Foot drop

Having foot drop means that weakness in one or both of your feet or legs makes it difficult (or impossible) to point your toes up towards the sky because the right muscles aren’t working properly to help you do so. When this happens, your foot remains in a dropped position when you walk with your toes hanging downwards. This makes it difficult for your foot to safely clear the ground as you walk, putting you at risk of tripping and falling from your toes hitting the ground - or forcing your body to compensate for the foot drop by excessively lifting and bending your knee and hip - which can cause a different series of pains and problems.

Having foot drop feels like a noticeable weakness when moving your foot up and around on your ankle, with your foot having a heavy feeling. You may also experience some tingling or numbness in your foot, notice that your toes are curling, and find that your foot drags along the ground or catches the ground during regular walking if you don’t lift your knee higher than normal to stop it from touching the ground.

Foot drop is actually a symptom of an underlying problem with one of your nerves called the peroneal nerve, which is responsible for innervating the muscles that work to seamlessly lift your foot up relative to your ankle. The peroneal nerve is a branch of the sciatic nerve, starting at the back of the knee, and runs down the lower leg and into the foot where it branches out further.

While one of the most common causes of damage to the peroneal nerve we see is through trauma or an accident, like during a sudden knee dislocation during skiing or a car accident, direct impact to the nerve during a fall or during sports, or a fracture to the fibula, there are many other issues that can also affect the peroneal nerve. One of these is from neurological conditions including strokes, multiple sclerosis and spinal injuries, where damage to the peroneal nerve can be sustained. Specifically:

• Strokes occur when there is a sudden interruption of blood flow to the brain, leading to brain tissue damage. Depending on the area of the brain affected, a stroke can lead to weakness or paralysis on one side of the body, including the leg and foot muscles. If the nerves controlling the muscles responsible for lifting the foot are damaged, foot drop can result.

• Multiple Sclerosis (MS) is an autoimmune disorder where the immune system attacks the protective covering of nerves in the central nervous system, including the brain and spinal cord. This disrupts the transmission of nerve signals, leading to a wide range of neurological symptoms, including muscle weakness and foot drop.

• Traumatic spinal cord injuries or conditions that compress the spinal cord can disrupt the nerve signals responsible for controlling muscle movements in the legs and feet. Damage to the spinal cord can lead to paralysis or weakness, affecting the ability to lift the foot properly while walking.

Other causes of foot drop can include:

• Long-term constriction of your lower leg (like from a surgical boot or cast)
• Habitually crossing your legs
• Pressure on your knees (while sleeping, during surgery)
• Labour and childbirth
• Prolonged bed rest
• Certain medical conditions (e.g., anorexia nervosa, Charcot-Marie-Tooth disease, ALS, muscular dystrophy, cerebral palsy, diabetes, Parkinson’s disease, multiple sclerosis)
• Symptoms resulting from a stroke
• Symptoms resulting from diabetes

Nerve irritation or damage can be a tricky problem to manage at home, and as such, home remedies typically are unable to cure the underlying cause of foot drop. In some cases, depending on the severity and cause of the nerve damage, there are a few things you can try that may help support your symptoms or mobility:

• Foot and ankle exercises: if you still have some strength and mobility available in your ankle, try some simple exercises like toe curls, ankle circles, or even resistance band exercises.
• Foot elevation: if your symptoms are related to swelling in your feet or legs, elevating your foot whenever possible may help to reduce swelling and alleviate some of the discomfort associated with foot drop.
• Ice: applying ice to your feet through a towel for no more than 20 minutes at a time, 3-4 times per day, may also help to reduce inflammation and soothe your discomfort.
• Assistive devices: using assistive devices such as a cane or walker may not help improve your symptoms, but it can help reduce your risk of further injuries that can be caused by tripping over your toes and falling.
• Good footwear: wearing supportive and comfortable shoes may also help - particularly if the shoes are light, so they don’t weigh your foot and toes down further.
• Avoiding prolonged standing or sitting: changing positions regularly as well as avoiding crossing your legs for prolonged periods may also help you manage your symptoms or improve your comfort, depending on the underlying cause of your foot drop.

Here at Matt Raden Podiatry, our trusted and experienced podiatrists listen to the concerns, goals and needs of our patients with foot drop, and utilise a range of evidence-based treatment methods to help you get the best outcome.

Every appointment starts with a comprehensive assessment to understand the status and function of your peroneal nerve, and then look beyond the nerve for any other signs and symptoms that can indicate what may be causing the problem, including:

• Numbness in the upper outer leg that may indicate a lesion close to the head of the fibula bone
• Reduced feeling in the lower outer leg and the top of the foot, which may also indicate the involvement of the superficial peroneal nerve
• Altered sensation in the first webspace of the foot between the first and second toes, which may indicate the involvement of the deep peroneal nerve
• Signs of a knee dislocation, which can compromise the nerves and vessels that pass from the thigh to the knee, and is a precursor for an urgent condition called acute compartment syndrome
  

We may also use the ‘Tinel sign’ test to help pinpoint the area of nerve irritation or entrapment by tapping along the course of the nerve, particularly around the neck of the fibula bone. If tingling or numbness is felt along the area that is tapped, it i ok s a positive Tinel sign and will guide our course of treatment.

We’ll then create a tailored management plan based on your results. You should know that managing foot drop is very different from managing muscle, tendon or joint injuries because nerve damage can often be unpredictable and multifaceted. Some cases of foot drop may resolve in weeks or months, while others may be longstanding or permanent. It can vary greatly depending on the way the nerve was injured and the severity of the injury. Either way, there are several therapies we can use with the goals of helping you move comfortably without pain, reduce the risk of further injury, and support your balance and confidence on your feet. To achieve this, we may use:

• Bracing: given that one of the biggest risks with foot drop is your toes hitting the ground and causing you to trip, fall and sustain more injuries, this is one of the first things we’ll address using a brace that will keep your foot positioned at an angle that is both comfortable and helps you minimise your injury risks during walking. We’ll discuss our range of braces that are suitable for you specifically during your appointment, how it works, and how long you may need it for.
• Orthotics (insoles): sometimes, we’ll recommend using custom-prescribed foot orthotics that sit inside your shoe (or your brace) to help if you have concurrent problems alongside foot drop.
• Footwear assessment and recommendations: when it comes to foot drop, your shoes can hold you back if they’re too heavy, not the right fit, or don’t give you the stability and support you need. We help you select the best shoes for your feet that work symbiotically with any braces or orthotics you may be wearing.
• Physical therapy: this is designed to help strengthen the musculature associated with foot drop while improving the range of motion at the ankle joint while reducing stiffness.

As a note, surgery is not a first-line treatment for foot drop, with many cases of foot drop resolving long before surgery should be considered. However, it can be explored in cases such as the presence of a rapidly deteriorating lesion, no signs of improvement within three months (or signs of worsening foot function with no other explanation), and open injuries with a suspected nerve laceration.