Fixing a Squat

I don’t often do articles like this, for a variety of reasons (I think the last one I did was Learning to Jump).  Not the least of which is that, if I write an article about how I fixed a specific problem in the weight room, it’s common for people to assume that article represents the be-all, end-all final word on fixing EVERY problem that looks kind of the same to what ever it is I’m talking about.

So they see knees breaking in and give the singular answer to the problem (usually the one that worked for them) that they have seen or know.  And often do either no good or even harm.  Please do not do this.  The same “issue” in a given movement can be caused by different things and thinking that there is a singular solution often causes more problems than it solves.

With that said, I’m going to  walk you through how I examined a problem, determined it’s cause and how I approached fixing it. This isn’t meant to be the last word on fixing this problem, it’s just a case study on what I did.  Nothing more, nothing less.  Don’t read it as the ultimate solution to all problems squat.  Rather, try to follow along the logic of what I did in terms of figuring out the problem and addressing it.

Please note that I do not claim to be a physical therapist or rehab guy.  I know more about it than most as a function of having dealt with a lot of trainees with dysfunctions (I’ve fixed more SI joint issues than I can count and sometimes wonder if association with me doesn’t cause people hip problems).   But there are certainly many out there with far more knowledge than I have on this topic. And certainly when you get into really complicated injuries, they know what I don’t.  I wouldn’t pretend otherwise.

But most weight room related stuff does honestly come down to fairly simple causes and effects.  Something is weak, something is tight, something is not firing, something is firing too much.  Please note my use of the word “most”. I’m not saying this is always the case.  It’s different if you have a traumatic injury.  It’s different when you have chronic pain and dysfunction.  In a different situation with a different cause of presentation, I wouldn’t have attempted to do what I’m going to describe.

Simple Problems Usually Have Simple Solutions
Because what I’m about to describe is your basic run of the mill “stuff you see in the weight room” kind of thing where one thing is tight and another thing is weak and the problem and solution are relatively easy.  For that, you don’t need a complicated approach since the problem is usually fairly simple and easily fixable.  When it’s not, or you fail to find what you think you should, refer the hell out.

I know it’s fashionable to crap on that old model of dysfunction (and certainly we know now that there can be far more going on) but to a first approximation, it tends to work for a lot of stuff.    That is, just because there often is far more complex stuff going on than tight/loose and weak/strong muscles, that approach (along with some neural retraining) often gets you pretty close to resolution of a lot of common injuries and issues.

A final note on this, one of my rules of thumb about this stuff.  When you come across an apparent injury or problem and start throwing simple fixes at it, you know that you’re on the right track if it starts to show progress in a couple of weeks.  It may not resolve completely in that time period but if there is a lessening of pain or improvement in function, you’re on the right track (I have the same rule for being sick, if you start to feel better in a few days, it’s nothing major; if you’re still sick 2 weeks down the road, go to the damn doctor).

That is, if someone says they have shoulder problems and 2 weeks into basic stretching and rotator cuff work, they report decreasing pain, I know it’s a very simple issue of tight one thing (internal rotators, pec major and minor, maybe scalenes) and weak another thing (external rotators, etc).  That plus some remedial shoulder control exercises will get the job done without my having to worry about SLAP tears and AC joint type and all that complex stuff that people love to wank about.

But if at the 2 weeks nothing has improved, I know that it’s not just a simple tight/loose and stretch/strengthen type of problem and it’s time to find an actual rehab expert to figure it out.  It’s not a perfect approach but it’s right more often that not.  And my way is a hell of a lot cheaper and easier than finding the expert first.
And with that said, here’s how I fixed a squat problem this past weekend.

Background
The trainee is female, with a multi-year training history in the weight room.  Her squat had been stuck at a given poundage for quite some time but that was more due to crappy programming (and other aspects of her life that cut into her recovery).  We got her squat poundages moving up but towards the end of the cycle she began reporting hamstring and hip flexor issues (she has an old injury from sprinting) that concerned me.

I asked her to send me a video of her squat from the back (I had not been working with her hands on, just doing programming and giving feedback through the training cycle).     She did and it became instantly apparent what was going on.  I took screencaps from the video and put them in a vertical series so I could compare them easily.  And this is what I saw (click to enlarge the photo).

Squat picture seriesThe first picture is the top position, second picture is the bottom position.  Third, fourth and fifth are the trainee standing back up.  The red line was drawn at the top to show the vertical evenly between her feet.

So before reading on, look at the picture series and see if you see what I saw (see?).  Did you?

In the bottom she’s fairly centered (maybe a tiny shift to the right) but as she starts to stand up, there is a clear deviation off to the right (i.e. she shifts away from her left foot) before returning to center at the top.

Basically she squats down evenly during the eccentric but shifts off to her right side as she comes out of the hole.  And while she was not happy about it, I told her that she’d have to put off her back squat poundage goals until she fixed this.

And this isn’t just an issue of technical nitpickery, this is the kind of asymmetry that will injure someone eventually.  I’ve seen my share of SI and hip problems and this is a great way to get them.   As well, ultimately this technical issue, even if it didn’t get her hurt would hold back her ability to move massive weights.  So we had to fix it.  But fixing it meant figuring out the problem.

 

Diagnosing the Problem with her Squat: Part 1

While I do not regularly work with this trainee hands on, she actually lives in Austin so I made a trip to observe her squat first hand.  There’s only so much you can see with a static video angle and often there is a twisting that accompanies this type of weight shift.  I needed to see her squat and watch from various angles while she was squatting.  Side, 3/4 back, back, if I could have gotten in front of her I would have.

Now I’ll be honest that I’m no fan of her squatting surface.  Cushy carpet is not ideal and I told her to get a piece of plywood to put in front of her power rack (she trains mostly at home) so she’d have a stable surface to stand on.  But I didn’t really think that was the source of the problem per se.  It wasn’t helping but it wasn’t the sole issue.

Watching her perform squats with a fairly moderate weight, I didn’t see any twisting, it was just a lateral shift out of the hole as I had seen before. But now I had to figure out the source of the problem.

The first thing I did was a quick check on flexibility.  Hamstrings with straight and bent knee, quads, hip flexor with both straight and bent knee, glutes, glute medius/minimus, internal and external rotators.    I’ll be honest, this came from one of Paul Chek’s old courses but it’s basic muscle length testing.

I was looking for two things here: one was overall flexibility as flexibility below a certain level can cause problems.  More than that, I was looking for an asymmetry, a situation where one side was significantly different than the other.  That was due to the assymetrical nature of the problem.

That is, if I had seen something like butt tucking symmetrically, I’d be looking more for general low flexibility somewhere.  Since this was a clear asymmetry, I was interested primarily in right/left balance.  In any case, not only was flexibility fine across the board, she was balanced on the right and left side.   I had no reason to believe that her issue was flexibility.

Mind you, these issues frequently are at least partially flexibility based: tight hip flexor, glutes or hamstring on one side makes the body do weird stuff in terms of twisting and shifting.   But when you’re trying to do a differential diagnosis, it’s just as important to know what is NOT causing the issue as what is.

Anything you can eliminate as a cause is one less thing to worry about.  No amount of stretching was going to fix this because her flexibility was not only sufficient but symmetrical on both sides (symmetry is actually more important than absolute flexibility here).  So that couldn’t explain her assymetrical ascent.

I put her back under the squat bar and immediately determined that she has a tendency to set up a bit unevenly under the bar.  So I went ahead and taught her a foolproof method for getting centered under the bar.

Basically I had her set her hands in an identical and even spot (using the inside rings as a marking point and going one thumb out) and then told her to make sure she feels even in her shoulders when she ducks under the bar.  That will put you centered under the bar.  She got used to that and then it was more squats.  With even a small load, she started shifting to the right out of the hole.

I should mention that occasionally you will see a problem that only shows up early in the workout but goes away as you do repeat sets: this usually indicates that something is being warmed up or stretched out during the initial sets and might suggest a different course of action.  But since I saw no change from her first to third set of moderate weight squats, this wasn’t a warm-up issue.

I should also mention that conmen often use this warmup effect to “prove” their approach.  They have a trainee squat cold and it looks horrid.  Then they do their magic voodoo, and then have them squat again.  The squat always improves and clearly their voodoo was the cause.  No, warming up was the cause of the improvement.

Diagnosing the Problem with her Squat: Part 2

In any case, her squat did not change from the first to third set but the shift was still occurring.  Since it wasn’t flexibility based, that suggested a neural or muscular issue (noting that you can’t really separate one from the other).  Maybe she was just favoring her left leg for some reason or it had gotten stronger than the right which happens.   Nobody is perfectly symmetrical and it’s normal to have slight side to side strength imbalances even without an injury or other problem.

Of course she had had an injury (recall her hamstring pull from sprinting) and I’ve seen some weird stuff where the body is quad dominant on one side and glute/ham dominant on the other during certain movements (usually after a hip injury).  Though that usually causes a weird twisting as you get more knee extension on the one side and hip extension on the other.  Since I hadn’t seen that, I didn’t think that was what was going on

The first thing I suggested was that she consciously attempt to just PUSH harder with the right leg.   Just to see if it was a cueing or technique issue.  Really just driving the right foot into the floor without focusing on pushing with the left.  She was also letting her right knee roll in a bit and I cued her to push the knee out.

That helped a bit in terms of not shifting off to the right though she did report feeling totally assymetrical despite being completely centered.  This is 100% normal, once the body has gotten to where an imbalance feels normal, fixing that makes stuff feel weird as hell.  When shifting to the right feels normal, being centered feels like you’re shifted left.  Over time, this goes away.

And while the very easy solution would be just to tell her to “Squat and focus on staying centered” my experience is that that doesn’t fix the problem nearly as quickly as really identifying the root cause and plugging in specific exercises to fix it.  At most properly technically performed movements have to be done in addition to the rehabby stuff to ensure transfer from any rehab movement to the movement having a problem.

The next thing I wanted to check was just good old neural activation.  Without addressing whether gluteal amnesia is real or not (hint: it is, sometimes) I wanted to see if her left side glute or whatever just wasn’t firing as well as the left  So the next task was the belted glute bridge exercise.

This is a favorite of mine from way back (I was into glute bridges long before a certain one-trick pony expert was) and I’ve used to belt glute bridges, leg presses and even squats for this goal (it’s mainly an exercise to teach/train the body to push the knees out during hip extension).

I know some are fans of going straight to banded or belted squats but I find it better to start with a simple/more controllable movement early on; the body can find too many goofy substitutions when you go too complex too soon.  Her squat was already messed up, squatting with a band around her knees wasn’t going to give her a shot at fixing the problem.  So I needed to move back a level and simplify a bit.

I find that the belted glute bridge is a nice compromise between a purely isolation movement (such as a Clamshell) and a complex compound movements (belted/banded squat).  It’s complex enough to be relevant without being so complex that the body finds substitutions.  Here it is.

GluteBridgeArrow

Basically, lie on your back with knees about 90 degrees and feet hip width.  Put a belt around your thighs so that when you push out into it, your knees are over your toes.  I’m using a dress belt here but you can use a weight belt if it’s big enough.  Set core, push out into belt (activating gluteus medius/minimus and the hip external rotators) and then drive off the heels to do the glute bridge.

Don’t hyperextend the back and make sure the knees stay out as you drive up so that everything in the gluteal region is fired in an integrated fashion.  This can be a teaching/activation exercise (done until both glutes are firing) or it can be a training exercise (done with weight).  I was using it here for activation and testing.

After that set, trying to focus on even pressure on the belt on every rep, I had her squat again.  It was a little bit better but absolutely not fixed.  I concluded that it wasn’t purely a neurological/technique issue at work.  So I did one more test: I had her do split squats under weight.  This is just a lunge in place and often you see things in a single-leg movement that doesn’t show up in a double-leg movement.

First she did left leg forward.  I watched her overall form and left knee.  Everything looked fine.
Then she did right leg forward.  And boom, there it was.  I’ve reproduced what I saw below.  I was looking from the back and it was very subtle but it’s easier to see with my picture from the front.

Split Squat with Deviation

It’s fairly subtle but you can see how the left picture (with left leg forward) has the knee tracking right over the foot and the ankle level.  On the right (right leg forward), the ankle is rolled into inversion and the knee breaks in (there is also a subtle hip internal rotation due to this since it’s all one big chain).

Since I had already found that she didn’t have ankle flexibility/mobility issues, I didn’t think the ankle rolling was the cause of the knee breaking in; rather, in this case, the knee breaking in was causing the ankle to roll. Note that this can easily be reversed, with the ankle causing the knee issue.  That’s why you have to test different things to get to the root of the issue.

Having noticed this, I cued her to actively push her right knee out to keep it over the knee while performing split squats.  She reported instantly that she had a feeling inside her right butt cheek that she had NEVER felt (or rather it felt different on the right vs. left side).  And I had my answer.

 

The Answer to her Squat Problem

For whatever reason, this trainee’s right glute (probably medius and minimus) isn’t doing it’s job.  Out of the hole, while her left side is firing, it’s overpowering the right side and that’s causing the shift to the side.  Again, note that this is absolutely NOT the only cause of this kind of deviation or weight shift.  It’s simply the conclusion I reached based on the assessment I did.

Also note that whether this is a neural issue or a muscular strength issue (noting that strength is a combination of muscular and neural factors in the first place) I can’t say.  I’d have had to have her do something like split squats or a single-leg glute bridge to failure to what’s really going on. But I don’t ultimately care since the fix is the same.  This is my patented “Throw stuff at the wall and see what sticks” approach to rehab.  It’s not as elegant an approach as a true rehab guy might use but it works well enough.

The Program
Belt glute bridge: 1 set of 15-20 reps.  This can’t hurt from an activation/warm-up standpoint.  Eventually it will be changed to a one legged glute bridge, maybe 2 weeks from now.

Back squat: 5 sets of 5, 2 warmups and 3 sets at a moderate weight.  She can only go as heavy as she can maintain proper centered form.  She knows what it feels like and I told her to simply focus on pushing the right knee out and pushing harder with the right leg until it feels natural.

She will be adding weight very slowly to the bar and had to drop back if she starts shifting again.  Inasmuch as her body has learned to shift like that, she needs a lot of reps to retrain it to stay centered.  Since she misses squatting, I also allowed her to perform 3 sets of 5 squats on her upper body days to get more good reps.

Split squats: This is the bread and the butter of the fix.  Again, whether the issue is strength per se or neural or both isn’t relevant since the fix is the same.  I gave her 1 set of 8 on the left side and 3 sets of 8 on the right side with the understanding that she can only go as heavy on the left leg as she goes for the right leg (this approach is explained more in this article).  Basically the left leg is on maintenance while the right leg is given a training load to bring it up.  Both by strengthening the glute medius/minimum and teaching her body to fire it to keep the knee out.

RDL: 3 sets of 8 for hamstrings (I saw NO deviation on this during her performance of the exercise)

Leg press: I told her to wreck herself on this one.  She’s bummed about not being able to squat heavy and this is the way she can get a good workout, keep her leg strength up and be happy with her training.  I told her simply to make sure that the pressure of the pads on her feet is identical and she could go to town on this in terms of going heavy.

Some core work: whatever.  Couple of heavy sets of crunches and back extensions (which gives a bit more glute work).

After she did her first real workout (two days after I assessd her), I waited a day and asked if she was sore in her right buttcheek.  The answer was yes.   And not that I feel that soreness means much but the fact that there is an asymmetry there (her left side has no soreness) tells me that this is the right approach.

In a few weeks I’ll re-assess her and maybe make stuff a little more challenging depending on her progress.  If things look resolved, I might let her start going heavier on squats and/or reduce the split squat sets.  The glute bridge will probably become a one-legged glute bridge and possibly even a one-legged squat.

As much as she is unhappy with a lack of heavy squatting, the fact is that this problem is an easy fix.  A rotated pelvis is a headache and takes a while to fix, an actual acute injury can take what seems like forever to resolve.

This trainee’s issue is a combination of a strength/neural issue on the right side which led to her picking up some bad technique since her right side isn’t firing as well as her left.  Fix the right glute firing/recruitment and retrain symmetrical squats and she’ll be back to squatting in no time.And with her symmetry reestablished, she’ll be in a much better place to crush her old PR’s.

Summing Up
And that’s how I assessed, “diagnosed” and approached fixing a very specific problem.  Once again please do not read the above as providing the only solution to the issue of someone shifting to one side while squatting; there are other things than can cause the problem to occur and a different problem would have yielded a different set of test results and/or a different process of elimination.  I tried to detail my assessment process to get that across. Try to focus on the logic of what I did more than on the details.

So had I found assymetrical flexibility across the hip, I’d have approached it very differently in how to fix it or what further assessments I’d have done.  Had my split squat test not given me the clue as to the problem, I’d have done more testing.  Perhaps single leg extension to failure to see if there was a strength imbalance.  If that failed, I’d have tested hamstrings single leg to see if there was an imbalance.  Hopefully you get the idea.

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