Pronation is a natural movement of the foot and ankle that occurs during the stance phase of walking. In some cases, this movement can be excessive, which will cause overpronation.

Overpronation is often linked to knee pain, but it can sometimes be difficult to tease out how much overpronation contributes to this knee pain.

Given there are likely some altered biomechanics at the knee joint and hip joint that contribute as well, overpronation can be both a contributor to knee pain, as well as a consequence of altered biomechanics in more proximal joints, and sometimes both.

This article will discuss the relationship between hip, knee, ankle, and foot biomechanics with a focus on the link between overpronation and knee pain. We will also discuss some general strategies and exercises that are commonly used to help assist in rehab of knee pain linked to overpronation.

What is pronation?

We mentioned that pronation is a natural movement that occurs in the foot and ankle that primarily occurs during dynamic weight bearing, for example, the stance phase of walking, running, or jumping.

We can break down pronation into three main isolated movements: Ankle eversion, ankle dorsiflexion, and forefoot abduction.

This movement will collapse the medial arch of the foot to some degree, which it normally accommodates. However, when this pronation movement is excessive, this can lead to overpronation, also commonly referred to as excessive foot pronation.

Overpronation vs. Flat Feet

If you looking for information online about the relationship between overpronation, flat feet, and knee pain, it’s important to understand that overpronation and flat feet are actually two separate entities.

Given that pronation occurs with movement, specifically during walking, running, or jumping, some amount of this movement is normal.

Flat feet, also known as valgus feet, is more structural and is often present from an early age. A flat foot refers to a collapsed medial arch of the foot, whereby the entire sole of the foot is in contact with the ground. This can be seen in a static standing position.

It’s certainly possible to see both conditions in the same individual; however, they don’t necessarily have to occur together.

For example, someone with normal foot arches may overpronate with higher impact activities like running, but don’t exhibit flat feet in a standing position.

Conversely, someone who has flat feet is very likely to overpronate with activities like walking and running due to underlying structural changes. Therefore, a flat foot can be a cause of knee pain as well.

Why can overpronation cause knee pain?

When it comes to answering this question, we have to look at the entire lower body, including the knee joint and hip joint, not just the foot and ankle.

This is where it becomes difficult to determine if overponation a cause or consequence of altered biomechanics higher up the chain.

Even if it’s a bit confusing, this can be really helpful in understanding how overpronation and flat feet can be linked to knee pain, and what can be done about it.

Overpronation + Knee Valgus + Hip Internal Rotation

I try to avoid using typical physio cliches, but the common saying “it’s all connected” actually applies here.

For the following information, keep in mind that it can be difficult to determine what biomechanical factors are causes or consequences of each other. Therefore, when trying to wrap your head around this stuff, it can be helpful to take a step back and look at the lower body as a unit.

Let’s work from top down. Imagine you are standing in a partial squat position, basically an “athletic stance”.

Keeping your foot planted on the ground, if you slowly rotate your thigh inwards (femoral internal rotation) and let your knee joint collapse inwards towards midline (knee valgus), you may notice the lower leg bone rotate (tibial rotation) and the medial arch of your foot collapse as the subtalar joint of the ankle is pushed into eversion.

Pausing to take a look at this position, we now see components of foot pronation in the presence of femoral internal rotation, knee valgus, and tibial rotation.

We can try the opposite as well. This time, in an athletic stance, try pushing your medial arch towards the floor. For most people, this will be naturally achieved by rotating the lower leg, moving into knee valgus, and moving into femoral internal rotation.

Patellofemoral Pain Syndrome (PFPS)

Patellofemoral pain syndrome, also known as PFPS, is an extremely common condition that causes pain on the front of the knee, commonly referred to as anterior knee pain, as well as pain around the patella (kneecap) or behind the patella.

This condition is commonly seen in runners, but can also result spontaneously and may cause day-to-day issues like anterior knee pain going down stairs.

Knowing that overpronation is at the very least strongly related to knee valgus and femoral internal rotation, we now have a risk factor for developing PFPS.

Consider running. This high-impact activity may lead to overpronation in certain individuals, and recognizing that thousands of these high impact steps may be occurring in a single bout of running, it now becomes easier to understand that overpronation can be involved in the development of knee pain.

To be more precise, a study conducted by Rodrigues et al, 2013, investigating the relationship between pronation and knee pain in runners found that it may be beneficial to consider that different people will naturally have different amounts of pronation available.

In this case, the investigators found that runners with anterior knee pain didn’t necessarily pronate way more than pain-free runners, but instead, used a larger proportion of their available pronation range of motion.

In other words, runners with anterior knee pain used up more of their available pronation when their foot hit the ground, whereas runners without knee pain didn’t use up as much of their available pronation range of motion, suggesting that neuromuscular control may be playing a key role in the prevention of overpronation and the development of knee pain.

While there are different items you can acquire to help reduce PFPS symptoms, such as a knee brace or kinesiology tape, understanding these mechanical factors can help you decide when to use those items, and will also provide more context as to why the exercises listed below can help relieve PFPS symptoms.

Knee Osteoarthritis

Overpronation has also been linked to other knee injuries and conditions. One study found that overpronation was associated with increased knee pain in those with confirmed medial compartment knee osteoarthritis (Salwa et al, 2018).

As an aside, it’s important to note that knee arthritis can come in many different forms, including degenerative (osteoarthritis) and more inflammatory forms (e.g. rheumatoid arthritis). When we talk about the link between overpronation knee pain and arthritis, we are referring specifically to osteoarthritis, not the other inflammatory conditions.

Anterior Cruciate Ligament (ACL) Injuries

Some studies have shown that subtalar pronation and calcaneal eversion, which are both key components of overpronation, may place excessive strain on the ligament and be linked to a higher susceptibility to ACL injuries in female basketball players (Carabasa Garcia et al, 2023), but the evidence is somewhat controversial on this one (Weiss and Whatmann, 2015).

Medial Collateral Ligament (MCL) Injuries

Another study found that people who sustained traumatic ankle injuries, such as fractures, that occurred with a mechanism of injury involving excessive pronation, were more likely to also sustain damage to the medial collateral ligament (MCL) of the knee, probably due to the concomitant knee valgus (Hwang et al, 2018).

Exercises for Overpronation and Knee Pain

There are many tools in a physiotherapy clinic and techniques that can be performed by a physical therapist to assist in treating pain in the knee joint and around the knee cap, and while helpful, they don’t always address the source of the issue, and simply may not be realistic for many people to access.

This is where exercises represent a safe and effective form of conservative treatment for knee pain linked to overpronation. The following exercises represent just a small portion of exercises that can be done to help relieve knee pain over the long term.

Additionally, we recognize that knee pain related to pronation can also be addressed with more functional strengthening involving the hip and knee joints.

Given we have been focusing on the foot and ankle more in this article, we will focus on foot and ankle strengthening exercises that can have an effect upstream to the knee to help relieve symptoms and prevent the occurrence of a secondary knee injury.

Short Foot Doming

This is a very subtle exercise that can be frustrating for some people in the beginning, as it involves contraction of smaller muscle groups with minimal movement.

On the plus side, it’s convenient to do, you don’t need any equipment, and can actually be quite effective.

In fact, one study found that performing this exercises led to better muscle activation of important toe muscles while walking down stairs for those with knee pain related to foot pronation, relative to other things like taping the foot (Lee et al, 2017).

The purpose of this exercise is to engage the small intrinsic muscles of the foot to provide a solid foundation for movement on top of the foot, and to assist in prevention of the foot arch collapsing.

Tor perform this exercise, you can be in a sitting or standing position. With your foot flat on the ground pointing straight ahead, try to draw the ball of your big toe in towards your heel, as if you are “tenting” the medial arch of your foot.

You may see a bit of subtle movement in the foot, particularly the medial arch, but don’t expect to see much. You should feel a subtle squeeze on the bottom of your foot.

The dose depends on the person and their ability to maintain this contraction. I like starting with 10 reps of 5-10s holds at least once a day, but in reality, the more the better.

To progress this exercise, you can incorporate this contraction into functional tasks like squats or stair climbing.

Towel Scrunches

Building on the short foot doming exercise, this one involves the toes to a greater degree, but you will still be working the intrinsic muscles of the foot.

Also convenient to do at home, or sometimes even at work if you have your own office space, all you need is a small towel or dish cloth.

Place your foot flat on the floor pointing straight ahead with the towel just under your toes. Slowly pull the towel towards your heel by flexing your toes and repeat until you’ve run out of towel.

I like starting somewhere between 10-15 reps in a set, and you can either perform multiple sets in one bout of exercise, or split it up throughout the day.

Resisted Toe Flexion

Again building on the intrinsic muscles of the feet, this exercise is a progression in the sense that it increases the resistance and load on the muscles, allowing you to target slightly larger muscles, such as flexor hallucis longus and flexor digitorum longus.

You will need a resistance band for this exercises, but fortunately, they are fairly cheap and widely available in physiotherapy clinics as well as online.

While sitting, place the resistance band on the floor in a straight line in front of you. Place your foot on top of the band. Keeping it pinned down with your heel, take the end of the band from in front of your foot and stretch it up towards your knee.

This will place tension on the band and bring your toes into an extended position (pointing upwards). Bend your toes down to the floor against the resistance of the band and slowly return up into the extended position fight the pull of the band.

The sets and repetitions will largely depend on the amount of resistance you have on the band.

For a greater focus on pure strength, aim for higher resistance and lower reps (e.g. 4 sets of 6-8 reps).

For a greater focus on endurance, aim for lower resistance and higher reps (e.g. 3 sets of 15 reps).

Given we are now adding in resistance, you may benefit from recovery days in between bouts of exercise, so aiming to do this every other day could be a good starting point.

Resisted Ankle Inversion

Progressing a little more proximally towards the ankle, we can now begin strengthening muscles of the ankle responsible for inversion, particularly tibialis anterior and tibialis posterior, which can help to bring your foot out of a pronated position.

I find this exercise easiest to perform in a seated position. You will also need a resistance band for this one. By sitting at a table, you can tie the band off to a table leg and comfortably perform this exercise.

With the band tied off to a table leg, wrap or tie the band to your foot such that the band is attempting to rotate your foot outwards towards the table leg.

Keeping your heel on the ground, “sweep” or “slide” your foot inwards keeping the outside edge of your foot on the ground and slowly return to the starting position fighting the resistance of the band. Try to avoid rotating the knee or hip inwards as you do this.

Some people also prefer doing this one sitting on the floor, as they feel like they have an easier time preventing unwanted knee or hip movement.

In this case, you’re still tying the band off to something where it’s trying to pull your foot outwards, and you are rotating the foot inwards against the resistance of the band, and slowly back out towards the start position while fighting the pull of the band.

For a nice blend between strength and endurance, I like starting with 3 sets of 12 repetitions. As mentioned previously, higher resistance and lower reps will have a greater focus on strength, while lower resistance and higher reps will have a greater focus on endurance.

Double Leg Tibialis Posterior Calf Raises

Calf raises will assist in strengthening the ankle plantarflexors, particularly the gastrocnemius and soleus muscles, and is a really common type of exercise to help with Achilles tendon injuries and conditions.

Additionally, given this exercise is done on your feet, it’s a little more functional relative to the resistance band exercises and foot intrinsic exercises.

By squeezing a ball between your ankles as you do this, you can also activate tibialis posterior a little more, which has an additional component of inversion, while still having the same strength component for the calf muscles and achilles tendon.

By combining these plantarflexion and inversion movements, we are going the opposite direction of pronation to some degree, more towards supination.

For this exercise, you can do it on flat ground or off the edge of a step, the latter of which will allow you to work through a larger range of motion. If on a step, have the front half of your feet on the step, and the back half of your feet, including the heel, hanging off the back of the step.

I like to start with 3 sets of 12 repetitions, and adjust from there according to strength or endurance preferences as mentioned in the exercise descriptions above.

Single Leg Tibialis Posterior Calf Raises

This is a progression of the double leg tibialis posterior calf raise. Not only does it increase the load by reducing support from the other leg, but it also challenges your control a little more, so while it may feel a little awkward, it’s actually fairly functional when it comes to resisting excessive pronation.

To bias the tibialis posterior with a single leg calf raise, you can lean into a wall so that the leg you are strengthening is a little further away from your body.

This will place the ankle into an inversion position, and while maintaining that inverted position, you can perform a single leg calf raise whereby your heel lifts straight up into the air.

Do not drive your force in towards the wall. The wall is simply there as support so you can keep the angle of inversion. Also, most people like doing this in shoes because it’s a lot of pressure on the ball of the foot.

This exercise can be quite challenging, and it’s important to focus on a slow controlled movement on the way down (eccentric phase). As such, I personally feel that 3 sets of 8 repetitions on each side is more than enough, but again, this can be adjusted based on your specific goals.

Summary

This article was intended to provide information about the possible relationship between overpronation and knee pain. We hope it provided some context as to the factors involved in this type of knee pain and what you can do about it, remembering that the exercises shown above are foot and ankle-specific and represent just a fraction of the options out there to help manage knee pain.

As usual, we always recommend checking in with your local physical therapy clinic to ensure a safe and effective home exercise program for your specific needs, and to also find other tools or modalities to help relieve pain that may not be available to you otherwise.

References

Carabasa García, L., Lorca-Gutiérrez, R., Vicente-Mampel, J., Part-Ferrer, R., Fernández-Ehrling, N., & Ferrer-Torregrosa, J. (2023). Relationship between Anterior Cruciate Ligament Injury and Subtalar Pronation in Female Basketball Players: Case-Control Study. Journal of Clinical Medicine, 12(24), 7539.

Hwang, K. T., Sung, I. H., Choi, J. H., & Lee, J. K. (2018). A higher association of medial collateral ligament injury of the knee in pronation injuries of the ankle. Archives of Orthopaedic and Trauma Surgery, 138, 771-776.

Lee, J., Yoon, J., & Cynn, H. (2017). Foot exercise and taping in patients with patellofemoral pain and pronated foot. Journal of bodywork and movement therapies, 21(1), 216-222.

Rodrigues, P., TenBroek, T., & Hamill, J. (2013). Runners with anterior knee pain use a greater percentage of their available pronation range of motion. Journal of applied biomechanics, 29(2), 141-146.

Salwa, F., Aalaa, M. S., Ahmad, H. A., & Ebtessam, F. G. (2018). Effect of pronated foot posture on the Arabic version of WoMAC index in women with medial compartment knee osteoarthritis. The Medical Journal of Cairo University, 86(June), 1111-1117.

Weiss, K., & Whatman, C. (2015). Biomechanics associated with patellofemoral pain and ACL injuries in sports. Sports medicine, 45, 1325-1337.

Disclaimer:

The content here is designed for information & education purposes only and is not intended for medical advice.