THE CONCEPT OF FUNCTIONING IN SUBTALAR JOINT NEUTRAL BEING ‘NORMAL’ HAS NEVER BEEN REPORTED IN ANY LITERATURE


is certainly clear is that the relationship between pronation and injury is poorly understood at this time and is far from consistent or predictable.


SUMMARY The available research points to the following conclusions: n It is difficult to accurately and repeatably measure foot level pronation


n The relationship between pronation and injury is very poorly understood


n The historical concept of ‘normal’ is erroneous n Variation between people in foot level movement patterns is high (and this is normal).


WHAT DOES THIS MEAN FOR “OVERPRONATION”? Overpronation is often used to describe a foot that is in a pronated position, but considered to be ‘too pronated’ or ‘more pronated than normal’. It is also generally referred to in a negative way, in that it will often be considered to be pathological and in need of ‘correction’. It is even used by some as a diagnosis.


The ambiguity of “overpronation” A golfer has just hit a shot 150 yards. Have they “over” hit it? To correctly answer that question you would need to know exactly how far they were supposed to hit it or what they were aiming for. In order to be able to confidently state that something is happening too much, then by definition we must be comparing it to how much it should happen. Hopefully what has become clear by now is that we do not know how much pronation is ‘normal’. All we do know is that it will likely be different from person to person (and of course activity to activity). Essentially, we do not necessarily know what we are aiming for in a given individual, so how can we say when it is “over”?


The diagnosis of “overpronation” In addition to the now obvious


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ambiguity of the term, the use of it as a diagnosis is most certainly to be discouraged. Many individuals present to clinic with the information that they have been previously diagnosed as an “overpronator”. As mentioned earlier, pronation is simply a motion – an observation, but never a diagnosis. Imagine two different patients present with feet that appear to function in a similar manner, and it is noted they are both in a maximally pronated position. Patient 1 complains of pain just inferior to the medial malleolus. Patient 2 complains of discomfort around the anterio-lateral ankle. How could they both be diagnosed with the same “condition”? Grouping all foot and ankle pains into one convenient ‘diagnosis’ is at best ill-informed, and at worst is delivering a care below the standard of that which patients deserve.


“Overpronation” as a scapegoat? The majority of patients presenting to sports injury clinics across the globe will already be injured. As the aforementioned research has shown, normative data suggests that most individuals have a mild to moderately pronated foot type (rather than the neutral alignment that is erroneously thought to be ‘normal’). Therefore while it has often been assumed that foot posture may be one of the contributing factors in a presenting lower limb injury (which, of course, it may well be for some), the subtle differences between causation and correlation should always be kept in mind. Just because a foot/lower limb that hurts is pronated, does not mean that it hurts because it is pronated. This is why a thorough history of the mechanism of the presenting injury and all other potential contributing factors are just as important as foot posture, and should be concurrently investigated.


“Overpronation” and management of lower extremity injury So does “overpronation” help formulate


treatment plans for injured individuals? In the fictitious patients mentioned above, how does classifying or terming them to be “overpronating” guide a clinician in treating Patient 1 and their suspected tibialis posterior tendinopathy or Patient 2 and their suspected sinus tarsi syndrome? It could be argued that doing so and treating them both in a similar manner (increasing subtalar joint supination moments, for example) may well achieve a desirable result. However, looking at a foot position, attaching a vague and meaningless term to it, and then initiating a blanket management plan that seems to be irrespective of the exact pathology is something a trained technician could do after a little practice. As sports injury professionals we are expected to have a far more robust and evidence-based approach to our management of injured individuals. Not forgetting, of course, that our understanding of athletic footwear recommendations (21), and of how orthoses actually exert their mechanical effects (they do not realign the skeleton as previously thought) (22) is also constantly changing. Although these topics are outside the scope of this particular article, it can be appreciated how they may all intertwine.


SO IF NOT “OVERPRONATION” THEN WHAT?


A fair question may be that if we are to abandon the term “overpronation” then what do we use in its place? The answer to this is: nothing. Hopefully it is now clear that this is a term that brings nothing to our clinical practice – it is not definable, not reliable or valid, not diagnostic, its relationship to injury is not fully understood, and it does not dictate what the most appropriate management plan may be. It should not be replaced, it should be removed. A more appropriate way to move forward with respect to assessing and treating injured individuals is to accurately identify the injured anatomical structure (formulate a diagnosis), identify the structural and functional characteristics of the foot and lower extremity, determine the most likely type of tissue stress that is causing the pathology,


sportEX dynamics 2012;32(April):10-13


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