Scaling the Squat

I just re-certified my CrossFit Level 1 Trainer course again (5 years has gone by quickly) and it got me thinking about scaling CrossFit movements. Here are some ideas for Scaling the Squat:

  1. Air Squat – your basic squat – goals are upright torso (relative to shins), hip crease below the top of the knees. Knees lined up with the toes (for most people). Neutral foot is really important here as well as sitting into your posterior chain (glutes, hamstrings).
  2. Making it easier:
    1. Don’t squat as low – for someone like me with some bony hip restrictions, this is what I have to do.
    2. Squat to a box: just tap your butt. See if you can shoot for the depth that just brings your hip crease below your knee, if not inch it up slightly so you can complete repetitions successfully.
    3. Sit to stand: don’t use your hands, once again same idea for the depth of the surface you are sitting on as above.
    4. TRX or Ring Squats: hold onto rings, Jungle Gym straps or TRX straps and squat back as far as you can, once again working on depth as tolerated.
    5. Sit to stand using hands for assistance – push off or rings, Jungle Gym or TRX works well. This could be done by almost anyone – this is what we do in PT with are most acutely ill patients, work on standing up.
  3. 1 leg doesn’t work as well:
    1. Pistol Squat: yes, it’s harder, but if you are strong and have a good leg and one bad leg, work on these.
    2. One Leg Squat to a box: tap your butt to the appropriate depth
    3. One Leg Sit to Stand: choose the appropriate height box.
    4. Step Up – choose an appropriate size step where you don’t have to vault or jump off your rear leg. Push the step through the floor.
    5. Lunge: most of your weight should be on the front leg.
    6. Rear Foot Elevated Split Squat: even harder than lunges.
    7. Assisted Lunge: hold onto Rings, Jungle Gym, TRX, Jerk Boxes, Box Jump boxes, etc.
  4. Make it Harder:
    1. Wall Ball
    2. Med Ball Clean
    3. Goblet Squat
    4. Back Squat
    5. Front Squat
    6. Overhead Squat
    7. Squat Clean
    8. Squat Snatch
    9. Weighted 1 legged squat
    10. Weighted rear foot elevated split squat
    11. Weighted lunge
    12. Offset kettlebell squat
    13. Double kettlebell front squat
    14. 1 arm overhead kettlebell squat
    15. 2 arm overhead double kettlebell squat
  5. Reps: a high level CrossFit Athlete squats about 60 times per minute. You should calculate the time it should take a high level CF Athlete to complete a workout and adjust reps accordingly. So if you squat 30 times per minute, decrease the number of reps of squats by 25-50%. Your workouts should probably take about 50% longer than the high level CF Athletes at most to get the desired stimulus.

 

Do you know your movement faults?

Are you aware of your movement faults from head to toe?  What about prior injuries, do you have to do anything to prevent them from coming back?  Do you have a “bad knee (shoulder, back, neck, ankle, hip, etc.)”?  How do you take care of it?

Your exercise routine should include ways to help manage all of these issues.  If you don’t know the answers, let me help you learn about yourself with a movement assessment?  Think of it like a semi annual checkup.  You go to the doctor and the dentist regularly, why not your physical therapist?  I can help you allow your body to age gracefully.

Call me 224-377-9327 or email me: jason@jasonsweas.com to set up a movement evaluation.

Heel Pain / Plantar Fasciitis

Plantar Fasciitis is one of those feared diagnoses as it takes a long time to get better. Fortunately, there is quite a bit of research on heel pain.  If you have plantar fasciitis, and you are in rehabilitation, your treatment should consist of the following (based on a clinical guideline published in the Journal of Orthopedic and Sports Physical Therapy in 2014):

Education
>Correct footwear – making sure shoes are not too old, and provide sufficient support
>This diagnosis is slow to heal and will take 3-12 months
>The problem is due to mechanical stress from an increase in activity.  If you are a runner who has developed this, you may have increased mileage too fast.  If you are overweight, you probably increased the amount of weightbearing activity too fast.

Manual Therapy:
>Joint mobilizations to improve talocrural joint mobility
>Soft Tissue mobilization should address the gastrocnemius and soleus as well as the plantar fascia.

Exercise:
>Stretching: stretch the plantar fascia and the gastroc / soleus.   Secondarily, address hamstrings, quadriceps, hip flexors.
>Strengthening (although not addressed specifically in the review, this was released last year): initiate plantar flexion strengthening with the great toe in extension.   Work on this every other day at an intensity of a 12 RM for 3 sets (https://www.researchgate.net/publication/264936255_High-load_strength_training_improves_outcome_in_patients_with_plantar_fasciitis_A_randomized_controlled_trial_with_12-month_follow-up_HL_strength_training_and_plantar_fasciitis)

Supportive Resources:
>Taping: support the foot into antipronation taping
>Night Splints: wear for 3 months
>Orthotics: use off the shelf orthotics for 3 months

http://www.jospt.org/doi/abs/10.2519/jospt.2014.0303#.VdvIzYgViko

 

 

3/4 of the way to CEEAA

I have passed the practical and the online test after the second weekend.  One more weekend and one more test in October and I’ll be a Certified Exercise Expert for Aging Adults.  This has been one of the best continuing education experiences I have been through and it is mostly due to the high priority on using evidence to support decision making.  I personally feel much more confident when I know there is research backing up my clinical decision making.

Rehab Exercises to Help You Over Time

A patient recently asked me about some exercises that would be beneficial to continue over time.  I strongly support evidence based and international guidelines.  The World Health Organization has some basic guidelines that I use all the time.  And while my bias is toward squats, deadlifts, horizontal upper body pushes, and pulls, then vertical upper body pushes and pulls (if the body allows it), I came up with a few really basic ideas for complementary rehab exercises.  This is largely based on many of the deficits I see in my patients.  Here they are:

1) Upper back strength with horizontal abduction or rows

2) Rotator cuff strength – specifically external rotation (at the side or 90 degrees abduction)

3) Posture

a. Awareness at the computer

b. Awareness when standing around

4) Abdominals / core with forward and side planks

5) Sit to stand with double leg at a minimum, but single leg is preferred (watch the alignment)

6) Lateral hip strength with side steps

7) Balance on one leg with eyes closed ideally, but open if needed

Adhering to the WHO guidelines above should cover all of these things with the possible exception of the rotator cuff strength.

SFMA Certification

SFMA_Certification_Exam

SFMA came out with their official certification this year.  I’m happy to share that I passed the test, it was pretty easy after doing the SFMA for 3 years now.  I am excited about their updated forms and will start using them soon.

http://functionalmovement.com/experts/jsweas

I’m also working on a Certified Exercise Expert for Aging Adults certification.  I passed the written test and the practical test is coming up in July.

Outpatient Total Knee Rehabilitation

I have seen most patients coming to me for outpatient total knee rehabilitation doing quite well after their initial stints in Acute Rehab or Home Health.  I find that my biggest role is to make sure people understand what the next 12 months will be like and to help them manage independently.  Here are my main guidelines:

1) Pain Science Education: Yes, you went through pretty severe trauma, so pain is ok, don’t be afraid of it, it definitely doesn’t indicate anything is wrong, you’re just healing from a surgery where someone took a saw and cut off the ends of two of your bones and hammered in metal parts (not to mention any soft tissue lacerations to see the bones).  It’s ok to be in pain.  Use meds as needed and remember the pain will get better.

2) When your knee is warm, it is moldable.  I use a warm metal analogy.  A blacksmith can mold metal if it is hot, and your knee can gain or lose range of motion if it is warm.  This assessment is really easy, compare the temperature of your knees, the surgical one is probably warmer.  Keep stretching every day until it cools down (this will probably be 4-6 months post op).

3) Don’t manually stretch knees.  Get someone on a bike, have them start at a high seat where they can go around easily.  Pedal there for a minute, then lower the seat level.  Every minute you should lower it a little more.  You’ll find flexion improves pretty quickly.  For extension, elevate the leg on a block / cushion at the heel and put weight on the knee.  Tell the person to stay there as long as they can tolerate it.  Shoot for 5-10 minutes, 2x/day.  Use any other pain modulating manual therapy techniques to ease these motions.  But with both of these, the patient is in control and can have a successful outcome.  I’ve seen a couple of nightmare joints where the patient clearly didn’t have control during stretching and the result was a knee that didn’t bend ideally and had long term residual spasm.

4) Strengthen the knee as much as possible with closed chain activities (this applies to everyone).  Sit to stand, step ups, floor transfers.  Then progress to more aggressive strengthening if they want to do it.

Infraspinatus pain or trigger points?

Are you struggling with infraspinatus trigger points, tightness or pain?  You might also have trigger points in your levator scapula and pec minor.  I  have a theory that this is a result of poor use of your upward rotation force couple neuro tag.  Serratus anterior, upper trap, and low trap should be working properly to rotate your scapula upward and decrease any impingement stresses.

If this is not occurring correctly, the glenohumeral joint elevates (flexes or abducts) with the anterior delt, biceps, etc. and the body runs out of motion around 120 degrees.  As those flexors start to bunch up, the work to go much further is difficult, so the scapula starts to get pulled upward by humeral adductors that attach to the scapula (infraspinatus, teres minor, teres major, and subscapularis).   I think infraspinatus becomes the main culprit because the shoulder is usually in relative internal rotation (ask a lot of people to raise their arms overhead and note which way the palm is facing) and it is put on tension in that position.  Passively placing the scapula in this upwardly rotated position should help alleviate any tension in the posterior shoulder.
Here are a couple of great ideas for helping improve this, thank you to Eric Cressey for putting out some great free material on youtube.
I also like to visualize the serratus actively upwardly rotating the shoulder blade to initiate an overhead lifting motion with a scooping motion.  Focusing on the elbow and going bottoms up with a kettlebell seems to help as well.

Movement Systems Approach to the Lower Quarter

After spending more time with the Movement Systems Impairment approach to evaluation and treatment, I’ve been feeling my entire exercise approach is more integrated than ever before.  Specifically, the lower quarter has been easier to treat and I’ve been looking at all my more primitive position exercises as a specific preparation for upright postures.  Specifically, I’m seeing positive results in treating knee and lateral hip pain.  As much of the research on these areas suggests, hip abduction weakness is a key component.  From a movement impairment perspective, this is easily seen with a pseudo trendelenburg gait pattern (I say pseudo because it is not true neurological weakness).  I find this pattern to be most apparent during both walking and running gait and on stairs.

Looking more specifically at exercises, here is a list of things that I use and how I try to integrate them into treating the movement impairment.  I’ll use a primitive pattern on up perspective:
1) Can the patient perform sidelying hip external rotation with the knees flexed to 45 (clamshell)?  The reason this exercise is important is because it tells me whether the person has any awareness of the hip abductor / external rotator muscles that I want them to use.  It also shows me how much they want to compensate with a hip abductor / flexor (TFL) and how much they would rather move their spine instead of moving their hip (relatively flexible spine). This is also very similar to the position of standing with one foot on a step and beginning to step up.
2) Can the patient perform hip extension in hooklying (bridge)?   This exercise once again tells me about hip extensor vs. lumbar extensor awareness and ability to utilize glutes vs. hamstrings.  Cramping of the hamstrings tells me we are a long way off from getting to doing anything standing up.  Eventually this exercise needs to get progressed to 75% of weight on one leg and finally to a single leg bridge.  It is crucial that the lumbar extensors do not substitute and the person does not feel their quadriceps working here – if you do, expect either anterior knee pain or lumbar extension pain.  Lastly, similar to the sidelying hip external rotation exercise, this is the same position as one would be when putting a foot on a step and preparing to step up.  This can be progressed to a hip thrust for those who have more problems walking or running vs. on stairs.
3) Can the patient perform kneeling to tall kneeling with a hip hinge?  The shoulders should remain above the knees throughout the movement and the glutes should drive the movement.  This is obviously very similar to a bridge, so once a patient can bridge, they should be able to connect these two movements.  This will be what I’ll ask the person to do on a step as well, lift up with their glutes.  I wish I had a way to do this unilaterally, but I haven’t quite figured it out.
4) Can the patient perform a standing hip thrust with a dowel connected to a band?   This is an extension of the kneeling to tall kneeling.  This gives great feedback of the hip thrusting motion that is required to step up with a hip extension dominant pattern.
5) Can the patient perform a standing hip hike with the stance leg hip abductors and contralateral abdominals?  It’s important that the contralateral side does not move into hip flexion and anterior tilt and that the stance side moves from hip adduction toward hip abduction (the outer hip should move in).  Inability to perform this movement suggests that it will be that much harder to do so while stepping up.
6) What is the result of stepping up with the shank stabilized?  I like to hold the shank (or lower leg) still and have the person attempt to step up and over the leg.  If this alleviates knee pain (more likely than affecting hip pain), then my diagnosis is a knee extension dominant pattern and the person need to work on hip extension patterning as much as possible.  If there is still a trendelenburg pattern present, hip pain may still be there and the next exercise / test should be checked.  I start this exercise with just holding the lower leg steady and then I progress the person to using my hands as guidance to where the lower leg should not go.  The goal is to remove all external feedback and for the patient to visually or proprioceptively detect where his or her lower leg is in space.
7) What is the result of hiking the hip of the down leg prior to stepping up?  If the patient can do this and maintain the position during the step up, hip or knee pain may be reduced.  This suggests hip abduction strengthening in this pattern needs to be repeated until this becomes automatic.  Performing Gray Cook’s RNT techniques (pulling the knee into valgus with elastic resistance) is a good option here.  If this cannot be controlled, the patient may need UE support to maintain the opposite hip hiked position or may have to be regressed to more basic hip abduction exercises.  This may include seated hip IR.
8) Can the patient exert equal force through each leg during a step up?  I have been experimenting with putting a scale on a shorter step and having the patient load the scale prior to stepping up.  It has been interesting to see deficits in ability to load a weaker or painful leg prior to stepping up, even though the loading it self is not painful.  This suggests a pattern of disuse to me, which seems to improve fairly quickly with proper cuing.
9) Can the patient walk with steady hips?  Have the patient walk with steady hips and see how it feels.
10) Is the gait pattern off?  The biggest problems I see here are feet that are turned out too much (but check tibial torsion before you tell someone to walk with their feet straight) and hyperextended knees upon heel strike.  The normal pattern is a slightly flexed knee upon heel strike that continues to flex with weight acceptance (Neumann, Rancho Los Amigos).

These are some of the main things I look at, but I also want to see if people can perform a side step exercise by pushing or reaching with either leg and for the person to help me understand if they feel asymmetry.  This can be visually detected as well with practice, but many patients will understand.

For sit to stand, elevating seat heights and deadlifts make great training tools (although deadlifts have to come after bridges and kneeling to tall kneeling).

Lower abdominal progressions become more important depending on the results of the top two exercises above.  This could span from Sahrmann’s lower abdominal progression to some of the DNS exercises 3 month, 4 month, 5 month positions, rolling supine to sidelying (hard rolling).  Anti Rotation presses (or pallof presses) are a good option here for abdominals.

Foot and ankle problems can be harder to treat due to chronic changes in structure, but trying to stop the provocative movement pattern is the best place to start.  A tripod foot is always a good place to start to look for where the person should be.