Foot Drop

Brief presentation on Foot Drop.
Introduction, Causes, Diagnosis and Treatment.
Also includes 2 short clips showing normal gait and high stepping gait

1. FOOT DROP Dr. Kevin Joseph Ambadan

2. Drop Foot T he 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 . C an happen to one or both feet at the same time. It can strike at any age . Temporary or permanent

3. 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)

4. 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

5. Rupture of Anterior Tibialis Fracture of fibula Compartment Syndrome Diabetes Alcohol Abuse

6. 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

7. MUSCLES DORSIFLEXORS TIBIALIS ANTERIOR EXTENSOR HALLUCIS LONGUS EXTENSOR DIGITORUM LONGUS PERONEUS TERTIUS EVERTORS PERONEUS LONGUS PERONEUS BREVIS

8. 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 ( hi gh stepping gait) Pain, weakness or numbness in the foot.

9. 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. .

10. 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

11. IMAGING X-Ray Post- T raumatic - 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 Neurography Tumor or a compressive mass lesion to the peroneal nerve

12. 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.

13. TReaTMENT Depends on the underlying cause. If cause is successfully treated foot drop may improve or even disappear. Medical treatment - Painful P aresthesia S ympathetic block A mitriptyline Nortriptyline Pregabalin Laproscopic S ynovectomy

14. 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

15. Physical Therapy Exercises that strengthen the leg muscles M aintain the range of motion in knee and ankle Improve gait problems associated with foot drop.

16. Nerve Stimulation S timulating the nerve ( peroneal nerve) improves foot drop especially if it caused by a stroke.

17. SURGICAL REPAIR Foot 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

18. BRIDALS PROCEDURE Tendon to bone attachment - posterior tibial tendon is attatched to the second cuneiform bone. Tendon to tendon attachment

19. 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 peroneal nerve. The nerve is sutured to the motor nerve of the gartronemius Active voluntary dorsiflexion of foot

20. AFTER TENDON TRANSFER Cast and Non-Weight Bearing ambulation for 6 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.

21. 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.

22. Thank you