Footdrop

foot drop

1. Foot Drop DR.ROSHAN ZAMEER 1 st YEAR ORTHO 1

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 unilateral or bilateral foot 2 Definition

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

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 4 Tibialis Anterior

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 5

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 6 Extensor Hallucis Longus

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 resistance 7 Extensor Digitorum Longus (EDL)

8. 8

9. 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 nerves which are tibial and peroneal nerve Those 2 nerves innervate different parts of the lower leg 9 Sciatic Nerve

10. Begin from L4, L5, SI, and S2 nerve roots Common peroneal nerve travels anterior, around the fibular neck Common peroneal nerve divides into superficial and deep peroneal nerve Deep peroneal nerve : innervation of tibialis anterior muscle that is responsible for dorsiflexion of the ankle 10 Peroneal Nerve

11. 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 11 Causes of Foot Drop

12. 12

13. 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 13

14. Infective: Leprosy Poliomyelitis Guillain-Barré Syndrome Syphilis Metabolic: Diabetes mellitus Beri beri Alcoholic neuritis Exogenous toxin: Lead Arsenic Mercury 14

15. Established compartment syndrome -foot drop is late finding -irreversible muscle and nerve ischemia occur in patient if fasciotomy is not performed 15

16. Inability to lift the front part of the foot Abnormal gait which drag the front of foot on the ground during walking ( stepping gait) An exaggerated, swinging hip motion Tingling, numbness & slight pain in the foot Difficulty in performing certain activities that require the use of the front of the foot Muscle atrophy in the leg Limp foot 16 Symptom of Foot Drop

17. 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 17 Clinical features of Type 1 foot drop

18. 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 18 Clinical features of type 2 foot drop

19. 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 19 Gait of Foot Drop

20. 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 20 Diagnosis

21. Conservative management: Its aim is to prevention of deformity and improvement of gait Proper positioning of foot splints Passive movements of the joints Electrical stimulation of the muscles Ankle foot orthosis : Provide toe dorsiflexion during swing phase Medial and lateral stability at ankle during stance phase Push off stimulation during the late stance phase 21 Management of foot drop

22. Traumatic conditions: Secondary to tibialis anterior and peroneal tendon injuries→→tendon repair Secondary to sciatic or common peroneal nerve injury→→manage according to the principle of treatment of peripheral nerve Infective conditions: control the infection and wait for recovery or regeneration Other conditions like PIVD(L4-L5) and spinal tumors treat the underlying cause 22

23. For surgical correction following points should be taken into consideration Mobility of joints Soft tissue and muscle contractures Availability of muscles and tendon for transfer Bony changes Age of the patient 23 Surgical correction of foot drop

24. When joints are mobile and muscles and tendons are available for transfer , tendon transfer surgeries are performed When joints are stiff with muscle and soft tissue contractures and bony changes( equinovarus deformity) bony operations can be performed 24 `

25. It is indicated when dynamic muscle imbalance results in a deformity that interferes with the ambulation or function of extremities Types of tendon transfer surgeries Anterior transfer of tibialis posterior Split transfer to tibialis posterior tendon Two tailed transfer of tibialis posterior 25 Tendon transfer operations

26. Lengthening of tendo achilles : Open lengthening of tendo calcaneus Percutaneous lengthening of tendo calcaneus Semiopen sliding tenotomy of tendo calcaneus 26

27. Lambrinudi arthrodesis : The wedge of bone is removed from the plantar distal part of the talus so that the talus remains equines at the ankle joint and while remainder of the foot is repositioned to the desired degree of plantar flexion Triple arthrodesis : It is a fusion of the subtalar , calcaneocubiod and talonavicular joints 27 Bony operations

28. 28 Triple arthrodesis : It is a fusion of the subtalar , calcaneocubiod and talonavicular joints

29. Campbells posterior bone block operation: Posterior arthrodesis permits lengthening of the tendo calcaneus and ankylosis of both the ankle and sub talar joint Ankle arthrodesis : It is recommended for severe paralytic equinovarus deformities in adults when muscles suitable for tendon transfer are not available 29

30. Campbell Gray’s anatomy 30 Reference

31. 31