The Journal of Arthroplasty Vol. 18 No.

5 2003

Knee Strength After Total Knee Arthroplasty

Mauricio Silva, MD,* Eric F. Shepherd, MD,* Walter O. Jackson, MD,*
Jeffrey A. Pratt, MD, MPH,* Christian D. McClung, MPhil (Cantab),* and
Thomas P. Schmalzried, MD*

Abstract: Fifty-two knees in normal healthy subjects and 32 knees more than 2
years after total knee arthroplasty (TKA) were evaluated. Average isometric extension peak torque values in TKA patients were reduced by up to 30.7% (P.01).
Isometric flexion peak torque values in patients with TKA were, on average, 32.2%
lower than those from control subjects throughout the motion arc (P.004). Knee
Society Functional Scores were positively correlated to the average isometric extension peak torque (r0.57; P.004) and negatively correlated to the average isometric hamstring to quadriceps (H/Q) ratio (r0.78, P.0001). Relatively greater
quadriceps strength was associated with a better functional score. Older TKA patients
(70 years) generated lower isometric extension peak torque values in terminal
extension than younger TKA patients (24.2%; P.05). Higher body mass index
(BMI) was associated with relative quadriceps weakness (r0.44; P.007). These
results suggest that more thorough rehabilitation after TKA would improve functional outcomes. Key words: knee, muscle strength, total knee arthroplasty, H/Q
ratio.
2003 Elsevier Inc. All rights reserved.

Improving knee function has become a premier

issue in total knee arthroplasty (TKA) [1]. Little
data exist, however, on knee strength after TKA
and its relationship to patient characteristics, outcome measures, and appropriate controls. A dynamometer can measure strength and provide objective measures of knee function, and this instrument
is commonly used to assess knee strength in athletic
training and the rehabilitation of knee injuries [210].

Berman et al. [3] reported that after TKA, the

quadriceps mechanism showed 83% of the strength
of the contralateral knee at a minimum of 2 years
after surgery. Patients with relatively better quadriceps strength had a more normal gait. The authors
found no significant decrease in hamstring strength.
However, 6 of the contralateral control knees
underwent a TKA during the evaluation period [3].
This suggests that the contralateral knee may not
necessarily be an appropriate control for knee
strength. Even if there is no arthritis, the strength of
the contralateral knee may be decreased because of
the functional limitation imposed by the other
knee. Huang et al. [2] measured knee strength 6 to
13 years after TKA. There was no statistically significant difference between the ratio of hamstring
strength to quadriceps strength in subjects with a TKA
and the 9 control subjects [2]. Unfortunately, the
results were not stratified by subject characteristics.
Therefore, no comparisons of absolute strength could
be made between controls and TKA patients.

From the *Joint Replacement Institute at Orthopaedic Hospital, Los

Angeles, California, and the Harbor-UCLA Medical Center, Torrance,
California.
Submitted May 21, 2002; accepted March 6, 2003.
Funds were received from Peidmont Fund of the Los Angeles
Orthopaedic Foundation in support of the research material
described in this article.
Reprint requests: Thomas P. Schmalzried, MD, the Joint Replacement Institute at Orthopaedic Hospital, 2400 S. Flower
Street, Los Angeles, CA 90007.
2003 Elsevier Inc. All rights reserved.
0883-5403/03/1805-0011$30.00/0
doi:10.1016/S0883-5403(03)00191-8

605

606 The Journal of Arthroplasty Vol. 18 No. 5 August 2003

The goals of this study are to measure and compare knee strength in control subjects (no TKA) and
in subjects with a clinically well-functioning TKA
and correlate those measurements to categorical
patient variables and clinical outcomes.

Materials and Methods

Subjects
After obtaining Institutional Review Board approval and informed consent, 52 control knees (no
TKA) in 31 volunteer subjects (16 women and 15
men) were evaluated. All control knees were clinically normal: no pain or other limitation. For this
reason, not all knees in control subjects were included. Demographics of control subjects are provided in Table 1.
Nineteen patient volunteers with a total of 32
knee arthroplasties were recruited because the arthroplasties were clinically well-functioning, and
the patient had no physical or mental condition that
would prohibit or inhibit participation. The outcome of the TKA was evaluated using the Knee
Society Clinical Rating System [11]. All TKAs were
cemented and posterior-stabilized, with a cemented
all-polyethylene patellar component. All patients
were at least 2 years after surgery (average, 2.8
years; maximum, 6 years). Thirteen subjects had
bilateral TKAs. Demographics of TKA subjects are
provided in Table 1.
Test Protocol
Using a LIDO Active Dynamometer (LIDO 2.1
model 200 300 A; Loredan Biomedical, Davis, CA),
isometric peak extension and flexion torques were
measured from 0 to 90 of knee flexion.
To warm-up for testing, subjects walked on a
treadmill at a moderately vigorous rate (2.5 to 3.5
miles per hour) for 5 minutes. Subjects were then
seated on the LIDO test apparatus and stabilized
around the pelvis and mid-thigh (Fig. 1). With the
knee flexed to 90, the center of rotation of the
LIDO lever arm was aligned in parallel with the
femoral condyles. The lower extremity was attached to the LIDO lever arm by way of a padded
cuff with a fastener just above the ankle. Subjects
were instructed on how to perform the tests, emphasizing the importance of maximum effort during the test and encouraged during the test to push
as hard as they could.
Isometric testing was performed at 7 positions,
beginning with 90 of flexion and moving to full
extension in 15 increments. At each position, the

patient performed 3 seconds of maximal knee extension (concentric quadriceps muscle contraction)
immediately followed by 3 seconds of maximal
knee flexion (concentric hamstrings muscle contraction). There was a 30-second rest period between testing at each position. During testing, a
computer monitor displayed a real-time column
graph of the generated torque. The test subjects
were allowed to observe this graph as feedback in
an attempt to enhance effort.
At each position, peak torque values (footpounds) of flexion (hamstrings) and extension
(quadriceps) were recorded and then used to calculate the hamstring to quadriceps (H/Q) ratios. The
ratio of knee flexion strength to knee extension
strength, the so-called H/Q ratio (hamstrings/quadriceps), is an established method to assess relative
strength of the muscle groups [3].
Statistical Analysis
The statistical analysis was performed using the
Stata 5.0 software (Stata, College Station, TX). Differences between groups were compared using a
2-sample Students t-test. The outcome measures
(isometric flexion and extension torques and H/Q
ratios) were adjusted for patient characteristics
(age, gender, weight, height, and BMI) using a
step-wise multivariate regression analysis. The control subjects were younger (P.0001), taller
(P.09), lighter (P.1), and had lower BMI
(P.008) than the subjects with a TKA.
In addition to the step-wise multivariate analysis,
we also compared subsets of matched patients. Ten
control subjects (7 women, 3 men) and 16 subjects
with TKAs (12 women, 4 men) were selected based
on similarities in age, height, weight, and BMI. For
the 10 control subjects (15 knees), the average age
was of 62.0 years (range, 51.4 72.2 years; SD, 7.3
years), the average height was 168.8 cm (range,
153.7188.0 cm; SD, 11.6 cm), the average weight
was 82.4 kg (range, 56.4 106.4 kg; SD, 18.3 kg),
and the average BMI was 28.9 (range, 21.9 38.2;
SD, 5,9). For the 16 subjects with TKAs (25 knees),
the average age was of 65.1 years (range, 50.4 78.9
years; SD, 8.1 years), the average height was 168.0
cm (range, 147.3198.1 cm; SD, 12.6 cm), the average weight was 87.6 kg (range, 55.9 101.8 kg;
SD, 12.9 kg), and the average BMI was 31.1 (range,
23.4 36.9; SD, 4.4). There were no significant differences, in age, height, weight, or BMI between
these 2 subgroups.
Correlations between patient characteristics and
outcome measures were obtained using univariate
and multivariate regression analyses. A Pearson

607

product-moment coefficient of correlation (r)

greater than 0.75 indicated a very good to excellent
correlation; 0.51 to 0.75 indicated a moderate to
good correlation; 0.25 to 0.50 indicated a fair degree
of correlation; and equal or less than 0.25 was
considered as little or no correlation. A P value of
.05 was considered statistically significant.

38.1 (20.172.2) [17.3]

67.3 (50.483.2) [9.1]
67.3 (53.083.2) [8.6]
67.1 (50.478.9) [12.0]
181.0 (167.6198.1) [8.3] 166.5 (147.3198.1) [12.6] 161.3 (147.3170.2) [7.0] 186.1 (177.8198.1) [9.1]
85.9 (66.4106.4) [13.1]
87.5 (55.9101.8) [12.5]
85.9 (55.9101.8) [12.3]
93.5 (74.1100.0) [13.0]
26.2 (21.634.0) [3.3]
31.8 (23.445.9) [5.3]
33.1 (25.845.9) [5.0]
27.0 (23.430.7) [3.2]

Results
Isometric Extension Torque

NOTE: Values are given as Mean (range) [standard deviation].

Abbreviations: BMI, body mass index; TKA, total knee arthroplasty.

41.7 (15.971.0) [18.2]

164.4 (152.4177.8) [18.2]
74.3 (53.6133.6) [22.6]
27.6 (20.452.2) [8.7]

Women (n 15)
Men (n 15)
All (n 31)

40.0 (15.972.2) [17.6]

172.4 (152.4198.1) [11.4]
79.8 (53.6133.6) [19.1]
26.9 (20.452.2) [6.6]
Age (y)
Height (cm)
Weight (kg)
BMI

Patients Undergoing TKA (n 19)

Women (n 16)

Table 1. Subject Demographics

All (n 19)
Control Subjects (n 31)

Men (n 4)

Knee Strength After Total Knee Arthroplasty Silva et al.

Isometric extension peak torque values decreased

as the knee came into extension (Table 2). There
was a high degree of variability in isometric extension peak toque at all positions tested. On average,
women control subjects generated 40.4% lower
isometric extension peak torque values than men
controls (P.0001). Regression analysis indicates a
correlation between average isometric extension
peak torque values and height (r0.67, P.0001)
and age (r0.82; P.0001) in control subjects.
On average, women TKA patients generated 52.4%
lower isometric extension peak torque values than
men TKA patients (P.0001). Height and weight
were positively correlated to isometric extension
peak torque values in subjects with a TKA (r0.82;
P.0001 and r0.47; P.007, respectively). In terminal extension (30, 15, and 0 of flexion), older
TKA patients (70 years) generated lower isometric extension peak torque values than younger TKA
patients (24.2%, P.05; 26.5%, P.05; 29.0%,
P.05, respectively).
After adjustments in patient characteristics, isometric extension peak torque values in control subjects were, on average, 9.7 ft-lb (95% CI, 0.7 to
19.4; P.05) higher than those in TKA patients. A
difference in adjusted isometric extension peak
torque values between control subjects and TKA
patients was evident at all positions tested (Table 2).
Isometric Flexion Torque
Isometric flexion peak torque values increased with
knee extension (Table 2). There was a high degree
of variability in isometric flexion peak torque at all
positions tested. On average, women control subjects generated 43.6% lower isometric flexion peak
torque values than men controls (P.0001). Isometric flexion peak torques were correlated to
height (r0.71, P.0001), age (r0.51, P.0001)
and weight (r0.38, P.005). On average, women
TKA patients generated 44% lower isometric flexion peak torque values than men (P.0001). In
TKA patients, age was not correlated to the average

608 The Journal of Arthroplasty Vol. 18 No. 5 August 2003

Fig. 1. Subjects were seated on the LIDO test apparatus and stabilized around the pelvis and mid-thigh.

Table 2. Isometric Extension Torque, Isometric Flexion Torque, and Hamstring to Quadriceps Ratio
All Knees
(n 84)*

Control
Knees
(n 52)*

Isometric extension torque (ft-lb)

90
109.3 (59.5)
135.2 (59.0)
75
115.2 (57.2)
142.8 (51.3)
60
106.6 (50.2)
129.9 (44.6)
45
89.8 (38.1)
105.9 (35.2)
30
69.8 (29.6)
81.5 (27.7)
15
59.2 (23.2)
59.3 (22.1)
0
35.1 (18.7)
41.1 (18.8)
Isometric flexion torque (ft-lb)
90
46.5 (29.0)
61.1 (27.0)
75
54.8 (31.2)
70.8 (28.7)
60
59.7 (32.5)
75.6 (31.0)
45
63.9 (32.8)
79.0 (30.8)
30
68.5 (33.2)
83.9 (31.2)
15
72.4 (36.9)
88.6 (35.4)
0
69.2 (34.0)
84.2 (32.3)
H/Q ratio
90
0.42 (0.12)
0.46 (0.99)
75
0.47 (0.12)
0.49 (0.11)
60
0.56 (0.15)
0.57 (0.10)
45
0.70 (0.17)
0.74 (0.13)
30
1.01 (0.42)
1.08 (0.46)
15
1.42 (0.39)
1.49 (0.29)
0
2.20 (0.97)
2.18 (0.64)

TKAs
(n 32)*

Raw Difference
Between
Groups

Difference Between
Groups

95% CI for the

Adjusted
Difference

P value for the

Adjusted
Difference

67.2 (28.6)
70.5 (33.2)
68.7 (32.9)
63.6 (26.7)
50.8 (22.0)
37.9 (18.5)
25.5 (14.3)

68.0
72.3
61.2
42.3
30.7
21.4
15.6

67.9
23.7
18.5
13.4
30.7
21.3
15.6

45.7 to 90.1
8.0 to 39.4
5.4 to 31.6
2.3 to 24.5
19.2 to 42.1
12.0 to 30.7
7.9 to 23.3

.0001
.004
.006
.02
.0001
.0001
.0001

22.1 (8.6)
28.8 (11.4)
33.9 (12.0)
39.2 (15.3)
43.6 (17.5)
46.0 (20.6)
44.8 (19.7)

39.0
42.0
41.7
39.8
40.3
42.6
39.4

11.6
15.0
12.1
12.2
13.1
9.6
9.1

3.4 to 19.3
7.0 to 22.9
3.5 to 20.7
3.0 to 21.4
3.5 to 22.6
0.5 to 19.7
1.7 to 19.9

.003
.0001
.006
.01
.008
.06
.09

0.35 (0.12)
0.43 (0.13)
0.54 (0.22)
0.65 (0.20)
0.92 (0.32)
1.32 (0.50)
2.22 (1.36)

0.11
0.06
0.03
0.09
0.16
0.17
0.04

0.11
0.06
0.03
0.09
0.16
0.24
0.04

0.06 to 0.16
0.01 to 0.11
0.04 to 0.10
0.02 to 0.16
0.03 to 0.34
0.06 to 0.43
0.48 to 0.40

.0001
.03
.44
.02
.1
.01
.86

*Mean (SD).
Adjusted by patient characteristics.
Degrees of flexion.
Abbreviations: TKAs, total knee arthroplasties; CI; confidence interval; H/Q, hamstring to quadriceps ratio; SD, standard deviation.

Knee Strength After Total Knee Arthroplasty Silva et al.

609

Table 3. Knee Strength Data Summary by Matched Subgroup

90
Isometric extension torque (ft-lb)
Control knees (n 15)
83.6 (30.5)
TKAs (n 25)
67.9 (32.2)
Isometric flexion torque (ft-lb)
Control knees (n 15)
37.1 (16.0)
TKAs (n 25)
22.6 (8.8)
H/Q Ratio
Control knees (n 15)
0.45 (0.11)
TKAs (n 25)
0.35 (0.12)

75

60

45

30

15

100.8 (36.7)
69.8 (37.1)

92.6 (32.4)
68.9 (36.9)

81.1 (29.3)
63.9 (30.0)

59.7 (24.0)
51.6 (24.3)

44.6 (16.4)
39.2 (20.2)

30.1 (13.6)
26.4 (15.5)

47.4 (21.4)
28.4 (12.2)

50.3 (21.6)
33.3 (12.6)

56.6 (23.2)
38.8 (16.4)

62.1 (22.5)
44.0 (18.7)

64.4 (27.8)
46.5 (22.5)

62.2 (24.7)
44.4 (21.2)

0.47 (0.11)
0.44 (0.14)

0.54 (0.09)
0.55 (0.23)

0.69 (0.11)
0.64 (0.20)

1.21 (0.81)
0.92 (0.30)

1.42 (0.34)
1.28 (0.46)

2.25 (0.94)
2.17 (1.42)

NOTE: Values are given as mean (standard deviation). All groups are matched subgroups.
Degrees of flexion.
Abbreviation: H/Q, hamstring to quadriceps.

isometric flexion peak torque (r0.16, P.4) but

height (r0.62, P0.0001) and weight (r0.44,
P.01) were. Multivariate regression analysis indicates that the average isometric flexion peak torque
is strongly correlated to height (r0.72, P.009).
Isometric knee flexion and extension strength were
highly correlated in all subjects (r0.95, P.0001).
After adjustments in patients characteristics, isometric flexion peak torque values in control subjects were, on average, 12.1 ft-lb (95% CI, 4.2 to
20.0; P.003) higher than those in TKA patients. A
difference in adjusted isometric flexion peak torque
values between control subjects and TKA patients
was evident at all positions tested (Table 2).
H/Q Ratios
For all subjects, isometric H/Q ratios increased with
knee extension (Table 2). There was a high degree
of variability in isometric H/Q ratios at all positions
tested. Univariate and multivariate regression analysis showed no correlation between average isometric H/Q ratios and other variables such as age,
gender, weight, height, or BMI. No significant differences in isometric H/Q ratios were found between men and women or between younger and
older subjects.
There was a trend for the isometric H/Q ratio to
increase near terminal extension as patient age
increased. Older TKA subjects (70 years old) had
isometric H/Q ratios that were 18.3% (P.15),
22.9% (P.1), and 46.3% (P.07) higher than
younger TKA subjects at 30, 15, and 0 of flexion,
respectively. Univariate regression analysis indicates that BMI and height are correlated to isometric H/Q ratios in TKA patients (r0.35, P.05, and
r0.42, P.02, respectively). At 90 of flexion, a
stronger correlation between isometric H/Q ratio

and BMI was found (r0.44, P.007); more obese

patients have relatively lower quadriceps strength.
After adjustments in patient characteristics, H/Q
ratios in control subjects were, on average, 0.8
(95% CI, 0.03 to 0.2; P.2) higher than those in
TKA patients. A difference in adjusted H/Q ratios
between control subjects and TKA patients was
evident at all but 2 of the position tested (60 and
0) (Table 2).
Matched Subgroups
Isometric extension peak torque values in TKA patients were highly variable and, on average, 21.2%
lower than those from control subjects, throughout
the motion arc (P.09) (Table 3). A reduction in
average isometric extension peak torque of 18.8%
(P.1), 30.7% (P.01), 25.6% (P.05), and 21.2%
(P.08) was observed at 90, 75, 60, and 45 of
flexion, respectively, in the TKA group (Fig. 2).

Fig. 2. Isometric extension. Knee extension strength was

generally lower in subjects with a TKA. Error bars indicate standard deviation.

610 The Journal of Arthroplasty Vol. 18 No. 5 August 2003

Fig. 3. Isometric flexion. Knee flexion strength was consistently lower in subjects with a TKA. Error bars indicate
standard deviation.

Isometric flexion peak torque values in patients

with a TKA were highly variable and, on average,
32.2% lower than those from control subjects
throughout the motion arc (P.004) (Table 3). Reduction of 39.5% (P.001), 40.0% (P.001), 33.9%
(P.003), 31.4% (P.007), 29.2% (P.009),
27.8% (P.03), and 28.6 (P.02) was found at 90,
75, 60, 45, 30, 15, and 0, respectively, in the
TKA group (Fig. 3). Isometric H/Q ratios in subjects
with TKA were, on average, 9.5% lower than those
from control subjects, throughout the motion arc
(P.3).
Knee Society Scores
The average Knee Society (KS) Clinical Score was
92 (range, 76 100) and the average KS Functional
Score was 92 (range, 70 100). Average isometric
extension or flexion strength did not show a correlation with the clinical score (r0.09, P.66 and
r0.15, P.46, respectively). The functional
scores were, however, positively correlated to the
average isometric extension peak torque (r0.57,
P.004) and to the average isometric flexion peak
torque (r0.33, P.1). The clinical score was not
correlated to the average isometric H/Q ratio
(r0.2, P.3). Functional scores were negatively
correlated to the average isometric H/Q ratio
(r.78, P.0001); in other words, relatively
greater quadriceps strength was associated with a
better functional score.

Discussion
As would be expected in a study of human performance, there is great variability in knee strength as

a function of gender, age, height, and degree of

obesity. Although knee strength can be restored to
normal levels after a TKA, it is uncommon. In the
present study, average isometric knee extension
and flexion strength of TKA subjects was more than
30% lower than matched control subjects (P.01).
Regardless of statistical analyses, such reductions in
strength have practical significance [12]. The reduction in muscle strength seen in TKA subjects is
probably the result of muscle atrophy caused by
disuse before the TKA that has not been recovered
after the TKA [13].
Knee strength is an important factor in the clinical outcome after TKA. In the current study, we
found that isometric extension peak torque and the
H/Q ratio had a strong correlation with the Knee
Society Functional Score (r0.57, P.004 and
r0.78, P.0001, respectively). The need for adequate extensor mechanism function is a prerequisite for common activities of daily living such as
climbing stairs, so it is logical that quadriceps
strength is associated with the functional score.
Caution should be taken in assigning any cause and
effect relationship. It could be argued that better
functioning knees allow more vigorous activity, and
greater quadriceps strength is a result of higher
activity.
Compared with normal controls, a significant reduction in flexion strength was observed at every
point on the arc of motion tested. This may be the
result of surgical technique, the design and resultant biomechanics of total knee prostheses, the
quadriceps-focused rehabilitation of our TKA patients, the postoperative activities of the patients, or
a combination of these or other factors.
As detected by the KSS, relative hamstring weakness had a lower level of functional significance
(r0.33, P.1). The absence of a stronger correlation between hamstring weakness after TKA and
the KSS is a reflection of the relatively low-level
activities assessed by the KSS. Hamstring weakness
would become apparent in more vigorous activities
such as fast walking, uphill walking, and running.
In a study of patients with a torn anterior cruciate
ligament, it was found that subjects whose hamstring strength was equal to or greater than the
quadriceps strength in the involved limb returned
to higher levels of participation in sports than did
subjects whose hamstring strength was less than
their quadriceps strength [12].
In the present study, nearly 70% of the patients
were women. Although this is biased toward
women, the female to male ratio for TKA is approximately 3 to 1 [14]. Because each subject is their
own control, H/Q ratios are less affected by patient

Knee Strength After Total Knee Arthroplasty Silva et al.

characteristics than the absolute values of extension

or flexion strength. In general, age, gender, weight,
height, and BMI did not affect the H/Q ratio. However, within the TKA group, women, older subjects,
and relatively obese subjects tended to have higher
isometric H/Q ratios (relatively lower quadriceps
strength) than other subjects, with greater variability in terminal extension. Having shown a positive
correlation between extension strength and functional outcome, these data indicate a need for more
aggressive rehabilitation, especially in these subgroups.
Compared with rehabilitation protocols after athletic injuries of the knee, structured rehabilitation
after TKA is inferior in both intensity and duration.
After anterior cruciate reconstruction, 52 weeks of
structured rehabilitation has been recommended to
reliably return the patient to a preinjury level of
function [15]. Because TKA is being performed on
younger and more active patients who desire a
higher level of function, the demands and expectations of the arthroplasty are increasing. Rehabilitation after TKA needs to evolve to meet these rising
demands and expectations. The aggregate data indicate that knee strength is an important element in
higher function. Similar to in other patients with
anterior cruciate ligament deficient knees, greater
emphasis is needed on hamstring strengthening.
Knee strength can be restored to normal levels
after TKA, but there is great variability. These data
suggest a need for more aggressive rehabilitation
after TKA, especially in women, older patients, and
more obese patients.

Acknowledgment
The authors thank Mylene A. de la Rosa, BS, for
her assistance in the preparation of this manuscript
and Frederick J. Dorey, PhD for his assistance with
the statistical analyses of the data.

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