This is Brent of the Brookbush Institute. In this video, we're going to go over two
less common signs in the overhead squat
assessment. We're going to go over a posterior pelvic tilt, as well as an
inadequate forward lean, and the reason why these two are in the same video is I
think, once we break down the dysfunction,
you're going to see these two things are very related. We're also going to take a
moment to discuss whether that posterior pelvic tilt, seen at the bottom of a deep
squat, sometimes referred to as a "butt wink" is a dysfunction, or just a sign
whether we've taken range of motion too far. I'm going to have my friend, Melissa,
come out. She's going to help me demonstrate.
Now the posterior pelvic tilt and the inadequate forward lean are two things
best seen from a lateral view.
So just to save some time in this video, I'm going to go ahead and have Melissa
set up so you guys have a lateral view.
One thing I need to point out is I need you to ignore this heel rise.
This was not my attempt to do an overhead squat assessment with
modification.
This was my attempt to cheat, because Melissa is missing some dorsiflexion.
The individuals who have this dysfunction generally do not lack
dorsiflexion, which is one of the reasons why these dysfunctions are so rare.
Just to get her to demonstrate the compensations we're looking for,
I had to give her some dorsiflexion back.
Other than that, we will start the same way we always do. Her second toe is pointing
forward. Her second toe should be lined up with her ASIS, or her feet underneath
her hips.
I'm going to have her reach up to the ceiling as high as she can, and then the
first thing Melissa is going to actually show us is an inadequate forward lean.
It's nice and slow.
These are sometimes referred to as "knee squatters." I think as Melissa does
this again, you can see her knees just jut straight out.
Right, her back is somehow maintaining relatively straight, which looks kind of
odd, right? You can see a lot of load getting transferred into those knees. Now
she holds the bottom for me, just as a textbook definition here,
I want you guys to note that tibia-torso angle is not parallel.
It's the opposite of an excessive forward lean, right? Now instead of
crossing at the head, these two lines, they're crossing down towards the feet.
All right, go ahead and come back up. So that's the inadequate forward lean.
Now that is a sign if we see it without a heel rise.
I should note that if you were doing a squat with modifications, which included
heel rise, to try to differentiate whether lower leg dysfunction is
involved. And you saw the inadequate forward lean,
that's not a dysfunction. So with heel rise,
not a dysfunction. Without heel rise, if you see an inadequate forward lean,
definitely a dysfunction.
The next thing we're going to talk about is a posterior pelvic tilt.
So Melissa's got her arms up, and what you'll notice is, all of a sudden, she gets
that tuck under fairly early in her squat form. Now, I've set her pants up so
that they're level with her PSIS and ASIS. You can see she's pretty level here when
she starts, but almost as soon as she dips down into that squat, here PSIS's drop.
She loses the lordosis in her lumbar spine.
Let's have you kind of, go down to the bottom there. You might even notice that her, her
trunk is collapsing. Right? She's actually going into lumbar flexion as she squats.
We can, we can imagine that's not a very healthy thing to do. Now you might
see the two things paired. She might go into a posterior pelvic tilt with an
inadequate forward lean, and I think what you guys will start to note, if you kind
of use your imagination, think about dysfunction, is there's no forward lean, and
a lot of force going through the knee.
Alot of these individuals are people who are past some sort of lumbar
pathology.
They're trying to protect their low backs. They almost have a fear of bending
forward. Thank you, Melissa.
So let's talk about the, let's talk about the actual dysfunction itself, which
muscles are overactive, which muscles are underactive. It gets a little
complicated here, because this is ,this is a tricky one.
We probably could figure out that our posterior hips are tight somehow.
But that kind of leads to this idea that our glute max is tight.
I've mentioned in previous videos, your glute max is not a muscle that gets
overactive. Never once in my entire career, have I came in to my clinic, to my
office, and had a patient walk in and go, "you know what Brent,
my ass is just too tight." You guys can imagine, that doesn't happen.
These are muscles that tend to get droopy. So it's not that I need to
stretch my glutes,
even though they almost appear short in this one.
This is actually the perfect example of synergistic dominance gone awry.
Right? Take it up another notch. The muscles that are overactive are all those
synergists of extension. All those synergists of external rotation. All
of those muscles that connect into
the sacrotuberous ligament, have something to do with that deep
longitudinal subsystem. Your piriformis, biceps femoris, adductor magnus, all go
in to overdrive, and they all become really, really, overactive trying to find
a way to not only extend the hip with a glute max that is inhibited,
but also maybe, pull down that sacrotuberous ligament to stabilize the SI
joint.
We also have a big, big, overactivity of our global core muscles.
You might notice these are also the people who, just bending over like, picking
up their purse ,or sit down into a chair, or pick up a pencil up off the floor,
they don't do the drawing-in maneuver, they flat-out brace. These are all the
muscles involved in bracing--rectus abdominis, external obliques, with like
bearing down, just to pick up a pen.
That's not a, that's not a great sign. Now the muscles that are under-active, as we
have synergistic dominance of your piriformis, biceps femoris, and adductor
magnus, your glute max and glute med have said, "well if these guys are going to do
it,
why would I even get involved?" They just kind of shut down. So we have this little
careful balance to play.
Although these muscles are also involved in extension, they're also involved in
external rotation.
We still need to get them active without contributing to further over-activity of
piriformis, biceps femoris, and adductor magnus. You'll see some under-activity,
some inhibition, of the transverse abdominis and multifidi.
Again, these are people who are bracing to try to stabilize their lumbar spine.
Generally speaking, these are not individuals who know how to just draw-in
and relax, and bend down. Alright, so here is the dysfunction itself.
The question then becomes, how do we fix it?
So we just go back to our, our basic model here.
What am I going to release? Well, I'm going to release all the things that are
overactive. So my piriformis, biceps femoris, adductor magnus. Getting a little
bit in arthrokinematic dysfunction, generally these people have a hip that
has moved anterior and superior, or femoral head that's moved anterior
superior, relative to the acetabulum, and lumbar facets that are almost
stuck open.
So this is going to require some mobilization. You guys got a couple
of self-administered hip mobilizations. This can be done manually by licensed
professionals.
Same thing with these lumbar mobilizations. This can be
done using, something like an open book, or Mckenzie press-ups, or can be done
manually if you're a licensed professional. Strengthen, I'm sorry
lengthen.
We're going to lengthen the same muscles we release, as always.
So you guys need to go back if you don't know stretches for the piriformis, biceps
femoris, and adductor magnus. You need to look those up.
What are we going to activate? We're going to need some glute max and glute
med activation, right? So that, that activation circuit, or individual
exercises to start slowly strengthening the glute max and glute med are all
going to help in this process. Note,
you can't just do this, though. If you start to try to do clams and side-lying
leg raises before you've released your piriformis, biceps femoris, and adductor magnus - all
you're going to do is start gearing piriformis up, specifically. A clam before
piriformis release is definitely going to be a piriformis activator.
Core- lots of quadruped progressions. So, I have all those quadruped
progressions for you guys. Everything from just the standard quadruped with
marching of the hands, all the way to that crazy, dynamic quadruped, which we
saw Melissa sweating on when she did the video. And then this is the tricky
part.
How do I get somebody to gain back that eccentric control of hip flexion so
that they'll start leaning forward. And that's where that deadlift with
posterior pull of the band comes real handy. So if I put a band pulling this
way, and then ask him to bend forward, that helps to get that cue in to sit back.
It also ensures that their glutes stay active as they come back up and thrust
against that band. So watch that video.
This exercise- very, very, helpful for somebody who doesn't want to lean
forward. That band ensures that if they try to stay upright this way and just
squat with their knees,
they're going over backwards. Now, the last thing we want to talk about is, is
that posterior pelvic tilt at the bottom of a deep squat, dysfunction? I'm going to
have my friend, Melissa, come out. She's going to help me demonstrate what I'm
talking about.
Once again, we're using the heel rise just because she lacks some dorsiflexion.
But if she were to do this deep squat, ass to grass, right, you notice how
everything tucks under the bottom? Right, and back up.
Let's go back down again, and back up.
Good. Thank you, Melissa.
The question you have to ask yourself before you automatically assume that
Melissa has a butt wink, and what I need to work on is hip flexion mobility,
you should probably test hip flexion. So normal hip flexion is a 110 to
135 degrees. Let's say a 125
degrees is a normal range of motion.
If you lie somebody on their back, go over that goniometry video, if you
don't know hip flexion goniometry. You bring their hip flexion up,
they have a 125 degrees, you can't say that that's a
dysfunctional movement pattern. What you can say is you pushed range of motion
too far for that particular individual.
Now we do have to throw out there,
I understand that some individuals in strength sports are going to be required
to squat "ass to grass." If you're tilting at the bottom of your deep squat, and you
have normal hip flexion,
you're going to have to decide whether your sport is worth the risk to your
orthopedic health, and this is the decision we all have to make in sport. I
play basketball.
I know it's very hard on my knees. It can be hard on my neck, which I've had some
previous injuries with, but I go ahead and keep playing because I know being
active is definitely healthier than not being active.
We also have to decide that if this isn't somebody's sport. If you are
squatting just for general strength or general health and fitness, or
performance in a field sport,
you probably want to stop their squat depth before they tuck under,
because of the potential risk for low back injury. As I said, these individuals
with posterior pelvic tilts, these individuals with inadequate forward
leans, most often have a history of either hip or lumbar spine
pathology, which brings me to my last point. If you try a corrective exercise
program and you do not get the results you're looking for,
you need to refer out on this one. It's not a very common sign because it is a
post-pathology sign in most cases. It is very rare that I come across a posterior
pelvic tilt or an inadequate forward lean, and that person doesn't have a
history of injury. So,
there you go guys. Two less common signs that we do see on the overhead squat
assessment that you are now aware of - a posterior pelvic tilt, an inadequate
forward lean. You now know how to differentiate on whether that posterior
pelvic tilt at the end of a deep squat is dysfunction or not, using hip flexion
goniometry, and you even know the history that many of these individuals
will come in with. I hope you enjoyed this video. I look forward to talking to
you again soon.