It’s very common that patients come to me and tell me that they overpronate or have really bad flat feet. Commonly, these people have been self diagnosed with the help of family and friends or have been told this by running shoe clerks etc. Unfortunately, this type of diagnosis is not always accurate, as knowledgeability on the subject isn’t universal across store clerks and family members. This can lead to people buying unnecessarily bulky shoes and even result in injuries from the mis-diagnosis.
Case in point, just this past week I had a patient come to me telling me that she had a flat foot. She had initially gone to a shoe store without any pain at all and left the store with a stiff motion control shoe and a diagnosis of flatfeet. She then ended up getting pain in her right arch because of the shoe and sought the opinion of a podiatrist. He or she recommended custom orthotics, which pressed even further into her arch and caused her unbearable pain. Finally, she ended up in my office with continued arch pain and a 400 dollar pair of paper weights. In examining her it became clear that she only had a marginally flat foot, and likely would never have had any pain in her arches if she had just gotten a neutral or mild stability shoe to begin with.
People often think of pronation as just having flat arches, but this doesn’t really tell the whole story. Technically, pronation is eversion of the heel, dorsiflexion of the ankle and foot abduction. The eversion of the heel is what unlocks the arch, resulting in partial arch flattening and splaying of the foot just after the heel or foot lands.
Note the heel on the left is angled in. This is called eversion of the heel or heel valgus. Imagine how much the tendons and ligaments are placed under stretch by this process.
Pronation is completely normal, and is useful in running and walking as this collapsing of the arch and splaying of the foot acts as shock absorption. Without this, the bones would be subject to tremendous forces and would become injured more easily, which is what happens in people with stiff high arches. Following pronation and shock absorption, the body weight carries forward over the leg and foot and the foot becomes more rigid as the arch rises, supinating in order to propel the body forward.
Pronation isn’t the issue, overpronation is. Overpronation occurs in certain individuals when the arches stay flat longer than they should during walking or running, or splay out like a duck when walking or running.
Normal arch height. Note the heel bone points upwards and the bone above it, the Talus, is relatively flat with a slight downward tilt.
Flat arch with collapse. Note that the heel bone is now more parallel to the ground and the Talus is pointed downward more with significant stress placed along the joints.
For the most part, this is hereditary and has little to do with shoe gear, but it can be exacerbated by certain shoe gear. It can also be exacerbated by an imbalance in musculature such as with tight achilles tendons. Over time, this can lead to common injuries such as plantar fasciitis, shin splints or posterior tibial tendonitis. This is because these soft tissue structures are stretched excessively by over pronation and/or become over-worked as is the case of the posterior tibial tendon as it attempts to hold up the arch during gait. Over time, overpronation can begin to have an effect on the bones and joints, causing arthritis in joints that are experiencing consistent excessive joint motion.
My recommendation for overpronators who have not been injured is to stick to a slightly heavier shoe with at least some support. In general I think the entry level stability shoes are the best for this group when it comes to running. I don’t typically recommend motion control shoes for uninjured runners because these can actually inhibit normal pronation and cause injuries in people that don’t need that level of rigidity. Some of the more stable neutral shoes can also work for this group, such as the Brooks Glycerin, Mizuno Wave Sky, New Balance 1080, or the Hoka One One Clifton to name a few. Just make sure to follow the comfort and fit guidelines from my previous post and grasp the shoe in both hands and twist lightly to ensure that there isn’t too much flexibility in the shoe. If you do choose to go this route with the neutral shoe, just remember that while these are perfectly fine for running, it may be wise to get a stability shoe or potentially even an over the counter insert to wear in your walking or standing shoe. This is because most people stand or walk on their feet far more often than they run, which can put a constant strain on the soft tissue structures.
The right foot represents over pronation with abduction of the forefoot. Basically, abduction can be thought of as a duck or splay foot where the foot points outwards as a result of the foot structure and compensation.
For over pronators who have been injured, my recommendation depends slightly on the injury. In general though, all patients will require some home therapy or potentially even formal physical therapy for the injured structure. I like to have all patients strengthen their PT tendons at home or in therapy with exercise bands one to two times a day, and stretch their calf muscles at least twice a day. In fact, everyone who over pronates would benefit from calf stretching, as tight calf muscles are almost universal in over pronators and can contribute to muscular imbalances that lead to injury.
As far as shoe gear goes, I like to recommend stability shoes for most injured runners. The exception would be those that have failed regular stability shoes, or those runners that are heavier. For these, I will recommend a motion control shoe such as the Brooks Beast or Asics Structure. I don’t like to do this if I can help it because they can feel clunky and heavy to run in, but sometimes it is necessary. All of these individuals will need either a motion control shoe for walking/standing or a good shoe insert at least during the recovery phase. If these all fail, I will sometimes resort to custom orthotics, gait retraining or even surgery rarely.
As always, remember to evaluate your training routine and make sure that you’re giving yourself enough rest days for you and your foot. You should also always seek medical advice if your injuries aren’t getting better or if you want an evaluation of your foot type with recommendations. Feel free to leave a reply with any comments, suggestions, or questions that you might have.