Knee Pain and SquattingWhen someone says, “my knee hurts when I squat,” that is real information without much specificity. The causes of pain may be multifaceted and difficult to pin down, and other than suggesting the person see a medical professional, diagnosing knee pain is not the coach’s prerogative. We may never know the causes of someone’s knee pain. Instead, we have to act on the information we have, observations we can make, experiments we can safely undertake, and move forward with imperfect information until better information is available.
Knee Pain While Squatting
By: Nick Soleyn, Editor in Chief
In 1784, John Mitchell wrote that a binary star system would provide data by which an observer could calculate the size of a central star by how it affects the orbiting star. He argued that a sufficiently dense body might have such great gravitational effect that “all light emitted from such a body would be made to return towards it, by its own proper gravity.” If this were the case, Mitchell wrote, “we could have no information from light; yet, if any other luminous bodies should happen to revolve about them we might still perhaps from the motions of these revolving bodies infer the existence of the central ones with some degree of probability, as this might afford a clue to some of the apparent irregularities of the revolving bodies, which would not be easily explicable on any other hypothesis.” (Mitchell 1784). In essence, a body so massive that its gravity trapped light would defy the contemporary means of observation but would give up its presence by its gravitational effects on other bodies. Scientists often operate in these kinds of negative spaces, inferring the Big Picture not by direct observation but by the effects of things unseen on things that are. Einstein would not publish his theory of general relativity for another 130 years after Mitchell’s paper, leading to black holes becoming a mainstream subject of research. And it was not until April 10th, 2019 that the first picture of a black hole was released to the public. The cycle of inference, hypothesis, and deduction often gives us best-guesses about the universe, allowing us to continue observing, exploring, experimenting, and discovering.
Scale the same “black hole” concept way down to the much more modest, but no less complex, realm of human-sized problems. People observe the world indirectly through sense organs and perception and can interpret and communicate experiences to one another. Every sense requires an interpretation. Light collected through your eyes is transmitted and made sense of by your brain. Assuming the interpretation is accurate, it is also ever so slightly in the past. Enough so that everything you see, experience, and react to is a little bit out of date. Our senses are not perfect, but they still give us information about what may be going on inside or around our bodies.
For internal senses, pain is a common experience—identifiable and describable. Pain may give us hints about what is causing it (location, intensity, frequency), but it often presents without an easily identifiable root cause. Like the black hole, we may not know exactly what triggers our pain sense, but we know they are experiencing something. It is easy to know why your foot hurts if you drop a barbell plate on it, but it is more difficult to know why someone’s knees or back hurt when they lift. When pain is not easily identifiable, we have to look at surrounding circumstances. Unless or until you see a doctor, all you may really know is that things hurt.
Strength coaches often operate in this realm of imperfect knowledge. We are not medical professionals who treat illnesses and injuries. We are strength professionals who treat your ability to train. Being unable to take a below-the-surface look at the person in front of us who just wants to train, we must take the person “as-is,” fixing form and making recommendations based on what they tell us and experience while training.
When someone says, “my knee hurts when I squat,” that is real information without much specificity. The causes of pain may be multifaceted and difficult to pin down, and other than suggesting the person see a medical professional, diagnosing knee pain is not the coach’s prerogative. We may never know the causes of someone’s knee pain. Instead, we have to act on the information we have, observations we can make, experiments we can safely undertake, and move forward with imperfect information until better information is available.
Knee pain while squatting is a common complaint. Without more information, the existence of knee pain will not signal an “all-stop” to the strength coach. We take the black hole approach, creating observations and experiments that try to help lifter in the context of their training.
There are several possible conditions of knee pain, one of which, “Patellofemoral Pain Syndrome” (PFPS), has been called “The Black Hole of Orthopaedics” because its mechanisms are not consistent from person to person (Sanchis-Alfonso). PFPS accounts for most of what we think of as patellar tendonitis due to acute injury or “overuse,” sometimes called runner’s knee, jumper’s knee, or anterior knee pain. Osteoarthritis is the most common cause of knee pain in adults over 50 years old. And bacterial infection rounds out the big three causes of chronic knee pain. The problem is that pain does not always neatly line up with one of these causes clearly or suggest an easy treatment by its presentation.
You can get imaging and professional help, but as Coach Jayson Ball mentioned in the Barbell Logic Podcast, when it comes to imaging “the resolution might not be fine enough to tell you what’s happening in the nervous system.” And, it is in the nervous system where pain lives. (Barbell Logic Podcast #264: The Pain Puzzle) As an example, imaging may show the malalignment of your patella and femur, suggesting a risk factor for PFPS, but many people with malalignments will experience no pain related to their sports or activities (Sanchis-Alfonso). For others, it will be a constant battle. Some people with osteoarthritis will have little pain, while others can only ever expect pain management sufficient to stay active and healthy and will never be without pain or the need for NSAIDs completely if they want to lift (See Carlesso et al. 2018).
This is not to say that you should avoid getting your knee pain evaluated by a professional. Information about what is happening inside your body is always valuable. But any strength coach with experience has had to operate between doctor visits, taking someone as they are right now, bundled up with pain complaints and other issues, and making decisions based on a few key goals.
When you find yourself in these interstitial spaces, experiencing knee pain but not yet able or determined to go see your doctor about it, you can approach your situation like a strength coach: lacking perfect information but able to observe, adjust, and tweak things in a way that allows you to keep training unless or until it becomes contraindicated.
What is the Goal?
The optimal state for training is progress with as little complexity as possible—inducing sufficient systemic and localized training stress to build muscle and get stronger—and progress without worsening some underlying condition or causing decommissioning levels of pain. The farther a person is from being a post-pubescent teenager with few of life’s witness marks, those aches and pains from living life, the less likely the person is going to train in an optimal state. But the goal of strength training always remains the same.
We do not know that strength improvements will fix knee pain, but we do know that pain thrives in weakness. The loss of muscle mass and the resulting instability around joints does not make pain better in the long run. The do-nothing, avoidance approach to pain management risks trading short-term, fleeting comfort for long-term pain, frailty, and drug dependence. With training, you are often giving yourself the best chance at bouncing back and mitigating the pain. But setbacks like knee pain requires adjustments.
All such adjustments should point, generally, in one direction: progress. Progress means training in a way that produces sufficient stress to require adaptive responses that lead to the outcomes desired. Note what progress is not: progress is not training without pain, and progress is not setting PR after PR. We want those things when we can get them, but some people with setbacks will never train pain-free, and for many people, adaptive responses do not mean they will set new PRs. Some may even need to avoid the performance aspect of new PRs, especially at the top-end of strength. What progress looks like will be different for each person. Get back to training in whatever form is closest to “optimal” for you.
Get Rid of the Obvious Suspects
Squats do not cause knee pain all by themselves, but bad squats or squats overdone may. Assuming you are not engaged in high-rep, high-impact activities, the first and most obvious suspect for knee pain from squats is your form. If you are low bar squatting, there are two main issues you want to eliminate from the lineup of possible problems. The first is not bending over enough during the descent. The second is leading upward with your chest from the bottom of the squat.
Not bending over enough when during the low bar squat causes a lifter’s knees to shift forward near the bottom of the movement. When the knees shift forward, the bar moves forward. When the bar moves forward, the lifter’s weight shifts toward the toes. A coach, seeing someone who complains about knee pain, who is also trying to low bar squat with a vertical torso, will likely address that form issue before making other changes to the person’s lifts or programming.
Similarly, in the low bar squat, lifters will often forget to use their hips to stand up. “Lead up with your hips” is a cue to help someone stay balanced while extending both the hips and knees. The low bar squat requires you to be bent over more, and for longer, than you may be comfortable with. Instead of leading with the hips, some people lead with their chest up from the bottom of the squat. Their hips shift forward, their knees shift forward, and their weight shifts forward. Again, this may be an aggravating factor or cause of knee pain while squatting.
Absent some underlying condition, poor form is the most common source of squat-specific knee pain. If you find that your knees are mostly fine except when you squat, then start by addressing your form. Barbell Logic recently worked on a collaborative article with Art of Manliness called Troubleshooting the Low Bar Squat. This is a great place to start fixing your form to help you rule out the most usual suspects. You can also visit the Barbell Logic Technique Page for all things technique and to sign up for a free form check and consult with a BLOC coach. Fixing the issue yourself may be possible, but hands-on help is always useful to either fix or rule out form issues.
Observe and Report (Does It Go Away on Its Own)
This next step is critical if you or a coach have identified a form issue that is a likely cause of your knee pain. Unfortunately, pain does not always go away just because you shined a light on its root cause. It often takes time to get better.
Reduce the volume a little bit. Maintain intensity at fewer reps per set if you can. Don’t expect pain-free training, but don’t push through. These are all general guidelines that can help you implement a form change and give it time to either let the pain go away or hone-in on other possible causes. A good rule of thumb is that if the pain is about the same or a little bit better by the end of the warmups, you are okay to keep training. If it gets worse with the warmup, then back-off or switch your focus for the day. Again, this presumes you have some confidence that you found the root cause of your knee pain while squatting and have worked to fix it. If you are having pain and just keep doing the same thing over and over again, do not expect anything to get better.
Changes to Exercise Selection (Goal Is Stress as Close to What You Had Before as Possible)
There are two ways to change your exercise selection when it comes to squatting. First, if you are high bar squatting and experiencing knee pain, consider learning how to low bar squat instead. At the same weights, the low bar squat takes some of the moment force off of the knee, making it a little bit more “knee-friendly” movement. That is not to say high bar squats are bad for your knees, but if you compare a well-executed high bar squat with a well-executed low bar squat (from the same person), the low bar squat will show a more knees-back position at the bottom and a more bent over torso. The low bar squat puts more of the work on the bigger muscles that extend the hip, shifting some of that work from the knee extensors. (Read More: The Squat: Muscles Worked.) Patellar tendonitis or some form of knee pain that increases with mechanical loading of the knee may improve from the switch to low bar. Making this change, you should give it a little bit of time (observe and report) before deciding whether it “worked” for you.
The other way to change your exercise selection is to choose a supplemental lift that might take some of the mechanical loading off of your knee, either for the short- or long run. Two options for this are the box squat and the pin squat.
Box squats are a great longer-term option for dealing with squat-related knee pain. The box squat allows you to reach a bottom position with almost vertical shins. It is like a low bar squat but with even less knee involvement. Once you have eliminated form issues as the underlying cause, it may be worth giving box squats a try to see if they allow you to train sufficiently heavy and at a high enough volume to make progress.
Pin squats are also a good option to “go around” knee pain. Often this requires that you start the pins above parallel, making them better for a temporary solution. A good pin squat, however, can help you ease back into full squats as pain dissipates or your knee heals. Find a pin height above parallel that allows you to squat with minimal pain, just before the pain increases during the descent. Using multiple sets of two or three reps, gradually work the pins lower over the course of several weeks until you are pin squatting to full depth. Often, you will find that once you reach full depth, you can return to squatting without the pins and continue to make progress with full squats.
Changes To Programming: Systemic And Localized Stress
Think about programming changes in light of your existing status. If you have tried fixing your form, cutting back your volume and overall stress, and using supplemental lifts to help you go around the pain, then programming changes are likely those changes that are allowing you to live with the pain while you get other help or with the knowledge that pain is going to be a part of your training more often than not. Even after being diagnosed with a root cause for their knee pain, people are often left with a prognosis of pain management—not elimination. For lifters, pain management should be directed at allowing them to engage in physical activity, preventing long-term weakness and possibly worsening pain as they age.
Programming changes are meant to meet your pain halfway. The farther down this rabbit hole you’ve gotten, the more specific to you programming changes have to become. Our observations have been that the maintenance of top-end strength and the ability to train at weights heavy enough to make a difference tend to come from higher intensity training. But holding onto muscle mass and the types of stress that tend to help you make progress, in the long run, require enough volume to create systemic and localized stress.
Both volume and intensity are optimal for making progress. To try and manage your pain while training, you can maintain volume and intensity by training with (generally) fewer reps per set. Instead of three sets of five, use five sets of three, six sets of three, ten sets of two, and so on. Fewer reps per set tend to help lifters maintain excellent form and allow for less fatigue, which can exacerbate some types of pain.
Programming may need to become more complicated, with you using multiple variations of the squat during a single cycle. Box squats and pin squats can help you train different aspects of volume and intensity.
Think “progress, not progression.” The more complicated your pain, the less your goal will be to find what you can do and go from there. More often, you will look for what you can do to create sufficient stress to make progress. Once you find that zone, stay in it as long as possible, making small adjustments to gradually increase the overall systemic and localized muscular stress. Stick to keeping things as simple as possible, adding complexity to treat a known problem with your programming as it relates to pain.
Every roadblock to training only highlights the uniqueness of the individual. It would be nice if a blanket treatment could fix all our individual problems, but that is almost never the case with pain and barbell training—where information and experience do not always neatly align and where our selfish goals often take precedence over some temporary discomfort. Hopefully, we gave you some perspective on training and squatting with knee pain. For more information, see some of the other resources on our site or reach out to a BLOC coach. They’d love to hear from you.
Carlesso, Seal, Frey-law, Zhang, Na, Nevitt, Lewis, and Neogi, “Pain Susceptibility Phenotypes in Those Free of Knee Pain With or at Risk of Knee Osteoarthritis: The Multicenter of Osteoarthritis Study,” Arthritis & Rheumatology, vol. 71, No. 4 (April 2019)
Mitchell, J., “On the Means of Discovering the Distance, Magnitude, &c. of the Fixed Stars, in Consequence of the Diminution of the Velocity of their Light, in case Such a Diminution Should be Found to Take Place in any of Them, and Such Other Data Should be Procured from Observations, as Would be Farther Necessary for that Purpose,” Philosophical Transactions of the Royal Society, 74, 35-57 (1784)
Montgomery, Orchiston, Whittingham, “Mitchell, Laplace and the Origin of the Black Hole Concept” J. or Astro. Hist. & Heritage, 12(2), 90-96 (2009)
Sanchis-Alfonso, Vicente, “Pathophysiology of Anterior Knee Pain,” in: Zaffagnini S., Dejour D., Arendt E. (eds) Patellofemoral Pain, Instability, and Arthritis, Springer, Berlin, Heidelberg (2010)