Sometimes it’s OK for “toes in“ squats

We hear from folks and also read on a lot of blogs and articles about whether your toes should be in or out for squats or other types of activities. The real answer is “it depends”.

What it depends on is the patient’s specific anatomy. That means we need to pay attention to knees and hips and things like femoral and tibial torsion‘s. It’s paramount to keep the knees in the sagittal plane, no matter what the lower extremity orientation is.

When somebody has external tibial torsion (i.e. when you drop a plumbline from there to view tuberosity it passes medial to the line between the second and third or second metatarsal) then having your feet and externally rotated position places the knees in sagittal plane. Having the patient go “toes in” with this type of anatomy will cause both knees to for medially and create patellofemoral tracking issues.

Likewise, like the patient in the video, (Yes, I know I say “external tibial torsion“ at the beginning of the video but the patient has internal tibial torsion as you will see from the remainder of the video) when somebody has internal tibial torsion (I.e. when you drop a plumbline from the tibial tuberosity it passes lateral to the second metatarsal or a line between the second and third metatarsal) you would need to point the toes inward to keep the knees in the sagittal plane as demonstrated in the video. You can also see in the video when her feet are placed “toes out“ they fall outside sagittal plane laterally which creates patellofemoral tracking issues like it was in this particular patient.

So, knees in or knees out? It depends…

Dr. Ivo Waerlop, one of The Gait Guys

#internaltibialtorsion #externaltibialtorsion #kneepain #kneesin #kneesout #squats #thegaitguys

Leg exercise is critical to brain and nervous system health

Leg exercise is critical to brain and nervous system health

"New research shows that using the legs, particularly in weight-bearing exercise, sends signals to the brain that are vital for the production of healthy neural cells."

This research supports what we already know, but in a new spin, that sensory input is just as important as motor output. This study gives new clues into why people with motorneuron diseases (spinalmuscular atrophy etc) decline so quickly as their movement impairment deepens.

This research might suggest that those who do not continue to weight bear load, such as bedridden or chronically ill patients and even the aging population, are at risk for faster decline. "Not only (do they) lose muscle mass, but their body chemistry is altered at the cellular level and even their nervous system is adversely impacted," says Dr. Raffaella Adami from the Università degli Studi di Milano, Italy.

"Limiting physical activity decreased the number of neural stem cells by 70 percent compared to a control group of mice, which were allowed to roam. Furthermore, both neurons and oligodendrocytes -- specialized cells that support and insulate nerve cells -- didn't fully mature when exercise was severely reduced."

"Reducing exercise also seems to impact two genes, one of which, CDK5Rap1, is very important for the health of mitochondria -- the cellular powerhouse that releases energy the body can then use. This represents another feedback loop."

Bottom line here folks, you have to move, you have to load, especially if you have a neurologic disorder and especially if you are declining in age. At the very least, throw some lunges or body weight squats into your day. Walk the stairs, don't ride the elevator. Move. Lift. Strain.

Pod #124: Gluteal gripping, Runner's dystonia. Are leg length differences real ?

Key tag words:
running, gait, injuries, kidney, kidneydamage, marathoners, foot, feet, dehydration, heatstroke, elon musk, neural lace, hip pain, crossfit, squats, deadlifts,  LLD, short leg, dystonia, runner's dystonia, posture, 

Summary:  Today we hit some very important topics on how to examine a client and how asymmetries play into gait, running, posture and pathomechanics. We hope you enjoy today's show, it is our first one back in 6 weeks. We are back strong after a brief early summer sabbatical. Back to the "podcast every 2 weeks" again. Thanks for being patient while Ivo recharged for the second half of the year.   Plus, on today's show, we also dive into Runner's kidney, dehydration, gluteal gripping, runner's dystonia, functional leg length differences due to asymmetries, and more !

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Show Notes:

Kidney Damage in Runners. 82%  !?
Kidney nephropathy in mesoamericans.  
Elon Musk's Neural Lace.
Leg length discrepancies,do they really even exist ?
Dystonia ?
The Gluteal gripping phenomenon.

Eliminating the fake out of ample ankle rocker through foot pronation in the squat and similar movements:  How low can you go ? 

This is a simple video with a simple concept. 

* Caveat: To avoid rants and concept trolling, am blurring lines and concepts here today, to convey a principle. Do not get to tied up in specifics, it is the principle I want to attempt to drive home.  What you see in this video is clearly more lunge/knee forward flexion rather than hip hinge movement. However, keep in mind, that this motion does occur at the bottom of many movements, including the squat. 

You can achieve or borrow what “appears” to be more ankle dorsiflexion, a term we also loosely refer to as ankle rocker, through the foot, foot pronation to be precise. Do not mistaken this extra forward tibial progression range as ankle rocker mobility however. When you need that extra few degrees of ankle dorsiflexion deep in your squat, or similar activities, you can get it through your foot. Often the problem is that you do not think that is where it is coming from, you might just think you have great ankle mobility.  Many deep squatters are borrowing those last few degrees of the depth of the squat from the foot. This is not a problem, until it is a problem.  Watch the video above.  Why ? Because when the foot pronates and begins to collapse (hopefully a controlled collapse/pronation) the knee follows. Forcing the knees outward in a squat like some suggest is a bandaid, but I assure you, the problem is still sitting on the table. 

Go do a body weight squat with the toes up like in this video. Toes up raises the arch from wind up of the windlass and increased activity of the toe extensors and some assistance from the tibialis anterior and some other associated “helper” muscles.  When the arch is going up, it cannot go down. So, you raise your toes and do your squat. This will give you a better, cleaner representation of how much mobility in your squat/lunge/etc is from ankle dorsiflexion, knee flexion and  hip flexion. You can cheat and get some from the foot. The foot can be prostituted to magnify the global range, and like I said, this is not a problem until it IS a problem.   We know that uncontrolled and unprotected increases in foot pronation can cause a plethora of problems like plantar tissue strain, tibialis posterior insufficiency and tendonopathies, achilles issues, compression at the dorsum of the cuneiform bones (dorsal foot pain) to name a few. This dialogue however is not the purpose of this blog post today. You can read more about these clinical entities, proper foot tripod skills and windlass mechanics on other blog posts on this site. 

Today, we just wanted to bring this little “honesty” check to your awareness. Has been a staple in my clinic for over a decade, to help me see where limitations are and to show folks how they can cheat so much through the foot. Go ahead, try it yourself, see how much you use your foot to squat further if you have end range mobility issues in the hips, knees or ankles.  The foot is happy to give up the goat, it just doesn’t know the repercussions until they show up. 

So, lift your toes, do a full squat. Go as low as you can with good form with the toes up.  Then, at the bottom of the squat or the bottom of  your clean mobility, suddenly drop your toes and let the arch follow if it must. Here is the moment of truth, at that moment the toes go down, feel what happens to the foot, ankle, tibial spin, knee positioning, pelvis posture changes. Careful, these are subtle. You may find you are using foot pronation more that you should, more than is safe.  Now try this, bottom out your cleanest squat as you regularly would, and at the bottom, raise your toes and try to reposition the foot arch and talus height. In other words, reposture your foot tripod, see how difficult this is if you can do it at all. Perhaps you will find your toe extensors are too weak to even get there.  This is how we cheat and borrow. We should not make it a habit, it should be used when we need it, but it should not be a staple of your squatting diet, it should not be a regular event where you prostitute sound biomechanics.  Unless you wish to pay for it in some way.  What should happen is that you should be able to bring your toes down and not let the arch follow, but that is a skill most have not developed. It is a staple move in your clients’ movement diets.

Does all this mean you should squat with your toes up ? No, but it may serve you well in awareness, evaluation, and looking for potholes and power leaks. At the very least, give it some thought and consideration. You may see some smiles and have some lightbulb moments between you and your athletes and clients. 

Plan on blocking this foot pronation range with an orthotic ? How dare you ! At least try to do it through reteaching this and the tripod skill first. Give your a client a chance to improve rather than a bandaid to cope. 

Dr. Shawn Allen, one of the gait guys

#92: Your Brain on running. Ankle tightness, Femur rotation and more.

Plus a little on Oliver Sacks and homeostasis.

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Show notes:

A General Feeling of Disorder: Oliver Sacks

How Running Keeps Your Brain Humming

Hey Gait Guys,
I’ve been reading your blog and listening to your pod-casts (now on 71 but have listened to some new ones too so maybe 10 more to go). I’ve become so much more aware of the body’s biomechanics. Maybe this has been discussed by you guys before but I haven’t come across it yet. I was in Walmart and saw the Dr. Scholl’s foot map system and arch supports. I don’t know if you’ve seen the machine or have tested it out but they are everywhere. I found it interesting that for EVERY foot type they are recommending a ‘specialized’ heel lift. It involves statically standing on the machine on one leg. Interestingly there are handles which one can hold to help support the body on this single leg stance. After listening to so many podcasts and applying my new found knowledge, it immediately raises red flags in my brain. Thought you might be interested.

Overtightening of the ankle syndesmosis: is it really possible?
Tornetta P 3rd1, Spoo JE, Reynolds FA, Lee C.
J Bone Joint Surg Am. 2001 Apr;83-A(4):489-92.

Femur rotation

Hi there Dr Ivo and Dr Allen
I thought this article may interest you.
This last paragraph/quote in particular caught my eye.
I was wondering what your opinion of this would be and wether you agree with it entirely?
Wenger et al (1989) suggest that, since flexible flat foot is generally a benign condition, it rarely requires treatment.

wreck method, squats ?

Tom Purvis hits some strong points in this video about squatting, hip hinges, ankle dorsiflexion, and movement as a whole.  * Keep in mind, this is all sagittal plane stuff….. it gets far more complicated when there are lateral (frontal) plane or rotational (axial) considerations ….. these are the “knees out” dialogues and debates you have read over and over on the web in the last year.

Dr. Shawn Allen


Food for thought after posting today’s Tom Purvis squat video.

Could this study below translate into the statement/question: 

“attempting to achieve sufficient dorsiflexion through the combined ‘foot pronation-ankle dorsiflexion’ mechanism, as opposed to just dorsiflexion from the ankle mortise joint alone, may change the dynamics of the entire limb…. in this case, hip flexion range observation. Is this because when dorsiflexion is cheated via foot pronation, instead of just ankle dorsiflexion, there is more internal tibia/femoral spin than would normally occur from just sagittal ankle hinging which can in turn impair terminal hip flexion range via impingement type action ? I think so. It would be cool to see what would have happened in the study had the pronating clients been shown my foot tripod restoration exercise (it’s on youtube).   -Dr. Allen

here is some new research on this point, for what it is worth.  It keeps the mind thinking though.

J Phys Ther Sci.  2015 Jan;27(1):285-7. doi: 10.1589/jpts.27.285. Epub 2015 Jan 9.The kinematics of the lower leg in the sagittal plane during downward squatting in persons with pronated feet.  Lee,Koh da,  Kim 


[Purpose] This study aimed to examine changes in lower extremity kinematics in the sagittal plane during downward squatting by subjects with pronated feet. [Subjects and Methods] This study selected 10 subjects each with normal and pronated feet using a navicular drop test. The subjects performed downward squatting, in which the knee joints flex 90° in a standing position. We recorded the angles of the hip, knee, and ankle joint in the sagittal plane through motion analysis. For the analysis, the squatting phase was divided into phase 1 (initial squat), phase 2 (middle squat), and phase 3 (terminal squat) according to the timing of downward squatting. [Results] In the pronated foot group comparison with the normal group, thehip joint flexion angle decreased significantly in phases 2 and 3. The dorsiflexion angle of the ankle joint increased significantly in phase 3. The flexion angle of the knee joint did not differ between groups in any of the phases. [Conclusion] The pronated foot group utilized a different squat movement strategy from that of the normal foot group in the sagittal plane.

Video: Wow he just lifted,  232 kg, that is 511 pounds !

What is one of our favorite areas to preach about ?  Yes, Ankle dorsiflexion range, or as we often term it, ankle rocker.  There are plenty of activities where we need that critical >90degrees (great than) in order to complete the movement at the appropriate joints.  Depending on the source you reference and the case by case evaluation, typically 110+ degrees are needed at the ankle hinge mortise (tibiotalar joint) in order to keep the motion from being forced elsewhere.  No sport seems to have it as an absolute critical range more than the Clean and Jerk Olympic lift. You can see in this video above, and particularly in this awesome slo-mo video here  that we need that magical range in order to do the lift properly.

What will happen if you try to do it with this critical ankle hinge range ? Well, the foot arch can collapse (pronate) to gain more tibial progression and get that tibia to move forward but this will mean that your tibia will be internally spinning which will drag the knee medially and this will create some serious knee loads and patellar tracking issues, to say the very least. Additionally, this spin can risk the anterior hip joint with issues which we will discuss another time.

The body has some pretty strict parameters when it comes to safe loading responses. And if those parameters are not met, then an alternate pattern must be employed if the motion or load must continue. And alternative loads usually lead to pain or injury.  

Make sure you have enough ankle range, amongst some other critical parameters, if you are going to lift, especially if you are going to lift  heavy.  Can you imagine the impacting load on the foot and the ankle if this fella had stiff ankles with less than 110 degrees ankle dorsiflexion ?  And remember, merely turning out your feet further doesn’t get you around the problem necessarily. It may help a little, but remember, if you are going to turn your feet out (increase your foot progression angle) the knee tracking has to follow that foot angle, and if it does not, then tibiofemoral torsion will increase and meniscal maceration is a foregone guarantee !

Ankle rocker, it is important stuff.  Especially when you are going this big ! But, even if you are doing more remedial squats or Turkish Getups or whatnot.

Shawn and Ivo, The Gait Guys