Foot drop: Difference between revisions
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== Clinically Relevant Anatomy == | == Clinically Relevant Anatomy == | ||
<br>Foot drop is caused by disruption to the [[Common Peroneal Nerve|common peroneal nerve]] which controls active dorsiflexion of the ankle leading to a lack of heel strike during gait hence the term foot drop. | <br>Foot drop is caused by disruption to the [[Common Peroneal Nerve|common peroneal nerve]] which controls active dorsiflexion of the [[Ankle and Foot|ankle]] leading to a lack of heel strike during gait hence the term foot drop. | ||
The common peroneal nerve is the smaller and terminal branch of the sciatic nerve which is composed of the posterior divisions of L4, 5, S1, 2. The nerve can be palpated behind the head of the [[fibula]] and as it winds around the neck of the fibula.<ref>Palastanga N & Soames R ''Anatomy and Human Movement, Structure and Function.'' 6th ed. China: Elsevier(Churchill Livingstone) Limited; 2012.</ref> | The common peroneal nerve is the smaller and terminal branch of the sciatic nerve which is composed of the posterior divisions of L4, 5, S1, 2. The nerve can be palpated behind the head of the [[fibula]] and as it winds around the neck of the fibula.<ref>Palastanga N & Soames R ''Anatomy and Human Movement, Structure and Function.'' 6th ed. China: Elsevier(Churchill Livingstone) Limited; 2012.</ref> | ||
Commonly with damage to the common peroneal nerve will be weakness to [[Tibialis Anterior|tibialis anterior]] and other key dorsiflexors of the foot. | Commonly, with damage to the common peroneal nerve, will be weakness to [[Tibialis Anterior|tibialis anterior]] and other key dorsiflexors of the foot. | ||
== Mechanism of Injury / Pathological Process == | == Mechanism of Injury / Pathological Process == | ||
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* Trauma or injury to the knee | * Trauma or injury to the knee | ||
* [[Total Knee Arthroplasty|TKA]]<ref name=":0" /> | * [[Total Knee Arthroplasty|TKA]]<ref name=":0" /> | ||
* Neurological disorders i.e. [[stroke]]<ref>Everaert DG, Stein RB, Abrams GM, Dromerick AW, Francisco GE, Hafner BJ, Huskey TN, Munin MC, Nolan KJ, Kufta CV. [https://journals.sagepub.com/doi/full/10.1177/1545968313481278 Effect of a foot-drop stimulator and ankle–foot orthosis on walking performance after stroke: a multicenter randomized controlled trial.] Neurorehabilitation and neural repair. 2013 Sep;27(7):579-91.</ref> | * [[Neurological Disorders|Neurological disorders]] i.e. [[stroke]]<ref>Everaert DG, Stein RB, Abrams GM, Dromerick AW, Francisco GE, Hafner BJ, Huskey TN, Munin MC, Nolan KJ, Kufta CV. [https://journals.sagepub.com/doi/full/10.1177/1545968313481278 Effect of a foot-drop stimulator and ankle–foot orthosis on walking performance after stroke: a multicenter randomized controlled trial.] Neurorehabilitation and neural repair. 2013 Sep;27(7):579-91.</ref> | ||
* Compression of the fibula head during surgery e.g. tourniquet<ref name=":0" /> | * Compression of the fibula head during surgery e.g. tourniquet<ref name=":0" /> | ||
* Fracture of the fibula | * Fracture of the fibula | ||
* Fracture to tibial plateau<ref name=":1" /> | * Fracture to tibial plateau<ref name=":1" /> | ||
* Use of a tight plaster cast of the lower leg | * Use of a tight plaster cast of the lower leg | ||
* [[Patellar dislocation|Patellar dislocations]] (33% chance of nerve damage)<ref>Henrichs A. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC535529/ A review of knee dislocations]. Journal of athletic training. 2004 Oct;39(4):365.</ref> | * [[Patellar dislocation|Patellar dislocations]] (33% chance of nerve damage)<ref>Henrichs A. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC535529/ A review of knee dislocations]. Journal of athletic training. 2004 Oct;39(4):365.</ref> | ||
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Typical presentation of foot drop can be noted when testing the foot and ankle in isolation, however, in a clinical setting it may be identified initially through gait assessment. | Typical presentation of foot drop can be noted when testing the foot and ankle in isolation, however, in a clinical setting it may be identified initially through gait assessment. | ||
=== Foot and ankle === | ==== Foot and ankle ==== | ||
When testing the foot and ankle a positive test for foot drop is '''NO''' active dorsiflexion in a non weight bearing position. | When testing the foot and ankle a positive test for foot drop is '''NO''' active dorsiflexion in a non weight bearing position. | ||
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See [[Foot and Ankle Examination|foot and ankle examination]] page for full assessment of the foot and ankle. | See [[Foot and Ankle Examination|foot and ankle examination]] page for full assessment of the foot and ankle. | ||
=== Gait assessment === | ==== Gait assessment ==== | ||
Gait should be assessed in any clinical setting. | Gait should be assessed in any clinical setting. | ||
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== Diagnostic Procedures == | == Diagnostic Procedures == | ||
* Subjective history: emphasis on any knee trauma, recent spinal/peripheral limb surgery or family history of neurological disease | |||
* Assessment of ankle dorsiflexion | |||
* Gait assessment | |||
* Electro-myograph (EMG) / Nerve conduction studies<ref name=":2">Masakado Y, Kawakami M, Suzuki K, Abe L, Ota T, Kimura A. [https://www.jstage.jst.go.jp/article/kjm/57/2/57_2_84/_article/-char/ja/ Clinical neurophysiology in the diagnosis of peroneal nerve palsy.] The Keio journal of medicine. 2008 Jun 25;57(2):84-9.</ref><ref>Brief J M, et al. [https://pdfs.semanticscholar.org/bae7/0e25f6e6d991a192d7cb713e96e1093b080c.pdf Peroneal Nerve Injury with Foot Drop Complicating Ankle Sprain A Series of Four Cases with Review of the Literatur]e. Bulletin of the NYU Hospital for Joint Diseases. 2009;67(4):374-7</ref><br> | |||
== Outcome Measures == | == Outcome Measures == | ||
* [[Foot and Ankle Disability Index|Foot and ankle disability index]] | * [[Foot and Ankle Disability Index|Foot and ankle disability index]] | ||
* [[Functional Gait Assessment|Functional gait analysis]] | * [[Functional Gait Assessment|Functional gait analysis]] | ||
* [https://www.researchgate.net/figure/stanmore-assessment-questionnaire_tbl1_23807118 Stanmore assessment] of foot drop<ref name=":3">Lingaiah P, Jaykumar K, Sural S, Dhal A. [https://www.ncbi.nlm.nih.gov/pubmed/30235981 Functional evaluation of early tendon transfer for foot drop.] Journal of Orthopaedic Surgery. 2018 Sep 19;26(3):2309499018799766.</ref> | |||
* Hand dynamometry of the dorsiflexors in the foot using the [[Muscle Strength|Oxford scale]] | * Hand dynamometry of the dorsiflexors in the foot using the [[Muscle Strength|Oxford scale]] | ||
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This has been shown to resolve in two thirds of patients by one year post injury. <ref name=":0">Park JH, Restrepo C, Norton R, Mandel S, Sharkey PF, Parvizi J. [https://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1067&context=orthofp Common peroneal nerve palsy following total knee arthroplasty: prognostic factors and course of recovery.] The Journal of arthroplasty. 2013 Oct 1;28(9):1538-42</ref> | This has been shown to resolve in two thirds of patients by one year post injury. <ref name=":0">Park JH, Restrepo C, Norton R, Mandel S, Sharkey PF, Parvizi J. [https://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1067&context=orthofp Common peroneal nerve palsy following total knee arthroplasty: prognostic factors and course of recovery.] The Journal of arthroplasty. 2013 Oct 1;28(9):1538-42</ref> | ||
==== Splinting ==== | |||
One way to improve function while the foot drop resolves is the use of splinting. | |||
A solid ankle-foot orthoses (AFO) or foot-up splint can be used to keep the foot in plantar-grade. | |||
These work to increase the amount of dorsiflexion the foot is held in during gait and can prevent falls as the toes do not get caught on the floor. | |||
[[File:AFO-Swedish-Leaf-Side-Shoe.jpg|none|thumb|Ankle-Foot orthoses used for foot drop]] | [[File:AFO-Swedish-Leaf-Side-Shoe.jpg|none|thumb|Ankle-Foot orthoses used for foot drop]] | ||
==== Exercise ==== | |||
Physiotherapy interventions normally are focused on graded exercises to encourage active dorsiflexion and muscle recruitment. These exercises have been shown to prevent atrophy and speed up recovery but more research is needed.<ref name=":0" /> | |||
In neurologically impaired patients such as [[Charcot-Marie-Tooth Disease: A Case Study|Charcot‐Marie‐Tooth disease]] improved with strengthening exercises to tibialis anterior, however, other neurological diseases like muscular dystrophy strength training was not found to be effective at reducing the foot drop. <ref>Sackley C, Disler PB, Turner‐Stokes L, Wade DT, Brittle N, Hoppitt T. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003908.pub3/abstract Rehabilitation interventions for foot drop in neuromuscular disease.] Cochrane Database of Systematic Reviews. 2009(3).</ref> | |||
Preventing contractures and stiffness is also an important maintenance goal of physiotherapy as this is likely in neurological disease patients more than following trauma to the knee. | |||
Electro-stimulation of the effected muscle groups has also been shown to improve recovery times.<ref name=":0" /> | Electro-stimulation of the effected muscle groups has also been shown to improve recovery times.<ref name=":0" /> | ||
In extreme cases [[Tibialis Posterior|tibialis posterior]] can be transposed to regain active dorsiflexion | ==== Surgery ==== | ||
Direct repair of the common peroneal nerve is possible for surgical intervention however, this has been shown to have poor outcomes with residual foot drop leading to further surgery.<ref name=":4">Özkan T, Tuncer S, Ozturk K, Aydin A, Ozkan S. [https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0028-1103502 Tibialis posterior tendon transfer for persistent drop foot after peroneal nerve repair.] Journal of reconstructive microsurgery. 2009 Apr;25(03):157-64.</ref> | |||
In extreme cases [[Tibialis Posterior|tibialis posterior]] can be transposed to regain active dorsiflexion by using the tendon not innervated by the common peroneal nerve, this surgery has been shown to be more successful than nerve repair.<ref name=":1">Baima J, Krivickas L. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684217/ Evaluation and treatment of peroneal neuropathy.] Current reviews in musculoskeletal medicine. 2008 Jun 1;1(2):147-53.</ref><ref name=":4" /><ref name=":3" /> | |||
Surgery has been shown to be successful at improving active dorsiflexion strength and reduced use of AFOs.<ref>Hove LM, Nilsen PT. [https://www.tandfonline.com/doi/abs/10.3109/17453679808999265 Posterior tibial tendon transfer for drop-foot: 20 cases followed for 1–5 years.] Acta Orthopaedica Scandinavica. 1998 Jan 1;69(6):608-10.</ref> | |||
== Differential Diagnosis == | == Differential Diagnosis == | ||
* L5 [[radiculopathy]]<ref name=":2" /> | |||
* Upper motor neuron lesion | |||
* <br> | |||
== Resources == | == Resources == | ||
[https://www.researchgate.net/figure/stanmore-assessment-questionnaire_tbl1_23807118 Stanmore assessment] | |||
== References == | == References == | ||
<references /> | <references /> | ||
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Clinically Relevant Anatomy[edit | edit source]
Foot drop is caused by disruption to the common peroneal nerve which controls active dorsiflexion of the ankle leading to a lack of heel strike during gait hence the term foot drop.
The common peroneal nerve is the smaller and terminal branch of the sciatic nerve which is composed of the posterior divisions of L4, 5, S1, 2. The nerve can be palpated behind the head of the fibula and as it winds around the neck of the fibula.[1]
Commonly, with damage to the common peroneal nerve, will be weakness to tibialis anterior and other key dorsiflexors of the foot.
Mechanism of Injury / Pathological Process[edit | edit source]
The common peroneal nerve is in a particularly vulnerable position as it winds around the neck of the fibula. It may be damaged at this site by:
- Trauma or injury to the knee
- TKA[2]
- Neurological disorders i.e. stroke[3]
- Compression of the fibula head during surgery e.g. tourniquet[2]
- Fracture of the fibula
- Fracture to tibial plateau[4]
- Use of a tight plaster cast of the lower leg
- Patellar dislocations (33% chance of nerve damage)[5]
Clinical Presentation[edit | edit source]
Typical presentation of foot drop can be noted when testing the foot and ankle in isolation, however, in a clinical setting it may be identified initially through gait assessment.
Foot and ankle[edit | edit source]
When testing the foot and ankle a positive test for foot drop is NO active dorsiflexion in a non weight bearing position.
It is important to test passive ROM to ensure the ankle is not stiff.
See foot and ankle examination page for full assessment of the foot and ankle.
Gait assessment[edit | edit source]
Gait should be assessed in any clinical setting.
Foot drop gait can manifest in different ways varying from patient to patient.
Some patients may increase the amount of hip flexion they produce on the effected side therefore, clearing the floor more effectively:
Other patients may circumduct the hip and drag the forefoot along the floor:
Diagnostic Procedures[edit | edit source]
- Subjective history: emphasis on any knee trauma, recent spinal/peripheral limb surgery or family history of neurological disease
- Assessment of ankle dorsiflexion
- Gait assessment
- Electro-myograph (EMG) / Nerve conduction studies[8][9]
Outcome Measures[edit | edit source]
- Foot and ankle disability index
- Functional gait analysis
- Stanmore assessment of foot drop[10]
- Hand dynamometry of the dorsiflexors in the foot using the Oxford scale
Management / Interventions[edit | edit source]
Following palsy of the common peroneal nerve the main residual symptom can be foot drop due to the disruption to L4/5 muscle groups which perform dorsiflexion.
This has been shown to resolve in two thirds of patients by one year post injury. [2]
Splinting[edit | edit source]
One way to improve function while the foot drop resolves is the use of splinting.
A solid ankle-foot orthoses (AFO) or foot-up splint can be used to keep the foot in plantar-grade.
These work to increase the amount of dorsiflexion the foot is held in during gait and can prevent falls as the toes do not get caught on the floor.
Exercise[edit | edit source]
Physiotherapy interventions normally are focused on graded exercises to encourage active dorsiflexion and muscle recruitment. These exercises have been shown to prevent atrophy and speed up recovery but more research is needed.[2]
In neurologically impaired patients such as Charcot‐Marie‐Tooth disease improved with strengthening exercises to tibialis anterior, however, other neurological diseases like muscular dystrophy strength training was not found to be effective at reducing the foot drop. [11]
Preventing contractures and stiffness is also an important maintenance goal of physiotherapy as this is likely in neurological disease patients more than following trauma to the knee.
Electro-stimulation of the effected muscle groups has also been shown to improve recovery times.[2]
Surgery[edit | edit source]
Direct repair of the common peroneal nerve is possible for surgical intervention however, this has been shown to have poor outcomes with residual foot drop leading to further surgery.[12]
In extreme cases tibialis posterior can be transposed to regain active dorsiflexion by using the tendon not innervated by the common peroneal nerve, this surgery has been shown to be more successful than nerve repair.[4][12][10]
Surgery has been shown to be successful at improving active dorsiflexion strength and reduced use of AFOs.[13]
Differential Diagnosis[edit | edit source]
- L5 radiculopathy[8]
- Upper motor neuron lesion
Resources[edit | edit source]
References[edit | edit source]
- ↑ Palastanga N & Soames R Anatomy and Human Movement, Structure and Function. 6th ed. China: Elsevier(Churchill Livingstone) Limited; 2012.
- ↑ 2.0 2.1 2.2 2.3 2.4 Park JH, Restrepo C, Norton R, Mandel S, Sharkey PF, Parvizi J. Common peroneal nerve palsy following total knee arthroplasty: prognostic factors and course of recovery. The Journal of arthroplasty. 2013 Oct 1;28(9):1538-42
- ↑ Everaert DG, Stein RB, Abrams GM, Dromerick AW, Francisco GE, Hafner BJ, Huskey TN, Munin MC, Nolan KJ, Kufta CV. Effect of a foot-drop stimulator and ankle–foot orthosis on walking performance after stroke: a multicenter randomized controlled trial. Neurorehabilitation and neural repair. 2013 Sep;27(7):579-91.
- ↑ 4.0 4.1 Baima J, Krivickas L. Evaluation and treatment of peroneal neuropathy. Current reviews in musculoskeletal medicine. 2008 Jun 1;1(2):147-53.
- ↑ Henrichs A. A review of knee dislocations. Journal of athletic training. 2004 Oct;39(4):365.
- ↑ Steppage Gait. Judy Mishriki Available from: https://www.youtube.com/watch?v=TijuPg8_JhY [last accessed 02/09/2013]
- ↑ Alaine Wambe MD. Right slap gait/steppage gait/foot drop in a post operative patient. Available from: https://www.youtube.com/watch?v=EjPUpKUbZSg [last accessed 11/03/2019]
- ↑ 8.0 8.1 Masakado Y, Kawakami M, Suzuki K, Abe L, Ota T, Kimura A. Clinical neurophysiology in the diagnosis of peroneal nerve palsy. The Keio journal of medicine. 2008 Jun 25;57(2):84-9.
- ↑ Brief J M, et al. Peroneal Nerve Injury with Foot Drop Complicating Ankle Sprain A Series of Four Cases with Review of the Literature. Bulletin of the NYU Hospital for Joint Diseases. 2009;67(4):374-7
- ↑ 10.0 10.1 Lingaiah P, Jaykumar K, Sural S, Dhal A. Functional evaluation of early tendon transfer for foot drop. Journal of Orthopaedic Surgery. 2018 Sep 19;26(3):2309499018799766.
- ↑ Sackley C, Disler PB, Turner‐Stokes L, Wade DT, Brittle N, Hoppitt T. Rehabilitation interventions for foot drop in neuromuscular disease. Cochrane Database of Systematic Reviews. 2009(3).
- ↑ 12.0 12.1 Özkan T, Tuncer S, Ozturk K, Aydin A, Ozkan S. Tibialis posterior tendon transfer for persistent drop foot after peroneal nerve repair. Journal of reconstructive microsurgery. 2009 Apr;25(03):157-64.
- ↑ Hove LM, Nilsen PT. Posterior tibial tendon transfer for drop-foot: 20 cases followed for 1–5 years. Acta Orthopaedica Scandinavica. 1998 Jan 1;69(6):608-10.
