Author – Kris Ceniza
Ask any trainer for a workout program and I guarantee you’ll find variations of squats in there. But, this versatile lift also comes with its challenges – and knee pain when squatting is one of the most common complaints I’ve come across in my practice as a physical therapist and fitness coach.
Today, let me walk you through some of the most common causes of this discomfort as well as a few easy solutions you can work on.
You ready? Let’s get it!
6 causes of knee pain while squatting
First of all, squats don’t normally cause knee pain. Unless you have an existing condition, your knees are mechanically designed to smoothly bend and straighten while carrying your weight. Hence, why we start off walking, running, jumping, and using the stairs without any issues as kids.
In the absence of previously known conditions, however, knee pain during squats is commonly attributed to poor technique and imbalances. These, in turn, lead to a number of injuries, including the following:
1. Patellofemoral Pain Syndrome (PFPS)
PFPS is otherwise known runner’s knee. It presents as anterior knee pain that hurts when you walk, run, jump, use the stairs, stay seated for too long, and, of course, when you squat.
This condition doesn’t actually have a single underlying cause that we can point to but it’s largely associated with overuse, poor technique, and both biomechanical and muscular imbalances. Moreover, these same issues commonly present together rather than as individual causes.
Although there isn’t much you can do when it comes to biomechanical issues, like being knock-kneed or flat-footed for example, the good news is that all the other risk factors are under your control.
2. Iliotibial Band Syndrome (ITBS)
Acronym’d ITBS and shortened to IT band syndrome. This injury is commonly seen in runners but other types of athletes – including weightlifters – frequently experience this, too. Per research, the common denominator is repetitive movement.
In theory, this happens because of the friction between your IT band and the bony prominence on the side of your thigh bone. The repetitive bending on squats irritates this contact point, eventually leading to inflammation and pain.
Although, there are several other theories explaining ITBS such as compression of fat pads and chronic inflammation – and all of them could just as easily be true to your situation.
In any case, IT band syndrome presents as pain on the side of the knee.
3. Patellar Tendonitis (Jumper’s Knee)
Jumper’s knee happens when your patellar tendon is damaged and inflamed, thus the name patellar tendonitis. It’s not just about repetitively jumping around, though. Research suggests that landing, sudden bursts of speed, and decelerating from said bursts are also risk factors.
As you might have guessed, it’s a common injury in jumping sports like basketball and volleyball.
But, the way I see it, us weightlifters are also at risk for this injury because many of us (including myself) are fond of adding plyometrics and HIIT to our routines. They are, after all, great ways for preserving muscle mass and power while achieving the elevated heart rates seen in cardio workouts.
Jumper’s knee is also linked with overuse and presents as knee pain right below your knee cap. It likely will also hurt more when you run, jump, walk, and squat.
4. Osteoarthritis (OA)
Another common cause of knee pain in weightlifters (and active people alike) is osteoarthritis.
It’s a degenerative disease of the articular cartilage that’s commonly seen in the knees. And, because it’s degenerative, it also gets more prevalent the older we get.
Like the previous injuries I mentioned, the primary cause of knee OA is overuse.
But, “overuse” here doesn’t just mean putting in rep after rep after rep. With squats, it could also mean that you’re lifting too heavy and using improper form when doing those reps. Whether that weight comes from the metal plates on your back or from your own body weight doesn’t matter.
If you do your squats right, however, the burden of that weight is carried more by your muscles rather than your joint, reducing the risk of developing osteoarthritis.
5. Sprains and meniscus injuries
Sprains are when your ligaments are damaged. Depending on the severity, they can either be stretched or torn. Meniscus injuries, on the other hand, mean damaged menisci (cartilage) which also has its grades of severity.
Both these injuries happen when your knees move in ways they aren’t supposed to. For example, suddenly twisting your knee with your foot planted to the ground tears your ACL. The twisting motion in ACL injuries also damage the meniscus. Direct trauma to your knees that forces them out of alignment also causes sprains and meniscus tears.
That being said, you can usually tell when and how these injuries happen. So, if you suspect either of these injuries and your knees hurt when you squat, I urge you to stop squatting until the injuries fully heal.
Often confused with sprains, strains are injuries to your muscles or tendons rather than to your ligaments or cartilage. So, when someone says they pulled a muscle, that’s a strain.
Now, in squats, you can “pull” your quads or hamstrings when you do quick movements that your muscles aren’t prepared to do. This is going to feel painful, especially when paired with spasms and cramps.
Strains while squatting are, in large part, because of improper technique and poor training ethics.
Solving the knee pain while doing squats problem
The way I see it, solving this comes down to 2 things:
- Preventing it from happening in the first place, or
- Dealing with it while it’s there
There are a bunch of things that work for both and there are things that are more appropriate as after-care solutions. Let’s start with the former.
Adjustments that both prevent and resolve knee pain
Improving your technique
A good majority of squatting injuries come down to poor technique. The good news is that form can always be worked on.
That being said, squat techniques are different for everybody because we also have different anatomies. So, get a knowledgeable trainer to work with you.
As a rule of thumb though, simply make sure that your feet, knees, hips, and shoulders are square all throughout every rep. If you can’t do that, you likely have mobility issues, imbalances, or simply aren’t prepared for that kind of intensity and movement yet.
This goes back to what I said about different people having different anatomies.
For instance, women have wider hips than men – and that plays a role in why women are also more prone to developing PFPS and ITBS. Men, on the other hand, are more prone to patellar tendonitis because of the speed at which we gain strength.
This isn’t a biological sex thing either. Men differ from other men the same way women differ from other women.
Regardless, a good rule of thumb is to make sure that your hamstrings are at least half as strong as your quads. If you’re a serious athlete, aim to get that ratio more equal. So, if you do squats and knee extensions, make sure to pair those with hamstring exercises of roughly the same intensity to prevent knee pain.
You could also use foam rollers, stretches, knee supports and other techniques/products to help activate the right muscles when you work out.
Gradually increasing the intensity
All of the most common causes of knee pain during squats that I just mentioned can point back to overuse. Whether that be from repetitions or weight, only you can tell.
I do have a couple of rules set for myself and my clients, though:
- Wait for 48 hours before working out the same muscle group. Research suggests that this amount of time is the minimum for adequate recovery. So if you did legs on Monday, you can’t do legs again until Wednesday.
- Drop your reps/sets when you increase your weight. This applies given that the 10-12 reps of your current maximum are also your failure. So if you’re squatting 200 pounds at 10 reps now, don’t immediately do 10 reps when you go up to 220 lbs.
How to relieve pain after squatting
PRICE is an acronym for Protect, Rest, Ice, Compress, and Elevate. It’s recommended in medical circles for fresh injuries as it helps control the damage and inflammation which, in turn, minimizes pain.
In the real world, it basically means not powering through the pain, putting ice on your knees for 10 minutes, using knee compression sleeves or ace bandages, and sleeping with a stack of pillows under your legs.
This should work for the first couple of days post-injury.
Contrary to using ice for acute knee pain, heat is generally better for the later stages of injury.
Heat facilitates warmth, relaxation, and blood flow which helps with recovery and pain. Apply heat for 15 minutes at a time.
Fix the underlying cause
PRICE and heat are temporary solutions. Without actually fixing what caused your injury, it’s going to keep coming back.
To start, ask yourself these questions:
- Are you following the 48-hour rule? If not, you’re doing too much.
- Did you perform the same amount of reps right after you loaded up on weights? If so, you probably did too much.
- When was the last time you checked your form? If it’s not recent, you should do it as soon as you’re able. Have another set of eyes look at it, too.
- Is there any other activity outside of the gym that may have caused your knee pain? If so, you might want to alter that as well.
Granted, these are all questions that relate to overuse, bad form, and a terrible routine – and they can all be addressed if you work with someone who knows what they’re doing.
If addressing these concerns don’t work, however, I highly recommend paying your local physical therapist or trusted doctor a visit.
Kris Ceniza is a fitness coach from the Philippines with a degree in Physical Therapy from Cebu Doctor’s University. He also functions as the website manager, editor, and content developer for the website KneeForce.com.