OBJECTIVE: To evaluate the effectiveness of various foot orthoses for flatfoot through a network meta-analysis. DESIGN: Randomized controlled trials on flatfoot were searched in PubMed, Cochrane Library, and Embase (up to November 2024), including interventions like insoles, exercises, or no treatment, with clinical, biomechanical, and radiological outcomes. RESULTS: Eight randomized controlled trials with 369 participants (mean age 6.76 to 26.8 years) were included. Significant pain reductions were observed with both insole plus exercise (SMD -2.591; 95% CI -3.469 to -1.714) and insole alone (SMD -1.651; 95% CI -2.237 to -1.065). For navicular drop, improvements were found across all interventions, with exercise alone showing the greatest effect (SMD -3.058; 95% CI -4.290 to -1.826). Insole use improved calcaneal pitch (SMD 0.513; 95% CI 0.040 to 0.986). Biomechanical outcomes also improved, with insole use reducing center of pressure displacement (SMD -0.751; 95% CI -1.386 to -0.115; I2 0%). Lateral talocalcaneal angles improved significantly in the insole group compared to control (SMD -0.572; 95% CI -1.047 to -0.097). CONCLUSIONS: These findings strongly support insoles as an effective conservative treatment for flexible flatfoot and underscore the need to incorporate clinical, biomechanical, and radiographic outcomes in future research to optimize management strategies.

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