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Inverted foot orthotics young means knee deterioration at 35?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Atlas, Feb 25, 2012.

  1. Atlas

    Atlas Well-Known Member

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    I've got a hunch, that we may start to see one negative finding of inversion therapy in years to come. The provision of devices with a strong rearfoot supination angle/force, has been common-place for the young (eg. primary school children), in the last two decades.

    But for all the benefits of this prescription (structural, symptomatic etc.), is there one potential pathology, that we podiatrists are accelerating? I fear that the resultant early increased compression forces impacting on the medial knee joint can only mean one thing: Earlier onset of medial knee joint OA.

    The study of Hinman & Payne on eversion wedging for medial knee joint arthritis, is on of the most clinically practical and relevant lower-limb studies I have come across. There is more to this study, than just a clincial response to late stage medial knee OA.

    The take-home message for clinicians hence might be:

    - Aim to get a clinical result with less rear-foot inversion angle/force; or
    - Think about upping your knee knowledge via your CPD

    Ron Bateman
    Physiotherapist (Masters) & Podiatrist
  2. Craig Payne

    Craig Payne Moderator

    Re: Inverted young means knee deterioration at 35?

    Hey Ron :drinks ... long time no hear!

    We had this thread on the related topic:
    Will the use of external supination moment Foot orthotics increase the rates of Medial knee OA in which I posted:
  3. This is a possibility. Another possibility is that since inverted orthoses are used in feet suffering from excessive subtalar joint pronation moments, where there is a more lateral position of the foot relative to the long axis of the leg, that the medial shift in center of pressure from an inverted orthosis, combined with the decreased pain and disability resulting from proper use of these orthoses, will positively affect both the mental and physical aspect of patients and equalize abnormal knee compartment loading forces so that the patient has decreased risk of developing knee osteoarthritis. I would think that this possibility is much more likely from my clinical experience of using these devices for over a quarter century.
  4. efuller

    efuller MVP

    If the theory on how varus wedged orthoses work is correct then you can predict who is going to get worse and who is going to get better. The theory is that the varus wedge shifts the center of pressure under the foot and when it does that it also shifts the center of pressure under the knee. The frontal plane moment at the knee will be determined by the relative position of the center of pressure under the foot and the center of pressure of the knee joint axis. In someone with tibial varum, they will start with the force on the ground more medial than the force on the knee. A varus wedge orthotic will shift the center of pressure further medial and increase the adduction moment from the ground acting at the knee. On the other hand, if there is tibial valgum, a medial shift in the center of pressure will reduce the moment from the ground acting at the knee.

  5. Atlas

    Atlas Well-Known Member

    I have focussed on knees from a bottom-up perspective for nearly 20 years, so whether that just 'sees your bid'; fails to see your bid; or raises your bet....is another complex issue.

    Pre-podiatry, I was using wedges (lateral and medial) for knee problems in my first years as a physiotherapist in the 1990's. This also pre-dated the wedge-knee study, to my knowledge.

    All I am advocating for the orthotic-prescribing podiatrist is to (at least) try and get the job done with more conservative rearfoot inversion angle/force. If the patient's signs and symptoms can't be or aren't resolved with conservative inversion, then yes, go as radical (inversion/supination) as you need to. In other words, kill the fly with a swatter, and not a shotgun. But if the swatter doesn't work, go over to the United States and walk into a corner-store and buy something more powerful.

    I am not talking about middle-aged knees. What matters with them is good function now. Do whatever it takes.
    But for the young, we might need to re-think.

    In the future, we will begin to see big numbers of 35-40 year olds that have been wearing heavily inverted orthotics for most of their life up to that date. I am just predicting what we may see in relation to medial knee compressive pathology.

    On another note, what is the relationship between inversion ankle sprains and inverted orthotic devices?

    Ron Bateman
    Physiotherapist (Masters) & Podiatrist
  6. Atlas

    Atlas Well-Known Member

    Re: Inverted young means knee deterioration at 35?

    G'day Craig.

    Apologise for the potential duplicity (moderator's nightmare), but I could further differentiate by adding lateral knee issues (instability? LCL dysfunction? Superior fibular migration etc.) in future 35-40 year olds.

    I am also being more specific in relation to applied clinical podiatric practice; which is "in children, use the most conservative rearfoot inversion angle/force to obtain the desired result (functional, signs & symptoms).

    When I went through as a student, several podiatric clinicians (small sample) advocated an inversion-first approach to young kids. The use of Joeys (Footwork) and DC Wedges (Foottech) have been the go-to devices for biomechanical intervention of children. I just think that if this is widespread, there needs to be some re-affirmation.

    Ron Bateman
    Physiotherapist (Masters) & Podiatrist
  7. According to the orthopedic surgeons I work with, they have been using such wedges for over a half century for knee osteoarthritis. This is really not a new technology. However, the research confirming their therapeutic effect is relatively new.

    I am not concerned in the least about inverted orthoses causing medial knee osteoarthritis as long as they are correctly applied. However, indiscriminate use of inverted orthoses for all feet obviously can be a serious mistake and could cause injuries such as inversion ankle sprains, lateral dorsal midfoot interosseous compression syndrome, peroneal tendinopathy and medial knee osteoarthritis. Podiatrists using this orthosis technique should know what they are doing.

    Last time I talked to Dr. Rich Blake, inventor of the Blake Inverted Orthosis, an orthosis technique which is now 30 years old, he sees no increase in inversion ankle sprains with his inverted orthoses.....of course, he knows what he is doing and is very careful who he gives these to.
  8. Atlas

    Atlas Well-Known Member

    Fair points Kevin.

    As for Orthopaedic Surgeons, who have probably the toughest job of all of us (difficult to reverse their odd error), in my experience, they are the bookends of treatment. They will give patient x two main options. Plan "a" is to go away and lose weight and do some typical things to improve the condition conservatively. Plan "b" is obviously let's operate and improve things surgically.

    I laud your orthopods that have more than 2 tricks (wedges, cortisone, blood injections, hydrodilitation etc.) in the showbag. Although I will concede that surgery is the toughest gig in town.

    Ron Bateman
    Physiotherapist (Masters) & Podiatrist
  9. Ron:

    Probably the best book I ever read on knee mechanics, knee DJD, biomechanical effects of transverse plane angulation of the tibia and the biomechanical effect of varus and valgus osteotomies for knee DJD is now, unfortunately, out of print, and by Paul Macquet (Maquet, Paul G.J.: Biomechanics of the Knee. Springer-Verlag, New York, 1984). After reading this book during my Biomechanics Fellowship in 1985, varus and valgus wedges for knee DJD made complete mechanical sense. Too bad no one at CCPM ever taught me this information....had to learn this information, along with many other things, by reading on my own from the CCPM library. This is a great book and really helped me understand knee mechanics from a whole new level.

  10. CraigT

    CraigT Well-Known Member

    Hi Ron
    This is a classic case of a geography specific issue. I have always had an issue with the use of the devices you mention generally because 'overcorrection' is so easy.
    For those that do not know these devices, they have no heel cup, but have a strong varus wedge- they are produced by only a couple of labs in Melbourne and no-where else (that I know of).

    They can be very effective, but I have seen a large number of cases where the inversion is replaced with a lateral shift of the heel in the shoe. You see lateral distortion of the upper of the shoe and instability with subsequent load on the peroneals, ITB etc. It is quite reasonable to also expect potential compression on the medial compartment of the knee...
    This design is different from a Blake inverted orthosis, but the same is possible if the execution of the device is poor (as Kevin stated above ). But this is why they are custom prescription orthoses- so the prescriber can ensure that the possibility of this occurring is minimal.
  11. Atlas

    Atlas Well-Known Member

    Ahh. Good old clincal books of the "anachronistic" pre-EBP pre-internet era. More gems there than we give credit for. Some of those old clinicians would eat generation X for breakfast. Horse-punters want to see a hypothetical race between Phar Lap, Secretariat, Black Caviar, Makybe Diva etc. I wouldn't mind seeing the pure clinical skills of Geoff Maitland, Robin McKenzie, Root and Co. going up against our statistically significant knowledge.

    Returning to your knee book.
    1984 or 1976?

    Out-of-print, but still available I gather?

    Ron Bateman
    Physiotherapist (Masters) & Podiatrist
  12. nwynd

    nwynd Welcome New Poster

    One other factor that needs to be considered with regards to inverted orthoses, or just orthoses in general, with regards to knee loads is that foot orthoses do not only influence frontal plane knee mechanics. It is possible that rotational/transverse plane motion of the tibia from foot pronation contributes to medial knee OA and thus while medial knee loads may be increased with inverted foot orthoses, rotational stresses may be decreased.
  13. CraigT

    CraigT Well-Known Member

    Agreed. I do not exclude the use of foot orthoses to provide medial support if the have medial knee O/A... but you DO need to be careful!
  14. Atlas

    Atlas Well-Known Member

    But when it comes to rearfoot inversion devices, the frontal plane influence on the knee is the biggest daddy of them all.

    Ron Bateman
    Physiotherapist (Masters) & Podiatrist
  15. CraigT

    CraigT Well-Known Member

    IS this your opinion Ron? Or have you a reference for this statement? I am not saying you are wrong, but I am not certain that you are always correct in this regard...
    The devices you mention earlier are a specific version of a 'rearfoot inversion device'
  16. Atlas

    Atlas Well-Known Member

    No references.

    Just years of playing with acute and chronic medial and lateral knee pathology.

    You are thinking more about rotational influences in the knee?

    Ron Bateman
    Physiotherapist (Masters) & Podiatrist
  17. CraigT

    CraigT Well-Known Member

    I have more than a couple of patients who have medial knee OA, and significantly pronated feet. I have managed them with orthoses designed to increase the supination moment and had a positive effect on the knee... (from memory the knee was not the primary problem in these cases). My feeling is that perhaps controlling some of the rotational forces was the mechanism of action in this case. I would never use a DC Wedge/ Joey type device in this type of case.
  18. phil

    phil Active Member

    Agreed! I would like to emphasise this point. Often someone with medial knee OA plus lots of pronation does really well with inverted orthotics. Theoretically this should shift the COP more medially, however when you put it all together and shake it up, the reduction of internal rotational force of the tibia seems to be more important than shifting the COP to the lateral knee.

    Need to learn more about knees i think!
  19. Atlas

    Atlas Well-Known Member

    But how do you know that the medial OA is the main pathology of symptom production. How do you work out that your case(s) are more about medial OA, and less about MCL, pes anserine and other medial tension pathology issues?

    Ron Bateman
    Physiotherapist (Masters) & Podiatrist
  20. CraigT

    CraigT Well-Known Member

    This is a good point. But at the end of the day does it matter??
    It is important to know if there is medial compartment OA, but they are there for their knee pain...
    If this patient returned for a review and the pain had changed in its behaviour then you could well conclude that you have robbed Peter to pay Paul- helped the medial tension pathologies but aggravated the medial compartment...
  21. Atlas

    Atlas Well-Known Member

    I think it does matter when we are debating the importance of which plane is the big daddy of them all.

    But clinically, you're right. All that counts is symptom reduction and normalisation of function.

    Ron Bateman
    Physiotherapist (Masters) & Podiatrist
  22. Dr Rich Blake

    Dr Rich Blake Active Member

    Ron, I think your comment is well put. Over pronation causes a lot of problems, and over supination caused from any cause can produce many problems including medial knee pain. It is not the technique, as I have over supinated patients with Root vertical orthotic devices, but the prescribing doctor not oversupinating the patient. If you over-supinate a heel, you can jam up the medial side of the knee, and the patient complains and you lower your correction. End of story. After 40 years with this technique, the Inverted Orthotic Technique makes the knees more stable, less prone to injury. There are knees with Varus thrust issues that I would never use an inverted orthotic device on. If you use the Inverted Orthotic Technique correctly you should be inverting the heel from everted position to vertical, in most cases, and not inverting them. You should also be protecting the lateral column with good cast technique, lateral phalanges, Denton modifications, Feehery and Fettig Modifications, etc. Rich Blake

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