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Inverted foot orthotics young means knee deterioration at 35?

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  #1  
Old 25th February 2012, 01:39 PM
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Default Inverted foot orthotics young means knee deterioration at 35?

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I've got a hunch, that we may start to see one negative finding of inversion therapy in years to come. The provision of devices with a strong rearfoot supination angle/force, has been common-place for the young (eg. primary school children), in the last two decades.

But for all the benefits of this prescription (structural, symptomatic etc.), is there one potential pathology, that we podiatrists are accelerating? I fear that the resultant early increased compression forces impacting on the medial knee joint can only mean one thing: Earlier onset of medial knee joint OA.


The study of Hinman & Payne on eversion wedging for medial knee joint arthritis, is on of the most clinically practical and relevant lower-limb studies I have come across. There is more to this study, than just a clincial response to late stage medial knee OA.



The take-home message for clinicians hence might be:

- Aim to get a clinical result with less rear-foot inversion angle/force; or
- Think about upping your knee knowledge via your CPD



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Old 25th February 2012, 01:51 PM
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Default Re: Inverted young means knee deterioration at 35?

Hey Ron ... long time no hear!

We had this thread on the related topic:
Will the use of external supination moment Foot orthotics increase the rates of Medial knee OA in which I posted:
Quote:
Originally Posted by Craig Payne View Post
I think I alluded to this in another thread.

If you look at some of Nigg's work and the flawed work from Kerrigan et al, then it looks as though a foot orthoses will increase the knee abduction moment in about 50% of people (bearing in mind that both the Nigg and Kerrigan studies did not use anything that resembles a 'foot orthotic' that people actually use in clinical practice) ... also bear in mind that this is also a zero sum game ... if the adduction moment increases, then the abduction moment must decrease (it don't figure that the above studies did not report on this!).

Also based on flawed research (again from Kerrigan et al!), it is possible that barefoot/minimalist/forefoot strike running can decrease the adduction moment ... again no one mentions what moments went up (...its a zero sum game!)

So if we accept the above data (I not quite prepared to do that yet), then when we put an orthotic under the foot, then there is a 50% chance that we increase the knee adduction moment and decrease the abduction moment --- that theoretically does increase the risk for medial knee OA (as a high abduction moment is a major risk factor) ... but in that same person we going to decrease the opposite moments ... that may help some with problems at the knee related to those moments.

Also bear in mind that there is a 50% chance that we decrease the risk for medial Knee OA as it decreases the adduction moment ... (and increased the abduction moment and risk for problems associated with that!)

How do we know if a foot orthotic is actually going to increase or decrease the risk for medial knee OA ..... I don't know. I suspect which moments get changed are all related to joint lever arms, tibial alignment and ranges of motion.

Should we be concerned about this? What if an orthotic does increase the knee adduction moment? Even if it does, this has to be moderated with the effect that the orthotic actually has on the pain the patient has.

I take this approach:
The other two main risk factors for knee OA are obesity and hereditary issues ... if they are present and there is a 50% chance that the orthotic add to that millieu then we have to acknowledge that (bear in mind there is a 50% we decrease the risk!)

If the patient is not overweight and has no family history OA, then its doubtful any increase in the knee adduction moment is going to cause any knee OA.

The same principle applies to barefoot/minimalist/forefoot strike running - if the injury history is related to high adduction moments, then they should be doing this. if the injury history is related to high abduction moments, then they should be rearfoot striking .... theoretically.
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Old 25th February 2012, 02:00 PM
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Default Re: Inverted foot orthotics young means knee deterioration at 35?

This is a possibility. Another possibility is that since inverted orthoses are used in feet suffering from excessive subtalar joint pronation moments, where there is a more lateral position of the foot relative to the long axis of the leg, that the medial shift in center of pressure from an inverted orthosis, combined with the decreased pain and disability resulting from proper use of these orthoses, will positively affect both the mental and physical aspect of patients and equalize abnormal knee compartment loading forces so that the patient has decreased risk of developing knee osteoarthritis. I would think that this possibility is much more likely from my clinical experience of using these devices for over a quarter century.
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Old 25th February 2012, 02:54 PM
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Default Re: Inverted foot orthotics young means knee deterioration at 35?

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Originally Posted by Atlas View Post

But for all the benefits of this prescription (structural, symptomatic etc.), is there one potential pathology, that we podiatrists are accelerating? I fear that the resultant early increased compression forces impacting on the medial knee joint can only mean one thing: Earlier onset of medial knee joint OA.
If the theory on how varus wedged orthoses work is correct then you can predict who is going to get worse and who is going to get better. The theory is that the varus wedge shifts the center of pressure under the foot and when it does that it also shifts the center of pressure under the knee. The frontal plane moment at the knee will be determined by the relative position of the center of pressure under the foot and the center of pressure of the knee joint axis. In someone with tibial varum, they will start with the force on the ground more medial than the force on the knee. A varus wedge orthotic will shift the center of pressure further medial and increase the adduction moment from the ground acting at the knee. On the other hand, if there is tibial valgum, a medial shift in the center of pressure will reduce the moment from the ground acting at the knee.

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Old 25th February 2012, 04:19 PM
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Default Re: Inverted foot orthotics young means knee deterioration at 35?

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Originally Posted by Kevin Kirby View Post
...... will positively affect both the mental and physical aspect of patients and equalize abnormal knee compartment loading forces so that the patient has decreased risk of developing knee osteoarthritis. I would think that this possibility is much more likely from my clinical experience of using these devices for over a quarter century.


I have focussed on knees from a bottom-up perspective for nearly 20 years, so whether that just 'sees your bid'; fails to see your bid; or raises your bet....is another complex issue.

Pre-podiatry, I was using wedges (lateral and medial) for knee problems in my first years as a physiotherapist in the 1990's. This also pre-dated the wedge-knee study, to my knowledge.

All I am advocating for the orthotic-prescribing podiatrist is to (at least) try and get the job done with more conservative rearfoot inversion angle/force. If the patient's signs and symptoms can't be or aren't resolved with conservative inversion, then yes, go as radical (inversion/supination) as you need to. In other words, kill the fly with a swatter, and not a shotgun. But if the swatter doesn't work, go over to the United States and walk into a corner-store and buy something more powerful.


I am not talking about middle-aged knees. What matters with them is good function now. Do whatever it takes.
But for the young, we might need to re-think.

In the future, we will begin to see big numbers of 35-40 year olds that have been wearing heavily inverted orthotics for most of their life up to that date. I am just predicting what we may see in relation to medial knee compressive pathology.




On another note, what is the relationship between inversion ankle sprains and inverted orthotic devices?




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Old 25th February 2012, 04:32 PM
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Default Re: Inverted young means knee deterioration at 35?

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Originally Posted by Craig Payne View Post
Hey Ron ... long time no hear!

We had this thread on the related topic:
Will the use of external supination moment Foot orthotics increase the rates of Medial knee OA in which I posted:
G'day Craig.



Apologise for the potential duplicity (moderator's nightmare), but I could further differentiate by adding lateral knee issues (instability? LCL dysfunction? Superior fibular migration etc.) in future 35-40 year olds.


I am also being more specific in relation to applied clinical podiatric practice; which is "in children, use the most conservative rearfoot inversion angle/force to obtain the desired result (functional, signs & symptoms).


When I went through as a student, several podiatric clinicians (small sample) advocated an inversion-first approach to young kids. The use of Joeys (Footwork) and DC Wedges (Foottech) have been the go-to devices for biomechanical intervention of children. I just think that if this is widespread, there needs to be some re-affirmation.




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Old 25th February 2012, 04:50 PM
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Default Re: Inverted foot orthotics young means knee deterioration at 35?

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Originally Posted by Atlas View Post
Pre-podiatry, I was using wedges (lateral and medial) for knee problems in my first years as a physiotherapist in the 1990's. This also pre-dated the wedge-knee study, to my knowledge.
According to the orthopedic surgeons I work with, they have been using such wedges for over a half century for knee osteoarthritis. This is really not a new technology. However, the research confirming their therapeutic effect is relatively new.

I am not concerned in the least about inverted orthoses causing medial knee osteoarthritis as long as they are correctly applied. However, indiscriminate use of inverted orthoses for all feet obviously can be a serious mistake and could cause injuries such as inversion ankle sprains, lateral dorsal midfoot interosseous compression syndrome, peroneal tendinopathy and medial knee osteoarthritis. Podiatrists using this orthosis technique should know what they are doing.

Last time I talked to Dr. Rich Blake, inventor of the Blake Inverted Orthosis, an orthosis technique which is now 30 years old, he sees no increase in inversion ankle sprains with his inverted orthoses.....of course, he knows what he is doing and is very careful who he gives these to.
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Old 25th February 2012, 05:11 PM
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Default Re: Inverted foot orthotics young means knee deterioration at 35?

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Originally Posted by Kevin Kirby View Post
According to the orthopedic surgeons I work with, they have been using such wedges for over a half century for knee osteoarthritis. This is really not a new technology. However, the research confirming their therapeutic effect is relatively new.

I am not concerned in the least about inverted orthoses causing medial knee osteoarthritis as long as they are correctly applied. However, indiscriminate use of inverted orthoses for all feet obviously can be a serious mistake and could cause injuries such as inversion ankle sprains, lateral dorsal midfoot interosseous compression syndrome, peroneal tendinopathy and medial knee osteoarthritis. Podiatrists using this orthosis technique should know what they are doing.

Last time I talked to Dr. Rich Blake, inventor of the Blake Inverted Orthosis, an orthosis technique which is now 30 years old, he sees no increase in inversion ankle sprains with his inverted orthoses.....of course, he knows what he is doing and is very careful who he gives these to.


Fair points Kevin.


As for Orthopaedic Surgeons, who have probably the toughest job of all of us (difficult to reverse their odd error), in my experience, they are the bookends of treatment. They will give patient x two main options. Plan "a" is to go away and lose weight and do some typical things to improve the condition conservatively. Plan "b" is obviously let's operate and improve things surgically.

I laud your orthopods that have more than 2 tricks (wedges, cortisone, blood injections, hydrodilitation etc.) in the showbag. Although I will concede that surgery is the toughest gig in town.




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Old 25th February 2012, 06:50 PM
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Default Re: Inverted foot orthotics young means knee deterioration at 35?

Ron:

Probably the best book I ever read on knee mechanics, knee DJD, biomechanical effects of transverse plane angulation of the tibia and the biomechanical effect of varus and valgus osteotomies for knee DJD is now, unfortunately, out of print, and by Paul Macquet (Maquet, Paul G.J.: Biomechanics of the Knee. Springer-Verlag, New York, 1984). After reading this book during my Biomechanics Fellowship in 1985, varus and valgus wedges for knee DJD made complete mechanical sense. Too bad no one at CCPM ever taught me this information....had to learn this information, along with many other things, by reading on my own from the CCPM library. This is a great book and really helped me understand knee mechanics from a whole new level.

http://www.amazon.com/gp/search?inde...rds=0387078827
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Old 25th February 2012, 10:37 PM
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Default Re: Inverted foot orthotics young means knee deterioration at 35?

Quote:
When I went through as a student, several podiatric clinicians (small sample) advocated an inversion-first approach to young kids. The use of Joeys (Footwork) and DC Wedges (Foottech) have been the go-to devices for biomechanical intervention of children. I just think that if this is widespread, there needs to be some re-affirmation.
Hi Ron
This is a classic case of a geography specific issue. I have always had an issue with the use of the devices you mention generally because 'overcorrection' is so easy.
For those that do not know these devices, they have no heel cup, but have a strong varus wedge- they are produced by only a couple of labs in Melbourne and no-where else (that I know of).

They can be very effective, but I have seen a large number of cases where the inversion is replaced with a lateral shift of the heel in the shoe. You see lateral distortion of the upper of the shoe and instability with subsequent load on the peroneals, ITB etc. It is quite reasonable to also expect potential compression on the medial compartment of the knee...
This design is different from a Blake inverted orthosis, but the same is possible if the execution of the device is poor (as Kevin stated above ). But this is why they are custom prescription orthoses- so the prescriber can ensure that the possibility of this occurring is minimal.
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Old 28th February 2012, 04:27 AM
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Default Re: Inverted foot orthotics young means knee deterioration at 35?

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Originally Posted by Kevin Kirby View Post
Ron:

Probably the best book I ever read on knee mechanics, knee DJD, biomechanical effects of transverse plane angulation of the tibia and the biomechanical effect of varus and valgus osteotomies for knee DJD is now, unfortunately, out of print, and by Paul Macquet (Maquet, Paul G.J.: Biomechanics of the Knee. Springer-Verlag, New York, 1984). After reading this book during my Biomechanics Fellowship in 1985, varus and valgus wedges for knee DJD made complete mechanical sense. Too bad no one at CCPM ever taught me this information....had to learn this information, along with many other things, by reading on my own from the CCPM library. This is a great book and really helped me understand knee mechanics from a whole new level.

http://www.amazon.com/gp/search?inde...rds=0387078827





Ahh. Good old clincal books of the "anachronistic" pre-EBP pre-internet era. More gems there than we give credit for. Some of those old clinicians would eat generation X for breakfast. Horse-punters want to see a hypothetical race between Phar Lap, Secretariat, Black Caviar, Makybe Diva etc. I wouldn't mind seeing the pure clinical skills of Geoff Maitland, Robin McKenzie, Root and Co. going up against our statistically significant knowledge.




Returning to your knee book.
1984 or 1976?


Out-of-print, but still available I gather?




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Old 28th February 2012, 07:27 PM
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Default Re: Inverted foot orthotics young means knee deterioration at 35?

One other factor that needs to be considered with regards to inverted orthoses, or just orthoses in general, with regards to knee loads is that foot orthoses do not only influence frontal plane knee mechanics. It is possible that rotational/transverse plane motion of the tibia from foot pronation contributes to medial knee OA and thus while medial knee loads may be increased with inverted foot orthoses, rotational stresses may be decreased.
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Old 28th February 2012, 11:11 PM
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Default Re: Inverted foot orthotics young means knee deterioration at 35?

Quote:
One other factor that needs to be considered with regards to inverted orthoses, or just orthoses in general, with regards to knee loads is that foot orthoses do not only influence frontal plane knee mechanics. It is possible that rotational/transverse plane motion of the tibia from foot pronation contributes to medial knee OA and thus while medial knee loads may be increased with inverted foot orthoses, rotational stresses may be decreased.
Agreed. I do not exclude the use of foot orthoses to provide medial support if the have medial knee O/A... but you DO need to be careful!
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Old 29th February 2012, 05:08 AM
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Default Re: Inverted foot orthotics young means knee deterioration at 35?

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One other factor that needs to be considered with regards to inverted orthoses, or just orthoses in general, with regards to knee loads is that foot orthoses do not only influence frontal plane knee mechanics.

But when it comes to rearfoot inversion devices, the frontal plane influence on the knee is the biggest daddy of them all.



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Old 29th February 2012, 05:16 AM
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Default Re: Inverted foot orthotics young means knee deterioration at 35?

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But when it comes to rearfoot inversion devices, the frontal plane influence on the knee is the biggest daddy of them all.
IS this your opinion Ron? Or have you a reference for this statement? I am not saying you are wrong, but I am not certain that you are always correct in this regard...
The devices you mention earlier are a specific version of a 'rearfoot inversion device'
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Old 4th March 2012, 05:09 PM
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IS this your opinion Ron? Or have you a reference for this statement? I am not saying you are wrong, but I am not certain that you are always correct in this regard...
The devices you mention earlier are a specific version of a 'rearfoot inversion device'


No references.


Just years of playing with acute and chronic medial and lateral knee pathology.


You are thinking more about rotational influences in the knee?




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Old 4th March 2012, 10:26 PM
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Default Re: Inverted foot orthotics young means knee deterioration at 35?

Quote:
You are thinking more about rotational influences in the knee?
I have more than a couple of patients who have medial knee OA, and significantly pronated feet. I have managed them with orthoses designed to increase the supination moment and had a positive effect on the knee... (from memory the knee was not the primary problem in these cases). My feeling is that perhaps controlling some of the rotational forces was the mechanism of action in this case. I would never use a DC Wedge/ Joey type device in this type of case.
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Old 5th March 2012, 08:30 PM
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Default Re: Inverted foot orthotics young means knee deterioration at 35?

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I have more than a couple of patients who have medial knee OA, and significantly pronated feet. I have managed them with orthoses designed to increase the supination moment and had a positive effect on the knee... (from memory the knee was not the primary problem in these cases). My feeling is that perhaps controlling some of the rotational forces was the mechanism of action in this case. I would never use a DC Wedge/ Joey type device in this type of case.
Agreed! I would like to emphasise this point. Often someone with medial knee OA plus lots of pronation does really well with inverted orthotics. Theoretically this should shift the COP more medially, however when you put it all together and shake it up, the reduction of internal rotational force of the tibia seems to be more important than shifting the COP to the lateral knee.

Need to learn more about knees i think!
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Old 8th March 2012, 01:25 AM
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Default Re: Inverted foot orthotics young means knee deterioration at 35?

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Agreed! I would like to emphasise this point. Often someone with medial knee OA plus lots of pronation does really well with inverted orthotics. Theoretically this should shift the COP more medially, however when you put it all together and shake it up, the reduction of internal rotational force of the tibia seems to be more important than shifting the COP to the lateral knee.

Need to learn more about knees i think!


But how do you know that the medial OA is the main pathology of symptom production. How do you work out that your case(s) are more about medial OA, and less about MCL, pes anserine and other medial tension pathology issues?



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Old 8th March 2012, 04:52 AM
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Default Re: Inverted foot orthotics young means knee deterioration at 35?

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But how do you know that the medial OA is the main pathology of symptom production. How do you work out that your case(s) are more about medial OA, and less about MCL, pes anserine and other medial tension pathology issues?
This is a good point. But at the end of the day does it matter??
It is important to know if there is medial compartment OA, but they are there for their knee pain...
If this patient returned for a review and the pain had changed in its behaviour then you could well conclude that you have robbed Peter to pay Paul- helped the medial tension pathologies but aggravated the medial compartment...
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Old 8th March 2012, 06:36 AM
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Originally Posted by CraigT View Post
This is a good point. But at the end of the day does it matter??
It is important to know if there is medial compartment OA, but they are there for their knee pain...
If this patient returned for a review and the pain had changed in its behaviour then you could well conclude that you have robbed Peter to pay Paul- helped the medial tension pathologies but aggravated the medial compartment...


I think it does matter when we are debating the importance of which plane is the big daddy of them all.


But clinically, you're right. All that counts is symptom reduction and normalisation of function.




Ron Bateman
Physiotherapist (Masters) & Podiatrist
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