Heel elevation increases ankle and knee range of motion during squatting in healthy adults: a systematic review with meta-analysis

Alterations in foot position, such as heel elevation, can alter squat multi-joint kinematics, though a definitive dose-response meta-analysis is unavailable. This systematic review and meta-analysis investigated the effect of heel elevation magnitude on sagittal-plane range of motion (ROM) during squatting. Databases were searched until September 2025. Fourteen studies (n = 177 participants) were included. Random-effects meta-analysis revealed that heel elevation significantly increased ankle (Hedges’ g = 0.370, p = 0.020, mean difference (MD) = 4.33°) and knee ROM (Hedges’ g = 0.288, p < 0.001, MD = 4.94°), but not hip or trunk ROM. Subgroup analysis revealed a dose-response effect at the ankle, with significant increases only at high heel elevations (>2.5 cm or >5°; MD = 5.09°). Knee ROM increased with both low and high elevations (MD = 3.39° and 6.65°, respectively). Meta-regression suggested greater heel height was associated with reduced hip (β = -0.028, p = 0.030) and trunk ROM (β = -0.067, p = 0.018). The findings elucidate kinematic adaptations to heel elevation, highlighting a proximal-to-distal gradient in joint responsiveness. This evidence can inform the prescription of heel elevations in biomechanical applications to modify loading patterns during rehabilitation and training.