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7293 Views 13 Replies Latest reply: May 27, 2010 11:20 AM by JamesJohnsonLMT RSS
steff137 Rookie 2 posts since
Jan 20, 2010
Currently Being Moderated

Jan 20, 2010 8:34 AM

Pretty Bad Supination...

I'm a new runner, doing Couch to 5K.  I'm having a problem.  I'm running/walking on the outer edge of my left foot.  The right foot's fine.  This happens regardless of what shoes I wear.  It's a pretty new problem; I blame wearing the same pair of Birkenstock sandals exclusively for three years, because I didn't have the issue before about 6-12 months ago.  A few weeks ago I bought a pair of Nike Air Max Moto+ athletic shoes, and they're incredibly comfortable to walk/run in.  The only problem is the supination.

 

So I get this terrible pain in the front of my leg, just above the ankle.  It happens even when I'm just walking for a 1/4 mile or more.  I've been trying to correct my gait, but I can't seem to figure out what to do.  Do I need shoes that help?  Some particular stretches?  Anything?

 

Thanks for any help you can give!

  • JamesJohnsonLMT Legend 1,153 posts since
    Aug 23, 2009
    Currently Being Moderated
    1. Jan 23, 2010 2:37 PM (in response to steff137)
    Re: Pretty Bad Supination...

    I'm glad you asked this question early in your running life, before full-blown shin splints or other problems begin.

     

    Since you are reading this, you are probably sitting down. If not, take a seat. Look down over your knee and feel the muscle running down the front side of your shin while you flex the foot upward (dorsiflexion). This is the Tibialis Anterior, and you can trace its tendon down the top of the foot toward the ball of the foot on the underside (plantar surface) as you supinate the foot. Is there pain along this pathway?

     

    Virtually everyone supinates and pronates with each footstrike during running to allow the arch of the foot to absorb shock. We refer to this in the biz as the "roll" of the footstrike. Normally, people with low arches and "flat feet" pronate more than others, and those with high arches tend to spend more time in supination. I say "normally" because an average foot would divide time in both phases more equally, while those with low or high arches tend to do more of one than the other. The "average" foot is probably less common than an "abnormal" one. The point is the brain will adapt the body to center the force of the footsrike on the kind of foot you have. This is OK for most people, and usually does not result in a lot of pain until you try to run. Running triples the weight of impact on the foot, so many muscles, bones, and tendons are recruited to minimize this impact.

     

    A popular series of videos showing under/over/"normal" pronation. Can't vouch for the conclusions...

    http://www.runnersworld.com/article/0,7120,s6-240-319-327-7727-0,00.html

     

    While the arch-height rule tends to hold true, there are exceptions. Sometimes the pronation process works the opposite of what we expect. If there is a reason why the body wants to protect from the motion of pronation, it will use the muscles to freeze the roll of the foot. This overuse of the supinating muscles can lead to the injuries you may be experiencing. Why would the body protect the foot from pronation? The answer is complicated, so remain seated.

     

    Bones continue to be shaped and oriented long after the fetal stage through early adulthood and even late in life, by heredity, nutrition, gravity, and skeletal muscle. Growth may stop, but remodeling never ends. While we are dealt a certain hand, a few cards will be slipped in and out throughout life (some of which we choose). Starting at the hip, not all pelvic bones are shaped the same, even side-to-side within a single individual. This shape can even be altered during pregnancy, disease or other conditions that soften the bones and joints - ditto for the femur (thigh) bone, and everything underneath.

     

    Some of us are born with a femur that is twisted toward the middle (femoral anteversion, particularly in females), yet this bone often reorients itself within normal limits by the end of early childhood. Unfortunately this is not usually before the brain learns to orchestrate the muscles during running. Similarly, the metatarsal bones of the foot may grow to varying lengths that are independent of the length of the toes attached to them. A common example is the Morton Foot (named after Dr. Dudley J. Morton), which features a short 1st metatarsal behind the great toe. Given only these variables and the possible combinations of them, it is easy to see why some strange adaptations take place in individuals to evenly distribute the extreme forces of running on the platform we have to work with at any given time.

     

    In your case, there is likely some reason why supination is being used to protect your foot and ankle from pronation. While this may be due to the shape of the bones, it is important to consider an important principle: Restriction of the natural motion of the foot, by your own body, shoes, or prosthetic devices, is not necessarily a good thing. There is a glut of devices on the market for fighting our bodies' adaptations, but some merely restrict motion, while others alter the neuromuscular feedback the brain uses to control movement. Restriction of motion alone rarely results in alleviating muscular dysfunction. You have to get the brain on board to retrain the footstrike for pain-free running. This may involve adding support to account for nature's variations, and it may involve taking some away. In some cases, the results are immediate; in others, it can take as much time to recover from dysfunction as it did to obtain it. Bones and joints may even be reshaped in the process, requiring a change in adaptation down the line. Mentally prepare yourself for this adventure.

     

    Some problems begin at the top and work their way down, while others work from the foot upward. You will need to deal with both directions, and can often do so without surgery. Starting from the top, you need to look down the leg while standing and during running to look for orientations of the hip, knee, and foot. You may need assistance from others to get an accurate view of each leg.

     

    It would be too ambitious a project to consider all possibilities in this post, and there are many resources on-line for this purpose, in addition to professional guidance, but I can review a few important considerations here.

     

    Standing: if the view from the top does not show the hip, knee, and ankle in line (referred to as Q angle), compensation by the upper/lower leg muscles and foot will likely take place to increase stability. If the view from the side shows the hip joint not populating the natural line from ear to ankle, there can be a number of issues including spinal, hip, and internal rotation of the leg that could force inversion (or eversion) of the foot.

     

    Running: if the view from the top shows exaggerated side to side movement of the foot, there is compensation taking place for hip width, hip angle, and/or foot structure.

     

    As Dr. Morton demonstrated early last century, the platform of the foot needs to be stable to avoid injury. In the case of a short 1st metatarsal, he placed a small pad under the ball of the foot to cause the brain to shift weight away from that direction, correcting overpronation without restriction of natural movement. In extreme cases, the body may shift impact away from the 1st few metatarsals in order to favor the stronger side of the foot (underpronation) and prevent pain. Either of these could be natural responses to Morton's condition and should be checked before proceeding, because they are temporary adaptations that lead to pain later. This bare-bones discussion has helped many people: http://www.triggerpointbook.com/mortons.htm

     

    At the hip, internal rotation must be countered by external rotation, and vice-versa, in order to prepare for the next footsrike. Excess reciprocating movement of the rotating muscles will eventually tire them, followed by involuntary tightening that leads to tremendous pain in the hip. This pain can influence the lower back, knee, ankle, and foot, increasing the chances of inflammation and/or injury to muscles, tendons, ligaments, bursa, joints and fascia in the entire power-train structure.

     

    Once again, controlling excess motion via restriction (braces, shoes, etc.) may slow the body's response to bone structure, but most likely will not prevent it. The reason the body uses muscles to shift weight must be identified and corrected first. After that, the muscles responsible for the movement must be relaxed to normal function. Stretching and strengthening alone can actually make things worse until the bone structure and muscles have been addressed.

     

    Thanks for your investment of time. This post may not eliminate your condition, but it should be a good start. If you consult a medical professional, make sure the above observations have been taken into consideration before a diagnosis or treatment has begun.

  • donmurf Amateur 31 posts since
    Nov 28, 2008
    Currently Being Moderated
    2. Jan 23, 2010 12:27 PM (in response to steff137)
    Re: Pretty Bad Supination...

    I do think stretching would help you.  Also, run with someone who can watch you as you run and let you know when you're not controlling your feet properly.

  • JamesJohnsonLMT Legend 1,153 posts since
    Aug 23, 2009
    Currently Being Moderated
    4. Jan 24, 2010 11:47 PM (in response to steff137)
    Re: Pretty Bad Supination...

    Hypermobility of the 1st Metatarsal is probably what the shoe guy was talking about (Morton's 2nd condition). Here is a link to Dr. Burton Schuler's site that discusses it in great detail (read past the commercial at the top)...

     

    http://whyyoureallyhurt.com/mortons-toe/what-is-a-mortons-toe/

     

    An ordinary podiatrist may not help much, but you should see a podiatrist that understands the needs of athletes, and is trained to solve -not simply control - this problem, or you'll wind up with some contraption on your foot you can't run in. Worse, they may say surgery is the only option. It's not. The ligament can tighten up in time if properly supported.

     

    Most footwear designed for the purpose will isolate or immobilize the problem by restricting motion, but will not exercise it to healthy operation. Proprioceptive feedback from the foot is necessary for the brain to properly control the many muscles of the foot and lower leg. Isolation will not accomplish this. The Birks did not hurt you, but they didn't help either. They are designed for normal feet.

     

    Your condition is rare enough that a simple solution may not be offered. Many professionals will look at it and see dollar signs, so you must educate yourself about it first. If you decide that professional care is necessary, you must demand the kind of care that allows you to run. Otherwise, some quack will try to turn you (or your insurance company) into a cash cow.

  • aj01 Pro 143 posts since
    Jul 8, 2008
    Currently Being Moderated
    5. Jan 24, 2010 4:03 PM (in response to JamesJohnsonLMT)
    Re: Pretty Bad Supination...

    I apologize if I'm hijacking the thread but I wanted to make some comments and ask a few questions also along similar lines.  1st off, I appreciate all the information I've learned from these forums and Mr. Johnson has been particularly helpful.  I've been fighting bad shin splints and other issues since I started running almost 2 years ago.  I have high arches and have been told that I don't overpronate by every running shoe store I've been too.  I've even watched the video of me on the treadmill and from the rear view of my foot, I saw no leaning in.  I've been to a podiatrist and a sports ortho. dr.  The doc thought I overpronated some and recomended custom orthotics that are very painful to wear.  Since the orthotics, I've had some PF and AT issues.  I do believe I overpronate but it appears to be at the later stages of the gait cycle more towards toe off which is probably why it's not visible from the normal rear view.  In fact it's like my foot never locks, it just keeps pronating into toe off.  I think that's why the orthotics don't work.  They support my arch but my problem seems to be in the forefoot.  It's very obvious that my knee rotates inward if I shift weight on one foot especially if I bend the knee slightly standing mostly on my forefoot. I have a weird wear pattern on my orthotics on the inside edge right by my big toe which seems to corfirm the turning motion and pressure on the inside edge during toe off.  I can't see that I have morton's toe by my toe or metatarsul length but I do have the slightly extended webbing between my 2nd and 3rd toes.  I also notice that my metatarsuls and pads are lower to the ground in the middle and higher under the 1st which would give me a very unstable forefoot instead of the normal tripod like shape, like trying to walk on a U shape.  I've tried one run with the padding under my 1st metatarsul and another with some new motion control shoes.  So far I feel better but it's still too early to tell for sure.  I really believe I'm onto the fix for all my problems.  I'm assuming this is something I've had all my life but is it possible it was from wear and tear walking on concrete at work for several years or anything else?  Should I use just the padding under the 1st metatarsul by itself or with an arch support or should I try to get some different custom orthotics that actually solve my problem.  Could just padding the big toe area by itself cause arch problems later.  I want this to be a long term fix and continue running for many years to come.  Thanks again for all your help.

  • JamesJohnsonLMT Legend 1,153 posts since
    Aug 23, 2009
    Currently Being Moderated
    6. Jan 25, 2010 1:41 AM (in response to aj01)
    Re: Pretty Bad Supination...

    The principle behind the "pad" is something called Proprioceptive Feedback. Basically, muscles have special cells called spindle cells that send a message to the brain when muscles reach a certain length. This allows the brain to "see" the position of bones and tension of muscles (it reminds me of the way an I-phone or Wii controller produces feedback when the device is moved). Obviously, this process has to be finely tuned or we would trip over ourselves.

     

    An elevated 1st metatarsal (Rothbart's Foot) is similar to the short 1st metatarsal (Morton's 1st condition) and the Hypermobile 1st metatarsal (Morton's 2nd condition), in that it alters proprioceptive feedback from the foot. The u-shaped surface you describe is obviously unstable, but that is only part of the problem. The other part is what the brain has to do with muscles of the hip, lower leg, and foot to find the best way of using what you have. Once a method of adaptation has been chosen, the brain will tend to stick with it until pain occurs or proprioceptive feedback changes.

     

    Fortunately for you (and other readers), we can "kill two birds with one stone" by supporting the first metatarsal only. The brain uses this new information to relax the tightened muscles that were needed to provide supplemental stability, and the support provides the stable platform that makes this possible.

     

    Other fixes may make perfect sense to our conscious mind, but absolutely no sense to the portion of our brain that senses and controls movement. Arch supports, orthotics, and motion control shoes send false information to the brain about the surface we are running on. A pad supporting the 1st metatarsal sends the correct message that efficient ambulatory movement (running included) requires, while simultaneously providing the necessary support. In other words, the pad makes your brain think you have a normal metatarsal, and the adaptations go away.

     

    I wouldn't worry about losing the gift of a generous arch, as long as you do not overuse your feet in their current form. Concrete is fine when impact force is low (it is bad for running because of the unnatural shock to the joints). If you want to really get serious about running, I recommend you try the simple fix first. Too many shoe gimmicks will drive your muscles crazy. Arches can collapse and be rebuilt due to proprioceptive feedback, because without muscular control, the foot is just a bag of bones. If only the brain could optimize hereditary bone length...

     

    More reading from other sources:

     

    http://www.posturedyn.com/commonsense.html

     

    http://www.pcopco.com/neuromas.html

     

    I am hoping that shoe manufacturers will eventually offer insoles for this metatarsal problem instead of shoe designs that restrict natural movement. Until then, we can make them ourselves. Yesterday, I bought some small anti-microbial self-adhesive quarter-sized gel pads at a Walmart shoe department (George brand), and used them in my shoes for a 15 mile run, which included 3 miles in the middle at near 5k pace. I sandwiched two of these pads onto the bottom of the "ball" of my left insole, and one pad onto the bottom of my right (my right foot is closer to normal). My stride and footstrike throughout were perfectly stable - no pain or ankle-knocking. Four pads cost me $3.49...Talk about lowering healthcare costs!

  • russhater Rookie 7 posts since
    Feb 8, 2008
    Currently Being Moderated
    7. Jan 27, 2010 1:04 PM (in response to steff137)
    Re: Pretty Bad Supination...

    I was pretty excited to see this post.  I have a similiar problem to an extent.  2 years ago, I underwent an ACL reconstruction and a meniscus repair on my right knee.  everything went fine and I feel that I am pretty well healed.  I don't have pain when I run (although I do when I plant and cut like in basketball for example, but I don't know if it is a muscle or joint or meniscus pain...but that is another story!) and have since finished 2 marathons.  The thing that is driving me crazy is the wear pattern on my shoes...my left is perfectly normal, but the right wears out so unevenly from the outside-in.  I saw a podiatrist who was shocked at the wear pattern and made a custom insert for me to wear.  The problem is the insert is very uncomfortable as it has a very high arch...so I don't wear it when I run.

     

    I try to keep my foot level, but no matter what I try, I always seem to wear out my right shoe around 200 miles or so (as in the whole outter edge of the shoe is completely gone) but the left seems almost brand new.  I guess I should consider myself lucky that I have no pain or swelling....but I hate buying new shoes every month.  Anyone else with this issue?

  • aj01 Pro 143 posts since
    Jul 8, 2008
    Currently Being Moderated
    8. Jan 27, 2010 8:35 PM (in response to JamesJohnsonLMT)
    Re: Pretty Bad Supination...

    Thanks again Jim for all your help.  I still haven't gotten out for any 5+ mile runs but with the few shorter ones, I'm pretty convinced that your fix is going to work.  Normally, I would at least feel something in my shins and that's with icing after runs and wearing compression socks.  Since adding some moleskin underneath the insoles, I've done nothing else and no pain.  I've even doctored up my work shoes and I think it really makes a difference.  It's just a matter of time waiting for the previous injuries to heal up and I think I'll be ready to ramp up the mileage.  You may have totally saved my running life.  Even if I quit running, my foot problems would probably show up again later in life causing other damage if things were left untreated.  I am so grateful for your expertise.

  • aj01 Pro 143 posts since
    Jul 8, 2008
    Currently Being Moderated
    9. Jan 27, 2010 8:44 PM (in response to russhater)
    Re: Pretty Bad Supination...

    As far as the orthotics go, mine were very painful to wear.  They were trying to fix a forefoot problem by supporting the arch which put lots of pressure on my arch and I still overpronated towards toe off.  I probably overpronated later but faster which may have been worse plus the AT and PF from the high arch support.  Going by my experience and what Mr. Johnson says, it seems that arch support is thrown out as a fix for everything but in many cases, doesn't help.  Look at your forefoot for stability issues.  Also could muscle weakness or tendon length from your surgery cause a stability problem on that side?  Good luck.

  • donmurf Amateur 31 posts since
    Nov 28, 2008
    Currently Being Moderated
    10. Jan 28, 2010 5:05 AM (in response to aj01)
    Re: Pretty Bad Supination...

    I know a guy who went with just a set of Dr. Scholl's foot inserts, and he has been praising them.  So, in short, don't think that price is everything when trying to fix a foot situation.

  • Mortonstoe Rookie 1 posts since
    Jan 31, 2010
    Currently Being Moderated
    11. Jan 31, 2010 9:29 AM (in response to JamesJohnsonLMT)
    Re: Pretty Bad Supination...

    Dear James,

    I just want to thank you for writing about the Morton's Toe.  I have spent over 30 years treating it and I really feel it is the underlying cause of most foot problems and  pain thru  out the whole body. As you know Dr. Travell also felt this. I would be happy to answer any questions about the Morton's Toe you may  have , or go to my website WWW.WhyYouReallyHurt.com. It has about 60 pages of good information about the Morton's Toe  and a 7 minute video about it. Again thanks for telling people about the Morton's Toe

     

    Sincerely

     

    Dr. Burton S. Schuler,

    Panama City, Fl

    FootMan@FootCare4u.com

  • runred12 Rookie 1 posts since
    Dec 7, 2007
    Currently Being Moderated
    12. May 27, 2010 10:00 AM (in response to JamesJohnsonLMT)
    Re: Pretty Bad Supination...

    Why support just the 1st metatarsal head with a pad and not the 1st toe as well as the 1st metatarsal head? Does it make a difference? Why? I see it done both ways on the web sites and want to know what is better. ie. the inserts on mortonsfoot.com vs the pad on whyyoureallyhurt.com

     

    Thanks for answering

     

    Message was edited by: runred12

  • JamesJohnsonLMT Legend 1,153 posts since
    Aug 23, 2009
    Currently Being Moderated
    13. May 27, 2010 11:20 AM (in response to runred12)
    Re: Pretty Bad Supination...

    The 1st metatarsal head is actually in contact with the ground (or  shoe) via its downward protrusion, floating sesamoid bone, and the fatty  pad underneath. In nature, there would be little feedback coming from  other parts of the metatarsal unless walking on very soft or rough  surfaces. The arch is there to absorb shock, not to bear it directly. Padding under the 1st toe is probably desirable but should be phased in for a runner, due to increased load on the Flexor Hallucis muscle along the fibula of the rear calf.

     

    DIscussion follows for newbies to this thread, to recap...

     

    Nevertheless,  many orthotics (even prescribed ones) rely on arch support to prevent  the foot from rolling to the 1st metatarsal. This defeats the purpose of  this bone, which is to bear the brunt of forefoot impact on the ball of  the foot - the strongest portion - during pronation. In the case  of a Morton foot, insufficient roll of the foot toward the 1st  metatarsal would place more of a load on the smaller/weaker 2nd  metatarsal, increasing pressure between the minor metatarsal bones and  increased risk of neuroma.

     

    In some cases, as in this thread, excess supination also protects the second metatarsal.

     

    This is not to say that  excess rolling of the foot inward (overpronation) is desirable; excess  motion never is. The best way to prevent muscular compensation for  Morton's foot is to produce the sensory and proprioceptive feedback the  brain is looking for when it orchestrates those muscles. When your 1st  metatarsal is too short, too high or hyperflexible, the ideal feedback  is to send the message that this is not so. The best way to accomplish  this would be to lengthen and/or tighten the 1st metatarsal to eliminate  the Morton condition. While some bone lengthening is done today in  other parts of the body, it is risky and difficult to implement with  bones that are subjected to as much pressure as the feet.

     

    The easiest way to make a metatarsal "feel" longer is  to build up the ball of the foot until it mechanically approximates a  metatarsal of normal length in actual operation. The foot will push off  from the ball of the foot, not the arch, and increased stable and firm  padding here will enhance the action of forefoot weight bearing the same  as a longer metatarsal would (the 1st toe provides additional thrust at the end of the footstrike). The brain gets the message that the foot  is normal, and after a period of adjustment to this new feature, it  begins to coordinate the muscles of the hip, leg, and foot in a way that  is also normal. The wear and tear of excess motion are no longer there  to produce chronic pain and dysfunction. Effects can range from  elimination of foot pain to elimination of tension headaches and other  mystery pains.

     

    So, while the solution seems absurdly  simple, it is a vital part of a complex mechanical and neurological  process. This is not, however, the last word. Not every Morton foot is  the same, and different states of dysfunction may need additional care  before rehabilitation is complete.

     

    http://www.human-anatomy.net/anatomy-foot-pictures.html

     

    Personally,  I found after very little adjustment, a change in the stability of my  stride and lower levels of fatigue after applying this simple fix. In  addition, the problem I had with an inflamed neuroma disappeared. The  minor metatarsals in one foot are still close enough to be felt, but the  pinching together around the nerve is no longer necessary after the pad  alters pronation. Yeh, the balls of my feet feel it, but I've run a few  marathons at a good clip in thin shoes and many more trainers of equal  and longer length without a problem in my feet. Before this  modification, my foot pain was increasing with each season. I'm currently phasing in the pad under the 1st phalange in order to improve performance, but taking my time, starting with casual shoes.

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