Training Log

Starting Strength in the Real World

Starting Strength Squat & Deadlift Utility: Case Study

ACL Deficient, Femoral Osteoarthritic Knee

by Darin Deaton, DPT, SSC | August 18, 2016

Using barbell training for knee health

Despite a background in strength coaching and training as a Doctor of Physical Therapy, I was challenged by the pragmatic method of teaching the barbell lifts used by Starting Strength. I immediately saw the potential of the basic barbell lifts for treating patients. Reading The Squat, or How I Learned to Stop Leg-Pressing and Use My Ass changed my conceptual view of the squat and eventually the deadlift.

Based on physics and observational human mechanics, it just made sense that the Starting Strength squat and deadlift would improve mechanics at the back, hip and knee. So, when a previous patient contacted me to consult with her on a painful knee condition, I couldn’t wait to discuss with her how we could help her reach her strength goals and potentially decrease her pain.

The theoretical construct that we worked with was that squatting and deadlifting using the Starting Strength model would reduce loading of the knee through a decreased knee moment arm, decreased flexion of the knee, and improved hamstring recruitment during squatting and deadlifting. This would, in turn, potentially reduce pain in the knee joint and promote improved strength and function. It might also improve anterior stability of the knee, which is lacking from the ACL deficiency. By performing a more efficient barbell movement, recruiting more muscle in the hip and back, and using a titrated linear progression of loading, the forces applied to the knee were reduced and my client with significant knee problems was able to develop strength with less pain.


The client is a 47-year-old female who has an ACL deficiency, femoral osteoarthritis in the right knee following an ACL injury and reconstruction. After two ACL reconstructions, two ACL graft failures, damage to the meniscus and articular cartilage, she developed osteoarthritis of the knee that produced pain, swelling and weakness.

Her athletic background includes competitive horseback riding and soccer. She is well nourished with an athletic body type. After the second ACL reconstruction, she completed an ACL rehabilitation program, was discharged and then continued to exercise using a cross-training type model for exercise. At that time, she was not actually training. 

After trying to progress back into her regular exercise program, she continued to experience swelling in the right knee, pain and lack of strength. She contacted her orthopedic surgeon to discuss whether she should have another ACL reconstruction and if that would help her symptoms improve. After discussion with her doctor, she contacted my office for an opinion on whether she should have another ACL reconstruction.

We performed a physical exam with history, review of recent diagnostic tests, and assessment of her functional report. Her pain and lack of function correlated to the osteoarthritis, lack of strength for joint stability, and her existing exercise program. Her current exercise program lacked consistent linear progression with specific goals to get stronger. Instead, she was “exercising” and performing movements that were not improving the knee. As a point of interest, she had been utilizing the high bar back squat and front squat when doing squats in her exercise program.

We met for a private coaching session to teach the squat and deadlift, and to establish working loads. Due to the severe osteoarthritis of the joint and existing joint health, I recommended squatting only two days per week, but deadlifting three days per week. I figured that, at first, less might be better than more in her circumstances. She wanted to continue to do some conditioning, which I recommended against but which we agreed upon for two days per week. This was a significant decrease from four to five conditioning “exercise” sessions per week. I requested that if the knee was not improving in pain and swelling, and that if she was not making her load increases, that she discontinue the conditioning workouts.


The client was taught the lifts, and we established working loads using a weight that slowed the bar speed while still allowing proper movement. This sets up the lifter to intentionally start light in order to get plenty of practice under the bar before the loads get challenging. This is particularly important with clients presenting with significant joint problems. The workouts consisted of:

  • Three days per week of deadlift, 1 set of 5 reps, load increases of 5-10 pounds per session
  • Two days per week of squat, 3 sets of 5, load increases of 5 pounds per session
  • Two days per week of conditioning, performed on non-lifting days

The client also performed the press, bench press, power clean using the Starting Strength novice program.

The Koos Knee Score, the Lysholm Knee Scoring System, the increase in load lifted, and the client’s self-report was used to measure performance before and after the program. The client was given instructions for the questionnaires.


After 9 weeks of training, using the Starting Strength novice barbell program, the client had the following results.

Squat 165x5 RM w/pain225x5x3
Deadlift 225x5x1*250x5x1
KOOS ScorePre – ProgramPost – Program
Lysholm Knee Score77/100 – 23% disability82/100 – 18% disability

According to client report, the pre-program deadlift load caused discomfort in her knee and low back, and she had to take time off from training due to perceived injury.

Overall, strength in the squat and deadlift increased with decreasing pain complaints. There was a 36% increase in squat strength performed over 3 sets of 5 versus a prior 5RM with pain limiting movement. In the deadlift, there was an 11% increase in strength with none of the pain or symptoms previously reported at a lower weight.

The client reported that she felt stronger and was more confident in the right knee when lifting using the squat and deadlift movement employed by Starting Strength. Even though the client lifted with greater frequency and loads that she had in her previous program, reported pain decreased from a 5 to 2 on a 0-10 linear pain scale. She was also able to transition to not using her ACL brace during squatting when desired.


It goes beyond the scope and reach of this simple case study to test and determine the exact mechanism for reduction in pain. Maybe it was due to decreased moment loading of the knee and improved recruitment of the hamstrings during squatting and deadlifting. Or, maybe it was due to decreased force at the knee or a titrated linear progression of loads over time. No matter what the mechanism, pain, strength and function improved when it had not with prior exercise.

Strength and function improved most likely due to applying a simple, consistent linear progression of barbell training with controlled forces and proper mechanics. We also controlled the volume and inputs of other concurrent training activities during conditioning workouts to insure that it was not deleterious to the strength training.

Pain, strength, and reported function all improved at some level. It is promising to see an appreciable change in all of these areas when we simply applied a linear progression barbell program using specific movement standards, coaching with a SSC and limited extraneous inputs. As previously stated, our program produced improvement, which had not been gained with other training models. It has hopefully provided a method for the client to manage her pain, fitness, and function without the need for surgical intervention in the near future, which is always a good thing.

To further investigate our construct, “that using the Starting Strength model for the squat and deadlift would reduce loading of the knee through a decreased knee moment arm, flexion of the knee and improved hamstring recruitment,” larger scale studies with a control group would be recommended.

The practical application for the strength coach and healthcare professional varies based on the specific pathology of each client. It is encouraging that strength coaches can utilize the Starting Strength barbell movements and programming to improve knee pain and strength in previously limited clients. Healthcare professionals can and should employ the use of barbell rehabilitation and training in their practices where appropriate to improve joint function.

Appendix – (Technical Stuff)

Traditionally with orthopedics, using the KOOS scoring system, 100 indicates no problems and 0 indicates extreme problems. The KOOS scoring system has high test-retest reliability. In clients with knee injury, ICCs for the Pain subscale range from 0.85-0.93, the Symptoms subscale from 0.83-0.95, the ADL subscale from 0.75-0.91, the Sport/Rec subscale from 0.61-0.89 and the QOL subscale from 0.83-0.95. In patients with knee OA, ICCs for the Pain subscale range from 0.8-0.97, the Symptoms subscale from 0.74-0.94, the ADL subscale from 0.84-0.94, the Sport/Rec subscale from 0.65-0.92 and the QOL subscale from 0.6-0.91.(1)

The Minimal Detectable Changes in clients with knee injury were for Pain 6-6.1, for Symptoms 5-8.5, for ADL 7-8, for Sport/Rec 5.8-12, and for QOL 7-7.2. The Minimal Detectable Changes in patients with knee OA were for Pain 13.4, for Symptoms 15.5, for ADL 15.4, for Sport/Rec 19.6, for QOL 21.1 andthe Minimal Important Change (MIC) is currently suggested to be 8-10.(2)

According to the KOOS scoring system, the client had greater than Minimal Detectable Change in most of the categories for knee injury. For clients with knee OA, she exceeded or met pain and symptom scoring. She did not meet the Minimal Detectable Change scoring requirement for ADL, Sport/Rec, and QOL. But, she did meet the Minimal Important Change for Sport/Rec and QOL. It should be noted that all measures after the program were greater than before the program, and some were very close to meeting the Minimal Detectable Change.

With the Lysholm Knee Scoring System, total scoring represents symptoms and disability. A score of 100 represents no disability. The client progressed from a score of 77 to 82. Both scores were in the Fair category.(3)

  • Excellent (95–100)
  • Good (84–94)
  • Fair (65–83)
  • Poor (64)


  1. Alviar MJ, Olver J, Brand C, Hale T, Khan F. Do patient-reported outcome measures used in assessing outcomes in rehabilitation after hip and knee arthroplasty capture issues relevant to patients? Results of a systematic review and ICF linking process. Journal of rehabilitation medicine : official journal of the UEMS European Board of Physical and Rehabilitation Medicine 2011;43:374-81.

  2. Collins NJ, Misra D, Felson DT, Crossley KM, Roos EM. Measures of knee function: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL), Lysholm Knee Scoring Scale, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Activity Rating Scale (ARS), and Tegner Activity Score (TAS). Arthritis care & research 2011;63 Suppl 11:S208-28.
  3. Reliability, Validity, and Responsiveness of the Lysholm Knee Score and Tegner Activity Scale for Patients with Meniscal Injury of the KneeKaren K. Briggs, MPH; Mininder S. Kocher, MD, MPH; William G. Rodkey, DVM; J. Richard Steadman, MD. J Bone Joint Surg Am, 2006 Apr; 88 (4): 698 -705 .

Starting Strength Weekly Report

Highlights from the StartingStrength Community. Browse archives.

Your subscription could not be saved. Please try again.
Your subscription has been successful.