Does muscle stiffness predict early-onset knee osteoarthritis?



Biceps femoris, Muscle stiffness, Osteoarthritis, Rectus femoris, Shear wave elastography


Background/Aim: The precise evaluation of the surrounding soft tissues and documenting it by clinical measurements are extremely important for detecting early-stage knee osteoarthritis (OA). Shear wave ultrasound elastography is the latest technology that directly measures the mechanical properties of a tissue, including muscle stiffness. This study was planned to investigate the relationship between Rectus Femoris (RF) and Biceps Femoris (BF) muscle stiffness and the relevant symptoms observed in OA. Methods: Thirty-one patients including 21 females and 10 males between 45-67 years of age, diagnosed with early-stage knee OA and 10 healthy individuals were included in this prospective case-control study. Both RF and BF muscle stiffness were evaluated by shear wave elastography (SWE), and the knee range of motion was calculated by a goniometer. The pain intensity was measured by the Visual Analogue Scale (VAS), knee function, with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and functional performance, using the 6-minute walk test and the step-climbing test. Results: There was a positive correlation between BF muscle stiffness and WOMAC stiffness (P=0.014, r=0.446). There was no difference in Rectus Femoris and Biceps Femoris muscle stiffness between the osteoarthritis patients and healthy individuals (P=0.11 and P=0.10, respectively). Conclusion: It can be concluded that the symptom of stiffness seen in early-stage knee OA is caused by BF muscle spasm related to the flexor reflex.


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van der Esch M, Holla JF, van der Leeden M, Knol DL, Lems WF, Roorda LD, et al. Decrease of muscle strength is associated with increase of activity limitations in early knee osteoarthritis: 3-year results from the cohort hip and cohort knee study. Arch Phys Med Rehabil. 2014;95(10):1962-8. doi: 10.1016/j.apmr.2014.06.007

Dıraçoğlu D, Başkent A, Yağcı İ, Oezcakar L, Aydın R. Isokinetic strength measurements in early knee ostedarthritis. Acta Reumatol Port. 2009;34(1):72-7.

Tuna S, Çelik B, Balcı N. The effect of physical therapy and exercise on pain and functional capacity according to the radiological grade of knee osteoarthritis. J Back Musculoskelet Rehabil. 2021 Jul 30. doi: 10.3233/BMR-200287. [Epub ahead of print].

Ahmad MA, Hamid MSA, Yusof A. Effects of low-level and high-intensity laser therapy as adjunctive to rehabilitation exercise on pain, stiffness and function in knee osteoarthritis: a systematic review and meta-analysis. Physiotherapy. 26 March 2021. doi: 10.1016/ [Epub ahead of print].

Luyten FP, Denti M, Filardo G, Kon E, Engebretsen L. Definition and classification of early osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc. 2012;20(3):401-6. doi: 10.1007/s00167-011-1743-2

Favero M, Ramonda R, Goldring MB, Goldring SR, Punzi L. Early knee osteoarthritis. RMD Open. 2015;1:e000062. doi: 10.1136/rmdopen-2015-000062

Wang L, Chen S, An K-N, Yang H-L, Luo Z-P. Theoretical prediction of ultrasound elastography for detection of early osteoarthritis. Sci World J. 2013;2013. doi: 10.1155/2013/565717

Yokuş A, Toprak M, Arslan H, Toprak N, Akdeniz H, Gündüz AM. Evaluation of distal femoral cartilage by B-mode ultrasonography and shear wave elastography in patients with knee osteoarthritis: a preliminary study. Acta Radiol. 2021;62(4):510-4. doi: 10.1177/0284185120930642

Brandenburg JE, Eby SF, Song P, Zhao H, Brault JS, Chen S, et al. Ultrasound elastography: the new frontier in direct measurement of muscle stiffness. Arch Phys Med Rehabil. 2014;95(11):2207-19. doi: 10.1016/j.apmr.2014.07.007

Alfuraih AM, Tan AL, O’Connor P, Emery P, Wakefield RJ. The effect of ageing on shear wave elastography muscle stiffness in adults. Aging Clin Exp Res. 2019;31(12):1755-63. doi: 10.1007/s40520-019-01139-0

Ebihara B, Mutsuzaki H, Fukaya T, Iwai K. Interpretation of causal relationship between quadriceps tendon Young’s modulus and gait speed by structural equation modeling in patients with severe knee osteoarthritis. J Orthop Surg (Hong Kong). 2021;29(2):1-7. doi: 10.1177/23094990211034003

Ebihara B, Fukaya T, Mutsuzaki H. Relationship between quadriceps tendon young’s modulus and maximum knee flexion angle in the swing phase of gait in patients with severe knee osteoarthritis. Medicina (Kaunas). 2020;56(9):437. doi: 10.3390/medicina56090437

Wu J, Qian Z, Liang W, Liu J, Ren L, Ren L. In vivo assessment of material properties of muscles and connective tissues around the knee joint based on shear wave elastography. J Mech Behav Biomed Mater. 2020;109:103829. doi: 10.1016/j.jmbbm.2020.103829

Gogia PP, Braatz JH, Rose SJ, Norton BJ. Reliability and validity of goniometric measurements at the knee. Phys Ther. 1987;67(2):192-5. doi: 10.1093/ptj/67.2.192

Taş S, Onur MR, Yılmaz S, Soylu AR, Korkusuz F. Shear wave elastography is a reliable and repeatable method for measuring the elastic modulus of the rectus femoris muscle and patellar tendon. J Ultrasound Med. 2017;36(3):565-70. doi: 10.7863/ultra.16.03032

Mendes B, Firmino T, Oliveira R, Neto T, Infante J, Vaz JR, et al. Hamstring stiffness pattern during contraction in healthy individuals: analysis by ultrasound-based shear wave elastography. Eur J Appl Physiol. 2018;118(11):2403-15. doi: 10.1007/s00421-018-3967-z

Tüzün E, Eker L, Aytar A, Daşkapan A, Bayramoğlu M. Acceptability, reliability, validity and responsiveness of the Turkish version of WOMAC osteoarthritis index. Osteoarthr Cartil. 2005;13(1):28-33. doi: 10.1016/j.joca.2004.10.010

Roos MK, LS Lohmander, EM. WOMAC osteoarthritis index: reliability, validity, and responsiveness in patients with arthroscopically assessed osteoarthritis. Scand J Rheumatol. 1999;28(4):210-5. doi: 10.1080/03009749950155562

Harada ND, Chiu V, Stewart AL. Mobility-related function in older adults: assessment with a 6-minute walk test. Arch Phys Med Rehabil. 1999;80(7):837-41. doi: 10.1016/s0003-9993(99)90236-8

Tolk J, Janssen R, Prinsen C, Latijnhouwers D, van der Steen M, Bierma-Zeinstra S, et al. The OARSI core set of performance-based measures for knee osteoarthritis is reliable but not valid and responsive. Knee Surg Sports Traumatol Arthrosc. 2019;27(9):2898-909. doi: 10.1007/s00167-017-4789-y

Dursun E. Diz ekleminde osteoartriti olan hastalarda egzersiz programının etkinliği [dissertation]. Ankara, Türkiye: Hacettepe Üniversitesi; 2007.

Hassan B, Doherty S, Mockett S, Doherty M. Effect of pain reduction on postural sway, proprioception, and quadriceps strength in subjects with knee osteoarthritis. Ann Rheum Dis. 2002;61(5):422-8. doi: 10.1136/ard.61.5.422

Bennell KL, Kyriakides M, Metcalf B, Egerton T, Wrigley TV, Hodges PW, et al. Neuromuscular versus quadriceps strengthening exercise in patients with medial knee osteoarthritis and varus malalignment: a randomized controlled trial. Arthritis Rheumatol. 2014;66(4):950-9. doi: 10.1002/art.38317

Wright LJ, Zautra AJ, Going S. Adaptation to early knee osteoarthritis: the role of risk, resilience, and disease severity on pain and physical functioning. Ann Behav Med. 2008;36(1):70-80. doi: 10.1007/s12160-008-9048-5

Osthoff A-KR, Niedermann K, Braun J, Adams J, Brodin N, Dagfinrud H, et al. 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Ann Rheum Dis. 2018;77(9):1251-60. doi: 10.1136/annrheumdis-2018-213585

Johansson H. Role of knee ligaments in proprioception and regulation of muscle stiffness. Journal of Electromyography and Kinesiology. 1991;1(3):158-79. doi: 10.1016/1050-6411(91)90032-Z

Ettema G, Huijing P. Skeletal muscle stiffness in static and dynamic contractions. Journal of biomechanics. 1994;27(11):1361-8. doi: 10.1016/0021-9290(94)90045-0

Madry H, Kon E, Condello V, Peretti GM, Steinwachs M, Seil R, et al. Early osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc. 2016;24(6):1753-62. doi: 10.1007/s00167-016-4068-3

Johansson H, Sojka P. Pathophysiological mechanisms involved in genesis and spread of muscular tension in occupational muscle pain and in chronic musculoskeletal pain syndromes: a hypothesis. Med Hypotheses. 1991;35(3):196-203. doi: 10.1016/0306-9877(91)90233-o

Masaki M, Ikezoe T, Yanase K, Ji X, Umehara J, Aoyama J, et al. Association of pain history and current pain with sagittal spinal alignment and muscle stiffness and muscle mass of the back muscles in middle-aged and elderly women. Clin Spine Surg. 2019;32(7):E346-E52. doi: 10.1097/BSD.0000000000000793

Houk JC. Regulation of stiffness by skeletomotor reflexes. Annu Rev Physiol. 1979;41(1):99-114. doi: 10.1146/

Serrão PR, Gramani-Say K, Lessi GC, Mattiello SM. Knee extensor torque of men with early degrees of osteoarthritis is associated with pain, stiffness and function. Braz J Phys Ther. 2012;16:289-94. doi: 10.1590/s1413-35552012005000031

Gustafson JA, Anderton W, Sowa GA, Piva SR, Farrokhi S. Dynamic knee joint stiffness and contralateral knee joint loading during prolonged walking in patients with unilateral knee osteoarthritis. Gait Posture. 2019;68:44-9. doi: 10.1016/j.gaitpost.2018.10.032

Kuo W-H, Jian D-W, Wang T-G, Wang Y-C. Neck muscle stiffness quantified by sonoelastography is correlated with body mass index and chronic neck pain symptoms. Ultrasound Med Biol. 2013;39(8):1356-61. doi: 10.1016/j.ultrasmedbio.2012.11.015

Ishikawa H, Muraki T, Morise S, Sekiguchi Y, Yamamoto N, Itoi E, et al. Changes in stiffness of the dorsal scapular muscles before and after computer work: a comparison between individuals with and without neck and shoulder complaints. Eur J Appl Physiol. 2017;117(1):179-87. doi: 10.1007/s00421-016-3510-z

Lee SS, Spear S, Rymer WZ. Quantifying changes in material properties of stroke-impaired muscle. Clin Biomech (Bristol, Avon). 2015;30(3):269-75. doi: 10.1016/j.clinbiomech.2015.01.004

Englund M, Niu J, Guermazi A, Roemer F, Hunter D, Lynch J, et al. Effect of meniscal damage on the development of frequent knee pain, aching, or stiffness. Arthritis Rheumatol. 2007;56(12):4048-54. doi: 10.1002/art.23071

Langan SP, Murphy T, Johnson WM, Carreker JD, Riemann BL. The influence of active hamstring stiffness on markers of isotonic muscle performance. Sports. 2021;9(5):70. doi: 10.3390/sports9050070

Soundarya N. A comparative study on the effectiveness of PNF stretching versus static stretching on Pain and Hamstring flexibility in osteoarthritis knee patients. Int J Res Pharm Sci. 2019;10(3):1789-94. doi: 10.26452/ijrps.v10i3.1312

Reid DA, McNair PJ. Effects of an acute hamstring stretch in people with and without osteoarthritis of the knee. Physiotherapy. 2010;96(1):14-21. doi: 10.1016/

Weng MC, Lee CL, Chen CH, Hsu JJ, Lee WD, Huang MH, et al. Effects of different stretching techniques on the outcomes of isokinetic exercise in patients with knee osteoarthritis. Kaohsiung J Med Sci. 2009;25(6):306-15. doi: 10.1016/S1607-551X(09)70521-2

Saito A, Wakasa M, Kimoto M, Ishikawa T, Tsugaruya M, Kume Y, et al. Age‐related changes in muscle elasticity and thickness of the lower extremities are associated with physical functions among community‐dwelling older women. Geriatr Gerontol Int. 2019;19(1):61-5. doi: 10.1111/ggi.13567

He X, Huang WY, Leong HT, Qiu JH, Ma CC, Fu S-C, et al. Decreased passive muscle stiffness of vastus medialis is associated with poorer quadriceps strength and knee function after anterior cruciate ligament reconstruction. Clin Biomech (Bristol, Avon). 2021;82:105289. doi: 10.1016/j.clinbiomech.2021.105289

Masaki M, Aoyama T, Murakami T, Yanase K, Ji X, Tateuchi H, et al. Association of low back pain with muscle stiffness and muscle mass of the lumbar back muscles, and sagittal spinal alignment in young and middle-aged medical workers. Clin Biomech (Bristol, Avon). 2017;49:128-33. doi: 10.1016/j.clinbiomech.2017.09.008

Ballyns JJ, Turo D, Otto P, Shah JP, Hammond J, Gebreab T, et al. Office‐based elastographic technique for quantifying mechanical properties of skeletal muscle. J Ultrasound Med. 2012;31(8):1209-19. doi: 10.7863/jum.2012.31.8.1209

Shinohara M, Sabra K, Gennisson JL, Fink M, Tanter M. Real‐time visualization of muscle stiffness distribution with ultrasound shear wave imaging during muscle contraction. Muscle Nerve. 2010;42(3):438-41. doi: 10.1002/mus.21723.






Research Article

How to Cite

Gökşen A, Can F, Yılmaz S. Does muscle stiffness predict early-onset knee osteoarthritis?. J Surg Med [Internet]. 2021 Nov. 1 [cited 2024 Jul. 15];5(11):1126-30. Available from: