Clinical Orthopaedics
Clin Orthop Relat Res (2014) 472:31143120
DOI 10.1007/s11999-014-3737-0
CLINICAL RESEARCH
Knee Muscle Strength After Recent Partial Meniscectomy Does
Not Relate to 2-year Change in Knee Adduction Moment
Michelle Hall MSc, Tim V. Wrigley MSc, Ben R. Metcalf BSc,
Rana S. Hinman PhD, Alasdair R. Dempsey PhD, Peter M. Mills PhD,
Flavia M. Cicuttini PhD, David G. Lloyd PhD, Kim L. Bennell PhD
Received: 10 December 2013 / Accepted: 3 June 2014 / Published online: 28 June 2014
The Association of Bone and Joint Surgeons1 2014
Abstract
Background Knee muscle weakness and a greater exter-
nal knee adduction moment are suggested risk factors for
medial tibiofemoral knee osteoarthritis. Knee muscle
weakness and a greater knee adduction moment may be
related to each other, are potentially modifiable, and have
been observed after arthroscopic partial meniscectomy.
Questions/purposes The aim of this exploratory study
was to determine if knee muscle weakness 3 months after
arthroscopic partial meniscectomy (baseline) is associated
with an increase in external knee adduction parameters
during the subsequent 2 years.
The institution of the authors has received funding from the National
Health and Medical Research Council (NHMRC project #334151),
Australia. Two of the authors (KLB and RSH) have received funding
from Australian Research Council Research Future Fellowships
(#FT 0991413 and # FT 130100175); one of the authors (MH)
received a scholarship from a NHMRC program grant (#631717).
All ICMJE Conflict of Interest Forms for authors and Clinical
Orthopaedics and Related Research editors and board members are
on file with the publication and can be viewed on request.
Each author certifies that his or her institution approved the human
protocol for this investigation, that all investigations were conducted
in conformity with ethical principles of research, and that informed
consent for participation in the study was obtained.
This work was performed at The University of Melbourne, Victoria,
Australia.
M. Hall, T. V. Wrigley, B. R. Metcalf, R. S. Hinman,
K. L. Bennell (&)
Centre for Health, Exercise and Sports Medicine, Department of
Physiotherapy, School of Health Sciences, Melbourne,
The University of Melbourne, Parkville, VIC 3010, Australia
e-mail: k.bennell@unimelb.edu.au
A. R. Dempsey, P. M. Mills, D. G. Lloyd
Centre for Musculoskeletal Research, Griffith Health Institute,
Griffith University, Gold Coast Campus, Southport, QLD,
Australia
123
and Related Research
A Publication of The Association of Bone and Joint Surgeons
Methods Eighty-two participants undergoing medial
arthroscopic partial meniscectomy were assessed at base-
line, and 66 participants who were reassessed 2 years later
were included in our study. Isokinetic muscle strength and
external adduction moment parameters (peak and impulse)
during normal and fast walking were measured at baseline
and followup. Multiple linear regression models were used
to examine the association between baseline muscle
strength and 2-year change in adduction moment parame-
ters. A post hoc power calculation showed we had 80%
power to detect a correlation of 0.31 between baseline
muscle strength and change in the external knee adduction,
with an alpha error of 0.05 and two-sided significance.
Results Maximal isokinetic muscle strength 3 months
after arthroscopic partial meniscectomy was not associated
with change in adduction moment parameters (p value
range from 0.12 to 0.96).
Conclusions No evidence was found to suggest that
improving maximal knee muscle strength after a recent
arthroscopic partial meniscectomy would reduce change in
knee adduction moment observed during the subsequent 2
years. As muscle function is modifiable, future investiga-
tion of other aspects of muscle function that may relate to
change in knee adduction moment is warranted.
A. R. Dempsey
School of Psychology and Exercise Science, Murdoch
University, Perth, WA, Australia
F. M. Cicuttini
Department of Epidemiology and Preventive Medicine, School
of Public Health and Preventive Medicine, Monash University,
Melbourne, VIC, Australia
Volume 472, Number 10, October 2014
Level of Evidence Level II, prognostic study. See the
Instructions for Authors for a complete description of
levels of evidence.
Introduction
After meniscectomy, patients are at increased risk of hav-
ing knee osteoarthritis develop [22], particularly in the
medial tibiofemoral compartment [18]. Knee osteoarthritis
is, in part, considered a mechanical disease [10], with
increased joint loading and knee muscle weakness thought
to be important in disease pathogenesis [6]. Knee muscle
weakness and increased knee loading, indirectly indicated
by the external knee adduction moment during walking,
have been observed after arthroscopic partial meniscec-
tomy [15, 33, 35] and may be related to each other in this
population group [33]. Determining whether knee muscle
weakness after a recent medial arthroscopic partial men-
iscectomy is associated with increases in the knee
adduction moment with time may assist in developing
rehabilitation interventions aimed at preventing or slowing
the onset of osteoarthritis in this at-risk group.
The knee adduction moment is of particular interest in
the pathogenesis of knee osteoarthritis because evidence
suggests that the peak knee adduction moment is positively
associated with radiographic disease progression [24] and
knee pain [2]. The knee adduction moment impulse also has
been associated with degenerative morphologic features of
the cartilage after arthroscopic partial meniscectomy [9]
and with cartilage loss in patients with established osteo-
arthritis [4]. A greater peak knee adduction moment [15, 33,
35] and knee adduction moment impulse [15] have been
found in people after arthroscopic partial meniscectomy as
compared with control subjects with intact menisci, and we
recently observed that the peak knee adduction moment
significantly increased during 2 years in patients after
medial arthroscopic partial meniscectomy [15]. Although
the clinical importance of the increase in the peak knee
adduction moment remains unknown, these findings overall
suggest that increased loading is likely to be an important
factor to address after arthroscopic partial meniscectomy.
Muscles are considered influential in the pathogenesis of
knee osteoarthritis given their ability to control load sharing
between the medial and lateral tibiofemoral condyles and
provide dynamic stability [6, 19, 23, 30, 38]. Biomechanical
investigations have found that the quadriceps and hamstrings
contribute to support the knee adduction moment [8, 21, 38].
Within 6 months of arthroscopic partial meniscectomy,
patients have been reported to have weak knee musculature
[14, 15, 33], which may impair their ability to control the
greater knee adduction moment observed during gait after
arthroscopic partial meniscectomy [15, 35]. Moreover,
Strength and Moments Postmeniscectomy 3115
cross-sectional evidence suggests that 3 months after
arthroscopic partial meniscectomy patients with weak knee
extensors have a greater peak knee adduction moment during
walking compared with patients whose strength is compa-
rable to that of control subjects with intact menisci [33].
Although the knee adduction moment and knee muscle
strength were reported previously in this cohort of patients
with arthroscopic partial meniscectomy [15], to our knowl-
edge, no longitudinal study has examined relationships
between muscle weakness and knee-loading change in this
population. Considering that muscle weakness can be mod-
ified with muscle-strengthening exercises, it is important to
explore associations between knee muscle strength and
dynamic knee load after arthroscopic partial meniscectomy.
Therefore, the aim of this exploratory study was to
determine if weaker knee muscle strength at 3 months after
arthroscopic partial meniscectomy is associated with an
increased knee adduction moment (peak and impulse)
during walking throughout the subsequent 2 years.
Patients and Methods
This is a retrospective analysis performed on a previously
published prospective longitudinal study [15]. During a
33-month period starting July 2005, we recruited partici-
pants between 30 and 50 years old who had an isolated
medial arthroscopic partial meniscectomy 3 months previ-
ously by one of five orthopaedic surgeons (HM, AS, JK, JF,
AT) in Melbourne, Australia. Participants were excluded if
.
they had a lateral meniscal resection; greater than 1 2 of the
medial meniscus resected; greater than two tibiofemoral
cartilage lesions observed at arthroscopy; any tibiofemoral
cartilage lesion larger than approximately 10 mm in diameter
as assessed at arthroscopy; previous knee or lower limb
surgery (other than current arthroscopic partial meniscec-
tomy); history of knee pain (other than that leading to
arthroscopic partial meniscectomy); postoperative compli-
cations; cardiac, circulatory, or neuromuscular conditions;
diabetes; stroke; multiple sclerosis; or a contraindication to
MRI. Our study was approved by the Human Research Ethics
Committee at The University of Melbourne and all partici-
pants provided written informed consent.
Of the 149 potentially eligible patients referred by sur-
geons (between 30 and 50 years old with a recent medial
arthroscopic partial meniscectomy), 20 did not fit the study
criteria, eight could not be contacted, and 39 were not
interested in participating. Thus, 82 participants were
enrolled in the 2-year longitudinal study. Sixteen partici-
pants (20%) did not return for followup gait assessments
for various reasons including relocation and they no longer
were interested in participating. One participant had
incomplete data for normal pace walking and two different
123
3116 Hall et al. Clinical Orthopaedics and Related Research1

Table 1. Participant baseline characteristics
Characteristics Number = 66
Age (years) 41.3 5.4
Male, number (%) 57 (86)
Height (m) 1.75 0.09
Mass (kg) 83.8 14.4
BMI (kg/m2) 27.3 4.2
Normal-pace walking
Self-selected walking speed (m/second) 1.37 0.15
Peak knee adduction moment (Nm/[BW 9 HT]%) 2.33 0.89
Knee adduction moment impulse 0.87 0.33
(Nm.second/[BW 9 HT]%)
Fast-pace walking
Self-selected walking speed (m/second) 1.92 0.19
Peak knee adduction moment (Nm/[BW 9 HT]%) 2.91 1.19
Knee adduction moment impulse 0.75 0.27
(Nm.second/[BW 9 HT]%)
Isokinetic strength (Nm/kg)
Eccentric quadriceps 2.22 0.71
Concentric quadriceps 1.71 0.50
Eccentric hamstrings 1.37 0.39
Concentric hamstrings 0.96 0.26
Values are mean SD; BW = body weight; HT = height.
participants had incomplete data for fast pace walking. As
such, all 66 participants who returned for re-assessment
were included in the analyses, with 65 participants used for
normal pace analyses and 64 used for fast pace walking
analyses. The minimum followup was 1.5 years (average,
2.2 years; SD, 0.2; range, 1.52.4 years). The participants
were predominantly male and many were overweight
according to the World Health Organization standards
(Table 1). During 2005 to 2008, participants underwent
baseline strength and gait assessments, returning 2 years
later for reassessment. All assessments were performed at
the Centre for Health, Exercise and Sports Medicine, The
University of Melbourne, Australia.
Maximal isokinetic knee extensor and flexor strength
(arthroscopic partial meniscectomy leg) defined as the
maximal voluntary contraction torque produced on a Kin-
Com 125-AP dynamometer (Chattecx, Chattanooga, TN,
USA) was assessed. Isokinetic strength at 60 per second
was assessed to characterize the low-velocity, high-muscle
force region of the muscle forcevelocity relationship. As
previously described [15], participants performed two tests
of five maximal concentricconcentric contractions of
knee extensors and flexors at 60 per second through a 5 to
95 range followed by reciprocal eccentriceccentric con-
tractions of the same knee muscles with 40 seconds
separating each set. Participants received strong, stan-
dardized verbal encouragement and were instructed to push
or pull as hard as possible. Peak torque for each muscle
group and condition was recorded with reported values
corrected for gravity and normalized to body mass (Nm/kg)
[12].
Kinematic data (120 Hz) were collected using an eight-
camera, Vicon M2/MX three-dimensional motion analysis
system (Vicon, Oxford, UK) in synchrony with ground
reaction force data (1080 Hz) recorded using three force
plates (Advanced Mechanical Technology, Watertown,
MA, USA). After familiarization, participants performed
five walking trials along a 10-m walkway at normal and
fast walking paces, respectively. Normal pace was de-
scribed as a natural and comfortable pace, whereas fast
pace walking was described as a pace that you would
walk in a hurry [15]. In accordance with Besier et al. [7],
33 reflective markers and four three-marker clusters were
placed on anatomic landmarks and body segments. Lower
limb joint kinematics and kinetics were estimated using a
custom seven-segment lower limb direct kinematics and
inverse dynamics model written in Matlab (Mathworks,
Natick, MA, USA) and BodyBuilder (Vicon) [7, 9, 15].
Hip centers and knee flexion and extension axes were
individually estimated using functional movement tasks,
and a foot calibration procedure, where the foot abduction
and adduction and rear foot inversion and eversion angles,
were measured to establish the foot alignment and coordi-
nate system [7]. The knee adduction moment was calculated
for the leg that had the arthroscopic partial meniscectomy
and was expressed as external and applied to the shank
segment. Similar to previous studies [4, 15], the peak knee
.
adduction moment during the first 1 2 of stance and positive
knee adduction moment impulse were extracted from each
of five trials, averaged, and normalized to the result of body
weight (N) multiplied by height (m) [29]. Change in peak
knee adduction moment, knee adduction moment impulse,
and walking speed were determined by subtracting the
baseline from the followup scores (ie, a negative score
represented a reduction at followup).
Dependent variables included the 2-year change in peak
knee adduction moment and knee adduction moment
impulse during normal and fast pace walking. Multiple
linear regression models were adjusted for longitudinal
change in walking speed (known to affect knee adduction
moment [26]) and baseline peak knee adduction moment
and knee adduction moment impulse (to account for
potential for change). All analyses were performed using
SPSS (Version 19.0; Chicago, IL, USA) and significance
was set at p less than 0.05.
With a minimum of 64 people included in the analyses,
post hoc power analysis confirmed that we had 80% power
to detect a correlation of 0.31 between baseline muscle
strength and change in the external knee adduction, with an
alpha error of 0.05 and two-sided significance.

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Volume 472, Number 10, October 2014
Table 2. Relationships between baseline isokinetic knee muscle strength and change in knee adduction moment
2-year change in knee adduction Normal-pace gait
moment parameters*
Regression coefficient (95% CI)
Peak knee adduction moment (Nm/[BW 9 HT]%)
Concentric quadriceps (Nm/kg) 0.16 ( 0.19 to 0.50)
Eccentric quadriceps (Nm/kg) 0.04 ( 0.28 to 0.20)
Concentric hamstrings (Nm/kg) 0.32 ( 0.33 to 0.97)
Eccentric hamstrings (Nm/kg) 0.17 ( 0.60 to 0.27)
Knee adduction moment impulse (Nm.second/[BW 9 HT]%)
Concentric quadriceps (Nm/kg) 0.04 ( 0.06 to 0.15)
Eccentric quadriceps (Nm/kg) 0.00 ( 0.08 to 0.07)
Concentric hamstrings (Nm/kg) 0.05 ( 0.15 to 0.25)
Eccentric hamstrings (Nm/kg) 0.03 ( 0.16 to 0.10)
* Adjusting for baseline scores and change in walking speed during 2 years; BW = body weight; HT = height.
Results
There were no associations between knee muscle strength
3 months after the arthroscopic partial meniscectomy and
the change in peak knee adduction moment or knee
adduction moment impulse, during normal or fast pace
walking in the subsequent 2 years (Table 2) after adjusting
for change in walking speed and baseline parameters (p
values range from 0.12 to 0.96). Results remained un-
changed when knee adduction moments and strength were
normalized similarly (ie, both to kg). As reported [15], the
peak knee adduction moment increased with time by
approximately 9% (mean SD peak knee adduction
moment, Nm/(BW 9 HT)% 0.22 0.71 during normal
pace gait and 0.25 0.91 during fast pace gait). The knee
adduction moment impulse did not change during the 2-
year period [15]. There was no change in normal or fast
pace walking speed during the 2 years, (mean difference
SD, 0.01 m/second 0.14; p = 0.665 for normal
walking pace and 0.01 m/second 0.19, p = 0.704 for
fast walking pace).
Discussion
After arthroscopic partial meniscectomy, patients have risk
factors associated with knee osteoarthritis, including a
greater knee adduction moment during gait and knee
muscle weakness. Cross-sectional evidence obtained after a
recent arthroscopic partial meniscectomy suggested that
weak knee muscle strength may be related to the knee
adduction moment [33]. Therefore, given that exercise can
improve knee muscle strength, investigating the longitu-
dinal relationship between these parameters is warranted.
The purpose of our study was to determine if weaker knee
muscle strength 3 months after arthroscopic partial
Strength and Moments Postmeniscectomy 3117
Fast-pace gait
p value Regression coefficient (95% CI) p value
0.37 0.01 ( 0.47 to 0.44) 0.96
0.73 0.17 ( 0.49 to 0.15) 0.30
0.33 0.14 ( 0.75 to 1.02) 0.76
0.45 0.40 ( 0.98 to 0.18) 0.18
0.43 0.03 ( 0.12 to 0.06) 0.47
0.93 0.05 ( 0.11 to 0.01) 0.12
0.62 0.01 ( 0.19 to 0.17) 0.93
0.63 0.08 ( 0.19 to 0.03) 0.18
meniscectomy was related to an increase in the knee
adduction moment during gait during the subsequent 2
years. We found no evidence to suggest that weak knee
muscle strength at 3 months after arthroscopic partial
meniscectomy is associated with subsequent knee adduc-
tion moment changes.
Our study has several limitations. First, 20% of our
cohort was lost owing to participant attrition by the 2-year
followup. Nonetheless, no differences in baseline charac-
teristics, including strength or knee adduction moment,
were reported for participants who dropped out compared
with participants who remained in the study [15]. There-
fore, there is no reason to suspect that participants who
dropped out differed in strength variables, and thus it is
unlikely to have influenced our findings. A second limita-
tion that may have influenced our ability to detect
relationships between baseline knee muscle strength and
changes in knee adduction moment was the absence of
matched walking speeds between baseline and followup.
Although there were no differences in walking speeds
between times and walking speed was statistically
accounted for, the knee adduction moment change scores
may be influenced by walking speed. Nonetheless, to per-
mit generalizable estimates of knee adduction moment
measures, participants were permitted to walk at self-
selected speeds.
A third limitation is that strength assessment was
restricted to the knee extensors and flexors. Hip muscles
also are considered to control the knee adduction moment
given their prominent role in controlling the center of mass
position [5, 25] and mediolateral acceleration [28]. Addi-
tionally, biomechanical modeling studies have found that
the gastrocnemius contributes to stabilizing the knee
adduction moment during gait [31, 38]. Given that quad-
riceps and hamstring weakness has been observed 3 months
after arthroscopic partial meniscectomy [15, 33], it is
123
3118 Hall et al.
possible that hip and gastrocnemius muscle weakness was
present and may have influenced knee adduction moment
changes after the arthroscopic partial meniscectomy [33].
Another limitation is the lack of information regarding
physical activity levels and rehabilitation by participants
immediately after surgery, because these factors may have
affected baseline strength measures. However, baseline
strength measures were normally distributed as skewness
and kurtosis ranged between 0.093 and 0.288. This may
suggest that physical activity and rehabilitation had mini-
mal influence on baseline strength measures. Finally, the
lack of information regarding the amount and exact loca-
tion of the meniscus removed is a limitation because
evidence suggests the amount removed alters knee contact
force [3] and possibly knee adduction moment measures.
To our knowledge, this is the first study to investigate the
longitudinal association between knee muscle strength and
change in knee adduction moment parameters. Although
biomechanical modeling studies have implicated the role of
quadriceps and hamstrings in stabilizing the knee adduction
moment [30, 38] during walking we found no evidence to
support this. As to our knowledge no other studies have
reported the association between strength and change in knee
adduction moment, comparison of findings is precluded.
There are several possible explanations why no associ-
ation between strength and change in knee adduction
moment was observed. First, the knee adduction moment
can be principally altered by changing the magnitude of the
frontal plane ground reaction force vector and/or its lever
arm. In turn, these two parameters are largely determined
by the position of the knee center and the center of pressure
under the foot (ground reaction force origin), body mass,
and the body center of mass position and acceleration
(vertical and mediolateral). These are potentially controlled
by submaximal activations of multiple lower extremity,
pelvic, and upper body muscles. Therefore, maximal is-
okinetic knee muscle strength may not be the most valid or
sensitive approach when investigating a relationship
between muscle strength and the knee adduction moment
during gait. Humans do not exhibit maximal contractions
of their knee extensors and flexors muscles during walking
and use an unknown individual-specific proportion of their
maximal strength (generally within maximum limits). Hunt
et al. [16] described how estimating individual specific
strength requirements during gait would require assessing
muscle activation during stance for each participant and
determining muscle strength at that activation level.
Despite the possibility of this approach, maximal knee
muscle strength was assessed because it is a clinically
reliable measure and less burdensome on participants.
Another consideration is that knee muscle strength 3
months after arthroscopic partial meniscectomy was not
stable, because we observed that knee muscle strength
123
Clinical Orthopaedics and Related Research1
significantly increased during the 2-year period in this
arthroscopic partial meniscectomy cohort [15]. Conse-
quently, the baseline knee muscle strength used to predict
change in knee load is not reflective of the whole 2-year
study period. Nonetheless, baseline knee muscle strength
was examined to predict change in knee load so that
rehabilitation programs aiming to prevent or slow the onset
of osteoarthritis after arthroscopic partial meniscectomy
could be better informed and improved. Although our
findings do not support a relationship, quadriceps
strengthening may still be important after arthroscopic
partial meniscectomy to delay symptomatic osteoarthritis
and functional decline. After arthroscopic partial menis-
cectomy, strong quadriceps strength has been found to be
positively correlated with less pain and better physical
function and quality of life [11], which generally concurs
with findings for patients with established knee osteoar-
thritis [6]. Therefore, consistent with current meniscal tear
rehabilitation recommendations [27] and as previously
discussed [15], we consider it clinically important for
patients to regain knee muscle strength after arthroscopic
partial meniscectomy.
We found that the peak knee adduction moment
increased during 2 years in this cohort despite substantial
improvement in the knee muscle strength during the same
period. This suggests that factors other than maximal knee
muscle strength may be more important in determining
increases in the knee adduction moment after arthroscopic
partial meniscectomy. Other interrelated aspects of muscle
function, which may be influenced by pain, may provide
insight into how muscles control the knee adduction
moment. These aspects include muscle activity patterns
and proprioceptive acuity [6, 19, 23, 33, 37, 38]. Future
research should explore these aspects of muscle function,
because muscle activity patterns during functional tasks
[34, 36] and proprioceptive acuity [1] reportedly are altered
after arthroscopic partial meniscectomy. Although the
mechanism by which these aspects of muscle function
would be related to increases in knee adduction moment
are undefined, theoretically each could alter the knee
adduction moment by affecting the main factors that
determine the knee adduction moment.
After meniscus surgery patients are at high risk for knee
osteoarthritis [22], which is partly thought to result from
compromised ability to absorb and distribute the load
across the joint [3, 17]. Our findings provide no evidence to
support a relationship between knee muscle strength as-
sessed 3 months after arthroscopic partial meniscectomy
and 2-year change in knee adduction moment parameters.
Our findings add to intervention studies not finding an
effect of muscle strengthening on the knee adduction
moment in patients with established osteoarthritis [5, 13,
20, 32]. Moreover, our findings provide an additional
Volume 472, Number 10, October 2014
rationale to investigate the role of other aspects of muscle
function controlling joint loading given that muscle func-
tion can be modified through conservative rehabilitation
[6]. Factors other than maximal knee muscle strength such
as dynamic alignment of the lower extremity and/or upper
body control may influence increases in the knee adduction
moment.
Acknowledgments We thank the following surgeons for assisting
with participant recruitment: Hayden Morris MBBS, Dip Anat,
FRACS FA Ortho A, The Park Clinic, Melbourne; Jim Keillerup
MBBS, FRACS, La Trobe University Medical Centre, Melbourne;
Andrew Shimmin MBBS, FRACS, Melbourne Orthopaedic Group,
Melbourne; Julian Fellar FRANCS, Faculty of Health Sciences, La
Trobe University, Melbourne; and Adrian Trivett MBBS, FRACS
(Ortho) FA Ortho A, Cabrini Medical Centre, Malvern, Australia.
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