The term "pronation" is a position at the foot and ankle often perceived as an injury or misalignment. Many people will say, "My foot pronates" as a way to explain why their foot hurts. In actuality, pronation is normal. We all pronate during walking as we progress during the gait cycle. The trouble begins if we fail to re-supinate.

Failing to re-supinate will cause excessive stress on the plantar fascia and medial structures of the ankle. "Excessive pronation" or "failure to re-supinate" can contribute to foot, ankle, knee, hip, and back pain. Often times during treatment sessions for this condition, interventions will focus on orthotic prescription and modalities to address the inflamed tissue. While these treatment interventions may temporarily help reduce pain, to resolve the issue completely, the cause of the excessive pronation must be addressed. The purpose of this article is to draw attention to the big toe, often referred to as the great toe, and its contribution to excessive pronation/ failure to re-supinate.

In gait, as you progress from mid-stance to terminal stance and into swing phase, ideally your great toe should achieve 85 degrees of extension while the ankle is in subtalar neutral. This extension range is necessary to allow the knee and hip to also extend correctly. As we age or experience trauma to the foot, our big toe can lose flexibility. If the big toe loses extension range, you will not be able to achieve terminal stance in gait. To continue to progress forward, you will begin to point the affected foot out to the side to utilize hip external rotation and the flexibility of the medial ankle/ foot structures draw the leg behind you.

Over time, walking in this fashion will begin to cause more permanent structural changes to your body. Pointing the toe out to the side and collapsing into your arch will place excessive pressure on the medial side of the big toe (check for calluses as a sign that you do this!), and can contribute to bunion and hammer toe formation. As you continue to collapse into the arch, over time the longitudinal arch of the foot and the posterior tibialis will become permanently lengthened and hypermobility develops at the midfoot. The knee will dive into a valgus position. The femur will adduct and consequentially you will develop weakness in your hips and trunk.

From the above biomechanical changes, you can see why just placing an arch support, using ultrasound, and massaging the foot will not fix excessive pronation in the long run. The root cause of the impairment must be addressed, and the great toe should always be considered in treatment options. If you see callus formation at the inside of the great toe, wearing on the medial aspect of your shoes, have pain at the metatarsal phalangeal joint at the great toe, experience arch pain/ plantar fasciitis, walk with your feet pointed to the sides, or demonstrate fallen arches, these are signs that your big toe may be compensating your gait pattern and contributing to your pain.

Depending on the degree of joint involvement, great toe flexibility can be improved through manual stretching, joint mobilizations, self stretching, functional gait based strengthening drills, postural awareness, toe spacers, and night splints. If you are experiencing pain with walking, check in with your qualified fitness professional, medical doctor, or physical therapist for an assessment and treatment plan. We always recommend contacting your treating practitioner before beginning a new fitness routine.

Carla Pryor PT, DPT, OCS, RYT 200. Co Owner of Redefine Health and Fitness located in North County San Diego. Redefine is a wellness based company focused on providing excellent comprehensive and research driven care to assist clients in meeting their fitness and nutrition goals. Contact carla@redefinehealthandfitness.com for further inquiry.