Lateral foot wedging for medial knee OA

Nope. As said above:

Theoretically (and based on the evidence) half the time an 'anti-pronator' shoe is going to decrease the risk.

 

hello,
just a question: I read somewhere that exercise increases cartilage thickness in the knee. If this is correct, wouldn't increasing medial knee cartilage stress reverse the effect of OA?

secondly: was there any examination to find the forefoot rearfoot realationship, or to assess the amount of movement of forefoot to rearfoot in the patient groups in Bennell et al's study (sorry the questions just continue..)

Peter

 

Yes. BUT, subsequent and secondary analyses have not yet been done.

 

Inexpensive and minimalist footwear decreases joint loading in elderly women with knee osteoarthritis during stair descent.
Sacco IC, Trombini-Souza F, Butugan MK, Pássaro AC, Arnone AC, Fuller R.
Arthritis Care Res (Hoboken). 2011 Nov 10.

 

I have been using a lateral heel wedges for a fair while now for medial knee OA. Doesn`t seem to have any detrimental effects, and in the majority of cases provides good relief, often quickly. Simple to use and when it works the patient is really appreciative. I am presently working with a 23 year old with medial knee pain. You can see his knees shift laterally at heel strike. I am playing about with some lateral wedging on his orthotic posts, so far so good. Both his father and grandfather have medial knee OA which he is worried about developing.

 

Hi Guys,
I am just pod student, but have read the posts here by Kevin Kirby, I have tried lateral wedging. I have grade 4 OA in my knee and was told by the orthopeadic surgeon that the only way to reduce the pain was a knee replacement (having previously had arthroscopy to tidy the joint up).

Desperate for an alternative I followed the advice here. The result was a significant (not total) reduction in pain, reduction of analgesic to just anti inflammatory meds, increased walking distance and to date it is manageable and no surgery.

Anecdotal, non scientific data, but brilliant result for me. Thanks Kevin

 

I have found that the real issue in DJD of the knee is whether or not the knee flexes in mid single support or if it fully extends (as it should) at the same time frame. Failure to extends predisposes the knee to being moderately unstable, having a strong tendency to collapse to a valgus alignment. This requires a sagittal plane "fix", ie, ankle manip and 1st ray mobilizing orthotic, but outcomes are excellent.

As an aside, so many running shoes are made now with lateral heel cushions. This tilts the foot as it would with a ridiculous amount of rearfoot varus posting. I have seen many, many patients who improve once they transfer to a more "neutral" shoe.

Howard

 

Hi Cj

Glad to here you are getting some improvement. I find patients are keen to try such a simple treatment approach and when they get some relief, often substantial, they are very grateful.

As a side, I having been getting into some great English ales the last year or 2. A couple of tasty ones from Kent. Must get back there someday.

 

And by quick result he means quick. Did another today and had immediate result on first pass on walking trial.

54 yr old female , waitress, moderate oa, tender to touch at medial meniscus medial tibial flare tender.....

For her it was 5mm xf nicklplast under her regular insole and pain relief was immediate.

 

I'm so glad you mentioned this issue with the lateral heel cushions- i've seen a few patients with those kind of shoes but i dont understand why the manufactures put it there. A lot of people getting neutral shoes have an everted heel at heel strike- so why would you want to create a varus wedge?
It sounds great as a gimmic "cushioning the lateral heel" but really creates a varus wedge that would exaserbate: medial knee loads and peroneal tendonitis.

 

Hi Guys

Good point about soft/cushioned lateral heels on shoes.

 

The varus heel wedge/ soft lateral heel is great for some STJ pronation related problems and people with genu valgum and lateral knee pain.

Eric

 

Hi Eric. If one of these patients came in wth the lateral heel worn all the way down would you still think this is acceptable? Its as though these shoe manufactorers are creating brand new,worn out shoes. From my perspective this is about the worst shoe design possible

Howard

 

The dual density midsole has been around for over 20 years. There's a study that shows that they reduce pronation velocity at heel contact. The theory is that the dual density midsole shoe will shift the center of pressure more medially and reduce the pronation moment from the ground. It will also reduce knee abduction moment from the ground. This will be good for some people. It will be bad for other people.

Eric

 

Actually, the dual density midsole for running shoes have been around since about 1981, or 30 years. Like Eric said, ths shoe design is good for many runners, including myself, to limit pronation, but bad for many walkers who over-supinate in gait. These dual density midsoles were one of the best running shoe inventions of the last 40 years but, like all inventions, aren't for everyone.

http://www.drpribut.com/sports/sneaker_odyssey.html

 

I am well aware that the dual density midsoles have been around for decades. What is new (or at least within the last 3-4 years) is the "enhanced" lateral cushioning in the heel. While the strong medial support column is fine, the addition of a much softer lateral heel had rendered these shoes unusable. If the lateral side of your running shoe was worn through, and the shoe tilted to 12-15 degrees of varus.....this would be a bad shoe to run in. This is my arguement....that once the difference between hard medial and soft lateral hit a point where the shoe overly inverts, this goes from a good to bad concept.

Howard

 

Howard:

I agree with you. The fairly recent trend toward "too soft" lateral midsoles seems to be making shoes break down much more rapidly than before. I have sent many of my patients back to the shoe store to exchange these shoes for other shoes with higher durometer lateral midsoles at the rearfoot. Maybe the shoe companies want customers to be buying shoes more frequently?

 

I would agree. The softer it gets, the fewer people it will be good for. And, the more people it will be bad for.

Eric

 

The knee does not fully extend in mid single support but at just before heel strike.

 

The effect of laterally wedged shoes on the loading of the medial knee compartment-in vivo measurements with instrumented knee implants.
Kutzner I, Damm P, Heinlein B, Dymke J, Graichen F, Bergmann G.
J Orthop Res. 2011 Dec;29(12):1910-5.

 

Not sure what you mean here, but I'll clarify my observations. During weight bearing, the knee IS fully extended by midstep, and maintains this position until heel strike of the contralateral limb. Following contralateral heel strike, flexion of the ipsilateral knee and hip occur with heel lift, signaling the onset of pre-swing phase. Following toeoff, the limb extends until it reaches endpoint, which occurs, as you said, just prior to the next heel strike. Each lower extremity therefore has two points when the knee is fully extended; one in weight bearing, and the other during swing phase.

Howard

 

Now thinking about how the knee responds to high heels or any heel rise on a shoe.

 

Influence of foot positions on the spine and pelvis.
Betsch M, Schneppendahl J, Dor L, Jungbluth P, Grassmann JP, Windolf J, Thelen S, Hakimi M, Rapp W, Wild M.
Arthritis Care Res (Hoboken). 2011 Dec;63(12):1758-65.

 

Lateral wedges decrease biomechanical risk factors for knee osteoarthritis in obese women.
Russell EM, Hamill J.
J Biomech. 2011 Aug 11;44(12):2286-91

 

Effect of footwear on the external knee adduction moment — A systematic review
Andy Oliver Radzimski, Annegret Mündermann, Gisela Sole
The Knee Volume 19, Issue 3, June 2012, Pages 163–175

 

Toe-out, lateral trunk lean, and pelvic obliquity during prolonged walking in patients with medial compartment knee osteoarthritis and healthy controls.
Bechard DJ, Birmingham TB, Zecevic AA, Jones IC, Giffin JR, Jenkyn TR.
Arthritis Care Res (Hoboken). 2012 Apr;64(4):525-32.

 

Hi Kevin,

thank you for a very interesting thread. With the patients that have maximally pronated STJ, do you still apply a rearfoot valgus wedge?


thank you

Peter

 

Peter:

Yes, but a rearfoot and forefoot valgus wedge both.

 

A small integrated lateral wedge does not alter knee joint moments during walking
Claudiane Fukuchi, Jay Worobets, John William Wannop & Darren Stefanyshyn
Footwear Science (in press)

 

Having read the 2011 paper by Bennell et al (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3100910/) I would lean towards not providing lateral wedge insoles for OA. When are those other RCTs due?

Josh Young

Student Prosthetist/Orthotist

 

I have not heard of any results that are imminent. But if you search the clinicaltrials.org site, there are some going on:
http://clinicaltrials.gov/ct2/results?term=lateral wedge AND knee

 

Josh:

Are you going to wait until results are in on RCTs before you do any treatment? I hope not since your practice will be very limited. Take it from my 27 years of practice experience, valgus rearfoot and forefoot wedging works quite well for mild to moderate medial compartment osteoarthritis of the knee, no matter what the studies say.

By the way, what would be the harm of trying these insole modifications to see if they work. Or would you rather tell your patients, "I'm so sorry I can't help you since I'm afraid to try any treatment on you until a randomized controlled trial clearly states that these simple devices may help your knee pain."

 

Kevin,

As I understand the research above indicates that the patients experienced a small improvement in pain whether their insoles were (5-degree) wedged or not. Admittedly this was based on blanket use of a single insole design for everyone. However it makes me skeptical that even if I provided an individually designed insole, perhaps with greater wedging, the improvement the patient reports may just be due to placebo effect.

I agree that a lot of orthotic treatment (including AFOs, spinal etc) has a limited evidence base. It's just that the above study seems to indicate contra-evidence, rather than a lack of evidence. I'll be keen to see what future studies find.

Many thanks,

Josh

 

Josh:

In clinical practice, people are in pain and need our help. I have helped literally thousands of people get out of pain with treatment methods that make good mechanical sense, but have no RCTs to back them up.

Don't limit yourself to just using methods that are researched to help your patients or you will become a relatively useless clinician. Understand the biomechanics of the foot and lower extremity, observe your treatment effects carefully, and do what it takes to help your patients get out of pain.

Honestly, after over a quarter century of practice and having treated literally tens of thousands of patients, I could care less about what the research says, even though it is nice when I see research supporting what I have been doing for a few decades to help people. Use your knowledge and creativity to help people get out of pain....your patients will appreciate it very much.

 

This recent review seems to be more optimistic towards lateral wedge insoles, despite issues with evidence:

Bracing and orthoses: a review of efficacy and mechanical effects for tibiofemoral osteoarthritis

PM R. 2012 May;4(5 Suppl):S89-96.

Segal N A

Abstract

The knee is the weight-bearing joint most commonly affected by osteoarthritis. Bracing of the knee or the foot can be a useful nonoperative and nonpharmacologic treatment for persons with osteoarthritis that predominantly involves either the medial or lateral tibiofemoral compartment. The aim of wedged insoles and realigning knee braces is to reduce articular contact stress in the more involved tibiofemoral compartment. There is evidence that even knee sleeves that do not have an effect on alignment may confer symptomatic relief and enhance joint position sense. This review summarizes the current state of knowledge regarding the degree to which bracing at the knee or foot can effectively correct tibiofemoral malalignment, improve knee joint pain, and enhance physical function, and provides clinical recommendations for prescription of these devices to optimize effectiveness.


http://www.ncbi.nlm.nih.gov/pubmed/22632708

 

Comparison of the efficacy of laterally wedged insoles and bespoke unloader knee orthoses in treating medial compartment knee osteoarthritis.
Arazpour M, Bani MA, Maleki M, Ghomshe FT, Kashani RV, Hutchins SW.
Prosthet Orthot Int. 2012 Aug 3.

 

Effectiveness of different orthoses on joint moments in patients with early knee osteoarthritis: Lateral wedge versus valgus knee bracing

Min Zhang, Pei-yu Qu, Mei-lan Feng, Lan Jiang, Xiao-yan Shen, Yan-hong Ma and Yue-hong Bai JOURNAL OF SHANGHAI JIAOTONG UNIVERSITY (SCIENCE) Volume 17, Number 4 (2012), 505-510

The purpose of the study was to test the biomechanical differences between a lateral wedge and a valgus knee bracing on the knee joint moment during walking in patients with early stage of medial compartment knee osteoarthritis (OA). We conducted a crossover randomized design to compare gait parameters of 32 patients (with early stage medial compartment knee OA) in three different conditions during walking: with a custom-made lateral wedge of 5° (in standard shoes), with a valgus knee bracing (in standard shoes), and with control condition (in standard shoes). Both two-orthose conditions showed decreased loading patterns (knee adduction moment and knee adduction angular impulse) on the knee joint in dynamic condition (statistic probability P < 0.05). The decreased loading on OA knee in wedge condition was associated with a laterally shifted location of centre of pressure and increased ankle valgus degree and moment at the same foot (P < 0.05). It was not found significant differences in loading of the knee between these two-orthose conditions. These results indicated that, under dynamic condition, patients wearing lateral wedge and valgus knee bracing showed changes of moments on knee joints. Lateral wedge was as effective as valgus knee bracing in the treatment of early stage of knee OA

 

A comparison of the biomechanical effects of valgus knee braces and lateral wedged insoles in patients with knee osteoarthritis
Richard K. Jones, Christopher J. Nester, Jim D. Richards, Winston Y. Kim, David S. Johnson, Sanjiv Jari, Philip Laxton, Sarah F. Tyson
Gait and Posture, In press, Corrected Proof

 

Foot kinematics in people with medial compartment knee osteoarthritis
Pazit Levinger, Hylton B. Menz, Adam D. Morrow, Julian A. Feller, John R. Bartlett, Neil R. Bergman
Rheumatology (2012) doi: 10.1093/rheumatology/kes222 First published online: August 25, 2012

 

Combined effects of a valgus knee brace and lateral wedge foot orthotic on the external knee adduction moment in patients with varus gonarthrosis
Rebecca F. Moyer, Trevor B. Birmingham, Robert F. Walsh, Kristyn M. Leitch, Thomas R. Jenkyn, J. Robert Giffin
Archives of Physical Medicine and Rehabilitation; Available online 17 September 2012