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orthotics for medial knee pain??

Posted by rosemary c on 3/25/01 at 19:43 (042447)

i am a 19 yr old female runner. i have been experiencing knee pain on the inner side of my knee in the pes anserine area. this was first diagnosed as pes anserine bursitis and it was treated with a cortisone shot. but pain, although slightly different, soon returned to around the same area but now more widespread and not as sharp. now it has been 5 months since the pain first came. i have tried to run through it but now have stopped running due to the fact that it was getting worse and worse. now i have not run in 6 wks and as soon as i do something like ride a bike, use a ski machine, elliptical trainer etc. i get knee pain afterward. it is also present sometimes when i am walking, going up/down stairs/ standing up after sitting etc. the thing that hurts the most is pronating my foot so the side of the ball of my foot is pressed to the floor(i don't know if that is clear but i cannot think of a better way to describe it) i know that at some point in my running stride i twist on the ball of my foot b/c my shoes get very worn down in a a small area under the ball of my foot. i have an extremely high arch. the dr. i just went to said that she recommended orthotics. she says that my foot is pronating too much and that is pulling on the tendons around the pes anserine area. ......
but i always thought that i supinated due to the high arch?????
two yrs ago i paid over 300 dollars for some orthotics after another injury and they only made the problem worse ( i had them adjusted but this did not help, finally it was a knee brace that cured that problem so i guess the orthotics were not needed at that time)i told her this and she said that maybe they were made wrong. i tried wearing those old orthotics but they have not helped my current problem at all. i have also tried over the counter arch supports as well as extra cushioning , new shoes etc with no success.
i am a collegiate runner. i was very much looking forward to continuing to run competitively or at the very least to being able to bike or something. i have already missed the indoor track season. it does not seem right to me that a 19 yr old would have pain with everyday activity despite resting the knee. i hope that you can help me with this. do you think that orthotics would be helpful or would i just be wasting my money? what material would you suggest? what kind of process should be used to take the mold of my foot. i want to go to the podiatrist appointment with as much information as possible. thank you for reading this extremely long post.

Re: orthotics for medial knee pain??

Julie on 3/26/01 at 01:27 (042479)

Rosemary, my firstorthotics, seven years ago, were suggested to remedy medial knee pain caused by over-pronation, and they did the trick. If you're going to make the investment, just be sure you have them casted and made by a reputable orthotist who is prepared to make adjustments.

Re: orthotics for medial knee pain??

Dr. Zuckerman on 3/26/01 at 14:57 (042543)

Hi,

If your gait analysis and lower extremity biomechanical show that abnormal pronation is present in your feet then orthosis can help the medial knee pain alot.

Re: orthotics for medial knee pain??

Richard, C.Ped on 3/26/01 at 15:44 (042553)

Dr. Z beat me to another one. I really should get a computer for home use.
Ditto to Dr. Z and Julie.
Richard

Re: orthotics for medial knee pain??

bg cped on 3/26/01 at 19:52 (042573)

I would be concerned about getting a device that 'controls pronation' if you really do have an extremely high arch as you say. Most female runners have over pronated feet and valgus or slightly knocked knee (symptomatic ones) If you do truely have very high arch, and more bowed or varus knee alignment, over correcting your feet or even just limiting your avaialble pronation can also cause knee pain in the medial joint compartment.

It is imortant that get a complete biomechanical eval done by a skilled practitioner, not just somebody that looks at you foot for a few seconds and says'you pronate you need arch supports'. Orthotics are great tools when done corectly, when not they can be as bad as putting near sighted glasses on a far sighted person. What area are you in? Let us know perhaps we can steer you to a good practitioner.

A at home test if you stand in front of a mirror with your ankles touching and your knees are more than a few inches apart, and you really do have very high arch feet, STAY AWAY FROM A PERSON THAT SAYS YOU NEED LOTS OF ARCH SUPPORT. Yhere is an article in biomechanics on orthotics for high arch feet, perhaps somebody can put a link for you on here. I would take it with you to your Dr and see if it sounds like you...good luck

Re: orthotics for medial knee pain??

Julie on 3/26/01 at 21:34 (042590)

Rosemary, I didn't read your post carefully enough, and missed the bit about your high arch. My problem was over-pronation, and I have slightly flat feet, so custom orthotics did work for me, and solved the knee pain problem at the time. (However, the underlying cause was a weakened cartilage the result of an old ski-ing injury, which eventually tore and needed micro-surgery - but that's another story.)

You can't be supinating and pronating at the same time (at least I don't think you can) and your next step should surely be a full biomechanical analysis to determine what kind of orthotics, if any, you need.

Re: orthotics for medial knee pain??

Donna SL on 3/27/01 at 01:32 (042604)

Rosmary,

Read this article on Cavus feet in Biomechanics Magazine. It it critical reading for a high arched foot, and an excellent article.

http://www.biomech.com/db_area/archives/2001/0101orthoses.55.bio.html

I have a high arched foot, yet my feet roll in on the ball of the foot the same way yours do, and the ball of the foot gets sore, and also the knee,etc. I was misdiagnosed as a pronator, and was put in anti pronation shoes, and anti pronation orthotics, and got severe PF, and a lot of other injuries. What usually happens in a high arch foot is that you roll out to far (supinate), and then the foot tends to roll in again to gain ground (so you don't fall over on your ankles. The forefoot appears to have mid or late stance pronation, yet it is NOT THE SAME PRONATION AS SOMEONE PRONATING AT THE HEEL. Actually you really are supinating and then pronating. Also a dropped first metatarsal, known as a plantarflexed first ray can cause late midstance pronation. The more the foot inverts, the more you will roll back in, sort of like a side ways seesaw.

You can actually stop the rolling in of the foot at the ball, by controlling the supination. The less you roll to the outside of your feet, the less you will roll back in at mid or late stance. Pods usually make the mistake of controlling the pronation at the heel with an orthotic, or wedge on the medial side, which supinates you more, which causes more late stance pronation, etc. Wearing this type of orthotic is dangerous.

To fix this an orthotic needs to made with some lateral support at the heel, and also forefoot valgus posting either intrinsically, or extrinsically posted on the orthotic. You need to bring the ground up to the foot on the lateral side, and this helps you from supinating. Look at the section on orthotics in the Biomechanics Magazine article carefully.
Sometimes instead of an orthotic just using a dancers pad in the shoe will help, if the rest of your foot is stable. I would try this first. A pod should know about these.

Also a good stable shoe like a cross trainer might help control you from rolling to the outside of your foot, because they are laterally stable. Most are too stiff for running, but fine for walking. Look at the New Balance 661, which is running/crosstrainer. Most neutral running shoes are too soft on the lateral side and will cause you to supinate more, and then roll in at the ball more. There aren't any running shoes for supinators. Make sure you are not wearing any medial posted, or motion control shoes. They will also push you out more. Sometimes putting a small wedge on the lateral side of the shoe under a simple over the counter soft orthotic (the spenco crostraining one) can do the trick, but you need someone who knows what they are doing to give you the wedging. A pod can experiment with felt or birkocork type wedges, under the shoe liner also, to see if you benefit from this.

Also, BG ped is absolutely right. (I think he wrote the article.) I found out the hard way that it is critical to not have a high arch in the orthotic. The arch area should NOT be filled in, and NOT be in contact with your arch. You don't need it, and it can make things worse. Not only does the higher arch in the orthotic push you out more, it can also put more strain on the entire foot, calves, achilles, etc, because high arched feet usually have tight heel cords, and some form of ankle equinus. The foot actually has to struggle to get over this high arch. Also, too deep of a heel cup in the orthotic will cause you to supinate more. I had an orthotic years ago, that DIDN'T contour to my arch, and I never got injured. It just needed some more lateral support on it. My current pod has lowered the arch on my newer orthotics with the stronger lateral support, but we're still experimenting with amounts of control.

As far as materials, I have had the most success with a very flexible thin plastic (2-3mm) , either of soft polyproplyene, or subortholon, with a soft arch fill, made of poron. You could also try a soft eva fill. It gives support, flexibility, and a lot of shock absorption. If you don't need a lot of control, then an orthotic made entirely out of EVA should do.

I think they mention in the article that an OTC for cavus foot will be on the market soon. I'm still waiting for them myself.

Donna

Re: orthotics for medial knee pain??

Julie on 3/27/01 at 04:18 (042609)

Donna, thanks for your brilliant explanation of what happens with a high-arched foot. So it is possible to supinate and pronate: your description of how that happens is very clear.

Re: orthotics for medial knee pain??

JudyS on 3/27/01 at 11:45 (042648)

Donna - I have to say thanks to you, yet again, for your excellent information re: high arches. I especially agree with your paragraph describing the problems associated with orthotics that have ANY arch. I've recently abandoned orthotics completely and find that my arch pain and related metatarsal joint pain is all but disappeared. I've tried continuously to communicate this to my docs but........they don't seem to hear. I still believe firmly that we can benefit from an orthotic as long as it's maker is really listening and really examining your arch (you were treated for overpronating - as so many sufferers automatically are!).

Re: orthotics for medial knee pain??

Barbara TX on 3/27/01 at 12:47 (042656)

I question the efficacy of the ankles together test of pronation/arch height. Excess fat on the legs gives the knees the appearance of touching. I think you really have to have the pedorthosist give you a total look-see and gait evaluation. You can't determine the amount of arch-support you need yourself. Don't you also have to determine whether your arches are high and rigid or high and flexible? Do these two variations get different kinds of support? Thanks for your info. B.

Re: orthotics for medial knee pain??

BG CPED on 3/27/01 at 18:27 (042698)

Yes Donna you seem to get it. We are currently speaking with a major orthopedic company regarding manufacturing and distributing this device. As always these things take time, never as fast as we want! Because we feel this device to be extremely vital to the treatment of cavus feet we want to make sure it is done right.
Since the article was published we have gotten a great deal of positive feedback from patients and Doctors from all over. When we get a solid timetable the folks on this site will be one of the first to know. In my facility I have fabricated 5 of these devices for patients in the last 2 days. That fact alone illustrates that it is a much 'under-diagnosed' condition. Of those 5 pt, 4 had already tried 1 or more pair of orthotics with no success. One of them was a Dr. that had peroneal tendonitis, he had a pair made a weeek ago to 'control pronation' it had about 8 degree of rf post, and a high arch. He wore it for 1 day and it increased his pain 3 fold. I am sure the practitioners on here that understand peroneal tendon and its function can picture what would happen if a cavus foot with this problem was put into more inversion....OUCH

So please be patient and we appreciate the positive comments and links to the article.

Re: orthotics for medial knee pain??

rosemary c on 3/27/01 at 18:50 (042707)

thank you everyone for the info.
donna, your input was especially helpful. i think i may print out what you wrote and take it with me. i think you are right about my foot supinating and then pronating. now i just hope that they can fit me in the right kind of orthotic bc i really need some help. even thought i am no longer running and have not in quite a while it still hurts, some times even when i walk so something is definitely wrong.
if anyone can add anything else or has any other input please add it. thank you very much.

Re: orthotics for medial knee pain??

bg cped on 3/27/01 at 19:09 (042709)

I may have asked this before, what area are you in rosemary? Perhaps spmebody can direct you to a good practitioner in your area

Re: orthotics for medial knee pain??

rosemary c on 3/28/01 at 12:04 (042804)

rochester new york area.
also, someone in another post asked whether i had a flexible high-arched foot or a rigid high-arched foot. i believe my arch is pretty rigid.

Re: orthotics for medial knee pain??

Mary J. on 3/29/01 at hrmin (042890)

bg cped,
I would love to know if there is a good practitioner in the area of Houston, TX. I live just south of Houston. Thanks, Mary J.

Re: orthotics for medial knee pain??

bg cped on 3/29/01 at 10:54 (042916)

There is an orthopedic foot specialist that did a fellowship near me. He is very adept at dx for the possible cavus foot/ orthotic. His name is Dr. Paul Bednarz, his number is 845-561-8325.

Re: orthotics for medial knee pain??

Julie on 3/26/01 at 01:27 (042479)

Rosemary, my firstorthotics, seven years ago, were suggested to remedy medial knee pain caused by over-pronation, and they did the trick. If you're going to make the investment, just be sure you have them casted and made by a reputable orthotist who is prepared to make adjustments.

Re: orthotics for medial knee pain??

Dr. Zuckerman on 3/26/01 at 14:57 (042543)

Hi,

If your gait analysis and lower extremity biomechanical show that abnormal pronation is present in your feet then orthosis can help the medial knee pain alot.

Re: orthotics for medial knee pain??

Richard, C.Ped on 3/26/01 at 15:44 (042553)

Dr. Z beat me to another one. I really should get a computer for home use.
Ditto to Dr. Z and Julie.
Richard

Re: orthotics for medial knee pain??

bg cped on 3/26/01 at 19:52 (042573)

I would be concerned about getting a device that 'controls pronation' if you really do have an extremely high arch as you say. Most female runners have over pronated feet and valgus or slightly knocked knee (symptomatic ones) If you do truely have very high arch, and more bowed or varus knee alignment, over correcting your feet or even just limiting your avaialble pronation can also cause knee pain in the medial joint compartment.

It is imortant that get a complete biomechanical eval done by a skilled practitioner, not just somebody that looks at you foot for a few seconds and says'you pronate you need arch supports'. Orthotics are great tools when done corectly, when not they can be as bad as putting near sighted glasses on a far sighted person. What area are you in? Let us know perhaps we can steer you to a good practitioner.

A at home test if you stand in front of a mirror with your ankles touching and your knees are more than a few inches apart, and you really do have very high arch feet, STAY AWAY FROM A PERSON THAT SAYS YOU NEED LOTS OF ARCH SUPPORT. Yhere is an article in biomechanics on orthotics for high arch feet, perhaps somebody can put a link for you on here. I would take it with you to your Dr and see if it sounds like you...good luck

Re: orthotics for medial knee pain??

Julie on 3/26/01 at 21:34 (042590)

Rosemary, I didn't read your post carefully enough, and missed the bit about your high arch. My problem was over-pronation, and I have slightly flat feet, so custom orthotics did work for me, and solved the knee pain problem at the time. (However, the underlying cause was a weakened cartilage the result of an old ski-ing injury, which eventually tore and needed micro-surgery - but that's another story.)

You can't be supinating and pronating at the same time (at least I don't think you can) and your next step should surely be a full biomechanical analysis to determine what kind of orthotics, if any, you need.

Re: orthotics for medial knee pain??

Donna SL on 3/27/01 at 01:32 (042604)

Rosmary,

Read this article on Cavus feet in Biomechanics Magazine. It it critical reading for a high arched foot, and an excellent article.

http://www.biomech.com/db_area/archives/2001/0101orthoses.55.bio.html

I have a high arched foot, yet my feet roll in on the ball of the foot the same way yours do, and the ball of the foot gets sore, and also the knee,etc. I was misdiagnosed as a pronator, and was put in anti pronation shoes, and anti pronation orthotics, and got severe PF, and a lot of other injuries. What usually happens in a high arch foot is that you roll out to far (supinate), and then the foot tends to roll in again to gain ground (so you don't fall over on your ankles. The forefoot appears to have mid or late stance pronation, yet it is NOT THE SAME PRONATION AS SOMEONE PRONATING AT THE HEEL. Actually you really are supinating and then pronating. Also a dropped first metatarsal, known as a plantarflexed first ray can cause late midstance pronation. The more the foot inverts, the more you will roll back in, sort of like a side ways seesaw.

You can actually stop the rolling in of the foot at the ball, by controlling the supination. The less you roll to the outside of your feet, the less you will roll back in at mid or late stance. Pods usually make the mistake of controlling the pronation at the heel with an orthotic, or wedge on the medial side, which supinates you more, which causes more late stance pronation, etc. Wearing this type of orthotic is dangerous.

To fix this an orthotic needs to made with some lateral support at the heel, and also forefoot valgus posting either intrinsically, or extrinsically posted on the orthotic. You need to bring the ground up to the foot on the lateral side, and this helps you from supinating. Look at the section on orthotics in the Biomechanics Magazine article carefully.
Sometimes instead of an orthotic just using a dancers pad in the shoe will help, if the rest of your foot is stable. I would try this first. A pod should know about these.

Also a good stable shoe like a cross trainer might help control you from rolling to the outside of your foot, because they are laterally stable. Most are too stiff for running, but fine for walking. Look at the New Balance 661, which is running/crosstrainer. Most neutral running shoes are too soft on the lateral side and will cause you to supinate more, and then roll in at the ball more. There aren't any running shoes for supinators. Make sure you are not wearing any medial posted, or motion control shoes. They will also push you out more. Sometimes putting a small wedge on the lateral side of the shoe under a simple over the counter soft orthotic (the spenco crostraining one) can do the trick, but you need someone who knows what they are doing to give you the wedging. A pod can experiment with felt or birkocork type wedges, under the shoe liner also, to see if you benefit from this.

Also, BG ped is absolutely right. (I think he wrote the article.) I found out the hard way that it is critical to not have a high arch in the orthotic. The arch area should NOT be filled in, and NOT be in contact with your arch. You don't need it, and it can make things worse. Not only does the higher arch in the orthotic push you out more, it can also put more strain on the entire foot, calves, achilles, etc, because high arched feet usually have tight heel cords, and some form of ankle equinus. The foot actually has to struggle to get over this high arch. Also, too deep of a heel cup in the orthotic will cause you to supinate more. I had an orthotic years ago, that DIDN'T contour to my arch, and I never got injured. It just needed some more lateral support on it. My current pod has lowered the arch on my newer orthotics with the stronger lateral support, but we're still experimenting with amounts of control.

As far as materials, I have had the most success with a very flexible thin plastic (2-3mm) , either of soft polyproplyene, or subortholon, with a soft arch fill, made of poron. You could also try a soft eva fill. It gives support, flexibility, and a lot of shock absorption. If you don't need a lot of control, then an orthotic made entirely out of EVA should do.

I think they mention in the article that an OTC for cavus foot will be on the market soon. I'm still waiting for them myself.

Donna

Re: orthotics for medial knee pain??

Julie on 3/27/01 at 04:18 (042609)

Donna, thanks for your brilliant explanation of what happens with a high-arched foot. So it is possible to supinate and pronate: your description of how that happens is very clear.

Re: orthotics for medial knee pain??

JudyS on 3/27/01 at 11:45 (042648)

Donna - I have to say thanks to you, yet again, for your excellent information re: high arches. I especially agree with your paragraph describing the problems associated with orthotics that have ANY arch. I've recently abandoned orthotics completely and find that my arch pain and related metatarsal joint pain is all but disappeared. I've tried continuously to communicate this to my docs but........they don't seem to hear. I still believe firmly that we can benefit from an orthotic as long as it's maker is really listening and really examining your arch (you were treated for overpronating - as so many sufferers automatically are!).

Re: orthotics for medial knee pain??

Barbara TX on 3/27/01 at 12:47 (042656)

I question the efficacy of the ankles together test of pronation/arch height. Excess fat on the legs gives the knees the appearance of touching. I think you really have to have the pedorthosist give you a total look-see and gait evaluation. You can't determine the amount of arch-support you need yourself. Don't you also have to determine whether your arches are high and rigid or high and flexible? Do these two variations get different kinds of support? Thanks for your info. B.

Re: orthotics for medial knee pain??

BG CPED on 3/27/01 at 18:27 (042698)

Yes Donna you seem to get it. We are currently speaking with a major orthopedic company regarding manufacturing and distributing this device. As always these things take time, never as fast as we want! Because we feel this device to be extremely vital to the treatment of cavus feet we want to make sure it is done right.
Since the article was published we have gotten a great deal of positive feedback from patients and Doctors from all over. When we get a solid timetable the folks on this site will be one of the first to know. In my facility I have fabricated 5 of these devices for patients in the last 2 days. That fact alone illustrates that it is a much 'under-diagnosed' condition. Of those 5 pt, 4 had already tried 1 or more pair of orthotics with no success. One of them was a Dr. that had peroneal tendonitis, he had a pair made a weeek ago to 'control pronation' it had about 8 degree of rf post, and a high arch. He wore it for 1 day and it increased his pain 3 fold. I am sure the practitioners on here that understand peroneal tendon and its function can picture what would happen if a cavus foot with this problem was put into more inversion....OUCH

So please be patient and we appreciate the positive comments and links to the article.

Re: orthotics for medial knee pain??

rosemary c on 3/27/01 at 18:50 (042707)

thank you everyone for the info.
donna, your input was especially helpful. i think i may print out what you wrote and take it with me. i think you are right about my foot supinating and then pronating. now i just hope that they can fit me in the right kind of orthotic bc i really need some help. even thought i am no longer running and have not in quite a while it still hurts, some times even when i walk so something is definitely wrong.
if anyone can add anything else or has any other input please add it. thank you very much.

Re: orthotics for medial knee pain??

bg cped on 3/27/01 at 19:09 (042709)

I may have asked this before, what area are you in rosemary? Perhaps spmebody can direct you to a good practitioner in your area

Re: orthotics for medial knee pain??

rosemary c on 3/28/01 at 12:04 (042804)

rochester new york area.
also, someone in another post asked whether i had a flexible high-arched foot or a rigid high-arched foot. i believe my arch is pretty rigid.

Re: orthotics for medial knee pain??

Mary J. on 3/29/01 at hrmin (042890)

bg cped,
I would love to know if there is a good practitioner in the area of Houston, TX. I live just south of Houston. Thanks, Mary J.

Re: orthotics for medial knee pain??

bg cped on 3/29/01 at 10:54 (042916)

There is an orthopedic foot specialist that did a fellowship near me. He is very adept at dx for the possible cavus foot/ orthotic. His name is Dr. Paul Bednarz, his number is 845-561-8325.