A New Approach to Assessment of Foot Pronation
Flat feet or “pronated” feet are some of the most commonly used terms used in medicine. The usage of pronation has become so frequent that it has lost its context. What is a pronated foot? Why is it pronated? People are spending hundreds if not thousands of dollars on custom orthotics that often do not address the cause of the pronation. People spend money to have gait analysis and shoes selected to “fit their foot” yet they still have pain. It would be similar to wearing a patellar stability brace for the knee for patella femoral syndrome but never address the cause behind why the knee hurts to start.
There are two ways to look at feet. You can look at the foot from the forwards (forefoot) to back (rearfoot) or from back to front. For our sake we will approach looking at the foot from the rearfoot first and that all dysfunction elsewhere relates to the rearfoot.
An interesting perspective on pronation is the theory of “compensated supination” which I first heard of from Greg Johnson of the Institute of Physical Art. He suggests that the majority of pronated feet are actually supinated and pronation to compensate for excessive lateral foot loading. A good way to test this is to have your client to stand and place the ankle in subtalar neutral. Once in a “neutral” alignment, where does the foot stand? Is the first ray off the ground? Is the calcaneus inverted? This would be a sign that the foot is actually in supination at rest. One can not walk in pure supination and thus must pronate to get the first ray on the ground and push off the big toe. To accomplish this one often does a quick whipping motion to get the medial foot to the ground. This presents as pronation but actually it is a compensation for supination. Take a look at your clients and see for yourself. Do you think a big medial wedge in an orthotic would fix this issue? In other words would pushing the foot into more supination address the cause? Often the calcaneus, the talus, the mid foot, and first ray require mobilization and neuromuscular re-education to get out of the supinated position.
A high level thought is why are feet supinated to begin? One could suggest that American babies are bigger, making less room in utero, and thus forced more into supination during pregnancy. No evidence or facts can determine why a foot is supinated to begin.
Several pathologies develop due to the supinated lateral loading posture of the feet. A bunion is likely to occur in reaction to excessive slamming of the 1st ray to the ground to achieve toe off. It is common to develop a fracture of the 5th metatarsal or an inversion ankle sprain due to excessive lateral foot loading. Additionally, Achilles pathologies are common due to calcaneal inversion placing stress on the medial Achilles resulting in tissue deformation. All these problems can be resolved if we get the calcaneus in neutral alignment under the ankle mortise, ensure the talus is gliding under the mortise appropriately, and ensuring the mid foot can pronate appropriate to get the 1st ray on the ground at rest.
It’s a new approach to think about foot pronation. Regardless some feet are so poor that orthotics are necessary. I do not use the terms always and never because each person is different. For that reason each person requires a specific analysis to themselves where no shoe or orthotic is ideal for everyone.