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Integrated Care - Part VI: Getting Everyone To Squat

 

by Art Horne

Since squatting and the decision to squat or not comes up more often than any other subject when it comes to sports medicine and performance professionals, we decided to tackle this subject head on in this latest post.  Everyone should be able to squat - there I said it. So whether you'll be teaching it after surgery, or training it in the weight room it's important that the beliefs and concepts that you have pertaining to the squat is the same as those that you work with in order to achieve the highest level of athlete success. 

Below is an outline which we have used in a staff journal club to finalize our teaching progressions and teaching cues for the squat pattern while also getting everyone on the same page and on board with the importance of squatting.

sports medicine

 

Squat Goal: all athletes should be constantly working towards a score of three on their OH Squat test. Whether they initially present to Sports Medicine with back, knee, hip or other LE injury or pain, all care and performance training providers should be able to look at this movement pattern and address any movement concerns IN ADDITION to their traditional rehab or performance program regardless of initial pain or injury presentation.

FMS Squat Test:  see functionalmovement.com  for complete details
(Have a staff member certified or familiar with the FMS review testing criteria, followed by staff members from both staff’s testing and evaluating each other).

 

What if the student-athlete describes PAIN during the squat test?

 

sports medicine

 

Only qualified medical professionals should deal with pain and painful movement patterns.  If a student-athlete experiences pain they should be referred to the athletic trainer coordinating their care at the college level or another health care professional if you are working in the private sector.  Although many “painful” maneuvers are often neglected and played down by the student-athlete, seldom do those with pain during a simple bodyweight squat ever go on to compete at a high level without future injury and time loss.

Since PAIN is complicated, multifactorial and often unpredictable, a painful pattern should be “broken down” to its component parts so to find the underlying pain generator or limiting factor.  The Selective Functional Movement Assessment TM offers health care providers a systematic approach and a common movement language among all staff members.

(Have a staff member certified or familiar with the SFMA squat breakout present this algorithm to the remainder of your staff and then follow up by having individuals from both groups evaluate each other while identifying the limiting factor within each individual’s squat pattern.


SFMA Squat Breakout:


1. Overhead deep squatting pattern

2. Fingers interlocked behind neck into deep squat position
a. This position lowers the difficulty by not having the shoulders flexed vertical
b. Removes the upper body components and reduces the level of dynamic stability needed to perform the squat.

3. Assisted Squat from ATC into deep squat
a. Athlete holds hands of evaluator while performing squat.
b. Looks at the true symmetrical mobility of the lower body (hips, knees, ankles) without the requirement of dynamic stability.

4. Half kneeling Dorsi-flexion (test for ankle ROM)
a. Place foot on weight bench and lean forward over the foot as far as possible without the heel coming off the bench.
b. The knee should move forward out past the toes at around 4 inches.
c. Repeat for both sides.

5. Supine Knees-to-chest – test for anatomical limitations at hip in non-weight bearing position.
a. Looks at mobility of the hips, knees and spine in a non-weight bearing position.
b. Can help differentiate a mobility vs. stability problem
c. Have the patient grab both shins and attempt to touch their thighs to their lower rib cage.
d. If they can’t get their calves to touch their thighs due to knee tightness, have them grab their thigh instead and repeat thin maneuver. (This will help differentiate between hip and knee mobility issues. If in this position they still can’t get their thighs to touch their rib cage, then there is a potential hip dysfunction).


What’s Next?

Since so many of us sit on our butts all day it’s no surprise that our butts are rarely working to the level they should be. 

(Unless of course you use your butt for a simple paper weight – then your butt works just fine).

Because the squat is the end goal for all athletes in terms of both health and performance, it’s important for athletic trainers and other health care professionals to begin grooving this pattern early on in the rehabilitation process so that there is not only a seamless transition from one Sports Medicine to Performance Training, but also a clear message when it comes to cueing and technique among all professionals on staff.  In order to have everyone speaking the same squat language, starting everyone back on the ground and building a solid and logical progression from post-surgical all the way to high performance only makes sense while the entire staff is playing nice together.

Below is a starting point with a few teaching cues to get the conversation started and a solid progression built between the two groups.   (I have purposefully not included a complete progression below so to force the issue with your own staff.  People tend to complete tasks fully if they have had an opportunity to contribute to so be sure to ask for feedback from both staffs – Sports Medicine and Strength & Conditioning).

 

Back to Basics: (Supine Table Series)


1. Teach Glute Max w/ Bridge
2. Supine Bridge w/ Thera-band
3. Supine Bridge w/ Marching
4. Single Leg Hip Bridge


Teaching Points:


a. Squeeze Glutes to hold “gold coin” between butt cheeks or pretend to “crack a walnut” while bridging
b. brace core musculature as taught by Stu McGill
c. Ensure hamstrings are not dominate during exercise by palpating medial tendons.
d. Add a theraband around knees or create an ADDuction force to the knees to facilitate additional glute max contraction


– NEVER PLACE A BALL BETWEEN THE KNEES!


Teaching Progression for the Troubled Squat

 

gobletsquat

 


1. Goblet Squat: hold Kettlebell by the horns and squat to depth (providing a weight to the anterior portion of body balances the athlete and gives an additional point of stability

2. Descend squat so that elbows touch VMO of each knee.

3. If depth is a problem “wedge” elbows inside of knees to mobilize the hips.

4. In the early stages be sure to stand behind your athlete to ensure safety – encourage thoracic extension and a flat back

5. ** use clinical judgment based on patient presentation and injury. If unsure, REGRESS activity and PERFECT – OWN THE MOVEMENT before progressing to more advanced alternatives.

 


READ:  Squatting - An Expression Of Health

 

Next week: Bringing both staffs together to learn and master the hip hinge – a must for avoiding and rehabilitating back pain and also pulling big deadlift numbers!

 

 

Integrated Care - Part III: Breaking Down Extension Based Problems

by Art Horne

 

Although identifying a poorly executed squat is easy for many sports medicine and strength professionals (especially given the “rules” and guidelines set forth by the FMS standards), identifying the actual underlying problem or major contributor to a deficit squat is never as easy.  However, with a systems based approach during your annual pre-participation screenings your team of health care and performance professionals can tease out these often overlooked deficiencies as part of your movement screen from the very beginning instead of reacting after future injury or poor performance.

As I mentioned in a prior post the ability to express a proper squat pattern is fundamental to human movement.  Included in this category of fundamental “expressions” is the overhead reach, or what is commonly known through the Selective Functional Movement Screen TM (SFMA) as the Multi-segmental Extension Pattern (MSE) pictured below (figure1).  This easy test that takes literally 10 seconds can produce some startling results when athletes and those observing them, witness an otherwise “healthy”  and  highly skilled athlete in the prime of their life unable to reach behind them while shifting their weight and hips forward. 

 

 

functional movement screen

figure 1.

 

Let’s break it down.


According to the SFMATM rules, or simple human movement fundamentals, normal range of motion during this test includes:

1. With heels together (this is important and often overlooked as it provides a test-retest standardization) an athlete or patient should be able to have their ASIS pass over their great toes while;

2. Reaching overhead with hands in line with their shoulders and have the spine of their scapula clear or pass behind the heels of their feet and;

3. Their hands clear or pass behind the spine of the scapula (Figure 2).

 

 

functional movement

figure 2.


These movement minimums allow clinicians and performance coaches a starting point to begin observing their athletes for general restrictions within this pattern.  If an athlete is unable to complete this movement (failure to pass the ASIS over the great toe) then the athlete is asked to cross their arms over their chest and repeat the movement.  If the athlete is unable to still exhibit this fundamental expression of extension then the athlete in my opinion should be referred to a staff athletic trainer for further evaluation with the underlying problem is identified and addressed.  Many times the athlete will not understand why they are being referred since they have never had a “problem” before, but after a quick evaluation and treatment you’ll often find their eyes beam wide open with the additional range and freedom of motion that you’ve given back to them.

To confirm your findings on the examination table (although authentic human movement rarely ever happens on an exam table. Side note: How come you can measure with a goniometer an athlete’s ankle, knee and hip range of motion on an examination table and determine that they have the requisite mobility to perform a normal and unrestricted squat pattern but when you stand them up, the pattern looks like a train wreck? Movement means so much more than just your standard orthopedic examinations), have the athlete lay prone and ask them to tighten up one butt check and extend their leg off the table.  Repeat with the opposite leg and compare.  Rarely will an athlete be able to exhibit the appropriate amount of hip extension during this prone table test and not be able to pass their ASIS over their toes during the standing evaluation with arms crossed over head.

So what’s next? How do I fix it?

Not so fast.  I think it’s worth mentioning here a few items that support adding this simple test into both your yearly screenings along with your general orthopedic examination (regardless of injury presentation).  First off, I have been utilizing the FMSTM screen for a very long time as a strength coach, and over the last year have been utilizing the SFMATM methodology during injury presentation in the clinic and the overwhelming end result to many movement dysfunction and injury/pain cases have always boiled down to two movement impairments – Shoulder Mobility (Which in the end really is T-Spine Mobility) and Hip Extension.  The FMSTM  includes a test called the Active Straight Leg Raise, and this test unfortunately has been deemed a “hamstring” flexibility test or a hip flexion test by most casual observers but this couldn’t be further from the truth or the original intent of the test (future post coming: Are your hamstrings tight or are they just not letting you go somewhere you have no business being?).

For those that are not familiar with the test, an athlete lays on their back with a 2x6 board under their knees and while keeping the bottom leg in contact with the board slowly raises an extended leg upwards exhibiting the DIFFERENCE and available motion between the two legs and NOT the amount of hamstring or hip flexion range that you have.  It is this DIFFERENCE that should be noted, which ultimately leads to an examination and treatment focus of the down-leg in most instances as I mentioned earlier as the limiting factor (hip extension).

This should really come as no surprise since we have clearly become a hip flexion dominant society (sitting at computers, video games, etc not to mention our affinity for sitting on bikes at the commercial gym and watching the TV screen instead of sprinting on an incline treadmill which of course requires a bit of hard work and the aforementioned hip extension) and have basically lost the ability to “express” hip extension.  Although strength coaches and sports medicine professionals alike advocate “stretching” this problematic area after injury I think it’s worth teasing out your future patients sooner than later with a simple test while they are healthy athletes and avoid their inevitable future visit to your sports medicine clinic as patients.

 

Next week: Addressing and Correcting this Hip Extension Problem from both sides of the wall.

 

 

Integrated Care - Assessment and Intervention

by Art Horne

 

At the college level many times both assessment and intervention decisions are made based on time availability and simple manpower, and not on what the student-athlete requires for optimal health and performance.  Juggling study hall, practice, classes along with rehabilitation and performance training leaves little time for “additional” work for either the student-athlete or the staff professional in charge to provide additional auxiliary services in the form of corrective work, soft tissue manipulation or additional strength training.  With that said, this extra “work” is often neglected or pushed aside until either the student-athlete is no longer able to participate in practices or games due to an injury or becomes crippled due to some form of debilitating pain.  In either case, unfortunately the student-athlete has now become a student-athlete-patient within your facility and the little time you had to address her problem prior (which of course is why it wasn’t taken care of in the first place, or even looked at – ignorance is bliss after all) has now become a major investment and drain on your time and services. 

In order to avoid the initial trap that so many sports medicine and performance departments fall into each fall it is paramount that both departments (Sports Medicine and Strength Training) first reach an agreement to implement a comprehensive screening program TOGETHER to tease out dysfunction, evaluate for painful movement patterns and address these minor “tweaks” before they become major pains.

 

athletic training

 

Where to start:


It’s hard to rank which movement pattern is more important over another as each of the “Big Three” (squat, lunge and step) are all integrated and hold value within the context of all sporting events and training.  However, the only pattern among the three that is universally tested among college athletes and Strength Coaches is the squat, and thus, at least with regards to an integrated approach takes precedent over the others if having to choose only one.  Administering the test takes under a minute and produces so much more than just a number via the traditional FMS scoring system.


1. There’s something powerful about having members of both your sports medicine and strength staffs stand beside each other while evaluating a student-athletes overhead squat pattern during a fall pre-participation examination.  Because the strength coaches typically tests each athlete’s squat either later the same day or the next, this “pre-screening” allows strength coaches to see the movement pattern in an authentic form, not to mention in a rare one-on-one format which is never the case in a collegiate weight room due to traditional low coach to student ratios. 

2. When an athlete scores a “1” which means they cannot achieve a proper squat, it’s always nice to see the strength coach cross the name off the list of kids to max test later that day.  If you cannot squat to at least a “2” in the FMS overhead squat test then you simply haven’t qualified to load the pattern and go balls to the wall during testing – PERIOD.  This will sometimes be an issue among sports medicine professionals and strength coaches if the athletic trainer simply tells the strength coach that the athlete shouldn’t squat; but this is never a problem when the strength coach sees for themselves the awful pattern that the student-athlete exhibits.  The strength staff must be involved in your yearly pre-participation screenings to ensure buy in from all those involved in the care and performance of the student-athletes.  Remember: squatting is not a weight room exercise, it’s an expression of health, and allowing a student-athlete to max test a pattern that they cannot perform with their own body weight is simply irresponsible – PERIOD.

3. So, with that said, what do you do with the kid that scores a “1” on the FMS overhead squat test? As we discussed prior, time is of the essence and thus the underlying deficiency needs to be “teased out” and an appropriate intervention applied.  Both the FMS and The Selective Functional Movement Screen (SFMA) allows the clinician and/or strength coach an easy algorithm to follow with suggestions for corrective  work once the underlying deficiency is discovered.  Often times it’s the usual mobility suspects – t-spine, hips and ankle but just as often, these mobility issues requires a skilled clinician’s assessment and intervention.  On the flip side, in the case of a neuromuscular-stability issue a Goblet squat progression can be implemented by a strength coach during a training time in place of the squat, to begin coaching them back towards their end goal of a “3” or at least a “2” prior to max testing. (more on Goblet squat progression in a future post)

4. For all those athletes that score a “0” during the test – which means they experience pain, a comprehensive follow up evaluation is scheduled either later that day or within the week by a skilled clinician, (most likely a member of your Sports Medicine Staff) to determine the pain generator along with a rehabilitation plan to properly address.  So many times athletes will state that they have no pain on intake but then suddenly realize that during a simple movement that pain is actually present.  I’ve never had an athlete experience pain during a simple movement test (“It’s not a big deal, I just put ice on it after I train”) not miss time during preseason due to this pain or another greater underlying problem.

 

Now, some would say that when evaluating the overhead squat pattern utilizing the FMS scoring criteria that we basically all fall in as a “2” and that only a very few athletes score a “1” or a “3” and therefore  the test may be a waste of time.  Although it is true that the majority of athletes that I’ve evaluated using this methodology score a “2”, the means certainly justify the end, especially when you’ve i. discovered pain in this simple pattern and were able to treat it immediately and ii. Discovered a poor movement pattern and provided corrections which over time allowed the athlete to squat normally (which always makes the strength guys happy) but most importantly allows the athlete to achieve success in their individual sport – the reason they showed up in August for pre-season in the first place.  In the end, the OH squat test really only takes a minute but the effects of this evaluation and correction last throughout their college career.


Next week we will talk about evaluating the Multi-segmental Extension Pattern and what to do when you find a problem.

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