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What Causes Knee Pain Running Downhill?

knee pain running downhill

Most runners have suffered from knee pain running downhills. It doesn’t matter if you are new to running or an experienced ultramarathoner.

There you are, enjoying the reward of that hard run uphill or to the top of the trail. Cruising over the top, you start to head back down, waiitng for your heart rate to recover when suddenly you start experiencing a sharp stabbing pain into the front of your knee which every step downhill. OUCH!!!

Knee pain, especially with running down hills or stairs is one of the more common joint complaints in runners and there can be a wide range of causes. (1)

What causes knee pain running downhill?

Running downhill places a significant amount of stress on the leg and knee. With each downhill stride, the quadriceps muscle contracts and increases tension on the two tendons that attach to the patella (the quadricep and patellar tendons).

Knee pain in the front of the knee below the knee cap is usually from irritation of the patellar tendon and is commonly referred to as “runner’s knee.” Pain just above the patella is usually from the quadriceps tendon.

If your knee pain running downhill feels like it’s deep inside your knee that could be a sign of knee arthritis or a meniscus issue in the knee joint. Finally, if you notice that your knee pain with running downhill is localized more in the back of the knee, it could be caused by calf or hamstrings issues or a Baker’s cyst.

Understanding Knee Anatomy for Knee Pain

Anatomy of the knee

Pain in the front of the knee

The most common cause of knee pain in the front of the knee is due to patellar tendon issues. Knee pain from the patellar tendon can be exacerbated by any activity that increases the load across of the knee, such as running down hills or walking down stairs.

If you are just starting to experience pain in the front of the knee, there may be irritation of the patellar tendon attachment to the tibia called tendonitis. However, if your knee pain has been going on for a while, meaning longer than a couple of weeks, you might have developed tendinosis, where the tendon develops scar tissue due to a failure to properly heal. This chronic tendinosis doesnt respond to anti-inflammatory medicaitons or ice because there isn’t any inflammation to reduce, just the resulting scar tissue or failed healing of the tendon.

What to do if you have knee pain running down hill

If the knee pain is new, it’s probably due to tendonitis. Try an ice pack on the knee for 10 to 15 minutes to reduce any severe inflammation as well as some relative rest for a couple of days and see if that helps. You can also try foam rolling and/or stretching of the quadriceps muscle.

If your knee pain run running downhill has been going on for several weeks, then you are probably dealing with tendinosis of the tendon and the treatment will be different than just ice and rest.

The best exercises to fix knee pain from downhill running

Most of the exercises to help fix your knee pain from running downhill focus on strengthening the quadriceps and the gluteal muscles that stabilize the hip. Stretching exercises also prevent you from having more pain running hills. (2)

Quad Set Exercise

The “Quad Set” is a simple but effective leg exercise to teach you how to properly contract the quadriceps muscle without overloading the knee.

The Quad Set is done sitting on the floor (or bed or couch) and requires a small rolled up towel or pillow under the knee. The focus of the exercise is simply to push the knee straight down, forcing the towel or pillow into the floor. This motion of pushing down with cause you to contract your quadriceps and is a great exercise for learning how to specifically focus on the quadriceps muscle.

Seated Quad Extensions – Short Arc Quads

The quad extension or short arc quadriceps exercise builds upon the Quad Set exercise above. With the Short Arc Quad exercise, the focus changes from pushing the knee into the floor to simply lifting the heel off the ground.

As you lift the heel off the ground, you’ll also feel the quadriceps muscle contract. Hold your foot off the ground with the knee straight for 5 to 10 seconds and then lower the foot back to the ground to rest. Repeat the Short Quad Arc exercise 10 to 15 times.

Advanced Exercises for Knee Pain from running downhill

The Single-Leg Squat is a great exercise once you’ve mastered the basic exercises and can help with your knee pain from downhill running. The single-leg squat strengthens the quadriceps muscle. This exercise also requires you to work the gluteal muscles on the leg you are standing on. As you build better gluteal strength, you’ll notice improved stability as you run downhill.

Eccentric Exercises for Knee Pain Running Downhill

Eccentric exercises for patellar tendinosis (3) and Achilles tendinosis have been shown to be effective exercises for knee pain due to tendinosis(4)

The eccentric exercises that focus on the patellar tendon require an angled decline board to do properly. If you don’t have accesss to a decline board, you can try dowing the rehab exercises on a treadmill. Raise the elevation of the treadmill all the way up and with the treadmill off, do the eccentric squats facing towards the back of the treadmill.

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When to see your doctor about knee pain from running downhill

If you have a sudden knee injury and have continued moderate or severe knee pain, then visit your sports medicine provider to see if there is an injury inside the knee.

You should also see your doctor if there is:

  • Significant swelling, redness or warmth to the knee
  • Inability to fully straighten or bend the knee
  • Swelling or bruising into the calf
  • Weakness or numbness into the leg or foot
  • Pain that is not getting better with rest, ice and elevation
  • Other concerns that the knee is not getting better (or getting worse).

Remember to be consistent with doing the exercises and you’ll soon find that you soon won’t have knee pain running downhill anymore!


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