Deep squat analysis

I decided a few months ago to start training towards the ability to do a pistol squat, and as I challenge my joints to achieve this position, I've had the cool opportunity to run into musculoskeletal limits and then diagnose/treat like a PT to get closer to my goal.

Today, I came across a great physio-network article about butt wink with deep squatting, and it brought up a few ideas that I think could form a great deep squatting analysis.

"Deep" may be a relative term. For my pistol squat I want to squat much deeper than 90 degrees-- but for many of my patients, a controlled squat to chair-height may be the goal. In that way, this analysis can be adapted to patient functional goals, but I recommend encouraging active patients to squat to their available limit.

Deep Squat Analysis

The following list contains a few profiles to determine what is limiting squat depth:

1. Balance/coordination

• many patients may not have tried this position in years, so their first try may demonstrate deficits that aren't true mobility or stability impairments

• excessive forward lean may mean the patient struggles to find a good balanced center of mass

  • have patient try to movement again while holding a weight in front of them

  • if squat depth improves, use this position as an exercise:

    • instruct pt to lower the weight to the ground at the bottom of the squat, while trying to maintain the squat position

  • this patient my also benefit from a graded progression of UE support including a TRX > countertop etc. to find their center, progressing to use UE for the eccentric lower only

  • motor learning will be relatively quick-- if the patient is struggling to progress, screen for strength/mobility deficits as well

2. Quad or Glute strength deficit

• visually, a patient with insufficient strength may present similarly to a patient with poor balance, may self-limit depth prematurely, may struggle to stand back up from lowest squat, or may demonstrate one of the following compensatory patterns:

  • Relative glute max deficit: pt may demonstrate a "quad dominant" squat with excess anterior tibial translation ("knees-over-toes")

  • Relative quad deficit:

  • Relative ER deficit: pt may demonstrate valgus collapse at the knees with hip internal rotation as squat depth increases

    • Rule out: medial longitudinal arch collapse causing the hip and knee to rotate in, which can be a compensation pattern for a patient with limited dorsiflexion. Make sure the measure dorsiflexion with a neutral calcaneus.

• Motor control deficits may also masquerade as true strength deficits in these functional screens:

  • have pt try to pre-activate or complete a muscle-group specific exercise and then re-test to screen for difficulty with activating the above muscles

3. Ankle DF mobility restriction:

• Heels raise off ground at lowest portion of squat

• pt may need to use exaggerated forward trunk/arm lean to keep balance if trying to keep heels down

• Rule out: fear of "knees-over-toes" and see if patient can squat deeper if you instruct them to allow knees to move anteriorly, within patient tolerance

4. Hip anatomical restriction

• test hip flexion ROM in quadruped rock-back position: if this ROM = squat ROM, the limitation is likely due to hip mobility

• possible bony X-ray findings for this population could include increased socket depth, retroversion, or coxa vaga

• possible muscular restrictions include glut max, adductor magnus, and possibly piriformis/ deep external rotators

5. Core stability deficit

• personal trainer Dean Somerset proposed a screen to see if the patient has delayed core activation/core motor control:

  • test squat, then have pt complete a plank, then re-test

• he proposes that the body may be guarding hip mobility in the absence of appropriate core support -- I look forward to testing this one out!

• if a patient is holding their breath through the squat, this may also indicate an impairment in functional core activation

If your patient passes the deep squat analysis, they may be appropriate to then assess in an overhead squat. I know the FMS (Functional Movement Screen) and the Titleist Performance Institute use the overhead squat to add considerations of thoracic mobility to the big picture.

The profiles above also don't consider side-to-side asymmetries-- Dr Aaron Horschig posts some great mini case descriptions for patients with lateral hip shifting on his instagram @squat_university. I may outline some of his principles in a post one of these days.

I got to think about these concepts in a new way today, so just thought I'd share!