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Point-Counterpoint: Does Pronation Control Matter in Athletic Shoes?

Yes.

Kristine Hoffman, DPM, FACFASWhile more research is necessary, this author says the current literature suggests the advent of pronation control technologies and modifications may offer biomechanical benefits and improved athletic performance.

By Kristine Hoffman, DPM, FACFAS

Lower extremity injuries are extremely common among runners with as many as 79 percent of runners sustaining lower extremity injuries annually.1 Researchers have identified several biomechanical variables, including foot strike pattern, impact forces and foot posture, as factors that can contribute to the development of sports-related lower extremity injuries.2-5

Various authors have proposed foot pronation as a risk factor for running injury. Taunton and colleagues found that 66 percent of runners diagnosed with the four most common overuse injuries (patellofemoral pain, medial tibial stress syndrome, Achilles tendonitis and plantar fasciitis) had varus foot alignment that was accommodated by foot pronation.6 Many shoe technologies, including cushioning, motion control and stability systems, have emerged with the aim of mitigating these biomechanical factors, reducing the risk of lower extremity running injuries and improving running performance.

Researchers have demonstrated that foot posture, specifically, is associated with lower extremity injuries in athletes. In a case-control study of 600 novice runners, Pérez-Morcillo and coworkers found high pronation, measured with the Foot Posture Index, to be associated with a 20-fold increase in the odds of sustaining a running-related injury.7 Neal and colleagues performed a systematic review and meta-analysis that examined the effect of static foot posture on lower limb overuse injuries.5 The authors found static pronated foot posture to be associated with an increased risk of medial tibial stress syndrome and patellofemoral pain. Tong and Kong similarly performed a systematic literature review with a meta-analysis to examine the association of high-arched and flatfoot (non-neutral) foot types with lower extremity injury.8 The authors found a significant association between non-neutral foot types and lower extremity injury.

Based on the premise that pronated foot posture is associated with lower extremity injury, shoe manufacturers have developed many technologies to accommodate for pronated foot position as a means to theoretically lower the risk of lower extremity injury, improve comfort during athletic activities and increase athletic performance.9,10

Shoe manufacturers have employed modifications in the upper, heel counter, midsole and sole as pronation control strategies. The midsole remains the most tested and modified shoe structure. Shoe companies and clinicians have also utilized numerous modalities, including gels, air, springs, varus posting and ethylene vinyl acetate (EVA) foam, in the midsole in an effort to provide both stability and cushioning. The heel counter of athletic shoes can be made of rigid material to control hindfoot eversion, which is associated with excess pronation.11 Hagen and Hennig found that shoe uppers that create a firmer foot contact to the midsole of the shoe optimize midsole impact absorption by establishing a better foot position in the shoe.12

Several studies have examined the effect of pronation control technologies in athletic shoes on foot position and biomechanics. Anselmo and colleagues recently examined the effect of pronation control shoes on static foot posture.13 Using a novel radiographic model, this study found that pronation control shoes could correct foot pronation in the transverse and sagittal planes in stance. Specifically, pronation control shoes improved the calcaneal-first metatarsal angle and the talonavicular coverage angle.

Cheung and coworkers examined the effect of external pronation controls (taping, orthotics and pronation control shoes) on excessive foot pronation.9 They found all modalities, including pronation control shoes, were able to control calcaneal eversion. In another study, Cheung and colleagues compared the effect of neutral and pronation control shoes on plantar force on medial foot structures.14 This study found plantar forces on medial foot structures increased with running mileage in neutral shoes but not with pronation control shoes. In a dynamic evaluation of navicular drop while running, Hoffman and coworkers found that pronation control shoes resulted in a significant reduction in the rate of navicular drop in comparison to barefoot and minimalist shoes.15

How Pronation Control Technologies Affect Muscle Activation

Researchers have shown that pronation control technologies affect muscle activation of the lower leg. Examining the electromyography (EMG) activity of the triceps surae and tibialis anterior in relation to various sports shoes, Roca-Dols and colleagues found pronation control shoes led to a statistically significant increase in the peak amplitude of the tibialis anterior muscle during the contact phase of gait.16
In another study, Roca-Dols and coworkers examined the effect of various athletic shoes on the EMG activity of peroneus longus and peroneus brevis muscles.17 They noted that pronation control shoes led to significant reductions in peak amplitude of both the peroneus brevis and peroneus longus in the propulsion phase of gait.

While these studies do not show a direct connection between pronation control shoes and reduction in injury risk, one can hypothesize that modification of biomechanical variables associated with lower extremity injury can lead to a reduction in injury risk with the use of pronation control shoes.

What Studies Reveal About Shoe Weight, Cushioning, Impact Forces And Muscle Tuning

Pronation control shoe modifications may also offer a means of improving athletic performance. While running performance is primarily determined by physiologic factors, shoe gear can affect running economy, defined as the submaximal aerobic demand at a given running speed. Increasing shoe weight reportedly increases oxygen consumption by approximately 1 percent for each 100 g of additional shoe weight.18
Shoe cushioning also reportedly affects oxygen consumption. In one study, researchers found that runners make kinematic adaptations to reduced shoe cushioning and these adaptations result in soft-soled shoes reducing oxygen consumption by 1 to 2 percent in comparison to hard sole shoes.19

Nigg and colleagues recently proposed a new paradigm for impact forces and foot pronation.20 Based upon their study, the authors propose that impact forces alone may not affect the development of running-related injuries. They propose instead that impact forces are input signals that affect muscle tuning. Muscle tuning may contribute to overuse injuries but may also affect fatigue and comfort, and additionally contribute to overall athletic performance.

Assessing The Evidence On Injury Rate Reduction

Numerous studies have shown the relationship of foot posture and foot injury.5,7,8 Additionally, many studies have shown the effect of pronation control modalities in athletic shoes on foot biomechanics.21-23

It has been more difficult, however, to show a relationship between pronation control modalities in athletic shoes and the reduction in injury rates. In a large randomized control trial involving 372 runners, Malisoux and coworkers examined injury risk in runners using standard and motion control shoes.24 The study found that overall injury risk was lower among the participants with pronated feet who received motion control shoes in comparison to standard shoes.  

In Conclusion

Shoe manufacturers have incorporated numerous pronation control technologies into athletic shoes. The research supports the effects of pronation control shoes on gait biomechanics. Further research is necessary to better identify the mechanics of injury prevention through pronation control. Additionally, research is needed to identify optimal shoe modifications that control pronation, reduce injury rates and optimize performance.

Dr. Hoffman is the Medical Director of the Orthopedic Clinic and an Attending Physician in the Department of Orthopedics at Denver Health Medical Center. She is an Assistant Professor in the Department of Orthopedics at the University of Colorado School of Medicine.

References

1.    Van Gent RN, Siem D, van Middelkoop M, van Os AG, Bierma-Zeinstra SM, Koes BW. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. Br J Sports Med. 2007;41(8):469-480; discussion 480.
2.    Mann R, Malisoux L, Nuhrenborger C, Urhausen A, Meijer K, Theisen D. Association of previous injury and speed with running style and stride-to-stride fluctuations. Scand J Med Sci Sports. 2015;25(6):e638-645.
3.    Lieberman DE, Venkadesan M, Werbel WA, et al. Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature. 2010;463(7280):531-535.
4.    Dowling GJ, Murley GS, Munteanu SE, et al. Dynamic foot function as a risk factor for lower limb overuse injury: a systematic review. J Foot Ankle Res. 2014;7(1):53.
5.    Neal BS, Griffiths IB, Dowling GJ, et al. Foot posture as a risk factor for lower limb overuse injury: a systematic review and meta-analysis. J Foot Ankle Res. 2014;7(1):55.
6.    Taunton JE, Clement DB, Webber D. Lower extremity stress fractures in athletes. Phys Sportsmed. 1981;9(1):77-86.
7.    Perez-Morcillo A, Gomez-Bernal A, Gil-Guillen VF, et al. Association between the Foot Posture Index and running related injuries: A case-control study. Clinical Biomech. 2019;61:217-221.
8.    Tong JW, Kong PW. Association between foot type and lower extremity injuries: systematic literature review with meta-analysis. J Orthop Sports Phys Ther. 2013;43(10):700-714.
9.    Cheung RT, Wong MY, Ng GY. Effects of motion control footwear on running: a systematic review. J Sports Sci. 2011;29(12):1311-1319.
10.    Nigg BM. Biomechanics of Sport Shoes. Topline Printing Inc., Calgary, Alberta, Canada, 2010.
11.    Goldberg DA, Whitesel DL. Heel counter stabilization of the running shoe. J Orthop Sports Phys Ther. 1983;5(2):82-83.
12.    Hagen M, Hennig EM. Effects of different shoe-lacing patterns on the biomechanics of running shoes. J Sports Sci. 2009;27(3):267-275.
13.    Anselmo DS, Skolnik J, Keeter E, El-Sayed AM, Love E. Comparative evaluation of radiographic parameters of foot pronation in two different conditions versus barefoot. J Am Podiatr Med Assoc. 2018;108(4):285-291.
14.    Cheung RT, Ng GY. Influence of different footwear on force of landing during running. Phys Ther. 2008;88(5):620-628.
15.    Hoffman SE, Peltz CD, Haladik JA, Divine G, Nurse MA, Bey MJ. Dynamic in-vivo assessment of navicular drop while running in barefoot, minimalist, and motion control footwear conditions. Gait Posture. 2015;41(3):825-829.
16.    Roca-Dols A, Elena Losa-Iglesias M, Sanchez-Gomez R, et al. Electromyography activity of triceps surae and tibialis anterior muscles related to various sports shoes. J Mech Behav Biomed Mater. 2018;86:158-171.
17.    Roca-Dols A, Losa-Iglesias ME, Sanchez-Gomez R, Lopez-Lopez D, Becerro-de-Bengoa-Vallejo R, Calvo-Lobo C. Electromyography comparison of the effects of various footwear in the activity patterns of the peroneus longus and brevis muscles. J Mech Behav Biomed Mater. 2018;82:126-132.
18.    Morgan DW, Martin PE, Krahenbuhl GS. Factors affecting running economy. Sports Med. 1989;7(5):310-330.
19.    Falsetti HL, Burke ER, Feld RD, Frederick EC, Ratering C. Hematological variations after endurance running with hard-and soft-soled running shoes. Phys Sportsmed. 1983;11(8):118-127.
20.    Nigg BM. The role of impact forces and foot pronation: a new paradigm. Clin J Sport Med. 2001;11(1):2-9.
21.    Maclean CL, Davis IS, Hamill J. Influence of running shoe midsole composition and custom foot orthotic intervention on lower extremity dynamics during running. J Appl Biomech. 2009;25(1):54-63.
22.    Milani TL, Hennig EM, Lafortune MA. Perceptual and biomechanical variables for running in identical shoe constructions with varying midsole hardness. Clin Biomech. 1997;12(5):294-300.
23.    Nigg BM, Stefanyshyn D, Cole G, Stergiou P, Miller J. The effect of material characteristics of shoe soles on muscle activation and energy aspects during running. J Biomech. 2003;36(4):569-575.
24.    Malisoux L, Chambon N, Delattre N, Gueguen N, Urhausen A, Theisen D. Injury risk in runners using standard or motion control shoes: a randomised controlled trial with participant and assessor blinding. Br J Sports Med. 2016;50(8):481-487.


No.

Jamie Mieras, DPM, AACFASThis author finds the use of pronation-controlled athletic shoes is not supported by evidence-based medicine and offers little benefit to many pronating athletes.  

By Jamie Mieras, DPM, AACFAS

The idea that pronation causes injury stemmed from early attempts to understand high injury rates in runners (> 65 percent) as running grew in popularity in the 1970s and 1980s.1-3 James and colleagues described alignment concerns with running injuries but attributed 60 percent of the injuries to training error.4 Nigg and coworkers suspected pronation and impact forces as major causes of running injuries.5

Cavanagh noted a lack of techniques for runner biomechanical assessment and treatment.6
Industry shoe gear has since evolved in attempts to neutralize pronation. However, injury rates have remained relatively constant with researchers ascribing these injuries to biomechanics (strike type, stride, tibial torsion, tissue loading, joint loading), environment (shoes and orthotics, surface), or training schedules.7-9

Pronation control shoes, as I am discussing here, are defined as road running shoes for training and running 3 km to 42 km distances. These shoes are defined per loose shoe industry standards as limiting rearfoot motion through adaptations to shoe sole, including an increased amount or density of medial rearfoot material, a lateral sole flare, wedge posts, or recent additions called “guide rails.” Possible midfoot sole changes may exist to increased medial rigidity.

Importantly, there is a lack of industry consistency in the term “pronation control” and how one evaluates shoe features. A systematic review performed by Ramsey and colleagues in 2019 found only 3 of 15 methods as valid and repeatable when describing shoe characteristics.10

Pronation Control: Assessing The Dearth Of Evidence

Regardless of extensive efforts to link athletic shoes and pronation control, there is little evidence that pronation control shoes actually prevent running injuries. In a 2009 meta-analysis of studies on adult recreational or competitive runners, Richards and colleagues found no prior studies supporting the prescription of this shoe type to distance runners to prevent injury.11

The literature has shown that an absence of pronation control does not result in injury to feet expected to need pronation control. A large prospective study published by Nielsen and coworkers in 2014 demonstrated that increased foot pronation is not associated with injury when wearing a neutral shoe. During this one-year cohort, 927 novice runners in Denmark were recruited and separated into groups of highly pronated (18), pronated (122), neutral (369), supinated (369) or highly supinated feet (53).12 Participants began running in a neutral shoe and researchers followed them for 250 km over one year. Interestingly, the pronator group, those with 7 to 10 degrees of eversion on resting calcaneal stance position (RCSP), had the significantly lowest number of injuries.

In a recent two-year prospective cohort trial sponsored by the United States National Center for Injury Prevention and Control, Messier and colleagues followed 300 recreational runners and found no correlation of injury to arch height, rearfoot motion or footwear.13

Knapik and coworkers have published multiple analyses of three randomized controlled trials that evaluated 7,203 military recruits.14 They found no reduction in injury rates when recruits with low arches were matched with motion control shoes and the study included multiple shoe brands. Additionally, researchers at one study location who abandoned the study protocol but continued to observe recruits showed decreased injury rates when the recruits were able to self-select shoe gear for comfort.14

A 2013 study on 59 runners, each running a total of 125 km, found no link between foot posture (pronated versus neutral) and injury.15 In a 2011 study involving 81 female runners, Ryan and coworkers concluded that in-shoe pronation control systems were “overly simplistic and potentially injurious.”16

Only one study has shown a direct benefit of pronation control in shoes for preventing injuries in runners. Malisoux and colleagues published a randomized controlled trial of 372 runners that demonstrated a significantly reduced injury rate in pronated runners with motion control shoes in comparison to pronated runners with standard shoes.17 Pronation control was curiously absent at the rearfoot and limited to the midfoot and forefoot in the study shoes.17 Other studies have been successful in correlating an increased rate of a specific injury with a pronated foot position.18-20 However, these studies were not extended to correcting the sources of pronation with footgear and thus cannot be correlated with shoe gear types preventing pronation injury.

Biomechanist Benno Nigg, who has spent a career correlating foot motion to injury at the Human Performance Lab at the University of Calgary, finds there is no evidence that foot pronation causes or is a strong predictor of injury.5 Additionally, Nigg’s studies analyzed the skeletal running movements via bone pins in the calcaneus, tibia and femur, and determined that while shoe or orthotic interventions caused small, non-systemic changes in range of motion, the pathway of movement was overall unchanged. In essence, footgear and orthoses have little effect on pronation control. Nigg and coworkers propose that the “preferred path movement” is the body’s most economic and thus comfortable route, and controlled more profoundly by intrinsic muscle activity.5

Interestingly, a meta-analysis by Cheung and colleagues identified that dynamic calcaneal eversion is controlled most by therapeutic taping, then by custom orthoses and least by control footgear with a heel flare or wedge.21 That well-placed tape exerts greater rearfoot control than custom orthoses underpins Nigg’s emphasis on the importance of muscle tuning and intrinsic factors.5 The dominance of active intrinsic muscles on motion calls into question the relevance of studies based on static stance measurements. Hoffman’s study indeed noted “static assessments of navicular drop and foot posture were found to be poor predictors of dynamic navicular drop in all footwear conditions.”22

Nigg’s recommendation for best preventing running injuries is to allow the athlete to choose the most comfortable combination of shoe and insert combinations.5 Studies by Nigg and Mundermann and their respective colleagues further validate that comfort-guided footgear combinations are associated with lower movement-related injury, lower oxygen consumption, and better efficiency.5,23,24

Final Notes

Pronation control in athletic shoes is based on outdated and unproven ideas. With over 40 years of failure in preventing high rates of running injuries, perhaps it is time to stop forcing athletic patients into pronation control shoe gear and encourage trials of a wide variety of shoes and inserts for optimal efficiency.

Dr. Mieras is an Associate of the American College of Foot and Ankle Surgeons. She is in private practice in Gresham, OR.

References

1.     Walter SD, Hart LE, McIntosh JM, Sutton JR. The Ontario cohort study of running-related injuries. Arch Intern Med. 1989;149(11):2561-4.
2.     Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med. 1987;15(2):168-71.
3.    Macera CA, Pate RR, Powell KE, Jackson KL, Kendrick JS, Craven TE. Predicting lower-extremity injuries among habitual runners. Arch Intern Med. 1989;149(11):2565-8.
4.     James SL, Bates BT, Osternig LR. Injuries to runners. Am J Sports Med. 1978;6(2):40-50.
5.     Nigg BM, Baltich J, Hoerzer S, Enders H. Running shoes and running injuries: mythbusting and a proposal for two new paradigms: ‘preferred movement path’ and ‘comfort filter’. Br J Sports Med. 2015;49(20):1290-4.
6.     Cavanagh PR. The biomechanics of lower extremity action in distance running. Foot Ankle. 1987;7(4):197-217.
7.     Van Gent RN, Siem D, van Middelkoop M, van Os AG, Bierma-Zeinstra SM, Koes BW. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. Br J Sports Med. 2007;41(8):469-80.
8.     Noakes T. Lore of Running. Human Kinetics, Champaign, IL, 2003, p. 743.
9.     Mann R, Malisoux L, Nührenbörger C, Urhausen A, Meijer K, Theisen D. Association of previous injury and speed with running style and stride-to-stride fluctuations. Scand J Med Sci Sports. 2015;25(6):e638-45.
10.     Ramsey CA, Lamb P, Kaur M, Baxter GD, Ribeiro DC. How are running shoes assessed? A systematic review of characteristics and measurement tools used to describe running footwear. J Sports Sci. 2019 Mar;17:1-13.
11.     Richards CE, Magin PJ, Callister R. Is your prescription of distance running shoes evidence-based? Br J Sports Med. 2009;43(3):159-62.
12.     Nielsen RO, Buist I, Parner ET, et al. Foot pronation is not associated with increased injury risk in novice runners wearing a neutral shoe: a 1-year prospective cohort study. Br J Sports Med. 2014;48(6):440-7.
13.     Messier SP, Martin DF, Mihalko SL, et al. A 2-year prospective cohort study of overuse running injuries: The Runners and Injury Longitudinal Study (TRAILS). Am J Sports Med. 2018;46(9):2211-2221.
14.     Knapik JJ, Swedler DI, Grier TL, et al. Injury reduction effectiveness of selecting running shoes based on plantar shape. J Strength Cond Res. 2009;23(3):685-97.
15.     Ramskov D, Jensen ML, Obling K, Nielsen RO, Parner ET, Rasmussen S. No association between q-angle and foot posture with running-related injuries: a 10 -week prospective follow-up study. Int J Sports Phys Ther. 2013;8(4):407-15.
16.     Ryan MB, Valiant GA, McDonald K, Taunton JE. The effect of three different levels of footwear stability on pain outcomes in women runners: a randomised control trial. Br J Sports Med. 2011;45(9):715-21.
17.     Malisoux L, Delattre N, Urhausen A, Theisen D. Shoe cushioning, body mass and running biomechanics as risk factors for running injury: a study protocol for a randomised controlled trial. BMJ Open. 2017;7(8):e017379.
18.     Taunton JE, Clement DB, Webber D. Lower extremity stress fractures in athletes. Phys Sportsmed. 1981;9(1):77-86.
19.     Pérez-Morcillo A, Gómez-Bernal A, Gil-Guillen VF, et al. Association between the Foot Posture Index and running related injuries: A case-control study. Clin Biomech (Bristol, Avon). 2019 Jan;61:217-221.
20.     Neal BS, Griffiths IB, Dowling GJ, et al. Foot posture as a risk factor for lower limb overuse injury: a systematic review and meta-analysis. J Foot Ankle Res. 2014;7(1):55.
21.     Cheung RT, Chung RC, Ng GY. Efficacies of different external controls for excessive foot pronation: a meta-analysis. Br J Sports Med. 2011;45(9):743-51. Erratum in: Br J Sports Med. 2012;46(5):373.
22.     Hoffman SE, Peltz CD, Haladik JA, Divine G, Nurse MA, Bey MJ. Dynamic in-vivo assessment of navicular drop while running in barefoot, minimalist, and motion control footwear conditions. Gait Posture. 2015;41(3):825-9.
23.     Mündermann A, Stefanyshyn DJ, Nigg BM. Relationship between footwear comfort of shoe inserts and anthropometric and sensory factors. Med Sci Sports Exerc. 2001;33(11):1939-45.
24.     Lam CK, Mohr M, Enders H, Nigg S, Nigg B. Subjective and biomechanical assessment of ‘ride’ during running. Footwear Science. 2017;9(supp1):S42–S43.
 

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By Kristine Hoffman, DPM, FACFAS; and Jamie Mieras, DPM, AACFAS
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