Pronation Distortion Syndrome

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Pronation is the neutral motion of your foot during walking and running. Your gait can show a pattern of neutral pronation, overpronation, or supination. Normal pronation refers to the neutral side-to-side movement of the foot as you either walk or run. Your foot regularly rolls a bit inward with each step. The following progress occurs when you perform normal pronation:

  • The arch rises and stiffens to provide stability as the foot rolls upward and outward.
  • Your weight shifts to the outside of your foot and then back to the big toe.
  • From the time your heel strikes the ground, your arch begins to flatten and cushion the shock.
  • All of the toes aid in push-off, but the big toe and second toe do more of the work, while the others stabilize.

Supination is a rolling motion to the outside edge of the foot during a step. The foot naturally supinates during the toe-off stage of your stride as the heel first lifts off the ground, providing leverage to help roll off the toes. However, with supination, the foot does not pronate enough at the toe-off stage.

This results in all of the work being done by the outer edge of the foot and smaller toes, placing extra stress on the foot. In overpronation, the ankle rolls too far downward and inward with each step. It continues to roll when the toes should be beginning to push off. As a result, the big toe and second toe do all of the push-off, and the foot twists more with each step.

Pronation distortion syndrome is a common lower extremity postural distortion pattern that can lead to other movement dysfunction patterns throughout the kinetic and ultimately pain/injury. It is characterized by excessive foot pronation with concomitant knee internal rotation and adduction. This condition can lead to a chain reaction of muscle imbalances throughout the kinetic chain, leading to foot and ankle, knee, hip, and low back pain.

Causes & Symptoms of PDS (Pronation Distortion Syndrome)

Pronation distortion syndrome signifies that when you walk, your weight will most likely be used more within your foot. Foot dysfunction is typically considered to be one of the primary causes of this significant body posture that can also be related to another known condition called hip dysfunction. Therefore, the following below are two different signs and causes associated with pronation distortion syndrome:


PDS with foot dysfunction

While you’re standing, you may notice a flat foot. This flat foot causes the tibia to turn around internally that as a result causes an internal rotation of the femur. The femur rests on the top of the tibia; this rotation in the femur while you are standing causes simultaneous adduction. This refers to an obligatory joint motion that occurs in closed chain movements.

PDS with hip dysfunction

In the case of a gluteus medius (weakness in the abductors), it is a symptom involving a hip dysfunction. In certain cases, the femur might rotate or begin to rotate and adduct which causes the foot to pronate.


Several patients with pronation distortion syndrome do not experience pain or other problems. However, certain types of this condition can be painful. Therefore, here are some symptoms associated with pronation distortion syndrome:

  • Knee pain
  • Hip pain
  • Limping

Who gets Pronation Distortion Syndrome?

Risk factors that are associated with pronation distortion syndrome include:

  • Genetic – Having flat feet can pass on from other relatives in the same genes.
  • Tarsal coalition – People who suffer from flat feet may also be at risk of developing another condition known as tarsal coalition. This condition causes the bones of the foot to fuse together unusually, resulting in stiff and flat feet.
  • Weakened arches – Patients who have a weakened arch (a visible arch when a patient sits but his / her foot flattens onto the ground when standing) are susceptible to pronation distortion syndrome.
  • Osteoarthritis and Rheumatoid arthritis – Both osteoarthritis and rheumatoid arthritis affect the joints. Both conditions result in consistent joint pain, stiffness, and tenderness. As the conditions progress, the knee joint suffers a great deal of pressure, and in an attempt to alleviate that pressure, the joint may twist or rotate, resulting in knock-knee related symptoms.
  • Obesity – People who are overweight are more prone to develop pronation distortion syndrome.

How Does Pronation Distortion Syndrome Affect You? How Serious is it?

Pronation distortion syndrome is generally a condition that is commonly affected early in childhood. But as you age, these ligaments may loosen and cause pronation distortion syndrome later in life. Therefore, if you experience severe cases of this condition, there will be two types of surgical treatment, which are called osteotomy and flatfoot reconstruction.

Osteotomy involves a surgeon inserting a small metal plate into the knee. The plate is used as a permanent knee brace to keep the knee correctly aligned.

Flatfoot reconstruction is a combination of surgical procedures that repair the foot’s ligaments and tendons and correct deformities of the bones to restore and support the arch. These adjustments can help reduce pain and help you return to an active lifestyle. Complication rates for this type of surgical procedure are quite low.

However, it carries risks of any surgery, including infection, bleeding, blood clots, nerve or blood vessel damage, and anesthesia-related problems. Other complications include a failure of the bones or longer-term foot pain.

Recommended Treatment & Rehabilitation for Pronation Distortion Syndrome

Diagnosis for pronation distortion syndrome typically begins with a physical examination in which your doctor examines and takes a complete medical history. If the patient with symptoms is a child, the doctor will look at the growth trajectory of their legs. If pain is present, your doctor will most likely ask you to describe the location, severity, and frequency.

In cases of flat feet, your doctor may refer you to a podiatrist for an accurate diagnosis. This may involve a visual exam as well as imaging tests to rule out other conditions associated with flatfeet-related symptoms. Your podiatrist may usually diagnose the condition by looking at your feet while standing among some of the visual tests used, such as the following:


Wet footprint inspection

This is performed by wetting the feet and standing on a smooth surface. The thicker the print between the heel and ball of the foot, the flatter the foot. By contrast, a high-arch foot would leave only a narrow print of the outer foot.


Tiptoe exam

Tiptoe testing is used to see if you have flexible or rigid flat feet. If a visible arch forms when you stand on your toes, you have flexible flat feet. If not, a healthcare provider would most likely recommend further treatment for a rigid flatfoot.


Shoe inspection

Shoe inspection tests can provide evidence of faulty foot mechanics. If you have flat feet, there will be more wear on the inside of your sole, especially in the heel area. The shoe’s upper will also tend to lean inward over the sole.


Many toes test

Also known as the “too many toes” test, this specific exam is performed as the healthcare provider stands behind you and counts the number of toes peeking out to the sides. While only the pinky toe would be seen in people with normal pronation, three or four may be seen in those who overpronate.

In addition, alongside the diagnosis, your doctor may order imaging tests to help pinpoint the underlying causes. Therefore, the following imaging tests include:

  • Ultrasound – This can be ordered to help produce detailed images of soft tissue damage, such as a ruptured tendon.
  • Magnetic Resonance Imaging (MRI) – MRI can provide detailed images of bones and soft tissue damage, ideal for people with rheumatoid arthritis, tendonitis, or an Achilles heel injury.
  • X-ray/Computed tomography (CT) scan – These two scans are ideal for diagnosing arthritis and evaluating irregularities in the angle and/or alignment of the foot or leg bones.

After a diagnosis has been done, physiotherapy may be further advised. After the first 2 weeks of recovery, a physiotherapist will be able to design the following programs and work with you to help recover from your condition:


Range-of-motion exercises

Dealing with pronation distortion syndrome can make you move your legs less. Your physiotherapist can teach you safe and effective exercises to restore movement to your leg so that you can perform your daily activities the usual way.

Balance training

When you are able to put enough weight on your leg without pain, your therapist may add agility exercises and activities using a balance board that challenges your balance and knee control.

Functional training

When you can walk freely without pain, your physiotherapist may begin to add activities that you were doing before you experienced pronation distortion syndrome. These might include community-based actions, such as crossing a busy street or getting on and off an escalator.

Regular exercise to restore strength and mobility to your knee and a gradual return to everyday activities are important for your full recovery from pronation distortion syndrome. Here are some exercise examples for you to try:



Stand with your feet hip-width apart and wrap a circular exercise band just below your knees. Next, slowly lift one leg backward and up as if you are preparing to kick a ball. Hold this position for 5-8 seconds, then release it back to a standing position. Repeat this method 10-15 times a day.

Straight let raises

Lie on your back and bend your uninjured knee so your foot is flat on the floor. Tighten your injured thigh and lift your straight leg to the height of your opposite knee. Lastly, hold for 2 seconds at the top and slowly lower back to the starting position. Repeat this exercise with 3 sets of 5-20 repetitions.

Calf raises

While standing, lift your heels as high as you can. Hold the upper position for 5 seconds, then lower back down to the floor. Repeat this exercise with 2-3 sets of 10 repetitions a day.


Stair arch raises

Stand on a stepper with your left foot one step higher than your right foot. Next, use your left foot for balance as you lower your right foot down so your heel hands are lower than the step.

Slowly lift your right heel as high as you can, focusing on strengthening your arch. Rotate your arch inward as your knee and calf rotate slightly to the side, causing your arch to become higher. Slowly lower back down to the starting position, while you repeat this exercise 2-3 sets of 10 repetitions on both sides, each day.

Alternative & Homeopathic Treatment for Pronation Distortion Syndrome

There are many home remedies that can help alleviate the symptoms linked to pronation distortion syndrome. Some of these include:

  • Custom-made orthotic shoe inserts – You can order orthotic supportive inserts or gel pads that are custom-made to shape your foot and your individual movement. Certain types include comfort shoes, insole shoes, and stability shoes.
  • Therapeutic massage – such as rolling a ball under your foot may help improve arch flexibility while alleviating aches and pains. You can also visit a professional massage therapist to help you massage your legs and help increase blood flow for a faster recovery.
  • Rest – Avoid activities that aggravate your condition. Participate in low-impact activities (such as walking, biking, or swimming) rather than jumping and running activities.
  • Medications – Over-the-counter pain relievers such as non-steroidal anti-inflammatory drugs (NSAIDs) may help reduce pain and inflammation.
  • Ice application – Applying ice for 20 minutes (for example, a bucket filled with ice) can help reduce inflammation and pain associated with your excessive pronation.

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