The information provided in this booklet is intended to be used by registered healthcare professionals trained in the use of foot orthotic devices. This booklet is not intended as a definitive statement on the subjects discussed within but rather to serve as a resource providing practical information to the reader. Nothing in this booklet shall be a substitute for professional medical advice, diagnosis or treatment. For the patient: Intended wearers must consult with a healthcare professional before using this product. Never disregard professional medical advice or delay in seeking it, because of something you have read in this booklet. Never rely on information in this booklet in place of seeking professional medical advice. ® 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. Español français
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The information provided in this booklet is intended to be used by registered healthcare professionals trained in the use of foot orthotic devices. This booklet is not intended as a definitive statement on the subjects discussed within but rather to serve as a resource providing practical information to the reader. Nothing in this booklet shall be a substitute for professional medical advice, diagnosis or treatment.
For the patient: Intended wearers must consult with a healthcare professional before using this product. Never disregard professional medical advice or delay in seeking it, because of something you have read in this booklet. Never rely on information in this booklet in place of seeking professional medical advice.
®
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.
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QUICKTHOTICS® | 2
Abbreviations used in this booklet:
BME Biomechanical examination LLD Limp length discrepancy
CIS Component insole system MPCT Medial plantar calcaneal tuberosity
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 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]
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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.
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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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.
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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
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.