Realigning Rehab: A Randomized Controlled Trial on Specific Exercises Versus Standard Care for Medial Knee Pain and Varus Alignment

Medial knee pain in adults with varus lower-limb alignment is a frequent presentation in orthopedic and physical therapy practice. Varus malalignment increases the medial knee adduction moment and concentrates load in the medial compartment, which is associated with greater cartilage loss, radiographic progression of knee osteoarthritis, and faster functional decline compared with neutral alignment. Prospective work has shown that higher dynamic medial knee load predicts greater medial cartilage loss over time in individuals with medial knee osteoarthritis. Conventional conservative management typically focuses on quadriceps strengthening, general lower-limb exercise, manual therapy, and activity modification. Although these approaches often reduce pain and improve function, they may not adequately address the underlying biomechanical factors related to varus alignment and medial loading.

Targeted neuromuscular and alignment-focused exercise interventions have been proposed as a way to optimize frontal-plane control and dynamic alignment of the lower limb. These programs place greater emphasis on hip adductors, abductors, and internal rotators, as well as neuromuscular training during functional tasks (e.g., squatting, stepping, and gait retraining). By improving the strength and coordination of muscles that control pelvic and femoral position, such protocols may help reduce excessive medial knee loading and improve overall joint mechanics during daily and sports activities. Previous studies in knee osteoarthritis and lower-limb malalignment populations suggest that well-designed exercise programs can yield clinically meaningful improvements in pain, function, and, in some cases, measures of alignment or dynamic loading. However, high-quality randomized controlled trials that directly compare a conventional physiotherapy program with a clearly defined, alignment-focused exercise protocol in adults with medial knee pain and varus deformity remain limited.

This trial is designed as a parallel-group randomized controlled study conducted in an outpatient setting. Active adults between 30 and 55 years of age with medial knee pain, mild to moderate varus deformity on long-leg radiographs, and radiographic knee osteoarthritis graded 1-3 on the Kellgren-Lawrence scale are eligible for inclusion, provided they meet predefined anthropometric and health-status criteria and have no significant comorbid musculoskeletal or neurological conditions affecting the lower limb. The target sample size is based on an a priori power analysis to detect a moderate effect size in repeated-measures comparisons between two groups across multiple time points, with allowance for attrition to reach an enrollment goal of approximately 80 participants.

Following baseline assessment, participants will be randomly assigned in a 1:1 ratio to one of two intervention arms using a computer-generated randomization schedule with allocation concealment. The control group will receive a conventional physical therapy program consistent with usual care for medial knee pain and early medial-compartment osteoarthritis. This program typically includes quadriceps and general lower-extremity strengthening, range-of-motion and flexibility exercises, manual therapy and modalities as deemed appropriate by the treating therapist, and functional training (e.g., gait and basic task practice). Exercise dosage and progression will follow standardized guidelines, while still allowing therapists to make minor individual adjustments within the protocol framework.

The experimental group will receive a targeted exercise program that retains core elements of evidence-based knee rehabilitation but places specific emphasis on restoring dynamic alignment and frontal-plane control. The program focuses on strengthening hip adductors and internal rotators, as well as other key hip and lower-limb muscle groups that influence knee valgus-varus mechanics during weight-bearing activities. Exercises include a combination of open- and closed-chain strengthening, neuromuscular control drills, and functional retraining tasks that challenge alignment under progressively increasing load and complexity. The intervention is structured into a 6-week, clinic-based program with supervised sessions, complemented by a structured home exercise component to reinforce gains between visits.