The Knee 22 (2015) 506509

Contents lists available at ScienceDirect

The Knee

Forward lunge knee biomechanics before and after partial meniscectomy

Michelle Hall a,, Jonas Hberg Nielsen b, Anders Holsgaard-Larsen c, Dennis Brandborg Nielsen c,
Mark W. Creaby d, Jonas Bloch Thorlund b
a
The University of Melbourne, Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, School of Health Sciences, Melbourne, Australia
b
Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
c
Orthopaedic Research Unit, Department of Orthopaedics and Traumatology, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Denmark
d
School of Exercise Science, Australian Catholic University, Brisbane, Queensland, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Patients following meniscectomy are at increased risk of developing knee osteoarthritis in the
Received 12 October 2014 tibiofemoral compartment and at the patellofemoral joint. As osteoarthritis is widely considered a mechanical
Received in revised form 28 January 2015 disease, it is important to understand the potential effect of arthroscopic partial meniscectomy (APM) on knee
Accepted 17 March 2015 joint mechanics. The purpose of this study was to evaluate changes in knee joint biomechanics during a forward
lunge in patients with a suspected degenerative meniscal tear from before to three months after APM.
Keywords:
Methods: Twenty-two patients (3555 years old) with a suspected degenerative medial meniscal tear participated
Rehabilitation exercise
Knee biomechanics
in this study. Three dimensional knee biomechanics were assessed on the injured and contralateral leg before and
Degenerative tear three months after APM. The visual analogue scale was used to assess knee pain and the Knee Injury Osteoarthritis
Osteoarthritis Outcome Score was used to assess sport/recreation function and knee-related condence before and after APM.
Results: The external peak knee exion moment reduced in the APM leg compared to the contralateral leg (mean
difference (95% CI)) 1.08 (1.80 to 0.35) (Nm/(BW HT)%), p = 0.004. Peak knee exion angle also reduced
in the APM leg compared to the contralateral leg 3.94 (6.27 to 1.60) degrees, p = 0.001. There was no
change in knee pain between the APM leg and contralateral leg (p = 0.118). Self-reported sport/recreation func-
tion improved (p = 0.004).
Conclusions: Although patients self-reported less difculty during strenuous tasks following APM, patients used
less knee exion, a strategy that may limit excessive patellar loads during forward lunge in the recently operated
leg.
2015 Elsevier B.V. All rights reserved.

1. Introduction important to discern the effect of arthroscopic partial meniscectomy

Osteoarthritis is a common disease that is considered by the World
Health Organisation as one of the ten leading causes of disease burden
in high-income countries [1]. The knee joint is the most commonly
affected lower limb joint [2]. A meniscal tear is a potent risk factor to de-
velop knee osteoarthritis [3] and both the patellofemoral and medial
tibiofemoral compartments are commonly affected by osteoarthritis fol-
lowing meniscectomy [4]. Degenerative tears in middle-aged adults are
associated with greater risk of knee osteoarthritis than traumatic
meniscal tears in younger individuals [3]. Following the removal of me-
niscus tissue, studies have reported a decrease in articulating contact
area and an increase in contact stress [5,6]. As knee osteoarthritis is
considered at least in part, a mechanically driven disease where higher
abnormally distributed forces are thought to play a role [7], it is
Corresponding author at: Centre for Health, Exercise and Sports Medicine Department
of Physiotherapy University of Melbourne Parkville, Victoria 3010, Australia. Tel.: +61 3
83444135; fax: +61 3 83444188.
E-mail address: halm@unimelb.edu.au (M. Hall).
(APM) on knee joint biomechanics.
The forward lunge is a challenging, functional exercise, which cou-
ples eccentric contractions and concentric contractions (also known as
stretch-shortening cycle). This is pertinent as eccentric contractions
typically precede concentric contractions, in the majority of daily living
activities (e.g. stepping, walking) [8]. The forward lunge is also com-
monly used in rehabilitation programmes to improve physical function
and knee muscle strength. Self-reported difculty with strenuous tasks
and knee muscle weakness has been described in people with degener-
ative meniscal tears pre-operatively [9] and within three months post-
operatively [10,11]. Understanding the effect of a meniscal tear and sub-
sequent APM on knee biomechanics during a task commonly prescribed
as a rehabilitation exercise to improve muscle strength and physical
function is warranted.
Studies investigating the squat and forward lunge have reported in-
creased patellar contact force and stress with increased knee exion
angle [12,13] and medial tibiofemoral joint contact force is inuenced
by the external knee exion moment during gait [14]. Furthermore, a
higher external knee adduction moment during gait relates to knee

http://dx.doi.org/10.1016/j.knee.2015.03.005
0968-0160/ 2015 Elsevier B.V. All rights reserved.
 M. Hall et al. / The Knee 22 (2015) 506509 507

pain onset [15] and disease progression in people with established knee
osteoarthritis [16,17]. Aberrant knee mechanics have been reported be-
fore and after APM [18], albeit inconsistently [19]. In particular, the knee
exion moment is reportedly reduced compared to healthy controls
during gait before and six months after APM [18]. However, these few
studies are limited by the lack of discrete measures and heterogeneous
samples. As such, it remains largely unknown if altered knee joint me-
chanics are present pre-operatively, and importantly if these measures
alter as a potential consequence of APM in middle-aged individuals
with degenerative meniscal tears at high risk of knee osteoarthritis.
The aim of this exploratory study was to compare changes in knee
joint biomechanics from before to after APM between the injured and
contralateral leg during a forward lunge. We hypothesized that knee
joint biomechanics would alter in the injured leg compared to the
contralateral leg as a potential result of APM.

2. Materials and methods

2.1. Patients

Individuals with a medial degenerative meniscal tear eligible for

APM were recruited from Odense University Hospital, Odense,
Denmark and Lillebaelt Hospital, Kolding, Denmark and Orthopedic
Clinic Fyn, Odense, Denmark. Patients were considered to have a degen-
erative meniscal tear based on age (3555 years) and how their knee
pain developed. Patients were asked how did the knee pain/problems
for which you are now having surgery develop? and provided with
the following options: a) the pain/problem evolved slowly over time;
b) as a result of a specic non-violent incident (i.e., kneeling, sliding
and/or twisting or similar); and c) as a result of a violent incident (i.e.,
during sports, a crash or similar). Patients who responded either a) or
b) were considered to have a degenerative meniscal tear and were
eligible. Exclusion criteria included: previous knee surgery, injuries/
problems limiting physical activity within the last 30 days, very low
activity level (e.g. walking restricted to indoors only), and radiographic
osteoarthritis dened as KellgrenLawrence grade 2 or above [20].
Ethical approval was provided by the Regional Scientic Ethics
Committee of Southern Denmark (ID: S-20120006). Patients provided
written informed consent.
2.2. Forward lunge analysis
Patients were assessed before (~ 2 weeks) and after (~ 12 weeks)
APM. Kinematic (100 Hz) and ground reaction force data (1000 Hz)
were synchronously collected using a 6 MX03-camera motion analysis
system (Vicon, Oxford, UK), one force plate (AMTI 0R6-7 Series Inc.,
Watertown, MA, USA) and a standard plug-in-gait marker set [21,22].
Following standardised instruction and familiarisation, patients per-
formed a forward lunge equivalent to their leg length [23]. Patients
were instructed to perform a forward lunge onto the force plate whilst
barefoot, with the aim to ex the leading knee to 90 and return to a
standing position. Patients were asked to maintain their trunk in an up-
right position during the forward lunge and ensure the contralateral leg
maintained oor contact throughout the duration of the lunge. With the
order of leading leg randomised, patients were instructed to perform
three trials in a smooth motion, for each leg, at a self-selected speed.
We considered the use of self-selected lunge speed appropriate as
patients were undergoing surgery.
In accordance with Thorlund et al. [23], stance was dened as the pe-
riod from foot strike to toe-off and the loading phase was dened from
foot strike to 80% of the peak ground reaction force (Fig. 1). Kinematic
data were ltered using a Woltring lter (mean square error of
15 mm2) and ground reaction force data were ltered using a 40 Hz
low-pass fourth order zero lag lter. External knee moments and im-
pulse were calculated using inverse dynamics (Vicon Plug-In-Gait;
Vicon) and were normalised to the product of body weight (N) and
Fig. 1. Representative vertical ground reaction force curve for one patient illustrating the
loading phase (dened from foot strike to 80% of vertical ground reaction force) and entire
stance phase.
body height (m). Loading rate was dened as the rate of change of
vertical ground reaction force during loading and was normalised to
body weight (N). Biomechanical dependent variables included: knee
adduction moment (peak during stance and impulse during loading),
peak knee exion moment (during stance), peak loading rate, and
knee exion angle (peak during stance and excursion during loading).
2.3. Self-reported measures
Before testing, patients scored their knee pain in both the injured
and contralateral leg on a 100 mm visual analogue scale (VAS) with ter-
minal anchors of no pain and worst pain possible [24]. Patients com-
pleted the Knee Injury Osteoarthritis Outcome Score (KOOS) item,
how troubled are you with the lack of condence in your knee in the
quality of life subscale and the KOOS sport and recreation subscale to
determine knee-related condence and difculties with strenuous
tasks [25] before and after APM.
2.4. Statistics
Paired t-tests and Wilcoxon signed rank tests were used to compare
biomechanical dependent variables preoperatively between the injured
and contralateral leg as appropriate. Change scores were calculated for
the dependent variables by subtracting the pre-operative scores from
post-operative scores. In the event where change scores did not
conform to the Gaussian distribution, data were squared and log-
transformed prior to analysis. A mixed linear model was used to evalu-
ate the difference in the change scores between legs with participant
entered as a random effect and leg (i.e., injured and contralateral leg)
as a xed effect in the model. Paired t-tests were used to compare VAS
pain between the APM leg and contralateral leg before and after APM,
and also to compare the change between legs from before to after sur-
gery. A chi squared test and a Wilcoxon signed rank test were used to
compare knee condence and self-reported function before and after
APM, respectively. Stata 13.1 (Statacorp, College Station, TX, USA) was
used for statistical analyses and signicance was set p b 0.05.
508 M. Hall et al. / The Knee 22 (2015) 506509

Table 1 Table 3
Baseline participant characteristics. Knee-related condence, before and after arthroscopic partial meniscectomy.

Characteristics n = 22 Before APM After APM p-Value

(n = 22) (n = 19)
Age (years) 47.0 (6.3)
Male, n (%) 17 (77) How troubled are you with condence
Body mass (kg) 81.32 (11.2) in your knee?
Body height (m) 1.78 (0.07) Not at all (n) 2 2 0.567
Body mass index (kg/m2) 25.7 (3.4) Mildly (n) 7 10
Affected knee (right:left) 14:8 Moderately (n) 7 5
Time before surgery (weeks) 2.8 (4.9)a Severely (n) 5 2
Time after surgery (weeks) 12.8 (1.2) Extremely (n) 1 0
Tear location, n: KOOS, sport and recreation subscale
Posterior 15 Mean (range)a 38.18 (090) 54.21 (0100) 0.004
Posterior and mid body 5
Boldface denotes p b 0.05; KOOS: Knee Injury Osteoarthritis Outcome Score; APM: arthro-
Mid body 1
scopic partial meniscectomy.
Anterior 1 a
0 represents worst possible score, 100 represents the best possible score.
Amount resected, n:b
025% 14
2650% 7 study, patients adapted an altered forward lunge movement strategy
N50% 0
as a potential consequence of APM. Our ndings show a 13% reduction
Values are mean (SD).
a
in the peak knee exion moment and approximately four degrees re-
One participant was 24.3 weeks.
b duction in peak knee exion angle during the forward lunge in the
Amount resected missing from one patient.
APM leg compared to the contralateral leg.
3. Results Our hypothesis that the APM leg would display altered knee joint
mechanics as a potential result of APM surgery was supported. Studies
At surgery, it was conrmed that all patients had a medial meniscal tear and no con- investigating the forward lunge and squat have observed increased pa-
comitant ACL, PCL or lateral meniscus damage, thus complying with eligibility criteria. The
tellar stress and contact force with increased knee exion angle [12,13].
majority of patients (91%) had a medial tear that involved the posterior horn resected by
025% (Table 1). Patients were predominantly male and slightly overweight according to Therefore, the reduced knee exion angle in the injured leg as potential
World Health Organisation standards [26] (Table 1). Before APM, the peak knee exion consequence of APM may reect a compensatory, protective motor
moment was lower in the injured leg compared to the contralateral leg (Table 2). Follow- strategy that might also reduce patellofemoral contact forces. Although
ing surgery, the peak knee exion moment decreased in the injured leg compared to the
this is perhaps clinically encouraging as patients are 2.6 times more like-
contralateral leg (Table 2). The adjusted peak knee exion angle also decreased in the in-
jured leg compared to the contralateral leg from before to after APM (Table 2). Patients ly to develop patellofemoral osteoarthritis following meniscectomy
self-reported less difculty with sport and recreation tasks and no change in knee- [12], the strengthening benets of this exercise are likely attenuated.
related condence was observed (Table 3). At baseline, patients reported greater VAS Additionally, in-vivo data suggest that knee exion moment alterations
pain for the APM leg (18.1 23.8 mm), compared to the contralateral leg (0.1 mediate medial tibiofemoral contact force [14]. As such, it is conceivable
0.2 mm, p = 0.0024). Similarly at follow-up, greater pain was reported for the APM leg
that the reduced peak knee exion moment in the injured leg alleviates
(11.3 16.0 mm), compared to the contralateral leg (2.0 5.3 mm, p = 0.0034). There
was no difference in the change of pain between legs (mean difference 7.1 medial tibiofemoral joint contact force in the recently operated medial
26.6 mm, 95% CI 20.6 to 2.3 mm, p = 0.118). One patient included in the analysis had compartment. As the knee exion angle is an easily modiable factor
their APM postponed following baseline testing and was assessed 24.3 weeks before sur- in determining the knee exion moment, we performed a post-hoc cor-
gery. Nonetheless, all results remained unchanged when excluding this patient from
relation to evaluate the relationship between the change in peak knee
analysis.
exion moment and the change in knee exion angle in the APM leg.
In contrast to a cross-sectional study in people with established osteoar-
4. Discussion thritis during gait [27], we observed no relationship between the
change in the exion angle and exion moment (r = 0.27; p = 0.22).
The forward lunge is a commonly prescribed exercise to improve Nonetheless, the current ndings indicate that knee joint biomechanics
physical function and knee muscle weakness following APM. In this following APM may have implications for knee joint loading and the

Table 2
Lower limb biomechanics during a forward lunge in people undergoing APM.

Before APM surgery
After APM surgery Unadjusted difference in the p-Value
change between legs given as
mean difference (95% CI)
(follow-up minus baseline)
Adjusted difference in the p-Value
longitudinal change between
legs as mean difference
(95% CI) (follow-up minus
baseline)a

Injured Contralateral Injured Contralateral Injured minus contralateral Injured minus contralateral

Loading duration (ms) 182 (67) 149 (47) 152 (53) 157 (69) 6 (63 to 50) 0.828 5 (39 to 30) 0.785
Peak KAM 2.03 (0.92) 2.34 (1.14) 1.90 (0.70) 2.24 (1.10) 0.02 (0.47 to 0.42) 0.919 0.17 (0.48 to 0.14) 0.276
(Nm/(BW HT)%)
KAM impulse 0.15 (0.14) 0.21 (0.15) 0.11 (0.15) 0.15 (0.17) 0.02 (0.08 to 0.11) 0.236c 0.02 (0.11 to 0.07) 0.712c
(Nms/(BW HT)%)b
Peak KFM 5.19 (1.53) 6.49 (1.23) 4.48 (1.47) 6.50 (1.77) 0.72 (1.42 to 0.02) 0.044 1.08 (1.80 to 0.35) 0.004
(Nm/(BW HT)%)
Max rate of loadingb (BW/s) 0.81 (1.09) 0.56 (0.47) 0.98 (1.14) 0.78 (0.16) 0.04 (0.32 to 0.24) 0.500c 0.04 (0.32 to 0.24) 0.379c
Peak knee exion angle () 94.70 (13.88) 98.39 (12.42) 87.44 (12.18) 93.50 (13.43) 2.37 (4.99 to 0.26) 0.078 3.94 (6.27 to 1.60) 0.001
Knee exion excursionb () 23.73 (14.38) 26.98 (14.44) 21.19 (11.92) 22.78 (13.92) 1.02 (5.77 to 3.74) 0.675 1.39 (5.27 to 2.50) 0.485

Boldface denotes p b 0.05; KAM, knee adduction moment; KFM knee exion moment.
a
Adjusting for baseline scores.
b
During the loading phase.
c
Log transformed.
 M. Hall et al. / The Knee 22 (2015) 506509
strengthening benets of the forward lunge in these patients may be at-
tenuated. Thus, alternative approaches to strengthening the quadriceps
in the months following surgery, such as resistance training, may be an
important adjunct to functional exercises.
Several possible suggestions may explain the altered knee joint bio-
mechanics observed during a forward lunge in the current study. First,
knee pain may inuence task performance, despite no change in pain
between legs, patients reported higher knee pain in the injured leg com-
pared to the contralateral leg at both assessments. Second, knee-related
condence may affect forward lunge performance and patients with
meniscal tears often report catching or locking of the knee. Although
the data show no change in knee-related condence as a result of
APM, only two patients report no issues relating to knee condence.
Third, self-reported difculty during strenuous tasks such as running,
jumping and pivoting may also affect knee biomechanics. Despite pa-
tients reporting improved function during strenuous tasks as a result
of APM, consistent with previous studies [25] our patients still reported
considerable difculties during these tasks compared to a reference
sample of similar age following surgery [28]. Overall, these reports of
pain, impaired knee-condence and difculties with strenuous tasks
may assist to explain the alterations in knee joint biomechanics during
a forward lunge as a result of APM.
Limitations of this study warrant consideration. First, the use of the
contra-lateral leg to compare against the injured leg may be considered
a limitation. However, to conclusively address the question regarding
the effect of APM on knee joint biomechanics would require a
randomised design with a sham surgery group. Third, we did not
measure in vivo knee joint loading. Nevertheless, the biomechanical
measures used in this study are known to reect knee joint load charac-
teristics [12,13,1517]. The fourth limitation relates to the performance
of the forward lunge. Patients performed the lunge at their own, self-
selected speed. As such, it is possible that the absolute speed at which
the forward lunge was performed inuenced our measures of loading.
Nonetheless, there was no difference in the duration of the loading
phase between assessments for either leg (Table 2), regressing concerns
that speed inuenced our measures. Finally, limiting the follow-up as-
sessment to three months post-APM may be viewed as a limitation as
participants may not be considered fully recovered from surgery.
5. Conclusions
The forward lunge is commonly used in rehabilitation to improve
physical function and knee muscle weakness. Despite patients reporting
improved function during strenuous tasks after APM, it appears that
patients continue to use less knee exion during the forward lunge
that may reect a protective strategy to limit excessive knee loads in
the recently operated leg.
6. Conict of interest
All authors declare that they have no conict of interest in the
authorship or publication of this contribution.
Acknowledgements
This study is supported by grants from The Danish Council for Inde-
pendent Research|Medical Sciences (#12-125457) and IMK Almene
Fond. We would like to thank the patients for their participation in the
study. Also we would like to acknowledge the Department of Orthope-
dics and Traumatology, Odense University Hospital, Odense and
Svendborg, Department of Orthopedics, Lillebaelt Hospital, Kolding
(Nis Nissen), MD Troels Laulund and project nurse Annie Gam-
Pedersen for their help. MH was supported by a PhD scholarship from
a National Health Medical Research Council, Australia program grant
509
(#631717) and an International Travel Grant from the International So-
ciety of Biomechanics.
References
[1] Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL. Global and regional burden
of disease and risk factors, 2001: systematic analysis of population health data.
Lancet 2006;9524:174757.
[2] Cushnagen J, Dieppe P. Study of 500 patients with limb joint osteoarthritis. 1. Anal-
ysis by age, sex and distribution of symptomatic joint sites. Ann Rheum Dis 1991;50:
813.
[3] Englund M, Roos EM, Lohmander LS. Impact of type of meniscal tear on radiographic
and symptomatic knee osteoarthritis: a sixteen-year followup of meniscectomy
with matched controls. Arthritis Rheum 2003;48:217887.
[4] Englund M, Lohmander LS. Patellofemoral osteoarthritis coexistent with
tibiofemoral osteoarthritis in a meniscectomy population. Ann Rheum Dis 2005;
64:17216.
[5] Kurosawa H, Fukubayshi T, Nakajima H. Load-bearing mode of the knee joint:
physical behavior of the knee joint with or without menisci. Clin Orthop 1980;
149:28390.
[6] Seedhom BB, Hargreaves DJ. Transmission of the load in the knee joint with special
reference to the role of the meniscus. Part I + II. Eng Med 1979;4:20728.
[7] Felson DT. Osteoarthritis as a disease of mechanics. Osteoarthritis Cartilage 2013;21:
105.
[8] Caserotti P, Aagaard P, Simonsen EB, Puggaard L. Contraction-specic differences in
maximal muscle power during stretch-shortening cycle movements in elderly males
and females. Eur J Appl Physiol 2001;84:20612.
[9] Stensrud S, Risberg MA, Roos EM. Knee function and knee muscle strength in
middle-aged patients with degenerative meniscal tears eligible for arthroscopic par-
tial meniscectomy. Br J Sports Med 2014;48:7848.
[10] Hall M, Wrigley TV, Metcalf BR, Hinman RS, Dempsey AR, Mills PM. A longitudinal
study of strength and gait after arthroscopic partial meniscectomy. Med Sci Sports
Exerc 2013;45:203643.
[11] Roos EM, Roos HP, Ryd L, Lohmander LS. Substantial disability 3 months after arthro-
scopic partial meniscectomy: a prospective study of patient-relevant outcomes.
Arthroscopy 2000;16:61926.
[12] Escamilla RF, Zheng N, MacLeod TD, Edwards WB, Hreljac A, Fleisig GS.
Patellofemoral joint force and stress between a short- and long-step forward
lunge. J Orthop Sports Phys Ther 2008;38:68190.
[13] Powers CM, Ho KY, Chen YJ, Souza RB, Farrokhi S. Patellofemoral joint stress during
weight-bearing and non-weight-bearing quadriceps exercises. J Orthop Sports Phys
Ther 2014;44:3207.
[14] Walter JP, D'Lima DD, Colwell CW, Fregly BJ. Decreased knee adduction moment
does not guarantee decreased medial contact force during gait. J Orthop Res 2010;
28:134854.
[15] Amin S, Luepongsak N, McGibbon CA, LaValley MP, Krebs DE, Felson DT. Knee adduc-
tion moment and development of chronic knee pain in elders. Arthritis Rheum
2004;51:3716.
[16] Bennell KL, Bowles KA, Wang YY, Cicuttini F, Davies-Tuck M, Hinman RS. Higher dy-
namic medial knee load predicts greater cartilage loss over 12 months in medial
knee osteoarthritis. Ann Rheum Dis 2011;70:17704.
[17] Miyazaki T, Wada M, Kawahara H, Sato M, Baba H, Shimada S. Dynamic load at
baseline can predict radiographic disease progression in medial compartment
knee osteoarthritis. Ann Rheum Dis 2002;61:61722.
[18] Bulgheroni P, Bulgheroni MV, Ronga M, Manelli A. Gait analysis of pre- and post-
meniscectorny knee: a prospective study. Knee 2007;14:4727.
[19] Durand A, Richards CL, Malouin F, Bravo G. Motor recovery after arthroscopic partial
meniscectomy. Analyses of gait and the ascent and descent of stairs. J Bone Joint
Surg Am 1993;75:20214.
[20] Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis
1957;16:494502.
[21] Davis RB, Ounpuu S, Tyburski D, Gage JR. A gait analysis data collection and reduc-
tion technique. Hum Mov Sci 1991;10:57587.
[22] Kadaba MP, Ramakrishnan HK, Wooten ME. Measurement of lower extremity kine-
matics during level walking. J Orthop Res 1990;8:38392.
[23] Thorlund JB, Damgaard J, Roos EM, Aagaard P. Neuromuscular function during a for-
ward lunge in meniscectomized patients. Med Sci Sports Exerc 2012;44:135865.
[24] Bellamy N. Osteoarthritis clinical trials: candidate variables and clinimetric proper-
ties. J Rheumatol 1997;24:76878.
[25] Roos EM, Roos HP, Ekdahl C, Lohmander LS. Knee injury and osteoarthritis outcome
score (KOOS) validation of a Swedish version. Scand J Med Sci Sports 1998;6:
43948.
[26] Obesity: preventing and managing the global epidemic. Report of a WHO consulta-
tion. World Health Organisation Tech Report Ser, 894. ; 2000. p. 1253 [i-xii].
[27] Creaby MW, Hunt MA, Hinman RS, Bennell KL. Sagittal plane joint loading is related
to knee exion in osteoarthritic gait. Clin Biomech (Bristol, Avon) 2013;28:91620.
[28] Paradowski PT, Bergman S, Sunden-Lundius A, Lohmander LS, Roos EM. Knee com-
plaints vary with age and gender in the adult population. Population-based refer-
ence data for the Knee injury and Osteoarthritis Outcome Score (KOOS). BMC
Musculoskelet Disord 2006;7:38.