Practical Musculoskeletal Testing for Runners

Original Editor - Dawn Nunes Top Contributors - Wanda van Niekerk, Jess Bell and Lucinda hampton

Introduction[edit | edit source]

Runners-635906 1920.jpg

This page relates to the practical course of the Complete Guide to Understanding Your Runner Programme by Dawn Nunes available on Physioplus. These tests are helpful in identifying common imbalances in muscle strength and length. Most of these tests assess a number of areas at the same time, making them effective and time-saving. Try to assess your runner in one position, complete all the tests, and then progress to the next position so your runner does not have to move in and out of too many positions.[1]

This musculoskeletal screening can be done in conjunction with a treadmill analysis with video recording. This will enable a full assessment of the runner from subjective history, their gear, their body mechanics, as well as how they run. Using all this information will give a great overview of your runner and enable you to fully assess any imbalances, weaknesses or changes in gear that need to be made in order to optimise their training and prevent injury.[1]

Key Assessment Tools[edit | edit source]

The following are some key assessment tools to consider[1]:

  • Know the test that you are performing
    • It is really important that you have a good understanding of the test, what position the runner must be in, the position you need to be in to effectively test and also what it is that you are observing. Explain to your runner what it is you want them to do and be very specific, so that the test is reproducible and accurate. If the runner is not in a good position or performs the test incorrectly, stop, re-position or explain, and then re-start rather than continuing in an incorrect manner.
  • Explain the test to your runner
    • There will be a better buy-in if the runner understands the reason and purpose behind an action. In explaining what it is that you would like from your runner – and how it could help them – they will be more eager and willing to do the test properly and, subsequently, the exercises following your assessment. Be specific with hand, leg and body positions as well as timing. Demonstrate the exercise first so that they are also able to see how it is done.
  • Know what you are testing
    • Remember to continually assess the runner while they are performing the test. Make notes especially if one side is weaker than the other so that you can refer back to them immediately rather than trying to remember all the tests at the end of your assessment.
  • Be prepared
    • Some equipment is needed for these tests. Make sure that you have everything you need in easy access so that you don’t spend time setting up or looking for the missing item. Being prepared and organised will show your professionalism, as well as your efficiency with testing. It will also build more trust with your runner as they see that you know exactly what you want to do and have everything organised.

Musculoskeletal Tests for Runners[edit | edit source]

Single Leg Balance Test[edit | edit source]

  • Ask runner to cross arms across chest and stand on one leg
  • Assess:
    • Hip movement for example: has the hip dropped?
    • Time: how long can the runner keep their balance? How long before the runner needs to place the other foot down or touchdown or how many touchdowns in 30 seconds?
    • Repeat test on both sides
    • Start with the runner performing the test with their eyes open
    • Progress to a more challenging position with the runner's eyes closed
  • The test can also be used as a rehabilitation exercise
  • See also: Single Leg Stance Test and Why you should include the single-leg stance test in every patient assessment

[2]

Lateral Step Down Test[edit | edit source]

  • This test is used to assess movement quality at the trunk, pelvis and knee,[3] as well as ankle mobility[1]
  • Always compare left and right sides
  • Ask runner to stand with their hands on the hips on a step with one foot placed on the medial edge of a step. Perform a single leg step down multiple times, without the runner's weight shifting onto the contralateral leg
  • The physiotherapist assesses the movement quality and deviations that occur during the test
  • Based on the cumulative number of deviations noticed, a quality category can be assigned according to the lateral step down test scoring criteria[4]
  • See Lateral Step Down Test
Lateral step down test scoring criteria[3]
Movement Deviation Interpretation Score
Arm Strategy Removal of a hand from the waist 1
Trunk Alignment Leaning in any direction 1
Pelvic Plane Loss of horizontal plane 1
Knee Position Tibial tuberosity medial to second toe 1
Tibial tuberosity medial to medial border of foot 2
Steady Stance Stepping down on contralateral limb or foot wavering 1
Cumulative Score
0 or 1 Good
2 or 3 Fair
4 or above Poor

[5]

Single Leg Sit to Stand Test (SLSTST)[edit | edit source]

  • A functional test to assess quadriceps strength, as well as the posterior sling - gluteal and hamstring muscles
  • Read more: Five Times Sit to Stand Test and 30 Seconds Sit to Stand Test
  • Runner sits on a chair - knees in 90° flexion, arms crossed over the chest
  • Ask runner to stand up and rise to full knee extension on the testing leg without the contralateral leg touching the floor
  • Runner then returns to a seated position
  • Assess movement quality, alignment of hip and knee, balance, pain
  • Compare left and right sides
  • Two variations of this test[6]:
    • Timed test to measure muscular endurance (SLST30sec)[6]
      • Runner performs as many repetitions as possible in 30 seconds
    • Test for speed over repetitions to assess power (SLST5rep)[6]
      • Runner performs 5 repetitions and is timed to assess how quickly 5 repetitions can be completed
    • These variations may be useful in the assessment of runners and athletes for comparison between left and right sides, but also to have a baseline for future assessments and rehabilitation programmes.[1]

[7]

Knee to Wall Test[edit | edit source]

  • This test assesses ankle dorsiflexion range of motion
  • Strong evidence exists for good inter-and intra-clinician reliability of the knee to wall test to assess dorsiflexion range of motion[8]
  • Always compare left and right sides
  • Assessment
    • Runner places foot up against a wall and then lunges forward to see if the knee can make contact with the wall before the heel comes off the ground
    • The foot is moved away from the wall to the point where the knee can only make slight contact with the wall, while the heel remains in contact with the floor
    • Measure the maximum distance from the wall to the tip of the big toe in centimetres (cm)
  • Read more: Knee to wall test
  • Evidence for ankle range of motion
    • Green et al.[9] reported that limited ankle dorsiflexion range is not a risk factor for calf muscle injuries.
    • Fong et al.[10] reported that increased dorsiflexion range of motion was associated with greater knee flexion and smaller ground reaction forces during landing. Furthermore, there is compelling evidence that there is an association between reduced/limited ankle dorsiflexion and dynamic knee valgus. It is, therefore, recommended that ankle dorsiflexion range of movement assessments be included in clinical practice as limitations in range may predispose individuals to harmful lower limb movement patterns.[11]

Calf Raise Test to Fatigue[edit | edit source]

  • This test assesses the tissue capacity of the calf musculature[14]
  • Runner stands upright on a step on one leg. The heel hangs over the edge of the step and only the ball of the foot is on the step
  • Maintain balance by keeping fingertips against a wall
  • Pelvis should remain level throughout the test
  • Runner fully plantarflexes the ankle (rise) and then descends into full dorsiflexion (drop)
  • Runner repeats this action until fatigue
  • The cadence should be 1 second up and 1 second down
  • No bouncing is allowed
  • Test is stopped when runner fatigues or when the range of motion or cadence is no longer maintained
  • Record the total number of repetitions performed
  • Compare left and right sides
  • Straight knee targets gastrocnemius muscle and a bent knee will isolate the soleus muscle
  • Calf raise senior test
    • The importance of strength in the calf muscle and the strengthening effect of calf raises in an older population is shown in a study by Helô-Isa et al.[15]
  • Normative values[16] for this test are available in the table below
Normative values for the single-leg calf raise test[16]
Age Males Females
20 - 29 37 reps 30 reps
30 - 39 32 reps 27 reps
40 - 49 28 reps 24 reps
50 - 59 23 reps 21 reps
60 -69 19 reps 19 reps
70 -79 14 reps 16 reps
80 -89 10 reps 13 reps

Reverse Lunge[edit | edit source]

  • Dynamic way to test hip mobility
  • Assessment[1]:
    • Runner stands with both hands behind their head
    • Runner lunges backwards and returns to starting position
    • They repeat this movement and the physiotherapist assesses movement quality and compensation methods
      • If the runner lacks hip extension, compensatory methods can include trunk leaning forwards or hinging into lumbar spine extension
      • If the runner lacks hip internal rotation, compensatory methods can include the knee falling into valgus position and the foot in external rotation

[19]

Side Copenhagen Bridge Hold[edit | edit source]

  • Targets the adductor muscles
  • Assessment:
    • Runner is in a side-lying position
    • Place the foot of the top leg on a bench
    • Elbow under the shoulder
    • Runner lifts the body up by pressing the top leg into the bench to assume a side bridge position
    • Hold this position for 20 seconds
    • Compare left to right
    • Ways to make exercise/test easier is to shorten the lever by placing the knee of the top leg on the bench
  • Copenhagen Adductor Exercise (CAE)
    • Leading on from the Side Copenhagen bridge hold, research shows that the Copenhagen adductor exercise has a positive influence on eccentric hip adductor strength and the importance of strengthening this muscle to prevent groin injuries.[20]

Forward Plank[edit | edit source]

  • Full body strength benefits[1]
  • Assessment:
    • Runner is in a prone position
    • Elbows underneath shoulders
    • Feet shoulder-width apart
    • Runner lifts body so that weight is distributed over forearms and feet
    • Keep the body in a straight line
  • How long can the runner hold this position? (Measure in seconds)
  • Progressions of plank - lift one leg into extension; lift one arm
  • Read more: Plank exercise

Side Plank[edit | edit source]

  • Assessment[1]:
    • Runner is in side-lying
    • Elbow underneath the shoulder
    • Lift body so that weight is distributed over forearm and feet
    • Lift top arm
    • Hold the body in a straight line
    • Time for how long the runner can hold this position
  • Progression of side plank
    • Abduct top leg
  • Regression of side plank
    • Keep knee on the floor and lift

[27]

Single Leg Bridge to Fatigue[edit | edit source]

  • Focus is on the posterior sling - gluteal and hamstring muscles[1]
  • Assessment:
    • Runner lies supine
    • Arms across the chest
    • Knees bent and feet on a bench/chair
    • One leg should be straightened (not tested leg)
    • Runner has to lift the pelvis off the floor until body is in a straight line and then lower pelvis again
    • Count and document the number of repetitions the runner can perform until fatigue
    • Always compare left and right sides
  • Assess what is happening with pelvic position i.e. drop on one side, rotation to one side

[31]

Modified Thomas Test[edit | edit source]

  • Measures the flexibility of hip flexors
  • Assessment[1]:
    • Runner hugs one knee to the chest and lies on their back on the plinth/bed with the gluteal fold at end of the plinth/bed
    • Make sure that the lumbar spine is in neutral
    • Runner relaxes one leg
    • If hip remains in flexion - indicative of tight hip flexors - iliopsoas
    • If knee remains in extension - indicative of tight quadriceps - rectus femoris
    • If knee moves into abduction - indicative of a tight iliotibial band
  • Read more: Thomas Test

[32]

Slump[edit | edit source]

  • Neural tension test to asses neurodynamics or neural tissue sensitivity[33]
  • Slump test combined with the Dejerine’s triad have clinical validity to discard lumbar or lumbar-sacral radiculopathy[33]
  • Assessment:
    • Runner seated with hands behind back
    • Ask runner to slump forward at the thoracic and lumbar spine
    • Ask runner to flex the neck, placing the chin on chest, the physiotherapist can place a hand gently over the head to maintain this flexion
    • Ask the runner to straighten one leg and assess for any neural signs or symptoms
    • Dorsiflexion of the ankle can be added to further add tension to the neural system
    • Compare left and right sides

[34]

Leg Length Discrepancy[edit | edit source]

  • Research suggests that there is poor consensus on a definitive treatment and diagnosis of leg length discrepancy[35]
  • Treatments that can be considered include[35]:
    • A shoe insert
    • A high shoe
    • An orthosis
    • Surgically induced slowing of growth by blockade of the epiphyseal plates around the knee joint
    • Leg lengthening with osteotomy and subsequent distraction of the bone callus with fully implanted or external apparatus
  • The option to treat conservatively or surgically remains elective[35]
  • Leg length differences between 2 and 5 cm can be normalised using one of the above-mentioned methods[35]
  • Assessment:
    • Runner in supine
    • Measure the length of the leg from the ASIS to the medial malleolus
    • Compare left and right sides

[36]

Single Leg Bridge Test[edit | edit source]

  • Quick screening tool for gluteal muscle strength and stability
  • Assess[1]:
    • Runner in supine knees bent and feet on the floor
    • Hands clasped together in front
    • Straighten one leg
    • Ask runner to lift pelvis off the floor/bed and hold this position
    • Runner should be able to hold this position for 30 seconds on each leg while maintaining a level pelvis and without cramping of hamstrings or lower back pain

[37]

Conclusion[edit | edit source]

There are many tests which could be used to assess runners. The tests on this page provide a good overview of muscle length, strength and movement related to running. If further testing is needed – for example, ankle stiffness is seen while doing calf raises – this can be looked at during a follow-up session in more detail.[1]

References[edit | edit source]

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 Nunes, D. Practical Musculoskeletal Testing for Runners Course. Physioplus. 2022
  2. Robbins Rehabilitation Allentown Beth Umac & Bangor. Single Leg Balance Test. Available from: https://www.youtube.com/watch?v=H7ehsrCSdQM [last accessed 21/4/2022]
  3. 3.0 3.1 Mansfield C, Spech C, Rethman K, Clagg S, Ingle A, Largent A, Vatti T, Morrow M, VanEtten L, Briggs M. Moderate reliability of the lateral step down test amongst experienced and novice physical therapists. Physiotherapy Theory and Practice. 2021 Aug 14:1-9.
  4. Piva SR, Fitzgerald K, Irrgang JJ, Jones S, Hando BR, Browder DA, Childs JD. Reliability of measures of impairments associated with patellofemoral pain syndrome. BMC musculoskeletal disorders. 2006 Dec;7(1):1-3.
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  6. 6.0 6.1 6.2 Waldhelm A, Gubler C, Sullivan K, Witte C, Buchheister D, Bartz-Broussard J. Inter-rater and test-retest reliability of two new single leg sit-to-stand tests. International Journal of Sports Physical Therapy. 2020 May;15(3):388.
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  8. Powden CJ, Hoch JM, Hoch MC. Reliability and minimal detectable change of the weight-bearing lunge test: a systematic review. Manual therapy. 2015 Aug 1;20(4):524-32.
  9. Green B, Pizzari T. Calf muscle strain injuries in sport: a systematic review of risk factors for injury. British journal of sports medicine. 2017 Aug 1;51(16):1189-94.
  10. Fong CM, Blackburn JT, Norcross MF, McGrath M, Padua DA. Ankle-dorsiflexion range of motion and landing biomechanics. Journal of athletic training. 2011 Jan;46(1):5-10.
  11. Lima YL, Ferreira VM, de Paula Lima PO, Bezerra MA, de Oliveira RR, Almeida GP. The association of ankle dorsiflexion and dynamic knee valgus: A systematic review and meta-analysis. Physical Therapy in Sport. 2018 Jan 1;29:61-9.
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  14. Howe LP, Read PJ. Movement Screening and Physical Capacity Assessments. In The Science and Practice of Middle and Long Distance Running 2021 Mar 29 (pp. 97-117). Routledge.
  15. André HI, Moniz-Pereira V, Ramalho F, Santos-Rocha R, Veloso A, Carnide F. Responsiveness of the Calf-Raise Senior test in community-dwelling older adults undergoing an exercise intervention program. PloS one. 2020 Apr 29;15(4):e0231556.
  16. 16.0 16.1 Hébert-Losier K, Wessman C, Alricsson M, Svantesson U. Updated reliability and normative values for the standing heel-rise test in healthy adults. Physiotherapy. 2017 Dec 1;103(4):446-52.
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  18. Health & High Performance.How strong are your calves? Feel the burn with this test | Sports Chiropractor Melbourne. Available from: https://www.youtube.com/watch?v=SyKDI1ZcROs [last accessed 22/4/2022]
  19. Intention2Action. Functional Hip Mobility Assessment. Available from: https://www.youtube.com/watch?v=Y-G0jFHqwxQ [last accessed 22/04/2022]
  20. Schaber M, Guiser Z, Brauer L, Jackson R, Banyasz J, Miletti R, Hassen-Miller A. The Neuromuscular Effects of the Copenhagen Adductor Exercise: A Systematic Review. International Journal of Sports Physical Therapy. 2021;16(5):1210.
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  22. E3 Rehab. How to Perform & Program the Copenhagen Plank for Eccentric Adductor Strength & Reduce Injury Risk. Available from: https://www.youtube.com/watch?v=kD1t1hWzIDE [last accessed 22/04/2022]
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  35. 35.0 35.1 35.2 35.3 Vogt B, Gosheger G, Wirth T, Horn J, Rödl R. Leg length discrepancy—treatment indications and strategies. Deutsches Ärzteblatt International. 2020 Jun;117(24):405.
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