Overpronation

What is it?

Overpronation means your feet roll inwards too much. It is often talked about alongside flat feet, where the arch (the curve along the inside of your foot) is low or absent and the foot presses almost flat against the ground. The two are related but they aren't the same thing.

Many people with flat feet have no symptoms at all. When symptoms do appear, they can include foot pain, pain in the shins or calves, pain or swelling on the inside of the ankle, and shoes that wear unevenly. Your feet, legs or ankles may also feel tired or sore, especially during or after activity. Rolling in too much can also make shoes wear out quickly.

What can cause it?

The most common cause in children is simply normal development. Babies and young children are born with flexible flat feet, and the arch builds up gradually over the first ten years or so. Flat is normal up to about eight years of age.

Other causes include:

• Family history. Many people inherit flat feet from their parents.
• Loose joints. Loose connective tissue (the tissue that holds your joints together), such as joint hypermobility or Ehlers-Danlos syndrome, can let the arch flatten.
• Extra weight. Being overweight puts more stress on the feet.
• Changes later in life. An injury to the tendons or ligaments in the foot can make the arch collapse. The connective tissue in the foot can also become stretched and sore. Possible reasons are overuse, unsupportive shoes, ageing, extra weight or arthritis.
• Muscle, nerve or connective tissue conditions. Examples are cerebral palsy, spina bifida and muscular dystrophy.
• The shape of the front of the foot. In forefoot varus, the front of the foot tilts inwards compared with the heel. This can add to rolling in and to foot, knee and hip problems.
• A stiff flat foot. In children this is rare. It is different from the usual flexible kind, where the arch comes back when the foot is not bearing weight.

Who gets it?

Flat feet are common in children. About 45 per cent of preschool children have them, and about 15 per cent of older children (average age 10 years). Flat feet become less common as children grow. How many people overpronate isn't known, as most figures are for flat feet.

In children, flat feet are linked with being a boy, being under 9, loose joints, wearing sports shoes, living in a city and doing less exercise. These are links, not proven causes. Extra weight is also a clear risk factor for flat feet that last.

How is the cause found?

Your podiatrist, physiotherapist or doctor will ask about your symptoms and examine your feet. They will look at your feet while you stand and walk, and check for swelling or changes in the shape of your feet.

Scans are usually not needed. An X-ray or other tests may be used to rule out other conditions, such as arthritis. In children, a footprint or pressure test may be used. To tell a flexible flat foot from a stiff one, the practitioner checks whether the arch comes back when your child stands on tiptoe.

Before your visit, note where and when the pain happens, and whether your shoes wear unevenly. Also mention any family history, loose joints, muscle or nerve conditions, past foot injuries and arthritis.

Treatment

If your feet are painless, you don't need treatment. In children, flexible flat feet are not a disease and don't routinely need a specialist review or inserts. If your feet hurt, there are a few simple things to try. These steps may ease some of the problems, but they won't change the shape of your feet.

Looking after it at home

Wear supportive shoes that fit well. If you are overweight, losing weight can take stress off your feet. Stretches or exercises for the muscles of your lower legs can also help, and your podiatrist or physiotherapist can show you what to do. Painkillers may help if you have discomfort.

Treatment from your podiatrist

Your podiatrist can advise on shoes, lower-leg and foot exercises, and shoe inserts (also called orthoses). Inserts are made to support your feet and stop them rolling inwards. For a child with painful flat feet, low-cost ready-made inserts with well-chosen shoes are the usual choice. In children and young adults with flat feet, insoles, with or without exercises, may reduce pain.

For a child with flexible flat feet and no pain, expensive custom inserts are not worth paying for. Inserts and shoes also don't seem to change how a child's foot develops, as young children's flat feet slowly improve with growth whatever shoes they wear. If inserts are needed, cheaper ready-made ones usually do the job. Custom inserts are kept for foot pain with arthritis, an unusual foot shape, or pain that hasn't eased with other care.

Other options

If pain carries on despite the advice, speak with your podiatrist again. Some people try gait retraining, which means changing the way you walk or run. The best way differs from person to person, so it should be planned for you and guided by a qualified health professional. One approach shifts your weight towards the outside of the foot. It may reduce rolling in, but it may raise the risk of a stress fracture in the foot and of overuse injuries in the lower leg.

Surgery is sometimes recommended by podiatrists or physiotherapists, but only in some cases.

Will it get better?

For children, the outlook is generally good. Flexible flat feet tend to improve with age, and the arch builds up over the first ten years or so. Fewer than 2 in 100 children develop pain. Most symptoms ease as they grow.

A flat foot that doesn't change, or that gets stiffer, in a child older than ten is worth raising with a podiatrist or GP. It isn't yet clear whether flat feet that cause no pain lead to problems later. What happens over time for adults, and what stops it coming back, isn't clear either. If your pain keeps coming back, ask your podiatrist for advice that suits you.

When to see a podiatrist

Book an appointment if

Book an appointment with your podiatrist if your foot or ankle pain hasn't improved after the first few days, is getting worse, or still causes problems after two weeks of looking after it yourself. Book too if your child's flat feet are painful, or your child is over ten and the flat foot isn't changing or seems to be getting stiffer. Your podiatrist can also help if your shoes wear unevenly and your feet, legs or ankles ache after activity.

Seek prompt assessment if

Go to the nearest emergency department if your foot or ankle looks out of shape or at an odd angle after an injury.

See your GP or another doctor today if you have foot or ankle pain after a fall or injury, severe heel pain after an injury, a snap or pop when you were hurt, or you can't walk on the foot. A fracture can look like a sprain. If you think you have broken your heel bone, don't try to treat it yourself. If your GP can't see you today, go to an urgent care clinic or an after-hours GP.

See your GP or another doctor today if you have diabetes with numb feet and you notice damaged footwear, a sore, a blister, an injury or signs of too much pressure on your foot.

See your GP soon if you have heel pain with tingling or loss of feeling in the foot, or heel pain and diabetes. See your GP soon too if you have pain in both feet or ankles with a lot of stiffness in the morning, or if you have foot or ankle pain and take steroids, biologics or other medicines that affect your immune system. Do the same if your child has flat feet and a stiff foot, or signs of a muscle, nerve or connective tissue condition.

Frequently asked questions

Does it matter that my feet look flat if nothing hurts?

Usually not. How a foot looks doesn't always show how well it works. Some flat or rolled-in feet cause no trouble, while some normal-looking feet hurt. If you have no pain, you don't need treatment.

Can rolling in cause knee or hip pain?

It can be part of the picture. Some foot shapes, such as forefoot varus, add to rolling in and to foot, knee and hip problems. Pain has many causes, though, so see your podiatrist or GP to find out what is behind yours.

Should I see a podiatrist or a physiotherapist?

Either can help. Both can advise on shoes and on foot and lower-leg exercises, and both can prescribe shoe inserts. If pain carries on after you've followed the advice, go back to your podiatrist to talk about what to try next.

Further reading

• What Is Overpronation? Cleveland Clinic
• Flat feet NHS
• Gait Analysis - Australian Podiatry Association Ltd Australian Podiatry Association
• Treating the Flat Foot NHS
• NHS Borders Podiatry NHS