You don’t know squat? …teaching your patients proper squatting technique

On past posts I have discussed the topic of performing the proper squat in the context of conditioning:

– Squatting isn’t hurting your knees…your technique is

– The Adductor Magnus and its role in Squatting: Part 1 – Anatomy

– The Adductor Magnus and its role in Squatting: Part II – Issues of form, strength, and safety

– The Adductor Magnus and its role in Squatting: Part III – Errors in Form

However, as important as performing proper squats in the gym is for strength development, I cannot stress enough the importance of teaching proper squatting technique to patients suffering from chronic knee pain, hip pain, or who are undergoing post surgical rehab on the pelvis or lower limbs.  This post outlines some of the key points that should be emphasized when teaching the standard bodyweight squat to lay persons/patients.

***As an aside, I am amazed at how many times I have patient demonstrate their squatting technique that has been shown to them by their previous therapists and/or trainers, only to see a technique that will surely cause more harm than good.***

1.  Foot & Knee position –

Figure 1: Proper foot position

Instruct the patient to stand with their feet approximately shoulder width apart, and their feet angled outwards approximately 30 degrees (Figure 1).  During the performance of the squat, the patient must ensure that the knees stay in line with the toes at all times.  This is to ensure that enough subtalar pronation is able to occur in order to achieve proper squat depth. If the feet are not angled outwards, dorsiflexion of the ankle will be limited at the ankle mortise joint (due to the larger anterior half of the talus) which will prevent the proper depth from being achieved.  If the proper depth is not achieved…as is the case with the dreaded (and heavily over-perscribed ‘partial squats’) there will be a quadricep dominant contraction which will cause shearing in the knee.  When performed properly, and to the proper depth, there is a counter contraction of the hamstrings which will negate the quad contraction, thus effectively guarding against shearing forces.  In addition, proper depth will engage the large gluteal muscles.  Further to the stress on the knees, the ‘feet forward’ position will force the person to lean anteriorly thus shifting the weight away from the centre of balance (the weight should remain in line with the midfoot).  This in turn causes incorrect back, hip, and knee angles that will lead to damaging shearing forces in each area (See point #2) (Figure 2).  As for the knees, if they do not track in line with the feet, but instead  travele anteriorly, this will in effect increase the Q-angle (the angle formed by a line drawn from the ASIS to central patella and a second line drawn from central patella to tibial tubercle) which leads to an abnormal laterality of patellar tracking (thus leading to patellofemoral problems).

2.  Spinal position – 

It is very common for people to be instructed to ‘look up’ and ‘keep your chest up’ during the squat…..I think this advice came out of an imaginary ‘righting reflex’ which is supposed to occur when the eyes look up and the neck is extended (although I have never been able to find any literature even coming close to proving this!).  Attempting to maintain this position causes the centre of mass to shift forward.  This shift must be counter balanced in order to keep the body from falling forward.  This leads to the knees tracking anteriorly over the toes (see point 1), excessive cervical lordosis, and the creation of an extension moment at the TL junction.  This extension moment causes what I refer to as “Bad squatters syndrome” which is characterized by excessive erector development at the TL junction accompanied by chronic TL pain.(Figure 2).

***of note, it is this incorrect position which often causes the persons heels to raise off the floor during the squat.  I see some people in the gym actually placing plates under their heels in order to compensate!!!  Rule of thumb, when squatting, if you are feeling off balanced, it is better to feel that you have to fall backward rather than forward.

Figure 2: Incorrect position - excessive neck extension, excessive TL extension, feet tracking over the toes, 'target' situated between the legs

During the squat, the spine should maintain a neutral posture (including the neck) and should flex forward at the hip as a solid unit.  Thus, due to hip flexion, the head and spine should bend forward during the squat with the hip being the hinge (Figure 3).

3.  The ‘target’ – 

It is important to understand the following concept, when performing a squat, it must appear that you are attempting to SIT back into a chair (‘target’) that is situated approximately 2 feet behind you (figure 3), not one that is located between your legs (figure 2).  This will ensure that you achieve the proper spine to thigh, and thigh to leg angle – which should keep your weight centred on your mid foot and your heel down.

4.  Coaching –

When teaching the squat to a non-athletic patient, or an athletic patient who has been shown the movement incorrectly (ie. 99% of all gym goers), I always begin with a ‘box squat’….or ‘chair squat’ if you are instructing in your treatment office.  I also insist that the patient begin with NO WEIGHT.  You will note that in order to learn the correct movement, body weight will be a challenge even for your more athletic patients.  It is my modo regarding training/rehab that “if you can’t control your body weight, you have no business trying to move external weight.”

Here are the most important coaching points to use (Figure 3):

I.  Stand approximately 1-2 feet in front of a chair or stool with your feet shoulder width apart and turned out 30 degrees (Fig 3a)

II.  Place your arms straight in front of you – this will help with the initial difficulty of counter balancing the persons weight as they get used to sitting back towards their ‘target’ (stool) (Fig 3a)

III.  Pick a visual target approximately 4 feet in front of you on the floor…never look away from the target – this will ensure that they maintain a neutral head position.

III.  ‘Pop your but out’ – ie.  slightly increase your lordosis by lifting the buttock up.  This will help the person with the concept of sitting back (Fig 3b)

IV.  Slowly sit back into the chair as you reach forward with your arms to counter-balance you (Fig 3c)

V.  Push your knees out as you squat so that they track over the toes, but also ensure that they stay behind the toes (Fig 3c)

VI.  Bend at the knees AND at the hip joint (Fig 3c).  DO NOT SIT ONTO THE CHAIR….gently touch it, then return to the standing position.

Fig 3a - Start position with the target approx 2 feet behind the patient

Fig 3b - 'butt pop' position

Fig 3c - Final squat positon: knees behind toes, sitting back, neck in line with neutral spine, eyes at a target on the floor

Once proper form is learned, and the patient has built up sufficient strength (approx 3 sets of 30), I then remove the ‘target’ and have them perform a free bodyweight squat.  NOTE:  the proper depth is lower than is learned with the ‘target’… proper depth has the hip joint beneath the top of the patella — this position will be difficult to achieve without sufficient hamstring flexibility.  Therefore I will always prescribe P.A.I.L’s exercises for the hamstrings as they work on their ‘chair squats.’

As always, questions and comments are welcome 🙂

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