Case of the Week 4-29-12: Unable to Deep Squat | Modern Manual Therapy Blog

Case of the Week 4-29-12: Unable to Deep Squat

It's amazing how kids can just do these things that we cannot! Well, this case is not about my daughter! We recently evaluated a golf pro who is TPI level 1, which use the FMS in screening.

History: 23 yo male who has painful right knee clicking with deep squat. He is able to golf pain free, but also has knee pain with lunging, descending stairs and running. Sx are intermittent, and have been worsening in the past 3-4 months. His complaints are rated as moderate.

Why is the deep squat so important to him if he can golf? Well, as a TPI Level 1, he screens his clients using the FMS. The deep squat is a functional movement that everyone should be able to do. It screens shoulder, thoracic, hip, knee, ankle mobility as well as core stability all in one! Agree with the test or not, you should be able to do it.

The adage is, if you are asking someone to do it, you should at least be able to demonstrate it correctly. As a golf pro, if you're paying someone to teach you, and screen you, what should he do... show a video of someone doing it, but say that he cannot?

Objective:

SFMA Screens:

  • MS (multisegmental) Trunk Rotation: limited bilaterally, dysfunctional non-painful (DN)
  • MS Flexion: functional, non-painful (FN)
  • MS Extension: DN
  • Shoulder screening, functional IR and ER scratch tests FN
    • Lumbar locked upper and lower body rotation, FN, meaning thoracic mobility WNL, lack of MSR most likely coming from the hips
  • Deep squat: dysfunctional, painful (DP) - with pain in the right knee
    • hip IR DN, severely limited bilaterally
    • tibial internal rotation DN, severely limited bilaterally
    • ankle dorsiflexion DN, severely limited left > right
    • knee mobility FN bilaterally
    • these breakouts show the reasons why he is unable to deep squat, lack of hip mobility and ankle mobility, causing right knee (painful side) to go into genu valgus
    • also, lack of tibial internal rotation would limit knee flexion, further limiting deep squat
  • Myofascia: severe restrictions in right > left TFL and ITB, left gastroc/soleus
  • MMT: weakness in right hip abductors, 3+/5
Treatment: I ended up seeing him on his second visit, an intern had already done bilateral ITB IASTM on him. I added MWM posterior talar glide, hip MWM to restore IR, IASTM to around the talocrural joints and subtalar joints, talocrural thrust. 

All of these improved the depth of his deep squat, but his hips were still not going below his knees. He had much less clicking. After adding tibial internal rotation MWM while deep squatting, he had virtually no pain, and his deep squat was much better! However, he was still unable to do it with UEs overhead - since his thoracic rotation and extension was normal, as well as shoulder mobility, the inability to do DS with UEs overhead is most likely a motor control/stability issue.

He was shown how to self perform the tibial IR MWM for HEP, but then had to leave. He is back this Friday, and we have a lot more to address, like looking at his upper and lower body rolling, and working more on his hips, ankles and tibial internal rotation. I predict he'll be able to DS in 3-4 visits after working on his various movement limitations, and then getting his motor control back under control! I'll keep you posted on how he does!

9 comments:

  1. I've just started to get acquainted with Mulligan's tecniques (took the A-course recently), mainly because you and other experienced therapists have been talking highly about MWMs in particular. I see you're frequently using MWMs for the extremeties, however I've yet to see you mentioning NAGs and SNAGs. Do you use these techniques at all, and what do you think of them?

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  2. I do use them on occasion, but more when traditional MDT, STM, and joint manips are not working. They are very effective, especially with a population that does not tolerate the other techniques since they're 100% pain free

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  3. Erson.
    Did you ever think about lying him supine with UE overhead and then maximally flexing his knees to his chest while DF his ankles to see if he has a mobility problem - a very quick way to screen, just unload them and place them into the position.
    I agree that this sounds more like a stability/motor control problem, and if that is true, you should be also able to identify it with other FMS mvmt patterns. The deep squat is usually the last place to try correcting because it involves both mvmt and stability issues and also involves the most joints. It is amazing that if you correct something like the trunk stability or inline lunge the deep squat may already be corrected.

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  4. Thanks Stacey! Hip and ankle definitely had mobility problems, I know Gray says to look at deep squat last, but he is a TPI level 1 and has to screen his clients using the FMS. So he has to be able to do it, just can't show a picture and say do this.

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  5. Hi Erson,

    Just a quick academic question and I sure am being picky but if I don't deconstruct something I can't buy into it.

    You mentioned that the lack of hip internal rotation was limiting his ability to deep squat.

    How do you think limited hip IR negatively influences a deep squat? How much hip IR occurs with squatting? Considering that your daughter is externally rotating your hip and many of us train a deep squat by adding hip ER might the loss of hip IR range not be factor?

    Conversely, the loss of hip IR may just be symptom of some other dysfunction that you are addressing with you mobilization with movement. I am assuming you are using a belt and tractioning laterally the hip. Does your patient ever feel pinch in the anterior hip with a deep squat? Could the real culprit limiting a deep range be femoral anterior and medial glide? I won't even touch on the nervous system.

    Thanks,

    Greg

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  6. Thanks for the question Greg! I knew as I was typing it that someone who was paying attention would question it. The way I see it, the loss of hip IR is part of a greater capsular pattern that may indicate as well loss of flexion. This particular patient did not have anterior impingement as his complaints were mainly in the knee. I did not overpressure into flexion, just screened his mid and lower areas using the SFMA and applicable breakouts.

    The MWM is the Mulligan technique you described using a belt, lateral traction and AROM IR. One of my favorites for lower quarter dysfunction. Does this answer your question?

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  7. Thanks Erson,

    A little bit. Sorry for being a pain. It makes me wonder two things:

    1. How common is a loss of hip flexion in the squat? I rarely see it. and never see it when they are supine. If you flex the knees they can bend their hip all the way, at least sufficient for a deep squat.

    2. Back to the hip IR. I see limited hip IR all the time, runners report the pinch when they are supine and I crank it in passively and they report the pinch when they squat BUT, they aren't rotating their hip internally when the squat (at least I don't think so). So w hat the hell is going and does a lack of hip IR really limit a deep squat...my bias is that things are anatomical/structural and we probably should not force this movement. There are a tonne of deep squat olympic lifters with their feet turned out.

    I am on the side of embracing variability and foregoing anything to do with proper posture. I don't even know what it is anymore.

    Thanks for the response and all the best,

    Greg

    PS. none of these questions take away from your clinical approach. I still think everything you do can be effective, it just might not be for the reason we think

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  8. Greg, you are absolutely not being a pain, fun discussion ! Actually, I see the loss of hip flexion concurrent with loss of hip IR quite a bit. In supine, I find those with hip impingements have a hard end feel around 90, but often the iliac crest ends up posteriorly rotating early and it seems as if they have normal hip flexion. Check the uninvolved side and it moves easily, end feel firm without pinch.

    One of the criteria for deep squat is that the hips have to get below the knees. Also, I never said they have to do this in HIP IR, was I restoring his lack of tibial IR, which is needed for knee flexion, and most likely closed chain hip flexion. The lack of tibial IR was causing excessive genu valgus, and contributing to his knee clicking and having pain. Restoration of ITB mobility, tibial mobility, and hip mobility really improved his deep squat.

    Again, in terms of FMS and SFMA screening, the deep squat is not my preference for a top tier test, it's just this guy is a level 1 TPI and has to screen all his golfers at the club he works at using this movement, and showing them a pic or a vid of something he can't do, but expects them to be able to wasn't really an option.

    Thanks for contributing Greg!

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  9. Also, one more quick DS criteria, ok to have feet everted 5 degrees at most.

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