The Oxford Ankle Foot Questionnaire for Children (OxAFQ-C)

Image from Health Outcomes

The Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) is a child – or parent (proxy)-reported self-report health status PRO.


The Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) is used to measure subjective well-being for child patients (aged 5-16) affected by foot and ankle conditions using issues that are considered important to children. Typical clinical assessments fail to capture the child patient’s perspective and may not accurately reflect how children function in their usual environments. The OxAFQ-C was therefore designed to supplement clinical assessments to evaluate the effectiveness of interventions for ankle/foot problems in children.

The OxAFQ-C is rapidly gaining acceptance as the PRO of choice for assessing the impact of ankle/foot conditions in children for the following reasons:

  • It is the only PRO available assessing the impact of ankle foot issues on children from both the child and parent/caregivers perspective;
  • The OxAFQ-C has broad utility both in routine clinical settings or applied research comparing different treatment programmes used in paediatric orthopaedics, trauma and rheumatology;
  • A short (15-item) questionnaire that has proven to be easy to complete and returns high completion rates;
  • Has been proven to be a valid and reliable (Morris et al 2008, see reference below) as well as being responsive and longitudinally valid (Morris et al 2009, see reference below).


The OxAFQ-C has 15 items, 14 of which are used to calculate domain scores:

  • Physical (6 items)
  • School and Play (4 items)
  • Emotional (4 items)

A final item (item 15 – Has your foot or ankle stopped you wearing any shoes you wanted to wear?) was added to reflect the concern by many children that they can or cannot wear the footwear they prefer.

Example studies

These are some of the more specific ways the OxAFQ-C is currently employed by our user community:

  • Clinical investigation into the impact of foot anomalies for patients with Aperts Syndrome,
  • A pilot study foot pain and shape in teenagers,
  • Multi Centre, randomised controlled trial, Heel raises versus prefabricated orthoses in the treatment of posterior heel pain associated with calcaneal apophysitis (Sever’s disease),
  • Ankle joint sprains in children and evaluating the outcome of therapy,
  • Prospective Comparison of Hind Foot Stabilization Procedures in Children,
  • Study to assess the efficacy of orthotic therapy in treatment of patients with a range of musculoskeletal/Orthopaedic foot and ankle conditions.

^ Back to top

Examples of conditions for which the OxAFQ-C has been used include

  • Juvenile inflammatory arthritis
  • Diagnoses
  • Pes plano-valgus
  • Benign joint hypermobility
  • Congenital Talipes Equino Varus
  • Tarsal coalitions
  • Pes cavus
  • Metatarsus varus
  • Hallux abducto-varus (bunion)
  • Toe deformity
  • Osteochondrosis/apophysitis
  • Idiopathic toe walking
  • Hereditary Motor Sensory Neuropathy
  • Cerebral Palsy
  • Down syndrome
  • Marfan Syndrome
  • Fractures

^ Back to top


The OxAFQ-C was developed and tested in a 3 step process:

Phase 1 – Understanding the patient’s experience of their condition through qualified research.

Focus groups were convened with children affected by foot and ankle problems (along with their parent / caregiver) in three age groups, 5-7, 8-11 and 12-15. This research resulted in themes that children felt were important and affected them. Consistent themes identified by all groups were Physical Symptoms, activity limitations, reduced participation in certain contexts and self-consciousness due to appearance and other people’s attitudes. The results formed the basis of the PRO.

Phase 2 – Evaluation of test version in order to develop scales.

Initially 28 items were proposed (25 from Phase 1 and 3 extra from clinicians). Item responses were rated on a five-point scale indicating how frequently the issue affects the child, from never (score=4) to always (score=0). A survey of 158 children and their parents was carried out to determine the scaling, reliability and validity of the instrument. Exploratory factor analysis and Rasch analysis were used to devise the scales and refine the scaling.

Three domain scales were identified:

  • Physical (6 items),
  • Emotional (4 items), and
  • School & Play (4 items)

As in classical approaches to measurement, domain scores are calculated as the total of the scale item scores and are transformed to a percentage scale (0-100), where a higher score represents better functioning. Although an item asking about ‘being able to wear the shoes you want’ did not fit with the scales, it was salient to many children and to most girls. The item has strong face validity and is included as a categorical descriptive variable but not allied to any domain scale. The remaining items were either redundant or did not improve the scaling and were dropped.

The three domain scales were shown to be internally consistent. The scales’ scores were also found to be stable at retest within two weeks, and to vary little whether reported by child or parent.

Phase 3 – Prospective study and further testing.

In the third phase, a prospective study was conducted with 80 children attending trauma and elective orthopaedic clinics to assess responsiveness and longitudinal validity of the domain scales. Children and parents completed PROs at an initial outpatient appointment (baseline) and again within two weeks (retest), and finally a third set of PROs to complete again after two months (follow-up).

The follow up PROs included an additional global rating of change ‘transition’ item asking respondents to indicate whether they thought, overall, the foot or ankle problem was about the same, better or worse, on a seven point scale, using increments of ‘slightly’, ‘quite a bit’ and ‘a lot’ better or worse. The global rating of change provided a patient-based anchor for comparing the magnitude of changes in domain scores.

^ Back to top

Scoring system

Details of the scoring system for the OxAFQ-C can be downloaded in Dossier Extracts section

^ Back to top

Administration Methods

The OxAFQ-C is to date validated for pen and paper completion. Careful migration to a digital delivery format (for example screen based device) can be authorised. Please contact us for advice.

^ Back to top

Request a
Sparks Background Image

Ready to get in touch?

Contact Us
Sparks Background Image
© Oxford University Innovation