Category Archives: Screening/Assessment

Repeated Adductor Strain During Squats: A Case Study

Last week I wrote a popular blog on knee valgus HERE. The post was very well-received, but I feel that I need to elaborate to keep driving this home to personal trainers and physical therapists. We pretty much have a knee valgus epidemic plaguing the entire world right now, and it’s not very hard to fix if you know what you’re doing.

Case studies have many drawbacks, but they can be very helpful for providing practitioners with methodology that they can integrate into their systems. There are many different ways to go about correcting knee valgus, and below is one approach that I’ve found to be highly effective.

Case Study

A few weeks ago I trained a newbie who had been experiencing issues with lower body training. His personal trainer had him doing squats, leg presses, and lying leg curls. Every single time he performed a set of squats with sufficient intensity, he’d strain his left adductor. In fact, he’d trained his lower body six times over the past six weeks, with each session resulting in a strained left adductor. Each session, this would occur on the very first set of squats, so the trainer would have him move to leg presses and leg curls while stretching his adductors in between sets.

His personal trainer is the type who starts everyone out with barbell squats and just has them go down as far as they can without really monitoring depth and form. This client was definitely not ready for barbell squats – especially not with 50 extra pounds on the bar (for a total of 95 lbs). Moreover, the leg presses would still irritate his adductor (just not to the extent of squats), and the adductor stretching was exacerbating the situation.

The gentleman was aware of me and had seen some of my articles online, so he decided to track me down, knowing that we both lived in Phoenix. Interestingly, the gentleman informed me that he used to be a mogul skier and that back in the day they’d do squats with their legs banded together. The client ended up visiting me three times and his issue is completely resolved. Due to financial issues, the client could only see me once per week and wished to solve the issue in as little number of sessions as possible.


Session One

I watched the client squat and saw that he collapsed at the knees (valgus). His left leg caved inward more than his right leg. I put him in side lying position and manually tested his hip abduction and hip external rotation strength balances. Predictably, he had a marked strength imbalance with the left side being weaker than the right in both positions.

He could indeed achieve full range squats with proper foot and ankle position when coached properly, so ankle dorsiflexion and hip flexion mobility weren’t culprits; just insufficient hip stability and lack of knowledge of proper form. These types of individuals are usually pretty easy to fix.

I showed him how a squat is supposed to look and had him mimic the form. I then had him hold onto a 15 lb dumbbell in the goblet position and saw that he was able to keep proper form for 8 repetitions. From time to time his left knee would want to creep into valgus, but I’d be sure to remind him to push the knee outward. I moved up to 25 lbs for goblet squats, and this seemed like the perfect load for him on that particular day. He did a total of 3 sets of 8 reps, staying far away from failure to ensure that his left adductor didn’t flare up. I filmed his sets and showed them to him immediately afterward and provided feedback so he could visually see what was going on, which leads to much quicker correction.

Next, I put him in a prone position to see if he could squeeze his glutes properly during an RKC plank. He couldn’t even turn them on. I modified the position and had him perform RKC planks from the knees with a wider hip stance. He was able to turn them on from this position, but they glutes would flutter, which is indicative of weak glutes and common in beginners. Finally, I showed him how to perform bodyweight hip thrusts. He could squeeze out 15 solid reps with good form, after 15 reps he’d start compensating with anterior pelvic tilt to make up for subpar glute strength. He performed 2 more sets of 15 hip thrusts. So the session looked like this:

  • goblet squats: 3 x 8
  • hip thrusts: 3 x 15

My findings for the first session were that the client possessed weak glutes in hip extension and posterior pelvic tilt along with a left side upper glute imbalance in hip abduction and hip external rotation.

I had the client stop stretching his adductors. I taught hip how to perform band seated hip abductions, band monster walks, and band sumo walks. Furthermore, I gave him a mini-band to take home. Last, I told him to stop training lower body with his personal trainer until I could get his squat form squared away.

Session One Homework

His homework was to perform the exercises below each day until we met again the following week:

  • 3 sets of 10 bodyweight full squats with knees tracking over toes properly
  • 2 sets of band seated hip abductions: 3 levels (see below)
  • 2 sets of crouched band monster & sumo walk combo (see below)
  • 2 sets of 15 bodyweight hip thrusts with the pelvis maintaining neutral position (or slight posterior tilt) into full hip extension
  • 1 set of 30 second front plank
  • 1 set of 15 second side plank

Session Two 

The following week, the client returned to me and his form had dramatically improved. His hip imbalance was already showing marked improvement as well. After the warm-up, I had the client perform 3 sets of goblet squats. First set was with 20 lbs. He performed 20 reps with great form. Second set was with 30 lbs. He performed 12 solid reps without the knee caving. Third set was with 40 lbs. He performed 8 quality reps with proper knee alignment.

Next up was hip thrusts. The client performed 20 solid reps on his first set. I had him place a 30 lb dumbbell in his lap for the second set and he performed 12 reps. For the third set, I placed a 50 lb dumbbell in his lap and he performed 10 reps.

I then went over hip hinging drills and moved onto Romanian deadlifts. The client did two sets of 20 reps with the barbell and one set of 10 with 95 lbs. So the session went like this:

  • goblet squats: 1 x 20, 1 x 12, 1 x 8
  • hip thrusts: 1 x 20, 1 x 12, 1 x 10
  • Romanian deadlift: 2 x 20, 1 x 10

Session Two Homework

His homework was to perform the exercises below each day until we met again the following week:

  • 4 sets of 15 bodyweight full squats with knees tracking over toes properly
  • 2 sets of band seated hip abductions: 3 levels (see below)
  • 2 sets of crouched band monster & sumo walk combo (see below)
  • 2 sets of 20 bodyweight hip thrusts with the pelvis maintaining neutral position (or slight posterior tilt) into full hip extension
  • 1 set of 60 second front plank
  • 1 set of 30 second side plank

Session Three

I included goblet squats in the warm-up and double-checked form, which made me decide to move him to barbell front squats. Client was able to do the bar for 10 reps, 65 lbs for 10 reps, 85 lbs for 10 reps, and 95 lbs for 5 reps. Form was absolutely perfect, and there was no adductor pain or discomfort whatsoever.

For hip thrusts, I went up to 135 lbs and the client was able to do 2 sets of 10 reps. For RDLs, the client was able to do 95 lbs for 20 reps and 115 lbs for 10 reps. So the session went like this:

  • front squats: 3 x 10, 1 x 5
  • hip thrusts: 2 x 10
  • Romanian deadlift: 1 x 20, 1 x 10

Ongoing Advice

Since the client’s adductor strains had completely vanished and his form was picture perfect, I released the client as my job was finished. However, I spent a good amount of time with him before we departed.

I filmed video clips of his front squat, hip thrust, and Romanian deadlift form and emailed them to him. I told him to continue to film his training sessions each month and to compare his form to the form exhibited in the videos I sent him.

I told him to continue performing 20 minutes of extra glute work 2-3X/week in the form single leg hip thrusts, hip thrusts, Bulgarian split squats, box squats, goblet squats, single leg RDLs, RKC planks, Pallof presses, lateral band walks, and band seated abductions. We went over form on each of these drills to make sure he understood how to do them.

I told him to keep performing front squats, back squats, deadlifts, sumo deadlifts, hip thrusts, and barbell glute bridges for his main exercises. We went over form on these lifts too.

Finally, I sent him YouTube links to the various exercises so he could watch them as a reminder to what good form entails.

This goes to show you, with a highly motivated client and good strategy, it is possible to see rapid, life-altering changes in movement and function.


Does it Hurt? by Mike Boyle

Today’s article comes from legendary strength coach Mike Boyle. This just might be my favorite article ever written for strength & conditioning. So simple, but so important. 

I get asked rehab questions all the time. I have rehabilitated athletes in almost every major sport who were told they were “all done” by a doctor or a team trainer. Because people know my background, they often ask for advice.

Most of the time they ignore the advice because the advice does not contain the answer they want. They say “it only hurts when I run”, I say things like “don’t run”.

A famous coach I know once told me “people don’t call for advice; they call for agreement or consensus. If you don’t tell them what they want to hear, they simply call someone else”. His advice to me, don’t bother wasting your time with advice.

Here I go again wasting time.

If you have an injury and are wondering whether or not a certain exercise is appropriate, ask yourself a simple question. “Does it hurt”? The key here is that the question ‘does it hurt?” can only be answered yes or no. If you answer yes, then you are not ready for that exercise, no matter how much you like it. Simple, right? Not really. I tell everyone I speak with about rehab that any equivocation is a yes. Things like “after I warm-up it goes away” etc. are all yes answers. It is amazing to me how many times I have asked people this simple question only to have them dance around it. The reason they dance around the question is that they don’t like my answer. They want to know things like “what about the magic cure that no one has told me about?”. What about a secret exercise? I have another saying I like, “the secret is there is no secret”. Another wise man, Ben Franklin I think, said “Common sense is not so common”.

If you are injured and want to get better, use your common sense. Exercise should not cause pain. This seems simple but exercisers ignore pain all the time and rationalize it. Discomfort is common at the end of a set in a strength exercise or at the end of an intense cardiovascular workout. Additional discomfort, delayed onset muscle soreness, often occurs the two days following an intense session. This is normal. This discomfort should only last two days and should be limited to the muscles not the joints or tendons. Pain at the onset of an exercise is neither normal nor healthy and is indicative of a problem. Progression in any strength exercise should be based on a full, pain-free range of motion that produces muscle soreness without joint soreness. If you need to change or reduce range of motion, this is a problem. Progression in cardiovascular exercise should also be pain free and should follow the ten percent rule. Do not increase time or distance more than ten percent from one session to the next. I have used these simple rules in all of my strength and conditioning programs and, have been able to keep literally thousands of athletes healthy. I’m sure the same concepts will help you. 

Mike Boyle

Strength Coach Mike Boyle

Basic Screening & Assessment

Most trainers, massage therapists, and strength coaches do not possess an adequate skill-set when it comes to screening and assessment. This isn’t necessarily their fault as it is poorly taught in most of these profession’s educational curriculum. In fact, so many people get very nervous and almost paralyzed by the idea of having to do some screening or evaluation that they choose to do nothing instead. Some people get so carried away with ridiculous assessments that are practically meaningless that it’s easy to see how one could get a nasty case of “paralysis by analysis!”

However, having a basic evaluation system for things like full-body mobility and movement capacity (including stability) will really set you apart from other professionals and allow you to be more effective at your job. The key is to stay within your specific scope of practice and realize that as non-medical professionals, we cannot “diagnose” anything and are simply obtaining information on each client to guide their safety and effectiveness in movement/exercise.

In this blog Keats Snideman is going to take Bret Contreras through a basic length-tension (mobility/flexibility appraisal) screening system that he uses to evaluate his clients. This screen is used in addition to more dynamic movement screening that includes the FMS as well as some basic table assessments. This blog will show videos outlining his table assessments.

The Functional Movement Screen (FMS)

Before we move onto the table assessments, it is important to have a basic understanding of the FMS. The FMS is a 7 test screen developed by Gray Cook and Lee Burton used to evaluate fundamental movement patterns. The screen will assess risk and can identify situations where the client experiences pain and should be referred to a specialist, situations where a client needs to work on balancing out asymmetries, situations where a client needs to work on increasing mobility, stability, or motor control to improve a particular pattern prior to engaging in various activities. The 7 tests include the deep squat, hurdle step, inline lunge, shoulder mobility, active straight leg raise, trunk stability push up, and rotational stability. The FMS is a very valuable assessment tool that every trainer should incorporate into their arsenal.

Basic Table Assessments

The table assessments that Keats uses consists of a breathing pattern assessment, a head & neck mobility assessment, a t-spine mobility assessment, a shoulder mobility assessment, and a hip, foot & ankle, and big toe mobility assessment. These basic tests are assessing what is called ”passive movement testing” (although they can all be done actively as well). Passive movement can be further broken down into what is called “physiologic motion,” which is what we are going to be demonstrating, and “accessory joint motion” (joint play, component movements). Accessory movement testing is beyond the scope of testing for the intended audience of this blog so those tests should be left to licensed professionals trained in orthopedic manual assessment.

Breathing Pattern Assessment

In this video, Keats takes a look at Bret’s breathing patterns. He’s looking for natural diaphragmatic breathing that involves breathing into the belly prior to breathing into the thorax.

Head and Neck Mobility Assessment

In this video, Keats takes a look at Bret’s neck mobility from various directions. Normal ranges include 0-80-90 degrees of cervical flexion, 0-70 degrees of cervical extension, 0-30-45 degrees of cervical lateral flexion, and 0-70-90 degrees of cervical rotation.

Thoracic Spine Mobility Assessment

In this video, Keats takes a look at Bret’s t-spine mobility from various directions. Normal ranges are difficult to isolate since the t-spine is intimately connected with cervical and lumbar spine function. Suffice to say people need to be able to at least reverse the normal thoracic kyphosis to straight and be able to rotate at least 45 degrees in each direction from a tall seated position with the hips/pelvis stabilized. The T-spine is truly a huge player in full body movement capacity, breathing, and posture. Its influence on the c-spine (including the jaw/TMJ) and shoulders is often ignored in painful conditions.

Shoulder Mobility Assessment

In this video, Keats takes a look at Bret’s shoulder and scapular mobility from various directions. Normal ranges include 0-180 degrees of shoulder flexion, 0-60 degrees of shoulder extension, 0-180 degrees for shoulder abduction, 0-90 degrees of external rotation, and 0-70 degrees of shoulder internal rotation. Also included are basic length tests for pectoralis major, pectoralis minor, latissimus dorsi and teres major which to a large part determine the mobility in this region.

Hip, Ankle, and Big Toe Mobility Assessment

In this video, Keats takes a look at Bret’s hip mobility, ankle mobility, and big toe mobility from various directions. Normal ranges include 0-120 degrees of hip flexion (with bent knee), 0-90 with straight/extended knee, 0-30 degrees of hip extension (from prone position (knee extended), 0-45 degrees of hip abduction, 0-30 degrees of hip adduction, 0-45 degrees of hip external rotation, 0-40 degrees of hip internal rotation, 0-20 degrees of ankle dorsiflexion, 0-50 degrees of plantar flexion, 0-35 degrees of inversion, 0-15 degrees of eversion, and 0-65 degrees of big toe extension (although only 45 degrees are needed for gait). Also included is the thomas test for hip-flexor length. Not shown but extremely important is the “obers test” for hip-abduction contracture/tightness.

What do I do if Clients Don’t Possess Normal Ranges of Motion in Various Joints?

There are three basic scenarios that can occur with your assessments:

1) The individual will possess adequate ROM that doesn’t require any remedial stretching or mobilizations. For these people, a quality training/conditioning program will serve to maintain the range they already have. Semi-frequent re-testing is needed to make sure this range of motion isn’t lost however.

2) The individual has excessive ROM which may or may not be a problem depending on the strength and motor control capacities of the person. Too much ROM (hypermobility) can be just as bad in some situations as too little ROM! For specifically assessing if someone has too much ligamentous laxity/hypermobility all over their body, the Beighton Score is an easy testing protocol to administer.

3) The individual will possess decreased ROM/hypomobility in a given joint motion which could signify that either a musculo-tendinous/fascial or “extra-articular” (outside the joint) problem exists. Or, there could be a problem within the joint (intra-articular) that would required more attention to the joint capsule and other structures that would be best performed by a licensed professional trained to administer joint mobilization (Osteopath, physical/physio-therapist, chiropractor). This is a good reason for personal trainers and bodyworkers to have a good network of other professionals who can perform any specific joint work that might be needed. The basic goal with these people is to improve the range of motion of the truly short or stiff tissues. Utilizing the corrective strategies concept as promoted by the FMS, once lost ROM is regained, it must be backed up with some stability training (static, then dynamic stability) in order for it to stick. Stretching in and of itself is often not enough to change movement in any meaningful way!

A Hypothetical Scenario – Tight Hamstrings

Corrective exercise for a mobility restriction or stability problem is an art unto itself and would require an entire book (just read Gray Cook’s new book which should be available soon) to list all the various protocols. To give one example of a corrective sequence, let’s say that an individual has poor hamstring flexibility. Perhaps they are overworked from synergistic dominance due to weak glutes and tight hip-flexors on the other side. You would want to incorporate self-myofascial release for the hip flexors and activation work for the glutes in order to “release the brakes” on the hamstrings and decrease hypertonicity.

You would also want to incorporate various types of stretches and mobility drills for the hamstrings. Finally, you may want to start the client off with rack pulls and work on gradually increasing the range of motion until a full range deadlift can be perform while maintaining a neutral spine. Knowing various drills and progressions is critical in improving motor patterns and eliminating dysfunction. Assessments & Screens provide you with great information but you also need to know what to do with that information in terms of exercise selection and program design.

At any rate, we hope you enjoyed the videos. Over time, we will try to post more blogs that provide more information on screening and corrective exercise. Thanks for reading and watching!

-Keats Snideman and Bret Contreras