Physiotherapy Theory and Practice, 27(8):586–594, 2011

Copyright © Informa Healthcare USA, Inc.

ISSN: 0959-3985 print/1532-5040 online
DOI: 10.3109/09593985.2011.552539

CLINICAL TECHNICAL NOTE

Concurrent validity and reliability of clinical evaluation

of the single leg squat
Daniel R. Poulsen, PT, PhD, MA, OCS and C. Roger James, PhD
Assistant Professor, Center for Rehabilitation Research, Texas Tech University Health, Sciences Center, Lubbock, Texas,
USA
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ABSTRACT
This study determined reliability and concurrent validity of measurements of the single leg squat made by novice
examiners. Twelve video recordings of individuals performing a single leg squat were evaluated by six student
physical therapists. Students assessed movement quality on an ordinal scale and manually measured frontal
plane knee movement quantity on a video monitor. Inter- and intrarater reliability of ordinal scale ratings were
determined via quadratically weighted kappa. Inter- and intrarater reliability of frontal plane knee measures
were determined through intraclass correlation coefficient models 2,k and 3,k (k = 3 ratings), respectively.
Concurrent validity of frontal plane knee measures was examined by comparison with Vicon-Peak motion-
tracking system measures via Bland-Altman scatterplots. Ordinal scale measures displayed intrarater reliability
ranging from 0.38 to 0.94 and interrater reliability of 0.68 (0.46–0.87). Intrarater reliability of frontal plane knee
For personal use only.

measures ranged from 0.88 to 0.98 and interrater reliability of 0.99 (0.97–1.00). Difference scores between
student and computer-generated measures of frontal plane knee movement were significantly different as
determined through Bland-Altman scatterplots and calculation of the upper and lower limits of agreement.

INTRODUCTION setting that can measure patient movement during the

It has been proposed that functional movements, such
as the single leg squat, can be measured to assess pre-
disposition to common degenerative and traumatic
musculoskeletal injuries (Chmielewski et al, 2007;
Hewett et al, 2005; McLean, Huang, and vanden
Bogert, 2005; Willson and Davis, 2007). For
example, evidence indicates that excessive valgus
angle at the knee during functional tasks is a risk
factor for noncontact anterior cruciate ligament
injury (Griffin et al, 2006). Because the measurement
methods used to detect abnormal movement patterns
during functional activities are expensive and techni-
cally sophisticated, it has been difficult to replicate
these types of movement analyses in the clinical
setting. Therefore, attempts have been made to bring
more cost-effective and pragmatic tools to the clinical
Accepted for publication 19 November 2010
Address correspondence to Daniel R. Poulsen, Center for Rehabilitation
Research, Texas Tech University Health, Sciences Center, 3601 4th
Street, Lubbock, TX 79430-6280. E-mail: dpoulsen@rocketmail.com
performance of functional tasks.
The frontal plane projection angle (FPPA) is a two-
dimensional (2D) knee angle measure that is manually
performed by using software or traditional angle-
measuring devices, such as a goniometer, on a compu-
ter monitor (Willson and Davis, 2008a). Knee valgus
angle during weight-bearing tasks, as measured
through FPPA, was shown to be greater in female sub-
jects diagnosed with patellofemoral pain syndrome
than healthy control subjects (Willson and Davis,
2007; Willson and Davis, 2008b). Despite the early
promise of the FPPA as a useful clinical tool, a
review of the literature indicates an absence of evi-
dence about the reliability and validity of measures
made by novice clinicians when using this measure-
ment method.
Chmielewski et al (2007) used an ordinal scale for
the measurement of quality of motion displayed
during performance of single leg activities. This
group found intrarater reliability of experienced clini-
cians, as measured by weighted kappa coefficients, to
range between 0.38 and 0.68 when used to assess
lateral step down (LSD) and single leg squat (SLS)
quality of motion. It was suggested in the same

586

report that the relatively low reliability might have been
due to a lack of heterogeneity in the subjects being as-
sessed and the use of a nonintuitive rating system that
consisted of a set of arbitrary symbols. Chmielewski
et al (2007) concluded that this method of assessment
can be used by clinicians to produce ratings of
movement with reliability greater than would be
found by chance, but less than what is necessary for
clinical use.
These newer methods for assessing movement hold
promise as useful clinical tools for measuring patient
motion while performing a functional task. However,
a review of literature indicates that nothing is known
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of the reliability of measures made by novice clinicians
when using the ordinal scale described by Chmielews-
ki et al (2007) and the FPPA method of assessment
described by Willson and Davis (2007). In addition,
recent publications mentioned here indicate that auto-
matic computerized tracking and calculation of the
knee frontal plane projection angle may be a useful
clinical measure. However, the relationship of hand-
measured FPPA to computer-generated FPPA has
not yet been investigated. If these tools are to be
used as standard methods of movement assessment
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in physical therapy practice, it is essential that ex-
pected levels of reliability and validity of measures
made by clinicians be elucidated, particularly in phys-
ical therapists with limited clinical experience.
Therefore, the objectives of the study were to 1)
investigate the intra- and interrater reliability of
measures of single leg squat (SLS) movement pro-
duced by novice physical therapists when using a
more intuitive numerical ordinal scale; 2) investigate
the intra- and interrater reliability of 2D FPPA
measures of SLS performance produced by novice
physical therapists; and 3) investigate the concurrent
validity of 2D knee FPPA measures produced by
novice physical therapists through comparison with a
Vicon-Peak (120 Hz, Motus 9.0; Vicon-Peak, Cen-
tennial, CO, USA) 2D computerized movement
tracking system which also produces a 2D measure
of FPPA. It was hypothesized that 1) ordinal scale
and FPPA measures would exhibit levels of intra-
and interrater reliability considered adequate for use
in the clinical setting and 2) measures of the FPPA
would not significantly differ from those of the com-
puterized movement-tracking system.
MATERIALS AND METHODS
Experimental design
A test-retest design was used to examine the intra- and
interrater reliability of ordinal scale and FPPA
Physiotherapy Theory and Practice
Physiotherapy Theory and Practice 587
measures. Concurrent validity of student-generated
FPPA measures was determined by comparison to cri-
terion standard values generated by a computerized
motion-tracking system.
Subjects performing single leg squat
Twenty-two individuals were recruited from a sample
of convenience at a local university through personal
communication. A solicitation script was used to
recruit these individuals. The inclusion criterion was
age of 18-60 years. Exclusion criteria consisted of
current injury to either lower extremity causing pain
or requiring treatment from a health care practitioner,
medical history including previous injury to either
lower extremity that required health care services
lasting greater than 1 week during the subject’s life-
time, self-reported balance disorder, or pregnancy.
Protocol for obtaining FPPA performance
data of each SLS performance
An electronic goniometer (elgon; model LS800 and
SG150; Biometrics, Ltd., Ladysmith, VA, USA) was
secured to the lateral aspect of the thigh and leg of
the stance (dominant) limb of each subject to
measure knee flexion angle in real time for the
purpose of standardizing depth of single leg squat.
The dominant limb was defined as the limb that the
subject would use to kick a ball. The elgon recorded
(120 Hz) sagittal (flexion-extension) plane knee
motion. Real-time sagittal plane elgon data were
used as biofeedback to inform the subject when the
desired amount of knee flexion (45°) had been
reached during the SLS.
By using previous works of Willson and Davis
(2008a; 2008b), a method of capturing 2D knee
motion was devised to create measures of the FPPA
through a computerized motion-tracking system. Six
reflective markers were applied to the subject, one at
each anterior superior iliac spine (ASIS), two on a
line approximating the mechanical axis of the thigh
segment, and two on a line approximating the mech-
anical axis of the leg segment (Figure 1). Two
additional reflective markers were placed 1 meter
apart on the floor to create a horizontal reference
line of known length used to verify the 2D scaling. Re-
flective markers were automatically tracked through a
computerized motion-tracking system (120 Hz,
Motus 9.0; Vicon-Peak, Centennial, CO, USA) to de-
termine the criterion standard FPPA measure. The
raw x- and y-coordinate data were scaled by using a
 588 Poulsen et al.
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FIGURE 1 Reflective marker configuration for collecting cri-
terion FPPA measure. Arrows indicate placement of reflective
markers.
0.562-meter by 1.072-meter rectangular scaling
grid and smoothed by using a fourth-order, two-pass
no phase shift Butterworth digital filter (6 Hz
For personal use only.
cutoff). Elgon data were synced with reflective
marker data automatically through the Vicon-Peak
system. This was done to ensure that the criterion
standard FPPA measure was always performed at the
lowest point of knee flexion during the SLS perform-
ance. This timing of the FPPA measure also correlated
with when clinician subjects were instructed to
perform measurement of the FPPA on the video
images. The FPPA was calculated as the angle
between the midline of the leg and midline of the
thigh in the frontal plane. The convention used to
interpret FPPA measures was as follows: a positive
FPPA indicated 2D medial position of the knee and
a negative FPPA indicated a 2D lateral position of
the knee.
A digital video camera (model DCR-HC40; Sony
Electronics, Inc., Oradell, NJ, USA) was positioned
approximately 4.5 meters in front of the subject and
set to record (30 Hz) a frontal plane view of the
SLS. The image was adjusted so that the subject was
visible in at least two thirds of the viewing area when
the person was in a neutral standing position. The
digital video camera and the infrared motion-tracking
camera were placed by using a floor reference grid to
ensure that they were both recording in an identical
distance and angle perpendicular to the frontal plane
of subjects performing the SLS maneuver. Video
files captured by the digital video camera were later
used by novice clinician raters to perform movement
measures (described below) via the ordinal scale and
FPPA methods.
Following a short instruction and demonstration by
the principal investigator, the subject was asked to
practice the SLS maneuver. After the subject felt com-
fortable with performing the maneuver, he or she then
performed five repetitions (trials) of the SLS. All five
trials were subsequently reviewed by the principal
investigator, and one video file was chosen for later
analysis by the novice clinician raters. Depth of squat
was standardized by using the elgon, which informed
the subject and investigator when knee flexion
reached 45°. Knee flexion of 45° was used to approxi-
mate a typical attainable squat depth commonly used
during functional activities. The rate of SLS motion
was controlled by instructing the patient to descend
to 45° of knee flexion over a minimum 1 second
period and returning to upright position over a
minimum 1 second period. The 2-second minimum
total SLS duration was chosen to minimize effect of
velocity on quality and quantity of movement as well
as rater ability to assess. All squat performances were
performed in a controlled manner and were per-
formed over a period of time equal to or greater than
3.4 seconds as determined by review of elgon data.
While performing the SLS, the subject was instructed
to maintain an upright trunk posture while the video
images and elgon data were recorded.
Protocol for creating single leg squat
video bank
From the original pool of 22 subject videos, video files
of 12 individuals performing the SLS test were se-
lected. These 12 videos were categorized by the inves-
tigators on the basis of objective quantitative measures
(digital computerized methods, described previously)
of their SLS performance derived through computer-
ized measure of reflective marker motion described
previously. Approximately one third of the individuals
displayed the least amount of 2D-medial knee move-
ment (FPPA < 5°), one third displayed an average
amount of 2D-medial knee movement (FPPA ≥ 5° to
<10°), and one third displayed the most 2D-medial
knee movement (FPPA ≥ 10°). The FPPA values
used to define the categories were based on previous
research findings that reported normal and abnormal
FPPA values displayed during the SLS maneuver by
healthy adults (DiMattia et al, 2005; Kralj, Jaeger,
and Munih, 1990; McKinley and Horowitz, 1992;
Nguyen and Shultz, 2007; Salem, Salinas, and
Harding, 2003; Willson and Davis, 2007; Zeller,
McCrory, Kibler, and Uhl, 2003; Zeller et al, 2005).
The neutral category is considered representative of
the average knee frontal plane movement in the
Copyright © Informa Healthcare USA, Inc.

normal healthy adult population. The 2D-medial knee
movement category individuals have a higher degree
of 2D knee medial movement relative to the average
healthy adult. The 2D-lateral knee movement cat-
egory individuals display greater 2D lateral knee
movement relative to the average healthy adult. The
aim of creating these categories was to develop a
bank of patient simulation video files that displayed
varying levels of movement quality and quantity.
Former research has cited the lack of heterogeneity
of movement displayed as a possible cause of limited
visual assessment reliability (Chmielewski et al,
2007; DiMattia et al, 2005).
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Novice clinician raters
A convenience sample of six volunteer physical
therapy students entering their final semester of
entry-level education was asked to participate. This
population was specifically chosen because it rep-
resented a controlled sample of clinician raters who re-
ceived all didactic lecture, lab, and clinical education
as physical therapists without bias of postgraduate
For personal use only.
functional assessment training. Raters were recruited
during regular lecture and lab instruction.
Evaluation of SLS performance by novice
clinician raters
Each novice clinician rater was asked to observe each
video and assess movement by using the ordinal
scale (Table 1) and to measure each subject’s FPPA
by using a manual goniometer. Video data collected
through use of the Sony DV Camera provided the
TABLE 1 Modified qualitative scoring method for evaluating
single leg squat
Point value Definition
0 No deviation from neutral alignment
5 A small-magnitude or barely observable
movement out of a neutral position and/or
moderate frequency of segment oscillation
10 A moderate-magnitude or marked movement
out of a neutral position and/or moderate
frequency of segment oscillation
15 Excessive or severe magnitude of movement
out of a neutral position and/or high
frequency of segment oscillation
Each anatomical segment (trunk, pelvis, and hips/thigh) being
assessed is given a value that correlates with the observed level of
movement quality. Simulated patient’s score for quality of
movement is then derived by summing the scores (Chmielewski
et al, 2007).
Physiotherapy Theory and Practice
Physiotherapy Theory and Practice 589
images that clinician raters analyzed. All video files
were observed on a standard 19-inch flat panel LCD
computer display (UltraSharp-1907FPt, Dell Compu-
ter Inc.). Quick Time Player (7.4 Pro; Apple, Inc.)
software was used to display video data.
Ordinal scale assessment
Immediately after watching each individual video,
the rater was asked to measure the SLS performance
for the subject by using the modified specific quality as-
sessment tool (Table 1). The term “modified” is used
here to describe the scale because the original ordinal
scale used by Chmielewski et al (2007) did not ask
the rater to apply numerical values to describe the ob-
served kinematics. Chmielewski’s original scale used
a randomly assigned group of nonintuitive symbols
that did not directly reflect a change in magnitude of
kinematics displayed by the individual performing the
SLS. The modified specific method of assessment re-
quires the clinician to assign one of four numerical
values (0, 5, 10, or 15) (Table 1) to each of the three seg-
ments of interest (trunk, thigh, and pelvis). The sum of
the segment scores was used for the reliability calcu-
lation. These numerical values increase in magnitude
in direct correlation with the descriptions of increasing
abnormal movement in the ordinal scale definitions.
Novice clinician raters were not limited to the
number of times they were allowed to view each
video. Each rater viewed each individual video an
average of three times.
Frontal plane projection angle assessment
Following the ordinal scale measurement of the
SLS performance, novice clinician raters were in-
structed to view the video again and to pause the
video at the time when the subject reached the
lowest position while performing the single leg squat.
While the video was paused, the clinician raters then
measured FPPA three times directly from the video
image using a 15-centimeter manual goniometer (E-
Z Read Manual Goniometer, Jamar Inc.). The
average of these three ratings was used for all reliability
calculations. The convention used to describe move-
ment with the FPPA was as follows: negative value
indicates a medial knee movement and a positive
value indicates a lateral knee movement (Willson
and Davis, 2007; Willson, Dougherty, Ireland, and
Davis, 2005).
The novice clinician raters were asked to return 4
weeks following the initial measurement session to
repeat all ordinal scale and FPPA measures. These
data were subsequently entered manually into a
spreadsheet by one of the principal investigators.
Both the principal investigator entering the data and
the novice clinician raters were blinded to measures
made at the first data collection session.
 590 Poulsen et al.

Statistical analysis TABLE 2 Interrater and intrarater reliability of quality of

motion ordinal scale easures
Descriptive statistics of all measurement variables
Interrater qualitative reliability: Coefficient (95% CI)
(qualitative assessment, FPPA obtained via the com-
puterized motion tracking system, and manually Generalized weighted kappa 0.68 (0.46–0.87)
measured FPPA) were compiled and recorded. Intrarater qualitative reliability:
Weighted kappa
Statistical analysis of ordinal scale measures Subject 1: 0.76∗ (0.36–0.93)
Intra- and interrater reliability of the ordinal scale Subject 2: 0.89∗ (0.66–0.97)
measures were calculated by using quadratically weighted Subject 3: 0.70 (0.23–0.90)
kappa as described by Norman and Streiner (1994). Subject 4: 0.38 (-0.22–0.77)
The interrater reliability analysis for both ordinal Subject 5: 0.85∗ (0.56–0.95)
scale measures and FPPA measures was completed Subject 6: 0.94∗ (0.80–0.98)
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by using measurements obtained only at the initial ∗

Reliability exceeds value considered necessary for clinical use
data collection session to control for possible matu- (Portney and Watkins, 2009).
ration and learning effect.
Statistical analysis of FPPA measures
Intrarater reliability was calculated for quantitative TABLE 3 Interrater and intrarater reliability of frontal plane
projection angle measures
FPPA measures by using intraclass correlation coeffi-
cient model 3,3. Interrater reliability was calculated
Interrater FPPA reliability: Coefficient (95% CI)
for FPPA measures by using intraclass correlation
coefficient model 2,3. Choice of intraclass correlation Intraclass correlation (ICC) 2,k 0.99∗ (0.97–1.00)
coefficient models was based on recommendations of Intrarater FPPA reliability:
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Portney and Watkins (2009). Intraclass correlation(ICC) 3,k

Concurrent validity of FPPA measurements was as- Subject 1: 0.98∗ (0.94–1.00)
sessed by comparing the average values of the manual Subject 2: 0.98∗ (0.94–1.00)
Subject 3: 0.98∗ (0.92–0.99)
goniometric measurements of FPPA and the compu- Subject 4: 0.88∗ (0.59–0.97)
ter-generated criterion standard measurements of knee Subject 5: 0.97∗ (0.89–0.99)
FPPA via Bland-Altman plots (Bland and Altman, Subject 6: 0.97∗ (0.90–0.99)
1986; Bland and Altman, 2010; Hanneman, 2008). A ∗
5° variation in agreement between clinician measures Reliability meets or exceeds value considered necessary for
clinical use (Portney and Watkins, 2009).
and computer-generated measures was determined to
be acceptable a priori. All statistics were calculated by
Bland-Altman plots indicated that novice clinician
using SPSS v.12 and Microsoft Excel 2007.
generated measures of the FPPA differed significantly
from computer-generated measures of the FPPA.
Examination of Bland-Altman scatterplots (Figures
RESULTS 2, 3, 4, 5, 6, and 7) and calculation of upper
(ULOA) and lower limits of agreement (LLOA) indi-
Ordinal scale visual observational cated that variability in difference scores between clin-
assessments of movement quality ician measures and computer-generated measures did
not fall within the a priori-determined limit of 5°
Intrarater ordinal scale assessment reliability ranged (Table 3). Datum points on the Bland-Altman scatter-
from 0.38 to 0.94 (Table 2). Interrater reliability of plots are generated by plotting the difference between
ordinal scale measures determined via generalized the student’s measure and the computer’s measure
quadratically weighted kappa coefficient with two- (Y) versus the mean of the student’s measure and
sided 95% confidence interval was 0.68 (0.46–0.87). the computer’s measure (X) for each subject.

Frontal plane projection angle measures DISCUSSION

Intrarater reliability of FPPA measures ranged from Ordinal scale assessment of movement
0.88 to 0.98 (Table 3). Interrater reliability of frontal
plane projection angle measures with two-sided 95% Results of this study are mixed for the hypothesis that
confidence interval was 0.99 (0.97–1.00). clinicians with minimal clinical experience can display

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 Physiotherapy Theory and Practice 591
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FIGURE 2 Bland-Altman scatterplot for clinician subject FIGURE 5 Bland-Altman scatterplot for clinician subject
1. Upper and lower limits of agreement (ULOA & LLOA) are 4. Upper and lower limits of agreement (ULOA & LLOA) are
represented by the upper and lower dashed lines, respectively. represented by the upper and lower dashed lines, respectively.
For personal use only.

FIGURE 3 Bland-Altman scatterplot for clinician subject FIGURE 6 Bland-Altman scatterplot for clinician subject
2. Upper and lower limits of agreement (ULOA & LLOA) are 5. Upper and lower limits of agreement (ULOA & LLOA) are
represented by the upper and lower dashed lines, respectively. represented by the upper and lower dashed lines, respectively.

FIGURE 4 Bland-Altman scatterplot for clinician subject FIGURE 7 Bland-Altman scatterplot for clinician subject
3. Upper and lower limits of agreement . (ULOA & LLOA) 6. Upper and lower limits of agreement (ULOA & LLOA) are
are represented by the upper and lower dashed lines, represented by the upper and lower dashed lines, respectively.
respectively.

the movement of patients over a period of time with

intrarater reliability of ordinal scale measures con- a degree of intrarater reliability necessary for clinical
sidered adequate for clinical use (≥0.75) (Portney use. However, two of the six novice clinicians dis-
and Watkins, 2009). Our results indicate that a played intrarater reliability that would not support
majority of the novice clinician raters could measure this hypothesis when using the ordinal scale.

Physiotherapy Theory and Practice

 592 Poulsen et al.
One possible reason for this mixed result in rater
reliability is lack of a more thorough education of
raters on consistent performance of measurement
using the ordinal scale. In this study the instruction
provided to raters prior to the initial rating session
was only a brief familiarization to the ordinal scale,
which described the scales purpose and instruction
to apply one definition from the scale to each body
segment. At this instruction period, raters were not
given a standard interpretation of the ordinal scale; it
was left to each individual rater to interpret the defi-
nition of each level of the ordinal scale leaving room
for variation in the application of the ordinal scale in-
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strument when rating subjects. Intrarater reliability
may improve, and exceed an acceptable level, if all
novice clinician raters are instructed in what each
ordinal scale definition looks like through a prelimi-
nary clinical education that includes examples of
varying levels of stability during a single leg squat.
Education of this type might allow an opportunity
for students to develop a static memory of the standard
method of application of the ordinal scale. Building
such a memory of consistent interpretation and appli-
cation of this assessment method might also result in a
For personal use only.
more reliable measurement from one rating session to
another.
Interrater reliability of ordinal scale measures failed
to reach a level considered adequate for clinical use.
This is in agreement with previous findings of Chmie-
lewski et al (2007). As described above for intrarater
reliability, a more thorough and uniform education
in the assessment method may improve levels of inter-
rater reliability. However, results may also indicate that
this ordinal scale does not lend itself to agreement
between raters due to the scales inherent subjectivity
and a more refined scale or uniform education may
not change this.
Intra- and interrater reliability of ordinal scale
measures in this study was higher than the single pre-
vious study that used a similar specific ordinal scale
(Chmielewski et al, 2007). Possible explanations for
this include the following: 1) In the study conducted
by Chmielewski et al (2007), the raters first scoring
session was completed by observing subjects in
person while they performed the functional task, and
the second round of observations was completed by
the raters observing a video of the prior performance.
In our study, mode of visualizing the patient perform-
ance was controlled (video only). 2) Chmielewski’s
group did not control for duration between the first
and second round of assessment (10 ± 1.5 weeks),
thus introducing the possibility of greater variability
between raters or a learning or maturation effect; the
current study controlled precisely for duration
between the first and second round of rater measures.
3) Chmielewski et al (2007) discuss that a limitation of
their study was the use of an arbitrary, nonintuitive,
symbol system to rank quality of movement; the
current study used a more intuitive numerical
ranking system with equidistant measures that may
have contributed to a more accurate representation
of novice clinician perception of movement.
Quantitative measures
Results suggest that a novice clinician who desires to
track an individual patient’s FPPA can do so with a
degree of reliability that exceeds the minimal clinical
standard. All novice clinician quantitative measures
exhibited intrarater reliability that was above the level
considered adequate for clinical use (≥0.75) (Portney
and Watkins, 2009). However, examination of
measures of FPPA does not support the hypothesis
that measures made by novice physical therapists are
similar to computer-generated criterion standard
FPPA measures.
Because clinician measures of FPPA are reliable,
both within raters and between raters, there is in-
creased confidence that these measures can be used
in the clinical setting. Previous research by Willson
et al (2008b) using FPPA measures generated by
hand indicates that the FPPA is a valuable measure
of human motion that may be used in the diagnosis
and treatment of individuals with lower extremity
pathology. Similar findings by Levinger and Gilleard
(2007) are also in agreement.
These results also suggest caution to researchers
who may try to apply a computerized method of
measuring the FPPA with the intention to interpret
them in the same manner as Willson et al (2007;
2008a; 2008b) have in previous publications. It is
not readily apparent why computer-generated
measures of the FPPA were different from those gen-
erated by humans. The hypothesis that they would be
concurrently valid was based on the fact that both the
computer and the human raters were “instructed” to
measure the FPPA based on the placement of the re-
flective markers. It is possible that human error in
placing and reading the goniometer or recording the
FPPA values resulted in significantly different
measures than were produced by the computer.
However, the high levels of inter-and intrarater
reliability in human measures indicate that human
error was not likely a substantial source of human
and computer disagreement.
Therefore, it is more likely that a difference in the
manner in which the computer and the human
measured FPPA existed, causing this difference in
measures. One possible explanation includes the
Copyright © Informa Healthcare USA, Inc.

small aspect difference created by the different place-
ment of the infrared camera and the digital video
camera. This difference in camera placement may
have created enough of a difference in the images pre-
sented to the computer and the human to undermine
concurrent validity between the two measurement
methods. The effect could be similar to two humans
standing in two different positions when measuring
the projection angle of any object. A small difference
in perspective between the infrared-computer camera
and the standard video camera could cause a signifi-
cant difference in measures made from the two differ-
ent videos generated.
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The current study indicates that the reliability of the
methods of movement measurement described shows
levels of reliability near or above that considered ade-
quate for clinical use. However, results also indicate
that quantitative measures of the FPPA derived
through inexpensive manual goniometric methods
are not concurrently valid compared to criterion
standard measures derived through 2D computerized
motion-tracking equipment.
For personal use only.
LIMITATIONS AND CONCLUSIONS
The results of this study do not shed light on the val-
idity of motion analysis through the ordinal scale.
Additional study should be focused on use of the modi-
fied ordinal scale and its relationship to musculoskeletal
pathology. Although novice clinicians were able to
perform consistent ordinal scale measures across time
and between raters, the ordinal scale used should be es-
tablished as a valid clinical examination tool that pro-
vides information useful for patient management.
Raters in this study performed measures of move-
ment through viewing video images. Most use of
movement assessment in the clinical setting is likely
to be through watching patients move in a live situ-
ation. Therefore, the implications for reliability and
validity of movement in the clinical setting remain
unknown. It is possible that viewing video images
may result in measures that are identical to, or very
similar to, measures created through watching live
action in the clinic. However, no evidence exists in
the literature for the correlation between measures
made through live action and those made through
viewing video images. Despite this limitation, using
video images was the only method to limit the intro-
duction of error that might occur due to variation in
what was being assessed by the raters.
Lastly, the pool of videos being assessed was artifi-
cially composed of an equal number of individuals in
each of the three categories of frontal plane knee angle
to create heterogeneity in the sample. It is possible that
Physiotherapy Theory and Practice
Physiotherapy Theory and Practice 593
this artificially improved the ICC values because
the within- and between-rater variability might have
been made artificially small relative to the sample
variability. It is recommended that future study not
purposefully create heterogeneity through sample
selection, but rather allow natural variability occur in
the pool of subjects being assessed.
Results indicate that FPPA measures of movement
generated by novice clinicians display intra- and inter-
rater reliability necessary for clinical application.
However, concurrent validity analysis indicates that
what novice clinicians are measuring during FPPA
analysis may not be the same as the FPPA measures
generated by 2D computerized motion analysis
systems. This is encouraging because it indicates that
even novice clinicians can reliably generate measures
of 2D knee movement. It also highlights a piece of
information not previously known; it is possible that
what clinicians measure when asked to assess knee
FPPA during a single leg squat may be different
from measures generated by a high-speed 2D motion
analysis system. Therefore, until the source of this dis-
agreement is determined and ameliorated, researchers
should proceed with caution when interpreting
computer-generated FPPA measures using previous
research that relied on handmade measures using
standard video equipment.
Future investigation should also continue to focus on
the interpretation and clinical validity of FPPA measures
generated by clinicians. Knowing the relationship of
human-generated measures to pathology is important
because the ultimate use of FPPA in the clinical setting
will likely be those generated by clinicians and not
expensive computerized motion-tracking systems.
Translation of this technique into the clinical
setting has also yet to be investigated. The ability to
teach a patient the single leg squat and then video
record this data takes approximately 2–3 minutes.
With the recent advances in video-capturing devices
that automatically transfer to computer memory, it is
possible that measuring the FPPA in the clinical
setting may only take a trained clinician approximately
3–5 minutes to capture video data, find the point of
peak knee angle during descent, and measure the
FPPA. Considering the reliability of this measure
shown here and the indication from previous study
by Willson et al that the FPPA holds valuable infor-
mation for the assessment of those suffering from
lower extremity pathology, it appears reasonable for
clinicians to begin exploring the use of this measure-
ment method as an additional tool for assessing
clients with lower extremity pathology. It is likely
that if clinicians begin adding this as a regular
measurement tool, the understanding of the value of
this technique will be greatly expanded, and previously
 594 Poulsen et al.
overlooked coordination deficits in the frontal plane
will be more readily treated through neuromuscular
coordination and therapeutic exercise.
Future investigation should also analyze if there is a
significant difference between novice raters and ad-
vanced professionals to determine if level of experi-
ence affects validity of measures made. If this is so,
it is possible that experience and training play a role
in validity of clinician measures indicating a need for
a period of training or experience in clinical practice
before measures of FPPA can be considered valid.
In conclusion, the reliability of novice clinician
ordinal scale measures of human motion failed to
Physiother Theory Pract Downloaded from informahealthcare.com by Michigan University on 11/05/14
reach levels necessary for clinical application. Concur-
rent validity assessment of clinician-generated FPPA
measures, as determined by comparison with compu-
ter-generated FPPA measures, indicates that clinician
measures are significantly different from those gener-
ated by 2D computer motion analysis. However,
both intrarater and interrater reliability of FPPA
measures successfully exceeded levels necessary for
application of this measurement method in the clinical
setting. Future study should be undertaken to
determine what relationships exist between novice
For personal use only.
clinician FPPA measures, experienced clinician
FPPA measures, and musculoskeletal pathology to
determine the value of this clinical measure.
Declaration of interest: The authors report no
conflicts of interest. The authors are responsible for
the content and writing of the article.
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