When suffering with patellofemoral pain there are two traits of the squat exercise which can initially bring on pain or discomfort in your knees. Here we will explain those traits and come up with short-term workarounds to help the beginner get started with squats, make some progress, and do so with limited discomfort in the knees.
Bending your Knees
Your knee pain has probably stopped you from putting much of your bodyweight through bent knees, instead favouring to keep your legs straight throughout your daily life, perhaps using your back strength to lift items off the floor or using your hands to assist getting out of chairs.
The first of these traits is therefore the angle that the knees need to bend to in order to squat down to a depth where your thighs are parallel to the floor (parallel depth in squats is generally considered the best depth to yield most benefit from the exercise). In the squat, the lower you squat down, the more acute the angle of knee bend required, the greater the demand on the strength of your quadriceps, and the more potential discomfort there is for someone with badly tracking kneecaps.
Correct torso angle
The second of these traits is the angle the torso should be to the floor during the squat. Whilst everybody’s anthropometry (body ratio) differs, as a general rule, by the time a person has squatted down to parallel, the torso will be leaning forwards but no more so than about 50 to 55 degrees from the floor. However, a patellofemoral pain sufferer is likely to find they would have to lean forwards much more than this to avoid knee pain. This is due to the fact that by leaning forwards excessively, less of the bodyweight load is borne through the quadriceps and knees, and more is taken by the strength of the back and the hamstrings, thus the use of painful knees is avoided.
Managing knee pain in the squat
The best way for the beginner to deal with the potential discomfort of these traits is to squat to limited depth by stopping at the first point where technical issues arise. To explain what this means and what technical issues may arise, we need to go through the exercise step by step:
Standing on non-slip flooring (such as carpet or rubber matting) and wearing shoes with good grip (the importance of grip is discussed here), stand with your heels just outside the width of your shoulders and keep your feet parallel to each other. In this position, whilst still keeping your legs entirely straight, try to externally rotate your legs from the hips. This will have the effect of pointing your kneecaps outwards with the feeling of your feet corkscrewing into the ground.
Try to balance your weight evenly on the feet so that the toes do not turn outwards from this force – the feet should remain parallel in spite of the outward rotation of your legs. (Note: If you are not used to generating external rotation from the hips, you may find that the glutes fatigue quickly – it takes time to develop good strength and stamina in these muscles. It may also feel uncomfortable for the ankles – see our ankle flexibility article.)
Next, keeping the glutes working hard to rotate the knees outwards, simultaneously unlock the hips and knees just a few degrees so that the hips move slightly backwards and the knees move slightly sideways. Hold this position, still aiming to generate the same level of external rotation from your hips and maintain the same feeling of the feet corkscrewing into the ground. Any feeling of reduction in the amount of external rotation force from this slight bend of the hips and knees is an indicator that your glutes need strengthening and that this exercise will require plenty of practice. If, however, after this slight bend, you still feel the knees are forcefully pointed outwards, slowly continue to sit the hips further down (and slightly backwards) keeping the knees rotated out to the sides and the feet corkscrewing into the ground. You should make this descent slowly in order to “catch” the point in squat depth where you feel any of the following set in:
- Orientation of knees moves inwards from their externally rotated direction
- Width of knees moves inwards from their current width
- A reduction in the rotation force felt through the feet occurs
- A reduction in the tension generated from the hips/glutes occurs
- Hips move too far backwards (such that the stretch in the inner thigh muscles reduces)
- Angle of torso inclines too far forwards (45 degrees to the floor or flatter)
- Angle of the pelvis cannot match torso angle, leading to a loss of the natural arch in the lower back
- Your patellofemoral knee pain kicks in
Should any of those faults set in, this is a sign you have descended too far for your current strength level. You should stand back up by continuing to turn the feet into the ground and rotating the knees out. On your next repetition try to squat down to a depth just shy of the depth where you felt that fault set in and repeat this style for the rest of the set and all other sets in the training session.
As you continue to practice the exercise you should always try to test your depth on the exercise by pushing it to the limit of your technical competence but not beyond. Gradually, over time, your technical competence, strength and flexibility will improve to the point where you can squat to parallel without faults.