Many people who suffer from knee pain often report that walking downhill, especially downhill hiking, can be quite aggravating, whereas walking up hill or up stairs doesn’t necessarily provoke their knee pain.

While this may seem counter-intuitive, there can be some good reasons for this, which we will discuss in this article.

Knee Pain Going Down Stairs vs. Up Stairs

While there are some differences between stairs and hills, starting the discussion by thinking about stairs often helps people visualize what’s going on a little better. We will then discuss downhill walking and downhill hiking, as there are a couple things we can then add to that.

Let’s consider going up stairs first:

When your leading foot lands on the step above, you begin to transition your weight forwards to be on top of that leading leg and then you have to exert force to push your body up from that leg to bring the back leg in front of you.

The tough part about this is that it requires energy to perform, especially since you are working against gravity, and it may feel like more exertion overall going up stairs relative to down stairs.

However, we need to consider the involvement of hip muscles, and how the position of the knee and hip joint will add additional support and strength.

Considering the leading leg, the both the knee and hip will be flexed. As you begin to push yourself up, the powerful glute muscles and hamstring muscles will help drive the motion by extending the hip. At the same time, the powerful quad muscles are contracting to help extend the knee joint, further aiding in helping you rise up the steps.

Given there is a lot of assistance from the powerful hip muscles in addition to the quad muscle of the knee, and the knee joint is going from a flexed to an extended position, there is generally less stress going through the knee joint itself, particularly the patellofemoral joint (the interface between the kneecap and femur).

Now let’s consider going down stairs:

When visualizing going down stairs, let’s consider the trailing leg, or in other words, the stance leg.

As you reach one foot forwards to eventually contact the step below, you are now in a single leg balance position. On top of this, given you have to reach below you for the next step, your centre of mass will be a little more forwards as you bend the knee, which shifts your centre of mass more on top of your knee, so there is still a lot of demand in general on the knee when going down stairs.

Additionally, it’s very difficult to have a substantial amount of hip flexion, and therefore glute involvement, when going down stairs because reaching lower for the next step will make this very difficult.

As such, with less support from the glutes and hamstrings, the quadricep muscle and calf muscles will now have to do lots of work to safely and effectively control the motion.

Furthermore, as you go down stairs, the stance leg will be bending as the quadricep continues to contract, leading to an eccentric contraction. This means the muscle is lengthening at the same time it is being contracted. This is a very normal and highly functional form of muscle contraction, but it can lead to a lot of stress going through the knee joints, especially the patellofemoral joints.

Therefore, many people complain of knee pain going down stairs due to a combination of knee position and centre of mass, relative lack of support from other powerful muscle groups, and type of contraction.

Knee Pain Walking Downhill

So how is it different going downhill versus down stairs? Realistically, it’s quite similar, hence people complaining that their knees hurt when hiking downhill and going down stairs, but there a couple factors to consider here.

First, given you are not landing on a flat surface when hiking downhill like you would with a step, the ankle joint is now in a different position, and will be relatively plantarflexed.

Depending on the slope of the hill, this can actually create much more demand on the knee joint and surrounding muscles (Kuster et al, 1995), as the calf muscles may not provide as much support, and the slope of the hill may kick your centre of mass further forwards relative to stairs, all of which can lead to more stress on the knee joint, ultimately causing knee pain.

Second, from a very simple perspective, hills don’t usually have railings! This, combined with possibly more environmental variations (e.g. slippery surface, uneven terrain, changing slopes, etc) can lead to more reliance on the knee joint and lower body in general.

What injuries can cause knee pain walking downhill or down stairs?

Some injuries and conditions can predispose you to knee pain going down stairs or with downhill walking. This is why it’s often a question asked by physical therapists when a patient is describing previously undiagnosed knee pain.

Patellofemoral Pain Syndrome (PFPS)

PFPS is an extremely common condition that can have many different contributing factors to its development, with or without a previous knee injury.

We described this condition in more detail in our article talking about knee pain when squatting, so feel free to check that out for more information.

In a nutshell, PFPS is an umbrella term for knee joint pain that involves the interface between the patella (kneecap) and femur (thigh bone). The patella needs to slide comfortably within the trochlear groove of the femur for normal pain-free knee function, and if this tracking is off for any number of reasons, there can be pain when this area is stressed.

It’s important to consider that the patella is considered a sesamoid bone, meaning it’s basically floating on top of the knee joint by being embedded within the quad/patellar tendon, with other ligamentous structures providing medial and lateral stability.

What this means is that the patella is at the mercy of the forces being placed upon it, especially by the quads. When going down stairs or hiking downhill, the knee is bending, which causes a stretch on the quad muscle and will cause the kneecap to pull in more snuggly to the femur.

Additionally, adding repetition to the mix, such as running, can further increase the chances of developing PFPS (Esculier et al, 2020), hence the more laymen term for this condition: Runner’s Knee.

Next, the quad is contracting more strongly since the knee doesn’t have the same support from the glutes and hamstrings when going downhill, which further amplifies the pulling of the kneecap in towards the trochlear groove of the femur.

On top of that, the kneecap needs to slide within its trochlear groove as it’s being compressed against it, which can create a higher level of friction forces. If there are other biomechanical faults at the knee joint, this can create high levels of uneven distributions of stress through the patellofemoral joint, and anterior knee pain is a common result.

For all of these reasons, treatment for PFPS typically involves a combination of load management (reducing or altering the pattern of activity that stresses the knee), as well as specific strength and mobility exercises to restore muscular balances and help provide adequate support for the patellofemoral joint.

Given that there is a huge variety of factors that could contribute to the development of PFPS, it’s highly recommended to visit a physical therapist for a personalized assessment, which will allow for an individualized exercise program that helps ensure safety and effectiveness.

Additionally, through physio, other methods to help prevent knee pain with activity can be identified, such as the application of kinesiology tape to alter forces on the kneecap with activities such as running.

Chondromalacia Patellae

Chondromalacia patellae and PFPS are often considered the same thing, but it’s important to consider that they aren’t entirely interchangeable.

Chondromalacia patellae refers to degenerative changes of the cartilage on the under surface of the patella. While this can happen over time in the presence of PFPS, you can also have PFPS without any identified wearing, softening, or fraying to the cartilage on the under surface of the kneecap.

All that said, for all the same reasons we listed with PFPS, walking downhill or going down stairs can increase knee pain for people with chondromalacia patellae, but walking up hill or up stairs can also be painful as well.

To determine if structural changes to the cartilage are a significant contributing factor to knee pain, usually some form of diagnostic imaging is required, and this usually requires a referral from a physician.

It’s also worth keeping in mind that chondromalacia patellae can be treated effectively with conservative measures, even without diagnostic imaging, through a guided physical therapy exercise program that is designed according to clinical assessment findings.

For example, there is a strong correlation between patellar malalignment and chondromalacia patellae (Damgacı et al, 2020).

A physical therapist can often identify contributing factors to this and subsequently identify which muscles could be strengthened, which muscles could be lengthened, and other ways to build appropriate patellar stability, all to help aid in improving function while reducing pain caused by an imbalance of stress on the patella.

Patellar Tendinopathy

Any dysfunction to the patellar tendon and the quad tendon can also lead to increased knee pain when going down stairs or downhill, as well as up stairs or uphill.

The most common of these conditions is patellar tendinopathy, often termed “jumper’s knee”. This is typically an overuse condition, especially with activities that involve a lot of repetitive jumping, such as volleyball and basketball.

With patellar tendinopathy, the tendon itself experiences a degenerative process that can lead to disorganization of its collagen fibres, weakening of the tendon itself through micro-tearing, thickening of the tendon, and sometimes a reactive inflammatory process.

Patellar tendinopathy can lead to anterior knee pain, particularly within the patellar tendon itself or at its attachment site to the bottom of the patella, and can be aggravated by the same activities that caused it (e.g. repetitive jumping), but can also be aggravated by any other activities that stress the tendon as well.

Therefore, for very similar reasons to PFPS, a dysfunctional patellar tendon and/or quadriceps tendon can be vulnerable going down stairs to do the high level of demand on these tendons. In this case, people usually experience knee pain within the tendon tissue itself or bottom of the kneecap, as opposed to deep in the knee or on the inside/outside of the kneecap.

Treatment for patellar tendinopathy usually involves building the tendon’s capacity to withstand the loads that it typically experiences. For this reason, exercises usually consist of slow heavy strengthening exercises that help strengthen that quadricep muscles and guide the tendon in its remodelling process, without flaring it up in the process.

Specifically, patellar tendinopathy exercises may include isometric strengthening, whereby the muscle contracts but that knee joint doesn’t move.

Eccentric strengthening has also been proven to be an effective treatment for patellar tendinopathy, as well as other forms of tendinopathy, for example, Achilles tendinopathy. These exercises involve lengthening the quadricep and patellar tendon while contracting the quadriceps muscle.

For example, if you consider a seated knee extension exercise, slowly lowering against resistance represents an eccentric form of strengthening, whereas straightening the knee against resistance would be concentric strengthening (muscle is contracting and shortening).

Given some discomfort is acceptable when treating tendinopathies, it’s highly recommended to consult with a physical therapist to ensure you are challenging the tendon appropriately, but not to a point where you may flare it up more.

Meniscus Tears and Knee Osteoarthritis

The meniscus is can often be involved in a knee injury. The meniscus is a figure-8 shaped ring of cartilage in the knee joint that helps distribute forces appropriately, can be prone to injury, as it’s basically like a shock absorber in the knee.

With acute meniscus injuries, meaning those that you can attribute to a particular event or mechanism of injury (e.g. twisting your knee) typically cause knee pain with any sort of weight bearing, bending, or twisting.

However, degenerative meniscus tears, meaning those that gradually develop over time from heavy use, can be a little more subtle and may only cause pain in certain situations, particularly if more mild.

For degenerative meniscus tears, the provoking factors may be slightly different based on the severity of the wearing and location of specific tears. Usually, deep knee flexion especially under body weight (e.g. deep squatting positions), twisting, and going up or down hill can often cause knee pain.

If these degenerative processes progress to the point where the articular cartilage that lines the bones themselves becomes worn, damaged, or otherwise structurally altered, then one can end up with knee osteoarthritis, which can be quite painful with any heavy or repetitive activity, including going up and down stairs or hills.

In fact, a recent pre-clinical study in mice demonstrated that excessive downhill training was associated with early signs of cartilage and bone problems that can be indicators of knee osteoarthritis (Morais et al, 2021).

Treatment for degenerative meniscus tears and osteoarthritis is often quite similar and typically involves physical therapy to restore range of motion, improve comfort with knee stability, and arguably most importantly – building strength and stability around the knee so that the knee joint has all the support it needs to prevent knee pain.

For this reason, it’s important to keep an open mind to exercise-based therapy, even if certain forms of activity cause an increase in symptoms, as an exercise program guided by a physical therapist can help restore function and improve comfort in a safe and effective manner.

If other investigations or interventions are recommended, physio is still a good start, as you can usually be working on something while your physio guides you on other potential referrals.

For example, other interventions can range from conservative, such as a knee brace to help unload the knee joint, to more invasive approaches like injections or even surgery. These options are usually explored after assessing the response to conservative care like physio and using an unloader knee brace.

Treatment – Common Themes for Knee Pain When Walking Downhill

Given that there are many different contributing factors to the development of knee pain when going downhill or down stairs, it’s very important to look into a physical therapy consult to assess your particular condition and ensure a safe and effective treatment program.

That said, all of these injuries and conditions listed above are typically amenable to conservative treatment, basically meaning physical therapy and other forms of activity-based treatment.

All of the above injuries and conditions can improve with a guided strength and mobility program, and can be further optimized based on your lifestyle and rehab goals.

Furthermore, activity-based treatment offers an opportunity to put you in the driver’s seat. While it may be uncomfortable or unfamiliar at first, developing a suitable exercise program provides you with the tools you need to self-manage your condition, not only to reduce pain, but to improve your overall function, health, and well being.

Lastly, don’t be surprised if your physical therapist offers exercises that seem counterintuitive, such as hip strengthening. This is where a physical therapist’s expertise can come in handy – identifying effective forms of treatment that you may not have identified on your own.

By asking questions and receiving proper education in the process, you can understand why you’re doing the recommended exercises, providing you with further control over your treatment, and will also help build a therapeutic relationship with your therapist, one that you can trust moving forwards.

Summary

There are many different injuries and conditions that can cause knee pain going down stairs or downhill. The ones listed above are simply more common presentations we see in the clinic, and fortunately, all of these can usually be treated safely and effectively via physical therapy.

Other physical therapy modalities, as well as other medical interventions also exist to help with these injuries and conditions, but are usually reserved as adjunct to treatment, or if the injury/condition is so severe that it’s needed in order to engage in exercise-based therapy, which is why these medical interventions were not a focus on this article.

We will be publishing more information on these conditions specifically in the near future, but for now, we hope this can provide some insight and reassurance that your knee pain can be managed if the proper steps are taken.

References

Damgacı, L., Özer, H., & Duran, S. (2020). Patella–patellar tendon angle and lateral patella–tilt angle decrease patients with chondromalacia patella. Knee Surgery, Sports Traumatology, Arthroscopy, 28, 2715-2721.

Esculier, J. F., Maggs, K., Maggs, E., & Dubois, B. (2020). A contemporary approach to patellofemoral pain in runners. Journal of Athletic Training, 55(12), 1206-1214.

Kuster, M., Sakurai, S., & Wood, G. A. (1995). Kinematic and kinetic comparison of downhill and level walking. Clinical biomechanics, 10(2), 79-84.

Morais, G. P., Chemerka, C., Masson, A., Seerattan, R. A., da Rocha, A. L., Krawetz, R., … & Herzog, W. (2021). Excessive downhill training leads to early onset of knee osteoarthritis. Osteoarthritis and Cartilage, 29(6), 870-881.

Disclaimer:

The content here is designed for information & education purposes only and is not intended for medical advice.