# Pronation causing medial knee problems. Which shoes, wedges, insoles?



## ari (Jan 25, 2005)

Hi all,

Before I fill in all the details, here's a quick summary of my question: I'm looking for new shoes to replace my current, ill-fitting ones, as well as to correct my severe over-pronation/flat feet, which have been the cause of some medial knee problems. I've heard that the Specialized Body Geometry shoes are excellent for this -- but I know that similar effects can be had with other shoes by using various insoles, wedges, etc. Have any of you had similar problems, and can you share your footwear experiences and recommendations?

Now, some background: I've been experiencing some medial knee pain when cycling for the past several months. I finally saw an orthopedist, and after an MRI confirmed that it was simply an overuse problem (and not a meniscus tear, as had been feared), he sent me to a physical therapist. The physical therapist was able to determine that my knee pain was caused by over-pronation, which makes my knees bow inwards towards the top tube when pedaling. Along with my PT program (exercises, stretching, ice, anti-inflammatories), she suggested that I get new cycling shoes and/or insoles to correct my foot position by supporting my arch and/or canting the feet outward.

My current Sidis are just slightly too large, which exacerbates the lack-of-support problem, so I'm on the hunt for new shoes. I've heard excellent things about the Specialized Body Geometry shoes, which are designed to correct pronation. Indeed, when I tried these on, my feet seemed noticeably better aligned. I also loved the fit of the Shimano R215 (much better than my Sidis, slightly better than the Specialized), but I noticed my feet pronating much more than in the Specializeds. I'm curious whether simply getting the Specialized shoes would be the best solution, or if I should consider some other combination of shoes, orthotics, and wedges. Would there be some reason to choose the BG shoes over, say, the Shimanos with insoles and/or a LeWedge -- or vice versa?

Thanks in advance for your advice!

Cheers,
Ari

P.S. I know someone is bound to mention this, but I *really* don't want to get Rocket 7s. I'd be willing to spend a mint on custom shoes *only* as a last resort -- I'd like to see if I can solve the problem with off-the-shelf products first.

P.P.S. I should also mention that my bike position (saddle height and fore/aft, cleat alignment, etc.) are excellent, as evaluated by a couple of fit professionals. Given the input of my PT, as well as feedback from my own body, I'm almost 100% certain that the problem stems from over-pronation. I say this because I know someone will suggest that I raise my saddle or rotate my cleats -- and believe me, I've tried it.


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## SilasCL (Jun 14, 2004)

I'm not much of a shoe junkie, so I can't really help you with which ones will offer him more support. But my experience has been that I pronated, had some knee pain, ended up getting custom orthotics, and have never had any problems again. I use some 3-4 year old northwaves, nothing too fancy, and the orthotics have made all the difference. They are expensive though. I don't know what the options are in your area, but they will likely be 100-200, maybe more depending on the level of fitting they do.

Silas


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## SkiRacer55 (Apr 29, 2005)

*I also have knee problems...*

..somewhat like yours. I'm a 57 year old ski racer, so I've never had to have my knees cut, but they're pretty wobbly. The Specialized BG shoes were designed by Andy Pruitt, and I think he knows what he's doing, because there's more than just a Varus wedge in the design. Some people don't like them, but BGs work for me...and I think my knees are a little solider for using them. I just got the '05 Comps, and they work just fine:

http://www.specialized.com/bc/SBCEqProduct.jsp?spid=12799

Bottom line? I'd get a pair and see how how you feel...then, if you're still having problems, you might be looking at more sophisticated and $$$ intensive stuff (for example, Q factor, which you can fix with Look pedals...)


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## NFields (Jan 9, 2005)

Your PT should also offer an insole/orthotics program as mine does. It is very common and should be part of your overall assessment/treatment plan provided by them.
Thanks,
NFields


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## bsdc (Feb 15, 2002)

Shoes and wedges won't correct pronation problems of the foot. For that, you need orthotics. Don't waste a bunch of money on custom orthotics. Get some slim over the counter orthotics. Fit your new cycling shoes with the orthotics. Actually, your Sidis may still work. Orthotics will require you to have a slightly larger shoe. I find almost every shoe fits like a glove when I have my orthotics in them. I recommend Slim Sport orthotics from Sole at www.yoursole.com. That's what I wear and what I sell in my office.


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## ari (Jan 25, 2005)

SilasCL said:


> But my experience has been that I pronated, had some knee pain, ended up getting custom orthotics, and have never had any problems again.


Were your orthotics "cycling specific," or were they just general orthotics? My main concern is that I'll drop a bunch of cash on custom orthotics, only to find that they're more tailored for running/walking biomechanics than cycling biomechanics, and that they won't do any good. I tend to trust the brains behind Specialized Body Geometry as knowing a thing or two about cycling biomechanics, so hopefully that'll solve the problem without going the expensive custom route. If not, I'm definitely going for the orthotics. Thanks!

Cheers,
Ari


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## ari (Jan 25, 2005)

bsdc said:


> Shoes and wedges won't correct pronation problems of the foot. For that, you need orthotics. Don't waste a bunch of money on custom orthotics. Get some slim over the counter orthotics. Fit your new cycling shoes with the orthotics. Actually, your Sidis may still work. Orthotics will require you to have a slightly larger shoe. I find almost every shoe fits like a glove when I have my orthotics in them. I recommend Slim Sport orthotics from Sole at www.yoursole.com. That's what I wear and what I sell in my office.


Thanks so much for the advice! I understand that insoles and footbeds are key, and from what I've heard, Specialized has 3 different footbed options depending on the height of one's arch. I'm hoping this "semi-custom" approach will make a separate orthotic unnecessary -- otherwise, I'll definitely check out the Sole orthotics.

Thanks again,
Ari


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## SilasCL (Jun 14, 2004)

ari said:


> Were your orthotics "cycling specific," or were they just general orthotics? My main concern is that I'll drop a bunch of cash on custom orthotics, only to find that they're more tailored for running/walking biomechanics than cycling biomechanics, and that they won't do any good. I tend to trust the brains behind Specialized Body Geometry as knowing a thing or two about cycling biomechanics, so hopefully that'll solve the problem without going the expensive custom route. If not, I'm definitely going for the orthotics. Thanks!
> 
> Cheers,
> Ari


They were just general orthotics. I use them for walking, running, and cycling. While the mechanics of running or cycling are different, they both demand alignment with the foot and knee, so general orthotics should be okay. Look for someone who's using good materials to make a thin, light orthotic. Mine is heavy, and tends to trap heat and moisture a bit.

BSDC knows his stuff though, so if he thinks off the shelf orthotics will do the job, he's probably right.

Silas


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## bsdc (Feb 15, 2002)

I have to say, I have not taken a close look at Specializes new shoes. My first thought is varus wedging of the forefoot doesn't sound like a good idea. The forefoot isn't the problem. Wedging the forefoot could cause other problems. The problem is usually in the medial arch. I'd like to see the medial arch in Specializes new shoe. I have found EXTREMELY few shoe companies provide significant medial arch support. All that said, I'm open to being wrong. I look forward to what you have to say once you buy the shoes and try them out for a while. I plan to go look at the new shoes sometime soon. Keep us posted.


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## ari (Jan 25, 2005)

*Specialized shoe update*

Well, I haven't bought the Specialized shoes yet, but I have found out a bit more information about them. I was waiting for the 2006 models, because I'd heard about the 3 different footbed options being introduced. However, I found out (from my dealer's Specialized brochure) that the 2006 shoes all have the <i>same</i> footbed, which appears to be the same as the 2005 shoes. Specialized is also introducing a line of "high performance" footbeds, in 3 foot profiles (low arch, medium arch, high arch), along with wedge inserts that can be used to increase or decrease the effect of the built-in varus wedge. However, these new footbeds and inserts are <i>accessories</i>, not anything that's included with or built into the shoes.

So basically, there's nothing super-new about the shoes -- Specialized is just getting into the after-market insole market, as well as responding to people who wish the shoes had more/less wedging. (Of course, one could probably put them in other brands of shoes, as well.)

My revised plan is to see how various insoles fit in my current shoes (the slightly-too-big Sidis), and how their support compares to the stock Specialized insoles. As Strong Bad says, "Stay tuned for partial excitement!"

Cheers,
Ari


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## Mr_Mojo (Mar 14, 2005)

fwiw, I'm a PT...

I'd recommend getting custom "rigid" orthotics and then take them with you to try on cycling shoes...they may not work with your foot and the Specialized. Orthotics will run you +/- $250 (check with your health insurance--though most don't cover it) but the benefit is they will last you many years. I'm still using ones that were made for me in 1989. If you want to use them for running or everyday use you may want "semi-rigid".

You can try over the counter insoles...look for the "superfeet" brand, at $30 or so. Don't get something with a huge arch.

Other tips: 

Try the Lemond "wedges" to cant the shoe on the pedal to take some pronation stress off the knee. 

Move your cleats to the outside of the shoes to bring you feet in closer to the crank.

have your PT assess your patellar alignment and IT band tightness


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## bsdc (Feb 15, 2002)

ari said:


> My revised plan is to see how various insoles fit in my current shoes (the slightly-too-big Sidis), and how their support compares to the stock Specialized insoles. As Strong Bad says, "Stay tuned for partial excitement!"


Again, I'll encourage you to check out www.yoursole.com. You can order their orthotics online for about $40. They are a semi-rigid orthotic that can easily be custom fit your feet at home in about 4 minutes. They use a heat moldable material called EVA. You heat them in the oven at 200 degrees for 2 minutes, then slip them into your shoe and stand on them for 2 minutes. It seemed too simple to me at first, but it really works. I have fitted hundreds of orthotics on patients. I've worn dozens of different brands. Sole orthotics are best I've ever come across at any price. I love them because they are so cheap, I don't hesitate to recommend them to my patients. I personally like them so much I've thrown all my old orthotics away. 

I never recommend rigid orthotics. Feet aren't rigid structures. The arch should be strongly supported but allowed to move.


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## ari (Jan 25, 2005)

bsdc said:


> Again, I'll encourage you to check out www.yoursole.com. You can order their orthotics online for about $40.


Thanks again for the recommendation, bsdc. I'm definitely going to check those out, since many people seem to have such good things to say about them. (Plus, you clearly know what you're talking about.) The "Slim Sport" version seems impossible to find at any of my local stores (most have the standard, thick version), so I may have to order online.

Cheers,
Ari


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## Mr_Mojo (Mar 14, 2005)

bsdc said:


> Again, I'll encourage you to check out www.yoursole.com. You can order their orthotics online for about $40. They are a semi-rigid orthotic that can easily be custom fit your feet at home in about 4 minutes. They use a heat moldable material called EVA. You heat them in the oven at 200 degrees for 2 minutes, then slip them into your shoe and stand on them for 2 minutes. It seemed too simple to me at first, but it really works. I have fitted hundreds of orthotics on patients. I've worn dozens of different brands. Sole orthotics are best I've ever come across at any price. I love them because they are so cheap, I don't hesitate to recommend them to my patients. I personally like them so much I've thrown all my old orthotics away.
> 
> I never recommend rigid orthotics. Feet aren't rigid structures. The arch should be strongly supported but allowed to move.


How could these possibly help correct a pronation problem? If you just heat them and stand on them till they harden then you have a perfect impression of a pronated foot...with no correction. You need to find someone who can get you into a "subtalar neutral" postion and then cast you there. Also they should look at you mid/forefoot orientation and make the needed metatarsal posting. It's not rocket science, but it is tricky to get right.

Cycling is the only sport that I recommend and use rigid orthotics...if you think of the dymanics of the foot/ankle and the super stiff carbon soles, these work pretty well.


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## bsdc (Feb 15, 2002)

ari said:


> Thanks again for the recommendation, bsdc. I'm definitely going to check those out, since many people seem to have such good things to say about them. (Plus, you clearly know what you're talking about.) The "Slim Sport" version seems impossible to find at any of my local stores (most have the standard, thick version), so I may have to order online.
> 
> Cheers,
> Ari


I don't carry the Slim Sport, either. Most people don't need it, but I order it for those that do. I only carry the Ultra Softec. I like it because it has the most padding, which makes it more comfortable.

I recommended the Slim Sport for you because it takes up the least amount of room and cycling shoes fit relatively tight. You said your Sidis were a little big, so the standard Soles may fit in your cycling shoes. If they don't, I still recommend getting a pair for you regular shoes. If you have flat feet, you need orthotics for walking as well as cycling. 

I'm sorry if I've been a little too helpful, but I'm a big proponent of orthotics. Your feet are the foundation of you body. Poor foot biomechanics can lead to foot, ankle, knee, hip, pelvis and low back problems.


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## Kevin Leonhardt (Aug 5, 2004)

bsdc,

When molding the orthotics do you remove the cleats from your shoes, or just stand in them with the cleats attached?

Kevin


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## bsdc (Feb 15, 2002)

Kevin Leonhardt said:


> bsdc,
> 
> When molding the orthotics do you remove the cleats from your shoes, or just stand in them with the cleats attached?
> 
> Kevin


First off, you may not have to mold them since you won't be baring a lot of weight throught the arch when you ride. I would try them without molding them first. If you need to mold them, do it in a pair of tennis shoes, then transfer them to your cycling shoes. Because cycling shoes are generally smaller than your regular shoes, you may need to trim them or do a second, non-weight baring molding in you cycling shoes to get them to snug up inside the shoe.


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## bsdc (Feb 15, 2002)

Mr_Mojo said:


> How could these possibly help correct a pronation problem? If you just heat them and stand on them till they harden then you have a perfect impression of a pronated foot...with no correction. You need to find someone who can get you into a "subtalar neutral" postion and then cast you there. Also they should look at you mid/forefoot orientation and make the needed metatarsal posting. It's not rocket science, but it is tricky to get right.
> 
> Cycling is the only sport that I recommend and use rigid orthotics...if you think of the dymanics of the foot/ankle and the super stiff carbon soles, these work pretty well.


Good question. That's exactly what I thought. If you heat them and step in them you're just going to get a mold of your bad foot, right? 

When I got my first pair I didn't mold them. After walking around in them the first day my medial arch hurt mildly and my lateral arch hurt moderately. It felt like the arch was too big, so I decided to go ahead and try heat molding them. After heat molding them, they felt great. The change when they molded was very small. What it did was take out the pressure points so it fit my foot like a glove.

Also, prior to getting the Sole orthotics, I was having some pain on my metatarsal heads for quite a few weeks. It came on after a very long ride. I tried all my orthotics, taping, gel pads, metataral pads, etc. It wasn't until I got the Sole orthotics that my metatarsal pain went away. All the other orthotics I owned provided some medial and lateral arch support, but not as much as the Sole orthotics do. Surprisingly, Sole orthotics provide more correction than any other orthotic I've seen

Here's what I think about "subtalar neutral":
http://www.biomech.com/db_area/archives/2000/0008orthoses.63-74.bio-.html

I can see that cycling shoes wouldn't be a bad place to use rigid orthotics since the foot isn't going through the gait cycle. The problem is most rigid orthotics are 3/4 length so they slip around and are custom so they cost $250 or more. 

Don't get me wrong. Some people may benefit from custom orthotics. Some may do better in rigid orthotics cast in "subtalar neutral". But I have found that I get great results with most of my patients for FAR less money with Sole orthotics. I encourage you to try them.


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## ari (Jan 25, 2005)

bsdc said:


> I recommended the Slim Sport for you because it takes up the least amount of room and cycling shoes fit relatively tight. You said your Sidis were a little big, so the standard Soles may fit in your cycling shoes. If they don't, I still recommend getting a pair for you regular shoes. If you have flat feet, you need orthotics for walking as well as cycling.


Well, I finally did my completely non-scientific comparison test today. I tried my Sidis with various insoles (incl. Superfeet -- sorry, bsdc, couldn't track down a pair of Soles), and compared them against the Specialized Pro Carbon shoes. Orthotics were a definite improvement over the flimsy Sidi insoles, and my shoes fit better and tighter than before. However, while all the orthotics I tried gave me some nice, firm support in the arch region, I <i>didn't</i> feel like they were putting my feet and knees into a more neutral/supinated position than they were before.

The Specialized shoes, however, did a much better job at this, which I'd guess is probably due to the varus wedge. The Specialized insoles also have good arch support, much more substantial than the stock Sidis, though not quite as much as the after-market insoles. I probably could have cobbled together (pun intended) a similar effect by using both orthotics <i>and</i> a LeWedge with the Sidis, but I decided that having the right shoes out-of-the-box would probably be a better solution, so I got the Specialized shoes. If my problem included foot pain, I might have made a different decision, but my knees are really the only thing that hurts.

Thanks to everyone for your input. I'll follow up with this thread once I've put some miles in, in case anyone is curious.

Cheers,
Ari


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## bsdc (Feb 15, 2002)

Very good. I'm glad you've found a solution you're happy with.


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## ari (Jan 25, 2005)

*Update*

So, I've been riding for about a week in the Specialized Pro Carbon shoes. I noticed a definite improvement in my medial knee soreness, as well as how my knee was tracking on the bike, but it still wasn't quite as good as it could be. My ankle kept wanting to turn inwards, bringing my knee it towards the top tube, and the Specialized insoles weren't providing quite enough support to prevent this. I replaced the insoles with Superfeet and my knees are much happier, so far -- they're finally going straight up and down when I pedal. Thanks again, everyone!

Cheers,
Ari


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