over the hurdle was considered the scoring side. The hurdle step observes single-leg stability, as well as stability in the knees and hips. The experimenter was looking for alignment of the lower extremities during the stepping motion. Therefore, it was important to look for the hip, knee, and ankle to keep movement within the sagittal plane. It was also important to look for stability, so the participant should also limit spinal movement and keep the dowel parallel to the floor for the entire movement. The participant got three attempts on each leg, and the highest of the three tries was recorded. If the moving leg stays aligned in the sagittal plane, with the participant showing no torso movement, then they received a score of three. If either of these errors were noted, then the participant received a score of two. If the participant could not complete the movement they received a score of one. A score of zero was only awarded if the subject experienced pain at any point during the movement.

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In-line lunge. The in-line lunge tested the participants stability in the knee and torso, flexibility in the quadriceps, and the stability and mobility of the hips and ankles. The participant began standing on the board with one foot in front of the other. The distance between the feet matched the height of the hurdle used in the hurdle step movement (the height of the participants tibia). The dowel was set along the participants spine, with one hand holding at the cervical spine, and the other holding at the lumbar spine. The arm on the cervical spine corresponded with the leg that was in the back. The instructor asked the subject to lunge down, tap their back knee on the board, and then return to the starting position. It was important that the dowel remained in three points of contact throughout the movement: at the head, the thoracic spine, and the sacrum. The in-line lunge measured many movement pattern deficiencies. It observed the stability in the hip, knee, and ankle joints. It required core stability and balance, and tested the flexibility in the calf and the quadriceps. Performance could also be affected if the individuals abductor muscles are tight, or their adductors are weak, as those groups serve to help stabilize the hips and keep the body aligned during the movement. There were several aspects of the movement that the researcher focused on. The dowel must have remained in contact with the participants head, thoracic spine, and sacrum for the entire duration of the test. The torso also had to remain straight and free from any movement in the transverse plane. The participant must have been able to get their knee to the board without their front heel coming up from the board. The feet and knees had to stay aligned in the sagittal plane for the entire movement duration, and avoid any internal or external rotations. If the participant performed the movement correctly, then they were awarded a score of three. If any of the above movement deficiencies occurred, then they were awarded a two. If the

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participant could not complete the movement, they were awarded a score of one. Examples of a person unable to complete the movement were extreme loss of balance, not being able to get into the start position, or not being able to return to the end position. A score of zero was awarded if the participant experienced pain at any moment during the test. Active Straight Leg Raise. The active straight leg raise test observed the flexibility of the hamstring gastroc-soleus complex while isolating the movement from the rest of the body. The participant began lying supine in anatomical position with the board positioned underneath the participants knees. The experimenter found the midpoint between the anterior superior iliac spine (ASIS) and the mid-patella, and held the dowel upwards in that spot next to the participants leg. On the experimenters cue, the participant extended both knees, dorsiflexed both ankles, and lifted one leg as high as possible. It was important that the hip being scored was isolated in its movement, and that there was no rotation in the torso or other hip. The participant got three attempts per leg. The participant was scored based off of where the position of their malleolus was when their leg was raised maximally. If the participants malleolus was located between the dowel and their ASIS, then they were scored a three. If the participants malleolus was between the dowel and their mid-patella, then they were scored a two. If their malleolus could not reach the midpatella line, then they were scored a one. If they experience pain at any point during the test, then they will be scored a zero. It was important to note that the participant should be scored at the position that the malleolus reaches before external rotation of the opposite hip. Balance Error Scoring System (BESS). The protocol that the researcher used for the BESS was outlined by Bell and colleagues (2011). The BESS has only been recently used to look at ankle stability. While only two studies have studied this, both have found that the BESS

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can be a valid measure of ankle stability (Bell et al., 2011; Docherty, Valovich McLeod & Shultz, 2006). The BESS test used three stances on two different surfaces to measure ankle stability. The researcher utilized a script during the BESS portion of the study to ensure that all participants were given the same cues (Appendix B). The first stance was the double leg stance, and it required the participant standing on two legs, with their feet together and their hands on their hips. The second stance was a single leg stance. The participant was asked to identify, and then stand on their non-dominant leg. The participant was to hold their dominant leg at thirty degrees of hip flexion and forty five degrees of knee flexion, and balance with their hands on their hips. The third stance was the tandem stance. The participant was asked to balance one foot in front of the other, heel to toe, with the non-dominant foot in back and their hands on their hips. Each of these stances was first performed on a hard, stable floor, and then on the Airex pad. The participants had to remain in their position for twenty seconds, which began when the participants shut their eyes. The participants were to keep their eyes closed for the duration of each stance, until the experimenter cued them to stop. During each twenty-second period, the researcher counted the number of errors that the individual made. An error was defined as: 1. Opening the eyes. 2. Lifting the hands off of the hips. 3. Stepping, or stumbling out of position. 4. Lifting forefoot or heel. 5. Abducting the hip more than thirty degrees.

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6. Failing to return to the test position in more than 5 seconds (Bell et al., 2011). The researcher recorded the number of errors for each individual stance. The researcher then summed the six scores together to create their total BESS score. The BESS has been shown to have good intra-rater reliability, with an intraclass correlation coefficient of 0.74 (Finnoff, Peterson, Holloman & Smith, 2009). Intra-rater reliability is noted for the purpose of this study, because all of the BESS tests will be given by the same researcher. It is believed that reliability is high for this test, because the protocol includes a script for the researcher to follow, ensuring that every test is performed exactly the same (Bell et al., 2011). Pilot Study: Learning Effect of the FMS and BESS The researcher originally intended to investigate the learning effects of both of the FMS and the BESS. The researcher pilot tested this methodology on fourteen participants. These participants performed the FMS and BESS as expected, but then immediately repeated both tests. There was no rest time in between the tests, and the researcher gave the same cues both times the tests were conducted. Due to lack of participants and time, the researcher chose not to further investigate this phenomenon. Design and Analysis The goal of this research study was to determine if the FMS was a valid tool for measuring ankle stability. For the analysis of data, the individual served as the independent variable. The two dependent variables were the individuals FMS score and BESS score. High FMS scores are associated with a lower risk for injury. Low BESS scores are associated with good ankle stability. The experimenters goal was to compare the two dependent variables to see if a relationship exists between them for each participant.

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Research Question 1. Is there a relationship between total FMS score and ankle stability? The researcher plans on using a bivariate correlation. The researcher will compare each individuals total FMS score to their total BESS score, and see if a relationship exists between the two scores. Research Question 2. Is there a relationship between each of the four FMS movements and ankle stability? The researcher will use a bivariate correlation to analyze these variables. The researcher will run the correlation between the participants total BESS score with each of the four FMS movements. Research Question 3. Is the relationship between total FMS score and ankle stability different in participants who have previously suffered injuries? The purpose of this question is to examine if the FMS can identify residual symptoms of ankle instability in those participants who have previously suffered an injury. The researcher will use a bivariate correlation to analyze this data. The researcher will compare the relationship between FMS score and BESS score in only those participants who have previously suffered from an ankle or knee doctor diagnosed injury. The researcher will also run the correlations between the BESS and each of the four individual FMS movements in this population. Research Question 4. Does the relationship between total FMS score and ankle stability differ by gender? The researcher will run bivariate correlations between the male and female populations separately. The researcher will first investigate any potential relationships between the participants FMS and BESS score. The researcher will investigate further by investigating the relationship between BESS score and the individual FMS movements in each of the male and female populations.

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Results The purpose of this study was to examine relationships between FMS scores and ankle stability. The researcher added the participants four FMS movement scores together to create the participants total FMS score. The total BESS score is used in this study as the measure of ankle stability. The number of participants (N) who were included in this research was sixty. The researcher set out to answer the following research questions: 1) Is there a relationship between total FMS score and ankle stability? 2) Is there a relationship between each of the four FMS movements and ankle stability? 3) Is the relationship between total FMS score and ankle stability different in participants who have previously suffered injuries? 4) Does the relationship between total FMS score and ankle stability differ by gender? For the purpose of this study, the researcher set an alpha level at 0.05. In order for the relationships to be deemed statistically significance, the p-value (p) must have been less than or equal to this alpha level. Relationship between FMS and Ankle Stability The researcher conducted a bivariate correlation between the participants total FMS score and total BESS score, for the purpose of examining the relationship between these two variables. The results showed a negative moderate correlation between the two variables, with a Pearson correlation (r) of -0.315 (p = 0.014) (Figure 3.1). Relationship between Individual FMS Movements and Ankle Stability The researcher further investigated the relationships between the participants ankle stability with the individual FMS movements (deep squat, hurdle step, in-line lunge, and active straight leg raise). The researcher conducted a bivariate correlation between the participants

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total BESS score and each of the four FMS movement scores. No statistically significant relationship was found between any of the movements and the total BESS score. Despite the statistical insignificance of the results, the deep squat and the in-line lunge approached statistical significance. The deep squat neared a negative minor correlation with the BESS score (r = -0.240, p = 0.065), as did the in-line lunge (r = -0.233, p= 0.73). Relationship between FMS and Ankle Stability in Participants with Past Injury Injured participants. For the purpose of this study, the researcher only included injuries that were doctor diagnosed to the knee or ankle joint. The researcher ran a series of bivariate correlations in only the participants who had previously suffered a past injury to the ankle or knee joint (N=26). A negative moderate correlation was found to exist between the previously injured participants total FMS score and total BESS score (r = -0.391, p = 0.048) (Figure 3.2). The researcher ran a series of bivariate correlations between the participants total BESS score and each of the four FMS movement scores. No statistically significant relationships were found to exist for any of the movements. Non-injured participants. The researcher also investigated the relationship between total FMS score and total BESS score in participants who have never suffered a doctor diagnosed ankle or knee injury (N= 34). The researcher ran a bivariate correlation to explore this relationship. No significant relationships were found to exist between the participants total FMS score and total BESS score. The researcher further investigated the relationship between each participants total BESS score with the four individual FMS movement, through the use of a bivariate correlation. No significant relationships were found to exist. Gender Differences in the relationship between the FMS and Ankle Stability

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Females. The researcher ran a bivariate correlation between the female participants (N=40) total FMS and total BESS scores. A negative moderate correlation was found to exist between the two variables (r = -0.345, p = 0.029) (Figure 3.3). The researcher further investigated the relationship between the female participants total BESS score with each of the four FMS movements. A negative moderate relationship was found to exist between the BESS score and the active straight leg raise (r = -0.398, p = 0.011) (Figure 3.4). No other significant relationships were found to exist between the BESS score and the individual FMS movements. Males. The researcher ran a bivariate correlation between the female participants (N=20) total FMS and total BESS scores. No significant relationship was found to exist between the participants total FMS score and total BESS score. The researcher further investigated the relationship between the male participants total BESS score with each of the four FMS movements. A negative large relationship was found to exist between the participants in-line lunge score and total BESS score (r = -0.624, p = 0.003) (Figure 3.5). No other significant relationships were found to exist between the participants total BESS score and individual FMS movement scores.

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Discussion The purpose of this study was to investigate the potential relationships between the Functional Movement Screen (FMS) and ankle stability. The ankle is well documented as the most common injury site in the body (Fong et al., 2007). Therefore, being able to screen an individual for their likelihood of ankle injury would be extremely useful. The FMS advertises itself as a way to predict the likelihood of injury in an individual (Cook et al., 2006a). The researcher sought out to examine whether or not the FMS can be a tool for identifying risk of the ankle joint. No previous research has been conducted to investigate the FMSs ability to predict ankle injuries, exclusively. In terms of general injury predictability, research has shown mixed results on the validity of the FMS. This study supports the notion that the FMS may not be the most valid tool for identifying ankle instabilities. Relationship between FMS and Ankle Stability The results of this study showed a negative moderate correlation between the FMS and the researchers measure of ankle stability. The moderate correlation suggests that the relationship between the two variables is not entirely strong. The FMS could not differentiate between participants with different levels of ankle stability. Therefore, this suggests that the FMS may not be an accurate way to determine a persons likelihood of ankle injury. Relationship between Individual FMS Movements and Ankle Stability None of the individual FMS movements showed a significant relationship with ankle stability. Despite this, the deep squat and the in-line lunge approached significant relationships. Their minor correlation suggests that those two tests would not be able to identify ankle stability

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on their own. However, no conclusions can be made due to the technical statistical insignificance of the results. Relationship between FMS and Ankle Stability in Participants with Past Injury For the purpose of this study, the researcher considered an injury to be a doctordiagnosed injury in the ankle or knee joint. The researcher collected information on hip injuries, but chose to leave this information out of the results due to the distance of the hip from the ankle joint. Previous ankle injuries often lead to symptoms of ankle instability (Chan et al., 2011; Yeung et al., 1994), which increases the risk of them suffering from further injury. The researcher investigated whether or not the FMS could identify these symptoms in previouslyinjured participants. A negative moderate correlation existed in participants who identified having a previous injury, as outlined by the definition for this study. This moderate correlation suggests that the instability present in the ankle joint was not identified in the FMS. Therefore, for this study, the FMS was not a useful tool for identifying ankle instability in individuals who have previously suffered from an injury. The researcher further investigated whether or not the FMS could identify symptoms of ankle instability in participants who have not previously been injured. No significant relationships were identified in this population. Therefore, no conclusions can be made from this study for this population. Gender Differences in the relationship between the FMS and Ankle Stability The researcher examined the relationships between the FMS and ankle stability in each gender. No previous research has investigated these relationships.

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Females. Overall, the FMS may not be a reliable tool for identifying ankle instabilities of the female population. The moderate correlation observed in female participants between their FMS scores and ankle stability measure suggests that the FMS was unable to identify ankle instabilities in this population. Furthermore, the moderate correlation found between the active straight leg movement and the measure of ankle stability suggests that this movement on its own may not be able to identify ankle instabilities. No conclusions can be made for the other three FMS movements since no statistically significant relationship could be identified. Males. Since no significant relationship was found between male participants FMS score and ankle stability measure, this study cannot conclude whether or not the FMS could be used to identify ankle injury risk in this population. However, the large relationship observed between the in-line lunge score and the ankle stability measure implies that this movement may be a useful tool to identify ankle instability symptoms in the male population. No other relationships were found in the other FMS movements, so this study cannot conclude if these movements can identify ankle injury risk or not. Limitations Several potential limitations exist within this study. The researcher outlined several potential limitations of the current methodology which are discussed below. Environment. Due to the nature of this study, not all of the tests were performed in the same environment. However, the researcher ensured that every participant completed their tests in similar environments. The researcher ensured that a safe, hard flooring surface was used and that the participants were surrounded by minimal distractions. Despite this, the results could

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have been affected by these inconsistencies in testing environment. The differences consisted of space available, lighting, temperature, and flooring surface. Injuries. The classification of an injury in this study was categorized very broadly. There was a wide range of injuries used during this research. The severity of the injury could have easily affected how the participants performed during this test. While the researcher expected that those with injuries would have lower ankle stability than those who have never suffered from an injury. However, this was found to not be the case as the mean BESS score for those who had not suffered an injury (22.76) was greater than the mean value for those who had previously suffered an injury (21.46). There are several limitations that could have contributed to this phenomenon. There were two outliers within the injured population; if these outliers were removed, the mean BESS score increases to a value greater than the mean of the uninjured population (23.04). Another contributing factor could be the effectiveness of physical therapy. Those who have been previously injured could have attended physical therapy for their injuries, in which they did similar activities to those required in the BESS (balancing on an unstable surface). This would have given them prior experience in this activity, which would give them a learning advantage over those who had not previously attended physical therapy before. However, the researcher did not collect physical therapy information on the participants, and therefore has no knowledge of the percentage of injured participants who attended physical therapy for their injuries. Research has shown that rehabilitation programs do improve symptoms of ankle instability (Hale, Hertel & Olmsted-Kramer, 2007). Future research on this subject should investigate whether or not physical therapy improves an individuals FMS score. Investigating the relationship between FMS score and ankle stability in participants who have sprained their

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ankles, and comparing the difference between those who have had therapy and those who have not, could help provide some insight to the effect of physical therapy on these injuries. Further research on this subject should also focus on targeting ankle sprains, specifically. Due to lack of participants, the researcher was unable to isolate ankle sprains in their own category. However, when investigating the prevalence of ankle instability, ankle sprains should be the main injury investigated since they are the common result of having an unstable ankle. Future research should isolate those who have suffered an ankle sprain as their own population category. Activity level of participants. The population chosen for this study featured a very wide range of current activity level. The participants ranged from completely sedentary individuals to division one NCAA athletes. During physical testing, such as the ones performed in this study, being an active individual would be an advantage and those participants likely saw better results. However, the researcher did not record current activity level in the participants, and therefore cannot classify the results based off of this assumption. Some of the participants in this study indicated that they had seen a FMS or BESS test be performed previously. Some participants indicated that they had even performed one of these tests prior to participating in this study. It has been well documented that there is a learning effect on the FMS (Frost, Beach, Callaghan, & Mcgill, 2013) which could have increased their performance during this study. The BESS has been shown to have a learning effect, but only after 5 and 7 day rest intervals (Valovich et al., 2004). Further research should be done on the more immediate learning effects of the BESS. The researcher pilot tested investigating the learning effect on the FMS and BESS by having some participants perform these tests back-to-

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back. However, due to lack of time and participants, the researcher chose not to pursue this research. Practical Applications The Functional Movement Screen is commonly used in several clinical settings as a tool for assessing movement quality and risk of injury. Despite its intended purpose, this study found that this screen could not identify individuals who were at higher risk for ankle injury based off of their ankle stability scores. With the high occurrence of ankle injuries, it is important for clinicians to know that the FMS may not be an effective way of identifying the risk factors for injuries of this joint. However, while evaluating any joint for injury, the researcher supports the claim that functional evaluation is important in determining how the joint functions in real-life movement situations. Clinicians should investigate other means of functionally evaluating the ankle joint in working with their patients

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References Balance Error Scoring System (BESS). Retrieved from: http://www.sportsconcussion.com/pdf/management/BESSProtocolNATA09.pdf Bell, D. R., Guskiewicz, K. M., Clark, M. A., & Padua, D. A. (2011). Systematic Review of the Balance Error Scoring System. Sports Health, 3(3), 287-295. Beynnon, B. D., Renstrm, P. A., Alosa, D. M., Baumhauer, J. F., & Vacek, P. M. (2001). Ankle Ligament Injury Risk Factors: A Prospective Study of College Athletes. Journal of Orthopaedic Research, 19(2), 213-220. Carcia, C. R., Martin, R. L, & Drouin, J. M. (2008). Validity of the Foot and Ankle Ability Measure in Athletes with Chronic Ankle Instability. Journal of Athletic Training, 43(2), 179-183. Chan, K. W., Ding, B. C., & Mroczek, K. J. (2011). Acute and chronic lateral ankle instability in the athlete. Bulletin of the NYU Hospital for Joint Diseases, 69(1), 17-26. Chorba, R. S., Chorba, D. J., Bouillon, L. E., Overmyer, C. A., & Landis, J. A. (2010). Use of a Functional Movement Screening Tool to Determine Injury Risk in Female Collegiate Athletes. North American Journal of Sports Physical Therapy, 5(2), 47-54. Cook, G, Burton, L, & Hoogenboom, B. (2006a). Pre-Participation Screening: The Use of Fundamental Movements as an Assessment of Function- Part 1. North American Journal of Sports Physical Therapy, 1(2), 62-72. Cook, G, Burton, L, & Hoogenboom, B. (2006b). Pre-Participation Screening: The Use of Fundamental Movements as an Assessment of Function- Part 2. North American Journal of Sports Physical Therapy, 1(3), 132-139. Docherty, C. L., Valovich McLeod, T. C., & Shultz, S. J. (2006). Postural control deficits in participants with functional ankle instability as measured by the balance error scoring system. Clinical Journal of Sport Medicine, 16(3), 203-208. Finnoff, J. T., Peterson, V. J., Holloman, J. H., & Smith, J. (2009). Intrarater and interrater reliability of the Balance Error Scoring System (BESS). P M &R: the Journal of Injury, Function, and Rehabilitation, 1(1), 50-54. Freeman, M. A. R., Dean, M. R. E., & Hanham, I. W. F. (1965). The Etiology and Prevention of Functional Instability of the Foot. The Journal of Bone and Joint Surgery, 47B(4), 678 685. Frost, D. M., Beach, T. A. C., Callaghan, J. P., & Mcgill, S. M. (in press). FMS scores change with performers knowledge of the grading criteria Are general whole-body movement screens capturing dysfunction?. Journal of Strength and Conditioning,

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Fong, D.T., Hong, Y., Chan, L.K., Yung, P.S., & Chan, K.M. (2007). A Systematic Review on Ankle Injury and Ankle Sprain in Sports. Sports Medicine, 37(1), 73-94. Garrick, J. G. & Requa, R. K. (1988). The Epidemiology of Foot and Ankle Injuries in Sport. Clinics in Sport Medicine.7(1), 29-36. Gribble, P.A., Brigle, J., Pietrosimone, B. G., Pfile, K. R., & Webster, K. A. (2013). Intrarater reliability of the functional movement screen. Journal of Strength and Conditioning Research, 27(4), 978-981. Glasgow, M., Jackson, A., & Jamieson, A. M. (1980). Instability of the Ankle after Ligament Injury to the Lateral Ligament. The Journal of Bone and Joint Surgery, 62B(2), 196-200. Hale, S. A., Hertel, J., & Olmsted-Kramer, L. C. (2007). The Effect of a 4-Week Comprehensive Rehabilitation Program on Postural Control and Lower Extremity Function in Individuals with Chronic Ankle Instability. Journal of Orthopaedic & Sports Physical Therapy, 37(6), 303-311. Hansen, H., Damholt, V., & Termansen, N. B. (1979). Clinical and Social Status Following Injury to the Lateral Ligaments of the Ankle. Acta Orthopaedica Scandinavica, 59(6 pt 1), 699-704. Hertel, J. (2002). Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability. Journal of Athletic Training, 37(4), 364-375. Hootman, J., Dick, R., & Agel, J. (2007). Epidemiology of Collegiate Injuries for 15 Sports: Summary and Recommendations for Injury Prevention Initiatives. Journal of Athletic Training, 42(2), 311319. Kaminski, T. W. & Hartsell, H. D. (2002). Factors Contributing to Chronic Ankle Instability: A Strength Perspective. Journal of Athletic Training, 37(4), 394-405. Kiesel, K., Plisky, P., & Voight, M. (2007). Can Serious Injury in Professional Football be Predicted by a Preseason Functional Movement Screen?. North American Journal of Sports Physical Therapy, 2(3), 147-158. Lee, A. J. Y., Lin, W., & Huang, C. H. (2006). Impaired Proprioception and Poor static Postural Controls in Subjects with Functional Instability of the Ankle. Journal of Exercise, Science and Fitness, 4(2), 117-125. Lephart, S. M., Pincivero, D. M., Giraldo, J. L., & Fu, F. H. (1997). The Role of Proprioception in the Management and Rehabilitation of Athletic Injuries. The American Journal of Sports Medicine, 25(1), 130-137. McGuine, T. A., Greene, J. J., Best, T., & Leverson, G. (2000). Balance as a Predictor of Injuries in High School Basketball Players. Clinical Journal of Sport Medicine: official Journal of the Canadian Academy of Sport Medicine, 10(4), 239-44.

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OConnor, F. G., Deuster, P.A., Davis, J., Pappas, C.G., & Knapik, J. J. (2011). Functional Movement Screening: Predicting Injuries in Officer Candidates. Medicine & Science in Sports & Exercise, 43(12), 2224-2230. Olmsted, L. C., Carcia, C. R., Hertel, J., & Shultz, S. J. (2002). Efficacy of the Star Excursion Balance Tests in Detecting Reach Deficits in Subjects with Chronic Ankle Instability. Journal of Athletic Training, 37(4), 501506. Riegger, C. L. (1988). Anatomy of the Ankle and Foot. Physical Therapy, 68(12), 1802-1814. Ross, S. E., Guskiewicz, K. M., Gross, M. T., & Yu, B. (2009). Balance Measures for Discriminating between Functionally Unstable and Stable Ankles. Medicine and Science in Sport and Exercise, 41(2), 399-407. Ross, S. E., Guskiewicz, K. M., & Yu, B. (2005). Single-leg jump-landing stabilization times in subjects with functionally unstable ankles. Journal of athletic training, 40(4), 298304. Shultz, R., Anderson, S. C., Matheson, G. O., Marcello, B., & Besier, T. (2013). Test-retest and interrater reliability of the Functional Movement Screen. Journal of Athletic Training, 48(3), 331-336. Smith, C. A., Chimera, N. J., Wright, N. J., & Warren, M. (2013). Interrater and intrarater reliability of the functional movement screen. Journal of Strength and Conditioning Research, 27(4), 982-987. Teyhen, D. S., Shaffer, S. W., Lorenson, C. L., Halfpap, J. P., Donofry, D. F., Walker, M. J., Dugan, J. L., & Childs, J. D. (2012). The Functional Movement Screen: a reliability study. The Journal of Orthopaedic and Sports Physical Therapy, 42(6), 530-540. Tropp, H., Odenrick, P., Gillquist, J. (1985). Stabilometry Recordings in Functional and Mechanical Instability of the Ankle Joint. International Journal of Sports Medicine, 6(3), 180-182. Valovich McLeod, T. C., Perrin, D. H., Guskiewicz, K. M., Shultz, S. J., Diamond, R., & Gansneder, B. M. (2004). Serial Administration of Clinical Concussion Assessments and Learning Effects in Healthy Young Athletes. Clinical Journal of Sports Medicine, 14(5), 287-295. Willems, T. M., Witvrouw, E., Delbaere K., Philippaerts R., De Bourdeaudhuij I., & De Clercq D. (2005). Intrinsic risk factors for inversion ankle sprains in females a prospective study. Scandinavian journal of medicine & science in sports, 15(5), 336-345. Wolfe, M. W., Uhl, T. L., Mattacola, C. G., & McCluskey, L. C. (2001). Management of Ankle Sprains. American Family Physician, 63(1), 93-104. Wright, I. C., Neptune, R. R., van den Bogert, A. J., & Nigg, B. M. (2000). The influence of foot positioning on ankle sprains. Journal of biomechanics, 33(5), 513519.

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Yeung, M. S., Chan, K., So, C. H., & Yuan, W. Y. (1994). An epidemiological survey on ankle sprain. British Journal of Sports Medicine, 28(2), 112-116.

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Appendix A

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35

Appendix B

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Figures
Relationship between FMS score and BESS score
40 35 30

BESS Score

25 20 15 10 5 0 0 1 2 3 4 5 6 7 8 9 10 11 12

FMS Score

Figure 3.1. Relationship between FMS score and BESS score Relationship between FMS score and BESS score in Previously Injured Participants

40 35 30 25

BESS Score

20 15 10 5 0 0 1 2 3 4 5 6 7 8 9 10 11 12

FMS Score

Figure 3.2. Relationship between FMS score and BESS score in Previously Injured Participants 37

Relationship between FMS score and BESS score in Female Participants

40 35 30

BESS Score

25 20 15 10 5 0 0 1 2 3 4 5 6 7 8 9 10 11 12

FMS Score Figure 3.3. Relationship between FMS score and BESS score in Female Participants Relationship between Active Straight Leg Raise and Ankle Stability in Female Participants
40 35 30 25

BESS Score

20 15 10 5 0 0 1 2 3

Active Straight Leg Raise Score

Figure 3.4. Relationship between Active Straight Leg Raise and BESS scores in Female Participants 38

Relationship between In-Line Lunge and BESS score in Male Participants

40 35 30 25

BESS Score

20 15 10 5 0 0 1 2 3

In-Line Lunge Score

Figure 3.5. Relationship between In-Line Lunge Score and BESS score in Male Participants

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