FOOT DROP: PHYSIOTHERAPY MANAGEMENT

A CASE REPORT PRESENTATION FROM PAEDIATRICS UNIT, DEPARTMENT OF PHYSIOTHERAPY, FMC OWO,ONDO STATE. BY ELOCHUKWU P.U (BMR) PT AND ABOLARIN D (BMR)PT

INTRODUCTION Foot drop is the dropping of the forefoot due

to weakness, damage to the peroneal nerve or paralysis of the muscles in the anterior portion of the lower leg.

It is usually a symptom of a greater problem, not a disease in itself.

It is characterized by the inability or difficulty in moving the ankle and toes upward (dorsiflexion).

The severity in foot drop can range from a temporary to permanent condition, depending on the extent of muscle weakness or paralysis.

It can occur unilaterally or bilaterally.

In walking, while stepping forward, the knees are slightly bent so that the front of the foot can be lifted higher than usual to prevent the foot from dragging along the ground.

Foot drop can be caused by nerve damage alone.

However, it is also caused by muscle or spinal nerve trauma, congenital deformity, toxins or disease.

Diseases that can cause foot drop include stroke, Amyotrophic lateral sclerosis (ALS or Lou Gehrig's Disease), muscular dystrophy, Charcot Marie Tooth disease, and multiple sclerosis.

FEATURES Steppage gait : While walking, people

suffering the condition drag their toes along the ground or bend their knees to lift their foot higher than usual to avoid the dragging. This serves to raise the foot high enough to prevent the toe from dragging and prevents the slapping.

A wide outward leg swing Weakness or paralysis of the dorsiflexors Sensory loss on the lateral aspect of the leg

which extends to dorsum of the foot Pain

FOOT DROP

ANATOMY OF THE SCIATIC NERVE

COURSE OF THE SCIATIC NERVE The sciatic nerve (L4, 5, S1–3) is the largest

nerve in the body.

It is broad and flat at its origin, although peripherally it becomes rounded.

The nerve emerges from the greater sciatic foramen distal to piriformis and under cover of gluteus maximus,

It crosses the posterior surface of the ischium, crosses obturator internus, with its gemelli, quadratus femoris and descends on adductor magnus.

Where it lies deep to the hamstrings and is crossed only by the long head of biceps.

The sciatic nerve terminates by dividing into the tibial and common peroneal nerves. The level of this division is variable—usually it is at the mid-thigh, but the two nerves may be separate even at their origins from the sacral plexus.

BRANCHES The trunk of the sciatic nerve supplies the

hamstring muscles (biceps, semimembranosus, semitendinosus) and also the adductor magnus, the latter being innervated also by the obturator nerve.

All the muscle branches apart from the one to the short head of biceps arise on the medial side of the nerve; its lateral border is therefore the side of relative safety in its operative exposure.

THE TIBIAL NERVE The tibial nerve (L4, 5, S1–3) is the larger of the two terminal

branches of the sciatic nerve. It traverses the popliteal fossa superficial to the popliteal vein

and artery, which it crosses from the lateral to the medial side. BRANCHES a) In popliteal fossa: •Muscular —to gastrocnemius, soleus and popliteus; •Cutaneous — the sural nerve, which descends over the

back of the calf, behind the lateral malleolus to the 5th toe; it receives a communicating branch from the common peroneal nerve and supplies the lateral side of the leg, foot and 5th toe;

•Articular —to the knee joint. It then descends deep to soleus in company with the

posterior tibial vessels, passes on their lateral side behind the medial malleolus to end by dividing into the medial and lateral plantar nerves.

b) In the leg:

The tibial nerve supplies flexor hallucis longus, flexor digitorum longus and tibialis posterior.

Its terminal plantar branches supply the intrinsic muscles and skin of the sole of the foot, the medial plantar nerve having an equivalent distribution to that of the median nerve in the hand,

the lateral plantar nerve being comparable to the ulnar nerve.

THE COMMON PERONEAL(FIBULAR) NERVE• The common peroneal nerve (L4, 5, S1, 2) is the

smaller of the terminal branches of the sciatic nerve.

• It enters the upper part of the popliteal fossa,passes along the medial border of the biceps tendon, then curves around the neck of the fibula where it lies in the substance of peroneus longus and divides into its terminal branches, the deep peroneal and superficial peroneal nerves.

BRANCHES• While still in the popliteal fossa, the common

peroneal nerve gives off the lateral cutaneous nerve of the calf, a peroneal (sural) communicating branch and twigs to the knee joint, but has no muscular branches.

THE DEEP PERONEAL(FIBULAR) NERVE

The deep peroneal nerve pierces extensor digitorum longus, then descends, in company with the anterior tibial vessels, over the interosseous membrane and then over the ankle joint.

Medially lies tibialis anterior, while laterally lies first extensor digitorum longus, then extensor hallucis longus. Its branches are:

•Muscular — to the muscles of the anterior compartment of the leg —extensor digitorum longus, extensor hallucis longus, tibialis anterior, peroneus tertius —and extensor digitorum brevis;

•Cutaneous — to a small area of skin in the web between the 1st and 2nd toes.

THE SUPERFICIAL PERONEAL(FIBULAR) NERVE

The superficial peroneal nerve runs in the lateral compartment of the leg.

Its branches are: •Muscular — to the lateral compartment

muscles (peroneus longus and brevis);

•Cutaneous —to the skin of the distal two-thirds of the lateral aspect of the leg and to the dorsum of the foot (apart from the small area between the 1st and 2nd toes supplied by the deep peroneal nerve).

MUSCLES INVOLVED (DORSIFLEXORS) Tibialis Anterior (L4-L5)

Extensor hallucis longus (LS-S1)

Extensor digitorum longus (L5-S1)

Fibularis (peroneus) tertius(L5-S1) All mentioned above ars supplied by the

deep fibular (peroneal) nerve with the nerve roots as mentioned.

CAUSES Most of the time, foot drop is the result of

neurological disorder; only rarely is the muscle diseased or non-functional.

The source for the neurological impairment can be central (spinal cord or brain) or(peripheral nerves located connecting from the spinal cord to an end-site muscle or sensory receptor).

Foot drop may be a temporary condition, or may be permanent, depending on it's cause. There are many different causes which may include:

o Injury to the peroneal nerve (peroneal nerve palsy which could be chemical, trauma or iatrogenic etc) eg Habitual crossing of the legs when sitting - compresses the peroneal nerve.

o Injury to the ankle dorsiflexor muscles, such as Tibialis Anterior.

o Spinal canal stenosis.

o Peripheral neuropathies.

o Compartment syndromes.

o Muscular conditions such as Muscular Dystrophy. Neurodegenerative disorders such as Multiple Sclerosis.

Motor neuron disorders, e.g. Polio.

Following surgery (such as knee replacement). This may be due to a haematoma causing compression or irritation of the nerve which is temporary, or nerve damage during surgery.

o Following a stroke.

o Genetic (as in Charcot-Marie-Tooth Disease and

hereditary neuropathy with liability to pressure palsies

)

DIAGNOSIS

Initial diagnosis is made during routine physical examination. Such diagnosis can be confirmed by a medical professional such as a neurologist, physical therapist, podiatrist, orthopedic spine surgeon or neurosurgeon.

However there are other tests that may help determine diagnosis. These tests include an MRI, or EMG to assess the surrounding areas of damaged nerves and the damaged nerves themselves, respectively. This nerve innervates the anterior muscles of the leg that are used during dorsi flexion.

TREATMENT Treatment of foot drop varies depending on the

cause of the problem and how temporary or permanent the condition may be.

It also depends on the underlying cause. If the underlying cause is successfully treated, foot drop may improve or disappear but if not treated, it may be permanent.

Specific treatment for foot drop include: Braces and Splints:

A foot drop splint is often the first line of treatment. These help to hold the foot up off the ground to make walking easier. These tend to be plastic splints which are inserted into the shoe.

BRACES AND SPLINTS

FOOT DROP BOOT

FOOT DROP NIGHT SPLINT

ANKLE FOOT ORTHOSES

LEG SPLINTS

Non-Surgical Treatmentso Physical therapy: exercises that strengthen

the leg muscles and help to maintain range of motion at the ankle and the knee which help improve gait problems associated with foot drop. Stretching exercises are important to prevent the development of tendon archilles contracture.

o Nerve stimulation: stimlation of the dorsiflexors help to improve foot drop.

o Treatments for other causes of foot drop may include epidural or steroid injections and anti-inflammatory medications.

Surgical treatment Surgery may be required in a number of the

conditions listed above, usually once non-surgical treatment has failed. Surgery will vary depending on the cause of the drop foot. It may be aimed at the cause such as with spinal canal stenosis or other back problems, or may be used to fuse the ankle joint to prevent the downward drop.

CASE REPORT

Patient’s name: Ale Oluwaferanmi Ward/clinic: paediatrics unit Unit number: phy/0803 Age: 2 years Sex: M Address: 4 Ibidunni st. Eyingbe, owo. Occupation: nil Diagnosis: Foot Drop of the (rt) lower limb as

a result of post intramuscular injection.

SUBJECTIVE EVALUATION Complaint: Abnormal gait pattern of the (rt)

lower limb History: patient was apparently healthy untill

about two months ago(as at the time of clerking) when the baby received an injection from a private nurse. The baby was said to be febrile hence the resultant injection by the nurse( grand mother’s sister-in-law). The baby was noticed to have developed an abnormal gait the same day he received the injection. Mother said there was no treatment since there was strike but after the strike, she took the baby to the state hospital (General hospital owo) where nothing was done for the baby instead she was referred to Federal Medical Centre, Owo for expert management.

PAST MEDICAL HISTORY Mother had malaria during pregnancy and

baby has completed immunization.

FAMILY AND SOCIAL HISTORY Baby is the third child in a family of three

children in a monogamous setting. Mother is a trader, father is a pastor in CAC church.

OBSERVATION AND EVALUATION General observation: A 2-year old boy who

was carried into the cubicle by the mother, afebrile, acyanosed and not in any obvious respiratory distress.

SEGMENTAL EXAMINATION Head and Neck: nil abnormality detected Upper limbs: nil abnormality detected Thorax and Abdomen: nil abnormality

detected

Lower Limbs: (left) lower limb: nil abnormality detected

(Right) lower limb: Range of motion: full and painfree Muscle tone: normal Pain on palpation of the dorsiflexors Sensation intact Muscle bulk: slight atrophy Muscle bulk measurement: (rt)LL (lt)LL Difference 16.5cm 17cm

0.5cm Land mark: 10cm on a straight line joining

the Lateral Condyle of femur to the lateral malleolus craniocaudally.

MUSCLE ASSESSMENT Knee flexors – 4 Knee extensors – 4 Plantar flexors – 4 Dorsiflexors – 1+ Functional Assessment Patient can feed self Patient sit without aid Patient can walk without aid but with an

abnormal gait pattern.

IMPRESSION: Foot drop of the right lower limb as a result of post intramuscular injection.

LIST OF PROBLEMS High steppage Gait Pain on palpation of the Dorsiflexors Slight atrophy of the dorsiflexors of the right lower limb Weakness of the right lower limb dorsiflexors

TREATMENT AIM: To preserve the physiological properties of the (rt)LL

muscles. To relieve pain on palpation. To prevent further deformities.

To preserve muscle bulk To prevent tendon Archilles contracture

Short –term goals: To relieve pain on palpation in two weeks. To improve functional ability(gait) i.e reduce

steppage gait by the use of orthoses in 8 weeks.

Long –term goal: To restore full funtional ability ie restore normal

gait pattern in 6 months. To restore muscle bulk to normal( ie from

16.5cm to 17cm) in 3 months.

MEANS OF TREATMENT Electrical stimulation to the affected muscles (current

used: faradic, wavelength: triangular, duration: 15 mins). Tactile stimulation to the affected muscles with tooth

brush. Use of ankle-foot orthoses on the the affected limb to

correct gait Tendon Achilles stretching One legged stance Soft tissue mobilization with vaseline.

TREATMENT MODALITIES USED TENS-Transcutaneous Electrical Nerve Stimulation Tooth brush Ankle foot orthoses Vaseline

OUTCOME OF TREATMENT Patient was treated two times a week for four

weeks. He was reviewed after the 4th treatment

session. The pain on palpation has reduced. The steppage gait has been resolved to near

normal. No further deformity was noted. Patient is yet to be discharged.

REFERENCES Clinical anatomy Harolds Ellis, 11th ed Mayo Clinic, Foot Drop (Nov,2010) www.wikipedia.com Case file from physiotherapy department

Fmc, Owo Ondo State.

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