Ask a trekking guide what actually slows groups down and the answer is rarely the dramatic stuff. It is a blister the size of a coin on day three. It is a knee that swells on the two-thousand-metre descent after the pass. Small mechanical problems, almost all of them preventable, cause more misery on Nepal's trails than altitude does.
Nepal's trails are harder on joints than most. They are steep, and a great deal of the lower walking is on stone staircases — thousands of irregular steps at a time. This guide covers the three things you can do about it: protect, treat, and medicate sensibly.
This article is general information for trip planning, not medical advice. Check with a doctor or pharmacist that any painkiller is suitable for you, particularly if you have stomach, kidney, heart or asthma problems or take other medication.
The Descent Problem
Going uphill is hard on the lungs. Going downhill is hard on the body. On a descent your thigh muscles work while lengthening, acting as brakes on every step, and the force through each knee is several times your body weight. That is why your legs ache more the day after a long descent than after a long climb, and why knees so often give trouble in the second half of a trek.
| Descent | Trek | Approximate drop |
|---|---|---|
| Thorong La to Muktinath | Annapurna Circuit | About 1,600 m in one day |
| Larke La to Bimthang | Manaslu Circuit | About 1,400 m in one day |
| Ghorepani to the valley by the Ulleri staircase | Poon Hill | More than 3,000 stone steps |
| High Camp to Siding | Mardi Himal | About 1,800 m, steep, in forest |
| Annapurna Base Camp to Bamboo | Annapurna Base Camp | About 1,800 m in one day |
| Namche Bazaar to Lukla | Everest Base Camp | A long final day with tired legs |
These days come late in the trek, when you are tired and inclined to rush for the hot shower. That combination is when knees are injured.
Protecting Your Knees
Before the trek
- Strengthen the thighs and hips. Squats, lunges and step-downs — lowering yourself slowly off a step — build exactly the braking strength descents demand. See how to train for a Nepal trek.
- Train on real downhills, with a pack. Stair machines do not prepare you for going down.
- Lose the spare kilos from your pack rather than your body: every kilogram on your back is multiplied at the knee.
- Sort out existing knee problems with a physiotherapist months ahead, not weeks.
On the trail
- Use two trekking poles. Lengthen them for descents and plant them ahead of you. They take a meaningful share of the load off your knees and save falls.
- Short steps, soft knees. Never lock the knee straight on landing. Small, quick steps are kinder than long lunging ones.
- Zigzag down steep slopes and wide staircases instead of stepping straight down.
- Carry a light day pack — 5 to 7 kg — and let a porter carry the rest.
- Go slowly downhill. This is where to lose time, not make it up.
- Take breaks every 45 minutes on a long descent.
- A knee support or tape helps some people with a known weakness. Try it at home first.
- Stretch each evening — quads, calves, hips. A routine is in yoga for trekkers.
Painkillers: What to Use and When
| Medicine | Good for | Cautions |
|---|---|---|
| Paracetamol (acetaminophen) | Headache, fever, general aches. The first choice at altitude | Stay within the daily maximum on the packet. Check combination cold remedies, which often contain it too |
| Ibuprofen | Sore joints and muscles, swelling, altitude headache | Take with food and plenty of fluid. Hard on the stomach and on dehydrated kidneys. Not for people with stomach ulcers or kidney disease; caution with asthma, heart disease and blood thinners |
| Anti-inflammatory gel | A sore knee, ankle or tendon | Works locally with far less reaching the stomach and kidneys. A good first step |
| Codeine, tramadol and other opioids | — | Avoid at altitude. They suppress breathing, especially in sleep, and cause constipation and nausea |
| Aspirin | — | Not recommended as a general trek painkiller; it increases bleeding and irritates the stomach |
- Do not take anti-inflammatories as a daily preventive. Masking pain so you can pound down a descent turns a sore knee into an injured one, and days of ibuprofen on a dehydrated body is a recognised cause of kidney trouble in endurance events.
- Drink. If your urine is dark, sort that out before you reach for ibuprofen.
- A headache at altitude can be treated with paracetamol or ibuprofen — and must also be reported. If it does not clear, it is altitude sickness until proved otherwise. See our altitude guide.
- Pain that needs tablets for more than three or four days needs a diagnosis, not more tablets.
The rest of what to carry is in the trekking first aid kit.
Blisters: Prevention
A blister is a friction burn. It needs three things: rubbing, moisture and heat. Remove any one and it does not form.
- Boots that fit and are worn in. At least 50 km of walking, including hills, in the socks you will wear. New boots on a trek are the commonest cause of ruined feet.
- Room for your toes. Feet swell over a long day and at altitude. You should be able to wiggle your toes, and they should not touch the front on a descent.
- Good socks. Wool or synthetic, never cotton. Many trekkers wear a thin liner sock under a thicker one so the layers rub against each other rather than against skin.
- Dry feet. Air them at lunch. Change into dry socks if they are soaked.
- Tape known trouble spots before you start each morning — heels, little toes, the ball of the foot.
- Stop at the first hot spot. The moment you feel rubbing, stop and tape it. Not at the next rest. Now. This one habit prevents most blisters.
- Lace properly. Snug over the instep to stop your foot sliding forward on descents; re-tie before every long downhill.
- Trim your toenails short and straight a few days before the trek.
- Shake out grit. A single grain of sand does the damage.
Blisters: Treatment
- Small and intact: leave the skin on. Cover with a hydrocolloid blister plaster and leave it in place until it comes off by itself, which may be several days.
- Large, tense and painful: drain it. Clean the skin and a needle with an antiseptic wipe, pierce the edge at two points near the base, and press the fluid out gently. Leave the roof of skin on as a natural dressing.
- Dress it: antiseptic, then a blister plaster or a non-stick dressing held with tape. Cut a ring of padding to take pressure off if it is on a weight-bearing spot.
- Burst or torn: clean with treated water and antiseptic, smooth the skin flap back down if it is clean, and dress it.
- Check it every evening. Let it air overnight where possible and re-dress before walking.
- Watch for infection: spreading redness, increasing pain, warmth, pus, red streaks up the leg or fever. That needs antibiotics and a doctor.
People with diabetes or poor circulation should treat any foot wound seriously and seek advice early — see trekking with a medical condition.
Other Common Niggles
| Problem | Cause | Fix |
|---|---|---|
| Black or bruised toenails | Toes hitting the front of the boot on descents | Trim nails; lace tightly over the instep; boots half a size up |
| Sprained ankle | A misstep on loose rock, usually when tired | Rest, compression bandage, raise it, cold water. Tape and poles to walk out. Cannot bear weight: evacuate |
| Sore shins | Long descents; overstriding | Shorter steps; rest; anti-inflammatory gel |
| Lower back ache | Badly adjusted or heavy pack | Load on the hip belt, not the shoulders; lighten it; stretch |
| Muscle cramp | Fatigue, fluid and salt loss | Stretch, drink, add rehydration salts |
| Chafing | Sweat and friction in skin folds | Petroleum jelly or anti-chafe balm; synthetic underwear |
| Split fingertips and heels | Cold, dry air | Thick moisturiser at night; tape over deep cracks |
| Sunburn and cracked lips | Strong ultraviolet light at altitude and off snow | SPF 50 and SPF lip balm, reapplied every two hours |
| Swollen hands and feet | Altitude and long days on your feet | Usually harmless; raise your legs in the evening. Report swelling of the face |
When Pain Means Stop
- A joint that locks, gives way or cannot take your weight.
- Rapid swelling of a knee or ankle after a twist or fall.
- A swollen, tender, warm calf, particularly in one leg — possibly a blood clot. This is urgent.
- An infected blister or wound with spreading redness, red streaks or fever.
- Numb, white or waxy toes or fingers in the cold — warm them at once; this is early cold injury.
- Pain that wakes you at night or gets worse each day despite rest.
- Any injury after a fall involving the head, neck or back.
On many routes a pony or mule can be hired to carry an injured walker down to a road. Where that is not possible or the injury is serious, evacuation is by helicopter, which is why your policy must cover it — see travel insurance for trekking in Nepal.
We Provide This Service: Pre- and Post-Trek Health Support
Green Compass Treks provides health support before, during and after every trek. Feet and knees are where it makes the most everyday difference.
- Before the trek: a training plan and kit list when you book, and a boot and kit check at the pre-trek briefing — including help hiring or buying trekking poles in Kathmandu or Pokhara.
- Porters, so you carry only a light day pack.
- Sensible stages. We split the big descents where the lodges allow it, and can add a day if your knees need one.
- On the trek: guides who carry a first aid kit, tape hot spots before they blister, strap ankles, and set a downhill pace that protects joints.
- If you cannot walk: a horse or helicopter arranged, with your insurer.
- After the trek: recovery days in Pokhara or Kathmandu with massage, restorative yoga and a clinic or physiotherapy appointment if something has not settled.
If you have a history of knee or ankle trouble, tell us when you enquire. We will suggest routes with gentler descents and build in the time to walk them slowly.
