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Sex- and obesity-related variations in pain and functional mobility among knee osteoarthritis patients: A cross-sectional analysis
*Corresponding author: Tarek M. El-gohary, Department of Physical Therapy, Taibah University, Madinah, Saudi Arabia. dr.elgoharyt@yahoo.com
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Received: ,
Accepted: ,
How to cite this article: El-gohary TM. Sex- and obesity-related variations in pain and functional mobility among knee osteoarthritis patients: A cross-sectional analysis. J Musculoskelet Surg Res. doi: 10.25259/JMSR_396_2025
Abstract
Objectives:
The primary objective was to compare overweight and obese patients on pain intensity and functional mobility in individuals with knee osteoarthritis (OA). The secondary objective was to examine the influence of sex differences on these outcomes within the same population.
Methods:
A cross-sectional study was conducted involving 56 patients diagnosed with knee OA. We evaluated pain intensity, knee range of motion, and functional mobility using the timed up and Go (TUG) and 50-foot timed walk (FTW) tests, comparing these outcomes between weight categories (overweight vs. obese) and sexes (male vs. female).
Results:
The Mann–Whitney U-test showed that obese patients had significantly longer walking times (P = 0.02, r [ES] = 0.33) and longer OA duration (P = 0.003, r = 0.39) compared to overweight patients. Females reported significantly higher pain intensity (P < 0.001, r = 0.50), longer TUG times (P = 0.02, r = 0.30), and longer disease duration (P = 0.02, r = 0.32) than males. Spearman’s analysis showed a moderate correlation between OA duration and TUG (P = 0.41) and a weak correlation with pain intensity (P = 0.23), suggesting slower mobility and slightly higher pain with longer disease duration.
Conclusion:
Body weight status and sex differences significantly affect pain intensity, functional mobility, and disease chronicity in knee OA. Obese patients and females exhibited higher pain levels, longer TUG times, and greater disease chronicity, highlighting the importance of individualized management approaches targeting these high-risk subgroups.
Keywords
Cross-sectional studies
Knee
Osteoarthritis
Pain
Physical functional performance
INTRODUCTION
Knee osteoarthritis (OA) is a common degenerative joint disorder characterized by the gradual deterioration of articular cartilage, resulting in joint pain, stiffness, and impaired mobility, which significantly impacts quality of life worldwide. Its progression is driven by mechanical loading, metabolic changes, and inflammation. Elevated body mass index (BMI) is a key modifiable risk factor, with overweight and obese individuals experiencing greater joint stress and accelerated cartilage degradation. Gender differences have also been observed, influencing pain perception, joint function, and mobility outcomes. In addition, sex-related differences in OA manifestation and progression have been widely reported, with females often experiencing higher pain intensity, reduced functional capacity, and more severe radiographic changes compared to males. These disparities highlight the importance of tailored assessment and intervention strategies.[1-5]
Functional outcome measures such as the timed up and go (TUG) test and the 50-foot timed walk (50-FTW) are critical clinical tools to objectively evaluate mobility, balance, and gait speed in knee OA patients.[5] Alongside these, pain intensity scales and knee joint mobility provide essential insights into symptom severity and physical limitations. Collectively, these assessments enable comprehensive evaluation of disease impact, guide clinical decision-making, and monitor therapeutic progress.[6,7]
Knee OA disproportionately affects individuals based on sex and body weight, with evidence suggesting that females and those classified as overweight or obese experience greater pain and functional limitations. However, the current literature lacks comprehensive observational data comparing functional outcomes, such as mobility, pain intensity, and knee joint range of motion, across these subgroups within clinical populations. Understanding these differences is crucial for physical therapists to develop personalized rehabilitation protocols that address the unique needs of diverse patient profiles. This study sought to fill this gap by systematically evaluating the impact of sex and weight category on key clinical and functional measures in knee OA, thereby enhancing targeted intervention strategies and improving patient-centered care. The primary objective of this study was to evaluate the influence of body weight status by comparing overweight and obese individuals on pain intensity and functional mobility in patients with knee OA. The null hypothesis posited that no significant differences would exist in pain intensity or functional mobility outcomes between overweight and obese individuals. The secondary objective was to examine whether sex differences (male vs. female) influence pain or functional mobility in the same population. It was hypothesized that no significant differences would be found between males and females in pain or functional outcomes.
MATERIALS AND METHODS
Study design
This cross-sectional study was conducted between January and May 2023 after obtaining ethical approval. All procedures adhered to the ethical principles outlined in the Declaration of Helsinki. A priori sample size estimation was performed using G*Power (version 3, Germany)[8] for detecting a large effect size (Cohen’s d = 0.8) at an alpha level of 0.05 and a power of 80%. The choice of a large effect size reflects the study’s aim to identify clinically meaningful differences between groups, rather than minimal or statistically significant effects. This approach was also guided by practical constraints related to participant recruitment within the target population. Based on these parameters, a minimum of 27 participants per group was determined to be sufficient for the planned comparisons. To estimate the appropriate sample size for detecting a statistically significant correlation between OA duration and functional performance outcomes, a priori power analysis was performed. Based on a two-tailed Spearman’s rank-order correlation, with an anticipated large effect size (P = 0.50), an alpha level of 0.05, and a desired power of 0.80, the analysis indicated that a minimum of 29 participants would be required.
Participants
A total of 56 individuals with a clinical diagnosis of knee OA were enrolled in the study. The sample consisted of 28 males and 28 females, all with a BMI of ≥25 kg/m2, comprising 27 overweight and 29 obese participants. The age of participants ranged from 45 to 70 years. Individuals were recruited through word-of-mouth referrals within Taibah University. Inclusion criteria required participants to have a radiologically confirmed diagnosis of knee OA (Kellgren-Lawrence grade II or III), report chronic knee pain for more than 3 months, and demonstrate the ability to walk independently or with customary assistive devices. Exclusion criteria included a history of knee surgery, intra-articular injections within the last 6 months, and any neurological or systemic condition affecting lower limb function.
Procedure
The principal investigator was responsible for screening eligible participants and systematically collecting all relevant data using a standardized data collection form. Before enrollment, all participants received a detailed explanation of the study procedures and provided written informed consent. In addition, participants completed a brief familiarization session before data collection to ensure a clear understanding of the testing protocols and to facilitate accurate performance of the required tasks. To minimize potential biases, including order effects, fatigue, and learning, the sequence of measurements was counterbalanced across participants. Participant confidentiality was rigorously maintained by securely storing all personal and outcome data.
Clinical outcome measures
Patients with knee OA were assessed using validated clinical outcome measures: Pain intensity numeric rating scale (PINRS), knee flexion and extension mobility, the TUG test, and the 50-FTW. All assessments were conducted by trained physical therapists following standardized protocols in adherence to total assessment, reassessment, and evaluation using biokinesiology.[9] These outcome measures were selected based on their clinical utility, feasibility in outpatient settings, and sensitivity in detecting changes following physical therapy interventions. Together, they provide a comprehensive assessment of pain, joint mobility, balance, and ambulatory function, domains commonly impaired in OA. Their integration into routine assessment facilitates informed clinical decision-making and individualized rehabilitation planning.
PINRS
Pain intensity was self-reported using an 11-point numeric rating scale, ranging from 0 (“no pain”) to 10 (“worst imaginable pain”). Participants were instructed to rate their average pain experienced during walking over the past 24 h. The PINRS is a widely accepted, simple, and responsive tool for evaluating pain in OA populations.[10,11] In knee OA populations, translated instruments like the Arabic numeric rating scale demonstrate excellent reliability (intraclass correlation coefficient [ICC] = 0.89) and validity, with minimal detectable change around 1.96 points.[10]
Knee flexion and extension mobility
Active range of motion was assessed for both knees using a standard universal goniometer, with participants positioned supine for extension and seated for flexion. Three trials were performed for each movement on each knee, and the mean value for flexion and extension was calculated per knee. To provide a single mobility index for analysis, the bilateral average of right and left knee values was computed for each participant. This approach follows recommendations for bilateral knee OA reporting when side-specific analysis is not the primary objective, ensuring that results reflect overall lower-limb mobility.[12-15]
TUG test
Functional mobility was assessed using the TUG test, a validated measure of dynamic balance, gait speed, and transitional movement performance. Participants were seated in a standard chair with a proper seat height and equipped with armrests, with their backs against the backrest and arms resting on the armrests. At the verbal cue “go,” each participant was instructed to rise from the chair, walk a distance of 3 m at a comfortable and safe pace, return, and sit down with their back against the backrest. The timing commenced on the command “go” and ceased when the participant was fully seated. All participants performed the test wearing their usual footwear and with any walking aids they routinely used. A single practice trial was provided to familiarize participants with the procedure, followed by one recorded trial. The time required, measured in seconds with a digital stopwatch, was recorded as the outcome variable, with shorter times reflecting superior functional mobility.[6,7,16-20]
The 50-FTW test
The 50-FTW test is a simple and reliable measure of short-distance walking speed commonly used in rehabilitation and orthopedic settings. It is a performance-based functional assessment used to evaluate gait speed, mobility, and lower-limb function in individuals with knee OA. The test entails timing a patient as they walk along a marked 50-foot path (approximately 15.24 m) along a flat, unobstructed walkway at their usual comfortable pace, as quickly and safely as possible, ensuring they maintain their pace until they fully cross the finish line. It is typically performed twice, with the faster time recorded in seconds using a stopwatch.[21,22] This test is quick to administer, requires minimal equipment, and permits the use of assistive devices when necessary. It has shown excellent test–retest reliability across diverse patient populations, including individuals with knee OA. Clinically, the test serves as an important indicator of functional mobility and is widely recommended as a core outcome measure for evaluating knee disorders. Its practicality and sensitivity make it useful for monitoring patient progress and guiding treatment decisions.[21,22] Standardized protocols ensure consistent administration, and the test’s strong psychometric properties support its use in both research and clinical practice. As a simple and clinically relevant test, it reflects ambulation capacity and real-world function in individuals with knee OA, making it suitable for routine use in outpatient clinics or rehabilitation programs. Slower completion times are typically associated with greater functional impairment and reduced physical performance.[5,21,22]
The 50-FTW test administration summary
Participants were instructed to walk 50 feet as quickly and safely as they could, maintaining their pace until they had fully crossed the finish line. The examiner first demonstrated the course, then initiated the test with the command “Ready, Set, GO,” starting the timer on “GO” and stopping it when the participant’s trunk crossed the 50-foot mark. The procedure was repeated with identical instructions to ensure consistency. Participants were permitted to stop if pain became excessive, and close supervision was provided throughout the test. This standardized protocol provides highly reliable measurements of short-distance gait speed.[22]
Statistical analysis
The Shapiro-Wilk test indicated that none of the data met normality assumptions; therefore, non-parametric statistical methods were employed throughout the analysis. Quantitative variables were summarized as medians with interquartile ranges (IQR), while categorical variables were presented as frequencies and percentages. The Mann–Whitney U-test was used to compare knee mobility, pain intensity, TUG, and 50-FTW outcomes between overweight and obese patients as well as between males and females in terms of clinical and functional outcome measures. Effect sizes (r) for the Mann–Whitney U tests were calculated using the formula , where Z is the standardized test statistic and N is the total number of observations. The resulting r values were interpreted according to Cohen’s criteria, with 0.1 indicating a small effect, 0.3 a moderate effect, and 0.5 a large effect.
Spearman’s correlation coefficient was used to evaluate the association between duration of OA and the functional outcome measures of TUG and 50-FTW. A significance level of P ≤ 0.05 was set, and analyses were performed using IBM Statistical Package for the Social Sciences Statistics, version 26 (IBM Corp., Armonk, NY, USA).
RESULTS
Table 1 presents the median and IQR for participants’ demographic and clinical characteristics, including age, weight, height, BMI, and duration of OA in months, alongside the outcome measures such as knee flexion and extension mobility, pain intensity rating scale, 50-FTW, and the TUG. Table 2 summarizes between-group comparisons of participants’ demographics and outcome measures, including median values, IQR, P-values, and effect sizes.
| Quantitative variable | Weight category | Median (IQR) | Sex | Median (IQR) |
|---|---|---|---|---|
| Age “years” | Overweight | 65 (47–66) | Male | 65 (47–66) |
| Obese | 61 (55–65.5) | Female | 65 (58–65) | |
| Weight | Overweight | 72 (72–73) | Male | 82 (72–85) |
| Obese | 90 (83–105) | Female | 78.50 (72–105) | |
| Height | Overweight | 1.64 (1.56–1.68) | Male | 1.61 (1.56–1.63) |
| Obese | 1.65 (1.60–1.77) | Female | 1.68 (1.65–1.77) | |
| BMI | Overweight | 26.81 (25.5–29.6) | Male | 31.2 (29.6–33.1) |
| Obese | 33.06 (31.6–36.8) | Female | 30.09 (25.5–33.4) | |
| Duration of osteoarthritis in months | Overweight | 12 (6–36) | Male | 24.5 (12–36) |
| Obese | 24 (12–60) | Female | 12 (6–24) | |
| Flexion mobility | Overweight | 105 (102–115) | Male | 105 (95–114) |
| Obese | 110 (97–117.5) | Female | 110 (102–118) | |
| Extension mobility | Overweight | 00 (00–19) | Male | 00 (8–00) |
| Obese | 00 (7–00) | Female | 00 (5–00) | |
| PINRS | Overweight | 4 (3–5) | Male | 4 (3–5) |
| Obese | 4 (3–5) | Female | 5 (4–6) | |
| 50-foot timed walk (sec) | Overweight | 32.7 (26–35) | Male | 27.4 (17.7–36.8) |
| Obese | 29.3 (18.02–33.20) | Female | 32.7 (28.6–33.2) | |
| Timed up and go (sec) | Overweight | 12.5 (12.5–12.5) | Male | 12.5 (12.5–18.2) |
| Obese | 16.6 (12.44–18.10) | Female | 13.7 (12.4–15.8) | |
| Qualitative variables | Number | Percentages% | ||
| Male | 28 | 50 | ||
| Female | 28 | 50 | ||
| Overweight | 27 | 48.2 | ||
| Obese | 29 | 51.8 | ||
IQR: Interquartile range, BMI: Body mass index, PINRS: Pain intensity numeric rating scale
| Quantitative variable | Weight category | Median (IQR) |
P-value r=Effect size |
Sex | Median (IQR) |
P-value r=Effect size |
|---|---|---|---|---|---|---|
| Age | Overweight | 65 (47–66) | P=0.32 | Male | 65 (47–66) | P=0.57 |
| Obese | 61 (55–65.5) | Female | 65 (58–65) | |||
| Weight | Overweight | 72 (72–73) | P<0.001 | Male | 82 (72–85) | P=0.39 |
| Obese | 90 (83–105) | Female | 78.50 (72–105) | |||
| Height | Overweight | 1.64 (1.56–1.68) | P=0.44 | Male | 1.61 (1.56–1.63) | P<0.001 |
| Obese | 1.65 (1.60–1.77) | Female | 1.68 (1.65–1.77) | |||
| BMI | Overweight | 26.81 (25.5–29.6) | P<0.001 | Male | 31.2 (29.6–33.1) | P=0.35 |
| Obese | 33.06 (31.6–36.8) | Female | 30.09 (25.5–33.4) | |||
| Duration of osteoarthritis in months | Overweight | 12 (6–36) |
P=0.003* r=0.39 |
Male | 24.5 (12–36) |
P=0.02* r=0.32 |
| Obese | 24 (12–60) | Female | 12 (6–24) | |||
| Flexion mobility | Overweight | 105 (102–115) | P=0.88 | Male | 105 (95–114) | P=0.14 |
| Obese | 110 (97–117.5) | Female | 110 (102–118) | |||
| Extension mobility | Overweight | 3 (00–07) | P=0.29 | Male | 3 (00–03) | P=0.72 |
| Obese | 4 (00–09) | Female | 5 (00–06) | |||
| PINRS | Overweight | 4 (3–5) | P=0.39 | Male | 4 (3–5) |
P=0.001* r=0.50 |
| Obese | 4 (3–5) | Female | 5 (4–6) | |||
| 50-foot timed walk | Overweight | 32.7 (26–35) | P=0.10 | Male | 27.4 (17.7–36.8) | P=0.10 |
| Obese | 29.3 (18.02–33.20) | Female | 32.7 (28.6–33.2) | |||
| Timed up and go | Overweight | 12.5 (12.5–12.5) |
P=0.02* r=0.33 |
Male | 12.5 (12.5–18.2) |
P=0.03* r=0.30 |
| Obese | 16.6 (12.44–18.10) | Female | 13.7 (12.4–15.8) |
IQR: Interquartile range, BMI: Body mass index, PINRS: Pain intensity numeric rating scale, r: Effect size, P: Probability, *: Statistical significance, Significance threshold ≤ 0.05
The Mann–Whitney U test revealed that obese patients exhibited significantly longer walking times than overweight patients (P = 0.02, r = 0.33) and a longer duration of OA chronicity (P = 0.003, r = 0.39), both of which reflected moderate effect sizes. In addition, females demonstrated significantly longer TUG completion times than males (P = 0.02, r = 0.30) and a significantly longer duration of OA (P = 0.02, r = 0.32). Both outcomes correspond to moderate effect sizes, indicating meaningful differences in functional mobility and disease chronicity between the sexes.
The Mann–Whitney U test revealed no significant difference in mean ranks for pain intensity between overweight (26.56) and obese (30.31) patients. In contrast, a significant difference was observed between males (36.04) and females (20.96) [Figure 1]. For the TUG test, significant differences in mean ranks were found between overweight (23.11) and obese (33.52) patients, as well as between males (23.68) and females (33.32). Obese patients and females exhibited higher mean ranks, indicating longer completion times [Figure 2].
- Mean rank distribution of pain intensity numeric rating scale (PINRS) for overweight versus obese and males versus females’ participants, analyzed using the Mann–Whitney U test.
- Mean rank distribution of timed up and go (TUG) for overweight versus obese and males versus females’ participants, analyzed using the Mann–Whitney U test.
Spearman’s correlation analysis demonstrated a moderate positive association between OA duration and TUG performance (P = 0.41), indicating that a longer history of knee OA was associated with slower functional mobility. In addition, a weak positive correlation (P = 0.23) was observed between chronicity duration and pain intensity, suggesting a slight increase in perceived pain with longer disease duration. These findings underscore the clinical significance of disease duration as a factor negatively affecting functional mobility and, to a lesser extent, pain severity. However, the observed associations were generally weak and fell below thresholds typically considered clinically meaningful; therefore, they should be interpreted with caution and may not support definitive clinical conclusions. Clinicians should consider the chronicity of OA when designing individualized treatment plans, as longer disease duration may be associated with greater functional limitations.
DISCUSSION
The findings of this study indicate significant variations in pain intensity, functional mobility, and disease chronicity based on body weight status and sex. Obese patients and females reported higher pain levels, longer TUG test times, and greater disease chronicity. However, the functional outcome measure of the 50-FTW test did not show any significant difference between groups. These results highlight the need for tailored management strategies focusing on high-risk subgroups, particularly obese patients and females, to improve outcomes in knee OA.
Knee OA represents a major global public health challenge, with its prevalence and associated burden projected to rise substantially in the coming decades. Both in Saudi Arabia and worldwide, the growing incidence of knee OA is strongly associated with population aging and obesity; however, the relative contributions of these factors differ by region. Conversely, on a global scale, population expansion remains the primary challenge to the increasing knee OA burden, emphasizing the necessity of integrating knee OA prevention within broader public health frameworks that address population growth and lifestyle-related risk factors.[1,10,16,23] Assessment of clinical and functional outcomes stratified by BMI status and identification of sex-based disparities represents an essential prerequisite for comprehensive patient management.
Emerging evidence suggests that obesity not only contributes to the onset of knee OA but also exacerbates its clinical severity through both mechanical and metabolic pathways. Excess body weight increases joint loading, particularly across the tibiofemoral compartment, accelerating cartilage degeneration and subchondral bone changes. In addition, adipose tissue secretes pro-inflammatory adipokines that may drive synovial inflammation and cartilage breakdown independent of mechanical loading. Clinical studies have demonstrated that obese individuals with knee OA often present with greater pain intensity, reduced functional mobility, and faster disease progression compared to their non-obese counterparts. These findings highlight the critical need for weight management strategies within physical therapy and rehabilitation programs to reduce symptom burden and slow disease advancement in this high-risk population. The present findings align with our results, demonstrating a higher prevalence of OA among obese patients compared to those who are overweight.[24]
Wang et al.[25] conducted a 7-year cohort study investigating the association between sarcopenic obesity and the risk of knee OA. Their findings are consistent with prior longitudinal evidence, indicating that both sarcopenic obesity and probable sarcopenic obesity confer an increased risk of Knee OA, with a more pronounced impact observed in women. Similar to these reports, our study observed a higher prevalence of knee OA among female and obese participants. This concordance highlights the combined influence of excess body weight and sex-related factors on disease development and progression. Targeted strategies focusing on weight management and the preservation of muscle strength may be critical in mitigating knee OA risk and improving functional outcomes, thereby enhancing quality of life in these high-risk groups.
Gill and McBurney[21] investigated the reliability of the 50-FTW test in 82 patients awaiting hip or knee joint replacement surgery. They recommended administering a practice trial immediately before data collection to minimize practice effects during baseline assessment, thereby enhancing the test’s reliability. Participants in this study were closely supervised during the practice trial preceding data collection to enhance the reliability of the test.
Kear et al.[18] reported that the TUG test is a reliable and readily applicable tool for assessing functional mobility. It can be employed to monitor physical capacity in individuals with both physical and mental health risk factors. The authors concluded that slower TUG performance was associated with higher BMI and comorbidities, as well as lower self-perceived physical and mental health. Nightingale et al.[17] evaluated the correlation between the TUG test and multiple balance parameters, concluding that the TUG is a valid screening tool for identifying balance impairments associated with an increased risk of falls.
The TUG and 50-FTW tests are widely utilized functional assessments for evaluating lower-extremity performance. These measures closely replicate the biomechanical demands of daily activities, including transitions between sitting and standing as well as walking on level surfaces. Their simplicity, coupled with the capacity to assess key components such as muscle power and balance, makes it a valuable tool in both clinical practice and research contexts.[6,7,19-22]
The integration of clinical and functional assessments offers a complementary and comprehensive evaluation of lower-extremity performance, thereby enhancing diagnostic accuracy and informing the development of targeted intervention strategies. In light of our findings indicating a higher prevalence of knee OA among obese and female subgroups, this combined approach is particularly valuable for early identification of high-risk populations. By aligning objective performance measures with clinical observations, clinicians can more effectively tailor preventive and rehabilitative interventions to address the specific biomechanical and physiological factors contributing to disease progression in these vulnerable groups. A key limitation of this study is its relatively small sample size, primarily due to logistical constraints and recruitment challenges. A smaller cohort inherently increases the likelihood of a Type II error, in which true differences between groups may remain undetected. These results should be interpreted cautiously, as they may reflect limited statistical power rather than a true absence of effect. Future studies should recruit larger, more diverse samples and use longitudinal designs to improve robustness and assess the predictive value of functional performance measures.
CONCLUSION
This study identified significant differences in pain and functional mobility based on body weight status and sex in knee OA patients. Obese individuals showed diminished function compared to overweight patients, and females reported higher pain and reduced mobility compared to males. These findings underscore the importance of considering both weight and sex in clinical assessment and management strategies to maximize patient outcomes.
Acknowledgment:
Thanks to coworkers and students at Taibah University for recruiting patients to participate in the research study.
Recommendations
Further research is warranted to explore targeted strategies that mitigate symptoms and optimize functional mobility in diverse patient subgroups.
Ethical approval:
The research/study was approved by the Institutional Review Board at the Ethics Committee of the College of Medical Rehabilitation Sciences, Taibah University, number CMR-PT-2023-21, dated January 18th 2023.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Conflicts of interest:
There are no conflicting relationships or activities.
Financial support and sponsorship: This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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