Investigating the validity and reliability of the functional movement screening tool in tennis as a predictor of injury

Investigating the validity and reliability of the functional movement screening tool in tennis as a predictor of injury | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Investigating the validity and reliability of the functional movement screening tool in tennis as a predictor of injury Sam Kazemi, Mohammad Hossein Alizadeh, Hassan Daneshmandi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4696915/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Apr, 2025 Read the published version in BMC Sports Science, Medicine and Rehabilitation → Version 1 posted 4 You are reading this latest preprint version Abstract Background Recently, researchers use functional movement tests and especially the functional movement screen (FMS) as a screening tool to prevent injuries in sports. However, limited studies are available to strongly support the validity and reliability of the FMS in different sports populations. Therefore, the FMS does not seem to be a comprehensive functional movement screening tool in order to investigate asymmetry and limitations in all sports. Therefore, the aim of the present study was to design and evaluate the validity and reliability of the screening tool for functional movements in tennis as a predictor of injury. Methods To determine validity and reliability, the results obtained from semi-structured and in-depth interviews with 18 tennis experts were used, which led to the selection of 27 tests out of 108 initial tests. Face validity was evaluated by 10 tennis players, content validity by 10 experts in this field, and construct validity of the questionnaire by 234 tennis players. The reliability of tool was estimated by test-retest method at a time interval of 2 weeks on samples consisting of 20 tennis players using the internal correlation index (ICC). Results Based on the results obtained from the calculation of the content validity ratio, 21 out of 27 tests had a content validity ratio higher than 0.62 and the rest of the tests were excluded. Exploratory factor analysis (EFA) extracted two latent factors that explained 54.05% of the total variance. Confirmatory factor analysis (CFA) confirmed the final construct model. The reliability of the tool was estimated: 95% CI: 0.53–0.92, p = 0.001, ICC = 0.91. Conclusion The functional movement screening tool designed for tennis had acceptable validity and reliability with the aim of investigating asymmetry and limitations in this sport. Factor analysis showed that considering the correct features of psychometrics, this tool can be used as a predictor of injury in tennis. functional movement screening tennis validity and reliability confirmatory factor analysis exploratory factor analysis Figures Figure 1 Introduction Screening tools are used to various goals, one of these important goals in sports science is the prevention of athletes' injuries ( 1 ). Screening can be used to help prevent injury by identifying functional defects and abnormalities related to the desired sport ( 2 ). The screening process in many advanced countries is done in the pre-season training of sports competitions in many developed disciplines ( 3 ). Pre-season screening can be important to determine and identify athletes who are at risk of injury. Functional screening is an important tool for predicting and systematically examining injuries in various sports fields ( 4 ). In this regard, in a study, performance screening tools that can be used as injury predictors in various sports have been reviewed ( 5 ). This study was done on team sports. The findings of this study showed that most of the screening tools have been used to predict a specific type of injury, such as anterior cruciate ligament (ACL), ankle and hamstring injuries, instead of examining a set of different injuries of a specific sport. The tests used to predict these injuries were classified into a series of anthropometric, flexibility, range of motion and balance tests. Each of these classes covered some performance tests and not all of them ( 5 ). The combination of this set of tests and information on the prevalence of injuries related to a specific sport can lead to the development of a functional screening tool ( 6 ). Looking at the background literature in the field of functional movement screening, it can be seen that this tool has been developed in some sports such as football ( 7 ), gymnastics ( 8 ), Australian football ( 9 ), dance ( 10 ) and volleyball ( 11 ). Sleeper, Kenyon and Casey ( 8 ) designed a tool to evaluate the functional fitness of gymnasts called gymnastics functional measurement tool (GFMT). By using tests that are specific to gymnastics, this tool has created unity among the variables of flexibility, speed, power, muscle strength, muscle endurance and balance and was approved by experts in this field. Also, the normative norm and validity of the GFMT tool has been investigated by studying gymnasts. Overall, the GFMT score had high validity. However, this tool is unable to determine the amount of injury and only reveals functional impairments and abnormalities ( 8 ). From the point of view of these researchers, this recent finding was considered an improvement in the field of screening. In addition, Tabatabaei, Daneshmandi ( 12 ) designed a tool to evaluate the functional fitness of volleyball players by screening functional movements with the aim of predicting injury ( 11 , 12 ). Recognizing the importance of a functional movement screening tool in volleyball, this study had designed a protocol that was able to identify functional limitations in the implementation of skills in this sport; And in this way, the injures related to these restrictions were predicted. This process led to the selection of 12 tests to be included in the functional screening tool of movement in volleyball. Afterwards, validity and reliability were examined and confirmed ( 11 , 12 ). Studies conducted on gymnastics and volleyball can serve as a guide and a cornerstone for the development of screening tools in various sports fields. Recently, physiotherapists and trainers use functional movement tests and especially Functional Movement Screening )FMS( as a screening tool in sports to predict injuries and then develop preventive strategies ( 13 ). Cook, Burton ( 14 ) first developed FMS to identify individuals with compensatory movement patterns in their kinetic chain. This screening tool consists of seven movement tests, which require a balance between mobility and stability ( 14 ). FMS is designed for all healthy people and not only sports populations, and some components specific to sports are neglected in it ( 15 ). It seems that the component that FMS did not pay attention to and neglected is speed. Movements performed at high speed, which are an integral part of any sport, are ignored in FMS. Therefore, it seems that FMS cannot be a complete provider of exercise-induced movement patterns ( 16 ). This issue was revealed by Parchman and McBride (2011) who compared FMS and back squat, and their relationship with 10/20m sprint, high jump and T agility test in golfers. By showing the lack of correlation between FMS and these executive tests, this study confirmed that FMS has a limited ability to predict physical performance evaluation, acceleration, power and agility, especially when compared to the maximum strength of the lower limbs ( 16 ). Ignoring the variables of deceleration and external forces, which are possible risk factors for injury, is evident in these tests ( 17 ). Taking this issue into consideration, it seems logical to use tests in order to evaluate the functional movements of athletes that can evaluate both the speed component and the ability to identify potential risk factors for injury. Performing this procedure can be a good supplement for FMS. Studies have emphasized that the assessment of basic movements through a functional approach should be more focused on adjusted sports movement patterns rather than being limited to the evaluation of specific joints or muscles alone ( 18 ). Also, in a study, the importance of this issue was emphasized by suggesting that screening tests need to be designed based on the performance and skill of the players ( 19 ). In fact, the evaluation should be done in such a way that it covers all the desired physical dimensions. Physical performance consists of many components. These components can be considered as consisting of tests that can include the evaluation of balance, proprioception, muscle strength, muscle endurance, muscle power, speed, agility, aerobic and anaerobic capacity, flexibility, muscle length tests and functional movement patterns ( 20 , 21 ). However, according to the needs of sports and the target community, the scope of these tests may vary. For example, in some cases, athletes may not need to evaluate balance and proprioception, and flexibility tests are more important for them. Especially for tennis, this topic includes upper and lower limb flexibility, dynamic balance, power, agility, movement speed and reaction speed ( 22 ). The test set should also be able to monitor the progress of rehabilitation programs for injured athletes. It seems that the FMS designed by Cook, Burton ( 14 ). still needs to be subjected to rigorous tests of validity and reliability in different sports. Considering that FMS cannot be a complete provider of movement patterns caused by sports; And the fact that the validity and reliability of this test and its predictability of injury in sports populations are still unclear ( 18 , 23 ). The researcher sought to develop a functional movement screening tool that has the ability to predict injury in the field of tennis by initially determining potential functional movement screening tests through interviews with specialists and experts. Then check its validity and reliability in the form of a questionnaire. Therefore, the aim of this study was investigating the validity and reliability of the functional movement screening tool in tennis as a predictor of injury. Method Study design By reviewing the background literature and taking into account the prevalence of injury, the type of movement patterns, and the functional and skill needs of tennis players, a questionnaire consisting of 108 tests in six categories of performance, agility, aerobic, non-aerobic, muscle length and anthropometric tests was designed. Through interviews with tennis experts including coaches, doctors and physiotherapists, preliminary tests were extracted to be included in the tool, and then the final tool was compiled through the validity and reliability of these tests in the form of a questionnaire. After collecting data through semi-structured interviews with tennis professionals, each data was independently transcribed after recording. Each transcript was imported into MAXQDA 11 ® software. Transcripts were coded and compared. In the next step, they were classified into categories and finally the items were extracted. The items were given to experts and tennis players in the form of a questionnaire to check validity and reliability. The required information was collected without including the names and surnames of the participants and with their informed consent. Validity Face validity Evaluation of face validity was done with two qualitative and quantitative approaches. In order to evaluate the face validity of the questionnaire, 10 tennis players were asked to give their opinion on the level of difficulty, appropriateness and ambiguity of the questionnaire. In the next step, in order to determine the importance, each of the items was evaluated quantitatively. For this purpose, 10 tennis players answered the items based on a 5-point Likert scale from score 5 (totally important) to 1 (not important at all). Then the effect score of the item was calculated based on the following formula ( 24 ). Impact Score = Frequency × (%) Importance The meaning of frequency in terms of percentage is the number of people who gave 4 and 5 points to each item, and importance is the average score given to each item. If the impact score exceeds 1.5, the item is of sufficient importance ( 25 ). Content validity The validity of the content was also done by qualitative and quantitative methods by experts. To evaluate the qualitative content validity during interviews with experts, the questionnaire was evaluated in terms of grammar, use of appropriate words, importance, descriptiveness, placement of items in their proper place, and time to complete the designed tool. Then, the quantitative content validity was measured according to the opinions of ten experts and by calculating the content validity ratio (CVR) and the content validity index (CVI). The CVR is used to ensure that the most important content is selected, and the CVI is used to ensure that the items of the instrument are designed in the best way to measure the content ( 24 ). The following formula was used to calculate the CVI. $$\:CVI=\frac{The\:number\:of\:evaluators\:who\:gave\:3\:and\:4\:scores\:to\:the\:sub-concept}{Total\:number\:of\:assessors}$$ Construct validity In order to evaluate construct validity with the help of exploratory factor analysis (EFA), items based on a 5-point Likert scale (strongly disagree-disagree-no opinion-agree-strongly agree) along with the executive instructions of the tests were administered to 234 tennis players, including 178 men and 56 women. It was placed in the age range of 19 to 36 years. Index (Kaiser-Meyer-Olkin) and Bartlett coefficient were calculated. 0.0–8.0 KMO is good and 0.0–9.0 is considered great. Then extraction of factors was done with the help of maximum likelihood estimation and using varimax rotation. The extracted factors were analyzed with the help of confirmatory factor analysis (CFA) and the most common goodness of fit indicators of the presented model based on the accepted threshold with the help of maximum likelihood estimation using SPSS-AMOS26 software. According to the recommendation of Meyers, Gamst and Guarino ( 26 ), chi-square goodness of fit index (GFI), root mean square approximation index, comparative fit index, normalized goodness-of-fit index, adjusted goodness-of-fit index, and in Finally, the ratio of chi square to degree of freedom (CMIN/DF) was checked ( 26 ). Reliability At first, reliability was evaluated by test-retest method. 20 tennis players completed the questionnaire at a two-week interval, and then the scores obtained in these 2 stages were checked using the intra-cluster correlation index (ICC) test. ICC was estimated with two-way mixed effects model and with 95% confidence interval. Then, the standard error of measurement was checked using the SD×√1-ICC formula. The internal stability of the structure was done with the help of McDonald's Omega assessment. Finally, with the help of CFA, structural reliability was calculated ( 27 , 28 ). In fact, structural reliability or stability of factors is an alternative to Cronbach's alpha coefficient in structural equation model analysis, which in the present study, structural stability of more than 0.7 was considered acceptable ( 29 ). Normal distribution, outliers and missing data The normal distribution of data and the evaluation of outlier data were evaluated in both univariate and multivariate ways. Univariate normal distribution was evaluated using the skewness index (± 3) and skewness (± 7) and multivariate distribution was evaluated using the Mardia coefficient < 0.0001 ( 30 ). On the other hand, univariate outlier data were evaluated with the help of descriptive indices and multivariate outlier data were analyzed with Mahalanobis coefficient. At first, the percentage of forgotten data was calculated and finally, the analysis was done by replacing it with the help of average response. Results The results of the interviews were analyzed to determine the items that were qualified to be included in the tool. In the process of analysis, the primary codes were identified and finally, 27 tests were extracted from among the 108 potential tests. Table 1 shows the list of extracted codes in the framework analysis process. After the framework analysis process, 27 sub-items were identified and specified for six main items. In the following, the validity and reliability of the items were investigated. Table 1 around here Validity Qualitative face validity: The results showed that all of the 27 items were clear, readable, simple and understandable by the interviewees from the content point of view. Quantitative face validity: According to the results obtained from the calculation of quantitative face validity, all items had an impact score greater than 1.5. Content validity ratio Based on the results obtained from the calculation of the content validity ratio for the sub-items based on the information in table 2 and comparing it with the values obtained by previous study (24), 21 test of the range of motion of internal and external rotation of the shoulder, range of motion of internal and external rotation of the hip in the prone position, cross adduction of the shoulder, lateral lunge, the strength of the shoulder rotators with a hand dynamometer at the angle of 90 degrees of abduction of the shoulder joint, Empty Can, stability of the scapula, range of motion of extension and flexion of the elbow, weight-bearing lunge, range of motion of extension and flexion knee, plank, one-leg stability, active leg raising, rotational stability, single-leg squat, bridging with one-sided knee extension, multi-directional hoping, core stability, Y-Balance, hexagon, and special endurance test with content validity ratio higher than were 0.62. The rest of the tests did not have content validity, so they were excluded. Content validity index The results obtained for CVI are given in table 2. Table 2 around here Construct validity Mean and standard deviation of age (26 ± 1.3 years), height (178 ± 2.5.8 cm), weight (77.9 ± 1.4 kg), weekly activity (9.7 ± 0.2) hours) and playing experience (12.4 ± 2.6 years) were tennis players. The frequency distribution of players according to gender, dominant leg, dominant hand, level of competition and history of injury is given in table 3. The amount of KMO was 0.885 and Bartlett's test was 1442.27, p<0.001. The results of EFA showed that two hidden factors had values of 4.796 and 3.312, respectively. In total, the two extracted factors explained 54.05% of the total variance of the functional movement screening tool (Table 5). Then, with the help of CFA and fit indices, the structural model of the structure was evaluated. Based on the goodness of fit test results, first the chi square index was evaluated [p<0.05, χ2=134.67. Then, in order to evaluate the fit of the model, other indices were examined, all indices were PCFI=0.819, PNFI=0.770, CMIN/DF=1.513, RMSEA=0.047, AGFI=0.930, IFI=0.967, that confirmed the good fit of the final model. Table 3 around here Convergent and divergent validity As seen in table 4, Average Variances Extracted (AVE) is two factors larger than Maximum Shared Squared Variance (MSV). Therefore, the results show that the construct has appropriate convergent and divergent validity (Table 4). Table 4 around here Reliability Stability reliability The stability reliability of the instrument was estimated by the test-retest method at a time interval of 2 weeks on a sample of 20 tennis players using the internal correlation index (ICC) with the Two-Way Mixed model and a 95% confidence interval. The results in the general scale of the questionnaire showed (CI: 0.53-0.92, p < 0.001, ICC = 0.91) according to the values obtained between the scores of the first and second test, there is a significant agreement, which confirms the high reproducibility and stability of the developed functional movements screening tool. Internal consistency reliability To check the internal consistency of the instrument, the alpha coefficient was calculated based on Cronbach's alpha and McDonald's omega. Based on the final structure of the structural model, table 5 shows that the first factor has Cronbach's alpha 0.896 and MacDonald's Omega 0.898, and the second factor has Cronbach's alpha 0.801 and McDonald's Omega 0.812. Considering the fact that coefficients above 0.70 are acceptable, it can be concluded that the designed tool has good internal consistency. Also, the final structure of the questionnaire model of the screening tool for functional movements in tennis is shown in figure 1. (Table 5 and figure 1) Table 5 and figure 1 around here Discussion The main purpose of the present study was to investigating the validity and reliability of the functional movement screening tool in tennis as a predictor of injury. In the current study, a questionnaire with 108 tests was designed in the form of six categories of functional, agility, anaerobic, aerobic, muscle length and anthropometric tests based on the background literature in this field. The results of interviews with tennis experts led to the extraction of 27 tests. After the initial design of the questionnaire with 27 items, the researcher investigated its validity and reliability. The amount of factor loadings obtained for 15 items was more than 0.3 and significant (p= 0.001); and the amount of factor loadings obtained for 6 items was so low that these 6 items were excluded from the total number of questions. Finally, 15 tests were extracted to be included in the tool. Of these 15 tests, two tests of rotational stability and active leg raising shared with the FMS designed by Cook, Burton (14). The selection of these tests by experts, in their opinion, is mostly based on the similarity of the tests with the movement patterns in tennis and the anatomical areas prone to injury in this sport. The results showed the appropriate validity and reliability of the whole instrument and showed that the items are measuring a similar concept and structure and there is no conceptual dispersion in it. The results showed that the reliability of this questionnaire is acceptable. The external stability of the tool was obtained after a time interval of two week, ICC = 0.91, which indicates the desired retest reliability of the questionnaire. These results were in line with the results of Frohm, Heijne (31) and Tabatabaei, Daneshmandi (11). Frohm, Heijne (31) investigated the reliability of a set of 9 tests in soccer players. The reliability of the tool was measured by the test-retest method at a time interval of one week on 26 elite soccer players. The ICC was reported as 0.80 and 0.81, respectively, which indicated the good reliability of the set of tests. In the study of Tabatabaei, Daneshmandi (11), the results of the validity and reliability of the functional movement screening tool in volleyball players showed a good reliability (ICC = 0.88) of the set of tests at a two-week interval. The results of the EFA showed that the factor structure of functional movement screening in tennis is two-dimensional. Koehle, Saffer (32) investigated the factor structure of FMS using EFA and CFA in adults. Two hidden factors included a main factor consisting of shoulder mobility and active leg raising and a complex movement factor consisting of full squat, lateral lunge, and push up were elicited. Rotational stability was present in both factors in the CFA, and it exclude from the factor structure model had little effect. The results of this study reflected the intended factorial structure of FMS well. In the present study, using principal factors analysis and Varimax rotation, two factors with values higher than one were extracted, which explained 54.05% of the total variances, in which the factor load related to the first factor was higher than the second factor. The first factor consisted of 8 items, based on the order of the highest factor load, including tests of range of motion of extension and flexion of shoulder, plank, shoulder cross adduction, rotational stability, Empty Can, strength of shoulder rotators with hand dynamometer at 90-degree abduction angle of shoulder joint, range of motion of extension and flexion of the elbow, and stability of scapula were. In the following, these tests are discussed in order. The range of motion of internal and external rotation of the shoulder joint in supine position and in 90-degree shoulder abduction in the coronal plane was measured using a goniometer. The athlete's elbow was kept in 90-degree flexion and in this state external and internal rotation of the shoulder was passively measured. This is while the examiner's hand was stabilizing the scapula to prevent additional movements (33). Final range of motion was determined by limb weight and gravity without excessive pressure applied by the examiner. The range of motion of total rotation was the sum of internal and external rotation measures of the shoulder joint. It is important that this measurement is done bilaterally to allow comparison with the non-dominant hand. In tennis, due to frequent repetitions, especially in forehand and service shots, there is a high probability of muscle imbalances in the shoulder joint, which can be one of the main causes of pain in this area. Also, in the reports registered by the Elite Tennis Players Association, the norm of internal and external rotation of shoulder joint in professional players has been specified (33). The test-retest reliability of shoulder internal rotation range of motion when the arm is abducted to 90° and the scapula is stabilized has been investigated in a previous study (34). Correlation coefficients of 0.62 for intra-examiner reliability and 0.43 for inter-examiner reliability were reported. Considering the frequent movement patterns of internal and external rotations in forehand and backhand shots. Then, the possibility of very common injuries to the elbows of tennis players and golfers in this sport. Taking into account the opinions of specialists and experts, this test can be one of the important tests in the path of predicting the mentioned injures. In the plank test, which includes keeping the whole-body stable in different positions of the prone, right side, and left side while maintaining alignment and controlling the body position, the athlete must maintain each of these positions for a period of 30 seconds. In this test, any postural disorders caused by the weakness of the core stabilizing muscles and the gluteal area can be identified and revealed. The movement pattern of this test is somewhat similar to the movement pattern of push up test, which is one of the seven items of the functional movement screening tool designed by Cook, Burton (14). It seems that the plank test can be a suitable supplement or alternative to this test when evaluating tennis athletes with the aim of identifying postural impairments caused by weak core stability (35, 36). The shoulder cross adduction test was performed using a digital inclinometer in the supine position. The athlete's shoulder was passively placed in a 90-degree shoulder flexion position in the sagittal plane, and no additional pressure was applied to the horizontal adduction movement, and the weight of the limbs against the force of gravity was used to determine the end point (37). The bilateral measurement of this movement pattern was recorded using the value indicated by the digital inclinometer relative to the vertical (neutral) starting position. During the interview process, tennis experts agreed on the theory that the final mechanism of forehand and backhand movements causes muscle imbalance in the range of motion of shoulder abduction. This mechanism can cause a significant difference in the norm obtained from two sides of the dominant and non-dominant hand among tennis players. This confirms the fact that this test can be effective in identifying unilateral muscular imbalance of the shoulder joint during the implementation of the forehand technique in which the movement pattern of horizontal adduction of the shoulder is repeated frequently (38). Another item selected in the first factor, which the experts confirmed to be suitable for inclusion in the instrument for the purpose of predicting injuries, was the rotational stability test. This test is one of the FMS tests whose movement pattern is similar to the basic movement pattern of a baby walking on all fours in the crawling stage (39). Cook, Burton (14) believed that the weakness of the core stabilizer muscles in the trunk area, which can be revealed during the symmetrical movement of rotational stability, will have an undeniable effect on causing postural impairments (39). This test was also included in the study of Tabatabaei, Daneshmandi (11). by experts in the field of volleyball. This issue can indicate the importance of the stability of the core region of the body in transferring energy to the distal parts for better and smoother movement of the organs (40). It seems that this test has been provided by evaluating the multipurpose movement patterns of the pelvis, trunk and thoracic scapular region, while glenohumeral joint stability, lumbo-pelvic joint control and hip joint mobility have been provided (40). It can detect any weight changes, increased lumbar extension and decreased shoulder joint flexion. In the sport of tennis, due to the importance of the power and speed of the hits, especially in the serve, energy transfer from the proximal area to the organs should be done well, and achieving this goal requires the optimal stability of the core area of the body. The Empty Can test, which is also known as the supraspinatus test, is used to evaluate the health of the supraspinatus muscle. The positive result of this test indicates the possibility of muscle tear or in other cases tendon and suprascapular nerve damage. Although, Boettcher, Ginn and Cathers (41), believe that this test should not be interpreted as a definitive test for the clinical diagnosis of supraspinatus muscle pathology. However, this test may be useful during shoulder muscle strengthening programs (41). The mechanism of overhead performance in throwing sports has been widely studied (42). This movement is abnormal and highly dynamic and often exceeds the physiological limits of the joint. Due to the overload of various anatomical structures, the shoulder is prone to injury. Optimal shoulder function requires good kinetic chain function, optimal stability, and scapular coordination in overhead action. Balanced function of the rotator cuff muscles and capsular structures is essential to obtain a stable center of rotation during overhead activity (43). Shoulder injuries related to overhead movement in tennis players can be very similar to the mechanism of injury of the throwing shoulder (44). This seems to be the case given that many shots in the sport of tennis are played in the plane of motion of the scapula. Taking into consideration that the evaluation of Empty Can test is done on this plane. Also, due to the many injuries of the upper limb, especially in the external rotator muscles of the shoulder, this test has the qualification to be included in the tool considered in the present study with the aim of predicting the injuries of the upper limb. Also, among the other items selected in the first factor, which confirmed the merit of this test to be included in the tool to predict injuries, was the strength of shoulder rotators with hand dynamometer at 90-degree abduction angle of shoulder joint test. The method of measuring this test was the same as the range of motion test of internal and external rotation of the shoulder joint. Rotator cuff injuries in tennis players are usually progressive overuse injuries, ranging from partial or pericapsular tears to full tears. Most injuries are partial tears, while full tears usually occur in older players. The serve is the most energetic movement in the sport, accounting for 45-60% of all strokes in a tennis match, putting the shoulder at risk for overuse injuries and rotator cuff tears. Studies have shown that impairments in shoulder range of motion and scapular dyskinesia occur after a tennis match. Unlike rotator cuff treatment in non-athletes, treatment in elite tennis athletes has a less-than-ideal return-to-sport rate at the same level of performance (45). With these interpretations, it seems that the strength of the rotator cuff muscles is very important in reducing injuries caused by frequent hits, especially the service. Tennis players often face changes in the mobility of upper limb joints due to the extreme range of motion required in this sport. Since the muscles that act on the upper limb pass through multiple joints, their length and tension are affected by the position of the joint. Changes in the passive range of motion of the joints of the upper limb may lead to postural impairments due to multiple and repeated hits in this sport. It may also lead to changes in the muscular demands necessary for stability or dynamic strength of the upper extremity, either of which could contribute to the development of lateral epicondyle tendinopathy elbow (46). Therefore, the stability of the shoulder and the appropriate range of motion of the elbow in different levels of motion can be factors that reduce overuse injuries in tennis. The second factor consisted of bridging with one-sided knee extension, single leg squat, active leg raising, range of motion of extension and flexion knee, weight-bearing lunge, range of motion of internal and external rotation of the hip in the prone position and multi-directional hoping. In the following, these tests are discussed in order. Bridging tests with one-sided knee extension and multi-directional knee extension had the highest and lowest factor loads, respectively. The musculoskeletal core of the body includes the lumbar spine, abdominal muscles wall, back extensors, quadratus lumborum, diaphragm and pelvic floor. The core is conceptually described as a muscle box. The abdominal wall includes the anterior and lateral walls, the extensors form the posterior wall, and the upper and lower parts of the box are formed by the diaphragm and the pelvic floor, respectively (40). The muscles of the pelvic area help to strengthen the lower part of the muscle box and are necessary for power generation and energy transfer to the end organs. The core acts as the center of movement of the functional kinetic chain. This is especially important in sports that require overhead movement, such as tennis, because it provides proximal stability for distal movement (47). One of the tests that involves the muscles of this area, especially the pelvic floor area, is the movement pattern of bridging. This test can be a suitable supplement along with other tests of core stability such as rotational stability in diagnosing disorders caused by muscle weakness in this area and predicting injuries in the tennis players. Also, among the other items selected in the second factor, which confirmed the suitability of this test to be included in the tool for predicting injuries in tennis players, was the single leg squat test. Strength training is one of the popular training methods for high performance tennis players of all age groups (48). Assessing an athlete's sports techniques is important not only to identify the athlete's ability to perform specific exercises correctly, but also to observe muscle imbalances, functional flexibility, and balance. Overhead squat, full squat and single leg squat are excellent tests to observe and diagnose things like muscle imbalance, shoulder stability, core stability, hip and ankle flexibility, hip muscle imbalance, hip stability and overall balance in tennis players with high performance (49). Moreover, another test that was approved in the second factor to be included in the tool for the purpose of predicting injuries was the active leg raising test. Several methods for evaluating hamstring flexibility have been reported in the background literature, which are also used in the screening of elite tennis players. One of these methods is the active leg raising test (SLR), which is performed by measuring the range of motion of passive hip flexion with a straight knee and recording the angle of the hip relative to the trunk using a goniometer (50). Another method involves actively extending the knee from the 90/90 position and measuring the vertical angle from the tibia (Range of motion of extension and flexion knee test). To measure each organ independently, leg raising test is used directly and passively (51). In general, forward movements in tennis players disturb the balance of strength in the flexor and extensor muscles of the knee, i.e. the quadriceps and hamstrings, and this difference is often shown in a short form in the hamstring muscles of tennis players. Furthermore, weight-bearing lunge test was approved in the second factor to be included in the tool for the purpose of predicting injuries. Reduced dorsiflexion is recognized as a risk factor for lower limb injury (52). In tennis players, with a decrease in ankle dorsiflexor, the possibility of lateral ankle sprain injury increases (53). The weight-bearing lunge test can evaluate ankle dorsiflexion reduction. Considering that the weight pressure is on the lower limb area, this test is functionally effective in identifying risk factors for injury, including muscle imbalance of the ankle area (54). In addition, range of motion of internal and external rotation of the hip in the prone position test was approved in the second factor to be included in the tool for the purpose of predicting injuries. Since rotational movements are very important in tennis and this issue is directly related to the range of motion and strength of the lower limb chain of motion; It seems necessary to have a test that measures the range of motion of internal and external rotations in the lower limb, especially the hip joint. The importance of this topic was well considered during the researcher's interview with specialists and experts. Ellenbecker, Ellenbecker (55) investigated the descriptive profile of the range of motion of the hip joint in a study on professional tennis and baseball players. In this study, they investigated and evaluated the movement rotation values of the hip active range symmetrically and bilaterally in elite tennis players and professional baseball pitchers. These researchers concluded that asymmetric rotational active range of motion of the hip joint encountered during clinical examination and screening may indicate postural abnormalities and disorders; and require the use of flexibility exercises, rehabilitation, and further evaluation for this category. It is essential for athletes (55). The results of studies conducted in this field show the importance of this issue, that tennis players, especially teenage tennis players, need to have sufficient flexibility in the hip and shoulder joints to achieve the complete kinetic chain of a tennis shot or serve (55-57). In addition to, multi-directional hoping test was approved in the second factor to be included in the tool for the purpose of predicting injuries. Studies show that the multi-directional hoping is a test with acceptable reliability and validity that is effective in identifying functional defects in athletes with chronic ankle instability (58). Eechaute, Leemans (59) in a study titled the prediction rate of the multi-directional hoping test in the first non-contact lateral sprint concluded that this test is a valid field test to identify athletes at risk for the first non-contact lateral ankle sprain. Many displacements and changes of directions as well as deceleration at high movement speeds during a tennis match are factors that always expose the athlete to acute and chronic injuries to the lower limbs, especially the ankle area (60). According to the findings of previous researchers as well as the opinions of the experts and specialists participating in the interview process, the multi-directional hoping test is a valid test to identify the risk factors of injury in this sports field. In order to check the construct validity of this questionnaire, in addition to EFA, the CFA model was also used. The most important goal of CFA is to determine the power of the predefined factor model with a set of observed data. In other words, CFA attempts to determine whether the number of factors and the variable loadings measured on these factors correspond to what was expected based on the theory and theoretical model. With the help of this method, it is possible to remove incompatible items that have a very low load on several factors and cannot be attributed to a specific factor (61). The chi-square goodness of fit test was significant in almost all the above sample sizes and the data analysis confirmed the appropriate fit of the final model. Conclusion In the present study, the appropriate psychometric properties and validity of the factorial structure of the questionnaire were confirmed. In total, the face validity, content and structure of the tool were approved by experts and tennis players. Then, after reducing the tests from 27 tests to 15 tests, the reliability of the tool was also confirmed. Afterward, by determining the normative norm for the tests and specifying a cut-off point, it is possible to check the reliability of predicting the injury of this tool by implementing the tests. More research is needed in the future to use this tool as an intervention tool in tennis. Also, prospective and follow-up research on different levels of tennis players will show the ability of this tool in predicting tennis injuries. Declarations Acknowledgments This study is a component of the doctoral dissertation authored by the primary contributor to the article. The research was carried out at the Faculty of Physical Education at the University of Tehran. The article's authors deem it essential to express their sincere gratitude to the Education Committee of the Tennis Federation, who provided unwavering support in facilitating the objectives of the study. Additionally, the authors extend their appreciation to the participants who generously shared their academic expertise. Funding This research received no funding from any agency in the public, commercial, or not-for-profit sector. Conflict of interest The authors have no conflicts of interest to declare. Informed consent All participants were informed of the purpose and procedure of this study, and informed consent was obtained from all participants Ethical Considerations Compliance with ethical guidelines This study has used the principles of the Declaration of Helsinki, the general guide to ethics in research with human subjects, and its governing regulations. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Consent for publication Not Applicable. Disclosure statement No potential conflict of interest was reported by the authors. Authors’ contributions S.K. & MH.A. & H.D.: data acquisition and analysis. S.K. & MH.A. & H.D.: data interpretation. S.K. & MH.A. & H.D..: wrote the main manuscript text and prepared the figures. S.K. & MH.A. & H.D.: conception/design of the work. All authors reviewed and contributed to the manuscript. 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Examination of the Shoulder. Clinical Examination of the Hand. CRC; 2022. pp. 248–54. O’Brien W, Khodaverdi Z, Bolger L, Tarantino G, Philpott C, Neville RD. The assessment of functional movement in children and adolescents: A systematic review and meta-analysis. Sports Med. 2022:1–17. Zemková E, Zapletalová L. The role of neuromuscular control of postural and core stability in functional movement and athlete performance. Front Physiol. 2022;13:796097. Boettcher CE, Ginn KA, Cathers I. The ‘empty can’and ‘full can’tests do not selectively activate supraspinatus. J Sci Med Sport. 2009;12(4):435–9. Paraskevopoulos E, Pamboris GM, Plakoutsis G, Papandreou M. Reliability and measurement error of tests used for the assessment of throwing performance in overhead athletes: A systematic review. J Bodyw Mov Ther. 2023. Economopoulos KJ, Brockmeier SF. Rotator cuff tears in overhead athletes. Clin Sports Med. 2012;31(4):675–92. Kekelekis A, Nikolaidis PT, Moore IS, Rosemann T, Knechtle B. 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Occurrence of Muscle Imbalance and Risk of Injuries in Athletes using Overhead Movements: A Systematic Review. Sport Mont. 2021;19(3):115–22. Willhuber GOC, Piuzzi NS. Straight leg raise test. StatPearls [Internet]: StatPearls Publishing; 2023. Olivencia O, Godinez GM, Dages J, Duda C, Kaplan K, Kolber MJ. The reliability and minimal detectable change of the ely and active knee extension tests. Int J sports Phys therapy. 2020;15(5):776. Almansoof HS, Nuhmani S, Muaidi Q. Role of ankle dorsiflexion in sports performance and injury risk: A narrative review. Electron J Gen Med. 2023;20(5). Kaiser P, Stock K, Benedikt S, Ellenbecker T, Kastenberger T, Schmidle G, Arora R. Acute tennis injuries in the recreational tennis player. Orthop J sports Med. 2021;9(1):2325967120973672. Manoel LS, Xixirry MG, Soeira TP, Saad MC, Riberto M. Identification of ankle injury risk factors in professional soccer players through a preseason functional assessment. Orthop J sports Med. 2020;8(6):2325967120928434. Ellenbecker TS, Ellenbecker GA, Roetert EP, Silva RT, Keuter G, Sperling F. Descriptive profile of hip rotation range of motion in elite tennis players and professional baseball pitchers. Am J Sports Med. 2007;35(8):1371–6. Young SW, Dakic J, Stroia K, Nguyen ML, Harris AH, Safran MR. Hip range of motion and association with injury in female professional tennis players. Am J Sports Med. 2014;42(11):2654–8. Oliver GD, Downs JL, Barbosa GM, Camargo PR. Descriptive profile of shoulder range of motion and strength in youth athletes participating in overhead sports. Int J Sports Phys Therapy. 2020;15(6):1090. Eechaute C, Bautmans I, De Hertogh W, Vaes P. The multiple hop test: a discriminative or evaluative instrument for chronic ankle instability? Clin J Sport Med. 2012;22(3):228–33. Eechaute C, Leemans L, De Mesmaeker M, De Ridder R, Beckwée D, Struyf F, et al. The predictive value of the multiple hop test for first-time noncontact lateral ankle sprains. J Sports Sci. 2020;38(1):86–93. Valleser CWM, Narvasa KEL. Common injuries of collegiate tennis players. Montenegrin J sports Sci Med. 2017;6(2):43. Nia HS, Ebadi A, Lehto RH, Mousavi B, Peyrovi H, Chan YH. Reliability and validity of the persian version of templer death anxiety scale-extended in veterans of Iran–Iraq warfare. Iran J psychiatry Behav Sci. 2014;8(4):29. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Apr, 2025 Read the published version in BMC Sports Science, Medicine and Rehabilitation → Version 1 posted Editorial decision: Revision requested 09 Jul, 2024 Editor assigned by journal 08 Jul, 2024 Submission checks completed at journal 08 Jul, 2024 First submitted to journal 06 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4696915","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":324735123,"identity":"e55eed56-993e-4add-b77c-c3eb7782c9f8","order_by":0,"name":"Sam Kazemi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYHACZjDJxsx8AEhJyJCghZ0tAaSFh3gtDPw8BiCKsBb59tPJBj/+2ETzMfN8fnWjxoKHgf3w0Q34tBicyd2c2MOTltvGzLvNOucY0GE8aWk38GphyN18gEfiMFiLcQ4bUIsEjxleLfL9bzcf/GPwH6iF55lxzj8itDDcyN2czJNwAKSF+XFuGxFaDG683WwscyAZqIXNjDm3T4KHjZBf5PtzN0u++WOXO7//8OPPOd/q5PjZDx/D7zAkwCYBJolVDgLMH0hRPQpGwSgYBSMHAACBGEM2zxRMTAAAAABJRU5ErkJggg==","orcid":"","institution":"University of Tehran","correspondingAuthor":true,"prefix":"","firstName":"Sam","middleName":"","lastName":"Kazemi","suffix":""},{"id":324735125,"identity":"bd07c18d-508a-40a8-9afc-dfc4a5751ad3","order_by":1,"name":"Mohammad Hossein Alizadeh","email":"","orcid":"","institution":"University of Tehran","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Hossein","lastName":"Alizadeh","suffix":""},{"id":324735127,"identity":"a977c16f-138e-47ab-86ff-fdf2ef80720c","order_by":2,"name":"Hassan Daneshmandi","email":"","orcid":"","institution":"University of Guilan","correspondingAuthor":false,"prefix":"","firstName":"Hassan","middleName":"","lastName":"Daneshmandi","suffix":""}],"badges":[],"createdAt":"2024-07-06 13:15:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4696915/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4696915/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13102-025-01152-z","type":"published","date":"2025-04-24T15:57:25+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":61468706,"identity":"d65039f5-7268-48a8-9af0-599fc01e8066","added_by":"auto","created_at":"2024-07-31 06:15:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":125102,"visible":true,"origin":"","legend":"\u003cp\u003eThe final structure of the questionnaire model for screening functional movements in tennis.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4696915/v1/07b5f2952741fc46c94b8070.png"},{"id":81569831,"identity":"aa4d1ae2-2512-4602-abb3-12913cc9510f","added_by":"auto","created_at":"2025-04-28 16:11:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":712902,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4696915/v1/bdd06f8d-dfa7-4ed1-892e-acf2ce695ef8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Investigating the validity and reliability of the functional movement screening tool in tennis as a predictor of injury","fulltext":[{"header":"Introduction","content":"\u003cp\u003eScreening tools are used to various goals, one of these important goals in sports science is the prevention of athletes' injuries (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Screening can be used to help prevent injury by identifying functional defects and abnormalities related to the desired sport (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The screening process in many advanced countries is done in the pre-season training of sports competitions in many developed disciplines (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Pre-season screening can be important to determine and identify athletes who are at risk of injury.\u003c/p\u003e \u003cp\u003eFunctional screening is an important tool for predicting and systematically examining injuries in various sports fields (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In this regard, in a study, performance screening tools that can be used as injury predictors in various sports have been reviewed (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). This study was done on team sports. The findings of this study showed that most of the screening tools have been used to predict a specific type of injury, such as anterior cruciate ligament (ACL), ankle and hamstring injuries, instead of examining a set of different injuries of a specific sport. The tests used to predict these injuries were classified into a series of anthropometric, flexibility, range of motion and balance tests. Each of these classes covered some performance tests and not all of them (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The combination of this set of tests and information on the prevalence of injuries related to a specific sport can lead to the development of a functional screening tool (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLooking at the background literature in the field of functional movement screening, it can be seen that this tool has been developed in some sports such as football (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), gymnastics (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), Australian football (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), dance (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) and volleyball (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Sleeper, Kenyon and Casey (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) designed a tool to evaluate the functional fitness of gymnasts called gymnastics functional measurement tool (GFMT). By using tests that are specific to gymnastics, this tool has created unity among the variables of flexibility, speed, power, muscle strength, muscle endurance and balance and was approved by experts in this field. Also, the normative norm and validity of the GFMT tool has been investigated by studying gymnasts. Overall, the GFMT score had high validity. However, this tool is unable to determine the amount of injury and only reveals functional impairments and abnormalities (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). From the point of view of these researchers, this recent finding was considered an improvement in the field of screening. In addition, Tabatabaei, Daneshmandi (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) designed a tool to evaluate the functional fitness of volleyball players by screening functional movements with the aim of predicting injury (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Recognizing the importance of a functional movement screening tool in volleyball, this study had designed a protocol that was able to identify functional limitations in the implementation of skills in this sport; And in this way, the injures related to these restrictions were predicted. This process led to the selection of 12 tests to be included in the functional screening tool of movement in volleyball. Afterwards, validity and reliability were examined and confirmed (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Studies conducted on gymnastics and volleyball can serve as a guide and a cornerstone for the development of screening tools in various sports fields.\u003c/p\u003e \u003cp\u003eRecently, physiotherapists and trainers use functional movement tests and especially Functional Movement Screening )FMS( as a screening tool in sports to predict injuries and then develop preventive strategies (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Cook, Burton (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) first developed FMS to identify individuals with compensatory movement patterns in their kinetic chain. This screening tool consists of seven movement tests, which require a balance between mobility and stability (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). FMS is designed for all healthy people and not only sports populations, and some components specific to sports are neglected in it (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). It seems that the component that FMS did not pay attention to and neglected is speed. Movements performed at high speed, which are an integral part of any sport, are ignored in FMS. Therefore, it seems that FMS cannot be a complete provider of exercise-induced movement patterns (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This issue was revealed by Parchman and McBride (2011) who compared FMS and back squat, and their relationship with 10/20m sprint, high jump and T agility test in golfers. By showing the lack of correlation between FMS and these executive tests, this study confirmed that FMS has a limited ability to predict physical performance evaluation, acceleration, power and agility, especially when compared to the maximum strength of the lower limbs (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIgnoring the variables of deceleration and external forces, which are possible risk factors for injury, is evident in these tests (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Taking this issue into consideration, it seems logical to use tests in order to evaluate the functional movements of athletes that can evaluate both the speed component and the ability to identify potential risk factors for injury. Performing this procedure can be a good supplement for FMS. Studies have emphasized that the assessment of basic movements through a functional approach should be more focused on adjusted sports movement patterns rather than being limited to the evaluation of specific joints or muscles alone (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Also, in a study, the importance of this issue was emphasized by suggesting that screening tests need to be designed based on the performance and skill of the players (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn fact, the evaluation should be done in such a way that it covers all the desired physical dimensions. Physical performance consists of many components. These components can be considered as consisting of tests that can include the evaluation of balance, proprioception, muscle strength, muscle endurance, muscle power, speed, agility, aerobic and anaerobic capacity, flexibility, muscle length tests and functional movement patterns (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). However, according to the needs of sports and the target community, the scope of these tests may vary. For example, in some cases, athletes may not need to evaluate balance and proprioception, and flexibility tests are more important for them. Especially for tennis, this topic includes upper and lower limb flexibility, dynamic balance, power, agility, movement speed and reaction speed (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The test set should also be able to monitor the progress of rehabilitation programs for injured athletes. It seems that the FMS designed by Cook, Burton (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). still needs to be subjected to rigorous tests of validity and reliability in different sports. Considering that FMS cannot be a complete provider of movement patterns caused by sports; And the fact that the validity and reliability of this test and its predictability of injury in sports populations are still unclear (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The researcher sought to develop a functional movement screening tool that has the ability to predict injury in the field of tennis by initially determining potential functional movement screening tests through interviews with specialists and experts. Then check its validity and reliability in the form of a questionnaire. Therefore, the aim of this study was investigating the validity and reliability of the functional movement screening tool in tennis as a predictor of injury.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eBy reviewing the background literature and taking into account the prevalence of injury, the type of movement patterns, and the functional and skill needs of tennis players, a questionnaire consisting of 108 tests in six categories of performance, agility, aerobic, non-aerobic, muscle length and anthropometric tests was designed. Through interviews with tennis experts including coaches, doctors and physiotherapists, preliminary tests were extracted to be included in the tool, and then the final tool was compiled through the validity and reliability of these tests in the form of a questionnaire.\u003c/p\u003e \u003cp\u003eAfter collecting data through semi-structured interviews with tennis professionals, each data was independently transcribed after recording. Each transcript was imported into MAXQDA 11 \u0026reg; software. Transcripts were coded and compared. In the next step, they were classified into categories and finally the items were extracted. The items were given to experts and tennis players in the form of a questionnaire to check validity and reliability. The required information was collected without including the names and surnames of the participants and with their informed consent.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eValidity\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eFace validity\u003c/h2\u003e \u003cp\u003eEvaluation of face validity was done with two qualitative and quantitative approaches. In order to evaluate the face validity of the questionnaire, 10 tennis players were asked to give their opinion on the level of difficulty, appropriateness and ambiguity of the questionnaire. In the next step, in order to determine the importance, each of the items was evaluated quantitatively. For this purpose, 10 tennis players answered the items based on a 5-point Likert scale from score 5 (totally important) to 1 (not important at all). Then the effect score of the item was calculated based on the following formula (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eImpact Score\u0026thinsp;=\u0026thinsp;Frequency \u0026times; (%) Importance\u003c/p\u003e \u003cp\u003eThe meaning of frequency in terms of percentage is the number of people who gave 4 and 5 points to each item, and importance is the average score given to each item. If the impact score exceeds 1.5, the item is of sufficient importance (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eContent validity\u003c/h2\u003e \u003cp\u003eThe validity of the content was also done by qualitative and quantitative methods by experts. To evaluate the qualitative content validity during interviews with experts, the questionnaire was evaluated in terms of grammar, use of appropriate words, importance, descriptiveness, placement of items in their proper place, and time to complete the designed tool. Then, the quantitative content validity was measured according to the opinions of ten experts and by calculating the content validity ratio (CVR) and the content validity index (CVI). The CVR is used to ensure that the most important content is selected, and the CVI is used to ensure that the items of the instrument are designed in the best way to measure the content (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The following formula was used to calculate the CVI.\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:CVI=\\frac{The\\:number\\:of\\:evaluators\\:who\\:gave\\:3\\:and\\:4\\:scores\\:to\\:the\\:sub-concept}{Total\\:number\\:of\\:assessors}$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eConstruct validity\u003c/h2\u003e \u003cp\u003e In order to evaluate construct validity with the help of exploratory factor analysis (EFA), items based on a 5-point Likert scale (strongly disagree-disagree-no opinion-agree-strongly agree) along with the executive instructions of the tests were administered to 234 tennis players, including 178 men and 56 women. It was placed in the age range of 19 to 36 years. Index (Kaiser-Meyer-Olkin) and Bartlett coefficient were calculated. 0.0\u0026ndash;8.0 KMO is good and 0.0\u0026ndash;9.0 is considered great. Then extraction of factors was done with the help of maximum likelihood estimation and using varimax rotation. The extracted factors were analyzed with the help of confirmatory factor analysis (CFA) and the most common goodness of fit indicators of the presented model based on the accepted threshold with the help of maximum likelihood estimation using SPSS-AMOS26 software. According to the recommendation of Meyers, Gamst and Guarino (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), chi-square goodness of fit index (GFI), root mean square approximation index, comparative fit index, normalized goodness-of-fit index, adjusted goodness-of-fit index, and in Finally, the ratio of chi square to degree of freedom (CMIN/DF) was checked (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eReliability\u003c/h2\u003e \u003cp\u003eAt first, reliability was evaluated by test-retest method. 20 tennis players completed the questionnaire at a two-week interval, and then the scores obtained in these 2 stages were checked using the intra-cluster correlation index (ICC) test. ICC was estimated with two-way mixed effects model and with 95% confidence interval. Then, the standard error of measurement was checked using the SD\u0026times;\u0026radic;1-ICC formula. The internal stability of the structure was done with the help of McDonald's Omega assessment. Finally, with the help of CFA, structural reliability was calculated (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). In fact, structural reliability or stability of factors is an alternative to Cronbach's alpha coefficient in structural equation model analysis, which in the present study, structural stability of more than 0.7 was considered acceptable (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eNormal distribution, outliers and missing data\u003c/h2\u003e \u003cp\u003eThe normal distribution of data and the evaluation of outlier data were evaluated in both univariate and multivariate ways. Univariate normal distribution was evaluated using the skewness index (\u0026plusmn;\u0026thinsp;3) and skewness (\u0026plusmn;\u0026thinsp;7) and multivariate distribution was evaluated using the Mardia coefficient\u0026thinsp;\u0026lt;\u0026thinsp;0.0001 (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). On the other hand, univariate outlier data were evaluated with the help of descriptive indices and multivariate outlier data were analyzed with Mahalanobis coefficient. At first, the percentage of forgotten data was calculated and finally, the analysis was done by replacing it with the help of average response.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe results of the interviews were analyzed to determine the items that were qualified to be included in the tool. In the process of analysis, the primary codes were identified and finally, 27 tests were extracted from among the 108 potential tests. Table 1 shows the list of extracted codes in the framework analysis process. After the framework analysis process, 27 sub-items were identified and specified for six main items. In the following, the validity and reliability of the items were investigated.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 1 around here\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eValidity\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQualitative face validity: The results showed that all of the 27 items were clear, readable, simple and understandable by the interviewees from the content point of view.\u003c/p\u003e\n\u003cp\u003eQuantitative face validity: According to the results obtained from the calculation of quantitative face validity, all items had an impact score greater than 1.5.\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eContent validity ratio\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the results obtained from the calculation of the content validity ratio for the sub-items based on the information in table 2 and comparing it with the values obtained by previous study\u0026nbsp;(24), 21 test of the range of motion of internal and external rotation of the shoulder, range of motion of internal and external rotation of the hip in the prone position, cross adduction of the shoulder, lateral lunge, the strength of the shoulder rotators with a hand dynamometer at the angle of 90 degrees of abduction of the shoulder joint, Empty Can, stability of the scapula, range of motion of extension and flexion of the elbow, weight-bearing lunge, range of motion of extension and flexion knee, plank, one-leg stability, active leg raising, rotational stability, single-leg squat, bridging with one-sided knee extension, multi-directional hoping, core stability, Y-Balance, hexagon, and special endurance test with content validity ratio higher than were 0.62.\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eThe rest of the tests did not have content validity, so they were excluded.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eContent validity index\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results obtained for CVI are given in table 2.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 2 around here\u003c/em\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConstruct validity\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMean and standard deviation of age (26 \u0026plusmn; 1.3 years), height (178 \u0026plusmn; 2.5.8 cm), weight (77.9 \u0026plusmn; 1.4 kg), weekly activity (9.7 \u0026plusmn; 0.2) hours) and playing experience (12.4 \u0026plusmn; 2.6 years) were tennis players. The frequency distribution of players according to gender, dominant leg, dominant hand, level of competition and history of injury is given in table 3. The amount of KMO was 0.885 and Bartlett\u0026apos;s test was 1442.27, p\u0026lt;0.001. The results of EFA showed that two hidden factors had values of 4.796 and 3.312, respectively. In total, the two extracted factors explained 54.05% of the total variance of the functional movement screening tool (Table 5). Then, with the help of CFA and fit indices, the structural model of the structure was evaluated. Based on the goodness of fit test results, first the chi square index was evaluated [p\u0026lt;0.05, \u0026chi;2=134.67. Then, in order to evaluate the fit of the model, other indices were examined, all indices were PCFI=0.819, PNFI=0.770, CMIN/DF=1.513, RMSEA=0.047, AGFI=0.930, IFI=0.967, that confirmed the good fit of the final model.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 3 around here\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConvergent and divergent validity\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs seen in table 4, Average Variances Extracted (AVE) is two factors larger than Maximum Shared Squared Variance (MSV). Therefore, the results show that the construct has appropriate convergent and divergent validity (Table 4).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 4 around here\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReliability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStability reliability\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe stability reliability of the instrument was estimated by the test-retest method at a time interval of 2 weeks on a sample of 20 tennis players using the internal correlation index (ICC) with the Two-Way Mixed model and a 95% confidence interval. The results in the general scale of the questionnaire showed (CI: 0.53-0.92, p \u0026lt; 0.001, ICC = 0.91) according to the values obtained between the scores of the first and second test, there is a significant agreement, which confirms the high reproducibility and stability of the developed functional movements screening tool.\u003c/p\u003e\n\u003cp\u003eInternal consistency reliability\u003c/p\u003e\n\u003cp\u003eTo check the internal consistency of the instrument, the alpha coefficient was calculated based on Cronbach\u0026apos;s alpha and McDonald\u0026apos;s omega. Based on the final structure of the structural model, table 5 shows that the first factor has Cronbach\u0026apos;s alpha 0.896 and MacDonald\u0026apos;s Omega 0.898, and the second factor has Cronbach\u0026apos;s alpha 0.801 and McDonald\u0026apos;s Omega 0.812. Considering the fact that coefficients above 0.70 are acceptable, it can be concluded that the designed tool has good internal consistency. Also, the final structure of the questionnaire model of the screening tool for functional movements in tennis is shown in figure 1. (Table 5 and figure 1)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 5 and figure 1 around here\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe main purpose of the present study was to investigating the validity and reliability of the functional movement screening tool in tennis as a predictor of injury. In the current study, a questionnaire with 108 tests was designed in the form of six categories of functional, agility, anaerobic, aerobic, muscle length and anthropometric tests based on the background literature in this field. The results of interviews with tennis experts led to the extraction of 27 tests. After the initial design of the questionnaire with 27 items, the researcher investigated its validity and reliability. The amount of factor loadings obtained for 15 items was more than 0.3 and significant (p= 0.001); and the amount of factor loadings obtained for 6 items was so low that these 6 items were excluded from the total number of questions. Finally, 15 tests were extracted to be included in the tool. Of these 15 tests, two tests of rotational stability and active leg raising shared with the FMS designed by\u0026nbsp;Cook, Burton (14). The selection of these tests by experts, in their opinion, is mostly based on the similarity of the tests with the movement patterns in tennis and the anatomical areas prone to injury in this sport. The results showed the appropriate validity and reliability of the whole instrument and showed that the items are measuring a similar concept and structure and there is no conceptual dispersion in it.\u003c/p\u003e\n\u003cp\u003eThe results showed that the reliability of this questionnaire is acceptable. The external stability of the tool was obtained after a time interval of two week, ICC = 0.91, which indicates the desired retest reliability of the questionnaire. These results were in line with the results of\u0026nbsp;Frohm, Heijne (31)\u0026nbsp;and\u0026nbsp;Tabatabaei, Daneshmandi (11).\u0026nbsp;Frohm, Heijne (31)\u0026nbsp;investigated the reliability of a set of 9 tests in soccer players. The reliability of the tool was measured by the test-retest method at a time interval of one week on 26 elite soccer players. The ICC was reported as 0.80 and 0.81, respectively, which indicated the good reliability of the set of tests. In the study of\u0026nbsp;Tabatabaei, Daneshmandi (11), the results of the validity and reliability of the functional movement screening tool in volleyball players showed a good reliability (ICC = 0.88) of the set of tests at a two-week interval.\u003c/p\u003e\n\u003cp\u003eThe results of the EFA showed that the factor structure of functional movement screening in tennis is two-dimensional.\u0026nbsp;Koehle, Saffer (32)\u0026nbsp;investigated the factor structure of FMS using EFA and CFA in adults. Two hidden factors included a main factor consisting of shoulder mobility and\u0026nbsp;active leg raising\u0026nbsp;and a complex movement factor consisting of full squat, lateral lunge, and push up were elicited. Rotational stability was present in both factors in the CFA, and it exclude from the factor structure model had little effect. The results of this study reflected the intended factorial structure of FMS well. In the present study, using principal factors analysis and Varimax rotation, two factors with values higher than one were extracted, which explained 54.05% of the total variances, in which the factor load related to the first factor was higher than the second factor.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe first factor consisted of 8 items, based on the order of the highest factor load, including tests of range of motion of extension and flexion of shoulder, plank, shoulder cross adduction, rotational stability, Empty Can, strength of shoulder rotators with hand dynamometer at 90-degree abduction angle of shoulder joint, range of motion of extension and flexion of the elbow, and stability of scapula were. In the following, these tests are discussed in order.\u003c/p\u003e\n\u003cp\u003eThe range of motion of internal and external rotation of the shoulder joint in supine position and in 90-degree shoulder abduction in the coronal plane was measured using a goniometer. The athlete\u0026apos;s elbow was kept in 90-degree flexion and in this state external and internal rotation of the shoulder was passively measured. This is while the examiner\u0026apos;s hand was stabilizing the scapula to prevent additional movements\u0026nbsp;(33). Final range of motion was determined by limb weight and gravity without excessive pressure applied by the examiner. The range of motion of total rotation was the sum of internal and external rotation measures of the shoulder joint. It is important that this measurement is done bilaterally to allow comparison with the non-dominant hand. In tennis, due to frequent repetitions, especially in forehand and service shots, there is a high probability of muscle imbalances in the shoulder joint, which can be one of the main causes of pain in this area. Also, in the reports registered by the Elite Tennis Players Association, the norm of internal and external rotation of shoulder joint in professional players has been specified\u0026nbsp;(33). The test-retest reliability of shoulder internal rotation range of motion when the arm is abducted to 90\u0026deg; and the scapula is stabilized has been investigated in a previous study\u0026nbsp;(34). Correlation coefficients of 0.62 for intra-examiner reliability and 0.43 for inter-examiner reliability were reported. Considering the frequent movement patterns of internal and external rotations in forehand and backhand shots. Then, the possibility of very common injuries to the elbows of tennis players and golfers in this sport. Taking into account the opinions of specialists and experts, this test can be one of the important tests in the path of predicting the mentioned injures.\u003c/p\u003e\n\u003cp\u003eIn the plank test, which includes keeping the whole-body stable in different positions of the prone, right side, and left side while maintaining alignment and controlling the body position, the athlete must maintain each of these positions for a period of 30 seconds. In this test, any postural disorders caused by the weakness of the core stabilizing muscles and the gluteal area can be identified and revealed. The movement pattern of this test is somewhat similar to the movement pattern of push up test, which is one of the seven items of the functional movement screening tool designed by\u0026nbsp;Cook, Burton (14). It seems that the plank test can be a suitable supplement or alternative to this test when evaluating tennis athletes with the aim of identifying postural impairments caused by weak core stability\u0026nbsp;(35, 36).\u003c/p\u003e\n\u003cp\u003eThe shoulder cross adduction test was performed using a digital inclinometer in the supine position. The athlete\u0026apos;s shoulder was passively placed in a 90-degree shoulder flexion position in the sagittal plane, and no additional pressure was applied to the horizontal adduction movement, and the weight of the limbs against the force of gravity was used to determine the end point\u0026nbsp;(37). The bilateral measurement of this movement pattern was recorded using the value indicated by the digital inclinometer relative to the vertical (neutral) starting position. During the interview process, tennis experts agreed on the theory that the final mechanism of forehand and backhand movements causes muscle imbalance in the range of motion of shoulder abduction. This mechanism can cause a significant difference in the norm obtained from two sides of the dominant and non-dominant hand among tennis players. This confirms the fact that this test can be effective in identifying unilateral muscular imbalance of the shoulder joint during the implementation of the forehand technique in which the movement pattern of horizontal adduction of the shoulder is repeated frequently\u0026nbsp;(38).\u003c/p\u003e\n\u003cp\u003eAnother item selected in the first factor, which the experts confirmed to be suitable for inclusion in the instrument for the purpose of predicting injuries, was the rotational stability test. This test is one of the FMS tests whose movement pattern is similar to the basic movement pattern of a baby walking on all fours in the crawling stage\u0026nbsp;(39).\u0026nbsp;Cook, Burton (14)\u0026nbsp;believed that the weakness of the core stabilizer muscles in the trunk area, which can be revealed during the symmetrical movement of rotational stability, will have an undeniable effect on causing postural impairments\u0026nbsp;(39). This test was also included in the study of\u0026nbsp;Tabatabaei, Daneshmandi (11). by experts in the field of volleyball. This issue can indicate the importance of the stability of the core region of the body in transferring energy to the distal parts for better and smoother movement of the organs\u0026nbsp;(40). It seems that this test has been provided by evaluating the multipurpose movement patterns of the pelvis, trunk and thoracic scapular region, while glenohumeral joint stability, lumbo-pelvic joint control and hip joint mobility have been provided\u0026nbsp;(40). It can detect any weight changes, increased lumbar extension and decreased shoulder joint flexion. In the sport of tennis, due to the importance of the power and speed of the hits, especially in the serve, energy transfer from the proximal area to the organs should be done well, and achieving this goal requires the optimal stability of the core area of the body.\u003c/p\u003e\n\u003cp\u003eThe Empty Can test, which is also known as the supraspinatus test, is used to evaluate the health of the supraspinatus muscle. The positive result of this test indicates the possibility of muscle tear or in other cases tendon and suprascapular nerve damage. Although,\u0026nbsp;Boettcher, Ginn and Cathers (41), believe that this test should not be interpreted as a definitive test for the clinical diagnosis of supraspinatus muscle pathology. However, this test may be useful during shoulder muscle strengthening programs\u0026nbsp;(41).\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eThe mechanism of overhead performance in throwing sports has been widely studied\u0026nbsp;(42). This movement is abnormal and highly dynamic and often exceeds the physiological limits of the joint. Due to the overload of various anatomical structures, the shoulder is prone to injury. Optimal shoulder function requires good kinetic chain function, optimal stability, and scapular coordination in overhead action. Balanced function of the rotator cuff muscles and capsular structures is essential to obtain a stable center of rotation during overhead activity\u0026nbsp;(43). Shoulder injuries related to overhead movement in tennis players can be very similar to the mechanism of injury of the throwing shoulder\u0026nbsp;(44). This seems to be the case given that many shots in the sport of tennis are played in the plane of motion of the scapula. Taking into consideration that the evaluation of Empty Can test is done on this plane.\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eAlso, due to the many injuries of the upper limb, especially in the external rotator muscles of the shoulder, this test has the qualification to be included in the tool considered in the present study with the aim of predicting the injuries of the upper limb.\u003c/p\u003e\n\u003cp\u003eAlso, among the other items selected in the first factor, which confirmed the merit of this test to be included in the tool to predict injuries, was the strength of shoulder rotators with hand dynamometer at 90-degree abduction angle of shoulder joint test. The method of measuring this test was the same as the range of motion test of internal and external rotation of the shoulder joint. Rotator cuff injuries in tennis players are usually progressive overuse injuries, ranging from partial or pericapsular tears to full tears. Most injuries are partial tears, while full tears usually occur in older players. The serve is the most energetic movement in the sport, accounting for 45-60% of all strokes in a tennis match, putting the shoulder at risk for overuse injuries and rotator cuff tears. Studies have shown that impairments in shoulder range of motion and scapular dyskinesia occur after a tennis match. Unlike rotator cuff treatment in non-athletes, treatment in elite tennis athletes has a less-than-ideal return-to-sport rate at the same level of performance\u0026nbsp;(45). With these interpretations, it seems that the strength of the rotator cuff muscles is very important in reducing injuries caused by frequent hits, especially the service. Tennis players often face changes in the mobility of upper limb joints due to the extreme range of motion required in this sport. Since the muscles that act on the upper limb pass through multiple joints, their length and tension are affected by the position of the joint. Changes in the passive range of motion of the joints of the upper limb may lead to postural impairments due to multiple and repeated hits in this sport. It may also lead to changes in the muscular demands necessary for stability or dynamic strength of the upper extremity, either of which could contribute to the development of lateral epicondyle tendinopathy elbow\u0026nbsp;(46). Therefore, the stability of the shoulder and the appropriate range of motion of the elbow in different levels of motion can be factors that reduce overuse injuries in tennis.\u003c/p\u003e\n\u003cp\u003eThe second factor consisted of bridging with one-sided knee extension, single leg squat, active leg raising, range of motion of extension and flexion knee, weight-bearing lunge, range of motion of internal and external rotation of the hip in the prone position and multi-directional hoping. In the following, these tests are discussed in order.\u003c/p\u003e\n\u003cp\u003eBridging tests with one-sided knee extension and multi-directional knee extension had the highest and lowest factor loads, respectively. The musculoskeletal core of the body includes the lumbar spine, abdominal muscles wall, back extensors, quadratus lumborum, diaphragm and pelvic floor. The core is conceptually described as a muscle box. The abdominal wall includes the anterior and lateral walls, the extensors form the posterior wall, and the upper and lower parts of the box are formed by the diaphragm and the pelvic floor, respectively\u0026nbsp;(40). The muscles of the pelvic area help to strengthen the lower part of the muscle box and are necessary for power generation and energy transfer to the end organs. The core acts as the center of movement of the functional kinetic chain. This is especially important in sports that require overhead movement, such as tennis, because it provides proximal stability for distal movement\u0026nbsp;(47). One of the tests that involves the muscles of this area, especially the pelvic floor area, is the movement pattern of bridging. This test can be a suitable supplement along with other tests of core stability such as rotational stability in diagnosing disorders caused by muscle weakness in this area and predicting injuries in the tennis players.\u003c/p\u003e\n\u003cp\u003eAlso, among the other items selected in the second factor, which confirmed the suitability of this test to be included in the tool for predicting injuries in tennis players, was the single leg squat test. Strength training is one of the popular training methods for high performance tennis players of all age groups\u0026nbsp;(48). Assessing an athlete\u0026apos;s sports techniques is important not only to identify the athlete\u0026apos;s ability to perform specific exercises correctly, but also to observe muscle imbalances, functional flexibility, and balance. Overhead squat, full squat and single leg squat are excellent tests to observe and diagnose things like muscle imbalance, shoulder stability, core stability, hip and ankle flexibility, hip muscle imbalance, hip stability and overall balance in tennis players\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003ewith\u0026nbsp;high performance\u0026nbsp;(49).\u003c/p\u003e\n\u003cp\u003eMoreover, another test that was approved in the second factor to be included in the tool for the purpose of predicting injuries was the active leg raising test. Several methods for evaluating hamstring flexibility have been reported in the background literature, which are also used in the screening of elite tennis players. One of these methods is the active leg raising test (SLR), which is performed by measuring the range of motion of passive hip flexion with a straight knee and recording the angle of the hip relative to the trunk using a goniometer\u0026nbsp;(50). Another method involves actively extending the knee from the 90/90 position and measuring the vertical angle from the tibia (Range of motion of extension and flexion knee test). To measure each organ independently, leg raising test is used directly and passively\u0026nbsp;(51). In general, forward movements in tennis players disturb the balance of strength in the flexor and extensor muscles of the knee, i.e. the quadriceps and hamstrings, and this difference is often shown in a short form in the hamstring muscles of tennis players.\u003c/p\u003e\n\u003cp\u003eFurthermore, weight-bearing lunge test was approved in the second factor to be included in the tool for the purpose of predicting injuries. Reduced dorsiflexion is recognized as a risk factor for lower limb injury\u0026nbsp;(52). In tennis players, with a decrease in ankle dorsiflexor, the possibility of lateral ankle sprain injury increases\u0026nbsp;(53). The weight-bearing lunge test can evaluate ankle dorsiflexion reduction. Considering that the weight pressure is on the lower limb area, this test is functionally effective in identifying risk factors for injury, including muscle imbalance of the ankle area\u0026nbsp;(54).\u003c/p\u003e\n\u003cp\u003eIn addition, range of motion of internal and external rotation of the hip in the prone position test was approved in the second factor to be included in the tool for the purpose of predicting injuries. Since rotational movements are very important in tennis and this issue is directly related to the range of motion and strength of the lower limb chain of motion; It seems necessary to have a test that measures the range of motion of internal and external rotations in the lower limb, especially the hip joint. The importance of this topic was well considered during the researcher\u0026apos;s interview with specialists and experts.\u0026nbsp;Ellenbecker, Ellenbecker (55)\u0026nbsp;investigated the descriptive profile of the range of motion of the hip joint in a study on professional tennis and baseball players. In this study, they investigated and evaluated the movement rotation values of the hip active range symmetrically and bilaterally in elite tennis players and professional baseball pitchers. These researchers concluded that asymmetric rotational active range of motion of the hip joint encountered during clinical examination and screening may indicate postural abnormalities and disorders; and require the use of flexibility exercises, rehabilitation, and further evaluation for this category. It is essential for athletes\u0026nbsp;(55). The results of studies conducted in this field show the importance of this issue, that tennis players, especially teenage tennis players, need to have sufficient flexibility in the hip and shoulder joints to achieve the complete kinetic chain of a tennis shot or serve\u0026nbsp;(55-57).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eto, multi-directional hoping test was approved in the second factor to be included in the tool for the purpose of predicting injuries. Studies show that the multi-directional hoping is a test with acceptable reliability and validity that is effective in identifying functional defects in athletes with chronic ankle instability\u0026nbsp;(58).\u0026nbsp;Eechaute, Leemans (59)\u0026nbsp;in a study titled the prediction rate of the multi-directional hoping test in the first non-contact lateral sprint concluded that this test is a valid field test to identify athletes at risk for the first non-contact lateral ankle sprain. Many displacements and changes of directions as well as deceleration at high movement speeds during a tennis match are factors that always expose the athlete to acute and chronic injuries to the lower limbs, especially the ankle area\u0026nbsp;(60). According to the findings of previous researchers as well as the opinions of the experts and specialists participating in the interview process, the multi-directional hoping test is a valid test to identify the risk factors of injury in this sports field.\u003c/p\u003e\n\u003cp\u003eIn order to check the construct validity of this questionnaire, in addition to EFA, the CFA model was also used. The most important goal of CFA is to determine the power of the predefined factor model with a set of observed data. In other words, CFA attempts to determine whether the number of factors and the variable loadings measured on these factors correspond to what was expected based on the theory and theoretical model. With the help of this method, it is possible to remove incompatible items that have a very low load on several factors and cannot be attributed to a specific factor (61). The chi-square goodness of fit test was significant in almost all the above sample sizes and the data analysis confirmed the appropriate fit of the final model.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn the present study, the appropriate psychometric properties and validity of the factorial structure of the questionnaire were confirmed. In total, the face validity, content and structure of the tool were approved by experts and tennis players. Then, after reducing the tests from 27 tests to 15 tests, the reliability of the tool was also confirmed. Afterward, by determining the normative norm for the tests and specifying a cut-off point, it is possible to check the reliability of predicting the injury of this tool by implementing the tests. More research is needed in the future to use this tool as an intervention tool in tennis. Also, prospective and follow-up research on different levels of tennis players will show the ability of this tool in predicting tennis injuries.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is a component of the doctoral dissertation authored by the primary contributor to the article. The research was carried out at the Faculty of Physical Education at the University of Tehran. The article\u0026apos;s authors deem it essential to express their sincere gratitude to the Education Committee of the Tennis Federation, who provided unwavering support in facilitating the objectives of the study. Additionally, the authors extend their appreciation to the participants who generously shared their academic expertise.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no funding from any agency in the public, commercial, or not-for-profit sector.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants were informed of the purpose and procedure of this study, and informed consent was obtained from all participants\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with ethical guidelines\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has used the principles of the Declaration of Helsinki, the general guide to ethics in research with human subjects, and its governing regulations. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo potential conflict of interest was reported by the authors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS.K. \u0026amp; MH.A. \u0026amp; H.D.: data acquisition and analysis. S.K. \u0026amp; MH.A. \u0026amp; H.D.: data interpretation. S.K. \u0026amp; MH.A. \u0026amp; H.D..: wrote the main manuscript text and prepared the figures. S.K. \u0026amp; MH.A. \u0026amp; H.D.: conception/design of the work. All authors reviewed and contributed to the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDorrel BS, Long T, Shaffer S, Myer GD. Evaluation of the functional movement screen as an injury prediction tool among active adult populations: a systematic review and meta-analysis. Sports health. 2015;7(6):532\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchneiders AG, Davidsson \u0026Aring;, H\u0026ouml;rman E, Sullivan SJ. Functional movement screenTM normative values in a young, active population. Int J sports Phys therapy. 2011;6(2):75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlfarraj F, Bousie J, Witchalls J, Newman P. 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Iran J psychiatry Behav Sci. 2014;8(4):29.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-sports-science-medicine-and-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ssmr","sideBox":"Learn more about [BMC Sports Science, Medicine and Rehabilitation](http://bmcsportsscimedrehabil.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ssmr/default.aspx","title":"BMC Sports Science, Medicine and Rehabilitation","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"functional movement screening, tennis, validity and reliability, confirmatory factor analysis, exploratory factor analysis","lastPublishedDoi":"10.21203/rs.3.rs-4696915/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4696915/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRecently, researchers use functional movement tests and especially the functional movement screen (FMS) as a screening tool to prevent injuries in sports. However, limited studies are available to strongly support the validity and reliability of the FMS in different sports populations. Therefore, the FMS does not seem to be a comprehensive functional movement screening tool in order to investigate asymmetry and limitations in all sports. Therefore, the aim of the present study was to design and evaluate the validity and reliability of the screening tool for functional movements in tennis as a predictor of injury.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eTo determine validity and reliability, the results obtained from semi-structured and in-depth interviews with 18 tennis experts were used, which led to the selection of 27 tests out of 108 initial tests. Face validity was evaluated by 10 tennis players, content validity by 10 experts in this field, and construct validity of the questionnaire by 234 tennis players. The reliability of tool was estimated by test-retest method at a time interval of 2 weeks on samples consisting of 20 tennis players using the internal correlation index (ICC).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBased on the results obtained from the calculation of the content validity ratio, 21 out of 27 tests had a content validity ratio higher than 0.62 and the rest of the tests were excluded. Exploratory factor analysis (EFA) extracted two latent factors that explained 54.05% of the total variance. Confirmatory factor analysis (CFA) confirmed the final construct model. The reliability of the tool was estimated: 95% CI: 0.53\u0026ndash;0.92, p\u0026thinsp;=\u0026thinsp;0.001, ICC\u0026thinsp;=\u0026thinsp;0.91.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe functional movement screening tool designed for tennis had acceptable validity and reliability with the aim of investigating asymmetry and limitations in this sport. Factor analysis showed that considering the correct features of psychometrics, this tool can be used as a predictor of injury in tennis.\u003c/p\u003e","manuscriptTitle":"Investigating the validity and reliability of the functional movement screening tool in tennis as a predictor of injury","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-31 06:15:51","doi":"10.21203/rs.3.rs-4696915/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-09T13:12:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-08T12:11:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-08T12:09:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Sports Science, Medicine and Rehabilitation","date":"2024-07-06T13:13:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-sports-science-medicine-and-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ssmr","sideBox":"Learn more about [BMC Sports Science, Medicine and Rehabilitation](http://bmcsportsscimedrehabil.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ssmr/default.aspx","title":"BMC Sports Science, Medicine and Rehabilitation","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e9d9d404-6bcd-4c48-8bb3-298906735c3b","owner":[],"postedDate":"July 31st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-28T16:05:23+00:00","versionOfRecord":{"articleIdentity":"rs-4696915","link":"https://doi.org/10.1186/s13102-025-01152-z","journal":{"identity":"bmc-sports-science-medicine-and-rehabilitation","isVorOnly":false,"title":"BMC Sports Science, Medicine and Rehabilitation"},"publishedOn":"2025-04-24 15:57:25","publishedOnDateReadable":"April 24th, 2025"},"versionCreatedAt":"2024-07-31 06:15:51","video":"","vorDoi":"10.1186/s13102-025-01152-z","vorDoiUrl":"https://doi.org/10.1186/s13102-025-01152-z","workflowStages":[]},"version":"v1","identity":"rs-4696915","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4696915","identity":"rs-4696915","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}