By Carl Valle
Every preseason, the online debate starts about the efficacy and validity of such screening systems as the Functional Movement Screen (FMS) and the Physical Competence Assessment (PCA). Last year, an article in the British Journal of Sports Medicine questioned the concept of screening athletes and left some coaches and sports therapists asking whether there is anything proactive they can do.
FMS research from the last twenty years indicates its extreme limitations for screening, but the vision of the system has good intentions. Attempts to connect specific injuries with screening will never end, but we do have enough information now to logically apply the known science and research to what’s practical in the trenches.
A training program over months will screen athletes, or more accurately, will evaluate them at a rate that reveals information valuable to everyone involved with athletic performance. I still do movement screens via exercise progression because I need to know what an athlete can do correctly at any given time.
Screening isn’t just for the coach or even sports medicine staff. It’s important for the athletes, allowing a commitment to improving their own body and mind. Exercises that gather more information outside their intrinsic value are very small parts of a program, and are not in any way a crystal ball.
Why Your Movement Screen Doesn’t Work Well
Chances are, if you’re using a movement screen, you’ve been disappointed with its limits or found the system to work better than the research has concluded. I believe that movement screens have some value, but not as much as the screening educators claim and more than some authors conclude. Keep in mind that the middle ground and balanced thinking don’t lead to commercial success; extremism is the only way to market successfully, especially in our age of social media.
Several coaches swear by the FMS, believing it’s the best option for screening athletes, while teams that do not screen at all are winning with healthy rosters. Really good coaches who screen with excellent protocols are losing athletes to career-ending surgeries and early retirements. One can ask, “What gives?” The answer is fairly straightforward.
Reasons movement screens will not fix injury problems:
- The workload, whether it’s acute or chronic, is a major cause of athletic injury. Screening is a preemptive strike to gather information but does nothing to manage volume or intensity.
- Movement screens use slow velocity and low force activities, characteristics that are not common to most musculoskeletal injuries.
- Most screens are only anatomical or evaluate range of motion, especially with general exercises that don’t identify probable sport injuries.
- The screening process usually has a scoring summary that doesn’t statistically have enough sensitivity or specificity to help target risk.
- Most importantly, they don’t screen actual sporting actions. Even replicating the pathomechanics of risk isn’t always effective in warding off the specific injury it was intended for, such as the drop landing research with ACLs.
These points are the small tip of the screening process iceberg. Perhaps the simple and better screening approach is to evaluate whether athletes are prepared to play at all.Training is the ultimate screen and predictor of injuries. Click To Tweet
Training is the ultimate screen and predictor of injuries, as aerobic fitness and strength are the weapons for reducing non-contact, and even some contact, injuries. Simple hamstring assessments from companies like Vald Performance do a very good job appraising valid risk because they quantify and connect the risk of injury with solid science.
What the Science Says About the Functional Movement Screen
The inconvenient truth is that FMS is not a very good screen. The science does not support the promise of the screen’s own name. The word functional, perhaps the most bastardized term in sports since the late 1990s, is very context-specific. Ironically, FMS requires very little movement; any certified user can perform the screen while in place. Thus it’s more of a slow joint movement action. An example is the system’s leg raise movement—the athlete is supine on their back lifting one leg toward their body.
Several good reviews already exist about FMS, and I’ve linked their details here. A fine write-up about whether FMS is truly a screen at all is available at Exercise Biology. The primary challenge with FMS and many movement screens is the actual goal of what they’re trying to accomplish. Is it to predict injuries? Is it to predict future performance?
The goal is clearly not to develop a diagnosis because injury lists don’t have sections for “movement dysfunction” followed by a specific duration for corrective exercise rehabilitation. As a performance assessment, general population subjects have similar FMS scores. Injury prediction? The verdict is still out, but most of the conclusions agree that FMS is not going to solve the injury crisis, based on the stronger literature.Most agree that the Functional Movement Screen is not going to solve the injury crisis. Click To Tweet
A recent study found a relationship between asymmetry during preseason and injury, although the sum of the seven tests (0-3 scoring) is more an observation of poor general function than clear identification of a problem. While MRIs and ultrasound require clinical examination for a complete diagnosis, every doctor wants confirmation with medical imaging, not an FMS report. Movement screens are not designed to be diagnostic tools, and they do not eliminate expected injuries in team and Olympic sports.
A good movement screen should identify general and specific risks, but they fail at this due to the challenge presented by the complexity of injury patterns. Injuries are a composite of variables and environmental factors unique to each athlete and team, so it’s hard to conclude that false negatives and false positives with a few movements will not make them low yield.
In general, movement screens are not effective regardless of how they’re presented by marketing campaigns.
The Value of Movement Screens
This discussion does not suggest not screening at all. That’s far from the case. I use parts of various screens. My priority, however, is managing the training load.
I continue to push for predictive tests because athletes’ workloads, which are increasing, are not very modifiable. Therapists who don’t focus on movement mechanics are great for the recreational runner but have nearly no impact on team sports. Performance coaches are the ultimate experts in workload. Some team coaches have a great feel for what their athletes can handle, and orthopedic surgeons know the unfortunate limits of what athletes can do.
So the question is not whether screens are worth doing. It’s which screens are worthwhile and whether they have an impact on injuries and performance. Several years ago, Dr. Murphy stated eloquently that sometimes performance decreases as risk increases with mechanical loading. Some see loading as a way to increase resilience, but the load adaptation model is much too simplified to use in team sports that don’t allow for training or preparation.
Screening provides a talking point, similar to subjective questionnaires. Screening assesses healthy athletes and teases out those who might be injury-prone and those who could benefit from interventions leading to improved athletic performance.Screening assesses healthy athletes and teases out those who might be injury-prone. Click To Tweet
Screens are valuable because they provide information at the start of the season before workloads are ramped up to full throttle. A classic clinical evaluation with good records can sometimes work well for an athlete with previous or lingering injuries. General screens, however, will never be as effective as holistic training.
Many successful users of screening systems falsely believe their athletes’ improvements evolve from the test results. We see a lot of great coaches and sports medicine practitioners who believe the tool produces the results when it’s more likely the athletes benefited from the talented and experienced craftsmen behind the test.
General, well-rounded screening should be provocative, forcing the athlete to communicate to those who don’t have a sports medicine degree that a problem exists. A change from previous baseline numbers, or scores severely different than specific norms (sport or athletic population), are indeed red flags.
When an athlete complains of pain and has a legitimate problem with a current or past injury, the movement screen works only because someone before failed to do their job.
It’s wise to invest some time and effort into evaluating athletes’ movements as they do general and specific activities with lower levels of intensities and volumes. If athletes are pulling hamstrings running, why not evaluate running? Other than managing the practice and game loads while mining data in training, only a handful of variables seem to have direct value.
General Screening Process Limitations
Screens are lousy for sports injuries overall, though they may help with health promotion. They don’t identify talent, nor do they measure performance. Teams want to reduce injuries as much as possible with tools that gather enough information to remove the problems that lead to injury. Sensitivity and specificity are a challenge with screens, and the limits of FMS prevent it from helping to discover why athletes are getting hurt.
The PCA (Physical Competitive Assessment) from Kelvin Giles is also a point-rating system. By using scores of 1-5, it’s a small improvement, but it still lacks strong methodology to evaluate and visualize data.
When analyzing risks, factor in these gaps in movement screens:
- Etiology: Etiology is different than screening because risk factors are often observational. The potential reasons for injuries are different from the information provided by movement screens. Programs should respect and value the current literature about why injuries are likely to happen. A multitude of risk factors found to lead to a problem are a true cause for concern; no one variable will destroy an athlete’s future.
- Anatomy: Having some anatomical abnormalities can be a problem, but athletes should not think that having different body structures means they’re cursed. Even temporary structural issues, such as posture, aren’t a sure-fire cause of injury. Remember, though, sport (high velocity, intensity, volume) isn’t the same as activities of daily life. Any anatomical problem that damages tissue to the point that it requires surgical repair or forced rest must be managed with a grain of reality.
- Pathomechanics: Similar to etiology, some body motions can create dysfunctional damage. Joint performance relies on mechanics, and some mechanical actions are not healthy for biomaterial (soft and hard tissue). Kinetic and kinematic motions include tissue adaptations like fascial length. This becomes part of the complete picture with hamstring injuries, for example.
- Record Keeping: Without any technology or even good logging, teams can create rationales as to why athletes are healthy and why some are chronically injured. Even in this modern era, most electronic health records are not useful because they’re incomplete and too vague to explain why an injury occurred. Having only dates of surgeries and access to medical imaging won’t stop the injury epidemic we see in some leagues.
- Team Testing: Strength, power, and conditioning tests are not perfect, but athletes with great aerobic systems and solid strength levels are functional. Using a hamstring strength test is more likely to help solve hamstring injuries than movement screens that don’t consider muscle power or similar information. Leg eccentric strength, aerobic fitness, and specific conditioning are more advantageous than movement screens to keep athletes healthy. (I’ll mention this example again. I share it to help coaches understand specific versus systemic risk.)
To see if an athlete is prepared to train with a team, movement screens provide only a sliver of assessment data needed. By itself, movement screening is not of major value. When programs can compare and analyze all of the information in a complete picture, they have a better chance of solving risk factors that are truly influencing injury patterns. Most programs that have fit and strong players with good movement mechanics will have a higher resilience to injury compared to their counterparts.
How to Improve Movement Screens
Movement screens cover a wide category of motion evaluation, ranging from a single joint activity all the way to sprinting and other athletic tasks. Their information is limited, time-sensitive, and difficult to measure and interpret. More testing may not mean more value, but more information gives a coach a fighting chance to understand what’s going on. Movement screens can still help address movements that matter to athletes in their respective sports.
One of the reasons I love the PCA is the exercises used are valuable for training. Tests that don’t create a significant change in learning or biological adaptation are not great investments. Vertical jump testing is important to evaluate jumping ability, but doing a lot of vertical jumps will not create freaks from added hypertrophy or power.
What I don’t love about the PCA is how the data is collected and scored. Criteria based screening, meaning achievements with specific milestones in the activity, is great for summarizing but not for scoring.
Improving screens starts with video recording. Five key reasons why a coach or medical professional should video their screening sessions are:
- Writing a score down is not the same as recording the screen. Recording the screen with video allows one to analyze it later. When only one set of eyes evaluates the motion, repeatability becomes a problem. Inter- and intra-reliability can be an issue for some screens that have poor criteria and objective measurement scoring.
- Video allows the athlete to see themselves. Biofeedback is phenomenal as it allows an athlete to make sure there are no issues with familiarization with the screen or interpretation of the instructions.
- Using video enhances speed or workflow because athletes only participate in the screening process, not the scoring period.
- Digital measurement tools automate the process and let us collect much more information almost instantly. Investing time up front to learn how to use digital tools like Dartfish and other systems pay off in the long run.
- Collaborating and communicating with others is difficult to do with large teams or colleges, and video allows everyone to be on the same page. If a photo is worth a thousand words, video is priceless.
After a solid assessment is performed and later scored, the real work begins. One of my issues with most screens is that athletes are expected to practice one or two days after the screen, and very few teams have enough time to address true impairments.
Even if screens were airtight about identifying risk, most organization and college wouldn’t buy into them. Team coaches don’t want to stop preparing for games on the court or pitch, they want to practice the Xs and Os. Olympic sport is easier, but with a championship on the line, time is the enemy and coaches want to train.
Skilled coaches who know how to work with athletes after they’re injured should be able to look and identify how many of the athletes who screened poorly truly need remedial training.
Most of the time, I find that the athletes who screen poorly with my combination of screens simply didn’t complete rehabilitation from the previous year and instead went on vacation. If the athlete did train in the offseason, much of the training was compromised later when the intensity and volume were ramped up, and screening did identify the impairments.
For some strange reason, many proponents of movement screens rarely rescreen athletes. If one believes a good score will reduce injury, then a great score should reduce injury even more if the interventions work. Screening without later action just labels an athlete. It’s not helpful if teams are truly trying to reduce injuries. The research also does not provide much support for “corrective exercise.” Many programs succeed because overloaded athletes are simply resting and learning to do new low-load exercises better, not because they are addressing dysfunction.
Why I Use Movement Screens with My Athletes
I still do movement screens via exercise progression because I need to know what an athlete can do correctly at any specific time. Screening anything, even if the movements are not perfectly connected to injury risk or performance, is a learning experience for both the coach and the athlete.
When a coach screens, subtleties about how the athlete receives instruction, their focus and effort with a task, and how they learn outside of the court or field is very useful. A great process can make an average screen very useful for coaches. I recommend screening; I just believe one has to construct their own screens.
Like many people, I use the warm-up for sprinting or other locomotive activity as the backbone of my system. Some things I can eyeball and others require far more analysis with video or kinetic sensors. Screening on the fly with warm-ups isn’t perfect, but injuries that are problems will usually be caught early and not made worse by training or competing while injured.