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Hyperpronation of the Foot

- Discussion:
    - hyperpronation refers to the inward rotation of the foot during gait;
    - the term is vague and probably should be replaced by precise descriptions of the relative positions of the hindfoot and forefoot during gait;
    - w/ hyper-pronation, there is an inability of the foot to supination during mid to terminal stance phase;
    - diff dx:
           - hindfoot valgus causes the talar head to move in a medial and plantar direction (in children w/ CP the talar head can touch the 
          - to compensate the mid-foot (talo-navicular joint) must actually supinate (spin laterally and superiorly) which leaves the talar head 
    - hyperpronation does place stress on the midfoot, but does not become a significant problem unless the patient develops a heel cord 
          - w/ heel cord contracture, the already stressed midfoot must now compensate for loss of dorsiflexion at the ankle joint;
          - the result is a midfoot break, either at the talo-navicular joint or the navicular-cuneiform joint which leads to chronic pain;
    - is associated w/ flat feet as well as both tibia vara (? and genu valgum);

- Exam:
    - patient is viewed from behind and relative ankle-subtalar valgus is noted;
         - patient is asked to rise up onto toes and amount of inversion is noted;
    - ankle motion is noted (w/ knee extended and hindfoot in varus);
         - this is compared to dorsiflexion of the opposite ankle;
    - amount of talar head coverage and uncoverage is noted;

- Treatment:
    - its essential to determine the cause of the hyperpronation deformity;
    - equinus contracture:
          - patients w/ flat feet often have a more horizontal sub talar axis which allows a relative increase in sub-talar dorsiflexion and 
                 - this may result in relative decrease in ankle dorsiflexion;
          - in the presence of a relative heel cord contracture, the patient should be started on a diligent course of stretching;
          - this will take the stress off the midfoot, and in most cases will relieve pain;
    - leg length descrepancy:
          - may cause a relative equinus contracture and hyperpronation of the foot;
          - treated w/ heel lift on contra-lateral side;
    - foot orthotics:
          - are generally very expensive and and in many cases ineffective;
          - generally orthotics should not be prescribed until the heel cord contracture is corrected;
          - note that after paying several hundred dollars for a pair of orthotics many patients will be embarased to admit that the orthotics don't work

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