Clinical Orthopaedics and Related Research®

, Volume 468, Issue 9, pp 2460–2468 | Cite as

Quadriceps and Hamstrings Muscle Dysfunction after Total Knee Arthroplasty

  • Jennifer E. Stevens-Lapsley
  • Jaclyn E. Balter
  • Wendy M. Kohrt
  • Donald G. EckhoffEmail author
Clinical Research



Although TKA reliably reduces pain from knee osteoarthritis, full recovery of muscle strength and physical function to normal levels is rare. We presumed that a better understanding of acute changes in hamstrings and quadriceps muscle performance would allow us to enhance early rehabilitation after TKA and improve long-term function.


The purposes of this study were to (1) evaluate postoperative quadriceps and hamstrings muscle strength loss after TKA and subsequent recovery using the nonoperative legs and healthy control legs for comparison, and (2) measure hamstrings coactivation before and after TKA during a maximal isometric quadriceps muscle contraction and compare with nonoperative and healthy control legs.


We prospectively followed 30 patients undergoing TKA at 2 weeks preoperatively and 1, 3, and 6 months postoperatively and compared patient outcomes with a cross-sectional cohort of 15 healthy older adults. Bilateral, isometric strength of the quadriceps and hamstrings was assessed along with EMG measures of hamstrings coactivation during a maximal isometric quadriceps contraction.


There were no differences in strength loss or recovery between the quadriceps and hamstrings muscles of the operative leg throughout the followup, although differences existed when compared with nonoperative and healthy control legs. Hamstrings muscle coactivation in the operative leg during a maximal quadriceps effort was elevated at 1 month (144.5%) compared to the nonoperative leg.


Although quadriceps dysfunction after TKA typically is recognized and addressed in postoperative therapy protocols, hamstrings dysfunction also is present and should be addressed.

Clinical Relevance

Quadriceps and hamstrings muscle strengthening should be the focus of future rehabilitation programs to optimize muscle function and long-term outcomes.


Healthy Control Subject Quadriceps Muscle Maximal Voluntary Isometric Contraction Hamstring Muscle Quadriceps Strength 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We acknowledge Pam Wolfe, MS, for statistical consultation in preparing this manuscript.


  1. 1.
    Adili A, Bhandari M, Petruccelli D, De Beer J. Sequential bilateral total knee arthroplasty under 1 anesthetic in patients > or = 75 years old: complications and functional outcomes. J Arthroplasty. 2001;16:271–278.CrossRefPubMedGoogle Scholar
  2. 2.
    American Academy of Orthopaedic Surgeons. Most commonly performed musculoskeletal-related procedures. Available at: Accessed June 27, 2009.
  3. 3.
    Baratta R, Solomonow M, Zhou BH, Letson D, Chuinard R, D’Ambrosia R. Muscular coactivation: the role of the antagonist musculature in maintaining knee stability. Am J Sports Med. 1988;16:113–122.CrossRefPubMedGoogle Scholar
  4. 4.
    Benedetti MG, Catani F, Bilotta PW, Marcacci M, Mariani E, Giannini S. Muscle activation pattern and gait biomechanics after total knee replacement. Clin Biomech (Bristol, Avon). 2003;18:871–876.CrossRefGoogle Scholar
  5. 5.
    Berman AT, Bosacco SJ, Israelite C. Evaluation of total knee arthroplasty using isokinetic testing. Clin Orthop Relat Res. 1991;271:106–113.PubMedGoogle Scholar
  6. 6.
    Berth A, Urbach D, Awiszus F. Improvement of voluntary quadriceps muscle activation after total knee arthroplasty. Arch Phys Med Rehabil. 2002;83:1432–1436.CrossRefPubMedGoogle Scholar
  7. 7.
    Berth A, Urbach D, Neumann W, Awiszus F. Strength and voluntary activation of quadriceps femoris muscle in total knee arthroplasty with midvastus and subvastus approaches. J Arthroplasty. 2007;22:83–88.CrossRefPubMedGoogle Scholar
  8. 8.
    Bonutti PM, Mont MA, Kester MA. Minimally invasive total knee arthroplasty: a 10-feature evolutionary approach. Orthop Clin North Am. 2004;35:217–226.CrossRefPubMedGoogle Scholar
  9. 9.
    Busse ME, Wiles CM, van Deursen RW. Co-activation: its association with weakness and specific neurological pathology. J Neuroeng Rehabil. 2006;3:26.CrossRefPubMedGoogle Scholar
  10. 10.
    Davies JM, Mayston MJ, Newham DJ. Electrical and mechanical output of the knee muscles during isometric and isokinetic activity in stroke and healthy adults. Disabil Rehabil. 1996;18:83–90.CrossRefPubMedGoogle Scholar
  11. 11.
    Fisher NM, Pendergast DR, Gresham GE, Calkins E. Muscle rehabilitation: its effect on muscular and functional performance of patients with knee osteoarthritis. Arch Phys Med Rehabil. 1991;72:367–374.PubMedGoogle Scholar
  12. 12.
    Forrest G, Fuchs M, Gutierrez A, Girardy J. Factors affecting length of stay and need for rehabilitation after hip and knee arthroplasty. J Arthroplasty. 1998;13:186–190.CrossRefPubMedGoogle Scholar
  13. 13.
    Huang CH, Cheng CK, Lee YT, Lee KS. Muscle strength after successful total knee replacement: a 6- to 13-year followup. Clin Orthop Relat Res. 1996;328:147–154.CrossRefPubMedGoogle Scholar
  14. 14.
    Hubley-Kozey C, Deluzio K, Dunbar M. Muscle co-activation patterns during walking in those with severe knee osteoarthritis. Clin Biomech (Bristol, Avon). 2008;23:71–80.CrossRefGoogle Scholar
  15. 15.
    Hurley MV. The role of muscle weakness in the pathogenesis of osteoarthritis. Rheum Dis Clin North Am 1999;5:283–298.CrossRefPubMedGoogle Scholar
  16. 16.
    Kennedy DM, Stratford PW, Riddle DL, Hanna SE, Gollish JD. Assessing recovery and establishing prognosis following total knee arthroplasty. Phys Ther. 2008;88:22–32.CrossRefPubMedGoogle Scholar
  17. 17.
    Krishnan C, Williams GN. Evoked tetanic torque and activation level explain strength differences by side. Eur J Appl Physiol. 2009;106:769–774.CrossRefPubMedGoogle Scholar
  18. 18.
    Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780–785.CrossRefPubMedGoogle Scholar
  19. 19.
    Lewek MD, Rudolph KS, Snyder-Mackler L. Control of frontal plane knee laxity during gait in patients with medial compartment knee osteoarthritis. Osteoarthritis Cartilage. 2004;12:745–751.CrossRefPubMedGoogle Scholar
  20. 20.
    Lewek MD, Rudolph KS, Snyder-Mackler L. Quadriceps femoris muscle weakness and activation failure in patients with symptomatic knee osteoarthritis. J Orthop Res. 2004;22:110–115.CrossRefPubMedGoogle Scholar
  21. 21.
    Lorentzen JS, Petersen MM, Brot C, Madsen OR. Early changes in muscle strength after total knee arthroplasty: a 6-month follow-up of 30 knees. Acta Orthop Scand. 1999;70:176–179.CrossRefPubMedGoogle Scholar
  22. 22.
    Lutz GE, Palmitier RA, An KN, Chao EY. Comparison of tibiofemoral joint forces during open-kinetic-chain and closed-kinetic-chain exercises. J Bone Joint Surg Am. 1993;75:732–739.PubMedGoogle Scholar
  23. 23.
    McArdle A, Vasilaki A, Jackson M. Exercise and skeletal muscle ageing: cellular and molecular mechanisms. Ageing Res Rev. 2002;1:79–93.CrossRefPubMedGoogle Scholar
  24. 24.
    Mizner RL, Petterson SC, Snyder-Mackler L. Quadriceps strength and the time course of functional recovery after total knee arthroplasty. J Orthop Sports Phys Ther. 2005;35:424–436.PubMedGoogle Scholar
  25. 25.
    Mizner RL, Petterson SC, Stevens JE, Axe MJ, Snyder-Mackler L. Preoperative quadriceps strength predicts functional ability one year after total knee arthroplasty. J Rheumatol. 2005;32:1533–1539.PubMedGoogle Scholar
  26. 26.
    Mizner RL, Petterson SC, Stevens JE, Vandenborne K, Snyder-Mackler L. Early quadriceps strength loss after total knee arthroplasty: the contributions of muscle atrophy and failure of voluntary muscle activation. J Bone Joint Surg Am. 2005;87:1047–1053.CrossRefPubMedGoogle Scholar
  27. 27.
    Mizner RL, Snyder-Mackler L. Altered loading during walking and sit-to-stand is affected by quadriceps weakness after total knee arthroplasty. J Orthop Res. 2005;23:1083–1090.CrossRefPubMedGoogle Scholar
  28. 28.
    Mizner RL, Stevens JE, Snyder-Mackler L. Voluntary activation and decreased force production of the quadriceps femoris muscle after total knee arthroplasty. Phys Ther. 2003;83:359–365.PubMedGoogle Scholar
  29. 29.
    Moffet H, Collet JP, Shapiro SH, Paradis G, Marquis F, Roy L. Effectiveness of intensive rehabilitation on functional ability and quality of life after first total knee arthroplasty: a single-blind randomized controlled trial. Arch Phys Med Rehabil. 2004;85:546–556.CrossRefPubMedGoogle Scholar
  30. 30.
    Newham DJ, Hsiao SF. Knee muscle isometric strength, voluntary activation and antagonist co-contraction in the first six months after stroke. Disabil Rehabil. 2001;23:379–386.CrossRefPubMedGoogle Scholar
  31. 31.
    Nichols AW. Achilles tendinitis in running athletes. J Am Board Fam Pract. 1989;2:196–203.PubMedGoogle Scholar
  32. 32.
    Noble PC, Gordon MJ, Weiss JM, Reddix RN, Conditt MA, Mathis KB. Does total knee replacement restore normal knee function? Clin Orthop Relat Res. 2005;431:157–165.CrossRefPubMedGoogle Scholar
  33. 33.
    O’Reilly SC, Jones A, Muir KR, Doherty M. Quadriceps weakness in knee osteoarthritis: the effect on pain and disability. Ann Rheum Dis. 1998;57:588–594.CrossRefPubMedGoogle Scholar
  34. 34.
    Ostenberg A, Roos E, Ekdahl C, Roos H. Isokinetic knee extensor strength and functional performance in healthy female soccer players. Scand J Med Sci Sports. 1998;8:257–264.CrossRefPubMedGoogle Scholar
  35. 35.
    Perhonen M, Komi PV, Hakkinen K, Von Bonsdorf H, Partio H. Strength training and neuromuscular function in elderly people with total knee endoprosthesis. Scand J Med Sci Sports. 1982;2(4):234–243.CrossRefGoogle Scholar
  36. 36.
    Petterson SC, Mizner RL, Stevens JE, Raisis L, Bodenstab A, Newcomb W, Snyder-Mackler L. Improved function from progressive strengthening interventions after total knee arthroplasty: a randomized clinical trial with an imbedded prospective cohort. Arthritis Rheum. 2009;61:174–183.CrossRefPubMedGoogle Scholar
  37. 37.
    Scuderi GR, Tenholder M, Capeci C. Surgical approaches in mini-incision total knee arthroplasty. Clin Orthop Relat Res. 2004;428:61–67.CrossRefPubMedGoogle Scholar
  38. 38.
    Sharma L, Dunlop DD, Cahue S, Song J, Hayes KW. Quadriceps strength and osteoarthritis progression in malaligned and lax knees. Ann Intern Med. 2003;138:613–619.PubMedGoogle Scholar
  39. 39.
    Silva M, Shepherd EF, Jackson WO, Pratt JA, McClung CD, Schmalzried TP. Knee strength after total knee arthroplasty. J Arthroplasty. 2003;18:605–611.CrossRefPubMedGoogle Scholar
  40. 40.
    Slemenda C, Brandt KD, Heilman DK, Mazzuca S, Braunstein EM, Katz BP, Wolinsky FD. Quadriceps weakness and osteoarthritis of the knee. Ann Intern Med. 1997;127:97–104.PubMedGoogle Scholar
  41. 41.
    Stevens JE, Mizner RL, Snyder-Mackler L. Quadriceps strength and volitional activation before and after total knee arthroplasty for osteoarthritis. J Orthop Res. 2003;21:775–779.CrossRefPubMedGoogle Scholar
  42. 42.
    Stevens JE, Mizner R, Snyder-Mackler L. Neuromuscular electrical stimulation for quadriceps muscle strengthening after bilateral total knee arthroplasty: a case series. J Orthop Sports Phys Ther. 2004;34:21–29.PubMedGoogle Scholar
  43. 43.
    Stevens-Lapsley JE, Petterson SC, Mizner RL, Snyder-Mackler L. Impact of body mass index on functional performance after total knee arthroplasty. J Arthroplasty. 2009 Oct 29 [Epub ahead of print].Google Scholar
  44. 44.
    Walsh M, Woodhouse LJ, Thomas SG, Finch E. Physical impairments and functional limitations: a comparison of individuals 1 year after total knee arthroplasty with control subjects. Phys Ther. 1998;78:248–258.PubMedGoogle Scholar
  45. 45.
    Watters JM, Clancey SM, Moulton SB, Briere KM, Zhu JM. Impaired recovery of strength in older patients after major abdominal surgery. Ann Surg. 1993;218:380–390.CrossRefPubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2010

Authors and Affiliations

  • Jennifer E. Stevens-Lapsley
    • 1
  • Jaclyn E. Balter
    • 1
  • Wendy M. Kohrt
    • 2
  • Donald G. Eckhoff
    • 3
    Email author
  1. 1.Physical Therapy Program, Department of Physical Medicine and RehabilitationUniversity of Colorado DenverAuroraUSA
  2. 2.Division of GeriatricsUniversity of Colorado DenverAuroraUSA
  3. 3.Department of OrthopedicsUniversity of Colorado DenverAuroraUSA

Personalised recommendations