The Best Damn Squat Article for Physios

11 min read. Posted in Exercise Prescription
Written by Eric Bowman info

One thing I’ve always prided myself on as a physio has been my ability to work with weight training clientele. It is an area that requires its own knowledge base and is unfortunately not an area that gets much (if any) attention in school. While I get that weightlifters and pro-athletes are low on the priority list, it’s amazing how many patients I’ve seen that have worked with a previous physio who didn’t have sufficient training in exercise prescription. We’re supposed to be the “exercise profession.” This isn’t a criticism of individual physiotherapists, it’s more a problem with:

  1. The educational system and lack of proper training on exercise prescription. You can’t criticize someone for not doing their job if not properly trained to do it.
  2. The overemphasis on passive treatment

In this series of articles I’m going to discuss general technique coaching for the barbell squat, bench press, overhead press and deadlift as well as ways to modify them for the clientele you work with.

Firstly, this is not meant to be a powerlifting or performance based series. There are people out there such as Brian Carroll and my old boss Travis Mash who know way more about powerlifting programming and maximizing performance than I do. The intent of these articles is more for rehab professionals to:

  1. Understand proper technique and how to individualize it to the client you’re working with
  2. How to coach/correct proper technique
  3. How to modify the movement for clients who may be dealing with specific injuries

Secondly, as you’ll know if you read my previous articles, injuries are multifactorial and “perfect technique” can never 100% guarantee no injury. I’d recommend reading my articles on the Pillars Of Sports Injury Prevention (1-2) and checking out my colleague Dr. Travis Pollen’s brilliant masterclass on Injury Prevention: Theory into Practice.

With that out of the way let’s get down to business…

 

Part 1: Squat setup – from bottom to top.

To make a long story short – it depends. Realistically, squatting technique is influenced by a myriad of individual factors which we will get into as this article progresses. I’m going to start with the bottom and work my way up.

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Stance

Stance is governed by several factors:

1) Hip anatomy: Many great articles have been written on the individual variation in the shapes, sizes and angles of people’s hip joints. This determines which stance will be optimal for you to minimize (you can never eliminate) spinal flexion and how deep you can get before the back starts to visibly round over.

Hip anatomy can be determined by a hip scour test (refer to my friend and mentor Dr. Stuart McGill’s books Low Back Disorders and Gift Of Injury for references) or simply by doing bodyweight squats at various stances with toes forward/toes out and determining which one gives you your deepest squat.

2) Injury history: most clients I work with do better with a (relatively) wider stance and the toes turned outward to minimize knee flexion and forward knee translation and to maximize the involvement of the glutes and hamstrings. However, some clients who tend to be more avoidant (e.g. due to lower back pain) may do better focusing on using a (relatively) narrower stance to load the knees and quads more.

Caveat: if you go too wide it can make it difficult to keep the knees from collapsing inward when squatting.

3) Goals: (as a disclaimer I’m not a hypertrophy coach) Squatting with a narrower stance emphasizes quads and knees, whereas a wider stance biases more hips and glutes.

Spinal position

The old school method of squatting was to excessively arch the back. I’m not a big fan of this as it can impinge the hip (3), limit ROM, and make it harder to do the movement. In general, (and accounting for individual differences in anatomy), I’m a fan of keeping a “neutral” lumbar spine and a neutral or slightly extended thoracic spine.

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Elbow & wrist position

Regardless of whether you squat low or high bar, or wide or narrow grip, I always advocate (as best you can) keeping a vertical elbow, forearm and wrist position to prevent the bar or upper back from dumping forward. I’ve described it here in this video at work.

Grip width and high bar vs low bar

I’m lumping these together as they depend on several factors including

  1. Anatomy/Mobility: Anatomically, some people can’t get enough external rotation in their shoulders to grip the bar with a narrow grip. This demographic may need to go wider. Many people with mobility limitations are better off (at least initially) with a higher bar position, performing front squats, or even using a safety squat bar if one can be accessed.

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  2. Injury/medical history: Going with above I find high bar or safety bar squats better for clients with elbow, wrist or shoulder issues due to the easier bar carriage. The more upright style of high bar squatting can be advantageous for some (not all) with back pain. However, I find low bar and wider stance squatting, due to its greater hip dominance, better for those with knee or ankle issues.
  3. Goals: High bar biases the quads due to its more upright style and is more conducive to olympic lifting or bodybuilding whereas low bar squatting is more hip based and is more conducive to powerlifting.

Setup

Generally, my tips for squatting are as follows:

  1. Grip the bar evenly
  2. Get under the bar and get your wrists and forearms set first
  3. Then pull the bar into you
  4. Tighten your stomach (imagine that you’re going to get punched in the stomach!)
  5. Walk the bar out, taking no more than 2-4 steps total
  6. Take a deep breath pushing your stomach out in all directions
  7. Push your hips back (the amount will depend on goals, anatomy and injury history)
  8. Squat down and then come up

Truthfully, when coaching squats (and other movements) I very rarely go step by step. I just see how they do with an empty bar or broomstick without my coaching and then correct as needed.

 

Part 2: Coaching cues and corrections

Some of the below coaching cues are more appropriate for goblet or bodyweight squats than barbell squats but most are appropriate for all three. I’m lumping these together for simplicity purposes:

1) Knees going forward

There are a number of ways to address this, below is what I tend to use:

  1. I aim towards a target (real or imaginary) to cue the client to sit back more. This can be a plyo box or (steady) weight bench of appropriate height (just as a touch and go, not a full box squat) or even the cue of sitting back several inches. If clients really aren’t getting it, I’ll sometimes cue them to sit back even further – sometimes aiming for a very far distance helps to cue the movement.
  2. Something to block the knees. Depending on the height of your client an upright plyo box an inch or two in front of the feet works pretty good. If cueing a goblet squat or a bodyweight squat, I will have the client stand approximately an inch or two away from the wall. This is an approach called “constraints based learning” (props to badass Rachel Balkovec for these ideas). If a client has knee pain that’s aggravated by forward knee translation I’ll have their feet touching the wall or the box.

Side note: I don’t lose sleep in the “don’t let your knees go over your toes” debate. This recent podcast by Mike Reinold sums it up far better than I could:

https://mikereinold.com/knees-over-toes-is-it-bad/

2) Knees going in

I’ve found the cue of corkscrewing the legs into the floor helps with proper knee, foot and ankle position. I will sometimes kneel in front of the client and get them to push the knees out into my hands for a few reps to cue knee alignment.

3) Falling forward

This can and should be addressed in two areas:

  1. Set up: see above paragraph
  2. Focus coming in and out of the squat. This can be achieved by:
    1. Having a target to focus on at eye level (when at the top of the squat) in order to keep you upright (i learned this from Matt Wenning)
    2. “Let me see the logo on your shirt” cue

Another side note: not all cues will work for everyone and sometimes, even though external cues are well established as superior, internal cues (i.e. chest up, knees out) do have a time & place if the external cues aren’t working. The intent of these articles is to give you some different options to work with that you can adjust based on the individuals you work with along with your own experience of what does and doesn’t work.

4) Visible low back rounding

This can be corrected by:

  1. Proper setup and stance
  2. The same cues for falling forward are often applicable here
  3. Cueing proper bracing with the lats, upper back and core can be helpful

5) Heels coming up

There are several cues I find helpful here:

  1. Again corkscrewing the legs into the ground can help with this one
  2. Mirror cueing (props to Trevor Cottrell for this) can also help. Sometimes making people aware that the heels are coming up remedies the problem.
  3. Getting people to imagine they’re on a beach (or in snow here in Canada) and they want to make an even imprint in the sand (or snow).

If those don’t work it may very well be an ankle mobility issue. With any knee/ankle/foot issue in the clinic I just about always assess knee-to-wall ankle dorsiflexion in standing. If that is limited, and these cues aren’t working, your best bet is to work on dorsiflexion mobility and to have the client squat with the heels elevated.

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6) Excessive walkout

This is usually just a matter of cueing. Some people just take too many steps and simply making them aware of it fixes the issue.

 

Part 3: Modifications for pain or injury

As a disclaimer, all injuries are different and need to be managed on a case by case basis. The majority squat issues I see are (anecdotally) due to either:

  • Technique issues (refer to above for management)
  • Doing WAYYYYYYY too much squatting too soon – especially people who jump on high frequency squatting programs (i.e. squat everyday)

Here are some of the most common modifications I’ve made to help people squat through various injuries:

1) Shoulder pain:

Usually this comes from difficulty holding the bar. High bar squats, front squats, or if you’re lucky enough to have access, safety bar squats can help with shoulder pain. Some emphasis on t-spine extension and/or shoulder external rotation is likely needed if you want to go low bar.

2) Wrist pain:

Similar modifications to the above can help. However, wrist pain can be helped via the arms crossed, “bodybuilder style” front squat in contrast to the front racked, “olympic lifting style” front squat.

3) Back pain:

Usually back pain with squats comes down to 3 issues:

  1. Flexion: Refer to #4 under cueing below
  2. Extension: It’s rare that I see people excessively arching but I do see it in people who are afraid of flexion, have poor body awareness and/or are from the old school of powerlifting that emphasized a lot of extension during squatting. Cueing a neutral (not extended) position by pulling the ribs down slightly (not rounding) or by emphasizing the t-shirt logo facing the wall and not the ceiling are usually useful.
  3. Compression: There are some clients I’ve worked with who don’t tolerate the compression of an empty bar, let alone a heavy barbell squat. In these cases I usually recommend some combination of:
    1. Goblet squats and/or single leg work
    2. If barbell squatting is a goal activity I usually recommend broomstick squatting a couple times a week to maintain technique (if technique is an issue).

4) Hip/Knee pain:

Most clients I’ve worked with who complain of hip/knee pain with squatting usually have it a certain depth. Using a squat to a box or a pin squat to a tolerable depth is usually an easy workaround. For clients with knee pain emphasizing sitting back more & using a wider stance can also be helpful.

5) Ankle pain:

This is a rarer one but worth mentioning. Again, squatting to a box or pin squat to a tolerable depth is fine. For some, a box squat with a more vertical shin angle works well.

 

Wrap up

Anyways this beast is well over the 2000 word mark. I hope this helps improve your confidence when coaching the squat. If you enjoyed this blog then check out Dr. Travis Pollen’s masterclass on Injury Prevention: Theory into Practice. Thanks for reading!

Want to master injury prevention?

Dr Travis Pollen has done a Masterclass lecture series for us on:

“Injury prevention: theory into practice”

You can try Masterclass for FREE now with our 7-day trial!

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