Lateral wedges reduce the peak knee adduction moment and are advocated for knee osteoarthritis. H... more Lateral wedges reduce the peak knee adduction moment and are advocated for knee osteoarthritis. However some patients demonstrate adverse biomechanical effects with treatment. Clinical management is hampered by lack of knowledge about their mechanism of effect. We evaluated effects of lateral wedges on frontal plane biomechanics, in order to elucidate mechanisms of effect. Seventy three participants with knee osteoarthritis underwent gait analysis with and without 5° lateral wedges. Frontal plane parameters at the foot, knee and hip were evaluated, including peak knee adduction moment, knee adduction angular impulse, center of pressure displacement, ground reaction force, and knee-ground reaction force lever arm. Lateral wedges reduced peak knee adduction moment and knee adduction angular impulse (-5.8% and -6.3% respectively, both P<0.001). Although reductions in peak moment were correlated with more lateral center of pressure (r=0.25, P<0.05), less varus malalignment (r values 0.25-0.38, P<0.05), reduced knee-ground reaction force lever arm (r=0.69, P<0.01), less hip adduction (r=0.24, P<0.05) and a more vertical frontal plane ground reaction force vector (r=0.67, P<0.001), only reduction in knee-ground reaction force lever arm was significantly predictive in regression analyses (B=0.056, adjusted R(2)=0.461, P<0.001). Lateral wedges significantly reduce peak knee adduction moment and knee adduction angular impulse. It seems a reduced knee-ground reaction force lever arm with lateral wedges is the central mechanism explaining their load-reducing effects. In order to understand why some patients do not respond to treatment, future evaluation of patient characteristics that mediate wedge effects on this lever arm is required.
American journal of physical medicine & rehabilitation / Association of Academic Physiatrists, 2002
Knee osteoarthritis has a major impact on quadriceps function, yet its effect on the specific tem... more Knee osteoarthritis has a major impact on quadriceps function, yet its effect on the specific temporal recruitment of vastus medialis obliquus and vastus lateralis is unknown. The aim of this study was to determine the electromyographic onset of vastus medialis obliquus activity relative to that of vastus lateralis in individuals with symptomatic knee osteoarthritis and in an asymptomatic control group during the functional task of stair climbing. Cross-sectional, comprising 41 participants with symptomatic knee osteoarthritis and 33 controls matched for age, sex, and body mass. No significant differences were detected in the timing of onset of vastus medialis obliquus relative to that of vastus lateralis between the osteoarthritis and control groups. Radiographic osteoarthritis severity, presence of patellofemoral joint disease, and pain intensity did not seem to influence the temporal relationship of the vastii in the osteoarthritis group. The presence of symptomatic, radiographic...
Clinical biomechanics (Bristol, Avon), Jan 18, 2015
Knee osteoarthritis is common in people who have undergone partial meniscectomy, and a higher ext... more Knee osteoarthritis is common in people who have undergone partial meniscectomy, and a higher external knee flexion moment during gait may be a potential contributor. Although the peak external knee flexion moment has been shown to increase from 3months to 2years following partial meniscectomy, mechanisms underpinning the increase in the peak knee flexion moment are unknown. Sixty-six participants with partial meniscectomy completed three-dimensional gait (normal and fast pace) and quadriceps strength assessment at baseline (3months following partial meniscectomy) and again 2years later. Variables included external knee flexion moment, vertical ground reaction force, knee flexion kinematics, and quadriceps peak torque. For normal pace walking, the main significant predictors of change in peak knee flexion moment were an increase in peak vertical ground reaction force (R(2)=0.55), mostly due to an increase in walking speed, and increase in peak knee flexion angle (R(2)=0.19). For fas...
Objective To investigate whether a 12-week physical therapist-delivered combined pain coping skil... more Objective To investigate whether a 12-week physical therapist-delivered combined pain coping skills training and exercise (PCST+EX) is more efficacious and cost-effective than either treatment alone for knee OA. Methods This was an assessor-blinded, 3-arm randomized controlled trial in 222 (73 PCST+EX, 75 EX, 74 PCST) people aged ≥50 years with knee OA. All participants received 10 treatments over 12 weeks plus a home program. PCST covered pain education and training in cognitive and behavioral pain coping skills. EX comprised strengthening exercises. PCST+EX integrated both. Primary outcomes were self-reported average knee pain (0-100mm visual analogue scale) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index 0-68) at week 12. Secondary outcomes included other pain measures, global change, physical performance, psychological health, physical activity, quality-of-life and cost-effectiveness. Analyses were by intention-to-treat with multiple imputation for missing data. Results 201 (91%), 181 (82%) and 186 (84%) completed week 12, 32 and 52 measurements, respectively. At week 12, there were no significant between-group differences for reductions in pain comparing PCST+EX versus EX (mean difference 5.8mm, 95%CI -1.4,13.0) and PCST+EX versus PCST (6.7mm, 95%CI -0.6,14.1). Significantly greater improvements in function were found for PCST+EX versus EX (3.7units, 95%CI 0.4,7.0) and PCST+EX versus PCST (7.9units, 95%CI 4.7,11.2). These differences persisted at weeks 32 (both) and 52 (PCST). Benefits favoring PCST+EX were seen on several secondary outcomes. Cost effectiveness of PCST+EX was not demonstrated. Conclusion This model-of-care could improve access to psychological treatment and augment patient outcomes from exercise in knee OA although it did not appear to be cost effective. This article is protected by copyright. All rights reserved.
Knee osteoarthritis (OA) is the most frequent cause of limited mobility and diminished quality of... more Knee osteoarthritis (OA) is the most frequent cause of limited mobility and diminished quality of life. Pain is the main symptom that drives individuals with knee OA to seek medical care and a recognized antecedent to disability and eventually joint replacement. Many persons with symptomatic knee OA experience recurrent pain exacerbations. Knowledge and clarification of risk factors for pain exacerbation may allow those affected to minimize reoccurrence of these episodes. The aim of this study is to use a Web-based case-crossover design to identify risk factors for knee pain exacerbations in persons with symptomatic knee OA. Web-based case-crossover design is used to study persons with symptomatic knee OA. Participants with knee pain and radiographic knee OA will be recruited and followed for 90 days. Participants will complete an online questionnaire at the baseline and every 10 days thereafter (totaling up to 10 control-period questionnaires); participants will also be asked to re...
To investigate associations between self-reported knee confidence and pain, self-reported knee in... more To investigate associations between self-reported knee confidence and pain, self-reported knee instability, muscle strength, and dynamic varus-valgus joint motion during walking. We performed a cross-sectional analysis of baseline data from 100 participants with symptomatic and radiographic medial tibiofemoral compartment osteoarthritis (OA) and varus malalignment recruited for a randomized controlled trial. The extent of knee confidence, assessed using a 5-point Likert scale item from the Knee Injury and Osteoarthritis Outcome Score, was set as the dependent variable in univariable and multivariable ordinal regression, with pain during walking, self-reported knee instability, quadriceps strength, and dynamic varus-valgus joint motion during walking as independent variables. One percent of the participants were not troubled with lack of knee confidence, 17% were mildly troubled, 50% were moderately troubled, 26% were severely troubled, and 6% were extremely troubled. Significant ass...
To compare the effects of neuromuscular exercise (NEXA) and quadriceps strengthening (QS) on the ... more To compare the effects of neuromuscular exercise (NEXA) and quadriceps strengthening (QS) on the knee adduction moment (an indicator of mediolateral distribution of knee load), pain, and physical function in patients with medial knee joint osteoarthritis (OA) and varus malalignment. One hundred patients with medial knee pain, mostly moderate-to-severe radiographic medial knee OA, and varus malalignment were randomly allocated to one of two 12-week exercise programs. Each program involved 14 individually supervised exercise sessions with a physiotherapist plus a home exercise component. Primary outcomes were peak external knee adduction moment (3-dimensional gait analysis), pain (visual analog scale), and self-reported physical function (Western Ontario and McMaster Universities Osteoarthritis Index). Eighty-two patients (38 [76%] of 50 in the NEXA group and 44 [88%] of 50 in the QS group) completed the trial. There was no significant between-group difference in the change in the pea...
Knee muscle weakness and a greater external knee adduction moment are suggested risk factors for ... more Knee muscle weakness and a greater external knee adduction moment are suggested risk factors for medial tibiofemoral knee osteoarthritis. Knee muscle weakness and a greater knee adduction moment may be related to each other, are potentially modifiable, and have been observed after arthroscopic partial meniscectomy. The aim of this exploratory study was to determine if knee muscle weakness 3 months after arthroscopic partial meniscectomy (baseline) is associated with an increase in external knee adduction parameters during the subsequent 2 years. Eighty-two participants undergoing medial arthroscopic partial meniscectomy were assessed at baseline, and 66 participants who were reassessed 2 years later were included in our study. Isokinetic muscle strength and external adduction moment parameters (peak and impulse) during normal and fast walking were measured at baseline and followup. Multiple linear regression models were used to examine the association between baseline muscle strengt...
Knee osteoarthritis is common following arthroscopic partial meniscectomy and a higher external p... more Knee osteoarthritis is common following arthroscopic partial meniscectomy and a higher external peak knee adduction moment is believed to be a contributor. The peak knee adduction moment has been shown to increase over 2 years (from 3-months post-arthroscopic partial meniscectomy). The aim of this study was to evaluate mechanisms underpinning the increase in peak knee adduction moment over 2 years observed in people 3-months following arthroscopic partial meniscectomy. Sixty-six participants with medial arthroscopic partial meniscectomy were assessed at baseline and again 2 years later. Parameters were evaluated at time of peak knee adduction moment as participants walked barefoot at their self-selected normal and fast pace for both time points. For normal pace walking, an increase in frontal plane ground reaction force-to-knee lever arm accounted for 30% of the increase in peak knee adduction moment (B=0.806 [95% CI 0.501-1.110], P<0.001). For fast pace walking, an increase in t...
Medicine and science in sports and exercise, Jan 13, 2014
Higher knee load and quadriceps weakness are potential factors involved in the pathogenesis of kn... more Higher knee load and quadriceps weakness are potential factors involved in the pathogenesis of knee osteoarthritis following arthroscopic partial meniscectomy (APM). In people following APM, this study evaluated the association between external knee joint moments and quadriceps strength and 2-year change in indices of cartilage integrity in the medial tibiofemoral compartment and patella. 70 people with medial APM were assessed 3-months following APM (baseline) and reassessed 2 years later (follow-up). At baseline, isokinetic quadriceps strength and the external knee adduction moment (peak and impulse), and knee flexion moment (peak) during walking were assessed. Magnetic resonance imaging was used to assess cartilage (cartilage volume and cartilage defects) in the medial tibial compartment and patella at baseline and follow-up. Increased peak knee adduction moment during fast pace walking at baseline was associated with onset or deterioration of medial tibiofemoral cartilage defect...
Individuals after arthroscopic partial meniscectomy (APM) are at increased risk of developing kne... more Individuals after arthroscopic partial meniscectomy (APM) are at increased risk of developing knee osteoarthritis (OA). Knee muscle weakness and a higher external knee adduction moment (KAM) are potential risk factors for knee OA. This exploratory longitudinal study assessed these risk factors at baseline in an APM group (3 months after surgery) and control group, and again 2 yrs later (follow-up). Eighty-two participants with medial APM and 38 healthy controls were assessed at baseline, with 66 (79%) and 23 (61%), respectively, retested at follow-up. Outcome measures included isokinetic knee muscle strength and medial knee joint load inferred through indices of the KAM during normal and fast-pace walking. Knee muscle strength was reduced by 14%-16% in the APM leg compared with controls at baseline (P ≤ 0.006). However, strength increased in the APM leg over the 2 yrs such that there were no differences compared with controls at follow-up. KAM impulse was at least 20% higher for the APM group (both legs) when compared with controls at baseline and remained similarly higher 2 yrs later (P ≤ 0.022). At baseline peak, KAM was 18% higher in the APM leg as compared with controls only during fast-pace walking (P = 0.013). The peak KAM increased over the 2 yrs in the APM leg by 8%-9% (P ≤ 0.032), although there were no differences in change in KAM between the APM leg and controls. This study found that although knee muscle strength improved, dynamic medial joint load increased over the 2 yrs after APM surgery. These findings may aid in developing therapeutic interventions aimed to prevent or delay the onset of knee OA after APM.
Lateral wedges reduce the peak knee adduction moment and are advocated for knee osteoarthritis. H... more Lateral wedges reduce the peak knee adduction moment and are advocated for knee osteoarthritis. However some patients demonstrate adverse biomechanical effects with treatment. Clinical management is hampered by lack of knowledge about their mechanism of effect. We evaluated effects of lateral wedges on frontal plane biomechanics, in order to elucidate mechanisms of effect. Seventy three participants with knee osteoarthritis underwent gait analysis with and without 5° lateral wedges. Frontal plane parameters at the foot, knee and hip were evaluated, including peak knee adduction moment, knee adduction angular impulse, center of pressure displacement, ground reaction force, and knee-ground reaction force lever arm. Lateral wedges reduced peak knee adduction moment and knee adduction angular impulse (-5.8% and -6.3% respectively, both P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). Although reductions in peak moment were correlated with more lateral center of pressure (r=0.25, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05), less varus malalignment (r values 0.25-0.38, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05), reduced knee-ground reaction force lever arm (r=0.69, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.01), less hip adduction (r=0.24, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05) and a more vertical frontal plane ground reaction force vector (r=0.67, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001), only reduction in knee-ground reaction force lever arm was significantly predictive in regression analyses (B=0.056, adjusted R(2)=0.461, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). Lateral wedges significantly reduce peak knee adduction moment and knee adduction angular impulse. It seems a reduced knee-ground reaction force lever arm with lateral wedges is the central mechanism explaining their load-reducing effects. In order to understand why some patients do not respond to treatment, future evaluation of patient characteristics that mediate wedge effects on this lever arm is required.
American journal of physical medicine & rehabilitation / Association of Academic Physiatrists, 2002
Knee osteoarthritis has a major impact on quadriceps function, yet its effect on the specific tem... more Knee osteoarthritis has a major impact on quadriceps function, yet its effect on the specific temporal recruitment of vastus medialis obliquus and vastus lateralis is unknown. The aim of this study was to determine the electromyographic onset of vastus medialis obliquus activity relative to that of vastus lateralis in individuals with symptomatic knee osteoarthritis and in an asymptomatic control group during the functional task of stair climbing. Cross-sectional, comprising 41 participants with symptomatic knee osteoarthritis and 33 controls matched for age, sex, and body mass. No significant differences were detected in the timing of onset of vastus medialis obliquus relative to that of vastus lateralis between the osteoarthritis and control groups. Radiographic osteoarthritis severity, presence of patellofemoral joint disease, and pain intensity did not seem to influence the temporal relationship of the vastii in the osteoarthritis group. The presence of symptomatic, radiographic...
Clinical biomechanics (Bristol, Avon), Jan 18, 2015
Knee osteoarthritis is common in people who have undergone partial meniscectomy, and a higher ext... more Knee osteoarthritis is common in people who have undergone partial meniscectomy, and a higher external knee flexion moment during gait may be a potential contributor. Although the peak external knee flexion moment has been shown to increase from 3months to 2years following partial meniscectomy, mechanisms underpinning the increase in the peak knee flexion moment are unknown. Sixty-six participants with partial meniscectomy completed three-dimensional gait (normal and fast pace) and quadriceps strength assessment at baseline (3months following partial meniscectomy) and again 2years later. Variables included external knee flexion moment, vertical ground reaction force, knee flexion kinematics, and quadriceps peak torque. For normal pace walking, the main significant predictors of change in peak knee flexion moment were an increase in peak vertical ground reaction force (R(2)=0.55), mostly due to an increase in walking speed, and increase in peak knee flexion angle (R(2)=0.19). For fas...
Objective To investigate whether a 12-week physical therapist-delivered combined pain coping skil... more Objective To investigate whether a 12-week physical therapist-delivered combined pain coping skills training and exercise (PCST+EX) is more efficacious and cost-effective than either treatment alone for knee OA. Methods This was an assessor-blinded, 3-arm randomized controlled trial in 222 (73 PCST+EX, 75 EX, 74 PCST) people aged ≥50 years with knee OA. All participants received 10 treatments over 12 weeks plus a home program. PCST covered pain education and training in cognitive and behavioral pain coping skills. EX comprised strengthening exercises. PCST+EX integrated both. Primary outcomes were self-reported average knee pain (0-100mm visual analogue scale) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index 0-68) at week 12. Secondary outcomes included other pain measures, global change, physical performance, psychological health, physical activity, quality-of-life and cost-effectiveness. Analyses were by intention-to-treat with multiple imputation for missing data. Results 201 (91%), 181 (82%) and 186 (84%) completed week 12, 32 and 52 measurements, respectively. At week 12, there were no significant between-group differences for reductions in pain comparing PCST+EX versus EX (mean difference 5.8mm, 95%CI -1.4,13.0) and PCST+EX versus PCST (6.7mm, 95%CI -0.6,14.1). Significantly greater improvements in function were found for PCST+EX versus EX (3.7units, 95%CI 0.4,7.0) and PCST+EX versus PCST (7.9units, 95%CI 4.7,11.2). These differences persisted at weeks 32 (both) and 52 (PCST). Benefits favoring PCST+EX were seen on several secondary outcomes. Cost effectiveness of PCST+EX was not demonstrated. Conclusion This model-of-care could improve access to psychological treatment and augment patient outcomes from exercise in knee OA although it did not appear to be cost effective. This article is protected by copyright. All rights reserved.
Knee osteoarthritis (OA) is the most frequent cause of limited mobility and diminished quality of... more Knee osteoarthritis (OA) is the most frequent cause of limited mobility and diminished quality of life. Pain is the main symptom that drives individuals with knee OA to seek medical care and a recognized antecedent to disability and eventually joint replacement. Many persons with symptomatic knee OA experience recurrent pain exacerbations. Knowledge and clarification of risk factors for pain exacerbation may allow those affected to minimize reoccurrence of these episodes. The aim of this study is to use a Web-based case-crossover design to identify risk factors for knee pain exacerbations in persons with symptomatic knee OA. Web-based case-crossover design is used to study persons with symptomatic knee OA. Participants with knee pain and radiographic knee OA will be recruited and followed for 90 days. Participants will complete an online questionnaire at the baseline and every 10 days thereafter (totaling up to 10 control-period questionnaires); participants will also be asked to re...
To investigate associations between self-reported knee confidence and pain, self-reported knee in... more To investigate associations between self-reported knee confidence and pain, self-reported knee instability, muscle strength, and dynamic varus-valgus joint motion during walking. We performed a cross-sectional analysis of baseline data from 100 participants with symptomatic and radiographic medial tibiofemoral compartment osteoarthritis (OA) and varus malalignment recruited for a randomized controlled trial. The extent of knee confidence, assessed using a 5-point Likert scale item from the Knee Injury and Osteoarthritis Outcome Score, was set as the dependent variable in univariable and multivariable ordinal regression, with pain during walking, self-reported knee instability, quadriceps strength, and dynamic varus-valgus joint motion during walking as independent variables. One percent of the participants were not troubled with lack of knee confidence, 17% were mildly troubled, 50% were moderately troubled, 26% were severely troubled, and 6% were extremely troubled. Significant ass...
To compare the effects of neuromuscular exercise (NEXA) and quadriceps strengthening (QS) on the ... more To compare the effects of neuromuscular exercise (NEXA) and quadriceps strengthening (QS) on the knee adduction moment (an indicator of mediolateral distribution of knee load), pain, and physical function in patients with medial knee joint osteoarthritis (OA) and varus malalignment. One hundred patients with medial knee pain, mostly moderate-to-severe radiographic medial knee OA, and varus malalignment were randomly allocated to one of two 12-week exercise programs. Each program involved 14 individually supervised exercise sessions with a physiotherapist plus a home exercise component. Primary outcomes were peak external knee adduction moment (3-dimensional gait analysis), pain (visual analog scale), and self-reported physical function (Western Ontario and McMaster Universities Osteoarthritis Index). Eighty-two patients (38 [76%] of 50 in the NEXA group and 44 [88%] of 50 in the QS group) completed the trial. There was no significant between-group difference in the change in the pea...
Knee muscle weakness and a greater external knee adduction moment are suggested risk factors for ... more Knee muscle weakness and a greater external knee adduction moment are suggested risk factors for medial tibiofemoral knee osteoarthritis. Knee muscle weakness and a greater knee adduction moment may be related to each other, are potentially modifiable, and have been observed after arthroscopic partial meniscectomy. The aim of this exploratory study was to determine if knee muscle weakness 3 months after arthroscopic partial meniscectomy (baseline) is associated with an increase in external knee adduction parameters during the subsequent 2 years. Eighty-two participants undergoing medial arthroscopic partial meniscectomy were assessed at baseline, and 66 participants who were reassessed 2 years later were included in our study. Isokinetic muscle strength and external adduction moment parameters (peak and impulse) during normal and fast walking were measured at baseline and followup. Multiple linear regression models were used to examine the association between baseline muscle strengt...
Knee osteoarthritis is common following arthroscopic partial meniscectomy and a higher external p... more Knee osteoarthritis is common following arthroscopic partial meniscectomy and a higher external peak knee adduction moment is believed to be a contributor. The peak knee adduction moment has been shown to increase over 2 years (from 3-months post-arthroscopic partial meniscectomy). The aim of this study was to evaluate mechanisms underpinning the increase in peak knee adduction moment over 2 years observed in people 3-months following arthroscopic partial meniscectomy. Sixty-six participants with medial arthroscopic partial meniscectomy were assessed at baseline and again 2 years later. Parameters were evaluated at time of peak knee adduction moment as participants walked barefoot at their self-selected normal and fast pace for both time points. For normal pace walking, an increase in frontal plane ground reaction force-to-knee lever arm accounted for 30% of the increase in peak knee adduction moment (B=0.806 [95% CI 0.501-1.110], P<0.001). For fast pace walking, an increase in t...
Medicine and science in sports and exercise, Jan 13, 2014
Higher knee load and quadriceps weakness are potential factors involved in the pathogenesis of kn... more Higher knee load and quadriceps weakness are potential factors involved in the pathogenesis of knee osteoarthritis following arthroscopic partial meniscectomy (APM). In people following APM, this study evaluated the association between external knee joint moments and quadriceps strength and 2-year change in indices of cartilage integrity in the medial tibiofemoral compartment and patella. 70 people with medial APM were assessed 3-months following APM (baseline) and reassessed 2 years later (follow-up). At baseline, isokinetic quadriceps strength and the external knee adduction moment (peak and impulse), and knee flexion moment (peak) during walking were assessed. Magnetic resonance imaging was used to assess cartilage (cartilage volume and cartilage defects) in the medial tibial compartment and patella at baseline and follow-up. Increased peak knee adduction moment during fast pace walking at baseline was associated with onset or deterioration of medial tibiofemoral cartilage defect...
Individuals after arthroscopic partial meniscectomy (APM) are at increased risk of developing kne... more Individuals after arthroscopic partial meniscectomy (APM) are at increased risk of developing knee osteoarthritis (OA). Knee muscle weakness and a higher external knee adduction moment (KAM) are potential risk factors for knee OA. This exploratory longitudinal study assessed these risk factors at baseline in an APM group (3 months after surgery) and control group, and again 2 yrs later (follow-up). Eighty-two participants with medial APM and 38 healthy controls were assessed at baseline, with 66 (79%) and 23 (61%), respectively, retested at follow-up. Outcome measures included isokinetic knee muscle strength and medial knee joint load inferred through indices of the KAM during normal and fast-pace walking. Knee muscle strength was reduced by 14%-16% in the APM leg compared with controls at baseline (P ≤ 0.006). However, strength increased in the APM leg over the 2 yrs such that there were no differences compared with controls at follow-up. KAM impulse was at least 20% higher for the APM group (both legs) when compared with controls at baseline and remained similarly higher 2 yrs later (P ≤ 0.022). At baseline peak, KAM was 18% higher in the APM leg as compared with controls only during fast-pace walking (P = 0.013). The peak KAM increased over the 2 yrs in the APM leg by 8%-9% (P ≤ 0.032), although there were no differences in change in KAM between the APM leg and controls. This study found that although knee muscle strength improved, dynamic medial joint load increased over the 2 yrs after APM surgery. These findings may aid in developing therapeutic interventions aimed to prevent or delay the onset of knee OA after APM.
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