What should we do when getting knee pain while squatting?
We should modify our activity in a way that allows us to keep training and reduce the amount of pain as much as possible. We can do this by adjusting workout variables such as intensity, volume, and tempo. In addition, implementing certain assistance exercises or modalities can help us achieve continued activity without pain.
Knee pain while squatting sucks, but there are several factors that can influence how you manage the pain and how to prevent any further pain in the future.
Disclaimer: This article is not intended to diagnose or treat your specific injury. Instead it is intended to give you some valuable information that may help you. Seek a medical professional if you are dealing with any sort of injury.
Why Do We Get Knee Pain When Squatting?
Pain is a mysterious thing. There is a lot that we still don’t yet understand.
A person can have no physical damage to their knees, yet experience pain. Whereas a person can have physical damage but experience no pain.
This is not to say there is no relationship, but that the relationship is not the end all be all. This is because the relationship between pain and physical injury is not causal. Pain is an experience and is different for everyone, so it is important to keep in mind that “x” may not necessarily lead to “y”.
Understanding the biopsychosocial model of pain
There are many factors at play that could be causing your knee pain, and using the biopsychosocial model is one way to dissect why your knee is causing you pain.
- From a biological perspective, the most obvious is having some type of physical trauma as tearing your ACL (Anterior Cruciate Ligament), which is a ligament that prevents anterior displacement of your patella. Furthermore, something mechanical can be causing your pain such as issues with knee tracking, patellar tendonitis, or perhaps you may even have an “impinged nerve” in your lumbar spine resulting in a radiculopathy causing referred pain in your knee.
- From a psychological perspective, your own beliefs and perceptions of pain could be affecting your pain experience. For example, if you associate that you “hurt” yourself squatting, you believe that squatting will cause you more pain when you do so.
- From a social perspective, your environmental factors can be causing you stress. For example, perhaps you got a new job that entails more physical exertion or your family is going through some trauma. This can all affect your pain experience and what you feel when squatting.
The point is, pain is multifactorial and subjective, so focusing solely on pain is a slippery slope. Furthermore, where you feel your pain may not be where the problem is like the example with lumbar radiculopathy (referred pain from the lower back).
I can’t tell you why exactly your knee hurts when squatting, but that doesn’t mean you can’t do anything about it. Regardless of what it is, management can be very similar when it comes to powerlifters and squatting.
What To Do When Experiencing Knee Pain When Squatting?
Based on the biopsychosocial model of pain, there are several ways that you can modify your training program, technique, and environment, in order to reduce the amount of pain you’re experiencing. Once we can rule out that the pain isn’t caused by a fracture or tumor, then the goal is to get back to squatting in a “pain-free” way as quickly as possible.
Physical Modification When Experiencing Pain
Physical modifications include:
- Modifying your training load
- Modifying your exercise selection
- Modifying your lifting technique
1. Modifying your training load
Quite often powerlifters get pain while preparing for a competition. This is when the training load is at its peak levels.
You could be experiencing knee pain during this time because the load has exceeded your adaptability. In other words, your ability to recover and adapt to the training stimulus.
If we think of the pain this way, then we should find ways to reduce the load. For example, if you start having knee pain at 100kg, try 90kg, or 80kg. If that is no good, then try adjust the sets and reps. If you are still having knee pain, then adjust the tempo, such as doing a 3 second eccentric and a 3 second concentric.
You can see here that there is a systematic way of modulating your load to see if you can avoid knee pain when squatting. As you can imagine, this works very well for people that only have knee pain at certain loads.
If you still have pain regardless of the load, then you should start looking at modifying the exercise selection.
2. Modifying your exercise selection
When making modifications to your exercise selection, this could be small or large.
A small modification could be adjusting the stance or bar placement of the squat. Larger modifications would include switching out the competition back squat with other types of squatting variations, such as front squats, or other lower body movements, such as lunges, Bulgarian split squats, or leg press.
There is likely something you can do without pain, and that is something you can work to build on while letting your body recover.
Pain normally resolves itself in most cases, but as powerlifters or serious trainees, we don’t have time to just sit around (which could even be more detrimental). Plus, we want to maintain our strength and come back stronger.
3. Modifying your lifting technique
If we want to look at technique modifications to our squat to get rid of knee pain, we can focus on three main areas: hips, feet, and core.
- What we do at the hip
When we think about the knee, we have a bunch of muscles attaching around it from the hip down. This includes our quads, hamstrings, adductors, and glutes via the IT band. Working on certain aspects of the hip can help with knee pain.
Learn more about the muscles used in squatting HERE.
For example, if you have pain whenever you utilize the quads via knee extension, then working on the hamstrings with knee flexion could help offset the pain.
If your pain is due to your patella tracking laterally from a tight IT band, then you’ll want to strengthen the muscles on the medial side of your patella such as your adductor muscles and vastus medialis (VMO). Slow eccentric squats have been shown to increase VMO activation and you could use a Copenhagen plank for the adductors.
Furthermore, we’ve all heard that our glutes are not activating, especially when our knees cave while squatting. While this is not always necessary, in some cases strengthening the gluteal muscles can help with your knee pain. Some of my go-to exercises are:
- What we do at the foot
How we load our foot can influence our patellar tracking which may be causing our pain. We can learn and focus on how to apply what is called a short foot.
Short foot is a form of loading your foot to properly disperse the forces throughout your foot, placing the load over your first and 5th metatarsal and the base of your heel.
For starters, try squatting barefoot, while keeping your big toe glued to the ground and see if that helps with your knee pain.
A common thing we like to blame for our knee pain is also a lack of ankle dorsiflexion. Essentially, a restriction at the ankle joint that prevents full range of motion when you squat. You can try squatting with plates on your heels to see if that helps at all.
- What we do with our core
Technical modifications can go beyond the hip and the foot, and include bracing mechanics for the core and lower back.
If your knee pain is actually referred nerve pain caused by lumbar spine instability, then performing core stabilization exercises and employing proper bracing techniques could help in that regard.
Key takeaways when modifying technique
You will run into a lot of trial and error as to what will work, but the point of all these modifications is to modify your mechanics to a point where you can squat without pain and build your load tolerance from there.
These types of technical modifications work very well for people that have knee pain associated with a certain movement. There is no inherently wrong way of doing things, but if it is causing you pain then there is certainly a better way of doing things for your case.
Technical modifications are not a one size fit all model, and there are no magical exercises to fix your knee pain even though it may seem that way. Similarly, just because something helps, does not mean that you have a certain diagnosis. Context is key, and trained professionals are available to help you.
Social & Psychological Modification When Experiencing Pain
We briefly talked about some social and psychological factors that could influence knee pain so it would be beneficial to implement strategies to work on your own coping skills and stress.
First off would be to reframe your mindset around pain, and focus on what you can do versus what you cannot do. Pain itself does not have to be a negative thing and can actually be a very normal and natural feeling (ie. childbirth). Just because you have some aches and pains does not mean you are “injured” and unable to do anything.
For example, in my own experience, when I discussed with clinicians about my own injuries, I realized the plethora of activities that I can still do despite having pain that prevents me from squatting or deadlifting. Instead of going to the gym thinking that I can’t squat, I instead focus on the things I can do, such as leg press, upper body or even engaging in other activities like rock climbing.
In addition, make sure you are getting enough sleep, and nutrition. In terms of stress, utilize coping strategies, such as talking with people and seeking help if you need it. It’s very easy to focus on our pain and to let that feeling leak out and affect other parts of our lives. Just because we can’t squat, shouldn’t mean that we can’t enjoy other aspects of our lives. It doesn’t mean to forget or ignore your pain, but to embrace it and move forward.
Now a quick note is that this does not mean the pain is all in your head and that you should just “think it away”. Many things can influence pain, and using a whole encompassing strategy is the best solution when it comes to management. After all, there’s no hard and fast rule that your pain has to come from one specific thing.
Prevention: Avoiding Knee Pain When Squatting
So what can we do now to hopefully prevent knee pain and keep squatting in the future?
At the end of the day, the best thing we can do as powerlifters is load management. Keep in mind, however, that even if we track everything “properly” that pain can still occur.
For a powerlifter who wants to squat, load management primarily comes from their own programming. Let’s take a look at some things you can do.
Progress your load in a smart manner
- Try not to max out every day, and make appropriate meaningful jumps in weight
- Have a system in place, and use tools such as RPE to gauge when to push and pullback in training
Manage your fatigue
- Use strategies such as by de-loading and again RPE to manage fatigue
- Try to get enough sleep and proper nutrition
Bulletproof your technique
- Always try to be better. You can always improve on something, and just because it’s good now doesn’t mean it’s guaranteed to stay that way.
- Focus on quality over quantity, good reps
Implement varied exercise selection
- Try to do more than just squat, bench, and deadlift, when you can afford to. It’ll likely do you some good to take some time away from training and focus on other areas of your life. You’ll come out stronger in the end.
Know that all the therapeutic modalities in the world are tools to help you achieve this, and are not fixes or magical techniques to prevent and eliminate pain.
Rehab is not a straight linear line, it can be all over the place. Everything is a tool that can be used to help you get better, they are not quick fixes. Things will take time, they will take work, and they will take discipline. Sometimes miracles seem to happen, but that is the hard truth. It can be a grueling journey, but you are not alone.
Sample Plan For When You Have Knee Pain While Squatting
So what if you have knee pain now, what if you encounter knee pain in the future?
Here’s a sample step by step approach on what you can do when you have knee pain squatting to get back to squatting.
This is just an example. I recommend seeing a professional to rule out anything serious and to diagnose your exact situation.
Step 1 – Reduce the weight
Reduce the weight of the exercises causes you pain.
Step 2 – Modify sets and reps
Adjust the number of sets and reps you do with the exercises that cause you pain. Reducing the number of reps will help you avoid fatigue.
Step 3 – Modify exercise tempo
See if modifying the exercise tempo (slowing it down) has an impact on your levels of pain.
Step 4 – Utilize assistance exercises/technical modifications
Implement some of the technical modifications discussed above, such as glute activation or short foot.
Step 5 – Utilize therapeutic modalities
Implement some passive and active therapies such as foam rolling, stretching, and seem health care professionals for massage or manual manipulations.
Step 6 – Modify squat position
Step 7 – Analyse exercise selection
Analyze what exercises give you pain and implement exercises that allow you to move pain-free. these could be exercises like Bulgarian split squats or leg press.
Step 8 – You’re lying go back to 7 and find something to do!
There is definitely something you can do in the gym that doesn’t cause pain. Go find what those exercises are and focus on improving in those areas.
Examples of Powerlifters With Knee Pain While Squatting
Here are some different scenarios of when powerlifters can experience knee pain and what to do in those specific cases. As you can see, there is no one-size-fits-all model when understanding the root cause of the pain and the path to recovery.
Lifter A: Knee pain is getting worse & reducing load doesn’t help
Lifter A has been having knee pain when squatting. It started a couple of weeks ago at 75% of their 1 rep max, and has continued to get worse. Today, he experiences knee pain every now and then when squatting, regardless of the load on the bar.
In this case, reducing the load has no effect on his symptoms, so now he can try changing the tempo. Tempo helped a little bit, but is still painful. Moving on to technical modifications, he tried to implement short foot which eliminated his knee pain in a bodyweight squat, but the squat with a bar on his back still hurts. He found that a front-loaded goblet squat with 15 pounds does not hurt.
Over time, Lifter A worked on short foot mechanics with a tempo using a goblet squat, slowly increasing the weight until he was able to squat pain-free with the barbell. Then he slowly added more weight onto his back squat. Some days were painful, and he reduced the weight, other days he felt great.
This is an example of a lifter using the step by step process. He tried to manage the load but failed, and ended up using some technical modifications in addition to different exercise selection to guide his rehab and get back to squatting. Not only did he modify his activity, but he took his time to build up his load tolerance.
Lifter B: Experiencing knee pain preparing for a powerlifting competition
Lifter B is prepping for a competition and started having knee pain 3 weeks out. He found massage to be helpful. Lifter B refuses to reduce the load as he is in season, but found therapeutic modalities and some assistance exercises such as eccentric leg extensions to help him with his pain. After his competition, he took time off, and his pain went away.
So in this case, Lifter B was in season and could not afford to reduce the load. Instead he used a therapeutic modality and an assistance exercise to help manage his pain while still training. After his competition, he was able to take time away from heavy loads and the pain dissipated. At this point, it is uncertain why he was experiencing pain. However, he can still work on load management and some technical modifications to improve his performance and hopefully help with preventing pain in the future.
Lifter C: Getting knee pain in every day life
Lifter C has bilateral knee pain when squatting. Walking up the stairs is difficult, and he has recently started having back pain as well. He reports trouble sleeping and going to the bathroom.
In this case, lifter C should go see their doctor immediately to screen for any red flags such as cancer or any sort of trauma. Sometimes things can be very serious so it is important to be conscious of and seek the appropriate care. Now I’m not saying this to scare anyone, but the point is people should be aware that not everything is “fixed” by “glute med activation”, a quick adjustment or reading an article.
Whatever the case may be, there is always something you can do. Try it out, and if it’s not achieving the effects you expect it to, then go back to the drawing board and try something else.
You can imagine that if a program is not yielding you any progress over a long period of time, you wouldn’t keep running it to the ground, you’d try something else. This is extremely difficult to do yourself, as it is hard/impossible to be objective about our own injuries and progress, but the good news is that there are people out there who are trained to help you.
Seeking a Professional – Choose The Therapist, Not The Therapy
Say you want to see a professional for your knee pain, where do you start?
Well, it’s a lot like shopping for clothes, you want to shop for the right fit for you.
For starters, find someone who knows what you are looking for. If you are a powerlifter, it’d likely be better if you found a practitioner who knows what powerlifters do. Call them, and see if you like what they are about and what they do.
Cost is obviously an issue for a lot of people, so see if you have insurance and find someone through your own network. Also, there is no harm in going to see multiple practitioners. Remember, they are there to help you, and if there is someone that can help you better then it is their jobs to refer you to them.
It doesn’t matter what profession you go to, but who you go to. Choose the therapist not the therapy. At the end of the day, don’t give up and find ways to keep moving.
Regardless of how careful you are, you can run into issues with whatever activity you choose to do. It is a natural part of life, but it doesn’t mean it’s the end of the world or the end of your lifting career. Take a breath, give it time and some honest work. Utilize the resources you have available around your community, and just keep moving.
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About The Author
Clifton’s most notable achievement is winning the 2017 IPF Classic World Championships in the Junior 66kg class whilst setting an Open World Record Deadlift. He graduated with a Bachelor of Science degree in Kinesiology and is currently pursuing a Doctor of Chiropractic.