Foot drop

1. FOOT DROP
PRESENTER : DR.JHANSI KUSUMA.
MODERATOR : Dr.NARASIMHA REDDY sir.
CHAIRPERSON: DR.SARATH sir.

2. Definition :
 Inability to actively
dorsiflex and evert the
foot due to damage to
common peroneal nerve.
 Foot drop is the condition
where the propulsion is
partially impaired due to
change in the gait.
 The foot is plantar flexed
and inverted due to
paralysis of dorsiflexers
and evertors of the foot ,
causing a high steeping
gait.

3. ANATOMY OF LEG:
Three compartments :
Posterior/ flexor compartment: ( TN)
Superficial: Gastrocnemius, Soleus, Plantaris.
Middle: Flexor Hallucis Longus, Flexor digitorum longus.
Deep: Tibialis posterior
Anterior/Extensor compartment: (DPN)
Tibialis anterior
Extensor hallucis longus
Extensor digitorum longus
Peroneus tertius
Lateral / peroneal compartment: (SPN)
Peroneus longus
Peroneus brevis

4. DORSIFLEXOR MUSCLE
-Tibialis anterior
-Extensor hallucis longus
-Extensor digitorum
longus
- Peroneus tertius

5. TIBIALIS ANTERIOR
 Origin : upper two thirds of lateral surface of
tibia and adjacent interosseous membrane.
 Insertion: medial surface of medial cuneiform
and the base of 1st metatarsal bone.
 Nerve supply : receive twigs from deep
peroneal nerve and recurrent genicular
nerve.
 Action: dorsiflexion of foot at ankle joint and
invertor of the foot at midtarsal and
Subtalarjoint.

6. EXTENSOR HALLUCIS LONGUS
 Origin: medial part of anteromedial
surface of the middle two forth of fibula
and adjacent interosseous membrane.
 Insertion: base of terminal phalanx of
great toe.
 Nerve supply: Deep peroneal nerve.
 Action: Dorsiflexion of foot at ankle and
dorsiflexion of great toe.

7. EXTENSOR DIGITORUM LONGUS
 Origin: upper three fourth of anteromedial
surface of fibula, adjacent interosseous
membrane and anterior intermuscular
septum
 Insertion: EDL is divided into four tendon on
the dorsum of foot.
 Nerve supply: deep peroneal nerve
 Action: produce dorsiflexion of ankle joint
and dorsiflexion of lateral four toes.

8. Anatomy of nerve

11. The common fibular nerve (common peroneal
nerve; external popliteal nerve; lateral popliteal
nerve is the smaller terminal branch of the sciatic
nerve. The common fibular nerve has root values of
L4, L5, S1, and S2. It arises from the superior angle
of the popliteal fossa and extends to the lateral
angle of the popliteal fossa, along the medial border
of the biceps femoris. It then winds around the
neck of the fibula to pierce the fibularis longus and
divides into terminal branches of superficial fibular
nerve and deep fibular nerve. Before its division,
the common fibular nerve gives off several branches
in the popliteal fossa.

12. Common peroneal nerve
Superficial peroneal nerve:
Nerve of lateral compartment
of leg
Motor branches :
peroneous longus
peroneous brevis
Sensory supply :
lateral aspect of lateral 1/3
rd of leg &dorsum of foot ,
2nd , 3rd,4th,interdigital clefts
Deep peroneal nerve:
Nerve of anterior
compartment of leg
Motor branches :
 -Tibialis anterior
 -Extensor hallucis longus
 -Extensor digitorum longus
 Peroneous tertius
Sensory supply :
1st interdigital clefts

14. Before dividing into terminal branches :
CPN branches -
Cutaneous branches:
Lateral sural cutaneous nerve: (lateral cutaneous
nerve of calf) - supplies the skin of the upper two-
thirds of the lateral side of leg.
sural communicating nerve - it runs on the
posterolateral aspect of the calf and joins
the sural nerve.
Articular branches:
Superior lateral genicular nerve
Inferior lateral genicular nerve
Recurrent genicular nerve
Motor branches:
There is only one motor branch that arises directly
from common fibular nerve, the nerve to the
short head of the biceps femoris muscle.

15. • Fasiculi of the peroneal nerve -
larger and have 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
• Adheres closely to the
periosteum of the proximal
fibula
VULNERABILITY OF PERONEAL NERVE

17. I. Traumatic:
• Tendon injuries to dorsiflexors of foot
• Neurogenic
4
Causes of Foot Drop
•A) Above the level of common peroneal nerve
At the thigh : Fracture of shaft of femur.
Penetrating injuries.
At the hip: Posterior dislocation of hip.
Fracture around the hip.
Acetabular fractures.
At gluteal region : Deep IM injection.
At the spine : IVDP
Spina bifida
Tumors.
CNS : Cerebral tumors and space occupying lesion.

18. B ) At or below the level of common peroneal nerve
 Direct injuries: incised and penetrating injuries
 Fracture & dislocations around
knee
 Fracture of lateral condyle of tibia
Fracture/ dislocation of head/neck of fibula ,
compound fracture of upper 1/3rd of tibia
 Iatrogenic :
•High tibial skeletal
traction
• Tight plaster around knee
• High tibial osteotomy
•Total knee replacement
 Others:
Lateral meniscal cyst
Exostosis
Tumor of head of fibula
Lateral meniscal tumour.

19. III. METABOLIC:
• Diabetes mellitus
• Beri beri
• Alcoholic neuritis
IV. EXOGENOUS TOXIN:
• Lead
• Arsenic
• Mercury
6
II. INFECTIVE:
• leprosy
• Poliomyelitis
• Guillain-Barré Syndrome
• Syphilis

21. SYMPTOMS
1. Weakness in dorsiflexion and eversion of
foot.
2. High stepping gait
3. Sensory loss :
Loss of sensation in the areas supplied by
peroneal nerve.
In the stance phase of foot drop patient, the
outer part of fore foot comes in contact with
ground first instead of heal.
This results in accumulation of stress in the
lateral part of fore foot and Causes ulceration.

22. High stepping gait due to paralysis of anterior muscles.
Foot slap followed by heel strike
Toe drag during swing phase
Increased hip and knee flexion
18
GAIT OF FOOT DROP

23. 1.SIGNS OF SENSORY DENERVATION:
Cutaneous sensation is impaired over the lateral aspect
of the lower leg and ankle and dorsum of the foot.
2.Sign of motor denervation :
• paralysis/weakness:
Reduced dorsiflexion and eversion of the foot
and toe extension. The patients will
compensate by having a steppage gait.
• Loss of tone
• Areflexia
• Insensibility to compression
• Atrophy/wasting of muscles involved.
• Inversion and plantar flexion are
normal.
SIGNS:

24.  Sign of Autonomic denervation :
 Loss of sweating
 Vasomotor paralysis: Early- warm/ pink
Late - cold /cyanotic
 Loss of cutaneous ridges and folds.
 Atrophy of subcutaneous tissues.
 Trophic ulceration
 Loss of hair.

25. TYPES OF FOOT DROP
• Type I – High
Above the level of
fibular head deep peroneal
nerve
• TYPE II- LOW
Below the level of fibular
head superficial peroneal
nerve

26. • High lesion : total /complete foot drop.
• Unable to dorsiflex and invert foot.
• Able to do eversion.
• Wasting of ant group of muscles.
• Loss of sensation over the 1st webspace.
16
• Type I – High
Above the level of fibular head - deep
peroneal nerve
Clinical features of type 1 foot drop

27. • Low lesion : incomplete foot drop.
• Unable to do eversion.
• Able to do dorsiflexion and inversion of the foot.
• Wasting of outer half of leg.
• Sensation lost over outer leg and foot.
17
Clinical features of type 2 foot drop
• TYPE II- LOW
Below the level of fibular head - superficial peroneal
nerve

28. DIAGNOSIS:
 Plain X-ray : Post-Traumatic - tibial/fibula injury and ankle
injury…..
 MYELOGRAM
 CT SCAN
 Magnetic Resonance Imaging (MRI): compressive mass lesion to
the peroneal nerve, Spine tumors, IVDP, spina bifida
 ELECTRODIAGNOSIS : Electromyography (EMG) and nerve
conduction study (NCV/NCS )
 SD curve (strength duration curves)
 Tinel sign
 Autonomic tests
 Special Investigations

29. TINELS SIGN :
ASSESSMENT OF RECOVERY:
Gentle percussion, from distal to proximal, by a finger
or percussion
hammer along the course of a injured nerve. A transient
tingling sensation should be felt by the patient on the
distribution of the injured nerve rather than at the area
percussed, and the sensation should persist for several
seconds after stimulation. A positive Tinel's sign is
presumptive evidence that regenerating axonal sprouts
that have not obtained complete myelinization are
progressing along the endoneronal tube.

30. Special investigation:
Leprosy : Bacteriological
examination, foot pad culture,
histamine test, biopsy,
immunological test.
Diabetes mellitus - Blood sugar
level.
Syphilis - Serological test.

31. MANAGEMENT OF FOOT DROP

32. TREATMENT :
• Conservative treatment : shows high incidence of
recovery
• Splintage – splint knee in 20° of flexion and ankle in
90° for night time
• In day time, walking is allowed by using ‘foot- drop
appliance’
• Varieties of foot drop appliances:
i) dynamic-spring shoe
ii) static- back stop shoe
26

33. • Ankle foot orthotics (AFO)
-support the foot with light-weight leg braces and shoe
inserts
• Exercises
-strengthen the muscle, help to maintain range of
motion (ROM) and improve gait
• Electrical Functional Stimulations
-electrically stimulate the peroneal nerve
27

34. SURGICAL MANAGEMENT
 TENDON TRANSFER SURGERIES:
BARR’S TECHNIQUE
OBER’S TECHNIQUE
KAUFER’S PROCEDURE
SRINIVASAN TECHNIQUE
TENDO ACHILLIS LENGTHENING PROCEDURES
BONE SURGERIES:
1. LAMBRINUDI ARTHRODESIS
2. TRIPLE ARTHODESIS
3.CAMPBELLS post bone block
4.ANKLE ARTHODESIS

35. 1. BARR’S TECHNIQUE
(anterior transfer of tibialis posterior)
cast:
long leg - calcaneovalgus-
foot 3weeks
after 3 weeks --B/K cast-
foot-N ;ankle- DF – 6weeks
>6WEEKS - remove
cast- Rehabilitation
6 months- Double bar
foot drop brace

36. 2. OBER’S TECHNIQUE
• ( tendon passed through
ant comparment of leg)
• Classic- 3rd metatarsal
• HATTS modified obers-
medial cuneiform
• Post op = barrs

37. 3. KAUFER’S PROCEDURE
( split transfer of tibialis post
tendon)

38. 4. SRINIVASAN TECHNIQUE
( two tailed transfer of tibialis post)

39. • Post op:
• B/K- foot in 70 deg dorsiflexion
• >3weeks- non-weight bearing
reeducative exercises
Advantage of Srinivasan technique :
can correct both foot drop & toe
drop

40. 5. TENDO ACHILLIS LENGTHENING
A. WHITES TECHNIQUE: (open)
Posteromedial incision- expose tendo calcaneus
Long cast- knee extension ;ankle-dorsiflexion
1ST post op- weightbearing
Knee extension – 3weeks
Short leg- 3 weeks
AFO- ankle in neutral dorsiflexion

42. B. HAUSER TECHNIQUE:
• Posteromedial incision- expose tendocalcaneus
• Plantaris tendon- incised-beneficial
• Cast- mid thigh to toe
knee-full flexion; ankle-neutral dorsiflexion – 6 weeks
>6WEEKS- AFO

43. C. PERCUTANEOUS LENGTHENING OF
TENDOCALCANEUS
• Position: prone knee-E; ankle- DF
3 partial tenotomies
1.medially
2.proximally & medially at musculotendinous junction
3.laterally in between 2 incisions
if the Heel in -varus-2 incisions medially
if the heel valgus in - 2 incisions laterally
After suregery Mx = White technique i.e.. ( long leg casting )

45. D. Semi open sliding tenotomy of
tendocalcaneus
• Position-prone
• 2 longitudinal incision of 2cm along the
tendocalcaneus
• Plantaris tendon- tenotomy
• Post op-=Hauser technique

47. BONE SURGERIES:
1. LAMBRINUDI ARTHRODESIS
2. TRIPLE ARTHODESIS
3.CAMPBELLS post bone block
4.ANKLE ARTHODESIS

48. 1. LAMBRINUDI ARTHRODESIS
Indication: Isolated fixed equinus deformity older than 10
years of age
C/I :
flail foot
hip& knee instability requiring brace
Lateral x-ray - if ant subluxation of talus present then 2
stage plantar arthodesis
Complications :
1. ankle instability
2.residual varus/valgus due to muscle imbalance
3.Pseudoarthrosis of talonavicular joint

50. • Long leg Cast & Sutures Removed – 10-14 days
• Short leg cast- x –ray satisfactory
• Weight bearing allowed after 6weeks
• Short leg walking cast applied till - fusion
complete(3months)

51. 2.TRIPLE ARTHODESIS
• Most effective stabilizing procedure in the foot.
• Subtalar-calcaneocuboid-talonavicular joints are fused
Indicated when most of the weakness and deformity are at the
subtalar & mid tarsal joints.
• obtain stable& static realignment of foot .
• To remove deforming forces.
• To arrest progression of deformity .
• To Eliminate pain.
• To eliminate use of short leg brace/ provide sufficient correction for
fitting long leg brace.
To obtain near normal correction of foot
After Rx: walk with crutches / walker

52. Subtalar-calcaneocuboid-talonavicular joints are
fused

54. 3. CAMPBELL post bone block
• Permits lengthening of tendocalcaneus & ankylosing both ankle and
subtalar joints
• Incision: medial and parallel to TA
• FHL retracted to capsule of ankle joint is exposed
• Post part of talus and articular surfaces of ankle and subtalar joints-
excised.
• Turn large flaps of bone distally from the posterior aspect of the tibia
and proximally from the superior aspect of the calcaneus, overlapping
them successively.
• Ilium- large bony bridge across the ankle and subtalar joints
• post op:
ankle- plaster cast- A/K- foot at right angle
>4 weeks- boot cast ( snugly fitting)
full weight bearing delayed > 8-12 weeks
cast immobilisation- until fusion
walking on irregular surfaces will be difficult.

55. Turn large flaps of bone distally from
the posterior aspect of the tibia and
proximally from the superior aspect
of the calcaneus, overlapping them
successively

56. 4. ANKLE ARTHODESIS
• Recommended by Barr & Record for Severe paralytic
equinus deformity in adults when muscle suitable for
transfer are not available.
• Subcutaneous plantar fasciotomy & lengthening of Tendo
calcaneus followed by ankle arthodesis .

57. THANK YOU…