Document Type : Research Paper


1 Assistant Professor, Health & Sport Rehabilitation Department, Faculty of Sport Science & Health, Shahid Beheshti University, Tehran, Iran.

2 faculty member of Department of sport science- university of Gonbade Kavoos

3 Faculty of physical education and Sport Science, University of Mazandaran, Babolsar, Iran.

4 Physical Medicine and Rehabilitation Department, Iran University of Social Medical sciences, Tehran, Iran.


The present study aimed to investigate the effect of the shoe’s external insole with different inclination percentages on the knee’s external adduction torque and its impulse in individuals with genu varum. Kinetic and kinematic indices of the knee joint during running calculated by inverse dynamic method with barefoot, no insoles shoes, and shoes having 0, 5, and 10 degrees of external slopes insoles. The results showed a significant difference in the amount of torque peak and adduction torque impulse of the knee, between insoles; as the insoles of 5- and 10-degrees external slopes, caused a significant decrease of variables compared to bare foot, no insoles shoes, and zero-degree slope insoles shoes. Thus, external slope insoles are suggested as an effective and non-invasive approach for preventing musculoskeletal disorders such as osteoarthritis related to inconsistency of genu varum in affected people.


Main Subjects

  1. Brouwer GM, van Tol AW, Bergink AP, Belo JN, Bernsen RM, Reijman M, et al. Association between valgus and varus alignment and the development and progression of radiographic osteoarthritis of the knee. Arthritis Rheum. 2007; 56(4): 1204-11.
  2. Lun V, Meeuwisse WH, Stergiou P, Stefanyshyn D. Relation between running injury and static lower limb alignment in recreational runners. Br J Sports Med. 2004; 38:576-80.
  3. Ramsey DK, Synder-Mackler L, Lewek M, Newcomb W, Rudolph KS. Effect of anatomic realignment on muscle function during gait in patients with medial compartment knee osteoarthritis. Arthritis & Rheumatism. 2007; 57(3): 389-397.
  4. Stief F, Bo¨hm H, Dussa CU, Multerer C, Schwirtz A, Imhoff AB, et al. Effect of lower limb malalignment in the frontal plane on transverse plane mechanics during gait in young individuals with varus knee alignment. Knee. 2014; 21(3): 688–93.
  5. Andriacchi, T.P. Dynamics of knee malalignment. Orthopedic Clinics of North America. 1994; 25(3): 395-403.
  6. Barrios, J.A., Higginson, J.S., Royer, T.D., Davis, I.S. Static and dynamic correlates of the knee adduction moment in healthy knees ranging from normal to varus-aligned. Clinical Biomechanics.2009; 24(10): 850- 4.
  7. Miller RH, Edwards WB, Deluzio KJ. Energy expended and knee joint load accumulated when walking, running, or standing for the same amount of time. Gait Posture 2015; 41(1): 326–8.
  8. Radzimski AO, Mündermann A, Sole G. Effect of footwear on the external knee adduction moment — A systematic review. The Knee. 2012; 19 (3): 163–175.
  9. Crenshaw, S.J., Pollo, F.E., Calton, E.F. Effects of lateral-wedged insoles on kinetics at the knee. Clin. Orthop. Relat. Res. 2000; 375: 185–192.
  10. Andriacchi, T.P., Mundermann, A., Smith, R.L., Alexander, E.J., Dyrby, C.O., Koo, S. A framework for the in vivo pathomechanics of osteoarthritis at the knee. Ann. Biomed. Eng. 2004; 32 (3): 447–457.
  11. Nuki, G., Salter, D. The impact of mechanical stress on the pathophysiology of osteoarthritis. In: Sharma, L., Berenbaum, F. (Eds.), Osteoarthritis, Mosby, Philadelphia. 2007; pp. 33–52.
  12. Thorp, L.E., Sumner, D.R., Block, J.A., Moisio, K.C., Shott, S., Wimmer, M.A. Knee joint loading differs in individuals with mild compared with moderate medial knee osteoarthritis. Arthritis Rheum. 2006; 54: 3842–3849.
  13. Mündermann, A., Dyrby, C.O., Hurwitz, D.E., Sharma, L., Andriacchi, T.P., 2004. Potential strategies to reduce medial compartment loading in patients with knee osteoarthritis of varying severity: reduced walking speed. Arthritis Rheum. 2004; 50: 1172–1178.
  14. Miyazaki, T., Wada, M., Kawahara, H., Sato, M., Baba, H., Shimada, S. Dynamic load at baseline can predict radiographic disease progression in medial compartment knee osteoarthritis. Ann. Rheum. Dis. 2002; 61: 617–622.
  15. Krohn K. Footwear alterations and bracing as treatments for knee osteoarthritis. Curr Opin Rheumatol. 2005; 17(5):653–656.
  16. Hinman RS, Bowles KA, Metcalf BB, Wrigley TV, Bennell KL. Lateral wedge insoles for medial knee osteoarthritis: effects on lower limb frontal plane biomechanics. Clin Biomech 2012; 27(1): 27-33.
  17. Kakihana W, Akai M, Nakazawa K, Takashima T, Naito K, Torii S: Effects of laterally wedged insoles on knee and subtalar joint moments. Arch Phys Med Rehabil. 2005; 86:1465-71.
  18. Butler RJ, Marchesi S, Royer T, Davis IS: The effect of a subject specific amount of lateral wedge on knee mechanics in patients with medial knee osteoarthritis. J Orthop Res. 2007; 25:1121-7.
  19. Hinman RS, Payne C, Metcalf BR, Wrigley TV, Bennell KL. Lateral wedges in knee osteoarthritis: what are their immediate clinical and biomechanical effects and can these predict a three-month clinical outcome? Arthritis Rheum (Arthritis Care Res). 2008; 59:408-15.
  20. Chapman G.J., Parkes M.J., Forsythe L., Felson D.T., Jones R.K. Ankle motion influences the external knee adduction moment and may predict who will respond to lateral wedge insoles? An ancillary analysis from the SILK trial. Osteoarthritis and Cartilage. 2015; 23(8):1316-22.
  21. Butler RJ, Barrios JA, Royer T, et al. Effect of laterally wedged foot orthoses on rearfoot and hip mechanics in patients with medial knee osteoarthritis. Prosthetics and Orthotics International. 2009; 33(2): 107-116.
  22. Dorsey S. Williams III, Irene McClay Davis, John P. Scholz,Joseph Hamill, Arch structure and injures pattern in runners. Clinical Biomechanics. 2001; 16: 341-347.
  23. Farahpour N, Jafarnezhad A, Damavandi M, Bakhtiari A, Allard P. Gait ground reaction force characteristics of low back pain patients with pronated foot and able-bodied individuals with and without foot pronation. Journal of biomechanics. 2016; 49(9):1705-10.
  24. Murley GS, Menz HB, Landorf KB. Foot posture influences the electromyographic activity of selected lower limb muscles during gait. Journal of foot and ankle research. 2009; 2(1):35.
  25. Buldt AK, Murley GS, Butterworth P, Levinger P, Menz HB, Landorf KB. The relationship between foot posture and lower limb kinematics during walking: A systematic review. Gait & posture. 2013; 38(3):363-72.
  26. Tweed JL, Campbell JA, Avil SJ. Biomechanical risk factors in the development of medial tibial stress syndrome in distance runners. Journal of the American Podiatric Medical Association. 2008; 98(6):436-44.
  27. Andrew K. Buldt, Pazit Levinger, George S. Murley, Hylton B. Menz, Christopher J. Nester, Karl. Landorf Foot posture is associated with kinematics of the foot during gait: A comparison of normal, planus and cavus feet. Gait & Posture. 2015; 42(1):42-8.
  28. Levinger, P., Menz, H.B., Fotoohabadi, M.R., Feller, J.A., Bartlett, J.R., Bergman, N.R. Foot posture in people with medial compartment knee osteoarthritis. J Foot Ankle Res. 2019; 3: 29.
  29. Faul F, Erdfelder E, Lang A-G, Buchner A. G* Power 3. A flexible statistical power analysis program fo the social, behavioral, and biomedical sciences. Behavior research methods. 2007; 39(2):175-91.
  30. Brody, D. Techniques in the evaluation and treatment of the injured runner. The Orthopedic Clinics of North America. 1982; 13(3): 541-58.
  31. Menz HB, Dufour AB, Riskowski JL, Hillstrom HJ, Hannan MT. Association of Planus Foot Posture and Pronated Foot Function with Foot Pain: The Framingham Foot Study. Arthritis Care & Research. 2013; 65(12): 1991–1999.
  32. Ferreira V, Simões R, Gonçalves RS, Machado L & Roriz P. The optimal degree of lateral wedge insoles for reducing knee joint load: a systematic review and meta-analysis. Archives of Physiotherapy. 2019; 18(9).
  33. Douglas Gordon Robertson DG,  Caldwell GE, Hamil J, Kamen J, Whittlesey SN. Research Methods in Biomechanics: Second edition. Human Kinetics. 2013.
  34. Winter DA. Biomechanics and motor control of human movement: John Wiley & Sons. 2009.
  35. De Leva P. Adjustments to Zatsiorsky-Seluyanov's segment inertia parameters. Journal of biomechanics. 1996; 29(9):1223-30.
  36. Sawada T, Tokuda K, Tanimoto K, Iwamoto Y, Ogata Y, Anan M, Takahashi M, Kito N, Shinkoda K. Foot Alignments Influence the Effect of Knee Adduction Moment with Lateral Wedge Insoles During Gait. Gait & Posture. 2016; 49:451-56.
  37. Lewinson, R.T., Fukuchi, C.A., Worobets, J.T., & Stefanyshyn, D.J. The effects of wedged footwear on lower limb frontal plane biomechanics during running. Clinical Journal of Sport Medicine. 2013; 23(3): 208-215.
  38. Sinclair, J & Stainton, P. Effects of medial and lateral wedged orthoses on knee and ankle joint loading in female runners. Kinesiology. 2019; 51(2):189-197.
  39. Nigg, B.M., Stergious, P., Cole, G., Stefanyshyn, D., Munderman, A., & Humble, N. Effect of shoe inserts on kinematics, center of pressure, and leg joint moments during running. Med.Sci.Sports Exerc. 2003; 35(2), 314 –319.
  40. Hume, P., Hopkins, W., Rome, K., Maulder, P., Coyle, G., & Nigg, B. Effectiveness of foot orthoses for treatment and prevention of lower limb injuries: a review. Sports Med. 2008; 38(9): 759-779.
  41. Hanington IJ. Static and dynamic loading patterns in knee jointa with deformities. J Bone Joint Surg. 1983; 65(2): 247-59.
  42. Maly MR, Culham EG, Costigan PA. Static and dynamic biomechanics of foot orthoses in people with medial compartment knee osteoarthritis. Clinical Biomechanics. 2002; 17(8): 603-10.
  43. Richards J. Biomechanics in Clinic and Research. Edition: 1. Publisher: Churchill Livingstone, London. 2008.
  44. Schmalz T, Blumentritt S, Drewitz H, Freslier M. The influence of sole wedges on frontal plane knee kinetics in isolation and in combination with representative rigid and semi-rigid ankle-footorthoses. Clin Biomech. 2006; 21(6): 631-9.
  45. Kakihana W, Akai M, Yamasaki N, et al. Changes of joint moments in the gait of normal subjects wearing laterally wedged insoles. American Journal of Physical Medicine and Rehabilitation 2004; 83(4): 273-278, 2004.
  46. Levangie PK, Norkin CC. Joint structure and function: A comprehensive analysis. 4th edition. Philadelphia: F.A. Davis Company; 2005.
  47. Li B, Xiang O & Zhang X. The center of pressure progression characterizes the dynamic function of high-arched feet during walking. Journal of Leather Science and Engineering. 2020; 2(1).