Expert insight from Dr. Richard Cunningham, Orthopaedic Surgeon at Vail-Summit Orthopaedics & Neurosurgery

If you experience pain when squatting, lunging, or descending stairs but feel fine while walking, you are not alone. Many active adults experience knee pain in the front of their knee during these activities, even though normal walking feels relatively comfortable.

This reason is that there is increased contact pressure under the kneecap when one bends deeply. Activities like squatting and lunging place significantly more stress on the kneecap cartilage and surrounding structures than walking on flat ground.

Understanding why you have bending knee pain during certain movements can help identify the underlying issue and guide the right treatment approach.

Quick Takeaways

• Knee pain when squatting is commonly related to inflammation and/or wear of the cartilage that lines the underside of our kneecap.
• Deep knee flexion increases the contact forces on the cartilage under our kneecap.
• Early evaluation and treatment can help prevent worsening symptoms.

Why Squatting Hurts More Than Walking

Walking on flat ground is a low impact activity. The knee bends only slightly, and the contact forces under the kneecap remain relatively low. Squatting is very different.

As the knee bends, there is increased loading of the cartilage under the knee cap. Over time, this can cause wear and thinning of this coating cartilage which starts off at about ¼” thick in our early teen years. This wear is usually eccentric such that certain areas of the cartilage wear more than others. This can lead to a vicious cycle where cartilage areas that have increased contact forces wear more quickly than other cartilage areas under the kneecap and then the kneecap tracks further out of place and this cartilage wears even faster. This can be made worse by a patient’s alignment. For instance, many women are somewhat knock kneed and this tends to cause the kneecap to track to the outside not centrally down the groove and this preferentially wears the cartilage under the outer half of the knee cap.

Dr. Cunningham explains, “Squatting or hiking down a hill places much higher loads across the knee cap cartilage than walking on flat ground does. Over time, the cartilage under the kneecap softens and then cracks and thins which and this process is arthritis. This patellar mal-tracking causes popping, pain, and swelling in the knee.”

Patellofemoral Pain Syndrome

The condition of pain under the knee cap is given several terms such as patellofemoral pain syndrome, lateral patellofemoral compression syndrome, chondromalacia patella, and lateral patellar maltracking. It is one of the most common reasons for knee pain when squatting or descending stairs, particularly in women due to their knock kneed alignment. This causes the kneecap to track laterally or to the outside instead of staying centered in the groove at the end of our femur (called the trochlea).

Symptoms often include:

• Pain when squatting, descending stairs, hiking downhill, or lunging
• Crepitus, cracking, and popping with knee range of motion under the knee cap.
• Pain after sitting for long periods
• Swelling above the kneecap and often in the back of the knee creating a popliteal cyst.

Why Walking Still Feels Fine

With walking there is much less knee bending (flexion) and therefore the knee cap is not being compressed in the groove in our femur. The less the compression, the less pain from cartilage overload. Activities like squatting, lifting, jumping, or kneeling cause much higher contact forces of the cartilage under the knee cap.

Treatment Options

Treatment depends on the underlying cause, but many cases improve with conservative care.

Common treatment approaches include:

• Physical therapy to stretch out the IT band and allow the patella to track more centrally.
• Improving hamstring and gluteal strength because the quadricep muscles are usually overpowering these opposing muscle groups.
• Activity modification
• NSAID medications
• Patellar taping or bracing to help push the patella medially
• Hyaluronic Acid Injections
• Platelet Rich Plasma injections
• Occasionally surgery to realign the patella and allow it to track more centered in the groove

Imaging such as X-rays and at times an MRI is utilized to help identify the degree of cartilage wear as well as evaluating alignment or other structural issues contributing to knee pain when squatting.

Dr. Cunningham notes, “The earlier we identify the source of pain, the easier it is to treat conservatively, avoid further cartilage damage, and help patients stay active.”

About Dr. Richard Cunningham

Dr. Richard Cunningham is a board certified orthopedic surgeon and sports medicine specialist at Vail-Summit Orthopaedics & Neurosurgery. He specializes in treating knee injuries and helping active patients return to skiing, hiking, cycling, and strength training safely.

If knee pain when squatting or descending stairs is limiting your activity, an evaluation can help determine the cause and the best path back to pain free movement. Contact his team today!