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Dynamic Deep Squat:

Lower-Body Kinematics and Considerations Regarding Squat Technique, Load Position, and Heel Height

Max Todoroff, PT, DPT, OCS, CSCS Manual Medicine Physical Therapy, Raleigh, North Carolina

ABSTRACT

THE DYNAMIC DEEP SQUAT IS AN IMPORTANT AND WIDELY USED EXERCISE BY STRENGTH AND CONDITIONING, REHABILITA- TION, AND HEALTH CARE PRO- FESSIONALS. THIS ARTICLE EXPLORES LUMBAR SPINE AND LOWER EXTREMITY KINEMATICS DURING THE DYNAMIC DEEP SQUAT AND CONSIDERS SQUAT TECHNIQUE, LOAD POSITION, AND HEEL HEIGHT INFLUENCES. BETTER UNDERSTANDING OF DYNAMIC DEEP SQUAT KINE- MATICS MAY HELP TO PREVENT LUMBAR SPINE INJURIES RELATED TO SQUAT- TING.

INTRODUCTION

T he dynamic deep squat is widely

used to improve lumbar spine

extensor strength, hip extensor

strength, and knee extensor strength,

reduce injury, and increase athletic

Address correspondence to Max Todoroff, max.todoroff@gmail.com.

performance (3–6,8–10,12,21,23,24,27–

29,34,36,39,40,42,44,46,49,50,52–55).

The dynamic deep squat is defined as squatting down to a position where the knees are in 140–1458 of flexion (2,15). Despite the widespread use of the squat, there is currently a debate whether deep squats are as safe as other squat variations such as the parallel squat or quarter squat in regard to lumbar spine health (15,44). Parallel squats are defined as squatting down to where the inguinal fold is parallel in the horizontal plane to the top of the knee musculature, whereas quarter squats are defined as squatting to 40–708 of knee flexion (15). Despite this contro- versy, it seems that most health and fitness professionals seem to believe that keeping the lumbar spine in a neutral position in the sagittal plane is important to protect passive interver- tebral structures (3,4,6,7,15,16,23,31,32, 39,40,42,43,44,51,53). In fact, this neutral spine position is advocated for by the National Strength and Condi- tioning Association (NSCA) (3,40). To the author’s knowledge, no publi- cation has critically examined dynamic deep squat lumbar spine and lower

extremity kinematics to explore how squat technique, load position, and heel elevation height influence this exercise. The purpose of this critical review is to explore these factors to identify what may limit neutral lumbar spine deep squat depth for potentially reduced lumbar spine injury risk.

APPROPRIATE NEUROMUSCULAR CONTROL OF THE SPINE

Essential fundamentals required before deep squatting is even attempted are appropriate thoracolumbar spine neu- romuscular control and positioning along with appropriate dissociation of hip and lumbar spine flexion (32,39,51). The thoracolumbar spine should be kept in a slightly extended position with slight anterior pelvic tilt to increase erector spinae activity and prevent the loss of lumbar lordosis dur- ing the squat exercise (15,51). This spine position should be rigid and not involve any planar motion (42,44). It is

KEY WORDS:

deep squat; squat; hip kinematics; injury prevention; weightlifting

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Dynamic Deep Squat

also important that the individual be able to bend forward using a hip flexion motor control strategy as opposed to

a lumbar spine flexion motor control

strategy otherwise known as a “hip

hinge” as described by McGill and Marshall (33).

HIP RANGE OF MOTION (COXOFEMORAL JOINT)

The dynamic deep squat requires sub- stantial ranges of motion at the hip, knee, and ankle to avoid lumbar spine movement. It is important that the indi- vidual has normal joint mobility of these joints and normal muscle length of surrounding muscles to even con- sider safe deep squats. The hip joint has a normal flexion range of motion of approximately 130.48 (95% confi- dence interval [CI]: 129.08 –131.88 ) in men aged 20–44 years (n 5 50) and 133.88 (95% CI: 132.58–135.18) in women aged 20–44 years (n 5 50) using

a standard goniometer (47). The Center

for Disease Control and Prevention currently advocates using the data ob- tained from the study of Soucie et al. (47) for normal joint range of motion.

With added combined movements of hip abduction, hip external rotation, or hip internal rotation, some individuals may be able to increase this range of motion because hip movement is 3 dimensional and will use multiple planes of movement during the squat. Soucie et al. (47) looked only at passive hip flexion range of motion measured while lying in supine. Individuals may be able to achieve more motion during the squat as combined multiplanar movements were not accounted for and passive weight-bearing move- ments (aid from an external force) are generally larger than passive non– weight-bearing movements because passive tension from surrounding tis- sues is stretched further (41). Because of the nature of squatting with a load, external forces will aid in stretching this passive tension from surrounding tissues to allow for increased hip sag- ittal plane range of motion.

Table 1 shows studies that have ex- amined hip flexion range of motion

kinematics in the deep squat with heels flat on the ground in healthy individuals. It is interesting to note that Hemmerich et al. (17) showed only 95.4 6 26.6 8 (mean 6 SD) of hip flexion, 26.1 6 11.6 8 of hip abduc- tion, and 16.5 6 10.5 8 of hip external rotation range of motion necessary to bodyweight deep squat with the heels flat on the ground in Indian individuals older than 40 years. However, lumbar spine position was not cued or consid- ered and the authors hypothesized this small hip flexion range of motion requirement being due to increased lumbar spine flexion.

In contrast, Wretenberg et al. (55) showed a larger hip flexion range of motion requirement (125.0 6 4.0 8) during the deep squat with heels flat on the ground in the Olympic- style weightlifter group performing

a high-bar position back squat. The

powerlifter group was not included

in this analysis because of the lack

of knee flexion which was not consid-

ered a deep squat. It is possible that the National Class Swedish weight- lifters kept a neutral spine during the deep squat which may demand more hip flexion range of motion (28,32). The study did not control for footwear as the weightlifter per- forming the deep squat in their study picture is wearing weightlifting shoes which can influence lower extremity kinematics (43,46,54). It is also impor- tant to recognize that these measure- ments in the study were not as precise as other studies as they did not pro- vide measurements to the nearest tenth. The study also excluded women which may not make their data generalizable. However, this was the only study to use external load which also may have influenced lower extremity kinematics. Other differences in hip flexion range of motion between these studies may be explained by different sample sizes, different cultural samples, and high SDs in hip flexion range of motion showing anthropometrical differences. Similar to the study by Hemmerich et al. (17), lumbar spine position was

72 VOLUME 39 | NUMBER 1 | FEBRUARY 2017

not cued in the study by Bagwell et al. (1), Han et al. (13), or Wretenberg et al. (55).

KNEE RANGE OF MOTION (TIBIOFEMORAL JOINT AND PATELLOFEMORAL JOINT)

Normal knee flexion range of motion is 137.78 (95% CI: 136.5–138.98 ) in men aged 20–44 years and 141.9 8 (95% CI:

140.9–142.98 ) in women aged 20–44 years using a standard goniometer (47). Knee flexion passive range of motion was measured in supine ac- cording to the study by Soucie et al. (47), which may underestimate total range of motion. Leszko et al. (26) showed knee flexion ranges of motion of 149.4 6 13.08 in male Caucasians (mean age 27.5 years, n 5 24), 157.1 6 10.48 in female Caucasians (mean age 25.2 years, n 5 24), 157.2 6 9.18 in male Japanese (mean age 30.9 years, n 5 13), and 161.1 6 10.38 in female Japanese (mean age 37.4 years, n 5 11) using fluo- roscopic surveillance during a deep knee bend lunge.

Table 2 shows studies that have exam- ined knee flexion range of motion kinematics in the deep squat with heels flat on the ground in healthy individuals. Analysis of Table 2 shows that the studies using weightlifters (6,55) seem to have less knee flexion during the deep squat. These studies (6,55) also used external load which could have influenced knee kinemat- ics. This seems less likely as Cotter et al. (6) showed only 1.89 6 2.1 8 dif- ference between bodyweight and external load conditions. This is the only study that cued a neutral lumbar spine lordosis and used a “light cur- tain” device to cue subjects of proper squat depth during the deep squat which may account for its smaller knee flexion range of motion and smaller SD compared with the other studies. It is important to note that the femur externally rotates (or tibia inter- nally rotates) during weight-bearing knee flexion with the lateral femoral condyle moving posteriorly (11,18,26,38). The differences in knee flexion range of motion between the above-mentioned studies may be

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method

               
 

Dynamic

tracking

system

Dynamic

tracking

system

Dynamic

tracking

system

Dynamic

tracking

system

spine position

cued

No

No

 

No

No

   

Deep squat hip flexion range of motion with heels flat on the ground in healthy individuals

 

Bodyweight

Bodyweight

 

Bodyweight

65% of their 1 repetition maximum

   
 

American

Chinese

 

Indian

National class

Swedish

weightlifters

   

Table 1

 

31.9

Men: 21.9

Women: 21.2

48.2

Powerlifters: 31.0

Powerlifters: 6 subjects Olympic-style weightlifters: 19.0

 
 

9/6

20/20

 

10/20

0/14

 

Olympic-style

weightlifters: 8

subjects

Hip flexion range of motion Subjects (women/men) Subject mean age (y) Study population Deep squat load Neutral lumbar Measurement

113.0 6 6.78

Men: 121.3 6 13.2 8

Women: 117.8 6 14.9 8

95.4 6 26.6 8

Powerlifters (low-bar position barbell): 146.0 6 3.0 8

 

Olympic-style weightlifters (high-bar position barbell):

125.0 6 4.0 8

 
   

Study

 

Bagwell et al. (1)

 

Han et al.

(13)

 

Hemmerich et al. (17)

 

Wretenberg et al. (55)

     
 

explained by different sample sizes in studies, different cultural samples, dif- ferent study protocols, and high SDs

in knee flexion range of motion show-

ing anthropometrical differences.

ANKLE RANGE OF MOTION (TALOCRURAL JOINT, TALONAVICULAR JOINT, AND SUBTALAR JOINT)

Normal ankle dorsiflexion range of motion is 12.7 8 (95% CI: 11.6–13.8 8 ) in men aged 20–44 years and 13.8 8 (95% CI: 12.9–14.7 8 ) in women aged 20–44 years using a standard goniom- eter (47). Ankle dorsiflexion was measured seated which may underes- timate the total range of motion (41). In fact, Rabin and Kozol (41) showed with 2 different examiners that weight-bearing ankle dorsiflexion (examiner 1: 49.7 6 6.4 8 , examiner

2: 49.3 6 5.9 8) using a fluid-filled incli-

nometer had approximately more

than twice the range of motion as non–weight-bearing ankle dorsi- flexion (examiner 1: 24.6 6 5.0 8 , examiner 2: 23.2 6 5.4 8 ) with a stan- dard goniometer. Rabin and Kozol used a weight-bearing lunge tech- nique in healthy (mean age 25.5 years) Israeli college students (29 women and 14 men) (41). Konor et al. (22) demonstrated less ankle dorsiflexion (43.2 6 5.8 8) using a dig- ital inclinometer when performing

a weight-bearing lunge technique in

healthy (mean age 24.0 years) Amer- ican individuals (13 women and 7 men). The differences in ankle dorsi- flexion range of motion between these studies may be explained by different sample sizes in studies, different cul- tural samples, different equipment, and high SDs in ankle dorsiflexion range of motion showing anthropo- metrical differences.

Table 3 shows studies that have exam- ined ankle dorsiflexion range of motion kinematics in the deep squat with heels flat on the ground in healthy individu- als. Analyzing Table 3, it seems that deep squatting with heels flat on the ground may require full ankle dorsiflex- ion range of motion as mean values and SDs seem to overlap with the ankle

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Dynamic Deep Squat

VOLUME 39 | NUMBER 1 | FEBRUARY 2017

 

Table 2

   

Deep squat knee flexion range of motion with heels flat on the ground in healthy individuals

   
   

Study

Knee flexion range of motion

Subjects (women/men)

Subject mean age (y)

Study population

Deep squat load

Neutral lumbar

Measurement

spine position

method

cued

Cotter et al.

Bodyweight: 139.89 6 2.1 8

0/16

22.7

American

Bodyweight and

Yes

Dynamic

 

(6)

(recreational

50% 1

tracking

 

weightlifters)

repetition

system

maximum

 

50% 1 repetition maximum:

           

141.78 6 2.18

Han et al.

Men: 147.6 6 11.1 8

20/20

Men: 21.9

Chinese

Bodyweight

No

Dynamic

 

(13)

tracking

 

system

 

Women: 154.1 6 10.3 8

 

Women: 21.2

       

Han et al.

Young: 145.3 6 11.5 8

Young: 8/8

Young: 22.2

Chinese

Bodyweight

No

Dynamic

 

(14)

tracking

 

system

 

Elderly: 142.8 6 10.7 8

Elderly: 3/5

Elderly: 63.6

       

Hemmerich et al. (17)

153.7 6 10.4 8

10/20

48.2

Indian

Bodyweight

No

Dynamic

tracking

 

system

Wretenberg et al. (55)

Powerlifters (low-bar position barbell): 126.0 6 4.0 8

0/14

Powerlifters: 31.0

National class

65% of their 1 repetition maximum

No

Dynamic

Swedish

tracking

   

weightlifters

system

 

Olympic-style weightlifters (high-bar position barbell):

Powerlifters: 6 subjects

Olympic-style

       

weightlifters: 19.0

138.0 6 3.0 8

   

Olympic-style

         

weightlifters: 8

subjects

 

Table 3

 
 

Deep squat ankle dorsiflexion range of motion with heels flat on the ground in healthy individuals

 
   

Study

Ankle dorsiflexion range of motion

Subjects

Subject mean

Study

Deep squat

Neutral lumbar

Measurement

(women/men)

age (y)

population

load

spine position

method

 

cued

Han et al. (13)

Men: 33.6 6 3.78

20/20

Men: 21.9

Chinese

Bodyweight

No

Dynamic

tracking

system

 

Women: 36.2 6

 

Women: 21.2

       

4.88

Hemmerich et al. (17)

38.5 6 5.98

10/20

48.2

Indian

Bodyweight

No

Dynamic

tracking

 

system

dorsiflexion study by Konor et al. (22). However, because of high ankle dorsi- flexion measurements in the study by Rabin and Kozol (41), it is hard to make this statement with confidence. Han et al. (13) and Hemmerich et al. (17) did not cue lumbar spine position during the bodyweight deep squat. It is possible that deep squatting with heels flat on the ground with the lumbar spine in a neutral position will require different ankle dorsiflexion kinematics than deep squatting without a neutral lumbar spine.

THE HIP AND ANKLE LOCK

Hip flexion, abduction, and external/ internal rotation range of motion along with ankle dorsiflexion and knee flex- ion range of motion will greatly affect how low the individual can squat in the sagittal plane while keeping a neu- tral lumbar lordosis. Because of the movement of the squat where the feet are always planted on the ground, squat technique and position of load

relative to the base of support will have

a dramatic impact on how joints are

stressed as the body has to position itself to maintain balance with the cen-

ter of mass being placed over the base

of support (42,55). In this situation, the

center of mass would be close to the barbell and the base of support would be the midfoot (42).

Despite the influence that squat tech- nique and position of the load relative

to the base of support will have on the

movement pattern during the squat,

the individual will travel through all of the hip and ankle sagittal plane range of motion before approaching end range of motion at the knee. This is due to different factors. The knee has more available sagittal plane range of motion as described above. Trunk inclination angle will take a large amount of the available hip flexion range of motion. The ankle will be either isometrically contracted to maintain balance by keeping the cen- ter of mass over the base of support in the powerlifting squat (Figure 1) or it will be at end range of motion in the traditional squat (Figure 2). As a result

of motion in the traditional squat (Figure 2). As a result Figure 1. Powerlifting squat technique.

Figure 1.

Powerlifting squat technique.

of these factors, downward movement

can only come from the knees or lum- bar spine. Because the hips and ankles

are locked in an end of movement posi- tion and the lumbar spine is being iso- metrically contracted to maintain

a neutral lumbar lordosis, the knees

are the only joint that can move at this point. However, the knees still have available range of motion because the angle of the center of mass would translate if the knees were to move in isolation. This would cause the individ- ual to lose their balance as the move- ment would be a curvilinear path

their balance as the move- ment would be a curvilinear path Figure 2. Traditional squat technique.

Figure 2.

Traditional squat technique.

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Dynamic Deep Squat

around the knee joint. Therefore, the lumbar spine ventrally flexing forward causing a loss of lumbar lordosis while the knees continue to flex is the only way the body can maintain balance after the hips and ankles have locked to allow for more knee range of motion. This observation of lumbar spine flexion or a posterior pelvic tilt during the deep squat has been sup- ported with research where lumbar spine position was not cued (1,25,35).

McGill (32) has also hypothesized that hip range of motion is a significant lim- iting factor during deep squatting with

a

neutral lumbar spine position. Kritz

et

al. (23) acknowledged in a literature

review on the bilateral squat that

a common compensatory movement

when hip range of motion is limited

will be increased trunk flexion. Macrum et al. (30) showed that when

a wedge causing a 12 8-forefoot angle

was placed under the foot to prevent

ankle dorsiflexion, subjects could not bodyweight squat as deep using

a powerlifting squat technique and

compensated by moving the knees medially. Kim et al. (21) showed that

ankle dorsiflexion range of motion in both men and women was the primary

variable effecting bodyweight deep squat depth with the heels flat on the ground, followed by hip flexion range

of motion in men using a stepwise mul-

tiple regression analysis. Lack of ankle dorsiflexion has been significantly cor- related (0.94) with the inability to bodyweight deep squat with the heels flat on the ground in 2 separate studies using a discriminant analysis model (19,20). A majority of these studies did not cue lumbar spine position dur- ing the deep squat with heels flat on the ground (1,19–21,25,30,35).

SQUAT TECHNIQUE AND TRUNK INCLINATION ANGLE

Because of the importance of hip sag- ittal plane range of motion as described above, trunk inclination angle is one of the limiting factors for the depth of

a squat with a neutral lumbar lordosis.

Trunk inclination angle (37), trunk lean displacement (43), or trunk lean (54) is defined as the pelvis and spine moving

as a unit anteriorly on the coxofemoral joints (hips) and is the same “hip hinge” (31) as described above. For instance, if the hip only has 1308 of flexion range of motion or potentially 1408 with other added combined movements (abduction/external rotation or internal rotation) and selected squat depth is where the top of the knee musculature

is parallel to the inguinal fold in the hor-

izontal plane where approximately 1008 of hip flexion is required. A trunk incli- nation angle larger than 408 in the sag- ittal plane from vertical will cause lumbar spine ventral flexion due to hip anatomy. Proposed key factors in determining this trunk inclination angle are squat tech- nique, load position relative to base of support (midfoot), and heel height.

Studies (10,55) have shown that squats can be performed in 2 distinct move- ment patterns. The squat that used

a horizontal posterior displacement of

the pelvis such as sitting onto a chair generated higher hip extensor kinetics, whereas the alternative squat using an immediate vertical downward dis- placement of the pelvis with less hori- zontal posterior pelvic displacement generated higher knee extensor and ankle plantar flexor kinetics (10). A squat technique that involves a large horizontal posterior displacement of the pelvis will potentially cause a larger trunk inclination angle and as a result, because of the early hip and ankle lock, limit safe lumbar spine neutral deep squat depth (Figure 1). This large trunk inclination angle is necessary to offset the center of mass shifting posteriorly (16,42) and is a common movement strategy used with powerlifting squats (50,55). The NSCA squat position statement advocates a vertical torso during squatting (3). However, this rec- ommendation will not be possible dur- ing this squat technique because of the physics required to maintain balance as the base of support (midfoot) will be anterior to the center of mass if the individual does not perform an anterior trunk lean (28).

In contrast, the squat technique that involves a more immediate vertical downward displacement of the pelvis

76 VOLUME 39 | NUMBER 1 | FEBRUARY 2017

without as much horizontal posterior pelvic displacement allowing the knees to track anteriorly past the toes theoretically will allow for a smaller trunk inclination angle (42) and allow for greater squat depth without losing the lumbar lordosis because the hip and ankle lock will occur later (Fig- ure 2). Frye et al. (12) and List et al. (27) support this observation in their research data where allowing the knees to track anteriorly over the toes reduced trunk inclination angle, whereas limiting this anterior knee translation increased trunk inclina- tion angle. In comparison, Swinton et al. (50) showed a larger L5-S1 ver- tebral peak external moment arm (in centimeters) in the traditional squats compared with powerlifting squats; however, the difference was not sta- tistically significant. This external moment arm was determined by measuring the horizontal distance from the L5-S1 joint center and bar- bell center (50). It is important to note that in this study, all participants were powerlifters and that load posi- tion and heel height were not con- trolled (50).

Allowing the knees to track anteri- orly past the toes while squatting has generally not been advocated because of the fear of high knee joint stresses (9,16,23,28,44). However, this concern has been questioned recently and warrants further research in this area (15,44,45). Some authors have even had concerns of increased lumbar spine stresses if the knees were restricted from trans- lating anteriorly past the toes (12,27,28), although this claim has been questioned (50). If the athlete’s goal is to deep squat or perform Olympic-style weightlifting (squat cleans, squat snatches, and clean and jerk) in a safe manner, this tradi- tional squat technique (Figure 2) is an essential squat technique that they must learn and use (55).

LOAD POSITION

Position of the load on the spine in relation to the base of support will influence the individual’s center of

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Figure 3. Low-bar barbell position. mass and may influence the type of squat technique that

Figure 3.

Low-bar barbell position.

mass and may influence the type of squat technique that will be performed (42,55), which may influence trunk inclination angle and lumbar spine kinematics as described above. Low- bar position back squats (barbell evenly on top of the posterior deltoids at the middle of the trapezius (40)) will cause a posterior shift of the individual’s cen- ter of mass due to this bar position being posterior to the base of support (Figure 3). This low-bar position will then require a compensatory anterior trunk lean to keep the center of mass over the base of support. This anterior trunk lean may facilitate a larger trunk inclination angle at the start of squat

descent and a larger posterior horizon- tal displacement technique of the pelvis (powerlifting movement technique) during the squat descent for the indi- vidual to avoid losing their balance (Figure 1). This observation has been documented in previous studies (12,27,44,55). Therefore, in most cases, these low-bar position back squats should not be reserved for squatting deep to avoid low back injury.

High-bar back squats (barbell above the posterior deltoid at the base of the neck (40))(Figure 4), front squats, overhead squats, or any squats with the center of mass shifting forward

or any squats with the center of mass shifting forward Figure 4. High-bar barbell position. or

Figure 4.

High-bar barbell position.

or staying close to neutral are theoret- ically more appropriate to allow for lower trunk inclination angles and potentially safe lumbar spine neutral deep squatting. However, it should be noted that only one study supports the notion that a neutral lumbar spine can be maintained during a deep squat with heels flat on the ground (6). This may suggest that only squats where the center of mass is shifted anterior to the base of support (front squats, goblet squats, etc.) are appropriate when lumbar spine neutral deep squat- ting with heels flat on the ground. These anterior loaded squats require

a compensatory posterior trunk lean

to keep the center of mass over the base of support allowing for a smaller trunk inclination angle.

HEEL HEIGHT

Ankle sagittal plane dorsiflexion is important to allow for as much sagittal plane downward movement to occur as possible before the hip and ankle lock. Another consideration is heel height in relation to the metatarsopha- langeal joints (ball of foot) because

a higher heel will shift the individual’s

center of mass forward (48) and also allow for more sagittal plane dorsiflex- ion which will aid in vertical down- ward displacement and a smaller trunk inclination angle (43) (Figure 5). This forward shift of the center of mass will cause a compensatory posterior trunk lean to keep the center of mass over the base of support facilitating a smaller trunk inclination angle. These are the principles that make weightlift- ing shoes advantageous when trying to deep squat or perform Olympic-style weightlifting. Most weightlifting shoes are designed with a raised heel (43). Sato et al. (43) failed to show improved squat depth with weightlifting shoes compared with running shoes; how- ever, squat technique was not consid- ered and the subjects were instructed to squat to parallel using their normal technique with a high-bar barbell position.

Whitting et al. (54) showed reduced ankle dorsiflexion necessary to squat to the same depth with weightlifting

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Dynamic Deep Squat

Dynamic Deep Squat Figure 5. Heel-elevated squats. shoes compared with running shoes; however, trunk lean was

Figure 5.

Heel-elevated squats.

shoes compared with running shoes; however, trunk lean was not effected. The authors hypothesized that this lack of effect on trunk lean may be due to the study subjects having suffi- cient ankle dorsiflexion to achieve the adequate squat depth with running shoes. This study did not control for squat technique or load position and had individuals squat to their normal training depth. Similarly, Sinclair et al. (46) showed that weightlifting shoes increased mean ankle dorsiflexion and knee flexion range of motion compared with running shoes, barefoot inspired shoes, and barefoot conditions while performing their normal back squat technique and training depth with 70% of their 1 repetition maximum. Squat technique, load position, and squat depth were not controlled in this study. On observation, many competi- tive Olympic-style weightlifters and powerlifters use weightlifting shoes.

OTHER CONSIDERATIONS

Anthropometrically speaking, the human body varies widely from individual to individual (6,13,14,17,22,26,41,47,55).

Because of this anatomical variability, in- dividuals may need different levels of heel height elevation to reach certain depths during the squat while maintain- ing a neutral position of the lumbar spine depending also on selected squat tech- nique and load position. Some individu- als may even be able to achieve the appropriate deep squat position with

a neutral lumbar spine position without any heel elevation.

Keeping the lumbar spine in a neutral to slightly extended position may not be as necessary as currently believed during the squat. McKean et al. (35) showed that as soon as 50% body- weight was placed across the shoulders before the squat descent, the lumbar spine curve flattens and becomes slightly kyphotic. They also hypothe- sized that slight lumbar flexion may be part of the normal movement pattern for a deep squat and cueing against this loss of lumbar lordosis during the descent may not be necessary. Squat technique, load position, lumbar spine position, shoe type, or squat depth was not controlled in this study, although the authors do state all participants squatted to at least a position where the thigh was parallel to the ground. The study participants were personal training students who regularly per- formed squats twice a week for at least 12 months.

Similar to McKean et al. (35), Lamontagne et al. (25) showed that

a considerable amount of lumbar spine

flexion movement (24.2 6 6.88) is necessary to deep squat to a distance

of 1/3 the individual’s tibial height with the heels on the ground; however, once again lumbar spine position was not cued and this study did not use trained individuals or an external load. Bagwell

et al. (1) used a similar protocol and also

observed that a posterior pelvic tilt (lumbar spine flexion) was a normal movement performed with deep squat- ting with heels flat on the ground. It is important to clarify that Lamontagne et al. (25) and Bagwell et al. (1) were not using external load in their deep squatting studies or hypothesizing to

78 VOLUME 39 | NUMBER 1 | FEBRUARY 2017

deep squat with an external load. Clearly, more research studies are needed in this area before abandoning current standards of squat technique that advocate for a neutral lumbar spine position during a deep squat.

CONCLUSION

There are many factors to consider when trying to deep squat in a neutral lumbar spine position. Strength and conditioning, rehabilitation, and health care professionals should consider squat technique, load position, and heel height when teaching and monitoring dynamic deep squats. Taking these fac- tors into account will allow for an improved lumbar spine neutral position and hopefully fewer injuries. Further research needs to be conducted on the dynamic deep squat to further understand factors that influence lum- bar spine kinematics and lumbar spine injury risk. Based on the paucity of lit- erature on hip flexion, knee flexion, and ankle dorsiflexion kinematics during the lumbar spine neutral deep squat with heels flat on the ground, this is suggested to be a specific avenue for future squatting research.

Conflicts of Interest and Source of Funding:

The author reports no conflicts of interest and no source of funding.

reports no conflicts of interest and no source of funding. REFERENCES Max Todoroff is the owner

REFERENCES

Max Todoroff is the owner of Manual Medi- cine Physical Therapy.

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