Treatment of Medial Gonarthrosis

with Valgus-Producing Orthoses

Osteoarthritis is the most common form of joint

shifts (further) toward varus. This shift can result

6% of the U.S. population over the age of 30,

the knee joint (7, 8) unless the patient develops a

disease. In 2000, Felson et al. reported that

or 9.7 million people, suffer from symptomatic
osteoarthrits of the knee (gonarthrosis) (1).
In

patients

with

gonarthrosis,

the

medial

compartment is more commonly affected than the

lateral joint section (2, 3, 4). During normal gait,
except for a brief valgus moment after initial heel

contact, the knee joint is subjected to an external

varus moment throughout the stance phase. The
external varus moment is responsible for shifting

compensatory gait pattern that involves toeing out

(11). Furthermore, a reduction in proprioception
(12)

occurring

regularly

in

patients

with

osteoarthritis predisposes the joint to abnormal

kinematics. Combined with the increased external

varus moment, which shifts more load to the

affected compartment, this may further facilitate

degeneration.

the load from the lateral to the medial compartment

Biomechanical relief of the knee joint is a

deformity at the knee (6-9). The predominance of

Patients with isolated medial gonarthrosis are

and can occur even in the presence of a valgus

a varus moment and the concomitant increased

medial compartment joint loads are thought to be

responsible, in part, for the higher incidence of
medial gonarthrosis (6 -10).

The external varus moment about the knee

depends on mechanical alignment of the knee as

Otto Bock 646D202=GB

in an even greater external varus moment about

well as on the ground reaction force. In patients

with medial gonarthrosis, the medial joint space

narrows as a result of cartilage degeneration

and as the mechanical alignment of the knee joint

promising method of therapy.

confronted with a variety of therapy options.

Nonsurgical, biomechanical options include the
use of canes, lateral shoe wedges (13-16) and
valgus-producing

orthoses.

Valgus-producing

orthoses are designed to reduce the load on the

medial knee joint compartment by applying an

external valgus moment about the knee joint that

opposes the varus moment in the stance phase.

Gait analysis studies of patients treated with a

valgus-producing orthosis have experienced a

change in the external moments affecting the

producing orthosis, all patients reported an

on the design of the orthosis, range from

reduction in pain while walking. The gait symmetry

knee joint. The biomechanical results, depending

insignificant changes in dynamic gait parameters
and the varus moment between sham orthosis (no

valgus correction) and actual valgus-producing

orthosis (21), to a significant improvement in gait

symmetry (19) and a reduction of the external

varus moment (18, 20, 22, 23). Pollo et al. (10)

performed a study in which 11 patients with

medial gonarthrosis were subjected to a threedimensional gait analysis. During gait, a valgus-

producing knee orthosis reduced the net varus

movement about the knee joint by an average of

13% (7.1 Nm), and the medial joint compartment
load by an average of 11% (114 N). At the same

time, knee joint relief increases as the valgus

alignment of the orthosis is increased (10).

immediate improvement in function as well as a

analysis also showed a significant improvement in

the symmetry index for the stance phase (p=0.03

and p=0.025) and the swing phase (p=0,02 und

p=0,005). This improvement occurred immediately

after wearing the orthosis as well as three

months later. These results also correlated with
a significant improvement in the mean Hospital

for Special Surgery (HSS) knee score, which

increased from 69.9 to 82.0 (p<0.001) (19).

Kirkley et al. (24) examined 110 patients with

varus gonarthrosis in a prospective, randomized

and controlled clinical study. 33 patients were

randomized into a control group, 36 patients

were treated with a neoprene sleeve and 41

patients were treated with a custom-made valgus-

producing knee orthosis. Following a 6-months

observation period, both the neoprene sleeve

and the valgus orthosis group showed significant

improvements in disease-specific quality of life

(p=0.001) and joint function (p=0.001) compared
to the control group. The valgus-producing knee

orthosis was far superior to the neoprene sleeve

with regard to pain reduction in the 6-minute
walking test (p=0.021), the 30-second stair

climbing test (p=0.016), and the pain domain

of the Western Ontario and McMaster University

Osteoarthritis Index (WOMAC) (p=0.045). The

WOMAC aggregate score (p=0.062) and the
Proven clinical efficacy of valgus
correction

Several studies have also investigated the

clinical efficacy of valgus-producing orthoses in

patients with medial gonarthrosis and found a
significant reduction in pain and an improvement
in biomechanical joint functions (17, 19, 24-29).

Draper et al. (19) studied 30 patients immediately

before and after application of the orthosis and

after three months with and without the orthosis

using a gait analysis. After applying the valgus-

WOMAC physical function score (p=0.081) (24)

also further proved that the valgus-producing

orthosis tended to be superior to the neoprene

sleeve.

Horlick et al. (25) examined 29 patients with medial

gonarthrosis according to double crossover

design in which a valgus-producing knee orthosis
with a medial joint was tested against an orthosis

with a lateral joint. Each patient was tracked

for six weeks as follows: without an orthosis,
with an orthosis in a neutral position, and with

an orthosis in valgus position. Patients used

special examination forms to document pain

reduction in pain was found which continued until

of each week. The statistical analysis showed

study, 78% of patients complained of pain during

and physical function every day and at the end

a significant reduction in pain with the orthosis

with a lateral joint (p=0.02) and the orthosis with

a medial joint (p<0.0004), but only for the valgus

alignment of each joint. This pain-relieving effect

occurred even though X-ray images were unable

the follow-up after one year. At the beginning of the

activities of daily living (ADL). After 9 weeks,

only 39% complained of this pain, and after one
year only 31% patients said they suffered from

this pain. Before wearing the orthosis, patients

were able to walk without pain for an average

51 minutes. After 9 weeks, painless walking time

had increased to 138 minutes. After one year, the

average was 107 minutes (17).

Finger et al. (29) treated 28 patients suffering from

varus and valgus gonarthrosis with varus- and/or

valgus-producing knee orthoses. The mechanical
axis of the knees tested ranged from 100 valgus
to 15 varus.

During the 3-month observation

period, the resting pain on the visual analog scale

(VAS) decreased by half from 4.2 to 2.1. Night

pain decreased from 3.9 to 2.6 and pain with

to prove changes to the femorotibial angle or knee

activity decreased from 7.2 to 3.9 (29).

joint width. 74% of the patients purchased their

Conclusion

Hillstrom et al. (27) provided 15 patients with a

affects the knee joint during the stance phase,

orthosis after the study.

valgus-producing knee orthosis for 24 knee joints

affected by medial gonarthrosis. After 12 weeks,
patients showed significant improvements in times

to ascend stairs (p=0.0008) and times to descend

stairs (p<0.0001), pain on stairs (p<0.0001),
time and pain (both p<0.0001) to walk 50 feet
at a comfortable speed, and pain (p=0.0015)

walking 50 feet at the fastest possible speed. The

biomechanical gait analysis for the patients with

the valgus orthosis showed significant changes

to average velocity, anterior pelvic tilt, hip flexion

angle, knee flexion angle, knee flexion moment,

foot rotation moment (all p<0.0001) and knee

varus angle (p=0.0108) (27).

Hewett et al. (17) performed a study of 18 patients

with symptomatic medial gonarthrosis. The
patients wore a valgus-producing knee orthosis

and were re-examined after 9 weeks and one

year (13 patients). After 9 weeks, a significant

The external varus moment (5, 6), which mostly

and the concomitant increased medial joint

compartment load are thought to be at least

in part responsible for the higher incidence of

medial gonarthrosis (6-10). In patients with medial

gonarthrosis, the medial joint space narrows as

the mechanical alignment of the knee joint shifts

(further) toward varus. This shift toward varus can

cause a vicious circle in which the external varus
moment on the knee joint is further increased,

putting a strain on the medial joint compartment

(7, 8).

Valgus-producing orthoses such as Genu Artho

relieve the medial knee joint compartment by

producing a valgus moment about the knee that
opposes that varus moment. This biomechanical

method of therapy has proven its therapeutic

efficacy in gait analyses (10, 17-21) and clinical

studies (17, 19, 24-29).

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