FOOT DROP

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

ANATOMY SCIATIC NERVE BIFURCATES INTO

TIBIAL AND PERONEAL NERVE

PERONEAL NERVE CROSSES LATERALLY OVER FIBULAR NECK

DIVIDES INTO SUPERFICIAL AND DEEP BRANCHES

SUPERFICIAL BRANCH TRAVELS BETWEEN TWO HEADS OF PERONEI AND SUPPLIES LATERAL COMPARTMENT

DEEP BRANCH SUPPLIES ANTERIOR COMPARTMENT

MUSCLESDORSIFLEXORS TIBIALIS ANTERIOR EXTENSOR HALLUCIS LONGUS EXTENSOR DIGITORUM LONGUS PERONEUS TERTIUS

EVERTORS PERONEUS LONGUS PERONEUS BREVIS

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

CAUSESNEUROLOGICAL

NM DISEASE PERONEAL NERVE INJURY SCIATIC NERVE INJURY LUMBAR SACRAL PLEXUS INJURY

SPINAL CORD LESIONS CAUDA EQUINA SYNDROME BRAIN – STROKE, TIA GENETIC

RUPTURE OF TIBIALIS ANTERIORFRACTURE OF FIBULA COMPARTMENT SYNDROMEDIABETESALCOHOL ABUSE

SYMPTOMSDifficulty 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.

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. .

FOOT DROPDrop 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

DIAGNOSISPHYSICAL EXAMINATIONTRAUMA – no lab investigations

INVESTIGATIONS FBS ESR CRP B.UREA S CREATININE ELECTROPHORESIS.

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 prosthesisMagnetic Resonance

Neurography tumor or a compressive mass lesion to the peroneal nerve

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.

TRAETMENTDepends on the underlying cause.If cause is successfully treated foot

drop may improve or even disappear.

Medical treatment - painful paresthesia

sympathetic block amitriptyline nortriptyline pregabalinLaproscopic synovectomy

SPECIFIC TREATMENTBraces 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

Physical therapy exercises that strengthen the

leg muscles maintain the range of motion in

knee and ankle improve gait problems

associated with foot drop.

Nerve stimulation stimulating the nerve

(peroneal nerve) improves foot drop especially if it caused by a stroke.

SURGICAL REPAIRFoot 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

BRIDALS PROCEDURE

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

Tendon to tendon attachment

NeurotendinoustranspositionLateral 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

AFTER TENDON TRANSFER

CAST AND NON WEIGHT BEARING AMBULATION FOR SIX 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.

COMPLICATIONSSurgical 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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