As we walk, there is a fine interplay between the movements of the
lower extremities and the balancing of the spine. Normal gait causes
predictable, repetitive motions to occur from the feet to the head. The
accurate timing of the many muscle contractions required during walking
and running depends on stimuli from a symmetrical gait. Recent research
in several fields has contributed to our appreciation of this
complexity. We now understand that excessive foot pronation, whether in
one foot or bilaterally, interferes with these carefully orchestrated
movements, and causes problems throughout the musculoskeletal system.
The effects of excessive pronation on the function of the spine are of
particular interest to doctors of chiropractic.
a foot pronates during the stance phase of gait (Fig. 1), there is a
normal inward (medial) rotation of the entire limb and pelvis. In
persons who have excessive or prolonged pronation, this twisting
movement is accentuated (Fig. 2). The increased rotational forces are
transmitted into the pelvis, and especially the sacroiliac joint.1 In
response, various compensatory pelvic subluxation complexes develop.
These include pelvic tilts (usually anterior or to one side), innominate
rotations (usually Postero-Inferior), and other complicated adaptations
(Fig. 3). Until the excessive pronation is corrected with custom-made,
flexible orthotic supports (Fig. 4), only short-term relief can be
achieved with chiropractic adjustments.
The loss of arch height which occurs with excessive pronation allows the
pelvis to drop to the more pronated side during stance and gait.2 The
resulting pelvic tilt lowers the sacral base and drops the lowest
freely-moveable vertebra. A lateral curvature develops in response to
the lack of solid support for the base of the spine. This
‘functional’ scoliosis starts in the lumbar region, but can
affect the entire spine. In young patients, this type of curvature
disappears when sitting or lying on the exam table. As patients age, the
spine becomes less flexible, and functional curves become stiffer and
Excessive Lumbar Lordosis
Excessive pronation of both feet often results in bilateral foot flare.
In response, the pelvis frequently tilts forward and there is an
increase in the lumbar lordosis. Symptoms develop in the compressed
posterior vertebral elements, usually causing a ‘facet syndrome.’ In
addition to adjustments and corrective postural exercises, custom-made,
flexible orthotics are necessary for comprehensive treatment of these
One of the interesting facets of excessive pronation is the large
variation in response seen from patient to patient. When the gait is
affected, the pelvis and spine must compensate in some manner. The
specific mechanism each patient uses to adapt to abnormal support from
the lower limbs is highly individual. This explains why patients often
notice so many areas of improvement when their excessive pronation is
corrected with Foot Levelers’ custom-made, flexible Spinal Pelvic
Stabilizer Orthotics. Sports performance increases,3-5and many chronic
and sub-clinical problems remote from the feet and legs improve when
their postural support is fine-tuned.6
Left untreated, all of the structural responses to excessive pronation
listed above will eventually progress to joint degeneration.
Biomechanical asymmetries transmit abnormal forces and sustained
stresses to the joints, resulting in microtrauma, cartilage wear, and
osteophytes.7 Early intervention with custom-made orthotics is best. If
the patient already has significant degeneration, additional shock
absorption will need to be included in the orthotic.
Much of the neurological coordination of the body is based on a
balanced, rhythmic gait. The ‘cross crawl’ pattern organizes many
fundamental musculoskeletal functions at the spinal cord level. In other
words, much of the smooth performance of daily physical activities
occurs without the need for conscious thinking or planning. This
includes such factors as balance, stability, and center of gravity.8
When this system is interfered with by one or both feet spending too
much time in pronation, muscles throughout the body (and around the
spine) don’t turn on and shut off in proper sequence. Such
interference also increases the work effort for doing simple activities,
and increases the consumption of oxygen during normal walking.9
If the foot and ankle complex is not functioning correctly during the
stance phase of gait, this stress is transmitted to the pelvis and spine
with every step. Excessive pronation results in abnormal firing of
muscles, and in inaccurate proprioceptive nerve impulses. This also
interferes with the toe-off phase, resulting in a less-efficient
propulsion. Walking with an abnormal gait and poor toe-off causes back
pain which can be treated with custom-made foot orthotics.10
Many chronic myofascial problems can begin with excessive pronation. The
gait abnormalities, neurological incoordination, and asymmetrical
structural stresses are often compensated by contracting the large
stabilizing muscles of the spine. This results in habit patterns with
detrimental effects on movement and eventual perpetuation of symptoms.
Myofascial trigger points, chronically contracted muscles, and even
outlet syndrome11 can develop when gait abnormalities continue.
Because a smooth and symmetrical gait is tied so closely to proper
vertebral function,12 excessive pronation in one or both feet can cause
subluxations to recur. When patients don’t respond as expected to
chiropractic adjustments, and particularly when we have to adjust the
same levels, foot function must be evaluated. The underlying cause in
many cases is found to be prolonged pronation.
The use of custom-made, flexible orthotics is frequently indicated to
restore balance and provide a level pedal foundation. Yochum
demonstrated how a 15.5mm leg length inequality (LLI) could be reduced
to just 4mm with the use of Foot Levelers’ custom-made, flexible SPS
Orthotics (Figs. 5A & 5B).13 Not only had the pelvic deficiency been
markedly reduced, but the right compensatory listing of the lower lumbar
spine had also diminished.
Orthotics are of special value in cases where
excessive foot pronation and arch collapse have been observed. Foot
Levelers’ Elite™ line of SPS Orthotics is the first to offer the
both the patented Extreme Gait Cycle System® and the innovative Dynamic
Response System™. The unique qualities of the Elite line allow it to
have variable degrees of support that work with the individual’s gait
cycle, lifestyle, physiology, and conditions.
every person who begins wearing flexible,
custom-made SPS Orthotics for excessive pronation will go through an
initial break-in period. That is to be expected. During this time,
avoidance of lengthy periods of standing and walking is best, and
running should be only gradually re-introduced. General stretching
exercises for the spine and pelvis will help eliminate the abnormal
muscular patterns, and should be performed daily. Massage therapy can
also speed up this adaptation process.
Retraining exercises for balance and coordination can
be introduced for athletes and those patients who want to return quickly
to complex physical activities. While these recommendations may be
difficult for some, those patients who are willing to invest the effort
will respond much more rapidly.
It is very important to assess and adjust the pelvis and spine as each
patient adapts to wearing SPS Orthotics. Since excessive pronation
places abnormal stress in predictable areas (especially the sacroiliac
joints and lumbar vertebrae), close evaluation of these regions is
needed. However, in light of the postural instability and neurological
balance factors discussed above, the entire spine must be checked
frequently during the initial adaptation period. In fact, because the
upper cervical region is often slow in adapting to the change in
posture, it needs to be carefully adjusted. Education of the patient
will help to smooth this transition to better foot function and improved
1. Botte RR. An interpretation of the pronation
syndrome and foot types of patients with low back pain. JAPA 1981;
2. Hammer WI. Hyperpronation: causes and effects. Chiro Sports Med 1992;
3. Stude DE, Brink DK. Effects of nine holes of simulated golf and
orthotics intervention on balance and proprioception in experienced
golfers. J Manip Physiol Ther 1997; 20(9):590-601.
4. Stude DE, Gullickson J. Effects of orthotic intervention and nine
holes of simulated golf on club-head velocity in experienced golfers. J
Manip Physiol Ther 2000; 23(3):168-174.
5. Stude DE, Gullickson J. Effects of orthotic intervention and nine
holes of simulated golf on gait in experienced golfers. J Manip Physiol
Ther 2001; 24(4):279-287.
6. Olsen JD. Grip strength improved with Foot Levelers’ orthotics.
Practical Res Studies 2003; 13(5):1-4.
7. Giles LGF, Taylor JR. Lumbar spine structural changes associated with
leg length inequality. Spine 1982; 7(2):159-162.
8. Horak FB, Nashmer LM. Central programming of postural movements:
adaptation to altered support surface configuration. J Neurophysiology
9. Otman S et al. Energy cost of walking with flat feet. Prosthet and
Orthot Intl 1988; 12:73-76.
10. Dananberg HJ, Giuliani M. Chronic low-back pain and its response to
custom-made foot orthoses. J Am Podiatr Med Assoc 1999; 89:109-117.
11. Sucher BM, Heath DM. Thoracic outlet syndrome — a myofascial
variant: structural and postural considerations. J Am Osteopath Assoc
12. Yekutiel MP. The role of vertebral movement in gait: implications
for manual therapy. J Man Manip Ther 1994; 2:22-27.
13. Yochum TR, Barry MS. The short leg (2003 revision). Practical Res
Studies 2003; 4(5):1-4.