A diagnosis of underpronation or supination, whether from a self-check or a professional assessment, gives you a chance to learn about the condition, your unique issues and how to manage these.

A also diagnosis provides a basis for making good decisions and choices. For example, which experts to use, what activities suit you (and what to avoid) and selecting appropriate footwear. Collectively your decisions help you to mitigate the risk of injury and pain and to live well with underpronation or supination.

What is underpronation or supination?

Here’s a brief explanation of underpronation or supination, starting with what pronation is.

Pronation’ refers to the motion your feet make with each stride. As the foot lands, its meant to roll slightly inward, the arch flattening a bit, and the foot then rolling forward to the toes to push off into the next step. This natural pronation motion helps absorb the impact of landing and distributes our weight. This is good for overall mobility and foot health.

Underpronation’ or ‘supination’, on the other hand, refers to feet that tend to roll outwards (instead of inwards) during a stride. This means there may be insufficient shock absorption and weight distribution during a stride. As a result, underpronation or supination can lead to stress and issues in the feet, ankles, and even up to the knees and hips - causing discomfort, pain, and limited mobility.

This image of a foot health professional examining a foot, shows part of the process for diagnosing underpronation or supination.

Causes of underpronation (supination)

According to MedicalNewsToday underpronation or supination is usually inherited, but external factors can also contribute.

Inherited traits, your genetics, include structural problems such as:

  • Leg length (and differences between leg length), foot width, and ankle stability. These can impact foot mechanics and increase risk of underpronation or supination.

  • High arches affect the foots ability to absorb shock during the stride.

External factors include:

  • Incorrect footwear: Wearing rigid, tight, or worn-out shoes may result in inadequate arch support and cushioning leading to supination problems. (Appropriate footwear is critical to supporting foot mechanics, especially when walking or running on hard surfaces.)

  • Body misalignment: Poor body alignment, whether from postural issues or incorrect exercise form, can force certain muscles and joints to overcompensate, leading to excess supination.

  • Previous injuries: Old injuries, like Achilles tendonitis or foot fractures, can weaken the muscles and ligaments, contributing to ongoing foot instability and supination.

  • Other factors: Sedentary lifestyle, repeated impact on hard surfaces, aging-related stiffness, and over-exercising can all contribute to excessive supination.

Symptoms of underpronation (supination)

Here’s a list of some of the symptoms that may occur (MedicalNewsToday), so an assessment and diagnosis by an expert may be a good idea.

  • Ankle Pain and Swelling: Frequent discomfort or inflammation in the ankle, especially after prolonged standing or walking.

  • Ankle Sprains: Recurrent ankle sprains due to instability in the foot’s mechanics.

  • Calluses or Bunions: Build-up of skin or bunions along the outer edge of the foot due to excessive pressure.

  • Iliotibial Band Pain Syndrome: Pain on the outer thigh or knee, often triggered by improper foot alignment during movement.

  • Ball of Foot Pain: Discomfort under the ball of the foot, as the outer part of the foot bears more weight.

  • Plantar Fasciitis: Sharp pain in the heel or arch due to strain on the plantar fascia.

  • Shin Splints: Pain along the front of the lower leg from improper shock absorption.

  • Stress Fractures: Small cracks in the bones of the feet and legs, particularly in the metatarsals, due to uneven impact distribution.

  • Weak feeling: A weakening sensation in the foot or ankle that worsens with activities like running, walking, or standing.

Diagnosing underpronation (supination)

Here are some of the ways people learn they have underpronation or supination. Once diagnosed, it’s a chance to build knowledge of the condition and their own issues.

Level 1: Self-diagnosis

You may begin by checking out your foot mechanics for yourself. Sometimes this gives you an initial clue In that you are experiencing underpronation.

  • The Wet Foot Test: Wet your feet and walk along a piece of paper. Observe the imprint; a high arch with minimal contact on the inner edge of your foot might indicate underpronation.

  • Shoe Wear Pattern: Check the wear on your shoes. Excessive wear on the outer edge could suggest that your feet roll outward excessively when you walk or run.

The clues from your walking pattern are often the beginning of your journey to get more information and expert help to confirm your findings and get more support.

Level 2: Footwear specialists (such as sports shoe shops)

Footwear specialists, such as running or sports brands stores, often have knowledge about underpronation and ways of testing for it (such as gait analysis or foot scanning technology). This personalized assessment can be used to select the right footwear to address your underpronation.

Note, you may need additional treatment such as orthotics and exercises, so it is wise to see a foot health specialist such as a podiatrist or physical therapist.

Level 3: Foot specialists (such as Podiatrists and Physical Therapists)

Foot specialists such as Podiatrists and Physical Therapists (also called PTs or Physiotherapists in some countries) can provide a professional diagnosis. They follow a structured approach to locate the causes of your pain and create an effective treatment and management plan. Their approach may include:

  • physical examination

  • visual assessment and tests

  • technology such as gait analysis technology and foot scanners to understand your specific foot mechanics

  • diagnostic tools such as X-rays, MRI or ultrasound - to identify any structural damage or abnormalities that may not be apparent from a physical examination.

If initial assessments and treatments do not resolve the issues, or there is a suspicion of more complex or severe underlying issues, a referral to a medical experts may be required.

Level 4: Medical experts

Medical experts such as Sports Medicine Doctors and Orthopedic Surgeons bring a deep level of understanding and expertise. In some cases, surgery might be considered if other treatments are ineffective.

Case Study: diagnosis process for underpronation or supination

Meet Tan: “I’ve always been really active – walking to work, hiking on weekends, and getting in a game of golf when I can. Then, over a period of about a month, one of my ankles started swelling, and it became painful to even walk!”

Over the next three months, Tan consulted a range of professionals (with complementary expertise) to assess, diagnose, and treat his issues. This set him on the path to self-manage his underpronation - with orthotics, specific footwear requirements and an understanding of what to look out for to avoid future deterioration of his condition.

Here are the steps Tan went through.

Step 1: Initial consultation

Tan consulted a General Practitioner (GP) about his swollen ankle and pain. The GP referred Tan to a Physical Therapist at a Sports Medicine Clinic for specialist support.

Step 2: Assessment

The Physical Therapist assessed the biomechanical and physical aspects of the pain. The ankle was initially immobilized in a ‘Moon’ boot and gentle foot exercises were given. Tan was also referred to a Sports Medicine Doctor for additional diagnosis and assessment.

Step 3: Formal diagnosis

The Sports Medicine Doctor requested Tan’s feet and ankles be x-rayed. As a result a formal diagnosis of underpronation or supination was made. The x-ray had highlighted an underlying issue of slight bow legs, which affected the ankle joint alignment, causing the feet to underpronate during a stride.

Step 4: Treatment plan

The Physical Therapist then referred Tan to a Podiatrist for an analysis of foot motion and recommendations for footwear.

Step 5: Podiatrist and custom orthotics

The podiatrist used treadmill gait technology to analyze walking or running mechanics in real time, providing further insights into Tan’s foot motion during a stride. A foot scanner was also used for an analysis of foot structure, and to help in the creation of custom orthotics and recommendations for specific types of footwear.

Step: 6 Appropriate shoes

A local running shop was recommended for purchasing the correct footwear to get started - with the correct sizing for orthotics.

Disclaimer: We at OutwardStride are not medical experts and cannot provide specific advice, diagnosis, or treatment. We strongly recommend consulting with a professional for personalized guidance tailored to your needs.


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