The nonsensical understanding of ‘overpronation’

The understanding of ‘overpronation’ on running blogs, forums, magazines and in the running shoe retail community has become so nonsensical its laughable and that nonsensical understanding is also filtering into the health professional community. Everyone who can spell the word seems to have become an expert in it and have an opinion on it. In most cases, clearly the understanding of it is so superficial, it has come close to being dangerous, so lets go through it:

What is ‘Overpronation’?
In the context of foot biomechanics, “pronation” is generally defined as a motion in which a joint simultaneously everts, abducts and dorsiflexes (supination is the opposite and is when a joint simultaneously inverts, adducts and plantarflexes). Pronation is nothing more than a motion, it is not a disease state or anything bad. Pronation and supination can occur at a number of joints, but only occurs when the putative axis of motion of a joint is not in any one of the three body planes and makes an angle with all three. The subtalar joint in the rearfoot is one joint that allows pronation and supination due to the orientation of its putative axis of motion. At the subtalar joint the rearfoot can pronate and supinate relative to the leg. The putative axis of motion of the midfoot joints allow pronation and supination of the forefoot on the rearfoot.

When you are standing (or running) and the subtalar joint pronates, then this simultaneous abduction, dorsiflexion and eversion of the calcaneus on the talus at the subtalar joint, the rearfoot rolls inwards at the ankle, the arch collapses and the forefoot abducts. Obviously, “overpronation” occurs when there is too much of this motion, whatever that may be! This is what the rearfoot typically looks like if the subtalar joint has overpronated and is what most people misunderstand to mean as “overpronation” (see images¹):

overpronation overpronation

To call that as “overpronation” is somewhat nonsensical as if the rearfoot is “overpronated”, then the forefoot must be “oversupinated” at the same time – can you see how bad it is to use that term? I have even seen people who should know better quote references on research on “pronation” and use the reference as though it was talking about the rearfoot, when the research was actually on pronation of the forefoot on the rearfoot (ie the rearfoot must have been supinated when the forefoot pronates!). This is complicated and not simple.

What is its link to injury?
The reason “overpronation” has got so much attention as most running injuries (and a whole lot of other things) have at one time or another been linked to it. Despite this widespread belief, the evidence linking excessive foot pronation to injury is not good. Most studies have found no relationship and those that have found a relationship reported that the link is weak. For those clinicians who try to adhere to the principles of evidence based practice, this is problematic. Having said that, the evidence is also clear that if you do something to treat excessive pronation, then people do get better.

Is ‘Overpronation’ a problem?
It certainly can be. “Overpronation” can be a problem if it contributes to increased load in the tissues beyond what the tissues can take (see: What causes an overuse injury). It is going to be a problem if the forces associated with that “overpronation” are high enough to cause damage to the tissues. Don’t forget that the evidence is clear that when you use a foot orthotic to treat “overpronation”, people do get better despite the evidence of no or weak links between it and injuries. There is no doubt about that, but it does point to the paradox as to why if the link between overpronation and injury is so tenuous do people get better? There is no debate that they work or don’t work (except in the minds of those who can’t or haven’t read the scientific evidence!), but the paradox points to the debate and poor understanding as to the mechanism of action of foot orthotics. Some have taken this debate or poor understanding of the mechanism of action to imply that orthotics do notwork,when the evidence is clear that they do.

This points to “overpronation” being a problem, we just need to learn, research and understand more about the mechanism and that has to do with moderating the forces associated with it that go through the tissues to cause the damage. Plenty of people overpronate and have no problems; yet others that only overpronate a small amount can have problems – this all points to it being related the the magnitude of the forces associated with that overpronating is possibly the problem (invariably that is probably related to variations in joint axes position and the lever arms that tendons have to those axes as a consequence).

What causes ‘Overpronation’?
If I was pushed, I could probably, come up with a 100 causes for “overpronation” of the rearfoot. There is no one cause. I will be here all day writing if I was to go through them all, so I will use four examples to illustrate the point I am trying to make with this post:

  • a tight calf muscle will cause the rearfoot to pronate excessively. As the leg moves over the foot at the ankle joint, if the calf muscle is tight, the ankle will reach its end range of motion early and will not go any further. The only way the leg can go further is if the midfoot (arch) collapses. This can only happen if the rearfoot pronates some more.
  • proximal control may be an issue. This is due to issues around the hip and pelvis that allow the leg to internally rotate more or at a time that it shouldn’t. The internal rotation of the leg causes the foot to pronate more at the rearfoot. This could be an issue with the sacroiliac joint; with the strength of the gluteal muscles; or simply a motor control or a co-ordination issue.
  • weakness of the posterior tibial muscle. This muscle is one of the most important supinators or resistors of pronation of the rearfoot, so any weakness is going to be problematic. However, if this muscle is the problem, it is not always a weakness that is the issue, it just may have a very short lever arm to the axis of motion of the joint it is trying to control, so it just can not do its job very well, despite being strong.
  • forefoot varus. This is just one of many bony alignment problems. It is uncommon, probably making up only 1-2% of osseous alignment problems in the foot. Even though it is rare, it is a very simple foot type to understand. Essentially a forefoot varus is when the forefoot is inverted (or in varus) on the rearfoot due to a bony or osseous issue. When standing with the rearfoot vertical, the medial or inside of the forefoot is off the ground. The whole foot has to pronate at the rearfoot to get the foot to the ground. This is a bony problem and nothing to do with the soft tissues or muscle strength.

How do you treat ‘Overpronation’?
You treat the cause (that is of course, assuming it actually needs treating!). Anyone who advocates one treatment over another for ‘overpronation’ are just showing that they are clowns and really have no idea what they are talking about. For example:

  • Strengthening the gluteal muscles will work brilliantly at fixing ‘overpronation’ if a weakness of the gluts is the cause of the ‘overpronation’; it will fail dismally if the cause of the ‘overpronation’ is, for eg, tight calf muscles – the leg still has to move forward over the foot and can only do that if the midfoot collapses (ie rearfoot overpronates); it does not matter how strong the gluts are, its still going to do it.
  • Transitioning to minimalist or barefoot running to strengthen the muscles will work brilliantly at fixing it if the weak muscles were the cause of it; this will fail dismally if it was not the cause of the “overpronation”! Running shoes do not weaken muscles.
  • If the cause is a bony alignment problem (eg forefoot varus), then only foot orthotics will work to stop the “overpronation”. No amount of barefoot running or gluteal strengthening is going to stop this one. In a forefoot varus, the medial side of the foot is going to have to get to the ground somehow and it does that by pronating at the subtalar joint. No amount of muscle strength is going to stop that (actually it probably could, but you will be running around with the big toe off the ground and I not sure anyone wants to be doing that!). Foot orthotics will fail dismally if a tight calf muscle is the cause of the excessive pronation.
  • A heel raise (short term) and calf muscle stretching (medium and long term) will work brilliantly if a tight calf muscle is the problem; it will fail dismally if the cause is, for example a posterior tibial muscle weakness or a proximal control issue. There is a caveat (and this applies to some of the others as well), in that there may be a lot of bony adaptation that occurred over a period of time and it may not be possible to reverse that (are you starting to get a feel for how complicated all this is?).
  • Strengthening muscles like the posterior tibial muscle will work brilliantly if it is weak; it will fail dismally if the calf muscles are tight or there is a bony alignment problem like forefoot varus. Additionally, it will probably also fail or be limited in its success if the lever arm that the tendon has to the subtalar joint axis is short – you can not make the muscle strong enough to overcome that mechanical deficit.

Can you see where I am going with this? I can’t possibly go through all the treatment options here for all the different causes, but hopefully you get the picture. If “overpronation” needs treating you treat what is causing it. There is not one cause of “overpronation” and so therefore, there is not one treatment of “overpronation”. Those who advocate a blanket, ‘one size fits all’ are talking through a hole in their heads. Foot orthotics are not a magical cure for it. Barefoot or minimalist running is not a magical cure for it. Strengthening the gluts is not a magical cure for it. Motion control running shoes are not a magical cure for it. {INSET WHATEVER HERE} is not a magical cure for it. Do you get the point: You treat whatever is causing it! (with the caveat that we are assuming that it actually needs treating in a particular individual).

Can a running shoe stop “overpronation”? Of course it can, but that will depend on the cause of the overpronation. All the research to date on running shoes stopping “overpronation” has mostly concluded that it can’t. But those studies included subjects with all causes of “overpronation”!  Can you see how that kind of information is not going to be particularly helpful? What if all the subjects in a particular study on “overpronation” and running shoes had, for eg, tight calf muscles? The shoes will change nothing! The response of “overpronation” and running shoes is going to be subject specific. It will stop some and not stop others and make others pronate more (so the mean response in the research will be no difference – ie the running shoes can’t control “overpronation”!) We need to sub-analyze the different groups based on what caused the “overpronation” to see which ones can and can’t be affected by which types of design features in the running shoes. I will blog separately about this as its too big of a topic for this post.

As always, I go where the evidence takes me until convinced otherwise. This is where the evidence has taken me in my understanding of “overpronation”. You are welcome to convince me otherwise, preferably with something that is consistent with the evidence, or backed up with evidence and not something supported by a nonsensical rant or anecdotes or cherry picking.

¹Images courtesy Ian Griffiths.

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The nonsensical understanding of 'overpronation'
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There are so many myths about ovepronation. This Article attempts to address those nonsensical myths about it.
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15 Responses to The nonsensical understanding of ‘overpronation’

  1. Christian August 28, 2013 at 11:43 am #

    Hey Craig,

    If you get the time could you please clarify something for me?

    1) Would you consider “Over-pronation” as anything beyond STJ neutral??? Or is this just a transient position that the foot passes in an out of during gait.

    2) Would you consider “over-pronation” as a motion occurring to the limits and beyond of available motion at the STJ?

    3) Is an individual with a medially deviated STJ going to present with a calcaneal bisection more everted when STJ is in neutral???

    4) Would you consider “over-pronation” as more a timing issue? i.e. the rearfoot remains relatively pronated late into the stages of propulsion

    5) If the MTJ “over pronates” to compensate for ankle equinis, would that not cause the STJ to supinate considering the belief that when one does one thing the other does the opposite?

    Thanks again for making all this information so freely available

    • Craig Payne August 29, 2013 at 4:16 am #

      I got the time, given my employment status just changed!

      I don’t really have an answer which is why I tend to usually put ‘overpronation’ in inverted commas!

      STJ neutral is just an arbitrary position that the foot momentarily passes through; it does not function around it. One way of defining ‘overpronation’ would be a position that is pronated beyond neutral, but the problem with that is, is it abnormal or not (it would be abnormal if there were high forces associated with it and not abnormal if low forces associated with it). See the post on supination resistance.

      In general, in medicine, normal is defined as within a couple of standard deviations of the asymptomatic population mean. If we use the foot posture index, then one standard deviation from the mean is an FPI of 7 …. which almost every clinician would probably consider ‘overpronated’! …. so that’s not a lot of much help.

      (2) not necessarily – the STJ can pronate to end range and not be symptomatic unless the forces that got it there are high… so we could use the term, ‘ovepronated’ but it does not necessarily mean that its symptomatic

      (3) not necessarily, but is it more likely. There are always the occasional exception.

      (4) that is another way of looking at it, esp when foot is in pronated position late in stance – — everything above is going in the opposite direction, so that conflict is going to be painful, IF the forces are high enough.

      (5) the MTJ supinates/inverts with STJ pronation; which can be one of a number of ways to compensate for an alleged ankle joint restriction.

  2. Mugen September 11, 2013 at 2:55 pm #

    Hi Craig,

    Thanks a lot for explaining about the different reasons that can cause overpronation.

    However, I have a different reason. I purchased a pair of new shoes which weren’t right for me. It was really awkward to walk around in but I just bought it at the time without much thought. Overtime I developed knee pain and over-pronation. My walk became noticeably awkward. So I discontinued the shoes and switched to something more comfortable.

    Do you have any idea as to which kind of correction method could apply to such a case?

    • Craig Payne September 11, 2013 at 7:44 pm #

      Sorry, could be a large number of reasons and really need to see it. I would only be guess to say more.

  3. julie greenhalgh October 9, 2013 at 12:58 pm #

    hi Craig, great article although i confess to not quite understanding some bits, i get the general drift!

    a quick question for you – can you over-pronate when running barefoot or wearing something like vibram five fingers?

    cheers

    julie

    • Craig Payne October 9, 2013 at 7:19 pm #

      Maybe/maybe not. All depends on the cause of the overpronation. There is no blanket answer. The fan boys will tell you that you don’t, but they are just confirming that they don’t know what they are talking about as there is no blanket answer.

      • julie greenhalgh October 10, 2013 at 11:06 am #

        had a feeling this may be the case, so much about running depends on our individuality and particular biomechanics. it’s a bugger when you are trying to look for answers!

        cheers for the reply

        julie

        • Paulo, a.k.a. FanBoy2014 August 3, 2014 at 4:17 am #

          Hi Julie,

          If you find arch supports and/or motion control shoes resolve your overpronation, then you might consider remaining with those methods, and/or also changing to a forefoot or midfoot strike. It’s been suggested that over-pronation is caused by ankle/foot rotation after the heel strike, so just changing to a forefoot or midfoot strikes are said to alleviate the issue as well.

          Transitioning to barefoot/minimalist is a very long (1-2yr or more), possibly injurious, process that reconditions the structure of your feet. The changes in musculature and tendons occur by not only strengthening them, but also possibly breaking them down and then rebuilding them.

          You’ll likely find that wearing mainstream footwear begins to hurt your feet, and I can only imagine how painful wearing high-heels could become.

          I like barefoot and minimalist. There’s a lot of anecdotal evidence and reasoning that I agree with, but very little is publicized about the possible injuries and other results like the aforementioned possible incompatibly with wearing mainstream footwear.

          However, being a woman, you might be accustomed to wearing flats, ballet shoes, and sandals so perhaps you might not have any transition issues.

          Anyway, just wanted to share an alternative viewpoint to the other fanboys. As you’ve probably read elsewhere, it’s suggested the best way to transition to barefoot and minimalist is to start walking barefoot at home regularly. After you feel sufficiently comfortable with that then just start running barefoot without any minimalist footwear…the idea being that you’ll intrinsically adjust your stride to prevent discomfort, and your soles will become sore before you’re able to structurally injure your feet. For this same reason it’s suggested you start with running on asphalt because you’ll naturally run more gently. Alternatively, just walk around barefoot everywhere for a long time.

        • Paulo August 3, 2014 at 4:41 am #

          Hi Julie,

          Firstly, this is the most informational article I’ve read regarding causes of over-pronation. It’d be wise to consider each of these reasons.

          If you find arch supports and/or motion control shoes resolve your overpronation, then you might consider remaining with those methods, and/or also changing to a forefoot or midfoot strike. It’s been suggested that over-pronation is caused by ankle/foot rotation after the heel strike, so just changing to a forefoot or midfoot strikes are said to alleviate the issue as well.

          Transitioning to barefoot/minimalist is a very long (1-2yr or more), possibly injurious, process that reconditions the structure of your feet. The changes in musculature and tendons occur by not only strengthening them, but also possibly breaking them down and then rebuilding them. Consider how long it takes for foot orthotics to permanently cure foot issues so an orthotic is no longer needed.

          You’ll likely find that wearing mainstream footwear begins to hurt your feet, and I can only imagine how painful wearing high-heels could become.

          I like barefoot and minimalist. There’s a lot of anecdotal evidence and reasoning that I agree with, but very little is publicized about the possible injuries and other results like the aforementioned possible incompatibly with wearing mainstream footwear.

          However, being a woman, you might be accustomed to wearing flats, ballet shoes, and sandals so perhaps you might not have any transition issues.

          Anyway, just wanted to share an alternative viewpoint to the other fanboys. As you’ve probably read elsewhere, it’s suggested the best way to transition to barefoot and minimalist is to start walking barefoot at home regularly. After you feel sufficiently comfortable with that then just start running barefoot without any minimalist footwear…the idea being that you’ll intrinsically adjust your stride to prevent discomfort, and your soles will become sore before you’re able to structurally injure your feet. For this same reason it’s suggested you start with running on asphalt because you’ll naturally run more gently. Alternatively, just walk around barefoot everywhere for a long time.

          On a personal note, rather than barefoot or minimal, I attribute my not over-pronating to developing both a forefoot and midfoot strike. Unfortunately, the biomechanics of cycling being different, as I’ve increased my mileage I’ve now developed an over-pronated pedal stroke. The solution…firmer soled shoes and arch supports.

  4. Dr James Stoxen DC October 16, 2013 at 4:46 am #

    Hi there,

    Your article states that

    Don’t forget that the evidence is clear that when you use a foot orthotic to treat “overpronation”, people do get better despite the evidence of no or weak links between it and injuries. There is no doubt about that, but it does point to the paradox as to why if the link between overpronation and injury is so tenuous do people get better? There is no debate that they work or don’t work (except in the minds of those who can’t or haven’t read the scientific evidence!), but the paradox points to the debate and poor understanding as to the mechanism of action of foot orthotics. Some have taken this debate or poor understanding of the mechanism of action to imply that orthotics do notwork,when the evidence is clear that they do.

    What to you mean by saying “they work” How do you qualify “work”? Do you determine they work based on a reduction of pain or that they raise the arch or decrease the degree of pronation? I really find it interesting how you can be so caught up in semantics which is fine yet you have a very vague description of the short and long term results of the use of orthotics.

    Can you please explain what is meant by “they work”?

    Thank you

    Dr James Stoxen DC
    Video Tutorial #157a What Is Foot Pronation And Foot Supination? Is It Good Or Bad? – See more at: http://teamdoctorsblog.com/2012/03/video-tutorial-157a-what-is-foot-pronation-and-foot-supination-is-it-good-or-bad/#sthash.Q3WRZuZs.dpuf

    • Craig Payne October 16, 2013 at 5:49 am #

      “They work” = every single clinical outcome study; patient satisfaction survey; randomized controlled trial; etc (except one on bunions in kids) show patients symptoms get better with foot orthotics. No study (except one on bunions in kids) show that they don’t work on symptoms.
      There is even a Cochrane Review that show they work on “pain” – its does not get more equivocal than that.

      Mechanism of action studies are a totally different kettle of fish and that is supposedly open to debate (though I think the mechanism of action is clear –> they reduce the load in the damaged tissue).

  5. Christian November 18, 2013 at 5:57 am #

    Hey Craig,

    Was wondering if time permitting if you couldshed some light on something for me?

    How can a pes cavus foot type with ankle equinis present with a stable rearfoot at midstance? I.e. As you’ve suggested here, the stj and mtj may compensate for a lack of ankle dorsiflexion at the ankle.

    Perhaps we need to look proximal to the ankle. I.e. Increased motion at the knee as a form of compensation?

  6. Amy February 17, 2014 at 10:17 pm #

    I know I’m late to this post, but thought I’d comment anyway.

    I have bilateral hindfoot valgus and forefront varus, a leg length discrepancy, and am currently scheduled to have the HyProCure surgery.

    In the past, I was diagnosed with plantar fasciitis, heel spurs in one foot, and Achilles tendonitis. I experienced severe foot and calf pain, and was unable to start for more than twenty minutes. Customized and OTC orthotics and motion-control shoes were disastrous for my feet and legs.

    Currently, I only deal with occasional pain, which is sometimes severe and/or prolonged. I frequently develop large blister and callous, and am unable to wear most heels. I no longer wear orthotics or “stabilizer” shoes. Despite the general ugliness of my feet, I’m really not in much pain, but was told by a surgeon that I’m a lot more likely to develop arthritis early, like in my thirties, but I don’t know if that’s true.. The more I read about overpronation, the more I question having this procedure. If anyone can offer guidance based on the information I provided, I’d really appreciate it.

    Thanks

  7. Allen August 14, 2014 at 9:35 am #

    Does shoe type affects or may be the cause of this pronation? This is just OUCH!

  8. Eric April 22, 2016 at 10:05 pm #

    Hi, I’m not sure if I’ll know how to ge back to this page, so I’m going to leave my email address And hope the website author or another reader like myself will answer me back.
    My question is this: My right foot pronates in at the ankle, and it’s a problem when I play hockey. The only things that helped and even things out are 1. A pretty steep pitch to the hockey blade – in other words instead of skating on a flat blade like most players my blade has some steel ground off of the front half of the blade. Somehow this downhill slant helps the probation.
    Another thing info is out in heel wedges on the inner side of each foot.
    2. The other thing that I’ve found helps is instead of skating on a blade that has a lot of pitch as described above, if I use a big heel lift inside the skate, something like a 1/4 inch at least, it also helps to normalize the foot and stop pronation.

    So I guess my question would be are these two methods I’ve come up with on my own after a lot of experimentation viable methods to help with pronation?

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