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Corrective Exercise

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A Comprehensive Guide to Corrective Movement Training

Corrective Exercise
Chad Waterbury, DPT First Edition
First Edition
Course Textbook for CORRECTIVE EXERCISE SPECIALIST
Course Textbook for CORRECTIVE EXERCISE SPECIALIST

International Sports Sciences Association
1015 Mark Avenue • Carpinteria, CA 93013
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ISSAonline.com
CORRECTIVE EXERCISE
Chad Waterbury, DPT

Corrective Exercise: A Comprehensive Guide to Corrective Movement Training (Edition 1)
Official course text for: International Sports Sciences Association’s Corrective Exercise Specialist Course
10 9 8 7 6
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Published by the International Sports Sciences Association, Carpinteria, CA 93013.
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About the Author | iii
ABOUT THE AUTHOR

Chad Waterbury is a graduate of the nation’s #1 ranked Doctor of Physical Therapy
(DPT) program at the University of Southern California (USC). Chad is a physical
therapist, neurophysiologist, and author whose unique training methods are used by a
wide range of athletes, bodybuilders, figure models, and fitness enthusiasts of all ages
and from all walks of life.
Chad was the director of strength and conditioning at the Rickson Gracie Interna-
tional Jiu Jitsu Center in West Los Angeles and now works with professional athletes,
celebrities and non-athletes one-on-one. Chad is the author of Huge in a Hurry and
Muscle Revolution and contributes to many publications such as Men’s Health, Men’s
Fitness, Fight! and T Nation.
Chad has a master’s degree in physiology from the University of Arizona, where his
focus on the neurophysiology of human movement and performance led him to make
radical changes in the way he trains competitive athletes as well as nonathletic clients.
His workouts are now shorter and faster, producing superior results in strength,
power, and muscular development, while at the same time inducing less fatigue and
allowing for shorter recovery periods between workouts.

CONTENTS
Introduction: What is Corrective Exercise? p.1
SECTION ONE: CORRECTIVE EXERCISE SCIENCE, p.9

1 Skeletal System, p.11
2 Muscle and Fascia, p.25
3 The Nervous System, p.43
4 Joint Actions, p.61
5 Movement, p.81
SECTION TWO: CORRECTIVE EXERCISE PRACTICE, p.93

6 Preparing for the Client, p.95
7 Create a Just Right Challenge, p.113
8 Perform a Single-Joint Movement Analysis, p.121
9 Perform an Upper Body Multi-Joint Movement Analysis, p.135
10 Perform a Lower Body Multi-Joint Movement Analysis, p.155
11 Restore Structural Alignment and Stability, p.173
12 Restore Mobility through Stability, p.185
13 Soft Tissue Assessments and Correctives, p.209
REFERENCES, p.239
GLOSSARY, p.248
Corrective Exercise
TOPICS COVERED IN THIS UNIT
Plato Was Right

Benefits of Corrective Exercise
Improve Performance
Restore Performance
Reduce Injury Risk
Target Audience of this Course
Health-Care Professionals
Certified Personal Trainers
Corrective Exercise Defined
Final Thoughts
INTRODUCTION
WHAT IS CORRECTIVE EXERCISE?

2 | Introduction
What You’ll Learn

In this unit, you’ll learn how important both posture and exercise are for optimal health. You will also learn
what has caused the surge in movement and postural dysfunctions over the last decade. Then we’ll cover
the three ways that corrective exercise can improve your client’s life or sport. Finally, we will wrap up by
outlining the perils of doing too little or too much exercise. By the end of this section, you should have a
clear understanding of the necessity and benefits of corrective exercise.
PLATO WAS RIGHT

I started working as a personal trainer in 1997, 18 years before I entered the doctor of
physical therapy (DPT) program at the University of Southern California. At the time,
Personal trainer: A person there was a relatively clear separation between the roles of a personal trainer and
who instructs and prescribes those of a physical therapist.
exercise.
A personal trainer helped people lose fat, gain strength, and build muscle (not always
Physical therapist: A licensed
in that order), whereas the primary job of a physical therapist was to help patients
health-care professional who
helps patients reduce pain, overcome some type of physical dysfunction. It might be an acute injury, like a torn
improve mobility, and enhance rotator cuff, or a chronic problem, like low back pain. But whatever it was, it was not
movement patterns. something that anyone expected a personal trainer to understand, much less treat.
Rotator cuff: A group of However, the line between the
tendons and four muscles that two professions has since blurred,
attach the upper arm to the
shoulder blade.
thanks to a dichotomous shift in
activity levels that I believe began
in the mid-2000s.
We start with the fact that many
people are now more sedentary
throughout the day, which is one
Risk factor: Any of the biggest risk factors for poor
physical, psychological, or health. Inactivity is exacerbated
environmental factor that can by the fact that most people are
increase a person’s likelihood of
developing an injury or disease.
doing things that encourage poor
posture. Indeed, these days it is
Posture: The position of a common for people to spend hours
person’s body while standing,
sitting, or moving.
throughout the day with a rounded
spine, anteriorly rotated shoul-
Forward head posture: ders, and a forward head posture,
An anterior positioning of the whether they’re sitting at a desk or
cervical spine. texting on a smartphone.
The average head weighs about
12 pounds. The soft tissues of the
neck are typically well suited to
stabilizing and balancing that load
when it’s positioned directly above
the shoulders in what we consider
“ideal” posture. However, for each Figure I.1. Typical posture with a smart-
inch the head moves forward, the phone. This posture results in excessive stress to
supporting muscles must control the neck, spine, and shoulder joints.
Corrective Exercise
What Is Corrective Exercise? | 3
an additional 10 pounds of weight. When your head is angled down 45 degrees—a Vital capacity: The maximum
common position while texting or working on a laptop—the load on the neck may be amount of air that can be
exhaled after a maximum
as much as 42 pounds. Not only does this strain the neck muscles, but it also can de-
inhalation.
crease your lung’s vital capacity by 30%. Chronic forward head posture can increase
curvature of the thoracic spine (i.e., thoracic kyphosis), which can increase mortality Thoracic kyphosis: An
abnormal forward curvature of
rate by 144% in older populations. Thoracic kyphosis can also increase the compres-
the thoracic spine.
sive loads on the intervertebral discs throughout the lower half of the spine.
Mortality rate: The number
Simultaneously, a significant increase in the number of people who engage in high-in- of deaths within a specific
tensity exercise has occurred. This can include individual workouts focused on population of people.
powerlifting; preparing for an extreme challenge such as a marathon, triathlon, or Intervertebral disc: The
adventure race; or participating in group classes supervised by someone with minimal shock-absorbing, gel-filled
training and coaching experience. Many of the individuals in any of these circum- structure between each
stances are unprepared for these extreme challenges—because of a lack of fitness, poor vertebra.
movement quality, or inadequate instruction in specific exercises like the powerlifts High-intensity exercise: A
and Olympic lifts. form of exercise that requires a
large percentage of a person’s
People are generally more sedentary than ever, yet when they do move, they often physical power.
perform workouts beyond their strength, mobility, and motor-control capacity. The
convergence of these opposite ends of the fitness spectrum creates a large population Powerlifting: A strength
sport that requires a person
of people with movement and postural dysfunctions that we rarely saw prior to the to lift the largest load possible
21st century. for one repetition in the squat,
deadlift, and bench press.
When one of them first experiences a problem, whether it’s knee pain or a nagging
discomfort in the shoulder, he or she will rarely make an appointment with a physical Movement: A physical motion
therapist or physiatrist. Instead, this person will go to a regularly scheduled workout occurring at one or more joints
that is influenced by mobility,
and tell the trainer about the new problem. In my experience, it plays out something
stability, posture, and motor
like this: “My shoulder hurts when I lift my arm overhead. What can we do to help it?” control.
In other circumstances, the trainer will observe a client’s physical dysfunction before Olympic lifts: The snatch and
the client even realizes something is wrong. the clean and jerk.
That’s why I believe it’s essential for trainers to learn how to identify problems and to Strength: The maximal force
develop the knowledge and skills to provide solutions. I say this knowing that some that a muscle or muscle group
can generate.
physical therapists, chiropractors, and medical doctors disagree with this sentiment.
After all, they have spent $100,000 or more to earn the degree and license that allows Mobility: The ability to move
them to lawfully treat painful joints and bulging discs. freely through a normal range
of motion using minimal effort.
However, after two decades of training clients from all walks of life, I can say this
Motor control: The process
with utmost certainty: Many physical problems do not require the intervention of a li- of activating and coordinating
censed clinician. The gym is often the best place to correct movement, eliminate pain, muscles during movement.
and restore performance, with no clinic or insurance copayment required.
Physiatrist: A physician who
Of course, some physical dysfunctions should only be treated by a qualified clinician, specializes in restoring normal
and I’ll tell you how to identify the symptoms in Section Two of this course. Knowing function to the bones, muscle,
and nervous system.
what you can’t do as a trainer—especially what you should never attempt—is just as
important as is being able to recognize, assess, and correct the more common move- Chiropractor: A licensed
ment flaws and structural imbalances. My point is that a certified personal trainer can clinician trained to restore
interactions between the spine
bridge the gap between simple, straightforward fitness training and more complex
and nervous system.
physical therapy offered by a health-care professional. Certified personal trainers can
thus be the first line of defense against rising health-care costs. Medical doctor: A physician
who specializes in treating
As noted, movement and postural dysfunctions are more common than ever, and this disease and injury with
trend has created a large and growing demand for Corrective Exercise Specialists. That medicine.
is, an increased need for trainers and therapists who know how to recognize these
problems and to correct them using the latest evidence-based interventions has arisen.
Plato was right: necessity is the mother of invention.

4 | Introduction
Movement dysfunction: The

faulty execution of an exercise BENEFITS OF CORRECTIVE EXERCISE
or multiple-joint movement Given the widespread increase in movement dysfunctions, muscle imbalances, and
due to a lack of mobility,
joint aches that afflict both active and sedentary populations, corrective exercise is a
stability, posture, and/or motor
control. necessary tool that seeks to help your clients achieve better results in their training
and to move without restrictions throughout the day. You can deliver three primary
Muscle imbalance: When one
benefits to clients once you become a Corrective Exercise Specialist.
muscle is stronger and/or stiffer
than is the muscle that opposes
its actions.
IMPROVE PERFORMANCE
The reason I entered a DPT program was to enhance my ability to identify and treat
movement disorders. Before I enrolled in the program, many of my clients were pro-
fessional athletes who wanted to take their strength, speed, or endurance to a higher
level.
When I assessed these athletes, I frequently discovered muscle weakness, joint stiff-
ness, or poor motor control—all dysfunctions that prevented my clients from achiev-
ing their performance goals. It was frustrating to realize I sometimes did not have the
knowledge or skills to make the necessary corrections. The more I learned, and the
more experience I accumulated, the better I became at helping my athletes. You’ll be
able to do the same with your own athletes and clients with the information in this
course.
RESTORE PERFORMANCE
Sometimes the goal is to help a client regain strength or to return to a previous level of
occupational performance. Suppose for example that your client is a 40-year-old male
construction worker who hangs drywall for hours each day. He’s not concerned with
how much weight he can add to his bench press. He just wants to be able to do his job
without shoulder pain. Or imagine a dentist who spends hours a day bent over exam-
ining the teeth of his or her patients. The only goal is to get through the day without
experiencing low backaches.
Sometimes your client will be an athlete whose goal is to perform without discomfort
or movement restrictions. If that athlete is already at the top of his or her game, your
job might be to help this person return to a previous level of performance, assuming
the athlete’s dysfunction does not require a medical intervention.
REDUCE INJURY RISK

In explosive, chaotic sports such as basketball, football, soccer, and mixed martial arts
(MMA), it’s impossible for any athlete to always move with perfect body mechanics.
And even if possible, he or she still wouldn’t be able to control when or where contact
with an opponent will be made. A wide receiver who takes a powerful medial hit to
Anterior cruciate ligament his knee just as he plants his foot is likely to suffer a torn anterior cruciate ligament
(ACL): A ligament that attaches (ACL) no matter how beautiful his stride may have been in the moment before the
on the femur and tibia that tackle.
resists excessive motion at the
knee joint. The same applies to the ordinary world that we all must navigate. Sidewalks can be icy.
Stairs can get slippery. Someone can accidentally bump into you at your most vulnera-
ble moment. The list of unpredictable events is endless.
Corrective Exercise
No trainer can make his or her client injury-proof. No amount of training or correc-
tive exercise can offset the chaotic, unpredictable events of life and sports. But when
the client’s muscles and joints have sufficient strength and mobility, and when the
nervous system can precisely control muscle activation, the client has a more durable Durable body: A body that
body, which is the best defense against injury. That’s what you can control and what is able to withstand wear or
you should strive to achieve in your training sessions. damage.
TARGET AUDIENCE OF THIS COURSE

This course is designed to teach you, the fitness professional, how to identify and
correct common muscular, neural, and soft-tissue problems related to movement.
The course’s goal is to improve the coaching and training guidance given by everyone
from chiropractors to certified personal trainers.
How you use this information will depend on your professional status. Thus if you’re a
licensed clinician, and qualified to put your hands on a client, you can use corrective
exercise as an adjunct to the manual therapies you provide to manipulate joints and
treat soft tissue injuries.
However, many of you taking this course are not licensed and qualified clinicians. For
you, this course teaches you to provide “hands-off” corrective exercise by visually as-
sessing movements and positions. If the motion or posture is faulty or compromised,
you’ll learn to employ corrective actions, either through movement retraining or soft Soft tissue mobilization:
tissue mobilization without hands-on corrections. This strategy is the foundation of a The act of removing restrictions
Corrective Exercise Specialist’s practice. from muscles and connective
tissues.
Research has mounted over the past 20 years that demonstrates the value of a hands-
off approach using exercise and mobility training. This is especially true for the ev-
eryday back, knee, shoulder, and neck pain your clients experience and hope that you
can address. This course is designed to help certified personal trainers and health-care
professionals identify and correct those problems.
HEALTH-CARE PROFESSIONALS
A health-care professional is someone who is trained and qualified to use a hands-on
approach with patients recovering from acute injuries or experiencing chronic pain.
This category includes chiropractors, physical therapists, and athletic trainers, all Athletic trainer: A health-
who have a license that allows them to put their hands on a patient. care professional trained to
help prevent and treat physical
injuries.
CERTIFIED PERSONAL TRAINERS
A certified personal trainer is someone who is only qualified to teach exercises,
whether it’s resistance training, stretching, or something in between. Because certified
personal trainers are not health-care professionals, they should minimize any hands-
on therapy and limit their coaching to verbal cues and minimal tactile feedback.
Importantly, a certified personal trainer is not qualified to work with clients who have
pain. All clients with pain should be referred to a health-care professional before you
employ any of the guidelines and techniques outlined in this course.

6 | Introduction
CORRECTIVE EXERCISE DEFINED

The goal of corrective exercise is to improve movement to enrich a person’s life or
sport. It seeks to identify the complex factors associated with poor movement patterns
and correct them with the simplest methods possible. Sometimes you can help a client
move better with nothing more than hands-off soft-tissue mobilizations on a few
overly stiff muscles. The client will be “fixed” within one or two sessions, and you’ll
look like a genius.
Often, though, the solution will require a multifaceted approach that includes static and
dynamic assessments, soft-tissue mobilizations, corrective exercises, and reassessments
over the course of months. That’s how long it takes to make permanent changes within
Motor program: A relatively tissues and motor programs. Nevertheless, when you master the information and tech-
automatic movement pattern niques outlined in this course, you will have the skills to help your clients move better
produced by the nervous within the first session, no matter how long it takes to fix the underlying issues.
system.
One problem you’ll encounter is your clients’ belief that rest is the answer to just
about any physical problem they experience, whether it’s a sprained ankle or chronic
back pain. Sometimes a few days off can indeed help, especially when walking itself is
contraindicated, as it would be with the aforementioned ankle sprain. The problem,
however, is that doing too little can be just as dangerous as doing too much.
Inactivity also has an opportunity cost. Current research demonstrates that challeng-
ing corrective exercises, when performed within a training program, create long-last-
Synapse: The area of ing changes to the structures and synapses of the brain and nervous system.
communication between two
neurons or between a neuron
and muscle.
Nervous system: The brain,
spinal cord, and associated
nerves.
Injury Risk
none moderate strenuous
Exercise Activity
Figure I.2. Relationship between injury risk and exercise. This hypothetical model
indicates a steep increase in risk with no exercise and with strenuous activity. (Adapted
from Campello et al., Scand J Med Sci Sports, 1996)
Corrective Exercise
FINAL THOUGHTS
Trainers and health-care professionals are continually reminded of the astound-
ing complexity of human movement. The more we learn, through newly published
research and the empirical evidence of our own practice, the more we appreciate how Empirical evidence: The
much we still do not know. A corrective exercise course cannot possibly cover every knowledge a person acquires
movement dysfunction within the human body. However, you will learn how to iden- through observation and
experience.
tify and correct the most common dysfunctions, the ones you’re most likely to see in
clients from all walks of life. These issues include problems in the feet, ankles, knees, Functional movement: A
hips, spine, shoulders, and neck. The goal is to restore your clients’ functional, pain- movement that is useful for its
intended purpose.
free movement patterns and, by extension, their quality of life.
Quality of life: The general
This brings us back to where we started this introduction. Your clients live in a world well-being of an individual.
that discourages movement and encourages poor posture. But when they do decide
to move, they often engage in popular but ill-advised exercise programs that include
high-intensity exercises and training systems far beyond their current fitness level and
movement competency.
In reality, if you’re a personal trainer, the vast majority of people you work with will
have some type of movement dysfunction. The problem could be caused by weakness,
stiffness, poor motor control, or any combination of the three. That’s why you need to
learn and develop the skills necessary to identify and correct these issues.
Research supports corrective exercise as an effective alternative to surgery for cor-
recting movement-related problems. In fact, sometimes participating in a corrective
exercise program is more effective. Even if you aren’t qualified to perform hands-on
treatments, the information in this course will provide you with many of the same
tools used by the world’s most successful rehabilitation professionals.

8 | Introduction
Summary
1. These days, people are more sedentary than ever and often perform activities
that encourage poor posture.
2. When people do exercise, it’s common for them to perform workouts beyond
their functional capacity.
3. Movement and postural dysfunctions are more common than in the past.
4. The quality of movement is affected by stability, mobility, posture, and motor
control.
5. Certified personal trainers will often encounter clients who possess one or
more physical dysfunctions that can be corrected without the intervention of
a health-care professional.
6. Corrective exercise strives to improve performance, restore performance, and
reduce the risk of injury.
7. Recent research indicates that performing challenging movements and exer-
cises can change the brain and other nervous system structures.
Corrective Exercise
SECTION ONE
Corrective Exercise Science
Skeletal System, p.11
Muscle and Fascia, p.25
The Nervous System, p.43
Joint Actions, p.61
Movement, p.81
Corrective Exercise
The Human Skeleton

Skeletal Function
Skeletal Structure
Bone Function
Bone Structure
Ligament Structure and Function
Ligament Creep, Laxity and Tears
Joint Capsule
Joints
UNIT 1
SKELETAL SYSTEM
12 | Unit 1
What You’ll Learn

In this unit, you’ll receive an overview of the human skeletal system, how it’s designed, and how it func-
tions. This structure is important to understand because it forms the framework of your body. You’ll learn
how the functions of the skeletal system work together and how they can compete with one another.
Additionally, you’ll learn how the bones and tissues that make up the skeletal system can grow, repair and
remodel. Finally, we’ll wrap up the unit by covering the major joints within the body that can become prob-
lematic in active individuals. Therefore, at the close of this unit, you should understand how the skeletal
system functions for movement, protection, and health.
THE HUMAN SKELETON

The framework of the body is made up of 206 bones, associated cartilages and joints
that form the human skeleton. It is easy to think of bone as a relatively lifeless tissue,
Organ system: A group of but that’s not the case. The skeleton is a living organ system that can grow, repair and
organs and tissues working remodel.
together to perform specific
functions.
SKELETAL FUNCTION
The skeletal system serves many roles that we require for optimum health, movement
and protection. The skeletal system has five primary functions.
• Movement: Bones come together to form joints that allow motion.
• Structure/support: The skeleton provides the structure and support we
need for movement. This is one factor that separates humans from amoeba
or jellyfish.
• Protection: Our essential organs such as the brain, spinal cord, heart and
lungs are protected by the skeleton.
• Calcium storehouse: Calcium and other minerals are stored within bone.
• Blood cell production: Marrow within bone produces blood.
Importantly, these five functions compete with one another. For example, movement
is best accomplished with a lighter skeleton; however, for bones to be strong they must
also be relatively heavy. If calcium is taken out of bone to provide nutrients to the
nervous system or muscles, bones can become weaker and reduce the protective role
the skeleton must play. Nevertheless, the bones that form the skeletal system can adapt
to those competing demands.
Corrective Exercise
Skeletal System | 13
Figure 1.1. Skeletal system of the human body. The front and back of the human
skeleton with the left side showing fibrous capsules between joints.
SKELETAL STRUCTURE
The bones that make up the human framework can be divided into the axial skeleton Axial skeleton: The bones
and appendicular skeleton. The axial skeleton is comprised of 80 bones from the of the skull, vertebral column,
sternum, ribcage and sacrum.
skull, vertebral column, ribcage, sternum and sacrum. The remaining 126 bones of the
upper and lower extremities form the appendicular skeleton. Appendicular skeleton: The
bones of the upper and lower
The size and shape of human bones can vary greatly, depending on role they play. The extremities.
largest bone in the body is the femur and it’s approximately 18.9 inches long and 0.92
inches in diameter in an average male. The smallest bone is the stapes, located within
the ear, and it’s approximately 3 × 2.5 millimeters. Based on their shape, bones are
classified as long, flat, short, irregular or sesamoid.
The vertebral column, sometimes referred to as the spinal column, is an especial-
ly important structure within the skeletal system. It consists of five regions, if we
picture it from the base of your skull down to the tailbone. The cervical region is
made up of 7 vertebrae, the thoracic region is 12 vertebrae, and the lumbar region
is 5 vertebrae. The sacrum consists of 5 vertebrae, and the coccyx has 4; however,
these vertebrae are fused together and don’t move. That means the vertebral column
is composed of 33 vertebrae, but only 24 can move independently ranging from the
first cervical vertebrae down to the last lumbar vertebrae. Movement between verte-
brae is made possible by facet joints, which are the spaces between the bony protru-
sions of two adjacent vertebrae.

14 | Unit 1
BONE FUNCTION
If you’ve ever held a human bone in your hand in anatomy class, you might think that
bones are generally light, brittle and easy to break. However, bones within a living
human are heavier, stronger and more durable. That’s because living bones are full of
vessels and nutrients that make them adaptable organs capable of growth, repair and
remodeling. In this section we’ll cover each of those functions.
Growth
All bones are in the form of cartilage before birth. After a person is born, and
throughout development, the softer cartilage is slowly replaced by harder bone
Ossification: The hardening through a processed called ossification. Therefore, because adolescents have softer
process of bones during bones, it’s more difficult for a four-year old to break a bone than it is for an adult. This
development. hardening process continues until a person reaches full development at 18-25 years.
Figure 1.2. Axial skeleton and appendicular skeleton. A) Axial skeleton and B) Appendicular skeleton.
Corrective Exercise
Bones not only get harder during devel-

opment, they also grow longer. The length
of bone increases at the epiphyseal plate Epiphyseal plate: The
where cartilage cells divide and push the location of bone growth near
newly formed cells toward the shaft of the the end of immature bones.
bone. Eventually, the cartilage cells become Epiphyseal line: A line of
mature bone cells to increase the bone’s cartilage near the end of
length. After a person reaches adulthood, mature long bones.
the epiphyseal plate closes and forms an
epiphyseal line. At this point, it’s not pos-
sible for the bone to grow longer. Each long
bone (a bone that is longer than it is wide)
within the appendicular skeleton has an
epiphyseal line at each end
Figure 1.3. Epiphyseal line. The two epi-

physeal lines of the right femur are shown.
The epiphyseal line closes in adulthood and
prevents the bone from elongating.
Repair
Bones can repair various types of damage, whether that damage is from a severe break
(macrodamage) or mild tears within a bone’s matrix that can’t be felt (microdamage).
When a bone breaks into two or more pieces, the painful macrodamage often requires
a medical intervention with a cast or screws that allow the bone to heal back to its
original form. The healing process takes anywhere from 1 to 3 months, depending on
the location of the break and the amount of blood supply it receives. In many cases,
a broken bone can heal stronger than it was before the break because the body will
produce extra bone at the site of damage.
Microdamage results from microscopic tears within the bone’s matrix. It occurs as a
normal daily process during activities such as walking, running, or lifting weights.
All bone is replaced every few years from the accumulation of the microdamage and
repair process. Stress fracture: A thin bone
crack due to an accumulation
Normally, microdamage isn’t felt. However, when people drastically increase their of microdamage.
activity levels to the point where the balance between microdamage and repair can’t
Remodeling: When a bone
be maintained, a stress fracture can occur. Because most stress fractures can’t be seen
changes shape either by
with a normal X-ray, a computed tomography (CT) scan is usually required to confirm increasing or decreasing its
the diagnosis. diameter.
Deposition: Adding new bone
Remodeling with osteoblasts.
Resorption: Removing bone
When a bone changes shape it’s known as remodeling. Bone can grow or shrink de- with osteoclasts.
pending on the stress, or lack of stress, that’s placed on it. For example, when a person
Wolff’s Law: A theory
lifts relatively heavy weights, the body responds by laying down extra bone to thicken developed by German surgeon,
the diameter in a process called deposition. On the other hand, if a person is bedrid- Julis Wolff, which states that
den or paralyzed the body can decrease the bone’s diameter through resorption. This bone will adapt to the loads
theory of bone adaptation is known as Wolff’s Law. placed upon it.

16 | Unit 1
TRAIN YOUR BRAIN: Can a poor diet weaken your bones?

Absolutely. Bones are living tissues that require nutrients for growth and
maintenance. Therefore, a diet that’s deficient in protein, vitamin C, calcium,
or vitamin D can all weaken the bones and potentially lead to disease. Rickets
is a bone disease that occurs from a Vitamin D deficiency.
Osteoclasts: Cells responsible Bones rely on three cell types during remodeling. After bone is damaged, osteoclasts
for bone resorption. chew up the impaired bone tissue (resorption). Importantly, osteoclasts are also re-
Osteoblasts: Cells responsible sponsible for the loss of bone when a person is inactive due to injury or disease. Next,
for bone deposition. if there’s a stimulus for growth, osteoblasts come into play and lay down new bone
Osteocytes: Mature bone cells (deposition). Finally, these osteoblasts transform into osteocytes, or mature bone cells.
that maintain a bone’s matrix. Importantly, bone remodeling occurs throughout life. When a person is younger,
remodeling happens at a faster rate. As a person grows older, the remodeling process
typically slows, but continues nonetheless.
BONE STRUCTURE
Bones are rich with blood vessels, cells, and nerves that allow it to perform the
Periosteum: The outer functions we just covered. The periosteum and endosteum are connective tissues
covering of bone where that cover long bones and they contain the cells responsible for growth, repair, and
osteoblasts are located. remodeling. The periosteum covers the outside of bones while the endosteum covers
Endosteum: Connective tissue the inner lining of bones and the medullary cavity.
that covers the inside of bone
and medullary cavity. Before we discuss blood supply and nerves, let’s go over the two primary types of bone
tissue. The structure of bone is not a uniformly hard material as it might seem if you
Medullary cavity: Central
held it in your hand. Indeed, bone consists of two different materials: the outer layer of
cavity of the bone shaft where
marrow is stored. compact bone and inner portion of spongy bone.
Compact bone: Hard outer • Compact (cortical) bone: This hard outer layer of dense tissue is strong,
layer of dense bone tissue. solid, and resistant to bending. Approximately 80% of a person’s skeletal
mass comes from compact bone.
Spongy bone: Porous, light
inner layer of bone tissue. • Spongy (trabecular or cancellous) bone: Light, porous inner bone ma-
terial that forms a latticework of bony structures called trabeculae. Osteopo-
Osteoporosis: Bone disease rosis mainly affects spongy bone.
characterized by a loss in bone
mass and density. The combination of compact and spongy materials is what gives bone its strength
while still being relatively lightweight. If bones were made entirely of compact materi-
al, they would be too heavy for efficient movement. And spongy bone alone wouldn’t
give bones the strength they need.
Corrective Exercise
Bony Protrusions
Various bony protrusions through- Bony protrusion: An
out the skeleton contribute to each eminence on the surface of
bone’s unique shape. For example, bones that increase strength
and contact area for muscle
the head of the femur contains two attachments.
primary protrusions: greater tro-
chanter and lesser trochanter. A
trochanter, or protrusion, is the site
of muscle attachment. The anatomi-
cal purposes of areas of bone swelling
are to strengthen the bone in that
region and provide a greater contact
surface for the muscles to attach.
Throughout the skeleton, these
areas of increased bone formation
go by different names depending on
the bone on which they reside. For
example, the upper humerus has
two protrusions, greater tuberosity
and lesser tuberosity, that serve as
attachment points for the rotator
cuff muscles. At the lower aspect of
the humerus, the protrusions by the Figure 1.4. Bony protrusions. Various areas of
elbow are called epicondyles. Moving increased bone formation that provide stronger,
further down the body, the protru- larger attachment points for muscles.
sions of the upper femur are known
as trochanters.
Blood and Nerve Supply

Even though bones are not actively growing longer in adults, they still require a con-
stant blood supply. Bone receives its blood from three sources: periosteal vessels nutri-
ent arteries, and epiphyseal vessels. These three vessels ensure that blood is available to
all areas of the bone, from the innermost spongy bone to the outer compact bone.
The functional unit of compact bone consists of osteons (Haversian systems). These Osteons (Haversian
vertically stacked units each contain a nerve and one or two blood vessels. systems): Functional units of
compact bone.
Trabeculae are functional units of spongy bone that consist of a network of plates and
Trabeculae: Functional units
rods. Because spongy bone is less dense than compact bone, it contains a richer source of spongy bone.
of blood vessels.
Not only do bones have a rich blood supply, they can also sense pain. One primary
source of bone pain is from the periosteum, the outer covering of bone that contains
pain- sensitive nerve endings. Therefore, we’ll now discuss the important connective
tissue within joints that diminish the pain signal.

18 | Unit 1
Cartilage Structure and Function

Articular cartilage is a connective tissue covering at the end of long bones that pro-
vides smooth bone contact in freely moving joints. When the cartilage is degraded or
lost from overuse or aging, bone-on-bone contact results in pain and stiffness at the
Osteoarthritis: Bone-on-bone joint. Because osteoarthritis is a common problem with athletes and older popula-
contact that results in joint pain tions, a thorough understanding of the structure and function of cartilage is import-
and stiffness due to a loss of ant for any trainer or therapist.
articular cartilage.
As mentioned earlier, bones can sense pain. The periosteum and endosteum coverings
Nociceptors: Pain sensitive of bone contain pain sensitive nerve endings called nociceptors. Because joint motion
nerve endings. shouldn’t be painful, articular cartilage covers the ends of moving bones to block the
pain signal and reduce compressive stress.
Importantly, articular cartilage is just one form of cartilage in the skeletal system.
Collectively, cartilage is a type of connective tissue made up of dense collagen fibers
embedded in a firm, gelatinous substance that gives it the consistency of plastic to
provide tensile strength while still being more pliable than bone. Let’s cover the three
types of cartilage.
• Hyaline cartilage: This deform-
able but elastic type of cartilage
is the most widespread form in
the body. It’s located in the nose,
trachea, larynx, bronchi; at the
end ribs, and at the end of bones
of many freely moving joints in
the form of articular cartilage.
• Fibrocartilage: This tough
tissue is located in the interverte-
bral discs and at the insertions of
tendons and ligaments.
• Elastic cartilage: As the name
implies, this is the most pliable
form of cartilage. It gives shape
to the external ear, the auditory
tube of the middle ear and the
epiglottis.
In addition to being a barrier to pain,
cartilage also plays an important role in
bone development. Indeed, most bones
begin as cartilage, and then the carti-
lage ossifies as you age to become the
hardest connective tissue in the body.
A newborn baby has the softest bones
since it contains the greatest percentage
of cartilage. Throughout development,
the bones become progressively harder
as cartilage is replaced with bone. Once
a person reaches full development, the
only remaining cartilage in bone is
articular cartilage to protect bone-on-
bone contact, along with an epiphyseal
line near the joint. Figure 1.5. Hyaline and fibrocartilage.
Corrective Exercise
However, not all cartilage is gone by the time a person reaches adulthood. Indeed,
cartilage is part of the adult skeleton and it provides important roles at specific joints.
For example, the knee joint contains hyaline cartilage to protect against painful bone-
on-bone contact. Unlike bone, cartilage doesn’t contain pain-signaling nerve endings.
And since hyaline cartilage is deformable, it reduces compressive stress at the joint.
When the hyaline cartilage is lost from aging, compressive stress, or disease, the joint
space narrows and unprotected bones can contact each other. Osteoarthritis occurs
when the loss of cartilage in the joint spaces results in pain and stiffness from bone-
on-bone contact. It most commonly occurs in the knees, hands, hips, and spine.
Unlike other types of tissues, cartilage doesn’t have its own blood supply. Therefore,
it’s very slow to heal and the body usually can’t replace it when it’s lost.
Now that we’ve covered the skeleton, bones, and cartilage, let’s finish with the connec-
tive tissue that holds it all together: ligaments. Elastin: An elastic protein
found in connective tissue that
gives the tissue extensibility.
LIGAMENT STRUCTURE AND FUNCTION Varus: An abnormal joint
Ligaments are 70% water with the remaining 30% made-up of dense, fibrous collage- movement away from the
nous tissue. The strength of a ligament is primarily derived from type I collagen fibers midline of the body. At the
that resist strain. Ligaments also possess a little bit of elastin, an important elastic pro- knee joint, varus can result in
“bow-leggedness.”
tein found in all connective tissue that allows those tissues to regain its original shape.
Joint capsule: A thin, strong
Without elastin, all connective tissues would stay deformed after being stretched. Skin layer of connective tissue that
also contains elastin, which allows it to bounce back after you pinch it. contains synovial fluid in freely
moving joints.
If you’ve ever sprained your ankle, you unintentionally learned the important role that
ligaments play. When an unexpected movement results in torques that are beyond a Valgus: An abnormal joint
movement toward the midline
ligament’s tensile strength, damage ensues. Nevertheless, the roles of ligaments go be-
of the body. At the knee joint,
yond resisting damage. Ligaments are responsible for attaching bone to bone, passively valgus can result in “knock
stabilizing and guiding a joint, resisting excess movement at a joint and allowing the knees.”
brain to sense the position of the joint in space (covered in Unit 4).
The location of a ligament can be extrinsic, intrin-
sic or capsular with respect to the joints. As the
knee joint contains all three types of ligaments,
let’s go over each form and how each contribute to
knee function.
• Extrinsic ligament: This type of ligament
is located on the outside of the joint. An
example is the lateral collateral ligament
(LCL) on the lateral side of the knee to resist
varus stress.
• Intrinsic ligament: This ligament is
located inside the joint. The anterior cruci-
ate ligament (ACL) and posterior cruciate
ligament (PCL) are situated inside the knee
joint to resist anterior and posterior move-
ment of the tibia, respectively.
• Capsular ligament: This type of ligament
is continuous with the joint capsule. The
medial collateral ligament (MCL) is a capsu- Figure 1.6. Ligaments of the right knee joint. The knee joint
lar ligament that resists valgus stress at the contains three types of ligaments: extrinsic (LCL), intrinsic (ACL, PCL)
knee by keeping the joint approximated. and capsular (MCL).

20 | Unit 1
TRAIN YOUR BRAIN:

Will weight training stunt a child’s growth?
According to George Salem, Ph.D., associate professor at the University
of Southern California’s Division for Biokinesiology and Physical Therapy,
“There’s absolutely no evidence that weight training will stunt a child’s
growth. When you see short athletes in gymnastics or weight training, it’s
due to genetics.” In other words, the young athletes who grew taller didn’t
make the cut.
Importantly, ligaments aren’t just passive tissues that only resist strain. Indeed,
part of their function is driven by nerve innervation. The ligaments within your
joints are connected to the central nervous system (CNS) through reflex pathways to
communicate strain to guard against injury. And during movement, the free nerve
endings detect joint position, speed and direction as part of the proprioceptive sen-
sory feedback circuit.
LIGAMENT CREEP, LAXITY AND TEARS

A ligament is a viscoelastic material that can return to its original shape when
Creep: A temporary stretched. This allows the ligament to creep, a temporary stretch that isn’t harmful.
deformation of connective For example, if you bend over to touch your toes, ligaments within the spinal col-
tissue. umn will stretch. And when you stand up, the ligaments shorten and return to their
Laxity: A permanent original shape.
deformation of connective
tissue caused by excessive However, like all tissues in the body, ligaments have a limit to how much they can
stretching. stretch before damage occurs. When a ligament is stretched beyond its structural and
Tear: A partial or complete
functional ability, it can develop laxity or tear.
separation of a tissue due to a Laxity is a permanent structural deformation due to frequent stretching of a tissue at
stretch beyond its structural
its end-range of elasticity. Think of a rubber band that’s constantly over-stretched.
capacity.
Eventually that rubber band will take on a new, longer shape compared to its original
form. When a ligament has laxity, the joint becomes less stable (i.e., loose) and makes
a person more susceptible to joint dislocations and osteoarthritis.
A tear occurs when a tissue is stretched beyond its structural capacity. The tear can
be either partial or complete. A partial ligament tear can heal with rest, whereas a
complete tear usually requires surgery to repair. Ligaments have a limited capacity to
heal due to their low blood supply. Indeed, blood flow to ligaments is less than that of
muscle or bone, which is why it can take months or a year to completely heal.
JOINT CAPSULE
A joint capsule is a thin, strong layer of connective tissue that surrounds freely moving
Synovial membrane: A joints. Its strength primarily comes from type I collagen fibers, as is also the case with
thin layer of connective tissue
ligaments. Directly beneath the joint capsule is a thin layer of synovial membrane
beneath the joint capsule that
makes a lubricating fluid. that lubricates the joint and reduces friction during movement.
Corrective Exercise
Much like the ligaments we just covered, joint capsules also resist excess tension at the
joints. Importantly, joint capsules are innervated by nerves. Therefore, they can trigger
reflex contractions of the surrounding muscles to protect the joint from damage.
Figure 1.7. Joint capsule. The joint capsule at the left hip and knee.
TRAIN YOUR BRAIN: Think like a physical therapist.

What’s the number one risk factor for injury to any joint? A previous injury to
that joint. This fact is especially true for the ligaments as they have a limited
capacity to recover.
When a ligament heals from a partial or complete tear, the tissues aren’t as
strong as they originally were due to an accumulation of scar tissue. Because
scar tissue consists of abnormal collagen, poor cross-linking, and smaller
fibrils, it’s a weaker form of connective tissue. This means the ligament is
more susceptible to future tears. Therefore, extra care should be taken when
stretching or training a joint that endured a ligament injury.
And joint laxity caused by an overly stretched ligament can make a joint less
stable than it needs to be. Unfortunately, a loose ligament cannot regain its
original shape and become “tight” again. Therefore, muscles that surround a
loose joint should be sufficiently strong as they must also provide the stabiliz-
ing effect the loose ligament can no longer perform.

22 | Unit 1
JOINTS
The human body has 360 joints; however, for the purposes of this course there are only
16 that we’ll need to cover. These 16 joints are emphasized because they’re the most
problematic areas of articulation for most active individuals. Throughout this course
we’ll spend much more time covering the actions and functions of these joints. But for
now, we’ll start with the names and locations of the 16 joints.
Table 1.1
Joint Area of Articulation
sternoclavicular (SC) sternum and clavicle
acromioclavicular (AC) acromion process (scapula) and clavicle
glenohumeral (GH) glenoid fossa (scapula) and humerus
scapulothoracic region (pseudo joint) scapula and ribcage
humeroradial humerus and radius
humeroulnar humerus and ulna
radioulnar (proximal) radius and ulna (elbow region)
radioulnar (distal) radius and ulna (wrist region)
radiocarpal Radius and carpal bones
sacroiliac (SI) sacrum and ilium
hip femur and pelvis
patellofemoral patella and femur
tibiofemoral tibia and femur
tibiofibular tibia and fibula
talocrural talus and tibia
subtalar talus and calcaneus
TRAIN YOUR BRAIN: What does it mean to be double-jointed?

Ligaments are normally very taut around a joint. However, some people are
born with “loose ligaments” that allow the joints to move through a greater
range of motion than is normal. Even though it might seem cool to have ex-
cessive flexibility and appear “double-jointed,” loose ligaments make people
more susceptible to joint dislocations and osteoarthritis.
Corrective Exercise
Figure 1.8. Primary joints of the body. The figure depicts the most common joints
that can become problematic in active people.
As this unit ends and we’ve reviewed the structure and function of the skeletal system,
it’s important to keep in mind the context of this information. The physiology of bone
and connective tissue is an essential part of the human body’s framework so it can move,
grow, adapt and remodel. However, those structures can also be limiting factors.
Therefore, all the connective tissue components covered in this unit should be consid-
ered when you assess clients who demonstrate movement limitations and joint pain.

24 | Unit 1
Summary
1. The human skeleton is made up of 206 bones that can be divided into the axial
and appendicular skeletons.
2. There are five functions of the skeletal system: movement, structure/support,
protection, calcium storehouse and blood cell production.
3. Bones that make up the skeleton are living, adaptable tissues that can grow,
repair, and remodel.
4. Bones can be either compact or spongy, and the combination makes the skeleton
both strong and lightweight. The functional units of compact bone are osteons;
the functional units of spongy bone are trabeculae.
5. Three types of cartilage help support and protect bones: hyaline cartilage, fibro-
cartilage and elastic cartilage.
6. Ligaments are dense, collagenous tissues that hold bones together and resist
tensile stress.
7. The joint capsule is a fibrous connective tissue that surrounds articulating joints
and resists compressive stress.
Corrective Exercise
The Muscular System

Muscle Attachments
Muscle Actions
The Roles of Muscle
Skeletal Muscle Groups
Fascia
Muscle Charts
UNIT 2
MUSCLE AND FASCIA

26 | Unit 2
What You’ll Learn

In this unit, you’ll receive an overview of the muscular system, how it’s designed, and how it functions. The
muscular system provides the contractile forces that create movement at the joints we covered in Unit 1.
You’ll learn the structure and function of muscles along with their attachments. Then you will become edu-
cated about the importance of fascia and how it connects seemingly unrelated joints together. Finally, you’ll
learn the origins and insertions of the muscles that move all the major joints in the body. Therefore, at the
close of this unit, you should understand how the muscular system functions to drive movement.
Cardiac muscle: A type of

muscle tissue found only in the THE MUSCULAR SYSTEM
heart, responsible for pumping The muscular system is made up of approximately 650 muscles, depending on the
blood throughout the body.
source cited. The stapedius is the smallest muscle in the body, which makes sense
Smooth muscle: A type because it’s attached to the stapes, the smallest bone in the body. The gluteus max-
of muscle tissue that moves imus is the largest muscle, and not surprisingly, it’s also connected to the largest
internal organs, such as the
bone: the femur.
bowels, and vessels, such as the
artery walls. Muscles are categorized under three primary types: cardiac, smooth and skeletal.
Skeletal muscle: The Cardiac muscle makes up the walls of the heart to make it contract. Smooth muscle
contractile tissue that produces is located throughout the body in regions such as the walls of the intestines, uterus,
force in the human body. blood vessels and inner eye. Skeletal muscle is the contractile tissue that drives and
Origin: The attachment controls movement.
of a muscle closest to the
Because this course is primarily about movement, the information in this unit will
head when viewed from the
anatomical position. pertain to the actions of skeletal muscle. Therefore, for the remainder of this unit the
word “muscle” will relate specifically to “skeletal muscle.”
MUSCLE ATTACHMENTS
Virtually every muscle in the body has two attachment points
that correspond to two different bones. The locations of the
attachment points are described as an origin and insertion.
When a person is standing in the anatomical position (arms
hanging at the sides and palms facing forward), the origin is
the muscle attachment closest the head, and insertion is the at-
tachment closest to the feet. Each origin and insertion end of a
muscle belly connects to its respective bone through a tendon.
Tendon Structure and Function

The primary function of a tendon is to transfer force between
activated muscle and the bone where it inserts. The structure of
tendons is formed from dense connective tissue formed by an
abundance of type I collagen fibers that provide strength.
Tendons are similar to ligaments and joint capsules because
they all have a limited blood supply and low metabolism. Nev-
ertheless, the metabolism within a tendon can increase when
Figure 2.1. Origin and insertion. The origin and in-
sertion points for the anterior deltoid and biceps brachii. it’s physically loaded during movement and resistance training.
From the anatomical position as shown, the origin is That is one of the reasons why doctors now recommend exer-
closer to the head; the insertion is closer to the feet. cise sooner rather than later after an injury.
Corrective Exercise
Muscle and Fascia | 27
Skeletal Muscle Structure and Function Insertion: The attachment of a

muscle closest to the feet when
For muscle to jump into action, it must be activated by the nervous system, as we’ll viewed from the anatomical
position.
cover in Unit 4. For now, what’s important to understand is the effect that muscle
activation has on a joint. A joint can either move (i.e., rotate around its axis) or Tendon: A strong connective
remain static, depending on how much force the muscle produces. We’ll start by tissue made primarily of
collagen that connects muscle
covering the functional units that allow a muscle to contract and then discuss the
to bone.
muscle and joint interaction.
Type I collagen: A structural
Skeletal muscle is made up of bundles of muscle fibers. Each bundle is a fascicle and protein contained within a
is covered by a layer of connective tissue called perimysium. Within the fascicle is a tendon. Fascicle: A bundle of
collection of muscle fibers, and each muscle fiber is made up of smaller myofibrils. muscle fibers contained within
a skeletal muscle. Myofibril: A
The myofibril contains sarcomeres, the functional units that can make the muscle rod-like unit of a muscle cell
fiber shorten. Sarcomeres are lined up in series within the myofibril to form a rod-like made up of sarcomeres.
structure. In other words, if the myofibril were a yardstick, the sarcomeres would be Sarcomere: The functional
the inch markers. Each sarcomere can shorten only a miniscule distance; however, the unit of a skeletal muscle fiber.
combined effect of all sarcomeres shortening at the same time causes the entire muscle Myosin: The thick myofilament
to significantly shorten. contained within a sarcomere.
Actin: The thin myofilament
The sarcomeres shorten due to sliding of myosin and actin past one another. Impor- contained within a sarcomere.
tantly, this process can’t occur in the reverse order. In other words, when a muscle
is activated, it can only shorten—or more specifically—attempt to shorten, as we’ll
discuss next.
Figure 2.2. Skeletal muscle. Structural and functional components of muscle.

28 | Unit 2
MUSCLE ACTIONS
As we just covered, when a muscle is activated it is only capable of shortening. But
there are times when a muscle could lengthen, or remain in a static position, even
though the muscle fibers are attempting to shorten. It is common for people to refer
to the action a muscle produces as being a “contraction”; however, the word contrac-
tion can easily create confusion because it refers to “shortening.” Therefore, it’s more
appropriate to think of a muscle’s possible functions in terms of actions, not contrac-
tions. In other words, a muscle can perform three possible actions: shorten, lengthen
or remain static. Let’s cover the terms used to describe each of those actions.
Concentric action: An action • Concentric action: when an activated muscle shortens.
that occurs when an activated
muscle shortens. Eccentric • Eccentric action: when an activated muscle lengthens.
action: An action that occurs • Isometric action: when an activated muscle remains in a static position.
when an activated muscle
lengthens. Isometric action: Whether a muscle performs a
An action that occurs when an concentric, eccentric or isometric
activated muscle remains in a action depends on the relationship
static position.
between the pulling force it pro-
Pulling force: A force a duces and the resistance force it’s
muscle produces to shorten. trying to overcome.
Resistance force: An external
A concentric action occurs when
force that opposes the force a
muscle produces to shorten. the pulling force a muscle generates
Plantar fasciitis: A common is greater than the force applied by
cause of heel pain due to an resistance in the opposite direction.
irritation of the connective This causes the muscle to shorten.
tissue on the bottom of the An eccentric action occurs when the
foot.
pulling force is less than the resis-
tance force (i.e., muscle lengthens).
An isometric action occurs when a
muscle’s pulling force equals the op-
posing force produced by any type
of resistance (i.e., muscle length
remains constant). Remember, even
if a muscle action is either eccentric
or isometric, the muscle fibers are
attempting to shorten.Therefore,
the elbow flexors will lengthen even
though the brain is attempting to
pull the forearm up.
Now that we’ve covered the three
actions a muscle can produce, let’s
Figure 2.3. Eccentric action of elbow flex-
move on and discuss how mus- ors. The pulling force produced by the elbow
cles are categorized according to flexors is less than the downward resistance
movement. force produced by the dumbbell.
Corrective Exercise
THE ROLES OF MUSCLE

Most movements are driven by a collection of muscles, and each muscle is capable of
playing a different role. A muscle can function as an agonist, antagonist or synergist, Agonist: The muscle or muscle
depending on the movement. Let’s discuss what each of those terms mean. group most directly involved in
producing a movement.
Antagonist: One or more
Agonist muscles that have the opposite
action of a specific agonist.
An agonist is the muscle or muscle group most directly involved in producing a move-
ment. For example, the biceps brachii is the agonist for elbow flexion. And the tibialis Synergists: Muscles that work
together during movement.
anterior is the agonist for dorsiflexion at the ankle.
Antagonist
An antagonist is one or more muscles that have the opposite action of a specific ago-
nist. Because the triceps extends the elbow joint and the biceps brachii flexes the elbow
joint, the triceps is an antagonist to the biceps brachii.
Synergists
Synergists are muscles that work together during movement. Because most move-
ments require a contribution from many different muscles, synergistic actions are
very common. For example, the biceps brachii and brachialis muscles act as synergists
during elbow flexion.
Imagine curling a dumbbell with your right arm. There will be synergistic actions
of the muscles that cross the wrist joint to hold it in a neutral position during the
movement.
Furthermore, muscles in the shoulder joint will contract to neutralize any movement
at the shoulder. Therefore, even a motion as seemingly simple as a biceps curl can
require the synergistic contribution of many muscle groups.
Figure 2.4. Agonist, antagonist and synergistic actions. A) The biceps brachii
performs elbow flexion. B) The triceps perform elbow extension. Therefore, each muscle is
an antagonist to the other. C) The biceps brachii and brachialis work in synergy to perform
elbow flexion.

30 | Unit 2
Force-Couple
Force-couple: When two or Another example of muscle synergy is a muscular force-couple. A force-couple occurs
more muscles concurrently when two or more muscles concurrently produce force in different linear directions
produce force in different linear to produce one movement. To make a right turn on a bicycle, the right arm must pull
directions to produce one
movement.
inward as the left arm pushes outward. The force each arm produces is in a different
direction; however, it results in one movement (i.e., a turn to the right).
A force-couple is required during deltoid and supraspinatus actions at the glenohu-
meral joint while lifting the arm out to the side. When the deltoid muscle shortens,
it pulls upward on the head of the humerus. This action would normally cause the
head of the humerus to compress up into the scapula if it weren’t for the simultaneous
inward pull from the supraspinatus.
In other words, the combined actions that produce a force-couple can allow joints to
move through a greater range of motion. The force-couple between the deltoid and
supraspinatus is a prime example because the coupling effect avoids impingement
within the subacromial space.
Figure 2.5. Force-couple
at the glenohumeral
joint. When the deltoid
contracts it pulls the humerus
upward, but the simultaneous
contraction of the supraspina-
tus pulls the humerus inward
to create a force couple. This
force-couple offsets gleno-
humeral impingement when
the arm is raised to allow the
humerus to rotate and elevate
without restriction.
SKELETAL MUSCLE GROUPS

Now that we’ve covered the structure and function of skeletal muscle, let’s take a look
at the major muscle groups across the body. Because extremely small muscles through-
out the face, hand and feet are mostly irrelevant to this course, they were not included
in the following figures.
However, later in this unit there are tables that outline the origin and insertion for
virtually every muscle group. The tables will serve as a valuable tool whenever you’re
unsure of a muscle’s origin and insertion.
Corrective Exercise
Figure 2.6. Anterior view

of major muscle groups.

32 | Unit 2
Figure 2.7. Posterior view

of major muscle groups.
Corrective Exercise
TRAIN YOUR BRAIN: What causes muscle soreness?

We’ve all experienced a burning sensation in our muscles during intense exercise. When training at a
high intensity, the oxygen demands of a muscle can be greater than the supply. To fuel more muscle
contractions, the body produces lactate (i.e., lactic acid) because it doesn’t require oxygen for energy.
When the lactate builds up in your bloodstream faster than your physiology can clear it, a burning
sensation is felt.
For decades, many fitness experts—and even some doctors and scientists—assumed that muscle sore-
ness was caused by lactic acid. That’s not the case. Actually, the discomfort you feel 24-72 hours after
exercise is delayed-onset muscle soreness (DOMS), a general term to describe muscular pain, stiffness
and tenderness that follows challenging exercise. This discomfort is caused by microtears within the
muscle. Microtears are a normal part of the training process, and the body will repair that damage
and make the muscle stronger a few days later.
Now that we’ve covered the structure and function of skeletal muscle, let’s take a look
at another tissue that works directly with muscle and movement: fascia.
FASCIA
The human body consists primarily of fluid. About 55%-75% of it is water, depending
on the person’s age, gender and body composition. Have you ever wondered why all
that fluid doesn’t pool down into the feet and lower legs?
There’s a soft tissue “net” throughout the body, from head to toe, that holds all the flu-
ids where they should be. This net also functions to connect seemingly unrelated parts
of the body together, such as the foot to the hip or wrist to the neck.
It’s common for many anatomy books and physical therapy programs to neglect the
crucial role this soft tissue plays during movement. Nevertheless, it’s crucial to un-
derstand that movement at one joint can have a significant effect on other areas of the
body. Therefore, in this section you will learn the structure and function of fascia - the
body’s continuous net that influences movement and posture.
Fascia Structure and Function

Your body begins as an ovum, a single cell that’s part of the female reproductive sys-
tem. This cell quickly begins to divide into more cells, and by day 14 of development,
a support structure has been developed that holds the collection of cells together. This
structure is made up of fascia, a form of connective tissue that acts like guide wires on
a suspension bridge. Once the human body is fully formed, this original net of fascia
has developed to function like girdles and guide wires that create interconnectedness
and structure throughout the body.
Plantar fasciitis: Irritation of
Fascia is a tough tissue consisting primarily of collagen, similar to ligaments and ten- the connective tissue on the
dons. If you’ve ever suffered from plantar fasciitis—an irritation of the connective tissue bottom of the feet.

34 | Unit 2
on the bottom of the feet—you know that fascia can become stiff and painful. This area
Plantar aponeurosis: A strong of stiff, connective tissue on the bottom of each foot is the plantar aponeurosis.
layer of connective tissue on the
bottom of the foot. Sheaths of fascia sit directly beneath the skin and traverse deep through the body to
form an interconnected matrix from head to toe. Indeed, movement at any joint can
have far- reaching effects throughout the body due to the interconnectedness of fascia.
The Seven Categories of Fascial Lines

In his book, Anatomy Trains, Thomas Myers describes seven primary lines of fascia
within the body. Importantly, each fascial line connects with numerous bones and
muscles along its path, and these connections are what form the complex matrix that
links the body together during movement and posture. For the sake of simplicity, the
following information describes the general path of each line of fascia, starting from
the most distal point (farthest from the trunk).
Superficial Back Line

This fascial line runs from the bottom of the toes, up the back of the legs, along the
spine, over the top of the skull and attaches at the forehead.
Superficial Front Line

There are two parts of the Superficial Front Line. The first part runs from the top of
the toes, up the front of the legs, and attaches at the front lateral aspect of the pelvis.
The second part runs from the anterior medial aspect of the lower pelvis up the medial
aspect of the trunk and splits at the top of the sternum to wrap up and around the lat-
eral aspects of the neck where both sections merge to form a continuous loop around
the back of the skull.
Lateral Line
This fascial line runs from the mid lateral aspect of the foot, up the lateral aspect of
the leg and pelvis, crisscrosses underneath the ribcage and up the lateral neck where it
attaches behind the ear.
Spiral Line
The spiral line loops around the bottom of each foot like a long scarf and runs up the lat-
Figure 2.8. Superficial back
line outlined by Anatomy eral aspect of the leg, then it takes two different routes at the hip. One track runs across
Trains. This line of fascia runs the front of the pelvis, up and across the abdomen, wraps around the upper ribcage on
from the bottom of the feet to the opposite side and continues up to the back of the skull. The other track crosses the
the browline at the forehead. back of the pelvis and runs up the spine until it attaches to the back of the skull.
Corrective Exercise
Arm Lines
This category of fascia consists of four lines. The deep front arm line runs from the tip
of the thumb, up the lateral arm, across the shoulder and attaches around the nipple.
The superficial arm line runs from the tips of the fingers on the palm side, travels up to
the medial elbow, up the medial upper arm, across the medial shoulder and attaches at
the medial clavicle, sternum and directly below the chest. The deep back arm line runs
from the outside of the little finger, up the forearm to the elbow, up the posterior up-
per arm, across the posterior shoulder and attaches on the spine at the lower cervical
and upper thoracic vertebral area. The superficial back arm line runs from the tips of
the fingers on the back of the hand, up to the elbow and posterior upper arm, across
the top of the shoulder, and attaches to the base of the skull, lower cervical and mid
thoracic areas.
Functional Lines
Three fascial lines make up the Functional Lines. The back functional line runs from
the lateral aspect of the knee, up the posterior thigh, across the posterior pelvis, over
the lower half of the ribcage and scapula and attaches to the upper humerus. There is
a front functional line that runs posterior, middle femur to the middle pelvis, up the
medial abdomen, and out across the chest to the upper humerus. The ipsilateral func-
tional line runs from the medial knee, up the inner thigh at a lateral angle that crosses
the lateral pelvis, over the lateral-posterior ribcage and attaches to the upper humerus.
Deep Front Line

This fascial line runs from the bottom of the toes, up the lower leg between the tibia
and fibula, behind the knee, up the medial thigh, over the front of the pelvis, up
through the ribcage, and continues up the anterior and lateral neck where it attaches
to the lateral aspect of the jaw and skull.
A Few Final Words About Fascia

The key element to understand about fascia is its role in connecting seemingly unre-
lated body parts or structures together. Indeed, a problem at one joint can, and will
often, lead to problems at other parts of the body. This is due to the interconnectedness
of fascia throughout the body’s soft tissue structures.

36 | Unit 2
MUSCLE CHARTS
The following tables outline the muscles, origins and insertions primarily associated with this course—and well beyond—
starting from the feet and moving up to the neck. These tables can prove invaluable whenever you’re unsure of a muscle’s
origin and insertion points.
Feet
Table 2.1. Foot muscles
Foot muscles
Muscle Origin Insertion
Extensor digitorum brevis Calcaneus, dorsal surface Base of middle phalanges 2-4
Extensor hallucis brevis Calcaneus, dorsal surface Base of 1st proximal phalanx
Abductor hallucis Medial calcaneal tuberosity Base of 1st proximal phalanx
Flexor hallucis brevis (medial head) Medial cuneiform Base of 1st proximal phalanx
Flexor hallucis brevis (lateral head) Intermediate cuneiform Base of 1st proximal phalanx
Adductor hallucis (oblique head) Base of metatarsals 2-4, cuboid, lateral Base of 1st proximal phalanx
cuneiform
Adductor hallucis (transverse Transverse metatarsal ligament, meta- Base of 1st proximal phalanx
head) tarsal phalanges 3-5
Abductor digiti minimi Lateral calcaneal tuberosity Base of 5th proximal phalanx
Flexor digiti minimi Base of 5th metatarsal Base of 5th proximal phalanx
Flexor digitorum brevis Calcaneal tuberosity Middle phalanges 2-5
Quadratus plantae Calcaneal tuberosity Lateral border of flexor digitorum lon-

gus tendon
Lumbricals 1-4 Medial border of flexor digitorum lon- Dorsal aponeuroses 2-5
gus tendons
Plantar interossei 1-3 Medial border of metatarsals 3-5 Medial base of proximal phalanges 3-5
Dorsal interossei 1-4 Two heads from opposing sides of Medial base of 2nd proximal phalange,
metatarsals 1-5 lateral base of proximal phalanges 2-4
Corrective Exercise
Calf/Shin
Table 2.2. Lower leg muscles (anterior and posterior regions)
Anterior lower leg (shin) muscles

Tibialis anterior Upper lateral tibia interosseous membrane Medial cuneiform
Extensor digitorum longus Anterior fibula, lateral tibial condyle, inter- Base of middle/distal phalanges 2-5
osseous membrane
Extensor hallucis longus Medial fibula interosseous membrane Base of 1st distal phalanx
Peroneus (fibularis) longus Proximal lateral fibula, head of fibula Medial cuneiform, base of 1st metatarsal
Peroneus (fibularis) brevis Distal lateral fibula, interosseous Base of 5th metatarsal
membrane
Peroneus (fibularis) tertius Distal anterior fibula Base of 5th metatarsal
Posterior lower leg (calf) muscles

Soleus Soleal line of tibia, head/neck of fibula Calcaneal tuberosity via Achilles tendon
Gastrocnemius Medial/lateral epicondyles of femur Calcaneal tuberosity via Achilles tendon
Plantaris Lateral epicondyle of femur Calcaneal tuberosity via Achilles tendon
Tibialis posterior Posterior tibia, interosseous membrane, Navicular, medial/intermediate/lateral

posterior fibula cuneiforms, base of metatarsals 2-4
Flexor digitorum longus Middle posterior tibia Base of distal phalanges 2-5
Flexor hallucis longus Distal posterior fibula Base of 1st distal phalanx
Thigh
Table 2.3. Thigh muscles (anterior and posterior regions)
Posterior upper leg (thigh) muscles
Biceps femoris (long head) Ischial tuberosity, sacrotuberous ligament Head of fibula
Biceps femoris (short head) Lateral lip of linea aspera Head of fibula
Semimembranosus Ischial tuberosity, sacrotuberous ligament Medial tibial condyle
Semitendinosus Ischial tuberosity, sacrotuberous ligament Medial of the tibial tuberosity via pes
anserinus
Popliteus Lateral femoral condyle Posterior tibial surface
Anterior upper leg (thigh) muscles

Rectus femoris Anterior inferior iliac spine, acetabular roof Tibial tuberosity via patellar tendon*
Vastus medialis Medial lip of linea aspera Tibial tuberosity via patellar tendon
Vastus lateralis Lateral lip of linea aspera Tibial tuberosity via patellar tendon
Vastus intermedius Anterior femur Tibial tuberosity via patellar tendon
*The patellar tendon is sometimes referred to as a patellar ligament since it connects the patella to the tibia (i.e., bone-
to-bone attachment).

38 | Unit 2
Hip
Table 2.4. Hip muscles
Hip muscles

Psoas major Lateral surface of T12-L4 vertebral Lesser trochanter
bodies
Illiacus Iliac fossa Lesser trochanter
Sartorius Anterior superior iliac spine Pes anserinus
Gluteus maximus: Upper portion Sacrum, posterior iliac crest, thoraco- Iliotibial tract
lumbar fascia
Gluteus maxium: Lower portion Sacrum, thoracolumbar fascia, sacrotu- Gluteal tuberosity
berous ligament
Gluteus medius Superior gluteal surface of ilium Greater trochanter
Gluteus minimus Inferior gluteal surface of ilium Greater trochanter
Tensor fascia latae Anterior superior iliac spine Iliotibial tract
Piriformis Anterior surface of sacrum Greater trochanter
Gemellus superior Ischial spine Medial greater trochanter
Obturator internus Inner surface of obturator membrane Medial greater trochanter
Gemellus inferior Ischial tuberosity Medial greater trochanter
Obturator externus Outer surface of obturator membrane Trochanteric fossa
Quadratus femoris Ischial tuberosity Intertrochanteric crest
Pectineus Pubic body Proximal linea aspera
Adductor longus Superior pubic ramus Medial lip of linea aspera
Adductor brevis Inferior pubic ramus Medial lip of linea aspera
Adductor magnus: Anterior portion Inferior pubic ramus & ischial ramus Adductor tubercle of femur
Adductor magnus: Posterior portion Ischial ramus & ischial tuberosity Medial lip of linea aspera
Gracilis Inferior pubic ramus Pes anserinus
Rectus femoris Anterior inferior iliac spine & acetabu- Tibial tuberosity via pes anserinus
lar roof
Biceps femoris: long head Ischial tuberosity & sacrotuberous Head of fibula
ligament
Semimembranosus Ischial tuberosity & sacrotuberous Medial tibial condyle
ligament
Semitendinosus Ischial tuberosity & sacrotuberous Pes anserinus
ligament
Corrective Exercise
Trunk
Table 2.5. Abdominals/low back/spinal erectors
Abdominal muscles
Rectus abdominis Ribs 5-7, xiphoid process Pubic ramus
External oblique Posterolateral ribs 5-12 Iliac crest, linea albea
Internal oblique Iliac crest, thoracolumbar fascia Linea alba, inferior ribs
Transversus abdominis Ribs 7-12, thoracolumbar fascia, iliac crest Linea alba
Low back and spinal erector muscles
Quadratus lumborum Upper lumbar transverse processes, 12th rib Iliac crest
Intertransversarii Lumbar to cervical transverse processes Lumbar to cervical transverse processes of
adjacent superior vertebrae
Interspinalis Lumbar to cervical spinous processes Lumbar to cervical spinous processes of adja-
cent superior vertebrae
Rotatores Lumbar to cervical transverse processes Lumbar to cervical spinous processes
Multifidus Sacrum, lower lumbar to lower cervical Spinous processes of vertebrae 2-5 superior
transverse processes to origin
Semispinalis Lower thoracic to lower cervical transverse Upper thoracic spinous processes to occipital
processes bone
Spinalis Upper lumbar and lower thoracic spinous Upper thoracic spinous processes
processes
Longissimus Lumbar to lower cervical transverse Thoracic spinous processes and lower 9 ribs
processes to mastoid process
Iliocostalis Iliac crest to upper ribs Lower ribs to lower cervical transverse
processes
Shoulder
Table 2.6. Shoulder girdle muscles (anterior and posterior)
Posterior shoulder girdle muscles
Upper trapezius Occipital bone, C1-C7 spinous Lateral clavicle, acromion
processes
Middle trapezius T1-T4 spinous processes Scapular spine
Lower trapezius T5-T12 spinous processes Medial scapular spine
Rhomboid major T1-T4 spinous processes Medial border of scapula above scapular spine
Rhomboid minor C6-C7 spinous processes Medial border of scapula below scapular spine
Levator scapulae C1-C4 transverse processes Superior angle of scapula
Anterior shoulder girdle muscles
Sternocleidomastoid Manubrium, medial clavicle Lateral clavicle, acromion
Subclavius Superior surface of 1st rib Inferior/lateral surface of clavicle
Pectoralis minor Anterior surface of ribs 3-5 Coracoid process of scapula
Serratus anterior: superior portion Lateral surface of ribs 5-9 Medial border scapula, inferior angle
Serratus anterior: inferior portion Lateral surface of ribs 5-9 Medial border of scapula, inferior angle

40 | Unit 2
Shoulder (Glenohumeral Joint)

Table 2.7. Muscles with actions at the glenohumeral joint
Glenohumeral (GH) joint muscles
Anterior deltoid Lateral clavicle Deltoid tuberosity of humerus
Middle deltoid Acromion Deltoid tuberosity of humerus
Posterior deltoid Scapular spine Deltoid tuberosity of humerus
Coracobrachialis Coracoid process of scapula Medial humerus
Teres major Inferior angle of scapula Medial border of bicipital groove
Pectoralis major: clavicular portion Medial clavicle Lateral border of bicipital groove
Pectoralis major: sternal portion Sternum & costal cartilages of ribs 2-6 Lateral border of bicipital groove
Latissimus dorsi T7-T12 spinous processes, thoraco- Medial border of bicipital groove
lumbar fascia, posterior iliac crest, ribs
9- 12, inferior angle of scapula
Table 2.8. Rotator cuff muscles

Muscles of the Rotator Cuff
Suprspinatus Supraspinous fossa Greater tuberosity of humerus
Infraspinatus Infraspinous foss Greater tuberosity of humerus
Teres minor Lateral border of scapula Greater tuberosity of humerus
Subscapularis Subscapular fossa of scapula Lesser tuberosity of humerus
Upper Arm
Table 2.9. Brachium (upper arm) muscles.
Posterior brachium (upper arm) muscles
Triceps brachii: long head Infraglenoid tubercle of the scapula Olecranon
Triceps brachii: medial head Distal posterior surface of humerus Olecranon
Triceps brachii: lateral head Proximal posterior surface of humerus Olecranon
Anconeus Lateral epicondyle of humerus Olecranon
Anterior brachium (upper arm) muscles

Coracobrachialis Coracoid process of the scapula Medial humerus
Biceps brachii: long head Supraglenoid tubercle of the scapula Radial tuberosity
Biceps brachii: short head Coracoid process of the scapula Radial tuberosity
Brachialis Distal anterior humerus Ulnar tuberosity
Corrective Exercise
Forearm
Table 2.10. Antebrachium (forearm) muscles
Posterior antebrachium (forearm) muscles
Brachioradialis Lateral supracondylar ridge of Styloid process of radius

humerus
Extensor carpi radialis longus Lateral supracondylar ridge of Base of 2nd metacarpal
humerus
Extensor carpi radialis brevis Lateral epicondyle of humerus Base of 3rd metacarpal
Supinator Lateral epicondyle of humerus, Lateral radius

supinator crest of ulna
Extensor digitorum Lateral epicondyle of humerus Middle/distal phalanges 2-5
Extensor digiti minimi Lateral epicondyle of humerus 5th middle/distal phalange
Extensor carpi ulnaris Lateral epicondyle of humerus, Base of 5th metacarpal

posterior ulna
Anterior antebrachium (forearm) muscles
Pronator teres Medial epicondyle of humerus, Lateral surface of radius

coronoid process of ulna
Flexor digitorum superficialis Medial epicondyle of humerus, Side of middle phalanges 2-5
coronoid process of ulna
Flexor carpi radialis Medial epicondyle of humerus Base of 2nd metacarpal
Flexor carpi ulnaris Medial epicondyle of humerus, Pisiform, hook of hamate

olecranon
Palmaris longus Medial epicondyle of humerus Palmar aponeurosis
Flexor digitorum profundus Proximal anterior ulna, interosse- Distal phalanges 2-5
ous membrane
Flexor pollicis longus Anterior radius, interosseous Distal 1st phalanx
membrane
Pronator quadratus Distal anterior surface of ulna Distal anterior surface of radius

42 | Unit 2
Hand
Table 2.11. Hand muscles
Hand muscles
Abductor pollicis brevis Flexor retinaculum, scaphoid, trapezium Base of 1st proximal phalanx
Adductor pollicis: transverse head 3rd metacarpal Base of 1st proximal phalanx
Adductor pollicis: oblique head Base of 2nd metacarpal, capitate Base of 1st proximal phalanx
Flexor pollicis brevis Flexor retinaculum, capitate, trapezium Base of 1st proximal phalanx
Opponens pollicis Trapezium 1st metacarpal
Abductor digiti minimi Pisiform Base of 5th proximal phalanx
Flexor digiti minimi Hook of hamate, flexor retinaculum Base of 5th proximal phalanx
Opponens digiti minimi Hook of hamate 5th metacarpal
Palmaris brevis* Palmar aponeurosis Skin of hypothenar eminence
*Not everyone has a palmaris brevis.
Neck/Head
Table 2.12. Anterior/lateral neck and posterior skull muscles (i.e., suboccipitals.)
Anterior/lateral neck muscles
Sternocleidomastoid Manubrium, medial clavicle Mastoid process, superior nuchal line
Scalenus anterior C3-C6 transverse processes 1st rib
Scalenus medius C2-C7 transverse processes 1st rib
Scalenus posterior C5-C6 transverse processes 2nd rib
Platysma Superior fascia of deltoid/pectoral Inferior border of mandible

regions
Suboccipital muscles (posterior skull)
Rectus capitis posterior, major Spinous process of the axis Inferior nuchal line
Rectus capitis posterior, minor Posterior arch of atlas Inferior nuchal line
Obliquus capitis, superior Transverse process of atlas Occipital bone
Obliquus capitis, inferior Spinous process of the axis Transverse process of the atlas
Corrective Exercise
Functions of the Nervous System

Components of the Nervous System
Nervous System Cells
Peripheral Nervous System (PNS)
Central Nervous System (CNS)
Nerves
Sensory Feedback
Interneurons
Basal Ganglia and Cerebellum
Neuroplasticity
UNIT 3
THE NERVOUS SYSTEM

44 | Unit 3
What You’ll Learn

We have all heard the human body described as some kind of inanimate object. Sometimes it’s a house (if
you’re talking about the importance of a solid foundation), and sometimes it’s a car (usually in the context of
food as fuel). I like to think of the body as a computer, albeit one that’s capable of complex movement. Like a
computer, our bodies are made of hardware (muscles, bones, organs, connective tissues) and run on software.
That software—the brain, spinal cord, and nerves—controls the hardware to initiate movement, to control it
and, in the right circumstances and with proper coaching, to improve it.
The “proper coaching” part is where you come in. As you get deeper into the corrective exercise program,
you’ll be employing increasingly complex muscle-activating and joint-stabilizing exercises. All of them are
based on the idea that the software your clients run to control basic movements such as lifting and squat-
ting can be reprogrammed to make those movements smooth and pain free. Put another way: you are the
client’s IT person. It’s up to you to deliver the instructions and performance cues that take the bugs out of
faulty movement software.
Yes, I’m stretching the metaphor, but not by much. New research shows that the nervous system is more
malleable than previously thought. We now know that movement experiences can change the structure and
function of the brain. When your clients move more and move better, their nervous system software runs
better, with fewer bugs.
We’ll start this unit with a look at the functions and components of the nervous system, take a journey
through its pathways, and finish by outlining how it produces and controls movement.
FUNCTIONS OF THE NERVOUS SYSTEM

The nervous system is your body’s most diverse, with these six primary functions:
• Coordinates movement. It plans, initiates, and asserts ongoing control
over every move you make.
• Processes sensory input. This amazingly diverse category includes smell,
vision, taste, hearing, and somatosensory information (pain, warmth, an itch
you need to scratch…) These functions allow you to receive and interpret
information from your joints, ligaments, muscles, and skin.
• Initiates and maintains life-sustaining functions. These include your
innate need to find water, food, and a mate.
• Learns and forms memories: Learning and memory are the primary
elements of cognition.
• Experiences emotions: These include feelings of fear, pleasure, attach-
ment, and drive.
• Controls arousal: Consciousness and sleep regulation are parts of this
function.
Through these six functions, the nervous system forms a complex network of
thoughts, emotions, and processes that go far beyond movement and performance.
But to keep it within our scope of practice, we’ll focus on the interplay between the
first two functions: coordinating movement and processing sensory input. We’ll start
by covering the components that make up the nervous system.
Corrective Exercise
The Nervous System | 45
COMPONENTS OF Central nervous system

(CNS): The nervous system
THE NERVOUS SYSTEM cells that make up the brain and

spinal cord.
Even though the nervous system generally functions as one interconnected system, it Peripheral nervous system
can be divided into the central nervous system (CNS) and peripheral nervous system (PNS): The nervous system
(PNS). The CNS consists of the brain, spinal cord, and all the structures contained cells that provide information to
within it. The PNS is composed of the neural circuitry that travels outside of the spinal the brain and spinal cord.
cord, down to the deepest layers of your joints and organs. Neuron: The nervous system
cell that produces action
potentials to communicate
NERVOUS SYSTEM CELLS with other neurons, muscles, or
glands.
The nervous system consists of two main types of cells: neurons and glia. The av-
Glia: The nervous system cell
erage human has approximately 86 billion neurons and one trillion glial cells. They that protects and supports
work together to make you who you are, from your ability to run or lift or kick a neurons but does not produce
soccer ball to your emotional response when you hold a newborn or stumble across action potentials.
a snake in the woods. Action potential: The
electrical signal produced by a
neuron or muscle spindle.
Neurons Motor neuron: A nervous
A neuron transmits information through electrical and chemical signals. Each neuron system cell that transmits
can produce an action potential—sometimes referred to as an “impulse” or “spike”— information away from the
which is the electrical signal required for movement and perception. spinal cord to muscles or
glands.
Three types of neurons are in the body: motor, sensory, and interneuron. Sensory neuron: A nervous
• Motor neurons transmit commands from the brain or spinal cord to mus- system cell that transmits
cles and glands. information regarding
movement, sight, touch, sound,
• Sensory neurons transmit information into the brain and spinal cord to and smell to the brain and
detect movement, sight, touch, sound, and smell. spinal cord.
• Interneurons, the most abundant in the nervous system, create circuits be- Interneuron: A nervous
tween sensory or motor neurons and transmit information among different system cell that creates circuits
parts of the brain. between motor or sensory
neurons, and within the brain
A typical neuron includes these components: and spinal cord.
• Dendrites are branches of the cell body that act as receivers, collecting Dendrites: The portion
information from other neurons. of a neuron that receives
information from other neurons.
• The cell body, or soma, is the bulbous end of a neuron that contains the
nucleus (DNA). This part of the neuron integrates information and deter- Cell body: The region of a
mines whether there’s enough to create an action potential. neuron that contains the DNA
and cytoplasm.
• The axon is the transmitter portion, relaying signals to other neurons, mus-
cles, or organs. The axons that travel from the spinal cord to the feet can be Axon: The projection of a
up to a meter long but just 100 microns (a tenth of a millimeter) wide. neuron that transmits an action
potential away from the neuron.
A muscle spindle is a sensory receptor within muscle that detects changes in length Muscle spindle: A sensory
and helps regulate contraction. It sends information to the sensory cell body. The receptor contained in the
information then travels through the axon to the spinal cord, where it communicates muscle belly that detects
with motor neurons or interneurons. changes in muscle length and
helps regulate contraction.
Neurons communicate with other neurons or with organs (muscles and glands)
through a synapse, an area where either electrical or chemical signals are transmitted. Synapse: An area between
neurons, or between a neuron
Synapses can be located between two neurons or between a motor neuron and a mus- and muscles or glands, where
cle or gland. For example, when a motor neuron that innervates a muscle is activated, electrical or chemical signals are
transmitted.

46 | Unit 3
Figure 3.1. Components of a motor and sensory neuron. Motor neuron: The dendrites receive information from other
neurons, and then the electrical signal travels down the axon and out through the terminal endings that synapse onto muscle
fibers. Sensory neuron: Receptors in the muscle, joints, or skin send an impulse to the cell body, which can transmit the signal to
a motor neuron or interneuron.
Acetylcholine: The chemical a it releases acetylcholine, a chemical neurotransmitter, at the neuromuscular junc-
motor neuron releases to cause tion. The binding of acetylcholine to receptors on the muscle triggers a cascade of
muscle contractions.
events that results in contraction.
Neuromuscular junction:
The area between a motor
neuron and muscle fiber where Glia
acetylcholine is released.
Unlike neurons, glia do not produce action potentials. Their role is to support the neu-
Glia: A nervous system cell that
protects and nourishes neurons
rons by providing the protection and nutrients necessary to keep them intact.
but doesn’t produce an action Myelin, a fatty sheath that covers the axon of a neuron (similar to insulation around
potential.
an electrical wire), is a glial cell that’s important for movement. It allows signals to
Myelin: A fatty sheath around travel quickly through nerves, up to 90 meters per second. When a disease breaks
the axon of a nerve that down the myelin covering of a neuron, it can lead to multiple sclerosis and other
provides electrical insulation,
movement disorders.
protection, nourishment, and
faster signal transmission.
Corrective Exercise
Now it’s time to look at how all these components come together, once again focusing Multiple Sclerosis: A disease
on movement and performance. that damages the myelin that
surrounds an axon.
Somatic nervous system:
PERIPHERAL NERVOUS SYSTEM (PNS) The division of the peripheral
nervous system that controls
The peripheral nervous system includes all the neurons and glia outside the brain and voluntary movement.
spinal cord, to which it sends constant information from the body. The PNS can be
Autonomic nervous system:
further subdivided into the somatic nervous system and autonomic nervous system: The division of the peripheral
nervous system that controls
subconscious actions such
Somatic Nervous System as breathing, heart rate, and
digestive processes.
This division of the PNS, responsible for voluntary movement, includes motor neurons
that control muscle along with sensory neurons that receive information from the Sympathetic nervous
muscles, skin, and joints. system: The division of the
autonomic nervous system that
generates the “fight or flight”
Autonomic Nervous System response.
Parasympathetic nervous
This part of the PNS controls the heart, lungs, and gut. It’s further divided into the system: The division of the
sympathetic and parasympathetic nervous systems. The sympathetic nervous system autonomic nervous system that
generates the “fight or flight” response through the release of norepinephrine. The generates the “rest or digest”
parasympathetic system balances the sympathetic by activating the “rest and digest” response.
physiological processes. These two systems work together to maintain homeostasis Norepinephrine: The
within the PNS. hormone/neurotransmitter
released by the CNS and
sympathetic nervous system
CENTRAL NERVOUS SYSTEM (CNS) that triggers the “fight or
flight” response.
When all the aforementioned information from the PNS
hits the brain and spinal cord, the CNS is charged with
figuring out what it means and what to do with it. For that,
the CNS delegates responsibilities to seven individual com-
ponents, which are found in four primary divisions:
• The forebrain includes the cerebrum, which
helps learn and control movement, and the dien-
cephalon, which relays and integrates information
from different parts of the brain and spinal cord.
The cerebrum is further divided into right and left
cerebral hemispheres, which are connected by the
corpus callosum.
• The brainstem consists of the midbrain, pons,
and medulla. It mediates sensory and motor
control of the head, neck, and face along with
balance. The brainstem also contains the sensory
and motor pathways that travel to other parts of
the CNS, as we’ll discuss later.
• The cerebellum (which literally means “little
brain”) plans and coordinates movement. It con-
tains more densely packed neurons than does any
other subdivision of the brain.
Figure 3.2. The seven components of the CNS. Cross-
• The spinal cord transmits motor information section showing the right half of the brain. The corpus cal-
down from the brain and sensory information up losum contains neural fibers that connect the right and left
to the brain. It also contains reflex circuits. cerebral hemispheres.

48 | Unit 3
Homeostasis: The process of Because the spinal cord is particularly important for understanding how movement is
keeping physiological systems produced, it’s worth exploring it in greater detail.
stable.
Corpus callosum: Neural
fibers that connect the right Spinal Cord
and left cerebral hemispheres.
The spinal cord is a long, slender tube of both white and gray matter that extends
White matter: The portion of from the bottom of the medulla down through the vertebral column. Both are made
the brain and spinal cord that
contain myelinated axons.
up of axons, but only white matter is covered by myelin. It gets its name from myelin’s
whitish appearance. Gray matter is gray because it includes cell bodies and terminal
Gray matter: The portion of endings of neurons, which have little or no myelin.
the brain and spinal cord that
contain axons with little or no Spinal nerves emerge from the spinal cord to provide motor and sensory information
myelin and cell bodies. to the body, which we’ll discuss in detail later in this unit.
Meninges: The membranes
Three layers of membrane known as meninges protect the spinal cord, with small
that cover the brain and spinal
cord to provide protection and spaces between each meningeal layer to provide nourishment through blood vessels
nourishment. and cerebrospinal fluid. There’s also a small amount of cerebrospinal fluid in the
central canal, the small opening within the center of the spinal cord that connects to
Cerebrospinal fluid (CSF):
A clear fluid found in the brain
ventricles of the brain.
and spinal cord that protects Most of us assume that the spinal cord, which begins at the base of the medulla, runs
and cleans the brain.
the entire length of the spine. In fact, the spinal cord ends around the second lumbar
Ventricles: Cavities in the vertebrae (L2). The area between L2 and the sacrum is filled with bundles of spinal
brain that contain cerebrospinal
fluid.
Figure 3.3. Spinal cord within the vertebral column. This part of the spinal cord is
in the cervical region of the vertebral column.
Corrective Exercise
Figure 3.4. Spinal cord components. White matter consists of axons that are covered
in whitish myelin; gray matter is composed of cell bodies and axons that have little or no
myelin. Three layers of meninges protect the spinal cord. The central canal contains a
small amount of cerebrospinal fluid.
nerves, known as the cauda equina. They extend to the bottom of the sacrum and Cauda equina: A bundle of
innervate the muscles of the hips, legs, pelvic organs, and sphincter. spinal nerves that begin around
the second lumbar vertebrae
The spinal cord is usually 15 to 19 inches long, depending on a person’s height, and where the spinal cord ends.
approximately one-half inch across at its narrowest section. The diameter increases in
Cervical enlargement: The
two areas: The cervical enlargement is wider because it contains the nerves that travel larger diameter area of the
to the arms, whereas the lumbar enlargement holds the nerves that travel to the legs. spinal cord that contains the
Both structures provide more room for additional cell bodies. nerves that travel to the upper
limbs.
As previously mentioned, the spinal cord transmits information up to and down from
the brain. It also serves as a center for coordinating reflexes. You can think of it as an Lumbar enlargement: The
larger diameter area of the
interstate highway, with information traveling up and down with (relatively) few ob- spinal cord that contains the
stacles to slow it down. At the same time, connecting highways pour new information nerves that travel to the lower
onto the interstate and take existing information off it. Of course, for the metaphor limbs.
to work, you need to imagine that the spinal cord’s on and off ramps transmit infor-
mation far more efficiently than the average interstate handles traffic. It’s particularly
strained when it comes to reflexes, which would be the equivalent of roundabouts that
allow information to jump on and off the highway without first crawling through a
commercial strip filled with gas stations and fast food restaurants.
We’ll start with the more straightforward flow of information between the spinal cord
and muscles.
NERVES
Nerves are bundles of axons that carry information within the PNS. They are the
pathways connecting muscles and other organs to the spinal cord and the spinal cord
to those organs. There are three types.

50 | Unit 3
Sensory (afferent) nerve: A sensory nerve (i.e., afferent nerve) carries information into the spinal cord. A motor
A bundle of axons that carries nerve (i.e., efferent nerve) carries information away from the spinal cord to innervate
sensory information into the
muscle. And a mixed nerve, as you can guess from its name, carries sensory and motor
brain or spinal cord.
information. It also handles autonomic information for the sympathetic and parasym-
Motor (efferent) nerve: A pathetic nervous systems, which we’ll disregard so we can keep the focus on movement.
bundle of axons that carries
motor information away from
the brain or spinal cord to
muscles or glands.
Spinal Nerves
Mixed nerve: A bundle of Thirty-one pairs of spinal nerves emerge from the spinal cord to control muscles in the
axons that carries sensory, body, from the neck down to the toes. They’re divided into regions that correspond with
motor, and autonomic the vertebrae from which they exit, giving you 8 pairs of cervical nerves, 12 pairs of tho-
information. racic nerves, 5 pairs of lumbar nerves, 5 pairs of sacral nerves, and 1 pair of coccygeal
Cranial nerves: Twelve pairs nerves. You can see the primary motor functions of each region in Table 3.1.
of nerves that emerge from the
brain or brainstem to relay pure
sensory, pure motor, or sensory
and motor information to the
head.
Spinal nerves: Thirty-one
pairs of nerves that emerge
from the spinal cord to relay
motor sensory and autonomic
information from the neck
to the feet, except for the C1
spinal nerve that transmits pure
motor information.
Cervical nerves: Eight pairs
of spinal nerves that exit
the cervical region of the
vertebral column above each
corresponding vertebrae except
for the C8 spinal nerve that
exits below the C7 vertebrae.
Thoracic nerves: Twelve
pairs of spinal nerves that
exit the thoracic region of the
vertebral column below each
corresponding vertebrae.
Lumbar nerves: Five pairs
of spinal nerves that exit
the lumbar region of the
vertebral column below each
corresponding vertebrae.
Sacral nerves: Five pairs
of spinal nerves that exit the
sacrum at the lower end of the
vertebral column.
Coccygeal nerves: One pair of
spinal nerves that exits below
the sacrum.
Figure 3.5. Posterior view of the spinal nerves, spinal cord, and cauda equina.
The spinal cord travels from the base of the medulla to approximately the L2 vertebral
region, where it splits into strands and becomes the cauda equina. There are 31 pairs of
spinal nerves, as depicted on the right side of the spinal cord.
Corrective Exercise
Table 3.1
Spinal Nerves Motor Functions
Cervical nerves C1-C8 (8 pairs) Control muscles of the neck, shoulders, upper limbs, and diaphragm
Thoracic nerves T1-T12 (12 pairs) Control muscles of the trunk
Lumbar nerves L1-L5 (5 pairs) Control muscles of the pelvis and lower limbs
Sacral nerves S1-S5 (5 pairs) Control muscles of the pelvis and lower limbs
Coccygeal nerves CO1 (1 pair) Control a few muscles of the pelvis
Before we move on, let’s summarize what we’ve covered so far:
• Spinal nerves create a pathway for communication • The large-diameter spinal nerves merge and then
between the spinal cord and muscles. divide into smaller nerves that innervate muscles,
similar to branches growing out from a tree trunk. For
• 31 pairs of spinal nerves link the muscles from
example, axons from the C5, C6, and C7 spinal nerves
neck to feet with the spinal cord. Because this
merge to form the musculocutaneous nerve that inner-
information travels in the periphery of the CNS, it’s
vates the biceps. And the axillary nerve that contracts
called the peripheral nervous system. Thus if the
the deltoid is formed by axons from the C5 and C6
CNS were downtown Chicago, the PNS would be
spinal nerves. Thus if a physical therapist suspects your
the suburbs.
C5 and/or C6 right spinal nerves are pinched, he or she
will check the strength of your right deltoid.
TRAIN YOUR BRAIN: Why are there eight pairs of cervical nerves?
A spinal nerve gets its name from the location where it exits the bones of the vertebral column. For
example, the spinal nerve that exits below the second lumbar vertebrae (L2) is the L2 spinal nerve root.
Because there are five lumbar vertebrae, there are five corresponding spinal nerves, which exit below
those vertebrae.
Then why are there eight pairs of spinal nerves in the cervical region, but only seven cervical vertebrae?
Because the spinal nerves of the cervical region exit above, instead of below, the corresponding verte-
brae. Therefore, the C1 spinal nerve exits above the C1 vertebrae and the C2 spinal nerve above the C2
vertebrae, and this above-the-vertebrae arrangement continues until the final C7 vertebrae. That allows
room beneath the C7 vertebrae for an extra spinal nerve, and then the below-the-vertebrae arrange-
ment continues down the rest of the vertebral column.

52 | Unit 3
Lower motor neuron: A

peripheral nervous system
Lower Motor Neurons
cell whose cell body is in the
Don’t let the word “lower” fool you: A lower motor neuron carries information that
brainstem or spinal cord that leads to muscle contraction. It can extend from any part of the brainstem or spinal
innervates muscles or glands. cord to control muscles in the face, the toes, or any place in between. Put another way,
Motor unit: A lower motor
it has nothing to do with being “low” in the nervous system.
neuron and all the muscle fibers Each muscle is innervated by many lower motor neurons, each of which controls many
it innervates.
muscle fibers. The combination of a single motor neuron and the fibers it innervates is
Henneman’s size principle: a motor unit.
The fixed, orderly recruitment
of motor neurons from smallest This arrangement allows the nervous system to gradually increase the force a muscle
to largest. produces. When the nervous system determines that the muscle requires relatively
Motor neuron pool: A little force, it activates relatively few motor units, and the ones it activates deploy the
vertical column of cell bodies muscle’s smallest fibers. When higher levels of force are required, the nervous system
within the spinal cord that brings in larger motor neurons, which activate more and bigger fibers. This order of
innervate a single muscle. recruitment is known as Henneman’s size principle.
Motor Neuron Pools

The cell bodies of the lower motor neurons cluster in vertical columns within the gray
matter of the spinal cord to form a motor neuron pool. Every muscle has a motor
neuron pool, which can span multiple segments within the spinal cord. For example,
as mentioned earlier, the neurons that innervate the biceps come out of three spinal
nerves: C5, C6, and C7. You can think of it as three highways that originate in three
distinct parts of a city but all travel to the same suburb.
The motor neuron pool can be activated by signals from the brain or from circuits
Figure 3.6. Motor neuron pool for the biceps. The cell bodies of lower motor neurons are arranged in vertical columns
that form a motor neuron pool. The motor neuron pool can span multiple segments within the spinal cord, as seen with the
biceps.
Corrective Exercise
within the spinal cord. How does the brain do this? How does it
feel what the muscle is doing? The answer starts with the pathways,
formed by upper motor neurons, where information travels from
the brain down to the motor neuron pools. That’s the focus of the
next section.
Motor Commands
Contract your right calf muscle. What just happened? Obviously, you
sent a signal from your brain to the muscle. But how did it get there?
Voluntary movement starts in the cerebral cortex, the outermost
layer of the brain. It’s approximately the size of a dinner napkin and
one-third as thick as a deck of cards. It wraps around the deeper
layers of the brain to form folds and ridges.
More specifically, voluntary movement is planned, initiated, and
directed by the motor cortex, a combination of three cerebral cortex
regions: premotor cortex, primary motor cortex, and supplementary
motor area.
The motor cortex communicates with lower motor neurons through Figure 3.7. Motor cortex. The premotor cortex,
pathways called neural tracts. Unlike spinal nerves, which carry primary motor cortex, and supplementary motor
area work together to plan, initiate, and direct
both motor and sensory neurons, neural tracts specialize in one or
movement.
the other. Thus, we have descending tracts for sending motor infor-
mation down toward the muscle and ascending tracts for sending
sensory information back up to the brain. Upper motor neuron: A
central nervous system cell
that synapses with lower motor
Descending (Motor) Tracts neurons.
Within the brain are eight descending tracts formed by the axons of upper motor neu- Cerebral cortex: The
rons. Three originate in the motor cortex; they’re charged with planning, initiating, outermost layer of the brain.
and directing movement. The others, which originate in the brainstem, control facial Motor cortex: The region
movement and posture. Those are mostly involuntary reflex actions. Unless you think of the brain consisting
of the premotor cortex,
primary motor cortex, and
supplementary motor area that
primarily controls movement.
TRAIN YOUR BRAIN: How do nerves heal? Neural tract: A bundle of
axons within the CNS that
Let’s say you’re in an accident and suffer a deep cut to your forearm.
carries motor or sensory
As long as the injury isn’t too severe, the nerves that control your hand information.
muscles will soon heal, restoring your motor and sensory functions. Descending tract: A bundle
of upper motor neuron axons
It’s possible because the two ends of a severed nerve continue that travel through the spinal
signaling each other, similar to the way you can sound an alarm in cord to activate lower motor
your cell phone if you forget where you left it. The signals tell the neurons.
nerves where to reattach, and the healing process closes the distance Ascending tract: A bundle
of axons that carry sensory
between them at a rate of approximately one millimeter per day. Un-
information through the spinal
fortunately, and often tragically, nerves within the spinal cord don’t cord to the brain.
have this same ability.

54 | Unit 3
Figure 3.8. Descending motor tracts. The eight tracks are represented on the right
and left side of the spinal cord.
someone’s looking, you don’t waste a

lot of energy controlling your facial
expressions or focusing your posture DESCENDING TRACTS
when sitting or standing. upper motor neurons
And yet, those involuntary actions Motor Cortex
are an essential aspect of complex plan / initiate / direct movement
movement. For example, if you press
a dumbbell overhead while standing, Brainstem
control movement / posture
your focus is on the moving parts in
your shoulder and elbow joints, not
on the long list of trunk and lower
body muscles that contract to keep
you upright. Motor Neuron Pools
lower motor neurons
Figure 3.8 shows the names and
locations of the eight descending
tracts.
Figure 3.9 illustrates how informa-
SKELETAL MUSCLES
tion flows from your brain to your
muscles.
Now we’ll look at how sensory infor-
mation flows in the opposite direc- Figure 3.9. The pathway between descend-
tion—from muscles and joints to the ing tracts and skeletal muscles.
spinal cord and then up to the brain.
SENSORY FEEDBACK
Imagine this: You’re standing blindfolded with your body relaxed, and someone
lifts one of your arms up and out to the side. You didn’t send a signal from your
brain telling your arm to move, and because of the blindfold, you can’t see that your
arm has moved. But you still know exactly where it is. Now imagine that, while still
Corrective Exercise
TRAIN YOUR BRAIN: What makes your arm “fall asleep”?
We’ve all experienced that nagging sensation of position for an extended period, is like putting a
numbness when your arm or leg “falls asleep.” kink in a garden hose. The limb can’t give ade-
There’s a fairly simple explanation: nerves receive quate sensory feedback, and it feels numb. Fortu-
oxygen and other nutrients from the blood. With- nately, the fix is easy and intuitive: move the limb
out a steady supply, nerves can’t transmit their around as much as possible to restore the blood
signals correctly. Lying on your arm in the wrong supply to the nerves.
blindfolded, someone hands you a barbell and tells you to lift it. Even though you Pyramidal tract: A pathway
can’t see exactly how much weight you’re lifting and lowering, the tension in your from the motor cortex that
helps regulate voluntary
muscles gives you a sense of whether the barbell is heavy or light. The important
movement.
information comes to you through proprioceptors that are located in the muscles and
joints and reach your brain through the ascending tracts. Extrapyramidal tract: A
pathway from the brainstem
that helps regulate involuntary
Ascending (Sensory) Tracts movement.
Proprioceptors: Sensory
Figure 3.10 illustrates the five ascending tracts that carry sensory information receptors in the muscles and
through the spinal cord up to the brain. Because the tracts are composed of axons joints that transmit information
covered in myelin, they’re contained in the white matter. Collectively, they communi- to the CNS.
cate the sensations of proprioception, touch, pain, pressure, and vibration.
Figure 3.10. Sensory and motor tracts. The sensory (ascending) tracts go up to the brain; the motor (descending) tracts
travel down from the brain. The sensory and motor tracts are represented on each side of the spinal cord. This figure shows the
cervical region of the spinal cord because some of the tracts aren’t present farther down the cord.

56 | Unit 3
TRAIN YOUR BRAIN: Why practice doesn’t make perfect.

When you repeatedly perform any movement, from shooting a bas-
ketball to lunging with dumbbells, your brain develops what’s called a
motor program. It’s a blueprint of the act, an effortless and automatic
movement your body can perform without you having to give it much
thought. Any movement you practice will be stored as a motor program.
If you practice a movement incorrectly, like jumping off the wrong foot
to shoot layups or rounding your back on a deadlift, your motor program
will give you a blueprint for bad form. The longer you reinforce that pro-
gram, the harder it will be to insert a new program in its place.
This is why it’s not enough to tell your children or athletes or clients that
“practice makes perfect.” It’s only true if you practice in a way that wires
your brain with the best possible technique. In other words, perfect prac-
tice makes perfect.
INTERNEURONS
So far we’ve focused on how muscles are activated and probably did so in more detail
than you expected. But we need to go even deeper and examine another aspect of
movement: how the nervous system inhibits a muscle. For that it turns to interneu-
rons, which, among many other duties, inhibit other neurons.
For a joint to move, the agonist muscle must be activated while the antagonist is
inhibited. For example, during elbow flexion, the descending tracts send a signal to
the motor neuron pool that activates the biceps while simultaneously signaling the
DESCENDING TRACTS
upper motor neurons
Motor Cortex
plan / initiate / direct movement
Brainstem
Interneurons Motor Neuron Pools

lower motor neuron integration lower motor neurons
SKELETAL MUSCLES
Figure 3.11. Pathways that influence muscle activity. The descending tracts acti-
vate motor neuron pools that contract muscles and interneurons that inhibit motor neuron
pools to the muscles that need to remain relaxed.
Corrective Exercise
TRAIN YOUR BRAIN: Why do we need sleep?

Scientists always knew that sleep was important, but they weren’t really
sure why. It appears that sleep opens up vascular areas of the brain between
neurons. This open space allows cerebral spinal fluid (CSF) to rush in and
“flush out” waste products. Indeed, it appears that CSF scrubs the brain free
of debris while you sleep. Think of CSF as your brain’s housekeeper.
pool that inhibits the triceps. Inhibition of the triceps requires an extra neuron — the Muscle spindle: A sensory
interneuron — to function as a roadblock. receptor within the skeletal
muscle belly that detects
changes in muscle length.
Spinal Cord and Brainstem Circuits Golgi tendon organ (GTO):
A sensory receptor within
Interneurons are also influenced by two sensory receptors in muscle: the muscle spin- the tendons of a muscle that
dle and Golgi tendon organ (GTO). detects changes in muscle
tension.
The muscle spindle is positioned parallel to muscle fibers, allowing it to lengthen or
shorten in sync with the muscle. That’s its job: to detect changes in muscle length due Alpha-gamma co-
activation: A process that
to alpha-gamma co-activation.
allows a muscle spindle to
When a muscle lengthens rapidly, a potentially injurious action, the muscle spindle contract at the same rate as the
sends a distress signal into the spinal cord. There it forms two synapses: one with the muscle where it resides.
muscle that’s being stretched and the other with its antagonist. This reciprocal inner- Stretch Reflex: A neural
vation causes the muscle that’s being stretched to contract and its antagonist to relax. circuit that allows activation
of a muscle to occur with
The Golgi tendon organ, located between the muscle and its tendon, detects changes simultaneous relaxation of its
in muscle tension. A muscle-generating force activates the GTO, which sends a signal antagonist.
into the spinal cord. The GTO thus helps regulate movement at all levels of force.
Figure 3.12. Stretch Reflex Circuit. When the muscle spindle is quickly stretched, it
sends a signal into the spinal cord where its sensory neuron activates two neurons: the
lower motor neuron to the biceps that makes it contract and an inhibitory interneuron
that blocks any activation out to the triceps.

58 | Unit 3
DESCENDING TRACTS
upper motor neurons
Motor Cortex
Brainstem

Sensory Feedback SKELETAL MUSCLES
Figure 3.13. Interneurons are influenced by descending tracts and sensory

feedback. Interneurons receive sensory information from the muscles and joints and
commands from the descending tracts.
To recap, sensory feedback from the muscle spindles and GTOs relay information to
the spinal cord and brain. Interneurons integrate signals to inhibit the appropriate
motor neuron pools.
Now we’ll finish with two brain structures that complete the motor system.
BASAL GANGLIA AND CEREBELLUM

So far we’ve looked at signals sent to muscles via the descending tracts and signals
received through the ascending tracts. But there’s a third part to the system: When
your brain receives information from the muscles, it needs to respond by sending back
instructions to fine-tune, coordinate, and otherwise regulate movement.
Basal ganglia: Structures Let’s return to our old friend the biceps curl. The basal ganglia would start the exer-
within the cerebrum that cise by telling the descending tracts to activate the muscles that produce elbow flexion.
communicate with the It would also regulate the movement’s smoothness and speed. If the basal ganglia
motor cortex to help initiate
movement.
become dysfunctional, movement disorders such as Parkinson’s disease or Hunting-
ton’s disease can result.
Parkinson’s disease: A
movement disorder caused by The other player is the cerebellum, which both initiates and predicts movement.
a deficiency of dopamine in the It then compares the actual motion to what it predicted and uses that information
basal ganglia. both to fine-tune the movement while it happens and to make better predictions in
Huntington’s disease: A the future. Therefore, although it doesn’t directly control movement, the cerebellum
movement disorder caused by influences movement in real time and works to make sure the movement is performed
damage to the cells of the basal a little better the next time around.
ganglia.
We’ll discuss all this in more practical terms in Unit 5.
If you’re wondering why there’s so much detail about the nervous system and how it
relates to corrective exercise, it’s because of this:
Research over the past few decades demonstrates that the way you move can have
a profound effect on the motor cortex. Thus, if a client’s brain is wired to perform a
movement incorrectly, leading to pain and dysfunction, it’s up to you to help the client
Corrective Exercise
DESCENDING TRACTS Basal Ganglia

upper motor neurons proper initiation of movement
Motor Cortex
Brainstem Cerebellum
control movement / posture sensory motor coordination

Sensory Feedback SKELETAL MUSCLES
Figure 3.14. Motor system. Parts of the motor system that collaborate to produce
voluntary and automatic movements. The interneurons and motor neuron pools are part
of circuits within the spinal cord and brainstem. (Adapted from Neuroscience, 5th Edition,
Figure 16.1).
create new connections. Those connections, over time, will change the brain’s struc-
ture and function and allow the client to do the movement correctly.
NEUROPLASTICITY
As recently as the 1980s, physicians and neuroscientists were taught that the brain Neuroplasticity: The
doesn’t change during adulthood. Sure, people could create new memories and learn brain’s ability to form new
new activities, but it was assumed that areas of the brain devoted to a specific task connections.
were structurally and functionally unchangeable.
One turning point was a landmark study published in 1995 in the Journal of Neuro-
physiology that suggested the human brain was capable of changes scientists previ-
ously had thought impossible. The study was led by Alvaro Pascual-Leone, MD, PhD,
who’s currently a professor of neurology at Harvard Medical School.
In the study, a group of people played the piano while Dr. Pascual-Leone and his team
observed brain activity following the practice. The researchers found that, within
a week, the subjects’ brains began to change. Areas of the brain that control finger
movements for playing the piano were taking over areas previously associated with
other movements.
There was even more to the study: Another group of subjects simply imagined prac-
ticing the piano, with no movement whatsoever. Surprisingly, those subjects also in-
creased the area of the motor cortex devoted to piano-playing movements. It was one
of the first studies to show that both thoughts and movements can change a brain’s
structure and function through a process called neuroplasticity.
But there’s a catch: These changes only occur if the movement or exercise is novel and
challenging. Easy exercises won’t have the same effect.
Going forward in the program, starting with the movements outlined in Unit 4, keep
in mind that your goal as a Corrective Exercise Specialist is to create these changes in
your clients to help them move better and feel better.

60 | Unit 3
TRAIN YOUR BRAIN: Why can’t you tickle yourself?
The nervous system is a bit like a professional Now imagine that you’re trying to tickle the
gambler. It makes predictions, and it needs those bottom of your foot. Your brain tells the muscles
predictions to be correct almost every time. That’s in your fingers to move. It cc’s your cerebellum,
why when you see a flight of stairs in front of you, which anticipates the sensation of fingers moving
the nervous system already has a good idea how across the bottom of your foot. The ensuing finger
to navigate those stairs and how the stairs will feel movement feels exactly the way your cerebellum
under your feet. Your brain senses these things predicted it would.
before you place a foot on the first step.
Why would that disable the sensation of being
Before you perform a movement, your brain cre- tickled? Because there has to be an element of
ates two commands. It sends the first one — “do surprise, a difference between what you thought
the movement” — down the spinal cord and out you’d feel and what actually happens. A tickle
to the muscles. At the same time, a copy of that feels like a tickle because your cerebellum doesn’t
command goes to the cerebellum, which makes a know exactly where and how someone else’s fin-
prediction about the experience of the movement gers will move, to the chagrin of every kid who’s
before anything happens. ever been tortured by his tickle-crazed older sister.
Summary
1. The nervous system has peripheral and central 6. Interneurons have a wide variety of functions
components that work together to control vol- within the brain and spinal cord. Some of the
untary and involuntary movement. interneurons within the spinal cord are con-
trolled by information they receive from sensory
2. The nervous system cells consist of neurons
receptors and the descending (motor) tracts.
and glia. Neurons produce the electrical signals
required for movement and sensory and reflex 7. The basal ganglia and cerebellum provide input
actions; glia protect and nourish the neurons. to the descending tracts to help initiate the
proper movement and then fine-tune the move-
3. Nerves and tracts form pathways through which
ment as it’s happening.
information can reach every part of the nervous
system. These pathways are formed by the axons 8. The motor cortex region of the brain that con-
of motor and sensory neurons along with inter- trols voluntary movement can reorganize its con-
neurons. nections to influence the structure and function
of the motor system in response to practicing
4. Skeletal muscle is activated by the lower motor
novel and skilled movements.
neurons within a motor neuron pool.
5. A motor neuron pool is controlled by descend-
ing pathways from the brain and interneurons
within the spinal cord.
Corrective Exercise
How to Reference
Locations of the Body
Anatomical Position
Anatomical Terms of Location
Planes of Movement
How to Use This Information
Joint Actions
Cervical Spine Actions and Muscles
Shoulder Girdle
Thoracic and Lumbar Spine Actions
and Muscles
Hip Actions and Muscles
Knee Actions and Muscles
Elbow Actions and Muscles
Wrist Actions and Muscles
Ankle/Foot Actions and Muscles
UNIT 4
JOINT ACTIONS
62 | Unit 4
What You’ll Learn

In Unit 1, you learned about the bones of the human body and how they form joints. Then in Unit 2, the names and
locations of the muscles that can move those joints were outlined. As we progressed through Unit 3, we covered
the ways the nervous system controls those muscles. Now it’s time to explain the basic actions that each joint can
perform, from the neck to the feet.
We’ll start with the key terms that reference anatomical locations of the body. Then we’ll outline the muscles that
drive each basic movement a joint can perform. These single-joint motions are essential to understand because they
form the multi-joint (compound) movement patterns discussed later in this course. However, we must first start by
explaining which movements occur at which joints along with the muscles that drive those motions.
HOW TO REFERENCE
LOCATIONS OF THE BODY
Anatomical position: Every good system needs a point of reference: in other words, a starting point. The hu-
The position from where all
man body is no exception. Therefore, we’ll start by explaining what the standard start-
locations of the body and
movements are referenced. ing position is and how it determines the way all locations of the body are described.
ANATOMICAL POSITION
The anatomical position is the reference point for all locations within the human
body. This formation is seen when a person is standing erect with the shoulder joints
externally rotated and palms facing forward.
ANATOMICAL TERMS OF LOCATION

Let’s say your job is to design a map that describes locations of the body in reference
to each other. At first, you might think of using the terms “above” and “below.” For
example, you decide to say that the left shoulder is above the right hip.
This set of descriptions will suffice when a person is standing, but what happens when
that person lies on his or her left side?
Now the left shoulder is below the right hip. In other words, this system wouldn’t
work, because a body part that is “below” another body part would shift based on
whether the person was standing or lying on his or her side.
Thus you scratch that idea and decide to use the terms “up” and “down.” But you
quickly run into the same problem. For example, which way is up? Is it toward the
head or toward the sky? The same challenge presents itself when using “top” and “bot-
tom.” But you’re smart, so you design a system of terms that works no matter whether
a person is standing, lying, or situated in any other possible position. And you want
to be concise, so instead of making people always say the phrase “toward the top of
the head,” you develop a single word that means the same thing. This is exactly what
anatomists did.
Figure 4.1. Anatomical position. We will now cover the most common terms used for describing the position of the
The anatomical position is the refer- muscles, joints, or bones in relation to each other, from front to back and head to
ence point for all locations in the body. toe. However, there’s one caveat: this naming system consists of two terms that both
Corrective Exercise
Joint Actions | 63
describe the same thing. Nevertheless, it’s essential to memorize the following 12
terms because they form the basis of human anatomy.
Ventral/anterior: These terms describe the front of the body from the neck to the Ventral: The anterior portion
feet. For example, the quadriceps are ventral (anterior) to the hamstrings. of the body. Dorsal: The
posterior portion of the body.
Dorsal/posterior: This pairing describes the back of the body from the neck to the Cranial: Toward the top of the
feet. The hamstrings are dorsal (posterior) to the quadriceps. head.
Superior/inferior: These terms can reference any position of the body from head
to toe. Superior is toward the top of the head; inferior is toward the bottom of the
feet. The sternum is superior to the pelvis, and the pelvis is inferior to the sternum.
Cranial/caudal: This pairing describes positions from the top of the head down Caudal: Toward the feet.
to the pelvis, without regard for the limbs. So cranial is toward the top of the head,
and caudal is toward the pelvis. The pectorals are cranial to the abdominals, and the
abdominals are caudal to the pectorals. Medial: Toward the midline of
the body.
Medial/lateral: From an anterior view of the anatomical position, the midline refers
to an imaginary vertical line that intersects the eyes, pelvis, and feet. Medial refers to Lateral: Away from the
midline of the body.
a point that is closer to the midline of the body; lateral refers to a point away from the
midline. The sternum is medial to the shoulders, and the shoulders are lateral to the Proximal: Moving closer to
sternum. where a limb attaches to the
trunk.
Proximal/distal: These terms are typically used in reference to the limbs. Proximal
is toward the trunk; distal is away from the trunk. The hip is proximal to the knee, and Distal: Moving away from
the knee is distal to the hip. The elbow is proximal to the wrist, and the wrist is distal where a limb attaches to the
to the elbow. trunk.
Figure 4.2. Anatomical terms of location. Medial is toward the midline of the body,
and lateral is the opposite direction. Proximal refers to the portion of the limbs closest to
the trunk, and distal is the opposite. Cranial is toward the head, and caudal is toward the
pelvis. Ventral is anterior and dorsal is posterior.

64 | Unit 4
PLANES OF MOVEMENT
Sagittal plane: An imaginary Three imaginary planes describe the direction of movements or the location of body
plane that divides the body into
structures. They consist of the sagittal plane, frontal plane, and transverse plane.
right and left segments.
The frontal plane also refers to the coronal plane, and the transverse plane is often
Frontal plane: An imaginary called the axial plane, depending on the source. The following information will de-
plane that divides the body
scribe these “three” planes and their associated movements.
into anterior and posterior
segments. Sagittal plane: This plane divides the body into right and left segments. Move-
Transverse plane: An
ments associated with the sagittal plane are flexion and extension.
imaginary plane that divides Frontal (coronal) plane: The frontal plane, or coronal plane, separates the body
the body into superior and into ventral (anterior) and dorsal (posterior) segments. Movements associated with
inferior segments. this plane are abduction, adduction, and lateral flexion.
Coronal plane: An imaginary Transverse (axial) plane: The transverse plane, or axial plane, separates the body
plane that divides the body
into superior and inferior segments. The movement associated with this plane is
into anterior and posterior
rotation.
segments.
Axial plane: An imaginary It is essential to understand that many movements, whether in sports or daily life, take
plane that divides the body into place in more than one plane. Throwing a baseball, shooting a basketball, and kicking a
superior and inferior segments. soccer ball are examples of multiplanar motions. In fact, it’s rare for any motion to be
Multiplanar motion: purely limited to one plane, unless a person is performing a movement using an exercise
Movement that occurs in more machine with a fixed axis. Nevertheless, it’s important to memorize the three primary
than one plane. anatomical planes because they’re frequently mentioned in literature and research.
Figure 4.3. Planes of movement. The sagittal, frontal (coronal), and transverse (axial)
planes are used to describe the direction of movement or the location of body structures
Corrective Exercise
Joint Actions | 65
HOW TO USE THIS INFORMATION

The following sections depict and outline the primary actions of all major joints and
the muscles that perform those actions. However, before we get to those elements, two
crucial elements must be explained. First, we will cover what the arrows in the photos
represent. Second, we will explain the relationship between joint movement and the
direction of resistance. Direction of resistance:
A vector that represents the
A joint can only rotate. Therefore, the arrows in the photos represent the joint’s direc- direction and magnitude
tion of rotation. of load produced by a free
weight, a cable, or a band.
Figure 4.4.
Relationship be- Direction of rotation: The
tween the arrow curved direction of movement
and joint action. around an axis.
A) The arrow depicts
the right elbow’s
direction of rotation.
=
B) The “phantom
limb” starting posi-
tion is omitted from
photos in this unit
for the purpose of
clarity.
For each joint movement, such as elbow

extension shown in Figure 4.4, the muscles
that drive each motion will be listed in this
chapter. However, it is critical to understand
that the muscles listed relate specifically to the
direction of resistance being in the opposite
direction of the arrow.
For any free weight, whether it’s a dumbbell or
a medicine ball, the direction of resistance is
always straight down due to gravity. There-
fore, for the triceps’ muscles to perform elbow
extension, the direction of resistance must be
opposite the direction of rotation. Thus, if the
direction of resistance needs to be anything
other than straight down toward the earth, it
must be supplied by a cable or band.
Now that we’ve covered the way you’ll deci-
pher the photos in this unit, let’s move on to
the joint actions and their associated muscles.
Figure 4.5. Direction of rota-
tion and direction of resistance.
The direction of resistance must be
opposite the direction of rotation to
explain the muscles listed in this unit.

66 | Unit 4
JOINT ACTIONS
When you observe a movement that is dysfunctional, you must know which muscles
driving that motion. This creates an invaluable skill set for any trainer or therapist
because it allows you to know the exact muscles that might require more strength or
mobility. Therefore, the following section will provide you with the information you’ll
need, from the neck down to the feet.
CERVICAL SPINE ACTIONS AND MUSCLES

The cervical spine consists of seven cervical vertebrae (C1-C7). This region of the neck
is designed for mobility so it can perform a wide range of movements. The cervical
spine can produce four primary movement patterns in all three anatomical planes.
Flexion and extension occur in the sagittal plane, rotation is in the transverse plane,
and lateral flexion is in the frontal plane. The sternocleidomastoid muscle of this re-
gion is unique, as it can perform two opposing actions—flexion and extension—due to
its broad range of attachment points.
Figure 4.6. Cervical flexion and extension

Action
Flexion Extension
Motion
Platysma, scalenus anterior, and Rectus capitis posterior major/mi-

Muscles
sternocleidomastoid (flexes lower nor, obliquus capitis superior, and

cervical). sternocleidomastoid (extends upper
cervical).
Corrective Exercise
Joint Actions | 67
Figure 4.7. Cervical rotation and lateral flexion

Action
Rotation Lateral flexion

Motion
Rectus capitis posterior major/minor Obliquus capitis superior, sternoclei-

and obliquus capitis inferior. The ster- domastoid, and scalenus posterior/
nocleidomastoid, scalenus posterior, medius/anterior.
Muscles
and scalenus medius/anterior per-

form rotation from the contralateral
side of the movement (e.g., the left
sternocleidomastoid rotates the head
to the right).
SHOULDER GIRDLE
The “shoulder” is often thought of as the attachment where the upper arm meets
the trunk. However, this region refers to the glenohumeral (GH) joint, just one of
Shoulder girdle: Where the
three primary joints that form the shoulder girdle. There is also an acromioclavic- clavicle and scapula connect
ular (AC) joint where the clavicle attaches to the uppermost portion of the scapula the humerus to the axial
(acromion) and a sternoclavicular (SC) joint where the medial portion of the clavicle skeleton.
attaches to the sternum.
There is also a fourth “joint,” the scapulothoracic (ST) joint, where the scapula sits
close to the ribcage. But it’s not a true joint with respect to the strictest definition of
the word, as discussed later.
Movements of the shoulder girdle are primarily driven by muscles that cross the
glenohumeral and scapulothoracic joints. Therefore, the 14 primary movements of the
shoulder girdle are described at these two joints. However, it should be remembered that
the acromioclavicular and sternoclavicular joints also contribute to these 14 movements.
The following sections outline the primary movements and muscles of the shoulder
complex.

68 | Unit 4
Glenohumeral (GH) Joint Actions and Muscles

The glenohumeral (GH) joint is formed by the round convex head of the humerus
sitting against the inward concave surface of the glenoid fossa. Think of the convex
head of the humerus as being the rounded portion of a cue ball cut in half and the
concave surface of the glenoid as being the curved center of a porcelain soap dish. This
convex-on-concave combination decreases stability of the GH joint, but it allows for a
wide range of motion in all three planes.
Figure 4.8. Glenohumeral flexion and extension

Flexion Extension
Action
Extension continues until the arms

lower and move behind the body as
far as possible.
Motion
Anterior deltoid, pectoralis major Posterior deltoid, latissimus dorsi,

Muscles
(clavicular and sternal heads), coraco- triceps brachii (long head), and the
brachialis, and biceps brachii (long pectoralis major (sternal head) when
and short heads). the GH joint is flexed >30°.
Figure 4.9. Glenohumeral horizontal adduction and abduction

Action
Horizontal adduction Horizontal abduction

Motion
Pectoralis major (clavicular and sternal Teres major/minor, infraspinatus, pos-

Muscles
portions), subscapularis, anterior terior deltoid, and latissimus dorsi.

deltoid, and coracobrachialis.
Joint Actions | 69
Figure 4.10. Glenohumeral abduction and adduction

Abduction Adduction
Action
Abduction continues to the maximum Adduction continues down and across
end range overhead. the midline of the body.
Motion
Supraspinatus, middle deltoid, ante- Latissimus dorsi, teres major, pecto-

rior and posterior deltoids when the ralis major (sternal portion), coraco-
Muscles
GH joint is abducted >60° and the brachialis, pectoralis major (clavicular

pectoralis major (clavicular portion) portion) when the GH joint is adduct-
when the GH joint is abducted >90°. ed <90° and the anterior/posterior del-
toids when the GH joint is adducted
<60°.
Figure 4.11. Glenohumeral internal and external rotation

Internal rotation External rotation with the GH joint
Action
abducted to 90°.
Movement continues until the end of
the range of motion. Movement continues until the end of
the range of motion.
Motion
Subscapularis, anterior deltoid, latissi- Teres minor, infraspinatus, and poste-

Muscles
mus dorsi, teres major, and pectoralis rior deltoid.

major (clavicular and sternal heads).

70 | Unit 4
Scapulothoracic (ST) Joint Actions and Muscles

The scapulothoracic (ST) joint is the position between the anterior portion of the scapula
and the ribcage. This region isn’t a true “joint,” because it lacks a ligamentous connec-
tion between the scapula and ribcage. However, it is an essential component of shoulder
motion. The ST joint can produce six primary movements: upward/downward rotation,
retraction/protraction (i.e., adduction/abduction), and elevation/depression.
Figure 4.12. Scapulothoracic elevation and depression

Action
Elevation Depression
Motion
Upper trapezius, rhomboid major/mi- Lower trapezius, pectoralis minor,

Muscles
nor, levator scapulae, and the serratus latissimus dorsi, and the serratus ante-
anterior (superior portion). rior (inferior portion).
Corrective Exercise
Figure 4.13. Scapulothoracic upward and downward rotation
Action
Upward rotation Downward rotation
Motion
The lines depict the medial border of the scapula

Upper/lower trapezius and the serra- Rhomboid major/minor, levator scap-
Muscles
tus anterior (inferior portion). ulae, pectoralis minor, latissimus dor-

si, pectoralis major (sternal portion),
and the serratus anterior (superior
portion).
Figure 4.14. Scapulothoracic retraction and protraction

Action
Retraction Protraction
Motion
The medial border of the scapula is depicted by the black line.

Upper and lower trapezius, rhomboid Pectoralis minor, pectoralis major
Muscles
major/minor, latissimus dorsi, and the (sternal portion), and the serratus an-
serratus anterior (superior portion). terior (superior and inferior portions).
72 | Unit 4
THORACIC AND LUMBAR SPINE ACTIONS AND MUSCLES

The thoracic spine consists of 12 vertebrae (T1–T12) that run from the base of the neck
to approximately two-thirds of the way down the spine. The lumbar spine is composed
of five vertebrae (L1-L5) in the low back region. Flexion and extension of the thoracic
spine and lumbar spine are described together in this section because they typically
move in sync and because many of the same muscles drive both motions.
Figure 4.15. Thoracic and lumbar flexion and extension

Action
Flexion Extension
Motion
Rectus abdominis, internal/external Splenius, iliocostalis, longissimus, spi-

Muscles
obliques, serratus posterior inferior nalis thoracis, semispinalis, multifidus,

(pulls ribcage downward), and trans- rotatores, interspinalis, and quadratus
versus abdominis (activated when the lumborum.
client pulls the abdomen inward).
Figure 4.16. Rotation and lateral flexion

Action
Rotation Lateral flexion

Motion
Internal oblique, external oblique External/internal obliques, splenius,

(from contralateral side), splenius, iliocostalis, longissimus, spinalis tho-
iliocoastalis, longissimus and spinalis. racis, semispinalis, multifidus, rota-
Muscles
The external oblique, semispinalis, tores, intertransversarii, and quadra-

multifidus, and rotatores perform tus lumborum.
rotation from the opposite side of the
movement’s direction (i.e., the right
external oblique rotates the thoracic
spine to the left).
Joint Actions | 73
HIP ACTIONS AND MUSCLES

The hip is a ball-and-socket joint, much like the glenohumeral joint of the shoulder.
The convex head of the femur sits against the concave surface of the acetabulum of
the pelvis to create a joint capable of a large range of motion. It can act in all three
planes of movement to perform flexion, extension, abduction, adduction, and inter-
nal/external rotation.
Figure 4.17. Hip internal and external rotation

Action
Internal rotation External rotation

Motion
Tensor fascia latae, pectineus, adduc- Gluteus maximus, gluteus medius/

tor longus/brevis, adductor magnus minimus (posterior portions), gemel-
Muscles
(anterior portion), and gluteus medi- lus superior/inferior, obturator inter-

us/minimus (anterior portions). nus/externus, psoas, iliacus, sartorius,
piriformis and adductor magnus
(posterior portion).

74 | Unit 4
Figure 4.18. Hip flexion and extension

Flexion Extension is the reverse of flexion,
Action
and it continues as far as the leg can
travel behind the body.
Motion
Psoas, iliacus, sartorius, tensor fascia Gluteus maximus (upper/lower

latae, pectineus, gracilis, rectus femo- portions), piriformis, semitendinosus,
Muscles
ris, gluteus medius/minimus (anterior semimembranosus, biceps femoris

portion), adductor magnus (anterior (long head), adductor magnus (poste-
portion), and adductor longus/brevis rior portion), obturator internus, and
(up to 70° of hip flexion). gemellus superior/inferior.
Figure 4.19. Hip abduction and adduction

Action
Abduction Adduction
Motion
Gluteus maximus (upper portion), Gluteus maximus (lower portion), ad-

gluteus medius/minimus, sartorius, ductor magnus/longus/brevis, gracilis,
Muscles
tensor fascia latae, and piriformis. pectineus, quadratus femoris, and

The gemellus superior/inferior and obturator externus. The gemellus su-
obturator internus work at >30° of hip perior/inferior and obturator internus
abduction. work at <30° of hip abduction.
Joint Actions | 75
KNEE ACTIONS AND MUSCLES

The knee is a pseudo hinge joint and the largest joint in the human body. It primarily
performs flexion and extension but is also capable of a small amount of internal and
external rotation from muscles that attach at the tibia. There are two areas of articula-
tion in the knee: one between the femur and tibia and another between the femur and
patella (kneecap).
Figure 4.20. Knee flexion and extension

Action
Flexion Extension
Motion
Semitendinosus, semimembrano- Rectus femoris and vastus lateralis/

Muscles
sus, biceps femoris (long and short medialis/intermedius.

heads), popliteus, gracilis, plantaris
and gastrocnemius.
Figure 4.21. Tibial internal and external rotation

Action
Internal rotation External rotation

Motion
Sartorius, gracilis, semimembrano- Biceps femoris (long and short heads).

Muscles
sus, semitendinosus, and popliteus.

76 | Unit 4
ELBOW ACTIONS AND MUSCLES

The elbow consists of articulations between the humerus, radius, and ulna. This
collection of bones creates three joints: humeroulnar, humeroradial, and proximal
radioulnar joints.
The humeroulnar and humeroradial joints produce flexion and extension, and the
proximal radioulnar joint allows the forearm to supinate and pronate. One muscle
within this region, the brachioradialis, is unique because it can assist in three move-
ments: elbow flexion, forearm supination, and forearm pronation.
Figure 4.22. Elbow flexion and extension

Action
Flexion Extension
Motion
Biceps brachii (long and short heads), Triceps brachii long/medial/short

Muscles
brachialis, and brachioradialis. heads, and anconeus.
Figure 4.23. Forearm supination and pronation

Action
Supination Pronation
Motion
These movements occur at the proximal radioulnar joint.

Supinator, biceps brachii (long and Pronator teres, pronator quadratus,
Muscles
short heads), and brachioradialis. and brachioradialis.

Joint Actions | 77
WRIST ACTIONS AND MUSCLES

The wrist is a complex structure typically defined as the area where the radius meets the
eight small carpal bones. For simplicity, this section will focus on four primary move-
ments the wrist performs: flexion, extension, radial deviation, and ulnar deviation.
Figure 4.24. Wrist flexion and extension

Action
Flexion Extension
Motion
Flexor digitorum superficialis, flexor Extensor carpi radialis (longus and

Muscles
carpi radialis, flexor carpi ulnaris, brevis), extensor digitorum, extensor

palmaris longus, and flexor digitorum carpi ulnaris, and extensor indicis.
profundus.
Figure 4.25. Radial and ulnar deviation

Action
Radial deviation Ulnar deviation

Motion
Extensor carpi radialis (longus and Extensor carpi ulnaris and flexor carpi
Muscles
brevis) and flexor carpi radialis. ulnaris.

78 | Unit 4
ANKLE/FOOT ACTIONS AND MUSCLES

The ankle joint is formed by three bones: the tibia and fibula of the lower leg and the
talus of the foot. This hinge joint only moves in the sagittal plane to produce dorsiflex-
ion and plantarflexion.
The area between the inferior portion of the talus and the superior portion of the
Subtalar joint: Where the calcaneus (heel bone) form the subtalar joint. This joint allows for inversion/eversion
talus and calcaneus meet in the and abduction/adduction of the foot.
foot.
Pronation and supination are triplanar motions of the ankle and foot joints. Prona-
Triplanar motion: Movement
that occurs in the three
tion, a movement that places the weight on the medial side of the foot, is a combina-
anatomical planes. tion of dorsiflexion, abduction, and eversion. Supination is a combination of plantar-
flexion, adduction, and inversion.
Figure 4.26. Plantarflexion and dorsiflexion

Action
Plantarflexion Dorsiflexion
Motion
Gastrocnemius, soleus, plantaris, Tibialis anterior, extensor digitorum

tibialis posterior, flexor digitorum longus, extensor hallucis longus, and
Muscles
longus, flexor hallucis longus, and peroneus tertius (i.e., fibularis tertius).
peroneus longus/brevis (i.e., fibularis
longus/brevis).
The subtalar joint (i.e., talocalcaneal joint) is the area between the inferior portion of
the talus and the superior portion of the calcaneus (heel bone). The primary move-
ments at this joint are inversion and eversion, although adduction and abduction oc-
cur with those motions too. Inversion is paired with adduction, and eversion is paired
with abduction.
Corrective Exercise
Joint Actions | 79
Figure 4.27. Inversion, eversion, adduction and abduction of the

subtalar joint
Action
Inversion Eversion
Motion
Action
Adduction Abduction
Motion
(for both inversion and adduction) (for eversion and abduction)

Gastrocnemius, soleus, plantaris, tibi- Tibialis anterior, extensor digitorum
Muscles
alis posterior, flexor digitorum longus, longus, extensor hallucis longus, and
flexor hallucis longus, and peroneus peroneus tertius (i.e., fibularis tertius).
longus/brevis (i.e., fibularis longus/
brevis).
The terms inversion and pronation or eversion and supination are commonly used
interchangeably. However, it is not correct to do so. Pronation and supination are a
combination of three movements, in the three anatomical planes, which occur simul-
taneously at the ankle and subtalar joints.

80 | Unit 4
Figure 4.28. Pronation and supination of the ankle/foot region

Pronation is a triplanar motion that Supination is the combined mo-
Action
occurs from dorsiflexion, eversion, tion of plantarflexion, inversion, and
and abduction. adduction.
Motion
Gastrocnemius, soleus, plantaris, Tibialis anterior, extensor digitorum

Muscles
tibialis posterior, flexor digitorum longus, extensor hallucis longus, and

longus, flexor hallucis longus, and peroneus tertius (i.e., fibularis tertius).
peroneus longus/brevis (i.e., fibularis
longus/brevis).
As we close out Unit 4, you’ve developed a thorough understanding of the muscles that
produce each primary joint action. Even though this section of the course is focused
on theoretical elements, it still contains practical applications. Indeed, any of the
movements described within this unit can be used as standalone exercises to strength-
en the corresponding muscles. The application is as simple as is providing a direction
of resistance that’s opposite of the direction of rotation for each joint.
Summary
1. The anatomical position is the reference point for describing all loca-
tions of the human body.
2. The anatomical terms of location describe the position of body parts
no matter how the body is positioned in space.
3. The sagittal, frontal, and transverse planes describe the direction of
movement or locations of body parts.
4. The direction of resistance is a vector that describes the orientation
and magnitude of load.
5. The direction of rotation is the angle that a joint rotates around its axis.
6. A multiplanar movement occurs in more than one anatomical plane,
and a triplanar movement occurs in all three anatomical planes.
7. To strengthen a movement, the direction of resistance must be posi-
tioned opposite the direction of rotation.
Corrective Exercise
Movement Overview
Balance
Sense of Balance (Equilibrium)
Motor Program
Motor Learning
Closed-Loop Motor Control
Synaptic Plasticity
Open-Loop Motor Control
Motor Learning Overview
UNIT 5
MOVEMENT
82 | Unit 5
What You’ll Learn

In Unit 1 you learned how the skeletal system forms the structure for the human body and the joints it cre-
ates to allow movement. Then in Unit 2 we covered how muscles provide the contractile tissue to potential-
ly move and stabilize those joints. As we moved into Unit 3, you learned how the nervous system controls
the muscles that, in turn, move the joints. In Unit 4 you learned the basic actions of the joints and the mus-
cles that drive those motions. Now it’s time to apply that information to complex movement patterns.
In this unit, you will learn the components necessary for optimal movement mechanics. We’ll start with
balance and explain how the body uses feedback from three different systems to maintain it. Then we’ll
move on to elements of motor learning and cover the ways the nervous system learns a new movement and
eventually makes that movement automatic. At the end of this unit you should understand the mechanisms
that regulate balance and motor learning.
MOVEMENT OVERVIEW
Imagine seeing a Lamborghini race down a long stretch of interstate. The movement
of the car would be easy to describe: it’s traveling in a straight line. However, if you
had to explain the Lamborghini’s inner workings that allow it to move straight ahead,
your understanding of the car would have to be more complex.
There is a chassis that forms the structure of the car, an engine that produces the
torque to make the wheels rotate, and numerous sensors throughout the engine and
drivetrain that constantly give feedback to a computer so it can make adjustments.
This analogy is fitting because it also describes how the human body works to produce
movement.
The skeletal structure forms the chassis. Muscle is the engine that produces torque at
the joints so they will rotate. And sensors within the muscles and joints (i.e., sensory
receptors) give feedback to the body’s computer, the brain, so it can make any neces-
sary adjustments during movement. Indeed, movement requires a complex interplay
between the joints, muscles and nervous system. That is why we delved deep into those
components in units 1-4.
As a Corrective Exercise Specialist, your job is to watch clients move and possess
the skill set to derive insightful information from their movement patterns. (Section
Two covers what you should do once you see a movement problem.) But for now, it’s
important to cover some of the essential components that drive optimal movement
and posture.
BALANCE
Within the realms of the universe, everything needs to be in balance. And the human
body is no exception. When a person stands tall with the feet shoulder width apart,
Center of mass: The point of
the body is stable. However, if the person were to lean forward there would be a point
relatively equal distribution of
mass within the human body. where balance is disrupted and the person must take a step forward to avoid falling
over. During posture and movement, the body works to maintain balance by keeping
Base of support: The area of its center of mass (COM) over its base of support (BOS).
contact beneath a person.
The COM (i.e., center of gravity) is the point of equal distribution of body mass. If
Corrective Exercise
Movement | 83
the body were rigid, the COM would be the point where it would balance evenly
on an axis, similar to a seesaw holding two people of equal weight. While standing,
and during most daily movements, the COM is between the navel and lumbar spine.
However, when lifting or carrying an external load, the COM can change based on
the position the load is held. For example, if a person holds a dumbbell in front of the
chest at arm’s length, the COM will shift forward.
Base of support (BOS) is the area of contact beneath a person. It consists of the direct
areas of surface contact and the areas in between those contact points. When stand-
ing, the BOS is the area of contact beneath both feet and the space between. In the
quadruped position, the BOS is the areas beneath the hands and feet and the entire
space between those four points of contact. The body is out of balance when the COM
falls outside the BOS.
However, a person can feel out of balance even when the COM is over the BOS. To
understand how this is possible, we’ll cover the ways the body maintains equilibrium.
center of mass
COM
base of support
BOS
Figure 5.1. Center of mass (COM) and base of support (BOS). The body maintains
balance by keeping the COM over its BOS. The body is out of balance when the COM falls
outside the BOS.

84 | Unit 5
SENSE OF BALANCE (EQUILIBRIUM)

Sense of balance: The feeling Balance and sense of balance is not the same thing. As we just covered, balance is the
of being stable due to input act of keeping the body’s center of mass over its base of support. Conversely, sense of
from the visual, vestibular and balance is the feeling of being stable.
somatosensory systems.
The nervous system maintains the body’s sense of balance by integrating the informa-
tion it receives from three sensory systems: visual, vestibular and somatosensory.
Visual system: The structures The visual system consists of feedback from the eyes to the cortex, and it helps deter-
and neurons that connect the mine body orientation and self-motion. The importance of an intact visual system isn’t
eyes to the cortex of the brain. difficult to conceive due to the fact that every imaginable movement is more difficult
to perform with the eyes closed.
Vestibular system: The The vestibular system, which consists of three fluid-filled canals within the inner ear,
structures and neurons that sends information to the brainstem where it helps coordinate movement of the eyes
connect the semicircular with movements of the head. The nauseating feelings of dizziness and vertigo are two
canals in the inner ear to the
brainstem.
side effects of a dysfunctional vestibular system.
Somatosensory system: The somatosensory system consists of receptors within the skin, muscles and joints that
The structures and neurons send information to the cerebellum, which helps control posture and gait. These three
that connect receptors within systems are constantly working together to maintain sense of balance within the body.
skin, muscle and joints to the
cerebellum. Not only does the cerebellum play an important role in balance, but it is also a key struc-
ture within the brain that facilitates a person’s ability to learn how to move correctly.
Figure 5.2. Sense of balance. The brain integrates input from the visual, vestibular and
somatosensory systems to maintain the sense of balance.
Corrective Exercise
Movement | 85
TRAIN YOUR BRAIN: Does practice make perfect?

Any movement you can perform with little or no conscious thought must be learned. Motor learning is a
process that creates a motor program, which is a blueprint of movement the nervous system can auto-
matically activate. This motor program is built on practice. Therefore, if your client practices a movement
with errors, the motor program will also contain the same errors.
This is why the mantra “practice makes perfect” isn’t accurate. Practice creates a motor program, and
that motor program only produces an optimal movement pattern when the practice is performed cor-
rectly. Therefore, only perfect practice makes perfect.
MOTOR PROGRAM
A motor program is the movement a person automatically produces without con- Motor program: The
scious thought. In other words, a motor program is a preprogrammed movement that movement produced
has been practiced numerous times. automatically by the brain.
Imagine a guy reaching for a cup of coffee at his kitchen table. The arm movement is
smooth and effortless. However, smoothness of that motion requires precise coordi-
nation from muscles throughout the trunk, shoulder, elbow and wrist. Because that
reaching motion has been replicated thousands and thousands of times in his life
(i.e. learned), a strong motor program has been developed and there’s no conscious
thought required, even though it’s a relatively complex movement pattern.
Importantly, a motor program is the movement pattern the nervous system develops
through repetition, whether that motion is ideal or not. Therefore, it’s essential to
practice a movement exactly the way it should be performed. Now let’s discuss how a
motor program is developed and the importance of getting it right.
MOTOR LEARNING
The brain and synapses within the nervous system are adaptable to the input they
receive. Practicing a movement can change the motor cortex’s structure, and synapses Neuroplasticity: The ability
can become stronger. For example, when a person starts learning to play the piano for for the central nervous system
to change its structure and
the first time, the motor cortex areas devoted to those finger movements will expand,
function based on the input it
and synapses between the brain and those motor units will strengthen. This neuro- receives.
plasticity underlies all learning.
Motor learning: A process
Motor learning is a process, influenced primarily by the cerebellum, which develops that develops or changes
or changes the way the nervous system performs a movement. In other words, the the way the nervous system
processes involved in motor learning are what create a motor program. performs a movement.
Closed-loop motor control:
The goal of motor learning is to enhance the smoothness, accuracy and speed of The motor learning process
movement through two neurological processes. The first way motor learning occurs is that uses sensory feedback to
through closed-loop motor control, which is the slow, deliberate focus required to learn develop a motor program.
an unfamiliar movement. Closed-loop motor control is what creates a motor program
Open-loop motor control:
(i.e., preprogrammed movement) after weeks or months of practice. Open-loop motor The execution of a motor
control is the execution of that motor program: it’s a preprogrammed, automatic move- program that doesn’t involve
ment, similar to a reflex action. Let’s discuss each type of motor control in greater detail. sensory feedback.

86 | Unit 5
CLOSED-LOOP MOTOR CONTROL

Cerebellum
Closed-loop motor control uses sensory feedback to learn a sensory motor coordination
movement. When an unfamiliar movement is performed, the
brain must constantly make adjustments through sensory
feedback from muscle spindles (within muscle) and Golgi DESCENDING TRACTS
tendon organs (within tendons). This sensory feedback is sent upper motor neurons
to the cerebellum where it corrects and coordinates the move-
Motor Cortex
ment while it’s happening. plan / initiate / direct movement
For example, imagine a person has never performed a body Brainstem
weight squat with a resistance band stretched across the lower control movement / posture
thighs. The “bandless squat” was effortless because it’s been
performed tens of thousands of times throughout the person’s
life; however, the addition of the band creates a new challenge
due to the fact its direction of resistance is trying to pull the Motor Neuron Pools
knees inward. Therefore, the cerebellum is brought into play lower motor neurons
to make the necessary adjustments.
The resistance band creates an inward pull at the knees that
– if not overcome by the cerebellum – also causes the hips MUSCLES / JOINTS
and ankles to rotate inward. Therefore, the pull of the band
causes internal rotation and adduction at the hips along with
pronation in the feet.
Figure 5.3. Closed-loop motor control. Receptors
To perform the squat while keeping the knees directly above within muscles and joints send sensory information to
the feet, the cerebellum must make adjustments at the hips the cerebellum, which fine-tunes output of the descend-
and feet to oppose those actions. The gluteus muscles at the ing (motor) tracts to correct movement.
external rotation /
internal rotation / abduction at
adduction at the hips
the hips
direction direction
direction direction of of
of of resistance resistance
resistance resistance
supination
pronation at the feet
at the feet
Figure 5.4. Body weight squat with resistance band. A) The band applies a constant force that tries to pull the hips into
internal rotation/adduction along with pronation in the feet. This creates new sensory feedback to the cerebellum. B) To over-
come the band’s resistance during the squat, the hips perform external rotation/abduction along with supination in the feet.
Corrective Exercise
Movement | 87
DESCENDING TRACTS Basal Ganglia

upper motor neurons proper initiation of movement
Motor Cortex
Brainstem Cerebellum
control movement / posture sensory motor coordination

lower motor neuron integration (glutes & posterior tibialis)
Sensory Feedback GLUTES & POSTERIOR TIBIALIS
Figure 5.5. Cerebellar influence on descending tracts. The highlighted areas of the figure depict the pathway along
which the cerebellum sends information to the descending tracts so they will activate the motor neuron pools connected to the
glutes and posterior tibialis muscles.
hips must be activated to perform external rotation/abduction at the hip, and the pos-
terior tibialis muscles are required to supinate the feet.
However, you might remember from unit 3 that the cerebellum doesn’t directly con-
trol muscle. Put another way, the cerebellum can’t send a direct signal to the glutes
and posterior tibialis muscles to perform the necessary actions at the hips and feet.
Instead, the cerebellum tells the descending (motor) tracts to make those adjustments
since they activate the motor neuron pools that go to those muscles. This process
involves three steps.
First, the cerebellum receives feedback information from sensory receptors located in
the muscles and joint at each hip and foot. Second, it processes the information and
determines the glutes and posterior tibialis muscles need to be activated. Third, the
cerebellum sends this new information to the descending tracts, which activate the
lower motor neuron pools connected to those muscles.
In other words, closed-loop motor control uses sensory information to conscious-
ly and continuously adjust movement while it’s happening. This additional sensory
feedback requires significantly more time for the nervous system to process. Therefore,
a new movement should be performed slowly during the early stages so the nervous
system can learn to do it correctly.
Furthermore, the new movement should be performed frequently. Through practice,
the motor cortex area associated with the novel movement will enlarge, which gives
the person better control of movement. Additionally, the synapses between neurons
and/or between neurons and muscle will strengthen. Let’s cover the processes that
synapses use to increase their strength.

88 | Unit 5
TRAIN YOUR BRAIN: Which movements are most important?

Any activity essential to a person’s life is based on meaningful movements.
These are the movements a person needs to fulfill his or her life and work
duties. The smooth, powerful swing of a baseball bat is a meaningful move-
ment to a professional baseball player, but it’s not to a lawyer who avoids
playing baseball at all costs. Put another way, not every possible movement
the human body can perform is meaningful.
However, there are certain movements that are meaningful to virtually every-
one, ranging from an NFL player to an elderly retired person. It is safe to as-
sume that everyone needs to be able to squat to and from a chair and lift the
arms overhead. The way you can assess and correct the essential meaningful
movements are covered in Section Two.
SYNAPTIC PLASTICITY
Synaptic plasticity: Synaptic plasticity is the ability for synapses to become stronger or weaker based on
The ability of synapses to the activity they receive. The synapse between a motor neuron and the muscle fibers it
strengthen or weaken based on innervates is the neuromuscular junction, as covered in Unit 3. This is the space where
the activity they receive.
the neurotransmitter acetylcholine (Ach) is released to activate the muscle receptors
that lead to muscle contraction.
It is believed that the synaptic strength of the neuromuscular junction can be en-
hanced through two mechanisms. First, the motor neuron will release a greater
amount of acetylcholine into the neuromuscular junction. However, the muscle has a
limited number of available receptors to bind that extra acetylcholine. Therefore, the
second necessary change occurs when the muscle adds more receptors to accommo-
date the extra acetylcholine. If additional receptors weren’t put in place, the extra ace-
tylcholine would go to waste, similar to adding gasoline to a tank that’s already full.
Importantly, synaptic plasticity is believed to not only happen at the neuromuscular
junction but also at all the synapses within the spinal cord and brain, such as the con-
nections between the cerebellum and descending (motor) tracts.
To recap, closed-loop motor control uses sensory feedback so the cerebellum can learn
a new movement. After the movement is frequently practiced, the synapses associated
with that motion will strengthen. Finally, after weeks or months of practice, a motor
program will be created, allowing the person to perform the movement automatically.
Corrective Exercise
Movement | 89
OPEN-LOOP MOTOR CONTROL

Great athletes can develop lightning fast movements. Michael DESCENDING TRACTS
Jordan’s first step as he drove past an opponent is a good example. upper motor neurons
He practiced that first step countless times throughout his career
in order to create a strong motor program for that movement. Motor Cortex
Therefore, when he needed to execute the quick first step, it was
Brainstem
virtually automatic. Once he made the decision to drive, the control movement / posture
movement followed within tens of milliseconds. This is an exam-
ple of open-loop motor control.
Open-loop motor control is the execution of a motor program.
Think of a motor program as the direct wire connection between
a light switch and bulb in your home. Once the switch is flipped, Motor Neuron Pools
lower motor neurons
the automatic response is an electrical signal that travels through
the wire to light the bulb. The execution of open-loop motor con-
trol is akin to flipping on the light switch.
With regard to the nervous system, once open-loop motor control
is executed (i.e., flipped on the switch), the motor program that SKELETAL MUSCLES
was created for that movement will occur automatically – no
thought required. Because there’s no sensory feedback to process,
it’s the fastest, most direct path between the brain and muscles.
This is how athletes develop lightning fast reflex movements. This Figure 5.6. Open-loop motor control. This
is also why it’s essential to have clients practice movements with figure shows a simplified model of open-loop motor
control, which is the execution of a motor program
the best form possible – whatever they practice most is what will without sensory feedback.
be produced when open-loop motor control is activated.
TRAIN YOUR BRAIN: How long does it take to perform a voluntary movement?
Imagine walking down an unfamiliar alley at night when a shadowy figure suddenly races around
the corner toward you. First, your eyes see the person running at you and your ears hear the pound-
ing of feet on the ground. This information is quickly sent to your brain. Next, your memories of this
situation—whether you’ve experienced it before or saw a similar scenario in a movie—interpret the
information your eyes and ears sent to your brain. Then your brain formulates a course of action:
will you quickly step to the right or left to avoid colliding with the person? Now your brain is ready
to execute a plan of action, so it sends a signal down your spinal cord to the motor neuron pool that
activates the muscles that make you leap to the right. This process takes approximately 200 millisec-
onds (one-fifth of a second) from start to finish.
Now imagine this same scenario is familiar to you because you walk down that alley every night
after your work shift is finished. And just like clockwork, the same guy rushes around the corner
toward you because he’s a late-night jogger. Your brain has experienced this same scenario nu-
merous times so it knows to activate the muscles that make you jump to the right once you see the
guy. Because your brain doesn’t need to interpret what your eyes see and develop a plan of action,
you’re able to react within 20 milliseconds.

90 | Unit 5
In summary, after a motor program has been created through closed-loop motor
control, athletes practice open-loop motor control to increase the speed that motor
program is executed. An athlete first creates a motor program of a movement through
deliberate practice. Then the athlete practices that movement faster and faster over the
months and years in order to create the fastest open-loop motor control possible.
Importantly, this information isn’t limited to professional athletes. Corrective Exercise
is about correcting the faulty exercise movements that can lead to pain or injury. When
a movement is faulty, a new motor program must be created: first by closed-loop motor
control and then developed into open-loop motor control so it becomes automatic.
MOTOR LEARNING OVERVIEW

The body weight squat with a resistance band was selected to explain motor learning
in this unit because it’s a fundamental corrective exercise within this course. The exer-
cise serves as an appropriate example for learning how to retrain movement.
During many lower body movements, whether it’s standing up from a chair or
Knee valgus: An inward performing a squat in the gym, it’s common for people experience knee valgus, an
buckling of the knees due to inward buckling of the knees due to weakness in muscles at the hips and/or feet.
weakness in the hips and/or Research demonstrates that valgus can be a cause of knee pain and can cause injury to
feet.
the anterior cruciate ligament (ACL) deep within the knee joint. For exercises ranging
from the squat and deadlift to the lunge and step-up, knee valgus is a common move-
ment dysfunction.
The corrective exercise treatment for knee valgus hinges on placing a resistance band
across the lower thighs while retraining a movement, such as the squat. At first, the
squat should be performed slowly so the client can learn to do it with the band (i.e.,
closed-loop motor control). After a few weeks of practicing the exercise slowly, a new
motor program for the squat will be created: one that activates muscles in the hips
TRAIN YOUR BRAIN: What limits movement?

Three components can limit movement: strength, mobility and motor con-
trol. A lack of any one of those components will disrupt normal biomechanics.
The potential limitations of strength and mobility are easy to understand.
When a muscle doesn’t have the strength to overcome an opposing resis-
tance, movement will not occur. And each joint has an available range of
motion. Therefore, any movement beyond that range isn’t possible.
A lack of motor control impairs the smoothness and accuracy of movement,
which increases the risk for joint pain and injury. Motor control is developed
through focused and dedicated practice to acquire new movement skills. It’s
the combination of closed-loop and open-loop motor control that can devel-
op movement patterns that will enhance a person’s life or sport.
Corrective Exercise
Movement | 91
Figure 5.7. Neutral and valgus knee positions. A) The knees are neutral when a
vertical line can be drawn from the center of each patella down to the center of the each
foot. B) Knee valgus, as shown by a vertical line inside the center of each foot, results in
hip internal rotation/adduction and pronation in the feet.
and feet that resist knee valgus. Finally, the movement speed will be steadily increased
until muscle activation in the hips and feet will become automatic during the squat,
deadlift or lunge (i.e., open- loop motor control). This is why motor learning can take
weeks or months.
Motor learning is a process that changes areas of the motor cortex and strengthens
synapses. These adaptations are possible because those regions have neuroplasticity—
the ability to change their structure and function.
Importantly, motor learning is the process of acquiring the skills to move better in
order to reduce or eliminate pain. It’s a challenging endeavor that requires focus and
patience, unlike many exercises that can be performed without much thought. Indeed,
research demonstrates that simple strength building exercises don’t create changes
within the motor cortex. Therefore, common exercises to build strength aren’t part of
exercise therapy.
To change to the way a person naturally moves, frequent practice is required. How-
Long-term potentiation:
ever, the practice must be meaningful and challenging to create stronger synapses. A long-lasting increase in
Over time, the increased synaptic strength will become long lasting through a process synaptic strength between two
known as long-term potentiation. neurons.

92 | Unit 5
Summary
1. Movement is a complex interplay between the joints, muscles and nervous
system.
2. The body is in balance when its center of mass is within its base of support.
3. A person’s sense of balance is maintained through feedback from the visual,
vestibular and somatosensory systems.
4. A motor program is the automatic movement a person executes without
sensory feedback.
5. Motor learning is a process that develops or changes the way the nervous
system performs a movement.
6. Motor learning first occurs through slow, deliberate practice of closed-loop
motor control. This creates a motor program. Then open-loop motor con-
trol is practiced to increase the speed of execution of the motor program.
7. The cerebellum is the primary area of the brain that fine-tunes movement
while its occurring.
8. Neuroplasticity is the ability of the brain and spinal cord to change through
the focused practice of movement.
9. Synaptic plasticity is the ability of synapses to strengthen or weaken based
on the activity they receive.
10. Challenging movement patterns that require a person to acquire new skills
is a cornerstone of motor learning.
Corrective Exercise
SECTION TWO
Corrective Exercise Practice
Preparing for the Client, p.95

Create a Just Right Challenge, p.113
Perform a Single-Joint Movement Analysis, p.121
Perform an Upper Body Multi-Joint Movement Analysis, p.135
Perform a Lower Body Multi-Joint Movement Analysis, p.155
Restore Structural Alignment and Stability, p.173
Restore Mobility through Stability, p.185
Soft Tissue Assessments and Correctives, p.209
Corrective Exercise
Step 1: Determine Whether Corrective

Exercise is Appropriate
Red Flags
Medical Pain vs. Movement Pain
Two Benefits of
Referring a Potential Client
Step 2: Identify the Outcome Goal
Step 3: Discuss Performance Goals
Know the Client’s Expectations
Step 4: Gather Quantifiable
Functional Data
UNIT 6
PREPARING FOR THE CLIENT

96 | Unit 6
What You’ll Learn

In this unit, you’ll learn the importance of your initial role as a Corrective Exercise Specialist. First, you will
learn how to determine whether a corrective exercise program is appropriate for a potential client. Second,
we’ll cover the importance of identifying the client’s ultimate goal, which is the driver of his or her motiva-
tion. Then you will learn why it’s necessary to discuss performance goals before you and your client ever
step foot inside a gym. Finally, you’ll learn the research-based measures that will generate the most accurate
data before your first training session. By the end of this unit, you’ll have learned the four steps necessary to
derive the most accurate and useful information for the initial stage of corrective exercise programming.
STEP 1:
DETERMINE WHETHER CORRECTIVE
EXERCISE IS APPROPRIATE
The design and intention of a corrective exercise program is to help your clients move
better. This creates two possible scenarios to consider before working with someone.
On one hand, a person might already know a physical problem exists. For example,
the client might have been battling shoulder pain when reaching overhead, or right
knee pain when standing up from a chair, over the last few weeks or months. In this
Reactive approach: An action scenario, he or she is taking a reactive approach because the problem is already
or actions taken to solve a present. It’s rare for a person to take the time and energy to fix a problem until pain is
problem after a person realizes present; therefore, this scenario is most common.
the problem exists.
On the other hand, there might not be an obvious movement problem. For example, a
woman who loves to run in her spare time, or a female athlete who strives to remain in-
jury-free in her sport, wants to ensure that no movement restrictions are present. Even
Proactive approach: An though this proactive approach is less common, it’s an important scenario to consider.
action or actions taken to solve The good news is that the vast majority of people have some type of physical restric-
a potential problem. tion—even if they don’t realize it—that can be helped through corrective exercise.
In either case, there’s a problem within the body, and it’s essential to gain a clear
understanding of why that problem exists. Therefore, the most important step before
meeting with any person is to have him or her be cleared for exercise from a physician
or licensed clinician within eight weeks of your first meeting. This is the most effective
way to minimize the chance of encountering a physical impairment that is caused by a
medical problem you cannot fix or could potentially exacerbate.
Red flags: Symptoms RED FLAGS

associated with conditions that
might require the care of a Pain is a virtually inevitable aspect of movement. At some point, it is almost guaran-
medical professional. teed that your potential client will have experienced pain during a workout. I’m not
referring here to the burning pain felt in a muscle after completing 20 repetitions or
the strain that is felt when a muscle is too stiff. I’m referring to pain deep within the
joints, sharp “nervy” pain and/or numbness and tingling.
Corrective Exercise
Preparing for the Client | 97
Five Important Questions: Identifying Red Flags
Does the pain feel like it’s inside the joint?

Reason to ask: This can be the sign of orthopedic impairments such as dam-
aged cartilage, torn ligaments, or bone problems.
Is there intense, localized pain in any part of the body?
Reason to ask: This is sometimes the sign of a serious injury that will take
weeks or months to heal before exercise is acceptable.
Are you experiencing numbness and/or tingling in the limbs?
Reason to ask: When a person experiences numbness, tingling, or a combina-
tion of the two, these issues can be attributed to a nerve-related problems or
an underlying neurological disorder.
Have you experienced unexplained weight loss or weight gain over
the last few weeks or months?
Reason to ask: This is a sign of a possible medical problem.
Have you recently had a fever, nausea, or unexplained fatigue?
Reason to ask: Any of these symptoms could be the sign of a medical problem.
For any of the aforementioned red flags, refer the person to a medi-
cal professional to get clearance to exercise with you.
These symptoms, along with a few others we are about to cover, are red flags that can
be the sign of a dysfunction a certified personal trainer isn’t qualified to treat. There
are five red flags to be aware of when determining whether a person who is in pain can
possibly benefit from participating in a corrective exercise program. Therefore, the
following five questions should be asked during your first communication with the
prospective client.
Does the pain feel like it’s inside the joint?
Reason to ask: This can be the sign of orthopedic impairments such as damaged carti-
lage, torn ligaments, or bone problems.
Reason to ask: This is sometimes the sign of a serious injury that will take weeks or
months to heal before exercise is acceptable.
Reason to ask: When a person experiences numbness, tingling, or a combination of
the two, these issues can be attributed to a nerve-related problems or an underlying
neurological disorder.

98 | Unit 6
Have you experienced unexplained weight loss or weight gain over the last few
weeks or months?
Reason to ask: This is a sign of a possible medical problem.
Reason to ask: Any of these symptoms could be the sign of a medical problem.
For any of the aforementioned red flags, refer the person to a medical professional to get
clearance to exercise with you. Even if the person hasn’t experienced any of the red flags,
it’s still mandatory to have him or her fill out the Physical Activity Readiness Question-
naire for Everyone (2017 PAR-Q+). This questionnaire should be completed before the
first session to help determine whether a person is medically ready for exercise.
Before we move on, it’s important to emphasize that the only people qualified and
trained to treat painful movement are athletic trainers, physical therapists, chiroprac-
tors, and medical professionals. The sobering truth is that pain is sometimes due to
cancer, a neurological disorder, or another medical problem that requires intervention
from a medical professional.
MEDICAL PAIN VS. MOVEMENT PAIN

Personal trainers have the ethical responsibility to refer their clients, or potential
clients, to a qualified clinician or medical professional if pain is a factor during any
exchange of information, assessment, or corrective exercise. And if you’re ever unsure,
always err on the safe side and refer out.
However, once a person has been cleared to exercise, the pain will probably still be
present. In fact, it’s likely that most of your clients will experience some type of dis-
comfort during their corrective exercise sessions with you. Therefore, for the purposes
of this course, we will consider two types of pain.
Medical pain: the type of Medical pain is the discomfort that requires intervention from a medical profes-
discomfort that could be sional. You should consider all pain a medical problem until the potential client has
caused by a medical condition, been cleared. After that, movement pain is defined in this course as the discomfort a
which requires the intervention
from a medical professional.
person experiences due to a lack of strength, mobility, and/or motor control.
Movement pain: the type of Because movement pain is not a medical problem, utilizing corrective exercise strate-
discomfort that’s not a medical gies can be appropriate to reduce or eliminate such pain. Importantly, if pain worsens
problem and often caused by a during or after a corrective exercise session, or if a new pain arises, the person should
lack of strength, mobility, and/ be referred to a medical professional. Nevertheless, for the remainder of this course,
or motor control.
the word “pain” will refer specifically to movement pain—the type of pain that doesn’t
require intervention from a medical or health-care professional.
TWO BENEFITS OF
REFERRING A POTENTIAL CLIENT
Even though it might not sound appealing to potentially lose a prospective client
because he or she is experiencing a painful medical problem, there are two positive
elements to keep in mind.
First, you will build your reputation with the potential client. As an exercise profession-
al, it’s essential to put the best interests of a person before anything else, and sometimes
that means referring this person to another specialist first. This will help build your
Corrective Exercise
credibility and gain respect from the potential client because he or she will know that
you put clients’ health before your business. Furthermore, by demonstrating your com-
mitment to clients’ well being, clients are more likely to recommend you to another per-
son who could use your help. This is an effective way to gain referrals for new business.
Second, you will build your reputation with licensed clinicians and medical profession-
als. As a personal trainer, you will find that nothing is more valuable than is establish-
ing a great reputation with physicians, therapists, and athletic trainers. When you build
this network of professional colleagues, it will help grow your business and build your
professional reputation. Indeed, throughout my career, the majority of high-profile
clients I’ve trained were referred to me by other clinicians and medical professionals.
In summary, the purpose of this first step is to determine whether corrective exer-
cise is appropriate for the client. The data you gather in this step will not only help
you prepare for the initial movement assessment but will also provide the infor-
mation you need to determine whether the client should see a licensed clinician or
medical doctor before meeting with you. Remember, if you’re ever in doubt, always
refer to a medical professional.
STEP 2:
IDENTIFY THE OUTCOME GOAL
After the client has been cleared for exercise, it’s time to determine why he or she
sought your help in the first place. What is the client’s ultimate goal? Over the last two
decades of working with clients, I’ve learned what to first ask a potential client before
determining whether I can help. At the initial stage, when you first talk seriously with
the client about the possibility of working with you, the most important question to
ask is What motivates you to participate in a corrective exercise program?
Everyone is motivated by something, and you’ll greatly benefit by discovering what
that is as soon as possible because it forms the client’s outcome goal. An outcome goal Outcome goal: the ultimate
is a goal you have no control over; however, it is what you strive to achieve through a goal of the client, which isn’t
corrective exercise program. For example, a man might want to eliminate his shoul- under the trainer’s control.
der pain so he can return to playing in his softball league. Or a woman might want to
be relieved of her nagging knee pain so she can return to dancing. In other cases, an
athlete might be driven to stay injury free.
It’s important to never forget the outcome goal because it drives your client’s behavior.
Any behavior that can impair your client’s success (e.g., missed workouts or showing
up late) can be overcome when the client is motivated to make a change.
The ways you can keep a client motivated, using evidence-based psychology research,
will be covered in Unit 7. For now, it’s important to know that everything you do with
the client should be linked to the outcome goal in some way. There will be times when
you’re coaching a client through an exercise or prescribing a soft tissue drill that won’t
make sense to the client.
Consider, for example, a woman who hires you to reduce her knee pain so she can
return to ballroom dancing. (You’ll learn later in Section Two that knee pain is often
associated with weakness of the hip abductors.) As you’re coaching her through a
corrective exercise that strengthens the hips, she might ask, “Why are we working on
my hips when my knee is the problem?”
At this point, you could give a logical answer, such as “We’re doing this exercise

100 | Unit 6
TRAIN YOUR BRAIN: How to “sell” an impatient client on cor-

rective exercise.
Some people have a fear of long-term commitment when it comes to exer-
cise. And they might justify this fear by convincing themselves that it’s going
to be a waste of time or money. In other words, these clients are impatient—
they want fast results because those save time and money. These potential
clients, like all clients, should be educated that permanent changes in move-
ment and tissues can often take months to occur.
However, I have learned that once that fact has been clearly established, it’s
not necessary or beneficial to belabor the point. Instead, ask your client to try
two or three corrective exercise sessions. The good news is that the tech-
niques covered in this course will often elicit positive changes, such as better
movement or less movement pain, within the first or second session. Once
clients experience a positive change, especially if they have been dealing with
the movement-related problem for months, their fears of committing to a
corrective exercise program, and their impatience, will be drastically reduced.
If you follow the techniques in this course, your clients will continue to ex-
perience and learn the benefits of your sessions and, by default, will end up
being long-term clients.
because strengthening your hips can reduce knee pain.” However, that answer doesn’t
clearly link the corrective exercise prescription with her outcome goal. Therefore, a
better answer would be “We’re doing this exercise to strengthen your hips in an effort
to reduce your right knee pain so you can return to ballroom dancing.”
It might be obvious to you why you’re having her perform a specific exercise or soft
tissue treatment, but it sometimes won’t be obvious to her. Thus, whenever your
corrective exercise choice is questioned, do your best to link the answer to the client’s
outcome goal. After all, your job is to enrich a client’s life by reducing or eliminating
the physical dysfunctions that lie between the client and the client’s outcome goal.
Of course, the factor or factors that motivate a person can change. This truth about
human psychology is beyond your control, and there’s no reason to worry about it un-
less you moonlight as a licensed psychiatrist. However, it is essential to know whether
a person’s outcome goal has changed so you can link it to the corrective exercises you
provide. Therefore, ask your client to let you know if the outcome goal ever changes.
That way, your communication with him or her can be directly linked to the new
outcome goal.
This point in the preparatory process is intended to help you gather relevant informa-
tion to determine the client’s mindset. Therefore, you will identify the outcome goal to
understand what drives the client’s motivation.
Corrective Exercise
STEP 3:
DISCUSS PERFORMANCE GOALS
We just covered the importance of identifying a client’s outcome goal, as it’s the driver
of human behavior. An outcome goal is something you cannot control—it’s whatev-
er the person desires. A performance goal, however, is measurable and under your Performance goal: A
control. The goal must also be realistic and specific. Performance goals are what you measurable, specific, and
establish with the client to bridge the gap, in a measurable way, between where that realistic outcome you establish
with a client.
person is now and where he or she wants to be.
Each performance goal you set with a client is an essential step toward your possible
success for achieving the outcome goal. Therefore, it’s crucial not only to learn how
to establish a performance goal but also to understand the client’s expectations for
achieving each one. Setting performance goals is a process that continues throughout
your time working with a client—not just the initial stages we are discussing here.
However, before you set performance goals with your client, it’s important to discuss
them upfront so you can understand, and possibly influence, what your client expects.
One way to make a performance goal measurable, and applicable to the corrective ex-
ercise program, is with a pain intensity measurement (PIM) scale. This scale matches Pain intensity
a numerical pain value to the level of discomfort a person feels during movement or measurement scale: An
posture. Research demonstrates that an 11-point PIM scale, with “0” being no pain outcome measure scale that
has been shown to effectively
and “10” being the highest pain imaginable, is as effective for assessing pain as are oth- determine a person’s level of
er scales that include significantly more points. For this reason, the 11-point scale is discomfort.
used in this course to determine a person’s PIM. It’s also the same scale I’ve used with
clients throughout my career, and I haven’t experienced any circumstance that has
made me question its accuracy or effectiveness.
The PIM scale is an example of an outcome measure, which is the result of a test that Outcome measure: the result
determines a person’s initial functional ability. Every performance goal should be estab- of a test used to determine a
lished using an evidence-based outcome measure to objectively determine whether an person’s baseline function.
improvement has occurred. That’s why the 11-point PIM scale is used in this course.
For each movement or body position that causes discomfort, your client will rate it
on a scale of 1–10 (0 is excluded here because there is pain in this hypothetical sce-
nario.) Let’s say your client Laura experiences 6 out of 10 pain in the right shoulder
while reaching overhead. In this case, the test is the overhead reach, and the outcome
measure is the PIM scale that resulted in a rating of 6/10. Therefore, your measurable
performance goal might be to reduce the pain of her right arm overhead reach to 3 out
of 10 within four weeks. This process will be discussed in greater detail in Unit 7.
KNOW THE CLIENT’S EXPECTATIONS

Of course, at this point in the preparatory process, it’s extremely difficult, if not
impossible, to establish specific performance goals. After all, you haven’t yet taken
the client through any of the assessments to determine whether there’s a movement
problem you’re qualified to fix or what might be causing the problem. You’ll learn how
to establish performance goals in Unit 7; however, the importance of discussing those
goals before the physical assessment can’t be overstated, because it will offer insight
into the client’s mindset.
Sometimes a client will have unrealistic expectations. For example, by the end of the
first session, a man might expect you to have eliminated his right knee pain that’s been

102 | Unit 6
Chronic pain: Any pain lasting lingering for the last six months. This is an example of chronic pain, which is a pain
longer than 12 weeks. that lasts for more than three months. Chronic pain is typically the most difficult to
overcome for two reasons.
First, the muscles and soft tissues around the area of discomfort have been irritated for
many months, resulting in scar tissue and/or other structural compensations. When
soft tissues are irritated, they must go through three stages of healing—a process that
can take months—before the tissues are healthy again.
Second, chronic pain usually creates changes within the brain that impair connec-
tions between the nervous system and muscle. Therefore, a new motor program for
the movement must be established, and this can take months. Chronic pain always
requires the intervention of a medical professional; however, if the person has al-
ready been cleared to exercise, he or she needs to know that long-lasting pain usually
requires a few months’ worth of corrective exercise to elicit the changes in the soft
tissues and motor programs.
Acute pain: Normal, short- Acute pain, however, is a normal pain that usually lasts a few days or weeks. The sore-
term pain or the initial pain that ness you feel in a muscle group for two or three days after a strength-training workout
indicates a more serious injury. is an example of acute pain. Nevertheless, acute pain could also be the sign of a new
injury, which won’t go away until the dysfunction is corrected through movement re-
training and tissue healing. In other words, acute pain can be similar to chronic pain,
as both can require many weeks or months of corrective exercise to overcome.
The point in discussing pain, and the changes that can occur within the body because
of it, is to prepare you for clients who expect unrealistically fast results. The perma-
nent changes in motor programs and tissue health required to “fix” a client typically
take months to occur. And sometimes the best fix you can provide is a significant
improvement in the way a person moves or feels, even if it doesn’t completely elimi-
nate the problem.
In any case, an ideal client is a person who understands that a corrective exercise pro-
gram is a process that requires commitment and patience. Sometimes your client will
already understand this, and no further action will be required on your part other than
providing the best service and support you can. Other times, you’ll need to use effective
communication skills to help the client better understand what’s realistic to achieve.
The best way to keep a client motivated for corrective exercise sessions is to continually
create positive changes, no matter how small, in the way he or she moves and feels.
To recap, at this stage in the preparatory process, it’s essential to understand whether
the client’s performance goal is realistic. Does your client expect to be fixed within
the first session? Or does your client hope to feel or move 50% better by the end of the
first month? Knowing this information upfront can save you unnecessary stress. If
you assume your client understands it will take three or four weeks’ worth of training
to produce a significant improvement but actually expects it to happen within the first
session, therein lies the problem.
You can avoid this potential dilemma by simply asking, “What would you need to
achieve, in what amount of time, in order to determine our corrective exercise pro-
gram was a success?”
The answer to that question will give you an accurate look at the client’s expectations. If
the answer seems unrealistic—based on the minimal information you currently know
about the client’s movement problem—you can explain to him or her that changes to
movement and tissues typically requires a month or more of consistent corrective exer-
cise. However, if the answer is realistic, you won’t have any extra explanations to give.
Corrective Exercise
TRAIN YOUR BRAIN:

It’s the little things that matter most, especially when it comes to money and time.
I had a high-profile client whose net worth was at carried, made him feel taken advantage of—a feel-
least $200 million. He was a generous person who ing no one enjoys, no matter how much money
donated to many charities, and having worked or power he or she has.
with him for many years, I can say with confidence
The hotel could have simply rolled that $16 into
that he definitely wasn’t frugal in any way.
the cost of the already expensive room, without
During one of our training sessions, after he had ever affecting his desire to stay there. No one,
returned from a business meeting in New York, including him or his assistant, would’ve ques-
I asked him which hotel he had chosen for the tioned why booking the suite cost $966 instead
trip. (I’m always interested in learning where the of $950, as room rates fluctuate almost daily.
well-to-do lay their heads in various cities.) He I’m sure he would’ve willingly paid $966 for the
mentioned that the high-end hotel where he had suite, and the “free” bottle of water by the bed
stayed for many business trips over the years was would’ve appeared to be a thoughtful gesture
no longer his choice; as such, he had used another made by the hotel. In fact, if the bottle of water
hotel chain instead. weren’t an extra charge, it would’ve appeared
that the hotel company over-delivered by put-
His answer piqued my curiosity. After all, I knew
ting the customer’s comfort—or thirst, in this
him as a person who was not only generous but
case—before its profit margin.
also loyal to the companies that treated him well.
I couldn’t image what caused him to switch hotel Throughout my career, I have frequently thought
companies. Was his usual presidential suite booked about the important business lesson this story
to someone else when he arrived? Or was his taught me. That $16 charge resulted in a loss of
favorite personal butler not available at that hotel tens of thousands of dollars to that hotel over
during his last business trip? the course of the year. Therefore, whatever you
charge a client, always strive to over- deliver on
No, it wasn’t either of those things or anything
your services and avoid extra fees.
close to it. He went on to explain that the high-end
hotel where he normally stayed had charged him It’s the smallest gestures—whether it’s buy-
$16 for a bottle of water during his last trip. The ing the client a bottle of water for the training
bottle of water was sitting on a nightstand next to session or stopping at the bookstore to surprise
his bed, so he assumed it was included in the room him or her with the latest autobiography the
charge. But it wasn’t, and that was the reason he client wanted to read—that matter most. All of
chose to use another hotel company. us, regardless of how much money we have,
appreciate it when someone saves us money and
Obviously, he could afford to spend the $16. In
time, no matter how little. Always take actions,
fact, he could spend $16,000 on a bottle of water
no matter how small, that demonstrate your
without ever worrying about the effect it would
desire to over-deliver on your services, and your
have on his lifestyle. However, the strategic place-
business will grow exponentially.
ment of the bottled water, and the inflated price it

104 | Unit 6
STEP 4: GATHER QUANTIFIABLE

FUNCTIONAL DATA
At this point, you’ll have accomplished three things. First, you took the necessary
steps to determine whether a person is qualified to participate in a corrective exercise
program and recommended referrals to a medical professional if not. Second, you
learned what motivates a client by identifying the outcome goal. Third, performance
goals were discussed to ensure that your client doesn’t have unrealistic expectations.
Quantifiable data: Now it’s time to gather quantifiable data that will better prepare you for the initial
Information that can be physical assessment.
measured or counted.
Earlier in this unit we discussed the importance of an outcome measure because it
quantifies a client’s results. As a Corrective Exercise Specialist, you need to have a set
of tools that clearly demonstrate a change in performance, and that’s what an outcome
measure does.
Two of the most respected evidence-based outcome measures for functional move-
Lower Extremity Functional ment impairments are the Lower Extremity Functional Scale (LEFS) and the Upper
Scale: An evidence-based Extremity Functional Index (UEFI). Both of these outcome measures have been
outcome measure that shown to be reliable and valid. Each scale provides a numerical value from 0–80 that
quantifies a person’s functional
ability for movements that
quantifies the difficulty a person has for 20 individual movements required in daily
involve the lower limbs. life. For example, the LEFS quantifies your client’s ability to do activities such as walk-
ing, standing, and running without discomfort. The UEFI quantifies activities such as
Upper Extremity Functional
Index: An evidence-based
lifting objects overhead, opening doors, and throwing a ball. A score of 80 indicates
outcome measure that no movement restrictions, whereas anything lower than that signifies some level of
quantifies a person’s functional difficulty from mild to extreme (depending on how low or high the client scores).
ability for movements that
involve the upper limbs. These scales serve two purposes. First, they inform you of the movement restrictions
a person already has before you do a physical assessment. Second, the scales provide a
Reliable: When a significant way to measure progress, in addition to the movements you perform in the gym. For
result has been shown to
be repeatable in different example, a man might hire you because he experiences discomfort in his right knee
populations. while doing squats, so he wants to be rid of that restriction. However, it’s likely he
experiences discomfort while doing other activities throughout the day such as getting
Valid: When the results of a
study meet all the requirements
in and out of his car, or going up and down the stairs in his home. Therefore, you’ll
of the scientific research have confidence the corrective exercise program is working when he can squat with
method. less discomfort and his LEFS value increases.
Minimum detectable Each scale has a minimum detectable change (MDC) of 9 points, which essentially
change: the smallest means that a shift in 9 points up or down will probably be noticeable to the client.
detectable change that
These forms will be filled out every four weeks to track and assess the effectiveness of
can be considered above a
measurement error. the corrective exercise program.
Meaningful change: A These data provide quantifiable information about the difficulties a new client has
change that is detectable to the during daily activities, which will help you determine which movements to assess in the
client. gym during your first session. For example, if a person experiences discomfort while
climbing stairs, a similar movement such as the step-up exercise would be an excellent
movement to assess. Or if a client has problems lifting objects overhead, a standing
shoulder press would be a logical assessment. However, it’s not necessary to have the
client fill out both forms, unless he or she is battling discomfort in both lower and upper
body movements. For most clients, either the LEFS or UEFI will provide you with the
data that are necessary to perform the most accurate physical assessment possible.
Corrective Exercise
FINAL WORDS
As this unit comes to a close, it’s important to underline At the end of your first meeting with a prospective client,
the fact that the more information you can acquire before have him or her fill out the following forms and ask that
the initial physical assessment, the more successful you’ll they be returned to you before your first training session
be with corrective exercise programming. The four steps to develop the best coaching strategy:
covered in this unit will provide you with the necessary • Corrective Exercise New Client Questionnaire
information that will not only make you look more pro-
fessional and adept at correcting movement dysfunctions • 2017 PAR-Q+
but will also save you and your new client from wasting • Lower Extremity Functional Scale (for lower body
time and energy. impairments)
• Upper Extremity Functional Index (for upper body
impairments)
Summary
1. The most important step when meeting with a pro- 4. Performance goals should be discussed before any
spective client is to determine whether a corrective other goals are established. It’s essential to learn
exercise program is appropriate for him or her. If the what the client expects so you can be aware of it and
person demonstrates any of the red flags, or current- possibly provide a more detailed explanation of the
ly experiences pain, refer to a medical professional time it takes to elicit movement or tissue changes if
first. he or she has unrealistic expectations.
2. Before your first session, it’s vital to know that if a 5. The Lower Extremity Functional Scale and Upper
client experiences new pain during or after a correc- Extremity Functional Index provide you with the
tive exercise session, refer him or her to a medical or necessary information to determine how the client’s
health-care professional. dysfunction affects his or her daily life.
3. After determining whether a corrective exercise pro- 6. Gathering preliminary data from the New Client
gram is appropriate for the client, your next job is to Questionnaire, PAR-Q+, LEFS, and/or UEFI will better
identify the outcome goal. The outcome goal is what prepare you for the first training session and demon-
drives his or her behavior; therefore, it’s crucial to strate your proficiency and professionalism as a
always keep it in mind because it forms the corner- Corrective Exercise Specialist.
stone of your success.

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1.800.892.4772 (toll-free) • 1.805.745.8111 (international)

issaonline.edu
New Client Questionnaire

Name
Yes No Please indicate your answer to the following:
If you have joint pain, does it feel like it’s deep inside the joint?
Have you experienced unexplained weight loss or weight gain within the last few months?
Important If you answered yes to any of the above questions, you must first get clearance from your
physician before starting any exercise program.
If you answered no to each question, please answer the following two questions with as
much detail as you feel comfortable sharing.
What motivates you to participate in a corrective exercise program?
What would you need to achieve, in what amount of time, to determine that the corrective exercise
program was a success?
Date
Client signature
Date
Trainer signature
Please note: possession of this form does not indicate that its distributor is actively certified with the ISSA. To confirm certification status, please call 1.800.892.4772 (1.805.745.8111 international). Information
gathered from this form is not shared with ISSA. ISSA is not responsible or liable for the use or incorporation of the information contained in or collected from this form. Always consult your doctor concerning
your health, diet, and physical activity.
2017 PAR-Q+
The Physical Activity Readiness Questionnaire for Everyone
The health benefits of regular physical activity are clear; more people should engage in physical
activity every day of the week. Participating in physical activity is very safe for MOST people. This
questionnaire will tell you whether it is necessary for you to seek further advice from your doctor
OR a qualified exercise professional before becoming more physically active.
GENERAL HEALTH QUESTIONS
Please read the 7 questions below carefully and answer each one honestly: check YES or NO. YES NO
1) Has your doctor ever said that you have a heart condition OR high blood pressure ?
2) Do you feel pain in your chest at rest, during your daily activities of living, OR when you do
physical activity?
3) Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?
Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).
4) Have you ever been diagnosed with another chronic medical condition (other than heart disease
or high blood pressure)? PLEASE LIST CONDITION(S) HERE:
5) Are you currently taking prescribed medications for a chronic medical condition?
PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:
6) Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue
(muscle, ligament, or tendon) problem that could be made worse by becoming more physically
active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.
PLEASE LIST CONDITION(S) HERE:
7) Has your doctor ever said that you should only do medically supervised physical activity?
If you answered NO to all of the questions above, you are cleared for physical activity.
Go to Page 4 to sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3.
Start becoming much more physically active – start slowly and build up gradually.
Follow International Physical Activity Guidelines for your age (www.who.int/dietphysicalactivity/en/).
You may take part in a health and fitness appraisal.
If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise,
consult a qualified exercise professional before engaging in this intensity of exercise.
If you have any further questions, contact a qualified exercise professional.
If you answered YES to one or more of the questions above, COMPLETE PAGES 2 AND 3.
Delay becoming more active if:

You have a temporary illness such as a cold or fever; it is best to wait until you feel better.
You are pregnant - talk to your health care practitioner, your physician, a qualified exercise professional, and/or
complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active.
Your health changes - answer the questions on Pages 2 and 3 of this document and/or talk to your doctor or a
qualified exercise professional before continuing with any physical activity program.
Copyright © 2017 PAR-Q+ Collaboration 1/4

01-01-2017
PAR-Q+
2017 PAR-Q+
FOLLOW-UP QUESTIONS ABOUT YOUR MEDICAL CONDITION(S)
1. Do you have Arthritis, Osteoporosis, or Back Problems?
If the above condition(s) is/are present, answer questions 1a-1c If NO go to question 2
1a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? YES NO
(Answer NO if you are not currently taking medications or other treatments)
1b. Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer,
displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the YES NO
back of the spinal column)?
1c. Have you had steroid injections or taken steroid tablets regularly for more than 3 months? YES NO
2. Do you currently have Cancer of any kind?

If the above condition(s) is/are present, answer questions 2a-2b If NO go to question 3
2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of YES NO
plasma cells), head, and/or neck?
2b. Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)? YES NO
3. Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure,
Diagnosed Abnormality of Heart Rhythm
If the above condition(s) is/are present, answer questions 3a-3d If NO go to question 4
3b. Do you have an irregular heart beat that requires medical management? YES NO
(e.g., atrial fibrillation, premature ventricular contraction)
3c. Do you have chronic heart failure? YES NO
3d. Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical YES NO
activity in the last 2 months?
4. Do you have High Blood Pressure?

4b. Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? YES NO
(Answer YES if you do not know your resting blood pressure)
5. Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes
If the above condition(s) is/are present, answer questions 5a-5e If NO go to question 6
5a. Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician- YES NO
prescribed therapies?
5b. Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or
during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, YES NO
abnormal sweating, dizziness or light-headedness, mental confusion, difficulty speaking, weakness, or sleepiness.
5c. Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or YES NO
complications affecting your eyes, kidneys, OR the sensation in your toes and feet?
5d. Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or YES NO
liver problems)?
5e. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future? YES NO
Copyright © 2017 PAR-Q+ Collaboration 2/4

01-01-2017
6.
2017 PAR-Q+
Do you have any Mental Health Problems or Learning Difficulties? This includes Alzheimer’s, Dementia,
Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome
6b. Do you have Down Syndrome AND back problems affecting nerves or muscles? YES NO
7. Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High
Blood Pressure
If the above condition(s) is/are present, answer questions 7a-7d If NO go to question 8
7b. Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require YES NO
supplemental oxygen therapy?
7c. If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough YES NO
(more than 2 days/week), or have you used your rescue medication more than twice in the last week?
7d. Has your doctor ever said you have high blood pressure in the blood vessels of your lungs? YES NO
8. Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia
8b. Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, YES NO
and/or fainting?
8c. Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic YES NO
Dysreflexia)?
9. Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event
9a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?
(Answer NO if you are not currently taking medications or other treatments) YES NO
9b. Do you have any impairment in walking or mobility? YES NO
9c. Have you experienced a stroke or impairment in nerves or muscles in the past 6 months? YES NO
10. Do you have any other medical condition not listed above or do you have two or more medical conditions?
If you have other medical conditions, answer questions 10a-10c If NO read the Page 4 recommendations
10a. Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 YES NO
months OR have you had a diagnosed concussion within the last 12 months?
10b. Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)? YES NO
10c. Do you currently live with two or more medical conditions? YES NO
PLEASE LIST YOUR MEDICAL CONDITION(S)

AND ANY RELATED MEDICATIONS HERE:
GO to Page 4 for recommendations about your current

medical condition(s) and sign the PARTICIPANT DECLARATION.
Copyright © 2017 PAR-Q+ Collaboration 3 / 4

01-01-2017
2017 PAR-Q+
If you answered NO to all of the follow-up questions about your medical condition,
you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:
It is advised that you consult a qualified exercise professional to help you develop a safe and effective physical
activity plan to meet your health needs.
You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise,
3-5 days per week including aerobic and muscle strengthening exercises.
As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week.
If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a
qualified exercise professional before engaging in this intensity of exercise.
If you answered YES to one or more of the follow-up questions about your medical condition:
You should seek further information before becoming more physically active or engaging in a fitness appraisal. You should complete
the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or
visit a qualified exercise professional to work through the ePARmed-X+ and for further information.
Delay becoming more active if:

You have a temporary illness such as a cold or fever; it is best to wait until you feel better.
You are pregnant - talk to your health care practitioner, your physician, a qualified exercise professional,
and/or complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active.
Your health changes - talk to your doctor or qualified exercise professional before continuing with any physical
activity program.
You are encouraged to photocopy the PAR-Q+. You must use the entire questionnaire and NO changes are permitted.
The authors, the PAR-Q+ Collaboration, partner organizations, and their agents assume no liability for persons who
undertake physical activity and/or make use of the PAR-Q+ or ePARmed-X+. If in doubt after completing the questionnaire,
consult your doctor prior to physical activity.
PARTICIPANT DECLARATION
All persons who have completed the PAR-Q+ please read and sign the declaration below.
If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care
provider must also sign this form.
I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this
physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my
condition changes. I also acknowledge that a Trustee (such as my employer, community/fitness centre, health care provider,
or other designate) may retain a copy of this form for their records. In these instances, the Trustee will be required to adhere
to local, national, and international guidelines regarding the storage of personal health information ensuring that the
Trustee maintains the privacy of the information and does not misuse or wrongfully disclose such information.
NAME ____________________________________________________ DATE _________________________________________
SIGNATURE ________________________________________________ WITNESS ______________________________________
SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDER ____________________________________________________________________
For more information, please contact The PAR-Q+ was created using the evidence-based AGREE process (1) by the PAR-Q+
www.eparmedx.com Collaboration chaired by Dr. Darren E. R. Warburton with Dr. Norman Gledhill, Dr. Veronica
Email: [email protected] Jamnik, and Dr. Donald C. McKenzie (2). Production of this document has been made possible
Citation for PAR-Q+
Warburton DER, Jamnik VK, Bredin SSD, and Gledhill N on behalf of the PAR-Q+ Collaboration. through financial contributions from the Public Health Agency of Canada and the BC Ministry
The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) and Electronic Physical Activity
Readiness Medical Examination (ePARmed-X+). Health & Fitness Journal of Canada 4(2):3-23, 2011. of Health Services. The views expressed herein do not necessarily represent the views of the
Key References Public Health Agency of Canada or the BC Ministry of Health Services.
1. Jamnik VK, Warburton DER, Makarski J, McKenzie DC, Shephard RJ, Stone J, and Gledhill N. Enhancing the effectiveness of clearance for physical activity participation; background and overall process. APNM 36(S1):S3-S13, 2011.
2. Warburton DER, Gledhill N, Jamnik VK, Bredin SSD, McKenzie DC, Stone J, Charlesworth S, and Shephard RJ. Evidence-based risk assessment and recommendations for physical activity clearance; Consensus Document. APNM
36(S1):S266-s298, 2011.
3. Chisholm DM, Collis ML, Kulak LL, Davenport W, and Gruber N. Physical activity readiness. British Columbia Medical Journal. 1975;17:375-378.
4. Thomas S, Reading J, and Shephard RJ. Revision of the Physical Activity Readiness Questionnaire (PAR-Q). Canadian Journal of Sport Science 1992;17:4 338-345.
Copyright © 2017 PAR-Q+ Collaboration 4 / 4

01-01-2017

issaonline.edu
Lower Extremity Functional Scale

We are interested in knowing whether you are having any difficulty at all with the activities listed below
because of your lower limb problem for which you are currently seeking attention.
Please provide an answer for each activity.
Extreme
difficulty
Quite a bit Moderate A little bit No
Today, do you or would you have any difficulty at all with: or unable
of difficulty difficulty of difficulty difficulty
to perform
activity
a. Any of your usual work, housework or school activities. 0 1 2 3 4
b. Your usual hobbies, recreational or sporting activities 0 1 2 3 4
c. Getting into or out of the bath. 0 1 2 3 4
d. Walking between rooms. 0 1 2 3 4
e. Putting on your shoes or socks. 0 1 2 3 4
f. Squatting. 0 1 2 3 4
g. Lifting an object, like a bag of groceries from the floor. 0 1 2 3 4
h. Performing light activities around your home. 0 1 2 3 4
i. Performing heavy activities around your home. 0 1 2 3 4
j. Getting into or out of a car. 0 1 2 3 4
k. Walking 2 blocks. 0 1 2 3 4
l. Walking a mile. 0 1 2 3 4
m. Going up or down 10 stairs (about 1 flight of stairs). 0 1 2 3 4
n. Standing for 1 hour. 0 1 2 3 4
o. Sitting for 1 hour. 0 1 2 3 4
p. Running on even ground. 0 1 2 3 4
q. Running on uneven ground. 0 1 2 3 4
r. Making sharp turns while running fast. 0 1 2 3 4
s. Hopping. 0 1 2 3 4
t. Rolling over in bed. 0 1 2 3 4
Column Totals
Client name Date Score _____/80
Client signature MDC (minimal detectable change) = 9 pts Error +/- 5pts
Binkley, J. M., Stratford, P. W., Lott, S. A., & Riddle, D.L. The Lower Extremity Functional Scale (LEFS): Scale development, measure-
ment properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Physical Therapy. 79(4),
371–383.
Please note: possession of this form does not indicate that its distributor is actively certified with the ISSA. To confirm certification status, please call 1.800.892.4772 (1.805.745.8111 international). Information gathered from this form is not
shared with ISSA. ISSA is not responsible or liable for the use or incorporation of the information contained in or collected from this form. Always consult your doctor concerning your health, diet, and physical activity.

issaonline.edu
Upper Extremity Functional Index

We are interested in knowing whether you are having any difficulty at all with the activities listed below
because of your lower limb problem for which you are currently seeking attention.
Please provide an answer for each activity.
Extreme
difficulty
Quite a bit Moderate A little bit No
Today, do you or would you have any difficulty at all with: or unable
of difficulty difficulty of difficulty difficulty
to perform
activity
Any of your usual work, housework, or school activities 0 1 2 3 4
Lifting a bag of groceries to waist level 0 1 2 3 4
Placing an object onto, or removing it from, an overhead shelf 0 1 2 3 4
Washing your hair or scalp 0 1 2 3 4
Pushing up on your hands (eg, from bathtub or chair) 0 1 2 3 4
Preparing food (eg, peeling, cutting) 0 1 2 3 4
Driving 0 1 2 3 4
Vacuuming, sweeping, or raking 0 1 2 3 4
Doing up buttons (Note: response numbering is correct) 0 1 2 3 4
Using tools or appliances 0 1 2 3 4
Opening doors 0 1 2 3 4
Cleaning 0 1 2 3 4
Laundering clothes (eg, washing, ironing, folding) 0 1 2 3 4
Opening a jar 0 1 2 3 4
Carrying a small suitcase with your affected limb 0 1 2 3 4
Your usual hobbies, recreational, or sporting activities 0 1 2 3 4
Tying or lacing shoesw 0 1 2 3 4
Dressing 0 1 2 3 4
Sleeping 0 1 2 3 4
Throwing a ball 0 1 2 3 4
Column Totals
Client name Date Score _____/80
Client signature MDC (minimal detectable change) = 9 pts Error +/- 5pts
Stratford, P.W., Binkley, J.M., and Stratford, D. M. (2001). Development and initial validation of the upper extremity functional index.
Physiotherapy Can. 53(4), 259–267.
Please note: possession of this form does not indicate that its distributor is actively certified with the ISSA. To confirm certification status, please call 1.800.892.4772 (1.805.745.8111 international). Information gathered from this form is not
shared with ISSA. ISSA is not responsible or liable for the use or incorporation of the information contained in or collected from this form. Always consult your doctor concerning your health, diet, and physical activity.
Make Corrective Exercise Meaningful

Motivation
Autonomy
Belonging
Competence
Feedback
How to Cue a Client
How Often Should You
Provide Feedback?
Capacity
Exercise Selection
Loading and Movement Speed
Sets, Repetitions, and Rest Periods
How Stress Affects Motor Learning
UNIT 7
CREATE A JUST RIGHT CHALLENGE

114 | Unit 7
What You’ll Learn

In Unit 6 you learned how to prepare for the client by gathering key data to help you understand his or her
goals, mindset, and readiness for exercise. In this unit, you’ll learn how to coach a client during each correc-
tive exercise session in order to facilitate better movement and motor control, without overwhelming the
client’s functional capacity.
Before watching your clients move, it’s essential to learn what strategies are optimal to provide the most effec-
tive coaching. By the end of this unit, you’ll have learned the steps necessary to make each corrective exercise
session as meaningful to your clients as possible by creating a challenging and rewarding experience.
MAKE CORRECTIVE EXERCISE

MEANINGFUL
Meaningful experience: Each corrective exercise session should be a meaningful experience for your clients. A
An experience that caters to a meaningful experience consists of three factors: the client’s psychological needs being
person’s psychological needs met, your coaching skills, and the exercise parameters you choose for him or her.
without negatively affecting Indeed, it’s the correct combination of motivation, feedback, and capacity that are
the exercise parameters.
necessary to create what physical therapists refer to as a Just Right Challenge (JRC).
Motivation: The general We’ll start this unit by discussing the three essential components of a JRC.
desire to do something.
Feedback: The verbal
information given to a
client regarding exercise
MOTIVATION
performance. The amount of motivation you give a client should depend on his or her personality.
Some clients will require a lot of motivational support, while others will need little
Capacity: The ability to do
something successfully.
more than to hear you say “good job” a few times during the session. As a trainer or
therapist it’s your job to hone in on a client’s personality traits as quickly as possible in
Just Right Challenge: order to give him or her the highest quality coaching.
The correct combination of
motivation, feedback, and To help you with the process of motivating clients, the following information will cov-
capacity during a corrective er the three fundamental psychological needs that drive it. These three needs consist
exercise session.
of autonomy, belonging, and competence. In physical therapy, we refer to these the
Autonomy: The need to feel “ABCs” of motivation. Let’s cover each one.
control and independence.
Belonging: The need to feel
connected to others and part of AUTONOMY
society.
Autonomy is the need to feel a sense of control and independence, and this is a funda-
Competence: The need to feel mental aspect of a healthy mindset. People want to feel like they have a choice in their
capable of doing something life, whether it’s in the home or gym. Research demonstrates that long-term, positive
successfully.
psychological changes can occur when your client has a choice or responsibility in
the corrective exercise process. Therefore whenever it’s possible, let your client make
choices during a session, no matter how small they might be. Here are a few examples.
• Ask your client if he prefers to warm up on the treadmill or elliptical machine.
• If your client doesn’t like performing a certain exercise, consider similar alter-
natives and let her pick one of them.
• Let the client choose which exercise he would like to start or finish the work-
out with, assuming it won’t negatively affect the corrective exercise session.
Corrective Exercise
Create a Just Right Challenge | 115
There might be times when it would be unwise to let the client choose different ways
to manipulate the session. This is especially true with clients that tend to be a little
lazy by nature. It could also be problematic to let a client change the structure of a
session that you’ve determined is ideal to produce the best results. However, you can
still develop the client’s important sense of autonomy by asking him or her to help you
choose things that aren’t related to corrective exercise. The options here are endless,
but the following examples will give you some good ideas.
• If you’re considering buying a new SUV, ask your client Steve which one he
prefers (assuming he drives one).
• Ask your client Sarah if you should repaint your office walls gray or tan.
• Ask your foodie client Jill which restaurant she recommends for your part-
ner’s birthday party.
These questions might seem inconsequential to you, but research demonstrates
that these seemingly meaningless exchanges will help develop your client’s sense of
autonomy. By default, a stronger sense of autonomy can lead to better results during
the sessions.
BELONGING
Belonging is the need to feel included, accepted, and connected with others. People
want to feel satisfaction in their involvement with the social world. The good news
is that it doesn’t take much to help a client feel a sense of belonging. It’s as simple as
listening to what your client says in order to figure out what interests him or her.
Everyone is interested in something. Maybe it’s sports, movies, or horse racing. The
most effective approach for developing your client’s sense of belonging is to focus on
an interest that’s common to both of you. For example, I’m a fan of professional box-
ing and so is one of my clients. I’ve lost count of how many sessions we’ve discussed
boxing – probably hundreds of times – and I can say with confidence that he seemed
to genuinely enjoy each one.
However, it’s possible that you’ll work with a client who’s only interested in things
you know nothing about or don’t like at all. That won’t negatively affect this process.
All you need to do is make a point to ask your client about one of those interests. For
example, maybe you loathe golf, but your client, Tom, enjoys nothing more than to
watch and play it. To develop the sense of belonging, just ask him to tell you what’s
new in the world of golf. He’ll surely have a passionate response, which will make him
happy, and you’ll provide him with the psychological need to feel connected with oth-
ers. This, in turn, will help drive his motivation to continue working with you.
COMPETENCE
Competence is the need to feel capable of doing something successfully. If you fre-
quently challenge your clients to do exercises that are beyond their capacity, they can
lose the feeling of competence. Or if they have no gauge on whether or not they’re
doing well in a session, it can lead to frustration and zap motivation. Therefore, to give
your clients a sense of competence it’s beneficial to set small, attainable goals and give
them feedback of the things they did well throughout the session.
Now that you know the three components of motivation, we’ll continue with the sec-
ond element that creates a JRC: feedback.

116 | Unit 7
FEEDBACK
The way you coach and cue your clients through an exercise can have a significant
influence on how quickly they learn to do it correctly (i.e., motor learning). When and
how you should give feedback is outlined in this section.
HOW TO CUE A CLIENT

It’s common for trainers and therapists to tell their clients to “squeeze this” or “brace
Internal cues: Cues that that” during an exercise. These are known as internal cues because they require the
target the inside of the body client to focus on something that’s happening inside the body. Even though an in-
and require an internal focus. ternal focus can be beneficial at times, research by Gabriele Wulf, Ph.D., has demon-
External cues: Cues that strated that external cues are better for learning a complex movement – the type of
target something outside the movement that is usually most meaningful to a person’s life or sport.
body and require an external
focus. Let’s start with an example that’s specific to basketball. While practicing a free throw,
Complex movement: A
the player would concentrate on hitting the back of the rim (external focus) instead
movement that involves motion of the movement of the wrist (internal focus). In the gym, this external focus would
at two or more joints. translate into telling your client to “try to bend the bar” during a pull-up instead of
saying, “squeeze your lats.” Another example: when your client is about to lock out
the hips at the end of a squat or deadlift, an external cue could be “push the bottom of
your shoes into the floor” instead of telling the client to “lock out the hips.”
Or imagine you place a mini resistance band around your client’s lower thighs to
activate the glute muscles during a squat. Instead of telling your client to “spread your
knees” during the squat, a more effective external focus would be to tell the client to
“stretch the band” during each repetition.
Learning to use external cues takes practice, and some exercises are easier to cue than
others. Nevertheless, if you make an effort to provide cues that require your clients to
have an external focus during complex movements, their motor learning and perfor-
mance can be enhanced.
HOW OFTEN SHOULD YOU PROVIDE

FEEDBACK?
It’s tempting to correct your client’s form as soon as you see a problem; however,
research has shown that it’s better to let a few faulty repetitions occur when learning a
new movement. This allows clients to feel how they naturally want to move before you
give feedback. Of course, if it’s a challenging exercise and the client’s form is so poor
that injury is likely, you should terminate the set immediately.
The ideal strategy for providing feedback to your client is to have him start with a light
load, or no load at all, and perform a few repetitions (e.g., 3-5), as outlined later. This
reduces the risk of injury while still allowing for enough repetitions so the client can
feel the movement. At the end of the set, summarize the feedback your client needs to
correct his faulty form.
For example, after watching your client perform a set of the standing dumbbell
shoulder press you might tell him to “push the dumbbells closer to the ceiling”
during an overhead press if his range of motion was less than optimal. This example
of feedback coalesces an external cue with the correct timing of information – at
Knowledge of results: A the end of the set. Research demonstrates that by providing your clients with their
form of verbal feedback where
information is given at the end
knowledge of results immediately after the set is finished, instead of during it, can
of the task. enhance their motor learning.
Corrective Exercise
TRAIN YOUR BRAIN: Should you W.A.I.T.?

The way you communicate with your clients of self-motivation and drive; however, my job was
during a corrective exercise session is crucial for to push him to a level of fitness that he couldn’t
developing a strong, professional relationship with achieve on his own. Therefore, I was keenly aware
him or her. Clients enjoy a friendly, low-stress en- of the times when he started to fatigue. The logical
vironment with open communication. Therefore, coaching solution was to give him encouragement
it’s inevitable that there will be times when you’re so he would complete a few more reps before I
chitchatting with a client during a session. had him stop an intense set. However, that ap-
proach didn’t work. Whenever I would tell him he
During the times when you’re unsure if you should
was doing great as he fatigued, or whenever I told
be talking during a session, ask yourself: Why am I
him to do a few more reps toward the end of a
talking? Are you nervous, or do you sense your cli-
challenging set, he would immediately lose focus
ent feels nervous? Are you trying to build rapport
and have to stop. Conversely, if I said nothing
with a client? Or are you just assuming that your
during his most challenging sets, he would stay
client wants to talk? These are all legitimate reasons
focused and push himself beyond what I thought
to strike up a conversation, and there isn’t a single
was possible.
best way to approach it. However, keep in mind
that the client is paying you to provide a service. If talking, coaching, or even encouraging a client
There will be times when talking with the client isn’t providing the result you want, remember the
could hinder his focus, and ultimately, his results. acronym W.A.I.T.? Why am I talking? Sometimes
it’s best to say nothing, other times it’s best to
For example, a young client once hired me to pre-
change the conversation so it’s more applicable to
pare him for the Navy SEALS tryout. He had plenty
the corrective exercise session.
CAPACITY EXERCISE SELECTION

At this point, you’ve learned how to motivate your clients An ideal corrective exercise movement is one that is
and provide them with the right type of feedback. How- neither too easy nor too challenging. In other words,
ever, those components mean little if you use parameters it’s at the edge of a client’s capacity. The exercise should
that are beyond the client’s capacity. Therefore, this section require focus and concentration; however, it shouldn’t be
covers the elements to consider when creating your client’s so challenging that it causes the client to lose his sense of
exercise parameters: exercise selection, loading, sets, reps competence. Indeed, an overzealous trainer who chooses
and rest periods. These parameters are highly variable, de- movements beyond the client’s motor control capacity can
pending on the client’s exercise experience and fitness level. zap motivation and impair the motor learning process.
Even though there aren’t any perfect, concrete param- A common theme in training and rehabilitation is to
eters to help your clients move better, the following “isolate then integrate.” Let’s say your client has right knee
information will provide you with the information you pain when performing a lunge. If you determine that this
need to make smart corrective exercise choices based on problem might be caused by weakness in his right hip
your client’s capacity. abductors (i.e., gluteus maximus/medius/minimus) you

118 | Unit 7
Just Right Challenge (JRC)
motivation feedback capacity
autonomy external cues exercises

belonging knowledge of results loading / speed
competence end of the set sets / reps / rest
Figure 7.1. Just Right Challenge. The components that create a meaningful experience
for your clients during each corrective exercise session
Isolation exercise: An might spend a few weeks performing an isolation exercise to strengthen those mus-
exercise that involves motion at cles. The idea is to first isolate and strengthen the weak muscle and then incorporate
one joint. the multi-joint exercise (e.g., lunge) back into the routine a few weeks later and hope
the issue is resolved.
However, that strategy can be time consuming and unnecessary. When a movement
is causing your client a problem (discomfort, instability, etc.) a more logical approach
is to try and correct that movement first. In other words, the goal with corrective ex-
ercise is to correct the problematic movement without regressing to isolation exercises
unless it’s necessary. The steps required to correct an exercise will be covered later in
this course, but for now, there are two things to keep in mind.
First, isolation exercises should be limited to the times when a multi-joint exercise
won’t suffice, due to movement or equipment restrictions. Second, isolation exercis-
es can be beneficial to enhance a client’s mind-muscle link, which is the ability to
voluntarily activate a muscle group. For example, it’s sometimes difficult for clients to
feel the glutes working because very little real estate in the motor cortex is devoted to
those muscles.
Therefore, isolation exercises for the glutes can help develop the mind-muscle con-
nection so those muscles can be more effectively activated when the client returns to a
multi-joint movement, such as a squat or lunge.
Bottom line: when selecting exercises for your clients, choose movements that are at
the edge of their functional capacity and multi-joint in nature whenever possible.
LOADING AND MOVEMENT SPEED

As a general rule, start your clients with a load that’s less than you think they need
and have them move at a speed that is slower than what’s necessary. By starting with
Corrective Exercise
TRAIN YOUR BRAIN: Focus on the load first.

Your client, Tom, demonstrates weakness in the hip hinge movement pattern.
Therefore, you select the Romanian deadlift as one of his corrective exercises.
During your first session, you test his strength and determine that the maxi-
mum load he can lift for that exercise is five reps with 200 pounds loaded on
a barbell.
Your goal for Tom is to increase his training load to 300 pounds for the Ro-
manian deadlift over the course of 12 weeks. To minimize a risk of injury and
improve his motor control, the movement speed throughout this phase of
training should remain slow. How slow? Generally speaking, a two-second
up and two-second down phase is a good starting point. There’s no need to
time the reps, or count out loud, because exactness isn’t necessary. However,
stick to a movement speed close to that.
Once he reaches the goal of a 300-pound Romanian deadlift for five slow
reps, then you can increase the lifting speed if you feel it’s necessary. Bottom
line: an increase in training load should take precedence over an increase in
movement speed for the initial phase of corrective exercise.
light loads and slow movement speeds it minimizes the risk of injury while making
the clients feel competent with your training parameters.
The first goal with corrective exercise is to increase the training load without increas-
ing the movement speed. The loading progression should be steady and methodical.
The movement speed should remain slow until the client reaches the loading goal you
have set for that phase of training. Once the client has demonstrated sufficient motor
control at a relatively slow, controlled tempo with the load you have determined is the
limit for that client’s needs, then you can increase the movement speed if you feel it’s
necessary for her development.
SETS, REPETITIONS, AND REST PERIODS

The goal of corrective exercise is to perform the highest quality movement patterns
possible. It’s impossible to prescribe a perfect number of sets or reps for your client;
however, there are some general guidelines that will help you determine if you’re doing
too little or too much.
The number of sets and reps are determined by the quality of the client’s movement
patterns. The sets should continue as long as the client’s movement quality is increas-
ing. Similarly, the reps should stop once the movement pattern starts to falter. Gener-
ally speaking, more sets of fewer reps are better for motor learning because less fatigue
accumulates. This is important since fatigue is the element most associated with Cardiovascular endurance:
diminished movement quality. The ability of the heart, lungs,
and blood vessels to deliver
The length of rest periods between sets will depend on how challenging the exercise is oxygen to the tissues in the
as well as the client’s cardiovascular endurance. Rest periods should be long enough body.

120 | Unit 7
to allow the cardiovascular system to recuperate and making a free throw when the game is on the line, even
restore energy but not so long that it augments the length though they’ve practiced it thousands of times.
of the session.
Stress also impairs your ability to focus on what you’re
It’s worth noting here that corrective exercise is not doing. The brain needs direct attention on your movement
intended to burn fat or build muscle. The goal is to restore so it can strengthen the synapses that are required by the
the client’s functional capacity and eradicate discomfort movement. Creating a Just Right Challenge for your cli-
in any movement pattern, which will allow the client to ents will help ensure that the stress of the workout doesn’t
eventually train with a level of intensity that’s necessary to negatively affect motor learning.
achieve the fitness goals the client desires.
HOW STRESS AFFECTS FINAL THOUGHTS

As this unit comes to a close, it’s important to consider
MOTOR LEARNING and develop the strategies necessary to provide each client
Let’s discuss the negative impact that stress can have on with a meaningful experience during every corrective
motor learning. When a client is stressed out or wor- exercise session. These steps will help keep your client
ried, two neurotransmitters are released: noradrenaline motivated, which is a key factor for avoiding cancellations
and dopamine. These two neurotransmitters bind to the and early withdrawal from the corrective exercise process.
prefrontal cortex area of the brain, impairing the brain’s Finally, once you master the information in this unit,
ability to respond with the precise movement patterns you’ll have developed the foundational coaching strategies
that can be achieved during periods of low stress. This is that will help your clients get the most out of each correc-
why professional basketball players have a difficult time tive exercise session.
Summary
1. Each corrective exercise session must be meaningful 7. Exercises that involve more than one joint should be
to your client. performed whenever possible as they are typically
the most functional and have the greatest carryover
2. To make each session meaningful, it’s important to
to life and sport.
create a Just Right Challenge.
8. Isolation exercises are beneficial when a multi-joint
3. A Just Right Challenge is created through the correct
movement isn’t possible or when the client needs to
combination of motivation, feedback, and capacity.
develop the mind-muscle link.
4. Building and maintaining a client’s motivation is
9. Corrective exercise first focuses on increasing the
essential to successful corrective exercise sessions.
client’s ability to exercise with a greater load followed
Motivation is enhanced when you provide the client
by an increase in movement speed.
with a sense of autonomy, belonging, and compe-
tence. 10. The number of sets, repetitions, and the length of
each rest period depend primarily on the client’s
5. Research demonstrates that providing your clients
with an external focus during exercise is more effec- fitness level.
tive for motor learning than an internal focus.
6. Feedback should primarily occur at the end of a set
when a client has felt how he or she naturally wants
to move.
Corrective Exercise
Why Fewer Corrective Exercises

Is Better
Movement Analysis
Step 1: Divide the Exercise Into
Concentric and Eccentric Phases
Step 2: Identify the Critical Events and
Observe the Exercise
Step 3: Make a List of What You Saw
Step 4: Develop a Hypothesis
Step 5: Provide the Proper Intervention
Final Words
UNIT 8
PERFORM A SINGLE-JOINT
MOVEMENT ANALYSIS
122 | Unit 8
What You’ll Learn

Now that you have gathered the necessary information to better understand your client’s mindset and
goals, along with the coaching strategies to develop the appropriate challenge during each session, it’s
time to learn how to perform a simple movement analysis for a single-joint exercise. In this unit you’ll learn
the steps required to understand all phases and components of an exercise. You’ll learn how to carefully
observe an exercise, gather the necessary data, and form a hypothesis of what could be causing any prob-
lem you see. By the end of this unit, you should have a clear understanding of the steps required to become
proficient at analyzing any simple movement.
WHY FEWER CORRECTIVE EXERCISES

IS BETTER
These days, myriad techniques exist that are intended to help a person move bet-
ter. The list of possible activities runs the gamut from foam roller drills to dynamic
stretches to corrective exercise for the spine or hips.
However, you would be hard pressed to find a person who truly enjoys foam rolling
the quadriceps or doing corrective exercises for the thoracic spine. Furthermore, you’d
probably have just as much difficulty finding a trainer who would rather have a client
foam roll the iliotibial band instead of spending that time doing more functional,
challenging exercises that help build strength, speed, or muscle.
Why then are those drills being performed? In the vast majority of cases, a person-
al trainer is prescribing those interventions because the client is unable to correctly
perform a much more beneficial exercise, such as a lunge, overhead press, or deadlift,
just to name a few.
Let’s consider the lunge, for example. When a person has problems performing that
exercise correctly, a personal trainer has two options. First, he or she could take an ed-
ucated guess at what is causing the problem. In this case, the trainer might have deter-
mined that the quadriceps are too stiff; therefore, his client performs foam rolling for
the quadriceps at the beginning of the session. Or the trainer could attempt to correct
the client’s lunge technique. Knowing how to correct a client’s technique is the fastest,
most effective way to keep him or her from needing any corrective drills. However,
many personal trainers don’t have the skill set to know exactly what to analyze while
watching the client move, which can lead to a client’s performing a corrective exercise
that might not be needed.
The goal of exercise is to perform the most beneficial activities, such as running and
lifting weights, to fulfill the five hours per week of training that most researchers and
medical experts recommend for optimal health. In a perfect world, people would
be able to participate in the sports and activities they enjoy without the burden of
corrective exercises cutting into that time. Frankly, I have never met a person who
complained of having too much time to exercise.
Nevertheless, there’s a time and place for foam rolling, stretches, and thoracic spine
Corrective Exercise
Perform a Single-Joint Movement Analysis | 123
drills. We’ll cover how and when to use those interventions later in this course.
However, they should be a last resort and only included in a client’s program after all
efforts have been made to correct the exercise that’s not being performed correctly.
Actively engaging a person’s brain to move with better form can sometimes resolve
other nagging issues that required stretches or foam roller drills.
Therefore, if personal trainers become better equipped to analyze any exercise, and
determine what’s wrong, there will be less need for time-consuming corrective inter-
ventions. Indeed, over the last few years, I often began seminars by telling the trainers
that, oftentimes, the best corrective exercise is to teach your clients how to move with
better form. Therefore, that’s where we’ll start.
MOVEMENT ANALYSIS
The purpose of a movement analysis is to determine whether there’s a problem with Movement analysis: A
the way your client performs an exercise. To derive the most benefits from an exercise, process of analyzing how a
a person must perform it correctly. When an exercise is being executed with poor client moves.
form, it impairs the fitness-building effects your client seeks and predisposes him or
her to an injury. It’s common for people to do exercises incorrectly, even when they
think they’re doing them the right way.
When I give seminars and workshops for personal trainers who want to improve their
coaching skills, I’ve often noticed two things that apply to most of them. First, they
don’t know how to correctly analyze a client as he or she performs an exercise. Second,
if these trainers do take the time to assess the way a client moves, they usually don’t
spend enough time watching and thinking about what they’re seeing.
Therefore, the first stage of corrective exercise programming is to carefully observe
the exercise your client is struggling with and figure out what can be improved. You’ll
accomplish that task by learning how to perform a movement analysis.
The system you follow to assess the way a client performs an exercise should be appli-
cable to anyone. It doesn’t matter what gender, age, weight, height, or dysfunction your
client might already have; the following steps will provide you with the information
you need to critically analyze an exercise. A movement analysis consists of answering
three crucial questions:
• What do you expect to see?
• What do you actually see?
• What could be causing the difference?
When a movement analysis is performed the way that’s outlined in this unit, that
analysis will provide you with the necessary information to not only identify the
movement problem but also to determine what’s causing it.
We’ll start with a movement analysis of a standing barbell curl. Even though you
might not ever have your client perform a barbell curl, it serves as a simple, straight-
forward example because movement is occurring at only one joint. Movement analysis
is a skill that takes time and practice to develop. And there’s no better way to learn a
skill than to start as simply as possible. The good news is that the steps you’ll take to
analyze a barbell curl will carry over to any other exercise. Keep that in mind as we go
through the following steps.

124 | Unit 8
STEP 1: DIVIDE THE EXERCISE INTO

CONCENTRIC AND ECCENTRIC PHASES
Most exercise movements—the ones you typically perform in the gym, with the
exception of Olympic lifts and a few others—consist of an up and down phase. When
Concentric phase: The using a free weight such as a barbell, dumbbell, or medicine ball, the concentric phase
portion of a movement when is the portion of a movement when the load moves up, and the eccentric phase is when
the muscles are shortening
the load moves down.
to overcome the direction of
resistance. As we covered in Unit 2, a concentric action occurs when a muscle shortens against
Eccentric phase: The portion the direction of resistance. For example, the elbow flexors perform a concentric action
of a movement when the to flex the elbow joint, which moves the barbell upward by overcoming the downward
muscles lengthen to yield the gravitational pull of the barbell. An eccentric action occurs when the muscle length-
direction of resistance. ens in the same direction as the resistance is pulling. In other words, an eccentric ac-
tion yields (i.e., slows) the downward directional pull when lowering the barbell under
control during a biceps curl.
If a cable or resistance band is used, the direction of resistance is the same direc-
tion that the cable or band is pulling. Because the cable or band could be providing
resistance at any angle, whether that angle is in a horizontal direction due the pulley
being positioned at chest height, or any position above or below that, there isn’t a clear
up and down phase. As mentioned, the concentric phase will be the portion of the
movement when the working muscles are shortening, and the eccentric phase will be
the portion when the working muscles are lengthening.
The purpose of dividing an exercise into a concentric and eccentric phase is to deter-
mine whether a movement problem is occurring while the muscle is shortening or
lengthening. This is the first step for honing in on what physical impairment might be
causing faulty technique.
Figure 8.1.
Concentric and
eccentric phases of
a barbell curl. A)
The concentric phase
occurs when the
biceps shorten (barbell
elevates) against the
direction of resistance.
B) The eccentric phase
occurs when the biceps
lengthen (barbell low-
ers) to yield the direc-
tion of resistance.
Corrective Exercise
STEP 2: IDENTIFY THE CRITICAL EVENTS AND

OBSERVE THE EXERCISE
In Unit 4, we discussed that motion can occur in three different planes: sagittal, fron-
tal, and transverse. As a gross generalization, flexion and extension movements occur
in the sagittal plane; abduction and adduction occur in the frontal plane; and rotation
and horizontal abduction/adduction occur in the transverse plane. Because a barbell
curl consists of elbow flexion, and extension, it’s a sagittal plane movement. In other
words, if a barbell curl is performed with strict form, the only motion you should see
is at the elbow joint while the barbell moves up and down within the sagittal plane.
This second step of the movement analysis process answers the question: What do I
expect to see? In other words, what are the only actions necessary to perform a stand-
ing barbell curl correctly? These necessary actions are what form the critical events, Critical events: The
and they’re applicable to any exercise. Any joint that’s required to move during an necessary steps for performing
a movement with ideal
exercise is performing a critical event. Furthermore, the ability to maintain proper
technique. Documentation:
posture (i.e., balance and alignment) is a critical event that’s necessary for any exer- The process of writing down
cise, whether it’s being performed while standing, seated, or even lying on the floor. what you see and do in a
Therefore, the fewest critical events you’ll have for any exercise is two. For the barbell training session. Hypothesis:
curl, the two critical events that should occur include flexion and extension of the A proposed explanation made
elbow joint through a full range of motion (ROM) and maintenance of posture. based on limited evidence.
If those two critical events are not met, or if any additional actions are occurring, the
exercise isn’t being performed correctly. Therefore, before you watch a client move,
you’ll make a list of the critical events for the exercise. This will condition your brain
to focus on the necessary components of any exercise so you won’t miss anything you
see. Knowing the critical events for an exercise is an essential step in the corrective
process that will be outlined later, so do not skip it.
At the end of this unit, there’s a complete movement analysis form you’ll fill out while
watching a client perform an exercise. However, that form contains many pieces of
Figure 8.2.
Critical events for
the barbell curl. A)
The concentric phase
requires elbow flexion
through a full ROM
while maintaining
postural control. B)
The eccentric phase
requires elbow exten-
sion through a full
ROM while maintaining
postural control.

126 | Unit 8
Figure 8.3. Barbell curl viewed in the three movement planes. A) Sagittal plane view B) Frontal plane view, and C)
Transverse plane view.
information that we haven’t yet covered. Therefore, we’ll arm, he’ll often twist his torso to the right as he curls up
look at each component of that form separately as we the barbell. This compensation can be identified, some-
move through the following information. Table 8.1 depicts what easily, when you view the movement from his side or
the first piece of information—the critical events—that front. Indeed, the sagittal plane and frontal plane views
you’ll fill in the movement analysis form. will give you all the information you need, as long as you
keep the transverse plane in mind by looking for rotation-
Now it’s time to carefully watch the client perform the al compensations.
exercise for as many reps as you require for the analysis.
Because it’s very difficult to notice all the possible com- To recap, after you make a list of the critical events for an
pensations your client might have if you observe him exercise, instruct your client to perform as many repe-
or her from only one angle, it’s necessary to analyze an titions as necessary so you can carefully view the move-
exercise with respect to all three planes. ment in the sagittal and frontal planes—and perhaps even
the transverse plane if possible.
The sagittal plane is viewed by standing at your client’s
side, and the frontal plane is viewed when standing in
front of him. Unfortunately, the transverse plane re-
Table 8.1: List critical events
quires an overhead view. This obviously makes viewing
the transverse plane extremely difficult unless you have Exercise: standing barbell curl
a video camera pointing down over the client’s head or a
very tall ladder. Critical event #1:
However, it’s not necessary to actually see the transverse maintenance of posture
plane from overhead. You can nearly as easily see any
transverse plane compensations after watching your client Critical event #2:
move from the sagittal and frontal plane viewpoints.
flexion and extension of the elbow through a full ROM
For example, if a man has weak elbow flexors in his right
Corrective Exercise
STEP 3: MAKE A LIST OF WHAT YOU SAW

Now that you’ve seen your client perform the exercise, it’s Did the elbow flex and extend through a full range of mo-
time to expand beyond your list of critical events. In this tion? Yes or no? Was the client able to maintain proper
step, you’ll answer the question “What did I actually see?” posture? Yes or no?
At this point, you’re still gathering data. It’s not helpful to If you’ve spent any time in a commercial gym or on
stop to think about what could be causing any problems YouTube watching exercise videos, you know that guys
you currently observe—that will come later. For now, your often perform a barbell curl with extra motion that
task is simple: consider the two critical events and deter- goes well beyond the elbow joint. Considering all of the
mine whether they’ve been met. You’ll accomplish that by possible compensations that could occur, it is essential to
answering the following two yes or no questions. answer one more question: “What other movements were
observed?”
TRAIN YOUR BRAIN: Document like a professional.

Let’s face it: writing down everything that’s import- three ways. First, you’ll able to document faster.
ant in each training session can be a real pain. Even Second, you’ll use the same abbreviations that other
though documentation can be time consuming, it’s health-care practitioners use, which will make you
an essential aspect of making accurate corrective ex- look more professional. Third, you’ll better under-
ercise prescriptions. Therefore, to save time without stand a note that a physical therapist or physician
overly simplifying what needs to be documented, might send you after referring a patient. Here’s a list
physicians, physical therapists, and chiropractors of the health-care abbreviations most applicable to
use multiple abbreviations that are universally ac- corrective exercise.
cepted in health care.
Here is a list of the health-care abbreviations most
Learning relevant abbreviations will benefit you in applicable to corrective exercise.
Documentation Abbreviations
Wt weight H&P history and physical examination ACL anterior cruciate ligament
P pulse h/o history of MCL medial cruciate ligament
BP blood pressure c/o complains of b.i.d. twice daily
T temperature CC chief complaint t.i.d. three times daily
ROM range of motion HA headache h.s. at bedtime
R right N/V nausea or vomiting s/p status post
L left HTN hypertension Example: a person who
B bilateral LBP low back pain had knee surgery would be
UE upper extremity TKR total knee replacement “s/p knee surgery.”
LE lower extremity THR total hip replacement

128 | Unit 8
Figure 8.4. Common compensations for the barbell curl. A) The sagittal plane compensations that are often seen are
trunk sway, shoulder flexion, and forward movement of the head/chin. B) In the frontal plane, shoulder elevation and elbow
flare are common. C) Trunk rotation is seen in the transverse plane.
You might see one or both shoulders shrug, the trunk

sway back and forth, the elbows flare in and out, the head/ Table 8.2 Note what you observed
chin push forward, or the torso rotate. Indeed, the list of
possible compensations is virtually endless. This is why Exercise: standing barbell curl
it’s important to observe the movement from multiple Critical event #1:
planes; doing so will allow you to identify all possible
maintenance of posture
compensations. In Figure 8.4, you’ll see examples of some
of the more common compensations that can occur with Was critical event #1 met? Yes No
the standing barbell curl.
Now it’s time to write down what you saw: Were the criti- Critical event #2:
cal events met? Were other movements observed? Make a flexion and extension of the elbow through a full ROM
list of each compensation you see with respect to the plane
Was critical event #2 met? Yes No
where it was viewed.
For example, you might see one or both elbows flare when What other movements were observed?
viewing the exercise from the frontal plane view or trunk
extension from the sagittal plane angle. As mentioned, it’s Sagittal plane:
not necessary to actually see the transverse plane from an
aerial view; however, any transverse plane compensations Frontal plane: left GH abduction (concentric phase)
should be noted. Thus, if your client rotated his or her
trunk to the left during the concentric phase, you’ll make Transverse plane:
a note of that in the transverse plane section of the move-
ment analysis form that’s included at the end of this unit.
Corrective Exercise
see and do in a training session is known in the profes-

sional health-care world as documentation. It’s part of
the daily tasks that all physicians, physical therapists,
and chiropractors must do to maintain a record of their
assessments and treatments.
If you’re a personal trainer, properly documenting what
you do with clients will not only make you look more pro-
fessional to your clients and colleagues but also will help
serve as an important reference for remembering what
you did in previous sessions.
Now, let’s move on to the final stage of the movement
analysis process:.
STEP 4: DEVELOP A
HYPOTHESIS
By now, you’ve seen your client perform the exercise
and made of a list of what you saw. To recap: what you
expected to see is the ideal technique; what you actually
saw could be any deviation from what’s ideal. The final
step is to develop a hypothesis for what could be causing
the problem. Therefore, in this step you will answer the
question “What could be causing the difference between
what I expected to see and what I actually saw?”
How far you dive into this step depends on your knowl-
edge of biomechanics and anatomy. However, regardless
of your educational background, the first thing worth
mentioning is that you’ve already accomplished more than
the vast majority of personal trainers are capable of doing.
Let’s say, for whatever reason, you weren’t able to have an-
Figure 8.5. Glenohumeral (GH) abduction during a
barbell curl. During the concentric phase, the left elbow
other session with this client. If you gave Table 8.2 to any
flares outward due to abduction at the left GH joint. physical therapist, chiropractor, or physician, he or she
would be extremely impressed. In essence, you’ve already
honed in on what’s right and wrong with the movement.
Let’s assume your client was able to flex and extend the That means you’ve already saved any health-care profes-
elbow joints through a full range of motion and was able sional a significant amount of time by giving him or her a
to maintain postural alignment from head to toe while good idea of what could be causing the compensation.
performing the barbell curl. Both critical events were met. What is it that is causing the left glenohumeral joint to
However, your client’s left elbow flared outward during abduct during the concentric phase the barbell curl?
the concentric phase of the curl. In other words, the left Throughout this course, it’s been emphasized that there
shoulder joint abducted. Specifically, the left glenohumer- are three possible reasons a movement can’t be per-
al (GH) joint abducted because it’s the joint that performs formed correctly.
shoulder abduction, as you learned in Unit 4.
• Poor mobility
Therefore, on the movement analysis form you’ll note that
• Poor strength
the left GH joint abducted during the concentric phase in
the section where frontal plane compensations are added. • Poor motor control
The process of writing down all the important things you If we think about the glenohumeral joint, we know that

130 | Unit 8
poor mobility isn’t the problem, because the joint doesn’t can’t, soft tissue work and stretches are in order until he
need to move at all. Therefore, we can eliminate that or she can achieve full elbow flexion and extension.
reason. The second reason—poor strength—is a logi-
cal option, and this leads us to an important aspect of
corrective exercise programming: If a joint that shouldn’t Is It Poor Strength?
be moving is moving, the muscles that oppose that action When can you assume that poor strength is the problem?
could be weak. Unfortunately, there’s no simple answer. On one hand,
you can assume that a lack of strength is the problem
In this case, the extra motion is abduction of the left gle- if the joint can naturally move through a full range of
nohumeral joint. Therefore, the muscles that oppose that motion, but that same range can’t be achieved with the
action—the adductors of the left glenohumeral joint— load that’s being lifted. This is assuming the technique is
could be weak. In other words, the left glenohumeral joint correct and no other compensations are occurring. In this
abducts because the adductors aren’t strong enough to case, the solution is usually as simple as decreasing the
hold the elbow close to the body. training load.
This is why Unit 4 outlined all the muscles involved in If you have clear evidence that a muscle is weak, you
every major joint action across the body. You can use that can target that muscle with another exercise to directly
information to help identify which muscles might be weak strengthen it. But if one limb is significantly weaker than
when a joint can be held static. With regard to the gleno- the other is, it’s likely there’s a neurological problem be-
humeral adductors, the list consists of: tween the nerve and muscle, which requires intervention
• Latissimus dorsi from a health-care professional.
• Teres major
• Pectoralis major (sternal portion)
Is It Poor Motor Control?
Poor motor control is often the source of movement
• Coracobrachialis compensations. Therefore, correcting it forms the founda-
• Pectoralis major (clavicular portion) when the GH tion of what corrective exercise aims to achieve. However,
joint is adducted <90° there’s a problem with semantics: what scientists define as
“strength” and “motor control” have significant overlap.
• Anterior/posterior deltoids when the GH joint is
adducted <60° Is the left shoulder abducting because the adductors are
weak or because the nervous system doesn’t have suffi-
That is obviously a long list. A trainer or therapist with cient motor control to hold that joint steady with the load
plenty of experience in anatomy and biomechanics might that’s being lifted?
be able to look at that list and hone in on the most likely
culprit. In many cases, the teres major is weak. How- Surprisingly, and perhaps counterintuitively, motor
ever, even if the teres major were the problem, it proba- control is actually easier to identify during more com-
bly wouldn’t be ideal to strengthen it with an isolation plex movements, such as a squat or overhead press. This
exercise. Each year, more and more physical therapists are is because multiple joints must work in concert to drive
moving away from the “isolate then integrate” mindset and stabilize those exercises. In other words, because a
in favor of doing everything possible to first correct the complex movement requires greater motor control, there’s
movement as it naturally occurs. more to see go awry.
These concepts will be covered in the next Unit; however,
you can assume that motor control is poor when a move-
Is It Poor Mobility? ment isn’t smooth and controlled, even when using a load
For the barbell curl, poor mobility would be the prob-
that’s appropriate for the client.
lem if one or both elbows were unable to flex and extend
through a full range of motion without regard for any The good news is that you don’t need to overwhelm your
exercise. In other words, can your client actively flex and brain to determine whether your client lacks strength or
extend through a full range of motion without any weight motor control. In either case, the most effective solution is
in hand? If so, mobility isn’t the problem. If the client often the same: cue the exercise correctly.
Corrective Exercise
STEP 5: PROVIDE THE PROPER

INTERVENTION
By now, you’ve spent a great deal of time analyzing the
movement and have given much thought to what could be
causing any problems you see. As we continue analyzing
the barbell curl with the client demonstrating left gle-
nohumeral joint abduction during the concentric phase,
you’ll now provide an intervention to correct it.
Whenever you see the client compensate during a move-
ment analysis, first ensure that the load being used isn’t
too heavy. Second, coach the exercise correctly to improve
motor control, and by default, the muscles that could be
“weak” will be strengthened as well.
Cue the Exercise Correctly

In Unit 7, we covered the components of effective coach-
ing, which ranges from keeping the client motivated to
providing the right type of feedback. In this step, we’ll
emphasize the importance of external cues because
they’re ideal for improving motor control and, subse-
quently, motor learning.
If a personal trainer sees his or her client flare the left elbow
during a curl, the trainer usually responds by cueing the
client to “keep your elbow pulled inward” or something
similar. However, that’s an internal cue because it’s making
the client focus his or her attention on one of his or her
body parts. An external cue, on the other hand, requires
the client to focus on something external to the body.
In this case, you could put a rolled up towel between the
left elbow and left torso and tell the client to “smash the Figure 8.6. External cue to offset glenohumeral
towel” during the concentric phase of the curl. That would abduction. The client externally focuses on smashing his
be an external cue to keep the left elbow in place during the T-shirt with his left elbow while performing the concentric
phase of the barbell curl.
curl. However, placing a towel between the left elbow and
torso could create in an imbalance because the left shoulder
would be more abducted than would the right. tell your client to “smash your shirt with your left elbow”
during the concentric phase of the barbell curl. This would
You could balance the difference by placing a towel between
provide the external cue he or she needs without giving you
the right elbow and right torso as well. However, the right
extra work finding a towel or any other accessory.
arm isn’t the problem because it’s holding steady. Thus not
only does this approach create the need for two towels, but In summary, the intervention you provide should coincide
also it breaks one cardinal rule of corrective exercise pro- with what you hypothesize is causing the problem. If the
gramming: Only correct what needs to be corrected. problem is due to poor mobility, soft tissue mobilizations
and stretches should be performed for that joint. If the
The point of this example is to help prepare your mind
problem is due to poor strength, and you’ve found a way to
for the challenges that come from giving external cues.
clearly identify which muscle is weak, you can perform an
Yes, you should give your client something to focus on
isolation exercise to strengthen that muscle. However, in
that’s external to the body; however, it shouldn’t require
most cases, the problem will be due to poor motor control,
any extra work, or equipment, on your part unless abso-
which is most effectively improved with external cues.
lutely necessary.
Keep in mind, this information applies to any single-joint
Therefore, in this case, the proper external cue would be to exercise—the barbell curl was just an example.

132 | Unit 8
FINAL WORDS
To be an intelligent and effective Corrective Exercise Spe- this chapter intended to do—teach you how to spend
cialist, it’s necessary to do two things. First, take the time to more time analyzing a movement so you can determine
carefully watch how your clients move. Second, spend time how to correct it. It’s much easier to solve a problem if you
determining what could be causing any problems you see. have a systematic approach that can identify and pinpoint
the cause. The steps covered in this unit will help you
Albert Einstein, one of the greatest minds of all time, become proficient at analyzing an exercise.
once said, “It’s not that I’m so smart; it’s just that I stay
with problems longer.” A personal trainer who strives to In the next unit, we will continue with this same theme
improve his or her coaching skills in corrective exercise and apply it to two of the most important exercises any
would be wise to do what Einstein did. Indeed, that’s what person should be able to do: the overhead press and squat.
Corrective Exercise
Summary
1. Each training session should primarily consist of 6. Determine whether the critical events were met and
functional exercises that help a client improve his or make a list of other movement compensations you
her fitness levels. Corrective exercises should only be observed.
used when necessary.
7. Carefully consider what you saw during the move-
2. A movement analysis is performed to determine ment analysis and form a hypothesis of what could
whether a client is doing an exercise correctly. If be causing the impairment. Movement problems
there’s a movement problem, the first step is to try to can be caused by a lack of mobility, strength, or
improve the exercise before implementing corrective motor control.
exercises into the client’s program.
8. Poor mobility is improved with stretches and soft
3. A movement analysis is intended to answer three tissue work for the joint that lacks range of motion.
questions: What do you expect to see? What do you Strength can be improved with an isolation exercise if
actually see? What could be causing the difference? you can clearly identify which muscle is weak. Motor
control is improved through proper cueing.
4. Divide each exercise into concentric and eccentric
phases to determine whether the movement prob- 9. Use external cues whenever possible to improve mo-
lem is occurring while the working muscles are tor control, and subsequently, motor learning.
shortening or lengthening.
5. Make a list of the critical events for an exercise to
focus on what’s necessary to do the exercise prop-
erly. As you observe the movement from different
angles, keep in mind the sagittal, frontal, and trans-
verse planes.


issaonline.edu
Single-Joint Movement Analysis

Client: Date:
Exercise:
Critical event #1:
Critical event #2:
What other movements were observed?
Sagittal plane:
Frontal plane:
Transverse plane:
Possible causes for the compensations?
Sagittal plane:
Frontal plane:
Transverse plane:
Please note: possession of this form does not indicate that its distributor is actively certified with the ISSA. To confirm certification status, please call 1.800.892.4772 (1.805.745.8111 international).
Information gathered from this form is not shared with ISSA. ISSA is not responsible or liable for the use or incorporation of the information contained in or collected from this form. Always consult your
doctor concerning your health, diet, and physical activity.
What Makes Being a

Corrective Exercise Specialist Unique?
What Is “Functional?”
Arm Elevation
Normal Scapulohumeral Rhythm
GH Stability and Mobility
ST Stability and Mobility
Trunk Stability
Arm Elevation
Overhead Press
Overhead Press Movement Analysis
Final Thoughts
UNIT 9
PERFORM AN UPPER BODY

MULTI-JOINT MOVEMENT ANALYSIS
136 | Unit 9
What You’ll Learn

This unit focuses on the upper body. If your client struggles with any upper body movement, he or she
would have filled out the upper extremity functional index (UEFI) questionnaire that was covered in Unit 6.
Analyzing and correcting the overhead press will usually provide the most far-reaching improvements to life
and sport for people experiencing upper extremity problems. As such, your goal is to assess the overhead
press and determine whether you can fix it before regressing to isolation exercises.
In this unit, you’ll learn how to perform a movement analysis for an upper body exercise that requires move-
ment at two or more joints. First, you’ll learn what makes an exercise “functional,” and then we’ll cover the
complexities of arm elevation. We will expand on the concept of arm elevation by performing a movement
analysis of the one-arm shoulder press. You will learn the components of that exercise, from the movement
of the joints to the activation of the muscles. Furthermore, you’ll learn how to identify compensations in
the upper limbs and trunk along with the reasons each might happen. By the end of this unit, you will have
gained a clear understanding of the role of the upper extremities and the trunk during multi-joint upper
body movements.
WHAT MAKES BEING A CORRECTIVE EXERCISE

SPECIALIST UNIQUE?
As a personal trainer or therapist, you are likely well to help correct that movement before regressing to isola-
aware of corrective exercise certification courses that are tion exercises.
based on observing the performance of predetermined ex-
We followed those steps to perform a movement analy-
ercises, such as an overhead squat or lunge. These courses
sis for a single-joint exercise. Now we’ll expand on that
teach you how to give a numerical score to each exercise
theme and apply those steps to movements that require
to determine whether the person is doing it correctly. If a
motion at more than one joint throughout the upper body.
person scores low on a movement, a list of recommended
Because multiple joints work simultaneously, these com-
corrective exercises are given. However, this course uses a
plex movements are often considered to be more “func-
different approach, as you had a glimpse of when we did a
tional.” Therefore, let’s start by explaining what that word
movement analysis of the barbell curl in the last unit.
means to the Corrective Exercise Specialist.
To recap, for each exercise that you want to analyze, you
will first determine the critical events that need to be
met to do it correctly. Knowing what critical events must WHAT IS “FUNCTIONAL?”
occur before you start watching your client move will
help you understand which joint actions should occur and In Unit 6, we discussed the Lower Extremity Function-
which ones shouldn’t. Next, you’ll watch the client move al Scale (LEFS) and Upper Extremity Functional Index
and determine whether the critical events have been met (UEFI). Your client filled out one form, or both, depend-
and make a note of any other compensations you see. ing on how widespread his or her movement problems
Then you’ll use the information you gathered to help iden- are. These questionnaires are designed for clinicians to
tify where the problem could be located and determine measure a person’s initial functional capabilities, monitor
whether the problem is due to a lack of mobility, strength, progress, and set appropriate functional goals.
or motor control. Finally, you will provide interventions Each questionnaire has the word “functional” in the
Corrective Exercise
Perform an Upper Body Multi-Joint Movement Analysis | 137
title for good reason. Of course, the root of functional is “function,” and it’s defined
in The Oxford English Dictionary as “The activity proper or natural to a person . . . ”
That’s why the UEFI and LEFS consist of activities that most people must do each day,
ranging from opening a door to climbing stairs, just to name a few. Importantly, these
activities require two or more joints to move.
At this point, we can infer three things. First, what’s functional to one person might
not be functional to someone else. For example, ice-skating is a functional activity for
a professional hockey player, but it’s not for a stockbroker with no desire to play the
sport. It’s safe to assume, however, that lifting/lowering objects overhead and sitting/
standing from a chair are functional for everyone.
Second, a movement that’s functional is natural to a person, per the definition. Joint
motions are affected by the shape of a person’s bones, the stiffness or laxity of his or
her ligaments, the strength and flexibility of his or her muscles, and the brain’s ability
to control the movement, among other things. Therefore, if you tell three people to
naturally lift their arms overhead, each one would perform the movement slightly
differently, even if your eyes aren’t trained to notice the nuances. Because free weights
such as a kettlebell, dumbbell, or a cable don’t restrict the natural motions of a per-
son’s joints, using these implements are considered more functional than is an exercise
machine that has a fixed axis. Free weights allow natural motion, whereas a fixed-axis
machine restricts it.
Third, a functional movement is typically associated with motion at two or more
joints. Therefore, when a trainer or therapist seeks to improve a client’s function-
al ability, the trainer will choose an exercise that requires simultaneous motion at
multiple joints. A multi-joint exercise is also referred to as a compound movement or
complex movement, depending on the source. The terms multi-joint, compound, and
complex are synonymous when describing movement.
Therefore, a functional movement, or functional exercise, comprises the following Functional exercise: An
three qualities: exercise that closely mimics the
actions necessary for a person’s
1. Closely mimics a movement pattern required for a person’s life or sport life or sport.
2. Allows unrestricted motion at the joints
3. Requires simultaneous motion at two or more joints
Considering all the possible functional movements that require the upper body,
reaching overhead is one of the most problematic. Therefore, we’ll start by covering
the complexities of arm elevation and then outline a functional exercise you will use
to perform a movement analysis.
ARM ELEVATION
Of all the tasks involving the upper limbs, lifting the arms overhead until they are
perpendicular to the ground is arguably the most complex and challenging. First, the
shoulders must have enough mobility to achieve that range of motion. Second, the
muscles that drive the motion must have sufficient strength, especially if you are lift-
ing something relatively heavy. Third, the nervous system must coordinate the precise
timing of each muscle action, much like an orchestra conductor, for optimal motor
control to occur.

138 | Unit 9
However, no one of those requirements is any different from any other movement.
What makes arm elevation particularly complex and challenging is that four “joints”
must work in concert for it to occur without a hitch. One of them, the scapulothoracic
(ST) region, isn’t truly a joint even though it’s often called the “scapulothoracic joint”
in books and magazines.
As you might remember from Unit 1, the ST region is the area between the scapula
and thoracic portion of the posterior ribcage. This bone-on-bone connection isn’t a
true joint, because it lacks any ligamentous connections. Because one of the primary
functions of ligaments is to limit excess motion at a joint, the scapula is free to move
any way that it’s pulled by the muscles that attach to it. That’s the problem.
Indeed, the ST region is similar to a crazy uncle: not easy to categorize and inherently
unstable.
Joking aside, scapular control during arm elevation creates a significant challenge that
many people cannot overcome. Furthermore, the scapulothoracic region is only one of
the four joints within the shoulder complex that must be functioning correctly.
But before we delve more thoroughly into shoulder mechanics and the ways you’ll as-
sess proper movement, let’s take a step back and cover some components of movement
analysis.
According to Christopher Powers, PhD, professor and director of the program in Bio-
kinesiology at the University of Southern California, arm elevation is optimal when
Objectives: The goals of a the following four objectives are achieved:
movement.
• Normal scapulohumeral rhythm
• GH stability and mobility
• ST stability and mobility
• Trunk stability
Importantly, most people lack one of the aforementioned qualities even if they don’t
realize it. Therefore, we’ll start by covering each objective in greater detail to better
understand the complexities of arm elevation.
But before we move on, it’s important to point out that objectives and critical events
are not the same thing. An objective is what you intend to do, whereas critical events
are the actions necessary to attain that goal. For example, if you want to kick a soccer
ball, your objective is to have your foot make contact the ball. The critical events
would be the necessary actions to kick the ball, such as hip flexion and knee extension.
The difference between an objective and critical event is emphasized here so you do
not become confused by any similarities between the objectives we’re about to discuss
and the critical events that we’ll cover later on.
NORMAL SCAPULOHUMERAL RHYTHM

The path from an arm hanging at a person’s side until it’s overhead and perpendicular
to the ground consists of 180° of motion. The first 30° of arm elevation occur solely
from the glenohumeral (GH) joint—the scapula doesn’t move. As the arm continues
to travel upward, the scapulothoracic region comes into play. By the time full arm
elevation is achieved, those two bones moved at approximately a 1:2 ratio. Therefore,
full elevation of the arm requires 60° of upward rotation from the scapula paired with
120° of abduction from the GH joint.
Corrective Exercise
When the scapulohumeral rhythm is normal, it provides three benefits:

1. Greater stability at the glenohumeral (GH) joint when the arm
is overhead
2. Optimal length-tension relationship of the rotator cuff mus-
cles
3. Minimizes impingement of the subacromial space
GH STABILITY AND MOBILITY

The head of the humerus and the glenoid fossa of the scapula form the
glenohumeral joint. This pairing creates a naturally unstable arrange-
ment because the cavity of the glenoid fossa is approximately one-third
the size of the head of the humerus, similar to a golf ball sitting on a
tee. The GH joint gets its stability from an inward pull of the four rota-
tor cuff muscles. This compressive force keeps the head of the humerus
held firmly against the glenoid fossa as the arm elevates.
Mobility at the GH joint, or any joint for that matter, requires sufficient
elasticity from the tissues that surround it. The muscles and capsule
around each joint must be able to stretch as far as necessary to achieve
a full range of motion. However, tissue flexibility isn’t the only limit- Figure 9.1. Normal scapulohumeral rhythm.
During full elevation of the arm, the scapulotho-
ing factor for arm elevation. As we covered in Unit 2, a force couple
racic (ST) region and glenohumeral (GH) joint
between the deltoid and supraspinatus is required during arm elevation average a 1:2 ratio of movement to achieve 180°.
to offset impingement within the subacromial space (Figure 2.5).
ST STABILITY AND MOBILITY

We have already discussed that lifting the arm overhead requires
upward rotation of the scapula and elevation of the humerus. Upward
rotation occurs from concentric actions of the upper trapezius, lower
trapezius, and serratus anterior. However, when the serratus anteri-
or contracts, it causes the scapula to potentially move two different
ways. One movement is upward rotation, a necessary action to elevate
the arm. The other action is a forward pull of the scapula around the
ribcage (i.e., protraction). Because protraction isn’t helpful for arm
elevation, the middle trapezius also contracts because it causes the
scapula to retract. Therefore, the middle trapezius plays an important
role during arm elevation to offset the forward pull created by the
serratus anterior.
Elevation of the humerus occurs through concentric actions of the
deltoid muscle. And, of course, lowering the arm from overhead requires
eccentric actions of all the muscles we just discussed.
Ligaments provide an important role during movement by restricting Figure 9.2. Muscle actions during arm eleva-
excess motion at the joint where they attach. However, because the scap- tion. Concentric actions of the upper trapezius
(UT), lower trapezius (LT), and serratus anterior
ulae aren’t connected to ligaments, they’re at the mercy of the muscles. (SA) upwardly rotate the scapula. The middle tra-
Therefore, smooth scapular movement requires the attached muscles to pezius (MT) pulls the scapula into retraction to off-
be strong as well as the nervous system to provide optimal motor control set the pull of the SA into protraction. Concentric
to coordinate those muscle actions. action of the deltoid, along with the supraspinatus
(not depicted), abducts the humerus. Proper tim-
All the factors we just discussed are what create mobility and stability ing of these muscle actions provides mobility and
within the scapulothoracic region. stability to the scapular region.

140 | Unit 9
TRUNK STABILITY
Imagine holding a heavy dumbbell in your right hand as your arm hangs down at
your side. The downward pull of the dumbbell creates a force that, if not resisted,
results in lateral flexion of your trunk to the right. Therefore, the muscles that oppose
that action must have sufficient strength to maintain your posture. I’m referring here
to the muscles that laterally flex the trunk to the left, such as the left internal/external
obliques and left quadratus lumborum just to name a few.
Optimal movement begins and ends with postural control. That’s why, in Unit 8, the
importance of ideal posture was emphasized, even during an exercise as simple as a
barbell curl. When posture isn’t maintained, it can impair breathing, nerve transmis-
sion, and joint mechanics. In fact, a slouched posture has been shown to reduce the ac-
tivity of important hormones and neurotransmitters that drive energy and alertness.
Keeping your spine erect and aligned is also necessary for optimal biomechanics.
If you stand with a slouched posture, you will not be able to reach your arm as high
overhead as you can when standing tall. Because the shoulder complex sits on top
of the thoracic portion of the ribcage, it will follow where the ribcage moves. Flex-
ion of the thoracic spine causes the ribcage to shift down and forward, which causes
the shoulder complex to do the same. Therefore, standing erect with a neutral spine
Kinematics: An area of changes the kinematics at the shoulder so it can achieve a great range of motion.
mechanics that describes the Therefore, when the trunk is strong and stable, it allows for greater mobility when a
motions of a body. person reaches overhead. This is one of the reasons the saying “proximal stability leads
to distal mobility” is accurate.
If you press a dumbbell overhead while standing, a force is transferred from your
feet to your hand. This path must travel through the trunk, so if weakness is present
in that region, it will bend or buckle. In other words, the energy of the force will be
Figure 9.3. Posture and

shoulder kinematics.
A) Thoracic flexion from a
slouched posture impairs kine-
matics at the shoulder complex,
which limits overhead mobil-
ity. B) A neutral thoracic spine
allows for full range of motion
during overhead reaching.
Corrective Exercise
lost along the way. Indeed, when people have poor trunk elevated in the frontal plane (i.e., shoulder abduction) or
stability and cannot maintain posture during movement, in the sagittal plane (i.e., shoulder flexion). Therefore, if
Stuart McGill, PhD, refers to this as “energy leaks.” As the arms are raised and lowered in the frontal plane, the
Professor McGill has stated, “Optimal performance re- critical events would be:
quires stability, and stability results from stiffness.” • Abduction/adduction of the GH joint through a full
Later in this course we will cover ways to increase trunk ROM
stability. But for now, it’s important to understand that • Upward/downward rotation of the scapula through
having sufficient levels of it is essential for arm elevation. a full ROM
• Maintenance of posture
ARM ELEVATION If the arms are elevated in the sagittal plane, the first criti-
There are numerous ways to elevate the arms overhead. cal event would change to:
You could keep the arms held straight and lift purely in • Flexion/extension of the GH joint through a full ROM
the frontal plane, or the sagittal plane, or any position
These critical events, however, are only applicable to arm
between those two planes.
elevation when the elbows remain static, which isn’t a
Regardless of the shoulder position, the goals for elevating particularly natural movement in life or sport. It’s rare to
the arms overhead remain the same. However, the critical elevate the arms overhead without the elbow joint mov-
events will change depending on whether the arms are ing at the same time. During normal daily tasks such as
Figure 9.4. Arm elevation in two different planes. A) Frontal plane. B) Sagittal plane.

142 | Unit 9
taking objects on and off a high shelf, the elbow joint naturally extends as the arm ele-
vates and flexes as it lowers. In other words, the joint actions required throughout the
upper extremities to lift objects on and off a high surface are similar to the overhead
press exercise.
OVERHEAD PRESS
There are numerous ways to perform an overhead press. You could do it standing or
seated using a barbell, cable, resistance band, or dumbbells for resistance. You could
press one arm overhead at a time or both arms together. The skills you learn in this
unit will apply to any of those variations, as well as every other multi-joint exercise for
the upper body.
Arthrokinematics: The
Nevertheless, the overhead press you’ll learn to analyze will be performed standing
motions that occur at the and with one arm at a time. Most of the time, a person is standing when he or she lifts
articulating surfaces between something overhead either on the job or sport; therefore, it’s more functional to have
bones. your client do it while standing. Another reason is because standing requires more
postural control. The overhead press is performed
one arm at a time for two reasons. First, you’ll be
able to carefully observe one shoulder complex
and therefore be less likely to miss any movement
compensations. Second, lifting a dumbbell overhead
with just one arm requires more postural control in
the frontal and transvers planes, which are the two
movement planes in which people most commonly
lack trunk stability.
Before we move on, it’s important to mention that
another one of the reasons an overhead press is
challenging is due to the arthrokinematics related
to arm elevation, which describes the motions that
occur at the contacting surface between two bones.
The head of the humerus can roll, slide, or spin with-
in the glenoid fossa to create motion. As you reach
your arm overhead, the humerus externally rotates
(i.e., spins). Thus, by the time the arm is completely
elevated and perpendicular to the floor, the GH joint
is in full external rotation. This is essential to under-
stand because an arm that’s elevated and externally
rotated is in one of the most unstable shoulder posi-
tions: that’s what makes it challenging to control.
However, the lack of stability at the shoulder complex
when the arm is fully elevated shouldn’t deter you
from overhead exercises. Every joint travels through
positions of greater or lesser stability during move-
Figure 9.5. Kinematics of arm elevation. Full elevation of the ment. Analyzing and correcting the shoulder in one
arm requires movement from four regions. The sternoclavicular of its most vulnerable positions will, in my experi-
(SC) joint elevates and posteriorly rotates. The acromioclavicular ence, carry over to virtually every other daily task
(AC) joint and scapulothoracic (ST) region perform upward rota-
tion. The glenohumeral (GH) joint externally rotates as the humerus or exercise that involves the upper limbs. In other
elevates, either from abduction or flexion. The shoulder position words, if you can improve your client’s ability to
depicted is inherently unstable and thus requires sufficient levels of reach fully overhead with a respectable load in hand,
motor control.
Corrective Exercise
it means he or she has sufficient mobility, strength, and motor control to do just about
anything else.
Therefore, the overhead press is emphasized as one of the most important upper ex-
tremity exercises to analyze for three reasons:
1. It closely mimics the functional movement pattern required to lift and lower
objects.
Static stabilizer: A muscle
2. It requires the most critical events of any upper extremity exercise. that performs an isometric
contraction to stabilize a joint
3. It has great carryover to other movements that require the upper extremities. during movement.
Dynamic stabilizer: A muscle
OVERHEAD PRESS MOVEMENT ANALYSIS that performs a concentric and/
or eccentric action to stabilize a
Now we’ll apply the same principles we learned in Unit 8 to perform a movement joint during movement.
analysis of the overhead press. Let’s review those concepts:
Step 1: Divide the Exercise

Into Concentric and
Eccentric Phases
This first step helps you determine whether
the movement problem occurs during concen-
tric or eccentric control. Concentric and ec-
centric muscle actions control the joints that
should move during an exercise. There are
also muscles that perform actions to stabilize
the joints that shouldn’t move. These static
stabilizer muscles perform isometric actions
that maintain proper posture (i.e., alignment)
from head to toe.
Stabilizer muscles not only control joints
that shouldn’t move; they also restrict excess
motion at a joint. For example, the actions
of the rotator cuff muscles stabilize the GH
joint during an overhead press so the con-
centric and eccentric phases are smooth and
void of any excess motion. Thus, even though
the GH joint is moving through the concen-
tric and eccentric phases, the rotator cuff is
working as a dynamic stabilizer to restrict
excess motion.
Indeed, the timing and activation of stabiliz-
er muscles are crucial components of motor
control. Therefore, a movement analysis starts
by observing the concentric and eccentric
phases of movement as you consider the roles Figure 9.6. Phases of the overhead press. A) Concentric phase and B)
of the stabilizer muscles to maintain posture Eccentric phase. The client uses a stance that’s slightly wider than shoulder
and motor control. width during the movement analysis.

144 | Unit 9

Identifying the critical events helps you focus on what should and shouldn’t occur
during the movement and should help answer the question: What do I expect to see?
Your client will perform as many reps as necessary for you to view the movement in the
frontal and sagittal planes while keeping transverse plane compensations (i.e., trunk ro-
tation) in mind. The critical events for the one-arm overhead press include the following:
• Maintenance of posture (i.e., postural control)
• GH joint abduction/adduction through a full ROM
• ST upward/downward rotation through a full ROM
• Elbow extension/flexion through a full ROM
Figure 9.7. Critical events for the one-arm overhead press. A) The concentric
phase requires full ROM for elbow extension, GH abduction, upward rotation of the
scapula, and maintenance of posture. B) The eccentric phase requires full ROM for elbow
flexion, GH adduction, downward rotation of the scapula, and maintenance of posture.
Corrective Exercise

The information you gather in this step will help you develop a hypothesis for what
could be causing the problem and should answer the question: What do I actually see?
During a one-arm overhead press, it’s natural for the trunk to shift. When the right
arm is pressing the dumbbell, you’ll likely see the trunk laterally flex to the left from
the frontal plane view. In the sagittal plane, the trunk might shift posteriorly, due to
thoracic extension and/or lumbar extension, as the arm elevates.
What’s important to know is whether these deviations are excessive. To determine
whether the trunk shifts too far in either plane, a reference point is required. For the
overhead press, the reference point from the frontal plane view consists of a perfectly
vertical line that runs from the navel through the center of the sternum. From the
sagittal plane view, the reference line runs vertically from the base of the neck to the
top of the pelvis.
When a person has sufficient trunk stability and normal mobility within the shoulder
complex and elbow, the trunk should not deviate more than approximately 5° within
Figure 9.8. Reference lines for the overhead press. A) The frontal plane view refer-
ence line runs perpendicular to the ground from the navel to through the center of the
sternum. B) The sagittal plane view reference line runs from the base of the neck to the top
of the pelvis. Any trunk deviation more than 5° in either plane isn’t optimal.

146 | Unit 9
the frontal or sagittal plane during the overhead press. Fortunately, there are smart-
phone apps that allow you to video the client’s movement and to subsequently draw
reference lines and measure angles.
Even if you don’t take that extra step, or if you don’t have a video camera available, you
will benefit by simply keeping these imaginary reference lines in mind as you view the
movement from both planes. In many cases, it’s simple to visually determine whether
the trunk is moving excessively, even without a way to measure angles. And of course,
don’t forget to look for rotational compensations, as any amount of trunk twisting
within the transverse plane isn’t ideal.
Intra-abdominal pressure
(IAP): Pressure within the Now it’s time to watch your client move, using an appropriate load, and to document
abdominal cavity. on the movement analysis form any compensations you see. Were the critical events
Open scissors syndrome: achieved? Were there any other movements you observed? Write everything down.
The combination of ribcage
elevation and anterior pelvic
tilt that alters movement Common Compensations During the Overhead Press
mechanics and reduces intra- There are numerous ways your client might compensate while performing an overhead
abdominal pressure. press. When people lack the shoulder mobility necessary to fully elevate their arms,
they will usually try to make up the difference
with compensations throughout the trunk.
They either will lean backward to extend the spine
or will lean to the side to laterally flex it, depend-
ing on the problem within the shoulder.
Trunk stability is primarily influenced by two
factors. First, the muscles within the midsection
must be strong enough to hold the spine and pel-
vis steady, such as the internal/external obliques,
rectus abdominis, and quadratus lumborum, just
to name a few. Second, intra-abdominal pressure
(IAP) must be sufficient to provide the necessary
stiffness throughout the midsection.
Sagittal Plane
Imagine your midsection is a plastic water bottle
you’re holding in hand and that the amount of
liquid in it represents IAP. If the bottle is 10% full
(i.e., low IAP), it’s easy to crush it with your hand.
But when the bottle is completely filled with water
(i.e., high IAP), it has plenty of stiffness, which
makes it extremely difficult to crush.
The position of the ribcage relative to the pelvis is
one of the most important factors that affect IAP.
When the lumbar spine extends beyond neutral,
the ribcage elevates, and the pelvis anteriorly
rotates, creating an open scissors syndrome. This
decreases IAP, and therefore, trunk stability. We’ll
Figure 9.9. Lumbar extension and open scissors syndrome. A) discuss the open scissors syndrome in greater de-
Excessive lumbar extension during an overhead press. B) An elevated tail in Unit 11. But for now, it’s important to note
ribcage and anteriorly tilted pelvis creates an “open scissors” effect, any lumbar extension you might see.
which decreases IAP.
Corrective Exercise
Alternatively, you might see extension within the thorac- “inadequate shoulder abduction.” Pair these descriptions
ic spine if your client lacks shoulder mobility. In terms with the angle you measured, assuming you did so.
of movement mechanics, and the risks associated with
Measuring numerous angles might seem like a nuisance,
compensations, thoracic extension is the ideal way for the
unless you moonlight as a geometry professor. But mak-
client to get the extra ROM needed. However, many peo-
ing the time do it for a week, or even a few days, will sig-
ple have a stiff thoracic spine, and therefore lack extension
nificantly increase your movement analysis skills. Think
in that region, due to poor posture. That’s why excessive
of it as counting calories. If you make the effort to look up
lumbar extension is more common to see.
the protein, carbohydrate, and fat content of the foods you
However, remember that spinal extension, whether it eat over the course of a few days, you develop the skills
occurs in the lumbar and/or thoracic region, isn’t a critical to essentially look at a plate of food and have a good idea
event for the overhead press. Therefore, if the client’s spine how many calories are in it. Therefore, measuring joint
extends during a right-armed overhead press, it’s safe to angles not only will improve your movement analysis
assume there’s a mobility problem somewhere. skills but also will provide you with important quantita-
tive data to monitor progress.
Frontal Plane Before we move on, there are two points worth noting
here. First, analyzing shoulder movement is a complex
You’ll likely see the most compensations from the frontal task—if you have not already discovered this. Even the top
plane view. There are two reasons for this. First, if a
person lacks shoulder mobility, he or she will typically
try to elevate the dumbbell higher by leaning away from
the working arm. Second, it’s common for people to lack
trunk stability strength within the frontal plane.
Therefore, this is a good time to videotape your client as
he or she moves and to use an app to measure the angles if
that is an option.
As you watch your client move, it’s essential to under-
stand what you’re seeing. Let’s say the client was only able
to abduct the right shoulder 135° relative to the ground;
however, his or her trunk laterally flexed to the left 20°
to reach that range. In other words, the client needed to
compensate just to reach 135° of arm elevation. Therefore,
you’ll subtract 20° of lateral flexion from 135° of shoulder
abduction to determine how much range the right shoul-
der actually achieved on its own. In this case, it was 115°.
Movement analysis is heavily influenced by angles, so the
more quantitative data you can gather, the better.
The simpler option is to just stand back, watch your client
move, and make a note of everything you see while keep-
ing the critical events in mind. Limiting your documenta-
tion to qualitative data is less accurate; however, it’s a good
place to start.
Figure 9.10. Qualitative and quantitative data for
Furthermore, if a critical event is not met, it’s helpful to the overhead press. A) The client demonstrates inad-
use the words excessive or inadequate to describe what you equate elbow extension and shoulder abduction along with
see. The inability to achieve a critical event means there’s excessive trunk lateral flexion to the left. B) Trunk lateral
too much or too little happening somewhere, so that’s why flexion and shoulder abduction are measured with respect
to the vertical reference line (broken line). The client elevates
those words are useful. For example, if your client later-
his right arm 135° relative to the ground; however, he
ally flexes the trunk beyond 5° to the left side, document simultaneously shifts his trunk to the left 20°. Therefore, the
“excessive lateral flexion to the left.” Or if he or she doesn’t actual shoulder abduction is 115°. Elbow extension is 13° less
achieve 180° of shoulder abduction, you would write than the 180° required for full ROM.

148 | Unit 9
clinicians with decades of experience struggle to deter- multi-joint exercise is that an impairment of one joint can
mine exactly what’s going on and why as they watch their affect another joint. One reason is due to fascial lines, the
patients reach overhead. Second, if you look closely at long bands of fascia that connect different segments of the
Figure 9.5, you’ll notice that there are two critical events body together, as we covered in Unit 2. The other reason is
necessary for arm elevation that weren’t included in this due to movement mechanics.
unit: elevation of the sternoclavicular (SC) joint and up-
During the concentric phase of the overhead press, elbow
ward rotation of the acromioclavicular (AC) joint. Those
extension and shoulder abduction occur simultaneously.
joints were omitted because they’re extremely difficult to
Thus if the shoulder is unable to fully abduct, the elbow
assess unless you’re a well-trained clinician. Just keep in
won’t fully extend. Therefore, an inability to fully extend
mind that damage to either joint will significantly impair
the elbow during an overhead press could be caused by
shoulder movement.
one or more of the three following problems:
• Inadequate hyperextension at the elbow
Step 4: Develop a Hypothesis • Inadequate strength of the triceps
In this step you’ll answer the question: What could be • Inadequate shoulder abduction
causing the difference between what I expected to see and
what I actually saw? First, it’s worth noting here that
restrictions within the cervical spine (i.e., neck) can Is it a shoulder problem?
significantly impair shoulder function. You’ll learn what You’ve learned throughout this unit that many elements
to assess and how to correct the neck in Unit 11. For now, are necessary to perform an overhead press correctly.
our goal is to consider the critical events and to determine First, the joints must have sufficient mobility to achieve
what could be causing any compensations you saw in step the range of motion required. Second, the brain must
3. coordinate the timing of muscle activation during the
concentric and eccentric phases. If one muscle contracts
Can the client correctly perform a one-arm overhead
too early, or too late, it will alter your client’s ability to
press without using any weight? If so, mobility isn’t the
perform the movement smoothly through a full range of
problem. The load is simply too much for the client’s
motion. And as we just discussed, motor control is nec-
strength and/or motor control. But let’s say he or she
essary within the lumbopelvic region as well. Therefore,
can’t correctly perform the movement without a weight
a high level of motor control is an essential component of
in hand. We’ll start by covering the causes of inadequate
the overhead press.
elbow extension.
Earlier in this unit you learned that the 180° of shoulder
abduction necessary for full arm elevation is achieved by a
Is it an elbow problem? combination of 120° of abduction at the GH joint and 60°
The elbow is a hinge joint that is capable of only one of upward rotation from the ST region (i.e., scapula). The
movement pattern: flexion/extension. Because it doesn’t muscles that oppose those actions, the GH joint adductors
have the freedom to perform any other movements, it’s and ST region downward rotators, must have sufficient
easy for the brain to control. Therefore, if the elbow joint mobility so they can lengthen far enough to allow 180°
is unable to fully extend or flex during the overhead press, of shoulder abduction. Therefore, stiffness in any of the
you can eliminate poor motor control of the elbow from following muscles can limit shoulder abduction.
your list.
ST region downward rotators: Rhomboid major/mi-
The problem could stem from a lack of mobility or nor, levator scapulae, pectoralis minor, latissimus dorsi,
strength. If the client can actively flex and extend the pectoralis major (sternal portion) and serratus anterior
elbow through a full range of motion, elbow mobility (superior portion).
isn’t the problem. Importantly, he or she should be able
to slightly hyperextend the elbow, as that’s what normal GH joint adductors: Latissimus dorsi, teres major, pecto-
extension means. If the client can’t, consider stretches or ralis major (sternal portion), and coracobrachialis.
soft tissue work to promote hyperextension or refer the You might look at those lists and think, “Wow, I don’t
client to a physical therapist. If decreasing the load allows have time to stretch all those muscles!” The good news
the client to fully extend the elbow, weakness of the elbow is that you can hit them all with one motion. Just have
extensors (i.e., triceps) could be the limiting factor. your client reach overhead as if performing a one-arm
However, one of the complexities of analyzing a shoulder press, without a weight in hand and hold that
Corrective Exercise
position to stretch all of the muscles that need to be stretched. Mobility work doesn’t
have to be complicated.
However, correcting shoulder mechanics is virtually never that simple. Let’s take a
step back for a moment and explain why.
Each joint can have up to three degrees of freedom, which correspond to the three Degrees of freedom: The
individual movement planes. For example, the GH joint can flex/extend in the sagittal number of independent
plane, abduct/adduct in the frontal plane, and perform internal/external rotation in movements allowed at a joint.
the transverse plane. Because the GH joint can move in all three planes, it has three
degrees of freedom, the highest possible for any joint. Now remember that the ST
region isn’t technically a joint, but it nevertheless has a huge amount of freedom to
move. In fact, the reason the ST region isn’t a joint is the same reason it can move so
freely: there are no ligaments connecting the scapula to the thoracic region. The scap-
ula’s freedom stems from the fact that it’s essentially floating and at the mercy of the
muscles that attach to it. Indeed, the ST region can do the following: elevate/depress,
abduct/adduct, rotate upward or downward, and tilt posteriorly or anteriorly, which
causes “winging” of the scapula. Because the GH joint and ST region can move so
freely, they require high levels of motor control.
Reaching one arm directly overhead obviously doesn’t require much strength; however,
it requires an enormous amount of motor control. The brain must precisely activate the
upper/middle/lower trapezius, serratus anterior, deltoid, and supraspinatus (Figure 9.2).
Indeed, the brain’s control over the shoulder is akin to a conductor’s leading an orches-
tra: everything must happen in a precise order, and be timed perfectly, for the perfor-
mance to go well. If the timing of activation between the upward rotators and shoulder
abductors is out of sync, the scapula won’t elevate, no matter how hard you try. The
muscles most commonly “out of tune” are the lower trapezius and serratus anterior,
which is why strengthening those muscles typically improves shoulder mechanics.
However, it is possible that the lower trapezius and serratus anterior aren’t necessarily
weak—it’s just that the brain doesn’t know how to activate them. For example, if a
person can’t reach fully overhead, a physical therapist will commonly prescribe drills
within a session to activate the lower trapezius and serratus anterior. If the physical
therapist did an effective job, the patient will likely be able to reach farther overhead.
However, it’s safe to say that those muscles didn’t get stronger within an hour as much
as they were reactivated by the brain.
But it’s not necessary to regress to isolation exercises for those muscles just yet. An
ideal solution is to stabilize the arm and reach overhead to retrain the firing pattern,
as we’ll cover in Unit 11.
Nevertheless, this goes back to the challenge of determining whether poor movement
is due to a lack of strength or motor control. When it comes to the shoulder, the first
step should be to improve motor control. In many cases, that will also improve shoul-
der mobility.
Is it a trunk stability problem?

Postural control, influenced heavily by trunk stability strength, is a critical event for
the overhead press. However, just because your client shifts his trunk while pressing
overhead doesn’t mean there’s weakness in the midsection. Commonly, there are
two other reasons. First, the load he or she is pressing overhead is too heavy for the
strength of the shoulder joint. Therefore, the client will lean the opposite direction
to put the shoulder in stronger, more stable position. Second, the shoulder can’t fully

150 | Unit 9
abduct, so the client will lean away to get greater arm elevation (Figure 9.10). But let’s
say you’ve determined that shoulder mobility is sufficient, and you suspect that the
load being lifted isn’t too heavy for the client’s shoulder.
Developing a hypothesis for the source of a movement problem is a process of elimi-
nation, and the trunk is no exception. The key is to determine whether the shoulder
has sufficient strength to lift the load, but the trunk lacks the stability to maintain the
client’s posture. In other words, if you suspect the trunk lacks stability, provide an in-
tervention that improves it. You can do that by having the client hold onto something
stable, such as a squat rack or the edge of a doorway, with the free hand.
For example, let’s say your client Paul can press a 40-pound dumbbell overhead using
his right arm without any problems. All the critical events were met, and there were
no compensations. But when he presses the same dumbbell overhead with his left arm,
his trunk leans to the right. In other words, he’s unable to maintain stability in the
frontal plane: the most common trunk compensation during an overhead press. You
suspect that a lack of strength in his left shoulder is not the problem, so you have him
repeat the overhead press with his left arm while holding onto a squat rack with his
right hand.
Is he able to press the dumbbell fully overhead while maintaining an upright posture?
If so, the problem is inadequate trunk stability strength within the frontal plane, and
you’ll learn how to improve that in Unit 11.
Could the thoracic spine be the problem?

Early we discussed that lumbar extension paired with anterior pelvic tilt is a common
compensation during the overhead press. This is usually due to two reasons. First,
the brain doesn’t have sufficient motor control to hold those bones in place, known as
Lumbopelvic control: The lumbopelvic control. Second, the thoracic spine is stuck in flexion.
ability of the nervous system to
stabilize the lumbar and pelvic Extension of the thoracic spine isn’t necessary to perform an overhead press correctly;
regions during movement. however, that assumes it’s capable of being in a neutral position during the movement.
The typical slouched posture, common to so many people, flexes the thoracic spine.
Over time, muscles within the thoracic region can weaken and stiffen, impairing the
person’s ability to extend it back to neutral, which is the position required to do an
overhead press correctly. When the thoracic spine is flexed beyond neutral, and can’t
extend, elevating the arm to perpendicular is difficult (Figure 9.3). Therefore, when
you see lumbar extension during an overhead press, it’s usually due to the person’s
inability to extend the thoracic spine back to neutral.

At this stage of the corrective exercise therapy process, you’ll provide the interventions
necessary to avoid regressing a multi-joint upper body exercise to an isolation exercise.
Remember, the goal of corrective exercise is to do what’s necessary to keep multi-joint
functional exercises in your client’s program.
The following cues are intended to correct the one-arm overhead press, but they carry
over to virtually every other upper body exercise. The cues consist of a mix of external
and internal cues. External cues are best for improving movement; however, some
Corrective Exercise
TRAIN YOUR BRAIN: Understand what’s truly functional.

Ironically, the term “functional exercise” led to the creation of many exercises that don’t mimic
movements required in virtually anyone’s life or sport, such as pressing dumbbells overhead while
standing on one leg on a Bosu ball. Some trainers apparently determined, for whatever reason, that
severely challenging a person’s balance during an exercise made it more functional.
To be clear, standing on one leg on a Bosu ball can be a functional activity for athletes such as hockey
players. However, adding an overhead dumbbell press to that activity doesn’t mimic any real-life
movement or sport I can think of.
Drastically reducing a client’s stability by having him or her stand on one leg or on a thick pad while
performing an exercise undoubtedly makes its performance more challenging. However, more chal-
lenging does not necessarily mean more functional. The loss of stability significantly reduces the load
a person can lift and requires the client to focus more on his or her balance than on exercise tech-
nique. This impairs the client’s strength development and motor learning.
internal cues are necessary to correct posture. You’ll start You might be surprised how effective the three aforemen-
by cueing the correct spinal alignment. tioned cues can be to correct movement. Provide those
cues in the order they’re given. The next two cues apply
Cue #1: “Maintain a double chin throughout the exercise.”
specifically to two common compensations seen in the
Reason: This cue places the cervical spine in proper align- overhead press: inadequate shoulder abduction/elbow
ment, which improves shoulder movement and neural extension and scapular elevation.
transmission throughout the cervical region.
Cue to correct inadequate shoulder abduction/elbow ex-
Cue #2: “Stand as tall as possible without elevating your tension: “Press the dumbbell as close to the ceiling as you
chin.” An external cue could work here if your client is can.” This is an external cue that works well to improve
wearing a hat. You would say, “move your hat as close to shoulder abduction and elbow extension. However, if that
the ceiling as possible without elevating your chin.” If the cue doesn’t cause an improvement, you can provide an
client isn’t standing, such as the case when doing a push- internal cue by saying, “Try to hyperextend your elbow at
up or one-arm row, cue the client to “maintain a long the top of the movement.”
spine.”
Reason: These cues can improve range of motion at the
Reason: These cues place the spinal column in the neutral shoulder and elbow joints.
position, which is optimal for upper extremity mechanics
Cue to correct scapular elevation: “Keep as much space
along with neural transmission to the muscles.
between your ear and the top of your shoulder as possi-
Cue #3: “Expand your midsection and maintain the ble.” Upward rotation of the scapula is a critical event for
tension during the exercise.” You can provide an exter- the one-arm shoulder press, but scapular elevation isn’t.
nal cue by placing a weightlifting belt on your client and Therefore, if your client shrugs his or her right shoulder
telling him or her to “stretch the belt during the exercise.” while pressing overhead with the right arm, use the afore-
However, the most accurate cue is one that some trainers mentioned cue to help the client keep his or her scapula
are embarrassed to give, “bear down as if you’re having a from elevating.
bowel movement.”
Reason: Scapular elevation will impair movement me-
Reason: These cues increase intra-abdominal pressure, chanics during an overhead press.
which increases trunk stability.

152 | Unit 9
We’ve already covered one intervention you can use with

any upper body multi-joint exercise that works one arm
FINAL THOUGHTS
at a time: provide additional trunk stability by having As we close out this unit, you’ve learned many things
your client hold onto something stable with his or her about upper body movement, ranging from the compo-
free hand. You will, of course, aim to directly improve nents of an overhead press to the cues that help correct
the strength of the trunk muscles that are weak using faulty form. Significant emphasis was placed on the
exercises outlined in Unit 11; however, in the meantime, overhead press because correcting it can have the most
the client will still be able to train with a load that’s heavy far-reaching benefits to other upper extremity exercises.
enough to build size and strength in the upper body. As we move into Unit 10, we’ll apply these same concepts
to correct exercises that involve the lower extremities.
Summary
1. A functional movement is one that closely mimics a 5. Timing of muscle activation is an essential com-
movement pattern required in life or sport, allows ponent of arm elevation. Precise activation of the
unrestricted motion at the joints, and requires upper/middle/lower trapezius, serratus anteri-
simultaneous motion at more than one joint. or, deltoid, and supraspinatus are necessary for
smooth, controlled shoulder movement.
2. Arm elevation is a complex process that requires
normal scapulohumeral rhythm, GH stability 6. The critical events necessary for an overhead press
and mobility, ST stability and mobility, and trunk are elbow extension/flexion, GH abduction/adduc-
stability. tion, upward/downward scapular rotation, and
maintenance of posture.
3. Posture significantly influences shoulder kinemat-
ics. A neutral spine allows for the most optimal 7. Inadequate motor control is a common problem at
shoulder mechanics. the ST region and GH joint. Therefore, improving
motor control in those regions should be the first
4. The shoulder joint allows for three degrees of free-
goal for improving shoulder ROM.
dom, the most possible for any joint. Therefore,
high levels of motor control are required during
arm elevation.
Corrective Exercise

issaonline.edu
One-Arm Shoulder Press Movement Analysis

Client: Date:
Exercise: one-arm shoulder press movement analysis
Critical event #1: maintenance of posture
Critical event #2: elbow extension through a full ROM
Critical event #3: GH joint abduction/adduction through a full ROM
Critical event #4: ST region upward/downward rotation through a full ROM
Sagittal plane:
Frontal plane:
Transverse plane:
Sagittal plane:
Frontal plane:
Transverse plane:
Notes

issaonline.edu
Multi-Joint Upper Body Movement Analysis

Client: Date:
Exercise:
Critical event #2:
Was c\ritical event #2 met? Yes No
Critical event #3:
Critical event #4:
Sagittal plane:
Frontal plane:
Transverse plane:
Sagittal plane:
Frontal plane:
Transverse plane:
Notes
Complexities of Analyzing the Squat

Step 1: Individualize the Squat
Step 2: Divide the Exercise Into Con-
centric and Eccentric Phases
Step 5: Develop a Hypothesis
Final Thoughts
UNIT 10
PERFORM A LOWER BODY

MULTI-JOINT MOVEMENT ANALYSIS
156 | Unit 10
What You’ll Learn

The information in this unit applies specifically to your clients with movement problems involving motion
throughout the lower extremities as determined when they filled out the Lower Extremity Functional Scale
(LEFS) that was covered in Unit 6. You’ll learn how to perform a movement analysis for a lower body multi-
joint exercise as we go through the steps using, for example, the goblet squat. You’ll learn how to identify
the physical limitations that can and can’t be changed before watching your client move. Then we’ll cover
the most common compensations seen during a squat and how to use cues to correct them. But the end of
this unit, you’ll have a clear understanding of the components required to perform a movement analysis for
the squat and many other lower body exercises.
COMPLEXITIES OF
ANALYZING THE SQUAT
Of all the movements a person is capable of doing, a squat is one of the most meaning-
ful. Activities such as getting on and off a chair or in and out of a car or on and off the
toilet are just a few examples of daily tasks that require a person to squat. Any move-
ment that’s meaningful to a person’s life is a functional movement. Because a squat is
a functional movement, the first logical question we must address concerns how low
your client should squat.
The first step for determining the ideal squat depth is based on their needs in life.
Which movements are most meaningful to their lives or sports? If your client is an
Olympic lifter or has a job or life that requires a full squat, that’s how low he should
squat. If he’s a powerlifter, he only needs to drop to a level where the hip joint is just
below the knee. But if a full squat or powerlifting squat isn’t necessary, the next logical
depth that applies to everyone is the height required to sit and stand from a stan-
dard-height chair, which is approximately 17 inches from floor to seat.
In the last unit, we covered the one-arm overhead press, which follows a relatively
standard protocol that applies to everyone. It was as simple as handing your client a
dumbbell and watching him or her perform the exercise as you followed the move-
ment analysis. Unfortunately, analyzing the squat isn’t going to be as straightforward.
We’ve already covered one aspect the squat that can’t apply to all: the depth. But
there’s more.
Indeed, there are certain unchangeable limitations that will drastically affect how your
client should perform any squat, even before you consider what needs to be corrected.
Factors such as the size of his leg muscles, along with the bony structures of his hip
joints, need to be factored into the process so you can clearly determine what can be
changed through corrective exercise.
Consider identical twin guys. One person is an elite marathon runner, and the other is
a competitive bodybuilder. The maximum depth the bodybuilder can achieve during a
full squat will be significantly less due to the girth of his calves and hamstrings.
Genetic factors play a significant role as well, especially within the hip joints. You’ll
recall that the hip is a ball-and-socket joint. The round head of the femur is the “ball,”
and the inward dome of the acetabulum is the “socket.” When the head of the femur
is positioned deep within the acetabulum, hip mobility is limited. This restriction is
Corrective Exercise
Perform a Lower Body Multi-Joint Movement Analysis | 157
due to the distance between the roof of the

acetabulum and the femoral head, known
as the acetabular depth. When this depth is
relatively small, the person has “shallow” hip
sockets, which means this person can squat
lower than a guy with deeper sockets before
the femur and pelvis run into each other. Re-
search demonstrates that taller people, or peo-
ple with proportionally long femurs, typically
have deep hip sockets. This is why it’s rare to
see a high-level Olympic weightlifter who’s
over six feet tall. It’s also the reason you’ve
probably noticed that shorter people typically
perform the squat with better technique than
do people with above average height.
Another factor to consider is the hip joint
capsule, the fibrous tissue that connects the
head of the femur to the pelvis. It’s common
for the capsule to stiffen over time, which
limits femur motion.
The bad news, and obvious point, is that the Figure 10.1. Acetabular depth. The acetabular depth is the perpen-
bony structure of the hips cannot be changed. dicular distance between the roof of the acetabulum and a straight line
(broken line shown) that runs between the lateral edge of the acetabulum
A man with deep hip sockets will not be able
and pubic symphysis. A greater acetabular depth limits hip mobility, as
to squat as deeply as someone with shallower well as stiffness of the hip joint capsule.
sockets, if they both assume a narrow stance.
Therefore, a standardized stance width won’t Acetabular depth: The
work when the trainer is assessing the squat. The good news is that you can increase perpendicular distance
the distance between the bony structures by widening the stance. between the roof of the
acetabulum and a straight line
It’s worth noting here that having a shallow acetabular depth isn’t always advanta- that runs between the lateral
geous. People with shallow hip sockets are more susceptible to hip dysplasia, which edge of the acetabulum and
can lead to pain, arthritis, and dislocations. pubic symphysis.
Ideally, everyone would be able to perform a full squat without restrictions. But given Hip dysplasia: An abnormal
the numerous factors that can impair a person’s ability to lower his or her hips signifi- shape or position of the hip
socket.
cantly below his knees, that’s not a realistic expectation. The principles you’ll learn
in this unit will apply to a squat of any depth; however, the ultimate decision of what
depth is truly functional, or meaningful, to a person’s life is up to you.
STEP 1: INDIVIDUALIZE THE SQUAT

In this first step, you’ll accomplish two things. First, you’ll determine how much knee
flexion is required to stand from a chair. Second, you will find the stance width that
allows the bony structures within the hip to move freely.
Determine the Necessary Amount of

Knee Flexion
Start by having your client sit in a regular chair with good spinal posture, arms
crossed at the chest, and the trunk shifted forward as if about to stand up. The person
should be actively engaged in the process of standing up for you to measure the

158 | Unit 10
Figure 10.2. Knee angle to stand from a chair. A) This 5’6” person requires 89° of knee flexion to stand from a standard-
height chair. B) This 6’3” person requires 80° of knee flexion to stand from the same chair. The line through the thigh should run
from the knee joint to the greater trochanter of the femur. The other line, through the lower leg, should run from the knee joint
to the lateral malleolus.
correct knee angle. You’ll perform the measurement just to stand from a chair, don’t assume he’ll be able to achieve
before his or her hips elevate from the chair. You can use that depth with the goblet squat. Furthermore, a squat
either a goniometer or a smartphone app that allows you that travels deeper than the knee angle required to stand
to measure angles from a photo or video. from a chair might be more functional, depending on the
demands of his life or sport.
This knee angle will tell you the minimum amount of
knee flexion necessary for your client to have the func- At this point in the course, you know it’s necessary to de-
tional ability to stand from a normal chair. Your client termine the critical events of an exercise before performing
should be able to achieve that angle, at the very least, the movement analysis. Because there isn’t a specific angle
while performing the goblet squat for your movement of knee flexion that’s appropriate for all clients, it’s import-
analysis. To be clear, the knee flexion angle that’s required ant to establish a point that everyone is required to achieve.
to stand from a chair should not necessarily be the same Again, the knee flexion angle from a standard-height chair
angle where the goblet squat reverses between the eccen- was chosen to establish that minimum value.
tric and concentric phases.
In summary, the purpose of this first step is to establish
Standing from a seated position is drastically different the critical events at the knee joints that are necessary for
from “standing” after performing the eccentric phase of a the goblet squat to be considered functional. How much
squat. Transitioning between the eccentric and concentric lower your client should squat during the movement anal-
phase requires significantly more strength and motor con- ysis will depend on what you determine is necessary for
trol. Therefore, if your client requires 85° of knee flexion his or her sport or life.
Corrective Exercise
Determine the Optimal Stance Width

You’ve undoubtedly seen a person’s pelvis tuck underneath (i.e., posteriorly rotate) when
he or she was in the bottom position of a full squat. This loss of lumbopelvic control is
due to a combination of posterior pelvic tilt and lumbar flexion, and it can put undue
stress on the intervertebral discs, especially when a person is holding an external load.
The structure of an intervertebral disc is similar to a jelly doughnut. The outer
“dough” is the annulus fibrosus, and the inner “jelly” is the nucleus pulposus. When Annulus fibrosus: The
the lumbar spine flexes, it compresses the anterior portion of the intervertebral disc, outer fibrous layer of an
which pushes the nucleus pulposus posteriorly into the outer wall of the annulus intervertebral disc.
fibrosus. Over time, the wall created by the annulus fibrosus can break down, and the Nucleus pulposus: The
nucleus pulposus will push through (i.e., herniate). inner jelly-like fluid of an
intervertebral disc.
To be clear, the lumbar spine is designed to flex, and there’s usually little risk when a
person isn’t holding an external load. However, repeated lumbar flexion, such as doing
100 toe touches each day, or allowing the lumbar spine to flex while holding a chal-
lenging load, are risks not worth taking.
If a person has deep hip sockets and uses a narrow stance, he or she will most likely
flex the lumbar spine at the bottom of virtually any squat depth below parallel. There-
fore, the appropriate stance width should be determined before a movement analysis
occurs to protect the intervertebral discs and allow the femurs to clear the pelvis. You
can determine this by using the quadruped rock back assessment, popularized by
Prof. Stuart McGill and Dr. Shirley Sahrmann. The goal is to determine how far apart
the legs should be to allow the knee necessary knee flexion you determined from the
last step—without a loss of the natural lordotic curve within the lumbar spine.
Remember, you’re performing a movement analysis to determine what compensations
can be helped with corrective exercise. Therefore, it’s important to avoid any genetic
limitations and to minimize your client’s risk of injury before watching him or her
move. That’s why these extra steps are necessary before you analyze the goblet squat.
Figure 10.3. Quadruped rock back test. A) Start with a neutral lordotic curve in the lumbar spine. B) Sit back until the lum-
bar spine starts to flex. This test determines the knee flexion and hip flexion angles that can be achieved while client maintains
the natural lordotic curve of the lumbar spine.

160 | Unit 10
Quadruped Rock Back Test

1. Begin in the quadruped position with a neutral
lumbar spine, which is slight lordosis. Knees are
the same width as the pelvis is.
2. Rock back until the lumbar spine starts to flex
and then slowly reverse the motion just until the
client comes out of lumbar flexion.
3. Measure the knee flexion angle the client could
achieve at the maximum rock back position while
maintaining lordosis. If the knee flexion angle
is larger than what’s necessary to stand from a
chair, or what’s necessary for his life or sport,
widen the knees a few inches and repeat.
4. Continue to widen the knees, a few inches at a
time, until the client can achieve the appropriate
knee flexion angle while maintaining lordosis.
Importantly, the knees shouldn’t be any wider
than is necessary to fulfill the requirements in
these steps.
5. Once you have determined the appropriate knee
width, measure the inside distance between the
knees. This is how wide apart your client’s heels
should be, from one inner heel to the other,
during the goblet squat movement analysis.
Now that you’ve determined how much knee flexion is
necessary for your client, and how wide the stance should
be, let’s move on to the next steps you are already familiar
with by now.
STEP 2: DIVIDE THE EXERCISE

INTO CONCENTRIC AND
ECCENTRIC PHASES
Before watching your client move, consider both phases
of the goblet squat. It starts with the eccentric phase as
the client descends. The concentric phase is the portion
when the client ascends. Your client should perform the
goblet squat without shoes so you can see any compensa-
tions that might occur within the ankles and feet, as we’ll
discuss later.
Figure 10.4. Phases of the goblet squat. A) Eccentric

phase. B) Concentric phase. The feet are angled slightly out-
ward to open the hip joint.
Corrective Exercise
STEP 3: IDENTIFY THE CRITICAL EVENTS AND OBSERVE THE EXERCISE

You know by now that identifying the critical events is an Those are just a few examples that explain why a move-
essential step to answer the question: What do I expect to ment analysis becomes less straightforward as the exercise
see? Your client will perform as many reps as necessary becomes more complex. What matters most is that you
for you to view the movement in the frontal and sagittal know what the optimal technique should look like and the
planes while keeping transverse plane compensations (i.e., critical events that coincide with that technique.
rotation) in mind. No matter which exercise you analyze,
the critical events help you focus on what should and
should not occur as you watch the client move.
The goblet squat was chosen for two reasons. First, be-
cause the dumbbell is held at the chest, it’s easier on the
shoulder joints. An exercise such as the barbell back squat
requires high levels of shoulder mobility and strength that
a person might not have. Second, holding a dumbbell in
front of the body shifts the person’s center of mass for-
ward, which allows the client to sit back further without
losing his ir ger balance. The critical events for the goblet
squat include the following:
• Maintenance of posture (i.e., postural control)
• Hip flexion/extension
• Knee flexion to the angle determined in Step 1
along with full extension of the knee
• Ankle dorsiflexion/plantarflexion
Notice that the critical events for the goblet squat are less
specific than those for the one-arm overhead press are.
There are two reasons for this.
First, the critical events will shift based on the individ-
ualized factors that were discussed earlier, such as the
optimal amount of knee flexion. Second, the range of mo-
tion that’s considered normal for full hip extension and
full plantarflexion isn’t required for the squat. One way
a physical therapist can assess a person’s hip extension
range of motion is by having the patient lie prone with
the legs straight. The PT will ask the patient to lift each
leg as high as possible to assess hip mobility. This motion
is sometimes referred to as hip hyperextension; however,
most clinicians refer to this hip extension range beyond
neutral simply as extension. The normal range of “hyper-
extension” a person should have at the hip is 10° to 15°,
depending on the source. Because hip hyperextension isn’t
required for the squat, a person can perform it perfectly
with suboptimal levels of hip extension. This issue is also
relevant to the ankle. The normal range of the ankle is
20° of dorsiflexion and 45° of plantarflexion. If your client
lacks dorsiflexion, you’ll likely see the heels elevate at the
Figure 10.5.
bottom of the squat. However, if the client lacks plantar- Critical events for
flexion, you won’t see any compensations because locking the goblet squat.
out the knee joint at the top of the squat doesn’t require A) Eccentric phase.
much ankle range of motion beyond neutral. B) Concentric phase.

162 | Unit 10
STEP 4: MAKE A LIST OF WHAT YOU SAW

Now that you have seen your client perform the exercise, it’s time to answer the ques-
tion: What did I actually see?
Common Compensations During the

Goblet Squat
You’ll look closely for the compensations we’re about to cover that can be seen from
the sagittal and frontal plane views. However, keep the transverse plane in mind as
you look for rotations within the trunk.
Sagittal Plane
There are three common compensations you’ll see when viewing the goblet squat from
the sagittal plane view. First, think about how your client initiated the movement.
To start the initial descent, did he push his hips back or let his knees travel forward?
When a person starts the exercise by pushing his knees forward, Prof. Christopher
Knee strategy: A Powers refers to it as a knee strategy. The other option, pushing the hips back at the
compensation seen when the beginning, is a hip strategy. A knee strategy is a compensation that can place undue
knees push forward at the stress on the knee joints, and it can indicate weakness of the hip extensors.
beginning of a squat, which
usually indicates weakness of The second compensation commonly seen from this view is a loss of spinal and/or pel-
the hip extensors. vic control. For starters, the thoracic spine might flex beyond neutral. Even though it’s
Hip strategy: A reliance on rare to herniate an intervertebral disc within the thoracic spine, it’s important to avoid
the hip extensors to initiate
a squat, which reduces the
demands at the knee joints.
Figure 10.6. Knee strategy vs. hip strategy. A) The knee strategy is a compensa-
tion seen when the client initiates the squat by pushing his knees forward. B) With a hip
strategy, the client pushes his hips back to initiate the movement. A hip strategy is the
preferred technique to minimize excess stress at the knees.
Corrective Exercise
encouraging kyphosis because it can negatively affect

posture in daily life. It’s far more common to see lumbar
flexion paired with posterior pelvic tilt at the bottom of
the squat. This loss of lumbopelvic control reduces spinal
stability, which is a vital component of postural control
during any movement. Furthermore, when lumbar flexion
and posterior pelvic tilt occur under load, the risk of a
disc herniation within the lumbar spine is increased.
The third common compensation is seen when one or
both heels elevate, which is usually at the bottom of the
squat where the greatest range of dorsiflexion is required.
Figure 10.7. Common sagittal plane compensations.

The thoracic spine might flex beyond neutral, lumbar flexion
is paired with posterior pelvic tilt, and one or both heels
might elevate.
Before we move on to the frontal plane compensations,

it’s important to discuss how far the trunk should shift
anteriorly when viewed from the sagittal plane. There’s
obviously a necessary amount of anterior trunk shift that’s
required to maintain a person’s balance.
To understand this important point, we’ll revert to the ex-
ample we covered earlier of two different people standing
up from a seated position in a chair. Figure 10.8. Relationship between center of mass and
trunk angle. A) This 5’6” person requires 22° of anterior trunk
Balance is maintained when a person’s center of mass shift to move his COM over his base of support to stand. B) This
(COM) is above his or her base of support (BOS). Recall 6’3” person requires 42° of anterior trunk shift to move his COM
that when a person isn’t holding an external load, the over his base of support to stand from the same chair.

164 | Unit 10
COM is a few inches behind the navel. Because his base of support (BOS) starts at his
heels, he needs to shift his COM forward until it reaches that point in order to stand
from a chair without the help of momentum. Therefore, a person with shorter femurs
requires less anterior trunk shift than a taller person does when standing from that
same chair.
Because the required amount of anterior trunk shift to maintain balance during a
squat largely depends on the length of the person’s femur, there’s not an optimal angle
that will apply to everyone. Therefore, your goal will be to identify and correct the
sagittal plane compensations we just covered. However, the spine should remain in a
neutral position throughout the exercise.
Frontal Plane
Throughout the last few units, the importance of maintaining posture during a move-
ment analysis has been emphasized. Postural control requires the muscles within the
trunk to have sufficient strength and motor control to maintain stability. It’s the pre-
cise relationship between stability and mobility that allows movement to occur freely.
Let’s expand on the issue of stability.
Generally speaking, the arms and legs have a similar design. The shoulder is similar to
the hip because they both allow a large range of motion in all three planes. The elbow is
similar to the knee because each joint primarily produces flexion and extension. And the
wrist is similar to the ankle because they both allow movement in all three planes.
The wrist was largely ignored during this course, as very few meaningful tasks require
a person to be on his or her hands. However, the ankle is a different story. Because
people spend most of their waking hours on their feet, and because the ankle/foot
complex is capable of movement in all three planes, stability within that region is
extremely important.
Many people have poor motor control of the muscles within their feet. The reason is
straightforward: we don’t do intricate, fine-motor tasks with our feet on a daily basis
like we do with our hands. We walk around, or climb stairs, or maybe jog and deadlift
in the gym. Even though these movements certainly work muscles within the feet,
the complexity of the tasks don’t compare to what you do with your hands: writing,
typing, or putting your key in a lock, just to name a few.
Because we don’t challenge the muscles of the feet to do fine-motor tasks, the brain
doesn’t have good motor control over those muscles. Therefore, the stability that’s
necessary to control the 33 joints that make up each ankle/foot complex is often
Fallen arch: Chronic, woefully inadequate. One example is a fallen arch, which you might recall from Unit
excessive pronation of the feet. 4 is technically known as foot pronation. Pronation within the ankle/foot complex
is a combination of dorsiflexion, abduction, and eversion. To be clear, pronation is a
necessary action to produce the mobility required for walking; however, a fallen arch
is due to excessive pronation. Even if a person does not clinically have a fallen arch, it
is common to see excessive pronation occur during the squat. Therefore, the ability to
maintain posture during the squat consists not only of stabilizing the spinal column
and pelvis but also the feet.
Having one or both feet overly pronated creates a chain of compensatory events up to
the hip. The hip adducts and internally rotates, and the knee shifts medially, which
creates knee valgus and all the problems that go with it. Therefore, excessive pronation
causes problems beyond the foot and ankle.
Or you might see the opposite, supination of the feet, which can excessively widen the
Corrective Exercise
Figure 10.9. Neutral foot vs. pronation. A) When the foot is neutral, a reference line (broken line) between the middle of
the ankle and hip will intersect the middle of the patella. B) When the foot is overly pronated, the patella falls medial to the line
between the ankle and hip (i.e., knee valgus).
Figure 10.10. Common knee positions during the squat. A) The knee position, which a vertical line can be drawn from
the center of the patella to the middle of the foot, is optimal. B) Knee valgus is indicated by the vertical line falling medial to the
middle of the foot. C) Knee varus is indicated by the line falling lateral to the middle of the foot.

166 | Unit 10
TRAIN YOUR BRAIN: What are the hamstrings doing during a squat?
Here’s a question that will stump many trainers. What actions are the hamstrings performing
during a squat? Intuitively, it would seem that they are lengthening during the down phase and
shortening during the up phase. However, that’s not the case when a person can do it correctly,
which consists of sufficient dorsiflexion and a relatively vertical trunk.
During the eccentric phase of the squat, the knee flexes as the hip flexes. Knee flexion causes the
hamstrings to shorten, and hip flexion makes them lengthen. During the concentric phase, the
knee extends as the hip extends. Knee extension lengthens the hamstrings, but hip extension
shortens them. Therefore, in either phase, the action at the hip is neutralized by the action at
the knee. As such, the hamstrings primarily perform an isometric contraction during the squat.
That’s why stretching the hamstrings usually does nothing to improve a person’s technique.
distance between the knees (i.e., knee varus). However,

this compensation doesn’t cause many problems other
STEP 5: DEVELOP A
than a loss of ground contact. HYPOTHESIS
These are the reasons your client should perform the You know that this step seeks to answer the question:
movement analysis without shoes. This allows you to de- What could be causing the difference between what I ex-
termine whether the client is capable of maintaining “foot pected to see and what I actually saw? Spending plenty of
posture” during the squat. time on this step is what greatly increases your corrective
exercise IQ. Think about movements you see that should
Now you know that pronation within the feet can internal-
not be occurring and use the information earlier in the
ly rotate and adduct the hip. However, the reverse is also
course to determine which muscles might not have the
true. If a person doesn’t have the strength or motor control
necessary strength or motor control.
to maintain neutral alignment of the hips, which causes
internal rotation and adduction, the feet will pronate. For example, you learned that the hips internally rotate
and adduct when the knees move inward. Therefore, the
If you happen to work in a gym where members are not
muscles that oppose those actions are most likely too
allowed to be barefoot, socks will suffice. And if for some
weak, or the brain has poor control over them, for the
reason you must perform the movement analysis while
demands of the task.
your client wears shoes, it’s likely you’ll still see the same
compensations if you watch closely. The steps you take to develop a hypothesis for any com-
pensations you saw will depend on how low your client
The good news is that you can find out almost everything
descended during the squat. Let’s say you used a chair
you need to know about the hip, knee, and ankle joints by
to determine the depth of the squat. Assuming he could
watching the knees from the frontal view. If one or both
stand up correctly with both heels on the ground and a
knees buckle inward, or if they move excessively outward,
neutral spine, mobility should not be an issue. He already
you’ll know the hips and feet are compensating as well.
proved his joints had the range of motion that’s necessary.
What you don’t know at this point is whether the problem
Therefore, any compensations you saw would be due to a
is coming from the hips, feet, or both.
lack of strength or motor control, as we’ll discuss later.
You’ll document any compensations you see from the sag-
For now, let’s say your client needed to squat lower than
ittal and frontal plane views while keeping the transverse
a chair, and you saw compensations. First, clear the knee
plane in mind. It’s common to see trunk rotation, so make
and then move to the ankle.
a note of it on your movement analysis form if you see any.
Corrective Exercise
Is it a mobility problem at the knee? closer to the shin,” which is an open-chain movement.
Because the knee doesn’t have much freedom to move However, the squat is a closed-chain movement because
beyond flexion and extension, motor control at that joint both feet are on the ground. Therefore, dorsiflexion isn’t
typically won’t be a problem. First determine the client achieved by pulling the top of the foot closer to the shin,
has the necessary range of motion. Can he actively flex but instead by pushing the shin (i.e., tibia) closer to the
each knee joint to an angle that’s required to reach his top of the foot. Thus, when a client lacks dorsiflexion
optimal squat depth? Can he actively lock out each knee during the squat, the tibia will remain more vertical than
joint while standing? Importantly, he should be able to it should when the knee joint is flexed.
slightly hyperextend each knee. This is similar to the When the tibia can’t shift forward 20° from vertical,
slight hyperextension that’s necessary in the elbow joint to the normal range of motion that’s necessary, you’ll see
fully press a dumbbell overhead, as we covered in Unit 9. one of two possible compensations. Either the heels will
If he lacks flexion and/or slight hyperextension, soft tissue elevate as the client descends, especially at the bottom of
or stretches are in order. the squat where the most dorsiflexion is required, or the
client will push his hips excessively backward during the
Is it a mobility problem at the ankle? lower phases of the squat, which in turn forces the client
The ankle joint is only capable of dorsiflexion and plan- to shift the trunk excessively forward to maintain the
tarflexion. Since it has only one degree of freedom, motor COM over his feet.
control shouldn’t be an issue. A lack of mobility is the most From a standing position, can your client push his knees
likely problem within the ankle, specifically dorsiflexion far enough forward to achieve 20° of dorsiflexion in both
since very little plantarflexion is required during a squat. ankles? If he can, you can coach him into the proper tech-
When a trainer talks about dorsiflexion to a client, he or nique. If not, you’ll use the corrective exercise to regain
she will often describe it as “pulling the top of the foot dorsiflexion that are covered in Unit 11.
Figure 10.11. Dorsiflexion

and posture. A) The lack of
dorsiflexion, 2° from vertical,
forces his trunk to shift exces-
sively forward to maintain bal-
ance. B) The necessary 20° of
dorsiflexion allows for optimal
tibial angle and posture.

168 | Unit 10
Is it a mobility problem at the hip? person can sit and stand from a chair, he or she should
The hip flexion that is required to squat below parallel is have enough strength to perform a movement analysis for
typically not a problem. The normal range of hip flexion the goblet squat while holding a light dumbbell.
is 120°, which is often achieved when a person of above Remember, this phase of the corrective exercise program
average height sits in a normal chair. If a person is unable is not intended to build full-body strength per se. Instead,
to flex the hips far enough to squat below parallel, this it’s a system that improves movement so your clients can
issue usually relates to the stance being too narrow. That’s build strength with the correct mechanics while minimiz-
why you performed the rock back test to determine which ing their risk of injury.
stance width allowed the most range into knee flexion as
well as hip flexion. That said, there are certainly times when you’ll need to
strengthen specific muscles using the correctives outlined
Sitting for hours each day makes people good at hip in Unit 11. But for now, the goal is to help your client’s
flexion but poor at hip extension. Because sitting for long brain activate crucial muscles to improve motor control
periods causes the hip flexors to stiffen, they frequently using the cues we’re about to cover. Then you’ll determine
become unable to stretch far enough to allow the hip joint whether those cues are sufficient to allow him or her to
to extend back to neutral at the top of the squat. Keep in train with a load you feel is appropriate.
mind, a normal range of hip extension is 20° beyond neu-
tral, behind the body (i.e., 20° of hyperextension). Indeed, Before we get to that, people typically lack the motor
it’s common for people to severely lack hip extension and control in these three areas that are necessary to perform
remain locked in anterior pelvic tilt. Stretching the hip a squat correctly:
flexors rarely produces a long-term improvement unless Lumbopelvic region: As a person descends into the lower
the hip extensors are actively engaged. This is why cueing portion of the squat, the lumbar spine will often flex, and
your client to “squeeze the glutes together” at the top of the pelvis will posteriorly rotate.
the squat is one of the better ways to improve mobility
of the anterior hip. If the client is unable to achieve hip Hip: The muscles that externally rotate the hip are
extension to neutral when actively squeezing the glutes, frequently underactive during the squat. That’s why it’s
other correctives will be required as we will outline later. common to see valgus in one or both knees.
Feet: The feet will often pronate due to poor motor control
of the supinators, which function to maintain a proper
Is it a thoracic extension problem? arch (i.e., foot posture).
In Unit 9, we discussed the importance of being able to ex-
tend the thoracic spine to neutral. And just like the over-
head press, thoracic extension is not a critical event for the
squat. However, if a person is locked in thoracic flexion
STEP 6: PROVIDE THE PROPER
(i.e., kyphosis), he or she will not be able to maintain the INTERVENTION
neutral spine required for postural control. Therefore,
Now it’s time to provide the most effective cues to improve
you’ll test to see whether your client can achieve the neu-
your client’s technique. Regardless of the compensations
tral thoracic position by cueing him or her to “stand tall
you saw, these cues will have far-reaching effects across
with a long spine” or “move the top of your head as close
multiple joints. The first two cues are applicable to any-
to the ceiling as possible without elevating your chin.”
one; the last three are specific to knee valgus, inadequate
Now that we’ve covered some common mobility problems lumbopelvic control, and inadequate hip extension. You’ll
that will affect the squat, let’s move on to motor control. notice however many are relevant to what you saw in step 4.
Motor control and stability go hand in hand. If you
Is it a motor control problem? improve one, you’ll improve the other. Therefore, the
Some of the most common problems you’ll observe during following cues are intended to improve both elements. The
the movement analysis of a squat will not be caused by first two cues were used in the last unit because they’re
a lack of strength but by inadequate motor control. If a appropriate for any exercise.
Corrective Exercise
Cue #1: “Stand as tall as possible without elevating your This last cue applies to a person who was unable to
chin.” If your client is wearing a hat, you could use an maintain lumbopelvic control. In other words, the lumbar
external cue such as: “Move your hat as close to the ceiling spine flexed, and the pelvis anteriorly rotated during the
as possible without elevating your chin.” The third possi- lower half of the movement.
ble cue is to say to “maintain a long spine.” Use whichever
Cue to correct inadequate lumbopelvic control: “Lift
one works best.
your tailbone during the lower half of the squat.” If this
Reason: These cues place the spinal column in the neutral doesn’t work, have your client imagine a logo on the back
position, which is optimal for neural transmission to the of his or her pants, across the glutes. Instruct client to
muscles. “keep the logo held high during the bottom half of the
squat.” You could also put a small piece of tape on client’s
Cue #2: “Expand your midsection and maintain tension
lower spine, just above the glutes, and cue client to “keep
during the exercise.” You can provide an external cue by
the tape elevated during the bottom half of the squat.”
having the client strap on a weightlifting belt and saying
to “stretch the belt” during the exercise. The best cue is to Reason: These cues maintain proper alignment between
say, “Bear down like you’re having a bowel movement.” the lumbar spine and pelvis.
Reason: These cues increase intra-abdominal pressure, Cue to correct inadequate hip extension: “Squeeze your
which increases trunk stability and lumbopelvic control. glutes together at the top of the squat.” Another cue that
not only helps hip extension but also helps knee extension
It’s important to provide the fewest cues possible to
is “Push your feet into the floor at the top of the squat.”
avoid overwhelming your client. The following external
If the client is wearing shoes, an effective external cue is
cue will improve motor control in both the hips and the
“Smash the bottom of your shoes into the floor at the top
feet. This is an especially important cue because it si-
of the movement.”
multaneously activates two muscle groups that the brain
usually has poor control over: hip external rotators and Reason: These cues promote full hip extension at the top
supinators of the feet. of the squat.
Therefore, the following cue applies to a client who
demonstrated knee valgus during any portion of the squat.
FINAL THOUGHTS
Cue to correct knee valgus: “Spread the floor with your In these last two units, we’ve covered a great deal of
feet.” Be sure the client isn’t rolling to the outside of the information to improve your movement analysis skills. As
feet. If needed, expand the cue to say, “Spread the floor mentioned throughout this section, the goal of the Cor-
with your feet while maintaining ground contact with rective Exercise Specialist is to take all possible measures
the big toes.” Because it’s most common for a person to to correct functional exercises such as the overhead press
experience knee valgus while ascending from the bottom and squat.
of the squat, you could save this cue for that portion of the
movement. It’s important to have your client move very However, in many cases, your client will require inter-
slowly during the movement analysis so you can give the ventions beyond cueing. Therefore, in Unit 11 you’ll
cues at the right time. learn the most effective assessments and correctives to
return your client to training with functional exercises
Reason: These cues activate the hip external rotators and as quickly as possible.
supinators within the feet, which helps maintain neutral
knee alignment and avoid valgus.

170 | Unit 10
Summary
1. There is no single squat depth that’s appropriate for 4. The most common sagittal plane compensations are
everyone. If a full squat isn’t possible, consider the lumbar flexion and posterior pelvic tilt along with
range that’s necessary for a person’s life or sport. The inadequate dorsiflexion.
knee angle required to stand from a standard-height
5. The most common frontal plane compensation is
chair should be the minimum depth achieved during
knee valgus, which can be caused by poor motor
the movement analysis.
control or strength of the hip external rotators and
2. The depth a person can squat depends heavily on supinators of the feet.
his or her acetabular depth. The rockback test is used
6. Compensations at the hips will affect the feet and
to determine the appropriate stance width that will
vice versa. Analyzing the knee position is the simplest
clear any bony restrictions.
way to determine whether the hips or feet have inad-
3. A knee strategy is an overreliance on the quadriceps equate motor control.
to initiate the squat, which usually indicates weak-
7. Inadequate motor control of the lumbopelvic region,
ness of the hip extensors. A hip strategy is the pre-
hips, and feet are the most common causes of com-
ferred method of initiating the squat to avoid undue
pensations occurring during the squat.
stress on the knee joints.
Corrective Exercise

issaonline.edu
Goblet Squat Movement Analysis

Client: Date:
Exercise: goblet squat
Critical event #2: hip flexion and extension
Critical event #3: knee flexion and extension
Critical event #4: dorsiflexion and plantarflexion
Sagittal plane:
Frontal plane:
Transverse plane:
Sagittal plane:
Frontal plane:
Transverse plane:
Notes

issaonline.edu
Multi-Joint Lower Body Movement Analysis

Client: Date:
Exercise:
Critical event #2:
Critical event #3:
Critical event #4:
Sagittal plane:
Frontal plane:
Transverse plane:
Sagittal plane:
Frontal plane:
Transverse plane:
Notes
Restore Alignment and Stability

Step 1: Correct Breathing and Ribcage
Alignment
Step 2: Teach Your Client to Bear Down
Step 3: Align the Pelvis
Step 4: Facilitate Trunk Stability
Step 5: Facilitate Postural Stability
Putting It All Together
UNIT 11
RESTORE STRUCTURAL
ALIGNMENT AND STABILITY
174 | Unit 11
What You’ll Learn

In this unit, you’ll learn how to put your client’s body in better alignment and improve postural control
from head to toe. We’ll begin by covering the components of breathing and how it can affect posture and
movement. Then you’ll learn the important roles of the pelvis and how to correctly align it. We’ll cover the
way your client can significantly increase intra-abdominal pressure followed by a simple exercise to facilitate
trunk stability. Finally, you’ll learn a novel exercise that increases postural stability throughout the upper
and lower extremities. By the end of this unit, you should have a clear understanding of the ways to assess
and correct total body alignment and stability.
RESTORE ALIGNMENT AND STABILITY

The human body functions as one interconnected machine that’s formed by many
individual parts. One or more of those parts being out of alignment or not function-
ing correctly can negatively affect the entire system and disrupt normal movement
mechanics.
If your client is struggling with, say, an overhead press, it’s easy to assume there’s a
problem at the shoulder. There might be, and we’ll cover those assessment and correc-
tive strategies in the next unit. But in many cases, the source of the problem could be
much farther away. That’s why this unit focuses on putting your client’s entire body
back into alignment.
Throughout Section Two of this course, it’s been emphasized that the goal of correc-
tive exercise programming is to take all possible measures to keep the most beneficial
exercises in your clients’ programs. Your clients benefit most by spending their time
and energy doing multi-joint functional exercises to build strength, muscle, and car-
diovascular endurance. Of course, single-joint exercises have their place, too. Regard-
less of the exercise in question, the point here is clear: nobody wants to lie on the floor
and do foam roller drills unless it’s absolutely necessary.
That’s why we spent so much time covering the necessary steps to perform a movement
analysis for simple and complex exercises. Those steps developed your understanding
of what an exercise requires along with the relevant cues to correct whatever is wrong.
In some cases, however, no amount of biomechanics training or cueing in the world
will be enough to allow your clients to perform certain functional movements correct-
ly. Sometimes a person will be too far out of alignment, whether due to a rotated pelvis
or flared ribcage or some other compensation. In other cases, a person will not be able
to create enough intra-abdominal pressure to stabilize the trunk. Therefore, interven-
tions beyond cueing are in order.
To be clear, the goal remains the same. You want to keep the squat, row, deadlift,
overhead press, and other functional exercises in your client’s program. Therefore, we
won’t assume that regressing to stretches, foam rolling, or isolation exercises are the
solution at this time. Instead, we’ll respect the fact that the human body functions as
Corrective Exercise
Restore Structural Alignment and Stability | 175
one interconnected machine. We’ll use five corrective strategies to restore full-body
alignment and stability, which in turn, improves your client’s ability to perform virtu-
ally any exercise.
Before we get to those correctives, let’s clarify what improve actually means.
On one hand, your client will perform an exercise with better technique, which
means that he can fulfill the critical events without compensating. Or at the very
least, the client will be closer to achieving the critical events with fewer compensa-
tions. That is progress.
The other way you’ll know your clients are improving is that they will have less joint
discomfort or pain during an exercise. For example, maybe a client’s right knee has
nagging pain when he or she squats. The client will rate the pain on a scale of 1–10,
with 10 being the highest, as the squat is performed with an appropriate load. After
performing a few reps of the goblet squat with a 25-pound dumbbell, let’s say, the cli-
ent rates the right knee pain as 6/10. You’ll perform the five steps outlined in this unit
to restore alignment and stability from head to toe, and then retest the goblet squat. If
the client’s knee pain decreases, you’ll know you’re on the right track.
Indeed, the strategies you’re about to learn can decrease or eliminate pain, whether
it’s in the low back, knee, shoulder, or any other region. But remember: all pain should
first be considered a medical problem. If a client has pain, he or she must first be
cleared for exercise by a physician or health-care professional.
To recap, before taking your client through the following steps, have him or her per-
form a few reps of the problematic exercise. You’ll carefully watch technique and note
any compensations, and the client will rate any joint discomfort on a scale of 1–10.
Then perform the following five steps and retest the exercise.
STEP 1: CORRECT BREATHING AND RIBCAGE

ALIGNMENT
The purpose of corrective exercise is to facilitate motor learning so your client can
make permanent changes in the way he or she moves. Recall that motor learning
is best achieved when your client has a low level of stress. That’s why, in Unit 7, we
detailed the psychological and coaching elements you’ll use to create a low- stress ex-
ternal environment. Now it’s time to cover the way you can help your client facilitate a
low-stress internal environment.
Imagine the rapid breathing pattern of a man in a high-stress situation. You’ll see his Diaphragmatic breathing:
The type of breathing that is
chest quickly expand with each inhalation as muscles within the neck and shoulders primarily driven by contraction
drive the respiratory pattern. This “chest breathing” looks stressful to the body because and relaxation of the
it is a dysfunctional way to breathe. To make matters worse, many people breathe in diaphragm.
this same pattern, albeit slower, even when they’re not feeling great stress. You can Thoracic cavity: The space
easily test this by asking your client to inhale deeply. Did his or her chest expand and enclosed by the ribs, vertebral
abdomen pull inward? If so, your client is a chest breather, and this should be fixed. column, and sternum where
the heart and lungs are
Diaphragmatic breathing, in contrast, is driven primarily by contraction of the contained.
diaphragm. The diaphragm is a dome-shaped muscle that attaches to the inner surface
Abdominal cavity: The
of ribs 7-12, the xiphoid process, and lumbar spine. The diaphragm looks similar to a
space between the diaphragm
parachute, and its position separates the thoracic cavity (i.e., lungs and heart) from the and pelvis that contains the
abdominal cavity. When the diaphragm contracts, it pulls the thoracic cavity down to abdominal organs.

176 | Unit 11
vertically expand it and simultaneously compresses the ab- rest of the skeleton by simply cutting the ligaments that
dominal cavity. During exhalation, the diaphragm relaxes connect the clavicle to the sternum.
and returns to its original dome shape. When a person
This single point of attachment at the sternoclavicular
primarily uses the diaphragm to inhale, three significant
joint means that any ribcage movement will move the
benefits are experienced.
clavicle too. Thus, if the ribcage is twisted or elevated, it
First, the lungs take in more air due to expansion of the will alter the position of the shoulder complex. Indeed,
thoracic cavity. Therefore, more oxygen enters the blood- optimal movement mechanics at the shoulder require the
stream, which triggers a cascade of physiological events ribcage to be correctly aligned, and the position of the
that help the brain and other organs achieve a state of low ribcage is dictated by the way a person breathes.
stress. This is why masters of yoga, meditation, and Tai
Because diaphragmatic breathing pulls the bottom of the
Chi always focus first on controlled diaphragmatic breath-
ribcage down and centers it over the pelvis, maintaining
ing to improve health, performance, and decrease stress.
this type of breathing is an essential strategy for restor-
Second, intra-abdominal pressure (IAP) increases due to ing structural alignment. Therefore, the first corrective
compression of the abdominal cavity. Recall from Unit 9 step you should take is to ensure that your client is
that a higher IAP increases trunk stability, a crucial com- breathing correctly.
ponent of postural control. Indeed, your client’s ability to
control his or her posture, from head to toe, is heavily in-
fluenced by the way your client breathes. In fact, research
demonstrates that people with chronic ankle instability
have poor activation of the diaphragm: that’s how far-
reaching the negative effects of poor breathing can travel.
The third benefit of diaphragmatic breathing relates to its
influence on the position of the ribcage. Let’s think back
to the stressed-out chest breather we mentioned earlier.
When a person inhales by contracting the neck and chest
muscles, the bottom of the ribcage elevates and pushes
forward, which contributes to the open scissors syndrome
we discussed in Unit 9. Conversely, contraction of the dia-
phragm pulls the bottom of the ribcage down and inward
as the abdominal cavity compresses.
Numerous muscles that link the ribcage to the pelvis
or lumbar spine. These muscles work like guy wires to
hold the ribcage centered over the pelvis. However, it’s
common for one or more of these muscles to shorten or
lengthen excessively due to poor posture or chest breath-
ing. This moves the ribcage out of alignment, which can
lead to compensations that move the shoulder complex
out of alignment. Figure 11.1. Sternoclavicular (SC) joints and dia-
That’s because the only point of attachment between the phragm. The SC joint is the only bony attachment be-
tween the shoulder complex and ribcage. The diaphragm
bones of the shoulder complex and ribcage is at the ster-
is a dome-shaped muscle that contracts when a person
num: the sternoclavicular joint. If you were working on a inhales and relaxes when he or she exhales. It attaches to
cadaver that had nothing left but the bones and ligaments, ribs 7-12, the xiphoid process, and upper lumbar vertebrae.
you could remove the right upper limb entirely from the Diaphragmatic breathing aligns the ribcage over the pelvis.
Corrective Exercise
Diaphragmatic Breathing
Assessment/Correction
Why you need it:
• Diaphragmatic breathing aligns the ribcage over the
pelvis and increases intra- abdominal pressure.
• It shifts the nervous system into a low stress state,
which is optimal for motor learning.
How to do it:
• Client lies on his or her back, knees bent and feet flat
with one palm on the sternum and the other palm
on the navel.
• Tell client to breathe normally and monitor whether
the chest or abdomen elevates with each inhalation.
If the hand on the abdomen elevates during inhala-
tion, he or she is a diaphragmatic breather (Figure
11.2B). Assess client’s ability to perform diaphrag-
matic breathing seated, standing, and walking. If
client passes all three, move on to the bear down
assessment.
• If client has dysfunctional chest breathing, with
each inhalation, the hand on the sternum will
elevate, and the hand on the abdomen will lower
(Figure 11.2A). Instruct client to focus on his abdo-
men elevating with each inhalation. The hand on
the sternum shouldn’t move.
• Spend a few minutes cueing the client to perform
diaphragmatic breathing until doing so becomes
automatic.
• When the client is able to sustain diaphragmatic
breathing in the supine position, perform the same
assessment with him seated, standing, and walking.
Once the client can breathe from the diaphragm
while walking, which is the most challenging
posture, he’s ready for the bear down assessment/
correction.
Figure 11.2. Chest breather vs. diaphragmatic breather.

A) During inhalation, the hand on the sternum elevates while
the hand on the abdomen simultaneously lowers. This is dys-
functional chest breathing. B) With diaphragmatic breathing,
inhalation causes the hand on the abdomen to elevate while the
hand on the sternum remains static.

178 | Unit 11
STEP 2: TEACH YOUR CLIENT • If he is unable to expand the lower abdomen on one
or both sides, have him wear a weightlifting belt to
TO BEAR DOWN provide tactile feedback. Cue him to increase out-
ward pressure against the belt to right side, left side,
Importantly, diaphragmatic breathing isn’t enough to or both sides, depending on what you saw. Remove
ensure that your client can produce optimal levels of the belt when he gets it right.
intra-abdominal pressure, a vital component of trunk • Once the client is able to bear down correctly, he
stability. You’ll need to determine whether he can expand can produce optimal levels of intra-abdominal pres-
his entire midsection, in all directions, during abdominal sure. Now it’s time to align the pelvis.
bracing. Therefore, the bear down assessment is in order.
STEP 3: ALIGN THE PELVIS

Bear Down Assessment/ A centered pelvis is one of the most important aspects of
Correction structural alignment from head to toe. That’s because the
pelvis is the meeting point of the spine and lower limbs.
Why you need it: When the pelvis is rotated, tilted, or lacks stability, it can
change the alignment of the upper and lower extremities,
• Correcting a person’s ability to bear down increases
which negatively affects movement and posture.
his or her intra-abdominal pressure throughout the
abdomen, a crucial component of trunk stability. For example, when the right hamstring is stiff, it will pull
the right side of the pelvis into a posterior tilt. Alternatively,
How to do it: stiff hip flexors on the left will pull the left pelvis into ante-
rior pelvic tilt, which leads to compensations down the leg
• Client is seated with good spinal posture with the
and into the subtalar joint. Countless muscles, ligaments,
lower back exposed. Instruct client to “bear down
and fascial lines interconnect the arms and legs through
as if you’re having a bowel movement” or “push
your lower abdominals laterally.” the pelvis. Indeed, research demonstrates that a properly
functioning pelvis is important for nearly every task.
• If the client is able to bear down correctly, both
sides of the low back—just above the pelvis—will Three joints that allow the pelvis to move in various ways:
move an equal distance laterally (Figure 11.3). If this 1. Lumbosacral junction: This is the meeting point
is the case, you can move on to step 3. between the fifth lumbar vertebrae and sacrum
2. Sacroiliac joints: There are two of these joints,
where the sacrum meets the ilium on the right and
left side.
3. Pubic symphysis: This is the meeting point be-
tween the two pubic bones.
Figure 11.3. Proper bear down technique.

When the client is cued to “bear down” or “push
the lower abdomen laterally,” you should see each Figure 11.4. Possible pelvic rotations. The right side of
side of the lower abdomen, just above the pelvis, the pelvis shows how the ilium can rotate: anterior/posterior
move an equal distance laterally. tilt and left/right rotation. The left side of the pelvis shows a
common unilateral rotation of the left ilium, which is ante-
rior tilt and right rotation. These compensations are possible
due to the joints created by the lumbosacral junction, SI
joints, and pubis symphysis.
Even though none of the aforementioned joints allow

much movement, the sacroiliac joints are particularly im-
portant because large amounts of force transfer through
them when you squat, deadlift, or land from a jump.
It’s important for the SI joints to be strong and stable
to minimize back pain and to keep the body in proper
alignment. This stability is created by numerous ligaments
and muscles that attach to the pelvis. If one or more of
these muscles are overactive (i.e., stiff) or underactive, the
sacrum can move out of proper alignment.
Of course, it would be extremely time consuming and
impractical to try to figure out what muscles aren’t doing
their job to hold the pelvis in line. The good news is that
the following sequence will get the job done, no matter
which way the pelvis is rotated.
Pelvic Alignment Correction

Why you need it:
• Realigns the pelvis to reduce strain of the attached
muscles, ligaments, and fascia
• Places the lower extremities and spinal column in
proper alignment
How to do it:
• Lie supine with a padded bar between the legs.
Right anterior thigh is under the bar, and left pos-
terior thigh is over it. Hold the bar firmly with both
hands, and then simultaneously attempt to flex
the right hip and extend the left hip (Figure 11.5A).
Neither leg will move due to the resistance of the
bar. This position isometrically activates the right
hip flexors and left hip extensors.
• Hold the isometric contraction for 10 seconds with
60% of maximum effort, rest for 10 seconds with the
feet on the ground, and repeat the 10-second hold.
• Next, switch legs and resist right hip extension and
left hip flexion for two sets of a 10-second isometric
contraction (Figure 11.5B).
• Lie supine with knees bent and feet flat on the floor.
Place a basketball or light medicine ball between the
knees (Figure 11.5C). Attempt to squeeze the knees Figure 11.5. Pelvic alignment correction. A) Resisted
together against the resistance of the ball for 10 sec- right hip flexion and left hip extension. B) Resisted left hip
onds with 60% of maximum effort. Rest 10 seconds flexion and right hip extension. C) Resisted hip adduction.
and repeat the 10-second squeeze.

180 | Unit 11
STEP 4: FACILITATE TRUNK

STABILITY
Now that breathing has been corrected, and the ribcage
and pelvis are in proper alignment, it’s time to activate
crucial muscles to promote a strong, stable midsection.
Trunk Stability Roll

Why you need it:
• It activates the core muscles that provide stability
throughout the trunk.
• It stabilizes and centers the ribcage over the pelvis.
How to do it:
• Client lies supine while hugging a large exercise ball
that’s resting on the sternum (Figure 11.6A).
• Cue the client to “push the lower abs laterally” or
“bear down like you’re having a bowel movement”
and then slowly flex the hips and knees simultane-
ously until the knees are lightly touching the ball
(Figure 11.6B). The knees are slightly wider than
shoulder width.
• With the lower back flat against the floor and
abdominals braced tightly, slowly roll slightly to
the right and left (Figures 11.6C and D). The client
should feel activation of the core muscles while
rolling to each side.
• Perform the side-to-side roll for 20–30 seconds. Rest
20–30 seconds and repeat.
Common mistakes:
• The entire body doesn’t move as one unit. Either the
hips rotate before the trunk does or vice versa.
• The client rolls excessively to one or both sides and
loses balance. Only a few inches of elevation are
required on one side of the body during the roll.
Figure 11.6. Trunk stability roll. A) Begin supine with the

arms wrapped around a ball that’s resting on the sternum. B)
Flex the hips and knees until the knees lightly touch the ball.
C) Roll slightly to the right. D) Roll slightly to the left.
Corrective Exercise
STEP 5: FACILITATE POSTURAL STABILITY

Now that you’ve learned how to put the body in better alignment and have taken steps
to activate muscles within the trunk, it’s time to facilitate full-body stability from the
feet up to the neck. We’ll briefly cover each region that’s of particular importance.
First, stability within the feet comes from maintaining a proper arch. Second, activa-
tion of the external rotators and abductors within the hips help stabilize the pelvis and
decrease excess tension within the iliotibial (IT) band. An overly stiff IT band, com-
monly referred to as IT band syndrome, is a common problem in many active people. IT band syndrome: Excessive
Third, the spinal column is stiffness and/or inflammation
stabilized by bearing down of the iliotibial band due to
overuse.
to increase intra- abdominal
pressure, which also pulls the
ribcage into ideal alignment.
Finally, activation of the lats
is an important component
of spinal stability due to
its insertion point into the
thoracolumbar fascia (Figure
11.7). Therefore, when the lats
contract, they help support the
lumbar spine, which in turn
allows better activation of the
abdominals.
The following corrective drill
activates all the aforemen-
tioned muscles. After the client
has performed the drill, it’s
likely he or she will be able
Figure 11.7. Thoracolumbar fascia. This strong to perform many functional
band of connective tissue forms a link between the exercises with better move-
lower and upper extremities. It transfers force and
ment quality and less joint
provides stability during movement.
discomfort.

182 | Unit 11
Postural Stability Hold • Squeeze the ball with the elbows, using the lats, and
stretch the band by pulling the knees apart (Figure
For this drill, you’ll need a pair of pens or markers, a 11.9). These actions occur simultaneously, using 50%
mini band, and a ball. The ball should be relatively light of maximum effort for 10 seconds. Perform three sets
and large enough in diameter so the client’s elbows are with 20 seconds of rest between each set.
approximately shoulder width apart. A basketball, light
medicine ball, or inflatable kick ball can all work. Figure 11.9. Postural
stability hold. The
knees are pulled laterally
Why you need it: to stretch the band to
• Activates many of the essential muscles necessary activate the hip external
for postural stability from the feet to the neck. rotators and abductors;
the elbows are pulled
inward against the ball
How to do it: to activate the lats and
abdominals.
• Place a mini band around the lower thighs, just
above the knees. Stand barefoot, or in socks, with
the feet shoulder width and pointing forward. Flex
the elbows and place a ball between them, with
the hands clasped and fingers interlocked. Shift the
weight to the outside of the feet, as far as possible,
while maintaining ground contact with the base
of each big toe. Place a pen or marker against each
arch to provide tactile feedback (Figure 11.8A).
• Bear down and hinge slightly at the hips by pushing
them back and letting the knees slightly flex. The
spine is held in a neutral position, meaning no ad-
ditional flexion or extension, with the chin is tucked
(i.e., double chin). Maintain this posture because it
serves as the starting position for the postural stabil-
ity hold (Figure 11.8B).
Common mistakes:
• The feet roll outward, causing a loss of contact be-
tween the base of the big toe and ground. Instruct
the client to maintain light contact between the
arch and the pen/marker.
• The knees move laterally past the feet. The knees
should not be wider than the outer edge of the feet.
• The elbows are held too high in front of the body,
causing the pecs to contract instead of the lats.
Figure 11.8. Hip hinge.

A) To start, stand tall with
a long spine, ball between
the elbows, band above the
knees, and a pen touching
each arch. B) The end posi-
tion is achieved by hinging
slightly at the hips as the
knees slightly flex.
Corrective Exercise
PUTTING IT ALL TOGETHER

All five of the aforementioned steps should be performed However, it might not be necessary for every client to per-
when the goal is to correct any problematic exercise. Per- form all three steps. Let’s say your client has left knee pain
haps you have a new client who struggles with an over- while doing a lunge. Perform step 3 and then reassess the
head press or a regular client who suddenly has knee pain lunge. If that helped, keep it in the client’s program. If not,
during a lunge. Follow the steps, in the order given, and move on to step 4, followed by a reassessment of the lunge,
then reassess the exercise. In most cases, your client will and then do step 5. Figure out which of those three steps
be able to perform the problematic exercise with better work best for your client and have him or her perform these
movement quality and/or less pain. at least once a day with the recommended parameters.
Even though all the steps won’t take much longer than The parameters for each step are the minimum number of
10–15 minutes, there will be times when you won’t need to sets required to elicit a positive change. Use your judg-
perform all five. Therefore, we’ll wrap up this unit with a ment to determine whether more sets are necessary for
few other important points. each client.
Steps 1 and 2 are primarily for assessment purposes. If The steps covered in this unit are extremely effective for
your client is a diaphragmatic breather and can bear down correcting virtually movement, whether it’s a simple
correctly, you won’t need to repeat those steps when cor- biceps curl or a more complex exercise such as a deadlift
recting an exercise for him or her in the future. Neverthe- or lunge. In the next unit, we will take a closer look at spe-
less, reassess the steps 1 and 2 every few weeks to check cific joints and soft tissue limitations that could be causing
that your client is able to perform them correctly. any problems that weren’t completely eliminated from the
five steps in this unit.
Steps 3–5 are recommended before any problematic exer-
cise, or training session, to improve alignment and stability.

184 | Unit 11
Summary
1. Efficient movement and motor control are best 4. The pelvis can rotate many different ways due to the
achieved when the skeletal structure is properly large number of muscles, ligaments, and fascia that
aligned and the client is able to induce high levels of connect to it. When the pelvis is out of alignment,
intra-abdominal pressure. it can create compensatory actions throughout the
upper and lower extremities.
2. It’s essential to assess and coach your client to per-
form diaphragmatic breathing to put the nervous 5. The trunk stability roll is a simple, effective exercise
system in a state of low stress and properly align the to engage the abdominal muscles that support the
ribcage over the pelvis. spine and pelvis.
3. The ability to bear down correctly is a crucial compo- 6. Simultaneous activation of the lats, abdominals, hip
nent for creating sufficient intra-abdominal pressure external rotators/abductors, and supinators within
to promote spinal stability. the feet promote postural stability from the neck to
the feet.
Corrective Exercise
Are You Obsessively Assessing?

What To Do First?
Interplay Between Mobility
and Stability
Proximal Stability Creates
Distal Mobility
Activation Exercises
Trunk and Pelvis
Hips/Pelvis
Feet
Before Moving On
Sphinx with Reach
Scapular Activation
How To Use This Information
Make a Home Exercise Program
Create a Joint Friendly Workout
Create a Customized Warm-Up
Final Words
UNIT 12
RESTORE MOBILITY THROUGH STABILITY

186 | Unit 12
What You’ll Learn

The goal of this unit is to keep your clients moving with exercises that minimize joint stress and activate cru-
cial muscles that promote stability. As we continue with a top-down approach to correcting exercise, you’ll
learn which functional exercises will provide the most benefits for decreasing pain and stiffness. You’ll first
learn why it’s often not necessary to learn a myriad of assessments, as every exercise is a test. Then you’ll
learn the complex interplay between mobility and stability and why it’s important to understand how one
can affect the other. Next, we’ll cover the muscles that are typically underactive and how they can negative-
ly affect movement and performance. The remainder of the unit will be devoted to the corrective exercises
that can produce far-reaching benefits from head to toe. By the end of this unit, you will have added many
corrective exercises to your skill set that are appropriate for clients at all fitness levels.
ARE YOU OBSESSIVELY ASSESSING?

A physical therapist or clinician’s most important yet most cases, a personal trainer doesn’t have the skill set to
challenging role is to become proficient at thoroughly as- decipher relevant information from a person’s history or
sessing a patient to improve his or her movement. Because his or her psychological state or have the special tests that
most health-care professionals follow a different system might indicate why a joint is stiff. A personal trainer, how-
when analyzing a patient, a “thorough assessment” means ever, can assess how a client moves, such as watching him
different things to different clinicians. or her perform a straight leg raise that’s intended to assess
hamstring mobility, and provide exercise interventions
Some experts, such as Craig Liebenson, DC, feel that
that are appropriate. But that common test and many oth-
more emphasis should be put on a patient’s history, such
ers usually aren’t as easy to decipher as they might seem, as
as previous injuries, job demands, exercise log, and so on.
we’ll discuss later.
Other clinicians feel that more time should be spent on a
person’s psychological state. What’s essential to keep in mind is that a personal train-
er’s job is to get clients into better shape through exercise
Maybe that chronic stiffness in the left side of the client’s
alone. That’s why personal trainers should focus their skills
neck and shoulder is due to the fear of being hit on that
on assessing and correcting functional exercises before
side by an abusive spouse. And some sports doctors feel
searching for joint or muscle tests. As the late Prof. Vladi-
that a long list of special tests for each joint, which analyze
mir Janda stated, “Every exercise is a test.”
ligament integrity, muscle activation, bony clearance, and
so on is the way to go. The problem with that approach? Even though a thorough assessment is beneficial, it is easy
The shoulder joint alone has over 100 special tests. Indeed, for personal trainers to spend too much time doing what
research demonstrates that there’s no single best test for they weren’t hired or trained to do. It’s best to leave the
the shoulder or for any other joint for that matter. complicated assessments to physical therapists, psychia-
trists, and orthopedists. Therefore, in this unit, you will
These days, it’s common to hear well-meaning personal
learn how to keep a client moving as safely and often as
trainers extol the virtues of the mantra, “If you’re not
possible, without obsessing over assessments. That way,
assessing, you’re guessing,” or something similar. The
you won’t go too far down a rabbit hole.
challenge, of course, is figuring out what to assess. In
Corrective Exercise
Restore Mobility through Stability | 187
WHAT TO DO FIRST?
There’s an ongoing debate about what should be done first when a client is too stiff
to move through a normal range of motion. On one hand, it makes sense to have the
client perform stretches, foam rolling, and soft tissue work to increase the range of
motion. That is a necessary and beneficial approach when a client has had an injury
resulting in scar tissue and damage to the muscle and fascia.
Here’s why. Normally, the structure of muscle and fascia are neatly aligned, allowing
the extensibility necessary for optimal movement. But an injury can disrupt this tissue
pattern, which must be broken down with soft tissue interventions that allow them
to reform in the correct alignment over the course of weeks and months. Remember,
tissue changes don’t happen quickly and usually require eight weeks or more before a
permanent change occurs.
However, the nervous system will often create stiffness in a muscle as a protective mech-
anism. This protective tension is a common problem in “healthy” populations that don’t Protective tension: Stiffness
have a recent injury. To better understand why this happens and what needs to be done within soft tissue that restricts
to correct it, we’ll start by discussing the relationship between mobility and stability. mobility.
INTERPLAY BETWEEN MOBILITY AND

STABILITY
Optimal movement requires a balance of mobility and stability: they go hand-in-hand.
Mobility is achieved when the soft tissues consisting of the muscles, fascia, and joint cap-
sules have the extensibility to allow the joints to move through a full range of motion.
Furthermore, the nervous system must not restrict the muscles and fascia from moving
freely, as we’ll discuss shortly. Stability is achieved when crucial muscles can contract at
the precise time and with enough force to provide stiffness where the body needs it.
You can appreciate the importance of stability for mobility when you consider how a
client who is capable of performing a full squat with perfect technique while standing
on stable ground alters his or her technique while squatting on a Bosu ball. On stable
ground, the client can easily perform a rock-bottom full squat. The instability of a
Bosu ball, however, shortens the depth that can be achieved, assuming the client hasn’t
practiced this exercise. The nervous system limits the client’s mobility, as a protective
mechanism, due to a lack of stability.
Another example: when the pelvis is unstable, the nervous system will often stiffen the
hamstrings to provide stability to that region. Therefore, a person with good inten-
tions will stretch his or her hamstrings to gain range of motion, not realizing that it
can actually create pelvic instability. That’s why stretching alone rarely produces a
long-term improvement: the underlying problem of poor stability wasn’t addressed.
Oftentimes, a muscle that’s shortened and filled with excess tension doesn’t need to
be stretched. Instead, the underactive (i.e., inhibited) muscles that aren’t providing
stability must be activated. This activation, in turn, will signal the nervous system to
release the excess tension at an adjacent joint. Therefore, activating principal muscles
that enhance stability around a joint can actually increase mobility.

188 | Unit 12
To better understand this concept, consider a straight leg

raise from the supine position, a common test of ham-
string mobility. If a person is unable to achieve 90° of
motion, it’s easy to assume that stiff hamstrings are the
problem. However, research demonstrates that the highest
level of tissue tension during a straight leg raise occurs in
the iliotibial (IT) band.
Here’s why that’s important to understand. During dy-
namic activities such as running and jumping, the gluteus
medius plays a vital role for keeping the knees directly
above the feet—by stabilizing the hip and pelvis. It’s
common, however, for the gluteus medius to not have the
strength, motor control, or timing of activation to do its
Figure 12.1. Straight leg raise. This is a common assess-
job. In other words, the glutes are inhibited, or the person
ment of hamstring mobility. However, many other factors
can limit the range of motion a person can achieve, such as has, as Prof. Stuart McGill likes to say, “gluteal amnesia.”
an anteriorly rotated pelvis, hip capsule stiffness, and stiff-
Therefore, the next muscle in line to provide hip and
ness in the IT band. In this photo, he’s pulling the leg into
more hip flexion as a measure of passive mobility. pelvic stability is the tensor fascia latae (TFL), which,
without the help of the gluteus medius, becomes overac-
tive and stiff. Because the TFL inserts into IT band, the IT
band becomes stiff as well. Thus in the end, the IT band
stiffens to support the knee when the gluteus medius is
underactive.
When the TFL shortens, it pulls on its insertion point in
the IT band, causing excess tension in the IT band as well.
Therefore, activating the gluteus medius reduces tension
in the TFL, which in turn reduces tension in the IT band.
Therefore, it’s no surprise that weakness of the gluteus
medius, along with stiffness in the TFL and IT band, are
common problems seen simultaneously: the three struc-
tures form a compensatory chain of events.
Let’s return to the straight leg raise example. Because
you know that IT band stiffness limits mobility in the
straight leg raise, and IT band stiffness is often due to a
weak gluteus medius, one of the most effective strategies
to improve a person’s straight leg raise is to activate the
gluteus medius. Therefore, turning on the glutes helps
the IT band release its protective tension. This is just one
of many examples throughout the body that explains
Figure 12.2. The TFL and IT band relationship. The how enhancing stability, through muscle activation, can
TFL muscle becomes overactive when the gluteus medius is improve mobility.
weak. This causes the TFL to shorten and stiffen.
Additionally, when you turn on an underactive muscle,
the benefits can sometimes travel farther than you would
expect. For example, a fallen arch that’s due to an under-
active posterior tibialis can lead to compensatory chains
up through the body that result in jaw pain. Indeed,
Corrective Exercise
progressive physicians who treat disorders of the temporomandibular joints (TMJ) Temporomandibular joints
analyze the patient’s feet and gait early on. (TMJ): Joints that allow the
mouth to open and close.
Therefore, at this stage of the corrective exercise process, the goal is not to stretch or
foam roll stiff muscles, unless it’s clearly necessary. Instead, you’ll learn how to acti-
vate crucial muscles that provide a stabilizing role, which in turn, will improve mobili-
ty at adjacent joints. Moreover, you’ll activate those muscles using the most functional
exercises possible, thus allowing your clients to correct imbalances while still getting a
challenging workout.
The hitch, of course, is determining which muscles aren’t doing their jobs. You could
spend hours isolating and testing the strength of every muscle group to establish what
isn’t firing correctly. However, that approach has two problems. First, testing a muscle
in isolation isn’t functional because the body works as one interconnected unit. A
muscle might be able to contract correctly when it’s isolated but is unable to function
as it should during a more complex task. Second, it’s extremely time consuming to
manually test all the major muscle groups, even if you have the skills to do so. Clients
hire you to get them into shape, so any time you spend that doesn’t improve their
strength, endurance, or performance is another reason for them to find someone else.
In other words, it’s beneficial to learn shortcuts.
Over the last 20 years, I’ve worked with everyone from teenagers to elderly people in a
hospital to the most skilled athletes on the planet. Regardless of the client, I typically
see the same patterns of muscle underactivity. Whether that underactivity should be
categorized as weakness, inadequate motor control, or a poor mind-muscle connec-
tion is irrelevant. What matters is that the underactive muscles become as active as
possible, and good things usually happen, sometimes immediately, as is the case when
the straight leg raise improves after the gluteus medius is turned on. Table 12.1 lists
the most common culprits, from the ground up.
Table 12.1: Common Underactive Muscles

Region Commonly underactive muscles
Feet Posterior tibialis
Hips/pelvis Hip abductors and external rotators
Trunk Obliques, lats, and diaphragm
Glenohumeral joint External rotators
Scapulothoracic region Serratus anterior, middle/lower trapezius, rhomboids
Neck Deep neck flexors
PROXIMAL STABILITY CREATES

DISTAL MOBILITY
A common mantra among the strength and conditioning community is, “You can’t
shoot a canon from a canoe.” Or as the glute training expert, Bret Contreras, PhD, has
stated, “You can shoot a canon from a canoe, but it wouldn’t be a good idea since the
canoe would be blown to smithereens.” Regardless, I think you get the point: an explo-
sive action requires a stable foundation, or else bad things will happen.

190 | Unit 12
The “canoe” in question here is the spine and pelvis, which form the foundation of
your skeletal structure. When the muscles that support the spine and pelvis don’t
have sufficient strength, or when they can’t contract at the precise time, instability
throughout those regions results. Therefore, accessory muscles stiffen, and joints can
fall out of alignment, as the nervous system searches for stability wherever possible.
This loss of spinal and pelvic stability can impair mobility throughout the upper and
lower extremities.
Here’s a real-world example. In my seminars, I’ll often ask for an audience member
who has stiff hamstrings to come up to the podium. I’ll have the volunteer attempt to
touch his or her toes, which of course, he or she isn’t able to do. I’ll indicate how far
the fingers reached by placing a piece of tape on the leg at that spot. Then I’ll take him
or her through a 30-second drill, using a Swiss ball to activate many muscles that sup-
port the spine and pelvis. When the person stands up and attempts to touch his or her
toes for the second time, the range of motion has drastically increased. This increased
mobility came directly from activating crucial muscles around the spine and pelvis:
no hamstring stretches necessary.
Now, it’s worth mentioning here that I didn’t permanently fix the volunteer’s stiff ham-
strings. He or she would need to continue doing the drill consistently until the muscles
have the strength to hold everything in place all day long. That’s why, when you find a
corrective exercise in this unit that increases your client’s performance and mobility, it’s
necessary to have him or her do it a few times each day until the problem is solved.
Physical therapists know that a key to progress hinges on the person’s adherence to a
home exercise program. There are 168 hours in a week, and you’ll only be with your
client for few of them at best.
Nevertheless, the example of the volunteer who increased hamstring mobility with a
drill that activates muscles around the spine highlights a crucial point of corrective
exercise: proximal stability creates distal mobility.
Therefore, regardless of where your client lacks mobility, you’ll first address the issue
with exercises that emphasize muscle activation throughout the trunk and pelvis.
Then we’ll merge outward to the hips and shoulders. Your client might need either, or
both, depending on the location of his or her limitations and based on the information
you gathered in Unit 6.
For example, let’s say your client is unable to reach overhead through a range of mo-
tion that’s necessary for common exercises. You’ll start with the activation exercises
for the trunk and pelvis and retest his or her overhead reach. If the client needs more
help, you’ll continue with the exercises that activate muscles in the glenohumeral
joint and scapulothoracic region that are outlined in Table 12.1. Or perhaps the client
lacks the mobility to perform a squat or lunge through a full range of motion. Again,
you’ll start by activating the trunk and pelvis, retest the problematic exercise, and then
move to the feet if necessary. If none of the interventions provide the results you need,
we’ll look more closely at structural limitations within soft tissue and outline ways to
mobilize them.
ACTIVATION EXERCISES
Most of the following exercises train muscle groups at once, which is a good thing.
The goal is to turn on underactive muscles while still challenging as many other
Deep neck flexors: Muscles muscles as possible to create a metabolically demanding workout for your client. And
in the anterior neck that flex the there’s plenty of carryover between exercises. For example, most exercises are per-
cervical spine. formed using a chin-tuck (i.e., double chin) to activate the deep neck flexors, a group
Corrective Exercise
of muscles that is commonly underactive. Furthermore, • Cue the client to “tuck the chin” or “make a double
exercises such as the monster walk will challenge many chin” to activate the deep neck flexors. Next, cue
muscles throughout the trunk and pelvis, even though the him to “squeeze the glutes and quads.” Now, cue
primary goal is to activate the hip external rotators and him to “bear down” as he simultaneously pulls his
elbows and feet toward the hips as hard as possible
abductors. Again, that is a good thing.
without any change in body position. The elbows
Finally, none of the exercises should cause pain. Move as and feet won’t move.
slowly as possible, or generate less tension in the muscles • Perform a 10-second hold with as much force as
at first if it reduces pain. You can always move faster and possible for three sets with 30 seconds of rest be-
generate more tension as the client becomes accustomed tween each set.
to the exercises.
How to modify it:
TRUNK AND PELVIS • If this version is too difficult, have your client rest his
Hard Style Plank or her knees on the floor. The body should be in a
straight line from neck to knees. You’ll cue the client
I learned about the hard style plank from strength train- to “pull the knees toward the hips” instead of “pull
ing expert and founder of StrongFirst, Pavel Tsatsouline. the feet toward the hips.”
This exercise is a challenging variation on the tradition-
al plank due to the high levels of muscle activation it Common mistakes:
requires.
• The pelvis lifts or lowers during the activation. Cue
the client to maintain a straight body position from
How to do it: neck to ankles.
• Your client starts by resting on the forearms and • The shoulder blades pull together. Instruct the
toes while keeping the body in a straight line from client to push through the elbows to keep the chest
neck to ankles (Figure 11.6A). as far from the ground as possible.
Figure 12.3. Hard style plank. From a standard plank position, the elbows and feet are pulled toward the hips as the glutes
and quadriceps are squeezed with maximum force.

192 | Unit 12
Modified Side Plank with Band

Technically, this exercise should be called the “modified
side plank with hip external rotation, hip abduction, and
lat activation.” This is an excellent exercise to strengthen
the obliques, quadratus lumborum, lats, and hip external
rotators/abductors.
How to do it:
• Your client starts by placing a mini resistance band
around the lower thighs, just above the knees. Then
he assumes the side lying position, propped up on
his right elbow with the knees bent to 90° and feet
together. The knees are slightly in front of, or in
line with, the trunk, whichever is most comfortable
(Figure 12.4A).
• Instruct the client to push down through his right
elbow and lift the hips while maintaining ground
contact with the right knee. His spine should be in
a straight line when viewed from the front (Figure
12.4B).
• Cue the client to make a double chin and then
instruct him to “bear down and stretch the band as
far as possible while the feet remain in contact with
each other.” The exercise begins when he pulls his
right elbow toward the hips to activate the right lat
(Figure 12.4C).
• Instruct him to maintain this position with as much
muscle activation as possible for 10 seconds.
• Have him switch to the opposite side and repeat
the drill. Perform three sets on each set, alternating
sides with each set. Rest 20 seconds between each
side.
How to modify it:

• If the lightest available band has too much tension,
perform the exercise without a band, but increase
the duration of the hold as long as possible.
Common mistakes:
• The spine laterally flexes. Cue the client to keep the
hips held high.
• The trunk and pelvis rotate posteriorly. Instruct the
Figure 12.4. Modified side plank with band. A) Starting
client to keep the trunk and pelvis facing straight
position. B) Modified side plank. C) Band stretch with lat
forward.
activation.
• After the client has performed the two aforemen-
tioned activation exercises, retest your client’s
mobility or have him repeat any exercise that was
problematic.
Corrective Exercise
HIPS/PELVIS
As previously mentioned, the muscles that are usually most underactive in the hips
are the external rotators and abductors. Weakness in those muscles is usually due to
a large emphasis placed on training the lower extremities in the sagittal plane, with
minimal activation in the frontal or transverse planes. Placing a mini resistance band
above the knees is a simple way to challenge the hip in the frontal and transverse
planes, even when the exercise is primarily in the sagittal plane (e.g., squat and lunge).
The cue to “bear down” is especially important in this section, as it activates the pelvic Pelvic floor: The muscular
floor musculature that increase stability within the pelvis. base of the abdomen that
attaches to the pelvis.
Low back and knee pain while exercising is a common problem. The following exer-
cises work well to activate muscles that are often linked to the source of discomfort.
Therefore, if the activation exercises for the trunk didn’t improve your client’s squat,
lunge, or deadlift technique or reduce low back pain or knee pain, you’ll perform the
following exercises.
You’ll start by challenging the hips and pelvis with dynamic, functional exercises
such as the lunge, squat, and deadlift using a mini resistance band. In many cases, the
following corrective actions will drastically reduce or eliminate low back or knee pain.
But if they don’t, we’ll regress to less demanding lower body exercises, albeit exercises
that will still give your clients a good workout. The goal is to find the most challenging
exercises that allow your client to move without pain.
Reverse Goblet Lunge with Band

The reverse lunge is an ideal single-leg exercise for people
with knee or low back pain because it puts less stress on
the knee joint than a forward lunge does. Holding a dumb-
bell or kettlebell in the goblet position allows the client to
maintain a more vertical trunk and encourages lat acti-
vation as the elbows are squeezed together, thus reducing
stress on the low back. Moreover, bearing down during the
exercise improves pelvic stability. Versions of this exercise
were popularized by the people at Functional Movement
Systems (FMS).
How to do it:
• Secure a resistance band to a stable structure that’s
the same height as your client’s knee joint is and
loop it around the knee that’s causing pain. Have
him hold a dumbbell or kettlebell in the goblet posi-
tion and instruct him to squeeze his elbows together
to activate the lats (Figure 12.5A).
• Instruct him to take a big step back with his free leg
and lower as far as possible into the lunge position
while maintaining a relatively vertical trunk and lat
tension (Figure 12.5B).
Figure 12.5. Reverse goblet lunge with band. A) Starting

position with a resistance band set at knee height. B) Ending
position when the client pulls the knee laterally against the
force of the band.

194 | Unit 12
How to modify it: Common problems:

• Perform the exercise while squeezing a ball be- • The feet roll excessively outward. Cue your client to
tween the elbows instead of holding a weight stretch the band while maintaining ground contact
(Figure 11.8). with the base of each big toe.
• Reduce the range of motion to the point where it’s • The knees buckle inward, or the client experiences
pain free and slowly increase the range over time. knee discomfort, during the concentric (i.e., ascend-
ing) phase. People are usually good at stretching the
band during the descending phase, but they often
Common mistakes: lack the motor control and mind-muscle connection
to do so during the ascending phase. Therefore,
• The front working leg buckles inward. Instruct him
instruct your client to pause briefly at the bottom of
to stretch the band as he lunges, especially during
the squat or deadlift and “stretch the band” or “pull
the positions where there is knee or low back pain.
the knees apart” as soon as he begins to ascend.
The knee joint of the working leg can move slightly
lateral to the foot if it reduces discomfort. • Using a resistance band or mini band during a
lunge, squat, or deadlift is a quick fix to many
• It’s common for people to lose tension on the band
problems you might encounter. In some instanc-
as they return to the starting position. Instruct the
es, however, it won’t be enough to get your client
client to move slowly and to stretch the band by
out of pain. If that’s the case, your next step is to
pulling the knee outward while returning to the
deconstruct the hip hinge pattern and make sure
starting position.
your client can do it correctly. These are the steps I
learned from Prof. Stuart McGill.
Squat or Deadlift with Mini Band
As a personal trainer, you already know the proper
technique for the squat and deadlift, and you gained even
more knowledge as we covered the steps for performing
a lower body movement analysis. Now you’ll learn how
to use a mini band for those exercises to activate the hip
external rotators and abductors.
How to do it:
• Have your client place a mini resistance band
around his lower thighs, just above the knees,
before performing any bilateral squat or deadlift
variation.
• Provide an external cue by instructing him to
“stretch the band” during the concentric and eccen-
tric phases of the squat or deadlift (Figure 12.6).
How to modify it:

• Perform the squat or deadlift movement pattern
while squeezing a ball between the elbows, instead
of holding a weight (Figure 11.8).
• Reduce the range of motion to the point where it’s
pain free and slowly increase the range over time. Figure 12.6. Squat or deadlift pattern with
mini band. In this photo, the client is stretching
the resistance band to activate the hip abductors
and external rotators during a body weight squat.
Importantly, the client is cued to stretch the band
during the eccentric (i.e., descending) and concentric
(i.e., ascending) phases. The band can be used with
any bilateral version of the squat or deadlift to reduce
stress on the knees and low back.
Corrective Exercise
Hip Hinge Posture

Teaching your client to perform the hip hinge correctly position to engage the hip abductors and external rotators,
is an essential aspect of movement because it’s required two commonly underactive muscle groups. Second, it
during numerous exercises and daily tasks. Doing the aligns the ribcage directly over the pelvis, which increases
hip hinge the way you’re about to learn will provide three intra-abdominal pressure. Third, it activates the muscu-
benefits. First, it places the hip joints in an advantageous lature throughout the posterior chain without placing
undue stress on the intervertebral discs.
How to do it: Common problems:

• Have your client place a resistance band around his • The client loses his neutral spine position. The lum-
lower thighs, just above the knees. Instruct him to bar spine should be neither flexed nor extended, so
stand tall with a “long spine,” feet slightly wider cue accordingly.
than shoulder width and pointed straight ahead.
• He feels discomfort in the low back or knees. This
The arms are held straight down with the palms
hip hinge posture places minimal stress on the
resting against the anterior thighs (Figure 12.7A).
spine and knees; therefore, your client shouldn’t
• Instruct him to push his hips back, allowing the feel any discomfort. But if he or she does, a few
knees to slightly flex, as he slides his hands down modifications are in order. First, have the client
the thighs until the weight of his upper body rests squeeze a ball between his elbows (Figure 11.9) to
through the palms. There should be minimal for- increase lat activation, which supports the lumbar
ward movement of the knees (Figure 12.7B). spine and helps activate the abdominals. Second,
adjust the hip, trunk, or knee position any way
• Have him push down through his palms, keeping
that’s necessary to achieve a pain-free hip hinge.
the arms held straight, to activate the lats (Figure
12.7C). If he struggles with this step, instruct him • Finding a hip hinge posture that suits your client is
to shrug his shoulders and then do the opposite a crucial component of this stage of the corrective
motion: anti-shrug to push the shoulders down. exercise process, because the following movements
are based on it. However, as we just covered, you
• Now tell him to flex his elbows and hold his hands at
can adjust from the ideal posture if it better suits
chest height, without losing his posture and lat acti-
your client. In some cases, your client might require
vation. Instruct him to keep his ribcage locked down
less of a hip hinge and anterior trunk shift to find a
over his pelvis and his chin tucked (Figure 12.7D).
comfortable starting position. Once you’ve found
the comfortable hip hinge posture, it’s time to ac-
tively engage the abductors and external rotators.
Figure 12.7. Hip Hinge Posture. A) Starting position with a band around the lower thighs. B) Hip hinge. C) Anti-shrug. D)
Hip hinge posture.

196 | Unit 12
Hip Hinge with Mini Band

This exercise is performed to help your client squat, lunge,
deadlift, and so on with better form. It accomplishes that
goal by engaging the hip abductors and external rotators
while fostering the maintenance of a proper arch in both
feet. The benefit is improved activation of crucial muscles
throughout the lower body and trunk that facilitate prop-
er muscle firing patterns.
How to do it:
• Have your client place a resistance band around his
lower thighs, just above the knees. Instruct him to
perform a hip hinge using the cues we just covered
(Figure 12.8A).
• Cue him to make a double chin, bear down, and
then stretch the band as far as possible while main-
taining contact with the base of each big toe for
10 seconds (Figure 12.8B). Have the client squeeze
a ball between his elbows during the exercise if it
improves his technique.
• Perform three sets of the hip hinge band stretch,
resting 20 seconds between each set.
• The goal is to achieve a 30-second hold, without
any discomfort in the low back or knees, before pro-
gressing to the lateral step that’s covered next.
Common problems:
• The feet roll excessively outward. Cue the client to
focus more on stretching the band while maintain-
ing ground contact with the big toes.
• The knees don’t spread an equal distance. When
you see one knee that’s more medial than the other
is, cue the client to increase the stretch on that side
of the band.
Figure 12.8. Hip hinge with mini band. A) Begin exer-

cise from hip hinge position. B) Stretch the band and shift
weight to the outside of the feet while keeping the base of
each big toe on the floor.
Corrective Exercise
Standing Fire Hydrant With Mini Band

Once your client is able to perform the hip hinge with How to do it:
a band, it’s time to progress to a single-leg exercise.
The standing fire hydrant is an excellent exercise that • Have your client place a resistance band around
strengthens the glutes through their three primary func- her lower thighs, just above the knees, and stand
approximately 18” in front of a wall.
tions: abduction, external rotation, and extension of the
hip. The keys here are to ensure the elevated leg is held • Instruct her to hinge at the hips and place her
at end range of motion, and the knee of the stance leg is fingertips lightly against a wall for balance. Then,
actively pulled in the lateral direction. This is an import- have her lift the right leg out to the side, back, and
ant exercise to master because single-leg stance stability is externally rotated until the end-range of motion for
the right hip is achieved. There should be minimal
essential for sport and life.
trunk rotation.
• Instruct her to actively pull the left knee laterally
(i.e., outward) to active the left glutes (Figure 12.9).
• Perform 2 sets of the standing fire hydrant, resting
30 seconds between each leg.
• The goal is to achieve a 60-second hold with a green
mini band, without any discomfort in the low back
or knees, before progressing to the next exercise,
the lateral step.
Common problems:
• The trunk rotates excessively toward the elevated
leg. A small amount of trunk rotation is normal;
however, there shouldn’t be any strain felt in the
lower back region. All muscle activation should be
felt in the glutes.
• The knee of the stance leg isn’t being pulled in a lat-
eral direction. When the client is in a left leg stance,
cue him or her to “pull your left leg outward while
maintaining ground contact with your big toe.”
Additional points:
• For athletes that rely heavily on single-leg stance
stability (e.g., hockey, soccer, basketball players), I
prefer to have them work up to a 60-second hold
without any balance support from a wall.
• Quadriceps strength is an important aspect of
athleticism. The standing fire hydrant is an excellent
way to increase quadriceps strength when your
client lacks it. Instruct the client to squat into deeper
knee flexion on the stance leg, without the knee
traveling past his or her toes.
• An excellent strategy for anyone that needs to take
single-leg stability to the highest level is to have the
client squeeze a ball between the elbows to activate
the lats.
Figure 12.9. Standing fire hydrant with mini band.
Female demonstrating the standing fire hydrant with mini
band using a left leg stance. The right leg is held in hip
abduction, external rotation, and extension at the end range
of motion. The left knee is pulled lateral to engage the left
glutes (blue arrow). To give a greater emphasis to the quadri-
ceps, instruct the client to achieve greater knee flexion in the
stance leg. International Sports Sciences Association
198 | Unit 12
Lateral Step with Mini Band

Once the client can hold the hip hinge with mini band place to start because hip hinge position gives the hip
for 30 seconds without discomfort, it is time to progress abductors and external rotators an effective line of pull
to a more dynamic movement. The lateral step is a good (i.e., mechanical advantage).
How to do it:
• Have your client place a resistance band around his • Perform three sets of the 3-1 rep sequence, with 30
lower thighs, just above the knees. Instruct him to seconds’ rest between each set.
perform a hip hinge (Figure 12.10A).
• The goal is to work up to a 5-1 rep sequence for all three
• Cue him to make a double chin, bear down, and sets with a band you feel is appropriate for the client.
then take a small step to the right, landing with a
flat foot. The left knee should remain directly over
the left foot as he steps to the right (Figure 12.10B). Common problems:
• Next, instruct him to take a small step to the right • The trailing leg buckles inward. For example, when the
with the left leg, thus returning his stance width client steps his right leg to the right, it’s common for the
to the starting position (Figure 12.10A). The feet left knee to buckle inward. Cue him to “pull your left
should not be narrower than shoulder width. knee to the left as you step to the right.”
• Instruct him to take three steps to the right • Both knees buckle inward (Figure 12.10C). This usually
followed immediately by three steps to the left. occurs when the resistance of the band is too high for
Without resting, have him take two steps to the the client.
right and two to the left. He’ll finish with one step
• The client’s weight shifts to the front of the feet. Cue the
in each direction. Have the client squeeze a ball
client to “push through and land with your heel.”
between his elbows during the exercise if doing so
improves his technique. • The client loses his chin tuck or spinal alignment while
stepping. If spinal alignment is lost, cue him again to
bear down while he’s stepping.
Figure 12.10. Lateral step with mini band. A) Start with hip hinge posture. B) Step the right leg to the right while keeping
the knees over the ankles. C) Client demonstrates valgus in both knees indicating incorrect form while stepping laterally. Both
knees should always remain directly over or slightly outside of the feet.
Corrective Exercise
Monster Walk
When the client demonstrates proper technique with the lateral step, you can progress to the monster walk. Most peo-
ple feel an intense glute contraction during this exercise, especially while stepping backward. The key is to take small
forward steps and land with a flat foot.
How to do it:
• Have your client place a resistance band around his lower
thighs, just above the knees. Instruct him to perform a
hip hinge (Figure 12.11A).
• Cue him to make a double chin, bear down, and then
take a small step forward with the right foot, landing
with a flat foot. The left knee should not pull inward as he
steps forward (Figure 12.11B).
• Next, instruct him to keep walking forward until he
takes three steps with each foot. Without resting, have
him take three steps backward with each foot, followed
by two steps forward and backward with each foot and
finishing with one step with each foot forward and back-
ward. Have the client squeeze a ball between his elbows
during the exercise if doing so improves his technique.
• Perform three sets of the 3-1 rep sequence, with 30 sec-
onds’ rest between each set.
• The goal is to work up to a 5-1 rep sequence for all three
sets with a band you feel is appropriate for the client.
Common problems:
• The steps are too long. Instruct the client to take the
smallest steps possible.
• The weight shifts forward onto the toes. Cue the client
to “keep your weight on your heels and land with a flat
foot.”
• Now you have various lower body exercise options to
improve your client’s mobility and reduce or eliminate
knee or low back pain.
Figure 12.11. Monster walk. A) Begin exercise from hip

hinge position. B) Take a small step forward with the right leg
and stretch the band wide when each foot is flat on the ground.
Then step forward with the left leg and continue moving for-
ward. This exercise is performed forward and backward.

200 | Unit 12
FEET How to do it:

The alignment of your feet can have a far-reaching impact • Have your client stand barefoot, or with socks,
up through your body. For optimal movement mechanics, and instruct him to roll his feet outward as far as
the feet should be in a neutral position, meaning your possible while maintaining contact with the base of
the big toe. You’ll do this for either one foot or both
client doesn’t roll onto the outside (i.e., supination) or
feet, depending on what you saw. Place the end of
inside (i.e., pronation) of the feet during a lunge, squat, or
a marker or pen lightly against the arch of the foot/
deadlift. However, the most common problem you’ll see is feet (Figure 12.13).
pronation of the feet, commonly referred to as eversion or
a fallen arch. Importantly, excessive pronation of the feet • Explain to your client that the marker/pen provides
tactile feedback so he can feel when his arch starts
and knee pain are closely linked.
to collapse. Cue him to maintain minimal pressure
on the marker while performing a lunge, squat, or
Posterior Tibialis Activation deadlift (Figures 12.13A/B)
Now you have multiple options to help your client per-
In many cases, placing a mini band around your client’s
form lower body exercises. Remember, virtually any of the
thighs while he or she is performing a squat or deadlift
lower body correctives can be performed while the client
will realign pronated feet, but sometimes it’s not enough,
is squeezing a ball between the elbows to activate the lats,
and direct interventions are required. That’s when a pen
thus supporting the lumbar spine. Now, let’s move on to
or marker becomes handy. Your client will place his or
the upper body.
her feet, or foot, in proper alignment using the informa-
tion we’re about to cover, and then you’ll place the tip
of a marker or pen against the client’s arch. The marker
provides tactile feedback against the shoeless feet, and the
client will feel whether his or her foot collapses into it.
This keeps the posterior tibialis, the primary muscle that
provides arch support, activated. The posterior tibialis ac-
tivation exercise is for anyone unable to maintain a proper
arch during a lunge, squat, or deadlift. It’s also for anyone
who experiences knee pain during lower body exercises,
assuming the aforementioned interventions didn’t work.
Figure 12.13. Posterior tibialis activation for bilat-

eral and single leg exercises. A) The markers are used
to provide tactile feedback during bilateral lower extremity
exercises such as the squat and deadlift. B) A single pen is
used during a lunge to activate the posterior tibialis.
Figure 12.12.
Posterior tibialis
activation. The client
rolls his foot outward
as far as possible while
maintaining ground
contact with the base
of the big toe. The tip
of a marker is placed
lightly against the arch
as tactile feedback to
promote activation of
the posterior tibialis.
Corrective Exercise
SHOULDER COMPLEX
Earlier in this unit, you learned that the external rotators of the glenohumeral joint,
along with the serratus anterior, middle/lower trapezius, and rhomboids of the scapu-
lothoracic region, are typically underactive or inhibited. The following exercises will
activate some or all of those muscles at the same time, depending on which exercise
your client performs.
Recall from Unit 10 that the scapulothoracic region is one of the most challenging for
the nervous system to control and that muscle inhibition is common, both leading to
many dysfunctions throughout the entire shoulder. Indeed, research demonstrates that
weakness around the scapula can impair capsular structures in the anterior shoulder,
increase stress on the rotator cuff, and decrease neuromuscular performance within the
shoulder complex.
That’s why shoulder pain and dysfunction are so common. Many people struggle
while pressing weights overhead or doing a bench press or performing a lateral raise
without pain. Furthermore, problems in the neck and shoulder are commonly linked,
thus making a corrective exercise strategy even more challenging.
Each of those challenges is addressed in this section. However, it’s worth noting here
that the shoulder region often requires the soft tissue interventions we’ll cover in Unit 13
before a person is able to do an upper body exercise with pain-free mobility. That’s be-
cause poor posture can create so much stiffness throughout the neck and shoulders that
activation exercises alone sometimes aren’t enough: but they’re the best place to start.
It’s assumed at this point that you know which of your client’s upper body exercises are
causing shoulder pain. Your client will perform that exercise and rate the discomfort
on a scale of 1–10 as you note any movement compensations you saw. Then your client
will perform the following activation exercises, and he or she will retest the problematic
exercise after each one. When you find a corrective exercise that benefits your client,
perform as many sets as necessary until the improvement plateaus. At that point, move
to the next corrective exercise and continue the process.
Postural Stability Hold (PSH) with

Head Movement
The first corrective exercise will be familiar to you because it stems from the pos-
tural stability hold (PSH) that was covered in Unit 11. The nerves that control all the
muscles within shoulders and upper extremities exit through the cervical spine. Thus
when the neck muscles are overly stiff, they can compress and trap nerves, causing
neural tension, pain, and dysfunction out to the shoulders and arms. Therefore, the Neural tension: The inability
first step for correcting a problematic upper body exercise starts by freeing up the of a nerve to move freely, which
cervical spine muscles so the signals from the nerves can travel freely to the muscles of often causes pain.
the shoulders and arms.

202 | Unit 12
Figure 12.14. PSH with head movement. A) Client rotates his head to the right. B) Client rotates his head to the left.
C) Client performs right lateral flexion of the neck. D) Client performs left lateral flexion of the neck. The client increases the
amount of squeeze on the ball, and stretch of the band, at whichever positions the neck feels stiffest.
How to do it:
• Have your client start with the PSH that was covered Additional points:
in step 5 of Unit 11. Instruct him to make a double
• The goal with this exercise is to increase your client’s
chin, which activates the deep neck flexors and
mobility within the cervical region. It might take
opens space between the cervical vertebrae.
weeks or months before a normal range of motion
• Then have him slowly rotate his head side to side, as is restored. However, as long as your client is able
far as possible in each direction (Figures 12.14A/B). to increase his or her range closer to 80° of rotation,
When he finds a head position where he feels and 45° of lateral flexion, his or her upper-body
restricted in the neck, cue him to “squeeze the ball exercises will likely be improved. Nevertheless, it’s
and stretch the band a little harder” to increase important to retest the problematic exercise after
activation of the postural stability muscles. The goal this drill to determine whether it’s helping.
is to achieve the normal head rotation range of mo-
• Your client should not experience any pain during
tion of approximately 80° to each side without pain
this exercise. If client does feel any sharp, nervy pain
or, at the very least, to increase the rotation range
in the neck, terminate the exercise and refer to a
of motion enough to make an improvement in his
health-care professional.
upper body exercises. Perform five slow rotations to
each side. • Cue the client to move slowly and to exhale when
the neck is in a restricted position to calm the ner-
• Next, have him perform a slow lateral tilt of the
vous system.
head side to side while maintaining a double chin
(Figures 12.14C/D). Again, have him increase the
amount of squeeze on the ball, and stretch of the
band, at any positions he feels restricted in his neck.
The normal range of motion for lateral flexion of the
cervical spine is 45°, so your goal is to get as close to
that as possible. Perform five slow reps to each side.
Corrective Exercise
Wall Elbow Walk with Band

This is an effective exercise to activate the external rota- • Next, instruct him to slowly walk his elbows up the
tors (i.e., teres minor and infraspinatus) while increasing wall, alternating between the right and left, a few
intra-abdominal pressure and improving ribcage align- inches at a time (Figure 12.15C). Then have him walk
ment. The key with this exercise is for your client to keep his elbows down the wall to the starting position
and repeat once more. He should feel this exercise
his ribcage pulled down and be cognizant of the appropri-
in the posterior shoulder region.
ate distance he should walk his elbows up the wall.
• The goal is for him to be able to walk his forearms
up the wall until the elbows are the same height
How to do it: as the forehead. However, many people won’t be
able to reach that range of motion at first, without
• Have your client wrap a single resistance band
elevating the ribcage. Therefore, have him walk his
around the back of his hands, holding the free ends
elbows up only as far as he can maintain the down-
between the thumb and index finger. While stand-
ward ribcage position.
ing, have him place his forearms and elbows against
the wall, with the elbows the same height and • Perform three sets with 30–60 seconds rest be-
width as the shoulders and forearms perpendicular tween each set.
to the floor (Figure 12.15A).
• Again, have your client retest the problematic upper
• Cue him to “bear down” or “pull the ribcage down body exercise and rate the discomfort on a scale of
and in” to correctly position the ribcage over the 1–10, noting any compensations you see, to deter-
pelvis and increase intra-abdominal pressure. Then, mine whether this is an exercise he or she needs. If
instruct him to externally rotate the shoulders it helped, you can always have the client perform
slightly, while maintaining the elbow position (Fig- an additional set and assess whether it helped even
ure 12.15B). This will increase the distance between more. If not, move on to plank roll.
his hands an inch or two and increase band tension.
Figure 12.15. Wall elbow walk with band. A) The client demonstrates an elevated ribcage at the starting position. B) The
client pulls the ribcage down to increase intra- abdominal pressure and reposition the ribcage, while performing slight external
rotation of the shoulders to stretch the band. C) The exercise is performed by slowly walking the elbows up and down the wall,
a few inches at a time. It’s important to avoid elevating the ribcage and extending the lumbar spine, as shown in the photo.

204 | Unit 12
Plank Roll • Instruct him to slowly rotate back to the starting

position, again moving the pelvis and trunk as one
The purpose of this exercise is to activate the serratus unit. Next, instruct him to rotate to the opposite
anterior and improve eccentric control of the scapular side, using the same cues while pushing through
region, which when lacking can cause scapular winging. the left elbow. He should feel it in the posterior
shoulder region and core muscles.
This exercise is also effective for developing trunk stability
because the core and hips are engaged during the roll. • Perform three slow rotations to each side, resting 30
seconds between each set.
How to modify it:

• If this version is too difficult, have your client rest his
or her knees on the ground throughout the move-
ment. At the starting position, and throughout the
roll, the body should form a straight line between
the neck and knees.
Common mistakes:
• The hips/pelvis move before the trunk during the
roll. This occurs when the client doesn’t bear down
correctly. Have the client focus on the chest and
pelvis rotating at the same time.
• The client doesn’t push down through his elbow
during the roll or at the end of the movement. You’ll
see his shoulder shrug on the side of the elbow
that’s down. Cue him to “push your trunk away
from the floor during the rotation.”
Downward Dog
The downward dog is a hugely popular exercise within
yoga and physical therapy. Former head athletic trainer to
Figure 12.16. Plank roll. A) In the starting position, the
the Los Angeles Dodgers, Sue Falsone, PT, considers the
client squeezes the glutes and pushes down through his
elbows to activate the serratus anterior, while maintaining a downward dog a favorite among the athletic populations.
double chin. B) During the roll, the hips and trunk move as It’s an excellent exercise to improve stability and mobility
one interconnected unit. throughout the shoulders and posterior chain.
How to do it:
• Have your client rest on his elbows, directly under
his shoulders, and on his toes while maintaining
a straight line from neck to ankles. Instruct him to
make a double chin and squeeze his glutes while
pushing down through his elbows. There should
be no valley between the shoulder blades (Figure
12.16A).
• Instruct him to bear down and then have him rotate
his trunk to the left, moving the pelvic region and
trunk as one interconnected unit. Cue him to “push
down through the right elbow” as he rotates until
his chest faces straight forward. There should be a
perpendicular line, relative to the ground, between
the elbows (Figure 12.16B).
Figure 12.17. Downward dog. The client pushes through

the palms to move the chest as close to the thighs as
possible.
Corrective Exercise
How to do it:
• Have your client place his hands on the ground with
the hips held high. The hands should be slightly
wider than shoulder width or any similar position
that feels comfortable to the shoulders. The legs are
held straight with the heels as close to the ground
as possible. Instruct him to make a double chin
(Figure 12.17).
• Cue him to “push through your palms to move your
chest as close to your thighs as possible.” Hold the
end position for 3–5 seconds while maintaining
slow, controlled breathing through the abdominals
and a double chin.
• Return to the starting position for a few seconds,
which should be relatively close to the end position,
and have him push again through his palms to move
the chest toward the thighs, and hold for another
3–5 seconds. Repeat the sequence once more to
complete the set.
• Perform three sets with 30–45 seconds rest be-
tween each set.
How to modify it:

• If this version is too difficult, have your client per- Figure 12.18. Y raise on a Swiss Ball. A) The client starts
with the hands just above the floor, with the arms held at ten
form the same steps with the elbows resting on the
and two o’clock, and the chin tucked. B) Lift the arms until
ground instead of the hands.
they’re parallel to the floor or stop before the shoulders shrug.
Common mistakes:
• The client does not maintain a double chin. Be sure • Instruct him to make a double chin and then cue
to cue accordingly. him to “pull your shoulder blades down toward
your hips to lift the arms.” The arms continue up-
• The client holds his or her breath. Instruct the client ward until they’re parallel to the floor, and then in-
to maintain a breathing pattern as slow and relaxed struct him to hold the top position for two seconds
as possible. (Figure 12.18B).
• Have him return slowly to the starting position, and
Y Raise on a Swiss Ball repeat for 8–10 reps.
• Perform three sets with 45 seconds rest between
As a personal trainer, you have likely seen versions of
each set.
the Y raise, as it’s a popular way to activate the lower and
middle trapezius muscles. The version I prefer is with the
client lying chest down on a Swiss Ball so he or she can’t Common mistakes:
compensate by extending the lumbar or thoracic spine.
• The client does not maintain a double chin. Be sure
to cue accordingly.
How to do it: • The shoulders shrug, especially when the arms are
in the highest position. Cue him to “pull from your
• Have your client grab two very light dumbbells and
shoulder blades” or shorten the range of motion on
lie chest down on a Swiss ball that’s large enough
the way up if necessary.
to cover his entire anterior trunk. His arms are held
straight at the ten and two o’clock position with the • The elbows flex during the movement. Instruct him
hands just above the floor and palms facing each to keep his elbows locked straight, or hyperextend-
other (Figure 12.18A). ed during the exercise.

206 | Unit 12
BEFORE MOVING ON Additional points:

At this point, we’ve covered five different exercises that • When the right arm reach and head turn are per-
activate crucial muscles throughout the shoulders and formed correctly, the left shoulder will remain in the
trunk. You’ve retested the problematic upper body exer- same position that’s shown in Figure 12.19B.
cise after each corrective to determine whether it helped • The legs should remain relaxed throughout the
your client. If the corrective exercises didn’t solve your exercise.
clients’ problems, you’ll have them perform the follow-
ing two exercises. Even though the following correctives
won’t do much to get your clients into better shape, these
correctives are still effective for activating the muscles
that might help your client return to more challenging
workouts in the near future.
SPHINX WITH REACH

I learned this exercise from Dr. Mark Cheng, an inter-
nationally recognized corrective exercise specialist and
speaker who is based in Los Angeles. The sphinx drill
is especially helpful for people with problems caused by
poor activation of the serratus anterior and rotator cuff.
How to do it and common errors:

• Have your client lie prone while propped up on the
elbows. The elbows are directly below the shoul-
ders, palms flat on the floor. Instruct him to pull his
shoulder blades together (Figure 12.19A).
• Cue him to “push down through your elbows to
elevate your chest as high as possible while making
a double chin” to activate the serratus anterior mus-
cles and deep neck flexors (Figure 12.19B).
• Next, instruct him to slowly reach his right arm to
the right side, until it’s approximately parallel to the
floor, while pushing down through the left elbow.
The left shoulder should not shrug, but it commonly
does (Figure 12.19C).
• Then instruct him to slowly rotate his head to the
right as far as possible while maintaining a double
chin. At this point, it’s common for the left shoulder
to shrug even farther due to poor activation of the
left serratus anterior (Figure 12.19D). If his shoulder
shrugs, cue him to “push your chest away from the
floor through your left elbow” or to “push down
harder through your left elbow.”
• Slowly return the right elbow to the floor while Figure 12.19. Sphinx with reach. A) To start, the client’s
maintaining activation of the serratus anterior elbows are directly below his shoulders and the palms are
(Figure 12.19B). Then instruct your client to sink into flat on the ground. B) The client pushes through the elbows,
the starting position by pulling his shoulder blades elevating the chest as high as possible, to activate the ser-
together (Figure 12.19A). ratus anterior muscles. As he reaches to the right, his left
shoulder starts to shrug, indicating poor technique. The cli-
• Finally, perform the same push off, reach, and head ent continues to lose the elevation of his chest, indicated by
turn with the left arm reaching to the left side. a left shoulder shrug, showing poor activation of the serratus
anterior. When done correctly, the left shoulder position
• Perform three slow reaches to each side and then
shown in photo B will be the same in photos C and D.
retest the problematic upper body exercise.
Corrective Exercise
SCAPULAR ACTIVATION • Then cue him to “pull your right shoulder blade
back and down as far as possible while keeping your
This exercise, popularized by Dr. Andreo Spina, a correc- right arm held straight.” Perform five slow reps with
tive specialist, is an effective way to increase activation each arm, focusing on muscle activation at the end
of the scapular retractors at the end range of motion. It’s range of motion, where the scapula is pulled back
and down.
common for people to lose the ability to fully retract the
scapulae; therefore, restoring that ability increases motor • Retest the problematic upper body exercise.
control of the scapulothoracic region.
Common mistakes:
How to do it:
• The shoulder shrugs when the arm is pulled from
• Have your client stand with his feet shoulder width out in front, parallel to the ground. Cue your client
apart, holding the right arm straight in front, par- to “maintain as much space as possible between
allel to the ground. Instruct him to make a double your ear and top of shoulder.” However, instructing
chin, and then reach his right arm in front as far as your client to “avoid shrugging your shoulder” is
possible, to fully protract the right scapula (Figure often sufficient.
12.20A). • The client doesn’t achieve his full range of scapu-
• Cue him to “pull your scapula back as far as possible lar motion. It’s important to instruct your client to
while keeping your right arm straight” to activate move slowly and focus on maximal activation at the
the scapular retractors (Figure 12.20B). Perform end range to regain motor control.
five slow reps, with each arm, focusing on muscle
activation at the end range of motion.
• Next, have him hold his right arm at an upward an-
gle, approximately 60° relative to the ground or any
similar position in which there’s no shoulder pain
(Figure 12.20C).
Figure 12.20. Scapular activation. A) The right arm is held straight in front, parallel to the ground with the scapula fully
protracted. B) The client pulls the scapula into full retraction to activate the rhomboids and middle trapezius. C) The right arm
is held straight at an upward angle, where the scapula is protracted and upwardly rotated, mimicking a position that causes him
shoulder discomfort. D) He retracts and downwardly rotates the scapula, pulling from the scapula, to activate the rhomboids,
middle trapezius, and downward rotators.

208 | Unit 12
HOW TO USE THIS INFORMATION

The corrective exercises we just covered are placed in a based on them. That way, you’ll get your clients into shape
specific order based on my experience with a wide array of while correcting their imbalances.
clients. What’s important, however, is that you retest the
problematic exercise after each corrective to determine
whether it helped your client move better or with less CREATE A CUSTOMIZED
pain. With that in mind, here are three additional ways
you can use the correctives.
WARM-UP
In many cases, just one of the correctives in this unit will
immediately eliminate a nagging joint pain or improve
MAKE A HOME EXERCISE your client’s range of motion so that he or she can per-
form a normal workout routine without restriction. For
PROGRAM example, the monster walk and modified side plank with
When you discover the correctives that improved your a mini band are two of the most popular and effective
client’s movement, print out the corresponding sheet or warm-up drills for my clients. Choose the best correc-
record video of your client doing the exercise while you tive exercises for your clients and make them part of the
give instructions on his or her smartphone. Have your clients’ warm-up before every workout until the problem
client perform the corrective exercises once or twice each is completely eliminated.
day until you see him or her again. Remember, permanent
changes to tissues and movement take weeks or months to
occur; however, the more often clients practice the exer- FINAL WORDS
cise, the faster they will improve. We covered a great of material in this unit and an array of
exercises that might be new to you. As a personal train-
CREATE A JOINT FRIENDLY er, it’s essential that you know how to do each corrective
exercise correctly. Therefore, practice any unfamiliar
WORKOUT correctives on your own so you will learn to coach them
more effectively.
Because most of the correctives in this unit are challeng-
ing and engage many muscle groups, they work well as In the next unit, we’ll take a closer look at each joint to de-
stand-alone exercises. Mix and match the exercises that termine which soft tissue structural limitations might be
worked best for your client and design an entire workout causing a problem that activation drills alone can’t fix.
Summary
1. It’s often difficult to decipher relevant information 5. Corrective exercises that mimic functional multi-joint
from common assessments due to the interconnect- exercises allow your clients to get into shape while
edness of the human body. restoring stability and mobility.
2. Stretching, foam rolling, and other soft tissue in- 6. Retest the problematic exercise after each corrective
terventions are important after an injury when the to determine whether it reduced your client’s pain
tissues need to reform in proper alignment. How- and/or improved movement. If it did, have the client
ever, in many cases, activation drills will improve a perform the corrective once or twice each day with
person’s mobility. the recommended parameters.
3. An appropriate balance between mobility and 7. Instructing the client to move slowly and maintain
stability is necessary for optimal movement and diaphragmatic breathing during corrective exercise is
performance. a crucial component of motor learning.
4. Proximal stability creates distal mobility. Therefore, 8. When appropriate, use the corrective exercises in this
it’s recommended that activation drills first target unit to create a home exercise program, a stand-
muscles that support the spine and pelvic region. alone workout, or a warm-up.
Corrective Exercise
Sometimes Movement Isn’t Enough

Postural Assessment/Correction
Neck Correctives
Upper Body Correctives
Lower Body
Lower Body Correctives
Correctives for Anterior Hip Mobility
Final Thoughts
UNIT 13
SOFT TISSUE ASSESSMENTS

AND CORRECTIVES
210 | Unit 13
What You’ll Learn

In this final unit, you’ll learn how to assess and correct many of the most common dysfunctions you’ll see
while working with athletes and non-athletes alike. We’ll start with a postural assessment, which will cover
the problems people typically have while standing or sitting and how to correct them. Then we will contin-
ue through the unit as you learn how to assess and correct the neck, shoulders, pelvis, and feet. By the end
of this unit, you should have a clear understanding of numerous evidence-based ways to correct many soft
tissue limitations that are holding your clients back from optimal, pain-free performance.
SOMETIMES MOVEMENT ISN’T ENOUGH

Throughout Section Two of this course, a large emphasis it can reform in the correct alignment. That new alignment
has been put on increasing your client’s motor control, is achieved by stretching a muscle to its end range, and
stability, and mobility with various exercises. The purpose holding it there, for at least a few minutes each day.
was to teach your client to voluntarily activate muscle
We’ve covered ways to improve a person’s movement and
groups that improve exercise technique and posture. That
then kept him or her moving with challenging corrective
approach, in most cases, will be sufficient to help clients
exercises covered in Unit 12. Now it’s time to look at how
move better. Therefore, most of what you’ll need to know,
poor posture can cause changes that require soft tissue
and what you’ll probably use most frequently with clients,
interventions. This is the lowest level of the top down
has already been covered.
approach, but within a few sessions, the interventions we’ll
However, there are people who can’t properly perform cover here should get your client back to the high-level
the interventions we covered in Units 8–12 due to soft functional exercises he or she needs to get into better shape.
tissue limitations. For example, if a person lacks normal
dorsiflexion, he or she won’t be able to correctly perform
a squat no matter how hard that person tries. Or a man POSTURAL ASSESSMENT/
might have excessively stiff pectorals, lats, or t-spine, lim-
iting his ability to perform an overhead press correctly. CORRECTION
Furthermore, many people have spent years accumulat- An essential component of corrective exercise is teach-
ing bouts of poor posture and lousy exercise technique, ing your clients how to maintain proper posture. The
causing stiffness within their soft tissues. Their muscles way they stand, walk, and sit have a significant impact
and tendons, along with the fascia and joint capsules, have on which muscles become stiff or weak and inhibited.
shortened and stiffened due to structural changes. Therefore, the more your clients know about their postur-
al compensations, and how to simply correct them, the
Recall from Unit 12 that increasing your client’s straight less time you’ll need to spend doing corrective exercises
leg raise performance was enhanced by activating the during their workouts. It’s important to mention here that
gluteus medius, which in turn decreased tension in the IT when you find a postural corrective that helps your client,
band. Nevertheless, the activation drill alone might not be or when your client clearly needs it, explain the impor-
sufficient if the hamstrings have also stiffened due to tissue tance of maintaining posture during all the of hours when
changes. In this case, and many other instances, soft tissue you aren’t working with him or her.
interventions are required to break down the soft tissue so
Corrective Exercise
Soft Tissue Assessments and Correctives | 211
SAGITTAL PLANE How to do it:

We’ll start by covering the ways to analyze your client’s • First, do not tell your client that you’re going to
standing posture from the sagittal plane view because it assess his posture, because he’ll inevitably improve
often identifies many compensations. Then we’ll look at it before you determine what’s wrong. Have your
client stand barefoot, with his feet together, and as
the frontal plane view to gather additional information.
relaxed as possible. Don’t give any other cues. Ask for
permission to take his photo on your smartphone. A
man should wear shorts, and a woman should wear
shorts and a sports bra, if possible.
• Next, take a photo of your client from the sagit-
tal plane view. Use an app to draw a vertical line,
perfectly perpendicular to the floor, that starts at
his lateral malleolus and continues to his ear. Draw a
mark at the center of his knee joint, middle deltoid,
and ear (Figure 13.1A).
• Show the figure to your client and explain to him that
the three marks should fall within the vertical line.
• Then, place a small piece of tape in the middle of
his knee joint, and medial deltoid, at the positions
shown in Figure 13.1A. A piece of tape on the ear isn’t
necessary because it’s easy to visualize. Perform the
postural analysis a second time, cueing him accord-
ingly, so the center of the knee joint, middle deltoid,
and ear fall within an imaginary vertical line.
• Take a second photo, as it’s difficult to accurately
visualize whether the landmarks are perfectly in line,
and draw a vertical line again (Figure 13.1B).
• Once you’ve cued the client into the correct posture,
instruct him to hold it for a minute while perform-
ing slow diaphragmatic breathing. Instruct your
client to try to maintain this posture. Explain to your
client that he or she should perform this same drill
throughout the day until the posture feels normal
and becomes automatic.
Figure 13.1. Postural assessment from the sagittal Additional points:

plane view. A) The client demonstrates common compen-
sations, including flexed knees due to quad dominance, • During the postural assessment, the common rec-
anteriorly rotated shoulders due to stiff pectorals, and a ommendation when viewing the head and shoulder
forward head position due to inhibited deep neck flexors. B) position is to look for the ear to be vertically aligned
The client demonstrates better posture, although, he should over the center of the deltoid. But given that ap-
be cued to pull his shoulder blades closer together so the proach, a person with anteriorly rotated shoulders
middle of the deltoid, indicated by the dot, falls within the and a forward-head position would be “properly
vertical line. aligned” (Figure 13.1A). Since that approach isn’t ide-
al, a vertical line is drawn from the lateral malleolus
to give a more accurate reference point.

212 | Unit 13
FRONTAL PLANE How to do it:

Now we’ll cover the ways to analyze your client’s pos- • Have your client stand barefoot with his feet about
ture from the frontal plane view. Even though you’ll an inch apart, and relaxed as possible. Again, ask for
typically see fewer compensations from this plane, it’s permission to take a photo for an assessment. A man
should wear shorts, and a woman should wear shorts
still important to assess. Often, a client won’t realize he
and a sports bra to expose the navel region.
or she holds one shoulder higher than the other, or has
pronation in one foot, until a static postural assessment is • Using an app, draw a vertical line that’s perfectly
performed. You’ll add the information in this step to what perpendicular to the floor, from between the heels,
you learned from the sagittal plane view. For example, through the navel, to the top of his head. Draw a
second line, parallel to the floor, that intersects it at
your client might need to be cued to lower his or her right
the upper sternum (Figure 13.2).
shoulder to achieve ideal posture.
• Use the vertical line to identify an asymmetry be-
tween the right and left sides, such as a rotated or
tilted head, or a rotated trunk. Use the horizontal line
to identify if one shoulder is elevated or depressed. In
addition, look for asymmetry between the feet, such
as pronation in one or both.
• If you see any asymmetry, use relevant cues to place
your client in proper alignment. Use the pen cue you
learned in Unit 12 for correcting the feet. Add these
cues to what you learned from the sagittal plane view.
Additional points:
• Reference dots aren’t required for the frontal plane
assessment because the navel serves as the refer-
ence point. Once the lines are drawn, it’s easy to
see any asymmetry throughout the head, shoulders,
and trunk.
MORE ABOUT POSTURE

It’s worth mentioning here that making permanent
changes to your client’s posture is one of the most difficult
things to do because it requires a great deal of practice
until the brain identifies the correct posture as nor-
mal. Therefore, explain to your client the importance of
practicing the correct posture as frequently as possible,
especially during long periods of sitting.
During the early stages of postural retraining, it’s easy for
your clients to forget the posture you taught them once
they have left the gym. You have a few options. First, you
could cue your clients into the correct posture, using the
video on their smartphones. That way they can watch
it and recreate the posture on their own. Or, at the very
least, instruct them to stand tall with their backs against
Figure 13.2. Postural assessment from the frontal

plane view. Two perpendicular lines are drawn to as-
sess symmetry between the right and left side of the body.
Common compensations include an elevated or depressed
shoulder, a tilted head, and/or pronation in one or both feet.
The client demonstrates good postural symmetry from head
to feet.
Figure 13.3. Correct pos-

ture while using a smart-
phone or computer. The
client demonstrates a neutral
head position, relaxed shoul-
ders, and an erect stance while
working on a smartphone.
B) Teach your clients to work
on a computer with proper
posture, which consists of hips
being a few inches higher than
the knees, shoulders relaxed,
armrest at elbow height, and
screen at eye level.
the wall a few times each day. The back of the head, posterior shoulders, glutes, and
calves should touch the wall.
Sometimes a client will have too much stiffness to achieve a posture that allows all the
landmarks to fall within a vertical line. This is especially true of the shoulders and cer-
vical regions. Therefore, the soft tissue interventions covered later might be required
before your client can achieve an ideal posture.
Furthermore, helping your clients achieve ideal posture goes beyond the way they
stand. Take the time to demonstrate the posture they should maintain while work-
ing on their smartphone or computer or sitting at a desk (Figure 13.3).
Finally, explain to your clients that proper posture not only will help overcome muscle
imbalances but also can also have a positive effect on health and psychological state.
Indeed, research demonstrates that optimal posture can increase testosterone, de-
crease cortisol, and heighten the feeling of being powerful.
Let’s move on to discuss the tissue changes that can occur with poor posture, includ-
ing muscle inhibition and stiffness, to provide the proper interventions for your clients.
UPPER CROSSED SYNDROME

Upper crossed syndrome:
Professor Janda identified, and named, a few postural compensations that he com-
A series of upper body
monly observed throughout his stellar career. One compensation, the upper crossed compensations, described by
syndrome, occurs from a client’s being in a slumped posture and forward head Prof. Janda, due to a slumped
position for prolonged periods. This syndrome is running rampant these days due to posture.

214 | Unit 13
the excessive time spent on a smart-

phone or computer. Indeed, if Prof.
Janda were alive today, he could make
a living just treating the upper crossed
syndrome (Figure 13.4). You’ll know
whether your client has this syndrome
if he or she indicated a forward head
and anteriorly rotated shoulders during
the sagittal plane postural assessment.
In Units 11 and 12, numerous correc-
tive strategies were used to activate
muscles that get your client out of the
upper crossed syndrome. For exam-
ple, cueing your client to perform a
chin tuck or double chin activates
the deep neck flexors and lengthens
Suboccipitals: Four pairs of the suboccipitals. That’s important
muscles located between the because an upper crossed syndrome
lower posterior skull and upper causes weakness/inhibition of the deep
vertebrae that extend and
rotate the cervical spine.
necks flexors along with stiffness of the
Figure 13.4. Upper crossed syndrome.
suboccipitals. The common slumped posture, consisting
However, if your client was unable to of a forward head position and thoracic
flexion, results in a chain of compensations
perform a double chin, or felt exces- leading to stiffness and weakness/inhibition
sive stiffness at the base of the skull throughout the upper body.
while doing it, soft tissue mobiliza-
tions with a lacrosse ball can help, as
we’ll cover shortly.
The upper crossed syndrome can
negatively affect the neck, which in
turn, can impair shoulder movement,
as they are connected through muscles
and fascia. Therefore, whenever a client
demonstrates poor mechanics or dis-
comfort during shoulder movements,
it is important to assess the neck. If the
correctives outlined in this course don’t
have a positive effect within the first
session, or if the client feels pain, refer
him or her to a physical therapist or
licensed practitioner. Figure 13.5 Suboccipital muscles. These
muscles, consisting of four pairs, stiffen due
to a forward head posture, which limits up-
per cervical flexion and rotation.
Corrective Exercise
HOW TO ASSESS YOUR

PROGRESS
To determine whether each of the following correctives
are helping your client, a reference movement is necessary.
You have two choices. First, you could use whatever upper
body exercise is problematic as your reference. Let’s say
it’s a standing lateral raise with dumbbells. You’ll do the
first corrective and then have your client repeat the lateral
raise to determine whether an improvement has been
made. Second, you could use the overhead reach as your
reference (Figure 13.6). Recall from Unit 10 that reaching
the arms overhead is one of the most complex and chal-
lenging tasks for the shoulders. Therefore, if your client is
able to improve the overhead reach assessment after any
corrective, make that corrective a part of the daily home
exercise program.
How to do it:
• Get your client’s permission to video the overhead
reach, or take photos, as a reference. Then, have your
client stand tall with a “long spine,” feet together,
and arms held out to the sides with the thumbs up.
Instruct your client to make a double chin (Figure
13.6A).
• Next, instruct your client to slowly lift his arms over-
head in the frontal plane as high as possible (Figure
13.6B). Then instruct your client to slowly lower his
arms to the starting position.
• Have your client lift and lower his arms as many times
as necessary for you to view the movement from all
angles. Make a note of any compensations you see,
such as a shoulder shrug on one or both sides or
forward movement of the head. There are countless
compensations you might see.
• If your client has discomfort, have him rate it on a
scale of 1–10 and take a photo of that position or
note it on the video.
• It’s important to note here that the following correc-
tives should be performed with the client as relaxed
as possible. If he or she is in pain while stretching or
mobilizing the soft tissue, it will engage the sympa-
thetic nervous system and offset tissue relaxation.
Remind your client to breathe slowly and to exhale
during any position of stretch discomfort to keep the
nervous system in a low state of stress.
• After performing each of the following correctives,
retest your client’s ability to perform any problematic Figure 13.6. Overhead reach assessment. A) The client
upper body exercise, or the overhead reach, to deter- stands tall with the feet together, arms held straight out to
mine which ones he or she needs. the sides with the thumbs up. B) The client lifts the arms
overhead as far as possible in the frontal plane.

216 | Unit 13
NECK CORRECTIVES CHIN TUCK

CHIN TUCK (STANDING OR SEATED)
If your client is unsure whether the lacrosse ball is posi-
WITH LACROSSE BALL tioned correctly or if a ball isn’t available or your client
The suboccipital muscles extend the upper cervical spine experiences too much discomfort during the drill, the
and rotate the head. Therefore, you’ll first mobilize the regular chin tuck is the next best option. The benefit of
suboccipitals, either with or without a lacrosse ball, and this drill is that it can be performed anywhere, standing
then you’ll assess the client’s ability to rotate the head or seated, at work or home.
side to side.
Figure 13.8. Chin tuck. Client demonstrating the stand-

ing chin tuck. A) Starting position. B) Ending position of chin
tuck with light pressure from the fingertips. The drill can be
performed standing or seated.
How to do it:
Figure 13.7. Chin tuck with lacrosse ball. Client dem-
onstrating the mobilization exercise with a lacrosse ball. A) • Instruct your client to stand, or sit, as tall as possible.
Starting position. B) Chin tuck ending position. Cue him to “maintain a long spine without elevat-
ing your chin.” With the head in a neutral position,
instruct your client to place his fingertips on the chin
How to do it: (Figure 13.8A).
• Have the client lie on his back on a mat or comfort- • Next, instruct him to make a double chin and then
able surface, knees bent and feet flat. Have him place have him lightly press his fingertips into the chin to in-
a lacrosse ball at the base of his skull with his head in crease the stretch on the suboccipitals (Figure 13.8B).
a neutral position and resting on it (Figure 13.7A). At the end position, cue him to “shift your eyes up
and down three times followed by an exhale.”
• Next, instruct him to slowly nod his head, moving
the chin as close to the chest as possible (Figure • Perform the drill for one minute—or longer if the
13.7B). The ball should not be directly on the spine client desires.
but on either side where the most stiffness is felt. At
the end of the nod, cue him to “shift your eyes up • Now that the suboccipital muscles have been mobi-
and down three times followed by an exhale.” Then lized, it’s time to look at your client’s cervical rotation
instruct him to return his head to the neutral posi- range of motion.
tion. Continue performing the drill, focusing on the
stiffest/sorest spots around the base of the skull.
• Perform the drill for one minute—or longer if the
client desires.
Corrective Exercise
CERVICAL ROTATION CERVICAL ROTATION

ASSESSMENT (STANDING OR WITH TOWEL
SEATED) When the head rotates to the right, the facets on the left
side of the cervical spine glide upward (i.e., upglide),
The normal range of motion for head rotation is approx- while the facets on the right side simultaneously glide
imately 80°; however, it is not necessary to use a goni- downward (i.e., downglide). Therefore, to gain extra
ometer. You will instead look for any glaring asymmetry mobility during right cervical rotation, a towel is used to
between the right and left side and provide interventions assist upglide on the left side and downglide on the right
to either or both sides that are significantly less than 80°. side of the neck.
Figure 13.9. Cervical rotation assessment. A) Starting Figure 13.10. Cervical rotation with towel. A) At the
position is standing or seated with the shoulders relaxed and starting position, the client pulls down with the right arm
chin slightly tucked. B) Rotate the head to the right as far as and up with the left arm. B) Throughout the rotation to the
possible without elevating the shoulders or tilting the head. right, the client continues to pull down with the right arm
Left cervical rotation not shown. and up with the left arm. Left cervical rotation not shown.
How to do it: How to do it:

• Instruct your client to stand, or sit, as tall as possible. • Have your client sit tall with a “long spine” and chin
Cue him to “maintain a long spine without elevating slightly tucked. He will hold the ends of a small towel
your chin.” Instruct your client to keep his shoulders that’s wrapped around the back of the neck and just
completely relaxed throughout the assessment (Fig- below the skull. Instruct him to pull the right side of
ure 13.9A). the towel down and left side of the towel up below
his left ear. The amount of pull with each arm should
• Next, instruct him to slightly tuck his chin and then
be moderate (Figure 13.10A).
to rotate his head as far to the right as possible (Fig-
ure 13.9B). Repeat the drill to the left side. • Instruct the client to slowly rotate his head to
the right as he maintains downward and upward
pressure with the right and left arm, respectively.
Common mistakes: Cue him to “rotate your head as far to the right as
possible while moderately pulling on both ends of
• The shoulder shrugs on same side of where the head
the towel.” The head should tilt slightly to the right at
is rotating (i.e., right shoulder shrug with right rota-
the end of right rotation (Figure 13.10B).
tion). This occurs when the client is trying to force
extra range beyond his mobility. Remind him to keep • At the maximum end range of rotation, instruct your
his shoulders down and completely relaxed. client to hold the position for one full second and
then exhale. The client should feel an upward pull on
• The head will tilt. Again, this is caused by the client’s
the left side of the head and a downward pull on the
attempting to gain extra range through accessory
right shoulder, directly next to the neck.
muscle activation. Look at him from the side view
and cue the client accordingly to level his head.
218 | Unit 13
• Next, return to the starting position. Repeat the How to do it:

sequence to the left side if necessary.
• Have your client lie supine with his knees bent and
• Perform two to three sets of five slow reps to the side
feet flat on the ground. Instruct the client to press the
or sides that lack mobility.
tongue against the roof of the mouth, lips together,
and teeth slightly apart to reduce any contribution
Common mistakes: from the jaw muscles.
• Next, cue the client to “tuck your chin as far as
• The client pulls hard on the towel. This drill should
possible and elevate your head” or “nod your head
not be uncomfortable. A moderate amount of pull is
as far as possible” until the head is elevated one inch
all that’s necessary with either arm.
(2.5cm).
• The towel is placed incorrectly. For right rotation, the
• Instruct the client to maintain the “tuck” or “nod”
left side of the towel should travel directly below the
hold for as long as possible (Figure 13.11). Look close-
left ear; the right side of the towel should be touch-
ly at the creases in the neck to determine whether the
ing the neck.
chin tuck is lost.
• Perform three sets of a 15-second hold with 20 sec-
DEEP NECK FLEXORS (DNF) onds rest between each set.
ACTIVATION
Common mistakes:
The upper crossed syndrome can cause inhibition of the
deep neck flexors. When those muscles don’t have the • The client holds his breath during the hold. Make
necessary strength to hold the cervical spine in a neutral sure the client maintains slow, controlled breathing.
position, they can impair upper body mechanics. Research • The shoulders shrug and/or chest muscles contract.
shows that activation of the deep neck flexors can reduce The only muscle action that should occur is within
discomfort in the neck and shoulders. Therefore, if none of the anterior neck. Instruct the client to keep the
the aforementioned steps helped improve function in the shoulders and chest relaxed, when necessary.
shoulders or neck or reduced discomfort, perform the fol-
lowing activation drill and retest the problematic exercise.
UPPER TRAPEZIUS AND
The deep neck flexors have been activated throughout the
preceding steps in this course from the cues to “tuck the LEVATOR SCAPULAE
chin” or “make a double chin.” In many cases, that will
be enough to fix any imbalances. However, some people
STRETCHES
benefit from further direct activation. The final compensations resulting from the upper crossed
syndrome that we haven’t covered yet are stiff upper
trapezius and levator scapulae muscles. Because these
muscles attach between the cervical spine and scapula,
they can impair upper body exercises and cause problems
in the neck and shoulders. This is the last step for deter-
mining whether any problems your client is having are
caused by the cervical region.
How to do the upper trapezius stretch:

• To stretch the left upper trapezius, have your client
place his left arm behind his low back.
Figure 13.11. Deep neck flexors activation. The patient

tucks his chin and elevates his head one inch (2.5cm) off the
floor and holds the position as long as possible.
Corrective Exercise
• Next, instruct him to place his right hand on the

posterior left side of his head. Have him pull his head
to the right and then at a downward angle so his nose
moves toward his armpit. Instruct him to simultane-
ously pull his left shoulder down (Figure 13.12A). Hold
the stretch for 30 seconds while breathing slowly and
deeply. Do the same steps for the opposite side.
• Perform two to three sets of a 30-second hold for
one, or both, sides.
How to do the levator scapulae stretch:

• To stretch the left levator scapulae muscle, have your
client reach his left arm up and over the left shoulder
so the left hand rests on the upper back.
• Next, instruct him to place his right hand on the
posterior left side of his head. Have him pull his head
to the right and then at a downward angle so his
nose moves toward his armpit (Figure 13.12B). Hold
the stretch for 30 seconds while breathing slowly and
deeply. He should feel a stretch on the left side of the
neck, up to the base of the skull. Do the same steps
for the opposite side.
• Perform two to three sets of a 30-second hold for
one, or both, sides with minimal rest between sets.
Additional points:
• If your client feels a great deal of stretch tension in
the appropriate muscles while doing the stretch,
keep it in the program until the stretch tension has
dissipated. It might take weeks.
• Your client might not need to stretch both sides,
depending on how his or her body has compensated.
Check both sides to determine what is appropriate.
• Up to this point, we have covered the assessments
and correctives for the cervical spine. In many cases,
the aforementioned drills will significantly improve
your client’s ability to perform an upper body
exercise and reduce discomfort. That’s because the
drills we just covered correct the cervical dysfunc-
tions caused by the upper crossed syndrome: weak/
inhibited deep neck flexors along with stiffness in the
subocciptals, upper trapezius, and levator scapulae
muscles.
• If your client still is not able to perform at least one
Figure 13.12. Upper trapezius and levator scapulae pain-free rep with the problematic upper body
stretches. A) Upper trapezius stretch. B) Levator scapula exercise, move on to the following correctives for the
stretch.
t-spine and shoulders.

220 | Unit 13
UPPER BODY CORRECTIVES How to assess pectoralis minor length:

• Have your client lie supine on a firm, elevated
PECTORALIS MINOR AND MAJOR surface, arms relaxed at the sides, palms facing up.
Get your eyes at the same height as your client and
LENGTH ASSESSMENT observe the posterior-lateral portion of each shoulder
Of all the compensations commonly seen in upper crossed (Figure 13.13A).
syndrome, and the population in general, shortened pec- • When the pectoralis minor muscles have a normal
toralis muscles rank at the top of the list. Indeed, if your length at rest, the posterior- lateral portion of each
client demonstrated anteriorly rotated shoulders from shoulder will rest comfortable on the table. Observe
the postural assessment, you can pretty much assume the the shoulder position closely because any elevation
pectoralis minor and major muscles are stiff and short- of the posterior-lateral shoulder indicates stiffness/
shortening. In some cases, the pectoralis minor
ened. Therefore, the first step for correcting an upper body
shortening will be obvious (Figure 13.13B).
exercise starts with assessments and soft tissue correctives
for the pectoralis muscles. • Now we’ll look at the length of the pectoralis major
muscles. Surprisingly, there isn’t a simple way to
Stiffness of the pectoralis minor is especially problemat- self-determine whether they have sufficient length.
ic because it attaches the scapula (i.e., coracoid process) Nevertheless, I’ve found the following assessment
to the ribs, thereby impairing optimal movement of the works well to determine the bare minimum level of
scapulothoracic region. In most research settings, clini- flexibility for the pectoralis major to allow for ideal
cians measure the length of the pectoralis minor with a posture. However, keep in mind that your client
cloth tape while the person is sitting or standing, but this might need significantly more mobility than this test
assesses, especially if he or she is an Olympic lifter or
requires a great deal of anatomical knowledge. However,
gymnast. Be sure to read the explanation carefully
you can get a good idea of whether the pectoralis minor is because the photo can be deceiving.
stiffened (i.e., shortened) on one or both sides by observ-
ing your client as he or she lies supine.
How to assess pectoralis major length:
• Have your client lie supine on the floor with his knees
bent and feet flat (i.e, hook lying position). The lower
back should be flat against the floor. Instruct the
client to position his arms palms up so the wrists are
in line with the top of the head (Figure 13.14).
• Cue him to “lock out the elbows” or “try to hyperex-
tend the elbows” while the arms are outstretched in
the starting position. Instruct him to completely relax
his shoulders while keeping the elbows locked.
• When the pectoralis major muscles have a “normal”
length, the elbows, wrists, and entire backside of the
hands will rest on the floor. In addition, the client
should not feel any stretch throughout the pectoralis
muscles. If any portion of the arm, from the shoulder
to the fingertips, is elevated from the floor, or if the
client feels any stretch in the pectoralis muscles, the
muscles have too much stiffness.
Figure 13.13. Pectoralis minor length assessment.

A) Client demonstrates normal pectoralis minor length in
the left shoulder, indicated by the lateral-posterior edge of
the shoulder resting on the table. There is minor stiffening/
shortening in the right shoulder, indicated by slight eleva-
tion of the posterior shoulder. B) Client demonstrates normal
pectoralis minor length in the left shoulder. There is exces-
sive pectoralis minor stiffening/shortening in the right shoul-
der, indicated by significant elevation of the lateral-posterior
shoulder region.
Figure 13.14. Pectoralis major length assessment.
The client demonstrates the minimum level of “normal”
pectoralis major flexibility, indicated by his elbows, wrists,
and backside of the hands resting passively on the floor. No
stretch should be felt in the pectoralis muscles.
PECTORALIS BALL ROLL CHEST OPENER

This lacrosse ball corrective is used if your client demon- The chest opener is a terrific mobility drill for the pectora-
strated shortening and stiffness in either the pectoralis lis minor and major that I learned from Heather Seyfert,
minor or major tests. The only possible modification will DPT, a physical therapist and yoga enthusiast. This drill
be the placement of the ball. For example, if your client works especially well because it pins the shoulder down
only demonstrated stiffness in the right pectoralis minor, and encourages posterior tilt of the scapula. That’s im-
you’ll work the ball primarily around that area. portant because a stiff pectoralis minor pulls the scapula
into anterior tilt, thus impairing shoulder mechanics.
How to do it:
How to do it:
• If the left pectoralis is the target, have your client
stand facing a wall with a lacrosse ball between the • To mobilize the left pectoralis minor/major, have your
left chest and wall, directly over the pectoralis minor. client lie prone with the left arm outstretched and
Instruct him to place his left hand behind his low perpendicular to the body, left palm facing down. In-
back (Figure 13.15). struct the client to place the right palm on the floor, as
close to the right shoulder as possible (Figure 13.16A).
• Instruct him to shift his trunk so the ball rolls over
the stiffest/sorest spots. The discomfort should be • Next, instruct the client to push through the right
minimal, and remind your client to breathe slowly, palm to twist the upper body right as he simultane-
stay relaxed, and exhale deeply when the ball is on a ously flexes his right hip and places his right foot on
sensitive spot. the floor (Figure 13.16B). From this position, cue him
to “push through the right palm and right foot while
• Perform the corrective for one minute, or longer, on
keeping the left shoulder pinned to the ground.”
one or both sides. Focus on the pectoralis minor if
that’s the only problem area or on the entire pectora- • Hold the end stretch position for 10 seconds. Cue your
lis major if needed. client to “take deep breaths through your nose and ex-
hale slowly through your mouth” during the 10- sec-
ond hold. Return to the starting position and repeat.
Additional points:
• Perform the 10-second hold five times on one or
• If a female client has large breasts, she can perform both sides.
the soft tissue mobilization by holding the lacrosse
ball in her opposite hand. Instruct her to press the
ball firmly into the breast tissue and roll it around the
stiffest areas, using the technique we just covered.
Figure 13.15.
Pectoralis minor
and/or major ball
roll. The client mo-
bilizes his left pec-
toralis minor with a
lacrosse ball, holding
the left hand behind
his low back.
Figure 13.16. Chest opener. A) Starting position for mobi-

lization of the left pectoralis minor/major. B) Ending position,
keeping the left shoulder pinned to the floor.

222 | Unit 13
Additional points:
• If the client lacks the hip mobility to place one foot
on the floor, the drill can be performed with both
legs straight, as depicted in the starting position.
• If the client experiences neck discomfort, place a
foam roller or large pillow under his or her head
during the stretch so the neck muscles can relax.
• If this version is too challenging, the client can
perform the same basic trunk rotation and push off
while standing and facing a wall. The key is to keep
the shoulder of the outstretched arm pinned against
the wall. Figure 13.17. T-spine foam roll. The client crosses
his arms at the chest and uses his feet to move the
• When a person spends considerable time in a foam roller up and down his thoracic spine while being
slumped posture, the muscles and fascia that attach “heavy” on the roller.
to the t-spine stiffen. This loss of t-spine mobility can
impair movement of the upper limbs, especially for
overhead exercises. It is easy to assume that stiff lats he’s hugging himself. This lengthens and exposes
might be the cause of a loss of overhead mobility, the muscles and fascia between the scapulae and
and it certainly can be, but recall from Unit 9 that a t-spine. Have him place his feet flat on the floor with
t-spine stuck in flexion will impair your client’s ability the knees bent and hips elevated as high as the chest
to reach overhead (Figure 9.3). (Figure 13.17).
• Therefore, the next step for correcting shoulder • Next, instruct him to slowly move the foam roller up
mechanics focuses on increasing mobility of the and down the entire t-spine by walking the feet back-
t-spine. Once again, you will perform each correc- ward and forward. Cue the client to “breathe slowly
tive and retest the problematic upper body exercise, and deeply, focusing on the stiffest, sorest spots.”
or overhead reach, until your client can perform
• Instruct the client to stay “heavy and relaxed” on the
either moves with proper mechanics and free of any
foam roller so the maximum amount of PA pressure
discomfort
is applied to the thoracic vertebrae. Have the client
maintain a double chin throughout the drill to acti-
T-SPINE FOAM ROLL vate the deep neck flexors.
• Perform the foam roller drill for one minute, or for
When a person has a t-spine that is stuck in flexion, a longer if the client desires.
common physical therapy technique is to have the patient
lie prone while the therapist pushes on the thoracic ver-
tebrae. This posterior-to-anterior (PA) pressure helps the Common mistakes:
t-spine extend back to a neutral position. Your client can • Excessive movement of the trunk. It is common for
achieve a similar type of PA pressure by lying with his or people to try to extend the t- spine back and over
her upper back resting on a foam roller. This drill will also the top of the roller so the back of the head is resting
help restore the proper water balance within the muscles on the ground. However, that can cause the spinal
and fascia around the t-spine. extensors to contract, which reduces the amount of
pressure the foam roller is applying to the thoracic
vertebrae.
How to do it:
• Excessive muscle activation throughout the upper
• Have your client lie on a foam roller running perpen- back. This goes with the previous point. Your client
dicular to the t-spine, between the shoulder blades. should remain as relaxed as possible so the foam
Instruct him to fully cross his arms at the chest, as if roller can really sink into the upper back tissues.
Corrective Exercise
T-SPINE ROTATION Common mistakes:

A common problem in a wide range of clients, whether or • The scapula retracts on the side of the arm that’s
not they have upper crossed syndrome, is weak, inhibited down. Make certain your client is constantly pushing
serratus anterior muscles. Another typical restriction is through the palm that’s down to keep the serratus
anterior activated.
poor t-spine rotation to one or to both sides. This is an ex-
cellent drill that can correct both problems. The goal is to • Your client loses his natural lordotic curve. A com-
identify an asymmetry between rotation to the right and mon compensation to gain extra range is to flex the
left and to focus on the side that is most restricted. lumbar spine. Instruct your client to maintain a natu-
ral arch in the low back throughout the rotation.
DNS T-SPINE EXTENSION

I learned this drill while taking the Dynamic Neuro-
muscular Stabilization (DNS) courses. It is an effective
way to increase t-spine extension for your clients who are
stuck in flexion. The key is to obtain the proper sequence
between breathing and movement.
Figure 13.18. T-spine rotation. A) At the start, the client

pushes through his left arm. B) At the end, the client has
rotated and reached as far as possible while maintaining
lumbar lordosis. Downward pressure through the left arm
continues in order to keep the serratus anterior activated.
How to do it:
• Have your client get in the quadruped position
with the knees hip width apart, hands shoulder
width apart, and the same distance forward as the
forehead. Instruct the client to lift his right arm and
hold it under the chest while maintaining a natural
lordotic curve in the lumbar spine. Cue the client to
“push down through your left palm” to activate the
left serratus anterior (Figure 13.18A). Figure 13.19. DNS t-spine extension. A) Starting posi-
tion. B) Ending position as the client stays relaxed through-
• Next, instruct the client to slowly rotate the trunk out the lower limbs while performing diaphragmatic
and to reach the right arm to the right as far as breathing.
possible while pushing through the left arm (Figure
13.18B). Cue the client to “exhale deeply at the end of
the reach and hold it for two seconds.” How to do it:
• Instruct the client to slowly return to the starting • Have your client lie supine, elbows bent to 90° and in
position and repeat for five slow reps. Do the same line with the forehead, palms flat (Figure 13.19A).
steps for the opposite side, noting which side is more
• Next, instruct him to make a double chin, inhale
restricted.
deeply using the diaphragm and then exhale as he
• Perform two sets of five slow reps with 30 seconds pushes his chest as far away from the floor as possi-
rest between sets. ble, through the elbows. Instruct him to hold the end

224 | Unit 13
position for 10 seconds, bear down for 2 seconds,

and then exhale again as he tries to push his chest
farther from the floor. His hands and legs should
remain relaxed (Figure 13.19B).
• Have him hold the new end position for another 10
seconds. If he’s shaking, wait until it stops. At that
point, instruct him to bear down for 2 seconds and
then exhale and push away from the floor once more.
Have him finish with a 10- second hold.
• Perform two sets of the sequence with 30 seconds
rest between sets.
Common mistakes:
• The double chin is not maintained. Cue your client
accordingly.
Figure 13.20. Ball wall push with hip hinge. A) At the
• The client holds his breath at the end position. Other start, the client pushes his right arm into the ball to activate
than the 2 seconds the client spends bearing down, the serratus anterior. B) At the end of the hip hinge, the client
he should perform slow, deep diaphragmatic breath- maintains constant pressure through the shoulder and into
ing throughout the hold. the ball.
• The pelvis lifts off the floor. Cue client to “maintain

relaxed and heavy hips into the floor.” ketball to a large Swiss ball. The smaller the ball, the
• Now that the t-spine has been mobilized, you’ll have more challenging it will be to maintain stability.
the client perform drills that are more functional in • Next, instruct the client to make a double chin and
nature to improve shoulder mobility. The following then have him push his right arm into the ball. Cue
steps are recommended when there is still a problem the client to “push into the ball so your right shoulder
with any overhead exercises. blade moves forward” or “push your body away from
the body through your palm.” The client should push
with approximately 50% of maximum strength.
BALL WALL PUSH • Then, instruct the client to hinge at the hip as he
WITH HIP HINGE pushes the ball up the wall, going down as far as his
shoulder mobility allows (Figure 13.20B). Instruct the
This corrective is an excellent way to activate the serratus client to exhale deeply when the shoulder is over-
anterior, improve shoulder stability, and increase overhead as far as possible.
head shoulder mobility. It is easy for your client to force
• Have the client slowly return to the starting position
him or herself into an excessive range of overhead shoul- while continuing to push the right palm into the ball.
der motion during the hip hinge, so be sure to perform
this corrective slowly and avoid positions of pain. Perform • Do this exercise for the left side as well, if your client
the following drill for the right or left shoulder, or both, lacks mobility. Perform two sets of five slow reps with
30 seconds rest between sets.
depending on whether your client lacks mobility on one
or both sides.
Common mistakes:
How to do it: • The double chin is not maintained. Cue your client
accordingly.
• Have your client stand tall with a “long spine” and
his feet slightly wider than shoulder width. Place a • The client bends his elbow as he pushes into the
ball between his right outstretched arm and a wall ball. Cue him to “maintain a locked elbow” or “try to
(Figure 13.20A). Any ball size will work, from a bas- hyperextend your elbow throughout the exercise.”
Corrective Exercise
POSTERIOR SHOULDER BALL

ROLL
The posterior region of the shoulder, around the area of
the infraspinatus and teres major/minor, can hold excess
tension and thereby limit overhead shoulder mobility. To
free up the fascia and muscle tissue in that area, a lacrosse
ball is used. Perform this drill on one or both sides de-
pending on your client’s needs.
How to do it:
• Have your client lie supine, knees bent and feet on
the floor, with a lacrosse ball resting on the stiffest/
sorest spot in the posterior shoulder region. The up-
per arm is perpendicular to the floor, elbow bent to
any comfortable angle, to expose the tissues in that
region (Figure 13.21A).
• Next, instruct him to make a double chin and then
have him pull his right arm across the body, using
the left hand, to lengthen the soft tissue in the right
posterior shoulder (Figure 13.21B).
• Instruct him to shift his trunk in any direction in order
to roll the ball over the stiffest/sorest spots. Cue to
him “exhale deeply” when he’s on the most tender Figure 13.21. Posterior shoulder ball roll. A) The
spots. lacrosse ball rests on the stiffest/sorest spot on the right pos-
terior shoulder region. B) The arm is pulled across the body
• Perform the ball roll for one to two minutes on one to lengthen the tissues that are in contact with the ball.
or both sides, once per day.
Common mistakes:
• The client applies too much pressure to the ball. This
area can be very sensitive; therefore, it’s important LOWER BODY
to cue your client to shift the ball up to the “edge of For the purposes of this section, the lower body is defined
where you feel discomfort,” exhale in that position, as the area between the lumbar spine and feet. Again,
and then move closer to the most tender spots. If you will use any problematic lower body exercise as your
the client is in pain, and holds his or her breath or
reference. Have your client rate his or her discomfort
grimaces, the nervous system won’t relax the tissues
as well.
on a scale of 1–10 and note any compensations you see.
Then perform each corrective and retest the problematic
• At this point, we’ve addressed the soft tissue restric- exercise to determine whether it should be part of your
tions created by the upper crossed syndrome along client’s program.
with few other compensations you’ll typically see.
Now, it’s time to move on to the lower body. There is an ongoing debate about whether weakness and
stiffness in the pelvis/hips causes problems in the feet,
or if problems in the feet cause dysfunctions up into the
pelvis/hips. We will cover both areas, so the debate is
irrelevant. Nevertheless, we’ll start with the pelvis and
hips because, in my experience, this area identifies more
problems than the feet do.
Let’s review the standing postural assessment we covered
earlier. In some cases, your client will have too much
stiffness and/or poor motor control to achieve the ideal

226 | Unit 13
spinal and pelvic alignment. Correcting the lumbar spine and pelvis is an essential
step in the corrective exercise process because improper alignment of those segments
can cause back pain, muscle imbalances, and poor overall performance throughout
the entire body.
ANTERIOR PELVIC TILT

The most common compensation you’ll see is anterior pelvic tilt. This is broadly de-
fined as more than 5° of anterior tilt for males, and more than 10° for females, relative
to horizontal from the sagittal plane view (Figure 13.22B). Professor Janda describes
Lower crossed syndrome: the compensations seen with anterior pelvic tilt as a lower crossed syndrome, which
A series of lower body is caused by overactive hip flexors and thoracolumbar extensors along with weakness/
compensations, described inhibition in the glutes and abdominals. The hamstrings are also overactive, as they
by Prof. Janda, due to poor
posture.
maintain constant stretch tension to keep the pelvis from further anterior tilt.
POSTERIOR PELVIC TILT

Posterior pelvic tilt is less common than anterior pelvic tilt; however, it’s likely you
will encounter enough people with it to warrant a lesson here. The normal pelvic posi-
tion is 0–5° of anterior tilt for males and 0–10° for females (Figure 13.22A). Therefore,
any amount of posterior pelvic tilt is considered excessive (Figure 13.22C). Posterior
pelvic tilt is usually caused by sitting for long periods in a slouched position and/or
shortened, stiff hamstrings. Even though research on stretching the hamstrings has
low levels of evidence for reducing back pain or increasing performance, this is one
scenario in which it’s recommended, as we’ll cover later.
Figure 13.22. Posture and

common compensations
within the lumbar spine and
pelvis. A) Ideal posture consists
of a neutral lordotic curve and
neutral pelvis, which is <5° of
anterior pelvic tilt for males
and <10° for females. B) Client
demonstrates excessive anterior
pelvic tilt, which coincides with
lumbar lordosis, an excessive
lordotic curvature due to lumbar lumbar flattened posterior
neutral lumbar
extension. C) Client demon- neutral lordosis pelvic
lordotic spine tilt
strates posterior pelvic tilt, curve pelvis anterior
which coincides with a flattened pelvic
lumbar spine. A line is drawn tilt
above the waistline of the shorts
to mimic the pelvic position.
Corrective Exercise
LOWER BODY CORRECTIVES

CAT-CAMEL
The first corrective to restore lumbar and pelvic alignment How to do it:
is the cat-camel, popularized by Stuart McGill. It is an
• Have your client get in the quadruped position with
excellent drill to restore motor control in the lumbopelvic
the hands directly below the shoulders and knees
region and to reduce friction within the spinal column.
directly under the hips. To perform the “cat” portion,
The key with the cat-camel is to avoid turning it into cue your client to “inhale and then slowly exhale
a stretch. Instead, focus on creating a slow, controlled as you tuck your pelvis under” or “inhale and then
motion through a relatively small range that opposes the slowly exhale as you push your low back toward the
pelvic compensation you observed from standing posture. ceiling” (Figure 13.23A). The client’s head should be
For example, if your client is stuck in anterior pelvic tilt, looking down at the end of the movement.
he or she will focus more on moving through the “cat” • To transition from the cat to the camel, cue the client
portion of the drill because it requires posterior pelvic tilt to “inhale as you lift your tailbone and head” or “in-
and lumbar flexion (Figure A). If the client shows posteri- hale and push your stomach toward the floor as you
or pelvic tilt from the postural assessment, he or she will look up” (Figure 13.23B).
focus more on the “camel” portion of the drill (Figure • Perform two sets of five slow, controlled reps
13.23B). To be clear, both phases of the cat-camel are per- through the range of motion that are pain free for the
formed for everyone, but one position is emphasized more client.
than the other to offset postural compensations.
Common mistakes:
• The client tries to go to an extreme end range of
motion. This drill should begin will small motion in
each direction and slowly increase as the client gains
motor control and reduces spinal friction.
MODIFIED THOMAS TEST

The modified Thomas Test, named after the late Hugh
Owen Thomas MD, a British orthopedic surgeon, is a
popular assessment of the hip, particularly the muscles
that surround the anterior portion. Unlike some static as-
sessments that might only demonstrate stiffness in one or
two muscles, the modified Thomas Test can identify three
potential dysfunctions at the hip: excessive shortening
of the iliacus/psoas, rectus femoris, and/or tensor fasciae
latae (TFL).
Given that most people spend the majority of their day
while sitting with the anterior hip muscles shortened, the
modified Thomas Test is an especially important assess-
ment to learn.
Figure 13.23. Cat-camel. The starting “cat” position con-

sists of spinal flexion and posterior pelvic tilt. B) The ending
“camel” position consists of spinal extension and anterior
pelvic tilt.

228 | Unit 13
Common compensations:
• The thigh is elevated off the table, and the knee joint
is extended more than 110°, indicating shortness
of the psoas, iliacus, and/or rectus femoris (Figure
13.25A). It’s worth noting here that a physical ther-
apist can determine whether the rectus femoris is a
contributing factor by holding the person’s right leg
in an extended position, but that step isn’t covered
in this hands-off course. Therefore, when you see
the combination of an elevated thigh and extended
knee joint, use the corrective strategies covered later
to increase mobility of the psoas/iliacus and rectus
femoris for that hip.
• The knee joint is extended more than 110°, indicating
shortness of the rectus femoris (Figure 13.25B). The
rectus femoris also crosses the knee joint; therefore,
when it’s shortened, it will extend the knee beyond
110°. Because the psoas/iliacus only cross the hip
joint, the posterior thigh is able to rest on the table
when those muscles have normal mobility.
Figure 13.24. Modified Thomas Test from the sagit-

tal plane view. A) For testing the right hip, the client starts
by holding below the left knee with both hands. B) In the
assessment position the client demonstrates 100° of right
knee flexion while the low back rests flat against the table,
indicating normal mobility of the hip flexors.
How to do it:
• Have your client lie on his back on the edge of a table
that’s high enough to allow his lower legs to hang
off the edge without his feet touching the ground.
The glutes are approximately 6 inches away from the
edge. Place a pillow under his head to avoid any neck
strain. Instruct him to pull both knees to his chest,
and posteriorly rotate the pelvis to flatten the lumbar
spine into the table. Have him hold his left leg, under
the knee, with both hands (Figure 13.24A).
• Next, instruct him to slowly lower his right leg until
it’s fully relaxed while his lumbar spine remains in
contact with the table. It is essential to make certain
his lumbar spine remains flat against the table during
the assessment.
• If your client has normal mobility of the hip flexors,
the right posterior thigh will rest on the table, and the Figure 13.25. Compensations in the modified Thomas
right knee will be flexed 100–110° (Figure 13.24B). Test from the sagittal plane view. A) The client dem-
onstrates shortened right hip flexors, indicated by the right
• Make a note of any possible compensations you see, posterior thigh being elevated from the table. B) The client
based on the following information, and then per- demonstrates a shortened right rectus femoris, indicated by
form the test for the left hip. the right knee joint’s being >110°.
CORRECTIVES FOR
ANTERIOR HIP MOBILITY
As previously mentioned, stiffness/shortening of the ante-
rior hip muscles is extremely common, and this is usually
paired with weak/inhibited glutes. Therefore, after any of
the following mobility drills are performed for the anteri-
or hip muscles you determined were too stiff, a hip thrust
will be performed to actively engage the glutes to move
your client’s hip through the new range of motion.
Mobilizing the muscles and fascia throughout the quadri-
ceps can be effectively accomplished with a foam roll-
er—if the drill is performed correctly. The most common
mistake people make is that they keep their quadriceps
contracted throughout the drill due to discomfort. The
Figure 13.26. Modified Thomas Test from the frontal rectus femoris and vastus lateralis are two muscles that
plane view. The right thigh is in line with the trunk, indicat- typically need the greatest amount of attention, as they
ing normal mobility of the right TFL. B) The right thigh is typically hold the most tension. The steps that have proven
abducted at rest, indicating shortness of the right TFL.
most effective for my clients, which we’re about to cover,
were taught to me by Dr. Mark Cheng.
• Next, you’ll assess the client from frontal plane view
to determine whether the TFL is shortened. Recall Your client needs it when:
from Unit 12 that the TFL abducts the hip and be-
comes overactive when the gluteus medius is weak. • The knee on the same side of the hip being tested
This overactivity of the TFL causes it to stiffen and during the modified Thomas Test was extended
shorten, which can impair normal hip mechanics. >110° (Figure 13.25B).
• How to assess from the frontal plane view: • He or she is unable to fully extend (i.e., lockout) the
hips during a deadlift or squat.
• When the right TFL has normal mobility, the lateral
edge of the right thigh will be in line with the right • He or she spends considerable time sitting each day.
side of the trunk (Figure 13.26A).
• When the right TFL is shortened, the right thigh How to do it:
will be abducted when the client is at rest (Figure
13.26B). • To foam roll the left quadriceps, have your client lie
prone with the left leg resting on the roller. The roller
• At this point, you’ve gathered information regarding should be placed perpendicular to the body with the
possible muscle shortening in the right and left hip. client’s left thigh near the edge. Instruct client to rest
Perform one or all the following correctives, based on his elbows and right knee (Figure 13.27). Any type
on what your client requires, after observing what of firm roller can be used.
he or she demonstrated during the modified Thomas
Test. • Instruct him to move his left quadriceps over the roll-
er, a few inches at a time, using his elbows and right
leg to shift his body. Cue him to “let your quadriceps
relax and sink into the roller as you breathe slowly.”
• Have him continue to move the roller around the
left quadriceps, focusing on the middle and lateral
aspects of the thigh. When he finds a sore, sensitive
spot, instruct him to move the roller up to the “edge”
of that spot, have him lift his head and look around
the room, and then cue him to “exhale deeply.” Lift-
ing the head and shifting the eyes around the room
helps the nervous system relax.
• Perform the drill for two minutes, on one or both
thighs.

230 | Unit 13
How to do it:
• To mobilize the right hip flexors, have your client
place right knee on the ground, resting on a thick
pad or towel. If the client experiences pain in the
kneecap, you can instead place a half foam roller
under the upper shin so the knee doesn’t contact the
ground.
• Have him place his left foot on the ground, in front of
the body, with left hip/knee flexed to approximately
90°. Elevate the right foot on a small step. Instruct
him to place both hands on the hips, pull the pelvis
forward, and lean his trunk slightly to the left (Figure
13.28). At this point, he should feel a moderate
stretch in the right hip and right anterior thigh.
• Next, instruct him to attempt to “pull” his right
knee forward to activate the right hip flexors. The
right knee will not move. Hold the contraction for 5
seconds.
Figure 13.27. Quadriceps foam roll. The client
moves the roller up and down the middle and lateral • Then, cue him to “relax and exhale deeply as you pull
aspects of the quadriceps, one leg at a time. the pelvis further forward.” Be certain his trunk re-
mains upright and leaning slightly to the left. At this
point, he should feel a more intense stretch through
Common mistakes: the right hip and anterior thigh. Have him hold the
stretch position for 10 seconds while instructing him
• The client places too much weight on the roller and to perform slow, deep diaphragmatic breathing. The
experiences pain. It’s imperative for your client to intensity of the stretch should be a 6–7/10.
keep quadriceps relaxed during this drill. That’s why
deep, diaphragmatic breathing, along with shifting • Perform four rounds of the contract-relax stretch and
the gaze of the head/eyes around the room are essen- then switch sides.
tial. Instruct your client to shift more weight onto the
elbows when the discomfort escalates.
HIP FLEXORS CONTRACT-

RELAX STRETCH
Because the psoas and iliacus muscles lie deep within the
trunk, a soft tissue mobilization drill with a lacrosse ball
isn’t appropriate. Therefore, the contract-relax stretch is
performed for the hip flexors to strengthen and stretch
those muscles at the same time.
Your client needs it when:

• The posterior thigh of leg being assessed in the mod-
ified Thomas Test was elevated from the table (Figure
13.25A).
• He or she is unable to fully extend (i.e., lockout) the
hips during a deadlift or squat.
• He or she spends considerable time sitting each day.
Figure 13.28. Hip flexors contract-relax stretch. Client
shown here mobilizing the right hip flexors. The client is lean-
ing his trunk slightly to the left as he performs the contract-
relax drill.
Corrective Exercise
Additional points: • Have your client place his hands or elbows on the
floor so he can shift his body over the area of the TFL.
• To increase the stretch throughout the trunk and pso- Instruct your client to work around the “edges” of
as, instruct your client to reach his right arm up and painful tissue. When he finds a sensitive spot, instruct
over to the left side while performing the contract-re- him to lift his head and look around the room, and
lax stretch for the right hip. then exhale deeply.
• It’s not necessary to elevate the foot on the same side • Perform the drill for one minute on one, or both,
of the hip that’s being stretched if your client has sides.
sufficient mobility in his rectus femoris. In that case,
• At this point, you’ve mobilized the appropriate mus-
the foot will rest on the ground.
cles based on what your client demonstrated during
• Your client can significantly improve the mobility of the modified Thomas Test. Now it’s time to actively
the hip flexors by spending time each day doing a engage the gluteus maximus to facilitate active mo-
modified walk. While the client walks throughout the bility into hip extension.
day, tell him or her to maintain heel contact with the
stance leg for as long as possible. Thus, as client’s right
leg travels behind the body, the right heel will remain SINGLE-LEG HIP THRUST
down for as long as possible to stretch the hip flexors.
The hip thrust, popularized by Dr. Bret Contreras, is an ex-
cellent exercise to strengthen the gluteus maximus. When
TFL BALL ROLL the hip of the working leg is fully extended, the muscles
around the anterior hip are stretched, which also makes
The TFL muscle is located at the upper, lateral portion of this exercise effective for increasing anterior hip mobility.
the thigh (Figure 12.2). It’s common for this muscle to
become stiffened and shortened. Because it’s difficult to
How to do it:
target the TFL with a large foam roller, a lacrosse ball is
used to provide more direct contact. • To work the right hip, have your client rest his arms
and upper back across a flat bench. His hips should
be as close to the ground as possible with the knee
Your client needs it when: joints flexed to approximately 90° and feet flat. In-
struct him to lift his left leg and hold it parallel to the
• The hip was abducted during the modified Thomas ground (Figure 13.30A).
Test (Figure 13.26B).
• He or she has weakness in the gluteus medius.
How to do it:
• To mobilize the left TFL, have your client lie prone
with a lacrosse ball resting between the muscle and
floor (Figure 13.29).
Figure 13.30. Single-leg hip thrust. A) Starting position

for training the right hip. B) In the ending position, the client
Figure 13.29. TFL ball roll. The client uses a lacrosse ball pushes through his right heel, focusing on tension within the
to target and mobilize the TFL of the left hip. right glutes.

232 | Unit 13
• Cue him to “push your right heel into the floor and elevate your hips as high as
possible.” Instruct your client to focus on squeezing his glutes at the top of the
motion (Figure 13.30B).
• Lower under control, until the hips are slightly above the ground and repeat.
• Perform two sets of five slow reps, with a focus on achieving full hip extension,
for each leg.
Additional points:
• It’s common for people to experience a hamstring cramp on the side of the
working leg. If that’s the case, have your client move the foot a few inches further
away from the body (i.e., extend the knee joint), and instruct the client to focus
on pushing more through the heel. In addition, the client might require a few
additional reps before working into full hip extension.
• If your client lacks the strength to perform the exercise with one leg, he or she
can perform it with both legs working at the same time.
THE HAMSTRING MOBILITY CONUNDRUM

How much hamstring mobility your client requires isn’t easy to determine. Some ath-
letes, such as gymnasts and punters, need high levels of it. On the other hand, basket-
ball players benefit from some stiffness in their hamstrings in order to remain explo-
sive. For non-athletes, they need as much hamstring mobility as their life requires.
With regard to low back pain, the benefit of increasing hamstring mobility isn’t clear.
To make matters even more complicated, the hamstrings can have excessive stiffness
whether they’re short or long. When a person is stuck in anterior pelvic tilt, the ham-
strings are under eccentric stretch tension, which causes stiffness. And when a person
has posterior pelvic tilt, it’s because the hamstring are short and stiff. Robert McAtee,
Locked long: A term author of Facilitated Stretching, describes these conditions as being locked long or
popularized by Robert locked short, respectively.
McAtee to describe a muscle
that has stiffness from being Generally speaking, it’s not a good idea to stretch hamstrings that are locked long,
overstretched due to eccentric since the stiffness is due to them already being in a lengthened position. Therefore, if
activity. your client has anterior pelvic tilt, stretches for her hamstrings might lead to more pel-
Locked short: A term vic instability. When the hamstrings are locked short, indicated by a posterior pelvic
popularized by Robert McAtee tilt, hamstring stretches could provide a benefit.
to describe a muscle that has
stiffness due to being held in Assessing hamstring mobility from the popliteal angle (i.e., knee angle) is the most
a shortened position for an common method reported in research. To assess your client’s left hamstring mobility,
extended period. have her lie supine with the left hip and knee flexed to 90°. Then, instruct her to extend
the left knee joint as far as possible while holding the hip at 90°. At her end range,
measure the popliteal angle with a goniometer, or take a photo and draw angles using
a smartphone app. The line should run from the lateral knee, down to lateral malle-
olus, and up to the greater trochanter of the hip. A popliteal angle of less than 125°
indicates excessive shortening (Figure 13.31).
It’s important to know if your client has excessively shortened hamstrings on one, or
both, sides. However, it’s recommended to consult with a health care professional if
your client’s hamstrings are short and stiff. The shortness could be due to protective or
neural tension, indicating a problem in the lumbar spine or pelvis that requires profes-
sional intervention. This is especially true if your client experiences low back pain, or
sciatic nerve pain that travels down the back of her leg.
The hamstrings are the most commonly strained muscle of the hip. The biggest predictor
of a future hamstring injury is a previous one. Therefore, when a client mentions that he
Corrective Exercise
had a previous injury, be sure to work closely with a physi- • Next, instruct him to relax, exhale deeply, and then
cal therapist to determine the appropriate course of action. pull the knee into further extension while the hip
remains fixed at 90°. Hold the stretch position for
Nevertheless, if it’s clear that your client needs to stretch 10 seconds, instructing the client to perform slow,
her hamstrings, and there are no underlying medical diaphragmatic breathing.
issues that are causing the problem, either of following
• Perform four rounds of the contract-relax stretch and
contract-relax stretches will do the trick. then do the same with the right leg, if necessary.
Hamstrings Contract-Relax Stretches How to do it:

There are two ways to have your client stretch his ham-
strings. One version is performed supine; the other is • To stretch the right hamstring, have your client stand
performed while standing. Use whichever version best tall with a long spine, hands on the hips, and chin
tucked. Have your client place his right heel on a
suits your client.
chair or elevated surface that’s high enough for him
to feel a mild-to-moderate stretch in the right ham-
Your client needs it when: string. The right knee joint should be slightly flexed
(Figure 13.32A).
• He or she demonstrates posterior pelvic tilt from the
• Next, cue him to “shift your trunk forward without
postural assessment.
rounding your spine” until a stretch tension of 6–7/10
• His or her popliteal angle is >125°, and has been is felt in the belly of the right hamstring. Then,
cleared of any possible underlying medical problem instruct him to attempt to pull his right heel down
in the lumbar spine or pelvis. against the resistance of the chair (Figure 13.32B).
Have him hold the contraction for five seconds.
How to do it:
• To stretch the left hamstring, have your client lie
supine with his left hip and knee flexed to 90°. Have
him hold the handles of a strong resistance band,
or long towel, with his hands close to his chest. The
band or towel is looped around the bottom of the
left foot (Figure 13.31).
• Instruct him to attempt to flex his left knee against
the resistance of the band or towel. The knee should
flex minimally, if at all. Cue him to “pull the band/
towel toward your chest as you attempt to flex the
left knee.” Hold the contraction for five seconds.
Figure 13.32. Hamstrings contract-relax stretch

from standing. A) Client demonstrates the starting
position to stretch the right hamstring. B) With the trunk
shifted forward, the client attempts to pull the right
heel down during the contract phase of the stretch.
• At the end of the contraction, instruct him to exhale

deeply and then shift the trunk farther forward until a
6–7/10 stretch is felt again. Have him hold the stretch
position for 10 seconds, instructing him to perform
slow, diaphragmatic breathing.
• Perform four rounds of the contract-relax stretch and
Figure 13.31. Hamstrings contract-relax stretch from then do the same with the left leg, if necessary.
supine. Client demonstrates the stretch with a resistance
band. Normal hamstring mobility is >125° when measured at
the popliteal angle, as depicted by the broken line.

234 | Unit 13
Common mistakes: body to release excess tension throughout the superficial

back line that was covered in Unit 2.
• The client has to shift his trunk excessively forward
to feel a hamstring stretch, which can cause low
back strain. The solution is to ensure that a stretch Your client needs it when:
is felt from the standing position before the client is
instructed to shift forward (Figure 13.32A). • Stiffness or soreness is felt in the bottom of the feet.
• The knee joint of the leg that’s being stretched is hy- • Stiffness or soreness is felt in the calves and ham-
perextended. It’s important to keep a slight bend in strings.
the knee to place the stretch tension in the belly (i.e.,
middle) of the hamstring muscle. How to do it:
• The pelvis and/or leg rotate. Be sure the pelvis
remains straight ahead and the toes are pointed • To roll the left plantar fascia, have your client stand
straight up. or sit without shoes. Place a lacrosse ball, or golf
ball, between the bottom of the left foot and floor
• At this point, make a list of the correctives that (Figure 13.33).
helped your client perform the problematic exercise
with better form and/or reduced discomfort during • Instruct your client to roll his foot over the ball,
the exercise. Now, let’s move on to the correctives for focusing on the stiffest/sorest spots. Cue the client
the foot and ankle joints. to “take slow deep breaths while working over the
most sensitive spots.” The level of discomfort should
be 6–7/10 and no higher. Remind the client to remain
PLANTAR FASCIA BALL ROLL calm and relaxed during the roll.
• Perform the roll for one minute, or longer, if your
The first corrective for the feet begins with a soft tissue client prefers. Do the same drill for the right foot if
mobilization drill for the plantar fascia. This tissue often necessary.
becomes excessively stiff due to poor foot mechanics while
standing, walking, and running. Furthermore, the bottom
of each foot has approximately 150,000 nerve endings. CALF BALL ROLL
Mobilizing the plantar fascia not only helps the feet move
The normal amount of dorsiflexion is 20°, as we covered in
better but also sends a powerful signal up through the
Unit 11. To be clear, this means the shin can shift forward
20° during a squat or lunge while the heel remains in con-
tact with the ground. However, much like the hamstring
mobility we discussed earlier, your client might require
more than 20° of dorsiflexion, especially if he or she per-
forms Olympic lifts.
Any restriction in dorsiflexion can be caused by stiffness in
the gastrocnemius, soleus, or both. The soleus is often the
biggest culprit; however, it’s just as easy to mobilize both
muscles, so that’s what the following correctives will do.
Nevertheless, you can determine whether, for example,
Figure 13.34. Calf ball roll. The client demonstrates

Figure 13.33. Plantar fascia ball roll. The client demon- the mobilization drill for the left gastrocnemius and soleus
strates the mobilization drill for the left plantar fascia. muscles.
Corrective Exercise
the right gastrocnemius is shortened. Have your client should be 3–4 inches away from the wall. Instruct
lie supine with the right hip and knee flexed to 90°. Then your client to roll his right foot outward as far as pos-
instruct your client to dorsiflex the right ankle as much sible while maintaining contact with the base of the
as possible and measure the ankle. Next, have your client right big toe. Place a marker lightly against the middle
of the arch to provide tactile feedback. Instruct the
straighten his or her right leg and rest it on the floor.
client to place his hands on his hips (Figure 13.35A).
Measure the dorsiflexion angle again. If it’s any less, the
gastrocnemius has shortened. Remember, the gastrocne- • Next, cue your client to “inhale and then exhale slowly
mius crosses the knee and ankle joints, unlike the soleus as you push your right knee as close to the wall as
possible.” Hold the stretch position for two seconds.
that only crosses the ankle.
Instruct your client to be aware of the marker and to
If you determined that your client needs more dorsiflex- avoid collapsing the arch into it. The trunk should re-
ion in one or both ankles, the following correctives are main vertical during the forward shift (Figure 13.35B).
recommended. A stretch should be felt in the lower portion of the
right calf. Return to the starting position and repeat.
• Perform two sets of 10 slow reps for one, or both,
ankles.
• He or she is unable to maintain heel contact at the
bottom of a squat, forward lunge, or Olympic lift. Common problem:
• His or her dorsiflexion range of motion is <20°.
• The client feels the ankle of the working leg is “stuck,”
especially in the anterior ankle joint. If that’s the case,
How to do it: instruct your client to push the right knee toward the
smallest right toe during the forward shift.
• To roll the left calf muscles, have your client sit on the
floor with his left leg straight. Place a lacrosse ball or
golf ball between the bottom of the left calf and floor
(Figure 13.34).
• Instruct your client to roll his entire calf over the ball,
focusing on the stiffest/sorest spots. Cue the client
to “take slow deep breaths while working over the
most sensitive spots.” The level of discomfort should
be 6–7/10 and no higher. Remind the client to remain
calm and relaxed during the roll.
• Perform the roll for one minute, or longer if your
client prefers. Do the same drill for the right calf if
necessary.
WALL ANKLE MOBILIZATION

If your client lacks dorsiflexion, the next step is to perform
an active mobility drill now that the tissues have been
loosened with the ball roll. The most common compensa-
tion with the wall ankle mobilization drill is that a person
will pronate his or her foot to force extra motion at the an-
kle. Therefore, a marker or pen is placed against the arch
of the foot that’s being worked to provide tactile feedback
so your client will feel whether the arch collapses.
How to do it: Figure 13.35. Wall ankle mobilization. A) The

starting position with a marker placed against the right
• To mobilize the right ankle, have your client stand in a arch to offset pronation. B) The ending position with
split stance with the right leg forward and left foot on the client’s right ankle in maximum dorsiflexion while
the floor behind the trunk. The toes of the right foot maintaining an arch in the foot.

236 | Unit 13
BIG TOE ASSESSMENT AND

STRETCH
The big toe is an important component of performance
during the push-off phase of walking, running, and
jumping. When your client lacks big toe extension,
which is broadly defined as anything less than 70°, it can
produce a chain a compensatory events up through the
legs, hips, and pelvis.
In this case, the assessment is the same as the corrective.
You’ll start by assessing the range of big toe extension on
each foot and then perform a stretch if your client lacks
mobility.
How to do the assessment:

• To assess extension of the right big toe, have your
client rest the outer shin of his right leg on his left
thigh. Instruct the client to cup his left heel with his
left palm and then pull the right toe toward the shin
as far as possible with the left hand (Figure 13.36).
• Take a photo of the stretch position and then use an
app to draw an angle. The lines should run from the
base of the heel to the base of the big toe and up Figure 13.36. Big toe assessment and stretch. The cli-
through the center of the big toe, as shown in Figure ent demonstrates 45° of big toe extension, indicating exces-
13.36. sive stiffness and shortening.
• Perform the same assessment for the left big toe. If

the client has less than 70° of extension on one or
Additional points:
both toes, perform the following stretch. • When a person lacks big toe extension, he or she will
typically rotate her foot outward at the end of the
Your client needs it when: stance phase of gait. Instruct her to keep her foot in
a neutral position when she walks and to focus on
• He or she has <70° of big toe extension. extending through the big toe before lifting the leg
at the end of the stance phase.
How to do the stretch:

• To stretch the right big toe, have your client rest the
outer shin of his right leg on his left thigh. Instruct
the client to cup his left heel with his left palm and
then to pull the right toe toward the shin as far as
possible with the left hand (Figure 13.36).
• Instruct your client to hold the stretch position with a
level of stretch discomfort of 6–7/10 for one minute.
Remind your client to perform slow, diaphragmatic
breathing throughout the stretch. Repeat with the
left toe if necessary.
Corrective Exercise
FOOT INVERSION ASSESSMENT How to do the stretch:

AND STRETCH • To stretch the right peroneals, have your client stand
in a split stance with right leg forward and the major-
The peroneals (i.e., peroneus or fibularis muscles) form ity of weight on his left leg (Figure 13.37A).
a group of three muscles that runs from the lateral shin
• Instruct him to roll his right foot outward, as far as
to the foot. These muscles act to evert the foot; therefore, possible, with the right knee joint fully extended
when they’re shortened, they limit inversion. Stiffness and (Figure 13.37B). A stretch should be felt through the
shortening of the peroneus muscles is a common problem lateral aspect of the right shin.
in people with pronated feet. This is another situation in
• Instruct your client to hold the stretch position with a
which the assessment is the same as the stretch is.
level of stretch discomfort of 6–7/10 for one minute.
Remind your client to perform slow, diaphragmatic
How to do the assessment: breathing throughout the stretch. Repeat with the
left foot if necessary.
• To assess inversion of the right foot, have your client
stand in a split stance with the right leg forward.
The majority of weight should be through his left leg
(Figure 13.37A).
FINAL THOUGHTS
Throughout this unit, you learned many assessments
• Instruct him to fully extend his right knee joint and
and correctives for your clients. Even though these steps
then to roll the right foot outward as far as possible.
If the client has normal mobility of the peroneals,
can be a little time consuming at first, it’s an important
the toes of the right foot will be perpendicular to the process to help your client achieve the highest level of
floor (Figure 13.37B). pain-free performance.
• Perform the same test with the left leg forward. At this point, it’s essential to make a list of the correctives
your client needed. Have your client perform the correc-
tives once or twice each day until the problem is resolved.
There are two ways you’ll know whether the client no lon-
• He or she is unable to invert the foot until the toes are ger needs the corrective. On one hand, he or she will be
perpendicular to the floor (Figure 13.37C). able to pass the relevant tests listed in this unit. But more
importantly, the way to know your client is ready to move
• He or she has pronation while standing.
on is that he or she will be able to perform any functional
exercise without pain and with proper technique.
Figure 13.37. Foot inversion assessment and stretch. A) Starting position to test inversion of the right foot. B) The client
demonstrates a normal range of inversion mobility, indicated by the toes being perpendicular to the ground. C) Client demon-
strates shortness of the right peroneal muscles.

238 | Unit 13
SECTION TWO
SUMMARY
We have covered all the necessary steps to help your client move better while
exercising and improve his or her muscle activation and soft tissue mobility.
In Unit 6, you learned how to gather the necessary information to determine
what movement compensations your client might have. Then in Unit 7, you
learned how to effectively coach and motivate a client. In Units 8–10, we
covered the components of performing a movement analysis. The goal was
first to address any issues your client had with functional exercises before
regressing to correctives. In Unit 11, you learned a five- step process to
improve structural alignment and stability. This simple 10-minute sequence
often produces immediate improvements in any exercise. Unit 12 covered
the exercises that can put your clients back in balance while still giving them
a challenging workout. And in this unit, you learned how to assess and cor-
rect the most common soft tissue limitations.
Finally, it’s important to take full advantage of today’s technology whenever
you can. Use your smartphone, as frequently as your client allows, to take
videos and photos of his or her movement and postural compensations. Use
apps to draw angles when necessary and share this information with your
client. This will help your client better understand the benefits of your correc-
tive exercise program and help ensure a strong, healthy relationship.
Corrective Exercise
References | 239
REFERENCES
INTRODUCTION
Abenheim L, Rossignol M, Valat JP, et al. The role of ac- Woo SL, Hollis JM, Adams DJ, et al. Tensile properties
tivity in the therapeutic management of back pain: Report of the human femur-anterior cruciate ligament-tibia
of the International Paris Task Force on Back Pain. Spine. complex: The effects of specimen age and orientation. Am
2000;25:1S-33S. J Sports Med. 1991;19(3):217-225.
Fisher BE, Southam AC, Kuo YL, et al. Evidence of altered
corticomotor excitability following targeted activation of UNIT 2
gluteus maximus training in healthy individuals. Neurore- Arnoczky SP, Lavagnino M, Whallon JH, Hoonjan A. In
port. 2016;27(6):415-421. situ cell nucleus deformation in tendons under tensile
Han JH, Soojin P, Youngju K, et al. Effects of forward head load; a morphological analysis using confocal laser mi-
posture on forced vital capacity and respiratory muscles croscopy. J Orthop Res. 2002;20(1):29-35.
activity. J Phys Ther Sci. 2016;28(10):128-131. Cheung K, Hume P, Maxwell L. Delayed onset muscle
Harrison DE, Colloca CJ, Harrison DD, et al. Anterior soreness: treatment strategies and performance factors.
thoracic posture increases thoracolumbar disc loading. Sports Medicine. 2003;33(2):145-64.
Eur Spine J. 2005;14(3):234-242. Howatson G, van Someren KA. The prevention and treat-
Kado DM, Huang MH, Karlamangla AS, et al. Hyper- ment of exercise induced muscle damage. Sports Medicine.
kyphotic posture predicts mortality in older communi- 2008;38(6):483-503.
ty-dwelling men and women: a prospective study. J Am Kjaer M, Magnusson P, Krogsgaard M, et al. Extracellular
Geriatr Soc. 2004;52(10):1662-1667. matrix adaptation of tendon and skeletal muscle to exer-
cise. J Anat. 2006;208(4):445-450.
UNIT 1 Myers TW. Anatomy trains. 3rd ed. London, UK: Churchill
Hayashi K. Biomechanical studies of the remodel- Livingston Elsevier; 2014.
ing of knee joint tendons and ligaments. J Biomech.
Rosager S, Aagaard P, Dyhre-Poulsen P, Neergaard K,
1996;29(6):707-716.
Kjaer M, Magnusson SP. Load-displacement properties
Huiskes R, Ruimerman R, van Lenthe GH, et al. Effects of of the human triceps surae aponeurosis and tendon
mechanical forces on maintenance and adaptation of form in runners and non-runners. Scand J Med Sci Sports.
in trabecular bone. Nature. 2000;405(6787):704-706. 2002;12(2):90-98.
Levangie PK, Norkin CC. Joint structure & function: a Schuenke M, Schulte E, Schumacher U. Atlas of anatomy.
comprehensive analysis. 5th ed. Philadelphia, PA: F.A. New York, NY: Thieme New York; 2010.
Davis Company; 2011.
Wackerhage H, Rennie MJ. How nutrition and exer-
Ruimerman R, Hilbers P, van Rietbergen B, et al. A theo- cise maintain the human musculoskeletal mass. J Anat.
retical framework for strain-related trabecular bone main- 2006;208(4):451-458.
tenance and adaptation. J Biomech. 2005;38(4):931-941.
Sampath SA, Lewis S, Fosco M, et al. Trabecular orien- UNIT 3
tation in the human femur and tibia and the relationship Brust, JCM. Current diagnosis & treatment: neurology. 2nd
with lower-limb alignment for patients with osteoarthritis ed. New York, NY: McGraw-Hill Medical; 2012.
of the knee. J Biomech. 2015;48(6):1214-1218.
Fisher BE, Lee YY, Pitsch EA, et al. Method for assessing
Schuenke M, Schulte E, Schumacher U. Atlas of anatomy. brain changes associated with gluteus maximus activa-
New York, NY: Thieme New York; 2010. tion. J Orthop Sports Phys Ther. 2013;43(4):214-221.
Shrive N, Chimich D, Marchuk L, et al. Soft-tissue Fisher BE, Southam AC, Kuo YL, et al. Evidence of altered
“flaws” are associated with the material properties of the corticomotor excitability following targeted activation of
healing rabbit medial collateral ligament. J Ortho Res. gluteus maximus training in healthy individuals. Neurore-
1995:13(6):923-929. port. 2016;27(6):415-421.

240 |
Fisher BE, Wu AD, Salem GJ, et al. The effect of exercise Levangie PK, Norkin CC. Joint structure & function: a
training in improving motor performance and corticomo- comprehensive analysis. 5th ed. Philadelphia, PA: F.A.
tor excitability in people with early Parkinson’s disease. Davis Company; 2011.
Arch Phys Med Rehabil. 2008;89(7):1221-1229.
Neumann DA. Kinesiology of the musculoskeletal system:
Goh HT, Lee YY, Fisher BE. Neural correlates of du- foundations for rehabilitation. 2nd ed. St. Louis, MO: Mos-
al-task practice benefit on motor learning: a repetitive by Elsevier; 2010.
transcranial magnetic stimulation study. Eur J Neurosci.
Schuenke M, Schulte E, Schumacher U. Atlas of anatomy.
2013;37(11):1823-1829.
New York, NY: Thieme New York; 2010.
Jiang C, Ranganathan VK, Zhang J, et al. Motor effort
training with low exercise intensity improves muscle UNIT 5
strength and descending command in aging. Medicine
(Baltimore). 2016;95(24):e3291. Brust, JCM. Current diagnosis & treatment: neurology. 2nd
ed. New York, NY: McGraw-Hill Medical; 2012.
Kandel ER, Schwartz JH, Jessell TM, et al. Principles of
neural science. 5th ed. New York, NY: McGraw-Hill Medi- Cook, G. Movement. Aptos, CA: On Target Publications;
cal; 2013. 2010.
Lin CH, Fisher BE, Wu AD, et al. Neural correlate of the Fisher BE, Lee YY, Pitsch EA, et al. Method for assessing
contextual interference effect in motor learning: a kine- brain changes associated with gluteus maximus activa-
matic analysis. J Mot Behav. 2009;41(3):232-242. tion. J Orthop Sports Phys Ther. 2013;43(4):214-221.
Lin CH, Winstein CJ, Fisher BE, et al. Neural correlates Fisher BE, Morton SM, Lang CE. From motor learning to
of the contextual interference effect in motor learning: physical therapy and back again: the state of the art and
a transcranial magnetic stimulation investigation. J Mot science of motor learning rehabilitation research. J Neurol
Behav. 2010;42(4):223-232. Phys Ther. 2014;38(3):149-150.
Mink, JW. The basal ganglia: focused selection and in- Fisher BE, Wu AD, Salem GJ, et al. The effect of exercise
hibition of competing motor programs. Prog Neurobiol. training in improving motor performance and corticomo-
1996;50(4):381-425. tor excitability in people with early Parkinson’s disease.
Arch Phys Med Rehabil. 2008;89(7):1221-1229.
Pascual-Leone A, Nguyet D, Cohen LG, et al. Modulation
of muscle responses evoked by transcranial magnetic Goh HT, Lee YY, Fisher BE. Neural correlates of du-
stimulation during the acquisition of new fine motor al-task practice benefit on motor learning: a repetitive
skills. J Neurophysiol. 1995;74(3):1037-1045. transcranial magnetic stimulation study. Eur J Neurosci.
2013;37(11):1823-1829.
Petzinger GM, Fisher BE, Van Leeuwen JE, et al. En-
hancing neuroplasticity in the basal ganglia: the role of Kandel ER, Schwartz JH, Jessell TM, et al. Principles of
exercise in Parkinson’s disease. Mov Disord. 2010;25 Suppl neural science. 5th ed. New York, NY: McGraw-Hill Medi-
1:S141-145. cal; 2013.
Purves D, Augustine GJ, Fitzpatrick D, et al. Neuroscience. Kantak SS, Sullivan KJ, Fisher BE, et al. Neural substrates
5th ed. Sunderland, MA: Sinauer Associates; 2012. of motor memory consolidation depend on practice struc-
ture. Nat Neurosci. 2010;13(8):923-925.
Rana M, Yani MS, Asavasopon S, et al. Brain connectivity
associated with muscle synergies in humans. J Neurosci. Lin CH, Fisher BE, Wu AD, et al. Neural correlate of the
2015;35(44):14708-14716. contextual interference effect in motor learning: a kine-
matic analysis. J Mot Behav. 2009;41(3):232-242.
Schmidt RA, Lee TD. Motor learning and performance:
from principles to application. 5th ed. Champaign, IL: Hu- Lin CH, Winstein CJ, Fisher BE, et al. Neural correlates
man Kinetics; 2014. of the contextual interference effect in motor learning:
a transcranial magnetic stimulation investigation. J Mot
Behav. 2010;42(4):223-232.
UNIT 4
Purves D, Augustine GJ, Fitzpatrick D, et al. Neuroscience.
Kendall FP, McCreary EK, Provance PG, et al. Muscles:
5th ed. Sunderland, MA: Sinauer Associates; 2012.
testing and function with posture and pain. 5th ed. Phila-
delphia, PA: Lippincott Williams & Wilkins; 2005. Schmidt RA, Lee TD. Motor learning and performance:
from principles to application. 5th ed. Champaign, IL: Hu-
man Kinetics; 2014.
Corrective Exercise
References | 241
UNIT 6 Hossner EJ, Ehrlenspiel F. Time-referenced effects of

an internal vs. external focus of attention on muscular
Binkley JA, Stratford PW, Lott SA, Riddle DL. The Lower
activity and compensatory variability. Front Psychol.
Extremity Functional Scale (LEFS): scale development,
2010;23;1:230.
measurement properties, and clinical application. Phys
Ther. 1999;79(4):371-383. Kal EC, van der Kamp J, Houdijk H. External attentional
focus enhances movement automatization: a comprehen-
Davenport TE, Kulig K, Sebelski CA, et al. Diagnosis for
sive test of the constrained action hypothesis. Hum Mov
physical therapists: a symptom-based approach. Philadel-
Sci. 2013;32(4):527-539.
phia, PA: F.A. Davis Company; 2013.
Lohse KR, Sherwood DE. Defining the focus of attention:
Downie WW, Leatham PA, Rhind VM, et al. Studies with
effects of attention on perceived exertion and fatigue.
pain rating scales. Ann Rheum Dis. 1978;37(4):378-381.
Front Psychol. 2011;13:332.
Fairchild SL. Pierson and Fairchild’s principles and
McKay B, Wulf G, Lewthwaite R, et al. The self: your own
techniques of patient care. 5th ed. St. Louis, MO: Elsevier
worst enemy? A test of the self-involving trigger hypothe-
Saunders; 2013.
sis. Q J Exp Psychol (Hove). 2015;68(9):1910-1919.
Farrar JT, Portenoy RK, Berlin JA, et al. Defining the
Porter JM, Nolan RP, Ostrowski EJ, et al. Directing atten-
clinically important difference in pain outcome measures.
tion externally enhances agility performance: a qualitative
Pain. 2000;88(3):287-294.
and quantitative analysis of the efficacy of using verbal in-
Farrar JT, Young JP Jr, LaMoreaux L, et al. Clinical structions to focus attention. Front Psychol. 2010;29;1:216.
importance of changes in chronic pain intensity mea-
Vance J, Wulf G, Töllner T, et al. EMG activity as a func-
sured on an 11-point numerical pain rating scale. Pain.
tion of the performer’s focus of attention. J Mot Behav.
2001;94(2):149-158.
2004;36(4):450-459.
Hall, JE. Guyton and Hall: textbook of medical physiology.
Wulf G, Chiviacowsky S, Schiller E, et al. Frequent
12th ed. Philadelphia, PA: Saunders Elsevier; 2011.
external-focus feedback enhances motor learning. Front
Haywood KL. Patient-reported outcome I: measuring Psychol. 2010;11;1:190.
what matters in musculoskeletal care. Musculoskeletal
Wulf G, Dufek JS. Increased jump height with an external
Care. 2006;4(4):187-203.
focus due to enhanced lower extremity joint kinetics. J
Johnson C. Outcome measures for research and clinical Mot Behav. 2009;41(5):401-409.
practice. J Manipulative Physiol Ther. 2008;31(5):329-330.
Wulf G, Dufek JS, Lozano L, et al. Increased jump height
Rowbotham MC. What is a ‘clinically meaningful’ reduc- and reduced EMG activity with an external focus. Hum
tion in pain? Pain. 2001;94(2): 131-132. Mov Sci. 2010;29(3):440-448.
Stratford PW, Binkley JM, Stratford DM. Development Wulf G, Lewthwaite R. Optimizing performance through
and initial validation of the upper extremity functional intrinsic motivation and attention for learning: the
index. Physiother Can. 2001;53(4):259-267. OPTIMAL theory of motor learning. Psychon Bull Rev.
2016;23(5):1382-1414.
Williamson A, Hoggart B. Pain: a review of three
commonly used pain rating scales. J Clin Nurs. Wulf G, Lewthwaite R, Cardozo P, et al. Triple play: ad-
2005;14(7):798-804. ditive contributions of enhanced expectancies, autonomy
support, and external attentional focus to motor learning.
UNIT 7 Q J Exp Psychol (Hove). 2017;24:1-9.
Abdollahipour R, Wulf G, Psotta R, et al. Performance of Wulf G, McNevin N, Shea CH. The automaticity of
gymnastics skill benefits from an external focus of atten- complex motor skill learning as a function of attentional
tion. J Sports Sci. 2015;33(17):1807-1813. focus. Q J Exp Psychol A. 2001;54(4):1143-1154.
Carney DR, Cuddy AJ, Yap AJ. Power posing: brief Wulf G, Shea C, Lewthwaite R. Motor skill learning and
nonverbal displays affect neuroendocrine levels and risk performance: a review of influential factors. Med Educ.
tolerance. Psychol Sci. 2010;21(10):1363-1368. 2010;44(1):75-84.
Chiviacowsky S, Wulf G, Wally R. An external focus of Wulf G, Shea C, Park JH. Attention and motor perfor-
attention enhances balance learning in older adults. Gait mance: preferences for and advantages of an external
Posture. 2010;32(4):572-575. focus. Res Q Exerc Sport. 2001;72(4):335-344.

242 |
Zachry T, Wulf G, Mercer J, et al. Increased movement Huang TS, Ou HL, Huang CY, et al. Specific kine-
accuracy and reduced EMG activity as the result of matics and associated muscle activation in individu-
adopting an external focus of attention. Brain Res Bull. als with scapular dyskinesis. J Shoulder Elbow Surg.
2005;67(4):304-309. 2015;24(8):1227-1234.
Kebaetse, McClure P. Thoracic position effect on shoulder
UNIT 8 range of motion, strength and three-dimensional scapular
Dutton M. Dutton’s orthopaedic: examination, evaluation kinematics. Arch Phys Med Rehabil. 1999; 80(8):945-950.
and intervention. 3rd ed. Columbus, OH: McGraw-Hill Kibler WB. The role of the scapular in athletic shoulder
Education; 2012. function. Am J Sports Med. 1998;26(2):325-336.
Fisher B, Yakura, J. Movement analysis: a different Kibler WB. Biomechanical analysis of the shoulder during
perspective. Ortho Phys Ther Clinics of No Amer 2. tennis. Clin Sports Med. 1995;14(1):79-85.
1993;pp:1-14.
Kibler WB, Sciascia A, Wilkes T. Scapular dyskinesis and
Ling S, Fisher BE. Functional recovery using movement its relation to shoulder injury. J Am Acad Orthop Surg.
analysis and task specific training in an individual with 2012;20(6):364-372.
chronic severe upper extremity hemiparesis. J Neurol Phys
Ther. 2004;28:91-99. Kibler WB, Wilkes T, Sciascia A. Mechanics and path-
omechanics in the overhead athlete. Clin Sports Med.
Hedman LD, Rogers MW, Hanke TA. Neurologic profes- 2013;32(4):637-651.
sional education: linking the foundation science of motor
Control sith physical therapy interventions for movement Lopes AD, Timmons MK, Grover M, et al. Visual scapular
dysfunction. Neurology Report. 1996;20(1):9-13. dyskinesis: kinematics and muscle activity alterations in
patients with subacromial impingement syndrome. Arch
Horak FB, Esselman P, Anderson ME, et al. The effects Phys Med Rehabil. 2015;96(2):298-306.
of movement velocity, mass displaced, and task certainty
on associated postural adjustments made by normal and Ludewig PM, Cook TM. Alterations in shoulder ki-
hemiplegic individuals. J Neurol Neurosurg Psychiatry. nematics and associated muscle activity in people
1984;47:1020-1028. with symptoms of shoulder impingement. Phys Ther.
2000;80(3):276-291.
Viallet F, Massion J, Massarino R, et al. Coordination
between posture and movement in a bimanual load Luime JJ, Verhagen AP, Miedema HS, et al. Does this
lifting task: putative role of a medial frontal region patient have an instability of the shoulder or a labrum
including the supplementary motor area. Exp Brain Res. lesion? JAMA. 2004; 292(16):1989-1999.
1992;88:674-684. Neumann DA. Shoulder complex. In: Neumann DA.
Kinesiology of the musculoskeletal system: foundations for
UNIT 9 rehabilitation. 2nd ed. St. Louis, MO: Mosby Elsevier; 2010.
Belling Sørensen AK, Jørgensen U. Secondary impinge- Sarhmann S. Diagnosis and treatment of movement im-
ment in the shoulder. An improved terminology in impairment syndromes. 1st ed. St. Louis, MO: Mosby; 2001.
pingement. Scand J Med Sci Sports. 2000;10(5):266-278. Struyf F, Nijs J, Baeyens JP, et al. Scapular positioning and
Borstad JD, Ludewig PM. Comparison of scapular movement in unimpaired shoulders, shoulder impinge-
kinematics between elevation and lowering of the arm ment syndrome, and glenohumeral instability. Scand J
in the scapular plane. Clin Biomech (Bristol, Avon). Med Sci Sports. 2011;21(3):352-358.
2002;17(9-10):650-659. Struyf F, Nijs J, Mottram S, et al. Clinical assessment of
Castagna A, Garofalo R, Cesari E, et al. Posterior superior the scapula: a review of the literature. Br J Sports Med.
internal impingement: an evidence-based review [correct- 2014;48(11):883-890.
ed]. Br J Sports Med. 2010;44(5):382-388. Uhl TL, Kibler WB, Gecewich B, et al. Evaluation of clin-
Dutton M. Dutton’s orthopaedic: examination, evaluation ical assessment methods for scapular dyskinesis. Arthros-
and intervention. 3rd ed. Columbus, OH: McGraw-Hill copy. 2009;25(11):1240-1248.
Education; 2012.
Corrective Exercise
References | 243
UNIT 10 de la Motte S, Arnold BL, Ross SE. Trunk-rotation differ-

ences at maximal reach of the star excursion balance test
Cook CE. Orthopedic manual therapy: an evidence-based
in participants with chronic ankle instability. J Athl Train.
approach. 2nd ed. Upper Saddle River, NJ: Pearson Educa-
2015;50(4):358-365.
tion, Inc; 2012.
Dutton M. Dutton’s orthopaedic: examination, evaluation
Daysal GA, Goker B, Gonen E, et al. The relation-
and intervention. 3rd ed. Columbus, OH: McGraw-Hill
ship between hip joint space width, center edge an-
Education; 2012.
gle and acetabular depth. Osteoarthritis Cartilage.
2007;15(12):1446-1451. Frank C, Kobesova A, Kolar P. Dynamic neuromuscular
stabilization & sports rehabilitation. Int J Sports Phys Ther.
2013;8(1):62-73.
and intervention. 3rd ed. Columbus, OH: McGraw-Hill
Education; 2012. Friel K, McLean N, Myers C, et al. Ipsilateral hip abduc-
tor weakness after inversion ankle sprain. J Athl Train.
Hartmann H, Wirth K, Klusemann M. Analysis of
2006;41(1):74-78.
the load on the knee joint and vertebral column with
changes in squatting depth and weight load. Sports Med. Gardner‐Morse MG, Stokes IAF. The effects of abdomi-
2013;43(10):993-1008. nal muscle co-activation on lumbar spine stability. Spine.
1998;23(1):86-92.
Loudon JK, Manske RC, Reiman MP. Clinical mechanics
and kinesiology. Champaign, IL: Human Kinetics; 2013. Gribble P, Robinson R. Differences in spatiotemporal
landing variables during a dynamic stability task in sub-
McGill S. Back mechanic. Gravenhurst, Ontario, Canada:
jects with CAI. Scand J Med Sci Sports. 2010;20(1):e63-71.
Backfitpro, Inc; 2015.
Hodges PW, Cresswell AG, Daggfeldt K, Thorstensson
McGill S. Low back disorders. 3rd ed. Champaign, IL: Hu-
A. In vivo measurement of the effect of intra-abdominal
man Kinetics; 2015.
pressure on the human spine. J Biomech. 2001;34:347-353.
Murray RO. The aetiology of primary osteoarthritis of the
Hodges PW, Eriksson AE, Shirley D, et al. Intra-abdom-
hip. Br J Radiol. 1965;38(455):810-824.
inal pressure increases stiffness of the lumbar spine. J
Neumann DA. Kinesiology of the musculoskeletal system: Biomech. 2005;38(9):1873-1880.
foundations for rehabilitation. 2nd ed. St. Louis, MO: Mos-
Hodges PW, Gandevia SC. Changes in intra-abdominal
by Elsevier; 2010.
pressure during postural and respiratory activation of the
Powers CM. The influence of abnormal hip mechanics on human diaphragm. J Appl Physiol. 2000;89(3):967-976.
knee injury: a biomechanical perspective. J Orthop Sports
Hodges PW, Gandevia SC. Activation of the human dia-
Phys Ther. 2010;40(2):42-51.
phragm during a repetitive postural task. J Appl Physiol.
Reiman MP, Matheson JW. Restricted hip mobility: clini- 2000;522:165-175.
cal suggestions for self-mobilization and muscle re-educa-
Hodges PW, Heijnen I, Gandevia SC. Postural activity of
tion. Int J Sports Phys Ther. 2013;8(5):729-740.
the diaphragm is reduced in humans when respiratory
Sarhmann S. Diagnosis and treatment of movement im- demand increases. J Physiol. 2001;537(Pt 3):999-1008.
pairment syndromes. 1st ed. St. Louis, MO: Mosby; 2001.
Kavcic N, Grenier S, McGill SM. Determining the stabiliz-
ing role of individual torso muscles during rehabilitation
UNIT 11 exercises. Spine. 2004; 29(11):1254-1265.
Bullock-Saxton JE, Janda V, Bullock MI. The influence Kolar P, Sulc J, Kyncl M, et al. Stabilizing function of the
of ankle sprain injury on muscle activation during hip diaphragm: dynamic MRI and synchronized spirometric
extension. Int J Sports Med. 1994;15(6):330-334. assessment. J Appl Physiol. 2010;109:1064-1071.
Cholewicki J, Juluru K, McGill SM. Intra-abdominal Liebenson C. Rehabilitation of the spine: a practitioner’s
pressure mechanism for stabilizing the lumbar spine. J manual. 2nd ed. Baltimore, MD: Lippincott Williams &
Biomech. 1999;32(1):13-17. Wilkins; 2007.
Cholewicki J, Juluru K, Radebold A, Panjabi MM, McGill McGill S. Back mechanic. Gravenhurst, Ontario, Canada:
SM. Lumbar spine stability can be augmented with an ab- Backfitpro, Inc; 2015.
dominal belt and/or increased intra-abdominal pressure.
Eur Spine J. 1999;8(5):388-395.

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McGill S. Low back disorders. 3rd ed. Champaign, IL: Hu- Dutton M. Dutton’s orthopaedic: examination, evaluation
man Kinetics; 2015. and intervention. 3rd ed. Columbus, OH: McGraw-Hill
Education; 2012.
McGill SM, Grenier S, Kavcic N, Cholewicki J. Coordi-
nation of muscle activity to assure stability of the lumbar Eubanks JD. Cervical radiculopathy: nonoperative man-
spine. J Electromyogr Kinesiol. 2003;13(4):353-359. agement of neck pain and radicular symptoms. Am Fam
Physician. 2010;81(1):33-40.
McGill SM, Norman RW, Sharratt MT. The effect of
an abdominal belt on trunk muscle activity and in- Fredericson M, Cookingham AM, Chaudhari BC, et al.
traabdominal pressure during squat lifts. Ergonomics. Hip abductor weakness in distance runners with iliotibial
1990;33:147-60. band syndrome. Clin J Sport Med. 2000;10(3):169-175.
McKeon PO, Hertel J. Systematic review of postural Gebremariam L, Hay EM, van der Sande R, et al. Sub-
control and lateral ankle instability, part I: Can deficits acromial impingement syndrome – effectiveness of
be detected with instrumented testing? J Athl Train. physiotherapy and manual therapy. Br J Sports Med.
2008;43(3):293- 304. 2014;48(16):1202-1208.
Neumann DA. Kinesiology of the musculoskeletal system: Lee JH, Cynn HS, Kwon OY, et al. Different hip rotations
foundations for rehabilitation. 2nd ed. St. Louis, MO: Mos- influence hip abductor muscles activity during isometric
by Elsevier; 2010. side-lying hip abduction in subjects with gluteus medius
weakness. J Electromyogr Kinesiol. 2014;24(2):318-324.
Powers CM. The influence of abnormal hip mechanics on
knee injury: a biomechanical perspective. J Orthop Sports Liebenson C. Rehabilitation of the spine: a practitioner’s
Phys Ther. 2010;40(2):42-51. manual. 2nd ed. Baltimore, MD: Lippincott Williams &
Wilkins; 2007.
Sarhmann S. Diagnosis and treatment of movement im-
pairment syndromes. 1st ed. St. Louis, MO: Mosby; 2001. McGill S. Back mechanic. Gravenhurst, Ontario, Canada:
Backfitpro, Inc; 2015.
Shirley D, Hodges PW, Eriksson Ae, Gandevia SC. Spinal
stiffness changes throughout the respiratory cycle. J Appl McGill S. Low back disorders. 3rd ed. Champaign, IL: Hu-
Physiol. 2003;95:1467-1475. man Kinetics; 2015.
Terada M, Kosik KB, McCann RS, et al. Diaphragm Niemuth PE, Johnson RJ, Myers MJ, et al. Hip muscle
contractility in individuals with chronic ankle instability. weakness and overuse injuries in recreational runners.
Med Sci Sports Exerc. 2016;48(10):2040-2045. Clin J Sport Med. 2005;15(1):14-21.
Van Deun S, Staes FF, Stappaerts KH, Janssens L, Levin Novak CB. Thoracic outlet syndrome. Clin Plast Surg.
O, Peers KK. Relationship of chronic ankle instabili- 2003;30:175-188.
ty to muscle activation patterns during the transition
from double- leg to single-leg stance. Am J Sports Med.
2007;35(2):274-281.
Phys Ther. 2010;40(2):42-51.
Vleeming A, Schuenke MD, Masi AT, et al. The sacroiliac
Reijneveld EA, Noten S, Michener LA, et al. Clinical
joint: an overview of its anatomy, function and potential
outcomes of scapular-focused treatment in patients with
clinical implications. J Anat. 2012;221(6):537-567.
subacromial pain syndrome: a systematic review. Br J
Sports Med. 2017;51(5):436-441.
UNIT 12
Sarhmann S. Diagnosis and treatment of movement im-
Aminaka N, Pietrosimone BG, Armstrong CW, et al. Pa- pairment syndromes. 1st ed. St. Louis, MO: Mosby; 2001.
tellofemoral pain syndrome alters neuromuscular control
and kinetics during stair ambulation. J Electromyogr Kine- Schenkman M, Deutsch JE, Gill-Body KM. An integrated
siol. 2011;21(4):645-651. framework for decision-making in neurologic physical
therapist practice. Phys Ther. 2006;86: 1681-1702.
Barton CJ, Lack S, Malliaras P, et al. Gluteal muscle activi-
ty and patellofemoral pain syndrome: a systematic review. Sidorkewicz N, Cambridge ED, McGill SM. Examining
Br J Sports Med. 2013;47(4):207-214. the effects of altering hip orientation on gluteus medius
and tensor fascae latae interplay during common non-
Davenport TE, Kulig K, Sebelski CA, Gordon J, Watts weight-bearing hip rehabilitation exercises. Clin Biomech
HG. Diagnosis for physical therapists: a symptom-based (Bristol, Avon). 2014;29(9):971-976.
approach. Philadelphia, PA: F.A. Davis Company; 2013.
Corrective Exercise
References | 245
Taunton JE, Ryan MB, Clement DB, et al. A retrospective Harris KD, Heer DM, Roy TC, et al. Reliability of a
case-control analysis of 2002 running injuries. Br J Sports measurement of neck flexor muscle endurance. Phys Ther.
Med. 2002;36(2):95-101. 2005;85(12):1349-1355.
Wilcox EL, Burden AM. The influence of varying hip Harvey D. Assessment of the flexibility of elite ath-
angle and pelvis position on muscle recruitment patterns letes using the modified Thomas test. Br J Sports Med.
of the hip abductor muscles during the clam exercise. J 1998;32(1):68-70.
Orthop Sports Phys Ther. 2013;43(5):325-331.
Heiderscheit BC, Chumanov ES, Michalski MP, et al. Ef-
Willy RW, Meira EP. Current concepts in biomechanical fects of step rate manipulation on joint mechanics during
interventions for patellofemoral pain. Int J Sports Phys running. Med Sci Sports Exerc. 2011;43(2):296-302.
Ther. 2016;11(6):877-890.
Hrysomallis C. Hip adductors’ strength, flexibility, and
injury risk. J Strength Cond Res. 2009;23(5):1514-1517.
UNIT 13
Jaggi A, Noorani A, Malone A, et al. Muscle activation
Bae WS, Lee HO, Shin JW, et al. The effect of middle and patterns in patients with recurrent shoulder instability. Int
lower trapezius strength exercises and levator scapulae J Shoulder Surg. 2012;6(4):101-107.
and upper trapezius stretching exercises in upper crossed
syndrome. J Phys Ther Sci. 2016;28(5):1636-1639. Janda V. Muscle function testing. London: Butterworths,
1983.
Butler RJ, Davis IS, Hamill J. Interaction of arch type and
footwear on running mechanics. Am J Sports Med. 2006; Kibler WB, Ludewig PM, McClure PW, et al. Clinical
34(12):1998-2005. implications of scapular dyskinesis in shoulder injury: the
2013 consensus statement from the ‘Scapular Summit.’ Br
Chiu TT, Lam TH, Hedley AJ. A randomized controlled J Sports Med. 2013;47(14):877-885.
trial on the efficacy of exercise for patients with chronic
neck pain. Spine. 2005;30(1):E1-E7. Kim GM, Ha SM. Reliability of the modified Thomas
test using a lumbo-pelvic stabilization. J Phys Ther Sci.
Davenport TE, Kulig K, Sebelski CA, Gordon J, Watts 2015;27(2):447-449.
HG. Diagnosis for physical therapists: a symptom-based
approach. Philadelphia, PA: F.A. Davis Company; 2013. Kuo L, Chung W, Bates E, et al. The hamstring index. J
Pediatr Orthop. 1997;17(1):78-88.
DiFiori JP, Puffer JC, Aish B, et al. Wrist pain in young
gymnasts: frequency and effects upon training over 1 Liebenson C. Rehabilitation of the spine: a practitioner’s
year. Clin J Sport Med. 2002; 12(6):348-353. manual. 2nd ed. Baltimore, MD: Lippincott Williams &
Wilkins; 2007.
Dimitriadis Z, Kapreli E, Strimpakos N, et al. Reliability
of the chin tuck neck flexion test for assessing short neck Lynn SK, Padilla RA, Tsang KW. Difference in static- and
flexors in healthy individuals. Physiother Theory Pract. dynamic-balance task performance after 4 weeks of in-
2015;31(4):299-302. trinsic-foot-muscle training: the short-foot exercise versus
the towel-curl exercise. J Sport Rehabil. 2012, 21:327-333.
and intervention. 3rd ed. Columbus, OH: McGraw-Hill Martin RL, Davenport TE, Paulseth S, et al. Ankle stabil-
Education; 2012. ity and movement coordination impairments: ankle liga-
ment sprains. J Orthop Sports Phys Ther. 2013;43(9):A1-40.
Ferber R, Davis IM, Williams DS 3rd. Gender differences
in lower extremity mechanics during running. Clin Bio- McGill S. Back mechanic. Gravenhurst, Ontario, Canada:
mech. 2003;18(4):350-357. Backfitpro, Inc; 2015.
Feinberg JH. Hip pain: differential diagnosis. J Back Mus- McGill S. Low back disorders. 3rd ed. Champaign, IL: Hu-
culoskeletal Rehabil. 1994;4(3):154-173. man Kinetics; 2015.
Hansen P, English M, Willick SE. Does running cause Novacheck TF. Running injuries: A biomechanical ap-
osteoarthritis in the hip or knee? PM R. 2012;4(5 proach. Instr Course Lect. 1998;47: 397-406.
suppl):S117-121. Paine R, Voight ML. The role of the scapula. Int J Sports
Harrington S, Meisel C, Tate A. A cross-sectional study Phys Ther. 2013;8(5):617-629.
examining shoulder pain and disability in division I Pink M, Perry J, Houglum PA, Devine DJ. Lower extrem-
female swimmers. J Sport Rehabil. 2014;23(1):65-75. ity range of motion in the recreational sport runner. Am J
Sports Med. 1994;22(4):541-549.

246 |

Phys Ther. 2010;40(2):42-51.
Reber L, Perry J, Pink M. Muscular control of the ankle in
running. Am J Sports Med. 1993;21(6):805-810.
Sahrmann S. Diagnosis and treatment of movement
impairment syndromes. 1st ed. Maryland Heights, MO:
Mosby; 2001.
Swift TR, Nichols FT. The droopy shoulder syndrome.
Neurology. 1984;34:212-215.
Thompson NS, Baker RJ, Cosgrove AP, et al. Musculo-
skeletal modeling in determining the effect of botulinum
toxin on the hamstrings of patients with crouch gait. Dev
Med Child Neurol. 1998;40(9):622-625.
Vigotsky AD, Lehman GJ, Beardsley C, et al. The modi-
fied Thomas test is not a valid measure of hip extension
unless pelvic tilt is controlled. PeerJ. 2017.
Wilson JD, Bjorhus JS, Williams DS 3rd, et al. Short-term
changes in running mechanics and foot strike pat-
tern after introduction to minimalist footwear. PM R.
2014;6(1):34-43.
Yeşilyaprak SS, Yüksel E, Kalkan S. Influence of pectoralis
minor and upper trapezius lengths on observable scapular
dyskinesis. Phys Ther Sport. 2016;19:7-13.
Yoo WG. Effect of the neck retraction taping (NRT) on
forward head posture and the upper trapezius muscle
during computer work. J Phys Ther Sci. 2013;25(5):581-582.
Corrective Exercise
Glossary | 247
GLOSSARY
A
Abdominal cavity: The space between the diaphragm and Belonging: The need to feel connected to others and part
pelvis that contains the abdominal organs. of society.
Acetabular depth: The perpendicular distance between
the roof of the acetabulum and a straight line that runs C
between the lateral edge of the acetabulum and pubic
symphysis. Capacity: The ability to do something successfully.
Acetylcholine: The chemical a motor neuron releases to Cardiovascular endurance: The ability of the heart, lungs,
cause muscle contractions. and blood vessels to deliver oxygen to tissues in the body.
Action potential: The electrical signal produced by a neu- Cauda equina: A bundle of spinal nerves that begin
ron or muscle spindle. around the second lumbar vertebrae where the spinal cord
ends.
Acute pain: Normal, short-term pain or the initial pain
that indicates a more serious injury. Caudal: Toward the feet.
Alpha-gamma co-activation: A process that allows a Cell body: The region of a neuron that contains the DNA
muscle spindle to contract at the same rate as the muscle and cytoplasm.
where it resides. Center of mass: The point of relatively equal distribution
Anatomical position: The position from where all loca- of mass within the human body.
tions of the body and movements are referenced. Central nervous system (CNS): The nervous system cells
Appendicular skeleton: The bones of the upper and lower that make up the brain and spinal cord.
extremities. Cerebral cortex: The outermost layer of the brain.
Arthrokinematics: The motions that occur at the articu- Cerebrospinal fluid (CSF): A clear fluid found in the brain
lating surfaces between bones. and spinal cord that protects and cleans the brain.
Ascending tract: A bundle of axons that carry sensory Cervical enlargement: The larger diameter area of the spi-
information through the spinal cord to the brain. nal cord that contains the nerves that travel to the upper
Autonomic nervous system: The division of the peripheral limbs.
nervous system that controls subconscious actions such as Cervical nerves: Eight pairs of spinal nerves that exit the
breathing, heart rate, and digestive processes. cervical region of the vertebral column above each cor-
Autonomy: The need to feel control and independence. responding vertebrae except for the C8 spinal nerve that
exits below the C7 vertebrae.
Axial plane: An imaginary plane that divides the body
into superior and inferior segments. Chronic pain: Any pain lasting longer than 12 weeks.
Axial skeleton: The bones of the skull, vertebral column, Closed-loop motor control: The motor learning process
sternum, ribcage and sacrum. that uses sensory feedback to develop a motor program.
Axon: The projection of a neuron that transmits an action Coccygeal nerves: One pair of spinal nerves that exits
potential away from the neuron. below the sacrum.
Competence: The need to feel capable of doing something
successfully.
B
Complex movement: A movement that involves motion at
Basal ganglia: Structures within the cerebrum that two or more joints.
communicate with the motor cortex to help initiate
movement.
Base of support: The area of contact beneath a person.

248 |
Concentric action: An action that occurs when an acti-

vated muscle shortens. Eccentric action: An action that
E
occurs when an activated muscle lengthens. Isometric Eccentric phase: The portion of a movement when the
action: An action that occurs when an activated muscle muscles lengthen to yield the direction of resistance.
remains in a static position. Epiphyseal line: A line of cartilage near the end of mature
Concentric phase: The portion of a movement when the long bones.
muscles are shortening to overcome the direction of Epiphyseal plate: The location of bone growth near the
resistance. end of immature bones.
Coronal plane: An imaginary plane that divides the body External cues: Cues that target something outside the
into anterior and posterior segments. body and require an external focus.
Corpus callosum: Neural fibers that connect the right and Extrapyramidal tract: A pathway from the brainstem that
left cerebral hemispheres. helps regulate involuntary movement.
Cranial nerves: Twelve pairs of nerves that emerge from
the brain or brainstem to relay pure sensory, pure motor,
or sensory and motor information to the head. F
Critical events: The necessary steps for performing a Fallen arch: Chronic, excessive pronation of the feet.
movement with ideal technique. Documentation: The Feedback: The verbal information given to a client regard-
process of writing down what you see and do in a training ing exercise performance.
session. Hypothesis: A proposed explanation made based
on limited evidence. Frontal plane: An imaginary plane that divides the body
into anterior and posterior segments.
Functional exercise: An exercise that closely mimics the
D actions necessary for a person’s life or sport.
Degrees of freedom: The number of independent move-
ments allowed at a joint.
G
Dendrites: The portion of a neuron that receives informa-
tion from other neurons. Glia: A nervous system cell that protects and nourishes
neurons but doesn’t produce an action potential.
Descending tract: Bundle of upper motor neuron axons
that travel through the spinal cord to activate lower motor Glia: The nervous system cell that protects and supports
neurons. neurons but does not produce action potentials.
Diaphragmatic breathing: Type of breathing that is Golgi tendon organ (GTO): A sensory receptor within
primarily driven by contraction and relaxation of the the tendons of a muscle that detects changes in muscle
diaphragm. tension.
Direction of resistance: A vector that represents the direc- Gray matter: The portion of the brain and spinal cord that
tion and magnitude of load produced by a free weight, a contain axons with little or no myelin and cell bodies.
cable, or a band.
Direction of rotation: The curved direction of movement H
around an axis. Henneman’s size principle: The fixed, orderly recruitment
Distal: Moving away from where a limb attaches to the of motor neurons from smallest to largest.
trunk. Hip dysplasia: An abnormal shape or position of the hip
Dynamic stabilizer: A muscle that performs a concen- socket. Annulus fibrosus: The outer fibrous layer of an
tric and/or eccentric action to stabilize a joint during intervertebral disc.
movement. Hip strategy: A reliance on the hip extensors to initiate a
squat, which reduces the demands at the knee joints.
Homeostasis: The process of keeping physiological sys-
tems stable.
Corrective Exercise
Glossary | 249
Huntington’s disease: A movement disorder caused by Lower crossed syndrome: A series of lower body compen-
damage to the cells of the basal ganglia. sations, described by Prof. Janda, due to poor posture.
Lower Extremity Functional Scale: An evidence-based
I outcome measure that quantifies a person’s functional
ability for movements that involve the lower limbs.
Insertion: The attachment of a muscle closest to the feet
when viewed from the anatomical position. Lower motor neuron: A peripheral nervous system cell
whose cell body is in the brainstem or spinal cord that
Internal cues: Cues that target the inside of the body and innervates muscles or glands.
require an internal focus.
Lumbar enlargement: The larger diameter area of the spi-
Interneuron: A nervous system cell that creates circuits nal cord that contains the nerves that travel to the lower
between motor or sensory neurons, and within the brain limbs.
and spinal cord.
Lumbar nerves: Five pairs of spinal nerves that exit the
Intra-abdominal pressure (IAP): Pressure within the lumbar region of the vertebral column below each corre-
abdominal cavity. sponding vertebrae.
Isolation exercise: An exercise that involves motion at one Lumbopelvic control: The ability of the nervous system to
joint. stabilize the lumbar and pelvic regions during movement.
IT band syndrome: Excessive stiffness and/or inflamma-
tion of the iliotibial band due to overuse.
M
Meaningful change: A change that is detectable to the
J client.
Just Right Challenge: The correct combination of motiva- Meaningful experience: An experience that caters to a
tion, feedback, and capacity during a corrective exercise person’s psychological needs without negatively affecting
session. the exercise parameters.
Medial: Toward the midline of the body.
K Medical pain: The type of discomfort that could be caused
Kinematics: An area of mechanics that describes the by a medical condition, which requires the intervention
motions of a body. from a medical professional.
Knee strategy: A compensation seen when the knees push Meninges: The membranes that cover the brain and spinal
forward at the beginning of a squat, which usually indi- cord to provide protection and nourishment.
cates weakness of the hip extensors. Minimum detectable change: The smallest detectable
Knee valgus: An inward buckling of the knees due to change that can be considered above a measurement error.
weakness in the hips and/or feet. Long-term potentiation: Mixed nerve: A bundle of axons that carries sensory, mo-
A long-lasting increase in synaptic strength between two tor, and autonomic information.
neurons.
Motivation: The general desire to do something.
Knowledge of results: A form of verbal feedback where
information is given at the end of the task. Motor (efferent) nerve: A bundle of axons that carries
motor information away from the brain or spinal cord to
muscles or glands.
L Motor cortex: The region of the brain consisting of the
Lateral: Away from the midline of the body. premotor cortex, primary motor cortex, and supplementa-
ry motor area that primarily controls movement.
Locked long: A term popularized by Robert McAtee to de-
scribe a muscle that has stiffness from being overstretched Motor learning: A process that develops or changes the
due to eccentric activity. way the nervous system performs a movement.
Locked short: A term popularized by Robert McAtee to Motor neuron pool: A vertical column of cell bodies with-
describe a muscle that has stiffness due to being held in a in the spinal cord that innervate a single muscle.
shortened position for an extended period.

250 |
Motor neuron: A nervous system cell that transmits infor-

mation away from the spinal cord to muscles or glands.
O
Objectives: The goals of a movement.
Motor program: The movement produced automatically
by the brain. Neuroplasticity: The ability for the central Open scissors syndrome: The combination of ribcage
nervous system to change its structure and function based elevation and anterior pelvic tilt that alters movement
on the input it receives. mechanics and reduces intra-abdominal pressure.
Motor unit: A lower motor neuron and all the muscle Open-loop motor control: The execution of a motor pro-
fibers it innervates. gram that doesn’t involve sensory feedback.
Movement analysis: A process of analyzing how a client Organ system: A group of organs and tissues working
moves. together to perform specific functions.
Movement pain: The type of discomfort that’s not a Origin: The attachment of a muscle closest to the head
medical problem and often caused by a lack of strength, when viewed from the anatomical position.
mobility, and/or motor control. Ossification: The hardening process of bones during
Multiplanar motion: Movement that occurs in more than development.
one plane. Outcome goal: The ultimate goal of the client, which isn’t
Multiple Sclerosis: A disease that damages the myelin that under the trainer’s control. Performance goal: A measur-
surrounds an axon. able, specific, and realistic outcome you establish with a
client.
Muscle spindle: A sensory receptor contained in the mus-
cle belly that detects changes in muscle length and helps Outcome measure: The result of a test used to determine a
regulate contraction. person’s baseline function.
Muscle spindle: A sensory receptor within the skeletal
muscle belly that detects changes in muscle length. P
Myelin: A fatty sheath around the axon of a nerve that Pain intensity measurement scale: An outcome measure
provides electrical insulation, protection, nourishment, scale that has been shown to effectively determine a per-
and faster signal transmission. son’s level of discomfort.
Parasympathetic nervous system: The division of the auto-
N nomic nervous system that generates the “rest or digest”
response.
Neural tension: The inability of a nerve to move freely,
which often causes pain. Parkinson’s disease: A movement disorder caused by a
deficiency of dopamine in the basal ganglia.
Neural tract: A bundle of axons within the CNS that car-
ries motor or sensory information. Pelvic floor: The muscular base of the abdomen that at-
taches to the pelvis.
Neuromuscular junction: The area between a motor neu-
ron and muscle fiber where acetylcholine is released. Peripheral nervous system (PNS): The nervous system
cells that provide information to the brain and spinal
Neuron: The nervous system cell that produces action cord.
potentials to communicate with other neurons, muscles,
or glands. Plantar aponeurosis: A strong layer of connective tissue
on the bottom of the foot.
Neuroplasticity: The brain’s ability to form new
connections. Proactive approach: An action or actions taken to solve a
potential problem.
Norepinephrine: The hormone/neurotransmitter released
by the CNS and sympathetic nervous system that triggers Proprioceptors: Sensory receptors in the muscles and
the “fight or flight” response. joints that transmit information to the CNS.
Nucleus pulposus: The inner jelly-like fluid of an interver- Protective tension: Stiffness within soft tissue that re-
tebral disc. stricts mobility. Temporomandibular joints (TMJ): Joints
that allow the mouth to open and close. Deep neck flexors:
Muscles in the anterior neck that flex the cervical spine.
Corrective Exercise
Glossary | 251
Proximal: Moving closer to where a limb attaches to the Skeletal muscle: The contractile tissue that produces force
trunk. in the human body.
Pulling force: A force a muscle produces to shorten. Somatic nervous system: The division of the peripheral
nervous system that controls voluntary movement.
Pyramidal tract: A pathway from the motor cortex that
helps regulate voluntary movement. Somatosensory system: The structures and neurons that
connect receptors within skin, muscle and joints to the
cerebellum.
Q
Spinal nerves: Thirty-one pairs of nerves that emerge from
Quantifiable data: Information that can be measured or the spinal cord to relay motor sensory and autonomic
counted. information from the neck to the feet, except for the C1
spinal nerve that transmits pure motor information.
R Static stabilizer: A muscle that performs an isometric
contraction to stabilize a joint during movement.
Reactive approach: An action or actions taken to solve a
problem after a person realizes the problem exists. Stress fracture: A thin bone crack due to an accumulation
of microdamage.
Red flags: Symptoms associated with conditions that
might require the care of a medical professional. Stretch Reflex: A neural circuit that allows activation
of a muscle to occur with simultaneous relaxation of its
Reliable: When a significant result has been shown to be antagonist.
repeatable in different populations.
Suboccipitals: Four pairs of muscles located between the
Remodeling: When a bone changes shape either by in- lower posterior skull and upper vertebrae that extend and
creasing or decreasing its diameter. rotate the cervical spine.
Resistance force: An external force that opposes the force Subtalar joint: Where the talus and calcaneus meet in the
a muscle produces to shorten. Plantar fasciitis: A common foot.
cause of heel pain due to an irritation of the connective
tissue on the bottom of the foot. Sympathetic nervous system: The division of the auto-
nomic nervous system that generates the “fight or flight”
response.
S Synapse: An area between neurons, or between a neuron
Sacral nerves: Five pairs of spinal nerves that exit the and muscles or glands, where electrical or chemical sig-
sacrum at the lower end of the vertebral column. nals are transmitted.
Sagittal plane: An imaginary plane that divides the body Synaptic plasticity: The ability of synapses to strengthen
into right and left segments. or weaken based on the activity they receive.
Sarcomere: The functional unit of a skeletal muscle fiber.
Myosin: The thick myofilament contained within a sar-
comere. Actin: The thin myofilament contained within a
T
sarcomere. Tendon: A strong connective tissue made primarily of
collagen that connects muscle to bone.
Sense of balance: The feeling of being stable due to input
from the visual, vestibular and somatosensory systems. Thoracic cavity: The space enclosed by the ribs, verte-
bral column, and sternum where the heart and lungs are
Sensory (afferent) nerve: A bundle of axons that carries contained.
sensory information into the brain or spinal cord.
Thoracic nerves: Twelve pairs of spinal nerves that exit
Sensory neuron: A nervous system cell that transmits in- the thoracic region of the vertebral column below each
formation regarding movement, sight, touch, sound, and corresponding vertebrae.
smell to the brain and spinal cord.
Transverse plane: An imaginary plane that divides the
Shoulder girdle: Where the clavicle and scapula connect body into superior and inferior segments.
the humerus to the axial skeleton.

252 |
Triplanar motion: Movement that occurs in the three

anatomical planes.
Type I collagen: A structural protein contained within
a tendon. Fascicle: A bundle of muscle fibers contained
within a skeletal muscle. Myofibril: A rod-like unit of a
muscle cell made up of sarcomeres.
U
Upper crossed syndrome: A series of upper body com-
pensations, described by Prof. Janda, due to a slumped
posture.
Upper Extremity Functional Index: An evidence-based
outcome measure that quantifies a person’s functional
ability for movements that involve the upper limbs.
Upper motor neuron: A central nervous system cell that
synapses with lower motor neurons.
V
Valid: When the results of a study meet all the require-
ments of the scientific research method.
Ventral: The anterior portion of the body. Dorsal: The
posterior portion of the body. Cranial: Toward the top of
the head.
Ventricles: Cavities in the brain that contain cerebrospinal
fluid.
Vestibular system: The structures and neurons that
connect the semicircular canals in the inner ear to the
brainstem.
Visual system: The structures and neurons that connect
the eyes to the cortex of the brain.
W
White matter: The portion of the brain and spinal cord
that contain myelinated axons.
Corrective Exercise
Index | 253
INDEX repair 15
structure 16
A blood and nerve supply 17

bony protrusions 17
acetabular depth 157
cancellous 16
acetylcholine 46
compact 16
action potential 45
cortical 16
activation exercises 190
spongy 16
acute pain 102
trabecular 16
agonist 29
bony protrusions 17
alpha-gamma co-activation 57
brain
anatomical position 62
ventricles 48
anatomical terms of location 62
brainstem 47
annulus fibrosus 159
circuits 57
antagonist 29
anterior 63
C
anterior cruciate ligament 4
calf ball roll 234
anterior pelvic tilt 226
cancellous bone 16
appendicular skeleton 13, 14
capacity 114, 117
arm elevation 141
capsular ligament 19
arthrokinematics 142
cardiac muscle 26
ascending sensory tracts 55
cardiovascular endurance 119
ascending tracts 53
cartilage
athletic trainers 5
elastic cartilage 18
autonomic nervous system 47
fibrocartilage 18
autonomy 114
hyaline cartilage 18
axial plane 64
structure and function 18
axial skeleton 13, 14
cat-camel 227
axon 45
cauda equina 49
B caudal 63
cell body 45
balance 82
center of mass 82
ball wall push with hip hinge 224
central nervous system 45, 47
basal ganglia 58
components of 47
base of support 82
cerebellum 47
belonging 115
cerebral cortex 53
big toe assessment and stretch 236
cerebrospinal fluid 48
bone
cervical enlargement 49
cartilage 18
cervical nerves 50
function 14
cervical rotation assessment 217
growth 14
cervical rotation with towel 217
remodeling 15

254 |
chest opener 221 E

chin tuck 216
eccentric action 28
chin tuck with lacrosse ball 216
eccentric phase 124
chiropractors 3
elastic cartilage 18
chronic pain 102
elastin 19
closed-loop motor control 85, 86
empirical evidence 7
coccygeal nerves 50
endosteum 16
compact bone 16
ense of balance 84
competence 115
epiphyseal line 15
concentric action 28
epiphyseal plate 15
concentric phase 124
equilibrium 84
coronal plane 64
exercise
corpus callosum 47
and injury risk 6
corrective exercise
exercises
benefits of 4
activation 190
defined 6
downward dog 204
cortical bone 16
hard style plank 191
cranial 63
hip hinge 195
critical events 125
lateral step with mini band 198
modified side plank with band 192
D
monster walk 199
deep neck flexors (DNF)
plank roll 204
activation 218
posterior tibialis activation 200
degrees of freedom 149
PSH with head movement 201
dendrites 45
reverse goblet lunge with band 193
deposition 15
scapular activation 207
descending motor tracts 53
sphinx with reach 206
figure 54
squat or deadlift with mini band 194
pathway to skeletal muscles 54
standing fire hydrant with mini band 197
diaphragmatic breathing 177
wall elbow walk with band 203
direction of resistance 65
Y raise on a swiss ball 205
direction of rotation 65
external cues 116
distal 63
extrinsic ligament 19
DNS t-spine extension 223
documentation abbreviations 127 F
dorsal 63
facia
dorsiflexion
fascial lines 34
posture and 167
structure and function 33
downward dog 204
fallen arch 164
durable body 5
fascia 33
dynamic stabilizer 143
fascial lines 34
Corrective Exercise
Index | 255
feedback 114, 116 hip strategy 162

fibrocartilage 18 human skeleton 12
foot inversion assessment and stretch 237 Huntington’s disease 58
foot muscles 36 hyaline cartilage 18
force-couple 30
forebrain 47 I
forward head posture 2 iliotibial (IT) band 181
frontal plane 64 TFL and 188
functional exercise 137 inferior 63
functional movement 7 injury risk

and exercise 6
G insertion 26
glenohumeral joint internal cues 116
mobility and stability 139 interneuron 45
glia 45, 46 interneurons 56
goblet squat intervertebral discs 3
compensations 162 intra-abdominal pressure 146
golgi tendon organ 57 intrinsic ligament 19
gray matter 48 isolation exercise 118
isometric action 28
H
hamstring mobility 232 J
locked long 232 joint 22
locked short 232 capsule 20
hamstrings contract-relax stretches 233 names and locations 22
hard style plank 191 joint actions 62
Haversian systems 17 ankle / foot 78
Henneman’s size principle 52 cervical spine 66
high-intensity exercise 3 elbow 76
hip correctives 229 hip 73
calf ball roll 234 knee 75
hamstrings contract-relax stretches 233 shoulder girdle 67
hip flexors contract-relax stretch 230 thoracic and lumbar spine 72
plantar fascia ball roll 234 wrist 77
single-leg hip thrust 231 joint capsule 20
TFL ball roll 231 joints 22
hip dysplasia 157 primary 23
hip flexors contract-relax stretch 230 Just Right Challenge 114, 118
hip hinge 195
hip hinge with mini band 196 K
posture 195 kinematics 140

256 |
knee strategy 162 motor cortex 53

knee valgus 90 motor learning 85, 90
motor neuron 45
L motor neuron pool 52
lateral 63 motor program 85
lateral step with mini band 198 motor programs 6
ligament motor unit 52
capsular ligament 19 movement 3, 82
creep, laxity and tears 20 overview 82
extrinsic ligament 19 movement analysis 123
figure 19 one-arm shoulder press - form 153
intrinsic ligament 19 step 1 124
structure and function 19 step 2 125
long-term potentiation 91 step 3 127
lower body correctives 227 step 4 129
cat-camel 227 step 5 131
Thomas Test - modified 227 movement dysfunctions 4
lower crossed syndrome 226 movement pain 98
Lower Extremity Functional Scale 104, 111 multi-joint movement analysis
lower motor neuron 52 goblet squat - form 171
lumbar enlargement 49 lower body 156
lumbar nerves 50 lower body - form 172
lumbopelvic control 150 squat 156
upper body 136
M upper body - form 154
major muscle groups 31, 32 multiplanar motions 64
meaningful experience 114 multiple sclerosis 46
medial 63 muscle
medical doctors 3 abdominal 39
medical pain 98 action 28
medulla 47 cardiac 26
medullary cavity 16 charts 36
meninges 48 common underactive 189
midbrain 47 foot 36
minimum detectable change 104 forearm 41
mixed nerve 50 glenohumeral joint 40
mobility 3 mobility and stability 139
modified side plank with band 192 hand 42
monster walk 199 hip 38
motivation 114 insertion 26
motor control 3 lower leg 37
Corrective Exercise
Index | 257
major muscle groups 31, 32 peripheral nervous system 45

neck/head 42 sympathetic nervous system 47
origin 26 neural tracts 53
roles 29 neuromuscular junction 46
rotator cuff 40 neurons 45
shoulder 39 neuroplasticity 59, 85
skeletal 26 New Client Questionnaire 106
smooth 26 nociceptors 18
thigh 37 nucleus pulposus 159
upper arm 40
muscle action 28 O
concentric action 28 Olympic lifts 3
eccentric action 28 omatosensory system 84
force-couple 30 omplex movement 116
isometric action 28 open-loop motor control 85, 89
muscle attachments open scissors syndrome 146
insertion 26 organ system 12
origin 26 origin 26
muscle imbalances 4 ossification 14
muscle roles osteoarthritis 18
agonist 29 osteoblasts 16
antagonist 29 osteoclasts 16
synergist 29 osteocytes 16
muscle spindle 45, 57 osteons 17
muscular system 26 osteoporosis 16
myelin 46 outcome goal 99

outcome measure 101
N overhead press 142
neck correctives 216 movement analysis 143
cervical rotation assessment 217
cervical rotation with towel 217 P
chin tuck 216 pain intensity measurement 101
chin tuck with lacrosse ball 216 parasympathetic nervous system 47
upper trapezius and levator scapulae stretches 218 Parkinson’s disease 58
nerves 49 PAR-Q+ 107
nervous system 6, 44 pectoralis ball roll 221
cells of 45 pectoralis minor and major length assessment 220
central nervous system 45, 47 pelvic alignment 179
components of 45 performance goal 101
functions of 44 periosteum 16
parasympathetic nervous system 47 peripheral nervous system 45, 47

258 |
personal trainer 2 Q
vs physical therapist 2
quadruped rock back test 159, 160
physiatrist 3
quality of life 7
physical therapist 2
quantifiable data 104
role of 2
planes of movement 64 R
axial / transverse 64
reciprocal innervation 57
coronal / frontal 64
reliable 104
sagittal 64
remodeling 15
plank roll 204
resistance force 28
plantar aponeurosis 34
resorption 15
plantar fascia ball roll 234
restore alignment and stability 174
plantar fasciitis 33
step 1 175
Plato 2
step 2 178
pons 47
step 3 178
posterior 63
step 4 180
posterior pelvic tilt 226
step 5 181
posterior shoulder ball roll 225
restore mobility 186
posterior tibialis activation 200
mobility and stability 187
postural assessment 210, 211
reverse goblet lunge with band 193
assess progress 215
risk factor 2
computer / smartphone 213
risk factors 2
frontal plane 212
rotator cuff 2
standing posture 211
upper crossed syndrome 213 S
postural stability hold 182 sacral nerves 50
with head movement 201 sagittal plane 64
posture 2 sarcomeres 27
powerlifting 3 scapular activation 207
preparing for the client scapulohumeral rhythm 138
five questions 97 scapulothoracic joint 70
red flags 96 mobility and stability 139
referring 98 sensory feedback 54
step 1 96 sensory nerve 50
step 2 99 sensory neuron 45
step 3 101 sensory tracts 55
step 4 104 shoulder girdle 67
proprioceptors 55 single-joint movement analysis 122
proximal 63 form 134
pulling force 28 single-leg hip thrust 231
skeletal function 12
Corrective Exercise
Index | 259
skeletal muscle 26 structure and function 26

major muscle groups 31, 32 tensor fasciae latae (TFL)
structure and function 27 IT band and 188
skeletal structure 13 texting
appendicular skeleton 13 posture and 2
axial skeleton 13 TFL ball roll 231
skeletal system 13 Thomas Test
smartphone modified 227
posture and 2 thoracic kyphosis 3
smooth muscle 26 thoracic nerves 50
soft tissue thoracolumbar fascia 181
assessments and correctives 210 trabeculae 17
soft tissue mobilization 5 trabecular bone 16
soma 45 transverse plane 64
somatic nervous system 47 trunk stability roll 180
sphinx with reach 206 t-spine foam roll 222
spinal cord 47, 48, 57 t-spine rotation 223
circuits 57 type I collagen 26
components of 49
gray matter 48 U
white matter 48 upper body correctives 220
spinal nerves 50 ball wall push with hip hinge 224
figure 50 DNS t-spine extension 223
motor function 51 pectoralis ball roll 221
spongy bone 16 pectoralis minor and major length assessment 220
squat or deadlift with mini band 194 posterior shoulder ball roll 225
standing fire hydrant with mini band 197 t-spine foam roll 222
static stabilizer 143 t-spine rotation 223
straight leg raise 188 upper crossed syndrome 213
strength 3 Upper Extremity Functional Index 104, 112
stress fracture 15 upper motor neurons 53
stretch reflex circuit 57 upper trapezius and levator scapulae stretches 218
superior 63
sympathetic nervous system 47 V
synapses 6 valid 104
synaptic plasticity 88 ventral 63
synergist 29 ventricles 48
vestibular system 84
T visual system 84
temporomandibular joint (TMJ) 189 vital capacity 3
tendon 26

260 |
W
wall ankle mobilization 235
wall elbow walk with band 203
white matter 48
Wolff’s Law 15
Y
Y raise on a swiss ball 205
Corrective Exercise
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Corrective Exercise

A Comprehensive Guide to Corrective Movement Training

Course Textbook for CORRECTIVE EXERCISE SPECIALIST

Chad Waterbury, DPT

Copyright © 2019 International Sports Sciences Association.

Published by the International Sports Sciences Association, Carpinteria, CA 93013.

Direct copyright, permissions, reproduction, and publishing inquiries to:

International Sports Sciences Association, 1015 Mark Avenue, Carpinteria, CA 93013

ABOUT THE AUTHOR

International Sports Sciences Association

SECTION ONE: CORRECTIVE EXERCISE SCIENCE, p.9

SECTION TWO: CORRECTIVE EXERCISE PRACTICE, p.93

Plato Was Right

WHAT IS CORRECTIVE EXERCISE?

What You’ll Learn

PLATO WAS RIGHT

International Sports Sciences Association

Movement dysfunction: The

REDUCE INJURY RISK

TARGET AUDIENCE OF THIS COURSE

International Sports Sciences Association

CORRECTIVE EXERCISE DEFINED

none moderate strenuous

International Sports Sciences Association

The Human Skeleton

What You’ll Learn

THE HUMAN SKELETON

International Sports Sciences Association

Bones not only get harder during devel-

Figure 1.3. Epiphyseal line. The two epi-

International Sports Sciences Association

TRAIN YOUR BRAIN: Can a poor diet weaken your bones?

Blood and Nerve Supply

International Sports Sciences Association

Cartilage Structure and Function

International Sports Sciences Association

TRAIN YOUR BRAIN:

LIGAMENT CREEP, LAXITY AND TEARS

TRAIN YOUR BRAIN: Think like a physical therapist.

International Sports Sciences Association

sternoclavicular (SC) sternum and clavicle

acromioclavicular (AC) acromion process (scapula) and clavicle

glenohumeral (GH) glenoid fossa (scapula) and humerus

scapulothoracic region (pseudo joint) scapula and ribcage

humeroradial humerus and radius

humeroulnar humerus and ulna

radioulnar (proximal) radius and ulna (elbow region)

radioulnar (distal) radius and ulna (wrist region)

radiocarpal Radius and carpal bones

sacroiliac (SI) sacrum and ilium

hip femur and pelvis

patellofemoral patella and femur

tibiofemoral tibia and femur

tibiofibular tibia and fibula

talocrural talus and tibia

subtalar talus and calcaneus

TRAIN YOUR BRAIN: What does it mean to be double-jointed?

International Sports Sciences Association

The Muscular System

MUSCLE AND FASCIA