MODIFYING WORKOUTS FOR ATHLETES WITH PAIN

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Squat – Front Squat, Back Squat, Overhead Squat

 

Common Problem Areas

1. Lumbar Spine
2. Knee
3. Hip

 

Lumbar Spine Pain During Squatting

 

During the squat, there are several different types of forces on the spine.  We’ll go over these in order to help you understand how best to work with these athletes.  These are:

 

1. Compressive Forces
2. Shear Forces
3. Positional Issues

 

Some athletes with low back pain have difficulty handling shear forces.  Others have trouble with compressive forces or certain positions of the spine.  Some have trouble with 2 or even all 3 of these forces.  Understanding what an athlete can or can’t handle allows us to modify accordingly.  

 

All three of these forces are taking place in the spine when we squat.  However, as we described previously most individuals will present with more difficulty handling certain types of forces.  Here are some examples to help clarify our point.

 

Example 1: An athlete that is intolerant to positional changes

• This athlete can squat to just above parallel with absolutely no pain.  Once they go deeper, the spine begins to flex and pain occurs.  If we give this athlete a more shallow squat they can train pain free

 

Example 2: An athlete intolerant to shear forces

• This athlete can squat pain free when they keep a very vertical torso.  Once they start to incline forward pain occurs.  We reduce shear forces when we squat with a vertical torso.

 

Also keep in mind that in some individuals the pain will be bad enough where squatting will just be off the table temporarily until pain subsides.  Let’s go over these forces more in depth.

 

1: Compressive Forces – Compressive forces are defined as forces acting down the long axis of the spine.  This is the force that directly presses the vertebrae together when squatting. In other words, the more weight on the bar, the greater the compressive forces on the spine.  

 

In this patient the more weight on the bar, generally the worse their pain is.  These patients tend to hurt as soon as they lift the bar out of the rack to squat.  These patients also tend to have pain when they rack the bar after a set as soon as the spine is unloaded.  

 

[Compressive forces act straight down along the spine]

 

With this knowledge in mind we can develop modifications for these athletes.

 

Modification Key Points:

1. Decrease the load or pick a squat variations that creates less compression
   1. Front Squat over a Back Squat
   2. Overhead Squat over a Front Squat
2. Goblet Squat or Kettlebell Front Rack Squats
   1. Limitation comes from the weight the athlete can hold and not from large compressive forces and pain
3. Single Leg Variations – The total compressive load is lowered given the legs are generally the limiting factor in this lift and not the spine
   1. Lunge, Step-up
   2. Unilateral loaded variations – These increase challenge to the core and hip without increased compression

 

[Kettlebell in opposite hand as stance leg]

 

2: Shear Forces – Shear is defined as a force that acts parallel to the mid-plane of the disk of a specified motion segment.  These forces are occurring at a 90 degree angle to compressive forces.

 

[Shear forces act perpendicular to the alignment of the spine]

 

Think of it this way.  During a task like bending forward one vertebrae will be subject to sliding forward off of the vertebrae below.  Your facet joints, ligaments and musculature all help to prevent this.  The more forward torso inclination a given squat variation has, the more shear forces the spine is subject to.   These are the athletes that have trouble with squat variations where the torso is inclined forward.  Generally a low bar box squat will be very painful whereas an upright torso front squat will be tolerated quite well.  These patients also have difficulty with deadlifting (given the inclination of the torso).

 

[Notice the difference in torso angle]

 

Modification Key Points:

1. Choose squat variations that require an upright torso
   1. Overhead, Front and Goblet Squats

1. Consider using a heel lift to keep your athlete more upright

1. Single leg variations are generally pain free because of the upright torso
   1. Split Squats, Lunges, Step-ups
   2. Utilize a shorter step to keep the torso more upright

 

3: Positional Intolerances – Positional intolerance refers to individuals who have pain when their spine is in a certain position.  

 

Often in lower back pain if the individual can load their spine in a neutral position then they won’t experience pain while squatting.  As soon as the spine starts to round (or flex) the pain starts.  This is important because in the bottom position of both squatting and deadlifting the spine will naturally flex some.  Some athletes won’t be able to tolerate this when their lower back is painful.  If we limit the depth of the squat in these individuals often times we can avoid flexion and subsequent pain.  

 

Lower Back Health Side Note:

 

Some backs don’t tolerate flexion well but others don’t tolerate the opposite motion, extension.  Remember our lower back pain and overhead pressing example from earlier in the book.  

 

Modification Key Points:

1. Coach your athletes to maintain a neutral spine position and how to brace while squatting
2. Choose squat variations that limit full depth
   1. Box Squats, Powerlift Style Squats, ¼ Squats
3. Consider using a heel lift
   1. Adding a heel lift will increase the depth an athlete can achieve before the lumbar spine begins to flex
4. Modify amount of toe out and stance width
   1. Increasing the amount of toe out and stance width can often allow an athlete to squat deeper with less lumbar flexion
5. Mobilize the hips and ankles
   1. More mobility at the hip and ankle will allow you to squat deeper before the lumbar spine starts to round
6. Single leg variations are generally pain free as long as the spine is kept in a neutral position
   1. Split Squats, Lunges, Step-ups

 

Squat Modifications – Exercises shown are from most to least challenging for the spine:

 

Back squat →  Front squat →  Goblet Squat →  Air Squat →  Split squat

 

Lower Back Pain and Squatting Health Exercises

• Based on the anatomy of the spine, the forces associated with pain and an understanding of the biomechanics of squatting we can give these athletes several exercises as homework to help them
• Mobility Work
  • Soleus Stretch and Foam Rolling
  • Posterior Hip Stretch on Hands and Knees
• Strengthening
  • 45 degree back raise or glute ham raise
  • Dead Bugs and Bird Dogs

 

Knee Pain During Squatting

 

Just as in the spine we have 3 major concepts to discuss in order to understand how to best work with these athletes:

 

1. Compressive Forces
2. Patellofemoral Alignment

 

Just as with the spine, there are a multitude of different stresses on the knees when we squat and all aspects are important to understand so that we can modify appropriately for these athletes.

 

Patellofemoral Pain Syndrome (PFPS)

 

Patellofemoral Pain Syndrome is far and away the most common injury we see clinically for athletes who have pain during squatting.  These athletes generally complain of pain somewhere in the front of the knee, usually around or behind the knee cap and the pain generally worsens as they descend deeper into a squat.  Several structures on the undersurface of the knee cap can get irritated in this condition.  PFPS may result from a dysfunction in patellofemoral compressive forces as we’ll discuss below.  

 

1: Patellofemoral Compressive Forces – These are the forces that come from the patella compressing the structures behind it.  The amount of force is related to how much quadriceps activity is present coupled with the depth of the squat and how much boney contact there is between the patella and the femur below.  

 

Generally, compressive forces in the knee have been shown to increase as we descend deeper into a squat, maximizing around 90 degrees of knee flexion (depending on the study and activity).  Beyond 90 degrees, the research is mixed as far how much compressive force the patellofemoral joint is exposed to.  Some studies show decreased stress as we descend below 90 degrees.

 

What I see generally in the clinic is that people who present with knee pain have worsening pain as they descend deeper into a squat.  The deeper they go the worse it is.  Because of this they can’t tolerate exercises that require a lot of loaded deep knee bending (Deep Squats).  If we decrease how much knee bend is required during squatting exercises we can decrease these forces and eliminate pain.  

 

The next consideration with knee pain and compressive forces relates to the angle of the shin while squatting.  When we squat with a more upright torso two things happen:

 

• The quadriceps muscles are more active
• The knee flexion angle is greater

 

Both of these factors will increase patellofemoral joint stress.  It’s the reason why a box squat with a vertical shin tends not to aggravate people’s knees when they’re painful but a front squat to the same depth does.

 

[Observe the difference in shin angle]

 

Modification Key Points:

1. Limit depth of squat variations
   1. Box Squats, ¼ squats
2. Make squatting movements more “hip dominant”
   1. Cue that athlete to send their hips back further when they squat and choose squat variations that require a less upright position
3. Substitute squat variations for hip hinge variations
   1. Limiting knee bend will decrease knee pain in these individuals
   2. Deadlifts, Good Mornings, Power Olympic Lifts

 

2: Patellofemoral Alignment – Patellofemoral alignment is the next important concept we’ll discuss as it relates to PFPS and pain during squatting.  

 

At the knee joint we have contact between 2 bones, the patella (knee cap) and femur (thigh bone).  The patella sits inside of a groove in your femur and aligns like a train on train tracks.  As we squat the patella is supposed to slide smoothly in alignment in the femoral groove.  Sometimes this doesn’t happen and the medical term for this is patellar maltracking.  The idea is that patellar maltracking increases patellofemoral compressive forces.  If the alignment is off and compressive forces increase then the structures underneath of the knee cap can get irritated and potentially damaged.  

 

How can we tell if this is occurring in our athletes?  We look to see if the knee is tracking over the 2nd toe.  We should see that the knees are not coming in while lifting and the toes are not spinning out further then the knees.  

 

[Note the optimal alignment on the left vs. toe out and knee-in on the right]

 

How does this alignment get out of whack?  This can happen for a variety of reasons:

1. Poor Mobility
   1. Limitations at specific joints can cause the knees to come in or the toes to spin out
   2. Hip
      1. External Rotation
         1. Posterior Hip Muscle Tightness
      2. Horizontal abduction
         1. Groin Tightness
   3. Ankle
      1. Ankle dorsiflexion
         1. Ankle Joint (Talocrural)
         2. Soleus
      2. Tibial Internal Rotation
         1. Joint Restriction
2. Weakness
   1. Hip
      1. Hip Abduction and External Rotation
   2. Foot
      1. Foot Intrinsics
3. Motor Control Issues
   1. Often times people have never been coached to keep proper alignment of the foot and ankle
4. Strength Issues
   1. When the load is too heavy our bodies can compensate in order to get additional strength to finish a lift

 

Generally for these athletes we need to figure out why they are falling into poor alignment and then coach them into better positions when squatting.  It may be a tall task to correct movement in these athletes but it will pay dividends in their long term knee health.  

 

Modification Key Points:

1. Cue proper alignment of knee over toe
   1. For squatting, lunging, step-ups, box jumps, pistols and all other lower body movements
2. Normalize ankle and hip mobility
   1. Modify depth of squat until the athlete can display healthy squat mechanics
3. Regress exercise difficulty
   1. Athletes will default to poor movement patterns when the load is too great.  Decrease load or difficulty of movement to improve maltrack and alignment

 

Knee Health Side Note:

 

Just as in the spine, shear forces occur in the knee while squatting.  Anterior shear forces on the knee are greatest as we descend between 0 and 60 degrees into a squat.  Posterior shear forces are greatest at 50-90 degrees.  If you have an athlete rehabilitating from a major ligament injury or they are lacking an ACL or PCL from a previous injury then shear forces become a more important consideration.  Shear forces tend not to be the largest factor in the fitness population that we see clinically.

 

Knee Pain Squatting Modifications – Exercises written from most stress on the knee to least stress

 

Front Squat → High Bar Back Squat → Low Bar Back Squat → Low Bar Box Squat (limited depth) → Hip Hinge Variations

 

Accessory Knee Health Exercises

• Based on the anatomy of the knees, the forces associated with pain and an understanding of the biomechanics of squatting we can give these athletes several exercises as homework to help them improve their knee health
• Mobility Work
  • Rear foot elevated ½ kneeling hip flexor stretch
  • Soleus Stretch and Foam Rolling
• Strengthening
  • 4-way resisted stepping
  • Single Leg Bridge Leg Lifts

 

Hip Pain During Squatting

 

Most pain problems in the hip we see regularly have something to do with a dysfunction called femoral acetabular impingement (FAI).  FAI generally occurs in the bottom of a squat.  The reason why this occurs is because of the boney anatomy of the hip.

 

Unlike the shoulder joint, the hip joint has a lot of boney stability.  This comes from a deeper hip socket.  In the shoulder, most limitation in the shoulder is coming from either muscular or capsular tightness.  In the hip joint our range of motion is limited in certain directions by the contour of the ball and socket joint.  What this means is that the reason for your limitation could be coming from bone contacting bone in the hip.  

 

What makes this worse sometimes is that everyone has a different shape to the ball and socket joint of the hip.  In some individuals they have a different shaped ball.  This is known as a CAM deformity.  In a CAM deformity there is extra bone on the ball portion of the socket.  

 

[Debell Link to Hip Variation Article]

 

Some individuals have extra boney coverage of the socket.  This is known as a pincer deformity.  Everyone also has a different position of their sockets (version).  Some sockets point more forward (anteversion).  Some sockets point more backwards (retroversion).  

 

What ends up happening in these individuals is that when they get into the bottom of their squat they get contact of the ball up against the socket.  This contact can compress or “pinch” structures in the front of the hip.  These athletes generally complain of a painful pinch or tightness in the front of the hip.  

 

They often associate this “tightness” as a normal sensation due to restricted hip muscles (usually hip flexors).  These athletes also tend to stretch their hip flexors due to the thought of muscular tightness in the front of the hip limiting their squat depth.  In reality, the “tightness” of the hip musculature is really a compression of structures in the front of the hip.  

 

[Rectus Femoris – Source: wikimedia commons]

 

The rectus femoris muscle is one structure that attaches on the anterior capsule of the hip.  It’s little wonder that it feels good to stretch this muscle after it’s been forcefully pinched after squatting.  Most athletes allow this pinching to go on until the pain is bad enough to force them to give up squatting.  

 

This misconception can be problematic especially because FAI is correlated with labral tears in the hip.  FAI and labral tears of the hip are also correlated with arthritis over time as well as more individuals undergoing total hip replacements later in life.  

 

Because of these reasons it’s extremely important that we don’t continue to deep squat in patients that present with these symptoms.  If squatting is painful it should be modified to eliminate pain.

 

Different Strokes for Different Folks

 

The next discussion we’ll have is about squat stance.  Ideal squat stance will vary widely based on the coach and the athlete.  There are world class athletes that squat with the toes straight ahead and world class athletes that squat with the toes pointed out.  There are world class athletes that squat with a narrow stance and world class athletes that squat with a wider stance.  What I’m getting at is that as coaches we should be more concerned about finding the stance that is best fit for the individual squatting in front of them.  We shouldn’t be trying to have our athletes conform to a specific stance.  This is because of the aforementioned differences in the ball and socket joint.  Limitations are coming from boney problems and that can’t be “mobilized” unless a surgeon wants to go into your hip and take some bone away.  

 

or?

 

Images source: Wikimedia Commons

 

I can’t tell you how many athletes I see with this problem and just a small tweak in their stance is enough to completely eliminate their pain.  Adding some toe out and widening the stance might be enough to clear the boney impingement in the hip and create enough space to eliminate the FAI.  

 

Modification Key Points:

1. Attempt to modify squat stance to eliminate symptoms

1. Increase toe out
2. Narrow or widen stance

1. Limit Depth of Squat Variation
   1. Box Squats
   2. ¼ Squats
2. Pick More Upright Squat Variations
   1. A more upright torso requires less hip mobility and can alleviate impingement
   2. Front and Overhead Squats in Substitution for Back Squats
3. Add Ankle Mobility
   1. More ankle mobility will decrease the need for additional hip mobility in a deep squat
   2. Mobilize the ankles
   3. Add a heel lift (oly shoes)
4. Modify pelvic position
   1. Extending the lumbar spine excessively and anteriorly tilting the pelvis will bring the socket portion closer into contact with the femur
   2. Ensure athletes aren’t overextending in the bottom of the squat

 

Squat Modifications (Exercises shown are from most to least challenging for the hip):

 

Back squat →  Front squat →  Overhead Squat →  Goblet Squat →  Box Squat (limited depth and upright) →  Split squat

 

Accessory Hip Health Exercises

• Based on the anatomy of the hips, the forces associated with pain and an understanding of the biomechanics of squatting we can give these athletes several exercises as homework to help them improve their hip health
• Mobility Work
  • 90-90 Hip Stretch
  • Soleus Stretch and Foam Rolling
• Strengthening
  • Off-set loaded split squats