How to do Box Squat for Knee Pain from Hashimoto’s

Hashimoto’s can cause joint pain, especially knee pain on both sides [1]. Sensibly, the very idea of squatting might make you cringe. But it’s a lift that your body needs because it’s so good for your knees, hips, and back. 

Squats don’t make my heart sing either and you probably feel the same. For women with an autoimmune condition like Hashimoto’s, knee pain in both knees is common, and doing squats can feel like torture especially when your form is not dialed in. 

Many of the general public, and even doctors, may think squats are bad for the knees because they’ve never lifted weights themselves. But when done right, squats can be good for your knees and even help with knee pain!

When done with impeccable form, they’ll set you up for less pain and better day-to-day functioning. They can lead to incredible transformations mentally and physically. Squats give you a better shot at surviving day to day, from getting out of cars, hopping up from your desk, and repeatedly scooping up a two-year-old in the air who only screams “More!” The benefits go on and on.

Why women with Hashimoto’s should squat

Hashimoto’s can cause joint hypermobility and pain due to lower tendon turnover [2]. Since thyroid hormones are important for muscle mass, low thyroid can also cause muscle loss and muscle pain [3]. Overall, these changes destabilize your body and cause more pain. 

Worse yet, most people already have pre-existing movement dysfunctions from prolonged sitting, poor posture, and unhealthy breathing patterns. These factors can make joint pain from Hashimoto’s worse.

Learning to squat correctly is the antidote to that. It will stabilize you through your natural ranges of motion which you were born with. Also, by helping to strengthen muscles around your knees and hip joints, I firmly believe that squats done correctly are the key to living pain-free.

If I never had to squat again and know with certainty that I would live a life without pain, I would choose this option. But knowing what I do physically every single day, like picking up my kids, pressing my suitcase into the airplane overhead, and crawling around on my knees to play horse with my toddler, squats are non-negotiable.

A bodyweight squat with the hips traveling below the level of the knees uses most of your muscles from head to toe. It’s a beautiful example of real mobility and true stability. The hips, knees, and ankles hit maximum end range. If you drew a line from the ears, shoulders, hips, think of this line as unbroken and long allowing the torso to descend with grace. Add a weight (kettlebell and barbell are my faves) and every muscle group benefits from the squat.

The benefits of squatting with amazing form [4]:

• Promotes both joint stability and mobility, especially in the knees, ankles, hip, and back. The stability and mobility can reduce pain
• Increased strength and resilience
• Fights gravity, aka just makes life easier
• Develops the glutes, hamstrings, core, and quads
• Improves muscle definition (who doesn’t love that?!?)
• A full-body movement makes for more muscles working together leading to more energy expenditure
• Improves bone density

We started off squatting naturally as toddlers in the first couple years of our lives and at many points along the way we got off track. Long hours of sitting in one place, old injuries, and poor chest breathing patterns have all robbed many of us of the muscle memory of squatting. But this is all re-trainable, and you can do it pain-free!

How to correctly squat if you have knee pain for Hashimoto’s

If you have Hashimoto’s, chances are that your joints, especially your knees, are tender. So, the thoughts of doing a full squat might scare you. But full squats are actually an advanced move that most adults lose the mobility and stability to perform, especially in their hip, core, and ankles. You can start where you are at, make modifications, and take baby steps toward that. Squatting isn’t just for people who are good at it.

Here are the baby steps I teach inside Thyroid Strong to progress towards it. While you may feel some discomfort, I don’t recommend pushing through pain. If you feel pain during squatting, find a variation or move within the pain-free range.

Step 1: Core stability

Many women with Hashimoto’s have hypermobility that causes their backs to hyperextend and their knees to cave towards the bottom of the squat. So, you need to learn correct spine stacking, breathing drills, and core bracing so that you can minimize pain and avoid injuries. You also want to pick a squat variation (see below) that you can perform without hyperextending your back or caving your knees inwards. 

Step 2: Addressing hip and ankle mobility

Your body generally follows a “use it or lose it” principle. Because most people nowadays spend a lot of time sitting, they never need the mobility in the hip and ankles to drop down to the bottom of the squats, so they lose it. The right warmup drills and mobility work, along with stabilizing the right joints, can help you get there eventually over time.   

Step 3: Solid warm-up to fire the core muscles and prime the nervous system

Squatting is a primal movement that we were born capable of doing as babies. Aside from moving your body, it also involves your nervous system and breathing to brace your core. So, I teach drills to help you breathe, correctly brace your core, and prepare your nervous system for squatting. 

Try the following moves:

BREATHING DRILLS

Start with breathing drills to get into your core engaged and prepped for squatting. Lie face down, make a pillow for your forehead with the backs of your hands. Breathe down and wide into your belly and feel your tailbone drop towards your heels as you breathe in. Do this for 15 breaths which is about a minute.

ROCK LIKE A BABY

Before babies start to crawl, they get on all fours, and rock their tushy back to their heels and then forward with their shoulders over their hands. Do the same with your toes tucked under to open up the hips and ankles. Do this for 15 breaths.

SQUAT PAUSE

Get into the bottom of the squat with a 12-kilo kettlebell and drive your elbows into the inner sides of your knees to drive the knees open. This will help to open up the hips. Then pause in the middle and exhale as you drive up to stand. The pause hold at the bottom makes it a wee bit harder without having to load more weight. 5 reps are all you need.

Step 4: Take baby steps towards full squats

How I squat

Let’s break down the squat form, shall we? It’s not easy, and it may not be pretty at first. But try this checklist, as this is what I take myself through every time I squat:

1. Stand with feet shoulder-width apart and the instep of the foot just wider than the shoulder. (For ladies – to accommodate our wider hips)
2. Toes turn out to 11 and 1 o’clock.
3. Long through the back of your neck, soft chin.
4. Sniff a breath in through the nose (just enough, but not so much your ribs flare) before your descent.
5. Drive your knees towards the 3rd toes on the way down (and up). But not so far that the big toe picks up or you roll to the outside of your foot.
6. Control the descent. Think “slow-motion elevator” not “drop it like it’s hot.”
7. Butt travels below the knees, and make sure not to butt wink and no tucking the pelvis under.
8. Solid exhale to stand. It should sound like “TSSSS-A.” Crisp, clear, audible.
9. Squeeze those heels towards each other without moving the feet on the way up, aka foot dialing.
10. Powerful glute squeeze at the top to finish, like you’re cracking a walnut between the cheeks.

This may seem like a hefty checklist but once you learn the basics, these cues will feel like second nature. Creating ownership of how you move takes work and time, but nothing will change unless you take action.

Now, if you don’t feel like you can do the full squat today, that’s totally fine. Wherever you’re at with squatting, you can build strength and progress. Over time, you’ll get stronger and your nervous system will learn that it is safe to squat. Start with one of the following easier variations that you can perform perfectly today and strive to improve with every workout session. 

Squat progressions and regressions for Hashimoto’s: Box squats and more

All squat progressions require the same breathing cues as in the “How I Squat” section above. However, you can pick the right variation for you based on what you can perform pain-free with perfect form today.

Variation 1: Wall squat

Wall squats or wall sits are the easiest squat variations where you can build strength even when you don’t have the mobility and stability, or even when your knees hurt. 

Instruction: With your feet parallel to each other and your back against the wall, bend your knees while leaning your back against the wall. Remember to brace your core and squeeze your quads to push your back against the wall. Hold for 10 seconds or as long as it takes for your legs to start to burn. 

Progressions for wall squats:

1. Sitting higher or lower. If your knees hurt at a certain range of motion, you can sit higher. If your knees don’t hurt, you can try to sit lower to build the strength in that range.
2. Holding the wall sits for longer
3. Holding a kettlebell or a weight to add the challenge 

Variation 2: Stability ball squat

With stability ball squat, you can move up and down a squat even if your core isn’t strong enough. You can also lean on the ball and put more weight on it so you put less load on your knees and ankles. It allows you to move through a squat while being supported upright. 

Instruction: Find the right stance that’s comfortable for you to squat. Typically, you’ll stand with your feet shoulder-width apart with feet turned out to the 11 and 1 o’clock positions. With a stability ball between your back and the wall, take a stiff breath and lower down to a squatting position as you exhale. Remember to never lose control of your straight spine. Then, take a solid exhale and drive through your knees as you stand up.

Progressions for stability ball squat:

1. Squatting deeper and lower without losing form
2. Adding weight 

Variation 3: Box squat

Box squat is an excellent squat variation for people who either don’t have the mobility to drop below the height of the box or lose core stability once they do so. People who lack the mobility may not be able to move past a sticking point, or they may topple and fall when they attempt to squat. Whereas, those who lack core stability or are hypermobile may hyper-extend their lower back or go from straight spine to flexing past their sticking points. Both of these scenarios can make it dangerous to squat full range, especially if you’re adding weight.

This variation allows you to learn to brace your core and get stronger within the range that you can.

Instruction: To perform box squats, you can use a plyometric box, a chair, or a bench. Typically, you’ll stand with your feet shoulder-width apart with feet turned out to the 11 and 1 o’clock positions. The movement resembles sitting down to the box and standing up, but you’ll do it with proper core bracing and breathing rather than just relaxing down to a seat.

Progressions:

1. Lowering the box or using a shorter chair/bench
2. Adding weight

Variation 5: Bodyweight, goblets, landmine, and barbell front squats

Once you feel that you’ve acquired the mobility and stability to squat well below where your thighs are parallel to the floor, it’s time to try body weight squats. The principles are generally the same.

Refer to the “How I Squat” section for instructions. 

Progressions/regressions:

1. Holding a kettlebell or a dumbbell in front of you to add weight 
2. Using a landmine (a barbell where one end is held to a hinge or simply a corner of a room) and playing around with different hand positions
3. Changing foot stances to see what is most comfortable

There are numerous ways to squat: front squat, goblet squat, high bar back squat, and low bar back squat. I love the front squat, especially with kettlebells aka the goblet squat or double-racked front squat. 

Front squat basically refers to when you put the weight in front of you rather than behind you, so you can use kettlebells in a goblet position or racked position. Once you’re ready, you can progress to using a barbell. 

Easier ways to load front squats such as goblet or the kettlebell rack positions allow you to work on form without feeling stuck or asymmetrical while holding a barbell. For us women with Hashimoto’s who tend toward hypermobility and sway back in the low back, a front squat will help what I call “close the box.” The box is your “tank of strength” core with your ribs STACKED over your pelvis. Way less chance for the swayback or that overarch your lower back.

Whereas, back squats refer to when you put the weight behind you, such as barbell back squats. While it requires less hip mobility, it causes you to lean further forward and put more weight on your lower back than front squats. This is also the pattern that people tend to follow if they just have to squat down with no weight. But for training, if your core bracing and breathing are not on point, adding weight to a back squat can be risky on the lower back. So, I teach Thyroid Strong members to really nail front squats first.

Notice in the image above how a front squat will create less rib flare and less low back sway than a back squat.

Want step-by-step guidance on exercises for Hashimoto’s that will help heal the Hashimoto’s and move pain-free? Check out Thyroid Strong. I had to do it for my own body and have helped thousands of women ever since doing the same.

In Good Health,

Dr Emily Kiberd

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