Why Heel Elevated Squats Could Be Causing More Knee Issues

Jessica Bento, Physical Therapist (Creator DVRT Restoration Certification, DVRT Rx Shoulder, Knees, Pelvic Control, & Gait Courses)

Ever since there has been an influx of what seems like everyone doing heel elevated squats, I have NOT been a fan! In fact, I am going to make a strong case (based on understanding the mechanics of the knee) that heel elevated squats do make people more prone to have knee issues. Let me explain with research to make up my points…

You Aren’t Performing A Full Range Of Motion Squat!

Probably the BIGGEST reason people give me on why they are doing heel elevated squats is because it allows them to do more of a full range of motion squat. That on its face may make sense since most people can go deeper because heel elevated squats artificially changes the mechanics at the ankle. However, it is THIS very reason that it is NOT doing a full range of motion squat.

The knee is part of a kinetic chain of the foot/ankle as well as the hip. The knee acts as a crucial hinge joint in this chain, transferring forces between the foot and hip. Any imbalance in the kinetic chain can lead to excessive stress on the knee, potentially causing injuries like patellofemoral pain syndrome or ACL tears (1,2). Probably most relevant here is that ankle issues can predispose people to knee problems like patellofemoral pain (3).

MOST important for our discussion is there is quite a bit of research demonstrating that reduced ankle dorsiflexion (where you point your toes up towards you) makes people more prone to knee injuries/pain (4,5). When you perform heel elevated squats you are compensating for the inability of the body to not having proper mobility in the ankles. This may look like you are getting a better squat, but only at certain joints and creating a dysfunctional pattern throughout the chain.

 

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Getting people to use their feet is the first step in helping mobility of the ankles and why heel elevated squats really don’t work well.

They DON’T Fix Strength Issues Better

There is an oversimplification of weakness and strength as well. Many people are told that the reason for their knee pain and why they need to emphasize heel elevated squats is because their quads are “weak”. This is a bit challenging because we usually can’t test people’s quad strength before they suffer an injury, usually testing only comes after pain has developed. Being a physical therapist for over 20 years I can tell you when you have pain in an area it is natural for the body demonstrate weakness.

This could occur for a host of reasons, but a big one that is overlooked is the fact our nervous system tries to protect the painful area by reducing the ability of the muscles to produce force. It is also largely misunderstood, if you buy into the weak quad idea, that it is ONLY the quadriceps that are weak. However, research has shown the hamstrings, the glutes, and even the core are relevant to helping knee pain (6,7,8)

Blaming the quadriceps is an easy sales pitch to people but doesn’t give them the big picture on issues that all impact knee health.

 

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Focusing on more integrated movements that work the entire chain can help knee issues much more than focusing on anyone muscle.

But There Is A TON Of Research On Heel Elevated Squats & Knee Pain

Well, I don’t know what is a ton, but I did some heavy digging and there is some research showing elevating the heel while squatting can be helpful. So, what’s my problem? These studies actually aren’t what you think they are! They show when mostly athletes perform a SINGLE leg squat with VERY limited range of motion, they can help patellofemoral pain. However, they ALSO note that they athletes often because this strategy actually causes pain while performing it and people have to deal with it.

What most people leave out the discussion on the research of heel elevated squats is that they found compared to just very basic strength training, such exercise didn’t offer any unique benefits.

Basically, both the heavier strength training and the heel elevated squat on single leg had positive effects, but the strength training with very familiar exercises had more overall benefits for the knees.

These were not crazy exercises and not huge ranges of motions. With all that said, it hopefully makes sense that you can help knee issues and improve your movement to reduce the risk of knee problems in the future more effectively. If you wish more how we are going to use the concepts of human movement to better results and understand how to apply the evidence to practical training, don’t miss our online Fascia Training Masterclass HERE

References:

1. Kramer LC, Denegar CR, Buckley WE, Hertel J. Factors associated with anterior cruciate ligament injury: history in female athletes. J Sports Med Phys Fitness. 2007 Dec;47(4):446-54. PMID: 18091686.
2. Hardy, Rich & Brand, Jefferson & Butler, Christopher & Monroe, Emily. (2018). Kinetic Chain Injuries and Their Relationship to Subsequent ACL Tears.
3. Tan, J.M., Crossley, K.M., Munteanu, S.E. et al. Associations of foot and ankle characteristics with knee symptoms and function in individuals with patellofemoral osteoarthritis. J Foot Ankle Res 13, 57 (2020). https://doi.org/10.1186/s13047-020-00426-8
4. Xu Y, Song B, Ming A, Zhang C, Ni G. Chronic ankle instability modifies proximal lower extremity biomechanics during sports maneuvers that may increase the risk of ACL injury: A systematic review. Front Physiol. 2022 Oct 18;13:1036267. doi: 10.3389/fphys.2022.1036267. PMID: 36330209; PMCID: PMC9623000.
5. Malloy P, Morgan A, Meinerz C, Geiser C, Kipp K. The association of dorsiflexion flexibility on knee kinematics and kinetics during a drop vertical jump in healthy female athletes. Knee Surg Sports Traumatol Arthrosc. 2015 Dec;23(12):3550-5. doi: 10.1007/s00167-014-3222-z. Epub 2014 Aug 12. PMID: 25112598; PMCID: PMC4977993.
6. Luc-Harkey, B.A., Safran-Norton, C.E., Mandl, L.A. et al. Associations among knee muscle strength, structural damage, and pain and mobility in individuals with osteoarthritis and symptomatic meniscal tear. BMC Musculoskelet Disord 19, 258 (2018). https://doi.org/10.1186/s12891-018-2182-8
7. Barton CJ, Lack S, Malliaras P, Morrissey D. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. Br J Sports Med. 2013 Mar;47(4):207-14. doi: 10.1136/bjsports-2012-090953. Epub 2012 Sep 3. PMID: 22945929.
8. Patel, M. S., & Mishra, N. (2024). Effect of core stability exercises on knee proprioception, function and quality of life in chronic total knee replacement patients. International Journal Of Community Medicine And Public Health, 11(5), 1852–1857. https://doi.org/10.18203/2394-6040.ijcmph20241177