Knees Out Or Knees In When You Squat?

Out (left) versus in (right)

Here is a post that will perhaps change the way you squat. It depends on what area you want to work on. Previously, some physiotherapists and personal trainers hated me for saying that you can let your knees move forward when you squat. Most, if not all, personal trainers teach their clients that it is taboo to let your knees move forward while squatting, They get their patients or clients to stick their bums out instead.

Those same physiotherapists and trainers may be aghast if I suggest squatting with your knees pointing in (gasp!) or pointing out. 

The author recruited 14 males and 18 females for the squatting study (Chiu et al, 2024). Using 3D motion cameras and force platform meausures, normal squats required hip extensor, adductor and lateral rotator net joint movements (NJM). The gluteus maximus muscle exerts hip extensor and lateral rotator moments. The adductor magnus (pictured below) exerts hip extensor and adductor moments. Both muscles combine meet hip demands contributing to hip extensor NJM.

When squatting with hip in lateral rotation (feet pointing outwards), there was smaller hip extensor, lateral rotator and larger hip adductor NJM than normal squats. This loads the adductor magnus.

Medial rotation squats (feet pointing inwards) had smaller hip extensor and adductor NJM and larger hip lateral rotator NJM than normal squats. This loads the gluteus maximus.

Likewise if you stick your bum out when you squat, you are engaging more of your bum (Gluteus Maximus) muscles. If your let your knees move forward when you squat, you are definitely using your thigh (quadricep) muscles. If you want to increase hip adductor (adductor magnus) work, squat with your knees out. It just depends on what muscles you want to engage or work harder. Try it yourself.

There is definitely no real need to restrict forward knee movement when you squat. It's one of the biggest training myths ever. You can add squatting with your knees pointing inwards and outwards to the list of myths as well. 

This information should 'challenge' some old school "perfect squat" gurus.

Reference

Chiu LZF. "Knees Out" Or "Knees In"? Volitional Lateral Versus Medial Hip Rotation During Barbell Squats. J Str Cond Res. 38(3): 435-443. DOI: 10.1519/JSC.0000000000004655.

Are S&C Coaches Or Physiotherapists The Real Exercise Professionals?

This week's post is on an article I read in the blog from the British Journal of Sports Medicine where the author asked whether physiotherapists or strength and conditioning (S&C) coaches are the real pros when it comes to prescribing rehabilitation exercises and getting patients/ athletes to return to sport (RTS).

The author compared physiotherapists and strength and conditioning (S&C) coaches working with athletic populations (in the UK). His view was that the physiotherapist has always been the decision maker or 'top dog' when it comes to managing the injured athlete or any patient that needed exercise to rehabilitate or improve physical function. 

He feels that the physiotherapy profession has not kept up to date with professional developments in exercise science and S&C, even falling behind and out of step in some aspects. This is despite the fact that there has been an increase in demand by physiotherapists in the UK for weekend courses in S&C training to fill in gaps in expertise and knowledge. 

The author thinks these short 2 day courses is "really an insult to those S&C professionals that have devoted time, effort and financial resources to their expertise" as they have studied exercise science, S&C at undergraduate level and gone on to postgraduate study and even advanced professional accreditation to work.

He also feels that the undergraduate training program for physiotherapists in the UK does not provide enough basic grounding in exercise prescription and training science despite claims by the physiotherapy profession that they have a firm grounding in basic clinical sciences so they can circumvent the need for extensive training in S&C.

This has then led to a deficit in rehabilitating athletic populations such that it even slows an athlete's full RTS. The athlete is usually handed to the S&C team or left to their own devices. He concludes that rehabilitation of recreational and professional athletes must be recognized as an advanced practiced skill requiring specialist training. If these gaps/ deficits in both under and post graduate training are not addressed, then physiotherapists will be relegated to technicians in the restoration of the patient/ athlete.

My thoughts? I used to work at the *Singapore Sports Council in the Sports Medicine department (the current Singapore Institute of Sport). The doctors, physiotherapists, S&C coaches and other sports science staff (nutrition, biomechanics, psychology) all have degrees and/ or postgraduate qualifications and definitely had a good working relationship. We had a weekly case discussion where the athletes who were not progressing well after injury were brought up and analyzed.

Other than that sort of setting and perhaps in the Singapore Sports School and Football Association of Singapore, I think that physiotherapists in  hospitals and private practices that treat sporting populations may differ in their ability to enable these patients to RTS. It boils down to the interest and exposure of each physiotherapist. Whether they had any previous sports/ athletic background, how interested they are in sports, and most importantly, their tenacity to want to better themselves. 

There will be S&C coaches, sports and functional trainers, CrossFit coaches and personal trainers who, with their interests and commitment to improve themselves, will be superior to some physiotherapists with regard to rehabilitation and returning patients to sport. Likewise, there will be physiotherapists who can more than hold their own. 

It is, ultimately, up to each individual in their respective line of work to keep themselves up to date, to keep improving to help athletes recover better and faster. And also to recognize when they aren't the best person to return an athlete to sport and refer them out to someone who is.

Here's another sugggestion for physiotherapists not working in those sort of sports settings. If, most if not all undergraduate physiotherapy courses does not provide enough basic grounding in exercise prescription (like the author writes), then perhaps we, as physiotherapists should be doing what we are trained best at. To use our hands! All the manual assessing, mobilizations, manipulations etc, that other heatlhcare professionals can't do. Why are we not doing more of what we are best trained for?

Instead of giving patients exercises to do during treatment sessions, physiotherapists should be doing things that the patients cannot do themselves. Now, the robots or other healthcare professionals cannot replace that type of physiotherapist.

Reference

Blog article from British Journal of Sports Medicine, published on May 2, 2021.

* Thanks to my former colleagues and former S&C coaches Todd Vladich and James Wong (also multiple SEA Games gold medalist and discus throw record holder), whom guided my S&C program when I was still competing. James, a few other colleagues and I used to train at the old KATC gym at the old National Stadium 3 mornings a week at 7:30 am before we started work when we were not traveling or competing. We did this year round, especially in the off season. Those sessions and attending a Level 1 Australian Weightlifting Federation course while working there definitely made me competent at getting patients to return to sport quickly and most importantly, safely.

Who Says Your Knees Cannot Come Forward When You Squat

For almost as long as I have been working as a physiotherapist (> 20 years), I have often heard other physiotherapists, trainers, strength and conditioning coaches tell patients that it's wrong to let their knees come forward when performing a squat. That by doing so, they will damage their knees. In fact, I've had many arguments/ disagreements with my ex colleagues at Sport Singapore (formerly Singapore Sports Council) regarding this.

To which I say that it's one of the biggest training myths ever. Yes, that your knees should not travel forward past the toes during a squat is definitely a myth.

In a study by Fry et al (2003), the authors looked at how joint forces at the knees and hips changed when restricting forward knee movement during a squat. What the authors found was that squatting with restricted forward knee movement showed a 22% decrease in knee forces while increasing hip forces by 1070%!

Picture A- knee travels forward, B restricted knee movement

Hence, you're simply shifting the load from the knees to the hips and lower back when you restrict forward movement of the knee. This is a lot more work for your hips and back to absorb and is potentially more dangerous for your hip and back.

Yes, I do agree it's true that it does stress your knees more when you allow your knees to come forward while squatting. However, this is well within the normal limits of what the knees can handle (Schoenfeld 2010).

You go to any Crossfit gym and/ or watch any  Olympic weight lifters and you will see that in order to reach full depth in the squat, their knees will almost always have to go forward past the toes (see picture below). The Olympic weight lifters will often do that with very high loads too.

Picture from Irving Henson taken at The Pit

If you stick your bum out when you squat, you are engaging more of your bum (Gluteus Maximus) muscles. If your let your knee travel forward when you squat, you are definitely using your thigh (Quadriceps) muscles. It just depends on what muscles you want to engage more. Try it yourself.

Different types of squats will have different types of knee forward movement as well. Front squat, high bar back squat, low bar back squat and box squats just to name a few.

So now you know that there is no real need to restrict forward knee movement when you squat, especially if you want to load your quadriceps more. As long as you are not squatting excessively  and with a super heavy load like the Olympic weight lifters.

References

Fry AC, Smith JC and Schilling BK (2003). Effect Of Knee Position On Hip And Knee Torques During The Barbell Squat. J Strength Cond Res. 17(4): 629-633.

Schoenfeld BJ (2010). Squatting Performance And Kinematics And Their Application To Exercise Performance. J Strength Cond Res. 24(12): 3497-3506. DOI: 10.1519/JSC.0b013e3181bac2d7.

Now surely the knees have to come forward .... picture from Catalyst Athletics

More On The Floss Bands

Floss band and fascia

I have been trying out the Floss bands on my patients when there is an indication for it's use since attending the Flossing course.

Here are a few suggestions on how the Floss bands work. A common hypothesis is that it works through our fascial system.We have more fascia (or connective tissue) than anything else in our body. Fascia is a spider web like structure that wraps our muscles, blood vessels and nerves. Tom Myers say that fascia is the biological fabric we have inside our bodies.

I often tell my patients that fascia is similar to the glad wrap (or cling wrap) that wraps the meat or fruit tightly that we see in supermarkets.

When our fascia is adhered to itself, dehydrated or has unhealthy tension, movement can be restricted and blood may not be able to flow freely. For example, those knots you feel in your upper back, they may not be muscle tightness but probably fascia that has adhered to itself.

When you release tight fascia and allow for space in the connective tissue, blood can flow freely, movement becomes fluid and pain stops as a result.

Flossing helps create motion between the fascial layers which then releases the unhealthy adhesions.

Those of you who've attended the Kinesio taping courses must be thinking that this sounds similar. Yes, similar to the fascia taping techniques covered in the Day 2 of the Kinesio Taping course.

There is also the occlusion effect, The compression from the Floss band will prevent blood flow to the area the band is wrapped around. When the band is released, a rush of blood hydrates that area and can have a healing effect.

No Floss band, not enough range ....

With the Floss band

This is probably how joint mechanics improved too since joints that are painful and/ or have decreased range of motion after flossing often change remarkably.

Joints that are swollen benefit as compression (from the Floss bands) moves the swelling or drain the swollen area to other parts just like how our own lymphatic (or drainage) system works.

My patient in the picture above (no prizes for guessing who) ruptured his patella tendon last month and after surgery to attach it back didn't have enough range to ride the stationary bike. After flossing, kaboom! He's got enough range to pedal a full revolution. He yelled really loudly though!

Personally, I feel the Floss bands seem to work best in aiding recovery. Flossing the thigh muscles after a hard run  makes the legs feel a lot lighter and looser in two minutes. Yes you read correctly, two minutes or less.

 I've had a Team Singapore swimmer, cyclist and a netball player come in to our clinic today with acute muscle soreness and responded favourably to flossing and all three were impressed with how quickly the results came. You've got to try it to believe it.

My CrossFit patients tell me after a heavy squatting session when the legs feel really "dead" and heavy, the Floss bands definitely help with muscle recovery.

So, I'm not saying you have to run out and grab one straight away. I'm still trying to understand how it works and how to get consistent results with the Floss band, But like I wrote earlier, you've got to try it to believe it.

Learning To Use The Floss Band

Floss Bands made bySanctband

I was invited by Jane Fong and Danny Ho from Sanctband to attend the Flossing workshop in Ipoh, Malaysia taught by a German physiotherapist, Sven Kruse.

Prior to this I've never heard of Floss Bands before. But Jane and Danny from Sanctband got me interested after telling me what the bands can do. Used correctly, they can decrease pain and increase joint range of motion, especially by altering the fascia. (Sounds like Kinesio Taping to me)!

In fact in the USA, they are also known as Voodoo bands and are extremely popular among CrossFitters. Other than being a good marketing ploy by enticing people into trying them out by calling it Voodoo bands, Danny told me it was also because no one seemed to understand how they work so well - almost like "Black Magic".

The Floss bands are supposed to be able to help decrease pain and increase mobility/ range of motion in your joints. Now, that will definitely help our patients.

It is also suggested that it can be helpful in breaking up adhesions in our fascia (connective tissue) by re-perfusing tissues and by compressing the swelling out of joints to restore joint mechanics.

With Sven Kruse

Let me practise what I've learnt and I'll write another post shortly. Stay tuned.