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Case Study: Squat Clean Analysis for Left Medial Knee and Anterior Hip Pain

by onsite, November 2, 2016

Discussion of Elite Female Athlete’s Movement Pattern and Biomechanics.

As coaches we often cue athletes to “Drive the knees out” as the athlete descends during a squat. From a biomechanical perspective, the reason we do this in my opinion is for two reasons:

  1. Avoid Knee Valgus Collapse: Many athletes present with knee valgus collapse, which involves the femur rotating internally with relative tibial external rotation. This shows up as a position in which the knee is medial to the hips and ankles.  By cueing the athlete to drive the knees out we can avoid this common movement dysfunction

2. Facilitate hip external rotation: by telling the athlete to drive their knees out, we are also trying to get the athlete into a biomechanically advantaged hip external rotation position. Our hip joints are very strong and stable in this position, and we get increased activation of the gluteal musculature, rather than dominating with the quadriceps musculature.

In Bri’s example, when looking to correct her squat technique we discussed how she is driving her left knee out too far, to the point where it’s not tracking appropriately over her 3rd-4th toes.  We see this sometimes with hypermobile athletes that have extensive joint flexibility.  She is focusing only on driving her knees out, rather than maintaining a hip external rotation position.  Always focus on starting movements at the hips, as a very common movement compensation pattern is to initiate power lifting movements at the knees or lumbopelvic region rather than with the hip joints.

Controlling the transitional component of the squat.

 Maintaining good biomechanical position of the spine, hips, knees, and ankles when transitioning from descend to ascent of the squat is very challenging.  This becomes even more difficult for a hypermobile athlete like Bri.  Most individuals begin to experience tightness in the hips, ankles, or spine towards the bottom of the squat, helping them to know how long to maintain tension in their posterior chain musculature.  However, an athlete that has more than normal (or even more than needed for functional movements) mobility throughout the body will have a difficult time learning how to control to bottom portion of the squat.

If we watch the video closely, we see several things break down as Bri transitions to begin lifting up in the squat.

  • The left knee moves excessively from a position too far outside the toes, to a medial position rather than staying nice and stable in line with the 3rd-4th toes. Because Bri isn’t attenuating force appropriately through her hips and core, excessive force is traveling downstream through the left knee.
  • It’s a bit tough to see from this angle, but her trunk shifts slightly to the right, and the right shoulder shoots a bit forward. I believe this helps explain why the right heel occasionally comes up off the ground.  Anytime we have asymmetrical loading through trunk, hips, knees, feet, ect its bad news.
  • Finally, when viewing Bri from the side (which wasn’t shown in this video) we see an overextended lumbar spine anterior pelvic tilt moment when transitioning up at the bottom of the squat.  An example of this is demonstrated in the figure to the right.  This is the exact point where Bri reports “pinching” or tightness in the anterior aspect of the hip.  Most athletes having these types of symptoms believe that they have a hip mobility limitation or “tight hip flexors.”  When breaking down Bri’s anatomy she had neither of these findings.  Rather, she was using her hip flexors as a core stabilizer inappropriately due to an anterior tilted hyper-lordotic lumbar spine posture.  Now, when testing in isolation, Bri does not have weak core or gluteal muscles…SO WHY IS SHE USING HER HIP FLEXOR AS A CORE STABILIZER DURING THIS MOVEMENT?

Image result for anterior pelvic tilt at bottom of squat

We have to realize that our body moves in patterns and our neuromuscular system develops very specific ways of performing movement patterns (such as a squat clean) in the most efficient manner.  Due to Bri’s anterior tilted pelvic posture, she was putting her core at a disadvantageous position, and making her hip flexors want to over work.  This is why we must always prioritize optimizing spinal position before we focus on stretching or foam rolling soft tissue structures in the periphery.  Even though Bri has a strong core, she wasn’t using it very effectively during this Squat Clean movement.

For those wondering….

Bri has been a great patient is making good progress with her rehabilitation program.  We have treated her with a combination or hands-on treatments and specific core activation drills to get her body to choose to utilize the deep core stabilizers instead of the hip flexor.  Single leg dead lifts have been an effective corrective technique to develop stability and motor control in the left hip and knee.  We have also begun some blood flow restriction training in the left lower extremity to combat pain inhibition weakness that has developed in the left medial quadriceps (VMO).

Many patients spend excessive time foam rolling and stretching.  Although these interventions can be effective at times, re-training your neuromuscular system is always the key and treating the soft tissue is usually a small/minor part of that!

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