Muscle Weakness, Proprioceptive Deficits, and Postural Stability in Unilateral Knee Osteoarthritis: A Comparative Analysis of Affected and Unaffected Limbs

Abstract

Objective: This study aimed to investigate quadriceps and hamstring muscle strength, postural stability, proprioceptive sense, and weight-bearing asymmetry between the affected and unaffected lower limbs in patients with unilateral knee osteoarthritis (OA). Materials and Methods: A total of 79 patients (70 women, nine men; mean age 61.08 ± 6.28 years) diagnosed with unilateral knee OA according to the Kellgren-Lawrence classification were included. Demographic and clinical characteristics were recorded. Pain intensity was assessed using the Visual Analog Scale, and functional status was evaluated with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Muscle strength was measured with a manual muscle dynamometer, proprioception with joint position sense tests at different knee flexion angles, and postural stability using a force platform under both eyes-open and eyes-closed conditions. Weight-bearing distribution during bilateral stance was also evaluated. Results: Quadriceps and hamstring strength were significantly lower in the affected limb compared to the unaffected side (p  0.001). Weight-bearing on the affected limb was reduced under both eyes-open and eyes-closed conditions (p  0.001). However, no significant interlimb differences were observed in postural stability parameters or proprioceptive accuracy at any tested angles (p > 0.05). Additionally, patients demonstrated a significant asymmetry in load transfer during bilateral stance, favoring the non-affected limb. Conclusion: Patients with unilateral knee OA exhibit reduced muscle strength and weight-bearing capacity in the affected limb, along with asymmetrical load distribution during stance. These findings highlight the importance of addressing weight-bearing asymmetry and muscle weakness in early rehabilitation programs to prevent further functional deterioration and disease progression.

Keywords

• knee
• osteoarthritis
• postural balance
• proprioception

References

1. Al-Johani, A. H., Kachanathu, S. J., Hafez, A. R., Al-Ahaideb, A., Algarni, A. D., Alroumi, A. M., & Alenazi, A. M. (2014). Comparative study of hamstring and quadriceps strengthening treatments in the management of knee osteoarthritis. Journal of Physical Therapy Science, 26(6), 817-820.
2. Alghadir, A. H., Anwer, S., Iqbal, A., & Iqbal, Z. A. (2018). Test–retest reliability, validity, and minimum detectable change of visual analog, numerical rating, and verbal rating scales for measurement of osteoarthritic knee pain. Journal of Pain Research, 851-856.
3. Ashraf, A., Shooshtari, S. M. J., Homayouni, K., Roshanzamir, S., Zafarghasempoor, M., Ajhdarnia, N., Satari, S., & Rezaianzadeh, A. (2011). Asymmetry of bone mineral density of the hips in patients with unilateral knee osteoarthritis: A cross-sectional study. Journal of Musculoskeletal Research, 14(1), 1150005. https://doi.org/10.1142/S0218957711500059
4. Baert, I. A., Lluch, E., Struyf, T., Peeters, G., Van Oosterwijck, S., Tuynman, J., Rufai, S., & Struyf, F. (2018). Inter-and intrarater reliability of two proprioception tests using clinical applicable measurement tools in subjects with and without knee osteoarthritis. Musculoskeletal Science and Practice, 35, 105-109.
5. Bakırhan, S., Unver, B., & Karatosun, V. (2013). [Investigation of body weight ratios on joint structures at different knee flexion angles in patients with unilateral knee arthroplasty]. Eklem Hastalik Cerrahisi, 24(1), 7-11. https://doi.org/10.5606/ehc.2013.03 (Tek taraflı total diz artroplastili hastalarda farklı diz fleksiyon açılarında ekstremiteler arasındaki vücut ağırlık oranlarının incelenmesi.)
6. Chen, Z., Shen, Z., Ye, X., Wu, J., Wu, H., & Xu, X. (2020). Association between foot posture asymmetry and static stability in patients with knee osteoarthritis: a case‐control study. BioMed Research International, (1), 1890917.
7. Dalle, S., & Koppo, K. (2020). Is inflammatory signaling involved in disease-related muscle wasting? Evidence from osteoarthritis, chronic obstructive pulmonary disease and type II diabetes. Experimental Gerontology, 137, 110964.
8. de Almeida, M. B., Oliveira, C., Ornelas, G., Soares, T., Souto, J., Póvoa, R., Ferreira, L. M. A., & Ricci-Vitor, A. L. (2023). Intra-Rater and Inter-Rater Reliability of the Kinvent Hand-Held Dynamometer in Young Adults. Medical Sciences Forum, 22,1-12.

9. Duong, V., Oo, W. M., Ding, C., Culvenor, A. G., & Hunter, D. J. (2023). Evaluation and treatment of knee pain: a review. Jama, 330(16), 1568-1580.
10. Eymir, M., Erduran, M., & Ünver, B. (2021). Active heel-slide exercise therapy facilitates the functional and proprioceptive enhancement following total knee arthroplasty compared to continuous passive motion. Knee Surgery, Sports Traumatology, Arthroscopy, 29, 3352-3360.
11. Geng, R., Li, J., Yu, C., Zhang, C., Chen, F., Chen, J., Ni, H., Wang, J., Kang, K., & Wei, Z. (2023). Knee osteoarthritis: Current status and research progress in treatment. Experimental and Therapeutic Medicine, 26(4), 1-11.
12. Goble, D. J., & Baweja, H. S. (2018). Postural sway normative data across the adult lifespan: Results from 6280 individuals on the Balance Tracking System balance test. Geriatrics & Gerontology International, 18(8), 1225-1229.
13. Gokeler, A., Benjaminse, A., Hewett, T. E., Lephart, S. M., Engebretsen, L., Ageberg, E., Engelhardt, M., Arnold, M. P., Postema, K., & Otten, E. (2012). Proprioceptive deficits after ACL injury: are they clinically relevant? British Journal of Sports Medicine, 46(3), 180-192.
14. Hislop, A., Collins, N. J., Tucker, K., & Semciw, A. I. (2022). Hip strength, quadriceps strength and dynamic balance are lower in people with unilateral knee osteoarthritis compared to their non-affected limb and asymptomatic controls. The Brazilian Journal of Physical Therapy 26(6), 100467.
15. Ikemoto-Uezumi, M., Matsui, Y., Hasegawa, M., Fujita, R., Kanayama, Y., Uezumi, A., Watanabe, T., Harada, A., Poole, A. R., & Hashimoto, N. (2017). Disuse atrophy accompanied by intramuscular ectopic adipogenesis in vastus medialis muscle of advanced osteoarthritis patients. The American Journal of Pathology, 187(12), 2674-2685.
16. Ishii, Y., Noguchi, H., Sato, J., Ishii, H., Ishii, R., & Toyabe, S.-i. (2020). Association of knee osteoarthritis grade with one-leg standing balance and quadriceps strength in male independent ambulators aged≥ 80 years. Journal of Orthopaedics, 21, 79-83.
17. Katz, J. N., Arant, K. R., & Loeser, R. F. (2021). Diagnosis and treatment of hip and knee osteoarthritis: a review. Jama, 325(6), 568-578.
18. Kim, D., Park, G., Kuo, L.-T., & Park, W. (2018). The effects of pain on quadriceps strength, joint proprioception and dynamic balance among women aged 65 to 75 years with knee osteoarthritis. BMC Geriatrics, 18(1), 245.
19. Knoop, J., Steultjens, M., Van der Leeden, M., Van der Esch, M., Thorstensson, C., Roorda, L., Lems, W., & Dekker, J. (2011). Proprioception in knee osteoarthritis: a narrative review. Osteoarthritis and Cartilage, 19(4), 381-388.
20. Labanca, L., Barone, G., Zaffagnini, S., Bragonzoni, L., & Benedetti, M. G. (2021). Postural stability and proprioception abnormalities in patients with knee osteoarthritis. Applied Sciences, 11(4), 1469.
21. Lawson, T., Morrison, A., Blaxland, S., Wenman, M., Schmidt, C. G., & Hunt, M. A. (2015). Laboratory-based measurement of standing balance in individuals with knee osteoarthritis: a systematic review. Clinical Biomechanics, 30(4), 330-342.
22. Lee, S.-S., Kim, H.-J., Ye, D., & Lee, D.-H. (2021). Comparison of proprioception between osteoarthritic and age-matched unaffected knees: a systematic review and meta-analysis. Archives of Orthopaedic and Trauma Surgery, 141(3), 355-365.
23. Lopes, H. S., Waiteman, M. C., Priore, L. B., Glaviano, N. R., Bazett-Jones, D. M., Briani, R. V., & Azevedo, F. M. (2024). There is more to the knee joint than just the quadriceps: A systematic review with meta-analysis and evidence gap map of hamstring strength, flexibility, and morphology in individuals with gradual-onset knee disorders. Journal of Sport and Health Science, 13(4), 521-536.
24. Mani, E., Tüzün, E. H., Angın, E., & Eker, L. (2020). Lower extremity proprioceptive sensation in patients with early stage knee osteoarthritis: a comparative study. The Knee, 27(2), 356-362.
25. Manlapaz, D. G., Sole, G., Jayakaran, P., & Chapple, C. M. (2019). Risk factors for falls in adults with knee osteoarthritis: a systematic review. Pm&r, 11(7), 745-757.
26. Marks, R. (2016). Muscle Function during Selected Weight-Bearing Activities in Adults with Knee Osteoarthritis-A Narrative Overview. International Journal of Orthopaedics, 3(4), 595-602.
27. Meras Serrano, H., Mottet, D., & Caillaud, K. (2023). Validity and Reliability of Kinvent Plates for Assessing Single Leg Static and Dynamic Balance in the Field. Sensors, 23(4), 2354.
28. Nagymate, G., & Kiss, R. M. (2017). Balancing strategy differences in bilateral knee osteoarthritis patients. Proceedings of the 13th IASTED International Conference on Biomedical Engineering, BioMed 2017.
29. Nagymate, G., Pethes, A., Szabo, G., Bejek, Z., Paroczai, R., & Kiss, R. M. (2016). The Impact of the Severity of Knee Osteoarthritis on the Postural Stability. Materials Today: Proceedings, 3(4), 1069-1073. https://doi.org/10.1016/j.matpr.2016.03.050
30. Nishizawa, K., Harato, K., Morishige, Y., Kobayashi, S., Niki, Y., & Nagura, T. (2021). Correlation between weight-bearing asymmetry and bone mineral density in patients with bilateral knee osteoarthritis. Journal of Orthopaedic Surgery and Research, 16(1), 102. https://doi.org/10.1186/s13018-021-02252-5
31. Onodera, C. M. K., Coelho-Junior, H. J., Sampaio, R. A. C., Lana, J. F. S. D., Teixeira, L. F. M., Uchida, M. C., & Bizzacchi, J. M. A. (2020). The importance of objectively measuring functional tests in complement to self-report assessments in patients with knee osteoarthritis. Gait & Posture, 82, 33-37.
32. Paillard, T., & Noé, F. (2020). Does monopedal postural balance differ between the dominant leg and the non-dominant leg? A review. Human Movement Science, 74, 102686.
33. Riva, D., Mamo, C., Fanì, M., Saccavino, P., Rocca, F., Momenté, M., & Fratta, M. (2013). Single stance stability and proprioceptive control in older adults living at home: gender and age differences. Journal of Aging Research, 561695. https://doi.org/10.1155/2013/561695
34. Roos, E. (1999). Klä ssbo M, Lohmander LS. WOMAC Osteoarthritis Index: Reliability, validity, and responsiveness in patients with arthroscopically assessed osteoarthritis. Scandinavian Journal of Rheumatology, 28(4), 210-215.
35. Samuel, A. J., & Kanimozhi, D. (2019). Outcome measures used in patient with knee osteoarthritis: With special importance on functional outcome measures. International Journal of Health Sciences, 13(1), 52.
36. Schepman, P. B., Thakkar, S., Robinson, R. L., Beck, C. G., Malhotra, D., Emir, B., & Hansen, R. N. (2022). A retrospective claims-based study evaluating clinical and economic burden among patients with moderate to severe osteoarthritis pain in the United States. Journal of Health Economics and Outcomes Research, 9(1), 58.
37. Scopaz, K. A., Piva, S. R., Wisniewski, S., & Fitzgerald, G. K. (2009). Relationships of fear, anxiety, and depression with physical function in patients with knee osteoarthritis. Archives of Physical Medicine and Rehabilitation, 90(11), 1866-1873.
38. Segal, N. A., & Glass, N. A. (2011). Is quadriceps muscle weakness a risk factor for incident or progressive knee osteoarthritis? The Physician and Sportsmedicine, 39(4), 44-50.
39. Sharma, L. (1999). Proprioceptive impairment in knee osteoarthritis. Rheumatic Disease Clinics, 25(2), 299-314.
40. Sørensen, R. R., Jørgensen, M. G., Rasmussen, S., & Skou, S. T. (2014). Impaired postural balance in the morning in patients with knee osteoarthritis. Gait & Posture, 39(4), 1040-1044.
41. Takacs, J., Carpenter, M. G., Garland, S. J., & Hunt, M. A. (2014). Test re-test reliability of centre of pressure measures during standing balance in individuals with knee osteoarthritis. Gait & Posture, 40(1), 270-273.
42. Tüzün, E., Eker, L., Aytar, A., Daşkapan, A., & Bayramoğlu, M. (2005). Acceptability, reliability, validity and responsiveness of the Turkish version of WOMAC osteoarthritis index. Osteoarthritis and Cartilage, 13(1), 28-33.
43. Zeng, Z., Shan, J., Zhang, Y., Wang, Y., Li, C., Li, J., Chen, W., Ye, Z., Ye, X., & Chen, Z. (2022). Asymmetries and relationships between muscle strength, proprioception, biomechanics, and postural stability in patients with unilateral knee osteoarthritis. Frontiers in Bioengineering and Biotechnology, 10, 922832.