Underpronation Injuries

Underpronation is commonly associated with high arches, but just because you have high arched feet it does not necessarily mean that you will be an underpronator. Many people with high arched feet fall into the neutral runner category, which is perfectly normal and highly desirable.

The best way to tell if you are an underpronator – or supinator to use the correct term – is to undergo a gait analysis. When a podiatrist or sports therapist examines your gait you can be sure that you will get an accurate diagnosis of your running style and will then be able to select the best products that suit your individual requirements. Overpronation is by far the most common gait abnormality and leaves runners with this style most prone to injury, but supinators also have an increased chance of sustaining overuse injuries in the feet and legs. Underpronation is almost always caused by an inherited structural deformity in the feet which sees the feet roll outwards (or remain highly rigid) when in contact with the ground.

Underpronators will strike the ground on the outside of the heel and the weight will remain on the outside of the foot. The toe off phase of the gait cycle will take place from the lesser toes, with most of the weight exerted on the fourth and fifth metatarsal.

Common Underpronation Injuries

Underpronation increases the chance of sustaining injuries when running as the body cannot deal with the forces as effectively as with a neutral running gait. With underpronators the heel and metatarsals are required to deal with forces that they are ill equipped to deal with. Unfortunately for the underpronator the problems are not restricted to the feet, and this running gait can take its toll on the ankles, shins, hips and even the lower back. If you are suffering from any of these conditions and you have not had a gait analysis completed, it would be a wise move to visit a podiatrist or sports therapist to determine whether underpronation is the reason, or whether you are actually an overpronator. If you are at either extreme you will need to be careful when choosing running shoes, and should be aware of the tell tale signs of injuries; which in most cases develop over a period of time. Spotting the symptoms early will ensure rapid treatment can be sought, which will reduce the recovery time considerably.

Some of the most common underpronation injuries are listed and summarized below.

Stress Fractures

Stress fractures – as the name suggests – are tiny fractures in bones which are caused by excessive stresses and forces acting on bones, which are normally absorbed by the muscles and shock absorbing foot arches. When the arch does not work efficiently – as with overpronation – greater forces are applied to the bones which can cause these cracks to appear. Although a single trauma can cause stress fractures, most commonly they develop over time. The most common locations for stress fractures when underpronation is concerned are the metatarsals, the heel (calcaneus) and the hips.

Stress fractures are more common with female runners than men as women have lower bone density and are more likely to suffer from bone weakening disorders such as osteoporosis. Metatarsal stress fractures tend to occur in the third, fourth and fifth metatarsals and cause pain on weight bearing, which tends to abate with rest. Stress fractures in the hips are the result of poor running posture with the forces from running traveling up the legs to the pelvis. Over time small fractures can develop. Stress fractures take approximately 6 weeks to heal, which means a considerable time away from your favorite exercise.

Shin Splints – Tibial Stress Syndrome

Shin splints is a common term used by runners to describe shin pain; however shin splints it is not one condition but covers a number of different running injuries. Shin splints is a set of symptoms affecting the shins or more specifically the anterior tibialis tendon or the posterior tibialis tendon. The correct medical term is tibial stress syndrome, which is usually accompanied by the name of the tendon that it affects – anterior tibial stress syndrome or posterior tibial stress syndrome for example – or most commonly – medial tibial stress syndrome (MTSS). Shin splints one of the most common running injuries and accounts for approximately 13 percent of all reported running injuries. It is an overuse injury which is all the more common with overpronation and underpronation. It presents as a dull persistent ache in the shins made worse during exercise. Shin splints can take many months to heal, and up to 6 months recovery time is not uncommon.

Plantar Fasciitis

Plantar fasciitis is one of the most common foot injuries, regardless of the running gait. It is more commonly associated with overpronation than underpronation as this gait places a greater strain on the plantar fascia – the band of tissue which runs from the heel to the ball of the foot. Plantar fasciitis is the inflammation of this tissue which occurs when small tears form in this tissue. Plantar fasciitis may also be accompanied by heel spurs, which are believed to form in response to the inflammation. Plantar fasciitis is the most common cause of heel pain and presents as pain underneath the heel, although the condition can affect any area between the heel and the ball of the foot. It is persistent, and can take up to 12 months to heal properly.


Metatarsalgia is a common injury experienced by underpronators which affects the ball of the foot. Metatarsalgia is inflammation of the tissues in the ball of the foot, and while it can affect the base of the big toe where underpronators are concerned it is most common at the base of the third and fourth toes. Metatarsalgia is characterized by a burning or stabbing pain in the ball of the foot which is worse on weight bearing and usually subsides with rest. The symptoms will vary from individual to individual, and can involve tingling or numbness in the toes and ball of the foot or pain. It is sometimes likened to a feeling that there is a stone in the shoe or that the socks have become bunched up. Healing can take a couple of weeks or longer.

Achilles Tendonopathy and Achilles Tendonitis

These are two names for the same condition. Achilles tendonopathy is the most common term used today, although the condition was previously known as Achilles tendonitis. The reason for the name change is that tendonitis refers to tendon inflammation, and with this condition there is usually very little inflammation; hence the change to tendonopathy. Regardless of what you call it, it is characterised by pain in the Achilles tendon and stiffness which is worst after a period of rest due to tendon contraction. Runners who try to run it off often manage to do so, only for the pain to return with a vengeance. Achilles tendonopathy is common with people with high arched feet and underpronators. Underpronators tend to have a tight Achilles tendon which can make this overuse injury more likely to develop. Healing can take between 3 to 6 months.

Iliotibial Band Syndrome

Iliotibial Band Syndrome (ITBS) and Iliotibial Band Friction Syndrome (ITFBS) are the two names often used for this painful condition which affects the outside of the thigh – or more commonly with underpronators – the outside of the knee. The condition affects a thick band of fascia tissue which runs from the hip down to the patella, with inflammation occurring on the outside of the knee where it inserts into the patella. Due to the common occurrence in runners it is often called Runner’s Knee. It can be highly painful especially when running downhill. It can be particularly difficult to treat and can take a long time to heal. Apart from a ligament strain, lateral knee pain is almost always due to ITBS and it is commonly linked to underpronation and overpronation of the feet.

Muscle Strains and Sprains

Ankle inversion sprains, knee and hip pain, lower back pain and foot arch pain are all commonly experienced by underpronators. Faulty biomechanics in the feet have a knock on effect on other parts of the legs and an increased strain can be placed on specific parts of the feet and legs depending on the degree of underpronation. Underpronation means there is a lack of movement in the ankle and low ankle stability, making an inversion sprain one of the most common underpronation injuries. Ankle inversion sprains are usually accompanied by swelling and stiffness in the ankle, and can be highly painful and make weight bearing impossible. Strains and sprains occur when tissues are pulled or torn and can affect ligaments – tissues which join bone to bone – or tendons – tissues which join muscles and bones.

How to Prevent Underpronation Injuries

Prevention of underpronation injuries is possible when underpronation is addressed with footwear choice or the wearing of orthotic insoles; and sometimes both. Stretching before and after exercise is all the more important for underpronators and will go a considerable way towards ensuring that injuries do not occur.

If you are an underpronator you need to select your footwear very carefully. Many running shoes fall into the stability category or cater to overpronators. This is because between 70 and 80 percent of runners are overpronators. Most running shoes are designed to offer extra stability or motion control to target overpronation. Underpronators require neutral and lightweight running shoes which promote pronation not restrict it.

Read about the underpronation running shoes here