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