What patient education should I give a patient with foot drop about treatment options such as ankle‑foot orthosis (AFO) or functional electrical stimulation (FES), home exercises, skin care, and follow‑up?

Patient Education for Foot Drop

For patients with foot drop, prescribe either an ankle-foot orthosis (AFO) or functional electrical stimulation (FES) as first-line treatment, as both are equally effective at improving gait speed and mobility. 1

Treatment Options

Ankle-Foot Orthosis (AFO)

• AFOs are the most established compensatory device for foot drop, improving mobility and normalizing ankle and knee kinematics, kinetics, and energy cost of walking. 1
• Explain to patients that the AFO mechanically supports the foot during walking, preventing it from dragging and reducing fall risk. 1
• The device must be custom-fitted by an orthotist to ensure proper alignment and pressure distribution. 2
• Patients should wear the AFO inside well-fitted walking shoes or athletic shoes with adequate depth to accommodate the brace. 1

Functional Electrical Stimulation (FES)

• FES provides an equally effective alternative to AFOs by electrically stimulating the peroneal nerve to activate ankle dorsiflexors during the swing phase of gait. 1, 2
• Educate patients that FES may offer advantages in cosmesis and the potential for therapeutic carryover effects with continued use. 3
• The device requires proper electrode placement and programming, which should be demonstrated during fitting. 2
• Patients need to understand battery maintenance and daily skin inspection at electrode sites. 3

Home Exercise Program

Strengthening Exercises

• Instruct patients to perform ankle dorsiflexor strengthening exercises combined with functional task training, as this produces better long-term outcomes than strength training alone. 2
• Specific exercises should include resisted ankle dorsiflexion, toe raises, and heel walking when safe to perform. 2
• Emphasize that exercises must be intensive and repetitive, performed daily for optimal benefit. 1

Functional Mobility Training

• Patients should practice functional tasks repeatedly with graded difficulty progression on a frequent basis. 1
• Include activities such as stepping over obstacles, walking on varied surfaces, and stair negotiation with appropriate supervision initially. 2
• Balance training should be incorporated, as patients with foot drop have increased fall risk. 1

Skin Care and Daily Monitoring

Daily Foot Inspection

• Educate patients to inspect their feet daily using visual examination or palpation, particularly if they have concurrent neuropathy. 1
• Instruct patients to check for areas of redness, blisters, calluses, or skin breakdown, especially at pressure points where the AFO contacts skin. 1
• Patients with visual impairment should use an unbreakable mirror or have a family member assist with inspection. 1

Skin Care Protocols

• Apply moisturizers to dry, scaly skin but avoid application between the toes to prevent maceration. 1
• Instruct patients to wash feet daily with careful drying, particularly between toes. 1
• Warn patients never to walk barefoot, in socks only, or in thin-soled slippers, whether at home or outside, as this increases injury risk. 1

Pressure Management

• Any areas of erythema, warmth, callus formation, or hemorrhage under calluses indicate tissue damage with impending breakdown and require immediate attention. 1
• Calluses should only be debrided by a foot care specialist with appropriate training—patients should not attempt self-removal with chemical agents or sharp instruments. 1

Footwear Recommendations

Appropriate Shoe Selection

• Prescribe well-fitted walking shoes or athletic shoes that cushion the feet and redistribute pressure, with sufficient depth to accommodate the AFO. 1, 2
• Shoes should have a broad and square toe box, laces with three or four eyes per side, padded tongue, quality lightweight materials, and adequate size for a cushioned insole. 1
• The upper covering should be leather or fabric mesh rather than plastic or synthetic materials to allow air circulation. 4

Custom Footwear Considerations

• If patients have concurrent bony deformities (hammertoes, prominent metatarsal heads, bunions) that cannot be accommodated with commercial therapeutic footwear, refer for custom-molded shoes. 1, 4
• Custom insoles may be needed to provide additional cushioning and pressure redistribution. 4

Follow-Up Schedule and Monitoring

Regular Assessment Intervals

• Schedule follow-up appointments every 1-3 months initially to assess device effectiveness, gait improvement, and skin integrity. 1, 4
• At each visit, evaluate gait speed, stride length, and any compensatory movement patterns that may indicate improper device fit or need for adjustment. 2
• Monitor for signs of device wear that indicate need for replacement or repair. 4

Adjustment and Progression

• Regularly adjust the treatment plan based on recovery progress, as some patients may regain function while others require long-term device use. 2
• Reassess the need for continued physical therapy and consider adding adjunctive therapies such as virtual reality or robotic-assisted training if progress plateaus. 1, 2

Critical Safety Education

Fall Prevention

• Emphasize that patients remain at increased fall risk and should participate in formal fall prevention programs with balance training. 1
• Instruct patients to clear home hazards such as loose rugs, electrical cords, and clutter. 1
• Recommend use of assistive devices (cane, walker) if balance confidence is low, even when wearing the AFO. 1

Warning Signs Requiring Urgent Attention

• Educate patients to seek immediate medical attention for any open ulceration, unexplained swelling, erythema, or increased skin temperature of the foot. 1
• New onset of acute red, hot, swollen foot or ankle requires urgent evaluation to exclude Charcot neuroarthropathy in at-risk patients. 1
• Worsening foot drop or development of new neurological symptoms warrants prompt reassessment. 5, 6

Common Pitfalls to Avoid

• Never allow patients to use standard off-the-shelf footwear without professional assessment, as improper footwear leads to pressure ulcers, pain, and further deformity. 4
• Avoid the misconception that foot drop always results from peroneal nerve injury at the fibular head—central causes including stroke and spinal pathology must be considered. 5, 6
• Do not assume that education alone will change behavior—knowledge is quickly forgotten and must be reinforced regularly at every visit. 1
• Patients often lack awareness of their risk status and why specialist referral is necessary—explicitly explain the rationale for multidisciplinary care. 1