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.