Rheumatology International

, Volume 39, Issue 2, pp 203–218 | Cite as

Strengthening the quadriceps femoris muscle versus other knee training programs for the treatment of knee osteoarthritis

  • Gamze Kus
  • Ipek YeldanEmail author
Systematic Review


People with knee osteoarthritis have atrophy of the muscles surrounding the knee joint. Therefore, exercise programs primarily have been focused on the strengthening of quadriceps femoris muscle (QFM). Primary aim of this systematic review was to determine which exercise increases strength of the QFM and describe the details of the training programs. Secondary aim was to determine effectiveness of strengthening of the QFM alone on pain and dysfunction in patient with knee osteoarthritis. PubMed, PEDro, and Cochrane were searched. PEDro for methodological quality of randomized controlled trials and Cochrane Collaborations’ tool for risk of bias were used. A total of 1128 articles were identified from the database searches. Ten studies which were moderate-to-high level of evidence were included. In the comparison of different strengthening exercises of the QFM, significant difference was not found between training groups. However, strengthening of the QFM exercise training was superior to proprioceptive training. Additional hot packs plus shortwave diathermy or ultrasound or transcutaneous electrical nerve stimulation had superiority to isokinetic strengthening of the QFM alone. Only additional Russian electrical stimulation showed the significant difference compared with strengthening of the QFM exercise. Most of the included studies showed that strengthening of the QFM exercises has an effect on pain reduction and improvement of function. This review indicated that the strengthening of QFM training compared with other knee exercises provided muscle strengthening, pain reduction, and improved function while combination with other electrotherapy modalities or combination with Russian electrical stimulation had superiority to alone strengthening QFM training.


Electric stimulation therapy Exercise Pain Rehabilitation Resistance training 



The authors would like to thank Goksen Kuran Aslan, Rustem Mustafaoglu, and Sezen Karaborklu Argut for their contribution in reviewing the writing style of the manuscript.


  1. 1.
    Chen D, Shen J, Zhao W, Wang T, Han L, Hamilton JL, Im H-J (2017) Osteoarthritis: toward a comprehensive understanding of pathological mechanism. Bone Res 5:16044CrossRefGoogle Scholar
  2. 2.
    Busija L, Bridgett L, Williams SR, Osborne RH, Buchbinder R, March L, Fransen M (2010) Osteoarthritis. Best Pract Res Clin Rheumatol 24(6):757–768. CrossRefGoogle Scholar
  3. 3.
    Woolf AD, Pfleger B (2003) Burden of major musculoskeletal conditions. Bull World Health Organ 81(9):646–656Google Scholar
  4. 4.
    Felson DT, Zhang Y (1998) An update on the epidemiology of knee and hip osteoarthritis with a view to prevention. Arthritis Rheum 41 (8):1343–1355.;2-9 CrossRefGoogle Scholar
  5. 5.
    Dawson J, Linsell L, Zondervan K, Rose P, Randall T, Carr A, Fitzpatrick R (2004) Epidemiology of hip and knee pain and its impact on overall health status in older adults. Rheumatology 43(4):497–504. CrossRefGoogle Scholar
  6. 6.
    Oiestad BE, Juhl CB, Eitzen I, Thorlund JB (2015) Knee extensor muscle weakness is a risk factor for development of knee osteoarthritis. A systematic review and meta-analysis. Osteoarthr Cartil 23(2):171–177. CrossRefGoogle Scholar
  7. 7.
    Rasch A, Byström AH, Dalen N, Berg HE (2007) Reduced muscle radiological density, cross-sectional area, and strength of major hip and knee muscles in 22 patients with hip osteoarthritis. Acta Orthop 78(4):505–510CrossRefGoogle Scholar
  8. 8.
    Slemenda C, Brandt KD, Heilman DK, Mazzuca S, Braunstein EM, Katz BP, Wolinsky FD (1997) Quadriceps weakness and osteoarthritis of the knee. Ann Intern Med 127(2):97–104CrossRefGoogle Scholar
  9. 9.
    Hurley MV (1999) The role of muscle weakness in the pathogenesis of osteoarthritis. Rheum Dis Clin North Am 25(2):283–298 (vi)CrossRefGoogle Scholar
  10. 10.
    Zhang W, Nuki G, Moskowitz RW, Abramson S, Altman RD, Arden NK, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P (2010) OARSI recommendations for the management of hip and knee osteoarthritis: part III: changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthr Cartil 18(4):476–499. CrossRefGoogle Scholar
  11. 11.
    Peter WF, Jansen MJ, Hurkmans EJ, Bloo H, Dekker J, Dilling RG, Hilberdink W, Kersten-Smit C, de Rooij M, Veenhof C, Vermeulen HM, de Vos RJ, Schoones JW, Vliet Vlieland TP (2011) Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation. Acta Reumatol Port 36(3):268–281Google Scholar
  12. 12.
    Pelland L, Brosseau L, Wells G, MacLeay L, Lambert J, Lamothe C, Robinson V, Tugwell P (2004) Efficacy of strengthening exercises for osteoarthritis (Part I): a meta-analysis. Phys Ther Rev 9(2):77–108. CrossRefGoogle Scholar
  13. 13.
    Jordan KM, Arden NK, Doherty M, Bannwarth B, Bijlsma JW, Dieppe P, Gunther K, Hauselmann H, Herrero-Beaumont G, Kaklamanis P, Lohmander S, Leeb B, Lequesne M, Mazieres B, Martin-Mola E, Pavelka K, Pendleton A, Punzi L, Serni U, Swoboda B, Verbruggen G, Zimmerman-Gorska I, Dougados M (2003) EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis 62(12):1145–1155CrossRefGoogle Scholar
  14. 14.
    Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, Towheed T, Welch V, Wells G, Tugwell P (2012) American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken) 64(4):465–474CrossRefGoogle Scholar
  15. 15.
    Neogi T (2013) The epidemiology and impact of pain in osteoarthritis. Osteoarthr Cartil 21(9):1145–1153CrossRefGoogle Scholar
  16. 16.
    Madsen OR, Bliddal H, Egsmose C, Sylvest J (1995) Isometric and isokinetic quadriceps strength in gonarthrosis; inter-relations between quadriceps strength, walking ability, radiology, subchondral bone density and pain. Clin Rheumatol 14(3):308–314CrossRefGoogle Scholar
  17. 17.
    Schiphof D, van den Driest JJ, Runhaar J (2018) Osteoarthritis year in review 2017: rehabilitation and outcomes. Osteoarthr Cartil 26(3):326–340CrossRefGoogle Scholar
  18. 18.
    Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM (2014) A systematic review of recommendations and guidelines for the management of osteoarthritis: the chronic osteoarthritis management initiative of the U.S. bone and joint initiative. Semin Arthritis Rheum 43(6):701–712. CrossRefGoogle Scholar
  19. 19.
    Brosseau L, MacLeay L, Robinson V, Wells G, Tugwell P (2003) Intensity of exercise for the treatment of osteoarthritis. Cochrane Database Syst Rev. Google Scholar
  20. 20.
    Bennell KL, Hinman RS (2011) A review of the clinical evidence for exercise in osteoarthritis of the hip and knee. J Sci Med Sport 14(1):4–9. CrossRefGoogle Scholar
  21. 21.
    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 6(7):e1000100. CrossRefGoogle Scholar
  22. 22.
    Bennell K, Hinman R (2005) Exercise as a treatment for osteoarthritis. Curr Opin Rheumatol 17(5):634–640CrossRefGoogle Scholar
  23. 23.
    Moseley AM, Herbert RD, Sherrington C, Maher CG (2002) Evidence for physiotherapy practice: a survey of the Physiotherapy Evidence Database (PEDro). Aust J Physiother 48(1):43–49CrossRefGoogle Scholar
  24. 24.
    Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M (2003) Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther 83(8):713–721Google Scholar
  25. 25.
    Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, Savović J, Schulz KF, Weeks L, Sterne JAC (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. The BMJ 343:d5928. CrossRefGoogle Scholar
  26. 26.
    Salli A, Sahin N, Baskent A, Ugurlu H (2010) The effect of two exercise programs on various functional outcome measures in patients with osteoarthritis of the knee: a randomized controlled clinical trial. Isokinet Exerc Sci. Google Scholar
  27. 27.
    Jan M-H, Lin J-J, Liau J-J, Lin Y-F, Lin D-H (2008) Investigation of clinical effects of high-and low-resistance training for patients with knee osteoarthritis: a randomized controlled trial. Phys Ther 88(4):427–436CrossRefGoogle Scholar
  28. 28.
    Lin DH, Lin CH, Lin YF, Jan MH (2009) Efficacy of 2 non-weight-bearing interventions, proprioception training versus strength training, for patients with knee osteoarthritis: a randomized clinical trial. J Orthop Sports Phys Ther 39(6):450–457. CrossRefGoogle Scholar
  29. 29.
    Lim BW, Hinman RS, Wrigley TV, Sharma L, Bennell KL (2008) Does knee malalignment mediate the effects of quadriceps strengthening on knee adduction moment, pain, and function in medial knee osteoarthritis? A randomized controlled trial. Arthritis Care Res Off J Am Coll Rheumatol 59(7):943–951CrossRefGoogle Scholar
  30. 30.
    Kean CO, Hinman RS, Wrigley TV, Lim B-W, Bennell KL (2017) Impact loading following quadriceps strength training in individuals with medial knee osteoarthritis and varus alignment. Clin Biomech 42:20–24CrossRefGoogle Scholar
  31. 31.
    Laufer Y, Shtraker H, Gabyzon ME (2014) The effects of exercise and neuromuscular electrical stimulation in subjects with knee osteoarthritis: a 3-month follow-up study. Clin Interv Aging 9:1153CrossRefGoogle Scholar
  32. 32.
    Cetin N, Aytar A, Atalay A, Akman MN (2008) Comparing hot pack, short-wave diathermy, ultrasound, and TENS on isokinetic strength, pain, and functional status of women with osteoarthritic knees: a single-blind, randomized, controlled trial. Am J Phys Med Rehabil 87(6):443–451. CrossRefGoogle Scholar
  33. 33.
    Bruce-Brand RA, Walls RJ, Ong JC, Emerson BS, O’Byrne JM, Moyna NM (2012) Effects of home-based resistance training and neuromuscular electrical stimulation in knee osteoarthritis: a randomized controlled trial. BMC Musculoskelet Disord 13:118. CrossRefGoogle Scholar
  34. 34.
    Park SH, Hwangbo G (2015) Effects of combined application of progressive resistance training and Russian electrical stimulation on quadriceps femoris muscle strength in elderly women with knee osteoarthritis. J Phys Ther Sci 27(3):729–731CrossRefGoogle Scholar
  35. 35.
    Tok F, Aydemir K, Peker F, Safaz I, Taskaynatan MA, Ozgul A (2011) The effects of electrical stimulation combined with continuous passive motion versus isometric exercise on symptoms, functional capacity, quality of life and balance in knee osteoarthritis: randomized clinical trial. Rheumatol Int 31(2):177–181. CrossRefGoogle Scholar
  36. 36.
    O’Reilly SC, Jones A, Muir KR, Doherty M (1998) Quadriceps weakness in knee osteoarthritis: the effect on pain and disability. Ann Rheum Dis 57(10):588–594CrossRefGoogle Scholar
  37. 37.
    Segal NA, Glass NA (2011) Is quadriceps muscle weakness a risk factor for incident or progressive knee osteoarthritis? Phys Sports Med 39(4):44–50CrossRefGoogle Scholar
  38. 38.
    Harrison AL (2004) The influence of pathology, pain, balance, and self-efficacy on function in women with osteoarthritis of the knee. Phys Ther 84(9):822–831Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Physiotherapy and Rehabilitation, Institute of Postgraduate EducationIstanbul University-CerrahpasaIstanbulTurkey
  2. 2.School of Physiotherapy and RehabilitationMustafa Kemal UniversityAntakyaTurkey
  3. 3.Division of Physiotherapy and Rehabilitation, Department of Physiotherapy and Rehabilitation, Faculty of Health SciencesIstanbul University-CerrahpasaIstanbulTurkey

Personalised recommendations