Video: Using Box Squats for Knee Tendonitis

[Mark Rippetoe]

Using Box Squats for Knee Tendonitis | Mark Rippetoe

[Brainstrain]

I started SS about a month ago at 6 ft 200lbs 16% BF. My squat on day one was 3x5 at 240lbs now it is 3x5 at 320lbs. My right patella tendon hurts pretty bad by Friday but after the weekend I’m 95% better. Would it be better to replace my entire week with box squats or would it be ok to just replace Wednesday’s workout? What percentage of my low bar squat should I use? Should I still use 3x5 progressing 5lbs at a time for the box squat? Any advice would be much appreciate.

[spacediver]

I've found that eccentric only squats are a great tool for tendinopathy. I've successfully cured two bouts of groin tendinopathy using eccentric only squats, and am currently rehabbing quad tendonitis using the same approach. After 3 treatments (starting with bodyweight, then 20lb, then barbell), I have been able to walk up and down stairs without pain.

Here's a video of me demonstrating the eccentric only technique, using front squats (this was when I was rehabbing groin, and I wanted to be conservative so I started with front squats, then moved to back squats).

[Mark Rippetoe]

I started SS about a month ago at 6 ft 200lbs 16% BF. My squat on day one was 3x5 at 240lbs now it is 3x5 at 320lbs. My right patella tendon hurts pretty bad by Friday but after the weekend I’m 95% better. Would it be better to replace my entire week with box squats or would it be ok to just replace Wednesday’s workout? What percentage of my low bar squat should I use? Should I still use 3x5 progressing 5lbs at a time for the box squat? Any advice would be much appreciate.

I'd rather see a video of your squat first.

[Yngvi]

I've found that eccentric only squats are a great tool for tendinopathy.
Here's a video of me demonstrating the eccentric only technique, using front squats (this was when I was rehabbing groin, and I wanted to be conservative so I started with front squats, then moved to back squats).

I agree with the first statement for many types of tendonopathy, but do not know if eccentrics are actually more effective than isometrics.


You did heavy back squats like this?

[Lasse Høi]

After several months of invalidating knee tendonitis last summer, I used this method, and behold; my knee recovered within a couple of weeks.

[spacediver]

I agree with the first statement for many types of tendonopathy, but do not know if eccentrics are actually more effective than isometrics.


You did heavy back squats like this?

Update on my current quad tendon rehab: the current rehab I mentioned using eccentric squats doesn't seem to be progressing. Might be because I'm using front squats instead of back squats and the stress is too much at those joint angles. Next session I'm gonna start testing Rip's approach (low bar box squats).

Yngvi, I've experimented a bit with isometrics, but not thoroughly. The one thing that gives me pause about isometrics is that you only load the tissue at one specific joint angle, and I wonder if this narrows the set of injured fibers that are targeted by the therapeutic loading.

I suppose you could do a series of isometrics at different joint angles, and it's an interesting question whether this is in some way equivalent to the effect of eccentric loading (e.g. if you did isometric contractions at 1000 different joint angles between, say, 45 and 90 degrees of joint angle, would this be similar to the effect of eccentrically contracting between 45 and 90 degrees?)

Here are a couple good papers on eccentric rehab that I keep meaning to read but haven't yet (both open access)

Frontiers | Quantification of Internal Stress-Strain Fields in Human Tendon: Unraveling the Mechanisms that Underlie Regional Tendon Adaptations and Mal-Adaptations to Mechanical Loading and the Effectiveness of Therapeutic Eccentric Exercise | Physiology
role of eccentric exercise in sport injuries rehabilitation | British Medical Bulletin | Oxford Academic

Worked up to 195 lb for eccentric squats for front, and then back squats, using this technique (when weight was low enough I'd do a curl or hang clean to re-rack it, and when it got heavier switched to the bent over row).

I also wonder whether incorporating front squats into the program can reduce the risk of quadricep muscle and tendon injuries.

Here's the reasoning:

When low bar squats start to get challenging, there's a substantial increase in the risk of knees sliding forward, and often suddenly sliding forwards.

This can be precipitated by a loss of tension in the hamstrings: if the net force of the hamstrings at the ischial tuberosity is not parallel to the femur (and if the force is pointing towards the knee joint), then tension in the hamstrings produces a torque on the femur around the knee such that the femur rotates up around the knee, essentially aiding the quads in knee extension.

In turn, a this torque of the femur around the knee produces a torque of the shank around the ankle (helping the knees stay back and not sliding forward). This can be understood through conservation of angular momentum around the ankle joint.

So the hamstrings support the quads by contributing to knee extension, thus reducing the load on the quads. And they also prevent the shanks from rotating forward, which prevents a potentially catastrophic increase in quad tension due to the sudden increase in the amount of stretching these tissues undergo when the knee suddenly flexes.

In particular, if you have not trained front squats, where the knees are trained in a fuller range of motion (and have adapted to high tension at more extreme angles of knee flexion), and tissue is suddenly put under a much higher tension than it has ever experienced, it's not hard to imagine that injury risk is increased.

[Yngvi]

Update on my current quad tendon rehab: the current rehab I mentioned using eccentric squats doesn't seem to be progressing. Might be because I'm using front squats instead of back squats and the stress is too much at those joint angles. Next session I'm gonna start testing Rip's approach (low bar box squats).

Yngvi, I've experimented a bit with isometrics, but not thoroughly. The one thing that gives me pause about isometrics is that you only load the tissue at one specific joint angle, and I wonder if this narrows the set of injured fibers that are targeted by the therapeutic loading.

I suppose you could do a series of isometrics at different joint angles, and it's an interesting question whether this is in some way equivalent to the effect of eccentric loading (e.g. if you did isometric contractions at 1000 different joint angles between, say, 45 and 90 degrees of joint angle, would this be similar to the effect of eccentrically contracting between 45 and 90 degrees?)

Here are a couple good papers on eccentric rehab that I keep meaning to read but haven't yet (both open access)

Frontiers | Quantification of Internal Stress-Strain Fields in Human Tendon: Unraveling the Mechanisms that Underlie Regional Tendon Adaptations and Mal-Adaptations to Mechanical Loading and the Effectiveness of Therapeutic Eccentric Exercise | Physiology
role of eccentric exercise in sport injuries rehabilitation | British Medical Bulletin | Oxford Academic

Worked up to 195 lb for eccentric squats for front, and then back squats, using this technique (when weight was low enough I'd do a curl or hang clean to re-rack it, and when it got heavier switched to the bent over row).

I also wonder whether incorporating front squats into the program can reduce the risk of quadricep muscle and tendon injuries.

Here's the reasoning:

When low bar squats start to get challenging, there's a substantial increase in the risk of knees sliding forward, and often suddenly sliding forwards.

This can be precipitated by a loss of tension in the hamstrings: if the net force of the hamstrings at the ischial tuberosity is not parallel to the femur (and if the force is pointing towards the knee joint), then tension in the hamstrings produces a torque on the femur around the knee such that the femur rotates up around the knee, essentially aiding the quads in knee extension.

In turn, a this torque of the femur around the knee produces a torque of the shank around the ankle (helping the knees stay back and not sliding forward). This can be understood through conservation of angular momentum around the ankle joint.

So the hamstrings support the quads by contributing to knee extension, thus reducing the load on the quads. And they also prevent the shanks from rotating forward, which prevents a potentially catastrophic increase in quad tension due to the sudden increase in the amount of stretching these tissues undergo when the knee suddenly flexes.

In particular, if you have not trained front squats, where the knees are trained in a fuller range of motion (and have adapted to high tension at more extreme angles of knee flexion), and tissue is suddenly put under a much higher tension than it has ever experienced, it's not hard to imagine that injury risk is increased.

Can you define "doesn't seem to be progressing" more specifically? Do you mean progress in loading progressively heavier weights for the rehab exercise?

Thanks for the articles; the first covers a topic that I have frequently thought about, but haven't seen much literature on. I will peruse it. I believe I have read the second article a few times over the years.

I had the same question in mind before I started experimenting with isometrics. In my experience, the overall efficacy is roughly the same as eccentrics, even when the isometrics are only performed at one angle. (I suspect that it may be more effective when the tendon is in elongated state)

First, we would have to ask: what is the incidence of new, persistent quadriceps tendinopathy in this population? My guess is that it is small enough to obviate the need for the recommendation of front squats as a preventative exercise, even if the injury mechanism you postulate is correct (which it may well be).

I also suspect that shear stresses in the frontal plane, such as those seen during squats with knee cave, may be the mechanism of injury in some cases.

[spacediver]

Can you define "doesn't seem to be progressing" more specifically? Do you mean progress in loading progressively heavier weights for the rehab exercise?

I meant that the progress in pain reduction wasn't getting better even when progressively loading the rehab exercise (was doing it once every 48-72 hours, starting with bodyweight only, and increasing load by 20 lb per session).

Did my first session of low bar box squats today. Ended up doing 3 sets of 5 at 70 lb. Will continue with this, adding 20 lb per session, and report back after a couple weeks.

[Yngvi]

I meant that the progress in pain reduction wasn't getting better even when progressively loading the rehab exercise (was doing it once every 48-72 hours, starting with bodyweight only, and increasing load by 20 lb per session).

Did my first session of low bar box squats today. Ended up doing 3 sets of 5 at 70 lb. Will continue with this, adding 20 lb per session, and report back after a couple weeks.

Too much intensity to recover from or not enough intensity to produce an adaptation? Or possibly frequency is too high? Or something else.

Tendonitis problems are difficult.