Effects of short-term foot orthoses application on walking kinematics and kinetics in adults with pronated feet: A systematic review with meta-analysis

Effects of short-term foot orthoses application on walking kinematics and kinetics in adults with pronated feet: A systematic review with meta-analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Effects of short-term foot orthoses application on walking kinematics and kinetics in adults with pronated feet: A systematic review with meta-analysis AmirAli Jafarnezhadgero, Ali Esmaeili, Seyed Hamed Mousavi, Urs Granacher This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3941166/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Foot orthoses (FO) are frequently used medical devices to correct lower limbs malalignment in the form of excessive foot pronation. This systematic review with meta-analysis aimed to investigate the effects of short-term FO application on walking kinematics and kinetics in adults aged ≥18 years with excessive foot pronation. Five electronic databases (MEDLINE, Scopus, PubMed, EMBASE, and Cochrane Central Register of Controlled Trials [CENTRAL]) were systematically searched from inception to January 2024. According to the PICOS approach, the eligibility criteria were: (P) healthy participants with pronated feet, (I) short-term FO interventions (one session), (C) other walking conditions (e.g., barefoot, only shoe, fake foot orthosis), (O) lower limbs kinematics (e.g., rearfoot eversion) and kinetics (e.g., knee joint moments) during walking, and (S) case-control studies, cross-sectional studies, randomized control trials, cohort studies, and case series designs. The modified version of the Downs and Black checklist was used to assess the methodological quality. Between-group standardized mean differences (SMDs) with 95% confidence intervals (CI) were computed using a random-effects model to elucidate the effects of short-term FO compared to controls. Statistical significance was set at p<0.05. The heterogeneity between studies was assessed using the I2 index. Twenty-two studies were identified and meta-analyzed. Overall, the methodological quality of the included studies was moderate, with 15 studies achieving high-quality and the remaining seven moderate quality. For kinematics, the meta-analysis showed significant effects of short-term FO application during walking on peak rearfoot eversion (nine studies: moderate SMDs=0.66, 95% CI 0.34 to 0.99), peak ankle dorsiflexion (five studies: small SMDs=-0.33, 95% CI -0.54 to -0.12), and eversion (seven studies: moderate SMDs=0.58, 95% CI 0.27 to 0.90). Concerning kinetics, the meta-analysis indicated significant effects of short-term FO application on the peak ankle eversion moment (five studies: small SMDs=0.38, 95% CI 0.17 to 0.59) and the peak knee adduction (six studies: small SMDs=-0.30, 95% CI -0.50 to -0.10). Study heterogeneity ranged from I² = 0-87%. Our meta-analysis showed significant effects of short-term FO application on the rearfoot eversion angle during walking in adults aged ≥18 years. Accordingly, the wearing of FOs can be recommended for adults with foot malalignment. However, between study heterogeneity was high for selected outcome parameters (e.g., peak ankle eversion). Therefore, more high-quality research is needed to elucidate the effects of short-term FO application on walking kinematics and kinetics as well as lower limbs muscular activation. Registration number: The protocol for this systematic review with meta-analysis was registered with PROSPERO on November, 17th 2023 (Project: https://www.crd.york.ac.uk/prospero/#myprospero, ID: CRD42023480039). Health sciences/Medical research/Study design Biological sciences/Physiology/Bone quality and biomechanics Health sciences/Health care/Diagnosis/Physical examination Gait Insoles Mechanics Pronation Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 1. Introduction Foot pronation can occur during standing, walking or running and is characterized by a multi-joint movement including the rear- and midfoot segments 1 . In dynamic situations, foot pronation serves as a shock absorber during the early to mid-stance phase of walking or running 2 . Excessive foot pronation however may cause lower limbs malalignment such as altered joint kinematics and pressure distribution of the plantar surface together with increased demands on the intrinsic foot muscles that control the arch deformation 3 . In this context, Levinger et al., reported that individuals with pronated feet demonstrated greater peak forefoot plantarflexion, forefoot abduction, and rearfoot internal rotation during walking compared to individuals with normal foot posture 4 . Another study indicated that calcaneal eversion resulted in increased hip flexion, medial rotation, and pelvic anterior tilt during the stance phase of walking 5 . Therefore, the treatment of excessive foot pronation is key to avoid acute and overuse injuries 6, 7 . Foot orthoses (FO) are often applied as therapeutic tools to treat excessive foot pronation and lower limbs malalignment 8, 9 . In addition, there is evidence from biomechanical research indicating that short-term FO application has a positive impact on the foot arch alignment 9 in the form of correcting talocalcaneal joint eversion, elevating the medial longitudinal arch (MLA), and suppressing foot elongation 10 . There is further evidence that short-term FO application results in acute improvements in direction and function of the arch during walking 11 by shifting the load from the forefoot and rearfoot towards the midfoot area 12 . Yet, the picture is not that clear and conflicting results exist in the literature on the short-term effects of FO treatment on walking kinematics and kinetics in individuals with pronated feet. While some studies reported significantly reduced rearfoot eversion angles due to FO usage 13, 14 , others found no difference between FO application and control condition 15, 16 . The reasons for the discrepancy in findings might be caused by methodological limitations such as heterogeneous study samples and different assessment protocols (e.g., walking speed, shoe type, foot model, etc.). Besides original research, a number of systematic reviews has been conducted over the past years, yet most of them were methodologically limited. The first systematic review with meta-analysis on the short-term effects of FO application on rearfoot eversion in individuals with pronated feet was conducted in 2011 17 . The authors found that particularly custom-made FOs were effective in controlling excessive foot pronation 17 . Another systematic review article focused on adults with flexible flat feet and found limited evidence supporting the long-term capacity of FOs to improve rearfoot kinematics (e.g., peak rear foot eversion) and kinetics (e.g., impact force) 18 . A more recent systematic review with meta-analysis found that short-term FO application in individuals with a medial forefoot or both a medial forefoot and a rearfoot posting resulted in lower peak rearfoot eversion angles in adults with flexible pes planovalgus (low level of evidence) 19 . These contradictory findings in original research and systematic reviews can, amongst others, be attributed to methodological limitations such as the definition of pronated feet. Previous systematic reviews 17-19 also considered the effects of short-term FO application on walking mechanics, including the evaluation of the navicular drop or the arch height index in individuals with pronated feet. However, the authors of the respective studies did not consider the methodological quality of different foot posture assessment methods 17-19 . Of note, some studies used the navicular drop method to assess foot mobility 20 but this test has been criticized lately because the navicular drop appears not to be a valid method for the assessment of foot posture 21 . Despite these critical reports on the navicular drop method, previous systematic reviews 17-19 included studies using the navicular drop as the preferred method for the assessment of foot pronation. Moreover , results of a previous study suggested that the foot posture index has strong predictive ability for dynamic rearfoot function 22 . Due to the described methodological limitations of previous systematic reviews and meta-analyses, it appears timely to update and aggregate the available literature on the short-term effects of FO application on walking kinematics and kinetics in adults with pronated feet to provide information for healthcare practitioners. Therefore, this systematic review with meta-analysis aimed to investigate the effects of short-term FO application (i.e., one session) on lower limbs kinematics and kinetics during walking in adults aged ≥18 years with excessive foot pronation. In the present systematic review with meta-analysis, studies were then categorized into five categories based on the applied foot pronation assessment method: (1) studies that used the foot posture index (FPI-6) or clinical observation; (2) studies that applied the foot print arch index; (3) studies that used the arch height index (including navicular drop, arch height index, navicular height normalized to foot length [NNHT]; (4) studies that applied the forefoot varus method; (5) studies that used the rearfoot eversion or rest calcaneal stance position (RCSP). By reporting findings according to the applied foot posture assessment method, readers receive a more differentiated picture on the effectiveness of the short-term application of FOs on walking kinematics and kinetics. 2. Methods When performing this systematic review with meta-analysis, we adhered to the standard PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines 23 . The protocol for this systematic review with meta-analysis was registered with PROSPERO on November, 17 th 2023 (Project: https://www.crd.york.ac.uk/prospero/#myprospero, ID: CRD42023480039). 2.1. Eligibility criteria EndNote 20 software (Bld 14672, Clarivate, Philadelphia, PA, USA) was used for the systematic search and the processing of potentially eligible papers. A PICOS (participants, intervention, comparators, outcomes, and study design) approach was applied to define inclusion and exclusion criteria (Table 1) a priori 24 . To be eligible for inclusion in this meta-analysis, articles had to be published in peer-reviewed journals in English language. Articles not written in English language were excluded (Table 1). Table 1 here 2.2. Information sources, search strategy The following five databases were systematically searched from inception to January 2024: MEDLINE, Scopus, PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL). The reference lists of published reviews and the identified studies were screened to find further potentially relevant papers. The search syntax was created using the PICOS scheme and free-text keywords as well as medical subject headings (Mesh terms). Keywords and Mesh terms were combined using a Boolean search syntax and the operators AND, OR. Searched keywords were included in Table 2. Table 2 here 2.3. Study selection All titles and abstracts were reviewed by two authors of this paper (A.E., and A.J.) to identify potentially eligible studies according to the a priori defined inclusion and exclusion criteria. In case titles and abstracts did not provide sufficient information, full-texts were examined. Any difference in the rating of the two authors was resolved through discussion with a third reviewer (SHM). 2.4. Quality assessment The methodological quality of the included studies was evaluated by the same two authors (A.E., A.J.) using a modified version of the Downs and Black checklist for non-randomized controlled trials 25 . The modified checklist includes 19 questions with eight reporting items (items 1, 2, 3, 4, 5, 6, 7, 10), two items for external validity (items 11 and 12), five items for internal validity (Bias) (items 14, 15, 16, 18, 20), three items for internal validity-confounding (items 21, 22, 25), and one item for power (item 27). The items were scored as 0 (“no” and “unable to determine”), 1 (“yes”), except for item 5 for the principal confounders which was scored 0 (“no”), 1 (“partially”), 2 (“yes”). The overall quality score of each study was calculated based on a percentage of the maximum score (20). In cases where there were discrepancies in the authors’ rating of the quality scores, consensus was reached through discussion. Studies with quality scores of 75% or higher were considered high quality, those with scores between 60% and 74% were classified as moderate quality, and those with scores of 60% or lower were categorized as low quality 26 . 2.5. Data collection One author (A.E.) extracted all relevant data according to the PICOS approach (population, foot posture measurement, study protocol, intervention, orthoses design, and outcomes related to kinematic and kinetic data) from the included articles. To reduce any errors in the extraction of data, all data were checked by the author (A.J.). Values of the peak, mean angle, and joint excursion were extracted and reported as kinematic variables. Joint moments were reported as kinetic variables. If more than one type of FO was examined, each FO type within the study was allocated simple identification (A, B etc.). In case study authors did not report outcomes, we attempted to obtain them directly through the corresponding author or a freeware web-based plot digitizer 27 to obtain data from graphs. Next, we categorized the data based on the specific foot assessment methods and compared the movement and force variables for each joint for both the FO and control conditions. The key outcomes according to validity and function are reported in the text, secondary outcomes in supplementary materials. 2.6. Statistical analyses Quantitative data synthesis was conducted using the Cochrane Review Manager (Version 5.1). To examine the main research question, standardized mean differences (SMDs) with 95% confidence intervals (CI) were computed as effect size measures using a random-effects model to elucidate the effects of short-term FO application compared to controls on kinematic and kinetic variables during walking. SMDs were categorized as trivial (0–0.2), small (0.2–0.5), moderate (0.5–0.8), and large (> 0.8) 28 . Study heterogeneity was assessed using the I 2 index. The level of heterogeneity was classified as high (> 75%), moderate (50%–75%), and low (25%–50%) 29 . 3. Results 3.1. Study selection The initial search identified 13,441 studies. After duplicate removal, 5,362 studies remained. Following the screening of titles and abstracts, 43 full texts were further considered. Finally, 22 studies were eligible to be included in this systematic review with meta-analysis. Quantitative analyses were computed with all 22 articles. Fig 1 presents a PRISMA flow chart and illustrates the study selection process. Studies were then categorized according to the applied foot pronation assessment methods: (1) using the foot posture index (FPI-6) or clinical observation; (2) using the foot print arch index; (3) using the arch height index (including the navicular drop, the arch height index, the navicular height normalized to foot length [NNHT]); (4) the forefoot varus method; (5) the rearfoot eversion or rest calcaneal stance position method (RCSP). Fig. 1 . PRISMA flow diagram of studies included in this systematic review with meta-analysis 3.2. Study characteristics Table 3 shows the characteristics of the included studies. The identified studies used different types of foot posture measurements (i.e., FPI-6, clinical observation, foot print arch index, navicular drop, arch height index, NNHT, forefoot varus, rearfoot eversion, RCSP) and different foot models for kinematic and kinetic analyses. For instance, six studies were identified with the FPI-6 or clinical observation 14, 30-34 , three with the foot print arch index 35-37 , six with the arch height index 3, 9, 15, 38, 39 , four with the forefoot varus method 13, 16, 40, 41 ; two with the rearfoot eversion or RCSP method 42, 43 . Tang et al. 37 reported values for participants with and without pronated feet. For the purpose of this study, we only extracted data for the foot pronation group. If authors reported multiple values for peak or mean joint excursion in different phases, we only included the phase with the higher value 14, 34, 35, 42 . Additionally, we reported numerical values for all types of foot orthotics used in the respective studies 13-16, 30-33, 38-42, 44 . We extracted data from graphs out of five studies 15, 30, 31, 33, 43 . The outcome measures peak rearfoot eversion angle, peak ankle eversion and dorsiflexion angle, peak ankle eversion moment and knee adduction moment were reported in five or more than five studies. The remaining outcome measures with lower clinical relevance were included in the supplementary material (Supplementary File: Appendix 1-27). Table 3 here 3.3. Quality assessment The methodological quality of the included 22 studies amounted to 74% on the modified version of the Downs and Black checklist 25 . This is indicative of moderate methodological quality (Table 4). Among the 22 included studies, 15 were rated high quality 3, 9, 14-16, 30, 32, 33, 35, 36, 39-42, 45 , and seven moderate quality 13, 31, 34, 37, 38, 43, 44 . Only two study 14, 31 involved assessors who were blinded for the experimental condition (FO or control) during testing. Authors from eleven studies 3, 9, 15, 16, 30, 35, 39, 41, 42, 45 reported the calculation of a priori power analysis to estimate the sample size. Table 4 here 3.4. Effects of short-term FO application on lower limbs kinematics 3.4.1. Rearfoot Nine studies reported the effects of short-term FO application on peak rearfoot eversion 3, 13, 14, 16, 37, 39, 40, 43, 44 . Findings indicated moderate effects of short-term FO application. The analysis further revealed moderate level of heterogeneity (moderate SMDs=0.66, 95% CI 0.34 to 0.99, p<0.0001, I 2 =71%). More specifically, across the nine included studies, the peak rearfoot eversion was 1.72° (95% CI 1.01 to 2.44) lower in the FO condition compared to control (Fig 2). The subgroup analyses taking the methodological approach for the assessment of foot pronation into account showed no significant effect of short-term FO wearing for the studies that assessed foot posture using the arch height index 3, 39 (2 studies: SMDs=0.42, 95% CI -0.20 to 1.05, p=0.18) or the foot print arch index 37 (1 study SMDs=0.64, 95% CI -0.26 to 1.55, p=0.16). Yet, we observed significant effects of short-term FO application in studies that used the forefoot varus method 13, 16, 40 (3 studies: small SMDs=0.36, 95% CI 0.13 to 0.6, p=0.002), the FPI-6 or clinical observation 14, 44 (2 studies: large SMDs=1.42, 95% CI 0.20 to 2.63, p=0.02, I 2 =87) and the rearfoot eversion or RCSP methods 43 (1 study: large SMDs=1.28, 95% CI 0.39 to 2.17, p=0.005) for determination of foot pronation (Fig 2, Table 5). Fig. 2. Forest plot illustrating the effects of short-term application of foot orthoses (intervention) versus control on peak rearfoot eversion during walking in individuals with pronated feet. The subtotal effect for each parameter and the total effect were calculated as standardized mean difference (95% CI). SD: Standard deviation; Std: Standardized; CI: Confidence interval. 3.4.2. Ankle Peak ankle dorsiflexion was measured in five studies 9, 31, 32, 35, 42 . Overall, our findings indicated small effects of short-term FO application (5 studies: small SMDs=-0.33, 95% CI -0.54 to -0.12, p=0.002, I 2 =0%). More specifically, the mean (five studies) peak ankle dorsiflexion was 0.61° (95% CI 1.05 to 2.75) lower in the FO compared to the control condition (Fig 3). The subgroup analyses showed no significant effects of short-term FO treatment in the studies that assessed foot posture using the arch height index 9 (1 study: SMDs=-0.19, 95% CI -1.03 to 0.65, p=0.18) or the foot print arch index 35 (1 study: SMDs=0.42, 95% CI -0.30 to 1.15, p=0.26). Significant effects of short-term FO application were found for the studies that used the FPI-6 or clinical observation 31, 32 (2 studies: small SMDs=-0.42, 95% CI -0.72 to -0.12, p=0.007, I 2 =0%) and rearfoot eversion or RCSP 42 (1 study: small SMDs=-0.42, 95% CI -0.78 to -0.06, p=0.02, I 2 =0%) to determine the foot posture (Fig 3, Table 5). Fig. 3. Forest plot of the effects of short-term foot orthoses application (intervention) versus control on peak ankle dorsiflexion during walking in individuals with pronated feet. The subtotal effect for each parameter and the total effect were calculated as standardized mean difference (95% CI). SD: Standard deviation; Std: Standardized; CI: Confidence interval. Peak ankle eversion was measured in seven studies 13, 30-33, 35, 40 . Based on findings from the seven included studies, the analysis indicated significant moderate effects of short-term FO treatment (moderate SMDs=0.58, 95% CI 0.27 to 0.90, p=0.0003) (Fig 4) with a moderate level of study heterogeneity (I 2 =72%). More specifically, the mean (7 studies) peak ankle eversion was 1.10° (95% CI 0.58 to 1.62) lower in the FO condition compared to control. The subgroup analysis showed no significant effect of short-term FO application in the studies that assessed foot posture using the foot print arch index 35 (1 study: SMDs=0.55, 95% CI -0.18 to 1.28, p=0.14). Significant effects were observed for the studies that used the FPI-6 or clinical observation 30-33 (4 studies: moderate SMDs=0.68, 95% CI 0.13 to 1.23, p=0.01, I 2 =83%) and forefoot varus 13, 40 (2 studies: moderate SMDs=0.5, 95% CI 0.24 to 0.77, p=0.0002, I 2 =0%) to determine foot pronation (Fig 4, Table 5). Fig. 4. Forest plot of the effects of short-term foot orthoses application (intervention) versus control on peak ankle eversion during walking in individuals with pronated feet. The subtotal effect for each parameter and the total effect were calculated as standardized mean difference (95% CI). SD: Standard deviation; Std: Standardized; CI: Confidence interval. 3.5. Effects of short-term FO application on lower limbs kinetics 3.5.1. Ankle Five studies reported peak ankle eversion moment in Nm/kg. Overall, the analysis indicated no evidence of study heterogeneity (I 2 =0%) and yielded significant differences between short-term FO application and control (5 studies: small SMDs=0.38, 95% CI 0.17 to 0.59, p=0.0004) (Fig 5). The applied subgroup analysis showed a significant difference only for the one single study that used the arch height index 39 (Fig 5, Table 5). More specifically, the peak ankle eversion moment was 0.07 Nm/kg (95%CI 0.04 to 0.11) larger in the control condition. Fig. 5. Forest plot illustrating the effects of short-term foot orthoses application (intervention) versus control on peak ankle eversion moment during walking in individuals with pronated feet. The subtotal effect for each parameter and the total effect were calculated as standardized mean difference (95% CI). SD: Standard deviation; Std: Standardized; CI: Confidence interval. 3.5.2. Knee Six studies reported the effects of short-term FO application on peak knee adduction moments 9, 30-33, 45 . For the FPI-6 and the clinical observation assessment of foot posture, the mean (4 studies) peak knee adduction moment was 0.04 Nm/kg (95% CI -0.07 to -0.02) greater in the FO compared to the control condition (Table 5). For the arch height index, findings did not reach the level of significance (2 studies) (Fig 6). Overall, there was a significant small effect of short-term FO application on the knee adduction moment (6 studies: SMDs=-0.30, 95% CI -0.50 to -0.10, p=0.004, I 2 =0%) (Fig 6, Table 5). Fig. 6. Forest plot illustrating the effects of short-term foot orthoses application (intervention) versus control on peak knee adduction moment during walking in individuals with pronated feet. The subtotal effect for each parameter and the total effect were calculated as standardized mean difference (95% CI). SD: Standard deviation; Std: Standardized; CI: Confidence interval. Table 5 contains a summary of the meta-analytical finding according to the applied methods that were used to assess foot pronation. Table 5 here 4. Discussion This systematic review with meta-analysis aimed to examine the effects of short-term FO application (one session) on walking kinematics and kinetics in adults aged ≥ 18 years with excessive foot pronation by taking different foot posture assessment methods into account. With regards to lower limbs kinematics, the meta-analysis showed significant effects of short-term FO application on peak rearfoot eversion, peak ankle dorsiflexion and eversion. In terms of lower limbs kinetics, the meta-analysis revealed significant effects of short-term FO application on the peak ankle eversion moment and the peak knee adduction moment. The main finding of this meta-analysis was that the short-term wearing of FO produces lower rearfoot control by 1.72° compared with control conditions in adults with excessive foot pronation. Lower limbs kinematic changes due to short-term FO application have previously been interpreted as clinical improvements as the medical device contributes to alleviating tissue stress 46, 47 . However, whether a FO-related change of 1.72° in lower rearfoot control is clinically relevant, remains to be elucidated. Accordingly, more high-quality research is needed in this growing field. 4.4. Effects of short-term FO application on lower limbs kinematics and kinetics during walking 4.4.1. Rearfoot Our meta-analysis revealed that the short-term application of FOs resulted in significantly lower peak rearfoot eversion and therefore less excessive foot pronation 3, 13, 14, 16, 37, 39, 40, 43, 44 . Findings from this meta-analysis showed significant effects of short-term FO application on the peak rearfoot eversion angle only in those studies that used the forefoot varus method for the assessment of foot pronation 13, 16, 40 , the FPI-6 or clinical observation 14, 44 , and the rearfoot eversion method or RCSP 43 . Reducing calcaneal eversion is a viable and achievable biomechanical target 17 . Adult individuals with excessive foot pronation lack a medial longitudinal arch to cushion the body mass during the stance phase of standing, walking, running due to an arch collapse caused by several congenital factors or other acquired predisposing factors 48 . Abnormal plantar pressure leads to discomfort in flat feet, which, if left untreated, will produce pain and disability 49 . The available evidence in the literature is weak with regards to the association between FO-related improved motion control and reduced injury rates in individuals with pronated feet 50 . It has been hypothesized that the acquired flat foot and excessive rearfoot motion regularly seen in inflammatory conditions such as rheumatoid arthritis 51, 52 are related to ultrasound and MRI confirmed features of joint and tendon damage, particularly those involved in controlling the frontal plane motion of the foot 53, 54 . While cause and effect relations have not been fully established, there is good evidence from randomized controlled trials that an early intervention using customized FO devices results in lower abnormal kinematics and improved patient reported outcomes such as pain 55, 56 . 4.4.2. Ankle Based on the results of this meta-analysis, short-term FO application resulted in a significant difference in the peak ankle dorsiflexion 9, 31, 32, 35, 42 and eversion in the FO versus control condition during walking 13, 30-33, 35, 40 . In addition, our analysis revealed a significant effect of FO versus control on ankle joint dorsiflexion in those studies that used the FPI-6 or clinical observation 31, 32 and the rearfoot eversion method or RCSP 42 to assess foot pronation. Furthermore, subgroup meta-analysis of peak ankle eversion showed significant effects of FO only in the studies that used the FPI-6 or clinical observation 30-33 and forefoot varus for determine foot pronation. The meta-analysis yielded significant differences between the FO and control conditions in the peak ankle eversion moment. Subgroup analyses showed significant differences only in one study that used the arch height index. Medial FOs are designed to position the heel bones vertically to the ground, bring the calcaneus back to normal alignment with the shank, and maintain the subtalar joint in the neutral position; thus, they can be used to prevent pronation and excessive movement of the whole foot 34, 42 . Genova and Gross 57 assumed that using the posting might be associated with clinical improvements. To compensate for the reduction in rearfoot eversion, and since rearfoot and midfoot frontal motion are strongly coupled 58 , an increase in midfoot eversion was observed when using the posting 59 . Increasing the stiffness at the medial arch may therefore help to better control midfoot frontal plane motion. In addition, the greater forefoot inversion that usually accompanied the higher rearfoot eversion in individuals with pronated feet was lower in this study 59 . Alsaafin and colleagues manufactured rigid FOs based on Blake's inverted orthotic technique 42 . This technique aims to invert the rearfoot and pronate the forefoot through the subtalar joint and longitudinal axis of the midtarsal joint to straighten the heel back to vertical. During walking, the ankle joint undergoes specific movements throughout the gait cycle. At heel strike, the ankle joint is initially and slightly dorsiflexed, but it rapidly plantarflexes until the foot is flat on the ground (loading response). This mechanism aids for shock absorption and facilitates the immediate acceptance of body mass during this phase. As the gait cycle progresses, the ankle gradually transitions from plantarflexion to a neutral position and then further into dorsiflexion during the mid-stance phase. Finally, at the toe-off, the ankle returns to a plantarflexed position, which assists for propulsion 60, 61 . Chen et al. 9 observed lower peak ankle plantarflexion angles and moments when walking with foot insoles compared with controls in individuals with pronated feet. This reduction can be attributed to the control of foot motion provided by the orthoses, suggesting a positive impact on foot mechanics by limiting excessive ankle movements 42 . This is particularly relevant for individuals with pronated feet, as excessive ankle motions during flatfooted walking can impair shock absorption and increase stress on the foot structures. The magnitude of the joint moment during walking could be considered a good indicator of injury prevention 62 . A biomechanical aspect directly affected by the FO is that the use of a smaller evertor moment could positively reduce injury risk induced through muscle fatigue or overuse 63 . The results from our meta-analysis showed that peak everted moments of the ankle joint in the FO conditions were significantly smaller than those of the normal condition. 4.4.3. Knee Our meta-analysis showed that there was a significant small effect of short-term FO application on the knee adduction moment during walking. Moreover, the analysis revealed effects of short-term FO application on the peak knee adduction moment if the FPI-6 method or clinical observation were used to assess foot posture. Using a three-dimensional moment analysis, Jafarnezhadgero et al. 64 showed that FOs may lower the ankle evertor moment, knee and hip abductor moment, and hip flexor moment in the dominant lower limbs of children during walking. Our study revealed that the medially FO resulted in greater knee adduction moment. Whilst we did not observe a change in the knee adduction angle, this might be due to the fact that we assessed the short-term effects of FO usage. In a longitudinal approach, it can be hypothesized that the change in adduction moments might produce a change in adduction knee motions. If so, this would lead to changes in the distribution of load between the medial and lateral femoral-tibial compartments. For example, Kostuik et al. 65 found that a 3° change in knee adduction motion was needed to totally unload the lateral compartment of osteo-ligamentous cadaver knees. Lack S, and colleagues found that the effects of FOs were significantly lower for knee internal rotation during a step-up task in individuals with patellofemoral pain 66 . These authors described that a change in knee kinematics appears to be associated with an altered rearfoot kinematics, as the subtalar joint provides an anatomical connection between the talus and the tibia. Of note, the knee joint is a hinge-type synovial joint, which mainly allows motion in sagittal plane and a limited motion in the frontal and transversal planes. In contrast, the hip and ankle joints allow angular motion in multiple directions and rotational movements. Thus, the observed changes may likely occur in the hip and ankle joints rather than the knee joint. In this context, Chen et al. 9 showed that custom-made insoles produced significant changes in ankle joint angles but had only minor effects on the knee and hip joint kinematics in adults during walking. Similarly, Nester et al. 67 demonstrated that both medially and laterally wedged FOs had the greatest effect on the kinematics and moments of the rearfoot complex, while the knee, hip, and pelvis were generally unaffected. 4.5. Clinical implications This meta-analysis revealed a lower peak rearfoot eversion angle (~ 1.72°) when using FOs compared to control. This device-related change has previously been hypothesized to be linked to clinical improvements in individuals with pronated feet 47 . Nevertheless, the association of kinematic changes with clinical benefits, especially from midfoot and forefoot control, is constrained by only one study 46 . Since the lower limbs act as a closed kinematic chain, significant angular changes in the ankle joint are translated to more proximal joints 68, 69 . A possible explanation is that FOs might indirectly affect the knee, hip, and pelvis kinematics by altering the proprioceptive mechanisms involved in regulating muscle function within these joints 70 . Although FOs are prescribed to alter foot abnormality in individuals with pronated feet, they may affect the mechanics of the above lying (more proximal) joints 14, 68, 69 . Indeed, there is evidence that the application of FOs improves knee and pelvic angles in the sagittal plane during the stance phase of walking 68, 69 . Park et al. 68, 69 suggested that the joint modifications were due to the rearfoot inversion allowed by a lower plantar and fascia muscle tension and an elevation of the talus joint. However, there is preliminary evidence that medially posted FOs may have adverse effects in the form of greater knee adduction moments 14 . Indeed, Telfer et al found that a lower rearfoot eversion, induced by s medially posted FO, was not only associated with a lower rearfoot eversion moment but also a greater knee adduction moment 14 . Since greater moments have been associated with the development and progression of medial compartment knee osteoarthritis 71 , medially posted FOs should be prescribed with caution. Moreover, a dose-response effect exists between the level of posting and the ankle and knee joint biomechanics, as a higher medially posted device results in a lower rearfoot eversion and a greater knee adduction moment 14 . In contrast, Cheung et al. 17 reported that custom-made FOs are more effective than prefabricated FOs. The authors argued that the personalized device enables adaptations through biomechanical changes which are more effective in the correction of the foot posture. Indeed, a FO with a contoured medial arch has been shown to prevent the deformation of the medial longitudinal arch and it may lead to lower foot pronation during walking 14 . Accordingly, new technologies, such as additive manufacturing (i.e., 3D printing), must be considered as they allow the production of custom shapes and geometries which is impossible through traditional fabrication techniques. Therefore, 3D printing appears to allow new options for individualized FO fabrication 14 . 4.6. Limitations and methodological considerations Due to a limited number of studies, we were unable to examine and aggregate the effects of short-term FO application on muscular activities and plantar pressure. These neuromuscular or pressure-sensitive outcome measures would additionally provide information on the underlying mechanisms responsible for FO-related changes in foot posture. Another limitation of this systematic review is that we only examined the effects of short-term FO application on walking mechanics but not running and standing mechanics. Again, the number of available studies did not allow to meta-analyze these experimental conditions. Of note, greater foot pronation and ground reaction forces have been reported during running compared with walking which is why a transfer from one physical activity mode (walking) to the other (running) appears possible 72, 73 . Another limitation is that the materials used for the FOs were not quantitatively considered in our meta-analysis. Instead, we reported qualitative information in regards of FO material for each study in Table 3. We further noted that the authors from the included studies applied different types of foot posture assessment methods. We tried to deal with this potential cause of bias by reporting our findings in the context of the respective foot posture method. Notably, we observed greater effects of short-term FO application on walking mechanics in the studies that used the FPI-6 to measure foot posture. A previous study reported that the FPI-6 method is a highly reliable (intraclass correlation coefficient [ICC] = 0.93) approach to be used for the assessment of foot posture. In contrast, the navicular drop method appears to be less reliable with an ICC=0.40 21 . Our meta-analysis included studies that assessed the effects of short-term FO application on walking kinematics and kinetics while walking barefoot, with sandals, or in standardized shoes. This could have affected the outcomes of our meta-analysis as well. Finally, several included studies (n=11) did not compute a priori sample size calculations. Therefore, it is attainable that some were underpowered to detect actual FO effects. Besides the influence of these methodological aspects, it should be kept in mind that each participant responds uniquely to the wearing of FOs 74, 75 . 5. Conclusions Our findings highlight the effects of short-term FO application (one session) versus control on lower limbs kinetics and kinematics during walking in adult individuals (≥18 years) with excessive foot pronation. Results from this study showed that FO application compared with control resulted in lower peak rearfoot eversion and peak ankle dorsiflexion and eversion angles. This meta-analysis further revealed that the peak ankle eversion moment was greater in the control condition and the peak knee adduction moment turned out to be larger in the FO condition. Since previous research showed particularly high test-retest reliability measures for the FPI-6 method 21 , we recommend to uniformly use this type of foot posture measure in future studies. In addition, the present study revealed the need to better standardize participant recruitment and the FO assessment protocol. This should make the management of individuals with pronated feet easier in the future for health practitioners. Declarations Authors’ contributions AE collected the data, analysed the data, and wrote the manuscript; AAJ analysed the data and wrote the manuscript; SHM collected the data and wrote the manuscript; UG analysed the data and wrote the manuscript. All authors have read and approved the final version of the manuscript, and agree with the order of presentation of the authors. Competing interests The authors declare that they have no competing interests. Declaration of interest None. Funding None. Financial interests The authors declare they have no financial interests. Data availability statement The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. References Lundberg A, Svensson OK, Bylund C, Goldie I, Selvik G. Kinematics of the ankle/foot complex—part 2: Pronation and supination. Foot & ankle 1989; 9 :248-53. Lafortune M, Cavanagh P, Sommer III H, Kalenak A. Foot inversion‐eversion and knee kinematics during walking. Journal of orthopaedic research 1994; 12 :412-20. Bishop C, Arnold JB, May T. Effects of taping and orthoses on foot biomechanics in adults with flat-arched feet. Medicine and science in sports and exercise 2016; 48 :689-96. Levinger P, Murley GS, Barton CJ, Cotchett MP, McSweeney SR, Menz HB. A comparison of foot kinematics in people with normal-and flat-arched feet using the oxford foot model. Gait & posture 2010; 32 :519-23. Tateuchi H, Wada O, Ichihashi N. Effects of calcaneal eversion on three-dimensional kinematics of the hip, pelvis and thorax in unilateral weight bearing. Hum mov sci . 2011, p. 566-73. Farahpour N, Jafarnezhad A, Damavandi M, Bakhtiari A, Allard P. Gait ground reaction force characteristics of low back pain patients with pronated foot and able-bodied individuals with and without foot pronation. Journal of biomechanics 2016; 49 :1705-10. Jafarnezhadgero AA, Sorkhe E, Oliveira AS. Motion-control shoes help maintaining low loading rate levels during fatiguing running in pronated female runners. Gait & posture 2019; 73 :65-70. Leung A, Mak A, Evans J. Biomechanical gait evaluation of the immediate effect of orthotic treatment for flexible flat foot. Prosthetics and orthotics international 1998; 22 :25-34. Chen Y-C, Lou S-Z, Huang C-Y, Su F-C. Effects of foot orthoses on gait patterns of flat feet patients. Clinical biomechanics 2010; 25 :265-70. Kido M, Ikoma K, Hara Y, et al. Effect of therapeutic insoles on the medial longitudinal arch in patients with flatfoot deformity: A three-dimensional loading computed tomography study. Clinical Biomechanics 2014; 29 :1095-8. Sheykhi-Dolagh R, Saeedi H, Farahmand B, et al. The influence of foot orthoses on foot mobility magnitude and arch height index in adults with flexible flat feet. Prosthetics and orthotics international 2015; 39 :190-6. Aminian G, Safaeepour Z, Farhoodi M, Pezeshk AF, Saeedi H, Majddoleslam B. The effect of prefabricated and proprioceptive foot orthoses on plantar pressure distribution in patients with flexible flatfoot during walking. Prosthetics and orthotics international 2013; 37 :227-32. Johanson MA, Donatelli R, Wooden MJ, Andrew PD, Cummings GS. Effects of three different posting methods on controlling abnormal subtalar pronation. Physical Therapy 1994; 74 :149-58. Telfer S, Abbott M, Steultjens MP, Woodburn J. Dose–response effects of customised foot orthoses on lower limb kinematics and kinetics in pronated foot type. Journal of biomechanics 2013; 46 :1489-95. Zifchock RA, Davis I. A comparison of semi-custom and custom foot orthotic devices in high-and low-arched individuals during walking. Clinical biomechanics 2008; 23 :1287-93. Hurd WJ, Kavros SJ, Kaufman KR. Comparative biomechanical effectiveness of over-the-counter devices for individuals with a flexible flatfoot secondary to forefoot varus. Clinical Journal of Sport Medicine 2010; 20 :428-35. Cheung RT, Chung RC, Ng GY. Efficacies of different external controls for excessive foot pronation: A meta-analysis. British journal of sports medicine 2011; 45 :743-51. Banwell HA, Mackintosh S, Thewlis D. Foot orthoses for adults with flexible pes planus: A systematic review. J Foot Ankle Res 2014; 7 :23. Desmyttere G, Hajizadeh M, Bleau J, Begon M. Effect of foot orthosis design on lower limb joint kinematics and kinetics during walking in flexible pes planovalgus: A systematic review and meta-analysis. Clinical Biomechanics 2018; 59 :117-29. McPoil TG, Cornwall MW, Medoff L, Vicenzino B, Forsberg K, Hilz D. Arch height change during sit-to-stand: An alternative for the navicular drop test. Journal of foot and ankle research 2008; 1 :1-11. Langley B, Cramp M, Morrison SC. Clinical measures of static foot posture do not agree. Journal of foot and ankle research 2016; 9 :1-6. Chuter VH. Relationships between foot type and dynamic rearfoot frontal plane motion. Journal of foot and ankle research 2010; 3 :1-6. Page MJ, McKenzie JE, Bossuyt PM, et al. The prisma 2020 statement: An updated guideline for reporting systematic reviews. International journal of surgery 2021; 88 :105906. Moher D, Liberati A, Tetzlaff J, Altman DG, Group* P. Preferred reporting items for systematic reviews and meta-analyses: The prisma statement. Annals of internal medicine 2009; 151 :264-9. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. Journal of epidemiology & community health 1998; 52 :377-84. Radzimski AO, Mündermann A, Sole G. Effect of footwear on the external knee adduction moment—a systematic review. The knee 2012; 19 :163-75. Rohatgi A. Webplotdigitizer user manual version 4.6. URL https://automerisio/WebPlotDigitizer 2022:1-18. McGough JJ, Faraone SV. Estimating the size of treatment effects: Moving beyond p values. Psychiatry (Edgmont) 2009; 6 :21. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. Bmj 2003; 327 :557-60. Costa BL, Magalhães FA, Araujo VL, et al. Is there a dose-response of medial wedge insoles on lower limb biomechanics in people with pronated feet during walking and running? Gait & posture 2021; 90 :190-6. Desmyttere G, Hajizadeh M, Bleau J, Leteneur S, Begon M. Anti-pronator components are essential to effectively alter lower-limb kinematics and kinetics in individuals with flexible flatfeet. Clinical Biomechanics 2021; 86 :105390. Hsu C-Y, Wang C-S, Lin K-W, Chien M-J, Wei S-H, Chen C-S. Biomechanical analysis of the flatfoot with different 3d-printed insoles on the lower extremities. Bioengineering 2022; 9 :563. Lourenço BM, Magalhães FA, Vieira FM, et al. An exploration of the effects of prefabricated and customized insoles on lower limb kinetics and kinematics during walking, stepping up and down tasks: A time series analysis. Gait & Posture 2022; 98 :297-304. Permsombat P, Pensri P. Effects of customized foot orthoses on lower limbs kinematics in adults with highly pronated foot. Chulalongkorn Medical Journal 2021; 65 :195-205. Peng Y, Wong DW-C, Wang Y, et al. Immediate effects of medially posted insoles on lower limb joint contact forces in adult acquired flatfoot: A pilot study. International journal of environmental research and public health 2020; 17 :2226. Prachgosin T, Leelasamran W, Smithmaitrie P, Chatpun S. Effect of total-contact orthosis on medial longitudinal arch and lower extremities in flexible flatfoot subjects during walking. Prosthetics and Orthotics International 2017; 41 :579-86. Tang SF-T, Chen C-H, Wu C-K, Hong W-H, Chen K-J, Chen C-K. The effects of total contact insole with forefoot medial posting on rearfoot movement and foot pressure distributions in patients with flexible flatfoot. Clinical neurology and neurosurgery 2015; 129 :S8-S11. Cobb SC, Tis LL, Johnson JT, Wang YT, Geil MD. Custom-molded foot-orthosis intervention and multisegment medial foot kinematics during walking. 46. National Athletic Trainers' Association, Inc; 2011:358-65. Han K, Bae K, Levine N, Yang J, Lee J-S. Biomechanical effect of foot orthoses on rearfoot motions and joint moment parameters in patients with flexible flatfoot. Medical science monitor: international medical journal of experimental and clinical research 2019; 25 :5920. Brown GP, Donatelli R, Catlin PA, Wooden MJ. The effect of two types of foot orthoses on rearfoot mechanics. Journal of Orthopaedic & Sports Physical Therapy 1995; 21 :258-67. Nawoczenski DA, Ludewig PM. The effect of forefoot and arch posting orthotic designs on first metatarsophalangeal joint kinematics during gait. Journal of Orthopaedic & Sports Physical Therapy 2004; 34 :317-27. Alsaafin N, Saad N, Mohammad Zadeh SA, Hegazy FA. Effect of different foot orthosis inverted angles on walking kinematics in females with flexible flatfeet. Journal of Multidisciplinary Healthcare 2023:2613-23. Dedieu P, Drigeard C, Gjini L, Dal Maso F, Zanone P-G. Effects of foot orthoses on the temporal pattern of muscular activity during walking. Clinical biomechanics 2013; 28 :820-4. Stacoff A, Kramers-de Quervain I, Dettwyler M, et al. Biomechanical effects of foot orthoses during walking. The Foot 2007; 17 :143-53. Kosonen J, Kulmala J-P, Müller E, Avela J. Effects of medially posted insoles on foot and lower limb mechanics across walking and running in overpronating men. Journal of biomechanics 2017; 54 :58-63. Neville C, Flemister AS, Houck J. Effects of the airlift pttd brace on foot kinematics in subjects with stage ii posterior tibial tendon dysfunction. journal of orthopaedic & sports physical therapy 2009; 39 :201-9. Genova JM, Gross MT. Effect of foot orthotics on calcaneal eversion during standing and treadmill walking for subjects with abnormal pronation. Journal of Orthopaedic & Sports Physical Therapy 2000; 30 :664-75. Souza TR, Pinto RZ, Trede RG, Kirkwood RN, Fonseca ST. Temporal couplings between rearfoot–shank complex and hip joint during walking. Clinical biomechanics 2010; 25 :745-8. Cohen LG, Bandinelli S, Topka HR, Fuhr P, Roth BJ, Hallett M. Topographic maps of human motor cortex in normal and pathological conditions: Mirror movements, amputations and spinal cord injuries. Electroencephalography and Clinical Neurophysiology-Supplements only 1994; 43 :36-50. Ryan MB, Valiant GA, McDonald K, Taunton JE. The effect of three different levels of footwear stability on pain outcomes in women runners: A randomised control trial. British Journal of Sports Medicine 2011; 45 :715-21. Turner DE, Helliwell PS, Siegel KL, Woodburn J. Biomechanics of the foot in rheumatoid arthritis: Identifying abnormal function and the factors associated with localised disease ‘impact’. Clinical Biomechanics 2008; 23 :93-100. Woodburn J, Helliwell PS, Barker S. Three‐dimensional kinematics at the ankle joint complex in rheumatoid arthritis patients with painful valgus deformity of the rearfoot. Rheumatology 2002; 41 :1406-12. Dubbeldam R, Baan H, Nene A, et al. Foot and ankle kinematics in rheumatoid arthritis: Influence of foot and ankle joint and leg tendon pathologies. Arthritis care & research 2013; 65 :503-11. Woodburn J, Udupa JK, Hirsch BE, et al. The geometric architecture of the subtalar and midtarsal joints in rheumatoid arthritis based on magnetic resonance imaging. Arthritis & Rheumatism 2002; 46 :3168-77. Hennessy K, Woodburn J, Steultjens MP. Custom foot orthoses for rheumatoid arthritis: A systematic review. Arthritis care & research 2012; 64 :311-20. Woodburn J, Helliwell PS, Barker S. Changes in 3d joint kinematics support the continuous use of orthoses in the management of painful rearfoot deformity in rheumatoid arthritis. The Journal of rheumatology 2003; 30 :2356-64. Genova JM, Gross MT. Effect of foot orthotics on calcaneal eversion during standing and treadmill walking for subjects with abnormal pronation. The Journal of orthopaedic and sports physical therapy 2000; 30 :664-75. Takabayashi T, Edama M, Yokoyama E, et al. Changes in kinematic coupling among the rearfoot, midfoot, and forefoot segments during running and walking. J Am Podiatr Med Assoc 2018; 108 :45-51. Desmyttere G, Hajizadeh M, Bleau J, Leteneur S, Begon M. Anti-pronator components are essential to effectively alter lower-limb kinematics and kinetics in individuals with flexible flatfeet. Clin Biomech (Bristol, Avon) 2021; 86 :105390. Brockett CL, Chapman GJ. Biomechanics of the ankle. Orthopaedics and trauma 2016; 30 :232-8. DeLisa JA, Gans BM, Walsh NE. Physical medicine and rehabilitation: Principles and practice. Lippincott Williams & Wilkins; 2005. Novacheck TF. The biomechanics of running. Gait & posture 1998; 7 :77-95. Williams 3rd DS, Davis M, Baitch SP. Effect of inverted orthoses on lower-extremity mechanics in runners. Medicine and science in sports and exercise 2003; 35 :2060-8. Jafarnezhadgero AA, Shad MM, Majlesi M. Effect of foot orthoses on the medial longitudinal arch in children with flexible flatfoot deformity: A three-dimensional moment analysis. Gait & posture 2017; 55 :75-80. Kostuik JP, Schmidt O, Harris WR, Wooldridge C. A study of weight transmission through the knee joint with applied varus and valgus loads. Clinical orthopaedics and related research 1975:95-8. Lack S, Barton C, Woledge R, Laupheimer M, Morrissey D. The immediate effects of foot orthoses on hip and knee kinematics and muscle activity during a functional step-up task in individuals with patellofemoral pain. Clinical Biomechanics 2014; 29 :1056-62. Nester C, Van Der Linden M, Bowker P. Effect of foot orthoses on the kinematics and kinetics of normal walking gait. Gait & posture 2003; 17 :180-7. Park K. Effects of wearing functional foot orthotic on pelvic angle among college students in their 20s with flatfoot. Journal of physical therapy science 2017; 29 :438-41. Park K, Seo K. Effects of a functional foot orthosis on the knee angle in the sagittal plane of college students in their 20s with flatfoot. Journal of physical therapy science 2015; 27 :1211-3. Stacoff A, Reinschmidt C, Nigg BM, et al. Effects of shoe sole construction on skeletal motion during running. Medicine & Science in Sports & Exercise 2001; 33 :311-9. Miyazaki T, Wada M, Kawahara H, Sato M, Baba H, Shimada S. Dynamic load at baseline can predict radiographic disease progression in medial compartment knee osteoarthritis. Annals of the rheumatic diseases 2002; 61 :617-22. Hreljac A, Marshall RN, Hume PA. Evaluation of lower extremity overuse injury potential in runners. Medicine & Science in Sports & Exercise 2000; 32 :1635-41. Sp M. Etiologic factors associated with selected running injuries. Med Sci Sports Exerc 1988; 20 :501-5. Mills K, Blanch P, Chapman AR, McPoil TG, Vicenzino B. Foot orthoses and gait: A systematic review and meta-analysis of literature pertaining to potential mechanisms. British journal of sports medicine 2010; 44 :1035-46. Mündermann A, Nigg BM, Humble RN, Stefanyshyn DJ. Foot orthotics affect lower extremity kinematics and kinetics during running. Clinical biomechanics 2003; 18 :254-62. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3941166","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":276175058,"identity":"871923e5-c08c-4b90-8475-119a65aa38c0","order_by":0,"name":"AmirAli Jafarnezhadgero","email":"","orcid":"","institution":"University of Mohaghegh Ardabili","correspondingAuthor":false,"prefix":"","firstName":"AmirAli","middleName":"","lastName":"Jafarnezhadgero","suffix":""},{"id":276175059,"identity":"bc27b118-8466-4341-bbc7-c1c626f71d3f","order_by":1,"name":"Ali Esmaeili","email":"","orcid":"","institution":"University of Mohaghegh Ardabili","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Esmaeili","suffix":""},{"id":276175061,"identity":"d43c6b13-9d21-44e8-9d61-bf54344404bd","order_by":2,"name":"Seyed Hamed Mousavi","email":"","orcid":"","institution":"University of Tehran","correspondingAuthor":false,"prefix":"","firstName":"Seyed","middleName":"Hamed","lastName":"Mousavi","suffix":""},{"id":276175064,"identity":"ec533765-aec2-4650-935e-df733fd915e4","order_by":3,"name":"Urs Granacher","email":"data:image/png;base64,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","orcid":"","institution":"University of Freiburg","correspondingAuthor":true,"prefix":"","firstName":"Urs","middleName":"","lastName":"Granacher","suffix":""}],"badges":[],"createdAt":"2024-02-08 21:14:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3941166/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3941166/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52102191,"identity":"1a86f3de-1755-470d-b06e-9ab65ac76b9b","added_by":"auto","created_at":"2024-03-06 19:15:01","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":40209,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram of studies included in this systematic review with meta-analysis\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3941166/v1/47d7e5bda167dfe190e49200.jpg"},{"id":52105760,"identity":"d083e6f1-8a14-48ca-b7ca-e120df4efc7d","added_by":"auto","created_at":"2024-03-06 19:31:01","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":188252,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot illustrating the effects of short-term application of foot orthoses (intervention) versus control on peak rearfoot eversion during walking in individuals with pronated feet. The subtotal effect for each parameter and the total effect were calculated as standardized mean difference (95% CI). SD: Standard deviation; Std: Standardized; CI: Confidence interval.\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3941166/v1/7dd9bad4c851ae401191851c.jpg"},{"id":52104047,"identity":"12bf7951-fb58-4351-8275-a40ba9ff1aa9","added_by":"auto","created_at":"2024-03-06 19:23:01","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":177123,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of the effects of short-term foot orthoses application (intervention) versus control on peak ankle dorsiflexion during walking in individuals with pronated feet. The subtotal effect for each parameter and the total effect were calculated as standardized mean difference (95% CI). SD: Standard deviation; Std: Standardized; CI: Confidence interval.\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3941166/v1/cf48556dedce6bce8b3df54e.jpg"},{"id":52102194,"identity":"2a6ca0b9-550e-4b5b-9b25-e148ed05242c","added_by":"auto","created_at":"2024-03-06 19:15:01","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":161583,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of the effects of short-term foot orthoses application (intervention) versus control on peak ankle eversion during walking in individuals with pronated feet. The subtotal effect for each parameter and the total effect were calculated as standardized mean difference (95% CI). SD: Standard deviation; Std: Standardized; CI: Confidence interval.\u003c/p\u003e","description":"","filename":"Fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3941166/v1/9fe4128dadb45bb12b1ba15a.jpg"},{"id":52104046,"identity":"bd4a9c01-91d2-4cc2-b376-09968ba7df59","added_by":"auto","created_at":"2024-03-06 19:23:01","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":123756,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot illustrating the effects of short-term foot orthoses application (intervention) versus control on peak ankle eversion moment during walking in individuals with pronated feet. The subtotal effect for each parameter and the total effect were calculated as standardized mean difference (95% CI). SD: Standard deviation; Std: Standardized; CI: Confidence interval.\u003c/p\u003e","description":"","filename":"Fig5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3941166/v1/038a9b36e8478c45c46f0c5e.jpg"},{"id":52102195,"identity":"983b331b-4090-450f-83ec-5c0e4a9d5033","added_by":"auto","created_at":"2024-03-06 19:15:01","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":123769,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot illustrating the effects of short-term foot orthoses application (intervention) versus control on peak knee adduction moment during walking in individuals with pronated feet. The subtotal effect for each parameter and the total effect were calculated as standardized mean difference (95% CI). SD: Standard deviation; Std: Standardized; CI: Confidence interval.\u003c/p\u003e","description":"","filename":"Fig6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3941166/v1/27275f2f418387ed77590e31.jpg"},{"id":56348902,"identity":"6218f42f-93a1-4fe5-8fa1-eafc1854ab66","added_by":"auto","created_at":"2024-05-13 03:18:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1177392,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3941166/v1/0405033e-753e-406a-87e0-de46f5d65d8b.pdf"},{"id":52102192,"identity":"e44e7c04-4b3b-4298-bdcd-4be0d98554a9","added_by":"auto","created_at":"2024-03-06 19:15:01","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":2795735,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile.docx","url":"https://assets-eu.researchsquare.com/files/rs-3941166/v1/115d38f54147825bf6869d57.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of short-term foot orthoses application on walking kinematics and kinetics in adults with pronated feet: A systematic review with meta-analysis","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eFoot pronation can occur during standing, walking or running and is characterized by a multi-joint movement including the rear- and midfoot segments\u0026nbsp;\u003csup\u003e1\u003c/sup\u003e. In dynamic situations, foot pronation serves as a shock absorber during the early to mid-stance phase of walking or running\u0026nbsp;\u003csup\u003e2\u003c/sup\u003e. Excessive foot pronation however may cause lower limbs malalignment such as altered joint kinematics and pressure distribution of the plantar surface together with increased demands on the intrinsic foot muscles that control the arch deformation\u0026nbsp;\u003csup\u003e3\u003c/sup\u003e. In this context, Levinger et al., reported that individuals with pronated feet demonstrated greater peak forefoot plantarflexion, forefoot abduction, and rearfoot internal rotation during walking compared to individuals with normal foot posture\u0026nbsp;\u003csup\u003e4\u003c/sup\u003e. Another study indicated that calcaneal eversion resulted in increased hip flexion, medial rotation, and pelvic anterior tilt during the stance phase of walking\u0026nbsp;\u003csup\u003e5\u003c/sup\u003e. Therefore, the treatment of excessive foot pronation is key to avoid acute and overuse injuries\u0026nbsp;\u003csup\u003e6, 7\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFoot orthoses (FO) are often applied as therapeutic tools to treat excessive foot pronation and lower limbs malalignment\u0026nbsp;\u003csup\u003e8, 9\u003c/sup\u003e. In addition, there is evidence from biomechanical research indicating that short-term FO application has a positive impact on the foot arch alignment\u0026nbsp;\u003csup\u003e9\u003c/sup\u003e in the form of correcting talocalcaneal joint eversion, elevating the medial longitudinal arch (MLA), and suppressing foot elongation\u0026nbsp;\u003csup\u003e10\u003c/sup\u003e. There is further evidence that short-term FO application results in acute improvements in direction and function of the arch during walking\u0026nbsp;\u003csup\u003e11\u003c/sup\u003e by shifting the load from the forefoot and rearfoot towards the midfoot area\u0026nbsp;\u003csup\u003e12\u003c/sup\u003e. Yet, the picture is not that clear and conflicting results exist in the literature on the short-term effects of FO treatment on walking kinematics and kinetics in individuals with pronated feet. While some studies reported significantly reduced rearfoot eversion angles due to FO usage\u0026nbsp;\u003csup\u003e13, 14\u003c/sup\u003e, others found no difference between FO application and control condition\u0026nbsp;\u003csup\u003e15, 16\u003c/sup\u003e. The reasons for the discrepancy in findings might be caused by methodological limitations such as heterogeneous study samples and different assessment protocols (e.g., walking speed, shoe type, foot model, etc.).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBesides original research, a number of systematic reviews has been conducted over the past years, yet most of them were methodologically limited. The first systematic review with meta-analysis on the short-term effects of FO application on rearfoot eversion in individuals with pronated feet was conducted in 2011\u0026nbsp;\u003csup\u003e17\u003c/sup\u003e. The authors found that particularly custom-made FOs were effective in controlling excessive foot pronation\u0026nbsp;\u003csup\u003e17\u003c/sup\u003e. Another systematic review article focused on adults with flexible flat feet and found limited evidence supporting the long-term capacity of FOs to improve rearfoot kinematics (e.g., peak rear foot eversion) and kinetics (e.g., impact force)\u0026nbsp;\u003csup\u003e18\u003c/sup\u003e. A more recent systematic review with meta-analysis found that short-term FO application in individuals with a medial forefoot or both a medial forefoot and a rearfoot posting resulted in lower peak rearfoot eversion angles in adults with flexible pes planovalgus (low level of evidence)\u0026nbsp;\u003csup\u003e19\u003c/sup\u003e. These contradictory findings in original research and systematic reviews can, amongst others, be attributed to methodological limitations such as the definition of pronated feet.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrevious systematic reviews\u0026nbsp;\u003csup\u003e17-19\u003c/sup\u003e also considered the effects of short-term FO application on walking mechanics, including the evaluation of the navicular drop or the arch height index in individuals with pronated feet. However, the authors of the respective studies did not consider the methodological quality of different foot posture assessment methods\u0026nbsp;\u003csup\u003e17-19\u003c/sup\u003e. Of note, some studies used the navicular drop method to assess foot mobility\u0026nbsp;\u003csup\u003e20\u003c/sup\u003e but this test has been criticized lately because the navicular drop appears not to be a valid method for the assessment of foot posture\u0026nbsp;\u003csup\u003e21\u003c/sup\u003e.\u003cstrong\u003e\u0026nbsp;Despite these critical reports on the navicular drop method,\u0026nbsp;\u003c/strong\u003eprevious systematic reviews\u0026nbsp;\u003csup\u003e17-19\u003c/sup\u003e included studies using the navicular drop as the preferred method for the assessment of foot pronation. \u003cstrong\u003eMoreover\u003c/strong\u003e, results of a previous study suggested that the foot posture index has strong predictive ability for dynamic rearfoot function\u0026nbsp;\u003csup\u003e22\u003c/sup\u003e. \u0026nbsp;Due to the described methodological limitations of previous systematic reviews and meta-analyses, it appears timely to update and aggregate the available literature on the short-term effects of FO application on walking kinematics and kinetics in adults with pronated feet to provide information for healthcare practitioners. Therefore, this systematic review with meta-analysis aimed to investigate the effects of short-term FO application (i.e., one session) on lower limbs kinematics and kinetics during walking in adults aged \u0026ge;18 years with excessive foot pronation. In the present systematic review with meta-analysis, studies were then categorized into five categories based on the applied foot pronation assessment method: (1) studies that used the foot posture index (FPI-6) or clinical observation; (2) studies that applied the foot print arch index; (3) studies that used the arch height index (including navicular drop, arch height index, navicular height normalized to foot length [NNHT]; (4) studies that applied the forefoot varus method; (5) studies that used the rearfoot eversion or rest calcaneal stance position (RCSP). By reporting findings according to the applied foot posture assessment method, readers receive a more differentiated picture on the effectiveness of the short-term application of FOs on walking kinematics and kinetics.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eWhen performing this systematic review with meta-analysis, we adhered to the standard PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines\u0026nbsp;\u003csup\u003e23\u003c/sup\u003e. The protocol for this systematic review with meta-analysis was registered with PROSPERO on November, 17\u003csup\u003eth\u003c/sup\u003e 2023 (Project: https://www.crd.york.ac.uk/prospero/#myprospero, ID: CRD42023480039).\u003c/p\u003e\n\u003cp\u003e2.1. Eligibility criteria\u003c/p\u003e\n\u003cp\u003eEndNote 20 software (Bld 14672, Clarivate, Philadelphia, PA, USA) was used for the systematic search and the processing of potentially eligible papers. A PICOS (participants, intervention, comparators, outcomes, and study design) approach was applied to define inclusion and exclusion criteria (Table 1) a priori\u0026nbsp;\u003csup\u003e24\u003c/sup\u003e. To be eligible for inclusion in this meta-analysis, articles had to be published in peer-reviewed journals in English language. Articles not written in English language were excluded (Table 1).\u003c/p\u003e\n\u003cp\u003eTable 1 here\u003c/p\u003e\n\u003cp\u003e2.2. Information sources, search strategy\u003c/p\u003e\n\u003cp\u003eThe following five databases were systematically searched\u0026nbsp;from inception to January 2024: MEDLINE, Scopus, PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL). The reference lists of published reviews and the identified studies were screened to find further potentially relevant papers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe search syntax was created using the PICOS scheme and free-text keywords as well as medical subject headings (Mesh terms). Keywords and Mesh terms were combined using a Boolean search syntax and the operators AND, OR. Searched keywords were included in Table 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2 here\u003c/p\u003e\n\u003cp\u003e2.3. Study selection\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll titles and abstracts were reviewed by two authors of this paper (A.E., and A.J.) to identify potentially eligible studies according to the a priori defined inclusion and exclusion criteria. In case titles and abstracts did not provide sufficient information, full-texts were examined. Any difference in the rating of the two authors was resolved through discussion with a third reviewer (SHM).\u003c/p\u003e\n\u003cp\u003e2.4. Quality assessment\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe methodological quality of the included studies was evaluated by the same two authors (A.E., A.J.) using a modified version of the Downs and Black checklist for non-randomized controlled trials\u0026nbsp;\u003csup\u003e25\u003c/sup\u003e. The modified checklist includes 19 questions with eight reporting items (items 1, 2, 3, 4, 5, 6, 7, 10), two items for external validity (items 11 and 12), five items for internal validity (Bias) (items 14, 15, 16, 18, 20), three items for internal validity-confounding (items 21, 22, 25), and one item for power (item 27). The items were scored as 0 (\u0026ldquo;no\u0026rdquo; and \u0026ldquo;unable to determine\u0026rdquo;), 1 (\u0026ldquo;yes\u0026rdquo;), except for item 5 for the principal confounders which was scored 0 (\u0026ldquo;no\u0026rdquo;), 1 (\u0026ldquo;partially\u0026rdquo;), 2 (\u0026ldquo;yes\u0026rdquo;). The overall quality score of each study was calculated based on a percentage of the maximum score (20). In cases where there were discrepancies in the authors\u0026rsquo; rating of the quality scores, consensus was reached through discussion. Studies with quality scores of 75% or higher were considered high quality, those with scores between 60% and 74% were classified as moderate quality, and those with scores of 60% or lower were categorized as low quality\u0026nbsp;\u003csup\u003e26\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e2.5. Data collection\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne author (A.E.) extracted all relevant data according to the PICOS approach\u0026nbsp;(population, foot posture measurement, study protocol, intervention, orthoses design, and outcomes related to kinematic and kinetic data) from the included articles. To reduce any errors in the extraction of data, all data were checked by the author\u0026nbsp;(A.J.). Values of the peak, mean angle, and joint excursion were extracted and reported as kinematic variables. Joint moments were reported as kinetic variables. If more than one type of FO was examined, each FO type within the study was allocated simple identification (A, B etc.). In case study authors did not report outcomes, we attempted to obtain them directly through the corresponding author or a freeware web-based plot digitizer\u0026nbsp;\u003csup\u003e27\u003c/sup\u003e to obtain data from graphs.\u0026nbsp;Next, we categorized the data based on the specific foot assessment methods and compared the movement and force variables for each joint for both the FO and control conditions. The key outcomes according to validity and function are reported in the text, secondary outcomes in supplementary materials.\u003c/p\u003e\n\u003cp\u003e2.6. Statistical analyses\u003c/p\u003e\n\u003cp\u003eQuantitative data synthesis was conducted using the Cochrane Review Manager (Version 5.1). To examine the main research question, standardized mean differences (SMDs) with 95% confidence intervals (CI) were computed as effect size measures using a random-effects model to elucidate the effects of short-term FO application compared to controls on kinematic and kinetic variables during walking. SMDs were categorized as trivial (0\u0026ndash;0.2), small (0.2\u0026ndash;0.5), moderate (0.5\u0026ndash;0.8), and large (\u0026gt; 0.8)\u0026nbsp;\u003csup\u003e28\u003c/sup\u003e. Study heterogeneity was assessed using the I\u003csup\u003e2\u003c/sup\u003e index. The level of heterogeneity was classified as high (\u0026gt; 75%), moderate (50%\u0026ndash;75%), and low (25%\u0026ndash;50%)\u0026nbsp;\u003csup\u003e29\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e3.1. Study selection\u003c/p\u003e\n\u003cp\u003eThe initial search identified 13,441 studies. After duplicate removal, 5,362 studies remained. Following the screening of titles and abstracts, 43 full texts were further considered. Finally, 22 studies were eligible to be included in this systematic review with meta-analysis. Quantitative analyses were computed with all 22 articles. Fig 1 presents a PRISMA flow chart and illustrates the study selection process. Studies were then categorized according to the applied foot pronation assessment methods: (1) using the foot posture index (FPI-6) or clinical observation; (2) using the foot print arch index; (3) using the arch height index (including the navicular drop, the arch height index, the navicular height normalized to foot length [NNHT]); (4) the forefoot varus method; (5) the rearfoot eversion or rest calcaneal stance position method (RCSP).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e PRISMA flow diagram of studies included in this systematic review with meta-analysis\u003c/p\u003e\n\u003cp\u003e3.2. Study characteristics\u003c/p\u003e\n\u003cp\u003eTable 3 shows the characteristics of the included studies. The identified studies used different types of foot posture measurements (i.e., FPI-6, clinical observation, foot print arch index, navicular drop, arch height index, NNHT, forefoot varus, rearfoot eversion, RCSP) and different foot models for kinematic and kinetic analyses. For instance, six studies were identified with the FPI-6 or clinical observation\u0026nbsp;\u003csup\u003e14, 30-34\u003c/sup\u003e, three with the foot print arch index\u0026nbsp;\u003csup\u003e35-37\u003c/sup\u003e, six with the arch height index\u0026nbsp;\u003csup\u003e3, 9, 15, 38, 39\u003c/sup\u003e, four with the forefoot varus method\u0026nbsp;\u003csup\u003e13, 16, 40, 41\u003c/sup\u003e; two with the rearfoot eversion or RCSP method\u0026nbsp;\u003csup\u003e42, 43\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eTang et al.\u0026nbsp;\u003csup\u003e37\u003c/sup\u003e reported values for participants with and without pronated feet. For the purpose of this study, we only extracted data for the foot pronation group. If authors reported multiple values for peak or mean joint excursion in different phases, we only included the phase with the higher value\u0026nbsp;\u003csup\u003e14, 34, 35, 42\u003c/sup\u003e. Additionally, we reported numerical values for all types of foot orthotics used in the respective studies\u0026nbsp;\u003csup\u003e13-16, 30-33, 38-42, 44\u003c/sup\u003e. We extracted data from graphs out of five studies\u0026nbsp;\u003csup\u003e15, 30, 31, 33, 43\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe outcome measures peak rearfoot eversion angle, peak ankle eversion and dorsiflexion angle, peak ankle eversion moment and knee adduction moment were reported in five or more than five studies. The remaining outcome measures with lower clinical relevance were included in the supplementary material (Supplementary File: Appendix 1-27).\u003c/p\u003e\n\u003cp\u003eTable 3 here\u003c/p\u003e\n\u003cp\u003e3.3. Quality assessment\u003c/p\u003e\n\u003cp\u003eThe methodological quality of the included 22 studies amounted to 74% on the modified version of the Downs and Black checklist\u0026nbsp;\u003csup\u003e25\u003c/sup\u003e. This is indicative of moderate methodological quality (Table 4). Among the 22 included studies, 15 were rated high quality\u0026nbsp;\u003csup\u003e3, 9, 14-16, 30, 32, 33, 35, 36, 39-42, 45\u003c/sup\u003e, and seven moderate quality\u0026nbsp;\u003csup\u003e13, 31, 34, 37, 38, 43, 44\u003c/sup\u003e. Only two study\u0026nbsp;\u003csup\u003e14, 31\u003c/sup\u003e involved assessors who were blinded for the experimental condition (FO or control) during testing. Authors from eleven studies\u0026nbsp;\u003csup\u003e3, 9, 15, 16, 30, 35, 39, 41, 42, 45\u003c/sup\u003e reported the calculation of a priori power analysis to estimate the sample size.\u003c/p\u003e\n\u003cp\u003eTable 4 here\u003c/p\u003e\n\u003cp\u003e3.4. Effects of short-term FO application on lower limbs kinematics\u003c/p\u003e\n\u003cp\u003e3.4.1. Rearfoot\u003c/p\u003e\n\u003cp\u003eNine studies reported the effects of short-term FO application on peak rearfoot eversion\u0026nbsp;\u003csup\u003e3, 13, 14, 16, 37, 39, 40, 43, 44\u003c/sup\u003e. Findings indicated moderate effects of short-term FO application. The analysis further revealed moderate level of heterogeneity (moderate SMDs=0.66, 95% CI 0.34 to 0.99, p\u0026lt;0.0001, I\u003csup\u003e2\u003c/sup\u003e=71%). More specifically, across the nine included studies, the peak rearfoot eversion was 1.72° (95% CI 1.01 to 2.44) lower in the FO condition compared to control (Fig 2). The subgroup analyses taking the methodological approach for the assessment of foot pronation into account showed no significant effect of short-term FO wearing for the studies that assessed foot posture using the arch height index\u0026nbsp;\u003csup\u003e3, 39\u003c/sup\u003e (2 studies: SMDs=0.42, 95% CI -0.20 to 1.05, p=0.18) or the foot print arch index\u0026nbsp;\u003csup\u003e37\u003c/sup\u003e (1 study SMDs=0.64, 95% CI -0.26 to 1.55, p=0.16). Yet, we observed significant effects of short-term FO application in studies that used the forefoot varus method\u0026nbsp;\u003csup\u003e13, 16, 40\u003c/sup\u003e (3 studies: small SMDs=0.36, 95% CI 0.13 to 0.6, p=0.002), the FPI-6 or clinical observation\u0026nbsp;\u003csup\u003e14, 44\u003c/sup\u003e (2 studies: large SMDs=1.42, 95% CI 0.20 to 2.63, p=0.02, I\u003csup\u003e2\u003c/sup\u003e=87) and the rearfoot eversion or RCSP methods\u0026nbsp;\u003csup\u003e43\u003c/sup\u003e (1 study: large SMDs=1.28, 95% CI 0.39 to 2.17, p=0.005) for determination of foot pronation (Fig 2, Table 5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig. 2.\u003c/strong\u003e Forest plot illustrating the effects of short-term application of foot orthoses (intervention) versus control on peak rearfoot eversion during walking in individuals with pronated feet. The subtotal effect for each parameter and the total effect were calculated as standardized mean difference (95% CI). SD: Standard deviation; Std: Standardized; CI: Confidence interval.\u003c/p\u003e\n\u003cp\u003e3.4.2. Ankle\u003c/p\u003e\n\u003cp\u003ePeak ankle dorsiflexion was measured in five studies\u0026nbsp;\u003csup\u003e9, 31, 32, 35, 42\u003c/sup\u003e. Overall, our findings indicated small effects of short-term FO application (5 studies: small SMDs=-0.33, 95% CI -0.54 to -0.12, p=0.002, I\u003csup\u003e2\u003c/sup\u003e=0%). More specifically, the mean (five studies) peak ankle dorsiflexion was 0.61° (95% CI 1.05 to 2.75) lower in the FO compared to the control condition (Fig 3). The subgroup analyses showed no significant effects of short-term FO treatment in the studies that assessed foot posture using the arch height index\u0026nbsp;\u003csup\u003e9\u003c/sup\u003e (1 study: SMDs=-0.19, 95% CI -1.03 to 0.65, p=0.18) or the foot print arch index\u0026nbsp;\u003csup\u003e35\u003c/sup\u003e (1 study: SMDs=0.42, 95% CI -0.30 to 1.15, p=0.26). Significant effects of short-term FO application were found for the studies that used the FPI-6 or clinical observation\u0026nbsp;\u003csup\u003e31, 32\u003c/sup\u003e (2 studies: small SMDs=-0.42, 95% CI -0.72 to -0.12, p=0.007, I\u003csup\u003e2\u003c/sup\u003e=0%) and rearfoot eversion or RCSP\u0026nbsp;\u003csup\u003e42\u003c/sup\u003e (1 study: small SMDs=-0.42, 95% CI -0.78 to -0.06, p=0.02, I\u003csup\u003e2\u003c/sup\u003e=0%) to determine the foot posture (Fig 3, Table 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig. 3.\u003c/strong\u003e Forest plot of the effects of short-term foot orthoses application (intervention) versus control on peak ankle dorsiflexion during walking in individuals with pronated feet. The subtotal effect for each parameter and the total effect were calculated as standardized mean difference (95% CI). SD: Standard deviation; Std: Standardized; CI: Confidence interval.\u003c/p\u003e\n\u003cp\u003ePeak ankle eversion was measured in seven studies\u0026nbsp;\u003csup\u003e13, 30-33, 35, 40\u003c/sup\u003e. Based on findings from the seven included studies, the analysis indicated significant moderate effects of short-term FO treatment (moderate SMDs=0.58, 95% CI 0.27 to 0.90, p=0.0003) (Fig 4) with a moderate level of study heterogeneity (I\u003csup\u003e2\u003c/sup\u003e=72%). More specifically, the mean (7 studies) peak ankle eversion was 1.10° (95% CI 0.58 to 1.62) lower in the FO condition compared to control. The subgroup analysis showed no significant effect of short-term FO application in the studies that assessed foot posture using the foot print arch index\u0026nbsp;\u003csup\u003e35\u003c/sup\u003e (1 study: SMDs=0.55, 95% CI -0.18 to 1.28, p=0.14). Significant effects were observed for the studies that used the FPI-6 or clinical observation\u0026nbsp;\u003csup\u003e30-33\u003c/sup\u003e (4 studies: moderate SMDs=0.68, 95% CI 0.13 to 1.23, p=0.01, I\u003csup\u003e2\u003c/sup\u003e=83%) and forefoot varus\u0026nbsp;\u003csup\u003e13, 40\u003c/sup\u003e (2 studies: moderate SMDs=0.5, 95% CI 0.24 to 0.77, p=0.0002, I\u003csup\u003e2\u003c/sup\u003e=0%) to determine foot pronation (Fig 4, Table 5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig. 4.\u003c/strong\u003e Forest plot of the effects of short-term foot orthoses application (intervention) versus control on peak ankle eversion during walking in individuals with pronated feet. The subtotal effect for each parameter and the total effect were calculated as standardized mean difference (95% CI). SD: Standard deviation; Std: Standardized; CI: Confidence interval.\u003c/p\u003e\n\u003cp\u003e3.5. Effects of short-term FO application on lower limbs kinetics\u003c/p\u003e\n\u003cp\u003e3.5.1. Ankle\u003c/p\u003e\n\u003cp\u003eFive studies reported peak ankle eversion moment in Nm/kg. Overall, the analysis indicated no evidence of study\u0026nbsp;heterogeneity\u0026nbsp;(I\u003csup\u003e2\u003c/sup\u003e=0%) and yielded significant differences between short-term FO application and control (5 studies: small SMDs=0.38, 95% CI 0.17 to 0.59, p=0.0004)\u0026nbsp;(Fig 5). The applied subgroup analysis showed a significant difference only for the one single study that used the arch height index\u0026nbsp;\u003csup\u003e39\u003c/sup\u003e (Fig 5, Table 5). More specifically, the peak ankle eversion moment was 0.07 Nm/kg (95%CI 0.04 to 0.11) larger in the control condition. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig. 5.\u003c/strong\u003e Forest plot illustrating the effects of short-term foot orthoses application (intervention) versus control on peak ankle eversion moment during walking in individuals with pronated feet. The subtotal effect for each parameter and the total effect were calculated as standardized mean difference (95% CI). SD: Standard deviation; Std: Standardized; CI: Confidence interval.\u003c/p\u003e\n\u003cp\u003e3.5.2. Knee\u003c/p\u003e\n\u003cp\u003eSix studies reported the effects of short-term FO application on peak knee adduction moments\u0026nbsp;\u003csup\u003e9, 30-33, 45\u003c/sup\u003e. For the FPI-6 and the clinical observation assessment of foot posture, the mean (4 studies) peak knee adduction moment was 0.04 Nm/kg (95% CI -0.07 to -0.02) greater in the FO compared to the control condition (Table 5). For the\u0026nbsp;arch height index, findings did not reach the level of significance (2 studies) (Fig 6). Overall, there was a significant small effect of short-term FO application on the knee adduction moment (6 studies: SMDs=-0.30, 95% CI -0.50 to -0.10, p=0.004, I\u003csup\u003e2\u003c/sup\u003e=0%) (Fig 6, Table 5).\u0026nbsp;\u003c/p\u003e\n\u003cp dir=\"RTL\"\u003e\u003cstrong\u003eFig. 6.\u003c/strong\u003e\u0026nbsp;Forest plot illustrating the effects of short-term foot orthoses application (intervention) versus control on peak knee adduction moment during walking in individuals with pronated feet. The subtotal effect for each parameter and the total effect were calculated as standardized mean difference (95% CI). SD: Standard deviation; Std: Standardized; CI: Confidence interval.\u003c/p\u003e\n\u003cp\u003eTable 5 contains a summary of the meta-analytical finding according to the applied methods that were used to assess foot pronation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 5 here\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis systematic review with meta-analysis aimed to examine the effects of short-term FO application (one session) on walking kinematics and kinetics in adults\u0026nbsp;aged ≥ 18\u0026nbsp;years with excessive foot pronation by taking different foot posture assessment methods into account. With regards to lower limbs kinematics, the meta-analysis showed significant effects of short-term FO application on peak rearfoot eversion, peak ankle dorsiflexion and eversion. In terms of lower limbs kinetics, the meta-analysis revealed significant effects of short-term FO application on the peak ankle eversion moment and the peak knee adduction moment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe main finding of this meta-analysis was that the short-term wearing of FO produces lower rearfoot control by 1.72° compared with control conditions in adults with excessive foot pronation. Lower limbs kinematic changes due to short-term FO application have previously been interpreted as clinical improvements as the medical device contributes to alleviating tissue stress\u0026nbsp;\u003csup\u003e46, 47\u003c/sup\u003e. However, whether a FO-related change of 1.72° in lower rearfoot control is clinically relevant, remains to be elucidated. Accordingly, more high-quality research is needed in this growing field. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4.4. Effects of short-term FO application on lower limbs kinematics and kinetics during walking\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4.4.1. Rearfoot\u003c/p\u003e\n\u003cp\u003eOur meta-analysis revealed that the short-term application of FOs resulted in significantly lower peak rearfoot eversion and therefore less excessive foot pronation\u0026nbsp;\u003csup\u003e3, 13, 14, 16, 37, 39, 40, 43, 44\u003c/sup\u003e.\u0026nbsp;Findings from this meta-analysis showed significant effects of short-term FO application on the peak rearfoot eversion angle only in those studies that used the forefoot varus method for the assessment of foot pronation\u0026nbsp;\u003csup\u003e13, 16, 40\u003c/sup\u003e, the FPI-6 or clinical observation\u0026nbsp;\u003csup\u003e14, 44\u003c/sup\u003e, and the rearfoot eversion method or RCSP\u0026nbsp;\u003csup\u003e43\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eReducing calcaneal eversion is a viable and achievable biomechanical target\u0026nbsp;\u003csup\u003e17\u003c/sup\u003e. Adult individuals with excessive foot pronation lack a medial longitudinal arch to cushion the body mass during the stance phase of standing, walking, running due to an arch collapse caused by several congenital factors or other acquired predisposing factors\u0026nbsp;\u003csup\u003e48\u003c/sup\u003e. Abnormal plantar pressure leads to discomfort in flat feet, which, if left untreated, will produce pain and disability\u0026nbsp;\u003csup\u003e49\u003c/sup\u003e. The available evidence in the literature is weak with regards to the association between FO-related improved motion control and reduced injury rates in individuals with pronated feet\u0026nbsp;\u003csup\u003e50\u003c/sup\u003e. It has been hypothesized that the acquired flat foot and excessive rearfoot motion regularly seen in inflammatory conditions such as rheumatoid arthritis\u0026nbsp;\u003csup\u003e51, 52\u003c/sup\u003e are related to ultrasound and MRI confirmed features of joint and tendon damage, particularly those involved in controlling the frontal plane motion of the foot\u0026nbsp;\u003csup\u003e53, 54\u003c/sup\u003e. While cause and effect relations have not been fully established, there is good evidence from randomized controlled trials that an early intervention using customized FO devices results in lower abnormal kinematics and improved patient reported outcomes such as pain\u0026nbsp;\u003csup\u003e55, 56\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4.4.2. Ankle\u003c/p\u003e\n\u003cp\u003eBased on the results of this meta-analysis, short-term FO application resulted in a significant difference in the peak ankle dorsiflexion\u0026nbsp;\u003csup\u003e9, 31, 32, 35, 42\u003c/sup\u003e and eversion in the FO versus control condition during walking\u0026nbsp;\u003csup\u003e13, 30-33, 35, 40\u003c/sup\u003e. In addition, our analysis revealed a significant effect of FO versus control on ankle joint dorsiflexion in those studies that used the FPI-6 or clinical observation\u0026nbsp;\u003csup\u003e31, 32\u003c/sup\u003e and the rearfoot eversion method or RCSP\u0026nbsp;\u003csup\u003e42\u003c/sup\u003e to assess foot pronation. Furthermore, subgroup meta-analysis of peak ankle eversion showed significant effects of FO only in the studies that used the FPI-6 or clinical observation\u0026nbsp;\u003csup\u003e30-33\u003c/sup\u003e and forefoot varus for determine foot pronation. The meta-analysis yielded significant differences between the FO and control conditions in the peak ankle eversion moment. Subgroup analyses showed significant differences only in one study that used the arch height index. Medial FOs are designed to position the heel bones vertically to the ground, bring the calcaneus back to normal alignment with the shank, and maintain the subtalar joint in the neutral position; thus, they can be used to prevent pronation and excessive movement of the whole foot\u0026nbsp;\u003csup\u003e34, 42\u003c/sup\u003e. Genova and Gross\u0026nbsp;\u003csup\u003e57\u003c/sup\u003e assumed that using the posting might be associated with clinical improvements. To compensate for the reduction in rearfoot eversion, and since rearfoot and midfoot frontal motion are strongly coupled\u0026nbsp;\u003csup\u003e58\u003c/sup\u003e, an increase in midfoot eversion was observed when using the posting\u0026nbsp;\u003csup\u003e59\u003c/sup\u003e. Increasing the stiffness at the medial arch may therefore help to better control midfoot frontal plane motion. In addition, the greater forefoot inversion that usually accompanied the higher rearfoot eversion in individuals with pronated feet was lower in this study\u0026nbsp;\u003csup\u003e59\u003c/sup\u003e. Alsaafin and colleagues manufactured rigid FOs based on Blake's inverted orthotic technique\u0026nbsp;\u003csup\u003e42\u003c/sup\u003e. This technique aims to invert the rearfoot and pronate the forefoot through the subtalar joint and longitudinal axis of the midtarsal joint to straighten the heel back to vertical. During walking, the ankle joint undergoes specific movements throughout the gait cycle. At heel strike, the ankle joint is initially and slightly dorsiflexed, but it rapidly plantarflexes until the foot is flat on the ground (loading response). This mechanism aids for shock absorption and facilitates the immediate acceptance of body mass during this phase. As the gait cycle progresses, the ankle gradually transitions from plantarflexion to a neutral position and then further into dorsiflexion during the mid-stance phase. Finally, at the toe-off, the ankle returns to a plantarflexed position, which assists for propulsion\u0026nbsp;\u003csup\u003e60, 61\u003c/sup\u003e. Chen et al.\u0026nbsp;\u003csup\u003e9\u003c/sup\u003e observed lower peak ankle plantarflexion angles and moments when walking with foot insoles compared with controls in individuals with pronated feet. This reduction can be attributed to the control of foot motion provided by the orthoses, suggesting a positive impact on foot mechanics by limiting excessive ankle movements\u0026nbsp;\u003csup\u003e42\u003c/sup\u003e. This is particularly relevant for individuals with pronated feet, as excessive ankle motions during flatfooted walking can impair shock absorption and increase stress on the foot structures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe magnitude of the joint moment during walking could be considered a good indicator of injury prevention\u0026nbsp;\u003csup\u003e62\u003c/sup\u003e. A biomechanical aspect directly affected by the FO is that the use of a smaller evertor moment could positively reduce injury risk induced through muscle fatigue or overuse\u0026nbsp;\u003csup\u003e63\u003c/sup\u003e. The results from our meta-analysis showed that peak everted moments of the ankle joint in the FO conditions were significantly smaller than those of the normal condition.\u003c/p\u003e\n\u003cp\u003e4.4.3. Knee\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur meta-analysis showed that there was a significant small effect of short-term FO application on the knee adduction moment during walking. Moreover, the analysis\u0026nbsp;revealed effects of short-term FO application on the peak knee adduction moment if the FPI-6 method or clinical observation were used to assess foot posture.\u0026nbsp;Using a three-dimensional moment analysis, Jafarnezhadgero et al.\u0026nbsp;\u003csup\u003e64\u003c/sup\u003e showed that FOs may lower the ankle evertor moment, knee and hip abductor moment, and hip flexor moment in the dominant lower limbs of children during walking.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study revealed that the medially FO resulted in greater knee adduction moment. Whilst we did not observe a change in the knee adduction angle, this might be due to the fact that we assessed the short-term effects of FO usage. In a longitudinal approach, it can be hypothesized that the change in adduction moments might produce a change in adduction knee motions. If so, this would lead to changes in the distribution of load between the medial and lateral femoral-tibial compartments. For example, Kostuik et al.\u0026nbsp;\u003csup\u003e65\u003c/sup\u003e found that a 3° change in knee adduction motion was needed to totally unload the lateral compartment of osteo-ligamentous cadaver knees.\u003c/p\u003e\n\u003cp\u003eLack S, and colleagues found that the effects of FOs were significantly lower for knee internal rotation during a step-up task in individuals with patellofemoral pain\u0026nbsp;\u003csup\u003e66\u003c/sup\u003e. These authors described that a change in knee kinematics appears to be associated with an altered rearfoot kinematics, as the subtalar joint provides an anatomical connection between the talus and the tibia. Of note, the knee joint is a hinge-type synovial joint, which mainly allows motion in sagittal plane and a limited motion in the frontal and transversal planes. In contrast, the hip and ankle joints allow angular motion in multiple directions and rotational movements. Thus, the observed changes may likely occur in the hip and ankle joints rather than the knee joint.\u003c/p\u003e\n\u003cp\u003eIn this context, Chen et al.\u0026nbsp;\u003csup\u003e9\u003c/sup\u003e showed that custom-made insoles produced significant changes in ankle joint angles but had only minor effects on the knee and hip joint kinematics in adults during walking. Similarly, Nester et al.\u0026nbsp;\u003csup\u003e67\u003c/sup\u003e demonstrated that both medially and laterally wedged FOs had the greatest effect on the kinematics and moments of the rearfoot complex, while the knee, hip, and pelvis were generally unaffected.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4.5. Clinical implications\u003c/p\u003e\n\u003cp\u003eThis meta-analysis revealed a lower peak rearfoot eversion angle (~ 1.72°) when using FOs compared to control. This device-related change has previously been hypothesized to be linked to clinical improvements in individuals with pronated feet\u0026nbsp;\u003csup\u003e47\u003c/sup\u003e. Nevertheless, the association of kinematic changes with clinical benefits, especially from midfoot and forefoot control, is constrained by only one study\u0026nbsp;\u003csup\u003e46\u003c/sup\u003e. Since the lower limbs act as a closed kinematic chain, significant angular changes in the ankle joint are translated to more proximal joints\u0026nbsp;\u003csup\u003e68, 69\u003c/sup\u003e. A possible explanation is that FOs might indirectly affect the knee, hip, and pelvis kinematics by altering the proprioceptive mechanisms involved in regulating muscle function within these joints\u0026nbsp;\u003csup\u003e70\u003c/sup\u003e. Although FOs are prescribed to alter foot abnormality in individuals with pronated feet, they may affect the mechanics of the above lying (more proximal) joints\u0026nbsp;\u003csup\u003e14, 68, 69\u003c/sup\u003e. Indeed, there is evidence that the application of FOs improves knee and pelvic angles in the sagittal plane during the stance phase of walking\u0026nbsp;\u003csup\u003e68, 69\u003c/sup\u003e. Park et al.\u0026nbsp;\u003csup\u003e68, 69\u003c/sup\u003e suggested that the joint modifications were due to the rearfoot inversion allowed by a lower plantar and fascia muscle tension and an elevation of the talus joint. However, there is preliminary evidence that medially posted FOs may have adverse effects in the form of greater knee adduction moments\u0026nbsp;\u003csup\u003e14\u003c/sup\u003e. Indeed, Telfer et al found that a lower rearfoot eversion, induced by s medially posted FO, was not only associated with a lower rearfoot eversion moment but also a greater knee adduction moment\u0026nbsp;\u003csup\u003e14\u003c/sup\u003e. Since greater moments have been associated with the development and progression of medial compartment knee osteoarthritis\u0026nbsp;\u003csup\u003e71\u003c/sup\u003e, medially posted FOs should be prescribed with caution. Moreover, a dose-response effect exists between the level of posting and the ankle and knee joint biomechanics, as a higher medially posted device results in a lower rearfoot eversion and a greater knee adduction moment\u0026nbsp;\u003csup\u003e14\u003c/sup\u003e. In contrast, Cheung et al.\u0026nbsp;\u003csup\u003e17\u003c/sup\u003e reported that custom-made FOs are more effective than prefabricated FOs. The authors argued that the personalized device enables adaptations through biomechanical changes which are more effective in the correction of the foot posture. Indeed, a FO with a contoured medial arch has been shown to prevent the deformation of the medial longitudinal arch and it may lead to lower foot pronation during walking\u0026nbsp;\u003csup\u003e14\u003c/sup\u003e. Accordingly, new technologies, such as additive manufacturing (i.e., 3D printing), must be considered as they allow the production of custom shapes and geometries which is impossible through traditional fabrication techniques. Therefore, 3D printing appears to allow new options for individualized FO fabrication\u0026nbsp;\u003csup\u003e14\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4.6. Limitations and methodological considerations\u003c/p\u003e\n\u003cp\u003eDue to a limited number of studies, we were unable to examine and aggregate the effects of short-term FO application on muscular activities and plantar pressure. These neuromuscular or pressure-sensitive outcome measures would additionally provide information on the underlying mechanisms responsible for FO-related changes in foot posture. Another limitation of this systematic review is that we only examined the effects of short-term FO application on walking mechanics but not running and standing mechanics. Again, the number of available studies did not allow to meta-analyze these experimental conditions. Of note, greater foot pronation and ground reaction forces have been reported during running compared with walking which is why a transfer from one physical activity mode (walking) to the other (running) appears possible\u0026nbsp;\u003csup\u003e72, 73\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother limitation is that the materials used for the FOs were not quantitatively considered in our meta-analysis. Instead, we reported qualitative information in regards of FO material for each study in Table 3.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe further noted that the authors from the included studies applied different types of foot posture assessment methods. We tried to deal with this potential cause of bias by reporting our findings in the context of the respective foot posture method. Notably, we observed greater effects of short-term FO application on walking mechanics in the studies that used the FPI-6 to measure foot posture. A previous study reported that the FPI-6 method is a highly reliable (intraclass correlation coefficient [ICC] = 0.93) approach to be used for the assessment of foot posture. In contrast, the navicular drop method appears to be less reliable with an ICC=0.40\u0026nbsp;\u003csup\u003e21\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur meta-analysis included studies that assessed the effects of short-term FO application on walking kinematics and kinetics while walking barefoot, with sandals, or in standardized shoes. This could have affected the outcomes of our meta-analysis as well.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, several included studies (n=11) did not compute a priori sample size calculations. Therefore, it is attainable that some were underpowered to detect actual FO effects. Besides the influence of these methodological aspects, it should be kept in mind that each participant responds uniquely to the wearing of FOs\u0026nbsp;\u003csup\u003e74, 75\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eOur findings highlight the effects of short-term FO application (one session) versus control on lower limbs kinetics and kinematics during walking in adult individuals\u0026nbsp;(≥18\u0026nbsp;years) with excessive foot pronation. Results from this study showed that FO application compared with control resulted in lower peak rearfoot eversion and peak ankle dorsiflexion and eversion angles. This meta-analysis further revealed that the peak ankle eversion moment was greater in the control condition and the peak knee adduction moment turned out to be larger in the FO condition.\u0026nbsp;Since previous research showed particularly high test-retest reliability measures for the FPI-6 method\u0026nbsp;\u003csup\u003e21\u003c/sup\u003e, we recommend to uniformly use this type of foot posture measure in future studies. In addition, the present study revealed the need to better standardize participant recruitment and the FO assessment protocol. This should make the management of individuals with pronated feet easier in the future for health practitioners.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAE collected the data, analysed the data, and wrote the manuscript; AAJ analysed the data and wrote the manuscript; SHM collected the data and wrote the manuscript; UG analysed the data and wrote the manuscript. All authors have read and approved the final version of the manuscript, and agree with the order of presentation of the authors. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no financial interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eLundberg A, Svensson OK, Bylund C, Goldie I, Selvik G. Kinematics of the ankle/foot complex\u0026mdash;part 2: Pronation and supination. \u003cem\u003eFoot \u0026amp; ankle\u0026nbsp;\u003c/em\u003e1989;\u003cstrong\u003e9\u003c/strong\u003e:248-53.\u003c/li\u003e\n \u003cli\u003eLafortune M, Cavanagh P, Sommer III H, Kalenak A. Foot inversion‐eversion and knee kinematics during walking. \u003cem\u003eJournal of orthopaedic research\u0026nbsp;\u003c/em\u003e1994;\u003cstrong\u003e12\u003c/strong\u003e:412-20.\u003c/li\u003e\n \u003cli\u003eBishop C, Arnold JB, May T. Effects of taping and orthoses on foot biomechanics in adults with flat-arched feet. \u003cem\u003eMedicine and science in sports and exercise\u0026nbsp;\u003c/em\u003e2016;\u003cstrong\u003e48\u003c/strong\u003e:689-96.\u003c/li\u003e\n \u003cli\u003eLevinger P, Murley GS, Barton CJ, Cotchett MP, McSweeney SR, Menz HB. A comparison of foot kinematics in people with normal-and flat-arched feet using the oxford foot model. \u003cem\u003eGait \u0026amp; posture\u0026nbsp;\u003c/em\u003e2010;\u003cstrong\u003e32\u003c/strong\u003e:519-23.\u003c/li\u003e\n \u003cli\u003eTateuchi H, Wada O, Ichihashi N. Effects of calcaneal eversion on three-dimensional kinematics of the hip, pelvis and thorax in unilateral weight bearing. \u003cem\u003eHum mov sci\u003c/em\u003e. 2011, p. 566-73.\u003c/li\u003e\n \u003cli\u003eFarahpour N, Jafarnezhad A, Damavandi M, Bakhtiari A, Allard P. Gait ground reaction force characteristics of low back pain patients with pronated foot and able-bodied individuals with and without foot pronation. \u003cem\u003eJournal of biomechanics\u0026nbsp;\u003c/em\u003e2016;\u003cstrong\u003e49\u003c/strong\u003e:1705-10.\u003c/li\u003e\n \u003cli\u003eJafarnezhadgero AA, Sorkhe E, Oliveira AS. Motion-control shoes help maintaining low loading rate levels during fatiguing running in pronated female runners. \u003cem\u003eGait \u0026amp; posture\u0026nbsp;\u003c/em\u003e2019;\u003cstrong\u003e73\u003c/strong\u003e:65-70.\u003c/li\u003e\n \u003cli\u003eLeung A, Mak A, Evans J. Biomechanical gait evaluation of the immediate effect of orthotic treatment for flexible flat foot. \u003cem\u003eProsthetics and orthotics international\u0026nbsp;\u003c/em\u003e1998;\u003cstrong\u003e22\u003c/strong\u003e:25-34.\u003c/li\u003e\n \u003cli\u003eChen Y-C, Lou S-Z, Huang C-Y, Su F-C. Effects of foot orthoses on gait patterns of flat feet patients. \u003cem\u003eClinical biomechanics\u0026nbsp;\u003c/em\u003e2010;\u003cstrong\u003e25\u003c/strong\u003e:265-70.\u003c/li\u003e\n \u003cli\u003eKido M, Ikoma K, Hara Y, et al. Effect of therapeutic insoles on the medial longitudinal arch in patients with flatfoot deformity: A three-dimensional loading computed tomography study. \u003cem\u003eClinical Biomechanics\u0026nbsp;\u003c/em\u003e2014;\u003cstrong\u003e29\u003c/strong\u003e:1095-8.\u003c/li\u003e\n \u003cli\u003eSheykhi-Dolagh R, Saeedi H, Farahmand B, et al. The influence of foot orthoses on foot mobility magnitude and arch height index in adults with flexible flat feet. \u003cem\u003eProsthetics and orthotics international\u0026nbsp;\u003c/em\u003e2015;\u003cstrong\u003e39\u003c/strong\u003e:190-6.\u003c/li\u003e\n \u003cli\u003eAminian G, Safaeepour Z, Farhoodi M, Pezeshk AF, Saeedi H, Majddoleslam B. The effect of prefabricated and proprioceptive foot orthoses on plantar pressure distribution in patients with flexible flatfoot during walking. \u003cem\u003eProsthetics and orthotics international\u0026nbsp;\u003c/em\u003e2013;\u003cstrong\u003e37\u003c/strong\u003e:227-32.\u003c/li\u003e\n \u003cli\u003eJohanson MA, Donatelli R, Wooden MJ, Andrew PD, Cummings GS. Effects of three different posting methods on controlling abnormal subtalar pronation. \u003cem\u003ePhysical Therapy\u0026nbsp;\u003c/em\u003e1994;\u003cstrong\u003e74\u003c/strong\u003e:149-58.\u003c/li\u003e\n \u003cli\u003eTelfer S, Abbott M, Steultjens MP, Woodburn J. Dose\u0026ndash;response effects of customised foot orthoses on lower limb kinematics and kinetics in pronated foot type. \u003cem\u003eJournal of biomechanics\u0026nbsp;\u003c/em\u003e2013;\u003cstrong\u003e46\u003c/strong\u003e:1489-95.\u003c/li\u003e\n \u003cli\u003eZifchock RA, Davis I. A comparison of semi-custom and custom foot orthotic devices in high-and low-arched individuals during walking. \u003cem\u003eClinical biomechanics\u0026nbsp;\u003c/em\u003e2008;\u003cstrong\u003e23\u003c/strong\u003e:1287-93.\u003c/li\u003e\n \u003cli\u003eHurd WJ, Kavros SJ, Kaufman KR. Comparative biomechanical effectiveness of over-the-counter devices for individuals with a flexible flatfoot secondary to forefoot varus. \u003cem\u003eClinical Journal of Sport Medicine\u0026nbsp;\u003c/em\u003e2010;\u003cstrong\u003e20\u003c/strong\u003e:428-35.\u003c/li\u003e\n \u003cli\u003eCheung RT, Chung RC, Ng GY. Efficacies of different external controls for excessive foot pronation: A meta-analysis. \u003cem\u003eBritish journal of sports medicine\u0026nbsp;\u003c/em\u003e2011;\u003cstrong\u003e45\u003c/strong\u003e:743-51.\u003c/li\u003e\n \u003cli\u003eBanwell HA, Mackintosh S, Thewlis D. Foot orthoses for adults with flexible pes planus: A systematic review. \u003cem\u003eJ Foot Ankle Res\u0026nbsp;\u003c/em\u003e2014;\u003cstrong\u003e7\u003c/strong\u003e:23.\u003c/li\u003e\n \u003cli\u003eDesmyttere G, Hajizadeh M, Bleau J, Begon M. Effect of foot orthosis design on lower limb joint kinematics and kinetics during walking in flexible pes planovalgus: A systematic review and meta-analysis. \u003cem\u003eClinical Biomechanics\u0026nbsp;\u003c/em\u003e2018;\u003cstrong\u003e59\u003c/strong\u003e:117-29.\u003c/li\u003e\n \u003cli\u003eMcPoil TG, Cornwall MW, Medoff L, Vicenzino B, Forsberg K, Hilz D. Arch height change during sit-to-stand: An alternative for the navicular drop test. \u003cem\u003eJournal of foot and ankle research\u0026nbsp;\u003c/em\u003e2008;\u003cstrong\u003e1\u003c/strong\u003e:1-11.\u003c/li\u003e\n \u003cli\u003eLangley B, Cramp M, Morrison SC. Clinical measures of static foot posture do not agree. \u003cem\u003eJournal of foot and ankle research\u0026nbsp;\u003c/em\u003e2016;\u003cstrong\u003e9\u003c/strong\u003e:1-6.\u003c/li\u003e\n \u003cli\u003eChuter VH. Relationships between foot type and dynamic rearfoot frontal plane motion. \u003cem\u003eJournal of foot and ankle research\u0026nbsp;\u003c/em\u003e2010;\u003cstrong\u003e3\u003c/strong\u003e:1-6.\u003c/li\u003e\n \u003cli\u003ePage MJ, McKenzie JE, Bossuyt PM, et al. The prisma 2020 statement: An updated guideline for reporting systematic reviews. \u003cem\u003eInternational journal of surgery\u0026nbsp;\u003c/em\u003e2021;\u003cstrong\u003e88\u003c/strong\u003e:105906.\u003c/li\u003e\n \u003cli\u003eMoher D, Liberati A, Tetzlaff J, Altman DG, Group* P. Preferred reporting items for systematic reviews and meta-analyses: The prisma statement. \u003cem\u003eAnnals of internal medicine\u0026nbsp;\u003c/em\u003e2009;\u003cstrong\u003e151\u003c/strong\u003e:264-9.\u003c/li\u003e\n \u003cli\u003eDowns SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. \u003cem\u003eJournal of epidemiology \u0026amp; community health\u0026nbsp;\u003c/em\u003e1998;\u003cstrong\u003e52\u003c/strong\u003e:377-84.\u003c/li\u003e\n \u003cli\u003eRadzimski AO, M\u0026uuml;ndermann A, Sole G. Effect of footwear on the external knee adduction moment\u0026mdash;a systematic review. \u003cem\u003eThe knee\u0026nbsp;\u003c/em\u003e2012;\u003cstrong\u003e19\u003c/strong\u003e:163-75.\u003c/li\u003e\n \u003cli\u003eRohatgi A. Webplotdigitizer user manual version 4.6. \u003cem\u003eURL\u0026nbsp;\u003c/em\u003e\u003cem\u003ehttps://automerisio/WebPlotDigitizer\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e2022:1-18.\u003c/li\u003e\n \u003cli\u003eMcGough JJ, Faraone SV. Estimating the size of treatment effects: Moving beyond p values. \u003cem\u003ePsychiatry (Edgmont)\u0026nbsp;\u003c/em\u003e2009;\u003cstrong\u003e6\u003c/strong\u003e:21.\u003c/li\u003e\n \u003cli\u003eHiggins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. \u003cem\u003eBmj\u0026nbsp;\u003c/em\u003e2003;\u003cstrong\u003e327\u003c/strong\u003e:557-60.\u003c/li\u003e\n \u003cli\u003eCosta BL, Magalh\u0026atilde;es FA, Araujo VL, et al. Is there a dose-response of medial wedge insoles on lower limb biomechanics in people with pronated feet during walking and running? \u003cem\u003eGait \u0026amp; posture\u0026nbsp;\u003c/em\u003e2021;\u003cstrong\u003e90\u003c/strong\u003e:190-6.\u003c/li\u003e\n \u003cli\u003eDesmyttere G, Hajizadeh M, Bleau J, Leteneur S, Begon M. Anti-pronator components are essential to effectively alter lower-limb kinematics and kinetics in individuals with flexible flatfeet. \u003cem\u003eClinical Biomechanics\u0026nbsp;\u003c/em\u003e2021;\u003cstrong\u003e86\u003c/strong\u003e:105390.\u003c/li\u003e\n \u003cli\u003eHsu C-Y, Wang C-S, Lin K-W, Chien M-J, Wei S-H, Chen C-S. Biomechanical analysis of the flatfoot with different 3d-printed insoles on the lower extremities. \u003cem\u003eBioengineering\u0026nbsp;\u003c/em\u003e2022;\u003cstrong\u003e9\u003c/strong\u003e:563.\u003c/li\u003e\n \u003cli\u003eLouren\u0026ccedil;o BM, Magalh\u0026atilde;es FA, Vieira FM, et al. An exploration of the effects of prefabricated and customized insoles on lower limb kinetics and kinematics during walking, stepping up and down tasks: A time series analysis. \u003cem\u003eGait \u0026amp; Posture\u0026nbsp;\u003c/em\u003e2022;\u003cstrong\u003e98\u003c/strong\u003e:297-304.\u003c/li\u003e\n \u003cli\u003ePermsombat P, Pensri P. Effects of customized foot orthoses on lower limbs kinematics in adults with highly pronated foot. \u003cem\u003eChulalongkorn Medical Journal\u0026nbsp;\u003c/em\u003e2021;\u003cstrong\u003e65\u003c/strong\u003e:195-205.\u003c/li\u003e\n \u003cli\u003ePeng Y, Wong DW-C, Wang Y, et al. Immediate effects of medially posted insoles on lower limb joint contact forces in adult acquired flatfoot: A pilot study. \u003cem\u003eInternational journal of environmental research and public health\u0026nbsp;\u003c/em\u003e2020;\u003cstrong\u003e17\u003c/strong\u003e:2226.\u003c/li\u003e\n \u003cli\u003ePrachgosin T, Leelasamran W, Smithmaitrie P, Chatpun S. Effect of total-contact orthosis on medial longitudinal arch and lower extremities in flexible flatfoot subjects during walking. \u003cem\u003eProsthetics and Orthotics International\u0026nbsp;\u003c/em\u003e2017;\u003cstrong\u003e41\u003c/strong\u003e:579-86.\u003c/li\u003e\n \u003cli\u003eTang SF-T, Chen C-H, Wu C-K, Hong W-H, Chen K-J, Chen C-K. The effects of total contact insole with forefoot medial posting on rearfoot movement and foot pressure distributions in patients with flexible flatfoot. \u003cem\u003eClinical neurology and neurosurgery\u0026nbsp;\u003c/em\u003e2015;\u003cstrong\u003e129\u003c/strong\u003e:S8-S11.\u003c/li\u003e\n \u003cli\u003eCobb SC, Tis LL, Johnson JT, Wang YT, Geil MD. Custom-molded foot-orthosis intervention and multisegment medial foot kinematics during walking. 46. National Athletic Trainers\u0026apos; Association, Inc; 2011:358-65.\u003c/li\u003e\n \u003cli\u003eHan K, Bae K, Levine N, Yang J, Lee J-S. Biomechanical effect of foot orthoses on rearfoot motions and joint moment parameters in patients with flexible flatfoot. \u003cem\u003eMedical science monitor: international medical journal of experimental and clinical research\u0026nbsp;\u003c/em\u003e2019;\u003cstrong\u003e25\u003c/strong\u003e:5920.\u003c/li\u003e\n \u003cli\u003eBrown GP, Donatelli R, Catlin PA, Wooden MJ. The effect of two types of foot orthoses on rearfoot mechanics. \u003cem\u003eJournal of Orthopaedic \u0026amp; Sports Physical Therapy\u0026nbsp;\u003c/em\u003e1995;\u003cstrong\u003e21\u003c/strong\u003e:258-67.\u003c/li\u003e\n \u003cli\u003eNawoczenski DA, Ludewig PM. The effect of forefoot and arch posting orthotic designs on first metatarsophalangeal joint kinematics during gait. \u003cem\u003eJournal of Orthopaedic \u0026amp; Sports Physical Therapy\u0026nbsp;\u003c/em\u003e2004;\u003cstrong\u003e34\u003c/strong\u003e:317-27.\u003c/li\u003e\n \u003cli\u003eAlsaafin N, Saad N, Mohammad Zadeh SA, Hegazy FA. Effect of different foot orthosis inverted angles on walking kinematics in females with flexible flatfeet. \u003cem\u003eJournal of Multidisciplinary Healthcare\u0026nbsp;\u003c/em\u003e2023:2613-23.\u003c/li\u003e\n \u003cli\u003eDedieu P, Drigeard C, Gjini L, Dal Maso F, Zanone P-G. Effects of foot orthoses on the temporal pattern of muscular activity during walking. \u003cem\u003eClinical biomechanics\u0026nbsp;\u003c/em\u003e2013;\u003cstrong\u003e28\u003c/strong\u003e:820-4.\u003c/li\u003e\n \u003cli\u003eStacoff A, Kramers-de Quervain I, Dettwyler M, et al. Biomechanical effects of foot orthoses during walking. \u003cem\u003eThe Foot\u0026nbsp;\u003c/em\u003e2007;\u003cstrong\u003e17\u003c/strong\u003e:143-53.\u003c/li\u003e\n \u003cli\u003eKosonen J, Kulmala J-P, M\u0026uuml;ller E, Avela J. Effects of medially posted insoles on foot and lower limb mechanics across walking and running in overpronating men. \u003cem\u003eJournal of biomechanics\u0026nbsp;\u003c/em\u003e2017;\u003cstrong\u003e54\u003c/strong\u003e:58-63.\u003c/li\u003e\n \u003cli\u003eNeville C, Flemister AS, Houck J. Effects of the airlift pttd brace on foot kinematics in subjects with stage ii posterior tibial tendon dysfunction. \u003cem\u003ejournal of orthopaedic \u0026amp; sports physical therapy\u0026nbsp;\u003c/em\u003e2009;\u003cstrong\u003e39\u003c/strong\u003e:201-9.\u003c/li\u003e\n \u003cli\u003eGenova JM, Gross MT. Effect of foot orthotics on calcaneal eversion during standing and treadmill walking for subjects with abnormal pronation. \u003cem\u003eJournal of Orthopaedic \u0026amp; Sports Physical Therapy\u0026nbsp;\u003c/em\u003e2000;\u003cstrong\u003e30\u003c/strong\u003e:664-75.\u003c/li\u003e\n \u003cli\u003eSouza TR, Pinto RZ, Trede RG, Kirkwood RN, Fonseca ST. Temporal couplings between rearfoot\u0026ndash;shank complex and hip joint during walking. \u003cem\u003eClinical biomechanics\u0026nbsp;\u003c/em\u003e2010;\u003cstrong\u003e25\u003c/strong\u003e:745-8.\u003c/li\u003e\n \u003cli\u003eCohen LG, Bandinelli S, Topka HR, Fuhr P, Roth BJ, Hallett M. Topographic maps of human motor cortex in normal and pathological conditions: Mirror movements, amputations and spinal cord injuries. \u003cem\u003eElectroencephalography and Clinical Neurophysiology-Supplements only\u0026nbsp;\u003c/em\u003e1994;\u003cstrong\u003e43\u003c/strong\u003e:36-50.\u003c/li\u003e\n \u003cli\u003eRyan MB, Valiant GA, McDonald K, Taunton JE. The effect of three different levels of footwear stability on pain outcomes in women runners: A randomised control trial. \u003cem\u003eBritish Journal of Sports Medicine\u0026nbsp;\u003c/em\u003e2011;\u003cstrong\u003e45\u003c/strong\u003e:715-21.\u003c/li\u003e\n \u003cli\u003eTurner DE, Helliwell PS, Siegel KL, Woodburn J. Biomechanics of the foot in rheumatoid arthritis: Identifying abnormal function and the factors associated with localised disease \u0026lsquo;impact\u0026rsquo;. \u003cem\u003eClinical Biomechanics\u0026nbsp;\u003c/em\u003e2008;\u003cstrong\u003e23\u003c/strong\u003e:93-100.\u003c/li\u003e\n \u003cli\u003eWoodburn J, Helliwell PS, Barker S. Three‐dimensional kinematics at the ankle joint complex in rheumatoid arthritis patients with painful valgus deformity of the rearfoot. \u003cem\u003eRheumatology\u0026nbsp;\u003c/em\u003e2002;\u003cstrong\u003e41\u003c/strong\u003e:1406-12.\u003c/li\u003e\n \u003cli\u003eDubbeldam R, Baan H, Nene A, et al. Foot and ankle kinematics in rheumatoid arthritis: Influence of foot and ankle joint and leg tendon pathologies. \u003cem\u003eArthritis care \u0026amp; research\u0026nbsp;\u003c/em\u003e2013;\u003cstrong\u003e65\u003c/strong\u003e:503-11.\u003c/li\u003e\n \u003cli\u003eWoodburn J, Udupa JK, Hirsch BE, et al. The geometric architecture of the subtalar and midtarsal joints in rheumatoid arthritis based on magnetic resonance imaging. \u003cem\u003eArthritis \u0026amp; Rheumatism\u0026nbsp;\u003c/em\u003e2002;\u003cstrong\u003e46\u003c/strong\u003e:3168-77.\u003c/li\u003e\n \u003cli\u003eHennessy K, Woodburn J, Steultjens MP. Custom foot orthoses for rheumatoid arthritis: A systematic review. \u003cem\u003eArthritis care \u0026amp; research\u0026nbsp;\u003c/em\u003e2012;\u003cstrong\u003e64\u003c/strong\u003e:311-20.\u003c/li\u003e\n \u003cli\u003eWoodburn J, Helliwell PS, Barker S. Changes in 3d joint kinematics support the continuous use of orthoses in the management of painful rearfoot deformity in rheumatoid arthritis. \u003cem\u003eThe Journal of rheumatology\u0026nbsp;\u003c/em\u003e2003;\u003cstrong\u003e30\u003c/strong\u003e:2356-64.\u003c/li\u003e\n \u003cli\u003eGenova JM, Gross MT. Effect of foot orthotics on calcaneal eversion during standing and treadmill walking for subjects with abnormal pronation. \u003cem\u003eThe Journal of orthopaedic and sports physical therapy\u0026nbsp;\u003c/em\u003e2000;\u003cstrong\u003e30\u003c/strong\u003e:664-75.\u003c/li\u003e\n \u003cli\u003eTakabayashi T, Edama M, Yokoyama E, et al. Changes in kinematic coupling among the rearfoot, midfoot, and forefoot segments during running and walking. \u003cem\u003eJ Am Podiatr Med Assoc\u0026nbsp;\u003c/em\u003e2018;\u003cstrong\u003e108\u003c/strong\u003e:45-51.\u003c/li\u003e\n \u003cli\u003eDesmyttere G, Hajizadeh M, Bleau J, Leteneur S, Begon M. Anti-pronator components are essential to effectively alter lower-limb kinematics and kinetics in individuals with flexible flatfeet. \u003cem\u003eClin Biomech (Bristol, Avon)\u0026nbsp;\u003c/em\u003e2021;\u003cstrong\u003e86\u003c/strong\u003e:105390.\u003c/li\u003e\n \u003cli\u003eBrockett CL, Chapman GJ. Biomechanics of the ankle. \u003cem\u003eOrthopaedics and trauma\u0026nbsp;\u003c/em\u003e2016;\u003cstrong\u003e30\u003c/strong\u003e:232-8.\u003c/li\u003e\n \u003cli\u003eDeLisa JA, Gans BM, Walsh NE. \u003cem\u003ePhysical medicine and rehabilitation: Principles and practice.\u003c/em\u003e Lippincott Williams \u0026amp; Wilkins; 2005.\u003c/li\u003e\n \u003cli\u003eNovacheck TF. The biomechanics of running. \u003cem\u003eGait \u0026amp; posture\u0026nbsp;\u003c/em\u003e1998;\u003cstrong\u003e7\u003c/strong\u003e:77-95.\u003c/li\u003e\n \u003cli\u003eWilliams 3rd DS, Davis M, Baitch SP. Effect of inverted orthoses on lower-extremity mechanics in runners. \u003cem\u003eMedicine and science in sports and exercise\u0026nbsp;\u003c/em\u003e2003;\u003cstrong\u003e35\u003c/strong\u003e:2060-8.\u003c/li\u003e\n \u003cli\u003eJafarnezhadgero AA, Shad MM, Majlesi M. Effect of foot orthoses on the medial longitudinal arch in children with flexible flatfoot deformity: A three-dimensional moment analysis. \u003cem\u003eGait \u0026amp; posture\u0026nbsp;\u003c/em\u003e2017;\u003cstrong\u003e55\u003c/strong\u003e:75-80.\u003c/li\u003e\n \u003cli\u003eKostuik JP, Schmidt O, Harris WR, Wooldridge C. A study of weight transmission through the knee joint with applied varus and valgus loads. \u003cem\u003eClinical orthopaedics and related research\u0026nbsp;\u003c/em\u003e1975:95-8.\u003c/li\u003e\n \u003cli\u003eLack S, Barton C, Woledge R, Laupheimer M, Morrissey D. The immediate effects of foot orthoses on hip and knee kinematics and muscle activity during a functional step-up task in individuals with patellofemoral pain. \u003cem\u003eClinical Biomechanics\u0026nbsp;\u003c/em\u003e2014;\u003cstrong\u003e29\u003c/strong\u003e:1056-62.\u003c/li\u003e\n \u003cli\u003eNester C, Van Der Linden M, Bowker P. Effect of foot orthoses on the kinematics and kinetics of normal walking gait. \u003cem\u003eGait \u0026amp; posture\u0026nbsp;\u003c/em\u003e2003;\u003cstrong\u003e17\u003c/strong\u003e:180-7.\u003c/li\u003e\n \u003cli\u003ePark K. Effects of wearing functional foot orthotic on pelvic angle among college students in their 20s with flatfoot. \u003cem\u003eJournal of physical therapy science\u0026nbsp;\u003c/em\u003e2017;\u003cstrong\u003e29\u003c/strong\u003e:438-41.\u003c/li\u003e\n \u003cli\u003ePark K, Seo K. Effects of a functional foot orthosis on the knee angle in the sagittal plane of college students in their 20s with flatfoot. \u003cem\u003eJournal of physical therapy science\u0026nbsp;\u003c/em\u003e2015;\u003cstrong\u003e27\u003c/strong\u003e:1211-3.\u003c/li\u003e\n \u003cli\u003eStacoff A, Reinschmidt C, Nigg BM, et al. Effects of shoe sole construction on skeletal motion during running. \u003cem\u003eMedicine \u0026amp; Science in Sports \u0026amp; Exercise\u0026nbsp;\u003c/em\u003e2001;\u003cstrong\u003e33\u003c/strong\u003e:311-9.\u003c/li\u003e\n \u003cli\u003eMiyazaki T, Wada M, Kawahara H, Sato M, Baba H, Shimada S. Dynamic load at baseline can predict radiographic disease progression in medial compartment knee osteoarthritis. \u003cem\u003eAnnals of the rheumatic diseases\u0026nbsp;\u003c/em\u003e2002;\u003cstrong\u003e61\u003c/strong\u003e:617-22.\u003c/li\u003e\n \u003cli\u003eHreljac A, Marshall RN, Hume PA. Evaluation of lower extremity overuse injury potential in runners. \u003cem\u003eMedicine \u0026amp; Science in Sports \u0026amp; Exercise\u0026nbsp;\u003c/em\u003e2000;\u003cstrong\u003e32\u003c/strong\u003e:1635-41.\u003c/li\u003e\n \u003cli\u003eSp M. Etiologic factors associated with selected running injuries. \u003cem\u003eMed Sci Sports Exerc\u0026nbsp;\u003c/em\u003e1988;\u003cstrong\u003e20\u003c/strong\u003e:501-5.\u003c/li\u003e\n \u003cli\u003eMills K, Blanch P, Chapman AR, McPoil TG, Vicenzino B. Foot orthoses and gait: A systematic review and meta-analysis of literature pertaining to potential mechanisms. \u003cem\u003eBritish journal of sports medicine\u0026nbsp;\u003c/em\u003e2010;\u003cstrong\u003e44\u003c/strong\u003e:1035-46.\u003c/li\u003e\n \u003cli\u003eM\u0026uuml;ndermann A, Nigg BM, Humble RN, Stefanyshyn DJ. Foot orthotics affect lower extremity kinematics and kinetics during running. \u003cem\u003eClinical biomechanics\u0026nbsp;\u003c/em\u003e2003;\u003cstrong\u003e18\u003c/strong\u003e:254-62.\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Gait, Insoles, Mechanics, Pronation","lastPublishedDoi":"10.21203/rs.3.rs-3941166/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3941166/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eFoot orthoses (FO) are frequently used medical devices to correct lower limbs malalignment in the form of excessive foot pronation. This systematic review with meta-analysis aimed to investigate the effects of short-term FO application on walking kinematics and kinetics in adults aged ≥18 years with excessive foot pronation. Five electronic databases (MEDLINE, Scopus, PubMed, EMBASE, and Cochrane Central Register of Controlled Trials [CENTRAL]) were systematically searched from inception to January 2024. According to the PICOS approach, the eligibility criteria were: (P) healthy participants with pronated feet, (I) short-term FO interventions (one session), (C) other walking conditions (e.g., barefoot, only shoe, fake foot orthosis), (O) lower limbs kinematics (e.g., rearfoot eversion) and kinetics (e.g., knee joint moments) during walking, and (S) case-control studies, cross-sectional studies, randomized control trials, cohort studies, and case series designs. The modified version of the Downs and Black checklist was used to assess the methodological quality. Between-group standardized mean differences (SMDs) with 95% confidence intervals (CI) were computed using a random-effects model to elucidate the effects of short-term FO compared to controls. Statistical significance was set at p\u0026lt;0.05. The heterogeneity between studies was assessed using the I2 index. Twenty-two studies were identified and meta-analyzed. Overall, the methodological quality of the included studies was moderate, with 15 studies achieving high-quality and the remaining seven moderate quality. For kinematics, the meta-analysis showed significant effects of short-term FO application during walking on peak rearfoot eversion (nine studies: moderate SMDs=0.66, 95% CI 0.34 to 0.99), peak ankle dorsiflexion (five studies: small SMDs=-0.33, 95% CI -0.54 to -0.12), and eversion (seven studies: moderate SMDs=0.58, 95% CI 0.27 to 0.90). Concerning kinetics, the meta-analysis indicated significant effects of short-term FO application on the peak ankle eversion moment (five studies: small SMDs=0.38, 95% CI 0.17 to 0.59) and the peak knee adduction (six studies: small SMDs=-0.30, 95% CI -0.50 to -0.10). Study heterogeneity ranged from I² = 0-87%. Our meta-analysis showed significant effects of short-term FO application on the rearfoot eversion angle during walking in adults aged ≥18 years. Accordingly, the wearing of FOs can be recommended for adults with foot malalignment. However, between study heterogeneity was high for selected outcome parameters (e.g., peak ankle eversion). Therefore, more high-quality research is needed to elucidate the effects of short-term FO application on walking kinematics and kinetics as well as lower limbs muscular activation.\u003c/p\u003e\n\u003cp\u003eRegistration number: The protocol for this systematic review with meta-analysis was registered with PROSPERO on November, 17th 2023 (Project: https://www.crd.york.ac.uk/prospero/#myprospero, ID: CRD42023480039).\u003c/p\u003e","manuscriptTitle":"Effects of short-term foot orthoses application on walking kinematics and kinetics in adults with pronated feet: A systematic review with meta-analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-06 19:14:56","doi":"10.21203/rs.3.rs-3941166/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"440d5b0c-24ca-44c6-a26e-a7cb2a43a5d3","owner":[],"postedDate":"March 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":29109611,"name":"Health sciences/Medical research/Study design"},{"id":29109612,"name":"Biological sciences/Physiology/Bone quality and biomechanics"},{"id":29109613,"name":"Health sciences/Health care/Diagnosis/Physical examination"}],"tags":[],"updatedAt":"2024-05-13T03:10:06+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-06 19:14:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3941166","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3941166","identity":"rs-3941166","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}