AFO vs Functional Electrical Stimulation: Which Is Better for Foot Drop?

An ankle-foot orthosis and functional electrical stimulation can both help improve foot clearance during walking, but they do so in very different ways.

An AFO supports, holds or guides the foot and ankle through a physical brace.

Functional electrical stimulation, usually shortened to FES, applies timed electrical pulses to a nerve or muscle to create a contraction that lifts the front of the foot.

Neither treatment is universally better.

The appropriate choice depends on:

• What caused the foot drop
• Whether the problem originates in the brain, spinal cord, peripheral nerve or muscle
• Whether the nerve and muscle respond to electrical stimulation
• Ankle range of movement
• Muscle tone and spasticity
• Side-to-side ankle stability
• Heel position
• Knee control
• Balance
• Sensation
• Skin condition
• Hand function
• Footwear
• Daily activities
• Whether the equipment can be used consistently

The NHS lists both braces and electrical stimulation among the potential treatments for foot drop. It notes that electrical stimulation may be particularly relevant following stroke or in multiple sclerosis, while treatment overall depends on the underlying cause.

What Is an AFO?

An AFO is an ankle-foot orthosis.

It is a physical support that can be designed to:

• Hold the front of the foot up
• Limit excessive downward ankle movement
• Improve toe clearance
• Stabilise the ankle
• Control inward or outward foot movement
• Hold the heel
• Influence knee position
• Improve standing and balance
• Make foot placement more consistent

AFOs can be made from:

• Textile materials
• Polypropylene
• Carbon-fibre composite
• Carbon fibre
• Several materials combined

They may be:

• Flexible
• Reinforced
• Rigid
• Hinged
• Prefabricated
• Custom-made

Guy’s and St Thomas’ NHS Foundation Trust explains that an AFO supports the foot and ankle and can also influence movement at the knee and hip, helping with standing, balance and walking.

What Is Functional Electrical Stimulation?

Functional electrical stimulation uses small electrical pulses to create useful muscle activity.

For foot drop, surface electrodes are commonly placed on the skin near the nerve and muscles involved in lifting the foot.

The system attempts to stimulate the movement at the appropriate point in the walking cycle.

NICE explains that FES aims to mimic useful voluntary gait movement by applying electrical pulses to the common peroneal nerve, helping lift the foot and position it for contact with the ground. Surface and implanted systems exist, although surface systems are commonly assessed through specialist rehabilitation services.

A surface FES system may include:

• A small battery-powered stimulator
• Skin electrodes
• A cuff or electrode holder
• Connecting leads
• A heel switch, foot sensor or movement sensor
• Controls for stimulation strength and timing

Some newer systems integrate several of these components into one wearable cuff.

How Does FES Lift the Foot?

The electrical pulse stimulates the nerve or muscle supplying the ankle dorsiflexors.

This produces a contraction that helps raise the front of the foot as the leg swings forwards.

A walking sensor is used to trigger the stimulation at the appropriate time.

A simplified sequence is:

1. The heel leaves the ground.
2. The FES system identifies the start of the swing phase.
3. Electrical stimulation activates the relevant nerve and muscles.
4. The front of the foot lifts.
5. The toes pass above the ground.
6. Stimulation reduces as the foot prepares to land.

An NHS FES clinic describes the sensation as similar to pins and needles and explains that stimulation causes the muscle to contract and lift the foot.

Does FES Repair the Nerve?

No.

FES uses the remaining electrical pathway to produce a functional contraction while the system is operating.

It does not necessarily:

• Repair damaged brain tissue
• Repair the spinal cord
• Regrow a peripheral nerve
• Cure multiple sclerosis
• Reverse a stroke
• Permanently restore normal ankle control

Some people may experience changes through repeated use and rehabilitation, but FES should not be described as a guaranteed cure.

Its main immediate purpose is to improve movement while stimulation is active.

What Is the Main Difference Between an AFO and FES?

The simplest difference is:

AFO

An AFO physically supports or controls the foot.

FES

FES activates a muscle contraction through electrical stimulation.

An AFO can work even when the muscle cannot produce a useful contraction, provided the brace can position and control the limb mechanically.

FES needs an appropriate nerve-and-muscle pathway that responds to stimulation.

This is why the cause of foot drop is so important.

What Does Central Neurological Origin Mean?

Central neurological origin means that the foot drop is associated with damage or disease involving the:

• Brain
• Spinal cord

rather than damage to the peripheral nerve or muscle further down the leg.

Conditions may include:

• Stroke
• Multiple sclerosis
• Cerebral palsy
• Brain injury
• Spinal cord injury above a suitable level
• Hereditary spastic paraparesis
• Some other upper motor neurone conditions

NICE guidance concerns FES specifically for foot drop of central neurological origin and states that it is used for upper motor neurone lesions arising from conditions such as stroke, cerebral palsy, multiple sclerosis and spinal cord injury.

What Does Peripheral or Lower Motor Neurone Foot Drop Mean?

Peripheral or lower motor neurone foot drop occurs when the problem involves the:

• Common peroneal nerve
• Sciatic nerve
• Nerve roots
• Peripheral nervous system
• Motor neurone
• Muscle itself

Possible causes include:

• Peroneal nerve injury
• Nerve compression around the knee
• A slipped disc affecting a nerve root
• Peripheral neuropathy
• Diabetes-related nerve damage
• Surgery-related nerve injury
• Motor neurone disease
• Guillain–Barré syndrome
• Neuromuscular disease

The NHS identifies peripheral nerve injury and neuropathy as common causes of foot drop.

FES is not normally suitable when the peripheral nerve pathway required to stimulate the muscle is damaged. NICE and UCLH both state that FES is generally intended for upper motor neurone presentations rather than peripheral or lower motor neurone lesions.

An AFO may still support the foot mechanically in these circumstances.

Is FES Suitable for Foot Drop Caused by Peroneal Nerve Damage?

It is not normally the standard option when the peripheral nerve itself is damaged and cannot transmit the required stimulation effectively.

UCLH lists peripheral nerve lesions, nerve impingement and other lower motor neurone conditions among presentations unsuitable for its FES service.

An AFO may be considered to:

• Hold the forefoot up
• Improve toe clearance
• Limit foot slap
• Stabilise the ankle
• Reduce compensatory high stepping

The cause should still be medically investigated, as some peripheral nerve problems may recover or require separate treatment.

Is FES Suitable After a Stroke?

Potentially, yes.

Stroke can produce an upper motor neurone lesion while leaving the peripheral nerve and muscles available for stimulation.

FES may be considered when the person:

• Has stroke-related foot drop
• Can produce a useful response to stimulation
• Has sufficient joint movement
• Can tolerate the electrodes
• Can walk or participate in a walking trial
• Can operate or receive help with the equipment

NICE states that evidence regarding safety and gait improvement is adequate to support FES for centrally caused foot drop when appropriate governance, consent and audit arrangements are in place.

An AFO may also be appropriate after stroke, particularly when:

• Greater ankle stability is needed
• Knee control is involved
• The foot turns strongly
• Stimulation does not produce sufficient movement
• FES cannot be applied consistently

Is FES Suitable for Multiple Sclerosis?

Potentially.

Multiple sclerosis can affect pathways in the brain and spinal cord and may cause central neurological foot drop.

A specialist FES service may assess whether stimulation:

• Produces sufficient foot lift
• Improves walking
• Remains effective with fatigue
• Is comfortable
• Can be managed independently
• Works alongside other symptoms such as spasticity

UCLH reports that people with multiple sclerosis form a substantial part of its specialist FES caseload.

An AFO may still be preferred where:

• Fatigue makes equipment setup difficult
• Skin does not tolerate electrodes
• Stronger mechanical ankle control is required
• The foot or knee is unstable
• FES does not provide a consistent response

Is FES Suitable for Cerebral Palsy?

It may be suitable for some people whose foot drop results from an upper motor neurone presentation.

Assessment must consider:

• Age
• Muscle tone
• Joint range
• Fixed deformity
• Walking pattern
• Ability to tolerate stimulation
• Whether the movement produced is useful

FES is not automatically suitable simply because cerebral palsy involves the central nervous system.

A rigid, hinged or custom-made AFO may provide more appropriate control where alignment, contracture or knee movement are important.

Is FES Suitable for Spinal Cord Injury?

It may be considered for selected injuries affecting the spinal cord above the lower motor neurone pathway needed for stimulation.

UCLH includes selected spinal cord injuries above T12 within its service criteria and excludes lower injuries or conditions involving lower motor neurone damage.

The neurological level and completeness of the injury require specialist assessment.

Do not assume that every spinal injury causing foot drop can be treated with FES.

Is FES Suitable for Motor Neurone Disease?

It is generally not considered suitable for foot drop caused by motor neurone disease because the lower motor neurone pathway may be affected.

Both UCLH and another current NHS FES clinic list motor neurone disease among presentations for which FES is generally unsuitable.

An AFO may instead be considered for mechanical support, although the brace should account for:

• Progressive weakness
• Fatigue
• Skin
• Weight
• Ease of fitting
• Changing mobility needs

Is FES Suitable for Guillain–Barré Syndrome?

It is generally not considered suitable where Guillain–Barré syndrome has affected the peripheral nerves.

Current NHS FES guidance lists Guillain–Barré syndrome among presentations generally unsuitable for FES.

AFO selection should still follow assessment of:

• Recovery
• Strength
• Sensation
• Ankle stability
• Knee control
• Fatigue

Is an AFO Suitable for More Causes of Foot Drop?

An AFO can often be considered across a broader range of causes because it does not depend on electrically activating an intact peripheral pathway.

Mechanical support may help foot drop associated with:

• Peripheral nerve injury
• Central neurological conditions
• Muscle weakness
• Some postoperative presentations
• Some spinal conditions
• Long-term paralysis

However, the correct AFO design still depends on:

• Muscle tone
• Joint range
• Deformity
• Skin
• Knee control
• Footwear
• Walking pattern

An AFO may be inappropriate or insufficient when selected without considering these factors.

Which Treatment Improves Toe Clearance Better?

Either may improve toe clearance in an appropriate wearer.

An AFO improves clearance by mechanically:

• Holding the foot up
• Resisting plantarflexion
• Guiding the ankle
• Stabilising the foot

FES improves clearance by stimulating:

• The common peroneal nerve
• Dorsiflexor muscles
• A timed active lifting movement

Research in people after stroke has generally found that both AFOs and FES can improve walking speed, without clear evidence that one is consistently superior for everyone. A 2020 systematic review of randomised trials found no superiority of AFOs over FES for walking speed or balance after stroke.

The practical result for an individual may still differ substantially.

Which Treatment Produces a More Natural Movement?

FES may feel more dynamic because it produces an active muscle contraction rather than relying only on an external brace.

Potential perceived advantages include:

• Active foot lift
• Less rigid restriction at the ankle
• Greater freedom during parts of the walking cycle
• Less material inside the shoe
• A movement that may feel closer to voluntary dorsiflexion

However, the movement produced may be:

• Insufficient
• Delayed
• Uneven
• Associated with foot inversion or eversion
• Affected by electrode placement
• Reduced by fatigue
• Uncomfortable

An AFO may provide a more controlled and predictable position where natural active movement cannot be produced safely.

“More natural” is not always equivalent to “safer” or “more effective”.

Which Treatment Provides More Ankle Stability?

An AFO generally provides more direct structural ankle stability.

Depending on the design, it may control:

• Plantarflexion
• Inversion
• Eversion
• Heel movement
• Ankle collapse
• Foot alignment

FES primarily creates muscle contraction.

It may improve the active position of the foot, but it does not provide the same physical shell or containment as a structured AFO.

Someone with substantial:

• Side-to-side instability
• Foot deformity
• Heel movement
• Joint laxity
• Fixed alignment problems

may require an AFO even when stimulation can lift the foot.

Which Treatment Provides More Knee Control?

An AFO has greater potential to influence knee position mechanically.

Changing ankle movement can affect the forces passing through the lower leg and knee during stance.

A suitable AFO may help manage:

• Mild knee hyperextension
• Excessive knee flexion
• Unstable foot placement contributing to knee problems
• Stance-phase control

FES may affect the knee indirectly by improving foot placement and walking timing, but standard foot-drop stimulation is not a rigid knee-control system.

A person whose knee gives way or moves sharply backwards requires assessment beyond the question of toe lift alone.

Which Is Better if the Foot Turns Inwards?

It depends on why the foot is turning and whether stimulation produces a balanced movement.

FES of the common peroneal nerve may activate muscles that:

• Lift the foot
• Influence outward movement

However, the response varies.

Incorrect electrode placement or a particular pattern of spasticity may produce:

• Excessive eversion
• Insufficient dorsiflexion
• Inward rotation
• An uncomfortable movement

A structured AFO may provide more physical control of foot alignment.

Significant inversion may require:

• An enclosed AFO
• A custom-made brace
• Specific straps
• Spasticity management
• Physiotherapy

Neither basic FES nor a simple leaf-spring AFO should automatically be assumed sufficient.

Which Is Better if the Ankle Is Stiff?

A stiff or fixed ankle can reduce the usefulness of FES because the stimulated muscles may not be able to move the joint through the required range.

One NHS FES service lists fixed contractures among presentations generally unsuitable for FES.

A standard prefabricated AFO may also fail if the heel cannot sit in the intended position.

A custom AFO may be designed to:

• Accommodate the available ankle angle
• Apply controlled support
• Protect pressure areas
• Influence the knee

The ankle should not be forced into either treatment.

Which Is Better for Spasticity?

It depends on the pattern and severity of the spasticity.

FES is used in upper motor neurone conditions, which may include spasticity, but the movement produced must still be useful and controllable.

Assessment should consider:

• Resting tone
• Triggered spasms
• Foot inversion
• Toe curling
• Ankle range
• Walking speed
• Fatigue

An AFO may provide:

• Physical restraint
• Alignment
• A consistent ankle position
• Greater control during stance

FES may provide:

• Timed active movement
• Less rigid restriction
• An alternative for selected people who tolerate stimulation well

Significant spasticity may also require:

• Physiotherapy
• Medication
• Botulinum toxin in selected cases
• A custom brace
• Other neurological management

Which Is Better for Foot Slap?

Foot slap occurs when the forefoot contacts the ground too quickly after heel strike.

AFOs may reduce foot slap by controlling plantarflexion after the heel contacts the ground.

FES may improve the position of the foot during swing and initial contact, but the timing and duration of stimulation must be adjusted appropriately.

The better option depends on whether the wearer needs:

• Swing-phase toe clearance only
• Controlled lowering after heel strike
• Stance-phase ankle stability
• Additional knee influence

An FES trial should assess more than whether the foot lifts while seated.

Which Is Better for Long-Distance Walking?

Either may be suitable.

FES may be preferred by some people because it:

• Avoids a rigid footplate
• Permits more ankle movement
• Can feel lighter
• Produces active muscle contraction

An AFO may be preferred because it:

• Provides predictable support
• Requires no electrical response
• Can offer greater stability
• May be simpler once fitted
• Is not dependent on batteries or electrode placement

Over longer distances, assess whether:

• Toe clearance remains consistent
• Muscle response reduces
• Skin beneath electrodes becomes irritated
• The AFO rubs
• Fatigue changes the walking pattern
• The knee remains stable
• Equipment remains correctly positioned

Research indicates comparable average walking benefits between AFO and FES groups after stroke, but individual tolerance and preference remain important.

Can Muscles Become Fatigued With FES?

Yes.

FES repeatedly activates muscles electrically, and the response may change as the muscle becomes tired.

Signs may include:

• Reduced foot lift
• Need for stronger stimulation
• Less consistent movement
• Toe catching later in the walk
• Muscle discomfort
• A change in foot direction

The stimulation settings, walking programme and rest periods may need adjustment by the specialist service.

Do not continually increase the intensity without instruction.

Excessive stimulation may become uncomfortable without correcting the underlying movement.

Can an AFO Cause Fatigue?

It can.

An AFO may:

• Add weight
• Restrict useful ankle movement
• Alter knee mechanics
• Change footwear
• Require greater hip movement if poorly selected

A correctly selected brace may instead reduce fatigue by:

• Improving toe clearance
• Reducing high stepping
• Reducing hip hiking
• Making foot placement more consistent

The question is not whether the brace has weight, but whether the complete walking pattern becomes more or less efficient.

Which Is Easier To Put On?

This varies.

An AFO may require:

• A smooth sock
• Positioning the heel
• Fastening calf or ankle straps
• Inserting the brace into footwear
• Securing the shoe

FES may require:

• Locating the correct electrode position
• Applying electrodes
• Fitting a cuff or sensor
• Connecting components
• Switching on the unit
• Adjusting or checking stimulation
• Charging or replacing batteries

A person with:

• One-handed weakness
• Poor dexterity
• Tremor
• Reduced vision
• Cognitive difficulty
• Difficulty reaching the leg

may find either system challenging.

A practical trial should include putting the equipment on and removing it, not only walking in it after a clinician has fitted it.

Is FES Difficult To Position Correctly?

It can be initially.

Small changes in electrode position may alter:

• The amount of dorsiflexion
• The direction of movement
• Comfort
• Muscle contraction
• Whether the foot turns inwards or outwards

The specialist normally identifies and marks or teaches the appropriate position.

Some systems use integrated cuffs to make repeat placement easier.

A device may not provide the same movement if:

• The cuff rotates
• The electrode is worn
• The skin is damp
• The placement changes
• The stimulation setting is altered

Which Is Easier To Use Every Day?

The answer depends on the wearer.

An AFO may be easier when the person prefers:

• A passive mechanical device
• No electrical sensation
• No battery charging
• No electrode replacement
• Predictable support

FES may be easier when the person prefers:

• Less material inside the shoe
• More ankle freedom
• Active foot lift
• A wearable electronic system
• A device that fits with their clothing and routine

Daily suitability should include:

• Morning fitting
• Work
• Toileting
• Travel
• Skin care
• Charging
• Replacement components
• Evening removal

Does FES Hurt?

It should not be painfully uncomfortable when correctly assessed and adjusted.

The sensation is often described as:

• Tingling
• Pins and needles
• A tapping or pulsing feeling

An NHS FES clinic explains that electrical stimulation can feel like pins and needles as it produces the muscle contraction.

Tell the clinician if stimulation causes:

• Sharp pain
• Burning
• Severe discomfort
• An unpleasant pulling movement
• Muscle cramp
• Persistent pain after removal

The intensity should not simply be increased until the foot moves regardless of comfort.

Can FES Irritate the Skin?

Yes.

Skin irritation may occur beneath the electrodes because of:

• Adhesive
• Moisture
• Repeated removal
• Incorrect placement
• High stimulation
• Worn electrodes
• Sensitive skin

An NHS FES service advises stopping and seeking advice if redness, irritation or skin breakdown does not disappear within 30 minutes.

Do not place electrodes over:

• Broken skin
• An infection
• An open wound
• A severe rash
• Unexplained swelling

Follow the device-specific skin-care instructions.

Can an AFO Irritate the Skin?

Yes.

Pressure or rubbing may occur around:

• Ankle bones
• Heel
• Calf
• Top of the foot
• Footplate edges
• Straps

Use:

• A suitable smooth sock
• Correct fitting
• Secure footwear
• A gradual wearing schedule
• Regular skin checks

NHS AFO guidance recommends checking the skin after wear, using suitable footwear and arranging repairs or review rather than modifying the device yourself.

Which Is Better for Sensitive Skin?

Neither is automatically better.

FES may be unsuitable when the skin:

• Reacts to adhesive
• Breaks down beneath electrodes
• Is affected by eczema or another condition
• Cannot tolerate repeated removal

An AFO may be difficult when the skin:

• Is fragile over bony areas
• Has previous pressure damage
• Is affected by swelling
• Cannot tolerate straps or rigid edges

A specialist can assess whether:

• Different electrode materials
• A different cuff
• A lined AFO
• Custom pressure relief
• Another treatment

would be more appropriate.

Which Is Better for Reduced Sensation?

Particular caution is needed with either treatment.

Reduced sensation may prevent someone from detecting:

• Electrode irritation
• Excessive stimulation
• A hot area
• A pressure point
• A folded sock
• Rubbing
• Skin breakdown

FES also depends on safe electrode placement and monitoring of the skin.

An AFO provides no automatic protection from pressure merely because it is passive.

People with neuropathy, diabetes, spinal conditions or reduced sensation should seek individual clinical advice.

Can You Use FES With a Pacemaker?

Some NHS FES services advise that it should not be used with a cardiac pacemaker or another implanted medical device.

The exact restriction may depend on:

• The implanted device
• FES equipment
• Electrode location
• Cardiology advice
• Manufacturer instructions

Do not trial or purchase an FES unit without telling the assessing service about:

• A pacemaker
• Implantable defibrillator
• Neurostimulator
• Cochlear implant
• Other implanted electronic equipment

An AFO may provide a non-electrical alternative.

Can You Use FES During Pregnancy?

Some NHS specialist services list pregnancy as a reason not to use FES.

Anyone who is pregnant or may be pregnant should tell the specialist service before assessment or continued use.

An AFO may still be considered, but pregnancy-related swelling and changes in balance can alter the fit.

Can You Use FES With Epilepsy?

A current NHS FES clinic advises against use where epilepsy is not well controlled.

Suitability should be discussed with:

• The FES clinician
• Neurology team
• Relevant consultant

Do not use an unsupervised electrical stimulation device based only on general online information.

Can You Use FES Over Broken Skin?

No electrodes should be placed over broken or damaged skin without specialist instruction.

Broken skin can increase:

• Irritation
• Infection risk
• Discomfort
• Unpredictable electrical contact

Current NHS FES guidance specifically identifies broken skin at electrode sites as a reason not to proceed.

Does FES Require Batteries?

Surface FES systems require electrical power.

Depending on the model, this may involve:

• Disposable batteries
• Rechargeable batteries
• A charging cable
• A control unit

Before leaving home, the wearer may need to check:

• Battery level
• Device function
• Electrode condition
• Sensor
• Connections
• Spare power

An AFO does not require power, although it still needs:

• Strap maintenance
• Suitable footwear
• Inspection
• Replacement when worn

What Happens if FES Stops Working During a Walk?

If stimulation fails, the foot-drop assistance may stop immediately.

Possible causes include:

• Flat battery
• Disconnected lead
• Sensor movement
• Electrode displacement
• Wet or dry skin affecting contact
• Device fault
• Incorrect settings

The person should have a safe plan for:

• Stopping
• Sitting
• Checking the system
• Using a walking aid
• Returning home
• Contacting the service

Some people carry an AFO or alternative support for particular journeys, but this arrangement should be planned rather than improvised.

What Happens if an AFO Breaks During a Walk?

Support may reduce or fail if:

• Plastic cracks
• Carbon splinters
• A strap opens
• A textile component stretches
• A footwear attachment disconnects

Stop and assess the device safely.

Do not repair it with:

• Glue
• Tape
• Safety pins
• Cable ties
• Household elastic

Contact the supplier or orthotics service.

Both treatment types require contingency planning.

Which Is Better for Travel?

An AFO may be easier to manage because it:

• Requires no charging
• Has no electrodes
• Is familiar to airport staff
• Can be inspected visually

However, it may:

• Take up luggage space
• Require specific footwear
• Be vulnerable to crushing
• Need replacement straps

FES may be:

• Compact
• Worn beneath clothing
• Easier to use with some footwear

but requires:

• Batteries or charging
• Electrodes
• Leads or sensors
• Protection from water
• Access through security
• Spare consumables

Keep essential equipment in accessible baggage and check airline rules where batteries or electronic medical devices are involved.

Which Is Better Around the House Without Shoes?

Some textile AFO systems have specific shoeless options, such as:

• Boxia® with its Shoeless Attachment
• StepUp®

A rigid AFO normally requires supportive footwear.

FES may lift the foot without a rigid footplate, but walking barefoot still raises questions about:

• Grip
• Foot protection
• Heel stability
• Sensation
• Floor hazards

FES does not replace suitable footwear where footwear is required for safety.

Which Is Better for Stairs?

Stairs require:

• Toe clearance
• Hip and knee strength
• Balance
• Accurate foot placement
• Controlled lowering

FES may assist active foot lift during swing.

An AFO may additionally provide:

• Ankle stability
• Foot alignment
• Knee influence

Neither guarantees safe stair use.

The treatment should be assessed during actual stair practice with a physiotherapist where required.

Which Is Better for Uneven Ground?

Uneven ground requires more than dorsiflexion.

It may require:

• Side-to-side ankle control
• Rapid adaptation
• Balance
• Sensation
• Knee stability
• Suitable footwear

FES may preserve more natural ankle movement but may not mechanically stabilise an unstable joint.

An AFO may provide greater stability but can restrict the ankle’s ability to adapt to the ground.

The better option depends on the specific impairment and terrain.

Which Is Better for Driving?

Neither treatment establishes fitness to drive.

An AFO may:

• Restrict ankle movement
• Alter pedal feel
• Catch within the footwell

An FES unit may:

• Stimulate movement unexpectedly if not configured appropriately
• Include a cuff or equipment around the leg
• Affect pedal control
• Require separate driving guidance

Driving suitability depends on:

• Affected side
• Vehicle
• Pedal control
• Reaction time
• Strength
• Sensation
• Underlying condition
• DVLA and insurance requirements

Arrange a specialist driving assessment when pedal control is uncertain.

Can FES Be Used While Sleeping?

A walking FES system is not normally used as an automatic overnight foot-positioning device.

It is primarily timed to produce functional movement during walking or used in a prescribed rehabilitation programme.

A separate night splint or resting AFO may be considered when the goal is:

• Maintaining ankle position
• Managing tightness
• Protecting the heel
• Resting support

Do not leave stimulation running during sleep unless a specialist programme and device instructions explicitly require it.

Can You Wear an AFO and Use FES Together?

Sometimes, but only as part of a planned clinical approach.

NICE notes that patients using FES may also use an AFO.

Possible arrangements might include:

• FES for selected walking
• An AFO for longer or more demanding journeys
• An AFO where greater stability is required
• A resting AFO at night
• FES during supervised rehabilitation

Using both simultaneously on the same leg may alter:

• Movement
• Electrode position
• Pressure
• Stimulation response
• Footwear fit

Do not combine them without professional advice.

Can You Switch Between an AFO and FES?

Yes, where a specialist has established when each should be used.

A person might prefer:

• FES for everyday level walking
• An AFO for uneven ground
• An AFO when the FES battery cannot be charged
• FES with one type of footwear
• A structured AFO when the knee needs greater control

The walking pattern should remain safe with each treatment.

Do not stop using a prescribed AFO before confirming that FES provides adequate support across the intended activities.

Does FES Strengthen the Muscle?

FES creates repeated contractions and may be included within rehabilitation.

However, the primary functional effect in foot-drop use is assistance while the device is operating.

The extent to which strength, control or walking without the device improves varies with:

• Diagnosis
• Severity
• Residual nerve pathway
• Duration of use
• Rehabilitation
• Muscle condition
• Disease progression

Do not assume that FES will permanently restore unassisted dorsiflexion.

Does Wearing an AFO Weaken the Muscle?

An AFO changes movement and may reduce the amount of active ankle motion required while it is worn.

That does not mean it automatically causes harmful dependence or weakness.

The purpose may be to:

• Improve safety
• Reduce trips
• Stabilise joints
• Protect the ankle
• Improve foot placement
• Reduce compensatory movement

A rehabilitation programme may include appropriate unsupported exercise where this is safe and clinically useful.

Do not stop wearing an AFO because of a general belief that the leg must work harder without it.

Which Is Better for Rehabilitation?

Either may be used alongside rehabilitation.

An AFO may help the person practise:

• Safer walking
• Better foot placement
• Longer distances
• More consistent steps

FES may provide:

• Timed active contraction
• Sensory input
• Repeated movement during walking
• A dynamic alternative to passive support

The rehabilitation goal should be clear.

A treatment that improves walking only when worn may still provide meaningful functional benefit.

What Happens at an FES Assessment?

A specialist assessment may include:

• Medical and neurological history
• Cause of foot drop
• Walking observation
• Strength testing
• Joint-range testing
• Spasticity assessment
• Skin examination
• Electrode placement
• Trial stimulation
• Walking with the device
• Adjustment of timing and intensity
• Discussion of goals
• Comparison with current aids or AFOs

UCLH states that its specialist physiotherapist assesses walking, strength, spasticity and joint range before trialling the device where appropriate.

An initial appointment at another NHS FES clinic may last up to 90 minutes.

What Does a Successful FES Trial Look Like?

The clinician may look for:

• A visible and useful foot-lifting response
• Improved toe clearance
• Better foot placement
• Improved walking safety
• Acceptable comfort
• Manageable electrode placement
• No harmful increase in spasticity
• No skin problem
• A result that remains useful over repeated steps

A visible twitch while seated does not automatically mean FES will improve walking.

The timing and direction of movement need to work during gait.

What if FES Produces No Foot Movement?

Possible reasons include:

• Peripheral nerve damage
• Severe lower motor neurone involvement
• Incorrect electrode position
• Insufficient stimulation
• Fixed ankle restriction
• Muscle changes
• Equipment problems

The clinician may adjust the setup, but stimulation should not simply be increased indefinitely.

An AFO or another treatment may be more appropriate if a useful movement cannot be produced.

What if FES Lifts the Foot but Feels Uncomfortable?

Tell the clinician.

Possible causes include:

• Electrode placement
• Stimulation intensity
• Skin sensitivity
• Muscle cramp
• An unwanted movement
• A poorly fitting cuff

The best technical movement is not useful if the person cannot tolerate the system consistently.

An AFO may offer a more acceptable alternative.

What if an AFO Lifts the Foot but Feels Uncomfortable?

The cause may include:

• Wrong size
• Heel not fully seated
• Footwear pressure
• Strap position
• Ankle stiffness
• A pressure area
• Excessive stiffness
• Wrong brace design

Arrange an orthotic review rather than immediately assuming that FES is the only alternative.

A different AFO may resolve the issue.

Is FES Available Through the NHS?

Specialist NHS FES services exist, but referral criteria, funding arrangements and available devices vary by area.

UCLH accepts referrals from GPs and hospital consultants for people meeting its specialist service criteria.

Another NHS service explains that provision may involve local NHS funding, charity support or private purchase following a successful trial, and that funding is not automatically guaranteed.

Ask your:

• GP
• Consultant
• Neurological physiotherapist
• Rehabilitation team

about the local pathway.

Can You Buy an FES Device Privately?

Private assessment and purchase may be available, but specialist fitting remains important.

Do not select a device solely through:

• Price
• Online reviews
• Advertising
• A video demonstration
• A diagnosis name

The clinician needs to establish:

• Whether FES is physiologically appropriate
• Correct electrode position
• Safe intensity
• Timing
• Skin tolerance
• Whether the movement improves walking
• Whether another treatment is more suitable

A privately purchased unit should not be applied without following its medical screening and fitting requirements.

Is an AFO Easier To Obtain?

Prefabricated AFOs are more widely available and some can be purchased directly.

However, online availability does not guarantee suitability.

Professional assessment is particularly important where there is:

• Spasticity
• Fixed ankle restriction
• Knee instability
• Strong foot rotation
• Reduced sensation
• Diabetes
• Recurrent falls
• Bilateral weakness
• A worsening neurological condition

A custom-made AFO requires an orthotic assessment and manufacture.

Which Costs More?

The answer varies.

A prefabricated AFO may have:

• A lower initial purchase price
• Occasional replacement-strap costs
• Footwear costs
• Eventual replacement costs

A custom AFO may involve:

• Assessment
• Individual manufacture
• Fitting
• Adjustment
• Repairs

FES may involve:

• Assessment
• Device cost
• Electrodes
• Batteries or charging equipment
• Replacement cuffs or leads
• Follow-up
• Maintenance

Cost should not determine treatment before suitability has been established.

A cheaper option that cannot be used safely is poor value, while a more expensive device is not automatically more effective.

Which Do People Prefer?

Preferences vary.

Someone may prefer an AFO because it is:

• Simple
• Passive
• Predictable
• Free from electrical sensation
• Quick to check
• Independent of batteries

Someone may prefer FES because it:

• Provides active movement
• Uses less material inside the shoe
• Permits more ankle freedom
• Feels more dynamic
• Works better with their chosen footwear

Research comparisons show broadly similar average walking outcomes in several stroke populations, meaning comfort, daily usability and individual response can become important deciding factors.

AFO Advantages

Potential advantages include:

• Works without an electrical muscle response
• Can be used for central or peripheral causes where appropriate
• Provides mechanical ankle stability
• Can control heel and foot alignment
• Can influence knee position
• Does not require batteries
• Does not require electrodes
• Several soft, plastic, reinforced, carbon and custom designs exist
• Can remain predictable throughout the day when correctly fitted

AFO Limitations

Potential limitations include:

• May restrict ankle movement
• Requires suitable footwear
• May occupy space inside the shoe
• Can create pressure or rubbing
• Can alter knee mechanics
• May feel warm
• May be visible beneath clothing
• Can crack, stretch or wear
• Must be matched to the required control

FES Advantages

Potential advantages include:

• Produces active muscle contraction
• May provide a dynamic foot-lifting movement
• Can preserve more ankle freedom
• Avoids a rigid footplate in some systems
• May suit selected central neurological foot drop
• Can be adjusted for stimulation intensity and timing
• May be integrated with neurological rehabilitation

FES Limitations

Potential limitations include:

• Not normally suitable for lower motor neurone or peripheral nerve damage
• Requires specialist assessment
• Requires a useful nerve-and-muscle response
• May irritate the skin
• Requires accurate placement
• Produces an electrical sensation
• Requires power and consumables
• May become less effective with fatigue
• Does not provide the structural control of every AFO
• Access and funding vary
• May be unsuitable with particular medical conditions or implanted devices

Questions To Ask Before Choosing

What caused the foot drop?

This is the first question.

Central neurological foot drop may make FES possible.

Peripheral nerve or muscle damage usually makes an AFO more likely.

Does stimulation produce useful movement?

A practical trial is needed.

Does the ankle remain flexible?

A fixed ankle may limit both treatments.

Does the foot turn strongly?

More structural control may be needed.

Is the knee unstable?

An AFO may need to influence the complete lower leg.

Is the skin healthy?

FES electrodes and AFO pressure both require skin tolerance.

Is sensation reduced?

Regular skin checks are essential.

Can the equipment be fitted independently?

Consider hand function, vision, reach and cognition.

What activities must it support?

Consider:

• Home mobility
• Work
• Long walking
• Uneven ground
• Stairs
• Travel
• Exercise
• Driving

What happens if the device stops working?

A safe backup plan is important.

Which option will actually be used?

A technically effective treatment provides little benefit if it cannot be fitted, tolerated or maintained in everyday life.

A Simple AFO-or-FES Decision Guide

An AFO may be more likely to suit someone who:

• Has peripheral nerve-related foot drop
• Does not produce a useful response to stimulation
• Needs greater ankle stability
• Needs heel control
• Has significant foot alignment problems
• Needs the brace to influence the knee
• Prefers a passive device
• Cannot manage electrodes or charging
• Has a medical reason that makes FES unsuitable

FES may be worth specialist assessment when someone:

• Has foot drop of central neurological origin
• Has an upper motor neurone condition
• Retains a suitable peripheral nerve-and-muscle response
• Has enough joint movement for useful dorsiflexion
• Can tolerate electrical stimulation
• Can manage the equipment
• Wants to trial active foot lift
• Does not require greater structural control than FES provides

A combination or different devices for different activities may be considered where clinically appropriate.

Neither Option Should Be Chosen Solely by Appearance

FES may look more technologically advanced.

A carbon AFO may look more premium.

A textile brace may look more discreet.

Appearance does not establish:

• Suitability
• Safety
• Comfort
• Walking improvement
• Stability
• Long-term usability

The best treatment is the one that produces safe, reliable and acceptable function for the individual.

Neither Option Guarantees That You Will Not Fall

Both may improve toe clearance, but falls can also be caused by:

• Poor balance
• Hip weakness
• Knee weakness
• Reduced sensation
• Vision problems
• Dizziness
• Fatigue
• Medication
• Environmental hazards
• Inattention
• An inappropriate walking aid

A broader falls assessment may still be required.

Can Either Treatment Cure Foot Drop?

No.

An AFO assists or controls the foot while it is worn.

FES stimulates a contraction while the system is operating.

Neither automatically repairs the underlying neurological, nerve or muscular condition.

Treatment may also include:

• Physiotherapy
• Management of spasticity
• Treatment of nerve compression
• Medical management of an underlying condition
• Walking aids
• Falls prevention
• Surgery in selected cases

The NHS advises GP assessment so the cause can be investigated and the most appropriate treatment considered.

When Should Foot Drop Be Medically Reassessed?

Arrange a GP or specialist review if:

• Foot drop is new
• Weakness is worsening
• Both feet are affected
• Numbness is increasing
• Weakness is spreading
• You are falling more frequently
• The ankle is becoming stiffer
• Spasticity is increasing
• A previously effective AFO or FES device no longer helps
• Symptoms followed surgery or injury
• You have developed new back or leg pain

Call 999 if sudden weakness occurs with:

• Facial drooping
• Arm weakness
• Slurred or confused speech

Seek urgent medical assessment if new foot or leg weakness occurs with:

• Severe or worsening back pain
• Numbness around the genitals or buttocks
• Difficulty starting or controlling urination
• Loss of bladder or bowel control
• Rapidly worsening weakness

Do not rely on purchasing an AFO or FES unit to manage a new or progressive neurological change without medical assessment.