Knee Pain When Doing Step-Ups: Box Height, Causes, Fixes

When to get help first

Exercise is for pain that has been checked or is clearly mild and settling.

Get urgent medical help if

Go to A&E if you've injured your knee and it has changed shape, it becomes very swollen very quickly, you felt a pop or snap, you can see bone sticking out, or it's bleeding heavily. Don't drive yourself: ask someone to take you, or call 999 if the pain means you can't move your leg to get there.
Get advice from NHS 111 now: you cannot move the knee or put any weight on it, or it is very painful, badly swollen or has changed shape.
Get advice from NHS 111 now: the knee locks, gives way or clicks painfully. Painless clicking is normal.
Get advice from NHS 111 now: after a twist, your knee won't go fully straight, or something blocks the last part of straightening, even if you can still walk on it. A torn piece of meniscus caught in the joint can do this, and it needs checking promptly.
Same day: a pop or tearing feeling at the front of the knee after a fall, stumble, jump, landing or a heavy squat, then you can't straighten the knee or lift the straight leg off the bed, there's a dent above or below the kneecap, or the kneecap sits higher or lower than on the other side. Go to A&E or an urgent treatment centre, or get help from NHS 111. A torn quadriceps or patellar tendon does best when it's repaired soon.
You hurt your knee and cannot take 4 steps, or you are 55 or over and have injured it: get it checked the same day for a broken bone.
Get advice from NHS 111 now: a hot, red or swollen knee with sudden severe pain, a very high temperature (although not everyone has one), or feeling hot, cold or shivery. This can be a joint infection.
Call 999 or go to A&E if your child gets sudden pain in their hip, knee or thigh (hip problems can sometimes be felt in the thigh or knee) or cannot put any weight on their leg. If your child is limping, ask for an urgent GP appointment or get help from NHS 111 the same day. This applies to teenagers too, and in some children knee pain is the only sign.
Same day (urgent GP appointment or NHS 111): throbbing pain in one leg (rarely both), usually the calf or thigh; swelling in one leg (rarely both); red, blue or darkened skin; or swollen veins; or sudden worse pain and swelling around a lump at the back of the knee (a possible clot or a burst Baker's cyst).
Call 999 or go to A&E if breathing suddenly becomes difficult, if pain in your chest or upper back comes on suddenly with breathlessness or a very fast heartbeat, or if someone passes out. Do not drive yourself. It can be a blood clot that has reached the lungs.
Same day (call NHS 111, or go to A&E if you feel very unwell): after a big or unusual session, such as a first spin class, a workout of 100 back squats, or intervals of wall sits, squats, lunges and jumps, a challenge or a new class, muscle pain, swelling or weakness far worse than the session explains, and dark pee (red, brown, tea or cola coloured), sometimes starting hours or days later. Dark pee isn't always there, so muscles far sorer, more swollen or weaker than the session explains still need the same-day check. It can be rhabdomyolysis, a breakdown of muscle that can harm the kidneys.
Call 999 or go to A&E: back or leg symptoms with numbness around the genitals or bottom, new trouble controlling your bladder or bowels, or severe or worsening weakness or numbness in both legs.

See a doctor or physiotherapist if

Knee pain that has not improved within a few weeks of looking after it at home. Many areas offer NHS physiotherapy without a GP referral.
Kneecap pain that hasn't improved within 6 weeks of changing your activities and doing the exercises, or that gets worse: talk to a GP or physiotherapist.
The knee gives way, the whole knee swells, or it catches or locks: that isn't typical of kneecap or tendon pain. Get it checked for a ligament or meniscus injury (our suggestion).
Catching, locking or swelling at the joint line that hasn't settled after about 3 months of exercise and other non-surgical care: ask your GP or physiotherapist about a specialist review. A magnetic resonance imaging (MRI) scan may be considered then.
Tendon pain above or below the kneecap and you take steroid tablets or have steroid injections, use anabolic steroids, have kidney disease, gout, rheumatoid arthritis, lupus or diabetes, or have recently taken a fluoroquinolone antibiotic: tell your GP or physiotherapist and build up more gradually. These can weaken the tendon. If you're taking a fluoroquinolone now, stop taking it and contact your doctor straight away, as the UK medicines regulator advises.
A child or teenager with pain at a bump just below the kneecap or at its lower tip, worse with squats, jumps and kneeling: see our Osgood-Schlatter and Sinding-Larsen-Johansson guides, and get it checked if it is getting worse.
A child or teenager whose knee pain is there at rest or worse at night, or comes with a limp, swelling, a high temperature, unusual tiredness or weight loss: see a GP.
Numbness, tingling or weakness that travels down the leg from the back. That points to a nerve (sciatica) rather than the knee.
Swelling in several joints, or morning stiffness that lasts more than 30 minutes: see a GP. It can be an inflammatory arthritis such as rheumatoid arthritis rather than osteoarthritis.

Where does it hurt?

Location narrows the likely causes; it does not diagnose.

Around or behind the kneecap, hard to point to, worse stepping down, on stairs, squatting and after sitting with bent knees

Usually kneecap pain (patellofemoral pain), the commonest pattern. A lower box, step-ups before step-downs, and hip and thigh strength usually help.

Read: Runner's knee →One point at the lower tip of the kneecap, worse with higher boxes, jumping and landing

Usually patellar tendon pain (jumper's knee). Still holds first, a lower box and no box jumps for now.

Read: Jumper's knee →One point at the top edge of the kneecap, worst at the deepest bend

Possibly quadriceps tendon pain. A lower box keeps the knee out of the deepest bend.

Read: Quadriceps tendinopathy →Below the kneecap, either side of the tendon, worse as the knee snaps straight at the top

Possibly the fat pad being pinched. Stand tall at the top without snapping the knee straight.

Read: Fat pad impingement →The inner or outer joint line, with catching, locking or swelling later that day, or after a twist

Often a meniscus tear. A worn tear often settles with exercise; a knee that locks needs checking.

Read: Meniscus tear →Both knees, a stiff ache from your mid-40s, with morning stiffness that wears off within 30 minutes

Often knee arthritis. Step-ups are part of the UK arthritis exercise programmes.

Read: Knee arthritis →The inner shin a few centimetres below the joint, worse on steps and getting up from a chair

Possibly pes anserine bursitis.

Read: Pes anserine pain →The outside of the knee in a runner or a step-class regular, building through a session

Possibly the IT band (iliotibial band).

Read: IT band syndrome →A teenager with a tender bump just below the kneecap, sore to kneel on

Osgood-Schlatter disease.

Read: Osgood-Schlatter →A pop at the front of the knee as you drive up or catch yourself, then you can't straighten the knee or lift the straight leg

Possibly a torn quadriceps or patellar tendon: get help the same day, as the warning signs say.

Read: Kneecap tendon rupture →The kneecap slipping out to the side as you turn on the box

A dislocated kneecap.

Read: Kneecap dislocation →The same pain on stairs in daily life

Our stairs guide covers how to use stairs for now and a plan back to step over step.

Read: Knee pain on stairs →The same pain in lunges, squats or on the leg press

Our lunge, squatting and leg press guides cover those moves.

Read: Knee pain when lunging →A child or teenager with knee or thigh pain and a limp, the knee itself looking normal

It can come from the hip: get it checked the same day, as the warning signs say.

Read: Knee pain in children →

Understand it

What a step-up asks of the knee, and what no study has countedEmerging evidence

A step-up puts one foot on a box and straightens that knee to lift your body. The higher the box, the more the knee bends at the start and the more force goes behind the kneecap. In 20 healthy adults, the modelled load behind the kneecap was 0.6 times body weight walking, 1.7 on a 10 cm step-up, 2.5 in a squat to 60 degrees, 3.6 on a 20 cm step-up and 5.1 in a lunge; the 10 cm step-up was the lightest single-leg exercise measured after walking. Lowering yourself slowly off the same step loaded it more: 3.1 times body weight from 10 cm and 5.8 from 20 cm. At the same knee bend, a forward step-down stressed the kneecap about a fifth more than a forward or lateral step-up (13.8 against 11.2 and 11.5 megapascals, a unit of pressure, in 20 adults). The tendon below the kneecap followed the same pattern, with step-ups in the lowest tier of tendon load.

Ordinary stairs are a slightly different task: across studies of healthy people, walking down loaded the kneecap no more than walking up (2.8 against 3.2 times body weight). It is the slow, one-legged lowering of a step-down that loads it most. People with kneecap pain naturally take stairs more slowly and use the front of the thigh less, which kept the stress behind the kneecap at normal levels in small lab studies, and they unloaded the thigh further when the pain was flared. All of these are lab studies of healthy people, not people in pain, and no study counts how often step-ups cause knee pain, so the map on this page is built from what each condition is known to do. Pain usually comes when the box height, the reps or the speed jump ahead of what the knee is used to, as with a new class or a challenge; a summary of the US physical therapy guideline names overexertion and rapid increases in training.

Sources 1, 2, 3, 4, 5, 6, 7, 8

The kneecap, the tendons and the joint lineStrong evidence

Kneecap pain is pain around or behind the kneecap brought on by loading a bent knee, such as squatting, long sitting, stairs, jumping or running, the US guideline says; pain on squatting is the most accurate test, and no pain on squatting makes it unlikely. One sore point at the lower tip of the kneecap, brought on by loading, points to the patellar tendon instead, the Dutch guideline says. A middle-aged knee with pain on the joint line, catching or swelling may have a worn meniscus, which did as well with 12 weeks of exercise as with keyhole surgery in 140 adults. Knee arthritis brings a stiff ache with activity, and the National Institute for Health and Care Excellence (NICE) diagnoses it from 45 without an X-ray when morning stiffness lasts no more than 30 minutes.

Sources 9, 8, 10, 11, 12, 13

Who gets it, and what is rareEmerging evidence

The people it usually bothers, in our reading: people new to step-ups or step classes, or who raise the box, the weight or the reps quickly; runners, hikers and skiers training for hills; teenagers and young adults, in whom kneecap pain is common; people from their mid-40s with arthritis; and people coming back from a knee injury. In military recruits, weak thigh muscles predicted kneecap pain while weak hips didn't (18 studies, 4,818 people). No study gives the share of each cause in step-ups.

Most of it is the kneecap or a tendon getting more load than it's ready for. Serious causes are rare: a torn tendon, a broken bone after a fall off the box, a joint infection, a blood clot, an inflammatory arthritis, a child's hip problem felt in the knee, and, very rarely in children, pain at rest or at night with weight loss. The warning signs pick these out.

Sources 14, 1

When a scan helpsStrong evidence

Kneecap pain is recognised from the story and an examination, and NICE diagnoses arthritis from 45 without an X-ray. Scans mislead on their own: from 40, cartilage defects showed in 43% and meniscal tears in 19% of knees without pain, across 63 studies. After a fall or a slip off the box, a short checklist (the Ottawa knee rule) decides whether you need an X-ray; it picked up 98% of fractures across 18 studies. Catching, locking or joint-line swelling that hasn't settled after about 3 months of exercise may need a magnetic resonance imaging (MRI) scan, and the Dutch guideline says to rethink the diagnosis if kneecap pain hasn't improved after 12 weeks of structured exercise.

Sources 8, 13, 15, 16, 11

How it usually goesEmerging evidence

No study follows knee pain from step-ups. Kneecap pain is often slow: in 310 people, 55% had not recovered well at 3 months and 40% at 12 months, and pain for more than 2 months at the start was the strongest warning sign, so start the changes early. With supervised exercise, 62.1% reported recovery at a year. An NHS trust leaflet says it can take about 3 to 6 months, and that most people improve with time and simple exercises. Of the fifth of one group who replied 5 to 8 years later, 57% had not recovered well, but 48 of the 50 who had an X-ray showed no arthritis. The NHS says see a GP if knee pain hasn't improved within a few weeks. No one can promise a date.

Sources 17, 18, 19, 20, 21

What helps, and how strong the evidence is

Box height and stepping down: lab studies in healthy peopleEmerging evidence

Doubling the step from 10 to 20 cm doubled the load behind the kneecap (1.7 to 3.6 times body weight), and lowering off a step loaded it more than stepping up the same step, in 20 healthy adults. The tendon followed the same pattern, though the tendon paper's abstract calls the same steps 20 and 30 cm, so we say a low and a higher step. Kneecap force rises as the knee bends further, a commentary on lab studies says. Higher steps meant more knee bend at foot contact, and people with and without kneecap pain timed their thigh muscles the same at every height, so there is no need to fire a particular part of the thigh. None of these studies tested a change to the step-up in people with pain.

Sources 1, 2, 3, 22, 23

Forward or lateral, and the trunk leanEmerging evidence

At the same knee bend, forward and lateral step-ups stressed the kneecap about the same, and both less than a forward step-down. In 21 older adults, the forward step-up asked more of the hip muscles and the lateral step-up more of the knee and ankle. On stairs, leaning the trunk forward a little lowered kneecap stress by 2.6 megapascals in 20 pain-free women, and standing bolt upright raised it by 3.3; a large lean (about 35 degrees more than usual) moved work to the hip muscles. These are stair studies, not step-up exercise.

Sources 2, 24, 25, 26

The trailing leg and stepping down: thin evidenceEmerging evidence

No study has measured how much a push from the back foot spares the leading knee. In 109 older women stepping up 30 cm fast, step-up speed went with the push from the lower foot, not the load on the upper one, and in stair descent with extra body weight the leg that stayed on the step took the extra load (10 men). So a little push from the back foot is likely to help the front knee for now, our reading.

There are two ways to step down, and neither has been tested for pain. The site's advice for a sore kneecap is to step down with the sore leg first so the other leg lowers you, the same idea as the NHS's sore leg first on stairs. King's College Hospital's kneecap leaflet does the opposite in its weeks 2 to 6 step-up: the other foot goes down first, so the sore leg lowers you. This plan uses the first way in its first stage and the leaflet's way in its second.

Sources 27, 28, 19

The knee travelling in: a cue, not a diagnosisMixed evidence

An NHS leaflet cues the knee to stay above the ankle and not move towards the other knee. But a summary of the US guideline says knee valgus (the knee travelling in) doesn't predict who gets kneecap pain; on video, the knee-in angle in a lateral step-down didn't track pain or function in 22 people, and a change under about 9 degrees was measurement noise; and judging a step-down by eye is only fair to moderately repeatable, even for physiotherapists.

Movement training has thin support: hip strengthening with movement-control practice beat thigh-only training at 3 months in 31 women, and a study of 25 women without a comparison group taught the knee over the second toe and a level pelvis, used a mirror and then faded it out, and raised the step only when pain didn't rise. So keep the cue, but the strength work is the treatment.

Sources 19, 8, 29, 30, 31, 32, 33

Exercise helps kneecap pain, with hip and knee work togetherStrong evidence

In a Cochrane review, exercise eased pain during activity by about 1.5 points out of 10 against no exercise (5 trials, 375 people), and hip and knee work together by a further 2.2 points against knee work alone; the evidence was very low quality but consistent, and no single exercise was shown to be best. Two international consensus statements recommend hip and knee exercise together, and the Dutch guideline (2025) says at least 6 to 12 weeks, adjusted to your pain. Supervised exercise beat a wait-and-see approach for pain at 3 and 12 months in 131 people.

Adding hip work to knee work gave less pain and better function for up to a year in 54 women; starting with the hips eased pain sooner in 33 women and about a week sooner in 199 people; the leg press and knee extensions did equally well in 45 men; and hip work alone helped 28 women. None of these trials, as far as their abstracts say, used step-ups, which are one sensible option among many.

Sources 10, 34, 35, 11, 36, 18, 37, 38, 39, 40, 41

The NHS leaflets, arthritis and the tendon trialEmerging evidence

King's College Hospital's kneecap leaflet puts step-ups at weeks 2 to 6 and step-downs at weeks 6 to 12, each 8 to 12 times, three times a day, raising the load once every 2 to 3 weeks. Bath's leaflet makes the step-up its advanced exercise, 10 times, three rounds, 3 times a week. For knee arthritis, Arthritis UK's step-up uses the bottom stair and the bannister, with each leg to fatigue, a minute's rest and two more rounds; NICE offers exercise to everyone with arthritis and warns that pain may rise at first; and a UK group programme (ESCAPE-pain) improved pain and function by about 10 points in 1,492 people, without a comparison group.

For patellar tendon pain, the largest trial (76 athletes) used still holds, then slow heavy leg presses or leg extensions, then springy loading, kept at 3 out of 10 or less, and beat eccentric squats at 24 weeks. Its supplement lists walking lunges and step-ups as the second-stage alternatives when no machine is available, every second day.

Sources 19, 42, 43, 13, 44, 45

How much pain is OK while you exercise?

0 to 2 is safe, up to 5 is acceptable, back to usual by the next morning, and 3 for a tendonEmerging evidence

This guide uses the knee hub's rule, as our other knee movement guides do. Rate your knee pain from 0 to 10 during and after exercise. In the pain-monitoring model used in knee trials, 0 to 2 counts as safe, up to 5 as acceptable and above 5 as too much. Aim for 0 to 3 most of the time. By the next morning your knee should be back to its usual level. If it is not, drop back one step next time (fewer sets, a shallower range, a lower step), not to nothing. For one sore point just below or above the kneecap (a tendon), keep it to 3 out of 10 or less, the limit the largest patellar tendon trial used.

NHS sources differ in strictness. NHS inform's knee exercises use 0 to 3 minimal, 4 to 5 acceptable and 6 to 10 excessive pain, and say pain should be no worse the morning after you've exercised; King's College Hospital moves you on only when the exercises are easy without discomfort; and NICE warns that joint pain may rise when people with arthritis start exercising. The hub's rule sits in the middle and suits people already training; if you're starting out or the knee flares easily, the stricter version is a fine choice.

For step-ups (our suggestion, built on the same rule): use the box height, the direction (up before down) and the load where the last reps stay at 5 out of 10 or less (3 for a tendon) and the knee is back to normal by the next morning. If not, lower the box one step, not to nothing. Raise the box only when you can keep the knee over the second toe without more pain, the rule a movement-training study used. Sharp, catching or giving-way pain, new swelling or a pop isn't a pain-rule question: see the warning signs.

Sources 45, 46, 19, 13, 33

The exercise plan: 3 stages

Start at the first stage. Each move opens a full guide with a 3D demo.

Stage 1

Keep stepping, lower the box

About the first 2 weeks, 2 or 3 strength sessions a week: keep a step-up in your week at a height that passes the pain rule, start the hip and thigh strength the guidelines recommend, and still holds for tendon pain. No high boxes, step-downs, weighted step-ups or box jumps for now. With a diagnosed condition (patellar or quadriceps tendon pain, a meniscus tear, arthritis, Osgood-Schlatter disease, a knee replacement), that guide's plan comes first; after surgery, your surgical team's plan does.

Low step-up demonstrated on the 3D figure

3D demoLow step-upBeginner · A step

Onto a 10 cm step or the bottom stair, a rail in reach, 8 to 12 each leg, three times a day; step down with the sore leg first so the other leg lowers you · King's College Hospital's step-up dose, from its weeks 2 to 6 stage, used here on the lowest step (borrowed). Stepping down this way is the site's advice, untested. A 10 cm step-up loaded the kneecap least of 35 exercises in a lab study

Harder: Step-up

Seated knee extension (chair) demonstrated on the 3D figure

3D demoSeated knee extension (chair)Beginner · A bench or box + Something with weight

3 sets of 10 to 15 each leg, 2 to 3 days a week; from 90 degrees to about 45 degrees of bend only if the kneecap hurts · The move page's dose and range

Easier: Quad set (static quads) · Harder: Leg extension

Spanish squat (band squat hold) demonstrated on the 3D figure

3D demoSpanish squat (band squat hold)Intermediate · A band + An anchor point

For tendon pain: 4 to 5 holds of 30 to 45 s, 1 to 2 minutes' rest, once a day · The move page's dose, modelled on the tendon trial's holds

Easier: Straight-leg raise · Harder: Pistol squat

Quad set (static quads) demonstrated on the 3D figure

3D demoQuad set (static quads)Beginner · No equipment

If even the low step hurts: hold 10 s, 2 to 3 at a time, building to 2 sets of 15 · NHS inform's static quads exercise and its pacing

Harder: Straight-leg raise

Glute bridge demonstrated on the 3D figure

3D demoGlute bridgeBeginner · No equipment

3 sets of 10 · Editorial: hip work alongside knee work, as the consensus statements recommend

Easier: Pelvic tilt into bridge · Harder: Single-leg glute bridge

3D demoClamshellBeginner · No equipment

3 sets of 12 to 15 each side · As in our runner's knee guide (editorial)

Easier: Supine isometric hip abduction (belt press) · Harder: Lateral band walk

Move on when: Low step-ups pass the pain rule and the knee is back to normal by the next morning, for a week (editorial). With tendon pain, one single-leg squat hurts 3 out of 10 or less after at least a week, the tendon trial's test.

Follow along: a timer, a cue and the next move, one step at a time.

Stage 2

Raise the box, and let the sore leg lower you

About weeks 2 to 6, 2 or 3 sessions a week: a normal stair or a 20 cm box, the sore leg now doing the lowering as King's College Hospital's step-up does, and more single-leg and hip strength.

3D demoStep-upBeginner · A step

A normal stair or about 20 cm: 10 each leg, 3 rounds, 3 times a week; the sore leg steps up, and once that passes the rule, the other foot goes down first so the sore leg lowers you · Bath's kneecap leaflet dose; the order is King's College Hospital's. For tendon pain, the tendon trial's alternative to the leg press when no machine is free, every second day at 3 out of 10 or less

Easier: Low step-up · Harder: Dumbbell step-up

3D demoLeg pressBeginner · Strength machine

3 sets of 10, from nearly straight to about 45 to 60 degrees of bend at first · As in our leg press guide (editorial); the leg press did as well as knee extensions for kneecap pain in a trial of 45 men

Harder: Bodyweight squat

Lateral band walk demonstrated on the 3D figure

3D demoLateral band walkBeginner · A band

3 sets of 12 steps each way · As in our squatting guide (editorial)

Easier: Hip abduction machine · Harder: Lateral band walk, band at the feet

Single-leg Romanian deadlift demonstrated on the 3D figure

3D demoSingle-leg Romanian deadliftAdvanced · A dumbbell

3 sets of 8 each leg, fingertips on a wall at first · As in our squatting guide (editorial)

Easier: Dumbbell Romanian deadlift

3D demoWall sitBeginner · A wall

4 holds of 20 to 45 s at a comfortable depth · As in our stairs guide (editorial)

Easier: Straight-leg raise · Harder: Spanish squat (band squat hold)

Single-leg stand demonstrated on the 3D figure

3D demoSingle-leg standBeginner · A wall

Build to 30 s each leg, a hand near a support · As in our stairs guide (editorial)

Easier: Tandem stance and heel-to-toe walk · Harder: Single-leg reach matrix

Move on when: 3 rounds of 10 step-ups onto a normal stair or a 20 cm box pass the pain rule with the sore leg doing the lowering, the knee over the second toe, and the knee is fine the next morning (editorial).

Follow along: a timer, a cue and the next move, one step at a time.

Stage 3

Step-downs, then your usual box and load

From about week 6, often later for tendon pain: the step-down, then the box height, weight and speed you trained at before, one change at a time by the written steps below. No study has tested a return to step-ups after knee pain; the order follows King's College Hospital's stages and the lab loads, and is editorial.

Patrick step-down demonstrated on the 3D figure

3D demoPatrick step-downIntermediate · A step

From a low step, slowly, hips level and the knee above the ankle: 8 to 12 each leg, three times a day · King's College Hospital's step-down dose, from its weeks 6 to 12 stage. A low step-down loaded the kneecap a little less than a 20 cm step-up in a lab study

Easier: Bodyweight squat · Harder: Skater squat

Dumbbell step-up demonstrated on the 3D figure

3D demoDumbbell step-upIntermediate · A dumbbell + A step

3 sets of 8 to 12 each side; drop back to a lower step when you first hold dumbbells, and raise the box before the weight · Our dumbbell leg workout's dose (editorial)

Easier: Step-up · Harder: Back squat with bands

Split squat demonstrated on the 3D figure

3D demoSplit squatIntermediate · No equipment

3 sets of 8 each leg · As in our lunge guide (editorial)

Easier: Bodyweight squat · Harder: Reverse lunge

Stair climbing demonstrated on the 3D figure

3D demoStair climbingIntermediate · A step

1 to 3 flights at your own pace, step over step, the rail within reach, 2 to 3 days a week · As in our stairs guide (editorial; the move page gives no dose)

Easier: Treadmill walking · Harder: Sprint intervals

Barbell step-up demonstrated on the 3D figure

3D demoBarbell step-upIntermediate · A barbell + A step

Only if you trained them before, last: 3 sets of 6 to 8 each leg with a light bar · Editorial. Step down carefully, as the move page says

Easier: Step-up · Harder: Back squat with bands

Leg extension demonstrated on the 3D figure

3D demoLeg extensionBeginner · Strength machine

Twice a week: 3 sets of 10 to 15 for kneecap pain, or 5 holds of 45 s for tendon pain · As in our lunge and leg press guides; the tendon trial kept its holds going

Easier: Straight-leg raise · Harder: Barbell box squat

Move on when: Your usual step-up sessions pass the pain rule for 2 weeks. If it flares after a big session, go back a stage for a few days, not to nothing (editorial).

Follow along: a timer, a cue and the next move, one step at a time.

What to change for now

Your step-up for now (written steps)

Our 3D figure can't show all of these. They come from lab studies of healthy people, NHS trust leaflets and the site's step-up guide; where a step is our suggestion or editorial, it says so. No trial has tested a change to the step-up for knee pain.

1. Start on a 10 cm step or the bottom stair, and raise it a few centimetres at a time: doubling the step from 10 to 20 cm doubled the load behind the kneecap. A box that puts your knee no higher than your hip is plenty for most people (the site's step-up guide, editorial).
2. The whole foot on the box, the knee over the second toe and the hips level, with the knee above the ankle and not moving towards the other knee, as an NHS leaflet cues.
3. Lean your chest forward a little from the hips: on stairs, that lowered kneecap stress, and standing bolt upright raised it.
4. For now, a little push from the back foot or a hand on a rail is fine; drive up with the box leg as the knee settles (our reading of studies of stepping, not step-up exercise).
5. Coming down: slowly. At first, step down with the sore leg so the other leg lowers you (the site's advice, untested); in the second stage, let the sore leg do the lowering, as King's College Hospital's step-up does. Step-downs from a low step come last: lowering loads the kneecap more than stepping up.
6. Add height before weight, and drop back to a lower step when you first hold dumbbells (the site's step-up guide). One small stair study found 15 kg on the shoulders stressed the kneecap less than in the hands, too thin to change the advice.
7. Fewer reps and rest days between harder sessions (editorial); King's College Hospital raises the load once every 2 to 3 weeks.
8. Step classes: a lower step (a 6 inch step gave a lower landing force than 8 or 10 inches). Box jumps: leave them out for now; in a CrossFit survey they had the highest injury share, and soft boxes are suggested.

Sources 1, 2, 19, 25, 27, 47, 48, 49

Back to stairs, hills and sport (written steps)

No study has tested how step-ups come back after knee pain, so these steps are our suggestion unless a source is named.

1. Stairs: for now one at a time with the rail, good leg first going up and sore leg first coming down, as our stairs guide says; back to step over step once the second stage passes.
2. Hiking and hill walking: shorter hills first, and long, steep descents last, because big step-downs load the kneecap most and the knee joint itself takes a little more going down than up; poles on the way down are a sensible extra.
3. Step classes and the stair machine: a lower step and shorter sessions, then build.
4. Running, jumping and team sport: after the third stage passes, following our running and jumping guides; King's College Hospital adds jumping and hopping before a return to jogging.
5. Box jumps last: step down rather than jumping down, on a soft box.
6. Keep two strength sessions a week with hip and knee work for a few months after the pain has gone.

Sources 19, 1, 50, 47, 48

Arthritis, a meniscus and the tendons

With knee arthritis, Arthritis UK's step-up on the bottom stair, holding the bannister, is a good place to start, and NICE says some pain at the start is expected. With a worn meniscus, exercise did as well as keyhole surgery, but a knee that locks needs checking first. With tendon pain, keep to 3 out of 10 or less: the tendon trial built from still holds to slow heavy loading over weeks, and the Dutch guideline advises at least 12 weeks of progressive thigh strengthening.

Sources 43, 13, 12, 45, 11

Positions to swap, and why

Habit or position	Why it matters	Instead
A high box while the knee is sore	Doubling the step from 10 to 20 cm doubled the load behind the kneecap in a lab study.	A 10 cm step or the bottom stair.Try: Low step-up
Dropping off the box onto the sore leg	Lowering loads the kneecap more than stepping up.	Step down slowly, at first with the sore leg leaving the box first so the other leg lowers you.
Step-downs early on	A forward step-down stressed the kneecap more than a step-up at the same knee bend.	Step-ups first; low step-downs in the third stage, as an NHS leaflet stages them.Try: Low step-up
Standing bolt upright and driving through the knee	On stairs, an upright trunk raised kneecap stress.	A slight forward lean from the hips.
The knee drifting in towards the other knee	An NHS leaflet cues the knee over the ankle; it's a control cue, not a proven cause of pain.	A lower box until the knee stays over the second toe.
Adding weight before height	The site's step-up guide says raise the step first, and drop back down when you first hold dumbbells.	Body weight on a lower step.Try: Step-up
Box jumps and fast step classes during a flare	Box jumps had the highest injury share in a CrossFit survey, and landing loads a sore tendon.	Slow step-ups, and a low step in classes.Try: Step-up
Step challenges and hundreds of reps	Kneecap pain often follows a sudden rise in load, the US guideline summary says.	Sets of 8 to 12 with rest days between (editorial).
Snapping into a locked knee at the top	The site's leg press and fat pad guides say soft knees at the top cost nothing.	Stand tall without snapping straight.
Resting completely	Supervised exercise beat a wait-and-see approach for kneecap pain.	The first-stage moves.Try: Glute bridge
A knee sleeve or strap as the plan	Taping and bracing are uncertain for kneecap pain, the consensus statements say.	Hip and knee strength.Try: Clamshell
Training through a knee that locks, gives way or swells	That isn't typical of kneecap or tendon pain.	Get it checked, as the warning signs say.

Routines to follow

Step-up workout: from the bottom stair to a loaded box

A 30-minute step-up workout at home or in the gym: step-ups, split squats, step-downs and calf raises on one step, with the height set to your level.

30 minBeginner9 movesA wall, A step

Knee strengthening workout: from first steps to full range

A 25-minute session for knees that don't currently hurt: thigh and hamstring strength, single-leg control, then an optional full-range block with knees over toes.

25 minBeginner13 movesA bench or box, A wall

Low-impact leg workout (no jumping)

A gentle leg strength routine with no jumping: sit-to-stands, step-ups, wall sits, bridges and calf raises.

20 minBeginner7 movesA bench or box, A step

Knee control warm-up

A 20-minute warm-up that trains your knees to track over your toes: side-hip strength, squats and lunges with alignment practice, balance and quiet landings.

20 minBeginner10 movesA wall, A band

Dumbbell leg workout

Legs and glutes with dumbbells: goblet squats, Romanian deadlifts, step-ups, split squats and calf raises.

35 minIntermediate10 movesA wall, A dumbbell

More moves for this area

Questions people ask

Why does my knee hurt when I do step-ups?

Most often the kneecap: the force behind it rises as the box gets higher and as you lower yourself down. Where it hurts is the clue: around the kneecap is usually kneecap pain, one point below it the tendon, and the joint line with catching a meniscus.

Are step-ups bad for your knees?

No. A low step-up is one of the lightest single-leg loads for the kneecap in lab studies, and NHS kneecap pain leaflets and Arthritis UK use them. Too high a box or too much too soon is the usual problem.

Are step-ups good for knee pain?

Often, at the right height: they strengthen the thigh and hip, which is the treatment for kneecap pain. Start on a low step and keep within the pain rule.

What box height should I use?

Start at about 10 cm or the bottom stair and raise it a few centimetres at a time; doubling the step from 10 to 20 cm doubled the kneecap load in a lab study. Raise the height before adding weight.

Why does stepping down hurt more than stepping up?

Lowering yourself slowly on one leg loads the kneecap more than lifting yourself up the same step: 5.8 against 3.6 times body weight from 20 cm in a lab study. While it's sore, step down with the sore leg first so the other leg lowers you, then let the sore leg do the lowering as it settles.

Should I push off my back foot?

For now, a little push or a hand on a rail is fine; the back foot does real work in a step-up. As the knee settles, let the leg on the box do the work.

My knee caves in on step-ups. Does it matter?

Keep it over your second toe, as an NHS leaflet cues, but knee valgus doesn't predict kneecap pain, a guideline summary says. Lower the box if it keeps drifting, and strengthen your hips and thighs.

Forward or lateral step-ups?

At the same knee bend they loaded the kneecap about the same, and both less than a step-down. Lateral step-ups work the knee a little more and forward ones the hip, so choose the one that passes the pain rule.

Can I do step-ups with knee arthritis?

Yes: Arthritis UK's knee exercises include them on the bottom stair, holding the bannister. NICE says exercise helps even if the pain rises a little at first.

Do I need a scan?

Usually not: kneecap pain is diagnosed by examination, and scans of painless knees often show cartilage changes. After a fall off the box, a short checklist decides whether you need an X-ray.

How long until step-ups stop hurting?

No one can promise a date. An NHS trust says kneecap pain can take 3 to 6 months, 40% hadn't recovered well at a year in one study, and starting early helps.

When should I see a doctor?

Go to A&E if your knee changed shape or swelled fast after a pop or a fall, get help the same day for a pop at the front of the knee with a knee you can't straighten, and get advice from NHS 111 if it locks, gives way or is hot and swollen with a high temperature. See a GP or physiotherapist if it isn't better within a few weeks. In the US, call 911 where this page says 999.

Knee pain when doing step-ups: the kneecap, the tendon, box height, knee path and stepping down

When to get help first

Get urgent medical help if

See a doctor or physiotherapist if

Where does it hurt?

Understand it

What a step-up asks of the knee, and what no study has countedEmerging evidence

The kneecap, the tendons and the joint lineStrong evidence

Who gets it, and what is rareEmerging evidence

When a scan helpsStrong evidence

How it usually goesEmerging evidence

What helps, and how strong the evidence is

Box height and stepping down: lab studies in healthy peopleEmerging evidence

Forward or lateral, and the trunk leanEmerging evidence

The trailing leg and stepping down: thin evidenceEmerging evidence

The knee travelling in: a cue, not a diagnosisMixed evidence

Exercise helps kneecap pain, with hip and knee work togetherStrong evidence

The NHS leaflets, arthritis and the tendon trialEmerging evidence

How much pain is OK while you exercise?

0 to 2 is safe, up to 5 is acceptable, back to usual by the next morning, and 3 for a tendonEmerging evidence

The exercise plan: 3 stages

Keep stepping, lower the box

Raise the box, and let the sore leg lower you

Step-downs, then your usual box and load

What to change for now

Your step-up for now (written steps)

Back to stairs, hills and sport (written steps)

Arthritis, a meniscus and the tendons

Positions to swap, and why

Routines to follow

Step-up workout: from the bottom stair to a loaded box

Knee strengthening workout: from first steps to full range

Low-impact leg workout (no jumping)

Knee control warm-up

Dumbbell leg workout

More moves for this area

Questions people ask

Related exercise guides

Other pain guides

Sources