APPLIED SCIENCES

Biodynamics

The Influence of Arch Supports on Knee

Torques Relevant to Knee Osteoarthritis
JASON R. FRANZ, JAY DICHARRY, PATRICK O. RILEY, KEITH JACKSON, ROBERT P. WILDER,
and D. CASEY KERRIGAN
University of Virginia, Department of Physical Medicine and Rehabilitation, Charlottesville, VA

ABSTRACT
FRANZ, J. R., J. DICHARRY, P. O. RILEY, K. JACKSON, R. P. WILDER, and D. C. KERRIGAN. The Influence of Arch Supports
on Knee Torques Relevant to Knee Osteoarthritis. Med. Sci. Sports Exerc., Vol. 40, No. 5, pp. 913–917, 2008. Purpose: Changes in
footwear and foot orthotic devices have been shown to significantly alter knee joint torques thought to be relevant to the progression
if not the development of knee osteoarthritis (OA) in the medial tibiofemoral compartment. The purpose of this study was to determine
if commonly prescribed arch support cushions promote a medial force bias during gait similar to medial-wedged orthotics, thereby
increasing knee varus torque during both walking and running. Methods: Twenty-two healthy, physically active young adults
(age, 29.2 T 5.1 yr) were analyzed at their self-selected walking and running speeds in control shoes with and without arch support
cushions. Three-dimensional motion capture data were collected in synchrony with ground reaction force (GRF) data collected from
an instrumented treadmill. Peak external knee varus torque during walking and running were calculated through a full inverse dy-
namic model and compared. Results: Peak knee varus torque was statistically significantly increased by 6% (0.01 T 0.02 NImI(kgIm)j1)
in late stance during walking and by 4% (0.03 T 0.03 NImI(kgIm)j1) during running with the addition of arch support cushions.
Conclusions: The addition of material under the medial aspect of the foot by way of a flexible arch support promotes a medial force
bias during walking and running, significantly increasing knee varus torque. These findings suggest that discretion be employed with
regard to the prescription of commonly available orthotic insoles like arch support cushions. Key Words: BIOMECHANICS,
ORTHOTICS, KINETICS, GAIT, JOINT TORQUES, FOOTWEAR

K
nee osteoarthritis (OA) develops in approximately
10% of adults over the age of 55 and represents a
major cause of pain and physical disability in the
elderly (8,18). The possibility that different types of foot-
wear contribute to the progression if not the development
of knee OA deserves strong consideration because footwear
is a potentially controllable and easily modifiable factor for
this prevalent and disabling disease. We (14–16) previously
found that typical forms of women`s shoes significantly
exaggerate knee external varus torque, which is thought to
be relevant to the progression if not the development of
Address for correspondence: Jason R. Franz, University of Virginia,
Department of Physical Medicine and Rehabilitation, 545 Ray C. Hunt Dr.,
Suite 240, Box 801004, Charlottesville, VA 22908; E-mail: JRF5N@
virginia.edu.
Submitted for publication July 2007.
Accepted for publication December 2007.
0195-9131/08/4005-0913/0
MEDICINE & SCIENCE IN SPORTS & EXERCISEÒ
Copyright Ó 2008 by the American College of Sports Medicine
DOI: 10.1249/MSS.0b013e3181659c81
knee OA. Specifically, we showed an increase in varus
torque during walking in both wide-based and narrow-based
high-heeled shoes with an average heel height of 2.8 inches
(7.1 cm) (14,16), and in shoes with heels as moderate as
1.5 inches (3.8 cm) (15). This increase implies exaggerated
compressive loading on the medial tibiofemoral compart-
ment (20,27,30), the typical site of knee OA (33). Similarly,
Shakoor et al. showed that even comfortable walking shoes
increase this varus torque by 11.9% as compared with bare-
foot walking in both men and woman with medial compart-
ment OA (29).
Considering the evidence that implicates varus torque in
the progression if not the development of knee OA (1,9–
12,14–17,19,23,29), conservative interventions designed to
reduce medial compartment loading are of great interest.
Previous research has shown the effectiveness of foot or-
thotic devices, specifically of lateral shoe wedges, in reduc-
ing knee varus torque and in lessening pain in patients with
medial compartment knee OA (4,13,17). Conversely, the use
of medial wedges has been found to significantly increase
this torque (28). Previous research evaluating the impact of
foot orthotic devices, hereafter referred to as orthotics, on

913

Copyright @ 2008 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 knee torques is not limited to walking alone. In a study
motivated by running overuse injuries, Mündermann et al.
observed that the addition of a full-length 6-mm medially
posted orthotic increased knee rotational torque and signifi-
cantly delayed peak knee varus torque during running (21).
The observation that changes in footwear and orthotics sig-
nificantly affect knee varus torque suggests that alterations in
foot and ankle kinetics cause biomechanical compensations
at the knee to maintain stability and forward progression
during walking and running. Walking is by far the most
common daily activity causing repetitive force through the
knee`s medial compartment, and running causes a signifi-
cantly greater magnitude of this repetitive force (20,22). Ex-
cessive repetitive loading is believed to be an important
etiological factor in the development of OA (1). In fact, nor-
mal walking and running biomechanics are such that coronal
plane knee torques are varus throughout stance (9,20), poten-
tially explaining why tibiofemoral knee OA begins pre-
dominantly in the medial compartment. Animal data also
support that repetitive knee varus loading leads to degener-
ative changes in the medial compartment of the knee (23).
Although custom-molded orthotics have been proposed
as an effective treatment of running overuse injuries (5,6,
26), the orthotic devices commonly available through re-
tailers typically provide for comfort alone. For example,
arch support cushions are widely prescribed by retailers
based upon claims that they aid in shock absorption, pro-
vide increased stability and support, and maintain proper
foot position during walking and running (Spenco Medical
Corporation, Waco, TX; Shock Doctor, Inc., Plymouth, MN;
Sting Free Technologies Company, Berwyn, PA). However,
APPLIED SCIENCES
it is possible that the addition of material under the me-
dial aspect of the foot by way of a flexible arch support
could promote a medial bias during gait similar to medial-
wedged orthotics, thereby increasing knee varus torque.
Therefore, the purpose of this study was to investigate the
effects of arch support cushions on knee torques relevant
to knee OA. We hypothesized that commonly available
arch supports would, like medial-wedged orthotics, increase
knee varus torque during both walking and running.
METHODS
A total of 22 healthy runners (10 female) were recruited
from the local population (Table 1). The subjects described
their running as recreational, running a minimum of 15
miles each week. Subjects had no history of chronic mus-
culoskeletal pathology and were without a running-related
injury at the time of testing. The experimental protocol was
TABLE 1. Subject characteristics.
Subjects N Age (yr) Height (cm)
Females 10 27.0 T 4.8 168.0 T 8.1
Males 12 30.9 T 5.3 182.1 T 5.8
Combined 22 29.2 T 5.1 175.7 T 9.8
Values presented are means (T standard deviation).
914 Official Journal of the American College of Sports Medicine
Copyright @ 2008 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
FIGURE 1—Full-length arch support cushions.
approved by the UVA institutional review board for health
science research, and written informed consent was ob-
tained from each subject before testing. Subjects were asked
to walk at their comfortable walking speed and to run at
their submaximal pace on an instrumented treadmill under
two conditions: in control running shoes with and without
arch cushion orthotics, the order of which was random-
ized. Randomization was done by alternating the condi-
tions according to the order of the subject`s admission to
the study. Submaximal running pace was defined using a
rate of perceived exertion (RPE) between 6 and 7 on a scale
of 10.
Standardized footwear was provided to all subjects. The
control shoe used in this study was the New Balance 755
(New Balance Athletic Shoe, Inc., Boston, MA). This
model was a neutral shoe with a single-density midsole and
semicurved last. The control shoe was chosen for its neutral
classification and lack of advanced structural elements de-
signed to alter force progression through the shoe. The or-
thotic examined in this study was the Spenco full-length
arch support cushion illustrated in Figure 1 (Spenco Medi-
cal Corporation, Waco, TX). The insole had a full-length
thickness of 4 mm, and an uncompressed arch support
height of 26 mm with a support material durometer of
28 shore c. Orthotic insoles of this type have been shown to
provide arch support and increased shock attenuation
during walking and running (32). Prior to all testing, each
subject completed a 4-min warm-up period at his or her
self-selected walking and running speeds on the treadmill.
Sixteen retro-reflective markers were placed by the same
physical therapist over anatomical landmarks of the pelvis
Mass (kg) Walking Speed (mIsj1) Running Speed (mIsj1)
60.2 T 8.6 1.11 T 0.18 2.82 T 0.24
80.5 T 7.6 1.10 T 0.16 2.96 T 0.38
71.3 T 14.3 1.10 T 0.15 2.90 T 0.33
http://www.acsm-msse.org

FIGURE 2—Knee varus torque during (A) walking and (B) running
plotted over an averaged gait cycle. Effect of arch support cushions
(gray line) vs control shoe (black line). Dottedlines indicate T one
standard deviation. Solid arrows indicate significant difference between
form units. Running data were obtained using the larger
unit. Raw treadmill data were preprocessed using algo-
rithms developed in house and implemented in LabView
before being down sampled and combined with motion
capture data (24,25). The preprocessing algorithms detected
gait cycle events, initial contacts and toe-offs, for each foot
during both walking and running.
Knee joint torque data in the sagittal, coronal, and trans-
verse planes were calculated through a full inverse dynamic
model implemented using Vicon Plug-in Gait (version 2.0).
Joint torques were normalized by body weight and barefoot
height and reported in newton-meters per kilogram-meters.
From each of two 15-s running trials, nine consecutive
cycles of gait were averaged for a total of 18 cycles for both
conditions. During walking, four consecutive cycles from
each of two 15-s trials for both conditions were averaged.
Average curves of knee joint torques were graphed over
the gait cycle (0–100%). Maximum and minimum torque
values at characteristic peaks during stance were obtained
from each subject`s average curves. A secondary examina-
tion was performed of knee torque values in the sagittal and
transverse planes, and of foot progression angle in the trans-
verse plane. Transverse plane foot progression angle was
used to quantify the amount of toe-out during walking and
running. Comparisons between conditions were made using
paired-samples t-tests. Statistical significance for the pri-
mary analysis of knee varus torque was defined at P G 0.05.
Applying a Bonferroni adjustment to all secondary com-
parisons for the use of multiple t-tests six variables during
walking and four during running, statistical significance
was defined at P G 0.005 (0.05/10).

APPLIED SCIENCES
conditions.

and lower extremity. The three dimensional positions of

each marker were captured at 250 Hz using a 10-camera
Vicon 624 motion analysis system (Vicon Peak, Lake
Forest, CA). Synchronized ground reaction force data were
captured at 1000 Hz using an AMTI (AMTI, Watertown
MA) instrumented treadmill described in detail elsewhere
(24,25). The treadmill consists of two side-by-side force
platform units (330 mm  1395 mm) positioned behind a
larger unit (663 mm  2750 mm) providing a continuous
treadmill surface for both walking and running. Walking
data were obtained by having the subject walk with each
foot striking one of the side-by-side treadmill force plat-
RESULTS
Graphs of the group mean coronal plane knee torque in
control shoes with and without arch support cushions are
illustrated in Figure 2A (walking) and 2B (running) over an
averaged gait cycle. Peak knee varus torque was signifi-
cantly greater for arch support cushions in stance during
running and in late stance during walking (Table 2). No
significant change was observed in the early stance peak of
knee varus torque during walking.
Of all exploratory parameters included in the secondary
analysis, only peak internal rotation torque during running

TABLE 2. Knee torque parameters.

Walking Running
Control Shoe Arch Cushion Mean Difference (CI) P* Control Shoe Arch Cushion Mean Difference (CI) P*
Primary parameters
Peak varus torque, early stance 0.31 T 0.06 0.31 T 0.07 0.01 (T 0.01) 0.22 — — — —
Peak varus torque, late stance 0.20 T 0.06 0.21 T 0.07 0.01 (T 0.01) 0.04 — — — —
Peak varus torque — — — — 0.73 T 0.18 0.76 T 0.18 0.03 (T 0.01) G 0.01
Secondary parameters
Peak external rotation torque 0.06 T 0.03 0.07 T 0.04 0.01 (T 0.02) 0.491 — — — —
Peak internal rotation torque 0.12 T 0.03 0.12 T 0.04 0.003 (TT 0.02) 0.709 0.24 T 0.07 0.26 T 0.08 0.02 (T 0.01) G 0.001
Mean (T standard deviation) values of select knee torque parameters normalized to body mass and barefoot height (NImI(kgIm)j1). All comparisons include 95% confidence intervals
(CI). * P G 0.05 significant for primary parameters; applying a Bonferroni adjustment for multiple tests, P G 0.005 significant for secondary parameters.

KNEE TORQUE AND ARCH SUPPORTS Medicine & Science in Sports & Exercised 915

Copyright @ 2008 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 was significantly greater for arch support cushions (Table 2).
In contrast to the changes in knee varus and internal rotation
torques induced by arch support cushions, no significant
effects on sagittal plane knee torque were observed during
either walking or running. Furthermore, there were no sig-
nificant changes in transverse plane foot progression angle
during walking (control: 2.7 T 3.7-; arch cushions: 1.9 T
3.5-, P = 0.017) or running (control: 5.4 T 4.7-; arch cush-
ions: 5.0 T 4.7-, P = 0.016), indicating no change in toe-out
angle between conditions.
DISCUSSION
As hypothesized, the addition of arch support cushions
significantly increased knee varus torque during both walk-
ing and running. Peak knee varus torque during running was
increased by a magnitude of 4% (0.03 T 0.03 NImI(kgIm)j1)
compared with the control shoe alone. This peak value was
increased by 6% (0.01 T 0.02 NImI(kgIm)j1) in late stance
during walking. The increases found during both walking
and running were noticeably consistent between conditions,
and indicate that arch support cushions exaggerate com-
pressive loading on the medial tibiofemoral compartment.
In prior studies assessing the role of footwear on knee varus
torque during walking, we reported 23% and 26% increases
in both early and late stance caused by high-heeled shoes
(2.8-inch height), and a 14% increase in late stance caused
by moderate heels (1.5-inch height). During running,
Williams et al. showed that aggressively inverted (15–25-)
graphite orthotics significantly increase knee varus torque
by as much as 27% (31).The present study addressed a more
APPLIED SCIENCES
subtle change in footwear. Consequently, the smaller mag-
nitude increases in knee varus torque observed for arch
support cushions were not unanticipated, and are still clini-
cally notable. Given that lateral-wedged orthotics are often
prescribed for patients with medial compartment knee OA,
we previously showed that a 5- lateral shoe wedge reduces
knee varus torque by a significant 5% and 7% in early and
late stance, respectively (17). Similarly, Crenshaw et al.
found in subjects with no knee OA that a lateral shoe wedge
reduces knee varus torque by approximately 7% (4). The
amount of change observed in this study is likely to be
clinically significant, given that changes of similar magni-
tude for lateral-wedged orthotics during walking have been
associated with clinical improvements (13). Particularly
so during running, for which medial compartment loading
is of a significantly greater magnitude than that during
walking, the 4% increase in knee varus torque is of extreme
clinical relevance.
Despite results presented by Baker et al. that show lim-
ited to no reduction in knee pain in patients with medial
knee OA when treated with lateral wedged orthotics, the
clinical implications of the present findings cannot be dis-
missed (2). Although the wedged orthotics Baker et al.
investigated were not associated with a change in symptom-
atic presentation, the same orthotics did have a significant
916 Official Journal of the American College of Sports Medicine
Copyright @ 2008 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
effect on knee varus torque. Additionally, while research
contends the connection between knee varus torque and
knee OA, given that varus torque is related to coronal
plane knee alignment, it is important to note that recent
research has questioned coronal plane static knee align-
ment as a predictor of incident medial compartmental knee
OA (11). However, Hunter et al. support that static align-
ment be used as a marker of disease progression, and
concede that malalignment measures provide no impression
of the causative nature of increased knee varus torque
measured dynamically during gait on the development of
knee OA.
Increasing toe-out angle during walking decreases the
moment arm of the coronal plane knee torque, and has been
proposed as a possible mechanism of knee pain relief (3).
A complete assessment of the effects of footwear on knee
varus torque, then, must consider a decreased toe-out angle
as a possible mechanism for any observed increase in varus
torque. The finding that no change in foot external rota-
tion during either walking or running resulted for arch sup-
port cushions eliminates the possibility that the increase
in knee varus torque was the consequence of a decrease in
toe-out angle.
While the methods used in this study are considered to be
the most technologically advanced noninvasive techniques
available to assess the biomechanics of walking and run-
ning, a limitation of our study, and of noninvasive gait
analysis in general, is that we must infer rather than directly
measure joint contact forces from measured net joint
torques. Biomechanical modeling provides support for this
inference, showing that differences in net knee varus
torques are the major determinants of differences in medial
and lateral tibiofemoral compartment contact forces (27).
Furthermore, while providing subjects with standardized
footwear allowed us to more purely evaluate the effect of
arch support cushions alone, we recognize that in studying
the effects of footwear on the mechanics of running, not
accounting for functional differences in subject-specific foot
mechanics prevents characterizing these findings with
regard to particular foot types. Finally, research has shown
that the effects of shoe interventions on knee varus torque
are enhanced in subjects with greater peak knee varus
torque prior to intervention (7). The healthy, physically ac-
tive population assessed in this study presented with a
normal range of knee varus torques, and, as such, the ef-
fects of arch support cushions on patients diagnosed with
knee OA or on those with high knee varus torques could be
much greater.
As a relationship is elucidated between footwear and
knee varus torque, future epidemiologic studies which eval-
uate the effect of footwear on the predisposition for knee
OA become ever more important. In addition, with the
popularity of running as a convenient method of exercise,
and given the high magnitude of repetitive lower-extremity
loading involved, discretion must be employed with regard
to the prescription of orthotic insoles. Furthermore, it is
http://www.acsm-msse.org
important to rationalize the impact of over-the-counter in-
serts on clinical care. The possibility that even subtle changes
in footwear influence factors related to the predisposition
for knee OA must instigate further biomechanical study in
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