“Overpronation”

By admin,

“Overpronation” is a term that gets bandied around a lot and really has no meaning. Pronation is a normal motion that occurs in the foot in which the ankle rolls in medially and the arch collapses. Overpronation is obviously when there is too much of that. The assumption of this is that too much is associated with problems.

However:

  • There is no real consensus as to what is normal and what is excessive (ie what is overpronated)
  • The actual evidence linking overpronation to symptoms is either just not there or very weak

Too many people are pretending to be experts on it, making statements about it and wishing those statements were true when they really and quite clearly do not understand it. This leads to so many nonsensical claims being made for it and so many ‘one-size-fits-all’ approaches to it which is destined to fail when applied to all. There is so much nonsense, quackery, mythology and poor advice that gets written about it.

Basically, overpronation is only a problem and needs treating if the loads in the tissues are high enough to cause damage. In many feet that overpronate, the forces are not high and they will generally never need an intervention. Not all overpronation is the same.

Overpronation is caused by many different thinks and the treatment should be directed at the cause of the overpronation and not directed at the ‘one-size-fits-all’. For example:

  • If it is caused by tight calf muscles then the only thing that will work is a heel raise and stretching of the calf muscles
  • If it is caused by weak muscles, then the only thing that will work is strengthening those muscles.
  • If it is caused by a bony alignment problem, then the only thing that will work are foot orthotics.
  • etc

This is of course based on the assumption that the overpronation needs to be treated in a specific individual. In some it will and in some it won’t. The challenge is working out which one is which.

The evidence is clear, overpronation is a risk factor for injury and the evidence shows that this is statistically significant. However, that evidence also shows that it is a small risk factor, meaning that a lot of other factors are at play.

Please, when it comes to reading something on overpronation, please use your critical thinking skills and no not fall for the nonsense, quackery, mythology and poor advice.

Credit: some of the above is based on the writings of Craig Payne.

Why is plantar fasciitis so hard to manage?

By admin,

Its not hard to manage.
What is had is sorting out the good from bad information on what it is and how to manage it.

Plantar fasciitis occurs when the cumulative load in the plantar fascia exceeds what the tissue can take. Its a mechanical issue, so mechanical problems need mechanical solutions. Long term you really only have two key options:

  1. Reduce the load (eg strapping, stretching, foot orthotics, activity reduction, footwear modifications, loose weight etc)
  2. Increase the tolerance of the plantar fascia in its ability to take the load (eg mechanical overload and adaptation exercises, etc)

Pretty much every other treatment that gets used for plantar fasciitis will either help facilitate healing or do nothing (ie its snake oil). A simple web search will turn up plenty of unhelpful testimonials for pretty much anything to treat it. No matter what is advocated, there is always someone who will claim it helped. Equally, there is always someone who will claim it did not help.

The reason for all the bad information and misinformation is probably:

  • Initially plantar fasciitis is an -itis (inflammation) and then it becomes an -osis (degeneration). Different treatments are needed for an -itis vs an -osis. Recommending an -itis intervention for and -osis is bad advice (and vice versa). This is why some are advocating for this to be called plantar fasciopathy.
  • the natural history of plantar fasciitis is that it gets better on its own, eventually. “Eventually” may be as long as years and it hurts a lot in the meantime, so yes it should still be treated. This also means that using any treatment (good or snake oil) just as the plantar fasciitis symptoms improve, that the treatment used is going to get the credit when it was going to improve anyway (and lead to a positive testimonial or that treatment). That is why we really should be sticking to treatments that have been shown in clinical trials to do better than that natural history.
  • the symptoms are not ‘level’. The symptoms go up and down naturally over time. If you were to use a totally useless treatment just as a natural downswing in symptoms was about to happen, the useless treatment will be given credit when it was totally ineffective. Similarly, if a known effective treatment was used just as an upswing in symptoms was about to happen, then the treatment may halt that upswing, so the symptoms remain the same – that treatment is then considered useless as the symptoms are the same, when in reality it was actually effective. That is why we really should be sticking to treatments that have been shown in clinical trials to do better than that natural history, and not putting much weight on testimonials.
  • all plantar fascitis is not the same. There is the -itis vs –osis issue above. The longer term cases are going to respond differently to treatments than a short term case to different interventions. There are different thicknesses of the plantar fascia which are likely to respond differently. There are different amounts hypoechoic signal on ultrasound which are likely to respond differently to different treatments. No one treatment is going to be effective in all cases.

It is knowledge of these ‘reasons‘ and how to work with them that distinguish good clinicians from the poor online advice based on testimonials.