How To Address Pronation-Related Pathology

By David Levine, DPM, CPed

Everyone pronates and everyone supinates. It is a matter of how much and when each occurs that determines whether lower extremity problems will occur. Shoe companies have marketed their products based on the words “pronation” and “supination.” They have done such a good job at this that people come into our offices thinking they are either pronators or supinators. As we know, high arched feet can pronate too much just as low arched feet may not pronate enough. Now more than ever before, there is more awareness of orthotic devices as a result of foot-related products becoming available over-the-counter in specialty stores or via the Internet. Indeed, people often try to help themselves before they even get to our offices. For some conditions, simple over-the-counter devices may be sufficient in alleviating symptoms. However, if people have problems that are a bit more complicated or there is asymmetry between lower extremities, custom-made devices are the best option. What makes custom devices the best option is the attention to casting as well as the fabrication. These factors separate custom devices from over-the-counter products. There are many specialties that have become familiar with making foot orthoses. Podiatry, physical therapy, chiropractors and certified pedorthists are a few that exist within this marketplace. It is hard to know the percentage of podiatry’s market share and whether it is going up or down. Our main job is to remain the experts in biomechanical knowledge as well as fabrication. With the trend of decreasing reimbursements for surgery, the possibility exists that we may see a greater interest and emphasis from practitioners on conservative care, including shoes, shoe modifications and orthotic devices. Interestingly, typing “pronation” into Google reveals several similar definitions concerning the heel and foot rolling in along with the arch flattening. None of the top 10 sites returned in this search even mentioned the word “podiatry” or were written by a podiatrist. Typing in “orthotic” into Google first leads to an orthopedic Web site. If one were trying to research the words pronation or orthotic using Google, one might think shoe stores and orthopedists were the experts in this area. However, no specialists look at the foot with as much attention to detail as we do. It is this detailed observation and assessment that will reveal pronation-related pathology. A simple example of this is a leg length discrepancy. This may present with one foot exhibiting more pronatory motion than the other. This clue not only helps determine where one should focus the examination but also affects how the clinician will prescribe the devices and how he or she will have them fabricated. First ray function also factors into pronation-related pathology. The amount of pronation within the subtalar and midtarsal joints directly impacts first ray function. Hallux limitus, bunion deformities and metatarsus primus elevatus are all conditions that affect the first ray and can be directly influenced by pronation. Unfortunately, the subtleties that occur during gait and contribute to these problems are often overlooked. Accommodations, modifications and different designs of orthotic devices are necessary to address these pathomechanical issues. Why Focusing On The Shoe Is Vital When it comes to writing prescriptions for pronation-related pathology, clinicians must start by focusing on the shoe. The shoe is the foundation. It is our interface with the ground. Our foundation directly impacts our function. In fact, the shoe serves as the ultimate orthotic device. Without a proper shoe, no matter how good the orthotic device is, function will be impacted. The shoe must have certain characteristics for it to allow the orthotic devices to function the way they were intended. The midsole. The midsole should not be too soft or too thin. In general, the midsole should exhibit a heel height of at least 1/4 inch. The necessary height can vary between individuals. Running shoe companies have tried to use the midsole as a way to control pronation. They have tried to accomplish this by offering dual density material by having a softer material laterally and the more dense material medially within the midsole. The thinking is the foot will not “roll in” as much if there is denser material medially.

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