Stairs can be a major stressor for those of us with sore knees. Oftentimes, older adults begin to avoid stairs as much as they can, and even choose homes that are on one level for this very reason. When stairs are the only option, there may be extra difficulty, both because of issues with the knee joints, as well as the deconditioning of muscles that may have occurred as a result of not going up and down stairs as frequently (use it or lose it). The act of choosing to continue to use stairs as we age is a great way to maintain strength in the lower body, but this will only be beneficial if we can climb stairs with ease and efficiency. Rather than making stairs the enemy, how can we begin to see stairs as a healthy challenge that will help us maintain our strength and mobility?
Biomechanics of stairs:
It may be helpful to understand a little bit of the biomechanics of stairs, or the physics of the movement. Going up stairs is a concentric action, in which the muscles shorten as they contract, creating a force that overcomes resistance. Most of the concentric action occurs about the hip and knee joint, and key muscles for going up stairs are the quadriceps (front of thighs) that act to extend the knee, and the hamstrings (back of thighs) and gluteus maximus (large buttock muscle) that shorten to extend the hip.
We also require use of our hip flexors (front of abdomen to front of hip) to lift our foot to the next step. In addition, if we learn to ascend stairs using more of our body, muscles on the sides of our bodies can also help, including our gluteus medius (side hip muscle) and quadratus lumborum (side of waist/low back). We can rely on the integrity of our skeletal structure to help direct the forces required to go upstairs, as we can send our body weight over our supporting leg, thereby requiring less overall muscular effort to go up stairs.
Going down stairs is actually more difficult for many people, especially those of us with knee issues. The skeletal system of our bodies is extremely important for supporting and directing forces. Going upstairs, we are able to rely on our skeletal structure more reliably, whereas going downstairs requires the supporting knee to be very bent, which makes the muscles in the front of the thigh have to work much harder. Going down is an eccentric action, which means muscles have to lengthen while contracting, as they control against the force of gravity. In other words, eccentric contractions are kind of like controlled falling. These types of contractions are actually more difficult for our muscles, which is why eccentric training is an excellent way to improve tissue strength and resilience. However, if our muscles lack the strength to control our movement during gravity, we might notice going down stairs, sitting down into a chair or toilet, or lowering ourselves to the floor may turn into more of a “plop” than a smooth motion. This indicates that our muscles lack eccentric strength, and our joint tissues may be taking a great deal of strain as we do these activities.
Another reason why going down stairs might be more difficult for some is that it tends to isolate the knee joint more than going up stairs. As described above, going up stairs can make great use of the muscles of the hips and core. In going down stairs, notice that the knee might travel far over the toes, and very little movement actually happens in our hip. As the knee travels over the toes and the quadriceps contract eccentrically, pressure builds up in our knee which can be an irritating factor, especially if we lack eccentric control or if there are other factors at play that are impacting our movement efficiency.
Strategies for a “bad day”:
Although practicing stairs is a great way to get better at stairs, sometimes we have to modify how we do it based on pain and discomfort. Think about an early morning. In the winter. Perhaps you “overdid it” yesterday, and your knee is speaking to you. Or perhaps, you had a knee replacement surgery not so long ago and your knee simply is not in shape to do stairs normally. If this is the case, here are some strategies for bringing more ease into your life:
1) Up with the strong, down with the sore:
This popular adage is well known for anyone who has had a knee replacement. Many will say “up with the good, down with the bad”, but why the negative self-talk if we could just say sore? This advice simply means to go up and down stairs one at a time, rather than your leg traveling past your other leg to the next step. Also, when going up, lead with the leg that is stronger, not experiencing as much discomfort, etc. And when going down, lead with the sore leg. This will make sure the strong leg is doing both the concentric and eccentric action to give the sore leg a break.
2) Try backwards, or sideways:
This tip is mainly for going down stairs. If one were to go down stairs backwards, mechanically, it would look a bit more like going up stairs in which we can use our hips a bit more rather than isolating the knee. For safety reasons, it is extremely necessary to practice this first before gallivanting down the stairs backwards. Try standing on the bottom step, holding on to the railing. Then slowly lower one foot down to the ground, followed by the other foot. Then come back up, practicing several times to get the hang of it. Similarly, when going down sideways, the knee does not have to travel so far over the toes. We are able to bend at the hip more to lower down to the next step. Going down sideways will also make it possible to hold on to a railing with both hands. On a bad day, consider going down backwards or sideways leading with the sore leg, just as described in the previous strategy.
Strategies for optimizing movement and preventing issues:
On a typical day perhaps if our knees are not a bother, and we would like to embrace the healthy challenge of doing stairs in an efficient and strain-free way, consider the following recommendations:
1) Root your heel to rise, bend side to side:
Rooting to rise means to take advantage of the force that the ground gives you, known as the ground reaction force. As we might remember from Sir Isaac Newton, every force has an equal and opposite reaction. When we put weight into the ground, the ground exerts an equal and opposite force back up into our skeleton, allowing our bodies to move. By focusing attention on our ability to harness ground forces, we might be able to navigate stairs and other movements with a greater sense of clarity. By placing our heel completely on the step when going up, we can actually push down through our heel as our body leans forward over our foot. By pushing down through our heel, we will rise up to the next step, thereby rooting down to rise up. The muscle that pushes our heel down is the same muscle that extends our thigh back, which is our gluteus maximus, the strongest muscle in our body. If our heel is dangling off the step, we cannot make as efficient use of ground force, and more force may be required from our knees.
When going up stairs, we can train ourselves to move partially in the lateral plane, rather than only the sagittal plane to take further stress off the knees. Put simply, we can let our body side bend help us ascend to the next step. This is a difficult concept to describe that must be felt in the body to understand. One way to think about it is relating the action to pushing down on a trash can pedal to lift the trash can lid. If the right foot presses down on the step, the left side of the pelvis will lift up, bringing the left leg to the next step. In this case, the right foot would be pressing on the imaginary trash can pedal and the left side of the pelvis would be the lid.
This action is accomplished mainly by the gluteus medius as well as the quadratus lumborum, which are muscles on the side of the pelvis and abdomen.
One way to practice this feeling before doing it on the stairs is to try a slow march standing in place. Place hands on the sides of your waist. Begin to lift your left thigh up, thinking about pressing down into the ground through the right foot. Notice that the left side of your waist would get shorter, and the right side of your waist would get longer. Continue in a slow march, paying attention to the changing length of your side body. Imagine that the leg that is holding your weight is pressing down into the trash can pedal, and the side that is coming up is the lid.
2) Practice Step Ups and Downs:
As we learned, eccentric strength is necessary to go down stairs with ease, and concentric strength is necessary to go up stairs. A great way to improve this strength is to practice step ups and downs. On the bottom step or perhaps using a stool as well as something to hold on to as needed, place heel up onto the step and practice driving down through the heel to step up. Keep the same heel on the step, and lower down backwards with control until your other foot touches the ground. Repeat several times, noticing the activation of your thigh, glutes, and side body muscles.
For a more challenging exercise, practice going down a step facing forward. We have learned, this is the most difficult and likely to elicit discomfort of the knee. For this reason, it is important to start practicing by holding on to something, as well as starting with a partial range if you are having difficulty controlling this motion. Start standing on the bottom step, keep one foot where it is, and begin to lower the other foot towards the ground, but only a couple of inches. Then return to the starting position. The key is to lower down very slowly, to ensure you are maintaining eccentric control. Try a few more times, perhaps each time letting the foot travel a little closer to the ground as your other knee bends. Notice the tracking of your standing knee on the leg that is holding your weight as you lower down. Does your knee bend straight forward over your toes? Does it drop in towards the big toe side, or out to the pinky toe side? Does making a change to where your knee tracks impact the comfort and ease of this motion? Spending a little time each day practicing these movements will condition your body and your mind to be primed and ready for the next time you encounter stairs.
Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team