Understanding and Working with Foot Drop

My foot has fallen and it can’t get up!

Foot drop is one of the most common neurological problems. It can happen from damage to the peroneal nerve near the knee as the result of a knee injury or, commonly, a knee surgery gone wrong. Often, a severe nerve injury can’t be fixed, and the injury recipient will have to use a foot drop brace to assist with walking.

Foot drop can also arise from a central nervous system problem such as multiple sclerosis, stroke, or other neurological diseases. Here, both weakness and spasticity can play a role in the problem.

When working with foot drop, I usually try to determine whether the foot drop is caused by weakness of the tibialis anterior muscle, damage to the peroneal (or sciatic) nerve, damage to the spinal cord, or damage to the brain. It’s also important to assess whether the foot drop is accompanied by spasticity in the antagonist muscles. An overly tight soleus muscle or gastrocnemius muscle can prevent the tibialis anterior from firing properly, might cause co-contraction of both the calf muscles and the muscles at the front of the shin, or it could limit the movements of the ankle joint.

If someone presents with spastic foot drop, in which the foot drop is accompanied by tightness that inhibits movement, I find it works best to minimize strengthening the calf muscles. The muscles at the front of the leg are much smaller and have to fight against the tightness of the opposite side. In those cases, I usually take a break from calf strengthening for a while to see if the muscles that lift the foot can catch up.

But (and here’s where it gets tricky), it’s important to note that any time a muscle has spasticity, it is also a weakmuscle. Spasticity is basically a failure of the communication pathway from the spinal cord to the brain (or vice versa), in which the stretch reflex isn’t mediated by the brain. The muscle keeps contracting in a misguided effort to try to protect the joint. Until you can break that cycle of miscommunication, the spasticity will not go away. Once the spasticity pattern is broken, usually through a combination of medication, stretching, and often PT, the weakened muscles can be strengthened. (More on spasticity to come in another post).

Why are the feet so prone to problems in neurological diseases? Simply, the feet are the furthest away from the brain. Nerves have to travel from your feet all the way to your brain and back again in order to work correctly. I always give my neurological clients plenty of homework exercises to do with their feet.

Here’s a favorite exercise for strengthening the tibialis anterior muscle, which is often weak with foot drop:

Place a Theraband over-the-top of your foot near the toes and step on it with your opposite foot using the Theraband as a resistance, Lift your toes off the floor while keeping your heel grounded. Repeat 10 or more times, and work on holding each lift for up to five seconds.

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A stretch that works great for very tight calf muscles comes from one of my favorite bloggers Katy Bowman. Place a half foam roller or rolled up towel on the floor, and step on it with the ball of your foot with your heel down on the floor. Step the opposite leg forward, but keep the weight in the back foot. This will be one of the most intense and effective calf stretches you will ever do.

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Also, for more foot exercises, check out this video that Pilates for MS faculty Meghann Koppele designed for clients with neurological problems. Whether or not foot drop is currently an issue, it can always become one. If you’re dealing with a neurological disease, never neglect exercising those parts of your body furthest from your brain.

To learn (a lot) more about the feet and what you can do to keep them strong, check out one of our Pilates for MS and neurological conditions workshops.

In health,


Smell, Memory, and Brain Medicine

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