A gallon of milk a day, a barbell, and a spreadsheet named after your favorite eastern bloc weightlifter is the simple recipe for back squat PR’s, lower body strength, and chronic knee pain.

Spending the last 20 years as a strength coach, physical therapist, and athlete, I have witnessed every squat cycle that has ever graced the internet. Embarking on McCallum’s 20 rep breathing squats, Wendler’s 5-3-1, Smolov, and baby Smolov, you are guaranteed two things:

1. Increased and imbalanced lower body strength
2. Knee pain

Sadly, without proper training and perfect technique, you cannot have one without the other.

Knee pain, however, is not limited to strength athletes or squatting. Running, lunging, jumping, and landing have created an epidemic of knee pain among all athletes.

Structural imbalances, poor movement patterns, and excessive volume create the perfect storm for knee pain. Fortunately, you already possess all the tools you need to assess and heal yourself.

Anatomy of the Knee – The Middle Child of the Lower Body

The knee gets no respect.

Positioned between the hip and ankle, the knee is the middle child, often forgotten, until it acts up and sidelines your training.

The sequence of joints in your body creates a symphony of mobility and stability that allow you to move through a full range of motion. In the lower body, the hip and ankle are mobility joints. They flex, extend, and rotate. To counterbalance the mobility of the hip and ankle, the knee is a stability joint connecting the upper and lower halves.

The knee is the largest joint in the body, connecting the femur, shin (tibia), and patella (knee cap). When you experience knee pain, you are feeling the soft tissue, cartilage, ligaments, and tendons surrounding the joint. When the soft tissue becomes inflamed, through stress and overuse, the brain recognizes a threat to the joint and fires a pain response to that area.

Despite the knee being the area of the pain, it is just a symptom…a symptom of poor movement, mobility, and stability from the hip and ankle causing the knee pain.

The Hip – The Top of the Chain

The principles of functional movement state that joints are designed to absorb impact from the largest joints to the smallest. The hip, attached to the glutes, hamstrings, and quads, is capable of supporting heavier loads than the smaller knee and ankle joints. Knee driven squats, or initiating the squat by pushing the knees forward, violates these principles, putting excess tension on smaller musculature and connective tissue.

Additionally, the musculature of the hip needs balance. Humans are built to be rear wheel drive animals. Sitting throughout the day turns off the glutes and hamstrings and creates quad-dominant movement patterns. This seated position also shortens the hip flexors leading to tight hips, an inability to reach full hip extension, and excess stress or pulling on the on the knee.

You may not experience chronic knee pain today, but you can see the signs of future pain by watching your movements. For example, the most obvious sign of missing glute strength is knee valgus squatting. Knee valgus is the term describing when the knees track inside the toes during squats, jumps, and landings. When the glutes do not fire properly, the knees will cave in, especially under bigger loads. Knee valgus squatting puts an extreme shearing force on the connective tissue in the knee.

3D Balance Assessment

Can you stand on one leg for 30 seconds while reaching North, East, South, and West with your other leg? Both sides?

The Ankle – Down the Chain

Below the knee, the ankle is just as problematic to the knee as the hip.

The ankle is designed to flex, extend and rotate. Ankle dorsiflexion, the ankle’s ability to flex the toes towards the shin, is a critical component in knee health.

With every step you take, the foot rolls from heel to toe. A tight calf or Achilles tendon will block the ankle from reaching its full range of motion in your walking stride. When the ankle stops short, the knee absorbs more impact with each step than it is designed to. The problem is compounded as you add the intensity of sprints or long distance running. Higher intensity, higher reps, and more weight being absorbed by the knee accelerates inflammation.

Mobility is not the only issue. Arches in the foot create stability in the ankle. A collapsed arch (flat feet),   characterized by the toes pointing out when walking, creates instability in the ankle. When the foot collapses, the instability moves up the chain causing the knees to slightly cave in. Over time, this shearing force on the knee moves into the connective tissue, specifically the ACL, leaving the knee vulnerable to injury.

Jump and Land Assessment

On a 12” box, jump and land. Do your knees track inside your toes at any point in the movement?