Solving Knee Problems, Part 1

By Kelly Starrett

In ExPhysiology, Medical/Injuries, Videos

August 09, 2009

Video Article

“The squat magically cures knee pain if you squat correctly,” Kelly Starrett told participants at a one day seminar at CrossFit Santa Cruz on March 14, 2009. Starrett is the owner of San Francisco CrossFit and a Doctor of Physical Therapy.

Improper squat mechanics under load will lead to problems over time. Muted hips and knees bent forward are common faults. Starrett said one patient at his clinic was an elite, world champion athlete who had flown in for a consultation. The problem was the athlete simply didn’t know how to squat. Starrett blamed the athlete’s coach and PE teachers for failing to provide proper instruction. “No one ever taught him to squat right,” Starrett said.

The body weight squat to a high box can be a good way to start. Kelly tells his clients to keep their spines straight, stick their butts back, break their knees at the same time as they reach back, and put their hands up for balance. Athletes find they can squat with no pain because they are unloading their quad tendons. It takes them off tension and they don’t get a down/up stretch cycle. The eccentric/concentric chain is broken and the athlete is able to rise properly from the squat. The shin is pretty vertical and the femur is rotating around a pretty vertical tibia.

When athletes are put in the best position, with maximum congruency of the joints, hotspots are unloaded. Keeping the shins vertical maximally unloads the patella tendon.

11min 58sec

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26 Comments on “Solving Knee Problems, Part 1”

1

wrote …

Question to the community. I have multiple clients who have a large sway to one side at the bottom of the squat, especially as the load increases. I think its because one of their glutes isn't firing but that is a pure assumption. Can anyone tell me some exercises to help improve that or tell me why that is occuring or point me to some resources that can help. Thanks.

Love this series by the way

The Pie
CrossFit Lions

2

replied to comment from Chris Harrison

Hello

Check the ankle mobility, I will sway or twist when performing the overhead squats or even a front squat because of a damaged ankle. Just like when you fell a tree the tree will twist around the uncut side to where you want it to land.

3

wrote …

I have had two knee surgeries in the past 8 months. The first one to remove a benign growth in the knee joint and the second one to repair a torn meniscus. After the second surgery, my orthopedic surgeon told me I was done...I should never squat or lunge again. It sounded like a death sentence to me so I went for a second opinion. The second doctor totally disagreed. He said squatting and lunging are the best exercises for someone in my position. My squat form was pretty damn good but he emphasized a few things which Kelly also emphasizes in this video: turn knees way out, keep shins vertical to ground, femur rotates around a vertical tibia, and keep knees back behind toes. I am still on the sidelines after the second surgery but when I return, I will squat taking care to keep my shins vertical and to turn my knees way out. Thanks Kelly for addressing this important issue.

4

wrote …

Kelly,
Doesn't Rip say it's ok (or possibly even optimal) for the knee to track in front of the ankle? So the shins are facing forward, not purely vertical. Is squatting for rehab different then squatting for a healthy athlete? You mention, to start people off easy, eg with a high box. Would you work them through a full ROM squat before adding the '10 pound plate across the chest'? Or work ROM issues and light weights simultaneously? Basically, does one take precendence over the other? Or would you let them continue squatting to a high box for some time (eg if it was an old lady)?

I love this series. I guess those questions aren't specific for K-star, just anyone who cares to answer.......

5

Charles Charbeneau wrote …

I shattered my patella into 7 pieces just under 18 years ago. It took two surgeries to fix completely. From day one I was mobile. Never had a cast and was in PT from the second day after the first surgery.

I've been active ever since (soccer, several eastern and western martial arts, etc), but always at a lower rate, and always with twinges of pain. Fast forward to recently and my intro to CrossFit, and suddenly, I can squat again pain free. Every squat is a compromise, but at least now I understand the mechanics of the squat and the compromises needed for MY mechanics.

6

replied to comment from Chris Harrison

Also check the IT Band for tightness....then work on strengthening the glute medius.

7

wrote …

as for exercises... for the IT band you can foam roll it, and stretch traditionally, however I prefer PNF stretching which requires some training but you could probably find a good find on youtube.

for glute medius - lateral walking with tubing or bands, balancing on airex pad or dyna disc.

hope this helps.

8

wrote …

K Star,
Thank you for the vid's. I love them, it's dead on with what I'm going through with some tendonosis of the patellar tendon.

Once again, a huge THANK YOU!!!

9

wrote …

Kelly,

As always a great video. Understandable and implementable.

10

Erik Preston wrote …

Outstanding video. You make complete trainers out of us, Kelly.

Erik
CrossFit San Elijo

11

Brendan Sonnichsen wrote …

Loving the videos! We started using box squats for our knee folk after I saw Dave Tate's presentation. Combine this with foam rolling of the IT and VMO and we get some fantastic results!

12

wrote …

Please remember there are cases when a perfect squat will not cure all knee pain despite a negative MRI and x-ray. Squatting without pain is much different than curing knee pain when, as humans, we need to go up and down stairs, get in and out of cars, squat with imperfect technique to pick up our child, jump down from a tailgate, etc. That is life and variability is part of life. I do realize that movement without pain is better than none at all. However, an internal mensical derangement (not usually seen on MRI)can produce knee pain with daily activity and not a proper squat. Also, hip or lumbar issues can refer pain to the knee since the squat is a multijoint "macromovement". These conditions require proper assessment and treatment. I do feel the squat is the one of the, if not the, most functional exericises we can teach therefore, I don't want to minimize it's importance. Yet, this video makes a squat sound like a miracle cure when there are other serious conditions to consider. So, if knee pain persists even though technique is solid and roughly 6 weeks has passed, please send your clients back to their physician for further evaluation.

13

wrote …

Great video! I just saw a patient (60 yo female, knee osteoarthrosis b/l). Much to treat with segmental and global ROM, lengthening and strengthening to provide stability, etc., but when I showed her the box squat she just about lost it...in a good way. Instead of hoping she might get relief, she is planning to start up yoga again when we are done. I have some other plans for her progression (X-fit!). Regardless, the physiology and psychology behind the squat made my job much easier. Thank you!

To mix a response to Chris' question and Ryan's comment, I think Kelly could have qualified the type of client and the extent of the injury. People who get the journal and who comment are much more experienced and intelligent than most; however, if a client has a knee problem that doesn't fall into the "most-common" list they need to see someone who specializes in fixing not only the symptom, but the functional faults that caused it (ex: swaying in the squat regardless of perfect coaching). As a trainer, the best thing you can do for clients like this is have a network of professionals that you trust to provide great results (their family physician is not likely to be the best resource). Networking with professionals, especially DPT's and/or Sports DC's, can increase your worth in your patient's eyes and most likely increase your revenue. And it's all in the best interest for the client.

14

wrote …

K-Star,

Any idea how this might help PFPS (Patellofemoral Pain Syndrome...for the audience)? I know PFPS is a complex issue that involves what can be several different factors...can the squat knock them all out at once? I have loud crepitus and pain when squatting, going down stairs...all the norms.

Thanks!
J

15

Joseph Doughty, DC wrote …

K,
Great video. For trainers out there (and even doc's) I've incorporated and have been working with squatting fundamentals and proper mechanix in my own practice for over 2 1/2 years. It's makes a huge difference when patients follow instructions and do what's asked of them at home once they have the basics down.

Chris H. FWIW: Sometimes sacral-illiac joints can be out of alignment, causing aberrant pelvic motion, esp. at extreme points of ROM (ie very bottom of squat, or even arbitrarily in the middle of the squat). The sacral joints are gliding joints held in place by muscles with many nerves running through the muscles. As well as many proprioceptive (nerves for sensing movement and placement in space). Over an extended period of time muscles can and will shut down and/or fatigue quicker because of this pelvic bone displacement. This causes the nerve system to compensate by shifting weight and altering movement. No DIY quick fix here, client may need an excellent chiro who knows what they are doing.

Good news is many chiro's are pretty good dealing with pelvic misalignment. If your looking for a way to check this, have the person lay face down on a massage table or other table/bench (its important the persons head faces straight down while they lay on their stomach). Take a look at the heels of the shoe to see if one leg appears shorter than the other. If so, possible problem. I fix this stuff in my office every day. Had a gymnast come in today with referred right hip pain and muted ROM. She couldn't get down into her proper squat w/o pain and the muscles guarding (tightening). No I didn't refer her out for a surgical orthopedic evaluation. Instead, I made some adjustments and we retested to see if she could squat. No pain and improved squat about 90%. Will follow up tomorrow with a recheck and more care as needed. Saved her months of aggravation.

Bottom line: Long standing pelvic misalignment's can also cause chronic knee problems.

Jared V. A. is right on. I see folks at my CF box and I'm constantly asked questions about this problem and that. I'm always glad to help a fellow Crossfitter. Offer to train a doc and/or other professional you like and want to build a business relationship gratis (for a set period of ime of course). Give them a taste of the cool-aid to get their attention and maybe even develop a mutually beneficial referring relationship. Be warned many doc's are pretty quirky and majorly pressed for time. Emphasize how quick CF WOD's can be done, it was one of the big things hat got my attention. Building these relationships makes you a more valuable trainer than just offering the advice to go see your physician. What kind of doc makes the world of difference.

16

wrote …

Per American Heritage Dictionary: Physician

A person licensed to practice medicine; a medical doctor.
A person who practices general medicine as distinct from surgery.
A person who heals or exerts a healing influence.

It doesn't matter what kind of physician the trainer recommends as long as it's a medically trained professional. My intent for posting was to expand the knowledge base and open eyes to the fact that all knee pain doesn't always come from the knee. It was neither a personal attack on Kelly nor a promotion of any specific treatment philosophy. I purposely used the term "physician" as it is nondescript and does not promote any one specific practice. Offering advice is fine, just not at the cost of your clients' safety. Therefore, when knee pain persists despite excellent technique, it's time to utilize your resources. Whomever the trainer has in their trusted network of contacts is fine. Some feel chiropractic is the answer, that is your decision. I post contributions for the good the Crossfit community and safety of all its participants. Hope this helps clear my position on this issue.

17

wrote …

I'd like to leave a personal testament to this article. I am (among other things) a surfer and I hurt my knee about 10 years ago in a surfing accident. Free fall floater off a 10 ft wave, landing in the flat on my board and my right knee completely buckled inward and I tore the MCL. I went to countless doctors, PTs, etc for YEARS and although I got my knee back to about 80%, it was never fully healed. I had pain almost daily and I eventually accepted it is part of my reality (not to mention I had doctors telling me to just accept it).

Then came CrossFit - I started training with Sam Radetsky at CrossFit West Santa Cruz and in the beginning, Sam had me working on proper squat form more than anything else. To make a long story short, after almost 8 years of chronic knee pain, 2 months of CrossFit and proper squatting completely healed my knee. I am 100% convinced of it and I am so thankful that I found such a great coach that not only got me fitter than I've ever been, but helped me to learn the proper mechanics to heal myself.

Consequently, I have since gone in to business with Sam (and Jocelyn Forest - Games Competitor) as partial owner of CFWSC. I'm consistently impressed by the quality and expertise of people involved with CrossFit. This series from K-Star has been a bible of sort to me over the last few months and it's been great to share all this knowledge with our clients and watch other people's injuries heal and improve as well!

Thanks K!

Cliff Hodges
CrossFit West Santa Cruz

18

wrote …

Thanks for another great lesson, K.

The timing on this video couldn't be more appropriate. I have an intro session lined up with an interested newcomer next week and she has forewarned me of her having osteoarthritis in both knees.

Thanks for the well-timed shot of confidence, and thank you for continuing to add to the arsenal of the well-rounded CF trainer!

Sky

19

wrote …

I was Dx'd with osteoarthritis. I've been exercising, stretching, squatting properly etc. It has helped with greatly with pain and mobility. Yet no panacea.


OA is a degenerative process cartilage breaks down, grinding occurs, crepitus and pain. Up to a point balancing muscles, stretching, strengthening/realigning support systems will increase ROM and ROM without pain.


Exercise alone is not going to reverse the process. If the OA is reversible at all.


I'm not refuting the that exercise etc will help with pain and ROM, but I'd be cautious in saying it cures or heals. Exercise, stretching etc will not grow back and/or smooth out the cartilage.


While video is specific to knee, what modalities are available for other joints? eg. shoulder, hip etc.

20

Tom Seryak wrote …

Be careful rocking back to a vertical spine on the box especially when loaded. There is no need to rock back then rock forward. When I first started doing box squats, I had the rock. This led to bad sciatica, via my tailbone being shifted to the one side. Now granted, I was under fairly heavy loads, but still I don't see the need for it.

21

wrote …

Kelly,

Thanks so much for such an excellent informative video. As a physical therapist and newcomer to Crossfit, I find myself automatically incorporating what I learn into therapeutic and home exercise programs for my patients. It is always such a joy to find other ways to make exercises as functional as possible, either approximating or actually being movements that are performed in activities of daily living. The fact that they often require very little equipment is again such a plus! I look forward to obtaining other info you are providing as this video appears to be spot on.

22

wrote …

My knees are a mess. I wrestled in college and I have had 9 meniscus surgeries, a tibia osteotomy (straitened out my tibia from being bowed), and torn ACL. I have started squating and rebuilding my strength again so I can continue CF training. I'm so gald I watched this series, it reconfirms how important the squat truely is. Thanks.

23

wrote …

Can anyone recommend a rep scheme for squatting to fix knee pain? Kelly mentions that squats magically heal knee pain but I'm not sure how much squatting should be done.

24

wrote …

Thank You! this has totally nailed why I'm having Knee pain and what to do about it. I never had knee pain until I started CF 3 mos ago, now it's constant especially squatting or going down stairs.

25

wrote …

This is so spot on and it's amazing how many people don't know it. Of course there are other methods to help knee pain like patella straps and knee supports which work great but strengthening the muscles around the knee is the best long term solution.

26

replied to comment from Clint Thompson

To add to the above comment, some knee supports don't work as well as others. If you want great quality knee supports check out www.BodyHelix.com.au

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