Foot Orthoses

Definition and Mechanics[edit | edit source]

ShoeCue insole.jpg

According to the Atlas of Orthoses and Assistive Devices, foot orthoses (FO) are like the tires on an automobile. They provide a critical, biomechanical contact point for the human body, and they can be helpful to correct problems in the foot, knee, hip, and spine''[1].

  • An orthosis is a single device, a group of them are referred to as orthoses.
  • We can use the term orthotic devices, but not orthotics as they refer to braces and splints.[2]

Foot orthoses were historically believed to work by correcting mechanical abnormalities that are observed visually - e.g. correcting a perceived ‘over-pronated foot’. However, more current understanding leans towards the therapeutic benefit being achieved from internal kinetic changes.

Tissue stress principals can be used to explain how orthoses work: i.e. altering the internal demands on the overloaded tissue through the use of proper orthoses can explain pain reduction and improvement in function in foot conditions with orthoses.[3]

There is also room for applying biopsychosocial modelling to foot orthoses.[3]

  • Understanding the patient's condition clearly and communicating effectively with them could have positive effects on the success of the orthoses.
  • Asking questions on how the patient feels about orthoses. If they have positive feelings, then using the orthoses could promote a therapeutic benefit. If they do not feel positive, then having an effective conversation can help determine the best route of treatment.[3]

Clinical Uses[edit | edit source]

The uses of orthoses vary from pain relief, comfort and enhancement of performance.

They are widely used in the treatment of different foot conditions:

Plantar Fasciitis insoles

Plantar Heel Pain[edit | edit source]

The use of foot orthoses for plantar heel pain is recommended by various research studies and reviews:

  • A best practice guide from 2022 by Morrissey et al.[4] found that core treatments for individuals with plantar heel pain should first include taping, stretching and individualised education. However, those who do not have sufficient improvements, "may be offered shockwave therapy, followed by custom orthoses."[4]
  • The Journal of Orthopedic Sports & Physical Therapy clinical practice guidelines[5] encourage the use of "foot orthoses, either prefabricated or custom fabricated/fitted, to support the medial longitudinal arch and cushion the heel in individuals with heel pain/plantar fasciitis to reduce pain and improve function for short- (2 weeks) to long-term (1 year) periods, especially in those individuals who respond positively to antipronation taping techniques."[5]
  • Wittaker et al. reviewed 19 clinical trials and reported moderate-quality evidence supporting the use of foot orthoses as an effective intervention at reducing pain in the medium term in plantar heel pain.[6]
  • A study by Bishop et al.[7] investigated the effect of wearing custom foot orthoses on: first-step pain; average 24-hour pain; and plantar fascia thickness in people with unilateral plantar fasciopathy over 12 weeks. The authors found improvement in first-step pain and reduced plantar fascia thickness over a period of 12 weeks compared to new shoes alone or a sham intervention.[7]
  • Rasenberg et al.[8] reviewed twenty studies investigating the effects of eight different types of foot orthoses on pain, function and self-reported recovery with plantar heel pain compared with other conservative interventions. Their findings suggested there isn't enough evidence to support the use of foot orthoses for plantar heel pain.[8]

Patellofemoral Pain Syndrome[edit | edit source]

A 2022 review and meta-analysis by Chen et al.[9] found that foot orthoses can significantly improve knee, sport and recreation function in individuals with patellofemoral pain syndrome (PFPS). The 2019 guidelines in the Journal of Orthopaedic & Sports Physical Therapy recommend that "clinicians should prescribe prefabricated foot orthoses for patients with greater than normal pronation to reduce pain, but only in the short term (up to 6 weeks)."[10] The use of foot orthoses should be combined with other interventions.[10]

The single leg squat or double leg squat can be used to assess for provocation of patellofemoral pain:[3]

  • If this test reproduces pain in the patellofemoral area, then the clinician asks the patient to repeat the test wearing a foot orthosis.
  • If this reduces the pain, it indicates that the patient might benefit from a foot orthosis.[11]

Another test that was developed to identify patients with PFPS who are likely to benefit from foot orthoses:

  • The width of the patient's foot is measured from a non-weight bearing position - this is then compared to standing mid-foot width.
  • If there is a great increase in midfoot width, then foot orthoses might help.[12] However, a study by Matthews et al. reported that the test is not reliable.[13]

Tibialis Posterior Tendon Dysfunction[edit | edit source]

Tibialis posterior is a powerful foot inverter (see image). A 2021 systematic review found that using orthoses in the early stages of tibialis posterior tendon dysfunction may reduce pain.[14] It has also been found that custom orthoses may be better than prefabricated foot orthoses for tibialis posterior tendon dysfunction.[15]

  • In case of dysfunction, an orthosis can be used to apply some external supinatory support and external inversion.
  • Theoretically, this will decrease the load on the tibialis posterior muscle.[3]

Peroneal Tendon Dysfunction[edit | edit source]

  • Opposite to the use of orthoses in tibialis posterior tendon pain.
  • It is possible to use an orthosis to provide an external eversion or pronatory force to the foot, which will hopefully have some therapeutic benefits.[3]

Midfoot Osteoarthritis[edit | edit source]

A carbon fibre type shell orthosis can reduce the amount of bending stress through the midfoot.

Achilles tendon.jpg

Achilles Tendinopathy[edit | edit source]

  • Wearing custom fit semirigid insoles for 4 weeks in combination with exercises has been found to reduce pain in Achilles tendinopathy patients.[16]
  • The use of higher heeled footwear and possibly orthoses can result in less load on the Achilles tendon compared to lower heeled and conventional footwear in runners.[17]
  • Theoretically, this could be applied to children with Sever's disease to assist in reducing the tensile pull around that growing calcaneum.[3]

Metatarsophalangeal (MTP) Joint Pathologies[edit | edit source]

MTP joint pathologies such as sesamoid problems, arthritic joints, hyper-extension injuries that are common in rugby and American football players may benefit from orthoses.

  • Depending on the pathology, foot orthoses can offload the area (e.g. in case of sesamoiditis) or offer support and reduce bending in case of capsular injuries.[3]

Plantar Plate Injury, Metatarsalgia and Freiberg Disease[edit | edit source]

  • A metatarsal dome can be used to shift the load away from the area of pain
  • The plantar plate could be used to reduce the reverse windlass phase time. This will reduce the tensile pull on the plantar fascia[3]

Prescribing Foot Orthoses[edit | edit source]

Time-frame[edit | edit source]

Footbalance Insole.jpg

The fear of dependency and overuse is often associated with prescribing orthoses. In some conditions, foot orthoses are recommended for long-term use or for patient's lifetime, such as in tibialis posterior dysfunction. However, in other conditions, they should only be used in the short term. For example, the patellofemoral pain guidelines recommended the use of foot orthoses for six weeks only.[10]

Prefabricated vs Customised[edit | edit source]

Prefabricated or off-the-shelf orthoses are often bought on the internet or at pharmacies. They come in various types and shapes such as full length, forefoot cut-outs and carbon polymer shells. There are various models and designs which allow the clinician and patient to choose freely depending on the desired therapeutic effect.

Prefabricated orthoses are recommended first before trying customised orthoses as you can always apply adaptations and test the results.[3] A clinical adaptation to individualising orthoses is tuning the dosage up or down to meet the demands. It is also important to consider the patient's feedback[3] and, for example, lower or increase the heel height.[7]

Several randomised controlled trials have shown prefabricated orthoses to have similar efficacy to customised orthoses in the management of plantar fasciitis.[3] A study by Pfeffer et al.[18] found prefabricated orthoses better in comparison to customised orthoses in the treatment of plantar fasciitis pain.[18] Another study found no difference between the two types of orthoses for the same condition.[19]

The Patellofemoral Pain 2019 guidelines reported insufficient evidence to recommend customised over prefabricated foot orthoses.[10]

Regardless of the type of orthoses, there are various considerations when choosing the type and design of the orthoses:

  • Body weight
  • Patient's beliefs
  • Current footwear
  • Activities[3]

Also, good clinical reasoning, detailed history taking, shared decision and communication play an integral role in the success of foot orthoses. Depending on the condition, orthoses should be combined with other interventions with considerations to the time-frame to avoid dependency and overuse.[3]

Why Do Some Clinicians Hesitate to Prescribe Foot Orthoses?[edit | edit source]

Some health professionals might be against the use of orthoses for the treatment of foot conditions. This might be due to to the fact that orthoses have been overused over time and the common belief that orthoses contribute to weakening the muscles. However, if they are prescribed properly and are tailored to the individual's needs and their condition, they can be a useful tool when combined with other interventions.[3]

An important point to consider is the difference between the use of orthoses in research and clinical practice. In some mechanical studies, customised orthoses are standardised and fabricated using scanning or casting method. Unlike in clinical practice, prescribing orthoses depends on the applied assessment of foot mechanics in the clinic, linking those findings to the presentation and applying corrections then testing their efficacy.[3]

In regards to muscle weakness, Jung et al.[20] reported an increase in cross-sectional area of abductor hallucis and flexor hallucis muscles in subjects with pes planus with a combined foot orthosis and short-foot exercises for 8 weeks. Contrary to this, a 2017 study by Protopapas[21] investigated the effect of a 12-week custom-made foot orthotic intervention on the intrinsic muscles of the foot and dynamic stability. The author found a significant reduction in the cross-sectional area of flexor digitorum brevis, abductor digiti minimi and abductor hallucis. The changes in the muscle size didn't affect the gait parameters and the dynamic stability which might indicate adaptations of these structures when off-loaded.[21]

References[edit | edit source]

  1. Fox JR, Lovegreen W. Lower Limb Orthoses. InAtlas of Orthoses and Assistive Devices 2019 Jan 1 (pp. 239-246). Content Repository Only.
  2. Merriam Webster Dictionary. orthotic definition. Available from: (accessed 28 May 2020)
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 Bruce K. Foot Orthoses: When, What and Why? course. Plus2020.
  4. 4.0 4.1 Morrissey D, Cotchett M, Said J'Bari A, Prior T, Griffiths IB, Rathleff MS, et al. Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values. Br J Sports Med. 2021 Oct;55(19):1106-18.
  5. 5.0 5.1 Martin RL, Davenport TE, Reischl SF, McPoil TG, Matheson JW, Wukich DK, McDonough CM, Altman RD, Beattie P, Cornwall M, Davis I. Heel pain—plantar fasciitis: revision 2014. Journal of Orthopaedic & Sports Physical Therapy. 2014 Nov;44(11):A1-33.
  6. Whittaker GA, Munteanu SE, Menz HB, Tan JM, Rabusin CL, Landorf KB. Foot orthoses for plantar heel pain: a systematic review and meta-analysis. Br J Sports Med. 2018 Mar 1;52(5):322-8.
  7. 7.0 7.1 7.2 Bishop C, Thewlis D, Hillier S. Custom foot orthoses improve first-step pain in individuals with unilateral plantar fasciopathy: a pragmatic randomised controlled trial. BMC musculoskeletal disorders. 2018 Dec 1;19(1):222.
  8. 8.0 8.1 Rasenberg N, Riel H, Rathleff MS, Bierma-Zeinstra SM, van Middelkoop M. Efficacy of foot orthoses for the treatment of plantar heel pain: a systematic review and meta-analysis. British journal of sports medicine. 2018 Aug 1;52(16):1040-6.
  9. Chen Z, Wu J, Wang X, Ren Z. The effect of foot orthoses for patients with patellofemoral pain syndrome: A systematic review and meta-analysis. Heliyon. 2022 Jun 6;8(6):e09656.
  10. 10.0 10.1 10.2 10.3 Willy RW, Hoglund LT, Barton CJ, Bolgla LA, Scalzitti DA, Logerstedt DS, et al. Patellofemoral pain: Clinical practice guidelines linked to the international classification of functioning, disability and health from the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2019 Sep;49(9):CPG1-95.
  11. Vicenzino B, Collins N, Crossley K, Beller E, Darnell R, McPoil T. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: a randomised clinical trial. BMC musculoskeletal disorders. 2008 Dec;9(1):27.
  12. Vicenzino B, Collins N, Cleland J, McPoil T. A clinical prediction rule for identifying patients with patellofemoral pain who are likely to benefit from foot orthoses: a preliminary determination. British journal of sports medicine. 2010 Sep 1;44(12):862-6.
  13. Matthews M, Rathleff MS, Claus A, McPoil T, Nee R, Crossley KM, Kasza J, Vicenzino BT. Does foot mobility affect the outcome in the management of patellofemoral pain with foot orthoses versus hip exercises? A randomised clinical trial. British Journal of Sports Medicine. 2020 Mar 25.
  14. Gómez-Jurado I, Juárez-Jiménez JM, Munuera-Martínez PV. Orthotic treatment for stage I and II posterior tibial tendon dysfunction (flat foot): A systematic review. Clin Rehabil. 2021 Feb;35(2):159-68.
  15. Chicoine D, Bouchard M, Laurendeau S, Moisan G, Belzile EL, Corbeil P. Biomechanical effects of three types of foot orthoses in individuals with posterior tibial tendon dysfunction. Gait Posture. 2021 Jan;83:237-44.
  16. Mayer F, Hirschmüller A, Müller S, Schuberth M, Baur H. Effects of short-term treatment strategies over 4 weeks in Achilles tendinopathy. British journal of sports medicine. 2007 Jul 1;41(7):e6-.
  17. Sinclair J, Richards J, Shore H. Effects of minimalist and maximalist footwear on Achilles tendon load in recreational runners. Comparative Exercise Physiology. 2015 Dec 7;11(4):239-44.
  18. 18.0 18.1 Pfeffer G, Bacchetti P, Deland J, Lewis AI, Anderson R, Davis W, Alvarez R, Brodsky J, Cooper P, Frey C, Herhck R. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot & Ankle International. 1999 Apr;20(4):214-21.
  19. Landorf KB, Keenan AM, Herbert RD. Effectiveness of foot orthoses to treat plantar fasciitis: a randomized trial. Archives of internal medicine. 2006 Jun 26;166(12):1305-10.
  20. Jung DY, Koh EK, Kwon OY. Effect of foot orthoses and short-foot exercise on the cross-sectional area of the abductor hallucis muscle in subjects with pes planus: a randomized controlled trial 1. Journal of back and musculoskeletal rehabilitation. 2011 Jan 1;24(4):225-31.
  21. 21.0 21.1 Protopapas K. The Effects of a 12-Week Custom Foot Orthotic Intervention on the Intrinsic Muscles of the Foot, and Dynamic Stability During Unexpected Gait Termination in Healthy Young Adults.