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SQUAT FORM – WHAT DOES IT TELL US? PART 1

SQUAT FORM – WHAT DOES IT TELL US? PART 1

BY DAVID CRUZ, DC, CSCS, FMS, SFMA

The ability to perform a squat or partial squat is an essential primal movement in life we must all be able to do, whether you are 8 or 80 years old. When we think of a squat, most of us associate the move with weight training or a specific sport activity. However, we all perform variations of a squat everyday with activities of daily living ranging from lifting a box to picking up a child or sitting down in a chair. Our ability to do this in a safe and correct manner can be the difference between injury and living a healthy, pain free life.

When done properly, the squat is a safe and effective exercise that can be used for strengthening the entire body. It is estimated that correctly performing a squat requires over 200 upper and lower body muscles to work synergistically. (17) Together, both the upper and lower body must properly work in unison to move through triple flexion and extension of the hip, knee and ankle. This exercise can also be used from rehabilitation to the sport-specific setting by simply changing the range of motion. For instance, in the rehabilitation setting, if quadriceps enhancement is the goal, then keeping the squat to less than 90 degrees is desirable since moving past this range of motion has limited benefit. (1) However, if the intent is to increase hip extensor strength, then increasing the squat depth would be beneficial. (2)

Performing a squat assessment can provide valuable information about a client and potentially reduce their risk of injury. In addition to musculature stability and postural control, dysfunctional movement patterns can also be identified. The inability to perform a squat can be a predictor of a low back or ACL injury. (2, 3, 4) In this article each body region will be discussed along with common movement faults to be aware of. Part 2 will discuss intervention strategies to correct these dysfunctions.

PERFORMING A SQUAT ASSESSMENT

Ask your client to wear shorts and a short sleeve shirt for the assessment. This will make it easier to identify faulty movement patterns. Position the client so that you can observe them from the front and side, as well as being able to observe any rotational movements in the transverse plane.

To perform a squat assessment, begin by instructing the client to stand with their feet shoulder width apart (inside of their feet aligned with the outside of their shoulders). Feet should be straight forward and arms straight above head or with hands gently behind their ears (Figure 1). This position retracts their shoulder blades and activates the upper back musculature providing stability. Their head should be in alignment with their shoulders and eyes gazing straight forward.

Figure 1

Figure 1

Figure 2

Figure 2

Instruct them to descend as far as comfortably allowed while keeping their heels on the ground and pushing the hips back as if sitting in a chair (Figure 2). The tempo should be 2-3 seconds on the way down. Do not attempt to cue them on improper movements you initially see. Have them repeat the squat 3 to 5 times. (2, 5, 6)

HEAD POSITION

Forward head posture has been associated with neck pain, shoulder pain, and temporomandibular joint dysfunction, therefore it is important to assess (Figure 3). (7, 8) Assess from the lateral (side) view watching for anterior head carriage or excessive extension of the neck. From the anterior and posterior view the head should remain in midline and not move side to side. (5, 6)

Figure 3

Figure 3

Eye gaze is also important to monitor as it indicates ones ability to disassociate eye from head movement. As they perform the squat, eye gaze should remain straightforward and not move upward with any head tilt. (5)

UPPER BACK AND SCAPULAR POSITION

Hyperkyphosis or excessive rounding of the upper back has been associated with forward head posture as well as limiting cervical range of motion. (9) Therefore it is important to maintain proper upper back and scapular position. When performing the squat assessment a slightly extended thoracic spine position is recommended to maintain a chest up position (Figure 4). This will also allow the scapula to be retracted. Any rounding of the shoulders and scapula protraction similar to upper cross syndrome should be quickly identifiable. (5, 6)

Figure 4

Figure 4

LOW BACK POSITION

Maintaining a neutral low back position with a slight lordosis is essential to proper and safe motion (Figure 5). Intravertebral disc pressure increases as lumbar lordosis is lost, putting one at risk for injury. (10, 11, 12) Therefore maintaining a lordosis throughout the squat movement is essential. It also allows for proper abdominal bracing necessary to maintain the intra abdominal pressure for proper support. (13)

Figure 5

Figure 5

PELVIC POSITION

Pelvic rotation and tilting should be assessed as this could be due to compensation for the low back or hip musculature. Monitor the level of the hips in relationship to the floor. If the hips lack mobility then this may be seen with excessive thoracic forward lean as the body attempts to compensate. Proper pelvic alignment also allows the muscles of the lumbar spine, erector spinae, quadratus lumborum and oblique muscles to function optimally providing support to the lumbar spine reducing the risk of injury. (5)

Figure 6

Figure 6

KNEE TOE ALIGNMENT

ACL injuries occur at a four to six fold greater incidence in females than males and have been associated with increased knee valgus angles. (14, 15) Therefore assessing the knee and toe alignment from the anterior and posterior view is essential (Figure 7). As the client squats down pay close attention and note if the outside of their knee crosses their medial malleolus. (5) This movement dysfunction may be the result of hip muscular weakness, an ankle dorsiflexion problem or over pronation.

Figure 7

Figure 7

TIBIAL TRANSLATION

There is a general consensus among fitness professionals that increased tibial translation allowing the knees to glide past the toes is harmful and should be avoided. Although knee torque increases as tibial translation occurs, there is no evidence to support ones risk of injury is increased (Figure 8). (5) Conversely, if tibial translation is limited, an increase in trunk anterior lean may occur in order to compensate. This is supported by Fry and colleagues who demonstrated limited tibial translation inappropriately transfers forces to the hips and low back. (16) Therefore as a general rule, assess whether the tibia and the spine are in parallel alignment (Figure 9).

Figure 8

Figure 8

Figure%209

Figure 9

FOOT POSITION

A stance with feet forward, or with a slight degree of external rotation, and approximately shoulder width apart is desired as a wider stance will change the torque about the knee and hips as well as the muscle activity of the lower extremities. (2) As one descends the foot pressure should shift from the mid foot toward the heel and lateral foot during this loading phase. (5) Toes should remain on the ground to maintain balance (Figure 10). From the lateral view assess if the heel is rising, which may be due to an ankle dorsiflexion limitation of the joint or from overactive gastrocnemius muscles. (18) When assessing from the anterior and posterior view, knee valgus as noted above may be the result of an over pronation problem.

Figure 10

Figure 10

START POSITION KEY POINTS:

  • Arms extended above head
  • Feet shoulder width apart
  • Feet pointing straight
  • Eye gaze is fixed straight ahead

BOTTOM POSITION KEY POINTS:

  • Arms stay straight
  • No excessive forward lean
  • Feet stay pointing straight
  • Heels stay on the ground
  • Knees stay in line with feet

It is of utmost importance that clients are pain free when performing any movement assessment. Refer to the NASM Essentials of Corrective Exercise Training book for recommendations. Part 2 of this article will discuss appropriate corrective exercise intervention strategies based on the movement dysfunctions identified here.

REFERENCES

1)        Escamilla, RF, Fleisig, GS, Zheng, N, Lander, JE, Barrentine, SW, Andrews, JR, Bergemann, BW, and Moorman, CT. Effects of technique variations on knee biomechanics during the squat and leg press. Med Sci Sports Exerc 33: 1552–1566, 2001a.

2)        Schoenfeld, B. 2010. Squatting Kinematics and Kinetics and Their Application to Exercise Performance. Journal of Strength and Conditioning Research 24(12):3497-3506.

3)       Chaudhari, A., et al. 2006. The mechanical consequences of dynamic frontal plane limb alignment for   non-contact ACL injury. Journal of Biomechanics. Volume 39, Issue 2, 2006, Pages 330–338.

4)       Myer, G., et al. 2008. Trunk and Hip Control Neuromuscular Training for the Prevention of Knee Joint Injury. Clin Sports Med 27:425-488.

5)        Myer, G., et al. 2014. The back squat: A proposed assessment of functional deficits and technical factors that limit performance. Strength Cond J. 2014 December 1; 36(6): 4–27.

6)        Clark, M., Lucett, S., Sutton, B. (2014) NASM Essentials of Corrective Exercise Training. Burlington, MA, USA: Jones & Bartlett Learning.

7)        Ruivo, R., et al. 2014. Cervical and shoulder postural assessment of adolescents between 15 and 17 years old and association with upper quadrant pain. Braz J Phys Ther. 2014 July-Aug; 18(4):364-371.

8)        Harman, K., et al. 2005. Effectiveness of an Exercise Program to Improve Forward Head Posture in Normal Adults: A Randomized, Controlled 10-Week Trial. The Journal of Manual & Manipulative Therapy Vol. 13 No. 3, 163- 176.

9)        Quek, J., et al. 2012. Effects of thoracic kyphosis and forward head posture on cervical range of motion in older adults. Manual Therapy 1-7.

10)      Harrison, D., et al. 1998. Elliptical Modeling of the Sagittal Lumbar Lordosis and Segmental Rotation Angles as a Method to Discriminate Between Normal and Low Back Pain Subjects. Journal of Spinal Disorders. Vol. 11(5).

11)      Panjabi, M., White, A. (1990) Clinical Biomechanics of the Spine, Second Edition, USA: LWW.

12)      Callaghan, J., McGill, S. 2000. Intervertebral disc herniation: studies on a porcine model exposed to highly repetitive flexion/extension motion with compressive force. Clinical Biomechanics 16:28-37.

13)      Kavcic, N., et al. 2004. Determining the Stabilizing Role of Individual Torso Muscles During Rehabilitation Exercises. Spine Volume 29, Number 11:1254–1265.

14)      Myer, G., et al. 2004. Rationale and Clinical Techniques for Anterior Cruciate Ligament Injury Prevention Among Female Athletes. Journal of Athletic Training. 39(4):352–364.

15)      Hewett, T., et al. 2010. Understanding and Preventing ACL Injuries: Current Biomechanical and Epidemiologic Considerations – Update 2010. North American Journal of Sports Physical Therapy. Vol. 5(4):234-251.

16)      Fry, A., et al. 2003. Effect of Knee Position on Hip and Knee Torques During the Barbell Squat. Journal of Strength and Conditioning Research, 2003, 17(4), 629–633.

17)      Solomonow, B., et al. 1987. The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability. Am J Sports Med 15: 207–213.

18)      Riddle, D., et al. 2003. Risk Factors for Plantar Fasciitis: A Matched Case-Control Study. The Journal of Bone and Joint Surgery. 85-A(5):872-877.

DAVID CRUZ, DC, CSCS, FMS, SFMA

Dr. David Cruz practiced as a sports chiropractor for 18 years treating athletic injuries, from weekend warriors to professional athletes. He received his bachelor’s of science degree in athletic training and has completed graduate course work in kinesiology. He is a Certified Strength and Conditioning Specialist (CSCS) as well as having both FMS and SFMA certifications. The combination of his background in sports medicine and interest in technology made him passionate about bringing these two worlds closer together, resulting in the foundation of his company WebExercises in 2005.
WebExercises is an end-to-end solution for exercise rehabilitation professionals and is currently integrated with several EHR companies. In addition to WebExercises.com, Dr. Cruz is co-founder and partner of two other software businesses within the health care and technology industry.

5 Exercises to Combat the Negative Effects of Bad Posture

5 Exercises to Combat the Negative Effects of Bad Posture

We all know that our clients are doing good things for their bodies while we are with them, but probably not during the other hours of the week. Especially the prolonged time they potentially spend sitting, now considered detrimental to overall health. We see the effects of this everyday in the form of poor posture, and we continue to overlook it as something benign that naturally occurs over time without consequences. According to the American Journal of Pain Management “Posture effects and moderates every physiological function from breathing to hormonal production. Spinal pain, headache, mood, blood pressure, pulse, and lung capacity are among the functions most easily influenced by posture.” 1 There is also evidence that poor thoracic posture shows “a trend towards greater mortality” as discussed in a study by the Journal of the American Geriatrics Society. 2

Another fairly new risk factor that is starting to become more common is excessive usage of mobile phones, tablets and PCs. Over the past seven years mobile device usage has grown from .3 hours a day to 2.8 hours a day for the average adult. Comparatively, our computer use has remained about the same over the same time period at 2.4 hours per day. 3 A recent article by Kenneth Hansraj, MD, the chief of Spine Surgery at New York Spine Surgery and Rehabilitation, describes that as the head tilts forward its weight effectively goes from 10 to 12 pounds in the neutral position to as much as 60 pounds at 60 degrees of flexion, which is the typical position that we have while using a mobile device. 4

Over time this forward head position leads to ligamentous creep deformation having lasting neurophysiological effects. This was demonstrated with a feline study that found the creep deformation that occurred over the first 30 minutes did not recover with 10 minutes of rest and was present up to seven hours later. 5 The other finding of this research was even more alarming: the primary risk factor was not the load but rather the duration of the load. The implication of this is concerning given we spend an average of 2.8 hours a day using our mobile device.

In addition to the ligamentous deformation, muscle adaptations occur resulting in the Upper Cross Syndrome (UCS) as described by Janda. The UCS is characterized by tightness of the upper trapezius, levator scapula and pectoral muscles along with weakness of the deep cervical flexors and middle to lower trapezius muscles.

As these postural changes occur with the neck and upper body, our lower body becomes susceptible to adaptions as well. These include weakened back muscles as evident in a study by Sanches-Zuriaga that found a decrease in low back muscle activation after soft tissue creep, suggesting that prolonged or repeated flexion could increase the risk of injury. 6 These findings support the fact that prolonged sitting should be interrupted with breaks in order to decrease this risk along with exercise intervention.

For the purpose of this article the focus will be on the Active Subsystem (spinal muscles) as described by Panjabi in his spinal stability system model. The following five exercises can be used for most clients, requiring minimal time and no equipment. These exercises will not only help with preventing the above-described deformation and adaptation risks, but also encourage clients to stand up regularly and perform mini-exercise breaks throughout the day.

We will start with the forward head posture as described by Harman and colleagues who found that this position is associated with weakness of the deep cervical flexor and mid thoracic scapular retraction muscles. 7 Additionally, shortening of the opposing cervical extensors and pectoral muscles was also noted. A combination of strengthening exercises for the deep cervical flexors and scapular retraction muscles coupled with stretching of the cervical extensor and pectoral muscles was performed for 10 weeks. The findings of the study demonstrated that a short, home-based targeted exercise program can improve the postural alignment related to forward head posture.

Based on the above findings, the following three upper body exercises are suggested as they are ‘low-barrier’ homework for clients that they can perform daily without any equipment.

  1. Head Retraction

Begin seated, or standing, looking forward with shoulders back, neutral posture. Activate core muscles. Attempt to draw head directly backwards. Maintain level head position. Do not tilt head up or down. Hold for two seconds. Return to start position. Beginners should start with 3 sets of 10 repetitions.

Head retraction start

Head retraction movement

 

 

 

 

 

 

 

  1. Shoulder Retraction
    Begin standing with good posture. Shoulders should be back and head up. Bend elbows to 90 degrees and keep elbows near sides. While maintaining good posture, draw shoulders back squeezing shoulder blades together. A stretch may be felt in the chest and front of shoulder. Do not allow shoulders to raise upward. Hold for 5-10 seconds. Beginners should start with 3 sets of 5 repetitions.

Scap retraction_1

Scap retraction_2

 

 

 

 

 

 

 

 

  1. Doorway Chest Stretch

Place forearm on wall, or doorway, with elbow bent at 90º. Elbows should be slightly below shoulder level. While maintaining forearm contact, lean body into doorway until gentle stretch is felt in the chest and shoulder. Hold for 20-30 seconds. Beginners should start with 3 repetitions on each side.

Chest Stretch 1Chest Stretch 2

 

 

 

 

 

 

As described earlier, prolonged sitting and its effect on posture is not limited to the upper body alone but also affects the lower body. Tightness of the hip flexors along with an inhibition of the extensor muscles can lead to an aberrant motor pattern know as “gluteal amnesia” according to McGill. 8 He recommends exercises to enhance gluteal muscle function to unload the back in addition to hip flexor mobility with specific psoas muscle targeting.

Here are two very effective and easy to perform exercises that clients can do during short exercise breaks throughout the day.

  1. Standing Hip Flexor Stretch
    Begin standing in front of a chair about 18 inches away. Place one foot flat on the chair seat. Slowly allow hips to glide slightly forward until a gentle stretch is felt on the front of straight leg. Hold for 20-30 seconds. Beginners should aim for 3 sets each per side.

Hip flexor_1Hip flexor_2

 

 

 

 

 

 

 

 

  1. Glute Hip Bridge
    Begin lying on floor, facing up. Bend knees so feet are firmly on floor and arms extended. Activate core muscles. Lift hips off floor to attain a bridge position with knees, hips, and shoulders in alignment. Slowly return to start position. Initially, some cramping in the back of the thigh may develop. A simple hamstring stretch, before and after, may prevent this from occurring. Beginners should aim for 3 sets of 10 repetitions.

Hip bridge_2Hip bridge_2

 

 

 

 

 

 

All of the above exercises are easy to execute and include minimal risks. Most important here is the regular execution and mid- to long-term adherence to the program. A calendar that reminds clients of the exercises and allows them to check off performed sets and reps could be a  motivational tool for them and helps you track their compliance.

 

References

(1) Lennon et al. (1994). Posture and Respiratory Modulation of Autonomic Function, Pain, and Health. American Journal of Pain Management. 4 (36-39).

(2) Kado et al. (2004). Hyper­kyphotic Posture Predicts Mortality in Older Community Dwelling Men and Women: A Prospective Study. Journal of the American Geriatrics Society. Volume 52 (10) 1662.

(3) Bosomworth, D. Mobile Marketing Statistics 2015. Retrieved from: http://www.smartinsights.com/mobile-marketing/mobile-marketing-analytics/mobile-marketing-statistics/

(4) Hansraj, K. (2014). Assessment of Stresses in the Cervical Spine Caused by Posture and Position of the Head. Surg Technol Int. Nov;25:277-9.

(5) Jam, B. (2005). The Neurophysiological Effects of the Creep Phenomenon and its Relation to Mechanical Low Back Pain.

(6) Sanchez-Zuriaga, D. (2010). Is Activation of the Back Muscles Impaired by Creep or Muscle Fatigue? Spine. Vol 35, (5) 517–525.

(7) Harman, K. (2005). Effectiveness of an Exercise Program to Improve Forward Head Posture in Normal Adults: A Randomized, Controlled 10-Week Trial. The Journal of Manual & Manipulative Therapy. Vol. 13 (3) 263-176.

(8) McGill, S. (2010). Core Training: Evidence Translating to Better Performance and Injury Prevention. Strength and Conditioning Journal. Vol. 32 (3) 33-46.