The squatting pattern is considered, by many health and fitness professionals, a fundamental human movement. Therefore, the ability to assess the squat is an essential skill for physical therapists. The squat is performed, in some capacity, during numerous daily activities, such as picking objects up from the floor or simply transferring from sit to stand (and vice versa). In cultures where chairs are not common place, the squat is often considered a position of rest. Developing a keen eye for squat dysfunctions will make you a better physical therapist.
Of course, the ability to squat to a position at or below parallel can be dependent on many factors, including, but not limited to, injury history, anatomical structure/genetics, and past athletic/training history. If your patient is not active, the need to develop the ability to squat below parallel may not be the top priority.
However, if you are working with athletes whose sport specific skills require a deep squat (Olympic style weightlifting, powerlifting, or Crossfit), or their training regimens include deep squatting, then the clinical significance of screening and improving this pattern is of greater significance. Many strength and conditioning programs load the squatting pattern with high frequency, making the ability to accurately assess the squat crucial. As noted by physical therapists such as Gray Cook, loading a movement pattern is like hitting the “save” button in our nervous system. If you load a less than optimal movement pattern, you are simply adding capacity to dysfunction.
This article will outline a simple protocol that clinicians can use to assess an athlete’s capacity to perform a squat. Our goal is to help you learn to assess the squat with improved accuracy. To do this, we will use a “top-down” approach, in which we look at multi-joint patterns in standing, then slowly regress the position and narrow the focus to the specific joints involved. Throughout the protocol, the clinician’s goal is to differentiate between true joint restriction or motor control deficits. In other words, we must ask ourselves,
"are we seeing a less than optimal squatting pattern because the athlete’s joints do not possess the adequate range of motion on a structural level, or does the joint structure possess the adequate range but the athlete does not possess the ability (strength, stability, or motor control) to express their mobility potential?"
Assess the Squat
We will define mobility as "the ability of a joint system or muscular system to move through its full range of motion." "Movement potential" is another way to describe this. For example, does an athlete possess sufficient length of the heel cord and joint mechanics of the ankle in order to attain adequate dorsiflexion when squatting? Does the athlete’s hip joint possess passive flexion past 90 degrees comfortably?
Stability can be defined as a joint or muscular system’s ability to control the mobility that it possesses, and can be static or dynamic. For example, static stability of the trunk when squatting is required to keep the spine relatively motionless, even though movement is happening elsewhere at the hips, knees, & ankles. Dynamic stability of the hip joint is needed to control the relationship between the acetabulum and femur in order to achieve full depth in the squat without impingement. Stability is largely regulated by the neuromuscular system, which is considered “active stability”.
“Passive stability” can be described as gaining leverage in a movement by using non-contractile tissues such as bony approximation, joint capsules, or ligaments. Someone who just seems to “hang on his or her ligaments” may rely on passive stabilizers. This may or may not lead to problems down the road, but it’s important to note that we need a combination of both passive and active stabilizers to squat heavy loads.
As previously mentioned, the assessment can help to differentiate these things for you.
I am not addressing interventions for pain in this article. If you're not a physical therapist and pain is noted, please refer the client to the appropriate health care professional, like a PT. :)
The Overhead Squat
This movement is context dependent, but the overhead squat is a great place to start our assessment. It requires an integration of the entire body and gives the assessor a broad picture of the athlete’s movement capabilities. For those familiar with the Functional Movement Screen, this is included in that protocol, as well.
- Hand placement should be at a width that results in the dowel resting at or just below the hip crease.
- Have the athlete barefoot, if possible, with feet roughly shoulder width apart. Allow for whatever degree of toe-out they wish. Some degree of toe-out is normal for most in regards to squat biomechanics. Allowing the athlete some freedom here gives the clinician an idea of movement preference. A toes-forward squat may yield many false positives in regards to dysfunctional patterning, as that is not conducive to the majority of hip structures (contrary to popular belief.)
- Raise dowel overhead, directly above upper back.
- Instruct the athlete: “keeping feet flat and upper body as motionless as possible, squat as deep as you can.”
What we are watching for:
- Dowel Position - we want the dowel to stay within the plane of the foot, indicating the ability to integrate the upper and lower body. If the bar comes forward past the toes, we could be looking at upper quarter restriction or a motor control issue (we will assess the upper quarter in more depth in a subsequent article.)
- Spinal Angle – we are looking for minimal motion in the spine throughout the movement. Where it starts, it stays.
- Depth – we are looking for the athlete to demonstrate the ability to squat below 90 degrees.
- Foot Position – we are looking for any change in foot position throughout the movement. Where the feet start, they should stay.
- Knee position – we are looking for the knees to track in the same plane from start to finish. Make note of any clear valgus or varus deviation.
Refrain from guessing at this point. If an athlete can drop into an effortless, barefoot overhead squat, this will give you a general idea that your interventions may not need to be “mobility” focused.
Overhead Squat with Elevated Heels
If you deemed the previous test to be dysfunctional based on the criteria, this is your next step.
Elevating the heels does 2 things:
- Provides the athlete with a surplus of ankle dorsiflexion, essentially taking any ankle joint restriction out of the equation
- Gives the athlete an anterior weight shift (a counter-balance), which makes it much easier to sit straight down without falling backwards.
Follow the exact same steps as the previous overhead squat test.
This is where the assessor may jump to the conclusion of ankle mobility being the limiting factor. However, this is a potential mistake. Remember, you have not assessed the ankles yet. As we mentioned, elevating the heels also gives the athlete a counterbalance. Ideally, our pelvic floor, abdominals, diaphragm (our core), should act as our natural “counter-balance”. We could still be dealing with a motor control issue.
Ankle Dorsiflexion (Closed-Chain)
This is where we stray from our “top-down” approach. I find that the faster we rule in or rule out the ankle as a limiting factor, the more accurate our thought process becomes.
For best carryover to the squat, we will screen ankle dorsiflexion in the closed-chain, with the foot fixed to the ground. Refer to the video below for the test:
The foot should be ~4 inches away from the wall (or the width or a fist), and is tested bilaterally. This position should yield approximately 20 degrees of closed-chain dorsiflexion, which is more than adequate for a deep squat (limb length in consideration, of course). This is especially true for any athletes that wear shoes with an elevated heel when they squat. Asymmetries of greater than half an inch will likely point you toward a focused area of mobility, especially if coupled with past history of injury to that side.
The picture should start coming together at this point, in regards to the athlete's movement capabilities.
To assess the squat further, we take out the overhead component. If we are still unclear where the limitations are coming from, this should provide a clearer picture.
The cues are exactly the same as the overhead squat, minus the arms being overhead. They can be wherever the athlete feels comfortable.
Is the pattern more fluid, comfortable, and/or functional? Did the athlete reach adequate depth, along with the other criteria mentioned above, to your satisfaction? Well, then you are beginning to clear the lower body of true mobility restrictions, but have identified the athlete’s inability to integrate the upper half. The upper quarter assessment will come in a subsequent article.
Air Squat with Elevated Heels
This relies on the same concept as the heels-elevated overhead squat. Now, we are determining whether or not the athlete can tolerate a deep squat position at all. Coupled with what you found in the ankle screen, you should have an idea of general joint capacity.
This “test” is also a great correction, and can be interchanged with the air squat tests above. Holding a kettlebell in front is another form of counterbalance. You may find that an athlete’s air squat is less than optimal, yet when you give them a weight to hold, their joints have been given magic mobility. As we know, what has really happened is the athlete has been provided external stability. In any case, it gives you a great idea of their joint’s mobility potential and capacity, and may be your first stop in re-training the squat.
Quadruped Rocking with Rotation Bias
We now move to more specific hip joint testing to determine the stance width and degree of hip rotation that is optimal and most comfortable for the individual athlete.
The use of developmental positions (supine, sidelying, quadruped, half kneeling, etc) can be a very effective way to both assess and improve movement. In this case, quadruped resembles a squat, but affords the athlete much more external stability (the floor and a lower center of gravity). This allows the assessor to manipulate specific variables in regards to hip position.
After performing the above screen, you should now have a more specific idea as to what "type" of squatter the athlete will be (wide, narrow, toe-out, toes forward, etc). At this point, it's not a bad idea to return to the goblet squat described above, and begin integrating what was found during the quadruped squat into the standing squat. Alternating back and forth between quadruped squatting and goblet or air squatting (with or without elevated heels) is a great way to teach and reinforce what the athlete should "feel".
Supine Hip PROM
Lastly, the assessor can truly get a feel for the athlete's hip structure, by manually assessing passive range of motion. The findings here should, theoretically, confirm what has been seen in previous testing. By manually assessing ROM, the positions of the hip joints yielding the greatest mobility can be pinpointed, further tuning individual squat stance. Here is a video of such a screen:
This is, of course, simply an overview of how one can screen and assess the squatting pattern of an athlete; this is not a comprehensive or definitive guide. However, the concept of differentiating between true mobility restriction and motor control can potentially save the clinician and athlete time and effort, in regards to the corrective strategies implemented.