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Bulletin of the NYU Hospital for Joint Diseases 2009;67(4):374-7

Peroneal Nerve Injury with Foot Drop

Complicating Ankle Sprain
A Series of Four Cases with Review of the Literature
James M. Brief, M.D., Rochelle Brief, M.D., Ph.D., Enrique Ergas, M.D., L. Paul Brief, M.D.,
and Andrew A. Brief, M.D.

Abstract
Foot drop has many etiologies. One rarely mentioned and
often neglected reason for foot drop is an acute inversion
sprain of the ankle. Over the past 14 years, a collection of
32 cases of foot drop have been compiled in our orthopaedic
and physiatric practices. All cases had appropriate evaluations, including electrodiagnostic studies (electromyography
and nerve conduction studies) to determine the location and
type of injury. Treatment and follow-up are also discussed.
Of the 32 case studies, four were caused by a straightforward acute inversion sprain of the ankle. These cases are
described with the electrodiagnostic evaluations, treatments,
and outcomes. Proposed mechanisms for this type of foot
drop are discussed, including traction and compression of
the common peroneal nerve as it winds around the neck of
the fibula, and possible compression by hematoma. Surgical
versus conservative treatment is described. The functional
impairment associated with foot drop is detailed.

oot drop may present a serious functional impairment.1 Often associated with common peroneal nerve
(CPN) dysfunction, it is caused by paresis of the ankle
dorsiflexor, the tibialis anterior, and the toe dorsiflexors,
the extensor digitorum brevis and extensor hallucis longus.
Clinically, foot drop can be seen with the characteristic
steppage gait, in which hip and knee flexion are increased;
hip hiking can occur to allow the weak ankle to clear the
James M. Brief, M.D., is from Maimonides Medical Center, Brooklyn, New York. Rochelle Brief, M.D., is from the Department of
Rehabilitation, Nyack Hospital, Nyack, New York. Enrique Ergas,
M.D., and L. Paul Brief, M.D., are from the Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New
York. Andrew Brief, M.D., is from the Department of Orthopaedic
Surgery, Englewood Hospital, Englewood, New Jersey.
Correspondence: James M. Brief, M.D., Bardonia Medical Arts,
175 Route 304, Bardonia, New York 10954; cyberdocs@aol.com.

floor during the swing phase of gait. Less noticeable dysfunction associated with drop foot includes paresis of foot
eversion and sensory impairment on the dorsum of the foot
and lateral leg.2
A brief review of the anatomy2-5 can easily elucidate the
dysfunction an injury to the CPN will carry. In the posterior
thigh, the sciatic nerve divides into two parts at the proximal
popliteal fossa: the CPN laterally and the posterior tibial
nerve medially. The CPN continues to proceed laterally,
where it passes behind the fibular neck. At this point, the
CPN passes under a fibrous edge of the peroneus longus
muscle origin, and then proceeds distally, dividing into
superficial and deep peroneal branches. The superficial peroneal nerve gives off branches to the peroneus longus and
brevis, ankle evertors, then distally supplies sensation to the
lower anterolateral leg and most of the dorsum of the foot.
The deep peroneal nerve runs anteriorly, supplying motor
branches to the tibialis anterior, extensor hallucis longus and
extensor digitorum brevis, ankle and toe dorsiflexors, and
finally the peroneus tertius, a minor ankle evertor. It also
supplies a small patch of sensation to the dorsal surface of
the web space between the hallux and second toe. In summary, lesions of the CPN will cause foot drop, weak or absent
ankle eversion, and sensory deficits over the anterolateral
leg and dorsum of the foot.
The CPN is the most frequently injured nerve in the
lower extremity1 and the most common cause of foot drop.2,6
Nevertheless, ankle sprain, albeit rarely, also has been
cited as a cause of foot drop. Few reported cases have been
documented and a review of the literature turned up only 16
cases of foot drop attributed solely to ankle sprain.7-16 Fewer
cases still, only six, have been examined by electrodiagnostic
evaluation.7,11,14-16 Nitz and colleagues17 report a series of 66
patients who had a diagnosis of inversion ankle sprain and
subsequently underwent electromyography (EMG) evaluation. Although 17% of grade II sprains and 86% of grade

Brief JM, Brief R, Ergas E, Brief LP, Brief AA. Peroneal nerve injury with foot drop complicating ankle sprain: a series of four cases with review of the
literature. Bull NYU Hosp Jt Dis. 2009;67(4):374-7.

Bulletin of the NYU Hospital for Joint Diseases 2009;67(4):374-7

375

Table 1 Summary of Patients with Foot Drop after Ankle Inversion Sprain


Patient
Age & Sex

Complications
Accompanying
Foot Drop

Treatment

1
21 M
None
Casted 3 weeks, surgical

decompression at 6 weeks, AFO
2
39 M
None
AFO
3
76 M
None
AFO, surgical decompression

at fibular neck

4
44 M
None
AFO, surgical decompression at

at fibular neck

III sprains sustained common peroneal nerve abnormalities

electrophysiologically, none were described with foot drop.
The purpose of the present study is to report a series
of four cases seen in the combined practices (orthopedic
surgery and physiatry) of the investigators over 14 years,
with the primary diagnosis of foot drop caused by inversion
sprain. Twenty-eight different cases of foot drop from other
etiologies were also seen in these same practices. All foot
drop cases that resulted from ankle sprain were evaluated
with EMG and nerve conduction studies (NCS). Clinical
outcomes are reported as well as probable mechanisms of
common peroneal nerve injury from inversion ankle sprains.

Case Descriptions
Thirty-two patients with a primary diagnosis of foot drop
were referred to our offices from 1993 to 2007. Of the various
etiologies for foot drop among our patients, four appeared
to have resulted from a simple inversion ankle sprain. Three
other sprains had additional injuries. Two of these were accompanied by fractures. The third case included a tear of the
Achilles tendon, a tibial nerve injury, and complex regional
pain syndrome. The 25 remaining cases of foot drop unrelated to ankle sprain had an assortment of etiologies. A summary of this series of four patients with foot drop resulting
from simple ankle sprain, treatments rendered, and clinical
outcomes is found in Table 1. Electrodiagnostic summaries
of the same four patients are seen in Table 2. Overall, two
patients showed complete return of common peroneal nerve
function following ankle sprain, while two showed partial
sensory and motor return.
In our series of patients with CPN injury at the fibular
neck, Case 1 (a neurapraxic lesion) achieved full recovery of
nerve function. Case 2, which demonstrated axonotmesis of
the common peroneal nerve, obtained full recovery as well.

Outcome
Full recovery at 14 weeks post-injury
Full recovery at 3 months
Partial recovery of ankle dorsiflexion
and leg sensation
Unimproved foot sensation
Partial recovery of sensation
Dorsiflexion remains weak at 6 months

Case 3 presented as a chronic foot drop from a severe ankle

sprain 4 years earlier. EMG and NCS showed axonotmesis
of the CPN. Following surgical intervention and decompression of the nerve, partial motor but no significant sensory
function returned. Finally, Case 4, which had significant
axonotmesis of the CPN, underwent surgical decompression,
and demonstrated improved sensation but little change in
motor function.

Discussion
The most commonly injured joint of the lower extremities is
the ankle.18,19 In the United States, 85% of acute ankle trauma
is described as sprain,20 the vast majority of which are of the
plantar flexion-inversion type.19 Few studies, however, have
described foot drop as a sequela of ankle inversion sprain.
Oppenheim21 first reported a case of peroneal palsy
complicating ankle sprain nearly 100 years ago. Since that
time, at least 53 documented cases have associated CPN
injury with ankle sprain. However, only 16 patients had foot
drop7-16 and only six of these underwent electrodiagnostic
evaluation to localize the site of the neuropathic lesion at the
neck of the fibula.7,13-16 Besides paresis or paralysis of ankle
dorsiflexion (foot drop), common peroneal injuries will also
affect foot eversion. In addition, paresthesias occur in the
lateral leg and over the dorsum of the foot. There is often
marked tenderness at the fibular neck as well.
Foot drop has also been known to occur with deep peroneal nerve injury. This can be distinguished clinically from
CPN etiologies in that reduced sensation is confined to the
small patch of the first web space on the dorsum of the foot.
Also, foot eversion is preserved. Gabison and Gentile22 describe a case of acute foot drop after ankle sprain, in which
the peroneus longus muscle was ruptured. This resulted in
a compartment syndrome from an expanding hematoma,

Table 2 Electrodiagnostic Findings

Patient

1
2
3
4

Electrodiagnostic Findings (EDx)

Neurapraxia of common peroneal nerve at fibular neck
Axonotmesis of common peroneal nerve at fibular neck
Axonotmesis of common peroneal nerve at fibular neck
Axonotmesis of common peroneal nerve at fibular neck

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with elevated pressures in the anterior compartment as well

as the lateral compartment distal to the CPN. The proximal
deep peroneal nerve was affected. After fasciotomy, sensation and ankle motion were restored. Anterior compartment
syndrome due to elevated pressures from excessive exercise
or other soft tissue injuries has been reported.23 Any direct
trauma or pressure upon the deep peroneal nerve can also
result in foot drop.3
Ankle sprains have also been associated with injury
to the superficial peroneal nerve.24-28 The level of injury
here, however, is thought to be at the ankle. The superficial
peroneal nerve appears to be compromised via a traction
mechanism, as noted in a recent cadaver study of ankles by
ONeill and coworkers.28 Redfern and associates26 found
that 15% of ankle fractures suffer some type of superficial
peroneal nerve injury. Ligamentous damage caused by inversion sprain, especially to the anterior talofibular ligament,
produces additional risk of superficial peroneal nerve injury.
Clinically, however, superficial peroneal nerve injury does
not produce foot drop. It primarily causes persistent ankle
pain and tenderness, as well as sensory impairment over the
dorsum of the foot.
In the present series of four patients with foot drop and in
similar previously cited cases, the level of nerve injury was
at the neck of the fibula. As noted, the CPN is essentially
tethered there by a thick fibrous band at the origin of the
peroneus longus. Inversion of the ankle is therefore thought
to produce a sudden forceful traction, leading to compression
of the nerve between the bony fibular neck and this fibrous
band.8,10,13,15,22 A delay in symptomatic foot drop after injury, however, has also been explained by a developing and
expanding hematoma in the peroneal sheath at this level or
due to rupture of the associated vas nervorum.10
Electrodiagnostic evaluation of foot drop caused by
CPN injury at the neck of the fibula can show neurapraxia
(a temporary conduction block), axonotmesis (axonal loss)
and reduced motor conduction velocity. Motor dysfunction
can also be revealed as denervation of affected muscles distal
to the point of injury, which is seen on needle electromyography.2,29
Neurapraxic lesions have good prognoses, usually with
full recovery of nerve function. With axonal loss, improved
function is also seen, but the prognosis is less certain. Most
uncomplicated cases show at least partial if not full recovery.
Chronic lesions, lesions with severe axonal loss, and those
with additional injury to the ankle fare less well.
Three patients in our series of four underwent surgical
decompression. Surgical exploration with decompression
and neurolysis of the CPN are most often performed for
severe foot drop, progressive symptoms, or for those who
show no improvement.2,3,11,20,30 We recommend that a foot
drop which shows no sign of improvement after 4 to 5
weeks of conservative treatment should undergo surgical
decompression and neurolysis.
Regardless of surgical treatment, however, patients with

foot drop should be prescribed an ankle foot orthosis (AFO)

to achieve a near normal, safe gait pattern. In addition, the
AFO secures and stabilizes the ankle and expedites recovery
from ankle sprains.
A recent study by deBruijn and colleagues,1 in which
patients with foot drop were prescribed AFOs, revealed
that AFO use eventually declined. This happened as clinical
improvement occurred, due to brace discomfort, or substitute
use of alternate orthopedic footwear.

Conclusions
An often overlooked cause of foot drop is ankle inversion
sprain. Thirty-two cases with foot drop were evaluated, four
of which were caused by injury to the common peroneal
nerve at the neck of the fibula after ankle sprain. Medical
personnel, such as orthopedic surgeons, physiatrists, podiatrists, emergency room physicians, primary care physicians,
physician assistants, athletic trainers, physical therapists,
and others who may see patients with ankle injuries, should
be aware of possible associated nerve injury so that proper
evaluation and treatment can proceed.
Disclosure Statement
None of the authors have a financial or proprietary interest in
the subject matter or materials discussed in the manuscript,
including, but not limited to, employment, consultancy, stock
ownership, honoraria, and paid expert testimony.

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