Muscle strength and osteoarthritis of the knee: a systematic review and meta-analysis of longitudinal studies

Skeletal Radiol. 2023 Nov;52(11):2085-2097. doi: 10.1007/s00256-022-04266-4. Epub 2022 Dec 23.


Objective: To evaluate the sex-specific association between low knee extensor and flexor muscle strength and the risk of knee structural worsening.

Materials and methods: Systematic searches in five databases identified longitudinal studies (≥ 1 year follow-up) reporting an association between knee extensor or flexor strength and structural decline in individuals with, or at risk of, knee osteoarthritis. Results were pooled for tibiofemoral and patellofemoral osteoarthritis worsening (and stratified by sex/gender where possible) using a random-effects meta-analysis estimating the risk ratio and 95% confidence interval or a best-evidence synthesis. Risk of bias and overall certainty of evidence were assessed.

Results: Fourteen studies were included with participants (mean age 27-72 years) with osteoarthritis (n = 8), at risk of osteoarthritis (n = 3), or a combination with, or at risk of, osteoarthritis (n = 3). Low knee extensor strength was associated with an increased risk of worsening tibiofemoral (12 studies: RR 1.18, 95% CI 1.04 to 1.35) and patellofemoral osteoarthritis (4 studies: RR 1.62, 95% CI 1.01 to 2.61). Significant associations between low knee extensor strength and worsening tibiofemoral osteoarthritis were observed for women (4 studies: RR 1.25, 95% CI 1.04 to 1.51) but not men (4 studies: RR 1.10, 95% CI 0.87 to 1.39). Low knee flexor strength increased the risk of worsening tibiofemoral osteoarthritis (5 studies: RR 1.16, 95% CI 1.07 to 1.26). Ten studies were high risk of bias, and all estimates were graded as very low certainty of evidence.

Conclusion: Low knee extensor and flexor strength increased the risk of worsening tibiofemoral osteoarthritis. Low knee extensor strength increased the risk of worsening patellofemoral osteoarthritis. The relationship between low knee extensor strength and worsening tibiofemoral osteoarthritis may be modified by sex/gender.

Keywords: Imaging; Knee osteoarthritis; Muscle strength; Radiography, Magnetic resonance imaging.

Publication types

  • Meta-Analysis
  • Systematic Review
  • Review

MeSH terms

  • Adult
  • Aged
  • Bone Diseases*
  • Female
  • Humans
  • Knee
  • Knee Joint / diagnostic imaging
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Muscle Strength / physiology
  • Osteoarthritis, Knee* / diagnostic imaging