Many people with stroke have the problem of foot drop. The toes cannot be lifted when stepping forward, so the foot drags and the patient trips easily, and the ankle wobbles when weight goes through the foot. Patients and families naturally ask: does wearing an ankle-foot orthosis (AFO) actually help? More practically, they usually have three concerns: whether it is worth the money, whether wearing it makes falls more likely, and whether getting used to it will get in the way of retraining later. This article answers each of these from a physiotherapy view, based on evidence from systematic reviews and RCTs.
The conclusion first. The current medical evidence is quite clear: for people with foot drop, putting on an AFO improves walking performance straight away. Walking speed, cadence, stride length and the Functional Ambulation Category are all better, and it takes less effort to walk the same distance. Two limits must be stated beforehand, however: it does not reduce falls automatically, and it cannot replace active strength training and gait retraining.
What is an AFO? What problems can it deal with?
An ankle-foot orthosis (AFO) is a brace that wraps the lower leg and foot, most often used to correct foot drop. It works as an immediate mechanical correction. When the leg swings forward (the swing phase), the brace helps the foot clear the ground so that the toes do not drag and trip. When the foot takes weight on the ground (the stance phase), it steadies the ankle and improves the angle of the foot as it first touches the ground. In other words, the effect does not come from being built up by training over days. It changes the mechanics of walking the moment it is put on.
What an AFO can deal with
- The toes drooping and dragging when stepping forward (the swing phase), so that the patient trips easily when walking
- An unsteady ankle when standing on one leg and taking weight (the stance phase), or a poor angle as the foot lands
- Slow walking, short steps and walking that takes a lot of effort
What an AFO cannot do
- It does not reduce falls automatically (see the RCT evidence below)
- It cannot replace training that builds muscle strength and movement control in the leg
- It is not a cure for foot drop, and there is not yet enough evidence on whether it changes the course of recovery in the long run
Immediate help: walking is better as soon as it is worn
This is the part of the AFO evidence that is best established. Choo and Chang (2021) pooled several studies in a systematic review and meta-analysis and found that an AFO immediately improves walking performance in people with stroke in several ways, and the improvement in the Functional Ambulation Category (FAC) is the most marked:
The biomechanical principle behind these improvements is also supported in the literature. The meta-analysis by Tyson, Sadeghi-Demneh and Nester (2013) confirmed that an AFO improves walking speed, cadence and stride length in stroke gait, and also the angle of the ankle at initial contact with the ground. This means that an AFO does more than make the assessment figures look better. It really changes how the foot lands and how the body moves forward. A pooled analysis also found that an AFO can improve both balance and walking ability after stroke (the pooled analysis of balance and walking, 2013).
The greatest benefit of an AFO is that it works as soon as it is put on. Usual rehabilitation exercises take a while to show results, while an AFO supports the foot directly with a brace, so that the patient can walk a little faster and a little steadier straight away. For patients who are rebuilding confidence in walking, or whose slow walking limits going out, this immediate help is very useful.
Walking takes less effort: less energy is used for the same distance
Besides faster walking, walking with an AFO also takes less effort. A randomised crossover trial in people with chronic stroke compared carbon and plastic AFOs for their effect on gait and energy cost. It found that, compared with no orthosis, wearing an AFO clearly reduced oxygen consumption (energy cost) in walking and also raised walking speed (carbon versus plastic AFO crossover trial 2024). A lower energy cost means the same distance takes less effort, which indirectly helps walking endurance and the total amount of daily walking. This matters for putting into practice the advice to move more and practise more.
AFO compared with functional electrical stimulation (FES)
Many patients ask whether functional electrical stimulation (FES) can be used instead of a brace. The comparison is reasonable, and the conclusion in the medical literature is fairly neutral. The RCT meta-analysis by Nascimento and colleagues (2020) found no significant difference between AFO and FES in improving walking speed (MD 0.00). The clinical guideline of the American Physical Therapy Association (APTA) also lists the two together as recommended options for gait problems after stroke.
- Immediate mechanical correction, steadying the ankle as soon as it is worn
- No power source or sticky electrodes, so it is direct to use
- Suits marked foot drop and people who need the most stability
- Rigid or hinged types are available (see below)
- The gain in walking speed is similar to that of the AFO (MD 0.00)
- Electrical stimulation triggers the muscle to contract and lift the foot
- Keeps natural ankle movement, with no brace showing
- Equipment has to be operated, and it depends on the skin and tolerance
The key point is this: there is no single best option that fits everyone. Whether to use an AFO or FES depends on the severity of the foot drop, the condition of the skin, the degree of muscle spasticity, how easy it is to use day to day and the cost, and should be decided after assessment by a therapist.
AFOs and the risk of falls
This is the point most easily misunderstood, and the one that most needs to be stated plainly. People generally assume that wearing a brace makes walking steadier and so prevents falls, but the RCT data do not support this. Nikamp and colleagues (2019) ran a randomised controlled trial in (sub)acute stroke patients comparing early with delayed provision of an AFO for its effect on falls, and the result was rather unexpected:
This study showed two important facts. First, giving an AFO early did not reduce falls, and the early group actually had more falls in the first 8 weeks. Second, most falls did not happen while walking with the AFO on, but at moments such as toileting without the AFO on, and getting in and out of bed at night. For an AFO to make things safer, it therefore depends on correct instruction in use and careful selection of the people it suits. Wearing one is no guarantee against falls.
Never assume that having an AFO means the patient will not fall. Walking with the brace on is a little steadier, but people with stroke often fall during bed transfers, on night-time trips to the toilet, when there is clutter at home, or when overall balance is not good enough. This page mainly covers the research data on AFO use and falls in people with stroke.
When is an AFO suitable? How is the type chosen?
Not every person with stroke needs an AFO, and wearing one as early as possible is not necessarily better. The UK NICE stroke rehabilitation guideline (NG236) sets out clearly when to use it: an AFO can be considered when the patient has difficulty lifting the foot clear of the ground in the swing phase (so trips or falls easily), or when poor ankle control in the stance phase gets in the way of walking. The main condition is that, within the rehabilitation plan, it is assessed and followed up by a qualified professional, and a ready-made brace is not bought and worn on your own.
- The toes droop and drag when stepping forward, and the patient trips easily when walking
- The ankle is unsteady when the foot lands and takes weight, which affects standing and walking
- Marked foot drop makes walking very slow, which affects going out in daily life
- It is fitted and used within the rehabilitation plan after assessment by a qualified therapist
- Buying a ready-made type online without professional assessment and wearing it for a long time
As for the types, they fall into two main groups, rigid (fixed) and hinged, each with its own trade-offs:
An AFO is an aid and cannot replace active training
One core point has to be made clear at the end. The role of an AFO is to give a safe and effective base for walking, so that the patient can move more and practise more, but the brace does not build muscle strength in itself and cannot rebuild movement control. Strength training, selective motor control and gait retraining still have to go on at the same time. An AFO and active rehabilitation training work together, and one is not chosen in place of the other.
The overall strategy for leg rehabilitation by severity belongs to home stroke rehabilitation, while the evidence for this aid and how it is chosen and fitted is covered on this page. From the occupational therapy (OT) point of view, for how to put on an AFO day to day and its use in daily living (ADL), see occupational therapy after stroke.
An AFO should be treated as an aid and not as a cure. Most current medical research concentrates on immediate and short-term effects (1 week to 6 months), and the evidence on whether wearing one for a long time changes the course of recovery is still limited. The most suitable way to use it is as an aid that helps the patient to walk and practise more safely, together with active strength and gait training.