Abstract

Introduction:Knee Osteoarthritis (OA) is a growing musculoskeletal burden,

globally. Knee OA is characterized by deterioration of articular cartilage resulting in
stiffness, pain, disability and impaired ability to perform function. Increasing
prevalence and early manifestation of OA demand exploration of risk factors and
healthy life style practices that can be adopted to delay its onset. However, negligible
efforts are noticed in the pre-clinical phase of OA to delay degenerative changes
occurring in knee by improving regular physical activity. Squatting, in addition to
being an inclusive component of ADL, is one such activity which can be self-
administered by an individual to strengthen lower limb muscles, improve joint motion
and provide the necessary loading stimulus to maintain articular cartilage health.
Articular cartilage is known to be influenced by habitual physical loading stimulus.
Multi-factorial interaction between biomechanical variables of loading, biochemical
markers of articular cartilage degradation and structural defects in the cartilage, would
enable early identification of altered mechanical loading and change in the tissue
biochemistry which serve as risk factors for development of early knee OA.
Understanding the dose-dependent response of articular cartilage in people with
varying habitual squatting exposure will enable guiding prescription of this excellent
weight-bearing activity as a life style measure to maintain mobility, muscle strength
and cartilage health which may delay early onset OA in healthy adults.

Aims and objectives: This study aimed to explore effect of squatting on knee
articular cartilage in healthy adults. Objectives of the study were i)to quantify squat
exposure, ii)to analyse natural biomechanical adaptations in terms of knee joint
motion, loading characteristics and muscle activity in healthy adults in age group 30-
45 years, with varying squat exposure i.e. non squatters(NS)-people who do not squat,
activity of daily living squatters (ADLS)-people who adopt squatting for activities of
daily living and occupational squatters(OS)-people who squat for performing
occupational activities.Secondary objectives of the study were to explore associations
between knee articular cartilage characteristics, levels of biochemical biomarker
urinary collage type II telopeptide (uCTx II), super-oxide scavenging activity, level of
habitual physical activity and BMI. Lastly, effect of deep-squatting intervention was
observed inexperimental and control group of non-squatters, to establish squatting as
an effective life-style strategy to improve lower extremity muscle strength.
Methods:Ethical approval was obtained from Ethical Committee for Research on
Human Subjects. Six hundred and fifty adults (375 females; 275 males, age 30-60
years)were recruited for a survey from rural and urban areas near Mumbai and Navi
Mumbai,Maharashtra. Written informed consent was soughtfrom all participants.

Demographic and anthropometric data were recordedand survey questionnaires were

administered. Socio-economicstatus was assessed using the Modified Kuppuswamy
Scale 2016. Magnitude of kneepain was assessed using Numeric Rating Scale (NRS).
Severity of pain, stiffness, and functional performancewas assessed using the
Modified Western Ontario and McMaster UniversitiesOsteoarthritis Index
(WOMAC).

The International Physical Activity Questionnaire (IPAQ) Short Version was usedto
assess level of habitual physical activity in low, moderate, and vigorous categories.
Participants were categorized based on dailysquat exposure into three groups: non-
squatters (no squat exposure), ADL-squatters (squats for self-care, household chores,
and leisure activities), and occupational-squatters(more than 60 minutes per day in
squats for occupation-related activity). Fifty people from each group (25 males, 25
females) and 30 people with knee OA (15 females:15 males, age 30-45 years) were
evaluated clinically. Outcome measures used were daily squat exposure, habitual
physical activity level, BMI, knee flexion angle in deep-squat and muscle strength
(using 30-second deep-squat test). Further, 100 participants (n=25 from each group)
underwent comprehensive biomechanical and biochemical evaluation. Kinematics and
kinetics during squatting were captured using 3D motion capture and muscle activity
using surface EMG from erector spinae, rectus abdominis, gluteus maximus, gluteus
medius, vastus lateralis, biceps femoris and gastrocnemius.

Second morning sample of urine was used to analyse urine cartilage telopeptide type
II collagen. Superoxide scavenging activity and phospholipase A2 activity in sweat
were explored as potential biomarkers.

Outcome variables analyzed were knee flexion angle in deep-squat, external knee
flexion and adduction moment representative of joint loading, root mean square of
muscle activity as a percent of maximum voluntary contraction as an adjunct measure
of muscle force, biochemical markers indicative of knee articular cartilage damage
uCTxII, sweat super oxide scavenging activity and phospholipase A2 (PLA2) activity.

Magnetic Resonance Imaging of knee (MRI) was performed for right knee in healthy
people or affected knee in people with knee OA in 47 participants. Structural mapping
of knee articular cartilage was performed using MRI Osteoarthritis Knee Score
(MOAKS). Outcome variables were compared among the three groups of healthy
adults using ANOVA or Kruskal-Wallis test as deemed appropriate for inferential
testing. Knee OA group was used as a reference group demonstrating established
changes of knee OA.

Further, a deep squatting intervention was administered to 25 non-squatters. 2D knee

flexion angle in deep-squat, deep-squat test repetitions and force developed during
trunk-leg dynamometry were used as outcome measures reflecting knee motion and
lower extremity muscle strength.

Results:Highest squat exposure was reported by occupational-squatters (average 104

min),ADL-squatters with moderate exposure (30min) while non-squatters reported nil
squat exposure. The interview-based survey revealed greatest prevalence of knee pain
in occupational squatters (33.2%), followed by non-squatters (21.5%) and lowest in
ADL squatters (18.7%). The clinical-testing based observation was replicated on MRI
which revealed highest prevalence of structural defects in knee articular cartilage in
occupational squatters (55%), followed by non-squatters (28%) and lowest in ADL
squatters (15%). Biomechanical evaluation revealed greater knee flexion angles in
squatting (p<0.001) and greater muscle strength (force during dynamometry) in
occupational squatters whereas high compressive loading (external knee flexion
moment) with lower muscle strength and motion was observed in non-squatters.
Associations were observed between BMI, external knee adductor moment, uCTxII,
and superoxide scavenging activity. Lastly, squatting intervention led to significant
increase in knee flexion angle and lower extremity muscle strength.

Discussion: Squatting exposure wasquantified using a novel validated tool.

Observations from the study support the hypothesis that high exposure to sustained
deep-squatting activity serves as a risk factor for early knee OA. People with nil squat
exposure demonstrated presence of risk factors such as high BMI, low physical
activity level, low antioxidant activity and structural defects in cartilage which can
serve as precursors towards development of knee OA in subsequent years.

People with moderate squat exposure demonstrated positive results such as better
knee motion, muscle strength, healthy BMI and lowest prevalence of changes in
articular cartilage.People with high squat exposure demonstrated greatest knee
motion, muscle strength and lowest BMI. Despite these positive factors, they
presented with greater prevalence of cartilage defects. Thus, a J shaped dose-
dependent relationship was observed between quantum of squatting exposure (ranging
from nil to high) and knee function.

Incorporating dynamic squatting in life style activities (for upto 30 min) may maintain
optimal knee health and potentially demonstrate a right-shift in the chronological age
at which OA knee is symptomatic. A longitudinal randomised controlled trial needs to
be undertaken to establish the same.

Conclusion:MGMGLAE Questionnaire emerged as reliable and valid tool for

quantifying exposure squatting exposure. People belonging to urban and rural areas
demonstrated a wide spectrum of daily squat exposure, ranging from 0 to 480 min.
People with moderate-high squat exposure demonstrated greater knee motion and
muscle strength compared to people with no squat exposure Positive correlations
between body mass, biochemical markers indicative of cartilage damage-urinary
CTxII, antioxidant and inflammatory activity and external knee adduction moment,
emphasized the association between micro-level biochemical-biomarkers and macro-
level biomechanical-markers.
Negative correlation between presence of alteration of articular cartilage morphology,
decrease in knee flexion angle in deep squat and 30 sec deep squat test repetitions,
indicate the utility of these non-invasive clinical tests for early identification of knee
OA.Both high and low squat exposure emerged as risk factors suggestive of early
knee OA.
Early intervention using load bearing activity such as squatting in appropriate
dosimetry was effective in increasing knee flexion angles and muscle strength in
healthy non-squatters in pre-OA age group.
Clinical applications: Deep-squatting emerged as a beneficial lifestyle activity which
can be prescribed as a therapeutic intervention among people with pre-OA to increase
knee motion and muscle strength. Dynamic squatting activity may be incorporated
into ADL or be included as an exclusive exercise intervention to maintain lower
extremity function.Thus, early identification of risk factors using non-invasive
methods and institution of early preventive therapeutic measures such as maintenance
of ideal body mass, engaging in moderate level of activities that optimally load the
knee joint such as squatting, enhancing anti-oxidant status of the body through
physical activity, may help to delay the onset of symptomatic knee OA.

Additionally, kinematic findings from this study may help in the design of better
indigenous, tailor-made artificial joints, prostheses and orthoses that can
accommodate demands of traditional lifestyle activities of Indian and Asian culture
and increase acceptance of knee replacement surgeries.