Effects of 8-weeks Systematic Corrective Exercise Program in Pronation Distortion Syndrome
Condition: Pronation; Ankle; Distortion
Study type: Interventional

Summary: 
      Pronation distortion syndrome is a postural complexity of lower extremity which primarily
      involves hyper pronation of feet leading to other dysfunctional movement patterns throughout
      the kinetic chain and gait mechanics. Excessive foot pronation is followed by internal tibial
      rotation and adduction of knees forming knock knees. This lower extremity distortion pattern
      causes a chain reaction of muscle imbalances. The objective of this study is to determine
      effects of 8-Weeks Systematic Corrective Exercise program on Body Posture and stability in
      Pronation Distortion Syndrome. This study will be a Randomized Controlled trial and will be
      conducted at Riphah college of rehabilitation sciences and Ibrahim medical Centre Lahore. The
      study will be completed within the time duration of 10 months. Convenient sampling technique
      will be used to collect the data. A sample size of Total 36 patients will be taken in this
      study. Patients will be divided into two groups. Group A will be treated with conventional
      treatment along with systematic corrective exercise program. Group B will be given
      conventional treatment only. The groups will participate in the training program one day
      after the pre-test, three sessions per week for two months. The diagnosis of pronation
      distortion will be detected by navicular drop in detectable flat feet without pain. Variables
      to be tested will be, functional movement screen test, navicular drop, knock knees and
      lordosis, and will be measured before the start of treatment and after 8 weeks of treatment.
      Data will be analyzed on SPSS 25.
    

Detailed description: 
      Pronation distortion syndrome is a common postural distortion of the lower extremity,
      involving the anterior part of the leg. In this deformity, the head of the talus and
      navicular bones are rotated inward and downward, and the body's center of gravity shifts
      inward, resulting in flat feet. It may cause pain in the leg and disturbances in the tarsal
      part, in addition to distal and proximal parts. Excessive foot pronation include inward
      rotation of the tibia, internal rotation of the thighs associated with flat feet, genu valgum
      (knock-knee), and increased lordosis thus causing abnormalities in lumbo-pelvic region and
      lower limb.

      In this deformity, peroneal muscle, gastrocnemius muscle, hamstrings, soleus muscle,
      iliotibial band, adductors, and psoas muscle are functionally tightened, while posterior and
      anterior tibialis, gluteus Medius, gluteus maximus, vastus medialis, and hip external
      rotators are inhibited. Excessive pronation will misalign the entire lower body, reducing the
      ability of powerful muscles like the quadriceps and glutes to maintain force production.
      Length tension relationships establish that the resting length of a muscle determines whether
      it can generate optimal tension, if the feet excessively flatten and the femur excessively
      rotates and adducts, then the joints don't stack, the tissues don't load, and energy is lost.
      Over time, tissues may become irritated, inflamed or even weakened, which often leads to more
      serious problems, such as ruptured tendons or stress fractures . The body weight normally
      falls on the center of the foot, and balance is maintained by the muscle activity of the
      foot. If the foot becomes diseased or deformed, the foot adapts to perform its functions
      under the conditions of disease or deformity. Several factors of pronation distortion can
      increase the likelihood of cuboid syndrome including midtarsal instability, excessive body
      weight, ill-fitting or poorly constructed orthoses or shoes and inadequate exercise recovery.
      The postural defects cause pronated subtalar joint, inverted forefoot and instability of mid
      tarsal joint leading to improper dynamic stabilization. Every degree of subtalar pronation
      that occurs produces an exponential increase in midtarsal joint instability. Pronated feet
      are very common among people with flexible flat feet in which the medial longitudinal arch of
      the foot largely collapses during the stance phase of gait causing over supination and over
      pronation but restores after removal of body weight. Kinetic coupling of 4 pronated feet
      alters during improper gait mechanics and results in changes of inter joint angle
      coordination. This disturbs the inter joint coordination which is involved in determining
      movement flexibility and stability thus effecting gait pattern leading towards occurrence of
      injury. In the case of postural distortion, instability and damage to the lower extremity
      cause hypermobility, and passive instability and more neurological control by the
      neuromuscular system is required to maintain stability and balance. The instability resulting
      from a flat foot could cause patho-mechanical problems as well as a compensating action in
      the close kinematic chain of the lower extremity. Excessive pronation transmitted to internal
      rotation of the tibia, may cause overloading of the knee joint or may be the cause of other
      changes in proximal part of the lower extremity. The feet support the body's weight and play
      the role of levers when an individual is performing work. By performing closed kinetic chain
      exercises under loads and by increasing the strength of the muscles proximal to the lower
      extremities, one can correct the hyper pronation of the foot in the distal lower extremities
      and can prevent ligamentous laxity. This study will determine the effects of 8 weeks
      systematic corrective exercises on body posture and stability in pronation distortion
      syndrome. PDS is a postural defect that occurs by initiation of foot hyper pronation that
      further causes forced tibial rotation, knock knees and progression of lumbar lordosis.
      Studies suggest women are more prone to pronated feet than men recording prevalence of 20-30
      percent.

      Furthermore, biomechanical abnormalities reported to be prevalent as 60-90 percent.

      In 2020 Ali Golchin et al conducted a study to emphasize on the postural deformities caused
      by pronation distortion syndrome. It was a randomized controlled trial. In this study
      functional movement screening were performed to evaluate subjects' performance. Treatment
      protocol included systematic and corrective exercise program that concluded reduction in
      likelihood of injury and improvement in posture with subjects with pronated feet.

      In year 2020 Marina gil-calvo et al studied the effects of custom-made and prefabricated foot
      orthoses on kinematic parameters in recreational runners with flat feet dysfunction.

      Initial field test was monitored to determine individuals maximum aerobic speed in athletes.

      Subjects with history of foot orthosis implementation were excluded. There were three groups,
      one with custom orthosis, 2nd group underwent with prefabricated orthosis and 3 rd was
      control group. Foot eversion parameters were measured before and after the intervention.

      Findings of the study suggested no significant difference in improvement even after weeks of
      intervention. Modification in the running mechanics to maintain ideal movement pattern in
      runners were suggested for better outcome . In 2020 Manuel Pabón-Carrasco et al checked the
      association of short foot exercises (SFE) with Non biomechanical function (NBF) exercises in
      the strength development of intrinsic muscles of pronated feet. The intrinsic foot muscle is
      considered primordial in maintaining the plantar arch and controlling foot posture. A
      randomized clinical trial was carried out with 85 asymptomatic participants with a bilateral
      Foot Posture Index (FPI) greater than 6 points.

      The pronation of each foot were measured twice. Changes were observed in the ND and FPI
      pre-intervention and post-intervention for the subjects of each independent group. A tendency
      of a more neutral position and a decrease of the ND were noted. 6 In 2019, according to
      Nikkhouamiri F et al, postural abnormalities due to dysfunction of pronated feet can irritate
      the functional and balance kinematic of walking resulting in skeletal abnormalities and
      postural control disorder. Navicular drop test was used to asses the flat feet deformity.
      Given the results, application of corrective exercise program on improving balance and
      function in female population were effective. Female adolescents showed improved postural
      control, coordination and stability. Farhan Alam et al in 2019, worked on selective
      strengthening of tibialis posterior and stretching of iliopsoas on navicular drop, dynamic
      balance, and lower limb muscle activity in pronated feet. A previous study reported that 20%
      of the adult population have flatfeet and 12.8% of adults with flatfeet are males and 14.4%
      are females. The experimental group performed stretching and strengthening of tibialis
      anterior, iliopsoas and adductor muscles whereas conventional group performed towel curl
      exercises. Improvement in biomechanical alignment was noted in this study. Ru-Lan Hsieh, MD
      et al in 2018, conducted a randomized controlled trial study to measure the effects of
      customized arch support insoles in children with flexible flat and pronated feet.

      In this 12-week intervention program subjects went through the measurement of calcaneal
      inclination angle; hypermobility score and navicular drop test. Physical activity i.e., 10-m
      normal and fast walking, stair ascent, stair descent, and chair rising were assessed within
      the intervention. The insoles helped subtalar joint to maintain its normal neutral position
      during mobility (14). The literature suggests to conduct a study on both males and females
      with age group more than 16 years. There has been studies that has worked on foot for
      correction of pronation but the correction of kinetic chain disturbance due to hyper
      pronation has been in neglection. Given the prevalence of flat feet and influence of proximal
      and distal chains, this study will be conducted to determine effects of 8-Weeks Systematic
      CCorrective Exercise program on Body Posture and stability in Pronation Distortion Syndrome.
    

Intervention name(s): Systematic corrective exercises and non-biomechanical functional exercises; Non biomechanical functional exercises
Intervention type(s): Other; Other
Intervention description(s): Restraint exercise or self-release: will involve the gastrocnemius muscle, soleus muscle, fibula, knee compressor muscles, adductors of the thighs, the short head of the biceps femoris, and iliotibial band for 30 seconds, using a foam roller.
Static stretching drills: involving the soleus and gastrocnemius muscles on an inclined plane, tensor fasciae latae muscle, short head of the biceps femoris, and ilio- psoas muscle;
Resistance exercises: will consist of strengthening the eccentric muscles of the feet including dorsiflexion and knee inversion, adduction, and extension, external rotation of the hip joint with TheraBand exercise band, and strengthening the intrinsic muscles of the foot.
Integrative exercises: including the star balance test on all planes and resistive exercises.; Conventional treatment involved Non biomechanical Functional exercises (NBF), these exercises indicated for the control group consists of dorsal and plantar flexion of the metatarsophalangeal joints in unloading of the subject in a long sitting position on a chair or couch with the knee at 90◦ for a period of eight weeks. Feet will be in hanging position to allow plantar flexion smoothly. The exercises will carry out daily without any kind of resistance for a period of 30s. A total of five series will be completed for each foot. These exercises will be considered as non-therapeutic which might have affected the foot's posture.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Pronation; Posture; Distortion; Navicular; Function