Reviewed by Matt Stanlake — Head Physiotherapist & Director, Upwell Health Collective. APA Member. AHPRA Registration: PHY0000975408. 20 years clinical experience. Last reviewed: May 2026.
The short answer: Knee pain that hurts going down stairs but not up is almost always caused by patellofemoral pain (pain at the front of the knee where the kneecap meets the thigh bone) or early-stage chondromalacia patellae. Descending stairs loads the kneecap with up to 3.5 times your bodyweight, while ascending loads it with about 2 times. The difference is enough to expose pain that's invisible during everyday walking. The good news: this pattern responds very well to targeted physiotherapy.
The kneecap sits in a groove on the front of the thigh bone. As your knee bends and straightens, the kneecap glides up and down in that groove. The further you bend the knee, and the more weight you put through it, the more force the kneecap experiences pressing back against the thigh bone.
Climbing stairs requires bending the back leg modestly and pushing up through it. Descending stairs requires the front leg to bend deeply while controlling your entire bodyweight slowly downward. That eccentric (lengthening) load combined with deeper knee flexion is exactly the position that compresses the kneecap most.
Biomechanics research consistently shows patellofemoral joint forces of 2 to 2.5 times bodyweight during stair ascent and 3.5 times bodyweight during descent. If anything irritated is sitting on the back of your kneecap, descending stairs will find it.
Patellofemoral pain is rarely caused by something structurally wrong in the joint. It's usually a load and tracking issue — the kneecap isn't gliding through its groove as smoothly as it should because of imbalances above and below the joint.
The four most common drivers we see in clinic are: 1) weakness in the gluteal muscles (particularly gluteus medius) allowing the thigh to drift inward on weight-bearing, which pulls the kneecap off-track, 2) tight outer thigh and IT band structures pulling the kneecap laterally, 3) weakness in the quadriceps (particularly vastus medialis) reducing dynamic stability of the kneecap, and 4) poor foot mechanics causing the thigh and knee to rotate inward with each step.
Notice none of these are at the kneecap itself. The pain is at the front of the knee. The cause is almost always above or below it.
"Patients are often shocked when their kneecap pain resolves with hip and glute strengthening exercises. They came in expecting kneecap-specific treatment, and 8 weeks later their stairs are pain-free because we strengthened muscles 30 centimetres away from the joint. The kneecap is rarely the problem — it's the messenger." — Matt Stanlake, Head Physiotherapist, Upwell Health Collective
While patellofemoral pain is by far the most common cause of this pattern, other conditions can produce similar symptoms: early patellofemoral osteoarthritis (more common in adults over 55), patellar tendinopathy (jumper's knee, particularly in athletes), fat pad impingement (pain at the front of the knee that worsens with deep knee bend), or rarely a meniscus tear at the front of the knee.
A thorough physiotherapy assessment can distinguish these in 15 to 20 minutes through targeted clinical testing. Imaging is generally not required to start treatment unless red flags are present.
The treatment is almost entirely exercise-based. Manual therapy can provide useful short-term pain relief, but the long-term fix is strength and control work around the hip, glute, quadriceps, and foot.
A typical 12-week program looks like this: weeks 1 to 3 focus on activity modification and gentle activation exercises for the gluteal and quadriceps muscles. Weeks 3 to 8 progress to loaded strength work including step-ups, split squats, single-leg work, and hip stability training. Weeks 8 to 12 progress to functional and sport-specific tasks. Most patients see meaningful change in stair pain by week 4 to 6 and full resolution by week 10 to 12.
Two simple changes help most people within the first week. First, when going down stairs, take them one at a time rather than alternating legs, and lead with your stronger or less painful leg going down. This reduces total time the painful knee spends under eccentric load.
Second, start two gentle exercises: clamshells (lying on your side, knees bent, lifting the top knee away from the bottom while keeping feet together) and single-leg balance with a slight knee bend. Do 3 sets of 15 of each, daily. These activate the gluteal muscles that almost always need work in patellofemoral pain.
Don't avoid stairs entirely — the joint needs progressive loading to adapt and recover. Just modify how you take them while you address the underlying drivers.
Generally no. Patellofemoral pain is not associated with permanent joint damage in most cases. It is, however, persistent if untreated — around 50% of patients with untreated patellofemoral pain continue to experience symptoms 12 months later. Active rehabilitation resolves most cases.
Usually not first. Most patellofemoral pain is diagnosed clinically without imaging. Imaging is appropriate if you have red flags (significant trauma, locking, giving way, swelling that won't settle) or if pain doesn't respond to 6 to 8 weeks of appropriate physiotherapy.
Sometimes. Running often aggravates patellofemoral pain, particularly downhill running which loads the kneecap similarly to descending stairs. Most physios will modify running volume and surface during the early treatment phase, then progressively reintroduce it as strength improves.
The ascending phase is usually fine. The challenge is most stair machines emphasise the descent, which loads the kneecap heavily. During treatment, alternative cardio options (cycling at a high seat height, elliptical) are usually better tolerated.
Sometimes, short-term. Patellar taping or a patellar tracking sleeve can provide short-term symptom relief during aggravating activities. They should be used alongside an exercise program, not as a substitute for one.
Most patients with patellofemoral pain experience meaningful reduction in stair pain by 4 to 6 weeks of appropriate physiotherapy, with full resolution typically by 10 to 12 weeks. Adherence to the home exercise program is the single biggest predictor of recovery speed.
If your knee hurts going down stairs and you've been putting up with it for weeks, a thorough physiotherapy assessment will identify the exact drivers and give you a clear plan to fix it. Upwell Health Collective in Camberwell offers 45 to 60 minute initial appointments. 28 free undercover carparks. All health funds accepted via HICAPS. Book online at upwellhealth.com.au or call (03) 8849 9096.
Matt Stanlake is the Head Physiotherapist and Director of Upwell Health Collective in Camberwell. He is a member of the Australian Physiotherapy Association (APAM) and AHPRA-registered (PHY0000975408) with 20 years of clinical experience. Matt has built Upwell into a 7x award-winning multidisciplinary allied health clinic trusted by AFL legends Mick Malthouse and Jonathan Brown. He is the author of Not Broken and the creator of the Whole Person Care framework.