Vastus medialis intramuscular fat is associated with reduced quadriceps strength, but not knee osteoarthritis severity


      • Vastus medialis intramuscular fat did not differ between knee osteoarthritis groups
      • Higher intramuscular fat was not associated with knee osteoarthritis severity
      • Higher intramuscular fat was associated with reduced quadriceps muscle torque
      • Vastus medialis intramuscular fat may impair quadriceps muscle strength



      Vastus medialis intramuscular fat has been proposed to be a modifiable determinant of knee cartilage loss in patients with knee osteoarthritis. The objective was to determine whether vastus medialis intramuscular fat relates to osteoarthritis severity and quadriceps muscle strength in patients with non-traumatic and post-traumatic knee osteoarthritis.


      For this cross-sectional study, participants with knee osteoarthritis were classified into two groups: non-traumatic (n = 22; mean age = 60 years) and post-traumatic (n = 19; mean age = 56 years). Healthy adults were included (n = 22; mean age = 59 years). A 3-Tesla magnetic resonance imaging was used to measure vastus medialis cross-sectional area and intramuscular fat. Isometric knee extensor muscle torque was assessed using an isokinetic dynamometer and normalized to body mass (Nm/kg). Knee osteoarthritis severity was assessed using standing antero-posterior radiographs (Kellgren-Lawrence scores). Regression analyses examined relationships between 1) vastus medialis intramuscular fat with knee osteoarthritis severity and osteoarthritis group, after accounting for sex and body mass index, and 2) knee extensor muscle torque with vastus medialis intramuscular fat, after accounting for sex and vastus medialis cross-sectional area.


      Vastus medialis intramuscular fat was positively associated with body mass index (B = 0.321, P < 0.001), but not with osteoarthritis severity or group (P > 0.05). Higher vastus medialis intramuscular fat was associated with reduced knee extensor muscle torque (B = -0.040, P = 0.018).


      Greater vastus medialis intramuscular fat was associated with lower quadriceps muscle strength in patients with knee OA. It is unclear whether this is due to the accumulation of vastus medialis intramuscular fat or other potential factors, such as diet and physical inactivity.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Biomechanics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Altman R.
        • Asch E.
        • Bloch D.
        • et al.
        Development of criteria for the classification and reporting of osteoarthritis: classification of osteoarthritis of the knee.
        Arthritis Rheum. 1986; 29: 1039-1049
        • Beattie K.A.
        • MacIntyre N.J.
        • Ramadan K.
        • et al.
        Longitudinal changes in intermuscular fat volume and quadriceps muscle volume in the thighs of women with knee osteoarthritis.
        Arthritis Care Res. 2012; 64: 22-29
        • Berenbaum F.
        • Wallace I.J.
        • Lieberman D.E.
        • Felson D.T.
        Modern-day environmental factors in the pathogenesis of osteoarthritis.
        Nat. Rev. Rheumatol. 2018; 14: 674-681
        • Chopp-Hurley J.N.
        • Wiebenga E.G.
        • Bulbrook B.D.
        • et al.
        Evaluating the relationship between quadriceps muscle quality captured using ultrasound with clinical severity in women with knee osteoarthritis.
        Clin. Biomech. 2020; 80105165
        • Conroy M.B.
        • Kwoh C.K.
        • Krishnan E.
        • et al.
        Muscle strength, mass, and quality in older men and women with knee osteoarthritis.
        Arthritis Care Res. 2012; : 15-21
        • Culvenor A.G.
        • Ruhdorfer A.
        • Juhl C.
        • Eckstein
        • et al.
        Knee extensor strength and risk of structural, symptomatic, and functional decline in knee osteoarthritis: a systematic review and meta-analysis.
        Arthritis Care Res. 2017; 69: 649-658
        • Dannhauer T.
        • Ruhdorfer A.
        • Wirth W.
        • Eckstein F.
        Quantitative relationship of thigh adipose tissue with pain, radiographic status, and progression of knee osteoarthritis: longitudinal findings from the osteoarthritis initiative.
        Investig. Radiol. 2015; 50: 268-274
        • Davison M.J.
        • Maly M.R.
        • Keir P.J.
        • et al.
        Lean muscle volume of the thigh has a stronger relationship with muscle power than muscle strength in women with knee osteoarthritis.
        Clin. Biomech. 2017; 41: 92-97
        • Deshpande B.R.
        • Katz J.N.
        • Solomon D.H.
        • et al.
        Number of persons with symptomatic knee osteoarthritis in the US: impact of race and ethnicity, age, sex, and obesity.
        Arthritis Care Res. 2016; 68: 1743-1750
        • Erik von Elm M.D.
        • Altman D.G.
        • Egger M.
        • et al.
        The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies.
        Ann. Intern. Med. 2007; 147: 573-577
        • Field A.
        Discovering statistics using IBM SPSS statistics (5th Edition)..
        Sage Publications Ltd, 2017: 2017
        • Frobell R.B.
        • Roos H.P.
        • Roos E.M.
        • et al.
        Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial.
        BMJ. 2013; 346f232
        • Gelber A.C.
        • Hochberg M.C.
        • Mead L.A.
        • et al.
        Body mass index in young men and the risk of subsequent knee and hip osteoarthritis.
        Am. J. Med. 1999; 107: 542-548
        • Goodpaster B.H.
        • Carlson C.L.
        • Visser M.
        • et al.
        Attenuation of skeletal muscle and strength in the elderly: the health ABC study.
        J. Appl. Physiol. 2001; 90: 2157-2165
        • Goutallier D.
        • Postel J.M.
        • Bernageau J.
        • et al.
        Fatty muscle degeneration in cuff ruptures. Pre-and postoperative evaluation by CT scan.
        Clin. Orthop. Relat. Res. 1994; 304: 78-83
        • Hawker G.A.
        • Davis A.M.
        • French M.R.
        • et al.
        Development and preliminary psychometric testing of a new OA pain measure–an OARSI/OMERACT initiative.
        Osteoarthr. Cartil. 2008; 16: 409-414
        • Hawker G.A.
        • Mian S.
        • Kendzerska T.
        • French M.
        Measures of adult pain: visual analog scale for pain (VAS pain), numeric rating scale for pain (NRS pain), mcgill pain questionnaire (MPQ), short-form mcgill pain questionnaire (SF-MPQ), chronic pain grade scale (CPGS), short form-36 bodily pain scale (SF-36 BPS), and measure of intermittent and constant osteoarthritis pain (ICOAP).
        Arthritis Care Res. 2011; 63: S240-S252
        • Heilbronn L.
        • Smith S.R.
        • Ravussin E.
        Failure of fat cell proliferation, mitochondrial function and fat oxidation results in ectopic fat storage, insulin resistance and type II diabetes mellitus.
        Int. J. Obes. 2004; 28: S12-S21
        • Hubley-Kozey C.L.
        • Robbins S.M.
        • Rutherford D.J.
        • Stanish W.D.
        Reliability of surface electromyographic recordings during walking in individuals with knee osteoarthritis.
        J. Electromyogr. Kinesiol. 2013; 23: 334-341
        • Ikemoto-Uezumi M.
        • Matsui Y.
        • Hasegawa M.
        • et al.
        Disuse atrophy accompanied by intramuscular ectopic adipogenesis in vastus medialis muscle of advanced osteoarthritis patients.
        Am. J. Pathol. 2017; 187: 2674-2685
        • Inhuber S.
        • Sollmann N.
        • Schlaeger S.
        • et al.
        Associations of thigh muscle fat infiltration with isometric strength measurements based on chemical shift encoding-based water-fat magnetic resonance imaging.
        Eur. Radiol. Exp. 2019; 3: 1-10
        • Jungmann P.M.
        • Baum T.
        • Nevitt M.C.
        • et al.
        Degeneration in ACL injured knees with and without reconstruction in relation to muscle size and fat content—data from the osteoarthritis initiative.
        PLoS One. 2016; 11e0166865
        • Kellgren J.H.
        • Lawrence J.S.
        Radiological assessment of osteo-arthrosis.
        Ann. Rheum. Dis. 1957; 16: 494-502
        • Kim H.J.
        • Lee J.H.
        • Ahn S.E.
        • et al.
        Influence of anterior cruciate ligament tear on thigh muscle strength and hamstring-to-quadriceps ratio: a meta-analysis.
        PLoS One. 2016; 11e0146234
        • Kohn M.D.
        • Sassoon A.A.
        • Fernando N.D.
        Classifications in brief: Kellgren-Lawrence classification of osteoarthritis.
        Clin. Orthop. Relat. Res. 2016; 474: 1886-1893
        • Kumar D.
        • Karampinos D.C.
        • MacLeod T.D.
        • et al.
        Quadriceps intramuscular fat fraction rather than muscle size is associated with knee osteoarthritis.
        Osteoarthr. Cartil. 2014; 22: 226-234
        • Kumar D.
        • Link T.M.
        • Jafarzadeh S.R.
        • et al.
        Quadriceps adiposity is associated with increase in lesions of the knee cartilage, meniscus, or bone marrow over 3-years.
        Arthritis Care Res. 2020; 2020: 1134-1139
        • Lisee C.
        • Lepley A.S.
        • Birchmeier T.
        • et al.
        Quadriceps strength and volitional activation after anterior cruciate ligament reconstruction: a systematic review and meta-analysis.
        Sports Health. 2019; 11: 163-179
        • Lohmander L.S.
        • De Verdier M.G.
        • Rollof J.
        • et al.
        Incidence of severe knee and hip osteoarthritis in relation to different measures of body mass: a population-based prospective cohort study.
        Ann. Rheum. Dis. 2009; 68: 490-496
        • Maly M.R.
        • Calder K.M.
        • MacIntyre N.J.
        • Beattie K.A.
        Relationship of intermuscular fat volume in the thigh with knee extensor strength and physical performance in women at risk of or with knee osteoarthritis.
        Arthritis Care Res. 2013; 65: 44-52
        • Meyer D.C.
        • Hoppeler H.
        • von Rechenberg B.
        • Gerber C.
        A pathomechanical concept explains muscle loss and fatty muscular changes following surgical tendon release.
        J. Orthop. Res. 2004; 22: 1004-1007
        • Øiestad B.E.
        • Engebretsen L.
        • Storheim K.
        • Risberg M.A.
        Winner of the 2008 systematic review competition: knee osteoarthritis after anterior cruciate ligament injury.
        Am. J. Sports Med. 2009; 37: 1434-1443
        • Øiestad 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
        • Panagiotopoulos E.
        • Strzelczyk P.
        • Herrmann M.
        • Scuderi G.
        Cadaveric study on static medial patellar stabilizers: the dynamizing role of the vastus medialis obliquus on medial patellofemoral ligament.
        Knee Surg. Sports Traumatol. Arthrosc. 2006; 14: 7-12
        • Papalia R.
        • Zampogna B.
        • Torre G.
        • et al.
        Sarcopenia and its relationship with osteoarthritis: risk factor or direct consequence?.
        Musculoskelet. Surg. 2014; 98: 9-14
        • Pedroso M.G.
        • de Almeida A.C.
        • Aily J.B.
        • et al.
        Fatty infiltration in the thigh muscles in knee osteoarthritis: a systematic review and meta-analysis.
        Rheumatol. Int. 2019; 39: 627-635
        • Raynauld J.P.
        • Pelletier J.P.
        • Roubille C.
        • et al.
        Magnetic resonance imaging–assessed vastus medialis muscle fat content and risk for knee osteoarthritis progression: relevance from a clinical trial.
        Arthritis Care Res. 2015; 67: 1406-1415
        • Robbins S.M.
        • Morelli M.
        • Martineau P.A.
        • et al.
        A comparison of muscle activation and knee mechanics during gait between patients with non-traumatic and post-traumatic knee osteoarthritis.
        Osteoarthr. Cartil. 2019; 27: 1033-1042
        • Ruhdorfer A.
        • Wirth W.
        • Dannhauer T.
        • Eckstein F.
        Longitudinal (4 year) change of thigh muscle and adipose tissue distribution in chronically painful vs painless knees–data from the osteoarthritis initiative.
        Osteoarthr. Cartil. 2015; 23: 1348-1356
        • Specogna A.V.
        • Birmingham T.B.
        • DaSilva J.J.
        • et al.
        Reliability of lower limb frontal plane alignment measurements using plain radiographs and digitized images.
        J. Knee. Surg. 2004; 17: 203-210
        • Teichtahl A.J.
        • Wluka A.E.
        • Wang Y.
        • et al.
        Vastus medialis fat infiltration–a modifiable determinant of knee cartilage loss.
        Osteoarthr. Cartil. 2015; 23: 2150-2157
        • Toivanen A.T.
        • Heliövaara M.
        • Impivaara O.
        • et al.
        Obesity, physically demanding work and traumatic knee injury are major risk factors for knee osteoarthritis—a population-based study with a follow-up of 22 years.
        Rheumatology. 2010; 49: 308-314
        • van Yperen D.T.
        • Reijman M.
        • van Es E.M.
        • et al.
        Twenty-year follow-up study comparing operative versus nonoperative treatment of anterior cruciate ligament ruptures in high-level athletes.
        Am. J. Sports Med. 2018; 46: 1129-1136
        • Visser A.W.
        • de Mutsert R.
        • Loef M.
        • et al.
        The role of fat mass and skeletal muscle mass in knee osteoarthritis is different for men and women: the NEO study.
        Osteoarthr. Cartil. 2014; 22: 197-202
        • Wang X.
        • Hunter D.
        • Xu J.
        • Ding C.
        Metabolic triggered inflammation in osteoarthritis.
        Osteoarthr. Cartil. 2015; 23: 22-30
        • Wang Y.
        • Wluka A.E.
        • Berry P.A.
        • et al.
        Increase in vastus medialis cross-sectional area is associated with reduced pain, cartilage loss, and joint replacement risk in knee osteoarthritis.
        Arthritis Rheum. 2012; 64: 3917-3925
        • Yoshida Y.
        • Marcus R.L.
        • Lastayo P.C.
        Intramuscular adipose tissue and central activation in older adults.
        Muscle Nerve. 2012; 46: 813-816
        • Zheng H.
        • Chen C.
        Body mass index and risk of knee osteoarthritis: systematic review and meta-analysis of prospective studies.
        BMJ Open. 2015; 5e007568
        • Zwart D.E.
        • Arjan H.
        • Dekker J.
        • et al.
        Factors associated with upper leg muscle strength in knee osteoarthritis: a scoping review.
        J. Rehabil. Med. 2018; 50: 140-150