Movement Chapter 8: SFMA Assessment Breakout Descriptions and Flowcharts

This is a chapter 8 summary of the book “Movement” by Gray Cook.

What to Look For

The SFMA breakouts are utilized to determine if one’s movement deficiencies have a mobility or stability origin. There are further possibilities in each of these categories.

It Could Be a Mobility Problem

There are two subsets of mobility problems that include tissue extensibility dysfunction (TED) and joint mobility dysfunction (JMD). From here, we can break it down even further in each subset.

Here are some potential TEDs

  • Active/passive muscle insufficiency
  • Limited neurodynamics (they said neural tension; come on Gray!)
  • Fascial tension
  • Muscle shortening
  • Hypertrophy
  • Trigger points
  • Scarring/fibrosis

And here are some potential JMDs

  • Osteoarthritis/arthrosis
  • Single-joint muscle spasm/guarding
  • Fusion
  • Subluxation
  • Adhesive capsulitis
  • Dislocation
This is the only TED that I deal with.

It could be a Stability Problem

These issues are also known as stability or motor control dysfunction (SMCD). Most conventional therapies would treat these complaints by strengthening the stabilizers, but this is problematic. When something works reflexively, how can we train something volitionally and expect changes? To train these muscles we must focus on proprioceptive and timing-based training.

There are several examples of SMCD problems.

  • Motor control dysfunction.
  • High threshold strategy.
  • Local muscle dysfunction/asymmetry.
  • Mechanical breathing dysfunction.
  • Prime mover or global muscle compensation behavior or asymmetry.
  • Poor static stability, alignment, postural control, asymmetry, and structural integrity.
  • Poor dynamic stability, alignment, postural control, asymmetry, and structural integrity.

Relatedness

Mobility and stability can influence one another. If I were to lose mobility at one segment, motor control can be distorted at nearby segments. Conversely, if I lack motor control, abnormal mobility may occur to compensate. However, the progression remains the same—restore mobility, then improve stability.

Honorable Mentions

Though the following testing protocols did not make the SFMA, they should still be tested per Gray:

  • Neurological exam.
  • Muscle strength.
  • Joint stability/mobility
  • Tissue tension testing (so…painful…to…write)
  • Identify neuromuscular trigger points
  • Impairment measurements

SFMA Rules

Here are some basic rules to implement when utilizing the SFMA that I picked up from there course.

1)      No warm up.

2)      If it looks like a dog and smells like a dog – it’s a dog.

3)      Be picky. Not bad = not good.

4)      No shoes.

5)      Monkey see, monkey do…perform the movement.

Sometimes it can go too far though...story of my life.
Sometimes it can go too far though…story of my life.

The SFMA generally also follows these basic ideas of testing, which can help assist you through the breakouts

  • Bilateral vs. unilateral
  • Loaded vs. unloaded
  • Active vs. passive

You will notice that the breakouts are a little different than what is presented in the book. These are the official breakouts from the current (6/2013) SFMA course.

Active Cervical Flexion

1. Start with supine cervical flexion (looking for chin to chest)

  •  FN: SMCD
  • DN, DP, FP: Move on

2. Passive supine cervical flexion (chin to chest)

  • FN: SMCD
  • DN, DP, FP: Move on

3. Active supine OA flexion test (20 degrees)

  • FN Bilaterally: If passive cervical flexion was DP/DN – TED/JMD; if FP – potential SMCD.
  • DN: OA flexion JMD/TED &/or possible cervical flexion JMD/TED
  • DP/FP: Stop; treat with modalities over exercise.

Active Cervical Extension

1. Supine cervical extension

  • FN: SMCD
  • DN: JMD/TED
  • FP/DP: Stop; treat with modalities over exercise.

Cevical Rotation-Lateral Bend

1. Active supine cervical rotation test (80 degrees)

  • FN: SMCD
  • DN/DP/FP: Move on

2. Passive supine cervical rotation test (80 degrees)

  • FN: SMCD
  • DN/DP/FP: Move on

3. C1-C2 cervical rotation test

  • FN: If test 2 was DP/DN, treat as lower cervical JMD/TED; if FP, could be an SMCD.
  • DN: C1-C2 JMD/TED &/or possible lower cervical spine JMD/TED.
  • DP/FP: Stop.

Upper Extremity Pattern 1 (MRE)

1. Active prone upper extremity pattern one (touch inferior angle)

  • FN: Move to supine reciprocal upper extremity pattern test shown below.
  • DN/DP/FP: Move on.

If the supine reciprocal upper extremity pattern test is…

  • FN: Mid-range SMCD; check spine extension breakout.
  • DP/FP: Stop the breakout.
  • DN: SMCD end-range SMCD. Check the spinal breakout.

2. Passive prone upper extremity pattern one (touch inferior angle)

  • FN: Move to supine reciprocal upper extremity pattern test shown above.
  • DN/DP/FP: Move on.

3. Active prone shoulder 90/90 IR test (60 degrees &/or total arc of 150 degrees)

  • FN: Move on to shoulder extension (#5).
  • DN/DP/FP: Move on to #4.

4. Passive prone shoulder IR (60 degrees &/or total arc of 150 deg)

  • FN: Shoulder IR SMCD; note this and move on.
  • DN: Shoulder IR JMD/TED; note this and move on.
  • DP/FP: Treat pain and move on.

5. Active prone shoulder extension test (50 degrees)

  • FN: Move on to elbow flexion (#7)
  • DN/DP/FP: Move on.

6. Passive prone shoulder extension (50 degrees)

  • FN: Shoulder extension SMCD; note this and move on.
  • DN: Shoulder extension JMD/TED; note this and move on.
  • DP/FP: Treat pain and move on.

7. Active prone elbow flexion test (thumb to shoulder)

  • FN: Move on to active lumbar locked extension (#9).
  • DN/DP/FP: Move on.

8. Passive prone elbow flexion test (thumb to shoulder)

  • FN: Elbow flexion SMCD; note this and move on.
  • DN: Elbow flexion JMD/TED; note this and move on.
  • DP/FP: Treat pain and move on.

9. Active lumbar locked extension (50 degrees).

  • FN: If no findings so far, combined pattern one JMD/TED.
  • DP/FP: Treat pain.
  • DN: Move on.

10. Passive lumbar locked extension (50 degrees)

  • FN: T-spine SMCD.
  • DN: T-spine JMD/TED.
  • DP/FP: Treat pain.

Upper Extremity Pattern 2 (LRF)

1. Active prone upper extremity pattern two (touch superior medial angle)

  • FN: Move to supine reciprocal upper extremity pattern test shown in the previous section.
  • DN/DP/FP: Move on.

2. Passive prone upper extremity pattern two (touch superior medial angle)

  • FN: Move to supine reciprocal upper extremity pattern test shown in the previous section.
  • DN/DP/FP: Move on.

If the supine reciprocal upper extremity pattern test is…

  • FN: Mid-range SMCD; check spine extension breakout.
  • DP/FP: Stop the breakout.
  • DN: SMCD end-range SMCD. Check the spinal breakout.

3. Active prone shoulder 90/90 ER test (90 degrees &/or total arc of 150 degrees)

  • FN: Move on to shoulder flexion/abduction (#5).
  • DN/DP/FP: Move on to #4.

4. Passive prone shoulder ER (90 degrees &/or total arc of 150 deg)

  • FN: Shoulder ER SMCD; note this and move on.
  • DN: Shoulder ER JMD/TED; note this and move on.
  • DP/FP: Treat pain and move on.

5. Active prone shoulder flexion/abduction test (170 degrees)

  • FN: Move on to elbow flexion (#7)
  • DN/DP/FP: Move on.

6. Passive prone shoulder flexion/abduction test (170 degrees)

  • FN: Flexion/abduction SMCD; note this and move on.
  • DN: Flexion/abduction JMD/TED; note this and move on.
  • DP/FP: Treat pain and move on.

7. Active prone elbow flexion test (thumb to shoulder)

  • FN: Move on to active lumbar locked extension (#9).
  • DN/DP/FP: Move on.

8. Passive prone elbow flexion test (thumb to shoulder)

  • FN: Elbow flexion SMCD; note this and move on.
  • DN: Elbow flexion JMD/TED; note this and move on.
  • DP/FP: Treat pain and move on.

9. Active lumbar locked extension (50 degrees).

  • FN: If no findings so far, combined pattern two JMD/TED.
  • DP/FP: Treat pain.
  • DN: Move on.

10. Passive lumbar locked extension (50 degrees)

  • FN: T-spine SMCD.
  • DN: T-spine JMD/TED.
  • DP/FP: Treat pain.

Multi-Segmental Flexion (MSF)

1. Single leg forward bend (touch toes)

  • FN/DN/DP/FP: Move on.

2. Long sitting (touch toes; 80 degree sacral angle).

  • FN: Move to rolling breakout.
  • DN/DP/FP: Move on.

3. Active SLR (70 degrees)

  • FN: Move on.
  • DN/FP/DP: Move on to passive SLR (#5)

4. Prone rocking (full rock back position)

  • FN: Move on to rolling breakouts.
  • FP/DP: Stop the breakout and treat the pain.
  • DN: Spinal flexion JMD/TED. Treat this first then reassess. Breakout can be stopped for now.

5. Passive SLR (80 degrees)

  • FN: Move on to rolling breakouts.
  • DN/DP/FP: Move on.

7. Supine Knee to chest (knees touch chest)

  • FN: Posterior chain TED &/or active hip flexion SMCD.
  • FP/DP: Stop the breakout and treat the pain.
  • DN: Hip JMD &/or posterior chain TED.

Multi-Segmental Extension (MSE)

SPINE BREAKOUT

1. Backward Bend (ASIS in front of toes, scapula pass heels, uniform curve).

  • FN: Stop the breakout; go to upper body extension flowchart.
  • DN/FP/DP: move on.

2. Single leg backward bend  (ASIS in front of toes, scapula pass heels, uniform curve).

  • FN: SMCD or anterior core TED; go to upper body extension flowchart.
  • DN/FP/DP: Move on.

3. Press up

  • FN: May have SMCD; but check other breakouts. Stop the spinal breakout.
  • DN/FP/DP: Move on.

4. Lumbar locked (IR) active rotation/extension (50 degrees)

  • FN: Move on to Prone on elbow unilateral extension (#6)
  • DN/FP/DP: Move on.

5. Lumbar locked (IR) passive rotation/extension (50 degrees)

  • FN: Thorax extension SMCD; check upper/lower extension breakouts.
  • DN: JMD/TED; check upper/lower extension flowcharts.
  • DP/FP: Stop and treat pain.

6. Prone on elbow unilateral extension (30 degrees)

  • FN: SMCD or anterior torso TED; check upper/lower extension breakouts.
  • DN: Move on.
  • FP/DP: Stop and treat pain.

7.  Prone on elbow unilateral extension (30 degrees)

  • FN: SMCD or anterior torso TED; check upper/lower extension breakouts.
  • DN: TED/JMD.
  • DP/FP: Stop and treat pain.

LOWER BODY BREAKOUT

1. FABER Test (2 fist distance)

  • FN: Move on.
  • DN/DP/FP: Hip/SI JMD/TED or SMCD (only if stabilized FABER changed mobility). Note this and move on.

2. Modified Thomas Test (flat to mat)

  • FN: Move on.
  • FN w/ knee straight: Lower anterior chain TED. Treat.
  • FN w/ hip abducted: Lower lateral chain TED. Treat.
  • FN w/ hip abducted & knee straight: Lower anterolateral chain TED. Treat.
  • DN: Hip extension JMD/TED &/or core SMCD. Treat.
  • DP/FP: Stop and treat pain.

3. Prone active hip extension (10 degrees or >)

  • FN: Move on to rolling breakouts.
  • DN/DP/FP: Move on.

4. Prone passive hip extension (10 degrees or >)

  • FN: Move on to rolling breakouts.
  • DN: Hip extension JMD/TED.
  • DP/FP: Stop and treat pain.

UPPER BODY BREAKOUT

1. Unilateral shoulder backward bend

  • FN: Double check press up on spine extension breakout as well as cervical spine.
  • DN/FP/DP: Move on.

2. Supine lat stretch hips flexed (arms to table)

  • FN: Move on to rolling breakouts.
  • DN/DP/FP: Move on.

3. Supine lat stretch hips extended (arms to table)

  • FN: Lat/posterior chain TED &/or possible hip extension dysfunction; check lower body flowchart.
  • Flexion improves but not full: Same as above. Note these changes and move on.
  • DN/DP/FP: Move on.

4. Lumbar locked (ER) Unilateral extension (50 degrees)

  • FN: Scapular/humero-glenoid SMCD.
  • DN/DP/FP: Move on.

5. Lumbar locked (IR) active rotation/extension (50 degrees)

  • FN: Shoulder girdle JMD/TED.
  • DN/DP/FP: Move on.

6. Lumbar locked (IR) passive rotation/extension

  • FN: Thoracic SMCD.
  • DN: Thoracic JMD/TED.
  • FP/DP: Treat the pain.

Multi-Segmental Rotation (MSR)

SPINE BREAKOUT

1. Seated rotation (50 degrees)

  • FN: Go to hip rotation breakout
  • DN/DP/FP: Move on.

2. Lumbar locked (ER) unilateral extension (50 degrees)

  • FN: Move on to prone on elbows unilateral rotation (#5)
  • DN/DP/FP: Move on.
  • DN/DP/FP switches sides: Move on to to rolling breakouts.

3. Lumbar locked (IR) active rotation (50 degrees)

  • FN: Shoulder girdle TED/JMD.
  • DN/DP/FP: Move on.

4. Lumbar locked (IR) passive rotation (50 degrees)

  • FN: Move on to rolling pattern breakouts.
  • DN: Thoracic JMD/TED.
  • FP/DP: Stop and treat pain.

5. Prone on elbows unilateral rotation (30 degrees)

  • FN: Move on to rolling pattern breakouts.
  • DN: Move on.
  • FP/DP: Stop and treat pain.

6. Passive prone on elbows unilateral rotation (30 degrees)

  • FN: Lumbar SMCD.
  • DN: Lumbar TED/JMD.
  • DP/FP: Stop and treat pain.

HIP ROTATION BREAKOUT

1. Seated active hip ER/IR (>40 degrees/>30 degrees)

  • FN: Move on to prone active hip ER/IR (#3)
  • DN/FP/DP: Move on.

2. Seated passive hip ER/IR (>40 degrees/>30 degrees)

  • FN: Move on.
  • DP/FP: Stop and treat pain.
  • DN: Hip JMD/TED. Make note of this and move on.

3. Prone active hip ER/IR  (>40 degrees/>30 degrees)

  • FN: If seated passive rotation was DN, stop and treat. If not, move on to rolling pattern breakouts.
  • DN/FP/DP: Move on.

4. Prone passive hip ER/IR (>40 degrees/>30 degrees)

  • FN: If seated passive rotation was DN, stop and treat. If not, move on to rolling pattern breakouts.
  • DN: Hip JMD/TED. Go to tibial roation and lower body extension breakouts
  • DP/FP: Stop and treat pain.

TIBIAL ROTATION BREAKOUT

1. Seated active Tibial ER/IR

  • FN: Double check lower body extension flowchart.
  • DN/DP/FP: Move on.

2. Seated Passive Tibial ER/IR

  • FN: Tibial rotation SMCD.
  • DN: Tibial rotation JMD/TED.
  • DP/FP: Stop and treat pain.

Single Leg Stance

VESTIBULAR AND CORE BREAKOUT

1. CTSIB (Static)

  • FN: Move on.
  • DN/DP/FP: Potential static vestibular dysfunction. Refer out/treat. Can move on to Half-kneeling narrow base (#3)

2. CTSIB (Dynamic)

  • FN: Move on.
  • DN/DP/FP: Potential Dynamic vestibular dysfunction. Refer out/treat. Move on in breakout.

3. Half-Kneeling narrow base

  • FN: Go to ankle breakout.
  • DN/DP/FP: Move on.

4. Rolling breakouts

  • FN: Move on.
  • DN: SMCD. Go to ankle flowchart.
  • DP/FP: Treat pain; go to ankle flowchart.

5. Quadruped Diagonals

  • FN: SMCD; go to ankle flowchart.
  • DP/FP: Treat pain; go to ankle flowchart.
  • DN: SMCD or shoulder flexion/hip extension are DN; go to ankle flowchart.

ANKLE BREAKOUTS

1. Heel walks

  • FN: Move on to toe walks (#3)
  • DN/DP/FP: Move on.

2. Prone passive dorsiflexion (20-30 degrees)

  • FN: Dorsiflexion SMCD; note and move on.
  • DN: Dorsiflexion TED/JMD; note and move on.
  • DP/FP: Treat pain and move on.

3. Toe walks

  • FN: Move on to seated ankle inversion/eversion (#5)
  • DN/DP/FP: Move on.

4. Prone passive plantarflexion (30-40 degrees)

  • FN: Plantarflexion SMCD; note and move on.
  • DN: Plantarflexion JMD/TED; note and move on.
  • DP/FP: Treat pain and  move on.

5. Seated active ankle inversion/eversion

  • FN: If no above impairments, then there is a proprioceptive deficits. Otherwise treat above impairments.
  • DN/DP/FP: Move on.

6. Seated passive ankle inversion/eversion

  • FN: SMCD.
  • DN: JMD/TED.

Overhead Deep Squat

1. Interlocked fingers behind neck deep squat

  • FN: Recheck extension breakouts
  • DN/DP/FP: Move on.

2. Assisted squat

  • FN: Core SMCD. Make sure MSE is clear.
  • DN/DP/FP: Move on.

3. Half-kneeling dorsiflexion (20-30 degrees)

  • FN/FP/DP: Move on.
  • DN: TED/JMD; check MSE/SLS breakouts, note and move on.

4. Supine knees to chest holding shins

  • FN: If dorsiflexion normal, then SMCD; If dorsiflexion was DN, then knees/hips/core are normal; if dorsiflexion was DP/FP, then treat dorsiflexion. Chec MSE.
  • DN/DP/FP: Move on.

5. Supine knees to chest holding thighs

  • FN: Knee JMD/TED. Check MSE.
  • FP/DP: Stop and treat pain.
  • DN: Hip JMD/TED. Check MSF for hips an MSE.

Segmental Rolling

1. Prone to supine upper body rolling

  • FN/DN: Move on.
  • DP/FP: Go back to chart that tested rolling.

2. Prone to supine lower body rolling

  • FN/DN: Move on.
  • DP/FP: Go back to chart that tested rolling.

3. Supine to prone rolling with upper body

  • FN/DN: Move on.
  • DP/FP: Go back to chart that tested rolling.

4. Supine to prone rolling with lower body

  • FN: Likely a weight-bearing or higher level SMCD if all patterns were FN; return to the chart that tested rolling.
  • DN: Likely a fundamental SMCD in any of the above patterns.
  • DP/FP: Go back to chart that tested rolling.

Conclusions

Phew, that 2000+ words later and we have a lot of stuff. Digest this information, and give these breakouts a try.

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3 thoughts on “Movement Chapter 8: SFMA Assessment Breakout Descriptions and Flowcharts

Add yours

  1. Zac,
    Great work with breaking down all of this info. Do you use the sfma system with all of your patients? After performing the smfa top tier, do you only go into the breakouts that are DN,DP,or FP?
    Jonathan

    1. Thank you for the kind words Jonathan.

      I use the top tier on most everyone to some extent, but as for the breakouts it depends on the patient. I kinda do my own breakouts based on what I feel is top priority.

      Ideally, I think you ought to look at everything, because even if something looks good you don’t know what they used to get there. The shoulder mobility assessment strikes me the most. You can have FN on MRE but have a large limitation in internal rotation…hor add and extension just pick up the slack potentially creating laxity.

      So, I do not do a true SFMA…PRI has influenced me too much for better or for worse 🙂

  2. Wow Zac! I can’t believe I haven’t seen this post before. And I’ve been following you for a while 😉 Anyhow, thanks for the heavylifting and the videos. I had questions about the breakdowns in Grey’s book and you answered them all!

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