Quickthotics® Component Insole System (CIS) by Waco Shoe Company

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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.

EspaĂąol franĂ§ais

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.

M13/W14

M9/W10

M4/W5

M2/W3

M1/W2

M12/W13

M10/W11 M8/W9

M6/W7

M5/W6

M14/W15

M0/W1

W4 M3

W8 M7

W12 M11

W16 M15

womens mens

1 thru 4

5 thru 8 4 thru 7

9 thru 12 8 thru 11

13 thru 16 12 thru 15

U.K. Europe

12.5 — 3 31 — 35

4—6 36 — 40

7 — 10 40 — 45

11 — 14 45 — 50

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

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

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Table of Contents

Anatomy of Quickthotics® Component Insole System (CIS)

The 5-Minute Quickthotics® CIS BME

Spenco® Quickthotics® CIS Pathology Specific Prescription Guidelines:

Common Plantar Forefoot Lesions

1st PMTPJ pain or lesion.

2nd PMTPJ pain or lesion.

5th PMTPJ pain or lesion.

Hallux PIPJ pain or lesion.

Common Musculoskeletal Pathologies of the Foot and Ankle

1st MTPJ pain.

Plantar fasciitis.

Plantar calcaneal bursitis.

Sinus tarsi syndrome.

Chronic lateral ankle instability.

Achilles tendonitis.

Common Musculoskeletal Pathologies of the Lower-LImb

Tibialis posterior tendonitis.

Peroneal tendonitis.

Patello-femoral pain syndrome.

Pes anserinus friction syndrome or bursitis.

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

Gait related low-back pain.

References 27 Appendix – Quickthotics® CIS Biomechanical Examination Form

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Anatomy of the QUICKTHOTICS® CIS Insole [1] Spenco® TOTALSUPPORT® Insoles The 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 Plugs QUICKTHOTICS® 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 Plugs QUICKTHOTICS® 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 Supports The 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 Wedges 75 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 Lifts 3.0mm, 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.

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[7]

[4]

[9]

[5]

[8]

[2]

[6] [3]

[1]

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QUICKTHOTICS® CIS

5-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.

Forefoot 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.

1st Metatarsal Head Position With 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.

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Passive Hallux Dorsiflexion Observe 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°.

Passive Ankle Joint Dorsiflexion Observe 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°.

Forefoot 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.

Limb Length Sit 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 | 7 ®

Foot Posture in Stance and Gait Observe 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.

Heel Position in Relaxed Stance Observe the heel positions relative to the ground in relaxed stance. Chart the positions as either VERTICAL, EVERTED, or INVERTED

Modified 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° +).

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Pathology Specific Prescriptions using the

QUICKTHOTICS® CIS When 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.

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Common Forefoot Pathology 1st PMTPJ Pain or Lesion For 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速 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.

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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 | 11 ®

Case Presentation 2 Fred W: An active 60-yearold 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 Lesion The 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.

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Case Presentation 3 Jim 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 Lesion In 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].

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Case Presentation 4 Erica 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 Pain Excessive 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.

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Case Presentation 5 Jonathan 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 | 15 ®

Case Presentation 6 Faith 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 Bursitis Pain 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.

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Case Presentation 7 Fiona 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.

FPO

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.

Sinus Tarsi Syndrome An 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

Subtalar joint pronation to end range may cause talo-calcaneal compression and soft-tissue impingement in the region of the sinus tarsi

the excessive pronation moments at the subtalar joint and add a heel lift if the shoe style permits.

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Case Presentation 8 Joshua 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 talofibular 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 Instability If 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.

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Case Presentation 9 Ryan 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 Tendonitis A 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.

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Case Presentation 10 Samuel 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 Tendonitis Excessive 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 | 20 ®

Case Presentation 11 Danny 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 Tendonitis A 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 cutout to enhance hallux dorsiflexion.

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Case Presentation 12 Lisa 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 Syndrome Excessive 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.

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Case Presentation 13 Sally 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.

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Case Presentation 14 Simon 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.

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Case Presentation 15 Maria 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 Pain A pelvic tilt due to an anatomically short leg may cause a compensatory scoliosis that may be the aetiology of posturerelated 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.

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Case Presentation 16 Lincoln 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.

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REFERENCES 1. Hastings MK, Mueller MJ, Pilgram TK, Lott DJ, Commean PK, Johnson JE. Effect of metatarsal pad placement on plantar pressure in people with diabetes mellitus and peripheral neuropathy. Foot Ankle Int. 2007 Jan;28(1):84-8. 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. 3. Guldemond NA, Leffers P, Schaper NC, Sanders AP, Nieman F, Willems P, Walenkamp GH. The effects of insole configurations on forefoot plantar pressure and walking convenience in diabetic patients with neuropathic feet. Clin Biomech (Bristol, Avon). 2007 Jan;22(1):81-7. Epub 2006 Oct 13. 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. 5. Harradine PD, Bevan LS: The effect of rearfoot eversion on maximal hallux dorsiflexion. A preliminary study. J Am Podiatr Med Assoc (2000) Sep;90(8):390-3. 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. 7. Wong L, Hunt A, Burns J, Crosbie J. Effect of foot morphology on center-of-pressure excursion during barefoot walking. J Am Podiatr Med Assoc. 2008 Mar-Apr;98(2):112-7. 8. Greisberg J, Sperber L, Prince DE. Mobility of the first ray in various foot disorders. Foot Ankle Int. 2012 Jan;33(1):44-9. 9. Van Beek C, Greisberg J. Mobility of the first ray: review article. Foot Ankle Int. 2011 Sep;32(9):917-22. 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 dorsiflexion. J Athl Train. 2006 Apr-Jun;41(2):159-65. 12. Scherer PR, Sanders J, Eldredge DE, Duffy SJ, Lee RY. Effect of functional 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 rearfoot-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.

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):50713. 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 walking. 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.

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.

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.

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

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.

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).

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.

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

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.

18. Patel A, DiGiovanni B. Association between plantar fasciitis and isolated contracture of the gastrocnemius. Foot Ankle Int. 2011 Jan;32(1):58. doi: 10.3113/FAI.2011.0005.

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 IlioTibial Band syndrome. J. Anat 2006 mar; 2008(3):309-16.

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

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).

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.

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).

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QUICKTHOTICS® CIS

5-Minute Biomechanical Examination Patient:

Ref #:

Examination Date:

Chief Complaint:

Observations

Findings

Examination Technique

RIGHT LEFT Forefoot to rearfoot position

 Perpendicular  Varus  Valgus

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.

First metatarsal head position

 Neutral  Plantarflexed  Dorsiflexed

Hallux dorsiflexion

 65° or greater  <65°

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

Ankle joint dorsiflexion

 10° or greater  < 10°

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.

Forefoot to rearfoot position (sagittal)

 Forefoot and heel  level  Forefoot equinus

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

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

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

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

Foot in relaxed stance and gait

 Neutral  Pronated  Supinated

Observe the feet in relaxed stance for  Neutral excessive pronation, including: everted  Pronated heels, medially prominent talar heads,  Supinated

Heel position in relaxed stance

 Vertical  Inverted  Everted

Hubscher Maneuver (Jack’s Test)

 30° dorsiflexion  <30° dorsiflexion

With the patient in relaxed stance, and  30° dorsiflexion without allowing the foot to invert, lift  <30° dorsiflexion

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Helbing’s sign, abducted forefeet, etc. Observe the heel position in relaxed stance.

the hallux off the supporting surface with a thumb.

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Spenco Medical Corporation P.O. Box 2501 Waco, TX 76702-2501 Tel.: 254-772-6000 Fax: 254-772-3093 Toll-free: 1-800-877-3626 e-mail: spenco@spenco.com www.spenco.com in Canada: Toll-free: 1-800-387-9538

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