











































MANUSCRIPT TYPE


EVIDENCE-TO-PRACTICE REVIEW  

 

52 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 

 
 

The Functional Movement Screen and Injury Risk in Sporting 
Populations: An Evidence-to-Practice Review  
Taylor Niles, MS, SCAT, ATC; Federico Rossi, SCAT, ATC; Zachary K. Winkelmann, PhD, SCAT, ATC 
University of South Carolina, Columbia, SC 

  

 
ABSTRACT 
The Functional Movement Screen (FMS) is a functional test, 
which aims to identify dysfunctional, asymmetrical, and 
painful movements that could contribute to future injuries. 
Medical professionals can clinically use this information to 
implement appropriate, specialized prehabilitation training 
aimed at reducing the dysfunctional, asymmetrical, and 
painful movements, to help prevent injury risk. Research on 
this tool, however, has contradictory findings regarding FMS 
composite score and future risk of injury. It is unclear to what 
extent FMS can predict those with future injury risk, and 
whether there are factors, such as age, sex, or sport-type, 
which may be contributing to these varying findings. 
Therefore, the purpose of this review was to identify which 
factors, if any, may contribute to the contradictory findings 
regarding the relationship between FMS composite score and 
subsequent injury risk in physically active populations. The 
review aimed to include any study which performed an FMS 
test at baseline on physically active individuals competing at 
any level, and determined risk groups based on composite 
scores, using odds ratios, sensitivity, and specificity as 
outcome measures. Subgroups were assessed based on 
athlete age, sex, sport-type, injury definition and injury 
mechanism. Reviewed participants were split into two age 
groups, senior (18+ years old) and junior (9-18 years old) 
athletes. It was found that age, sex, and sport-type 
explained some of the variable findings in the literature, 
however, effect sizes were often small in magnitude. 
Functional Movement Screen composite scores and 
asymmetry seemed to be the most useful in estimating injury 
risk for senior athletes, as well as individuals participating in 
rugby, American football, and ice hockey. There were many 
gaps identified in the research that may help get a consensus 
on optimal populations and uses for FMS. Thus, we 
recommend utilizing appropriate clinical judgment when 
determining if FMS would be a beneficial tool for identifying 
those with higher injury risk at your clinical site and with your 
patient population. 
 
Key Phrases 
Preparticipation exams and screening, functional testing, 
injury risk reduction 
 
Correspondence 
Dr. Zachary Winkelmann, 1300 Wheat Street, Columbia, 
SC 29208. 
E-mail: winkelz@mailbox.sc.edu   
Twitter: @zachwinkelmann 
 
 
 
 
 
 
 

Full Citation 
Niles T, Rossi F, Winkelmann ZK. The functional 
movement screen and injury risk in sporting 
populations: An evidence-to-practice review. Clin 
Pract Athl Train. 2021;4(2): 52-57. 
https://doi.org/10.31622/2021/0004.2.8.     
 
Submitted April 20, 2020 Accepted: March 8, 2021. 

 
ORIGINAL REFERENCE 
Moore E, Chalmers S, Milanese S, Fuller JT. 
Factors Influencing the Relationship Between the 
Functional Movement Screen and Injury Risk in 
Sporting Populations: A Systematic Review and 
Meta-analysis. Sports Med. 
2019;49(9):1449-1463 

SUMMARY 
 
CLINICAL PROBLEM AND QUESTION 
 

Musculoskeletal screening tests such as the 

Functional Movement Screen (FMS), are designed 
to identify modifiable risk factors so that 
healthcare providers can implement appropriate 
training strategies to reduce the incidence of 
injury.1,2 The FMS is composed of 7 subtests, 
including the squat, step over, in-line lunge, reach, 
leg raise, push-up, and rotary stability, where 
each test is scored on a scale 1-3, to produce a 
maximum score of 21. Functional Movement 
Screen pain and asymmetry are dichotomous 
outcomes based on the presence or absence of 
pain during FMS testing and at least one FMS test 
difference between left and right sides of the 
body, respectively. While FMS is one of the more 
popular injury risk screening tools, there is little 
agreement on what factors of the test contribute 
to injury risk; therefore, the primary purpose of 
this meta-analysis was to identify factors that 
contribute to the investigated relationship 

mailto:winkelz@mailbox.sc.edu
https://doi.org/10.31622/2021/0004.2.8


The Functional Movement Screen and Injury Risk in Sporting Populations: An Evidence-to-Practice Review 

 

53 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

between FMS and injury risk in sporting 
populations, especially the difference between 
the senior (18+ years old) and junior (9-18 years 
old) athletes. The second aim of this study was to 
examine the results of studies that have assessed 
the relationship between FMS asymmetry and 
injury risk. 

SUMMARY OF LITERATURE 

The authors for the guiding systematic review and 
meta-analysis conducted a systematic search of 
Medline, Scopus, EBSCOhost (including 
SportDiscus, Academic Search Premiere, Health 
Source: Consumer Edition, Health Source: 
Nursing/Academic Edition), Embase and Web of 
Science databases, to identify whether 
participant age, sex, sport-type, injury definition 
and mechanism contributed to the variable 
findings. Studies that were included in the 
systematic review had to meet the following 
inclusion criteria: 1) peer reviewed and published 
in the English language, 2) participants were 
competing at any level of sporting competition, 3) 
prospective cohort study design that assessed FMS 
performance at baseline using the complete FMS 
test battery and subsequently observed 
participants during sports training and 
competition, 4) identified risk groups based on 
FMS composite score, asymmetry or pain, and 5) 
outcome measures were injury incidence that could 
be categorized within the six injury level 
classifications provided by Orchard and Hoskins.3 

Systematic database searches identified 1028 
potential studies that, after screening, resulted in 
36 studies included in the systematic review. Nine 
of 36 studies did not explicitly state that 
participants were injury-free at the time of testing. 
Five of 36 studies were deemed to not describe 
the injury surveillance method in enough detail. 
Four of 36 studies used a follow-up period that 
was less than one complete competitive season. 
Twenty-three studies were unclear whether 
follow-up was completed for all participants, and 
18 were unclear whether strategies to account for 

incomplete follow-up were implemented. Six 
studies did not utilize statistical analysis that 
resulted in the reporting of injury-risk statistics. 

 

SUMMARY OF OUTCOMES 

This review looked at the odds ratio for injury risk 
given a specific criteria of FMS testing, to see if 
any differences in effect size existed between 
participant age, sex, sport type, injury definition 
or injury mechanism. The review also looked at the 
sensitivity and specificity based on risk groups 
determined by the different FMS testing criteria. 
The FMS criteria analyzed included a 1) FMS 
composite score threshold of < 14, 2) >1 subtest 
with reported asymmetry, or 3) >1 subtest with 
reported pain. Injury mechanism was grouped as 
either all-cause injury or non-contact injury. Injury 
definitions were divided into tissue damage or 
presentation to medical staff, limited or loss of 
training/match, and limited or loss of match only.  

FINDINGS AND CLINICAL IMPLICATIONS 

This review looked to identify factors that 
contribute to the contradictory findings regarding 
FMS composite score and subsequent injury risk in 
sporting populations. Kiesel et al found that 
individuals with a composite score of < 14 have 
an 11 times greater injury risk, while a systematic 
review by Bonazza, et al. reported a 3-fold or 
smaller increase in injury risk.4,5 There could be a 
few reasons for the differences in the findings 
between these studies. For example, the 
systematic review mentions how only 2 other 
studies replicated the findings of Kiesel, et al. via 
independent ROC curves. The review also 
identifies how there may be an effect of sex and 
population characteristics on a cutoff. This could 
have contributed to the differences between the 
studies, as Kiesel, et al. focused only on male 
professional football players who form one 
individual team, while Bonazza, et al. included 
studies with men and women, as well as athletes 



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54 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

and non-athletes. Overall, this review identified 
that there were few studies that show a significant 
relationship between composite scores and 
subsequent future injury risk, and many of the 
results that were significant were only of small 
effect size.  While the general understanding is 
that FMS testing’s purpose is to identify 
dysfunctional, asymmetrical, and painful 
movements that could contribute to future injuries, 
more focused research is needed investigating 
which aspects of FMS testing work best at 
identifying risk and for which subgroups of 
individuals.  

There are several gaps in the literature that still 
need to be identified to justify FMS use in many 
settings. First, of the studies used in this review, 3 
studies used only female participants,1-3 while 18 
used only males,4-21 which leaves a sex bias in the 
literature, making it difficult to generalize 
females. It should also be considered that 
individual subtests of the FMS may have stronger 
association with injury risk due to the differing 
demands and injury risks presented in varying 
sports. More consideration should be focused on 
whether poor scores for specific subtests are more 
strongly associated with injury to the region of the 
body that was tested. While there are a few 
studies which investigate this,6-9 there is still a 
general lack of literature looking into subtests and 
their relation to specific injury types and body 
regions. Finally, the results of this study showed a 
smaller effect for junior athletes (OR = 1.03 
[0.67–1.59]; p = 0.881) compared to senior 
athletes (OR = 1.80 [1.17–2.78]; p = 0.008), 
however, there is little research that explains why 
we see this difference. 

Based on the findings of this meta-analysis, our 
own review of the evidence, and clinical expertise, 
we suggest that clinicians consider their patient 
population and possible contributing risk factors 
which may lead to injury in their setting before 
implementing FMS. The contradictory findings of 
research on this topic, as well as the lack of 
clinically significant findings of this meta-analysis, 

identify various gaps in the research on FMS 
testing. A composite score threshold of < 14 was 
only found to have significant increase in injury risk 
for males, senior athletes, male and female rugby 
players, and baseball players. Composite scores 
were also found to be a better predictor of all-
cause injuries, than non-contact injuries. There is 
not enough evidence to support a relationship 
between subtest and corresponding injury to 
subtest body region, though we recommend 
looking at the individual subtest scores, rather than 
just the composite score to best understand where 
an individual's movement deficiencies lie. Because 
of these findings, we suggest clinicians consider 
FMS testing for senior male athletes, especially 
those who participate in rugby or baseball. 
Although the findings were not significant for other 
sport-types and subgroups, we recommend that 
sports or groups which have higher incidence of 
all-cause injuries should consider FMS testing as 
well. Functional Movement Screen testing is a 
feasible test, so the general loss and harm of 
implementing FMS, even for subgroups that did 
not have a significant relationship to injury risk 
prediction, is minimal.   

CLINICAL BOTTOM LINE 

Functional testing has the potential to be a helpful 
tool in identifying at-risk individuals for future 
injury, thus allowing healthcare providers to 
create tailored prevention programs to address 
movement disparities identified by the screening 
tool. It should be considered, however, that full-
body movement screens, such as the FMS, may not 
be the best tool for all population groups. Due to 
inconsistent and unclear methodology of the 
various research into FMS testing, it is difficult to 
create a clear consensus on the effectiveness of 
the tool as a predictor for future injury in many 
subgroups of individuals. Overall, most effect 
sizes were only small in magnitude and unlikely to 
be clinically meaningful in most sports, except for 
rugby, American football, and ice hockey. This 
could be due to the similarities between these 



The Functional Movement Screen and Injury Risk in Sporting Populations: An Evidence-to-Practice Review 

 

55 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

sports mentioned and the 7 components of the 
FMS test.  

It may be beneficial for clinicians to consider 
assessing for movement quality based on the 
subtests instead of the composite score. Different 
subtests assess for different movement qualities, 
such as range of motion, strength, or balance. 
Identifying movement qualities that are crucial to 
specific sports and using only the FMS subtests 
which assess those movement qualities may be 
more beneficial for sport types that did not have 
significant results with the composite score. 
Similarly, if a sport consists of upper extremity 
use, it may be more beneficial for clinicians to 
focus the examination on the movement quality of 
the upper extremity using subtests that specifically 
assess the upper extremity. We are not 
suggesting that injury prevention be hyperfocused 
to a singular joint, rather there is a need to 
examine the kinetic chain and how movement 
patterns at the ankle can affect the hip, and so on. 
We suggest that clinicians consider the individual 
subtest of the FMS as a better tool than the 
composite score of the FMS. For example, the 
hurdle step of the FMS is a multi-joint assessment 
that could be very helpful for a lower extremity 
activity like ballet or soccer, which the guiding 
review did not identify as having a clinically 
meaningful finding. Reviewing subtests 
individually would allow the clinician to identify 
movement patterns which most affect the patient, 
rather than performing a complete FMS test to get 
a composite score. 

The composite score and presence of asymmetry 
are strong predictors of injury risk in senior 
compared to junior athletes, though again, this 
effect size was small in magnitude. Junior cohorts 
may benefit from a lower composite score 
threshold, as suggested by the consistent null 
findings in junior athletes. There have been many 
false positives in junior cohort studies, in relation 
to FMS composite scores and injury risk, so 
creating a new composite threshold for junior 
athletes may produce more significant findings 

and make the screening tool more useful in these 
cohorts. It is likely that the painful scores seen in 
junior athletes is related to poor neuromuscular 
control as they develop, rather than dysfunctional 
movements. Many of the FMS subtests use body 
weight and asymmetrical movements are a result 
of motor control deficits which may lead to 
increased injury risk. Since senior athletes are 
exposed to higher game speeds and increased 
force impacts, a stronger relationship between 
FMS composite scores and injury risk in this 
population may be expected. Injury mechanism 
and definition do not have a significant impact on 
the relationship between FMS testing and injury 
risk, and due to the sex bias in the literature, 
findings from this review indicate a stronger 
correlation with male athletes than female 
athletes.  

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

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All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

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https://doi.org/10.23736/s0022-4707.17.07717-9
https://doi.org/10.23736/s0022-4707.17.07717-9
https://doi.org/10.1519/jsc.0000000000002399
https://doi.org/10.1519/jsc.0000000000002399
https://doi.org/10.1519/jsc.0000000000001838
https://doi.org/10.1519/jsc.0000000000001838
https://doi.org/10.1519/jsc.0000000000000962
https://doi.org/10.1519/jsc.0000000000000962
https://doi.org/10.1519/jsc.0000000000001422
https://doi.org/10.1519/jsc.0000000000001422
https://doi.org/10.1007/s12662-018-0515-2
https://doi.org/10.1007/s12662-018-0515-2
https://dx.doi.org/10.1136%2Fbmjsem-2018-000357
https://dx.doi.org/10.1136%2Fbmjsem-2018-000357
http://dx.doi.org/10.5455/pos.20150803113054
http://dx.doi.org/10.5455/pos.20150803113054
https://doi.org/10.1519/jsc.0000000000001757
https://doi.org/10.1519/jsc.0000000000001757

	ABSTRACT

