Does Arch-Support Help Flat Feet?
Key insights: 60-second read
- Evidence for foot orthoses in flatfoot is surprisingly weak – A 2021 systematic review found only 12 low-quality studies, with most lacking robust methodology.
- "The common prescription of foot orthoses is surprising" – The researchers noted this given the lack of evidence and inconsistent diagnostic criteria.
- Orthotics create dependency – Long-term use may weaken intrinsic foot muscles and doesn't address proximal contributors like hip strength or ankle mobility.
- Active rehabilitation is key – Use orthotics as a temporary bridge, not a permanent crutch, while strengthening the entire kinetic chain.
As physiotherapists, we often see patients who have been told their flat feet are a lifelong problem requiring permanent arch supports. However, an interesting systematic review published in the Journal of Foot and Ankle Research challenges this common practice, revealing a significant lack of evidence supporting the long-term use of foot orthoses for adults with flatfoot. This research compels us to re-evaluate our approach and shift from passive support to active rehabilitation. (1)
Key Research Finding
After reviewing 110 studies, researchers found only 12 that met the inclusion criteria, with most being low-quality and lacking robust methodology. The review concluded there is a "lack of evidence on the effect of foot orthoses for flatfoot in adults" and that "the common prescription of foot orthoses is somewhat surprising" given this weak evidence base.
On this page
1. Study Overview and Methodology
This systematic review aimed to synthesise all available evidence on foot orthoses for adults with flatfoot. The researchers conducted a comprehensive search across multiple databases, including PubMed, Scopus, and PEDro, following established methodological frameworks and PRISMA guidelines to ensure transparency and minimise bias. (1)
Included Studies at a Glance
| Study Characteristic | Details |
|---|---|
| Total Studies Included | 12 out of 110 identified |
| Total Participants | 170 across all studies |
| Sample Sizes | Ranged from 8 to 80 participants |
| Study Designs | 9 repeated-measures, 1 RCT, 1 before-after, 1 non-randomized |
| Participant Age | Mostly young adults (18-45 years) |
2. Critical Gaps in the Evidence
The review highlighted several important limitations in the current research landscape:
- Inconsistent Terminology: Studies used terms like "orthotic device" and "foot orthoses" interchangeably, creating confusion
- Variable Diagnostics: Flatfoot was diagnosed using different methods across studies (static posture, radiographs, arch index, FPI)
- Missing Information: Most studies provided no information on wearing time, measurement timing, or symptom severity
- Diverse Outcomes: Studies measured different outcomes using various methods, making comparisons difficult
3. Key Research Findings and Clinical Implications
The review's findings have significant implications for how we approach flatfoot management in clinical practice.
The Evidence Gap in Orthotic Prescription
Despite foot orthoses being a standard conservative treatment for flatfoot deformity alongside exercise therapy, the review found "currently no guidelines or checklists for the prescription of foot orthoses for flatfoot". This lack of standardisation leads to inconsistent prescribing practices that range from purely clinical assessment to digital motion analysis and radiographic examination.
Questionable Long-Term Value
While some individual studies showed short-term biomechanical changes (such as altered plantar pressure distribution or reduced ankle eversion), the review authors noted these findings "must be interpreted with caution" due to methodological limitations and the absence of long-term follow-up data on functional outcomes or pain relief.
The Comfort and Adherence Factor
Only two of the twelve included studies assessed the comfort of wearing foot orthoses—a critical oversight since "discomfort may be an important factor influencing patients' adherence" to wearing orthoses as prescribed.
4. A Physiotherapist's Perspective: Time for a Paradigm Shift
This research validates what many forward-thinking clinicians have observed in practice: we need to stop treating arch supports as a permanent solution and start addressing the underlying causes of dysfunctional foot mechanics.
The Problem with Permanent Orthotics
- Creates Dependency: Telling patients they need to wear orthotics forever creates a cycle of dependency without addressing why the arch collapsed initially
- Potential for Weakening: Long-term use of external support may potentially lead to weakening of the intrinsic foot muscles that naturally support the arch
- Addresses Symptom, Not Cause: Orthotics treat the foot in isolation without considering proximal contributors from the ankle, knee, hip, or core
A Better Approach: Orthotics as a Bridge, Not a Crutch
In my clinical practice, I advocate for using orthotics strategically as part of a comprehensive rehabilitation plan:
- Short-Term Pain Management: Use orthotics temporarily if needed to reduce pain during initial rehabilitation phases
- Exercise Enabler: Implement supports that allow patients to engage in therapeutic exercises with less discomfort
- Weaning Strategy: Develop a structured plan to gradually reduce orthotic use as strength and mechanics improve
- Address the Kinetic Chain: Focus on hip and ankle mobility, hip rotational strength, and proper lower extremity alignment that influences foot posture
5. Study Limitations and Generalisability
Methodological Quality Concerns
The authors noted that "in most of the studies, the methodological quality was low and a lack of information was frequently detected". With only one randomised controlled trial identified, the potential for confounding and bias cannot be ruled out, limiting the strength of any conclusions.
Limited Participant Diversity
Most participants in the included studies were young adults, which may limit generalisability to older populations who often present with acquired flatfoot due to age-related changes or posterior tibial tendon dysfunction.
Inconsistent Outcome Measures
The review highlighted that "studies included assessed different outcomes and due to inconsistent outcome measurement, results are difficult to interpret". This lack of standardisation makes it challenging to draw firm conclusions about orthotic effectiveness.
Conclusion and Clinical Takeaways
This systematic review serves as an important wake-up call. The evidence supporting foot orthoses for adults with flatfoot is far weaker than commonly assumed, suggesting we need to reconsider our automatic reach for arch supports.
Rather than defaulting to permanent orthotics, a more effective approach involves comprehensive assessment of the entire kinetic chain, targeted strengthening of intrinsic foot muscles and proximal stabilisers, and using orthotics strategically as a temporary tool within an active rehabilitation program. As the researchers concluded, "Against this background, the common prescription of foot orthoses in adults with flatfoot is surprising" - and it's time we look to broaden our thinking in order to improve on this pattern long-term.
By shifting our focus from passive support to active rehabilitation, we can help patients develop resilient, functional feet capable of supporting themselves without lifelong dependence on external devices.
I genuinely hope this article offers a fresh perspective - or at least one useful takeaway. If you have a different issue, or simply want to learn more about how your body moves, head over to the Your Wellness Nerd YouTube channel. Subscribe if you feel inclined, and let me know in the comments what you'd like me to cover next.
– Grant
Frequently Asked Questions
Do foot orthoses actually work for flat feet?
A 2021 systematic review found surprisingly weak evidence. After screening 110 studies, only 12 low-quality studies met inclusion criteria. The researchers concluded there is a "lack of evidence on the effect of foot orthoses for flatfoot in adults" and called the common prescription "somewhat surprising."
Should I wear arch supports permanently?
Probably not. Long-term orthotic use may create dependency and potentially weaken the intrinsic foot muscles. A better approach is to use orthotics temporarily as a bridge while actively rehabilitating the entire kinetic chain—including hip strength, ankle mobility, and foot intrinsic muscles.
What are the limitations of the flatfoot orthotics research?
Key limitations include: low methodological quality, inconsistent diagnostic criteria, small sample sizes, lack of long-term follow-up, and no standardised outcome measures. Only one RCT was identified, and most studies didn't assess comfort - a critical factor for adherence.
What's a better alternative to permanent orthotics?
Active rehabilitation that addresses the whole kinetic chain. This includes strengthening intrinsic foot muscles, improving hip and ankle mobility, enhancing hip rotational strength, and correcting lower extremity alignment. Orthotics can be used temporarily to enable exercise, not as a lifelong crutch.
One profound insight from this post
"The common prescription of foot orthoses for adults with flatfoot is surprising given the lack of evidence. A paradigm shift from passive support to active rehabilitation - addressing the entire kinetic chain - is long overdue."
Reference:
(1) Herchenröder, M., Wilfling, D., & Steinhäuser, J. (2021). Evidence for foot orthoses for adults with flatfoot: a systematic review. Journal of Foot and Ankle Research, 14(1), 57. https://doi.org/10.1186/s13047-021-00499-z
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