All Posts tagged squats

Squats

Developing lower-limb strength and then power helps improve speed, acceleration and jumping. This in turn helps improve many track and field events, as well as field sports, gymnastics, weightlifting and martial arts.

Developing maximal strength in the lower body is an essential prerequisite of developing power. I still think the barbell squat is the king of all strength exercises. That’s because the squat exercise uses most of the major muscle groups in the lower body, overlapping with those used in running and jumping, so it is very suited to most sports. 

At the very least, you should keep bodyweight squats in as one of your core exercises. I always say that we should be able to do our age in bodyweight squats. For my advanced clients I recommend that you have a minimum strength base of squatting one rep maximum (1RM) of the equivalent to your own bodyweight.

Strength training develops the muscles’ ability to exert force, for example pushing a heavy object. Power training develops the ability to exert this force in less time – ie to make the movement quicker, for example throwing a ball. Sprinters can generate forces of up to three and half times their bodyweight when racing, so having sufficient leg strength to generate this force without injury is necessary. This explains the commonly quoted guideline that a power athlete needs to be able to squat a weight equivalent to twice their body weight – eg an 80kg male rugby player should be able to squat 160kg.

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“Butt tucking under” squat

When a client squats and maintains a slight anterior pelvic tilt, the hamstring is actually lengthening during the descent. Clients with tight lateral hamstrings will reach the end of their hamstring range of motion before they reach full squat depth. As the descent continues and the client attempts to get the femur parallel to the floor the short lateral hamstring will begin to force the pelvis to rotate posteriorly.

 Clients who “tuck under”  should not be loaded until they have developed enough flexibility to prevent the posterior rotation. Loading a spine that is moving into flexion is a prescription for disaster. The spine is meant to be loaded in a slightly lordotic position (anterior tilt). Loading in a posterior tilt can be dangerous. 

Improve this condition by having the client foam roll the hamstring, stretch the hamstring, perform glut activation & then do the squats.

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How do I do the calm exercise? Why do you ask me to squat each session?

When I ask you to perform a squat, I get so much information about the way you move and walk. The info in the chart below explains some of that. The strength and function of the gluteal muscles is probably the most important active muscle in the achievement of efficient walking or running. One of our major treatment goals is to improve your gait.

The deep-lying glut med muscle is normally associated with movement, and it’s key role in running is to act as a stabilising force, to slow the downward drive of the pelvis on the opposite side during stance phase. I see all kinds of adaptations & compensations for weak gluteus medius muscles. 

How clients cheat to compensate for weak buttocks

Adaptations Areas at risk of structural overload
1. Excessive lateral pelvic tilt (Trendelenburg) Lumbar spine, sacroiliac joint (SIJ), greater trochanter bursa, insertion of muscle on greater trochanter, overactivity of piriformis and tensor fascia lata (TFL)
2. Medial knee drift Lateral tibiofemoral compartment (via compression), patellofemoral joint, patella tendon and fat pad, pes anserinus, iliotibial band (ITB)
3. Lateral knee drift Medial tibiofemoral compartment (via compression), ITB, posterolateral compartment, popliteus
4. Same-sided shift of trunk (lateral flexion of trunk) Lumbar spine (increased disc and facet joint compression), SIJ (increased shear)

I gave you the “clam” maneuver to improve your glute medius:

Here it is: In side-lying, both hips are flexed to 30 degrees with knees bent and hips and feet stacked in line. You have to open the top knee while keeping heels together, and most importantly, holding the pelvis completely still (one on top of the other). Don’t let your pelvis rotate – if it does like when we were together in the office, it means you are not able to isolate the muscle and you are trying to recruit (‘cheate’) with the  TFL muscle.

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Single-leg training provides less back stress

Single leg training is very overlooked in the gym & in rehab! Yet walking is the number one single leg activity. In sports, a split stance, single leg stance and pushing off one leg from a parallel stance is used. Doesn’t it make sense to train your body on a single leg?

Anything that causes less load to the low back is a good thing. The rear-foot-elevated split squat (RFESS), also known as the Bulgarian split squat (BSS) or Bulgarian lunge (BL) (it didn’t originate in Bulgaria) is an exercise I like for fat loss and muscular conditioning . This exercsie puts more stress onto your legs and therefore builds more useable strength, and it works around the vulnerable low back, which is often the weak link in bilateral leg squats.

From a functional training point of view I’ve never liked the leg press machine for leg strength because the low back has a tendency to round, which over time might create disc damage. I know in sports the goal is to build stronger legs, and as an injry prevent rehab specialist, I think it’s a good idea to target the leg muscles without having to place heavy loads on the spine. The rear-foot-elevated split squat (RFESS), is a better way to do it.

Benefits of RFESS: Targets the leg extensors (it’s a primary lower-body exercise). Develops balance, hip flexibility, strength, size, and you can use heavy weights to target the leg muscles with limited spinal compression.

Technique:
• Elevate your rear foot. An exercise bench or box works. If the stretch to the quads and hip flexors of your elevated leg is too extreme or uncomfortable, switch to a slightly lower box or step. I like the way the stretch feels and I personally need it for tight hip flexors.

• Start the exercise like a back squat, in that you position the bar on your shoulders in a squat rack, lift it off the supports, and take a step back. From there, lift one foot and place it on the bench behind you. Rest the top of your foot on the bench.

• How deep should you go? Place an Airex pad or mat on the floor under the rear knee, and tell they have to touch the pad with their knee on each rep. This creates consistent depth, and also serves to cushion the knee.

• Keep chest up. Core control is especially critical in the RFESS, as the elevated rear foot can create an unwanted back arch.

Add this in to your program for at least six weeks. Start with 50% of your one-rep max on the back squat.

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Squats: A Functional Assessment of Movement

by Jeffrey H. Tucker, DC, DACRB

Editor’s note: The following article expands upon concepts introduced in “Overhead Deep Squats: Understanding Movement and Function,” which appeared in the Sept. 28, 2006 issue of DC.

What do you do when your patient with musculoskeletal pain gets 80 percent better and progress seems to be stalled? What’s missing to help this patient gain further progress and relief? The answer is in the human movement system. What information are we missing that will allow us to evaluate the human movement system? We can look at how the kinetic chain operates as an integrated functional unit. We need to take a closer look at what our muscles do when we move in everyday life. Functional movements are multidimensional and multiplanar in nature. I find that the deep overhead squat is a useful functional biomechanical analysis.

Current concepts in human movement science provide a useful framework to classify muscle function. We have two distinct yet interdependent muscle systems: the stabilization system (stabilizers or local muscles) and the movement system (mobilizers or global muscles). The local and global muscle systems must integrate for efficient, normal function. Neither system in isolation can control the functional stability of body motion segments. In the presence of chronic or recurrent musculoskeletal pain, patients employ strategies or patterns of muscle recruitment that are normally reserved for high-load function. Pain and pathology do not have to be present concurrently with local muscle dysfunction.

In the presence of pathology and/or pain, a variety of different dysfunctions may present (related to the weak link) in an individual’s integrated stability system. Identifying the dysfunction is a priority of treatment. Musculoskeletal pathology can heal and the symptoms may subside; however, the dysfunction does not always automatically return to a normal baseline. The clinical challenge is how to identify the weak link. Commonly accepted methods of identifying the weak link include posture analysis, gait analysis, flexibility assessment, neuromuscular assessment, single-leg balance excursion, multiplanar lunge test, multiplanar step-up test, push-up test, multiplanar vertical jump/hop, multiplanar horizontal jump/hop, shark skill test, multiplanar cone jump/hop test, and speed tests. Other functional tests to assess core stability, strength, and sequencing include the hurdle step and the wall sit with overhead reach. We can divide these assessments for stability and sequencing into static tests, such as drawing-in maneuvers, plank postures, and holding postures in different planes; and dynamic tests, such as Janda’s movement patterns. The important thing is to not take out the static tests, but to add dynamic testing to understand the human movement system!

As mentioned in my previous article, the overhead deep squat is a valuable dynamic assessment and exercise. If you wish to exercise the glutes, a full-depth squat is highly recommended. I start my evaluation by saying to the patient, “Just do a squat for me” or “Squat down for me.” Observe the patient’s natural or normal pattern of movement. Note the feet, knees, hips (lumbar spine), shoulders and the head while the patient performs the squat. After I observe several squats, I ask the patient to squat down while holding the dowel or a barbell over their head. Both elbows should be in the extended position.

To reiterate, the ideal criteria for a well-performed overhead deep squat are as follows:

  1. upper torso parallel with the tibia or toward vertical;
  2. femur below horizontal;
  3. knees aligned over feet;
  4. dowel aligned over feet;
  5. toes pointed forward;
  6. knees not turned in or out.

Observe: The foot turns outward (externally rotates) while the patient descends. Relate: This implicates a short soleus and gastrocnemius; and long posterior tibialis and medial gastrocnemius. Assess: If the there is excessive outward foot rotation and the hip adducts and/or internally rotates during the descent and/or ascent, this indicates restricted adductors. Rehab solution: Mobilize the external hip rotators; have the patient squat with a spacer between the knees. Place a foam roll or a ball between the patient’s knees and have them squeeze the object as they squat. The size of the ball or roll should place the knees approximately shoulder-width apart.

The question often comes up, “Should the knees go over the toes?” The answer is not that it is necessarily wrong, but that it tends to be the way weak people squat. Weak people will exhaust ankle range of motion first and then begin to flex the knee. This results in excessive knee angles or hitting 90 degrees sooner. Think 4:1 knee-to-ankle movement: 4 degrees of knee movement for every 1 degree of ankle movement. If a patient experiences knee pain while doing a squat, they do not necessarily have to be discouraged from performing them. Teach the movement so they are doing the proper technique, loading the correct muscles and joints and not overloading the knees.

The rehab regression for knee pain while squatting is to perform the “airbench” exercise. Have the patient stand against a wall with their feet facing straight ahead; their hips, upper back and head should be against the wall. The patient should walk their feet away from the wall approximately one foot-length; bend their knees and start sliding down the wall until the knees cover the toes as they look down at their feet. Instruct the patient to hold this position and lift the toes upward to keep the weight in their heels; the lower back should be flush up against the wall. Make sure they hold this pose for one to two minutes.

If you have a patient whose chief complaint is low back pain, yet they can do the deep overhead squat and achieve the benchmark of having the upper torso parallel with the tibia or toward the vertical and the femur below horizontal – but the foot flattens, turns outward and the hip abducts – they must stretch the gastrocsoleus complex for improvement within the kinetic chain. This patient can use the overhead deep squat as therapy to correct the tightness in the calf. For rehab, have the patient perform squats with a 1- to 2-inch board under the heels while squatting. Gradually (over many weeks) lower the board until the patient can achieve the benchmark of keeping the feet flat on the ground. Squat repetitions will stretch the tight tissue out.

A method to help stretch tight tissue is postfacilitation technique (PFS) over the gastrocsoleus complex. This is indicated for chronically shortened muscles. The patient performs a maximal contraction with the tight muscle from a midrange position. On relaxation, the doctor quickly stretches the muscle, taking out all the slack. The exact steps for PFS are:

    1. apply strong force against resistance for approximately seven to 10 seconds;
    2. instruct the patient to relax immediately;
    3. elongate the muscle fast and maintain muscle in stretched position (10 to 15 seconds);
    4. wait approximately 20 seconds before the next resistance, allowing the muscle to regain normal irritability threshold;
    5. repeat three to five times.

Note: Never stretch if the patient is unable to relax.

A question that often comes up in rehab is, “What should this patient do first, stabilize or mobilize?” Both have significant positive clinical benefits, and it is often advantageous to do both at the same time. The overhead deep squat allows the body to integrate both stability and mobility into function.

If your patient does not meet the benchmark criteria for the overhead deep squat evaluation, you should ask yourself, “Do they need mobilization or stabilization to improve the movement pattern?” The following functional knee-to-chest test will help you sort out this question. Have your patient lie down in the supine position and ask them to “bring the knees to the chest.” If they can bring the knees to the chest and maintain a flat back on the floor, they do not have a mobility problem. If you stood them upright on their feet while in the knee-chest position, they should be in the ideal posture for the squat.

Observe: Patient supine – raises arms overhead and performs knee-to-chest. Assess and relate: If the patient has increased ROM, they can do a full squat. It’s not a ROM issue. Retest: Challenge the patient for stability versus mobility. Stability is reliably tested under low-load situations. Patient position: Supine; perform bilateral knee-to-chest. Doctor notes the distance and location of the thighs on the torso. Patient’s arms are outstretched in front of the body. The practitioner resists bilateral arm flexion. Reassess: Can the patient bring the knees closer to the chest?

Indicates: Increased ROM or decreased pain indicates patient cannot perform the deep overhead squat due to poor stability. Relate: The patient will benefit from a stabilization program. Observe and test: Perform the overhead deep squat with resistance to abduction at the knees (with a band or belt around the knees). Reassess: This leads to increased ROM, but the patient still has pain. Indicates: This is not a gluteus medius issue.

Functional child’s pose. Ideally, there should be even flexion throughout the lumbar and thoracic regions. Observe and test: The patient performs a yoga-type child’s pose with outstretched arms over the head. Instruct the patient to perform posterior rocking such that the posterior glutes touch the heels. Visually observe the spinal contours. Assess: If a patient has an area of increased kyphosis and is unable to get the spine in a natural curved posture, it is likely a hypomobile or stiff area. The purpose is to assess patients who may be hypomobile. It is important to identify stiff or restricted segments, because these may be a cause of compensatory hypermobility or “give” at an adjacent joint. The site of the “give” or compensation can be the site of the pathology and pain. The stiff area will need to be mobilized with manual techniques and/or the patient can be instructed in the use of a foam roll for self-mobilization.
Improving the quality of the deep overhead squat: Here are four specific progressions and sequences that will improve the deep overhead squat:

Toe-Touch Progression #1:

    • Stand erect with feet side by side, heels and toes touching.
    • Elevate balls of the feet onto a 1- to 2- inch platform.
    • Insert a towel roll or foam roll between the knees.
    • Reach for the ceiling, stretching the arms as high as possible with palms facing forward.
    • Touch fingertips to toes.
    • Repeat for 10 to 12 reps.

Toe-Touch Progression #2:

    • Stand erect with feet side by side, heels and toes touching.
    • Elevate the heels on a 1- to 2-inch platform; toes on ground.
    • Insert a towel roll or foam roll between the knees.
    • Reach for the ceiling, stretching the arms as high as possible with palms facing forward.
    • Touch fingertips to toes.
    • Repeat for 10 to 12 reps.

Reverse Squat Sequence:

    • Stand with the heels on a 1- to 2-inch platform, feet spread shoulder-width apart or wider.
    • Bend forward until the entire palm can be laid flat on the floor or on a 2-, 4- or 6-inch platform. The entire palm must be flat.
    • Lower the body, knees outside of elbows; keep the feet straight.
    • Sit deeply into the squat.
    • Stretch for 20 seconds.

Deep Squat to a “Y” Position Sequence:

    • Start from a deep squat position with the hands on the platform.
    • Raise the right arm over the head. Follow the hand with the eyes.
    • Raise the left arm over the head. Follow the hand with the eyes.
    • With both hands in a “Y” position, extend the spine as much as possible.
    • Stand up.
    • Repeat for 10 to 12 reps.

How to identify impairment in the overhead deep squat. Observation: The patient complains of flexion-related symptoms in the lumbar spine. The lumbar spine flexes during the descent. Relate: The lumbar spine has greater motion into flexion relative to the hips under flexion load. Rehab: The patient needs to learn to forward lean with a straight back and independent hip flexion, but only as far as the neutral lumbopelvic position can be maintained. Observation: Abnormal lumbar extension during the descent/ascent. Relate: This implicates short illiopsoas, lumbar erectors, quadratus lumborum and latissimus dorsi muscles. Rehab: The patient performs a “single-leg forward bend” with the foot of the tight side on a stool. This puts the knee and hip into slight flexion. Put the foot of the tight side flat on a stationary stool approximately 12 inches high. Ask the patient to bend forward and touch the fingertips to the floor. Repeat this 10-12 times.

Functional stability grip assist. Observe: During the overhead deep squat, the doctor observes that the heel of foot rises while descending from the neutral starting position. Retest: Ask the patient to keep their feet flat. If you notice a lack of depth with the heels flat on the ground, this may be from a lack of stability and/or a short soleus muscle. Retest: Have the patient perform the “functional stability grip assist deep squat: – the patient grips each hand to a door knob, a bar or the back of a chair. Perform the deep squat. Depth should improve; then stretch the Achilles, gastrocnemius, quadriceps and gluteals. Holding onto a rail or bar will enhance stability that provides active control of the local or global muscle’s ability to control motion. Relate: Lack of depth indicates restricted Achilles, gastroc, quads and superficial glut max. Observation: There is a lack of depth and the knees drift internally during descent and/or ascent. Assess: Lack of depth indicates dysfunction of the adductors, gluteals and proximal hamstring. Rehab solution: Lie on your back with your feet up on the wall. As you get more functional, your hips will sit closer to the wall and be flat on the floor at the same time. When you get your legs up on the wall, allow them to spread apart to stretch the adductors. Tighten the thighs and pull your toes back toward your knees and hold for one to four minutes. Your feet must be pointed straight behind you for your hips to be doing the work needed to stabilize the spine. Progression: Perform the above with a foam roll under the lumbar spine to enhance the lordosis. Spread eagle with the legs and feet up along the side of a wall. This will simultaneously stretch the adductors and hamstrings. Observation: The low back goes into flexion during the overhead deep squat. Assess: If the low back goes into flexion to get depth, this implicates the iliotibial band that inserts into the glut max or lack of lumbar control. Solution: Stretch the gluteus and iliotibial region.

Overhead deep squat asymmetry. Observe: Lack of depth or asymmetry occurs during the range of descent motion. Assess: Does the pelvis shift? The pelvis will shift away from restriction. Relate: Asymmetry when squatting indicates restriction in the hip rotators. Rehab: Stretch or mobilize hip rotators. Instruct the patient to lie on their back with both knees bent and their feet flat on the floor, pointed straight ahead. The patient should place their arms out to the side at shoulder level, cross their right ankle over the left knee and rotate the ankle/knee junction in that same direction to the floor. Instruct them to press the right knee away from their body with the right hip musculature; repeat the exercise on the opposite side.

Dysfunction: Asymmetry when squatting shifting to a side. To determine what hip may be causing the dysfunction, check hip height in prone position. Rehab: Stretch and mobilize hips. The prone anterior hip stretch is performed. With the patient in the prone position, place one ankle under the opposite patella. Ideally, the hips should be symmetrical and the height of the anterior hips should be equal distance from the table top. Observe and assess: Asymmetry when squatting shifting to a side indicates weak abductors. Rehab solution: Strengthen the abductors. Perform an abductor exercise by having the patient stand sideways next to the wall. The leg that is closest to the wall should be placed in 90 degrees at the hip and knee. Push with the outside leg into the wall. Progress to wall ball exercises.

Tucker test. As noted in my previous article, the purpose of this test is to help recruit a deeper and stronger contraction of the gluteal group. Test: Place a quarter on the outside of the clothes between the buttocks at the level of the anus and have the patient hold it in place with a strong gluteal contraction. Assess: Can the patient contract the gluteals strong enough and continuously while performing the bridge exercise up and down so the quarter does not drop to the floor? Relate: In order to hold the quarter in place, the patient must concentrate on performing a strong gluteal contraction. This forces the continuous contraction of the gluteus and initiates a co-contraction of the abdominals. Progression: Have the patient perform the overhead deep squat with the quarter held in the buttocks.

Resources

  1. Bergmark A. Stability of the lumbar spine. A study in mechanical engineering. Acta Orthopaedica Scandinavia 1989;230(60):20-24.
  2. Caterisano A, Moss RF, Pellinger TK, Woodruff K, Lewis VC, Booth W, Khadra T. The effect of back squat depth on the EMG activity of 4 superficial hip and thigh muscles. J Strength Cond Res August 2002;16(30:428-32
  3. Cholewicki and McGill. Mechanical stability in the vivo lumbar spine: implications for injury and chronic low back pain. Clinical Biomechanics 1996;11(1):1-15.
  4. Clark M. “Introduction to Kinetic Chain Dysfunction.” Course notes, 2005. Copyright NASM.
  5. Comerford M. “Lumbo-Pelvic Stability.” Course notes, 2003. Copyright M. Comerford.
  6. Vermeil A. “Sports & Fitness.” Course notes, 2005. Copyright A. Vermeil.
  7. All the coaches, sports medicine specialists and sports scientists who have shared their knowledge with me.
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Overhead Deep Squats: Understanding Movement & Function

by Jeffrey H. Tucker, DC, DACRB

What are the most common imbalances patients present with? The obvious answer is musculoskeletal imbalances. This article discusses the functional assessment of stability and mobility to movement re-education. Assessment of the overhead deep squat for stability and mobility imbalances will improve your awareness of the patient’s movement dysfunction. Training stability and providing manual mobilization and/or self mobilization are current concepts of movement dysfunction.

A restricted segment can cause a compensation that leads to uncontrolled and increased motion. The uncontrolled segment or region is the most likely site of the source of pathology and symptoms of mechanical origin. Common dysfunctions within the movement system occur when the ankle, hip or thoracic spine needs mobilization, or when the knee, lumbar spine or glenohumeral joint needs stabilization.

There is plenty of evidence to support the link between uncontrolled intersegmental translation or uncontrolled range of motion and the development of musculoskeletal pain and degenerative pathology. Motor control dysfunction within the ankle, knee, hips, lumbar region, thoracic region and shoulder contribute to insidious onset, chronicity and recurrence of pain.

We need to restore ankle dorsiflexion, hip flexion/extension and/or hip adduction/abduction, and thoracic flexion and extension, because there is a frequent relationship between the loss of range of motion at one or more motion segments, and the development of compensatory excessive movement at adjacent segments. Learning to refine mobility and stability will reduce asymmetries and limitations as a means of injury prevention. It is important to establish stabilization prior to strengthening. Evaluate flexibility limitations and asymmetries between the left and right sides of the body. An individual conceivably could overcome a deficit in range of motion in one joint by using more ROM at another joint to achieve the specified goal.

The body is a “kinetic chain” of interconnected parts. I recommend overhead deep squatting as the primary assessment to evaluate whether mobility or stability is required.

The overhead deep squat: The ideal criteria for a well-performed overhead deep squat are:

    1. upper torso parallel with the tibia or toward vertical (back is relatively upright);
    2. femur below horizontal;
    3. knees aligned over feet;
    4. both arms overhead with the dowel aligned over feet;
    5. toes pointed forward; and
    6. knees don’t turn in or out.

Hypomobility at any joint in the lower extremity kinetic chain can challenge the motor-control mechanisms of the patient and lead to joint instability. Joint hypomobility can present as dysfunction of intra-articular motion, producing limitations of the accessory movements of roll and glide between the joint surfaces. Limited range of motion also can occur in the myofascial system (extra-articular in nature). These two components are interrelated and often occur together. The abnormal displacement or restrictive barrier to movement changes the normal pattern of movement of the instantaneous axis of rotation (IAR). Movement around an abnormal axis of rotation imposes abnormal compression or impingement on some aspect of the joint tissues and produces altered proprioceptive input to the central nervous system. The motor-control system must adapt to maintain function. These faulty movements increase microtrauma in the tissues around the joint, which, if accumulative, lead to dysfunction and pain.

After an ankle sprain, hypomobility may occur at the subtalar joint, talocrural joint, distal tibiofibular joint, or proximal tibiofibular joint. Limited dorsiflexion after lateral ankle sprain has been attributed to tightness in the gastrocnemius-soleus complex, capsular adhesions developed during immobilization, and subluxations or any combination.

Ankle: The hypomobility of the ankle or tissue tightness can be observed during the overhead deep squat if the heel of the foot rises while descending from a neutral starting position. This is the result of limited soleus muscle motion (e.g., ankle dorsiflexion). Motion can be restored and maintained despite restricted arthrokinematic motion. Restoration of dorsiflexion and normal gait patterns occurs after anterior-to-posterior (manual or self) mobilizations of the talus in the mortise.

If the patient’s toes turn outward while descending from the starting position, it means he or she may have weak, tight lateral gastrocnemius, hamstrings, weak inner thighs, and is at risk for Achilles tendonitis.

The progression of rehab to improve the foot dysfunction is to start the patient with ankle self-mobilization. The patient starts out in the double-leg stance. Take a single step forward onto a stool with the right foot. Ask the patient to flex the ankle and knee over the stool as far as they can go. Compare to the left side. The restricted side can be stretched and mobilized while on the stool by repetitively moving the knee over the foot. Altered movement of the subtalar joints and soft tissue tightness can be restored through self repetitive range of motion maneuvers. Next, have the patient perform a wall stretch. With their hands against a wall, feet flat on the ground and one foot at least 18 to 20 inches behind the other, have them bend the front knee. Hold the static stretch for at least 30 seconds. Do this at least two times per leg. The next exercise involves standing on one foot, turned in 45 degrees with the heel hanging off a step. The patient’s body’weight is on the forefoot. Have them hold onto a wall or rail handle and let their body weight drop down. Instruct the patient to hold this stretch for at least 60 seconds.

Knee: If the knees drift inward while descending from the start position of the overhead deep squat it may mean the patient has weak glutes, tight inner thighs, and is prone to knee and low back problems. The patellofemoral joint may be influenced by the segmental interactions of the lower extremity. Abnormal motions of the tibia and femur in the transverse and frontal planes are believed to have an effect on the patellofemoral joint. The first progression for the knee is to use a foam roll on the adductor and abductor muscles. Firmly press and roll along the tight tissue for several minutes or until you feel a release of tight tissue. Have the patient perform a lunge at a 2 o’clock or 3 o’clock pose with the right leg and a 10 o’clock to 11 o’clock pose with the left leg. The patient should next perform side-lying leg raises. Do not allow the quadratus lumborum muscle to activate early. Raise and lower the top leg, keeping it straight. Isolate the TFL and glute medius. Only perform this on the side that drifts.

Hip: If the patient can keep the feet straight ahead or have only slight external rotation, plus the heels stay flat on the floor while squatting, but they cannot achieve the depth of getting the femurs below the horizontal, they may have tightness where the TFL attach into the glutes. The hip joints may be restricted. The rehab progression is to start with manual mobilization of the hips. Teach the patient how to perform hip range of motion on their own. Part of this solution is simply to do repetitive squats. Over time and many repetitions, the patient will break up the tissue tightness and be able to squat lower and lower.

If you suspect a patient is having a hip extension firing problem during gait, with the hamstrings dominating the movement pattern, rocker sandals can help retrain the gluteus maximus. There are a number of ways to “wake up” the gluts while squatting: for example, weight shift toward the heels, bridges up and down with a therapy band around knees to provide resistance to abduction; side steps with a band around the ankles; or bridges on a gym ball with alternate heel raises. Tight hip flexors will inhibit the gluteus, so these need to be evaluated for length.

For a stronger gluteal contraction, perform the Tucker test, the purpose of which is to help recruit a deeper and stronger contraction of the gluteal group. Test: Place a quarter on the outside of the patient’s clothes between the buttocks at the level of the anus, and have the client hold it in place with a strong gluteal contraction. Assess: Can the patient contract the gluteals strong enough and continuously while performing the bridge exercise up and down so the quarter does not drop to the floor? Relate: In order to hold the quarter in place, the patient must concentrate on performing a strong gluteal contraction. This forces the continuous contraction of the gluteus and initiates a co-contraction of the abdominals. Progression: Have the patient perform the overhead deep squat with the quarter held in the buttocks.

Lumbar: If the patient’s back bends into flexion while performing the overhead deep squat, it may mean they have tight hip flexors, a weak core and poor posture. This is such an important diagnostic tool. Why is this point so important? The lumbar spine may be more flexible relative to the hips in flexion due to lengthened erector spinae and shortened hamstrings. This can lead to a hamstring strain, but more importantly, the muscles that control excessive lumbar flexion (lumbar erector spinae) have more “give” than the muscles that limit hip flexion (hamstrings). Consequently, during trunk flexion the lumbar spine gives more easily than the hips and excessive flexion occurs in the lumbar spine relative to the amount and time of flexion at the hip joints, resulting in compensatory lumbar flexion and a potential lumbar flexion stability dysfunction. The patient complains of flexion-related symptoms in the lumbar spine. You can see how this will translate to their everyday life. See if you can detect the following possible flexion movement dysfunctions in the low back when the patient forward leans while performing the overhead deep squat:

    1. Shortened back extensor mobilizer muscles (longissimus and iliocostalis): The pelvis shifts more than 4 to 5 inches posteriorly during forward bending and the spine demonstrates limited flexion.
    2. Shortened hamstrings: The hips demonstrate less than 70 degrees of hip flexion during forward bending.
    3. Lengthened gluteus maximus: The hips demonstrate more than 90 degrees of hip flexion during forward bending.
    4. Lengthened back extensor stabilizer muscles (superficial multifidus and spinalis): The spine demonstrates excessive flexion during forward bending.

The progression of rehab is to use the foam roll on the anterior and lateral sides of the hips. Work out as much tissue tightness as you can on the foam roll. To stretch the hip flexors, teach your patient to do a lunge with an arm raised overhead. The precise steps are as follows: Leading with the right foot, the patient performs a lunge while raising the left arm overhead and rotating the upper body to the left. Instruct the patient to hold this pose for 30 seconds and to perform at least two stretches on each side. The most important solution for this movement dysfunction is to control movement at the site of the instability. This concept is a process of sensory-motor re-programming to regain proprioceptive awareness of joint position, muscle activation and movement coordination. This training is beyond the scope of this article. However, you can start by teaching clients to co-contract the mutifidus and transverse abdominus muscles.

Thoracic: During the overhead deep squat, the patient presentation of lack of mobility in the thoracic spine may include the inability to get the dowel directly over the feet. I usually find the arms way out in front of the feet. These patients lack thoracic extension. You will feel restricted motion on palpation of the thoracic spine into extension. The patient may have an obvious forward-drawn posture, anterior head and shoulder carriage (slumping) and/or an increased kyphosis. The rehab solution for this dysfunction is mobilization. The foam roll will allow for self mobilization into extension. The repetition of performing self-mobilization of the thoracic spine into extension, while the patient performs the overhead deep squats, is an exercise in and of itself. Another self-mobilization maneuver involves asking the patient to sit on a chair facing the wall, leaning the forehead on crossed arms against the wall. The patient’s knees and toes touch the wall. Taking deep breaths in and out, on the exhalation the patient forces thoracic extension movement, repeating the process about 10 times. I often find the thoracolumbar junction, T6 and above, as the key joints to manipulate to create flexibility.

Shoulder: The gleno-humeral functions. Stability is sacrificed to a large degree to achieve this mobility. During the overhead deep squat you will observe the patient pushing the dowel behind their back instead of over the head. To correct the instability in the shoulder we need to correct the length-tension relationship, improve muscle endurance and coordination of the rotator cuff muscles. These muscles act in a manner to generate a force balance to maintain centering of the joint throughout the range of motion.

Assessment of the overhead deep squat provides analysis of stability and mobility. An exercise program based on the assessment can be implemented to achieve stability and mobility. Stability is only tested reliably under low-load situations. Mobility is based on the ability to pass or fail the ideal criteria of the overhead deep-squat posture. The benefits of having good stability function of both the local and global stabilizer muscles, as well as good joint flexibility, are improved low-threshold motor control and reduced mechanical musculoskeletal pain.


Resources

  1. Bergmark A. Stability of the lumbar spine. A study in mechanical engineering. Acta Orthopaedica Scandinavia 1989;230(60):20-24.
  2. Caterisano A, Moss RF, Pellinger TK, Woodruff K, Lewis VC, Booth W, Khadra T. The effect of back squat depth on the EMG activity of 4 superficial hip and thigh muscles. J Strength Cond Res August 2002;16(30:428-32
  3. Cholewicki and McGill. Mechanical stability in the vivo lumbar spine: implications for injury and chronic low back pain. Clinical Biomechanics 1996;11(1):1-15.
  4. Clark M. “Introduction to Kinetic Chain Dysfunction.” Course notes, 2005. Copyright NASM.
  5. Comerford M. “Lumbo-Pelvic Stability.” Course notes, 2003. Copyright M. Comerford.
  6. Vermeil A. “Sports & Fitness.” Course notes, 2005. Copyright A. Vermeil.

Dr. Jeffrey H. Tucker graduated from Los Angeles College of Chiropractic in 1982. He is a diplomate of the American Chiropractic Rehabilitation Board and teaches a 14-hour postgraduate diplomate series on cervical and TMD rehab and lumbar spine biomechanics and rehab. Dr. Tucker practices in West Los Angeles and Encino, Calif.

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