We commonly prescribe walking boots, sometimes referred to as controlled ankle motion (CAM) walkers, for the treatment of diabetic foot ulcerations, fractures and tendon injuries of the lower extremity. Clinicians continue to be baffled and frustrated by the fact that, in spite of the significance of these pathologies, patients have very poor adherence in wearing these devices that are a vital part of the treatment plan. An eye-opening study by Armstrong and colleagues showed that patients who were prescribed walking boots to treat active diabetic foot ulcerations only wore the devices 28 percent of the time they were ambulating.1 Many have speculated on why patients are non-adherent in the use of walking boots, including the fact that the devices are bulky and a perception that they may negatively affect balance.2 Despite the perception that walking boots impair balance, few studies exist to validate this notion. Several studies have shown the negative effects of solid ankle-foot orthoses (AFOs) on balance while articulated AFOs in these same studies showed no negative effects but actual improvements in balance.3,4 Researchers speculate that solid AFOs and walking boots negatively affect balance by limiting ankle joint motion, which decreases proprioceptive feedback from ankle joint receptors and muscle spindles around the ankle joint while also limiting the “ankle strategy” for correcting postural alignment.5,6 Even healthy patients who have no balance impairments appear to be non-adherent in wearing walking boots on a daily basis. In my own practice, I am always concerned about the fact that many patients report that walking boots cause pain in proximal joints including the knees, hips and spine. One reason for this is the fact that walking boots establish a limb length discrepancy, which we often overlook when fitting the devices to the patient. A recently published study in the Journal of Prosthetics and Orthotics has shown some interesting insight into how walking boots affect balance and limb length compensations.7 Goodworth and co-workers conducted balance tests on patients wearing walking boots with and without heel lifts applied to the contralateral limb and compared them to people without walking boots. As expected, the wearing of a walking boot on one lower extremity caused significant compromise of balance during quiet stance, functional reach tests and perturbed walking tests. Applying a heel lift to the contralateral foot reduced the negative effects of the walking boot but only in the quiet stance test. The authors of this study speculated that the negative effects on balance, which they measured when patients wore a walking boot, were due to decreased ankle motion as well as reduced surface contact with the floor due to the rocker bottom of the boot and a leg length discrepancy imposed by the sole of the boot. At least some of the negative balance effects can improve with the use of a heel lift on the opposite foot customized to the patient to ensure leveling of the pelvis in the frontal plane.