Practical Musculoskeletal Testing for Runners

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Introduction

This is the practical part of the course. These tests I’ve found to be really helpful in identifying common imbalances for 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, then progress them to the next position to save moving them in and out of too many positions.

Key assessment tools to keep in mind

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 one understands the reason and purpose behind doing 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 able to visually see how it is done too.

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. I find this is really helpful.

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

Single leg balance test

• 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 runner keep their balance, how long before runner needs to place other foot down or touchdown or how many touchdowns in 30 seconds
  • Repeat test on both sides
  • Start with runner performing test with their eyes open
  • Progress to more challenging position with runner's eyes closed
• The test can also be used as rehabilitation exercise
• See also: Single Leg Stance Test and Why you should include the single-leg stance test in every patient assessment

Lateral step down test

• The test is used to assess movement quality at the trunk, pelvis and kneeas well as ankle mobility
• Always compare left to right side
• Ask runner to stand with hands on the hips on a step with the foot placed on the medial edge of a step and 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 occurs 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

Lateral step down test scoring criteria

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 horisontal 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

Single leg sit to stand test (SLSTST)

• Functional test to assess quadriceps strength as well as 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 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 seated position
• Assess movement quality, alignment of hip and knee, balance, pain
• Compare left and right sides
• Two variations of this test:
  • Timed test to measure muscular endurance (SLST30sec)
    • Runner performs as many repetitions as possible in 30 seconds
  • Test for speed over repetitions to assess power (SLST5rep)
    • 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.

Knee to wall 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
• Always compare left to right
• 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 of 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. (2017) reported that limited ankle dorsiflexion range is not a risk factor for calf muscle injuries.
  • Fong et al. (2011) 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.

Calf raise test to fatigue

• Test assesses the tissue capacity of the calf musculature
• Runner stands upright on a step with 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 finger tips 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 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 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. (2020)
• Normative values for this test are available in the table below

Normative values for the single-leg calf raise test

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

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

Side Copenhagen bridge hold

• Targets the adductor muscles
• Assessment:
  • Runner in a side-lying position
  • Place the foot of the top leg on a bench
  • Elbow under shoulder
  • Runner lifts 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.

Forward plank

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

Side plank

• Assessment:
  • Runner in side lying
  • Elbow underneath 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 floor and lift

Single leg bridge to fatigue

• Focus is on the posterior sling - gluteal and hamstring muscles
• 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 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

Thomas Test

Slump

Leg Length Discrepancy

Single leg bridge test

Conclusion

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. Taking all this information will give a great over view 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.

Conclusion

There are many tests which could be used to assess our runners. I found that these ones gave a great overview of muscle length, strength and movement related especially for a runner. If further testing is needed – for example ankle stiffness seen while doing calf raises – this can be done at a follow up session with more depth.

Articles

Leg length Discrepancy

This article suggests that there is poor consensus on a definitive treatment and diagnosis of leg length discrepancy. Treatments that can be considered include a shoe insert, a high shoe, or an orthosis, surgically induced slowing of growth by blockade of the epiphyseal plates around the knee joint, or 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. Leg length differences between 2 and 5 cm can be normalised using one of the above mentioned methods.

Slump Test

Slump Test combined with the Dejerine’s triad have clinical validity to discard lumbar or lumbar-sacral radiculopathy. The slump test is used as one of the neurodynamic tests for neural tension.

Single leg sit to stand test (SLSTST)

Functional test to assess quadriceps strength. This article describes how one can use the test to see how many SLSTST can be done in 30 seconds and how long it takes to perform 5. This may be a useful guideline for our runners comparing how many they can do in 30 seconds – comparing left to right and then have a score which can later be used as a baseline for future assessments.

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