MRI, Força de Extensores

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Arthritis Rheum. Author manuscript; available in PMC 2010 September 15.
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Arthritis Rheum. 2009 September 15; 61(9): 12101217. doi:10.1002/art.24541.
The Effect of Thigh Strength on Incident Radiographic and

Symptomatic Knee Osteoarthritis in the Multicenter
Osteoarthritis (MOST) Study
Neil A Segal, MD, MS1, James Torner, PhD1, David Felson, MD, MPH2, Jingbo Niu, DSc2,
Leena Sharma, MD3, Cora E. Lewis, MD, MSPH4, and Michael Nevitt, PhD5
1University of Iowa, Iowa City, IA
2Boston
University, Boston, MA
3Northwestern
University Feinberg School of Medicine, Chicago, IL
4University
of Alabama at Birmingham, Birmingham, AL
5University
of California San Francisco, San Francisco, CA
Abstract
ObjectiveTo assess whether knee extensor strength or hamstring:quadriceps (H:Q) ratio
predict risk for incident radiographic tibiofemoral and incident symptomatic whole knee
osteoarthritis (OA) in adults age 5079.
MethodsWe followed 1617 participants (2519 knees) who, at the baseline visit of the
Multicenter Osteoarthritis (MOST) Study, did not have radiographic tibiofemoral OA and 2078
participants (3392 knees) who did not have symptomatic whole knee OA (did not have the
combination of radiographic OA and frequent knee symptoms). Isokinetic strength was measured
at baseline and participants were followed for development of incident radiographic tibiofemoral
OA or incident symptomatic whole knee OA at 30-months. Generalized estimating equations
accounted for 2 knees per subject and multivariable models adjusted for age, BMI, hip BMD,
history of knee surgery or pain, and physical activity score.
ResultsIn the studies of incident radiographic and incident symptomatic knee OA, mean ages
were 62.48.0 and 62.38.0 years and mean BMI were 30.65.8 and 30.25.5 kg/m2,
respectively. Knee extensor strength and H:Q ratio at baseline significantly differed between men
and women. Neither knee extensor strength nor the H:Q ratio was predictive of incident
radiographic tibiofemoral OA. Compared with the lowest tertile, the highest tertile of knee
extensor strength protected against development of incident symptomatic whole knee OA in both
sexes (adjusted OR=0.50.6). H:Q ratio was not predictive of incident symptomatic whole knee
OA in either sex.
ConclusionsThigh muscle strength does not appear to predict incident radiographic, but does
seem to predict incident symptomatic knee OA.
INTRODUCTION
Knee osteoarthritis (OA) is a major public health concern worldwide(1) and one of the
foremost causes of chronic disability in older adults.(2) Preventive care is dependent upon
identification of risk factors for development of incident knee OA. Additionally, since pain
Corresponding author: Neil Segal, MD, MS, Assistant Professor, Department of Orthopaedics & Rehabilitation, University of Iowa
Hospitals and Clinics, 200 Hawkins Drive, 0728 JPP, Iowa City, IA 52242-1088.
Segal et al.
Page 2
is the primary complaint that leads to physician visits as well as functional limitations, it is
important to clarify risk factors not only for radiographic, but also for symptomatic knee
OA. In order to develop therapies directed at underlying mechanisms for incident knee OA,
there has been a long-standing need for longitudinal assessment of risk factors.
There is evidence that muscle dysfunction is involved in the pathogenesis of knee OA.(36)
As lower limb musculature is the natural brace for the knee joint, potentially important
muscle dysfunction may arise from either quadriceps weakness or relative weakness of the
hamstrings in comparison to the quadriceps, usually assessed as the hamstrings:quadriceps
(H:Q) ratio. An H:Q ratio of greater than or equal to 0.6 is considered to be normal.(79)
Thus, evaluation of muscle dysfunction in relation to the knee joint should examine both
quadriceps strength as well as the balance of muscle strength.
Numerous cross-sectional studies have shown that persons with knee OA have lower knee
extensor strength than control participants without knee OA.(35,1012) Although some of
these studies indicate quadriceps muscle weakness may precede knee OA,(3,4) this
weakness has largely been attributed to joint pain that may limit muscle use and lead to
atrophy. To our knowledge, there has been only 1 report of longitudinal data suggesting a
link between relative quadriceps weakness (strength per body weight) and incident OA and
this was found only in women and even then, was of borderline statistical significance
perhaps because the numbers of men and women developing incident OA in this study were
small. In this study, women who later developed knee OA were 18% weaker at baseline than
those who did not develop knee OA.(13)
The longitudinal study suggested an effect of weakness on the development of radiographic
knee OA, but since radiographic knee OA is often unaccompanied by pain,(14) the public
health implications of this finding are uncertain. In addition to assessing the effect of
quadriceps strength on incident radiographic knee OA in a longitudinal study, there is also a
need to assess whether quadriceps strength alters risk for incident symptomatic knee OA
de novo knee pain or stiffness in the context of radiographic stigmata of OA. Symptomatic
knee OA has been the focus of increasing interest because it parallels clinical OA, agrees
with ACR criteria for OA, is unlike incident radiographic OA, and has clear-cut clinical and
public health implications. While certain risk factors for radiographic knee OA have been
characterized, less is known about risk factors for incident symptomatic knee OA.
Therefore, the objective of our study was to evaluate the relationship between quadriceps
muscle dysfunction (strength and balance with the hamstrings) and incident radiographic
tibiofemoral and incident symptomatic whole knee OA.
MATERIALS and METHODS

The Multicenter Osteoarthritis Study (MOST) is a prospective, longitudinal cohort study of
risk factors for knee osteoarthritis (OA). Enrollment was from a volunteer sample of
individuals from two communities and surrounding regions in Iowa and Alabama. The study
enrolled 3026 men and women (6052 knees), 5079 years of age, who responded to mass
mailings or advertisements and were screened by telephone for risk factors including age,
sex, previous knee injury or surgery and overweight status based on percentiles derived from
the Framingham Heart Study cohort (i.e. women in the 6th, 7th, and 8th decades weighing
over 154, 151, and 148 lbs respectively and men weighing over 194, 187 and 182 lbs
respectively.) Exclusion criteria included a history of (or planned) bilateral knee
replacement; cancer with the exception of non-melanoma skin cancer or breast, cervical,
colon, prostate, rectal, or uterine cancer successfully treated with surgery; history of
Segal et al.
Page 3
chemotherapy or radiation therapy; rheumatologic disease; or plan to move out of the area in
the next 3 years. Inclusion criteria are outlined in Figure 1.
Participants were from Iowa City, IA, and Birmingham, AL or the surrounding
communities. The Institutional Review Boards (IRB) of participating institutions approved
this study. All participants provided written informed consent using an IRB-approved
consent process. We report here data from the baseline and 30month follow-up visits.
Participants
The study of incident radiographic tibiofemoral OA included 2519 knees (1617
participants) without pre-existing radiographic tibiofemoral OA (Kellgren-Lawrence grade
of 2 or greater)(15) at baseline, who met inclusion criteria (Figure 1).
Using previous approaches that have characterized symptomatic whole knee OA (16), we
excluded knees with frequent symptoms. Knees were considered free of frequent knee
symptoms at baseline if participants answered No at either the telephone screen or clinic
visit in response to "During the past 30 days, have you had any pain, aching, or stiffness in
your knee on most days?"
The study of incident symptomatic whole knee OA included 3346 knees (2046 participants)
that did not have symptomatic whole knee OA at baseline and met inclusion criteria
depicted in Figure 1.(15)
The following evaluations were completed at the baseline visit.
Strength Measurements
Concentric knee extensor strength was assessed with a Cybex 350 computerized isokinetic
dynamometer (Avocent, Huntsville, AL) at 60 degrees per second and a chair back angle of
85 degrees. HUMAC software version 4.3.2/Cybex 300 for Windows98 Software Package
was used for data acquisition. Participants were provided instructions using a standardized
script for subject testing and three practice trials using 50% effort. After the practice trials,
four repetitions were completed for flexor and extensor torque. Participants' concentric knee
extensor and flexor strength (Nm) were considered the peak torque obtained over 4 trials.
Trained examiners, certified in the standardized MOST strength testing protocol, underwent
annual recertification to assure uniformity in following the strength testing protocol.
Examiners calibrated the isokinetic dynamometer position, angular velocity and torque (at
25 and 245 Nm) monthly.
Participants with unilateral knee replacement performed the test on the contralateral side
only. There were no participants tested who had a systolic blood pressure greater than 199
mmHg, a diastolic blood pressure greater than 109 mmHg, history of cerebral aneurysm,
cerebral bleeding within the past six months, back surgery within the previous 3-months,
myocardial infarction or cataract surgery within the previous 6-week period, untreated
inguinal hernia, or pain that precluded participation were excluded from strength testing. To
avoid potential pain or injury associated with a maximal eccentric contraction, peak torque
was recorded concentrically. In a validity study conducted with the isokinetic dynamometer
used, conducted concurrent with the MOST study, the strength testing protocol had an
intraclass correlation coefficient of .94 (.82.99), a coefficient of variation of 8% (612%)
and a within subject variation of 6.3 Nm (4.719.63).
Hamstring to Quadriceps muscle strength ratio (H:Q)A ratio of the peak torque
of the knee flexors to knee extensors was calculated to investigate whether antagonist/
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Page 4
agonist imbalance may alter risk for incident OA. Cutoff for dichotomizing H:Q ratio was
defined at 0.6.(79) A confirmatory analysis was also performed using 0.8 as a cutoff.(8)
Knee radiograph assessments

Weight-bearing, fixed flexion posteroanterior(17) and lateral radiographs(18) of the knees
were obtained at baseline, and 30 months according to the MOST radiograph protocol as
previously described.(19) Radiographs were taken of the contralateral knee in participants
with unilateral knee replacement. Each subjects baseline and follow-up radiographs were
paired and scored by two independent readers (an experienced academically-based
musculoskeletal radiologist and a rheumatologist experienced in study reading) according to
Kellgren-Lawrence scale.(15) Readers were not blinded to radiograph sequence, but were
blinded to subject strength, the predictor in this study. For cases where the two readers
disagreed on the presence of incident radiographic tibiofemoral OA, an adjudication panel of
3 experienced readers decided.
Knee Symptoms
During the telephone screen, trained and certified interviewers asked participants: "During
the past 30 days, have you had pain, aching or stiffness in or around your knee on most
days?" Knee symptoms were assessed again at the baseline clinic visit, where participants
were asked the same question again about knee pain, aching, or stiffness. Participants who
responded negatively on either the telephone screen or the baseline visit questionnaire were
considered free of knee symptoms at baseline.
At the 30-month telephone screen and clinic visit, participants were again asked the same
question regarding pain, aching, or stiffness in each knee on most of the past 30 days.
Incident knee symptoms were defined by an affirmative response on both the screen and
visit at 30 months.
Femoral Neck Bone Mineral Density (BMD)
As femoral neck BMD has been related to both knee extensor strength and incident OA, we
controlled for BMD in our analyses. We obtained a bone mineral density scan of the
proximal femur in participants without a history of bilateral hip replacement using dual
energy x-ray absorptiometry (DXA, Hologic, 4500a and 4500w, Bedford, MA). Bone
mineral density of the femoral neck region was recorded in g/cm2.
Anthropometric Measures
Height and WeightAt baseline, height in centimeters (stadiometer, Holtain, Wales,

UK) and weight in kilograms were obtained by trained and certified staff and BMI (kg/m2)
was calculated as reported previously.(19) Two height measurements were initially taken. If
measurements differed by 3 mm, then 2 additional measurements were completed. All
measurements were recorded and averaged.
Physical Activity
At baseline, participants completed the validated Physical Activity Scale for the Elderly
(PASE: New England Research Institute, Watertown, MA) questionnaire, and activity scores
were calculated.(20)
Definition of Incident Radiographic Tibiofemoral OA
Knees met criteria for incident radiographic tibiofemoral OA if they had no radiographic
tibiofemoral OA at baseline (KL grade of less than 2) and had radiographic tibiofemoral OA
(KL grade of 2 or greater) on 30-month radiographs.
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Definition of Incident Symptomatic Whole knee OA
At the baseline and 30 month visits, we obtained radiographs and asked on the phone and at
the clinic about the presence of knee pain or stiffness on most days. Incident symptomatic
whole knee OA was defined as the combination of knee symptoms and radiographic OA in
the tibiofemoral or patellofemoral compartments (whole knee OA) at the follow-up but not
at the baseline visit. Recognizing that OA symptoms fluctuate,(21) we felt that at follow-up
participants needed to answer yes to the knee symptom questions both times.
Therefore, knees met criteria for incident symptomatic whole knee (tibiofemoral or
patellofemoral) OA if:
1.
at baseline they did not have radiographic whole knee OA (x-ray ) regardless of
symptoms, but at 30months they had the combination of radiographic whole knee
OA (x-ray + ) and knee symptoms on both the screen and clinic visit as described
above (symptoms + )
2.
at baseline they had radiographic whole knee OA (x-ray + ) but did not have
symptoms on both the screen and clinic visit (symptoms +/ or / ), but at 30
months they had knee symptoms both times when asked (symptoms +/+ ), or if
3.
they did not have radiographic whole knee OA and symptoms at baseline (x-ray or symptoms ) and underwent knee arthroplasty between baseline and follow-up
as treatment for OA.
Statistical Methods
Participant characteristics were summarized with frequencies and means. Comparisons of
peak strength and H:Q ratio by logistic regression for categorical groups (sex, and surgery)
and by Pearson correlation coefficients or linear regression for continuous measures (age,
body mass index, PASE score). Use of generalized estimating equations (GEE) is an
accepted statistical method for using weighted combinations of observations to extract the
appropriate amount of information from correlated data, providing conservative calculations
of standard errors in datasets with clusters of correlated data.(22) Thus, we elected to use
GEE to control for between-knee correlations within participants in our knee-based
analyses.
We tested the following hypotheses using logistic regression models:
1.
High isokinetic (a) knee extensor strength, and (b) H:Q ratio at baseline decrease
risk for incident radiographic tibiofemoral OA by 30-month follow-up.
2.
High isokinetic (a) knee extensor strength, and (b) H:Q ratio at baseline decrease
risk for incident symptomatic whole knee OA at 30-month follow-up.
Analyses of outcomes were lower limb-based, considering thigh strength and H:Q ratio
ipsilateral to each knee. Knees were stratified by (1) sex-specific tertiles of peak knee
extensor strength and (2) whether hamstring:quadriceps ratio was 0.6 or <0.6.(79) Strata
were compared using generalized estimating equations, adjusting for the correlation between
knees within participants. Known correlates with knee extensor strength or knee OA (age,
body mass index, hip bone mineral density, history of lower limb surgery, pain, and PASE
score) were included in all multivariable models.
Separate analyses were performed for men and women due to differences in strength and
H:Q ratio by sex. SAS Version 9.1 (SAS Institute Inc., Cary, NC) was used for all analyses
and overall significance level was set at <.05.
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RESULTS
Incident radiographic tibiofemoral OA
For the 2713 participants (5426 knees) with 30-month follow-up, the mean age was 62.4
8.0 years, body mass index was 30.65.8 kg/m2, PASE score was 176.6 88.8, and peak
knee extensor strength was 91.3 43.3 Nm. Baseline peak knee extensor strength
significantly differed between men (124.8 42.4) and women (69.5 26.7) (p<.0001) and
between participants with (90.845.7) and without (90.142.3) prior knee surgery or injury
(p<.0001). The proportion of men and women with a hamstring:quadriceps (H:Q) ratio less
than 0.6 also significantly differed between men (50%) and women (57%) (p<.0001). Figure
1 depicts participants' analysis groups.
Of the 5,426 knees followed, 2519 eligible knees without baseline radiographic tibiofemoral
OA were included (Figure 1). Baseline characteristics are summarized in Table 1. Fortyeight out of 680 men (49 knees) and 93 out of 937 women (99 knees) developed incident
radiographic tibiofemoral OA. The mean knee extensor strength of those who developed
incident radiographic tibiofemoral OA was 123.1 47.7 for men and 74.4 29.0 for
women, compared with 131.2 42.8 for men and 76.1 25.4 for women in those who did
not develop this endpoint. Approximately 55 % of men and 63% of women who developed
incident radiographic tibiofemoral OA had H:Q ratios <0.6. After adjusting for age, BMI,
femoral neck BMD, and PASE score, neither knee extensor strength nor H:Q ratio was a
significant predictor of incident radiographic tibiofemoral OA (Table 2). This result
remained constant whether knee extensor strength was analyzed as a categorical (tertile) or
continuous variable.
Incident symptomatic whole knee OA
Out of 5,464 knees, there were 3,392 eligible knees without pre-existing symptomatic knee
OA (as defined above) at baseline. Excluded from the analyses were 981 knees with preexisting symptomatic whole knee OA and 1091 knees with missing radiographic or strength
data, or reported pain that prevented pushing during the measurement of muscle strength
(Figure 1). Baseline characteristics of participants are summarized in Table 3. As shown in
Table 4, strength was associated with KL grade at baseline among knees without
symptomatic whole knee OA in both men (P=.0189) and women (P=<.0001) and H:Q ratio
was not associated with KL grade at baseline in men or women.
At the 30-month visit, 201 out of 1989 knees in women (10.1%) and 109 out of 1403 men
(7.8%) had incident symptomatic whole knee OA. In men, mean baseline knee extensor
strength for limbs with and without incident symptomatic whole knee OA at 30 months was
114.3 41.4 and 130.2 42.1, respectively. In women, mean baseline knee extensor
strength in limbs with and without incident symptomatic whole knee OA at 30-month
follow-up was 65.3 25.6 and 74.7 25.3 respectively. Compared with the lowest tertile,
women in the highest tertile of peak knee extensor strength had reduced odds of incident
symptomatic whole knee OA with and OR of 0.5 (95%CI: 0.3, 0.8) (Table 5). There was a
slightly reduced OR of 0.5 (95% CI: 0.3, 1.1) for incident symptomatic whole knee OA in
men in the highest compared with the lowest tertile of peak KES, but this lost significance
after also adjusting for baseline knee pain (Table 5). When treated as a continuous measure,
there was a statistically significant association between knee extensor strength and incident
symptomatic whole knee OA (p=0.0143 in men, 0.0034 in women). However, H:Q ratios
were not predictive of incident symptomatic whole knee OA in either women or men .
Segal et al.
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DISCUSSION
To our knowledge, this is the first longitudinal study of a community-based cohort that
simultaneously assessed the role of quadriceps muscle strength in risk for incident
radiographic and incident symptomatic whole knee OA. Our results suggest that neither
higher knee extensor strength nor normal hamstring:quadriceps balance is protective against
development of incident radiographic tibiofemoral OA. However, in women, being in the
highest tertile of knee extensor strength appeared protective against development of incident
symptomatic whole knee OA.
Our results concur with those of others with respect to the finding that strength was lower
with increasing KL grade of tibiofemoral OA at baseline (Table 4).(12,2326) The finding
that there was no correlation between KL grade and H:Q ratio also is in agreement with
prior work.(24,27) This may indicate that although quadriceps strength is lower, hamstring
strength may also be lower with increasing KL grade, resulting in no change in overall
sagittal plane muscle balance.
Our longitudinal results appear to differ from those of Slemenda, who reported that knee
extensor weakness per body weight was a risk factor for radiographic knee OA in women.
(13) An important difference between our analysis and that of Slemenda et al. may account
for our respective findings. The prior report divided strength by body weight. Since women
with incident OA in that study were more obese, dividing strength by body weight may have
resulted in the participants with incident knee OA having a lower strength per body weight,
due to their increased weight.
The analytic approach used in the prior study recognized that absolute strength values,
devoid of context, are of limited usefulness in the assessment of weakness. For example, a
certain degree of strength may be either normal or weak depending on the body size, age and
sex. However, as fat mass increases with obesity, the ratios of both strength and muscle to
body weight will necessarily decrease due to the increased denominator. For example,
strength would not be expected to double with a doubling of body mass. Thus, such 1:1
ratios would not accurately reflect whether the absolute strength should be considered weak.
In order to understand the true relationship between strength and knee OA in people of
different body sizes, it is important to assess the relationship recognizing that although a
positive correlation between strength and body size is expected,(28,29) like other biological
standards, it may not be a 1:1 ratio.(3033) Therefore, we chose to scale strength by
controlling for BMI using logistic regression to determine body-size-independent index of
strength, rather than to assume a linear ratio. This difference in methodology may account
for the seemingly different results.
If there were a subgroup in which knee extensor strength may be more important for
protecting against incident knee OA, we would anticipate that study of the MOST cohort
would have revealed this. Participants were recruited to the MOST cohort due to the
presence of known risk factors for knee OA overweight or obese, knee pain, prior knee
surgery or injury. Therefore, the absence of an association between knee extensor strength or
balance with incident radiographic tibiofemoral OA in this study of 5426 at-risk knees with
148 incident radiographic outcomes suggests that a clinically significant association is
unlikely to exist.
The MOST study has several unique features that enabled this study to advance knowledge
beyond that of prior epidemiologic studies of knee osteoarthritis, which focused on only
radiographic knee OA.(13,34) To our knowledge, this is the first study of the effect of lower
limb strength on risk for incident symptomatic whole knee OA. The ability to assess risk for
Segal et al.
Page 8
development of symptomatic disease allowed this study to provide information most

relevant to adults who have activity limitations and present for medical care. Therefore, the
results are useful in testing prior supposition that weakness may increase risk for
radiographic knee OA,(4,35) and also extend knowledge regarding risk for incident
symptomatic whole knee OA using the same cohort and methods. In addition, the MOST
study focused on participants representative of those who would most benefit from
prevention opportunities, those who have known risk factors for knee OA. Third, this study
included comprehensive and reproducible radiographic techniques as well as measuring the
outcome on a cohort of 3026 with very little loss to follow-up.
A potential limitation is inherent in the measurement of strength. The lower strength in

participants with radiographic knee OA at baseline may indicate true weakness, or it may
indicate co-activation of knee flexors during knee extensor testing, leading to a lower
estimate of knee extensor strength due to simultaneous antagonist action.(36) For example,
if participants attempted to stabilize their knee during isokinetic testing, using 10 Nm of
knee flexor torque during knee extensor testing, this would have reduced the measured knee
extensor strength value. Such co-contraction has been reported, particularly in people who
report a sensation of knee instability.(37) However, since weakness was not predictive of
incident knee OA, this potential limitation is unlikely to have influenced the results. Another
limitation of the strength assessment was that this study focused on knee extension and
flexion strength, and did not include assessments of hip abductor strength. Study of hip
abductor strength, which is recognized as important for control of the knee joint,(3840)
may be useful in a more comprehensive assessment of risk for incident knee OA.
In this study, we aimed to identify individuals with current knee symptoms. In order to
confirm the presence of consistent knee symptoms, individuals were asked about knee
symptoms on most days of the last 30 days. This question is based on ACR criteria for
establishing presence of symptomatic knee OA and has also been used in the Framingham
knee study as well as in the Osteoarthritis Initiative. However, as symptoms can fluctuate,
this question may not have identified participants who had frequent symptoms at some point
outside of the past 30 days. Lastly, a study with a greater number of knees or endpoints or
longer follow-up duration may be able to detect a smaller protective effect of knee extensor
strength than was possible in this study that followed approximately 5400 knees over a 30month period.
CONCLUSIONS
The highest tertile of knee extensor strength appears to protect against incident symptomatic
whole knee OA. Neither knee extensor strength nor the balance of knee extensors and
flexors (H:Q ratio) appear to protect against incident radiographic tibiofemoral OA in either
sex. These findings suggest that targeted interventions to reduce risk for symptomatic whole
knee OA may be directed towards increasing knee extensor strength, but alternative
strategies should be considered for reducing risk for incident radiographic tibiofemoral OA.
Acknowledgments
This study was supported by NIH grants to: Boston University (David Felson, MD - 1 U01 AG18820);University of
Iowa (James Torner, PhD - 1 U01 AG18832); University of Alabama (Cora E. Lewis, MD MSPH - 1 U01
AG18947); University of California San Francisco (Michael Nevitt, PhD - 1 U01 AG19069); and the Association of
Academic Physiatrists (Neil Segal, MD -5K12HD001097-08).
Segal et al.
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Segal et al.
Page 11

Figure 1.
Subject Inclusion Diagram
MeanSD except as indicated
0.1039
61.7 7.8
Women
N=937
(1465 knees)
p-value
61.0 7.9
Men
N=680
(1054 knees)
Age
(years)
0.0277
29.3 5.5
29.8 4.7
Body Mass
Index
(BMI)
(kg/m2)
<0.0001
0.8 0.1
0.9 0.1
Bone
Mineral
Density
(BMD)
Femoral
Neck
(g/cm2)
<0.0001
76.0 25.6
130.8 43.1
Knee
Extensor
Strength
(KES, Nm)
0.0076
58.3%
51.7%
Hamstring:
Quadriceps
(H:Q) Ratio
(% <0.6)
<0.0001
164.5 78.6
209.7 97.9
Physical
Activity Scale
for the
Elderly
(PASE) score
Baseline Characteristics for the Study of Incident Radiographic Tibiofemoral Osteoarthritis (OA) (N=1617 participants, 2519 knees.)
Table 1
Segal et al.
Page 12
Segal et al.
Page 13
Table 2
Association Between Knee Extensor Strength and H:Q Ratio and Incident Radiographic Tibiofemoral OA
Knee Extensor
Strength
Sex-Specific Tertiles
N of
case
(%)
OR (95% CI),
Adjusting for
age, BMI, BMD,
surgery, and
PASE at
baseline
OR (95% CI),
Adjusting for
age, BMI, BMD,
surgery, PASE,
and knee pain at
baseline
Men
Lowest, 12109 Nm
(n=334)
22
(6.5)
1.0
1.0
Middle, 110144 Nm
(n=350)
12
(3.4)
0.5 (0.2, 1.0)
0.5 (0.3, 1.1)
Highest, 145276 Nm
(n=370)
15
(4.1)
0.5 (0.2, 1.2)
0.6 (0.3, 1.4)
1SD
0.76 (0.52, 1.11)
0.81 (0.55, 1.21)
Test for linear trend
p=0.1529
p=0.3024
Women
Lowest, 461 Nm
(n=416)
33
(7.9)
1.0
1.0
Middle, 6283 Nm
(n=514)
30
(5.8)
0.7 (0.4, 1.1)
0.7 (0.4, 1.2)
Highest, 84206 Nm
(n=535)
67
(6.7)
0.7 (0.4, 1.2)
0.8 (0.4, 1.4)
1SD
0.86 (0.65, 1.14)
0.92 (0.70, 1.21)
Test for linear trend
p=0.2868
p=0.5469
H:Q Ratio
H:Q Cut-off
N of
case
(%)
OR (95% CI),
Adjusting for
age, BMI, BMD,
surgery, and
PASE at
baseline
OR (95% CI),
Adjusting for
age, BMI, BMD,
surgery, knee
pain and PASE
at baseline
Men
<0.6 (n=545)
27
(5.0)
1.0
1.0
0.6 (n=509)
22
(4.3)
0.9 (0.5, 1.7)
0.9 (0.5, 1.6)
<0.6 (n=854)
62
(7.3)
1.0
1.0
0.6 (n=611)
37
(6.1)
0.8 (0.6, 1.3)
0.8 (0.5, 1.2)
Women
BMI: Body Mass Index

BMD: Bone Mineral Density
PASE: Physical Activity Scale for the Elderly
MeanSD except as indicated
0.0337
62.6 7.8
Women
N=1232
(1989 knees)
p-values
61.9 8.2
Men
N=846
(1403 knees)
Age
(years)
0.4637
30.1 5.9
30.3 4.9
Body Mass
Index
(BMI,
kg/m2)
<.0001
0.8 0.1
0.9 0.1
Bone
Mineral
Density
(BMD)
Femoral
Neck
(g/cm2)
<.0001
73.8 25.5
128.9 42.3
Knee
Extensor
Strength
(KES, Nm)
0.0011
58.0%
51.5%
Hamstring:
Quadriceps
(H:Q) Ratio
(% <0.6)
<.0001
159.4 77.6
206.8 97.4
Physical
Activity
Scale for
the Elderly
(PASE)
Score
Baseline characteristics for the Study of Incident Symptomatic Whole Knee OA (N=2078 participants / 3392 knees)
Table 3
Segal et al.
Page 14
270
130
188
37
108.8 38.2
124.9 41.2
124.6 36.7
128.7 40.9
131.7 43.8
Mean SD
(Nm)
Men*
54
228
248
391
1068
Total
# of
knees
55.9 + 22.0
67.4 + 23.6
71.2 + 23.8
74.3 + 26.4
76.5 + 25.4
Mean SD
(Nm)
Women*
Peak Knee Extensor Strength
37
188
130
270
778
Total
# of
knees
Men
48.7
48.9
53.9
52.6
51.4
54
228
248
391
1068
Total
# of
knees
51.9
57.9
58.1
52.9
60.2
Women
H:Q Ratio <0.6
p<.05 for peak knee extensor strength trend among KL grades within each sex
778
Total
# of
knees
Baseline
KL
Grade
Incident Symptomatic Whole knee Osteoarthritis Cohort: Mean Knee Extensor Strength and Frequency of Hamsting:Quadriceps (H:Q) Ratio <0.6 by
Baseline Kellgren-Lawrence (KL) Grade
Table 4
Segal et al.
Page 15
Segal et al.
Page 16
Table 5
Association Between Knee Extensor Strength and Hamstring:Quadriceps (H:Q) Ratio and Incident
Symptomatic Whole Knee Osteoarthritis
Knee Extensor
Strength
Sex-Specific
Tertiles
N of case
(%)
OR (95% CI),
Adjusting age,
BMI, BMD,
surgery, and
PASE at baseline
OR (95% CI),
Adjusting age,
BMI, BMD,
surgery, PASE,
and knee pain
at baseline
Men
Lowest, 12109
Nm
(n=462)
52 (11.3)
1.0
1.0
Middle, 110144
Nm (n=465)
30 (6.4)
0.6 (0.4, 1.0)
0.6 (0.4, 1.1)
Highest, 145276
Nm (n=476)
27 (5.7)
0.5 (0.3, 0.9)*
0.6 (0.3, 1.1)
1SD
0.7 (0.5, 0.9)
0.7 (0.6, 0.9)*
P for linear trend
0.0026
0.0143
Women
Lowest, 461 Nm
(n=647)
96 (14.8)
1.0
1.0
Middle, 6283 Nm
(n=676)
62 (9.2)
0.7 (0.5, 0.9)*
0.7 (0.5, 1.0)
Highest, 84206
Nm (n=666)
43 (6.5)
0.4 (0.3, 0.7)*
0.5 (0.3, 0.8)*
1SD
0.7 (0.6, 0.9)*
0.7 (0.6, 0.9)*
P for linear trend
0.0004
0.0034
H:Q Ratio
H:Q cut-off
N of case
(%)
OR (95% CI),
Adjusting age,
BMI, BMD,
surgery, and
PASE at baseline
OR (95% CI),
Adjusting age,
BMI, BMD,
surgery, knee
pain and PASE
at baseline
Men
<0.6 (722)
57 (7.9)
1.0
1.0
0.6 (681)
52 (7.6)
1.0 (0.6, 1.5)
1.1 (0.7, 1.7)
<0.6 (1154)
118(10.2)
1.0
1.0
0.6 (835)
83 (9.9)
1.0 (0.7, 1.3)
1.0 (0.7, 1.3)
Women
BMI: Body Mass Index
BMD: Bone Mineral Density

PASE: Physical Activity Scale for the Elderly

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Published in final edited form as:

The Effect of Thigh Strength on Incident Radiographic and

University Feinberg School of Medicine, Chicago, IL

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of Alabama at Birmingham, Birmingham, AL

of California San Francisco, San Francisco, CA

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MATERIALS and METHODS

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Knee radiograph assessments

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Height and WeightAt baseline, height in centimeters (stadiometer, Holtain, Wales,

Definition of Incident Symptomatic Whole knee OA

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development of symptomatic disease allowed this study to provide information most

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A potential limitation is inherent in the measurement of strength. The lower strength in

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Subject Inclusion Diagram

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MeanSD except as indicated

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0.5 (0.2, 1.0)

0.5 (0.3, 1.1)

0.5 (0.2, 1.2)

0.6 (0.3, 1.4)

0.76 (0.52, 1.11)

0.81 (0.55, 1.21)

Test for linear trend

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0.7 (0.4, 1.1)

0.7 (0.4, 1.2)

0.7 (0.4, 1.2)

0.8 (0.4, 1.4)