Awareness, framework-based proficiency, and clinical implementation of Ankle Foot Orthosis–Footwear Combination (AFO–FC) tuning: A cross-sectional survey

Background: Ankle foot orthosis–footwear combination (AFO–FC) tuning involves structured adjustment of the AFO relative to footwear to optimise shank alignment and ground reaction force (GRF) positioning during stance. Although established biomechanical frameworks and clinical algorithms are available, variability in clinical implementation persists. Previous investigations have primarily relied on self-reported practice within single healthcare settings and have not, to our knowledge, systematically examined how orthotists articulate and apply tuning principles within structured clinical reasoning across diverse educational and practice environments. Objectives: This study aimed to determine the level of awareness and framework-based proficiency in AFO–FC tuning among practising orthotists in a geographically diverse convenience sample, to examine the extent to which AFO–FC tuning is integrated into routine clinical practice, and to explore associations between framework-based proficiency level and selected professional characteristics. Methods: A cross-sectional study was conducted using an online survey of practising orthotists (n = 245). Awareness of AFO–FC tuning and self-reported routine implementation were assessed. Framework-based proficiency was evaluated among respondents reporting awareness (n = 212) using structured content analysis of open-text responses within a predefined exploratory five-domain biomechanical framework, and classified as limited (0–1 domains), partial (2–3 domains), or full (4–5 domains). Associations between framework-based proficiency level and professional characteristics were examined using chi-square tests. Binary logistic regression was performed to assess the association between framework-based proficiency level and self-reported routine implementation. Results: Self-reported awareness of AFO–FC tuning was high (86.5%), whereas 53.5% reported routine implementation. Based on the framework scoring, 59.0% demonstrated limited framework-based proficiency, 31.6% partial framework-based proficiency, and 9.4% full framework-based proficiency. No statistically significant associations were observed in this sample between framework-based proficiency level and educational qualification, years of clinical experience, or annual AFO case volume (p > 0.05). Full framework-based proficiency was associated with higher odds of self-reported routine implementation (OR = 4.03, 95% CI 1.44–11.25, p = 0.008). Conclusions: Despite high self-reported awareness, framework-based proficiency in AFO–FC tuning was limited within this sample. Self-reported routine implementation was more frequently reported among respondents with higher framework-based proficiency, whereas no statistically significant associations were observed with educational level, clinical experience, or annual AFO case volume. These hypothesis-generating findings should be interpreted cautiously given the cross-sectional design and framework-based (non-validated) classification.