What could be causing my leg pain that worsens when walking uphill compared to downhill?

Leg Pain Worse Walking Uphill vs. Downhill: Diagnostic Approach

Your symptom pattern—leg pain that worsens walking uphill compared to downhill—is most consistent with lumbar spinal stenosis causing neurogenic claudication, which requires clinical confirmation through focused examination and ankle-brachial index testing to exclude vascular disease. 1

Key Distinguishing Features

The critical diagnostic clue is that uphill walking increases spinal extension and loading, worsening neurogenic claudication, while downhill walking allows more spinal flexion, providing relative relief. 2 This contrasts sharply with vascular claudication from peripheral artery disease (PAD), where uphill walking would worsen symptoms but downhill walking would also cause pain due to continued muscle oxygen demand. 2

Neurogenic Claudication (Spinal Stenosis) Pattern:

• Bilateral buttock and posterior leg pain that worsens with standing or spinal extension (uphill walking) and improves with sitting or spinal flexion (downhill walking allows forward lean). 1
• Pain relief requires postural change—specifically sitting or forward bending—not just stopping movement. 3
• Difficulty rising from sitting or lying down strongly suggests mechanical spinal pathology. 1
• Symptoms may include leg numbness, heaviness, or weakness that develops with walking. 3

Vascular Claudication (PAD) Pattern:

• Pain occurs predictably after walking a certain distance and resolves within 10 minutes of rest in any position—no postural change needed. 4, 3
• Uphill walking worsens symptoms more than level walking, but downhill walking also causes pain (though potentially less severe). 2
• Symptoms are typically unilateral or asymmetric initially. 2

Immediate Diagnostic Steps

1. Obtain Resting Ankle-Brachial Index (ABI) Bilaterally

This is mandatory to exclude PAD, as bilateral leg symptoms can mimic spinal stenosis. 4, 3 An ABI ≤0.90 confirms PAD and fundamentally changes management. 4

2. Focused Neurological Examination

Perform straight-leg-raise testing and assess:

• Knee strength and reflexes (L4 nerve root)
• Great toe and foot dorsiflexion strength (L5 nerve root)
• Foot plantarflexion and ankle reflexes (S1 nerve root)
• Sensory distribution in lower extremities 2, 1

Note: Normal neurological examination does not exclude spinal stenosis, as deficits may be absent or intermittent. 1

3. Assess Weight Distribution and Posture

Observe for even weight distribution in sitting, standing, and walking—asymmetry suggests spinal stenosis. 1

Critical Differential Diagnoses to Exclude

Venous Claudication (Post-Thrombotic Syndrome):

• Tight, bursting leg pain in entire leg during exercise that subsides slowly with leg elevation
• History of deep vein thrombosis
• Pain pattern differs from your uphill-specific worsening 2, 3

Hip Arthritis:

• Lateral hip/thigh aching that varies with activity but not quickly relieved by position change
• Worsens with weight-bearing regardless of incline 1

Peripheral Neuropathy:

• Numbness and loss of protective sensation that does not worsen specifically with standing or walking
• Common in diabetic patients 3

Management Algorithm

If ABI is Normal (>0.90) and Clinical Features Suggest Spinal Stenosis:

1. Conservative Management (First-Line):

• Maintain physical activity—avoid bed rest 1
• Postural modifications: encourage optimal spinal alignment with even weight distribution, avoid prolonged end-range positioning, use pillows/furniture to support limbs 1
• Simple analgesics and NSAIDs for pain reduction 1
• Avoid splinting or prolonged immobilization, which leads to muscle deconditioning and increased pain 1

2. Imaging Considerations:

• Do not routinely obtain imaging initially for nonspecific symptoms 1
• Obtain MRI if symptoms persist beyond 1 month of conservative management, or if severe pain or progressive neurological deficits develop 1

3. Specialist Referral Indications:

• Immediate referral for bilateral motor weakness, saddle anesthesia, urinary retention, or new bowel/bladder dysfunction (cauda equina syndrome—surgical emergency) 1, 3
• Multidisciplinary rehabilitation if symptoms persist despite conservative measures 1

If ABI is Abnormal (≤0.90):

• Diagnosis is PAD requiring vascular specialist evaluation 4
• Comprehensive cardiovascular risk factor modification 2
• Consider supervised exercise therapy and pharmacotherapy 2

Common Pitfalls to Avoid

Do not assume vascular disease without ABI testing—bilateral leg symptoms can mimic PAD, but spinal stenosis is relieved by lumbar flexion rather than simple rest. 1

Do not overlook psychosocial factors (depression, passive coping strategies, job dissatisfaction) which predict poorer outcomes and should be addressed. 2, 1

Do not ignore the biomechanical evidence: Research confirms uphill walking at 10-15% inclines results in greater tibial stress than level or downhill running 2, and uphill walking has higher impact on gait kinematics than downhill walking 5. However, downhill walking can impair joint position sense and proprioception 6, which may explain why some patients experience different symptom patterns.