Not long ago I posted a video about the difference between box squats and squats to a box. To many casual fitness fans these might seem the same, but they’re not. Some people treat box squats as just another squat, but there are real differences. I won’t go into every detail here, but my friend Nia Shanks wrote a similar post (with a video) about the benefits of squats to a box.
A reader once asked for squat variations for people with hip flexor issues (tendonitis). Nia asked me for input, so I’m sharing what I wrote in reply.
1. Know the difference between tendonitis and tendinosis.
Tendonitis is usually linked to some joint inflammation and tends to improve after a few days of rest, ice, and NSAIDs. Tendinosis is a more chronic condition where the joint has undergone degeneration and doesn’t go away in a few days. If someone has an ongoing issue labeled tendonitis, it may actually be tendinosis.
2. Take a grenade approach with soft tissue work.
Foam roll every day—yes, every day. If your knees bother you constantly, your tissue quality likely needs work. Foam rolling helps a lot. Treat tense areas like the hip flexors (rectus femoris and TFL), adductors, IT band, and glutes. A tennis or lacrosse ball can target the vastus medialis and vastus lateralis, which are common knee pain trigger points. Consider seeing a reputable manual therapist who can do Graston, ART, or similar work. They can be more helpful than basic band exercises or electrical stimulation alone.
3. Preach to yourself: vertical shin angle.
“Stacked” joints are happy joints. Often knee pain comes more from technique than the knees themselves. I didn’t invent the cue for vertical shin angle, but it’s proven effective for knee-friendly squats. Instead of breaking with the knees, sit back and push the knees out. This keeps the torso more upright and distributes the load properly. Start the descent with the hips sitting back, which emphasizes the glutes and hamstrings and tends to produce a more upright shin angle.
4. Build hip stability.
The knees depend on the hips (and ankles). Many people have subpar hip stability. Start with simple drills like side-lying clams and X-band walks. Single-leg work helps too, since it engages the lateral subsystem (glute medius and adductor complex on the standing leg, plus the contralateral quadratus lumborum). For knee issues, choose knee-friendly single-leg movements such as reverse lunges over forward or walking lunges, which can be tougher on the knee due to deceleration. Don’t overload with weight; technique matters more than how heavy you can lift.
5. Glute work matters.
Glutes strongly influence how the femur is controlled. When they’re not firing, you get anterior pelvic tilt, internal rotation of the femur (and tibia), and a lot of knee strain. When the glutes work properly, you’ll see better pelvic position and more external rotation of the femur and tibia. You can start with glute bridges (supine or single-leg) and progress to movements like deadlifts, pull-throughs, glute-ham raises, kettlebell swings, sled pushes, and other hip-dominant moves. The goal is stronger, better-functioning glutes.
6. Don’t neglect the core.
The front core and external obliques matter too. Weak core stability, especially in the obliques, can contribute to anterior pelvic tilt. Include rotational chops and lifts, and don’t skip dedicated rectus abdominis work.
7. And when all else fails, deadlift.
Deadlifts generally require less hip and knee flexion and can be knee-friendlier than squats. If you want more quad work, trap-bar deadlifts are a quad-dominant, hip-dominant option. But overall, squats to a box can be a valuable step for knee pain: the box lets you squat in a pain-free range of motion and helps re-teach a proper pattern. Once you’re pain-free, you can work toward full depth. None of the above should replace attention to technique and quality work; watching the videos referenced above will help you get it right.
Hope this sheds some light on a pretty involved topic.
