JRSR 3 (2015) 47-52

Journal of Rehabilitation Sciences and Research

Journal Home Page: jrsr.sums.ac.ir

Original Article

Flexibility of Knee Joint Muscles in Women with Knee Osteoarthritis

and Healthy Controls

Sara Abolahrari Shirazi1, Farahnaz Ghafari Nezhad1, Maryam Ebrahimian1, Elham Nouraddini2,
Azadeh Mansoorian2, Farahnaz Emami1*

1
Center for Human Motion Science Research, Department of Physiotherapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences,
Shiraz, Iran
2
Student Research Committee, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran

ARTICLE INFO ABSTRACT

Article History: Background: Osteoarthritis is one of the most common diseases in synovial
Received: 8/8/2015 joints. Due to high loading forces during weight-bearing activities, the knee joint
Revised: 1/9/2015 is prone to degenerative processes. This study aimed to compare the flexibility
Accepted: 28/9/2015
of muscles around the knee joint in patients with knee osteoarthritis with those
of healthy individuals.
Keywords:
Osteoarthritis
Methods: Twenty-three women with bilateral knee osteoarthritis and 23 healthy
Range of motion women matched with the patient group for age, height and weight participated
Knee pain in this study. Flexibility of the quadriceps, hamstring, iliotibial band, adductor
and gastrocnemius muscles was evaluated with a goniometric device. Pain
intensity was assessed with a visual analogue scale. The data were analyzed
with independent t-tests to compare the two groups, and Pearson correlation
coefficient was calculated to correlate muscle flexibility and pain intensity.
Results: significant lower flexibility of the bilateral quadriceps muscles was found
in patients compared to healthy women (P<0.05). No significant differences
were detected between groups regarding other muscles. Quadriceps flexibility
correlated significantly with pain intensity in patients (P<0.001).
Conclusion: In patients with osteoarthritis, quadriceps flexibility may be
decreased although other muscles may remain unaffected. Quadriceps stretching
is thus a potentially important component of treatment, which may influence
pain reduction in these patients.
2015© The Authors. Published by JRSR. All rights reserved.

Introduction years suffer from knee OA that restricts their ability

to stand, walk, rise from a chair and climb stairs [4].
Osteoarthritis (OA) is a common joint disorder in The prevalence of knee OA is 10% in males and 13% in
industrial societies, and a major cause of disability. females among the population aged 60 years and older [5].
Weight-bearing joints such as the knee, hip and vertebrae Zachezeweski has defined muscle flexibility “as the
are susceptible to degenerative changes that can interfere ability of a muscle to lengthen, allowing one joint to
with physical activities and quality of life [1, 2]. In older move through a range of motion” [6]. Therefore it is an
people, knee OA is the main cause of pain and disability important component of musculoskeletal health. The lack
[3]. One third of individuals aged between 63 and 94 of muscle flexibility is generally assumed to increase the
risk of injury [7]. Muscle weakness and poor flexibility are
*Corresponding author: Farahnaz Emami, School of Rehabilitation Sciences, two major components of joint pain and dysfunction [8,
Shiraz University of Medical Sciences, Chamran Blvd., Abiverdi 1 Street, 9]. In the knee joint, muscle imbalance plays an important
P.O. Box 71345-1733, Shiraz, Iran. Tel/Fax: +98 7136272495
E-mail: emamif@sums.ac.ir role in the appearance and progression of OA. Changes
 Abolahrari Shirazi S et al.

in muscle function lead to alterations in ground reaction were included in this research [24]. Another criterion
forces, the progression of degenerative changes and the comprised experiencing pain in the majority of the days
development of pain [10]. Patients with knee OA thus of the week during the 6 months prior to the study. All
have different gait kinematics and kinetics compared to participants provided their written informed consent.
asymptomatic persons [11, 12]. Alterations in gait include Those with any history of low back pain, unilateral
decreased knee excursion and different muscle activity knee OA, trauma to the knee joint, loss of joint play
patterns in lower extremity. Although these alterations in tibiofemoral and patellofemoral articulations, lower
may protect the knee joint from further degeneration they extremity fracture and surgery, neurological deficit or
have numerous adverse effects [13]. movement disorder, and those who were athletes or who
The knee consists of two joints [14]: the patellofemoral had been treated with physiotherapy during the previous
and tibiofemoral joint. The former can be involved in 6 months, were excluded from the study. Initially, age,
biomechanical problems in the young and physically active weight and height were recorded on a data collection form.
population [15, 16]. Various factors such as abnormal All measurements were obtained with a goniometer. The
lower limb biomechanics, insufficient flexibility and goniometry reliability for measuring the range of motion
quadriceps deficit may lead to patellofemoral dysfunction. in limb joints is considered good to excellent [25].
Previous studies have shown that the flexibility of muscles In the present study joint play in knee complex was
around the knee joint was decreased in patellofemoral evaluated at first. If the joint play is found to be normal,
pain syndrome (PFPS) and in athletes with anterior knee the limitation of range of motion is most likely due to
pain [7, 17, 18]. Pone et al. noted that in patients with PFPS, lack of flexibility [26].
decreased flexibility in the quadriceps was greater than To measure hamstring flexibility, passive knee extension
in healthy people [17]. Similar studies have documented tests were done in the supine position, as follows. The
decreased flexibility in the gastrocnemius [18], hamstring pelvis was immobilized, and the leg to be measured was
and quadriceps muscles in patients with PFPS compared positioned in 90-90 degree hip and knee flexion. Then one
to controls [7]. Research on the association between examiner extended the knee joint passively to the point
PFP and lower extremity biomechanics by Ohjeoung et where she felt resistance to movement. A second examiner
al. suggested that less flexibility in the hamstring was placed the center (fulcrum) of a universal goniometer
increased in patients with PFPS compared to healthy on the lateral femoral condyle with the stationary arm
controls [19]. of the goniometer aligned on the lateral malleolus and
In middle-aged and elderly people OA is a relatively the moving arm aligned with the greater trochanter,
common problem that can influence self-efficacy for and recorded the angle as shown in figure 1 [27-32]. All
physical tasks, and that is associated with a risk of falling. measurements performed by the same examiner.
Muscle flexibility is an important characteristic, which
deceases with age. The resulting lack of muscle flexibility
can lead to changes in joint function [20], and may be a
risk factor for injuries during activities that require a full
range of motion [21]. Knee OA-related stiffness can be
observed during walking in patients [22]. According to
Oatis et al., joint stiffness showed a moderate negative
correlation with stride length in patients with knee OA
[23]. Thereby performing regular stretching exercises
increase muscle flexibility, ROM and provide functional
benefits for patients with knee OA and may delay the need
for surgical interventions.
To the authors’ knowledge, no previous studies have
explored the flexibility of muscles around the knee joint Figure 1: The measurement of hamstring flexibility.
in patients with knee OA. We accordingly designed the
present study to compare the flexibility of muscles around To measure quadriceps flexibility the examiner flexed
the knee in patients with OA and healthy asymptomatic the knee joint passively in the prone position. The center
control participants. Our hypothesis was that the amount of of the goniometer was positioned on the femoral lateral
knee joint muscles flexibility in patients with knee OA was condyle with the stationary arm aligned on the thigh and
differs from healthy subjects. Also we hypothesized that the moving arm aligned on the tibia, and the angle was
the muscle flexibility would correlate with pain intensity. recorded after 90% (figure 2) [33, 34].
To measure adductor flexibility in the supine position,
Methods the non-test leg was immobilized at the midline and the
other leg was abducted passively until firm resistance
Twenty-three non-athlete women with OA and 23 was felt. The center of the goniometer was placed on
healthy women between 40 and 60 years of age were the anterior superior iliac spine (ASIS), and the moving
enrolled in this cross-sectional study. According to arm was positioned along the thigh midline while the
Kellgren and Lawrence grading system, each participant stationary arm was placed along the imaginary line
had grades 2 or 3 knee OA in bilateral tibiofemoral connecting the two ASIS (figure 3) [35].

48  JRSR. 2015;2(3)

 Abolahrari Shirazi S et al.

goniometer was placed on ASIS with the stationary arm

aligned with line connecting the two ASIS and the other
arm positioned on the longitudinal axis of the adducted
extremity [36, 37].
Pain sensation was measured with an 11 point scale
(0-10) VAS.

Statistical Analysis
All statistical analyses were done with SPSS v. 16
software and P<0.05 was considered significant. The
normality of our data was examined by using Kolmogorov-
Smirnov. Independent t tests were used to compare
Figure 2: The measurement of quadriceps flexibility. muscle flexibility in patients with knee osteoarthritis
and controls, and Pearson’s correlation coefficient was
calculated to search for correlations between knee muscle
flexibility and pain intensity.

Results

The descriptive characteristics of participants are

shown in Table 1. There were no significance differences
between the groups in baseline characteristics.
Muscle flexibility differed significantly between groups
only for the right (P=0.001) and left quadriceps (P=0.004)
(Table 2). There were no significant difference between
groups in flexibility of the hamstring, gastrocnemius,
iliotibial band or adductor muscles (P>0.05) (Table 2).
The correlations between muscle flexibility and pain
Figure 3: The measurement of adductor flexibility.
intensity are shown in table 3. We found a statistically
significant negative correlation between pain intensity and
As shown in figure 4, to evaluate gastrocnemius right quadriceps (r=−0.458), left quadriceps (r=−0.461)
flexibility the participant was asked to lie prone with and left adductor flexibility (r=−0.314).
her knee extended and the foot hanging from the end
of the plinth. Passive ankle dorsiflexion was done until Discussion
resistance was felt. The center of the goniometer was
placed on the lateral malleolus, and the stationary arm We found that quadriceps muscle flexibility in women
was aligned with the leg while the moving arm was with knee OA was lower than in healthy women –our
positioned on the lateral side of foot [35]. result was consistent with the other studies on knee
pain [7, 17, 18]. Piva et al. reported less flexibility in the
quadriceps, hamstring, gastrocnemius and soleus muscles
in individuals with PSPF compared to healthy controls
[18]. In addition, Smith et al. found a relationship between
quadriceps muscle flexibility and anterior knee pain in
adolescent athletes [7]. It is believed that in response to
joint damage or dysfunction, postural muscles such as the
quadriceps tend to become shorter [38]. Lake of flexibility
in quadriceps has a profound effect on patellofemoral
joint alignment [39] and may cause greater stress on this
structure and thus predispose individuals to developing
symptoms [40]. Because of the pain, these patients
Figure 4: The evaluation of gastrocnemius flexibility. apparently cannot flex their knee joint more than 100
degrees over prolonged periods during activities of daily
living. On their physician’s advice, they modify their
Iliotibial band flexibility was recorded with the activities to avoid sitting cross-legged or kneeling on the
participant lying on her side. The lowermost limb was floor. In addition, a sedentary life style may influence
flexed and the uppermost (test) limb was extended and quadriceps flexibility.
abducted with the knee flexed at 90 degrees. The examiner Another purpose of our study was to document the
helped to keep the test limb in the above position and relationship between muscle flexibility and pain intensity
prevent unwanted hip rotation. Then adduction was in patients with OA. The results supported our hypothesis
allowed with the force of gravity. The center of the that flexibility would correlate with pain intensity. In other

JRSR. 2015;2(3)   49
 Abolahrari Shirazi S et al.

Table 1: Baseline characteristics of the women who participated in the patient and control groups
Group Patient (n=23) Healthy (n=23) P value
Variable Mean±SD Mean±SD
Age (years) 3.89±49.6 5.71±48.72 0.590
Weight (kg) 11.07±68.52 8.9±68.04 0.873
Height (cm) 6.23±1.58 6.56±1.61 0.265

Table 2: Comparison of muscle flexibility in patients with knee osteoarthritis and controls
Group Patient Healthy P. value
Muscle Flexibility (degrees) SD±Mean SD±Mean
RT Hamstring 13.83±69.04 13.75±69.6 0.890
LT Hamstring 12.08±69.34 13.71±68.26 0.777
RT Quadriceps 13.14± 26.52 8.97±39.73 0.001*
LT Quadriceps 12.05±27.13 7.64±36.17 0.004*
RT Iliotibial band 7.28±17.47 8.4±20.65 0.120
LT Iliotibial band 6.18 ±17.17 9.07±18.00 0.720
RT Adductor 7.92±32.30 12.31±34.86 0.405
LT Adductor 6.46±28.95 9.96±33.26 0.089
RT Gastrocnemius 9.22 ±35.08 10.93±31.95 0.300
LT Gastrocnemius 8.24 ±30.73 10.39±30.86 0.963
RT, Right; LT, Left, *P. value<0.05

Table 3: Correlation between flexibility of muscles around the knee joint and pain intensity
Correlation r P. value
VAS (cm) × RT Hamstring (P) -0.017 0.911
VAS (cm) × LT Hamstring (P) 0.020 0.894
VAS (cm) × RT Quadriceps (P) -0.458 0.001*
VAS (cm) × LT Quadriceps (P) -0.461 0.001*
VAS (cm) × RT Ilitibial band (P) -0.046 0.759
VAS ( cm) × LT Iliotibial band (P) -0.003 0.986
VAS (cm) × RT Adductor (P) -0.258 0.084
VAS ( cm) × LT Adductor (P) -0.314 0.033*
VAS (cm) × RT Gastrocnemius (P) 0.085 0.575
VAS ( cm) × LT Gastrocnemius (P) -0.054 0.719
RT, Right; LT, Left; VAS, Visual analog scale; *P. value<0.05

words, quadriceps flexibility was lower in patients with ability to voluntary activation of quadriceps impaired
more intense perceived pain. One possible explanation in individuals with knee OA. Muscle activation failure
is that to prevent pain, the patients flex their knee joint can result in abnormal articular afferent inputs being
less than 100 degrees and this behavior leads to a decline sent to α.motor neurons and this may occur due to joint
in quadriceps flexibility, patella alta and recurrent pain degeneration [43].
– all of which create a vicious cycle [41]. In contrast to Our results for iliotibial band flexibility showed no
our results, some researchers have found a relationship significant differences between the two groups. We are
between hamstring tightness and pain in adolescent aware of no previous studies of iliotibial band flexibility
athletes with anterior knee pain [7]. A possible explanation in patients with knee OA. One earlier study found no
for these different findings is that the participants in the differences in flexibility between patients with PFPS and
study by Smith et al. were young athletes with anterior healthy individuals [18]. However, Hudson et al. reported
knee pain due to jumper’s knee, Osgood Schlatter disease, decreased iliotibial band flexibility in these patients [44].
patellofemoral pain or combinations of these whereas We believe this difference with our results may exist
the participants in the present study were middle-aged because all participants in our study had knee OA.
women with tibiofemoral joint OA. Therefore the pattern According to comprehensive approach in dysfunction of
of muscle tightness in athletes and patients with knee OA lumbopelvic-hip, shortening of iliotibial band trends to
may be dissimilar. occur in low back pain patients and necessarily not be
We found no significant differences between groups seen in all of patients with knee OA [45].
in hamstring, iliotibial band, gastrocnemius or adductor Our patients with knee OA did not differ significantly
muscle flexibility. One probable reason is that all from asymptomatic controls in hamstring muscle
participants in both groups were non-athletes and middle– flexibility. A previous study, however, noted that hamstring
aged and therefore probably experienced a similar trend tightness may be one of the contributing factors to PFPS
toward loss of contractile function and flexibility [20, 42]. [27]. The discrepancy between our results and those
Another hypothesis is that the central nervous system’ reported by White et al. may be attributed to differences

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 Abolahrari Shirazi S et al.

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