Squat Foundational Exercise
Goals
- Controlled active stability
- Alignment
- Maintained arch
- Neutral ankle
- Knee between 1st and 2nd dtoe
- Sequencing speed: Controlled
Sequencing Speed
When working on stability, it is important to use slow eccentric movements in order to cue the joints to actively control descent, rather than relying on passive structures.
Assessment
- Bar path
- Arch control
- Knee and hip timing
Bar Path
Bar path refers to the line that the bar moves when viewed in the sagittal plane. The bar should move perpendicular to the floor.
Timing
The knee and hip should start their descent at the same time and reach the end at the same time1.
Knee
The knee is considered a reactive joint: it becomes malaligned as a reaction of improper hip or foot/ankle mechanics1. However, the knee can control its own sequencing speed, thus can change how quickly it moves through its range relative to the other joints.
Individuals with knee pain generally ease their symptoms by keeping the knees directly above the ankles to minimize knee extensor torque. In order to keep the knees in this position, the body compensate for the lack of dorsiflexion and knee flexion ROM1. This will result in a high thigh angle and the trunk moving towards parallel1.
The knee does not function to create alignment, this is the coordinate effort between the ankle and hip1. However, the knee’s primary function is controlling sequencing speed of compound movements and the resultant timing1.
Hips
The hips are “reluctant team members” and if they are not performing their job as shock absorbers, this responsibility can be pushed onto the knees and low back1.
The most common hip compensation occurs when the knees and trunk are used to absorb the lack of hip range1.
Pelvis
Pelvic stability is created through the tug-of-war between the trunk muscles and lower extremity muscles1. The sacroiliac joint (SIJ) has limited mobility and any movement must be handled by the above lumbar segments and the inferior segments (hip joints)1.
Trunk
The trunk’s role during a squat is to align and stabilize against the pivoting movements of the hip.
Instructions
When initially cueing a client for squats, employ a minimalist approach. This will allow you to see the client’s most natural squat position.
- Feet between hip and shoulder width and pointed forward
- Engage your abdominals the same way we did during the warmup
- “pull your belly button towards your spine”
- Demonstrate the exercise
- “Pretend like you are sitting back into a chair”
Patient Presentations
Low-back Pain Patient
Patients with low back pain will prioritize their lumbar lordosis throughout the movement in order to minimize low back motion1. In addition, these patients tend to maintain a vertical trunk, in order to reduce shearing loads on the spine1. The arching required to attain this vertical compensation causes a posterior shift in the center of mass. This is countered by excessive anterior knee translation to shift the center of mass forward to the center.
Knee Pain patient
Individuals with knee pain will attempt to limit the amount of torque on the knee by keeping the knees directly above the ankles, minimizing the moment arm. Since the knees are translated more posterior than normal, the center of mass is shifted posteriorly. The trunk and pelvis compensate for lack of knee range. The pelvis will prevent the thigh angle from dropping past horizontal (<90° knee flexion). The trunk will move into flexion in order to shift the center of mass anteriorly to return to center.
Compensations
Individuals will attempt to compensate in order to find stability1. Leaning on instability is not stability1.
For example, a common compensation while squating is toeing out (hip ER) and flattening the arch (pronation)1. This creates a stable surface, but at the cost of alignment of the lower leg, knee, and upper leg since these must counter the foot position1. Malalignment can result in excessive torsion through these regions.
Back Pain
Progression
- Balance Assisted rack
- Bodyweight
- Barbell
- Challenges sagittal plane
- Split squat
- Challenges frontal/coronal plane
- Squat + Paloff
- Challenges transverse plane
- Eyes closed
- Ground contact
- Airex
- Indo board
Balance-assisted squat
Use a balance assisted squat with a squat rack in order to help the patient overcome stability limitations and access the end-position of the squat. This is important in building the proprioceptive sense of center.
Intra-progressions of balance-assisted:
- Double hand hold on static object (i.e. squat rack)
- double handhold on dynamic object (i.e. elastic bands)
Squat
Purpose
The purpose of squatting is to keep the shoulders vertical while going into triple flexion. This is different from the deadlift, where we focus on keeping a vertical path of the bar rather than the shoulders. The squat has a much more open hip angle at the bottom position compared to the deadlift due to the vertical trunk position.
The lower extremity must balance lower extremity speed with lower extremity range of movement1.
Setup
- Active tall position
- knees in extension to slight flexion but not in hyperextension.
- Stance width can vary based on the functional goal.
- If depth is the goal then use feet outside of shoulders stance.
Keys & Focus
Use a rack to provide additional stability and end position. It is more important to have the correct position with balance assistance, in order to build the correct motor pattern. Once they can attain the correct position, progressively decrease balance assist.
Barbell Back squat
- Shoulder: Requires shoulder retraction/abduction/ER for proper setup.
Use shoulder W exercises to achieve this position.
Split Squat
The split squat provides insight into posture and movements related to stride. The patient must achieve the squat position while balancing the opposing leg positions.
- Front knee: Stable
- Torso: Stable
- Rear hip: Extension
Setup
- Stance:
- Hip width apart
- Leg spacing:
- Leg spacing that is too short will prevent the patient from descending without losing form
- Leg spacing that is too far will make the rear hip immobile and drives the trunk forward
To find the correct stance, straighten the front knee (0° extension) over the ankle.
- Pelvis
- Pointed forward (no rotation)
- Level in frontal/coronal plane
- Assess pelvic tilt (sagittal plane)
- Trunk
- Assess the trunk after assessing setting the pelvis.
I think you could try going into a half-kneeling position where the rear knee is directly under the hip and the front knee is directly above the front ankle.
Movement
The rear leg’s position with the extreme anterior knee translation places increased torque on the knee extensors. The front leg’s position with the knee directly above the ankle places increased torque on the hip extensors.
The focus should be on maintaining trunk alignment, keeping a vertical tibia on the lead leg, and maintaining end-range hip extension during the movement.
To maintain end-range hip extension, you will need to perform constant adjustments at the knee and ankle to maintain the hip position. If the ankle remains plantarflexed, this will push the knee forward and result in hip flexion.