Foot drop

1. Name: Rahila Najihah Ali M atrix N umber : DPH/0102/11 Batch : July/11 Date: 19 th June 2013 1 Foot Drop

2. Definition 2 Inability to raise the front part of foot due to weakness or paralysis of tibialis anterior muscle that lift the foot Foot drop occur due to peroneal nerve injury Can happen to one foot or both feet

3. Muscle and Nerve 3 Dorsiflexor Muscle - Tibialis anterior -Extensor hallucis longus -Extensor digitorum longus Peroneal Nerve

4. Tibialis Anterior 4 Origin : upper two thirds of lateral surface of tibia and adjacent interosseous membarane Insertion: medial surface of medial cuneiform and the base of 1 st metatarsal bone Nerve supply : receive twigs from deep peroneal nerve and recurrent genicular nerve Action: dorsiflexion of foot at ankle joint and invertor of the foot at midtarsal and subtalar joint

5. 5 Testing the function of Tibialis Anterior : patient is asked to dorsiflex the foot against the resistance of therapist’s hand placed across the dorsum of the foot Injury to deep peroneal nerve leads to paralysis of dordiflexors

6. Extensor Hallucis Longus 6 Origin: medial part of anteromedial surface of the middle two forth of fibula and adjacent interosseos membrane Insertion: base of terminal phalanx of great toe Nerve supply: Deep peroneal nerve Action: dorsiflexion of foot at ankle and dorsiflexion of great toe Testing Functional : patient attempts to dorsiflex the great toe against resistance

7. Extensor Digitorum Longus (EDL) 7 Origin: upper three fourth of anteromedial surface of fibula, adjacent interosseous membrane and anterior intermuscular septum Insertion: EDL is divided into four tendon on the dorsum of foot Nerve supply: deep peroneal nerve Action: produce dorsiflexion of ankle joint and dorsiflexion of lateral four toes Testing functional: patient is asked to do dorsiflexion of the toes against ressistance

8. Sciatic Nerve 8 Sciatic nerve the thickest and largest nerve in the body It’s start in lower back and runs through the buttock and lower limb with root value of L4 until S3 It’s supply biceps, semitendinosus , semimembranosus and adductor magnus muscle In lower thigh, just above the back of the knee, sciatic nerve divides into two nerve which are tibial and peroneal nerve Those 2 nerve innervate different parts of the lower leg

9. Peroneal Nerve 9 Begin from L4, L5, SI, and S2 nerve roots and joint the tibial nerve to form the sciatic nerve Common peroneal nerve travels anterior, around the fibular neck Common peroneal nerve divide into superficial and deep peroneal nerve Deep peroneal nerve : innervation of tibialis anterior muscle that responsible to the dorsiflexion of the ankle

10. Causes of Foot Drop 10 L4-L5 disc herniation -the herniated disc compressing the L5 nerve root Lumbosacral Plexus injuru - due to pelvic fracture Sciatic nerve injury -hip dislocation Injury to the knee -knee dislocation

11. 11 Neurodegenerative disorder of the brain -multiple sclerosis, stroke, cerebral palsy Motor neuron disorder -polio and amyotrophic lateral sclerosis Injury to the nerve roots -spinal stenosis Peripheral nerve disorder -acquire peripheral neuropathy Damage to the peroneal nerve -muscular dystrophy

12. 12 Established compartment syndrome -foot drop is late finding -irreversible muscle and nerve ischemia occur in patient if fasciotomy is not performed

13. LEVEL OF LESION IN SCIATIS NERVE INJURY 13 High lesion (above the knee) -both tibial and common peroneal nerve are paralaysed Low lesion (below knee) -spared : peroneus longus and brevis Type 1 : anterior tibial nerve injury lost : Tibialist anterior, extensor hallucis longus , extensor digitorum longus and peroneus tertius Type 2 : musculocutaneus nerve injury spared : all above muscle innervated by anterior tibial nerve lost : peroneus longus and brevis sensation : over outer leg and foot

14. Symptom of Foot Drop 14 Inability to lift the front part of the foot Abnormal 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

15. Clinical features of Type 1 foot drop 15 High lesion : total foot drop Unable to do dorsiflexion and inversion of foot Able to do eversion Front of leg is wasted Sensation lost over dorsal web space of the leg

16. Clinical features of type 2 foot drop 16 Low lesion : incomplete of 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. Gait of Foot Drop 17 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. Diagnosis 18 Occur during routine examination where patient find it’s difficult to walk on their heel Plain X-ray Magnetic Resonance Imaging (MRI) Electromyography (EMG) and nerve conduction study SD curve Tinel sign

19. Treatment of early foot drop 19 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

20. 20 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 during footfall

21. 21 Surgery – done if conservative management fails Repairs or decompresses a damaged nerve that fuses the foot and ankle joint or transfers tendons from stronger leg muscles Choices of surgery i ) tendon transfers – for mobile foot drop ii) tendo-archilles lengthening - in fixed equinus iii) subtalar stabilizer procedur – for fixed varus iv)triple arthrodes – for fixed varus at the subtalar joint

22. Physiotherapy- Exercise 22 When problem stems from weak muscles Proper physical therapy exercises can strengthen ankle muscle and improve symptoms

23. 23 Toe curls exercise Place 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 towel Relax and repeat this exercide for 5 times

24. 24 Marble picked up exercise Place 20 marbles on the floor.  Pick up one at a time with your toes and put each marble in a bowl.

25. 25 Toe-to-heel plantar flexion Ask patient to standing at edge of table Do dorsi flexion and plantarflexion Hold for 10 second for 10 times

26. 26 Foot stretch Patient sit with the knee straight and towel around the affected foot Gently pull a towel until comfortable stretch at the calf muscle is felt Hold for 10 second and do for 10 times

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28. 28 Isometric dorsiflexion

29. 29 Toes band exercise Put the rubber band around the toes Do the abduction of the toes by against the rubber band Hold for 5 sec for 10 times

30. Electrical stimulation 30 Electrical 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

31. Reference 31 Neeta V Kulkarni , 2006, Clinical Anatomy for Students Problem Solving Approach,New Delhi, Jaypee Brothers Jules M.Rothstein , 2005, The Rehabilitation Specialist’s Handbook, 3 rd edition, Thailand, F. A. Davis Company Chris Kirtley , 2006, Clinical Gait Analysis Theory and Practice, Sydney, Churchill Livingstone Elsevier Susan B. O’Sullivant & Thomas J. Schmitz, 2007, Physical Rehabilitation, 5 th edition, Philadelphia, F. A. Davis Company S Lakshmi Narayanan, 2005, Textbook of Therapeutic Exercises, New Delhi, Jaypee Brother

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