Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Lateral foot wedging for medial knee OA

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

  1. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    Here is abstract of one of the preliminary projects we did - the full publication is 'in press':
    Laterally Wedged Insoles in Knee Osteoarthritis: What are their Immediate Clinical and Biomechanical Effects and can they Predict 3-month Clinical Outcome?
    Rana S Hinman, Kim L Bennell, Craig Payne, Ben R Metcalf
    Although some parameters were found to predict clinical outcome these explained only a quarter of the variance in outcome - one of these was a greater amount of rearfoot eversion (ie STJ was probably at end ROM).
     
  2. Using radiographs of the knee to assess the biomechanical effects of valgus shoe wedges for the treatment of medial knee osteoarthritis (OA) really does not make good biomechanical sense. As I have said before, and I will keep saying it again and again, the valgus shoe wedge does not need to cause a "opening up of the medial joint space" or a "widened medial joint space" for it to also be therapeutically effective at the knee joint. If the valgus shoe wedge significantly decreases the external knee adduction moment, then it will likely relieve some medial knee OA symptoms, without a concomitant change in radiographic appearance of the knee.

    Using radiographs to assess how in-shoe wedging mechanically affects the intracompartmental pressure at the knee makes about as much mechanical sense as using lateral radiographs of the foot to assess how accommodative orthoses might relieve plantar pressures in diabetic patient with plantar foot ulcers. Does the plantar foot no longer touch the ground when accommodative orthoses are placed under the foot (i.e. does the orthosis "open up the plantar foot-floor space"??) or, more correctly, do these orthoses cause decreased force per unit area (i.e. pressure)?

    In much the same way, static radiographic assessment of the knee joint spaces does not tell us whether there has been a change in the intracompartmental force per unit area (i.e. pressure) within the knee. Therefore, since pressure [pressure is measured in the same units as stress, force per unit area] is probably the mechanical factor which is actually responsible for the pain of medial knee OA, why even take knee films other than to assess actual remaining joint space in each knee compartment and to assess the overall frontal plane aligment of the hip, knee and foot for possible surgical treatment?

    Again, for those that don't understand the mechanical logic behind this, please go back to Thought Experiment #7 for a review of these important concepts.
     
  3. kerstin

    kerstin Active Member

    hello Freeman,
    I didn't say that I don't use valgus wedges for medial knee OA. I just use a valgus wedge for a few patients with specific (mis)aligment (if we can use the word "mis") in relation with there gait pattern. I would never use it on patient that I have explained before (STJ pronation in combination with knee exorotation, so torsion around the knee). But because of the results of the study on pain relief mentioned before (Craig) I was prepared to chalange my brain. Even I am not convinced it will work with this patients because the torsion will be still the same and even get worser, but I believe that a valgus wedge will change something in the joint not on the angle but on the compression in the joint??? (reduce adduction knee moment). SO I find it worth to try. Of course when my initial treatment doesn't work well, so no patient rabits.
    So my goal was to chalange others to look not only at the knee and foot but also higher and to think about what a valgus wedge will do to the other structures and will cause other complains. But I have chalange myself too, so good job.

    The study that you have mentioned was the one of Hillstrom. He had looked at the effect of valgus knee bracing and neutral position foot orthoses for varus knee OA. So one group only used the braces and the other group both the brace and NPFO. And they came to the conclusion that the combination of bracing and NPFO was more effective. So they didn't use valgus weged foot orthosis.

    Best regards,
    knocking kerstin
     
  4. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Knee alignment vs knee load

    Radiographic Measures of Knee Alignment in Patients With Varus Gonarthrosis
    Effect of Weightbearing Status and Associations With Dynamic Joint Load

    The American Journal of Sports Medicine 35:65-70 (2007)
     
  5. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Here is the run down:
     
  6. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    The effect of a subject-specific amount of lateral wedge on knee mechanics in patients with medial knee osteoarthritis.
    Butler RJ, Marchesi S, Royer T, Davis IS.
    J Orthop Res. 2007 Apr 27; [Epub ahead of print]
     
  7. Interesting thread which i did not notice first time around. A question springs to mind:-

    If valgus wedging decreases compressive forces within the medial compartment of the knee joint does it follow that Varus wedging increases compressive forces in the medial compartment of the knee?

    If the answer to the above is yes it raises another question,

    Will orthotics which supinate the foot excacerbate / cause medial knee pain and joint degeneration in some cases?

    or

    Can orthotics which supinate the STJ beyond a certain point (which is probably nothing to do with STJ neutral :rolleyes: ) cause medial knee pain / joint damage.

    The implications of these questions are substantial. Anyone got some answers?

    Regards
    Robert
     
  8. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    My belief is no. If you use varus wedging (ie a foot orthotic), you tend to get external leg rotation (because of the range of STJ inversion most people have) and no (or minimal) change in frontal plane moments at the knee. If you use a valgus/lateral wedge, the STJ goes to end range of eversion easily (and in the case of most in the age group we are talking about, the STJ is already at end ROM), so we get no or very minimal change in tibial rotation, but there will be changes in frontal plane moments at the knee. What limited data is available supports this.

    I in the middle of preparing powerpoint on some of our data for a conference next week.
     
  9. kerstin

    kerstin Active Member

    so when my interpretation is right, you are saying that there is a correlation between age and maximal eversion in the subtalair joint, so the older the more eversion???
     
  10. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    Most of those who we recruit into our knee OA studies have very limited or no eversion available from RCSP - all are >50yrs. When the lateral wedge them is used, we see no changes in alginment, but changes in kinetics.
     
  11. Atlas

    Atlas Well-Known Member

    Unquestionably yes.

    But that doesn't mean that we suddenly become fearful of increasing compressive forces in the medial compartments of all knees.
     
  12. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    In healthy subjects without knee osteoarthritis, the peak knee adduction moment influences the acute effect of shoe interventions designed to reduce medial compartment knee load.
    Fisher DS, Dyrby CO, Mundermann A, Morag E, Andriacchi TP.
    J Orthop Res. 2007 Apr;25(4):540-6.
     
  13. kerstin

    kerstin Active Member

    Hello Graig,
    So one of the inclusion criteria was that they have in stance position a limited eversion mobility? Which makes a great difference because then you have more influence on the adduction moment of the knee, but is this a representative population??
     
  14. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    It was not an inclusion criteria - its just that all of the subjects are >50 years and in that age group the range of eversion is limited (mnay had no eversion from RCSP).
     
  15. I asked:-

    If valgus wedging decreases compressive forces within the medial compartment of the knee joint does it follow that Varus wedging increases compressive forces in the medial compartment of the knee?

    Craig said

    Atlas Said

    Hmmmm. Vive la difference.

    Atlas also said

    Where is the emphasis in that sentance? Is it the word "all"? As it we should be fearful of increasing the compressive force in some knees?

    I'll put it another way. If you have a patient with little or no eversion available from RSCP, who has a pathology which it seems likely is caused by this (lets say a functional HL or a fascitis) and who has medial knee pain caused by compressive OA would you still use a supinating orthotic to treat the foot pain?

    Anyone?

    Regards
    Robert
     
  16. Phil Wells

    Phil Wells Active Member

    Robert
    Maybe a slight deviation from your question but is our orthotic intervention only affecting one plane or is the composite effect on all three planes giving us the desired outcome at the local level of the foot?
    I believe that a significant amount of the positive orthotic interaction is to accelerate/decelerate the CoP/CoM. If we reduce the amount of time spent at intial contact, will the destructive force caused by the adductor moments associated with intial contact be alterted? Consequently the potential for increasing the adductor moments assocaited with medial compartment OA will be negated or reduced.
    I am waffling a bit(!) but I think that the phasic timing of gait is extermely important and is effected by orthoses but we are still struggling to measure this due to individual reactions to the orthoses.

    Phil
     
  17. Phil
    Deviation is good! Its all interesting.

    I presume by Accelleration /decelleration of COM COP you are referring to gait analysis with F scan or similar and that cool little Dot which wanders up the foot on playback (or i may have misunderstood you completely).

    For the benefit of those of us who only have a passing aquaintance with this technology would you mind elaborating on the "initial contact" bit. From my technologically challanged persperctive i would have thought "initial contact" is the moment the foot hits dirt. How can you spend more or less time doing this?

    I tend to agree that what you call "phasic timing of gait" is of vital import and is an oft overlooked aspect of orthotic design. Probably because its a little too easy to see the patient standing still and imagine that that is the whole story.

    Regards
    Robert

    (I put a bid in for an F scan to carry out better gait analysis. They offered me a broom to sweep the bit of corridor i walk people up and down on instead. :mad: NHS <> Money = Blood<>Stone)
     
  18. Phil Wells

    Phil Wells Active Member

    Robert
    Glad that deviation is good - it will give Cameron something to add to his sex therapy courses!!
    Yes I was refering to the F-Scan dot thing - I love it and use it in an NHS clinic - I am a very lucky boy.
    My thoughts on intial contact being variable are based on some work I have been doing on footwear adaptions. Using SACH and striker heel mods to the heel of footwear, I have been attempting to increase the duration of heel contact and to consequently reduce plantarflexion moments at the ankle.
    I am making large assumptions as I am 'defining' the intial period as the 1st 10-15% of the CoP info that I am getting from the F-Scan in shoe system.
    This is all based on trying to reduce forefoot pressure in the diabetic foot by reducing plantarflexion moments at intial contact. It seems to be a good theory but needs a lot more research - I am hoping to do it soon but a 4 month baby at home has cramped by style a bit.

    Phil
     
  19. Phil

    You lucky dog! Who did you have to kill to get that kind of hardwear!?!?

    That sounds like an interesting idea but theres a lot i don't understand about it. For one thing how will reducing PF moments at initial contact affect forefoot pressure. Forefoot's not on the ground at initial contact! I can see how delaying forefoot contact might reduce the impulse at forefoot load areas, is that what you mean? The other thing which springs to mind is that forefoot pressure is a somewhat vague idea. Are we talking peak pressure, impulse, total presure?

    Interesting stuff, might be worth cracking off a new thread if you are so minded. Or we could just wait for your research. I won't hold my breath. My daughter is now 8 months old and i'm starting to think we've bred the world first nocturnal Baby. The idea of working when i could be sleeping is anathema!

    Regards
    Robert
     
  20. Phil Wells

    Phil Wells Active Member

    Robert

    The idea started as an attempt to treat the neuropathic diabetic foot. There are a few articles (Sorry I havn't got the references to hand) that showed that as neuropthy increases, one of the 1st muscle groups to be effected is the tib ant = reduced dorsiflexion force available. Secondly the glycosilation of the tendons - especially the TA- led to increased stiffness in the TA and increased plantarflexory force. The CoP was seen - subjectively in my patients - to accelerate anterioly faster than non-neruo feet with increased duration of loading times on the forefoot. This seemed to translate into higher forefoot pressure but more importantly, increased duration of load at the met heads.
    Therefore the idea is to slow down the CoP at 'initial' contact, decrease the early loading of the forefoot and reduce impulse at the forefoot.
    Subjectively this seems to be working but I am finding that rocker soles and other footwear mods are better at producing the right results than FFO's alone. Combined Footwear and FFo's seems the 'gold' standard but I am a million miles away from being able to say this with any confidence.

    What do you reckon?

    Phil
     
  21. LCBL

    LCBL Active Member

    You are about to show what UK trained orthotists* in diabetic foot clinics have been doing since Morris and Edwards' paper about the treatment protocol in King's since the 80's.

    Would have killed for that kind of kit when I was doing the foot clinic in the diabetic clinic in City Hospital.

    You lucky lucky bar steward Wells :p

    *the good ones
     
  22. Have recently seen a recent study (Maly et al 2006) which indicates that the knee adduction moment is unrelated to the pain and disability associated with medial compartment osteoarthritis (OA). OA is multifactorial and perhaps there is too much emphasis placed on the knee adduction moment. Perhaps this is why other orthotic devices seem to help rather than relying on the lateral wedge.

    Reference:

    Maly MR, Costigan PA, Olney SJ. Role of knee kinematics and kinetics on performance and disability in people with medial compartment knee osteoarthritis. Clinical Biomechanics 21: 1051 -1059 2006.
     
  23. Phil

    I reckon i half agree.

    I can certainly see the idea that if the Tib ant is not being very passionate about it's work the forefoot will hit the ground sooner and that this will increase the forefoot impulse for that phase of gait. From that point of view i can see the beneifit to delaying forefoot contact for as long as possible.

    However.

    I would be interested to know more information about the "subject group". For example we tend to find a lot of neuropathic patients are in the "old and tottery" bracket. Does this mean the forefoot load times are more to do with a reduced stride length than Tib ant activity? I'm not familier with the SACH and striker mods you referred to but it does strike me that if the increased PF moments when the foot is pivoting on the heel are decreased by heel mods those same mods may have a different effect when the foot hits mid stance and a different one again when the heel starts to unload!

    I would be interested to know what SACH s and striker mods are and what footwear mods you are using. I've had some good results by splitting the sole of a trainer, stiking a teardrop type rocker in then glueing the sole back together when i am trying to reduce impulse. Don't do so much of that sort of thing now cos most of my patients are kiddywinks but it has worked before.

    There's a study there, certainly for the footwear mods! Take some F scans of random people in ordinary shoes then modify the shoes and do it again. All you'd need are 50 odd folk who would'nt mind you taking a bandsaw to their footwear.

    I've never quite seen how to use F scan with FFO's. Under the device its not an accurate picture of the forces on the foot. Over the device it never conformed to the orthotic properly. Maybe i was doing it wrong.

    One last thing. Is your clinic insured? If so then could you see your way clear to letting me know where the F scan is kept and leaving the cupboard open one night? It'd be ever so sweet of you.

    Regards
    Robert
     
  24. Phil Wells

    Phil Wells Active Member

    Robert

    Consider the F-Scan now attached to a Rotweiller just in case you call by!!!!

    The SACH is a 'V' of poron inserted into the heel of the shoe. At heel stike it compresses - abit like heel striking onto sand verse concrete. The Striker mod is also called a reverse grind off - the edge of the heel is ground off so that the a flat 45 degree slant is added to the heel - a bit like a sagital rocker - the point of conact of the heel sole is moved 'away' from the ground causing a flat spot that neither df or pf the shoe.
    The patient group so far have been active 'yougsters' that are still working so have good gait dynamics - possibly part of the problem.

    I let you know how the research goes when I finally figure out the secret to time travel.

    Dave
    Have you used this appoach much and have you had much experience with SACH and reverse grinds offs? I though all the good orthotist had re-trained as podiatrist? (only kidding)


    Cheers

    Phil
     
  25. Phil

    Not to be pedantic but would'nt putting something springy like poron under the heel encourage an earlier heel lift and increase pf moments from mid stance?

    Robert
     
  26. Phil Wells

    Phil Wells Active Member

    Robert

    The poron isn't strong/stiff enough to return its energy quick enough - from what I remember from my engineering stuff, if a material was to act like the heel pad - a low hysterses system - then it would have to have similar properies, both material and structure.
    Good point though, I wonedr if there are any materials that may do this. Could be useful in patients with delayed heel lift.

    Phil
     
  27. So far as the returning force is concerned i would guess a lot would depend on how thick it was. 10 mm poron or ppt will exert a considerable upward force when compressed! For a material which mimics the hydraulic properties of fibrofatty padding maxacaine is hard to beat.

    Regards
    Robert
     
  28. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    A randomized crossover trial of a wedged insole for treatment of knee osteoarthritis
    Arthritis & Rheumatism
    Volume 56, Issue 4 , Pages 1198 - 1203
     
  29. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Inconsistent knee varus moment reduction caused by a lateral wedge in knee osteoarthritis.
    Kakihana W, Akai M, Nakazawa K, Naito K, Torii S:
    Am J Phys Med Rehabil 2007;86:446-454.
     
  30. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Influence of concomitant heeled footwear when wearing a lateral wedged insole for medial compartment osteoarthritis of the knee.
    Toda Y, Tsukimura N.
    Osteoarthritis Cartilage. 2007 Aug 9; [Epub ahead of print]
     
  31. Atlas

    Atlas Well-Known Member

    Reading the last few posts, I can imagine those that react to 'evidence' going from a-z, and back again, every 5 minutes.
     
    Last edited: Aug 20, 2007
  32. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Study protocol
    Effects of laterally wedged insoles on symptoms and disease progression in medial knee osteoarthritis: a protocol for a randomised, double-blind, placebo controlled trial

    Kim Bennell , Kelly-Ann Bowles , Craig Payne , Flavia Cicutinni , Richard Osborne , Anthony Harris and Rana Hinman
    BMC Musculoskeletal Disorders 2007, 8:96doi:10.1186/1471-2474-8-96Published: 24 September 2007
    Full text of provisional paper
     
  33. The study protocol on the effects of lateral wedges seems very thorough and comprehensive except that the foot to which the wedge is being applied is not considered. I find that surprising given the involvement of podiatrists in the study. Was there a reason for this ? kathleen reilly
     
  34. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    Plenty of foot data has been collected on FPI; STJ range of eversion; rearfoot kinetics and kinematics; etc. --- all of which will be used in secondary analyses.

    We are up to subject ~180 as of today; not sure of total number finished the 12 month follow up; BUT, so far we have only had one subject report foot symptoms following the use of wedges (post tib insertion pain); given the age group we are talking about, this is somewhat remarkable as I would expect a lot more than one out 200 people in that age group to develop foot pain anyway.

    Have an Hons student writing up now who did a comprehensive look at 20 of the subjects and the effects of lateral wedges on foot function -- will post abstract of that in a few week ....
     
  35. Daniel Bagnall

    Daniel Bagnall Active Member

    Hi Craig,

    Would you happen to know the actual name of the 2 rheumatology assocuations in Australia that that recommend lateral wedging in their guidlines?

    Cheers,

    Dan
     
    Last edited by a moderator: Dec 4, 2007
  36. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    They weren't Australian, but were two other national organisation:

     
  37. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    The lateral wedged insole with subtalar strapping significantly reduces dynamic knee load in the medial compartment Gait analysis on patients with medial knee osteoarthritis
    Y. Kuroyanagi, T. Nagura, H. Matsumoto, T. Otani, Y. Suda, T. Nakamura and Y. Toyama
    Osteoarthritis and Cartilage
    Volume 15, Issue 8, August 2007, Pages 932-936

     
  38. Admin2

    Admin2 Administrator Staff Member

    There are a lot of clinical trials going on using lateral foot wedging for medial knee OA. Here is just a sampling of them from the clinicaltrial.gov site.
     
  39. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Effects of foot orthoses and valgus bracing on the knee adduction moment and medial joint load during gait.
    Shelburne KB, Torry MR, Steadman JR, Pandy MG.
    Clin Biomech (Bristol, Avon). 2008 Mar 23 [Epub ahead of print]
     
  40. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Effectiveness of medial-wedge insole treatment for valgus knee osteoarthritis Priscilla T. Rodrigues, Ana F. Ferreira, Rosa M. R. Pereira, Eloísa Bonfá, Eduardo F. Borba, Ricardo Fuller
    Arthritis Care & Research Volume 59, Issue 5 , Pages 603 - 608
     
Loading...

Share This Page