Association between Hamstring Flexibility and Functional Performance of Patients with Knee Osteoarthritis

Sejal Sailor; Amisha Limbani; Dhruva Dhola

doi:10.4103/JIHS.JIHS_28_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 8 | Issue : 2 | Page : 57-60

Association between Hamstring Flexibility and Functional Performance of Patients with Knee Osteoarthritis

Sejal Sailor, Amisha Limbani, Dhruva Dhola
Department of Musculoskeletal Physiotherapy, SPB Physiotherapy College, Surat, Gujarat, India

Date of Submission	30-Jul-2020
Date of Decision	19-Oct-2020
Date of Acceptance	20-Nov-2020
Date of Web Publication	12-Jan-2021

Correspondence Address:
Dr. Sejal Sailor
Department of Musculoskeletal Physiotherapy, SPB Physiotherapy College, Ugat Bhesan Road, Surat - 395 005, Gujarat
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JIHS.JIHS_28_20

Abstract

Background: Knee Osteoarthritis is the most prevalent degenerative joint disease. The treatments of patient with knee osteoarthritis focused on pain reduction, improve joint motion, enhancement of muscle strength and endurance. However, little attention was given to hamstring flexibility training. It is believed that hamstring flexibility plays an important role in functional performance of patient with knee osteoarthritis. Aim: The present study was aimed to find out the correlation between hamstring flexibility and functional performance in patient with knee Osteoarthritis. Materials and Methods: Thirty-five patients with knee osteoarthritis matched with the inclusion criteria were included in the study. Active Knee Extension Test (AKET) was used to evaluate the hamstring tightness. Functional performance of participants was assessed using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire. Pearson's product moment correlation was used to determine the relationship between hamstring flexibility and functional performance of patients with knee osteoarthritis. Results: A statistically significant positive correlation between hamstring flexibility and total WOMAC score (+0.467, p = 0.005). The component of WOMAC was also analysed separately pain (+0.369, p = 0.029), physical function (+0.418, p = 0.012) and (+0.273, p = 0.113). The results of the present study shows that decreased in hamstring flexibility in patient with knee osteoarthritis causes significant reduction in physical functional and pain. Conclusion: The results states that decreased in hamstring flexibility in patient with osteoarthritis causes functional limitation. Therefore, it is essential to suggest flexibility exercises for knee osteoarthritis patients during physical therapy.

Keywords: Functional performance, hamstring flexibility, osteoarthritis

How to cite this article:
Sailor S, Limbani A, Dhola D. Association between Hamstring Flexibility and Functional Performance of Patients with Knee Osteoarthritis. J Integr Health Sci 2020;8:57-60

How to cite this URL:
Sailor S, Limbani A, Dhola D. Association between Hamstring Flexibility and Functional Performance of Patients with Knee Osteoarthritis. J Integr Health Sci [serial online] 2020 [cited 2023 Mar 28];8:57-60. Available from: https://www.jihs.in/text.asp?2020/8/2/57/306719

Introduction

Osteoarthritis (OA) is gradually developing articular diseases that originate in the cartilage and affects the underlying bone, soft tissues as well as synovial fluid. OA usually occurs late in life and mainly it affects the hand and large weight-bearing joints such as the knee and hip.^[1] It is associated with pain, joint stiffness, and progressive loss of function and thereby affects daily activities.^[2] There are many factors that affect the disease progression of OA. Alignment issues resulting from either degenerative changes or movement compensations because of pain can also lead to the progression of disease.^[3] The knee joint is largely affected due to its weight-bearing nature.^[4] In many studies, this functional loss is related to muscular weakness caused by OA in particular the quadriceps and hamstring muscles.^[5],[6]

Flexibility is the ability of a particular single joint or series of joints to move easily and smoothly through an unrestricted pain free range of motion (ROM).^[7] Flexibility is associated with the extensibility of musculotendinous components that cross a joint, based on its ability to relax, deform, and yield to a stretch force.^[8] Zachezeweski has defined muscle flexibility as the ability of a muscle to lengthen, allowing one joint to move through a ROM.^[9] Therefore, muscle flexibility is an essential component of musculoskeletal health. The lack of muscle flexibility is generally increasing the risk of injury.^[10] Muscle weakness and lack of adequate flexibility are two major components of joint pain and dysfunction. In the knee joint, muscular imbalance plays an important role in the appearance and progression of OA.^[11] The flexibility of the quadriceps and hamstring groups of muscles determines the smoothness and precision of ambulatory pattern while inadequate flexibility predisposes individuals to injury and musculoskeletal dysfunctions.^[11] Muscle flexibility decline with age and lack of muscle flexibility can lead to alteration in joint function and may be risk factor for injuries during activities that require a full ROM.^[12]According to Oatis et al., joint stiffness showed a moderate negative correlation with stride length in patients with knee OA.^[13] Thereby performing regular stretching exercises increase muscle flexibility, ROM, and provide functional benefits for patients with knee OA and may delay the need for surgical interventions like total knee replacement. OA usually affects the older population as the cartilage wears occurs naturally with increasing degeneration as aging progresses.^[14] Piva et al. reported less flexibility in the quadriceps, hamstring, gastrocnemius, and soleus in individuals with patellofemoral pain syndrome compared to healthy controls.^[15] According to Joshi et al. along with quadriceps flexibility, the hamstring flexibility also more affected as the hamstring muscle have tendency to shorten and tighten which leads to patellofemoral compression and patellofemoral syndrome associated with knee OA.^[16] Enhancing joint flexibility among OA participants and athletes is a strong factor in attaining smooth gait and good athletic performance.^[17] It was also reported that progressive decline in flexibility with age and changes in elasticity and decrease the level of physical activity in participants with knee OA.^{[18],[19],[20]} Thus, during the evaluation of muscle dysfunction in relation to knee OA, along with strength of muscles, flexibility of hamstring muscle should be considered.[21] Thus, it can be stated that OA patients have reduced hamstrings flexibility along with effect on functional performance. However, no one has studied the correlation between hamstring flexibility and functional performance in patient with knee joint OA. Therefore, the present study was aimed to find out the correlation between hamstring flexibility and functional performance in patient with knee OA.

Methodology

The study was conducted at the SPB Physiotherapy College, Surat. The patients with knee OA were recruited from the institution outpatient department as per the inclusion criteria for the study. We included subjects of both gender with an age between 45 and 65 years having unilateral or bilateral knee OA for the past 3 years.

Participants with a medical history of any back injury, inflammatory conditions, who undergone any surgery in the past 3 months, hamstring strain or injury and other knee injury or deformities, fracture on affected limb in the past 6 months, external implantation in lower limb, neurological condition, peripheral vascular disease, and those who were unwilling to participate in the study were excluded.

A sample of 35 patients was calculated using a simple correlation formula with a zα value of 2.326 and a significance level of 95% for a two-tailed test, and a zβ value of 0.772 with a power of 80% with a minimum expected correlation of 0.5.

All patients who met the criteria signed an informed consent before participation in the study. The patients were assessed for the hamstring flexibility using self-monitored active knee extension test (AKET)^[22] for three times and average of all three values were taken as final value. Other data such as age, sex, unilateral or bilateral OA knee affected, time since diagnosis, dominant leg, and treatment received were recorded using the general questionnaire.

The Gujarati Version of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was used to assess pain, stiffness, and physical function. Reliability and validity of the modified Gujarati version of WOMAC have been established.^[23] Individual score of pain, stiffness, and physical functioning was calculated separately and gross score also calculated according to interpretation guidelines.

Statistical analysis was conducted using the SPSS, Version 20.0 (IBM Corp., Armonk, N.Y., USA). The data were analyzed using the descriptive statistic and parametric inferential statistics. The alpha level of 0.05 with 95% confidence interval was used to denote statistical significance difference. Pearson's correlation coefficient (r) test was used to determine the relationship and thereby to find out the correlation between hamstring muscle flexibility and it effect on functional performance of the patient suffering from OA of the knee joint.

Results

A total 35 participants with knee OA were included in this study. Out of these, 19 were female and 16 were male. The mean age was 58 years. Among 35 participants, 6 (17%) were classified as healthy as per body mass index (BMI) calculation, whereas majority 25 participants (71%) were overweight and 4 (11%) were obese. Mean hamstring flexibility is 158.72 ± 5.10. Twenty-one (60%) participants had bilateral knee affected while 20% had equally right and left knees affected. Mean ± standard deviation for AKET was 153.73 ± 5.10 while for WOMAC score (physical function) was 21.60 ± 4.36, WOMAC score (stiffness) was 4.6 ± 1.05, WOMAC (pain) was 10.63 ± 2.17, and WOMAC total score was 36.89 ± 6.13 [Table 1].

Table 1: Demographic features and self-reported outcomes in participants with knee osteoarthritis

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Correlation between AKET and WOMAC score is summarized in [Table 2] which shows the significant positive correlation between hamstring flexibility and total WOMAC score (+0.467, P = 0.005). We have also analyzed all WOMAC component separately, there was positive significant correlation between AKET score and pain (+0.369, P = 0.029) as well as physical function component (+0.418, P = 0.012). However, stiffness component of WOMAC (+0.273, P = 0.113) shows nonsignificant correlation.

Table 2: WOMAC Correlation with average hamstring flexibility

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Discussion

In knee OA, tightness in quadriceps, hamstrings, and calf muscles affects the physical function of knee joint.^[20] Physical therapy has an important role in the treatment of knee OA, with the main objectives being to reduce pain and inflammation, increase muscle strength, and finally, maintain or improve ROM.^[24],[25] The present study was conducted to evaluate the association between hamstring flexibility and functional performance of knee OA patient. In this study, AKET was used to measure the hamstring flexibility^[26] while WOMAC, a disease specific tool, made for the purpose of measuring the pains, physical function, and stiffness in knee OA.^[27]

The demographic data such as age, BMI, and gender were collected due to its strong association with knee OA as a risk factor.^{[28],[29],[30]} However, in the present study, we does not found any significant correlation (r = −0.195, P = 0.307) of age while BMI show significant negative correlation (r = −0.566, P = 0.001) with hamstring flexibility. Furthermore, the effect of gender on hamstring flexibility was also analyzed using t-test which show nonsignificant (t = 2.03 > 0.05) difference between hamstring flexibility of male and female.

In addition, the results also indicate significant positive correlation between AKET score and WOMAC physical functional score indicates that hamstring flexibility reduces in patient with OA of knee joint which reduced patient's functional performance and quality of life. Previous study also reported that enhancement of ROM, especially knee extension, has been associated with improvement in pain and muscle function.^[31],[32] Individual comparison of WOMAC component also revealed significant positive correlation with hamstring flexibility except the stiffness. It also showed the greater impact of physical function on hamstring flexibility followed by pain and stiffness. The tightness of hamstring muscle if not correlated it is likely to develop flexion contracture of knee in advanced stage of OA. Hence, the physical therapy protocol for patient with knee OA should be designed to take in to account the association between hamstring flexibility and functional performance. However, our study was limited to only 35 samples aged between 45 and 65 years so, we cannot generalize the result in other age groups. We recommend future research with large sample size.

Conclusion

This study concludes that decrease in hamstring flexibility in patient with OA causes functional limitation and pain. This finding suggests that hamstring muscle flexibility is significantly associated with physical performance and pain in the patient with knee OA. Therefore, it is essential to provide greater importance to prescribe hamstring flexibility exercises for patient with knee OA.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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