The Beyond Pain Podcast

Episode 22: Are Squats Bad for Your Knees?

• Par Four Performance • Episode 22

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Summary
In this episode, Joe Gambino and Joe LaVacca discuss the topic of squats and whether they are bad for the knees. They start by sharing their experiences of watching football and their morning routines. They then introduce themselves and their podcast, Beyond Pain. The conversation shifts to the question of when someone should be concerned about their pain and seek professional help. They emphasize the importance of addressing pain that affects daily activities and quality of life. The main topic of squats and knee health is then explored, with both hosts expressing their belief that squats are not inherently bad for the knees. They discuss the importance of progressive overload and adapting tissues to load, as well as the role of fear avoidance and self-confidence in managing pain. They conclude by encouraging listeners to not be fearful of pain and to let pain guide their dosage and ability guide their treatment.

Takeaways
Address pain that affects daily activities and quality of life.

Squats are not inherently bad for the knees, but modifications may be necessary depending on individual circumstances.

Progressive overload and tissue adaptation are important for managing knee health.

Fear avoidance and low self-confidence can contribute to chronic pain.

Let pain guide dosage and ability guide treatment.

Joe Gambino (00:00.345)
Welcome back into the Beyond Pain podcast. am your host Joe Gambino. I'm sitting here with the wonderful, beautiful, one day off of football watching. Did you watch? I'm assuming that you watched Joe Lavonka here.

Joe LaVacca (00:14.315)
one day.

I watched as long as a probably 39 year old, a 38 year old male can watch on the East Coast. So I'm actually putting you in that bucket. How late did you stay up? Because I was only able to stay up till about 11 o 'clock. You made it to the end. Whoa.

Joe Gambino (00:29.753)
I made it to the end. I made it to the end. Yes, I don't know if you, I do draft Kings with a bunch of friends. We had five people in this week, but it's usually between like five and 10 of us that do it every single week. And I was right up at the top of the leaderboard and I was like, have to see, and the game got really good towards the end. So I kind of got sucked in. Needless to say the game was good and I won 150 bucks. you know, so it kept me going.

Joe LaVacca (00:49.484)
Yeah.

Joe LaVacca (00:56.29)
All right.

Joe Gambino (00:59.57)
So yeah, that's it. But anyway, back to our intro here. You can find us on Instagram at joe Gambino DPT. That's for myself and for Joe over there at strength of motion underscore PT podcast is on YouTube cups and Joe underscore PT. And you can find it on Instagram as well. Beyond pain podcast over there.

Joe LaVacca (01:03.932)
Yeah, I I'll let you finish the intro though

Joe Gambino (01:21.591)
Application form if you do need some help with pain and you would like to work with this you can fill that out We'd be more than happy to reach out to you And if you just want to have a conversation have a couple questions, please feel free to reach out to us on our Instagram accounts. I have conversations with people every single day. I absolutely love doing it. So Please do reach out to us. We're more than happy to chat That's it Joe. Go ahead. Well, we're gonna are we back to football?

Joe LaVacca (01:44.718)
That's it. Yeah. So 11 o 'clock, 11 o 'clock. Well, I just, just, I'm amazed by a couple of things because we were just chatting right before the podcast started and you were mentioning how it's, you know, nine o 'clock in the morning. You have a, know, almost two year old. You have another one coming very, very shortly and you not only stayed up to the end of the game, which I'm assuming based on when I went to bed and everything that happened was probably what? 11 45 ish. 11.

Joe Gambino (02:10.713)
Yeah, I think it wrapped up around like 1150. I got in bed like just at midnight. Just at midnight.

Joe LaVacca (02:15.336)
Okay, well, that's just at midnight and you worked out already showed up for the podcast. No doubt Lily was up already. You were probably taking care of her. You were upping.

Joe Gambino (02:27.001)
She actually woke me up 10 minutes before my alarm went off.

Joe LaVacca (02:30.402)
Wow, look at that. And you're telling me how you upped your game in the ice latte category. So I would say, Joe, you are winning today.

Joe Gambino (02:39.653)
Winning today. We'll see how, you know, usually, you know, it's a workout in the morning with some pre -workout that will get me going to at least four or five o 'clock and then the crash, if I'm tired, will start to hit. So I'll be good for a little while here.

Joe LaVacca (02:50.318)
Then the crash happens. All right, well, let's see, what did I do? So by going about at 11, my Garmin told me my body battery is 100%. The last two days I woke up with 100 % body battery, full recovery, right? And my sleep score the last couple of days, which also my Garmin registers was in the 90s and higher. So there you go. We are prioritizing.

Joe Gambino (03:11.673)
Wow. And now here's the question, Joe, do you actually feel like your battery is 100 % short?

Joe LaVacca (03:17.774)
don't ever really pay attention to that. just think it's funny. and I have like this mini comp. Well, Courtney has a mini competition with herself every day, I think. And then I kind of get pulled into it because when we wake up, she immediately looks at me she's like, what was your score? How did you do? What did your garment say? I'm like, well, I don't know, I sleeping. Why don't we just like, you know, wake up and enjoy the day? And she's like, no, I want to know what your score was because she's always in this competition of like who can sleep better or longer.

Joe Gambino (03:26.584)
Mm

Joe Gambino (03:36.387)
Yeah.

Joe LaVacca (03:46.862)
who's more recharged and you know, heaven forbid, because I go first, I never really know what to do. Like, so I'm always like, I'm like, yeah, it was only like a 60. And she was like, okay, good. Mine was like a 65, but I know yours wasn't a 60. So really what was it? I'm like, it was, you know, 83. She was like, you know, she gets really upset. So I really have to be careful with all these recovery scores. I think, look, you're just looking for trends. I think maybe we had touched on this a little bit. I literally just look for it as like, hey,

or three or four days in a row, my watch is telling me something's wrong, maybe with a heart rate, maybe with my sleep being a little bit off, maybe with like a body battery, but I'm never gonna look for a one -off. I don't believe in that. Who knows how my arm was positioned, if my wrist was crushing the watch one night versus getting pushed off to the side. So too many variables for me. I just go by how I feel and I think most people should too. And if you see big trends, yeah, nah.

Joe Gambino (04:39.321)
Yeah, that's I was curious if you actually felt like, hey, you know, this is telling me I'm 100 % charged. Do you feel the battery is charged? Is it lining up?

Joe LaVacca (04:49.676)
I would say, I don't really feel much different. I'd say there is a little bit of a boost. know, like when you wake up, you look at the watch and you're like, I crushed that last night. Good job. You know, but then like you wake up and you're almost like you want to feel better. You know, so I get up, I'm like, all right, well, I still feel the same, you know, heading to make some coffee. I still feel the same, you know, making breakfast. I still feel the same. I still feel the same, but I know I'm better. You know, so you just keep telling yourself that all day long. But no, generally speaking, I think it's salt.

Joe Gambino (04:58.607)
Yeah.

Joe LaVacca (05:19.18)
more psychosomatic than anything.

Joe Gambino (05:21.017)
Yeah, I'm sure. actually pulled up, we have a sleep number bet and it gives us a sleep score too. And mine was 83 last night, which is actually up from my 30 day average. So I should just watch more football, you know?

Joe LaVacca (05:30.702)
There we go. There we go. Watch more football. You know, have that excitement of winning 50 bucks. That's probably what it was too. You know, maybe give yourself $50 every night before you go to bed. Just spend it all yourself.

Joe Gambino (05:34.381)
win more money and call it a day.

It's just just put on my pillow All right, let's move in over here question of the day this one comes from me This actually is based off a conversation. have with somebody yesterday He was interested in Potentially working with me we got down a call and then as we're kind of going through it. The biggest objection was does he really want? To make a change

That was like the biggest thing. Like, you know, we're kind of going through it. I couldn't really figure out, like he couldn't give me any reason. Like you say, I have this pain for like three years. It only bothers me. when I loaded heavy or if I'm playing basketball or tennis and it's like a four pain and it goes away later in the day, doesn't stop him from doing anything. so we were chatting for quite a while and the theme was, you know, it's like this thing he wanted some answers, but.

He wasn't in a place where he really wanted to, or it wasn't a need to take care of it. So I just sent him a free resource. I think it's gonna help him. But my question to you is maybe you have, I'm just actually just maybe think about it. When do you think someone should be concerned about their pain and actually go out and get it looked at?

Joe LaVacca (06:58.668)
Yeah, think this is something I've actually been, yeah, I think this is something I've been diving into a little bit more, trying to understand it myself. And the thing that it's taking me to is this idea of pain versus disability in our profession. Right? Now, of course, if your pain is concerning to you, then of

Joe Gambino (07:00.409)
because I feel this is common.

Joe LaVacca (07:21.25)
get it looked at. There are so many resources. It could be your PCP, it could be your PT, it could be a massage therapist, it could be your strength coach, but bring it up to someone that may know a little bit more about that topic than you. Even if they don't have the exact answer for pain, which let's face it, probably nobody does, can they point you like you did?

towards some resources. Hey, you know what? I don't really know too much about this, but you might want to check out this Instagram page. You might want to check out this blog. You might want to check out this YouTube video that I found that, you know, personally I thought was helpful. So I think if you find pain concerning, it's always worth getting an opinion for. Where you get your information, I think is really important. When you should definitely, definitely take a look at it is when it starts to affect your ability to do different things that you want to do.

So if you find that you're not going into the gym and strengthening, you know, legs for some reason, if you're canceling plans with friends and family, if you're calling out of work, those are the things where you absolutely should, and I don't say that too often, but you absolutely should go get things looked at because those are the types of things your disability will lead to more chronicity usually in the long run. And then those are the things that will lead to poor coping strategies.

So pain on one end, right? Again, generally speaking, I'm never too concerned about pain by itself, but I wanna know how it affects your mindset, your day to day, but most importantly, your ability. So I'd say that's probably the gist I gave in a nutshell, which seemed pretty similar to yours.

Joe Gambino (08:58.711)
Yeah, no, I actually like that. And I would agree with you. Specifically, unlike the, you know, is it starting to impact your life? I think it becomes more more important as far as needing to go get it checked out. You know, if it's your mood is changing, it's affecting relationships, the ability to be with your kids, the ability to play a sport that you like doing. And it feels like you're just like.

you're almost losing enjoyment because you have to like, you know, you may feel like you're going to suffer afterwards, then go get it checked out. Don't keep pushing that aside. But if it's just like, I have some low level pain, it doesn't stop me from doing anything and you're don't find it to be concerning, then it is what it is, right? I would just continue to find things to put some TLC into those areas and see, you know, you know, if you, if you can manage it and it's perfectly fine. And I mean, I have some

I feel like always has something that's a little bit, but it's nothing that lingers. It's nothing that gets bad. Nothing that really ever gets over like a one these days. I mean, I've been almost kind of, I would say used to pain at this point because my back, but it's in like a very different place than it was a long time ago where I don't really like flare ups for like a one or two for me. And it happens like every few months now. So just like, okay, well, I don't need to stop anything. It's not concerning. I'm doing the work to keep it.

feeling good anyway. And I have a bunch of tools in my toolbox that even if I have a one, can just do like this or that. And then all of it's back to like feeling good. yep, that's what I would say. I like that. I really like how you broke that down. And today we are talking about squatting and particularly if they're bad for your knees. I feel like this is something common that we both hear it. I see it in social media all the time and I see it in like

comments and when I'm working people that there is sometimes a fear around loading the knee especially if they have some pain so why don't you give me your thoughts on squats and if they're bad for your knees and whatever you want to talk about from there we'll go forward.

Joe LaVacca (11:08.086)
Yeah, well if anyone follows me on social media, the answer right away they should know is Joe does definitely not think squats are bad for your knees. It's pretty much all I do. I feel like in a lot of my daily training, there's always some sort of like knee dominant squat type exercise. Again, know, shout out to Ross, coach extraordinaire has really helped me grow my thighs over the last, you know, three, four years. So no, I think squatting is

Obviously one of the most fundamental necessary human movement patterns that we all should have access to. Right now, how much access we have to those things will vary, you know, person to person. What's your training age? What sort of apparatus is do you use? I know when I came to your place, you have barbells and kettlebells. I just have kettlebells and dumbbells here at my gym or my home gym. So it's going to depend on your setup. It's going to depend on your goals.

It's going to depend on so many different things, but if you have knee pain, and maybe we'll just keep it in this variety. If you have knee pain, squats are absolutely not detrimental for your knees. And I think the category of that patients seem to be most concerned about is, you know, I'm squatting, but I'm not going below 90 because I heard that's bad for your knees. And I still see that, you know, when I'm squatting, you know, I'm not letting my knees go over my toes.

or I'm keeping my toes super, super straight. Because again, that's how you quote unquote should squat. And I think that again, the variability that we talked about last week or two weeks ago now in our other episode, pick a pattern or pick a position that works well for you, that you can tolerate your loading in and that you can build on.

because what's really funny about the whole knees over toasting, because that's probably what comes up the most consistently I see with clients and I see you shaking your head. it's probably, you know, kind of similar across the board, state to state, across the country, across the world is this, your body mass doesn't change, right? Or if you're holding 50 pounds, it's still 50 pounds. So your body mass doesn't change. The weight that you're holding doesn't change. Gravity doesn't change. So if you

Joe LaVacca (13:26.798)
take a position where you're deliberately not putting your knee over your toe, the only thing that does for forces is change where they go. So when you don't squat your knee over toe or purposely limit it, you can see a reduction in force at the knee by about 20, 22%. Right? According to some data I have here, which is good. If you're, if you're mechanically sensitive around the knee, that can really help you. But here's the kicker. It's going to increase the demands on the hip and the lumbar spine.

by close to a thousand percent, at least according to one study that I found. So if you are protecting your knee or you have sensitivity in your knee, this is why we, right, and I'm putting us collectively, might say, hey, why don't we start working on your hips? Why don't we start working on your back? Why don't we start working away from the sites of pain? Because if we are going to modify a movement pattern or you're going to modify a movement pattern, there's going to be other forces placed in other areas that we should probably prepare for.

So if you are modifying because you think something is bad for you, just know you're not really doing much service to the rest of your body unless you're preparing your body for those types of loads or movements. So with you shaking your head and you know, the knees over toes conversation and you know, maybe not squatting below 90 or parallel. Do you have similar thoughts or guidelines that you would give to people where you would

Say to them, yeah, these are good ideas or these are false beliefs. How would you navigate that in the patients you've seen?

Joe Gambino (15:03.001)
Yeah. So the way I would navigate it is, you know, what can your, your body do in general? So, I mean, I think it's actually really interesting that this stat that you bring in here, 22 % less load in the knee, but it really starts to increase demand hips, lower back, things like that. So I think really it all is a goal dependent. I mean, if your goal is to really load your hips, then making that kind of modification is worth it. Right. If you're looking from a fitness perspective, if you're trying to load the quads,

All right. Let him, the knee come over toes is going to be beneficial. think, with Ben Patrick and the whole knees over toes and things like that has gone like really kind of shifted in like a really large direction. I don't think people need to get too crazy with it. but the way I look at it overall is if you are avoiding it because you have knee pain. Well, if you constantly avoid it, those tissues are never going to get stronger. So the biggest thing I see from people is, and,

One of the biggest themes I hear from people when they've had knee pain for a long time is they try to avoid squats and they try to avoid lunges. They don't even do them. It's not even like I'm going to try to keep my knees from going over my toes. I'm just going to completely avoid these movement patterns because I'm afraid that is going to make my knee worse. And then what ends up happening is that you end up having pain for years and squats just get harder and harder for you to do. So then it's like a vicious cycle of I'm going to avoid them because it's painful. And then you just don't...

Joe LaVacca (16:11.522)
Yeah.

Joe Gambino (16:29.837)
do it anymore so your tissues don't adapt to it anymore. And it gets harder and harder for you to do. And it just keeps you away from doing it. it's, I mean, if you have a kid, good luck avoiding squatting. mean, like I'm on the ground all the time with Olivia. You know, I have to even like, mean, same goes for like deadlifting. And if you're afraid to bend forward, like putting her in her crib, right? That's you can't avoid it, right? I mean, once she gets older, I don't have to do that stuff anymore, but like,

Joe LaVacca (16:40.327)
Hehehehehe

Joe LaVacca (16:52.972)
Mm -hmm. Right.

Joe Gambino (16:59.929)
Little things like that. You know, you can't really avoid these positions and you want to work your way back to them. So typically when I'm telling people is OK, right now you can't squat. You're nervous about it. It's painful. What can we do? Can you do like a quarter squat? And is it fine? Can we start there? Can you bend your knee like can we just maybe start with some isometrics and knee flexion and build that that capacity up? And it kind of goes into our next episode, but like.

with like, we're gonna be talking about prerequisites of movement. You what does a squat look like and what does your body need to do to be able to get back to squat? And can your knees flex? Can you, you know, do you have ankle dorsiflexion? Like do your hips flex? Like maybe there's something movement related that's really increasing why, you know, your knees are doing something or you have pain somewhere, right? Because of compensation. So can you start to clear up some of those other things?

but to say that they're bad for your knees, I think that is, I agree with you a hundred percent that squats are not bad for your knees. they just might not be the best choice for you, depending on your situation, your pain levels. You know, if you have osteoarthritis, squats are probably going to be great for you in the long run, but they may not be the first thing that you're doing. Right. Cause we do know that resistance training is going to be highly beneficial for people of OA and help them kind of navigate, reduce pain, stay functioning over the long run. So.

How can we find those opportunities for movement? And then how can we move them into a direction where they're just the capacity gets better and that like, I'm always, anytime I hear someone scared of moving in a position or there's apprehension, it's always the first thing I wanna kind of tackle because if you are someone who likes to be active, but you're kind of worried about things, you're going to be changing your movement. You're always gonna be kind of sub.

consciously on edge and I think that's going to change movement and increase your risk for injury. So how can we start to bring that confidence up?

Joe LaVacca (18:54.602)
Right. And two points that I really want to emphasize there that you brought up. Your tissues are going to adapt, right? Just like everything else in your body with progressive overload. So if you are having pain with squatting, it is normal, rational, reasonable to think, Hey, squats are bad for my knees. Right. But when we do an assessment with you, we're trying to determine what tissues are sensitive.

What compartment of the knee is most sensitive? And sometimes I'll break it down very simply for clients like this. Hey, when you're squatting with two legs, kind of even on the floor, we're gonna push a lot of this load to the lateral portion of your knee, right? And again, maybe depending on if it's a little bit more painful at the top, we know maybe some of these anterior structures are a little bit more sensitive. If it's a little bit more painful as we get toward the bottom, maybe more of these posterior structures are a little bit more sensitive. But typically,

We can start to then say to your point, well, we know this range is a little bit sensitive. It might lead us to believe that this tissue or this side of the compartment of the knee for kind of separating it is just a little bit kind of like hesitant to take load. But look at all these other ranges. Look at all these other tissues that are primed to take load that can take load that we can train. And we can always make little modifications around there. So if you're having that pain with a double leg,

Let's split it out. Let's go single leg. Let's go step ups, right? Cause that will push a little bit more load immediately into the knee or the knee compartment on the inside. And a lot of people are like, wow, well that one doesn't really hurt that much. Yeah. Because we're just playing with forces. So we can still expose you to a knee dominant position and take away your pain and maybe then break that fear that you were talking about before, because that second part, that's the next part I wanted to talk about.

The number one thing that's going to build chronicity or like chronic pain in people is fear avoidance and low self -efficacy or low self -confidence that they're ever going to be able to get back to things. And that kind of brings us full circle to how we started the episode, because if you want to just get out of pain and then think that's going to change your behavior or change your activities at the gym, you're probably mistaken because you'll be out of pain.

Joe LaVacca (21:16.312)
But if you think it's because your torn meniscus is so delicate, well then why would you ever go back to squatting? Right? So we really have to play with these variables of force, right? This is for me where biomechanics do come in and can really help us and play a good role in our rehab. But then we also have to say, Hey, look, there's no reason for you to fear this. And here's why. So let us prove it to you. Let us show you how to load this knee because it is fundamental motion.

Like you said, it's going to pop up whether you have kids or not, whether you sit down in a chair or how you get up, how you negotiate stairs, how do you go to the bathroom, right? All of these things, especially as we get older, are going to be really, really key for independent living and for quality.

Joe Gambino (22:02.827)
Yeah, I love that last point. I mean, we know that as you get older, power declines, and I think that has a high correlation with falls as you get older. So if you can't squat, you're not doing anything to maintain power output. You're not doing anything to maintain muscle mass. It's just going to lead to more and more issues as you get older. But I want to go back to here. You mentioned, you know, fear avoidance, low self -confidence. And I think that if you are dealing with chronic pain,

Joe LaVacca (22:13.838)
Totally.

Joe Gambino (22:30.839)
that one thing that you, that everybody struggles with and really should kind of realize is that pain isn't always bad. You you can do things, especially if you're trying to get back to something, you're going to have to play the dance of pain in order to, to do so, right? Like if you can't squat right now because it's painful, you can't expect like to do a couple of little stretches here and some foam rolling here and some active mobility work here. And then just like,

Okay, now I can go squat full range of motion without pain, right? Like you're going to have to kind of go in low level discomfort is usually kind of a good sign that we're loading tissue at an appropriate level to actually make changes. Same way people view muscle soreness and like, you know, higher intensities is almost when we're looking at pain in the rehab perspective, you know, having some.

knee soreness or having some like, you know, I did some squatting yesterday for the first time in a while. And it was a three level pain. It went away by the end of night, kind of like the story of the guy in the morning, right? It's like, four level pain, goes away by the time I wake up in the morning. Is that really bad? I would say with it being super chronic and going on for three years and constant every time he does it, you know,

you know, might be time to start to see if you can find some answers or try some new things. You don't need to hire somebody, but keep looking for new solutions because I think that you can reverse that and actually enjoy those things a little bit more. But you know, you have to play that line of symptoms sometimes. And we talked about this before where we're not just playing with symptoms and like we're just only looking at pain in a vacuum. We're also looking at how

movement is maybe we have one or two movement tests that we're doing and you know when we're playing with swaths we're making sure those two things aren't also moving backwards you know that they're they're feeling better and moving better and that we're seeing objective changes alongside because pain as we know is a very terrible outcome measure to know progress is happening so

Joe Gambino (24:34.541)
I think anyone in chronic pain, one of the big takeaways here is don't be fearful of pain, but at the same time, you don't want to be overdoing it so that you're making things worse. And it's it's a harder, same thing with overtraining. All right. These lines are like, kind of like, it's like this line is like really easy to go over and it's really easy to be really far under. And, it does take some experience to, learn your body and what you can do. And if you're not fearful of pain, like, it doesn't matter.

Joe LaVacca (24:49.41)
Mm -hmm.

Joe Gambino (25:00.841)
sure, it really sucks if you sit off your knee and you're you can't do something for a few days because you really bothered it, but it's not going to make your knee significantly worse where you're going to need a surgery tomorrow because you did that, right? Like just let the tissue recover and you know you did too much and now you can modify intensity, you can modify volume and you can reestablish and try to find a little bit more comfort and movement.

Joe LaVacca (25:05.326)
Sure.

Joe LaVacca (25:23.214)
Right. And even if it did make your knee worse, that's okay. Right. That is okay. and I said something to the other, the other day to a client and then, and then this is how I'll kind of close out our topic right now, at least on my end, unless you want to add some more stuff to this. But if you load your knee and you have pain, let pain guide your dosage. So if you did three sets of 10 or a hundred pounds, reduce that, go to sets of five, go to 50 pounds, but

Let ability guide your treatment. So if you woke up and your knee was swollen and you couldn't walk and you're limping and you couldn't sleep that night and you cancel work, well then yeah, maybe let's find a different intervention for you because squatting wasn't the right entry point. So I found that that's been kind of helpful for some clients this week as I blurted that out.

Joe Gambino (26:15.693)
No, I love that. And the last thing I'll say on that is, you you learn from it, but don't say because it was painful that you can't do it anymore, right? There's another variation or just less intensity or less volume that will likely be okay for your knee or whatever body part. And that's where you start. just, you might've just, you know, bit off more than you can chew, so to speak.

All right, well, I think that's it for today's episode. Joe, I love you. Listeners, we love you. And if you made it this far into the episode, extra love for you.

Joe LaVacca (26:41.814)
Love you.