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SQUAT PREHAB: QUAD / ANTERIOR THIGH EDITION

Jun 16, 2021

Alrighty, y’all. Today we’re gonna talk about some great prehab exercises that focus on your quads! These are beneficial for anyone who is stronger in their posterior chain than their quads to try to “even out” (I’ll explain that more in a sec here), but these are also great for anyone who’s been dealing with pain in the front of your knee, particularly the spanish squats - start with those, and then try the others, keeping the range such that pain doesn’t go above 5/10 (with tendon issues, we actually WANT to feel like a 1-2/10 to know we’re actually challenging the tissues enough to make a difference!). In FACT - I periodically have patellar tendonitis flare ups (I’ve had 3 knee surgeries, one of which was an ACL surgery where they cut out part of my patellar tendon to use it for my ACL - they now know that causes some frequent tendon issues long term). One of those flare ups started this morning working on squat cleans - a few sets of spanish squats, and I was able to finish my training pain free!

Ok, so now onto when you may need to do these even if you aren’t dealing with any pain:

One of the faults I see often with squats is when the hips shoot out of the bottom. You maybe have heard some coaches jokingly call this “stripper squats” or the more politically correct term is “good morning squats”. Well, what’s likely happening is that person is stronger/ more dominant in the posterior chain (glutes/hammies/low back) versus their quads. Therefore, they shoot their hips up to get in a position where they can take advantage of that extra strength to get the weight back up. If it’s really obvious, it’ll almost look like they finish with a good morning versus a squat pattern.

Ideally though, what we wanna see is the chest and hips rise at the same rate, utilizing a full leg drive to get the weight up. If you tend to squat with the hip dominant pattern noted above, it can be really beneficial to do some training to bias the quads to make them have a more balanced ratio compared to the posterior chain. The movements listed here are great for that, along with belt squats which allow you to really load up your squat but the weight is positioned in a way where it’s tough to allow this hips-shooting compensation to happen.

My 4 fave rehab movements for building up your #quadsquad status:

Spanish Squats

Biggest thing here is to keep tension on the band the whole time, esp at the bottom! Shins should be perpendicular with the floor and the tension from the band will help unload the knees (for the anatomy nerds like me, this happens via anterior translation of the tibia). You can hold a weight goblet style (like I am in this video) to counterbalance as well.

Sissy Squats

Biggest thing here is to maintain a straight line from shoulders - hips - knees (ie don’t let your hips bend back). Props if you can make it allll the way to the floor and back up without losing position!! I used to be able to, so apparently I need to work on these again!

Theses are pretty difficult, so by all means, attach a band/strap to something in front of you to hold on so you can use that to assist - as much as needed, but as little as possible.

Skater Squats

Bend one leg up and “lunge” back as shown with that knee touching just behind the stabilizing foot. Note that the knee touches the ground first, not the foot like it would in a lunge.

If you struggle with balance on these, try holding a weight out in front of you to counter balance. You can also scale these a bit and have the knee go a little back versus all the way behind the knee

Reverse Nordic Curls

Start in a tall kneel position. Make sure to place something soft under your knees if needed. You want to maintain a solid line from your knees - hips - shoulders as you slowly lower yourself back as far as you can control. Once you have to break at the hips and let them bend, come back up to the start. This is a little nerve wracking the first time you ever do it, so give yourself a couple reps to get comfy with the movement! Big thanks to Jinx here for the emotional support (even though I’m pretty sure he was just in it for pets)

Alrighty, hit me up (in the comments below or on IG @moveonthedaley ) with any questions you have about these! And if you feel like you want a little more idividualized guidance on dealing with knee pain, schedule a discovery call with me!

I'D LOVE TO CHAT!

"Your knees are shot and if you keep up all the activity you're doing, you won't walk at 30"- what I was told by medical professionals at age 18 after my 3rd knee surgery. Fast forward to today, and I'm 32 and not only do I Crossfit 4-5 days a week, but my off days are usually spent trail running and/or hiking. And the only time I have knee pain is when I take 4 or more days off from activity. You see, the stronger the muscles around a joint are, the more they can unload the joint - i.e. the ligaments, meniscus, and cartilage in the knee don’t have to absorb quite as much force as they would otherwise. And less pressure = less risk of damage or pain.

For years, I avoided squatting below parallel, catching heavy weight in a squat such as full cleans and snatches, and had a crazy wide squat stance. I also avoiding running and would get nervous hiking downhill. Why? Because I let the nocebo (negative thoughts) given to me medical professionals dictate my movement. You see, I've had three knee surgeries, with the 1st one being in 5th grade and the last being a cartilage graft during college. Most of my knee injuries have been due to Osteochondritis Dissecans (Rare condition. Lack of blood flow to bone causing cracks to form in the cartilage and underlying bone. Cause unknown). Though one surgery was an ACL reconstruction where they took out part of my patellar tendon and put it where the ACL should be.

With each of these instances (a few others didn't require surgery), I was told yet again that I should stop doing any high impact activity, never run on hard ground, that I should never do heavy squats, and definitely don't go below parallel even without weight. This is devastating news to a very active and athletic fifth grader. And let's be real, still devastating to an active college student. Thankfully, I'm stubborn. I agreed to quit all hard court sports like basketball (though to be fair, as soon as everyone else hit their growth spurt, I probably wouldn't have lasted) and gymnastics. But I refused to give up soccer. And with that came weight training once I got to high school.

I still lift and do Crossfit 4 days a week and trail run or hike in the off days. I honestly LOVE heavy squats and deadlifts, and I am constantly challenge myself! And you know what I realized once I left soccer but was still in the gym doing weightlifting? My knees only bothered me when I did one of 2 things: wayyyyy overdid it or skipped the gym and hiking several days in a row.

Two main takeaways from this bit:

1. Don't let a doctor's opinion dictate your own opinion or your life.

Every profession has it's bad and good apples. And a certain degree does not make one infallible.

2. Heavy squats fix everything (read: your body wants to be loaded. Strength training has countless benefits and should definitely be a part of your life)

So I bet you’re like “Sweet, so strength is important. Got it. But what are some ways to build up strength?” Here ya go:

First, I should explain that it’s not always as simple as “get stronger.” Mobility and technique also need to be considered when figuring out the cause of knee pain. And it’s almost never directly the knee. Typically, if a mobility issue is at play, it is either from the hips or ankles, though it could be from further up as well. This will be it’s own blog (or maybe Eboko!) soon

As far as technique goes, it really kind of depends on when you’re having pain. For example, if it’s just with running, maybe you’re not keeping enough bend in your knee throughout the gait cycle, causing increased stress on the knee. If it’s just at the transition point at the bottom of a squat, maybe you’re only going to parallel, which is actually the knee angle with the highest amount of pressure on the knees. Or maybe you’re letting your knees come inward even just slightly with squats or sumo deadlifts and causing undue stress. If you are having pain with a certain lift/movement and want it assessed, or just want to dial in technique, I do offer movement assessments. Ok, gonna get nerdy and dive a bit deeper to include some research on technique for the next few paragraphs...(if you don’t care about research and just want the takeaways…skip to the next bolded line)

Research by Bloomquist et al showed that deep squats improved strength throughout the range of motion while shallow squats did improve strength a little more at shallow depth, but minimal strength increase at deeper positions. In other words, if you constantly squat above parallel, you;ll get stronger in that position, but not really improve strength for things like getting up and down from the floor, squatting down to pick up heavy items off the ground, catching nd standing a clean or snatch at full depth. Squat jump strength also improved only with full depth squats, not quarter squats according to research by Hartmann et al.

Hartmann et al also found that the compressive forces in the knee are highest at 90 degrees and have little quad tendon support, yet when you squat deeper, there is actually a protective wrapping effect around the knees! My mom can attest to that. One of my biggest recent “wins” is finally getting my mother to listen to me (seriously, it’s like pay back for not listening as a child) about squats. She does not have ACLs in either knee and then retore an MCL about 10 years ago while waterskiing. She has at least listened to me for awhile that the best thing she can do for her knees is keep up strength to create the extra support needed in lieu of those ligaments. About a month ago, I finally got her to start doing a few exercises I wrote including some goblet squats with increased weight. However, she’s been scared to squat below parallel. So she called me up and told me her knees were achy. I explained the above research and told her to just give going below parallel a shot for a few days and call me back. Guess what?! Her knee pain was GONE!

The other major lie that we’ve all heard is that your knees can’t past your toes. Absolute BS. In fact, I can personally say that the first time I really felt my quads fire during a squat was when I finally let my knees go past my toes. It’s also the first time I didn’t end of having soreness in my low back after a bunch of squats. Here’s why: Fry et al did some research looking at joint forces at the hips and knees when knee movement is restricted to avoid going past the toes or allowed to do so. They found that if it is restricted, there’s a 1000% increase in hip forces. One thousand y’all! It also caused your torso to come more forward since the hips had to stay back. This then places more pressure on your back. Between those factors, it’s no wonder my back was getting sore with back squats! Some of whether or not your knees need to come forward and the degree to which they do is definitely dependent on your specific anatomy.

Okay, now for the fun stuff. Strength. Note that this is specific for the person dealing with knee pain with squatting…

As I mentioned earlier, if you have strength surrounding the joint, it will unload it and you won’t deal with pain that comes from pressure on the internal structures (for example, osteoarthritis bone changes won’t cause pain) But…how do you build strength if you’re dealing with knee pain already?? The following exercises will be a great start!!

Even better if you mix in things to spike your heart rate like a 30” arm only bike sprint…gets your heart rate going, thereby increasing fluid circulation to the legs/knees which will drastically help “flush out” any inflammatory chemicals. Therefore, decreased swelling and pain!

There are plenty of great drills not listed here, but this is a great start:

-Knee Gapping.

Ok this one is for you if you just feel a lot of pressure in your knee when you squat and feel like it limits you. You know that feeling when your knee is even a little swollen and it won’t quite bend all the way back into full flexion? Yea, this helps with that. A ton. You can use a small ball, like a lacrosse ball, or a tightly rolled up towel like I am here. This helps glide the tibia (the lower leg bone) forward as you go into end range motion, which is what’s needed, and increase the joint space so it doesn’t get as much of that pressure feeling. Help yourself into end range flexion by grabbing your lower leg and pull it in, as shown. Make sure to get some calf motion in by moving your ankle around as the gastroc does cross up over the knee and assist in this motion. (side note: please ignore the squeeky ball in the background from the pups)

- Spanish squats.

Easily my favorite exercise to not only get a quick solid quad burn, but to unload the knee and allow better movement. I’ve used this countless times with acute knee pain, chronic arthritis, post surgical, and a whole host of other people (and myself) to be able to squat sooner and build/maintain strength. The band is placed directly behind the knees. You want to make sure there is solid tension in the band throughout the movement - as you can see in this video, the band can hold my weight. Unlike a normal squat, you keep your shins perpendicular to the ground. The kettlebell is mostly to counterbalance and help me keep my chest upright. Shoutout to Zach Long, PT, DPT (aka @thebarbellphysio) for introducing me to these several years ago while we were at a course together.

- Copenhagen Planks.

So it may not be readily obvious how these help your squat, but the truth is the inner thigh muscles play a HUGE role in full depth squats, and if their capacity isn’t adequate, it can cause knee pain, particularly on the inside of the knee. Now, this exercise is MUCH harder than it looks, so I highly recommend starting it where you have the top knee supported on the bench (or couch or whatever you’re using). If that’s still too much, you can leave the bottom leg on the ground and allow it to help support as much as needed, but as little as possible (don’t cheat yourself!)

- Bulgarian Split Squats.

Not just for lifters. This is a fantastic exercises for hikers and trail runners as it not only works on the muscles you use in your sport, but it also challenges single leg and trunk/core stability which are very important. Get into a lunge position with the back leg up on a box/bench/couch/whatever and then drop your trunk straight down while both knees bend. I’m using a kettlebell in a goblet hold here, but you can also do a barbell in the front/back/Zercher position

- Hip Thrusters

Yes, I know, this is a butt exercise. But without strong glutes, your knees will be trying to compensate for lack of stability. No bueno. Besides, lets be real, is there a downside to having a nice ass? No.

In this video, my fiancé is demonstrating with both legs, but going single leg is a great option as well! Please note, he’s also going absurdly light with the weight here. You want to go HEAVY on this exercise. You’ll probably surprise yourself with how heavy you can go…I have multiple patients over 65 that do this one well over 100, if not 200 pounds for reps. Just make sure you can actually hit full extension at the top (meaning your hips finish in line with your knees and shoulders)

No barbell? That’s fine! Use a super heavy dumbbell or kettlebell…just know you’ll be limited by getting the weight on/off your lap and will need to up the reps to have any benefit.

Ok, hopefully these exercises are helpful!

One last quick note that I’d be remiss if I didn’t mention: When discussing knee pain, you have to consider lifestyle factors. All too often, knee pain is due to any increase in the body’s inflammatory response. And I’m not just taking about the injury response. If our diet, our sleep, and/or our stress is trash, it affects our entire system. So while I don’t wanna vilify the occasional cup of ice cream (that would make me a hypocrite), I do want to point out that if you’re crushing a whole pizza, McDonalds, and M&Ms every day, then it’s not entirely surprising that you feel lie you have “bad knees”…but if you take away the inflammatory-inducing foods, get 8 hrs of sleep, and move your body regularly, I bet you would find that you actually have good knees! They were just mad at you and letting you know they were mad…