ORIGINAL RESEARCH
Efficacy of Hip Strengthening Exercises Compared With Leg
Strengthening Exercises on Knee Pain, Function, and
Quality of Life in Patients With Knee Osteoarthritis
Victor Lun, MSc, MD,* Andrew Marsh, MSc, MD,† Robert Bray, MD,‡
David Lindsay, BHMS, BPhty, MSc,* and Preston Wiley, MPE, MD*
Objective: The purpose of this study was to compare the efficacy
of hip and leg strengthening exercise programs on knee pain,
function, and quality of life (QOL) of patients with knee osteoar-
thritis (KOA).
Design: Single-Blinded Randomized Clinical Trial.
Setting: Patients with KOA.
Participants: Male and female subjects were recruited from
patients referred to the University of Calgary Sport Medicine Center
and from newspaper advertisements.
Interventions: Thirty-seven and 35 patients with KOA were
randomly assigned to either a 12-week hip or leg strengthening
exercise program, respectively. Both exercise programs consisted of
strengthening and flexibility exercises, which were completed 3 to 5
days a week. The first 3 weeks of exercise were supervised and the
remaining 9 weeks consisted of at-home exercise.
Main Outcome Measures: Knee Injury and Osteoarthritis Score
(KOOS) and Western Ontario McMaster Arthritis Index (WOMAC)
questionnaires, 6-minute walk test, hip and knee range of motion
(ROM), and hip and leg muscle strength.
Results: Statistically and clinically significant improvements in the
KOOS and WOMAC pain subscale scores were observed in both the
hip and leg strengthening programs. There was no statistical
difference in the change in scores observed between the 2 groups.
Equal improvements in the KOOS and WOMAC function and QOL
subscales were observed for both programs. There was no change in
hip and knee ROM or hip and leg strength in either group.
Submitted for publication January 13, 2014; accepted August 31, 2014.
From the *University of Calgary Sport Medicine Centre, Faculty of Kinesiology,
University of Calgary, Alberta, Canada; †Division of Orthopaedic Surgery,
Department of Surgery, Faculty of Health Sciences (Resident), Queen’s
University, Kingston, Ontario, Canada; and ‡Department of Surgery, Faculty
of Medicine, University of Calgary, Calgary, Alberta, Canada.
Supported by the Canadian Academy of Sport Medicine Research Fund.
The authors report no conflicts of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.cjsportmed.com).
Corresponding Author: Victor Lun, MSc, MD, CCFP, University of Calgary
Sport Medicine Centre, Faculty of Kinesiology, University of Calgary,
376 Collegiate Boulevard, N.W., Calgary, Alberta T2N 1N4, Canada
(vmylun@ucalgary.ca).
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Clin J Sport Med  Volume 25, Number 6, November 2015
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Conclusions: Isolated hip and leg strengthening exercise programs
seem to similarly improve knee pain, function, and QOL in patients
with KOA.
Clinical Relevance: The results of this study show that both hip
and leg strengthening exercises improve pain and QOL in patients
with KOA and should be incorporated into the exercise prescription
of patients with KOA.
Key Words: knee osteoarthritis, exercise therapy, hip strengthening,
randomized control trial
(Clin J Sport Med 2015;25:509–517)
INTRODUCTION
Knee osteoarthritis (KOA) is the most common form
of osteoarthritis affecting approximately 6% of the adult
population older than 30 years and 11% of the adult
population older than 65 years.1,2 Options for conservative
treatment of KOA include patient education, weight loss,
knee bracing, walking aids, nonsteroidal anti-inflammatory
medications, analgesic medications, and exercise therapy.
Although there is consistent evidence that physical exercise
of various forms has a beneficial effect on improving pain,
joint function, and quality of life (QOL) of patients with
KOA, the most effective exercise prescription for patients
with KOA has yet to be established.3–34 Exercise therapy
usually focuses on strength and flexibility training of the
thigh muscles around the knee, which have been found to
have strength deficits in patients with KOA.35–37 However, it
has been observed that strengthening the musculature of the
pelvis and hips may also be an important component of
exercise prescription for KOA.38–41 Previous studies have
shown beneficial effects of hip strengthening exercises in
other knee injuries such as patellofemoral pain syn-
drome42,43 and iliotibial band syndrome.44 Bennell et al45
found that hip adduction and abduction strengthening exer-
cises alone result in improved knee pain and function in
patients with KOA, but did not change knee adduction
moment. No previous studies have compared the effects of
hip strengthening exercises alone against leg strengthening
exercises alone. The objective of this study was to compare
the isolated effects of hip strengthening exercises to leg
strengthening exercises on measures of knee pain, function,
and QOL in patients with KOA.
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 Lun et al
METHODS
This study was approved by the University of Calgary
Conjoint Bioethics Committee.
Study Population/Subjects
Male and female subjects were recruited from patients
referred to sport medicine physicians at the University of
Calgary Sport Medicine Center and from local newspaper
advertisements. Prospective subjects underwent an initial
screening of eligibility followed by a clinical evaluation by
1 of 2 sport medicine physicians (co-authors V.L. and P.W.).
Each clinical evaluation consisted of a review of clinical
history, physical examination, and plain film x-rays (standing
anterior posterior, lying lateral/decubitus lateral, and supine
skyline views). A diagnosis of KOA was made using
previously validated criteria incorporating clinical and radio-
graphic findings.46,47 Besides the clinical diagnosis of KOA,
subjects were included only if their reported severity of knee
pain on the Knee Injury and Osteoarthritis Score (KOOS)
pain subscale score was less than or equal to 68.
Potential subjects were excluded if they had any physical
or medical contraindications for exercise; bony abnormalities,
including bone fracture, osteochondritis dissecans, biparitite
patella of affected knee; had scheduled knee surgery within the
time frame of the study; regularly participated in an organized
strength exercise program; received viscosupplementation or
steroid injection within the past 6 months; or received
physiotherapy treatment within the last 3 months.
Subjects who met the inclusion criteria and agreed to
participate in the study then signed informed consent.
Study Procedure
Subjects completed a baseline assessment of the
following outcome measures: KOOS questionnaire, Western
Ontario McMaster Arthritis Index (WOMAC) questionnaire,
modified Six Minute Walk Test (SMWT), and knee and hip
range of motion (ROM) and strength.
The KOOS and WOMAC questionnaire’s are validated
outcome measurements of knee pain and function.48–52 The
KOOS pain subscale was the primary outcome measure of the
study. The WOMAC Pain, Stiffness, and Physical Function (PF)
subscale scores were used as secondary outcome measures.
The SMWT is a reliable measurement of functional
exercise capacity.53–57 Compared with previous studies, the test
in this study was performed on a 200-m oval indoor running track
instead of in a hallway. At completion of the test, the total distance
walked was measured by counting the number of 200-m laps and
using a tachometer to measure any extra distance walked.
Active hip internal and external rotation, Patrick Hip
ROM Test (flexion, abduction, external rotation) and knee
flexion and extension ROM were measured as described by
Norkin and White58 and Ross et al.59
Cybex isokinetic measurement of knee flexion and
extension and hip internal and external rotation were
measured at 908/s and 608/s, respectively, a reliable measure-
ment of strength in patients with KOA.60 A modified version
of the methodology described by Schilke et al61 and Lindsay
et al62 was used for this study.
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Clin J Sport Med  Volume 25, Number 6, November 2015
After baseline evaluation of the outcome measurements,
a research assistant gender block randomized subjects to 1 of 2
treatment groups: Hip exercise group or Leg exercise group.
The exercises for the Hip group consisted of dynamic
resistance strengthening and stretching exercises for the hip
primarily using Thera-Band (Thera-Band, The Hygenic Cor-
poration, Akron, Ohio) elastic bands. The exercises for the Leg
group consisted of dynamic resistance exercises primarily
using Thera-Band elastic bands for the muscles of the lower
extremities (quadriceps, hamstrings, and calves). The exercises
for each group are described in the Supplemental Digital
Content 1 (see Appendix, http://links.lww.com/JSM/A51).
Subjects in both treatment groups initially attended 3 super-
vised exercise sessions a week for the first 3 weeks of the
study to ensure familiarity with their exercise program.
A physiotherapist taught the initial 2 sessions with the assis-
tance of student volunteers. During these 2 sessions, each
exercise was taught in detail, with demonstration and observa-
tion by both the physiotherapist and the student volunteers.
The physiotherapist had the discretion to change the exercise
technique for a particular exercise if considered necessary.
After the initial 2 sessions, the remaining supervised sessions
were taught and observed by the student volunteers. In addi-
tion to 3 supervised sessions during the initial 3 weeks, sub-
jects were instructed to perform the exercise routine at home
twice a week to ensure that they were capable of performing
the exercises on their own. Thereafter, subjects were required
to perform the exercise program at home 3 to 5 days a week
with follow-up sessions at the completion of 6 and 9 weeks of
the study. Subjects in both exercise groups were requested to
follow only the exercises assigned for their group and to not
make any significant lifestyle or exercise regime changes dur-
ing the time of the study.
All subjects maintained a log documenting when they
performed the exercise program (number of sets and repeti-
tion of each exercise) for the 12-week study period.
At the completion of the 12-week exercise program,
subjects underwent reassessment of all outcome measures.
A research coordinator completed all the outcome
measurements at baseline and at 12 weeks and was blinded
to the treatment group of each subject.
Sample Size Calculation
A minimum sample size of 60 subjects (30 subjects
per group) was calculated based on the KOOS question-
naire, which has a minimum clinically significant change of
10 points and an SD of 15 points per subscale.63 Using
an expected change of 11 points and an SD of the differ-
ence of 15 points, it was calculated that 30 subjects per
group was required to detect a statistically significant dif-
ference between groups with the KOOS questionnaire with
80% power.
Analysis
Two-sided 1 sample t-tests were used to determine
whether there was a statistically significant difference in the
average change of the KOOS and WOMAC Pain scores
within each treatment group. Two-sided 2-sample unpaired
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 Clin J Sport Med  Volume 25, Number 6, November 2015
t-tests were used to determine whether there was a statistically
significant difference (P , 0.05) in mean change scores
between the 2 treatment groups.
Mean change with 95% confidence intervals (CIs) for
the Hip and Leg treatment groups and the difference
between the mean changes with 95% CIs between treat-
ment groups were assessed for the KOOS Symptoms,
Activities of Daily Living (ADL), Sport and Recreation
Function (SRF), and QOL scores and the WOMAC
Stiffness and PF scores.
Mean change with 95% CIs for the Hip and Leg
treatment groups and the difference between the mean
changes with 95% CIs between the Hip and Leg treatment
FIGURE. Flowchart of subjects through the
12-week study protocol.
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Hip Strengthening and Knee Osteoarthritis
groups were assessed for SMWT distance, ROM measures of
the knee and hip for the most affected joint, and Cybex peak
torque of the leg and hip of the most affected joint.
RESULTS
Subjects
The Figure shows the flow of subjects through the
study. One hundred two subjects were randomized into treat-
ment groups with 51 subjects per treatment group. Four sub-
jects who were randomized into a treatment group did not
start the group exercise therapy. Thirteen and 14 subjects
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 Lun et al Clin J Sport Med  Volume 25, Number 6, November 2015

TABLE 1. Demographic Data for Study and Dropout Populations (Mean 6 SD, Unless Otherwise Indicated)
Subject Characteristics Dropout Characteristics
Hip (n = 37) Leg (n = 34) Hip (n = 14) Leg (n = 17)
Age (yr) 63.42 6 9.61 61.38 6 7.70 62.00 6 8.92 58.76 6 8.03
Gender
Male 16 16 6 6
Female 21 18 8 11
Height (m) 1.72 6 0.10 1.72 6 0.08 1.69 6 0.10 1.68 6 0.12
Weight (kg) 86.33 6 14.79 90.49 6 19.24 86.61 6 18.38 87.82 6 22.21
BMI 29.33 6 4.17 30.75 6 6.27 30.36 6 5.47 30.92 6 6.20
KL grade, median 3* 3 3† 3‡
Bilateral/unilateral, n/n 27/10 29/5 9/5 11/6
KOOS pain 51.95 6 11.53 53.27 6 8.22 50.00 6 10.56 51.53 6 12.50
*n = 34, 3 subjects without x-ray evaluation.
†n = 9, 5 subjects without x-ray evaluation.
‡n = 14, 3 subjects without x-ray evaluation.
BMI, body mass index.

from the Hip and Leg exercise groups, respectively, withdrew
from the study after starting their exercise programs. The
reasons for subject withdrawal included lack of time avail-
ability/lack of compliance (14 subjects), personal/health-
related reasons (5 subjects), knee surgery (2 subjects), or no
reason provided (10 subjects). Thirty-seven and 34 subjects
from the Hip and Leg exercise groups, respectively, com-
pleted the exercise program and 12-week testing and were
included for analysis.
A comparison of the study population and dropout
population subject characteristics according to treatment
group is seen in Table 1. The baseline characteristics of
the patients within the 2 intervention groups were generally
similar.
Change in Subjective Scores of Pain
A statistically and clinically significant improvement in
the KOOS and WOMAC pain subscale scores was observed
in both Hip and Leg groups (Tables 2 and 3, respectively).
There was no statistical or clinical difference (P = 0.19) in the
change in KOOS score observed between the 2 groups. There
was a statistically significant (P = 0.041) but not clinically
significant (Δ = 7.79) improvement in score between the 2
groups in the WOMAC score.
Secondary KOOS and WOMAC Subscales
The change in KOOS Symptom, ADL, SRF, and QOL
subscales and WOMAC Stiffness and PF subscales scores for
both treatment groups are seen in Table 4. The improvements
observed in these secondary subscales tended to be larger in
magnitude in the Leg exercise group.
Secondary Outcome Measures of Function
Six-Minute Walk Test
The Hip exercise group improved their walking
distance by an average of 20.8 m (3%), whereas the Leg
exercise program improved their distance by approximately
26.0 m (4%) (Table 5). The change in both groups was not
significant.
Range of Motion
None of the hip or knee ROM measures changed
significantly (Table 6).
Cybex Isokinetic Muscle Strength
There were small increases in both leg and hip strength
at the completion of 12 weeks of exercise in both groups
(Table 7). Based on the 95% CI, only knee flexion strength in
the Leg group significantly increased.
Program Progression
Table 8 shows a similar progression of subjects using
greater resistance Thera-Band elastic bands as they pro-
gressed through the 12 weeks of the study.

TABLE 2. The Baseline and Posttreatment KOOS Pain Scores, Mean Change in KOOS Pain Scores (95% CI), Difference Between
Mean Scores (95% CI), and the Detected P Value for the 2-Sided t Test Between the Hip and Leg Exercise Groups
Difference in Mean D, Difference
Baseline, Mean 6 SD Posttreatment, Mean 6 SD Mean D, (95% CI) (95% CI) P
Hip program 51.96 6 11.52 62.26 6 12.47 10.27 (5.79-14.75)* 24.68 (211.81 to 2.45) 0.19
Leg program 53.27 6 8.22 68.22 6 14.79 14.95 (9.34-20.56)*
*P , 0.01 for within-group 1 sample t test comparison of mean.

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 Clin J Sport Med  Volume 25, Number 6, November 2015 Hip Strengthening and Knee Osteoarthritis

TABLE 3. The Baseline and Posttreatment WOMAC Pain Scores, Mean Change in WOMAC Pain Scores (95% CI), Difference
Between Mean Scores (95% CI), and the Detected P Value for the 2-Sided t Test Between the Hip and Leg Exercise Groups
Difference in Mean D, Difference
Baseline, Mean 6 SD Posttreatment, Mean 6 SD Mean D, (95% CI) (95% CI) P
Hip program 60.27 6 15.94 70.27 6 13.49 10.00 (5.40-14.60)* 27.79 (215.25 to 20.33) 0.04
Leg program 58.53 6 14.54 76.32 6 16.34 17.79 (11.84-23.75)*
*P , 0.01 for within-group 1 sample t test comparison of mean.

DISCUSSION of 60 and 59.52 reported by Thorstennson et al64 and King

This is the first study to compare the isolated effects of
hip strengthening exercises to leg strengthening exercises on
measures of knee pain, function, and QOL in patients with
KOA. The study results show that the completion of 12 weeks
of hip or leg strengthening exercises resulted in equally
significant improvements in self-reported pain, function, and
QOL of patients with KOA.
Knee Pain
The findings of this study confirm the results of
previous studies that have also reported significant improve-
ments in self-reported pain with the completion of leg
strengthening6,8–12,16–24,27,28 and hip strengthening45 exercise
programs. However, the magnitude of improvement in the
KOOS pain subscale score in this study (10.27 points in the
hip group and 14.95 in the leg group) was substantially greater
than the 1.8 and 2.76 point increase reported by Thorstennson
et al64 and King et al,65 respectively. Similarly, the improvement
in the WOMAC pain score in this study (10 points in the hip
group and 17.79 points in the leg group) is greater than the 9- and
13-point increase reported by Topp et al6 and Lim et al,24 respec-
tively. One possible reason for the greater magnitude of improve-
ment observed in this study is that the baseline level of pain in
this study (average KOOS pain score of 51 and 53 for the knee
and hip groups, respectively; average WOMAC score of 60 and
58 for the knee and hip groups, respectively) was greater than
that reported in the previous studies (average KOOS pain score
et al,65 respectively; range of WOMAC pain score of 10.75 to
12.40 and 33.1 to 39.2 reported by Topp et al6 and Lim et al,24
respectively). Therefore, there was more room for improvement
in this study and thus, a large change in outcome scale scores.
Although no previous study has investigated the
isolated effects of hip strengthening, 2 previous studies have
used programs consisting of both leg and hip strengthening
exercises. Topp et al6 observed a non-statistically significant
improvement of 9 points (22%) in the WOMAC pain score
with a dynamic isotonic exercise program of the legs and
hips. Baker et al18 observed a 36% (79 mm) improvement
in WOMAC pain (VAS) with a home-based exercise pro-
gram, which included isotonic hip extension, adduction, and
abduction in addition to extension and flexion of the knee.
Unfortunately, from the design of these 2 studies, it cannot be
determined what influence the hip exercises had on the re-
ported improvements or if the hip and leg strengthening ex-
ercises have a synergistic or additive effect.
Lim et al24 have suggested that the improvement in
KOA pain after completing leg strengthening exercises may
be due to the increased ability of the quadriceps to improve
functional joint stability, shock absorption, and ground reac-
tion forces during ADL, such as walking. Moreover, improve-
ments in pain after leg strengthening exercises have been
demonstrated to be associated with improvements in biome-
chanical variables of gait, including velocity, cadence, and
stride length.22

TABLE 4. The Baseline and Posttreatment KOOS and WOMAC Subscale Scores for the Hip and Leg Exercise Groups (Mean 6 SD),
Mean Change With 95% CI for Both Treatment Groups, and the Difference Between Mean Changes With 95% CI for the KOOS
and WOMAC Subscale Scores
Difference in Mean D, Difference
Baseline, Mean 6 SD Posttreatment, Mean 6 SD Mean D, (95% CI) (95% CI)
Hip KOOS symptoms 53.44 6 12.26 64.48 6 14.79 11.04 (6.11-15.98) 3.04 (24.22 to 10.32)
Leg KOOS symptoms 56.18 6 13.38 64.18 6 16.60 8.00 (2.64-13.35)
Hip KOOS ADL 60.95 6 15.04 69.47 6 14.07 8.52 (3.75-13.30) 26.10 (213.90 to 1.60)
Leg KOOS ADL 61.93 6 13.62 76.55 6 16.36 14.62 (8.51-20.74)
Hip KOOS SRF 38.10 6 22.18 48.92 6 25.28 10.81 (2.52-19.10) 215.07 (229.10 to 21.08)
Leg KOOS SRF 33.68 6 20.39 59.56 6 25.95 25.88 (14.41-37.35)
Hip KOOS QOL 33.61 6 17.14 42.26 6 17.43 8.65 (3.99-13.30) 26.24 (213.75 to 1.27)
Leg KOOS QOL 33.27 6 14.33 48.16 6 15.73 14.89 (8.91-20.86)
Hip WOMAC stiffness 58.45 6 17.44 68.89 6 15.93 8.45 (3.81-13.78) 212.50 (222.00 to 22.30)
Leg WOMAC stiffness 48.69 6 21.38 69.62 6 23.52 20.94 (13.15-28.73)
Hip WOMAC PF 61.83 6 16.38 70.63 6 13.97 8.80 (3.81-13.78) 27.40 (214.86 to 0.05)
Leg WOMAC PF 60.12 6 13.66 76.32 6 17.10 16.20 (10.63-21.77)

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 Lun et al Clin J Sport Med  Volume 25, Number 6, November 2015

TABLE 5. The Baseline and Posttreatment SMWT Distances for the Hip and Leg Treatment Groups (Mean 6 SD), Mean Change
With 95% CI for Both Treatment Groups, and the Difference Between Mean Changes With 95% CI for the SMWT Distances
Difference in Mean D, Difference
Baseline, Mean 6 SD Posttreatment, Mean 6 SD Mean D, (95% CI) (95% CI)
Hip SMWT (m) 618.6 6 81.3 639.3 6 81.3 20.8 (5.9-36.0) 25.2 (226.4 to 16.0)
Leg SMWT (m) 605.3 6 86.3 631.3 6 92.4 26.0 (11.0-41.0)

The exact mechanism by which improvements in
symptoms occur with hip strengthening exercises is unknown.
However, it may be that improvements in hip strength help
provide a more stable pelvis and improved dynamic lower
extremity alignment, including lowering the knee adduction
moment.38,41,66 This may explain many of the improvements
seen in both groups; however, because biomechanical varia-
bles were not measured in this study, no conclusion can be
made as to if these changes occurred.
Secondary KOOS and WOMAC Subscales
From the secondary subscales of the KOOS and WOMAC
questionnaires, both the Hip and Leg exercise programs also
result in improved self-reported symptoms of joint function and
QOL outcomes. This would not be unexpected because if there is
a decrease in knee pain, an increase in knee function and QOL
should correspondingly occur.
Six-Minute Walk Test
The improvement in walking distance in both treatment
groups was small (,5%) and would be unlikely to be con-
sidered a clinically significant finding.53,67 The improvement
observed in this study is less than the 9% improvement re-
ported by Deyle et al17. One possible explanation for this
finding is that the baseline function of subjects within both
treatment groups was high, as reflected by the baseline meas-
urements of 615 m for the Hip group and 605 m for the Leg
group. Jenkins67 reported that a high pretraining test distance
of 600 m implies an average walking speed of 6 km an hour.
The high pretraining performance may have limited the abil-
ity to improve walking distance because the determinant of
performance at that speed is based on the mechanical factors
of walking like stride length rather than joint function; thus,
a ceiling effect may be created for the test. In this study, the
SMWT was performed on a circular 200-m track as opposed
to walking back and forth on in a corridor.5,13,16,17,19,68 This
difference in protocol may have resulted in greater walking
distances because subjects did not need to pause to turn
around within a corridor but would not have affected the
change in walking distance.
The magnitude of SMWT change did not correspond
the magnitude of change in the subjective measures of
function as measured by the KOOS ADL and the WOMAC
PF subscales (Table 4). Similar findings have been previously
reported,13,17,68 suggesting that the subjective interpretation of
PF may improve more with exercise therapy than the actual
performance of functional tasks such as walking.
Joint Range of Motion
Knee and hip ROM were not significantly changed in
either treatment group. This finding is not unexpected because
degenerative joint disease results in intra-articular changes
that will limit ROM. Previous studies have not measured knee
and hip ROM as an outcome, so the finding of this study
cannot be compared.
Leg and Hip Muscle Strength
Leg and hip muscle strength did not change signifi-
cantly in either treatment group (Table 7). This finding is
somewhat unexpected given the significant improvements in
knee pain and QOL outcome measurements. When the com-
pliance data for both exercise programs were examined
(Table 8), higher resistance Thera-Band was progressively
used by all the subjects as the program progressed. This
would indirectly indicate that the subjects were in fact get-
ting stronger and requiring more resistance while performing

TABLE 6. The Baseline and Posttreatment ROM Measures for the Hip and Leg Exercise Groups (Mean 6 SD), Mean Change With
95% CI for Both Treatment Groups, and the Difference Between Mean Changes With 95% CI for the ROM Measures
Difference in Mean D, Difference
Baseline, Mean 6 SD Posttreatment, Mean 6 SD Mean D (95% CI) (95% CI)
Hip KE (degrees) 5.19 6 4.16 5.35 6 3.91 0.16 (20.73 to 1.06) 20.01 (21.12 to 1.09)
Leg KE (degrees) 6.35 6 6.08 6.53 6 5.48 0.18 (20.45 to 0.80)
Hip KF (degrees) 121.35 6 8.31 123.35 6 8.57 1.89 (0.06 to 3.73) 21.22 (23.67 to 1.21)
Leg KF (degrees) 119.91 6 10.81 123.03 6 9.81 3.12 (1.53 to 4.70)
Hip HIR (degrees) 29.73 6 9.12 30.92 6 9.28 1.19 (20.47 to 2.85) 20.75 (23.03 to 1.52)
Leg HIR (degrees) 26.76 6 10.25 28.32 6 5.35 1.94 (0.40 to 3.48)
Hip HER (degrees) 28.81 6 8.84 31.31 6 7.45 2.51 (0.66 to 4.36) 1.28 (21.27 to 3.84)
Leg HER (degrees) 28.32 6 5.35 29.56 6 6.17 1.23 (20.51 to 2.98)
Hip patrick (cm) 29.17 6 8.11 28.05 6 8.51 21.06 (22.50 to 0.39) 0.84 (20.97 to 2.65)
Leg patrick (cm) 30.34 6 6.81 28.44 6 6.72 21.90 (22.96 to 20.83)

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 Clin J Sport Med  Volume 25, Number 6, November 2015 Hip Strengthening and Knee Osteoarthritis

TABLE 7. The Baseline and Posttreatment Strength Measures for the Hip and Leg Exercise Programs (Mean 6 SD), Mean Change
With 95% CI for Both Treatment Groups, and the Difference Between Mean Changes With 95% CI for the Strength Measures
Difference in Mean D, Difference
Baseline, Mean 6 SD Posttreatment, Mean 6 SD Mean D, (95% CI) (95% CI)
Hip KE (Nm) 97.99 6 38.71 100.26 6 39.44 2.26 (1.67 to 6.67) 25.90 (212.73 to 0.93)
Leg KE (Nm) 93.28 6 36.99 101.45 6 38.20 8.16 (2.37 to 13.96)
Hip KF (Nm) 63.47 6 28.27 67.64 6 28.76 4.17 (1.67 to 6.67) 25.28 (210.54 to 20.02)
Leg KF (Nm) 57.20 6 21.56 66.65 6 28.42 9.45 (4.68 to 14.22)
Hip HIR (Nm) 70.90 6 29.54 74.63 6 27.59 3.73 (20.63 to 8.09) 0.10 (26.12 to 6.32)
Leg HIR (Nm) 72.64 6 26.80 76.27 6 29.54 3.62 (20.80 to 8.06)
Hip HER (Nm) 46.12 6 15.98 49.34 6 18.20 3.21 (1.38 to 5.05) 0.68 (22.29 to 3.65)
Leg HER (Nm) 46.38 6 16.06 48.91 6 14.42 2.54 (0.17 to 4.90)

the exercises. Studies examining leg strengthening in exercises used in this study were closed-kinetic chain isotonic
healthy older adults show that subjects may lose their ability exercises, whereas open-chain isokinetic strength was mea-
to generate greater torque at higher velocities with age.69 sured. It is possible that the isotonic exercises used in this
Another study suggested that when strengthening with elas- study developed strength that was functional and not detected
tic resistance, early strength gains are explained by neural by isokinetic measurement. Another possible reason for mea-
adaptations, which results in resistance progression; how- suring an increase in muscle strength is that measurement of
ever, over 10 weeks, their subjects saw increases in both muscle strength depends on voluntary effort. Knee pain dur-
muscular endurance and fat-free mass.70 ing the strength testing may have prevented subjects from
A possible reason for an apparent lack of improved providing maximum effort, and thus underestimate a subject’s
strength was the difference between strengthening and true muscle strength.72 However, subjectively, pain was
measurement techniques.71 Many of the leg strengthening reduced through the course of the study, which makes this
hypothesis less likely. The final possible reason for not seeing
an improvement in strength is that KOA may cause a form of
TABLE 8. Thera-Band Color Used to Perform Exercises Over reflexive inhibition of the leg muscles, which prevents a mea-
the 12-Week Strengthening Programs (Percent of Group surable change in leg strength.73 Other mechanisms and adap-
Population) tations such as improved joint stability and coordination and
Yellow Red Green Blue Black intramuscular biomechanical and neuromuscular adaptations
Week No. (%) (%) (%) (%) (%) may affect the knee joint in a way that knee pain and function
Hip exercise could be improved.
1 75 25 One limitation of the study was that the location of
2 20 51 26 3 KOA (ie, medial, lateral, patellofemoral, or 3-compartment
3 3 49 36 12 disease) was not controlled. Another limitation of the study
4 3 32 41 24 was that there was no combined leg and hip strengthening
5 3 32 41 24 treatment group, so it is unknown if there is an additive
6 5 14 50 31 or synergistic effect of exercise on the subject’s symptoms.
7 3 11 47 39 Another limitation of this study was that intention-to-
8 6 46 48 treat analysis was not performed. However, Table 1 shows
9 3 34 63 that there were a similar number of dropouts from both
10 38 62 treatment groups, and that the characteristics of the study
11 38 62 subjects and drop-out subjects are essentially identical.
12 38 62 Also, the reasons for subject drop-out were not directly
Leg exercise related to the effectiveness or other aspects exercise inter-
1 64 30 6 vention per se.
2 19 47 31 3 The results of this study indicate that hip strengthening
3 3 42 42 13 exercises should be strongly recommended as part of the
4 22 39 39 exercise prescription of patients with KOA. Future studies
5 17 39 44 should explore the mechanism by which hip strengthening
6 21 34 45 exercises improve knee pain and if the effects of hip and leg
7 13 41 46 strengthening exercises are additive or synergistic.
8 7 30 56 7
9 7 30 56 7
10 3 40 50 7 CONCLUSIONS
11 3 40 50 7 The results of this study found that hip and leg strength-
12 3 40 50 7 ening exercises provided an equally significant improvement

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Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 Lun et al
in subjective measures of pain, function, and QOL of patients
with KOA.
ACKNOWLEDGMENTS
The authors thank the Canadian Academy of Sport
Medicine Research Fund for their unrestricted financial
support of this study.
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