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Wedge orthoses: A distal slant on knee OA therapy

Discussion in 'Biomechanics, Sports and Foot orthoses' started by LER, Feb 27, 2012.

  1. LER

    LER Active Member

  2. Midway through this article, I am quoted as saying:

    This is an error. The paragraph should read as follows:

  3. Admin2

    Admin2 Administrator Staff Member

  4. Timely. Today I reviewed a chap that I'd applied valgus wedging to for his medial knee O/A about 4months ago. The orthoses had definitely helped with his knee pain, but he had recently developed plantar faciitis a couple of weeks ago. I'd explained the risk of foot pathology at the time of dispensation. I explained to him today that I could change the orthoses to help with the plantar-fasciitis, but it might bring his knee pain back. He said he preferred the knee pain to the plantar fasciitis. And no, he wasn't maximally pronated in stance and no, I didn't exceed the maximal eversion height- but he did have a reasonably high tibial varus- didn't measure it.

    True story.
  5. LER

    LER Active Member

    Thank you for pointing out the error - it has been fixed online.
  6. markjohconley

    markjohconley Well-Known Member

    I have a pronounced lower leg varus alignment, I have 'significant medial knee osteoarthrosis', I have renal impairment.
    When I used 2/3 length valgus wedges my knee felt great almost instantly, however two days later I developed a gouty arthritis episode in my 1st metatarsophalangeal joint and have been unprepared to try the wedges again, knee pain over gout any day of the week!
  7. Craig Payne

    Craig Payne Moderator

    At least you have other modalities (eg aggressive stretching) that can be used to manage the plantar fasciitis
  8. Griff

    Griff Moderator

    This is timely indeed. This is a case I had a few weeks back now:

    15 year old lad who was a high level tennis player. Wears orthoses (polypropylene prefabricated devices) and has done for many years. He found he was suffering significant lower limb muscular 'aches' before he was recommended to wear them - they quickly resolved all these symptoms.

    He has a flexible planovalgus foot, with medially deviated STJ axes, reduced 1st ray dorsiflexion stiffness (global ligamentous laxity infact), and moderate supination resistance. Forefoot eversion height test = 25mm. Dynamically he functions in close to a maximally pronated position at the STJ. With this in mind, and his previous symptoms, it is perhaps no suprise he was recommended orthoses to increase external STJ supination moments (and also perhaps no surprise he felt great benefit from them).


    First time I see him I'm informed that following an acute twisting injury during a tennis match, and subsequent 'complications' during an arthroscopy for his medial meniscus bucket handle tear, at 15 years old he now has full thickness loss of the cartilage - he is essentially bone on bone in the medial compartment.

    Whilst aware of the evidence suggesting that symptoms of medial compartment OA can be successfully treated with lateral foot wedging (by reducing the internal abduction moment at the knee) there is no research I'm aware of which currently suggests this intervention is successful or proven for the prevention of OA in the medial compartment (unless I've missed it and someone can point me to it?) To me however, it makes intuitive sense that it may do.

    So the challenge here was what to do at foot level. Increase external STJ supination moments, and continue with his more "normal" kinematic alignment (by conventional theory at least) and keep muscular aches and pains at bay, but maybe increase risk of accelerated progression to OA?? ---> Or.... increase external STJ pronation moments, on the basis that it may be best for the knee, but possibly give him back his lower extremity symptoms related to said increased external STJ pronation moments??
  9. efuller

    efuller MVP

    Give him the information and let him make the choice. Informed consent. He might want to go back and forth between the two evils.

  10. markjohconley

    markjohconley Well-Known Member

    Goodaye Ian, should he not be displaying increased supination resistance if his STJ axis was medially deviated, thanks, mark

  11. Ian:

    In this specific case, I would likely do a slightly lower medial-arched orthosis with a 2 mm lateral heel skive and a 3 mm reverse Morton's extension to try and offload the medial knee compartment, while still providing the medial longitudinal arch with some support. In addition, if he has lost most of his medial meniscus, tell him to expect a gradual increase in tibial varum over time that may require further foot orthosis adjustments and/or a knee brace and/or a high tibial osteotomy.

  12. markjohconley

    markjohconley Well-Known Member

    "wouldn't you expect an increased supination resistance"
  13. Good point

    2 different devices dependent on where the pain is today

    ie 1 external supination moment device

    1 external pronation moment device with instructions of which device is for which pain
  14. Griff

    Griff Moderator

    Thanks all.

    I must confess, I genuinely didn't know what it would be best to do. I discussed all the above scenario's with Mum, and provided a similar report for the external Physio they were seeing for ongoing proximal stability/movement control work. They wanted to have a think over it all - which I encouraged. I also suggested that Tennis might not be the best sport for the future given its multi-directional nature. Anyone agree or disagree? Heart-breaking to tell a 15 year old that his potential future career is over...

    Hey Mark - I'd say that would be a fair expectation given the published research on supination resistance so far, and the current understanding of lever arms.
  15. The right thing to do

    Probably should not have been you though - the surgeon and physio who saw the kid before you should have already done that, imo
  16. Atlas

    Atlas Well-Known Member

    How good a player is he? If he is elite or just off that, his knee only has to take him to early 30's. If tennis is the most important thing for him, the finish line is early 30's.

    I think the challenge is to put in place what I suggested in the "Inverted orthoses young OA at 35" thread. And, that is to use the most conservative rearfoot inversion forces to obtain (muscular aches) symptom relief.

    It's hard to judge without reading an operation report and locating exactly where the full thickness pathology is, but sometimes signs and symptoms will not represent dire radiological diagnosis-and-hence-prognosis. For instance, if the full thickness (hyaline??) cartilage loss is postero-inferior femoral condyle, this might be more relevant when the knee is in flexion ranges beyond typical tennis requirements.

    If the pathology is antero-inferior condyle and pinches in extension, his physios (if they can forget pilates for one minute) might institute an aggressive hamstring/gastroc regime that might limit/avoid end-range knee extension. Not ideal, because you are influencing normal physiological extension range and LLD etc., but if tennis is super important, every stone must be overturned.

    I think we must pay less attention to exact measurements (FPI) and exact radiological descriptors, and be prepared to allow signs and symptoms to chart the clinical course.

    Ron Bateman
    Physiotherapist (Masters) & Podiatrist
  17. CraigT

    CraigT Well-Known Member

    I would not necessarily throw the baby out with the bathwater.
    You can still apply inversion forces and provide lateral support at the same time- you would need to pay quite close attention not to over correct, but this is an advantage of a true custom orthosis...
    From the other thread Atlas mentioned from nwynd (a good first post!) which is potentially quite appropriate in this case-
    Sometimes you have to try these ideas as, at the end of the day, you can always take a foot orthosis out of the shoe...
  18. Atlas

    Atlas Well-Known Member

    Spot on Craig.

    Too many pods don't have a plan b, c, d, etc...

    How many patients have we seen whereby the previous orthotics have been too uncomfortable and/or ineffective; and yet the original prescription/device has not been altered one iota.

    Ditto for other allied health professionals trying to help a patient with a musculo-skeletal problem.

    Ron Bateman
    Physiotherapist (Masters) & Podiatrist

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