Exercise and Knee Health

I’ve had the opportunity to work with many people with varying degrees and kinds of knee pain. Through all of this I’ve heard a few misconceptions when it comes to exercise and knee health, and I’ve also learned a few things about what actually causes knee pain.

If you’re interested in exercising around knee pain and keeping your knees healthy for the long-run then keep reading!


Joint health is not simply a matter of age, and joint deterioration is not merely a result of getting older. Although many people, including those in the medical world, are quick to blame aging and genetics for the onset of joint problems, there are really many factors that are within your control which determine your joint health as you age.

Factors such as how you move, what you eat, what your body weight is, and how you manage stress and recuperate all play a large roll in whether or not you’ll develop arthritis and other musculoskeletal problems.

Barring previous traumatic injury to a joint, arthritis and other degenerative joint conditions are not simply bound to happen due to aging. Instead, joint wear and tear from improper movement, poor recovery, and poor diet are some of the largest factors predicting arthritis and degenerative joint conditions.

In this article, I’ll primarily discuss how improper movement and improper exercise technique influences the health of the knee joint over the long haul. But first, let’s look at some misconceptions about exercise and knee pain.

Misconceptions about Exercise and Knee Pain

There are, I’m sure, many misconceptions out there about exercise and knee pain. While I probably won’t bring up all of them, here are some of the most common misconceptions that I see:

  1. Exercises requiring bending of the knees, such as squats, cause knee pain

  2. Lifting heavy weights to build lower body strength causes knee pain

  3. Knee pain is caused by tightness of the muscles surrounding the knee (e.g. the hamstrings, quads, or calves)

  4. Knee pain is caused by aging

  5. Knee pain is caused by genetics (i.e. my parents have bad knees so I’m prone to having bad knees)

While these five common misconceptions may at times contribute to the onset of knee pain, they are almost never the main driver of knee pain. I’ll explain this further in a minute, but first let me tell you what I believe to often be the real causes of knee pain.

The Real Causes of Knee Pain

  1. Poor alignment of the knee joint

  2. Suboptimal movement patterns

  3. Muscle strength imbalances around the knee

  4. Poor tissue quality around the knee

  5. Lack of mobility and/or stability of the foot, ankle, and hip

  6. Previous traumatic injury to the knee

As you can see, the real causes of knee pain have little to do with the specific exercises you perform, your age, or how tight your hamstrings are.

Rather, knee health has everything to do with how well you move during everyday life movement and during exercise. Therefore, proper joint alignment plays the largest role in long-term knee health. In addition to proper alignment, proper movement patterns ensure that the knees stay healthy as you perform exercises and as you move in everyday life.

With that in mind, let’s look at the common misconceptions listed above, and compare them with the real causes of knee pain.

#1: Exercises that require bending of the knees, such as squats, cause knee pain

Squats are a common lower body exercise that involve significant bending of the knees, and they are often thrown under the bus as a cause of knee pain. But squats in and of themselves do not cause knee pain. It all comes down to how you perform squats. If you perform them with poor alignment at the knee joint, and suboptimal movement patterns, then squats will lead to knee pain. However, if you perform squats with good alignment and proper technique, they will be beneficial for knee health.

An example of poor alignment during a squat would be allowing the knees to cave inwards as you descend into the squat, or as you push back up out of the squat. The following video gives an example of this:


While it may not look like much – and to the untrained eye this might even appear to be a pretty good squat – that subtle inward collapse of the knees is a red flag for poor alignment that can lead to knee pain. When the knee collapses inwards during the squat, the load on the knee is not evenly distributed. Instead, there is a large amount of force directed at the inner part of the knee which can lead to uneven wear and tear on that part of the knee and ultimately pain.

To fix this, think about pressing your knees out to the side as you squat down as if you were trying to resist someone pressing your knees together. The knees should remain in line with the mid to outer portion of the foot.

Another example of a poor movement pattern during the squat would be the case where you rock forward onto your toes during the squat movement and allow the knees to shoot in front of the toes. This is a faulty movement pattern because you’re not engaging the hips and hamstrings, but rather primarily using the quadriceps to perform the squat. As you might imagine, this leads to an imbalance in strength around the knees!

Below is an example of what this squat might look like. Notice the knees extending several inches in front of the toes, the heels coming off the floor, and the hips descending straight down, rather than sitting back as if into a chair.

Image by No Excuses Health


To fix this, think about sitting back onto your heels, and feeling your body weight on the whole foot throughout the squat, and not just the toes. You can either visualize sitting back to a chair that is a foot behind you, or actually put a chair behind you to give you the cue to sit back to it.

When squats are performed with good alignment and proper recruitment of the quads, hamstrings, and hip muscles, they become a great exercise to build strength and power in the lower body while simultaneously improving knee stability and health.

#2: Lifting heavy weights to build lower body strength causes knee pain

Many people are scared to squat heavy weights, or lift heavy weights in general because they think that doing this will cause their joints to deteriorate. However, this couldn’t be further from the truth. In fact, lifting heavy weights with the lower body, when done with proper form of course, serves to build balanced strength around the knees, and to develop a tolerance to increased stress in the knees. The result of this is that you will have knees that are stronger and more resilient in the long-run.

As I mentioned under the real causes of knee pain, an imbalance of strength around the knees is what leads to knee pain. Imbalances happen when you perform a squat in which you’re rocking onto your toes, because in this case you’re almost exclusively using the quadriceps to perform the movement, rather than recruiting the hamstrings and hip muscles for balance around the knees.

In addition to squatting with proper form to promote balanced strength, it’s also important to vary the type of exercises you do in your workout routine. Some exercises, such as a squats or lunges are inherently more focused on knee movement and quad strength. Other exercises, such as deadlifts and hip or glute bridges are inherently more focused on hip movement and hamstring/glute strength.

It’s important to have an even mix of knee dominant and hip dominant exercises as part of your workout routine.

So, lifting heavy weights with improper form and improper alignment at the knee will lead to knee pain. On the other hand, lifting heavy weights with gradual progression and proper form will have the positive effects of developing balanced strength around the knees, and increasing their resilience to other forms of stress placed upon them in everyday life.

#3: Knee pain is caused by tightness of the muscles surrounding the knees (hamstrings, quads, and calves)

This misconception comes from the fallacy that if something is tight – or feels tight – we necessarily need to stretch it. While this is sometimes the case, not every “tight” muscle needs to be or should be stretched. You first must consider if the tight muscle is the problem, or if it is just a symptom of the real problem that is caused somewhere else in the body.

For example, tight hamstrings are many times the result of poor stability of the core and pelvis. In this case, the hamstrings are tight because they are making up for a lack of stability elsewhere. If you simply stretch the hamstrings, you’ll never fix the problem. But if you address the root cause of the issue, then you will get rid of the problem as well as the symptoms of that problem.

Another example of a case in which it’s counter-productive to simply stretch the muscles is the case in which someone has very lax/unstable joints. This is another scenario in which the muscles may feel tight because they are making up for a lack of stability in the joints. If you simply stretch the muscles to alleviate the tightness, you are not addressing the root cause, and possibly even contributing to it. Someone with unstable, loose joints needs increased stability around the joint, not increased stretching.

Some people may also have poor soft-tissue quality in the muscles around the knee, which can lead to imbalances. This may be the case if you have had a previous injury, like a strained hamstring. In this case, there may be scar-tissue that has developed in the muscle, which leads to a lack of flexibility and strength in the muscle.

Poor soft-tissue quality can also be brought on by myofascial trigger points, more commonly known as “muscle knots.” In this case there really is no “knot” in the muscle, but rather an isolated part of the muscle and fascial network which is holding excessive tension, and preventing proper blood flow and extensibility.

These trigger points can be caused by a number of different things, but in any case they serve to inhibit proper extensibility of the muscle, and thus can lead to imbalances around the joint. Massage therapy and self-myofascial release techniques like foam rolling can be effective means of improving soft-tissue quality.

So, the bottom line is that “tight muscles” are rarely a cause of joint pain, but rather they are a symptom of a deeper issue which is the true cause of joint pain. Seek to treat the cause and not the symptoms, and you will set yourself up for success.

#4: Knee pain is caused by aging

The fourth misconception is the point I lead off with in this article, and that is that knee pain is caused by aging. To say this would be an oversimplification of the matter, to say the least. Sure, aging plays a role in deterioration of the joint, and to some extent there will be joint degeneration in everyone if you live long enough. However, just growing older is not the main cause of knee pain.

I know many people who have bad knees and knee replacements, but I also know many older people who have perfectly healthy knees. The fact is that you can play a bigger role in the long-term health of your knees by being aware of the real causes of knee pain, and doing things to address them. A smart exercise program that teaches your body how to move in proper alignment, promote balanced strength around the knees, and maintain good soft-tissue quality and mobility, will go a long way in ensuring that your knees stay healthy as you age.

#5: Knee pain is caused by genetics (i.e. my parents have bad knees so I’m prone to having bad knees)

Finally, genetics is a popular scape-goat for many diseases and joint pains, but it’s not nearly as large of a factor as many make it out to be.

For example, many people blame the development of various chronic diseases on genetics, because their parents had the same diseases. However, in the book, “Disease-Proof: The Remarkable Truth About What Makes Us Well” Dr. David L. Katz maintains that you can reduce your risk of developing any chronic disease by 80 percent by doing four simple things – not smoking, eating well, being active, and maintaining a healthy weight.

So, lifestyle factors play a much larger role in the prevention of chronic disease than genetics in most cases. Perhaps it was your parent’s lifestyle that brought about much of their health situation (whether it was good or bad), and not just their genetics?

The same goes for knee health. By focusing on all of the things discussed in this article, you can develop and maintain good knee health for the long-run, in spite of your genetic predisposition.

To wrap things up then, there are many misconceptions about knee health and what causes knee pain. Some people blame knee pain on squats, some blame it on tight hamstrings, some blame it on getting older, and still others blame it on their parents.

However, I know people who are older, have tight hamstrings, and perform squats in their workouts. Perhaps these same people even had parents with knee pain? But these individuals don’t have bad knees because they don’t have any of the real causes of knee pain.

So, if you want to exercise for knee health, then you must focus on good alignment, proper movement patterns, balanced strength around the knees, good soft-tissue quality around the knees, and developing and maintaining hip and ankle mobility.

If you can do these things, you can maintain knee health throughout your life. You can exercise to promote knee health instead of doing exercise that promotes knee pain.

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