Is There Such a Thing As “Knee Friendly” Squats?

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Not long ago I filmed a vlog about the difference between box squats and squats TO a box.  While to the casual fitness enthusiast there may be no differentiation between the two variations (a squat’s a squat, right?), these are probably the same people who feel PCs are the same thing as Macs.

That’s just crazy talk.

Crazy I tell you!!!!!

I’m not going to beat a dead horse and go into the details here (you can just click on the link above to found out the difference between the two), but I will say that my fellow partner in all things awesome, Nia Shanks, wrote a similar blog (with video) HERE which expounds on the benefits of squats TO a box.

Anyhoo, a day or two after her post went live, she received a question from one of her readers:

“Any suggestions for squat variations for people with hip flexor issues? (Tendonitis)?”

Her response (what she actually wrote):

“Good question. I’m going to pass this on to one of my friends that could provide a better answer. I’ll post his response here.”

Her response (with what I would have added if I were her):

“Good question. I’m going to pass this on to one of my friends that could provide a better answer. I’ll post his response here.

Not that this matters, but he’s incredibly intelligent, good looking, and possibly more manly than a lumberjack.”

All kidding aside (although I’m not really kidding), Nia reached out to me and asked if I had any feedback. Below is what I wrote back to her last nightl, which I decided to make into a blog post because, well, I can.

NOTE:  I was watching the RedSox game as I was typing it, so please forgive the ADD nature of the post.

Goddamit Youkils, you have to swing at that pitch!!!!!

1. Know the difference between tendonitis and tendonosis.

The former is generally accompanied with slight joint inflammation and typically goes away after a few days of rest, ice, and NSAIDS.

The latter, though, refers to more of a chronic condition where the joint itself has seen some (or maybe significant) degeneration.  Basically, it’s something that doesn’t go away after a few days.

That being said, when someone complains of tendonitis, and it’s been an on-going issue, it’s probably really tendonosis.

…..and some of the following may help take some of the burden off the joint itself.

 

2. Take a grenade approach with soft tissue work.

Foam roll EVERY…….SINGLE…….DAY.  Not once a week, not only on the days that you train, but every day!

It stands to reason that if one’s knees are bothering them all the time, they have less than optimal tissue quality and it’s something that needs to be addressed.  Foam rolling is one of the best ways to do so.

Healthy tissue shouldn’t hurt when you palpate it, and if it does, that’s a tall tale sign that something’s up.

Hammering areas such as the hip flexors themselves (Rectus femoris, and TFL), as well as the adductors, ITB, and glutes will undoubtedly help and often alleviate much of the symptoms.

I also like to be a bit more “specific” and target both the vastus medialis and vastus lateralis with a tennis or lacrosse ball.  Both are major trigger points for knee pain, and are an often overlooked area most people ignore – along with the glute medius for that matter.

People will ignore the areas that often cause the most discomfort, but those are the areas that SHOULD be targeted.

Better yet, seek out a reputable manual therapist who will get hers or his hands on you.  Nothing bothers me more than PTs who do nothing but band exercises, electrical stim and then ultra sound.

Sure they all have a time and place, but finding a therapist who provides Graston, ART, or whatever will be a definite advantage.

 3.  Preach to yourself vertical shin angle.

“Stacked’ joints are happy joints (as Mike Robertson would say).  More often than not, it’s not squatting that bothers people’s knees, but rather, what they’re doing that bothers their knees.

I can’t take credit for the vertical shin angle cue – that goes to Charlie Weingroff – but it’s something that works wonders for people with knee pain.

Many trainees make the mistake of breaking with their knees when squatting and end up with significant forward translation of the tibia.  This induces a lot more shear loading on the joint, which as you can imagine, is going to piss it off.

Instead, I like to cue the following: Make sure to SIT BACK and PUSH THE KNEES OUT.

This does two things:  maintains a more upright torso and ensures there’s proper task distribution.

The initial decent should be with the hips sitting back.  Doing so will not only place more emphasis on the glutes and hamstrings (hips!), but also ensure more of a vertical shin angle, which is going to be MUCH more knee friendly.

I guess, in a way, this is just a long-winded way of saying that the reason most people’s knees hurt when they squat is because of technique that makes my eyes bleed.

4.  Hammer hip stability.

The knees are at the mercy of the hips (and ankles).  Most trainees have piss poor hip stability and are unable to control the femur properly, which is something that Mike Robertson touches on his is Bulletproof Knees Manual.

Taking a step back and implementing some simple drills like side lying clams, x-band walks, etc would bode well.

Yes, they’re girly and seemingly worthless, but you’d be surprised at how hard side lying clams are when done correctly. We use them quite a bit in our programming at Cressey Performance, and it’s always interesting when a dude who can squat 400+ lbs has a hard time performing clams.

Taking it a step further, I’d also make a concerted effort to include more single leg work into the mix as that will automatically force one to work on their hip stability.  When in single leg stance, we’re forced to utilize what’s known as the lateral sub-system to keep the pelvis steady.

For those unaware what the lateral sub-system entails:  it’s the glute medius and adductor complex on standing leg, along with the quadratus lumborom on the opposite leg.

One point to consider, however, is the type of single leg work you’re doing.  For those with knee issues, variations like forward lunges or walking lunges are going to be problematic due to the deceleration factor.

Ie: You have to decelerate your bodyweight in order to perform the movement.

Reverse lunges will  inherently be more “knee friendly” due to the more “accelerative” nature of the movement.

Along those same lines, don’t be a hero and be too aggressive with loading when it comes to single leg work. Most trainees use waaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaay too much weight, and as a result, end up using less than exemplary technique (which defeats the purpose in the first place).

5. Booty, Booty, Booty, Booty Rockin Everywhere

As a corollary to the above, placing a premium on more glute work isn’t a bad idea either. The glutes have a VERY strong influence with regards to control of the femur.

Think of what happens when the glutes aren’t doing their job.

– You see more of an anterior pelvic tilt.

– APT results in more internal rotation of the femur.

– IR of the femur also results in in internal rotation of the tibia (and pronation of the feet).

– Your knee hates you.

Once we got those puppies firing and doing their job, we see the opposite happen:

– We see more posterior pelvic tilt of the pelvis.

– In addition, because they control the femur, we see more external rotation of the femur

– Which, of course, leads to more external rotation of the tibia (and more supination of the feet).

– Now girls will want to hang out with you.

To that end, whether you keep it simple and perform more supine or 1-legged glute bridges, or start upping the ante and perform things like deadlifts, pull-throughs, glute ham raises, KB swings, sled pushes, or grizzly wrestling………

…..the name of the game is GLUTES!!!!!!

6. We can’t neglect the core either.

More specifically, we can’t neglect the anterior core.

Even more specifically, we can’t neglect the external obliques.

Much like the above, lack of core strength and stability (especially as it relates to the obliques) will cause someone to go into more of an anterior pelvic tilt.

Utilizing movements like various chops and lifts would be of great benefit.

As would some dedicated rectus abdominus work – GASP!!!!!!!!!

7.  And what the hell, when all else fails, just deadlift

Deadlifts = less hip and knee flexion, which are going to be far more knee friendly than squats. What’s more, if you really wanted to get some more quad work into the mix, you could always revert to trap bar deadlifts which are more of a quad dominant hip dominant variation anyways.

But at the end of the day, I feel that squats TO a box will definitely be a step in the right direction as far as helping those with knee pain.  For starters, the box will allow one to squat in a pain free ROM – whatever the height may be. But even more importantly, it will help re-groove the proper squat pattern which most people suck at anyways.

Then, at some point, one can work on getting to full depth (which can be argued are more knee friendly as well).  But lets not get too off track here, because that can be another blog post in of itself.

Now, this doesn’t mean that all the other stuff discussed above is any less important. Far from it.

But I do feel that when it comes to technique, most fail miserably.  Watch both the videos that both myself and Nia provide above, and you should be golden.

Hope that sheds some light on a pretty extensive topic.

 

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Comments for This Entry

  • Niel

    I believe I had a minor case of tendonitis a few weeks ago. I did a lot of icing, temporarily skipped the knee-dominant lifts, and worked the glutes, hamstrings, and core much more (correcting APT). Doing good now!

    June 13, 2012 at 3:20 pm | Reply to this comment

  • Gordon Wayne Watts

    Did u skip a few numbers just to see if we were paying attention. :D

    June 13, 2012 at 5:22 pm | Reply to this comment

  • guest

    Hate on PT's giving band exercises then follow it up with two examples of band exercises?

    June 13, 2012 at 8:23 pm | Reply to this comment

    • TonyGentilcore

      Well, since you failed to leave your name, I assume you're a PT whom I called out.  Sorry about that.  I guess the truth hurts, huh?  And, while I did say that I'm not a fan of PTs who do nothing but regurgitate band exercises to their clients, I should say that there are plenty of those that I do like that have their time and place.   I mean, it's not like I ALSO stressed improving movement patterns, strengthening the glutes and core, and several other things. Sorry your feelings were hurt "Guest"

      June 13, 2012 at 8:54 pm | Reply to this comment

      • TYLER

        Actually I'm just a PT student so i don't know much yet.  I have to agree though if PT's merely give general exercises and ultrasound that they are pretty much being useless.  However, I do feel like most PT's are moving away from using useless modalities for patients and more towards manual therapy (although there isn't a ton of evidence on this yet, either, and a lot of the techniques such as ART and MFR are very cultlike and expensive).  Although a lot of patients who are in PT because of pain have awful movement patterns and recruitment of important muscles, in which case they do need focused strengthening exercises...and bands are the easiest thing to give to these patients to use at home...even though not ideal. Love, Tyler

        June 13, 2012 at 8:59 pm | Reply to this comment

        • TonyGentilcore

          Hey Tyler - Thanks for chiming in, and I think you and I are both on the same page. I could have worded what I said differently, and I DO recognize the importance of band work. I just find it frustrating when "some" PTs do nothing as far as manual therapy, let alone actually show their clients how to do things correctly. I can't tell you how many times we've had players come into the facility with shoulder pain, and have seen various PTs, and can't even perform a side lying ER correctly. And then they wonder why they're not getting better Simple stuff like that is uncalled for. Thankfully we have more students like yourself who are recognizing the importance of using a variety of modalities to get the job done. I mean, lifting heavy stuff CAN be corrective. And, of course, band work DOES come into play as well. Again, I didn't mean to come across like a pompous a-hole.....;o) Tony

          June 14, 2012 at 7:20 am | Reply to this comment

  • James

    Really nice post! I remember getting what was probably tendonosis 3-4 years ago from doing insane amounts of plyometrics. The solution then was loads of myofascial release, back squatting for the first time through the knee pain and doing glute ham raises. Some how it worked. Anyway I have a question....With the vertical shin angle reducing shear forces on the knees, doesn't that mean there's more force translated to the hip joint instead?

    June 14, 2012 at 6:43 am | Reply to this comment

  • Tyler

    Agreed 100%. Obviously since I'm an avid reader of your blog and CSCS myself I wish we could incorporate more heavy lifts into rehab. Idk if PT are afraid or what but a lot just give out 3x10 of random stuff. My comment was dickish and I apologize. PT needs to move more towards movement assessment and away from throwing crap and hoping it sticks. Gray and Weingroff etc among others are good examples of what we need. Most classes for ther ex arent complete and like you said a lot of theraband. Thanks Tony

    June 14, 2012 at 9:04 am | Reply to this comment

  • Stevo Reed

     A most excellent post Tony. "Great stuff" is all I really have to say at the moment.

    June 14, 2012 at 10:59 am | Reply to this comment

  • studtotal

    great stuff about knee health, but how does this answer the question about hip flexors?  "Any suggestions for squat variations for people with hip flexor issues? (Tendonitis)?"

    June 14, 2012 at 12:12 pm | Reply to this comment

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    June 17, 2012 at 10:37 am | Reply to this comment

  • Troy Adashun

    Great Post- I was a basketball player until the age of 22 in highschool and college and dealt with lots of aches and pains in my knees. The Foam Roller was a great help for my knees and recovering from intense training sessions. 

    June 17, 2012 at 5:32 pm | Reply to this comment

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  • Hilcox

    In tip #3 you mention that one benefit of sitting back is a more upright torso. Can you elaborate on how sitting back results in a more upright torso?  Seems that in order not to topple over backwards the torso would need to bend forward even more.   Which is why powerlifters keep a vertical shin and perform more of a "squat morning", while Oly lifters shin translates forwards, while their spine stays more vertical. Maybe I misunderstood?

    June 18, 2012 at 11:37 pm | Reply to this comment

    • TonyGentilcore

      This isn't to say that there won't be ANY forward lean - there is! Absolutely. What I mean is that most people initiate the squatting pattern by breaking with their knees going forward, which places more stress on the knees. I didn't mean to say that sitting back along causes more of an upright torso, but that sitting back AND pushing the knees out allows for a more upright torso. Stacked joints are happy joints (as Mike Robertson would say).

      June 19, 2012 at 8:07 am | Reply to this comment

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    September 12, 2013 at 9:52 pm | Reply to this comment

  • Daniel Dinesh Karunairatnam

    So I've been getting knee pain when squatting. Doc said it was tracking issue and to keep toes pointed forward. Been on and off. Recently came back really bad; not even sure what I'm doing differently. Doing some ankle mobility work, stretch hips flexors, hammies, foam roll quads and ITB, but still sore squatting even as little as 40kg. It only hurts when I'm squatting. Normal walking/climbing stairs its fine. Just occasionally gets sore/uncomfortable. Doc says its not a knee-based issue, but overloading is causing bone to rub against bone and cause pain. But if squatting 40kg causes it I can't really squat at all? Even after a week off, still sore when trying to squat. Any ideas?

    September 20, 2013 at 7:51 am | Reply to this comment

    • TonyGentilcore

      Granted I'm just making an internet assumption here. but more often than not it comes down to this: technique! This isn't to say that you may not have any orthopedic issues to deal with, but in my experience, it's generally shitty technique that's the culprit. As Dan John notes: "it's not squats that are hurting your knees, it's whatever it is you're doing that's hurting your knees."

      September 20, 2013 at 11:08 am | Reply to this comment

      • Daniel Dinesh Karunairatnam

        Well I stopped after a set yesterday cause it hurt. Tried again today. Here is my body squatting and squatting with 40kg. Tried pushing my knees out more and ended up pointing toes out almost 45 degrees but it didn't hurt as much. Any insight would be appreciated:) http://youtu.be/6a9mEBkU21k http://youtu.be/U4VboBkKG5Y

        September 21, 2013 at 7:55 am | Reply to this comment

      • Daniel Dinesh Karunairatnam

        and yeah, I lean forward a lot. Any suggestions to improve that would be awesome too :)

        September 21, 2013 at 7:57 am | Reply to this comment

  • Ronald

    what worked for me for shoulder, back, knee, hip issues was simply focusing on posterior training FIRST every workout. Also modifications like mentioned above. I switched to front squats and trap bar deadlifts and added some glute warmups and occasional regular romanian deadlift. but i do some varation of an rdl before ANY leg exercise. i also get knee pain with trap bar unless i do RDL's prior. light cardio on off days helps a lot too and this is really the formula. for upper back before shoulders and chest to avoid the shoulders being dragged forward. great article!

    June 19, 2019 at 1:00 pm | Reply to this comment

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