Orthoses Provide Greater Improvement in AKP Than Wait-and-See Approach

In-shoe foot orthoses provide greater improvements in clinically
diagnosed anterior
knee pain than a wait-and-see approach, according to results
of a single-blind, randomized controlled trial published in the British
Journal of Sports Medicine.

“Comfortable in-shoe foot
orthoses offer a speedier resolution of the condition beyond
a wait-and-see approach, but this is likely to be better in those who have
mid-foot mobility,” said researcher Bill Vicenzino, PhD,
professor and head of physiotherapy at the School of Health and Rehabilitation
Sciences, University of Queensland in Brisbane, Australia.

Vicenzino, along with Kathryn Mills, PhD, post-doctoral research fellow
at the Running Injury Clinic, The University of Calgary in Alberta, Canada, and
colleagues investigated the short-term clinical efficacy of in-shoe foot
orthoses compared with a wait-and-see policy when used for the treatment of
anterior knee pain.

The secondary aim was to evaluate whether foot posture or mobility
predicted those who reported success with orthoses, according to Mills.

“People with patellofemoral pain syndrome can be successfully
managed with comfortable orthoses and are more likely to experience
improvements in function if they have a mobile midfoot,” Mills told
O&P Business News.

Methods compared

The study included 40 participants aged 18 to 40 years with clinically
diagnosed patellofemoral pain, which Mills described as “pain at the front
of the knee that is exacerbated with activities such as stair climbing,
squatting, prolonged sitting with knees bent, and running/jogging.”

Participants were not treated with orthoses in the past 5 years and
in-shoe foot orthoses were prescribed on the basis of comfort.

Results showed that use of comfortable foot orthoses was a significantly
better treatment option compared with the wait-and-see approach.

“That is, for every two people being treated with foot orthoses one
more patient would have to be treated to get a successful outcome than if they
had observed a wait and see policy,” Mills said. “Interestingly, when
considering all of the outcome measures we took, this level of success reflects
improvements in the domain of patient function rather than pain

Further, those with a change in midfoot width from weight bearing to
non-weight bearing (ie, from standing to sitting) of more than 11.25 mm had a
more successful outcome, according to the study.

Midfoot mobility

Vicenzino said that of these findings, the most interesting in a
clinical practice sense is that participants with more mobility were more
likely to report being totally better or much improved than those in the
wait-and-see group.

“The numbers needed to treat is one for those with more midfoot
mobility,” he told O&P Business News. “However, we
would caution clinicians that the study was not adequately powered to test this
hypothesis and further research must now be conducted.”

Vicenzino added that although these results add to the literature, they
are not surprising because orthoses can result in immediate- to short-term
benefits compared with other treatments, so weighed against a wait-and-see
approach, these current findings are anticipated.

However, what makes this study unique is that no other study has
evaluated the natural resolution process of patellofemoral pain, according to

“Our findings provide clinicians and researchers with the
information that the orthoses used in treatment can be prescribed based on
comfort alone without consideration of rearfoot motion augmentation or varus
correction,” Mills said.

The researchers are currently working on additional studies, one of
which includes a large clinical trial to evaluate the difference in midfoot
width between standing and seated non-supported position, and a separate study
exploring factors that make an orthosis more or less comfortable, according to
Vicenzino. — by Tara Grassia

For more information:

  • Mills K, et al. A randomized control trial of short term efficacy
    of in-shoe foot orthoses compared with a wait and see policy for anterior knee
    pain and the role of foot mobility. Br J Sports Med. 2011;

Disclosure: Mills and Vicenzino
reported no relevant financial disclosures.


After many decades of discussions with orthopedic surgeons, physical
therapists and a myriad of other disciplines that anterior knee pain can be
helped greatly with proper full-length foot orthoses, I was told repeatedly my
claim was not supported by research to be correct and therefore less likely to
be prescribed. I was continuously told, especially in my early years, that
there is no study supporting my belief that biomechanical orthotic control can
help relieve anterior knee pain. Today, after years of practice and thousands
of my patients preaching to the same doctors much more effectively then I alone
could ever do, it is with a grin and a nod that I acknowledge the results of
this small but meaningful study.

  Art Smuckler
  Art Smuckler

I am a little more fascinated with the midfoot mobility portion of the
study. In this limited study, utilizing a mere cushioned single shape insert
regardless of the participant’s midfoot mobility, the researchers are
almost pre-deciding the final results. My belief is that results would differ
with the flat rigid midfoot if using a more individualized insert for all
participants in the study as long as all foot types are defined. Still, this is
a very important study within the treatment of anterior knee pain and should
lead to larger and broader studies. I would encourage such studies that will
both help patients that are suffering with anterior knee pain but also educate
our providing practitioners.

— Art Smuckler, CPed
Owner, General
Orthopedic Inc.

Leave a Reply

Your email address will not be published.