A Deep Investigation into the Safety and Performance of the Deep Squat: Part 5 – Hip Health, Should we Squat With the Toes Straight Ahead?

By djpope

December 6, 2015

cam, deep squat, deformity, FAI, femoral acetabular impingement, Hip OA, Hip Replacement, hip. Squat stance, Labral tears, labrum, pincer, Retroversion, squat, Toe out

So last week we discussed what the hips needs to do in a deep squat and what compensations occur when we lack hip flexion in the squat. Before moving on I wanted to recap these compensations:

Compensatory lumbar flexion or low back rounding
Hip external rotation and horizontal abduction of the hip
- In this case our athletes compensate with a wider stance and increased toe out (Remember the example above in the supine knees to chest test where our athletes can get the knees to the chest with exaggerated knee out position but not with the knees closer together). You see this scenario a lot in individuals that lack pure hip flexion and internal rotation motion.
Hip internal rotation and adduction of the hip
- This scenario happens frequently in individuals that like a wide stance during the squat (Think powerlifting, low bar back squat). These athletes struggle with knee position during a squat (particularly at the bottom of the squat). Tight adductors would create some compensatory knee-in at the bottom of the squat as those muscles are being lengthened with increased hip flexion

We also spoke about muscular and joint limitations in the article and ways to correct these. What we didn’t talk about was specific boney limitations that can limit our squat.

Now, what about these boney issues? Well, as opposed to the shoulder joint, the hip is a pretty deep ball and socket joint. It has quite a bit of stability coming from the socket portion of the ball (femoral head) and socket (acetabulum) joint. Because of this, in deep flexion (and internal rotation) we may be getting some abutment of the femoral head into the acetabulum. This usually occurs in the anterior/superior (front/top) portion of the joint and people typically complain of a pinching sensation in the front top of the hip. The medical term for this when it becomes symptomatic is femoral acetabular impingement (FAI) syndrome.

Note: How many people have told you that the front of the hip feels “tight” at the bottom of the squat? Is this truly a muscular tightness?

The reason why this can become an issue is because we can’t really change the shape of our boney structure (Unless you want to go for a surgery). Also, if we stretch/train through these symptoms we may be potentially worsening the situation. Boney FAI is linked to acetabular labral tears, early osteoarthritis and subsequent total hip replacements in the medical literature (2). Now that I’ve thoroughly scared you, let’s dive a bit deeper into FAI and squatting shall we?

If we look through survey literature about where injuries occur in weightlifting and powerlifting, the hip is not an area that is typically injured (1). However, as a physical therapist I see my fair share of hip problems. Patients come in and complaint about hip pain, tightness or pinching in the front of the hip/groin area at the bottom of the squat. Now as we discussed before, I think we know what may be happening.

**Disclaimer: This is not an article designed to diagnose and treat medical conditions. If you’re training with pain of any type please go see a doctor to get it checked out.

There are 4 types of boney impingement that correlate with FAI. They are:

CAM deformities – Basically the neck of the femur is overgrown and the femoral head is shaped like a CAM shaft
Pincer Deformities – The acetabulum is deeper in nature
Femoral Retroversion – The socket and femoral head face backwards when the femoral head is situated in the center of the socket
Coxa Vara – The neck of the femur is flatter then in a normal individual

In each of these situations our athletes will be more likely to have boney abutment of the femoral head against the acetabulum at the end of their range of motion.

The reason why it is important to understand this is because the test positions for FAI as well as the bottom position of our squats can start to look a bit like what causes this abutment to occur. Take a look at the flexion adduction internal rotation test for anterior/superior FAI in the image above and right. If we have our athletes squat with a narrow stance and bring the toes facing ahead or inward, we could be creating this same boney abutment.

How can we tell if we are dealing with athletes that may potentially have these issues? Well unfortunately we aren’t human X-ray machines but we do have a few tests that help us determine who may have these issues. As a coach / therapist what can we do?

Those with CAM deformities typically present with less hip internal rotation ROM (Hip IR deficits correlate with CAM deformities)

Femoral Retroversion can be assessed using the Craig’s Test

Athletes with a history of playing specific sports are more likely to have boney deformities and subsequent hip osteoarthritis (Ice Hockey, Soccer, Basketball, Handball, Raquetball)
Athletes with a prior history of hip injury (Having to seek medical attention due to an injury, having to stop playing your sport due to an injury, fractures, internal derangement of the hip, dysplasia)
This is not an evidence based guideline but I’d also include anyone who is complaining of symptoms (pinching/tightness in the front of the hip) during a deep squat or with the above shown flexion, adduction and internal rotation test.

As a coach, if I have an athlete where I throw the kitchen sink at them and they aren’t making improvements over a large period of time and or they are complaining of anterior/superior hip pain during a deep squat, I’m not going to press the issue. Chances are, they’re dealing with something that can’t be fixed without surgery and I may be making them worse potentially. Also, the areas that tend to wear on the acetabulum do not tend to have good blood supply and therefore don’t tend to heal well.

Also keep in mind that in individuals that have FAI diagnostically confirmed, they present with a more shallow squat and less hip internal rotation range during the squat(4). As a coach, these are 2 situations that might have you start re-thinking mobilizing their hips.

What I think is the most challenging piece of the puzzle is that a large portion of hip deformities and labral tears don’t produce any symptoms at all. However, these individuals are more likely to eventually undergo total hip replacement surgery due to hip arthritis in time (Potentially they have more wear and tear on the hip joint over time but don’t feel anything until things get pretty damaged in there). Whether or not modifying your squat stance has any effect on this who knows at this point but I do believe it is a point worth considering.

Given this knowledge I have difficulty recommending that all athletes use the same squat stance. Everyone’s hips are shaped differently, for a more visual demonstration check out Ryan Debell’s article HERE. Chad Vaughn recommends between 5 and 15 degrees of toe out during a squat. Individuals with deformities may have to be closer to the 15 degree mark. I’m sure some individuals may have to be even greater then that or potentially gain more motion at the ankles / tibia to make up for a lack of motion into pure flexion.

Keep in mind that you can also alter the squat by varying the depth and stance width, all of which can be potentially important in the athlete with FAI. At the end of the day we’re looking for the ideal squat but ideal will need to change from person to person.

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