Author’s response to the commentary on “sex- and obesity-related variations in knee osteoarthritis”

Dear Editor,

I appreciate the constructive insights offered in the letter^[1] responding to my recent article examining sex- and obesity-related variations in pain and functional mobility among patients with knee osteoarthritis (OA).^[2] The insights emphasize the importance of situating my findings within the broader interplay of biological, behavioral, and sociocultural factors influencing OA. This condition continues to impose a substantial global health burden. Recent epidemiological evidence highlights a rising prevalence of OA attributable to high body mass index, reinforcing the dual contribution of mechanical overload and adiposity-driven inflammation in disease progression and symptom severity.^[3]

Sex-based disparities in OA presentation and outcomes have been well described, with women typically exhibiting higher pain intensity and greater functional limitation than men. These differences have been linked to hormonal influences, pain modulation mechanisms, and neuromuscular variations. My study’s findings were consistent with these established patterns, showing measurable differences in functional performance between male and female patients.^[2] However, I agree that physiological factors alone cannot fully explain such disparities. Sociocultural determinants, including health beliefs, access to care, and gendered expectations regarding physical activity, play a significant role in shaping both disease onset and progression. This study highlights the significance of sex- and obesity-related differences in pain and functional mobility among individuals with knee OA, supporting more personalized, equitable, and multifactorial approaches to rehabilitation and clinical decision-making.

In Middle Eastern contexts, qualitative research has documented unique cultural and environmental influences on exercise behaviors, perceptions of OA, and engagement in self-management practices.^[4,5] For example, social norms in some communities may limit women’s mobility, reducing opportunities for outdoor activities such as walking, light exercise, and sunlight exposure. Consequently, physical activity often shifts indoors, which may inadvertently contribute to lower overall activity levels and poorer functional outcomes. These contextual considerations are essential for interpreting sex-based differences observed in OA research conducted in a Saudi Arabian cohort, where population-specific patterns have also been documented.^[6] Furthermore, failure to clearly distinguish between overweight and obese patients may mask meaningful differences in functional performance and mobility limitations, thereby reducing the ability to interpret functional outcomes and tailor rehabilitation interventions accurately.

I concur with the authors of the letter that future investigations would benefit from longitudinal designs, larger cohorts, and advanced modeling techniques to clarify the interactions between modifiable and non-modifiable risk factors. Furthermore, recent calls to transition from multidisciplinary to interdisciplinary rehabilitation frameworks highlight the need to integrate medical, behavioral, and sociocultural perspectives to optimize OA care pathways.^[7] Continued academic dialogue on these issues will enhance the precision of OA research and promote the development of culturally relevant, evidence-based interventions tailored to diverse populations. Building on the discussion of sex- and gender-related differences in knee OA, it becomes evident that addressing these disparities requires not only clinical awareness but also targeted research and educational initiatives.

• Research priority: Integrate biological, behavioral, and sociocultural variables into future OA studies to clarify sex- and obesity-related differences in pain perception, functional mobility, and disease progression using longitudinal and mixed-methods designs.

• Educational focus: Enhance clinician and patient education to address sociocultural influences on physical activity, pain reporting, and adherence, promoting individualized, gender-sensitive OA care.