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!

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