As an orthopedic surgeon and lifetime avid hiker who spent Father’s Day weekend on top of Mount Mansfield, Mount Hunter, and White Rocks, I know how that kind of weekend can be pretty hard on the knees. Fortunately, most of the problems I see from these kinds of excursions rarely put somebody into the operating room. There are, however, a number of diagnoses that should be considered when trying to help someone with knee pain after hiking. I will review some of the common problems, a little bit of the biochemical pathways that caused them, and some treatment options to keep you on the trails.
Knee pain can be categorized into the chronic problems like arthritis or malalignment, traumatic injuries, and acute problems such as overuse or tendinitis. Recognizing the pattern of the problem can help direct how you wish to treat it. If you already have knee problems going into a hike, you can expect to make them worse in the short term. Morning stiffness, night pain, swelling, pain at rest, weather sensitivity (predicting the cold, damp, rainy days) are all likely signs of some underlying arthritis. If you are dependent upon anti-inflammatories—Tylenol, glucosamine and chondroitin, aspirin, or arthritic creams and rubs—do not forget them when you pack your gear. If you tend to have some malalignment issue with your ankles or knees, be sure that you have the most supportive and corrective footwear, so you do not exacerbate your problem.
If you experience some acute trauma on the trail, such as twisting your knee or ankle, contusing or bruising your leg against a rock or root, feel something “let go” or “catch” inside your knee or ankle, you best hobble down as quickly and carefully as you can and get an X-ray to be sure you do not have a fracture in or around the joint. This is especially true if you see sudden swelling in the area, within 30 minutes or so, which might mean that you have bled into the joint, causing a hemarthrosis.
More likely, you are going to notice that as soon as you have crested the summit and start down what are usually the steepest parts of the trail on hard rock, your knees are going to feel quite achy. Invariably, this seems to get worse and worse the longer you descend. Thinking about what parts of your knees seem to hurt the most can give clues to what’s going on.
Pain above the patella—or kneecap—could likely involve tendinitis of the quadriceps tendon.
Pain laterally (on the outside) may be iliotibial (IT) band syndrome, biceps or hamstring tendinitis, ligament sprain, or meniscus tear.
Pain directly around the kneecap could be a sign of patellofemoral syndrome or chondromalacia. This can be made worse if there is an imbalance of the muscles controlling the path and motion of the kneecap.
Pain along the medial (inside) of the knee can be related to a medial plica syndrome (irritated fold of the lining of the knee), medial meniscus tear, medial collateral ligament sprain, or pes anserine bursitis (swelling and irritations of the tendons that support the medial front side of the knee).
Pain in the very back of the knee could be from a Baker’s or popliteal cyst (fluid pressing out from the knee sac like a hernia).
Pain below the kneecap could be a tendinitis of the patellar tendon, or if in someone is still growing, an irritation of the growth plate tendon junction at the very front of the tibia bone.
The injured areas release a host of chemicals that generally dilate the blood vessels, increase their permeability, and trigger a cascade of reactions resulting in pain, swelling, and soreness. As prostaglandin, leukotriene, thromboxane, prostacyclin, nitric acid, interleukin, bradykinin, serotonin, and histamine are released around your knee, you start wondering how long until you see the parking lot. These pathways can be blocked with aspirin, ibuprofen, naproxen, or other anti-inflammatories. In my experience, starting them even before the hike can be beneficial, if you anticipate a much steeper or longer hike than usual. You can also break the cycle by walking in a stream above your knees for 10 minutes. The cold therapy can have a dramatic effect on limiting the amount of swelling and soreness for at least a limited period of time. Repeat as needed on the way down. Compression can also be helpful—a light knee sleeve or elastic wrap is a useful trick. Hiking poles are a great help. Smaller steps, more switchbacks, frequent, short breaks for stretching, and even walking backwards for a short distance can help.