Guideline for the management of knee and hip osteoarthritis

Recommendations

Braces, orthotics, taping, footwear and canes

Guideline for the management of knee and hip osteoarthritis
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Last revised: 01 Jul 2018

Non-pharmacological interventions 

Braces, orthotics, taping, footwear and canes


 

Knee braces

Recommendation

We are unable to recommend either for or against the use of varus unloading/realignment braces for people with lateral tibiofemoral compartment knee osteoarthritis (OA). 

Strength of recommendation

Conditional (neutral) recommendation
(varus unloading/ realignment braces)

Quality of evidence

Very low
(varus unloading/ realignment – no randomised controlled trial [RCT] data)

Recommendation

We suggest not offering valgus unloading/realignment braces for people with medial tibiofemoral compartment knee OA.

Strength of recommendation

Conditional against recommendation
(valgus unloading/ realignment braces)

Quality of evidence

Low
(valgus unloading/ realignment braces)

Recommendation

We suggest not offering realigning patellofemoral braces for patellofemoral OA.

Strength of recommendation

Conditional against recommendation
(realigning patellofemoral braces)

Quality of evidence

Very low
(realigning patellofemoral braces)

What is it? 

Knee braces are widely available for purchase by consumers from pharmacies, clinicians and other healthcare outlets. Varus unloading braces realign the tibiofemoral joint by providing a varus-directed force that aims to reduce valgus malalignment in those with lateral tibiofemoral compartment knee OA.

Valgus unloading braces provide a valgus-directed force that aims to reduce varus malalignment in those with medial tibiofemoral compartment knee OA. 

Patellofemoral braces aim to realign patellar position for those with patellofemoral OA. 

Rationale 

There is no RCT evidence on the effects of varus unloading braces on pain or physical function in people with knee OA. There is limited low-quality evidence that valgus unloading braces have no significant effect on pain or physical function (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). Similarly, there is limited, very lowquality evidence that patellofemoral realigning braces have no significant effect on pain or function (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). Knee braces can impose a considerable financial cost to an individual, and may be associated with difficulties in applying the brace independently. Adherence with wearing knee braces can also be a limiting factor in the appropriateness of such braces.

Harms 

There is a low likelihood of adverse effects, which can include skin irritation.

Shoe orthotics (medial and lateral wedge insoles – knee, shock-absorbing insoles and arch supports – knee and/or hip)

Recommendation

We are unable to recommend either for or against the use of medial wedged insoles for people with lateral tibiofemoral OA and valgus deformity.

Strength of recommendation

Conditional (neutral) recommendation  
(medial wedge insoles for lateral tibiofemoral OA)

Quality of evidence

Very low
(medial lateral wedged insoles)

Recommendation

We suggest not offering lateral wedge insoles for people with medial tibiofemoral knee OA.

Strength of recommendation

Conditional against recommendation  
(lateral wedge insoles)

Quality of evidence

Very low
(medial lateral wedged insoles)

Recommendation

We are unable to recommend either for or against the use of shock-absorbing insoles or arch supports for knee and/or hip OA.

Strength of recommendation

Conditional (neutral) recommendation  
(shock-absorbing insoles, arch supports)

Quality of evidence

Very low
(shockabsorbing insoles,  arch support –  no RCT data)

Very low  
(all hip orthotics –  no RCT data)

What is it? 

Various shoe orthotics that are designed to alter walking biomechanics are available. Wedge insoles are orthotics placed inside shoes that are angulated on their medial or lateral side, thereby shifting the distribution of load across the tibiofemoral compartments. Medial wedge insoles are higher on the medial side, shifting weight towards the medial tibiofemoral compartment, and are thus applicable for people with lateral compartment tibiofemoral knee OA and valgus knee deformity. Lateral wedge insoles are higher on the lateral side (and may include a subtalar strapping component), shifting weight toward the lateral tibiofemoral compartment, and are applicable for those with medial compartment tibiofemoral OA and varus deformity. Shock-absorbing insoles are made of a material that aims to absorb impact loading during walking. Arch supports are insoles designed to support and realign the foot. 

Rationale 

Very low-quality evidence from a single, small RCT investigating medial wedge insoles found significant benefits of clinically relevant magnitude for pain and function in people with lateral tibiofemoral compartment knee OA and valgus deformity (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). The working group felt that this study provides preliminary evidence that would need to be confirmed in larger trials and, as such, was unable to recommend either for or against medial wedge insoles. Conversely, for lateral wedge insoles, very low-quality evidence from a number of RCTs found no significant benefits for pain, function, quality of life or structural disease progression in people with medial knee OA (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). As there is no RCT data available in people with either knee or hip OA for either shock-absorbing insoles or arch supports, no recommendations about their use can be currently made.

Harms 

There is a low likelihood of adverse effects.

Footwear – Knee

Recommendation

We suggest not offering unloading shoes, minimalist footwear or rocker-sole shoes for people with symptomatic knee OA. However, clinicians may consider advising people to wear footwear with shock-absorbing properties and avoid high-heeled shoes.

Strength of recommendation

Conditional against recommendation

Quality of evidence

Very low
(unloading shoes, minimalist footwear)

Low  (rocker-sole shoes)

What is it? 

A number of footwear styles have been developed and/or marketed for OA and other musculoskeletal conditions. Unloading shoes are walking shoes that contain variable-density midsoles and a lateral wedge insole, designed to reduce medial tibiofemoral compartment knee loads. Minimalist shoes are footwear styles that are flexible, flat and non-heeled, advertised to reflect barefoot walking and develop intrinsic foot muscle strength. Rocker-sole shoes are shoes with a thicker than normal sole and a convex curvature in the sagittal plane, designed to create an unstable platform, thereby encouraging increased muscle activity while walking.

Rationale

While unloading and minimalist shoes reduce medial tibiofemoral compartment knee joint loading,88,89,90 there is limited evidence of very low quality that these shoes offer no additional benefit on pain or clinically relevant effects on function, compared with conventional walking shoes (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). There is limited evidence of low quality that rocker-sole shoes offer no significant benefit on pain or function, compared with conventional walking shoes (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). Clinicians may consider advising people to consider wearing footwear with shock-absorbing properties, and to advise avoidance of high-heeled shoes, given they increase knee joint loads,91 albeit in the absence of RCT data about which individual footwear features are beneficial and/or harmful.

Harms 

There is a low likelihood of adverse effects.

Taping – knee and/or hip

Recommendation

We are unable to recommend either for or against the use of patellar taping for people with knee OA.

Strength of recommendation

Conditional (neutral) recommendation
(patellar taping)

Quality of evidence

Very low

Recommendation

We suggest not offering kinesio taping for people with knee and/or hip OA.

Strength of recommendation

Conditional against recommendation
(kinesio taping)

Quality of evidence

What is it? 

Different forms of taping are available, generally as a self-management strategy. Patellar taping uses rigid tape that aims to create a mechanical realignment of the patella in the trochlear groove in order to reduce pain and improve function. Kinesio taping uses non-rigid tape that is applied in various configurations; it is purported to offer support and stability to muscles and joints, and to stimulate somatosensory receptors.

Rationale 

There is some evidence that patellar taping can immediately change patellar alignment measured on imaging and reduce pain.92,93 However, very low-quality evidence from a single RCT did not find any significant effect of taping when worn continuously for three weeks on pain and function, compared with sham tape in people with knee OA not specifically selected for patellofemoral pain (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). People with specific patellofemoral pain symptoms may benefit from self-application of patellar taping to minimise pain, and enable engagement in physical activity and rehabilitation. A limited number of trials of very low quality and with small sample sizes have evaluated kinesio taping for knee OA. These trials used different configurations of kinesio tape that was reapplied by the clinician after various intervals. There is no trial of kinesio taping for hip OA. The evidence shows no significant benefits of kinesio taping for pain or function (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). 

Harms 

The side effects are minor, and include skin irritation from the tape.

Assistive walking device – Knee and/ or hip

Recommendation

It may be appropriate to offer an assistive walking device (eg cane) for some people with knee and/or hip OA, depending on a person’s preference  and capability.

Strength of recommendation

Conditional for recommendation

Quality of evidence

Low (knee)

Very low (hip

What is it? 

Assistive walking devices include devices such as canes (eg walking sticks), crutches and walkers. As appropriate to the needs to individual users, these can help walking ambulation by reducing lower limb loading, improving stability and assisting movement. They may also help reduce falls risk.

Rationale 

People with knee and/or hip OA often adopt an abnormal gait pattern because of pain, muscle weakness, joint mobility restrictions or other pain conditions. The use of an assistive walking device may be useful to improve gait pattern and posture to normalise musculoskeletal loads. There is low-quality evidence from one trial that the use of a walking aid (eg single point stick) is effective in improving pain and function in people with knee OA (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). The working group felt these data could be reasonably transferred to people with hip OA (very low-quality evidence). Clinicians should assess an individual’s gait pattern to consider the indication for a walking device. Walking devices also can assist with balance problems, and may be indicated for those with an increased risk of falling. It is important that the individual is instructed on how to use the device, how to safely and effectively ambulate with the device, and how to adjust the device. 

Harms 

There are a few adverse events associated with this recommendation.

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