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ORIGINAL ARTICLE
the knee, which was effective for the treatment of knee pain in
patients with osteoarthritis (OA). Since the early 1990s, the
evidence relating to the clinical efficacy of wearing a laterally
wedged insole as a treatment for patients with OA has also
been reported in dynamic conditions,4-7 but these studies did
not answer the question of what mechanisms reduced symptoms in OA patients. The effect of wearing a laterally wedged
insole has not been sufficiently studied.
Recently, Crenshaw8 and Kerrigan9 and colleagues reported
that wearing a laterally wedged insole reduced the knee joint
varus moment, suggesting an effective mechanism for knee
pain reduction in patients with OA. However, Maly et al10
found that wearing a laterally wedged insole did not significantly reduce the knee joint varus moment during gait. These
studies suggested that the beneficial effects of wearing a laterally wedged insole were not consistent for OA patients, and
hence we were interested in the biomechanic details that affected the knee joint varus moment during gait with a laterally
wedged insole.
Keating et al5 suggested that the knee joint varus moment
during gait with a laterally wedged insole was associated with
the subtalar joint valgus angle. Our previous study11 found that
healthy young adults wearing a laterally wedged insole had
changes in knee joint varus moment and subtalar joint valgus
moment during gait via the more laterally shifted location of
the center of pressure (COP). Our current study focused on
how the knee joint varus moment in patients with OA was
associated with the angle and moment at the subtalar joint
during gait while wearing a laterally wedged insole. In particular, our objective was to assess frontal plane kinematic and
kinetic effects of wearing a 6 wedged insole on the knee joint
moments. We hypothesized that the same knee joint varus
moment reduction obtained with a 6 laterally wedged insole
during gait in healthy elders would also be present in agematched patients with OA.
METHODS
Participants
After informed consent was obtained, 26 elderly women (13
healthy elders, 13 osteoarthritic patients with a varus deformity
of the knee) participated in the experiments. There were no
statistically significant differences in age, height, and weight
(table 1). OA patients were recruited through public advertisements in local community programs about knee OA in the area
around the National Rehabilitation Center. The inclusion criteria for OA patients were: 50 years of age or older, knee pain
for at least 6 months, and bilateral knee OA with a definite
osteophyte indicated by radiograph. In addition to these inclusion criteria, the subjects must have met one of the following
conditions: morning (initial) stiffness for less than 30 minutes,
or crepitus on active motion of the knee (ie, with weightbearing, eg, squatting).12 Patients with OA were excluded if
they were currently using a wedged insole or other custom
orthotics in their shoes; had had surgery on the lower extremArch Phys Med Rehabil Vol 86, July 2005
1466
Healthy Elders
(n13)
OA Patients
(n13)
Age (y)
Height (cm)
Weight (kg)
Femorotibial angle (deg)
64.62.3
150.03.0
54.17.2
172.93.7
63.35.6
152.75.6
57.310.3
177.53.9
.424
.183
.376
.007
Experimental Protocol
Before the trials, reflective markers (diameter, 20mm) were
placed over bony landmarks to minimize skin movementthe
greater trochanter, lateral and medial femoral condyles, anterolateral and anteromedial tibial condyles, lateral and medial
malleoli, lateral and medial calcaneal tubercles, head of talus,
and 1st and 5th metatarsal headsto define the thigh, shank,
and foot segments.11 After the markers were attached, subjects
were instructed to stand barefoot for 5 seconds to establish the
relationship among the markers for the subjects initial anatomic position.14,15 In this barefoot standing trial, they were
instructed to stand with knees as fully extended as possible, the
ankles at 0 dorsiflexion, and a comfortable degree of toeingout.
For the walking trials, insoles were attached to the subjects
feet and they were asked to walk at a walking speed of 95
steps/min, indicated by a metronome, to match the cadence of
the patients with OA. This threshold speed corresponded to the
self-selected walking speed of the OA patients (954 steps/
min). The insoles with the N and W wedges were randomly
assigned to subjects and no attempt was made to control stride
length, stride width, or foot progression angle during gait.
Data Analysis
A 3-segment rigid link model was used to describe the
motion of the lower extremity in the frontal plane (fig 1).11 We
used local reference systems to obtain the angles and moments
at the knee and subtalar joints with respect to the actual rotation
axes of the joints.16,17 The rotation of the knee joint was
defined as the rotation of the tibial condyle relative to the
femoral condyle.16 The rotation of the subtalar joint was defined as the rotation of the calcaneus relative to the lateralmedial malleoli.17 The axis of rotation of the knee joint was
midway between the markers on the lateral and medial femoral
condyles and the anterolateral and anteromedial tibial condyles. The axis of rotation of the subtalar joint was defined by
using the markers on the lateral calcaneal tubercle and head of
the talus. The moments acting about each joint were calculated
using an inverse dynamics algorithm and expressed as external
Fig 1. The models and coordinate systems of the subtalar joint and
knee joint are shown. Abbreviations: , angle; GRF, ground reaction
force; M, moment; W, segment weight. Adapted with permission
from Kakihana et al.11 Copyright by Am J Phys Med Rehabil.
1467
1468
Moment (Nm/kg)
Knee joint varus
Subtalar joint valgus
Angle (deg)
Knee joint varus
Knee joint valgus
Subtalar joint varus
Subtalar joint valgus
Ground reaction force (N/kg)
ML
Vertical
Distance (mm)
Subtalar joint moment arm
OA Patients (n13)
P Value
0.290.01
0.180.01
0.260.02
0.230.01
0.360.02
0.170.01
0.340.02
0.210.01
.001
.001
.005
.548
.325
.331
0.270.18
6.611.47
3.380.99
1.020.37
0.350.18
6.461.49
1.990.56
1.460.34
2.230.84
2.681.09
1.750.38
1.350.40
2.180.83
2.881.17
1.960.47
2.140.71
.094
.915
.142
.070
.008
.039
.324
.411
.702
.408
.051
.613
0.530.03
7.520.11
0.540.02
7.490.10
0.530.02
7.580.16
0.550.01
7.620.09
.035
.942
.700
.777
.538
.426
20.721.82
26.801.52
22.582.24
26.081.95
.001
.827
.084
NOTE. Values of columns N and W are mean standard error. Boldface denotes significance.
Abbreviations: 1, difference between insole conditons; 2, difference between subject groups; 3, interaction between insole conditions and
subject groups.
1469
the OA patients in the knee joint varus moment. These reductions were associated with a significant increase in the subtalar
joint valgus moment, which to our knowledge have not been
published elsewhere. There was a 27.7% increase for the
healthy elders and a 23.5% increase for the OA patients in the
subtalar joint valgus moment with insole W.
There have been few reports on the effects of wearing a
laterally wedged insole on the angle and moment at the subtalar
joint. Yasuda and Sasaki2 found that, in a static standing
position, the laterally wedged insole increased the valgus angle
of the subtalar joint, and therefore reduced the load in the
medial compartment of the knee joint. Keating et al5 suggested
that during walking an increased valgus angle of the subtalar
joint obtained by a laterally wedged insole might be effective
for the reduction of knee pain in OA patients. In our study, the
subtalar joint valgus angle did not increase significantly with
1470
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Suppliers
a. Oxford Metrics Ltd, 14 Minns Estate, West Way, Oxford OX2 0JB,
UK.
b. Kistler Japan Co Ltd, 2-7-5 Shibadaimon, Minato-ku, Tokyo, Japan.
c. Kyowa Shokai, 2-4-3 Sotohama-cho, Suma-ku, Kobe, Japan.
d. SPSS, 1-1-39 Hiroo, Shibuya-ku, Tokyo, Japan.