This article is brought to you by ISSA (International Sports Sciences Association)
The basic squat is such a great exercise for so many reasons:
- It works several muscles, including glutes, hamstrings, and quads.
- As a compound exercise, you get a more efficient workout in less time.
- Squatting elevates the heart rate with cardio benefits.
- It’s a functional movement that improves mobility and stability.
Of course, doing a squat involves sinking down into the knees, which can cause pain for some people. Many people with knee problems—from pain to arthritis—can still squat but with care and modifications.
If you’re uncertain about squatting and knee health, the best person to ask is your doctor. For clients, insist they talk to their doctors about safe exercises for their specific knee problems.
Overview of the Knee Anatomy
When we talk about pain in the knee area, we could be talking about many different things. We could be referencing pain in the knee joint, for instance. This joint connects the femur (thigh bone) to the tibia (shin bone). It makes it possible to flex and extend the lower leg.
Sitting directly on top of the knee joint is the patella, also known as the kneecap. The kneecap connects the quadriceps tendon with the patellar tendon. We might experience pain in the kneecap if we bump it into a piece of furniture, such as the leg of a table or desk. It’s also possible to break the patella. In fact, roughly 1% of all broken bones are a fractured kneecap (1).
There are also other soft tissues in the knee area. They include the collateral ligament and articular cartilage. So, if someone says that they are having knee pain, they could be talking about pain in any one of these areas.
What Does it Mean to Have Bad Knees?
Most people refer to knee pain or poor mobility as having bad knees, but this means a lot of different things. Some of the most common causes of knee pain are injuries, repeated stress, and osteoarthritis associated with aging (2).
Knee Overuse and Injury
Knee pain can result from both long-term overuse of the joint and acute injuries. A common overuse injury is tendonitis. The tendons are connective tissue linking bones to muscles. Knee tendons can become inflamed and painful. Athletes are particularly vulnerable, but anyone who is active throughout the day may develop tendonitis.
Acute injuries to the knee occur suddenly. Anyone can develop these injuries, which include torn cartilage, especially the meniscus, torn ligaments, and strains or sprains of the ligaments or muscles around the knee.
Arthritis occurs when cartilage in the joint wears away. Bone rubs on bone, resulting in inflammation and pain. Everyone gets some degree of arthritis as a natural part of aging. This is called osteoarthritis. Arthritis may develop earlier or be worse in people with frequent injuries or who engage in certain physical activities regularly.
Problem knees can also result from issues in other parts of the body. For instance, a tight IT band pulls on the knee, causing pain. This is particularly common in distance runners. Pain or injury in the hips or feet may force you to move the knee in a way that causes pain and damage over time.
Can You Do Squats if You Have Bad Knees?
If you or a client has some knee issues, but your doctor gives you the go-ahead, proceed with caution. According to the Arthritis Foundation, a good way to start and to take pressure off the knees is with a wall squat (3). Resting your back against the wall forces good form too.
You can also make squats safer for bad knees by reducing the range of motion. Squat only as deep as you can go without pain. If you feel pain, shorten the range of motion.
What if You Have Pain When Squatting
Pain during squatting may have several causes, most often injuries, but poor form can also cause pain. Squats are not inherently dangerous, but bad form is. If you have a client complaining of knee pain during squats, stop and evaluate before they cause damage.
If you can’t rule out bad form as the cause, be sure they see their doctor for an evaluation. They could have an injury that requires rest or treatment.
Knee Pain Prevalence and Common Causes
One in five U.S. adults has chronic pain according to a 2022 study (4). Results of this study, which were published in the journal Pain, also indicate that one of the most common places to experience chronic pain is in the knee area.
In the medical field, pain around the kneecap is called patellofemoral pain syndrome. Less formally, it is also referred to as runner's knee or jumper's knee.
Knee pain can have numerous causes. Among them are:
- knee osteoarthritis, a form of wear-and-tear arthritis in the knee joint
- rheumatoid arthritis, which is when the body’s immune system malfunctions and erroneously attacks the body’s healthy tissues
- gout, another form of arthritis that can lead to pain and swelling in the knee
- knee injury, such as a strained ligament, meniscus tear, or broken patella
- patellar tendonitis, or inflammation of the patellar tendon
- knee bursitis, inflammation affecting the bursae in the knee
- overuse, placing repeated stress on the knee, such as by running every day
Why Do You Get Knee Pain from Squats?
Any of the above conditions can cause pain in the knee while squatting. But there are other causes as well, some of which relate to how this exercise is performed.
One of the main causes of sore knees during a squat is improper form. If you lean too far forward, for instance, this places more stress on the knee area. It can also lead to pain if you allow the knee to extend beyond the toes while squatting.
Pain during squatting may be caused by a structural or functional misalignment in the knee area. So, every time you squat, it creates more stress on the joint or soft tissues surrounding it.
Knee valgus is an example of structural misalignment. Also known as knock knees, this condition exists when the knees rotate internally. The opposite of knee valgus is knee varus, also commonly referred to as being bowlegged.
Dysfunctional alignment in the ankles or hips can also contribute to knee pain when doing a squat. Since all these joints are connected, if one is out of line, it can negatively impact the others.
If You Feel Pain in the Knee Joint During Exercise
If you feel knee pain when squatting, stop the exercise immediately. If the pain is not severe, it may go away simply by allowing the knee to rest. Take a day or two off from lower body movements and give the area time to recover.
If you experience symptoms that suggest that the knee pain is serious, such as pain that is severe or getting worse, seeing a doctor is recommended. Diagnostic tests can help determine the cause of the pain. Once this is established, a plan can be created to help the knee recover.
This plan might involve physical therapy or, if the injury is severe, it may even require surgery. The healthcare provider can help determine the best course of action based on the exact injury and its severity.
How to Prevent Knee Pain When Squatting
Fortunately, there are several things you can do to keep a squat from creating knee pain. Options include:
- Focus on proper form. Pay attention to the body as you lower to the floor. Keep the hips back versus allowing them to come straight down or even tip forward, and don’t lock the knees. Also, make sure the knees aren’t pointing to the side. They should be pointing in the same direction as the toes. When the correct form is used during squatting, more pressure will be felt in the heels than in the toes.
- Don’t squat with weights. Instead of using a barbell or dumbbells during the squat, only use your body weight for resistance. This lightens the load on the knee.
- Hold something when you squat. Some people hold a wall, bar, or the back of a chair to help stay balanced when squatting. But using this type of assistance has another benefit: reducing strain on the knee joint.
- Squat with a resistance band. Another way to prevent knee pain when squatting is to place a resistance band either directly above or below the knees. This provides the joints extra support during the squat movement. It also makes it easier to keep proper form, preventing the knees from pointing outward.
- Stretch the quadriceps and hamstrings. This helps prevent knee pain by increasing the flexibility of these leg muscles. It also reduces the risk of injury during a squat due to muscle tightness. Dynamic stretches are best at the beginning of a workout while static stretches should be performed at the end of the training session.
- Increase your ankle mobility. If the ankle lacks flexibility, it affects the knees during a squat. A sign that this may be an issue is if the heels lift when squatting. If they do, perform exercises to make the ankle more flexible. Options include toe raises, heel walks, and lunges.
- Strengthen the legs and hips. It’s also helpful to work on building lower body muscle strength. The stronger these muscles are, the better their ability to support the knee. Add targeted strength training to your routine 2-3 times per week. Incorporate exercises that work the glutes, quads, hamstrings, and calves.
- Avoid a deep squat. The closer you get to the ground when doing a squat, the greater the strain on the knee. So, those who experience knee pain during this exercise can benefit from not squatting as deep. This enables them to still do the exercise but not to the point where it creates discomfort or pain.
- Wear a knee sleeve. Research suggests that the use of a knee sleeve can reduce pain in this area (5). It may also provide other benefits, such as increasing walking speed in people with knee osteoarthritis.
- Lose weight if necessary. One pound of excess weight places four pounds of pressure on the knee joint according to the Arthritis Foundation (6). And not just during a squat, but also during everyday activities such as walking or climbing the stairs. So, losing even a few pounds can greatly reduce knee problems.
The Best Squat Variations for Bad Knees
Good form, wall squats to start, and limited range of motion are all important ways to make squats safer for bad knees. Here are some other modifications and variations to try:
- Box or chair squats. Using a box is helpful for limiting range of motion, especially if you worry about a client being unable to control their squat depth. Do a squat by lowering down to a box or chair of the appropriate height. You won’t be able to go any deeper than the box.
- Stability ball. If you feel comfortable with wall squats, add a stability ball between your back and the wall. This allows you to increase range of motion but still provides some support and pressure relief.
- Wide squats. For a standard squat, feet are typically shoulder-width apart. Widen the stance and turn the toes out a little bit more to reduce knee pain.
What If You Can’t Do Squats at All?
Recovery from surgery or an injury, and a doctor’s orders are all good reasons to avoid squats entirely, if temporarily. A squat is an efficient strength move, but it’s not the only effective one. What can you do instead of a squat? Try these alternatives to avoid knee pain or making an injury worse.
Squats are great for the glutes, but you can use these exercises to build strength in this big muscle group without stressing the knees:
- Glute bridges. These work the glute and are simple to progress. Start with a standard bridge to build strength, then try doing it one leg at a time or adding weight across the hips.
- Hip thrusters. For even more of a challenge than a glute bridge, try the same movement but with your upper back resting on a bench, feet flat on the floor, and knees bent.
- Lateral walk. With a resistance band around the ankles, walk side to side, squeezing the glutes as you step. Increase the resistance of the band to progress.
- Clamshells. This move targets the gluteus medius, an important glute muscle for stability and proper knee alignment. Lying on your side, one leg on top of the other and knees bent, lift the top leg up and squeeze. Add a resistance band around the legs as you get stronger.
For the Legs
To target the quads and hamstrings try these exercises:
- Deadlifts. This is a great hamstring exercise that also targets the glutes and lower back. Add weight to progress. Try single-leg deadlifts for stability and a core workout.
- Stability ball curls. On your back on a mat, rest your calves on a stability ball. Lift your hips up and squeeze, then roll the ball toward your bottom. You should feel the burn in your hamstrings.
- Leg extensions. To hit the quads but keep knees safe, sit on the edge of a chair or bench and lift your legs, straightening but not locking the knees. You can add ankle weights to make this more challenging.
Hip Strength and Mobility
Squats are not just about legs and glutes. They also strengthen and improve mobility in the hip flexors and the hip joint. Glute bridges and hip thrusters will help with this, as will deadlifts. You can also use resistance bands to do knee lifts, which strengthen hip flexors.
Add in some hip stretches, or yoga sessions, to really improve flexibility and mobility in these major joints. This will help stabilize the knees and reduce pain during all kinds of movements.
So, Can You Do Squats if You Have Bad Knees, or Should You Avoid Them?
There is no simple answer to this question, unfortunately. If you have a client with a knee injury, pain, or arthritis or who has had knee surgery, urge them to talk to their doctor about this question. It really depends on the individual and the particular knee issue.
For many people, squats can actually reduce knee pain over time. If their doctor gives them the go-ahead, work slowly with these clients. Start with a small range of motion and no weights to build strength and mobility.
The Personal Trainer’s Role in Knee Pain Prevention
Personal trainers can help clients avoid knee pain during exercise by reinforcing proper form. This reduces stress on the knee joint while going through the movement’s full range of motion.
Read the article here: https://www.issaonline.com/blog/post/can-you-do-squats-if-you-have-bad-knees
1. Kneecap Fractures (Patella Fractures). John Hopkins Medicine . (n.d.). Retrieved February 3, 2023, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/kneecap-fractures
2. Knee Pain and Problems. John Hopkins Medicine. (n.d.). Retrieved February 3, 2023, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/knee-pain-and-problems
3. How to squat correctly: Arthritis foundation. How to Squat Correctly | Arthritis Foundation. (n.d.). Retrieved February 3, 2023, from https://www.arthritis.org/health-wellness/healthy-living/managing-pain/joint-protection/how-to-squat-correctly
4. Yong, R. J., Mullins, P. M., & Bhattacharyya, N. (2021). Prevalence of chronic pain among adults in the United States. Pain, 163(2). https://doi.org/10.1097/j.pain.0000000000002291
5. Mohd Sharif, N. A., Usman, J., Wan Safwani, W. K., Siew Li, G., Abdul Karim, S., Mohamed, N. A., Khan, S. S., & Khan, S. J. (2019). Effects of simple knee sleeves on pain and knee adduction moment in early unilateral knee osteoarthritis. Proceedings of the Institution of Mechanical Engineers, Part H: Journal of Engineering in Medicine, 233(11), 1132–1140. https://doi.org/10.1177/0954411919874614
6. Weight loss benefits for arthritis: Arthritis foundation. Weight Loss Benefits for Arthritis | Arthritis Foundation. (n.d.). Retrieved February 3, 2023, from https://www.arthritis.org/health-wellness/healthy-living/nutrition/weight-loss/weight-loss-benefits-for-arthritis