"With degenerative knees, do I have to give up hiking for good?" Many people in Hong Kong who love hiking feel this fear as soon as they see an X-ray report. When going downhill in particular the knee hurts especially, and they worry that carrying on will damage the joint further. This article answers the question head on: should you keep walking, or stop here?
Many people think that with knee degeneration they should walk less and rest more, and this is in fact a myth. The facts are the opposite. International guidelines list exercise as the core first-line treatment for knee arthritis, and it applies however severe the structural degeneration of the joint is. If hiking is given up completely in order to "protect" the knee, the muscles only waste further and the knee hurts more easily.
Can you still hike with knee osteoarthritis?
The core question first. For the great majority of people with knee osteoarthritis, the answer is that hiking can continue. What matters is "how you walk" and not "whether you give it up". The 2019 guideline of the Osteoarthritis Research Society International (OARSI) states clearly that exercise (including walking and recreational sport) is a core first-line treatment for knee arthritis and applies whatever the structural severity. This means that even if the X-ray shows clear degeneration, exercise is still the recommended course and is not forbidden.
Exercise is a core first-line treatment for knee arthritis, whatever the structural severity. Walking the right way matters far more than not walking.
So rather than asking "can I still walk", it is better to think about "how to walk safely and for a long time". Of course, if any of the following warning signs appear, stop first: the knee is red, swollen and hot, clearly deformed, locks after a few steps or gives way. In these cases do not push on, and have a physiotherapist assess in detail first before deciding.
Why does the knee hurt especially going downhill?
Many people have a similar experience: all is well going uphill, but as soon as the path slopes down the knee hurts badly. This is not an illusion, and there is a clear biomechanical reason.
Once this principle is understood, pain on the way down no longer needs to be read as a signal that "the body is calling a halt". It should be seen as a reminder that the braking ability of the quadriceps needs retraining.
How strengthening the thigh and gluteal muscles prevents knee pain on slopes
Since pain going downhill comes from not enough eccentric braking force, the method with the most evidence behind it is naturally to strengthen the quadriceps (front of the thigh) and the gluteal muscles (especially the gluteus medius). The former brakes on the way down, and the latter steady the pelvis and stop the knee collapsing inwards. Training both groups together effectively improves the knee load and pain when going downhill.
- 1Start: wall sitLean the back against a wall, slowly squat down to an angle that feels comfortable, hold for a few seconds and stand up again. This trains the ability of the quadriceps to keep working, and while doing it watch that the knees do not go past the toes.
- 2Progress: sit-to-standFind a sturdy chair, sit down slowly and then stand up slowly. The process of "sitting down slowly" is the eccentric control, which is closest to how the muscles work going downhill.
- 3Add the buttocks: side-lying leg raise / bridgeWorking the gluteus medius and gluteus maximus helps steady the pelvis and the path of the knee, reducing the stress from the knee collapsing inwards on slopes.
- 4Closer to real life: stepping up and downHold the handrail, step slowly down one step and then go back to the original position, to imitate the eccentric load of going downhill. Once the movement is steady, the number of repetitions and the load can be increased gradually.
This order of training is a practical consensus in physiotherapy: start with low-load, supported movements and progress step by step to movements close to real hiking. With the right training, pain going downhill can mostly improve clearly.
Strength training must progress step by step and be matched to the person. The degree of knee degeneration, muscle strength and hiking habits differ from person to person, and blindly following online videos may give the wrong amount of exercise. The best approach is for a physiotherapist to assess first and then set a graded exercise prescription for the individual, and this is where the value of home physiotherapy lies.
How hiking shoes and hiking poles reduce the load on the knees
Besides training the muscles, suitable gear is also a very practical pain-relieving tool, and it works especially well against the impact of going downhill. There are two main points: choosing the right shoes and using poles the right way.
- Paterson 2021 randomised controlled trial: stable supportive shoes ease walking pain more than flat flexible shoes
- Rough hill paths need support in the shoe and non-slip grip all the more
- Hiking shoes that fit, support and do not slip are themselves pain-relieving gear
- "The softer the better" is a common misunderstanding, and soft flat shoes in fact relieve pain less well
- Without support, the knee has to take more impact on a downhill
- Hill paths are uneven, and a soft sole makes a sprain and losing footing more likely
As for hiking poles, they work on the same principle as holding a stick on the opposite side: the upper limbs share the impact of going downhill, taking away the load that the affected knee carries.
- If only one knee hurts more, hold the hiking pole in the opposite hand for support, to ease the load on the painful knee joint.
- If both knees are unsteady, or the path is very steep, using two hiking poles is steadier and shares more of the impact overall.
- When going downhill, remember "pole first, foot after", so the pole takes the weight first and cuts the force the knee takes in that instant.
- Do not rely on the poles alone without training the muscles. Gear is only a support, and building up the quadriceps is the way to get at the root of the problem.
Points to note when hiking with knee osteoarthritis
Putting these points together, the answer to this question is quite clear: you can keep hiking, but you must do it with a strategy.
- Keep up the habit of hiking but progress step by step. Start with short and gentle routes and then slowly increase the distance and the slope.
- Strengthen the quadriceps and gluteal muscles regularly to build a base and improve the muscles' braking ability when going downhill.
- Wear hiking shoes with firm support when hiking, and use hiking poles to ease the load on the painful knee.
- If the knee becomes red, swollen and hot, deformed, locked or gives way, stop at once and have a physiotherapist assess it.
Knee degeneration by no means means saying goodbye to the hill paths for good. With "the right muscle training, the right gear and the right difficulty", most people can still enjoy hiking, going from not daring to walk to walking steadier and longer. Of the three conditions, "the right difficulty" is the hardest to judge alone. When a doctor says "do not walk too much", does that mean the length of the route, the steepness of the slope, or the number of hill trips a week? A home physiotherapy assessment can turn this advice into concrete indicators, setting a suitable route length, gradient and pace for going up and down for the patient. Pairing hiking with alternating low-impact exercise reduces the load on the affected knee while keeping fitness up.