Pronation distortion syndrome affects the entire body, not just the feet and ankles, and is often unilateral. Optimal outcomes in treating this issue begin with an accurate assessment and finish with an individualized multimodal treatment plan. The chiro-centric approach is to consider the upstream effects of an imbalanced pedal foundation, as opposed to a reductionistic model of simply treating the pronated foot.
Start with assessment
A static postural assessment of the patient standing is the initial assessment. Instruct the patient to stand barefoot in a “normal” stance, and observe the position of the entire foot, not simply the medial longitudinal arch. Anteriorly, the plumb line from the middle of the patella should track between the first and second toes, and from the posterior look to see if the Achilles tendon bows medially or laterally. Inspect the navicular bone and examine if it exhibits navicular drift (bowing medially between the calcaneus and first ray), indicating an extremely weak and flat foot.1,2
Relevant tip: From the posterior, if you see more than three of the lateral toes, the foot is externally rotated and you should suspect pronation to also be present. This is called the “too many toes sign.” While standing, continue the postural assessment to observe for additional upstream effects of pronation. Specifically, the following3 is often present:
- Medial shifted patella
- Valgus knee
- Medially rotated and adducted femur
- Lower ipsilateral iliac crest
- Pelvic obliquity to the opposite side
- Lumbar spine shifts away from the midline
- Elevated ipsilateral shoulder
If the pronated foot creates a functional short leg, the lumbar spine will tend to shift toward the short leg. However, if the pronation creates tension in the iliopsoas with minimal impact on the leg length, the lumbar spine can actually shift away from the pronated foot. The serial distortion from a pronated foot does translate through the entire body, but it does differ depending on the patient’s individual compensations.
Dynamic assessment
Beyond postural assessment, the foot must be assessed dynamically. This begins with the Navicular Drop Test. In a relaxed sitting posture with the foot non-weight-bearing and resting on the floor, observe the medial longitudinal arch and place a mark on the navicular tubercle. Then instruct the patient to stand and measure the distance the navicular tubercle lowers. If the navicular tubercle falls more than 10 mm, the foot needs support.
An effective dynamic assessment for the entire lower extremity is a single leg quarter squat or a Dynamic Trendelenburg Test. Under full body weight, dysfunctional movement of the foot and leg will be magnified as well as serial distortion throughout the pelvis, spine or upper quarter. It is best performed without shoes.
Relevant tip: Dynamic assessment of the foot for the active patient and athlete includes jump and hop mechanics. Observe for the same anatomical checkpoints as in static alignment, but with rapid loading.
Next, have the patient walk. Discussion of the biomechanical and arthrokinematic changes in the foot that occur during the phases of gait is beyond the context of this article. However, globally, there are common dysfunctional gait pattens that can be observed in foot placement, knee alignment, pelvic rotation and arm swing. Remember to observe movement of the neck and shoulders while walking, too.
A pronated foot will often demonstrate toeing out, limited great toe extension, reduced stride length and a hard shift from heel strike to the stance phase. The swing phase may show a drop in the iliac crest on the same side or there may be a compensatory wide circumduction of the leg in the swing phase. From the posterior, the contralateral ilium will rotate anteriorly due to loss of normal nutation/counternutation of the sacroiliac joint.
The pronated foot tends to have decreased joint play in the subtalar, calcaneo-cuboid and talonavicular joints. If restricted in joint play, they obviously will need to be adjusted. If the foot is hypermobile and flexible, these joints may not need to be adjusted, but the foot will need to be stabilized. A pronated or flat foot is usually flexible, but it may be rigid. Be sure to motion palpate the articulations of the foot and ankle for an accurate assessment.4
Additional structural asymmetries with the pronated foot include medial rotation of the tibia and femur resulting in irritation of the pes anserine bursa and knee pain. Reduced acetabular joint play in internal rotation is common due to a medially rotated and adducted femur. The SI joint may be hyper or hypomobile but the ilium will be rotated PI on that side.
Relevant tip: The patient with decreased first MCP extension (hallux rigidus) as seen in the pronated foot will have an oblique crease in their shoes across the toe box as opposed to a normal linear crease.
Muscular involvement of pronation distortion places muscles in two broad categories: those that are hyperactive and tight and those that are lengthened and weak. Generally, the lateral chain muscles will be hyperactive and tight, and their antagonists will be lengthened and weak. (See Table 1.) The intrinsic foot stabilizers will also need to be addressed for both strength and flexibility.
Treatment for these abnormal muscular length/tension relationships is straightforward. The weak/lengthened muscles need isolated strengthening followed by repatterning faulty movement patterns. If the foot is flexible, short foot exercises are perfect. The tight and shortened muscles require soft tissue work which can be done with emerging technologies, such as shockwave and TECAR or with traditional technologies, such as foam roller and manual myofascial release. Stacking these principles with chiropractic manipulative therapy to the areas of joint dysfunction is the active care prescription for the pronation distortion patient.
Perhaps the two most significant muscles involved from a chiropractic perspective are the gluteus medius and iliopsoas. A weak gluteus medius is related to low back, SI and knee pain, whereas a tight iliopsoas creates low back pain, SI dysfunction and pelvic obliquity. Be sure to address them in patients that present with pronation.
Relevant tip: Patients with scoliosis will often have a tight and shortened iliopsoas on the side of concavity of the curve which will need to be released/lengthened.
Patients with pronation distortion have reduced proprioception and balance and need all three arches of the foot supported, not just the medial longitudinal arch. A custom flexible foot orthotic can support the arches as well as stimulate proprioception to further increase activation of the intrinsic foot muscles. Ideally, this would be combined with strengthening the extrinsic foot stabilizers (flexor digitorum longus, hallucis longus and posterior tibialis) for comprehensive treatment of pronation distortion syndrome from the ground up.
Final thoughts
Pronation distortion syndrome, whether unilateral or bilateral, presents a complex biomechanical challenge that demands a comprehensive approach to assessment and treatment. Its influence extends beyond the foot and ankle, often contributing to dysfunctions in the pelvis and spine, particularly involving the iliopsoas and gluteus medius muscles. Effective management requires both static and dynamic evaluation to fully understand the scope of the distortion. The assessment and treatment of this postural dysfunction is applicable to each of our practices, regardless of your practice style.
Donald Defabio, DC, DACBSP, DACRB, DABCO, teaches Relevant Rehab, CCSP/DABCO to Rehab Diplomate seminars throughout the US, and his ebook, “The Six Keys to In Office Rehab,” is available free on his website defabiodifference.com. His protocols can be found on his YouTube channel, which has more than 42,000 subscribers. He can be reached at defabiochiropractic@gmail.com for questions, to schedule a presentation and to register for his workshops.
References
- Clark M, Russell A. Essentials of performance enhancement. 2007. Jones and Bartlett Learning, www.nasm.org. Accessed August 28,2025.
- Golchini A, et al. Effect of systematic corrective exercises on the static and dynamic balance of patients with pronation distortion syndrome: A randomized controlled clinical trial study. Int J Prev Med. 2021;12:129. https://pubmed.ncbi.nlm.nih.gov/34912505/. Accessed August 28, 2025.
- Almutairi AF, et al. The Prevalence and factors associated with low back pain among people with flat feet. Int J Gen Med. 2021;14:3677-3685. https://pubmed.ncbi.nlm.nih.gov/34321913/. Accessed August 28, 2025.
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Pabón-Carrasco M, et al. Randomized clinical trial: The effect of exercise of the intrinsic muscle on foot pronation. Int J Environ Res Public Health. 2020;17(13):4882. https://pubmed.ncbi.nlm.nih.gov/32645830/. Accessed August 28, 2025.
