What is the evidence base for the therapeutic management of overpronation of the feet when walking?

Management of Overpronation During Walking

For individuals with overpronation during walking, prescribe properly fitted footwear with arch-support orthotic inserts or custom orthotics, as these interventions effectively reduce excessive ankle eversion and normalize foot pressure distribution patterns. 1, 2, 3

Primary Intervention: Orthotic Devices

Effectiveness of Arch-Support Orthotics

• Arch-support inserts with medial arch-heel support significantly reduce ankle eversion by 2.5-3.0 degrees in pronators during walking, demonstrating biomechanical correction of the abnormal foot mechanics 2
• These devices normalize dynamic foot pressure distribution patterns, specifically correcting the medial shift of pressures during the loading response phase 3
• Modified UCBL shoe inserts reduce the degree and duration of abnormal pronation during stance phase, decreasing strain on plantar ligaments and reducing abnormal tibial rotation 4

Orthotic Prescription Specifications

• For patients with foot deformities or at-risk conditions, prescribe therapeutic footwear with demonstrated plantar pressure-relieving effects (≥30% reduction in peak pressure at high-pressure locations or in-shoe peak pressure <200 kPa) 1
• Custom-made orthotics or extra-depth shoes should be selected based on the type and severity of deformity present 1
• Orthotics should be fabricated to accommodate the specific foot structure and may require periodic adjustment or replacement 5

Footwear Modifications

Proper Shoe Selection

• Prescribe shoes with adequate depth, width, and length to accommodate the foot without causing pressure points 1
• Footwear should have good flexibility, flat heel, heel support, laces or straps, and flat or absent seams to prevent excessive foot movement inside the shoe 1
• The upper covering should be leather or fabric mesh rather than plastic or synthetic materials to allow air circulation 1
• Open-backed shoes may reduce pressure on irritated areas in symptomatic patients 5

Critical Footwear Considerations

• Inappropriate footwear with inadequate length or width increases the risk of complications and perpetuates symptoms 1, 5
• Properly fitting footwear provides protection against thermal and mechanical trauma beyond just addressing pronation 1

Adjunctive Conservative Therapies

Exercise and Stretching

• Implement regular calf-muscle and anterior compartment stretching exercises to reduce tension on affected structures 5
• Eccentric strength training promotes tendon healing if tendinopathy develops secondary to overpronation 5
• Deep transverse friction massage can reduce pain in affected tendons 5

Pain Management

• NSAIDs effectively relieve pain associated with overpronation-related tendinopathy 1, 5
• Topical NSAIDs reduce tendon pain while eliminating the increased risk of gastrointestinal hemorrhage associated with systemic NSAIDs 1
• Cryotherapy through ice application for 10-minute periods through a wet towel reduces inflammation and pain 1, 5

Activity Modification

• Temporarily reduce weight-bearing activities that exacerbate symptoms, particularly high-impact activities 5
• Technique modification for athletes and manual laborers minimizes repetitive stresses on tendons 1

Treatment Algorithm

Initial Management (0-6 weeks)

1. Prescribe properly fitted footwear with arch-support orthotic inserts 1, 5, 2
2. Implement stretching exercises for calf and anterior compartment 5
3. Provide NSAIDs for pain management 1, 5
4. Apply cryotherapy to symptomatic areas 1, 5
5. Modify activities to reduce stress on affected structures 5

Follow-Up Assessment (6-8 weeks)

• If symptoms improve, continue prescribed treatments until full resolution 5
• If no improvement occurs, refer to podiatric foot and ankle surgeon for advanced evaluation 5

Advanced Interventions (If Conservative Management Fails)

• Consider immobilization with cast or fixed-ankle walker-type device for persistent symptoms 5
• Surgical evaluation may be warranted if pain persists despite well-managed conservative treatment 1

Evidence Quality Considerations

Biomechanical Evidence

• The strongest biomechanical evidence demonstrates that medial arch-heel support effectively reduces ankle eversion in 84% of pronators during running, with similar effects in walking 2
• However, some older studies show variable effectiveness of foot orthotic devices, with only certain variables (maximum pronation angle and percentage of support time in pronation) showing significant improvement 6

Clinical Application

• The effectiveness of orthotics is product-specific and depends on proper design and fitting 2, 6
• Orthotics are effective during dynamic activities (walking, running) but not in static standing 2
• The benefits of orthotic intervention outweigh potential harms, which are minimal when properly fitted 1

Common Pitfalls to Avoid

• Inadequate footwear modification or continuing to use tight, poorly fitted shoes will perpetuate symptoms 1, 5
• Premature return to high-impact activities before adequate adaptation can lead to symptom recurrence 5
• Prescribing generic orthotics without considering individual foot structure and biomechanics may result in suboptimal outcomes 2, 6
• Failing to address modifiable risk factors and biomechanical problems such as excessive foot pronation or pes planus deformity 1
• Not reassessing orthotic fit periodically, as foot structure and needs may change over time 5