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.