Hip Strengthening After Total Knee Arthroplasty: A Meta-analysis and Systematic Review

Document Type : SYSTEMATIC REVIEW

Authors

1 Hotel Dieu de France, Orthopedics department, Beirut, Lebanon

2 Division of Orthopaedic Surgery and Sports Medicine, McGill University Health Centre, Montreal, Quebec, Canada

10.22038/abjs.2024.76202.3520

Abstract

Objectives: As the population is growing older, incidence of knee osteoarthritis is largely increasing 
and the rate total knee arthroplasty surgery is following that same trend. However, patients postoperatively are retaining weakness in the quadriceps and hip abductors for a period reaching up to 3 
years following surgery. The current literature results on the effectivenes s of rehabilitation programs 
that also includes hip strengthening exercises are still highly contradicting. This meta -analysis studies 
and assesses the efficacy of hip strengthening exercises following total knee arthroplasty surgery.
Methods: PubMed, Embase, Cochrane and Google Scholar (page 1-20) were searched till January 2024. The 
clinical outcomes consisted of the post-operative tests (6MWT, TUG, SLS), pain, and range of motion (flexion and 
extension).
Results: Three randomized clinical studies were included in the meta-analysis. When compared to the standard 
rehabilitation, hip strengthening exercises proved a better improvement of single leg stance with no difference 
observed in the remaining outcomes.
Conclusion: Hip strengthening exercise protocols ensured a better improvement of single leg stance scores. 
However, no difference was observed in the remaining analyzed outcomes. This contradictions between studies 
can be explained by the different physical therapy protocols used. Nevertheless, more randomized controlled studies 
are needed to confirm such results.
 Level of evidence: II

Keywords

Main Subjects


1. Felson DT, Naimark A, Anderson J, Kazis L, Castelli W, Meenan 
RF. The prevalence of knee osteoarthritis in the elderly. The 
Framingham Osteoarthritis Study. Arthritis Rheum. 1987; 
30(8):914-918. doi:10.1002/art.1780300811.
2. Mizner RL, Petterson SC, Snyder-Mackler L. Quadriceps 
strength and the time course of functional recovery after total 
knee arthroplasty. J Orthop Sports Phys Ther. 2005; 
35(7):424-436. doi:10.2519/jospt.2005.35.7.424.
3. Petterson SC, Mizner RL, Stevens JE, et al. Improved function 
from progressive strengthening interventions after total knee 
arthroplasty: a randomized clinical trial with an imbedded 
prospective cohort. Arthritis Rheum. 2009; 61(2):174-183. 
doi:10.1002/art.24167.
4. Bade MJ, Kohrt WM, Stevens-Lapsley JE. Outcomes before and 
after total knee arthroplasty compared to healthy adults. J 
Orthop Sports Phys Ther. 2010; 40(9):559-567. 
doi:10.2519/jospt.2010.3317.
5. Mizner RL, Snyder-Mackler L. Altered loading during walking 
and sit-to-stand is affected by quadriceps weakness after total 
knee arthroplasty. J Orthop Res. 2005; 23(5):1083-1090. 
doi:10.1016/j.orthres.2005.01.021.
6. Schache MB, McClelland JA, Webster KE. Lower limb strength 
following total knee arthroplasty: A systematic review. Knee. 
2014; 21(1):12-20. doi:10.1016/j.knee.2013.08.002.
7. Walsh M, Woodhouse LJ, Thomas SG, Finch E. Physical 
Impairments and Functional Limitations: A Comparison of 
Individuals 1 Year After Total Knee Arthroplasty With Control 
Subjects. Phys Ther. 1998; 78(3):248-258. 
doi:10.1093/ptj/78.3.248.
8. Alnahdi AH, Zeni JA, Snyder-Mackler L. Hip Abductor Strength 
Reliability and Association with Physical Function After 
Unilateral Total Knee Arthroplasty: A Cross-Sectional Study. 
Phys Ther. 2014; 94(8):1154-1162. 
doi:10.2522/ptj.20130335.
9. Loyd BJ, Jennings JM, Judd DL, et al. Influence of Hip Abductor 
Strength on Functional Outcomes before and After Total Knee 
Arthroplasty: Post Hoc Analysis of a Randomized Controlled 
Trial. Phys Ther. 2017; 97(9):896-903. 
doi:10.1093/ptj/pzx066.
10. Piva SR, Teixeira PEP, Almeida GJM, et al. Contribution of Hip 
Abductor Strength to Physical Function in Patients with Total 
Knee Arthroplasty. Phys Ther. 2011; 91(2):225-233. 
doi:10.2522/ptj.20100122.
11. Harikesavan K, Chakravarty RD, Maiya AG, Hegde SP, Y. 
Shivanna S. Hip Abductor Strengthening Improves Physical 
Function Following Total Knee Replacement: One-Year 
Follow-Up of a Randomized Pilot Study. Open Rheumatol J. 
2017; 11(1):30-42. doi:10.2174/1874312901711010030.
12. Do K, Yim J. Effects of muscle strengthening around the hip on 
pain, physical function, and gait in elderly patients with total 
knee arthroplasty: A randomized controlled trial. Healthc. 
2020; 8(4). doi:10.3390/healthcare8040489.
13. Schache MB, McClelland JA, Webster KE. Incorporating hip 
abductor strengthening exercises into a rehabilitation program did not improve outcomes in people following total 
knee arthroplasty: a randomised trial. J Physiother. 2019; 
65(3):136-143. doi:10.1016/j.jphys.2019.05.008.
14. Sled EA, Khoja L, Deluzio KJ, Olney SJ, Culham EG. Effect of a 
home program of hip abductor exercises on knee joint 
loading, strength, function, and pain in people with knee 
osteoarthritis: a clinical trial. Phys Ther. 2010; 90(6):895-
904. doi:10.2522/ptj.20090294.
15. Minns Lowe CJ, Barker KL, Dewey M, Sackley CM. 
Effectiveness of physiotherapy exercise after knee 
arthroplasty for osteoarthritis: systematic review and metaanalysis of randomised controlled trials. BMJ. 
2007; 335(7624):812. doi:10.1136/bmj.39311.460093.BE.
16. Mündermann A, Asay JL, Mündermann L, Andriacchi TP. 
Implications of increased medio-lateral trunk sway for 
ambulatory mechanics. J Biomech. 2008; 41(1):165-170. 
doi:10.1016/j.jbiomech.2007.07.001.
17. Mündermann A, Dyrby CO, Andriacchi TP. Secondary gait 
changes in patients with medial compartment knee 
osteoarthritis: increased load at the ankle, knee, and hip 
during walking. Arthritis Rheum. 2005; 52(9):2835-2844. 
doi:10.1002/art.21262.
18. Yamada H, Koshino T, Sakai N, Saito T. Hip adductor muscle 
strength in patients with varus deformed knee. Clin Orthop 
Relat Res. 2001 ;( 386):179-185. doi:10.1097/00003086-
200105000-00023.
19. Gottschall JS, Okita N, Sheehan RC. Muscle activity patterns of 
the tensor fascia latae and adductor longus for ramp and stair 
walking. J Electromyogr Kinesiol. 2012; 22(1):67-73. 
doi:10.1016/j.jelekin.2011.10.003.
20. Henderson KG, Wallis JA, Snowdon DA. Active physiotherapy 
interventions following total knee arthroplasty in the hospital 
and inpatient rehabilitation settings: a systematic review and 
meta-analysis. Physiotherapy. 2018; 104(1):25-35. 
doi:10.1016/j.physio.2017.01.002.
21. Bade MJ, Struessel T, Dayton M, et al. Early High-Intensity 
versus Low-Intensity Rehabilitation after Total Knee 
Arthroplasty: A Randomized Controlled Trial. Arthritis Care 
Res (Hoboken). 2017; 69(9):1360-1368. 
doi:10.1002/acr.23139.