Practical Case Study: Carl's Journey

Where do your initial thoughts lead you in terms of identifying the causes of the issues we observed in Carl's technique?

Myer et al (2015) suggests that deficits (in technique) that are commonly associated with poor squat performance can be categorised as either:

• Neuromuscular – Inefficient muscle recruitment or co-ordination (this is common in new lifters who haven’t had time for their neuromuscular system to hone the new skill).
• Muscular – weakness of certain muscles, strength asymmetry (dominant/non-dominant limb) or joint instability
• Mobility – joint immobility or muscle/tendon tightness

Previously, when trainers encountered poor technique like this, their initial thoughts led them towards issues with recruiting the correct muscles. The general assumption is that if the client spent enough time practicing the movement and received excellent coaching, their technique would significantly improve. It is true that practice and quality instruction are necessary for the client to make the required neuromuscular adaptations for efficient movement.

However, movement impairment can also be a result of soft tissue issues, such as tight muscles and tendons. These issues can impede achieving a full range of motion and lead to compensatory movements, which we identify as technique deficiencies. For instance, tight calves can serve as an example of such a limitation.

Kim et al (2015) reported a significant association between ankle dorsiflexion range of motion and squat depth in their study on 101 subjects. Tight calf muscles are thought to limit ankle dorsiflexion which then causes compensatory movements to achieve desired squat depth.

Wouldn’t it be nice to have a process you could follow to test Carl’s muscle function and get to the root of the issue?

To address and correct structural or functional issues in any exercises, including Carls, you will require the following:

• A comprehensive understanding of the anatomy associated with the joints we focus on. 
• The knowledge of common issues that have potential impact for each joint and how they present. 
• The mastering of a range of general and specific functional muscle and neuromuscular tests, you will be equipped to identify potential causes of these issues. 
• The skills to identify and implement corrective strategies to improve or resolve the identified issues.

It's important to remember that not all issues can be easily resolved. But what if your functional testing doesn't provide a clear answer or identify the cause of the problem?

In such cases, it's possible that you're dealing with a structural issue. Unfortunately, structural issues are more prevalent than you might realise.

The challenge with structural issues is that many of them cannot be fixed or significantly improved. The reality is that some individuals have limitations that prevent them from performing squats with optimal form.

Why can’t we all squat with “proper form”?

We can’t all squat with “proper form” because of our unique structural or functional differences.

“Proper form” is based on the assumption that we are all symmetrical in terms of our body structure. This simply isn’t the case! Trying to get every client to squat in exactly the same way is a very frustrating and ultimately pointless exercise.

While factors like experience with the squatting exercise play a role in the quality of performance, other factors will likely have a larger influence on squat technique in your clients.

This quote from a blog by Building Better Athletes (2016) sums it up nicely…

"I’ve worked with close to a thousand athlete’s and guess what? They all squat differently....and that’s ok. If I work with a group of 20 athletes and had them all squat with a stance of their own preference, to a depth they are all comfortable with, with a toe angle that allows them the most freedom, you know what I would find? 20 different squats with different widths, foot angles, depths, trunk angles, etc"

Let’s research some possible contributing factors to Carl’s squatting woes!

Structural issues

No two skeletal structures are the same. Significant variations exist among individuals regarding the shape, alignment, positioning, and angles of specific bones and joints. As a result, one person's ability to move a joint can be entirely different from another person’s.

Certain joints have a limited range of motion that ends when bones come into contact with each other. The hip joint is an example of such a joint.

When a range of motion (ROM) is restricted due to bone-to-bone contact, it's impossible to increase the range of motion without causing harm to the joint or forcing neighbouring joints to compensate by increasing their movement.

This is often why we observe individuals leaning forward more during squats as they attempt to achieve a deeper position.

Femoral neck angle and tilt differences

The alignment and positioning of the femoral neck and head can vary, leading to different angles and tilts when they insert into the hip socket, known as the acetabulum. It's important to observe the diverse insertion angles of the femoral head and neck into the socket, which can be posterior or anterior, as depicted in the images below. These variations in insertion angles contribute to the unique structure and movement potential of each individual's hip joint.

Click the arrows below the following images for some of these examples.

Zalawadia et al (2010) demonstrated that a difference in posterior (retroversion) or anterior (anteversion) tilt of the femoral neck and head of as much as 24-degrees was common in humans. The following image shows these differences using three different femurs from humans.

According to the authors, individuals with a posterior tilt of their femoral neck may experience an earlier contact between their femoral head and the pelvic bone compared to those with an anterior tilt. As a result, their range of motion becomes more limited, restricting their ability to perform deep squats without resorting to compensatory movements.

Strength and conditioning coach Dean Somerset (2015) suggested that a variance of up to 20 degrees could be the difference in being able to squat to the floor and being forced to stop at above parallel.

Understanding this concept is important because it sheds light on the underlying factors that can affect an individual's squatting ability. By recognising the impact of femoral neck tilt on the range of motion and the potential need for compensatory movements, we can tailor training strategies and exercises to accommodate each client's unique anatomical characteristics. This knowledge allows us to approach squatting techniques with a greater understanding of the factors that may limit or enhance performance, ultimately helping our clients optimise their training outcomes.

Zalawadia et al (2010) also demonstrated that there were also significant differences in the right and left hip structure on the same subject. The following table shows how common these differences are.

Table-2 Distribution of femoral anteversion angle

Angle of Anteversion (In degree)	Female				Male				Total %
	Left		Right		Left		Right
	No.	%	No.	%	No.	%	No.	%
<0	1	3.7	1	4.3	1	4.5	3	15	6.5
-1 to +1	1	3.7	1	4.3	2	9	1	5	5.4
+5 to +10	4	14.8	2	8.6	0	0	2	10	8.6
+10 to +15	3	11.1	3	13	3	13.6	11	55	33.6
+15 to +20	11	40.07	2	8.6	9	40.9	1	5	25
>20	7	25.9	0	0	4	18.1	0	0	11.9
Zalawadia et al (2010)

In the bottom row you can see that 25.9% of the studies female subjects had an anterior tilt of more than 20 degrees in their left hip, but none of them had an anterior tilt to their femoral neck on the right leg. This likely means that these subjects wouldn’t be able to squat with a standard foot position as the neutral position for individual legs would be somewhat different. It would also mean that one hip would reach its limit for hip flexion sooner than the other, causing compensatory measures to achieve full depth.

These compensatory measures could include things like:

• valgus knees, a medial collapse at the knee (caving in)
• a lateral shift towards the leg with a greater range of motion, or 
• increased flexion of the spine.

These are all things that can happen daily with clients in the gym.

Hip Socket and Shape Differences

Laborie et al (2012) noted that anteversion and retroversion aren't strictly contained to the femoral head. It can also be present in the acetabulum (hip socket).

They looked at over 2000 samples of centre-edge angles of the acetabulum and found angles differed from 20.8-45 degrees. The shape of the hip socket will again determine the range of motion the femoral head and neck can achieve without hitting the pelvic bone. Shallower sockets will allow more total range of motion than deep sockets. Those that are deep anteriorly and posteriorly and shallow laterally will mean a person is limited with hip flexion and extension but has a greater range in abduction.

Click the arrows below the following images to view examples of differently shaped hip sockets.

Dr Stuart McGill, considered one of the world’s foremost experts in spinal health, sums this issue up nicely -

"The most important matter on all of this (squat depth) is the depth of the hip socket.....There are groups in the world with very shallow hip sockets (allow greater hip flexion) and some with deep hip sockets (make it difficult for deep hip flexion)."

So, the ability to squat deep with good form seems to be mainly dictated by hip joint structure.

Leg length differences

Another factor to consider, many individuals possess slight differences in leg length! Knutson (2005) looked at leg length and found that about 90% of people have a discrepancy with an average difference of about half a centimetre. If this is a marked difference, it could result in a lateral shift during the squat lift.

In summary, there are issues that you, as a trainer, will have to work around rather than try and fix. Therefore, it makes sense that we will see a range of different techniques used in the gym to accommodate individual issues.

Key takeaways from the anatomical structure in this case study:

• Most of us are asymmetrical.
• Everyone has differences in their hip structure.
• Some people may have actual structural impairments and will never achieve “perfect” form or depth.

According to experts, it is acceptable to deviate from the traditional "proper form" in squats as long as individuals are squatting without pain, maintaining a flat back position, ensuring the bar follows a vertical path, and keeping their knees tracking in line with their toes.

There are some common issues associated with structural limitations and squats. Structural limitations (related to bone structure) are something you cannot change.

Trying to get a client with structural limitations to squat to full depth with “proper form” could cause more harm than good.

If you don’t have the hip structure for squatting low, you will eventually pay the price for trying. Common issues resulting from this include:

• Femoroacetabular (Cam) impingement
• Pincer lesions (callus formation on the pelvic bone)
• Labral tears
• Sacro Iliac joint pain

Let's learn more.

Femoroacetabular (Cam) impingement

The femoral head changes shape and grinds against the socket causing irritation of the labrum (a layer of soft tissue that sits between the femoral head and the socket). This video shows the mechanism of hip impingement and the issues it causes.

Pincer lesions (callus formation on the pelvic bone)

Caused by bone-on-bone contact and the body laying down additional calcium deposits as protection. These may need to be surgically removed and can restrict movement altogether.

Labral tears

Tearing of the soft tissue labrum due to grinding of the femoral head into the socket.

Sacro Iliac joint pain

These are from compensatory movements (particularly excessive forward bend or lateral shift during lift).

The video from Hopkins Medicine gives a comprehensive view of hip impingement. It illustrates clearly how hip impingement is caused, its symptoms and treatments.

How common is this issue?

Fabricant et al (2015) found 37% of asymptomatic individuals (no symptoms) had significant markers of hip impingement. (54.8% in athletes).

Morgan et al (n.d) showed that 47% of people who suffered from SI joint pain had deep hip sockets and impingement.

Ok, so we have established the multiple causes that could be associated with Carl’s poor squat form. He may have a structural limitation, like deep hip sockets. He may have:

• a functional issue like tight calves
• a neuromuscular issue like poor recruitment of key muscles required to squat (e.g. gluteals).

Once we are aware of the possible contributing factors, we need to try and narrow things down a little. Luckily, the experts in our field have developed a range of tests that we, as trainers can use to try and isolate the key factors contributing to poor technique.

Let’s look at a few broad tests related to squatting that can help identify solutions for Carl’s issue. You can use these to begin practicing early on in your learning.

More importantly, these tests can be performed on clients in the gym to immediately optimise their squatting stance and approach given their current issues (i.e. workarounds).

Let’s take a look at the following three tests.

Supported Squat Test: Tests hip flexion range of motion in the squat

This method offers a simple way to determine a client's ideal squat stance and depth while working around their current limitations. By conducting a supported squat test, you can identify the key factors contributing to their issues. This test will help you find their optimal stance and depth, ensuring their back position remains uncompromised during squat exercises.

For some clients, this may mean they can only achieve a parallel squat position or even slightly above parallel. This is perfectly fine and indicates limited hip flexion ability, a structural limitation. The primary goal is to identify a safe range of motion for the client to work within.

Note: It's important to note that the foot positions attained during this test may differ for each client. Remember, this variation can be attributed to the inherent differences in hip structure within individuals, as we have previously learned.

The Hip extension mobility test/ The hip bridge test

This test is designed to assess a client’s ability to extend their hips and their range of motion. The inability to extend the hips may come down to poor recruitment or strength of the gluteal muscles. In squatting, if the gluteals are not firing properly or they are weak, the lower back is often used as a compensatory source of force, and this can lead to back pain.

The Goalie Stretch: Tests lateral hip range of motion

This test assesses a lateral range of motion at the hip. This is a useful test to help determine how wide your stance for squats should be. If a client can achieve considerable range in this movement, it would suggest that their hip socket is shallow laterally, allowing for greater mobility in this plane. If their socket is deeper anteriorly and posteriorly, they will likely find it easier to achieve deeper hip flexion and therefore squat depth with a wider stance.

These three tests can give you a lot of information about a client in a short time:

• What position gives your client the best squat depth (i.e. what is the limit of their ability to go into hip flexion)
• How much hip extension they have (indicative of mobility and gluteal function/strength)
• How much lateral mobility they have.

From this, you can determine whether they have a lot of mobility, a specific directional limitation, or are generally limited in hip mobility. It will also help you determine a squatting stance allowing them to squat safely.

Analysing your tests

Here is a useful way of analysing the results of the three tests and what they mean for you and your clients.

1. Suppose your client struggles with all three tests (i.e. they have low flexion, extension and lateral movement). This means that, likely, achieving depth with good form will always be an issue for your client. Doing partial squats to a box may be their reality.
2. If the test show that your client has good flexion but low extension and lateral movement.

While clients should be able to perform squats effectively, it is possible for them to experience issues where their back becomes excessively engaged during exercises. Shoulder width stance will be fine for your client, but going wider than this will probably cause some lateral hip discomfort.

1. If your client's results indicate that they have good flexion, low extension, and good lateral movement.
   They can pick their squat stance from a wide array of possibilities and still squat to good depth without compromising their back position.
2. If your client has low flexion, low extension, and high lateral movement.
   They can squat deep but need a wider stance to maintain their back position. If they try to squat with a slightly wider than shoulder width, they will lose their ability to squat to depth without compromising back position.
3. On the other hand, if the three tests showed your client had great flexion, high extension and lateral movement, and very mobile hips!
   Your client can pretty much adopt any stance they like (including very narrow stances) and will have no problem achieving good depth while maintaining form.

Analysing the Overhead Squat test

Another broad testing tool that can be used to identify factors contributing to squat performance is the overhead squat test. This testing tool is actually a subjective screening tool that trainers commonly use to assess total body dynamic posture while squatting.

The test is designed to identify compensatory movements and helps a trainer identify muscle imbalances (over or under-active muscles). The test comes complete with a solutions table that suggests which muscles are over or under-active and offers targeted solution exercises to combat these.

To conduct the overhead squat test, you will need to take three photos (anterior, lateral and posterior) of a client adopting the overhead squat position indicated in the following images:

See the following process and steps:

1. Collecting the data
   Conduct a meaningful warm-up with the client. Ask the client to remove their shoes, as different types of shoes can shift your weight in certain directions (often forward). It is also important that you can assess how the ankle and foot behave during the testing. Your instructions should be kept simple, and a demonstration of the movement you are looking for is a good idea.
   Instruct the client to...
   1. raise their arms straight above their head (upper arms next to ears) and attempt to hold them in that position throughout the test.
   2. squat as low as they feel comfortable for a few repetitions. If you suspect the client is not performing the movement well due to unfamiliarity with the movement, you may offer coaching and cues.
   3. perform the movement to the bottom of the squat and hold the position (for a picture to be taken at the bottom of the movement/lowest point of squat).
   4. turn 90 degrees and repeat the task twice more to get the lateral and posterior views (Note:  you can also take a video of the movement and pause the video for scoring/analysis).
2. Evaluating the data
   You will now evaluate the client’s overhead squat from the three different points of view and compare the client’s performance of the movement against the ‘Overhead Squat Solutions Table’ (National Academy of Sports Medicine)
3. Observable common issues
   The following images depict some compensations you might see when your client performs their overhead squat

Click the arrows below the following images to identify where compensations can be seen during an overhead squat.

4. Evaluation and Correction
Once you have identified the probable issues causing compensation movements, the NASC Solutions Table offers corrective strategies employing the stretch-strength hypothesis (i.e. stretches for the tight muscles, strengthening exercises for the weak muscles).  Note: These corrective strategies will be useful in improving functional muscle imbalance but will have no effect if structural issues are present).

 

Let’s continue to learn more into the fascinating world of joint anatomy and common issues related to exercise. Understanding these details is crucial for your journey as a personal trainer. If you enjoyed exploring the functional tests we've covered so far, get ready for more! These tests will set you apart from other trainers, helping you pinpoint the likely causes of your clients' issues. But that's not all. We'll also equip you with corrective strategies to address, improve, or even eliminate these issues. It's an exciting journey of knowledge and practical skills that will empower you in your training career. Let's Get started!