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Lateral foot wedging for medial knee OA

Discussion in 'Biomechanics, Sports and Foot orthoses' started by admin, Aug 13, 2005.

  1. NewsBot

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    Articles:
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    Medial Wedging

    Effectiveness of medial-wedge insole treatment for valgus knee osteoarthritis.
    Rodrigues PT, Ferreira AF, Pereira RM, Bonfá E, Borba EF, Fuller R
    Arthritis Rheum. 2008 May 15;59(5):603-8
     
  2. NewsBot

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    Articles:
    1
    A variable-stiffness shoe lowers the knee adduction moment in subjects with symptoms of medial compartment knee osteoarthritis
    Jennifer C. Erhartab, Annegret Mündermannbd, Barbara Elspasa, Nicholas J. Gioriabc, Thomas P. Andriacchiabc
    Journal of Biomechanics (in press)
     
  3. NewsBot

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    Articles:
    1
    Is there an evidence-based efficacy for the use of foot orthotics in knee and hip osteoarthritis? Elaboration of French clinical practice guidelines.
    Gélis A, Coudeyre E, Hudry C, Pelissier J, Revel M, Rannou F.
    Joint Bone Spine. 2008 Aug 20. [Epub ahead of print]
     
  4. NewsBot

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    Articles:
    1
    Predicting changes in knee adduction moment due to load-altering interventions from pressure distribution at the foot in healthy subjects
    Jennifer C. Erharta, Annegret Mündermannb, Lars Mündermann, Thomas P. Andriacchia
    Journal of Biomechanics (In Press)
     
  5. NewsBot

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    Articles:
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    Control of knee coronal plane moment via modulation of center of pressure: A prospective gait analysis study.
    Haim A, Rozen N, Dekel S, Halperin N, Wolf A.
    J Biomech. 2008 Sep 19. [Epub ahead of print]
     
  6. NewsBot

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    Articles:
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    Addition of an arch support improves the biomechanical effect of a laterally wedged insole
    Kohei Nakajima, Wataru Kakihan, Takumi Nakagawa, Hiroyuki Mitomi, Atsuhiko Hikita, Ryuji Suzuki, Masami Akai, Tsutomu Iwaya, Kozo Nakamura, Naoshi Fukui
    Gait and Posture (Articles in Press)
     
  7. NewsBot

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    Articles:
    1
    Walking shoes and laterally wedged orthoses in the clinical management of medial tibiofemoral osteoarthritis: A one-year prospective controlled trial.
    Barrios JA, Crenshaw JR, Royer TD, Davis IS.
    Knee. 2008 Dec 20. [Epub ahead of print]
     
  8. NewsBot

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    Articles:
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    Effect of laterally wedged foot orthoses on rearfoot and hip mechanics in patients with medial knee osteoarthritis.
    Butler RJ, Barrios JA, Royer T, Davis IS.
    Prosthet Orthot Int. 2009 Jun;33(2):107-16.
     
  9. NewsBot

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    Articles:
    1
    Walking shoes and laterally wedged orthoses in the clinical management of medial tibiofemoral osteoarthritis: a one-year prospective controlled trial.
    Barrios JA, Crenshaw JR, Royer TD, Davis IS.
    Knee. 2009 Mar;16(2):136-42.
     
  10. I am really pleased that the ideally of a clinical examination of the foot is seen as important before the application of a lateral wedge in the study by Butler et al.
     
  11. NewsBot

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    Articles:
    1
    Advances in insoles and shoes for knee osteoarthritis.
    Hinman RS, Bennell KL.
    Curr Opin Rheumatol. 2009 Mar;21(2):164-70
     
  12. NewsBot

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    Articles:
    1
    Static and dynamic correlates of the knee adduction moment in healthy knees ranging from normal to varus-aligned
    Joaquin A. Barrios, Jill S. Higginson, Todd D. Royer, Irene S. Davis
    Clinical Biomechanics (in press)
     
  13. NewsBot

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    Articles:
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    Effects of concurrent use of an ankle support with a laterally wedged insole for medial knee osteoarthritis.
    Segal NA, Foster NA, Dhamani S, Ohashi K, Yack HJ.
    PM R. 2009 Mar;1(3):214-22.
     
  14. spike2260

    spike2260 Member

    Re: Lateral wedging for medial joint line OA


    I am glad you mentioned the comprimise in degrees when using lateral wedging, the, it seems a difficult one does it not, when you simply must medially post the pronated foot, but also require lateral wedging for the medial knee pain.

    Chris
     
  15. Recent guidelines from the American Academy of Orthopaedic Surgeons has stated that lateral heel wedges should not be prescribed for patients with symptomatic medial compartmental osteoarthritis (MCOA) of the knee as their is insufficient evidence for their use. There has been debate about this as lateral wedges do seem to offer short term pain relief but no improvement in the MCOA. Pronation and supination are not simply adaptions to uneven ground and shock absorbing mechanisms they also are the mechanism of torque conversion. Normal gait demonstrated external and internal rotation of the lower limb. This transverse movement is much less than sagittal plane movement which is the main component of gait but is nevertheless signficant. The movement about the subtalar joint acts as a closed chain torque converter. If this is blocked by use of a lateral wedge then the effects of this will be felt somewhere else in the lower limb. I understood that the use of a medial wedge is usually to prevent overpronation but not to completely prevent it. Advocates of the use of use of lateral wedges have said that it can only function if there is some range of pronation which can still be reduced and it is not effective if the foot is already maximally pronated. This means that the subtalr joint is not functioning - is the lack of torque conversion not important ?
     
  16. Kathleen:

    I have been using lateral heel and forefoot wedges on patients with medial compartment osteoarthritis for the last 20 years without any problems. If the wedge or orthosis starts to cause problems then simply take it out of the shoe! This "insufficient evidence" stuff that is floating around now for therapies that have been used successfully on patients for over a half century is, to my mind, ridiculous! I'll bet you won't find orthopedic surgeons not doing a new surgery because there is "insufficient evidence"!!
     
  17. Craig Payne

    Craig Payne Moderator

    Articles:
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    Herein is a dilemma that I have been wrestling with trying to reconcile recently (not just for lateral wedging but for many other things as well).

    The use of lateral wedging for medial knee OA has been in the guidelines from two rheumatology associations for a while now. Since they were included a lot more evidence has been published. I do not dispute the AAOS view and there is also a recent evidence based review for GP's in Australia that said pretty much the same thing.

    The problem is that what evidence do you include in the meta-analysis or systematic review? Do you just include those RCT’s that meet certain quality criteria? (which is what the standard practice is).

    The problem I have with this in lateral wedging for medial knee OA is on the inclusion criteria for studies. There is this publication, that shows that lateral wedging is more effective at reducing the adductor moment if it is full length rather than just under the heel – so should the RCT’s that only used heel wedges be excluded from the review. A high BMI is a predictor of OA progression, so any study that included subjects with a high BMI are going to progress regardless of the intervention, so should those RCT’s with high BMI subjects be excluded? Etc etc.

    Would there be any studies left to be included in the systematic review? – I have not looked closely enough to know the answer; but it is possible that the same conclusion may still actually be reached – I do not know.

    There is some good theoretical reasoning and it is biologically plausible that those with limited or no eversion are more responsive to the lateral wedging (and some anecdotal clinical experience supporting this). None of the systematic reviews account for this (and they can’t as none of the RCT’s sub-analysed for this), let alone any guidelines (but should they in the absence of evidence?).

    A similar example happened in the shockwave for heel pain systematic reviews. A couple of the RCT’s that were included in the systematic reviews used a very low dose of shockwave and found it did not work at those doses (that is what they set out to do, so nothing wrong with that); but no one uses shockwave therapy clinically at that dose! But, those RCT’s got included in the systematic reviews that made conclusions about shockwave’s efficacy for heel pain. Should those studies have been excluded? Would the result of the systematic review be different if they were excluded? (I not looked closely enough to know).

    I have no doubt in my mind that lateral wedging for medial knee OA is effective for certain sub-populations. It is just the lack of evidence and clear guidelines as to who is in that sub-population.

    On the one hand we have to believe in evidence based practice but on the other had we have to make clinical decisions to treat patients.....
     
  18. efuller

    efuller MVP

    A couple of issues with this. One: a valgus wedge is not going to "block" all motion. Two: There is more than one joint that alows transverse plane movement of the trunk relative to the ground. We will often see patients with late stance phase internal leg rotation (at a time when external rotation would allow optimal stride length). Therefore, external rotation of the tibia relative to the foot is not critical for walking, even if we could block that motion.

    So, if someone's knee feels better with a valgus wedge, I think it would be better than the effects of any potential loss of motion of the STJ. If the valgus wedge causes symptoms somewhere else take it out. It is a very cheap and reversable treatment.

    Regards,

    Eric
     
  19. I am a physiotherapist working within the NHS in Britain and am constrained by the fact that treatment has to be evidenced based. However, it does not need to be research evidence it can also be clinical. I have seen the improvement to gait patterns and relief of pain afforded by the use of orthotics and often refer patients to biomechanical podiatrists even if the original problem has been solved as aberrant gait patterns due to minor foot dysfunctions mean that the problem may well recur. The alteration of gait by the use of orthotics has major potential in musculo skeletal medicine although it is difficult to prove in randomised controlled trials which were after all designed to test drugs. Physiotherapy aims to relieve pain and restore function by restoring normal smooth movement when possible. The use of lateral wedges presents difficulties as it changes the gait pattern to one that is less smooth and less anatomically correct. It may ease the pain in walking but over time it has the potential to cause pain and dysfunction further up the chain. The results of what happens at the foot, which is at the end of a long lever arm, are hugely magnified at the other end of the lower limb or even the lumbar or cervical spine. Would someone think to stop wearing a lateral wedge because they had neck, back or hip pain? I have tried lateral wedges with patients with MCOA but I personally found that the gait pattern which they produced was not an improvement and therefore could not clinically advocate them except as a means of very temporary pain relief.
     
  20. Graham

    Graham RIP

    Kathleen,

    Use of lateral wedging alone may in deed be detrimental to a smooth an progressive gait pattern. however, when used appropriately as a component of an orthotic device designed around sagittal plane facilitation principals it is very effective.

    As with most orthotic or wedging principals they rarley work alone. When used within a framework of biomechanical theoretical consideration they can contribute to a positive outcome.

    Regards
     
  21. efuller

    efuller MVP

    So, are you recommending no change for the medial knee osteoarthritis because there is potential to cause problems elsewhere? If the lateral wedge helps the arthritis use it until other problems develop and then remove it. I have a patient with significant genu varum with pronation related foot problems. I gave him orthotics with somewhat of a varus heel effect. His knee started to hurt and he took the orthotics out and his knee felt better, but his foot started to hurt. He went through this many times. Finally, I got him to tape a coin on the bottom of his orthotic add a little more wedge in the direction he needed. He's a well educated patient who can treat himself now. The key to the tissue stress approach is knowing which direction to tilt the wedge.


    You cannot always extrapolate about additive effects of a lever arm if there are joints in between the point of application of force and the body part in question. Which anatomical structure are you claiming a huge magnified lever arm for?

    How do you know the gait pattern you saw was not an improvement? Shouldn't you give the patient the choice? How would a lateral wedge cause hip neck or back pain?

    Regards,
    Eric Fuller
     
  22. kerstin

    kerstin Active Member

    Yes I agree when it helps the patient, then the treatment is OK, and when it starts to give problems elsewhere you have to look how you can change the orthotics so it stays Ok without pain. But I try to avoid the lateral wedges, when the patient significantly pronates in the subtalair joint.
    But still I believe most of the OA patients has a torsional problem around the knee, so the motion occurs around the femur/hip is also important to look at. Sometimes you really need to give strengthening exercises for the hip for an optimal result.

    Best regards,
    kerstin
     
  23. Dear Eric,

    As a physio I do not feel very comfortable with the very complex mechanisms of the foot in motion but I feel that there is a pattern in gait. At heel strike the foot is supinated, the knee extended the lower limb externally rotated, this is a rigid position which will accept weight, the other foot is not in contact at this time. As the knee is extended the end of the lever when the foot is supinated is therefore the hip joint. The foot then moves into pronation, the knee flexes and the lower limb is internally rotating the other foot is on the ground in a weight accepting position. This is a shock absorbing balancing phase of gait. As the knee is flexed, the end of the lever when the foot is pronated is the knee joint. Would you agree ?

    Kathleen
     
  24. Graham

    Graham RIP

    Kathleen,
    No! At heel strike of one foot the other foot is at toe off phase but still in contact with the ground. Double support phase.

    single support phase is when the other limb is in swing phase. Only in running is there no double support phase.

    Regards
     
  25. efuller

    efuller MVP

    I think you are making it more complex than you need to. You are describing a pattern that happens some of the time. It appears that you are assuming that STJ pronation "unlocks" the knee and allows flexion and shock absorption. The knee and the STJ are independent joints and motion in one is not required for motion in the other.

    I really don't understand your sentence "As the knee is extended the end of the lever when the foot is supinated is therefore the hip joint. "

    Regards,

    Eric
     
  26. Dear Eric, Sorry about my rather poor way of expressing myself, I think what I have said is quite clear then when I re-read it I see why it causes confusion. But I don't always have time to re-read carefully so sorry about that. Physios think of patterns of gait, like the PNF patterns that are used to strengthen muscles. The pelvis moves forward by about 10-15 degrees and the hip flexes to initiate gait.At this time the knee is extended, the ankle dorsiflexion and the foot supinated - this gives a rigid limb for heel strike. That's when the hip is at the end of the lever because the knee is in extension. When moving to weight acceptance the knee flexes and the foot pronates. At this point the knee is the end of the lever. Does that make sense. If there was no pronation or supination then the rotation of the lower limb which occurs as a result of the pelvis moving in the transverse plane would result in torque and if the amount or timing of pronation and supination is not synchronous then torque will occur at either the hip or the knee. that's my take on it. regards, kathleen
     
  27. NewsBot

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    Articles:
    1
    Dynamic alignment and its association with knee adduction moment in medial knee osteoarthritis.
    Foroughi N, Smith RM, Lange AK, Baker MK, Singh MA, Vanwanseele B.
    Knee. 2009 Nov 4. [Epub ahead of print]
     
  28. NewsBot

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    Articles:
    1
    Immediate effect of lateral-wedged insole on stance and ambulation after stroke.
    Chen CH, Lin KH, Lu TW, Chai HM, Chen HL, Tang PF, Hu MH.
    Am J Phys Med Rehabil. 2010 Jan;89(1):48-55.
     
  29. NewsBot

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    Articles:
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    Laterally wedged insoles in knee osteoarthritis: do biomechanical effects decline after one month of wear?
    Hinman RS, Bowles KA, Bennell KL.
    BMC Musculoskelet Disord.;10:146.
     
  30. NewsBot

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    Articles:
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    Medial Knee Osteoarthritis Treated by Insoles or Braces: A Randomized Trial.
    van Raaij TM, Reijman M, Brouwer RW, Bierma-Zeinstra SM, Verhaar JA.
    Clin Orthop Relat Res. 2010 Feb 23. [Epub ahead of print]
     
  31. NewsBot

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    Articles:
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    Gait Modification via Verbal Instruction and an Active Feedback System to Reduce Peak Knee Adduction Moment.
    Dowling AV, Fisher DS, Andriacchi TP.
    J Biomech Eng. 2010 Jul;132(7):071007.
     
  32. Kahuna

    Kahuna Active Member

    Lateral forefoot wedges for medial knee pain...

    {ADMIN NOTE: Threads merged}

    Hi All

    A few months ago, I started a thread about lateral forefoot wedging as a therapy in the tx of plantar fasciitishttp://www.podiatry-arena.com/podiatry-forum/showthread.php?t=44298

    I just thought I'd post an update to say that some research at Salford University has shown that lateral forefoot wedging also helps reduce medial knee pressure (I'll post a reference as soon as it's available).

    This is an interesting difference to the approach of increasing medial rearfoot posting in the management of medial knee pain.

    Any thoughts? Has this been reported on previously?

    Thanks
     
  33. Peter

    Peter Well-Known Member

    Re: Lateral forefoot wedges for medial knee pain...

    Andy Horwood talked about this at Summer School about 10 years ago!

    Essentially, with genu varum and medial knee compartment OA, increasing RFT medial control worsened symptoms, due to closing the medial knee compartment down.

    The Japanese are big on treating medial compartment OA with lateral RFT posting.
     
  34. admin

    admin Administrator Staff Member

  35. csmcinnes

    csmcinnes Welcome New Poster

    I have also successful used a lateral wedge to relieve medial knee pain due to OA.
    My therory being that with the knees in a valgus position the joint space medially is opened up thus reducing bone on bone contact in this area.
     
  36. NewsBot

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    Articles:
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    A treatment applying a biomechanical device to the feet of patients with knee osteoarthritis results in reduced pain and improved function: a prospective controlled study.
    Bar-Ziv Y, Beer Y, Ran Y, Benedict S, Halperin N.
    BMC Musculoskelet Disord. 2010 Aug 10;11(1):179.
    BSTRACT:
     
  37. NewsBot

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    Gait modification strategies for altering medial knee joint load: A systematic review.
    Simic M, Hinman RS, Wrigley TV, Bennell KL, Hunt MA.
    Arthritis Care Res (Hoboken). 2010 Oct 27. [Epub ahead of print]
     
  38. NewsBot

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    Articles:
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    Changes in in vivo knee loading with a variable-stiffness intervention shoe correlate with changes in the knee adduction moment.
    Erhart JC, Dyrby CO, D'Lima DD, Colwell CW, Andriacchi TP
    J Orthop Res. 2010 Dec;28(12):1548-53
     
  39. HansMassage

    HansMassage Active Member

    In my work I find in such cases the plantaris becomes hypertonic [not returning to neutral during rest] The treatment I use [Structural Relief Therapy] holds the muscle in the shortest length possible for 90 seconds. With recent onset medial knee pain this often gives immediate relief.
    The proposed full length lateral wedge shortens the plantaris so there may be a correlation.
    There is usually a postural pattern that is perpetuating the problem. if it is bilateral it is usually forward head posture. [The podiatrist that refers to me tells clients he is going to say it is in your neck but make sure he also treats you foot.]
    Hans Albert Quistorff, LMP
    Antalgic Posture Pain Specialist
     
  40. CamWhite

    CamWhite Active Member

    Perhaps this is a stupid question, so please indulge me

    This discussion is focusing on rearfoot valgus wedges to offload medial OA pressure on the knee. That makes sense to me during the contact and mid-stance phase of the gait cycle.

    If the same person has a forefoot varus/supinatus tendency, does that exacerbate medial knee OA compression during the propulsive phase of the gait cycle?
     
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