Pronation and Lower Back Pain

Lower back pain is a common complaint among clients. The problem with lower back pain is the source of the pain is rarely the actual cause of the pain (Page, Frank, & Lardner, 2010). “Alexis”, a client of mine who is slightly overweight and in her mid-fifties, suffered from mild to severe lower back pain. She had no obvious history of back injury, and spent several hundred dollars a month on temporary relief treatments like acupuncture. After the initial client interview in which she described her symptoms, I asked to observe her walk. It turns out her problems stemmed from over-pronating her foot while walking.

Foot pronation is when the foot rolls inward slightly to absorb torque from the axial rotation of the leg and prepares the body to react to the surface, which helps the person absorb shock and adjust to uneven surfaces (O'Leary, Cahill, Robinson, Barnes, & Hong, 2013). Pronation is a normal part of walking but excessive pronation can cause the body to negatively adapt. A couple studies in O’Leary and colleagues’ (2013) meta-analysis came to the conclusion that over-pronation caused either leg length differences or pelvic tilt. The spine adapts to the faulty foot biomechanics by laterally deviating causing a functional scoliosis and lower back pain. Khamis and Yizhar (2007) found that excessive pronation leads the tibial internal rotation, knee valgus and internal hip rotation. These compensatory mechanisms lead to an anterior pelvic tilt, which can cause increased lumbar curvature associated with lower back pain.

Something seemingly as remote and benign as over-pronation was a major factor in Alexis’s lower-back pain. I found out through more questioning that she broke her fifth metatarsal three years ago. Since that is on the outside of the foot it makes sense that she began over-pronating to avoid putting pressure on her injured side. Unfortunately, the compensatory movement pattern became ingrained and led to her dysfunction.

Alexis’s treatment plan to fix her over-pronation consisted of multipronged plan of attack. First, I recommended she get orthotics for shoes. Custom made orthotic devices for the foot have been shown to control excessive foot pronation by supporting the medial longitudinal arch and calcaneus, and lessen lower back pain by fixing the kinetic chain (Castro-Mendez, Munuera, & Albornoz-Cabello, 2013). I recommended a podiatry supply store called Foot Solutions near the gym. Secondly we worked on strengthening the gluteals through clam-shells, glute bridges, mini-band walks, and slider rear lunges as over-pronation is associated with weak gluteals (Andreasen et al., 2013). Lastly, I told Alexis to be mindful of her walking form and keep the foot straight during her gait. In a couple of months Alexis’s back pain was greatly reduced due to improved lower body biomechanics.

References

Andreasen, J., Mølgaard, C. M., Christensen, M., Kaalund, S., Lundbye-Christensen, S., Simonsen, O., & Voigt, M. (2013). Exercise therapy and custom-made insoles are effective in patients with excessive pronation and chronic foot pain—A randomized controlled trial. The Foot, 23(1), 22-28.

Castro-Mendez, A., Munuera, P. V., & Albornoz-Cabello, M. (2013). The short-term effect of custom-made foot orthoses in subjects with excessive foot pronation and lower back pain: A randomized, double-blinded, clinical trial. Prosthetics and Orthotics International,37(5), 384-390.

Khamis, S., & Yizhar, Z. (2007). Effect of feet hyperpronation on pelvic alignment in a standing position. Gait & Posture, 25(1), 127-134.

O'Leary, C. B., Cahill, C. R., Robinson, A. W., Barnes, M. J., & Hong, J. (2013). A systematic review: The effects of podiatrical deviations on nonspecific chronic low back pain. Journal of Back and Musculoskeletal Rehabilitation, 26, 117-123.

Page, P., Frank, C. C., & Lardner, R. (2010). Assessment and treatment of muscle imbalance: The Janda approach. Champaign, IL: Human Kinetics.