Effects of a Short Foot Exercise Program with and without Reactive Neuromuscular Training on Ankle Kinematics and Kinetics in Adolescents with Flexible Flatfoot

Effects of a Short Foot Exercise Program with and without Reactive Neuromuscular Training on Ankle Kinematics and Kinetics in Adolescents with Flexible Flatfoot | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of a Short Foot Exercise Program with and without Reactive Neuromuscular Training on Ankle Kinematics and Kinetics in Adolescents with Flexible Flatfoot Ghazal Taghizadeh, Seyed Sadredin Shojaedin, Raghad Memar, Behrouz Jafari This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8837911/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Flexible flatfoot (FFF) is a prevalent musculoskeletal condition in adolescents and is associated with altered ankle–foot kinematics, impaired shock absorption, and increased risk of lower-extremity injuries. Short Foot Exercises (SFE) have been shown to enhance intrinsic foot muscle function; however, the biomechanical effects of combining SFE with Reactive Neuromuscular Training (RNT) have not been sufficiently investigated. Methods This single-blinded, three-arm randomized controlled trial (RCT) included 48 adolescent girls (12–15 years) with clinically diagnosed FFF. Participants were randomly assigned to an SFE group, an SFE combined with RNT (SF + RNT) group, or a control group. The intervention lasted eight weeks with three supervised sessions per week. Ankle kinematics were assessed using a three-dimensional motion capture system, and kinetic and center of pressure (COP) variables were collected using a force plate during barefoot walking. Outcome measures included ankle range of motion (ROM), moment dorsiflexion (DF), vertical ground reaction force (GRF) peak, loading rate, and frontal-plane ankle motion. Data were analyzed using mixed-design ANOVA with post hoc comparisons. Results Significant time × group interactions were found for moment DF, ankle DF, plantarflexion, inversion, and eversion (p < 0.05). The SF + RNT group demonstrated the most pronounced improvements, including increased ankle DF and inversion, reduced eversion and plantarflexion, and a greater reduction in moment DF compared with the control group. Loading rate decreased significantly over time in both intervention groups (p < 0.001), whereas Peak GRF showed no significant group or interaction effects. Conclusions An eight-week SFE program improved ankle kinematic and kinetic parameters in adolescents with FFF, with superior outcomes observed when combined with RNT. This combined approach may enhance neuromuscular control, optimize gait biomechanics, and reduce injury risk in this population. Trial Registration: IRCT20250610066157N1 on 2025 / 07 / 04. Flexible flatfoot Short Foot Exercise Reactive Neuromuscular Training Ankle Biomechanics Ground Reaction Force Center of Pressure Figures Figure 1 Figure 2 1. Introduction Flexible flatfoot (FFF) is one of the most common musculoskeletal deformities of the lower extremity in children 1 and adolescents and is associated with complex biomechanical alterations in the foot–ankle complex 2 , 3 . These alterations may impair functional performance, increase muscular energy expenditure, reduce the mechanical efficiency of the foot lever system, and increase the risk of musculoskeletal injuries 4 . Clinically, FFF is characterized by a reduced medial longitudinal arch during weight bearing, calcaneal eversion, and midfoot abduction, and its persistence has been linked to conditions such as plantar fasciitis 5 , Achilles tendinopathy, patellofemoral pain syndrome, and other lower-limb kinetic chain disorders 6 . From a biomechanical standpoint, foot posture is associated with distinct lower-extremity injury risks, although the underlying mechanisms remain unclear. Individuals with FFF typically demonstrate reduced ankle dorsiflexion, increased plantarflexion of the calcaneus relative to the tibia, greater subtalar joint eversion, and reduced inversion 7 . These kinematic alterations may compromise dynamic foot control, alter plantar loading patterns, and reduce shock absorption during walking and running 6 , 8 . Plantar pressure variables, particularly COP trajectory measures, provide important insight into spatiotemporal force distribution, dynamic stability, and functional foot performance during gait 8 . Compared with region-based plantar pressure analyses, COP-derived parameters show greater reliability and repeatability and may better discriminate functional differences among foot posture types. However, many previous studies have relied on limited COP metrics or inconsistent classification methods, restricting the strength of their conclusions 9 , 10 . Kinetic parameters such as the vertical GRF peak and loading rate are also critical indicators of mechanical stress and overuse injury risk. Evidence suggests that individuals with flatfoot exhibit altered GRF patterns and force thresholds, potentially reflecting reduced kinetic stability and postural control 11 , 12 . Nevertheless, methodological heterogeneity and limited three-dimensional kinetic analyses have led to inconsistent findings across studies. In recent years, non-invasive corrective exercise interventions—particularly SFE—have been proposed to enhance intrinsic foot muscle strength and provide dynamic support for the medial longitudinal arch 11 , 13 . SFE has been shown to increase intrinsic muscle activation, reduce navicular drop, improve balance, and modulate pronation patterns 14 , 15 . However, most studies have focused on morphological or electromyographic outcomes, with limited investigation of functional ankle–foot kinematic and kinetic variables 16 . RNT has emerged as a complementary approach aimed at improving neuromuscular control, correcting faulty movement patterns, and enhancing dynamic joint stability 17 . Combining SFE with RNT may improve lower-limb motor control and kinetic chain stability 14 ; however, the comparative effects of SFE alone versus SFE combined with RNT on key ankle and foot kinematic and kinetic variables—particularly in adolescents with FFF—remain largely unexplored 7 , 14 . Given the high prevalence of FFF in adolescents and its potential impact on movement efficiency and injury risk, RCTs evaluating targeted exercise interventions using sensitive biomechanical outcomes are warranted. Although SFE have been shown to improve intrinsic foot muscle function and foot posture, their effects on dynamic ankle–foot kinematics and kinetics during gait remain unclear, particularly in adolescents. Furthermore, the potential additive benefits of combining SFE with RNT have not been sufficiently investigated. We hypothesized that both the SFE and the combined SFE + RNT interventions would significantly improve ankle kinematics and kinetics during walking compared with the control condition, with greater improvements expected in the SFE + RNT group. Therefore, the purpose of this RCT was to investigate the effects of a short-term SFE program, performed with and without RNT, on ankle and foot kinematic and kinetic variables—including ankle dorsiflexion, rearfoot eversion, COP parameters, vertical GRF peak, loading rate, and arch-related indices—in adolescents with FFF. 2. Materials and Methods Study Design This study was designed as a three-arm RCT with a pre-test–post-test structure and single-blinded outcome assessment to investigate the effects of targeted exercise interventions on foot biomechanics in adolescent girls with FFF. Participants were randomly allocated into two experimental groups and one control group. Ethical approval was obtained from the Ethics Committee of Kharazmi University (IR.KHU.REC.1404.051), and the study protocol was prospectively registered in the Iranian Registry of Clinical Trials (IRCT20250610066157N1). All procedures were conducted in accordance with the Declaration of Helsinki. Since all participants were under 16 years of age, written informed consent to participate was obtained from their parents or legal guardians, and assent was also obtained from the participants prior to enrollment. Participants The study population consisted of girls aged 12–15 years with clinically diagnosed flexible flatfoot. Sample size estimation was conducted using G*Power software (version 3.1.9.2), assuming an effect size of 0.40, a statistical power of 0.80, and an alpha level of 0.05. Based on these parameters, a minimum of 42 participants was required. To account for a potential dropout rate of approximately 20%, a total of 48 participants were recruited and equally allocated to the three study groups. Participant recruitment, allocation, and reporting procedures were performed in accordance with the Consolidated Standards of Reporting Trials (CONSORT) 2010 guidelines, and a detailed flow diagram of the study process is presented in Fig. 1 . Inclusion criteria included a confirmed diagnosis of FFF, age between 12 and 15 years, absence of prior lower-limb surgery, and medical clearance from a specialist physician. Exclusion criteria were rigid flatfoot, neuromusculoskeletal disorders affecting gait, participation in corrective exercise programs within the previous six months, occurrence of lower-limb injury during the intervention period, absence from more than three training sessions, or withdrawal of informed consent. Randomization and Blinding Block randomization was used to ensure equal sample sizes across the three groups. Random allocation sequences were generated using Randomizer.org by an independent researcher who was not involved in participant recruitment, assessment, or intervention delivery. Allocation concealment was ensured through the use of opaque, sealed, and sequentially numbered envelopes. Outcome assessors and data analysts were blinded to group allocation throughout the study to minimize assessment and analysis bias. Interventions The intervention period lasted eight weeks, with three supervised training sessions per week, each lasting approximately 40–70 minutes. Participants in the first experimental group performed a structured SFE program based on previously published protocols, which were modified and supervised by a multidisciplinary expert panel. Each session consisted of a general and foot-specific warm-up lasting approximately 10 minutes, followed by progressive SF exercises advancing from seated to standing and single-leg tasks for 30–50 minutes, and concluded with a 5-minute cool-down phase. Exercise progression was individualized and adjusted weekly based on correct technique execution, maintenance of the medial longitudinal arch, and avoidance of excessive knee or heel valgus during task performance 18 , 19 . Participants in the second experimental group performed the same SF exercise program combined with RNT aimed at enhancing sensorimotor control, postural stability, and neuromuscular responsiveness. This combined intervention followed established protocols, and exercise intensity and task complexity were progressively increased throughout the intervention period while ensuring appropriate movement quality and lower-limb alignment 20 – 22 . Detailed descriptions of the exercise protocols are provided in Table 1 . Participants in the control group did not receive any intervention during the eight-week study period. Based on consultation with a medical specialist, the absence of exercise intervention during this period was not expected to negatively influence participants’ daily functioning or health status, as FFF in this population was non-urgent and not associated with immediate functional risk. For ethical reasons, the exercise program was offered to control group participants after completion of the trial. Table 1 Exercise Protocol Warm-up SF Exercise RNT Exercise Cool-down Plantar foot massage Hallux abduction Resistance band ankle inversion and dorsiflexion Plantar foot rolling Active dorsiflexion and plantarflexion Heel raises Squat with resistance band around the knees Standing lunge stretch Active inversion and eversion Bilateral heel raises on a step Lateral walking with a resistance band Forefoot stretch Passive forefoot ROM Towel scrunches Single-leg deadlift with a resistance band around the knee Short foot exercise Modified forward lunge with a resistance band around the knee Toe abduction exercise Forward step-down from a box with a resistance band Note : Short foot exercise (SF), Reactive Neuromuscular Training (RNT), Range of Motion (ROM) Clinical Screening Procedures Initial clinical screening was conducted to confirm the presence of FFF. The navicular drop test was used to quantify medial longitudinal arch collapse by measuring the difference in navicular height between seated and standing weight-bearing positions 23 . Dynamic arch reconstruction and rearfoot alignment were assessed using the Jack test through passive DF of the hallux in a standing position to observe medial arch elevation and rearfoot alignment, reflecting activation of the windlass mechanism 24 , 25 . Additionally, the heel-rise test was performed to evaluate dynamic rearfoot function by assessing medial arch formation and the transition of calcaneal alignment from valgus to varus during a single-leg heel rise 26 . Participants demonstrating arch reconstruction without signs of rigid deformity were classified as having FFF. Kinematic Assessment (Motion Capture) Ankle joint kinematics were recorded using an eight-camera three-dimensional motion capture system (Kistler, USA) operating at a sampling frequency of 100 Hz. Reflective markers (15 mm diameter) were bilaterally placed on anatomical landmarks of the lower extremities according to the Plug-in Gait marker set. A static calibration trial was first performed to establish participant-specific anatomical coordinate systems. Participants then walked barefoot at a self-selected speed along a standardized walkway. At least six valid walking trials were collected from each participant. Trials were considered valid when at least three clean force plate contacts per foot were obtained without evidence of gait targeting or alterations in walking pattern. Marker trajectories were tracked using Cortex software, and kinematic modeling and joint angle computations were performed using Visual3D software 27 (C-Motion, USA). The extracted ankle kinematic variables were subsequently prepared for statistical analysis (Fig. 2 ). The gait cycle was defined from initial heel contact to the subsequent heel contact of the same limb and was time-normalized to 100% of the gait cycle. Force plate data were used to accurately identify initial contact and toe-off events, applying a 10 N threshold 28 , 29 . Ankle kinematic variables included dorsiflexion, plantarflexion, inversion, and eversion angles, as well as step length. For each participant, outcome measures were averaged across three successful trials and used for subsequent statistical analysis. Center of Pressure Assessment Plantar COP variables were measured using a Kistler force plate (USA) operating at a sampling frequency of 1000 Hz and synchronized with the motion capture system. Participants walked barefoot along an 8-meter walkway at a self-selected speed to ensure a natural gait pattern and accurate foot contact with the force plate. Six valid trials, including three trials per foot, were collected for each participant. COP displacement in the anteroposterior and mediolateral directions, as well as mean COP velocity during the stance phase, were calculated. COP displacement values were expressed in millimeters (mm). COP data were normalized to foot length and processed and analyzed using MATLAB software prior to statistical evaluation 30 (Fig. 2 ). Statistical Analysis Statistical analyses were performed using IBM SPSS Statistics version 24. Data normality was assessed using the Shapiro–Wilk test, and homogeneity of variances was evaluated using Levene’s test. Between-group and within-group effects across time were analyzed using a two-way mixed-design analysis of variance (mixed ANOVA), with group (SF, SF + RNT, control) as the between-subjects factor and time (pre-test, post-test) as the within-subjects factor. When significant main or interaction effects were observed, Tukey’s post hoc tests were applied for pairwise comparisons. Within-group changes were further examined using paired-samples t-tests. Statistical significance was set at p < 0.05, and effect sizes were calculated using Cohen’s d and interpreted as small (0.20), medium (0.50), and large (0.80). 3. Results Baseline Characteristics The baseline demographic and anthropometric characteristics of the participants in the Control, SF, and SF + RNT groups are presented in Table 2 . One-way analysis of variance (ANOVA) revealed no statistically significant differences between the three groups in height, weight, age, or body mass index (BMI) at baseline (all p > .05). These findings confirm the initial homogeneity of the groups and indicate that the randomization procedure was successful. Table 2 Baseline Demographic and Anthropometric Characteristics of Participants (Mean ± Standard Deviation), Variable SF + RNT (n = 16) SF (n = 16) Control (n = 16) Hight (cm) 1.51 ± 141.06 2.42 ± 147.06 1.27 ± 143.16 Wight (kg) 1.93 ± 38.37 2.80 ± 44.18 2.00 ± 39.58 Age (year) 0.15 ± 12.62 0.21 ± 13.31 0.19 ± 12.91 BMI (kg/m²) 0.75 ± 19.17 0.73 ± 20.08 0.85 ± 19.24 Note : body mass index (BMI), Short foot exercise (SF), Reactive Neuromuscular Training (RNT) Descriptive Statistics of Biomechanical Variables Descriptive statistics (means and standard deviations) for all biomechanical variables at pre-test and post-test across the three groups are reported in Table 3 . Visual inspection of the descriptive data suggests that the magnitude and direction of changes over time differed between groups. Overall, the SF + RNT group exhibited the most pronounced improvements from pre-test to post-test across several key biomechanical outcomes. Table 3 Descriptive Statistics for Biomechanical Variables by Group and Assessment Time (Mean ± Standard Deviation). Variable Group Pre-test Mean ± SD Post-test Mean ± SD N Peak GRF Control 15.62 ± 2.05 15.13 ± 2.02 16 SF 15.97 ± 4.91 14.49 ± 3.54 16 SF + RNT 15.78 ± 1.79 12.94 ± 3.27 16 Moment DR Control 0.65 ± 0.17 0.64 ± 0.18 16 SF 0.55 ± 0.16 0.48 ± 0.12 16 SF + RNT 0.52 ± 0.08 0.48 ± 0.11 16 Loading rate Control 0.16 ± 0.02 0.15 ± 0.03 16 SF 0.17 ± 0.03 0.14 ± 0.02 16 SF + RNT 0.17 ± 0.02 0.12 ± 0.01 16 DF Control 15.76 ± 1.54 16.20 ± 3.28 16 SF 15.24 ± 2.28 20.09 ± 4.42 16 SF + RNT 14.64 ± 2.39 22.46 ± 3.07 16 Plantar Flexion Control 8.84 ± 2.12 8.77 ± 1.67 16 SF 7.74 ± 2.02 7.26 ± 3.31 16 SF + RNT 7.06 ± 2.24 9.14 ± 2.20 16 Inversion Control 3.39 ± 0.90 3.39 ± 0.77 16 SF 2.60 ± 1.13 3.92 ± 1.44 16 SF + RNT 2.98 ± 0.95 5.18 ± 1.27 16 Eversion Control 4.76 ± 0.81 4.74 ± 1.01 16 SF 5.55 ± 1.36 4.76 ± 1.04 16 SF + RNT 5.40 ± 1.48 3.06 ± 1.10 16 Note : Short foot exercise (SF), Reactive Neuromuscular Training (RNT), Dorsi Flexion (DR), Ground Reaction Force (GRF). Mixed Repeated-Measures ANOVA The results of the 3 (Group: Control, SF, SF + RNT) × 2 (Time: Pre-test, Post-test) repeated-measures ANOVAs for each biomechanical variable are summarized in Table 4 . Main Effect of Time A significant main effect of Time was observed for Peak GRF, Moment DR, Loading Rate, Dorsi Flexion, Inversion, and Eversion (all p ≤ .001; see Table 3 ). These results indicate that, regardless of group assignment, participants demonstrated significant changes in these variables from pre-test to post-test. Main Effect of Group A significant main effect of Group was found for Loading Rate, Dorsi Flexion, Inversion, and Eversion (p < .05; Table 4 ), indicating overall differences in these biomechanical measures between the groups across assessment times. Time × Group Interaction Most importantly, significant Time × Group interactions were detected for Moment DR, Dorsi Flexion, Plantar Flexion, Inversion, and Eversion (p < .05; Table 4 ). These interactions demonstrate that the pattern of change from pre-test to post-test differed as a function of the intervention received. The magnitude of these interaction effects, as indicated by partial eta squared (partial η²), ranged from moderate to large, suggesting meaningful practical significance. Table 4 Results of Repeated Measures ANOVA Variable Time F(p) Group F(p) Time×Group F(p) Partial η² Peak GRF 11.56 (0.001) 0.668 (0.518) 2.09 (0.135) 0.085 Moment DR 5.37 (0.025) 1.22 (0.304) 5.26 (0.009) 0.052 Loading rate 66.52 (0.000) 9.79 (0.000) 1.12 (0.335) 0.303 DF 39.50 (0.000) 8.92 (0.001) 9.53 (0.000) 0.298 Plantar Flexion 1.91 (0.174) 1.79 (0.178) 4.62 (0.015) 0.171 Inversion 31.10 (0.000) 5.01 (0.011) 9.19 (0.000) 0.290 Eversion 21.28 (0.00) 4.73 (0.014) 9.02 (0.001) 0.286 Note : df = degrees of freedom; Partial η² = partial eta squared , Dorsi Flexion (DR), Ground Reaction Force (GRF). Post-hoc Analyses To further examine the significant Time × Group interactions, post-hoc between-group comparisons at post-test were conducted using Tukey’s HSD test. The results of these comparisons are presented in Table 5 . For Moment DR, the SF + RNT group exhibited a significantly greater reduction compared with the Control group at post-test (p = .013), while the difference between the SF and Control groups approached statistical significance (p = .032; Table 5 ). For DF, both intervention groups (SF and SF + RNT) demonstrated significantly greater improvements than the Control group at post-test (SF vs. Control: p = .027; SF + RNT vs. Control: p < .001; Table 5 ). For Inversion, the SF + RNT group showed a significantly greater increase compared with the SF group (p = .015), whereas the difference relative to the Control group approached significance (p = .052; Table 5 ). For Eversion, the SF + RNT group demonstrated a significantly greater reduction compared with the SF group (p = .011; Table 5 ). No significant between-group differences were observed at post-test for Peak GRF, Loading Rate, or Plantar Flexion (all p > 0.05; Table 5 ). Table 5 Post-hoc Comparisons Between Groups at Post-test. Variable Groups Mean Difference (I-J) Std. Error Sig. Peak GRF Control, SF 0.15 0.94 0.98 Control, SF + RNT 1.01 0.94 0.53 SF, SF + RNT 0.86 0.94 0.63 Moment DR Control, SF 0.124 0.047 0.032 Control, SF + RNT 0.142 0.047 0.013 SF, SF + RNT 0.017 0.047 0.929 Loading rate Control, SF 0.001 0.009 1.00 Control, SF + RNT 0.012 0.009 0.529 SF, SF + RNT 0.01 0.009 0.705 DF Control, SF 1.68 0.619 0.027 Control, SF + RNT 2.57 0.619 0.000 SF, SF + RNT 0.88 0.619 0.477 Plantar Flexion Control, SF 1.30 0.691 0.194 Control, SF + RNT 0.70 0.691 0.932 SF, SF + RNT 0.59 0.691 1.00 Inversion Control, SF 0.13 0.274 1.00 Control, SF + RNT 0.67 0.274 0.052 SF, SF + RNT 0.80 0.274 0.015 Eversion Control, SF 0.40 0.301 0.549 Control, SF + RNT 0.51 0.301 0.278 SF, SF + RNT 0.926 0.301 0.011 Note: Standard Error (SE), Confidence Interval (CI), Short foot exercise (SF), Reactive Neuromuscular Training (RNT), Dorsi Flexion (DR), Ground Reaction Force (GRF). In summary, the results indicate that while some biomechanical variables changed over time irrespective of group, the combined SF + RNT intervention produced the most favorable pattern of change in key kinematic and kinetic variables. These findings highlight the differential effectiveness of the interventions on biomechanical outcomes. Repeated measures ANOVA revealed three distinct patterns. First, for anxiety, quality of life, and well-being, significant time × group interactions were found (PS < 0.05), indicating differential effects of interventions across time. Second, for depression, stress, and coping skills, only the main effect of time was significant (PS 0.05). 4. Discussion The present study demonstrated that exercise-based interventions, particularly the combination of with RNT, effectively improved foot biomechanics in adolescents with FFF. Meaningful adaptations were observed across several biomechanical variables, including Peak GRF, Moment DR, loading rate, ankle DF, plantarflexion, inversion, and eversion. Peak GRF showed a significant main effect of time (p = 0.001); however, no significant group or time × group interaction effects were observed, and post hoc comparisons between the control, SF, and SF + RNT groups were not significant (all p > 0.05). These findings align with previous studies indicating that Peak GRF alone is not a sensitive marker for distinguishing FFF from normal foot function, as alterations are more commonly reflected in force distribution and temporal GRF characteristics rather than peak magnitudes 20 , 31 . Accordingly, Peak GRF should be interpreted in conjunction with complementary kinetic parameters such as loading rate. A significant reduction in Moment DR was observed following SFE, with the greatest improvement occurring in the SF + RNT group (p < 0.05), indicating enhanced neuromuscular control of the ankle during stance and push-off phases 4 . This improvement likely reflects improved coordination between dorsiflexor muscles and intrinsic foot musculature, leading to increased active stiffness of the medial longitudinal arch and reduced compensatory torque demands 13 , 32 . Loading rate decreased significantly from pre-test to post-test (p < 0.001), despite the absence of significant group differences. Reduced loading rate represents improved shock absorption and slower force application at initial contact, which has been associated with a lower risk of lower-extremity injuries 33 , 34 . These findings suggest that SFE and RNT enhance foot shock-attenuation capacity even when Peak GRF remains unchanged. Ankle kinematic adaptations included increased DF and decreased plantarflexion following the interventions, reflecting improved windlass mechanism function and reduced reliance on compensatory plantarflexion strategies commonly observed in FFF 18 , 35 . Although reduced plantarflexion is often interpreted as mechanical inefficiency, the changes observed in this study appear to result from strengthened intrinsic foot muscles and increased arch stiffness, thereby improving force distribution during stance 13 , 36 , 37 . In the frontal plane, increased inversion and reduced eversion were observed following SFE, particularly in the SF + RNT group, indicating improved control of excessive pronation and enhanced rearfoot alignment 38 , 39 . These adaptations are consistent with previous findings demonstrating the role of intrinsic foot muscle activation in improving medial longitudinal arch stability in children with FFF 36 , 37 . The combined SFE and RNT intervention appears to induce coordinated distal–proximal adaptations, whereby improved intrinsic foot muscle function enhances center of pressure control, while proximal neuromuscular training contributes to improved lower-limb alignment. This interaction likely facilitates more efficient gait mechanics and reduces undesirable loading on the ankle and medial longitudinal arch 13 , 18 , 35 . Several limitations should be acknowledged, including the limited sample size, lack of control over daily physical activity, footwear, and environmental conditions, absence of long-term follow-up, and limited control over body weight, all of which may have influenced the outcomes. This study was limited to female participants aged 12–15 years to control for sex- and age-related effects, which may restrict generalizability. Although testing procedures were standardized, environmental factors such as diet, daily physical activity, and rest patterns, as well as genetic differences and individual motivation levels, could not be fully controlled and may have influenced the results. Conclusion Short-term SFE interventions, particularly when combined with RNT, did not significantly alter Peak GRF but produced meaningful improvements in ankle moment control, reduced loading rate, increased ankle DF and inversion, and decreased plantarflexion and eversion. These biomechanical adaptations reflect enhanced shock absorption, improved neuromuscular control, and more efficient force distribution during gait, suggesting that combined SFE and RNT may be an effective strategy for improving gait biomechanics and reducing injury risk in adolescents with FFF. Abbreviations FFF Flexible flatfoot SFE Short Foot Exercises ROM Range of Motion RNT Reactive Neuromuscular Training RCT Randomized Controlled Trial COP Center of Pressure DF dorsiflexion GRF Ground Reaction Force BMI Body Mass Index SD Standard Deviation Declarations Acknowledgements The authors would like to thank all staff and participants in the present study for their valuable contributions. Author contributions Taghizadeh G., data collection, literature study, information classification, methodology, statistical analysis, and writing. Shojaeddin S., supervisor, supervision, methodology, and conceptualization. Memar R., the idea of design and writing, and conceptualization. Jafari B., Guide to the research and monitoring process. Funding None Data availability The dataset presented in the study is available on request from the corresponding author during submission or after its publication. The data are not publicly available due to privacy concerns and ethical restrictions related to participant confidentiality. Ethics approval and consent to participate This single-blind, single-center, prospective randomized controlled trial was approved by the Ethics Committee of Kharazmi University (IR.KHU.REC.1404.051). The study was conducted at the Faculty of Physical Education and Sport Sciences, Kharazmi University, Tehran, Iran. All procedures adhered to the ethical principles outlined in the Declaration of Helsinki (2013 revision). The trial was prospectively registered in the Iranian Registry of Clinical Trials (IRCT) under the registration number IRCT20250610066157N1. Written informed consent was obtained from all participants before enrollment. All intervention sessions were supervised by a licensed physiotherapist to ensure participant safety and adherence to institutional ethical standards. Consent for publication Not Applicable. Competing interests The authors declare no competing interests. Author details Master, Department of Biomechanical & Sports Injuries, Kharazmi University, Tehran, Iran Professor, Department of Biomechanical & Sports Injuries, Kharazmi University, Tehran, Iran Associate professor, Department of Biomechanical & Sports Injuries, Kharazmi University, Tehran, Iran PhD, Department of Sports Injury and Biomechanics, Faculty of Sport Sciences and Health, University of Tehran, Tehran, Iran References Evaluation and Comparison of the Upper. Limb Musculoskeletal Structure and the Static Balance in Children with Visual and Hearing Impairment. J Except Child. 2021;21:52–41. Hara S, Kitano M, Kudo S. The effects of short foot exercises to treat flat foot deformity: A systematic review. Journal of Back and Musculoskeletal Rehabilitation vol. 36 21–33 Preprint at https://doi.org/10.3233/BMR-210374 (2023). Romanova E, et al. 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Intra-rater reliability and validity of navicular drop test for the assessment of medial longitudinal arch in patients having pronated feet with chronic low back pain. Clin Epidemiol Glob Health 32, (2025). Mosca VS. Flexible flatfoot in children and adolescents. J Child Orthop. 2010;4:107–21. Kardm SM, Alanazi ZA, Aldugman TAS, Reddy RS, Gautam AP. Prevalence and functional impact of flexible flatfoot in school-aged children: a cross-sectional clinical and postural assessment. J Orthop Surg Res. 2025;20:783. Ross MH, Smith MD, Mellor R, Durbridge G, Vicenzino B. Clinical tests of tibialis posterior tendinopathy: Are they reliable, and how well are they reflected in structural changes on imaging? J Orthop Sports Phys Ther. 2021;51:253–60. Jafarnezhadgero A, Madadi Shad M, Ferber R. The effect of foot orthoses on joint moment asymmetry in male children with flexible flat feet. J Bodyw Mov Ther. 2018;22:83–9. Nourbakhsh S-A, Sheikhhoseini R, Piri H, Soltani F, Ebrahimi E. Spatiotemporal and kinematic gait changes in flexible flatfoot: a systematic review and meta-analysis. J Orthop Surg Res. 2025;20:223. Leitch J, Stebbins J, Paolini G, Zavatsky AB. Identifying gait events without a force plate during running: a comparison of methods. Gait Posture. 2011;33:130–2. Zuil-Escobar JC, Martínez-Cepa CB, Martín-Urrialde JA, Gómez-Conesa A. Reliability and Accuracy of Static Parameters Obtained From Ink and Pressure Platform Footprints. J Manipulative Physiol Ther. 2016;39:510–7. Piri E, Jafarnezhadgero A, Stålman A, Alihosseini S, Panahighaffarkandi Y. Comparison of the Ground Reaction Force Frequency Spectrum during Walking with and without Anti-Pronation Insoles in Individuals with Pronated Feet. J Sport Biomech. 2025;11:20–33. Zarali A, Raeisi Z, Aminmahalati A. The effects of combined exercises, short foot exercises, and short foot exercises with isometric hip abduction on navicular drop, static parameters, and postural sway in women with flat foot: A randomized trial. BMC Sports Sci Med Rehabil. 2024;16:233. ghazaleh L, Hoseini Y, masoomi F. Taghi Karimi, M. Ground reaction force analysis in flexible and rigid flatfoot subjects. J Bodyw Mov Ther. 2024;39:441–6. Piri E et al. Effect of double- density foot orthoses on ground reaction forces and lower limb muscle activities during running in adults with and without pronated feet. BMC Sports Sci Med Rehabil 17, (2025). McKeon PO, Hertel J, Bramble D, Davis I. The foot core system: a new paradigm for understanding intrinsic foot muscle function. Br J Sports Med. 2015;49:290–290. Koshino Y, et al. Abductor hallucis muscle activity during short foot exercise in combination with static and dynamic functional tasks. Gait Posture. 2024;113:498–503. Zarali A, Raeisi Z, Aminmahalati A. The effects of combined exercises, short foot exercises, and short foot exercises with isometric hip abduction on navicular drop, static parameters, and postural sway in women with flat foot: A randomized trial. BMC Sports Sci Med Rehabil. 2024;16:233. Fischer G et al. Validity and Efficacy of the Elite HRV Smartphone Application during Slow-Paced Breathing. https://doi.org/10.3390/s23239496 (2023) doi:10.3390/s23239496. Okamura K, et al. Effects of plantar intrinsic foot muscle strengthening exercise on static and dynamic foot kinematics: A pilot randomized controlled single-blind trial in individuals with pes planus. Gait Posture. 2020;75:40–5. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8837911","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":605314299,"identity":"91fd2e75-de3b-4062-b1b8-8e28c0d6d602","order_by":0,"name":"Ghazal Taghizadeh","email":"","orcid":"","institution":"Kharazmi University","correspondingAuthor":false,"prefix":"","firstName":"Ghazal","middleName":"","lastName":"Taghizadeh","suffix":""},{"id":605314300,"identity":"463cdf58-bc67-43c4-ae31-f3f3dac970f0","order_by":1,"name":"Seyed Sadredin Shojaedin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYDACCQYGAwYGZsY2BubDzBAhxgZitbAlE6+FAaSlgYHHmJkod8nPbj5Q8KPCWrZPuuezcWEbgzx/A3PbB3xaDO4cSzDsOZNu3CZzdnPyzDYGwxkHGJtn4NUikWNgwNt2OLFNInfzYd42BsYNDIzN+B02I8fA8O8/kJacxyAt9gS1MNzIMTDmbQBrYU4GakkkqMXgRlqCscwxoF8k0oyNec5JJM84TNBhyccM39RYy86fkfxYmqfMxra/vf0xfocxMLAZIHGA0URE7DA/IKxmFIyCUTAKRjQAAPlnQ5Ybw2mpAAAAAElFTkSuQmCC","orcid":"","institution":"Kharazmi University","correspondingAuthor":true,"prefix":"","firstName":"Seyed","middleName":"Sadredin","lastName":"Shojaedin","suffix":""},{"id":605314301,"identity":"2b1c8709-dd33-4b2f-93d3-9ee90e966a20","order_by":2,"name":"Raghad Memar","email":"","orcid":"","institution":"Kharazmi University","correspondingAuthor":false,"prefix":"","firstName":"Raghad","middleName":"","lastName":"Memar","suffix":""},{"id":605314302,"identity":"58f9fbca-f67d-4047-bf90-f8bd4a153606","order_by":3,"name":"Behrouz Jafari","email":"","orcid":"","institution":"Department of Sports injury and biomechanics, Faculty of Sport Sciences and health","correspondingAuthor":false,"prefix":"","firstName":"Behrouz","middleName":"","lastName":"Jafari","suffix":""}],"badges":[],"createdAt":"2026-02-10 07:41:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8837911/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8837911/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104668111,"identity":"43b44707-d765-408a-8508-0d86bff5bb39","added_by":"auto","created_at":"2026-03-15 16:51:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":80732,"visible":true,"origin":"","legend":"\u003cp\u003eCharactristic of geoups, Note: Short-Foot protocol (SF), reactive neuromuscular exercises (RNE).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8837911/v1/6402e9f380587542861c1043.png"},{"id":104668110,"identity":"41f0a670-9007-47cb-8af0-59a34f16dc46","added_by":"auto","created_at":"2026-03-15 16:51:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":623045,"visible":true,"origin":"","legend":"\u003cp\u003e1. Marker placement 2. Anterior marker placement 3. Lateral marker placement 4. Posterior marker placement 5. Static standing position on the force plate from the anterior view 6. Static standing position on the force plate from the posterior view\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8837911/v1/18bf7f460225631105436dc0.png"},{"id":106775041,"identity":"500dacdd-5ef4-4cac-8c62-ab9eef719355","added_by":"auto","created_at":"2026-04-13 10:43:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1832272,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8837911/v1/58ea25ca-17cf-4ed5-8c5d-01fe6ab10041.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of a Short Foot Exercise Program with and without Reactive Neuromuscular Training on Ankle Kinematics and Kinetics in Adolescents with Flexible Flatfoot","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eFlexible flatfoot (FFF) is one of the most common musculoskeletal deformities of the lower extremity in children \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e and adolescents and is associated with complex biomechanical alterations in the foot\u0026ndash;ankle complex \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. These alterations may impair functional performance, increase muscular energy expenditure, reduce the mechanical efficiency of the foot lever system, and increase the risk of musculoskeletal injuries \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Clinically, FFF is characterized by a reduced medial longitudinal arch during weight bearing, calcaneal eversion, and midfoot abduction, and its persistence has been linked to conditions such as plantar fasciitis \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e, Achilles tendinopathy, patellofemoral pain syndrome, and other lower-limb kinetic chain disorders \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFrom a biomechanical standpoint, foot posture is associated with distinct lower-extremity injury risks, although the underlying mechanisms remain unclear. Individuals with FFF typically demonstrate reduced ankle dorsiflexion, increased plantarflexion of the calcaneus relative to the tibia, greater subtalar joint eversion, and reduced inversion \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. These kinematic alterations may compromise dynamic foot control, alter plantar loading patterns, and reduce shock absorption during walking and running \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePlantar pressure variables, particularly COP trajectory measures, provide important insight into spatiotemporal force distribution, dynamic stability, and functional foot performance during gait \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Compared with region-based plantar pressure analyses, COP-derived parameters show greater reliability and repeatability and may better discriminate functional differences among foot posture types. However, many previous studies have relied on limited COP metrics or inconsistent classification methods, restricting the strength of their conclusions \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eKinetic parameters such as the vertical GRF peak and loading rate are also critical indicators of mechanical stress and overuse injury risk. Evidence suggests that individuals with flatfoot exhibit altered GRF patterns and force thresholds, potentially reflecting reduced kinetic stability and postural control \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Nevertheless, methodological heterogeneity and limited three-dimensional kinetic analyses have led to inconsistent findings across studies.\u003c/p\u003e \u003cp\u003eIn recent years, non-invasive corrective exercise interventions\u0026mdash;particularly SFE\u0026mdash;have been proposed to enhance intrinsic foot muscle strength and provide dynamic support for the medial longitudinal arch \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. SFE has been shown to increase intrinsic muscle activation, reduce navicular drop, improve balance, and modulate pronation patterns \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. However, most studies have focused on morphological or electromyographic outcomes, with limited investigation of functional ankle\u0026ndash;foot kinematic and kinetic variables \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRNT has emerged as a complementary approach aimed at improving neuromuscular control, correcting faulty movement patterns, and enhancing dynamic joint stability \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Combining SFE with RNT may improve lower-limb motor control and kinetic chain stability \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e; however, the comparative effects of SFE alone versus SFE combined with RNT on key ankle and foot kinematic and kinetic variables\u0026mdash;particularly in adolescents with FFF\u0026mdash;remain largely unexplored \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eGiven the high prevalence of FFF in adolescents and its potential impact on movement efficiency and injury risk, RCTs evaluating targeted exercise interventions using sensitive biomechanical outcomes are warranted. Although SFE have been shown to improve intrinsic foot muscle function and foot posture, their effects on dynamic ankle\u0026ndash;foot kinematics and kinetics during gait remain unclear, particularly in adolescents. Furthermore, the potential additive benefits of combining SFE with RNT have not been sufficiently investigated. We hypothesized that both the SFE and the combined SFE\u0026thinsp;+\u0026thinsp;RNT interventions would significantly improve ankle kinematics and kinetics during walking compared with the control condition, with greater improvements expected in the SFE\u0026thinsp;+\u0026thinsp;RNT group. Therefore, the purpose of this RCT was to investigate the effects of a short-term SFE program, performed with and without RNT, on ankle and foot kinematic and kinetic variables\u0026mdash;including ankle dorsiflexion, rearfoot eversion, COP parameters, vertical GRF peak, loading rate, and arch-related indices\u0026mdash;in adolescents with FFF.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003ch3\u003eStudy Design\u003c/h3\u003e\n\u003cp\u003eThis study was designed as a three-arm RCT with a pre-test\u0026ndash;post-test structure and single-blinded outcome assessment to investigate the effects of targeted exercise interventions on foot biomechanics in adolescent girls with FFF. Participants were randomly allocated into two experimental groups and one control group. Ethical approval was obtained from the Ethics Committee of Kharazmi University (IR.KHU.REC.1404.051), and the study protocol was prospectively registered in the Iranian Registry of Clinical Trials (IRCT20250610066157N1). All procedures were conducted in accordance with the Declaration of Helsinki. Since all participants were under 16 years of age, written informed consent to participate was obtained from their parents or legal guardians, and assent was also obtained from the participants prior to enrollment.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe study population consisted of girls aged 12\u0026ndash;15 years with clinically diagnosed flexible flatfoot. Sample size estimation was conducted using G*Power software (version 3.1.9.2), assuming an effect size of 0.40, a statistical power of 0.80, and an alpha level of 0.05. Based on these parameters, a minimum of 42 participants was required. To account for a potential dropout rate of approximately 20%, a total of 48 participants were recruited and equally allocated to the three study groups. Participant recruitment, allocation, and reporting procedures were performed in accordance with the Consolidated Standards of Reporting Trials (CONSORT) 2010 guidelines, and a detailed flow diagram of the study process is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e Inclusion criteria included a confirmed diagnosis of FFF, age between 12 and 15 years, absence of prior lower-limb surgery, and medical clearance from a specialist physician. Exclusion criteria were rigid flatfoot, neuromusculoskeletal disorders affecting gait, participation in corrective exercise programs within the previous six months, occurrence of lower-limb injury during the intervention period, absence from more than three training sessions, or withdrawal of informed consent.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRandomization and Blinding\u003c/h3\u003e\n\u003cp\u003eBlock randomization was used to ensure equal sample sizes across the three groups. Random allocation sequences were generated using Randomizer.org by an independent researcher who was not involved in participant recruitment, assessment, or intervention delivery. Allocation concealment was ensured through the use of opaque, sealed, and sequentially numbered envelopes. Outcome assessors and data analysts were blinded to group allocation throughout the study to minimize assessment and analysis bias.\u003c/p\u003e\n\u003ch3\u003eInterventions\u003c/h3\u003e\n\u003cp\u003eThe intervention period lasted eight weeks, with three supervised training sessions per week, each lasting approximately 40\u0026ndash;70 minutes. Participants in the first experimental group performed a structured SFE program based on previously published protocols, which were modified and supervised by a multidisciplinary expert panel. Each session consisted of a general and foot-specific warm-up lasting approximately 10 minutes, followed by progressive SF exercises advancing from seated to standing and single-leg tasks for 30\u0026ndash;50 minutes, and concluded with a 5-minute cool-down phase. Exercise progression was individualized and adjusted weekly based on correct technique execution, maintenance of the medial longitudinal arch, and avoidance of excessive knee or heel valgus during task performance \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e .\u003c/p\u003e \u003cp\u003eParticipants in the second experimental group performed the same SF exercise program combined with RNT aimed at enhancing sensorimotor control, postural stability, and neuromuscular responsiveness. This combined intervention followed established protocols, and exercise intensity and task complexity were progressively increased throughout the intervention period while ensuring appropriate movement quality and lower-limb alignment \u003csup\u003e\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Detailed descriptions of the exercise protocols are provided in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Participants in the control group did not receive any intervention during the eight-week study period. Based on consultation with a medical specialist, the absence of exercise intervention during this period was not expected to negatively influence participants\u0026rsquo; daily functioning or health status, as FFF in this population was non-urgent and not associated with immediate functional risk. For ethical reasons, the exercise program was offered to control group participants after completion of the trial.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eExercise Protocol\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWarm-up\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF Exercise\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRNT Exercise\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCool-down\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePlantar foot massage\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHallux abduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eResistance band ankle inversion and dorsiflexion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ePlantar foot rolling\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive dorsiflexion and plantarflexion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHeel raises\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSquat with resistance band around the knees\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eStanding lunge stretch\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive inversion and eversion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBilateral heel raises on a step\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLateral walking with a resistance band\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eForefoot stretch\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePassive forefoot ROM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTowel scrunches\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSingle-leg deadlift with a resistance band around the knee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShort foot exercise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModified forward lunge with a resistance band around the knee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eToe abduction exercise\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eForward step-down from a box with a resistance band\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eNote\u003c/b\u003e: Short foot exercise (SF), Reactive Neuromuscular Training (RNT), Range of Motion (ROM)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eClinical Screening Procedures\u003c/h3\u003e\n\u003cp\u003eInitial clinical screening was conducted to confirm the presence of FFF. The navicular drop test was used to quantify medial longitudinal arch collapse by measuring the difference in navicular height between seated and standing weight-bearing positions \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Dynamic arch reconstruction and rearfoot alignment were assessed using the Jack test through passive DF of the hallux in a standing position to observe medial arch elevation and rearfoot alignment, reflecting activation of the windlass mechanism \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Additionally, the heel-rise test was performed to evaluate dynamic rearfoot function by assessing medial arch formation and the transition of calcaneal alignment from valgus to varus during a single-leg heel rise \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Participants demonstrating arch reconstruction without signs of rigid deformity were classified as having FFF.\u003c/p\u003e\n\u003ch3\u003eKinematic Assessment (Motion Capture)\u003c/h3\u003e\n\u003cp\u003eAnkle joint kinematics were recorded using an eight-camera three-dimensional motion capture system (Kistler, USA) operating at a sampling frequency of 100 Hz. Reflective markers (15 mm diameter) were bilaterally placed on anatomical landmarks of the lower extremities according to the Plug-in Gait marker set. A static calibration trial was first performed to establish participant-specific anatomical coordinate systems. Participants then walked barefoot at a self-selected speed along a standardized walkway.\u003c/p\u003e \u003cp\u003eAt least six valid walking trials were collected from each participant. Trials were considered valid when at least three clean force plate contacts per foot were obtained without evidence of gait targeting or alterations in walking pattern. Marker trajectories were tracked using Cortex software, and kinematic modeling and joint angle computations were performed using Visual3D software \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e (C-Motion, USA). The extracted ankle kinematic variables were subsequently prepared for statistical analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e The gait cycle was defined from initial heel contact to the subsequent heel contact of the same limb and was time-normalized to 100% of the gait cycle. Force plate data were used to accurately identify initial contact and toe-off events, applying a 10 N threshold \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Ankle kinematic variables included dorsiflexion, plantarflexion, inversion, and eversion angles, as well as step length. For each participant, outcome measures were averaged across three successful trials and used for subsequent statistical analysis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCenter of Pressure Assessment\u003c/h2\u003e \u003cp\u003ePlantar COP variables were measured using a Kistler force plate (USA) operating at a sampling frequency of 1000 Hz and synchronized with the motion capture system. Participants walked barefoot along an 8-meter walkway at a self-selected speed to ensure a natural gait pattern and accurate foot contact with the force plate. Six valid trials, including three trials per foot, were collected for each participant. COP displacement in the anteroposterior and mediolateral directions, as well as mean COP velocity during the stance phase, were calculated. COP displacement values were expressed in millimeters (mm). COP data were normalized to foot length and processed and analyzed using MATLAB software prior to statistical evaluation \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using IBM SPSS Statistics version 24. Data normality was assessed using the Shapiro\u0026ndash;Wilk test, and homogeneity of variances was evaluated using Levene\u0026rsquo;s test. Between-group and within-group effects across time were analyzed using a two-way mixed-design analysis of variance (mixed ANOVA), with group (SF, SF\u0026thinsp;+\u0026thinsp;RNT, control) as the between-subjects factor and time (pre-test, post-test) as the within-subjects factor. When significant main or interaction effects were observed, Tukey\u0026rsquo;s post hoc tests were applied for pairwise comparisons. Within-group changes were further examined using paired-samples t-tests. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, and effect sizes were calculated using Cohen\u0026rsquo;s d and interpreted as small (0.20), medium (0.50), and large (0.80).\u003c/p\u003e\u003c/div\u003e\n"},{"header":"3. Results","content":"\u003ch3\u003eBaseline Characteristics\u003c/h3\u003e\n\u003cp\u003eThe baseline demographic and anthropometric characteristics of the participants in the Control, SF, and SF\u0026thinsp;+\u0026thinsp;RNT groups are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. One-way analysis of variance (ANOVA) revealed no statistically significant differences between the three groups in height, weight, age, or body mass index (BMI) at baseline (all p \u0026gt; .05). These findings confirm the initial homogeneity of the groups and indicate that the randomization procedure was successful.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Demographic and Anthropometric Characteristics of Participants (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;Standard Deviation),\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF\u0026thinsp;+\u0026thinsp;RNT (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSF (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHight (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.51\u0026thinsp;\u0026plusmn;\u0026thinsp;141.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.42\u0026thinsp;\u0026plusmn;\u0026thinsp;147.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e1.27\u0026thinsp;\u0026plusmn;\u0026thinsp;143.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.93\u0026thinsp;\u0026plusmn;\u0026thinsp;38.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.80\u0026thinsp;\u0026plusmn;\u0026thinsp;44.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e2.00\u0026thinsp;\u0026plusmn;\u0026thinsp;39.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.15\u0026thinsp;\u0026plusmn;\u0026thinsp;12.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.21\u0026thinsp;\u0026plusmn;\u0026thinsp;13.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.19\u0026thinsp;\u0026plusmn;\u0026thinsp;12.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.75\u0026thinsp;\u0026plusmn;\u0026thinsp;19.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.73\u0026thinsp;\u0026plusmn;\u0026thinsp;20.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.85\u0026thinsp;\u0026plusmn;\u0026thinsp;19.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eNote\u003c/b\u003e: body mass index (BMI), Short foot exercise (SF), Reactive Neuromuscular Training (RNT)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive Statistics of Biomechanical Variables\u003c/h2\u003e \u003cp\u003eDescriptive statistics (means and standard deviations) for all biomechanical variables at pre-test and post-test across the three groups are reported in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Visual inspection of the descriptive data suggests that the magnitude and direction of changes over time differed between groups. Overall, the SF\u0026thinsp;+\u0026thinsp;RNT group exhibited the most pronounced improvements from pre-test to post-test across several key biomechanical outcomes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive Statistics for Biomechanical Variables by Group and Assessment Time (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;Standard Deviation).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre-test Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePost-test Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePeak GRF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.62\u0026thinsp;\u0026plusmn;\u0026thinsp;2.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e15.13\u0026thinsp;\u0026plusmn;\u0026thinsp;2.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.97\u0026thinsp;\u0026plusmn;\u0026thinsp;4.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e14.49\u0026thinsp;\u0026plusmn;\u0026thinsp;3.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e12.94\u0026thinsp;\u0026plusmn;\u0026thinsp;3.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMoment DR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.52\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eLoading rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.76\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e16.20\u0026thinsp;\u0026plusmn;\u0026thinsp;3.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.24\u0026thinsp;\u0026plusmn;\u0026thinsp;2.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e20.09\u0026thinsp;\u0026plusmn;\u0026thinsp;4.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e14.64\u0026thinsp;\u0026plusmn;\u0026thinsp;2.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e22.46\u0026thinsp;\u0026plusmn;\u0026thinsp;3.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePlantar Flexion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e8.84\u0026thinsp;\u0026plusmn;\u0026thinsp;2.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e8.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e7.74\u0026thinsp;\u0026plusmn;\u0026thinsp;2.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e7.26\u0026thinsp;\u0026plusmn;\u0026thinsp;3.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e7.06\u0026thinsp;\u0026plusmn;\u0026thinsp;2.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e9.14\u0026thinsp;\u0026plusmn;\u0026thinsp;2.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eInversion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.60\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.92\u0026thinsp;\u0026plusmn;\u0026thinsp;1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.98\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e5.18\u0026thinsp;\u0026plusmn;\u0026thinsp;1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEversion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e4.74\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e5.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e4.76\u0026thinsp;\u0026plusmn;\u0026thinsp;1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e5.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.06\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eNote\u003c/b\u003e: Short foot exercise (SF), Reactive Neuromuscular Training (RNT), Dorsi Flexion (DR), Ground Reaction Force (GRF).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eMixed Repeated-Measures ANOVA\u003c/h2\u003e \u003cp\u003eThe results of the 3 (Group: Control, SF, SF\u0026thinsp;+\u0026thinsp;RNT) \u0026times; 2 (Time: Pre-test, Post-test) repeated-measures ANOVAs for each biomechanical variable are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eMain Effect of Time\u003c/strong\u003e \u003cp\u003eA significant main effect of Time was observed for Peak GRF, Moment DR, Loading Rate, Dorsi Flexion, Inversion, and Eversion (all p \u0026le; .001; see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). These results indicate that, regardless of group assignment, participants demonstrated significant changes in these variables from pre-test to post-test.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eMain Effect of Group\u003c/strong\u003e \u003cp\u003eA significant main effect of Group was found for Loading Rate, Dorsi Flexion, Inversion, and Eversion (p \u0026lt; .05; Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), indicating overall differences in these biomechanical measures between the groups across assessment times.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTime \u0026times; Group Interaction\u003c/strong\u003e \u003cp\u003eMost importantly, significant Time \u0026times; Group interactions were detected for Moment DR, Dorsi Flexion, Plantar Flexion, Inversion, and Eversion (p \u0026lt; .05; Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). These interactions demonstrate that the pattern of change from pre-test to post-test differed as a function of the intervention received.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe magnitude of these interaction effects, as indicated by partial eta squared (partial η\u0026sup2;), ranged from moderate to large, suggesting meaningful practical significance.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of Repeated Measures ANOVA\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime F(p)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup F(p)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTime\u0026times;Group F(p)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePartial η\u0026sup2;\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeak GRF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11.56 (0.001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.668 (0.518)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.09 (0.135)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.085\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoment DR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.37 (0.025)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.22 (0.304)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.26 (0.009)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLoading rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e66.52 (0.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.79 (0.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.12 (0.335)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.303\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39.50 (0.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.92 (0.001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.53 (0.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.298\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlantar Flexion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.91 (0.174)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.79 (0.178)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.62 (0.015)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.171\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInversion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31.10 (0.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.01 (0.011)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.19 (0.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.290\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEversion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21.28 (0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.73 (0.014)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.02 (0.001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.286\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eNote\u003c/b\u003e: \u003cem\u003edf\u0026thinsp;=\u0026thinsp;degrees of freedom; Partial η\u0026sup2; = partial eta squared\u003c/em\u003e, Dorsi Flexion (DR), Ground Reaction Force (GRF).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePost-hoc Analyses\u003c/h2\u003e \u003cp\u003eTo further examine the significant Time \u0026times; Group interactions, post-hoc between-group comparisons at post-test were conducted using Tukey\u0026rsquo;s HSD test. The results of these comparisons are presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eFor Moment DR, the SF\u0026thinsp;+\u0026thinsp;RNT group exhibited a significantly greater reduction compared with the Control group at post-test (p = .013), while the difference between the SF and Control groups approached statistical significance (p = .032; Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor DF, both intervention groups (SF and SF\u0026thinsp;+\u0026thinsp;RNT) demonstrated significantly greater improvements than the Control group at post-test (SF vs. Control: p = .027; SF\u0026thinsp;+\u0026thinsp;RNT vs. Control: p \u0026lt; .001; Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor Inversion, the SF\u0026thinsp;+\u0026thinsp;RNT group showed a significantly greater increase compared with the SF group (p = .015), whereas the difference relative to the Control group approached significance (p = .052; Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor Eversion, the SF\u0026thinsp;+\u0026thinsp;RNT group demonstrated a significantly greater reduction compared with the SF group (p = .011; Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNo significant between-group differences were observed at post-test for Peak GRF, Loading Rate, or Plantar Flexion (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05; Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePost-hoc Comparisons Between Groups at Post-test.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean Difference (I-J)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStd. Error\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSig.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePeak GRF\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl, SF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl, SF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF, SF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eMoment DR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl, SF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl, SF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF, SF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.929\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eLoading rate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl, SF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl, SF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.529\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF, SF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.705\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eDF\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl, SF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.619\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl, SF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.619\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF, SF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.619\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.477\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePlantar Flexion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl, SF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.691\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.194\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl, SF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.691\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.932\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF, SF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.691\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eInversion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl, SF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.274\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl, SF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.274\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF, SF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.274\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eEversion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl, SF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.301\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.549\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl, SF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.301\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.278\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF, SF\u0026thinsp;+\u0026thinsp;RNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.926\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.301\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote: Standard Error (SE), Confidence Interval (CI), Short foot exercise (SF), Reactive Neuromuscular Training (RNT), Dorsi Flexion (DR), Ground Reaction Force (GRF).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn summary, the results indicate that while some biomechanical variables changed over time irrespective of group, the combined SF\u0026thinsp;+\u0026thinsp;RNT intervention produced the most favorable pattern of change in key kinematic and kinetic variables. These findings highlight the differential effectiveness of the interventions on biomechanical outcomes.\u003c/p\u003e \u003cp\u003eRepeated measures ANOVA revealed three distinct patterns. First, for anxiety, quality of life, and well-being, significant time \u0026times; group interactions were found (PS\u0026thinsp;\u0026lt;\u0026thinsp;0.05), indicating differential effects of interventions across time. Second, for depression, stress, and coping skills, only the main effect of time was significant (PS\u0026thinsp;\u0026lt;\u0026thinsp;0.05), suggesting general changes over time regardless of group. Finally, self-esteem showed no significant changes across time or between groups (PS\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe present study demonstrated that exercise-based interventions, particularly the combination of with RNT, effectively improved foot biomechanics in adolescents with FFF. Meaningful adaptations were observed across several biomechanical variables, including Peak GRF, Moment DR, loading rate, ankle DF, plantarflexion, inversion, and eversion.\u003c/p\u003e \u003cp\u003ePeak GRF showed a significant main effect of time (p\u0026thinsp;=\u0026thinsp;0.001); however, no significant group or time \u0026times; group interaction effects were observed, and post hoc comparisons between the control, SF, and SF\u0026thinsp;+\u0026thinsp;RNT groups were not significant (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). These findings align with previous studies indicating that Peak GRF alone is not a sensitive marker for distinguishing FFF from normal foot function, as alterations are more commonly reflected in force distribution and temporal GRF characteristics rather than peak magnitudes \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Accordingly, Peak GRF should be interpreted in conjunction with complementary kinetic parameters such as loading rate.\u003c/p\u003e \u003cp\u003eA significant reduction in Moment DR was observed following SFE, with the greatest improvement occurring in the SF\u0026thinsp;+\u0026thinsp;RNT group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), indicating enhanced neuromuscular control of the ankle during stance and push-off phases \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. This improvement likely reflects improved coordination between dorsiflexor muscles and intrinsic foot musculature, leading to increased active stiffness of the medial longitudinal arch and reduced compensatory torque demands \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLoading rate decreased significantly from pre-test to post-test (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), despite the absence of significant group differences. Reduced loading rate represents improved shock absorption and slower force application at initial contact, which has been associated with a lower risk of lower-extremity injuries \u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. These findings suggest that SFE and RNT enhance foot shock-attenuation capacity even when Peak GRF remains unchanged.\u003c/p\u003e \u003cp\u003eAnkle kinematic adaptations included increased DF and decreased plantarflexion following the interventions, reflecting improved windlass mechanism function and reduced reliance on compensatory plantarflexion strategies commonly observed in FFF \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. Although reduced plantarflexion is often interpreted as mechanical inefficiency, the changes observed in this study appear to result from strengthened intrinsic foot muscles and increased arch stiffness, thereby improving force distribution during stance \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn the frontal plane, increased inversion and reduced eversion were observed following SFE, particularly in the SF\u0026thinsp;+\u0026thinsp;RNT group, indicating improved control of excessive pronation and enhanced rearfoot alignment \u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. These adaptations are consistent with previous findings demonstrating the role of intrinsic foot muscle activation in improving medial longitudinal arch stability in children with FFF \u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe combined SFE and RNT intervention appears to induce coordinated distal\u0026ndash;proximal adaptations, whereby improved intrinsic foot muscle function enhances center of pressure control, while proximal neuromuscular training contributes to improved lower-limb alignment. This interaction likely facilitates more efficient gait mechanics and reduces undesirable loading on the ankle and medial longitudinal arch \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSeveral limitations should be acknowledged, including the limited sample size, lack of control over daily physical activity, footwear, and environmental conditions, absence of long-term follow-up, and limited control over body weight, all of which may have influenced the outcomes.\u003c/p\u003e \u003cp\u003eThis study was limited to female participants aged 12\u0026ndash;15 years to control for sex- and age-related effects, which may restrict generalizability. Although testing procedures were standardized, environmental factors such as diet, daily physical activity, and rest patterns, as well as genetic differences and individual motivation levels, could not be fully controlled and may have influenced the results.\u003c/p\u003e "},{"header":"Conclusion","content":"\u003cp\u003eShort-term SFE interventions, particularly when combined with RNT, did not significantly alter Peak GRF but produced meaningful improvements in ankle moment control, reduced loading rate, increased ankle DF and inversion, and decreased plantarflexion and eversion. These biomechanical adaptations reflect enhanced shock absorption, improved neuromuscular control, and more efficient force distribution during gait, suggesting that combined SFE and RNT may be an effective strategy for improving gait biomechanics and reducing injury risk in adolescents with FFF.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFFF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFlexible flatfoot\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSFE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eShort Foot Exercises\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eROM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRange of Motion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRNT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eReactive Neuromuscular Training\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRandomized Controlled Trial\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCenter of Pressure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003edorsiflexion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGRF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGround Reaction Force\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody Mass Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all staff and participants in the present study for their valuable contributions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTaghizadeh G., data collection, literature study, information classification, methodology, statistical analysis, and writing. Shojaeddin S., supervisor, supervision, methodology, and conceptualization. Memar R., the idea of design and writing, and conceptualization. Jafari B., Guide to the research and monitoring process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset presented in the study is available on request from the corresponding author during submission or after its publication. The data are not publicly available due to privacy concerns and ethical restrictions related to participant confidentiality.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis single-blind, single-center, prospective randomized controlled trial was approved by the Ethics Committee of Kharazmi University (IR.KHU.REC.1404.051). The study was conducted at the Faculty of Physical Education and Sport Sciences, Kharazmi University, Tehran, Iran. All procedures adhered to the ethical principles outlined in the Declaration of Helsinki (2013 revision). The trial was prospectively registered in the Iranian Registry of Clinical Trials (IRCT) under the registration number IRCT20250610066157N1. Written informed consent was obtained from all participants before enrollment. All intervention sessions were supervised by a licensed physiotherapist to ensure participant safety and adherence to institutional ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMaster, Department of Biomechanical \u0026amp; Sports Injuries, Kharazmi University, Tehran, Iran\u003c/p\u003e\n\u003cp\u003eProfessor, Department of Biomechanical \u0026amp; Sports Injuries, Kharazmi University, Tehran, Iran\u003c/p\u003e\n\u003cp\u003eAssociate professor, Department of Biomechanical \u0026amp; Sports Injuries, Kharazmi University, Tehran, Iran\u003c/p\u003e\n\u003cp\u003ePhD, Department of Sports Injury and Biomechanics, Faculty of Sport Sciences and Health, University of Tehran, Tehran, Iran\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEvaluation and Comparison of the Upper. 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Gait Posture. 2020;75:40\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Flexible flatfoot, Short Foot Exercise, Reactive Neuromuscular Training, Ankle Biomechanics, Ground Reaction Force, Center of Pressure","lastPublishedDoi":"10.21203/rs.3.rs-8837911/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8837911/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFlexible flatfoot (FFF) is a prevalent musculoskeletal condition in adolescents and is associated with altered ankle\u0026ndash;foot kinematics, impaired shock absorption, and increased risk of lower-extremity injuries. Short Foot Exercises (SFE) have been shown to enhance intrinsic foot muscle function; however, the biomechanical effects of combining SFE with Reactive Neuromuscular Training (RNT) have not been sufficiently investigated.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis single-blinded, three-arm randomized controlled trial (RCT) included 48 adolescent girls (12\u0026ndash;15 years) with clinically diagnosed FFF. Participants were randomly assigned to an SFE group, an SFE combined with RNT (SF\u0026thinsp;+\u0026thinsp;RNT) group, or a control group. The intervention lasted eight weeks with three supervised sessions per week. Ankle kinematics were assessed using a three-dimensional motion capture system, and kinetic and center of pressure (COP) variables were collected using a force plate during barefoot walking. Outcome measures included ankle range of motion (ROM), moment dorsiflexion (DF), vertical ground reaction force (GRF) peak, loading rate, and frontal-plane ankle motion. Data were analyzed using mixed-design ANOVA with post hoc comparisons.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSignificant time \u0026times; group interactions were found for moment DF, ankle DF, plantarflexion, inversion, and eversion (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The SF\u0026thinsp;+\u0026thinsp;RNT group demonstrated the most pronounced improvements, including increased ankle DF and inversion, reduced eversion and plantarflexion, and a greater reduction in moment DF compared with the control group. Loading rate decreased significantly over time in both intervention groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), whereas Peak GRF showed no significant group or interaction effects.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAn eight-week SFE program improved ankle kinematic and kinetic parameters in adolescents with FFF, with superior outcomes observed when combined with RNT. This combined approach may enhance neuromuscular control, optimize gait biomechanics, and reduce injury risk in this population.\u003c/p\u003e\u003ch2\u003eTrial Registration:\u003c/h2\u003e \u003cp\u003eIRCT20250610066157N1 on 2025 / 07 / 04.\u003c/p\u003e","manuscriptTitle":"Effects of a Short Foot Exercise Program with and without Reactive Neuromuscular Training on Ankle Kinematics and Kinetics in Adolescents with Flexible Flatfoot","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-15 16:51:52","doi":"10.21203/rs.3.rs-8837911/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5403023a-723f-477d-acac-0a66a4dee3ee","owner":[],"postedDate":"March 15th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T10:42:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-15 16:51:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8837911","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8837911","identity":"rs-8837911","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}