Foot & Ankle PROMs: A Clinician's Guide to Selecting the Right Outcome Measures
Choosing the right patient-reported outcome measures (PROMs) for your foot and ankle patients can significantly impact the quality of your clinical data and, ultimately, your treatment decisions. Yet a comprehensive systematic review reveals that many clinicians continue using suboptimal measures.
This guide, informed by the latest evidence from a decade-long analysis of over 4,400 foot and ankle articles, will help you select validated, reliable PROMs that genuinely measure what matters to your patients.
What's in This Guide
The Current State of Foot & Ankle PROMs
A systematic review by Al Shdefat and colleagues analysed every article published between January 2012 and December 2022 in six major orthopaedic journals: Foot and Ankle International, Foot and Ankle Surgery, Clinical Orthopaedics and Related Research, Knee Surgery, Sports Traumatology and Arthroscopy, The Bone and Joint Journal, and American Journal of Sports Medicine.
The findings paint a striking picture of our field's PROM usage. Of the 4,402 foot and ankle articles identified, 1,553 (35.3%) reported at least one patient-reported outcome measure. Remarkably, 125 unique PROMs were identified across these studies—highlighting significant inconsistency in outcome measurement.
Top 10 PROMs in Foot & Ankle Literature
125 unique PROMs identified across 1,553 articles (2012-2022). Here are the top 10:
The American Orthopaedic Foot and Ankle Society (AOFAS) score remains the most commonly used measure, appearing in over half of all studies (51.5%). This is followed by the Visual Analogue Scale (VAS) for pain (43.2%), SF-36 (13.5%), FAOS (10.8%), FAAM (7.6%), FFI (7.5%), ATRS (5.5%), SF-12 (5.2%), Karlsson (4.2%), and EQ-5D (3.9%).
Notice how validated, condition-specific measures like FAOS, FAAM, and ATRS are used far less frequently than the poorly-validated AOFAS—despite AOFAS's limitations being well documented since 2011.
The AOFAS Score: Why It's Time to Reconsider
Here's the uncomfortable truth: the most widely used foot and ankle outcome measure lacks adequate validation. In 2011, the American Orthopaedic Foot and Ankle Society issued a position statement highlighting significant limitations in the AOFAS score:
- Lack of measurement precision – the scoring system doesn't reliably detect small but meaningful changes
- Limited construct validity – it doesn't necessarily measure what it claims to measure
- Poor reliability – repeated measurements may not be consistent
AOFAS subsequently advised against continued use of the score. Yet as the research shows, it remains ubiquitous in the literature.
PROM Usage Trend (2012-2022)
Annual % of studies reporting AOFAS, VAS, SF-36, FAOS, and FAAM (Al Shdefat et al.)
The good news? AOFAS usage has declined over the study period. The concerning news? This decline has been gradual, and validated alternatives like FAOS and FAAM remain relatively underutilised.
Which PROM for Which Condition?
This is the question clinicians ask most often. Based on the systematic review's analysis of over 1,500 studies, here are the evidence-based recommendations for each major foot and ankle condition:
| Condition | Recommended PROM | Evidence | Clinical Note |
|---|---|---|---|
| Achilles tendinopathy | VISA-A | 43 studies analysed • 60.5% usage | VISA-A is the validated gold standard for this condition |
| Achilles tendon rupture | ATRS | 118 studies analysed • 71.2% usage | ATRS is specifically designed and validated for ruptures |
| Chronic lateral ankle instability | Karlsson + CAIT | 108 studies analysed • 48.1% usage | Consider CAIT for instability-specific assessment |
| Ankle fracture | OMAS | 112 studies analysed • 37.5% usage | OMAS is specifically validated for ankle fractures |
| Hallux valgus | MOXFQ | 164 studies analysed | MOXFQ has superior psychometrics for forefoot surgery |
| Plantar fasciitis | FFI | 55 studies analysed • 23.6% usage | FFI is condition-specific; VAS useful for pain tracking |
| Osteochondral lesions (talus) | FAOS | 139 studies analysed • 23.0% usage | FAOS provides comprehensive ankle function assessment |
| Total ankle arthroplasty | FAOS + EQ-5D | 130 studies analysed | Consider FJS-12 for high-functioning patients |
| Sports injuries (general) | FAAM | FAAM Sports subscale essential for return-to-sport |
Validated Alternatives You Should Consider
The foot and ankle field has several well-validated PROMs that provide reliable, meaningful data. Here's a comprehensive comparison:
| PROM | Domains Measured | Best For | MCID |
|---|---|---|---|
| FAOS Foot and Ankle Outcome Score | Pain, Symptoms, ADL, Sport/Recreation, Quality of Life | General foot/ankle conditions, post-operative assessment | 8-10 points per subscale |
| FAAM Foot and Ankle Ability Measure | Activities of Daily Living, Sports | Athletes, sports injuries, high-demand patients | 8 points (ADL), 9 points (Sports) |
| MOXFQ Manchester-Oxford Foot Questionnaire | Walking/Standing, Pain, Social Interaction | Forefoot surgery, hallux valgus, lesser toe deformities | 12-13 points (0-100 scale) |
| FJS-12 Forgotten Joint Score | Joint awareness | Post-total ankle replacement, ligament reconstruction | 10-15 points |
| VISA-A Victorian Institute of Sport Assessment - Achilles | Pain, Function, Activity | Achilles tendinopathy | 12 points |
| ATRS Achilles Tendon Total Rupture Score | Symptoms, Physical activity, Return to sport | Achilles tendon rupture - used in 71% of rupture studies | 10 points |
| CAIT Cumberland Ankle Instability Tool | Ankle stability, Function, Giving way | Chronic ankle instability, post-sprain assessment | 3 points |
| OMAS Olerud-Molander Ankle Score | Pain, Stiffness, Swelling, Stairs, Running, Jumping, Squatting, Supports, ADL | Ankle fracture outcomes - used in 37.5% of fracture studies | 12 points |
| FFI Foot Function Index | Pain, Disability, Activity limitation | Plantar fasciitis (23.6% of studies), general foot pain | 7 points |
| Karlsson Karlsson-Peterson Ankle Function Score | Pain, Swelling, Instability, Stiffness, Stairs, Running, Work, Supports | Chronic lateral ankle instability - used in 48% of CLAI studies | 10 points |
| EQ-5D-5L EuroQol 5 Dimensions 5 Levels | Mobility, Self-care, Usual activities, Pain/Discomfort, Anxiety/Depression | Health economic analysis, cross-condition comparisons | 0.08 (utility score) |
| VAS Pain Visual Analogue Scale for Pain | Pain intensity | Pain assessment across all conditions | 1.3 (on 0-10 slider) |
FAOS: The Comprehensive Choice →
The Foot and Ankle Outcome Score (FAOS) is extensively validated and covers five key domains. It's particularly useful when you need a comprehensive assessment across multiple aspects of foot and ankle function. The questionnaire takes approximately 10 minutes to complete and provides subscale scores that can be analysed independently.
FAAM: For Active Patients →
The Foot and Ankle Ability Measure (FAAM) excels for sports medicine settings and patients with high functional demands. Its Sports subscale specifically captures activities that matter to athletes and active individuals—making it invaluable for monitoring return to sport.
MOXFQ: Forefoot Focus →
The Manchester-Oxford Foot Questionnaire (MOXFQ) offers excellent psychometric properties for forefoot surgery. If you're treating hallux valgus, lesser toe deformities, or other forefoot conditions, MOXFQ provides targeted, validated measurement.
Condition-Specific Options
For specific pathologies, consider condition-specific measures like VISA-A for Achilles tendinopathy, CAIT for chronic ankle instability, or the FFI (Foot Function Index) for general foot pain. These targeted instruments often provide greater sensitivity to change within their specific domains.
How to Choose the Right PROM for Your Practice
Use this decision framework to select the most appropriate PROMs for your patients:
Quick Decision Guide
The "VAS-Only" Trap
The review found VAS pain was used in 43% of studies—often as the only measure alongside AOFAS. While VAS is validated and quick, it only measures pain intensity. It misses:
- Function: Can patients walk, climb stairs, return to sport?
- Activity restriction: What activities have they had to give up?
- Quality of life: How does their condition affect daily life?
Recommendation: Always pair VAS with at least one validated foot/ankle-specific measure for a holistic assessment.
Frequency Strategy: Keep Patients Engaged
One challenge with longer PROMs is patient fatigue—asking patients to complete a 42-item FAOS every week will quickly lead to drop-off. A smarter approach uses different frequencies for different measures:
Recommended Collection Frequency
- • VAS Pain (10 seconds)
- • Single-item function question
- • Medication/flare tracking
Keeps patients engaged, tracks trends, catches flares early
Why this works: Weekly VAS takes seconds and maintains the patient habit. Quarterly comprehensive PROMs feel less burdensome when spaced out, and you get the detailed data when it matters—at follow-up appointments.
Making Sense of Results: MCID, PASS, and SCB
Perhaps the most striking finding from the systematic review: only 1.5% of studies reported whether patients achieved a Minimally Clinically Important Difference (MCID). This matters because statistical significance doesn't tell us if the change actually mattered to patients.
Understanding the Three Thresholds
The article highlights that MCID alone may not be sufficient for interpreting outcomes. Here's how to think about the three key thresholds:
MCID
Minimally Clinically Important Difference
The smallest change a patient perceives as beneficial. A "floor" threshold—useful but represents only minimal improvement.
PASS
Patient Acceptable Symptom State
The threshold at which patients consider themselves "well" or satisfied with their current state. More meaningful than MCID for many interventions.
SCB
Substantial Clinical Benefit
A higher threshold indicating substantial improvement. Particularly relevant when considering invasive procedures with material complication risks.
Practical MCID Values
Quick Reference MCID Values
How to Apply This in Practice
When reviewing patient progress:
- Individual patients: Check whether their change exceeds MCID. A 5-point FAOS improvement may be statistically significant but falls short of what they'd notice.
- Audit your outcomes: Report the proportion of patients achieving MCID, not just mean changes. The review found only 1.5% of studies do this properly.
- For surgical decisions: Consider whether expected improvement reaches PASS/SCB levels, especially for invasive procedures.
Practical Implementation Tips
Making the switch to validated PROMs doesn't have to be disruptive. Here are practical steps:
1. Automate Collection
Manual PROM collection is time-consuming and prone to missing data. Digital platforms can:
- Send automated reminders at scheduled intervals
- Score questionnaires instantly
- Flag patients who haven't responded
- Generate longitudinal charts showing progress over time
2. Use Validated Electronic Versions
Most validated PROMs have electronic versions with equivalent psychometric properties to paper versions. Ensure you're using the official, validated electronic format rather than ad-hoc digital recreations.
3. Train Your Team
Brief your secretaries and clinic nurses on:
- Why you're collecting PROMs
- How to explain them to patients
- When reminders should be sent
- How to handle patients who haven't completed forms
Conclusions: What Should You Do Tomorrow?
The systematic review by Al Shdefat and colleagues provides a clear message: the foot and ankle field needs to improve its PROM usage. Here are concrete actions you can take:
Your Action Plan
- Pick one condition-specific PROM to start
If you treat Achilles problems, start with VISA-A (tendinopathy) or ATRS (ruptures). For forefoot surgery, MOXFQ. For ankle fractures, OMAS. - Add a validated general foot/ankle measure
FAOS for comprehensive assessment, or FAAM if you see athletic patients. - Use weekly VAS + quarterly comprehensive PROMs
Quick weekly check-ins maintain engagement; detailed PROMs at follow-up appointments give you the data you need. - Report MCID in your audits and publications
State how many patients achieved MCID, not just mean scores. Only 1.5% of studies do this—you'll be ahead of the curve.
By improving PROM selection and consistent usage, we strengthen the evidence base that guides our clinical decisions and ultimately deliver better outcomes for our patients.
Primary Research Citation
Al Shdefat S, Arshad Z, Khan R, Inzarul Haq I, Bhatia M. Patient reported outcome measures in the foot and ankle literature: A systematic review. The Foot. 2025. https://doi.org/10.1016/j.foot.2025.102209
MCID Citations & References
- FAOS: Roos et al. (2003). Foot and Ankle Outcome Score (FAOS) — User's Guide.
- FAAM: Martin et al. (2005). Evidence of Validity for the Foot and Ankle Ability Measure. Foot & Ankle International.
- MOXFQ: Dawson et al. (2012). The Manchester-Oxford Foot Questionnaire (MOXFQ). The Bone & Joint Journal.
- FJS-12: Behrens et al. (2016). The Forgotten Joint Score-12 in Foot and Ankle Surgery. Foot & Ankle International.
- VISA-A: McCormack et al. (2015). The Minimal Clinically Important Difference of the VISA-A. AJSM.
- CAIT: Hiller et al. (2006). The Cumberland Ankle Instability Tool (CAIT). Archives of Physical Medicine and Rehabilitation.
- VAS Pain: Gallagher et al. (2001). Prospective validation of the 13-mm visual analog scale. Annals of Emergency Medicine.
- EQ-5D-5L: Coretti et al. (2014). Systematic review of MCID for EQ-5D. Expert Review of Pharmacoeconomics & Outcomes Research.
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