There are few things as annoying as being midway through your squat workout only to be sidelined by knee pain. Unfortunately, knee pain is a very common issue that lifters and athletes
deal with, so today we’re going to discuss some common causes of knee pain, as well as what you can do about it!
With our patients, the most common situation that we see is knee pain either directly above or below the kneecap (patella). Knee pain directly above the patella is often called “quadriceps tendinitis” and knee pain directly below the patella is often called “patellar tendinitis.” These conditions are often sometimes referred to as runner’s knee, jumper’s knee, or weightlifter’s knee.
However, these issues actually aren’t technically cases of tendinitis. You see, the ending of tendinitis, the -itis part, means that there is a large, active inflammatory process that is causing a bunch of issues. And after studying these conditions for many years, we’ve found out that most cases of knee pain in these areas don’t have a large inflammatory process going on. Therefore, the correct term for these conditions is quadriceps tendinopathy and patellar tendinopathy, respectively.
What these conditions are is actually the result of an overuse injury, in which we’ve simply placed too much stress on the tendons of the knee over a period of time. The tendons can’t keep up with the demands that we’re placing on them, and then they become irritated and painful, and limit or stop us from being able to do things like run, lunge, squat, jump, clean, box jump, and snatch.
Now you’re probably thinking “great, so now I know what is going on, but what can I do to solve my knee pain?!”
The good news is that, most of the time, these conditions are self-limiting, which means that they simply get better over time without the need for specific treatment. However, some cases persist for many weeks or months, and eventually need specific treatment to help solve the knee pain. Luckily, the vast majority of these cases can be fully treated with physical therapy, exercise, and activity modification, without having to undergo injections or surgery.
The key to properly rehabbing quadriceps or patellar tendinopathy is the exercise and training progressions that you use, as progressively building up the strength and work capacity of the tendons is how you solve your knee pain and get back to the activities that you love.
Next, we are going to show you two of our favorite progressions for treating these types of knee pain. The first progression is going to use the leg extension machine (which is a very safe and effective machine, despite popular opinion *gasp*), and the second progression is a squat progression.
LEG EXTENSION PROGRESSION
The leg extension machine is a great tool to use when treating these types of knee pain because we can very carefully apply the right amount of stress to the knee and the tendons to build up their strength and work capacity.
The progression that we use involves progressing both the weight that is being lifted, as well as how fast the weight is being lifted over time to properly stress the tendon, but without doing so much that it becomes further irritated.
Leg Extension Isometric
For this leg extension variation, you simply select a weight that you can tolerate without noticeable pain and kick your leg out straight to a certain angle (we usually start at about 45-60 degrees away from being fully straight), and hold it there for a specific period of time.
Isometrics are a great beginning point because, since you’re not actively moving your knee, they tend to be tolerated very well, even for people with significant knee pain!
Tempo Leg Extension
For the next step in this quadriceps tendinopathy/patellar tendinopathy progression, we are going to add some active movement of the knee. However, we are going to move intentionally slowly, as this is often tolerated better than moving at regular speeds.
Be warned though, this variation causes a wicked quadriceps burn/pump!
Regular Leg Extensions
The next step up involves performing leg extensions at a regular speed! By now, the knee pain has probably subsided quite a bit, and we can begin loading this movement a little bit heavier without flaring up the pain.
The faster speed of this variation allows us to both use heavier weights than the tempo variation, and it stresses the tendons a bit more since we are moving faster (remember, force is determined by both the amount of weight and how fast it’s moving).
Drop Leg Extensions
Many physical therapists would simply stop the progression here, but at Barbell PT and Performance we work with athletes and lifters, and they often have different demands than the average person!
For instance, many lifters use a “bounce” out of the bottom of the squat that requires the ability to absorb and produce force quickly, and field athletes (such as those who play soccer, football, lacrosse etc) have to run, cut and change direction quickly, which also require fast force absorption and production.
To start getting our clients ready for these types of demands, we’ll use a type of leg extension called a “drop” leg extension.
This variation involves fully straightening your knee, but then letting the weight drop back down, but you “catching” it and quickly stopping it from getting all of the way to the bottom.
Now while we’re doing isolated exercises to build up the quad and tendons strength and work capacity, we absolutely do NOT want you to stop squatting. It is important that you continue squatting during this time to reduce any losses of strength, muscle mass, or technical proficiency. But, just like with the leg extensions, there are specific variations and progressions that we can use to make squatting much less painful while rehabbing the knee pain.
The squat progression that we are going to use can be applied to really any type of squatting, whether that’s back squats, front squats, goblet squats, even zercher squats if you want to get a little crazy.
We are going to be manipulating range of motion and tempo in this progression to allow you to continue training while dealing with this knee pain with squatting.
Slow Eccentric Pin Squats
For this squat variation, we are going to perform each rep with a slow eccentric (3-5 seconds long) down to pins or safeties. The key is that we are going to set the pins/safeties to a height where the knee feels comfortable in the bottom. Over time, our goal is to decrease the height of the pins/safeties, which will allow us to squat through a larger range of motion.
3-0-3 Tempo Squats
For this variation, we are going to perform our squat through as large of a range of motion that is comfortable, but we are going to use a 3-0-3 tempo. This means that we are going to lower the weight over 3 seconds, and lift the weight over 3 seconds, with no pauses during the reps.
Eccentric Pause Squats
The next progression to get back to pain-free squatting is to use slow eccentric squats with a pause in the bottom. We will often have our clients use a 3-5 second eccentric, with a 2-3 second pause in the bottom of the rep.
This is different than the 3-0-3 tempo squat because we are now trying to lift the weight as fast as possible, which more mimics how we would actually squat without knee pain.
The last progression, before getting back to regular squatting, is to perform paused squats. These are very similar to the eccentric pause squats, but now the eccentric portion of the squat is performed at whatever speed you would normally squat.
Again, we typically use 2-3 second pauses in the bottom, but we can make these longer or shorter depending upon how well the knee is tolerating the movement and this position.
If you are struggling with knee pain and want to learn more about how we can help you, click the button below to book a free phone consult with our team!
[button to talk to a PT page]
Barbell Physical Therapy and Performance is the premier sports physical therapy clinic in North Haven that specializes in helping athletes, lifters, and active adults solve their pain and get back to the activities that they love.