Effects of Non-surgical Interventions on Standing Posture and Pain in Children with Flexible Flatfoot: A Network Meta-Analysis of Randomized Controlled Trials

IMPORTANCE: Pediatric flexible flatfoot (PFF) is a common condition affecting children's foot biomechanics. While various conservative treatments exist, their relative effectiveness remains unclear. OBJECTIVE: The objective was to compare the effectiveness of non-surgical interventions-orthotic devices, active exercise-based interventions, and neuromuscular electrical stimulation (NMES)-for managing PFF. DESIGN: A systematic review and network meta-analysis of randomized controlled trials was conducted and registered in PROSPERO (CRD42024539990). PARTICIPANTS: Eleven trials encompassing 761 children with flexible flatfoot were included. INTERVENTIONS: Non-surgical interventions included orthotic devices (traditional insoles, talus control insoles, corrective shoes, heel cups) and active exercise-based physical therapist interventions (corrective exercises, core stabilization exercises, and NMES combined with corrective exercises). OUTCOME MEASURES: Outcome measures included the Staheli index (static footprint measurement), barefoot radiological measures (anterior-posterior and lateral talocalcaneal angles, calcaneal pitch angle), pain scores, and treatment discontinuation rates. RESULTS: NMES combined with corrective exercises demonstrated significant improvement in the Staheli index compared to no intervention (mean difference [MD] = -0.28, 95% CI = -0.35 to -0.22; certainty of evidence [CoE]: moderate). Talus control insoles showed significant improvements in radiological outcomes compared to conventional flat footwear, including lateral talocalcaneal angle (MD = -5.56°, 95% CI = -9.81 to -1.30; CoE: low) and calcaneal pitch angle (MD = 2.74°, 95% CI = 0.41 to 5.06; CoE: low). Traditional insoles effectively reduced pain scores compared to flat insoles (MD = -2.92 points, 95% CI = -3.73 to -2.11; CoE: very low). Pain outcomes were not assessed in exercise or NMES studies, preventing comparative effectiveness conclusions across intervention types. No significant differences in treatment discontinuation rates were observed among orthotic interventions. CONCLUSIONS: Both active exercise-based and orthotic interventions demonstrated beneficial effects. NMES with corrective exercises improved standing foot alignment by static footprint analysis, while orthotic interventions enhanced radiological alignment (talus control insoles) and pain relief (traditional insoles) compared to conventional footwear. Outcome measurement differences between intervention types limited direct comparisons. Ten studies measuring gait, functional, or developmental outcomes were excluded due to insufficient outcome overlap. RELEVANCE: This network meta-analysis provides evidence-based guidance for selecting conservative PFF interventions based on primary treatment objectives. LEVEL OF EVIDENCE: Therapeutic Level I.