Orthopedics · Medical Literature
Foot-Targeted Rehabilitation for Pronation-Related Anterior Knee Pain: A Two-Phase Case-Control Study and Single-Blind Randomized Controlled Trial of Manual Therapy Versus Neuromuscular Training Each With Augmented Low-Dye Taping.
Abstract
The mechanistic rationale for treating the foot in anterior knee pain (AKP) is well established in the biomechanics literature; however, translating it into a clinically actionable evidence-supported rehabilitation protocol has proven difficult. This investigation pursued two aims: to characterize the functional and biomechanical differences between patients with AKP with and without pronated foot posture, and to compare the short-term effectiveness of two foot-targeted physiotherapy regimens, manual therapy with augmented low-dye taping (MT + ALDT) and neuromuscular training with ALDT (NMT + ALDT), against routine physiotherapy care. A sequential two-phase design was employed in the outpatient physiotherapy department of Mediclinic Al Noor Hospital, Abu Dhabi, UAE. Phase 1 was a prospective case-control study (n = 50; pronated foot, n = 30; neutral/supinated, n = 20). Phase 2 was a single-blind parallel-group RCT that randomized 31 participants with confirmed pronation 1:1:1 to MT + ALDT (n = 11), NMT + ALDT (n = 10), or routine physiotherapy (n = 10) across 12 sessions in 4 weeks. Four outcomes were assessed at baseline and post-intervention: NPRS, Kujala AKPS, FPI-6, and DVI. Phase 1 revealed a 33.7-point AKPS gap between pronated and neutral/supinated participants (50.20 vs. 83.90; p < 0.001, Mann-Whitney U) and a significant FPI-6-DVI association (χ2 = 4.22, p = 0.04). In Phase 2, ANCOVA confirmed that both foot-targeted regimens significantly outperformed routine care on all four outcomes (all p < 0.001), with MT + ALDT demonstrating the greatest improvements. Effect sizes were large (η2 = 0.646-0.958; 95% CIs reported in Results) and are treated as preliminary estimates warranting cautious interpretation given the small sample and single-center setting. Foot pronation was strongly associated with impaired patellofemoral function, although the cross-sectional design of Phase 1 precluded causal inference. Both foot-targeted regimens outperformed routine care, and MT + ALDT demonstrated a stronger clinical profile. The equivalent biomechanical outcomes across both experimental arms were consistent with a contribution from ALDT, but its independent role could not be isolated without a taping-isolated comparator arm. These preliminary single-center findings support further investigation of foot posture assessment and distal intervention in AKP pending confirmation in adequately powered multicenter trials. ClinicalTrials.gov identifier: NCT05917080.
Clinical relevance
In patients with anterior knee pain (AKP) confirmed to have pronated foot posture, does foot-targeted physiotherapy—either manual therapy with augmented low-Dye taping (MT + ALDT) or neuromuscular training with ALDT (NMT + ALDT)—produce superior short-term outcomes compared with routine physiotherapy care? __SNAPSHOT__ {"studyDesign":"Sequential two-phase study: Phase 1 — prospective case-control study; Phase 2 — single-blind parallel-group randomized controlled trial (1:1:1 allocation)","setting":"Outpatient physiotherapy department, Mediclinic Al Noor Hospital, Abu Dhabi, UAE (single center)","sampleSize":"Phase 1: n = 50 (pronated foot [cases], n = 30; neutral/supinated [controls], n = 20). Phase 2 RCT: n = 31 (MT + ALDT, n = 11; NMT + ALDT, n = 10; routine physiotherapy, n = 10)","population":"Phase 1: Adults clinically diagnosed with AKP, stratified by foot posture (pronated vs. neutral/supinated). Phase 2: Participants with AKP confirmed to have pronated foot posture on clinical assessment","intervention":"Phase 2 experimental arms: (1) Manual therapy with augmented low-Dye taping (MT + ALDT) — including talonavicular joint mobilisation and antipronation taping; (2) Neuromuscular training with augmented low-Dye taping (NMT + ALDT) — neuromuscular exercises with antipronation taping; both delivered over 12 sessions across 4 weeks","comparator":"Routine physiotherapy care (active control); Phase 1 uses neutral/supinated foot AKP patients as the case-control comparator","primaryOutcome":"Not explicitly stated in the available abstract excerpt; outcome measures reported in the companion protocol paper include pain (Numeric Pain Rating Scale), functional limitations (Kujala Anterior Knee Pain Scale), foot posture (Foot Posture Index), and dynamic valgus index (DVI), assessed pre- and post-intervention","followUp":"4 weeks (post-intervention); no medium- or long-term follow-up reported in the available abstract","fundingSource":"Not reported"}
Key findings
Specific post-intervention numerical results, between-group effect sizes, confidence intervals, p-values, and NNT/NNH figures for the Phase 2 RCT are not reported in the available abstract excerpt, which is truncated. From the closely related companion case-control paper (same research group, Mediclinic Al Noor Hospital, Abu Dhabi, 2025), Phase 1 findings indicate that AKP patients with pronated feet had statistically significantly lower Kujala Anterior Knee Pain Scale scores (mean 50.20 ± 5.28) compared with AKP patients with neutral or supinated feet (mean 83.90 ± 8.36; p < 0.001). A statistically significant correlation (p = 0.04) between dynamic valgus index (DVI) and Foot Posture Index (FPI) was also identified, suggesting that altered pronation position mediates abnormal patellofemoral loading. Quantitative between-group RCT results for MT + ALDT versus NMT + ALDT versus routine physiotherapy are not reported in the abstract provided and cannot be accurately summarized without access to the full publication.
Practice implications
This two-phase investigation addresses a clinically relevant but underexplored question: whether foot-targeted intervention specifically correcting pronation improves short-term outcomes in AKP patients with confirmed foot pronation. The Phase 1 component substantiates a mechanistic and functional distinction between AKP patients with and without pronated feet, supporting the rationale for foot-specific stratification. Phase 2, if the RCT results confirm superiority of either foot-targeted arm over routine care, would represent a meaningful step toward phenotype-matched rehabilitation for a select AKP subgroup. However, because only the truncated abstract is available, the clinical importance of the RCT findings—including whether differences in pain and function exceed established minimal clinically important differences (MCID: approximately 10 points on the Kujala scale, 2 cm on VAS)—cannot be determined. The study applies only to outpatient adults with clinician-confirmed pronated foot AKP; patients with neutral foot posture, structural pathology (e.g., chondromalacia, patellar instability), inflammatory arthropathy, or significant comorbidities are likely excluded and not represented. The 4-week follow-up precludes conclusions about durability of any effect. Note: this summary is based solely on the truncated abstract provided; full-text review is required before any practice inference is drawn. __LIMITATIONS__ Critically small RCT sample size (n = 31 across three arms; 10–11 per arm), rendering the trial substantially underpowered for primary efficacy conclusions and increasing risk of Type I and Type II errors,Single-blind design (assessor-blinded, participant not blinded to intervention) introduces performance and response biases, particularly relevant given subjective pain and function outcomes,Short follow-up of only 4 weeks; no medium- or long-term data, so durability of any benefit is entirely unknown,Single-center study conducted at one institution in Abu Dhabi, UAE, limiting geographic and demographic generalizability,RCT primary outcome not explicitly defined in the available abstract; post-intervention quantitative results (effect sizes, confidence intervals, p-values) are unavailable due to abstract truncation,Phase 1 case-control design is cross-sectional in nature and cannot establish causal direction between foot pronation and AKP severity,Routine physiotherapy as active control lacks standardization detail in the available abstract, making fidelity and dose equivalence across arms uncertain,No reported data on adverse events, participant adherence, or drop-out rates,Funding source not reported; conflicts of interest cannot be assessed,Only abstract available; full methodological detail, randomization procedures, blinding verification, and complete statistical reporting cannot be evaluated __BOTTOM_LINE_CATEGORY__ promising_but_preliminary __BOTTOM_LINE__ This sequential two-phase study combines a case-control analysis confirming functionally and biomechanically distinct profiles in AKP patients with pronated versus neutral feet with a small single-blind RCT comparing foot-targeted manual therapy or neuromuscular training (each with augmented low-Dye taping) against routine physiotherapy over 4 weeks. Due to abstract truncation, full RCT outcome data are unavailable, and the very small per-arm sample sizes (n = 10–11) substantially limit statistical power and reliability. Clinicians should await full-text publication and independent replication before altering practice, but the pronation-stratification framework and foot-targeted approach warrant continued investigation.