The Knee 19 (2012) 163175

Contents lists available at ScienceDirect

The Knee

Review

Effect of footwear on the external knee adduction moment A systematic review

Andy Oliver Radzimski a, Annegret Mndermann b, Gisela Sole a,
a
b

Center for Physiotherapy Research, University of Otago, P.O. Box 56, Dunedin, New Zealand
University of Constance, Universittsstrae 10, D-78464 Constance, Germany

a r t i c l e

i n f o

Article history:
Received 2 November 2010
Received in revised form 25 May 2011
Accepted 30 May 2011
Keywords:
Osteoarthritis
Knee adduction moment
Footwear
Orthoses
Barefoot

a b s t r a c t
Context: Footwear modications have been investigated as conservative interventions to decrease peak
external knee adduction moment (EKAM) and pain associated with knee osteoarthritis (OA).
Objective: To evaluate the literature on the effect of different footwear and orthotics on the peak EKAM during
walking and/or running.
Methods: A systematic search of databases resulted in 348 articles of which 33 studies were included.
Results: Seventeen studies included healthy individuals and 19 studies included subjects with medial knee OA.
Quality assessment (modied Downs and Black quality index) showed an (average SD) of 73.1 10.1%. The
most commonly used orthotic was the lateral wedge, with three studies on the medial wedge. Lateral
wedging was associated with decreased peak EKAM in healthy participants and participants with medial knee
OA while there is evidence for increased peak EKAM with the use of medial wedges. Modern footwear
(subjects' own shoe, stability and mobility shoes, clogs) were likely to increase the EKAM compared to
barefoot walking in individuals with medial knee OA. Walking in innovative shoes (variable stiffness)
decreased the EKAM compared to control shoes. Similarly, shoes with higher heels, sneakers and dress shoes
increased EKAM in healthy individuals compared to barefoot walking.
Conclusions: Further development may be needed toward optimal footwear for patients with medial knee OA
with the aim of obtaining similar knee moments to barefoot walking.
2011 Elsevier B.V. All rights reserved.

Contents
1.
2.

3.

4.

5.

Introduction . . . . . . . . . . . . . .
Methods . . . . . . . . . . . . . . . .
2.1.
Search strategy . . . . . . . . . .
2.2.
Inclusion criteria . . . . . . . . .
2.3.
Study selection . . . . . . . . . .
2.4.
Risk of bias . . . . . . . . . . . .
2.5.
Data synthesis . . . . . . . . . .
Results . . . . . . . . . . . . . . . . .
3.1.
Database search . . . . . . . . . .
3.2.
Risk of bias . . . . . . . . . . . .
3.3.
Overview of included studies . . .
3.3.1.
Wedged insoles or shoes .
3.3.2.
Shod compared to barefoot
Discussion . . . . . . . . . . . . . . .
4.1.
Clinical implications . . . . . . .
4.2.
Research implications . . . . . . .
4.3.
Limitations
. . . . . . . . . . .
Conclusion. . . . . . . . . . . . . . . .

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walking
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Conict of interest: The authors state that there are no conicts of interest, which might have inuenced the preparation of this manuscript.
Corresponding author. Tel.: + 64 3 479 7936; fax: + 64 3 479 8414.
E-mail address: gisela.sole@otago.ac.nz (G. Sole).
0968-0160/$ see front matter 2011 Elsevier B.V. All rights reserved.
doi:10.1016/j.knee.2011.05.013

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164

6.
Conict of interest
Funding . . . . . . . .
Acknowledgment . . .
References . . . . . .

A.O. Radzimski et al. / The Knee 19 (2012) 163175

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1. Introduction
Osteoarthritis (OA) of the knee is one of the most common
rheumatic diseases with an estimated 12% of the American population
over the age of 60 years being affected [1]. It is commonly associated
with substantial pain and immobility [1]. More recently, the lifetime
risk of symptomatic knee OA has been found to be nearly 1 in 2
overall, more than 1 in 2 for those with a history of a knee injury, and
nearly 2 in 3 for obese people [2].
It is widely accepted that biomechanical forces are associated with
the pathogenesis of OA [35]. In healthy subjects, the peak medial
knee compartment load during early stance of walking is 2.32.6
times the bodyweight (BW) [69], while the lateral compartment is
subjected to a peak load of 1.7 times BW [9]. The higher bone mineral
density of the subchondral bone of the proximal medial tibia
compared to the lateral side supports the difference in mechanical
stress between both knee compartments [10]. These ndings may
explain the higher prevalence of medial knee OA, which is estimated
to be 10 times more frequent than lateral knee OA [11].
Since direct measurement of knee joint load is invasive, gait
analysis has been used as an indirect method to quantify forces acting
upon the lower extremity. The external knee adduction moment
(EKAM) is a valid and reliable representative of the medial-to-lateral
knee load distribution [7,12]. This varus torque shows a typical
pattern of a higher rst peak and a lower and less distinct second peak
during early and late stance, respectively, in both healthy and
symptomatic subjects [13,14]. There is evidence showing that patients
with medial knee OA have a signicantly higher rst peak EKAM
compared to a healthy population [1422].
The EKAM during walking has been linked to the symptoms, initiation
and progression of knee OA [2326]. Consequently, the rst peak EKAM
has become an important variable in research to determine the risk and
progression of medial knee OA, and to evaluate the effects of interventions, such as surgery, in the management of patients with this
disorder. Further, other lesions of the lower limb, such as an anterior
cruciate ligament (ACL) or meniscal injury have also been associated with
increased peak EKAM during walking [27,28]. As these injuries form a
high risk for the development of future knee OA, [5,29,30] it may be
important that rehabilitative strategies are implemented with the goal of
decreasing EKAM during activity.
Over the past two decades, modied footwear has been investigated as potential conservative management of knee OA. More
specically, lateral wedging has been used with the goal of reducing
symptoms associated with medial knee OA, hypothetically by
reducing the peak EKAM in these patients [4]. If specic footwear
interventions are associated with decreased EKAM during walking
and other physical activity, these may be useful toward the
management of symptoms of patients with medial knee OA, and
potentially to reduce the risk of future OA in people who are at
increased risk, such as those with knee injuries. This review aims to
evaluate the current knowledge on various footwear interventions in
relation to the peak EKAM in healthy and subjects with disorders of
the knee.
2. Methods
2.1. Search strategy
An electronic search was undertaken without language restriction
of Medline, PubMed, AMED, CINAHL, EMBASE and Scopus databases

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174
174
174
174

from their original available dates to January 2011. The search

strategy included a combination of keywords for inclusion and
exclusion factors (Appendix A). These were followed by hand
searches relevant journals. Finally, the citation lists of included
studies were screened for additional relevant articles via the database
Web of Science.
2.2. Inclusion criteria
i. Peer-reviewed and published randomized controlled trials,
quasi-randomized controlled trials, laboratory based trials, case
series and case reports.
ii. Human participants with or without disorders of the knee,
dened as ligamentous or meniscal injury, or as OA.
iii. Independent variables included footwear, such as different
shoes, insoles or foot orthotics, and/or barefoot.
iv. Dependent variables included EKAM (or dened as knee varus
moment) during daily physical activities such as walking, stair
climbing or running.
Papers testing participants with lower limb fractures, systemic
diseases such as rheumatoid arthritis, or neurological disorders such
as stroke were excluded.
2.3. Study selection
After exclusion of duplicates, the principal investigator (AOR)
screened all titles and article types for relevance. Irrelevant articles,
such as animal studies or unrelated clinical conditions were excluded.
Two independent assessors (AOR and GS), blinded to authors and
journals, screened all potentially relevant titles and abstracts for
inclusion criteria. Full articles were retrieved if no abstract or
insufcient information from title and abstract was available. In case
of disagreement the two assessors' consensus was reached following
discussion, or after full article assessment.
2.4. Risk of bias
As this systematic review included mainly laboratory-based
biomechanical studies, a modied Downs and Black quality checklist
was used [31]. Twelve questions (items 4, 8, 9, 13, 14, 17, 19, 21, 22,
24, 25 and 26) from the original checklist were excluded as they were
irrelevant to non-randomized studies. Thus, the modied checklist
included 15 questions from the following sub-groups: reporting
(items 1, 2, 3, 5, 6, 7 and 10), external validity (items 11 and 12),
internal validity bias (items 15, 16, 18 and 20), internal validity
confounding (selection bias) (item 23) and power (item 27).
Questions ve and 27 were adapted, as the majority of studies
investigated different footwear conditions in one group of subjects.
The reliability and validity of the modied Downs and Black quality
checklist used in this review were not assessed as similar modied
versions have already been published [32,33]. Walking speed was
considered as the most important principal confounder to be
reported, as this variable has shown to be correlated with the EKAM
[34].
Two reviewers (AOR and GS) independently assessed the quality
of all included articles. Items on the statistical tests used for the main
outcomes and the accuracy of main outcome measures were also
scored by a third reviewer (AM). If the quality scores differed among
the assessors, consensus was reached through discussion. For the

A.O. Radzimski et al. / The Knee 19 (2012) 163175

165

purpose of this review the quality of studies meeting 75% of the

applicable criteria was considered as high, 6074% as moderate and
b60% as low.

investigation. Further, probability values (P-values) for mean differences in EKAM

between conditions were not presented in four studies. Only seven studies reported
power calculations with more than half of the studies (17/33) using a sample size of 20
participants or less.

2.5. Data synthesis

3.3. Overview of included studies

Mean differences (95% condence intervals, CIs) for the outcome

of interest between footwear conditions were calculated for specic
population groups (healthy subjects vs. symptomatic subjects).
Forrest plots were drawn for the effect sizes of the main footwear
conditions and population groups. Clinical heterogeneity was
assessed by examining the types of subjects and footwear interventions. A meta-analysis of the studies was not performed as high
variability was expected for the interventions and included subjects.
3. Results
3.1. Database search
The full search yielded 348 articles (Fig. 1). After exclusion of duplicates, irrelevant
titles and screening of abstracts 39 remained. Six articles were excluded after full
assessment as they did not use knee joint moments as an outcome measurement, used
a biomechanical model instead of common footwear or were not published in peerreviewed journals. Thus, 33 articles qualied for this review.
3.2. Risk of bias

Identification

The mean quality score SD of the included studies was 73.1 10.6% (Appendix
B). Fifteen of the studies were classied as high quality, 16 were ranked as moderate
quality and two studies had a low quality. High scores were found for reporting,
however, ve research groups did not dene subjects' walking speed although this
inuences the EKAM [34]. Articles provided poor scoring in the category of external
validity with only two articles clearly dening if included subjects were representative
of the recruited population. Within the subgroup internal validity (bias) only three
studies blinded the data collectors or processors to different footwear conditions under

Records identified through

database searching
(n = 385)

Seventeen studies included healthy subjects, and subjects with medial knee OA
were included in 18 studies. Two of these studies [35,36] included a group of healthy
individuals and a group with medial knee OA (Tables 1 and 2). The severity of medial
compartment OA was reported using the KellgrenLawrence (KL) scale, with most of
the studies including subjects with a grade 2.
One study included a group of uninjured subjects and a group with lateral ankle
sprains [37]. Only data of the uninjured group from this study [37] were included in this
review. Three of the studies with healthy subjects included running [3840], with the
remainder instructing subjects to walk at a self-selected or at a comfortable pace. Eight
studies with healthy participants [35,36,39,4145] and eight with subjects with knee
OA [35,36,4651] included a barefoot condition. The main orthotic device under
investigation was the laterally-wedged insole with two studies on an additional ankle
support [47,51]. Three studies included medially-wedged orthotics, shoes or a medial
arch support [40,52,53]. The type of footwear included high-heeled shoes, dress shoes,
clogs, ip-ops, sneakers and innovative mobility shoes or variable-stiffness shoes.
3.3.1. Wedged insoles or shoes
3.3.1.1. Healthy subjects. Eight studies described the effect of laterally-wedged insoles or
shoe soles on the EKAM for healthy participants while walking (Fig. 2) [35
37,41,45,5355], with the amount of wedging ranging between 4 and 14. Lateral
wedging decreased EKAM between 5.56 and 12.56% compared to the control condition.
One study indicated a mean decrease of the EKAM of 24.44%, however had wide 95% CIs
[41]. One study used two types of intervention shoes with identical uppers, but
laterally-wedged soles of 4 and 8 respectively., The intervention shoes reduced the
peak EKAM on average by 7.6% and 12.6%, respectively, compared to a shoe with a
neutral sole [55]. In contrast, Schmalz et al. [53] attached a 14 lateral wedge to the sole
of a standardized shoe and found no signicant changes in the rst peak EKAM
compared to a non-wedged shoe.
Four studies investigated the effect of insoles attached to bare feet on knee
moments [3537,45]. Decreased peak EKAM ranging from 8.8 to 11.3% was reported for
a 6 lateral wedge compared to a non-wedged insole.

Additional records identified

through other sources
(n =3)

Records screened
(n =164)

Records excluded
(n =125)

Eligibility

Full-text articles
assessed for eligibility
(n =39)

Full-text articles excluded

(n= 6):
Other injuries (n=2);
Outcome determined with
accelerometry (n=2);
No immediate effects (n=2)

Included

Screening

Records after duplicates removed

(n =224 removed)

Studies included in
qualitative synthesis
(n =33)

Fig. 1. Flow chart of literature search.

166

Table 1
Effect of footwear interventions on the external knee adduction moment in healthy subjects.
Subject characteristics
(mean age, height, mass, SD)

Methodology of data collection

Task and measured variable

Conditions and footwear description

% Mean difference (95% CI)a

Crenshaw
et al.
[54]
Erhart et
al. [55]

17 subjects
27.7 years ( 6.5), 167.1 cm
(9.6), 67.7 kg (15.1)
9 females + 6 males
28.6 years ( 4), 167 cm
(10), 62.8 kg (9.8)

5-camera motion analysis system;

7 markers (Helen Hayes
conguration)
8-camera optoelectronic motion
analysis system;
6-marker joint link system

Walking at a self-selected
speed;
Peak EKAM (Nm/kg)
Walking at self-selected
slow, normal and fast
speeds;
1st peak EKAM
(Nm/kg m%)

C: No insole vs.
I: 5 lateral wedge from hindfoot to forefoot,
made of nickleplast, tted into subjects' own shoes
C: 0 laterally wedged-shoe vs.
I 1: 4 laterally-wedged shoe vs.
I 2: 8 laterally-wedged shoe
All shoes had identical uppers and an uniform sole stiffness
(durometer score of 55 2)

C vs. I:
6.76 (4.69 to 8.83)

Eslami
et al.
[38]
Fisher et
al. [56]

11 males
27.9 years ( 4.5), 179 cm
(5.9), 86.1 kg (7)
9 males + 5 females
31.6 years ( 13.7), 169 cm
(6.5), 67 kg ( 10.5)

6 cameras;
9 markers

Running at controlled speed

(170 steps/min);
Peak EKAM (Nm/kg)
Walking at self-selected speed;
Peak EKAM (Nm/kg m%)

C: sandal vs.
I: sandal plus semi-rigid foot orthotic

Franz et
al. [40]

12 males + 10 females
29.2 years ( 5.1), 175.7 cm
(9.8), 71.3 kg (14.3)

Vicon 624 10-camera motion

analysis system;
16 markers

Walking and running at selfselected speed;

1st and 2nd peak EKAM
(Nm/kg m)

Kakihana
et al.
[41]

5 females + 5 males
25 years (3.2), 166.4 cm
(5.4), 54.7 kg (6)

Vicon motion analysis system

(712 cameras);
8 markers

Walking at self-selected speed;

Knee varus moment (Nm/kg)

Kakihana
et al.
[35]d

13 females
64.6 years ( 2.3), 150 cm
(3), 54.1 kg ( 7.2)

Vicon 512 12-camera motion

analysis system;
12 markers

Walking at controlled speed

(95 steps/min);
Knee varus moment (Nm/kg)

Kakihana
et al.
[37]d

25 males
20.7 years ( 1.2), 175.2 cm
(4.8), 77.1 kg (13.1)

Vicon 512 12-camera motion

analysis system;
12 markers

Kakihana
et al.
[36]d

19 females
67.1 years ( 4.2), 150.8 cm
(4.6), 54.9 kg (7.7)

Vicon 512 12-camera motion

analysis system;
12 markers

Kerrigan
et al.
[44]

20 females
34.6 years ( 9.3), 167 cm
(6), 61.8 kg ( 7.6)

4-camera motion analysis system;

8 markers

Walking at self-select
ed speed;
Knee varus moment
(Nm/kg)
Walking at self-selected
speed;
Knee varus moment
(Nm/kg m)
Walking at self-selected speed;
1st and 2nd peak knee varus
torque (Nm/kg m)

7-camera system;
6-marker joint link system

C: subject's own walking shoe vs.

I 1: regular at walking shoe vs.
I 2: 120% lateral stiffness show vs.
I 3: 150% lateral stiffness shoe vs.
I 4: 4 valgus shoe sole angle vs.
I 5: 8 valgus shoe sole angle
Durometer scores of 5055 for I 1, I 4 and I 5, 6065 for I
2 on the lateral sole and 7580 for I 3 on the lateral sole
C: no insole vs.
I: 4 mm insole with a 26 mm arch support (durometer score of 28)
Insoles were tted into New Balance 755 Athletic shoe
(single-density midsole)

C: non-wedged insole vs.

I 1: 3 lateral wedge vs.
I 2: 6 lateral wedge
Insoles, made of ethylene vinyl acetate,
were tted into subjects' own shoes
C: non-wedged insole vs.
I: 6 lateral wedge
Insoles, made of ethylene vinyl acetate,
were attached to bare feet
C: non-wedged insole vs.
I: 6 lateral wedge
Insoles, made of ethylene vinyl acetate,
were attached to bare feet
C: 5 mm non-wedged insole vs.
I: 6 lateral wedge
Insoles, made of ethylene vinyl acetate, were attached to bare feet
C: barefoot walking vs.
I: subject's own high-heeled shoe with a heel height
of 6 cm (1)

C vs. I:
Slow:
8.89 (6.74 to 11.04)
Normal:
7.62 (5.78 to 9.46)
Fast:
8.54 (6.47 to 10.60)
C vs. I 2:
Slow:
17.33 (13.15 to 21.15)
Normal:
12.56 (9.52 to 15.49)
Fast:
19.11 (14.49 to 23.72)
C vs. I:
19.66 (5.68 to 33.64)b
No data available for
subject's own shoe.
According to authors I 2 to
I 5 signicantly reduced the
peak EKAM up to 16%
compared to C.

C vs. I 1:
Walking:
1st peak:
0 (0 95% CI)
2nd peak:
5 ( 2.72 to 7.28)
C vs. I:
Running:
Peak: 4.11 (2.66 to 5.56)
C vs. I 1:
8.89 (4.96 to 12.82)c
C vs. I 2:
24.44 (13.64 to 35.25)c
C vs. I:
10.34 (7.95 to 12.74)

C vs. I:
9.38 (6.87 to 11.88)

C vs. I:
11.33 (8.44 to 14.22)

C vs. I:
1st peak:
23.08 ( 27.79 to 18.36)
2nd peak:
23.81 ( 28.67 to 18.95)

A.O. Radzimski et al. / The Knee 19 (2012) 163175

Authors

20 females
34.9 years (7.1), 162 cm
(5), 59.1 kg (9.7)

Vicon 6-camera motion

analysis system

Walking;
1st and 2nd knee varus
torque (Nm/kg m)

C: Barefoot walking vs.

I 1: subject's own narrow-heeled
shoe (width: 1.2 cm ( 0.4))
I 2: subject's own wide-heeled shoe
(width: 4.5 cm (1.2))
All shoes had a heel height of 7 cm (1)

Kerrigan
et al.
[42]

22 males
30.6 years (6), 178 cm
(6), 76.6 kg (12.3)

Vicon 512 6-camera motion

analysis system;
7 markers

Walking at self-selected speed;

1st and 2nd peak EKAM
(Nm/kg m)

C: Barefoot walking vs.

I 1: subject's own dress shoe vs.
I 2: subject's own sneaker
Dress shoes had rm soles
Sneakers had rubber soles

Kerrigan
et al.
[57]

50 females
Group A (n = 30):
26.7 years (5), 165 cm
(6), 58.7 kg (9)
Group B (n = 20):
75.3 years (6.5), 160 cm
(7), 63.4 kg (13.3)

Vicon 512 6 camera motion

analysis system;
9 markers

Walking at self-selected
comfortable speed;
1st and 2nd peak varus
torque (Nm/kg m)

C: dress shoe with no heel height vs.

I: dress shoe with 3.8 cm heel height
All shoes had identical uppers and midsole design

Kerrigan
et al.
[39]
Nakajima
et al.
[45]

37 females + 31 males
34 years (11.3), 172 cm
(8), 65.6 kg (9)
11 males + 9 females
28.4 years (6.1), 167.2 cm
(9.4), 59.8 kg (10.9)

Vicon 624 10-camera motion

analysis system;
16 markers
Vicon 12-camera optoelectronic
motion analysis system;
14 markers

Running at self-selected,
comfortable speed;
Peak EKAM (Nm/kg m)
Walking at self-selected
speed;
Peak EKAM (Nm/kg m)

C: barefoot running vs.

I: standardized running shoe (Brooks Adrenaline)

Nester
et al.
[52]

8 males + 7 females
1941 years

3D coordinate system

Walking at controlled speed

(108 steps/min);
1st and 2nd peak EKAM
(Nm/kg)

Schmalz
et al.
[53]

6 males + 4 females
34 years (9), 178
(9), 73 kg (9)

Vicon 6-camera system;

7 markers

Walking at self-selected speed;

Knee varus moment (Nm/kg)

C: 5 mm non-wedged insole vs.

I 1: 5 mm non-wedged insole with arch support vs.
I 2: 6 lateral wedge vs.
I 3: 6 lateral wedge with arch support
Insoles, made of ethylene vinyl acetate, were attached to bare feet
C: shoe vs.
I 1: shoe plus 10 medial wedge with an arch ller vs.
I 2: shoe plus 10 lateral wedge
Insoles, made of high density vinyl acetate, were tted into
subject's own shoes
C: unmodied shoe vs.
I 1: 14 lateral wedge vs.
I 2: 14 medial wedge vs.
I 3: 14 lateral wedge plus semi-rigid ankle support vs.
I 4: 14 medial wedge plus semi-rigid ankle support vs.
I 5: 14 lateral wedge plus ankle-foot-orthotic vs.
I 6: 14 medial wedge plus ankle-foot-orthotic

C vs. I 1:
1.97 (0.89 to 3.04)
C vs. I 2:
8.80 (5.73 to 11.88)
C vs. I 3:
7.49 (4.21 to 10.77)
No data available.
Authors reported no changes
in EKAM between conditions.

C vs. I 1:
5.56 (3.85 to 7.27)e
C vs. I 2:
9.26 (6.41 to 12.11)
C vs. I 3: 9.26 (6.41 to 12.11)
C vs. I 4:
3.70 ( 2.56 to 4.84)
C vs. I 5:
29.63 (20.51 to 38.75)
C vs. I 6:
24.07 (16.67 to 31.48)

167

SD = standard deviation; C: control condition; I: intervention condition.

a
Mean differences (95% condence intervals, CI) between control and intervention conditions. Positive and negative values indicate decrease and increase respectively in comparison to the control.
b
Data obtained from graph in article.
c
No p-value reported; signicance level was set at P b 0.05.
d
Study on healthy and symptomatic subjects.
e
Reported as non-signicant in article.

C vs. I:
1st peak:
18.18 (21.89 to 14.74)
2nd peak:
25.93 (31.22 to 20.63)
C vs. I 2:
1st peak:
21.21 (25.54 to 16.88)
2nd peak:
29.63 (35.68 to 23.58)
C vs. I 1:
1st peak:
8.82 (5.49 to 12.15)
2nd peak:
3.13 (9.61 to 3.36)
C vs. I 2:
1st peak:
11.76 (16.21 to 7.32)
2nd peak:
0 (0 95% CI)
Group A:
C vs. I:
1st peak:
3.13 (0.69 to 5.56)e
2nd peak:
13.64 (9.91 to 17.36)
Group B:
C vs. I:
1st peak:
6.45 (4.79 to 8.11)3
2nd peak:
8.70 (6.46 to 10.93)
C vs. I:
38.33 (49.47 to 27.20)

A.O. Radzimski et al. / The Knee 19 (2012) 163175

Kerrigan
et al.
[43]

168

Table 2
Effect of footwear interventions on the external knee adduction moment in symptomatic subjects.
Subject characteristics (mean age,
height, mass or BMI SD)

Methodology of data collection

Task and measured variable

Conditions and footwear description

% Mean differences (95% CI)a

Butler
et al.
[58]

11 females + 9 males with

medial knee OA (KL 2)
63 years (6), 33.4 kg/m
(7.8)

Vicon motion analysis system;

21 markers

Walking at intentional
speed 5%,
1st and 2nd peak EKAM
(Nm/kg m)

Butler
et al.
[59]

17 females + 13 males with

medial knee OA (KL 2)
63.1 years ( 6.8), 33.8 kg/m
(6.9)
42 males + 37 females with
symptomatic medial
knee OA
60.2 years ( 9.8), 169 cm
(8), 79.2 kg ( 13.5)

Vicon 6-camera motion analysis system;

8 markers

Walking at intentional
speed 5%;
Peak EKAM (Nm/kg m)

C vs. I:
1st peak:
8.71 (6.46 to 10.95)
2nd peak:
2.04 ( 1.23 to 5.31)
C vs. I:
1st peak:
8.67 (5.53 to 11.82)b

8-camera optoelectronic system

for 3D motion analysis;
6-marker joint link system

Walking at self-selected slow,

normal and fast speed;
Peak EKAM (Nm/kg m%)

C: non-wedged orthotic vs.

I: 9.6 3.2 lateral wedge
Individually wedge degree determined
Orthotics (durometer score of
70) were tted into New Balance Athletic shoe 810
C: non-wedged orthotic vs.
I: 10 3.2 lateral wedge
Individually wedge degree determined Orthotics
(durometer score of 70) were tted into New Balance Athletic shoe 812
C: athletic shoe with a constant sole stiffness
(durometer score of 55 2) vs.
I: Variable-stiffness athletic shoe with durometer scores
of 55 2 for medial sole and 7076 2 for lateral sole

Erhart
et al.
[61]

42 males + 37 females with

medial knee OA based
on MRI
60.2 years ( 9.8), 169 cm
(8), 79.2 kg ( 13.5)

8-camera optoelectronic system

for 3D motion analysis;
6-marker joint link system

Walking at self-selected speed;

Peak EKAM (Nm/kg m%)

C: athletic shoe with a constant sole stiffness (durometer

score of 55 2) vs.
I 1: variable-stiffness athletic shoe with durometer
scores of 55 2 for medial sole and 7076 2 for
lateral sole vs.
I 2: subject's own shoe

Hinman
et al.
[62]

24 females + 16 males with

medial knee OA (KL 14)
64.7 years ( 9.4), 164 cm
(9), 79 kg (12)

Vicon 6-camera motion analysis system;

8 markers (standard Plug-In-Gait set)

Walking at comfortable speed;

1st and 2nd peak EKAM
(Nm/kg m)

C: subject's own shoe without insole vs.

I: ~5 lateral wedge, made of high-density ethyl-vinyl
acetate, tted into subject's own shoes

Hinman
et al.
[63]

7 females +6 males with

medial knee OA (KL 23)
59.7 years ( 6.2), 169 cm
(14), 81 kg ( 20.4)

Vicon 8-camera motion analysis system;

8 markers (standard Plug-in-Gait set)

Walking at self-selected speed;

1st and 2nd peak EKAM
(Nm/kg m%)

C: subject's own shoe without insole vs.

I 1:~5 full length lateral wedge vs.
I 2: ~5 rearfoot lateral wedge (calcaneus to mid-shaft
of 5th metatarsal head)
Insoles, made of high-density ethyl vinyl acetate, were
tted into subjects own shoes

Hinman
et al.
[64]

12 females + 8 males with

medial knee OA (KL 23)
63.5 years ( 9.4), 169 cm
(7), 83.1 kg ( 14.2)

Vicon 8-camera motion analysis system;

8 markers (standard Plug-in-Gait set)

Walking at comfortable speed;

1st and 2nd peak EKAM
(Nm/kg m)

C: subject's own shoe without insole vs.

I: ~5 lateral wedge, made of high-density ethyl-vinyl
acetate, tted into subjects' own shoes

Erhart
et al.
[60]

C vs. I:
Slow:
2.20 (1.37 to 3.03)c
Normal:
4.53 (2.81 to 6.25)
Fast:
6.40 (3.98 to 8.83)d
C vs. I 1:
Baseline:
4.25 (3.01 to 5.49)e
6 months:
5.90 (4.18 to 7.63)f
C vs. I 2:
Baseline:
2.33 (0.89 to 3.78)g
6 months:
4.72 (3.34 to 6.10)
C vs. I:
1st peak:
5.45 (3.71 to 6.93)
2nd peak:
8.65 (6.23 to 11.07)
C vs. I 1:
1st peak:
11.94 (7.24 to 16.65)
2nd peak:
14.14 (10.87 to 17.42)
C vs. I 2:
1st peak:
7.50 (2.52 to 12.48)
2nd peak:
7.07 (2.87 to 11.27)
I 2 vs. I 1:
1st peak:
4.80 (2.54 to 7.07)
2nd peak:
7.61 (4.66 to 10.56)
C vs. I:
Baseline:
1st peak:
5.24 (3.89 to 6.58)
2nd peak:
4.18 (3.10 to 5.25)
C vs. I:

A.O. Radzimski et al. / The Knee 19 (2012) 163175

Authors

Kakihana
et al.
[35]h
Kakihana
et al.
[36]h
Kemp
et al.
[46]
Kerrigan
et al.
[65]

Maly
et al.
[66]
Segal
et al.
[51]

Shakoor
et al.
[49]

Vicon 512 12-camera motion analysis system;

12 markers

Walking at controlled
speed (95 steps/min);
Knee varus moment
(Nm/kg)
Walking at self-selected
speed;
Knee varus moment
(Nm/kg m)
Walking at controlled
speed (1 m/s 10%);
Peak EKAM (Nm/kg m%)

C: non-wedged insole vs.

I: 6 lateral wedge
Insoles, made of ethylene vinyl acetate, were attached
to bare feet
C: 5 mm non-wedged insole vs.
I: 6 lateral wedge
Insoles, made of ethylene vinyl acetate, were attached
to bare feet
C: subject's own shoe vs.
I: barefoot walking

Vicon 512 motion analysis system;

9 markers

Walking at self-selected
speed;
1st and 2nd peak knee varus
torque (Nm/kg m)

C 1: no insole vs.
C 2: 3.175 mm non-wedged insole vs.
I 1: 5 lateral wedge vs.
I 2: 10 lateral wedge
Insoles (durometer score 55), made of
Amerifoam, were tted into subjects' own shoes

21 subjects with medial

knee OA (KL 2)
72 years, 152 cm (4),
50 kg (5)
9 males + 3 females with
medial knee OA
60 years (9.4), 99.2 kg
(15.9), 32.4 kg/m (5)
10 females + 4 males with
medial knee OA (KL 23)
51.9 years (8.3), 166 cm
(7.8), 32.8 kg/m (7.6)

4-camera system;
6 markers

Walking at comfortable
speed;
Peak knee varus moment
(Nm/kg m%)
Walking;
Peak EKAM (Nm/kg)

C: barefoot vs.
I 1: ~7.6 lateral wedge vs.
I 2: ~7.6 lateral wedge with subtalar strapping
Insoles, made of silicon rubber, were attached to bare feet
C: routine footwear vs.
I 1: 5 valgus heel wedge vs.
I 2: off-the-shelf orthotic, modied to 5 rearfoot valgus

Optotrak motion analysis system;

Sets of 3 noncollinear markers

Walking at self-selected
speed;
Peak EKAM (Nm/kg)

C: barefoot vs.
I 1: 6 lateral wedge vs.
I 2: 6 lateral wedge plus ankle support
Insoles composed of a thermoplastic elastomer
(durometer score of 50)

59 females + 16 males with

medial knee OA (KL 23)
59 years (10), 170 cm
(10), 78.9 kg (14.4)

Multicamera optoelectronic system;

6 markers

Walking;
Peak EKAM (Nm/kg m)

C: subject's own walking shoe vs.

I: barefoot

Vicon 512 12-camera motion analysis system;

12 markers

Vicon 612 6-camera motion analysis system;

8 markers (Vicon Plug-in-Gait model)

Questor gait analysis in 3D system;

8 diodes and 2 markers

C vs. I:
5.96 (4.26 to 7.67)

C vs. I:
7.34 (5.34 to 9.51)

C 1 vs. I 1:
1st peak:
5.30 (2.60 to 8.01)
2nd peak:
6.49 (4.92 to 8.06)
C 2 vs. I 1:
1st peak:
3.85 (2.08 to 5.61)
2nd peak:
4.23 (2.69 to 5.77)
C 1 vs. I 2:
1st peak:
8.33 (6.32 to 10.35)
2nd peak:
7.96 (6.04 to 9.89)
C 2 vs. I 2:
1st peak:
8.10 (6.14 to 10.06)
2nd peak:
6.87 (5.21 to 8.52)
C vs. I 1:
7.14 (4.63 to 9.65)i
C vs. I 2:
11.90 (6.20 to 17.61)j
C vs. I 1:
2.08% (0.92 to 3.25)k
C vs. I 2:
4.17 ( 1.84 to 6.49)k
C vs. I 1:
Baseline:
1.54 ( 5.52 to 2.45)
I 1 vs. I 2:
Baseline:
3.03 (0.64 to 5.42)k
C vs. I 2:
2 weeks:
2.82 (9.96 to 15.61)
C vs. I:
11.90 (8.43 to 15.38)

A.O. Radzimski et al. / The Knee 19 (2012) 163175

Kuroyanagi
et al.
[47]

13 females with medial

knee OA
63.3 years (5.6), 152.7 cm
(5.6), 57.3 kg (10.3)
51 females with medial knee
OA (KL 14)
65.5 years (3.8), 153.6 cm
(6), 55.4 kg (6.8)
24 females + 16 males with
medial knee OA (KL 14)
64.7 years (9.4), 164 cm
(8), 79.1 kg (12)
8 males + 7 females with
medial knee OA (KL 3)
69.7 years (7.6), 167 cm
(7), 83.9 kg (11.9)

4 weeks:
1st peak:
5.31 (3.94 to 6.67)
2nd peak:
7.11 (5.28 to 8.94)
C vs. I:
5.56 (4.27 to 6.84)

(continued on next page)

169

170

Table 2 (continued)
Subject characteristics (mean age,
height, mass or BMI SD)

Methodology of data collection

Task and measured variable

Conditions and footwear description

% Mean differences (95% CI)a

Shakoor
et al.
[48]

Experiment A:
24 females + 4 males with
medial knee OA (KL 23)
59 years (9), 170 cm
(10), 80 kg (17)
Experiment B:
16 females + 4 males with
medial knee OA (KL 23)
57 years (9), 170 cm
(10), 83 kg (16)

4 Qualisys optoelectronic cameras;

6 markers

Walking at self-selected speed;

Peak EKAM (Nm/kg m%)

Experiment A:
C: subject's own walking shoe vs.
I 1: barefoot walking vs.
I 2: mobility shoe, a exible and lightweight shoe to
mimic barefoot walking
Experiment B:
C: stability shoe (Brooks Addiction Walker) vs.
I 1: barefoot walking vs.
I 2: mobility shoe

Shakoor
et al.
[50]

21 women + 10 men with

medial knee OA (KL 23),
57 years (10), BMI 29.3 kg/m2
(4.8)

4 Qualisys optoelectronic cameras,

6 markers

Walking at self-selected
speed;
Peak EKAM: (Nm/kg
CIXm%)

C: barefoot walking
I 1: clogs
I 2: stability shoes
I 3: at walking shoes
I 4: ip-ops

Shimada
et al.
[67]

17 females + 6 males with

bilateral medial knee OA
(KL 14);
67 years (8.7), 150.2 cm
(7.2), 60.3 kg ( 7.1)

3D gait analysis system (model G1812);

8 markers

Walking at natural
speed;
Peak EKAM
(Nm/kg)

C: No insole vs.
I: 10 mm lateral wedge, made of silicon
Rubber

Experiment A:
C vs. I 1:
11.81 (6.05 to 17.56)
C vs. I 2:
8.12 (4.16 to 12.07)
I 1 vs. I 2:
4.18 ( 2.14 to 6.22)
Experiment B:
C vs. I 1:
11.73 (6.12 to 17.33)
C vs. I 2:
13.36 (6.97 to 19.74)
I 1 vs. I 2:
No p-value reported
C vs. I 1:
14.81 (7.56 to 22.07)l
C vs. I 2:
11.11 (16.55 to 5.67)l
C vs. I 3:
3.70 ( 5.51 to 1.89)l
C vs. I 4:
Difference reported to be non-signicant.
C vs. I:
4.44 (3.27 to 5.62)

BMI = Body Mass Index; SD = standard deviation; KL = Kellgren and Lawrence Scale; OA = osteoarthritis; C = control condition; I = intervention condition.
a
Mean differences (95% condence intervals, CI) between control and intervention conditions. Positive and negative values indicate decrease and increase respectively in comparison to the control.
b
10% reported in article.
c
2.4% reported in article.
d
6.2% reported in article.
e
3.5% reported in article.
f
6.6% reported in article.
g
1.2% reported in article.
h
Study on symptomatic and healthy subjects.
i
8% reported in article.
j
13% reported in article.
k
Reported at non-signicant in article.
l
Precise P-values not given; calculated at P = 0.05.

A.O. Radzimski et al. / The Knee 19 (2012) 163175

Authors

A.O. Radzimski et al. / The Knee 19 (2012) 163175

171

Kerrigan et al. [44]

Crenshaw et al. [54]

Kerrigan et al. [43], 1

Erhart et al. [55], 1

Kerrigan et al. [43], 2

Erhart et al. [55], 2

Kerrigan et al. [42], 1

Kakihana et al. [41], 1

Kerrigan et al. [42], 2

Kakihana et al. [41], 2

Kerrigan et al. [39]

-55 -50 -45 -40 -35 -30 -25 -20 -15 -10 -5

Kakihana et al. [35]

Favours barefoot

Kakihana et al. [37]

10

Favours
shoe

Kakihana et al. [36]

Nakajima et al. [45]
Schmalz et al. [53], 1
Schmalz et al. [53], 2
-15

-10

-5

10

15

Favours no wedge

20

25

30

35

40

Favours wedge

Fig. 2. Forrest plot for EKAM for healthy individuals during walking with lateral and
medial wedges compared to control conditions. Crenshaw et al. [54] No insole in
subject's shoes vs. 5 lateral wedge (n = 17). Erhart et al. [55], 1 Neutral shoe vs. 4
lateral wedged shoe (n = 15). Erhart et al. [55], 2 Neutral shoe vs. 8 lateral wedged
shoe (n = 15). Kakihana et al. [41], 1 Non-wedged insole vs. 3 lateral wedge (n = 10).
Kakihana et al. [41], 2 Non-wedged insole vs. 6 lateral wedge (n = 10). Kakihana et al.
[35] Non-wedged insole vs. 6 lateral wedge (n = 13). Kakihana et al. [37] Non-wedged
insole vs. 6 lateral wedge (n = 25). Kakihana et al. [36] Non-wedged insole vs. 6
lateral wedge (n = 19). Nakajima et al. [45] Non-wedged insole vs. 6 lateral wedge
(n = 20). Schmalz et al. [53], 1 Unmodied shoe vs. 14 lateral wedge (n = 10). Schmalz
et al. [53], 2 Unmodied shoe vs. 14 medial wedge (n = 10).

Three studies investigated medially-wedged orthotics in healthy individuals

[40,52,53]. Walking in standardized shoes with an attached 14 medial wedge to the
sole resulted in a 9.3% higher rst peak EKAM than a non-wedged shoe (Fig. 2) [53]. The
addition of an ankle foot orthotic increased the peak EKAM by 24.1% compared to the
neutral shoe. One study concluded a non-signicant increase in the peak EKAM during
walking for a medially-wedged condition compared to no insole [52]. Further, running
in standardized shoes with a medial arch support of 26 mm increased the peak EKAM
by 4.1% compared to no orthotic [40].

Butler et al. [58]

Butler et al. [59]
Hinman et al. [62]

Fig. 4. Forrest plot for EKAM for healthy individuals during walking and running in
different shoes compared to barefoot. Kerrigan et al. [44] Barefoot vs. high-heeled shoe,
min 6 cm (n = 20). Kerrigan et al. [43], 1 Barefoot vs. narrow-heeled shoe, height 7 cm
(n = 20). Kerrigan et al. [43], 2 Barefoot vs. wide-heeled shoe, height 7 cm (n = 20).
Kerrigan et al. [42], 1 Barefoot vs. dress shoe (n = 22). Kerrigan et al. [42], 2 Barefoot vs.
sneaker (n = 22). Kerrigan et al. [39] Barefoot vs. standard running shoe while running
(n = 68).

3.3.1.2. Symptomatic subjects. The largest sub-group of 12 studies [36,37,47,51,58,59,6267]

investigated the effect of lateral (valgus) wedged insoles on the rst peak EKAM compared to
non-wedged insoles or no insoles during walking in subjects with knee OA. Five studies from
this group [58,6265] also reported outcomes for the second peak EKAM.
In six of these studies the orthotic device was inserted into the subject's own
walking shoe or a standardized shoe was provided [58,59,6265]. The amount of
wedging ranged from 5 to 15. While three studies compared the lateral wedge to no
insole [6264] two studies used a non-wedged insole as the control condition [58,59].
One research group compared the lateral wedge to both aforementioned control
conditions [65]. With the exception of two studies [51,66], results indicated a reduction
in the rst EKAM with lateral wedges reduced the rst EKAM compared to the control
conditions (Fig. 3). Mean differences ranged between 2.1% and 11.9%. One study with
14 subjects using 6 rearfoot lateral wedges found no signicant reductions in the rst
peak EKAM compared to barefoot walking [51]. Maly et al. [66] found that the use of offthe-shelf orthotics with a 5 rearfoot lateral wedge led to a signicantly increased
EKAM compared to routine footwear alone for 12 subjects. A signicant reduction of
the second peak EKAM with the lateral wedge was found in three of ve studies,
ranging from 4.2% to 14.2% [6264].
In four other studies of this sub-group [35,36,47,67] the insoles were attached with
tape to the bare feet. Two studies compared a 6 lateral wedge to a non-wedged insole
and reported a mean reduction of 5.6% and 6.0% in the knee varus moment [35,36]. The
remaining two studies [47,67] where barefoot walking without wedging was used as a
control condition found average decreases in the peak EKAM of 4.4% and 7.1% with
lateral wedges of 7.6.
Three studies reported inconsistent individual changes in EKAM. Butler et al. [58]
showed that eight of their 20 subjects had increased EKAM when wearing lateral
wedging, and Hinman et al. [62] found similar results for ve of their 40 subjects and for
two of 13 subjects with full length lateral wedges [63].

Hinman et al. [63]

3.3.2. Shod compared to barefoot walking and running

Hinman et al. [64]

3.3.2.1. Healthy subjects. Five studies by the same research group investigated effects of
different types of footwear on the rst peak EKAM in healthy subjects during walking
(Fig. 4) [39,4244,57]. Female participants walking in high-heeled shoes with narrow
heels of an average heel height of 6 cm showed a mean increase of 23.1% in the rst

Kakihana et al. [35]

Kakihana et al. [36]
Kerrigan et al. [65], 1
Kerrigan et al. [65], 2
Kuroyanagi et al. [65]

Kemp et al. [46]

Maly et al. [66], 1

Shakoor et al. [49]

Maly et al. [66], 2

Shakoor et al. [48], 1

Segal et al. [51]
Shakoor et al. [48], 2

Shimada et al. [67]

-10

-5

Favours no wedge

10

15

20

Favours wedge

Fig. 3. Forrest plot for EKAM for individuals with medial knee osteoarthritis during
walking with lateral compared to control conditions. Butler et al. [58] Non-wedged
orthotic vs. 9.6 wedge (n = 20). Butler et al. [59] Non-wedged orthotic vs. 10 wedge
(n = 30). Hinman et al. [62] Own shoe vs. shoe plus 5 wedge (n = 40). Hinman et al.
[63] Own shoe vs. shoe plus 5 wedge (n = 13). Hinman et al. [64] Own shoe vs. 5
wedge (n = 20). Kakihana et al. [35] Non-wedge insole vs. 6 wedge (n = 13). Kakihana
et al. [36] Non-wedged insole vs. 6 wedge (n = 51). Kerrigan et al. [65], 1 No insole vs.
5 wedge in shoes (n = 13). Kerrigan et al. [65], 2 No insole vs. 10 wedge in shoes
(n = 13). Kuroyanagi et al. [47] Barefoot vs. 7.6 wedge (n = 21). Maly et al. [66], 1
Routine footwear vs. 5 lateral wedge (n = 12). Maly et al. [66], 2 Routine footwear vs.
5 lateral wedge on orthotic (n = 12). Segal et al. [51] Barefoot vs. 6 wedge (n = 13).
Shimada et al. [67] No insole vs. 10 mm lateral wedge (n = 23).

Shakoor et al. [48], 3

Shakoor et al. [50], 1
Shakoor et al. [50], 2
Shakoor et al. [50], 3
-30

-25

-20

-15

Favours barefoot

-10

-5

10

Favours shoe

Fig. 5. Forrest plot for EKAM for individuals with medial knee osteoarthritis during
walking in different shoes compared to barefoot. Kemp et al. [46] Barefoot vs. subjects
own shoe (n = 40). Shakoor et al. [49] Barefoot vs. subjects own shoe (n = 75). Shakoor
et al. [48], 1 Barefoot vs. subjects own shoe (n = 28). Shakoor et al. [48], 2 Barefoot vs.
mobility shoe (n = 28). Shakoor et al. [48], 3 Barefoot vs. stability shoe (n = 28).
Shakoor et al. [50], 1 Barefoot vs. clogs (n = 31). Shakoor et al. [50], 2 Barefoot vs.
stability shoe (n = 31). Shakoor et al. [50], 3 Barefoot vs. at shoe (n = 31).

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A.O. Radzimski et al. / The Knee 19 (2012) 163175

peak EKAM compared to barefoot walking [44]. The width in the base of high-heeled
shoes has also been associated with increased moments, as an average 1.2 cm narrowheeled shoe and an average 4.5 cm wide-heeled shoe resulted in 18.2% and 21.2%
higher rst peak EKAM respectively [43]. In contrast, a wide-heeled shoe with a heel
height of 3.8 cm showed no signicant increase in the rst peak EKAM compared with a
shoe with no heel height in younger and elderly women [57]. Male subjects showed
that wearing rm-soled dress shoes and rubber-soled sneakers had mean increases of
8.8% and 11.8% respectively in the rst peak EKAM compared to barefoot walking [42].
Further, a standardized running shoe was investigated in runners [44]. These subjects
showed a 38.3% higher rst peak EKAM in the shod condition compared to barefoot
running on a treadmill.
An innovative type of footwear with a stiffer lateral than medial sole was described
by Fisher et al. [56]. Walking in these shoes with and without the addition of a lateral
wedge decreased the EKAM up to 16% compared to control shoes [56,60,61].
3.3.2.2. Symptomatic subjects. Four studies investigated differences in the peak EKAM
between shod and barefoot walking in subjects with medial knee OA (Fig. 5) [46,48
50]. Signicantly higher rst peak EKAM (mean differences from 3.7 to 14.81%) were
found for shod conditions compared to barefoot walking. In patients with medial knee
OA, mobility shoe reduced the peak EKAM by 8.1% compared to a conventional shoe.
In contrast, stability shoes and clogs increased the EKAM by approximately 10 to 15%
compared to at walking shoes, ip-ops and barefoot [48,50].
Two articles described the effect of the innovative variable-stiffness shoe in
subjects with medial knee OA [60,61]. These shoes were associated with mean
decreases from 4.3 to 4.5% for the rst peak EKAM when compared to a standardized
shoe with a constant stiffness of the sole during normal walking speed [60]. A longterm study showed mean decreases of 5.9% in the peak EKAM compared to the control
shoe after wearing the intervention shoes for 6 months [61].

4. Discussion
This review investigated the effect of various footwear types on the
EKAM in healthy and symptomatic subjects. Main subgroups were
found for studies comparing wedges to a non-wedged or no insole,
and studies comparing shod to barefoot walking. With the exception
of two studies, all those that included subjects with medial knee OA
using lateral wedges in a shoe reported signicant reductions in the
rst peak EKAM, with a mean reduction ranging between 2.1 and
11.9%. A 5 lateral wedge was the most commonly studied insole,
however, wedges that were approximately 10 had a greater
reduction. Lateral wedges attached to barefoot with taping were
also found to reduce the EKAM compared to barefoot walking without
the wedge. Subjects with medial knee OA experienced higher rst
peak EKAM walking in various types of shoes compared to barefoot.
Lateral wedging was also shown to be associated with reductions in
peak EKAM during walking in the healthy population, while the use of
a medial wedge led to increased EKAM [53]. High-heeled shoes, dress
shoes, clogs, sneakers and running shoes all increased the rst peak
EKAM compared to barefoot walking or running in healthy subjects.
Nearly all articles presented moderate to high methodological
quality, with 31 of the 33 studies scoring 60% or more. The main
methodological limitation regarding external validity was a lack of
clear reporting of subject recruiting processes, thus reduced the
ability to generalize the results across the population. Studies scored
highly on the internal validity, apart from blinding the data collectors.
Blinding of subjects to a footwear condition is often difcult, but
masking the data investigation may be feasible and could reduce the
bias of internal validity. Future laboratory-based studies can be
improved with respect to statistical power by performing a priori
sample size estimations.
The studies differed in their methodology with regard to the
coordinate system used to measure knee moments. Most researchers
employed a Vicon motion analysis system, however the number of
cameras varied from six to 12. Additionally, differences were found in
the count of reective markers and their placement on anatomical
reference points. This methodological heterogeneity could contribute
toward different results. For instance, Newell et al. [22] showed that
differences in peak EKAM between healthy subjects and patients with
medial knee OA vary between 6 to 14% if measured with a 2D axis-, 3D
oating axis- and a 3D axis model. Reliability, although not dened by
each research group, has been shown to be excellent with an

Intraclass Correlation Coefcient of 0.86 for patients with medial

knee OA [12]. Although some discrepancies in results obtained from
these different measurement systems can be expected, all included
studies compared between conditions within subjects. Thus, care
must be taken when comparing absolute data between studies.
However, relative differences between conditions assessed within
each study can be compared to results obtained in other studies.
Various factors contributed toward clinical heterogeneity of the
included studies, preventing pooling of data. Although all included
studies used the EKAM (or dened as a varus moment) as an
outcome measure, different normalization procedures were
reported, such as normalizing the moments only to BW, or to BW
and height (HT). Further, different inclusion factors relating to the
KL grade of OA were used. For example, Kerrigan et al. [65]
included participants with Grade 3 or 4 on the KL scale, compared
to Hinman et al. [62,64] who included participants with Grades 1 to
4. Patients with more severe medial knee OA (KL Grades 34)
have been shown to have a 28% increased rst peak EKAM
compared to subjects with mild to moderate medial knee OA (K
L Grade 12) [36]. These ndings were supported by a further
study, indicating that subjects with moderate radiographic OA of
the knee had a 35% higher rst peak EKAM than those in a mild
stage of the disease [41]. Including participants of a larger spectrum
of severity may have contributed toward larger 95% CI (such as by
Hinman et al. [63]).
Clinical heterogeneity was also affected by different wedging and
control footwear being used. The amount of wedging ranged between
5 and 15 with most studies using a lateral wedge of 5 to 7. Further
variation was found in control conditions which included either nonwedged insoles or no insoles. Differences in the design of insoles and
their material properties, particularly the reported densities, were
found. For instance, Kerrigan et al. [65] tested insoles with a
durometer score of 55, while Butler et al. [58] utilized orthotics with
durometer scores of 70. This may inuence the outcome measure
because varying density or stiffness of the sole and the wedges affects
the peak EKAM [60,61]. In two studies researchers provided a
standardized shoe [58,59], while subjects in the other studies wore
their own shoes. This may affect the walking pattern of subjects, thus
inuence the outcomes.
This review found that different degrees of lateral wedging either
worn in a shoe or attached to the bare feet were likely to be associated
with decreased rst peak EKAM in healthy subjects and patients with
medial knee OA (Figs. 2 and 3). However, ndings were not always
consistent, with Segal et al. [51] nding no statistically signicant
change with the use of lateral wedging compared to barefoot walking
in subjects with medial knee OA. Our calculations of ndings by Maly
et al. [66] showed an increase in EKAM when combining lateral
wedging with an off-the-shelf orthotic. The reason for these results
compared to those of other studies is not clear. It is not clear in both of
these studies [51,66] whether subjects used standardized shoes or
their own footwear. Different shoes, by themselves, can inuence the
EKAM, as indicated in the studies comparing the effects of shoes to
barefoot walking on this variable. Thus, not standardizing shoes in
which insoles are placed can have an effect on responses associated
with the addition of insoles. As shoes age, the outer- or mid-sole of the
heel is likely to wear or compress, more commonly on the lateral side,
thereby accentuating the effect of medial wedges, or decreasing those
of lateral wedges [68,69]. With increasing shoe wear, there may be a
need to change the wedging or orthotics to accommodate for these.
Our ndings suggest that a higher degree of wedging may lead to
higher reductions in the rst peak EKAM. However, subjects wearing a
10 lateral wedge reported discomfort in contrast to a wedge of only
5 [65]. Thus, it is possible that smaller wedges (such as 5) could be
sufcient to lower the rst peak EKAM to levels of clinical signicance
when also considering the decrease of cumulative loading over a
dened period of time.

A.O. Radzimski et al. / The Knee 19 (2012) 163175

The results of this review indicate that the knee experiences higher
loads on the medial compartment during various shod conditions
compared to barefoot walking in healthy (Fig. 4) and subjects with
medial knee OA (Fig. 5). Patients with medial knee OA had higher rst
peak EKAM of 7.4 to 11.9% while walking in their own comfortable
shoes compared to barefoot walking [46,4850]. Gait of these subjects
was not affected by other variables such as speed or stride length,
conrming the shoe as being responsible for the increased knee
moments. A recent study by Shakoor et al. [50] indicates that these
individuals also exhibit increased rst peak EKAM during walking
when wearing stability shoes or clogs compared to barefoot. Smaller
increases were seen when wearing at shoes. The authors [50]
reported that no statistically signicant changes were observed for
EKAM when wearing ip-ops compared to barefoot, however the Pvalues were not recorded. It may thus be advisable for patients with
medial knee OA to walk barefoot where possible, and to wear shoes
with low heels.
Different common types of shoes have been studied in a healthy
population. Kerrigan et al. [43,44] concluded that women walking on
high-heeled shoes with a narrow or wide base and a minimum heel
height of 5 cm experienced increased rst peak EKAM up to 23.1%.
Men also experienced increased load on the medial knee compartment when wearing shoes. In the latter group the elevated EKAM was
associated with higher gait velocity during the shod conditions
compared to barefoot walking. However, no signicant changes in
speed between shod and barefoot walking were reported by other
research groups [35,45,48,51]. As both genders experience similar
peak EKAM during barefoot walking, differences in footwear may be
responsible for the high discrepancy found in knee moments between
women and men shoes. The lower knee moments in the male
population may be explained, in part, by the lower heel height in the
men shoes under investigation.
Shod running was shown to increase the peak EKAM by 38.3%
compared to barefoot running in a healthy population [39]. Injuries to
the knee, such as of the ACL and menisci, have been shown to be
associated with increased EKAM during walking [27,28]. Similar
studies have not been conducted to determine EKAMs during running
or sporting activities in subjects with past knee injuries. However,
these injuries pose a higher risk for the development of future OA,
thus it may be important to consider the effects of footwear on EKAMs
in sportspeople with previous knee injuries. As barefoot running is
often not feasible and uncommon, particularly in the Western society,
further development is needed for sport shoes that do not increase the
load on the knee.
Two types of shoes were shown to be effective in reducing knee
moments in subjects with medial knee OA. A variables-stiffness
shoe with a stiffer lateral sole compared to the medial side has shown
similar effects as a 5 lateral wedge in patients with medial knee OA,
even after 6 months of wear [60,61]. Hence, this shoe could be an
alternative load-reducing intervention for patients who may experience discomfort with insoles or show no benet from the orthotics. A
mobility shoe resulted in an 8.1% lower rst peak EKAM than a
personal walking shoe in patients with medial knee OA [48]. However,
the former shoe still increased the knee moment by 4.2% compared to
barefoot walking. Nevertheless, this trend shows the possibility of
developing footwear which results in similar knee moments as
observed for barefoot walking.
Whether a reduction to the amount of less than 12% for the rst
peak of the EKAM is clinically important has not yet been established.
A 1% increase in the EKAM has been shown to correlate with a 6.46
times higher risk of radiographic knee OA progression [24]. Thus,
there is a possibility that any reduction in EKAM may be of
signicance. EKAM established during walking or running in
laboratories are based on a small number of trials, which may
under-represent a potentially cumulative load throughout the day.
Robbins et al. [70] proposed a measure for cumulative loading that

173

combines laboratory-established EKAM with number of steps taken

by the participants over a specied time period. For example, it has
been suggested that 10,000 steps per day improved general health
and psychological well-being in elderly individuals [71] and a group of
healthy subjects aged 5559 years averaged 8605 steps per day [72].
Hence, the impact of small reductions of the peak EKAM on the loadreducing effect on the medial knee compartment measured during
one gait cycle will increase with the high number of repetitive loading
experienced during daily walking.
4.1. Clinical implications
In the clinical setting, practitioners are facing a dilemma for the
prescription of footwear for people with knee OA. One approach for
footwear is to focus on assessment of the foot, such as using the Foot
Posture Index [73,74]. Based on these assessments it may be more
likely to prescribe footwear to reduce the amount of foot pronation by
the use of medial wedges and arch supports [73]. However, the
current review has found laboratory-based evidence that these may
be associated with increased EKAM, indicating increased joint loading
at the knee. A goal of treatment of medial knee OA is to reduce load on
this compartment, and other strategies, such as gait training or the use
of gait aids may be prescribed for this goal [75]. The present review
indicates that patients may benet from wearing a lateral wedge to
achieve decrease knee joint loading. However, it has to be taken into
consideration that a small number of patients may not respond to the
lateral wedge or show increased EKAM [59,63]. Findings by Butler et
al. [59] suggest that the use of lateral wedges may increase rearfoot
eversion which is traditionally considered to place individuals at risk
of injuries. For patients presenting with knee pain during walking and
other activities, the assessment of appropriate footwear can be based
on pain response to the intervention [4,62]. Difculty exists, from a
clinical approach, to assess appropriate interventions for individuals
who are not presenting with pain during functional activities. The
main aim of the intervention in these patients would be to decrease
the EKAM, however, measurement of the knee adduction moment is
only possible in a laboratory setting. Clinical assessments of EKAM still
need to be established.
Patients with medial knee OA or those at risk of OA could be
advised to walk barefoot where feasible because common shoes were
shown to increase the EKAM. Although not studied in symptomatic
subjects yet, patients could be encouraged to avoid dress shoes with
heel heights of 5 cm or higher. The variable-stiffness shoes,
developed with a more dense lateral than medial sole, was shown
to decrease EKAM compared to standard shoes in a group of subjects
with medial knee OA [60,61]. Once these are available commercially,
they may possibly be alternatives to lateral wedging; however, this
still needs to be conrmed with clinical trials.
4.2. Research implications
Three studies reported inconsistent results, with individual subjects showing increased peak EKAM when using lateral wedges
[58,62,63]. These individual-specic differences remain unclear,
however, are consistent with other studies investigating the responses of various biomechanical variables to footwear interventions
[33,76]. It is likely that a combination of factors, such as differences of
static and dynamic alignment, individual neuromuscular responses,
and presence or absence of symptoms, may explain individualspecic responses. Further research on lateral wedges should
investigate possible adverse reactions of the insoles. To date only
one study investigated the long term effects of the lateral wedge on
the rst peak EKAM [64]. After 4 weeks subjects experienced a similar
reduction as that observed at the baseline measurement independent
of the participant's compliance over this period [64]. A limitation of
past studies is that the current footwear of patients was not assessed.

174

A.O. Radzimski et al. / The Knee 19 (2012) 163175

Future investigations should include assessment of the state of shoes

worn by individuals and the effect this may have on outcomes of
wedges and orthotics. In particular, longer follow-up studies are
warranted to investigate long-term effects of footwear and wedging
on the EKAM and symptoms of patients with knee OA.
There is evidence for higher rst peak EKAMs in healthy subjects
while wearing different modern footwear such as high heeled shoes
or other dress shoes. Individuals with previous knee injuries, such as
those of the ACL or meniscal injury are at greater risk of knee OA
compared to uninjured individuals [5,29,30]. We speculate that
strategies to decrease EKAM during walking in running in these
individuals may decrease their risk for future knee OA. To our
knowledge, the effects of footwear on the EKAM in this population
have not been investigated and future research may be warranted to
test this hypothesis. It needs to be conrmed in longitudinal studies
whether reductions in the EKAM with footwear result in clinically
relevant changes in the presentation of disorders, such as pain and
disability, and risk for future OA.

4.3. Limitations
Calculations of mean differences for the EKAM between different
conditions for all included studies were not feasible due to missing
data or graphical illustrations in articles. Appropriate authors were
contacted by email, but not all researchers answered within the
process of this review. Where graphic data was provided the EKAMs
were measure from the published gures. Mean differences of the
peak EKAM between conditions calculated in our review did not
always reect those reported by the respective authors. This could be
by P-values not precisely reported in articles, or by missing data. To be
consistent, we reported the mean differences (and 95% CI) calculated
by the current reviewers.

5. Conclusion
This systematic review provides evidence for immediate effects of
footwear on the EKAM. There is evidence that: (i) the lateral wedge
decreases the rst peak EKAM during walking and (ii) shod conditions
increase the rst peak EKAM compared to barefoot walking and
running. The orthotic is effective as a load-reducing intervention for
patients with medial knee OA, while normal walking shoes were
shown to be unfavorable compared to barefoot. In healthy subjects
modern footwear increased EKAM indicating increased medial knee
compartment load during walking and running. Further research is
warranted to develop shoes which result in similar knee loading as
barefoot walking.
Supplementary materials related to this article can be found online
at doi:10.1016/j.knee.2011.05.013.

6. Conict of interest
There is no conict of interest.

Funding
No funding has been received for this study.

Acknowledgment
We wish to thank Professor Peter Herbison (Department of
Preventive and Social Medicine, University of Otago) for his assistance
with the analysis of this review.

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