Treatment for Genu Varum of the Knee

We were recently asked about treatment methods for genu varum of the knee, so we thought we would do a little literature review on the subject. We believe the request was directed towards an exercise-based approach. Unfortunately, we were unable to find much evidence regarding treating genu varum with exercise. With genu varum, the line of gravity runs farther medial to the knee than normal, putting increased stress on the medial compartment of the knee. This puts the individual at risk for developing OA. Due to the increased risk in developing unicompartmental osteoarthritis, it is desireable for the patient to restore normal alignment in order to delay the need of having a Total Knee Replacement. There are several methods of managing genu varum right now, which we will briefly review.

The traditional method of treating genu varum involved an osteotomy of the proximal tibia with the goal of restoring normal knee alignment. Goutallier et al found a desirable range for realignment: 3-6 degrees of valgus. At < 3 degrees of valgus, individuals developed recurrent genu varus, while at > 6 degrees of valgus, individuals developed deterioration of the lateral tibiofemoral joint. A newer method that is currently being developed is known as the llizarov method (Park et al, 2012). During the osteotomy, the surgeon also places an external fixator on the patient. This allows gradual adjustments to be made to the knee alignment during the 24 weeks it remained on. While the method was able to restore normal alignment to the knee, there was a high level of complications to the patients.

An alternative method of treating genu varum includes bracing and heel wedges. The brace under discussion is called a compartmental unloader. An individual with genu varum would want a valgus orthosis. It functions by either having a valgus stress built into it or the ability to develop the stress while donning the orthosis. With the valgus stress placed on the knee, the natural varus moment decreases, lowering the stress on the medial tibiofemoral joint. This hopefully delays the need for a Total Knee Replacement. Both a compartmental unloader and a lateral heel wedge have been shown to be effective as short-term pain relief methods (Brouwer et al, 2005). This can play a role in at least delaying the need for a Total Knee Replacement (Wilson et al, 2011). 

Additionally, we must consider what mechanical issues may be predisposing a patient to genu varum alignment. It is well documented that abnormal strength of the hip muscles can alter knee mechanics. Strengthening the hip external rotators and hip extensors, for example, is a key component in the rehabilitation of patients with patellofemoral pain syndrome. Zeni and Synder-Mackler discuss the importance of strengthening the contralateral limb following a total knee replacement. They also report that decreasing body mass may have an impact on forces across the knee following replacement. Other authors discuss quadriceps strength as an important measurement to consider when viewing the success of a total knee replacement. There are examples across the literature that stress the importance of a lower limb strengthening and endurance program to decrease stresses at the knee to help prolong total joint replacements. While there may not be direct evidence linking hip strengthening programs to decreasing genu varum alignment, hip strength is definitely a measure to address when working with this population. 

Again, unfortunately, we were unable to find much evidence on exercise as a treatment for genu varum. What about you, what has your research and experience shown in addressing the condition?

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References:
Brouwer RW, Jakma TS, Verhagen AP, Verhaar JA, Bierma-Zeinstra SM. (2005). Braces and orthoses for treating osteoarthritis of the knee. Cochrane Database Syst Rev. ;(1):CD004020. Web. 28 Jan 2013.

Goutallier D, Hernigou P, Medevielle D, Debeyre J. (1986). Outcome at more than 10 years of 93 tibial osteotomies for internal arthritis in genu varum (or the predominant influence of the frontal angular correction. Rev Chir Orthop Reparatrice Appar Mot.;72(2):101-13. Web. 28 Jan 2013.

Park YE, Song SH, Kwon HN, Refai MA, Park KW, Song HR. (2012). Gradual correction of idiopathic genu varum deformity using the Ilizarov technique. Knee Surg Sports Traumatol Arthrosc. Web. 28 Jan 2013.

Wilson B, Rankin H, Barnes CL. (2011). Long-term results of an unloader brace in patients with unicompartmental knee osteoarthritis. Orthopedics. ;34(8):e334-7. Web. 28 Jan 2013.

Zeni J, Synder-Mackler L. (2010). Early post-operative measures predict 1- and 2- year outcomes after unilateral total knee arthroplasty: importance of contralateral limb strength. Journal of the American Physical Therapy Association.; 90(1): 43-54. Web. 29 Jan 2013.