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Year : 2019  |  Volume : 33  |  Issue : 2  |  Page : 76-80

Association between the lower extremity biomechanical factors with osteoarthritis of knee

Department of Physiotherapy, K M Patel Institute of Physiotherapy, Karamsad, Gujarat, India

Date of Submission18-Sep-2018
Date of Decision17-Nov-2018
Date of Acceptance14-Sep-2019
Date of Web Publication11-Feb-2020

Correspondence Address:
Jigar Mehta
K M Patel Institute of Physiotherapy, Karamsad, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jms.jms_59_18

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Introduction: Osteoarthritis (OA) of the knee joint is one of the causes of pain and physical disability. Our aim is to prevent the OA of the knee joint. Hence, to prevent and to treat, the OA knee pain needs to find an association between various biomechanical factors of the lower limb and OA knee pain. Therefore, to assess the association between the lower extremity biomechanical factors with osteoarthritis of knee pain.
Materials and Methods: Our study was a cross-sectional study, in that we have taken fifty participants who already diagnosed OA. The various biomechanical factors of the lower limb were measured along with outcome scales such as the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for the OA knee and Numeric Rating Scale (NRS) for the knee pain from each participant.
Results: There was a significant correlation found between femoral anteversion and navicular drop with WOMAC scale with a P = 0.001 and 0.03, respectively. The significant correlation between femoral anteversion, hamstring muscle length, Q angle (dynamic), and tibial torsion with NRS pain scale with P = 0.07, 0.06, 0.07, and 0.06, respectively.
Conclusion: The study concluded that body mass index, femoral anteversion, hamstring's length, navicular drop, tibial torsion, and Q angle (dynamic) are various biomechanical factors which might be responsible for the incidence of the OA knee along with functional limitation and OA knee pain.

Keywords: Biomechanical factors, femoral anteversion, first ray of foot, hamstring length, navicular drop, osteoarthritis knee pain, Q angle, tibial torsion

How to cite this article:
Parekh S, Mehta J, Vaghela N, Ganjiwale D. Association between the lower extremity biomechanical factors with osteoarthritis of knee. J Med Soc 2019;33:76-80

How to cite this URL:
Parekh S, Mehta J, Vaghela N, Ganjiwale D. Association between the lower extremity biomechanical factors with osteoarthritis of knee. J Med Soc [serial online] 2019 [cited 2021 Dec 7];33:76-80. Available from:

  Introduction Top

Osteoarthritis (OA) knee pain is a significant health problem worldwide, affecting approximately 10% of men and 18% of women over 60 years of age. OA knee pain is a major cause of morbidity, disability, and deficit in daily activities.[1] Some physical risk factors may also be associated with an increased rate of early onset of OA knee pain and require further investigation.[2] For example, longitudinal studies provide evidence of a significantly increased risk of knee pain, 12–20 years postknee injury (i.e., meniscus or anterior cruciate ligament injury).[3] In addition, there is evidence that knee and ankle injuries, specifically, result in an increased risk of early development of OA knee leading to knee pain.[4]

There has been increased health-care cost in various countries due to joint damage related to injury, sports specificity, physical activity, overweight/obesity, and occupational activity which may lead to OA Knee pain, so it is necessary to take a step towar prevention and reduce down the rising health-care costs. OA knee pain has a multifactorial nature and multiple parameters have been proposed as potential risk factors, classified as intrinsic and extrinsic.[5] Some of the intrinsic factors are modifiable and may be approached in treatments. Identification of potentially modifiable risk factors for lower extremity joint pain is critical to inform the development and evaluation of primary and secondary prevention strategies targeted to reduce the significant burden of knee pain. While there are several contributions in the literature identifying risk factors for knee pain, there has not been a comprehensive review examining modifiable physical risk factors associated with the onset of hip, knee, and ankle pain.[6]

The role of biomechanical factors in the pathogenesis of knee OA has been well described. Radin et al. suggested that one of the mechanisms of initiation and progression of articular cartilage damage is increased density or stiffness of the underlying subchondral bone. Although chondrocytes of the articular cartilage can adapt to the changing demands placed upon them, they may still fail when subjected to supraphysiological mechanical stress for long periods of time.[7] In epidemiological studies, people whose occupations require repetitive knee bending and high physical demand show higher rates of subsequent radiographic knee OA than those with less physically demanding occupations.[8],[9] Obesity is a potentially important biomechanical factor, but it is also associated with systemic and hormonal factors responsible for bone and cartilage metabolism,[10] especially in women, thus making it difficult to interpret its biomechanical effects on the progression of OA. Biomechanical studies have proven association of lower limb flexibility of iliotibial band and strength of the quadriceps muscles, strength deficit in hamstrings, quadriceps, hip abductors and external rotators abnormal vastus medialis oblique/vastus lateralis reflex timing, an excessive quadriceps (Q) angle, patellar compression, or tilting. Other causes may include poor mechanics with activities such as weight lifting, a change in shoes or bike fit, and incorrect or worn out footwear.[11]

There are many outcome measures which are used for functional assessments of OA knee pain, namely, Visual Analog Scale, Functional Index Questionnaire, but for the pain severity and functional usually assessed by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale, which is valid and reliable tool.[12]

Therefore, the present study was undertaken to identify potentially biomechanical risk factors which might be responsible for OA knee pain. Hence, it was hypothesized that there would be an association between biomechanical risk factors with OA knee pain. So, the aim of the present study is to find the association between the biomechanical factors of the lower extremity with the OA knee joint.

  Materials and Methods Top

This study is a cross-sectional study that was conducted in the Outpatient Department of the tertiary care hospital in Western Gujarat in Anand district with convenient sampling. A total of fifty participants were recruited for the present study with inclusion criteria participant age should be >40 years, the participant should have first episode of knee pain, symptom >4 weeks, history consists of following activities: aascending/descending stairs, hoping jogging, and prolonged sitting squatting. Participants having a history of previous knee fractures, the traumatic onset of knee pain, neurological symptoms, limb length discrepancy, systemic arthritis, peripatellar bursitis, or tendonitis were excluded from the study.

The research project was conducted after getting clearance from the Human Research Ethics Committee of the institution. The participants were included who fulfilling the inclusion and exclusion criteria. Participants were made aware of the purpose and procedure of the study. Then, written consent from the participants were obtained prior to data collection demographic data including age, gender, height, weight, prior history of knee problems, mechanism of injury, current episode duration, and symptom location was recorded following the physical examination including following measurements were carried out.

Femoral anteversion

It was measured by using Craig's test with the participant in prone position and knee flexed to 90°. The examiner palpates the posterior aspect of the greater trochanter of the femur. The hip was passively rotated until the most prominent portion of the greater trochanter reached the horizontal plane. The degree of anteversion was estimated based on the angle of the lower leg with the vertical.[13]

Q angle

It was measured with the knee in full extension and the supine position. The angle formed by the intersection of the line of application of the quadriceps force, with the center of the patella tendon was measured in degrees with the goniometer. The same procedure was done in standing for the dynamic Q angle.

Navicular drop

Navicular height was measured from the floor to the most anterior-inferior portion of the navicular. Foot measurements were taken in two stance conditions: 10% of weight bearing and 90% of weight bearing. Participants were weighed on a standard scale, and 10% and 90% of each participant's total weight were calculated. For the measurements, the participants were made to stand with their hands resting on a countertop for the support and also they were using to assist in controlling their amount of weight bearing. Then, they were asked to place one foot on the scale and the other foot on an even adjacent surface. The patients were asked to lower their amount of weight bearing by lifting the foot on the scale straight up and not leaning to either side until the scale showed that 10% of weight bearing achieved. Foot measurements were taken. The process was repeated for 90% of weight bearing. The most navicular height was measured from the floor to the most anterior-inferior portion of the navicular bone.[14]

First ray of foot

Foot was placed on the floor then the angle of the first ray was measured between the floor and the long axis of the first metatarsal using a goniometer.[14]

Lower extremity muscle length

The hamstring and a calf muscle length test were checked for lower extremity. The participants remove their footwear. The assistant secures the ruler to the box top with the tape so that the front edge of the box lines up with the 15 cm (6 inches) mark on the ruler and the zero end of the ruler points toward the participants. The participants sit on the floor with their legs fully extended with the bottom of their bare feet against the box. The participants place one hand on top of the other, slowly bends forward, and reaches along the top of the ruler as far as possible holding the stretch for 2 s. The assistant records the distance reached by the participant's fingertips (cm). The participants perform the test three times. The assistant calculates and records the average of the three distances and uses this value to assess the participant's performance.[15]

Tibial torsion

Patient position is in a prone-lying position. With the patient's knee flexed 90, the ankle in the neutral position, and the sole parallel to the floor, the angle between the longitudinal axis of the thigh and longitudinal axis of the foot was measured.[16]

All measurements were obtained from the participants who were diagnosed as OA knee from the physician or orthopedics clinics. Investigators also recorded WOMAC score to know the effect of the OA knee of their daily activities, along with the Numeric Rating Scale (NRS) for the pain assessment.

  Results Top

In the present study, a total of fifty patients were recruited in that minimum age of the participant is 41 years and maximum age is 83 years with mean 62 years and standard deviation (SD) 29.62 years. [Table 1] represents the minimum and maximum value and mean and SD of the all biomechanical factors.
Table 1: Characteristics of participants

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For the correlation Pearson's correlation test was used, where all the variables were analyzed [Table 2] values shows the P value between all factors with WOMAC and NRS in movement, in which WOMAC pain component had clinically correlation with femoral anteversion with P= 0.001 and navicular drop with the P= 0.03. Whereas, NRS shows P value was significantly correlated with body mass index (BMI) (P = 0.031), femoral anteversion (P = 0.077), hamstring length (P = 0.06), Q angle dynamic (P = 0.07), and tibial torsion (P = 0.06). (P < 0.05) all biomechanical factors were measured, and correlated with all components of the WOMAC scale and NRS pain scale.
Table 2: Relationship between factors and OA knee paint

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  Discussion Top

The existing literature has found a strong correlation between various biomechanical factors with knee pain. Considering the same fact, the present study aimed to find the association between the biomechanics of lower extremities and OA. A biomechanical factor which is femoral anteversion and navicular drop which strongly correlate with WOMAC scale. Along with that, there is a strong correlation between BMI and NRS pain scale. A biomechanical factor which were a moderate correlation with hamstring length, Q angle, and tibial torsion with NRS pain scale. In the current study, we found that there is a strong correlation between the WOMAC and femoral anteversion. Similar findings were found in study conducted by the Papaioannou et al. in 2013 which can be explained by that alteration of femoral version its tendency of the medial compartment to establish its bearing toward posteromedial directions at the knee joint, as a consequence of that changes leads to corresponding anteroposterior changes of the hip center over the horizontal tibiofemoral plan. Altered femoral neck version was associated with increased pressure of the medial knee compartment up to 28.5%. So it can be one of the reasons for the increase in pain and functional improvement of the knee joint.[17] The present study shows that there is a strong correlation between WOMAC and navicular drop. A study conducted by Levinger et al. in 2010 found the same findings, and it explained that as navicular drop occurs in the patient with OA knee, pronation of foot would be more likely to occur, and thus, it leads to lateral force vector on patella and between the lateral face of patella and lateral femoral condyle that is in standing position along with the stress would be more over to the lateral condyle of knee joint, but the more the compressive load weight bearing or line of gravity would be shifted more to the medial condyle of the knee joint.[18] In the present study, it has a strong association between the NRS pain scale and BMI. Powell et al. in 2005 showed a strong correlation between BMI and OA knee. It has explained that obesity will reduce the range of motion of the joint that leads to stiffness in the joint and reduce the flexibility of the soft tissue. In addition to this, adductor force which is associated with an increase in the area of tibial bone rather than the amount of knee cartilage leads to the more risk of the degenerative changes of the cartilages. Another reason can be that there will be more vertical forces over the knee joint and leads to axial loading can be changed in articular cartilages leads to OA knee.[19],[20] This study indicates that there is a moderate correlation between NRS pain scale of the OA knee and hamstring muscle length, a study conducted on the OA knee patient they found a strong correlation between knee pain to hamstring length. It can be explained by that shortening of the hamstring muscle results in weakening of quadriceps femoris muscle, producing muscle imbalance, and with hamstring tightness if one has to extend knee, then extrapower is needed from the quadriceps femoris which will increase the reaction force on patella femoral joint and causes pain. The other reason could be that as age increases alteration seen at cellular level. So, that leads to decreases in the range of motion and muscle flexibility. Therefore, it indicates that loss of hamstring muscle length affects knee joint and its articulation.[21] In the current study, there is a moderate correlation between Q angle (dynamic) and NRS pain scale. A study was done by Cahue et al. in 2004 gave evidence of quadriceps muscle achieving extension or flexion with the patella lever arm, so that distribution of compressive stress on the femur which acts as a guide for quadriceps tendon to centralize at patella.[22] It serves a bony shield to protect the cartilage. Theoretically, aspect suggested that bi compartment patello-femoral (PF) OA progression in settings of varus may reflect the varus stress on medial patella femoral joint. The changes in Q angle resulted in a medial shift of the contact area, with unloading of the lateral facet, or separation of contact areas into distinct lateral and medial region.[22] The study has evidence of a moderate correlation between tibial torsion and NRS pain chart. The previous study done by Mandeville et al. in 2011 suggested that tibial torsion or external rotation of the tibia lead to torsion deformity on the insertion sites of the extensor musculature, if insertion of four muscles to the patella has properly aligned, then there is equal weight-bearing force and stress will be equally distributed, but if there is malalignment at the insertion site, then more stress comes to lateral patella femoral joint and weight bearing goes to medial patella femoral joint. Hence, there will be more chances of degeneration at medial condyle of patella femoral joint compartment.[23]


In the present study, the sample size was small, so the same study can be conducted in the larger sample size. Along with that, all factors were measured clinically, for that one can use the sophisticated tools to measure the values of the various biomechanical factors.

  Conclusion Top

The present study concluded that femoral anteversion and navicular drops were major biomechanical factors that affect the OA knee pain and functional activity limitation. Whereas, BMI, femoral anteversion, hamstring length, Q angle (dynamic), and tibial torsion were moderate factors which affect the OA knee pain.


This study should be conducted with the larger sample size and participant should be confirmed diagnose with the radiograph.


We sincerely thanks to Dr. R. Harihara Prakash for their guidance and support during the study, we would also like to thank Noopur Patel, Rinkal Shah and Shivani Dave for their help in literature search and data collection as well as the statistics department of our Institute to help us with the analysis of the study data and lastly we would like to extend our gratitude towards the IEC Committee for approving our research proposal and to all the participants for contributing in our study without them the study would not have been completed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bull World Health Organ 2003;81:646-56.  Back to cited text no. 1
Lohmander LS, Englund PM, Dahl LL, Roos EM. The long-term consequence of anterior cruciate ligament and meniscus injuries: Osteoarthritis. Am J Sports Med 2007;35:1756-69.  Back to cited text no. 2
Griffin LY, Albohm MJ, Arendt EA, Bahr R, Beynnon BD, Demaio M, et al. Understanding and preventing noncontact anterior cruciate ligament injuries: A review of the hunt valley II meeting, January 2005. Am J Sports Med 2006;34:1512-32.  Back to cited text no. 3
Zazulak BT, Hewett TE, Reeves NP, Goldberg B, Cholewicki J. Deficits in neuromuscular control of the trunk predict knee injury risk: A prospective biomechanical-epidemiologic study. Am J Sports Med 2007;35:1123-30.  Back to cited text no. 4
Bahr R, Holme I. Risk factors for sports injuries – A methodological approach. Br J Sports Med 2003;37:384-92.  Back to cited text no. 5
Richmond SA, Fukuchi RK, Ezzat A, Schneider K, Schneider G, Emery CA. Are joint injury, sport activity, physical activity, obesity, or occupational activities predictors for osteoarthritis? A systematic review. J Orthop Sports Phys Ther 2013;43:515-B19.  Back to cited text no. 6
Radin EL, Burr DB, Caterson B, Fyhrie D, Brown TD, Boyd RD. Mechanical determinants of osteoarthrosis. Semin Arthritis Rheum 1991;21:12-21.  Back to cited text no. 7
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;61:617-22.  Back to cited text no. 8
Buckwalter JA, Saltzman C, Brown T. The impact of osteoarthritis: Implications for research. Clin Orthop Relat Res 2004;427:S6-15.  Back to cited text no. 9
Teichtahl AJ, Wluka AE, Proietto J, Cicuttini FM. Obesity and the female sex, risk factors for knee osteoarthritis that may be attributable to systemic or local leptin biosynthesis and its cellular effects. Med Hypotheses 2005;65:312-5.  Back to cited text no. 10
Griffin TM, Huebner JL, Kraus VB, Guilak F. Extreme obesity due to impaired leptin signaling in mice does not cause knee osteoarthritis. Arthritis Rheum 2009;60:2935-44.  Back to cited text no. 11
Litcher-Kelly L, Martino SA, Broderick JE, Stone AA. A systematic review of measures used to assess chronic musculoskeletal pain in clinical and randomized controlled clinical trials. J Pain 2007;8:906-13.  Back to cited text no. 12
Souza RB, Powers CM. Concurrent criterion-related validity and reliability of a clinical test to measure femoral anteversion. J Orthop Sports Phys Ther 2009;39:586-92.  Back to cited text no. 13
Williams DS, McClay IS. Measurements used to characterize the foot and the medial longitudinal arch: Reliability and validity. Phys Ther 2000;80:864-71.  Back to cited text no. 14
Gabbe BJ, Bennell KL, Wajswelner H, Finch CF. Reliability of common lower extremity musculoskeletal screening tests. Phys Ther Sport 2004;5:90-7.  Back to cited text no. 15
Shultz SJ, Nguyen AD, Windley TC, Kulas AS, Botic TL, Beynnon BD. Intratester and intertester reliability of clinical measures of lower extremity anatomic characteristics: Implications for multicenter studies. Clin J Sport Med 2006;16:155-61.  Back to cited text no. 16
Papaioannou TA, Digas G, Bikos CH, Karamoulas V, Magnissalis EA. Femoral neck version affects medial femorotibial loading. ISRN Orthop 2013;2013:328246.  Back to cited text no. 17
Barton CJ, Bonanno D, Levinger P, Menz HB. Foot and ankle characteristics in patellofemoral pain syndrome: A case control and reliability study. J Orthop Sports Phys Ther 2010;40:286-96.  Back to cited text no. 18
Powell A, Teichtahl AJ, Wluka AE, Cicuttini FM. Obesity: A preventable risk factor for large joint osteoarthritis which may act through biomechanical factors. Br J Sports Med 2005;39:4-5.  Back to cited text no. 19
Holliday KL, McWilliams DF, Maciewicz RA, Muir KR, Zhang W, Doherty M. Lifetime body mass index, other anthropometric measures of obesity and risk of knee or hip osteoarthritis in the GOAL case-control study. Osteoarthritis Cartilage 2011;19:37-43.  Back to cited text no. 20
Woods C, Hawkins RD, Maltby S, Hulse M, Thomas A, Hodson A. The football association medical research programme: An audit of injuries in professional football – Analysis of hamstring injuries. Br J Sports Med 2004;38:36-41.  Back to cited text no. 21
Cahue S, Dunlop D, Hayes K, Song J, Torres L, Sharma L. Varus-valgus alignment in the progression of patellofemoral osteoarthritis. Arthritis Rheum 2004;50:2184-90.  Back to cited text no. 22
Krackow KA, Mandeville DS, Rachala SR, Bayers-Thering M, Osternig LR. Torsion deformity and joint loading for medial knee osteoarthritis. Gait Posture 2011;33:625-9.  Back to cited text no. 23


  [Table 1], [Table 2]


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