Foot drop, which is also sometimes called a dropped foot, is a condition in which it is difficult to lift up the front part of your foot. As a result your forefoot and toes tend to catch or drag on the floor as you walk. It can be temporary or permanent and most commonly affects one side only.
What is foot drop?
Foot drop is an abnormal walk (gait) which is caused by a tendency of the front half of the foot to drop downwards as you walk along. Your foot can catch on the floor as you swing your leg forwards to take a step. The gait of foot drop may involve:
- As you walk along, the affected foot (or feet) catches on the floor.
- As you walk along you lift the leg high to avoid the foot catching (high stepping gait). People who do this often tend to walk on tiptoe on the other side to equalise the sides.
- As you walk you swing the affected leg out to the side to avoid it catching on the floor.
Foot drop usually affects just one foot. However, it can affect both sides, either equally or to different degrees. It may be temporary or permanent.
There are several grades of foot drop. These are measured from 0 to 5 depending on the degree of strength and movement there is in the muscles which lift the foot. 5 is normal strength and 0 is total paralysis.
What causes foot drop?
Foot drop is usually caused by malfunction of a nerve in the lower leg. This can be due to problems affecting it either low down in the leg, or higher up in the spine where its nerve fibres originate.
This nerve is called the common peroneal nerve. However, it is also sometimes called the common fibular nerve, the external popliteal nerve or the lateral popliteal nerve. It's a small nerve that branches off from the sciatic nerve in the thigh. It runs down the back of the knee and winds around the top of the fibula to go into the muscles of the lower leg. It is very near the surface at this point and can be easily bruised or compressed.
The most common causes are:
- Injury to the common peroneal nerve.
- Lower back damage (including a 'slipped' disc (prolapsed disc) affecting the nerves in the lower leg).
Foot drop can also be due to other causes of nerve damage. More rarely, it can be due to damage to the muscles of the lower leg or to poisonous substances or a tumour.
Other causes include:
- Hip replacement.
- Knee surgery.
- Sciatic nerve damage.
- Cauda equina syndrome. (This is compression of the nerves in the tail of the spinal cord, usually caused by a 'slipped' disc or tumour.)
- Diabetes with peripheral neuropathy.
- Transient ischaemic attack (TIA).
- Multiple sclerosis (MS).
- Cerebral palsy.
- Charcot-Marie-Tooth disease.
- Poliomyelitis (rarely causes isolated foot drop).
- Motor neurone disease.
- Friedreich's ataxia.
- Brain tumour.
- Adverse drug or alcohol reaction.
Patients with pain on the soles of the feet may also walk with a high stepping gait which looks similar. However, they do not have foot drop; they are lifting their feet for a different reason.
What does the common peroneal nerve do and how can it be injured?
The peroneal nerve controls the muscles that lift your foot. This nerve is quite exposed to trauma where it runs just under the skin on the outer side of the knee. Activities that compress this nerve can increase your risk of foot drop. Examples include:
- Crossing the legs. People who habitually cross their legs can compress the peroneal nerve on their uppermost leg, particularly if they are slim.
- Prolonged kneeling. Occupations that involve prolonged squatting or kneeling can result in temporary foot drop. Certain yoga positions can also cause nerve compression resulting in foot drop.
- Wearing a leg cast. Plaster casts that enclose the ankle and end just below the knee can exert pressure on the peroneal nerve and cause foot drop.
How does foot drop differ from normal walking?
The cycle of action in normal walking is as follows:
- The foot moves forwards (swing phase).
- The foot touches the ground. Usually the heel touches the ground first (initial contact, sometimes called heel strike or foot strike) and then you move forwards on to the ball of the foot.
- The foot pushes off and leaves the ground again (terminal contact, or 'foot off').
The normal foot can flex upwards (dorsiflexion). It can also invert (turn so that the soles tend to face each other) or evert (the opposite of inversion). In foot drop these movements (which occur mainly in heel contact and in the swing phase, are absent. Therefore:
- The swing phase may involve bending the leg at the knee to lift the foot away, rather like climbing stairs.
- The initial contact is not with the heel but with the whole of the foot which 'slaps' or plants on to the floor at once
- The 'foot off' motion does not function properly at all and a walking stick or cane may be needed to help lift the foot.
How is foot drop diagnosed?
Foot drop is usually diagnosed on examination. Your doctor will watch you walk and may check your leg muscles for weakness. They will also assess nerve function by checking your reflexes and the sensation in the skin.
How is foot drop investigated?
Foot drop is a symptom rather than a diagnosis and your doctor will want to understand what has caused it. Investigations for the cause of foot drop may include:
- X-rays. Plain X-rays may be used to look for a soft tissue growth or a bone abnormality that may be causing your symptoms.
- Ultrasound. This may be used to check for cysts or tumours that may be pressing on the nerve.
- Computerised tomography (CT) scan. This can be used to look for growths (masses) or other changes anywhere in the body.
- Magnetic resonance imaging (MRI). MRI is particularly useful in visualising soft tissue lesions that may be compressing a nerve, such as a 'slipped' disc (prolapsed disc) in the back. It can also examine the brain for the characteristic lesions of MS.
- Electromyography (EMG) and nerve conduction studies. These measure electrical activity in the muscles and nerves to look for the location of the damage along the affected nerve.
How is foot drop treated?
If the underlying cause can be treated, foot drop may improve or disappear. If the underlying cause can't be treated, foot drop may be permanent. Some nerve damage can heal but full recovery can take up to two years.
In addition to treatment of the underlying problem, specific treatment may include:
- Braces or splints. These help hold the foot in a normal position.
- Ankle-foot orthoses (AFOs). These are specialised L-shaped ankle splints. They simply hold the foot at 90° to the lower leg so that it can't drop down.
- Physiotherapy. Exercises to strengthen leg muscles may improve walking problems associated with foot drop. Stretching exercises can prevent the development of stiffness in the heel. Learning to use a high stepping gait or swinging gait is an alternative approach that some people prefer.
- Specialised shoes. Shoes fitted with spring-loaded braces can help prevent the foot dropping whilst walking. One type uses a cuff around the ankle, a spring above and a hook in the shoelace area which connects to the spring and pulls the foot up during walking.
- Nerve stimulation. Sometimes stimulating the common peroneal nerve electrically improves foot drop. This type of treatment is usually used in people with disabilities and is sometimes called neuromuscular electrical stimulation or functional electrical stimulation. Many people with multiple sclerosis, or who have had a stroke, have had success with it.
- Surgery. Depending upon the cause, nerve surgery is occasionally helpful, aiming to repair or graft the nerve. If foot drop is long-standing, complex surgery that shifts working tendons to a different position is occasionally considered.
What can I do myself?
The danger of foot drop is that it can increase your risk of tripping as the toe catches on the floor. It can be sensible to take precautions at home to reduce the risk of falls and injury:
- Keep all floors clear of clutter.
- Avoid loose rugs, electrical cords and other trip hazards.
- Make sure rooms and stairways are well lit.
- Stick fluorescent tape on the top and bottom steps of stairways to remind you to prepare for them.
- Seek advice from a suitably qualified health professional on walking aids and exercises that may help keep you safe.
Further reading and references
Stevens F, Weerkamp NJ, Cals JW; Foot drop. BMJ. 2015 Apr 27350:h1736.
Functional electrical stimulation for drop foot of central neurological origin; NICE Interventional Procedure Guidance, January 2009
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