Q&A Time! | Modern Manual Therapy Blog

Q&A Time!

Today's Q&A question is "What are some common causes of forefoot pronation and how do you treat it?


Very few patients who "over" pronate need orthotics, and even when they do, the research shows that there are no significant differences in custom orthotics vs appropriate OTC. If patients did not respond to manual therapy and corrective exercise then I usually found partially customizable orthotics like vasyli work well enough.

Look to the following areas for dysfunction.
  • lack of dorsiflexion
    • often causes excessive eversion, that classic "too many toes" sign and then excessive pronation during mid stance phase
    • the talus often loses not only posterior glide, but posterior glide medially, when still gliding posteriorly and laterally, then causes eversion
    • focus Tx on
      • IASTM anteriorly over the talus, gastroc/soleus, medial and lateral calcaneus
      • joint mobilization with movement in WB positions as demonstrated here
  • great toe
    • when everting and not WB thru the 1st ray (often laterally, and having callous formation on the 5th MT greater than the 1st), there will most likely be a lack of great toe extension
    • concentrate IASTM on the plantarfascia and use A/P glides/distractions on the 1st MT head to improve extension  
  • gluteus medius
    • ipsilateral weakness will often cause genu valgus and leading to pronation
    • start with clams, then sidelying wall slides with heel pressed into the wall - trunk also against the wall to prevent the hip from flexing
    • progress to single leg step downs, controlling for genu valgus and then my favorite anti-rotation in single leg stance with bilateral arm press using cables or therabands - it can be tough!
  • ITB/TFL
    • often facilitated as a result of gluteus medius weakness or inhibition
    • release with IASTM, functional release
There are many more, but these are my go-to areas. Feel free to share yours!

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