FOOT DROP
FOOT DROP
DROPING OF FOREFOOT DUE TO WEAKNESS
DAMAGE TO COMMON PERONEAL NERVE
PARALYSIS 0F MUSCLES IN ANTERIOR PORTION OF LOWER LEG
INABILITY TO DORSIFLEX ANKLE AND TOES
UNILATERAL OR BILATERAL
TEMPORARY OR PERMANENT
ANATOMY SCIATIC NERVE BIFURCATES INTO
TIBIAL AND PERONEAL NERVE
PERONEAL NERVE CROSSES LATERALLY OVER FIBULAR NECK
DIVIDES INTO SUPERFICIAL AND DEEP BRANCHES
SUPERFICIAL BRANCH TRAVELS BETWEEN TWO HEADS OF PERONEI AND SUPPLIES LATERAL COMPARTMENT
DEEP BRANCH SUPPLIES ANTERIOR COMPARTMENT
MUSCLESDORSIFLEXORS TIBIALIS ANTERIOR EXTENSOR HALLUCIS LONGUS EXTENSOR DIGITORUM LONGUS PERONEUS TERTIUS
EVERTORS PERONEUS LONGUS PERONEUS BREVIS
MORE VULNERABLE TO INJURY
Funiculi of the peroneal nerve - larger and less connective tissue
Fewer autonomic fibers, so in any injury, motor and sensory fibers bear the brunt of the trauma.
More superficial course, especially at the fibular neck
Adheres closely to the periosteum of the proximal fibula
CAUSESNEUROLOGICAL
NM DISEASE PERONEAL NERVE INJURY SCIATIC NERVE INJURY LUMBAR SACRAL PLEXUS INJURY
SPINAL CORD LESIONS CAUDA EQUINA SYNDROME BRAIN – STROKE, TIA GENETIC
RUPTURE OF TIBIALIS ANTERIORFRACTURE OF FIBULA COMPARTMENT SYNDROMEDIABETESALCOHOL ABUSE
SYMPTOMSDifficulty in lifting the foot.Dragging the foot on the floor as
one walks.Slapping the foot down with each
step.Raising thigh while
walking(stepping gait)Pain , weakness or numbness in the
foot.
GAIT CYCLE
Swing phase (SW): The period of time when the foot is not in contact with the ground. In those cases where the foot never leaves the ground (foot drag) - phase when all portions of the foot are in forward motion.
Initial contact (IC): when the foot initially makes contact with the ground; represents beginning of the stance phase - foot strike.
Terminal contact (TC): when the foot leaves the ground - end of the stance phase or beginning of the swing phase - foot off. .
FOOT DROPDrop foot SW: Greater flexion at the
knee to accommodate the inability to dorsiflex - stair climbing movement.
Drop foot IC: Instead of normal heel-toe foot strike, foot may either slap the ground or the entire foot may be planted on the ground all at once.
Drop foot TC: Terminal contact is quite different - inability to support their body weight – walker can be used
DIAGNOSISPHYSICAL EXAMINATIONTRAUMA – no lab investigations
INVESTIGATIONS FBS ESR CRP B.UREA S CREATININE ELECTROPHORESIS.
IMAGING
Plain films posttraumatic - tibia/fibula and ankle-any
bony injury. anatomic dysfunction (eg, Charcot joint)
Ultrasonography If bleeding is suspected in a patient with
a hip or knee prosthesisMagnetic Resonance
Neurography tumor or a compressive mass lesion to the peroneal nerve
Electromyelogram
◦This study can confirm the type of neuropathy, establish the site of the lesion, estimate extent of injury, and provide a prognosis.
◦Sequential studies are useful to monitor recovery of acute lesions.
TRAETMENTDepends on the underlying cause.If cause is successfully treated foot
drop may improve or even disappear.
Medical treatment - painful paresthesia
sympathetic block amitriptyline nortriptyline pregabalinLaproscopic synovectomy
SPECIFIC TREATMENTBraces or splint-a brace on the
ankle and foot or splint that fits into the shoe can help to hold the foot in the normal position
Physical therapy exercises that strengthen the
leg muscles maintain the range of motion in
knee and ankle improve gait problems
associated with foot drop.
Nerve stimulation stimulating the nerve
(peroneal nerve) improves foot drop especially if it caused by a stroke.
SURGICAL REPAIRFoot drop due to direct trauma to
the dorsiflexors generally requires surgical repair.
When nerve insult is the cause - restore the nerve continuity - nerve grafting or repair.
If there is no significant neuronal recovery at one year - tendon transfer maybe considered.
Bridal procedure
Neurotendinous transpositon
BRIDALS PROCEDURE
Tendon to bone attachment - posterior tibial tendon is attatched to the second cuneiform bone.
Tendon to tendon attachment
NeurotendinoustranspositionLateral head of gastronemius is
transposed to the tendons of the anterior muscle group with simultaneous transposition of the proximal end of deep peroneal nerve.
The nerve is sutured to the motor nerve of the gartronemius
Active voluntary dorsiflexion of foot
AFTER TENDON TRANSFER
CAST AND NON WEIGHT BEARING AMBULATION FOR SIX WEEKS
PHYSIOTHERAPY TO CORRECT GAIT ABNORMALITIES
CHRONIC AND CONTRACTURE CASES ACHILLES TENDON LENGTHENING
In patients whom foot drop is due to neurologic and anatomic factors (polio, charcot joint ) - arthodesis
Subtalar stabilising procedure or triple arthodesis can be done.
COMPLICATIONSSurgical procedure- wound infection
may occur.
Nerve graft failure
In tendon transfer procedures- recurrent deformity
In arthrodeses or fusion procedures- pseudoarthrosis,
delayed union, or nonunion.
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