CURRENT Sports Med 2006; 36 (3): 189-198

0112-1642/06/0003-0189/$39.95/0

OPINION  2006 Adis Data Information BV. All rights reserved.

The Role of Core Stability in

Athletic Function
W. Ben Kibler,1 Joel Press2 and Aaron Sciascia1
1 Lexington Clinic Sports Medicine Center, Lexington, Kentucky, USA
2 Rehabilitation Institute of Chicago, Chicago, Illinois, USA

Abstract The importance of function of the central core of the body for stabilisation
and force generation in all sports activities is being increasingly recognised.
‘Core stability’ is seen as being pivotal for efficient biomechanical function to
maximise force generation and minimise joint loads in all types of activities
ranging from running to throwing. However, there is less clarity about what
exactly constitutes ‘the core’, either anatomically or physiologically, and
physical evaluation of core function is also variable.
‘Core stability’ is defined as the ability to control the position and motion of
the trunk over the pelvis to allow optimum production, transfer and control of
force and motion to the terminal segment in integrated athletic activities. Core
muscle activity is best understood as the pre-programmed integration of local,
single-joint muscles and multi-joint muscles to provide stability and produce
motion. This results in proximal stability for distal mobility, a proximal to distal
patterning of generation of force, and the creation of interactive moments that
move and protect distal joints. Evaluation of the core should be dynamic, and
include evaluation of the specific functions (trunk control over the planted leg)
and directions of motions (three-planar activity). Rehabilitation should include
the restoring of the core itself, but also include the core as the base for extremity
function.

1. What is the Core? to its local functions of stability and force genera-
The musculoskeletal core of the body includes tion, core activity is involved with almost all ex-
the spine, hips and pelvis, proximal lower limb and tremity activities such as running, kicking and
abdominal structures. The core musculature in- throwing. Therefore, the position, motion and con-
cludes the muscles of the trunk and pelvis that are tributions of the core must be evaluated and treated
responsible for the maintenance of stability of the
as part of the evaluation and treatment of extremity
spine and pelvis and help in the generation and injuries.
transfer of energy from large to small body parts This article provides a general functional defini-
during many sports activities. The muscles and
[1,2] tion of core stability, describes the anatomy and
joints of the hip, pelvis and spine are centrally
physiology of core muscles, discusses core stability
located to be able to perform many of the
stabilisingthat the body will require in order for the in function and dysfunction, provides principles of
functions
distal segments (e.g. the limbs) to do their specific clinical evaluation of core stability, and describes
function, providing the proximal stability for the rehabilitation and conditioning programmes to
distal mobility and function of the limbs. In max- imise the effect of core stability on athletic
addition function.
19 Kibler et al.

2. Definition of Core Stability single-joint segmental stabilisation that allow the

Core stability is an important component max- longer, multi-joint muscles to work more efficiently
imising efficient athletic function. Function is most to control spine motions.[5] This combination of
often produced by the kinetic chain, the muscle activations helps create the ‘neutral zone’
coordinated, sequenced activation of body segments control of the spinal segments. In this ‘neutral zone’
that places the distal segment in the optimum the ligaments see minimal tension.[5-8]
position at the optimum velocity with the optimum The abdominal muscles consist of the transverse
timing to pro- duce the desired athletic task.[2] The abdominus, the internal and external obliques, and
core is impor- tant to provide local strength and rectus abdominus. Contracting the transverse ab-
balance and to decrease back injury. In addition, dominus increases intra-abdominal pressure and
since the core is central to almost all kinetic chains tensions the thoracolumbar fascia. The transverse
of sports activi- ties, control of core strength, abdominals have been shown to be critical in
balance and motion will maximise all kinetic chains stabilisation of the lumbar spine. [9,10] Abdominal
of upper and lower extremity function. muscle contractions help create a rigid cylinder,
There is no single universally accepted enhancing stiffness of the lumbar spine.[11] It is
definition of core stability. A general definition of important to note that the rectus abdominus and
core stabili- ty that will be used in this article is the oblique abdominals are activated in direction-spe-
ability to control the position and motion of the cific patterns with respect to limb movements, thus
trunk over the pelvis and leg to allow optimum providing postural support before limb move-
production, transfer and control of force and ments.[3,12-14] Contractions that increase intra-ab-
motion to the terminal segment in integrated kinetic dominal pressure occur before initiation of large
chain activities. segment movement of the upper limbs. [15,16] In this
manner, the spine (and core of the body) is
3. Anatomy, Physiology
stabilised before limb movements occur to allow
and Biomechanics
the limbs to have a stable base for motion and
muscle activa- tion.[17] Clinically, it has been shown
that only a very
3.1 Anatomy small increase in activation of the multifidi and
The core acts as an anatomical base for motion abdominal muscles is required to stiffen the spinal
of the distal segments. This can be considered segments (5% of maximal voluntary contraction for
‘proxi- mal stability for distal mobility’ for activities of daily living and 10% of maximal
throwing, kick- ing or running activities.[2,3] Most of volun- tary contraction for rigorous activity).[18]
the prime mov- er muscles for the distal segments Core stability requires control of trunk motion in
(latissimus dorsi, pectoralis major, hamstrings, all three planes. In order to provide stability in all
quadriceps and iliop- soas) attach to the core of the planes of motions, muscles may be activated in
pelvis and spine. Most of the major stabilising patterns that are different from their primary func-
muscles for the extremities (upper and lower tions. For example, the quadratus lumborum (QL)
trapezius, hip rotators and glutei) also attach to the muscle functions mainly as a stabiliser of frontal
core. plane flexion and extension activities. However, the
Numerous muscles make up the complex known QL is attached from the transverse processes of the
as core muscles. Some are small, short muscles spine and the 12th rib to the iliac crests. This orien-
with small lever arms to span single joints. These tation allows QL muscle activation that occurs in
are activated in ‘length dependent’ muscle association with flexion, extension and lateral bend-
activation patterns.[4] Others span numerous spinal ing activities to buttress shearing of the spine in the
segments and function as prime mover muscles to plane of movement, making it more than just a
integrate several joints and produce force. They are frontal plane stabilising muscle.[19]
activated in ‘force dependent’ activation patterns.[4]
Coordina-
tion of both activation patterns is required in the The roof of the core muscle structures is the multi-
 2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (3)
The Role of Core Stability in Athletic Function 19
segmented structure like the spine. The mul- diaphragm. Simultaneous contraction of the dia- tifidi are
an example of short muscles that provide phragm, the pelvic floor muscles, and the abdominal

 2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (3)
muscles, is required to increase intra-abdominal 3.2 Physiology
pressure, providing a more rigid cylinder for trunk
support, decreasing the load on the spine muscles Muscle activation in kinetic chain function is
and allowing increased trunk stability.[16,18,20] The based on pre-programmed patterns of muscle
diaphragm contributes to intra-abdominal pressure activa- tion that are task oriented, specific for the
before the initiation of limb movements, thereby athletic activity, and are improved by repetition.
assisting spine/trunk stability. This activation These pat- terns are grouped into the following two
occurs independently of the respiratory actions.[21] classes:
• length-dependent patterns, which confer stability
At the opposite end of the trunk component of around one joint, are mediated by gamma affer-
the ent input and involve reciprocal inhibition of
core muscles are the pelvic floor muscles. Because muscle to provide stiffness around a joint;
of the difficulty in directly assessing these muscles, • force-dependent patterns integrate activation of
they are also often neglected or ignored with respect multiple muscles to move several joints and de-
to musculoskeletal rehabilitation. Synergistic acti- velop force, and are mediated by Golgi tendon
vation patterns exist involving the transverse receptors.[4]
abdominus, abdominals, multifidi and pelvic floor Force-dependent patterns of activation are
muscles that provide a base of support for all the demonstrated in many aspects of core-related
trunk and spinal muscles.[16] activi- ties. Evaluation of muscle activation patterns
in association with rapid arm movement shows that
The hips and pelvis and their associated struc- the first muscles to be activated are the contralateral
tures are the base of support for the core structures. gastrocnemius/soleus,[3] and that patterns of activa-
Critical to functioning of the hip and pelvis are the tion proceed up to the arm through the trunk. [14,26]
many major muscle groups in this area. These mus- Maximum foot velocity in kicking is more highly
cles have large cross-sectional areas and, in addition related to hip flexor muscle activation than knee
to their stabilising role, can generate a great deal of extension.[3] A study of baseball throwing demon-
force and power for athletic activities. The glutei strated that in all levels of pitching there is a pattern
are stabilisers of the trunk over the planted leg and of muscle activation that starts from the
provide power for forward leg movements. [2,22] The contralateral external oblique and proceeds to the
hip/trunk area also contributes around 50% of the arm.[26]
kinetic energy and force to the entire throwing mo- These muscle activation patterns also result in
increased levels of muscle activation in the
tion.[23]
extremi- ties, improving their capability to support
or move the extremity. Maximum gastrocnemius
plantarflex-
The thoracolumbar fascia is an important struc- or power is generated by use of the hip muscles.
ture that connects the lower limbs (via the gluteus Twenty-six percent more activation can occur in the
maximus) to the upper limbs (via the latissimus ankle as a result of proximal muscle activation.[22]
dorsi). This allows the core to be included in inte- Similarly, a 23–24% increase in maximal rotator
grated kinetic chain activities such as throwing.[24] cuff activation occurs when the scapula is stabilised
It covers the deep muscles of the back and trunk by the trapezius and rhomboid muscles, either in
[27,28]
including the multifidi. The thoracolumbar fascia asymptomatic or symptomatic individuals. In
also has attachments to the internal obliques and addition, the distal muscle activity can be more
transverse abdominus muscles, thus providing directed towards precision and control, rather than
power generation, when proximal muscle activation
three-dimensional support to the lumbar spine and
is maximum. This can be seen in the function of the
aiding core stability.[24] It helps to form a ‘hoop’ elbow muscles in throwing.[26]
around the abdomen, consisting of the fascia poste- Core muscle activation is used to generate rota-
riorly, the abdominal fascia anteriorly, and the ob- tional torques around the spine. Most studies of
lique muscles laterally, which creates a stabilising muscle activation demonstrate a differential pattern
corset effect.[25] of intensity and timing of muscle activation,
starting
 that minimise internal loads at the joint. There are
many examples of proximal core activation provid-
ing interactive moments that allow efficient distal
segment function. They either provide maximal
force at the distal end, similar to the cracking of a
whip, or they provide precision and stability to the
distal end. Maximum force at the foot segment in
kicking is developed by the interactive moment re-
sulting from hip flexion.[2] Maximum shoulder
inter- nal rotation force to rotate the arm is
developed by the interactive moment developed by
trunk rota- tion.[2] Maximum elbow varus torque to
protect against elbow valgus strain is produced by
the inter- active moment resulting from shoulder
internal rota- tion.[2] Maximal fast ball speed is
correlated with the interactive moment from the
shoulder that stabilises elbow and shoulder
distraction[29] and produces el- bow angular
velocity.[30] Accuracy of ball throwing is related to
the interactive moment at the wrist produced by
shoulder movement.[30]
Fig. 1. One-leg stance. No verbal cues are given. Attention should
be paid to alterations in posture or arm position. As a result of the activations and interactive
moments, there is a proximal to distal development
on the contralateral side, that creates rotation as of force and motion, according to the ‘summation
well as force generation.[16,24,26] of speed’ principle[2] that includes core activation.
Finally, core muscle activation provides stiffness This is not always a purely linear development
to the entire central mass, making a rigid cylinder strictly from one segment to the next. In the
that confers a long lever arm around which rotation tennis serve,
can occur and against which muscles can be
stabilised as they contract.[16,24,25]

3.3 Biomechanics

Physiological muscle activation results in several

biomechanical effects that allow efficient local and
distal function. The pre-programmed muscle
activa- tions result in anticipatory postural
adjustments (APAs), which position the body to
withstand the perturbations to balance created by
the forces of kicking, throwing, or running.[3,14] The
APAs create the proximal stability for distal
mobility.
The muscle activations also create the
interactive moments that develop and control forces
and loads at joints. Interactive moments are
moments at joints that are created by motion and
position of adjacent segments.[2] They are developed
in the central body segments and are key to
developing proper force at
distal joints and for creating relative bony positions Fig. 2. Trendelenburg position, with the contralateral hip dropped.
 the moment of inertia in these distal areas is less,
allowing the summation of higher velocities. Final-
ly, by allowing joint force control to be largely
influenced and controlled by pre-programmed mus-
cle activation patterns and interactive moments de-
veloped through core activation, instead of being
based on local ligament size or feedback-based
local muscle activation, the ligaments can be
smaller in size, and the smaller local muscles can
be activated for precision and control of
performance variables.

5. Examples of Failure of Core Stability

Associated with Dysfunction

Weak hip muscles and resulting alteration of

hip/ trunk position are a common finding associated
with knee injury. Weak hip abductors and tight hip
Fig. 3. ‘Corkscrewing’ – using hip rotators to stabilise the trunk flex- ors are seen in association with anterior knee
over the planted leg in the presence of hip abductor weakness. pain and chondromalacia.[33,34] Alterations in hip
muscle activity are associated with increased hip
elbow maximal velocity is developed before maxi- varus and hip flexion positioning and increased
mal shoulder velocity. However, this general pattern knee valgus positioning in squatting or landing
of force development from the ground through the manoeuvres, all of which increase load on the
core to the distal segment has been demonstrated in anterior cruciate liga- ment. A recent longitudinal
the tennis serve,[23,31] baseball throw[26] and kick.[2] study looked at core stability parameters and found
Force control is also maximised through the core. that weakness in hip external rotation was
The trunk is essential in re-acquiring the forward correlated with incidence of knee injury.[35] Based
momentum in throwing,[24] and approximately 85% on these associations, most rehabilitation and
of the muscle activation to slow the forward- conditioning programmes for the knee now
moving arm is generated in the periscapular and emphasise core stabilisation and hip strengthening.
[33,34,36]
trunk mus- cles, rather than the rotator cuff.[32]

4. Advantages of Core Stability in

Function

Core stability creates several advantages for

inte- gration of proximal and distal segments in
generat- ing and controlling forces to maximise
athletic func- tion. The larger, bulkier muscles in
the central core create a rigid cylinder and a large
moment of inertia against body perturbation while
still allowing a sta- ble base for distal mobility. In
addition, it places most of the ‘engine’ of force
development in the
central core, allowing small changes in rotation relatively smaller mass in the peripheral segments,
around the central core to effect large changes in
rotation in the distal segments, similar to the crack-
ing of the end of a whip. Because of the need for
Fig. 4. Sagittal plane evaluation. The shoulders should barely touch
the wall.
 muscles to be tested should be tested in functional
positions when possible. If the muscle is mainly
used in a closed chain manner, it should be tested in
a closed chain manner. If the muscle is activated in
different planes of motion, it should be tested in
various planes of motion. If muscles are used
prima- rily in an eccentric manner, they need to be
tested in an eccentric manner. Often, to assess all of
the different muscles that function together to
provide core strength, evaluation of specific motion
patterns and quality of movement may be done.
[39,40]
This method of analysis is harder to quantify,
but is more similar to actual three-planar core
function. There is no consensus regarding the most
reliable or repro- ducible evaluation system.
Fig. 5. Frontal plane evaluation. One option to assess core strength that incorpo-
rates many of these variables is to look at one-leg
Alteration of knee flexion has also been standing balance ability, a one-leg squat, and a
associat- ed with increased stresses in the arm. standing, three-plane core strength test. In a
Tennis players who did not have adequate bend in standing balance test, the patient is asked to stand
the knees, break- ing the kinetic chain and on one leg with no other verbal cue (figure 1).
decreasing the contribution by the hip and trunk, Deviations such as a Trendelenburg posture or
had 23–27% increased loads in horizontal internally or external- ly rotating the weightbearing
adduction and rotation at the shoulder and valgus limb indicates inability to control the posture and
load at the elbow.[37] A mathematical analy- sis of suggests proximal core weakness (figure 2).
the tennis serve showed that a decrease in 20%
of the kinetic energy developed by the trunk resulted A one-leg squat would be the next progressive
in a requirement of 34% more arm velocity or 80% evaluation if the standing balance test is done well.
more shoulder mass to deliver the same energy to Assuming the same starting point as the standing
the ball.[23] balance test, the patient is asked to do repetitive
Weakness or tightness at the hip can also affect
the arm. Decreased hip flexibility in rotation or
strength in abduction (positive Trendelenburg) was
seen in 49% of athletes with arthroscopically
proven posterior-superior labral tears.[38]

6. How is Core Strength Evaluated?

There is no standard way that has been described
to measure core strength. Different investigators
have used different techniques to try to gauge the
relative strengths of specific core muscles via elec-
tromyogram data[39] and isometric dynamometer
values.[40,41] These data can give an approximate
estimate of core strength. Firing of numerous mus-
cles in task-specific patterns to provide core
strength makes evaluation of any specific single
muscle as a reference point questionable. Any
evaluation tech-
nique will need to take into consideration that the Fig. 6. Transverse plane evaluation.
 patient stand 8cm away from the wall, and progress
like the sagittal plane test from bilateral
weightbear- ing to single-leg stance and alternately
touch one shoulder then the other just barely against
the wall (figure 6). Quality of motion and speed can
be assessed. With lesser degrees of core strength,
there is a greater breakdown in the ability to
maintain single-leg stance and the ability to just
Fig. 7. Horizontal side support exercises.
barely touch the wall. This test will assess
transverse plane mo- tions that incorporate
abdominal muscles, hip rota-
partial quarter to half squats with no other verbal tors and spine extensors. Therapy can then be insti-
cues. Similar deviations in the quality of the move- tuted based on the muscles and planes of motion
that ment are assessed as in the standing balance test. A are found to be deficient.
Trendelenburg posture, which may not be noted on
standing balance, may be brought out with a single- 7. Principles of Core Rehabilitation
leg squat. The patient may use their arms for balance
or may go into an exaggerated flexed or rotated Rehabilitation of the core should concentrate on
posture (‘corkscrewing’) in order to put the gluteal both the intrinsic needs of the core for flexibility,
or short rotator muscles on greater tension to com- strength, balance and endurance, and on the
pensate for other muscular weakness (figure 3). function of the core in relation to its role in
extremity func-
tion and dysfunction. A thorough pre-rehabilitation
Three-plane core testing is an attempt to quantify examination including the core and the extremity is
core control in the different planes of spine and core required prior to rehabilitation.
motion. Reliability and validity studies have not The early focus is on the deficiencies discovered
been done on specific tests. Clinical experience has
demonstrated that this battery of tests does give during the pre-rehabilitation examination. These
usually include both altered patterns of motion of
useful information that allows specific rehabilitation the hip, trunk and shoulder, and actual weakness or
protocols to be instituted for increased core func- inflexibilities of muscles, and may be seen locally or
tion. Testing is done with the patient standing a distantly. Specific inflexibilities and weaknesses
given distance (usually 8cm) away from a wall. In may be addressed locally by specific exercises, but
sagittal plane testing, they will be facing away from motion patterns should be addressed on a global
the wall. They are asked to slowly move their body level involving the entire kinetic chain motion. Re-
backwards, keeping their feet flat on the floor, to just
barely touch their head against the wall (figure 4).
Initially, this can be done with both legs on the
ground, then progressed to partial weightbearing on
each side and ultimately to single-leg standing.
Sag- ittal plane core strength testing creates
eccentric activation in the abdominals, the
quadriceps and hip flexor muscles, and concentric
activation in the hip and spine extensors. Frontal
plane testing is done by having the patient standing
with one side then the other 8cm away from the
wall (figure 5). While standing on the inside leg,
they are asked to barely touch their inside shoulder
to the wall. This test evaluates eccentric strength of
the quadratus lumborum, hip abductors, and some
long spinal muscles that are working in a frontal
plane. Finally,
transverse plane motion is tested by having the Fig. 8. Isometric trunk rotation.
 of rehabilitation is not only to restore core function
by itself, but also is the first stage of extremity
rehabilitation.
Progressions for lower extremity rehabilitation
include forward and side lunges, integrated trunk
rotation/hip rotations, and knee flexion/extensions
with trunk rotations.[34,36] The frequency and
intensi- ty of each of the exercises will depend on
the indi- vidual response to the exercises.
Shoulder and upper extremity rehabilitation may
begin with a posture of bilateral leg stance, hip
extension and trunk extension.[36] Activation pat-
Fig. 9. Diagonal trunk rotation around a stable base: starting posi-
terns may start with ipsilateral muscles and proceed
tion. to contralateral activations. Diagonal patterns in-
volving trunk rotation around a stable base imitate
habilitation for extremity injury should start with the throwing motion (figure 9, figure 10, figure 11).
The lower extremity activation drives the scapular
core emphasis.
and shoulder activation. All upper extremity exer-
In order to create a stable base, the rehabilitation cises should end in the same position of trunk/hip
protocols start with the primary stabilising muscula- extension. One method to assure this posture is to
ture such as the transverse abdominus, multifidus, ask the patients to end with ‘the elbows in the back
and the quadratus lumborum. Due to their direct pockets’. Progression for upper extremity rehabilita-
attachment to the spine and pelvis, they are tion include integrated scapular retraction/arm ab-
responsi- ble for the most central portion of the duction/external rotation and ‘low rows’, integrated
core stability. Exercises include the horizontal side trunk extension/scapular retraction/arm extension
support (figure (figure 12) and hip/trunk rotation with scapular re-
7) and isometric trunk rotation (figure 8). This stage traction (figure 13).
Core stabilisation should avoid emphasising the
use of single planar exercises that isolate specific
muscles or specific joints. They may be used at
times during the rehabilitation protocol, but empha-
sis should be on early progression to functional

Fig. 10. Diagonal trunk rotation: maximal external rotation. Fig. 11. Diagonal trunk rotation: cross body motion
positions, motions and muscle activation
sequences. In this manner, normal physiological
activations are restored, which lead to restoration of
normal biome- chanical motions. Exercises may be
started with the extremity close to the body,
decreasing the moment arm, then progressing to
more abducted positions, increasing the forces and
loads. The goal is to achieve coordination of
activation of the segments throughout the entire
kinetic chain.
Rehabilitation should be viewed as a ‘flow’ of
exercises that build a base of stability and force
generation, and then proceed distally to establish
control of the forces while allowing maximal
mobil- ity of the distal segment. [42] The core is the
central part of this flow. It acts as the base of
stability and the ‘engine’ of force generation, and
also acts as the controller to regulate the forces.
Since it is involved in many aspects of all athletic
activities, it should be evaluated as part of the
workup of any extremity injury, and should be
rehabilitated prior to rehabili-
Fig. 13. Hip/trunk rotation with scapular retraction. These may be
tation of the injured extremity. done in various planes of arm elevation.

8. Conclusion
be approximated by evaluations that reproduce the
Core stability is a pivotal component in normal three-planar motions that are used by the core to
athletic activities. It is best understood as a highly accomplish its functions. Better understanding of
integrated activation of multiple segments that pro- the complex biomechanics and muscle activations
vides force generation, proximal stability for distal will allow more detailed evaluations and more spe-
mobility, and generates interactive moments. It is cific rehabilitation protocols.
difficult to accurately quantify by isolating
individu- al components, but its function or Acknowledgements
dysfunction can
No sources of funding were used to assist in the prepara-
tion of this review. The authors have no conflicts of interest
that are directly relevant to the content of this review.

retraction/arm extension. It may be started isometrically and then

progressed to isotonic motion.

Fig. 12. The low row exercise-integrated trunk extension/scapular

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