This document provides an overview of foot drop, including its anatomy, causes, symptoms, diagnosis, and treatment. Some key points: - Foot drop is caused by paralysis of the muscles in the anterior and lateral compartments of the leg, resulting in inability to dorsiflex the foot. - It can be caused by injury or entrapment of the common peroneal nerve, conditions that weaken muscles like polio or muscular dystrophy, or neurological issues such as stroke. - Symptoms include difficulty lifting the foot and an equinus deformity. Treatment depends on the underlying cause but may include physical therapy, nerve stimulation, nerve grafting, or tendon transfers to restore function.

1. COURSE OF COMMON PERONEAL NERVE
FOOT DROP
AND
it's management
Dr. Manas Kanti Sarkar.
2nd yr. PGT
BMCH

2. ANATOMY OF
COMMON
PERRONEAL NERVE
LUMBO SACRAL PLEXUS [VENTRAL RAMI OF
(L1 –S3) IN LOWER LIMB.]
SCIATIC NERVE(WIDEST 2 cm in diameter )
1)TIBIAL –VENTRAL BRANCH (L4-S3)
2)COMMON PERONEAL-DORSAL BR.(L4-
S2)
SUPERFICIAL DEEP
BOTH HAVETERMINATING MEDIAL LATERAL
DIVISIN

3. COURSE
Smaller terminal br. Of sciatic nerve conveys fibres from dorsal branch of ventral rami.
IN POPLITTEAL FOSSA
Nv. enter the fossa beneath long head of biceps femoris and slopes down laterally along
the medial margin of biceps tendon.
At the lateral angle of the popliteal fossa it crosses superficial to plantaris, lat. Head of
gastrocnemius and on reaching the back it rests on the fleshy sheet of soleus(where it can
be rolled against bone)
Finally nerve curves forward on the lateral side of neck of fibula deep to peroneus longus
tendon divided into 2 terminal branches- i) superficial & ii)deep.
BRANCHES- A) CUTANEOS- *LATERAL CUTANEOU S NERVE OF CALF.
*SURAL COMMUNICATING.
B)ARTICULAR- 3 branches
*SUPERIOR LATERAL GENICULAR
*INFERIOR LATERAL GENICULAR
* RECURRENT GENICULAR.

4. *** SUPERFICIAL PERONEAL NERVE***
• ARISE FROM-
Superficial division of common peroneal nerve on the lat.
Side of neck of fibula.
 COURSE-
Initially deep to peroneus longus & passes downward
between peroneus longus and brevis(supplies both muscles)
&pierce the deep fascia behind the ant. Inter muscular
septum at the jn. b/n upper two third and lower third and
divide into med. & lat. Br above the ankle joint & appear on
the dorsum of foot.
 BRANCHES – Muscular (peroneus longus and Brevis)
cutaneous

5. ***DEEP PERONEAL NERVE***
• COURSE-
After winding round the neck of fibula pierces the ant inter
muscular septum appear in the ant extensor compartment
Deep to EDL & superficial to IOM.
$In prox. third –intervenes TA
EDL.
$In middle third TA
. EHL
$In distal third EHL& EDL

6. BRANCHES OF DEEP PERONEAL
NERVE:
MUSCULAR: All four muscles of ant crural
compartment-
1. TIBIALISANT.
2. EHL
3. EDL
4. PERONEUSTERTIUS.
ARTICULR: ANKLE JOINT

7. NERVE SUPPLY OF DORSUM OF FOOT

8. FOOT DROP-
 PARALYSIS OF MUSCLES OF EXTENSOR AND PERONEAL COMPARTMENT CAUSES
PLANTIFLEXION AND INVERSION OF FOOT ALONG WITH CERTAIN DEGREE OF
FLATTENING OF LONGITUDINAL ARCH, WHICH IS NORMALLY MAINTAINED SOME
EXTENT BYTIBIALIS ANTERIOR AND PERONEUS LONGUS.
 FOOT BEING ELEVATED TO ALLOW THE DROPPED TOESTO CLEAR THE GROUND,SO
THE PATIENTWALKS IN A HIGH STEPPING GAIT.

9. Causes
Injury to the peroneal nerve
1. Fracture head ,neck of fibula.
2. prolonged external pressure as application of tight plaster cast.
3. severe varus injuries of knee.( injury of postero lateral corner of knee)
4. surgical procedure like – HTO.
KNEE PROSTHESIS.
5. knee dislocation.
6.weight loss.
7. sports specific nerve entrapment in runners.
 SCIATIC NERVE INJURY CAUSING COMMON PERONEAL NERVE PALSY
1. fracture dislocation of hip.
2.penetrating injury in the proximal buttock.
3.shaft femur fracture.
4.Hip exposure.

10. Neurological conditions that can contribute to foot drop include:
• stroke
• multiple sclerosis (MS)
• cerebral palsy
• Charcot-Marie-Tooth disease
Conditions that cause the muscles to progressively weaken or
deteriorate may cause foot drop:
• muscular dystrophy
• amyotrophic lateral sclerosis (Lou Gehrig’s disease)
• polio

11. Rupture of AnteriorTibialis
Compartment Syndrome
Diabetes
Alcohol Abuse

12. Vulnerability of Peroneal Nerve
• Anatomy around the neck of fibula implicated as the main
reason for susceptibility nerve injury – fibular tunnel formed by
peroneus longus blending with crural fascia anteriorly &
posteriorly with fibular neck and soleus muscle. Dynamic
contraction of these muscles causes repeatative stretching of
nv.
• 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

13. MUSCLES in MAINTAING
NEUTRAL POSITION OF FOOT.
• DORSIFLEXORS
TIBIALISANTERIOR
EXTENSOR HALLUCIS LONGUS
EXTENSOR DIGITORUM LONGUS
PERONEUSTERTIUS
• EVERTORS
PERONEUS LONGUS
PERONEUS BREVIS

14. SYMPTOMS
• Difficulty in lifting the foot.
• Pain, weakness numbness along the distribution of nerve.

15. SIGN
• INS- EQUINOUS DEFORMITY , CLAWING OFTOES ,
WASTING OF MUSCLES.
• MOTOR- INABILITYTO DORSIFLEXTHE FOOT AND
TOES
• SENSORY LOSS- LATERAL ASPECT OF LEG AND
DORSUM OF FOOT.

18. FOOT DROP
• Drop 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 footTC:Terminal contact is quite different -
inability to support their body weight – walker can be
used

21. IMAGING
• X-Ray :
Post-Traumatic - tibia/fibula and ankle - any bony injury.
Anatomic dysfunction (eg. Charcot joint)
• High resolution Ultrasonography :
Helpful in diagnosing masses around peroneal nerve
Additional advantage of allowing for dynmic
examination with muscle contraction, joint motion
and palpation of tender area.
• Magnetic Resonance: to detect Tumor or a
compressive mass lesion to the peroneal nerve.

22. Electromyogram
• 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.

23. TREATMENT
• Depends on the underlying cause.
• If cause is successfully treated foot drop may improve or
even disappear.
• Medical treatment - Painful Paresthesia
• Sympathetic block
• Amitriptyline
• Nortriptyline
• Pregabalin

24. PhysicalTherapy
• Exercises that strengthen the leg muscles
• Maintain the range of motion in knee and ankle
• Improve gait problems associated with foot drop.

25. Nerve Stimulation
Stimulating the nerve (peroneal nerve) improves foot drop
especially if it caused by a stroke.

26. SURGICAL REPAIR
• When nerve insult is the cause - restore the nerve continuity
– by Autogenous interfascicular nerve grafting is the
preferred technique for bridging the gap.
MINIMUM GAP CAN BE SUTURED- SCIATIC NERVE 15CM & CPN 12CM.
INDICATION-
If failing to show any clinical and electrophysiological
evidence of recovery 3 months or more after the injury:
CRITICAL LIMIT OF DELAY-SCIATIC NOT >(12-15)&CPN NOT>12
MONTHS.
In the mean time patient is put on a foot drop splint or srung caliper to improve
the gait.
AFTER CARE- Hip spica 6 wks (suture removal after 10 days)
Hinged knee brace 6wks
physiotherapy and exercises.

27. • WHEN THE NERVE DOES NOT RECOVERAND
FUNCTION IS SUFFICICINTLY IMPAIRED
1.BARR procedure(1947);
Tendon tibialis posterior is freed from its insertion and
transferred through IOM and insertion of tendon on medial
cuneiform on the dorsum of foot.
it is necessary to stabilize the hind foot by triple
arthrodesis.
advantage
Provide active dorsiflexion of ankle joint and improve gait.

28. 2.SRINIVASAN et al (1968)
Distal end ofTibialis posterior tendon is splitted into 2
halves one half inserting to EHL other half to EDL &
peroneus brevis with ankle held in ankle held in 10 degree of
dorsiflexion knee in 30 degree flexion .
they also recommend TENDO ACHILLIS lengthening by Z
plasty.
Walking commenced at 6 weeks. After cast removal.

29. • Neurotendinous transposition
• Lateral head of gastrocnemius 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
gartrocnemius.

30. N.B.-
• AFTERTENDONTRANSFER Cast and Non-
Weight Bearing ambulation for 6 weeks
• PHYSIOTHERAPY
To correct gait abnormalities
• CHRONICAND CONTRACTURECASES
Achilles tendon lengthening
• In patients whom foot drop is due to neurologic and anatomic factors
(polio,Charcot joint ) - Arthrodesis
• Subtalar Stabilizing procedure orTriple Arthrodesis can be done.

31. COMPLICATIONS
• Surgical procedure- wound infection may occur.
• Nerve graft failure
• In tendon transfer procedures- recurrent deformity
• In arthrodesis or fusion procedures- pseudoarthrosis,
delayed union, or nonunion.

32. Thank you