A Longitudinal Study of Strength and Gait after

Arthroscopic Partial Meniscectomy

CLINICAL SCIENCES

MICHELLE HALL1, TIM V. WRIGLEY1, BEN R. METCALF1, RANA S. HINMAN1, ALASDAIR R. DEMPSEY2,3,
PETER M. MILLS2, FLAVIA M. CICUTTINI4, DAVID G. LLOYD2, and KIM L. BENNELL1
1
Department of Physiotherapy, Centre for Health, Exercise and Sports Medicine, School of Health Sciences, The University
of Melbourne, Melbourne, VIC, AUSTRALIA; 2Centre for Musculoskeletal Research, Griffith Health Institute, Griffith
University, Gold Coast Campus, QLD, AUSTRALIA; 3School of Psychology and Exercise Science, Murdoch University, Perth,
WA, AUSTRALIA; and 4Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive
Medicine, Monash University, Melbourne, VIC, AUSTRALIA

ABSTRACT
HALL, M., T. V. WRIGLEY, B. R. METCALF, R. S. HINMAN, A. R. DEMPSEY, P. M. MILLS, F. M. CICUTTINI, D. G. LLOYD,
and K. L. BENNELL. A Longitudinal Study of Strength and Gait after Arthroscopic Partial Meniscectomy. Med. Sci. Sports Exerc., Vol.
45, No. 11, pp. 20362043, 2013. Purpose: Individuals after arthroscopic partial meniscectomy (APM) are at increased risk of developing
knee osteoarthritis (OA). Knee muscle weakness and a higher external knee adduction moment (KAM) are potential risk factors for knee
OA. This exploratory longitudinal study assessed these risk factors at baseline in an APM group (3 months after surgery) and control group,
and again 2 yrs later (follow-up). Methods: Eighty-two participants with medial APM and 38 healthy controls were assessed at baseline,
with 66 (79%) and 23 (61%), respectively, retested at follow-up. Outcome measures included isokinetic knee muscle strength and medial
knee joint load inferred through indices of the KAM during normal and fast-pace walking. Results: Knee muscle strength was reduced by
14%16% in the APM leg compared with controls at baseline (P e 0.006). However, strength increased in the APM leg over the 2 yrs
such that there were no differences compared with controls at follow-up. KAM impulse was at least 20% higher for the APM group (both
legs) when compared with controls at baseline and remained similarly higher 2 yrs later (P e 0.022). At baseline peak, KAM was 18%
higher in the APM leg as compared with controls only during fast-pace walking (P = 0.013). The peak KAM increased over the 2 yrs in
the APM leg by 8%9% (P e 0.032), although there were no differences in change in KAM between the APM leg and controls.
Conclusion: This study found that although knee muscle strength improved, dynamic medial joint load increased over the 2 yrs after
APM surgery. These findings may aid in developing therapeutic interventions aimed to prevent or delay the onset of knee OA after APM.
Key Words: KNEE JOINT LOADING, KNEE MUSCLE, OSTEOARTHRITIS, WALKING, KNEE ADDUCTION MOMENT

M
eniscal injury is an established risk factor for knee
osteoarthritis (OA) (20), with estimates suggest-
ing that 50% of patients show radiographic signs
of knee OA within 1015 yr after arthroscopic partial men-
iscectomy (APM) (13,27). However, magnetic resonance im-
aging (MRI) data assessing cartilage integrity post-APM show
osteoarthritic changes much earlier, within 5 yr from surgery
(7,23,40). Understanding whether known risk factors as-
sociated with knee OA development and/or progression are
actually present in this patient group, and how they may
change over time, could help to better target conservative
Address for correspondence: Kim L. Bennell, B.App.Sc.(Physio.), Ph.D.,
Department of Physiotherapy, Centre for Health, Exercise and Sports
Medicine, School of Health Sciences, The University of Melbourne,
Melbourne, Victoria 3010, Australia; E-mail: k.bennell@unimelb.edu.au.
Submitted for publication December 2012.
Accepted for publication April 2013.
0195-9131/13/4511-2036/0
MEDICINE & SCIENCE IN SPORTS & EXERCISE
Copyright 2013 by the American College of Sports Medicine
DOI: 10.1249/MSS.0b013e318299982a
therapeutic interventions for OA prevention in this at-
risk group.
Knee muscle weakness has been suggested as a modifi-
able risk factor in the pathogenesis of knee OA, with longi-
tudinal studies supporting a link to disease onset (29,37).
There are conflicting data about the timing and extent of
muscle weakness after APM. Several studies report knee
muscle weakness up to 6 months post-APM (15,31,33).
However, limited research with longer follow-ups has
reported either no significant strength weakness at 2 or 4 yr
post-APM (32,35,36) or muscle weakness at 4 yr post-
APM (3,14). Collectively, interpretation of these study
findings is limited by their study design (often cross-
sectional), small sample sizes, various assessment methods,
and heterogeneous samples. Longitudinal studies are needed
to determine how muscle strength changes after APM.
A large knee adduction moment (KAM) during the stance
phase of walking, a surrogate indicator of medial knee load,
has also been suggested as a risk factor in the pathogenesis
of knee OA. The peak KAM is positively associated with
knee pain onset (1), osteoarthritic morphology (9) as well as
structural knee OA progression (24). Similarly, the KAM

2036

Copyright 2013 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
impulse (which takes into account both the average magni-
tude and duration of medially distributed load throughout
stance) has been positively associated with cartilage degra-
dation and progression in those with established knee OA
(4,9). Moreover, a study including data from participants in
the current study found a significant positive relation be-
tween KAM impulse and adjusted medial tibial plateau area
(10). This is particularly relevant because a larger tibial pla-
teau area is associated with more severe cartilage defects and
increased risk of joint replacement (8). Importantly, for the
APM population, there is evidence of significantly higher
peak KAM bilaterally during walking in individuals 3 months
post-APM as compared with healthy controls (34). It is
unclear why individuals who have undergone an APM have
a higher peak KAM than controls. Theoretically, the KAM
may increase as a result of increasing varus malalignment
associated with resection of the medial meniscus. This could
increase the frontal plane kneeground reaction force lever
arm and therefore elevate the KAM. Longitudinal changes
in knee load have not been assessed in this patient group.
The primary purpose of this exploratory study was two-
fold: 1a) to compare surrogates of knee joint loading and
knee muscle strength in the APM leg (operated leg) of indi-
viduals who had undergone a medial APM 3 months earlier
with healthy controls (baseline) and 2 yrs later (follow-up),
and 1b) to determine whether knee joint loading and knee
muscle strength change overtime in the APM leg. The sec-
ondary purposes of this study were 2a) to compare knee joint
loading in the non-APM leg (nonoperated leg) with the
APM leg and with controls at baseline and follow-up, and
2b) to determine whether longitudinal changes between the
APM leg, non-APM leg, and controls differed over time.
METHODS
This was a 2-yr longitudinal cohort study investigating
APM participants and healthy age-matched controls. Eighty-
two participants between 30 and 50 yr old with isolated
medial APM performed 3 months previously were recruited
from five orthopedic surgeons in Melbourne, Australia. These
participants are a subgroup of participants in other cross-
sectional studies previously described focusing on MRI
parameters (10,40). Participants in the APM group were
excluded if they had the following: evidence of lateral
meniscal resection; greater than one-third of medial menis-
cus resected; less than two tibiofemoral cartilage lesions; a
single tibiofemoral cartilage lesion greater than approxi-
mately 10 mm in diameter or exceeding half of cartilage
thickness; previous knee or lower limb surgery (other than
current APM); history of knee pain (other than that leading
to APM); postoperative complications; cardiac, circulatory,
or neuromuscular conditions; diabetes; stroke; multiple scle-
rosis; and contraindication to MRI.
Healthy controls (n = 38) were recruited from the local
community and screened for the following exclusion criteria:
GAIT STRENGTH AFTER PARTIAL MEDIAL MENISCECTOMY
Copyright 2013 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
current knee pain; knee injuries in the past year that required
medication, reduced physical activity for at least 1 wk, or
resulted in time off from work; previous knee arthroscopy
CLINICAL SCIENCES
that demonstrated the presence of osteophytes or involved
diagnosis or treatment on a knee problem; cardiac, circula-
tory, or neuromuscular conditions; diabetes; stroke; and
multiple sclerosis. The study was approved by the Human
Research Ethics Committee at The University of Melbourne,
and all participants provided written informed consent.
A KinCom 125-AP dynamometer (Chattecx, Chattanooga,
TN) was used to assess maximal isokinetic knee muscle
strength. Participants were seated and secured in a posture
with their trunk upright and their hips flexed to 90-. For a
randomly selected leg of controls and the surgery leg for
the APM cohort (APM leg), participants performed two tests:
five repetitions of reciprocal, maximal concentricconcentric
contractions of knee extensors and knee flexors and ham-
strings at 60-Isj1 through a range of 5- to 95-, followed by
reciprocal eccentriceccentric contractions of the same mus-
cle groups, efforts, and 40-s rest separating the two bouts.
Before each test, participants performed two submaximal
warm-up efforts for familiarization. No feedback was pro-
vided. Each participant received strong and standardized
verbal encouragement to push/pull as hard as you can for
tests, respectively. The highest gravity-corrected peak torque
was recorded for each muscle group and condition, and
reported as torque normalized to body mass (NImIkgj1). The
testretest reliability for isokinetic knee muscle strength
using a KinCom dynamometer has been reported as excel-
lent intraclass correlation (ICC) Q0.96 (19). A clinical mea-
sure of static knee alignment was taken using a gravity
inclinometer attached to calipers (Acuangle Iosmed, Portland,
OR) (17). As participants stood comfortably, the tibial angle
was measured vertically. This measure has been shown to be
reliable (ICC, 0.94) and to correlate with knee alignment mea-
sured from long leg x-rays (correlation coefficient, 0.80) (17).
An eight-camera Vicon M2/MX motion analysis sys-
tem (Vicon, Oxford, UK) was used with three force plates
(Advanced Mechanical Technology, Watertown, MA) to col-
lect motion (120 Hz) and ground reaction force data (1080 Hz).
After practice, participants performed five walking trials bare-
foot and landed the whole foot on the force plate during
normal-pace walking and fast-pace walking. Normal pace
was described to participants as a natural and comfort-
able pace, whereas fast pace was described as a pace that
you would walk in a hurry. Reflective markers and marker
clusters were placed on body segments and anatomical land-
marks in accordance with Besier et al. (6). Functional cali-
bration trials were used to define hip joint centers, and knee
joint flexionextension axes and knee flexionextension and
adductionabduction moments from walking trials were cal-
culated using previously described procedures (6) and imple-
mented in BodyBuilder software (Vicon). Joint moments
were expressed as external moments applied to the distal
segment. The peak external KAM (in the first half of stance)
and positive KAM impulse were measured from each trial,
Medicine & Science in Sports & Exercised 2037
 TABLE 1. Baseline demographic characteristics of APM (3 months postsurgery) and analyses of gait variables. Gait variables at baseline and at
control participants.
follow-up were compared between the following: (A) APM
APM (n = 82) Control (n = 38) P
leg and controls, (B) non-APM leg and controls, and (C)
CLINICAL SCIENCES

Age (yr) 41.0 T 5.4 40.8 T 6.5 0.823

Men (%) 72 (88%)
Height (m) 1.75 T 0.1
Body mass (kg) 84.3 T 14.2
BMI (kgImj2) 27.3 T 4.0
Static knee alignment (-) 0.4 T 2.6
Values indicate mean T SD or number (%).
averaged, and normalized to the product of body weight
and height. The testretest reliability of the University of
Western Australia model for the external frontal plane mo-
ment curve during walking was 0.75 (coefficient of multiple
determination, r2) (6). The peak external knee flexion mo-
ment (KFM) was also measured because some evidence has
shown that medial knee joint load (contact force) measured
by an instrumented knee joint replacement did not reduce
during a gait modification task despite a reduction in peak
KAM (39). The absence of a reduction in medial knee joint
load was attributed to a concurrent increase in the KFM.
Therefore, for the purpose of the current study, we consider
a higher medial knee joint load as higher KAM indices
without a concurrent reduction in peak KFM. Photoelec-
tronic timing gates measured walking speed as participants
walked along the 10-m walkway. The APM group completed
the Knee Injury Osteoarthritis Outcome Score (KOOS) to
assess pain and function at baseline and follow-up. The
KOOS is reliable and valid in meniscectomy patients (26).
Independent t-tests or chi-square tests were used to ex-
plore baseline differences in descriptive variables between
APM and control groups. Within-group differences in descrip-
tive variables over time were assessed using paired t-tests.
Longitudinal differences in change of descriptive variables
between groups were assessed using ANCOVA, adjusting for
baseline levels of the dependent variables. Due to participant
dropout (see Results), baseline and follow-up data were
assessed independently rather than using repeated measures
ANOVA. Paired t-tests confirmed that there were no dif-
ferences in any of the gait parameters between the legs of
controls (data not presented), and subsequently, the mean of
the left and right legs of controls were used in statistical
32 (84%) 0.611 APM and non-APM legs of APM participants. Univariate
1.77 T 0.1 0.405 ANCOVA analyses were used to determine between-group
78.6 T 13.4 0.040
25.1 T 3.4 0.003
differences (A and B) for peak KAM, KAM impulse, and
j0.5 T 2.8 0.100 peak KFM with walking speed as a covariate. Paired t-tests
were used to test for differences within legs of the APM
group at baseline and follow-up (C). Changes in strength
and gait variables from baseline to 2-yr follow-up within
the APM and control groups were compared using paired
t-tests. Differences between APM leg, non-APM leg, and
controls in change of strength and gait variables over time
were assessed using ANCOVA, adjusting for baseline levels
of the dependent variable (to control for scope to change),
as well as change in walking speed for gait variables and
gender for strength data (A and B). Significance was set at
P e 0.05.
RESULTS
Sixty-six (79%) participants with APM returned later
(2.3 yr T 2.4 months) for follow-up testing, and 23 (61%)
healthy controls returned later (2.2 yr T 2.6 months) for
follow-up testing. No significant differences were found
between the APM and control groups for most baseline
demographic characteristics; however, the APM group was
significantly heavier than the controls (Table 1). No differ-
ences in participant characteristics, including body mass, were
found between groups at follow-up (data not presented).
Within each group over time, age significantly increased and
the static knee position became more varus (Table 2). The
control group also significantly increased body mass and
body mass index (BMI) over time (Table 2). Finally, there
were no differences in baseline demographic characteristics,
knee muscle strength, and parameters of knee joint loading
between those who returned at 2 yrs and those who did not
return (data not presented). Pain and function significantly
improved over time in the APM group (all P e 0.001).
The APM leg was 14%16% weaker than controls for
all knee extensor and knee flexor strength measures at base-
line (all P e 0.006) (Table 3). However, at follow-up, there

TABLE 2. Longitudinal changes in group demographics and between-group differences in demographics (APM, n = 66, and controls, n = 22).
Unadjusted Difference in Longitudinal Change Adjusted Difference in Longitudinal Change
between Groups Given as Mean Difference between Legs Given as Mean Difference (95% CI)
Longitudinal Change (Mean T SD) (95% CI) (Follow-up Minus Baseline) (Follow-up Minus Baseline)
APM Control Difference between APM Group and Control Difference between APM Group and Control
Age (yr) 2.21 T 0.23** 2.30 T 0.18** j0.05 (j0.16 to 0.06) j0.05 (j0.16 to 0.06)
Height (m) 0.00 T 0.01 0.00 T 0.01 0.00 (0.00 to 0.00) 0.00 (0.00 to 0.00)
Body mass (kg) 0.18 T 4.5 1.65 T 3.23* j1.47 (j3.52 to 0.57) j1.49 (j3.57 to 0.59)
BMI (kgImj2) 0.50 T 1.49 0.49 T 0.95* j0.44 (j1.10 to 0.22) j0.45 (j1.14 to 0.23)
Static alignment (-) 1.04 T 2.89* 0.95 T 2.14* j0.08 (j1.39 to 1.23) j0.28 (j1.47 to 0.91)
Values indicate mean T SD unless indicated otherwise.

Data adjusted for baseline values.
*Indicates significant between-group differences at P G 0.05.
**Indicates significant between-group differences at P G 0.01.
CI, confidence interval.

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TABLE 3. Gait, strength, and self-reported measures at baseline and follow-up for the APM and control participants.
Baseline (3 Months Post-APM) Follow-up (2 yr Later)
APM Group (n = 82) APM Group (n = 66)

CLINICAL SCIENCES
APM Leg Non-APM Leg Control (n = 38) APM Leg Non-APM Leg Control (n = 23)
Normal pace walk
Gait speed (mIsj1) 1.36 T 0.15a 1.44 T 0.15 1.38 T 0.16 1.43 T 0.17
Stance time (s) 0.64 T 0.05 0.64 T 0.05 0.62 T 0.05 0.63 T 0.05 0.63 T 0.05 0.62 T 0.05
Peak KAM (NIm/(BW  HT)%) 2.30 T 0.95b 2.59 T 0.90aa 2.04 T 0.73 2.56 T 0.96 2.62 T 0.86a 2.25 T 0.89
a,bb
KAM impulse (NImIs/(BW  HT)%) 0.85 T 0.33 0.96 T 0.35aa 0.71 T 0.26 0.90 T 0.34 a
0.94 T 0.30aa 0.71 T 0.26
Peak KFM (NIm/(BW  HT)%) 4.51 T 1.44bb 4.84 T 1.40aa 4.64 T 1.26 5.00 T 1.45 aa
5.00 T 1.53aa 4.49 T 1.23
Fast pace walk
Gait speed (mIsj1) 1.88 T 0.26 1.97 T 0.21 1.90 T 0.21 1.93 T 0.21
Stance time (s) 0.52 T 0.05 0.52 T 0.05 0.51 T 0.05 0.51 T 0.05 0.51 T 0.05 0.51 T 0.05
Peak KAM (NIm/(BW  HT)%) 2.83 T 1.19a,bb 3.27 T 1.25aa 2.40 T 0.89 3.12 T 1.20 3.17 T 1.12 2.64 T 1.11
KAM impulse (NImIs/(BW  HT)%) 0.75 T 0.28aa,bb 0.85 T 0.31aa 0.62 T 0.22 0.78 T 0.30a 0.82 T 0.27aa 0.62 T 0.26
Peak KFM (NIm/(BW  HT)%) 6.87 T 1.87bb 7.71 T 1.92a 7.31 T 1.42 7.70 T 1.65 7.68 T 1.88 7.26 T 1.57
Isokinetic strength (NImIkgj1)
Concentric quadriceps 1.72 T 0.49aa NA 2.05 T 0.41 1.95 T 0.43 NA 2.03 T 0.45
Eccentric quadriceps 2.23 T 0.72aa NA 2.61 T 0.66 2.44 T 0.67 NA 2.48 T 0.72
Concentric hamstrings 0.96 T 0.26aa NA 1.12 T 0.26 1.09 T 0.26 NA 1.16 T 0.29
Eccentric hamstrings 1.38 T 0.44aa NA 1.61 T 0.32 1.49 T 0.38 NA 1.50 T 0.38
KOOS
Self-reported function 91.6 T 10.0 NA 95.7 T 8.9 NA
Self-reported pain 86.3 T 11.5 NA 92.9 T 12.2 NA
Values indicate mean T SD. KOOS, 0100 score; 100 is the best possible score.
a
P G 0.05 compared with control.
aa
P G 0.01 compared with control.
b
P G 0.05 compared with non-APM leg.
bb
P G 0.01 compared with non-APM leg.
BW, body weight; HT, height; NA, not available.

were no significant strength differences between groups.
From baseline to follow-up, the APM leg significantly in-
creased in knee muscle strength by 9%13% (all P e 0.003).
Although there was no change in concentric quadriceps or
hamstring strength from baseline to follow-up in the con-
trols, eccentric quadriceps and hamstrings strength reduced
by 9% and 8%, respectively (all P e 0.012) (Table 4).
At baseline, the peak KAM was 18% higher during fast-
pace (P = 0.013) and 13% higher during normal-pace (P =
0.053) walking (albeit not significant) in the APM leg com-
pared with controls (Table 3). However, at follow-up, there
were no significant differences in peak KAM between the
APM leg and controls during either fast- or normal-pace
walking (Table 3). The peak KAM significantly increased
over time by 8%9% for the APM leg (all P e 0.032, Table 5)
and 15% in controls (all P e 0.017, Table 5). There were
no differences in change in peak KAM over time between
the APM leg and controls (Table 5). At baseline, the
peak KAM was 27%36% higher in the non-APM leg as
compared with controls (all P e 0.001) (Table 3). Although
the differences were less pronounced at follow-up, the
peak KAM for the non-APM leg was still 16% higher than
controls during normal-pace walking (P = 0.037). Within the
APM group at baseline, the peak KAM was 13%16%
higher for the non-APM leg compared with the APM leg (all
P e 0.002). At follow-up, there were no differences between
the APM leg and non-APM leg. Furthermore, peak KAM
for the non-APM leg did not change over time (Table 5).
At baseline, KAM impulse was 20%21% higher for the
APM leg when compared with the controls (all P e 0.028)
(Table 3). Similarly at follow-up, KAM impulse was 25%26%
higher for the APM leg compared with the controls (all P e
0.030) (Table 3). The KAM impulse did not change over
time for the APM leg or controls (Table 5). At baseline,
the KAM impulse was between 35% and 37% higher in the
non-APM leg compared with the controls (all P e 0.01)
(Table 3). Furthermore, at follow-up, the KAM impulse
remained 31%32% higher in the non-APM leg compared

TABLE 4. Longitudinal strength changes and between-group differences in longitudinal strength changes of the APM and control groups.
Unadjusted Difference in Longitudinal Change Adjusted Difference in Longitudinal Change
between Legs Given as Mean Difference between Legs Given as Mean Difference (95% CI)
Isokinetic Strength Longitudinal Change (Mean T SD) (95% CI) (Follow-up Minus Baseline)a (Follow-up Minus Baseline)b
(Peak Torque, NImIkgj1) APM Leg Control APM Leg Minus Control APM Leg Minus Control
Concentric quadriceps 0.24 T 0.39** j0.07 T 0.18 0.31** (0.14 to 0.48) 0.16* (0.00 to 0.31)
Eccentric quadriceps 0.22 T 0.54** j0.21 T 0.28** 0.44** (0.20 to 0.67) 0.29* (0.07 to 0.52)
Concentric hamstrings 0.13 T 0.23** j0.02 T 0.13 0.15** (0.05 to 0.25) 0.06 (j0.04 to 0.17)
Eccentric hamstrings 0.12 T 0.33** j0.16 T 0.27* 0.28** (0.13 to 0.43) 0.17* (0.03 to 0.32)
Values indicate mean T SD.
b
Strength data adjusted for gender and baseline values.
*Indicates significant between-group differences at P G 0.05.
**Indicates significant between-group differences at P G 0.01.
CI, confidence interval.

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Copyright 2013 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 with controls (P e 0.005) (Table 3). Within the APM group

Difference between
at baseline, the KAM impulse was approximately 13%

j0.09 (j0.42 to 0.24)

0.02 (j0.08 to 0.11)

0.17 (j0.15 to 0.49)

j0.08 (j0.52 to 0.36)

0.01 (j0.08 to 0.11)

0.03 (j0.58 to 0.64)

Non-APM Leg
and Control
Adjusted Time Changes for the Difference between Legs higher in the non-APM leg compared with the APM leg (all
CLINICAL SCIENCES

P e 0.002) (Table 5). However, at follow-up, no differences

in peak KAM were apparent between legs of APM group.
Given as Mean Difference (95% CI)

Furthermore, KAM impulse for the non-APM leg did not

change over time (Table 5).
0.09 (j0.15 to 0.32) For the peak KFM, there were no differences between
0.03 (j0.04 to 0.10)

0.14 (j0.17 to 0.44)

0.02 (j0.04 to 0.09)

Difference between

0.55* (0.08 to 1.01)

0.30* (0.03 to 0.56)
Non-APM Leg
APM Leg and

the APM leg and controls at baseline (Table 3). However,

for normal-pace walking at follow-up, the peak KFM was
11% higher for the APM leg as compared with controls (P =
0.003). The peak KFM increased by 13%14% for the APM
leg over time (P = 0.000), whereas there was no change in
APM Leg and Control

peak KFM for the controls over time (Table 5). At baseline,
0.05 (j0.37 to 0.48)

0.04 (j0.05 to 0.12)

0.57 (j0.72 to 1.21)

j0.07 (j0.38 to 0.25)

j0.01 (j0.11 to 0.08)

Difference between

0.48* (0.07 to 0.89)

the peak KFM was 4%5% higher in the non-APM leg as

compared with the controls (all P G 0.041). In the APM
NA

NA

group at baseline, the peak KFM was 7%12% higher in

the APM leg as compared with the non-APM leg (all P e
0.005) (Table 3). There was no change over time in peak
j0.24 (j0.57 to 0.09)

j0.07 (j0.47 to 0.03)

0.42 (j0.13 to 0.96)

j0.33 (j0.76 to 0.11)

j0.05 (j0.14 to 0.04)

0.07 (j0.61 to 0.75)

KFM for the non-APM leg (Table 5).

TABLE 5. Longitudinal knee joint loading changes and between-leg differences in longitudinal knee joint loading changes (APM, n = 66, and controls, n = 23).

Difference between

Leg and Control

Unadjusted Time Changes for the Difference in between Legs

Non-APM

NA

NA

Gait data adjusted for change in walking speed (between group comparisons) and baseline values (between group and within group comparisons).

DISCUSSION
Given as Mean Difference (95% CI)

This longitudinal study of participants post-APM found

0.79** (0.24 to 1.34)
Difference between

0.15 (j0.10 to 0.40)

0.05 (j0.03 to 0.12)

0.36 (j0.07 to 0.78)

0.23 (j0.10 to 0.56)

0.05 (j0.02 to 0.11)

that deficits in knee muscle strength in the APM leg ob-

Non-APM Leg
APM Leg and

served at 3 months after surgery relative to controls were no

NA

NA

longer apparent 2 yrs later. For KAM impulse, the APM leg
had a higher KAM impulse at both time points compared
to controls while the peak KAM increased over the 2-yr
follow-up period for the APM. These findings provide in-
j0.09 (j0.41 to 0.23)

j0.02 (j0.12 to 0.07)

j0.10 (j0.53 to 0.33)

j0.01 (j0.10 to 0.08)

APM Leg and Control
Difference between

0.77* (0.16 to 1.39)

0.86* (0.08 to 1.65)

sight into the changes occurring in people who have under-

gone an APM for medial meniscal injury and may provide
NA

NA

targets for the prevention of knee OA in this population.

Knee muscle weakness is considered a potential risk fac-
tor for knee OA (5). Consistent with previous investigations
of patients within 6 months from meniscus surgery (15,31,33),
0.31 T 0.45**

j0.19 T 1.13*

0.35 T 0.62*

knee muscles were weaker in the APM leg as compared with

0.00 T 0.04

0.05 T 0.10

0.01 T 0.04

0.03 T 0.13

0.04 T 1.17
Control

controls at baseline 3 months postsurgery. However, there

Longitudinal Changes (Mean T SD)

**indicate significant differences at P G 0.05 and P G 0.01, respectively.

were no differences in knee muscle strength between APM

leg and controls 2 yr later. In part, this was because the
APM leg increased in all measures of strength over this time
Non-APM Leg

j0.01 T 0.04
0.07 T 0.73

j0.02 T 0.22

0.23 T 1.10

j0.01 T 0.04
0.03 T 0.94

j0.02 T 0.20

0.11 T 1.41

and also partly because there was an unexpected, yet sig-

nificant reduction in eccentric strength for the controls. We
have considered factors that may influence the strength data,
including age, previous injury, and testing protocol. It seems
0.58 T 1.28**

0.90 T 1.67**

*Indicate significant differences at P G 0.05.

0.22 T 0.71*

0.25 T 0.91*
j0.01 T 0.04

0.03 T 0.21

0.00 T 0.04

0.03 T 0.19

CI, confidence interval; NA, not applicable.

APM Leg

unlikely that age explains the observed decrease in eccen-

tric knee muscle strength in controls. The participants in the
current study were on average 40 yr old, which is below
the 50-yr-old threshold when age-related declines in strength
(NImIs/(BW  HT)%)

(NImIs/(BW  HT)%)
(NIm/(BW  HT)%)

(NIm/(BW  HT)%)

(NIm/(BW  HT)%)
(NIm/(BW  HT)%)

generally commence (19). However, individuals in the con-

trol group may have reduced knee muscle strength at follow-
Normal pace walk
Stance time (s)

Stance time (s)

KAM impulse

KAM impulse
Fast pace walk

up because of an undocumented lower extremity injury

Peak KAM

Peak KAM
Peak KFM

Peak KFM

sustained during the 2-yr study period. Finally, although

testretest reliability for isokinetic knee muscle strength using
a KinCom dynamometer has been reported as excellent (19),

2040 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org

Copyright 2013 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
there is some evidence that eccentric protocols are less reli-
able than concentric (38).
Our findings of improved strength over time concur with
an initial longitudinal report, showing that muscle strength
recovered by 28 months postmeniscus surgery (32) and with
more recent cross-sectional evidence showing similar strength
levels between APM and controls at 2 yrs (36). However,
the nature of strength changes in APM patients at time
points beyond 2 yrs is somewhat unclear. One recent study
found no differences in longitudinal change from 2 to 4 yr
between APM patients and controls (36), whereas cross-
sectional studies at 4 yr postsurgery have found significant
muscle weakness (3,14). Further longitudinal studies are
needed to examine muscle strength over a longer time
frame after APM surgery.
It is perhaps clinically encouraging that our APM cohort
increased muscle strength and returned to strength levels
comparable with those of controls at follow-up. However,
given that we only had measures at two time points, the
point at which this recovery was achieved for each partic-
ipant over the 2 yrs is unknown. Periods of muscle weak-
ness can be detrimental to joint integrity because muscles are
involved in controlling force transfer across the joint (22).
The importance of muscle function on cartilage was high-
lighted in an animal study that experimentally induced ex-
tensor weakness and found knee joint degeneration as early
as 4 wk in rabbits (16). Therefore, weak knee musculature,
even if for a short time, is potentially detrimental to carti-
lage integrity by altering the mechanical environment. In
addition, longitudinal data from the Multicentre Osteoar-
thritis Study emphasize the need for good muscle strength,
because individuals with muscle strength in the top tertile
reported a lower incidence of knee symptoms as compared
with those with strength in the lower tertile (30). Therefore,
even though muscle strength recovered for 2 yrs in our study,
the significant muscle weakness evident at 3 months post-
APM suggests that knee strengthening exercises could be
considered in postmeniscal surgery rehabilitation, which is
consistent with advice from expert clinicians (25).
This is the first longitudinal study to describe changes
in dynamic knee joint loading post-APM. Compared with
controls, we found higher indices of the KAM at baseline,
FIGURE 1Representative of the KAM during fast-pace walking of
one trial for one APM participant and one control participant.
GAIT STRENGTH AFTER PARTIAL MEDIAL MENISCECTOMY
Copyright 2013 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
3 months post-APM, consistent with results of Sturnieks
et al. (33,34). However, we also showed that high KAM
remains and even increases for 2 yrs in the same individuals.
CLINICAL SCIENCES
As previously outlined, this could have longer term clinical
sequelae given that both the peak KAM and KAM impulse
have been related to the pathogenesis of knee OA. Specifi-
cally, a greater peak KAM during several daily activities
contributed to the development of future chronic knee pain
in a longitudinal study of 132 asymptomatic individuals (1).
Peak KAM is associated with osteoarthritic changes (9) and
structural knee OA progression in those with established
disease (24), whereas the KAM impulse has been related to
early OA-related bony changes in people with APM (10)
and cartilage degradation in those with established knee OA
(4). Although it remains unclear as to how the peak KAM
increased post-APM surgery, it is possible that the APM
group adopt a greater knee varus position during walking be-
cause we observed an increase in the static varus knee po-
sition over time. An associated increase in the dynamic lever
arm of the KAM could therefore increase the magnitude
of the KAM. Future research should investigate the mech-
anisms underpinning higher medial knee joint load in
individuals post-APM.
Although peak KAM increased over the 2-yr follow-up
period in the APM leg, there was no change in KAM im-
pulse, this being greater compared with both the non-APM
leg and controls at baseline and at follow-up. The discordant
findings between the peak KAM and KAM impulse (Fig. 1)
likely reflect the fact that although these measures are re-
lated (r = 0.840 (P G 0.001) for APM leg at baseline for
normal-pace walking), they are still measuring different
aspects of load. Such discordance is consistent with a pre-
vious knee OA study in which KAM impulse predicted
cartilage degeneration for 12 months although peak KAM
did not (4).
The peak KFM increased in the APM leg over time, and
the peak KFM was also higher for the APM leg compared
with controls at 2 yrs. The increase in peak KFM over time
with concurrent increase in peak KAM may suggest a higher
medial knee joint loading in light of findings from the in-
strumented knee replacement whereby peak KFM and KAM
were both shown to influence the magnitude of medial con-
tact force (39). Furthermore, increases in the peak KFM may
increase load across the patellofemoral joint during walk-
ing and could contribute to the greater prevalence of carti-
lage defects observed in this compartment in patients with
APM (40).
Although our study used three-dimensional gait analy-
sis to infer joint loading, our findings are supported by bio-
mechanical modeling and ex vivo studies that investigate
the specific effects of meniscectomy. For example, recent fi-
nite element analyses have found that meniscectomy not only
increases the loading on tibial articular cartilage (2,18) but
also alters the distribution and the rate of dissipation of fluid
pressure in cartilage (2). Given an altered mechanical envi-
ronment after APM, interventions to reduce knee loading
Medicine & Science in Sports & Exercised 2041
 may be important in these patients to lower the potential for
future knee OA.
We observed that the non-APM leg had higher dynamic
CLINICAL SCIENCES
loading (KAM impulse, peak KAM, and peak KFM) as
compared with both the APM leg and with controls at
baseline, again similar to the results of Sturnieks et al. (34).
This may be indicative of a compensatory gait strategy to po-
tentially alleviate loading on the recently operated leg (34),
although as evidenced by the self-reported KOOS, the APM
group experienced relatively low pain levels and good func-
tion. This hypothesized compensatory strategy is further af-
firmed, because no differences were apparent by follow-up
between the non-APM leg and APM leg for any of the in-
dices of loading. However, at follow-up, the non-APM leg
continued to show higher loading as compared with controls.
This result is interesting given reports that patients with uni-
lateral isolated meniscectomy have increased risk of OA in
the contralateral, otherwise healthy, knee, albeit to a lesser
extent than the operated knee (12). Taken together, these
findings might encourage bilateral rehabilitation post-APM,
targeting reduction in medial knee joint loading.
This study has several limitations. Although we per-
formed multiple statistical comparisons that increase the risk
of type 1 error (finding a significant result by chance), we
opted not to apply a statistical correction. This was firstly
because of the already increased type 2 error rate introduced
from our reduced sample size at follow-up and secondly
because this was an exploratory, hypothesis-generating study
designed to investigate OA-related factors in APM patients.
Another limitation is participant attrition from baseline to
follow-up, especially in the controls. However, there was
no difference in baseline characteristics, including strength
or knee load, in those who dropped out compared with those
who remained in the study. Thus, there is no reason to sus-
pect that those who dropped out differed in changes in the
variables of interest over time, thereby affecting the results.
Although controls were screened at baseline for knee inju-
ries, it is possible that controls developed undocumented
knee pathology during the 2-yr period. Furthermore, we did
not document physical activity in both groups, so it is not
possible to discern whether any differences, particularly in
strength changes over time, might be attributed to physical
activity. In addition, knee muscle strength was only assessed
unilaterally; this was an effort to reduce participant burden
due to excessively long testing sessions. However, compar-
ing strength of the APM leg to a comparable control group is
considered appropriate given the inherent limitations of com-
paring strength against a potentially weakened contralateral
limb that is often described in those with meniscectomy (21).
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We would like to thank the following surgeons for assisting with
participant recruitment: Mr. Hayden Morris, Mr. Andrew Shimmin,
Mr. Jim Keillerup, Professor Julian Feller, and Mr. Adrian Trivett.
This work was funded by the Australian National Health and
Medical Council project (NHMRC 334151) and program grant
(NHMRC 631717) and the Western Australian Heath and Medical
Research Infrastructure Fund.
The authors declare no conflict of interest.
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