Quadriceps-strengthening exercise and quadriceps and knee biomechanics during walking in knee osteoarthritis: A two-centre randomized controlled trial


      • Quadriceps strength training or no training were given to groups of knee osteoarthritis patients.
      • Training increased strength and reduced pain but did not change quadriceps or knee forces in walking
      • Biomechanical mechanism of improved health with strengthening in knee OA patients remains unknown.



      To assess the effect of quadriceps strengthening on quadriceps muscle force, power, and work and tibio-femoral compressive loads during walking in adults with knee osteoarthritis.


      Study design: Two-center, randomized, controlled trial. Intervention: Patients with knee osteoarthritis were randomly allocated to quadriceps strengthening program (3 times weekly) or no attention control group. Main outcome measures: Primary outcome was change from baseline in peak quadriceps force during walking at 12 weeks. Secondary outcomes included quadriceps power and work, knee compression forces during walking estimated with musculoskeletal modeling, muscle strength and pain and function. Outcomes were measured at baseline and 12 weeks.


      30 patients were randomized to receive either training (n = 15) or no attention (n = 15). At follow-up, there were no statistical differences between groups for maximum quadriceps force, quadriceps positive power, negative work, and positive work, and knee compressive force. Maximum negative quadriceps power in early stance was statistically significantly increased 36% in the training group compared to the control group which was most likely partially a response to faster walking velocity at follow-up. Muscle strength and patient reported pain and function were improved in the training group compared to the control group.


      Quadriceps strength training leads to increased muscle strength and improved symptomatic and functional outcomes but does not change quadriceps or knee joint biomechanics during walking. The biomechanical mechanism of improved health with strength training in knee osteoarthritis patients remains unknown. Identifier: NCT01538407.


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        • Aaboe J.
        • Bliddal H.
        • Messier S.P.
        • Alkjaer T.
        • Henriksen M.
        Effects of an intensive weight loss program on knee joint loading in obese adults with knee osteoarthritis.
        Osteoarthr. Cartil. 2011; 19: 822-828
        • Altman R.
        • Asch E.
        • Bloch D.
        • Bole G.
        • Borenstein D.
        • Brandt K.
        • Christy W.
        • Cooke T.D.
        • Greenwald R.
        • Hochberg M.
        • et al.
        Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association.
        Arthritis Rheum. 1986; 29: 1039-1049
        • Andriacchi T.P.
        • Koo S.
        • Scanlan S.F.
        Gait mechanics influence healthy cartilage morphology and osteoarthritis of the knee.
        J. Bone Joint Surg. Am. 2009; 91: 95-101
        • Anwer S.
        • Alghadir A.
        Effect of isometric quadriceps exercise on muscle strength, pain, and function in patients with knee osteoarthritis: a randomized controlled study.
        J. Phys. Ther. Sci. 2014; 26: 745-748
        • Baker K.R.
        • Nelson M.E.
        • Felson D.T.
        • Layne J.E.
        • Sarno R.
        • Roubenoff R.
        The efficacy of home based progressive strength training in older adults with knee osteoarthritis: a randomized controlled trial.
        J. Rheumatol. 2001; 28: 1655-1665
        • Baliunas A.J.
        • Hurwitz D.E.
        • Ryals A.B.
        • Karrar A.
        • Case J.P.
        • Block J.A.
        • Andriacchi T.P.
        Increased knee joint loads during walking are present in subjects with knee osteoarthritis.
        Osteoarthr. Cartil. 2002; 10: 573-579
        • Beijersbergen C.M.
        • Granacher U.
        • Vandervoort A.A.
        • DeVita P.
        • Hortobagyi T.
        The biomechanical mechanism of how strength and power training improves walking speed in old adults remains unknown.
        Ageing Res. Rev. 2013; 12: 618-627
        • Bennell K.
        • Hinman R.S.
        • Wrigley T.V.
        • Creaby M.W.
        • Hodges P.
        Exercise and osteoarthritis: cause and effects.
        Compr. Physiol. 2011; 1: 1943-2008
        • Brandt K.D.
        • Dieppe P.
        • Radin E.
        Etiopathogenesis of osteoarthritis.
        Med. Clin. N. Am. 2009; 93: xv
        • Chang A.H.
        • Moisio K.C.
        • Chmiel J.S.
        • Eckstein F.
        • Guermazi A.
        • Prasad P.V.
        • Zhang Y.
        • Almagor O.
        • Belisle L.
        • Hayes K.
        • Sharma L.
        External knee adduction and flexion moments during gait and medial tibiofemoral disease progression in knee osteoarthritis.
        Osteoarthr. Cartil. 2015; 23: 1099-1106
        • Chang S.Y.
        • Lin Y.J.
        • Hsu W.C.
        • Hsieh L.F.
        • Lin Y.H.
        • Chang C.C.
        • Chou Y.C.
        • Chen L.F.
        Exercise alters gait pattern but not knee load in patients with knee osteoarthritis.
        Biomed. Res. Int. 2016; 20167468937
        • Chehab E.F.
        • Favre J.
        • Erhart-Hledik J.C.
        • Andriacchi T.P.
        Baseline knee adduction and flexion moments during walking are both associated with 5 year cartilage changes in patients with medial knee osteoarthritis.
        Osteoarthr. Cartil. 2014; 22: 1833-1839
        • Chow J.W.
        • Darling W.G.
        • Ehrhardt J.C.
        Determining the force-length-velocity relations of the quadriceps muscles: I. anatomical and geometrical parameters.
        J. Appl. Biomech. 1999; 15: 182-190
        • DeVita P.
        • Hortobagyi T.
        Functional knee brace alters predicted knee muscle and joint forces in persons with ACL reconstruction during walking.
        J. Appl. Biomech. 2001; 17: 297-311
        • DeVita P.
        • Helseth J.
        • Hortobagyi T.
        Muscles do more positive than negative work in human locomotion.
        J. Exp. Biol. 2007; 210: 3361-3373
        • Foroughi N.
        • Smith R.M.
        • Lange A.K.
        • Baker M.K.
        • Fiatarone Singh M.A.
        • Vanwanseele B.
        Lower limb muscle strengthening does not change frontal plane moments in women with knee osteoarthritis: a randomized controlled trial.
        Clin. Biomech. (Bristol, Avon). 2011; 26: 167-174
        • Fransen M.
        • McConnell S.
        • Bell M.
        Exercise for osteoarthritis of the hip or knee.
        Cochrane Database Syst. Rev. 2003; : CD004286
        • Henriksen M.
        • Klokker L.
        • Graven-Nielsen T.
        • Bartholdy C.
        • Schjodt Jorgensen T.
        • Bandak E.
        • Danneskiold-Samsoe B.
        • Christensen R.
        • Bliddal H.
        Association of exercise therapy and reduction of pain sensitivity in patients with knee osteoarthritis: a randomized controlled trial.
        Arthritis Care Res. 2014; 66: 1836-1843
        • Hunt M.A.
        • Pollock C.L.
        • Kraus V.B.
        • Saxne T.
        • Peters S.
        • Huebner J.L.
        • Sayre E.C.
        • Cibere J.
        Relationships amongst osteoarthritis biomarkers, dynamic knee joint load, and exercise: results from a randomized controlled pilot study.
        BMC Musculoskelet. Disord. 2013; 14: 115
        • Hurley M.V.
        The role of muscle weakness in the pathogenesis of osteoarthritis.
        Rheum. Dis. Clin. N. Am. 1999; 25: 283-298
        • Hurley M.V.
        • Newham D.J.
        The influence of arthrogenous muscle inhibition on quadriceps rehabilitation of patients with early, unilateral osteoarthritic knees.
        Br. J. Rheumatol. 1993; 32: 127-131
        • Hurley M.V.
        • Scott D.L.
        Improvements in quadriceps sensorimotor function and disability of patients with knee osteoarthritis following a clinically practicable exercise regime.
        Br. J. Rheumatol. 1998; 37: 1181-1187
        • Igawa T.
        • Katsuhira J.
        Biomechanical analysis of stair descent in patients with knee osteoarthritis.
        J. Phys. Ther. Sci. 2014; 26: 629-631
        • Juhl C.
        • Christensen R.
        • Roos E.M.
        • Zhang W.
        • Lund H.
        Impact of exercise type and dose on pain and disability in knee osteoarthritis: a systematic review and meta-regression analysis of randomized controlled trials.
        Arthritis Rheumatol. 2014; 66: 622-636
        • Karamanidis K.
        • Oberlander K.D.
        • Niehoff A.
        • Epro G.
        • Bruggemann G.P.
        Effect of exercise-induced enhancement of the leg-extensor muscle-tendon unit capacities on ambulatory mechanics and knee osteoarthritis markers in the elderly.
        PLoS One. 2014; 9e99330
        • Kellgren J.
        • Lawrence J.
        Radiological assessment of osteo-arthrosis.
        Ann. Rheum. Dis. 1957; 16: 494-501
        • Kim H.J.
        • Fernandez J.W.
        • Akbarshahi M.
        • Walter J.P.
        • Fregly B.J.
        • Pandy M.G.
        Evaluation of predicted knee-joint muscle forces during gait using an instrumented knee implant.
        J. Orthop. Res. 2009; 27: 1326-1331
        • Knoop J.
        • Steultjens M.P.
        • Roorda L.D.
        • Lems W.F.
        • van der Esch M.
        • Thorstensson C.A.
        • Twisk J.W.
        • Bierma-Zeinstra S.M.
        • van der Leeden M.
        • Dekker J.
        Improvement in upper leg muscle strength underlies beneficial effects of exercise therapy in knee osteoarthritis: secondary analysis from a randomised controlled trial.
        Physiotherapy. 2015; 101: 171-177
        • Lim B.W.
        • Hinman R.S.
        • Wrigley T.V.
        • Sharma L.
        • Bennell K.L.
        Does knee malalignment mediate the effects of quadriceps strengthening on knee adduction moment, pain, and function in medial knee osteoarthritis? A randomized controlled trial.
        Arthritis Rheum. 2008; 59: 943-951
        • Lim B.W.
        • Kemp G.
        • Metcalf B.
        • Wrigley T.V.
        • Bennell K.L.
        • Crossley K.M.
        • Hinman R.S.
        The association of quadriceps strength with the knee adduction moment in medial knee osteoarthritis.
        Arthritis Rheum. 2009; 61: 451-458
        • Markolf K.L.
        • Graff-Radford A.
        • Amstutz H.C.
        In vivo knee stability. A quantitative assessment using an instrumented clinical testing apparatus.
        J. Bone Joint Surg. Am. 1978; 60: 664-674
        • McAlindon T.E.
        • Bannuru R.R.
        • Sullivan M.C.
        • Arden N.K.
        • Berenbaum F.
        • Bierma-Zeinstra S.M.
        • Hawker G.A.
        • Henrotin Y.
        • Hunter D.J.
        • Kawaguchi H.
        • Kwoh K.
        • Lohmander S.
        • Rannou F.
        • Roos E.M.
        • Underwood M.
        OARSI guidelines for the non-surgical management of knee osteoarthritis.
        Osteoarthr. Cartil. 2014; 22: 363-388
        • McQuade K.J.
        • de Oliveira A.S.
        Effects of progressive resistance strength training on knee biomechanics during single leg step-up in persons with mild knee osteoarthritis.
        Clin. Biomech. (Bristol, Avon). 2011; 26: 741-748
        • Messier S.P.
        • Loeser R.F.
        • Miller G.D.
        • Morgan T.M.
        • Rejeski W.J.
        • Sevick M.A.
        • Ettinger Jr., W.H.
        • Pahor M.
        • Williamson J.D.
        Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the arthritis, diet, and activity promotion trial.
        Arthritis Rheum. 2004; 50: 1501-1510
        • Messier S.P.
        • Gutekunst D.J.
        • Davis C.
        • DeVita P.
        Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis.
        Arthritis Rheum. 2005; 52: 2026-2032
        • Messier S.P.
        • Legault C.
        • Loeser R.F.
        • Van Arsdale S.J.
        • Davis C.
        • Ettinger W.H.
        • DeVita P.
        Does high weight loss in older adults with knee osteoarthritis affect bone-on-bone joint loads and muscle forces during walking?.
        Osteoarthr. Cartil. 2011; 19: 272-280
        • Messier S.P.
        • Mihalko S.L.
        • Beavers D.P.
        • Nicklas B.J.
        • DeVita P.
        • Carr J.J.
        • Hunter D.J.
        • Williamson J.D.
        • Bennell K.L.
        • Guermazi A.
        • Lyles M.
        • Loeser R.F.
        Strength training for arthritis trial (START): design and rationale.
        BMC Musculoskelet. Disord. 2013; 14: 208
        • Messier S.P.
        • Mihalko S.L.
        • Legault C.
        • Miller G.D.
        • Nicklas B.J.
        • DeVita P.
        • Beavers D.P.
        • Hunter D.J.
        • Lyles M.F.
        • Eckstein F.
        • Williamson J.D.
        • Carr J.J.
        • Guermazi A.
        • Loeser R.F.
        Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial.
        J. Am. Med. Assoc. 2013; 310: 1263-1273
        • Mikesky A.E.
        • Meyer A.
        • Thompson K.L.
        Relationship between quadriceps strength and rate of loading during gait in women.
        J. Orthop. Res. 2000; 18: 171-175
        • Oiestad B.E.
        • Juhl C.B.
        • Eitzen I.
        • Thorlund J.B.
        Knee extensor muscle weakness is a risk factor for development of knee osteoarthritis. A systematic review and meta-analysis.
        Osteoarthr. Cartil. 2015; 23: 171-177
        • Penninx B.W.
        • Abbas H.
        • Ambrosius W.
        • Nicklas B.J.
        • Davis C.
        • Messier S.P.
        • Pahor M.
        Inflammatory markers and physical function among older adults with knee osteoarthritis.
        J. Rheumatol. 2004; 31: 2027-2031
        • Sasaki K.
        • Neptune R.R.
        • Burnfield J.M.
        • Mulroy S.J.
        Muscle compensatory mechanisms during able-bodied toe walking.
        Gait Posture. 2008; 27: 440-446
        • Schipplein O.D.
        • Andriacchi T.P.
        Interaction between active and passive knee stabilizers during level walking.
        J. Orthop. Res. 1991; 9: 113-119
        • Segal N.A.
        • Glass N.A.
        • Felson D.T.
        • Hurley M.
        • Yang M.
        • Nevitt M.
        • Lewis C.E.
        • Torner J.C.
        Effect of quadriceps strength and proprioception on risk for knee osteoarthritis.
        Med. Sci. Sports Exerc. 2010; 42: 2081-2088
        • Serrao P.R.
        • Vasilceac F.A.
        • Gramani-Say K.
        • Lessi G.C.
        • Oliveira A.B.
        • Reiff R.B.
        • Mattiello-Sverzut A.C.
        • Mattiello S.M.
        Men with early degrees of knee osteoarthritis present functional and morphological impairments of the quadriceps femoris muscle.
        Am. J. Phys. Med. Rehab. 2015; 94: 70-81
        • Sharma L.
        • Cahue S.
        • Song J.
        • Hayes K.
        • Pai Y.C.
        • Dunlop D.
        Physical functioning over three years in knee osteoarthritis: role of psychosocial, local mechanical, and neuromuscular factors.
        Arthritis Rheum. 2003; 48: 3359-3370
        • Shelburne K.B.
        • Torry M.R.
        • Pandy M.G.
        Contributions of muscles, ligaments, and the ground-reaction force to tibiofemoral joint loading during normal gait.
        J. Orthop. Res. 2006; 24: 1983-1990
        • Sled E.A.
        • Khoja L.
        • Deluzio K.J.
        • Olney S.J.
        • Culham E.G.
        Effect of a home program of hip abductor exercises on knee joint loading, strength, function, and pain in people with knee osteoarthritis: a clinical trial.
        Phys. Ther. 2010; 90: 895-904
        • Slemenda C.
        • Brandt K.D.
        • Heilman D.K.
        • Mazzuca S.
        • Braunstein E.M.
        • Katz B.P.
        • Wolinsky F.D.
        Quadriceps weakness and osteoarthritis of the knee.
        Ann. Intern. Med. 1997; 127: 97-104
        • Slemenda C.
        • Heilman D.K.
        • Brandt K.D.
        • Katz B.P.
        • Mazzuca S.A.
        • Braunstein E.M.
        • Byrd D.
        Reduced quadriceps strength relative to body weight: a risk factor for knee osteoarthritis in women?.
        Arthritis Rheum. 1998; 41: 1951-1959
        • Thorp L.E.
        • Wimmer M.A.
        • Foucher K.C.
        • Sumner D.R.
        • Shakoor N.
        • Block J.A.
        The biomechanical effects of focused muscle training on medial knee loads in OA of the knee: a pilot, proof of concept study.
        J. Musculoskelet. Neuronal Interact. 2010; 10: 166-173
        • Topp R.
        • Woolley S.
        • Hornyak 3rd, J.
        • Khuder S.
        • Kahaleh B.
        The effect of dynamic versus isometric resistance training on pain and functioning among adults with osteoarthritis of the knee.
        Arch. Phys. Med. Rehabil. 2002; 83: 1187-1195
        • Vincent K.R.
        • Vincent H.K.
        Resistance exercise for knee osteoarthritis.
        PM & R: J. Injury Funct. Rehab. 2012; 4: S45-S52
        • Zhang W.
        • Moskowitz R.W.
        • Nuki G.
        • Abramson S.
        • Altman R.D.
        • Arden N.
        • Bierma-Zeinstra S.
        • Brandt K.D.
        • Croft P.
        • Doherty M.
        • Dougados M.
        • Hochberg M.
        • Hunter D.J.
        • Kwoh K.
        • Lohmander L.S.
        • Tugwell P.
        OARSI recommendations for the management of hip and knee osteoarthritis, part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence.
        Osteoarthr. Cartil. 2007; 15: 981-1000