Sample Post-Op Squat Progression
Ian Wright, PT, DPT, SCS, OCS, CSCS
Physical Therapy Medical Director l Founder @ Competitive Advantage Athletics LLC | Doctor of Physical Therapy, ABPTS Orthopedic and Sports Clinical Specialist, Strength and Conditioning Coach (CSCS)
Squat Post-Surgery:
UE Assisted Stationary Above Parallel
The patient athlete will take their squat stance as determined by the Quadruped “Frog” test[1] (dependent on hip anatomy, previous injury history, lever lengths in lower extremities and trunk, joint mobility, balance, and pain) while holding onto a fixed object (table, squat rack upright, handrail, etc.) with their upper extremities (UE’s). The patient athlete’s UE’s should be roughly at shoulder height (90 degrees of shoulder flexion), and their fingers should be interlaced around the fixed object.
The patient athlete will squat by flexing their LE joints to an external object (Bench/chair with cushions or airex pad depending on targeted depth) while pulling on the fixed object with their UE’s in order to unweight their body weight as needed. Joints in the lower extremities (LE’s) should remain stacked (3 points of contact at foot- big toe, little toe, and heel in order to form a “tripod” position, with knee in line with ankle, hip in line with knee), along with the joints in the patient athlete’s trunk/torso (neutral spine by keeping cervical, thoracic and lumbar vertebrae stacked over one another). The patient athlete should attempt to maintain their BW over their midfoot throughout the duration of the intervention.
Once the patient athlete reaches their desired depth, the patient athlete simply extends their hips and all their LE joints (hips and shoulders should rise or extend at the same time and rate) to stand back up to the original starting position, utilizing their UE’s as needed by reversing the steps described above.
This intervention in a patient athlete’s rehabilitation is best performed with visual cues due to the acuteness of their injury and/or surgery (i.e. in front of a mirror) to prevent the patient athlete from loading the uninvolved LE to a greater extent than the involved LE, although a patient athlete should progress to using no visual cues as indicated.
It is recommended that this intervention be performed in a ROM where the patient athlete’s hip is above their knee. Pain is a feedback mechanism in the beginning, be sure to listen to it. At no point should a patient athlete be experiencing sharp, throbbing pain. Dull, ache pain that is 3/10 or less is permitted. Pain should not be traveling outside of the knee (should be localized to the knee only).
The patient athlete will repeat for prescribed sets and reps as dictated by their treating clinician.
UE Assisted Stationary to Parallel
See description for UE Assisted Stationary Squat Above Parallel for proper execution and cueing.
The only difference with this intervention is that the knee and hip joint of the patient athlete’s LE’s are now even (parallel) with regard to one another. Progress to no external targets (patient athletes will feel less secure due to a lack of a safety net that external target created) with regards to squat depth as psychological readiness is as important as physical readiness for exercise and intervention progression.
The patient athlete will repeat for prescribed sets and reps as dictated by their treating clinician.
Wall Squat Above Parallel
The patient athlete will take their squat stance as determined by the Quadruped “Frog” test[1] (dependent on hip anatomy, previous injury history, lever lengths in lower extremities and trunk, joint mobility, balance, and pain) while pressing their torso/trunk and cervical spine firmly into a wall with their LE’s so that the patient athlete’s balance is not challenged (only the patient athlete's strength and ROM is challenged) through the improved stability that the wall affords them.
The patient athlete will squat by flexing their LE joints to an external object (Bench/chair with cushions or airex pad depending on targeted depth) while pulling on the fixed object with their UE’s in order to unweight their body weight as needed. Joints in the lower extremities (LE’s) should remain stacked (3 points of contact at foot- big toe, little toe, and heel in order to form a “tripod” position, with knee in line with ankle, hip in line with knee), along with the joints in the patient athlete’s trunk/torso (neutral spine by keeping cervical, thoracic and lumbar vertebrae stacked over one another). The patient athlete should attempt to maintain their BW over their midfoot throughout the duration of the intervention.
Once the patient athlete reaches their desired depth, the patient athlete simply extends their hips and all their LE joints (hips and shoulders should rise or extend at the same time and rate) to stand back up to the original starting position, utilizing their UE’s as needed by reversing the steps described above.
This intervention in a patient athlete’s rehabilitation is best performed with visual cues due to the acuteness of their injury and/or surgery (i.e. in front of a mirror) to prevent the patient athlete from loading the uninvolved LE to a greater extent than the involved LE, although a patient athlete should progress to using no visual cues as indicated.
It is recommended that this intervention be performed in a ROM where the patient athlete’s hip is above their knee. Pain is a feedback mechanism in the beginning, be sure to listen to it. At no point should a patient athlete be experiencing sharp, throbbing pain. Dull, ache pain that is 3/10 or less is permitted. Pain should not be traveling outside of the knee (should be localized to the knee only).
A tempo variation of this exercise can also be utilized that emphasizes the isometric “bottom” position of the wall squat known as a Wall Sit. The cueing and set-up will otherwise be the same as described above with the exception of the patient athlete simply holding their “bottom” position of the wall squat for the prescribed time as dictated by their clinician.
This intervention is commonly selected over a wall squat to better emphasize and strengthen a specific position in the wall squat or to recruit specific muscles post-op (i.e. the quadriceps after ACL-R) by fatiguing a patient athlete’s more preferentially recruited prime movers to the point of where that targeted muscle group MUST assist contractile wise during the intervention.
The patient athlete will repeat for prescribed sets and reps as dictated by their treating clinician.
Wall Squat to Parallel
See description of Wall Squat Above Parallel for proper execution and cueing.
The only difference between the two interventions is the patient athlete will squat lower in this intervention until they reach a “bottom” squat position that is parallel (knee and hip at the same level with regards to one another).
TRX Assisted Above Parallel
See description of UE Assisted Stationary Squat Above Parallel for proper execution and cueing.
The only difference between the two interventions is that the patient athletes UE’s will NOT be able to assist their LE’s to the same magnitude in this intervention with regard to the unloading of their body weight (BW). This is due to the greater degrees of freedom in the patient athlete’s UE’s from the unstable nature of the TRX.
Perform intervention in a ROM where the patient athlete’s hip is Above their knee.
The patient athlete will repeat for prescribed sets and reps as dictated by their treating clinician.
TRX Assisted to Parallel
See description of UE Assisted Stationary Squat to Parallel for proper execution and cueing.
The only difference between the two interventions is that the patient athletes UE’s will NOT be able to assist their LE’s to the same magnitude in this intervention with regard to the unloading of their body weight (BW). This is due to the greater degrees of freedom in the patient athlete’s UE’s from the unstable nature of the TRX.
Perform intervention in a ROM where the patient athlete’s hip and knee are parallel. Progress to no external targets with regards to squat depth (patient will feel less secure due to a lack of a safety net that the external target created) as psychological readiness is as important as physical readiness for exercise and intervention progression.
The patient athlete will repeat for prescribed sets and reps as dictated by their treating clinician.
Unassisted Squat (Air Squat)
The patient athlete will take their squat stance as determined by the Quadruped “Frog” test[1] (dependent on hip anatomy, previous injury history, lever lengths in lower extremities and trunk, joint mobility, balance, and pain) and descend into a parallel squat position by flexing their LE joints, as described throughout this squat series, while concomitantly flexing their UE’s to 90 degrees or shoulder height (for a counter-movement in order to assist the patient athlete with balance).
Progress to fingers interlaced behind the back of the head (Prisoner Air Squat) and finally to arms locked-out overhead (Overhead Squat). The patient athlete should keep the joints in their lower extremities (LE’s) stacked (3 points of contact at foot- big toe, little toe, and heel in order to form a “tripod” position, with knee in line with ankle, hip in line with knee), along with the joints in their trunk/torso (neutral spine by keeping cervical, thoracic and lumbar vertebrae stacked over one another). The patient athlete should attempt to maintain their BW over their midfoot throughout the duration of the intervention.
Avoid lumbar flexion or posterior pelvic tilt (PPT) when squatting to lower depths. Best performed with visual cues (i.e. in front of a mirror) to prevent the patient athlete from loading the uninvolved LE to a greater extent than the involved LE. Over time, the patient athlete should progress to no visual cues.
The patient athlete will repeat for prescribed sets and reps as dictated by their treating clinician.
Tempo Unassisted Squat (Air Squat)
See description of Unassisted Squat (Air Squat) for proper execution and cueing.
Isometric contractions (or static holds) maintaining a specific position, and eccentric contractions (slow lowering or “negatives”) are useful for lower extremity (LE) muscle recruitment and engagement, especially after surgery, due to the greater fatigue and force production that these types of contractions create. Overcoming central activation deficits in the quadriceps after an ACL surgery is just one of many scenarios where tempo exercises are utilized in rehabilitation. Tempo exercises also allow the patient athlete to spend time in specific positions to better “own” that position in order to facilitate proper motor learning and achieve a more versatile movement profile.
The only difference between an Unassisted Squat (Air Squat) and a Tempo Unassisted Squat (Air Squat) is the emphasis on which component(s) of the movement the patient athlete should focus on (Eccentric, isometric, concentric). Commonly written in a x:x:x format [6] for time and convenience sake, this shorthand abbreviation should be read and interpreted as the specified time periods of the eccentric: isometric: concentric muscle contractions for an intervention if found in a program, regardless of the specified intervention and/or exercise. For example, a 3:2:0 exercise should be read as a 3 seconds eccentric or lowering/lengthening phase (depending on if the context is a movement versus muscle action), a 2 second isometric or static hold phase, and a 0 or “fast as possible” concentric or shortening phase with the intended intervention.
The patient athlete will repeat for prescribed sets and reps as dictated by their treating clinician.
Elevator Unassisted Squat (Air Squat)
See description of Unassisted Squat (Air Squat) for details on cueing and proper execution.
The main difference between an Unassisted Squat (Air Squat) and an Elevator Unassisted Squat (Air Squat) is that in this intervention, the patient athlete will experience much more time under tension due to the multiple positions that they will need to achieve within the movement.
From the initial start position of the Unassisted Squat (Air Squat), the patient athlete will flex their LE’s to a three-quarter standing position, or phrased another way, the patient athlete will perform a quarter squat. Once achieving this position, the patient athlete will return to the above described start position for an air squat (the patient athlete will maintain a slight unlock of the knees when standing in order to maintain tension within their musculature as full extension of the patient athlete’s knees and hips would allow the patient athlete to shift demands to their passive restraints- ligaments, joints, and so on).
The patient athlete will then repeat the above described steps by descending into a half-standing position (half squat), quarter standing position (three-quarter squat), and a full squat position that is within the patient athletes’ limits of stability and mobility constraints of their trunk and LE joints. The patient athlete needs to be sure to return to the start position for an air squat before descending into consecutively lower positions as described above, while being sure to maintain a slight unlock of the knees during this start position for the above-mentioned reasons of maintaining tension on targeted musculature.
Once the patient athlete returns to the start position from the full standing position, the patient athlete will repeat for prescribed sets and reps as dictated by their treating clinician.
Great insights! Implementing squats in rehabilitation programs not only boosts physical recovery but also empowers mental resilience. ?? The intersection of sports medicine and training practices is fascinating! #PhysicalTherapy #TrainingAdvancements