Foot Drop
Name: Rahila Najihah AliMatrix Number : DPH/0102/11Batch : July/11Date: 19th June 20131Foot Drop 1Definition2Inability to raise the front part of foot due to weakness or paralysis of tibialis anterior muscle that lift the footFoot drop occur due to peroneal nerve injuryCan happen to one foot or both feetMuscle and Nerve3
Dorsiflexor Muscle-Tibialis anterior-Extensor hallucis longus-Extensor digitorum longusPeroneal NerveTibialis Anterior4Origin : upper two thirds of lateral surface of tibia and adjacent interosseous membaraneInsertion: medial surface of medial cuneiform and the base of 1st metatarsal boneNerve supply : receive twigs from deep peroneal nerve and recurrent genicular nerveAction: dorsiflexion of foot at ankle joint and invertor of the foot at midtarsal and subtalar joint5Testing the function of Tibialis Anterior : patient is asked to dorsiflex the foot against the resistance of therapists hand placed across the dorsum of the footInjury to deep peroneal nerve leads to paralysis of dordiflexorsExtensor Hallucis Longus6Origin: medial part of anteromedial surface of the middle two forth of fibula and adjacent interosseos membraneInsertion: base of terminal phalanx of great toeNerve supply: Deep peroneal nerveAction: dorsiflexion of foot at ankle and dorsiflexion of great toeTesting Functional : patient attempts to dorsiflex the great toe against resistanceExtensor Digitorum Longus (EDL)7Origin: upper three fourth of anteromedial surface of fibula, adjacent interosseous membrane and anterior intermuscular septumInsertion: EDL is divided into four tendon on the dorsum of foot Nerve supply: deep peroneal nerveAction: produce dorsiflexion of ankle joint and dorsiflexion of lateral four toesTesting functional: patient is asked to do dorsiflexion of the toes against ressistance
Sciatic Nerve8Sciatic nerve the thickest and largest nerve in the body Its start in lower back and runs through the buttock and lower limb with root value of L4 until S3Its supply biceps, semitendinosus, semimembranosus and adductor magnus muscleIn lower thigh, just above the back of the knee, sciatic nerve divides into two nerve which are tibial and peroneal nerveThose 2 nerve innervate different parts of the lower leg
Peroneal Nerve9Begin from L4, L5, SI, and S2 nerve roots and joint the tibial nerve to form the sciatic nerveCommon peroneal nerve travels anterior, around the fibular neckCommon peroneal nerve divide into superficial and deep peroneal nerveDeep peroneal nerve : innervation of tibialis anterior muscle that responsible to the dorsiflexion of the ankle
Causes of Foot Drop10L4-L5 disc herniation-the herniated disc compressing the L5 nerve rootLumbosacral Plexus injuru- due to pelvic fractureSciatic nerve injury-hip dislocationInjury to the knee-knee dislocation 11Neurodegenerative disorder of the brain-multiple sclerosis, stroke, cerebral palsyMotor neuron disorder-polio and amyotrophic lateral sclerosisInjury to the nerve roots-spinal stenosisPeripheral nerve disorder-acquire peripheral neuropathyDamage to the peroneal nerve-muscular dystrophy 12Established compartment syndrome-foot drop is late finding-irreversible muscle and nerve ischemia occur in patient if fasciotomy is not performed LEVEL OF LESION IN SCIATIS NERVE INJURY13High lesion (above the knee)-both tibial and common peroneal nerve are paralaysedLow lesion (below knee)-spared : peroneus longus and brevisType 1 : anterior tibial nerve injurylost : Tibialist anterior, extensor hallucis longus, extensor digitorum longus and peroneus tertius
Type 2 : musculocutaneus nerve injuryspared : all above muscle innervated by anterior tibial nervelost : peroneus longus and brevissensation : over outer leg and foot
Symptom of Foot Drop 14Inability to lift the front part of the footAbnormal gait which drag the front of foot on the ground during walking (steppage gait)An exaggerated, swinging hip motion Tingling, numbness & slight pain in the foot Difficulty performing certain activities that require the use of the front of the foot Muscle atrophy in the leg Limp foot
Clinical features of Type 1 foot drop15High lesion : total foot dropUnable to do dorsiflexion and inversion of footAble to do eversionFront of leg is wasted Sensation lost over dorsal web space of the leg Clinical features of type 2 foot drop16Low lesion : incomplete of foot dropUnable to do eversionAble to do dorsiflexion and inversion of the footWasting of outer half of legSensation lost over outer leg and footGait of Foot Drop17Gait of foot drop gait is high stepping gaitThe patients lift the knee high and slaps the foot to the ground on advancing to the involved sideDiagnosis18Occur during routine examination where patient find its difficult to walk on their heelPlain X-rayMagnetic Resonance Imaging (MRI)Electromyography (EMG) and nerve conduction studySD curveTinel signTreatment of early foot drop19Conservative treatment : shows high incidence of recoverySplintage splint knee in 20 of flexion and ankle in 90 for night timeIn day time, walking is allowed by using foot-drop applianceVarieties of foot drop appliances:i) dynamic-spring shoeii) static- back stop shoe20Ankle foot orthotics (AFO)-support the foot with light-weight leg braces and shoe inserts Exercises-strengthen the muscle, help to maintain range of motion (ROM) and improve gaitElectrical Functional Stimulations-electrically stimulate the peroneal nerve during footfall
21Surgery done if conservative management failsRepairs or decompresses a damaged nerve that fuses the foot and ankle joint or transfers tendons from stronger leg musclesChoices of surgeryi) tendon transfers for mobile foot dropii) tendo-archilles lengthening - in fixed equinusiii) subtalar stabilizer procedur for fixed varusiv)triple arthrodes for fixed varus at the subtalar jointPhysiotherapy- Exercise22When problem stems from weak musclesProper physical therapy exercises can strengthen ankle muscle and improve symptoms
2223Toe curls exercisePlace a small towel and curl it toward you by using only your toes. You can increase the resistance by putting the weight at the end of the towelRelax and repeat this exercide for 5 times
24Marble picked up exercisePlace 20 marbles on the floor. Pick up one at a time with your toes and put each marble in a bowl.
25Toe-to-heel plantar flexionAsk patient to standing at edge of tableDo dorsi flexion and plantarflexion Hold for 10 second for 10 times
26Foot stretchPatient sit with the knee straight and towel around the affected footGently pull a towel until comfortable stretch at the calf muscle is feltHold for 10 second and do for 10 times
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28Isometric dorsiflexion
29Toes band exercisePut the rubber band around the toesDo the abduction of the toes by against the rubber bandHold for 5 sec for 10 times
Electrical stimulation30Electrical stimulation to the nerves controls the dorsiflexor muscles. It was first proposed as a treatment for foot drop in 1961 They send electronic pulses to fire the nerve response for the front of your foot to lift. It's programmed to each individual separately It provides normal range of motion to the foot and ankle during walking Stroke and multiple sclerosis had success with it
Reference31Neeta V Kulkarni, 2006, Clinical Anatomy for Students Problem Solving Approach,New Delhi, Jaypee Brothers Jules M.Rothstein, 2005, The Rehabilitation Specialists Handbook, 3rd edition, Thailand, F. A. Davis CompanyChris Kirtley, 2006, Clinical Gait Analysis Theory and Practice, Sydney, Churchill Livingstone ElsevierSusan B. OSullivant & Thomas J. Schmitz, 2007, Physical Rehabilitation, 5th edition, Philadelphia, F. A. Davis CompanyS Lakshmi Narayanan, 2005, Textbook of Therapeutic Exercises, New Delhi, Jaypee Brother32
