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Foot drop
1. Name: Rahila Najihah Ali
Matrix Number : DPH/0102/11
Batch : July/11
Date: 19th June 2013
1
Foot Drop
2. Definition
2
๏ Inability to raise the front part of foot due to
weakness or paralysis of tibialis anterior muscle
that lift the foot
๏ Foot drop occur due to peroneal nerve injury
๏ Can happen to one foot or both feet
4. Tibialis Anterior
4
๏ Origin : upper two thirds of lateral surface of tibia
and adjacent interosseous membarane
๏ 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 subtalar joint
5. 5
๏ Testing the function of Tibialis Anterior : patient is
asked to dorsiflex the foot against the resistance
of therapistโs hand placed across the dorsum of
the foot
๏ Injury to deep peroneal nerve leads to paralysis
of dordiflexors
6. Extensor Hallucis Longus
6
๏ Origin: medial part of anteromedial surface of the
middle two forth of fibula and adjacent
interosseos 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
๏ Testing Functional : patient attempts to dorsiflex
the great toe against resistance
7. Extensor Digitorum Longus
(EDL)
7
๏ 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
๏ Testing functional: patient is asked to do
dorsiflexion of the toes against ressistance
8. Sciatic Nerve
8
๏ Sciatic nerve the thickest and largest nerve in the
body
๏ Itโs start in lower back and runs through the
buttock and lower limb with root value of L4 until
S3
๏ Itโs supply biceps, semitendinosus,
semimembranosus and adductor magnus muscle
๏ In lower thigh, just above the back of the knee,
sciatic nerve divides into two nerve which are
tibial and peroneal nerve
๏ Those 2 nerve innervate different parts of the
lower leg
9. Peroneal Nerve
9
๏ Begin from L4, L5, SI, and S2 nerve roots and
joint the tibial nerve to form the sciatic nerve
๏ Common peroneal nerve travels anterior, around
the fibular neck
๏ Common peroneal nerve divide into superficial
and deep peroneal nerve
๏ Deep peroneal nerve : innervation of tibialis
anterior muscle that responsible to the
dorsiflexion of the ankle
10. Causes of Foot Drop
10
๏ L4-L5 disc herniation
-the herniated disc compressing the L5 nerve root
๏ Lumbosacral Plexus injuru
- due to pelvic fracture
๏ Sciatic nerve injury
-hip dislocation
๏ Injury to the knee
-knee dislocation
11. 11
๏ Neurodegenerative disorder of the brain
-multiple sclerosis, stroke, cerebral palsy
๏ Motor neuron disorder
-polio and amyotrophic lateral sclerosis
๏ Injury to the nerve roots
-spinal stenosis
๏ Peripheral nerve disorder
-acquire peripheral neuropathy
๏ Damage to the peroneal nerve
-muscular dystrophy
12. 12
๏ Established compartment syndrome
-foot drop is late finding
-irreversible muscle and nerve ischemia occur in
patient if fasciotomy is not performed
13. LEVEL OF LESION IN SCIATIS
NERVE INJURY
13
๏ High lesion (above the knee)
-both tibial and common peroneal nerve are
paralaysed
๏ Low lesion (below knee)
-spared : peroneus longus and brevis
Type 1 : anterior tibial nerve injury
lost : Tibialist anterior, extensor hallucis longus,
extensor digitorum longus and peroneus tertius
Type 2 : musculocutaneus nerve injury
spared : all above muscle innervated by anterior tibial
nerve
lost : peroneus longus and brevis
sensation : over outer leg and foot
14. Symptom of Foot Drop
14
๏ Inability to lift the front part of the foot
๏ Abnormal gait which drag the front of foot on the
ground during walking (steppage gait)
๏ An exaggerated, swinging hip motion
๏ Tingling, numbness & slight pain in the foot
๏ Difficulty performing certain activities that require
the use of the front of the foot
๏ Muscle atrophy in the leg
๏ Limp foot
15. Clinical features of Type 1 foot
drop
15
๏ High lesion : total foot drop
๏ Unable to do dorsiflexion and inversion of foot
๏ Able to do eversion
๏ Front of leg is wasted
๏ Sensation lost over dorsal web space of the leg
16. Clinical features of type 2 foot
drop
16
๏ Low lesion : incomplete of 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. Gait of Foot Drop
17
๏ Gait of foot drop gait is high stepping gait
๏ The patients lift the knee high and slaps the foot
to the ground on advancing to the involved side
18. Diagnosis
18
๏ Occur during routine examination where patient
find itโs difficult to walk on their heel
๏ Plain X-ray
๏ Magnetic Resonance Imaging (MRI)
๏ Electromyography (EMG) and nerve conduction
study
๏ SD curve
๏ Tinel sign
19. Treatment of early foot drop
19
๏ Conservative treatment : shows high incidence of
recovery
๏ Splintage โ splint knee in 20ยฐ of flexion and ankle
in 90ยฐ for night time
๏ In day time, walking is allowed by using โfoot-drop
applianceโ
๏ Varieties of foot drop appliances:
i) dynamic-spring shoe
ii) static- back stop shoe
20. 20
๏ 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 during
footfall
21. 21
๏ Surgery โ done if conservative management fails
๏ Repairs or decompresses a damaged nerve that
fuses the foot and ankle joint or transfers tendons
from stronger leg muscles
๏ Choices of surgery
i) tendon transfers โ for mobile foot drop
ii) tendo-archilles lengthening - in fixed equinus
iii) subtalar stabilizer procedur โ for fixed varus
iv)triple arthrodes โ for fixed varus at the subtalar
joint
22. Physiotherapy- Exercise
22
๏ When problem stems from weak muscles
๏ Proper physical therapy exercises can strengthen
ankle muscle and improve symptoms
23. 23
๏ Toe curls exercise
๏ Place a small towel and curl it toward you by
using only your toes. You can increase the
resistance by putting the weight at the end of the
towel
๏ Relax and repeat this exercide for 5 times
24. 24
๏ Marble picked up exercise
๏ Place 20 marbles on the floor. Pick up one at a
time with your toes and put each marble in a
bowl.
25. 25
๏ Toe-to-heel plantar flexion
๏ Ask patient to standing at edge of table
๏ Do dorsi flexion and plantarflexion
๏ Hold for 10 second for 10 times
26. 26
๏ Foot stretch
๏ Patient sit with the knee straight and towel around
the affected foot
๏ Gently pull a towel until comfortable stretch at the
calf muscle is felt
๏ Hold for 10 second and do for 10 times
29. 29
๏ Toes band exercise
๏ Put the rubber band around the toes
๏ Do the abduction of the toes by against the
rubber band
๏ Hold for 5 sec for 10 times
30. Electrical stimulation
30
๏ Electrical stimulation to the nerves controls the
dorsiflexor muscles.
๏ It was first proposed as a treatment for foot drop
in 1961
๏ They send electronic pulses to fire the nerve
response for the front of your foot to lift.
๏ It's programmed to each individual separately
๏ It provides normal range of motion to the foot and
ankle during walking
๏ Stroke and multiple sclerosis had success with it
31. Reference
31
๏ Neeta V Kulkarni, 2006, Clinical Anatomy for
Students Problem Solving Approach,New Delhi,
Jaypee Brothers
๏ Jules M.Rothstein, 2005, The Rehabilitation
Specialistโs Handbook, 3rd edition, Thailand, F. A.
Davis Company
๏ Chris Kirtley, 2006, Clinical Gait Analysis Theory
and Practice, Sydney, Churchill Livingstone
Elsevier
๏ Susan B. OโSullivant & Thomas J. Schmitz, 2007,
Physical Rehabilitation, 5th edition, Philadelphia,
F. A. Davis Company