Exercise programmes incorporating proximal kinetic-chain components in flexible flatfoot: a systematic review and meta-analysis of foot posture, neuromuscular, and dynamic outcomes.

PURPOSE: To evaluate the effects of exercise programmes incorporating proximal kinetic-chain components versus local or basic foot-ankle exercise in individuals with study-defined flexible flatfoot or low-arch/pronated-foot phenotypes. METHODS: PubMed, Web of Science, Scopus, and SPORTDiscus were searched from inception through 19 July 2026. Randomised controlled trials comparing exercise programmes incorporating proximal kinetic-chain components with local or basic foot-ankle exercise programmes were included. Random-effects meta-analyses used restricted maximum likelihood estimation. Risk of bias was assessed with RoB 2 and certainty of evidence with GRADE. RESULTS: Fourteen randomised trials reported in 15 publications were included; 13 trials (14 reports) contributed to at least one meta-analysis. Programmes containing proximal or kinetic-chain components were associated with lower navicular-drop values (11 trials, 410 participants; mean difference -2.34 mm, 95% CI -3.30 to -1.37; I²=84.6%; low-certainty evidence). The Foot Posture Index estimate was uncertain (4 trials, 157 participants; mean difference -1.67 points, 95% CI -3.36 to 0.01; I²=89.1%; very-low-certainty evidence). The exploratory Plantar Arch Index and all three exploratory Y-Balance estimates had confidence intervals including the null and very-low-certainty evidence. Evidence for muscle, plantar-pressure, gait, kinematic, patient-reported, adherence, and adverse-event outcomes was limited and mainly derived from individual trials. CONCLUSION: Programmes incorporating proximal kinetic-chain components may reduce short-term navicular drop compared with local or basic foot-ankle exercise programmes, but substantial heterogeneity limits confidence in the magnitude of this response; effects on FPI-6 remain uncertain. Evidence for dynamic, functional, and patient-reported outcomes remains insufficient. SYSTEMATIC REVIEW REGISTRATION: identifier CRD420261455079.