Lower Limb Pain in the Lifter

6 min read. Posted in Exercise Prescription
Written by Eric Bowman info

When you think of injuries in the weight training population, usually backs & shoulders are high up there but lower limb conditions are certainly not uncommon. Veteran lifters in particular talk about sore hips & knees and using things ranging from 90/90 hip lifts to help.

In the final article of this series, I discuss lower limb pain in the weight lifting audience. Others in the series can be found here Upper Limb pain in the Lifter & Low Back pain in the Lifter.

If you want to learn more about lower limb injuries, check out this excellent Masterclass by Claire Patella on Patellofemoral Pain here.



Common conditions

Cases of foot/ankle pain related to lifting are pretty rare – I’ve only seen a few in my career and these usually pertain to some kind of ankle impingement or, the most common weight training injury in the world, dropping weights on the feet (1). Yes – believe it or not the most common weight training injury is dropping weights on the feet.

Problematic exercises and modifications

Sometimes a lot of dorsiflexion such as in squats, lunges, split squats or step ups can be painful. However, performing these movements with a more vertical shin angle tends to reduce symptoms.

Regarding the weight dropping injuries, I find that any exercise heavily involving grip such as carries or plate pinches are ones to be aware of along with thick handled dumbbells, kettlebells and/or bars where grip can be a challenge.

General programming considerations

Reducing dorsiflexion stretches can be helpful if some clients with ankle pain are doing excessive amounts. I’ve found, in an MDT influenced style, if people have pain or limitation with dorsiflexion, that performing repeated plantarflexion (i.e. calf raises or even kneeling plantarflexion) can improve symptoms.

The only things you may want to consider are:

  1. Depending on the sport and injury history of the individual, having a raised heel may be appropriate.
  2. Also using a heel wedge for exercises like squats may also be appropriate.

As far as not dropping weights on your feet goes – I tend to push grip heavy exercises to a lower RPE (7-8/10 RPE) so as to avoid the issue of grip giving out.




Common conditions

These quite often fall within the anterior knee pain category such as:

  • Quad or Patellar Tendon Strain (or in rare cases rupture)
  • Patellar Tendinopathy
  • Patellofemoral Pain Syndrome
  • (In rarer cases) Infrapatellar Fat Pad Syndrome

Problematic exercises and modifications

For most conditions, any Squat, Split Squat or Lunge involving a lot of knee flexion & forward knee translation tend to be the aggravating movements.

That said:

  • For Patellofemoral conditions, the Leg Extension can be symptomatic
  • For Fat Pad Syndrome, and for some people with meniscus tears or OA, end-range knee extension can be problematic

The big modifications are to work within a range of motion that is comfortable for the knee. If flexion and anterior knee translation are problematic doing more vertical shin versions of Squats (i.e. Box Squats), Split Squats and Lunges (along with potentially Reverse Lunges instead of traditional Lunges) represent the sensible way to go. If end-range knee extension is problematic than doing “piston” reps, stopping just shy of lockout is the way to go.

General programming considerations

The three big programming considerations that jump out at me with regards to knee pain in the lifter are:

  1. Too much quad and not enough glute/hamstring work – often doing more hip dominant work is a common workaround
  2. Too high of a frequency of squatting and other forward knee heavy movements
  3. Deficiency in ankle dorsiflexion mobility.



Hamstring strains

Hamstrings are technically both a hip and knee muscle so I’m giving them their own special section.

The biggest consideration with lifting related hamstring injuries is that; in contrast to sporting related injuries where speed and running volume need to be more tightly managed; the tonnage and frequency of hamstring specific training need to be managed more predominantly in this situation.



Common conditions

Femoroacetabular Impingement (FAI) tends to be the main hip issue that I see aside from lumbar spine referrals to the hip. On occasion you may see adductor strains or tendinopathies, which may require a bit of dedicated adductor strengthening in the program.

Problematic exercises and modifications

With FAI, as with a lot of knee conditions, I find exercises involving a lot of deep hip flexion (i.e. Squats, Split Squats, Lunges and Hip Hinge variations) tend to be the most aggravating ones.

Working within a painfree range of motion to start is the way to go.

General programming considerations

A lot of this relates to technical considerations:

  1. One mistake I see a lot of people make is trying to do Squats or Deadlifts (or variations) with the textbook “feet shoulder width and toes straight ahead” stance even though their hip anatomy may not be appropriate for that and they may be better off using a different stance. To find the ideal stance I recommend either:
    1. Using the hip scour test used by Dr. Stuart McGill
    2. Practicing the movement and experimenting with different stances and toe angles to find what is comfortable for you.
  2. Another consideration; especially for people with poor body awareness, people who may be afraid of some forward trunk lean, or the old school powerlifters that were taught to arch their backs during everything; is to make sure that clients aren’t overextending the back during those movements as that can reduce the available ROM of the hip (2). This is where proper coaching and cueing of these movements, as well as use of properly done bridges/hip thrusts and anti-extension core movements (i.e. planks, deadbugs), can be helpful as well.


Wrapping up

We have concluded a four part series on musculoskeletal pain in weight training clientele. I hope this series has made you feel more confident in working with that population with regards to identifying common conditions, understanding problematic exercises and how to modify training, along with ways to tweak the programming of your clients.

If you want to learn more about lower limb injuries, check out this excellent Masterclass by Claire Patella on Patellofemoral Pain here.

Want to learn more about anterior knee pain?

Claire Patella has done a Masterclass lecture series for us on:

“Patellofemoral pain”

You can try Masterclass for FREE now with our 7-day trial!

preview image


Don’t forget to share this blog!

Leave a comment

If you have a question, suggestion or a link to some related research, share below!

You must be logged in to post or like a comment.

Elevate Your Physio Knowledge Every Month!

Get free blogs, infographics, research reviews, podcasts & more.