Foot drop

presentation on foot drop

1. FOOT DROP Dr.A.Supraja PG II YEAR Gandhi Medical College

2. Inability to actively dorsiflex and evert the foot Definition

3. Traumatic: Tendon injuries to dorsiflexors of foot Neurogenic A)At or below the level of common peroneal nerve Direct injuries: incised and penetrating injuries Fracture and dislocations: Fracture of lateral condyle of tibia Fracture/ dislocation of head/neck of fibula Dislocation of knee compound fracture of upper 1/3 rd of tibia 4 Causes of Foot Drop

4. Iatrogenic : High tibial skeletal traction Tight plaster around knee High tibial osteotomy Total knee replacement B) Above the level of common peroneal nerve Fracture of shaft of femur Posterior dislocation of hip Deep intra muscular injection PIVD Spina bifida If any cerebral tumors and space occupying lesions of CNS 5

5. infective leprosy Poliomyelitis Guillain-Barré Syndrome Syphilis Metabolic: Diabetes mellitus Beri beri Alcoholic neuritis Exogenous toxin: Lead Arsenic Mercury 6

6. COURSE OF THE COMMON PERONEAL NERVE

7. COURSE OF THE COMMON PERONEAL NERVE

8. Fasiculi of the peroneal nerve - larger and have 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 Vulnerability of Peroneal Nerve

9. Cutaneous sensation is impaired over the lateral aspect of the lower leg and ankle and dorsum of the foot. Reduced dorsiflexion and eversion of the foot and of toe extension The patients will compensate by having a steppage gait . N.B Inversion and plantar flexion are normal . Signs

10. Progressive weakness of the peronei and tibialis anterior muscles which result in foot drop. peroneus longus , tibialis anterior and the extensor digitorum wasting N.B The paresis results in ankle weakness and predispose to ankle sprains

11. 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(stepping gait) Pain , weakness or numbness in the foot. SYMPTOMS

12. Types of foot drop Type I – High above the level of fibular head deep peroneal nerve Type II- Low below the level of fibular head superficial peroneal nerve

13. High lesion : total foot drop Unable to dorsiflex and invert foot Able to do eversion Wasting of ant group of muscles Loss of sensation over the 1 st web space 16 Clinical features of Type 1 foot drop

14. Low lesion : incomplete foot drop Unable to do eversion Able to do dorsiflexion and inversion of the foot Wasting of outer half of leg Sensation lost over outer leg and foot 17 Clinical features of type 2 foot drop

15. Gait of foot drop gait is high stepping gait The patients lift the knee high and slaps the foot to the ground on advancing to the involved side 18 Gait of Foot Drop

16. X-Ray Post-Traumatic - tibia/ injuryfibula and ankle - any bony. 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 DIAGNOSIS

17. 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. Electromyelogram

18. Depends on the underlying cause. If cause is successfully treated foot drop may improve or even disappear. Medical treatment - painful paresthesia amitriptyline nortriptyline pregabalin TREATMENT

19. Assistive and adaptive devices and equipment. Canes , crutches, or walkers may be used to help prevent falling, normalize gait patterns, or unload a painful weight-bearing limb . Electrical Stimulation. Transcutaneous electrical nerve stimulation (TENS) for the reduction or obliteration of pain .

20. Positioning. Correct positioning of limb Protective Devices and Equipment eg splints, orthoses Cryotherapy , massage

21. Conservative treatment : shows high incidence of recovery Splintage – splint knee in 20° of flexion and ankle in 90° for night time In day time, walking is allowed by using ‘foot-drop appliance’ Varieties of foot drop appliances: i ) dynamic-spring shoe ii) static- back stop shoe 26 Treatment

22. Ankle 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 gait Electrical Functional Stimulations -electrically stimulate the peroneal nerve 27

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

24. 30

25. Surgery – done if conservative management fails Repairs or decompression of a damaged nerve, fusion of the foot and ankle joint or transfers tendons from stronger leg muscles 31

26. SURGICAL MANAGEMENT Points to be considered age Mobility of joints Availability of muscles and tendons for transfer Soft tissue and muscle contractures Bony changes

27. TENDON TRANSFER SURGERIES Objectives: Provide active motor power – paralysed muscle Eliminate deforming effect of muscle- antagonist paralysed Improve stability- muscle balance

28. PRINCIPLES Muscle transferred-strong—good/better Nerve and blood supply-not impaired Free end of tendon- close to insertion of paralysed muscle Retained in its own sheath/ another tendon Routed direct in line bet muscle origin and new insertion Contractures near the joint on which muscle acts- released Agonists> antagonists Tendon =range of excursion=one reinforcing /replacing

29. BARR’S TECHNIQUE (anterior transfer of tibialis posterior) Classic- 2/3 cuniform ; 2/3 metatarsal modified - cuboid ( tendon passed through ant interossois membrane) cast: long leg calcaneovalgus -foot >3weeks- B/K- foot-N ;ankle- DF >6WEEKS- remove cast- Rehabilitation 6 months- Double bar foot drop brace with an outside T STRAP

30. OBER’S TECHNIQUE ( tendon passed through ant comparment of leg) Classic- 2 nd metatarsal HATTS modified obers - medial cuneiform Post op = barrs

31. KAUFER’S PROCEDURE ( split transfer of tibialis post tendon) Incision- 1 st - curvilinear- navicular tuberosity Extend- inf and post to medial malleolus Proximal- post midline over tendocalcaneus Tibialis Post –split longitudinally-plantar and dorsal Tendocalneus lengthening 2 nd - tip of lateral malleolus -base of 5 th metatarsal Peronius brevis - pass tendon carrier –proximally –just post to lat malleolus - t.post tendon- foot in corrected position- t.post sutured to brevis under tension. Post op: long leg cast- 2months short leg cast – 2 months

32. SRINIVASAN TECHNIQUE ( two tailed transfer of tibialis post) Position- supine – passive dorsiflexion of ankle- knee extension 1 st -Short transverse incision- navicular-tibialis post endon exposed Flexar retinaculum split 2 nd -Medial aspect of L/3 rd of leg-incision-FDL retracted- tibialis post hooked up-split 3 rd & 4 th -2 curvilinear – dorsum of foot- medial- tendon of EHL-LOWER SLIP( anderson tunneler ) Lateral- tendon of EDL- UPPER SLIP- laced up

33. Post op: B/K- foot in 70 deg dorsiflexion > 3weeks- non-weight bearing reeducative exercises Bivalve POP cast- crutches 7 th post op week- weight bearing

34. TENDO ACHILLIS LENGTHENING WHITES TECHNIQUE: (open) Posteromedial incision- expose tendocalcaneus Long cast- knee extension ;ankle- dorsiflexion 1 ST post op- weight bearing Knee extension – 3weeks Short leg- 3 weeks AFO- ankle in neutral dorsiflexion

35. HAUSER TECHNIQUE: Posteromedial incision- expose tendocalcaneus Plantaris tendon- incised-beneficial Cast- mid thigh to toe knee-full flexion; ankle-neutral dorsiflexion skin blanching- little equinus (1 st cast change-N) >6WEEKS- AFO

36. PERCUTANEOUS LENGTHENING OF TENDOCALCANEUS Position: prone knee-E; ankle- DF 3 partial tenotomies Heel-varus-2 incisions medially valgus - 2 incisions laterally After suregery Mx = White technique

37. Semiopen sliding tenotomy of tendocalcaneus Position-prone 2 long incision 2cm along the tendocalcaneus Plantaris tendon- tenotomy Post op-=Hauser technique

38. BONE SURGERIES

39. LAMBRINUDI ARTHRODESIS Indiactions:Isolated fixed equinus deformity > 10 years CI: flail foot hip& knee instability requiring brace Lateral x-ray- ant subluxation of talus- 2 stage plantar arthodesis Complications-1. ankle instability 2.residual varus / valgus due to muscle imbalance 3.Pseudoarthrosis of talonavicular joint

40. S/R – 10-14 days Short leg cast- x –ray satisfactory Weight bearing- > 6weeks Short leg walking cast- fusion complete(3mon)

41. TRIPLE ARTHODESIS Most effective ; age > 12 years Subtalar-calcaneocuboid-talonavicular joints Indications: weakness and deformity of subtalar & mid tarsal joints stable& static realignment remove deforming forces arrest progression of deformity Eliminate pain eliminate use of short leg brace/ provide sufficient correction for fitting long leg brace obtain near normal correction of foot After Rx: walk with crutches / walker

42. CAMPBELLS post bone block Permits lengthening of tendocalcaneus & ankylosing both ankle and subtalar joints Incision: medial and parallel to TA FHL retracted to capsule of ankle joint is exposed Post part of talus and articular surfaces of ankle and subtalar joints-excised Ilium- large bony bridge across the ankle and subtalar joints post op: ankle- plaster cast- A/K- foot at right angle >4 weeks- boot cast ( snugly fitting) full weight bearing delayed > 8-12 weeks cast immobilisation - until fusion walking on irregular surfaces difficult

43. ANKLE ARTHODESIS BARR & BONE Severe paralytic equinus deformity in adults Subcutaneous plantar fasciotomy - lenthening of TA – ankle arthodesis