Orthotics can be very useful in posterior tibial tendon disorders, but they should solve a mechanical problem rather than simply accompany the diagnosis. In isolated early tendinopathy with preserved alignment, progressive loading may be sufficient. When the tendon is struggling to control hindfoot valgus or arch collapse, an orthotic or ankle-foot brace can reduce demand and improve walking mechanics while the tendon and surrounding musculature are rehabilitated.
Posterior tibial tendon pain is not automatically flatfoot
The tibialis posterior tendon runs behind the inside ankle bone and attaches at the navicular in the midfoot. It helps control the medial arch as weight moves over the foot. When the tendon is irritated, the result can be pain behind the ankle or along the arch with perfectly normal foot alignment.
A low arch on its own is also not a diagnosis. Many people have naturally low, flexible arches without pain or progressive change. A naturally low arch is not the same thing as progressive collapsing foot deformity. The concern is acquired or progressive change combined with pain, loss of function or mechanical instability.
What is progressive collapsing foot deformity?
The historical term posterior tibial tendon dysfunction (PTTD) is still widely used, but advanced arch collapse is now more accurately described as progressive collapsing foot deformity (PCFD). PCFD reflects a broader three-dimensional failure pattern rather than a problem involving the posterior tibial tendon alone.
A 2020 expert consensus group proposed the name after noting that the older terminology, including adult acquired flatfoot deformity and posterior tibial tendon dysfunction, was confusing and inconsistent. The group described PCFD as a complex three-dimensional deformity with varying degrees of hindfoot valgus, forefoot abduction and midfoot varus, and noted that many, but not all, of these deformities are associated with posterior tibial tendon rupture.
As the deformity develops, the problem can involve the posterior tibial tendon, the spring ligament under the arch, the deltoid ligament on the inside of the ankle, hindfoot and midfoot alignment, forefoot position and, in advanced cases, the ankle itself. Once the foot is collapsing, treatment cannot focus exclusively on the tendon because the problem has become a multiplanar mechanical deformity.
What orthotics actually change mechanically
An orthotic can change the load placed on the foot. It does not rebuild the tendon by itself.
When the heel rolls outward and the arch lowers with each step, the tendon is asked to resist those forces repeatedly. A foot orthosis that supports the medial arch and heel, or an ankle-foot orthosis that also controls the ankle and hindfoot, can reduce how far the foot collapses and how hard the tendon has to work. That can make walking more comfortable and create room for rehabilitation to progress.
What the 2026 meta-analysis found
The newest systematic review and meta-analysis strengthens the case for mechanical support when true progressive collapsing foot deformity is present. Across 14 studies, orthotic interventions improved pain and function and measurably altered pathologic foot mechanics.
PCFD orthotic meta-analysis · 2026 · 14 studies
Hindfoot eversion
−3–5°
less eversion with orthoses
Foot Functional Index
56.8%
improvement (95% CI 41.1–72.58)
AOFAS ankle/hindfoot
+28.5 points
(95% CI 22.66–34.4)
These results come from people with progressive collapsing foot deformity. They should not be applied to isolated tendon pain with normal foot alignment.
Khaliliyan and colleagues searched three databases and included 14 studies of orthotic interventions for progressive collapsing foot deformity. They reported major improvements in disability, pain and patient satisfaction. Orthoses reduced hindfoot eversion by roughly 3–5° and increased forefoot plantarflexion by roughly 6–9°. Ankle-foot orthoses with lateral extensions or an articulated design improved forefoot adduction and hindfoot inversion. Pooled analyses reported a 56.84% improvement in Foot Functional Index (95% CI 41.1 to 72.58) and a 28.53-point improvement in AOFAS ankle/hindfoot scores (95% CI 22.66 to 34.4).
The review assessed study quality with a tool designed for nonrandomized studies, so much of the evidence is observational. Even so, it is the most comprehensive synthesis to date and consistently points in the same direction for PCFD.
What early-stage randomized trials show
A systematic review of four randomized trials involving 186 patients found that orthoses can reduce pain in early-stage posterior tibial tendon dysfunction. Personalized arch support appeared more effective than flat insoles, and orthoses generally performed better when combined with exercise rather than used as the entire treatment. Three-quarters of the trials were at high risk of bias for blinding, which is difficult to avoid with visible treatments.
In a randomized trial of 36 patients with early-stage disease, all groups improved with orthotic support and stretching, but adding progressive resistance exercise, particularly eccentric loading, produced greater improvement in pain and function. The orthosis-and-stretching group improved least.
A separate randomized study of stage-II disease found substantial improvement in both orthosis-based groups, with relatively little added benefit from its moderate-intensity home strengthening program. That result reinforces that mechanical support itself can matter when deformity is present, while also highlighting that exercise dose and program design matter. Thirty-nine patients were randomized and 36 completed the 12-week trial.
In a prospective series of 47 stage-I/II patients treated with an orthosis plus structured strengthening, 83% achieved successful subjective and functional outcomes and only 11% progressed to surgery. Patients used a short articulated ankle-foot orthosis or a foot orthosis with a high-repetition exercise program over a median of 10 physical therapy visits across about four months, and 89% were satisfied. The study was not randomized, so 83% is not a universal success rate.
Who is more likely to benefit from orthotic support?
External support tends to be more valuable when:
- Meaningful hindfoot valgus is present
- The medial arch is collapsing, especially if it has changed over time
- Symptoms are strongly load dependent
- The tendon cannot yet control the foot adequately
- Walking tolerance is poor
- Progressive collapsing foot deformity mechanics are present
- Temporary unloading would allow rehabilitation to progress
There is no validated numeric threshold for when an orthotic becomes necessary. The decision is clinical, based on the overall picture.
Who may not need an orthotic?
Support may be less important when:
- Tendon pain is isolated and mild
- Foot alignment is normal and symmetrical
- Tendon capacity can be rebuilt without external support
- Symptoms are already resolving with load management and exercise
Orthotics are selectively indicated rather than automatically prescribed. For isolated early tendon pain they may be unnecessary. For PCFD they can be an important part of conservative management.
Foot orthosis vs. ankle-foot orthosis
A foot orthosis sits inside the shoe and supports the arch and heel. It is usually enough for milder, flexible mechanics. An ankle-foot orthosis extends above the ankle and controls the hindfoot more strongly. It is generally reserved for more significant deformity, poor tolerance of a foot orthosis, or situations where the hindfoot needs more control than an insert can provide. In the 2026 meta-analysis, ankle-foot orthoses with lateral extensions or an articulated design improved hindfoot inversion and forefoot adduction.
Does wearing an orthotic weaken the foot?
An orthotic changes mechanical load; it does not replace strengthening. When support is needed, Novo pairs it with progressive loading whenever appropriate so the tendon and surrounding musculature continue to build capacity. Whenever possible, mechanical support should be paired with progressive strength and functional loading.
Should an orthotic be permanent?
The goal is not necessarily permanent dependence on an orthotic. Support can be temporary or long term depending on whether the underlying deformity is flexible, progressive and symptomatic. Some people use support for a period while tendon capacity is rebuilt and then reduce it. Others, particularly with structural PCFD, may appropriately need ongoing support.
Why exercise still matters
A systematic review found a moderate signal favoring eccentric strengthening when combined with orthoses and stretching, but the number of randomized trials was small and exercise prescriptions were poorly standardized. Across the trials above, exercise programs varied widely in type, dose and supervision, which likely explains some of their different results. Progressive loading of the tendon, calf and foot muscles remains foundational, with or without an orthotic.
What Type of Orthotic Does Novo Use?
When custom orthotic support is indicated, Novo uses Sole Supports. Their flagship devices are custom-molded and fabricated through trained healthcare providers, with the device selected and configured according to the patient's foot mechanics, activity demands and footwear.
The brand is secondary to the clinical decision. The important question is whether the patient actually has a mechanical problem that benefits from external support. A painful posterior tibial tendon with preserved alignment may not require an orthotic at all, while flexible arch collapse or progressive collapsing foot deformity may benefit substantially from mechanical support.
Novo does not prescribe an orthotic simply because a patient has medial ankle pain or a low arch. External support becomes more valuable when the examination shows a mechanical problem that the tendon cannot currently control, particularly meaningful hindfoot valgus, arch collapse or progressive collapsing foot deformity. In those cases an orthotic or brace can reduce mechanical demand while tendon capacity is rebuilt.
Learn more about Sole Supports →
When deformity requires orthopedic evaluation
Referral to a foot and ankle specialist is appropriate when the deformity is rigid rather than flexible, is progressing despite appropriate support, a substantial tendon tear is suspected, the single-leg heel rise is lost, the ankle is becoming involved, or well-structured conservative care has not worked. Surgical options for PCFD are tailored to which parts of the deformity are present.
How Novo approaches posterior tibial tendon pain
We confirm whether the tendon is the pain generator, test it under load, assess foot alignment side to side and decide whether the problem is isolated tendinopathy or part of progressive collapsing foot deformity. Loading, temporary or longer-term support, shockwave, imaging or referral are selected from those findings. See how we approach posterior tibial tendinopathy, how it differs from plantar fasciitis and other medial foot pain, or book a new patient exam.
References
- Khaliliyan H, Vosoughi AR, Bahramizadeh M, Zare A, et al. Clinical and biomechanical outcomes of orthotic devices for progressive collapsing foot deformity: a systematic review and meta-analysis. Foot and Ankle Surgery. 2026;32(1):1-10. PMID 40480881. (link)
- Gómez-Jurado I, Juárez-Jiménez JM, Munuera-Martínez PV. Orthotic treatment for stage I and II posterior tibial tendon dysfunction (flat foot): a systematic review. Clinical Rehabilitation. 2021;35(2):159-168. PMID 33040609. (link)
- Kulig K, Reischl SF, Pomrantz AB, Burnfield JM, et al. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Physical Therapy. 2009;89(1):26-37. PMID 19022863. (link)
- Houck J, Neville C, Tome J, Flemister A. Randomized controlled trial comparing orthosis augmented by either stretching or stretching and strengthening for stage II tibialis posterior tendon dysfunction. Foot & Ankle International. 2015;36(9):1006-1016. PMID 25857939. (link)
- Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program. Foot & Ankle International. 2006;27(1):2-8. PMID 16442022. (link)
- Ross MH, Smith MD, Mellor R, Vicenzino B. Exercise for posterior tibial tendon dysfunction: a systematic review of randomised clinical trials and clinical guidelines. BMJ Open Sport & Exercise Medicine. 2018;4(1):e000430. PMID 30271611. (link)
- Myerson MS, Thordarson DB, Johnson JE, et al. Classification and nomenclature: progressive collapsing foot deformity. Foot & Ankle International. 2020;41(10):1271-1276. PMID 32856474. (link)
