Comparison of Maximum Isometric Strength of the Hip Joint Abductor and Knee Joint Extensor Muscles between Knee Osteoarthritis Patients with and without Self-reported Instability

Abstract

Background

Patients with knee osteoarthritis (KOA) often have impaired muscle function of the weight-bearing muscles, particularly in the knee and hip joints. This can lead to a significant loss of strength and power and may play a role in the perceived instability of the knee joint. The purpose of this study was to compare the maximum isometric strength of the hip abductor and knee extensor muscles between patients with KOA with and without perceived instability.

Methods

Nineteen patients with KOA participated in this cross-sectional study and were divided into two groups. The first group (n = 10; women = 4, men = 6, mean age = 67.4 ± standard deviation [SD] 6.4 years) consisted of patients with self-reported instability in the knee joint, and the second group (n = 9; women = 5, men = 4, mean age = 69.6 ± SD 6.7 years) consisted of patients without self-reported instability. Functional and activity limitations were quantified using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Maximum isometric strength of the hip abductors and knee extensors was measured using a belt-mounted handheld dynamometer and expressed as torque (Newton meters [Nm]) by multiplication with the determined lever arm. Torque was normalized to body weight and height.

Results

Patients with instability (median WOMAC score = 68) achieved a significantly lower mean torque in hip abduction than the patients without instability (median WOMAC score = 39) (p = 0.01; Cohen’s d = 1.31). There was no significant difference in knee extension torque between the groups (p = 0.202; Cohen’s d = 0.58).

Conclusion

KOA patients with instability were able to develop significantly lower hip abductor strength than those without instability, suggesting that targeted strength training of this muscle group may be important for this group of patients.

Zusammenfassung

Hintergrund

Patienten mit Kniearthrose (KOA) haben häufig eine eingeschränkte Muskelfunktion der gewichtstragenden Muskeln, insbesondere in den Knie- und Hüftgelenken. Dies kann zu einem erheblichen Verlust an Kraft und Leistungsfähigkeit führen und eine Rolle bei der wahrgenommenen Instabilität des Kniegelenks spielen. Ziel dieser Studie war es, die maximale isometrische Kraft der Hüftabduktoren und Knieextensoren bei Patienten mit KOA mit und ohne wahrgenommene Instabilität zu vergleichen.

Methoden

19 Patienten mit KOA nahmen an dieser Querschnittsstudie teil und wurden in 2 Gruppen eingeteilt. Die 1. Gruppe (n = 10; Frauen = 4, Männer = 6, mittleres Alter = 67,4 ± Standardabweichung [SD] 6,4 Jahre) bestand aus Patienten mit selbst berichteter Kniegelenkinstabilität, die 2. Gruppe (n = 9; Frauen = 5, Männer = 4, mittleres Alter = 69,6 ± SD 6,7 Jahre) bestand aus Patienten ohne selbst berichtete Instabilität. Die Funktions- und Aktivitätseinschränkungen wurden mit dem Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) quantifiziert. Die maximale isometrische Kraft der Hüftabduktoren und Knieextensoren wurde mit einem Handdynamometer, das mit einem Gurt fixiert wurde, gemessen und durch Multiplikation mit dem ermittelten Hebelarm als Drehmoment (Newtonmeter [Nm]) ausgedrückt. Das Drehmoment wurde auf das Körpergewicht und die Körpergröße normiert.

Ergebnisse

Patienten mit Instabilität (Median WOMAC-Score = 68) erreichten ein signifikant geringeres mittleres Drehmoment in Hüftabduktion als Patienten ohne Instabilität (Median WOMAC-Score = 39; p = 0,01; Cohens d = 1,31). Beim Drehmoment in Knieextension gab es keinen signifikanten Unterschied zwischen den Gruppen (p = 0,202; Cohens d = 0,58).

Schlussfolgerung

KOA-Patienten mit Instabilität konnten eine signifikant geringere Hüftabduktionskraft entwickeln als Patienten ohne Instabilität, was darauf hindeutet, dass ein gezieltes Krafttraining dieser Muskelgruppe für diese Patientengruppe wichtig sein könnte.

Keywords

osteoarthritis - instable knee joint - lower extremity muscle strength - patient reported outcome - assessment

Schlüsselwörter

Arthrose - instabiles Kniegelenk - Muskelkraft der unteren Extremitäten - patientenberichtetes Therapieergebnis - Bewertung

Publication History

Received: 18 March 2024

Accepted after revision: 02 December 2024

Article published online:
09 January 2025

• References

• 1 Vos T, Flaxman AD, Naghavi M. et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2163-2196
• 2 Liao CD, Chen HC, Kuo YC. et al. Effects of Muscle Strength Training on Muscle Mass Gain and Hypertrophy in Older Adults With Osteoarthritis: A Systematic Review and Meta-Analysis. Arthritis Care Res (Hoboken) 2020; 72: 1703-1718
• 3 Tevald MA, Murray A, Luc BA. et al. Hip abductor strength in people with knee osteoarthritis: A cross-sectional study of reliability and association with function. Knee 2016; 23: 57-62
• 4 Alnahdi AH, Zeni JA, Snyder-Mackler L. Muscle impairments in patients with knee osteoarthritis. Sports Health 2012; 4: 284-292
• 5 Liikavainio T, Lyytinen T, Tyrvainen E. et al. Physical function and properties of quadriceps femoris muscle in men with knee osteoarthritis. Arch Phys Med Rehabil 2008; 89: 2185-2194
• 6 Sebesi B, Fésüs Á, Varga M. et al. The indirect role of gluteus medius muscle in knee joint stability during unilateral vertical jump and landing on unstable surface in young trained males. Appl Sci 2021; 11: 7421
• 7 Hurley MV. The role of muscle weakness in the pathogenesis of osteoarthritis. Rheum Dis Clin North Am 1999; 25: 283-298
• 8 van der Esch M, Steultjens M, Harlaar J. et al. Joint proprioception, muscle strength, and functional ability in patients with osteoarthritis of the knee. Arthritis Rheum 2007; 57: 787-793
• 9 Knoop J, van der Leeden M, van der Esch M. et al. Association of lower muscle strength with self-reported knee instability in osteoarthritis of the knee: results from the Amsterdam Osteoarthritis cohort. Arthritis Care Res (Hoboken) 2012; 64: 38-45
• 10 Ramsey DK, Briem K, Axe MJ. et al. A mechanical theory for the effectiveness of bracing for medial compartment osteoarthritis of the knee. J Bone Joint Surg Am 2007; 89: 2398-2407
• 11 Skou ST, Wrigley TV, Metcalf BR. et al. Association of knee confidence with pain, knee instability, muscle strength, and dynamic varus-valgus joint motion in knee osteoarthritis. Arthritis Care Res (Hoboken) 2014; 66: 695-701
• 12 Felson DT, Niu J, McClennan C. et al. Knee buckling: prevalence, risk factors, and associated limitations in function. Ann Intern Med 2007; 147: 534-540
• 13 Schmitt LC, Fitzgerald GK, Reisman AS. et al. Instability, laxity, and physical function in patients with medial knee osteoarthritis. Phys Ther 2008; 88: 1506-1516
• 14 Deasy M, Leahy E, Semciw AI. Hip Strength Deficits in People With Symptomatic Knee Osteoarthritis: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther 2016; 46: 629-639
• 15 Hewett TE, Myer GD. The mechanistic connection between the trunk, hip, knee, and anterior cruciate ligament injury. Exerc Sport Sci Rev 2011; 39: 161-166
• 16 Jacobs CA, Uhl TL, Mattacola CG. et al. Hip abductor function and lower extremity landing kinematics: sex differences. J Athl Train 2007; 42: 76-83
• 17 Chaudhari AMW, Schmitt LC, Freisinger GM. et al. Perceived Instability Is Associated With Strength and Pain, Not Frontal Knee Laxity, in Patients With Advanced Knee Osteoarthritis. J Orthop Sports Phys Ther 2019; 49: 513-517
• 18 Keenan OJF, Holland G, Maempel JF. et al. Correlations between radiological classification systems and confirmed cartilage loss in severe knee osteoarthritis. Bone Joint J 2020; 102-B: 301-309
• 19 Litwic A, Edwards MH, Dennison EM. et al. Epidemiology and burden of osteoarthritis. Br Med Bull 2013; 105: 185-199
• 20 Stucki G, Meier D, Stucki S. et al. [Evaluation of a German version of WOMAC (Western Ontario and McMaster Universities) Arthrosis Index]. Z Rheumatol 1996; 55: 40-49
• 21 Dolak KL, Silkman C, Medina McKeon J. et al. Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized clinical trial. J Orthop Sports Phys Ther 2011; 41: 560-570
• 22 Petterson SC, Barrance P, Buchanan T. et al. Mechanisms underlying quadriceps weakness in knee osteoarthritis. Med Sci Sports Exerc 2008; 40: 422-427
• 23 Bowen W, Frazer AK, Tallent J. et al. Unilateral Strength Training Imparts a Cross-Education Effect in Unilateral Knee Osteoarthritis Patients. J Funct Morphol Kinesiol 2022; 7: 77
• 24 Otten R, Tol JL, Holmich P. et al. Electromyography Activation Levels of the 3 Gluteus Medius Subdivisions During Manual Strength Testing. J Sport Rehabil 2015; 24: 244-251
• 25 Widler KS, Glatthorn JF, Bizzini M. et al. Assessment of hip abductor muscle strength. A validity and reliability study. J Bone Joint Surg Am 2009; 91: 2666-2672
• 26 Narici MV, Hoppeler H, Kayser B. et al. Human quadriceps cross-sectional area, torque and neural activation during 6 months strength training. Acta Physiol Scand 1996; 157: 175-186
• 27 Luc-Harkey BA, Safran-Norton CE, Mandl LA. et al. Associations among knee muscle strength, structural damage, and pain and mobility in individuals with osteoarthritis and symptomatic meniscal tear. BMC Musculoskelet Disord 2018; 19: 258
• 28 Pua YH, Liang Z, Ong PH. et al. Associations of knee extensor strength and standing balance with physical function in knee osteoarthritis. Arthritis Care Res (Hoboken) 2011; 63: 1706-1714
• 29 Koblbauer IF, Lambrecht Y, van der Hulst ML. et al. Reliability of maximal isometric knee strength testing with modified hand-held dynamometry in patients awaiting total knee arthroplasty: useful in research and individual patient settings? A reliability study. BMC Musculoskelet Disord 2011; 12: 249
• 30 Bohannon RW. The clinical measurement of strength. Clin Rehabil 1987; 1: 5-16
• 31 Burns SP, Spanier DE. Break-technique handheld dynamometry: relation between angular velocity and strength measurements. Arch Phys Med Rehabil 2005; 86: 1420-1426
• 32 von Elm E, Altman DG, Egger M. et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008; 61: 344-349
• 33 Cohen J. Statistical Power Analysis for the behavioral Sciences. 2. Hillsdale (New Jersey): L. Erlbaum Associates; 1988
• 34 Mundermann A, Dyrby CO, Andriacchi TP. Secondary gait changes in patients with medial compartment knee osteoarthritis: increased load at the ankle, knee, and hip during walking. Arthritis Rheum 2005; 52: 2835-2844
• 35 Farrokhi S, Voycheck CA, Klatt BA. et al. Altered tibiofemoral joint contact mechanics and kinematics in patients with knee osteoarthritis and episodic complaints of joint instability. Clin Biomech (Bristol) 2014; 29: 629-635
• 36 Katoh M, Yamasaki H. Test-retest reliability of isometric leg muscle strength measurements made using a hand-held dynamometer restrained by a belt: comparisons during and between sessions. J Phys Ther Sci 2009; 21: 239-243
• 37 Mentiplay BF, Perraton LG, Bower KJ. et al. Assessment of Lower Limb Muscle Strength and Power Using Hand-Held and Fixed Dynamometry: A Reliability and Validity Study. PLoS One 2015; 10: e0140822
• 38 Thomas DT, Shruthi R, Prabhakar AJ. et al. Hip abductor strengthening in patients diagnosed with knee osteoarthritis – a systematic review and meta-analysis. BMC Musculoskelet Disord 2022; 23: 622
• 39 Alammari A, Spence N, Narayan A. et al. Effect of hip abductors and lateral rotators’ muscle strengthening on pain and functional outcome in adult patients with patellofemoral pain: A systematic review and meta-analysis. J Back Musculoskelet Rehabil 2023; 36: 35-60
• 40 Du W, Cornett KMD, Donlevy GA. et al. Variability between Different Hand-Held Dynamometers for Measuring Muscle Strength. Sensors (Basel) 2024; 24: 1861
• 41 Hansen EM, McCartney CN, Sweeney RS. et al. Hand-held Dynamometer Positioning Impacts Discomfort During Quadriceps Strength Testing: A Validity and Reliability Study. Int J Sports Phys Ther 2015; 10: 62-68
• 42 Garcia MAC, Souza VH. The (un)standardized use of handheld dynamometers on the evaluation of muscle force output. Braz J Phys Ther 2020; 24: 88-89
• 43 Thorborg K, Bandholm T, Holmich P. Hip- and knee-strength assessments using a hand-held dynamometer with external belt-fixation are inter-tester reliable. Knee Surg Sports Traumatol Arthrosc 2013; 21: 550-555
• 44 Freisinger GM, Hutter EE, Lewis J. et al. Relationships between varus-valgus laxity of the severely osteoarthritic knee and gait, instability, clinical performance, and function. J Orthop Res 2017; 35: 1644-1652
• 45 Rice DA, McNair PJ. Quadriceps arthrogenic muscle inhibition: neural mechanisms and treatment perspectives. Semin Arthritis Rheum 2010; 40: 250-266
• 46 Ishii Y, Noguchi H, Sato J. et al. Association of knee osteoarthritis grade with one-leg standing balance and quadriceps strength in male independent ambulators aged ≥ 80 years. J Orthop 2020; 21: 79-83
• 47 Ishii Y, Noguchi H, Sato J. et al. Knee Osteoarthritis Grade does not Correlate with Quadriceps Muscle Strength or Bone Properties of the Calcaneus in Men Aged 80 Years or More who Can Walk independently. Int J Environ Res Public Health 2020; 17: 1709
• 48 Rasch A, Bystrom AH, Dalen N. et al. Reduced muscle radiological density, cross-sectional area, and strength of major hip and knee muscles in 22 patients with hip osteoarthritis. Acta Orthop 2007; 78: 505-510