Understanding the Lower Limb Orthosis User: Key Insights for Clinicians and Life Care Planners 

Journal

Journal of Nurse Life Care Planning
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Authors

Phil Stevens, PhD, CPO¹, Kendall Brice, MS, CPO²  

1. Hanger Institute for Clinical Research and Education, Austin, Texas, United States of America.
2. Hanger Clinic, Salt Lake City, UT, United States.  

Background

Lower limb orthosis users (LLOU) represent one of the most clinically complex and historically understudied populations in orthotics and prosthetics. Spanning a wide range of diagnoses, from stroke and multiple sclerosis to spinal cord injury and Charcot-Marie-Tooth disease, LLOU share a common reliance on mechanical support to facilitate safe standing and ambulation. Yet even in aggregate, the most commonly cited clinical populations account for fewer than 40% of all LLOU.

Recent population-level research has begun to characterize the broader health burden this group bears. Using the PROMIS-29 patient-reported outcome instrument, which assesses anxiety, fatigue, depression, pain interference, and physical function relative to U.S. population norms, researchers identified several domains where LLOU profiles diverge significantly from national averages.

Physical function scores among LLOU averaged in the 13th percentile of the U.S. population, reflecting severe functional compromise. Pain interference scores averaged at the 74th percentile, meaning the typical LLOU experiences more pain interference than approximately three-quarters of the general population. A separate analysis of nearly 1,300 individuals prescribed lower limb orthoses found that 91% reported pain interference above the U.S. average, with 67% exceeding it by more than one standard deviation.

These deficits translate directly into safety risks. A six-month injurious fall rate of 18.6% was observed among LLOU, exceeding rates reported for lower limb prosthesis users (12.7%) and elderly adults (10.7%) over comparable periods.

With elevated pain levels, reduced functional capacity, and high fall risk, this population benefits immensely from thoughtful assessment and targeted orthotic strategies. Understanding the biomechanical phenotypes that drive these outcomes is essential for clinicians, case managers, and life care planners seeking to improve mobility outcomes and long‑term safety for individuals relying on lower limb orthoses.

Objective

To characterize the health burden of the lower limb orthosis user population, describe common gait deficit phenotypes and their orthotic remediation, and outline key considerations for life care planners when developing long-term orthotic care projections. 

Design

Narrative clinical review synthesizing population-level patient-reported outcome data from a cohort of 1,036 adults with chronic lower limb impairments (Balkman et al., 2024) and 1,300 adults presenting for a new or replacement lower limb orthosis (Stevens et al., 2025).

Results

Common Gait Deficit Phenotypes

The LLOU population presents with a wide array of biomechanical gait deviations requiring orthotic remediation. The most frequently encountered include:

• Crouch Gait: Persistent knee flexion during stance phase due to plantar flexor weakness, often seen in individuals with myelomeningocele or cerebral palsy. Creates inefficient walking patterns and long-term orthopedic risk.
• Genu Recurvatum: Knee hyperextension in stance due to fixed plantarflexion contracture or paired plantar flexor/quadriceps weakness. Common in stroke and polio survivors; progresses to painful joint destruction if unaddressed.
• Foot Drop / Steppage Gait: Inability to dorsiflex the foot in swing phase due to Tibialis Anterior deficit, resulting in compensatory high-stepping and elevated fall risk. Frequently associated with peripheral nerve injury, compression, or trauma.
• Equinus: Fixed plantarflexion contracture preventing ankle dorsiflexion during both swing and stance. Associated with central nervous system conditions, including cerebral palsy and traumatic brain injury.
• Antalgic Gait: Pain-avoidant compensatory strategies that reduce walking efficiency and increase risk of secondary overuse injuries in adjacent joints.

Life Care Planning Considerations 

For nurse life care planners and other professionals developing long-term care projections for LLOU, several key considerations include: 

• Frequent reassessment is essential due to evolving gait patterns and compensatory behaviors.  
• Pain interference may require coordinated pain management strategies alongside orthotic intervention. 
• Fall mitigation should be explicitly incorporated into care plans. 
• Individualized orthotic solutions, such as stance control, energy‑return systems, or improved ankle mechanics, are critical for optimizing mobility. Complexity of deficit guides device selection. Single-plane deficits may be managed with non-custom solutions; multi-plane deficits generally require custom-fabricated devices capable of controlling complex movement patterns. 
• Consultation with a certified orthotist who has directly evaluated the patient is essential for accurate projections regarding device type, customization needs, replacement frequency, and cost.
• Global health measures, including standardized pain and mobility assessments, should be incorporated into life care planning evaluations to capture the full scope of patient burden, not just the mechanical deficit. 

Conclusion

• LLOU represent a heterogeneous population with significantly compromised physical function, elevated pain interference, and injurious fall rates that exceed those of other high-risk mobility groups. 
• Common gait deviation phenotypes, including foot drop, crouch gait, genu recurvatum, and equinus, respond to targeted orthotic intervention when device design, stiffness, and alignment are carefully matched to individual biomechanical needs. 
• Life care planners should collaborate with certified orthotists to develop accurate, individualized projections that reflect current clinical practice guidelines, replacement cycles, and the full global health burden of the LLOU population. 

More Published Research

This publication is just one of the studies conducted by the Hanger Institute for Clinical Research and Education, in collaboration with leading researchers, clinical, and academic institutions.

Learn More

1. Balkman, G.S., Bamer, A. M., Stevens, P. M., Weber, E. L., Morgan, S. J., Salem, R., Amtmann, D., & Hafner, B. J. (2024). Evaluating patientreported health outcome profiles of lower limb orthosis users. Archives of Physical Medicine and Rehabilitation pending.

2. Stevens PM, England D, & Carrol K. (2025, Sept 3-6) Injurious Falls Among Individuals Prescribed Lower Limb Orthoses: Relationships with
Mobility, Pain Interference, Lower Limb Strength, Sex and Age [Conference presentation]. AOPA 2025 National Assembly, Orlando, FL, United States.