In the winter 2006 newsletter, Timothy Agnew’s article, SUPINATION AND PRONATION AND ITS AFFECT ON THE HIP, stated that pronation of the foot causes it to roll out, and supination causes the foot to roll in. The correct movements are that during pronation the foot rolls in, and during supination the foot rolls out. This was a text error and we apologize for the confusion.

Supination and Pronation and Its Effect on the Hip
Tim Agnew

Recently, a 40-year-old male patient presented foot, knee, and hip pain at my clinic. Matt also said his back had been bothering him for some time. The patient, an airline pilot for a major airline, said walking the terminal was excruciating. Sitting was the only thing that relieved his pain.

After observing his awkward gait as he walked from one end of the clinic to the other, I said, “You’re too young to walk like that.” And it was true. Matt’s gastrocnemius was short on both feet, so he was not getting the correct push off he needed to take the next step. He also pointed his right foot out as he walked. “Do you have right side knee pain?” I asked him.

He pointed to his lateral knee, at the insertion of the iliotibial band (IT), then reached down to rub it.

Matt’s hips were not moving right, either. During the swing phase, his hip rotated forward about 25-30 degrees. The normal hip should have about a 40 degree forward rotation, a telling sign that Matt’s psoas was shortened, especially on his right side. Matt also leaned forward as he walked, as though he were chasing his center of gravity. He took his tennis shoes off and I flipped them over to examine the souls. They were worn on the outer lip of the shoe, and the right side was especially worn. This was a telling sign that Matt’s feet pronated, or rolled out, as he walked.

Supination (rolling in) and pronation are natural movements of the foot, but too much of either can cause enormous dysfunction in the entire body. While the feet are the source of the dysfunction, they should not be isolated and treated singularly. The entire body must be included if the dysfunction is to be helped. In Matt’s case, his foot pronation had snowballed over time to include irritation in the knees, hips, and low back.

Flat foot, or pes planus, is common in many individuals, and it essentially means that the arch of the foot has collapsed, or, in some cases, never formed. During the gait cycle, the foot must transition from a flexible construct at heel strike to accommodate irregular surfaces to a rigid construct at push off to maintain a rigid lever for ambulation. The foot provides structural support for the body during the stance phase of gait - from heel strike through foot flat to toe-off. The foot and leg must bear the full weight of the body and maintain the pelvis and spine in normal alignment. If one or more of the foot’s arches is not able to provide the necessary support, abnormal postural adaptations are created. Additional stress is placed on the many joints, ligaments and muscles involved in helping to maintain upright posture. Whenever there is an unequal amount of support from each leg during weight-bearing stance (due to either an anatomical or a functional shortening), posture will definitely suffer. This results in an uneven foundation for the pelvis and the spine, causing various postural shifts in response.
Over-pronation of the foot causes internal rotation of the femur, which in Matt’s case transfers forces to the hip. The result is pain, especially in the sacroiliac joint.

Foot supination can cause some of the same issues, with chronic knee and hip tendonitis and bursitis on the top of the list. The psoas muscle, which is a vital muscle for gait and support of the spine, can weaken over time because of compensation from other hip muscles. If the foot over-supinates, the normal function of the psoas is disrupted.

To treat foot dysfunction, it is necessary to look at muscles in the hip. Clinical Flexibility and Therapeutic Exercises (CFTE) is a modality rooted in kinesiology and biomechanics, and it examines the entire body from a movement perspective. For a condition like Matt’s, the hip muscles would be lengthened using dynamic flexibility, then strengthened to support the distorted movement of the feet. For example, the iliotibial band is of major concern because of its involvement on both the hip and the knee. Matt clearly had irritation where the IT band crosses the knee. The large piece of fascia can be lengthened by applying a specific isolated stretch, and this releases its tremendous pull on the patella, helping correct the action of the foot.

In Matt’s case, his treatment in CFTE went something like this: Over 15 specific stretches were applied to his hip and lower extremities using an isolation belt over the ASIS. Areas of tightness, i.e. his right side, were restored, including a quarter of an inch leg length discrepancy; once his legs were even in length, his gait changed dramatically. His psoas muscle was “unlocked” so he achieved a more dramatic hyperextension of the hip during gait. Attention was given to the tight gastrocnemius muscles, as well as anterior tibialis. In later treatments, his hip flexors, hamstrings, and gastrocnemius were strengthened. And the best part of Matt’s treatment? He was shown how to perform the movements he needed to maintain his dysfunction. As long as he did this, he would be pain free.

Foot pronation and supination has a dangerous affect on the hip, knee, and low back. It is important to correct this dysfunction before a snowballing occurs to the entire body. It’s simple, if you look beyond the feet.

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