In this third and final blog on this topic I will discuss how we will take the considerations of body proportions and variation in mobility and motor control to individualize squat form. As stated in part 1 our goal of this squat pattern is to achieve good depth while limiting lumbopelvic flexion to promote the ability to efficiently and safely move under loaded situations.
The first thing I do in a squat assessment is simply have the patient squat in their preferred position without cuing and note the quality of movement. The qualitative judgement part does require some experience but you should have a general sense of when the squat looks off . If it doesn’t look quite right, try following the steps below and you should arrive be able to determine what is limiting correct squat technique. If the squat is nearly correct but some lumobpelvic reversal takes place in the bottom of the squat you may consider widening the stance a bit to see if this addresses the issue. If it completely resolves the issue, then great, but I would still advise going through the steps below to rule out any concomitant limitations.
The next thing I do is to elevate the person’s heels and have them reattempt the squat. This: 1) Eliminates insufficient dorsiflexion from affecting the squat and 2) Shifts the person slightly forward to compensate for inability to “sit back” sufficiently during a squat. “Sitting back” is a strength and conditioning term for moving the hip posteriorly and into flexion with an increase in corresponding forward trunk lean. An inability to sit back can come from hip flexion limitations, hip extensor tissue extensibility issues, or a motor control issue. Often if a patient exhibits this inability to sit back with hip flexion while maintaining good lumbopelvic position, it is a situation where the posterior chain muscles are actually stiff (artificially tight) in an attempt to impart stabilization to the lumbopelvic area in situations of reduce trunk stability. So here it is important to recognize that “stiffness” is not the same as “tightness.” Stiffness comes as a result of increased tone to stabilize a joint whereas true tightness comes from a shortening of muscles and their associated connective tissues often from maintaining positions of decreased tissue length. This mechanism of stabilization is a primitive adaptation strategy because while it does improve the body’s ability to overcome the body’s overall external flexion moment it also predisposes the lumbar spine to excessive mobility requirements. The topic of tightness vs stiffness is not a true dichotomy, however, as the two can exist in varying amounts at the same time. Also to note,there is not a ton of abdominal strength required during a squat rather it is likely more a goal of stability and control. A study by Stuart McGill showed surprisingly modest levels of abdominal musculature activity during functional exercises such as squats (Study.)
Now if the squat has improved with heels elevated you can assume that the problem exists with corrective explanations given in points 1 and 2 in the above paragraph. To further the assessment I find it most useful (and simple) to begin with the ankle. We must determine whether dorsiflexion insufficiency is hindering the squat technique. To do this have the individual assume a half kneeling position in front of a wall with the forward toes about 4 inches from the wall. Next have them lean the front knee forward towards the wall while keeping the heel down. The amount of dorsiflexion achieved in this position is sufficient for any squat form. If significantly lacking then dorsiflexion mobilizations and soleus stretching should be implemented before squat training.
If the ankle dorsiflexion test is negative, showing sufficient dorsiflexion, then we will assess the second point from above- the ability to sit back. To check this have the patient perform a squat with the arms extended in front of them. As mentioned in a part 2 this shifts the center of mass slightly forward which allows the squatter to remain slightly more forward and can decrease the amount of hip flexion and forward lean. Next I compare this arms forward form with the squat form with a relatively light weight held against the chest. This also shifts the weight forward but also acts to impart a flexion load to the lumbar spine which should engage the lumbar extensors and abdominals prior to movement. If the form improves further with this strategy is likely that their exists a motor control issue involving the dissociation of hip and lumbar flexion. If the form does not improve or only partially improves, I then look further into what is happening at the hip and lumbar spine.
I have the client supine on a table and perform an assessment of core stabilization using a comparison of the active straight leg raise and passive straight leg raise test. During the active straight leg raise the client should begin with both legs extended straight. The client then lifts one leg keeping both knees straight and the down leg in contact with the table. Observe the active range of each leg and note whether the contralateral leg moved out of full extension. Next perform a standard straight leg raise on each leg while palpating the anterior superior iliac spine to check for posterior rotation of the pelvis. Stop the motion when pelvic rotation begins. If the active straight leg raise flexion range of motion to the furthest point without contralateral hip flexion is significantly less (> 10 degrees) as compared to the passive straight leg raise to the point of pelvic rotation then there likely is a lumbopelvic stability issue. This is because with poor stabilization of the lumbar spine during active straight leg raise the building tension in the hip extensors will cause an unchecked posterior rotation of the pelvis which will lift the contralateral thigh slightly off the table.
I then perform a gentle scour test on both hips to get a general sense of the hip shape and depth. Typically you will notice that the hip achieves hip flexion much easier in a slightly abducting and externally rotated femoral position. Check to be sure that sufficient hip flexion can be achieved, usually requiring 120 degrees for a parallel squat. If passive hip flexion is limited in this position it is likely that limitations in the tissue extensibility of hip extensors is contributing to lumbopelvic reversal or lumbar flexion deeper in a squat. Incorporating tissue extensibility and hip flexion mobilization should precede squat training if this is the case.
Next I have the patient quadruped on the floor or table and have them perform quadruped rocking observing the angle of hip flexion at which lumbar flexion occurs. I then have the patient assume the same hip position as was determined to be the most mobile into flexion via the scour test above. Greater hip flexion should occur and this gives you a good idea of where the person’s feet should be positioned during the squat. If the patient has difficulty differentiating hip flexion and lumbar flexion in this position then you should coach them in this position until they achieve a feel for allowing the hip to flex while stabilizing the spine.
From here, I will use what I have observed to appropriately position the individual’s stance and then have them sit down onto a low box to get the individual in a near parallel squat position. From the low box I use tactile cues to get the patient to achieve appropriate neutrality in their lumbar spine with some paraspinal muscle contraction if they have some amount of flexion. I will have the patient cross their arms across the chest and lean forward, cuing them to keep thoracic extension, just until they are about to un-weight themselves from the box. Here is where those strange proportions I talked about in part 2 may come into play. If the patient happens to have very long femurs you will notice that they may maintain good lumbar position, exhibit satisfactory dorsiflexion, but they require a lot of forward lean to balance and require a ton of hip flexion due to having to sit way back. These individuals may even look like their torso is nearly parallel to the floor. In these cases you will need to adjust the width of the stance wider and continue to assess. It comes down to clinical judgement on what you deem acceptable for squat form. This individuals with disadvantaged proportions will do better with anterior loading, significant attention to maximizing dorsiflexion, and possibly even using elevated heel shoes to properly achieve parallel in the squat.
This is simply my method of assessing squat form and this manner is usually only done for those with grossly aberrant movements. In those clients with form that shows only slight limitations they may benefit from immediate cuing or coaching to correct their form. This should be done only if it is clear that mobility and stability impairments are not limiting the squat and that it is simply motor control. Mobility and stability components are not directly influenced with cueing, only motor control is. Furthermore, I also believe it is important to have the patient achieve a full squat pattern as outlined in Gray Cook’s FMS/SFMA systems. This system would advocate training the full pattern before the squat pattern laid out in this blog series. I do not necessarily disagree with the rationale of teaching the full squat before the “loaded” squat form, but I believe many clinicians will prefer to teach the mechanically efficient pattern I have described which allows for safe loading.