Foot Drop: Manual Therapy and Functional Exercises
Updated: Oct 18
When the toes catch the ground or the foot slaps down unexpectedly, walking can demand attention that it never required before. Stairs, uneven surfaces, and even a familiar hallway may become harder to navigate with confidence.
Foot drop describes difficulty lifting the front of the foot. It is a clinical sign, rather than a diagnosis. The cause may involve a peripheral nerve, a spinal nerve root, the brain or spinal cord, or less commonly a muscle disorder. Identifying where the weakness originates helps determine the appropriate treatment and prospects for recovery.
For practitioners, assessment must connect neurological findings with walking safety and daily function. This article explores the main causes, examination priorities, and rehabilitation options, including where MSR manual care may address associated restrictions. New or worsening foot drop warrants prompt medical assessment.
Article Index
Causes of Foot Drop
The most common cause of foot drop is peroneal nerve injury, which can result from various conditions affecting the nerves and muscles. Peripheral neuropathy, often due to diabetes or inherited conditions like Charcot-Marie-Tooth disease, can lead to foot drop. Other causes include muscular dystrophy, a group of disorders that weaken muscles and lead to tissue loss, and polio, a viral infection that can cause muscle weakness and paralysis, with endemic wild poliovirus type 1 still present in Pakistan and Afghanistan as of 2022 (WHO).
Everyday habits, such as crossing the legs, can damage the peroneal nerve, contributing to foot drop. Additionally, brain and spinal cord disorders, including stroke, amyotrophic lateral sclerosis (ALS), and multiple sclerosis, can cause muscle weakness and paralysis leading to foot drop. This article explores the anatomy and biomechanics of foot drop, examining its signs, symptoms, and diagnostic methods. It also highlights promising treatment options, focusing on manual therapy, specifically motion specific release (MSR) techniques, and functional exercises for those affected by foot drop.
Signs and Symptoms
Individuals suffering from foot drop may exhibit a range of signs and symptoms that significantly impact daily life and mobility. The primary manifestations include:
Impaired dorsiflexion: Difficulty lifting the front part of the foot, leading to an inability to perform proper dorsiflexion.
Foot dragging: Patients often drag their affected foot while walking, increasing the risk of tripping or falling due to the inability to dorsiflex.
High-stepping gait: To compensate, individuals may adopt a high-stepping gait, characterized by exaggerated lifting of the knee to prevent the foot from dragging.
Sensory disturbances: Numbness or tingling sensations on the top of the foot or the outer part of the shin due to damage to the sensory fibers within the common peroneal nerve.
Ankle weakness: Weakness in ankle dorsiflexion and eversion, complicating the ability to walk and maintain balance.
Muscle atrophy: Prolonged nerve damage or disuse of the affected muscles may lead to muscle wasting, exacerbating weakness in the foot and ankle.
Pain: Depending on the underlying cause, some individuals may experience pain in the affected leg, knee, or ankle.
These signs and symptoms can vary in severity, depending on the underlying cause of foot drop. Early recognition and intervention are critical in managing this condition and improving overall patient outcomes..
Article Index
Anatomy, Biomechanics & Related Causes
The common peroneal nerve, a crucial branch of the sciatic nerve, plays a vital role in innervating the anterior and lateral compartments of the leg. It is responsible for several key functions, such as controlling dorsiflexion and eversion of the foot. The peroneal muscles, including the peroneus longus and peroneus brevis, are essential for various movements and actions:
Eversion: Turning the sole of the foot outward or laterally
Plantar flexion: Pointing the toes and foot downward, away from the body
Damage to the common peroneal nerve or the peroneal muscles can lead to foot drop. Several factors may contribute to this damage:
Direct trauma: Fractures or dislocations around the knee or ankle can injure the common peroneal nerve.
Compression: Prolonged pressure on the nerve, such as from a tight cast or crossing the legs, can cause nerve damage.
Inflammation: Conditions like vasculitis, which causes inflammation of blood vessels, can damage the peroneal nerve.
Tumors: Benign or malignant growths may compress or infiltrate the nerve, leading to foot drop.
Iatrogenic injury: Surgical procedures, particularly those involving the knee or ankle, can inadvertently damage the common peroneal nerve.
Diagnosis
A thorough diagnosis of foot drop is essential to identify the root cause and develop an appropriate treatment plan. The diagnostic process typically involves orthopedic, neurological, and vascular assessments, which can help determine the underlying factors contributing to the condition.
Orthopedic Testing:
Orthopedic examinations focus on evaluating joint and muscle function, as well as range of motion. These assessments can help determine if the foot drop is caused by musculoskeletal issues, such as muscle weakness, or if it stems from a neurological problem. In the context of foot drop, orthopedic testing may include evaluating ankle strength, flexibility, and stability. Click on the video to see our orthopedic examination of the ankle and foot.
Neurological Testing:
A comprehensive neurological examination can help pinpoint the location and extent of nerve damage, which is crucial for targeted treatment. This may involve testing for sensation, reflexes, and muscle strength in the affected limb. Identifying the specific nerve(s) involved in foot drop can guide the treatment approach and optimize the chances of successful recovery. Click on the video to see our Lower Limb Neurological Examination.
Vascular Testing:
Vascular assessments aim to evaluate blood flow to the affected leg to determine if a vascular issue, such as peripheral artery disease, is contributing to foot drop. Ensuring adequate blood supply to the nerves and muscles is essential for proper function, and addressing any vascular issues can be a critical component of the overall treatment plan. Click on the video to see our Peripheral Vascular Examination.
Functional Exercises and Treatment
Addressing foot drop effectively often entails a blend of functional exercises and manual therapy, aimed at tackling the root causes of the problem.
Best Foot Drop Exercises and Treatment
In this video, Miki Burton, showcases six effective exercises for treating Foot Drop. Then Dr. Brian Abelson demonstrates how to address the larger kinetic chain, including the hips, spine, and upper body, to further support the treatment of Foot Drop.
Combining manual therapy and functional exercises provides a comprehensive approach to treating foot drop, addressing both the immediate symptoms and the underlying causes of the condition to promote long-term recovery and improved quality of life.
Alternative Options
In some cases, despite a comprehensive approach involving manual therapy and functional exercises, foot drop may not improve significantly. If conservative treatments do not yield the desired results, it may be necessary to explore additional options to manage the condition and maintain mobility.
Ankle-Foot Orthosis (AFO): An AFO is a custom-made brace that supports the foot and ankle, assisting with dorsiflexion and providing stability during walking. This can help compensate for the lack of muscle function and reduce the risk of tripping or falling.
Functional Electrical Stimulation (FES): FES uses electrical impulses to stimulate the nerves and muscles responsible for lifting the foot. A small device sends signals to the affected muscles, promoting muscle contraction and improved foot function during walking.
Consultation with Specialists: If conservative treatments have not been effective, it is essential to consult with healthcare professionals such as neurologists, orthopedic surgeons, or physiatrists. These specialists can offer further evaluations and recommend alternative treatment options, which may include medications or surgical interventions if deemed necessary.
It is crucial to maintain open communication with your healthcare team throughout the treatment process, as they can help monitor your progress, reassess your condition, and adjust the treatment plan accordingly.
Conclusion
For someone with foot drop, progress may mean clearing the ground more reliably, negotiating stairs, or walking without constantly anticipating a trip. Those goals give assessment and rehabilitation a practical direction.
Care begins with identifying the cause and protecting mobility while recovery is pursued. Depending on the findings, management may include medical or surgical treatment, an ankle-foot orthosis, selected electrical stimulation, gait training, and individualized exercise. Manual care may address associated joint restrictions or muscle symptoms when appropriate.
Within MSR, reassessment helps determine whether treatment supports useful changes in movement and function. Persistent or increasing weakness calls for investigation and collaboration, rather than simply repeating the same procedures.
Recovery varies with the underlying condition and extent of nerve or muscle involvement. Throughout that process, coordinated care can help people maintain participation, develop effective strategies, and work toward greater independence.
References
Baima J, Krivickas L. Evaluation and treatment of peroneal neuropathy. Current Reviews in Musculoskeletal Medicine. 2008;1(2):147–153.
Carolus AE, Becker M, Cuny J, Smektala R, Schmieder K, Brenke C. The interdisciplinary management of foot drop. Deutsches Ärzteblatt International. 2019;116(20):347–354.
Johnston TE, Keller S, Denzer-Weiler C, Brown L. A clinical practice guideline for the use of ankle-foot orthoses and functional electrical stimulation post-stroke. Journal of Neurologic Physical Therapy. 2021;45(2):112–196.
Kluding PM, Dunning K, O’Dell MW, et al. Foot drop stimulation versus ankle foot orthosis after stroke: 30-week outcomes. Stroke. 2013;44(6):1660–1669.
Tyson SF, Kent RM. Effects of an ankle-foot orthosis on balance and walking after stroke: a systematic review and pooled meta-analysis. Archives of Physical Medicine and Rehabilitation. 2013;94(7):1377–1385.
Disclaimer:
The articles and embedded videos on the MSR website are provided for educational and informational purposes only. They are not a substitute for individualized assessment, diagnosis, or treatment by an appropriately qualified healthcare professional.
Some videos demonstrate clinical examination and manual therapy procedures intended for licensed or regulated healthcare professionals with appropriate training. These procedures should be performed only within the practitioner’s legal scope of practice and should not be attempted as self-treatment.
Viewing or using this content does not establish a practitioner-patient relationship. If you have questions about a medical condition or symptoms that are new, severe, or worsening, consult an appropriately qualified healthcare provider.
MSR is not responsible for decisions made or actions taken solely on the basis of this educational content. For complete information about website use, third-party links, privacy, and legal terms, please review the MSR Terms of Use, Privacy Policy, and full website disclaimer.
DR. BRIAN ABELSON, DC. - The Author
Dr. Brian Abelson is a chiropractor, author, and educator with more than 30 years of clinical experience in musculoskeletal care, rehabilitation, and sports performance. His educational work focuses on musculoskeletal conditions, human movement, sports biomechanics, and evidence-informed approaches to treatment and rehabilitation.
He is the developer of Motion Specific Release (MSR) and Clinical Director of Kinetic Health in Calgary, Alberta, Canada.
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