Many people troubled by degenerative knees say that going downstairs makes the knee hurt as if it would come apart, so they simply take the lift and stop using the stairs. Older people living in walk-up tenement buildings with no lift in Hong Kong cannot avoid them, though, and still have to go up and down several floors every day. Many just cut down their activity as far as possible and avoid the stairs whenever they can. This article unpicks a very common myth: if the knee hurts, avoid the stairs. In fact, reducing the load for a short time is fine, but avoiding stairs for a long time only makes things steadily worse.
The myth is so deeply rooted because half of it is correct. Going downstairs really is especially hard on the knee, and avoiding the stairs for a while when it hurts seems reasonable. The wrong half is in turning "short-term protection" into "long-term avoidance", which leaves the legs weaker and the joint less stable. Each point is explained below.
Why going downstairs hurts more
The mechanism has to be understood first before it is clear why simply avoiding stairs is not the way out. When going downstairs, the muscle at the front of the thigh (the quadriceps) is not pushing the body "up". It uses eccentric contraction to "brake" the speed at which the body drops, much like keeping a foot on the brake when going down a slope. Because this movement takes a load of several times body weight and is especially hard work, going downstairs is often more painful than going up for people with degenerative knees.
The point here is: that going downstairs hurts and is hard work does not mean the stairs must be avoided for good. It shows that both legs need enough strength to "brake" the body. Once this principle is understood, all the methods below make sense, whether building up the thigh quadriceps, changing which leg goes first on the stairs, or using a handrail and walking stick. All of them help the legs brake more steadily and share the load.
What happens if you avoid the stairs for a long time
Since going downstairs is so demanding, it is quite reasonable to cut down on stairs for the first few days when the pain is severe. But avoiding them completely for a long time causes problems. Muscles follow the rule of "use it or lose it", and the less the quadriceps and gluteal muscles are used, the weaker they get. The weaker the legs, the less stable the knee joint and the greater the pain. The more it hurts, the less the person dares to move. In the end this forms a vicious circle: the more you avoid, the weaker you get, and the weaker you get, the more it hurts.
Avoiding stairs is not the same as protecting the knee.Real protection is to train the legs well so that the person has the strength to cope with the stairs. If the joint is only "looked after" by avoiding the stairs, the end result is wasting of the thigh muscles and a less stable joint. The direction for managing knee osteoarthritis has never been "stop moving". It is "move in the right way".
Strengthening the thigh and gluteal muscles through exercise
To break the vicious circle, the key is exercise and not simply rest. International guidelines state clearly that structured land-based exercise is a core treatment for knee osteoarthritis and is safe and effective for all patients (OARSI 2019). For going up and down stairs in particular, the most important thing is to strengthen two groups of muscles: the quadriceps, which is responsible for braking control, and the gluteal muscles, which steady the hip and ease the pressure on the knee.
The biggest worry for many patients is whether knee pain during exercise or on stairs means the joint is being damaged and they must stop at once. The answer is: not necessarily. During exercise for degenerative knees, mild pain (≤3/10) is safe and does not mean the damage is getting worse. Being clear on this is very important, because stopping activity completely out of fear of pain is often exactly where the vicious circle starts. Of course, if the pain goes beyond this level or keeps getting worse and does not settle, adjust the exercise intensity or seek an assessment from a physiotherapist.
- Structured land-based exercise is a core treatment for knee osteoarthritis and is safe and effective for all patients (OARSI 2019), so do not stop activity altogether for fear of pain.
- The focus of training is strengthening the quadriceps at the front of the thigh (which brakes on the stairs) and the gluteal muscles (which steady the pelvis and ease the pressure on the knee).
- Mild pain (≤3/10) during exercise or on stairs is still safe and does not mean the damage is getting worse.
- Do not avoid the stairs completely for a long time to "look after the joint", because this only makes the muscles weaker and forms a vicious circle.
Coping with daily stairs in a walk-up tenement with no lift
For people living in walk-up tenements with no lift, who cannot avoid the stairs every day, the right technique for going up and down is needed. The following load-reducing strategies are commonly used in physiotherapy, and it is advisable to use them alongside the strength training above.
- The stronger, less painful leg (the "strong leg") goes down one step first and does the main braking
- The affected "weak leg" follows down to the same step, reducing the eccentric load on the affected knee
- Hold the handrail to share the weight when needed, do not hurry and do not take two steps at a time
- ACR 2019 strongly recommends using walking aids (such as a walking stick) to share the load
- Handrails and walking sticks are not "for older people first" but practical tools to protect the knee
- The correct stick length and grip are best adjusted by a physiotherapist
Remember the rule: "Going up, the strong leg goes up first. Going down, the strong leg goes down first and the weak leg follows." The principle is to let the stronger side take the main load and reduce as far as possible the pressure on the affected knee at the hardest moment (the eccentric braking). Using a handrail or stick as well gives immediate relief and buys time for the strength training to take effect. For which hand should hold the stick and how to adjust its length, see the article on knee braces, insoles and walking sticks.
Clinical evidence on exercise and walking aids
One last point matters in everyday stair use. Whether the family member accompanying the patient should stand on the step above or below, from which side to support, and when to let go are hard to get right from a written description alone. One part of home physiotherapy is to demonstrate these supporting techniques and positions in the real setting, and guide the carer through doing it once in person.
Another movement at home that also puts a high load on the joint is getting up from a squat toilet or a low stool with knee pain. This movement likewise depends on the quadriceps working, and the load can be reduced by fitting handrails and modifying the home. It is advisable to read the two articles together to get a full picture of knee protection strategies for everyday movements at home.