Does foot pronation increase risk of injury?

There is a misconception that certain structural features of the body are directly related to injuries. For years, people with lower arches were referred to as “pronators” and those with even flatter feet were “overpronators” or “hyperpronators.” They were all thought to have more injuries, and a portion of the shoe industry has really kept that mentality alive. The other two general foot types, neutral and supinated, were the supposed ideal.

Image Courtesy

Image Courtesy

If you watched the pronator group walk, they might not appear to maintain their arch height very well. But is that always a problem? In the people labeled as pronators there are often joint structure differences that allow more inward collapse of the ankle and foot. In the supinator group there are joint differences that would keep the ankle and foot raised upward. Regardless of foot type, some level of pronation is a normal movement because it allows for shock absorption as the leg is loaded. A certain amount of supination is also normal because it allows for a rigid push off.

We begin our childhood with a lower inner arch height, largely due to a lack of bony structure, and this results in a pliable foot. With normal growth, as the foot bones develop, the inner arch tends to rise and the bones of the leg also change their orientation a bit. In some people the arch really doesn’t increase its height much with growth. And even if it does, in adulthood there can be contributing changes that would affect foot and ankle position:

  • degenerative or use dependent joint changes at front of the foot, the middle of the foot, or the rear of the foot  
  • lower leg muscle shortening
  • weak, inhibited, or injured lower leg muscles or tendons (commonly the posterior tibialis)
  • general hypermobility throughout many of the body’s joints
  • tibia and femur bone structure (twisting, length discrepancy)

The concern is that these changes are also able to affect the movement of the knee, the hip and then even the pelvis and back. We all have a certain acceptable range of motion within each of these areas. If the changes in the foot allow the knee or hip to operate just on the edge of their tolerated position of use then, conceivably, you might have an increase in risk for knee or hip injury.

In actuality, foot structure may be more related to the type of injuries acquired than frequency of injury.

  • According to a 2001 research article in Clinical Biomechanics, higher arched runners developed injuries most often on the lateral side of the leg and had more ankle and bony injuries. Their lower arched counterparts had more knee and medial lower leg injuries.
  • A 2005 research article in the Journal of the American Podiatric Medical Association indicated that triathletes with a more rigid, high arch were at a higher risk of injury compared to neutral and pronated foot types.
  • More recently, in 2014, a meta-analysis in the Journal of Ankle and Foot Research indicated a very slight increase in risk of overall injury rate with the more pronated foot type being related to increased risk of kneecap pain and medial tibial stress syndrome (a.k.a. one of the types of shin splints.)

As you can see, the research is conflicting. The rate of injury is similar between athletes with all foot types. Perhaps we would have different results if we broke the common groups (pronator, neutral, supinator) down into subgroups based upon strike patterns (heel, midfoot, forefoot) to account for variations in demand.

My concern is that many of these studies assess the foot arch height while standing still. Unfortunately, this does not mimic how you use the foot in activity. Someone with a pronated foot structure while standing may not even touch their heel to the ground with running. Is it really going to be effective to put them in a motion control or stability shoe designed with a heel striker in mind?

A 2009 study by J. Dicharry demonstrated that while running the total motion of the navicular bone in the arch isn’t drastically different regardless of foot type. They called the pronators the hypermobile group in this case. Even if the arch of a pronated foot is at a lower position in standing, it’s total amount of motion is only slightly increased from a neutral or supinated foot while running. Neutral and supinated feet were 0.3 mm different between walking and running. Pronated feet were 1.2 mm different from walk to run. 

Should you be concerned with such minor differences and trying to use external devices like shoes to accommodate for them? The first step is to determine whether the pronation that is occurring is structural or a compensation. If forced to compensate, as in the case of decreased calf muscle length, you may need to focus on increasing mobility where it has been lost, like at the ankle joint, by elongating the calf muscles. Forcing mobility where it has already reached an excessive level in the midfoot by neglecting the calf length is not going to be helpful.

Our bodies are very good at adapting to gradually applied stresses, so a person with a more flexible, lower arch should be able to safely progress their activity just like anyone else. The research would suggest addressing the tissues that are the most likely to be injured with each foot type.

For instance, someone with a higher arch could focus on single leg balance and strengthening of the outer lower leg muscles. Those with a lower arch could focus on increasing strength of the inner lower leg muscles. I suggest we should focus on keeping both sides of the lower leg as strong as possible without one side becoming more dominant.

An often overlooked factor is inner foot muscle strength. Several of those muscles are meant to stabilize the arches of the foot, so it would be no surprise to me that decreased inner arch height can be associated with decreased muscle strength. But it’s not always a 1:1 relationship. Little research exists on this because it’s difficult to measure intrinsic foot muscle strength. Look for my blog article on intrinsic foot muscle strengthening soon.

Final thoughts:

  • Progress running intensity and duration in a safe manner using the 10% rule.
  • Keep the calf muscles loose to prevent ankle motion loss with a combination of rolling, massage, dry needling, and maybe stretching.
  • Strengthen the muscles that take the ankle and foot in all directions.
  • Strengthen the intrinsic foot muscles.
  • A pronated foot type does not necessarily require a bulky, stiff shoe and orthotics.
  • A pronated foot type is not going to be an immediate cause of injury, there are other factors to consider.
  • Don’t spend too much time worrying about your foot type because anatomical variation is normal.
  • Let your feet work how they were intended.

Geek out:

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Training errors in the athlete, part 5

Training with other people all the time. Do you thrive on attention and praise in order to push through a workout? Sometimes you just need to go it alone to build the mental fortitude required to perform at a higher level. I mean Rocky Balboa trained alone most of the time and he seemed pretty talented so that has to be a sign it will work for you too. Gonna fly now...

I don't see anyone else around, do you?

I don't see anyone else around, do you?

Moving on to the other end of the spectrum, there’s the chance that other athletes can push you too hard, too often. Peer pressure kicks in and although your instinct says “that’s enough,” you go beyond your safe limitations and become injured. Save it for the competition. That’s where it is nice to have a coach to tell you when to shut it down.

Skipping the warm-up. Warm your muscles up slowly and they will perform better. A gradual warm-up can improve performance. Research indicates muscle fiber exposure to lactic acid just before intense exercise allows the fibers to tolerate even more lactic acid production. The physiology of the muscle fiber can function better at a higher temperature too (up to a point of course).

According to a 2012 literature review in BioMed Central Medicine, a proper warm-up containing “stretching, strengthening, balance exercises, sports-specific agility drills and landing techniques” can be effective for preventing injury. This is unfortunately more involved than many athletes envision when thinking about a warm-up routine and they shy away from it as a result. 

At the least, warming-up should be a whole body routine that emphasizes full joint mobility, a gradual increase in heart rate, directional changes, and most importantly, rock music. The warm-up period, especially just before a competition, can be a powerful psychological motivator.

image courtesy

image courtesy

Ignoring joint mobility and flexibility. Some people have really poor mobility. I don’t mean, can you bend over and touch your toes? I mean will your hip flex to a full 120 degrees to allow you to squat all the way down at Crossfit? Do your ankles have the full range of motion necessary to prevent your arch from collapsing while running? Limits in mobility set by a single joint or muscle can impact movement further away than you might realize (ie. ankle movement can change hip movement).

The type of exercise you expect to participate in should dictate what motions you need to improve. If there are specific known limitations, they should be addressed in order to decrease stress on adjacent tissues and regions. Mobility limitation is the reason that the Crossfit “Mobility WOD” exercises exist. The point is that you have to take care of your body with a little routine supplemental work in order to enjoy your regular sport safely and improve performance. 

To Foam Roll the IT Band or Not to Foam Roll the IT Band?

There are about 50,000 articles on rolling or not rolling the IT band, or iliotibial band, on the internet right now. So now there’s 50,001 with my addition. There’s every topic from “you’ll never get the ITB to stretch out” to “don’t roll it because the problem is actually at your hip” to “keep rolling the ITB.”

I agree, the ITB is so thick and strong you are wasting your time to try to specifically stretch it or roll it out. According to an older article (1931) from the Journal of Bone and Joint Surgery by C.M. Gratz, MD:

“The specific gravity of fascia lata is about 1.31 and the average ultimate tensile strength is approximately 7,000 pounds per square inch. Soft steel has a specific gravity of 7.83 and an ultimate strength of about 45,000 pounds per square inch. Thus fascia lata is nearly as strong as soft steel, weight for weight.”

Image courtesy MedBridge Education

Image courtesy MedBridge Education

The IT band needs to be a strong material. The IT band functions are to stabilize your knee and produce hip movement by working along with the tensor fascia latae and gluteus maximus muscles (refer to the image below). And yes, lateral knee overuse injuries, including IT band region problems, tend to be related to weakness or abnormal activity at the hip and trunk muscles. Maybe something is wrong down at the ankle and foot too.

You shouldn’t be relying on the rolling, or any soft tissue technique for that matter, to make up for lost strength or bad exercise mechanics. Those body mechanics need addressed and your strength needs to improve. It wouldn’t surprise me that a lateral knee pain sufferer would also have weak gluteus medius and gluteus maximus muscles. Most people could use stronger glutes. And maybe you shouldn't have suddenly done a 2 hour long workout when your longest had been 1 hour. 

What the anti-rolling crowd is forgetting is the fact that the IT band is covering a pretty big portion of quadriceps muscle. Because it’s generally a positive to routinely roll or massage the rest of the quadriceps, why would you suddenly neglect such a big part of it? I wouldn’t, personally.

And what if that lateral knee pain is actually coming from trigger points in the quadriceps? At least the rolling was helping to keep the quadriceps relaxed and generally making the nervous system happier.

If you bought into the “no ITB rolling” philosophy, think it over again. At the very least, use a tennis or lacrosse ball to roll the thigh directly in front of the IT band and directly behind it. Take care of your quadriceps and hamstrings muscles. Use the ball, massage stick, or foam roller on the tensor fascia latae muscle too, up at the front/side of each hip.

Strengthen your hips and keep on rolling.

Training errors in the athlete, part 4

Underestimating the importance of proper recovery. When it’s time to work hard in a workout or competition you need to have some gas in the tank. That tank doesn’t get filled up without good recovery techniques like full days off, active recovery days, consistent sleep, compression, nutrition quality and timing, proper hydration and muscle maintenance.

If you start every competition or workout on a half tank, guess what happens? You go half as far with half the intensity. Sometimes that's intentional and planned. But many times it's not. Then as injury and overtraining occur, you have to ask yourself, “What am I really getting out of this?” In order to feel your best, remain healthy, and perform at your best, recovery is a huge part of the equation. Don't dig yourself into a hole that you can't get out of. 

Not working hard enough to produce a strong stimulus that the body wants to adapt to. Athletes are supposed to be constantly pushing their bodies on many of their training days. That’s how you become better, right? Unfortunately it’s also how you become overtrained, injured, stale, and burned out.

This leads you to constant training at a moderate effort on “dead” muscles. Or running the same distance every day. Monotony is the straw that broke the camel’s back. For runners, yes, you need days to emphasize aerobic conditioning in easy efforts ranging from 30 minutes to 3 hours. Other days you can have interval training that emphasizes anaerobic work at a really high effort for anywhere from 30 seconds to 5 minutes. Sure there’s a place for a moderately paced tempo run of 15 to 60 minutes, but not every day.

Strength training athletes need to avoid constantly using a weight that causes failure at 10, 12 or 15 repetitions. Or always doing just one set. If you are really after a change in performance, there needs to be a training cycle where the weight is significant enough to cause failure at other points, like 8, 5, or even 3 repetitions. And other times it’s fine to do 20 repetition sets. The point is, change the stimulus.

Indoor general fitness athletes are often one of the most guilty of this mentality. Three and four times per week they bounce from one cardio machine to another, being sure to start breathing harder and break a sweat at each machine for 10 or 20 minutes. They occasionally check their heart rate and compare it to the machine’s chart. No surprise to see a heart rate of 70% of the predicted maximum. And they wonder why they never see significant fitness changes.

Then there are the athletes that push a little harder but it’s just to that 85% level, which definitely hurts more. But then they struggle to sustain it as one steady effort for longer than 10 minutes (because it hurts) at which point the effort drops a notch. Meanwhile, other people in the gym are barely working at all.

In any sport, the key is variety. Variety in intensity, duration, training surface, speed, force produced, and direction of movement. Yes, you want adaptation to a consistent stimulus for a while but then you have to change that stimulus to continue making gains. 

Ignoring injuries when you first begin to have symptoms. Some injuries classically only hurt at certain times in their formation. That doesn’t mean they aren’t a problem. It doesn’t have to hurt all of the time to be a problem. Don't ignore it. Never ignore it. Yes, you can try to treat it yourself for a little while. That really might work.

But please make your life and my life easier by just coming to Physical Therapy within a couple weeks of the problem onset, even if it’s just for a consultation. If you don’t like what I have to say about it then seek another opinion. Regardless, if you intervene early, and start the right treatments, your recovery time is going to be drastically different.

For instance, if I see someone with back pain from a sacroiliac joint sprain in the same week they are injured, then they often recover in well under a week. If the sacroiliac joint has been a problem for 2 months and had no proper treatment, then buckle up for at least a month of consistent work. #getPT1st

8 Shoulder pain and rotator cuff care tips

While shoulder pain can be caused by a variety of injuries, rotator cuff impingement is one of the more common causes. It can occur in a variety of people, younger and older. The rotator cuff is made up of four muscles on your shoulder blade that stabilize your shoulder joint, as seen below. Impingement occurs when part of the tendon is repeatedly compressed. It is often poorly managed with corticosteroid injections. Mechanical stress that would have caused these tendons to become painful requires mechanical treatments, not a drug, for true correction. 

Copyright 2014 Primal Pictures Ltd. 

Copyright 2014 Primal Pictures Ltd. 

You are at risk for rotator cuff tendon or "subacromial" impingement if you currently have or have had:

1. Decreased total shoulder motion - Can you get your arm straight overhead? Can you touch your hand all the way up to the bottom of your opposite shoulder blade?

2. A rotator cuff muscle or tendon injury, like a strain or a tear - This would have been diagnosed by a medical professional.

3. A “frozen” shoulder - Also would have been diagnosed by a medical professional.

4. Poor trunk and shoulder blade posture - All people are guilty of this at some time or another. We round our backs and let the shoulders rock forward. We drop our heads forward and down.

5. Weak rotator cuff muscles - This applies to many people, even those that have labor jobs or athletes that demand heavy use from their shoulders.

6. Weak shoulder blade muscles - This occurs in most people, unless they are specifically strengthening these muscles and is often a result of the poor trunk posture. 

7. Irritable rotator cuff muscle trigger points (aka knots) - Applies to many people, unless they regularly have a deeper massage or routinely dig and smash on those knotted trigger points themselves.

Certain activities also make shoulder impingement more likely:

1. Long periods of work with the arms overhead

2. Participating in throwing sports, like baseball

3. Participating in swimming, especially freestyle, backstroke, and breaststroke

Combine any of these activities with the problems listed above and it is not unusual to start having shoulder pain from rotator cuff impingement.

Here is a list of items you can try to decrease the chance of developing a rotator cuff impingement issue or to address an early rotator cuff problem.

1. Massage the rotator cuff muscles with a ball, like a tennis ball, while leaning against a wall. A couple of these muscles are easy to reach because they are on the back of your shoulder blade. Move your body up and down and side to side while keeping a moderate pressure on the ball. Focus on the more tender areas. Perform for 1-3 minutes.  

2. Light rotator cuff muscle activity with your arm at your side. This could be as simple as the “isometric” exercises in the pictures below. Push 5-10 seconds with a minimal to moderate level of pressure. The goal is to perform repetitions without pain, not to create maximum force. More is not always better. Try just 5 repetitions of each position early and if that lowers your pain then attempt to work up to 20 repetitions over one week of time.

Hand pushes into wall 5-10 seconds from the shoulder. 

Hand pushes into wall 5-10 seconds from the shoulder. 

hand Pushing into wall 5-10 seconds from the shoulder. 

hand Pushing into wall 5-10 seconds from the shoulder. 

Hand or wrist pushes into wall 5-10 seconds from the shoulder. 

Hand or wrist pushes into wall 5-10 seconds from the shoulder. 

Wrist pushes into wall 5-10 seconds from the shoulder.

Wrist pushes into wall 5-10 seconds from the shoulder.

3. When sitting or standing, focus on remaining tall with your torso posture. Focus on the shoulder blades squeezing back even if it’s just a little more than your usual. A small change can go a long way toward decreasing stress on the shoulder muscles and tendons.

4. For swimmers, address any swimming technique issues such as crossing midline during the freestyle stroke. You may need to discuss this with a swim coach or a medical professional experienced with treating swimming athletes.

Copyright Johnson, JN in Physician and Sportsmedicine, January 2003

Copyright Johnson, JN in Physician and Sportsmedicine, January 2003

5. Move your keyboard and mouse closer toward your body if you work at a desk in order to keep your arms closer to your side and not reaching forward.

Screaming for shoulder and neck problems. 

Screaming for shoulder and neck problems. 

Get a little bit closer...

Get a little bit closer...

6. Avoid working overhead. This is especially true if you have to push firmly with the arm, like while using a drill or paint roller.

7. Do not completely avoid moving the arm. This increases the chance of developing stiffness in the joint that could lead to adhesive capsulitis, otherwise known as a frozen shoulder. Please don't put your arm in a sling unless a medical professional determines there's a bone broken or you just had surgery on the shoulder.

8. Avoid heavy overhead lifting. Of course, heavy means different things to different people. If you *think* it’s heavy at all, it probably is.

Don’t let your shoulder pain stick around for too long. One to two weeks is reasonable if it is steadily improving from a moderate level of pain. In some instances, these suggestions can help shoulder pain. By no means are they meant to resolve a major shoulder injury though. They are not intended to provide diagnosis or true medical treatment. When in doubt, seek medical advice from a qualified medical professional.

If you have any questions about resolving shoulder pain with your work or hobbies, mail me at


Training errors in the athlete, part 2

Poor hydration habits before, during, and after exercise. Our bodies are around 55-65% water. Humans can live for weeks without food but only days without water. We depend on good hydration for basic function of our systems. For athletic performance, the demand is even greater because athletes need to maintain a greater blood volume, sweat for temperature regulation, sustain tissue integrity, and repair exercise-induced damage and injuries.

Dehydration will decrease blood volume and with that decrease you won’t be able to cool yourself effectively or supply the working muscles with enough blood. If your core temperature reaches 103-104 degrees, the hypothalamus in the brain will just say “no.” Your movements will slow down and your entire nervous system will not function at its optimal level. And nobody loves that dizzy feeling of decreased blood pressure after you stand up from sitting or lying down when dehydrated.

As far as structure is concerned, hyaluronan molecules bind with water to keep your connective tissues, like cartilage and tendon, strong, supple and resilient. Keep the hyaluronan happy by staying hydrated! And we want the muscles to remain loosey-goosey!

Take in 5-10 ounces of fluid every 15 minutes in a warm to hot environment during exercise. Otherwise, try to keep your urine nearly clear. Don’t over drink though, as that can have negative consequences as well.

Avoiding strength training. People tend to gravitate toward what they enjoy most. For many athletes, they just want to do their sport and that’s it. Unfortunately, regardless of sport, some muscles and movements aren’t worked hard enough or frequently enough. We will become very good at using certain muscles, like the hip flexors, which slowly shuts down important muscles like the gluteus maximus.

Core strength is important regardless of sport because your trunk needs to be a stable base while the arms and legs move. As running guru and PT Jay Dicharry says, “You can’t fire a cannon from a canoe.”

A loss of muscle mass as we age can be counteracted (to some extent) with strength training. Overall, it comes down to being a healthy, well-rounded athlete -- and without strength training that’s not possible.

Being afraid to let go of a regimented training program. For those Type-A personalities this is difficult. Your long run doesn’t always have to be on Sunday. Some weeks, you might even need to skip that long run altogether. That twinge in your shoulder while swimming is trying to tell you something, so listen up.

Sticking to a “must do” mentality is a great way to dig yourself into a hole of over-training, injury, staleness, and boredom. That’s particularly true when you aren’t able to optimize the other aspects of training, like nutrition, soft-tissue work, compression, sleep, and so on.

I liken it to the “pay me now or pay me later” philosophy. Take an easier intensity day or a day off when you clearly need it or end up taking several of them in a row once your performance drops, you become ill, or you develop an injury.

Training errors in the athlete, part 1

Which of these are you guilty of performing?

Specializing in a sport and being entirely unwilling to deviate: Variety is critical for injury prevention, mental outlook, and general health. Unless you are a triathlete, pentathlete, or decathlete, you might find yourself unwilling to stray from the single sport you know. First off, you should strength train. Strength training is no longer an option; it is a requirement. Crosstrain before you get hurt (and you might not get hurt in the first place). Try something that is non-competitive and don’t turn it into a competition. (Yes, that’s probably hard.) Take a yoga class. Play pickup basketball with a couple friends or just shoot around. Try swimming. Just do something that is very different than your normal and do it often. This is especially true for young athletes who aren’t finished maturing. Research suggests that athletes who didn’t specialize at a young age can perform better as long as they were performing some form of athletics. The key for all of us is simply being an athlete.

Assuming your skills and technique don’t need further work: Skill work is primarily about training your nervous system to use a specific pattern. A good overall athlete has more options for movement patterns. Some patterns are highly ingrained and some are not. You want instinctive patterns to be close to an ideal. That way, when fatigue occurs you still demonstrate precision and efficiency. Every athlete could improve their performance with at least weekly emphasis on movement drills, strengthening specific motions, increasing muscle power output, and basically fine-tuning they way the nervous system creates each sports-specific motion. Regardless of sport, there’s room for greater efficiency and adding skills to your repertoire. Even running, which some people assume is innate, is a skill that should be broken into components for drill work. 

Training alone all the time: Sure, you are probably mentally tougher than the average bear, but this problem allows you to slack off occasionally when there’s no one there to push you. Which means you drop into the dreaded moderate efforts that lead to “dead” muscles, overtraining, and slower than optimal nervous system patterns. My motto is “there’s always someone faster and stronger.” Go train with that person at least once a week. A coach could assume part of the role of a training partner, so I’ll give that half an exception.