1. Cinderella and arthritic knees
Mary Ann Forciea MD
September

2. Source
Hinman, RS et al. Unloading Shoes for Self-management of Knee Osteoarthritis. Ann Int Med :381
Editorial: P 443

3. Background OA of knee common, self management often recommended
Weight loss, exercise, FOOTWEAR
Medial compartment loading greater, damage greater
Unloading shoes: soles stiffer laterally than medially reduce medial knee loads
Now available commercially

5. hypothesis Unloading shoes will Reduce pain Improve physical function
At 6 months
Compared to convential ‘walking shoes’

6. method 2 group, parallel group, comparative effectiveness RCT
Melbourne,
Eligible:
>50 yrs
knee pain on most days of prior month
average pain of 4 on 11 point scale in prior week
XR evidence of OK and medial compartment greater disease than lateral

7. Method 2 Exclude: Lateral disease >medial
IA steroids or surgery in prior 3 months
Prior TKR or planned in 3 months
Systemic rheumatic illness
Other condition limiting lower leg use
Prior 6 month use of shoe inserts
Inability to walk unassisted
BMI >36
-pain in ankle or foot

8. Method 3 Randomized in blocks by radiographic severity
Shoes identical; everyone blind
Wear >4hr/day every day for 6 months
Log of hours – 7 consecutive days/month
Shoe mounted pedometer for step count
7 days in 4th week of months 2 and 5

9. Outcomes Self reported pain scales 3 mo, 6 mo
NRS (clinically impt 1.8 points)
WOMAC function (MCID 6)
WOMAC pain (MCID) >18%
Harms – pain >2 days or required meds

10. Results Matching good (Table 1) (slightly young for us)
Primary (Table 2): both groups improved in primary, no meaningful mo
Did wear shoes(7 hrs), little drop out(2%), incorrect guessing
At 6 mo, improved function with unloading shoes, not pain
Secondary no differences

11. Conclusions (authors)
No difference in shoe group for pain and function
Both types did improved function, unloading shoes better for pain
“Knee osteoarthritis symptoms may not be as strongly influenced by abnormal biomechanics as the literature suggests”
Of course subgroups might exist

12. Conclusions Mine Both groups improved
Surprising number of steps/day for patients with OA
I am unconvinced of clinical differences in any outcome.
What is the influence of ‘special shoes’ whether walking shoes or unloading shoes?
Isn’t it the WALKING that helps?