Knee extension range of motion and self-report physical function in total knee arthroplasty: mediating effects of knee extensor strength
- Yong-Hao Pua†1Email author,
- Peck-Hoon Ong†1,
- Hwei-Chi Chong1,
- William Yeo2,
- Celia Tan3 and
- Ngai-Nung Lo4
© Pua et al.; licensee BioMed Central Ltd. 2013
Received: 13 July 2012
Accepted: 15 January 2013
Published: 18 January 2013
Knee extensor strength and knee extension range of motion (ROM) are important predictors of physical function in patients with a total knee arthroplasty (TKA). However, the relationship between the two knee measures remains unclear. The purpose of this study was to examine whether changes in knee extensor strength mediate the association between changes in knee extension ROM and self-report physical function.
Data from 441 patients with a TKA were collected preoperatively and 6 months postoperatively. Self-report measure of physical function was assessed by the Short Form 36 (SF-36) questionnaire. Knee extensor strength was measured by handheld dynamometry and knee extension ROM by goniometry. A bootstrapped cross product of coefficients approach was used to evaluate mediation effects.
Mediation analyses, adjusted for clinicodemographic measures, revealed that the association between changes in knee extension ROM and SF-36 physical function was mediated by changes in knee extensor strength.
In patients with TKA, knee extensor strength mediated the influence of knee extension ROM on physical function. These results suggest that interventions to improve the range of knee extension may be useful in improving knee extensor performance.
Knee osteoarthritis (OA) is associated with substantial functional limitations in older adults. Specifically, knee OA, along with hip OA, accounted for the largest proportion of disability in walking and stair climbing more than any other chronic diseases. In patients with advanced stages of painful knee OA, although a total knee arthroplasty (TKA) can effectively restore function, 1 in 6 patients with TKA continue to have substantial physical function limitations. Clearly, an in-depth understanding of the modifiable predictors of physical function and their aetiological pathways is needed which, in turn, could assist the refinement of interventions to improve function.
Clinically, two common knee impairments before and following a TKA are reduced knee extensor strength and deficits in knee extension range-of-motion (ROM). Although most[5–12] but not all previous studies have implicated knee strength and knee extension ROM as important predictors of physical function, notably absent from these studies was an evaluation of the interrelation between knee extensor strength and knee extension ROM: previous studies – by their choice of standard regression analyses – assumed that these 2 knee measures have distinct and unrelated etiologies and that they act through different pathways to influence physical function.
Is it possible that knee extensor strength and knee extension ROM are interrelated? Based on what is known about the length-dependent nature of muscle force production,[14, 15] we believe it is biologically plausible that knee extensor strength may play a role in the mechanistic pathway connecting knee extension ROM and physical function. Indeed, many activities of daily living – for example, level walking – require the knee extensors to produce forces at lesser degrees (~30°) of knee flexion. Ostensibly, at a given knee joint angle near full extension, a flexion contracture may limit force production because the knee extensors – the monoarticular vastii in particular – are operating at a disadvantaged (lower) position on the ascending limb of their force-angle curves[14, 15]. In as much as this concept may make sense and lead to the refinement of theoretical and intervention models, supporting data in patients with TKA are surprisingly sparse.
Because the interrelation between knee extensor strength and knee extension ROM is possible and important to understand clinically, we initiated the present study to examine whether changes in knee extensor strength mediate the association between changes in knee extension ROM and self-report physical function in a large group of patients before and following a TKA.
Settings and participants
Our study used a longitudinal pre- and post-TKA design that took advantage of the substantial differences in change for knee impairments and self-report physical function. The study involved 836 consecutive patients aged 50 years or older who underwent a primary TKA for knee OA performed by three high-volume surgeons at Singapore General Hospital, Singapore, from 3 January 2006 to 29 January 2009. To avoid potential confounding effects from a contralateral TKA operation, we excluded patients if they had a contralateral TKA within the 12 months before or 6 months after their index TKA (n = 152). We also excluded patients who (i) had a history of stroke or other neurological disorders (n = 30), (ii) had a history of lower limb fracture (n = 12), (iii) had previously undergone a hip arthroplasty or high tibial osteotomy (n = 26), (iv) had previously undergone a unicompartmental knee arthroplasty (UKA) on their index knee (n = 4), or (v) developed medical or surgical complications prior to the follow up session (n = 64). Finally, because this exploratory study is concerned with the effects of knee flexion contractures, we excluded patients with missing knee data (n = 48) and patients with knee hyperextension (extension ROM <0°) at the preoperative or follow-up assessment (n = 59). (The recruitment process is summarized in a flowchart in Additional file1.) Thus, the sample for analysis comprised the remaining 441 patients who underwent a preoperative evaluation within 5 weeks prior to their operation. Of note, this sample size was not based on a formal power calculation but on all eligible patients in our database. Follow-up assessment was conducted approximately 6 months after the operation. All data were collected, as part of the clinical process, by physical therapists and entered into an electronic database per routine practice policies of our institution. All patients in this study were managed using a coordinated clinical pathway to ensure standardized medical, pharmacological, and rehabilitation care. Within two weeks post TKA, these patients began a 4- to 6-week rehabilitation program at the Singapore General Hospital outpatient physiotherapy clinic. The Centralized Institutional Review Board of Singhealth (CIRB), Singapore, approved the study and waived the need for informed consent due to the retrospective and anonymous nature of the study.
The demographic information collected in this study included age (in years), sex, ethnicity (Singaporean Chinese, as compared with others), and education (1 = primary school or less, 2 = vocational or secondary school, 3 = college or university). Data about comorbidities were retrieved from patients’ medical records by a research assistant using a checklist modeled after the Self-Administered Comorbidity Questionnaire. Patients’ height and weight were also obtained and body mass index (BMI) was calculated as the ratio of weight to squared height (kg/m2).
Self report physical function
At each assessment, patients were interviewed in either English or Mandarin using the Short Form-36, of which we used the physical function subscale as the outcome variable and the bodily pain and mental health subscales as the study covariates. All subscales range from 0–100, with higher scores representing better health state. The English and Chinese versions of the SF-36 have been previously validated for use in Singapore.
Knee extensor strength
A hand-held dynamometer (Lafayette, IN, USA) was used to measure isometric knee extensor strength based on the testing procedures described by Martin et al.. A total of five raters – two physiotherapists and three technicians – obtained the knee strength (and ROM, vide infra) measurements. A “make” test was used as it was deemed more reliable than a “break” test. Knee extensor strength was measured with the patients in supine position, and the knee was positioned in approximately 30° flexion by a firm wedge. The dynamometer force pad was placed just proximal to the ankle joint and knee extensor strength was quantified in kilogram force. All patients performed two maximal trials for 3 to 5 seconds with a 30-second rest interval. Additional measurements were taken if the patient reported a failure to achieve maximum effort. The higher of two valid trials was recorded and normalized as a direct percentage of body weight (%BW) because we believe that this index of knee strength made intuitive sense to our patients. Although we and others have shown, using allometric analyses, that the association between muscle force generation and body weight is not a strict 1:1 ratio, analyzing our data using allometrically-scaled knee extensor strength did not qualitatively alter our study conclusions (data not shown). Also of interest, we performed strength testing in the supine position – and not in the seated position – with the intent to reduce the influence of the rater’s strength on the patient’s measurements. We attempted to ensure that the same rater evaluated the same patient at each time point although this was not fully achievable due to the large patient volume in our hospital (~1,500 TKAs per annum). Nevertheless, all technicians were trained and audited by authors HCC and WY who have a combined experience of over 30 years in orthopaedic and sports physiotherapy. Furthermore, for the supine knee strength measurements, previous studies have demonstrated good test–retest reliability (intraclass correlation coefficients, 0.80 to 0.86) and concurrent validity with Biodex dynamometry measurements[20, 25].
Knee extension ROM
A large standard goniometer (Jamar, Clifton, NJ, USA) was used to measure passive knee extension ROM. Knee extension ROM was measured with the patients in supine position with the heel elevated on a firm wedge. The axis of the goniometer was placed on the femoral lateral epicondyle. The proximal arm of the goniometer was directed toward the greater trochanter of the femur whilst the distal arm of the goniometer was directed toward the lateral malleolus of the ankle. Patients were asked to relax to allow the knee to passively extend. Two sets of measurements were taken, and the lower measurement (greater knee extension) was recorded. For the knee extension ROM measurements, one previous study in patients with knee OA has demonstrated good test–retest reliability (intraclass correlation coefficient = 0.85).
We used descriptive statistics to characterize the study sample: we used means (SDs) for continuous variables and percentages for categorical variables. Analysis of variance (ANOVA) for repeated measures was used to test for change over time in the SF-36 and knee measures. Pearson correlation was used to quantify the correlation between knee measures.
Demographics and patient characteristics ( n = 441)
67.9 ± 7.8
Male sex, no. (%)
Singaporean Chinese, no. (%)
1.54 ± 0.08
Body mass, kg
65.9 ± 13.1
27.9 ± 4.8
Overweight or obese, no. (%)
Education, no. (%)
Primary or less
Comorbidities, no. (%)
Postoperative recovery of SF-36 and knee measures ( n = 441)
Extensor strength, %BW
Extension ROM, deg
Figure 1 shows the results of the mediational analyses. Overall, the mediator model accounted for ~29% of the variance in physical function (P < 0.001). Improving knee extension ROM was significantly associated with increasing physical function (P < 0.01 for path c, Figure 1). Controlling for covariates, the mediation effect of knee extensor strength on the association between changes in knee extension ROM and physical function was statistically significant (path axb = 0.13; 95% CI, 0.05 to 0.23). In contrast, no mediation effect was observed in the reversed mediation model (path axb = 0.04; 95% CI, -0.01 to 0.11).
The purpose of this study was to explore, in patients before and 6-months following a TKA, whether knee extension ROM had an indirect effect on SF-36 physical function through the putative pathway of knee extensor strength. Our results suggest that changes (pre to post TKA) in knee extensor strength mediated the association between changes in knee extension ROM and self-report physical function. To our knowledge, these findings have not been previously described in patients with TKA.
Our results, without considering mediating effects, are consistent with cross-sectional studies[7, 9, 12] of a positive association between knee extension ROM and physical function in TKA (path c in Figure 1). Furthermore, case series[28, 29] and small trials are available demonstrating that in patients before and following a TKA, rehabilitation interventions – for example, such as manual therapy and splinting – increased knee ROM and improved physical function. Overall, our large study using longitudinal change scores extends the previous literature to suggest that knee extension ROM is an important correlate of physical function in TKA.
Consistent with theoretical expectations, changes in knee extension ROM were associated with changes in knee extensor strength (Figure 2) which, in turn, were associated with changes in physical function (Figure 1). Furthermore, the results from the sensitivity analysis using a reversed mediation model support the direction of the proposed mediation. How do we explain our results? As mentioned in the Introduction, a knee flexion contracture (knee extension ROM > 0°) may potentially compress the force-length relationship[14, 15] of the knee extensors such that strength production diminishes at lesser degrees (~30°) of knee flexion. As a corollary, our results indicate that deficits in knee extension ROM are a putative multivariate cause of knee extensor weakness in TKA. And if future studies can substantiate this notion, the discussion in the literature about whether knee ROM or knee muscle strength should be given greater prominence in TKA rehabilitation[31–33] would become moot.
Our study has limitations. First, although our use of change scores permitted a more rigorous exploration of mediation than do cross-sectional data, our study variables were measured concurrently at each time point which precluded an examination of temporal associations between variables. Accordingly, to better assess the criterion of temporality, future longitudinal studies should evaluate the changes in the independent variable, mediator, and outcomes sequentially over different time points. Second, and relatedly, because we did not have multiple sequential measurements at successive time intervals, as pointed out by the reviewer, we were unable to evaluate whether the rate of change in knee extension ROM influenced (moderated) the proposed mediation effects. Third, we did not have any follow-up strength measurements later than 6 months post TKA; hence, we were unable to evaluate the effects of improving knee extension ROM post 6 months on knee extensor strength and functional ability. Finally, whilst we used a self-report measure of physical function to facilitate data collection, we acknowledge that performance-based measures of physical function are necessary because they provide important, complementary information about functional status.
Our results indicate that knee extension ROM is an important correlate of physical function in patients with TKA. More important, changes in knee extension ROM and knee extensor strength interrelated to influence physical function. If future studies could demonstrate that the etiology of knee extensor muscle weakness is associated, inter alia, with knee extension ROM deficits, these findings would suggest that interventions to improve the range of knee extension may be useful in improving knee extensor performance.
Range of motion
Total knee arthroplasty
Short form 36.
We thank Ms. Tan Bee Yee, the head of the Department of Physiotherapy, Singapore General Hospital, for supporting this study. We also thank Ms. Tiffany Ang, Ms. Alicia Ang, and Ms. Yinjie Lee for their research assistance. Finally, we thank the orthopaedic surgeons from the Singapore General Hospital for allowing us access to their patients. This work is supported by a Singhealth Foundation grant (SHF/FG398S/2009).
- McNeil JM, Binette J: Prevalence of disabilities and associated health conditions among adults. Morb Mortal Wkly Rep. 2001, 50: 120-125.Google Scholar
- Guccione AA, Felson DT, Anderson JJ, Anthony JM, Zhang YQ, Wilson PWF, et al: The effects of specific medical conditions on the functional limitations of elders in the Framingham Study. Am J Public Health. 1994, 84: 351-358. 10.2105/AJPH.84.3.351.View ArticlePubMedPubMed CentralGoogle Scholar
- Ranawat CS, Ranawat AS, Mehta A: Total knee arthroplasty rehabilitation protocol: what makes the difference?. J Arthroplasty. 2003, 18: 27-30.View ArticlePubMedGoogle Scholar
- Bhave A, Mont M, Tennis S, Nickey M, Starr R, Etienne G: Functional problems and treatment solutions after total hip and knee joint arthroplasty. J Bone Joint Surg Am. 2005, 87 (Suppl 2): 9-21.View ArticlePubMedGoogle Scholar
- Franklin PD, Li W, Ayers DC: The Chitranjan Ranawat Award: functional outcome after total knee replacement varies with patient attributes. Clin Orthop. 2008, 466: 2597-2604. 10.1007/s11999-008-0428-8.View ArticlePubMedPubMed CentralGoogle Scholar
- Parent E, Moffet H: Preoperative predictors of locomotor ability two months after total knee arthroplasty for severe osteoarthritis. Arthritis Care Res. 2003, 49: 36-50. 10.1002/art.10906.View ArticleGoogle Scholar
- Zeni JA, Snyder-Mackler L: Preoperative predictors of persistent impairments during stair ascent and descent after total knee arthroplasty. J Bone Joint Surg Am. 2010, 92: 1130-1136. 10.2106/JBJS.I.00299.View ArticlePubMedPubMed CentralGoogle Scholar
- Lingard EA, Katz JN, Wright EA, Sledge CB: Predicting the outcome of total knee arthroplasty. J Bone Joint Surg Am. 2004, 86-A: 2179-2186.PubMedGoogle Scholar
- Ritter MA, Lutgring JD, Davis KE, Berend ME, Pierson JL, Meneghini RM: The role of flexion contracture on outcomes in primary total knee arthroplasty. J Arthroplasty. 2007, 22: 1092-1096. 10.1016/j.arth.2006.11.009.View ArticlePubMedGoogle Scholar
- Devers BN, Conditt MA, Jamieson ML, Driscoll MD, Noble PC, Parsley BS: Does greater knee flexion increase patient function and satisfaction after total knee arthroplasty?. J Arthroplasty. 2011, 26: 178-186. 10.1016/j.arth.2010.02.008.View ArticlePubMedGoogle Scholar
- Meneghini RM, Pierson JL, Bagsby D, Ziemba-Davis M, Berend ME, Ritter MA: Is there a functional benefit to obtaining high flexion after total knee arthroplasty?. J Arthroplasty. 2007, 22: 43-46.View ArticlePubMedGoogle Scholar
- Mitsuyasu H, Matsuda S, Miura H, Okazaki K, Fukagawa S, Iwamoto Y: Flexion contracture persists if the contracture is more than 15 degrees at 3 months after total knee arthroplasty. J Arthroplasty. 2011, 26: 639-643. 10.1016/j.arth.2010.04.023.View ArticlePubMedGoogle Scholar
- Miner AL, Lingard EA, Wright EA, Sledge CB, Katz JN: Knee range of motion after total knee arthroplasty: how important is this as an outcome measure?. J Arthroplasty. 2003, 18: 286-294. 10.1054/arth.2003.50046.View ArticlePubMedGoogle Scholar
- Savelberg HH, Meijer K: The effect of age and joint angle on the proportionality of extensor and flexor strength at the knee joint. J Gerontol A Biol Sci Med Sci. 2004, 59: 1120-1128. 10.1093/gerona/59.11.1120.View ArticlePubMedGoogle Scholar
- Anderson DE, Madigan ML, Nussbaum MA: Maximum voluntary joint torque as a function of joint angle and angular velocity: model development and application to the lower limb. J Biomech. 2007, 40: 3105-3113. 10.1016/j.jbiomech.2007.03.022.View ArticlePubMedGoogle Scholar
- Nadeau S, McFadyen BJ, Malouin F: Frontal and sagittal plane analyses of the stair climbing task in healthy adults aged over 40 years: what are the challenges compared to level walking?. Clin Biomech (Bristol, Avon). 2003, 18: 950-959. 10.1016/S0268-0033(03)00179-7.View ArticleGoogle Scholar
- Sangha O, Stucki G, Liang MH, Fossel AH, Katz JN: The self-administered comorbidity questionnaire: A new method to assess comorbidity for clinical and health services research. Arthritis Care Res. 2003, 49: 156-163. 10.1002/art.10993.View ArticleGoogle Scholar
- Ware JE, Sherbourne CD: The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992, 30: 473-483. 10.1097/00005650-199206000-00002.View ArticlePubMedGoogle Scholar
- Thumboo J, Fong KY, Machin D, Chan SP, Leon KH, Feng PH, et al: A community-based study of scaling assumptions and construct validity of the English (UK) and Chinese (HK) SF-36 in Singapore. Qual Life Res. 2001, 10: 175-188. 10.1023/A:1016701514299.View ArticlePubMedGoogle Scholar
- Martin HJ, Yule V, Syddall HE, Dennison EM, Cooper C, Aihie SA: Is hand-held dynamometry useful for the measurement of quadriceps strength in older people? A comparison with the gold standard Bodex dynamometry. Gerontology. 2006, 52: 154-159. 10.1159/000091824.View ArticlePubMedGoogle Scholar
- Stratford PW, Balsor BE: A comparison of make and break tests using a hand-held dynamometer and the Kin-Com. J Orthop Sports Phys Ther. 1994, 19: 28-View ArticlePubMedGoogle Scholar
- Pua YH: Allometric analysis of physical performance measures in older adults. Phys Ther. 2006, 86: 1263-1270. 10.2522/ptj.20060034.View ArticlePubMedGoogle Scholar
- Jaric S, Radosavljevic-Jaric S, Johansson H: Muscle force and muscle torque in humans require different methods when adjusting for differences in body size. Eur J Appl Physiol. 2002, 87: 304-307. 10.1007/s00421-002-0638-9.View ArticlePubMedGoogle Scholar
- Ministry of Health. Knee replacement surgery. http://www.moh.gov.sg/content/moh_web/home/costs_and_financing/HospitalBillSize/knee_replacementsurgery.html 2011
- Arnold CM, Warkentin KD, Chilibeck PD, Magnus CR: The reliability and validity of handheld dynamometry for the measurement of lower-extremity muscle strength in older adults. J Strength Cond Res. 2010, 24: 815-824. 10.1519/JSC.0b013e3181aa36b8.View ArticlePubMedGoogle Scholar
- Cibere J, Bellamy N, Thorne A, Esdaile JM, McGorm KJ, Chalmers A, et al: Reliability of the knee examination in osteoarthritis: effect of standardization. Arthritis Rheum. 2004, 50: 458-468. 10.1002/art.20025.View ArticlePubMedGoogle Scholar
- Preacher KJ, Hayes AF: Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behav Res Methods. 2008, 40: 879-891. 10.3758/BRM.40.3.879.View ArticlePubMedGoogle Scholar
- McGrath MS, Mont MA, Siddiqui JA, Baker E, Bhave A: Evaluation of a custom device for the treatment of flexion contractures after total knee arthroplasty. Clin Orthop. 2009, 467: 1485-1492. 10.1007/s11999-009-0804-z.View ArticlePubMedPubMed CentralGoogle Scholar
- Bonutti PM, Marulanda GA, McGrath MS, Mont MA, Zywiel MG: Static progressive stretch improves range of motion in arthrofibrosis following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2010, 18: 194-199. 10.1007/s00167-009-0947-1.View ArticlePubMedGoogle Scholar
- Pollard H, Ward G, Hoskins W, Hardy K: The effect of a manual therapy knee protocol on osteoarthritic knee pain: a randomised controlled trial. J Can Chiropr Assoc. 2008, 52: 229-242.PubMedPubMed CentralGoogle Scholar
- Mizner RL, Petterson SC, Stevens JE, Axe MJ, Snyder-Mackler L: Preoperative quadriceps strength predicts functional ability one year after total knee arthroplasty. J Rheumatol. 2005, 32: 1533-1539.PubMedGoogle Scholar
- Lamb SE, Frost H: Recovery of mobility after knee arthroplasty: expected rates and influencing factors. J Arthroplasty. 2003, 18: 575-582. 10.1016/S0883-5403(03)00110-4.View ArticlePubMedGoogle Scholar
- Park KK, Chang CB, Kang YG, Seong SC, Kim TK: Correlation of maximum flexion with clinical outcome after total knee replacement in Asian patients. J Bone Joint Surg Br. 2007, 89: 604-608. 10.1302/0301-620X.89B5.18117.View ArticlePubMedGoogle Scholar
- MacKinnon DP: Introduction to statistical mediation analysis. 2008, Mahwah, NJ: Erlbaum Psych PressGoogle Scholar
- Stratford PW, Kennedy DM, Maly MR, Macintyre NJ: Quantifying self-report measures’ overestimation of mobility scores postarthroplasty. Phys Ther. 2010, 90: 1288-1296. 10.2522/ptj.20100058.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/14/33/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.