When talking about the squat, a common ‘problem’ that is frequently brought up is the ‘butt wink’. A ‘butt wink’ refers to when an individual rounds their lower back as they approach the bottom position. It’s called ‘butt wink’ because it looks like the butt is ‘winking’, rather than staying stable throughout the movement.

It is often blamed for causing or contributing to lower back pain, since the spine is loaded in a flexed position. It is important to note that there is an unavoidable amount of forward bending that occurs at the lumbar spine with all individuals during a deep squat, and it usually only warrants attention if there is pain with it. 

Before discussing solutions, it is important to go over what actually happens in the lumbar spine and pelvis during a butt wink. As the athlete approaches the bottom of a squat, flexion or rounding in the lumbar spine is accompanied by a posterior pelvic tilt. This dipping motion usually reverts back to the starting position as the athlete ascends from the bottom position. This quick reversal of movement in the lumbar spine and pelvis is why it is termed “butt wink”.

Starting Position

The Butt Wink™ can happen simply due to the starting position of the pelvis in relation to the lower back. If the athlete starts with hyperextension in the lumbar spine, usually accompanied with anterior pelvic tilt, the “butt wink” will appear more prominent, as the lumbar spine and pelvis is moving from one extreme of motion to the other (from hyperextension to flexion). In this case, addressing the starting position of the pelvis and lumbar spine can reduce this movement significantly. See video below for a demonstration:

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Mobility

From a mobility standpoint, we must break down the squat into the demands on each individual joint, since achieving a deep squat requires close to end-range flexion across the ankles, hips, and knees. If we are lacking motion in any of these areas, the lumbar spine and pelvis can compensate by going into flexion and posterior pelvic tilt in order to achieve depth. 

Assessing Ankle Mobility

We can take a bottom up approach when assessing the squat and start at the ankle joint. Getting to the bottom position requires end-range ankle dorsiflexion and is often the main limiting factor for athletes getting into a deep squat position. We can assess this motion by using an ankle wall test:

The exact amount of motion needed varies across different body types and morphologies, but a general guideline is if the athlete can touch their knee to the wall with their heel down and their big toe at least a hands-width away from the wall, they have adequate ankle mobility for the squat.

Assessing Knee and Hip Mobility

If we determine the athlete has sufficient ankle dorsiflexion, we can direct our attention to the knees and hips. To screen knee flexion, we can use the tall kneeling position and transition to short kneeling to assess ability to bend the knees.

 To screen for hip internal and external rotation, we can use the hip 90-90 position, as limitations here can restrict end-range hip flexion. 

Stability

Butt wink can also occur due to the inability to maintain tension at the bottom of a squat. If this is the case, we can assess breathing and work on positional stability where limited.

Keep in mind that everyone’s squat will look different due to differences in body proportions. Assuming there is no pain, butt wink falls into the category of individual movement differences and may not necessitate a change. 

One of the most common reasons for heel pain in the US is due to plantar fasciitis.

The plantar fascia is a thick band of connective tissue (fascia) attaching from the heel to the toes. This structure provides arch support and aids with shock absorption while walking, running, jumping–pretty much whenever we’re on our feet and moving dynamically!

Plantar Fasciitis Explained

Despite its name, plantar fasciitis, denoting inflammation (“-itis”), research shows that it is not really inflammation. The cause of injury can be multifactorial; however it is commonly due to an overuse injury that causes a repetitive strain and results in irritation, if untreated, it can create degenerative changes like micro-tears to the plantar fascia. 

Common presentation:

• sharp localized pain in the heel area

•  pain with steps after long periods of non-weight bearing like taking the first steps out of bed in the morning

• barefoot walking 

• sometimes the pain will improve with short distance walking, but worsens with prolonged walking or standing

• worsening pain towards the end of the day as activity increases. 

• heel spurs can also be found in some cases

While it is most commonly seen in active adults including runners, it is not uncommon for people with different levels of activity lifestyles to experience it as well. 

Risk Factors:

• foot mechanics: flat or high arches, over pronation or supination of the foot with weight bearing

• tightness of the heel cord or calf region

• heel pad thickness changes with age

• people with occupations requiring prolonged standing or weight bearing

Medical providers will take these factors into consideration when diagnosing, as well as refer to imaging if appropriate.

Most patients respond well to  treatment including physical therapy and patient education. Depending on the chronicity and the individual’s activity goals, it can take a few weeks to several months to resolve.

Role of Physical Therapy

PT can help to address both acute symptoms and help with long term treatment. Since plantar fasciitis is most commonly an overuse injury, the guidance of a physical therapist with managed load strengthening can be key for rehab success.

The rehab goal of treatment while addressing acute symptoms is to provide pain relief. Under the care of a physical therapist, the interventions may include patient education on pain relieving stretches, soft tissue work, activity modification, and footwear education.   

For long term treatment, physical therapy can address the root of why this overuse injury occurred with a managed load strengthening program and guide your safe return to sport.

By Dr. Otto Lam, PT, DPT

At Good Reps Physical Therapy, we work with many different types of athletes. We see runners of every sort; casual, short distance, long distance and even ultra marathoners. Every so often, we have runners with stress fractures looking to return to running. A stress fracture is when tiny cracks form in the bone (usually in the lower leg or foot) due to repetitive trauma, most commonly seen in participants with sports that require a lot of running. This is an injury that requires immediate medical attention because the affected leg must be offloaded to prevent further damage and allow the bone to heal (usually it takes at least 6 weeks for initial healing to occur depending on severity). Stress fractures usually occur in runners due to a training load error, whether there was a sudden increase in mileage or intensity. Below are signs and symptoms to look out for a stress fracture:

• Pinpoint tenderness in the local region

• Pain with hopping on one leg

Further examination by a medical professional is a must if you suspect that you have a stress fracture. An MRI can help to detect and confirm a stress fracture early on so that the appropriate steps can be taken to facilitate healing and subsequent rehab.

If the goal is to return to running, a comprehensive rehab program led by a licensed Physical Therapist is crucial for a safe return. The greatest predictor for a future stress fracture is a previous stress fracture that has not healed properly. 

Rehab for Stress Fractures

Once you’ve been diagnosed with a stress fracture, rehab can help to safely return you to running. Recovery and rehab time varies depending on the severity of the stress fracture and individual differences. The following is a general guideline for stress fracture return to sport rehab:

Offloading Phase 

During the first couple weeks after your stress fracture, you will be instructed to reduce the amount of weight you put on the affected side throughout day to day activities by using crutches or a boot. This will allow initial bone healing to occur without disruption. Rehab will focus on minimizing mobility and strength loss. This generally will encompass weeks 1-4.

Loading Phase

During the loading phase, Wolff’s Law is the overarching theme which dictates that bones will adapt based on the stresses placed on them. When adequate healing has occurred, you will be instructed to place more weight on the affected side and wean off of the crutches/boot. At this point, rehab will focus on building strength and capacity of the lower extremities and core. A walking program is usually recommended as well. This usually takes 2-4 weeks.

Plyometrics/Return to Running

In this phase, plyometrics will be introduced to gradually expose the bone to greater impact. This can take many forms, but generally starts with landing drills. The ability to land and tolerate impact forces is similar to making sure the brakes of a car work before accelerating. When certain criteria have been met as determined by your physical therapist, a walk/run program will be initiated to facilitate a return to continuous running. This takes us to a total of at least 8-12 weeks to return to continuous running from initial onset of injury, keeping in mind that timeline for recovery can vary from person to person.