Sometimes it’s OK for “toes in“ squats...

I often hear from folks and also read on a lot of blogs and articles about whether your toes should be in or out for squats or other types of activities. The real answer is “it depends”.

What it depends on is the patient’s specific anatomy. That means we need to pay attention to knees and hips and things like femoral and tibial torsion‘s. It’s paramount to keep the knees in the sagittal plane, no matter what the lower extremity orientation is.

When somebody has external tibial torsion (i.e. when you drop a plumbline from there to view tuberosity it passes medial to the line between the second and third or second metatarsal) then having your feet and externally rotated position places the knees in sagittal plane. Having the patient go “toes in” with this type of anatomy will cause both knees to for medially and create patellofemoral tracking issues.

Likewise, like the patient in the video, (Yes, I know I say “external tibial torsion“ at the beginning of the video but the patient has internal tibial torsion as you will see from the remainder of the video) when somebody has internal tibial torsion (I.e. when you drop a plumbline from the tibial tuberosity it passes lateral to the second metatarsal or a line between the second and third metatarsal) you would need to point the toes inward to keep the knees in the sagittal plane as demonstrated in the video. You can also see in the video when her feet are placed “toes out“ they fall outside sagittal plane laterally which creates patellofemoral tracking issues like it was in this particular patient.

Now, I think about the possibilities with needling. Oftentimes, folks with internal tibial torsion will have tracking issues from the vastus medialis having a mechanical advantage over the lateralis, causing the patella to track medially. They will also often have a tight peroneal group and medial gastroc. Needling these can make a huge difference in your outcomes. Also adding in some "circle the dragon" about the patella can help alleviate some of the patellofemoral symptoms. Always remember to look above and below the joint in question as well. Often times, but not always, folks with internal tibial torsion will also have femoral retrotorsion so they will have weakness of the internal rotators of the hips, particularly the gluteus minimus and anterior fibers of the gluteus medius which respond to needling as well.

So, knees in or knees out? It depends…

Dr. Ivo

#internaltibialtorsion #externaltibialtorsion #kneepain #kneesin #kneesout #squats