Foot pain affects a quarter of the population at one time or another negatively impacting quality of life, daily activities and one’s ability to engage in a program of regular exercise (Thomas et al., 2011; Hill et al., 2008). So why is foot pain so prevalent and what can you do to help your clients (and yourself) understand and alleviate the underlying causes of this pervasive problem?
- The reader will learn why pronation is a necessary and vital function of the feet and ankles
- The reader will learn how overpronation can cause pain and dysfunction in the feet and ankles
- The reader will learn how to visually assess a client for overpronation and general recommendations for addressing/correcting this imbalance
Pronation Is Not a Dirty Word
Many people with recurring foot pain search for solutions on the Internet, seek advice from salespeople touting the benefits of supportive shoes/orthotics and try all sorts of inserts/devices to cushion/support their feet in an attempt to alleviate their pain. In pursuit of a cure, these people are often informed that the root cause of their problem is that their feet pronate. Trusting they have found the “cause” for their pain they latch on to the idea that pronation is bad and must be prevented at all costs. However, when it comes to understanding and alleviating foot pain, nothing could be further from the truth!
Pronation is a necessary (and extremely important) function of the foot and ankle complex that helps not only the foot, but the entire body, transfer and accept weight during virtually all weight-bearing activities (e.g., standing, lunging, squatting, walking, surfing, skiing, running, playing almost all sports, cooking, cleaning, taking a shower, etc.). Think of pronation as akin to salt. Sodium (i.e., salt) is a vital and important nutrient that enables the body to function optimally and efficiently. It helps us retain water, digest foods and maintain the musculoskeletal/neuromuscular system. However, too much salt is extremely dangerous and can cause hypertension, water retention and even death (MacGregor & Wardener, 1998). Therefore, while pronation is essential for optimal foot function, too much pronation or overpronation on the other hand is extremely detrimental. Over time, overpronation can lead to recurring foot pain (as well as a whole host of aches and pains elsewhere as the rest of the body tries to compensate for dysfunction at the foot).
Why Pronation Is Helpful
Pronation is typically thought of as simply a moving inward of the foot toward the midline of the body (i.e., a frontal plane motion). However, pronation actually incorporates three planes of motion. This means that movement not only occurs from side-to-side during pronation, but forward and in rotation as well; the shin bones come forward over the foot (i.e., dorsiflexion: a sagittal plane motion), the heel bone rolls inward (i.e., eversion: a frontal plane motion) and the foot turns out slightly in relation to the ankle (i.e., abduction: a transverse plane movement) (Houglum, 2016). These three movements inherent in pronation enable the ankle, shins, knees, thighs, hips, pelvis, spine, shoulders and head to move forward, sideways, and rotate over the foot. Equally, these movements also ensure that all the strong, supportive structures of the feet (i.e., Achilles tendon, medial longitudinal arch, lateral longitudinal arch, transverse arches and all five toes) are stimulated correctly to absorb and dissipate shock. Overpronation, on the other, hand disrupts all of these movements. It causes the heel to collapse inward too far, the ankle to not bend forward enough and the foot to turn out too much. These dysfunctional movements cause strain, stress and eventually pain.
How You Know If Someone “Over”pronates
There are many hands-on assessment techniques that can be used to evaluate if someone overpronates. However, some of the simplest and most applicable assessments in a personal training setting are visual assessments that can be performed easily by a trained observer (Price & Bratcher, 2010).
Start the visual assessment for overpronation by instructing your client to stand in bare feet facing you in their normal standing position. Now take a look at the client’s feet, ankles and toes. Specifically, you are looking for the appearance of bunions, calluses, toes that are not pointing forward (i.e., a big toe that points toward the lesser/smaller toes is called hallux valgus), swelling and inflammation of the feet/ankles and feet that are turned out like a duck (i.e., abducted) (see images below). The presence of any (or all) of these suggest that the client habitually overpronates and is not accepting, transferring, or absorbing shock through their feet correctly.
Why do these visual clues point to overpronation? Because overpronation is characterized by a collapsing inward of the foot and ankle toward the midline of the body and the lower leg not coming forward over the entire foot as it should. This means that weight is transferred across the inside border of the foot upon weight acceptance, rather than being transferred forward over the big toe and the lesser (i.e., smaller) toes. This excessive pressure over the inside of the foot causes inflammation to the first joint of the big toe (i.e., bunions) and calluses on the skin. Since the rest of the big toe is not being utilized to help transfer weight, it eventually shifts position to move out of the way (i.e., hallux valgus) (see image above). The lesser toes find themselves constantly gripping the ground in an effort to maintain balance and end up appearing bent and crooked. Furthermore, as the foot and ankle collapses inward it compresses the tissues in these areas which can result in swelling and pain.
The excessive inward movement of the ankle and knee characteristic of overpronation also pulls the knee and upper leg out of alignment and toward the midline of the body. To compensate for this internally rotated position of the ankle and knee, a person will unconsciously turn their foot/feet noticeably outward to help externally rotate the tibia and fibula (i.e., shin bones) and align the kneecap forward again. This is why a person who overpronates would have an abducted foot position when standing or walking.
What You Can Do to Prevent Overpronation
Habitual overpronation can cause inflammation to the joints of the foot and ankle. This inflammation prompts the nervous system to restrict movement in these areas to prevent further pain/inflammation. As a result, some muscles and soft tissues “tighten up” to limit movement while others work overtime to make up for those that are not doing their job(s) correctly. Therefore, the first stages of retraining and rehabilitating the feet involve following a regular program of self-myofascial release and/or self-massage. This will help improve the health and flexibility of those soft tissue structures that have become restricted as a result of overpronation. These strategies should focus on those muscles that promote motion (i.e., pronation) in all three planes of movement (e.g., tibialis anterior, tibialis posterior, peroneals, flexor hallucislongus, gastrocnemius and soleus).
Stretching techniques should then be introduced after the self-myofascial work has been performed to increase the ability of the feet and ankles to roll inward, bend forward, and rotate. These range of motion exercises are vital for preparing the feet and ankles to progress to corrective strengthening and weight-bearing movements. As you lead your client into the strengthening phase of their corrective exercise program it is important to remember to add weight/load gradually so you do not overload their body and simply trigger their nervous system to “tighten back up” in protection.
If you are interested in learning more about assisting clients affected by foot/ankle pain, check out Corrective Exercise Solutions: Foot & Ankle Pain. Also available from the Biomechanics Method is the Corrective Exercise Specialist Course, a complete guide on helping clients who have foot, ankle, knee, shoulder, neck or back pain.
Hill C., Gill T., Menz H. & Taylor A. (2008). Prevalence and correlates of foot pain in a population-based study. Journal of Foot and Ankle Research, July, 1, 2.
Houglum, P. (2016). Therapeutic exercise for musculoskeletal injuries. (Fourth edition). Champaign, Illinois: Human Kinetics.
MacGregor, G. A., & Wardener, H. E. (1998). Salt, diet and health. New York: Cambridge University Press.
Price, J., & Bratcher, M. (2010). The BioMechanics Method corrective exercise specialist certification program. San Diego, CA: The BioMechanics Press.
Thomas, M. J., Roddy, E., Zhang, W., Menz, H. B., Hannan, M. T., & Peat, G. M. (2011). The Population Prevalence of Foot and Ankle Pain in Middle and Old Age: A Systematic Review. Journal of Pain. Dec;152 (12):2870-80.