Pronation deviations that occur at the feet and ankles — called overpronation or underpronation (also known as supination) — are some of the most common underlying postural problems that adults develop. To one degree or another, collapsed arches may now affect the majority of the adult population living in industrialized nations.
Overpronation is such a prevalent problem due to people wearing unsupportive shoes, having weak legs and walking on flat, hard surfaces. All of these contribute to changes in soft tissue structures of the feet, including loosened joints that cause foot bones to shift.
Considering our feet are usually the only point of contact we have with the ground, it’s not that surprising to learn that pronation abnormalities of the feet are common source of aches and pains. These problems begin in the arches of the feet and heels, but often spread up to the calves, ankles, knees and even back. People could be searching for low back pain relief without even understanding the source of the pain is the foot. And over- or underpronation during exercise or while playing sports can raise your risk for experiencing injuries, since pronation affects how you stand, run and distribute your body weight.
Today, a key focus of physical therapists, personal trainers, coaches and other practitioners who treat muscular compensations is identifying and correcting moderate-to-severe cases of overpronation problems (such as foot flattening) or those due to underpronation/excess supination (like having high arches). Because these affect the entire “kinetic chain” of the body, they can alter how the body’s weight is distributed and shock is absorbed during movement.
The definition of pronation is “the rotation of the medial bones in the midtarsal region of the foot inward and downward, so that in walking the foot tends to come down on its inner margin.” (2)
Although no one’s body is perfectly symmetrical and balanced, and therefore some over- or underpronation is considered normal, too much pronation in either direction will affect the normal gait cycle. The gait cycle takes place as the body moves forward. Rotation of the feet helps to provide shock absorption in the lower half of the body and keeps correct form/posture through the pelvis and spine.
The body moves in one continuous kinetic chain, which depends on the position of the subtalar joint. According to the American Orthopedic Foot & Ankle Society, the subtalar joint accounts for a large portion of the inversion and eversion range of motion of the hindfoot, plus determines how the tibia and femur bones of the legs are lined up. (3)
It also allows the foot to accommodate to uneven or irregular surfaces. Over time, an over-pronated subtalar joint typically forces the tibia and femur bones to rotate inward, sometimes only very slightly, but in other cases more severely.
What are the causes of pronation abnormalities? These can include a combination of:
Common signs and symptoms of overpronation or underpronation usually include:
The good news is this: the arches in your feet are just like any other muscle in the body. They can be “taught” or trained to improve in terms of functionality, so pain from overpronation or underpronation is definitely treatable.
Even very small changes in the alignment of the ankles, knees and hips can cause visible changes to your posture or straining (such as valgus stress, the cause of collapsed knees or runner’s knee pain).
How do you know if you’ve developed abnormal pronation? To give you an idea of what healthy posture should look and feel like, try observing your posture.
Starting from your toes moving upward, here are several key areas to observe in your stance. These observations can clue you in to overpronation or underpronation/supination issues:
Most orthopedics or trainers will complete a physical exam of the lower extremities to look for signs of abnormal pronation and imbalances. Usually, they pay particular attention to any loss of functionality or sensory function (due to nerve damage) if pain is strong.
Improper form when standing, exercising or especially running is one of the most common underlying reasons for foot, heel and leg pains. This can lead to dysfunctions that causes symptoms to reappear again and again, even if you begin gradually and then rest enough in between sessions. When it comes to exercise-related injuries, many of the most common are due to fallen arches and flat feet.
Look for any of the signs below that indicate you’re using incorrect form:
Try to have the foot/heel make contact with the ground from the outside. Experiment with landing closer to the midfoot if you’re a heel striker and aim for a softer landing. Most runners naturally land more lightly when they don’t lead with the heel. Slightly increase cadence — the number of steps you take per minute. Avoid having only the toes do most of the pushing during lift-off. This might take some time to improve, but with training and practice it will become easier.
Overpronation often causes extra stress and stiffness in the leg and lower back muscles that can make matters worse. Regularly stretching the legs, especially after workouts, can help increase flexibility, range of motion and blood flow in painful areas. Ways to stretch the calves and hamstrings include:
Massaging, loosening and activating muscles throughout the lower body and feet can help restore proper alignment and break up tissue adhesions/scar tissue that’s contributing to arch problems. Even if you currently overpronate (or underpronate), it doesn’t mean you have to remain this way forever. You can “reteach” your muscles and joints how to distribute your weight in a healthier way — and having assistance makes this easier.
If you stand for prolonged periods during the day, if you’re an athlete or very active or if you’re suffering from overuse heel/knee pain, techniques like physical therapy, active release technique or those using cross friction can be useful for improving range of motion and reducing pronation deviations. Other soft tissue therapies to consider that may reduce pain from over- or underpronation, plus prevent future injuries, include: chiropractic adjustments, Graston technique or seeing a massage therapist who can treat the calves, hamstrings and quadriceps.
If you’re overpronating, you may notice that the inside soles of your shoes experiences more wear-and-tear than the outside. Your shoes may appear to roll inward. Here are tips for choosing the best shoes or sneakers that will be most supportive for overpronators:
People who overpronate can develop growths or other minor injuries on their toes and feet, like calluses or bunions, from their outside heels or toes rubbing against their shoes too much. When pain becomes bad, you can apply ice several times a day for 20 minutes at a time. Elevate your affected foot to help reduce swelling, and try massaging the foot with an anti-inflammatory essential oil.
You can try applying a homemade muscle rub on your foot to help keep swelling down; a few drops of organic essential oils, like frankincense and peppermint oil, diluted in a carrier oil, work for that purpose, in my opinion.
Supinators should do extra stretching of the calves, hamstrings, quads and iliotibial band. See above for recommended leg stretches and foam rolling tips, plus add some of these routine:
Leg exercises to help reduce muscular weakness in the legs include:
Signs of underpronation (excess supination) will show up in your sneakers or shoes, usually causing the outer edge of the shoe to become flimsy more quickly. Replace your sneakers regularly, especially if you exercise often. To see if you’re due for a new pair, place your shoes down on a flat surface and look for the outer edge to tilt outward. Experts also recommend trying more flexible, lightweight sneakers for underpronators who spend lots of time on their feet (including running or walking). Lightweight shoes can withstand more foot motion, especially those with flexible inner edges.
If working with a trainer to correct a pronation problem you’ve identified, keep in mind that attempting to treat the problem too quickly or aggressively can result in muscle fatigue and further compensations. Pronation problems should be adjusted over time so that susceptible or sore muscles and joints can get used to redistributing weight and shock absorption. Otherwise postural problems may become worse. If you feel heel pain or pain radiating upward from your ankles, consider that other problems might be contributing to your symptoms. Heel spurs, tendonitis and arthritis should be ruled out as the causes of stiffness and pain, for example.
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