Our articles are not designed to replace medical advice. If you have an injury we recommend seeing a qualified health professional.
The trails near my home in Brighton are seriously hilly. So much so, that some of the toughest climbs have names! My favourite/ nemesis is ‘the snake’, so called because it winds on and on. Just when you think you’ve reached the top you turn a bend and find another long incline!
Alongside being a tough workout, training on the hills significantly alters how we run so let’s explore this.
Uphill running
The energy cost of uphill running is higher, making it a challenging but potentially rewarding type of training. This is largely due to the increased work of driving the body up the hill. As a result, we see an increase in activity in the quads, calf, glute max and hamstrings during the propulsive phase of running.
Uphill running tends to increase load on the Achilles tendon and Tibia but decreases it on the Patellofemoral Joint. So we may suggest to reduce uphill running in those with Achilles pain or Medial Tibial Stress Syndrome (MTSS), especially if painful.
However, with Patellofemoral pain, if it’s well tolerated by a runner we might suggest continuing these uphills runs. They may be a useful replacement as a high-intensity workout if faster running is painful for the knee (which it can be as peak knee load tends to increase with speed).
Uphill running graphic summary – influence on gait, load and muscle activation:
Downhill running
Running downhill tends to increase patellofemoral joint stress, so if the runner in our example above is doing hill repeats it may be better to run up and walk down. ITBS also tends to be aggravated by downhill running.
Peak Achilles load is reduced running downhill but with Tibial load there are some conflicting findings in the studies. Van Hooren et al’s excellent recent paper reported increased peak Tibial load with downhill running, while Rice et al. (2023) reported decreased Tibial load and suggested running downhill may reduce risk of of Tibial stress injury.
A key point with both uphill and downhill running is the individual response will vary.
Speed, gradient, step rate and tissue load all interact and are influenced by technique. For example, a runner aiming to run faster downhill may increase stride length and use a low step rate. This would be expected to increase muscular demands during load absorption, especially on the quads and would likely increase peak load on the knee and Tibia.
However, a more cautious runner aiming to run downhill more slowly may increase step rate, taking short, quick strides to control the descent. While this will increase loading cycles it may reduce muscle demands and load on the knee and Tibia, especially if speed remains low.
Downhill running graphic summary – influence on gait, load and muscle activation:
Key references:
Vernhillo et al. (2017) and Van Hooren et al. (2024)
Clinical application
As technique will vary it’s best to assess someone running on the hills during gait analysis if that’s a specific aggravating factor for them. Then you can explore strategies to help, such as taking short, quick steps downhill to reduce knee load.
You may wish to adapt your strength work too if hill running is the goal. For example, including eccentric quads work for downhill and strengthening the glutes and hamstrings for the uphill.
We cover strength and conditioning in detail in Running Repairs Online, alongside evidence-based rehab for patellofemoral pain, Achilles tendinopathy, MTSS and all key running injuries. Visit our course page to find out more.
