Latest / The Ask Mike Reinold Show / Should You Squat Through Patellofemoral Pain? - #AMR399

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Should You Squat Through Patellofemoral Pain? - #AMR399 · The Ask Mike Reinold Show

• 0:50
  SPEAKER_04: On this episode of The Ask My Criano Show, we talk about whether or not you should squat through to telephone moral things.
• 0:56
  SPEAKER_04: The Ask My Cryal Joe.
• 1:01
  SPEAKER_04: Helping people feel better.
• 1:04
  SPEAKER_04: Move better.
• 1:14
  SPEAKER_04: Before we get to the podcast, I wanted to make sure you knew about my free online course on the introduction to performance therapy and training.
• 1:21
  SPEAKER_04: If you want to learn how to get started optimizing and enhancing performance, this is the course for you.
• 1:27
  SPEAKER_04: Head to micrenault.com/slash performance to sign up today.
• 1:30
  SPEAKER_04: Welcome back, everybody, the latest episode of the Ask Mike Reynolds Show.
• 1:32
  SPEAKER_04: We are here, champion P Team Performance up in Boston, answering your questions.
• 1:37
  SPEAKER_04: Head to micrunnell.com, click on that podcast link, and you can ask away.
• 1:41
  SPEAKER_04: Fill out the form and we'll answer anything you guys want to talk about.
• 1:45
  SPEAKER_04: Let's see.
• 1:45
  SPEAKER_04: Who do we have today?
• 1:46
  SPEAKER_04: We have Dave Tilley, Lenny McCrena, Logan McCrena, Brendan Gates, Kevin Coughlin, Dewesh Podell, and Len, who do we who do you have for a student today?
• 1:56
  SPEAKER_05: We have uh one student again, but don't worry, Luke.
• 1:59
  SPEAKER_05: Like I said last week, another student is coming.
• 2:01
  SPEAKER_05: I promise you.
• 2:02
  SPEAKER_05: Um no, we have Luke Alfonso from Creighton University, the home of our friend Terry Grindstaff.
• 2:08
  SPEAKER_05: Terry, if you're listening, thank you for sending Luke.
• 2:11
  SPEAKER_04: Luke, what do we have today for a question?
• 2:15
  SPEAKER_00: We got a question from Sarah in Nashville today.
• 2:17
  SPEAKER_00: She says, when someone with patello femoral pain has pain during squats, do you stop all squats or do you modify?
• 2:24
  SPEAKER_00: One of the doctors that sends me patients always tells his patients to stop squatting.
• 2:28
  SPEAKER_00: How do you decide whether to stop squatting or keep loading through some discomfort?
• 2:33
  SPEAKER_00: I feel like I'm either being too cautious or pushing too aggressively.
• 2:37
  SPEAKER_04: Awesome.
• 2:37
  SPEAKER_04: Sarah, great question.
• 2:38
  SPEAKER_04: I I like questions like this.
• 2:40
  SPEAKER_04: I like when P P PTs send in questions based on like weird things doctors say.
• 2:47
  SPEAKER_04: Sorry, doctors.
• 2:48
  SPEAKER_04: None of you are listening to our podcast.
• 2:50
  SPEAKER_04: But but like we should.
• 2:53
  SPEAKER_04: We need an episode.
• 2:54
  SPEAKER_04: Yeah.
• 2:55
  SPEAKER_04: Weird things doctors say.
• 2:59
  SPEAKER_04: That wouldn't go over well.
• 3:00
  SPEAKER_04: Yeah.
• 3:01
  SPEAKER_04: But okay, so somebody has patelephamorphia, which again, like I don't I don't want to call patelephemoral pain a junk term, but like let's just call that a broad term.
• 3:10
  SPEAKER_04: So like this is like a knee pain thing.
• 3:12
  SPEAKER_04: I think what when I hear patelephemoral pain, to me, that means like this isn't a meniscus, an ACL.
• 3:18
  SPEAKER_04: It probably isn't even patellar tendonites, right?
• 3:21
  SPEAKER_04: Because that has its own name, right?
• 3:22
  SPEAKER_04: So to me, this is somebody in knee pain.
• 3:24
  SPEAKER_04: A doctor says, Oh my gosh, you're squatting, that's why that's the issue.
• 3:27
  SPEAKER_04: And now you get a patient that's you know afraid, right?
• 3:30
  SPEAKER_04: Like maybe they're afraid to squat because they're like, oh gosh, is that why I'm in this position?
• 3:35
  SPEAKER_04: So you have all these things, and then you have the therapy community and the strength and communicate uh conditioning community that wants you to do stuff because we know how important it is.
• 3:44
  SPEAKER_04: So oh, all right, where do we start?
• 3:46
  SPEAKER_04: Let's let's let's let's start at the top.
• 3:48
  SPEAKER_04: Um, Dave, you want to jump in here, just kind of like your thoughts on this in general, because yeah, I feel like you probably deal with this even not just from doctors, but even from like coaches and maybe even parents and stuff too.
• 3:58
  SPEAKER_01: Yeah.
• 3:59
  SPEAKER_01: I think the first thing that the reason that we're laughing or making kind of a joke of it is because you always think about like, well, this person or daily life, this person not not allowed to ever go to the bathroom again, they can't sit in their car again.
• 4:09
  SPEAKER_01: Like that's frustrating sometimes because they have to squat, right?
• 4:11
  SPEAKER_01: Like there's no way around that.
• 4:12
  SPEAKER_01: And I think the nuance there is like squatting as an exercise and squatting for load is probably where we're getting into this.
• 4:17
  SPEAKER_01: So yeah, I think it's really important that you mentioned first is that like patelloepemoral pain, even if you take away, you know, um patellotendinitis, meniscus, all that stuff, there's still a lot of variants of patellophemoral pain that um I think a lot of work from Tim Gabb and others has shown us that, like, yes, maybe acutely you want to deload tissue that's really irritable or cranky, but like at some point, um, load is good.
• 4:38
  SPEAKER_01: You know, the right type of load and the right amount is probably good.
• 4:41
  SPEAKER_01: And even for those with patellar ephemeral pain, is you want to try to load tissue to remodel, you know, on the mechanical side, some of the tissue that's cranky.
• 4:48
  SPEAKER_01: And then there's that aspect too, which is like you want to desensitize some of the stuff like a fat pad irritation, or maybe it is truly the back of the kneecap and you know, one side's just irritated.
• 4:56
  SPEAKER_01: But at some point, you have to actually load the tissue to try to allow it to get used to whatever demands are coming down the way.
• 5:03
  SPEAKER_01: And if you have someone who's in a sport, they want to hike, um, they have kids at home, they have to be down, kind of like bending up and down to pick people up, like it's unrealistic to say, well, you're never gonna be able to do this, so we just we should avoid it at all costs because it's pretty much just not gonna happen with the reality of life as parents or sporting athletes.
• 5:19
  SPEAKER_01: So I think that's the nuance of it.
• 5:21
  SPEAKER_01: I think one thing that's really important is to remember is there's a lot of ways that we can modify squatting for people.
• 5:25
  SPEAKER_01: And that's kind of what I always try to educate people on is like, yes, maybe you got into I'll use I love CrossFit, but like the best thing is like someone goes to CrossFit, they learn about stuff.
• 5:33
  SPEAKER_01: I love CrossFit and Olympic lifting, but they learn how to front squat and clean, like as soon as they get there.
• 5:37
  SPEAKER_01: And it's like, okay, well, that's a very challenging type of squat for the knee because of how much force it puts across like the shears.
• 5:43
  SPEAKER_01: So it's one thing to say, never squat.
• 5:46
  SPEAKER_01: It's another thing to say, is there a different version of a squat we can temporarily try to see if it's more of your hips, less of your knees?
• 5:51
  SPEAKER_01: Can we do a low bar box squat when you go to CrossFit when everybody else is front squatting or cleaning, or like can we stay away from full depth cleaning?
• 5:58
  SPEAKER_01: Can you just do power cleans when you're learning?
• 6:00
  SPEAKER_01: And maybe that will help calm things down.
• 6:02
  SPEAKER_01: So there's an entire, and Dan has a really good graphic on his website.
• 6:05
  SPEAKER_01: It's like literally like the most knee-dominant squat you could possibly do, like a slant board squat or a sissy squat, all the way to the most hip dominant squat you could do, like a low bar box squat.
• 6:14
  SPEAKER_01: There's probably six or seven variations across there that that person just might need a different option for a little while until their knee comes down, and then you know, somebody else can pick up and jab.
• 6:23
  SPEAKER_01: But like there's many other reasons why someone's knee would bug them and patel or ephemeral issues with hip stuff or ankle stuff or the way their squatting mechanics.
• 6:31
  SPEAKER_01: So yeah, I'll let somebody else jump in there.
• 6:32
  SPEAKER_01: But I think the type of squat somebody gets, they don't understand that maybe I just did this because someone told me to, but you know, they learned from Dewesh or one of our strength coaches, like, here's nine types of squats.
• 6:43
  SPEAKER_01: Let's find one that feels good temporarily.
• 6:45
  SPEAKER_04: Love it.
• 6:46
  SPEAKER_04: And you know, that's exactly what I want to hear from Dewesh in a little bit.
• 6:49
  SPEAKER_04: But before we get to that, I let's talk, let's talk maybe the biomechanics of this a little bit and just say, like, um, you know, and Kevin, like I consider Kevin and Dan right now like my my PubMeds.
• 7:01
  SPEAKER_04: They're uh they're my two PubMed uh gene geniuses, gene genii, what's the plural geniuses?
• 7:07
  SPEAKER_04: So but they're um uh they're just like they're they're so on top of everything.
• 7:10
  SPEAKER_04: But um I'll ask you the question, Kevin.
• 7:14
  SPEAKER_04: So it if you squat to a certain point, does your knee explode?
• 7:19
  SPEAKER_04: Like, is there just like a a point of no return where all of a sudden, like bam, like you're down on the ground and you can't go any further?
• 7:25
  SPEAKER_04: But like, but why do people even think this is a consideration from like a biomechanical perspective?
• 7:32
  SPEAKER_02: That's awesome.
• 7:33
  SPEAKER_02: I wish Dan was here because I'm sure he'd have a funny response to that question.
• 7:36
  SPEAKER_02: Um but yeah.
• 7:39
  SPEAKER_02: So yeah, no, I mean, I I think just the important things to keep in mind when we're thinking about the patella femoral joint is that you know, if you're in closed chain, the deeper that you go, um, I think a lot of the research will say around 45 to 60 degrees and beyond, you get more joint contact between the back of the patella and the uh the groove that it's sitting in in the femur.
• 8:02
  SPEAKER_02: So, you know, with that, as we increase knee flexion and closed chain, that's gonna potentially increase pain for people.
• 8:08
  SPEAKER_02: Because if we're thinking of the total force going through the patella femoral joint, it's gonna be a combination of the contact surface area and the force or the load that you're holding with like an external load with a weight.
• 8:20
  SPEAKER_02: So we have a couple levers we can pull there to reduce the total force.
• 8:24
  SPEAKER_02: We can reduce the amount of range of motion where we might have less joint contact between the two surfaces, or we can reduce the external load and that might have an effect on reducing pain.
• 8:35
  SPEAKER_02: Um, and then as well, I think the opposite is true in in open chain.
• 8:39
  SPEAKER_02: So when you're kind of at like from 90 degrees of knee flexion up to about 45, you're usually pretty good.
• 8:46
  SPEAKER_02: Uh, as you get closer to full knee extension, you get more contact there again, uh, in the patello femoral joint.
• 8:53
  SPEAKER_02: So you might see on either end of that when they're in a deeper range in closed chain, or they're at the terminal range near lockout in open chain, they're reporting symptoms.
• 9:03
  SPEAKER_02: Uh so I think like Dave's point, you know, makes a ton of sense is there's so many different variants and options we can do here to try to reduce the amount of load going through the patellofemoral joint that if you know, maybe we just we can keep squatting, the same exact variation they like to do, but we reduce their range of motion.
• 9:22
  SPEAKER_02: Or, you know, one thing I know that Dan will do a lot with his lifters is if we have to back off total load and range of motion, let's just increase like a tempo and make it more challenging.
• 9:32
  SPEAKER_02: And I know Duesh will, you know, he sees this a lot in the gym and will have good recommendations on how to modify, but I think those concepts are important.
• 9:40
  SPEAKER_02: The other thing I'll say is that in the patellophemoral joint kind of research, you do see cases to be made for like doing um kind of McConnell taping can be helpful.
• 9:52
  SPEAKER_02: So, you know, it whether it's something like that or adding an insert in in your shoe could be helpful.
• 9:58
  SPEAKER_02: And that gets confusing for people because you'll then turn that into if you're too pronated or if you have like a weak VMO or your patell is maltracking, you're at increased risk of patelli femoral pain.
• 10:11
  SPEAKER_02: But it actually seems like once you've developed it, working on those things seems to be helpful.
• 10:15
  SPEAKER_02: So it might not be um something that is like prognostic, like you're gonna end up developing this, but it can help reduce symptoms.
• 10:23
  SPEAKER_02: So, you know, we do know that if you're having a lot of like valgus in your knee when you're squatting, whether you have a very flat foot posture or something like that, and the patelephemoral joint's already sensitized, that changing the position of your foot can probably change the contact area in the patelephemoral joint, and that might reduce symptoms as well.
• 10:42
  SPEAKER_02: So I think those are important concepts to keep in mind too.
• 10:45
  SPEAKER_02: Um, it's not just things that are happening in the sagittal plane.
• 10:48
  SPEAKER_02: There's probably some influence in the frontal plane and the transverse plane and playing around with foot posture once you're sensitized can be helpful.
• 10:57
  SPEAKER_02: Um, so that's another thing I think biomechanically just to keep in mind.
• 11:01
  SPEAKER_04: Yeah, and this goes back to like the, you know, we talk about this a lot all the time, but like, you know, there's this movement online sometimes where like there's no such thing as a bad squat.
• 11:10
  SPEAKER_04: You know, I uh I and and maybe that's true.
• 11:12
  SPEAKER_04: I don't even know if that's actually if I if I even want to agree with that, to be honest with you.
• 11:16
  SPEAKER_04: But there is a such thing as a better squat and a worse squat, right?
• 11:20
  SPEAKER_04: So like you can change things.
• 11:22
  SPEAKER_04: Like if you squat in a certain position, it's gonna change patelfemoral contact forces and it's gonna probably decrease your ability to have a proper output, right?
• 11:29
  SPEAKER_04: So it's not even gonna be beneficial for it.
• 11:31
  SPEAKER_04: So I love that.
• 11:32
  SPEAKER_04: I think that's an important part, you know.
• 11:34
  SPEAKER_04: And I think that that blows my mind biomechanically here, too.
• 11:36
  SPEAKER_04: Is if you actually think about patelfemoral compression forces, even like you know, tibiofamoral, there are so many things that are probably more stressful than doing a squat, right?
• 11:45
  SPEAKER_04: Like running and jumping and stuff like that.
• 11:47
  SPEAKER_04: That could be that could be even worse.
• 11:49
  SPEAKER_04: But for some reason, those aren't like you know, as shunned by the physicians as much.
• 11:53
  SPEAKER_04: But um, all right, look, Dewesh, okay.
• 11:55
  SPEAKER_04: So we know, you know, you aren't gonna fall to the floor and crumble to the ground if you if you do a squat, right?
• 12:02
  SPEAKER_04: We know that Dave said it very, very well.
• 12:04
  SPEAKER_04: Tissue loading is important, right?
• 12:07
  SPEAKER_04: But we probably need to modify.
• 12:09
  SPEAKER_04: So, Dewesh, you probably deal with people with some knee pain every day, right?
• 12:13
  SPEAKER_04: That doesn't even warrant them coming into us to see us in the physical therapy side.
• 12:17
  SPEAKER_04: You know, how do you how do you help get them through?
• 12:19
  SPEAKER_04: How do you regress them?
• 12:20
  SPEAKER_04: How what are some of your tips for physical therapists?
• 12:23
  SPEAKER_04: Because this is the great opportunity where we learn from our expert strength coaches and become better physical therapists.
• 12:30
  SPEAKER_03: Yeah, so our um our big philosophy is we we don't want to make the biggest change right away.
• 12:35
  SPEAKER_03: We just want to start to make small tweaks to either form and how we execute that movement and changing the lever lengths at the knee joint versus at the hip joint and see if that symbol cue or that correction um or a slight modification within a stance is gonna make a difference.
• 12:49
  SPEAKER_03: So a good example is right, if we're let's say we have a beginner, um they're starting with a goblet squat because that's it's that's you know, it's a good entry-level exercise to get someone squatting with really good form.
• 12:59
  SPEAKER_03: Um but because that load is out in front, your torso is a little bit more upright, shin is gonna travel forward, you're gonna have a little bit more anterior knee stress, right?
• 13:07
  SPEAKER_03: So we went in with a good intention, but let's say in that scenario, that person's experiencing a little bit of knee pain and they've already had a prior history.
• 13:14
  SPEAKER_03: So my my immediate regression isn't gonna be all of a sudden like, hey, like let's just go body weight and see how that works, right?
• 13:21
  SPEAKER_03: I can simply just pull the weight in a little bit closer to me, set my hips back a little bit more, maybe even push my knees out a little bit more, or even go slightly wider stance.
• 13:29
  SPEAKER_03: So similar to what Kevin was kind of uh finishing off with, is we can make this movement either a little bit more hip dominant, or we can open up through the hips and groin a little bit more to create a little bit more frontal plane stress and have a little bit less sagittal plane, anterior knee stress.
• 13:45
  SPEAKER_03: So we would start with something like that as like the initial entry point, right?
• 13:49
  SPEAKER_03: Can we make a small change with how they're performing the movement?
• 13:51
  SPEAKER_03: And can we bring that pain down from let's say a five or six out of ten to maybe a one or a two out of ten?
• 13:57
  SPEAKER_03: Because if it's a one or a two and it's staying a one or a two throughout the entire 10 reps that they're doing, and it's still a one or a two on set number two, on set number three, set number four, um, it's probably okay, right?
• 14:07
  SPEAKER_03: So, like part of the tissue adaptation concept that Dave was talking about is we do need to strain and stress the tissue a little bit.
• 14:14
  SPEAKER_03: So um a little bit of that strain is fine.
• 14:17
  SPEAKER_03: Now, if that slight modification doesn't work, we do have to kind of change and make maybe a little bit more of a bigger change within the exercise.
• 14:26
  SPEAKER_03: And this is where we we do kind of go into our variations of squatting um and start to modify there, right?
• 14:32
  SPEAKER_03: So similar to what what Dave was saying early on is like we know the spectrum that exists from the most hip dominant that has the least amount of forward knee translation on a squat to the most amount of knee translation.
• 14:43
  SPEAKER_03: So if we need to go down that path, right, we can go down into like a low bar back squat where you're really sitting back into your hips, it almost looks like a deadlift.
• 14:51
  SPEAKER_03: Um, and maybe you're even limiting depth by going to a box or you're just saying, hey, don't go as low.
• 14:56
  SPEAKER_03: So now we just took that stress and put it mainly on the hip joint, but still have some level of knee joint stress so we can create a little bit of that adaptation.
• 15:04
  SPEAKER_03: And you know, we'll see how long the the client can you know tolerate that or even progress on that exercise.
• 15:10
  SPEAKER_03: And then maybe we start adding in a little bit more knee stress by going into a slightly higher bar position.
• 15:16
  SPEAKER_03: Let's say just a regular back squat where towards us still push forward a little bit, um, and it's just a little bit less stress on the hip and a little bit more stress on the knee.
• 15:26
  SPEAKER_03: And then we just keep going down that path until hopefully we make that adaptation, and then eventually, you know, we might be able to handle whatever kind of squat, and maybe we're doing front squats that are full depth and you know, knee translating forward and all that stuff, and they no longer have pain because we've taken the time to make them adapt.
• 15:42
  SPEAKER_03: Um, and they should be good and ready to squat whatever variation, hopefully.
• 15:46
  SPEAKER_03: You know, so that's kind of the the way that we progress is start with the small little changes, and then if needed, we'll make the bigger changes and you know, swap exercise types or variations entirely if we need to.
• 15:57
  SPEAKER_04: Awesome.
• 15:58
  SPEAKER_04: Yeah, love it.
• 15:58
  SPEAKER_04: Great, great episode, guys.
• 16:00
  SPEAKER_04: Sarah, hopefully that helps.
• 16:01
  SPEAKER_04: Um, I think the answer is always gonna be modify before stop, right?
• 16:05
  SPEAKER_04: I think we're always gonna say that on almost anything.
• 16:08
  SPEAKER_04: Uh, but you know, there's an intelligent way to do that as well.
• 16:11
  SPEAKER_04: So hopefully we gave you some good tips that you can handle that.
• 16:13
  SPEAKER_04: Um, you know, good luck with your physician, but um, you know, sometimes, sometimes it is what it is.
• 16:18
  SPEAKER_04: You can try your hardest.
• 16:19
  SPEAKER_04: But remember, there's other things you can do other than squatting that can still help them as well.
• 16:24
  SPEAKER_04: Like, and Dewesh kind of brought up some really good concepts on how to handle that.
• 16:28
  SPEAKER_04: So, another great episode.
• 16:29
  SPEAKER_04: Thank you so much, Sarah, for submitting your question.
• 16:31
  SPEAKER_04: If you have anything like that, head to micround.com, click on that podcast link and fill out the form and subscribe on Spotify, Apple Podcasts, or wherever the heck you listen to these days.
• 16:41
  SPEAKER_04: And we will keep doing these episodes.
• 16:42
  SPEAKER_04: We'll see you on the next episode.