Accuracy of Functional Movement Screen Deep Squat Scoring and the Influence of Optimized Scoring Criteria: A 3-Dimensional Kinematic Approach

in Journal of Sport Rehabilitation

Context: The deep squat (DS) test is a component of the functional movement screen, which is used to assess the quality of fundamental movement patterns; however, the accuracy of the DS has not been studied. The DS is a complex, total body movement pattern with evaluation required at several points along the kinematic chain. Objective: To assess the accuracy of DS scoring by an athletic trainer, physical therapist, and exercise science professional via a comparative analysis with kinematic data (KD) and to identify scoring criteria that would improve agreement between raters and KD scores. Design: Cross-sectional study. Setting: Motion analysis laboratory. Participants: A rater from each of 3 movement science disciplines rated the DS of 23 male college athletes (20.3 [1.2] y; 70.5 [3.5] kg). Interventions: Subjects were outfitted with reflective markers and asked to perform the DS. The DS performance was scored by 3 raters and kinematic analysis. Subsequently, the optimal set of criteria that minimized the difference between mode rater score and KD was determined via a Nelder–Mead simplex optimization routine. Main Outcome Measures: Intraclass correlation coefficients (ICCs) were calculated using SPSS (version 23; IBM, Armonk, NY) to determine tester agreement with the KD score and between the mode score and KD score. Results: Agreement was poor for the athletic trainer (ICC = .387), physical therapist (ICC = .298), exercise science professional (ICC = .378), and raters’ DS scores when compared with the KD. Agreement was poor for the mode score when compared with KD prior to optimization and good following optimization (ICC = .830), thereby allowing identification of specific scoring errors. Conclusions: Agreement for DS scores is poor when compared with KD; however, it may be improved with optimization of DS scoring criteria.

The functional movement screen (FMS) is a screening tool that consists of 7 tests developed to identify physically active individuals that may be at risk for sustaining musculoskeletal injury.13 These tests are meant to assess fundamental movement patterns2 that require a combination of strength, range of motion, and balance.4 Raters subjectively measure FMS patterns to identify movement dysfunction that may lead to musculoskeletal injury.4 While the tests of the FMS do not specifically identify the anatomical site that is likely to sustain an injury, they indicate the presence of dysfunctional movement(s) that may ultimately lead to musculoskeletal breakdown. This concept, in which musculoskeletal pain in one part of the body is caused by musculoskeletal dysfunction in another part of the body, has been termed “regional interdependence.”5

The deep squat (DS), one of the more complex of these test movements, requires both mobility and stability of the ankles, knees, and hips as well as stability of the spine and mobility of the shoulder complex. DS scoring requires that the rater evaluates several components along the kinematic chain while the individual being tested transitions through the movement pattern. Successful completion of the DS requires an individual to assume the starting position with feet shoulder width apart, toes pointing straight forward, and a bar pressed directly overhead. The athlete then descends into a full squat position and returns to the start position.6 While observing this movement, which typically takes no more than 5 to 7 seconds to perform, the rater applies stringent scoring criteria (Table 1) to grade specific movement components.6,7 The DS is scored as either 3—indicating successful completion; 2—indicating successful completion with modification of the movement pattern; or 1—indicating unsuccessful completion of the movement pattern. A score of 0 is assigned if the individual experiences pain at any point during the movement pattern.6 Subjects are given 3 opportunities to successfully complete the DS. If they are unable to complete the DS, they are placed in a modified position with their heels elevated on a 2 × 6 board, which places the ankle in a plantar-flexed position, shortening the gastrocnemius–soleus complex. If the subject is able to successfully complete the movement pattern in the modified position, they are not able to score higher than a “2” on the DS. This score is then factored into a composite score for the complete 7-item FMS. Previous research indicates that lower composite FMS scores are linked to the likelihood of sustaining a musculoskeletal injury in sports,13,8,9 but not to measures of performance.1012

Table 1

DS Scoring Criteria

ScoreStandard DS scoring criteriaScoring criteria with defined body segments
3—Upper torso parallel with tibia or toward vertical—Segment between acromion process and greater trochanter parallel with the segment between lateral malleolus and lateral epicondyle of the knee, or toward vertical
—Femur horizontal or below—Segment between greater trochanter and lateral epicondyle horizontal or below
—Knees aligned over feet—Distance between right and left tibial tuberosities does not vary through the movement
—Bar aligned over feet—Bar does not extend beyond vertical line from the distal end of foot
2—Heels elevated on 2 × 6 board—Heels elevated on 2 × 6 board
—Same scoring criteria as above—Same scoring criteria as above
1—Unable to successfully complete the movement with heels elevated on 2 × 6 board—Unable to successfully complete the movement with heels elevated on 2 × 6 board
0—Pain—Indicated by the athlete raising their hand

Abbreviation: DS, deep squat.

Previous research has indicated that there is considerable variability in interrater reliability of the DS.7,1317 Gulgin and Hoogenboom13 reported slight agreement in the DS when comparing novice raters to an expert rater. Minick et al7 reported excellent reliability between novice and expert raters; however, expert raters were found to have a lower agreement than novice raters. Teyhen et al17 reported substantial reliability between novice raters, while Onate et al14 found high reliability between an FMS-certified rater with athletic training and strength and conditioning backgrounds and a novice FMS rater with a strength and conditioning background. Smith et al16 found good reliability between an FMS-certified rater, a physical therapy student with FMS experience, a physical therapy student without FMS experience, and an athletic training faculty member without FMS experience. One possible explanation for these contradictory findings is that scoring criteria may not always be accurately applied. The lack of consistent reliability could be the result of having to assess several joints and body segments simultaneously.13 It has also been shown that interrater reliability ranges from poor to good when comparing expert raters from the movement science disciplines of athletic training, exercise science, and physical therapy.15

It has been suggested that FMS scoring would benefit from a 3-dimensional assessment, as the ability to view tests from multiple positions would potentially improve scoring accuracy.7,16 The previous reports on interrater reliability of DS scoring had raters to evaluate the movement from one position, and this could explain the differences in their results.

Only one previous investigation has measured the lower-extremity kinematics of the DS. Butler et al18 evaluated the mechanics of the DS at the ankle, knee, and hip utilizing a 3-dimensional motion capture approach. Twenty-eight participants performed the DS and were subsequently scored by raters, who have completed the FMS training, and grouped by their score (1, 2, or 3). The only significant kinematic difference between athletes scoring a 3 and a 2 occurred at the knee. Athletes scoring a 3 displayed significantly greater peak knee flexion (PKF) and overall knee excursion than those scoring a 2. Participants scoring a 1 displayed significantly different kinematics at the ankle, knee, and hip compared with those scoring a 2 or a 3. This report highlights the similarities of lower-extremity motion between a score of 2 or 3; this potentially could explain why interrater reliabilities of DS scoring have been inconsistent. Based upon this report, a score of 1 would be easier to discern from a score of 2 due to significant differences at all 3 lower-extremity joints. Trunk motion and bar position were not measured, thus preventing researchers from determining whether the published DS scoring criteria were being correctly applied by the rater(s). As a result, it is possible that there were errors in initial grouping that may have obscured true differences between DS scores.

As accurate DS scoring is one component necessary for determining an individual’s potential injury risk, it is essential to confirm that the rater’s score accurately applies to the defined criteria. There is currently no published investigation that addresses whether raters are able to accurately score the DS, as defined by published criteria, when compared with 3-dimensional kinematic data (KD). The current investigation had the following 2 specific aims:

  1. 1.To assess the accuracy of DS scoring by expert raters of 3 movement science disciplines (athletic training, physical therapy, and exercise science) via a comparative analysis with kinematically determined (KD) scores derived from 3-dimensional motion capture.
  2. 2.To identify scoring criteria, via a data optimization approach, that would improve agreement between expert and KD scores.

Methods

Subjects

This study obtained institutional review board approval. Twenty-eight National Collegiate Athletic Association Division I, male athletes were recruited to perform the DS while being recorded on digital video (DV). Five athletes were removed from the study due to incomplete KD in at least one of the 6 trials, leaving 23 athletes (20.3 [1.2] y; 70.5 [3.5] kg). Athletes were at least 18 years of age and free of any chronic or acute musculoskeletal injuries at the time of testing. Three raters, an athletic trainer, a physical therapist, and an exercise science professional, viewed and rated the DV of the 23 athletes performing the DS. All raters were FMS certified and had a minimum of 1 year of clinical experience using the FMS.

Procedures

Athletes participated in one testing session in which they completed an informed consent and were instructed on the study procedures. Athletes wore spandex shorts and shirts as well as the athlete’s choice athletic shoes for the testing session. Forty-six reflective markers (10 mm diameter) were placed on each athlete at the following structures bilaterally: distal second metatarsal, midpoint of the tibia, medial/lateral malleoli, tibial tuberosity, medial/lateral epicondyles of knee, midpoint of thigh, anterior superior iliac spine, posterior superior iliac spine, greater trochanter, distal second metatarsal, radial styloid process, ulnar styloid process, midpoint of radial shaft, medial/lateral epicondyle, midpoint of upper arm, and acromion process. Four reflective markers were placed around the perimeter of the head and additional markers were placed at C7, T10, sternoclavicular notch, and xiphoid process, respectively. Markers were also placed at the end of an FMS Test Kit bar (Functional Movement Systems, Chatham, VA) to track the path of the bar.

The DS testing followed the standard FMS protocol for this assessment tool.6 Athletes were read standardized scripted instructions prior to the first and second attempts of each test, but not the third attempt. All athletes performed the DS 3 times in the standard position and 3 times in a modified position with their heels raised on the FMS test kit (height = 44.5 mm). Athletes who indicated that they felt pain during the trial were removed from the study. DV of each trial was collected in the frontal and sagittal planes using Microsoft LifeCam HD webcams (Microsoft, Inc, Redmond, WA; 75 Hz). Qualisys Track Manager (Qualisys, Inc, Gothenburg, Sweden) was used to capture DV.

Each rater independently viewed each of the trials on DV and recorded their scores. Frontal plane DV was viewed first followed by the sagittal view, with each angle being viewed only one time. DS scoring was identical to the published FMS scoring criteria (Table 1).6,7 The maximum score possible for trials 1 to 3 was a 3 indicating successful completion of the DS during one of those 3 trials. For trials 4 to 6, a maximum score of “2” was assigned if the athlete was able to successfully complete the DS in the modified position, with a “1” being assigned if they were not able to complete the DS in the modified position. The maximum score generated from across the 6 trials was used as the DS score for that athlete.

Three-dimensional marker coordinates were measured during DS testing using a 9-camera motion capture system (OQUS 100; Qualisys) with a sampling frequency of 480 Hz. Residual accuracy of the 3-dimensional motion capture system was <0.39 mm. A custom MATLAB (MathWorks, Natick, MA) program (1) filtered marker coordinate data with a fourth-order Butterworth low-pass filter with a cutoff frequency of 25 Hz, (2) computed lower-extremity KD, and (3) determined DS score for each trial. An anatomical reference position was captured to normalize all kinematic variables. For all 6 trials, 3 with heels flat and 3 with heels elevated, PKF, tibial tuberosity-to-tibial tuberosity distance (knee separation, dTT-TT) at PKF, right/left (R/L) thigh projection angle at PKF, trunk projection angle (Θtrunk) at PKF, R/L tibial projection angle (Θtibia) at PKF, and sagittal plane distance between bar marker and distal second metatarsal marker (dbar-foot) at PKF were calculated. Six kinematic criteria (knee separation, R/L thigh inclination angle, trunk-tibia angle differential, and R/L bar-foot displacement) were used to determine a KD score in accordance with traditional FMS DS scoring criteria and procedures outlined in Table 1. Table 2 provides the KD that corresponds to each of the DS scoring criteria.

Table 2

DS Scoring and Kinematic Criteria

FMS scoring standardKinematic criteria
Upper torso parallel with tibia or toward verticalΘtrunk − Θtibia > 0°
Femur horizontal or belowΘL thigh ≤ 0°, ΘR thigh ≤ 0°
Bar aligned over feetdL bar-foot > 0 cm, dR bar-foot > 0 cm
Knees aligned over feetdTT-TT > 0 cm

Abbreviations: dTT-TT, tibial tuberosity-to-tibial tuberosity distance; DS, deep squat; FMS, functional movement screen; L, left; R, right.

A secondary analysis was conducted to determine the set of kinematic criteria that would optimize the KD DS score compared with the mode score of 3 expert raters (Figure 1). A custom-written MATLAB program utilized a Nelder–Mead simplex optimization routine to determine kinematic criteria that minimized differences between the mode score of 3 expert raters and KD score. In order for the optimization routine to find search gradients, a continuous objective function was defined, as opposed to the ordinal scoring scale typically used when visually grading test movements. Following determination of optimized kinematic criteria, each athlete was rescored with the new optimized criteria and compared with the mode score of expert raters.

Figure 1
Figure 1

Flowchart depicting steps involved to numerically optimize deep squat scoring criteria.

Citation: Journal of Sport Rehabilitation 2020; 10.1123/jsr.2019-0041

Statistical Analysis

To assess the consistency of scoring between the expert raters and KD score for the 4-point (0–3) scoring system of the DS, a 2-way random-effect intraclass correlation coefficient (ICC) model with absolute agreement was calculated to account for any rater bias. ICCs, F ratios, and 95% confidence intervals were calculated. ICC values of .75 to 1.0 indicated good agreement, .5 to .74 indicated moderate agreement, and .0 to .49 indicated poor agreement.19 SPSS (version 23; IBM, Inc, Armonk, NY) was used to calculate all statistics for this study. ICCs, F ratios, 95% confidence intervals, and percent agreement were computed between (1) score from each of the 3 raters and KD score, (2) mode score from 3 expert raters and KD score, and (3) mode score from 3 expert raters and KD-optimized score.

Results

Results demonstrated that there was poor agreement between the athletic trainer rater and the KD score (ICC = .387), the exercise science professional rater and KD score (ICC = .378), as well as the physical therapist rater and the KD score (ICC = .298) (Table 3). There was agreement across all raters for only 10 of the 23 participants.

Table 3

ICC for Agreement Between DS and KD

95% CI of ICC
TestICCF (df)LowerUpperLevel of agreement
AT/KD.3874.47 (22, 22)−.106.728Poor
PT/KD.2982.59 (22, 22)−.085.622Poor
EX/KD.3783.40 (22, 22)−.073.698Poor

Abbreviations: AT, athletic trainer; CI, confidence interval; DS, deep squat; EX, exercise science professional; ICC, intraclass correlation coefficient; KD, kinematic data; PT, physical therapist.

Prior to the optimization analysis, a comparison of the mode rater score to KD was performed. These analyses also resulted in poor agreement (Table 4), as there was agreement for only 9 of 23 (39.1%) athletes. The optimization analysis determined that adjusting scoring criteria to a right thigh projection angle of 16.1°, left thigh projection angle of 27.1°, a right bar-foot displacement of 20.6 cm, and left bar-foot displacement of 20.9 cm substantially improved agreement with the mode score of expert raters. Following optimization, agreement was good (ICC = .830) with agreement in 20 of 23 athletes (87%; Figure 2). Two scoring criteria, knee separation and trunk-tibia angle differential, did not have any effect on agreement.

Table 4

ICC for Agreement Between DS Mode Score and KD Before and After Optimization

95% CI of ICC
TestICCF (df)LowerUpperLevel of agreement
Before optimization.4174.49 (22, 22)−.096.744Poor
After optimization.83011.73 (22, 22).777.961Good

Abbreviations: CI, confidence interval; DS, deep squat; ICC, intraclass correlation coefficient; KD, kinematic data.

Figure 2
Figure 2

Percent agreement for individual raters and mode score with kinematic data before and after criteria were optimized. AT indicates athletic trainer; EX, exercise science professional; PT, physical therapist.

Citation: Journal of Sport Rehabilitation 2020; 10.1123/jsr.2019-0041

Discussion

With the squat movement pattern and its variations being widely used as both a training exercise and a clinical assessment tool to identify faulty movement patterns in active individuals, it is essential that clinicians can accurately score the FMS DS. Previous investigations have reported mixed findings with regard to interrater reliability of DS scoring,7,1317 but no report has investigated if scoring criteria were being properly applied. The primary aim of this study was to determine if 3 expert raters of the FMS DS were accurately applying scoring criteria compared with 3-dimensional data in a group of Division I athletes. The results of this study indicate that raters were not accurately assessing DS performance, with scoring agreement in only 9 of 23.

It has been suggested that some tests in the FMS such as the DS, inline lunge, and hurdle step over may be more difficult to rate due to the complexity of the movement patterns, and that the accuracy of these tests would improve if they could be viewed from multiple angles.7,16 For instance, an optimal vantage point for evaluating thigh position would be in the sagittal plane, but this would prevent a proper vantage point to discern knee separation, which is based viewed in the frontal plane. Consequently, it is difficult for a rater to simultaneously assess each body segment and bar movement during the DS. During live DS assessments, a rater must view from a single location or be moving during the assessment. In either case, the rater will not have the ability to view the movement from both sides of the body (sagittal planes) and frontal planes concurrently. In this study, even though raters were shown DV in the frontal and from one side of the sagittal plane, agreement with 3-dimensional data was poor for 2 out of 3 raters as well as for the mode score. It is likely that rater’s scores would have diverged more from the 3-dimensional data if they had viewed the DS in person, although the current study cannot confirm this.

The secondary aim of this study was to determine which of the published scoring criteria was not being accurately observed by the raters in their observation of DV. A numerical optimization methodology was conducted to determine the set of scoring criteria that would best improve agreement between raters and the 3-dimensional data. It was determined that adjusting the thigh projection angles from 0° (indicative of the thigh being parallel with relation to the ground) to values of 16.1° and 27.1° (indicative of the thigh not reaching parallel with relation to the ground) and adjusting the bar-foot displacement from 0 (indicative of the bar even with the foot) to 20.5 cm (indicative of the bar moving anterior with the foot) greatly improved agreement between expert raters and 3-dimensional data. These errors in scoring result in scores that are inaccurate, resulting in a measurement error such that movement impairments would not be identified when they are present, thereby resulting in a lost opportunity to address the condition causing the movement impairment. Adjustment of all other scoring criteria had minimal influence on improving score agreement.

There are several potential reasons why the thigh projection angle was a scoring criteria that was most frequently misinterpreted by the expert raters. It is possible that raters were not accurately assessing the location of the femur and were instead using the posterior contour of the thigh to judge femur position. Raters may assume that when they see either the anterior or the posterior thigh contour parallel to the horizontal, the femur is also parallel. This is not an accurate representation of femur position. As a result, raters inaccurately determined that the thigh was parallel or beyond parallel when this was not the case according to 3-dimensional data. Figure 3 provides an example of a subject where the contour of the thigh musculature may influence the rater’s perception of where the femur is. In this study, the true femoral position was measured based on markers placed on the greater trochanter and lateral epicondyle of the knee. Another plausible explanation could be related to the necessity of simultaneously rating other scoring criteria. As the athlete was only holding the DS position for a count of 1 second, it is possible that raters focused attention on other criteria (eg, trunk-tibia angle differential) more heavily than on thigh position. It should be noted that the athletes wore spandex clothing, and reflective markers were placed on the lateral femoral epicondyle and greater trochanter. Markers in this study were 10 mm and may have been easily viewable for raters as they viewed the trials. Although the current study cannot confirm this, we speculate that loose-fitting clothing and the absence of reflective markers would increase the difficulty of accurate assessment of this criteria.

Figure 3
Figure 3

The vertical line from the end of the bar represents the bar position relative to the foot. The position of the femur is also shown relative to the horizontal position.

Citation: Journal of Sport Rehabilitation 2020; 10.1123/jsr.2019-0041

The complexity of the movement pattern along with the dynamic nature of the movement could have contributed to the raters’ difficulty in assessing the bar position relative to the foot. The published scoring criteria indicate that the bar should not move past the feet, but is not clear in its definition of “feet.” The simultaneous perception of the bar end and “foot” may be challenging and vary between raters. When the scoring criteria were adjusted to 20.5 cm (indicative of a clear anterior positioning of the bar relative to the foot), agreement between the raters and 3-dimensional data substantially improved. If the only scoring criteria that were adjusted were the bar-foot displacement, then agreement between expert raters and 3-dimensional data would improve to 70% (16/23). These results highlight the challenges of accurate assessment of these criteria and the potential for an improved written description of the movement pattern. Figure 3 shows athlete whose arms are in line with their trunk, but the bar is still anterior to the placement of the feet.

There are several clinical ramifications of the current work. The poor agreement that was demonstrated in this study when comparing DS scores of expert raters to a KD score highlights the issue that inaccurate scoring of the DS may either be inaccurately placing individuals who are at an increased risk of injury in a low-risk category or placing individuals who have a decreased risk of injury in a high-risk category. This type of decision may influence training programs, corrective exercise program design, or rehabilitation programs. This may result in missed opportunities to have a positive effect on an individual who may be at risk for sustaining musculoskeletal injury. It also potentially explains why ratings of reliability for the DS have varied in the literature.

While the findings of the numerical optimization suggest that the current scoring criteria should be modified, a more appropriate suggestion would be to provide instruction that draws the attention of the raters to the commonly misidentified errors. Instead of simply stating that the femur should reach horizontal or below, a secondary instruction could be provided to inform the rater to form an imaginary line between the lateral epicondyle and the greater trochanter to provide a more clear reference point to when determining the position of the femur. Additionally, the use of visible markers on the lateral epicondyle and greater trochanter may assist the rater in more accurately determining the position of the femur during the DS. It is also important for raters to not only assess the bar relative to the foot position, but also relative to the torso to make an accurate assessment regarding shoulder mobility. While the DS is typically scored real time, it may be helpful for raters to use DV in the frontal and sagittal planes to accurately assess the movement pattern.

Several limitations to this study should be noted. The ability of the rater to see the marker placement on the athletes may have influenced their rating of the athlete. The presence of markers would likely bias the study results such that reliability coefficients would be larger, suggesting that the true reliability measures would be poorer than those reported in the study. The FMS is designed to be viewed live meaning that the rater has one attempt to view each movement. In the current study, raters viewed DV in the sagittal and frontal planes, which allowed them an additional vantage point to view the movement pattern, also potentially increasing reliability coefficients. Conversely, viewing DV did not allow raters to self-select their ideal viewing angle, which may not be directly in the frontal or sagittal planes if the athlete is viewed live. Furthermore, the placement of the marker at the end of the distal second metatarsal may not have allowed for an accurate representation of the bar-foot displacement as the most distal point on the second metatarsal does not represent the most distal point of the foot. Both of these limitations may have negatively impacted reliability coefficients. Additionally, DV in the sagittal plane was only viewed from the left side, which may have caused raters to miss movement deviations that would have been viewed from the opposite side. Finally, raters with different clinical backgrounds were used to assess the athlete’s performance on the DS. It is worth noting that these raters and their assessments may not be an accurate representation of a larger population of raters from their respective clinical backgrounds.

Conclusions

The results indicate the inability of raters to correctly score the DS when scoring DV in the frontal and sagittal planes compared with a KD score or gold standard. A numerical optimization analysis revealed that the identification of bar position relative to the foot and femur position relative to the horizontal were common reasons for misidentification. The bar tended to move further anteriorly than the raters perceived, and the raters identified the femur to reach a horizontal position or below, when the femur had not reached a horizontal position. Better instruction and training with regard to the body segments being assessed, and the landmarks to view would likely allow for more accurate assessment of the DS. Placing visible body markers on the lateral femoral epicondyle and greater trochanter may improve DS scoring accuracy. Accuracy of DS scoring may also be improved if raters use DV from multiple angles and are given the opportunity to view the trials several times and pause the DV at selected points during the movement pattern. Future research on the DS should include an assessment of the accuracy of DS scoring when comparing a self-selected view versus frontal plane only, sagittal plane only, or frontal and sagittal plane views during testing. Additional research could focus on the use of DV and allow raters to view trials several times as well as pause the DV when needed.

Acknowledgments

This work was presented at the 2014 World Congress of Biomechanics, Boston, MA. All authors have no financial interest to report.

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Scibek and Moran are with Sacred Heart University, Fairfield, CT. Edmond is with Rutgers University, Newark, NJ.

Scibek (scibeke@sacredheart.edu) is corresponding author.
  • View in gallery

    Flowchart depicting steps involved to numerically optimize deep squat scoring criteria.

  • View in gallery

    Percent agreement for individual raters and mode score with kinematic data before and after criteria were optimized. AT indicates athletic trainer; EX, exercise science professional; PT, physical therapist.

  • View in gallery

    The vertical line from the end of the bar represents the bar position relative to the foot. The position of the femur is also shown relative to the horizontal position.

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