Foot and Ankle Biomechanics in Individuals With Patellofemoral Pain: A Systematic Review and Meta-Analysis

Patellofemoral pain (PFP) is a common, multifactorial musculoskeletal condition that primarily affects young and physically active adults. Although previous studies have emphasized proximal and local impairments, the contribution of distal joint biomechanics remains unclear. This systematic review and meta-analysis aimed to determine whether biomechanical and clinical parameters of the foot and ankle differ between individuals with and without PFP. A systematic search was conducted in PubMed, ScienceDirect, SciELO, and SPORTDiscus. Studies comparing adults with and without PFP in distal joint outcomes, including muscle strength, kinematics, range of motion (ROM), plantar pressure, and clinical measures (e.g., navicular drop and foot mobility), were included. Methodological quality was assessed using a modified Downs and Black scale. Random-effects meta-analyses were performed using Hedges' g, and the level of evidence for each outcome was classified according to predefined criteria based on methodological quality, statistical significance, and between-study heterogeneity. Forty-two studies were included in the systematic review, and 38 were included in the meta-analysis, comprising 2314 participants (PFP: n = 1211; controls: n = 1103). Individuals with PFP demonstrated greater navicular drop (SMD = -0.46; p = 0.004), supported by strong evidence, although this finding was based on only four studies (PFP: n = 84; controls: n = 84). Greater rearfoot eversion during landing and step-down tasks, as well as greater ankle dorsiflexion during the step-down task, were also observed; however, these findings were supported by very limited evidence. No significant between-group differences were identified for ankle dorsiflexion ROM measured in clinical tests, foot posture index scores, or plantar pressure distribution. Overall, altered distal biomechanics, particularly greater navicular drop, appear to be associated with PFP. However, the available evidence remains limited for most outcomes, and the predominantly case-control design of the included studies precludes causal inference.