ROYAL COLLEGE OF PODIATRY
Evidence in practice
Evidence in Practice is a new regular series from The New Podiatrist bringing together clinicians and researchers to highlight new evidence and explore what it could mean for day-to-day practice. This month, the team explores three studies examining movement, function and rehabilitation. From foot orthoses and balance to whether common strengthening exercises are really doing what we think they are.
Investigating the effect of foot orthotics on dynamic stability in females with pes planus foot posture
Source: Gait and Posture :124 (2026)
What did the study look at?
This study explored how the postural balance of healthy females with pes planus foot posture reacted when wearing an off-the-shelf insole while walking on wedged surfaces.
Footwear was controlled and the participants all wore the same preformed device. This lab-based study used infrared markers to track changes in gait parameters as well as sway-related centre of mass perturbations.
What did it find?
The higher foot posture participants, indicating a greater degree of pes planus, had different perturbations of balance than those with a lower foot posture when standing on wedged surfaces.
When walking in trainers only on a lateral wedge (increasing eversion), walking velocity was significantly slower than walking on a flat surface or a medial wedge (increasing inversion). Walking on either wedge condition with the insole and trainers slowed walking velocity.
Wearing orthoses during wedge walking conditions altered sway balance measures, with range of motion significantly improved compared with flat-floor walking.
When walking on inclined surfaces, wearing insoles in a trainer altered balance and walking parameters in asymptomatic females with pes planus.
What does this mean in practice?
The exact science of how orthoses assist wearers has been speculative for many years – a large amount of the evidence is based only on theories.
Although this paper does not investigate participants with symptoms, it demonstrates a clear change in gait and balance function in a group of females with a controlled foot posture.
Future research should now explore whether symptomatic pes planus groups demonstrate similar responses
With additional research, clinical application is more credible – as an understanding of desired outcomes can be utilised in clinical practice.
Equally, regaining function and control of stability by utilising footwear and over-the-counter orthoses to improve postural stability can be included as an overall component to rehabilitating normal function.
When a patient has responded to interventions for pain management, it is important to rehabilitate to a strong healthy foot that has effective postural control in all environmental conditions.
Any limitations?
The application of this work to clinical practice is limited as the group was a healthy cohort. However, this is a step towards understanding how individuals respond to different environmental changes when walking in trainers and over-the-counter insoles
The group of 18 participants has a wide outcome measure range, increasing variability of the results. This demonstrates the complexity of applying group-level averages to individuals who may respond differently despite tightly controlled inclusion criteria.
The influence of body posture and added mass on intrinsic and extrinsic foot muscle activation and force output during common foot strengthening exercises
Source: Osborne JWA, Menz HB, Landorf KB, Whittaker GA, Cotchett M, Kelly LA. J Sport Health Sci. 2026;15:101110.
Link: https://pmc.ncbi.nlm.nih.gov/articles/PMC13090714/pdf/main.pdf
What did the study look at?
This study examined how commonly prescribed foot-strengthening exercises, such as the short foot, toe spread out, hallux flexion and heel raises, affect muscle activation and force production at the metatarsophalangeal (MTP) joints.
The authors also tested whether two simple modifications, leaning forward or adding external mass (20% of body weight), could boost muscle activity and torque output during these exercises.
What did it find?
Common exercises such as the short foot and toe spread out produced high levels of intrinsic muscle activation on electromyography (EMG) but generated very low MTP joint torque. This suggests that muscles were firing but producing very little meaningful force.
A simple forward-lean cue produced a moderate increase in MTP joint torque, bringing force output to levels comparable to the demands experienced during walking. This was more effective and more consistent than adding external mass.
Single-leg heel raises with a forward lean produced the highest combined muscle activation and torque of any exercise tested, approaching the functional demands placed on the foot during gait.
Despite being frequently included in foot-strengthening programmes, the squat produced low levels of both foot muscle activation and MTP joint torque.
What does this mean in practice?
This paper should encourage us to think more critically about the foot-strengthening exercises we prescribe.
Many of us routinely hand out short-foot exercises and toe curls as cornerstones of rehabilitation for conditions such as plantar heel pain and chronic ankle instability.
This study suggests that while those exercises activate the intrinsic muscles, they don't generate functionally relevant force – the kind the foot needs to cope with walking, let alone running.
High EMG activity does not automatically mean the muscle is working hard in a way that translates into real-world strength gains.
The practical takeaway is simple – adding a forward lean to weight-bearing exercises, such as hallux flexion and heel raises, can meaningfully increase force production without special equipment. It shifts the centre of mass forward, loads the forefoot, lengthens the toe flexor muscle-tendon units and brings the exercise closer to replicating what these muscles do during gait.
For clinicians looking to progress patients beyond early-stage motor control work, this is a straightforward modification that could make a genuine difference to patient outcomes.
The authors also present a helpful framework for progressive exercise selection based on both activation and torque, which could be a useful clinical reference for different patient populations.
Any limitations?
This was a small study of 15 healthy participants with no foot pathology, so caution is needed on generalising these findings to patients with plantar fasciitis, ankle instability or other conditions where muscle function may already be compromised.
The forward lean was not standardised to a specific angle – it was a pragmatic verbal cue, which is clinically realistic, but it does introduce variability. Not all exercises were tested with both the lean and added mass modifications, so direct comparisons across the full set of exercises are not possible.
A real strength of the study is the use of fine-wire EMG, but this method can also limit the sample size due to the invasive nature of the procedure. Importantly, this was a single-session study measuring acute responses. Therefore, it is unknown whether these exercises, prescribed over weeks or months, would lead to meaningful strength gains, symptom reduction or improved function.
Exploring experiences and perspectives of prescribed foot orthoses in people with diabetes
Source: Journal of Foot and Ankle Research Feb 2026
Link: https://doi.org/10.1002/jfa2.70130
What did the study look at?
As we move towards more personalised medicine, understanding the experiences of patients and what matters to them is essential to help clinicians consider what issues are important to people when formulating care plans.
This qualitative study interviewed eight people at risk of diabetic foot ulceration who had been prescribed foot orthoses to better understand their experiences of using them.
Interviews were conducted through online focus groups or one-on-one telephone calls, with researchers’ identifying themes from participants’ experiences.
What did it find?
The study reported three overarching themes.
Adherence and barriers to effective use of foot orthoses.
Perceived benefits of foot orthoses and desired improvements.
Anxiety and psychological impacts.
Adherence to using prescribed foot orthoses was influenced by factors such as:
discomfort of the orthoses, especially feeling unstable
the problem of replacing them when they were worn out
the difficulty of accessing professional healthcare support
the complex relationship of fitting orthoses inside different types of footwear where they often did not align
Participants recognised the benefits of the foot orthoses. However, there were huge variations in how people suggested that their design could be improved. Some people wanted them to be thicker, some thinner, some more cushioned and some harder.
Participants were anxious and worried about the risk of further foot complications which influenced some people to wear their orthoses and look after their feet. But for others, the opposite happened – and it became a source of disengagement and loss of confidence.
What does this mean in practice?
Recommendations from the International Working Group for Diabetic Foot (IWGFD) and National Institute for Health and Care Excellence (NICE) highlight the importance of footwear and orthoses as an important treatment modality when trying to prevent foot ulcers in people with diabetes. However, ‘compliance/adherence’ to wearing footwear and orthoses is known to be low.
These findings suggest that when prescribing foot orthoses, clinicians need to listen to their patients to understand their individual perspectives. Working in partnership with the patient, clinicians need to be more aware of what is important to the individual and how they can tailor the design, support and education around orthoses to meet the patient’s needs and expectations. It is hoped that these measures will enhance people’s engagement with the use of foot orthoses.
Any limitations?
This was a small study of eight people, of which seven were male and one was female
All the participants were from Scotland.
There was no standardisation of foot orthoses or footwear prescribed to the participants.
If you read one thing this month, make it:
Links and references
You can read more original research and commentary in The Journal of Foot and Ankle Research – the official journal of The Royal College of Podiatry and a co-production with the Australian Podiatry Association.
About the authors
Dr Helen Branthwaite is the Chief Clinical Advisor at the Royal College of Podiatry, with over 25 years’ experience in musculoskeletal practice across NHS, independent and academic settings.
Dr Richard Collings is Head of Podiatry and Orthotics in Torbay and a visiting specialist and Honorary Clinical Research Fellow at the School of Health Professions, University of Plymouth. He has over 18 years’ experience in musculoskeletal practice in the NHS. He is also the Chair of the Royal College of Podiatry’s Research, Development and Innovation Committee.
Professor Sarah Curran is Professor of Podiatric Medicine and Rehabilitation
at the Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, and the UK Editor-in-Chief of the Journal of Foot and Ankle Research
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