Healthy joints and the myth of knees-over-toes.

Recently, I’ve been seeing the deep squat promoted as a sort of panacea for back, hip, and knee pain, as well as other physical ailments. It’s caused me to explore ways to spend more time in this posture. When I dip myself down into a deep squat I can feel muscles throughout my hips and legs engaging in a way that is novel and quite challenging. Already from spending just a few weeks in this posture, sometimes for just five minutes a day, I can feel a greater sense of flexibility in my lower-body. In this article, I’d like to explore this posture as well as delve into how joints work and how we can make them feel better and less stiff.

Squatting is commonly thought of as a movement exercise done inside the gym. But if you’ve ever watched a toddler navigate the process of reaching down to grab or touch something, you will see him execute a flawless squat every time. This is because the squat is one of the basic building blocks of human movement. This movement is like basic-training (along with crawling) for every other complex human movement that will be learned as a toddler matures toward more coordinated movements. Unfortunately, as we age and spend more time in our modern world where tables, chairs, cars, and our sedentary lifestyle lock us into a kind of movement-prison; we will very rarely, if ever, do a squat. Unless diligent effort is spent in counteracting these tendencies, the sad truth is that our overall movement-ability will most likely degenerate. I believe that losing access to our natural ability to squat is one of the most detrimental backward-steps that lead us toward feeling severely limited in our bodies and its ability to move well, and feel good.

In many countries it’s not uncommon to see people eating, working, and resting while in a complete squat. While squatting appears to require significant effort, it’s actually a very comfortable and restful position. It relieves body tension throughout the back and hips, much more than sitting. Interestingly, it’s been shown that hip and low-back pain in Asia and parts of Africa (where squatting is commonly performed) is basically non-existent. As I will later describe the biomechanics of joints, it becomes easy to understand why.

So we know that squatting is good for us. But what if you’re like many people today who no longer have access to a basic squat? In our culture of chairs which only allow a limited range of movement for our hips, knees, and ankles; we lose substantial flexibility. When it comes to flexibility, the saying is true: use it or lose it. Our hips and knees have the ability to flex around 130-140 degrees. Most of us are lucky if we can get them to 90 degrees. Ankle dorsiflexion (when the knee moves over the toes) is similarly difficult to access. Ankles need to flex to at least 40 degrees when getting into a deep squat. Without joints that can access this flexibility, squats simply aren’t possible.

So why do we lose this flexibility? The reason we feel stiff all the time is because at any given point in our joint movement, we are already near what our nervous system would consider the maximum end stage of safe movement for that joint. This is because many of us never move beyond that point, as we would in a deep squat. We have designed our environment to only allow a very narrow range of movement during our daily life. Tables, chairs, cupboards, shelves, and even our sleeping arrangements have made such movements like a squat with deep knee, ankle, and hip flexion obsolete. When we do find ourselves in the rare scenario where we need to do something below the level of our knees; instead of squatting down we will instead keep our legs mostly straight and bend our spine, putting a lot of unsupported force and torsion through our spine. Our backs very quickly will begin to complain about this kind of abuse.

So if flexibility is lost through lack of movement, why do we stop moving? There seems to be a kind of movement-phobia that has infiltrated the minds of many adults. I think part of it stems from an out-dated understanding of how joint mechanics work and the idea that they simply wear out with use. From speaking to many of my clients, it’s apparently very common to hear those in the medical field use terms such as “wear and tear,” and “bone-on-bone,” quite often. Talk about nocebo. (Nocebo is the opposite of placebo. It's a very real, scientifically proven phenomenon where a doctor or other authority figure can negatively influence a person's health in a very real, concrete way merely through suggestion.) The idea here is that joints have a given lifespan and simply wear out with use like a ball-joint in your car’s suspension, or a set of tires. It can be true that a joint will become inflamed with chronic misuse, bad diet, poor sleep, or degenerative disease; and this can lead to a deterioration of the joint. But healthy, regular movement will not lead to this deterioration. And the most important point that is usually never mentioned to patients: when given the right inputs joints can heal!

What is a joint? We’re specifically talking about synovial joints, or diarthroses, meaning they are freely mobile. The key feature of these joints is that they are enclosed by a joint cavity. The joint cavity is enclosed by a synovial membrane, which secrete synovial fluid into the joint cavity. Movement stimulates the release of synovial fluid, which provides lubrication and nutrients to the cartilage lining the joint space, as well as to the articular discs. Whenever movement occurs, there is circulation of nutrient-rich synovial fluid inside the joint. If you limit the range of motion a joint regularly receives, you severely limit the amount and scope of synovial fluid that gets released. Only taking a joint through its full range of motion, safely and regularly, can ensure that it receives an adequate amount of circulation to maintain health and flexibility.

But this is typically not the kind of information you will receive when visiting the hospital complaining of joint pain. There’s a good chance you’ll be told that it’s just part of the aging process and there’s no action you can take on your own to better your situation. It’s very likely you would be told that surgery, steroid shots, and pain-killers are the solution. You can see how this sets up a kind of fatalistic, victim-mentality in the patient. The solutions offered may also be attractive because they require no commitment or work on the part of the patient. And so an addictive relationship of dependency develops between patient and hospital.

So how do joints become strong and resilient? This is an area of study in which athletic trainers are deeply involved. It's important to note that your doctor or orthopedic surgeon has probably never heard of such research. One such researcher is Charles Poloquin, who directly trained many Olympic medalists and believed that a knee that can go farthest and strongest over the toe has the least chance of knee pain and injury. The training philosophy of Charles Poliquin has been popularized most recently by Ben Patrick, aka “the knees over toes guy”. Ben Patrick claims to have great success rehabilitating many a knee slated for surgery. The way he does this is by developing exercises which progressively and safely load a joint through their full range of motion. This involves performing movements in which the knees flex far over the toes. Doing this forces the hip, ankle, and foot to reach toward the very end range of motion. But wait, isn’t that dangerous?

As long as you have the flexibility, mobility, and proper form, it’s not only safe to plant your foot and push your knees over your toes, it’s beneficial. The American Council on Exercise (ACE) says it’s a myth to never let knees go past toes while squatting or lunging. Instead, they recommend focusing on proper form, flexibility, and progression to achieve a safe and effective squat. A study by Fry et al. (2003) found that limiting knee translation (i.e., not allowing knees to pass over toes) resulted in a 22% decrease in knee torque, suggesting that allowing knees to move over toes may actually be beneficial for knee health. Research by Hamill (1994) found that Olympic weightlifters, who regularly squat with knees over toes, have less likelihood of injury compared to other sports. This could mean that, with proper training and flexibility, knees over toes is not a significant risk factor. The myth that said it was dangerous to translate your knees over your toes came from a study that showed there was an increase in pressure in the patellofemoral area (knee cap). But that does not mean it’s dangerous. However, it is important to not move, work, or exercise if there is significant pain. It’s important to progress in these movements in safe ways. I think Ben Patrick’s methods are the best and most accessible. He has written a book for the aging population who may currently only have very limited flexibility and movement in their joints. Check out his “ATG for Life” book.

A more promising solution that is sometimes mentioned by doctors is physical therapy. With physical therapy, when a patient is diligent and proactive, there is a much greater likelihood that their pain will improve. However, even that approach is flawed. The mistake is that you only do a prescribed set of movements with your physical therapist for a limited amount of time until the pain goes away. Maybe this intervention will work, but without the patient being taught how to integrate these movements into their daily life, it’s likely the pain and dysfunction will return. How could this not be the case? Without proper and full movement, joint circulation ceases to supply nutrients to the joint cavity. It becomes imperative that we move our joints often through the full range of motion throughout daily life to have healthy, strong, pain-free joints as we age. This is actually easier to do than one may think, but it takes diligence and a commitment to building new habits and patterns. With a little creativity, it isn’t hard to find ways to move better as part of our daily routine, without having to ‘do exercises’.

I don’t think anyone explains how to do this better than Katy Bowman. She shows how you can design aspects of your home to force you to perform what she calls, “nutritious movement.” When you think back about what we learned about synovial joints and the circulation of nutritious synovial fluid, ‘nutritious movement’ is a perfect name. I’d encourage you to look at her website and see what it’s about and it may give you a few ideas that would be easy to implement. Your joints will thank you for it.

Many clients come to see me complaining of back, hip, and knee pain. It’s often apparent by watching them walk or sit down that their joints are stiff and lack flexibility. I typically will begin by taking their hips, knees, and ankles through a passive range of motion to assess mobility and to watch for any presentation of pain. Afterward I may do some light passive stretching. Then we will begin teaching the joints and the nervous system to permit greater mobility through a series of active stretches in which the client will activate their muscles against my resistance to a count of ten after which the client will relax as I passively stretch the joint further before beginning the process over again until we have achieved a significantly great range of motion. To understand why this works we need to understand a bit more about the nervous system.

One of the main roles of the nervous system is to predict danger and safety. The primary way that the nervous system will alert you to the possibility of danger is through pain. I will very shortly be writing an article on the perplexing nature of pain. But in short, if your joints only move through a very narrow range of motion, the nervous system will learn that this is the furthest extent of motion a joint can safely move. In order to prevent you from moving past this set range, the nervous system will trigger the sensation of stiffness or pain the moment your body creeps toward that limit. If your daily movement is very limited, it’s likely you may feel stiff all the time, since you’re never far from that end-range the nervous system has set. The nervous system believes that by doing this it is keeping you safe. However, when that “safe” range is extremely narrow, it can be so limiting that it can interfere with your daily life, or cause you to be in pain almost all of the time. But unless the nervous system experiences movement beyond this very limited range, it has no way of knowing whether it is safe or not. When I begin performing active stretches with my clients, we are expanding the limits of what the nervous system deems as safe by loading the joints from a great range of motion in the joints.

This article started out with a discussion of the deep squat position and we ended up with the nervous system and how it triggers feelings of tension and pain. I went here because so many of us don’t have access to the deep squat and I felt it was important to talk about how it’s possible to work our way back toward this movement. Since this is such a restorative, fundamental movement, I feel that if we can retrain our bodies to have access to the squat again, we can resolve so many of the aches and pains that are misattributed to old age. In my practice one of the objectives I have is not only to relieve muscle tension, but to retrain the nervous system so that the work is more long-lasting. And if I’ve been convincing enough, I may even motivate some of my clients to take up the task of persuading their joints to feel as supple as they once did when they were kids. I believe this is possible if we are diligent and believe in the body’s ability to learn and adapt.