Healthcare Professionals:The information in this booklet is intended for the sole use of healthcare professionals trained in foot orthotic therapy. As prescription protocols vary widely depending on discipline and training, the information provided herein should not be considered a definitive statement on the use of orthotic devices in clinical practice, but rather an illustration of therapy using the Quickthotics® CIS. Prescribers should assemble Quickthotics® Insole based on their own understanding of prescription protocols for foot orthotic devices. Nothing in this booklet shall be a substitute for professional medical advice, diagnosis or treatment.

Patients:Intended wearers must consult with a registered healthcare professional before using the Quickthotics® CIS. Never disregard professional medical advice, or delay seeking it based on something you have read in this booklet. The advice given to you by your healthcare professional supersedes all and any advice offered herein.

®

Component Insole System (CIS) A quick, cost-effective, customizable, chair-side orthotic insole to address the mechanical etiologies of the most common musculoskeletal pathologies of the lower limb.

QUICKTHOTICS® | 2

Abbreviations used in this booklet:

BME Biomechanical examination LLD Limp length discrepancy

CIS Component insole system MPCT Medial plantar calcaneal tuberosity

FHL Functional hallux limitus MTPJ Metatarsophalangeal joint

FR First ray PFPS Patello-femoral pain syndrome

GRF Ground reaction force PIPJ Proximal interphalangeal joint

HAV Hallux abducto-valgus PIPJH Plantar interphalangeal joint hallux

IPK Intractable plantar keratoma PMTPJ Plantar metatarsophlangeal joint

ITB Ilio-tibial band

5 thru 8 womens

mens

U.K.

Europe

1 thru 4 9 thru 12 13 thru 16

4 thru 7 8 thru 11 12 thru 15

4 — 612.5 — 3 7 — 10 11 — 14

36 — 4031 — 35 40 — 45 45 — 50

XL

M14/W15

W16M15

M12/W13

M13/W14

L

W12M11

M10/W11

M8/W9

M9/W10

M

W8M7

M6/W7

M4/W5

M5/W6

S

W4

W3

W1

W2

QUICKTHOTICS® | 3

Anatomy of Quickthotics® Component Insole System (CIS) 5

The 5-Minute Quickthotics® CIS BME 6

Spenco® Quickthotics® CIS Pathology Specific Prescription Guidelines: 10

Common Plantar Forefoot Lesions

1st PMTPJ pain or lesion. 10

2nd PMTPJ pain or lesion. 11

5th PMTPJ pain or lesion. 12

Hallux PIPJ pain or lesion. 13

Common Musculoskeletal Pathologies of the Foot and Ankle

1st MTPJ pain. 14

Plantar fasciitis. 15

Plantar calcaneal bursitis. 16

Sinus tarsi syndrome. 17

Chronic lateral ankle instability. 18

Achilles tendonitis. 19

Common Musculoskeletal Pathologies of the Lower-LImb

Tibialis posterior tendonitis. 20

Peroneal tendonitis. 21

Patello-femoral pain syndrome. 22

Pes anserinus friction syndrome or bursitis. 23

Greater trochanteric and ilio-tibial band friction syndrome at the knee. 24

Gait related low-back pain. 25

References 27

Appendix – Quickthotics® CIS Biomechanical Examination Form 28

Table of Contents

QUICKTHOTICS® | 4

Anatomy of the QUICKTHOTICS® CIS Insole [1] Spenco® TOTALSUPPORT® InsolesThe full-length, medium density EVA (55 Asker C) insoles incorporate Spenco’s proprietary TOTALSUPPORT® Technology—the combination of a deep heel cup, a medial and lateral longitudinal arch support, plus a 2-4 metatarsal pad. Pre-molded into the inferior aspect of each insole is a 2.5mm deep bi-directional 1st MTPJ/FR cut-out and a calcaneal dell. The TOTALSUPPORT® Design means that even without modification, QUICKTHOTICS® Insoles may be effective in the management of the mechanical etiologies of a number of common musculoskeletal pathologies of the lower-limb, including: Metatarsalgia, Plantar fasciitis, Tibialis anterior and posterior tendinitis, Sinus tarsitis, Pes anserinus affections, Ilio-tibial band friction syndrome at the hip and knee, Patello-femoral pain syndrome, and Gait related low-back pain.

[2] 1st Metatarsal Head PlugsQUICKTHOTICS® Insoles incorporate 1st MTPJ/FR cut-outs filled with easy to remove and replace self-adhesive, 57 Asker C EVA plugs, which allow the insoles to be modified in seconds to off-load the 1st metatarsal head.

[3] Central Heel PlugsQUICKTHOTICS® Insoles incorporate a 2.5mm calcaneal dell filled with easy to remove and replace, self-adhesive, 47 Asker C EVA plugs, which allow the insoles to be modified in seconds to off-load the central heel area and to reduce the insole thickness beneath the heel.

[4] [5] [6] Interchangable Arch SupportsThe choice of flexible, semi-flexible, and rigid self-adhesive arch supports allows the midfoot section of QUICKTHOTICS® Insoles to be stiffened as a prescription variance. Interchangeable arch supports allow the stiffness of the insoles to be tried and tested to patient tolerance during the early treatment period.

[7] Forefoot Valgus Wedges (Posts)75 Asker C EVA forefoot valgus wedges are used to create a pronation moment around the midfoot to: 1) “Stabilize” the forefoot against the rearfoot, 2) Reduce mid-foot supination moments, 3) Offload the 1st metatarsal head by increasing GRF beneath the lateral aspect of the forefoot, and 4) Reduce abnormal supination moments around the subtalar joint caused by a rigid forefoot valgus or plantarflexed first ray.

[8] Rearfoot Varus Wedges75 Asker C EVA rearfoot varus wedges are used to increase the supination moments (reduce the pronation moments) around the subtalar joint to enhance the anti-pronation effect of the QUICKTHOTICS® Insoles.

[9] Heel Lifts3.0mm, 75 Asker C EVA heel lifts are used in the management of adverse kinetic and kinematic effects associated with a forefoot or ankle joint equinus, or to “balance” a LLD.

QUICKTHOTICS® | 5

[1]

[2]

[3]

[4]

[5]

[6]

[7]

[8]

[9]

QUICKTHOTICS® | 6

QUICKTHOTICS® CIS5-Minute Biomechanical Examination The recommended BME consists of nine quick and easy clinical observations. With practice, the BME

should take no longer than 5-minutes to complete (see Appendix for the BME data form). Based on

the presenting symptoms and the BME observations, QUICKTHOTICS® Insoles—targeted to the

underlying mechanical etiologies of the chief complaint—may be assembled and dispensed in just a

few minutes.

1Forefoot to Rearfoot Position (frontal plane)With the patient lying prone; the talo-navicular

joint maintained in a congruous position by

palpation, and the forefoot fully pronated

against the rearfoot by loading the 4th & 5th

metatarsal heads in what is often called “Foot

Neutral Position,” observe the plantar plane

of the forefoot through metatarsal heads 2-5

relative to a longitudinal bisection of the heel.

Chart the forefoot to rearfoot position as either

PERPENDICULAR, VARUS, or VALGUS.

21st Metatarsal Head PositionWith the patient’s foot maintained in Foot

Neutral Position, observe the position of the

first metatarsal head relative to the plane of the

forefoot through metatarsal heads 2 to 5. Using

palpation, if necessary, to determine the level,

chart the first metatarsal head position as either

LEVEL, PLANTARFLEXED, or DORSIFLEXED.

QUICKTHOTICS® | 7

4Passive Ankle Joint DorsiflexionObserve the lateral aspect of the foot and ankle.

With the knee fully extended and the foot

maintained close to talo-navicular congruency

during the movement, gently push against the

forefoot to maximally dorsiflex the ankle. Estimate

the degree of passive ankle joint dorsiflexion as

either 10°+, or <10°.

3Passive Hallux DorsiflexionObserve the medial aspect of the forefoot.

Gently push the hallux to end range dorsiflexion.

Estimate the degree of hallux extension relative to

the shaft of the first metatarsal. Chart the degree

of passive hallux dorsiflexion as either 65°+,

30°-65°, or < 30°.

5Forefoot to Rearfoot Position (sagittal plane)With the foot held in “Neutral Position,” observe

the lateral aspect of the foot and estimate the

forefoot to rearfoot position on a sagittal plane.

Chart the position as either LEVEL, or FOREFOOT

EQUINUS.

6Limb LengthSit the patient with their back pressed firmly

against a flat surface to “level” the pelvis; with their

legs fully extended out in front of them. Press on

both heels to push the femoral heads back into

the acetabulae and check the level of the tips

of the medial malleoli. Chart the limb length as

LEVEL, SHORT RIGHT, or SHORT LEFT

QUICKTHOTICS® | 8

8Heel Position in Relaxed Stance Observe the heel positions relative to the ground

in relaxed stance. Chart the positions as either

VERTICAL, EVERTED, or INVERTED

7Foot Posture in Stance and GaitObserve the feet in relaxed stance and gait.

Use your preferred examination method to

chart the static and dynamic foot posture as

either NEUTRAL, EXCESSIVELY PRONATED, or

EXCESSIVELY SUPINATED.

9Modified Hubscher Maneuver (Jack’s Test)With the patient in relaxed stance, and with gentle

pressure applied to the dorsum of the foot to stop

any other joint motion, lift the hallux away from

the supporting surface with your thumb. Chart the

range of hallux dorsiflexion from the ground as

either STIFF (< 20° ) or FLEXIBLE (20° +).

QUICKTHOTICS® | 9

Pathology Specific Prescriptions using the

QUICKTHOTICS® CISWhen correctly assembled, Spenco® QUICKTHOTICS® Insoles with TOTALSUPPORT® Technology

target the underlying kinetic and kinematic etiologies of the common musculoskeletal pathologies

of the lower-limb as part of a total treatment plan, which may include activity modification (including

rest), analgesics and NSAIDs, muscle stretching and strengthening programs, footwear adjustments,

compression and support dressings, physical therapy, chiropractic adjustments, etc.

The following hypothetical case presentations are illustrations designed to highlight classic

biomechanical scenarios met in clinical practice. Furthermore, they only deal with the prescription of

QUICKTHOTICS® Insoles and not the other components of a comprehesive treatment program.

As a general rule, even in the absence of an ankle equinus, calf muscle stretching exercises should be

prescribed to stop secondary contracture of the gastrocnemius-soleus complex when heel lifts are used on

QUICKTHOTIC® Insoles.

QUICKTHOTICS® | 10

Common Forefoot Pathology

1st PMTPJ Pain or LesionFor pain or a lesion beneath the first metatarsal head related to a plantarflexed

first metatarsal, remove the plug from the 1st MTPJ/FR cut-out to reduce the

magnitude of GRF beneath the 1st MTPJ. The metatarsal pad incorporated in

the QUICKTHOTICS® Insole will become more effective in redistributing

ground reaction force away from the area of pain [1,2,3].

If the 2-5 forefoot to rearfoot position is EVERTED, add a forefoot valgus wedge

to further redistribute GRF to the lateral aspect of the plantar forefoot [4].

In an excessively pronated foot with calcaneal eversion (and limited first ray

dorsiflexion), the first metatarsal head may receive excessively high magnitudes of GRF causing a FHL

[5,6,7]. In this case, remove the plug from the 1st MTPJ/FR cut-out, add an arch support to patient

tolerance, and apply a rearfoot varus wedge.

QUICKTHOTICS® | 11

Case Presentation 1 Julia B: A 37-year-old

primary school teacher.

CO: “Burning pain beneath the left big toe joint.”

HX: Intermittent episodes of pain during sports activities

for many years. Worse since starting step classes 3-times a

week. Had to pull out of the last class due to severe soreness.

OE: Pain with direct pressure beneath an inflamed left 1st MTPJ,

especially over the tibial sesamoid.

DX: Tibial “Sesamoiditis.”

BME: Plantarflexed first metatarsals bilaterally, L>R. Forefoot valgus on the left.

Slightly everted heels in stance and gait.

QUICKTHOTICS® CIS RX: Remove the plugs from both 1st MTPJ/FR cut-outs to reduce the magnitude of GRF

beneath the plantarflexed first metatarsal heads. Apply a forefoot valgus wedge to the left insole to further

redirect GRF away from the 1st metatarsal head. Apply rearfoot varus wedges to reduce the excessive

rearfoot pronation moments. RX Options: Apply arch supports to patient tolerance to further reduce

excessive pronation moments.

2nd PMTPJ Pain or Lesion The metatarsal pad incorporated into the QUICKTHOTICS® Insole may be enough to provide symptom

relief from a high magnitude of GRF beneath the plantar aspect of the 2nd metatarsal head without

further insole modifications [1,2,3]. Excessive foot pronation may

cause hypermobility of the first ray and an increase in the magnitude

of GRF beneath the 2nd metatarsal head [8,9]. In this case, add an arch

support to patient tolerance and a rearfoot varus wedge to increase

the magnitude of supination moments acting around the rearfoot,

especially if the heels are everted in relaxed stance [10]. If a forefoot or

ankle equinus is identified as part of the aetiology of the excessive foot

pronation, consider a heel lift if the shoe style permits [11].

If the forefoot to rearfoot position is EVERTED, add a forefoot valgus

wedge to further redistribute GRF away from the 2nd metatarsal

head to the lateral aspect of the plantar forefoot. If the forefoot to

rearfoot position is INVERTED, remove the plug from the 1st MTPJ/

FR cut-out to relatively increase the thickness of the metatarsal pad

incorporated into the shell, to further redistribute GRF away from the

2nd metatarsal head.

QUICKTHOTICS® | 12

Case Presentation 2Fred W: An active 60-year-

old retail sales associate.

CO: “Painful lump on the ball of the left foot.”

HX: Calluses on the soles of both feet for many years,

but the left foot has become increasingly more red,

swollen, and painful over the last 3-months.

OE: Area of thick callus with edema and erythema

beneath the left 2nd MTPJ.

DX: Plantar Metatarsal Bursitis.

BME: Bilateral excessive foot pronation with calcaneal eversion in static stance and gait. 0° ankle joint

dorsiflexion bilaterally. Metatarsus primus elevatus on the left.

QUICKTHOTICS® CIS RX: The metatarsal pad and cushioned forefoot extension incorporated in the

QUICKTHOTICS® Insole will help reduce excessive GRF beneath the 2nd MTPJ. Rigid arch supports (flexibility

may be changed to patient tolerance) and rearfoot varus wedges will reduce the excessive pronation

moments. RX OPTIONS: Bilateral heel lifts may be applied for the ankle equinus, although for better shoe fit,

omit the heel lifts and increase the patient’s shoe heel height if possible.

5th PMTPJ Pain or LesionThe metatarsal pad and soft forefoot extension in the QUICKTHOTICS®

Insole may be enough to provide symptom relief from a high

magnitude of GRF beneath the 5th metatarsal head without further

modifications [1,2,3]. In the presence of an inverted heel position in

static stance and gait caused by a “rigid” forefoot valgus or plantarflexed

first ray, apply a forefoot valgus wedge to reduce the magnitude of GRF

beneath the 5th metatarsal head. Remove the plug from the 1st MTPJ

cut-out to enhance the effect of the metatarsal pad and forefoot valgus

wedge if required.

If a plantarflexed 5th metatarsal is identified, add a forefoot valgus

wedge, which lies proximal to the joint, to reduce the high magnitude

of GRF from the 5th metatarsal head.

QUICKTHOTICS® | 13

Case Presentation 3Jim S: A 39-year-old

construction worker.

CO: “Painful, swollen lumps of hard skin on the

outside of the balls of the feet.”

OE: Bilateral IPK with swelling and erythema

beneath the 5th MTPJ .

DX: Plantar metatarsal bursitis with overlying IPK.

BME: Inverted heel positions in static stance and

gait and bilateral forefoot valgus.

QUICKTHOTICS® CIS RX: Apply forefoot valgus wedges to both insoles to reduce the magnitude of GRF

beneath the 5th metatarsal heads and to possibly reduce the degree of heel inversion.

RX OPTIONS: If the pain persists, remove the plugs from the 1st MTPJ/FR cut-outs to enhance the effect of

the metatarsal pads and forefoot valgus wedges.

PIPJ Hallux Pain or LesionIn the absence of a true anatomical hallux limitus or rigidus (or an Os

Interphalangeus) the etiology of a lesion beneath the IPJ of the hallux may be

FHL, often caused by excessive foot pronation leading to a high magnitude

of GRF beneath the first metatarsal head and IPJ of the hallux during the

propulsive phase of gait [5,6]. In this case, stiffen the medial longitudinal arch

with an arch support to patient tolerance and add a rearfoot varus wedge

to reduce the magnitude of pronation moments. Remove the plug from

beneath the 1st MTPJ to encourage improved hallux dorsiflexion [12,13,14].

QUICKTHOTICS® | 14

Case Presentation 4Erica S: A 36-year-old postal

worker.

CO: “Soreness beneath the right big toe at the end of a

long day at work.”

HX: Cushioned insoles help but not enough.

OE: Inflamed callous beneath the IPJ of both halluces, R>L.

BME: Excessive foot pronation in static stance and gait. Everted heel

and flexible plantarflexed first ray on the right. FHL right foot as evidenced

by a stiff right 1st MTPJ with with the Modified Hubscher Maneuver.

QUICKTHOTICS® CIS RX: Add flexible arch supports and rearfoot varus wedges to counteract the excessive

pronation moments. Remove the 1st MTPJ/FR plug from the right insole to accommodate the plantarflexed

1st ray and help reduce the FHL.

Common Musculoskeletal Pathology of the Foot and Ankle

1st MTPJ PainExcessive foot pronation with calcaneal eversion may cause high magnitudes

of GRF beneath the 1st MTPJ causing a FHL and an increase in compression

forces within the joint during the propulsive phase of gait causing an acute

arthritis [5, 13, 14]. In this case, add an arch support to patient tolerance and

a rearfoot varus wedge to reduce the pronation moments . Remove the plug

from the 1st MTPJ/FR cut-out to encourage improved FR plantarflexion and

associated hallux dorsiflexion.

A plantarflexed FR may lead to a high magnitude of GRF beneath the 1st MTPJ

leading to FHL [12,13]. In this case, remove the plug from the 1st MTPJ/FR cut-out

to encourage improved hallux dorsiflexion.

If the forefoot to rearfoot position is EVERTED add a forefoot valgus wedge to further redistribute

GRF away from the 1st MTPJ to the lateral aspect of the plantar forefoot.

If the forefoot to rearfoot position is INVERTED, rely on the metatarsal dome and empty 1st MTPJ/FR

cut out to promote improved hallux dorsiflexion.

QUICKTHOTICS® | 15

Case Presentation 5Jonathan P: A 24-year-old

electrician.

CO: “Painful right big toe joint.”

HX: The right big toe aches in boots at work, but the pain

worsens in the evening in soft house slippers.

OE: Bilateral HAV with bunion R>L. Right 1st MTPJ is sore at end range

dorsiflexion and plantaflexion.

DX: HAV with bunion and 1st MTPJ capsolitis.

BME: Excessive foot pronation with everted heels (R>L) in static stance and gait. <10° ankle joint dorsiflexion

bilaterally. 30°-65° hallux dorsiflexion bilaterally. Plantarflexed FR with a Modified Hubscher Maneuver of

<20° on the right.

QUICKTHOTICS® CIS RX: Use semi-rigid arch supports and rearfoot varus wedges to reduce the pronation

moments. Remove the 1st MTPJ/FR plug from the right insole to accommodate the plantaflexed FR. Heel lifts

may be applied for the ankle joint equinus if the shoe style permits, otherwise raise the patient’s shoe heel

height if possible.

Plantar Fasciitis A compensated forefoot valgus is a primary etiological factor in plantar fasciitis [15], and a forefoot valgus wedge has been shown to reduce tension in the plantar fascia [16].

A tight calf muscle (ankle joint equinus) often creates a high magnitude of GRF beneath the forefoot during the midstance phase of gait [17] leading to greater tensile stress and strain in the plantar fascia [18, 19, 20]. In this case, add a heel lift.

A flexible forefoot equinus (anterior cavus) may cause the forefoot to excessively dorsiflex against the rearfoot, thereby lengthening the foot and straining the plantar fascia [21,22]. In this case, “balance” the sagittal plane forefoot to rearfoot discrepancy with a heel lift to reduce the magnitude of GRF beneath the forefoot.

Excessive foot pronation with an everted heel may cause dorsiflexion (and inversion) of the medial column of the forefoot, exposing the medial band of the plantar fascia to excessive tensile stress and strain [15]. In this case, add a rearfoot varus wedge and an arch support to patient tolerance to reduce the pronation moments and to support the arch . If the medial plantar calcaneal tuberosity is painful to direct palpation, omit the rearfoot wedge in the early stages of treatment and rely upon the arch support to reduce rearfoot pronation and forefoot medial column dorsiflexion moments.

A plantarflexed FR may abnormally dorsiflex with weight-bearing, placing excessive tensile stress and strain on the medial band of the plantar fascia [15]. In this case, remove the plug from the 1st MTPJ/FR cut-out to reduce GRF beneath the 1st MTPJ.

QUICKTHOTICS® | 16

Case Presentation 6Faith M: An active 64-year-old

woman.

CO: “Painful left heel for 3/52.”

HX: Patient has been busier around the house in a new

pair of flat house slippers.

OE: Pain with direct pressure to the MPCT of the left foot.

DX: Proximal Plantar Fasciitis

BME: Moderate degree of flexible forefoot equinus (L>R).

Limited ankle joint dorsiflexion bilaterally. Bilateral plantarflexed FR (L>R). Forefoot valgus on the left.

Moderately pronated feet to heel vertical in static stance and gait.

QUICKTHOTICS® CIS RX: Apply heel lifts to “balance” the forefoot and ankle equinus’ if shoe style permits.

Remove the1st MTPJ/FR plugs to accommodate the plantarflexed first metatarsals. Apply a FF valgus wedge

to the left insole. As the degree of abnormal foot pronation is “moderate,” rearfoot varus wedges may be

omitted in the initial prescription to avoid irritation to the MPCT. The arch support incorporated into the

insole may be enough to reduce the excessive pronation moments, otherwise add arch supports as required.

RX OPTIONS: Increase the patient’s shoe heel height and omit the heel lifts.

Plantar Calcaneal BursitisPain with pressure to the centre of the plantar aspect of the heel with a

palpable mass is characteristic of a plantar calcaneal bursitis.

Excessive foot pronation with calcaneal eversion may cause the medial

plantar calcaneal tuberosity (MPCT) to “irritate” the plantar fat pad

of the heel causing a bursitis. In this case, remove the heel plug and

add a rearfoot varus wedge If the heel is acutely painful to direct

pressure, omit the rearfoot varus wedge and rely upon a medial arch

support (rigidity to patient tolerance) to reduce the excessive pronation

moments until the plantar aspect of the heel is able to accept the

increase in GRF created by a rearfoot varus wedge.

QUICKTHOTICS® | 17

Case Presentation 7Fiona C: A 20-year-old

student.

CO: “Pain on the sole of the left heel.”

HX: Hit the sole of the left heel on a rock while

swimming on holiday.

OE: Palpable mass in the centre of the left heel,

painful to direct pressure.

DX: Plantar Calcaneal Bursitis.

BME: Moderate degree of foot pronation to heel vertical in static and gait bilaterally.

QUICKTHOTICS® CIS RX: The arch support incorporated into the insole may be enough to reduce excessive

pronation moments and to redistribute GRF away from the left heel and into the arch, otherwise use an

arch support. A rearfoot varus wedge may increase the magnitude of GRF beneath the heel and should

be avoided in the first instance. Remove the plug from the calcaneal dell on the left insole to reduce the

magnitude of GRF beneath the central heel.

FPO

Subtalar joint pronation to end range may cause talo-calcaneal compression

and soft-tissue impingement in the region of the sinus tarsi

Sinus Tarsi SyndromeAn unstable talo-calcaneal joint, and compression

of the talus against the floor of the calcaneus at the

sinus tarsi with a maximally pronated foot have been

described as the two most common etiologies of

sinus tarsitis [23, 24, 25].

The medial longitudinal arch support and deep

heelcup incorporated into QUICKTHOTICS®

Insoles may be enough to reduce the magnitude

of pronation moments acting around the joints of

the rearfoot leading to a reduction in compression

forces at the subtalar joint without further insole

modifications; otherwise apply an arch support to

patient tolerance and a rearfoot varus wedge.

Check for ankle equinus as part of the aetiology of

the excessive pronation moments at the subtalar

joint and add a heel lift if the shoe style permits.

QUICKTHOTICS® | 18

Case Presentation 8Joshua Z: A 48-year-old

male nurse.

CO: “Painful left ankle.”

HX: Flat feet for many years, but severe left ankle

pain for the last 2-1/2.

OE: Patient points to the region of the anterior talo-

fibular ligament (ATFL) on the left ankle as the site

of pain. Palpation of the lateral ankle ligaments and

passive foot inversion fails to elite pain, but forceful

passive pronation does.

DX: Sinus Tarsitis.

BME: Severe foot pronation with medial and plantar “subluxation” of the talus on the navicular L>R. 0° ankle

joint dorsiflexion bilaterally

QUICKTHOTICS® CIS RX: Apply flexible arch supports and rearfoot varus wedges to reduce the excessive

pronation and to reduce the magnitude of compression force at the sinus tarsi. Apply heel lifts if the shoe

style permits.

RX OPTIONS: Increase the rigiity of the arch supports if tolerated by the patient. If possible, increase the

shoe heel height and omit the heel lifts to aid shoe fit

Chronic Lateral Ankle InstabilityIf the forefoot to rearfoot position is EVERTED or

PERPENDICULAR, add a forefoot valgus wedge to

reduce excessive supination moments as a possible

cause of lateral ankle instability.

A rigid plantarflexed first ray may cause abnormal

supination moments and chronic lateral ankle

sprains[27]. Remove the plug from the 1st MTPJ/FR

cut-out.

QUICKTHOTICS® | 19

Case Presentation 9Ryan S: A 16-year-old

school football player.

CO: “I keep going over on my right ankle.”

HX: No instability when walking or training

on flat surfaces, but inversion sprains right

ankle on an uneven field.

OE: Grade 1 right ankle sprain. Retains good

proprioception and peroneal strength.

DX: Chronic lateral ankle sprain.

BME: Bilateral forefoot valgus R>L. Plantarflexed first ray on the right foot. The right foot is slightly

supinated in static stance and gait.

QUICKTHOTICS® CIS RX: Apply a forefoot valgus wedge to both insoles, and remove the plug rrom the right

1st MTPJ/FR cut-out. Remove the plugs from both calcaneal dells to lower the heel in the shoe to decrease

the risk of ankle instability during sport.

Achilles TendonitisA tight calf muscle is a common aetiology of an Achilles tendonitis[28]. In this case, add a heel lift. Calf

muscle stretching exercises should be employed as part of the treatment programme to reduce the

primary contracture and the risk of secondary contracture of the gastrocnemius-soleus complex.

A rigid forefoot equinus may compensate by retrograde ankle joint

dorsiflexion (often called a “pseudo equinus”) during the midstance

phase of gait, causing excessive tensile stress and strain within the

Achilles tendon[29]. In this case, “balance” the forefoot equinus

using a heel lift.

A compensated plantarflexed first ray may case a FHL, which

“stiffens” the 1st MTPJ may cause the calf muscles to work harder

to raise the heel during the propulsive phase of gait. In this case,

remove the plug from the 1st MTPJ/FR cut-out to enhance hallux

dorsiflexion.

With excessive calcaneal eversion, the first metatarsal may abnormally dorsiflex to end range causing a

FHL and calf muscle strain during propulsion as described above[5]. In this case, remove the plug from

the 1st MTPJ/FR cut-out and add an arch support to patient tolerance and a rearfoot varus wedge.

QUICKTHOTICS® | 20

Case Presentation 10Samuel T: A 13-year-old,

1500m runner.

CO: “Painful Achilles tendons.”

HX: Pain on and off for 12-months despite a

conscientious stretching program. Pain became

worse 2/52 ago during training for the National

Schools. Physiotherapist prescribed ice, rest, and

gave ultrasound 3-times a week, which has helped.

OE: Both Achilles tendons are tender to direct

pressure and appear moderately edematous. Passive and active ankle joint dorsiflexion causes pain

immediately above the calcaneal insertion and there is tenderness at the myotendinous junction.

DX: Achilles tendonitis.

BME: A moderately cavus foot type with less than 10° of ankle joint dorsiflexion, forefoot equinus,

plantarflexed first ray, and forefoot valgus bilaterally.

QUICKTHOTICS® CIS RX: Apply heel lifts for the ankle and forefoot equinus. Remove the plugs from the 1st MTPJ/

FR cut-outs to accommodate the plantarflex first rays, and forefoot valgus wedges for the forefoot valgus.

RX OPTIONS: Add additional heel lifts if symptoms fail to resolve.

Common Musculoskeletal Pathology of the Leg

Tibialis Posterior TendonitisExcessive pronation moments may cause a high magnitude of tensile stress

and strain through the Tibialis Posterior tendon during gait [30]. Symptoms

are most often experienced immediately posterior to the anterior crest

at the lower-1/3 of the tibia. The condition is often referred to as “Shin

Splints”. In this case, the medial longitudinal arch support incorporated into

the QUICKTHOTICS® Insole may be enough to reduce the symptoms,

otherwise apply an arch support to patient tolerance and a rearfoot varus

wedge to further reduce the magnitude of pronation moments.

Check for ankle equinus as part of the etiology of the excessive foot pronation, and if present add a

heel lift if the shoe style permits.

A FHL may cause excessive foot pronation during the propulsive phase of gait to compensate for the

inability of the hallux to dorsiflex[31]. In this case, remove the plug from the 1st MTPJ/FR cut-out to

enhance hallux dorsiflexion.

QUICKTHOTICS® | 21

Case Presentation 11Danny P: A 55-year old chef.

CO: “Shins splints.”

HX: Has had a few episodes over the last few years,

most usually in the high season when the hotel

gets busy.

OE: Pain to direct pressure immediately posterior

to the medial borders of the tibae, immediately

proximal to the medial malleolus, and with foot

inversion against resistance.

DX: Tibialis Posterior tendinitis.

BME: Bilateral excessive foot pronation with calcaneal eversion in static stance and gait. Less than 10° ankle

joint dorsiflexion, and 0° dorsiflexion of both halluces with the Modified Hubscher Maneuver.

QUICKTHOTICS® CIS RX: Apply heel lifts for the ankle joint equinus. Use rigid arch supports and rearfoot

varus wedges to reduce the magnitude of excessive pronation moments. Also, remove the plugs from the 1st

MTPJ/FR first ray cut-outs for the FHL.

RX OPTIONS: Increase the patient’s shoe heel height and omit the heel lifts. If the patient complains of arch

irritation, replace the rigid arch supports with the semi-flexible or flexible options for improved comfort.

Peroneal TendonitisA supinated foot throughout the whole stance phase of gait

may place excessive tensile stress and strain on the peroneal

tendon. In this case, apply a forefoot valgus wedge to reduce the

supination moments and the magnitude of tensile force within

the peroneal tendons [32]. Remove the plug from the 1st MTPJ/

FR cut-out to further enhance the effect of the forefoot valgus

wedge, especially with an associated plantarflexed FR.

A FHL may cause excessive foot supination during the propulsive

phase of gait to compensate for the inability to dorsiflex the

hallux. In this case, remove the plug from the 1st MTPJ/FR cut-

out to enhance hallux dorsiflexion.

QUICKTHOTICS® | 22

Case Presentation 12Lisa M: A 36-year-old street

vendor.

CO: “Pain on the outside of the left shin following a mild

ankle sprain 2/52 ago.”

HX: Tripped off a curb. Thought nothing of it, but the outside

of the left shin became painful 2-days later. No previous

treatment.

OE: Tenderness along the course of the peroneal tendons at

the lower-1/3 of the left leg.

DX: Peroneal tendinitis

BME: Moderately high-arch, cavus feet with bilateral forefoot valgus, plantarflexed first rays, and slightly

inverted heels in relaxed stance.

QUICKTHOTICS® CIS RX: Apply forefoot valgus wedges bilaterally to reduce the tensile force through the

peroneals and remove the plugs from the 1st MTPJ/FR cut-outs to accommodate the plantarflexed first rays.

Patello-Femoral Pain SyndromeExcessive foot pronation may create excessive internal rotation of

the tibia and femur that increases the Q-angle, which may promote

abnormal lateral displacement of the patella during quadriceps

contraction[33-37], along with a high magnitude of knee flexion

moments. In this case, the medial longitudinal arch support

incorporated into the QUICKTHOTICS® Insole may be enough to

reduce the symptoms without further modifications, otherwise apply

an arch support to patient tolerance and a rearfoot varus wedge to

further reduce abnormal compensation at the knee [39].

Check for ankle equinus as part of the etiology of the excessive foot

pronation and associated internal rotation of the leg and if present

add a heel lift if the shoe style permits.

A FHL may cause abnormal pronation of the foot to compensate for the inability of the 1st MTPJ to

move efficiently through the propulsive phase of gait. In this case, remove the plug from the 1st MTPJ/

FR cut-out to enhance hallux dorsiflexion.

QUICKTHOTICS® | 23

Case Presentation 13Sally W : A 14-year-old

basketball player.

CO: “Pain under the right knee cap when playing

basketball; when going up and down stairs, and when

rising from a sitting position.”

HX: Has been taking Ibuprofen PRN, which causes acid

reflux. Physiotherapist prescribed a knee support with

patella aperture and VMO strengthening exercises,

which has helped. Patient mentions she always stands

with the right knee flexed.

OE: Pain on compression of the right patello-femoral joint and the Patella Apprehension Test.

DX: Patello-femoral pain syndrome (PFPS)

BME: Excessive pronation (with calcaneal eversion) of the right foot only in static stance. Right plantarflexed

first ray. Reduced right hallux dorsiflexion with the Modified Hubscher Maneuver. A short left leg by

approximately 8.0mm.

QUICKTHOTICS® CIS RX: Apply a rigid arch support and rearfoot varus wedge to the right insole. Remove

the plug from the right 1st MTPJ/FR cut-out to accommodate the plantarflex first ray and to encourage

improved hallux dorsiflexion. Add a heel lift to the left insole to correct for the limb-length discrepancy.

Pes Anserinus Friction Syndrome (or Bursitis)Excessive foot pronation may create an excessive valgus moment at

the knee, which may place increased tensile stress and strain through

the components of Pes Anserinus causing a friction syndrome or

bursitis over the medial femoral condyle of the knee; or symptoms

at the entheses of the tendons. [40]. The medial longitudinal

arch support incorporated into the QUICKTHOTICS® Insole

may be enough to reduce the symptoms without further insole

modifications, otherwise apply an arch support to tolerance and a

rearfoot varus wedge to further reduce the genu valgum and internal

rotation moments at the knee.

Check for ankle equinus as part of the etiology of the excessive foot

pronation and if present add a heel lift if the shoe style permits.

A FHL may cause abnormal pronation of the foot during the propulsive phase of gait to compensate

for the inability of the hallux to dorsiflex during the propulsive phase of gait. In this case, remove the

plug from the 1st MTPJ/FR cut-out to enhance hallux dorsiflexion.

QUICKTHOTICS® | 24

Case Presentation 14Simon B: A 30-year-old trail

runner.

CO: “Pain and swelling over the inside of both knees, worse

when running downhill”

HX: Insidious onset. No history of knee twists or

direct trauma.

OE: Sharp pain to direct pressure over the medial aspect of

both shins at the attachement of Pes Anserinus.

DX: Pes Anserinus enthesitis.

BME: Moderate forefoot equinus. Excessive foot pronation (mostly forefoot abduction) to heel vertical in

static stance and gait. Less than 10° ankle joint dorsiflexion bilaterally.

QUICKTHOTICS® CIS RX: Apply heel lifts to “balance” the forefoot equinus and to reduce the excessive

pronation moments caused by the ankle equinus. The incorporated medial longitudinal arch support may

be enough to reduce the associated excessive genu valgum moments without further modification to the

insoles, although arch supports to patient tolerance and rearfoot varus wedges may be required.

Ilio-tibial Band Syndrome (Knee and Hip)Excessive foot pronation may create excessive internal rotation of the tibia that stretches the

iliotibial band over the lateral condyle of the tibia creating a friction syndrome[41]. The iliotibial

band may also become tight over the greater

trochanter of the femur causing a friction syndrome

or bursitis at the hip. In these cases, the medial

longitudinal arch support incorporated into the

QUICKTHOTICS® Insole may be enough to reduce

the symptoms, otherwise apply an arch support to

tolerance and a rearfoot varus wedge to further reduce

the magnitude of the pronation moments.

Check for ankle equinus as part of the aetiology of the excessive foot pronation and if present add a heel

lift if the style of shoe allows.

A Functional Hallux Limitus may cause abnormal pronation of the foot during the propulsive phase

of gait to compensate for the inability to dorsiflex the hallux. In this case, remove the plug from the

1st MTPJ and first cut-out to enhance hallux dorsiflexion to reduce the excessive internal rotation of

the leg.

QUICKTHOTICS® | 25

Case Presentation 15Maria J: A 29-year-old

aerobics instructor.

CO: “Pain on the outside of the right knee.”

HX: Pain started on a skiing holiday, where the

lateral aspect of right knee became painful on

side stepping. Pain now continues during aerobics

classes.

OE: Pain with direct pressure to the lateral femoral

condyle and proximally along 4-5cm of the iliotibial band (ITB)

DX: ITB friction syndrome and “tendinitis.”

BME: Excessive foot pronation with calcaneal eversion in static stance causing excessive internal leg rotate

as evidenced by “squinting” patellae.

QUICKTHOTICS® CIS RX: As the symptoms are acute in nature, the patient may begin to wear

QUICKTHOTICS® Insoles without modifications to see if the incorporated medial longitudinal arch support

reduces the symptoms. If symptoms persist, apply arch supports to both insoles and a rearfoot varus wedge

to the right insole to reduce the excessive pronation moments.

Gait Related Low-Back PainA pelvic tilt due to an anatomically short leg may cause a

compensatory scoliosis that may be the aetiology of posture-

related lower-back pain. In this case, apply a heel lift to the

QUICKTHOTICS® Insole for the short leg to improve frontal

plane pelvic alignment.

Unilateral excessive foot pronation may cause a pelvic tilt by

creating a functional limb length discrepancy. In this case use

a pair of QUICKTHOTICS® Insoles, but apply an arch support

and varus heel wedge only to the excessively pronated foot.

Research has shown that a Functional Hallux Limitus (FHL) may be a primary aetiology of gait related

lower-back pain[31,42,43]. If FHL is determined during BME, remove the plugs from the 1st MTPJ and

first ray cut-outs to promote improved hallux dorsiflexion during the propulsive phase of gait. N.B.

if excessive foot pronation is part of the aetiology of the FHL, add arch supports to tolerance and

rearfoot varus wedges.

QUICKTHOTICS® | 26

Case Presentation 16Lincoln N: A 42-year-old

jogger.

CO: “Low-back pain when walking, exacerbated when

jogging over 1-mile, which improves with rest.

HX: Prior orthopaedic examination and imaging

reveals no lesion or definitive pathological condition.

Prior DX: “History consistent with gait related

Idiopathic low-back pain.” Core stability exercises

prescribed by a physiotherapist have reduced the

symptoms by approximately 50%.

OE: Patient points to the area of the lumbar spine as the site of pain.

DX: History consistent with gait related Low-back Pain.

BME: Short left leg of approximately 8.0mm causing a pelvic tilt to the left in static stance. Pronated feet

bilaterally with everted heels L>R. A marked plantarflexed first ray on the left foot with restricted left hallux

dorsiflexion with the Modified Hubscher Maneuver.

QUICKTHOTICS® CIS RX: Add a heel lift (with caution and close monitoring) to the left device to reduce the

pelvic tilt. Apply arch supports to patient tolerance and rearfoot wedges to both devices to reduce the excessive

pronation moments. Remove the 1st MTPJ/FR plug from the left insole to improve hallux dorsiflexion.

QUICKTHOTICS® | 27

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2. Chang AH, Abu-Faraj ZU, Harris GF, Nery J, Shereff MJ. Multistep measurement of plantar pressure alterations using metatarsal pads. Foot Ankle Int. 1994 Dec;15(12):654-60.

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4. Van Gheluwe Bart, Dananberg HJ. Changes in Plantar Foot Pressure with In-Shoe Varus or Valgus Wedging. J Am Podiatr Med Assoc 94(1): 1-11, 2004.

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6. Rao S, Song J, Kraszewski A, Backus S, Ellis SJ, Deland JT, Hillstrom HJ. The effect of foot structure on 1st metatarsophalangeal joint flexibility and hallucal loading. Gait Posture. 2011 May;34(1):131-7. doi: 10.1016/j.gaitpost.2011.02.028. Epub 2011 May 1.

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10. Johanson MA, Donatelli R, Wooden MJ, Andrew PD, Cummings GS. Effects of three different posting methods on controlling abnormal subtalar pronation. Phys Ther. 1994 Feb;74(2):149-58; discussion 158-61.

11. Johanson MA, Cooksey A, Hillier C, Kobbeman H, Stambaugh A. Heel lifts and the stance phase of gait in subjects with limited ankle dorsiflex-ion. J Athl Train. 2006 Apr-Jun;41(2):159-65.

12. Scherer PR, Sanders J, Eldredge DE, Duffy SJ, Lee RY. Effect of func-tional foot orthoses on first metatarsophalangeal joint dorsiflexion in stance and gait. J Am Podiatr Med Assoc. 2006 Nov-Dec;96(6):474-81.

13. Munuera PV, Domínguez G, Palomo IC, Lafuente G. Effects of rear-foot-controlling orthotic treatment on dorsiflexion of the hallux in feet with abnormal subtalar pronation: a preliminary report. J Am Podiatr Med Assoc. 2006 Jul-Aug;96(4):283-9.

14. Dubbeldam R, Nester C, Nene AV, Hermens HJ, Buurke JH. Kinematic coupling relationships exist between non-adjacent segments of the foot and ankle of healthy subjects. Gait Posture. 2013 Feb;37(2):159-64. doi: 10.1016/j.gaitpost.2012.06.033. Epub 2012 Aug 27.

15. Scherer, PR. Heel Spur Syndrome- Pathomechanics and non-surgical treatment. Journal American Med Assoc, 81:68 (1991).

16. Kogler, GF, et. al.: The influence of medial and lateral placement of orthotic wedges on loading of the plantar aponeurosis. Journal Bone Joint Surgery 81-A: 1403 (1999).

17. Aronow MS, Diaz-Doran V, Sullivan RJ, Adams DJ. The effect of tri-ceps surae contracture force on plantar foot pressure distribution. Foot Ankle Int. 2006 Jan;27(1):43-52.

18. Patel A, DiGiovanni B. Association between plantar fasciitis and iso-lated contracture of the gastrocnemius. Foot Ankle Int. 2011 Jan;32(1):5-8. doi: 10.3113/FAI.2011.0005.

19. Abbassian A, Kohls-Gatzoulis J, Solan MC. Proximal medial gastroc-nemius release in the treatment of recalcitrant plantar fasciitis. Foot Ankle Int. 2012 Jan;33(1):14-9. doi: 10.3113/FAI.2012.0014.

20. Garrett T, Neibert PJ. The Effectiveness of a Gastrocnemius/Soleus Stretching Program as a Therapeutic Treatment of Plantar Fasciitis. J Sport Rehabil. 2013 May 22.

21. Yi TI, Lee GE, Seo IS, Huh WS, Yoon TH, Kim BR. Clinical characteristics of the causes of plantar heel pain. Ann Rehabil Med. 2011 Aug;35(4):507-13. doi: 10.5535/arm.2011.35.4.507.

22. Pfeffer, G.B. ed. Plantar Heel Pain. First ed. Foot and Ankle Disorders. Ed. S.M. Myerson. Vol. 2. 2000, W.B. Sunders Co.: Philadelphia. pp834-850.

23. Helgeson K. Examination and intervention for sinus tarsi syndrome. N Am J Sports Phys Ther. 2009 Feb;4(1):29-37.

24. Pisani G, Pisani PC, Parino E. Sinus tarsi syndrome and subtalar joint instability. Clin Podiatr Med Surg. 2005 Jan;22(1):63-77.

25. Kjaersgaard-Andersen P, Wethelund JO, Helmig P, Søballe K. The stabilizing effect of the ligamentous structures in the sinus and canalis tarsi on movements in the hindfoot. An experimental study. Am J Sports Med. 1988 Sep-Oct;16(5):512-6.

26. Verrall G, Schofield S, Brustad T. Chronic Achilles tendinopathy treated with eccentric stretching program. Foot Ankle Int. 2011 Sep;32(9):843-9.

27. Anthony RJ. The Manufacture & Use of the Functional Foot Orthosis. Karger AG, Basle, 1991, pp 120-121 & 167, ISBN:3-8055-5298-X.

28. Schepsis AA, et. al. Achilles tendon disorders in athletes. Am J Sports Med Mar-Apr; 30(2): 287-305.

29. Whitney AK, Green DR. Pseudoequinus. J Am Podiatry Assoc. 1982 Jul;72(7):365-71.

30. Rabbito M, Pohl MB, Humble N, Ferber R. Biomechanical and clinical factors related to stage I posterior tibial tendon dysfunction. J Orthop Sports Phys Ther. 2011 Oct;41(10):776-84. doi: 10.2519/jospt.2011.3545.

31. Dananberg HJ. Gait style as an etiology to chronic postural pain. Part II. Postural compensatory process. J Am Podiatr Med Assoc. 1993 Nov;83(11):615-24.

32. Kakihana W, Torii S, Akai M, Nakazawa K, Fukano M, Naito K. Effect of a lateral wedge on joint moments during gait in subjects with recurrent ankle sprain. Am J Phys Med Rehabil. 2005 Nov;84(11):858-64.

33. McClay I, Manal K: A comparison of three-dimensional lower extremity kinematics during running between excessive pronators and normals. Clin Biomech, 1998 Apr; 13(3):195-20.

34. Souza TR, Pinto RZ, Trede RG, Kirkwood RN, Fonseca ST: Temporal couplings between rearfoot shank complex and hip joint during walk-ing. Clin Biomech. 2010 Aug;25(7):745-8.

35. Nguyen AD, Boling MC, Levine B, Shultz SJ: Relationships between lower extremity alignment and the quadriceps angle. Clin J Sports med. 2009 may; 19(3):201-206.

36. Livingston LA. The quadriceps angle: A review of the literature. J Orthop Sports Phys Ther 1998; 28:105-9.

37. Puckree, T, Govender A, Govender K, Naidoo P: The quadriceps angle and the incidence of knee injury in long-distance runners. S Afirst-rayic Jour Sport Med, Vol. 19, No. 1, 2007.

38. Thijs Y, De Clercq D, Roosen P, Witvrouw E: Gait-related intrinsic factors for patello-femoral pain in novice recreational runner. Br J Sports Med. 2008 Jun: 42(6):466-71.

39. Saxena A, Haddad J: The effect of foot orthoses on patello-femoral pain syndrome. J Am Podiatr Med Assoc. 2003 Jul-Aug; 93(4):264-71.

40. Alvarez-Nemegyei J: Risk factors for pes anserinus tendinitis/bursitis syndrome: a case control study. J Clin Rheumatol. 2007 Apr; 13(2):63-5.

41. Fairclough J Hayashi K, Toumi H, Lyons K, Bydder G, Phillips N, Best TM, Benjamin M: The functional anatomy of the Ilio-Tibial Band during flexion and extension of the knee: implications for understanding Ilio-Tibial Band syndrome. J. Anat 2006 mar; 2008(3):309-16.

42. Dananberg, H.J.: Gait style as an etiology to chronic postural pain. Part 1. Functional Hallux Limitus. J Am Podiatr. Med Assoc. Aug, 83(8):433-441 (1993).

43. Dananberg, H.J. and Guiliano, M: Chronic low-back pain and its response to custom-made foot orthoses. J Am Podiatr. Med Assoc. Mar, 89(3):109-117 (1999).

QUICKTHOTICS® | 28

Patient: Ref #: Examination Date:

Chief Complaint:

Observations Findings Examination Technique

RIGHT LEFT

Forefoot to Perpendicular Perpendicularrearfoot position Varus Varus Valgus Valgus

First metatarsal Neutral Neutral head position Plantarflexed Plantarflexed Dorsiflexed Dorsiflexed

Hallux dorsiflexion 65° or greater 65° or greater <65° <65°

Ankle joint 10° or greater 10° or greaterdorsiflexion < 10° < 10°

Forefoot to rearfoot Forefoot and heel Forefoot and heel position (sagittal) level level Forefoot equinus Forefoot equinus

Limb Length Malleoli are level Malleoli are level Short: Short: Right Right Left Left

Foot in relaxed Neutral Neutral stance and gait Pronated Pronated Supinated Supinated

Heel position in Vertical Vertical

relaxed stance Inverted Inverted

Everted Everted

Hubscher 30° dorsiflexion 30° dorsiflexion Maneuver <30° dorsiflexion <30° dorsiflexion(Jack’s Test)

Lay the patient prone (or kneeling on an ordinary chair). Place the foot into talo-navicular congruency and fully pronate the forefoot by loading the 4th & 5th metatarsal heads. Observe the plantar forefoot position relative to a longitudinal bisection of the heel.

Keep the patient’s foot in the same posi-tion as described above, and note the position of the first metatarsal head rela-tive to the plane of the forefoot through metatarsal heads 2 to 5.

Observe the medial aspect of the foot and ask the patient to maximally dorsiflexion the toes.

Observe the lateral aspect of the foot and ensuring the knee is extended and foot does not evert, ask the patient to maximally dorsiflex the ankle.

Observe the lateral aspect of the foot and check forefoot to rearfoot position of the foot on a sagittal plane.

Sit the patient on the couch with their legs extended and their back pressed hard up against the wall to level the pelvis. Hold-ing the ankles push the femoral heads back into the acetabulae and check the level of the tips of the malleoli.

Observe the feet in relaxed stance for excessive pronation, including: everted heels, medially prominent talar heads, Helbing’s sign, abducted forefeet, etc.

Observe the heel position in relaxed stance.

With the patient in relaxed stance, and without allowing the foot to invert, lift the hallux off the supporting surface with a thumb.

QUICKTHOTICS® CIS5-Minute Biomechanical Examination

QUICKTHOTICS® | 29

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