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recommendations and their supporting rationales will be hosted on www.OrthoGuidelines.org. Selected clinical practice guidelines are disseminated by webinar, an Online Module for the Orthopaedic Knowledge Online website, Radio Media Tours, Media Briefings, and by distributing them at relevant Continuing Medical Education (CME) courses and at the AAOS Resource Center. RECOMMENDATIONS Lateral Wedge Insoles Lateral wedge insoles are not recommended for patients with knee osteoarthritis. Strength of Recommendation: Strong Evidence from two or more “High” quality studies with consistent findings for recommending for or against the intervention. Also requires no reasons to downgrade from the EtD framework. Rationale Although lateral heel wedges had historical support for their use in knee arthritis, contemporary studies have not shown a reliable improvement in pain relief and no contemporary studies have shown sufficient functional improvement for patients suffering from knee arthritis to recommend using lateral wedge insoles. Lateral heel wedges can be prepared as an insert for the heel alone, or included in the heel of an independent arch support (i.e. lateral heel wedge arch support of LWAS) or built into shoe itself (as was used by Hinman et al 2016). In the arthritic knee, medial compartment compression forces are commonly increased, especially in the knee with varus tibiofemoral alignment. The knee adduction moment can be calculated by gait analysis. The lateral wedge is thought to change the knee adduction moment thus relieving medial compartment pressure, hence relieving arthritic pain. Our literature review screening culled several papers for analysis. Baker and Goggins 2007 was a highquality study finding no important differences between insole and wedged insole. 90 patients were randomized to one treatment for 6 weeks followed by a 4-week washout period and then the opposite treatment. There were no major differences in pain during either phase of the study. More musculoskeletal symptoms and more blisters occurred with neutral insoles. No patient falls were attributed to the treatment alternatives. Felson and Parke 2019 prescreened patients to eliminate those with patellofemoral OA and biomechanical non-responders. Lateral wedge insoles reduced knee pain, but the effect of treatment was small and was considered likely of clinical significance in only a minority of patients. 21 of 83 of patients did not show sufficient biomechanical correction. Only 28% of patients in the active phase of treatment had minimally important improvement whereas 22% of patients wearing neutral insoles reached the same level of improvement. 2 patients stopped treatment while wearing lateral wedge insoles (calf pain at night and increased knee pain) and 2 stopped while wearing neutral insoles (toe blister and increased knee pain). They also looked at volume of arthritic bone marrow lesions (BML) found by MRI and saw no significant difference in BML change between study and control groups. In Bennell 2011, 89 patients with mild to moderate knee arthritis completed follow up with lateral insoles worn daily for 12 months. 90 patients completed follow up as the control group wearing neutral insoles. Pain relief after 12 months showed no significant difference between the groups. In Hsieh 2016, 90 patients with Kellgren-Lawrence Grade 2 or higher radiographic changes were randomized to either a rigid insole with lateral wedge arch support (LWAS) or a soft insole with lateral wedge.
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