A 2-year follow-up of a study to compare the efficacy of lateral wedged insoles with subtalar strapping and in-shoe lateral wedged insoles in patients with varus deformity osteoarthritis of the knee

OBJECTIVE: This study was conducted in order to assess the effect of wearing a lateral wedged insole with a subtalar strap for 2 years in patients with osteoarthritis varus deformity of the knee (knee OA). DESIGN: The setting was an outpatient clinic. The efficacies of the strapped insole and a traditional shoe insert wedged insole (the inserted insole), as a positive control, were compared at the baseline and after 2 years of treatment. Randomization was performed according to birth date. The 61 female outpatients with knee OA who completed a prior 6-month study were asked to wear their respective insoles continuously as treatment during the course of the 2-year study. The femorotibial angle (FTA) was assessed by standing radiographs obtained while the subjects were barefoot and the Lequesne index of the knee OA at 2 years was compared with those at baseline in each insole group. RESULTS: There were 61 patients in the original study, but 13 patients (21.3%) did not want to wear the insole continuously and five (8.2%) withdrew for other reasons. The 42 patients who completed the 2-year study were evaluated. At the 2-year assessment, participants wearing the subtalar strapped insole (n=21) demonstrated significantly decreased FTA (P=0.015), and significantly improved Lequesne index (P=0.031) in comparison with their baseline assessments. These significant differences were not found in the group with the traditional shoe inserted wedged insole (n=21). CONCLUSION: Only those participants using the subtalar strapped insole demonstrated significant change in the FTA in comparison with the baseline assessments. If the insole with a subtalar strap maintains FTA for more than 2 years, it may restrict the progression of degenerative articular cartilage lesions of knee OA.     

The lateral wedged insole with subtalar strapping significantly reduces dynamic knee load in the medial compartment gait analysis on patients with medial knee osteoarthritis

OBJECTIVE: Two lateral wedged insoles were compared: one with, and the other without, subtalar strapping. METHODS: Twenty-one patients (age 58-83, mean 72) with medial knee osteoarthritis (OA) were enrolled. Thirty-seven knees in the patients were divided into three groups based on the Kellgren and Lawrence OA grading system; grades 2 (cases=20), 3 (cases=11), and 4 (cases=6). The subjects were tested during walking barefoot and during walking with a silicon rubber lateral wedged insole with elevation of 10 mm attached to a barefoot. Gait analysis was performed on a 10 m walkway for each subject under three different walking conditions; barefoot, wearing a conventional insole, and a subtalar strapping insole. Peak knee varus moment during gait was measured under each condition, and compared between the three conditions and between the OA grades. RESULTS: On the whole (cases=37), the peak varus moment was significantly reduced by wearing either of the insoles, compared to walking barefoot. The reduction was more obvious with the strapping insole (-13%, P<0.01), compared with the conventional insole (-8%, P<0.05). In moderate OA patients (grades 2 and 3), the moments were significantly lower with the strapping insole, compared with the conventional insole (P=0.0048 and 0.005, respectively). However, no significant difference was detected in severe OA patients (grade 4) between the two types of insoles (P=0.4). CONCLUSIONS: Both lateral wedged insoles significantly reduced the peak medial compartment load during gait. The subtalar strapping insole had a greater effect than the conventional insole, particularly in patients with moderate medial knee OA.     

An optimal duration of daily wear for an insole with subtalar strapping in patients with varus deformity osteoarthritis of the knee

OBJECTIVE: To assess the optimal duration of daily wear for a laterally wedged insole with subtalar strapping in subjects with medial compartment osteoarthritis of the knee (knee OA). DESIGN: The setting was an outpatient clinic. Eighty-one patients with knee OA were prospectively randomized according to birth date and to either 2 weeks of treatment with a lateral wedge with subtalar strapping for less than 5 h (the short group), 5-10 h (the medium group) or greater than 10 h (the long group) each day, or to treatment with a subtalar strapping band without lateral wedge (the placebo group). Standing radiographs were used to analyze the femorotibial angle for each subject, both with and without their respective orthotic device. The remission scores of Lequesne index were compared among the four groups at the conclusion. RESULTS: The short (n=21), medium (n=20) and long (n=18) groups demonstrated a significant greater valgus correction of the femorotibial angle than the placebo group (n=22) (P<0.0001). The remission score was significantly improved in the medium group compared to the placebo (P=0.001) and long (P=0.001) groups. CONCLUSIONS: An optimal duration of insole with subtalar strapping wear for patients with varus deformity knee OA may be between 5 and 10 h each day.     

The effect of laterally wedged shoes on the loading of the medial knee compartment‐in vivo measurements with instrumented knee implants

A conventional method to unload the medial compartment of patients with gonarthrosis and thus to achieve pain reduction is the use of laterally wedged shoes. Our aim was to measure in vivo their effect on medial compartment loads using instrumented knee implants. Medial tibio‐femoral contact forces were measured in six subjects with instrumented knee implants during walking with the following shoes: without wedge, with 5 and 10 mm wedges under the lateral sole, and with a laterally wedged insole (5 mm). Measurements were repeated with the shoes in combination with an ankle‐stabilizing orthosis. Without orthosis, peak medial forces were reduced by only 1–4% on average. With orthosis, the average reduction was 2–7%. Highest reductions were generally observed with the 10 mm wedge, followed by the 5 mm wedge, and the 5 mm insole. Individual force reductions reached up to 15%. Medial force reductions while walking with wedged shoes were generally small. Due to high inter‐individual differences, it seems that some patients might benefit from lateral wedges, whereas others might not. Further analyses of the individual kinematics will show which factors are most decisive for the reduction of medial compartment load. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 29:1910–1915, 2011     

Kinetic and kinematic changes with the use of valgus knee brace and lateral wedge insoles in patients with medial knee osteoarthritis

The effect of a valgus knee brace and a lateral wedged insole on knee and ankle kinematics and kinetics was evaluated in ten patients with medial knee osteoarthritis (OA). The knee orthosis was tested in two valgus adjustments (4° and 8°), and the laterally wedged insole was fabricated with an inclination of 4°. A motion capture system and force platforms were used for data collection and joint moments were calculated using inverse dynamics. The valgus moment applied by the orthosis was also measured using a strain gauge implemented in the orthosis' rotational axis. For the second peak knee adduction moment, decreases of 18%, 21%, and 7% were observed between baseline and test conditions for the orthosis in 4° valgus, in 8° valgus, and insole, respectively. Similar decreases were observed for knee lever arm in the frontal plane. Knee adduction angular impulse decreased 14%, 18%, and 7% from baseline to conditions for the orthosis in 4° valgus, in 8° valgus, and insole, respectively. Knee angle in the frontal plane reached a more valgus position during gait using the valgus knee brace. The valgus moment applied by the orthosis with 8° valgus adjustment was 30% higher than with 4° valgus adjustment. The valgus knee orthosis was more effective than the laterally wedged insole in reducing knee adduction moment in patients with medial knee OA.     

Lateral wedges alter mediolateral load distributions at the knee joint in obese individuals

Obesity is the primary risk factor for knee osteoarthritis (OA). Greater external knee adduction moments, surrogate measures for medial compartment loading, are present in Obese individuals and may predispose them to knee OA. Laterally wedged insoles decrease the magnitude of the external adduction moment in Obese individuals but it is unknown how they alter the center of pressure on the tibial plateau. A gait analysis was performed on 14 Obese (avg. 29.3 years; BMI range: 30.3–51.6 kg/m²) and 14 lean women (avg. 26.1 years; BMI range: 20.9–24.6 kg/m²) with and without a full‐length, wedged insole. Computed joint angles, joint moments, and knee extensor strength values were input into a musculoskeletal model to estimate center of pressure of the contact force on the tibial plateau. Statistical significance was assessed using a two‐way ANOVA to compare the main effects of group and insole condition (α = 0.05). The insole resulted in a significant (p < 0.01) lateral shift in the center of pressure location in both the Obese and Control groups (mean: 2.9 ± 0.7 and 1.5 ± 0.7 mm, respectively). The insole also significantly reduced the peak external knee adduction moment 1.88 ± 1.82 N m in the Control group (p < 0.01) and 3.62 ± 3.90 N m in the Obese group (p < 0.01). The results of this study indicate the effects of a prophylactic wedged insole for reducing the magnitude of the load on the knee's medial compartment in Obese women who are at risk for knee OA development. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 31: 665–671, 2013     

Force patterns of heel strike and toe off on different heel heights in normal walking

This study investigated the changes of force patterns of the heel strike and toe off phases at different heel heights during normal walking. Ten healthy female college students wore running shoes, flat leather shoes and high heeled shoes while walking on a Kistler force platform at their self-comfortable paces. It was found that the high heeled shoes and the leather shoes generated significantly greater vertical impact forces and anterior-posterior forces in the toe off phase than those in the heel strike phase. Accumulated impulses did not show significant increase while the heel heights increased and total support time while wearing the high heeled shoes was significantly longer than while wearing the running shoes.     

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

Background  

Whilst laterally wedged insoles, worn inside the shoes, are advocated as a simple, inexpensive, non-toxic self-administered intervention for knee osteoarthritis (OA), there is currently limited evidence to support their use. The aim of this randomised, double-blind controlled trial is to determine whether laterally wedges insoles lead to greater improvements in knee pain, physical function and health-related quality of life, and slower structural disease progression as well as being more cost-effective, than control flat insoles in people with medial knee OA.     

The ability to wear heeled footwear following first metatarsophalangeal joint fusion

IntroductionFusion remains the gold standard treatment for symptomatic first metatarsophalangeal joint (MTPJ) arthritis. Surgeons have traditionally advised female patients during the consenting process that they would have limitations or be unable to wear heeled footwear following first MTPJ fusion due to the loss of dorsiflexion at the first MTPJ. Anecdotally, surgeons have found that some patients were still able to continue wearing heeled footwear post fusion surgery. Heeled footwear has long been a trendy fashion accessory dating back from ancient Egyptian times and are regularly worn by a significant proportion of women today. Given the lack of literature in this matter, this study was conducted to investigate the effect of first MTPJ fusion surgery on the ability to wear heeled footwear, to aid in the consenting process.MethodsA retrospective review of 50 female patients who have had an isolated first MTPJ fusion between 2004 and 2015 at the authors’ institution was undertaken with a follow-up telephone survey which included questions on ability to wear heeled footwear pre and post-operatively, duration, and the height of heels they could wear.ResultsThis study included 50 patients (62 feet) with a mean age of 63 years (range 43–78 years) at the time of surgery, with a mean follow-up of eight years (range 5–16years) from surgery. Of the 42 patients who wore heeled footwear pre-surgery, 26 (62%) continued wearing them. The majority of them (n = 23, 88%) were able to wear the same height heels. Patients could use heeled footwear from 30 min to eight hours continuously (mean=3 h) and, 88% were able to wear heel heights of 1.5 in. or higher. None of the patients wearing heeled footwear returned to the clinic with midfoot/hindfoot symptoms, one returned for worsening of pre-existing first IPJ (interphalangeal joint) symptoms.ConclusionThis study has important implications for information given to patients during the consent process for this operation. The results have shown that many patients continue to wear heeled footwear following first MTPJ fusion with minimal or no symptoms in neighbouring joints.     

Comparing Two Orthoses for Managing Medial Knee Osteoarthritis: Lateral Wedge with Subtalar Strap While Barefoot Versus Lateral Wedged Insole Fitted Within Sandal

BackgroundUsing foot orthoses for managing medial knee osteoarthritis (MKOA) is common, although its effectiveness is in debate. Most orthoses are placed inside the shoe as a lateral wedged insole. Thus, most studies in this area have focused on the effect of insoles used with shoes. This study compared the effects of a lateral wedge with subtalar strap (combined insole) used while barefoot and lateral wedged insole fitted within sandal on pain, function and external knee adduction moment (EKAM) in patients with MKOA to consider which orthotic treatment is better.MethodsIn this quasi-experimental pretest–posttest study, 29 participants with medial knee osteoarthritis were divided into two groups: (1) combined insole (n = 15) and (2) sandal (n = 14) groups. We recorded their gait while walking with and without orthoses using a motion analysis system. We evaluated their pain and performance with visual analog scale, Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire, 30 s chair stand, and Timed Up and Go functional tests. The pain and performance evaluations were repeated after one month.ResultsThe pain immediately decreased after walking with both orthoses (p < 0.001). There was no significant difference in EKAM results between the two orthoses. Pain and performance improved in both groups after a one month using the orthoses (p < 0.01).ConclusionBoth types of orthoses have similar effect and lead to better performance and less pain after 1 month.     

穿高跟鞋对中青年女性腰椎生理曲度的影响

目的探讨穿高跟鞋对中青年女性腰椎生理曲度的影响。方法对20例健康中青年女性志愿者在穿不同高度的高跟鞋后,摄立位腰椎X线侧位片,测量腰椎曲线指数（LCI）、腰椎前凸度（Cobb角）和骶骨倾斜角（SSA）,并对其进行2 km行走试验调查腰背不适情况。结果高鞋跟组的LCI、Cobb角、SSA明显高于低鞋跟组（P〈0.05）。2 km行走试验后腰背不适情况,60%发生在7 cm以上鞋跟组。结论穿高跟鞋可使腰椎生理曲度增大,易引发腰痛。     

Effects of lateral‐offset sole shoes on knee adduction moment in women with medial compartment knee osteoarthritis

This study aimed to determine the impact of wearing a lateral‐offset sole shoe (LOSS) on knee adduction moment (KAM) in patients with medial knee osteoarthritis (OA). From December 2012 to November 2016, patients with medial knee OA were recruited. Ninety‐three knees (50 left, 43 right) of 93 female patients were analyzed. The first peak KAMs were measured with patients (i) walking barefoot; (ii) walking in conventional shoes; and (iii) walking in LOSSs. The patients had grade 1 (n = 19), grade 2 (n = 49), grade 3 (n = 20), and grade 4 (n = 5) knee OA. First peak KAMs differed significantly in all three conditions (p = 0.031). In the post hoc analysis, first peak KAMs were significantly lower during LOSS walking than during conventional shoe walking (p = 0.001), but there were no differences in peak KAMs between barefoot and LOSS walking (p = 0.784). In the subgroup analysis, patients with grades 2 and 3 OA showed significantly lower first peak KAMs during LOSS walking than during conventional shoe walking (p = 0.029 and p = 0.011, respectively). Both the peak eversion ankle angle and moment of barefoot walking showed a significant increase compared with LOSS and conventional shoe walking, while there was no significant difference between LOSS and conventional shoe walking (p = 0.612 and p = 0.197, respectively). Our results suggest that LOSS wearing caused significant KAM reductions compared with conventional shoe wearing. Since LOSS wearing does not cause changes in the peak eversion ankle angle and moment during the load response, it may be an effective method to reduce the KAM in women with knee OA. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1694–1700, 2018.

     

Aceclofenac vs paracetamol in the management of symptomatic osteoarthritis of the knee: a double-blind 6-week randomized controlled trial

OBJECTIVE: To evaluate the efficacy and tolerability of aceclofenac, 200 mg/day, and paracetamol, 3000 mg/day, in the treatment of osteoarthritis (OA) of the knee. METHODS: This was a double-blind, parallel-group, multicentre clinical trial involving patients with symptomatic OA of the knee, conducted in Spain. Patients were randomly allocated to aceclofenac 100 mg twice daily (n=82) or paracetamol 1000 mg three times daily (n=86). Patients were assessed at baseline and 6 weeks. Primary efficacy measures were severity of pain (visual analogue scale, VAS), Lequesne OA knee index, and patient's and physician's global assessment of disease activity. Severity of knee pain at rest or walking, stiffness, knee swelling and tenderness, and assessment of health-related quality of life (Health Assessment Questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index, and Short Form 36) were included as secondary endpoints. RESULTS: Both treatment groups showed significant improvement compared with their baseline values in the four primary endpoints. Mean between-treatment differences favoured aceclofenac over paracetamol on pain (VAS, 7.64 mm [95% confidence interval (CI), 0.44-14.85 mm]), Lequesne OA index (1.41 [95% CI, 0.45-2.36]), and patient's (0.33 [95% CI, 0.06-0.61]) and physician's (0.23 [95% CI, 0.01-0.47]) global assessments. Adverse events were similar for both drugs (paracetamol, 29% patients vs aceclofenac, 32%; P=0.71). Four patients withdrew in each group due to adverse events. Patients tended to prefer aceclofenac to paracetamol (P=0.001), and more treated with paracetamol withdrew from the study due to lack of efficacy (n=8 vs n=1, P=0.035, for paracetamol and aceclofenac, respectively). CONCLUSION: At 6 weeks, patients with symptomatic OA of the knee showed a greater improvement in pain and functional capacity with aceclofenac than paracetamol with no difference in tolerability.     

Hip and knee joint rotations differ between patients with medial and lateral knee osteoarthritis: gait analysis of 30 patients and 15 controls.

The motions and moments in the hip and knee in female patients on the waiting list for knee prosthesis surgery with medial (n = 15) or lateral (n = 15) osteoarthritis (OA) were compared with a control group (n = 15). We hypothesized that not only the kinematics and kinetics of the knee but also of the hip would differ between patients the medial and lateral groups. At midstance, patients with lateral OA showed slightly (2 degrees) more maximal (peak) adduction (p = 0.015) of the hip joint and patients with medial OA had 7 degrees more abduction (p < 0.001) than did controls. In patients with lateral OA, the femur was positioned in about 7 degrees more maximum external rotation (p = 0.001), but femur position did not differ between medial OA and controls (p > or = 0.8). There was a tendency to higher internal hip rotation moment in lateral OA compared to controls (p = 0.021). The maximum values of the internal knee abduction moments were 52% higher in medial OA (p = 0.005) and 63% lower in lateral OA (p < 0.001) compared to controls. Cases with medial OA had 9 degrees more, whereas those with lateral OA had 6 degrees less external tibial rotation than controls (medial vs. lateral OA, p = 0.001). We found an association between presence of lateral OA of the knee and the biomechanics of the hip joint. It remains to be evaluated if the changed biomechanics of the hip joint is a reason for development of lateral OA or an observation that is a result of this disease.     

Mechanical effectiveness of lateral foot wedging in medial knee osteoarthritis after 1 year of wear

The use of lateral foot wedging in the management of medial knee osteoarthritis is under scrutiny. Interestingly, there have been minimal efforts to evaluate biomechanical effectiveness with long‐term use. Therefore, we aimed to evaluate dynamic knee loading (assessed using the knee adduction moment) and other secondary gait parameters in patients with medial knee osteoarthritis wearing lateral foot wedging at a baseline visit and after 1 year of wear. Three‐dimensional gait data were captured in an intervention group of 19 patients with symptomatic medial knee osteoarthritis wearing their prescribed laterally wedged foot orthoses at 0 and 12 months. Wedge amounts were prescribed based on symptom response to a step‐down test. A control group of 19 patients wearing prescribed neutral orthoses were also captured at 0 and 12 months. The gait of the intervention group wearing neutral orthoses was additionally captured. Walking speed and shoes were controlled. Analyses of variance were conducted to examine for group‐by‐time (between the groups in their prescribed orthoses) and condition‐by‐time (within the intervention group) interactions, main effects, and simple effects. We observed increased knee adduction moments and frontal plane motion over time in the control group but not the intervention group. Further, within the intervention group, the mechanical effectiveness of the lateral wedging did not decrease. In patients with medial knee osteoarthritis, the effects of lateral foot wedging on pathomechanics associated with medial knee osteoarthritis were favorable and sustained over time. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 31: 659–664, 2013     

The mechanics of treatment of the osteoarthritic knee with a wedged insole

The mechanism of the static effects of the wedged insole for the medial osteoarthritic knee was studied in ten women. They stood with one leg on the wedged sole board, and the change of the position of the line through the center of gravity, the femorotibial angle, the tibiocalcaneal angle, and the spatial position of the whole lower limb were investigated using load transducers and roentgenograms. When the subjects stood on the wedged sole board, the line through the center of gravity and femorotibial angle did not change. The change in the spatial positions of the lower limb (p less than 0.02), i.e., the mechanical axis of the lower limb near an upright position, and the change of the calcaneus to valgus direction in the subtalar joint (p less than 0.01) were observed. These changes were considered from two-dimensional analysis to reduce the excessive loading on the medial joint surface and the excessive tensile force of the lateral side. The wedged insole thus proved effective for the conservative treatment of the medial compartment osteoarthritic knee.     

Superior responsiveness of the pain and function sections of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) as compared to the Lequesne-Algofunctional Index in patients with osteoarthritis of the lower extremities

OBJECTIVE: To compare the responsiveness of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and a questionnaire format of the Lequesne-Algofunctional Index in patients with OA of the lower extremities. METHODS: Longitudinal analysis of the instruments' responsiveness [standardized response mean (SRM), effect size (ES)] in ambulatory patients undergoing hip or knee arthroplasty. RESULTS: At six months 36, and at one year 40 out of 43 patients undergoing hip (N=30) or knee arthroplasty (N=13) could be examined. Both responsiveness statistics revealed the same order of responsiveness. For both indices and for both locations, the pain sections were more responsive than the function sections. However, the WOMAC scales and the WOMAC global index (hip at 12 months: SRM=2.4; knee at 12 months: SRM=2.0 ) were more responsive than the comparable Lequesne sections and Lequesne index (hip at 12 months: SRM=2.1; knee at 12 months: SRM=1.5). CONCLUSIONS: Although our results are based on a German version using a self-report format, the WOMAC scales appear to be more responsive than the Lequesne index in patients with OA of the lower extremities.