Squat form with CAM type FAI, and exercise replacements in the beginner template

[Ben Cohen]

Hi BBM,

Just to give a bit of backstory before I ask the questions, I have been struggling with hip pain which is caused by CAM type femoroacetabular impingement, which subsequently caused a slight tear in the upper part of my labrum (Started around two years ago, am currently 20 years old). I have been doing physiotherpay on and off have been training on and off since the injury, but in the past 4-5 months have been very committed to doing everything my physiotherpaist has told me. The physio mainly had me doing banded exercises and working on strengthening all the muscles around the hip, and has slowly reintroduced me to training legs (I started off with doing leg press with a shortened ROM, and have now gotten to squatting with only the bar).

The problem I have been having lately is that for the past 2 months I have been stuck in the same place in terms of progressing in training without pain. I can currently squat only 3/4 of a full ROM without feeling pain (only with the bar as weight), and whenever I try to get lower I feel a bit of pain so I don't push it. My physio said I might need to change the angles in which I squat, and said that I sould not let my knees travel past my toes, be as upright as possible and sit back onto my heels. My question is, does this advice about the squat technique that my physio gave me good advice? From all that I have seen about squat technique, people have said that it's false that you cannot let your knees travel past your toes, and to always keep your balance over the middle of your foot, which contradicts what my physio has told me.
(1) Is there a specifc way in which I should be squatting with a hip impingement, or should I be squatting with a "normal" high-bar / low-bar technique?
(2) Is the advice about my squat technique from my physio good advice or in this case it is false advice?
(3) How do I keep progressing with recovery in order to be able to squat "normally" again and start making progress?

My second question has to do with what I should be doing in training in the meantime. I am currently running a simple A-B program 4 times a week, but have bought the beginner template a few months ago and have been waiting until I can squat normally again in order to start the program.
My questions are:
(4) Should I start the beginner template now? If so, what should I do about the squat exercise as there is squatting 3 times per week in this template?
(5) Should I start the template and replace the squat with a differant exercise which I can do pain free? Or should I wait until I can squat without pain before starting the template?

Any help would be much appreciated!

[jhartman]

I have FAI in both hips. In the left I had a labrum torn and surgically fixed, as well as the lesions shaved down.

I'm not strong (slowly getting out of being skinny-fat) - 315 squat E1RM. I do most of my training with paused squats and that made the difference. Limiting range of motion is a good idea. Play around with pause squats, pin squats, etc. See what gives you the least pain. You will probably be able to increase the weight and ROM slowly over time and maybe then get to a point where some of your training can be a competition variant.

[Derek Miles]

I would recommend with starting here:

https://www.barbellmedicine.com/blog/training-with-hip-pain-part-iv-femoroacetabular-impingement-syndrome/

In terms of the physio's advice, changing your stance width or where your knees are tracking can be beneficial variables to change to return to squatting. The pattern is often different for each athlete and often what is assigned to why a certain pattern is chosen is more problematic than anything else. There is a decent bit of variability in squat technique from person to person and sometimes it is as much about finding the combination that works best for a particular athlete. To your questions:
1) Sometimes you really need to "play with it" in order to find the best current combo. It does not need to be a permanent change and sometimes it is allowing for changes to take place before returning to some prior patterns.
2) It would get a "meh" out of me. I do think changing stance is a very good idea in the short term but not because there is one best way to squat.
3) If you are feeling like things have stalled, I would recommend a consult with us. The rock across the water answer is it is often good to frame different sessions with different goals i.e. taking one session and squatting through a range with minimal symptoms where the goal is to add weight then taking the next session with a lighter weight where the goal is to add range of motion. Now you also have two changes for improvement versus one as well.
4) If you do the beginner template you could take the sessions with a focus as mentioned in answer (3)
5) You can also sub in things like split squats, leg press, and knee extensions here.

[Ben Cohen]

I have FAI in both hips. In the left I had a labrum torn and surgically fixed, as well as the lesions shaved down.

I'm not strong (slowly getting out of being skinny-fat) - 315 squat E1RM. I do most of my training with paused squats and that made the difference. Limiting range of motion is a good idea. Play around with pause squats, pin squats, etc. See what gives you the least pain. You will probably be able to increase the weight and ROM slowly over time and maybe then get to a point where some of your training can be a competition variant.

I have tried doing paused squats in my last workout and although I was using only the bar, it felt better than the normal squat, thanks for the advice!

I would recommend with starting here:

https://www.barbellmedicine.com/blog/training-with-hip-pain-part-iv-femoroacetabular-impingement-syndrome/

In terms of the physio's advice, changing your stance width or where your knees are tracking can be beneficial variables to change to return to squatting. The pattern is often different for each athlete and often what is assigned to why a certain pattern is chosen is more problematic than anything else. There is a decent bit of variability in squat technique from person to person and sometimes it is as much about finding the combination that works best for a particular athlete. To your questions:
1) Sometimes you really need to "play with it" in order to find the best current combo. It does not need to be a permanent change and sometimes it is allowing for changes to take place before returning to some prior patterns.
2) It would get a "meh" out of me. I do think changing stance is a very good idea in the short term but not because there is one best way to squat.
3) If you are feeling like things have stalled, I would recommend a consult with us. The rock across the water answer is it is often good to frame different sessions with different goals i.e. taking one session and squatting through a range with minimal symptoms where the goal is to add weight then taking the next session with a lighter weight where the goal is to add range of motion. Now you also have two changes for improvement versus one as well.
4) If you do the beginner template you could take the sessions with a focus as mentioned in answer (3)
5) You can also sub in things like split squats, leg press, and knee extensions here.

I've read the article about training with hip pain, and it was very helpful, though I have a few followup questions.
1) Which stance width and toe angle tend to be better to start with in my case? I currently squat high-bar, with around a shoulder width stance and my toes pointed out at around 45 degrees (My height is 180 cm and I weigh 70 kg if it matters for the squat mecaniques). Should I go a bit wider with my stance? and what toe angle is usually best to start with for people with hip pain?

2) After reading the article about hip pain, I think that I will try to incorporate it in the following way in the first phase of the beginner template which I will also use as a sort of "rehab" template for the squat:

• Day 1 - Paused Box Squat (to tolerable depth, emphasis on weight; may experiment with stance width)
  • 1 set of 6 reps at RPE 6
  • 1 set of 6 reps at RPE 7
  • 1 set of 6 reps at RPE 8
• Day 2 - Paused Squat (with tolerable weight, emphasis on depth, may experiment with stance width)
  • 1 set of 6-8 reps at RPE 6
  • 1 set of 6-8 reps at RPE 7
• Day 3 - 3-0-3 tempo Squat (with tolerable weight, emphasis on depth, may experiment with stance width)
  • 1 set of 10 reps at RPE 6
  • 1 set of 10 reps at RPE 7
  • 1 set of 10 reps at RPE 8

In addition, as I will probably not be working at a very high intensity at first, I might add an additional quad focused exercise (Such as lunges / Split squats / Leg extensions) to supplment the volume.

Does the current outlay of the plan look like a reasonable way to approach this or are there differant recommendations as to how I should set up the beginner template?


The final question has to do with additional quad focused exercises. If I have the same hip problem with exercises such as lunges split squats / goblet squats, should I be using a similar approach and try to increase weight / depth over time?