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Tag archives for overpronation

“Too many toes” or “all the toes”

9th April 2022 by under Biomechanics     

I think most of us have heard of the ‘too many toes sign’. This is when there are more than a few of the toes are visible on the lateral side due to an abduction of the forefoot when standing or walking.

This image from a screen grab of video that I did of a case I talk about during the Clinical Biomechanics Boot Camp could just about be considered as the “too many toes” sign:

Below is a screen grab of the video of the other foot. I like to call that one the “all the toes” sign rather than just the “too many toes” sign as all of the toes are visible laterally.

The key point in talking about this case was that it was the right foot that was the painful one and the left one with that severe “overpronation” was not the problem one. This means that the “too many toes” sign is not something to be necessarily worried about. What you need to be worried about is the forces behind the foot posture and be worried about them if they are high.

The “too many toes” sign is not really good terminology and is just something that clinicians may say to patient as part of a conversation. It is not a diagnosis. It is probably better to use the components of the Foot Posture index to put a number on the amount of forefoot abduction rather than just say too many toes.

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Posterior tibial tendon dysfunction or adult acquired flat foot or progressive collapsing foot deformity?

3rd July 2021 by under Biomechanics     

What should it be called? I have long been part of the school that thinks we should be sticking with the posterior tibial tendon dysfunction name as that is the one that has mostly stuck and the problem was considered one of the posterior tibial muscle no longer being able to do its job – it just made sense. Two things are starting to change my mind:

  1. The pathomechanical and other studies have shown there is a lot more to it than just the posterior tibial tendon.
  2. The confusion between posterior tibial tendon dysfunction and posterior tibial tendonitis is too common and leading to wrong treatment choices (especially in runners).

It is the later point that is getting more and more attention. They are not the same thing. Posterior tibial tendonitis is an overuse injury in active healthy people. Posterior tibial tendon dysfunction is a progressive flatfoot deformity in older, often overweight adults. Two totally different sets of symptoms; two totally different populations; two totally different sets of clinical features …. yet some think they are the same thing on a continuum and some mix the two up and use the same treatment interventions. Nope.

I now think we should be calling posterior tibial tendon dysfunction either adult acquired flatfoot or progressive collapsing foot deformity to avoid the confusion and better reflect the underpinning pathological process. This terminology of progressive collapsing foot deformity is the name that seems to be being used more frequently in the most recent literature on this problem.

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“Overpronation” …. oh no!

26th June 2021 by under Biomechanics     

In social media, everyone is an expert on this. Opinions vary, but facts don’t, but all so often those opinions are being stated in the ignorance of the actual research evidence.

I have written so many times about this in so many places (eg here, here and here), so lets type it slowly and make it clear:

Firstly, there is no clear definition of “overpronation” which is why I generally put it in the “x”, but we all know it when we see it. Yes, pronation is normal, but we generally lack a clear definition of when that normal becomes too much. However, we do have normative data on the foot posture index (FPI), so there is some consensus as to what is normal and abnormal. I am pretty sure most of those posting in social media about “overpronation” have no clue what this normative data is or even what the FPI is that its based on is. This is also probably complicated that the division between normal and abnormal is most likely to be subject specific and mediated by many other factors, such as tissue capacity.

Secondly, yes there is something wrong with “overpronation”. Too many in social media keep saying that it is not a problem. Yes, there are studies that show its not and yes, there are studies showing that it is a problem. This also has to be interpreted in the context of how each study actually measured “overpronation”. When you get conflicting evidence you then need to turn to the systematic reviews and meta-analyses which assess the quality of studies and how much weight to give each of those studies. All those most recent reviews of the preponderance of that evidence have shown the same thing: “overpronation” is a problem; it is a risk factor for running injury. However, it is only a small risk factor, but it is still a statistically significant risk factor.

Thirdly, just becasue someone can show an example of someone who massively “overpronates” and does not have a problem is not evidence that it is not a problem. The video of Haille Gebrselassie (“the truth”) come to mind. This is no different to showing someone who has smoked cigarettes their whole life who did not develop lung cancer. Does that mean smoking does not cause lung cancer? People who use examples like that video of Haille Gebrselassie to support their case really should know better and are just showing their ignorance of causation and the actual scientific evidence and just what a risk factor is and how it works.

Fourthly, there are multiple causes of “overpronation” and if it needs to be dealt with, it is dealt with by dealing with that cause in that individual. Anyone who is advocating one particular treatment for “overpronation” really have no clue what they are talking about. There are multiple options, but the option that will only work is the one that is directed at the specific cause in each individual. You can tell how much someone in social media knows about this based on what they say you need to do to deal with it. One hit wonders are clueless, so ignore them.

Enough said … again.

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