Flat Feet? The Myth of Overpronation

The purpose of this blog is to discuss pronation & over-pronation, review what pronation actually is, examining what motions are occurring with this, review the research surrounding pronation, and what to do in cases where pronation may be symptomatic.

Introduction

Our ankle and foot connect our leg to the ground, allowing us to absorb and produce force for motion. Across our foot and ankle, there are 33 joints that function to help in navigating movement. Pronation is one of these motions, and it’s associated with various beliefs that it can lead to a range of injuries and cause pain, and should be avoided. Along with this, it is common for individuals to be given a label or describe themselves as a “pronator” or “over-pronator.”  Today I want to tackle this topic, explaining what pronation is, break down some of the misinformation and myths on it, and discuss when it may benefit from being modified and how to do so.

What is Pronation?

Pronation is a triplanar motion that occur s at one of the joints in the foot, the subtalar joint. When pronation occurs during stance, it leads to a lower arch height, widening of the foot, and and what most think of – the foot rolling inwards.

Pronation is not a diagnosis or something we need to label people by – it’s a motion. Each person’s pronation motion differs. How much you pronate, how fast you pronate, and when you pronate can differ from person to person. Labeling someone as a pronator is unnecessary, it would be like calling someone a shoulder flexor. All people with shoulders can flex their shoulders, just how much, how fast, how strong it is, etc. differs.

To better understand this, consider the elevator analogy from. You call it an elevator, not an upper or downer, even though it goes in both directions. The number of floors it may go through can vary from trip to trip and from elevator to elevator, and where the main floor sits can also differ. One elevator may have 4 floors above the ground level and 1 floor below, whereas another one may have 2 floors up and 3 floors down. The number of floors is the same, but where the ground floor starts is different.

Your foot is like the elevator and the number of floors you have is like the amount of pronation and supination. The ground floor is just an arbitrary resting position. 

Pain & Injuries

The individual resting in more pronation is usually called a pronator, and this is typically presented and explained as being problematic. People will cite pronation as the CAUSE of certain problems, such as plantar fasciitis, heel spurs, achilles tendinopathy, knee pain, hip pain, and even back pain. However, research doesn’t quite agree with this. 

There are two papers in particular that bring light to this. Neal 2014 completed a systematic review examining the research covering the association between static foot posture and lower limb overuse injuries. They found that the only relationship for pronation and an injury was with medial tibial stress syndrome and patellofemoral pain syndrome, however it was found that pronation was only a small risk factor for these conditions. 

Dowling 2014 completed a systematic review examining the research on the association between dynamic foot function and lower limb overuse injuries. Their systematic review had mixed results. They did find that those who developed non-specific lower limb overuse injuries did have a small risk factor for greater pronation excursion, meaning having more total pronation range of motion. However, pronation was not a risk factor for any other lower limb injuries.

Overall, research doesn’t support that pronation as an independent variable is associated with many injuries. Some argue that while it might not be associated directly, having more pronation leads to more injuries over all That’s where a study from Williams et al. comes in.

The group examined runners and looked to find an association between injuries and arch type. They found that whether someone had a higher or lower arch the incidence of injuries did not significantly differ, just where the location of the injury did. For instance, those with a low arch tended to experience more soft tissue injuries, more medial ankle injuries, and more knee injuries, whereas those with a high arch tended to experience more bone injuries, more lateral ankle injuries, and more foot injuries.

As such, you can see that pronation isn’t inherently the boogey man it’s often made out to be.

Movement & Performance

In general, our bodies are very adaptive and are able to find solutions to movements to allow us to execute tasks using different strategies. During stance, there is a range of relative motion that the foot and ankle joints are able to use, with some individuals using more or less at different stages, and this can change over time.

In Nester’s landmark paper for podiatry, the author explains the foot has many kinematic options for movement and that we should look to move away from the concept of the ideal mechanical foot and transition to a patient specific model for foot function.

Pronation is often viewed as a negative, but it may very well be a positive adaptation that allows you to be successful in activities. For example, Joshua Cheptegei is the current 5k world record holder and a runner who is often noticed for his high degree of pronation during stance. He utilizes pronation to his advantage by having quick ground contact, allowing him to have a faster step rate than other individuals in his group.

Modifying Pronation

Typically the topic of pronation comes up when individuals are having some kind of pain or injury. In some situations, it may be worth experimenting with altering pronation, such as the excursion amount with lower limb overuse injuries or the rate of pronation with anterior knee pain.

Pronation is typically occurring as a means of decelerating locomotion, or it may be occurring along with knee flexion as a way of allowing more forward knee travel once dorsiflexion has maxed out. Trying to have someone actively just limit pronation can be very challenging and likely leave the person just underloading whatever movement they’re trying to do as they focus on just controlling pronation.

Instead, taking an approach where you make an alteration to the task you are trying to do can allow you to reduce demand on pronation. For instance, in the case of deceleration with running, you could increase your cadence, which will decrease the amount of motion the ankle goes through, while also reducing the amplitude of ground reaction forces with each step, likely decreasing both the excursion and velocity of pronation. This will reduce the forces on the structures that are loaded more with pronation.

Or in the situation of doing activities like squatting or lunging where the knee travels forward and the person gets medial ankle symptoms, elevating the heel to reduce the relative motion demand on dorsiflexion can decrease the excursion the ankle goes through.

Doing this will decrease the demand on the tissues being loaded with pronation. Then over time you can grade your way back to full activities as your tolerance improves and symptoms reduce.

Load Management

Other options would be managing the total load. You may find that you’re able to run with your normal mechanics and cadence for 3 miles, but once you pass that, you start to get a flare up. In that case, you could focus on sticking to the mileage you can tolerate and try to slowly ramp that up over time.

This will limit pushing beyond your tissues current tolerance and let it build up slowly to a level that it can handle more.

Increasing Capacity

You could also look to begin performing a regular exercise program targeted at improving the capacity of the structures being loaded with pronation to be able to tolerate the forces and positions in your desired activities.

For example, you may be experiencing medial ankle pain associated with tibialis posterior tendinopathy and while using the load management options discussed prior will be beneficial, it would also be ideal to do structured exercises aimed at loading the area and encouraging adaptations.

Foot Orthoses

The last thing you may consider is the usage of some kind of foot orthosis. A foot orthosis can be a beneficial option to help off load certain structures temporarily, decreasing the force demands on them.

Our muscles and other soft tissues can get irritable if the load exceeds their tolerance. So by choosing an orthotic that can reduce the load, it can give the tissue time to calm down. This allows you to gradually improve your tolerance and capacity with the previously outlined options. Then over time, you can remove the orthosis.

Summary

Pronation is often misunderstood and inappropriately blamed as the source of all problems related to the foot, ankle, and lower body. In reality, pronation is a motion much like any other our body can do.

When examining the association between pronation and injuries, evidence doesn’t demonstrate a significant relationship for many injuries. Generally the main associations are for lower limb injuries such as medial tibial stress syndrome and posterior tibial tendinopathy, and patellofemoral pain syndrome.

There may be value in modifying pronation temporarily when someone is symptomatic, particularly through modifying activities such as changing cadence or forward knee travel demands in squatting activities, however this doesn’t need to be done forever. In addition, the tissues that are under demand with pronation can have their capacity increased through direct loading and developing these tissues.

If you want to learn more, I highly recommend checking out our podcast episode with Ian Griffiths:

Thanks for reading. Check out the video and please leave any questions or comments below.

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