Unlocking he Sec e s o Knee Join
Unloading: A Sys ema ic Re iew
and Biomechanical S udy o he
In asi e and Non-In asi e Me hods
and Thei In luence on Knee Join
Loading
Nuno A. T. C. Fe nandes, Ana A iei a, Be ina Hinckel, Filipe Samuel Sil a, Ósca Ca alho and
Ana Leal
Re iew
h ps://doi.o g/10.3390/ heuma o5030008
Academic Edi o : B uce M. Ro hschild
Recei ed: 26 Ma ch 2025
Re ised: 2 June 2025
Accep ed: 18 June 2025
Published: 25 June 2025
Ci a ion: Fe nandes, N.A.T.C.;
A iei a, A.; Hinckel, B.; Sil a, F.S.;
Ca alho, Ó.; Leal, A. Unlocking he
Sec e s o Knee Join Unloading: A
Sys ema ic Re iew and Biomechanical
S udy o he In asi e and
Non-In asi e Me hods and Thei
In luence on Knee Join Loading.
Rheuma o 2025,5, 8. h ps://doi.o g/
10.3390/ heuma o5030008
Copy igh : © 2025 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and
condi ions o he C ea i e Commons
A ibu ion (CC BY) license
(h ps://c ea i ecommons.o g/
licenses/by/4.0/).
Re iew
Unlocking he Sec e s o Knee Join Unloading: A Sys ema ic
Re iew and Biomechanical S udy o he In asi e and
Non-In asi e Me hods and Thei In luence on Knee
Join Loading
Nuno A. T. C. Fe nandes 1,*, Ana A iei a 1, Be ina Hinckel 2, Filipe Samuel Sil a 1,Ósca Ca alho 1
and Ana Leal 1
1CMEMS-R&D Cen e o Mic oelec omechanical Sys ems, School o Enginee ing, Uni e si y o Minho,
4710-091 B aga, Po ugal; [email p o ec ed] (A.A.); [email p o ec ed] (F.S.S.);
osca [email p o ec ed] (Ó.C.); [email p o ec ed] (A.L.)
2Depa men o O hopaedic Su ge y, William Beaumon Hospi al, Royal Oak, MI 48067, USA;
[email p o ec ed]
*Co espondence: [email p o ec ed]
Abs ac
Backg ound/Objec i es: This e iew analyzes he e ec s o in asi e and non-in asi e
me hods o knee join unloading on knee loading, employing a biomechanical model o
e alua e hei impac . Me hods: PubMed, Web o Science, Coch ane, and Scopus we e
sea ched up o 15 May 2024 o iden i y eligible clinical s udies e alua ing Join Space
Wid h, Ca ilage Thickness, he Wes e n On a io and McMas e Uni e si ies Os eoa h i is
Index, he Knee Inju y and Os eoa h i is Ou come Sco e sys em, Gai eloci y, Peak
Knee Adduc ion Momen , ime o e u n o spo s and o wo k, g ound eac ion o ce,
and he isual analogue scale pain sco e. A second sea ch was conduc ed o selec a
biomechanical model ha could be pa ame ized, including he modi ica ions ha each
ea men would impose on he knee join and was capable o es ima e join loading o
compa e he e ec i eness o each me hod. Resul s: Analyzing 28 s udies (1652 pa icipan s),
including 16 andomized clinical ials, e ealed signi ican imp o emen s mainly when
pe o ming knee join dis ac ion su ge y, inc easing Join Space Wid h e en a e emo al,
and high ibial os eo omy, which ealigns he knee bu does no educe loading. Implan able
shock abso be s a e also an a ac i e op ion as hey pa ially unload he knee bu equi e
u he in es iga ion. Non-in asi e me hods imp o e biomechanical indica o s o knee
join loading; howe e , hey lack quan i a i e analysis o ca ilage olume o Join Space
Wid h. Conclusions: Cu en e idence indica es a clea ad an age in knee join unloading
me hods, emphasizing he impo ance o adap ed he apy. Howe e , mo e ex ensi e
esea ch, pa icula ly using non-in asi e app oaches, is equi ed o u he unde s and he
unde lying knee join loading mechanisms and ad ance he s a e o he a .
Keywo ds: biomechanics; medical de ices; os eoa h i is; join unloading; o ho ics
1. In oduc ion
The human knee join , a ema kable and in ica e s uc u e essen ial o mobili y and
weigh suppo [
1
], is suscep ible o knee os eoa h i is (OA), a p e alen degene a i e join
disease impac ing knee ca ilage [
2
]. This pa hology a ec s a ound 32.5 million adul s in he
Uni ed S a es [
3
], wi h an es ima ed annual cos o USD 486.4 billion [
4
]. Knee OA, esul ing
Rheuma o 2025,5, 8 h ps://doi.o g/10.3390/ heuma o5030008
Rheuma o 2025,5, 8 2 o 26
om ca ilage wea , causes join pain and se e ely impac s daily ac i i ies, limi ing millions
o indi iduals au onomy wo ldwide [
3
–
7
]. Fac o s like gene ics, obesi y, de o mi ies, and
exe cise con ibu e o i s de elopmen [
5
,
8
]. While he e is no cu e, ea men s aim o
symp oma ic elie and, in se e e cases, o al knee a h oplas y (TKA) is he inal su gical
ecou se [
2
,
5
,
9
]. Al hough TKA is ecognized as an allu ing solu ion, i s u iliza ion in
younge pa ien s (unde 65 yea s) ca ies an ele a ed isk o po en ial u u e e isions due
o he p os heses’ limi ed li espan [10].
Se e al s udies ha e explo ed he impac o a ious ea men s o knee OA, including
sys ema ic e iews on su ge ies and compa isons o o hosis e icacy. Takahashi e al.
e iews he iabili y o Knee Join Dis ac ion (KJD) su ge y as a ea men o knee OA,
compa ing i wi h o he ea men s like high ibial os eo omy and o al knee a h oplas y.
KJD su ge y, which uses an ex e nal ixa o o empo a ily unload he join , has shown
imp o emen s in unc ional ou comes, pain sco es, and Join Space Wid h a 1-yea pos -
ea men . Howe e , a high isk o pin si e in ec ion is no ed. The e iew sugges s ha KJD
could be a po en ial al e na i e o younge pa ien s wi h knee OA, bu emphasizes he
need o u he ials o es ablish i s long- e m e icacy and sa e y compa ed o con empo-
a y ea men s [
11
]. Bin Abd Razak e al. conduc ed a pa allel sys ema ic e iew abou
KJD p ocedu e in younge pa ien s, demons a ing p omising esul s, wi h imp o emen s
in unc ional ou comes and pain sco es. Howe e , once again, i exhibi s a high isk o
pin si e in ec ion. The e iew emphasizes he need o u he esea ch o alida e hese
indings, op imize he p ocedu e, and explo e ways o minimize complica ions. Despi e
he challenges, KJD is seen as a po en ial game-change in managing knee os eoa h i is
in younge pa ien s, aligning hei indings wi h Takahashi e al.’s obse a ions [
12
]. Liu
e al. compa ed High Tibial Os eo omy (HTO) echniques, discussing i s biomechanics,
and implica ions o ea ing medial compa men os eoa h i is wi h a us de o mi y. I
highligh s he impo ance o unde s anding HTO’s biomechanics o imp o e pos ope a i e
sa is ac ion and long- e m su i al. The a icle co e s a ious aspec s, such as alignmen
p inciples, su gical echniques, ixa ion pla es, and he impac o HTO on pos ope a i e
gai and knee join mechanics. I also emphasizes he need o comp ehensi e s udies
combining musculoskele al dynamics modeling and ini e elemen analysis o be e unde -
s and pa ien -speci ic biomechanics a e HTO, concluding by s essing he signi icance o
biomechanical en i onmen in add essing complica ions and enhancing su gical accu acy
in HTO [
13
]. S iebel e al. discuss he challenges o ea ing pos - auma ic knee OA in
young pa ien s. The s udy highligh s he dilemma physicians ace due o he lack o he a-
pies ha a e bo h sa e and e ec i e o long- e m join pain elie and pa ien accep ance.
The documen e iews cu en ea men s, including biologics, disease-modi ying d ugs,
pa ial join esu acings, and minimally in asi e join -unloading implan s, which a e being
explo ed o add ess his gap. I emphasizes he need o mo e esea ch o ind op imal
ea men s o young pa ien s wi h pos - auma ic knee OA conside ing hei longe li e
expec ancy and desi e o main ain an ac i e li es yle. The documen also explo es he pa ho-
physiology o pos - auma ic knee OA, de ailing how auma ic knee inju ies con ibu e
o he de elopmen o OA and he subsequen biomechanical changes ha exace ba e he
condi ion [
14
]. Mis y e al. p o ides a comp ehensi e li e a u e e iew on he e ec i eness
o unloading knee b aces in ea ing unicompa men al knee OA o e he pas decade.
Va ious s udies a e discussed ha suppo he use o knee b aces o educe pain, imp o e
unc ion, and enhance quali y o li e, po en ially delaying he need o su ge y. I also no es
mino complica ions like so issue i i a ion due o poo i ing, which can be managed
wi h egula ollow-ups. The au ho s conclude ha unloade b aces a e a cos -e ec i e
and bene icial ea men o unicompa men al knee os eoa h i is, ad oca ing o a mul-
idisciplina y app oach and conse a i e managemen be o e conside ing su ge y [
15
].
Rheuma o 2025,5, 8 3 o 26
Ne e heless, he e is a gap in explana ions o mechanical changes in he knee join , as well
as de ailed s udies compa ing a ious su gical and non-in asi e he apies. While hese
disco e ies p ima ily conce n he medical domain, i is c i ical o a biomedical enginee
o unde s and he easoning and mechanics unde lying he a o emen ioned app oach. As
a esul , he e is a need o conduc biomechanical s udies o cu en solu ions, including
bo h in asi e and non-in asi e p ocedu es, and connec hem o he insigh s o e ed in
he li e a u e.
This sys ema ic e iew aims o p o ide a ho ough examina ion o he in asi e and
non-in asi e me hods employed o join dis ac ion, and how hey change he biome-
chanics o he knee. Ca ilage lacks a ascula supply, causing i o hinde he deli e y
o essen ial nu ien s and oxygen o i s epai , limi ing he human body’s esponse [
5
].
Thus, he ac o mechanically unloading he knee join is an app oach ha seeks o mi iga e
he degene a i e e ec s o knee condi ions by empo a ily al e ing he mechanical o ces
expe ienced by he join by exe ing o ces o sepa a e he bones o he knee, opposing
knee loading and a emp ing o c ea e space. This p ocess e ec i ely edis ibu es loading
pa e ns wi hin he knee, po en ially p omo ing ca ilage p ese a ion and egene a ion. By
sys ema ically e iewing he la es esea ch indings, clinical ou comes, and echnological
ad ancemen s, his e iew aims o o e a comp ehensi e unde s anding o he cu en
s a e o he a o knee join unloading me hods, hei e ec i eness, and hei implica ions
and unde s anding o knee join loading. Ul ima ely, by gaining a deepe insigh in o
hese me hods and hei impac on knee join loading, we aspi e o pa e he way o mo e
a ge ed and e icacious in e en ions, o e ing enewed hope o indi iduals seeking elie
om he bu dens o knee join degene a ion.
2. Ma e ials and Me hods
2.1. Resea ch S a egy
This e iew adhe ed o he guidelines ou lined in he P e e ed Repo ing I ems o
Sys ema ic Re iews and Me a-Analyses (PRISMA) [16] when applicable.
2.1.1. Sea ch S a egy
This e iew u ilized ou da abases, PubMed, Coch ane, Web o Science, and Scopus,
wi h documen e ie al conduc ed on 15 May 2024. The sea ch s a egy in ol ed he
e ms (“knee” o “lowe limb” o “gona h osis” o “ ibio emo al” o “pa ello emo al”)
and (“dis ac ion” o “unloading” o “ elie ” o “o loading”). Ini ially, e ms ela ed o
“ca ilage” and “ egene a ion” we e included bu yielded limi ed and i ele an in o ma-
ion, making i challenging o align wi h p ede e mined sea ch s a egies like PICO [
17
].
Consequen ly, a mo e comp ehensi e sea ch was conduc ed wi h ewe e ms o ensu e
a icles wi h pe inen in o ma ion we e cap u ed. The sea ch encompassed i les, abs ac s,
and keywo ds in each da abase, and whe e applicable, he a icles we e limi ed o ials o
clinical ials.
2.1.2. S udy Selec ion
E e y a icle e ie ed om he ini ial sea ch was analyzed o see how ele an i
was o his e iew. This p ocess was pe o med wi h he aid o Zo e o so wa e e sion
7.0.15. Duplica e a icles we e emo ed using he “ ind duplica es” op ion. The emaining
iles we e also manually e i ied o elimina e any duplica e ha could no be ound by he
algo i hm. A icles we e excluded i hey me he ollowing c i e ia: (1) e iews, le e s
o he edi o , con e ence pape s and abs ac s, mee ings, p oceedings, and commen a ies;
(2) he a icle was no w i en in English; (3) measu ed uni s we e no ansla able o he
Rheuma o 2025,5, 8 4 o 26
in e na ional sys em o uni s; (4) none o he chosen pa ame e s we e e alua ed. The
a icles we e hen sc eened based on hei abs ac , and a e i , acco ding o hei ull ex .
2.1.3. P ocedu e Classi ica ion
This a icle explo es a o al o six p ocedu es. Th ee in asi e in e en ions we e
analyzed: KJD, HTO, and he Implan able Shock Abso be (ISA). No ably, TKA is excluded
om conside a ion as i in ol es knee join eplacemen a he han he dis ac ion mecha-
nism examined in his s udy. The selec ed non-in asi e in e en ions comp ised o ho ic
de ices, namely Knee Unloading B aces (KUBs), u ilizing a h ee-poin p essu e sys em,
Knee Dis ac ion B aces (KDBs), employing a mechanism o coun e ac knee loading, and
Physical The apy (PT) designed o p o ide knee dis ac ion. The selec ion o hese p oce-
du es allows o a comp ehensi e analysis o a ious app oaches o add ess knee- ela ed
issues, each o e ing dis inc cha ac e is ics and applica ions.
2.1.4. Da a Collec ion and Ex ac ion
The p ima y ou comes selec ed o analysis included Radiog aphic Join Space Wid h
in mm (JSW), Ca ilage Thickness in mm (CT), bo h o al and pa ial Wes e n On a io and
McMas e Uni e si ies Os eoa h i is Index (WOMAC) [
18
,
19
], pa ial and o al Knee inju y
and Os eoa h i is Ou come Sco e sys em (KOOS) [
20
], Gai eloci y in m/s (GV), Peak
Knee Adduc ion Momen KNm/Kg (PKAM), ime o e u n o spo s (RTS), ime o e u n
o wo k (RTW), g ound eac ion o ce in N (GRF) and isual analogue scale in mm (VAS)
pain sco e, all o which we e examined. A icles ha did no con o m o he co ec scale
o had uni s incompa ible wi h con e sion o he SI sys em we e excluded, e en i hey
sa is ied o he speci ied c i e ia.
2.1.5. Risk o Bias Assessmen
The e alua ion o bias isk in he inco po a ed s udies u ilized he Re ised Coch ane
isk-o -bias ool o andomized ials (ROB 2) [
21
] o Randomized Clinical T ials and
ROBINS-I [
22
] o non-Randomized Clinical T ials. The c i e ia o each domain we e
ailo ed o he con ex o ou sys ema ic e iew, allowing o a speci ic analysis o bias isk
associa ed wi h each conside ed p ocedu e.
2.2. Biomechanical Model
In he selec ion o an app op ia e model, i was conside ed essen ial ha he model
could assess he knee join ’s condi ion in he co onal plane and ha i s pa ame e s could
be eadily ob ained and adjus ed o his s udy. Va ious elec onic da abases, including
OpenSim, PubMed, Embase, and Web o Science, we e sys ema ically sea ched o iden i y
a sui able model o his e iew ha aligns wi h he speci ied condi ions.
Models such as he one de eloped by E demi use he ini e elemen analysis (FEA)
me hod o desc ibe he geome y and ma e ials o he knee join [
23
]. His model was u he
de eloped by Chokhand e e al. wi h he goal o p o iding ee access o h ee-dimensional
ini e elemen ep esen a ions o he knee join [
24
]. Howe e , he u iliza ion o an FEA
model, wi h i s mul i ace ed complexi ies, su passes he in ended scope o his e iew,
which aims o o e a concise examina ion o knee join dis ac ion me hodologies wi hou
del ing in o he in ica e in icacies o FEA model implemen a ion.
Se e al models u ilize musculoskele al sys ems wi h pa ame e s aiming o comp e-
hend muscle con ibu ions and dynamic in e ac ions. Fo ins ance, Ma ieswa an e al. [
25
]
ex ended Xu e al.’s o iginal model, ini ially designed o gai analysis wi h knee join s and
ligamen s o assess he s ains in connec i e issues [
26
]. Simila ly, A nold e al. de eloped
a musculoskele al model capable o calcula ing muscle– endon leng hs and momen a ms
ac oss a ious body posi ions, acili a ing de ailed examina ions o o ce and momen
Rheuma o 2025,5, 8 5 o 26
gene a ion capaci ies a ound he ankle, knee, and hip. Despi e hei impo ance, hese
models, alling unde musculoskele al models, ace limi a ions when muscle condi ions
canno be pa ame ized, as obse ed in his case [27].
Fo example, in a ecen s udy, a compu a ional mul ibody knee models o assess
he impac o an e io c ucia e ligamen (ACL) inju y on medial meniscus o ces. The
models p edic inc eased o ces, especially in he pos e io ho n, highligh ing ulne abili y
o inju y, pa icula ly wi h ACL loss. The s udy also illus a es he ole o he deep medial
colla e al ligamen in cons aining pos e io medial meniscus mo ion. Mul ibody models
a e aluable o analyzing dynamic o ces and mo ion in in e connec ed s uc u es, o e ing
insigh s in o complex sys ems [
28
,
29
]. Howe e , his s udy does no ocus on s udying
dynamic knee mo emen , making mul ibody models less ideal o his speci ic applica ion.
Minns’ de eloped model demons a es a high deg ee o accu acy and e ec i eness in
p edic ing knee loading [
30
]. Howe e , i s p ac ical implemen a ion encoun e ed challenges
s emming om he una ailabili y o ull-leg adiog aphs and baseline pa ame e alues.
This implies ha 16 necessa y pa ame e s o he model a e una ailable. The absence o
comp ehensi e adiog aphic da a o he selec ed me hods, combined wi h he complexi y
o nume ous pa ame e s, signi ican ly hinde ed he ansla ion o hese me hods in o he
model and hinde ed compa a i e analyses.
Ke elkamp’s model was ini ially designed o assess o ce dis ibu ion on he ibial
pla eau, p ima ily in he con ex o p oximal ibial os eo omy [
31
]. Impo an ly, Ke elkamp
emphasized ha i s u ili y ex ended beyond his speci ic applica ion. This model is based
on a wo-leg s ance simula ion u ilizing AP long-leg adiog aphs, yielding ou pu s o
bo h medial and la e al knee join o ces and hei o ien a ions. Howe e , due o he
una ailabili y o long leg adiog aphs, we we e unable o desc ibe six pa ame e s and hus
did no implemen his model in ou s udy.
The model de eloped by Maque e al. was selec ed o i s obus accu acy, well-
de ined baseline pa ame e s, and i s adap abili y o he chosen knee join dis ac ion
me hods [
32
]. While his model also elies on long-leg adiog aphs, he au ho ’s de ini ion
o alida ion pa ame e s acili a ed i s implemen a ion in ou s udy. A ecen s udy imple-
men ed hese h ee models o assess wo-dimensional biomechanical models o p edic ing
knee join o ces in o al knee a h oplas y p eope a i e planning. While he models show
po en ial, hei accu acy needs imp o emen , equi ing u he op imiza ion. In i , he
au ho s e i ied ha Ke elkamp’s model ends o unde es ima e knee join o ces (
−
17%
o +128% Body Weigh ), while Minns’ and Maque ’s models align closely wi h e e ence
o ces (
−
55% o 80% body weigh and 80 o +50% body weigh , espec i ely). Thus, Minns’
and Maque ’s models a e conside ed a o able choices [33].
This model is cen e ed on he ibio emo al join , p edic ing he esul an knee join
o ce, i s o ien a ion, and a la e al muscle o ce. Wi hin his join , he ibia expe iences he
in luence o h ee dis inc o ces: he pa ial weigh o ce (P), he muscula o ce (L), and
he esul an o ce I, as ep esen ed in Figu e 1.
The muscula o ce L unc ions as a ension band ha exe s i s e ec on he ibia,
wi h i s line o ac ion c ossing pa hs wi h ha o he pa ial weigh o ce a poin C. I is
impo an o no e ha he esul an o ce R also needs o pass h ough his designa ed poin ,
C. This alignmen o o ces is u he ein o ced by he ac ha , in a no mally unc ioning
knee, R mus inhe en ly a e se h ough he geome ic cen e o he ibio emo al con ac
a ea, deno ed as poin G. Consequen ly, his a angemen yields a s a ically de e minable
p oblem, as depic ed in he iangle o o ces illus a ed in Figu e 2A.
Rheuma o 2025,5, 8 6 o 26
Figu e 1. This knee join illus a ion depic s P as he o ce eccen ically applied o he loaded knee,
ep esen ing he pa ial mass o he body (body weigh minus he suppo ing leg and oo weigh ).
L signi ies he muscula s ay coun e balancing P, while R is he esul an o ce o bo h P and L.
Addi ionally, a ep esen s he le e a m o o ce P, b deno es he le e a m o o ce L, and
σD
signi ies
comp essi e s esses wi hin he join exe ed by con ac .
Figu e 2. Illus a ions depic ing he Maque ’s biomechanical model o he knee join : (A) The
illus a ion on he le depic s bone alignmen , ea u ing a line h ough he geome ic cen e o he
ibio emo al con ac a ea coinciding wi h he di ec ion o esul ing o ce R.
β
signi ies he angle
be ween his line and o ce L, while sigma deno es he angle be ween he di ec ions o o ces L and R.
The igh side o he illus a ion illus a es he igonome ic ela ionships among hese o ces and
angles coun e balancing P, while R is he esul an o ce o bo h P and L. Poin C is he in e sec ion o
he o ce ec o L and P, and is ypically on he oo . (B) The impac o genu a um on knee alignmen
is e iden . On he igh , he change in angle al e s he geome ic cen e (G’), causing i o de ia e
om he ypical ibio emo al con ac a ea cen e (G). This in oduces a new angle (ε) be ween Fo ce
P and he adjus ed geome ic cen e . The esul ing o ce R is now calcula ed using hese modi ied
ela ions, as depic ed in he iangle on he igh . x ep esen s he new angle ha has been o med by
he genu a um condi ion.
Rheuma o 2025,5, 8 7 o 26
As such he esul ing Fo ce R, can be exp essed h ough Equa ion (1).
R=Psin ψ
sin β(1)
In o de o apply his model o a pa ien , i needs a one-leg s ance an e opos e io
long-leg adiog aph, including he pel is, as inpu . Du ing ou in es iga ion, we adhe ed
o he pa ame e s s ipula ed by Maque e al.’s model, whe e he pa ella o ce (P) was
deemed o ep esen 93% o he body weigh . Fu he mo e, he angles, deno ed as
ψ
and
β
, we e de e mined o be 10.78
◦
and 4.62
◦
, espec i ely, in acco dance wi h his
es ablished model [
32
]. I is wo h no ing ha due o he una ailabili y o ex ensi e long
leg adiog aphs o knee modeling, we we e cons ained om making al e a ions o hese
angles, and hence, we e ained he o iginal alues. All he compu a ional models we e
implemen ed using he Py hon 3.10.0 p og amming language, ensu ing he p ecision and
consis ency o ou analyses.
In ligh o hese pa ame e s, he esul an o ce calcula ed amoun ed o 215.95% o
an indi idual’s body weigh , signi ying he subs an ial biomechanical implica ions o he
imposed condi ions.
This model is adap able o examine algus and a us knee alignmen s. Maque e al.
modi ied he model ela ions, as illus a ed in Figu e 2B, o accommoda e hese a ia ions.
Thus, Equa ion (1) unde goes modi ica ion o become Equa ion (2). I is no ewo hy
ha when x = 0, bo h equa ions con e ge in o he same equa ion.
R=qP2+L2+2PLcos(β±x)(2)
To assess s ess le els wi hin he knee join ac oss he ange o mo ion, we employed
he con en ional s ess o mula as p esen ed in Equa ion (3), whe e R ep esen s he
calcula ed esul ing o ce and S is he a ea o he con ac su ace.
σ=R
S(3)
No signi ican da a was ound ha quan i ied how much his con ac a ea changed
wi h genu a us o algum. I is widely acknowledged ha inc easing misalignmen
gene ally leads o a dec ease in he ibio emo al con ac a ea, whe e he la e al con ac a ea
dec eases wi h genu a um, and he medial con ac a ea dec eases wi h genu algum.
In ou s udy, we ep esen ed S as a unc ion o he knee de o ma ion angle x h ough
a quad a ic ela ionship, as shown in Equa ion (4).
S=Smedial +Sla e al,i x =0
S=Smedial +Sla e al −
x
30◦2
×0.75Smedial,i x <0
S=Smedial +Sla e al −
x
30◦2
×0.75Sla e al,i x >0
(4)
Th oughou he cou se o his e iew, he me hodologies employed will sys ema ically
adjus he pa ame e s wi hin he model, culmina ing in a se o ou comes ha will se e as
he ounda ion o a biomechanical analysis o knee mo emen .
In his s udy, we assumed
x∈[−30, 30]◦
, whe e nega i e alues deno e genu algum
misalignmen and posi i e alues indica e genu a um misalignmen . These alues we e
de i ed om hose employed by Maque e al. [
32
]. The model was implemen ed in Py hon,
and he angle s ep was i e a i ely adjus ed un il con e gence was achie ed.
Schmid e al. epo ed a mean ibio emo al con ac a ea o 452 mm
2
o he medial
compa men and 314 mm
2
o he la e al compa men , o aling 766 mm
2
. I was assumed
Rheuma o 2025,5, 8 8 o 26
ha a an ex eme angle (30
◦
), only 25% o he co esponding knee compa men would be
engaged [34].
3. Resul s
3.1. Sea ch Resul s
Iden i ied om he ini ial 655 eco ds, 29 s udies ha me he eligibili y c i e ia we e
subsequen ly included in his sys ema ic e iew. The PRISMA lowcha , illus a ing he
sea ch p ocess, is depic ed in Figu e A1 and was buil using a ool made o his end [
35
].
The ex ac ed da a om he a icles is p esen in Table 1.
Table 1. Expe imen al da a ga he ed om he a icles e ie ed om he sys ema ic sea ch.
Re .
Expe imen al
Compa a o Popula ion
Pa ien s
Ou come Follow-Up Resul
[36]
KJD HTO Mild and Se e e Knee OA
Pa ien s
18 JSW
2 yea s
0.22
KJD TKA 18 JSW 0.15
HTO KJD 33 JSW −0.47
[37]ISA HTO Mild Symp oma ic Knee OA 73 WOMAC (To al) 2 yea s 46.2
HTO ISA 65 WOMAC (To al) 33
[38]KUB Regula Ca e Mild Symp oma ic Knee OA 30 VAS (Pain) 1 yea −0.1
HTO (Open
Wedge)
HTO (Closed
Wedge) 83 0
[39]
KJD TKA
Mild and Se e e Knee OA
Pa ien s
20
WOMAC (To al)
2 yea s
38.9
KOOS 28.7
JSW 0.99
VAS (Pain) −3.19
KJD HTO 23
WOMAC (To al) 26.8
KOOS 21.6
JSW 0.83
VAS (Pain) −2.14
HTO KJD 46
WOMAC (To al) 34.4
KOOS 30
JSW 0.88
VAS (Pain) −3.85
[40]
KJD HTO
Mild and Se e e Knee OA
Pa ien s
23
JSW
1 yea
0.5
WOMAC (To al) 18
KOOS (To al) 17
HTO KJD 46
JSW 0.2
WOMAC (To al) 29
KOOS (To al) 19
[41]KJD TKA Se e e Knee OA Pa ien s 20
JSW
1 yea
1.9
WOMAC (To al) 30
KOOS (To al) 27
VAS (Pain) -3.6
[42]KJD KJD Mild and Se e e Knee OA
Pa ien s
84 WOMAC (To al) 6 Weeks 22.2
KJD KJD 62 WOMAC (To al) 28.3
[43]
KJD HTO Knee OA Pa ien s ha
Unde wen KJD o HTO
16 RTS
1 yea
0.79
RTW 0.94
HTO HTO 35 RTS 0.8
RTW 0.97
[44]ISA -Pa ien s wi h Knee OA ha
Unde wen ISA Su ge y
26 WOMAC (Pain) 2 yea s 38.5
26 WOMAC
(Func ion) 29.5
[45]KUB PKUB Knee OA Pa ien s 14 PKAM No
Follow-up
−0.82
PKUB KUB 14 PKAM −0.75
[46] KUB Regula Ca e Medial Knee OA Pa ien s 52 PKAM No
Follow-up −0.02
[47] PT Regula Ca e Heal hy Pa ien s 10 GV No
Follow-up 0.03
[48]DRKB Regula Ca e Symp oma ic Medial Knee OA 20
VAS (Pain)
5 weeks
−3.3
WOMAC (To al) 20.66666667
GV 0.1
PKAM 0.018
[49]DRKB -Medial Knee OA Pa ien s 20
KOOS
52 weeks
13.62
VAS (Pain) −25
GV 0.1
[50]KUB PT Se e e knee OA Pa ien s 20 Pain (VAS) 1 yea −2.3
PT KUB 21 Pain (VAS) −2.3
Rheuma o 2025,5, 8 15 o 26
Implemen ing his modi ica ion allows us o obse e, in Figu e 4e, how i can in luence
he knee loading condi ion. As he alue o alpha is adjus able, he e is a po en ial o
signi ican ly alle ia e he knee join loading on a empo a y basis, al hough his is only
achie able du ing he he apy session.
The immedia e educ ion in load esul ed in a no able inc ease in GV o 0.03 m/s
among heal hy pa ien s [
47
]. Following ou weeks o consis en PT, he pa ien s epo ed a
ise o 6.17 in he o al WOMAC sco e [
60
]. The pa ien s unde going ecu en PT exhibi ed
a educ ion in epo ed VAS pain, expe iencing a dec ease o 2.3 mm a e ou weeks,
which pe sis ed o up o a yea [
50
,
60
]. Following consis en PT, he pa ien s wi nessed
a subs an ial imp o emen in he o al KOOS sco e, wi h an inc ease o 19.92 a e one
mon h [55].
No signi ican ad e se e en s we e documen ed du ing he pa ien s’ pa icipa ion
in PT.
4. Discussion
4.1. E iciency o In asi e Me hods
Ou s udy emphasizes ha in asi e me hods, no ably KJD and HTO, we e iden i-
ied as highly e ec i e in dis ac ing he knee join , despi e hei highe associa ed isks,
ollowed by ISA. Non-in asi e app oaches ha e shown p omising esul s; howe e , hey
lack quan i a i e pa ame e s ela ed o ca ilage o join dis ac ion, hinde ing he abil-
i y o measu e hei absolu e e ec i eness and make a comp ehensi e compa ison wi h
in asi e me hods.
KJD and he ISA cu en ly s and as he exclusi e in asi e me hods speci ically de-
signed o he di ec applica ion o join dis ac ion. No ably, KJD exhibi s he abili y o
inc ease JSW e en a e he emo al o he de ice, e ec i ely unloading he knee du ing i s
applica ion. This obse a ion inds co obo a ion in o he e iews exclusi ely add essing
he ole o KJD, highligh ing i s e icacy, pa icula ly when applied o younge pa ien s,
posi ioning i as a p omising al e na i e o TKA. Howe e , he necessi y o ex ensi e and
p olonged RCTs emains c ucial o comp ehensi e alida ion [
77
,
78
]. HTO eme ges as a
iable app oach, bu ou indings indica e ha i does no signi ican ly al e he magni ude
o o ce exe ed on he knee. Ins ead, i induces a shi in knee posi ion, he eby inc easing
he con ac a ea and indi ec ly mi iga ing knee loading condi ions. Howe e , he bene i s
o HTO a e limi ed o pa ien s wi h misaligned knees, as hose wi h os eoa h i is may no
expe ience subs an ial ad an ages om his su gical in e en ion. While i is acknowledged
ha knee misalignmen poses a isk ac o ha may e en ually lead o os eoa h i is [
79
],
no all end-s age pa ien s de elop i [
80
], making HTO a less uni e sal solu ion. This
pe spec i e aligns wi h o he e iews sugges ing ha HTO could be a iable ea men
op ion o algus knee de o mi ies [
81
,
82
]. Spo and wo k pa icipa ion ou comes we e
compa able be ween KJD and HTO, indica ing ha bo h in e en ions a e iable choices
wi h simila e ec i eness. The ISA p esen s an in iguing solu ion by di ec ly applying
a load o coun e ac weigh . Howe e , i s e icacy is impeded by he pa ien ’s weigh ,
diminishing i s e ec i eness as weigh inc eases, as demons a ed by ou esul s. No ably,
he se e i y o in ec ions appea s o be signi ican ly lowe when compa ed o HTO and KJD,
making ISA a mo e a ac i e op ion om he pa ien ’s s andpoin . None heless, u he
ials and implemen a ion a e impe a i e o asce ain i s iabili y gi en i s ela i ely limi ed
cu en use [
70
,
83
,
84
]. Ano he sys ema ic e iew also unde sco es he high p omise o his
me hod, posi ioning i as compa able o bo h in asi e and non-in asi e al e na i es [85].
In add essing he clinical impac o hese ea men s, speci ically pa ien -cen e ed
ou comes, ehabili a ion in eg a ion, and ea men pe sonaliza ion, while mos s udies
consis en ly epo imp o emen s in JSW, WOMAC, and KOOS sco es, he e emains a
Rheuma o 2025,5, 8 16 o 26
gap in sys ema ically e alua ing how hese enhancemen s ansla e in o daily unc ional
gains and indi idualized eco e y pa hways. Fo ins ance, he epo ed a es o e u n o
wo k and spo a e knee join dis ac ion and high ibial os eo omy sugges p omising
unc ional eco e y, bu hese me ics alone do no ully cap u e he nuanced expe iences o
pa ien s na iga ing ehabili a ion o adap ing o pe sonalized egimens. Simila ly, while he
implan able shock abso be ials epo signi ican imp o emen s in WOMAC sco es, he
absence o quan i a i e gai o ac i i y da a limi s ou unde s anding o long- e m pa ien -
speci ic bene i s. Fu u e esea ch should ocus on in eg a ing s uc u ed ehabili a ion
p o ocols, pa ien - epo ed sa is ac ion, and unc ional mobili y assessmen s o en ich
he clinical ele ance o hese in e en ions. Such a comp ehensi e app oach would no
only alida e he obse ed clinical bene i s bu also in o m mo e p ecise, pa ien - ailo ed
ea men plans, ul ima ely enhancing ou comes in knee join unloading he apies.
Gi en hese insigh s, i appea s ha KJD is a pa icula ly p omising op ion o younge
pa ien s who may be e ole a e i s in ec ion isks and po en ial o ca ilage egene a-
ion, while HTO is mos sui able o pa ien s wi h signi ican knee malalignmen a he
han ad anced os eoa h i is since ealignmen does no di ec ly add ess join unload-
ing. Such subg oup-speci ic conside a ions should be u he explo ed o guide clinical
decision-making.
4.2. E iciency o Non-In asi e Me hods
Conce ning non-in asi e me hods, none di ec ly measu e ou comes ela ed o dis ac-
ion me hods o Join Space Wid h. KUBs eme ge as an in iguing app oach, esembling
HTO wi h sho - e m esul s on pa in asi e p ocedu es [
50
]. While a KUB ealigns he
knee join , i lacks he abili y o co ec knee bone de o mi ies, a capabili y inhe en in
HTO. Va ious de ice a ia ions, u ilizing pneuma ic sys ems o shape adjus men and
i ing [
45
,
58
,
86
], o ib a ional sys ems o s imula e ca ilage [
87
], show p omise. S udies
sugges ha ul asound applica ions induce he apeu ic e ec s on chond ocy es, making
hese inno a ions applicable o hese de ices [
88
]. Addi ionally, ligh he apy is consid-
e ed o ca ilage egene a ion in knee os eoa h i is (OA), adding u he in e es o hese
non-in asi e echniques [
89
]. Pa ien s seem o ha e a be e eac ion o hem, acco ding o
hei epo ed ou comes. Ou esul s e eal ha knee unloading b aces p omp ly educe
he adduc ion momen o he knee and inc ease Gai eloci y, aligning wi h he exis ing
li e a u e [
90
]. Conside ing he ad an ages i o e s, a DRKB eme ges as an in iguing
op ion, hough e alua ing hei e ec i eness is challenging due o a lack o e idence e-
ga ding bone loading h ough skin displacemen . Pa ien - epo ed ou comes indica e an
imp o emen in quali y o li e a e using a DRKB, despi e limi ed esea ch on his ela i ely
new o ho ic de ice. Unlike KUBs, a DRKB demands igidi y and may be less com o -
able in compa ison. Rega ding Physical The apy (PT), i is a p ominen non-in asi e
app oach, di ec ly in ol ing knee join dis ac ion. Al hough no con inuously applicable
du ing daily ou ines, pa ien s unde going mul iple he apy sessions epo mo e com-
o able and endu ing esul s [
91
–
93
]. While PKAM se es as an indica o o knee join
loading [
94
,
95
], a ce ain le el o alida ion o knee join loading and ca ilage s a us is
necessa y. Biomechanical analyses alone do no in e his le el o e idence [
96
]. Despi e
epo ed imp o emen s in indi ec biomechanical pa ame e s and pa ien ou comes, he
impac on ca ilage emains unclea , necessi a ing u he s udies, as highligh ed in he
li e a u e [97].
When conside ing he clinical impac o non-in asi e in e en ions o knee join
unloading, he epo ed da a emphasizes p omising imp o emen s in key pa ien -cen e ed
ou comes. No ably, hese me hods consis en ly yielded measu able enhancemen s in
GV and load educ ion (PKAM and GRF), which a e c i ical biomechanical ma ke s o
Rheuma o 2025,5, 8 17 o 26
imp o ed join unc ion. Fu he mo e, signi ican gains in WOMAC and KOOS sco es
ac oss hese app oaches highligh hei po en ial o enhance o e all pa ien well-being,
pain elie , and unc ional capaci y, ex ending up o wo yea s pos -in e en ion. De-
spi e hese encou aging indings, he in eg a ion o s uc u ed ehabili a ion p og ams
and pe sonalized ea men plans emains unde explo ed in cu en s udies. Speci ically,
while hese in e en ions demons a e bene icial ends in objec i e gai pa ame e s and
subjec i e pain/ unc ion assessmen s, he e is limi ed e idence linking hese imp o e-
men s o indi idualized pa ien goals, ac i i y-speci ic demands, o long- e m li es yle
modi ica ions. Addi ionally, hough ad e se e en s such as skin i i a ion we e minimal,
unde s anding hei po en ial impac on pa ien adhe ence and quali y o li e is essen ial
o op imizing ea men pe sonaliza ion. Fu u e esea ch should ocus on connec ing hese
quan i a i e measu es o eal-wo ld unc ional miles ones and in eg a ing pa ien eedback
o ensu e ha non-in asi e unloading s a egies a e holis ically ailo ed o each pa ien ’s
ehabili a ion jou ney.
To compa e in asi e and non-in asi e me hods, eliance on pa ien - epo ed ou comes
is essen ial gi en he dis inc quan i a i e measu emen s employed by hese app oaches.
While bo h ca ego ies gene ally enhance he pa ien ’s quali y o li e and alle ia e pain,
indi iduals o en epo mo e signi ican imp o emen s wi h in asi e me hods. This
di e ence may be a ibu ed o he ac ha many epo ed in asi e me hods unde go
ex ensi e long- e m ollow-ups in e alua ed s udies, impa ing a mo e las ing impac
by conside ing long- e m e ec s om he ou se . The pa ien sample size is no ably
smalle in non-in asi e s udies compa ed o in asi e ones. Howe e , a no able ad an age
o non-in asi e me hods lies in hei non-in usi e na u e, ensu ing minimal ha m o
he pa ien . Mo eo e , hese non-in asi e app oaches can seamlessly in eg a e in o he
ehabili a ion phase ollowing su ge y, sugges ing ha a combined in e en ion may be
an ideal app oach. Ne e heless, pa ien compliance is a c ucial ac o o conside . In he
case o implan ed de ices, pa ien s a e mo e likely o consis en ly use hem, whe eas wi h
emo able knee b aces o ea men plans, pa ien s may o ge o use hem o miss he apy
sessions [86,93,98–100].
Addi ionally, non-in asi e me hods can se e as b idging he apies, o e ing symp om
elie and unc ional suppo o pa ien s who ei he a e no ye candida es o in asi e
p ocedu es o a e awai ing de ini i e su gical ea men s.
5. Limi a ions
Despi e i s comp ehensi e app oach, his e iew is subjec o se e al limi a ions
ha wa an ca e ul conside a ion. These limi a ions, spanning model adap a ions, da a
a ailabili y, s udy selec ion, and me hodological a iabili y, unde sco e he complexi y
o accu a ely cap u ing he biomechanical and clinical eali ies o knee join unloading
s a egies. Fu he mo e, some inhe en cons ain s o he chosen models and his e iew’s
eliance on he exis ing li e a u e highligh he challenges in ex apola ing indings o
eal-wo ld applica ions.
Maque e al.’s model [
32
] was adap ed o mos o he chosen me hods, al hough
alida ion was no pe o med o said modi ica ions. While he p esen ed esul s o e a
concep ual unde s anding, i is impo an o no e ha hey may no accu a ely e lec eal-
wo ld scena ios. This s udy was cons ained by he una ailabili y o ull-leg adiog aphs,
limi ing he implemen a ion o models wi h mo e complex pa ame e s. This wo k’s scope
was ocused on compa ing he exis ing li e a u e ega ding di e en me hods, and inco po-
a ing mo e complex da a was deemed imp ac ical ela i e o his s udy’s objec i es. The
selec ed model assumes s a ic condi ions o a one-leg s ance, o e looking dynamic loads
in daily ac i i ies. In es iga ing he impac o hese ac o s on indings and ex ending he
Rheuma o 2025,5, 8 18 o 26
esea ch o inco po a e dynamic aspec s would be an in e es ing and aluable con inua ion
o his s udy. To emula e a eal-wo ld scena io mo e accu a ely, a complex model such as a
Fini e Elemen Analysis (FEA) model wi h a well-de ined geome y could be employed.
Due o he lack o pa ien -speci ic adiog aphs, he model’s eliance on ixed pa ame e s
(such as angles
ψ
/
β
and con ac a ea assump ions) may limi i s gene alizabili y, unde -
sco ing he need o u u e s udies o inco po a e pa ien -speci ic imaging, like MRI-based
modeling, o enhance accu acy and clinical ele ance. Howe e , ex ensi e alida ion ac oss
he s udied s a egies, o en una ailable, would be necessa y. While in iguing, his alls a
beyond he scope o his a icle.
This wo k aced cons ain s s emming om he absence o pa ame e s explici ly o-
cused on knee join loading o dis ac ion indica o s. Limi ed quan i a i e da a on ca ilage
olume and Join Space Wid h changes o non-in asi e me hods such as b aces and
physical he apy, especially when compa ed o he mo e obus da ase s a ailable o in-
asi e echniques, highligh s a c i ical knowledge gap. This dispa i y may be a ibu ed
o ac o s like he ela i e sca ci y o andomized con olled ials (RCTs) in es iga ing
hese non-in asi e in e en ions and he high cos s and logis ical challenges associa ed
wi h ad anced imaging (e.g., MRI). Consequen ly, u u e high-quali y, pa ien -cen e ed
s udies a e essen ial o quan i y hese s uc u al changes and suppo e idence-based
ecommenda ions o non-in asi e knee OA ea men s. While some kinema ic pa am-
e e s like PKAM and GV we e aken in o accoun , hey did no di ec ly align wi h knee
join loading. Pa ien - epo ed ou comes we e he mos equen ly chosen pa ame e s,
unde sco ing he signi icance o add essing pain in knee os eoa h i is. None heless, i is
essen ial o ecognize ha pain alle ia ion does no inhe en ly signi y a comp ehensi e
enhancemen in he condi ion. This is because pain is a dis inc i e, p o oundly pe sonal,
and subjec i e expe ience, ende ing i challenging o gauge he se e i y and in ensi y o
an indi idual’s pain [
101
]. Addi ionally, his e iew aced cons ain s in acqui ing ele an
in o ma ion abou he ans e o load om knee skin o he knee join , unde sco ing he
need o addi ional da a o in o m he de elopmen o non-in asi e o ho ic de ices.
This e iew encoun e ed challenges due o he limi ed a ailabili y o high-quali y
s udies in he ield, po en ially a ec ing he dep h and obus ness o he e idence base.
Addi ionally, he inclusion o s udies wi h di e se designs and me hodologies may in o-
duce he e ogenei y, posing di icul ies in syn hesizing indings and d awing consis en
conclusions. These limi a ions emphasize he need o cau ious in e p e a ion and may
impac he o e all eliabili y and gene alizabili y o his e iew’s esul s.
6. Conclusions
In conclusion, ou s udy in es iga ed he biomechanical and p ac ical impac o join
dis ac ion, aiming o assess i s e icacy in educing knee join loading, alle ia ing pain and
imp o ing join unc ion. The indings demons a ed a signi ican educ ion in pain le els
and be e unc ional ou comes among pa icipan s, pa icula ly while comple ing KJD and
HTO. KJD was shown o be able o biomechanically comple ely unload he join , whe eas
HTO was able o educe join loading by ealigning i , al hough bo h ha e a high isk o
in ec ion. ISA has also demons a ed se e al ad an ages, as i can pa ially unload he
knee. I s e icacy may, howe e , be limi ed i he pa ien s ha e a high body mass, and mo e
ials a e equi ed o e alua e i s long- e m e icacy. Mo eo e , he lack o obus long- e m
da a o ISA, pa icula ly in younge and ac i e popula ions, emains an impo an gap
ha u u e s udies mus add ess.
Se e al clinical ials ha e ound ha non-in asi e ea men s can educe pain and im-
p o e a a ie y o biomechanical measu es. Howe e , i is c i ical o ecognize he exis ing
Rheuma o 2025,5, 8 19 o 26
s udies’ sho comings, which include a ela i ely small sample size and he subjec i i y o
he chosen pa ame e s, pa icula ly when compa ed o in asi e p ocedu es.
Despi e hese limi a ions, ou esea ch con ibu es aluable insigh s in o he posi i e
ou comes associa ed wi h join dis ac ion. Mo ing o wa d, la ge -scale, long- e m ials
a e wa an ed o u he alida e ou indings and es ablish he du abili y o he obse ed
bene i s, pa icula ly in younge pa ien s unde 50 yea s old who may bene i mos om
join p ese a ion s a egies. Addi ionally, u u e esea ch should explo e he biomechanical
analysis o he knee join loading condi ion (e.g., MRI-based modeling) o cla i y hei ue
impac on ca ilage heal h and load dis ibu ion. Focusing on hese objec i es will be
essen ial o alida e and e ine ou cu en indings, ensu ing ha he mos e ec i e and
pe sonalized unloading s a egies can be o e ed o pa ien s in clinical p ac ice.
Au ho Con ibu ions: Concep ualiza ion, N.A.T.C.F., Ó.C., and A.L.; me hodology, N.A.T.C.F. and
Ó.C.; so wa e, N.A.T.C.F.; alida ion, N.A.T.C.F.; o mal analysis, A.A., B.H., F.S.S., Ó.C. and A.L.;
in es iga ion, N.A.T.C.F. and Ó.C.; esou ces, N.A.T.C.F.; da a cu a ion, N.A.T.C.F.; w i ing—o iginal
d a p epa a ion, N.A.T.C.F.; w i ing— e iew and edi ing, N.A.T.C.F.; isualiza ion, N.A.T.C.F.;
supe ision, Ó.C. and A.L.; p ojec adminis a ion, A.L.; unding acquisi ion, F.S.S. All au ho s ha e
ead and ag eed o he published e sion o he manusc ip .
Funding: This wo k is unde he na ional suppo o R&D uni ’s g an h ough he e e ence
p ojec UIDB/04436/2020 and UIDP/04436/2020 and h ough he p ojec “Mechanobiological de-
ice o s imula e ca ilage egene a ion” wi h g an e e ence PTDC/EME-EME/4520/2021. N. F.
acknowledges he suppo om FCT o his indi idual PhD g an wi h e e ence 2022.11063.BD
(h ps://doi.o g/10.54499/2022.11063.BD accessed on 17 June 2025).
Con lic s o In e es : The au ho s decla e no con lic s o in e es . The unde s had no ole in he design
o his s udy; in he collec ion, analyses, o in e p e a ion o da a; in he w i ing o he manusc ip ; o
in he decision o publish he esul s.
Abb e ia ions
The ollowing abb e ia ions a e used in his manusc ip :
OA Os eoa h i is
TKA To al Knee A h oplas y
KJD Knee Join Dis ac ion
HTO High Tibial Os eo omy
ISA Implan able Shock Abso be
KUB Knee Unloading B ace
DRKB Dis ac ion Ro a ion Knee B ace
PT Physical The apy
JSW Join Space Wid h
CT Ca ilage Thickness
WOMAC Wes e n On a io and McMas e Uni e si ies Os eoa h i is Index
KOOS To al Knee inju y and Os eoa h i is Ou come Sco e sys em
GV Gai eloci y
PKAM Peak Knee Adduc ion Momen
RTS Time o Re u n o Spo s
RTW Time o Re u n o Wo k
GRF G ound Reac ion Fo ce
VAS Visual Analogue Scale
Rheuma o 2025,5, 8 20 o 26
Appendix A
Figu e A1. Flowcha illus a ing he inclusion and exclusion o s udies ollowing he P e e ed
Repo ing I ems o Sys ema ic Re iew and Me a-Analysis (P iSMa) guidelines.
Rheuma o 2025,5, 8 21 o 26
Figu e A2. Rep esen a ion o he a ic ligh s plo illus a ing he isk o bias (RoB). [
42
,
44
–
50
,
53
,
54
,
57
,
58
].
Figu e A3. T a ic ligh s plo illus a ing he Risk o Bias In Non- andomized S udies o In e en ions
(ROBINS-I) [36–41,43,51,52,55,56,59–63].
Rheuma o 2025,5, 8 22 o 26
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