Knee Pain During Squats and a 6-Week Progression
Your client is a 41-year-old woman who wants to strengthen her legs and reduce knee pain when climbing stairs. During a bodyweight squat she shifts her weight to the left, her right knee moves inward, and her right heel lifts at the bottom. She reports a dull ache on the front of the right knee that appears at about 10 repetitions and resolves with rest. She has no swelling, locking, giving way, or recent injury. Ankle dorsiflexion on the right is limited: she cannot touch the wall with her knee when her foot is 10 cm away. She sits 8 hours a day and has been walking 15 minutes three times per week. She has no history of knee surgery and has not seen a physical therapist. She asks whether she should 'push through the pain' to get stronger and wants a 6-week plan.
1. Identify the likely technique and mobility factors contributing to her knee pain and select two cues or modifications you would use. Explain why.
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The right heel lift plus inward knee movement suggests limited ankle dorsiflexion and a dynamic valgus pattern. When the ankle cannot dorsiflex enough, the heel rises and the knee may collapse inward to reach depth. The leftward shift also suggests she is unloading the painful right side. I would not diagnose patellofemoral pain, but I would modify the squat.
Cue 1: 'Knee tracks over the second toe; spread the floor with your feet.' This gives an external focus for hip and knee alignment. Cue 2: elevate both heels on a 2–3 cm wedge or reduce depth to the point where the heel stays down. This addresses the dorsiflexion limitation and reduces knee stress. I would also use a box squat to control depth and tempo. I would explain why the cue matters rather than just saying 'knees out,' and I would check that the change reduces pain during the set.
2. What are the boundaries of your scope, and when would you refer?
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I can coach exercise technique, modify load and range of motion, and monitor symptoms, but I cannot diagnose the cause of knee pain or prescribe rehabilitation. I would refer to a physical therapist or physician if she has swelling, locking, giving way, night pain, pain that worsens over 24 hours, or pain above 3/10 during exercise; if the ache persists despite two weeks of modification; or if she cannot climb stairs without pain. I would also refer if she has a history of trauma or surgery.
My scope includes teaching pain monitoring: pain should stay at a tolerable level during exercise and settle within 24 hours. If it does not, that is a reason to regress and refer, not to push through. I would document the findings, modifications, and referral with her consent.
3. Outline a 6-week progression that respects her knee symptoms and explain how you would progress or regress.
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Weeks 1–2: chair sit-to-stand, box squat to a comfortable depth with heels elevated, glute bridges, and calf and ankle mobility drills; 2 sets of 8–10, 2–3 times/week. The goal is pain-free range and confidence. Weeks 3–4: add light goblet squats, step-ups to a low box, and side-lying hip abduction; keep reps 8–12 and stop before pain exceeds 3/10. Weeks 5–6: increase load or depth only if the 24-hour response is clean; add split squats or leg press if tolerated.
I would progress by one variable at a time-load, range, or volume-not all three. I would regress to a higher box, shallower depth, or unloaded sit-to-stand if pain rises. I would reassess ankle dorsiflexion and squat mechanics each week. If pain does not settle or red flags appear, I would refer to a PT. This is a strength and motor-control plan, not a diagnosis or rehab protocol.