Forefoot Varus and Overpronation

Working over the last several months to correct my own problems with ovepronation has been a learning experience. During each stage of this process I discovered new issues to target, the latest one being forefoot varus. Luckily, most of the problems, like ankle mobility and calf flexibility, are interrelated. Improvement in one area indirectly benefits all the others. I’ve been extremely satisfied with my progress up to this point and plan to continue working on arch strengthening and gait mechanics as long as I continue to see positive changes.

To start, here’s a comparison of my standing foot and ankle positioning at the start of this project and today:

Varus Pronation

June 4, 2012

Oct 12, 2012

Oct 12, 2012

footprintpodThe biggest change you can see from this angle is the alignment of the heels. In the before picture both heels are everted, or turned outward. You can also see how the Achilles tendon curves on its path from the heel up toward the calf.

In the recent photo my heels are a lot less everted and the Achilles lines up straight. Excessive eversion is one of the measurements used to determine if someone is overpronating and as you can tell from the before pictures, an excessively pronated, collapsed arch position was my default standing alignment. Essentially, flat feet.

Now that my heels (rearfoot) are in a more neutral position I’ve noticed a change in the positioning of the forefoot. Specifically, the inside part of the ball of my foot (the underside of the knuckle of the big toe) is not making as solid contact with the ground as it was before. When I walk, particularly in stiff-soled shoes, that the big toe often isn’t pressing very hard into the ground.

This is a concern because the foot is designed to function like a tripod. Having three solid points of contact allows the foot to be both more stable and more responsive. The reason my big toe is lifting up with the decrease in heel eversion is because of the altered way the forefoot is angled on the rearfoot, a positioning known as forefoot varus. Tackling this problems seems like the reasonable next step on the path toward better mechanics.

Alignment

Forefoot varus is the angling or inverted position of the bones in the front of the foot in relation to the heel. A true forefot varus is a structural deformity involving the shape and alignment of the bones in the foot. A flexible forefoot varus position is more accurately called supinatus. Supinatus may be an adaptive position of the forefoot in response to a high degree of rearfoot eversion (overpronation).  

In an uncompensated forefoot varus deformity, the causes the bones on the inside edge of the foot to sit higher off the ground than the outside of the foot during weight bearing.

As I mentioned eariler, the preferred position of the foot is a tripod, so the body often compensates to make a third contact with the ground by way of everting the heel outward to bring the plane of the toes level with the ground. It is this compensatory mechanism for the varus forefoot that contributes to overpronation.

Forefoot Varus

Some degree of forefoot varus is common. A study of healthy individuals published in the Journal of Orthopaedic and Sports Physical Therapy found out of 120 subjects, 87% had a varus forefoot-rearfoot relationship. Other studies have reported similar findings, for the most part, although some variability among percentages may be related to the different methods used to measure the varus angle.

Such a high prevalence raises the question whether this is abnormal. My answer is a tentative yes. That is because these studies do not tell us if the varus is something people acquire during their lifetime, or whether they are born with it. This is a question that should be asked when attempts are made to describe the characteristics of a normal foot because, as I’ve brought up in previous posts, we cannot discount the effect lifelong shoe wear has on the positioning and mechanics of the foot.

I think there is a good chance that footwear alters the shape of the foot so that what scientists are really examining in studies of so-called “normal” subjects are joints that have been influenced by shoes and not really indicative of how the foot would normally appear and function.

It’s well understood how forefoot varus causes overpronation, but it’s less clear the relationship between overpronation and injury. This is an area that requires more research, but I don’t see how the altered alignment and joint mechanics associated with overpronation could not be a risk factor, particularly for overuse type injuries. There is some evidence that forefoot varus is associated with both hip pain and patellofemoral syndrome. There is no downside to working on this issue and there’s the potential for a huge upside if it means warding off injuries and degenerative joint problems, so that’s enough incentive for me to explore the issue.

Gait

varus pronationThe picture to the left is another illustration of how a forefoot varus can lead to excessive pronation during the stance phase of the gait cycle. The dotted lines represent the position of the toes and the colored lines representing the angulation of the heel and forefoot. The everted heel position at mid stance looks very similar to my foot position in the before photo posted above.

A small amount of pronation is a part of the body’s natural shock absorption system. The amount of heel eversion that is considered excessive I’ve seen reported as anywhere between 8 and 15 degrees. At a certain point, too much pronation will not only pull the rest of the leg out of good alignment, but it will also limit the foot’s ability to function as an efficient and effective arch.

The two ends of the medial arch are the heel and the base of the big toe. Both rely on the strength of the muscles in the foot and around the ankle to hold them in position and prevent the arch from collapsing under the weight of the body. There are other things you can do to reduce the load on the arch, like increasing ankle dorsiflexion mobility, but I want to limit this discussion to correcting forefoot varus.

Can The Varus Angle Be Changed?

The forefoot varus angle is only going to respond to corrective exercises if muscle weakness and soft tissue tightness are the cause. Since I’m able to bring my foot into a level position with effort I know the problem is soft tissue related and not structural. I suspect the majority of cases are this way with the rare exceptions being instances where the bones themselves are in a position that block this movement.

I couldn’t find any information on what percentage are flexible vs rigid, and I think part of the reason is traditionally this problem has been treated with orthotics that build up the space underneath the foot to fill in that gap so there really hasn’t been much interest in seeing what could be done to fix the problem.

I’m not a big believer in orthotics and think the science behind them is flawed in several ways, especially when it comes to correcting overpronation. I believe exercises are a more reasonable and effective way to manage the problem, ultimately restoring the body’s own ability to control pronation.

varus correctionThe goal of any exercise for correcting forefoot varus then is to strengthen the muscles that pull the base of the big toe down to the ground to stabilize the arch, while the heel is held in a stable position to prevent it from everting. This will involve some of the intrinsic muscles in the sole, like the flexor hallucis brevis, and a few of the calf muscles with tendons that influence the arch.

In some ways this is what the short foot exercise does. Breaking down that movement into separate components, though, seems to allow for better isolation of the muscles at work, so I’m hoping doing so leads to faster improvement.

The exercise I felt was the most effective, and the one I’ve decided to perform, involves first inverting (turning in) the heel slightly and then actively pressing the big toe down into the ground. The ball of the big toe (the metatarsalphalangeal joint) is what forms the tripod so it’s important to avoid curling or gripping with the toes as that would work different muscles and defeat the purpose of the exercise. Here’s a video demonstrating the movement:

Hopefully this gives you the general idea (I’ve just starting doing the exercise so don’t be too critical). After only a few repetitions this really starts to burn. I’m lifting the other four toes up while pressing the big toe down because I feel better isolation of the target muscle groups that way, though the exercise could also be done without lifting the rest of the toes. Also, from the same start position, toe abduction (moving the big toe away from the second toe) can be added to target the abductor hallucis, another important arch stabilizer muscle. Making firm ground pressure with the underside of the big toe is the basic concept of varus correction and ideally should also be practiced during normal walking so that the strength gains achieved by doing the exercises will translate over into better gait mechanics.

Comments

  1. Tom Nall says

    Hello James,

    I just found your website last week. I have the same problem that you do – hyperpronation caused by forefoot varus. I have almost all of the same symptoms and observations that you have had, such as the lifting of the big toe in mid stride and the inability to spread my toes.

    I have two questions:
    1. In the October 12 photo, are your feet in a relaxed state or are you manually correcting?
    2. What is your exercise regimen? How many reps? How many sets? How often?

    I am ready to start my exercise program now. I was thinking I should start with the Toe Spreading and the Short Foot. What do you recommend?

    Thanks for any advice you can lend.

    Tom

    • James Speck, PT says

      Hi Tom,

      Since it’s difficult to truly determine cause and effect, my approach has been to target all potential factors that might be associated with increased pronation. I started off with exercises addressing local factors first, like foot muscle strength, and then as I gained a better understand of the problem, added in exercises targeting other important areas, especially ankle dorsiflexion range and hip strength.

      During the months in between those photos I was spending about 10 minutes a day on exercises related to controlling pronation. I never followed a set routine (since I was frequently changing around exercises) but I generally followed the basic principles of strengthening and stretching (i.e. putting adequate stress on the tissues to cause change).

      The Oct picture is in a relaxed stance, but I feel a big part of my success was that from the time I started working on this I WAS consistently trying to hold an arch in my foot throughout the day. At the very least this helped reinforce what I was attempting to accomplish with the exercises.

      Regards,

      James

  2. Christian says

    Hey mate. I think you will find what you have is a forefoot supinatus and not a forefoot varus. Fore foot varus is a structural deformity that rarely ever (if at all) exists. The reason your foot is positioned the way is is because you have increased ground reaction forces acting through you medial foot due to reafoot pronation. Over time the soft tissue of your forefoot will adapt to this and take on the position that it has.
    Rather than concentrating you attention at the forefoot, work on strengthening your tib post as it is likely not sufficiently controlling your foot during pronation. This will lead to less force acting at the region of your foot that has taken on the soft tissue adaptation. Over time the offloading of force to this region will allow the soft tissue to relax, but manipulation and mobilisation from a podiatrist or chiropractor will hurry things along.
    As for best exercise stand slightly pigeon toed, ensure you raise your toes off the ground. Once in this position perform calf raise by lifting the heels (as opposed to lifting up onto the balls of the foot). Ensure the toes remain off the ground and invert your heel as your raise up. You can progress this an appropriate sequence of exercises but then I’d be outta business if I gave you all my tricks ;)
    If you had a bony deformity (forefoot varus), you’d find that you’d be unable to keep the reafoot neutral when plantarflexing your 1st metatarsal (as shown in your video). Instead the reafoot would promate beyond neutral as you have indicated in your explanation of the condition.

    Goodluck and hope this helps

    P.s. Not all podiatrists are bad and orthotics may even help in short term to fasten along that soft tissue relaxation ;)

  3. says

    Hi Christian,

    Thanks for the well-informed comment! I see now that forefoot supinatus is the more accurate term for what’s being explained in the article. I’ve always used forefoot varus to describe forefoot inversion and many physical therapists do the same. I’ve then typically used structural or functional to specify either osseous and soft tissue restriction, but supinatus is a lot more succinct.

    You bring up an excellent point about supinatus being a soft tissue adaptation resulting from insufficient pronation control, not the cause. I’ll give this article an update in the near future to reflect this.

    My gripe with orthotics is that their prescription seems more driven by financial motives than by an evidence based, pathology-specific model for their use. This is my perception of the whole orthotic industry, not specific to any one profession. I know that podiatrists for the most part are the biomechanical experts when it comes to the foot and ankle so hopefully I don’t come off as too critical ;)

  4. SB says

    You have not touched on something I observed in your foot which is part of the problem I have with my feet. You have a long second toe. That means when you walk, your second met head hits before your first (great toe). This is commonly called a Morton’s toe though true Morton’s toe is when the first met is much shorter than the second.

    So getting that first met down to the ground is difficult since structurally that met head is elevated. If you stand in front of a mirror and hold your foot so you can see the transverse arch of your foot, you should see that the space under your first toe curves up.

    Once upon a time, this was treated by either putting an addition to an orthotic or simply building up the area under your great toe with foam of some type called a Morton’s extension. Podiatrist now avoid Morton’s extensions thinking they are evil and instead, incredibly, use cut-outs so that the great toe can get more motion.

    How this is supposed to work when the met head is already elevated and can not get down to the ground easily is a mystery to me but cut outs are currently in vogue.

    So instead of a forefoot varus or a forefoot supinatus, what you have is an elevated first met which can behave like a forefoot varus. Forefoot supinatus is compensatory from long stand pronation. Meaning the force of your foot pronating and turning out pushed the medial part of your forefoot up repeatedly during gait. It should improve once pronation is controlled.

    And I have to correct you. Only a handful of podiatrist are biomechanical experts. Most actually only know about foot biomechanics and are not so cognizant that those feet are connected to the rest of your body. So you cannot just “correct” feet or you may screw up a person’s back or pelvis.

    The majority of podiatrists who prescribe orthotics rely heavily on the labs they work with and they are not capable of making orthotic adjustments themselves. That field is called Pedorthics.

    So sadly, there is a lot of money being made from orthotics that are being made by Podiatrists who really are not so knowledgeable.

  5. James Speck says

    Hi SB,

    I was going to write about Morton’s toe or the effects of the second toe being longer than the first, but now I don’t think it matters much. It’s never been a problem for me and I know plenty of runners with a much greater difference in length who have never had problems either.

    I understand what you’re saying about the second met head contacting the ground first, but this is not the case for me. There is not a space under my first met head when looking at the transverse arch in non-weightbearing. If I palpate through the metatarsal fat pads they feel level as well. So I agree with the above poster about having a supinatus.

    In cases where the first met head is elevated I can see how this can create biomechanical or plantar pressure problems because the first ray will be held off the ground and prevented from stabilizing the arch. As long as there is flexibility in the foot though, this is something that can be addressed without cut outs or orthotics.

    If the second met head makes contact with the ground first, the force of the ground should drive it up allowing the first met head to make contact. If the first met head stays elevated, there’s probably a soft tissue restriction that needs stretching as well as a strength or motor control issue with the toe flexors/extensors and the muscles that attach at the proximal end of the metatarsal.

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