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Of all the hiking-related issues Taylor Rossi sees as a physical therapist, knee pain is one of the most common.
This pain, she says, often occurs as hikers head down hill. “You’re on your descent, and you’re already fatigued because it’s the second half of the hike, the second half of the day, and your quads are exhausted,” says Rossi. As a result, all of the tension is placed on the patellar tendon, causing inflammation.
The knee’s vulnerability to such stress, she says, is a consequence of anatomy.
“The knee is really just a victim of what’s happening above and below it.”
“The leg is a continuous chain, and it is influenced — especially the knee joint — by the ankle, which is a very mobile joint below it, and by the hip, a very mobile joint above it,” Rossi explains. “The knee is really just a victim of what’s happening above and below it.”
Rossi earned a doctorate in physical therapy from Chapman University in Southern California and now lives and works near Atlanta, Ga., where she does a lot of hiking-oriented training and rehab.
“I always ask my patients, ‘What are some goals you want to achieve with physical therapy? What are some things that you’re not doing now that you want to get back into doing?’ Hiking is often one of them, especially here in north Georgia,” she says. “There are so many parks and trails, and it’s a very active community.”
In addition to ankle sprains in hikers and shin splints in trail runners, Rossi often hears from patients complaints of patellar tendinitis, which she describes as “inflammation of the tendon that connects the bottom of the kneecap to the top of the shin bone” — an extension of the quadriceps muscle. When this muscle is not strong enough and experiences chronic overuse, whether from one hike or recurrent hiking, patellar tendinitis can result.
To prevent this and other issues, Rossi says it’s critical that hikers have strong ankles, calves and quads as well as flexible and stable ankles and hips.
Avoiding hiking-related injuries and pain such as patellar tendinitis comes down to a combination of several factors, which include proper form and maintenance.
The most important part of maintaining proper form, Rossi says, is keeping your pelvis level. Although doing so may be more or less difficult depending on the terrain, when on flat ground, she says your shirt or pant line should not move up or down as you walk. Because it’s easy to let your form deteriorate on long hikes or backpacking trips, she recommends packing trekking poles.
“They significantly help reduce the load that your glutes have to carry so they don’t get as fatigued as quickly, and therefore, your form doesn’t suffer as much or as soon,” says Rossi. “That way you can maybe prevent knee pain or rolling your ankle because you have help from your trekking poles.”
Foot placement also matters. The best approach is a heel-to-toe progression — “landing on your heel and then rolling over the toe to push off,” explains Rossi. A method that is easiest on flatter ground. Downhill, however, the progression would be the opposite, with toes hitting the ground first.
“It definitely depends on the terrain, and you need to be adaptable,” Rossi says. “Your ankles and hips need to be flexible enough, but also stable enough, to be able to catch you in very vulnerable positions.”
To help prevent issues related to patellar tendinitis, she recommends several stretches to keep the quads both flexible and strong, including the flamingo stretch. For this, stand on one foot while holding the heel of your other foot up toward your butt, “bending the knee all the way while keeping your thighs together,” Rossi says, adding that this can also be done lying on your stomach.
Wall sits are a great way to improve quad strength: “The quad is in a lengthened position, your back is against the wall, and you lower yourself down until your hips and knees are at a 90-degree angle, and you hold,” says Rossi. “Start with 30 second increments, and each day or each week, as long as you don’t have any worsening pain, increase the amount of time you hold it by 15 seconds. The goal is to be able to hold that for up to two minutes in one sitting before you rest.” She recommends doing wall sits five times a day.
Another beneficial activity for hikers — whether they suffer from patellar tendinitis or not — is double-leg squats, which Rossi likens to the movement of sitting down on the toilet. To accustom her patients to the squatting motion, she has them do butt taps on a chair. This involves them “trying to stick their butt back as if they are going to sit down, but not actually sitting down — just tapping the chair and standing back up,” she says. Backpackers can train by building on this, adding weight on both legs, which they can gradually increase.
Once a person becomes comfortable with double-leg squats, Rossi has them progress to single-leg squats, doing butt taps while standing on only one leg.
“A single-leg squat kind of simulates helping you slow your descent down the trail.”
“That is also a really great way hikers can train for the descent, specifically, of a very rocky trail, where the rocks or the roots of trees kind of create steps,” she says. “A single-leg squat kind of simulates helping you slow your descent down the trail.”
For avid hikers, especially those who experience issues with pain, Rossi advises doing squats two to three times a day, holding them for about a minute each.
“You want to do them more on the days that you are hiking. You want to do it right before and right after the hike,” she says. “You can even do it in the middle of the hike if your quads start to feel tight.”
Flat Feet and Plantar Fasciitis
To both manage and alleviate pain associated with flat feet or plantar fasciitis, Rossi recommends two key stretches: the calf stretch and what she simply refers to as the plantar fasciitis stretch. For the latter, kneel and sit on your heels with your toes tucked under. The calf stretch involves “letting your heel fall of the edge of a stair,” Rossi explains. “You have the front half of your foot on a stair and let the heel fall off so that you’re bending the ankle.”
Single-leg balance is another great way for hikers, particularly those who have flat feet, to prevent pain and injuries as it helps build core foot muscles and ankle stabilization.
“Stand on one leg while keeping your weight evenly distributed between the big toe side and the little toe side of your foot, and see how long you can balance,” explains Rossi. “Don’t let your foot fall into that flat foot position; try to lift your arch a little bit, almost treating your foot like a suction cup on the ground.”
Once you are able to balance for one minute, try progressing to more challenging ways of balancing, such as standing on a pillow. “Once you master that, go to brushing your teeth while standing on one leg,” she says. “[That] will provide an added challenge.”
To strengthen the hips — which will also benefit the knees — Rossi suggests what she calls the “monster walk.” This requires a resistance band, either a circular one or one with a loop at each end.
“Put the band around your knees, right above the kneecap, and sit back into a partial squat position. Maintain that position, and then side step; take lateral steps, pushing out into the band,” she says. “That’s a great combination of ankle and hip strengthening, and the knee is just along for the ride so it’s going to reap all the benefits, too.”
While proper form and maintenance are good tools for preventing hiking-related injuries, they can still occur. Yet many of the stretches Rossi recommends off trail can also be used if and when issues arise on the trail: For pain at the front of the knee, try the quad stretch; for calf or foot pain or cramping, do the calf stretch; and for pain in the arch of the foot, opt for the plantar fasciitis stretch. However, you’ll have to make sure your hiking boots are flexible enough and “you’re in a place where you can get down onto your knees,” Rossi says.
While she says it’s not necessary to completely cut outdoor activities out of your life if you suffer from certain conditions, she does encourage those individuals to take it easy during flare-ups. During those times, it’s important to avoid a lot of downhill activity to avoid further inflaming the problem area.
“So, if you still want to get out and go hiking, but your knee is a little flared up and you don’t really want to push it too much, then pick a flatter trail,” she says.
“I think that is really important — to have [orthotics] that can go in your hiking shoes — if you have flatter feet and need more arch support.”
She also recommends, for people with flatter feet, wearing either custom or over-the-counter orthotics, or insoles, to help increase your tolerance for weight-bearing.
“The Superfeet brand makes some really great over-the-counter orthotics that are much more affordable than custom orthotics, which can cost up to $400 from a podiatrist,” says Rossi. “I think that is really important — to have ones that can go in your hiking shoes — if you have flatter feet and need more arch support.”
When it comes to hiking shoes, she is impartial to KEENs. “They’re really sturdy,” she says, “and the grip is really great so I never slip on the trail.”
For longer hikes or more difficult terrain, hiking boots are critical for protecting the ankle joint by providing more stability. “On those longer hikes where you’re hiking all day, you’re going to fatigue, and to prevent injury that could likely come from fatigue — like rolling your ankle or having a slower reaction time and not being able to catch yourself quick enough after rolling your ankle — it’s important to have hiking shoes that go above the ankle,” says Rossi.
For more on hiking fitness, check out our story “Hiking Fitness: The Importance of Exercise, Nutrition and Hydration.”