All About Knee Health [Guest Post by Danny Baladi]

Alright yall, I’ve got an exciting guest post for today.  My friend Danny is one of the funniest guys I knew in high school…these days, he’s still hilarious, and he’s a Strength and Conditioning Coach at St. Mary’s College here on the west coast.  He’s a CSCS (Certified Strength and Conditioning Specialist) and has his M.S. in Clinical Exercise Physiology.  Needless to say – Danny knows his stuff! So when I reached out to him about guest posting and he mentioned specializing in injury prevention, I knew exactly what I wanted him to post about…allthethings.

For now, we narrowed it down to one of the most common areas of chronic and acute injuries for gym goers – the knees.

Like I said, Danny’s the expert, so I’ll let him take it from here…

The Knee…and its (not so) complicated existence

You walk into the gym. You see a big, ripped guy, thin tank with a backwards cap of the local rival baseball team, throwing weight around like he just lost a bench press contest/beer pong semi-final. This is an example of an unstable knee. Looking for the flash, not concerned with stability or longevity but all about risky lifts and muscle ups. In the back of the gym you see a well-balanced man, who hasn’t skipped leg day and is doing a proper deadlift with a straight back.  He’s not about showing off with flashy lifting, but dedicated to proper progression and limiting muscular imbalances.  This is an example of a stable knee.

The knee joint is the largest in the body and needs to be managed well. Knees take on so much impact, especially in those living highly active lifestyles. Let’s go over some basics structural components and terminology. The knee joint is created by joining two of the strongest bones in the body, the Femur (thigh bone) and Tibia (shin bone). They are divided by two Menisci or Left/Right Meniscus which act as a shock absorbers of the knee. There are 4 ligaments that support the knee joint during dynamic movements1,4. This includes the ACL or Anterior Cruciate Ligament, which supports lateral movement and squatting mechanics. The knee joint mainly has two functions: to be flexed and extended (or, bent and straightened). There are over 14 muscles that attach to the knee and contribute to its function. As to not drown everyone in Latin anatomical terms, the “Quads” are responsible for knee extension, whereas the “Hamstrings” are responsible for knee flexion1,4.

knee pain

With so many muscles surrounding the knee joint, the knee has the potential to be pulled in multiple directions. The glutes, groin muscles, quads and the hamstrings could all be adding tension throughout the knee, especially during the process of flexing and extending. Let’s use the squat for example. During the descent, the knee seeks to travel along the path of least resistance. Everyone’s knees are different and everyone will have different paths. Most commonly however, the knees bow in (knee valgus) especially during the ascent of a squat. Less common is when the knees push outward (knee varus) during the ascent of a squat.

valgus neutral varus knee positino

This tendency for the knee to travel in such extreme directions can be mainly affected by muscular imbalance1,2.

Simply put – muscular imbalances develop when a specific group of muscles (agonists) are tighter and producing more force than their opposing muscle groups (antagonists) which are more lengthened and producing less force.

For example, a muscular imbalance that could affect the knee which is common among field sport athletes is when the quad muscle group becomes overdeveloped compared to the hamstring muscle group.  In this case, the quads are acting as the “gas pedal” of the lower limbs with the hamstrings being the ”brakes”. Without proper brakes, the knee loses function, stability and overall proper force displacement. During a sprint the hamstring helps to stabilize the knee during the plant and drive and if not properly able to function this could lead to decreased performance and potential injury.

This problem can be fixed by proper stretching and adequate variation of strength training1,2. This means that if you only like to do quad dominant exercises, you may injure that quad due to tightness and over activity…or you may injure your hamstring due to it being lengthened and unable to properly fire. Let’s further dive into the concept of muscular imbalances to narrow down specific issues some people may be dealing with.

Let’s say for example that when you squat, your knees tend to move along the knee valgus path, wherein the knees travel inward towards each other. Although multiple imbalances could explain this behavior, the most common come from either Tight Quads/Weak Hamstrings or Tight Groin/Weak Glutes1. To improve such a condition, you would:

  • roll out and stretch the quads
  • strengthen and improve force production in the hamstrings
  • roll out and stretch out the Adductors (muscles from groin to knee)
  • strengthen and increase control of the glute muscle group

This should eventually improve the imbalance between the muscle groups and improve function and performance, all while decreasing the likelihood of injury. This would all lead us back to proper function and technique. During the squat movement, you should try your best to keep your knees in line with the toes, specifically, the patella (knee cap) should travel over the 2nd Phalange (2nd tow inward from the big toe)1,2. The toes should also be in a neutral position (straight forward) or slightly turned outward. This will ultimately help with glute activation and limiting potential valgus positions.

This is best accomplished with a partner or a video recording to visually examine what changes need to be made. This allows for proper load on the low back, hips and limiting highly stressful knee moments such as extreme valgus or varus2. It is encouraged however that knees should be driven outward to increase glute activity during the squat, especially during ascension. This can be a valuable visualization for those who tend to squat with knee valgus. Imagine yourself driving the knees out to neutral which should help slowly develop improved movement patterns.

knee xray

Can we also talk about front/back squat depth? It’s a topic that is surprisingly, incredibly, confusingly controversial. Coming from a lower limb longevity and overall wellness perspective, a squat should go no deeper than slightly past the point when the thighs are parallel to the ground1. Any deeper and the glutes become less likely to activate, putting a majority of the load on the knees and the low back. This over time can lead to chronic pain or discomfort due to the incorrect mechanics and stress placed on the hip and knee joints. This could lead to improper movement patterns, muscular imbalances and structural issues, especially if heavy loads are used.

Take care of those knees, people; you only get two for the duration of your life! With balanced training techniques, adequate rest and maintenance of surrounding muscle groups your knees should be good to go! Portion out your lifting with your plyometric work. Box jumps, cone drills, burpees and any other high impact exercises can lead to increase stress on the knee tendon and if chronic can lead to tendonitis. That is why high impact exercises cannot be done on a daily basis. Lifts or high impact circuits should always be followed by Myofascial release (foam rolling) and stretching as needed. This will help release tension and limit the presence of muscular imbalances. Get quality sleep and make sure you’re getting consistent slumber, because without it, your performance and recovery potential could be jeopardized. Ice those knees if they are sore, massaging around the knee can help improve blood flow and release tension of attaching tendons. If these simple steps are followed than the road to healthy, long-lasting, fully functioning knees will be closer than you think!


Tell me…

Have you ever had knee injuries?
(I’m very quad dominant and have all the patellofemoral pain to show for it!)

How proactive are you about protecting/strengthening your knees?
(It’s a work in progress – trying to bring my sad hams and glutes up to par…and the stretching thing is a struggle, but I’m getting there!)

Any questions for Danny or topics you’d like him to cover in the future???
(AKA help me convince him to do another guest post!)




  1. Clark, M. (2011). NASM essentials of corrective exercise training (1st ed). Baltimore, MA: Wolter Kluwer.
  2. Baechle, T. (2008). Essentials of strength training and conditioning (3rd ed.). Champaign, IL: Human Kinetics.
  3. Sean Croxton – Founder of Underground Wellness. (Thursday, June 13th, 2013) “The Dark Side of Fat Loss: Everything My University Forgot to Teach Me About Health and Wellness. St. Mary’s College of CA Summer Graduate Kinesiology Colloquium.
  4. Clark, M., & Lucett, S. (2008). NASM essentials of personal fitness training (3rd ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

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