Foot drop

1. FOOT DROP

2. DROPING OF FOREFOOT DUE TO WEAKNESS DAMAGE TO COMMON PERONEAL NERVE PARALYSIS 0F MUSCLES IN ANTERIOR PORTION OF LOWER LEG INABILITY TO DORSIFLEX ANKLE AND TOES UNILATERAL OR BILATERAL TEMPORARY OR PERMANENT

3. ANATOMY SCIATIC NERVE BIFURCATES INTO TIBIAL AND PERONEAL NERVE PERONEAL NERVE CROSSES LATERALLY OVER FIBULAR NECK DIVIDES INTO SUPERFICIAL AND DEEP BRANCHES

4. SUPERFICIAL BRANCH TRAVELS BETWEEN TWO HEADS OF PERONEI AND SUPPLIES LATERAL COMPARTMENT DEEP BRANCH SUPPLIES ANTERIOR COMPARTMENT

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

6. MORE VULNERABLE TO INJURY 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. CAUSES NEUROLOGICAL NM DISEASE PERONEAL NERVE INJURY SCIATIC NERVE INJURY LUMBAR SACRAL PLEXUS INJURY SPINAL CORD LESIONS CAUDA EQUINA SYNDROME BRAIN – STROKE, TIA GENETIC

8. RUPTURE OF TIBIALIS ANTERIOR FRACTURE OF FIBULA COMPARTMENT SYNDROME DIABETES ALCOHOL ABUSE

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

10. 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. .

11. 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

12. DIAGNOSIS PHYSICAL EXAMINATION TRAUMA – no lab investigations

13. INVESTIGATIONS FBS ESR CRP B.UREA S CREATININE ELECTROPHORESIS.

14. IMAGING Plain films posttraumatic - 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

15. 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 .

16. TRAETMENT 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

17. SPECIFIC TREATMENT Braces or splint-a brace on the ankle and foot or splint that fits into the shoe can help to hold the foot in the normal position

18. Physical therapy exercises that strengthen the leg muscles maintain the range of motion in knee and ankle improve gait problems associated with foot drop.

19. Nerve stimulation stimulating the nerve ( peroneal nerve) improves foot drop especially if it caused by a stroke.

20. 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.

21. If there is no significant neuronal recovery at one year - tendon transfer maybe considered. Bridal procedure Neurotendinous transpositon

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

23. Neurotendinoustransposition 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

24. AFTER TENDON TRANSFER CAST AND NON WEIGHT BEARING AMBULATION FOR SIX WEEKS PHYSIOTHERAPY TO CORRECT GAIT ABNORMALITIES CHRONIC AND CONTRACTURE CASES ACHILLES TENDON LENGTHENING

25. 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.

26. 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.

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