Using the Squat as an Assessment Tool; Treating ‘Flat Bum’ and Hip Pain

In a healthy body, squatting is one of the most basic anatomically functional movements. Historically the squat has been done to give birth, to recover from exertion-yes, the squat was considered a resting position! As well, it was used to defecate. Unfortunately today we have adopted the sitting position excessively (usually on chairs, benches or toilets) which we know does more harm to the human body than good.

bad posture cat

In GUT The Inside Story of our Body’s Most Underrated Organ, Giulia Enders provides a straightforward analysis of the relationship between our stomach and our brain. Specifically, she writes about digestion and the connection to our moods-a true breakthrough for those suffering from digestive issues, anxiety and even stress. On the topic of squatting she writes, “squatting has been the natural defecation position for humans since time immemorial” and she blames the prevalence of digestive diseases, hemorrhoids and constipation on our righteous sitting behaviour. Conventional toilets seem ill suited to provide what our bodies need in terms of defecation efficiency and empirical evidence points to squatting as the ideal position for defecation yet even in the face of many digestive and anorectal disorders excessive sitting persists in our culture and this habit, for the most part, is what informs our biomechanics.

 

In The Alexander Technique In the World of Design, Galen Cranz attributes bad posture to modern chair design as well as excessive sitting. She defines posture as use in the body (posture assumes a static condition and the body is designed for functional movement), claiming that posture “…is shaped by culture, including family, class and shared mores and technologies…chairs are an important medium for shaping, [as well as] distorting the body” and “the practice of chair sitting is responsible for having undermined good use in numerous ways.” We experience sitting as something passive and something we do to conserve energy or even reward ourselves with. Ironically, it contributes to chronically over active and tight hip flexors, weak hamstrings, weak stabilizers and under functioning glutes. Over time this habit can contribute to a tucked bum or a posteriorly rotated pelvis. Sitting for prolonged periods of time leads to weak/tight hamstrings as well as slumped shoulders, a forward head shear as well as back pain.

This article is not meant to do away with chairs or toilets, rather it draws on the physiology of the pelvis to help understand alignment, fascia and segments of the body. The squat can be used as a prescription to address the negative effects of sitting and it can also be used as an assessment tool that highlights poor or dysfunctional body mechanics and muscle imbalances. At the very least, understanding the pelvis may influence reducing sitting time and provide a framework for achieving more balanced posture.

 

Excessive Sitting Posture Analysis

Let us look in detail at a typical swayback posture that is a result of habitually sitting for long periods of time:

 

Swayback

 

Above is an image of the human body standing in neutral. In the foreground is an image of a “sway back” which depicts the negative effects sitting for long periods of time can have. In an anatomically neutral / ideal position, the ankles, knees, pelvis, ribcage, shoulders and head /ears would stack vertically.  Notice the knee joint is forward of the plumb line-an indication of an overstretched ligament at the knee joint. The effect that sitting has can lead to impressive musculoskeletal imbalances. At the very least, it promotes the femurs (upper leg/thighs) to be positioned forward in the hip socket-a posture which is more taxing and presents more wear and tear on the hip joint. This deviation of the femurs has potentially debilitating consequences since our hips are designed as a ball and socket joint and therefore designed to rest in the capsule, neither forward (as in a tuck) or out of it (in the case of a shallow hip socket).

Below is an image of a ball and socket joint:

 

 

hip-joint-1

 

A posteriorly rotated pelvis / “tuck” distorts the alignment of the pelvis, inhibits the recruitment of the middle and lower fibres of transversus abdominus (one of the many supportive muscles that facilitates stabilization of the thoracolumbar fascia and pelvis) leading to reduced levels of spinal support and an excess lengthening of the lower back extensors and multifidus (deep back muscles that run parallel on either side of the spinal column). Tucking draws the sits bones under and the leg bones forward, causing the bum to appear flat. The minimal gluteal presence and development is a result of the limited hip extension that results over time with weak or very tight glutes. All these factors, in combination with weak spinal stabilizers, can eventually lead to pelvic floor/urinary incontinence issues.

Screen-Shot-2015-11-27-at-11.54.27-am

In addition to the appearance of a flat bum, often “tuckers” feel pain in the sacroiliac joint. Sometimes, such as after child birth, the pain is felt in the pubic symphysis , the joint between the two pubic bones.  Because the sacrum provides a three way transfer point between the iliac bones and the spine, it can be considered a hub for the distribution of tensile forces through the pelvis. Thus, it is critical for the muscles and ligaments be in balanced tension in order to support the dispersion of forces through the pelvis when walking, running,  jumping or squatting.

In general, poor biomechanics whether from our chairs or in exercise is problematic because it can lead to excessive pulling or stress on the ligaments around the sacroiliac joint leading to pain cycles, and injuries. Both the sacroiliac joint and pubic symphysis compensate for lack of hip mobility, leg length discrepancies and poor postural habits in negative ways. Abnormal pelvic tilting such as in poor sitting behaviours or twisting increases shear stresses at these joints.

 

Your Physical Proportions Influence Your Squat Technique

Did you know that even in healthy bodies there are some that can squat more easily than others and physiological proportions are critical for a proper squat? A 5’4” body with long legs and a shorter torso will squat differently than the same length body with shorter femurs (legs) and a longer torso. Femur length/ knee to hip, tibia length/ floor to knee and ankle mobility or dorsiflexion all play a critical role in squat mechanics. Below is a depiction of different segmental proportions in a squat:

images-3

There are many ways to progress into a squat or into similar movement using props and specialized equipment in order to optimize structural integrity without pain. That said, there may also be valid restrictions preventing someone from ever being able to squat efficiently such as leg length discrepancies, inhibited ankle joint movement, knee, hip pain / hip dysplasia or if there is a major balance issue.

In the first example, the knee to hip proportion is the longest of the three. Note the torso is leaned forward more dramatically.  Individuals with longer femurs will feel very unstable in a squat unless they lean forward, whereas an individual with a longer torso and shorter femurs as seen in the second example, may find the squat quite natural, without the need to lean forward significantly for balance.   The third example falls in the middle proportionally;  the femurs are not significantly longer, nor the torso significantly longer.  As a result of the segmental proportions being more balanced, the degree of flexion at the ankle, knee and hip appears balanced.

 

Squatting 101

In a functional squat the ankles, knees and hips flex and the feet pronate as the pelvis anteriorly rotates on the femoral heads but the orientation of the hip does not change as the body is lowered-even if the upper body leans forward to adjust for the change in the centre of mass.  The legs should remain over the arch of each foot and the knee joint should also line up over the second/third toe. The knee should not rotate or collapse into varus or valgus:

knee valgus:varus

 

When a client with a posterior tilt or “tuck” attempts to squat, the back appears to be round and the sits bones located at the base of the pelvis, also known as the ischial tuberosities, point down or forward instead of back:

 

tuck squatproper squat

 

 

 

 

 

 

 

 

 

This is an important distinction because good squat mechanics requires that the back be flat and the pelvis be neutral in order to disperse heavy load that is placed upon it either through gravitational force or when lifting a heavy object. If the back is rounded and the pelvis “tucked”,  the load is not dispersed through the pelvis as it is designed to, instead, it is transferred to the spine. Squatting in a flexed position can result in injury.

 

Troubleshooting with a Posteriorly Rotated Pelvis

Tight hamstrings are often the culprit for the posterior tilt of the pelvis as well as tight  glute complex, including adductor magnus and piriformis but not always so.  As discussed earlier, the hips are a ball and socket joint.  If the hip socket is shallow, no amount of stretching or strengthening will change the physiology of the hip joint.  How to tell if your tucking comes from a muscle imbalance or an anatomical variant?

The first thing to do after mobilization exercises is to stretch the hamstrings and the glutes, priformis as well as the adductor magnus to see if there is an increase in awareness of and change in the relationship of the hip to spine and femur to hip.  This is done in order to bring the pelvis as close to a neutral position as possible and to teach what neutral spine/neutral pelvis feels like.  The hamstrings are the culprit if hamstring length (tightness) affects neutral spine.  For example, if a client already “lives” in a tuck that has become the “normal”/default position, learning to “unbury” the sits bones by lengthening the hamstrings at the origin/insertion will be a challenge initially but is the first step to discovering whether the tuck is muscular or anatomical.  Below is a hamstring stretch..  and also check out my post on Four Point Hip Hinge (knee slides) on Instagram which demonstrates how to “dissociate” the legs from the hip/lumbopelvic-hip, ensuring an effective integration of hip flexion in a neutral spine.

 

hamstring stretch

 

*The most important factor in an effective hamstring stretch is that the pelvis (and spine) remain neutral.  Notice the bend in the  knee above?  The bend ensures that the pull (stretch) on the leg does not result in a posterior rotation (tilt) of the pelvis.  If the leg were to straighten, the back would flatten. The result? The stretch may be felt at the hamstring, but most likely it would be felt in the lower back or minimally at the origin/insertion of the hamstring and no stretch would occur.  In fact, by allowing the leg to straighten and the pelvis to tuck, the inefficient movement pattern and associated issues would continue.

 

Anatomical Variances and Physiological Challenges

If the four point kneeling and hamstring / glute work results in a deeper hip hinge then continue to stretch those muscles and look for exercises that correct and improve upon alignment and consider functional movement training.   If however, stretching and four point kneeling or other methods to release the glute complex and hamstrings do not influence a change in hip hinge or do not result in a feeling of “widening of the sits bones” it means that squatting for this posture needs to be modified to accommodate hip socket depth and anatomical variance. There are a myriad number of exercises, including squats, that will support and strengthen the hip-critical to avoiding or postponing hip replacement surgery. In fact, movement as well as a diet that reduces inflammation are the most recommended treatments for hip dysplasia (regular and persistent hip clicking and pain).  Correct movement and strengthening of the hip joint improves lubrication in the acetabulum (the shallow socket) so that there is less wear and tear of the cartilage.

Non operative and least invasive treatments are chosen for individuals with  mild dysplasia or if the hip is too arthritic for surgeries. Non operative approaches designed to decrease pain include, weight loss, lifestyle modification as well as physical therapy, including pilates. Choosing cycling or swimming over running or high impact sports may put less stress on the hips.

When mobilizing and strengthening the hip joint focus on external rotation and abduction of the leg. Below is an example of  external rotation, “Clam Shells”, that can be done at home using a theraband or a resistance strap tied around the knees.

clamshell

Inhale to open the top leg, exhale to lower. You can do as many as you are comfortable doing but work up to 8-10 repetitions up to 3 x per leg.

Squatting requires balanced tension. It requires the segments at the ankle joint, tibia, femur and hip to hinge and the muscles that support-concentrically and eccentrically, contracting and stretching around the joints glide with fluidity, muscle function and connection to the sensory-motor system. If muscles are weak from sitting or from misalignment of the pelvis (such as when the legs are shoved forward in a pelvic tuck) or from overly tight thighs and superficial hip due to improper shoes or overuse, a squat is going to be challenging so adjustments need to be made based the individual and on the movement patterns already established. The squat is an essential movement in many modalities because it is a multi joint exercise requiring many of the major muscles including spinal erectors, multifidus, glutes, hamstrings, quadriceps as well as adductors, pelvic floor and iliopsoas. Done properly, it is a fundamental functional movement that relies on agonists and antagonist pairings as well as synergistic muscles to support through the dynamic phases.  Routine movements such as walking, jumping and climbing stairs all require the musculature involved in a squat. The squat is not the only measure of strength nor is it the only tool used to measure uniform development in the body but it is a reliable way to assess for balanced tension and functional movement efficiency in a healthy body.

References:

Earles, James. (2014). Born to Walk; Myofascial Efficiency and the Body in Movement. Berkeley, CA: North Atlantic Books

Enders, Giulia. (2015). Gut; The Inside Story of Our Body’s Most Underrated Organ. Vancouver/ Berkeley: Greystone Books

Lee, Diane. (2011). The Pelvic Girdle; An Integration of Clinical Expertise and Research, 4th Ed. Toronto: Elsevier

Myers, Thomas. (2001). Anatomy Trains; Myofascial Meridians for Manual and Movement Therapists. Tottenham Court Road, London: Elsevier

1 Comment

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Christopher Goodfellowreply
January 24, 2019 at 6:28 pm

Testing the comment section to see what happens when I leave a comment. Here we go!

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