Arch Supports
Inserts
​Orthotics 

​What Are They?
Arch supports, inserts, and orthotics (foot orthoses) are devices placed inside footwear (or sometimes externally) to support, align, or change the function of the foot. They range from simple prefabricated insoles to custom-molded devices engineered to match a person’s foot anatomy and biomechanics.
Orthotics can serve many functions:

• Offload stress from painful areas
• Support or raise a collapsed arch
• Control excessive pronation or supination
• Improve alignment of the foot and lower limb
• Help redistribute plantar pressures
• Assist in symptom relief for various foot, ankle, and lower-extremity conditions

Because the foot is complex, orthotics are often used in conjunction with other treatments (e.g. exercises, footwear changes, manual therapy).


Why (Rationale) & When They’re Used (Indications)
Orthotics are prescribed when foot mechanics, structure, or pathology contribute to pain or dysfunction. Some common clinical scenarios include:

• Plantar fasciitis / arch pain: to reduce tensile loads on the plantar fascia
• Posterior tibial tendon dysfunction / adult acquired flatfoot: to support the medial arch and reduce progression
• Overuse / running injuries: especially when pronation or load distribution is abnormal
• Foot deformities, structural abnormalities: e.g. pes planus (flatfoot), pes cavus, leg-length discrepancy
• Arthritis, especially in foot and ankle: to offload painful joints
• Diabetic foot / ulcer prevention: as part of offloading strategies (especially in high-risk patients)
• Hallux valgus or first metatarsophalangeal pain: to shift loading or reduce joint stress

Orthotics are rarely a standalone cure; they are part of a comprehensive management plan.


Design & Types of Orthotics
Orthotics vary widely in material, rigidity, customization, and features. Some key distinctions:
Type
Characteristics
Pros & Cons
Prefabricated (off-the-shelf)
Mass-produced inserts available in common shapes and sizes
Lower cost, easy to try in clinic; may not match individual anatomy precisely

Custom-made / prescription orthoses
Made from molds, scans, or imaging of the patient's foot, tailored to geometry and biomechanics
Best fit and individualized control, but higher cost and need for adjustments

Semi-rigid / functional orthoses
Use of reinforced materials (e.g. shell plus polymer or carbon) to provide control but some flexibility
Balanced support with some compliance

Rigid orthoses / shell-based
Strong, firm materials for maximal control
Good for corrections but can be less forgiving and less comfortable

Soft / cushioning orthoses
Focus on shock absorption and comfort rather than structural correction
Useful in sensitive feet, arthritis, or cushioning needs

Modular / adjustable orthoses
Allow addition or removal of pads, wedges, or inserts
Good adaptability with evolving needs

Orthotic prescription may include features such as medial arch support, heel cups, forefoot posting, varus or valgus wedges, metatarsal pads, and cushioning zones. The design must consider shoe type, patient weight, activity level, and co-existent pathology.


Evidence & Efficacy
The scientific evidence for orthotics is complex and mixed. While many practitioners use them, rigorous, high-quality trials are still limited in many areas.
What the Literature Shows

• A systematic review on adult flatfoot and orthoses found inconsistent evidence and weak methodological quality in most studies. The review concluded that firm recommendations are difficult due to limited and heterogeneous data.
• Among runners, wearing foot orthoses is associated with immediate and long-term reductions in pain and symptoms of overuse injuries.
• In a meta-analysis of trials on foot orthoses and shock-absorbing insoles, orthoses were effective in reducing overall injuries and stress fractures, though they did not consistently prevent soft-tissue injuries.
• For patients with hallux valgus, functional orthoses (and taping) showed improvements in pain and function over up to six months.
• In posterior tibial tendon dysfunction (PTTD), articulated ankle-foot orthoses showed a 77% success rate in conservatively managing early-stage disease.
• A critical review of orthoses in rheumatoid arthritis highlighted that while orthoses may aid in comfort and symptom control, rigorous evidence remains limited, and the complex nature of RA (joint deformity, systemic disease) means they are a helpful adjunct, not a panacea.

In summary: orthotics can provide symptom relief, redistribution of forces, and biomechanical support in many patients, but they are not universally effective nor a substitute for addressing underlying pathology. Patient selection, proper fitting, and regular follow-up are key.


Application & Best Practices (Treatment Role)
To maximize benefit from orthotics, clinicians and patients should follow best practices:

1. Comprehensive evaluation
   • Assess foot posture, gait, alignment of knee/hip, leg-length, muscle strength and flexibility
   • Identify primary pain generators (e.g. plantar fascia, tendons, joints)
   • Consider co-factors such as obesity, activity level, footwear
2. Trial period & adaptation
   • Patients often need a break-in period (several weeks)
   • Start with shorter wear time, then gradually increase
   • Monitor for discomfort, pressure spots, or changes in symptoms
3. Integration with therapy
   • Orthoses are more effective when combined with exercises (strengthening, stretching), gait retraining, manual therapy, and proper footwear
   • Relying solely on orthoses without addressing soft-tissue dysfunction or alignment often limits outcomes
4. Regular reassessment
   • Adjust or replace orthoses as needed
   • Changes in weight, activity, or foot condition may require modifications
   • Monitor for signs of worsening (e.g. increasing pain despite orthoses)
5. Patient expectations
   • Orthotics often reduce symptoms, but do not necessarily “cure” underlying conditions
   • Some residual discomfort or activity limits may persist
   • Compliance is critical—many orthoses fail to help if patients stop wearing them
6. When to reconsider
   • Little or no improvement after adequate trial
   • Progressive structural pathology (severe arthritis, deformity)
   • Need to escalate to surgical or more invasive interventions

What Patients Can Expect

• Symptom relief: Many patients report reduced pain, improved comfort, and less fatigue, especially in the first few months.
• Adjustment period: Some mild discomfort is normal initially as foot adapts.
• Performance improvements: Especially in athletes or runners, orthoses may enhance stability, reduce overuse symptoms, and improve comfort.
• Variable long-term outcomes: Success depends on the match between orthosis design, individual biomechanics, and adherence. Not every patient will achieve full symptom resolution.
• Durability: Orthoses wear with use and may need replacement or adjustment every 1–5 years, depending on materials and usage.
• Expansion of therapy: Orthoses are often one component of a broader treatment strategy—patients should be prepared for complementary treatments.

 
References

1. Collins N, Bisset L, McPoil T, Vicenzino B. Foot orthoses in the prevention of injury in initial military training: a randomized trial. BMJ. 2009;339:b4724. https://doi.org/10.1136/bmj.b4724
2. Hume PA, Hopkins WG, Rome K, Maulder PS, Coyle G, Nigg BM. Effectiveness of foot orthoses for treatment and prevention of lower limb injuries: a review. Sports Med. 2008;38(9):759-779. https://doi.org/10.2165/00007256-200838090-00005
3. Landorf KB, Keenan AM, Herbert RD. Effectiveness of foot orthoses to treat plantar fasciitis: a randomized trial. Arch Intern Med. 2006;166(12):1305-1310.
4. Morrissey D, Cotchett MP, Rome K, et al. Management of plantar heel pain: a best practice guide. Br J Sports Med. 2021;55(19):1106-1118.
5. Koc T A Jr, Martin RL, Houck J, et al. Revision 2023 Clinical Practice Guideline: Heel Pain—Plantar Fasciitis. J Orthop Sports Phys Ther. 2023;53(2):CPG1-CPG38.
6. Uritani D, Tashiro Y, Mori T, et al. Foot orthoses and footwear interventions for adults with flatfoot: a systematic review. J Foot Ankle Res. 2021;14(1):23.
7. Bonanno DR, Murley GS, Munteanu SE, et al. Foot orthoses for the prevention of injury in naval recruits: a randomized trial. Br J Sports Med. 2018;52(5):298-302. https://doi.org/10.1136/bjsports-2016-097395
8. Rome K, Gray J, Stewart F, et al. Evaluating the clinical effectiveness and cost-effectiveness of foot orthoses in the treatment of plantar heel pain: a systematic review. J Foot Ankle Res. 2016;9:4. https://doi.org/10.1186/s13047-016-0132-1
9. Chiu MC, Wang MJ. Professional footwear and foot orthoses for people with rheumatoid arthritis: a narrative review. Rheumatology (Oxford). 2006;45(2):139-145.