Do you experience knee pain with squatting? If so, how can you modify the motion to reduce pain?
Squatting is a fundamental task that is performed daily for exercise, lifting, and sit-to-stand transfers. There are common faults that people utilize when squatting that can increase the stress placed on the knees and can be easily adjusted to reduce pain and improve mobility, function, and proper muscle activation with squatting.
It is important to understand how and why certain positions create or increase knee pain with squatting and how to make proper adjustments to minimize pain and abnormal forces being placed on the knees with this motion.
Common Errors with Squatting & Modifications to Reduce Pain and Improve Proper Loading
Common Error: When squatting, if you begin the motion by bending at the knees first, the body weight is shifted forward which will increase the load that is in front of the center of gravity and therefore increases compressive and shearing forces on the knee.
Modification: When squatting, we want to maintain a balanced load of weight that is forward and behind the center of gravity. To improve posterior chain loading and reduce stress on the knees, you should start the motion by sitting the hips backward and keeping the weight in the midfoot or heels. This will also ensure improved efficiency and muscle function during squatting.
KNEES DIVING-IN (KNEE VALGUS)
Common Error: When the knees dive in towards each other, there is increased stress placed on the inside of the knees from the weight distribution at the feet shifting to the middle of the foot.
Modification: When squatting, we want to keep the weight distribution in the middle of the foot (and slightly to the inside) and not let it shift too far to the inside or outside of the foot. This will allow for better tracking of the knees and therefore reduce pain.
Inability to control or maintain proper knee alignment may be the result of hip weakness or foot instability.
Weakness in the hips, specifically the Gluteus Medius, may be the cause of poor knee alignment with squatting. Weakness of this muscle will result in the knees driving towards each other, which places increased stress on the medial side (inner side) of the knee.
The arch of the foot and the rearfoot may have increased motion causing it to collapse too much, which will limit stability with squatting and cause the knees to dive in towards each other.
EXCESSIVE FORWARD TRUNK LEAN
Common Error: This position will also create an unbalanced load when looking at how much body weight is in front of and behind the center of gravity. As more weight is shifted in front of the center of gravity, more stress will be placed on the knee joints as seen with a knee-driven squat. Also, when the trunk travels more toward a horizontal position, increased stress will be placed on the low back due to being in a more gravity-dependent position.
Modification: If we keep the trunk more upright, we can maintain a more balanced squat over our center of gravity, which will reduce excessive stress on the knees. The inability to maintain proper trunk alignment can be the result of weakness through the posterior chain (back extensors and glutes).
If you experience knee pain with squatting, try modifying your mechanics by adjusting your positioning to the corrections seen in the photos above or follow the instructions listed below:
Begin the motion by sitting the hips backward first, and then bending the knees to get deeper into the squat. The foot should remain flat on the ground and the weight should be in the heels or midfoot (arch), and should not shift towards the forefoot or toes. This is easily replicated by utilizing a chair as a target. Take 1-2 steps forward from the chair, begin by sitting your hips backward, and then lower your hips to the chair.
If your trunk begins to fall forward too much, you can reach your hands out in front of you or overhead to keep the chest upright and therefore reduce stress on the knees.
If your knees are diving in towards each other, work on keeping them in line with the toes and focus on keeping them pulled apart
If you continue to experience knee pain with squatting or want to improve depth or mobility, give us a call and speak with a physical therapist, or come into one of our eight Rehab United locations throughout San Diego for a thorough evaluation of mobility, strength, and stability.
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Chelsea Sanscartier PT, DPT, is a physical therapist working at the La Mesa Rehab United Clinic. She graduated with her Doctorate of Physical Therapy from San Diego State University in 2018 and has been focusing on challenging her knowledge of Applied Functional Science to work with an outpatient orthopedic population for pain management.