Marks Daily Apple
Serving up health and fitness insights (daily, of course) with a side of irreverence.
3 Dec

Dear Mark: Can’t Squat, Please Help; Plus, High CRP, No Symptoms, and Glutathione

ScreenShot2012 12 03at45449PMIn this week’s edition of “Dear Mark,” I answer two reader emails that end up being more like three questions. First, I try to help out Alex, who’s having trouble reaching full depth in the Grok squat without falling over backwards. This is a common issue, believe it or not, and luckily there are some pretty simple fixes that people can try. In my response, I explain why he might be toppling over and what he can do to fix it. After that, I answer a question about C-reactive protein, the “inflammation” marker. One reader is feeling great and sitting at an ideal body weight, but a recent blood test in which CRP was elevated has worried her. She wants to know what she can do about it, so I explain why it might be elevated, why it might not be an issue, why it might be one, and what she can do to boost glutathione, which her doctor recommended she increase.

Let’s go:

Hi Mark,

I’m having trouble with the Grok Stretch.

I feel like I’ve read everything I could find about how to do it properly and watched all the videos you have available, but I can’t get down there without falling over.

What I’m wondering is: is my balance issue just one of my muscles and joints needing to be accustomed to the stretch? The reason I’m curious is that you describe it over and over as a “relaxation”, that is, I shouldn’t be contracting my muscles or leaning forward on the balls of my feet. Rather, I should just relax and sit back and be comfortable. My problem is that when I get down into the position where my heels are on the floor and I’ve got my center of mass lined up properly, I can’t not fall over backward. I can hold it for maybe 10 seconds tops, but, when I do that, my muscles are all very tight and it’s clearly not relaxing.

If you have any thoughts, they’d be very much appreciated!

Best,

Alex

I can think of two things that may be impeding your progress: your calves are tight and you’re trying to maintain a vertical torso. Most people who spend any time wearing shoes with heels (even slightly pronounced ones) probably have tight calves. When your heel is elevated, whether it’s because you’ve raised up on your toes or you’re wearing a shoe with heels, your ankle is in a state of plantarflexion, or moving toward an angle greater than 90 degrees. When your ankle is in plantarflexion, your calf is contracted and “shortened.” Calf raises also put your ankle into plantarflexion in order to target and work your calves. If you’re just walking around in some tennis shoes with a half inch or two of heel, your calves are going to languish in mild contraction and, over time, this contraction can be a semi-permanent position for your calves.

When you try to squat with tight calves, you run into problems. You’ll naturally want to shift enough body weight forward to maintain your balance over your feet, but this requires ample amounts of ankle dorsiflexion (angle less than 90 degrees). If your calves are too tight, you won’t be able to dorsiflex your ankle, and your knees won’t be able to travel forward enough to shift a sufficient amount of bodyweight forward to maintain balance. Tight calves force you to keep all the weight on the back half, causing you to fall backward.

Second, you’re probably trying to maintain too vertical a torso. This is understandable, because so many people talk about the need for a neutral spine when squatting, and that gets mixed up with a vertical spine.  Squatting is all about balance, and counter balance. If you’re squatting and want to keep an upright torso, you need full ankle dorsiflexion, particularly if you have tight calves. Otherwise, all the weight will stay in the back, and you’ll fall over. If you ever watch Olympic lifters doing a front squat, their backs are only able to stay vertical because they’re able to push their knees far ahead of their toes; this allows them to maintain balance. That takes flexible calves – flexible enough to allow full dorsiflexion at the ankle and a knee forward position. If they tried to keep a vertical torso with tight calves, vertical shins, and knees behind the toes, they would fall over, just like you’re doing. Does that sound familiar? Watch what happens to this guy when he tries to squat – is that you?

Going up onto your toes is a lot easier because it elevates the heel, reduces the need for full ankle dorsiflexion, and makes it easier to maintain and upright torso, which is why most Westerners must default to a toes down, heel up squat. There’s nothing wrong with doing that kind of squat as long as it’s unweighted, but you want to have enough flexibility to sit in a full heels down squat, too.

  • Reduce the time you spend in passive ankle plantarflexion.
  • Start wearing minimalist shoes with a zero-drop heel, or go barefoot more often.
  • When you sit down, try to keep your feet flat on the floor. Too often we point our toes to the ground and elevate our heels.
  • Mobilize your calves.

You’re gonna have to stretch and mobilize your calves, particularly if you continue to plantarflex your way through life (hey, sometimes you just wanna wear some nice heels). This is the best calf stretch I’ve found (skip to around 3:00 for the actual stretch, if you’re short on time). Here’s an article describing it, with plenty of helpful pictures. Try the stretch for two minutes for each calf, with knee straight and bent, and see how it affects your squat.

I’d also recommend you practice sitting deep into a full squat while holding onto something in front of you for stability, like a pole as in the picture above. By holding on to the pole, you provide an external counterbalance and eliminate the need for an internal counterbalance. This allows you to really accentuate the ankle dorsiflexion; you can almost pull yourself into it and really stretch those calves and get used to being in a proper squat. Make sure you keep those heels down or you’ll lose the stretch.

Also, a Grok squat stretch doesn’t have to be perfect. Your back probably won’t be totally vertical, and that’s fine. You might lean forward. The lower back might even round! Don’t stress over it. Even the pros let their backs round at the bottom of a bodyweight squat. However, let me make this clear: your lower back should not round on weighted squats.

Dear Mark,

I have been primal for over two years and I feel great. My weight is perfect and so is pretty much everything – that is until I got my blood tests done (by a primal doc!). All results came back in glorious primal fashion except my inflammatory numbers! My CRP was 7.4 (optimally it should be below 1.00). My other inflammation/oxidation numbers were also high. The thing is I have no symptoms. My doctor recommended taking whey because it helps the body produce Glutathione, the body’s master anti-oxidant. The thing is, I dislike taking it. It feels processed and not the whole food I am used to. Is there a better way to get Glutathione into my body? I know supplements aren’t supposed to work that well…and any other ideas to bring down the inflammation? Thank you!

Diane

That is an interesting case. Elevated CRP is potentially worrisome, I agree, because it’s a sensitive barometer of any kind of inflammation occurring in the body. You sprain an ankle, CRP goes up. You get an infection, CRP goes up. You run a marathon or do an intense CrossFit WOD, CRP goes up. You get a cold or the flu, CRP goes up. You have an autoimmune disease flare-up, CRP goes up. It could be multiple sclerosis, or chronic stress, or acute stress, or sleep apnea, or almost anything. So, CRP going up can mean something very bad, or it can simply represent a transient, benign increase in inflammation due to exercise or a single bad night’s sleep. It’s nothing to freak out about, but it’s definitely something to investigate.

Did you have a particularly intense workout prior to the test? CRP levels can be significantly elevated 24 hours after physical exertion, so this may be confounding the results. One study – in marathoners – even found that CRP levels went up 2000%. Other inflammatory markers were also affected.

You may have a variant in the “CRP gene” that predisposes you to higher CRP numbers without any additional base inflammation. Folks with the variants effectively have a CRP set point 64% higher than “normal” folks. So, a 7.4 CRP in one of these people might be equal to a 1.0 CRP in a “normal” person, even though they have the same “level” of inflammation. In fact, a recent study showed that although people with genetically high CRP numbers are theoretically at a greater predicted risk of developing heart disease when you go by the traditional understanding of CRP, those genetic polymorphisms themselves are not associated with increased risk. Their inflammation isn’t necessarily higher; their CRP is just hyper-responsive.

And finally, the blood test you just got was a snapshot in time. Far more troublesome would be an upward trend of CRP, or a perpetually elevated reading. So, get another test done in a few weeks, and maybe a couple more at regular intervals to see if your elevated reading was a trend or just a momentary blip. Judging from your subjective results, I’d lean toward it being an aberration, but that’s just a guess.

As for boosting glutathione, whey protein is a good way to do it because of its cysteine content. Raw whey proteins are even better, and raw egg whites (from trusted sources) can do it, too. Cysteine is an amino acid and a precursor to glutathione synthesis, but whey isn’t the only source. N-acetyl-cysteine, a relatively inexpensive supplement, has also been shown to boost glutathione status. (My Advanced Health Formula and Damage Control Master Formula contain it.) Good sleep matters, too, as melatonin can increase glutathione production.

That’s it for today, folks. Thanks for reading and keep the questions coming!

You want comments? We got comments:

Imagine you’re George Clooney. Take a moment to admire your grooming and wit. Okay, now imagine someone walks up to you and asks, “What’s your name?” You say, “I’m George Clooney.” Or maybe you say, “I’m the Clooninator!” You don’t say “I’m George of George Clooney Sells Movies Blog” and you certainly don’t say, “I’m Clooney Weight Loss Plan”. So while spam is technically meat, it ain’t anywhere near Primal. Please nickname yourself something your friends would call you.

  1. Inflammation has been on my mind lately, mainly the insane amount of Omega 6 in nuts. With the exception of macadamia nuts, all nuts have thousands if not tens of thousands of mg a Omega 6 in each ounce. If you want to maintain a 1:2 ratio of omega 3:6 you would need to either supplement with a ton of fish oil or eat fish every day if you even want to consume one ounce of nuts. Lately I have just cut out all nuts except macadamia nuts so my inflammation doesn’t get out of hand. I got to wonder about the people who eat all kind of paleo baked goods, all that almond flour.

    Wayne Atwell wrote on December 3rd, 2012
    • I personally think that the entire O6/O3 ratio thing is entirely false or useless.
      Why?
      Part of the reason why O6 is considered bad is because it is present in huge quantities in the SAD whereas O3 is practically absent in the SAD.
      I think its just a coincidence/correlation more so than a direct cause.
      I don’t think it is the O6 of the SAD that is killing Americans but the high simple carb content, low activity, obesity, etc. that is more responsible.
      I highly doubt that people eating 100 grams of nuts a day (within caloric limits) are hurting themselves.
      There was a study that even found that vegans who took no fish oil caps had normal DHA levels in their blood. So, it may even be unnecessary.
      Nonetheless, I think that the daily requirement of EPA and DHA should total to 1g and you don’t need to seriously limit nut intake or any natural O6 intake. Of course, eating processed carbs bound together with high-O6 fats is a recipe for disaster, but I think the real reason is the effect it has on appetite, insulin, FBG, trigs, etc.

      lighthouse084 wrote on December 3rd, 2012
      • I strongly disagree that the O6/O3 ratio is useless/false. For me, I’ve discovered that elevated levels of O6 result in very dry and sensitive skin that gets even more prone to breakouts.

        Mad Allen wrote on December 3rd, 2012
        • Taking larger (15g/d) doses of fish oil works tremendously for my psoriasis. The effect takes weeks (as expected) to appear and is gradually lost upon discontinuation of supplementation.

          Bertie McElfluff wrote on December 3rd, 2012
        • I agree. Even a little bit of anything cooked/fried in high O6 vegetable oils causes a major breakout for me as well. O3 supplements help me keep it in check.

          Wafaa wrote on December 3rd, 2012
      • I have had moderate rosacea most of my adult life. After switching to a mostly primal diet, it improved quite a bit, but it improved significantly within about 3 weeks of the date I started taking fish oil regularly.

        DuncaN wrote on December 4th, 2012
      • The problem with O6s is the chain structure. You can make them rancid by just looking at them. The only way to have them is fresh off the tree and raw. If they’ve been sitting around or exposed to heat they will be inflammatory.

        Dude wrote on December 6th, 2012
    • “I got to wonder about the people who eat all kind of paleo baked goods, all that almond flour.”

      Regardless of the fats balance, I’m guessing Grok probably wasn’t into baked goods. ;) I can eat some nuts, but not when I consume in the volumes that seem “normal” when ground into flour or butter. I definitely react when I consume too much. All nut butters are off limits for me because I don’t have enough control to daintily consume an amount that would not cause an issue.

      Paleo baked goods are occasional holiday/weekend only foods for us. Backing away (slowly) from the bakery aisle is part of the lifestyle for us. ;)

      Amy wrote on December 3rd, 2012
      • Grok did roast hazelnuts in large quantities. Modern day !San roast mongongo nuts. Roasted nuts are about as paleo as it gets.

        George wrote on December 3rd, 2012
      • Bake an apple. Stuff with nuts and dried friut. Forget pies. :)

        Grok Fox wrote on December 4th, 2012
        • Or, Bake an apple. Core it, cut it in half, and sprinkle a large dose of cinnamon all over the exposed cuts. Bake until it softens to the desired texture.

          Granny smith works great because it retains more texture when cooked, or you can use any apple recommended for baking.

          For non-Primal friends and family, you could have a bit of brown sugar on hand to sprinkle on the apple after baking, if they like. But it really doesn’t need it.

          PhilmontScott wrote on December 4th, 2012
  2. I’ve had an elevated CRP for several years. It is always around 15, but in my country the desirable range is up to 6 mg/l, not 1; don’t know why. This is actually how I learned about the Primal diet – I was researching the significance of CRP and found a discussion about an anti-inflammatory diet at this very website. I’ve lost a lot of weight, and my health has improved tremendously, but the CRP persists… I try not to worry about it but I’d still like to know why I can’t keep it under control. Perphaps I am one of those people who are genetically predisposed to a higher CRP.

    Vera wrote on December 3rd, 2012
  3. If taking whey protein powder feels too processed, why not drink some whey (captured from yogurt or raw clabbered milk). If you’re able to take whey protein you shouldn’t have any sensitivities with liquid whey, and if you can get it from raw milk it might really help you.

    Abby J. wrote on December 3rd, 2012
    • Another whole-food source of glutathione is broccoli. Here is a page on all the food sources that boost glutathione intake: http://www.livestrong.com/article/335859-food-sources-of-glutathione/

      Wenchypoo wrote on December 3rd, 2012
    • Dave Asprey’s upgraded whey is a good product if you want to avoid processed weirdness. I have no connection to him or the product whatsoever btw.

      Dude wrote on December 6th, 2012
  4. Thanks for the article, Mark. When I was in BHIP (boot camp) at UCLA, I had a terrible time squatting. My calves are very tight from years of wearing heels (even though I now stretch them daily). Then, I tore one of my calves running and jumping at the same time back in June. Now? Both calves give me grief from time to time (the injured calf not yet fully healed and the other calf as I think I over-compensated using it when first injured and had to limp around). I finally gave up and just began holding on to something to achieve a full squat. I’ve discovered two things – 1) it makes no darn difference as long as you fully and properly squat; and 2) I’ve gotten so much stronger simply from giving in to holding on for balance. I figure “whatever gets ‘er done” is what I’ll do, so you could very well catch me any day at the gym or at the track holding on to the side of something getting my squats on! Nice to see you demonstrate and encourage this as well for those of us with tight/injured calves. :)

    Mary wrote on December 3rd, 2012
  5. Milk thistle has been found to boost glutathione levels. Probably due to its liver protection abilities somehow. I’ve been working on boosting glutathione for years with my Autism spectrum child. Do not waste money on supplementing directly with glutathione no matter how tempting the lipoceutical glutathione claims might be. I just don’t think they work. Also, do NOT take Tylenol; it depletes glutathione.

    Pam wrote on December 3rd, 2012
    • Tylenol is surprisingly harsh on the liver for an OTC drug. On that note, you really don’t want to mix tylenol + caffeine or alcohol.

      mm wrote on December 5th, 2012
      • I almost cried when I read this. :( My OBGYN suggested me to take tylenol extra strength with coffee to stop my migraine. I was pregnant and getting a lot of migraines at that time. I did not know any better back then and I followed her advice. Two years later I figured I might have gluten allergy and I stopped consuming gluten without any tests. My migraines stopped cold turkey. Now I worry about my liver because I took so many excedrin migraine and other painkiller out of desperation. How can I clean my liver? Do you have any mild suggestion?

        Sumey wrote on August 22nd, 2013
  6. For squatting, I also fell over backwards at first. Holding a wall or pole helped train my body in no time and now I can go all the way down and back up without a wobble.

    Knifegill wrote on December 3rd, 2012
  7. Squatting – It may be easier if you place your feet pretty far apart with the toes pointed out – in line with the knees which are also splayed out, not straight ahead. You can use your elbows to keep your knees from caving in – see images of Garland or Malasana Pose, such as http://lovemyyoga.com/garland-pose.html

    This variation gives plenty of room to lean forward between you legs to shift your center of gravity forward. Also, when I started doing flat-footed squats, I found it helpful to hold a small weight (2-5 pounds – NOT a heavy weight) or book straight out in front of me to maintain balance. This might be the equivalent of holding onto a pole.

    Kathy wrote on December 3rd, 2012
  8. If your CRP level is high, get checked for dental problems. Mine was around 7 and my doctor seemed stumped. I’d read that it could be tooth-related, so I got some dental work done that I’d been putting off. CRP dropped to 1.

    onewomanband wrote on December 3rd, 2012
  9. wayne, interesting how you mention this, I love almonds and use them as a snack at the office,
    Lately after I have been eating cashews I have achy elbows and wrist and I think it may have been caused by the cashews.

    Shirley skinner wrote on December 3rd, 2012
    • For the squat issue, great job on calves, Mark! Be sure to do an ankle band distraction (search ankle Mulligan on Mwod). I do this before every squat workout – the test/retest is unbelieveable.

      The function of a shortened achilles is also a big deal here – takes alot of work if you’ve been in heels for much of your life.

      William wrote on December 3rd, 2012
    • Roasted or raw?

      cancerclasses wrote on December 3rd, 2012
    • Cashews are a FODMAP

      Danielle Thalman wrote on December 3rd, 2012
      • …roasted or raw

        Danielle Thalman wrote on December 3rd, 2012
  10. Ok, I seriously need to start doing that calf exercise!

    Harry Mossman wrote on December 3rd, 2012
  11. Whenever I try to squat for an extended period of time my feet go numb! I’m sure that can’t be right since there are cultures who squat all day, so any ideas on what’s going wrong?

    Vikki wrote on December 3rd, 2012
  12. Barring physical abnormalities, we are all born with squatting potential. Over time, squatters develop indentations on their femurs called “squatting facets”. These allow them to easily and comfortably adopt the Grok squat position. Forensic anthropologists can tell by looking at skeletal femurs whether or not a person was a squatter.

    People in the Western World stop squatting early on, so their squatting facets disappear. It’s then awkward and painful for them to squat. Fortunately, it’s possible to reverse this condition by – SQUATTING again!

    The squatting position adopted by most Westerners (balancing on the toes and balls of the feet with heels raised) is actually a very good way to stretch your Achilles tendons and calves. It’s great for balance as well. The Japanese call this posture “sonkyo”, and it’s used in martial arts such as Aikido and Sumo. When you squat in sonkyo, straighten and extend your spine, and keep your center of gravity over your ankles. It’s a comfortable and relaxing position, and, as I mentioned, it’s a good way to stretch those tight Achilles tendons.

    Anyway, keep practicing your Grok squats (holding onto something as in Mark’s photo); stretch your Achilles tendons several times a day; and walk barefoot whenever possible.

    Helga wrote on December 3rd, 2012
  13. “When you sit down, try to keep your feet flat on the floor. Too often we point our toes to the ground and elevate our heels.”

    In my case, this is because I’m short, and in most chairs, my heels don’t reach the ground if I’m not wearing high heels already. If I want my feet flat on the ground, I have to perch on the front of the chair as if I’m wearing a hoop skirt or something.

    At home, I solve this problem by sitting cross-legged in the chair, but this generally doesn’t go over too well in public, and sitting on the edge of your chair makes people think you’re nervous or restless (I can be perfectly relaxed this way, but I’ve had other people tell me I make them edgy by sitting forward so my heels reach the ground).

    Kym wrote on December 3rd, 2012
    • You can use something to put your feet on under your desk. A cardboard box might work or some old telephone books.

      Diane wrote on December 3rd, 2012
      • I use an old Singer sewing machine case turned on its side with the shorter side (top) toward me. It’s trapezoidal. Great foot rest for short person.

        Karen wrote on December 3rd, 2012
  14. best stretch-prep for a full squat I’ve seen comes from ‘katysays’ (it’s a blog about alignment).

    http://www.alignedandwell.com/katysays/you-dont-know-squat/

    it’s got almost the same calf stretch along with some others in case that helps anyone :)

    Milthra wrote on December 3rd, 2012
    • These exercises look like they would be helpful to someone trying to regain their squat.

      Helga wrote on December 3rd, 2012
  15. Thanks for squat advice – I struggle with tight calf and hamstring muscles. I am going to try that pole method next time I go to work out.

    Glen wrote on December 3rd, 2012
  16. When you squat, shove your knees OUT!

    Chaloney wrote on December 3rd, 2012
  17. Aren’t those of you who are older concerned over blowing out knees with routine squats?

    crowley wrote on December 3rd, 2012
    • Age shouldn’t be a problem if you’ve worked up slowly to full squats, or, of course, if you’ve been doing them all along. As long as you keep your hips, knees, and ankles aligned and keep your centre of gravity over your ankles/heels, I don’t see that age would make a difference to your ability to squat.

      I would not, however, recommend explosive, Cossack-style squats to anyone but Cossacks.

      Helga wrote on December 3rd, 2012
      • How do you squat while keeping your hips, knees, and ankles aligned? LOL.

        Mary wrote on December 4th, 2012
        • Good question, and this is where a picture is worth a thousand words! Look at the photo above of Mark. You could play connect-the-dots with his hips, knees, ankles and toes.

          As you lower yourself into the squat, those four points should still be aligned, whatever the angle. If your knees collapse inward, they are no longer aligned with hips, ankles and toes.

          I use two positions for the Grok squat, toes forward, and toes at 45-degrees. Either way, my hips, knees, ankles and toes are aligned. If your hips are tight, it might be difficult to get a good turn-out, so you’ll have to work on opening your hips. But that’s another story.

          Here are some photos of Asian squats. Notice there’s quite a bit of variety, from splayed knees squats to the hip-width, toes forward squat of the young man with the scooter.

          http://johnnysideburns.wordpress.com/2012/07/02/the-asian-squat/

          I should add, however, that you have some leeway in this whole alignment thing, and you have to know what feels right for your body. I do some toes-forward exercises with a slight pigeon-toe because that feels better and more natural to me. Experiment!

          Helga wrote on December 4th, 2012
  18. As a trainer one of the first things I want to see is how people squat. It’s pretty surprising how many people lack the understanding to move from their hips and not their knees. A lot of time once clients realize they have to stick there butt back it’s kind of an “aha” or “oh that makes sense ” moment. Great demo on the calves. Gotta say I feel bad for anyone hobos forced to stad I’m heals all day for work!

    Luke DePron wrote on December 3rd, 2012
  19. The best source of whey outside of taking processed powders is ricotta cheese. It’s made out of whey concentrate. If you (understandably) do not want to take a highly processed powder filled with oxidized, powdered cholesterol, eat ricotta cheese. If you want to take it as a protein source, simply purchase the (GASP!) reduced fat version. Just read the labels to make sure it’s actually all milk ingredients and not a dozen different gums and thickeners.

    ChocoTaco369 wrote on December 4th, 2012
  20. Wouldn’t a 64% rise in CRP from 1.0 result in a CRP of 1.64 and not 7.4? Or am I reading this wrong?

    AndreasDK wrote on December 5th, 2012
  21. Difficulty attaining a full squat can also be the result of very high arches, as a supinated forefoot limits how far the tibia can progress forward, which is a necessary element of a successful deep squat. This is a rather difficult issue to remedy on your own but if you were able to find a good physical therapist who is knowledgeable about the foot, they could help you mobilize your foot. Getting used to minimalist footwear/going barefoot would also likely help with this issue, just as Mark suggested that it would help remedy tight heel cords/plantar flexors.

    Fritzy wrote on December 6th, 2012
    • Interesting info on the high arches. Thanks! I’ve had Plantar Facsitis on and off over the past 6-7 years, but always am able to ease it back to normal with conscious efforts training in my five fingers, stretching, and “taking it easy.”

      craig almaguer wrote on December 16th, 2012
  22. Regarding difficulty squatting: try putting something under your heels. This effectively lengthens your lower leg relative to your femur allowing you to center your mass more easily.

    Jenfit12 wrote on December 23rd, 2012

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