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Rehabil. Sci."],"abstract":"<jats:p>Medial compartment knee osteoarthritis (OA) is the most common form of knee OA and can be influenced by off-axis (frontal and transverse plane) biomechanics. Abnormalities such as varus malalignment, elevated knee adduction moment (KAM), dynamic varus thrust, altered step width, lateral trunk lean, reduced tibial rotation, and abnormal foot progression angle (FPA) contribute to excessive medial loading and are associated with symptom severity and structural progression. These modifiable factors present important targets for conservative management. This mini-review synthesizes current evidence on off-axis biomechanical impairments in medial knee OA and evaluates rehabilitation strategies designed to modify these mechanics. Gait retraining strategies, particularly personalized FPA modification, can reduce KAM and improve pain, with real-time biofeedback enhancing effectiveness. Valgus off-loader bracing alleviates pain related to medial knee OA and may be used as an adjunct for appropriately selected patients, especially when combined with practitioner guidance on brace fit and use. Lateral wedge insoles may provide small biomechanical benefits in a subset of individuals, while its effectiveness on symptom relief is not affirmative. Hip abductor strengthening reliably improves symptoms and function, although its load-modifying mechanisms and structural benefits remain unclear. Overall, current evidence supports a personalized, biomechanically informed approach targeting on off-axis biomechanics to managing medial knee OA. Future work should prioritize long-term randomized controlled trials and precision-based methods to identify individuals most likely to benefit from off-axis biomechanical interventions. Future clinical trials should also distinguish structural and functional off-axis biomechanical factors to optimize intervention effectiveness across distinct biomechanical phenotypes within medial knee OA.<\/jats:p>","DOI":"10.3389\/fresc.2026.1759442","type":"journal-article","created":{"date-parts":[[2026,2,19]],"date-time":"2026-02-19T05:23:25Z","timestamp":1771478605000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["Off-axis biomechanical alterations and related interventions in medial knee osteoarthritis: a mini review"],"prefix":"10.3389","volume":"7","author":[{"given":"Zongpan","family":"Li","sequence":"first","affiliation":[{"name":"Department of Physical Therapy & Rehabilitation Science, University of Maryland Baltimore","place":["Baltimore, MD, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Raziyeh","family":"Baghi","sequence":"additional","affiliation":[{"name":"Department of Physical Therapy & Rehabilitation Science, University of Maryland Baltimore","place":["Baltimore, MD, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Li-Qun","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Physical Therapy & Rehabilitation Science, University of Maryland Baltimore","place":["Baltimore, MD, United States"]},{"name":"Fischell Department of Bioengineering, University of Maryland College Park","place":["College Park, MD, United States"]},{"name":"Department of Orthopaedics, University of Maryland Baltimore","place":["Baltimore, MD, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,2,19]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"445","DOI":"10.1016\/j.joca.2020.10.011","article-title":"The compartmental distribution of knee osteoarthritis\u2013a systematic review and meta-analysis","volume":"29","author":"Stoddart","year":"2021","journal-title":"Osteoarthritis Cartilage"},{"key":"B2","doi-asserted-by":"publisher","first-page":"1380","DOI":"10.1016\/j.joca.2010.08.013","article-title":"Dynamic knee loading is related to cartilage defects and tibial plateau bone area in medial knee osteoarthritis","volume":"18","author":"Creaby","year":"2010","journal-title":"Osteoarthritis Cartilage"},{"key":"B3","doi-asserted-by":"publisher","first-page":"386","DOI":"10.23736\/s1973-9087.23.07798-5","article-title":"Higher knee flexion moment during walking is associated with a lower risk of knee pain developing among the elderly after 24 months","volume":"59","author":"Li","year":"2023","journal-title":"Eur J Phys Rehabil Med"},{"key":"B4","doi-asserted-by":"publisher","first-page":"65","DOI":"10.23736\/s1973-9087.22.07634-1","article-title":"Passive stiffness of the quadriceps predicts the incidence of clinical knee osteoarthritis in twelve months","volume":"59","author":"Li","year":"2023","journal-title":"Eur J Phys Rehabil Med"},{"key":"B5","doi-asserted-by":"publisher","first-page":"1275","DOI":"10.1002\/jor.26090","article-title":"Knee flexion excursion mediates the association between quadriceps stiffness and knee loads during the mid-stance phase of gait","volume":"43","author":"Li","year":"2025","journal-title":"J Orthop Res"},{"key":"B6","doi-asserted-by":"publisher","first-page":"171","DOI":"10.1016\/j.joca.2014.10.008","article-title":"Knee extensor muscle weakness is a risk factor for development of knee osteoarthritis. 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