FOOT DROP
Presenter- Dr. Gyanendra Verma
PG Resident
Dr. Baba Saheb Ambedkar Medical College and
Hospital
INTRODUCTION
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ETIOLOGY AND
ETIOPATHOGENESIS
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CLINICAL FEATURES
5
MANAGEMENT
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Foot drop is a symptom
that arises from various
pathological conditions;
these can be located at
any point along the
neuromuscular pathway,
beginning from the
cortical pyramidal tract
neurons of the cerebral
cortex and ending in the
foot lifting musculature.
ANATOMY
• Sciatic nerve arises from the root of L4 L5 S1 S2 and sometimes even S3 of the
Lumbo- Sacral plexus
• It divides into tibial nerve and common peroneal nerve in the distal thigh
• Tibial nerve(L4-S3) descends as sciatic nerve in posterior thigh deep to the hamstring
and superficial to the adductor magnus muscle. It has no sensory branch in thigh but
supplies to
Long Head of Biceps Femoris
Semi T
Semi M in the posterior thigh and the descends down to supply the muscles of the
posterior compartment of the leg.
And gives off the sensory supply to the sole of foot as medial and lateral branches.
• Common Peroneal Nerve(L4-S2) descends as sciatic nerve in posterior thigh and only
gives of the motor supply to the short head of biceps femoris.
It further descends down around fibular neck and divides into two- Superficial PN and
Deep PN
• Deep PN supplies the anterior compartment and the superficial PN supplies the lateral
compartment of leg
• The divisions of the CPN gives sensory supply as well, the Deep PN supplies the first
web space on the dorsum of foot and rest of the dorsum of foot is supplied by the
Superficial PN.
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CAUSES
• Traumatic- Direct penetrating injuries
• Fractures and Dislocations
Posterior Hip Dislocation
Fracture Lateral condyle tibia
Fracture Fibular Head
Knee Dislocation
• Iatrogenic
Deep Intramuscular Injections
high tibial skeletal traction
tight plaster around knee
high tibial osteotomy
total knee replacement
• PIVD
• Spina bifida
• Cerebral tumors or any other space
occupying lesions
• Infections such as leprosy, polio, beri-
beri, alcoholic neuritis
• Mtabolic causes- Diabetes
• Toxins- Lead Mercury Arsenic
VULNERABILITY OF PERONEAL NERVE
• Funiculi of the peroneal nerve- larger and less connective tissue
• Fewer autonomic fibers, so in any injury, motor and sensory fibers bear
the burn of the trauma.
• More superficial course, especially at the fibular neck
• Adheres closely to the periosteum of the proximal fibula.
PRESENTATION
• Most commonly occurs due to the injury to the common peroneal nerve.
• Paralysis of the anterior muscles give rise to foot drop.
• Characteristic high stepping gait is found in patients with foot drop.
• Ball of the foot instead of heel hits the ground first.
• Inversion of foot leads to overloading on outer part.
• Cutaneous sensation on the lateral aspect of lower leg, ankle and dorsum is
impaired.
• Inability to dorsiflex and evert the foot and to extend the toes.
• Inversion and Plantar flexion are normal.
• Muscle wasting
• Difficulty in lifting the foot.
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TYPES
1. HIGH TYPE
Above the level of fibular
head, deep peroneal nerve
is involved
2. LOW TYPE
Below the level of fibular
head, Superficial peroneal
nerve is involved.
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CLINICAL FEATURES IN HIGH CLINICAL FEATURES IN LOW
TYPE TYPE
• Complete foot drop • Incomplete foot drop.
• Unable to dorsiflex or invert • Unable to evert the foot
the foot • Able to dorsiflex and invert the
• Eversion is possible foot
• Wasting of anterior group of • Wasting of outer half of the leg
muscles • Sensory loss over the outer leg
• Loss of sensation over the first and foot.
web space.
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DIAGNOSIS
XRAYS- Post traumatic to rule out any bony injury
Anatomic dysfunction eg Charcots
USG- If bleeding is suspected in a patient with hip or knee prosthesis
Magnetic Resonance Neurography- Tumor or any compressive mass
to the peroneal nerve
Electromyelogram
To 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.
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MANAGEMENT
• Depending upon the underlying cause it may either be conservative or
surgical.
• Medical management for pain includes- amitriptyline, nortriptyline, pregabalin,
Gabapentin etc.
• Assistive and adaptive devices and equipment-
Canes, crutches, walkers may be used to prevent falling, normalising gait
patterns, or unload a painful weight bearing limb
• Electrical Stimulations-
TENS- Transcutaneous electrical Nerve Stimulation for the reduction or
obliteration of pain.
• Correct positioning of the limb.
• Orthoses and Splints.
• Exercises and Physiotherapy- Strengthen the muscles help to maintain ROM
and improved gait
• FUNCTIONAL ELECTRICAL STIMULATION
It was first proposed as a treatment for foot drop in 1961.
it is programmed for each individual separately.
It provides normal range of motion to the foot and ankle during walking.
Stroke and MS patients with foot drop have had success with it.
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SURGICAL MANAGEMENT
• Its done when conservative management has
failed.
• Certain points to consider before planning a
surgical intervention.
1. Age
2. Mobility of the joints
3. Availability of muscles and tendons for transfer
4. Soft tissue and muscle contracture
5. Bony changes.
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TENDON TRANSFERS
• Objective is
-to provide active motor power to the paralysed group of muscles
-to eliminate deforming forces
-to improve the stability
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BARR’S TECHNIQUE
• Transfer of tib post to anterior.
• Classically the transfer was done on 2/3 of cuneiform and
2/3 of metatarsal. But can be modified and attached to the
cuboid.
• Tendon passes through the interossei membrane.
• Below knee cast to be given for 6 weeks and the rehab
is done
• Double bar foot brace with an outside T starp is given.
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OBER’S TECHNIQUE
• Tendon is transferred on the 2nd
metatarsal.
• Tendon is passed through the
anterior compartment of the leg.
• In HATTS modification, tendon is
attached to the medial cuneiform.
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KAUFER’S PROCEDURE
It is the split transfer of the tib
post tendon.
One half is freed distally and,
flexor tendons of toes and
neurovascular bundle is retracted
posteriorly.
Freed tendon is passed from
medial to lateral behind the tibia
and sutured to peroneus brevis
tendon near its insertion.
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BONY PROCEDURES
LAMBRINUDI ARTHRODESIS
Indicated in fixed eqinus deformity.
Age more than 10 years.
Contraindicated in flail foot, hip and
knee instability requiring brace.
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TRIPPLE ARTHRODESIS
• Most effective ; age more than
12 years.
• Subtalar, talo-navicular and
calcaneo-cuboid joints are
fused.
• Indicated in weakness and
deformity of subatalr and mid
tarsal joints.
• Provides stable and static
alignment
• Removes deforming forces
• Eliminates pain
• Obtains near normal correction
of foot.
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Thank You
