this makes sense, however this is lower order thinking and does not solve the lower leg

Functional Knee Valgus in a Barbell Squat 1 One of the most common lower leg dysfunction we see in athletes, particularly general population is functional knee valgus, or better referred to as the knees caving in during a squat pattern movement. Often you hear coach s giving the cue drive your knees out! at first glance this makes sense, however this is lower order thinking and does not solve the lower leg dysfunction in the long run. After this case study, you will hopefully see that simply cueing to drive the knees out is not enough. We must look deeper into this problem to make long term lasting changes in proper movement pattern. This case study will discuss Things that could have potentially caused this lower leg dysfunction to appear. Through analysis on Dart Fish and the overhead squat assessment taught by Brent Brookbush of the Brookbush institute we will examine the Acetabular femoral joint (AFJ), Tibiofemoral joint (TFJ), and the Talocrural joint (TJ). Through this we will find musculature that is short and overactive, long and underactive, and long and overactive. Once we identify this through thorough analysis we can the better prescribe corrective exercises and manual release and mobility drills to clear up this lower leg dysfunction. We will Examine five key positions in a barbell back squat. The five positions will be hip flexion, knee flexion, Dorsiflexion, Knee Extension, and hip extension. Movements Analysis The athlete may not currently be experiencing pain caused by the functional knee valgus, however the athlete is losing out on performance and running the risk of overuse and injury to

Functional Knee Valgus in a Barbell Squat 2 the Medial side of the knee due to the medial displacement caused by the knees bowing in (Brookbush, 2017). This movement dysfunction may only be present during loaded squatting movements. A major contributor to this problem is caused by a lack of isolated hip extension activity s as well very minimal training of the Femoral external rotators such as the Gluteus Maximus and the Gluteus Minimis outside of her main barbell movements causing them to lose tone and become long and underactive(firing late or weak). Below is the Dartfish Link Highlighting the five key positions and the associated movement dysfunction. http://dartfi.sh/rtz2tnvzky0 Key position one: Hip Flection (Eccentric Phase)

Functional Knee Valgus in a Barbell Squat 3 Table 1: Musculature acting on the hip joint. Muscle Origin Insertion Action Plane of motion Iliacus Psoas major and minor Rectus Femoris Sartorius Inner surface of Illium Lower borders of transverse process L1-L5, T-12 Anterior inferior iliac spine of the Illium Anterior superior iliac alpine Lesser trochanter of femur Lesser trochanter of femur, Pectineal line of pubis Superior aspect of the patella and patella tendon of the tibial Anterior medial surface of tibia just below condyle Hip flexion, External rotation of hip, anterior pelvic rotation Hip flexion, flexion of lumbar spine, external rotation of hip, Hip flexion, knee extension Hip flexion, knee flexion, external rotation of femur when knee is bent, hip abduction Sagittal transverse, frontal

Functional Knee Valgus in a Barbell Squat 4 Pectineus Adductor Brevis Superior ramus of pubis Inferior ramus of pubis Pectineal line of femur Pectineal line and medial lip of linea aspera Adductor Longus Pubic tubercle Medial lip of linea aspera Adductor Magnus Gracilis Semitendinosus Inferior ramus of the pubis, ramus of ischium and ischial Inferior ramus of pubis Ischial Semimembranosus Ischial Biceps Femoris Long head: ischial Medial lip of linea aspera and adductor tubercle Proximal, medial shaft of tibia at pes anserinus tendon Upper anterior medial surface of tibia Posteromedial surface of the medial tibial condyle Head of fibula and lateral condyle of tibia Adduct the hip, hip joint Adduct the hip, the hip, flex hip, flexed knee Adduct the hip, the hip, flex hip, flexed knee Adduct the hip, the hip, flex hip, flexed knee Flex knee, flexed knee, hip adduction, internal rotation of hip Knee flexion, hip extension, posterior pelvic rotation, internal rotation of hip, internal rotation of flexed knee Knee flexion, hip extension, posterior pelvic rotation, internal rotation of hip, internal rotation of flexed knee Knee flexion, extension of hip, posterior pelvic rotation, external rotation frontal, transverse Frontal, transverse, sagittal Frontal, transverse, sagittal Frontal, transverse, sagittal Frontal, transverse, sagittal transverse

Functional Knee Valgus in a Barbell Squat 5 Gluteus Maximus Gluteus Medius Gluteus Minimis Tensor Fasciae Late Piriformis Gemellus inferior & superior Obturator internus Obturator Short head: lower half of linea aspera Coccyx, edge of sacrum, posterior iliac crest Lateral surface of Illium just below crest Lateral surface of Illium Anterior iliac crest, and surface of the Illium just below crest Anterior surface of sacrum Inferior: ischial Superior: ischial spine obturator membrane and inferior surface of obturator foramen Rami of pubis Iliotibial tract and gluteal Posterior and middle surfaces of the greater trochanter of femur Anterior surface of greater trochanter of the femur Iliotibial tract Superior aspect of greater trochanter Inferior and superior: medial surface of greater trochanter Medial surface of greater trochanter Trochanteric of hip, external rotation of knee Hip extension, external rotation of hip, abduct the hip, lower fibers assist in adduction Abduction of hip, flex hip hip, extend the hip, externally rotate the hip Abduct, the hip, Flex hip Flex hip, hip, Abduct the hip External rotation of hip, Abduction of hip External rotation of hip External rotation of hip External, Frontal Frontal,, Sagittal Frontal, transverse, sagittal Frontal, Externus and ischium fossa of femur rotation of hip Quadratus Femoris Lateral border of ischial intertrochanteric crest External rotation of hip

Functional Knee Valgus in a Barbell Squat 6 The first phase of hip flexion in the eccentric phase of the loaded barbell back squat gives very little insight as to what musculature is causing the knee valgus. The hip extensors, external rotators, internal rotators are eccentrically decelerating the body so the athlete can support the weight in a controlled manner during her descent. In this phase of the squat the athlete is in a good position. What I am looking for is upright torso, knees tracking over the second toe (not bowing in or out), feet remain pointing forward they do not go out, and there is no inversion or eversion of the feet. At this point in the movement the transverse abdominis, Rectus abdominis, internal and external oblique s, multifidi s, and rotators are all in an isometric contraction to keep the torso stable. Table 1 list s all the muscles that act on the hip joint. The main muscles that are involved in eccentric deceleration are Gluteus Maximus, Biceps Femoris long and short head, Semimembranosus, Semitendinosus, Adductor Magnus posterior fibers, Gluteus medius posterior fibers, rectus Femoris, vastus lateralis, vastus medialus, vastus intermedius, Sartorius, and Gastrocnemius. Key position 2: Knee flexion (Eccentric phase)

Functional Knee Valgus in a Barbell Squat 7 Table 1.1: Musculature acting on the knee joint. Muscle Origin Insertion Action Plane of motion Biceps Femoris Semitendinosus Semimbranosus Long head: ischial Short head: lower half of linea aspera Ischial Ischial Head of fibula and lateral condyle of tibia Upper anterior medial surface of tibia Posteromedial surface of the Knee flexion, extension of hip, posterior pelvic rotation, external rotation of hip, external rotation of knee Knee flexion, hip extension, posterior pelvic rotation, internal rotation of hip, internal rotation of flexed knee Knee flexion, hip extension, posterior pelvic transverse

Functional Knee Valgus in a Barbell Squat 8 Gracilis Sartorius Gastrocnemius Popliteus Plantaris Inferior ramus of pubis Anterior superior iliac alpine Condyles of the femur, posterior surfaces Lateral condyle of femur Lateral supracondylar line of femur medial tibial condyle Proximal, medial shaft of tibia at pes anserinus tendon Anterior medial surface of tibia just below condyle Calcaneus Proximal, posterior aspect of tibia Calcaneus rotation, internal rotation of hip, internal rotation of flexed knee Flex knee, flexed knee, hip adduction, internal rotation of hip Hip flexion, knee flexion, external rotation of femur when knee is bent, hip abduction Knee flexion, plantar flex Talocrural joint Internal rotation of flexed knee, knee flexion Plantar flexion, Weak flexion of knee Frontal, transverse, sagittal transverse, frontal Sagittal Sagittal Much like key position 1, in this phase of the squat the athlete is not showing any signs or symptoms of lower leg dysfunction. This is because the muscles that play a large role in causing functional knee valgus are acting as eccentric decelerators, the muscles that are long and underactive causing a loss in muscle tone leading to improper firing pattern are also either eccentrically decelerating the athlete or not truly active. However, although not visibly present in this phase, loss of Dorsiflexion is a major contributor to lower leg dysfunction, causing tibial internal rotation, eversion of the foot, and alters muscle recruitment patterns (Brookbush, 2017). It may not be visible now, but it is likely there is dorsiflexion restriction taking place, this will be looked at in more detail in Key position3. Key position 3: Dorsiflexion (Eccentric phase)

Functional Knee Valgus in a Barbell Squat 9 Table 1.2: Musculature acting on the ankle joint. Muscle Origin Insertion Action Plane of motion Tibialis Anterior Extensor Digitorum longus Extensor halluces longus Lateral condyle of tibia; proximal lateral surface of tibia Lateral condyle of tibia; proximal lateral surface of tibia Middle anterior surface of fibula and interosseous membrane Medial cuneiform and base of first metatarsal Middle and distal phalanges of second through fifth toe Distal phalanx of first toe Dorsiflexion, inversion of foot Dorsiflexion of ankle, eversion of foot, Extension of four lesser toes Dorsiflexion, Weak inversion, Extension of great toe Frontal Frontal Frontal Much like the previous two positions the Tibialis Anterior, Extensor Digitorum longus,

Functional Knee Valgus in a Barbell Squat 10 and the Extensor halluces longs are not currently active, that is because the ankle joint is passively in dorsiflexion, the body is not actively dorsi flexing. The Gastrocnemius, soleus, tibialis posterior, peroneus longus, peroneus brevis, flexor digitorum longus, flexor halluces longus, and Plantaris (planter flexors Antagonist on dorsiflexion) are acting as eccentric decelerators. The plantar flexors play a larger role in body control in this phase than the dorsiflexors even though the ankle is in dorsi flexion, they are still acting passively only lengthening because the weight is pushing the athletes body down. Although still not present, the athlete may be experiencing loss of dorsiflexion. Loss of Dorsi flexion can be caused by Long and underactive Tibialis anterior, tibialis posterior, Gracilis, popliteus. It is also caused by Short and overactive Gastrocnemius, Soleus, Fibularis, flexor halluces longus, flexor digitorum longus. A loss in dorsiflexion would decrease the optimal range of motion of 15-20 degrees causing the body to compensate at the ankle by causing inversion or eversion of the feet, or the knee joint causing knee valgus or Varus (Knees bowing out). Key position 4: Knee extension (Concentric phase)

Functional Knee Valgus in a Barbell Squat 11 Table 1.3: Musculature acting knee extension. Muscle Origin Insertion Action Plane of motion Rectus Femoris Vastus lateralis Vastus medialus Anterior inferior iliac spine of Illium and groove above acetabulum Intertrochanteric line, anterior and inferior borders of greater trochanter, gluteal, upper half of linea aspera Whole length of linea aspera and medial condyle ridge Superior aspect of the patella and patellar tendon to tibial Lateral border of patella and patellar tendon to tibial Medial half of upper border of patella and patellar tendon Knee extension, Hip flexion, Anterior pelvic rotation Knee extension Knee extension Sagittal Sagittal Sagittal

Functional Knee Valgus in a Barbell Squat 12 Vastus intermedius Upper 2/3 of anterior surface of femur to tibial Upper border of patella and patellar tendon to tibial Knee extension Sagittal As seen above the concentric phase of the squat is where the athlete is showing the presence of a lower leg dysfunction. The athlete s knees are caving in (functional valgus) and the feet flatten out (Eversion/Pronation). Both lower leg dysfunctions are related to each other as the body functions in a connected kinetic chain. From Brent Brookbush s overhead squat assessment of the Brookbush institute we can determine what musculature is responsible for the lower leg dysfunction. Functional valgus is caused by Overactive tibial external rotators, Tensor fasciae latae, biceps Femoris short head, and lateral Gastrocnemius. Overactive femoral internal rotators, Tensor fasciae latae, gluteus minimums, and Adductors. Underactive tibial internal rotators, Gracilis, Semitendinosus, semimembranosus, Sartorius, medial gastrocnemius, and vastus medialus. Underactive Femoral external rotators, Gluteus maximus, gluteus medius. The musculature that is overactive is usually short and compensating for the musculature that is underactive and usually long causing them to fire weak or late. In the case of knees bow in the tibia is attempting to externally rotate while the femur is internally rotating causing medial knee displacement (Brookbush, 2017). This dysfunction is a major problem for sports performance and injury prevention. The main concern is the long and underactive gluteus maximus, gluteus medius which is classified as our posterior oblique subsystem. Glute function and hip extension are highly important in activities of daily living and force production. Our glutes being our most

Functional Knee Valgus in a Barbell Squat 13 powerful hip extensors having them become long and underactive is a problem even if you are not in search of sports performance. Key position 5: Hip Extension (concentric phase) Table 1.4: Musculature acting on hip extension (concentric phase) Muscle Origin Insertion Action Plane of motion Gluteus maximus Biceps Femoris long head Coccyx, edge of sacrum, posterior iliac crest Ischial Iliotibial tract and gluteal Head of fibula Extend hip, externally rotate the hip, abduct the hip, lower fiber adduct hip Flex knee, extend hip, externally rotate bent knee,, Frontal

Functional Knee Valgus in a Barbell Squat 14 Semitendinosus Semimembranosus Adductor Magnus Gluteus medius Ischial Ischial Inferior ramus of the pubis, ramus of ischium and ischial Gluteal surface of Illium, between posterior and anterior gluteal lines Proximal, medial shaft of tibia and pes anserinus Posterior aspect of medial condyle of tibia Medial lip of linea aspera and adductor tubercle Lateral aspect of greater trochanter laterally rotate hip joint Flex knee, flexed knee, extend hip, tilt pelvis posteriorly Flex knee, flexed knee, extend hip, tilt pelvis posteriorly Adduction of hip, internal rotation of hip, assist in hip flexion, Hip abduction, flexion and extension of hip, internal and external rotation of hip Frontal,, sagittal At this point the hip joint and knee joint are in full extension. The athlete is no longer presenting signs of a lower leg dysfunction. Even though in position 4 the hip extensors fire weak or late at this point they are functioning. The strength curve at this point is at its lowest since the muscles are fully contracted. When assessing an athletes squat mechanics, it is important to focus on the entire movement. Functional knee valgus only occurred in knee extension during the concentric phase of the squat. If you do not asses all phases you may miss out on identifying a postural or movement dysfunction ultimately leading to loss in performance and injury.

Functional Knee Valgus in a Barbell Squat 15 Functional knee valgus corrective Exercise Techniques In functional knee valgus, the muscles that were identified as short and overactive are the Tensor fasciae latae, Biceps Femoris short head, lateral gastrocnemius, glute minimums, and the adductor complex. Muscles that were identified as long and under active are the Gracilis, Semimbranosus, Semitendinosus, medial gastrocnemius, vastus medialus, gluteus maximus, and Gluteus medius. Muscles that are short and overactive should be manually released and stretched and muscles that are long and underactive should be activated (Brookbush, 2017). For release and stretch you should focus on the Tensor Fasciae latae and the biceps Femoris short head since they play a major role in femoral internal rotation. For activation techniques, you should focus on the gluteus maximus and gluteus medius. This is because they are or most powerful hip extensors and activating them will benefit the athlete beyond just fixing a movement dysfunction. Tensor fasciae latae/hip flexor manual release http://dartfi.sh/4af3j7noof9 For the TFL release it is important to use a softball or lacrosse ball, a foam roller will not apply enough pressure per square inch. Find a trigger point, you will know you found it because it will be very tender. Remain on that spot for 30 seconds or until the trigger point releases. Repeat on the opposite side. This can be done up to three times on each side.

Functional Knee Valgus in a Barbell Squat 16 Tensor fasciae latae/hip flexor stretch http://dartfi.sh/68bgbgyhiz1 For the TFL hip flexor stretch attach a heavy resistance band to a stable structure, in the video it is attached to a bolted in squat rack. The band should be just lower than hip height. When doing this, it is important to find a stretch by posteriorly tilting your pelvis rather than gaining as much hip extension as possible. The hip only has 10-15 degree extension, any farther and mobility is being gained in other areas of the body. This stretch should be held for 45-60 seconds for up to three times on each side. Biceps Femoris short head manual release http://dartfi.sh/ehqrei8xg7a For this manual release, it is important to be on a box and use a softball or lacrosse ball, if not you will not get enough pressure per square inch to gain a release. Place the ball under you lateral lower femur just above the knee. Find a tender spot, once you do slowly extend your knee. You can perform 10-15 knee extensions on each side for up to three sets or until you have achieved a release. Biceps Femoris manual stretch http://dartfi.sh/xdl5iubvevl For this stretch lay flat on your back pinning both shoulders on the ground, it is highly important that bot shoulders remain on the ground during the duration of this stretch. Flex you knee towards your chest, take your opposite arm and pull your leg just past your midline. Once you

Functional Knee Valgus in a Barbell Squat 17 are in the position flex and extend your knee while maintaining a hold on your leg with your opposite hand. You can do 10-15 knee extension on each leg for up to three sets. Glute maximus Activation Glute bridge http://dartfi.sh/wbynwhuqcv7 For this activation drill lay flat on your back, Shoulders pinned to the ground, knees flexed and feet flat. Your feet should be placed wider than your shoulders in a sumo type stance. Drive your hips up into full extension fully contracting your Glutes, it is important to hold this position at the top for 1-2 seconds. This activation drill can be done for up to 30 reps, and for up to three sets. Glute medius Activation http://dartfi.sh/b6lca9k94ze For this Activation drill lay on your side on the ground with your hips stacked evenly on top of each other. In a controlled manner abduct and adduct your leg. During this drill, it is highly important to minimize your hips moving anteriorly or posteriorly. Also, do not allow your hips to be flexed they should be in a neutral position. Perform this activation technique for 15-20 reps on each side for up to three sets. This movement can be progressed by adding ankle weights, be sure to start very light and progressively add external resistance. References

Functional Knee Valgus in a Barbell Squat 18 Brookbush, B. (2014, July 28). Exercises to Reduce Knee Valgus During Squatting. Retrieved December 5, 2017, from brentbrookbrush.com Brookbush, B. (2017, May 23). Lower Extremity Dysfunction (LED). Retrieved December 5, 2017, from Brentbrookbrush.com Brookbush, B. (2017). Overhead Squat Assessment: Signs of Dysfunction. Retrieved December 5, 2017, from Brentbrookbrush.com Floyd, R. T., & Thompson, C. W. (2018). Chapter 9. In Manual of structural kinesiology (19th ed., pp. 229-272). New York, NY: McGraw-Hill Education. Floyd, R. T., & Thompson, C. W. (2018). Chapter 10. In Manual of structural kinesiology (19th ed., pp. 273-293). New York, NY: McGraw-Hill Education. Floyd, R. T., & Thompson, C. W. (2018). Chapter 11. In Manual of structural kinesiology (19th ed., pp. 293-328). New York, NY: McGraw-Hill Education.