Lower Limb Orthotics/Therapeutic Footwear

Overview and Description

Terminology: Orthosis is the medical term for a brace while orthoses is the plural form. The term orthotics refers to the science and practice of patient assessment, fabrication, fit and adjustment of an orthosis. Orthotic device can be used interchangeably with the term orthosis. An orthosis or orthotic is an external device applied to the body parts to modify or control skeletal structure or function. A basic principle for limb orthoses follows the three-points principle of pressure to properly control a joint. They serve to perform at least one of the following functions: 1) pain reduction; 2) improve alignment and range of motion; 3) prevent deformities; 4) spasticity control; 5) assist with weak muscle action, 6) off load pressure from a joint or body part 7) support stability of joints or 8) reduce energy cost in ambulation Orthoses are named for the joints/segments they manage according to the International Organization for Standardization (ISO) and are classified based on action (static vs. dynamic or accommodative vs. corrective).¹

“Off the shelf” orthoses are prefabricated, mass-manufactured and are available in various designs, sizes, and materials. Custom molded orthoses refer to those made specifically for individual patients.

A static orthosis has no motion across the joint or segment involved. A dynamic orthosis indicates that there is motion across the joint. A static progressive orthosis is a type of adjustable orthosis that applies force to a joint and holds it at end range with a goal to improve passive joint range of motion.¹

Orthoses in acute injury tend to focus on maintaining range of motion, preventing contractures, managing pain, protecting damaged or weakened soft tissue, or providing immobilization. Chronic orthosis use aims to prevent or control unwanted motion, enhance desired motion, decrease abnormal tone, alleviate pain, or maximize function. These interventions apply to all phases of a rehabilitation plan and depend on the patient’s level of impairment.

Medical conditions which warrant the use of limb orthoses or therapeutic footwear may include trauma, stroke, brain injury, spinal cord injury, multiple sclerosis, cerebral palsy, peripheral nerve injury, peripheral neuropathy, arthritic conditions, burns, hypotonia, hypermobility, neuromuscular disorders, and contracture management in both pediatric and adult populations.

Common complications associated with orthotic management include pressure injuries, infection, and pain. Thus, it is essential that special attention be made to examine the skin, neurological function, vascular status, and musculoskeletal system in patients who will be using an orthosis.

Relevance to Clinical Practice

Lower limb orthoses

Ankle Foot Orthoses (AFOs)

• AFOs are commonly prescribed for to augment weak ankle dorsiflexors, plantar flexors, invertors, and evertors as well as control spastic muscles, correct deformity, limit or assist ROM, provide support and stability, and improve overall function.² They can be used in many pediatric cases of cerebral palsy, spina bifida, muscular dystrophy, etc., as well as cases of stroke, multiple sclerosis, neuropathy, severe pain and instability.³ AFOs improve gait deviations by taking advantage of ground reaction force, such as, controlling the progression of the tibia over the ankle and limiting knee flexion and/or extension during stance. An AFO can also assist pre-swing phase toe off and foot clearance during swing phase.
• Mechanical design improvements include the development of passive, quasi-passive, and active (actuated) AFOs. Passive AFOs are common for stabilization and include static AFO, partial hinged AFOs and dynamic AFOs. With the development of sensors, brakes and controls, semi-active AFOs are used to provide dynamic assistance, reduce energy expenditure, and promote more natural gait patterns by releasing mechanical energy when needed and storing energy generated by the body movement in elastic units. Active AFOs use external energy to transmit enhanced torque to the ankle and are gaining more attention.²
• Important considerations for prescribing an AFO include patient’s primary condition, occupation, functional status and expected time of use. Physical exam should include checking the skin for edema, wounds adhesions, and palpating bony landmarks. Strength ROM and joint stability should also be taken into consideration as well as static and dynamic assessment to evaluate for balance and joint position in different planes of movement during ambulation, transfers, etc.³
• Anterior ground reaction AFOs feature a strap or plate across anterior tibia to translate forces which provide maximal resistance to plantar flexion and promote knee extension. Of note, the AFO neutral angle and degree of dorsiflexion in stance will influence the position of the knee; ground reaction AFOs and solid ankle AFOs have been found to be equivalent for correcting crouch gait in children with cerebral palsy.
• Carbon fiber AFOs are effective for patients without abnormal tone and with neutral foot alignment and distal muscle weakness.⁴

AFOs with metal upright(s) are less common than plastic AFOs. However, some patients (such as those with morbid obesity, edema or insensate skin) may benefit from a metal AFO due to the risk of excessive pressure or skin breakdown on the leg or foot. Plastic AFOs are either prefabricated out of thermal plastic or custom molded over the patient’s limb through casting. They are often desired due to their light weight, cosmetic appear and lack of attachment to the shoe.

The construction of a hinged AFO with ankle joints with channels allows for a greater control of gait. The following table explains the ankle joint motion control with pins (stops) or springs.

Permutations for articulated/hinged AFO

Knee Ankle Foot Orthoses (KAFOs)

KAFOs extend the AFO to control the knee. Quadriceps weakness below antigravity strength or knee hyperextension not controlled by an AFO are indications for a KAFO, in addition to correcting irregular alignments, providing skeletal support after surgery or fracture, or contractures.¹

In order to stabilize the knee, different locks can be used and can be either adjustable or locked, Locked knee joints aim to prevent knee buckling. In order to lock the knee, full knee extension is needed either active or passive.⁶

One of four locks can be used at the knee – cam lock, bail lock, ratchet lock, and drop lock. The most common is the Ratchet lock with 12-degree increments built into the joint. A lever allows for the knee to be released for flexion and to allow sitting.⁵

Knee orthoses (KO):KOs can stabilize the knee joint, control range of motion, redistribute load, and improve alignment to reduce pain and injury risk. Orthotics made with hard materials can generate increased forces in the knee, thus generating increased stability while soft material orthoses provide much less mechanical support but can improve proprioception and patellar tracking.⁷

Hip Orthoses (HOs)

Hip orthoses exert forces on the trunk and thigh and are commonly used for post-operative care, hip dislocation, dysplasia, and osteoarthritis.

Hip-Knee-Ankle-Foot Orthoses (HKAFOs)

HKAFO are typically used in patients with spina bifida (myelomeningocele) or acquired spinal cord injury to stabilize the entire lower limb in order to stand and walk with assistive devices. They require high amounts of energy expenditure to use which limits their feasibility of use for community distances.¹

Other Lower Limb Orthoses

Off the shelf ankle braces are semi-rigid, are worn inside the shoe, and can feature air cells on both sides of the ankle to improve ankle stability. They have been shown to improve ankle joint function in ankle sprains.¹¹

Foot orthoses and therapeutic footwear

Foot Orthoses (FOs)

• FOs, sometimes referred to as insoles, may be prescribed as stand-alone devices or serve as the foundation for other lower limb orthoses. They align and support the foot, prevent or correct deformity, accommodate fixed deformities, and improve overall foot function. FOs are frequently paired with therapeutic footwear, which should be properly fitted and provide adequate room for the foot to expand during weight-bearing.
• FOs can be classified as accommodative or functional. Accommodative orthoses are softer, designed to relieve pressure and protect insensate or painful feet (e.g., in diabetes or peripheral neuropathy). Functional orthoses are more rigid and aim to control abnormal motion, particularly at the subtalar and midtarsal joints.
• Common indications include plantar fasciitis, metatarsalgia, pes cavus, pes planus, posterior tibial tendon dysfunction, and forefoot deformities. FOs may also help redistribute plantar pressures to reduce the risk of ulceration.¹
• Design features include medial or lateral posting to influence pronation or supination, heel cups and flanges for rearfoot stability, and padding or top covers to reduce pressure over bony prominences. Material selection is guided by the desired balance between flexibility and rigidity, with softer materials, like EVA and foam, providing cushioning and rigid materials, like polypropylene and carbon fiber, providing motion control.¹²
• Supramalleolar orthoses (SMO) are commonly used in pediatric patients with hypotonia or flexible pronation to provide medial-lateral ankle support and improve foot alignment during standing and gait.^13,14
• Leg length discrepancies less than 2cm without symptoms typically do not require correction. The total leg length discrepancy is not corrected. At most, 75% of the discrepancy should be corrected. Up to 1cm lift can fit in a shoe. For shoe lifts that need more than 1cm, the patient would need a custom-built shoe with a shoe lift or have an external shoe lift added.
• Carbon fiber foot plates have recently started to be incorporated into athletic shoes, with studies suggesting they redistribute power to the distal foot and decrease energetic demand on the ankle.¹⁵ These also offer a less restrictive bracing option for idiopathic toe walking with similar results in the brace and improved carryover after brace is removed.¹⁶

Therapeutic Footwear

• Therapeutic footwear is essential in preventing and managing complications, such as foot ulcers and amputation, in patients with diabetes, peripheral neuropathy, peripheral artery disease, and various forms of arthritis.
• There are two principal categories of therapeutic footwear: extra-depth shoes and custom molded shoes. Extra-depth shoes are constructed over modified lasts to provide increased width and depth, often with removable insoles to accommodate custom orthoses or fluctuating edema. They are indicated for patients with diabetes and moderate deformities, as proper fit is essential to prevent pressure injuries in those with impaired sensation or circulation. Custom molded shoes are reserved for individuals with severe deformities, advanced neuropathy, partial foot amputation, or those unable to achieve adequate fit with extra-depth shoes. The success of custom molded footwear depends on precise casting techniques that accurately represent the weight bearing, functioning foot, including any dressings or orthoses that will be worn inside the shoe. Shoe modifications, performed by pedorthists, can be both external (e.g., cushion heels, flares, rocker soles, metatarsal bars) and internal (e.g., arch pads, metatarsal pads, heel cushions).¹
• Heel and internal sole excavation may be used to offload painful areas or ulcers over bony prominences. Pad placement provides arch support or relieves pressure heel and lateral wedges promote appropriate foot positioning or alignment. Bars on the soles of shoes can be added to assist with weakness, relieve pressure, transfer load, or promote dorsi or plantar flexion.
• Heel flares widen the base and support with different heel material providing cushioning, stability, positioning, and arch support.¹⁷
• High top shoes or boots can provide ankle stability in patients with mild ankle instability or mild foot drop, especially in young patients.

Cutting Edge/Unique Concepts/Emerging Issues

Lower limb orthotics have been widely studied since the mid 1980s, along with rapid advancement of technology in the field of orthotics and prosthetics. A hybrid prosthesis merges the technologies and biomechanical principles of orthotics and prosthetics, giving rise to the term “prosthosis.” Moseley device is an example that provides advantages such as (1) augmented stability of the knee, (2) significantly better gait consciousness and limb proprioception, (3) spontaneity of the use because the ankle joint is homologous to the opposite knee in function and posture with respect to gait cycle, and (4) physiological, mental, and social developmental rewards, regarding the sustenance of proper structural image of torso with lower extremity.¹⁸ Developments in 3D modeling, material science, and lightweight design have made it possible to fabricate orthotic devices in a more customized and patient-specific manner. 3D printed lower extremity orthoses, primarily insoles and AFOs, have demonstrated significant potential for improving patient comfort, fit, and functional performance. However, further research is required to validate the value of 3D printed orthotics and to optimize their biomechanical benefits.¹⁹

Traditional AFOs often fail to meet patients’ needs, particularly in pediatric populations such as children with cerebral palsy. They can cause muscle disuse atrophy, skin damage, and adverse neural adaptations. In recent years, new innovations have emerged using biomimetic robots powered by artificial muscles made from an electroactive polymer called dielectric elastomers. These artificial muscles drive the AFO and assist with ankle movements. By detecting gait phases, the DE-AFO can synchronize its artificial muscles to mimic the function of natural ankle muscles, providing up to 69% and 100% of the required assistive force during the pre-swing phase and swing period of gait.²⁰ Functional electric stimulation (FES) devices are also available as an alternative to traditional orthoses. These devices generate an electrical current that stimulate a muscle causing muscle contraction in a predictable movement pattern to create physiological bracing. The most common FES device for the lower limb is the FES-AFO which stimulates the tibialis anterior muscle to produce ankle dorsiflexion and eversion.²¹ These devices have shown moderate gait improvements when compared to traditional AFO. Recent improvements in traditional lower limb orthoses include stance control orthotic knee joints to provide stance-phase stability, while allowing swing-phase flexion and permitting a more normal gait pattern by eliminating some of the motion restrictions of other orthoses.

Brain-computer-interface (BCI) devices serve as yet another area of innovation in prosthetics and orthotics. BCIs utilize non-invasive electroencephalography (EEG) or invasive electrocorticography (ECoG) to allow patients to use their mind to control devices that can assist with mobility. Some applications of this technology include control of lower body exoskeletons in patients with paraparesis and control of motorized ankle foot orthoses (MAFOs) in stroke patients with foot drop.^22,23 Some notable considerations on the use of BCI include high cost, the practical challenges of maintaining high-quality EEG during non-invasive BCI use, and the surgical risks involved in establishing invasive BCI via ECoG.

Artificial intelligence (AI) has demonstrated potential in improving the fabrication and use of lower extremity prosthetics and orthotics. In fabrication, AI has been studied in the selection of materials for insoles and in detecting prosthetic misalignment. Machine learning has also been used in selecting appropriate prostheses, predicting the need for orthotics after stroke, assisting in prosthetics training, and intelligent control of active AFOs.^24,25,26

Gaps in Knowledge/Evidence Base

Despite controversies, orthoses that allow patients to use their paretic limb for functional tasks and a broader range of rehabilitative interventions, generally result in improved limb function and improved quality of life. Patients rely on orthotic intervention as a cost effective and less invasive means to manage common medical conditions such as a valgus knee braces for symptomatic knee osteoarthritis relief.

The cost of orthotic devices varies based on complexity, materials used and fabrication process. To optimize both patient care and utilization of health care resources, it is paramount to have an in-depth knowledge of the patient’s deficits, as well as an understanding of the environmental and personal factors that will influence a patient’s orthoses use. Typical barriers to device utilization include its appearance, weight, and ability to don and doff the orthoses.²⁰ Incorrectly prescribed orthoses may lead to functional impairment and biomechanical derangement which cause medical complications. Orthosis fit and function should be re-assessed to maintain optimal effect of orthosis. To limit these obstacles, a team including orthotists, therapists, and physicians must work in concert to maximize patient benefit.

Reference

1. Webster, J.B., D. Murphy, and W. Lovegreen, Atlas of orthoses and assistive devices. Sixth edition. ed. 2026, Philadelphia, PA: Elsevier.
2. Zhou, C., et al., Research and Development of Ankle-Foot Orthoses: A Review.
   Sensors (Basel), 2022. 22(17).
3. Physiopedia contributors. Foundations for Ankle Foot Orthoses. Physiopedia. August 25, 2026. Accessed September 10, 2026.https://www.physio-pedia.com/index.php?title=Foundations_for_Ankle_Foot_Orthoses&oldid=382337
4. Betancourt, J.P., et al., Impact of Ankle-Foot Orthosis on Gait Efficiency in
   Ambulatory Children With Cerebral Palsy: A Systematic Review and Meta-analysis.
   Am J Phys Med Rehabil, 2019. 98(9): p. 759-770.
5. Frontera, W.R., DeLisa’s physical medicine & rehabilitation : principles and practice. Sixth edition. ed. 2020, Philadelphia: Wolters Kluwer. xix, 1448 pages.
6. Cuccurullo, S., Physical medicine and rehabilitation board review. Fourth edition. ed. 2020, New York, NY: Demos Medical Publishing.
7. Kemker, B.P., 3rd, et al., Hip and Knee Bracing: Categorization, Treatment Algorithm, and Systematic Review. J Am Acad Orthop Surg Glob Res Rev, 2021. 5(6): p. e20
   00181-12.
8. Hunter, C.W., et al., Consensus Guidelines on Interventional Therapies for Knee Pain (STEP Guidelines) from the American Society of Pain and Neuroscience. J Pain Res, 2022. 15: p. 2683-2745.
9. Michalik, R., et al., Do hip-abduction braces work?-A biomechanical evaluation of a commercially available hip brace. Arch Orthop Trauma Surg, 2022. 142(6): p. 1275-1281.
10. Marletta, D.A., et al., Impact of age and timing of hip orthosis on treatment
    outcomes in infants with developmental dysplasia of the hip: A systematic review and meta-analysis. J Clin Orthop Trauma, 2025. 64: p. 102944.
11. Hiller, C.E. and P.R. Beckenkamp, Effect of Braces on Performance in the Context of Chronic Ankle Instability. Foot Ankle Clin, 2023. 28(1): p. 145-154.
12. Cifu, D.X. and B.C. Eapen, Braddom’s physical medicine and rehabilitation. Sixth edition. ed. Physical medicine and rehabilitation. 2021, Philadelphia, PA: Elsevier.
13. Davids, J.R., F. Rowan, and R.B. Davis, Indications for orthoses to improve gait in children with cerebral palsy. J Am Acad Orthop Surg, 2007. 15(3): p. 178-88.
14. Martin, K., Effects of supramalleolar orthoses on postural stability in children with Down syndrome. Dev Med Child Neurol, 2004. 46(6): p. 406-11.
15. Henderson, A., et al., Deformable foot orthoses redistribute power from the ankle to the distal foot during walking. J Biomech, 2021. 128: p. 110728.
16. Herrin, K. and M. Geil, A comparison of orthoses in the treatment of idiopathic toe walking: A randomized controlled trial. Prosthet Orthot Int, 2016. 40(2): p. 262-9.
17. Buldt, A.K. and H.B. Menz, Incorrectly fitted footwear, foot pain and foot disorders: a systematic search and narrative review of the literature. J Foot Ankle Res, 2018. 11: p. 43.
18. Moseley, M. R. (2003, October 7). Alternatives to surgery in the treatment of proximal femoral focal deficiency: The patient friendly functional device. PFFD VSG2.
    https://www.pffd.org/Moseley_device.htm
19. Atallah, H., et al., The current state of 3D-printed orthoses clinical outcomes: a systematic review. BMC Musculoskelet Disord, 2025. 26(1): p. 822.
20. Prenton, S., et al., Functional electrical stimulation and ankle foot orthoses provide equivalent therapeutic effects on foot drop: A meta-analysis providing direction for future research. J Rehabil Med, 2018. 50(2): p. 129-139
21. Boyce, S.H., M.A. Quigley, and S. Campbell, Management of ankle sprains: a randomised controlled trial of the treatment of inversion injuries using an elastic support bandage or an Aircast ankle brace. Br J Sports Med, 2005. 39(2): p. 91–6.
22. Tariq, M., P.M. Trivailo, and M. Simic, EEG-Based BCI Control Schemes for Lower-Limb Assistive-Robots. Front Hum Neurosci, 2018. 12: p. 312.
23. Bockbrader, M.A., et al., Brain Computer Interfaces in Rehabilitation Medicine. Pm r, 2018. 10(9 Suppl 2): p. S233–s243.
24. Choo, Y.J. and M.C. Chang, Use of machine learning in the field of prosthetics and
    orthotics: A systematic narrative review. Prosthet Orthot Int, 2023. 47(3): p. 226–240.
25. Zhang, L.Y., et al., AI-Enhanced Modular Material Selection for Patient-Specific Diabetic Insoles via Silicone Molding. Hum Factors, 2026: p. 187208261442810.
26. Han, J.I., et al., Policy Design for an Ankle-Foot Orthosis Using Simulated Physical Human-Robot Interaction via Deep Reinforcement Learning. IEEE Trans Neural Syst Rehabil Eng, 2022. 30: p. 2186–2197.

Original Version of the Topic

Marlis Gonzalez-Fernandez, MD, PhD, David Taftian, MD, Mark Hopkins, PT, CPO. Upper and lower limb orthoses and therapeutic footwear. 9/20/2014

Previous Revision(s) of the Topic

Mi Ran Shin, MD, Olga Morozova, MD, Jeffery Rubin, DO. Upper and lower limb orthoses and therapeutic footwear. 2/26/2019

Mi Ran Shin, MD, MPH, Katherine DeGraaff, DO, Olga Morozova, MD. Lower Limb Orthotics/Therapeutic Footwear. 12/21/2022

Author Disclosure

Andres Gronda, MD
Nothing to Disclose

Cherie Chen, DO
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Sarah Abraham, MD
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Gabrielle Avancena, MD
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Salvador Portugal, DO, MBA
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