HYPERPRONATION

What is Hyperpronation?

a normally pronated foot versus a hyperpronated foot

To understand "hyperpronation" it's important to first understand pronation. Pronation is a normal function of the foot. It is the inward motion of the ankle bone and outward motion of the rest of the foot bones, which occurs naturally when the foot hits the ground and weight is applied. Pronation is a good thing; it cushions the foot and the entire body during the walking cycle. It keeps the foot and ankles protected from hard impact and an uneven ground surface.

Hyperpronation occurs when too much pronation is present. In other words, hyperpronation occurs when the inward motion of the ankle bone is excessive and goes past the healthy point necessary for its intended functions. This excessive motion is caused by a misalignment between the ankle bone and the hindfoot bones. It creates an imbalance of forces and weight distribution in the foot that propagates throughout the entire body. Over time, this functional imbalance causes repetitive damage to joints, ligaments and bone structures.

Left untreated, hyperpronation can lead to foot ailments such as bunions, heel pain (plantar faciitis), hammertoes, etc. Furthermore, the excessive motion in the foot can travel up the body and cause knee, hip and lower back pain.


Who is affected by Hyperpronation?

walking

Hyperpronation can affect people of all ages and it is particularly problematic for patients with high levels of activity. This problem is generally present at birth. Hyperpronation occurs with EVERY STEP taken. Considering the average person takes almost 8,000 steps per day and millions of steps in a lifetime, it's easy to see how the cumulative trauma from the unbalanced strain and excessive forces can lead to serious damage.


How do you treat Hyperpronation?

This condition will not resolve on its own. There are several methods, from conservative to aggressive, to treat hyperpronation. Each option comes with its own risks and benefits.

observation

Observation

Primary Benefit: N/A

Primary Risk: Condition and disease process progress.

Particularly with children, some doctors will recommend "observing" the condition to see if/when symptoms occur. The reality is that eventually damage will occur as patients do not grow out of it.

Orthotics

Foot on Orthotic

Primary Benefit: Conservative method, no surgical risks. Can provide symptom relief, especially in the short term.

Primary Risk: Does not stop the osseous (bone) malalignment from occurring; can lead to other problems.

The way a foot orthotic works is by altering the weight-bearing surface of the foot. The simulated foot improvement is only possible when standing still with full weight applied. Orthotics are of little help through most of the actual walking cycle. observationPatients may experience some symptom relief, but the orthotic cannot correct the internal osseous misalignment.

Over-the-counter foot orthotics are usually of little help and wear out quickly. Custom-made foot orthotics, obtained through your doctor's office, are generally expensive. Though they last longer and have less chance of ill-effects than OTC brands, they still need to be replaced often. Over a lifetime, an individual can spend several thousands of dollars in total costs associated with orthotics and see little or no results. This is because orthotics only work when you are wearing them and do not treat the cause of the problem. In many cases, the external pressure points created by orthotics can cause more problems than solutions. Blisters, sore feet, sore joints and many other long-term complications can arise as a consequence of wearing orthotics.

Physical Therapy, Prescription Drugs and Other Treatments

Primary Benefit: Conservative method, no surgical risks. Can provide symptom relief, especially in the short term.

Physical Therapy

Primary Risk: Does not stop the osseous (bone) malalignment from occurring.

Medication

Solutions typically presented will include physical therapy sessions, prolonged prescription drug regimens, occasionally non-traditional approaches like holistic medicine and acupuncture. These options can provide symptom relief in the short term for some patients. However, these treatment methods cannot correct the internal osseous misalignment. Ligaments are not effective in limiting the motion of the ankle bone when excessive joint motion is present. Furthermore, there is not a single, specific ligament that is "too tight" that needs to be "stretched out." The muscles supporting the bones are already being "over-worked" and they cannot be strengthened enough to realign these bones. There is no evidence to suggest that any of these measures are effective in re-establishing or maintaining the normal joint alignment and function.

Surgery

Hyperpronation can only be properly corrected by internally stabilizing the ankle bone on the hindfoot bones. Several options are available:

Extra-Osseous TaloTarsal Stabilization (EOTTS)

There are two types of EOTTS procedures. Both are minimally invasive with no cutting or screwing into bone, and therefore have relatively short recovery times. Both are fully reversible should complications arise, such as intolerance to the correction or prolonged pain. However, the risks/benefits and potential candidates vary.

Subtalar Arthroereisis

Subtalar Arthroereisis

Primary Benefit: Minimally invasive; fully reversible.

Primary Risk: High chance of device displacement; generally not tolerated in adults.

An implant is pushed into the foot to block the excessive motion of the ankle bone. Generally only used in pediatric patients and in combination with other procedures, such as tendon lengthening. Reported removal rates vary from 38% - 100%, depending on manufacturer.


Type II EOTTS (the HyProCure Procedure)

HyProCure ImplantHyProCure Placement

Primary Benefit: Minimally invasive; fully reversible; allows for normal joint function.

Primary Risk: Device intolerance; intolerance to correction.

A stent is placed into a naturally occurring space between the ankle bone and the heel bone/midfoot bone. The stent realigns the surfaces of the bones, allowing normal joint function. Generally tolerated in both pediatric and adult patients, with or without adjunct soft tissue procedures. Reported removal rates, published in scientific journals vary from 1%-6%.

Calcaneal "Slide" (Sliding Calcaneal Osteotomy)

Osteotomy

Primary Benefit: Corrects osseous malalignment.

Osteotomy

Primary Risk: Non-union, infection, prolonged swelling and over- and under-correction.

A wedge is cut into the heel bone (calcaneus) and a fixation device (screws, plate) is used to hold the bone in its new position. This is an aggressive option with a prolonged period of non-weightbearing, long recovery times and many potential complications. However, it can and has provided for successful patient outcomes.


Joint Fusion/Arthrodeses Procedures

Subtalar Arthroereisis

Primary Benefit: Corrects osseous malalignment.

Primary Risk: Non-union, infection, misalignment of the hindfoot, lateral impingement, degenerative changes to surrounding joints and sural nerve injury.

The ankle and hindfoot bones/midfoot bones around the joint are fused, locking the bones in place and preventing all joint motion. This may also be done in combination with fusion at other joints. This is a very aggressive option usually reserved for extreme cases where no joint flexibility is present and/or the patient has severe arthritic changes in the joint.


Choosing a Treatment Option

Depending on the severity of your condition, your surgeon may recommend one or more of the above treatment options. Ultimately, however, it's YOUR decision as to which makes the most sense to you. There are many resources available online and elsewhere for you to research the various options and make an informed decision.


Related Links

American College of Foot & Ankle Surgeons (www.acfas.org)

American Podiatric Medical Association (www.apma.org)

HyProCure Patient Information Site (www.HyProCure.com)

Journal of Foot & Ankle Surgery (www.jfas.org)

Journal of the American Podiatric Medical Association (www.japmaonline.org)

Orthotics (a few major manufacturers)

Subtalar Arthroereisis Information (www.arthroereisis.com)