I pretty much make all my patients squat. If you have been a patient in past clinics, or you are currently one at Arrow, you are nodding your head in agreement. As a physical therapist who for years, has mostly treated patients with hip pain, I have came to note that learning to squat was key!
In prescribing the squat, it has become clear to me that many people are not comfortable squatting, have been told not to, or, for whatever reason, just don’t do it as part of their regular routine. I would like to spend some time reflecting on this and discussing why it is my clinical opinion that you should be squatting, whether you are or aren’t a patient with hip pain.
If done properly, the below-parallel (hips just below the knees) squat position is a perfectly natural position for the human body. Below, I have outlined some reasons why the squat is a safe and important exercise for humans:
1. The ability to fully squat is a good indication of one’s overall fitness level and biomechanics.
Squatting is a task that requires both trunk stability and extremity mobility. Ankles, knees and hips must flex while the core must remain strong to maintain an upright torso. The squat is a functional movement that I want even my older adult patients to be able to perform in order to help in maintaining independence and fitness. I want them to be able to reach the floor to retrieve something without causing undue stress to the low back by bending over at the waist or pain in the knees by squatting improperly.
2. Correct squatting will assist in strengthening the entire body from gluteals to hamstrings to abdominals to thoracic extensors.
As previously mentioned, squatting requires core stability in order to achieve and maintain an upright trunk. Additionally, squatting can strengthen the posterior chain (gluteals and hamstrings). By breaking parallel with the thighs during a squat, the gluteals and hamstrings can be fully recruited in order for this strengthening to occur.
It should be mentioned here that many doctors and trainers believe that quarter or half squats are safer for the knees than a below-parallel squat. However, bending the knee only 15-30 degrees actually yields the greatest force across the ACL. Studies show that there is less force on the cruciate ligaments of the knee (ACL and PCL) with knee flexion of 60 degrees or greater, making the below parallel squat safer for the knees than the quarter squat. Additionally, increased hamstring recruitment can lower the anterior stresses on the knee. Read more about various squat positions here.
Finally, squatting can improve your hip, knee, and lower back pain through proper strengthening of the supporting structures. There is literature to support that in addition to muscles, bones and connective tissue are also strengthened in response to resistance training.
3. Proper squatting can help to retrain poor motor pathways and reduce a quad dominant pattern, aggravated (and sometimes caused) by chronic sitting.
Again, squatting requires trunk stability, posterior chain recruitment, and extremity mobility throughout a dynamic movement. None of these are required in order to sit for long periods of time. Without getting too off topic, I would like to state here that sitting is the new smoking! Some resources on the issue include:
Not only is sitting affecting our medical profile, but it is affecting our physical anatomy. From poor cervical positioning to forward shoulders to a posterior pelvic tilt, poor core strength, tight hamstrings, and an anterior femoral head position, sitting is not an ideal posture to assume for several hours at a time. And since, on average, Americans sit for more hours per day than they sleep (insert your best shocked face here!), it is imperative that we move our bodies in ways that might address these impairments – correcting them over time.
4. Squatting is useful in reducing pelvic floor dysfunction.
This is thought to be related to when people do too many Kegel exercises and not enough gluteal exercises. Imbalance between these muscle groups can pull the sacrum inward. To balance this anterior (forward) pull, patients need to perform gluteal exercises, including, but not limited to squatting. Additionally, if a person has caused tightness to their pelvic floor through over-recruiting and over strengthening the muscles, they may consequently find difficulty contracting those muscles when they need to. A weak muscle may be unable to produce force because it is tight and/or short. If this is the case, concentrically strengthening the muscle might not be the best option. Perhaps it needs to be lengthened, and this can be achieved with squatting, as the glutes and pelvic floor muscles go through an eccentric phase of lengthening during the descent and are on full stretch at the bottom of a squat. There is a great explanation of this here.
5. Squatting is a natural, every-day task.
6. Adding squatting to your exercise routine can increase exercise efficiency.
Wikipedia’s definition is that “efficiency generally describes the extent to which time, effort or cost is well used for the intended task or purpose.” Essentially, squatting is an exercise that brings a lot of bang for your buck. When done properly, heavy squat sets not only increase strength but also tax the system cardiovascularly. Full body exercises such as the squat increase natural hormone release and are a great stimulus for muscle growth.
To reiterate, squatting is natural and should be safe. Historically, squats have received a bad reputation for causing low back, hip and knee injuries. But, perhaps the issue is that we have gotten out of the habit of squatting and are performing the task incorrectly. Have you ever noticed that a small child displays perfect squat form? Almost all young children will demonstrate correct technique for the squat when they move to pick something up from the floor, yet they have had no coaching at all in how to perform the movement. So why is squatting so difficult, even painful, for many grown humans? Many would argue that it has much to do with the fact that in developed countries, we use our bodies in many ways that we are not designed to (ie. sitting at a computer all day).
Of interest is that adults and children do squat differently for several different reasons. Do not be fooled and please do not be dogmatic about this or other squat technique - everyone has a snowflake squat! I love the way this article explains why we don't squat like babies.
I am not indicating here that squatting is for everyone. There are certainly conditions or circumstances to consider when assessing if a squat is appropriate or not. We will not go into that here and patients should speak directly with their physical therapist about their specific situation. Additionally, correct squatting technique is of upmost importance and often needs to be refined by a physical therapist, coach, or athletic trainer.
This article will not address how to squat properly or how to fix the below dysfunctions. However, if you are squatting and having difficulty achieving full depth or correct positions, you might consider a meeting with a physical therapist or other movements specialist. Below are some common faults associated with incorrect squatting:
Poor ankle mobility
Poor hip mobility including hip impingement
Quad dominant patterning
Poor thoracic mobility
Lack of core stability
These are some tools to get started. So, let’s sit less and squat more! And if squats DO cause pain, please do not push through. Seek professional help and see what can be addressed mechanically.