Foot drop is a gait impairment commonly encountered in physical therapy practice and can significantly impact mobility, safety, efficiency of walking, and overall quality of life. Rather than being a diagnosis itself, foot drop is a clinical presentation that can result from a wide range of neurological and musculoskeletal conditions. Common causes include stroke, spinal cord injury, multiple sclerosis and other inflammatory neurologic disorders, peripheral nerve injuries, traumatic brain injury, lumbar radiculopathy, and neurodegenerative conditions, among others. The severity, prognosis, and optimal management approach can vary substantially depending on the underlying cause and the specific impairments contributing to the gait dysfunction.
The prevalence of foot drop is difficult to quantify because it spans so many diagnoses and patient populations. However, a 2024 review estimated that at least 128,000 new cases of foot drop occur annually in the United States, highlighting the significant number of individuals affected each year.
One of the most common interventions used to address chronic foot drop is an ankle foot orthosis (AFO). AFOs are designed to improve foot clearance, stability, limb positioning, and walking efficiency. Over the years, the number and variety of available orthotic options have expanded dramatically. Clinicians now have access to an enormous range of devices that differ in material properties, rigidity, trim lines, articulation, energy storage capabilities, adjustability, fit, cost, and intended function. Options now range from highly customized carbon fiber designs to increasingly sophisticated off-the-shelf solutions.
While this growth in available technology is exciting, it has also created a new challenge for clinicians: navigating the overwhelming number of choices to determine which device may best match a patient’s specific presentation, goals, environment, and functional needs. Even experienced providers may struggle to stay current with the rapidly evolving orthotics landscape and the expanding body of research surrounding orthotic management.
In the early 2000s, Rancho Los Amigos National Rehabilitation Center developed an orthotic algorithm formally titled the Recommendations for Orthotic Assessment, Decision-Making, and Prescription (R.O.A.D.M.A.P.). Beyond being an excellent acronym, the framework provided meaningful clinical guidance for rehabilitation professionals seeking a more systematic approach to AFO prescription. It became widely referenced among physical therapists and orthotists and helped establish a more structured clinical reasoning process for orthotic selection. However, aside from a revision in 2005, there has not been a major comprehensive update to the algorithm despite the substantial evolution in both orthotic technology and the supporting literature over the past two decades.
Since that time, the number of available AFO options has expanded significantly, alongside a growing body of evidence examining how different orthotic characteristics influence gait mechanics, energy expenditure, balance, muscle activity, and functional mobility. As clinicians, we recognized the need for an updated clinical tool that could help bridge the gap between emerging evidence and real-world decision-making.
In response to this need, the Mission Gait Orthotic Decision Tree was developed by Bethany Russell PT, DPT and Gloria Han PT, DPT. This tool was designed to be a free resource that is available to clinicians at the Mission Gait Orthotic Decision Tree page on our website. The goal of the Decision Tree was not to create a rigid prescription algorithm, but rather to provide clinicians with an evidence-informed framework to help narrow down orthotic options based on key patient characteristics and gait presentation. Development of the tool involved an extensive literature review in combination with formal surveying of clinicians experienced in orthotic prescription and gait rehabilitation.
Importantly, the Decision Tree is intended to serve as a clinical starting point rather than a definitive answer. As many rehabilitation professionals know, selecting the most appropriate AFO is rarely a purely “textbook” process. A device that appears ideal biomechanically may ultimately prove unsuccessful due to patient comfort, cosmetic concerns, ease of use, lifestyle demands, environmental considerations, tolerance, or personal preference. Orthotic prescription is often an iterative process involving clinical reasoning, patient feedback, and trial and error. The purpose of the Mission Gait Orthotic Decision Tree is to make that process more efficient, more evidence-informed, and more approachable for clinicians seeking to optimize outcomes for individuals living with foot drop.
Reference:
Seruya M. Differential Diagnosis of “Foot Drop”: Implications for Peripheral Nerve Surgery. J Reconstr Microsurg. 2024 Sep;40(7):566-570. doi: 10.1055/a-2253-6360. Epub 2024 Jan 24. PMID: 38267007
If you found this tool helpful and would like to explore additional information on orthotic prescription please check out the Mission Gait YouTube page! We produce educational videos that cover a wide range of topics. Particularly of use to anyone utilizing the Orthotic Decision Tree is our Orthotic Selection and Training series where we go in depth about important details to consider when prescribing an orthosis.
