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Reducing joint loading in medial knee osteoarthritisShoes and canes.

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Arthritis & Rheumatism (Arthritis Care & Research)
Vol. 59, No. 5, May 15, 2008, pp 609 – 614
DOI 10.1002/art.23578
© 2008, American College of Rheumatology
ORIGINAL ARTICLE
Reducing Joint Loading in Medial Knee
Osteoarthritis: Shoes and Canes
GEORGINA KEMP, KAY M. CROSSLEY, TIM V. WRIGLEY, BEN R. METCALF,
AND
RANA S. HINMAN
Objective. Increased medial knee loading is associated with a much higher risk of disease progression in knee osteoarthritis (OA). Interventions that can reduce medial knee joint load have the potential to slow disease progression over
time. We evaluated the effects of shoes and a cane on knee load in people with knee OA.
Methods. Forty people with medial knee OA underwent 3-dimensional gait analysis to measure their peak knee
adduction moment, an indicator of medial knee joint load. Results when walking in bare feet were compared with those
obtained when walking in their own usual shoes. Twenty participants also underwent testing using a cane, and results
were compared with walking unaided.
Results. Compared with barefoot, walking in shoes was associated with a significant increase in the peak knee adduction
moment (mean ⴞ SD N ⴛ m/BW ⴛ H% 3.49 ⴞ 0.84 versus 3.77 ⴞ 0.90; P < 0.001), although there was considerable
individual variation. The use of a cane resulted in a 10% decrease in the knee adduction moment (mean ⴞ SD N ⴛ
m/BW ⴛ H% 3.76 ⴞ 0.95 versus 3.38 ⴞ 0.68; P ⴝ 0.001).
Conclusion. Wearing shoes increases medial knee joint load compared with walking barefoot. Given the variable
response to shoes observed, further research is required to ascertain which shoe types might be optimal for those with
knee OA. The use of a cane significantly reduces medial knee loading and has the potential to reduce the risk of disease
progression in knee OA.
INTRODUCTION
Osteoarthritis (OA) is a leading cause of pain and disability in elderly people (1,2). The knee, particularly the
medial tibiofemoral compartment, is commonly affected
(3). Conservative management of knee OA has historically focused on relief of symptoms such as pain and
impaired physical function (4). However, treatment
should also aim to reduce the risk of disease progression, given that a significant proportion of patients demonstrate worsening of disease over time and that knee
OA is incurable. A biomechanical marker of knee OA
progression is the knee adduction moment. The knee
adduction moment, as measured by 3-dimensional (3-D)
gait analysis, is an indirect measure of dynamic loading
Dr. Hinman’s work was supported by an Early Career
Researcher Grant provided by the University of Melbourne.
Georgina Kemp, BAppSc(Physio), Kay M. Crossley, PhD,
PostGradDip(Research), BAppSc(Physio), Tim V. Wrigley,
BSc(Hons), MSc, Ben R. Metcalf, BSc(Hons), Rana S. Hinman, BPhysio(Hons), PhD: The University of Melbourne,
Victoria, Australia.
Address correspondence to Rana S. Hinman, BPhysio
(Hons), PhD, Centre for Health, Exercise and Sports Medicine, School of Physiotherapy, The University of Melbourne,
Victoria, Australia, 3010. E-mail: ranash@unimelb.edu.au.
Submitted for publication April 1, 2007; accepted in revised form November 18, 2007.
on the medial tibiofemoral compartment (5–7). A 20%
increase in the peak knee adduction moment is associated with a ⬎6-fold increase in the risk of progression of
medial knee OA over 6 years (8). A higher knee adduction moment has also been implicated in the development of chronic knee pain (9) and poorer outcome after
high tibial osteotomy (10,11).
Treatment strategies that reduce the knee adduction moment have the potential to slow progression of medial knee
OA over time. Health practitioners frequently advise patients with knee OA regarding footwear choices and cane
use to unload the affected knee joint. While these simple,
inexpensive interventions have the potential to alter the
peak knee adduction moment, there is little research attesting to their effects on knee load in patients with OA. To
our knowledge, the one study that has evaluated the effect
of a cane in people with knee OA found only a trend
toward decreased knee load when using the gait aid in the
contralateral hand (12). There is evidence that usual footwear can increase knee loading in healthy individuals
(13–16), possibly related to the height of the shoe heel, but
there is little information regarding footwear effects in
patients with knee OA; to our knowledge, only 1 study has
been conducted in knee OA. Its results showed that, compared with barefoot walking, wearing shoes significantly
increased knee loading (17). It is thus presently difficult
for health professionals to give appropriate, evidence609
610
based recommendations to patients regarding these management strategies.
The aim of this study was to investigate the immediate
effect of footwear and a walking cane on the peak knee
adduction moment in people with knee OA. We hypothesized that the knee adduction moment would be higher
when people walked in their own footwear compared with
barefoot and lower when walking with a cane compared
with unaided gait.
PARTICIPANTS AND METHODS
Participants. Forty community-dwelling volunteers
were recruited, each fulfilling clinical and radiographic
criteria for knee OA (age ⬎50 years, osteophytes, and knee
pain) (18). All demonstrated medial tibiofemoral osteophytes (although concomitant lateral tibiofemoral or patellofemoral OA cannot be excluded) and had experienced
knee pain averaging more than 3 points out of 10 on a
numerical pain rating scale on most days of the previous
month. Exclusion criteria included a history of hip or knee
joint replacement, knee surgery or injection in the previous 6 months, current use of a gait aid, and any condition
affecting gait or the ability to complete testing. The study
was approved by the University of Melbourne Human
Research Ethics Committee, and all participants provided
written informed consent.
Knee OA symptoms were evaluated using the Western
Ontario and McMaster Universities OA Index (19) with
regard to pain (scores range 0 –20, with higher scores indicating worse pain) and physical function (scores range
0 – 68, with higher scores indicating worse function). Radiographic severity of tibiofemoral OA was assessed with
the Kellgren/Lawrence scale (20), where 0 ⫽ normal, 1 ⫽
possible osteophytes, 2 ⫽ minimal osteophytes and possible joint space narrowing, 3 ⫽ moderate osteophytes, some
narrowing, and possible sclerosis, and 4 ⫽ large osteophytes, definite narrowing, and severe sclerosis. Participant characteristics are presented in Table 1.
Gait analysis. Participants underwent 3-D gait analysis
using a 6-camera VICON 612 motion analysis system (Vicon, Oxford, UK). Two force plates (Advanced Mechanical
Technology, Inc., Watertown, MA) embedded in the walkway captured ground reaction force data. Reflective markers placed on the anterior superior iliac spine, posterior
superior iliac spine, midlateral thigh, lateral knee joint,
lateral shank, lateral malleolus, on the shoe over the second metatarsal head, and over the posterior calcaneus
were used to capture limb movement. The Vicon Plug-inGait (V2) model (Vicon, Oxford, UK) used inverse dynamics to calculate external joint moments about an orthogonal axis system located in the distal segment of the joint
(21). The model determines the hip joint center from the
regression equations in Davis et al (21). It places the knee
joint center at half the intercondylar width from the lateral
femoral condyle marker, medially in a direction perpendicular to that from hip center to knee center, and in the
plane of these joint centers and the lateral thigh marker.
The ankle joint center is placed analogously, medially in a
Kemp et al
Table 1. Participant characteristics*
Characteristic
Age, years
Height, meters
Mass, kg
Body mass index, kg/m2
Symptom duration, years
Sex, no. (%)
Male
Female
Symptoms, no. (%)
Unilateral
Bilateral
Symptom severity†
Pain
Physical function
Disease severity, no. (%)‡
Grade 1
Grade 2
Grade 3
Grade 4
Footwear
(n ⴝ 40)
Cane
(n ⴝ 20)
64.7 ⫾ 9.4
1.64 ⫾ 0.08
79.1 ⫾ 12.0
29.6 ⫾ 4.2
8.9 ⫾ 7.9
65.0 ⫾ 10.2
1.60 ⫾ 0.07
75.3 ⫾ 11.2
29.6 ⫾ 4.7
7.5 ⫾ 7.7
16 (40)
24 (60)
2 (10)
18 (90)
14 (35)
26 (65)
7 (35)
13 (65)
9⫾3
29 ⫾ 11
9⫾4
28 ⫾ 13
3 (8)
10 (25)
11 (28)
16 (40)
2 (10)
6 (30)
5 (25)
7 (35)
* Values are the mean ⫾ SD unless indicated otherwise.
† As measured by the Western Ontario and McMaster Universities
Osteoarthritis Index. Higher scores indicate worse symptoms (pain
scored 0 –20 and function scored 0 – 68).
‡ Assessed via Kellgren/Lawrence disease severity scale. Higher
scores indicate more severe radiographic change.
direction from the lateral malleolus and perpendicular to a
line from knee center to ankle center, in the plane including the lateral shank marker. The lateral thigh and shank
markers were adjusted to align the abovementioned planes
to include the intercondylar axis of the knee and intermalleolar axis of the ankle, respectively. The overall peak
external knee adduction moment (N ⫻ m) was determined
for the stance phase of the gait cycle and normalized to
body weight (BW) multiplied by height (H) (22). Only the
most symptomatic knee of each participant was analyzed.
Test–retest reliability in our laboratory was excellent (intraclass correlation coefficients 0.92– 0.97 in 11 elderly
patients with knee pain tested 1 week apart).
Two photoelectric beams monitored walking speed and
participants were given feedback to ensure that their walking speed for each trial varied ⱕ10% from the required
speed of 1 meter/second. Control of walking speed was
necessary to negate a potential influence of speed on the
magnitude of the peak knee adduction moment (23). A
speed of 1 meter/second was selected to facilitate comparison of data across the literature (24,25). Participants were
not informed about the embedded force plates in order to
prevent them from altering their gait in an attempt to target
the plates. Data from 5 successful trials were collected for
each test condition and a mean score was used in the
analyses. All participants were tested first in bare feet,
followed immediately by testing in their own shoes. Footwear was not standardized; participants were instructed to
bring a pair of comfortable shoes that they would typically
use for walking. Twenty consecutive participants from the
cohort underwent further testing wearing their shoes and
using a cane in the contralateral hand to the study knee.
Effect of Shoes and Canes on Medial Knee OA
611
Table 2. Change in gait parameters by intervention*
Footwear (n ⴝ 40)
Walking speed, meters/second
Cadence, steps/minute
Stride length, meters
Vertical ground reaction force,
N/kg
Peak adduction moment, N ⫻
m/BW ⫻ H%
Cane (n ⴝ 20)
Barefoot
Shoes
P
Unaided
Aided
P
1.00 ⫾ 0.04
53 ⫾ 4
1.14 ⫾ 0.09
9.9 ⫾ 0.4
1.01 ⫾ 0.04
51 ⫾ 4
1.20 ⫾ 1.00
10.1 ⫾ 0.5
0.060
⬍ 0.001
⬍ 0.001
⬍ 0.001
1.01 ⫾ 0.04
52 ⫾ 4
1.17 ⫾ 0.09
10.2 ⫾ 0.4
0.97 ⫾ 0.03
48 ⫾ 4
1.22 ⫾ 0.07
9.6 ⫾ 0.5
⬍ 0.001
⬍ 0.001
⬍ 0.001
⬍ 0.001
3.49 ⫾ 0.84
3.77 ⫾ 0.9
⬍ 0.001
3.76 ⫾ 0.95
3.38 ⫾ 0.68
0.001
* Values are the mean ⫾ SD.
The cane was adjusted so that its height corresponded to
the distance from the proximal wrist crease to the ground
when the participant stood erect with arms by the sides.
Each participant was briefly trained to walk by a physiotherapist so that the cane was on the ground during the
stance phase of the study knee.
Statistical analyses. Analyses were performed using the
Statistical Package for the Social Sciences, version 13
(SPSS, Chicago, IL). Descriptive information was examined via means, SDs, and frequencies where appropriate.
Two-tailed paired t-tests were used to compare variables
between conditions, with an alpha level set at 0.05.
RESULTS
Changes in gait parameters across testing conditions are
presented in Table 2. The peak knee adduction moment
when walking with shoes was significantly higher than
walking barefoot (mean difference 0.28; 95% confidence
interval [95% CI] 0.18 – 0.37). Walking in shoes resulted in
a 7.4% increase in the peak knee adduction moment (P ⬍
0.001). However, the effect of footwear was not systematic.
While most participants demonstrated an increased knee
adduction moment in shoes, considerable individual variation was observed, with 6 participants actually demonstrating a decrease while wearing shoes (Figure 1).
Changes in the peak knee adduction moment when wearing shoes ranged from a 10.8% decrease to a 30.8% increase. A mean increase in the vertical ground reaction
force by 2% was observed with shoes (P ⬍ 0.001). Temporal parameters changed when participants went from
walking barefoot to wearing shoes. When wearing shoes,
there was a small but significant increase in stride length
(5% increase; P ⬍ 0.001) and a reduction in cadence (4%
decrease; P ⬍ 0.001) compared with walking barefoot. The
small increase in walking speed with shoes (1%) was not
statistically significant.
The peak knee adduction moment was significantly
higher when walking unaided compared with using the
cane (mean difference 0.38; 95% CI 0.13– 0.63). Using a
cane reduced the peak knee adduction moment by 10.1%
(P ⫽ 0.001). While the majority (75%) of participants demonstrated a decrease in the peak knee adduction moment
when using a cane, 5 participants actually demonstrated
an increase (Figure 2). Changes in the peak knee adduction
moment when using a cane ranged from a 43.9% increase
to a 34.6% decrease. A mean decrease by 5.9% in the
vertical ground reaction force was observed with the cane
(P ⬍ 0.001). While participants walked more slowly when
using the cane (P ⬍ 0.001), they used a greater stride length
(8% increase; P ⬍ 0.001) and reduced cadence (4% decrease; P ⬍ 0.001).
DISCUSSION
An increased peak knee adduction moment is associated
with poorer clinical outcomes in knee OA, including a
much higher risk of disease progression over time (8).
Accordingly, management of knee OA should aim not only
to reduce symptoms of the disease, but also to decrease
load across the joint in order to minimize the risk of
disease progression. However, there is very little research
evaluating the efficacy of conservative interventions in
reducing knee joint load. We found that people with knee
OA increased their peak knee adduction moment by 7.4%
while wearing their own shoes as compared with walking
barefoot. Our findings concur with the only other study we
know of that has evaluated the effects of footwear on the
knee adduction moment in knee OA (17). In that study, 75
participants with moderate medial knee OA were tested,
and the magnitude of their peak knee adduction moment
during barefoot walking was compared with that demon-
Figure 1. Percentage change in peak knee adduction moment
among individual participants when walking in shoes as compared with walking in bare feet (n ⫽ 40).
612
Figure 2. Percentage change in peak knee adduction moment
among individual participants when using a cane as compared
with walking unaided (n ⫽ 20).
strated while walking in their own comfortable shoes.
Findings indicated an 11.9% increase in the knee adduction moment with shoes.
It is unclear why wearing shoes increases the knee
adduction moment. Because the effect of shoes on the
adduction moment is subject to considerable individual
variation, it seems likely that individual shoe or foot characteristics (e.g., foot and ankle joint stiffness or compliance, flattening of the medial longitudinal arch, rearfoot
supination) may mediate the influence of footwear on the
knee adduction moment. Although we did not control the
type of shoe worn by our participants, most shoes demonstrated a slight heel raise. It has been shown in healthy
young adults that a high or moderate heel height results in
an increased knee adduction moment; thus, heel height
may be an important factor that explains our results
(13,15,16). Both a thicker lateral shoe sole and the insertion of a laterally-wedged orthotic into the shoe have been
shown separately to decrease the knee adduction moment
(26,27), probably due to an increase in the valgus moment
arm of the subtalar joint, creating a lateral shift in the
location of the center of pressure (27). It is believed that
the lateral shift in center of pressure reduces the knee joint
moment arm, thereby causing a reduction in the adduction
moment magnitude. Thus, it is feasible that wearing down
the lateral shoe sole, as a result of foot and leg posture or
walking mechanics, may have the opposite effect. Preferential wearing down of the lateral sole of the shoe, or
inbuilt medial arch supports, could move the center of
pressure medially, which can increase the knee adduction
moment. It is also possible that such shoe features could
result in sufficient subtalar supination to lead to a more
varus knee alignment, which could also explain the increase we observed in the knee adduction moment. Another aspect of shoe design that may alter knee load is the
stiffness of the sole. Stiffer shoe soles have been shown to
increase hip joint loading and have the potential to
heighten knee loads as well (26,28). Further research into
the effect of different types of shoes on loading in knee OA
is warranted so that appropriate clinical recommendations
regarding footwear can be made.
Our findings show that using a cane in the contralateral
Kemp et al
hand to the symptomatic knee can reduce the knee adduction moment by an average of ⬃10%. However, much
greater reductions are possible, as analysis of individual
results revealed that a quarter of participants demonstrated a reduction of more than 20%. Although canes are
widely recommended clinically to reduce knee load for
patients with knee OA, only 1 other study has investigated
whether using a cane actually reduces knee loading in
knee OA (12). Although the authors found that using a
cane in the contralateral hand to the affected knee reduced
the mean peak knee adduction moment compared with
unaided gait (0.55 versus 0.51 Nm/kg), in contrast to our
findings the change was not statistically significant. The
conflicting findings may be due to differences in the cohorts, particularly because Chan and colleagues (12) did
not specifically utilize participants with medial knee OA
and their sample size was only 14, which may have lead to
insufficient power to detect significant differences.
We did not evaluate all possible mechanisms explaining
how the cane reduced the knee adduction moment. However, we did demonstrate a 5.9% reduction in the ground
reaction force when using a cane compared with unaided
walking. This reduction is probably due to load relief
provided by the upper limb via the cane. It is also possible
that improved proximal stability may explain our findings.
In hip OA, contralateral cane use acts to augment the hip
abduction moment on the affected limb (29). Hip abductor
weakness is believed to contribute to an elevated ipsilateral knee adduction moment (30) by causing excessive
pelvic drop on the contralateral swing limb during walking, resulting in a shift in the body’s center of mass toward
the swing limb and thus increasing the knee joint moment
arm (31). It is therefore possible that use of the cane improves pelvic control and moves the center of mass closer
to the knee joint center.
Alterations in gait patterns between conditions may also
partially explain the observed effects of shoes and the cane
on the knee adduction moment. For example, previous
studies have shown that factors such as walking speed and
toe-out angle may influence the magnitude of the adduction moment (23,24). As our study was not designed to
evaluate mechanisms of change observed with shoes or the
cane, we did not evaluate the many kinematic or kinetic
gait adaptations that an individual might employ when
moving between walking barefoot and in shoes, or when
using a cane. However, in our participants, cane use resulted in slower walking speeds. While it is possible that
such speed changes may have influenced our observed
effects, Mundermann et al (23) noted that walking speed
only accounted for ⬃9% of the variation in peak knee
adduction moment. Considering that our differences in
speed were very small (4%), it is unlikely that such temporal changes influenced our results. In the only other
study that has evaluated the effects of shoes on the adduction moment in knee OA (17), the authors measured a
number of gait parameters (speed, stride, cadence, toe-out
angle, and ankle, hip, and knee ranges of motion) in order
to evaluate their contribution to changes in the moment
with shoes. Despite significant differences in all parameters except speed between walking barefoot and in shoes,
regression analyses revealed that these gait alterations did
Effect of Shoes and Canes on Medial Knee OA
not explain the reduction in loading observed with barefoot walking.
Findings of the current study have important clinical
implications. In a study of knee OA progression, Miyazaki
et al (8) determined that an increase of 1 unit (N ⫻
m/BW ⫻ H%), or 20.4%, in the peak knee adduction
moment increased the risk of progression of knee OA 6.5
times. Although participants in that study had a higher
baseline adduction moment (mean ⫾ SD 4.9 ⫾ 1.6 BW ⫻
H%) compared with ours and a different system for data
collection was used, the findings highlight the clinical
relevance of our own. We showed that wearing shoes
increased the peak knee adduction moment on average
from 3.49 to 3.77 N ⫻ m/BW ⫻ H%, an increase of 7.4%.
Therefore, based on the analysis of Miyazaki et al (8), it is
possible that wearing shoes may increase the risk of knee
OA progression by a factor of 2.8 on average. Furthermore,
several individuals demonstrated increases of more than
20%, which may increase their risk of disease progression
⬎6-fold. Because it is potentially dangerous as well as
impractical to advise patients with knee OA to walk about
in bare feet, further research is needed to determine which
types of shoes least increase the knee adduction moment
(or, ideally, reduce it), and to evaluate the effect of wearing
shoes on long-term disease progression. Using a cane in
the opposite hand was associated with a mean decrease in
the knee adduction moment by more than 10%. However,
longitudinal, randomized controlled trials are required to
establish whether using a cane leads to important clinical
outcomes, such as a reduced risk of disease progression or
reduction in knee symptoms in the long term.
In our cohort evaluating the effect of the cane, 90% of
participants were women. This under-representation of
men has implications for the generalizability of results.
Our finding that use of a cane reduces the adduction moment is thus only valid in women with knee OA, and
future research should determine whether similar findings
occur in men. Although sex differences in osteoarthritic
gait have been shown by other studies (32,33), it is unclear
whether differences in the response to gait interventions
exist across the sexes.
A number of limitations exist in this study. We evaluated only immediate changes in the knee adduction moment with shoes and the cane. It is unclear whether the
immediate changes observed persist in the short or long
term. Further studies are required to establish whether
knee loading remains lower with ongoing use of a cane,
and whether the reductions in loading translate to a reduced risk of disease progression. Also, we did not measure changes in knee pain, and thus it is unknown whether
reductions in the adduction moment observed with barefoot walking and use of the cane are associated with concomitant alterations in pain.
In summary, we found that wearing shoes and using a
cane each affect the magnitude of the peak knee adduction
moment during walking in people with knee OA. As shoes
were observed to increase the adduction moment and it is
impractical to recommend that patients with knee OA
walk barefoot, future research should evaluate which aspects of shoe design contribute to this increase in knee
load. The shoe type optimal for knee OA with regard to its
613
effects on symptoms and disease progression must be determined. Because use of a cane resulted in significant
decreases in the adduction moment, patients with knee
OA should be encouraged to consider using a cane on a
regular basis.
AUTHOR CONTRIBUTIONS
Dr. Hinman had full access to all of the data in the study and
takes responsibility for the integrity of the data and the accuracy
of the data analysis.
Study design. Kemp, Crossley, Hinman.
Acquisition of data. Kemp, Wrigley, Metcalf.
Analysis and interpretation of data. Kemp, Crossley, Wrigley,
Metcalf, Hinman.
Manuscript preparation. Kemp, Crossley, Wrigley, Hinman.
Statistical analysis. Kemp, Crossley, Hinman.
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