What are the management options for foot drop (peroneal nerve palsy)?

From the Guidelines

Foot drop management should prioritize the use of ankle-foot orthoses (AFOs) as the primary treatment, as recommended by the most recent guidelines 1. The management of foot drop, also known as peroneal nerve palsy, requires a multifaceted approach that addresses both the underlying cause and the resulting functional impairment.

Key Management Options

• The use of an AFO is essential to hold the foot in a neutral position, preventing tripping and improving gait, as supported by the International Journal of Stroke guidelines 1.
• Physical therapy plays a crucial role and should include exercises to strengthen the anterior tibialis and peroneal muscles, range of motion exercises, and gait training.
• For patients with potentially reversible causes, treating the underlying condition is vital, which may involve surgical decompression for nerve entrapment, vitamin supplementation, or discontinuation of offending medications.
• Electrical stimulation devices, such as Functional Electrical Stimulation (FES) of the wrist and forearm muscles, can be beneficial for some patients by stimulating the peroneal nerve during the swing phase of gait, as suggested by the guidelines 1.

Additional Considerations

• In cases of permanent foot drop, surgical interventions like tendon transfers or ankle arthrodesis may be considered.
• Proper footwear with adequate toe clearance is important to prevent falls.
• The management of foot drop should be individualized, as it can result from various conditions affecting the common peroneal nerve, L5 nerve root, or muscles controlling dorsiflexion, including stroke, multiple sclerosis, ALS, diabetes, or direct trauma to the nerve.

Guideline Recommendations

• The International Journal of Stroke guidelines recommend the use of AFOs for selected patients with foot drop following proper assessment and with follow-up to verify effectiveness 1.
• The guidelines also suggest considering mirror therapy for patients with very severe paresis and using force platform biofeedback for people with difficulty standing 1.

From the Research

Management Options for Foot Drop (Peroneal Nerve Palsy)

The management options for foot drop (peroneal nerve palsy) include:

• Ankle-foot orthoses (AFO) to support paralyzed extensor muscles of the foot 2
• Surgical treatment, which can include:
  • Neurolysis of the nerve
  • "End to end" repair
  • Autogenous nerve graft procedures
  • Nerve transfers
  • Direct neuromuscular neurotization
  • Tendon transfers, such as tibialis posterior tendon transfer 2, 3
• Physiotherapy 4
• Use of technological devices, such as:
  • Robot-based ankle-foot orthosis (RAFO)
  • Functional Electrical Stimulation (FES) devices 4, 5
• Assistance-as-needed support using musculoskeletal human models to determine the required support from an ankle-foot orthosis 6

Surgical Treatment Outcomes

Surgical treatment outcomes for foot drop have been reported in several studies, including:

• A study on tibialis posterior tendon transfer, which found excellent or good outcomes in 75.67% of patients at 1-year postoperative follow-up 3
• A study on the use of a foot drop stimulator, which found significant orthotic and therapeutic effects on walking performance in subjects with chronic nonprogressive and progressive neurological disorders 5

Non-Surgical Treatment Options

Non-surgical treatment options for foot drop have also been reported, including:

• The use of ankle-foot orthoses (AFO) to support paralyzed extensor muscles of the foot 2, 6
• Physiotherapy and the use of technological devices, such as robot-based ankle-foot orthosis (RAFO) and Functional Electrical Stimulation (FES) devices 4