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Effect of Exercise Therapy Compared with

Arthroscopic Surgery on Knee Muscle Strength
and Functional Performance...

Article in American journal of physical medicine & rehabilitation / Association of Academic Physiatrists October 2014
DOI: 10.1097/PHM.0000000000000209 Source: PubMed

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Authors:
Silje Stensrud, PT, PhD
May Arna Risberg, PT, PhD Exercise
Ewa M. Roos, PT, PhD

Affiliations:
From the Research Unit for
Musculoskeletal Function and
Physiotherapy, Institute of Sports
Science and Clinical Biomechanics,
University of Southern Denmark,
Denmark (SS, EMR); and Norwegian
Research Center for Active
Rehabilitation, Department of
Orthopedic Surgery, Oslo University
Hospital, and Norwegian School of
Sport Sciences, Oslo, Norway (MAR).
Correspondence:
All correspondence and requests for
reprints should be addressed to: Ewa
M. Roos, PT, PhD, Research Unit for
Musculoskeletal Function and
Physiotherapy, Institute of Sports
Science and Clinical Biomechanics,
University of Southern Denmark,
Campusvej 55, DK-5230 Odense M,
Denmark.
Disclosures:
Funded by Sophies Minde Ortopedi AS;
Health Region South-East Oslo,
Norway; The Swedish Rheumatism
Association; the Swedish Scientific
Council; the Region of Southern
Denmark; and the Danish Rheumatism
Association. The Norwegian Sport
Medicine Clinic (NIMI) has supported
the project with rehabilitation facilities
and research staff.
Financial disclosure statements have
been obtained, and no conflicts of
interest have been reported by the
authors or by any individuals in control
of the content of this article.
0894-9115/14/0000-0000
American Journal of Physical
Medicine & Rehabilitation
Copyright * 2014 by Lippincott
Williams & Wilkins
DOI: 10.1097/PHM.0000000000000209
ORIGINAL RESEARCH ARTICLE
Effect of Exercise Therapy
Compared with Arthroscopic Surgery
on Knee Muscle Strength and
Functional Performance in
Middle-Aged Patients with
Degenerative Meniscus Tears
A 3-Mo Follow-up of a Randomized Controlled Trial
ABSTRACT
Stensrud S, Risberg MA, Roos EM: Effect of exercise therapy compared with
arthroscopic surgery on knee muscle strength and functional performance in
middle-aged patients with degenerative meniscus tears: a 3-mo follow-up of a
randomized controlled trial. Am J Phys Med Rehabil 2014;00:00Y00.
Objective: The aim of this study was to compare the effect of a 12-wk exercise
therapy program and arthroscopic partial meniscectomy on knee strength and
functional performance in middle-aged patients with degenerative meniscus tears.
Design: A total of 82 patients (mean age, 49 yrs; 35% women) with a symp-
tomatic, unilateral, magnetic resonance imagingYverified degenerative meniscus tear
and no or mild radiographic osteoarthritis were randomly assigned to a supervised
neuromuscular and strength exercise program or arthroscopic partial meniscectomy.
Outcomes assessed 3 mos after intervention initiation were isokinetic knee muscle
strength, lower extremity performance, and self-reported global rating of change.
Results: Mean difference in isokinetic knee extension peak torque between the
two groups was 16% (95% confidence interval, 7.1Y24.0) (P G 0.0001),
favoring the exercise group. Patients in the exercise group improved isokinetic knee
extension peak by a mean of 25 Nm (range, 18Y33 Nm) from baseline to follow-up.
Furthermore, patients assigned to exercise therapy showed statistically significant
improvements (P e 0.002) in all other measured variables, with moderate to large
effect sizes (0.5Y1.3). Patients reported a similar and positive effect of both
interventions.
Conclusion: A 12-wk supervised exercise therapy program yielded clinically
relevant and statistically significant improvement in isokinetic quadriceps strength
immediately after completion of the program, as compared with treatment with
arthroscopic partial meniscectomy.
Key Words: Degenerative Meniscus, Exercise Therapy, Arthroscopy, Quadriceps,
Knee Osteoarthritis

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Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 A rthroscopic partial meniscectomy (APM) in
middle-aged adults has shown no long-term clinical
secondary aims were to evaluate knee flexion strength
and lower extremity performance, in addition to
patient-reported overall effect of the treatment. It
benefits over placebo in large-scale, well-designed, was hypothesized that there will be greater im-
randomized controlled trials; neither has it been provement in quadriceps muscle strength in the
shown to be superior to optimized nonsurgical treat- exercise therapy group than in the surgery group.
ment including exercise.1Y4 However, the focus in Future studies will include long-term results of
these studies has been on the surgical procedure, and self-reported pain and function, and radiographs
less attention has been given to the exercise inter- will be obtained at 5 yrs to study OA onset and
vention in the control group. Thus, the therapeutic progression.
validity of these exercise programs is unknown. An
exercise therapy program needs to be of sufficient MATERIALS AND METHODS
intensity, load, frequency, and duration to yield
Patients referred from primary care to either
neuromuscular adaptations and structural changes.
one of two hospitals for treatment of symptom-
Improved muscle strength, especially quadriceps
atic nontraumatic, degenerative meniscus tears
strength, and neuromuscular function can provide
between October 2009 and January 2012 were
functional improvements, pain relief, and possibly
invited to participate in the study. This was a
also a delay in the onset of osteoarthritis (OA)
randomized, stratified by gender, parallel-group
as muscle weakness and reduced functional per-
(1:1) study, approved by the Regional Ethics Com-
formance may be risk factors for self-reported or
mittee of the Health Region South-East Oslo,
radiographic OA.5Y7 Middle-aged adults with a de-
Norway. All participants signed a written informed
generative meniscus tear are at considerably high
consent form before inclusion. The rights of the
risk of OA; accordingly, they constitute a good
patients were protected by the studys adherence
model in which to study OA development.8,9
to the Declaration of Helsinki. The study is regis-
An exercise therapy program aimed at re-
tered in www.clinicaltrials.gov, NCT01002794.
storing muscle strength and neuromuscular func-
The inclusion criteria were (1) unilateral knee
tion in middle-aged patients with a degenerative
pain for more than 2 mos without a history of
meniscus tear was designed, and the program was
significant trauma, where Bsignificant trauma[ was
found to be feasible and effective in a case series.10
defined as a single event of sufficient impact
Discovering that such a program is associated with
provoking the initial knee pain and problems; (2) a
neuromuscular and structural improvements, not
tear in the medial meniscus confirmed by magnetic
only in individuals but also in a group of patients,
resonance imaging (MRI); (3) a Kellgren-Lawrence
would further justify exercise as treatment for this
OA grade 2 or less,13 graded with a standing
patient population. This would also provide im-
anterior-posterior radiograph of the injured knee
portant information as to whether long-term
held in a fixed flexed position, using a Plexiglas
changes seen in self-reported pain and function
frame (SynaFlexer)14; (4) between 35 and 60 yrs of
are caused by actual exercise-induced improve-
age; (5) eligible for arthroscopic surgery; and
ments. When comparing exercise therapy with
(6) able to perform physical activities and exercise.
arthroscopic surgery, there are several factors to
Eligibility for surgery was defined as a clinical
consider. Attending exercise programs takes time;
diagnosis of a symptomatic meniscus tear, which
however, it is associated with positive effects on
consisted of the treating orthopedic surgeons
more global health parameters apart from knee
clinical opinion based upon physical examination,
strength/control. Surgery is less time-consuming
history, and MRI.15 Exclusion criteria were acute
for the patient; however, the postoperative period of
locked knee, ligament injury, or knee surgery
increased symptoms and functional limitations
within the previous 2 yrs. Patients had to meet all
often result in sick leave after surgery. Surgical
six inclusion criteria and none of the exclusion
complications and the increased rate of OA seen
criteria to be eligible.
after surgery should also be considered.11,12
Therefore, the primary aim of this report was
to evaluate whether a neuromuscular and strength Procedure
exercise therapy program was effective in improving At inclusion, patients underwent a clinical ex-
quadriceps muscle strength when measured after amination by one physical therapist and one or-
a 12-wk intervention. Patients surgically treated thopedic surgeon. The surgeon also examined
with APM were included as a control group. The the MRIs and scored the radiographs with the

2 Stensrud et al. Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2014

Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Kellgren-Lawrence system. Included patients were
tested and then randomly assigned with the use of
a computer-generated schedule immediately after
baseline testing. The patients received either exer-
cise therapy or APM. Baseline data were obtained
by the same physical therapist who trained the
patients randomized to the exercise therapy group.
The postintervention test was performed by another
physical therapist blinded to group allocation. The
two therapists followed the same detailed test
protocol, and one common practice session was
performed before the start of the study. Both ther-
apists had considerable experience in using the tests
and were familiar with the test procedure from
their participation in previous studies. To preserve
blinding, each patient wore long pants or neoprene
sleeves over both knees so that any surgical scars
were not identified. At each test occasion, patients
completed a standardized 10-min warm-up on a
stationary bike followed by the muscle strength
tests and the lower extremity performance tests.
The leg to be tested first was randomly chosen
before baseline testing by reference to the contents
of an unmarked envelope. The same test order was
applied at follow-up. At follow-up, physical activity
performed during the intervention period, other
than that included in the interventions, was self-
reported by all patients. The type of physical activity,
number of sessions, and duration and intensity of
the sessions were recorded. The intensity of exer-
cise was categorized based on the patients own
perception as low (not warm; sweaty), moderate (a
little warm; sweaty), or high (very hot; sweating a
lot) density. An activity score was calculated for
each patient by multiplying frequency (average
sessions per week), duration (average minutes per
session) and intensity (categorized as low = 1, mo-
derate = 2, high = 3).
Interventions
Exercise Intervention
The date for exercise therapy initiation was the
week after randomization, or later if preferred by
the patient. The exercise therapy program consisted
of progressive neuromuscular and strength exer-
cises over 12 wks, performed during a minimum of
two and a maximum of three sessions per week
(total of 24Y36 sessions). The program has previ-
ously been described in detail,10 and the main
principles and progression are presented in Table 1.
Briefly, all patients were instructed about the aim of
the program and how to perform the exercises.
Patients were then supervised individually by the
same physical therapist once a week throughout
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the program. Other sessions were performed
unsupervised in the same or another similar gym
facility. Each session lasted approximately 60 to
80 minutes. About 20 minutes was spent warming
up and cooling down on a stationary cycle, 20 to
30 minutes was spent on neuromuscular exercise,
and 20 to 30 minutes was spent on strength training.
The aim of the neuromuscular exercises was
to improve neuromuscular control and achieve
compensatory functional stability of the lower ex-
tremity.16 All patients were instructed to position
their knee over the foot during all exercises and to
avoid a medial or lateral position of the knee in
relation to the foot. Supervision was essential to
monitor the quality of the performance and pro-
vide feedback to the patient. Progression, that is,
changing the support surface, varying the number
of repetitions, or including more challenging exer-
cises, was based on the clinicians evaluation of the
patients ability to control the trunk and lower limb
joints relative to each other. Every exercise included
at least three predetermined levels of progression.
The strength exercises were aimed at improving
muscle force output so that the shock-absorbing
function of the lower extremity muscles could be
optimized and subsequent rates of knee load during
activity could be reduced.17 Single leg exercises
were performed with both the involved and the
uninvolved leg, in weight-bearing and nonYweight-
bearing positions. Both concentric and eccentric
exercises were included. Progression was performed
according to the Bplus-two principle,[10 indicating
that the last set of each exercise should be per-
formed with as many repetitions as possible. If the
patients are able to add two extra repetitions to the
set, the load is increased next session.
Compliance was monitored through a training
diary, which recorded type of exercises, number of
repetitions, and load (strength exercises) during
each week. Furthermore, self-reported pain imme-
diately after the training sessions was monitored
with the training diary, using a numeric rating
scale, where 0 indicates no pain and 10 indicates
worst possible pain. Levels 0 to 5 were defined as
acceptable pain.18 Adverse events from exercise
were determined as (1) not attending or not com-
pleting a training session because of increased pain
or problems in the injured knee related to the
exercise therapy program and (2) self-reported pain
scored as greater than 5 on the 0-to-10 numeric
rating scale immediately after training. Adverse
events were recorded in the training diary and
during the weekly supervision.
Effect of Exercise Therapy on Knee Muscle Strength 3
 TABLE 1 Main principles of the 12-wk neuromuscular and strength exercise program (A) and the
postoperative home exercises (B), with regard to intensity, rest period, progression, and type of
exercise
Intensity
A (Sets  Repetitions) Rest Period Progression Main Exercises
Warm-up (20 mins) Preferred resistance Stationary
and cadence cycle
Neuromuscular exercises
Week 1Y4 3  10 30 secs Support surface Squat
(i.e., balance pads)
Single-leg squat
Step-up/down
Knee-stability
in pull loop
Week 5Y12 2  6Y15 30 secs Challenging One-leg
variations Bflying -balance[
Skating
Limping cross
Lunges
Strength exercises
Week 0Y4 2  15 30 secs (+2) Single-leg leg press
Week 5Y6 3  12 1 min (+2) Single-leg knee
extension
Week 7Y9 38 1 min (+2) Single-leg leg curl
Week 10Y12 3Y4  6 1Y2 mins (+2) Hamstring on
Fitball
Cool-down (95 mins) Preferred resistance Stationary cycle
and cadence
Intensity
a
B (Sets  Repetitions) Rest Period Main Exercises
Supine position 1  10 Y Ankle motion; dorsiflexion/plantar flexion
2  4Y12 30 secs Isometric quadriceps contraction
1  10 Y Hip abduction
Side-lying position 1  4Y12 Y Hip abduction, with isometric hold
Seated position 2  10 30 secs Knee motion; flexion/extension
Standing position 2  10 30 secs Knee motion; flexion/extension
1  10 Y Squat
The Bplus-two principle[ (+2) indicates that the last set should be performed with as many repetitions as possible, and if the
patients are able to add two/three extra repetitions to the set, the load is increased next session.
a
Patients were encouraged to perform the exercises two to four times daily from the day of surgery. Intensity and progression were
controlled by pain and swelling.

Surgical Intervention anteromedial and anterolateral, but if surgically re-

Arthroscopic surgery was performed as soon as
possible after randomization, depending on wait-list
timing at the respective hospital or because of
patient preference. The arthroscopic intervention
was a standard arthroscopic partial meniscus
resection, and the study patients followed normal
preoperative, perioperative, and postoperative rou-
tines for the respective hospitals. The surgery was
performed with the patients under general anes-
thesia with or without a thigh tourniquet, with or
without antibiotic prophylaxis, and with or without
antithrombotic prophylaxis. An arthroscope with
30-degree optics and standard arthroscopic in-
struments were used. Ringer acetate was used for
lavage. Normal procedure involved two portals:
quired, a lavage cannula was inserted laterally in the
cranial recessus or into additional portals in the joint
line. Both menisci were probed for tears and unstable
meniscus tissue was resected. Articular cartilage was
inspected and injuries were classified by the International
Cartilage Repair Society classification. Additional injuries
(ligaments, neurovascular structures) were registered.
The patients were discharged from hospital the day of
surgery and were advised to use two crutches postoper-
atively until gait was normalized and no swelling or
discomfort occurred during weight-bearing. Written
and oral instructions for simple home exercises, aimed
at regaining knee range of motion and strength,
were provided to the patients before hospital

4 Stensrud et al. Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2014

Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
discharge (Table 1). They were encouraged to per-
form the exercises two to four times daily.
Outcomes
The primary outcome was isokinetic knee ex-
tension peak torque at 3-mo follow-up. Isokinetic
knee muscle strength was tested using an isokinetic
dynamometer (Biodex 6000 System; Biodex Medical
Systems Inc, Shirley, NY). Testing at 60 degrees
per second consisted of four practice repetitions,
followed by five maximum-effort repetitions. The
patients were seated in an upright, sitting position
on the Biodex dynamometer and secured with
straps to minimize body movements. Arms were
crossed over the chest. The tested range of motion
was from 90 degrees of knee flexion to full exten-
sion. The chair settings were recorded and stored in
the Biodex Software program during the first test,
to duplicate the testing position at the follow-up
test. Isokinetic peak torque values were measured in
Newton meters (Nm) and total work in joules (J).
Peak torque was defined as the highest value of the
five repetitions. Knee pain during testing was
reported by the patients immediately after com-
pleting the test, using a 0-to-10 numeric rating
scale ranging from no pain to worst possible pain.
Three physical performance tests reported to
be reliable and valid for middle-aged adults under-
going meniscectomy19Y21 were used for evaluation
of lower extremity function: the maximum number
of knee-bends in 30 secs,21,22 the one-leg hop
for distance (OLH), and the 6-m timed hop
(6MTH).23,24 For the knee-bends test, each patient
stood on one foot, with the long axis of the foot on a
straight line and toes placed on a perpendicu-
lar line. The examiner gave the patient fingertip
support to prevent rotation at the pelvis and to
provide some balance control. The patient was
asked to bend the knee until the line along the toes
was no longer visible, without bending forward
from the hip (approximately 30 degrees of knee
flexion). The number of knee-bends performed in
30 secs (timed with a stopwatch) was recorded.
Before the test, the patient performed a sufficient
number of practice trials to become familiar
with the test, including the desired degree of knee
flexion. In the OLH test, the patient stood on one
foot, with hands behind the back, and was asked to
hop as far as possible, landing and balancing on
the same foot long enough for the examiner to
determine the distance of the jump using a tape
measure fixed to the floor. No foot movement after
landing was permitted. Distance was measured in
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centimeters from the big toe at the starting
position to the heel at the landing position. Patients
performed two practice trials to familiarize them-
selves with the test and then two test trials on each
leg. The best trial of the two test trials was recorded.
The 6MTH requires the patient to hop for a distance
of 6 m. Time (in seconds) to hop over 6 m was
recorded using a stopwatch. Arms could be used
freely, but the other foot was not allowed to touch
the ground during the test. One practice trial was
performed, followed by two test trials on each leg.
The best trial of the two was recorded.
To assess overall self-reported effect of the two
respective study interventions, a 7-point global
rating scale of change (GRC) was administered
at follow-up.25 Patients were asked: BIn your opin-
ion, what effect has the treatment had on you?[
The answer options were Bvery much worse[ (j3),
Bmuch worse[ (j2), Bworse[ (j1), Bunchanged[
(0), Bbetter[ (1), Bmuch better[ (2), and Bcom-
pletely recovered[ (3). The GRC was applied to allow
for calculation of correlation to change in quadri-
ceps strength.
Sample Size and Statistical Analysis
Randomization was carried out immediately
after baseline testing by drawing a sealed opaque
envelope, numbered and prepared by an investiga-
tor not otherwise involved in the randomization
procedure, according to a computer-generated
randomization schedule. It was stratified by sex to
ensure equal distribution in the two groups. Blocks
of eight were used. Assuming a normal distribution
of the main outcome (isokinetic knee extension
peak torque) in both groups, and further assuming
a common standard deviation of 12 Nm,26 32 pa-
tients would be needed in each group to detect
a statistically significant difference of 10% bet-
ween the group means in isokinetic knee exten-
sion peak torque. The significance level was set at
> = 0.05 and A = 0.1, yielding a statistical power of
90%. To account for dropouts at 3 mos, it was de-
cided to increase the sample size to 40 patients in
each group. Because of logistical issues, it was de-
termined to stop enrolment by the end of January
2012. A total of 83 patients were randomized.
For the primary analysis, change in mean iso-
kinetic knee extension peak torque on the injured
leg from baseline to follow-up was compared in the
two study groups with the use of a linear regression
model. Change or percentage change was modeled
as the dependent variable to adjust for baseline
scores. Percentage change was calculated from the
individual change scores. A similar approach was
Effect of Exercise Therapy on Knee Muscle Strength 5
 used to analyze the change in the secondary out-
come scores. The self-reported GRC between groups
was analyzed with the use of a chi-square linear-
by-linear association test. The paired samples t test
was used for within-group comparisons of outcome
scores between baseline and follow-up, both on the
injured and the noninjured leg. To evaluate the
clinical relevance of the within-group changes, the
standardized response mean was calculated for changes
in absolute torque values, hop lengths (OLH), time
(6MTH), and numbers (knee-bends in 30 secs) from
baseline to follow-up. The standardized response
mean was computed by dividing the mean change
by the standard deviation of the change and was
regarded as small between 0.2 and 0.49, moderate
between 0.5 and 0.8, and large above 0.8.27,28 The
characteristics of the two treatment groups were com-
pared at baseline and follow-up using independent-
samples t tests or chi-square tests for independence
(with Yates Correction for Continuity), depending on
the test variable. Physical activity score was not nor-
mally distributed; thus, the Mann-Whitney U Test was
used. The Spearman rho correlation coefficient
was used to verify the association between the change
in quadriceps strength on the injured leg (as measured
by isokinetic knee extension peak torque) and the
self-reported GRC. To give an indication of the
degree of knee dysfunction of the injured knee prior
FIGURE 1 Enrollment of patients and completion of the study.
6 Stensrud et al.
Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
to intervention, a Limb Symmetry Index (LSI) was
calculated for baseline measures (injured leg/
noninjured leg  100). An LSI of 90% or greater
for an individual in a single test was considered
normal.29,30
All analyses were performed according to the
intention-to-treat principle. Missing data were im-
puted using the baseline observation carried forward
or the follow-up observation carried backward ap-
proach. Baseline data are reported as mean and
standard deviation, and the between-group
and within-group changes are given as means with
corresponding 95% confidence intervals (CIs). Sta-
tistical analyses were conducted in SPSS version 19.0
(IBM SPSS Inc, New York, NY). A two-sided P value
e0.05 was considered statistically significant.
RESULTS
Participant Flow
Figure 1 shows the disposition of the study
participants. A total of 254 patients were assessed
for eligibility; 87 of them were not eligible and
64 declined participation, resulting in a total of
83 patients who underwent randomization. Forty-
one patients were assigned to exercise therapy, and
42, to APM. The number of patients for whom follow-
up data were available was 37 (90%) in the exercise
therapy group and 35 (83%) in the APM group.
Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2014
 TABLE 2 Baseline characteristics for all randomized patients
Treatment Groupsa Combined

Variable ET (n = 40) APM (n = 42) Total (N = 82)

Women, n (%) 13 (32.5) 16 (38.0) 29 (35.4)
Age, yrs 49.2 T 6.4 48.6 T 6.4 48.9 T 6.4
Body mass index, kg/m2 26.9 T 4.1 26.3 T 3.6 26.6 T 3.8
Kellgren Lawrence OA grade, n (%)
Grade 0 30 (75.0) 29 (69.1) 59 (72.0)
Grade 1 8 (20.0) 10 (23.8) 18 (22.0)
Grade 2 2 (5.0) 3 (7.1) 5 (6.0)
Duration of pain, mos 8.5 (6.0; 18.0) 6.5 (5.0; 11.0) 7.5 (5.0; 12.0)
Isokinetic knee muscle strength
Peak torque extension, Nm 158.0 T 48.9 157.5 T 54.0 157.7 T 51.2
Total work extension, J 804.0 T 246.3 778.6 T 261.3 791.0 T 252.8
Peak torque flexion, Nm 85.1 T 25.7 85.1 T 26.4 85.1 T 25.9
Total work flexion, J 471.9 T 185.8 476.4 T 167.1 474.2 T 175.4
Lower extremity performance
OLH, cm 82.0 T 33.6 82.6 T 36.1 82.3 T 34.7
6MTH, secs 3.0 T 1.4 2.9 T 1.4 2.9 T 1.4
Knee-bendings 30s, n 26.2 T 10.0 25.2 T 10.6 25.7 T 10.3
Values are mean T SD, unless otherwise indicated. Duration of pain is reported as median (IQR, q1; q3).
a
P values ranging from 0.12 to 0.99 for the different variables.
ET indicates exercise therapy; Knee-bendings 30s, maximum number of knee-bendings in 30 secs; IQR, interquartile range.

Patient and Group Characteristics
Baseline characteristics are presented in Table 2.
As anticipated, most patients were men (n = 55, 65%).
Most patients (n = 77, 94%) had grade 0 or 1 on the
Kellgren-Lawrence scale,13 indicating no or minimal
radiographic OA. There were no statistically signifi-
cant differences between the two groups with regard
to baseline characteristics. Figure 2 shows the
proportion of patients with normal and abnormal
LSI for the two groups. For the exercise therapy
group, normal LSI values ranged from 43% to 53%
for the different measures, and for the APM group,
normal LSI values ranged from 45% to 61%. Char-
acteristics for the groups at follow-up are presented
in Table 3. On average, the number of days from
baseline to follow-up was significantly greater for the
APM group (53 more days, P G 0.0001); there was,
however, no significant difference between treatment
groups in number of days from the intervention ini-
tiation to follow-up (Table 3). Ten patients in the APM
group had physical therapy visits other than those
included in the study, compared with none in the
exercise therapy group (P = 0.002). Of the ten
patients, six received active treatment (exercise), two
received passive treatment, one received a combina-
tion of active and passive treatment, and one received
advice only. In the exercise therapy group, no patients
skipped or aborted any exercise session because of
pain, only two patients reported pain scored greater
than 5 after training sessions, and the number of

FIGURE 2 Percentage of patients with normal and abnormal LSI in isokinetic knee extension strength and three
lower extremity performance tests, presented separately for the two interventions. A test score for an
individual was considered normal if the LSI was 90% or greater. ET indicates exercise therapy;
Kneebends/30s, maximum number of knee-bends in 30 secs; PT, peak torque.

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 TABLE 3 Characteristics of the two treatment groups at follow-up
ET (n = 40) APM (n = 42) P
Days from baseline 115.6 (109.8Y121.3) 168.5 (148.6Y188.3) G0.0001
to follow-up
Days from baseline 15.6 (9.9Y21.3) 52.4 (34.5Y70.2) G0.0001
to intervention initiation
Days from intervention 103.7 (98.8Y108.6) 107.3 (101.0Y113.5) 0.36
initiation to follow-up
Patients attending physical therapy 0 (0) 10 (28.6) 0.002
other than study treatment, n (%)
Exercise therapy intervention
Number of exercise sessions 22.4 (20.6Y24.2) NA NA
(study intervention)
Sessions with pain 11 (1.4) NA NA
95 after training, n (%)a
Self-reported physical activities
(other than study intervention)
Patients performing additional 29 (78.4) 29 (82.9) 0.86
physical activities, n (%)
Physical activity score,b median 270 (60; 450) 240 (135; 338) 0.83
(IQR, q1; q3)
Values are presented as mean (95% CI) unless otherwise stated.
a
Self-reported pain immediately after the training sessions was monitored through the training diary, using a numeric rating
scale from 0 to 10, where 0 indicates no pain and 10 indicates pain as bad as it could be. Level 0 to 5 was defined as acceptable pain.
b
An activity score was calculated for each patient by multiplying frequency (average sessions per week), duration (average minutes per
session), and intensity (intensity was categorized as low = 1, moderate = 2, high = 3).
ET indicates exercise therapy; NA, not available; IQR, interquartile range.

performed sessions with acceptable pain was 751 of a
possible 762 (98.6%) (Table 3). Median (range) pain
reported during isometric strength testing was
0 (0Y7) for both groups at baseline and 0 (0Y7) and
0 (0Y6) for the APM group and exercise therapy
group, respectively, at follow-up. Because pain during
testing was uncommon, no adjustments were made.
Primary Outcome Measure
As depicted in Figure 3, exercise therapy was
mostly successful in terms of improved isokinetic
knee extension strength on the injured leg from
baseline to 3 mos follow-up. The mean difference in
change between the exercise therapy group and the
APM group was 16% (95% CI, 7.1Y24.0) (P G 0.0001).
Secondary Outcome Measure
There were statistically significant differences
between the treatment groups for isokinetic knee
extension total work (P G 0.0001) and isokinetic
knee flexion peak torque (P = 0.018) on the injured
leg, favoring the exercise therapy group. No statis-
tically significant differences were observed be-
tween the two groups for any of the lower extremity
performance tests, nor the self-reported GRC scale
(Table 4).
Within-group comparisons of the injured side
from baseline to follow-up in the exercise therapy
group showed statistically significant improvements
(P e 0.002) in all isokinetic muscle strength and lower
extremity performance variables, with moderate to
large effect sizes (0.5Y1.3). In the APM group, there
were statistically significant improvements (P e 0.013)
in the two isokinetic knee flexion variables and in one
of three lower extremity performance variables, with
small to large corresponding effect sizes (0.4Y1.0)
(Table 4).
There was a moderate,27 positive association
between change in isokinetic knee extension
peak torque and self-reported effect due to the
intervention in the exercise therapy group (Q = 0.49,
P G 0.01), with greater improvement in muscle
strength associated with greater self-reported
improvement, supporting the clinical relevance of
the improved knee extension strength.
For the noninjured leg in the exercise therapy
group, there were statistically significant improve-
ments from baseline to follow-up in three of
four strength variables (isokinetic knee extension
peak torque improved by 10.1 Nm [P = 0.009],
isokinetic knee flexion peak torque improved by
8.8 Nm [P G 0.0001], and isokinetic knee flexion
total work improved by 43.3 J [P = 0.006]) and one
of four lower extremity performance variables
(maximum number of knee-bends in 30 secs im-
proved by 9.4 [P G 0.0001]). For the noninjured leg
in the APM group, there was a statistically signifi-
cant reduction in one strength variable (isokinetic

8 Stensrud et al. Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2014

Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
FIGURE 3 Change in knee extension peak torque (%) from baseline to follow-up according to treatment group.
Scores are mean change with 95% confidence intervals. ET indicates exercise therapy.

knee extension total work was reduced by 21.2 J
[P = 0.036]) and a statistically significant improve-
ment in one lower extremity performance variable
(maximum number of knee-bends in 30 secs im-
proved by 8.4 [P G 0.001]).
DISCUSSION
This report from a randomized controlled trial
evaluating the improvements of muscle strength
and functional performance of the lower extremity
in middle-aged patients with a degenerative meniscus
tear found that a 12-wk exercise therapy program
resulted in greater improvements in muscle strength
compared with APM. A mean difference of 16%
change in isokinetic knee extension peak torque
was found in favor of the exercise therapy group
(P G 0.0001), indicating therapeutic validity of
the program.31 Furthermore, in all strength vari-
ables, except for total work knee flexion, there were
statistically significant differences favoring the ex-
ercise therapy group. Mean change for the func-
tional performance tests favored the exercise
therapy group; however, no significant differences
were seen for any of the variables (Table 4). The study
was not sufficiently powered to detect changes in
these secondary outcomes. However, the direction of
the changes seen in these secondary outcomes sup-
ports the results of the primary outcome. Within the
exercise group, patients improved significantly from
baseline to follow-up in all isokinetic strength and
performance variables (P e 0.002), with moderate to
large corresponding effect sizes.
Development of a therapeutically valid31 exer-
cise therapy program for middle-aged adults with a
degenerative meniscus tear is important. Indeed,
guidelines not only recommend exercise therapy in-
terventions but also recommend against arthros-
copy in this patient population.32 The drawbacks of

www.ajpmr.com Effect of Exercise Therapy on Knee Muscle Strength 9

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 10
TABLE 4 Change in outcomes on the injured leg from baseline to follow-up in patients with degenerative meniscus tears who were randomized to either ET or APM

Stensrud et al.
Treatment Groups Comparison

ET APM Difference in Means

Variable (n = 40) SRM (n = 42) SRM (95% CI) P
Primary outcome
Isokinetic knee 25.2 (17.8 to 32.6)a 1.09 0.5 (j7.3 to 8.4) 0.02 24.7 (14.0 to 35.3) G0.0001
extension peak
torque, Nm
Secondary outcomes
Isokinetic knee 76.4 (40.4 to 112.4)a 0.67 j22.8 (j57.4 to 11.8) 0.20 99.2 (50.1 to 148.4) G0.0001
extension total work, J
Isokinetic knee 12.7 (7.7 to 17.8)a 0.80 5.9 (3.1 to 8.8)a 0.64 6.9 (1.2 to 12.5) 0.018
flexion peak torque, Nm
Isokinetic knee 64.4 (25.2 to 103.5)a 0.53 27.4 (6.1 to 48.7)a 0.40 36.9 (j6.4 to 80.2) 0.094
flexion total work, J
Knee-bendings 30s, n 11.2 (8.5 to 13.8)a 1.34 8.5 (5.8 to 11.2)a 0.99 2.7 (j1.1 to 6.4) 0.16
OLH, cm 7.9 (3.2 to 12.6)a 0.54 3.4 (j1.3 to 8.0) 0.23 4.6 (j1.9 to 11.1 ) 0.16
6MTH, s 0.4 (0.1 to 0.6)a 0.52 0.1 (j0.04 to 0.3) 0.23 0.2 (j0.04 to 0.5 ) 0.087
Global Rating 2 (j1 to 3) NA 2 (j3 to 3) NA NA 0.43
scale of Change
(score, j3 to 3),b
median (range)
Values are mean (95% CI) unless otherwise stated.
a
Statistically significant change between baseline and follow-up (P G 0.005)
b
A 7-point scale including the categories very much worse (j3), much worse (j2), worse (1), unchanged (0), better (1), much better (2), and completely recovered (3).
ET indicates exercise therapy; SRM, standardized response mean; Knee-bending 30s, maximum knee-bendings in 30 secs; NA, not available.

Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2014
previously applied exercise therapy programs include
programs not being sufficiently described or being
administered as part of different treatment modali-
ties3 and their effect on muscle strength and func-
tional performance not being reported.1 In addition,
muscle dysfunction could play a role in the develop-
ment of both clinical and structural knee OA.5,33Y35
Meniscectomy and APM are associated with an in-
creased risk of incident OA,11,12,36 and therefore,
middle-aged adults with a degenerative meniscus tear
constitute an important and identifiable subgroup
where preventive measures could be taken. To the au-
thors knowledge, only two small studies have evaluated
knee muscle strength before meniscectomy.37,38 Both
reported impaired isokinetic knee muscle strength
compared with a control group or the noninjured leg,
indicating a potential for exercise therapy. Recent
findings from the authors group showed that middle-
aged adults with a symptomatic degenerative menis-
cus tear experienced quadriceps weakness and func-
tional limitations when eligible for meniscectomy,
thus confirming these findings.39 This strengthened
the need for developing an effective exercise therapy
program targeting these impairments. Recently, a case
series based on 20 of the first participants included in
this study was published to describe the details of the
exercise therapy program in middle-aged adults with a
degenerative meniscus tear. The program was found to
be feasible and effective10 for improvements in self-
reported outcomes, muscle strength, and functional
performance. In the current randomized controlled
trial, it was shown not only that this is true for in-
dividuals, but also that the program is effective and has
therapeutic validity in a group of patients.
There was a statistically significant difference
(P G 0.0001) between the two interventions in
quadriceps muscle strength on the injured leg from
baseline to follow-up. Patients assigned to exercise
therapy improved their quadriceps strength by an
average of 18% (95% CI, 12.7Y23.5), whereas the
APM group improved by 2% (95% CI, j4.1 to 9.1).
A change of 15% for knee extension peak torque
is considered to be more than the minimal detect-
able change in young, healthy individuals,40 and
therefore, improvements of more than 15% have
the potential to be clinically meaningful. However,
a minimal detectable change is context dependent
and may vary with patient group and intervention;
thus, the same cutoff for middle-aged adults with
knee injury may not apply. The corresponding
effect size was large (1.09) for the exercise therapy
group, suggesting that patients assigned to exer-
cise therapy had a clinically relevant improvement
in quadriceps muscle strength. Furthermore, the
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improvements in strength seen from this pro-
gram correspond to what can be expected. During a
12-wk exercise period, with frequency and load
applied comparable with the current study, muscle
strength measured with a one repetition maximum
test is expected to increase approximately 1% for
every training session.41 This equals an average
estimated increase of 25% to 30% in one repetition
maximum quadriceps muscle strength from the
number of weeks and sessions applied in this study.
However, quadriceps muscle strength was tested
using an isokinetic knee extension test, and it is
common to find less improvement in muscle
strength using isokinetic compared with one repe-
tition maximum testing.42,43 An 18% improvement
in isokinetic knee extension strength at a group
level, as seen in this study, seems an adequate
improvement in strength over the 12 wks of exer-
cise. At an individual level, relatively large variations
are expected,44 as also observed in the current
study. This could be a result of different hereditary
disposition to respond to strength training, different
quality of performance of the exercises, and differ-
ences in health status and optimal diet during the
training period, which all could affect the outcome.
The patients assigned to exercise therapy im-
proved not only quadriceps strength during the
intervention period but also all other strength and
performance variables significantly (P e 0.002)
during the 12-wk program. The corresponding
effect sizes were moderate to large (0.52Y1.34),
indicating that the observed improvements were
clinically relevant and, thus, that the program
performed as intended. The patients reported being,
on average, Bmuch better[ at the 3-mo follow-up
(Table 4), and in the exercise therapy group, a
moderate association was found between self-
reported perception of improvement and change
in quadriceps strength (Q = 0.49, P G 0.01). Thus,
the improvement in knee muscle strength partly
explains the variance in patients self-reported im-
provement. Determinants of pain and disability in
degenerative joint disease are unclear,45 but in knee
OA, it is thought that muscle strength is more
closely related to pain than other features.46 Fur-
thermore, it is well established that quadriceps
strength training is effective in relieving pain and
improving physical function in patients with knee
OA,47 which could also apply to patients at earlier
stages of the degenerative disease. Interestingly,
the patients in the APM group, like the exercise
therapy group, reported being, on average, Bmuch
better[ at the 3-mo follow-up (Table 4), indicating
that factors other than improved muscle strength
Effect of Exercise Therapy on Knee Muscle Strength 11
 accounted for the experienced improvement. More
invasive procedures are associated with greater pla-
cebo effects, and it cannot be ruled out that a short-
term placebo effect from surgery could explain why
both groups considered themselves as much better
after the intervention despite no improvement in
muscle strength in the surgical group.4
To the authors knowledge, only one study has
previously measured muscle strength 12 wks after
APM. Recovery of the quadriceps beyond preoperative
levels seems not possible without training, as the
quadriceps was found to be weaker than the contra-
lateral side up to 12 wks after surgery,37 supporting
the findings from this study. Previous randomized
studies on patients with degenerative meniscus tears
have focused on evaluating the surgical procedure
and used exercise alone or exercise in combination
with other nonsurgical treatments as control
groups.1,3 The studies failed to show an additional
benefit of arthroscopic surgery. However, in these
studies, strength- and performance-based outcomes
were not included. Kirkley et al.3 included patients
who had already developed knee OA, and one could
argue that arthroscopic surgery would be more
beneficial for patients with earlier stages of the dis-
ease. Herrlin et al.1,2 found the same result in patients
with no or mild knee OA, a group that was similar to
ours in terms of age and stage of joint degeneration.
However, lack of objective outcome measures and
sufficiently described exercise programs makes the
therapeutic validity of the programs used in these
studies difficult to interpret.
A few limitations need to be addressed. Middle-
aged adults with features of a degenerative menis-
cus tear as determined by one of two experienced
orthopedic surgeons were included. All MRIs were
read according to criteria for degenerative meniscus
tears, but not all MRIs were taken by the same
imaging unit. Because of the clinical readings and
the use of more than one imaging unit, subgroup
analyses for those with different meniscal features
were not reliably performed, and thus, the possible
effect from specific pathologies is not known. Bias is
possible because no Btrue[ control group to moni-
tor the natural course was included. In theory, a
natural-course group could have a better longitu-
dinal progression than the surgery group could,
where the joint is subjected to a trauma and where
pain and swelling may occur postoperatively. Thus,
including a natural-course group instead of a sur-
gical group as the control group would possibly
reduce the difference between groups. However,
because patients were recruited from departments of
orthopedic surgery, they were expecting treatment
12 Stensrud et al. Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2014
Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
for their problems, and a natural-course control
group was not considered compatible with retention
of patients in the study. Another aspect is that two
different physical therapists collected the baseline
and the follow-up data, respectively. This may be
considered a limitation; however, this limitation ap-
plies to the within-group comparisons only and not
to the between-group comparisons. There were no
restrictions due to participation in leisure-time
physical activities during the study period and no
differences were reported in terms of type, frequency,
or intensity of leisure-time physical activities between
the groups. Approximately 80% of the patients par-
ticipated in physical activities other than those in-
cluded in the study, and it cannot be ruled out that
this may have affected the outcome. There is no in-
formation about physical activity level before inclu-
sion, and thus, it is not known whether the patients
increased or decreased their activity level during the
intervention period. Leisure-time physical activities
were self-reported at follow-up, which is limited by
recall bias and overestimation of fitness level. Only
36% of patients who were screened and 73% of pa-
tients who were eligible were ultimately assigned to
treatment, representing a limitation. However, most
of the nonincluded patients declined participation
(42%), did not have any current knee pain (26%), or
had bilateral knee pain (14%). The inclusion and
exclusion criteria were set to include as many as
possible of those referred to orthopedic care to
maximize the external validity of the results from the
trial. Follow-up of patients declining participation
was not possible. Another limitation is that there is a
large difference in time between baseline and inter-
vention initiation between the two groups (Table 3).
It cannot be ruled out that strength and other mea-
sured variables declined in the APM group while
waiting for surgery and that the changes reported in
the APM group are thus artificially low. Lastly, the
LSI was not reported as an outcome measure in the
current study despite common use to express both
isokinetic muscle strength48 and single-leg hop per-
formance.49 Using the noninjured leg as a control has
some methodologic advantages; however, the status
of the leg may also lead to misinterpretation of
the results28 considering that all the single-leg
exercises during the exercise intervention were
performed with both the injured and the noninjured
leg. The use of LSI may therefore be ambiguous in
evaluating the response to exercise and improvement
in knee function primarily in the injured leg.50
To add to the evidence for use of exercise in
treatment of patients with a degenerative meniscus
tear, long-term results of self-reported pain and
function are needed, in addition to cost differences
between exercise therapy and APM.
CONCLUSION
A 12-wk supervised neuromuscular and strength
exercise therapy program yielded clinically relevant
and statistically significant improvements in isokinetic
quadriceps muscle strength immediately after com-
pletion of the program, as compared with patients
treated with APM. Surgery was not associated with
changes in muscle strength at 3 mos postoperatively,
and exercise seems necessary to improve muscle
strength in these patients. Clinicians may consider
applying this therapeutically valid exercise therapy
program in the treatment of middle-aged patients with
a degenerative meniscus tear to improve knee muscle
strength and functional performance. Future reports
will show whether these short-term improvements
will translate into long-term clinical benefits.
ACKNOWLEDGMENTS
The authors acknowledge orthopedic surgeons
Lars Engebretsen and Nina Kise and physical thera-
pists Marte Lund and Karin Rydevik for assistance
in data collection. They also acknowledge Robin
Christensen for statistical advice. Lastly, the authors
acknowledge the Norwegian Sport Medicine Clinic
(NIMI), Oslo, Norway for supporting the Norwegian
Research Center for Active Rehabilitation (NAR)
with rehabilitation facilities and research staff. The
NAR is a collaboration between the Norwegian
School of Sport Sciences, Department of Ortho-
pedic Surgery, Oslo University Hospital, and NIMI
(www.active-rehab.no).
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