Look to the Ankle to Help with Back Pain During the Squat

We are not always going to be able to train completely pain-free, and having pain in our low-back while trying to perform different variations of the squat is one of the more common complaints that you will hear from people that engage in strength training.  Most often our intuition would tell us that if I am having pain in my back than my problem must be in my back. So people will resort to performing some sort of stretching and core strengthening routine to make their back more mobile and strong. This can be part of the answer, but for many this will not lead to the effect on their symptoms that they were hoping for. For these people often times the cause of their pain is something wrong with the squat movement pattern itself, and the key to fixing this issue is often all the way down at the ankle.

When a person does not have the necessary ankle mobility to get into a full squat position it can lead to compensation in which we may utilize increased amounts of lumbar and hip flexion to get all the way to the bottom of the squat.  This can lead to increased shear forces in the lumbar spine, especially as the load/weight increases. In these cases it can help to be able to perform the squat with a more upright torso. However, to get into a more upright torso position a person will need to have the prerequisite ankle mobility to do so.   

When talking ankle mobility most people just think about ankle dorsiflexion as it relates to proper squat mechanics, however it can be just as important to have proper tibial internal rotation and lateral tibial glide.  In this week’s blog we will discuss the concepts of ankle dorsiflexion, tibial internal rotation, and lateral tibial glide. We will talk about how each impacts the squat pattern and give an example of a simple mobilization to address decreased mobility in these ankle movements.  

Ankle Dorsiflexion
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Ankle dorsiflexion refers to the ability to bend the foot backwards bringing your toes closer to your shin, this would be in a non-weight bearing position just moving your foot.  However, when we are in a weight-bearing position the foot will be fixed and so it is more about how well can the tibia slide anteriorly over the dome of the talus, essentially meaning can the knee go in front of the toes while being able to keep the foot flat on the ground. When performing a full squat with decreased ankle dorsiflexion a person will increase the forward angle of their torso to allow for full squat which can then lead to increased load and shear forces of the lumbar spine.  Ankle dorsiflexion can be assessed by the ankle lunge test, which is performed with a person standing or in a half-kneeling position and they move their knee forward in an attempt to touch it to the wall and is scored by the distance that the big toe is from the wall. A normal amount of dorsiflexion is considered 4 inches from the wall.  

To improve ankle dorsiflexion you can simply perform the ankle lunge test by trying to touch your knee to the wall and keeping the foot flat.  To increase the mobilization I prefer using banded distraction to apply a posterior force to the dome of the talus. As seen in the picture below, utilize a band around the front of your ankle joint with the band placed below the two large bones on both sides of the ankle called the medial and lateral malleoli.  Then just like the ankle lunge test or stretch attempt to lunge forward pushing the knee over the toes of the foot keeping the foot flat on the ground. Perform the mobilization for 1-2 minutes. 
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​Tibial Internal Rotation

Internal rotation of the tibia helps to keep the knee in line with the foot during a full squat.   Having good tibial internal rotation and help to allow for a more forward foot position in the squat will help to minimize medial knee collapse during the squat leading to a more stable position of the squat.  The more efficient the pattern the better we are able to use the hip and knee musculature to manage the load being lifted reducing the stress to the lumbar spine and associated musculature. It is tested in the seated position with a person placing weight through their heel and then attempt to point the toes toward the inside as far as possible, a normal test is when the knee is in line with the third toe.

To perform mobilizations for tibial internal rotation you can use the same banded technique as for ankle dorsiflexion, but point the toes as far inward as possible with keeping the knee straight and then perform your lunge again for 1-2 minutes.  An alternative if you do not have access to a band is pictured below. Place foot on a stool, box, step etc. then place hands around you lower leg and apply a rotary force toward the inside sustain that force as you lunge forward and back. Again to keep it simple perform for 1-2 minutes.  

​Lateral Tibial Glide

Lateral tibial glide describes the ability of the tibia to glide over the dome of the talus to the outside of the ankle.  This allows for an improved ability to maintain the knees in a wider position in the squat which allows for a more upright torso angle as a person is able to bring their hips more straight down between their feet instead of having to lean forward at the trunk and torso to get into the full squat position.  This will reduce lumbar flexion shear forces produced during the movement, and also, as described with tibial internal rotation, it will lead to better efficiency in using the hip and knee musculature to perform the movement which also reduces load to the lumbar spine and associated musculature. Pictured below is a common assessment for looking at lateral glide of the tibia.  You can see here that the foot is being maintained in a flat position on the ground and the knee is being allowed to drop to outside as far as it can before the inside of the foot comes off the ground. The normal range is considered to be a 30 degree angle from the foot the knee.

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To perform a mobilization to improve lateral tibial glide get into the lunge position and use the opposite hand to brace the foot into position and then use hand on same side to give help give downward and outward pressure to the leg as you perform a lunge motion. This can be seen in the picture below. Can also perform with foot on top of a box.  Again we suggest 1-2 minutes. 

These are all great mobilizations that will help to improve ankle mobility.  However, if you only perform them in isolation you will not get the effects that you are really looking for.  As with all mobilizations the new movement gained from the mobilization works best if it is able to be put immediately into practice.  These should be programmed in on days in which your workout will be involving some sort of squat pattern work. When really tight it can work well to perform these mobilization between sets.  We always need to understand that when dealing with the human body the work is never done, so if you find that mobilizing your ankles improves your squat pattern and any pain associated with it, this is something that should be incorporated into your normal movement practice.  It takes consistency to make something become a habit and to become a Prime Mover!

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