Heels Lifting in the Deep Squat: 1 or 2?
A 34-year-old recreational triathlete training 12–15 hours a week, with no current pain, is screened at the start of a build block toward an Olympic-distance race. She wears neutral trainers, uses no orthoses, and warms up for five minutes on a stationary bike before the screen. In the deep squat she places her feet shoulder-width with toes forward and holds the dowel overhead. She descends until the thighs are just above horizontal; both heels lift about 2 cm, the right slightly more than the left; the torso leans forward roughly 30 degrees so the dowel travels well ahead of the toes; and the arms drift forward, losing the overhead position at the bottom. She reports no pain at any point. Retested with the 2×6 board under both heels she reaches the full position - femur below horizontal, torso upright, dowel over the feet, heels down - and repeats it for all three attempts. She describes "permanently tight calves", sits more than 20 hours a week, and asks whether the heel lift "counts against her".
1. Assign a deep squat score, name the specific criteria you applied, and explain what the board trial tells you and what it does not.
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Score: 2.
The deep squat is scored against a fixed hierarchy. A 3 requires the upper torso parallel with the tibia or leaning toward vertical, the femur below horizontal, the knees tracking over the feet, the dowel held overhead and aligned over the feet, and the heels down. A 2 is recorded when those criteria are met with the 2×6 board under the heels, or when the criteria are not fully met. A 1 is reserved for someone who cannot reach the position at all - including with the board - or who needs external support. A 0 is any pain.
She fails the 3 clearly: heels lift, torso leans far forward, and the overhead position collapses. She is not a 1, because the 1 is not a "worse version of the 2" - it is a different category, reserved for people who cannot achieve the position even with the heel lift. Her board trial meets the full criteria on all three attempts. So the correct score is 2.
What the board proves: she has enough hip flexion, trunk extension, and shoulder capacity to reach the position when the ankle demand is reduced. That makes ankle dorsiflexion the leading hypothesis for the restriction.
What it does not prove: the board is not an ankle test. Elevating the heels also changes the centre of mass and reduces the trunk lean and hip-flexion demand, so it can mask a thoracic or hip limitation. It also unloads nothing diagnostically - it just tells you the squat improves in that condition.
Two things not to miss: the heels lifted unequally (right more than left), which the single deep squat score cannot capture, so add a bilateral ankle measure to the follow-up; and no coaching or cueing belongs inside a screen, because a cued rep no longer represents her uncoached strategy.
2. Design a same-session differential: how would you decide whether the limiting factor is ankle dorsiflexion, hip flexion and thoracic extension, or a motor-control/balance issue?
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Work from the most distal and most easily measured constraint outward, and stop testing once you have a coherent story - you are prioritising, not diagnosing.
1. Ankle dorsiflexion (weight-bearing). Knee-to-wall, both sides, heel flat, foot straight ahead, measuring the toe-to-wall distance and repeating with the knee over the second toe. A meaningful side-to-side difference or a small absolute distance supports the ankle hypothesis and explains the asymmetric heel lift. Watch the arch: if the foot pronates hard as the tibia advances, the ankle restriction may be partly a foot-posture issue and not a calf issue.
2. Hip flexion and thoracic extension (non-weight-bearing). Supine knee-to-chest and a Thomas-style check for the hip flexors and rectus femoris; seated thoracic extension over the back of a chair, and compare it with the shoulder mobility screen, which she has not yet had. A thoracic restriction shows up in both the squat and the shoulder screen, and is easy to overlook when the squat looks like an ankle problem.
3. Motor control and centre of mass. Retest a squat with the arms reaching forward or a light counterbalance held in front, no board, no cueing beyond the setup. If the heels now stay down and the depth is similar, the ankle is probably not the sole limit - the overhead position was driving the trunk lean. If the heels still lift, the ankle hypothesis strengthens.
Interpretation. The most likely answer is additive: a modest ankle restriction plus a thoracic extension limitation. Rank for intervention by which one is (a) most asymmetric, (b) most likely to change with 4 weeks of work, and (c) most relevant to her running load. For a triathlete in a build block, that usually means daily low-dose ankle work plus thoracic extension, and not a general "mobility" programme.
3. She races a 10 km in nine days and asks you to "fix the squat" before then. What do you actually do in the next two weeks, and how do you explain the score?
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What I do: nothing heroic. Nine days out, the goal is to not create a problem, not to chase a screening score.
- Keep running volume exactly as planned. Do not add novel calf stretching or eccentric loading in race week - new soreness in the calves nine days before a 10 km is a self-inflicted injury.
- Add 4–6 minutes of daily low-level ankle dorsiflexion work (knee-to-wall holds, calf mobility on a step), which is low-risk and low-soreness.
- For her gym squats, allow a 1–2 cm heel wedge as a temporary modification so she can train depth without the compensation, and treat it as a tool, not a fix.
- Defer the thoracic work to the post-race block, and retest at 3–4 weeks, not sooner.
What I say: "You scored 2 out of 3, not because you failed, but because you need your heels slightly raised to reach the position cleanly. Your score is a flag, not a diagnosis, and it doesn't mean anything is wrong with your body. What it tells me is where your ankles and upper back are relative to your hips. We'll work on that, but not the week of a race - we'll do a small amount of ankle work now and retest in a month."
The reasoning to make explicit: the score matters only if it is linked to something she cares about or to a pattern that is changing under load. She is asymptomatic, and a 2 with no pain in a well-trained athlete is common. The mistake would be either to ignore the asymmetric heel lift completely or to sell her a six-week corrective programme for a screening number she does not need to change. What I do want to know is whether the asymmetric ankle shows up in her running - calf tightness, Achilles symptoms, a history of plantar issues on the right side.