Foot drop, also called drop foot, is a condition in which a person has difficulty lifting the front part of the foot due to weakness or paralysis of the muscles responsible for dorsiflexion (lifting the foot upward). As a result, the toes drag on the ground while walking unless compensatory movements, such as exaggerated knee lifting (known as steppage gait), are used. Over time, abnormal walking patterns can lead to joint stress, muscle imbalance, and deformities like Achilles tendon shortening or equinus contracture.
How Common It Is and Who Gets It? (Epidemiology)
Foot drop is a relatively common clinical symptom, though its exact prevalence is unknown due to variations in underlying causes and the absence of a specific diagnostic code. Studies estimate that up to 14% of stroke survivors develop persistent foot drop, and as many as 76% of patients with spinal cord injuries experience some degree of the condition. It is most often seen in adults with neurological, muscular, or spinal disorders but can affect individuals of all ages. The peroneal (fibular) nerve is involved in roughly 15% of adult mononeuropathies, making peroneal neuropathy the most frequent peripheral cause of foot drop.
Why It Happens – Causes (Etiology and Pathophysiology)
Foot drop is a symptom rather than a disease. It results from weakness or paralysis of the muscles that lift the foot, caused by disruption of the neural pathway from the brain to the muscles. Causes can be divided into three broad categories:
- Central Causes
Lesions in the brain or spinal cord can interrupt motor control pathways.- Stroke (anterior cerebral artery territory)
- Brain tumors or hemorrhages
- Multiple sclerosis or other demyelinating diseases
- Spinal cord injury or inflammation
Approximately 14% of stroke patients and up to 76% of spinal cord–injured individuals may experience foot drop.
- Spinal Nerve Causes
Compression of the L5 nerve root from lumbar disc herniation or spinal stenosis is a common cause.- L5 radiculopathy
- Degenerative spine disease
- Foraminal stenosis
Around 23% of patients with L5 root involvement develop clinical foot drop.
- Peripheral Causes
Injury to the peroneal nerve is the most frequent isolated cause of foot drop.- Compression at the fibular head (from crossing the legs or tight casts)
- Direct trauma or laceration
- Iatrogenic injury during orthopedic surgery
- Space-occupying lesions such as ganglion cysts or tumors
Peripheral nerve injury accounts for the majority of unilateral foot drop cases.
- Systemic or Muscular Causes
- Diabetes-related peripheral neuropathy
- Charcot-Marie-Tooth disease
- Muscular dystrophy or motor neuron disease
- Prolonged immobility or muscle atrophy
How the Body Part Normally Works? (Relevant Anatomy)
Normal foot movement during walking depends on coordination between the tibialis anterior, extensor hallucis longus, and extensor digitorum longus muscles. These muscles, innervated by the deep peroneal nerve (branch of the sciatic nerve), dorsiflex the ankle to lift the foot. Damage to this nerve or its central connections prevents this action, resulting in the foot dragging or slapping against the ground during gait.
What You Might Feel – Symptoms (Clinical Presentation)
- Difficulty lifting the front of the foot while walking.
- Toes drag or scrape the ground.
- Exaggerated knee lifting (steppage gait).
- Foot slaps down with each step.
- Numbness or tingling over the shin or top of the foot.
- Muscle weakness or visible atrophy of the lower leg.
- In long-standing cases, tightness and deformity in the Achilles tendon.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis begins with a detailed neurological and musculoskeletal evaluation.
- Clinical Examination:
- Manual muscle testing (especially dorsiflexion and eversion strength).
- Reflex testing (tibialis posterior and Achilles reflexes).
- Sensory mapping to locate numbness patterns.
- Observation of gait mechanics.
- Electrophysiology:
- Nerve conduction studies (NCS) and electromyography (EMG) determine whether the lesion is in the nerve root, peripheral nerve, or muscle.
- EMG can detect early signs of nerve injury before they are clinically visible.
- Imaging:
- MRI of the brain or spine helps identify central or radicular causes such as disc herniation or stroke.
- Ultrasound or MR neurography visualizes peripheral nerve compression or cystic lesions.
Classification
Foot drop is classified according to the site of lesion and underlying mechanism:
- Central: Upper motor neuron lesions (stroke, spinal cord injury).
- Peripheral nerve: Peroneal nerve compression or trauma.
- Myopathic: Primary muscle disease or degeneration.
- Functional: Pseudo-foot drop from psychogenic or biomechanical dysfunction.
Other Problems That Can Feel Similar (Differential Diagnosis)
- Peroneal tendinitis or rupture
- Myasthenia gravis or Guillain-Barré syndrome
- Lumbosacral plexopathy
- Motor neuron disease (ALS)
- Functional gait disorders
Treatment Options
Non-Surgical Care
- Functional Electrical Stimulation (FES):
Delivers electrical impulses to activate the peroneal nerve during walking. Improves gait speed and reduces effort; effective in post-stroke and multiple sclerosis–related foot drop. Long-term users often maintain benefits for over a decade. - Botulinum Toxin Injections:
Reduces spasticity in cases of upper motor neuron lesions (such as stroke), especially when combined with stretching and physical therapy. - Orthotic Devices (AFO):
Ankle-foot orthoses maintain foot position and prevent tripping. While they provide immediate support, some patients report gait alteration or skin irritation. - Rehabilitation:
- Strengthening exercises for the tibialis anterior and dorsiflexors.
- Gait training to prevent compensatory movement.
- Balance and proprioception therapy.
- Stretching to prevent Achilles contracture.
Surgical Interventions
- Decompression or Neurolysis: Early decompression of compressed peroneal nerves (within 48 hours) yields the best outcomes.
- Spinal Surgery: Indicated for lumbar disc herniation or stenosis causing L5 nerve compression.
- Peripheral Nerve Repair or Grafting: Used for sharp injuries; grafts longer than 6 cm have reduced success.
- Tendon Transfer: For irreversible nerve damage, the posterior tibial tendon is rerouted through the interosseous membrane to restore dorsiflexion. Patients typically regain about 30% of normal dorsiflexion strength but experience major functional improvement.
Recovery and What to Expect After Treatment
Recovery depends on the cause and timing of intervention.
- Mild peroneal nerve injuries may recover within 6–12 weeks.
- After decompression or repair, nerve regeneration occurs at about 1 mm per day.
- Chronic or central lesions may lead to partial or permanent weakness, requiring long-term orthotic or functional support.
Possible Risks or Side Effects (Complications)
- Permanent weakness or paralysis if nerve damage is severe or untreated.
- Achilles tendon contracture from chronic plantarflexion.
- Skin pressure sores from prolonged orthotic use.
- Balance issues or compensatory knee and hip strain.
Long-Term Outlook (Prognosis)
The prognosis depends on the etiology and promptness of treatment. Acute compression injuries treated early may recover completely. Chronic nerve damage or central lesions (stroke, ALS) may lead to persistent disability. Tendon transfer and FES can restore functional gait even when full nerve recovery is not possible.
Out-of-Pocket Costs
Medicare
CPT Code 64708 – Neuroplasty, Major Peripheral Nerve (e.g., Common Peroneal Nerve Decompression or Neurolysis): $119.08
CPT Code 64910 – Nerve Repair with Synthetic Conduit or Vein Graft (for Nerve Grafting Procedures): $178.73
CPT Code 27691 – Transfer or Transplant of Single Tendon, Leg (e.g., Posterior Tibial Tendon Transfer for Foot Drop): $175.25
Medicare Part B typically covers 80% of the approved cost for these procedures once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield usually cover that 20%, minimizing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These plans are designed to work alongside Medicare to fill the coverage gap.
If you have Secondary Insurance such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans often cover any remaining balance, including coinsurance or small deductibles, which typically range from $100 to $300 depending on your plan and provider network.
Workers’ Compensation
If your foot drop is caused or aggravated by a work-related injury, Workers’ Compensation will cover all medical expenses, including nerve decompression, tendon transfer, and nerve grafting if required. You will not have any out-of-pocket expenses, as your employer’s insurance carrier directly covers all approved procedures.
No-Fault Insurance
If your foot drop condition resulted from an automobile accident, No-Fault Insurance will typically cover the entire cost of your treatment, including surgery, rehabilitation, and follow-up visits. The only possible out-of-pocket cost may be a small deductible or co-payment depending on your insurance policy.
Example
Mark Daniels developed foot drop following a nerve injury and underwent posterior tibial tendon transfer (CPT 27691) with an estimated Medicare out-of-pocket cost of $175.25. Since Mark had supplemental insurance through AARP Medigap, his remaining balance was fully covered, leaving him with no out-of-pocket expenses for his treatment.
Frequently Asked Questions (FAQ)
Q. What is foot drop?
A. Foot drop is a condition where the patient is unable to lift the front part of the foot, leading to difficulty in walking and a high-stepping gait.
Q. What causes foot drop?
A. Foot drop is caused by weakness or paralysis of the muscles involved in lifting the foot, often due to nerve injuries, muscle disorders, or central nervous system conditions.
Q. What are the common symptoms of foot drop?
A. Symptoms include difficulty lifting the front part of the foot, dragging of the toes while walking, high-stepping gait, numbness on the top of the foot or toes, and possible muscle atrophy in the lower leg.
Q. Which nerve is commonly involved in foot drop?
A. The peroneal nerve is most commonly involved in foot drop.
Q. What conditions can lead to peroneal nerve damage causing foot drop?
A. Conditions include trauma, compression at the fibular head, prolonged leg crossing, kneeling, or squatting, as well as systemic conditions like diabetes.
Q. Can spinal problems cause foot drop?
A. Yes, spinal conditions such as herniated discs or spinal stenosis affecting the L4-L5 nerve roots can result in foot drop.
Q. How is foot drop diagnosed?
A. Diagnosis involves a clinical examination, patient history, electromyography (EMG), nerve conduction studies, and imaging such as MRI.
Q. What are the treatment options for foot drop?
A. Treatment options include physical therapy, bracing, medications, nerve stimulation, and in some cases, surgical intervention.
Q. What type of brace is used for foot drop?
A. An ankle-foot orthosis (AFO) is commonly used to support the foot and improve walking.
Q. When is surgery considered for foot drop?
A. Surgery is considered when there is no improvement with conservative treatment, or if there is a compressive lesion or nerve injury that requires surgical repair.
Q. Can foot drop be reversed?
A. The prognosis depends on the cause; some patients recover fully with treatment, while others may have persistent symptoms requiring long-term management.
Q. What are tendon transfer surgeries in foot drop?
A. Tendon transfer surgeries involve redirecting functional tendons to replace the action of the paralyzed muscles, typically transferring the posterior tibialis tendon to the foot dorsum.
Q. What is the recovery like after surgery for foot drop?
A. Recovery includes immobilization followed by physical therapy to retrain the new tendon function and improve gait.
Q. Can foot drop affect both legs?
A. While it usually affects one leg, certain systemic or neurological conditions can lead to bilateral foot drop.
Q. What role does physical therapy play in treating foot drop?
A. Physical therapy helps strengthen muscles, improve gait, and maintain joint flexibility, which is essential in both conservative and post-operative management.
Summary and Takeaway
Foot drop is a symptom of neurological or muscular dysfunction causing difficulty in lifting the front of the foot. It may result from stroke, nerve compression, or peripheral injury. Prompt diagnosis and targeted treatment are essential for recovery. Conservative measures such as orthoses, physical therapy, and electrical stimulation often improve function, while surgery is reserved for structural or irreversible nerve injuries. A multidisciplinary approach combining neurology, orthopedics, and rehabilitation ensures optimal outcomes.
Clinical Insight & Recent Findings
A 2025 meta-analysis published in the Journal of Stroke and Cerebrovascular Diseases evaluated 37 randomized controlled trials involving over 2,300 stroke patients with foot drop. The study found that electrical stimulation (ES)—particularly when combined with conventional rehabilitation—significantly improved ankle dorsiflexion and lower limb motor function compared to standard therapy alone.
Among the various types of stimulation, electroacupuncture (EA) showed the greatest overall benefit, followed by transcranial direct current stimulation (tDCS) and transcutaneous electrical nerve stimulation (TENS). ES was most effective during the recovery phase (1–6 months post-stroke), where muscle and nerve responsiveness are optimal.
These findings highlight that early, targeted use of ES—especially electroacupuncture—can enhance gait recovery and functional outcomes in patients experiencing foot drop after stroke. (“Study on electrical stimulation therapies for post-stroke foot drop – see PubMed.“)
Who Performs This Treatment? (Specialists and Team Involved)
Foot drop is managed by a multidisciplinary team including neurologists, orthopedic or neurosurgeons, and physical medicine and rehabilitation specialists.
When to See a Specialist?
Seek evaluation if you have sudden or progressive weakness, numbness, or difficulty lifting your foot when walking. Early diagnosis is crucial for preventing permanent damage.
When to Go to the Emergency Room?
Go to the ER if foot drop occurs suddenly after trauma, severe back pain, or neurological symptoms such as numbness, incontinence, or paralysis—these may indicate a spinal emergency.
What Recovery Really Looks Like?
Recovery may take weeks to months depending on the cause. Conservative measures help mild cases recover fully, while nerve repair or tendon transfer restores functional walking ability in chronic cases.
What Happens If You Ignore It?
Untreated foot drop can lead to permanent deformity, chronic gait imbalance, falls, and joint contractures. Early intervention greatly improves the chances of recovery.
How to Prevent It?
- Avoid prolonged leg crossing or kneeling.
- Maintain proper posture and body mechanics during work and sports.
- Manage diabetes and other systemic conditions that damage nerves.
- Wear protective gear to prevent leg or knee trauma.
Nutrition and Bone or Joint Health
A balanced diet rich in B vitamins, calcium, vitamin D, and omega-3 fatty acids supports nerve and muscle health. Avoid excessive alcohol intake and smoking, both of which impair nerve regeneration.
Activity and Lifestyle Modifications
During recovery, avoid high-impact activities that strain the lower leg. Gradually reintroduce walking or cycling under supervision. Stretching the Achilles tendon and strengthening dorsiflexors help maintain mobility and prevent contracture recurrence.
Dr. Mo Athar
