Acta Orthopaedica et Traumatologica Turcica 50 (2016) 405e408

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Acta Orthopaedica et Traumatologica Turcica

journalhomepage:https://www.elsevier.com/locate/aott

Effects of two different degrees of lateral-wedge insoles on unilateral lower

extremity load-bearing line in patients with medial knee osteoarthritis

Bilge Yılmaz, Serdar Kesikburun*, Ozlem Koro€glu, Evren Yas¸ ar, Ahmet Salim Goktepe,€ Kamil
Yazıcıoglu
Gülhane Military Medical Academy, Department of Physical Medicine and Rehabilitation, Turkish Armed Forces Rehabilitation Center, Ankara, Turkey

article info abstract

Article history: Objective: The aim of this study is to assess the effect of 5 and 10 lateral-wedge insoles on unilateral lower extremity load
Received 25 May 2015 carrying line in patients with medial knee osteoarthritis using the L.A.S.A.R. posture alignment system.
Received in revised form
10 September 2015
Patients and methods: Twenty subjects (10 females and 10 males, mean age 67.7 ± 5.4 years (range: 58 e78) with bilateral
Accepted 5 October 2016
medial knee osteoarthritis were included in the study. The laser line projected on the person by the L.A.S.A.R. posture
Available online 21 July 2016
alignment system showed joint load carrying line. The location of the joint load carrying line in static standing with one foot
on the force plate was assessed with barefoot, and 5 and 10 lateral-wedge insoles. Displacement of the load carrying line was
Keywords:
Lateral-wedge insoles measured using a ruler placed tangentially to the patella at the level of joint line.
Osteoarthritis
Knee biomechanics Results: The load carrying lines measured with 5 and 10 lateral-wedge insoles were significantly laterally located compared to
L.A.S.A.R. posture that without wearing insole (p < 0.001). 10 lateral-wedge insole caused a significant more lateral shifting of the load carrying
line than 5 lateral-wedge insole (p < 0.001).
Conclusion: Both wedge insoles was effective in moving of the unilateral lower extremity load carrying line to the lateral.
Lateral wedged insoles are biomechanically effective and reduce loading of the medial compartment in patients with medial
knee osteoarthritis.
© 2016 Turkish Association of Orthopaedics and Traumatology. Publishing services by Elsevier B.V. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/ 4.0/).

Introduction 9
during gait, and a good correlation has been reported. The effect of lateral-
wedge insoles on reducing knee adduction moment may result from the more
Knee osteoarthritis (OA) is a common medical problem which is a 5
laterally shifted location of the center of pressure on the ground. However,
potential source of disability. In the general population, knee OA most the effect of lateral-wedge in-soles on knee load-bearing line has not been
commonly affects the medial compartment due to greater medial contact studied.
1,2
forces and knee joint adduction moment during weight-bearing activities. The L.A.S.A.R. posture alignment system (Laser Assisted Static
Based on this pathophysiological mechanism, lateral-wedge insoles are Alignment Reference Posture, Otto Bock, Duderstadt, Germany) measures the
utilized to unload weight from the medial compartment. Lateral-wedge vertical component of the ground reaction force acting on the force plate of
insoles were shown to reduce knee joint adduction moment during gait by 10
the platform, visualizing the load line while standing. The purpose of this
3 8
using a motion analysis system. e Knee adduction moment has been study was to assess the effect of 5 and 10 lateral-wedge insoles on the
proposed as a surrogate measure for medial compartment load unilateral lower extremity load-bearing line in patients with medial knee OA
using the L.A.S.A.R. posture alignment system.

* Corresponding author. TSK Rehabilitasyon Merkezi, 06530, Bilkent, Ankara,

Patients and methods
Turkey. Tel.: þ90 (0) 312 2911707; fax: þ90 (0) 312 2911009. E-mail
address: serdarkb@gmail.com (S. Kesikburun).
Peer review under responsibility of Turkish Association of Orthopaedics and Twenty subjects (10 females and 10 males) diagnosed with having
Traumatology. bilateral medial knee OA and KellgreneLawrence grade of

http://dx.doi.org/10.1016/j.aott.2016.06.004
1017-995X/© 2016 Turkish Association of Orthopaedics and Traumatology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
406 B. Yılmaz et al. / Acta Orthopaedica et Traumatologica Turcica 50 (2016) 405e408

11
2 were included in the study. Mean age of the patients was
67.7 ± 5.4 years (range: 58e78 years), mean weight was
77.0 ± 7.7 kg (range: 62e87 kg), and mean body mass index was
2 2
28.7 ± 4.4 kg/m (range: 24.1e33.3 kg/m ). According to Kell-
greneLawrence grading scale, 8 patients had grade 2, 10 had grade 3, and 2
had grade 4 knee OA. The demographics of the subjects are presented in
Table 1.
Exclusion criteria included flexion contracture of >5 at the knee joint,
history of major trauma or surgery to the knee, infective or inflammatory
pathologies of the knee joint, hip and ankle pathol-ogy, and involvement of
the lateral compartment of the knee. Written informed consent of the
participants was obtained. The study protocol was approved by the
Institutional Review Board.
Unilateral lower extremity load-bearing line in patients with medial knee
OA was documented using the L.A.S.A.R. posture alignment system. The
patient's weight and location of the weight-bearing line in static standing with
both feet on the force plate was determined. If the patient was standing with
only 1 foot on the force plate, the force of that side and the resultant load line
were measured. The system contained a force plate, a projection system, and
electronics with a stepper motor, service, and display unit. The force plate
included 4 sensor cells located in the corners. The microprocessor determined
the center of the pressure and amount of the ground reaction force. The
electronics triggered the stepper motor, whereupon it positioned a
semiconductor laser to the center of the measured forces. The laser line was
then projected on the subject, illustrating the location of center pressure. The
location of the vertical ground reaction force was visibly indicated on the
10
subject.

Fig. 1. L.A.S.A.R. posture alignment system.

Firstly, the subject's weight was measured in static standing with both feet
on the force plate. Subjects stepped onto the force sensor platform and placed
their contralateral leg on the leveling step plate (Fig. 1). For an objective from the reference point to the load line was measured on the ruler. Subjects
measurement of unilateral lower extremity load line, subjects were asked to were evaluated first without wearing insoles. The mea-surements were
adjust the pressure applied by the foot on the force plate, with on-screen repeated with the subjects wearing lateral-wedge insole inclined at 5 and 10 .
monitoring to confirm that half of the total body weight was being measured. All measurements were performed by the same investigator.
When the researcher was certain that patients could adjust half of their weight
on the force plate, the measurements were calculated. The joint space of the Results were expressed as the mean ± SD. Paired sample t-test was used
knee was defined by palpation at the medial and lateral sides. The joint line to compare the measurements. Significance level was determined as p < 0.05.
was an imaginary line between these 2 points and perpendicular to the long All statistical tests were performed using SPSS software (version 20.0, SPSS
axis of the tibia. A ruler on the arm of a goniometer was placed tangentially to Inc., Chicago, IL, USA).
the patella at the level of the joint line. The goniometer was fixed at 90 for
proper tangential placement. The ruler formed a straight line cor-responding Results
to the joint line. The patients practiced using lateral-wedge and the
L.A.S.A.R. posture alignment system. When they felt comfortable with the The load-bearing lines measured with 5 and 10 lateral-wedge insoles were
process, the measurements were taken. The projection of the medial margin of significantly moved laterally compared to those without wearing insoles (p <
the joint line on the ruler was the reference point for the measurements (Fig. 0.001) (Table 2). Lateral-wedge in-soles of 10 caused significantly more
2). The distance lateral shifting to the load-bearing line than 5 lateral-wedge insoles (p <
0.001) (Table 3).
Subjects with a range of knee OA severity according to Kell-
greneLawrence grading scale were compared in terms of lateral shifting of
the knee load-bearing line with 5 and 10 lateral-wedge insoles. There was no
significant difference between the groups (p > 0.05).
Table 1
Patient characteristics.

Sex Discussion
Male 10 (50%)
Female 10 (50%)
Age (years)a 67.7 ± 5.4 (58e78) The results of this study support the hypothesis that a lateral-wedge insole
Height (m)a 1.64 ± 0.08 (1.55e1.78) of either 5 or 10 laterally shifts the knee load-bearing line, indicating
Weight (kg)a 77.0 ± 7.7 (69e94) reduction of the loading of the medial compartment in patients with medial
Body mass index (kg/m2)a 28.7 ± 4.4 (24.6e36.2) knee OA. In addition, the findings demonstrate the effect of 10 lateral-wedge
KellgreneLawrence grade
1 0 (0%) insoles is greater than that of 5 lateral-wedge insoles.
2 8 (40%)
3 10 (50%) To the best of our knowledge, this is the first study evaluating the changes
4 2 (10%)
in unilateral lower extremity load-bearing line with lateral-wedge insoles in
a patients with medial knee OA by using the
Mean ± SD (range).
 B. Yılmaz et al. / Acta Orthopaedica et Traumatologica Turcica 50 (2016) 405e408 407

Fig. 2. Diagram (a) of the knee joint in transverse plane shows placement of the ruler on the arm of a goniometer that was placed tangentially to the patella at the level of joint line. The projection of
the medial margin of the joint line on the ruler was the reference point for the measurements. The distance from the reference point to the load line was measured on the ruler. The photograph (b)
shows the placement of the goniometer fixed at 90 for proper tangential placement.

Table 2
Distances between the medial end point of the knee joint line and the load line without wearing insoles and with 5 and 10 lateral-wedge insoles.

Right side p-value t-value Left side p-value t-value

Barefootc 2.27 ± 0.53 cm 2.20 ± 0.41 cm
5 lateral-wedge insolec 3.50 ± 0.45 cm <0.001a 13.322a 3.53 ± 0.58 cm <0.001a 11.546a
c
10 lateral-wedge insole 4.59 ± 0.65 cm <0.001 b 16.006
b
4.62 ± 1.03 cm <0.001 b 10.812
b

a Barefoot vs 5 lateral-wedge insole.

b
Barefoot vs 10 lateral-wedge insole.
c
Mean ± standard deviation (range).

Table 3
Comparison of lateral shifting of the load line with 5 and 10 lateral-wedge insoles.

5 lateral-wedge insolea 10 lateral-wedge insolea p-value t-value

Right side 1.28 ± 0.38 cm 2.37 ± 0.63 cm <0.001 11.733
Left side 1.34 ± 0.52 cm 2.42 ± 1.00 cm <0.001 7.252
a Mean ± standard deviation (range).

L.A.S.A.R. posture alignment system. Previous studies on the subject have gait analysis methods. One study showed that pressure distribu-tion at the foot
investigated the mechanical effect of orthotics in people with medial knee OA may allow for predictions of changes in joint mo-ments with the use of foot
by using the knee adduction moment as an indirect measure of medial 13 14
wear modifications but cannot predict magnitude changes. Shelburne et al
3
compartment loading. Crenshaw et al used 3-dimensional gait analysis to used computer modeling and simulation to show decreased knee adduction
examine the kinetics of the use of lateral wedges with healthy subjects. moment and medial compartment load with lateral displacement of the center
Kinetics at the knee demon-strated reduced adduction moment. Kerrigan et of pressure of the ground reaction force. The L.A.S.A.R. posture alignment
4 system is a relatively easy technique to show knee joint loading.
al used gait analysis to determine the effect of a lateral-wedge insole on knee
adduction moment. A reduction in knee adduction moment was noted with
both wedged insoles compared with non-wedged in-soles in early and late
5 Lateral-wedge insoles of 10 were found to have greater effect on lateral
stance. Using a 3-dimensional motion anal-ysis system, Kakihana et al shifting of the load-bearing line than 5 insoles in the present study. Previous
showed that a 6 lateral-wedge insole significantly reduced knee adduction studies found that 5 , 6 , and 10 lateral-wedge insoles were effective in
moment during gait compared with the no-wedge insole. 4,5
reducing knee adduction moment in patients with knee OA. However, 3
5
lateral-wedge insoles were found to be ineffective. The optimal degree of
Malalignment influences how mechanical load is transferred. incline for lateral-wedge insoles has not yet been determined. Ideally, the
Malalignment affects the contact stress that occurs in a particular insole should effectively reduce the disease progression and provide with
compartment of the knee. Consequently, the force cannot be dissipated 7
good compliance. Butler et al studied the effect of a subject-specific amount
uniformly. Knee varus loading increases contact stress across the cartilage of of lateral-wedge on knee joint kinematics. The prescribed wedge amount was
12 the minimal wedge amount that provided the maximum amount of pain
the medial compartment, causing cartilage degeneration. Lateral-wedge
insoles help correcting the location of knee load line by increasing subtalar reduction during a lateral step-down test. Their results demonstrated that a
valgus and decreasing knee varus. custom lateral-wedge insole was able to reduce knee adduction moments,
which may increase compliance. Future studies are needed to confirm the
Measuring alterations in knee joint loading due to lateral-wedge insole has
been considered difficult using conventional
408 B. Yılmaz et al. / Acta Orthopaedica et Traumatologica Turcica 50 (2016) 405e408

degree of incline for the most comfortable and most beneficial lateral-wedge reducing knee adduction moment. While gait analysis was not used to
insoles. measure knee adduction moment in this study, the results might still be
There are some biomechanical issues present in this study. The lateral- assessed as consistent with previous reports in the literature that showed the
wedge insole might alter the joint biomechanics in not only the knee joint but reducing effect of lateral-wedge insoles on knee adduction moment.
also the ankle and subtalar joints. In other words, the change in the
measurement data with the L.A.S.A.R. posture alignment system reflects the
change in alignment of the ankle and subtalar joint as well. Lower limb Funding
alignment was not assessed due to the lack of long leg standing X-ray in the
study. Future studies may investigate the relationship between radiological No.
leg align-ment and load line excursion with a lateral-wedge insole. This
correlation, if indicated, could suggest the clinical value of the L.A.S.A.R. Conflict of interest
posture alignment system as a tool to assess weight-bearing leg alignment in a
simple and less-invasive manner. None declared.

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