What Came First, the Meniscus Injury or Osteoarthritis?

What Came First, the Meniscus Injury or Osteoarthritis

I am working on this month’s Injury of the Month. It is on meniscus injuries.

I started my research for the injury workout and came across some interesting findings. Let me share with you what I have found.


CLICK HERE to watch the YouTube video.

Does Toe Out or Toe In Put More Stress on the Knee When Walking?

What They Looked At:

Journal-of-science-and-medicine-in-sportThose with knee osteoarthritis tend to externally rotate their feet during gait, to unload the medial aspect of the knee by decreasing the adduction moment at the knee during late stance walking.

They got 11 healthy subjects to walk with their foot internally rotated and externally rotated to see how this affected the knee.

What They Found Out:

Internal rotation of the foot increased knee adduction moment and lateral-medial shear force magnitude during the late stance phase of walking, while external rotation decreased both.

What Does This Mean:

The foot position is a compensation strategy to unload the medial and lateral compartments of the knee.

Rick’s Comments:

We might have to rethink toeing out for clients with knee osteoarthritis. The common thinking has been to work to move them back to the ideal foot position, but this may not be the best solution. The toeing out may be a modification to decrease pain and knee stress and prevent the progression of the injury.

Forcing a correction in the foot position may not be the best thing, but I still would work on recovery strategies for this patient to manage muscle tension and length.

You can get more information here: Lynn SK, Kajaks T, Costigan PA. (2008). The effect of internal and external foot rotation on the adduction moment and lateral-medial shear force at the knee during gait. J Sci Med Sport. Epub 2007 Sep 4. 2008 Sep;11(5):444-51.

Can Walking Lead to a Meniscus Injury?

If you are researching meniscus injuries, I know you are thinking, why are you talking about osteoarthritis? Give me a minute. Keep reading.

What They Looked At:

Arthritis-research-therapyThey looked at 30 non-osteoarthritic women and looked at the knee forces during the stance phase of walking.

They looked at the peak external knee adduction moment, a combination of the ground reaction forces passing through the medial aspect of the center of the knee joint.

The big deal about peak external knee adduction moment is that it’s responsible for 70% of the total knee joint load passing through the medial tibiofemoral compartment during walking.

Interesting Stuff from the Introduction:

  • Meniscal injury is a risk factor for the development and progression of knee osteoarthritis
  • Meniscal injuries may be present with or without a history of significant trauma
  • Meniscal injuries are risk factors for severe cartilage defects, diminished tibial cartilage volume, and increased tibial bone area.

What They Found Out:

“The presence of medial meniscal tears was also positively associated with the degree of internal foot rotation when the external knee adduction moment peaked during late stance, independent of the magnitude of the adductor moment.”

To sum it up, one’s walking gait can affect one risk of meniscal injury.

Rick’s Comments:

Very interesting. Those with more of an internally rotated foot during walking put greater force (peak external knee adduction moment) on the knee’s medial side, which led to an increased risk of meniscal damage.

You can get more information here: Davies-Tuck ML, Wluka AE, Teichtahl AJ, Martel-Pelletier J, Pelletier JP, Jones G, Ding C, Davis SR, Cicuttini FM. (2008). Association between meniscal tears and the peak external knee adduction moment and foot rotation during level walking in postmenopausal women without knee osteoarthritis: a cross-sectional study. Arthritis Res Ther. 2008;10(3): R58. Epub 2008 May 20.

Can Foot Position Affect Hamstring Activation?

What They Looked At:

Suppose they changed the natural foot position during gait. In that case, the researchers ask how this would affect knee adduction moment (KAM), lateral-medial shear forces, and the medial-lateral hamstring muscle activation ratio in those with knee osteoarthritis compared to a control group.

What They Found Out:

  • Those with knee osteoarthritis have an increased late stance knee adduction moment compared to a healthy group
  • Those with knee osteoarthritis have a decreased medial-lateral hamstring activation compared to a healthy group
  • External foot rotation decreased the knee adduction moment, lateral-medial shear force, and hamstring activation ratio.
  • Internal foot rotation did not increase the knee adduction moment, lateral-medial shear force, and hamstring activation ratio

Rick’s Comments:

Clin-Biomech-Bristol-AvonThis confirms the articles from above.

The two interesting points are the research involved injured subjects (people diagnosed with knee osteoarthritis), and you can see how results can change with healthy and injured subjects. This can be seen with the internal rotation of the foot not affecting things compared to the papers above.

The second point is the hamstring and how the foot position decreased the hamstring ratio. Remember, they looked at foot position, not hip rotation. I can’t find the article, but it showed that hip position did not affect KAM.

Effect of foot rotation on knee kinetics and hamstring activation in older adults with and without signs of knee osteoarthritis. Clin Biomech (Bristol, Avon). 2008 Jul;23(6):779-86. Epub 2008 Mar 14. You can get more information here: Lynn SK, Costigan PA. (2008).

A Few Other Comments on Foot Position, Meniscus Injuries, and Osteoarthritis:

– The peak external knee adduction moment during stance walking is similar in both dominant and non-dominant limbs.

You can get more details here – Teichtahl AJ, Wluka AE, Morris ME, Davis SR, Cicuttini FM. (2009). The associations between the dominant and nondominant peak external knee adductor moments during gait in healthy subjects: evidence for symmetry. Arch Phys Med Rehabil. 2009 Feb;90(2):320-4.

Osteoarthritis-and-Cartilage– Hip muscle strengthening reduces knee symptoms in people with medial tibiofemoral osteoarthritis but does not affect knee adduction moment. Therefore focusing on hip strengthening will not influence the progression of osteoarthritis.

Hip strengthening reduces symptoms but not knee load in a randomized controlled trial for people with medial knee osteoarthritis and varus malalignment. Osteoarthritis Cartilage. 2010 May;18(5):621-8. Epub 2010 Feb 6. You can get more information here – Bennell KL, Hunt MA, Wrigley TV, Hunter DJ, McManus FJ, Hodges PW, Li L, Hinman RS. (2010).

– They are investigating how traditional quadriceps strengthening or neuromuscular exercises affect peak external knee adduction moment. Neuromuscular exercises are effective in ACL injury recovery, and that is what I go through in Knee Injury Solution.

Comparison of neuromuscular and quadriceps strengthening exercise in treating varus malaligned knees with medial knee osteoarthritis: a randomized controlled trial protocol. BMC Musculoskelet Disord. 2011 Dec 5;12:276. You can get more details here – Bennell KL, Egerton T, Wrigley TV, Hodges PW, Hunt M, Roos EM, Kyriakides M, Metcalf B, Forbes A, Ageberg E, Hinman RS. (2011).

I hope you enjoyed that research review.

I hope to you are thinking about foot position and meniscus injuries.

Rick Kaselj, MS

Meniscus Tear Solution