- Knee pain from squatting: What to do
- Identify what is wrong with your form
- Work your way up to the perfect squat
- Perfect your squat position
- If you want to learn how to get rid of knee pain when squatting for good… Then you need to read this article.
- Mistake #1 – Letting Your Weight Shift Forward
- What to do Instead
- The Ankle Mobility Test
- Increasing Your Ankle Mobility
- Mistake #2 – Not Actively Using The Hip Flexors
- Mistake #3 – Knees and Toes Not Inline
- Why Does the Knee Collapse Inwards and How to Fix It?
- Mistake #4 – Doing Too Much Too Soon
- How To Fix Knee Pain From Tendonitis
- The Box Squat: A Knee-Friendly Squat Alternative
- The Takeaway For Knee Pain When Squatting
- Why Do We Get Knee Pain When Squatting?
- What To Do When Experiencing Knee Pain When Squatting?
- Prevention: Avoiding Knee Pain When Squatting
- Sample Plan For When You Have Knee Pain While Squatting
- Step 1 – Reduce the weight
- Step 2 – Modify sets and reps
- Step 3 – Modify exercise tempo
- Step 4 – Utilize assistance exercises/technical modifications
- Step 5 – Utilize therapeutic modalities
- Step 6 – Modify squat position
- Step 7 – Analyse exercise selection
- Step 8 – You’re lying go back to 7 and find something to do!
- Examples of Powerlifters With Knee Pain While Squatting
- Seeking a Professional – Choose The Therapist, Not The Therapy
- Final Thoughts
- Get Our Best Articles
- Medical Disclaimer
- About The Author
- ILIOTIBIAL BAND SYNDROME
- PATELLOFEMORAL COMPRESSION SYNDROME and BIOMECHANICAL DYSFUNCTION (LATERAL PATELLA TRACKING)
- PATELLA AND QUAD TENDINOPATHY
- DIAGNOSING YOUR KNEE PAIN
- OTHER HELPFUL TESTS
- Fix It
- Prevent It
- When to Call a Doctor
- What is knee pain?
- Myth: Don’t do ANY exercise if you have any knee pain
- Myth: You should rest until knee pain goes away
- Myth: Don’t exercise if you have arthritic knees
- Myth: You shouldn’t run
- Myth: You shouldn’t squat
- Fact: You shouldn’t jump
- Exercises to strengthen your knees
- Persistent mild knee pain due to squats – push through or stop?
- Update 2011-09-09
- How to Make a Splint
Knee pain from squatting: What to do
Possible reasons why a person might experience knee pain from squatting include:
Share on PinterestA person may have knee pain from squatting if they are performing the move incorrectly.
If people are not squatting correctly, they may experience knee pain. Performing this movement incorrectly can put pressure on the knees rather than the thigh muscles and glutes.
We cover how to squat correctly later in this article.
A person who continues to experience pain after adjusting how they squat should visit their doctor to check for any underlying knee problems.
Spraining the knee
Twisting the knee awkwardly while squatting or receiving a blow to the knee may cause a sprain.
Sprains are painful and can cause swelling. These injuries can make it painful to squat and do other exercises that involve the knee. A person with a sprained knee may also find it hard to walk or put any weight on this joint.
Patellofemoral pain syndrome
Patellofemoral pain syndrome can cause pain around the kneecap and in the front of the knee, making it painful to squat.
Anyone can develop patellofemoral pain syndrome, but some people refer to it as “runner’s knee” or “jumper’s knee” because it often affects individuals who do a lot of sport. Any injury to the knee may also cause knee pain when squatting.
Tendons connect the muscles to the bones. Tendonitis of the knee can happen if a person strains or overuses the tendons around the knee, causing them to swell.
Tendonitis is more likely to occur as a result of repetitive movements, particularly if these exert a lot of force on the tendon. People often make repetitive movements while playing sports or working in a manual labor job.
Arthritis of the knee
Arthritis causes the joints to become painful and inflamed. Different types of arthritis can affect almost any of the joints in the body, including the knee.
Cartilage is the flexible, firm tissue that surrounds the joints and enables them to move smoothly. Osteoarthritis develops if this cartilage breaks down.
People with knee osteoarthritis may experience pain and swelling around the knee and feel as though the joint is stiff.
Osteoarthritis is most common in people over the age of 65 years.
Rheumatoid arthritis is an autoimmune condition that affects joints all over the body. The immune system attacks healthy tissue surrounding the joints, causing pain, swelling, and stiffness.
Post-traumatic arthritis can happen after an injury to the knee that damages the joints or ligaments. If an infection spreads to the knee, it can cause infectious arthritis of this joint.
Tendon or cartilage tears
A severe injury or sprain can cause the cartilage in the knee to tear. People may need to wear a knee support during physical activity after a cartilage tear.
A patellar tendon tear is one that occurs in a tendon of the knee, which can happen due to a blow, jumping, or a weakened tendon.
Symptoms of a patella tendon tear include:
- difficulty walking
- buckling of the knee
- a moving kneecap
- pain and tenderness
- an indentation under the kneecap
The type of treatment will depend on the size of the tendon tear. Physiotherapy may sometimes be sufficient, but surgery is usually necessary.
Iliotibial band syndrome
The iliotibial band, or IT band, is tissue that runs the length of the upper leg from the hip to the knee. When a person bends their knee, the IT band moves to support it.
If the IT band becomes inflamed, it can rub on the outer knee and cause pain, especially during movements that involve the joint, such as squatting. IT band syndrome often affects runners. People who do not stretch properly before exercising also have a higher risk of sustaining this injury.
There are two types of people in the world: The ones who love squats (ahem: J. Lo), and the ones who would rather be forced to spend three days at Fyre Festival than suffer through a set of them. Regardless of which category you fall into (ICYWW, I am very much in the second), we can all agree that they are effective at blasting booties and building muscles, and will almost definitely pop up in your schedule no matter which type of workout you’re doing. Which raises the oh-so-important question: How can you avoid knee pain when squatting?
To understand how to avoid it, it’s important to figure out why exactly it happens to begin with, which is actually pretty simple. “Knee pain stems from improper form,” says Karl Smith, Director of Residential Well Living at Cortland, DHEd, noting that doing the move properly is the number one way to ensure you don’t hurt yourself in pursuit of a more perfect umm peach. “When looking at form, make sure your feet are flat on the ground. Then, when you start the move, engage your glutes immediately by pushing them back and hinging from your hips allowing your body to go down in a smooth motion.”
The problem is compounded, however, by certain muscle groups not being strong enough to carry out the motion. “A lot of the times it’s not that people don’t know how to squat. They understand the concept of it, but they they just don’t have the neuromuscular strength, explains Aaptiv trainer Michael Septh. “They don’t know how to access the muscles that should be doing the work to make the squat happen.”
If that happens to you, as with pretty much any post-workout injury, the good old “ice, rest, compress, and elevate” prescription holds true for knee pain when squatting, too. “Rest, of course, is going to be your primary source of recovery,” says Smith. “After that, you want to make sure you’re icing the area. If it comes to the point that compression is necessary, compress and then elevate if the joint is swollen or the musculature around the joint is swollen. You definitely want to elevate to relieve the pressure and allow some of the blood to escape from that area.” Septh also recommends soft tissue work, through either foam rolling, myofascial release, or work with a massage or physical therapist.
Both trainers note that post-squat pain should diminish if you’re working with the correct form (it all comes back to form, fam!), and if things are still feeling tweaky you may want to start back at square one and reevaluate the way you’re doing the move. For more on how to figure out what’s sabotaging your squat, keep on scrolling.
Identify what is wrong with your form
To figure out what might be causing your knee pain, you have to work backwards. “Ask yourself: Why am I feeling tension at my knee? What’s generating tension at my knee? How can I fix it?” explains Septh. Look at the area from the joint up in order to understand what could be causing the discomfort. “If the knee hurts, it’s usually something above the knee is forcing and generating all that tension in the knee,” he explains. Consider the following when figuring out whether or not something is going on with your knees.
1. You have lack of connection to your glutes: “Most people are way too quad dominant or thigh dominant, so they don’t even really know how to access their glutes and do everything in their quads or the front part of their thighs,” explains Septh. “But after awhile your thighs can only do so much and the joint below, which is your knees, tends to get the brunt of the load.”
2. You have tight calves and ankles: If your ankles and calves are tight, it may prevent the muscles from flexing all the way. “Sometimes you’ll see people sort of lean forward and they’ll get on their toes, which will then make their knee actually point forward and go over their toes, and that’s the first sign that their form is incorrect,” says Smith. Stretching the calves can help to balance things out, so regularly foam roll and stretch your lower legs ahead of heavy squats.
3. You have tight quads, abductors, adductors or IT bands: Just like with your calves and ankles, if other muscles involved in the move are tight, you won’t be able to get the full range of motion.
Work your way up to the perfect squat
Whether you’re learning to squat for the first time or re-learning how to do it properly after an injury, it’s important to go back to the basics in order to build up your strength to do the move properly. “I start everybody on the floor—it’s the safest place to start,” says Septh. “If you’re not feeling right on the floor, 9 times out of 10, the same will hold true on your feet.” Here, he lays out how to work your way up to perfect form.
1. Basic glute bridges: “I would use this as a test for anyone who wants to figure out if they’re doing hip work the right way,” he says. “If you’re doing glute bridges and you still feel your quads, that should be a red flag for you right away because that’s not where hip extensions or gluteal bridges should happen—they should be happening from your glutes, your hamstrings, your core, and everything around your trunk and your pelvis.” He notes that you can use these to strengthen different parts of your body, and get feedback on what’s going on with your muscles.
2. Single-leg or weighted glute bridges: Once you’ve gotten regular glute bridges down pat, it’s time to spice things up by adding weights or a single-leg element. “Anything that reinforces that connection to your glutes is definitely a good place to start, whether you’re coming back from an injury or you just want to learn how to find your hips,” says Septh.
3. Bench-sit bodyweight squats: “If you’ve become pretty sufficient at glute bridges and you’ve added load, you’ve added resistance, you’ve worked both legs, and you’re confident the work is coming from the right place, that would more than likely be your cue to start up with your squats again,” says Septh, with one caveat. Don’t just squat into the oblivion though. Use a bench or a chair (some point of reference) to help ease the transition between going down and coming back up. “Having that box or bench to sit down to gives you a second to kind of reset yourself, figure out what’s going on at the bottom of your squat, fix it, and get yourself back up.”
Perfect your squat position
As we’ve already established many, many times, form really is everything. It’s important to understand that you’re not actually initiating the move by bending your knees—doing it the right way requires more muscular understanding than that. “The idea is that you’re pushing your entire hips back. You’re pushing your belly back into your spine, you’re sitting back into your hips as best you can to initiate the movement,” says Septh. “And then, from there, your knees will start to bend naturally—you’re not generating the movement by bending at your knees to initiate it.”
The majority of the move, he explains, should come from you loading and pushing tension and weight back into your hips and heels, and then the bending at the knees should follow. It should be a secondary portion of the movement, not the primary one. Here, he breaks down how to master the art of the squat once and for all:
1. Start with feet hips-width apart Separate your feet about hips width distance apart, or wherever you feel the strongest connection with the floor and are at your most stable.
2. Tuck your pelvis: Tuck your pelvis into a sort of anterior tilt. “It’s almost like a zipper: You’re pulling your bellybutton back into your spine,” explains Septh.
3. Sit back into the outer-edges of the feet: Once you’ve tuned into that connection with your pelvis, push the weight back away from your knees and toes, sitting back into the heel and outer part of your feet.
4. Push your legs apart: As you’re pushing the weight into your heels and hips, your knees will start to follow. “As you’re working yourself toward the bottom of the squat, you want to actively rip the floor apart, meaning that you don’t want your knees to travel toward one another, you almost want then to rip slightly apart from one another as you hit the bottom of the squat,” explains Septh.
5. Stand back up: Take a big inhale on the way down, then exhale and drive through your hips and your heels on the way back up.
Once you’ve got the regular squat perfected, mix things up with Meghan Markle’s favorite move (or at least, what we like to imagine is Meghan Markle’s favorite move), the “curtsy squat.” And if your knees are still hurting, try one of these supplements for joint pain.
If you want to learn how to get rid of knee pain when squatting for good… Then you need to read this article.
Squats are a complex exercise that allows people to target multiple muscles, primarily the quads and the glutes.
And if you want bigger legs, then your best bet is to do some form of squats in your leg workouts.
However, the squat is also known as one of the most “dangerous” exercises as many people experience knee pain when squatting or knee pain after squats. The pain can present itself as discomfort around the knee cap:
…or above/below the knee at the tendon attachment points:
The thing is though, most people don’t have “bad knees”.
In fact, the pain their knees hurt when squatting due to damage around the knee because of a few common mistakes they make during the squat.
In this post, we will go through exactly what these mistakes are AND how to fix them.
In so doing, future injury can be prevented to allow you to get back into the gym and perform squats without knee pain.
Mistake #1 – Letting Your Weight Shift Forward
A very common mistakes people make with the squat is leaning forward and shifting the weight onto their toes. This is often accompanied by raising the heels upwards as they shift forward.
As a result, this movement error transfers more load onto the knee joint and strains the surrounding tendons.
Over time, these additional strains to the knee can manifest itself as symptoms of knee pain when squatting, especially around the knee cap.
What to do Instead
During the squat, ensure that the bar remains over your mid-foot and travels vertically up and down.
You should also apply pressure into the ground with your entire foot rather than just your toes. This will help better distribute the load onto the ankle and hip joints to prevent excessively straining the knees.
If you struggle to do this, then you may suffer from ankle stiffness.
Stiff ankles can’t bend enough, forcing the body to compensates by creeping up on the toes.
To test your ankle mobility using a research validated method; you can find out if that really is the problem.
The Ankle Mobility Test
Simply kneel down by a wall without shoes on and place your toes five inches from the base.
Move your knees forward towards the wall and attempt to touch the wall without lifting your heels from the ground.
If you cannot touch the wall without your heel lifting off the ground, then we’ve found a weak link in your ankle mobility. Something that believe it or not, can be responsible for the knee pain you feel when squatting.
Increasing Your Ankle Mobility
This is easy enough when said, but it will take some time. I would recommend regular ankle mobility stretching in addition to foam rolling the calves and shins, especially right before you squat.
You can also experiment with a wider squat stance and/or pointing your toes out more.
These adjustments decrease the level of ankle mobility needed to properly perform a squat.
Mistake #2 – Not Actively Using The Hip Flexors
Another common mistake people make is not actively engaging the hip flexors during the squat.
Try to visualize the hip flexor muscles shown here actively pulling you into the bottom of the squat:
When you begin the squat, think about actively pulling yourself down into the bottom position. Avoid letting gravity and the weight of the bar do the work.
Engaging the hip flexor muscles stabilizes the trunk and allows you to sit deeper into the squat. It also gives you more balance, as the center of gravity is kept above your feet and results in less pressure being placed on the knees.
If you’ve never properly done this, then you’ll likely feel immediate relief in your knee pain during squats.
And to get this activation down, I’d suggest attaching a band above your head and hold onto it during the squat (see above image).
The counter resistance will force you to learn how to actively use your hip flexors to pull yourself down.
Mistake #3 – Knees and Toes Not Inline
Not properly aligning the knees with the toes during the squat can disrupt your form. This leads to inward knee collapse when squatting, also called “knee valgus”.
This leads to instability in the knee which can wear away at the knee cartilage and result in pain around the knee cap during squats or after squats.
Why Does the Knee Collapse Inwards and How to Fix It?
The main reason is poor coordination and an inability to activate the lateral glutes (gluteus medius).
Luckily, fixing it is often quite simple with the use of something called RNT.
Reactive neuromuscular training or RNT, has been shown to reduce knee collapse and improve lateral glute activation.
One such exercise is the RNT split squat.
To perform it, place a resistance band around your forward foot as you perform the split squat such that it pulls your knee inwards (see the image shown above).
The resistance from the band should stimulate your lateral glutes to keep the knee in a stable position. The feet and the knees should stay aligned during the entire range of motion.
Adding 2-3 sets of 15-20 reps into your leg workouts is a great way to help teach your body to properly activate the lateral glutes. This will in turn prevent knee valgus and alleviate any pain you feel in your knees during the squat.
Mistake #4 – Doing Too Much Too Soon
Here’s a mistake that even I’ve been guilty of in the past. And it’s simply doing too much leg work too soon, or getting back into your usual leg workouts after you’ve taken time off.
Overtime, this can lead to quadriceps and/or patellar tendinopathy. If you suffer from this, you will experience knee pain pain located above or below the knee cap at the attachment point of these tendons.
The good news is that tendinopathy is easily reversible if properly managed. Research shows that these tendons recover within a few weeks if training load is significantly reduced.
How To Fix Knee Pain From Tendonitis
The best way to go about fixing your knee pain from tendonitis is to simply reduce your training load. What I’d suggest though is for you to play around with decreasing various components of your lower body workout.
By so doing, you will find which component of your workout is causing the most problems.
Then, by cutting out this component, you will begin to experience relief from the knee pain. You can also still continue to train at sufficient volumes to allow your tendons to heal and strengthen.
Suggestions for components to reduce:
- Decrease training frequency.
- Reduce load and do higher reps instead.
- Reduce number of sets
As an alternative, you can replace your regular squats with other exercises that don’t stress the knee as much.
The Box Squat: A Knee-Friendly Squat Alternative
The box squat is a great alternative to the squat for two main reasons:
- The box squat can help you control the depth to which you squat. This can effectively mitigate the point at which knee pain becomes an issue.
- Studies show that box squats elicits more vertical shin angles than regular squats. This will correspond to better pressure distribution in the foot as discussed above.
Simply meaning that if you’re struggling with knee pain during regular squats, then box squats are a great alternative.
Using other exercises can allow you increase strength in the same muscle groups that squats target to avoid knee pain when you go back to regular squats.
The Takeaway For Knee Pain When Squatting
I hope this was able to help you pinpoint what exactly might be causing your knee pain during squats.
As I always emphasize, it’s absolutely vital that you pay close attention to how exactly you perform your exercises (like the bench press and deadlift) in order to prevent injuries overtime and to progress faster. I personally could have prevented a lot of injuries and set backs had I applied this when I first started lifting.
And if you’re looking for a complete evidence-based program that’s fully equipped with in-depth tutorials for each and every movement…
…so you can ensure you’re safely maximizing your efforts in the gym and building muscle as effectively as possible…
…then click the button below to take the free body type analysis quiz I have up in order to discover what program is best for you:
As always, thank-you for the continuous support! I always enjoy reading the questions you have posted in the comments section and implementing your suggestions!! If you have enjoyed this content, please follow me on Instagram and subscribe to my Youtube channel where I will continue to frequently post videos on a wide range of work-out related topics.
How To Squat Without Knee Pain (4 Mistakes You’re Probably Making)
What should we do when getting knee pain while squatting?
We should modify our activity in a way that allows us to keep training and reduce the amount of pain as much as possible. We can do this by adjusting workout variables such as intensity, volume, and tempo. In addition, implementing certain assistance exercises or modalities can help us achieve continued activity without pain.
Knee pain while squatting sucks, but there are several factors that can influence how you manage the pain and how to prevent any further pain in the future.
Disclaimer: This article is not intended to diagnose or treat your specific injury. Instead it is intended to give you some valuable information that may help you. Seek a medical professional if you are dealing with any sort of injury.
- Why do we get knee pain when squatting
- What To Do When Experiencing Knee Pain When Squatting?
- Prevention: Avoiding Knee Pain When Squatting
- Sample Plan For When You Have Knee Pain While Squatting
- Seeking a Therapist
Why Do We Get Knee Pain When Squatting?
Pain is a mysterious thing. There is a lot that we still don’t yet understand.
A person can have no physical damage to their knees, yet experience pain. Whereas a person can have physical damage but experience no pain.
This is not to say there is no relationship, but that the relationship is not the end all be all. This is because the relationship between pain and physical injury is not causal. Pain is an experience and is different for everyone, so it is important to keep in mind that “x” may not necessarily lead to “y”.
There are many factors at play that could be causing your knee pain, and using the biopsychosocial model is one way to dissect why your knee is causing you pain.
Image from Research Gate
- From a biological perspective, the most obvious is having some type of physical trauma as tearing your ACL (Anterior Cruciate Ligament), which is a ligament that prevents anterior displacement of your patella. Furthermore, something mechanical can be causing your pain such as issues with knee tracking, patellar tendonitis, or perhaps you may even have an “impinged nerve” in your lumbar spine resulting in a radiculopathy causing referred pain in your knee.
- From a psychological perspective, your own beliefs and perceptions of pain could be affecting your pain experience. For example, if you associate that you “hurt” yourself squatting, you believe that squatting will cause you more pain when you do so.
- From a social perspective, your environmental factors can be causing you stress. For example, perhaps you got a new job that entails more physical exertion or your family is going through some trauma. This can all affect your pain experience and what you feel when squatting.
The point is, pain is multifactorial and subjective, so focusing solely on pain is a slippery slope. Furthermore, where you feel your pain may not be where the problem is like the example with lumbar radiculopathy (referred pain from the lower back).
I can’t tell you why exactly your knee hurts when squatting, but that doesn’t mean you can’t do anything about it. Regardless of what it is, management can be very similar when it comes to powerlifters and squatting.
What To Do When Experiencing Knee Pain When Squatting?
Based on the biopsychosocial model of pain, there are several ways that you can modify your training program, technique, and environment, in order to reduce the amount of pain you’re experiencing. Once we can rule out that the pain isn’t caused by a fracture or tumor, then the goal is to get back to squatting in a “pain-free” way as quickly as possible.
Physical Modification When Experiencing Pain
Physical modifications include:
- Modifying your training load
- Modifying your exercise selection
- Modifying your lifting technique
1. Modifying your training load
Quite often powerlifters get pain while preparing for a competition. This is when the training load is at its peak levels.
You could be experiencing knee pain during this time because the load has exceeded your adaptability. In other words, your ability to recover and adapt to the training stimulus.
If we think of the pain this way, then we should find ways to reduce the load. For example, if you start having knee pain at 100kg, try 90kg, or 80kg. If that is no good, then try adjust the sets and reps. If you are still having knee pain, then adjust the tempo, such as doing a 3 second eccentric and a 3 second concentric.
You can see here that there is a systematic way of modulating your load to see if you can avoid knee pain when squatting. As you can imagine, this works very well for people that only have knee pain at certain loads.
If you still have pain regardless of the load, then you should start looking at modifying the exercise selection.
2. Modifying your exercise selection
When making modifications to your exercise selection, this could be small or large.
A small modification could be adjusting the stance or bar placement of the squat. Larger modifications would include switching out the competition back squat with other types of squatting variations, such as front squats, or other lower body movements, such as lunges, Bulgarian split squats, or leg press.
There is likely something you can do without pain, and that is something you can work to build on while letting your body recover.
Pain normally resolves itself in most cases, but as powerlifters or serious trainees, we don’t have time to just sit around (which could even be more detrimental). Plus, we want to maintain our strength and come back stronger.
3. Modifying your lifting technique
If we want to look at technique modifications to our squat to get rid of knee pain, we can focus on three main areas: hips, feet, and core.
- What we do at the hip
When we think about the knee, we have a bunch of muscles attaching around it from the hip down. This includes our quads, hamstrings, adductors, and glutes via the IT band. Working on certain aspects of the hip can help with knee pain.
Learn more about the muscles used in squatting HERE.
For example, if you have pain whenever you utilize the quads via knee extension, then working on the hamstrings with knee flexion could help offset the pain.
Leg Curl Machine
If your pain is due to your patella tracking laterally from a tight IT band, then you’ll want to strengthen the muscles on the medial side of your patella such as your adductor muscles and vastus medialis (VMO). Slow eccentric squats have been shown to increase VMO activation and you could use a Copenhagen plank for the adductors.
Furthermore, we’ve all heard that our glutes are not activating, especially when our knees cave while squatting. While this is not always necessary, in some cases strengthening the gluteal muscles can help with your knee pain. Some of my go-to exercises are:
- What we do at the foot
How we load our foot can influence our patellar tracking which may be causing our pain. We can learn and focus on how to apply what is called a short foot.
Short foot is a form of loading your foot to properly disperse the forces throughout your foot, placing the load over your first and 5th metatarsal and the base of your heel.
For starters, try squatting barefoot, while keeping your big toe glued to the ground and see if that helps with your knee pain.
A common thing we like to blame for our knee pain is also a lack of ankle dorsiflexion. Essentially, a restriction at the ankle joint that prevents full range of motion when you squat. You can try squatting with plates on your heels to see if that helps at all.
- What we do with our core
Technical modifications can go beyond the hip and the foot, and include bracing mechanics for the core and lower back.
If your knee pain is actually referred nerve pain caused by lumbar spine instability, then performing core stabilization exercises and employing proper bracing techniques could help in that regard.
Stu Mcgills Big Three
Key takeaways when modifying technique
You will run into a lot of trial and error as to what will work, but the point of all these modifications is to modify your mechanics to a point where you can squat without pain and build your load tolerance from there.
These types of technical modifications work very well for people that have knee pain associated with a certain movement. There is no inherently wrong way of doing things, but if it is causing you pain then there is certainly a better way of doing things for your case.
Technical modifications are not a one size fit all model, and there are no magical exercises to fix your knee pain even though it may seem that way. Similarly, just because something helps, does not mean that you have a certain diagnosis. Context is key, and trained professionals are available to help you.
Social & Psychological Modification When Experiencing Pain
We briefly talked about some social and psychological factors that could influence knee pain so it would be beneficial to implement strategies to work on your own coping skills and stress.
First off would be to reframe your mindset around pain, and focus on what you can do versus what you cannot do. Pain itself does not have to be a negative thing and can actually be a very normal and natural feeling (ie. childbirth). Just because you have some aches and pains does not mean you are “injured” and unable to do anything.
For example, in my own experience, when I discussed with clinicians about my own injuries, I realized the plethora of activities that I can still do despite having pain that prevents me from squatting or deadlifting. Instead of going to the gym thinking that I can’t squat, I instead focus on the things I can do, such as leg press, upper body or even engaging in other activities like rock climbing.
In addition, make sure you are getting enough sleep, and nutrition. In terms of stress, utilize coping strategies, such as talking with people and seeking help if you need it. It’s very easy to focus on our pain and to let that feeling leak out and affect other parts of our lives. Just because we can’t squat, shouldn’t mean that we can’t enjoy other aspects of our lives. It doesn’t mean to forget or ignore your pain, but to embrace it and move forward.
Now a quick note is that this does not mean the pain is all in your head and that you should just “think it away”. Many things can influence pain, and using a whole encompassing strategy is the best solution when it comes to management. After all, there’s no hard and fast rule that your pain has to come from one specific thing.
Prevention: Avoiding Knee Pain When Squatting
So what can we do now to hopefully prevent knee pain and keep squatting in the future?
At the end of the day, the best thing we can do as powerlifters is load management. Keep in mind, however, that even if we track everything “properly” that pain can still occur.
For a powerlifter who wants to squat, load management primarily comes from their own programming. Let’s take a look at some things you can do.
Progress your load in a smart manner
- Try not to max out every day, and make appropriate meaningful jumps in weight
- Have a system in place, and use tools such as RPE to gauge when to push and pullback in training
Manage your fatigue
- Use strategies such as by de-loading and again RPE to manage fatigue
- Try to get enough sleep and proper nutrition
Bulletproof your technique
- Always try to be better. You can always improve on something, and just because it’s good now doesn’t mean it’s guaranteed to stay that way.
- Focus on quality over quantity, good reps
Implement varied exercise selection
- Try to do more than just squat, bench, and deadlift, when you can afford to. It’ll likely do you some good to take some time away from training and focus on other areas of your life. You’ll come out stronger in the end.
Know that all the therapeutic modalities in the world are tools to help you achieve this, and are not fixes or magical techniques to prevent and eliminate pain.
Rehab is not a straight linear line, it can be all over the place. Everything is a tool that can be used to help you get better, they are not quick fixes. Things will take time, they will take work, and they will take discipline. Sometimes miracles seem to happen, but that is the hard truth. It can be a grueling journey, but you are not alone.
Sample Plan For When You Have Knee Pain While Squatting
So what if you have knee pain now, what if you encounter knee pain in the future?
Here’s a sample step by step approach on what you can do when you have knee pain squatting to get back to squatting.
This is just an example. I recommend seeing a professional to rule out anything serious and to diagnose your exact situation.
Step 1 – Reduce the weight
Reduce the weight of the exercises causes you pain.
Step 2 – Modify sets and reps
Adjust the number of sets and reps you do with the exercises that cause you pain. Reducing the number of reps will help you avoid fatigue.
Step 3 – Modify exercise tempo
See if modifying the exercise tempo (slowing it down) has an impact on your levels of pain.
Step 4 – Utilize assistance exercises/technical modifications
Implement some of the technical modifications discussed above, such as glute activation or short foot.
Step 5 – Utilize therapeutic modalities
Implement some passive and active therapies such as foam rolling, stretching, and seem health care professionals for massage or manual manipulations.
Step 6 – Modify squat position
Adjust components of the squat such as bar placement and stance width.
Step 7 – Analyse exercise selection
Analyze what exercises give you pain and implement exercises that allow you to move pain-free. these could be exercises like Bulgarian split squats or leg press.
Step 8 – You’re lying go back to 7 and find something to do!
There is definitely something you can do in the gym that doesn’t cause pain. Go find what those exercises are and focus on improving in those areas.
Examples of Powerlifters With Knee Pain While Squatting
Here are some different scenarios of when powerlifters can experience knee pain and what to do in those specific cases. As you can see, there is no one-size-fits-all model when understanding the root cause of the pain and the path to recovery.
Lifter A: Knee pain is getting worse & reducing load doesn’t help
Lifter A has been having knee pain when squatting. It started a couple of weeks ago at 75% of their 1 rep max, and has continued to get worse. Today, he experiences knee pain every now and then when squatting, regardless of the load on the bar.
In this case, reducing the load has no effect on his symptoms, so now he can try changing the tempo. Tempo helped a little bit, but is still painful. Moving on to technical modifications, he tried to implement short foot which eliminated his knee pain in a bodyweight squat, but the squat with a bar on his back still hurts. He found that a front-loaded goblet squat with 15 pounds does not hurt.
Over time, Lifter A worked on short foot mechanics with a tempo using a goblet squat, slowly increasing the weight until he was able to squat pain-free with the barbell. Then he slowly added more weight onto his back squat. Some days were painful, and he reduced the weight, other days he felt great.
This is an example of a lifter using the step by step process. He tried to manage the load but failed, and ended up using some technical modifications in addition to different exercise selection to guide his rehab and get back to squatting. Not only did he modify his activity, but he took his time to build up his load tolerance.
Lifter B: Experiencing knee pain preparing for a powerlifting competition
Lifter B is prepping for a competition and started having knee pain 3 weeks out. He found massage to be helpful. Lifter B refuses to reduce the load as he is in season, but found therapeutic modalities and some assistance exercises such as eccentric leg extensions to help him with his pain. After his competition, he took time off, and his pain went away.
So in this case, Lifter B was in season and could not afford to reduce the load. Instead he used a therapeutic modality and an assistance exercise to help manage his pain while still training. After his competition, he was able to take time away from heavy loads and the pain dissipated. At this point, it is uncertain why he was experiencing pain. However, he can still work on load management and some technical modifications to improve his performance and hopefully help with preventing pain in the future.
Lifter C: Getting knee pain in every day life
Lifter C has bilateral knee pain when squatting. Walking up the stairs is difficult, and he has recently started having back pain as well. He reports trouble sleeping and going to the bathroom.
In this case, lifter C should go see their doctor immediately to screen for any red flags such as cancer or any sort of trauma. Sometimes things can be very serious so it is important to be conscious of and seek the appropriate care. Now I’m not saying this to scare anyone, but the point is people should be aware that not everything is “fixed” by “glute med activation”, a quick adjustment or reading an article.
Whatever the case may be, there is always something you can do. Try it out, and if it’s not achieving the effects you expect it to, then go back to the drawing board and try something else.
You can imagine that if a program is not yielding you any progress over a long period of time, you wouldn’t keep running it to the ground, you’d try something else. This is extremely difficult to do yourself, as it is hard/impossible to be objective about our own injuries and progress, but the good news is that there are people out there who are trained to help you.
Seeking a Professional – Choose The Therapist, Not The Therapy
Say you want to see a professional for your knee pain, where do you start?
Well, it’s a lot like shopping for clothes, you want to shop for the right fit for you.
For starters, find someone who knows what you are looking for. If you are a powerlifter, it’d likely be better if you found a practitioner who knows what powerlifters do. Call them, and see if you like what they are about and what they do.
Cost is obviously an issue for a lot of people, so see if you have insurance and find someone through your own network. Also, there is no harm in going to see multiple practitioners. Remember, they are there to help you, and if there is someone that can help you better then it is their jobs to refer you to them.
It doesn’t matter what profession you go to, but who you go to. Choose the therapist not the therapy. At the end of the day, don’t give up and find ways to keep moving.
Regardless of how careful you are, you can run into issues with whatever activity you choose to do. It is a natural part of life, but it doesn’t mean it’s the end of the world or the end of your lifting career. Take a breath, give it time and some honest work. Utilize the resources you have available around your community, and just keep moving.
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About The Author
Clifton’s most notable achievement is winning the 2017 IPF Classic World Championships in the Junior 66kg class whilst setting an Open World Record Deadlift. He graduated with a Bachelor of Science degree in Kinesiology and is currently pursuing a Doctor of Chiropractic.
Welcome back to Squat University! Today I want to introduce a simple guide to help you figure out which type of knee pain you may have.
When most people develop knee pain while barbell training, they’ll receive a vague diagnosis from the doctor of “Patellofemoral Pain Syndrome” (PFPS). Unfortunately, this is a junk term that covers several possibilities. Some have described it as a ‘condition of many conditions’ as the name is often overused as an acceptable diagnosis without a clear understanding for the source of pain. Using such an ambiguous term only leads to confusion.
In 1998 four leaders in the field of sports medicine and rehabilitation (Kevin Wilk, George Davies, Bob Mangine, and Terry Malone) came together to develop the most detailed classification for patellofemoral syndrome or generalized knee pain.2
By separating the different causes of knee pain into special categories, it allows for a better understanding for how to fix the problem.
Listed below are common knee injuries that barbell athletes sustain.
- Iliotibial Band Syndrome
- Patellofemoral Compression Syndrome
- Biomechanical Dysfunction (aka Bad Technique)
- Patellar and Quad Tendinopathy
There are other causes of knee pain, of course, but a large majority of the problems I see with barbell athletes can be traced back to these four diagnoses.
ILIOTIBIAL BAND SYNDROME
The IT band is a thick band of fascia that starts at the hips and runs the entire length of your leg, connecting to the outside part of the patella (knee cap), tibia, and lateral hamstrings (biceps femoris tendon).1 This pain usually presents on the lateral part of the knee and is caused by excessive compression of the band as it pushes into the fat pad that covers the prominent bony part of the femur (lateral epidondyle). Symptoms often grow over time and aren’t often linked to one specific incident or trauma (like getting hit on the side of the leg).
The location of pain is actually one of the best diagnostic tools for differentiating IT Band Syndrome from other forms of knee pain. While this pain can start off dull and achy, it can often progress to a sharp pain that you can pin point to one specific area on the lateral surface of the knee where the band inserts. Some people will even complain of a painful “popping” or “snapping” sensation at times.
This injury will not create pain often around the knee cap, as that symptom is usually reserved for the next two diagnoses (compression syndrome and biomechanical dysfunction).
PATELLOFEMORAL COMPRESSION SYNDROME and BIOMECHANICAL DYSFUNCTION (LATERAL PATELLA TRACKING)
If you have pain generally around your knee cap (patella) or directly underneath it, you’re likely dealing with one of two issues: a tracking/compression issue of the patella or a biomechanical dysfunction. This pain usually increases in intensity the more you lift (squatting 100 lbs. may bring out 1/10 pain while 300 lbs. will create 5/10 intensity).
As you move your knee, your kneecap travels within a small notch in your femur called the patellar groove. As your knee bends and straightens the tissues (muscles and fascia) that surround the joint keeps the patella traveling in a stable position. If, the patella fails to track and move correctly within this groove, injury can occur.
For example, when the tissues that surround the knees are stiff and bogged down, the patella will be smashed into the femur’s groove. This type of compression can cause the patella to shift and tilt to the side (creating uneven pressure on the underside of the bone). When this occurs, it can create pain under the kneecap where there is excessive pressure between the two bones (femur and patella) or on the inner or medial side where the tissues are being stretched out.
Poor knee control (instability) can also cause the patella to sit and track incorrectly within the femur’s groove. Poor technique when barbell training can lead to knee pain (this is the most common reason why!). Even the most subtle problems in knee control can lead to the gradual development of pain over time.
When I screen an athlete who has knee pain, I ask them to first perform a bodyweight squat without shoes on and with their toes straight relatively forward (about 5-7 degrees of toe out angle). In order to perform a good full depth squat the athlete must have good ankle and hip mobility, adequate core/pelvic control, sufficient balance and knee control.
Next I will ask the athlete to perform a single leg squat on each side. You have to be very observant during this part of the examination (taking video of this movement can be helpful for review) as even the smallest differences in side to side mechanics may be the reason behind the current symptoms. Many athletes will be strong enough to “hide” their imbalances in mobility or stability when on two legs. However, when you challenge them to squat with one leg then the once “invisible” problems are now uncovered.
The “why” behind both compression and tracking injuries of the knee can often be traced back to a deficit or “weak link” in either mobility and/or stability. For example, did you notice what happened at your own feet during the single leg squat?
The foot is like your body’s house of cards’. Its stability sets the foundation for the rest of your body to move. When the foot collapses over (pronation) it leads to rotation in the tibia that forces the patella to move laterally.3 This same problem (wobbly knees) can also occur due to poor hip coordination that leads to knee collapse during the squatting motion. If you only poked and prodded around the knee during your examination and never take a step back and take into account the entire person in front of you, you’ll miss valuable insight into why your injury occurred.
Flexibility and mobility issues in the lower body can also create a number of movement problems that lead to knee pain. For example, limited ankle mobility or stiffness in the lateral hamstrings can lead to excessive toe-out angle during the squat that again pulls the patella laterally. When the knee moves in this off-axis manner with enough repetition, pain eventually develops around the kneecap. We will go over how to screen for this later on.
PATELLA AND QUAD TENDINOPATHY
Athletes who are involved in sports that include sudden explosive and repetitive movements of the knee can develop pain and tenderness at these tendons. Of the two, patellar tendon pain is usually the more common injury especially in sports such as basketball and volleyball due to the excessive jumping (this is where the term “jumper’s knee” was coined). Interestingly enough, it is due to the high volume of jumping rather than the amount of running that facilitates these injuries as running usually doesn’t place high enough load on the tendon to create symptoms.5 Patellar and quadriceps tendon pain are also prevalent in sports such as weightlifting, powerlifting and CrossFit due to the high forces that are sustained during the repetitive strength and ballistic movements.
Classically, those with patellar tendinopathy will complain of tenderness and pain at the connection point of the kneecap and patellar tendon (called the inferior pole of the patella).6 You may even experience pain where the patellar tendon attaches to the tibia (a small bump on the front of your shin called your tibial tuberosity). Usually you won’t have pain directly in the center of your patellar tendon unless you’ve sustained a direct blow to the knee (like hitting your knee into a corner of a desk). Those with quadriceps tendinopathy will have pain and tenderness at the connection point of the kneecap and the quad tendon (called the superior pole of the patella).
Do not assume that you have patellar or quad tendinopathy just because of the location of your pain! Poking and prodding tender tissues is not enough. This is one of the most common pitfalls to the diagnostic process and can lead you down the wrong path of treatment!
Also, do not rely on medical imaging to diagnose yourself with tendinopathy! Many times people will have imaging that shows degrading pathology in the tendons, however the source of their knee pain is actually something!4
There are two hallmark features of tendinopathy:4,5
- Pain remains localized to the inferior pole of the patella (you should be able to point directly to where your pain is and it should not move as you perform different activities).
- The intensity of your pain is proportional to the amount of energy stored in your tendon. The more you use your tendon like a spring, the more pain you have (a reason riding a bike will never create tendinopathy as the tendon is not used in that manner).
With these key points in mind, try these simple tests. Perform your basic bodyweight squat again and rate your pain from 0-10 (zero being no pain and ten being the absolute worst pain you could imagine). Next, perform 10 tuck jumps in a row as high off the ground as you can without any rest in between each jump. Did your pain intensity go up? If it did increase, did the pain remain localized to the inferior pole of the kneecap or did it start to spread over time to other parts of the knee joint? Compression and tracking issues rarely co-exist with patellar tendinopathy so make sure you can clearly answer each of the prior questions.
DIAGNOSING YOUR KNEE PAIN
|IT Band Syndrome||Patellofemoral Compression Syndrome or Biomechanical Dysfunction||Patellar & Quad Tendinopathy|
|Pain is on the side of the knee just above the bony prominence (lateral epicondyle). Your kneecap is not sensitive to touch.||Pain is located in or around the kneecap. It is not comfortable to push on your kneecap while contracting your quads.||Pain can be localized to either above or below the knee cap (often in the tendon that attaches to the bone). It will remain localized and increase in intensity as you increase load and use the tendon as a spring.|
OTHER HELPFUL TESTS
5 inch Ankle Mobility Screen
Testing ankle mobility should always be a part of the screening process when dealing with a knee injury. For example, if the gastroc and/or soleus muscles are stiff or short, there is less range of motion to absorb load during activities like landing from a jump. For example, research shows that between 37-50% of the total forces absorbed by your body when landing from a jump occur at the ankle joint.8 Ankle stiffness therefore reduces the capacity of the body to absorb energy in this manner, which means higher loads are transferred up the body to the patellar tendon. Therefore, the patellar tendon is placed under greater strain as the tendon has to take more loads more quickly, increasing the risk of tendinopathy.9
Limited ankle mobility can also play a part in changing how our knee moves when we perform movements like a squat, clean or jump. In the book Anatomy for Runners physical therapist Jay Dicharry, uses a perfect metaphor for describing how these types of restrictions change our movement patterns.10 If you have ever driven your car through a European-inspired roundabout, you know that you can’t just drive straight through the intersection. You have to go around the center island.
An ankle with full mobility will allow the tibia to move freely on the foot. Think of this like a car being able to move straight through an intersection. A bony block is like a roundabout in the intersection. When the car enters the intersection, it must now go around the island in order to proceed on its previous route. Essentially our lower leg spins off its normal route and falls inward. As our lower leg goes around the bony block, the knee is pulled inwards. Movement breaks down. Limited ankle mobility is therefore a potential factor in why someone could develop a patellar tracking or compression injury!
The 5 inch wall test is a very simple screen you can perform on your own.11,12 Kneel down by a wall and place your toes five inches from its base. Drive your knee straight forward over your toes attempting to touch the wall without letting your heel pop off the ground.
What did you find? Were you able to touch the wall with your knee, or did your heel pull off the ground? If you failed the 5-inch wall test, you just uncovered a weak link in ankle mobility that needs to be addressed.
SINGLE LEG BRIDGE SCREEN
It is common to see strength deficits and coordination issues in how muscles are activated at the hip with athletes dealing with knee pain. In my experience, many athletes demonstrate underactive or weak glutes. A simple screen to expose this weakness is a single leg bridge test.
Lay on your back with one leg bent and the other straight. Perform a single leg bridge and hold the highest position for 10 seconds. What muscles did you feel working hard after holding this single-leg bridge for 10 seconds?
Our goal with this screen is to identify your “go-to” muscles for hip extension (the movement that drives you out of the bottom of the squat, clean, snatch, etc.). If you felt anything other than your butt muscles (glutes) working hard, you have a coordination and/or strength problem we need to work on.
Finding the source for you aching knees can be a daunting task, however with the proper diagnosis we’ll be able to better direct you in fixing your pain. None of these injuries will bring out locking or clicking of the knee, significant swelling, tingling, numbness, or throbbing in the back of the knee. If you have any of these symptoms, it’s likely an indication of a more significant problem that requires a medical evaluation by a professional.
Until next time,
Dr. Aaron Horschig, PT, DPT, CSCS, USAW
Dr. Kevin Sonthana, PT, DPT, CSCS
- Khaund R & Flynn SH. Iliotibial band syndrome: a common source of knee pain. American Family Physician. April 15, 2005; 71(8): 1545-155
- Wilk KE, Davies GJ, Mangine RE, Malone TR. Patellofemoral disorders: a classification system and clinical guidelines for nonoperative rehabilitation. JOSPT. November 1998; 28(5): 307-322
- Sammarco GJ, Burnstein AH, Frankel VH. Biomechanics of the ankle: a kinematic study. Orthop Clin North Am. 1973; 4(1):75-96
- Rio E. Isometrics for tendon pain. Practical implementation and considerations. Sports Health. 2016;34:33-35
- Cook J, Rio E, Docking S. Patellar tendinopathy and its diagnosis. Sports Health. 2014;32(1):17-20
- Rudavsky A, Cook J. Physiotherapy management of patellar tendinopathy (jumper’s knee). Journal of Physiotherapy. 2014;60:122-129
- Malliaras P, Cook JL, Kent P. Reduced ankle dorsiflexion range may increase the risk of patellar tendon injury among volleyball players. J Sci Med Sport. 2006;9(4):304-9
- Devita P, Skelly WA. Effect of landing stiffness on joint kinetics and energetics in the lower extremity. Med Sci Sports Exerc. 1992;24(1):108-115.
- Backman LJ, Danielson P. Low range of ankle dorsiflexion predisposes for patellar tendinopathy in junior elite basketball players: a 1-year prospective study. Am J Sports Med. 2011;39(12):2626-33
- Dicharry, J. (2012).Anatomy for Runners. New York, NY. Skyhorse Publishing.
- Bennell K, Talbot R, Wajswelner H, Techovanich W, Kelly D. Intra-rater and inter-rater reliability of a weight-bearing lunge measure of ankle dorsiflexion. Australian Journal of Physiotherapy. 1998; 44(3):175-180.
- Reinold M. (2013) Ankle mobility exercises to improve dorsiflexion. Retrieved from MikeReinold.com.
A swollen knee is never normal and warrants a trip to the doctor.
A swollen knee is never normal and warrants a trip to the doctor. But for the medical sleuths among you, here’s how to assess the situation—and prevent it from happening again.
A swollen knee may also be painful, stiff and keep you from fully extending your leg. To figure out why it’s swollen, identify when it first puffed up.
Within an hour or two of activity: Swelling that occurs soon after an activity is much more serious than swelling that shows up, say, the next day. Example: You twist your knee trail running and it swells up. This is a sign of bleeding within the knee, or hemarthrosis. Basically, something has been torn or broken. About 80 percent of hemarthrosis cases are caused by a torn anterior cruciate ligament (ACL). Sudden-onset effusion is a sign that something serious is going on.
Hours later or the day after activity: Swelling that arrives later is generally caused by excess synovial fluid (the lubricant in joints) in the knee, much like too much oil in a car. Overuse and an underlying medical condition are the most common causes.
Something in there is irritated or rubbing during activity, and the body responds by over-lubricating the knee to compensate. Osteoarthritis is one of the most common causes, but far less common maladies can also be the culprits, such as rheumatoid arthritis, infection, gout, bursitis, cysts, bleeding disorders, tumors and Lyme disease. Advancing age and participation in sports that require sudden changes in speed and direction raise your risk.
See a doctor. Anytime you have a swollen joint, you should see a doctor. This is especially true with sudden-onset effusion
Employ dynamic rest. Even if the swelling comes without pain, avoid loading the knee until the swelling subsides. Trade knee-loading exercises for intense upper-body and core work.
Ice it. Apply ice for 15 minutes 4–6 times a day for the first two days of swelling. Elevating the knee as you ice it can also help reduce the swelling.
Strengthen your legs. Strong legs protect your knees. Be sure your workout regimen includes regular lower-body strength training in addition to any running, and biking that you do. You may not be able to prevent knee effusion caused by health issues, but properly trained legs will help your knees recover in the long run no matter what the issue turns out to be.
When to Call a Doctor
My philosophy is that any time you have joint swelling, you should see a doctor because you need to figure out what the problem is. Try to pinpoint when the effusion began in relation to your athletic activities, especially if your knee has swelled up with no discernible cause such as an overt injury and you have no other symptoms that suggest a related illness. A physician can help shed light on the mystery, whether by physical exam, analysis of fluid drawn from the knee, or review of images such as MRIs or X-rays.
Also, if the knee is swollen but has some extra symptoms like redness or warmth of the skin and/or you have a fever, it could signal an infection. Get to an ER pronto.
More Med Tent
Think you can’t run, squat, lift or cycle because of your dodgy knee? Think again. A sore knee is not a death sentence and keeping as active as possible is just as important if you suffer from knee problems.
If fact, choosing the right type of exercise can actually help to ease joint pain and make you fitter and healthier in the long run.
Sports physiotherapist and osteopath Tim Allardyce offers his expert advice on what you can and can’t do if you suffer from knee pain:
What is knee pain?
Knee pain is typically anterior, which means it’s at the front of the knee. But you may be able to feel the pain at the sides, back or along the joint line of the knee.
‘There are a number of things that could be causing knee pain, such as cartilage tear, ligament tear or other things like muscle problems,’ says Allardyce. ‘And there’s also a chance that you could be suffering from osteoarthritic knees.’
⚠️ If you are concerned, speak to your GP, who might refer you for an X-ray. If the problem is due to the joint capsule and the supporting muscles, a course of physiotherapy to strengthen the quadriceps muscles that form the front of the thigh, may also help.
Myth: Don’t do ANY exercise if you have any knee pain
If you have knee pain, you need to be careful when doing weight-bearing exercises, such as body pump classes, Zumba, step aerobics, jumping, running and sprinting, as these can all put a strain on your knee joints. But you can still exercise! You just need to choose wisely.
‘It’s dependent on the knee problem to what exercise you can do,’ says Allardyce. ‘If you get pain, stop or slow down. Don’t push through the pain – listen to what your body is telling you.’
Opt for non-weight-bearing exercises, such as cycling, cross-training and swimming. You can even power walk, which will put much less strain on the knee.
Myth: You should rest until knee pain goes away
This is a common mistake people make. You can exercise the knee with care. However, if it’s a fresh injury and your knee has been sprained and is swollen, or if you’re having difficulty bending it then this is a different matter.
‘You should rest for around 48 to 72 hours and use either crutches, a walking stick or rest it completely by lying down,’ says Allardyce. ‘Apply ice and do gentle mobilisation exercises. But thereafter you can gently exercise it.’
Myth: Don’t exercise if you have arthritic knees
Not exercising because you have arthritis is one of the most common myths about knee pain. As a general rule, if you have osteoarthritis it is fine to exercise.
A report by the American College of Sports Medicine (ACSM) provides strong evidence that exercise is, in fact, good for the knees. The findings concluded that exercise actually helps improve the cartilage in between joints instead of breaking it down.
‘For years, doctors have said for years that patients should rest their knees – but now we think differently about this,’ says Allardyce. ‘Osteoarthritis is probably one of the biggest problems in the UK with knees – one of the most common surgeries is a knee arthroscopy or a knee replacement and typically osteoarthritis develops after any knee injury.’
Myth: You shouldn’t run
You do need to be careful running with a sore knee, because any weight-bearing exercise can potentially cause knee pain, but unless you’re in acute pain, there’s no reason why you should stop running.
If you run regularly, it is common to feel occasional twinges in your legs. Try to run off-road on gentler surfaces such as trails and paths, and book regular appointments with a sports massage therapist to keep your knees in tip-top shape.
Will running on a sore knee cause future health problems? Research by Hansen P at the University of Utah Orthopaedic Center concluded that low- and moderate-volume runners appear to have no more risk of developing osteoarthritis than non-runners. ‘The jury is still out and different experts disagree – some say it does some say it doesn’t,’ says Allardyce.
⚠️ If you’re a keen runner and you experience occasional knee pain, it’s worth investing in a foam roller!
Myth: You shouldn’t squat
Squatting is generally considered good for your knees. The main function of the knee is to be able to bend – so it’s perfectly normal to keep on squatting.
‘For some reason when we’re in the gym, we’re more apprehensive to squat. If you have painful knees, you may want to make the squat easier,’ says Allardyce.
‘You could just do a quarter leg squat where your knee just bends a little bit – or a half squat where your knee bends half way. Or you could put a Swiss ball behind your back and do a wall squat. This is a great way to rehab people with knee problems.’
Fact: You shouldn’t jump
Jumping is not recommended if you have knee problems and it’s actually one of the tests sports physios use to see how fit athletes are after knee problems.
‘We’ll get them jumping off a high wall to see if their knee can take it,’ says Allardyce. ‘Someone with a knee problem will know instinctively that they won’t want to jump. They will be very apprehensive.’
⚠️ Avoid jumping if you are experiencing knee pain, because it will put too much pressure on your knees.
Exercises to strengthen your knees
1. Knee flexion exercise
- Lie face down, and bend your knee bringing your heel towards your bottom.
- You will feel a gentle stretch to the quadricep muscles at the front of your thigh.
- Make sure you bend the leg in a controlled way.
- Return to the start position slowly and using the same level of control.
- Repeat this exercise 10 times, and perform three times per day to improve range of mobility to your knee joint.
2. Half wall squat with gym ball
- Place a Swiss ball behind your lower back, and keep your feet shoulder width apart.
- Bend your knees to the half squat position.
- Keep the middle of your knee-cap in line with the middle toes of your foot.
- Return to the start position.
- Repeat the exercise 10 times, twice a day to strengthen your quadricep muscles and knees.
3. Knee extension
- Sit down on a chair and place a towel under your thigh.
- Pull your toes up, tighten the muscles in the front of your thigh (quadriceps muscles), and slowly pull your leg to a straight position.
- You will feel a stretch to the hamstring at the back of the thigh, and contraction of the quadriceps in the front of the thigh.
- Hold this stretch for 15 seconds, and relax.
- Repeat three times, twice a day.
Last updated: 07-11-19
Dr Roger Henderson Dr Roger Henderson is a Senior GP, national medical columnist and UK medical director for LIVA Healthcare He appears regularly on television and radio and has written multiple books.
Persistent mild knee pain due to squats – push through or stop?
Over the last 2 months or so of doing heavy squats (200 lbs – 262 lbs) I’ve frequently had pain in my knees. During the last 2 weeks, it’s been especially persistent and seems to be mostly in my left knee. I’m normally sore after working out, especially in my legs and lower back, but the knee pain seems to persist long after the other pains go away.
What does it feel like? Well, it’s on the front side of the leg, centered just below the knee cap. By “below” I mean “in the direction of my foot”, not “closer to the bone”. It’s hard to describe the sensation exactly. It’s kind of a pulling/burning feeling. It feels somewhat different than muscle soreness elsewhere, but I don’t feel like anything’s grinding or scraping or popping. It’s not a “sharp” pain.
As far as intensity goes, it’s not excruciating. Actually it’s mild enough that I feel that I could ignore it when doing my squats and continue performing my workouts as planned. I’m just not sure that’s a good idea. It is bad enough though that running for more than a minutes or so is a very unpleasant idea.
I do not feel any pain when standing, sitting, or walking. I do feel it whenever I ascend/descend at all. Getting up from a chair, walking up or down a flight of stairs, and of course when doing squats. I also feel it when running.
I’ve tried skipping a couple workouts, and although the pain seems to gradually get better with time, 5-6 days is not enough to get rid of it, and it comes right back when I resume my workouts. I had been more or less ignoring it for the last month or so, but since it’s now preventing me from running, I’m getting more concerned.
I have also tried using a foam roller on the muscles surrounding my knee (but avoiding the knee itself). This seemed to help with some other pains/soreness I’d had, but not with the knee pain.
I’m 95% sure the pain is caused by my squatting. It always gets worse during/after I squat. I squat just below parallel, with a shoulder-width stance and my feet pointing outwards about 15 degrees. I try to keep my knees following that 15 degree direction, pointing in the direction of my feet, when I descend. Historically I’ve done 5 sets of 5 reps, but more recently I’ve been doing 3 sets of 5. I rest about 5 minutes in between sets.
So, should I be concerned about this, if so how should I handle it? Is it likely that I’m doing something wrong? Should I take a couple weeks off from squatting and running? Ignore it and keep going? Deload significantly and work back up so my body adapts more? See a doctor? I know you are (probably) not a doctor and not qualified to give medical advice. I’m just hoping to find out if this (1) ignorable, (2) a concern, but something that can be solved with a period of rest and/or dealoading or (3) a big problem I’ll need professional help with.
Update: I saw an osteopathic doctor yesterday. He told me my tendons and ligaments were fine. In fact he said “your ligaments look like they’re built to take a lot of punishment!”. He diagnosed patellofemoral pain syndrome AKA “runners knee”. He told me the inside of my knee cap had become rough. He prescribed R.I.C.E (Rest, Ice, Compression, Elevation) as well as a twice-daily stretching regimen, and weighted leg extensions 3 times a week. He also suggested I take ibuprofin, especially if I’m doing anything to aggravate my knees. He told me recovery could take 6 weeks or more, but call him if I didn’t see a significant difference by the end of the month.
So at this point I’m going to follow the routine the doctor gave me for the next 6 weeks or so, and avoid squats, deadlifts, and running. I will continue doing the other exercises I’d been doing (bench press, overhead press, rows, and pull-ups). I may also try swimming if I feel like doing cardio (but I’m a terrible swimmer). After I feel I’ve recovered I’ll start squats with about 50% of the weight I was last doing (262 lbs was my peak work weight) and I’ll work my way back up. I’ll have someone check my form then too.
Thanks for the answers. They helped me to realize that this wasn’t something I should ignore, and that my squat form was likely at fault. I’m marking Dave’s answer as “most helpful” for the strong suggestion to see a doctor, which I did. But I also really appreciate Berin Loritsch’s answer for the form tips and the TUBOW suggestion especially.
≫ Understand the functional anatomy and physiology of the knee.
≫ Learn about the serious limb-threatening injuries that can occur as a result of trauma to the knee.
≫ Learn practical tips to help you successfully evaluate and manage serious knee injuries in the prehospital setting.
Foot drop: Gait abnormality in which the forefoot is unable to be lifted upward due to weakness, irritation or damage to the peroneal nerve.
Knee dislocation: Complete displacement of the tibia in relationship to the femur in either the anterior or posterior direction. Associated with serious injury to the cartilage, ligaments, blood vessels and nerves of the knee and lower leg.
Patella dislocation: Displacement of the patella (kneecap) out of its normal midline position in the patellofemoral groove. The patella typically dislocates laterally.
Popliteal artery: Continuation of the femoral artery that passes directly behind the knee.
It’s 11:00 p.m. when you’re dispatched to the southbound lanes of Interstate 5 at mile marker 171 for a confirmed multi-vehicle crash. You’re the second unit on scen eand upon arrival are directed by the incident commander to a front seat passenger inside her vehicle. She’s 32 years old and was restrained when her car rear-ended a truck that suddenly stopped in the left lane of the freeway. There’s extensive front-end intrusion but your patient is awake, alert and denies losing consciousness or hitting her head. Her chief complaint is left knee pain.
As the rescue company completes extrication and your partner begins the rapid trauma assessment, you can’t help but notice your patient’s left knee is swollen and her lower leg looks slightly dusky. You’re eight minutes from a busy community hospital and 30 minutes from a trauma center.
There are more than 1.3 million annual visits to EDs for knee trauma in the United States, with many of these patients initially being treated by EMS.1 The knee’s anatomic and functional complexity mean trauma can result in diverse injury patterns, including fractures, dislocations, sprains/strains, ligamentous and cartilaginous injuries, as well as potentially devastating neurovascular compromise.
Knee trauma can be a high- or low-energy mechanism of injury. High-energy knee injuries are largely caused by motor vehicle crashes (MVCs), falls from a great height and pedestrians struck by motor vehicles. They warrant immediate recognition, emergent evaluation and timely transport. Low-energy mechanisms include routine sports-related injuries, ground level falls and repetitive overuse trauma that can also cause significant long-term complications and decreased functional ability.
All knee trauma warrants a thorough prehospital assessment as missed or delayed recognition of serious injury can result in potentially limb-threatening consequences.
ANATOMY & PHYSIOLOGY
The knee is the largest joint in the human body.2 It’s a complex synovial hinge joint with many components vulnerable to injury. The four major components are bones, cartilage, ligaments and tendons. (See Figure 1, below.)
Figure 1: Anatomy of the knee
The three major bones that make up the knee joint are the femur, tibia and patella. The femur and the tibia form the articular component of the joint, and between the mare the medial and lateral menisci, which are wedge-shaped pieces of cartilage that distribute weight and act as shock absorbers.
Interfacing bone surfaces are covered with articular cartilage that allows gliding across one another as the knee flexes and extends.
Ligaments are bands of tissue that connect bones to one another, while tendons are bands of tissue that connect muscle to bone. The knee contains two categories of ligaments: collateral and cruciate. The collateral ligaments are located medially and laterally, bracing the knee against extreme sideways motion. The cruciate ligaments, both anterior and posterior, cross one another to form an X shape deep inside the joint. This provides rotational support and prevents the tibia from sliding forward or backward on the femur.
The patella protects the front of the knee and provides an attachment for both the quadriceps and patellar tendon. The quadricep tendon attaches the strong muscles of the anterior thigh to the patella and allows for extension of the lower leg at the knee. The patellar tendon anchors the patella to the anterior proximal tibia and also contributes to this motion.
The popliteal artery and peroneal nerve are two key structures that EMS providers must consider with every knee injury. Significant trauma to the knee or mismanagement and poorly applied splints can result in serious, often permanent, injury.1–4
The popliteal artery is the major artery that supplies blood to the lower leg. It’s formed by the femoral artery as it travels down the leg toward the knee. Its pulse can often be palpated on exam and is found on the posterior side of the knee, in the popliteal fossa. With its close and fixed proximity to the knee bones, the popliteal artery can be compressed or disrupted by knee dislocations and severe fractures. Assessing for the presence of a dorsalis pedis in the foot and posterior tibial pulse in the ankle are critically important when evaluatinginjuries.5
Originating from the sciatic nerve in the posterior thigh, the peroneal nerve supplies sensation to the front and lateral aspect of the lower leg and to the top of the foot, as well as motor function to the lower leg muscles that dorsi flex the ankle and toes upward. The peroneal nerve branches course superficially around the head of the fibula, just lateral and below the knee, and can also be injured in knee dislocations and fractures and by poorly applied splints. Injury to the peroneal nerve can result in a “foot drop,” or the inability to raise the forefoot during walking.
Fractures (patella, distal femur, proximal tibia): The most commonly fractured bone in the knee is the patella,2 which usually occurs from direct trauma to the front of the knee, such as with a fall or MVC. If the patella fractures into multiple pieces, the patient may be unable to actively straighten the knee. (See Figure 2, below.) Fractures to the distal femur and the proximal tibia can also occur and can be devastating to the overall function of the knee. In younger patients these fractures are typically from high-energy mechanisms, but in elderly patients with less dense bones, proximal tibia fractures can occur with lower energy mechanisms such as ground-level falls. Significantly displaced fracture fragments of the distal femur and proximal tibia can cause limb-threatening neurovascular compromise to the lower leg.
Figure 2: Open fracture of the patella
Ligamentous injuries: The anterior cruciate ligament (ACL) is the most commonly injured major ligament in the knee1 and is frequently injured in snow skiing accidents and in contact sports such as football.1,6 The ACL can also be injured in a non-contact fashion, classically when the patient is decelerating, pivoting, or changing direction with weight applied to thatleg.7 (See Figure 3, below.) About 67–80% of patients will report feeling or hearing a “pop” in their knee at the time of injury and will report significant joint instability.7 ACL injuries are often associated with immediate and significant swelling due to tearing of the synovium and small blood vessels. This swelling typically occurs within three hours but can take up to a day to develop.7 Injuries can be devastating, resulting in significant functional impairment. In addition, about half of ACL injuries are associated with damage to other structures in the knee such as a meniscus, cartilage or other ligaments.2
Figure 3: Ligamentous injuries of the knee (right knee, front view)
The posterior cruciate ligament (PCL) is less commonly injured due to its inherent strength and location within the knee. It’s typically torn after a direct high-energy impact to the anterior tibia of a bent knee such as by the dashboard during an MVC. Similar to ACL injuries, PCL injuries can cause significant joint instability and are often associated with damage to other structures in the knee.
The medial collateral ligament (MCL) and the lateral collateral ligament (LCL) help to stabilize the medial and lateral aspects of the knee and are typically injured by forces applied to the opposite side of the knee. This commonly occurs in lower-energy mechanisms such as a collision playing sports. The MCL is more commonly injured than the LCL and often associated with an ACL injury. These can be classified as sprains, representing partial injuries to the ligament, or as complete tears.
Meniscus tears: Meniscus injuries often occur as a result of a twisting motion put onto a flexed or weight-bearing knee. Meniscus injuries are often caused by a low-energy mechanism but can coexist with more serious injuries to other structures of the knee.1 Patients with meniscus injuries often note increased pain with weight bearing and describe a “popping” or “locking” sensation in the joint. Locking of the knee (i.e., fixed in flexion) immediately after injury is due to a mechanical block from the displaced cartilage.1
Tendon injuries: The quadriceps and patellar tendon can also be torn. Tears are more common in middle-aged patients during running or jumping sports such as basketball ortennis.2 Direct trauma to the knee such as a significant fall can also cause traumatic tendon rupture. Although the patient may lose the ability to actively extend the lower leg, remember that patients with quadriceps or patellar tendon ruptures often can still walk by leaning forward and allowing gravity to extend theknee.1 Early diagnosis of both quadriceps and patellar tendon rupture is important as urgent surgical repair is frequently necessary to preserve the extensor mechanisms of the knee.
Dislocations: A joint dislocation occurs when an injury forces the surfaces of two bones out of normal contact with each other, preventing the joint from moving through its normal range of motion. Dislocations of the patella and knee are often confused by both lay people and healthcare providers alike, but represent different pathologies with different treatment modalities.
Patellar dislocations are more common than true knee dislocations and often occur with a low-energy twisting mechanism while the foot is planted.1 Patellar dislocations mainly affect young active people, specifically young women, with a peak age between10 and 20 years old.5,8 They’re typically caused by the patella becoming displaced laterally out of the groove where it normally lies and can be very obvious on physical exam because of the grossly deformed appearance of the knee. Many patellar dislocations will self-reduce when the muscles of the thigh relax and the leg is straightened, such as for splinting, but some may require sedation and manual reduction in the ED. Although dislocation of the patella may spontaneously reduce, providers should remember that 12% of these dislocations will have a major coexisting knee injury.1,9 Lastly,patellar dislocations can be associated with ruptures of the medial patellofemoral ligament(MPLF), which can make future and recurrent dislocations more common.8
True knee dislocations are less common than patellar dislocations but are associated with much greater morbidity. Given that the knee is normally a very stable joint, a high-energy mechanism is typically required to dislocate the joint.5 Knee dislocations are termed anterior or posterior based on the direction the tibia is displaced in relation to the femur, but 50–60% are anterior.10
By its very definition, a knee dislocation is associated with serious injury to other structures in the knee such as the ACL, PCL and MCL ligaments, as well as the joint capsule, nerves, arteries and cartilage.3,11 Knee dislocations can be dangerous because the blood vessels (namely the popliteal artery) that run behind the knee can be compressed or torn during a dislocation event, thus compromising distal circulation to the lower leg.3,11 Popliteal artery injury has been reported in20–40% of knee dislocations, and between 20–25% of patients who suffer a serious popliteal artery injury require a lower leg amputation.4,5,12,13 In addition, injury to the peroneal nerve occurs in 25–35% of knee dislocations, thus proper immobilization and neurovascular checks before and after splinting are criticallyimportant.5,11,12
The key to prehospital management of a true knee dislocation is maintaining a high level of suspicion for the injury. Up to 50%of patients who suffered a knee dislocation will have spontaneous reduction in the field prior to ED evaluation, thus making diagnosis more difficult.10 The patient may not always give the classic history of the knee “popping out of place” and then suddenly returning to normal. Typically, if spontaneous reduction of a knee dislocation has occurred, the knee will still be significantly swollen, painful and structurally unstable on exam. However, if the patient has had complete disruption of the joint capsule, the hematoma may spread into the thigh or calf, resulting in the knee appearing almost normal in size.1
Lastly, it’s entirely possible to have a popliteal artery injury and still have a warm foot with palpable dorsalis pedis and posterior tibialpulses.12 It’s imperative providers remember that palpable pulses don’t rule out significant arterial injury.
TREATMENT & TRANSPORT
High-energy mechanisms that result in devastating knee injuries also frequently cause other potentially life-threatening injuries to the head, chest, abdomen, etc. Thus, personnel may become task saturated in caring for these time-sensitive, critical trauma patients. Providers should follow their department protocols and standard Prehospital Trauma Life Support principles in management of these multisystem trauma patients.
Initial assessment by EMS can prove critically important in successfully managing knee trauma. First, it’s imperative to establish the mechanism of injury, taking note of the position of the leg at the time of injury and the patient’s ability to walk post-injury. Understanding the injury pattern can raise suspicion for hidden neurovascular injury, resulting in very specific triage and management decisions for both EMS and in the ED.
A thorough examination of the knee should then follow. This includes a visual inspection of the entire leg, assessing peripheral pulses and determining if there are any sensory or motor deficits distal to the injury. An important area to assess for sensory loss is on the top of the foot, between the first and second toe. Numbness in this area following knee trauma is highly suggestive of a peroneal nerve injury.
Splinting/immobilization: At the cornerstone of prehospital management for knee trauma is splint application and joint immobilization.4,14 The goal of splinting isn’t only to support potentially unstable fractures, but to also decrease the patient’s pain and reduce the chance of further neurovascular or soft tissue injury from uncontrolled bone motion.14,15 (See “The Lost Art of Splinting: How to properly immobilize extremities & manage pain,” by Jennifer Cuske, RN, EMT-P, at jems.com/art-of-splinting.)
Prehospital providers are classically taught to splint musculoskeletal injuries in the position found unless there’s compromised distal circulation. However, in recent years there’s been increased recognition of the importance of realigning extremities into near anatomic position as early as possible to control pain and protect the site from additional vascular injury.11,14-16 The decision to reduce or realign a fracture or dislocation in the field is controversial and thus truly situation dependent.14,19 When splinting the knee, immobilize the limb in the position found or that of maximum comfort.18,19 However, providers should discuss with their medical direction specific indications and contraindications to attempting repositioning or realignment of serious knee deformities based on specific patient care environments (e.g., wilderness vs. urban setting), available local resources, level of training, and geographic proximity to the trauma center.17,18
Regardless of whether a knee injury is splinted in the position found or after a gentle attempt at realignment, care should be taken not to splint the leg fully extended as this may compress the neurovascular bundle against the posterior tibia.18,19 Splinting the knee with approximately 10 degrees of flexion is thought to be ideal.15 There are a variety of options for splinting the knee, ranging from preformed cardboard and vacuum splints to the sophisticated Reel Splint Immobilizer. Frequently utilized by the U.S. military, the Reel Splint Immobilizer with its unique multi-hinge system allows you to easily adjust the length and angle of the splint to fit almost any knee deformity.3
Regardless of the splint utilized, it’s most important to ensure it adequately prevents movement of the joint, is appropriately sized both circumferentially and lengthwise above and below the knee, is well padded, and allows continued assessment of the injured extremity during transport. Lastly, it’s critically important to complete and document a neurovascular exam both before and after any manipulation or splinting of the injured knee.14
Pain control: Knee injuries can be extremely painful—especially those sustained from a high-energy mechanism. It’s been well documented that prehospital providers often don’t provide adequate pain relief for patients with lower extremity injuries.20-22
This is especially true of pediatric patients, who are much less likely to receive appropriate prehospital analgesia than adults with similar extremity injuries.20 In addition to splinting and elevating and icing the injured knee, providers should strongly consider early administration of IV, intranasal or intramuscular pain medication per department protocol. This classically includes narcotic analgesia such as morphine or fentanyl; however, more recently the role of low-dose ketamine in prehospital pain management is being explored and gaining favor.14,23
Transport considerations: Vascular injuries from knee trauma may require time-sensitive intervention by orthopedic and vascular surgeons in an attempt to restore distal leg blood flow and salvage the patient’s limb. Thus, patients who have any evidence of vascular injury, knee dislocation or neurological deficit, or those patients with significant mechanisms that raise suspicion fora spontaneously reduced knee dislocation, should be transported directly to a traumacenter.12,13 Upon arrival at the trauma center, it’s important EMS providers clearly communicate their initial neurovascular exam of the injured extremity and clinical suspicion for a potentially devastating knee injury.
Your rapid trauma exam reveals a Glasgow coma scale of 15, patent airway, clear and equal lung sounds, a non-tender abdomen and vital signs significant only for tachycardia to 116.As you complete your secondary survey, you again note the left leg appears slightly dusky below the knee. There’s no obvious deformity of the knee bones but there’s swelling to the posterior knee and the patient refuses to bend her knee secondary to pain.
The goal of splinting isn’t only to support potentially unstable fractures, but to also decrease the patient’s pain and reduce the chance of further neurovascular or soft tissue injury from uncontrolled bone motion. Photo courtesy Colerain Township Department of Fire and EMS
You have difficulty finding a dorsalis pedis pulse but are able to palpate a weak posterior tibial pulse. The patient also has decreased sensation to the top of her foot. You astutely recognize the patient may have suffered a knee dislocation with spontaneous reduction and recall that this injury can result in significant damage to the popliteal artery and peroneal nerve. You discuss your findings with your partner and decide to transport your patient the extra distance to the regional trauma center where you know there’s 24-hour orthopedic and vascular surgery capability. You apply a vacuum splint to appropriately immobilize the leg in a position of comfort and begin transport.
En route, you establish an 18-gauge IV and administer two weight-based doses of IV fentanyl per protocol for her significant knee pain. You cover the patient and the affected limb with warm, dry blankets to promote circulation.
On arrival to the trauma center, you note that the patient’s posterior tibial pulse seems stronger and you can now palpate a dorsalis pedis pulse. The color of the lower left leg has also improved. Upon transferring care to the ED you discuss your initial exam findings and clinical suspicion with the attending emergency physician. Later in the evening you return to the trauma center to drop off a different patient and the physician tells you your patient with the knee injury indeed had a popliteal artery injury on CT angiogram, likely from a spontaneously reduced, posterior knee dislocation. The physician compliments you on your astute prehospital examination skills and intuition, as diagnosing this limb-threatening injury could have been easily delayed without the exam findings you noted in the field.
1. Freeman L, Corley A. Orthopedic sports injuries: Off the sidelines and into the emergency department. Emerg Med Practice.2003;5(4):1–24.
3. Heightman AJ. Articulating knee injuries: Placing proper emphasis on the recognition & stabilization of severely dislocated knees. JEMS.2004;29(7):46–55.
4. Kauvar DS, Sarfati MR, Kraiss LW. National trauma data bank analysis of mortality and limb loss in isolated lower extremity vascular trauma. J Vasc Surg. 2011;53(6):1598–1603.
6. Coury T, Napoli AM, Wilson M, et al. Injury patterns in recreational alpine skiing and snowboarding at a mountainside clinic. Wilderness Environ Med.2013;24(4):417–421.
7. Heard WM, VanSice WC, Savoie FH 3rd. Anterior cruciate ligament tears for the primary care sports physician: What to know on the field and in the office. Phys Sportsmed. 2015;43(4):432–439.
8. Petri M, Ettinger M, Stuebig T, et al. Current concepts for patellar dislocation. Arch Trauma Res. 2015;4(3):e29301.
9. Laskowski ER. Snow skiing. Phys Med Rehabil Clin N Am.1999;10(1):189–211.
11. Bitterman AD, Leonard B, Midgley J, et al. Orthopedic considerations of the polytrauma patient: Management of lower extremity fractures and dislocations. JEMS. 2014;39(5):50–55.
12. Henrichs A. A review of knee dislocations. J Athl Train.2004;39(4):365–369.
14. Lee C, Porter KM. Prehospital management of lower limb fractures. Emerg Med J. 2005;22(9):660–663.
15. Cuske J. The lost art of splinting: How to properly immobilize extremities & manage pain.” JEMS. 2008;33(7):50–64.
16. Collopy KT, Kivlehan SM, Snyder SR. Managing unstable musculoskeletal injuries. EMS World. 2012;41(2):36–43.
21. McEachin CC, McDermott JT, Swor R. Few EMS patients with lower extremity fractures receive prehospital analgesia. Prehosp Emerg Care.2002;6(4):406–410.
How to Make a Splint
You can follow the instructions below to learn how to apply a splint.
1. Attend to any bleeding
Attend to bleeding, if any, before you attempt to place the splint. You can stop the bleeding by putting pressure directly on the wound.
2. Apply padding
Then, apply a bandage, a square of gauze, or a piece of cloth.
Don’t try to move the body part that needs to be splinted. By trying to realign a misshapen body part or broken bone, you may accidentally cause more damage.
3. Place the splint
Carefully place the homemade splint so that it rests on the joint above the injury and the joint below it.
For example, if you’re splinting a forearm, place the rigid support item under the forearm. Then, tie or tape it to the arm just below the wrist and above the elbow.
Avoid placing ties directly over the injured area. You should fasten the splint tightly enough to hold the body part still, but not so tightly that the ties will cut off the person’s circulation.
4. Watch for signs of decreased blood circulation or shock
Once the splinting is completed, you should check the areas around it every few minutes for signs of decreased blood circulation.
If the extremities begin to appear pale, swollen, or tinged with blue, loosen the ties that are holding the splint.
Post-accident swelling can make the splint too tight. While checking for tightness, also feel for a pulse. If it’s faint, loosen the ties.
If the injured person complains that the splint is causing pain, try loosening the ties a little. Then check that no ties were placed directly over an injury.
If these measures don’t help and the person is still feeling pain from the splint, you should remove it.
The injured person may be experiencing shock, which might include them feeling faint or taking only short, rapid breaths. In this case, try to lay them down without affecting the injured body part. If possible, you should elevate their legs and position their head slightly below heart level.
5. Seek medical help
After you’ve applied the splint and the injured body part is no longer able to move, call 911 or your local emergency services. You can also take your loved one to the nearest urgent care clinic or emergency room (ER).
They’ll need to receive a checkup and further treatment.