Injures Caused by Foot Overpronation

Foot Overpronation Can Cause Many Different Injures.

Pronation of the foot involves dorsiflexion of the ankle, abduction of the foot, and eversion of the foot. In layman's terms this is described below, but the important aspect is that these movements drop the medial arch of the foot.

• Dorsiflexion involves a bend of the ankle in the direction of the dorsum or top of the foot. It brings the top of the foot towards the knee.
• Abduction is a turning out of the foot away from the midline.
• Eversion is a turning out of the foot which brings the medial arch down.

Fig. 1: Comparing a neutral foot (middle) to foot overpronation (left) and supination (right). Notice how the pronated foot turns away from the midline (this is abduction) and the medial arch falls towards the floor (this is eversion). Image Ducky2315 (Own work) [CC BY-SA 3.0 9http://creativecommons.org/licenses/by-sa/3.0)]

A certain amount of pronation is normal in weight bearing as this acts as a shock absorption. Connective tissue structures in the foot elongate and produce a certain amount of tension which, upon recoil, helps propel the movement, thus acting as an energy saving mechanism during walking and running. However, overpronation is a frequent occurrence which is an excessive pronation. This can lead to a range of injuries of the foot, ankle and lower leg, but also can cause or contribute to injuries of the knee, hip and really anywhere in the body.

Frequent injuries are listed below with a brief description of how overpronation contributes.

• Plantar fasciitis/fasciosis: As the foot goes excessively into pronation, the plantar fascia is overstretched. The reoccurring motion eventually irritates the plantar fascia and can lead to chronic pain in the bottom of the foot, usually where this tissue attaches to the calcaneus.

Fig. 2: Both tibialis anterior and tibialis posterior attach to 

the medial arch. In foot overpronation, the arch drops and these 

muscles are pulled long. This can irritate the tendons of these 

muscles and can also contribute to shin splints.

• Tibialis posterior tendinopathy: This condition can be misdiagnosed as plantar fasciitis, but pain is usually more at the medial ankle. The tibialis posterior supports the medial arch and can become irritated with excessive pronation as it too is repetitively overlengthened when walking or running.
• Shin splints: Shin splints can be classified as anterior or medial shin splints. The involve either the tibialis anterior or the tibialis posterior, respectively. Both of these muscles support the medial arch and can have a shearing effect where they attach to the tibia with overpronation.

Fig. 3: Note the effects on the knee and hip.

• Knee pain: There are many knee conditions that can become aggravated with overpronation. As the foot pronates, the lower leg turns inward. This becomes excessive with overpronation, and the knee tends to collapse in. This can contribute to medial knee pain from conditions such as pes anserine tendinopathy or lateral knee pain from conditions such as iliotibial band friction syndrome.
• Hip pain: Like knee pain, there are many hip conditions that can be aggravated from foot overpronation. One example is greater trochanteric bursitis which is often caused by an excessive raising of the hip during weight bearing. This frequently occurs with foot overpronation and with the knee moving in.
• Back pain, shoulder pain, neck pain: Foot overpronation can be involved with many other muscle imbalances as described above with knee pain and hip pain. These imbalances can affect regions as far away as the neck.

Sports Medicine Acupuncture® is a great system for treating both the injury and the underlying causes of the injury such as foot overpronation. It employs acupuncture, manual therapy, and corrective exercises in addition to other possible treatment options. Both local acupuncture and manual therapy techniques can be used to reduce pain and improve the health of the injured soft tissue. And acupuncture to specific points within the muscles can correct the underlying muscle imbalances that occur with foot overpronation which lead to the injury and, if uncorrected, will cause a recurrence. Corrective exercises help the treatment hold and further corrects the underlying muscle imbalance.

Fig. 4

A simple exercise which can strengthen the intrinsic muscles of the foot and help to correct foot overpronation is the short foot exercise. This exercise strengthens the adductor hallucis (hallucis refers to the big toe) muscle (Fig. 4), in particular. The following steps are followed to perform this exercise:

1. Sit upright with both feet flat on the floor. Alternately, the exercise can be performed standing on the foot to be exercised. This is more advanced.
2. Raise the arch of your foot by bringing your big toe towards your heel. The trick is to do this without curling your toes. Your emphasis is on lifting the arch away from the floor.
3. Hold for 5-10 seconds. You can perform this exercise multiple times. 

While this exercise is helpful, foot overpronation often involves other structures not only in the foot. These include muscle imbalance in the lower leg, knee and thigh, hip and low back. Comprehensive work with these structures is often necessary for lasting effects. Evaluation and treatment of these contributing muscle imbalances along with treatment of associated injuries are what your certified Sports Medicine Acupuncturists® work with.

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Foot Pain and Plantar Fasciitis

Treatment of Foot Pain Caused by Plantar Fasciitis and Plantar Fasciosis.

Fig. 1: Ed Yourdon [CC BY-SA 2.0
'(https://creativecommons.org/licenses/by-sa/2.0)],
via Wikimedia Commons

The new year is here and many people are going to be starting new exercise regimens as part of their resolutions. Some of those starting exercise programs that involve running will develop pain on the plantar surface of the foot (the bottom of the foot) and will develop plantar fasciitis. If the pain persists, the condition may well be reclassified as plantar fasciosis. This post will discuss these two related conditions, will look at self-help techniques, and will discuss treatment options with acupuncture, deep tissue massage, and herbal therapy so that you can quickly get back to becoming more fit in 2016.

Fig. 2: Image from: Sobotta's Atlas and
Text-book of Human Anatomy 1909.
This author uses the term Plantar 
aponeurosis for Plantar fascia

Plantar fasciitis and plantar fasciosis are common pain syndromes involving the plantar surface of the feet, and, since this problem affects us when we are weight-bearing (standing, walking, running, etc.) it is an especially annoying problem. This condition results in pain at the attachment site of the plantar fascia to the calcaneus (heel) as seen in Fig. 2. One of the hallmark symptoms of plantar fasciitis, at least in the early stages, is pain with the first few steps in the morning or upon rising after sitting for a long time, though it can become more severe over time and the pain can persist during weight-bearing activities.

First off, it is important to understand the difference between plantar fasciitis and plantar fasciosis. This is rarely discussed, even by most physicians, but it is very important when considering treatment. For plantar fasciitis, the suffix -itis means inflammation, so this would imply that there is an inflammation of the plantar fascia. In the very early stages of pain of the plantar fascia, this could very well be the case. This would be especially evident if someone starts a new exercise regimen that involves weight-bearing activities such as running, jumping, martial arts, etc. Conventional medical treatment might consist of corticosteroid injections or the use of NSAIDs (non-steroidal anti-inflammatory drugs) to reduce the inflammation. In my clinic I would consider a Traumeel injection and/or would use herbal medications that have an anti-inflammatory action. Other treatment strategies will be discussed below.

For those suffering from chronic pain of the plantar fascia, the inflammation model is likely not correct. There is a significant amount of research now which shows that inflammatory cells are often not present in these types of chronic pain conditions which affect connective tissues such as tendons and aponeurotic structures (such as the plantar fascia). Usually these signs of inflammation are no longer present after about two to three weeks after the initial tissue insult.

Fig. 3: Image modified from:
Phulvar (Own work) [CC BY-SA 3.0
(https://creativecommons.org/licenses/by-sa/3.0)],
via Wikimedia Commons

Researchers and, increasingly, some physicians are now referring to chronic pain associated with the plantar fascia as plantar fasciosis. The suffix -osis­ indicates a diseased state, in this case involving a degenerative process which results from a decreased blood flow to this tissue. This decreased blood flow is caused by an increase in scar tissue and fibrosis (fibrous tissue buildup) of the region. For these chronic cases, breaking up this scar tissue and actually causing a mild inflammation in the area is necessary to bring an adequate supply of blood to the region. Acupuncture and deep tissue massage techniques such as myofascial release are very effective for accomplishing this, especially when combined.

Fig. 4: Deep myofascial release to the attachment of the plantar fascia. Very little to no lotion is used and the a slow gliding movement is used to break up fibrous adhesions. This is especially effective after acupuncture.

In either case, whether the pain is acute or chronic, the localized treatments described above are just one aspect of recovery from these painful conditions. It is crucial to look at strain and tension patterns in the legs, especially the calves, and it is also necessary to look at how weight transmits through the foot.

Fig. 5: Foot overpronation. This image also
illustrates inhibition of the gluteus medius 
and minimus leading to  an elevated right ilium. 
Due to this, the knee moves in during weight 
bearing and the foot overpronates.

Over-pronation (a collapse into the medial arch of the foot) is a common contributing factor. In addition, restriction in the muscles of the calf (the gastrocnemius and soleus) are very often contributing factors. When these muscles are restricted, they transmit too much pull on the Achilles tendon during walking, which prevents proper ankle movement and requires the foot to undergo too much movement to make up the difference, therefore overstretching and irritating the plantar fascia.

Stretching these calf muscles to return proper flexibility can be very helpful for plantar fasciitis. Improving flexibility here allows proper ankle movement and takes the strain off the plantar fascia. Besides this, the calf muscles are continuous with the plantar fascia via their fibrous connective tissue components. These muscles and the plantar fascia are on the same fascial plane, so increasing flexibility and suppleness in the muscles will reinforce an increase in suppleness at the plantar fascia.

For chronic cases, self-massage can be a helpful tool. I give a very simple, yet useful, self-help technique to patients suffering from plantar fasciitis. When waking in the morning, but before getting out of bed and stepping on the foot, I recommend using the thumb to perform a circular massage at the attachment of the plantar fascia to the calcaneus (heel bone). This is the most common site of pain and inflammation; the goal of this circular massage is to warm up and create suppleness in the plantar fascia before putting an abrupt and forceful motion through it by stepping on the foot. For many people, doing this every morning (and even after sitting for several hours) is very helpful. However, for more recalcitrant pain and dysfunction, this will not be enough and other measures need to be looked at.

A combination of acupuncture and deep myofascial release to these and related regions yields excellent results and is often necessary when dealing with the pain associated with plantar fasciitis. If it is painful to stand and walk, exercise becomes difficult and people become more sedentary, leading to other health complications. It is essential to deal with this problem so that you can do all the things that are important to you and start your new year off right.

Note: In Sports Medicine Acupuncture® we first assess the condition to see if it is truly plantar fasciitis. There are many other conditions which can cause pain in this region and they need to be ruled out. Included are tarsal tunnel syndrome and tibialis posterior tendinopathy. Proper treatment of these conditions will be much more successful if the condition can be properly diagnosed.

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