Lateral foot wedging for medial knee OA

NewsBot · Aug 10, 2019

Combined effects of knee brace, laterally wedged insoles, and toe-out gait on knee adduction moment and fall risk in moderate medial knee osteoarthritis patients.
Khan SJ et al
ProsthetOrthot Int. 2019 Apr;43(2):148-157

BACKGROUND::
Knee osteoarthritis is a major contributor to the global burden of disease. There is a need of reducing knee joint load and to improve balance and physical function among knee osteoarthritis patients.

OBJECTIVES::
To test the hypothesis that toe-out gait will reduce second peak knee adduction moment further and increase fall risk when combined with knee brace and laterally wedged insole in knee osteoarthritis patients.

STUDY DESIGN::
Single visit study with repeated measures.

METHODS::
First and second peak knee adduction moments, fall risk and comfort level. First and second peak knee adduction moments were determined from three-dimensional gait analysis, completed under six randomized conditions: (1) natural, (2) knee brace, (3) knee brace + toe-out gait, (4) laterally wedged insole, (5) laterally wedged insole + toe-out gait, and (6) knee brace + laterally wedged insole + toe-out gait. Fall risk was assessed by Biodex Balance System using three randomized stability settings: (1) static, (2) moderate dynamic setting (FR12), and (3) high dynamic setting (FR8).

RESULTS::
The reduction in first peak knee adduction moment and second peak knee adduction moment was greatest (7.16% and 25.55%, respectively) when toe-out gait combine with knee brace and laterally wedged insole. Significant increase in fall risk was observed with knee brace + laterally wedged insole + toe-out gait (42.85%) at FR12. Similar significant balance reductions were found at FR8 condition for knee brace + toe-out gait (35.71%), laterally wedged insole + toe-out gait (28.57%), and knee brace + laterally wedged insole + toe-out gait (50%) as compared to natural. However, knee brace decreased fall risk at FR12 by 28.57%.

CONCLUSION::
There is a synergistic effect of toe-out when combined with knee brace and laterally wedged insole concurrently in second peak knee adduction moment reduction but with a greater degree of fall risk. Simultaneous use of conservative treatments also decreases comfort level.

CLINICAL RELEVANCE:
Patients with mild and moderate knee osteoarthritis are usually prescribed conservative treatment techniques. This study will provide an insight whether or not a combination of these techniques have a synergistic effect in reducing knee joint load.
Click to expand...

NewsBot · Sep 13, 2019

Does gait retraining have the potential to reduce medial compartmental loading in individuals with knee osteoarthritis whilst not adversely affecting the other lower limb joints? A systematic review
JakeBowdMScabPaulBiggsPhDabCathyHoltPhDabGemmaWhatlingPhDab
Archives of Rehabilitation Research and Clinical Translation; 5 September 2019, 100022

Objectives
To review the literature regarding gait retraining to reduce knee adduction moments and its effects on hip and ankle biomechanics.

Data sources
Twelve academic databases were searched from inception to January 2019. Key words “walk*” OR “gait”, “knee” OR “adduction moment”, “osteoarthriti*” OR “arthriti*” OR “osteo arthriti*” OR “OA”, and “hip” OR “ankle” were combined with conjunction “and” in all fields.

Study selection
Abstracts and full-text articles were assessed by two individuals against a pre-defined criterion.

Data synthesis
Out of the 11 studies, sample sizes varied from 8-40 participants. Eight different gait retraining styles were evaluated: hip internal rotation, lateral trunk lean, toe-in, toe-out, increased step width, medial thrust, contralateral pelvic drop, and medial foot weight transfer. Using the Black and Downs tool, the methodological quality of the included studies was fair to moderate ranging between 12/25 to 18/28. Trunk lean and medial thrust produced the biggest reductions in first peak knee adduction moment. Studies lacked collective sagittal and frontal plane hip and ankle joint biomechanics. Generally, studies had a low sample size of healthy participants and assessed gait retraining during one laboratory visit, whilst not documenting the difficulty of the gait retraining style.

Conclusions
Gait retraining techniques may reduce knee joint loading, however the biomechanical effects to the pelvis, hip and ankle is unknown, as well as a lack of understanding for the ease of application of the gait retraining styles.
Click to expand...

NewsBot · Oct 17, 2019

The Effects of Short-Term Wearing of Customized 3D Printed Single-Sided Lateral Wedge Insoles on Lower Limbs in Healthy Males: A Randomized Controlled Trial.
Jin H et al
Med Sci Monit. 2019 Oct 15;25:7720-7727

BACKGROUND Unbalanced standing and gait asymmetry are common in individuals with musculoskeletal disorders. Achieving symmetrical posture and gait is an important goal of rehabilitation. This study investigated the biomechanical differences in the lower extremities observed immediately after an insole was used and without the use of different one-sided insoles. MATERIAL AND METHODS Thirty young, healthy adult males received 3 different insole interventions: experimental group A had a customized 3-dimensional (3D)-printed single-sided lateral wedge insole (CLWI) inserted on the left side, and experimental group B had on the left side, a traditional single insert. The control had unilateral flat insoles; no insole inserted into the socks. Motion mechanics and gait parameters were collected at the 2-time points, after insertion of the insole and after 20 minutes of walking with the insole. RESULTS Asymmetric posture and gait appeared immediately after using the 2 insoles (lower joint moment, P<0.05). Compared with the control group, the abnormal posture and gait of experimental group B after wearing the traditional insole for 20 minutes were not obvious (P>0.05). However, the asymmetrical posture and gait remained in experimental group A after wearing the CLWI for 20 minutes (P<0.05). The center of pressure (COP) trajectory of the left foot of experimental group A was significantly higher than that of experimental group B and the control group at the 2-time points (P<0.05). CONCLUSIONS The asymmetry of posture and gait can be observed in a short time using a customized 3D-printed single-sided lateral wedge insole. This experiment provides guidance for the application of customized 3D-printed single-sided lateral wedge insoles for gait rehabilitation.
Click to expand...

NewsBot · Oct 27, 2019

Effect of lateral-wedge insole on the center of foot pressure and lower extremity muscle activity at gait initiation in patients with medial knee osteoarthritis.
Katoh H
J Phys Ther Sci. 2019 Oct;31(10):776-779

[Purpose] In clinical settings, patients with knee osteoarthritis often complain of pain at gait initiation. In the present study, we aimed to determine the differences in the center of foot pressure and lower extremity muscle activity at gait initiation in healthy volunteers compared to patients with medial knee osteoarthritis. [Participants and Methods] The study comprised of 10 females without medial knee osteoarthritis (healthy group) and 10 females with medial knee osteoarthritis (medial knee osteoarthritis group). We measured the center of foot pressure trajectory and muscle activity onset times of the tibialis anterior and internal gastrocnemius at gait initiation. Moreover, we examined the effects of insole use in the medial knee osteoarthritis group. [Results] The posterior center of foot pressure displacement was significantly smaller in the medial knee osteoarthritis group (barefoot and insole) than in the healthy group. The anterior center of foot pressure displacement significantly improved with insole use. The muscle activity onset time of the tibialis anterior was significantly delayed in the medial knee osteoarthritis group (barefoot) than in the healthy group. [Conclusion] Postural control decreased at gait initiation in the medial knee osteoarthritis group.
Click to expand...

NewsBot · Dec 24, 2019

The optimal degree of lateral wedge insoles for reducing knee joint load: a systematic review and meta-analysis
Vitor FerreiraRita SimõesRui Soles GonçalvesLeandro MachadoPaulo Roriz
Archives of Physiotherapy December 2019

Background
Lateral wedge insoles are traditionally used to reduce the adduction moment that crosses the knee during walking in people with medial knee osteoarthritis. However, the best degree to reduce knee joint load is not yet well established.

Methods
Electronic databases were searched from their inception until May 2017. Included studies reported on the immediate biomechanical effects of different degrees of lateral wedge insoles during walking in people with knee osteoarthritis. The main measures of interest relating to the biomechanics were the first and second peak of external knee adduction moment and knee adduction angular impulse. For the comparison of the biomechanical effects of different degrees of insoles, the studies were divided in three subgroups: insoles with a degree higher than 0° and equal to or lower than 5°; insoles higher than 5° and equal to or lower than 9°; and insoles higher than 9°. Eligible studies were pooled using random-effects meta-analysis.

Results
Fifteen studies with a total of 415 participants met all eligibility criteria and were included in the final review and meta-analysis. The overall effect suggests that lateral wedge insoles resulted in a statistically significant reduction in the first peak (standardized mean difference [SMD] –0.25; 95% confidence interval [CI] –0.36, − 0.13; P < 0.001), second peak (SMD –0.26 [95% CI –0.48, − 0.04]; P = 0.02) and knee adduction angular impulse (SMD –0.17 [95% CI –0.31, − 0.03]; P = 0.02). The test of subgroups found no statistically significant differences.

Conclusion
Systematic review and meta-analysis suggests that lateral wedge insoles cause an overall slight reduction in the biomechanical parameters. Higher degrees do not show higher reductions than lower degrees. Prior analysis of biomechanical parameters may be a valid option for selecting the optimal angle of wedge that best fits in knee osteoarthritis patients with the lowest possible degree.
Click to expand...

NewsBot · Apr 16, 2020

The effect of a lateral wedge insole and a subtalar strap on gait parameters in knee osteoarthritis.
Esfandiari E et al
Med J Islam Repub Iran. 2019 Dec 30

Background: Lateral wedge insole (LWI) aims to reduce loading on medial compartment of tibiofemoral joint in mild knee osteoarthritis (KOA). This effect may be augmented by concomitant use of subtalar strap to fix the ankle joint. Moreover, longitudinal arch support embedded in insoles can cause foot comfort and may be beneficial for people with KOA. Therefore, this study aimed to assess the immediate effect of LWI with an arch support with and without a subtalar strap on the kinetics and kinematics of walking in mild KOA. Methods: A convenient sample of 17 individuals with mild KOA (Kellgren and Lawrence grade II), aged ≥ 40 years were assessed in 3 conditions: without the insole; LWI; and LWI with a subtalar strap, where an arch support was embedded in all insoles. The primary outcomes were external knee adduction moment and angular impulse. The secondary outcomes were hip flexion and adduction moments, knee flexion angle, ankle eversion moment, and walking speed. The repeated measurements ANOVA was used to compare the primary and secondary outcomes between the conditions using SPSS. Significance level was set at 0.05. Results: LWI and a subtalar strap can significantly increase the knee flexion angle at 0%-15% of the stance phase compared to no insole (p<0.001). No other changes were observed (p=0.142). Conclusion: LWI with an arch, with or without a subtalar strap, cannot impose any immediate changes on the kinetics and kinematics of lower limb joints during walking in people with mild KOA.
Click to expand...

NewsBot · Jun 27, 2020

Influence of foot posture on immediate biomechanical responses during walking to variable-stiffness supported lateral wedge insole designs
Calvin T.F.Tse et al
Gait & Posture; 27 June 2020

Highlights
•Walking biomechanics at the knee and ankle differ with different insole properties.
•Individuals with supinated feet exhibit less biomechanical changes with insoles.
•Supported lateral wedge insoles reduce maintaining ankle kinematics.
•Future work in people with knee osteoarthritis is justified.
Click to expand...

Background
Novel designs of lateral wedge insoles with arch support can alter walking biomechanics as a conservative treatment option for knee osteoarthritis. However, variations in foot posture may influence individual responses to insole intervention and these effects are not yet known.

Research question
How does foot posture influence biomechanical responses to novel designs of lateral wedge insoles with arch support?

Methods
This exploratory biomechanical investigation categorized forty healthy volunteers (age 23 to 34) into pronated (n = 16), neutral (n = 15), and supinated (n = 9) foot posture groups based on the Foot Posture Index. Three-dimensional gait analysis was conducted during walking in six orthotic insole conditions: flat control, lateral wedge, uniform-stiffness arch support, variable-stiffness arch support, and lateral wedge + each arch support. Frontal plane knee and ankle/subtalar joint kinetic and kinematic outcomes were compared between insole conditions and foot posture groups using a repeated measures analysis of variance.

Results
The lateral wedge alone and lateral wedge + variable-stiffness arch support were the only insole conditions effective at reducing the knee adduction moment. However, the lateral wedge + variable-stiffness arch support had a smaller increase in peak ankle/subtalar eversion moment than the lateral wedge alone. Supinated feet had smaller ankle/subtalar eversion excursion and moment impulse than neutral and pronated feet, across all insole conditions.

Significance
Supinated feet have less mobile ankle/subtalar joints than neutral and pronated feet and as a result may be less likely to respond to biomechanical intervention from orthotic insoles. Supported lateral wedge insoles incorporating arch support design that is variable-stiffness may be better than uniform-stiffness since reductions in the knee adduction moment can be achieved while minimizing increases in the ankle/subtalar eversion moment.
Click to expand...

NewsBot · Aug 31, 2020

Gait initiation and lateral wedge insole for individuals with early knee osteoarthritis
Elham Esfandiari et al
Clin Biomech: August 28, 2020

Highlights
•Early knee osteoarthritis is associated with longer gait initiation cycle.
•Anticipatory postural adjustment phase is longer in early knee osteoarthritis.
•Bipedal standing phase is longer in early knee osteoarthritis.
•Lateral wedge insole can improve locomotor phase in knee osteoarthritis.
Click to expand...

Background
People with knee osteoarthritis are at higher risk of postural deficits and locomotor adaptations which could be manifested in transient tasks like gait initiation. To better understand the effect of early knee osteoarthritis on gait initiation, we measured the gait initiation in two groups of early knee osteoarthritis and healthy age-matched controls and assessed the effect of lateral wedge insole in knee osteoarthritis group.
Methods
Twenty-one individuals with early knee osteoarthritis, mean (SD) age = 53.1 (7.4, years), and 19 age- and sex-matched asymptomatic healthy individuals, mean (SD) age = 47.5 (11.2, years), participated. Centre of pressure trajectories were used to quantify the two phases of gait initiation in barefoot condition: anticipatory postural adjustment, and locomotor phase. The immediate and four-week effect of lateral wedge insole and shod condition were also compared for individuals in knee osteoarthritis group.
Findings
Longer duration of anticipatory postural adjustment phase ( P = 0.046), locomotor phase ( P = 0.049), and total duration of gait initiation ( P = 0.035) with lower length and velocity of the center of pressure trajectories in anticipatory postural adjustment phase ( P = 0.002, and 0.008, respectively) were observed in knee osteoarthritis group compared to controls. Lateral wedge insole could increase the length and velocity of the centre of pressure in locomotor phase compared to barefoot condition ( P = 0.001, and 0.002, respectively).
Interpretation
Our study outlined that people with early knee osteoarthritis adopt different gait initiation strategies mainly in postural preparation phase. The potential effect of lateral wedge insole was shown with better performance of the locomotor phase.
Click to expand...

NewsBot · Dec 5, 2020

How foot progression angle affects knee adduction moment and angular impulse in people with and without medial knee osteoarthritis: a meta-analysis
Sizhong Wang et al
Arthritis Care Res (Hoboken). 2020 Aug 16

Objective: To investigate effects of foot progression angle (FPA) modification on the first and second peaks of external knee adduction moment (EKAM) and knee adduction angular impulse (KAAI) in individuals with and without medial knee osteoarthritis (OA) during level walking.

Methods: PubMed, Embase, CINAHL, Web of Science and SPORTDiscus were searched from inception to February 2020 by two independent reviewers. Included studies compared FPA modification (toe-in or toe-out gait) interventions to lower EKAM and/or KAAI with natural walking. Studies were required to report the first or second peaks of EKAM or KAAI.

Results: Sixteen studies were included and more than 85% of included patients were graded with Kellgren-Lawrence II-IV knee OA. Toe-in gait reduced the first EKAM peak (standard mean difference (SMD): -0.75; 95%CI: -1.05~-0.45) and KAAI (SMD: -0.46; 95%CI: -0.86~-0.07), while toe-out gait reduced the second EKAM peak (SMD: -1.04; 95%CI: -1.34~-0.75) in healthy individuals. For patients with knee OA, toe-out gait reduced the second EKAM peak (SMD: -0.53; 95%CI: -0.75~-0.31) and KAAI (SMD: -0.26; 95%CI: -0.49~-0.03) while toe-in gait did not affect both EKAM peaks and KAAI.

Conclusion: Discrepancy in biomechanical effects of FPA modification was demonstrated between individuals with and without medial knee OA. Compared with natural walking, both toe-in and toe-out gait may be more effective in lowering EKAM and KAAI in healthy individuals. Toe-out gait may reduce EKAM and KAAI in patients with mild to severe knee OA. There is insufficient data from patients with early-stage knee OA, indicating future research is required.
Click to expand...

NewsBot · Mar 17, 2021

Effects of tailored lateral wedge insoles on medial knee osteoarthritis based on biomechanical analysis: 12-week randomized controlled trial
Vitor Ferreira et al
Clin Rehabil. 2021 Mar 15

Background: Lateral wedge insoles adjusted by biomechanical analysis may improve the condition of patients with medial knee osteoarthritis.

Design: This is a prospective, randomized, controlled, single-blind clinical trial.

Setting: The study was conducted in a biomechanics laboratory.

Subjects: A total of 38 patients with medial knee osteoarthritis were allocated to either an experimental group (lateral wedge insoles) or a control group (neutral insoles).

Interventions: Experimental group (n = 20) received an adjusted lateral wedge insole of 2, 4, 6, 8, or 10 degrees, after previous biomechanical analysis. Control group (n = 18) received a neutral insole (0 degrees). All patients used the insoles for 12 weeks.

Main measures: Visual analogue scale, Knee Injury and Osteoarthritis Outcome Score questionnaire, biomechanical parameters: first and second peak of the external knee adduction moment and knee adduction angular impulse, and physical performance tests: 30-second sit-to-stand test, the 40-m fast-paced walk test, and the 12-step stair-climb test.

Results: After 12 weeks, between-group differences did not differ significantly for pain intensity (-12.5 mm, (95% CI -29.4-4.4)), biomechanical parameters (p = 0.05), Knee Injury and Osteoarthritis Outcome Score, and physical performance tests, except on the Knee Injury and Osteoarthritis Outcome Score subscale other symptoms (p = 0.002; 13.8 points, (95% CI 5.6-22.0)).

Conclusion: Tailored wedge insoles were no more effective at improving biomechanical or clinically meaningful outcomes than neutral insoles, except on symptoms. More participants from the experimental group reported they felt some improvement. However, these effects were minimal and without clinical significance
Click to expand...

NewsBot · Mar 17, 2021

Estimation of the External Knee Adduction Moment during Gait Using an Inertial Measurement Unit in Patients with Knee Osteoarthritis
Yu Iwama et al
Sensors (Basel). 2021 Feb 18;21(4):1418

Although the external knee adduction moment (KAM) during gait was shown to be a quantitative parameter of medial knee osteoarthritis (OA), it requires expensive equipment and a dedicated large space to measure. Therefore, it becomes a major reason to limit KAM measurement in a clinical environment. The purpose of this study was to estimate KAM using a single inertial measurement unit (IMU) during gait in patients with knee OA. A total of 22 medial knee OA patients (44 knee joints) performed conventional gait analysis using three-dimensional (3D) motion capture system. At the same time, we attached commercial IMUs to six body segments (sternum, pelvis, both thighs, and both shanks), and IMU signals during gait were recorded synchronized with the motion capture system. The peak-to-peak difference of acceleration in the lateral/medial axis immediately after heel contact was defined as the thrust acceleration (TA). We hypothesized that TA would represent the lateral thrust of the knee during the stance phase and correlate with the first peak of KAM. The relationship between the peak KAM and TA of pelvis (R = 0.52, p < 0.001), shanks (R = 0.57, p < 0.001) and thighs (R = 0.49, p = 0.001) showed a significant correlation. The root mean square error (RMSE) of linear regression models of pelvis, shanks, and thighs to estimate KAM were 0.082, 0.079, and 0.084 Nm/(kg·m), respectively. Our newly established parameter TA showed a moderate correlation with conventional KAM. The current study confirmed our hypothesis that a single IMU would predict conventional KAM during gait. Since KAM is known as an indicator for prognosis and severity of knee OA, this new parameter has the potential to become an accessible predictor for medial knee OA instead of KAM.
Click to expand...

efuller · Mar 24, 2021

NewsBot said: ↑

Estimation of the External Knee Adduction Moment during Gait Using an Inertial Measurement Unit in Patients with Knee Osteoarthritis
Yu Iwama et al
Sensors (Basel). 2021 Feb 18;21(4):1418
Click to expand...

I'm impressed that an inertial measurement unit was able to detect a difference. I'm assuming that the device is detecting motion, or relative motion between parts. I have seen some patients that you can, with the naked eye, see knee adduction at heel contact. Where the device might miss some people with a high knee external knee adduction moment is when there is a moment and no motion. There will be a knee adduction moment when the center of pressure under the foot is medial to the center of pressure of contact between the tibia and the femur. You will see this with genu varum when the foot is medial to the knee. I wonder if anyone has looked at the amount of bow leggedness in relation to the knee adduction moment.

NewsBot · Mar 30, 2021

A comparison between laterally wedged insoles and ankle-foot orthoses for the treatment of medial osteoarthritis of the knee: A randomized cross-over trial
Martin Schwarze et al
Clin Rehabil. 2021 Mar 29

Objective: To compare biomechanical and clinical outcome of laterally wedged insoles (LWI) and an ankle-foot orthosis (AFO) in patients with medial knee osteoarthritis.

Design: Single-centre, block-randomized, cross-over controlled trial.

Setting: Outpatient clinic.

Subjects: About 39 patients with symptomatic medial knee osteoarthritis.

Interventions: Patients started with either LWI or AFO, determined randomly, and six weeks later changed to the alternative.

Main measures: Change in the 1st maximum of external knee adduction moment (eKAM) was assessed with gait analysis. Additional outcomes were other kinetic and kinematic changes and the patient-reported outcomes EQ-5D-5L, Oxford Knee Score (OKS), American Knee Society Clinical Rating System (AKSS), Hannover Functional Ability Questionnaire - Osteoarthritis and knee pain.

Results: Mean age (SD) of the study population was 58 (8) years, mean BMI 30 (5). Both aids significantly improved OKS (LWI P = 0.003, AFO P = 0.001), AKSS Knee Score (LWI P = 0.01, AFO P = 0.004) and EQ-5D-5L Index (LWI P = 0.001, AFO P = 0.002). AFO reduced the 1st maximum of eKAM by 18% (P < 0.001). The LWI reduced both maxima by 6% (P = 0.02, P = 0.03). Both AFO and LWI reduced the knee adduction angular impulse (KAAI) by 11% (P < 0.001) and 5% (P = 0.05) respectively. The eKAM (1st maximum) and KAAI reduction was significantly larger with AFO than with LWI (P = 0.001, P = 0.004).

Conclusions: AFO reduces medial knee load more than LWI. Nevertheless, no clinical superiority of either of the two aids could be shown.
Click to expand...

NewsBot · May 23, 2021

Effect of medial foot loading self-practice on lower limb kinematics in young individuals with asymptomatic varus knee alignment
Seobin Choi, Gwanseob Shin
Knee. 2021 May 17;30:305-313

Background: Varus alignment of the knee is a risk factor for developing knee osteoarthritis. Recently, voluntary shifting the plantar pressure distribution medially (medial foot loading) during gait has been found to reduce knee adduction angle during stance, which may lower the joint load. However, it is not yet known whether such effect would persist after long-term self-practice. This study aimed to determine whether medial foot loading can be an effective self-care protocol for reducing the knee adduction angle.

Methods: Eight subjects with asymptomatic varus knee alignment were trained on medial foot loading once in a laboratory, then carried out as self-practice for 8 weeks outside the laboratory. Spatiotemporal gait parameters and lower limb joint kinematics data were collected during natural walking prior to the training (baseline walking), during the practice session immediately after the initial training (trained walking), and during natural walking after the self-practice period (post-practice walking).

Results: Participants walked significantly faster after the self-practice period with longer step length compared with the baseline. The knee adduction angle at initial contact, maximum angle during stance, and mean angle during a gait cycle were significantly decreased during both the trained and post-practice walking compared with baseline. The 8-week self-practice caused larger decrements in the three angles than the single training, but no significant differences were found between the two conditions.

Conclusions: Self-practice of medial foot loading walking could be an effective gait strategy to reduce the knee adduction angle. The effect could be sustained for individuals with asymptomatic varus knee alignment.
Click to expand...

NewsBot · Aug 20, 2021

Exploring the relationship between pain intensity and knee moments in participants with medial knee osteoarthritis: a cross-sectional study
Chen. Huang, Ping-Keung. Chan, Kwong-Yuen. Chiu, Chun-Hoi. Yan, Shun-Shing. Yeung & Siu N. Fu
BMC Musculoskeletal Disorders volume 22, Article number: 685 (2021)

Background
High biomechanical loading is believed to be a risk factor to pain in people with knee osteoarthritis (OA), but controversial findings have been reported on the relationship between external knee adduction moment (KAM) and pain. A more comprehensive analysis considering other factor such as external knee flexion moment (KFM) could help better reveal this relationship. This study explored the relationship between external knee adduction moment and pain intensity in participants with knee osteoarthritis (OA) using an integrated path analysis model.

Methods
This was a cross-sectional study based on laboratory setting. Forty-seven participants with clinical and radiographic medial knee OA were analyzed for their external knee adduction moment (KAM) and knee flexion moment (KFM) during walking using a motion analysis system. Pain intensity was measured by visual analogue scale (VAS) and the pain subscale of the Knee Injury and Osteoarthritis Outcome Score. Varus/valgus alignment was captured and quantified using a bi-planar X-ray system. Using a path analysis model, the relationships between pain intensity, KAM, KFM, OA radiographic severity, knee varus angle and walking speed were examined.

Results
The proposed path model met the goodness-of-fit criteria. Based on this model, KAM had a negative effect on VAS pain indirectly through the mediation of KFM. The model indicated KAM and KFM were negatively related to one another; and KFM was positively related to VAS. The KAM index, defined as (KAM/ (KAM + KFM)), was negatively related to VAS.

Conclusions
Path analysis enabled the construction of a more integrated pathokinematic framework for people with knee OA. The KAM index which reflected the load sharing on the frontal and sagittal planes also revealed its relationship with pain. Re-distribution of mechanical loading from frontal to sagittal plane might be a strategy for pain avoidance associated with mechanical irritation.
Click to expand...

NewsBot · Oct 8, 2021

An exploration of changes in plantar pressure distributions during walking with standalone and supported lateral wedge insole designs
Calvin T. F. Tse, Michael B. Ryan, Jason Dien, Alex Scott & Michael A. Hunt
Journal of Foot and Ankle Research volume 14, Article number: 55 (2021)

Background
Lateral wedge insoles (LWI), standalone or with medial arch support (supported-LWI), have been thoroughly investigated for their effects on modifying gait biomechanics for people with knee osteoarthritis. However, plantar pressure distribution between these insole types has not been investigated and could provide insight towards insole prescription with concomitant foot symptoms taken into consideration.

Methods
In a sample of healthy individuals (n = 40), in-shoe plantar pressure was measured during walking with LWI, with or without medial arch support (variable- and uniform-stiffness designs), and a flat control insole condition. Pressure data from the plantar surface of the foot were divided into seven regions: medial/lateral rearfoot, midfoot, medial/central/lateral forefoot, hallux. Plantar pressure outcomes assessed were the medial-lateral pressure index (MLPI) for the whole foot, and the peak pressure, pressure-time integral (PTI), and contact area in each plantar region. Comfort in each insole condition was rated as a change relative to the flat control insole condition. Repeated-measures analyses of variance were calculated to compare the plantar pressure outcomes between insole conditions.

Results
Regionally, medial rearfoot and forefoot pressure were reduced by all wedged insoles, with the variable-stiffness supported-wedge showing greater reductions than the standalone wedge. Lateral rearfoot and forefoot pressure were reduced by both supported-LWI, but unchanged by the standalone wedge. In the midfoot, the standalone wedge maintained pressure but reduced regional contact area, while both supported-LWI increased midfoot pressure and contact area. All LWI increased the MLPI, indicating a lateral shift in plantar pressure distribution throughout the weightbearing phase of gait. Comfort ratings were not significantly different between insole conditions.

Conclusions
Regional differences in plantar pressure may help determine an appropriate lateral wedge insole variation to avoid exacerbation of concomitant foot symptoms by minimizing pressure in symptomatic regions. Lateral shifts in plantar pressure distribution were observed in all laterally wedged conditions, including one supported-LWI that was previously shown to be biomechanically ineffective for modifying knee joint load distribution. Thus, shifts in foot centre of pressure may not be a primary mechanism by which LWI can modify knee joint load distribution for people with knee osteoarthritis.
Click to expand...

NewsBot · Jan 17, 2022

A comparison of the biomechanical and clinical effects of a biaxial ankle-foot orthosis and lateral wedge insole in individuals with medial knee osteoarthritis
Kourosh Barati et al
Disabil Rehabil. 2022 Jan 11;1-8

Purpose: This study aimed to compare a biaxial ankle-foot orthosis (AFO) with a lateral wedge insole in terms of the biomechanical and clinical outcomes in individuals with knee osteoarthritis.

Materials and methods: A cross-over randomized design was used where 31 individuals (25 females and six males, mean age of 52.19 ± 4.12 years) with knee osteoarthritis wore each intervention for two weeks with two weeks washout period. Three-dimensional kinematic and kinetic data and clinical outcomes were collected to evaluate the effects of each intervention on knee adduction moment (KAM), pain, stiffness, and function.

Results: Both orthoses significantly improved pain by 17 and 22%, function by 11 and 14%, the first peak KAM by 15.7 and 19.2%, the second peak KAM by 10.4 and 16.7%, and KAM impulse by 14.8 and 22.2%, respectively. However, the biaxial AFO significantly reduced the KAM and improved function compared to the lateral wedge insole (p < 0.01).

Conclusions: The results of this study have shown that both orthoses have a potential role in the conservative management of medial knee osteoarthritis. The biaxial AFO proved statistically better at improving function and KAM; though these differences do not seem to be clinically significant.IMPLICATION FOR REHABILITATIONOrthotic interventions have been reported to be effective in the management of medial knee osteoarthritis.Lateral wedge insole and biaxial ankle-foot orthosis (AFO) are effective in the improvement of pain, function, and knee adduction moment (KAM) in people with medial knee osteoarthritis.The biaxial AFO, compared with lateral wedge insole, contributes to statistically more improvement of function and KAM. However, these differences do not seem to be clinically significant.
Click to expand...

NewsBot · Mar 15, 2022

Hindfoot flexibility influences the biomechanical effects of laterally wedged insoles and ankle-foot orthoses in medial knee osteoarthritis
Leonie P Bartsch et al
Arch Phys Med Rehabil. 2022 Mar 11

Objective: To investigate the relationship of frontal plane ankle mobility with the effects of an ankle-foot orthosis (AFO) and a laterally wedged insole (LWI) on knee adduction moment (KAM) in the treatment of medial knee osteoarthritis.

Design: Randomized, non-blinded cross-over trial.

Setting: Outpatient clinic of university hospital.

Participants: Referred sample of 20 patients with medial knee osteoarthritis stage 1-3 (Kellgren and Lawrence), aged 56.4 ± 6.5 years. 58 patients assessed, 21 included, 1 drop-out. 14 healthy reference subjects (convenience sample), matched by age.

Interventions: Patients received AFO and LWI for 6 weeks each with gait analysis after each 6-week intervention. Patients underwent additional barefoot gait analysis, walking on even ground and on a cross slope of 5° lateral elevation, and standing on inclinations of 0°, 5°, 10°, and 20°.

Main outcome measures: Spearman correlation between the immediate change in 1st peak of KAM with each aid and the change in hindfoot varus on the cross slope relative to level ground.

Results: The KAM reduction with AFO correlated significantly with hindfoot varus reaction to the cross slope during walking: the greater the hindfoot valgization on the cross slope, the greater the KAM reduction with AFO (Spearman's rho = 0.53, p = 0.02). The KAM reduction with LWI correlated moderately negatively with the change in hindfoot varus: the greater the hindfoot valgization on the cross slope, the smaller the KAM reduction with LWI (r = -0.31 p = 0.18).

Conclusions: LWI may be suitable for patients with limited to normal frontal plane ankle mobility. Patients with greater frontal plane ankle mobility benefit most from frontal plane ankle bridging with AFO. Studies with larger samples are necessary.
Click to expand...

NewsBot · Mar 29, 2022

Radiographic analysis using the hip-to-calcaneus line and its association with lower limb joint kinetics in varus knee osteoarthritis
Naoya Kikuchi et al
Knee. 2022 Mar 19

Background: This study aimed to (1) determine whether the hip to ankle (HA) line or hip to calcaneus (HC) line better reflects knee coronal plane kinetics, (2) to examine whether the HC line reflects ankle coronal plane kinetics, and (3) to evaluate the radiological and biomechanical aspects of ankle in varus knee osteoarthritis (OA).

Methods: Full-length, postero-anterior radiographs (hip-to-calcaneus radiographs) were taken and gait analysis was performed in 21 varus knee OA patients. The %HA where the HA lines pass through the tibial plateau, and the %HC and the mechanical ankle joint axis point (MAJAP), where the HC line passes through the tibial plateau and tibial plafond, respectively, were calculated. Knee adduction angular impulse (KAAI) and ankle inversion angular impulse (AIAI) were collected as kinetic data. Finally, we divided the patients into two groups with and without ankle OA, and compared each parameter between both groups.

Results: The %HA and %HC were correlated with KAAI (%HA; r = -0.68, P = 0.001, %HC; r = -0.81, P < 0.001, respectively) and MAJAP was correlated with AIAI (r = -0.55, P = 0.009). MAJAP was significantly smaller, and KAAI and AIAI were significantly larger in the ankle OA group.

Conclusions: Radiographic analysis using the HC line was more strongly correlated to knee joint kinetics than the HA line and was also correlated to ankle joint kinetics. Assessing lower limb alignment using the HC line could be useful to evaluate the knee and ankle joints for varus knee OA.
Click to expand...

NewsBot · Jun 16, 2022

Knee braces and foot orthoses multimodal treatment of medial knee osteoarthritis
XavierRobert-Lachaine et al
Gait & Posture Volume 96, July 2022, Pages 251-256

Background
Knee braces and lateral wedge foot orthoses are two treatment options recommended for medial knee osteoarthritis, but the combination of both of them could further improve their effectiveness.

Research question
The aim was to evaluate whether the combination of lateral wedge foot orthoses with two types of knee brace enhances the biomechanical effects and pain relief during the stance phase of gait while maintaining comfort.

Methods
Ten patients with medial knee osteoarthritis were fitted with a standard valgus brace, an unloader brace with valgus and external rotation functions, and 7° lateral wedge foot orthoses. The pain relief, comfort, kinematics and kinetics of the lower limb were measured during walking without orthotics, with the combined and with the isolated treatments.

Results
The valgus and external rotation brace significantly reduced the knee adduction moment and allowed more knee flexion both in isolation and in combination to foot orthoses compared to the valgus brace or without treatment. Pain relief was not significant with the different orthotic treatment modalities. The valgus brace and combined treatment with either brace significantly increased the discomfort level, whereas the valgus and external rotation brace or foot orthoses in isolation did not induce significant discomfort.

Significance
Amongst the tested orthotic treatment modalities, the valgus and external rotation brace obtained better biomechanical outcomes while maintaining comfort. The combined treatment with foot orthoses enhanced the effectiveness of the valgus brace, however foot orthoses may be unnecessary with the valgus and external rotation brace.
Click to expand...

NewsBot · Aug 5, 2022

Varus Knee Limits Pain Relief Effects of Laterally Wedged Insoles and Ankle-Foot Orthoses in Medial Knee Osteoarthritis
Leonie P Bartsch, Martin Schwarze, Julia Block, Merkur Alimusaj, Marcus Schiltenwolf, Ayham Jaber, Sebastian Wolf
J Rehabil Med. 2022 Aug 5

Objective: To investigate the impact of varus malalignment of the knee on pain reduction achieved by an ankle-foot orthosis and a laterally wedged insole in patients with medial knee osteoarthritis.

Design: Secondary analysis of a randomized, clinically prospective cross-over study.

Patients: Twenty-eight participants with medial knee osteoarthritis.

Methods: All participants wore a 5-mm laterally wedged insole and an ankle-foot orthosis for a period of 6 weeks each in a randomized order. Pain was reported on a numerical rating scale and was correlated with limb alignment, as defined by the mechanical axis deviation in full-leg standing radiographs.

Results: Insole and orthosis use reduced pain compared with baseline (median knee pain change: insole -0.5 (? -5 to +6), orthosis -1.5 (-7 to +5). A higher mechanical axis deviation (greater varus) correlated significantly with smaller pain reduction for both aids (insole p = 0.003, orthosis p < 0.001). A cut-off to predict pain response was found at a mechanical axis deviation of 14-15 mm for both aids, i.e. > 3° knee varus.

Conclusion: There is a correlation between varus malalignment and pain reduction. There seems to be a mechanical axis deviation cut-off that predicts the response to treatment with the aids with good sensitivity.
Click to expand...

NewsBot · Aug 9, 2022

Changes in the Kinematics of Midfoot and Rearfoot Joints with the Use of Lateral Wedge Insoles
Álvaro Gómez Carrión, et al
J. Clin. Med. 2022, 11(15), 4536;

The lateral wedge insole (LWI) is a typical orthopedic treatment for medial knee osteoarthritis pain, chronic ankle instability, and peroneal tendon disorders. It is still unknown what the effects are in the most important joints of the foot when using LWIs as a treatment for knee and ankle pathologies. Objectives: The aim of this study was to determine the influence of LWIs on the position of the midfoot and rearfoot joints by measuring the changes using a tracking device. Methods: The study was carried out with a total of 69 subjects. Movement measurements for the midfoot were made on the navicular bone, and for the rearfoot on the calcaneus bone. The Polhemus system was used, with two motion sensors fixed to each bone. Subjects were compared by having them use LWIs versus being barefoot. Results: There were statistically significant differences in the varus movement when wearing a 4 mm LWI (1.23 ± 2.08°, p < 0.001) versus the barefoot condition (0.35 ± 0.95°), and in the plantarflexion movement when wearing a 4 mm LWI (3.02 ± 4.58°, p < 0.001) versus the barefoot condition (0.68 ± 1.34°), in the midfoot. There were also statistically significant differences in the valgus movement when wearing a 7 mm LWI (1.74 ± 2.61°, p < 0.001) versus the barefoot condition (0.40 ± 0.90°), and in the plantar flexion movement when wearing a 4 mm LWI (2.88 ± 4.31°, p < 0.001) versus the barefoot condition (0.35 ± 0.90°), in the rearfoot. Conclusions: In the navicular bone, a varus, an abduction, and plantar flexion movements were generated. In the calcaneus, a valgus, an adduction, and plantar flexion movements were generated with the use of LWIs.
Click to expand...

NewsBot · Jan 9, 2023

A Study on the Effects of Lateral-Wedge Insoles on Plantar-Pressure Pattern for Medial Knee Osteoarthritis Using the Wearable Sensing Insole
Wei-Ching Hsu et al
Sensors (Basel). 2022 Dec 22;23(1):84

Patients with knee osteoarthritis have a unique plantar-pressure pattern during walking, and lateral-wedge insoles are one of the treatment options. Participants were randomly assigned to either the lateral-wedge insole group or the ordinary insole group. The Visual Analog Scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and plantar-pressure test scores were evaluated at the baseline and at 20 weeks. Plantar pressure data were collected using a pressure insole with 89 sensing locations. In the ordinary insole group, the function and total WOMAC scores decreased significantly (function score, 24.8 (baseline) to 16.5 (week 20); total score, 34.9 (baseline) to 24.6 (week 20)). During walking, the transverse width of the center of pressure as a percentage of foot width (%Trans) significantly increased in the ordinary insole group (baseline, 6.3%; week 20, 14.8%). In addition, the values of partial foot pressure as a percentage of body weight (%PFP) on the forefoot (baseline, 30.3%; week 20, 39.2%) and heel (baseline, 28.1%; week 20, 16.9%) also increased significantly in the ordinary insole group. Significant group-by-time interaction effects were observed for partial foot pressure per body weight in the forefoot (p = 0.031) and heel (p = 0.024). In the ordinary insole group, the plantar pressure on the heel significantly decreased (p = 0.011) and that on the forefoot significantly increased (p = 0.023). In contrast, plantar pressure remained stable in all regions in the lateral-wedge insole group. Thus, lateral-wedge insoles may protect against plantar pressure deterioration in patients with knee osteoarthritis.
Click to expand...

NewsBot · Sep 5, 2023

Kinematic effects of lateral wedged insoles in
patients with medial knee osteoarthritis
Takehito Ueda et al
J. Phys. Ther. Sci. 35: 667–672, 2023

[Purpose] To examine the effect of lateral wedged insoles on the rotation mechanism of the knee joint
in patients with knee osteoarthritis. [Participants and Methods] The participants included 11 patients with medial
knee osteoarthritis. We asked all participants to stand up from a 40-cm-high chair, and we measured the rotation
angle of the knee joint during the movement. The standing motion was performed under four conditions: barefoot
and with 7-, 10-, and 13-mm lateral wedged insoles. We also measured four healthy participants as controls for
comparison. [Results] During the standing motion, we internally rotated the tibia relative to the femur. In healthy
participants, we measured 19.6° internal rotation of the tibia relative to the femur. Patients with knee osteoarthritis
had internal rotations of approximately 9.8° when barefoot and 7.1°, 6.4°, and 7.1° when wearing lateral wedged
insoles of 7, 10, and 13 mm, respectively. [Conclusion] Lateral wedged insoles do not modify the knee joint rotation
motion of patients with knee OA to the correct style.
Click to expand...

NewsBot · Oct 30, 2023

Clinically-accessible and laboratory-derived predictors of biomechanical response to standalone and supported lateral wedge insoles in people with knee osteoarthritis
Michael A Hunt et al
J Foot Ankle Res. 2023 Oct 26;16(1):74

Background: Lateral wedge insoles (both standalone and those incorporating individualized arch support) have been frequently studied for the effects on knee joint loading and pain in people with knee osteoarthritis. It has been shown that many people who use these insoles do not obtain the intended biomechanical effect, and thus may not experience a clinical benefit. The ability to identify biomechanical responders to lateral wedge insoles before research or clinical intervention is an important objective for efficient resource use and optimizing patient outcomes. The purpose of our exploratory, hypothesis-generating study was to provide an initial assessment of variables that are associated with the biomechanical response to lateral wedge insoles in people with knee osteoarthritis.

Methods: We collected a number of demographic (age, sex, body mass index, foot posture), clinical (knee pain, foot pain, radiographic disease severity), and walking-related (speed, knee alignment, frontal plane subtalar movement, and foot rotation) outcomes from 53 individuals with painful, radiographically-confirmed knee osteoarthritis. The walking-related outcomes were obtained using equipment both from the research laboratory and the clinical setting. We used logistic regression to generate predictive models to determine candidate variables associated with a reduction in the knee adduction moment during walking - a surrogate for tibiofemoral load distribution, and a known biomechanical risk factor for osteoarthritis progression - with the use of standalone and arch-supported lateral wedge insoles. Three different response thresholds (2%, 6%, and 10% reductions in the knee adduction moment) were used.

Results: In general, biomechanical responders were those who walked faster, were female, had less varus alignment, and had less severe radiographic severity. Findings were similar between the standalone and arch-supported lateral wedge insoles, as well as between models using the laboratory-derived or clinically-available measures of walking performance.

Conclusions: Our hypothesis-generating study provides valuable information that will inform future research into the efficient and effective use of lateral wedge insoles in the conservative management of knee osteoarthritis.
Click to expand...

Brian A. Rothbart · Nov 2, 2023

Orthotics incorporating lateral wedges is, IMO, a misfeasance (at best). It distorts the posture, up to and including the jaw, in many cases resulting in chronic musculoskeletal pain.

I wonder how many more years will transpire before Podiatrists stop using these draconian insoles.

NewsBot · Nov 9, 2023

Lateral Wedging of the Foot: A Scoping Review
Aaron Jackson et al
J Am Podiatr Med Assoc. 2023 Sep-Oct;113(5):21-180. doi: 10.7547/21-180.

Lateral wedges are a common intervention used to alter biomechanical function of the lower limb. Although there is evidence investigating the use and impact of lateral wedges in individuals with medial knee osteoarthritis, knowledge of how these wedges affect foot function in healthy adults is limited. Therefore, this study intends to investigate how lateral wedging affects foot function in healthy adults and, furthermore, how wedge design influences the outcome. The framework outlined by Arksey and O'Malley was used for this scoping review. To ensure methodologic quality and transparent reporting, the study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews preferred reporting guidelines. A systematic search was conducted using MEDLINE by means of EBSCO; SPORT Discuss; CINAHL; AMED by means of OVID; and Scopus. The initial search yielded 252 articles in total; 21 studies were included in the final analysis. Significant incongruence exists in descriptions of wedge length among the 21 included studies. Thirteen studies (61%) reported using full-length wedges, five studies did not report wedge length, and only one study analyzed more than one wedge length. Ethylene vinyl acetate was the most common material, and reporting of hardness was inconsistent. A broad range of inclination angles were used, with limited explanation for why these values were selected. All but one study that analyzed ankle/subtalar joint frontal plane moments reported an increase in the external eversion moment. The review identified significant variation in the design of wedges used within this body of work and a lack of investigation into the influence of wedge design. Wedge design appears to be a secondary consideration, with very few studies examining multiple material types or wedge placements. All but one of the included studies reported a significant change in ankle/subtalar joint moments with lateral wedging. Unfortunately, further generalization was not possible because of the inconsistency and variation.
Click to expand...

Brian A. Rothbart · Nov 9, 2023

NewsBot said: ↑

Lateral Wedging of the Foot: A Scoping Review
Aaron Jackson et al
J Am Podiatr Med Assoc. 2023 Sep-Oct;113(5):21-180. doi: 10.7547/21-180.
Click to expand...

Lateral wedging underneath the ankle joint definitely changes joint movements within the ankle joint. I am not suggesting otherwise.

However, using any type of wedging underneath the foot can change the global postural alignment. Which, in turn, can have an inordinate impact on the musculoskeletal health of the individual, from foot to jaw.

Are we, as Podiatrists, so myopic, that we are only concerned with the results lateral wedging makes in the knee, and ignore any possible iatrogenic outcomes above the knee?

Lateral foot wedging for medial knee OA

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

efuller MVP

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

Brian A. Rothbart Well-Known Member

NewsBot The Admin that posts the news.

Brian A. Rothbart Well-Known Member

Lateral wedging for fully compensated rearfoot varus

Laterally deviated foot types; 1st & 5th MPJ ulcerations - explanation & management

Bilateral Foot Pain in a Child With Crouzon Syndrome

Cavovarus of one foot with planovalgus deformity of the contralateral foot (Wind swept heels)

Genu valgum & 'flat foot' but lateral deviation of STJ and low supination resistance??

Chiari malformation presenting as isolated unilateral foot drop

Cuboid / Lateral foot pain

Share This Page

Lateral foot wedging for medial knee OA

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

efuller MVP

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

Brian A. Rothbart Well-Known Member

NewsBot The Admin that posts the news.

Brian A. Rothbart Well-Known Member

Lateral wedging for fully compensated rearfoot varus

Laterally deviated foot types; 1st & 5th MPJ ulcerations - explanation & management

Bilateral Foot Pain in a Child With Crouzon Syndrome

Cavovarus of one foot with planovalgus deformity of the contralateral foot (Wind swept heels)

Genu valgum & 'flat foot' but lateral deviation of STJ and low supination resistance??

Chiari malformation presenting as isolated unilateral foot drop

Cuboid / Lateral foot pain

Share This Page

Useful Searches