FOOT DROP Dr. Kevin Joseph Ambadan
Jul 02, 2015
FOOT DROPDr. Kevin Joseph Ambadan
• Drop Foot
• The inability to lift the front part of the foot.• Paralysis of anterior muscles of lower leg
• Inability to dorsiflex at the ankles and toes
• Causes the toes to drag along the ground while walking.
• Can happen to one or both feet at the same time.It can strike at any age.
• Temporary or permanent
CAUSES
• Injury to the peroneal nerve.
• sports injuries
• diabetes
• hip or knee replacement surgery
• spending long hours sitting cross-legged or squatting
• childbirth
• large amount of weight loss
• Injury to the nerve roots in the spine (L5)
• Neurological conditions that can contribute to foot drop include:
• stroke
• multiple sclerosis (MS)
• cerebral palsy
• Charcot-Marie-Tooth disease
• Conditions that cause the muscles to progressively weaken or deteriorate may cause foot drop:
• muscular dystrophy
• amyotrophic lateral sclerosis (Lou Gehrig’s disease)
• polio
• Rupture of Anterior Tibialis
• Fracture of fibula
• Compartment Syndrome
• Diabetes
• Alcohol Abuse
VULNERABILITY OF PERONEAL NERVE
• 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
MUSCLES
• DORSIFLEXORS
TIBIALIS ANTERIOR
EXTENSOR HALLUCIS LONGUS
EXTENSOR DIGITORUM LONGUS
PERONEUS TERTIUS
• EVERTORS
PERONEUS LONGUS
PERONEUS BREVIS
SYMPTOMS
• Difficulty in lifting the foot.
• Dragging the foot on the floor as one walks.
• Slapping the foot down with each step.
• Raising thigh while walking (high 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 DROP
• Drop 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
IMAGING
• X-Ray
Post-Traumatic - 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 prosthesis
• Magnetic Resonance NeurographyTumor 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.
TREATMENT
• Depends on the underlying cause.
• If cause is successfully treated foot drop may improve or even disappear.
• Medical treatment - Painful Paresthesia• Sympathetic block
• Amitriptyline
• Nortriptyline
• Pregabalin
• Laproscopic Synovectomy
SPECIFIC TREATMENT
• Braces or splint
• 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 REPAIR
• Foot drop due to direct trauma to the dorsiflexorsgenerally 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
NEUROTENDINOUS TRANSPOSITION
• Lateral head of gastronemius is transposed to the tendons of the anterior muscle group with simultaneous transposition of the proximal end of deep peronealnerve.
• 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 6
weeks
• PHYSIOTHERAPYTo 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.
COMPLICATIONS
• Surgical procedure- wound infection may occur.
• Nerve graft failure
• In tendon transfer procedures- recurrent deformity
• In arthrodeses or fusion procedures- pseudoarthrosis, delayed union, or nonunion.
THANK YOU