The squat is an essential part of human movement, whether you do it in the gym or at home as an exercise or if you just do it as part of your daily house hold chores – the squat is a functional and necessary movement. As young children we have great ability to squat freely due to good flexibility in our joints and lack of pain at a young age. In other cultures around the world a squat position is a part of everyday life when using the toilet or in fact when trying to rest the body – when seats are not available you will commonly see people adapt a squat position.
As we age however, the squat can become difficult and sometimes painful for a number of factors. Having a good squat for function is important and if we don’t have a simple competence with this action then it can change the way we move and make us less functional.
In most gym routines these days – the squat is a staple movement and it is highly encouraged as a way to build strength in the quads, maintain healthy knees and also work other large muscle groups in the lower limbs – whilst also having a decompressive effect on the spine. It is not uncommon though that we may have difficulty with squatting due to pain that we experience in the knees and we then avoid the exercise or movement to stop us getting pain.
It is extremely important hat when we experience pain or discomfort that we do not avoid it and that we face it and address it. Low levels of pain aren’t typically a sign that there is damage but that tissues are sensitive and need some attention.
In this article we will look at the anatomy of the knee, causes of why our knees become painful while squatting and what we can do to correct this.
The knee’s anatomy when broken down is quite simple and gaining further understanding of this can help you to self-analyse the reasons why your knee is painful and what solutions are needed. If you know what each part of the knee is doing while you are squatting then this helps to give you the knowledge of the exercises and modifications you need and how it affects your body. When it comes to the body having knowledge is king for your health and performance!
A squat movement is quad dominant and it is facilitated by the hinge joint of the knee The elbow is also a hinge joint in the body which allows for movement in to flexion and extension and the knee also allows a small amount of rotation. During a squat you should never see the knee rotate – if you do, its bad news. There are also 2 other movements that the knee performs and one is called a valgus knee – this is when the knee is poorly controlled and it moves towards the centre of your body – if not properly corrected this can lead to serious injury if force is applied or repeated valgus stress can aggravate the knee over time. It’s best for the knee to operate in an up and down linear motion. The other movement the knee can perform is a varus movement and this is movement of the knee line towards the outside of the body – again this rarely happens with squatting.
The knee joint is made up of the femur which is the thigh bone and this sits on to the tibia which is the shin and then finally the knee cap sits in a small groove on the end of the femur and glides perfectly in this groove when the knee is happy as the flexes and extends. The knee is made up of 2 different joints out of those 3 bones – the tibio-femoral joint and the patello-femoral joint.
The end of the femur which forms the knee joint has 2 prominent heads called femoral condyles and they are coated in a smooth articular cartilage and the top of the tibia has 2 discs of cartilage tissue called meniscus which contact each other to provide the shock absorption which is so important for the knee. When squatting, especially when we add weight to the equation – in order for our knee to be pain free it needs to move smoothly and also to absorb the weight we are adding to it. This is where the soft tissue called cartilage comes in. Smooth surfaces of this firm, yet spongy material help with regulating knee pain and maintaining full movement of the knee through its full range. Cartilage has a decreasing blood supply as we age and it tends not to heal very well but the latest research shows that squat like movements and compression help to aid maintenance of healthy cartilage tissue by giving it the movement it requires and refreshment of the synovial fluid which sits in the knee.
Our knee must remain well lubricated and within the knee is a liquid called synovial fluid and this helps the knee to remain ‘well oiled’ just like a piece of mechanical machinery. As we age it is important to remain active and exercise as this helps to refresh the fluid within our knee and this makes for happy joints.
The main ligaments of the knee are the medial and lateral collateral ligaments which sit on the inner side and outer side of your knee respectively. The cruciate ligaments which help to connect the femur and tibia to each other – and they run through the middle of the knee. The only time as a runner you may be in danger of hurting ligaments is if you have a fall, twist your knee or suffer impact from a third party which takes the joint beyond its normal range. Typically your ligaments are nice and safe when you are running. Small ligaments along with your quadriceps muscle help to secure your knee cap.
During squatting the main tendons that are placed under the most load are the 2 tendons above the knee and below. The quad tendon and the patella tendon help to absorb load as we lower along with the hamstring tendons – then when we get ready for the concentric phase tey generate force and power which allow us to send this to the knee muscles to propel us up and achieve a standing posture!
During the introduction we talked about the squat being a quadriceps dominant movement – there is assistance from the hamstrings and glutes but the most activity occurs in the quad muscles. This is the reason that if someone who squats with weight consistently will develop well defined legs with lots of strength.
Causes / Symptoms
Muscle Imbalance & Weakness
The squat is a quad dominant exercise which means the muscles on the front of your thighs take most of the workload and the rest if shared by the other muscle groups in the lower limbs. If you are weak in your quads then this places a lot of excess load on the knee joint – instead of the muscles doing the work – the bone and cartilage takes too much – leading to pain. Muscle imbalance is a major factor – if we are weak in the hamstrings and the glutes then this does not support an equal and balanced squat movement and again we may become more dominant in other areas leading to excess loading and development of pain.
Joint & Soft Tissue Irritation
As mentioned previously – if we already have an aggravated knee joint then bearing load with a squat is going to be uncomfortable. Other injuries around the knee’s anatomy can make a squat painful such as ligament injuries to the medial and lateral knee and more commonly patella tendon issues elicit pain when performing squat as when coming back up and straightening the knee this causes discomfort. A squat is good for this type of issue but it must be done at the right amount and with the right weight – a physiotherapist can help you if you have this type of problem.
Poor Joint ROM
Reduced ankle dorsiflexion (movement of the foot upwards) is a cause of poor squatting – if we do not have range in the ankle it does not allow us to lower sufficiently in to an accepted squat form. Reduced range of motion in the hips and the knees can also majorly limit the squat and put strain on the knees to cause pain. The aim will be for all joints to share the load equally and for the knee to not become too overloaded.
Poor Form / Technique
Knowing how to squat is half of the battle – although it should be a natural movement there are a lot of reasons with different people in why they cannot squat properly. You may find that if people have poor control of their technique and allow their knees to stray inside (valgus position) this puts excess shear on the knee and can cause pain to develop. The knee mainly works through its centre line and works effectively there – if it is placed under too much stress in the wrong places especially in the medial knee then it could cause symptoms to develop.
Fixes / Exercises
So how do we fix the above issues..? Easily. There is a simple logical answer for all of these problems which we can now explain.
A squat is a compound movement involving large muscle groups – even if you squat bodyweight, you are asking your body to bear a lot of weight. Now as we discussed earlier in the article – if some of your muscle groups like the quads, hamstrings or glutes are particularly weak, then this could cause issue with knee pain when squatting. A good solution to this is accessory training – which simply means to focus and isolate each muscle group. If you know which muscles are weak then focusing on them would be a good start to make them more capable of the squatting task. If your hamstrings are weak focus on some hamstring curls on a machine, if your glutes are weak, perform hip thrusters and if your quads are weak get on a knee extension machine – give it 6 weeks and see how your strength changes – compare your squat at the start and the beginning to see how your knees feel.
Joint and soft tissue irritation obviously needs to settle before squatting – if you know what is causing it and know how to fix it then great. If you don’t – see a health professional, gain a diagnosis, get treatment and a plan for your rehab so you can put a safe timescale on when you can return to squatting. Remember – if you have some aggravated tissues – continuing to overload it with weight may make the problem worse or keep it there longer than is necessary – listen to your body.
Poor joint range of movement has 2 different ways to fix this issue – if your hips, knees or ankles are especially immobile then look at some mobility exercises and stretches that you can add to your regime to improve your body’s function and this will improve your overall range of motion if restricted and reduce any extra pressure on the knees. If it is simply your ankles which are restricted as this is the common issue with squatting then the fix is easy. Put 2.5kg plates on the floor which go underneath heel and this promotes the amount of movement in the ankle allowing your knees to come forward for you to gain a full range with your squat – this is a simple, quick fix and allows greater performance of the squat as you achieve full range.
Poor form and technique can be corrected – again there are plenty of options for this. Starting with a simple recording of your own technique to look and analyse. There are multiple videos on YouTube and education sources online which can teach you how to squat correctly. There are apps available which can analyse your positioning and give you pointers. If you are still not sure then it may be worth hiring a personal trainer who can walk you through this and give you live correction and pointers. The basics of the squat would be to have your feet about hip width apart, keep your back straight, and slowly drop down until you reach your limit then return up at your own pace.
In summary, if you get knee pain while squatting then it shouldn’t be too much of a deal as there’s plenty of ways to deal with it. Ensure you prepare your body for exercise by ensuring your body is fit enough to squat by looking at your range of motion, each muscle group’s strength. Ensure you aren’t injured prior to starting and also educate yourself on proper technique and ways to squat properly to keep your knees happy.