Yuenyongviwat et al.

BMC Musculoskeletal Disorders (2020) 21:284

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RESEARCH ARTICLE Open Access

Effect of hip abductor strengthening

exercises in knee osteoarthritis: a
randomized controlled trial
Varah Yuenyongviwat* , Siwakorn Duangmanee, Khanin Iamthanaporn, Pakjai Tuntarattanapong and
Theerawit Hongnaparak

Abstract
Background: Osteoarthritis knee (OA) for patients whom had varus malalignment had higher peak adductor
moment. Hip abductor strength played an important role in the decreasement of knee adduction moment. This
study aimed to evaluate the effect of hip abductor exercises for patients who had medial compartment knees OA.
Methods: Patients who had medial compartmental OA knee were randomized into two groups. The first group
performed hip abductor strengthening exercises, combined with quadriceps strengthening exercises; whereas, the
second group performed standalone quadriceps strengthening exercises. Self-reported Knee Injury and
Osteoarthritis Outcome Scores (KOOS) were collected by patients on follow-up visits.
Results: Eighty-six patients completed the trial. All KOOS subscales were significantly improved in both groups after
10 weeks of treatment. However, there was no significant difference in the scores between either group at 2–10
weeks after treatment. Nevertheless, the effects of exercise for pain, symptoms, function in daily living and knee-
related quality of life were found to have faster improvement within the hip abduction exercise group compared to
the control group (2 weeks faster; pain, function in daily living and knee-related quality of life, 4 weeks faster;
symptoms.)
Conclusion: Since, adding quadriceps exercises could expedite improvement of less pain, symptoms, activity in
daily living and quality of life faster than quadriceps exercises solely for a 2–4 weeks period. However, the effect size
was small and there were no differences after this; hence, consideration of adding hip abductor exercises in the
treatment protocol should be based on the patients and doctors appraisal.
Trial registration: TCTR, TCTR20180517005. Registered 17 May 2018.
Keywords: OA knee, Hip abductor exercise, KOOS

Background exercise therapy [1–3]. Although, there were many exer-

Knee osteoarthritis (OA) is a disease that produces pain cises that are purposed for treatment of knee osteoarth-
and limits the functional movement of patients. Whilst ritis [4] Quadriceps strengthening exercises have been a
there are many clinical practice guidelines for treatment cornerstone for treatment for OA knee patients [5], as it
of this condition [1–3], all clinical practice guidelines has the benefit of reducing patient symptoms and pre-
emphasize non-pharmacological approaches; particularly serves function [6]. Another exercise, that is a specific
muscle group exercise, is hip abductor exercises [7].
* Correspondence: [email protected] There have been a number of studies reporting the ef-
Department of Orthopedics, Faculty of Medicine, Prince of Songkla
fectiveness of hip abductor exercises for treatment of
University, Hat Yai, Songkhla 90110, Thailand

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Yuenyongviwat et al. BMC Musculoskeletal Disorders (2020) 21:284 Page 2 of 7

medial tibiofemoral OA, in which they reported the from; May, 2018 to December, 2019. This study was ap-
benefits of hip abductor strength for improving pain, proved by the local ethics committee and institutional
physical function, muscle strength [5] and reduced risks review board. The procedures in this study were
of 2-year tibiofemoral cartilage damage, which was eval- performed under the Declaration of Helsinki’s ethical
uated by magnetic resonance imaging (MRI) [8]. principles for medical research involving human partici-
OA knee patients, especially for patients who have pants. Written informed consent was obtained from all
varus malalignment, had higher peak adduction mo- individual participants included in the study.
ments in comparison to the normal population [9, 10].
Knee adduction moment is the moment that acts on the Participants
joint in the frontal plane. This acts to rotate the tibia Patients who had medial compartmental knee osteoarth-
medially on the femur while walking [11]. Knee adduc- ritis, were aged 50 years and above, able to walk without
tion moment tends to force the knee outwards, com- gait aids, could flex the knee more than 90 degrees, had
pressing the medial joint compartment and stretching knee alignment with a varus of less than 10 degrees as
the lateral joint structures [12]. This adduction moment well as plain standing radiographs; showing medial com-
also relates to the severity and progression of the dis- partment OA with Kellgren and Lawrence classification
ease, higher adduction moments are related with a (KL-classification) II-III in knee radiographic, were in-
higher rate of disease progression [13, 14]. High, peak cluded into the study. The exclusion criteria’s were pa-
knee adduction moments were positively associated with tients who had inflammatory arthritis, osteoarthritis of
greater pain, and were negatively associated with the the hips, having had previous knee or hip surgery, re-
knee functional score in OA knees [15]. ceived intraarticular injection within 6 months, and pa-
There was a report stating that hip abductor muscle tients who had neurological and muscle problems.
strength played a major role for reducing knee adduction
moments, because it counteracts pelvic drop in the Accounting for all patients
contralateral swing limb during the single-limb stance One hundred and 15 patients were approached for the
phase of gait. This intensifies forces at the medial com- study, 5 patients declined to participate, 3 patients had
partment knee of the stance limb [16, 17]. inflammatory arthritis and 10 patients had spinal sten-
Theoretically, the higher hip abduction strength, the osis. Finally, 97 patients participated in the study, from
lower knee adduction moment, which could lower pain these 86 patients completed the trial and were subse-
and improve function in OA knee patients. quently analyzed. Eight patients (4 patients in each
Previous studies that compared hip abductor strength- group) considered withdrawing from the study by them-
ening exercises in OA knee patients, against control pa- selves after first visit, because they felt improvement of
tients who did not undergo any strengthening exercise symptoms. Two patients in the hip abductor exercise
programs revealed that: the exercise group had lesser knee group along with one patient in the control group did
pain and better performance-based physical function than not attend their 2-week follow up appointments, and
that of the control group [5]. There was also a small ran- they could not be contacted by the research assistance.
domized study that reported improved Western Ontario Intention-to-treat analysis was performed in this study.
and McMaster Universities Arthritis Index (WOMAC) (Fig. 1).
and the 6 min walk test in hip abductor strengthening ex-
ercise [18]. However, this was a limit study that evaluated Randomization
the benefits of hip abductor strengthening exercises com- Random numbers were generated by computer, upon
bined with quadriceps exercises, which was the most which the Block-of-four randomization method was
widely used recommendation, comparing with quadriceps used for randomizing patients into two groups. Sealed,
strengthening alone in terms of pain and other aspects. opaque envelopes were used for allocating patients, and
Our study aimed to evaluate the effect of hip abductor ex- were only opened in the rehabilitation unit after patients
ercises combined with quadriceps exercises in patients were enrolled in the study.
who had OA knee. The authors considered performing The first group of patients performed hip abductor
the study in medial compartment OA knees only, this was strengthening exercises combined with quadriceps
based on the theory that abnormal lower limb adductor strengthening exercises. Patients received instructions
moment might have more effect at the medial compart- on how to perform these exercises by a physical therap-
ment of the knee [9, 10]. ist. The patients performed quadriceps exercises and hip
abductor exercises following the protocol: 3 days/ weeks
Method (Table 1). Knee quadriceps exercises were performed by
This study was a prospective randomized control trial. patients sitting in a chair and flexing their knee to a 90-
The study was conducted at a tertiary care hospital, degree flexion position, then gradually extending the
Yuenyongviwat et al. BMC Musculoskeletal Disorders (2020) 21:284 Page 3 of 7

Fig. 1 A diagram of the study enrollment process

knee to full extension, holding this position for 10 s; be- modification, sport and weight control. Patients were
fore flexing the knee. The hip abductor exercise was followed up at 2 weeks, 4 weeks, 6 weeks, 8 weeks and
done by patients lying down in a side-lying position and 10 weeks.
abducting the hip to a 45-degree abduction position, Self-reported Knee Injury and Osteoarthritis Outcome
then holding this position for 10 s. While performing ei- Scores (KOOS) were collected by patients on each
ther quadriceps exercises or hip abduction exercises, the follow-up visit. The score consisted of 5 separately
ankle of the patient was strapped with a sandbag, which scored subscales; Pain, Symptoms, Function in daily liv-
as weighted as per protocol. Both knee and hip exercises ing (ADL), Function in Sport and Recreation (Sport/Rec)
were performed as a combination of 4 sets- of 10 repeti- and knee-related Quality of Life (QOL). The score is
tions in the morning, and then again in the evening; for from 0 to 100, 0 representing extreme problems and 100
3 days a week. The second group was the control group, representing no problems [19]. The amount of analgesic
patients performed only quadriceps strengthening exer- used for rescue medication was recorded by patients.
cises with the same protocol. All patients were pre-
scribed naproxen as rescue medication, which would be
occasionally used upon patient demand, but no more Statistical analysis
than twice daily in case of moderate-severe pain, or pain Analyses were performed using R version 3.1.0 software
limit patient function. In case of being allergic to na- (R Foundation for Statistical Computing, Vienna,
proxen, tramadol was used instead. Austria). Patient demographic data, such as age, weight,
Both groups of patients were taught with the same pa- height, Body Mass Index (BMI) and tibiofemoral angle
tient education program for self-care, such as activity were evaluated with t-test. Gender, side of osteoarthritis,
history of diabetes, KL-classification and rescue medica-
Table 1 Exercise protocol tion usage were compared with Fisher’s exact test.
Week Weight (Repetitive maximum; RM) KOOS were analyses via t-test in every subscale. Gener-
1–2 50% of 10 RM alized estimating equation (GEE) modelling was used for
2–4 60% of 10 RM studying the longitudinal association between type of ex-
4–6 70% of 10 RM ercise, and KOOS in each subscale. We considered the
minimum clinically important differences (MCID) of
6–8 80% of 10 RM
KOOS on the 100-point scale to be 8 points, based on
8–10 90% of 10 RM
prior evidence [19].
Yuenyongviwat et al. BMC Musculoskeletal Disorders (2020) 21:284 Page 4 of 7

Results [hip exercise group 2.4% / control group 2.3%, P = 1], 8–

Baseline demographic data were not different between 10 wk. [hip group 4.8% / control group 4.5%, P = 1]).
groups in terms of age, gender, weight, height, BMI, side,
KL-classification and history of diabetes (Table 2). Discussion
Knee injury and Osteoarthritis Outcome Scores were Strengthening exercises are a general accepted treatment
not significantly different between both groups of pa- for OA knees. Quadriceps exercises were studied, and
tients at the start of treatment. (Pain; P = 0.39, Symptom; reported the effectiveness for reduced pain and im-
P = 0.57, ADL; P = 0.27, Sport/Rec; P = 0.66, QOL = 0.62) proved function in OA knees [20, 21]. Hip abductor ex-
All subscales were also not significantly different be- ercises were of interest as an adjuvant exercise for OA
tween both groups at 2 weeks, 4 weeks, 6 weeks, 8 weeks knee patients [7]. This was based on the hypothesis that
and 10 weeks after treatment (P > 0.05). GEE analyses gluteus medius muscles effected external knee adduction
showed both groups also had no difference in each sub- moment during level walking [22]. In so saying, the au-
scale at 10 weeks. (Table 3). thors conducted this study to evaluate the efficacy of hip
GEE analyses revealed both groups had significantly abductor exercises in combination with quadriceps exer-
improved KOOS pain at 10 weeks. (Hip abductor exer- cises, as a comparison to quadriceps strengthening
cise group + 18.68 (95% CI, 11.8–25.6, P = < 0.01), Con- alone, for patients who had medial compartment knee
trol group; + 16.69 (95% CI, 10.9–22.5, P < 0.01). (Fig. 2) OA. Our study found that adjuvant hip abductor exer-
The other subscales also showed improvement at 10 cises coupled with quadriceps exercises helped improve
weeks (P < 0.01) (Table 4). pain reduction and function in OA knee patients to the
The effects of exercise for pain management along same degree as patients who performed quadriceps exer-
with many subscales were found to be faster in the hip cise alone, but added hip abductor exercises did have a
abduction exercise group, compared to the knee exercise faster effect in the reduction of both pain and function.
only group. The hip abductor exercise group had signifi- This study had a number of limitations. First, patients
cant improvement of lesser pain, improved QOL and were not blinded to the exercise protocol, because the
ADL after 2 weeks, while the control group had signifi- strengthening exercises required patient participation.
cantly better results at 4 weeks. Symptoms improved in So, patients might have had biases, in that the exercise
the hip abductor exercise group at 2 weeks; while the protocol might have had an effect on both symptoms
control group showed improvement at 6 weeks. (Table and function. Second, our study had a high proportion
4) However, function in Sport and Recreation improved of females. This being said, based on theory, we believe
faster in the control group, which improved at 8 weeks; that our results should be able to be applied to male pa-
whereas, the hip abductor exercise group improved at tients equally. Third, this study reported the results in
10 weeks. only mild and moderate severity of OA knee patients.
All patients used naproxen as rescue medication, with- So, further studies in more severe cases would be of
out allergic reactions. There was no difference in terms interest. Finally, we did not exclude patients who might
of rate of rescue medication usage between both groups, have self-home exercise therapy or any aerobic exercise
at any time point. (0–2 wk. [hip exercise group 0%, con- prior to participation in the study, which might have in-
trol group 9.1%,P = 0.18], 2-4wk [hip exercise group fluenced the results. However, no patients had ever
4.8% / control group 9.1%, P = 0.68], 4–6 wk. [hip exer- undergone our education program, or rehabilitation
cise group 9.5% / control group 11.4%, P = 1], 6-8wk treatment protocol prior to this study.

Table 2 Demographic data

Characteristic Hip exercise group n = 42 Control group n = 44 p value
Age (years) 62.8 ± 6.80* 62.5 ± 8.4* 0.85
Sex (male:female) 4:38 3:41 0.71
Weight (kg) 65.3 ± 11.7* 61.2 ± 9.1* 0.07
Height (cm) 158.1 ± 7.4* 156.5 ± 6.3* 0.26
BMI (kg/m2) 26.2 ± 5.2* 25.1 ± 4.4* 0.3
Side (right:left) 20:22 21:23 1.0
KL-classification (II/III) 16:26 16:28 0.87
Tibiofemoral angle 180.86 ± 2.96* 180.71 ± 2.57* 0.65
Diabetes 2 3 1.0
* Mean values with SDs
Yuenyongviwat et al. BMC Musculoskeletal Disorders (2020) 21:284 Page 5 of 7

Table 3 Mean Knee Injury and Osteoarthritis Outcome Scores (KOOS)

Baseline 2 wk 4 wk 6 wk 8 wk 10 wk p value
Pain Hip exercise 70 79 85 86 88 89 0.67
Control 74 79 82 84 88 91
Symptoms Hip exercise 76 86 86 84 87 90 0.22
Control 80 84 85 86 91 89
Activities of daily living Hip exercise 77 84 91 91 94 92 0.77
Control 81 86 88 90 92 95
Sports and recreation Hip exercise 29 34 32 39 40 47 0.57
Control 32 37 38 42 45 55
Quality of life Hip exercise 48 57 62 66 86 72 0.61
Control 50 58 61 64 70 77

This study found that hip abductor exercises com- better WOMAC physical function scale, and 6 min walk
bined with quadriceps exercises, or quadriceps exercises test (6MWT) in a hip abduction exercise group, which
alone could improve patient pain and function in medial combined quadriceps exercises in comparison to standa-
compartment OA knees. Previous studies on hip ab- lone quadriceps exercises after 6 weeks of treatment
ductor exercises had the same results. Bennell KL et al. [18].
compared the effects in a hip abductor exercise group However, we found that our hip abductor exercise
against a control group who performed no exercises, and group had earlier improvement than that of the quadri-
this report stated that: the hip exercise group had signifi- ceps exercise group for pain, symptom, activity in daily liv-
cantly greater improvement in pain reduction and phys- ing and quality of life. Our study considered 8 points for
ical function [5]. There was also a small randomized the minimum clinically important differences of KOOS,
study, containing 30 patients, which compared a hip ab- based on prior evidence [19]. The mean difference of
ductor strengthening group combined with quadriceps, KOOS at 2 weeks, and baseline in the hip exercise group,
along with a control group that performed only quadri- which had statistically significant improvement, were also
ceps exercises. From this study the results showed both above the minimum clinical importance range (range
groups had improvement of WOMAC scores after treat- 8.14–9.95). However, the effect size of these results; even
ment [18]. though greater than the minimum clinically important dif-
Our results demonstrated that our hip abductor exer- ference, was small. Moreover, the difference only appeared
cise group had no difference in the improvement of pain to be over a 2–4 weeks period, after which both groups
and function when compared with those only doing obtained the same level at the end of the treatment.
quadriceps exercises; from a longitudinal prospective. To our knowledge, our study is the first study that
Our study did however have contradicting results with both controlled and evaluated rescue medication usage,
this previous, small randomized trial that reported a in which we found that there was no difference between

Fig. 2 Knee Injury and Osteoarthritis Outcome Scores (KOOS) subscale; Pain
Yuenyongviwat et al. BMC Musculoskeletal Disorders (2020) 21:284 Page 6 of 7

Table 4 Mean different from base line (95% CI) of Knee Injury and Osteoarthritis Outcome Scores (KOOS)
2 wk 4 wk 6 wk 8 wk 10 wk
Pain Hip exercise 8.83 (1.82–15.8) 14.45 (7.97–20.9) 15.88 (9.25–22.5) 17.23 (10.6–23.8) 18.68 (11.8–25.6)
p = 0.01 p < 0.01 p < 0.01 p < 0.01 p < 0.01
Control 5.05(−1.69–11.8) 7.94 (1.04–14.8) 10.24 (4.22–16.3) 14.32 (8.30–20.3) 16.69 (10.9–22.5)
p = 0.14 p = 0.02 p < 0.01 p < 0.01 p < 0.01
Symptoms Hip exercise 9.95 (3.14–16.8) 9.85 (2.97–16.7) 8.23 (1.39–15.1) 11.75 (4.83–18.7) 14.65 (8.20–21.1)
p < 0.01 p < 0.01 p < 0.01 p = 0.02 p < 0.01
Control 3.68(−2.70–10.1) 5.14 (− 1.14–11.4) 6.21 (0.38–12) 10.47 (4.70–16.3) 9.09 (2.84–15.3)
p = 0.26 p = 0.11 p = 0.04 p < 0.01 p < 0.01
Activities of daily Hip exercise 8.14 (1.05–15.2) 14.05 (7.78–20.3) 14.84 (8.63–21) 17.08 (11.1–23.0) 15.19 (8.77–21.6)
living p = 0.02 p < 0.01 p < 0.01 p < 0.01 p < 0.01
Control 4.91(−1.86–11.7) 7.29 (0.38–14.2) 8.72 (1.98–15.5) 11.18 (4.47–17.9) 13.84 (7.29–20.4)
p = 0.16 p = 0.04 p = 0.01 p < 0.01 p < 0.01
Sports and recreation Hip exercise 5.24(−5.54–16) 3.89(−6.02–13.8) 9.99(− 1.14–21.1) 11.22(− 1.35–23.8) 17.79 (5.08–30.5)
p = 0.34 p = 0.44 p = 0.08 p = 0.08 p < 0.01
Control 4.55(− 13.8–7.53) 6.25(− 6–15.1) 10.13(− 4.22–16.7) 13.34(− 0.74–21) 22.69 (2.6–24.1)
p = 0.4 p = 0.24 p = 0.07 p = 0.02 p < 0.01
Quality of life Hip exercise 8.4 (0.35–16.5) 13.92 (5.38–22.5) 17.28 (8.59–26) 19.92 (11–28.9) 24.12 (15.6–32.6)
p = 0.04 p < 0.01 p < 0.01 p < 0.01 p < 0.01
Control 7.32(− 0.36–15) 10.2 (2.33–18.1) 13.74 (6.09–21.4) 20.1 (12.4–27.8) 27.09 (19.3–34.9)
p = 0.06 p = 0.01 p < 0.01 p < 0.01 p < 0.01

either group. Further studies in patients with more se- Authors’ contributions
verity, or a study combined with gait analysis to evaluate VY designed the study and performed the analysis and manuscript
preparation; SD, KI designed the study and performed the data analysis; SD
knee adduction moment differences should be expanded, collected data; TH, PT designed the study and reviewed the manuscript. All
so as to evaluate the benefits of this exercise. authors have read and approved the final manuscript.

Funding
Conclusion Funding for this research was provided by the Faculty of Medicine, Prince of
Songkla University, Songkhla, Thailand (grant number 60–372–11-1). The
In conclusion, we found that either hip abductor exer- funders had no role in study design, data collection and analysis, decision to
cises combined with quadriceps exercises or quadriceps publish, nor preparation of the manuscript.
exercises alone could lessen patient pain and improve
Availability of data and materials
function. Adding quadriceps exercises could expedite The datasets generated during this current study are available from the
improvement of less pain, symptoms, activity in daily liv- corresponding author upon reasonable request.
ing and quality of life faster than quadriceps exercises
alone; however, this only appeared to be over a 2–4 Ethics approval and consent to participate
This study was approved by the Ethics Committee and Institutional Review
weeks period with small effect size, after which there Board of the Faculty of Medicine, Prince of Songkla University (EC 60–372–
was there were no differences. Hence, considering to 11-1).
add hip abductor exercises in the treatment protocol Written informed consent was obtained from all individual participants
included in the study.
should be based on the patients and doctors perspective.
Consent for publication
Not Applicable.
Abbreviations
OA: Osteoarthritis; WOMAC: Western Ontario and McMaster Universities
Arthritis Index; KOOS: Knee Injury and Osteoarthritis Outcome Scores; Competing interests
ADL: Function in daily living; Sport/Rec: Function in Sport and Recreation; The authors declare that they have no competing interests.
QOL: Knee-related Quality of Life; KL-classification: Kellgren and Lawrence
classification Received: 15 February 2020 Accepted: 27 April 2020

Acknowledgements References
The authors wish to thank Andrew Jonathan Tait for his assistance in 1. Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra
proofreading the English of this report. SMA, et al. OARSI guidelines for the non-surgical management of knee, hip,
and polyarticular osteoarthritis. Osteoarthr Cartil. 2019;27:1578–89.
2. Fernandes L, Hagen KB, Bijlsma JWJ, Andreassen O, Christensen P,
Public trials registry Conaghan PG, et al. EULAR recommendations for the non-pharmacological
Thai Clinical Trials Registry (http://www.clinicaltrials.in.th). core management of hip and knee osteoarthritis. Ann Rheum Dis. 2013;72:
Registry number: TCTR20180517005. 1125–35.
Yuenyongviwat et al. BMC Musculoskeletal Disorders (2020) 21:284 Page 7 of 7

3. McGrory BJ, Weber KL, Jevsevar DS, Sevarino K. Surgical Management of

Osteoarthritis of the knee: evidence-based guideline. J Am Acad Orthop
Surg. 2016;24:e87–93.
4. Bennell KL, Hinman RS. A review of the clinical evidence for exercise in
osteoarthritis of the hip and knee. J Sci Med Sport. 2011;14:4–9.
5. Bennell KL, Hunt MA, Wrigley TV, Hunter DJ, McManus FJ, Hodges PW, et al.
Hip strengthening reduces symptoms but not knee load in people with
medial knee osteoarthritis and varus malalignment: a randomised controlled
trial. Osteoarthr Cartil. 2010;18:621–8.
6. Huang L, Guo B, Xu F, Zhao J. Effects of quadriceps functional exercise with
isometric contraction in the treatment of knee osteoarthritis. Int J Rheum
Dis. 2018;21:952–9.
7. 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;
90:895–904.
8. Chang AH, Chmiel JS, Almagor O, Hayes KW, Guermazi A, Prasad PV, et al.
Hip muscle strength and protection against structural worsening and poor
function and disability outcomes in knee osteoarthritis. Osteoarthr Cartil.
2019;27:885–94.
9. Hurwitz DE, Ryals AB, Case JP, Block JA, Andriacchi TP. The knee adduction
moment during gait in subjects with knee osteoarthritis is more closely
correlated with static alignment than radiographic disease severity, toe out
angle and pain. J Orthop Res Off Publ Orthop Res Soc. 2002;20:101–7.
10. Shrader MW, Draganich LF, Pottenger LA, Piotrowski GA. Effects of knee
pain relief in osteoarthritis on gait and stair-stepping. Clin Orthop. 2004:
188–93.
11. Creaby MW. It’s not all about the knee adduction moment: the role of the
knee flexion moment in medial knee joint loading. Osteoarthr Cartil. 2015;
23:1038–40.
12. Hinman RS, Wrigley TV, Metcalf BR, Hunter DJ, Campbell P, Paterson K, et al.
Unloading shoes for osteoarthritis of the knee: protocol for the SHARK
randomised controlled trial. BMC Musculoskelet Disord. 2014;15:48.
13. Miyazaki T, Wada M, Kawahara H, Sato M, Baba H, Shimada S. Dynamic load
at baseline can predict radiographic disease progression in medial
compartment knee osteoarthritis. Ann Rheum Dis. 2002;61:617–22.
14. Mündermann A, Dyrby CO, Hurwitz DE, Sharma L, Andriacchi TP. Potential
strategies to reduce medial compartment loading in patients with knee
osteoarthritis of varying severity: reduced walking speed. Arthritis Rheum.
2004;50:1172–8.
15. Nie Y, Wang H, Xu B, Zhou Z, Shen B, Pei F. The relationship between knee
adduction moment and knee osteoarthritis symptoms according to static
alignment and pelvic drop. Biomed Res Int. 2019;2019:7603249.
16. 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;52:2835–44.
17. Chang A, Hayes K, Dunlop D, Song J, Hurwitz D, Cahue S, et al. Hip
abduction moment and protection against medial tibiofemoral
osteoarthritis progression. Arthritis Rheum. 2005;52:3515–9.
18. Singh S, Pattnaik M, Mohanty P, Ganesh GS. Effectiveness of hip abductor
strengthening on health status, strength, endurance and six minute walk
test in participants with medial compartment symptomatic knee
osteoarthritis. J Back Musculoskelet Rehabil. 2016;29:65–75.
19. Roos EM, Lohmander LS. The knee injury and osteoarthritis outcome score
(KOOS): from joint injury to osteoarthritis. Health Qual Life Outcomes. 2003;
1:64.
20. Suzuki Y, Iijima H, Tashiro Y, Kajiwara Y, Zeidan H, Shimoura K, et al. Home
exercise therapy to improve muscle strength and joint flexibility effectively
treats pre-radiographic knee OA in community-dwelling elderly: a
randomized controlled trial. Clin Rheumatol. 2019;38:133–41.
21. Eyigor S, Hepguler S, Capaci K. A comparison of muscle training methods in
patients with knee osteoarthritis. Clin Rheumatol. 2004;23:109–15.
22. Henriksen M, Aaboe J, Simonsen EB, Alkjaer T, Bliddal H. Experimentally
reduced hip abductor function during walking: implications for knee joint
loads. J Biomech. 2009;42:1236–40.

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