Six Steps to Squats: Design, Feasibility, and Baseline Results of a Pilot Functional Rehabilitation Protocol After Orthopaedic Trauma

Background and objective Functional, multi-joint assessments provide more insight into orthopaedic recovery than isolated range-of-motion or time-based metrics. The squat requires coordinated hip, knee, and ankle motion and reflects mobility, strength, and neuromuscular control. Squat-based assessments have shown value in anterior cruciate ligament injury, osteoarthritis, and arthroplasty populations, but no standardized squat-focused protocol exists for orthopaedic trauma rehabilitation. This article describes the Six Steps to Squats protocol, a structured, progressive squat-based rehabilitation and assessment program for isolated lower extremity fractures; evaluates the feasibility of administering it in a Level 1 trauma clinic; and reports baseline squat mechanics in the first enrolled cohort. Comparative outcomes of this ongoing pilot study will be reported upon completion. Methods This prospective comparative pilot study enrolled adults recovering from isolated lower extremity fractures. Patients were assigned to an experimental group if designated weight-bearing as tolerated (WBAT) within the prior 1-2 months or to a control group if 4-12 months post-WBAT. Exclusion criteria included prior lower extremity surgery, multiple injuries, arthroplasty, inflammatory arthritis, paraplegia, BMI >45, or more than three active comorbidities. The Six Steps to Squats protocol consists of six progressive phases targeting ankle mobility, hamstring flexibility, squat range of motion, unilateral flexion, assisted descent, and full unassisted squat ascent, with a standardized exercise prescription and defined graduation criteria for each step. Baseline assessments were supervised by trained research staff; the home program was supported by a patient guide with video demonstrations and monitored through monthly clinic visits and biweekly telephone calls. Hip, knee, and ankle flexion angles were measured using goniometry and digital image analysis during assisted and unassisted squats. Functional status was assessed with the SF-36, administered before the squat assessment. Results Twelve patients were enrolled (seven control and five experimental). Mean baseline unassisted flexion angles (control vs experimental) were 104.4° ± 19.1° vs 112.5° ± 25.7° at the hip, 95.5° ± 26.8° vs 88.5° ± 36.3° at the knee, and 98.6° ± 10.5° vs 100.8° ± 5.3° at the ankle. Assisted squat flexion angles averaged 119.2° ± 12.4° vs 111.0° ± 21.9° at the hip, 112.2° ± 26.5° vs 109.6° ± 40.6° at the knee, and 98.2° ± 8.8° vs 94.8° ± 5.7° at the ankle. All patients successfully rose from an unassisted squat, all 12 completed the full baseline assessment within a single routine clinic visit, and no adverse events occurred during testing. Preliminary subgroup analysis suggested reduced multiplanar flexion among patients with bimalleolar ankle fractures treated with open reduction and internal fixation. Conclusion The Six Steps to Squats protocol and its assessments proved feasible to administer in a Level 1 trauma clinic, and baseline data showed wide variability in squat mechanics after lower extremity fracture. Ongoing enrollment and follow-up of the full planned cohort will evaluate its effects on joint biomechanics, patient-reported outcomes, and long-term functional performance.