Some physicians condemn squat, citing how destructive they are to the tibiofemoral joints (knees), despite scientific studies and millions of personal experiences to contrary. One sports medicine doctor dared to explain to me why squats were considered to be bad for the knees between his sets of squats! Since sports medicine doctors only see people with injuries, one can guess why they may have developed this belief. The individuals they treat certainly do not constitute a random sample, let alone a representative population, which, as any scientist knows, is essential to even attempt to formulate inferences.
The NSCA position statement notes
"Some reports of high injury rate may be based on biased samples. Others have attributed injuries to weight training, including squat, which could have been caused by other factors. Injuries attributed to squat may result not from the exercise itself, but from improper technique, pre-existing structural abnormalities, other physical activities, fatigue or excessive training."
An early study suggested, deep knee bends with weights (squats) were hazardous to ligamentous structures of knee. Later studies conclude squats improve knee stability if lifting technique does not place rotary stresses on the knee (Fleck and Falkel, 1986). The NSCA state:
"Squats, when performed correctly and with appropriate supervision, are not only safe, but may be a significant deterrent to knee injuries."
The squat develops leg strength by imposing torques on the respective joints. Joint torques are the product of the magnitude of the force and the perpendicular distance from the line of force to the center of the joints.
Torque force is necessary for muscles and joint structures to adapt to respected overload. For example, if the knees do not travel forward during the barbell squat, the quadriceps muscles (ie: knee extensors) are not significantly loaded. On the other hand, injury may result if knee (or low back) experience greater torque forces than to what they are accustomed.
Contrary to propaganda, prominent weight training authorities demonstrate squat with knees flexing forward at same distance as hips flex backwards. Fredrick Hatfield, Ph.D., the first man to squat over 1000 lbs, recommends knees to extend over feet with back more upright for quadriceps development. Strength Training for Young Athlete" by Steven J. Fleck, PhD and William J. Kraemer, PhD, illustrate parallel squats with knees extending beyond feet (knees moving forward with similar magnitude as hips moving backwards).
Fry (2003) examined hip and knee torque forces of variations of parallel barbels squats and concluded appropriate joint loading during this exercise may require knees to move slightly past the toes.
Palmitier (1991) showed that knee shear forces are less in the squat as compared to the seated knee extension. Closed chain exercise like the squat can be more protective than open chain exercise like the knee extension because it reduces shear forces across the knee.
Typically the torque forces in the barbell squat are slightly greater for the stronger hip joints as compared to the knee joint, although both the knee and hips travel in opposite direction away from the line of force. During execution of a barbell squat, knees and hips travel in opposite directions away from the foot, or away from center of gravity. Torque forces increase through the knee, hip, spine and ankle as exerciser descends. The greatest torque forces are experienced concomitantly through the hip, spine, knee. and ankle when initiating the rise out of bottom position.
Torque on the Spine is greater when the torso is at a more bent over angle and the bar is placed higher of the back of the shoulders.
Rotary forces through the knee can be caused by functional valgus, also known as 'knees caving in'. Valgus during heavy squats is most commonly caused by the Adductor Magnus over powering the Gluteus Maximus, Medius, and Minimus in the lower concentric portion of the squat. The Adductor Magnus tends to adduct transversely as it extends the hips in but only in the lower concentric portion of the squat. The Gluteus Maximus tends to abduct the hip transversely. The gluteus muscles, particularly the Gluteus Medius, and Minimus normally counter and stabilize these forces as transverse abductors of the hip. Also see Hip Abductor Weakness.
Vargas during squatting is generally not recommended to maintain joint integrity. However, it is interesting that some individuals seem to tolerate minor Vargus. Some high-level strength athletes such as Dan Green (Powerlifter), Ray Williams (WR Holder Powerlifter), Long Qiingquan and other successful Chinese Olympic weightlifters regularly exhibit moderate degrees of Vargus during their maximal and near maximal lifts.
Contreras (2015) theorizes that hip vargus may increase the moment arm of the adductor magnus through hip extension, thereby increasing hip extension torque. Contrerus coined the term 'valgus twitch' to to describe the tendency of high-level lifter to utilize a quick 'knees in' movement when rising out of the hole during squats. (Contreras 2015)
The practice of adopting foot rotation to selectively strengthen individual muscles of quadriceps is not supported by literature (Boyden 2000; Signorile 1995). Knee rotation during squat can increase risk of injury (Fleck & Falkel 1986). Signorile (1995) states:
"Extreme outward toe point greatly reduces stability, it does not allow the proper drift of hips as lifter descends... Extreme inward toe points are equally dangerous, coupling same problems of stability, base size and lower body drift with added danger of bringing knees together...this movement would place high stress on all connective tissues."
The Quadriceps extend the knee. Its involvement is increased when the knee travels more forward relative to the ankle. Coactivation of the quadriceps and hamstrings occurs to increase knee stability by functionally reduce shear forces and strain across the knees. The three heads (of 4 heads) of the Hamstrings acting as Dynamic Stabilizers by virtually 'shortens' at the hip and simultaneously 'lengthen' at the knee (via quadriceps). When the knee is bent >90, the tension of the hamstrings help stabilize the knee by countering the anteriorly directed forces of the Quadriceps (dislocating force) on the knee (see Components of Force). The countering dislocating component with antagonist stabilizing component is characteristics of closed chained exercises (see Knee Stability). Also see simplified diagram of countering forces next to Hamstring Weakness and more detailed Quadriceps and Hamstrings countering forces in somewhat an opposing movement.
A wider stance increases Hip Adductor involvement but does not appear to alter Quadriceps or Biceps Femoris involvement (McCaw and Melrose 1999). The Gluteus Maximus involvement increases with a wider stance, but only at heavier load (eg: 75%).
The Spine is held ridged by the Erector Spinae acting as a Stabilizer with the Rectus Abdominis and Obliques acting as Antagonist Stabilizers countering the pull of the Erector Spinae. Erector Spinaes involvement is increased when spine is positioned at a greater forward angled.
Through the lower leg, Soleus Planter Flexes the ankle allowing the shin to become upright from the forward angled position at the bottom of the squat. Like the Quadriceps, its involvement is increased when the knee travels more forward relative to the ankle. The Gastrocnemius acts as a Dynamic Stabilizer, virtually 'shortened' through the ankle and 'lengthened' at the knee.
The mechanics of the squat change as the load increases. Hay (1982) examining the effects of varying squat load observed changes in the kinematics that effectively amounted to a technique change. At lower loads a larger moment production was required by the knee extensors (quadriceps). As the load increased (40, 60, and 80% of 1-RM) increase in forward inclination of the trunk was noted, shifting the damand to the hip extensors.
Generally speaking, during a powerlift type squat (bar lower behind the shoulders and a wider stance), knee does not travel forward as far as bodybuilding type squat. The hips typically travel back further with torso bent forward on powerlift type squat unless the stance is substantially wide, as in a sumo stance. However, a wide stance requires greater hip torque (requiring greater strength through hip abduction) while reducing both knee and spinal torque.
Although powerlifters have sizable trunk extension moments, elite powerlifters have less forward trunk lean, less backward displacement of the hips, yet less forward displacment of the knees and bar compared to lower ranked powerlifters. Elite lifters also have a slower descent into the lowest position (McLaughlin 1977).
Also see Qualitative Torque Analysis (comparison image to above).
Kreighbaum (1996) illustrates safe position of a deep squat with the knees extending beyond toes. Kreighbaum explains how deep squat can be performed with little chance of injury to knee. The variables of concern:
- speed of descent
- size of calves and thighs
- strength of controlling muscles
The primary danger to knee occurs when tissues of calf and thigh press together, altering center of rotation back to contact area creating a dislocation effect. The danger of knee injury in this situation may be prevented if either of the following factors are present:
- center of gravity of body system is kept forward of altered center of rotation
- muscles of thigh are strong enough to prevent body from resting or bouncing on calves.
Kreighbaum concludes deep squat is of little danger to knees unless these variables and factors are disregarded. Certainly, only limited type of athletes and performers may have the need to perform a full squat. Olympic weightlifters commonly bounce out of full front squat with near maximum resistances during both Clean & Jerk and Snatch. Incidentally, wide stance during Olympic-style squat further reduces knee torque forces. Reportedly, those proficient in Polzunec movement in style of Ukrainian national folk dance appear to experience few orthopedic problems (up until middle ages where their incident of orthopedic problems seems to be no greater than general population) despite their ability to perform a seemingly contraindicative movement for decades; body upright, bounding from one leg to the other in deepest squat position. Also see Over Generalizations.
During the lower portions of a squat, the lumbar spine may flex if hip flexibility is limited. This posterior rotation of the pelvis is also known as butt wink.
It is thought that the risk of low back injury is increased during spinal flexion under a load, particularly if muscles of lower back are not strong enough to support the flexed spine or if joint structures have not progressively adapted to such movement. Some suggest that the depth of the squat should stop just short of posterior pelvic rotation.
However, there is no evidence in the research that pelvic posterior rotation increases risk of lumbar spine injury. In fact, many individuals exhibit butt wink with no lumbar pain or irritation, presumably adhering to Adaptation Criteria. During a loaded squat, there appears to be a relatively safe range of motion in which the lumbar spine can adapt (eg: slight lumbar hyperextension to neutral or very slight lumbar flexion).
Structural factors contributing to butt wink include an individual’s hip socket depth, anteversion angle of the acetabulum or femoral neck, and diameter of the femoral neck. As one descends into the squat, the femoral neck (ball) makes contact with the superior rim of the acetabulum (socket). (Mee 2017)
To continued the descent, the spine must flex as the pelvis posteriorly rotates to compensate for the inability of the hips to continue flexing, in order to keep the weight (barbell and upper body mass) over the base of support (feet). Likewise, inadequate ankle dorsiflexion may contribute to butt wink by preventing knees from traveling forward and effectively shifting hips back. Torso must be angled more forward to maintain center of gravity over feet, possibly requiring spinal flexion once maximal hip range of motion is achieved. A long femur or short torso can contribute to but wink in much the same way.
A wider stance can both slightly increase hip range of motion and decrease the required magnitude of ankle dorsiflexion, possibly preventing butt wink, decreasing its magnitude, or increasing the depth in which it occurs. With a wide stance squat, the Adductor Magnus inflexibility may have greater potential of inhibiting hip range of motion contributing to the onset of hip wink in a deep squat, particular if ankle flexibility and structural hip issues are not contributing.
If hip mobility or ankle range of motion is insufficient to perform parallel or full squats, particular hip and ankle flexibility exercises can be performed in effort to eliminate or decrease spinal articulation throughout the lower portion of the squat. See Full Squat Flexibility and Deep Squat Test.
The squat can decrease knee injury (NSCA) and increase leg power (Adams 1992) when implemented into a sound strength and condition program. Early in off season, squat training will develop foundation for more sports specific training, such as plyometric work. See Conditioning Work recommendations.
The strength and conditioning coaches may choose from a variety of squat movements. The type(s) of squat(s) prescribed should prepare athlete for specific biomechanical stresses demanded by sport as well as other conditioning exercises. Coaches commonly prescribe powerlifting squat (wide stance, bar low on back, little knee torque) at exclusion exercises with greater knee torque, namely Olympic style front squat and bodybuilding style squat. Coaches cite the importance of hip extension strength and power. The Glutes are after all, the most powerful muscles of the body.
Exercises that are most beneficial for sports performance are generally those that are similar to the type of forces and counter forces experienced on the playing field. See Training Specificity and Resistance Training for the Reduction of Sports Injury. The coach must consider the unique biomechanic requirements of the sport as well as the requirements of each athlete's position. The hip/knee/ankle torque ratio should be similar to actual biomechanics experienced on playing field. Motor skills such as blocking, jumping, leaping, etc. generally involve greater knee and ankle torque than what is required of the traditional 'powerlifting' squat. The 'bodybuilding' squat and power training exercises, such as Olympic-style weightlifting and plyometrics, require a higher ratio of knee/ankle versus hip torque than the 'powerlifting' squat.
Conversely, some coaches cite knee injuries as a reason to avoid any other squat than the 'powerlifting style' squat when in fact the risk of knee injury may be attributed to other factors. In fact, including exercises such as Olympic-style weightlifts and their component lifts such as front squats, both requiring greater knee torque as compared to the 'powerlifting style' squat, can potentially increase sports performance and decrease the risk of injury on the playing field as long as sound exercise practices are followed. See squat safety above and Exercise Safety:
If the body has not adapted to a greater torque force, injury can result. It is not necessary to avoid torque force if muscles and joint structures can adapt. See adaptation criteria. Of hip and knee joint, knee is more vulnerable to injury than hip due to structural and functional differences. Certainly, if an individual has had a history of knee pain associated with these types of movements, squat can be modified to place more torque on hip and consequently less on the knee joint. Based on the above analysis, this can be accomplished two ways. Simply, by not squatting down all the way (e.g. 90°) both knees and hip do not experience as great of torque forces. Although, this decrease may be offset by tendency to add more weight to exercise. Alternatively, by bending at hip more than the knee, the knee will travel forward less, as in powerlifting type squat. Recall, quadriceps will not be exercised as intensely since there is less torque on knee joint. In addition, since balance must be maintained over the feet, bending over not only transfers more torque to hips, the torque forces through spine (lower back) increase, another vulnerable joint for some. Certainly a compromise must be made to evenly distribute torque force between knee and hip/lower back, particularly when both knees and lower back are healthy.
If the ankle is not flexible enough to allow knee to travel forward sufficiently, the back will need to be bent forward more to maintain center of gravity within foot base. Consequently, lower back will be subjected to greater torque forces. Squatting with feet wide apart can alleviate part of the problem, allowing back to be positioned more upright. This solution does not, however, distribute equal stresses on quadriceps and glutes as would be possible with adequate ankle flexibility.
Until flexibility can be restored, a temporary solution is to elevate the ankles on board or platform. This will allow knees to travel forward same distance as hip travels backwards. Elevating heels may present a risk to individuals with adequate ankle flexibility who have not adapted to greater torque forces through knee. In which case, knees can potentially travel forward more than what they are accustomed to. Even when elevating heels with insufficient ankle flexibility, resistance should begin light and progress incrementally every workout until a true workout weight is achieved, so joint adaption can occur.
Obviously, individuals who are at higher risk for specific types of knee pain may choose to perform powerlifting squat or box squats while avoiding certain exercises specifically designed to emphasize quadriceps' involvement by increased knee torque (e.g. front squat, sissy squat, safety squat, barbell hack squat, leg extension). Likewise, individuals who are prone to particular types of lower back problems may favor the weighted squat or leg press while avoiding certain exercises specifically designed to emphaisis torque on spine increasing lower back torque (e.g. powerlifting squat, convenitional deadlift).
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Most line drawings from Trainer ClipArt.