Update of Concepts Underlying Movement System Syndromes
Update of Concepts Underlying
Movement System Syndromes
Presented by: Zinat Ashnagar
An important physiological system of the body
is the movement system and that
dysfunctions of this system can be classified
These syndromes provide direction for
diagnosis, treatment, and pursuing
The syndromes for orthopedic conditions causing
musculoskeletal pain are:
(1) based on the movement directions or
alignments that cause pain
(2) associated with movement impairments
(3) improved by correction of the movement
impairment that decreases or eliminates the
Key concepts of the movement system that
contribute to the development of pain
syndromes are proposed.
Understanding key concepts and their
application to patients with musculoskeletal
pain will enable the practitioner to develop an
appropriate movement system (MS) diagnosis
and treatment program.
1. The majority of musculoskeletal pain
syndromes both acute and chronic are the
result of cumulative microtrauma from stress
induced by repeated movements in a specific
direction or from sustained alignments,
usually in a nonideal position.
• Musculoskeletal pain is the result of a progressive
condition that is related to lifestyle and
degenerative changes in tissues.
• The transition from tissue microtrauma to
macrotrauma is influenced by a variety of
intrinsic (genetics, sex, and age) and extrinsic
(amount and type of fitness, work activity)
• These repeated movements and sustained
alignments occur during the performance of daily
2. The site (joint region) that is moving or stressed
in a specific direction is the site of pain
3 . The stress occurs most often during the
initiation or earliest phase of the motion rather
than at the end of the physiological motion.
4. Hypermobility, usually accessory motion
hypermobility, is the cause of the pain.
Therefore the offending motions are most often
very subtle, and the more chronic the condition
or the older the subject, the more subtle the
5. The body follows the law of physics and takes
the path of least resistance for motion, which
contributes to the hypermobility.
6. The path of least resistance is affected by
variation in the stiffness or relative flexibility
of tissues attached to adjoining joints.
Most activities involve movement across several
contiguous joints that are arranged in series
and one of these joints moves more readily in
a specific direction than the other joints.
7. The predisposition of a joint to move readily
in a specific direction contributes to the
development of a movement pattern.
8. Insufficient muscle stiffness (because of
greater relative flexibility) and increased
resting muscle length are more problematic
adaptations than specific muscle weakness and
9. The way everyday activities are performed is
the critical issue.
For efficiency, the body establishes a pattern
of motion that reinforces the relative
hypermobility and participation of specific
joints, including the joint that moves the most
readily in a specific direction.
Hypermobility is reinforced and becomes
10. The relative participation of some muscle
groups (disuse or overuse) is the result of
movement patterns and biomechanical
• In the swayback posture, if the pelvis is tilted
posteriorly and the hip is extended, the use of
the gluteus maximus muscle is minimized.
11. Muscle performance is determined by the
pattern of movement.
Correction of faulty patterns is best
achieved by training the correct pattern and not
by isolated "strengthening" of a muscle.
12 . The human body is highly capable of motor
equivalency, which is the ability to realize the
same motor outcome with different effectors.
Stopping the offending motion at the joint that
moves the most readily and redistributing the
motion to other adjoining segments expands
one's ability to vary patterns of motion.
13 . The most important treatment is correcting
the movement pattern that is causing the tissue
to become painful or irritated rather than
directing treatment to the affected tissue.
14. The critical issue is how an activity is
performed not just performing the activity.
• Proper movement strategy can optimize
performance and minimize tissue injury.
Faulty strategy can compromise performance
and lead to tissue injury.
15 . An exercise is not effective unless the exercise
limits or corrects the movement at the painful
joint and produces the desired appropriate
movement at adjoining joints.
• Redistributing the movement to appropriate
joints is the goal.
• The same exercise can be used for contrasting
problems, depending on the instruction and
performance (quadruped rocking to either
increase or decrease lumbar flexion).
16. If a muscle contributes to the impaired
motion of a painful joint, stretching the muscle
will not stop the motion causing pain, but
stopping the motion may stretch the muscle.
If the tensor fascia lata-iliotibial band
contributes to tibiofemoral rotation, stretching
the band will not stop the impaired motion
during the stretch or functional activities.
If the tibiofemoral rotation is controlled and the
hip joint does not medially rotate or abduct, the
tensor fascia lata iliotibial band can be stretched
17. Training movement patterns will induce
appropriate muscular and biomechanical
adaptations that will reinforce the development
of optimal neuromuscular action.
18. All neuromuscular adaptations can contribute
to and correct problems. Thus "indiscriminate"
core strengthening exercises can become a
cause of pain as readily as a lack of muscle
strength can contribute to pain problems.
19. Every patient with musculoskeletal pain
should have a MS diagnosis.
20. MS syndromes consist of multiple contributing
factors or impairments that combine to produce
the principal movement impairment that is the
cause of the symptoms. The syndrome is named
for this principal impairment.
• The contributing factors are movement and
• A systematic examination is required to identify
all of the contributing factors.
21. The examination must include tests and
assessments of all regions of the body,
including a determination of how all regions
affect the movement of the painful joint
because of the biomechanical interactions of
the human body.
22 . The movement system needs to be periodically
examined, beginning in childhood and continuing
into old age to:
(1) evaluate optimal tissue development
(2) ascertain the progression of degenerative
(3) determine and guide exercises to maintain the
health of the cardiovascular and metabolic systems.
• Guiding exercise for appropriate use can prevent
disuse, misuse, or overuse.
THE GENERAL PREMISE: MOVEMENT
SYSTEM IMPAIRMENTS CAUSE
The belief is that correction or modification of
factors altering the precision of motion
(physiological motion but also as much as
possible the accessory/arthrokinematic motion)
alleviates or reduces the tissue irritation and
thus the painful condition.
A major premise of the model is that pain most
often arises from tissues that are stressed by
subtle impairments in movement or alignment
and that key factors contribute to these
One important factor is that the body, following
the laws of physics, takes the path of least
resistance for movement.
The activities an individual performs require
movements of multiple joints that are
contiguous, in the same kinematic chain (i.e.,in
serial arrangement), and all of which have
different flexibility characteristics.
The result is that one joint of those that are
anatomically arranged in series moves the most
easily and most readily when an individual
performs an activity.
Our research supports the premise that the ease
and rapidity with which a joint moves are more
important factors in a movement pattern
associated with pain than muscle
shortness, soft tissue restrictions, or limited
range of motion (ROM) of an adjoining joint.
These latter factors may have contributed to the
initial development of the flexibility of the
joint causing the pain, but once established, the
offending motion has to be addressed primarily
and the tissue adaptations, secondarily.
Stretching muscles or soft tissues will not stop
the offending motion. But when the offending
motion is stopped or controlled, the
appropriate tissues will be stretched.
The motion contributing to the stress occurs
during the first few degrees of motion or with
initiation of an activity.
The primary impairment is believed to be an
accessory rather than a physiological motion,
which is consistent with the problem arising
during the first few degrees of movement.
Accessory motion hypermobility is an underlying
characteristic of degenerative joint disease.
Lumbopelvic motion with lower extremity
motions in patients with low back pain is an
example of abnormal early onset joint motion.
In the prone position, lumbopelvic rotation
occurs earlier and to a greater extent during the
first few degrees of knee flexion and hip
rotation in patients with low back pain than in
control subjects, and the pattern was specific to
the MS category.
The predisposition of these joints to move
readily contributes to the frequency of their
movement and furthers the tendency for
Thus, a specific joint or joints of the lumbar
spine, for example, develop a tendency or
susceptibility to move readily in a specific
direction (directional susceptibility to
movement [DSM]) during all activities.
In most joints, the accessory motion impairment is
not clinically observable, thus the physiological
motion associated with the pain is most often
designated as the DSM.
when a joint moves more readily than other joints
in the same kinetic chain, the repeated
movements and prolonged postures associated
with everyday activities can be the precipitating,
as well as the perpetuating, factors of the joint's
As a result, movement in the offending direction
has been associated with pain and is often
(deviates from the kinesiological standard).
When the movement is corrected, the symptoms
decrease or are eliminated.
Based on the premise that the diagnosis should
direct treatment, the DSM is most often also
Correcting the pattern or stopping the movement
in the painful direction is the focus of
treatment because the symptoms are decreased
or eliminated by this action.
The movement direction or alignment that most
consistently causes or increases the patient's
symptoms and that, when corrected, decreases
or alleviates the symptoms is considered the
The complete description of all the impairments
evident as signs or causing symptoms that
contribute to the offending or principal
movement impairment is the syndrome.
Impairment is defined as any disorder in structure
or function resulting from
anatomical, physiological, or psychological
abnormalities that interfere with normal
The human movement system is a physiological
system of the body that produces motion of the
body or its component parts, or the functional
interaction of the structures that contribute to
the act of moving.
The physiological actions of other body systems
combine to compose the movement system, with
biomechanics playing an important role as the
interface among the skeletal, muscular, and
Kinesiopathological refers to how movement
that is excessive, imprecise, or insufficient
contributes to the development of pathology.
ELEMENTS OF THE MODEL
The components of the base elements are the
muscular and skeletal systems.
These systems are considered the base elements
because they consist of the tissues that provide
the foundation and the structure of the system.
The component of the modulator element is the
The term modulator is used to emphasize the
regulator activity of the nervous system.
The components of support elements are the
cardiovascular, pulmonary, and metabolic
These systems do not contribute directly to
movement, but as indicated by the term
support, they provide the nutrients and
substances required for maintaining the
viability and health of those systems that do
directly produce movement.
The model indicates that biomechanics is an
interface between muscular and neurological
The pattern of muscular recruitment is highly
influenced by relationships to gravity, as well as
the force required to move the extremity and react
to external forces.
The design of the movement system also provides a
variety of strategies to develop a moment about a
joint. Many of those strategies are determined by
The dynamic and biological characteristics of the
components of the movement system enable
tissues to adapt to the demands placed on them.
The specific tissue adaptations are normal
biological responses to forms of stress but may
contribute to deviations from principles of
For example, alterations in muscle length,
strength, and stiffness can affect the precision
in joint motion.
In combination, these adaptations can become
The repeated movements and sustained
alignments associated with everyday activities
are the inducers of the tissue adaptations.
Every aspect of an individual's activities,
whether passive or active, also induces
changes in tissues.
Although the physically active person will
improve and increase the size of muscles and
connective tissues, at the same time, the risk of
injury also increases.
Musculoskeletal pain problems and injuries of
athletes mostly occur from noncontact stress.
Golfers develop back, elbow, wrist, shoulder,
and knee problems.
The repetitive use of specific segments of the
body combined with high and rapid force
development can exceed tissue tolerance,
resulting in microtrauma.
At the other extreme, even individuals who are
inactive induce changes by the alignment and
movements while sitting and during work
Alignments maintained for prolonged periods
can induce changes in muscle length.
Without activity, muscle and connective tissues
are not stressed enough to provide optimal
The modifiers are factors such as age, sex,
height, weight, and genetic characteristics that
include predisposition to osteoarthritis, benign
general joint hypermobility, structural or
anthropometric characteristics, and the amount
and type of activity.
In young individuals, tissues are more extensible
and joints more flexible than in older
Thus the offending motions are usually of greater
ROM than the motions in an older patient.
In older individuals or those with a chronic
condition, the movement impairments are
usually more subtle so that the examination
requires careful observation and usually slight
The treatment using movement corrections and
stabilizing exercises requires even greater
precision in the older individual than in the
Studies of patients with low back pain have
demonstrated a difference in the pain-inducing
movements and alignments between men and
The broader shoulders, higher center of gravity,
and larger and stiffer muscles in men as
compared to women also contribute to
differences in tissue adaptation and movement
Of the genetic factors, benign joint hypermobility
syndrome is one of the important problematic
Individuals with hypermobility seem to be more
disposed to musculoskeletal pain problems than
individuals with tissues that limit joint
excursions; this occurs not only with the
physiological motion but particularly in the
Maintaining good alignment and precise motion is
more difficult if the individual is hypermobile
as compared to individuals with tissue stiffness.
Therefore one of the important assessments
during the examination is obtaining information
about the general tissue and joint mobility and
the effects on alignment and movement
Body proportions are also a contributing factor in
predisposing an individual to musculoskeletal
For example, a long trunk is usually associated
with depressed shoulders and often neck pain.
The activity level can range from
excessive, which tends to exacerbate the
development of musculoskeletal pain
problems, to insufficient activity.
The therapist needs to also factor into the
examination whether the pain condition is
from excessive activity that can be associated
with problems from muscle hypertrophy and
associated stiffness, as well as motor pattern
incoordination, or from a lack of activity in
which a systematic increase in physical
activity and exercise to improve the force
production deficit is necessary.
In the former situation, part of the treatment may
be to decrease the demands on specific muscles
and increase the extensibility of those muscles.
Tissue Adaptations of the Skeletal System
Although skeletal structures seem relatively
fixed, bone is a dynamic tissue that is
constantly being modified by the forces acting
For purposes of this material, the modifications
of skeletal structure and alignment can be
considered both dynamic and static.
Dynamic conditions are correctable and
sometimes easily modifiable, whereas the
static conditions are relatively permanent or
Another consideration is the effect of prolonged
forces on the shape of bones and joints.
Wolff (1836- 1902) proposed that
"changes in the form and function of bones, or
changes in function alone, are followed by
changes in the internal structure and shape
of the bone in accordance with mathematical
During development, the bones will adopt a
shape according to the forces imposed on
In mature bone in which the general shape is
established and no changes are made in the
distribution of forces, the change is in the
mass according to the mechanical demands.
Changes in the shape and alignment of the joint
also affect the characteristics of the ligaments
and the distribution of forces on the articular
cartilage, as well as alter the precision of joint
A major consideration is how skeletal
alignment, both acquired and structural, affects
the demands on muscle participation.
The initial observations of a patient with pain
problems should be an assessment of the
alignment and the participation of musculature
based on the relationship to the line of gravity.
Tissue Adaptations of the Nervous
Motor control plays a key role in musculoskeletal
there are two general theories about changes in
movement in patients with musculoskeletal
1. One theory is that pain causes the change in
movement patterns and alters motor control.
2. The other theory is that changes in movement
patterns cause the problems that result in
Certainly an acute and intense onset of pain can
affect the patient's alignment and movement
But the major question is, "What precipitated the pain
As suggested by the model, the repeated
movements and sustained postures of daily
activities induce the changes in tissues and
movement patterns that cause the pain
Therefore the pathological changes are
secondary to the altered movement pattern and
motor control and not primary.
Both concepts require that treatment emphasize
correction of the movement patterns and the
altered motor control.
If altered movement patterns cause the problem,
then guidelines for prevention are possible.
If the pain causes the problem, then the
precipitating factors may not be easy to
Clinical experience with correcting movement
patterns and alleviating symptoms supports
the belief that the altered movement patterns
are the key factor in causing pain and that
correcting the movements and the contributing
factors is the most effective long-term
A prevailing characteristic of the human body is
to reduce the degrees of freedom when
establishing a movement pattern, thereby
achieving a degree of efficiency and
minimizing energy expenditure.
Movement patterns become established as they
are repeated, and the pattern is reinforced by
changes in both the nervous and muscular
When considering the factors contributing to
musculoskeletal pain problems, the patterns of
recruitment and derecruitment are primary.
The belief is that the patterns are established by
the requirement of the activity, personal
characteristics, and intensity of use.
Tissue Adaptations of the Muscular
The adaptations of muscle are changes in:
( 1 ) length, both increased and decreased;
(2) tension development capacity, hypertrophy,
(3) stiffness, the resistance to passive elongation.
A, Patient's hip joint angle is almost 90 degrees with
his knees flexed.
B, With passive knee extension to only 45 degrees,
his pelvis tilts posteriorly, and his lumbar spine
flexes. The position of the pelvis and lumbar
spine indicates that the hamstring muscles are
stiffer than the supporting tissues of the lumbar
spine. The alignment change occurred before the
end of the excursion of the hamstring muscles.
C, when the hip joint angle is maintained at 90
degrees, the knee cannot be fully extended. The
hamstring muscles are short.
Muscle stiffness is defined as the change in
tension per unit change in length.
Stiffness refers to the resistance present during
the passive elongation of muscle and
The stiffness is a normal property of muscle and
is the passive tension of a muscle when
When a muscle is being elongated and there is
movement at the proximal attachment of the
muscle, the best explanation is that the tissues
stabilizing the joint are not stiff enough
relative to the stiffness of the muscle being
A, The patient's pelvis is tilted posteriorly, and his
lumbar Spine is flexed when his knee is passively
The position of the pelvis and spine can be the result
of relative flexibility,which indicates that the
hamstrings are stiffer than the supporting tissues
of the lumbar spine but not that the hamstring
muscles are short.
B, The patient's hip joint angle is 90 degrees, and
no motion of the pelvis or lumbar spine occurs
when the knee is fully extended passively. The
hamstring muscles would not be considered short.
The concept is that the hamstrings and the
tissues (muscles and ligaments) of the lumbar
spine are springs in series.
When the passive tension of the spring being
stretched (hamstrings) is greater than the
passive tension of the spring in series (lumbar
spine tissues), there will be motion at the
The earlier the movement at this joint the greater
the indication of the lack of "stiffness or
stability“ of the joint.
A major source of the passive tension (stiffness)
in muscle fibers is an intracellular contractile
protein called titin.
Titin is the largest connective tissue protein in
the body and provides the passive tension for
both striated and cardiac muscle.
Titin attaches the myosin filament to the Z-line of
the sarcomere and there are 6 titin proteins for
every myosin filament.
Therefore, muscle hypertrophy that increases the
number of sarcomeres in parallel and consequently
the amount of myosin will also increase the
passive tension or stiffness of the muscle.
Realizing that an intrinsic property of the human
body is the minimization of energy expenditure
when inactive or even when active, the role of
passive tension becomes particularly important.
Passive tension is a primary contributing factor to
alignment, often stability, and even the timing
and effectiveness of the mechanical event
connected with muscle contraction.
The passive tension provided by muscle plays an
important role in joint stability, alignment, and
in some situations contributes to pain.
Muscle stiffness is an extremely valuable
property of muscle that enables the body to be
supported with minimal energy expenditure.
Good alignment is indicative of balanced passive
tension of muscles attaching to a joint or
skeletal segment, such as the thorax or pelvis.
The passive tension, which also has a high
correlation to active tension, is the key to the
alignment and stabilizing properties of the joint.
As in all things, stiffness can become excessive or
The relative stiffness/flexibility properties are
often the contributing factor to:
(1) alignment impairments,
(2) one joint moving more readily than an
(3) inadequate stabilization or inappropriate
movement during the passive elongation of a
Muscle Length Adaptations
Small changes in muscle length are changes in
passive resting tension,while greater increases
in muscle length are associated with addition
of sarcomeres in series in the muscle fibers.
The development of true muscle shortness is
associated with loss of sarcomeres in series in
There is a lack of clarity in clinical practice
about the various mechanisms involved in
muscle shortness and tissues affected by
stretch or the need to stretch.
If the decreased ROM of hip flexion with the
knee extended is only 10 to 15 degrees and
can be regained by stretching for a few
minutes, the alteration can best be explained
by the creep or viscoelastic properties of
In contrast, if the hamstring muscles are limiting
the motion of the joint by 30 to 40 degrees, then
the most likely explanation is that the muscle
fibers have lost sarcomeres in series and the
treatment has to be stretching of long duration
(for example, 30 minutes or more, several
times a day for many days) and as sustained as
Stretching should not be forceful because a
reasonable explanation for this condition is
that the muscle has lost sarcomeres in series
and that requires protein synthesis and not just
a change in the conformation of the proteins in
the muscle cells.
Although muscles can become shortened by loss
of sarcomeres in series, this is not the most
common problem contributing to
The most common problem is the relative
stiffness of muscles attaching to the joint.
Performance includes timing, length, passive
tension, and the ability to generate active
tension and endurance.
Assessment of muscle strength provides
information about muscle performance, and the
results of the test can provide at least four
possible determinations about the muscle.
Manual muscle testing (MMT) can be used to
discern whether the muscle is:
(1) weak because of atrophy and the lack of
sarcomeres in parallel and thus unable to
develop adequate active tension;
(2) Strained because of being subjected to forces
that have torn or disrupted the Z-lines of the
sarcomeres and unable to develop adequate
(3) Too long, having added sarcomeres in series,
and the muscle does not develop the appropriate
tension throughout the ROM,
As depicted in the model, the problematic
outcome of the tissue adaptations is the
development of a relative stiffness or flexibility
condition that becomes exaggerated because the
body takes the path of least resistance for
The result of this cascade of events is that a joint
Hypothetically, the hypermobility is an accessory
or arthrokinematic motion rather than
physiological or orthrokinematic motion.
One of the consequences of imprecise movement
is the development of points of high contact
stress because of inadequate distribution of
forces within the joint.