The Controversial Squat for Knee Pain: Why Doctors Disagree

On a wet Tuesday night at an overflowing physiotherapy clinic, the waiting area resembles a queue for a gig nobody would choose to attend. Patients hold ice packs, stretchy bandages and those small plastic bags containing scans that seem to crinkle far too loudly. A middle-aged runner rubs his kneecap through his jeans; an office worker in heels flicks through her phone while pressing the outside of her knee; by the window, a woman in leggings performs a subtle stretch with her gaze locked on the floor.

When the physiotherapist eventually invites her through, he does not recommend swimming or Pilates. Instead, he indicates a low bench and says the single word that makes the room tense: “Squats.”

But these are not the squats you are familiar with.

Why a simple squat now splits doctors

For years, advice for knee pain played like a recorded message: “Go swimming, try Pilates, avoid impact.” Everything was low-load, low-risk and, in many cases, low on results. It sounded reassuring, yet many people found it did nothing. Their knees still hurt, and their everyday lives remained restricted.

A newer group of specialists is now advocating an approach that can sound almost reckless: carefully targeted, deep and frequently slow squats, including for people who are already in pain. These are not macho gym “leg day” squats. They are clinical, technical and supervised movements that intentionally load the joint rather than treating it as though it were made of delicate glass.

Some doctors see this as brilliant. Others consider it irresponsible.

Consider Julia, a 47-year-old office manager, former runner and self-described expert at abandoning hobbies. After three years of patellofemoral pain and a demoralising succession of “just rest it” recommendations, she arrived at a sports medicine clinic using a disputed protocol. There was no more pool work and no more instruction to “avoid stairs”. In its place came a 12-week programme based almost entirely on a progressively developed squat.

In week 1, she could scarcely bend to 30 degrees without grimacing. By week 8, she could lower herself to almost chair height while holding a light kettlebell. At week 12, her pain score had fallen by more than half, and she climbed two flights of stairs before noticing that she had not thought about her knees even once.

Her GP was delighted by the outcome, while still muttering, “I hate that they made you squat.”

The principle behind these squats is starkly simple, and distinctly uncomfortable for anyone brought up on the “rest and protect” approach. Joints require more than rest: they also require load. The muscles surrounding the knee must become strong and coordinated under the forces of real life, not merely while you lie on a treatment table squeezing a foam roller. Cartilage benefits from movement, circulation and variety.

Rather than steering clear of the movement that causes discomfort, some therapists now teach patients to practise it gradually and with intent. A controlled squat works the quadriceps, glutes and hamstrings in a way that may steady the knee and recalibrate pain signals. Critics see an obvious danger: progress too hard or too quickly and symptoms can flare dramatically. Supporters argue that the greater danger is allowing millions of people to keep tiptoeing around stairs, chairs and pavements indefinitely.

The “controversial squat” protocol moving into rehab rooms

The squat being debated by experts is not the quick, ego-led gym version. It is more like a slow, supervised routine. Stand with your feet roughly hip-width apart and your toes turned slightly outward, facing a wall or holding the back of a chair. Next, bend at the hips and knees as though lowering yourself onto a low stool behind you, allowing your knees to travel over your toes without folding inwards.

Only lower as far as you can manage without sharp pain, pause for two or three seconds, then return to standing at the same measured pace. Certain protocols place a small wedge beneath the heels or use a slant board to alter the angles, moving load away from the hips and more towards the quadriceps. The goal isn’t depth or heroics, it’s precision under load.

When knees have been deconditioned for years, ten repetitions can feel like an entire workout.

This is also the stage at which people often go wrong when trying it alone. They drop too fast, pursue the “burn”, or imitate a TikTok tutorial made by a 22-year-old with perfect cartilage and no medical context. Pain then surges, leading to the conclusion: “Squats ruined my knees.”

Usually, the explanation is less dramatic and far less exciting. The load increased too rapidly, rest days disappeared, or form fell apart as soon as fatigue set in. Honestly, hardly anybody manages this every day with a monk’s patience. That is not weakness; it is simply human.

Effective therapists now factor in weeks with more flexibility, easier sessions and frank discussions about what patients can genuinely maintain alongside work, children and a leaking kitchen sink.

“The squat itself isn’t the villain,” says Dr. Léa Marceau, a French sports physician who co‑designed a knee rehab program based on progressive squats. “The real problem is dosage and supervision. A well‑coached squat can be medicine. A rushed, copied‑from‑YouTube squat can be a disaster for a sensitive joint.”

Across research papers and treatment rooms, several common principles recur around this newer protocol. Most programmes broadly follow the same straightforward guidance:

• Begin higher and with less range than your ego would prefer: use a shallow movement, a slow pace and no extra weight initially.
• Work with a pain scale: mild discomfort (3–4/10) is acceptable, while sharp or persistent pain is a warning sign.
• Exercise two to three times weekly rather than daily, giving tissues time to adapt.
• Combine squats with hip and ankle mobility work so that the knee is not carrying the whole burden.
• Review progress after 6–8 weeks, rather than after 3 painful sessions.

Knee pain rehabilitation: protect the knee or train it?

This division within medicine can leave patients caught between completely opposing directions. One doctor tells you never to kneel again; another advises sitting deeply with a kettlebell. One physiotherapist champions Pilates on the reformer, while another casually puts a barbell in your hands. For anyone simply hoping to climb stairs without negotiating with the universe, it can be infuriating.

People therefore begin testing things privately. They attempt a few cautious squats in the kitchen as pasta cooks, or make a half-depth bend beside the office printer. Symptoms worsen one day and improve the next, while the story they tell themselves about their knees changes wildly. Are their knees worn out, or merely undertrained? Are they recovering them, or damaging them further?

On one side, traditionalists maintain that a degenerative joint should be protected from compressive loading. They cite X-rays, age, weight and surgical history. Their concern is that promoting squats may encourage vulnerable people towards overuse, particularly in the absence of medical follow-up. On the other side, progressive clinicians point to evidence that suitably loaded exercise can lessen pain, improve function and, for some people, postpone or even prevent surgery.

They also highlight an uncomfortable reality: telling people to “avoid” knee bending often means that they become less active in every respect. They walk less, see people less and lose confidence. The knee turns into both an excuse and a prison. That emotional decline may not appear on an MRI, but its effects appear everywhere else.

A more understated truth lies somewhere between the two positions: both sides are right and wrong simultaneously. Not every knee can, or should, be driven into deep squats, especially during a flare-up or following a recent injury. Equally, not every frightening-looking MRI represents a ticking time bomb. Context is decisive.

For certain people, the controversial squat offers a way to renegotiate their relationship with their own body, one slow repetition at a time. For others, it is simply too risky, too painful or too triggering after years of unsuccessful treatment. Both reactions are valid. The meaningful question is not “Are squats good or bad for knees?” but “What kind of squat, at what stage, for whom, and under whose guidance?” That is where the discussion becomes both real and personal.