‘Overpronation’ … the quack is strong in this one …

…so is the Dunning-Kruger effect. I have written before on some of the nonsensical stuff that gets written on ‘overpronation’, but most of that is limited to the crankosphere blogosphere, and forums where you can just make stuff up and wish it was true and not provide any citations or evidence to back up the wishful thinking. This has not filtered through to the scientific academic literature, presumably as the peer review process keeps out the nonsensical stuff. That is until now. I am referring to two papers that recently appeared in Journal of Bodywork and Movement Therapies. Those who have been reading some of my recent posts will be familiar with the occasional failure of the peer review process to get it right. The papers are:

Don’t get caught flat footed – How over-pronation may just be a dysfunctional model
Matt Wallden
Journal of Bodywork and Movement Therapies, Vol. 19, Issue 2, p357–361 Published online: March 11 2015
The over-pronated foot – A new paradigm
Matt Wallden
Journal of Bodywork and Movement Therapies; Published online: September 23 2015

A metaphorical Mack Truck can be driven through the holes in what is being proposed by the author. There are so many issues to be addressed, but I am only going to pick on a few to show just how strong the quack is in this one, otherwise I will be here all day writing:

One of the early premises advanced by the author was the effect of foot orthotics on weakening muscles. The first thing you notice that the author cited no reference for such a claim. Secondly, the author did not reference any of the studies that have looked at muscle strength and foot orthotics. The problem is that if  they did cite them, then they would have had to debunk their own theory! Two published studies (here and here) have shown muscles getting stronger with the use of foot orthotics. One unpublished conference abstract (here) has shown foot orthotics not weakening muscles and another unpublished study (here) has shown the orthotic wearing group was the strongest. Why did they not cite the evidence around this? I can think of two reasons:
1. They did not know about the studies; in which case they should not be publishing on a topic in which they are not familiar with the body of literature that underpins it; or
2. They did know about them but did some serious cherry picking or intellectual dishonesty to not cite them as they debunk their own theory

Either way where was the adequacy of the peer review and editorial processes in not pointing this out and dealing with it?

They then propose their new “paradigm” to deal with overpronation and that being certain exercises. I got two things to say about that:
Firstly, they fail to point out the relationship between muscle strength and arch height/’overpronation’. All the studies show that there is no relationship between muscle strength and arch height or ‘overpronation’ (here, here, here, and here) except that there are two studies showed that increasing strength led to a lower arch (here and here). If the author were to cite those studies, then they would have had to debunk their own “paradigm”. Why did they not cite the evidence around this? I can think of two reasons:
1. They did not know about the studies; in which case they should not be publishing on a topic in which they are not familiar with the body of literature that underpins it; or
2. They did know about them but did some serious cherry picking or intellectual dishonesty to not cite them as they debunk their own theory

Either way where was the adequacy of the peer review and editorial processes in not pointing this out and dealing with it?

Secondly, the proposal that the exercises proposed will stop overpronation. There are many causes of ‘overpronation’ of which weak muscles is one; there could be as many as a 100 others. I can see how the exercises proposed by the author would help those with weak muscles (and I assume that this is an uncommon cause of ‘overpronation’) but that would be an epic fail at dealing with the other 100 causes! For example, a common cause is tight calf muscles. If the tibia can not move forward over the foot at the ankle joint an adequate amount, then the one way it can keep moving forward is for the midfoot to collapse (ie ‘overpronation’). How are strengthening exercises supposed to fix that? It will not matter how strong the muscles are made, the midfoot will still collapse to allow the tibia to move over the foot. These people need calf muscle stretching (and fibula mobs and a heel raise). As another example, an uncommon cause of ‘overpronation’ is the construct of an osseous forefoot varus which is a foot type in which the forefoot is inverted relative to a neutral rearfoot. This foot has to ‘overpronate’ to get the medial side of the forefoot to the ground. No amount of exercises anywhere is going to change that; that medial side of the forefoot has to get down to the ground. If exercises could stop the ‘overpronation’ in this foot type, then they would be walking around (and running) with their big toes off the ground!

I have just used two examples (tight calf muscles and forefoot varus) to illustrate the folly of the proposed approach to all of the ‘overpronations’. It is easy to go through all the other potential causes to make the same point. Why did the author not mention anything on all the different causes of ‘overpronation’ and the potential of the paradigm that they are proposing to deal with them? I can think of two reasons:
1. They did not know about all the other causes; in which case they should not be publishing on a topic in which they are not familiar with the body of literature that underpins it; or
2. They did know about them but did some serious cherry picking or intellectual dishonesty to not mention them as they debunk their own theory
Either way where was the adequacy of the peer review and editorial processes in not pointing this out and dealing with it?

I could keep going with the holes in this proposed model, but the above three more than debunk it. Models and paradigms to base clinical practice on are important. However they need to be consistent with the evidence; they need to explain the available evidence or they are not much use to base clinical practice on. This model or paradigm fails on that.

None of this means exercises proposed are not helpful to manage some clinical conditions. They are helpful and I use them.

If someone has ‘overpronation’ and if there is an indication that it needs to be addressed, then you address what is causing it. There is no one blanket approach to all.

As always, I go where the evidence takes me until convinced otherwise …. and this is not a new paradigm for ‘overpronation’.

POSTSCRIPT: I have just been informed (and confirmed) that the author of the two papers is on the Editorial Board of the journal. That conflict of interest was not declared in the paper as it does affect the editorial and peer review process. Oh dear!

Wallden M (2015). Don’t get caught flat footed – how over-pronation may just be a dysfunctional model. Journal of bodywork and movement therapies, 19 (2), 357-61 PMID: 25892392

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8 Responses to ‘Overpronation’ … the quack is strong in this one …

  1. Nigel Biggs October 16, 2015 at 9:49 pm #

    “These people need calf muscle stretching”

    Any evidence that stretching leads to lengthening of muscle,or does it just increase stretch tolerance?What type of stretching,eg passive or active,static or dynamic?

    • Craig Payne October 16, 2015 at 10:32 pm #

      Not sure on evidence; as not have looked at that literature in a while. BUT, those that do yoga can increase range of motions. I use a mix of “passive or active,static or dynamic” clinically for those that need it.

  2. Simon Kirkegaard October 23, 2015 at 10:39 am #

    Is there any association with overpronation and pain?

    • Craig Payne October 23, 2015 at 10:41 am #

      According to the evidence there is.

  3. Simon Kirkegaard October 23, 2015 at 2:23 pm #

    Would you be able to point me in a direction? 🙂

    What references do you have if I may be so bold to ask you for these.

  4. martin robson September 21, 2016 at 1:06 pm #

    The two references you provide seem to contradict your opinion that orthotics increase muscle strength. In your first reference the conclusion in the study is clear; foot orthotics and exercise is better than foot orthotics in isolation. The second study you list measured outcomes in pain not muscle strength. Did you read the studies you referenced?

    • Craig Payne September 21, 2016 at 6:55 pm #

      I did read them. Did you? The first one showed the orthotic group did get stronger (the orthotic and exercise group got stronger’er). The second one clearly showed that the calf muscles got stronger in the orthotic group. Suggest you re-read them.

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