For an introduction to the Overhead Squat Assessment (OHSA) including intent, validity, reliability, signs of dysfunction, analysis and set-up please review:

This article is includes a video, table with analysis and intervention recommendations, and relevant research for each of the 8 commonly noted signs during the OHSA.

    Printable PDF of the Movement Assessment Template (including the OHSA):

    Feet Flatten:

    Feet Flatten = Excessive Eversion

    Note: This compensation pattern is often driven by a lack of dorsiflexion

    Short/Over-active Long/Under-active
    Evertors: Invertors:
    Plantar Flexors: Dorsiflexors:


    • Feet flatten has been correlated with tibialis posterior dysfunction (14-18), and selective activation/exercise for the tibialis posterior has been shown to have a positive effect on foot/ankle and lower extremity kinematics (19-20).  Although these studies did not use the OHSA as an outcome measure, description of the sign”eversion/pronation” in these studies is similar to the description of the sign “feet flatten” used for the OHSA.  Most of these studies referred to the “Navicular Drop Test”, which may be used as an objective interval measure in conjunction with the OHSA to monitor progress. In a study by Trimble et al. this sign, assessed with a lower extremity posture test was found to be a better indicator of tibial translation than recurvatum or thigh foot angle (84).

    Feet Turn Out

    Feet Turn Out = Tibial External Rotation

    Note: This compensation pattern is often driven by a lack of dorsiflexion

    Short/Over-active Long/Under-active
    Tibial External Rotators Tibial Internal Rotators:
    Plantar Flexors: Dorsiflexors:
    Special notes:


    • Feet Turn Out - Only two studies have correlated feet turn-out with dysfunction.  In a study by Winslow et al., feet turn out was correlated with a positive “Ober’s Test” (tensor fascia latae restriction/over-active) and knee pain (21), and in a study by Andrew et al., feet turn out was correlated with a functional varus and linked to knee osteoarthritis (40).  However, other studies have shown a correlation between an increase in biceps femoris activity (a strong tibial external rotator) and knee dysfunction/pain (22, 23). In an interesting study by Hasegawa et al., biceps femoris stretching resulted in a relative increase in vastus medialis activity (23); this may be evidence that conservative treatment (exercise/manual therapy) may improve this impairment.  It is worth noting, tibial external rotation may also be a component of “Knees Bow In” (functional valgus), as femoral internal rotation can be viewed as relative tibial external rotation.

    Knees Bow In

    Knees Bow In = Tibial External Rotation & Femoral Internal Rotation

    Note: This compensation pattern may be driven by ankle or hip dysfunction. If this dysfunction is driven by ankle dysfunction, it may be necessary to add Plantar Flexor and Evertor: Release and Lengthening and Tibialis Anterior Activation

    Short/Over-active Long/Under-active
    Tibial External Rotators Tibial Internal Rotators:
    Femoral Internal Rotators Femoral External Rotators
    Special notes:


    Knees Bow In (functional valgus) – Research has correlated a functional valgus with a decrease in gluteus maximus and medius activity, sacroiliac joint dysfunction, excessive hip internal rotation and adduction, a loss of dorsiflexion, and excessive pronation (20, 24-33, 87-88). Studies have also correlated this sign of dysfunction with increased risk of anterior cruciate ligament (ACL) injury and patello-femoral pain (ACL) (24, 27, 28). Several studies have also noted the effectiveness of specific exercise intervention for correcting this dysfunction (20, 35-36).  Although the OHSA is not used by name in any of these studies, in many of them, a squat or depth jump (LESS test) was used as to assess to measure the presence as knees bow in (referred to this sign as a “functional valgus” or “medial knee displacement”) (20, 24, 28 – 34)

    Knees Bow Out

    Knees Bow Out = Femoral External Rotation & Ankle Eversion

    If this dysfunction is driven by ankle dysfunction, it may be necessary to add Plantar Flexor and Evertor: Release and Lengthening and Tibialis Posterior Activation

    Short/Overactive Inhibited Agonists
    Synergists of External Rotation: Agonists of External Rotation:
    Evertors: Invertors:
    Special notes:
    1. This is a tricky dysfunction to analyze.  Although it is tempting to label the hip dysfunction as "excessive abduction", this would imply the ineffective practice of inhibiting an under-active gluteus medius and activating the commonly over-active adductors.  Practice and other clues offered by various research studies has lead to the hypothesis that synergistic dominance of the external rotators of the hip in conjunction with relatively under-active glute complex drive hip dysfunction for this sign.
    2. Experience has also shown that if correcting this dysfunction results in “Knees Bow In”, this is an improvement.  This sign is our first “compensations within a compensation.”  If the “Knees Bow In” on reassessment treat the dysfunction as such and use the corrective strategy implied by the table “Knees Bow In.”


    • Knees Bow Out (functional varus) – In a study by Noda et al., this sign correlated with reduced ankle dorsiflexion and hip internal rotation using goniometric assessment (86).  Further, there are several studies showing a correlation between functional varus (measured via gait or imaging) and knee osteoarthritis (37-39).  Further, one study correlated an increase in varus loads on the knee with increased feet turn out and feet flatten during gait (40).  One study showed that gait retraining (a conservative, exercise based approach) was effective for reducing a functional varus (41).

    Excessive Forward Lean

    Excessive Forward Lean = Hip Flexion & Lack of Dorsiflexion

    Note: Relative to movement analysis, a "lack of dorsiflexion" is the same as "excessive plantar flexion".

    Short/Overactive Long/Underactive
    Hip Flexors: Hip Extensors


    Plantar Flexors: Dorsiflexors:
    Special notes:
    1. In this dysfunction we find our first "long/over-active" muscles (those marked with an"*").  Generally, as is the case above, this pairing of maladaptive length and activity is a sign of the muscle(s) becoming synergistically dominant for an inhibited prime mover.  These muscles should not be stretched, activated or strengthened, however, release techniques may be effective for improving function.
    2. The “Tibial Internal Rotator Activation” is added as a means of increasing semitendinosus and semimembranosus activity.


    • Excessive Forward Lean – Two studies have shown a relationship between dorsiflexion restriction and excessive trunk flexion during squatting (and additional changes in kinematics)  (32, 56).  Two additional studies have demonstrated a decrease in gluteus maximus strength and activity related to ankle dysfunction (34, 57), which may partially explain the inability to maintain upright posture.  Clinically, addressing dorsiflexion range of motion and addressing gluteus medius and gluteus maximus activity and strength have consistently resulted in positive outcomes.

    Anterior Pelvic Tilt (Excessive Lordosis)

    Anterior Pelvic Tilt (Excessive Lordosis) = Hip Flexion & Lumbar Extension

    Note: The pelvis is not a joint; it is a bone whose position is influenced by lumbosacral joints and hip joints.

    Short/Overactive Long/Underactive
    Hip Flexors: Hip Extensors:
    Lumbar Extensors: Trunk Flexors:
    Special notes:


    • Anterior Pelvic Tilt (excessive lordosis) – This is an interesting sign relative to available research.  Although it is not possible to find a single study that correlates all factors related to this sign, for example – an increase in lumbar lordosis, with a loss of hip range of motion, with an Anterior pelvic tilt, with altered motor control and low back pain –  there are numerous studies that correlate 2 or more of these signs/symptoms (42-50). The strongest correlations likely exist between an Anterior pelvic tilt, low back pain and a loss of hip extension and internal rotation, and a relative reduction in transverse abdominis, multifidus, gluteus medius and gluteus maximus activity (42 – 50, 82). In one study by Cholewicki et al., a correlation was made between altered motor control and future low back pain (42); a rare study that implies dysfunction precedes pain!  Several studies have shown that exercise is effective in the treatment of low back pain (and presumably an Anterior pelvic tilt) (51-55), especially long-term (55).

    Arms Fall

    Arms Fall Forward = Shoulder Internal Rotation

    Note: The muscles that cause the shoulders to internally rotate in static standing posture are the same muscles that would cause extension/adduction of the arms from an overhead position (180° of Flexion/Abduction).

    Short/Overactive Long/Underactive
    Shoulder Internal Rotators: Shoulder External Rotators
    • Special notes:In this dysfunction we find "long/over-active" muscles (those marked with an "*").  Generally, as is the case above, this pairing of maladaptive length and activity is a sign of the muscle(s) becoming synergistically dominant for an inhibited prime mover.  These muscles should not be stretched, activated or strengthened, however, release techniques may be effective for improving function.
    • It is very rare that shoulder dysfunction presents without scapula and thoracic spine dysfunction.  Most often a corrective strategy would include many of the techniques recommended in the graph below “Shoulders Elevate


    • Arms Fall – Although this sign would seem to indicate over-activity (or a loss of extensibility) of shoulder extensors, it is important that analysis of this sign considers extensors only from 180° of shoulder flexion, as performed during the OHSA.  With some analysis and review of anatomy, the list of muscles generated could be summarized as “all shoulder internal rotators and the “posterior deltoid“.  This list of muscles, has the added benefit of agreement with various texts that note  “excessive internal rotation” in static posture in those exhibiting upper body postural dysfunctions (1-4, 9-10). Research has confirmed a portion of this list, as an increase in subscapularis and posterior deltoid activity has been observed in those experiencing shoulder pain  (58, 59).  However, there may be any easier method of validating this sign on the OHSA.  “Arms fall” is nothing more than an inability to maintain 180° of shoulder flexion, and shoulder flexion goniometry has been shown to be a very reliable assessment (60-64).  Although the OHSA may not be a good measure of progress due to the binary nature of assessment results; shoulder flexion goniometry may be used in conjunction with the OHSA as an objective interval measure to monitor progress.  There is a gap in the research regarding this sign.  There is no single study that correlates the sign “Arms Fall” with common shoulder pathologies (like shoulder impingement syndrome (SIS)), and further, no study that correlates how specific interventions may improve the sign “Arms Fall”.  However, pain during end range shoulder flexion (as performed in the OHSA) is perhaps the most common complaint among those exhibiting symptoms of SIS, and there is a significant amount of research on external rotator activation (a commonly used intervention to treat SIS), and various studies have demonstrated that exercise is effective for the treatment of SIS (70 – 72).

    Shoulders Elevate:

    Shoulders Elevate = Scapula Downward Rotation + Anterior Tipping

    Note: The observable elevation of the shoulder girdle is actually the superior angle elevating around a fixed glenoid fossa - in essence, relative downward rotation.

    Short/Overactive Long/Underactive
    Downward Rotators: Upward Rotators:
    Anterior Tippers Posterior Tippers
    Special notes:
    1. This dysfunction is most often paired with shoulder dysfunction (graph above).
    2. The Upper Trapezius fall on both sides of the graph (another strange occurrence). Based on research correlating muscle activity and shoulder girdle dysfunction is likely best to treat the Upper Trapezius as short/over-active (release and lengthen)


    • Scapula Elevate – This sign, like the sign above (Arms Fall), must be considered relative to functional anatomy. Although it may be presumed that “elevation” of the scapula is observed, closer examination will reveal this motion is actually elevation of the superior angle of the scapula around a relatively fixed glenoid fossa, in conjunction with sagittal plane motion of the scapula over the top portion of the rib cage.  The resulting excessive joint actions are relative downward rotation and anterior tipping of the scapula.  Once this discrepancy between observation and analysis is solved for, this sign is presumably valid based on agreement with research relative to shoulder dysfunction. Research by Lawrence et al., demonstrated relative downward rotation and an increase in anterior tipping of the scapula in those with shoulder pain (65). Further, research by Scavozzo et al found that swimmers with symptoms of shoulder impingement exhibited less than half the normal activity of the serratus anterior (an upward rotator and posterior tipper of the scapula) during the pull-through phase of stroke (58). An indirect relationship may also exist between this sign and a thoracic kyphosis, as a thoracic kyphosis has been correlated with shoulder impingement syndrome (66), and shoulder impingement syndrome with scapular dyskinesis (58, 65, 67 – 69).  There is a significant amount of research to refine and support the use of scapular mobility techniques, serratus anterior activation and trapezius activation, and as mentioned above, exercise has been shown to be effective for the treatment of SIS (70 – 72).

    The Next Step:

    The next step in understanding the Overhead Squat Assessment is the recognition of "Clusters of Signs", also known as "Compensation Patterns."

    These common clusters may be described by the Predictive Models of Movement Impairment discussed in the articles below:


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      • Feet Turn Out
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      • Exercise Helps Functional Valgus
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      • Knee Bows Out
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      • Low Back Pain Altered Recruitment
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      • Excessive Forward Lean
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      • As well as studies 32 and 34
      • Arms Fall
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      • Shoulders Elevate
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      • and 58
      • Regional Interdependence
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    © 2017 Brent Brookbush

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