Foot Position in the Squat: A Sports Medicine Perspective

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Article written by Seth Larsen

            We all love to squat, right?  If not, you’re probably on the wrong site.  If there’s one thing that has been a hot topic of late, especially since the release of a certain mobility book that will not be discussed here, it is foot and knee position during the squat.  Since I’m not into abusing deceased equines, I’ll leave the “knees in/knees out” debate out of this article.  Let’s talk about something equally as important (and arguably as controversial): foot position.

            Before I get into the meat of the article, I’ll tell you all a little about myself.  I’m not here to toot my own horn about credentials or diplomas, but I can tell you one thing: I have a long history of knee pain and have been playing with my squat form for some time to find what is optimal for my body.  After a decade of football, a few years of triathlons and obstacle racing, and my more recent obsession with strength sports of all kinds, my knees are pretty jacked up to say the least. Most, if not all of us LBEB followers can relate to this.  Why do I keep mentioning knees in an article about foot positioning? I’m glad you asked.

            Anyone who has run distance before can tell you how important your foot strike is for knee health in the long term.  For example, supination on the strike with a slam into pronation places a significant amount of stress on the lateral leg and knee, and is a common cause for iliotibial band (IT band) syndrome.  Foot positioning is equally as important in the squat. The direction in which your toes are pointed determines which muscles are most active during the squat, and how those muscles move your knee joint.  This is the same reason you see our bodybuilder counterparts playing with their foot direction on the leg extension machine.  Take a look down at your quads right now.  Flex them with your feet pointed towards the midline of your body.  Notice how your vastus lateralis (outside of your thigh) appears to flex harder?  Pointed forward, you’ll notice an equal flex in the majority of your quadriceps, with the rectus femoris (upper middle thigh) working hardest.  Now point your toes outwards.  This will make your vastus medialis (inner thigh) most active.  These different foot directions fire the same sets of muscles when you squat.

            You may be saying to yourself, “Great, another pompous, overeducated douche talking about some anatomy that I don’t care about.”  I get that.  But this anatomy is what drives arguably the most important movement in all strength sports: the squat!  Understanding it, even on a very basic level, is crucial to deciding what foot position in the squat is best for you and your goals.  In the aforementioned  mobility book and in the mind of many coaches, the only way to squat properly is with your toes pointed straight forward, and that any other choice will set you up for a multitude of problems down the line.  I’m here to tell you that this is not the case for every athlete.  Disregarding the fact that absolutes in any context are shortsighted and ultimately flawed, it has become apparent to me during my time as both an athlete and in clinical practice that every person’s body and movement patterns are different.  In light of this, trying to prescribe one “perfect squat position” for every athlete is extremely problematic.  We all have our little idiosyncrasies, and this is no more apparent than in the squat.

            One of these that is all too common is known as valgus collapse, a condition in which the knees collapse inward.  While not always problematic, as many olympic lifters have shown us time and again, repeated valgus collapse in the majority of the population can lead to other comorbid issues such as ACL tears, meniscal tears, patellofemoral pain syndrome, and IT band syndrome. From an anatomical standpoint, the prime culprits for this are weak hip abductors (primarily the gluteus medius), weak vastus medialis, overactive/tight vastus lateralis, and tight IT bands.  I know it sounds like I am going back to the “knees in/knees out” debate, but let’s revisit that anatomy for a second.  If so many people have this issue, wouldn’t pointing your toes out in a squat help to activate some of these important muscles that can help to solve the valgus collapse issue?  A foot pointing straight forward does not activate the vastus medialis and gluteus medius in the same way that one pointing away from midline does.

            Foot position is not simply about valgus collapse, however.  Even if your knees stay straight during the squat, repeating these squats over and over with your toes pointed forward can lead to impaired activation in the vastus medialis and gluteus medius.  Abductor weakness and VM weakness in and of themselves can lead to IT band syndrome, simply from repetitive adduction while walking.  With an overall incidence of IT band syndrome approaching 52% in trained athletes, it would seem to follow that an avoidance of these contributing factors would be beneficial for the majority of us.  This repeated lateral stress can also lead to weakening and tearing of the lateral meniscus.  As someone who has suffered from both IT band syndrome and a lateral meniscus tear, I can assure you that this is very unpleasant.  Fortunately, both of these problems can be treated by strengthening the vastus medialis (in addition to other mobility and flexibility exercises, obviously). In fact, greater than 50% of lateral meniscus tears (including my own) can be treated non-surgically through VM strengthening and activation.  So if you have lateral knee pain, try turning those toes out and strengthening what the bodybuilders call your “teardrop.”

            One final reason, which I would argue is the most applicable to the LBEB crowd, for not following the “toes forward” squat idea too dogmatically is something the overwhelming majority of strength athletes need to improve upon (except for those pesky olympic lifters): mobility and flexibility.  As I am sure many of you have felt when trying to squat with your feet close together and toes pointed forward, it can be difficult to keep your heels on the ground.  One’s heels coming up is due to a lack of ankle mobility, which many of us possess (this is one of the reasons oly shoes exist).  When your heels elevate, your weight shifts forward, placing an inordinate amount of shear force on your knees, specifically your patellar tendons.  This leads to another overly fancy medical word, patellofemoral pain syndrome, also known as pain in the front of and below your kneecap.  If you’ve been diagnosed with this, you know how much it sucks.  So why flirt with disaster when you can stay pain-free, helping you compete better and longer?

            Now before the trolls start marching in, I’ll go back to what I said before about absolutes: they are idiotic.  If squatting with your toes forward lets you lift more, doesn’t cause any pain, and you have the mobility to keep doing it, then go for it.  But if you’re like me, with a laundry list of injuries and you just can’t seem to figure out a way to squat that doesn’t hurt like hell, try turning your feet out and see what happens.  Who knows, you might even hit a squat PR.  And isn’t that we all want anyways?

Seth Larsen has a Bachelor’s of Science in Biology and Neuroscience and is a Doctor of Osteopathic Medicine candidate for 2015 at Midwestern University.  He is a former NASM-CPT and student athletic trainer.  He currently serves as a reserve officer in the US Navy Medical Corps while he finishes medical school with a specialization in primary care sports medicine.  Seth is a former NCAA football player who now competes as a LW (105kg) strongman, Highland Games athlete, and powerlifter. 

References:

1.      “Iliotibial band friction syndrome—A systematic review.”  Ellis, R., Hing, W., Reid, D.  Health Rehabilitation Research Centre, Division of Rehabilitation and Occupation Studies, Faculty of Health & Environmental Sciences, AUT University. Auckland, NZ. August 30, 2006.

2.      “The long-term evaluation of lateral meniscus tears left in situ at the time of anterior cruciate ligament reconstruction.” Shelbourne K.D., Heinrich J. Arthroscopy. Apr 2004;20(4):346-351.

3.      “Prospective study of the biomechanical factors associated with iliotibial band syndrome.” Noehren B., Davis I., Hamill J.  JClin Biomech. Nov 2007; 22(9):951-956.

4.      “ Iliotibial band syndrome in runners: innovations in treatment.” Fredericson M., Wolf C. Sports Med. 2005; 35:451–459.

5.      “Poor correlation of clinical signs with patellar cartilaginous changes.” Niskanen, R.O., Paavilainen, P.J., Jaakkola, M., Korkala, O.L. Arthroscopy 2001; 17:307.

6.      “ A prospective investigation of biomechanical risk factors for patellofemoral pain syndrome: the Joint Undertaking to Monitor and Prevent ACL Injury (JUMP-ACL) cohort.” Boling, M.C., Padua, D.A., Marshall, S.W., et al. Am J Sports Med 2009; 37:2108.

7.      “An evaluation of knee extensor and knee flexor torques and EMGs in patients with patellofemoral pain syndrome in comparison with matched controls.” Werner, S. Knee Surg Sports Traumatol Arthrosc 1995; 3:89.

8.      “Acute knee injuries.” Cooper, R., Crossley, K., Morris, H. Clinical Sports Medicine, 2nd edition, Brukner, P, Khan, K (Eds), McGraw-Hill, 2000. p.426.

9.      “Iliotibial tract friction syndrome in athletes–an uncommon exertion syndrome on the lateral side of the knee.” Orava, S. Br J Sports Med. 1978; 12:69.

10.  “Knee Valgus (Valgus Collapse), Glute Medius Strengthening, Band Hip Abduction Exercises, and Ankle Dorsiflexion Drills.” Contreras, B. June 14, 2013. Knee Valgus (Valgus Collapse), Glute Medius Strengthening, Band Hip Abduction Exercises, and Ankle Dorsiflexion Drills.

  • Really good write up here! Death is the only definite we have in life. If you aren’t messing with your form to see what is optimal for yourself and will allow you to move the most weight from A to B, you’re an idiot and won’t see progression in your strength.

    Luke Clement

  • A very well written article, its refreshing to speak candidly over a highly debated topic. And basing your form and technique on the “needs of the athlete” which is the basis of personal coaching and development.
    Chris Daly
    S10Fitness

  • I don’t disagree, but I have never seen any research actually confirming that angling the foot one way will target different muscles. Watching your own muscles while doing leg extensions is interesting, but lacks scientific confirmation. Do you know of any such research?

  • The pain in your knees is happening because the muscle to thekneecaps feels pain and tightens up, pulling the kneecap up on and into the knee making it hard and painful to bend your knees.
    http://www.footcentersofnc.com/

  • Sports Injury has been successfully treating it’s clients since 2005, assisting in everything from injury recovery for athletes to providing relaxing massages to those that simply wish to indulge themselves.

  • R Linville

    Can you direct me to the article/study describing foot position and quadriceps activity? Thank you