The Application of Kneeling Exercise, Guided by the Tendon-Bone Balance Theory, as a Public Health Strategy in the Management of Knee Osteoarthritis

Background：Knee osteoarthritis (KOA) is the most common degenerative joint disease in an aging world. In China, its prevalence exceeds 85 % among people aged 70 years and older. Although current guidelines recommend exercise as first-line management, they provide little detail on which forms of exercise suit specific patient phenotypes. Existing programmers often carry high costs, require professional supervision, or depend on specialized facilities, creating barriers to population-wide implementation. Traditional Chinese Medicine (TCM) proposes the “tendon–bone balance” theory, which maintains that coordinated muscle and bone function is essential for joint integrity; however, modern empirical evidence for this concept is lacking. Kneeling ambulation—an equipment-free, home-based manoeuvre rooted in traditional practice—has been proposed as a highly accessible intervention, yet its biomechanical mechanisms and clinical efficacy have never been rigorously examined. Objective：Guided by the TCM “tendon–bone balance” theory, we aimed to evaluate the biomechanical effects and clinical efficacy of kneeling ambulation in KOA patients and to explore its potential as a public-health strategy. Methods：Biomechanical study: Twenty healthy volunteers underwent three-dimensional gait analysis and surface electromyography while kneeling and while walking normally; thirteen additional volunteers completed repeat sessions to verify reliability. Clinical study: In a single-centre randomized controlled trial, 30 participants who met the 2015 OARSI/AAOS criteria for KOA were randomly assigned to a kneeling group (three 5-minute sessions daily for 12 weeks) or to a no-exercise control group. The primary endpoints were total and pain scores on the WOMAC; secondary endpoints included the isokinetic peak flexor/extensor torque ratio at 60 °/s, knee range of motion, and safety. Results：Biomechanics: Compared with walking, kneeling increased peak knee flexion range of motion (117° vs 48°, P < 0.05) and reduced the knee adduction moment toward zero, shifting the load axis from the medial to the lateral compartment. Clinical: After 12 weeks, the kneeling group showed significantly greater improvements than controls in total WOMAC score (P = 0.013) and pain score (P = 0.012), a flexor/extensor torque ratio closer to unity (P < 0.05), and a marked increase in maximum knee flexion angle (P < 0.01); no serious adverse events were reported. Conclusion：Kneeling ambulation redistributes joint load and restores balanced flexor–extensor strength, leading to clinically meaningful pain relief and functional improvement. Its low cost, lack of required equipment, and suitability for home use position it as an evidence-based, scalable adjunct for population-level KOA prevention and management.