What is Pronation?

Has anyone ever told you that you are a “pronator” or that you “over pronate?”  There are two key takeaways as an athlete to understand when it comes to pronation:

1.      Different degrees of pronation occur for different individuals: some level of pronation occurs at the foot during most movements; a high degree of pronation during movement may have correlation with poor alignment and injury for some individuals, but this is not always the case.

2.      The amount of pronation that an athlete has can be changed.  Implementing mobility and stability exercises, as well as improving loading and propulsion capacity and mechanics can have a positive effect on movement quality, including at the foot and ankle.

As an athlete, if you are concerned about the movement at your foot, it is important to consult with a professional such as a Sports Performance Coach, Physical Therapist or Podiatrist.  As an athlete and later as a coach and researcher, I was very interested in the foot and learning how to improve movement.  This is the first post in a series about the foot that will cover pronation, flat feet, arch support, compensation patterns, and performance plans.

Pronation is the inward rotation of your foot as you load your body’s weight and momentum.  Pronation has become a controversial topic.  There are different perspectives on pronation, and contradicting statements on the topic such as:

• “over pronation leads to flat feet and injury”

• “pronation happens because of weak feet”

• “you should pronate, it is a normal part of gait”

• “we need to teach the foot to pronate”

Pronation is often discussed as being either good or bad in relation to performance, pain level, and injury risk.  The degree of pronation can have correlation with the alignment of the foot, ankle, knee, hip, back, and body as a whole.  An excessively pronated position of the foot can have correlation with acute and chronic injuries to the ankle, Achilles, knee, and hips.  However, it is important to note:

1.      There are different degrees of pronation that occur by individual and activity: walking, jogging, and sprinting all have different rates of loading and propulsion, and different timing and degrees of rotations (including pronation).

2.      In certain situations, limiting pronation by adding stability (whether internally through strengthening or externally through arch support) can have positive outcomes. 

3.      In other situations, increasing pronation by adding mobility can have positive outcomes. 

4.      In some situations, an individual may have a moderately or significantly pronated foot position, but have no injury history correlated with their foot position

In order to fully understand pronation, we have to understand a few elements:

1.      What does pronation mean and where does this term come from?

2.     Why does pronation occur at the foot?

3.     Why has pronation become controversial?

What Does Pronation Mean?

The word prone means facing down, while supine means facing up.  At your hand, pronation and supination are very simple: starting from a neutral handshake position, rotation towards facing down is pronation (inward rotation), and rotation towards facing up is supination (outward rotation).  At your foot, it gets a bit more complex: your foot is already facing down when it is in a neutral position, but we keep the rotational directions of pronation and supination.  The words pronated and supinated describe positions: a foot that has rotated inward past a neutral position is now in a “pronated” position and a foot that has rotated outward past a neutral position is now in a “supinated” position. 

Pronate, pronation, pronating, supinate, supination, and supinating are all actions of rotation.  Pronated and supinated are positions relative to a neutral vertical reference line.  It is important to note that we can:

1.      Pronate from a supinated position to a neutral position

2.      Pronate from a supinated position (past neutral) to a pronated position

3.      Pronate from a neutral position to a pronated position

4.      Supinate from a pronated position to a neutral position

5.      Supinate from a pronated position (past neutral) to a supinated position

6.      Supinate from a neutral position to a supinated position

Why Does Pronation Occur at the Foot?

Pronation occurs primarily for two reasons: The first reason is that in gait the foot usually approaches the ground from a slightly supinated position: pronation occurs so that the bottom of the foot comes in full contact with the ground.  It is very challenging to generate the force needed to go through loading and propulsion by only contacting the ground with the outside of the foot.  The second reason pronation occurs is because of the rotations that occur during loading and propulsion at the ankle and foot. 

During loading, the joints in the hip, knee, and ankle go through flexion with an element of rotation.  During propulsion, the joints in the hip, knee, and ankle go through extension with an element of rotation.  What does loading and propulsion look like at the ankle and foot, and how does that correlate with pronation?  Below is a traditional model of movement at the foot and ankle during a walking gait:

1.      At the approach: the ankle and forefoot are in a moderately extended and supinated position

a.      The shin is behind the ankle (traditionally known as plantar flexion)

b.      The forefoot is extended towards the ground

These two joint positions put the foot in a higher arch position, in which the rearfoot is inverted in relation to the forefoot (or neutral in some cases)

2.      During loading: the ankle and forefoot move through flexion and pronation into a flexed and pronated position: The muscles and tendons are lengthened and gain tension

a.      The shin moves over the ankle (traditionally known as dorsi flexion)

b.      The forefoot flexes (the first MTP has a greater movement range than the fifth MTP)

These two joint positions put the foot in a lower arch position, in which the rearfoot is everted in relation to the forefoot (or neutral in some cases*).

3.      During propulsion: the ankle and forefoot extend and supinate back into an extended and supinated position: The muscles and tendons are shortened and release tension

a.      The hip, knee, and ankle extend in sequence

b.      This end position is often a greater degree of extension than the approach position

* In some specific athletic situations, the foot remains in a high arch position with the rearfoot inverted in relation to the forefoot during loading (this will be covered in a later post, please reach out if you have any specific questions on this loading technique, as it can be very challenging to implement and coach).

Why Has Pronation Become Controversial?

Pronation is controversial primarily for two reasons.  The first reason is that pronation can be good or bad, and heavily depends on the individual situation.  If the pronation is excessive, too early, or sustained for too long, there is a potential correlation with misalignment and injury risk. 

What Are Potential Causes of Excessive Pronation?

Poor loading mechanics at the foot and ankle

• Hypermobility

• Lack of general stability during loading

• Lack of proper forefoot position and contact during loading

• Lack of ankle mobility

• Lack of lower leg muscle activation during loading

• Lack of proprioception in the foot to the contact surface

• Unstable contact surface: foot’s ability to load tension and transition into propulsion is limited

• General position of the foot

• Foot being turned out excessively at initial contact (potential compensation for lower back and hips)

• Foot strikes too far in front at initial contact position

• Foot is excessively supinated at initial contact

• Foot is pronated at initial contact

Poor loading mechanics at the hips

• Lack of mobility at the hips and lower back

• Lack of tension loaded into the upper leg muscles and hips (hamstrings, quads, adductors, glutes)

• Body (hips, knees, upper body) is not in a good position at initial contact: not ready to load weight

• Inability to hinge or squat, particularly on a single leg

• Trunk is rotated away from the stance leg at initial contact and loading

• Trunk is excessively swayed over the stance leg at initial contact

Foot Misalignment

• Forefoot supinatus (forefoot is inverted in relation to the sub talar joint, determined to be a soft tissue cause)

• Forefoot varus (forefoot is inverted in relation to the sub talar joint, but is determined to be a bone structure cause)

• Calcaneal varus (heel bone is inverted in relation to the sub talar joint)

• Calcaneal valgus (heel bone is inverted in relation to the sub talar joint)

Body Misalignment

• Alignment of the body as a whole, particularly at the ankle, knee, and hip

• Genu Varum or Genu valgus (bow leg or knock knees)

• Leg length discrepancy

• Weight shifted in front or away from the stance leg

• Excessive forward position of the pelvis

• Excessive anterior orientation of the pelvis

• Excessive orientation of the pelvis towards one side

Environment Influences

• Landing on a downward slope

• Landing on a sideways tilted slope

• Poor fitting footwear: general shape and width restriction to the individual’s foot

• Footwear that influences accelerated loading

• Footwear that influences eversion

• Footwear that reduces the foot’s ability to stabilize at mid stance and transition into propulsion

• Footwear that restricts the loading and propulsion mechanics at the foot and ankle

The key takeaway is that pronation occurs during the loading phase of gait due to the skeletal structure of the ankle and foot.  Therefore, any instability or altering of the approach or loading can potentially influence excessive pronation.  However, none of the above mean that you will certainly have excessive pronation, or that it will lead to injury.  In addition, it is common to have one foot that is more pronated than the other.  Asymmetry is common in our bodies, and may or may not need to be reduced.

As discussed earlier, in certain situations, limiting pronation by adding stability (internally through strengthening or externally through arch support) can have positive outcomes.  In other situations, increasing pronation by adding mobility can have positive outcomes.  Most importantly, a good assessment is important to understand the individual’s situation and to develop the best possible performance plan.  It is also important to re-assess, and to be able to work with a clinician if there is significant injury risk or if the individual is not responding well to the performance plan.

The second reason that pronation is controversial is because the use of the word is inconsistent.  The word pronation is primarily used in three ways: Pronation as a direction of rotation, pronation as a relative movement of the foot between the rearfoot and forefoot, and pronation as a tri planar movement. 

Pronation as a Direction of Rotation

This is a simple use of the word pronation, and is consistent with the origin of the word.  Pronation of the entire foot can occur after initial contact, as the foot moves from a slightly supinated position to a neutral position.  In some cases, the entire foot can continue to pronate past neutral.  Some coaches and clinicians would argue that this is not ideal, and that once the foot is on the ground, pronation should be a relative movement.

Pronation as a Relative Movement

At the hand, pronation is primarily a direction of rotation.  At the foot, pronation is often a relative movement between the rearfoot and the forefoot.  As the foot comes into contact with the ground, the forefoot will slow down its pronation, while the rearfoot continues to pronate.  Therefore, the rearfoot is pronating relative to the forefoot, with mobility at the midfoot allowing this relative movement to occur.  To break down this relative movement, the terms eversion and inversion are used.  Rearfoot eversion and forefoot inversion occur during pronation: this movement lengthens and lowers the medial arch.  The opposite actions of rearfoot inversion and forefoot eversion occur during supination: this movement shortens and raises the medial arch.  Because the forefoot is on the ground for the majority of gait, the movement observation is primarily of the rearfoot.  However, the relative movement at the forefoot is important, especially when considering compensation patterns. 

Pronation as a Tri Planar Movement

In a traditional gait cycle, pronation occurs during the loading phase.  While pronation is occurring, dorsi flexion of the ankle, and abduction of the rearfoot are also occurring.  For this reason, people will say that pronation occurs as tri planar movement. I would agree that this is true in most movements, although pronation can also occur primarily in a single plane. An example of this would be an ankle eversion exercise without changing the degree of ankle flexion. 

Other people say that pronation is the term for the entire tri planar movement during loading, meaning that dorsi flexion and rearfoot eversion are both a part of pronation: they are describing the entire foot action during loading as pronation.  This is confusing for a couple of reasons: the origin of the word pronation is used to describe a single plane movement (eversion).  Out of the three planes, pronation is not the most significant in terms of degrees of rotation.  It would make more sense to me to say that pronation is an element of dorsi flexion, rather than saying that dorsi flexion is an element of pronation.

If pronation is the term for the movement that is occurring at the foot, it can become confusing when attempting to distinguish between different movements.  For example, three distinct movements of your foot and ankle could be:

1.      foot and ankle dorsi flexion with minimal rearfoot eversion

2.     foot and ankle dorsi flexion with significant rearfoot eversion

3.     foot and ankle rearfoot eversion without dorsi flexing 

Each of these movements could be argued as pronation, or also argued as not being true pronation, according to the observer’s definition of pronation.  This causes issues that lead to inconsistent exercise selection and coaching cues.

One example I see of this occurring is with ankle mobility exercises from thought leaders in the rehab space.  In the rehab space, introducing mobility is often a very important step.  The clinician may say that it is important to teach the individual how to properly pronate.  By this, they may mean unlocking the ankle to allow dorsi flexion with minimal to moderate rearfoot eversion.  But a coach or clinician who does not fully understand what they mean by “properly pronate” may misinterpret this to mean we have to teach individuals how to evert their rearfoot (without implementing the dorsi flexion aspect).  This results in a completely different exercise, which may not be ideal for that individual.

Conclusion

Pronation is an interesting topic because of its complexity.  Pronation can be associated with pain and injury for some individuals, while others can have the same degree of pronation without any problems.  There are various performance and rehab plans related to the foot and ankle: in some cases, limiting pronation has positive outcomes.  In other cases, increasing mobility (which may or may not mean increasing the degree of pronation) has positive outcomes.

When observing and discussing pronation, it is important to zoom out and take different perspectives: in my opinion, pronation is as aspect of foot movement, it is not the foot movement.  The keys to success are a good assessment and performance plan, re-assessment, and working with a clinician when needed.  Implementing mobility and stability and learning good loading and propulsion technique can have positive outcomes, without even directly aiming to reduce or increase the degree of pronation. 

An important takeaway about pronation for athletes and coaches is to consider that both the degree of pronation and the position of pronated foot posture are not necessarily fixed for an individual.  Pronation can be reduced or increased, and the positions of the foot during approach, loading, transition, and propulsion can all be improved through proper training.  In addition, training to improve foot mechanics should include working on the hips.  As a coach, I do not want athletes to worry about pronating less or more, I just want to coach them to move better.  If this is not working, or if there is a limitation, it is important to get a clinician involved (such as an experienced physical therapist with a sports performance background).

Thanks for reading!

Coach Brooks