Introduction
Since 1980, Shirley Sahrmann and her colleagues have pioneered the development of Movement System Impairment (MSI) syndromes, a diagnostic and treatment framework designed for physical therapists. This approach aims to guide treatment strategies and inform prognosis for a range of musculoskeletal conditions. The significance of the movement system in healthcare was underscored when the American Physical Therapy Association adopted it as the identity of physical therapy in 2013. Washington University defines the movement system as “a system of physiological organ systems that interact to produce movement of the body and its parts,” encompassing key components as illustrated in Fig. 1.
At the heart of MSI syndromes lies the kinesiopathologic model (KPM) (Fig. 2). This model operates on the fundamental principle that both repetitive movements and sustained postures can be primary contributors to musculoskeletal pathologies. MSI syndromes are theorized to arise from the cumulative effect of habitually using non-optimal alignments and movement patterns. Over time, these patterns become ingrained impairments, potentially leading to pathoanatomical changes within tissues and joint structures. The KPM highlights the interconnected roles of: (1) the musculoskeletal system as the effector of movement, (2) the nervous system as the regulator, and (3) the cardiovascular, pulmonary, and endocrine systems providing essential support and also being influenced by movement. For instance, the link between metabolic syndrome and insufficient physical activity is well-documented. The prevailing theory, supported by evidence, suggests that daily activities involving sustained alignments and repetitive movements are the main drivers of changes across these systems. These changes are further modulated by individual intrinsic factors, such as personal characteristics, and extrinsic factors, like the intensity and nature of physical activity at work and during leisure.
A crucial concept within MSI is that the body, particularly at the joint level, operates according to basic physics, favoring the path of least resistance in movement, often consistently in directions like flexion, extension, or rotation. This path is determined by: (1) relative flexibility both within and between joints, (2) the relative stiffness of muscles and connective tissues, and (3) the learned motor patterns that evolve into motor learning. When a joint consistently moves more easily in a specific direction, it can lead to the gradual development of hypermobility in accessory motions or micro-instability. This micro-instability can cause tissue microtrauma, which, with repeated stress, can escalate to macrotrauma.
Figure 1.
Alt Text: The human movement system graphic illustrating the interconnected physiological systems responsible for body movement, as developed by Washington University’s Physical Therapy Program.
Figure 2.
Alt Text: Kinesiopathologic model diagram showing the movement system impairment framework, highlighting the relationship between movement, alignment, and potential pathology.
The KPM framework suggests that detectable signs of movement impairments may precede the onset of noticeable symptoms. Furthermore, it posits that addressing and correcting these impaired alignments and movements, along with their contributing factors, represents the most effective strategy for managing musculoskeletal pain. This approach emphasizes identifying and treating the root cause of tissue injury, rather than solely focusing on the pathoanatomy of the affected tissues. Diagnosis within the MSI system begins by identifying specific impaired alignments and movements through a series of targeted clinical tests. These assessments often involve movements or positions that provoke or exacerbate the patient’s symptoms. The therapist then guides the patient in correcting these alignments and movements to assess whether symptom improvement occurs. Following a comprehensive examination, the information gathered is used to: (1) determine the specific MSI syndrome, (2) pinpoint contributing factors, (3) design corrective exercises, (4) identify necessary adjustments to alignments and movements during daily activities, and (5) educate the patient about the factors contributing to their condition, empowering them to practice corrections in their daily routines.
Consider the example of a patient diagnosed with Supraspinatus Tendinopathy. While tendinopathy indicates the pathoanatomical source of pain, an MSI assessment focuses on scapular and humeral alignment and movement patterns and their correlation with symptoms. A potential MSI diagnosis might be Scapular Insufficient Upward Rotation with Humeral Anterior Glide. Further examination would identify contributing factors such as (1) relative stiffness, (2) muscle strength imbalances, and (3) neuromuscular activation pattern deficits. The core principle of KPM is that classifying the patient based on these movement impairments (e.g., Scapular Insufficient Upward Rotation, Humeral Anterior Glide) provides more actionable guidance for physical therapy treatment than simply identifying a pathoanatomical diagnosis. Table 1 summarizes the key concepts underpinning the MSI syndromes.
Table 1.
Kinesiopathologic Model: Core Principles.
| Principle | Description |
|---|---|
| Cumulative Micro-trauma | Musculoskeletal pain syndromes often result from cumulative micro-trauma due to sustained postures or repetitive movements in specific directions during daily activities, leading to tissue stress and irritation. |
| Joint as Pain Generator | The joint that moves too readily in a particular direction becomes a primary site of pain generation due to instability and stress. |
| Path of Least Resistance | Micro-instability at a joint, combined with relative stiffness, neuromuscular activation patterns, and motor learning, contributes to establishing and maintaining a path of least resistance in movement, often exacerbating impairments. |
| Treatment Focus | Effective treatment aims to correct impaired alignments and movements that contribute to tissue irritation, as well as addressing secondary tissue adaptations like stiffness, weakness, and neuromuscular imbalances. |
| Integrated Training | Training that focuses on correcting impaired alignments and movements, rather than isolating individual muscles, promotes more effective neural and musculoskeletal adaptations and functional recovery. |
Relative Flexibility and Stiffness in MSI
Central to the MSI concept are the principles of relative flexibility and relative stiffness. Relative flexibility pertains to the joint itself. Intra-joint relative flexibility refers to hypermobility in accessory motions—spin, roll, or glide. This means one or more of these motions occurs too easily, resulting in an excessive range or frequency of motion. Inter-joint relative flexibility describes a scenario where motion occurs more readily in one joint of a joint pair, even when it should ideally occur in the adjacent joint. A classic example is during forward bending, where the lumbar spine may flex excessively compared to the hips.
Stiffness, conversely, is defined as the resistance encountered during passive elongation of muscle and connective tissue. Stiffness is influenced by muscle hypertrophy and collagen content. Viscosity also plays a role, particularly dependent on the speed of movement. Movement, adhering to physical laws, will always seek the path of least resistance. The determinants of this path are (1) relative flexibility, (2) relative stiffness, and (3) motor learning. When movement involves multiple joints, the body naturally favors increasing motion at the joint with less resistance or lower stiffness compared to a joint with greater resistance or stiffness. For instance, during hip extension, the lumbar spine might extend more readily than the hip joint itself. Relative flexibility impairments can also manifest in single-joint movements. For example, during seated knee extension, early posterior pelvic tilt and lumbar flexion suggest a relative flexibility impairment in the lumbar spine, indicating stiffer hamstring muscles compared to back extensors.
Inducers and Modifiers of Movement System Impairments
Sustained postures and repetitive movements inherent in daily activities are considered the primary inducers of tissue adaptations and the impaired alignments and movements characteristic of MSI syndromes. For instance, individuals engaged in activities with high rotational demands often exhibit increased lumbopelvic rotation compared to those who are not. Numerous studies have demonstrated that repetitive movements associated with various sports and occupations lead to tissue adaptations across bones, joints, and surrounding tissues, including muscles.
However, the impact of sustained alignments and repetitive movements on tissue adaptation and symptom development is modified by a variety of factors. These include age, gender, tissue mobility, anthropometrics, activity level, and psychological factors. Older individuals may exhibit different responses to repetitive movements compared to younger people due to age-related joint and tissue degeneration. Pain sensitivity also varies with age. Gender differences in alignment may also influence the effects of movement patterns. For example, men and women with low back pain may present with different pain-provoking alignments and movements. Women tend to exhibit increased knee abduction during weight-bearing activities, which can elevate their risk of patellofemoral pain and ACL injuries. Tissue mobility itself is a modifier; joint hypermobility can reduce proprioception and increase the risk of musculoskeletal conditions. Anthropometric factors, such as femoral neck shaft angle in women, can predispose individuals to conditions like greater trochanteric pain syndrome. Body structure, like a long trunk, may contribute to depressed shoulder alignment and reduced pain threshold in the upper trapezius. Activity levels also play a modifying role; both inadequate and excessive physical activity can increase musculoskeletal risk, while appropriate activity levels are protective. Finally, psychological factors can significantly modulate pain intensity and outcomes in musculoskeletal conditions like tendinopathy, low back pain, and post-ACL reconstruction.
Alignment and Movement Impairments: Symptomatic vs. Asymptomatic Individuals
The core principle of KPM is to restore optimal alignment and correct movement impairments. While some studies have not found significant differences in alignment and movement patterns between healthy individuals and those with musculoskeletal symptoms, numerous others have identified notable distinctions. For example, patellofemoral pain is associated with increased peak hip adduction, internal rotation, and contralateral pelvic drop. Kinematic studies of the shoulder complex have revealed clear differences between individuals with and without shoulder pain. Sitting posture has been linked to upper quadrant musculoskeletal pain experienced during sitting. Individuals with femoroacetabular impingement exhibit altered pelvic movement patterns during hip flexion compared to healthy controls. People with low back pain tend to move their lumbopelvic region more extensively and earlier during lower limb movements than those without back pain.
Importantly, research also indicates that certain alignment and movement impairments observed in asymptomatic individuals may actually increase their future risk of developing musculoskeletal pain. For example, lumbopelvic movement impairments during hip abduction and standing with excessive lumbar lordosis have been identified as potential risk factors for low back pain development, especially in professions requiring prolonged standing.
MSI Examination and Classification Process
The MSI examination and classification process involves a detailed interpretation of data collected from a series of alignment and movement tests. During these tests, clinicians assess the timing and magnitude of movements, the degree of end-range alignment in specific joints, and the impact on the patient’s symptoms. Symptom-provoking tests are immediately followed by systematic corrections of the identified impairment to determine its direct role in the patient’s symptoms. Correction strategies typically involve: (1) minimizing excessive or premature movement, especially accessory motions, in the symptomatic joint while promoting movement in adjacent joints, or (2) reducing end-range alignment positions in specific directions. A positive response, indicated by symptom improvement upon correction, confirms the association of the identified alignment or movement impairment with the patient’s symptoms.
MSI syndromes have been comprehensively developed for all major body regions, including the cervical, thoracic, and lumbar spine, shoulder, elbow and hand, hip, knee, and ankle and foot (Table 2).
Table 2.
MSI Syndromes Categorized by Body Region.
| Body Region | Syndrome Examples |
|---|---|
| Cervical Spine | Cervical Extension, Cervical Extension-Rotation, Cervical Flexion, Cervical Flexion-Rotation, Cervical Rotation |
| Thoracic Spine | Thoracic Rotation-Flexion, Thoracic Flexion, Thoracic Rotation-Extension, Thoracic Rotation, Thoracic Extension |
| Shoulder | Scapular Insufficient Upward Rotation, Scapular Internal Rotation, Scapular Depression, Scapular Abduction, Scapular Adduction, Scapular Winging and Tilting, Humeral Anterior Glide, Humeral Superior Glide, Shoulder Medial Rotation Glenohumeral Hypomobility |
| Elbow | Wrist Extension with Forearm Pronation, Elbow Hypomobility, Elbow Flexion, Elbow Valgus, Elbow Extension, Wrist Flexion with Forearm Pronation Elbow Impairment |
| Wrist and Hand | Insufficient Finger and/or Thumb Flexion, Insufficient Finger and/or Thumb Extension, Insufficient Thumb Palmar Abduction and/or Opposition, Thumb Carpometacarpal Accessory Hypermobility, Finger or Thumb Flexion with or without Finger Rotation, Source or Regional Impairment of the Hand |
| Lumbar Spine | Lumbar Flexion, Lumbar Extension, Lumbar Rotation, Lumbar Rotation with Flexion, Lumbar Rotation with Extension |
| Hip | Femoral Anterior Glide, Femoral Anterior Glide with Medial Rotation, Femoral Anterior Glide with Lateral Rotation, Femoral Posterior Glide, Femoral Multidirectional Accessory Hypermobility, Femoral Hypomobility with Superior Glide, Hip Adduction, Hip Adduction with Medial Rotation, Femoral Lateral Glide, Hip Extension with Knee Extension, Hip Extension with Medial Rotation, Hip Lateral Rotation |
| Knee | Tibiofemoral Rotation, Tibiofemoral Hypomobility, Knee Extension, Knee Extension with Patellar Superior Glide, Knee Hyperextension, Patellar Lateral Glide Knee Impairment |
| Foot and Ankle | Pronation, Supination, Insufficient Dorsiflexion, Hypomobility, Foot and Ankle Impairment, Proximal Tibiofibular Glide |
Validity and Reliability of MSI Syndromes
The validity of MSI syndromes has been investigated in several studies, primarily focusing on the lumbar and knee regions. Research has reported partial construct validity for MSI syndromes proposed for these areas. Other studies have compared movement impairments and associated signs and symptoms across different MSI syndromes. For example, research has shown that individuals with Lumbar Rotation with Extension Syndrome exhibit distinct asymmetric lumbar movement patterns during trunk lateral flexion compared to those with Lumbar Rotation Syndrome. Systematic differences in hip and lumbopelvic movement during active hip lateral rotation tests have also been observed between individuals with Lumbar Rotation Syndrome and Lumbar Rotation with Extension Syndrome. Furthermore, individuals with Lumbar Rotation with Flexion Syndrome have been found to demonstrate greater lumbar flexion during trunk flexion tests compared to those with Lumbar Rotation with Extension Syndrome. In slumped sitting, individuals with Lumbar Rotation Syndrome showed greater end-range lumbar flexion compared to those with Lumbar Rotation with Extension Syndrome.
The reliability of clinicians in classifying patients into MSI syndromes has also been evaluated, particularly for the lumbar spine and knee. Studies indicate that clinicians can reliably classify patients into lumbar MSI syndromes, even with varying levels of clinical experience. Reliability assessments for knee MSI syndromes have shown moderate to substantial intra-rater and inter-rater reliability for classification judgments.
Treatment Strategies Based on MSI Syndromes
Treatment within the MSI framework encompasses patient education, detailed analysis and modification of daily activities, and the prescription of specific corrective exercises. Patient education is crucial for helping individuals understand how repetitive impaired movements and sustained non-optimal postures can contribute to their musculoskeletal conditions. Patients are taught how to recognize and correct these impairments in their daily routines, especially during activities that trigger symptoms. For instance, someone with Scapular Depression Syndrome might be instructed to maintain scapular elevation by using arm supports while working at a computer, thereby reducing sustained load on the cervical spine and scapular elevator muscles.
A cornerstone of MSI treatment is teaching patients to perform their daily activities correctly and without provoking symptoms. Since sustained alignments and repetitive movements are considered causal factors, their correction is paramount. This correction process also enhances patient awareness of symptom triggers and empowers them to manage or minimize these symptoms. Patients are encouraged to apply these corrections throughout their day. Recent research highlights that, for individuals with low back pain, greater adherence to corrected daily activities, compared to exercise adherence, is linked to more significant improvements in function, pain levels, and other relevant outcomes.
Exercise prescription in MSI is syndrome-specific and targets the contributing factors identified during the initial examination. Exercises focus on practicing the correction of impaired alignments and movements that were pinpointed during clinical tests. For example, a patient with Hip Adduction Syndrome who demonstrates excessive hip adduction and associated hip pain during a partial squat test would use the squat movement itself as a corrective exercise. The focus would be on modifying the amount and timing of hip adduction during the squat to promote correct movement patterns.
These specific exercises and activity modifications are practiced both during therapy sessions and as part of a home exercise program. Patients are typically provided with visual aids, such as pictures or diagrams of exercises and corrected daily activities, along with written instructions. Videos can also be used to enhance understanding and proper execution. The patient’s ability to perform their program correctly is continually assessed during follow-up visits to guide program progression. Evaluating the patient’s grasp of the core principles behind each exercise or activity and their independence in performing them is vital for making informed decisions about when and how to progress the treatment plan.
Clinical Evidence for MSI Treatment
Numerous case reports have documented the application of MSI treatment across a range of conditions, including shoulder pain, low back pain, abdominal pain, cervicogenic headache, and knee pain. A feasibility randomized clinical trial has also explored MSI treatment for chronic hip pain. A randomized controlled trial specifically investigating the treatment of chronic low back pain compared the effectiveness of a Classification-Specific (CS) treatment approach (based on MSI principles) to a non-Classification-Specific (NCS) treatment. Both CS and NCS treatments included exercise and daily activity modification. The CS treatment incorporated education, exercise, and daily activity correction aligned with MSI syndromes. The NCS treatment focused on education and daily activity correction emphasizing the maintenance of a neutral spine, with exercises aimed at trunk strengthening and flexibility in the trunk and lower limbs. Interestingly, the study found no significant difference in efficacy between the CS and NCS approaches. The authors suggested that the comparable improvements observed in both groups might be attributed to the shared emphasis on daily activity correction, particularly the focus on maintaining a neutral spine and promoting movement in other joints during daily tasks. This interpretation was further supported by the finding that participants in both groups demonstrated greater adherence to daily activity corrections than to prescribed exercises.
Conclusion
The MSI-based classification and treatment system provides physical therapists with a robust framework for diagnosing and treating musculoskeletal conditions rooted in the principles of the Kinesiopathologic Model. This model posits that impaired alignments and movements are primary contributors to pain and pathology. MSI syndromes and corresponding treatment protocols have been established for all major body regions. The reliability and validity of the MSI system have been partially substantiated for certain anatomical areas. Numerous case reports detail the MSI examination and treatment of diverse musculoskeletal conditions. While case evidence is supportive, further randomized controlled trials are needed to rigorously evaluate the efficacy of MSI syndrome treatment, particularly beyond chronic low back pain where some RCT evidence exists. Additional research in this area will be crucial to fully establish the evidence-based effectiveness of Shirley Sahrmann’s Movement System Impairment approach in physical therapy.
Conflicts of interest
Daniel Azevedo is an instructor in continuing education courses that include MSI content.
Shirley Sahrmann teaches continuing education courses on MSI and receives royalties from her book “Diagnosis and Treatment of Impairment Syndromes” published by Elsevier.
Linda Van Dillen declares no conflicts of interest.
Acknowledgements
This work was partially supported by NIH/NICHD/NCMRR Grant number HD 047709 (PI: Van Dillen).
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