Pronation 101: Running Shoe Choices, DIY Analysis, Injuries

Posted on 06 August, 2021 by Jovana Subic

pronation-intrograph

Do you supinate? Can shoes correct overpronation? How is pronation related to injuries? We’ve spent over 40 hours researching pronation and presented it all in this guide. 

If your runs are comfortable with no issues, don’t bother with pronation. However, if you’re experiencing discomfort, it’s always best to consult a specialist (e.g. podiatrist). 

Disclaimer: The purpose of this guide is to educate, not to make any medical diagnosis or recommendation.

What is pronation? 

When running, the foot hits the ground, the arch collapses to absorb the shock, and the rearfoot rolls inward at the ankle. This motion is called pronation. It’s normal for a joint to pronate and it’s a necessary component of the gait cycle. 

Based on the angle of pronation, there are 3 types of this motion: 

  1. Overpronation - when the ankle rolls far too inward. This is the most common case. Runners who overpronate place more weight on the medial side of the foot. 
  2. Neutral or “normal” pronation. 
  3. Underpronation (also called supination) - when the ankle rolls outward. Only a small percentage of runners underpronate (or supinate). Those who do place more weight on the lateral side of the foot. 

overpronation-underpronation-supination

There isn’t a consensus regarding the angle that separates types of pronation. We found 15° to be mentioned, but it’s not a widely accepted criteria.

Why pronation matters? 

Because when a runner overpronates or supinates, it’s more difficult for their foot to handle the shock and their stride is less efficient than of runners who pronate neutrally. This messes up with the running form and might lead to injuries - whatever the cause is. That’s why scientists and running enthusiasts pay so much attention to pronation and work on improvements by exercising and/or finding specific shoes. 

Do you overpronate, supinate or pronate neutrally? 

There are numerous methods used for pronation determination. But, not all are good enough

Some methods cover only arch height (footprint analysis) and relate that to pronation. Pronation has more components to it and they are often neglected. The main issue here is that someone can be overpronated based on one parameter and not overpronated based on another parameter. Also, the best assessments are done when a person is moving (running on a treadmill, for example), since pronation is about motion not standing still. 

The best way to determine pronation (in order of quality): 

  1. Visit a specialist (e.g. biomechanics specialist or podiatrist) who has the equipment and knowledge to do it. 
  2. Go to a running store that has the equipment for this, usually a treadmill with sensors and cameras. 
  3. Self-assessment methods. They are of the least quality. As shown in this study, runners correctly determine their foot type in less than 50% of cases. 

Some of the methods used for pronation and arch height measurements are: footprint analysis (the wet test), medial longitudinal arch angle, navicular drop test, rearfoot angle, subtalar joint neutral, forefoot angle, arch height index, foot pronation index. 

Here we will focus on the footprint analysis and foot pronation index. The first one is the most popular self-assessment method among runners. The second one is the only one to offer an insight into what pronation determination should cover without fancy equipment. In scientific studies, the foot pronation index is becoming a norm.  

Test: DIY footprint analysis (the wet test)

Here runners rely on the wet test and these criteria: 

Arch Height Pronation
Low or flat Overpronation (Look for overpronation or severe overpronation running shoes)
Normal Neutral (Look for neutral running shoes)
High Underpronation (Look for neutral running shoes)
  • Pros: easy, fast, DIY, no fancy equipment needed. 
  • Cons: not reliable for pronation. One can have a high arch but also an everted heel bone. Or one can have a low arched foot with a vertical heel bone. This means it’s important to determine the height of the arch, but keep it as only one part of the puzzle. 

The process looks like this: 

  1. Perform a wet test 
  2. Look at results and 
  3. Compare the results to the ones in the table. 

wet-test-for-pronation

wet-test-results-pronation

Keep in mind that the wet test is just an approximation. 

Foot posture index 

Foot Posture Index (FPI) quantifies the degree to which a foot is pronated, neutral or supinated.

It is usually practiced by specialists, but we describe it in detail, mainly so the complexity of the process can sink in. This way, the other methods should become of less value as standalone pronation tests. 

  • Pros: captures information in multiple foot segments without complex measurement techniques or equipment, more valid than other static methods.
  • Cons: it’s still a measure of standing foot posture, so it’s not a replacement for gait assessment, plus you can’t do it yourself.

Series of six observations and palpation are made and scored from -2 to 2. 0 is considered a neutral foot, a positive score is given for a pronated and negative for a supinated foot. 

 

Here we’ll describe all 6 steps in FPI using the defined values

Step 1: Talar head palpation.

Talar head palpation

Talar head palpation: possible scores
Score Criteria
-2 Palpable on the lateral side (it is protruding there) and not at all on the medial side.
-1 Palpable on the lateral side and slightly on the medial side.
0 Equally palpable on both sides.
1 Palpable on the lateral side and slightly on the medial side.
2 Palpable on the medial side and not at all on the lateral side.

Step 2: Curves above and below the lateral malleolus. 

Lateral malleolus curvature

Lateral malleolus curvature (viewed from behind)
Score Criteria
-2 The curve below the malleolus is either straight or convex.
-1 The curve below the malleolus is more convex or more flat than the one above the malleolus.
0 No difference between the curves above and below the malleolus.
1 The curve below the malleolus is more concave than the one above the malleolus.
2 The curve below the malleolus is significantly more concave than the one above the malleolus.

Step 3: Calcaneal inversion and eversion, the frontal plane.

Calcaneal inversion and eversion

Calcaneal frontal plane position (viewed from behind)
Score Criteria
-2 Inverted more than 5 degrees (varus)
-1 Between vertical and an estimated 5 degrees inverted (varus)
0 Vertical
1 Between vertical and an estimated 5 degrees everted (valgus)
2 Everted more than 5 degrees (valgus)

Step 4: Foot in the transverse plane with a focus on the taillow navicular congruence. 

Foot in the transverse plane (navicular congruence)

Taillow navicular prominence
Score Criteria
-2 Markedly concave.
-1 Slightly concave.
0 Flat
1 Slightly bulging.
2 Markedly bulging.

Step 5: Sagittal plane with the focus on medial arch height. 

Sagittal plane: medial arch height

Congruence of medial longitudinal arch viewed from inside.
Score Criteria
-2 High arch and acutely angled toward the posterior end of the medial arch.
-1 Moderately high arch and slightly acute posteriorly.
0 Normal height and concentrically curved.
1 Lowered arch with some flattening in the central position.
2 Arch very low with severe flattening in the central portion (arch making ground contact).

Step 6: Transverse plane with the focus on forefoot adduction and abduction. 

Too many toes method

Abduction/adduction of the forefoot (viewed from behind)
Score Criteria
-2 No lateral toes visible. Medial toes clearly visible.
-1 Medial toes more visible than lateral.
0 Medial and lateral toes equally visible.
1 Lateral toes more visible than medial.
2 No medial toes visible. Lateral toes clearly visible.

Now all these scores are filled in the FPI sheet and added. 

It’s obvious that a possible score falls in the range between -12 to 12. This is where it gets tricky: Scientists and specialists didn’t find a consensus on the results. The lack of strong consensus led to different studies choosing different score ranges for each category. These are some of the possible results: 

  • Normal foot: 0 up to +5 
  • Pronated foot: +6 to +9 
  • Highly pronated foot: 10 and up 
  • Supinated foot: -1 to -4 
  • Highly supinated: -5 to -12

Another study went by these numbers: 

  • Neutral 0-7
  • Pronated 7-10 
  • Highly pronated higher than 10 

The issue with this approach is that anything above 0 is pronated. Generally, 0-4 is considered to be a normal range and anything above 4 overpronated. The normal adult population has an FPI Score of +4 which confirms that a slightly pronated foot posture is the normal position at rest (as described in detail here).

Shoes you need based on your pronation or arch height

If you’re enjoying your pair of running shoes and experiencing no problems, don’t overthink pronation and enjoy your run. 

If you’re not paying a visit to someone knowledgeable and owning the equipment needed for pronation determination, you will probably base your decision on the shoe wear or footprint analysis (the wet test). 

This means you’ll use the logic shown in the table below to choose your running shoes. You might notice that supinators are left out - shoe brands aren’t making shoes for them. They run in neutral shoes. 

foot-types-pronation-compared

Even if you had your pronation determined by a doctor, if you’re overpronating you’ll go for stability running shoes or motion control shoes, if you’re pronating neutrally or if you’re an underpronator, you’ll look for neutral running shoes

Features of neutral, stability and motion control running shoes   

This is an overview of the most important shoe features and how they differentiate between neutral, stability and motion control running shoes.  

Comparison of neutral, stability and motion control running shoes

When it comes to supportive elements, brands usually use:

  • Guide rails - they support your foot and “nudge” it so it pronates less.

Guide rails in stability running shoes

  • Midfoot support elements - they appear in various forms of overlays and their purpose is to keep your midfoot more stable.

Support elements in the midfoot

  • Dual-density foam - placed in a midsole and it also has a stabilizing role.

Dual-density midsole

Buying shoes in stores: if you want to judge the shoe “in person”, you are supposed to try to bend it, twist it, look at the outsole, and give the heel counter a squeeze. Use the table below to recognize each running shoe type:

Features of motion control, stability and neutral running shoes

In general, you can also differentiate shoes by looking at the shape of the outsole. Keep in mind that not all the shoes follow this rule and there are overlapping categories (e.g. some shoes work both for stability and motion control) so they might not fit perfectly into the description below.

Shape of the running shoe outsole

Can shoes help with overpronation?

Yes, but not a lot. 

The scientific evidence is all over the place and this is why: they all put overpronating runners in the same group. As explained above, there are many causes of overpronation. That’s why shoes can’t help everyone. Ideally, a study should control for the cause of overpronation. But none does. 

The effects of shoes on pronation
Motion control shoes can reduce pronation by ~2% when compared with barefoot or simple cushioned shoes, as shown in this study
Motion control shoes control rearfoot motion better than cushion shoes. This was found in a study where 20 high-arched and 20 low-arched recreational runners were recruited to wear motion control and cushioning shoes.
In a study where female runners overpronated more than 6 degrees, motion control shoes were found to reduce pronation by 3.3 degrees before the run, but after 1 mile they made no difference (compared to the cushioned shoes).
It was observed that anti-pronation shoes reduce peak rearfoot eversion by ~3 degrees in this study.
Runners who overpronate and use standard shoes have a higher injury risk compared to those with neutral feet [source].

What definitely does work is foot orthotics and if you’re looking into that solution, the best thing is to consult a specialist, not buy over-the-counter ones.

Pronation and injury 

There is no definitive proof of excessive pronation directly causing injuries. 

There are runners who overpronate only a bit and experience problems and there are runners who have a moderate case of overpronation and yet experience no issues. 

Pronation becomes a cause of the injury when it contributes to increased load in the tissues and when this load is beyond what the tissues can take. Then, the forces associated with the load are high enough to cause damage.  

There is a magnitude of forces related to pronation. That’s why there are many issues when trying to correlate (excessive) pronation to injuries directly. And that’s why scientific findings are all over the place as shown below: 

Question Answer
Who’s at greater risk?

This metastudy of 28 studies found that high-arched and low-arched feet have a slightly higher risk of injury than normally arched feet. 

A year-long study of 927 runners showed no correlation between arch height and injury rates. They all ran in neutral shoes, no matter their pronation.

The US military did a 7,203-person study that reported no difference in injury rates between those who were assigned shoes based on the shape of their arch and those who got stability shoes regardless of their arch. 

When 372 recreational runners were given either the motion control or the standard running shoes and followed up for 6 months, it was found that the overall injury risk was lower in overpronating runners who had received motion control shoes compared to those who got standard shoes.

Where do injuries happen?

A study has tested 40 runners and discovered that the location of the injuries varies with arch height
High-arched runners reported a greater incidence of ankle injuries, bony injuries and lateral injuries. 
Low-arched runners exhibited more knee injuries, soft tissue injuries and medial injuries.

Another study of 1,597 showed that those with the lowest arches were more likely to have knee pain than those with the highest arches.

Things you must know about pronation (and never be fooled again)

Given all the noise out there regarding pronation, we decided to create a summary of things we do (not) know:

  1. Pronation is not a disease. It’s a type of motion and it’s completely normal. 
  2. You should look for treatment if you’re overpronating AND feeling discomfort. The best way to do this is to discover what’s causing excessive pronation first. 
  3. There isn’t one cause of overpronation and supination and that’s why they can’t be “fixed” with one thing (e.g. shoes) only. 
  4. There are no shoes for people who underpronate, they wear neutral running shoes (just like people with neutral pronation). 

Also, in scientific terms, during overpronation, eversion, dorsiflexion (bending backward) and abduction (moving away from the midline of the body) happen at the same time.

Underpronation is just the opposite: it’s when inversion, adduction (moving toward the midline of the body) and plantarflexion (bending forward) happen simultaneously. 

Eversion, inversion, abduction, adduction

Dorsiflexion, plantarflexion, inversion, eversion

Why is pronation so confusing? 

Pronation as a motion is straightforward. 

However, there are many unknowns behind standardized data on pronation. They are the source of all the confusion. Here’s a list of them: 

Understand pronation

What causes overpronation

MANY things. 

There are many forces involved in this motion and, therefore, many possible causes of excessive pronation: bony alignment issues (e.g. inverted position of the bones in the forefoot called forefoot varus), weak muscles (e.g. glutes, foot muscles, posterior tibial muscle), damaged arch, a tight calf muscle, etc.

The best thing would be not to experiment and see a specialist. 

Excessive overpronation is in most cases a sign of weakness and poor technique elsewhere in your running gait, not a disease to be treated.

If you watch elite runners and play the video in slow-mo or freeze-frame, you’d be surprised how many of them are overpronating and to what degree and yet they are pain-free. Keep in mind they devote themselves to running which means they work on their gait, form, everything. 

To treat overpronation there should be an actual need for treatment and one needs to know the cause of it. This is the most difficult part which specialists should be consulted about. 

Overpronation treatment

If you google possible treatments without knowing the cause of your overpronation, you just might waste your time on strengthening the glutes when you should have gotten foot orthotics for a bony alignment issue. 

Running-shoe market representation and prices 

We’ve looked at all running shoes in the RunRepeat database and compared prices (manufacturer’s suggested retail price or MSRP) as well as the percentage of running shoes grouped by stability features and different brands. 

Average price of running shoes grouped by stability features

Market breakdown by stability features of running shoes

Brands making neutral running shoes

Brands making stability running shoes

Brands making motion control running shoes

Author
Jovana Subic
Jovana Subic

Whether it's a vertical kilometre or an ultra, climbing in the Alps or exploring local mountains, Jovana uses every opportunity to trade walls and concrete for forests and trails. She logs at least 10h/week on trails, with no off-season, and 4x more on research on running and running shoes. With a background in physics and engineering management, she prefers her running spiced with data.