Approach to pt with drop foot.pptx

1. Approach to pt with
drop foot

2. • Foot drop is a deceptively simple name for a potentially complex problem. It can be defined as a
significant weakness of ankle and toe dorsiflexion. The foot and ankle dorsiflexors include the
tibialis anterior, the extensor hallucis longus (EHL), and the extensor digitorum longus (EDL).
These muscles help the body clear the foot during swing phase and control plantarflexion of the
foot on heel strike.
• weakness of anterior tibialis (primarily L4 and to a lesser extent L5), often accompanied by a
weak extensor digitorum longus and extensor hallucis longus (primarily L5 with some S1
contribution), all of which are innervated by the deep peroneal nerve
• This condition may be the result of a muscular, skeletal, or nervous system problem

3. Etiology of drop foot
• A lesion of the L5 root, lumbar plexus, sciatic nerve, common peroneal, or
the deep peroneal nerve can potentially lead to foot drop due to the
weakness of the anterior compartment musculature.

6. Etiology of Drop Foot
Compressive disorders Trauma Compartment
syndrome
Iatrogenic Neurologic
disorders
most common cause of
peroneal nerve palsie, site of
compression include:
1. at the level of the fibular
head
2. At level of piriformis due
to scaring or hypertrophy
3. Lumbar degenerative at
level L4/L5 (disc, stenosis
These often occur in
association with orthopedic
injuries such
• knee dislocations
• severe ankle inversions,
fractures
• blunt trauma
• musculoskeletal injuries
with nerve traction or
direct nerve laceration
Mainly anterior
compartment
syndrome
due to
• surgical
procedures
• protracted
positioning in
anesthesia
• prolonged
bed rest
• splinting
• pneumatic
compression
devices
Cortical lesion
(UMN): parasagittal
lesions
Spinal cord injury
Charcot-Marie-Tooth
ALS
Other causes:
muscular dystrophy
lead toxicity
Stroke
Mononeuritis
multiplex
Risk factor:
1. history of significant
weight loss
2. in those who habitually
cross their legs
3. who perform squatting
exercises
the peroneal nerve is more
susceptible to injuries at
the level of the knee

7. • Check medical history for other causes of neuropathy or mononeuritis
multiplex (although these are less likely if symptoms are sudden or isolated),
such as:
 diabetes
alcohol misuse
vitamin B12 deficiency
or chemotherapy

9. Flail foot results from paralysis of dorsiflexors plus plantarflexors, e.g. in sciatic nerve
dysfunction as can occur during surgery for hip fracture-dislocation or injection injuries

11. Clinical picture
• Patients may complain of dragging their toes, problems walking or climbing stairs,
or frequent falls.
• When foot drop occurs due to peripheral nerve entrapment, the symptoms will
differ depending on the affected nerve and site of entrapment.
• Foot drop caused by entrapment of the peroneal nerve may also result in decreased
sensation, tingling, numbness, or burning from the lower lateral leg to the top of the
foot

12. • Numbness may be present along the lateral leg, dorsal foot, and/or first toe webspace. Pain may be
present but is not a common complaint in patients with foot drop due to peroneal nerve entrapment
• Patients with L5 radiculopathy or compression of the sciatic nerve may present with deficits similar
to those with peroneal neuropathy, including foot drop, as well as lateral lower limb pain, and dorsal
foot pain.
• the presence of concurrent low back pain or posterolateral thigh pain suggests the presence of
lumbar radiculopathy.
• Patients with foot drop caused by sciatic neuropathy may also complain of weakness in knee flexion
and hamstring weakness.
• Lumbosacral plexopathy may result in foot drop as well as weakness of knee flexion, internal hip
rotation, and hip abduction

14. DIAGNOSIS
• Workup of foot drop proceeds according to the suspected cause. In cases where a cause (eg,
trauma) is readily identified, no specific diagnostic laboratory studies are required. In cases
where unilateral foot drop occurs spontaneously in a previously healthy patient, further
investigation into metabolic causes (eg, diabetes, alcohol abuse, and exposure to toxins) is
required. The following tests may be helpful:
Fasting blood sugar
Hemoglobin A1c
Erythrocyte sedimentation rate (ESR)
C-reactive protein (CRP)
Serum protein electrophoresis/immunoelectro-osmophoresis
Blood urea nitrogen (BUN)
Creatinine
Vitamin B12 level

15. • If foot drop is posttraumatic, plain films of the tibia, fibula, and ankle are
appropriate to uncover any bony injury. In the absence of trauma, when
anatomic dysfunction (eg, Charcot joint) is suspected, plain films of the foot
and ankle provide useful information.
• If bleeding is suspected in a patient with a hip or knee prosthesis,
ultrasonography can be helpful.

16. • Magnetic resonance (MR) imaging of the lumbar spine, knee, or ankle may
be considered to evaluate for potential soft tissue lesions that may be
compressing a nerve

17. Electrodiagnostic studies
• EMG and nerve conduction studies (NCS) can also be helpful in localizing the lesion.
Motor nerve conduction studies of the peroneal nerve and tibial nerve and sensory nerve
conduction studies of the sural and superficial peroneal nerves are recommended.
• can help differentiate L5 radiculopathy from peroneal nerve palsy, plexus lesion or motor
neuron disease
• EMG typically examines at least two muscles innervated by the deep peroneal nerve (eg,
tibialis anterior, extensor hallucis longus) and at least one muscle innervated by the
superficial peroneal nerve (eg, peroneus longus, peroneus brevis).
• EMG is not reliable until symptoms have been present at least ≈3 weeks

18. Management
• Treatment plans are individualized based upon the evaluation and diagnostic
findings:
For nerve transection (traumatic, iatrogenic), surgical nerve reconstruction should
ideally occur within 72 hours of the injury.
For patients with a confirmed nerve compression, nerve decompression and
neurolysis should be performed. Nerve transfers, tendon transfers, and combined
procedures play an important role in cases of significant nerve dysfunction such
as in patients unresponsive to decompression, or those with irreversible damage.

19. • For other etiologies, treatment is often initially conservative due to the fact
that partial or complete resolution of symptoms may occur spontaneously
over time. Patients who do not respond adequately to conservative care or
who experience deterioration may be candidates for surgical intervention,
which usually occurs three to six months after the onset of symptoms.

20. Conservative management
• The goal of conservative management is to stabilize the gait and prevent "foot slap," as well
as to prevent contracture of the denervated muscles.
• Conservative care includes physical therapy and/or splinting, and pharmacologic
therapy to manage neuropathic pain
• Splints and braces are used in conjunction with physical therapy to optimize treatment
outcomes. Different types of footwear and splints are used, depending on the location of
the nerve injury and the extent of physical manifestation of peroneal nerve dysfunction.

21. • Pain management may include topical analgesics, as well as selective
serotonin reuptake inhibitors, antiepileptics, opioids, or µ-receptor agonists

23. Prognosis