Effect of Electrical Stimulation and Splint in Foot Drop

View with images and charts

Effect of Electrical Stimulation and Splint in Foot Drop

Introduction

Foot drop is a simple term for a potentially complex problem. It is usually a symptom of a greater problem. It is characerized by the inability or difficulty in moving the ankle and toesupward (dorsiflexion). In walking, while stepping forward, the front of the foot must be lifted upward to prevent the foot from dragging along the ground. Foot drop can be caused by just nerve damage. It is also caused by muscle damage, or abnormal anatomy, neurological damage, tumors, or diseases, neuro-spinal injury or diseases or associated problems, diabetes, neuropothies, stroke, dorsiflexor injuries, drug toxicities, multiple sclerosis, amyotrophic lateral sclerosis (ALS), Parkinson’s disease, Lou Gehrig’s disease, and muscular dystrophy. It may be caused by incorrect posture, sitting with the foot unrested on the floor or other surface, for extended periods of time, such as whilst using a PC.

Foot drop is caused by problems and diseases, such as those listed above, that damage the long nerves or communication between them, or more directly, damage the brain/spinal cord. The deep fibular/peroneal nerve innervates the front (anterior) compartment of the leg. Damage to this nerve will lead to the inability for the leg to dorsiflex the foot, therefore causing foot drop. The result is an abnormal gait.

Features

Foot drop is characterized by steppage gait. When the person with foot drop walks, the foot slaps down onto the floor. To accommodate the toe drop, the patient may use a characteristic tiptoe walk on the opposite leg, raising the thigh excessively, as if walking upstairs, while letting the toe drop. This serves to raise the foot high enough to prevent the toe from dragging and prevents the slapping. Other gaits such as a wide outward leg swing (to avoid lifting the thigh excessively or to turn corners in the opposite direction of the affected limb) may also indicate foot drop.

Patients with painful disorders of sensation (dysesthesia) of the soles of the feet may have a similar gait but do not have foot drop. Because of the extreme pain evoked by even the slightest pressure on the feet, the patient walks as if walking barefoot on hot sand.

links

ANATOMY

¢ There are 26 bones in the foot

¢ 7 tarsals , 5 metatarsals, 14 phalanges

¢ The tarsals are :

Calcaneum ,talus,cuboid ,naviculum and the three cuniforms (medial,

intermediate,lateral)

¢ The ankle joint is a synovial hinge joint .

¢ Articulation : The lateral malleolus of the fibula and the medial malleolus of the tibia along with the inferior surface of the distal tibia articulate with three facets of the talus. These surfaces are covered by cartilage.

Bone Anatomy

n Ankle Mortise

n Talus

n Trochlea

n Anterior surface vs Posterior surface

n Leg

n Tibia

n Fibula

n Remember Foot and Ankle are Interrelated

n Biomechanics of Foot, Ankle and Leg

Articulations and Ligament Support

n Talocrural Joint

n Comprised of:

n Talus acts as a wedge

n Ligaments of the Lateral Talocrural Joint

n Anterior Talofibular

n Talocrural Joint

n Comprised of:

n Talus acts as a wedge

n Ligaments of the Lateral Talocrural Joint

n Anterior Talofibular

n Sinus Tarsi

n Calcaneofibular

n Posterior Talofibular

n Talocrural Joint

n Ligaments of the medial Talocrural Joint

n Deltoid

n Anterior Tibiotalor

n Tibiocalcaneal

n Posterior Tibiotalor

n Tibionavicular

n Talocrural Joint

n Ligaments of the medial Talocrural Joint

n Deltoid

n Anterior Tibiotalor

n Tibiocalcaneal

n Posterior Tibiotalor

Tibionavicular

Tibia-Fibula Fixation

n Interosseous Membrane

n Distal Tibiofibular Ligament

n Anterior

n Posterior

n 3 structures stabilize syndesmosis joint

n Biomechanics of Syndesmosis Joint

Muscles of the Leg and Ankle

n Anterior Compartment

n Borders

n Lateral Shaft of Tibia

n Medial Shaft of Fibula

n Interosseous membrane

n Anterior Compartment

n Structures

n Tibialis Anterior

n Extensor Hallucis Longus

n Extensor Digitorum Longus

n Peroneus Tertius

n Deep Peroneal Nerve

n Anterior Tibial Artery

n Anterior Tibial Vein

n Anterior Compartment

n Structures

n Tibialis Anterior

n Extensor Hallucis Longus

n Extensor Digitorum Longus

n Peroneus Tertius

n Deep Peroneal Nerve

n Anterior Tibial Artery

Anterior Tibial Vein

n Lateral Compartment

n Borders

n Lateral Fibula

n Intermuscular fascia between anterior compartment and posterior compartment

n Lateral Compartment

n Structures

n Peroneus Longus

n Peroneus Brevis

n Superficial Peroneal Nerve

n Peroneal Artery

n Superior and Inferior Peroneal Retinaculum

n Lateral Compartment

n Structures

n Peroneus Longus

n Peroneus Brevis

n Superficial Peroneal Nerve

n Peroneal Artery

n Superior and Inferior Peroneal Retinaculum

n Lateral Compartment

n Structures

n Peroneus Longus

n Peroneus Brevis

n Superficial Peroneal Nerve

n Peroneal Artery

n Superior and Inferior Peroneal Retinaculum

n Superficial Posterior Compartment

n Borders

n Deep posterior compartment

n Fascia

n Superficial Posterior Compartment

n Structures

n Soleus

n Gastrocnemius

n Plantaris

n Tibial Nerve

n Posterior Tibial Artery

n Superficial Posterior Compartment

n Structures

n Soleus

n Gastrocnemius

n Tibial Nerve

n Posterior Tibial Artery

n Borders

n Interosseus Membrane

n Posterior Tibia

n Posterolateral Fibula

n Superficial Posterior Compartment

n Structures

n Tom, Dick and Harry

n Tibialis Posterior

n Flexor Digitorum Longus

n Flexor Hallucis Longus

n Tibial Nerve

n Posterior Tibial Artery

Ankle Bursa

n Retrocalcaneal Bursa

n Subcutaneous Calcaneal Bursa

NEUROVASCULAR SUPPLY OF FOOT

OBJECTIVES

By the end of this lecture students should be able to:

• Describe vascular and nervous supply of sole and dorsum of foot

• Tell their course through foot

• Explain relationships

ARTERIES OF THE SOLE OF THE FOOT

• Medial plantar arteries

• Lateral plantar arteries

• Both are terminal branches of the posterior tibial artery.

MEDIAL PLANTAR ARTERY

• Smaller than the lateral

• Arises: beneath flexor retinaculum

• Course:

– Runs along the medial side of the foot

– First: above the abductor hallucis

– Then: b/w abductor hallucis and flexor digitorum brevis

• Anastomose: with the first dorsal metatarsal artery

• Supplies: Abductor hallucis, Flexor digitorum brevis, medial side of big toe

LATERAL PLANTAR ARTERY

• Larger than the medial

• Arises: beneath flexor retinaculum

• Course:

– Runs Laterally and forward

– First : between the calcaneus and abductor hallucis

– Then : between the flexor digitorum brevis and quadratus plantæ

– Turns Medially and extends from the base of the fifth metatarsal bone to the proximal part of the first interosseous space, and forms the plantar arch

– Unites with the deep plantar branch of the dorsalis pedis artery

PLANTAR ARCH

• Perforating branches :

– Three in number

– Anastomose with the dorsal metatarsal arteries

• Plantar metatarsal arteries:

– Divides into a pair of plantar digital arteries

– To adjacent side of lateral four toes and lateral side of little toe

NERVE SUPPLY OF FOOT

• Terminal branches of the tibial nerve:

– Medial planter nerves

– Lateral plantar nerves

MEDIAL PLANTAR NERVE

• Arises: beneath flexor retinaculum

• Course:

– Runs forward deep to abductor hallucis with medial planter artery

– Lies in interval between abductor hallucis and flexor digitorum brevis

• Branches:

• Muscular:

– abductor hallucis muscle

– flexor digitorum brevis

– flexor hallucis brevis (in the third layer)

– 1st lumbrical

• Cutaneous:

– Plantar digital nerve – Skin of medial three and half toes

– On dorsum, nail bed and tips of toes

LATERAL PLANTAR NERVE

• Arises: beneath flexor retinaculum

• Course:

– Runs forward deep to abductor hallucis and flexor digitorum brevis with lateral planter artery

– On reaching base of 5th metatarsal bone, divides into superficial and deep branch

• Branches:

• Main trunk:

– abductor digiti minimi

– accessory flexor (quadratus plantae)

– Cutaneous: Skin of lateral part of sole

• Superficial terminal:

– flexor digiti minimi brevis

– interossei (4th intermetatarsal space)

– Planter digital branch – lateral one and half toes

– On dorsum – nail beds and tips of toes

• Deep terminal:

– lumbricals 3, 4, 5

– adductor hallucis

– Interossei (except 4th intermetatarsal space)

VEINS OF SOLE OF FOOT

• Medial plantar vein

• Lateral plantar vein

• Accompany corresponding arteries

• Unite behind medial malleolus to form posterior tibial venae comitantes

ARTERIES OF DORSUM OF FOOT

DORSALIS PEDIS ARTERY

• Continuation of the anterior tibial

• From the ankle joint along the tibial side of the dorsum of the foot to the proximal part of the first intermetatarsal space

• Pass down b/w 2 heads of 1st dorsal interossei muscle

• Joins lateral plantar artery

BRANCHES OF THE DORSALIS PEDIS ARTERY

• Lateral tarsal artery :

– Crosses navicular àsupply extensor digitorum brevis

• Medial tarsal arteries :

– Ramify on the medial border of the foot and join the medial malleolar net-work

• Arcuate artery :

– Passes lateralward, over the bases of the metatarsal bones

– Gives off the second, third, and fourth dorsal metatarsal arteries

• First dorsal metatarsal artery :

– Supply the adjoining sides of the great and second toes.

SUPERFICIAL PERONEAL NERVE

• Emerges from between peroneus brevis and extensor digitorum longus

• Branches:

– medial and lateral cutaneous

• Supply:

– Skin on dorsum of foot

– Medial side of big toe

– Adjacent dies of 2nd, 3rd, 4th and 5th toes

DEEP PERONEAL NERVE

• It enters the dorsum of the foot by passing deep to extensor retinacula on lateral side of dorsalis pedis artery in front of the ankle joint

• Divides into a lateral and a medial terminal branch

• Lateral terminal branch: supplies the extensor digitorum brevis

• Medial terminal branch: At the first interosseous space, divides into two dorsal digital nerves, supply the adjacent sides of the great and second toes

• Both give articular branches to joints of foot

SAPHENOUS NERVE

• Passes onto dorsum of foot in front of medial malleolus

• Supply: Skin along medial side of foot as far forward as head of 1st metatarsal bone

SURAL NERVE

• Enters foot behind lateral malleolus

• Supply:

– Skin along lateral margin of foot

– Lateral side of little toe

DORSAL VENOUS ARCH

• Lies in subcutaneous tissue over heads of metatarsal bones

• Drains:

– on medial side into great saphenous vein

– on lateral side into small saphenous vein

• Greater part of blood from whole foot drains into arch via digital veins and communicating veins from sole, which pass through interosseous spaces

Other joints in the foot :

1- the sub-talar joint.

2- This joint lies between the calcaneum and the talus .

3-the mid-tarsal joint.

This joint is really two joints – the joint between the talus and the navicular bone as well as the joint between the calcaneum and the cuboid bone.

¢ There is only one muscle on the dorsum of the foot ( digitorum brevis).

¢ The muscles on the planter aspect of the foot are divided into four layers:

üfirst layer:abductor hallucis,flexor digitorum brevis,abductor digiti minimi.

üsecond layer:quadratus plantae,lumbricalis,flexor digitorum longus tendon,flexor hallucis longus tendon.

üthird layer: flexor hallucis brevis,adductor hallucis,flexor digiti minimi brevis.

ü Forth layer: interossei , peroneus longus tendon,tibialis posterior tendon

The planter fascia is a very important structure that takes its origin from the heel (calcaneum) and inserts into the bases of the proximal phalanges of the toes.

¢ Blood supply of the foot is from :

1-anterior tibial artery which gives dorsalis pedis artery.

2-posterior tibial which gives the medial and lateral plantar arteries.

3- peroneal arteries.

Blood supply

¢ Nerve supply of the foot is from:

*****(saphenous, sural, superficial & deep peroneal)*****

Nerve supply

Movements at the ankle joint : are mainly dorsiflexion and plantarflexion.

The anterior talus is wider than the posterior talus. When the foot is dorsiflexed, the wider part of the superior talus moves into the articulating surfaces of the tibia and fibula, creating a more stable joint than when the foot is plantar flexed.

¢ The foot externaly rotates with dorsiflexion and internally rotates with plantarflexion

BIOMECHANICS

“Bio” means life or living organism. “Mechanics” is the original discipline of physics as it applies to forces on matter. For our purposes, biomechanics is defined as the mechanics of the human body, especially the forces of the muscles and gravity on the skeletal structure of the lower extremity.

Biomechanics is the term used to describe movement of the body. This section is a review of basic foot and ankle biomechanics. In order to understand the biomechanics of the foot and ankle it is important to understand their anatomy. Please read the sections on basic foot anatomy and basic ankle anatomy before reading this section.

The ankle is a modified hinge joint. It plays a key role in transferring the forces from the foot to the leg. The ankle joint is made up of three bones, which are connected by ligaments, muscles and tendons. A strong ligament joins the ends of the tibia and fibula to form the ankle “mortis”. The “dome” of the talus (the highest bone of the foot) fits inside the ankle mortis to form the ankle joint. The ankle allows movement in only one plane. It allows the foot to move upwards (dorsiflexion) and downwards (plantar flexion).

The foot is made up of 26 bones. There are numerous joints between these bones that allow the foot to be both a rigid lever and a shock absorber. The largest joint in the foot is the subtalar joint. Inward movement of the foot (inversion), and outward movement of the foot (eversion) occur primarily at the subtalar joint.

The normal end ranges of motion for the foot and ankle vary between individuals and between children and adults. The following are approximate end ranges of motion for adults:

• Dorsiflexion – 20 degrees

• Plantar flexion – 60 degrees

• Eversion – 15 degrees

• Inversion – 35 degrees

Foot Terminology: Anatomic terms for location of body parts and motions are necessary for a variety of reasons. We can not simply say “outside of the toe” because not everyone will agree on which part of the toe is the “outside.” Although it may seem simple to refer to the “top of the foot”, as soon as the foot moves or is rotated or has a deformity, the top of the foot is no longer on top. Medical professionals need a uniform way to describe both locations and movements.

Locations

Medial means towards the center line of the body.

Lateral means away from the center line of the body.

Distal means further from the body.

Proximal means closer to the body.

Anterior means the front of the body

Posterior means the back of the body

Dorsal means the top of the foot

Plantar means the bottom of the foot

foot orientation image

Looking at the foot diagram above, the big toe is medial and the little toe is lateral. The toes are distal to the midfoot and the midfoot is distal to the heel bone. The heel bone is proximal to the toes. The toes are also considered anterior to the midfoot and the heel sits posterior to the midfoot.

Definitions: Motions of the foot and ankle

Dorsiflexion: movement of the foot up.

Plantarflexion: movement of the foot down.

Abduction: movement of the foot away from the center line of the body.

Adduction: movement of the foot towards the center line of the body.

Inversion: twisting movement of the foot inward

Eversion: twisting movement of the foot outward.


Supination and Pronation

Supination and pronation are a combination of the above motions. It is common to use supination and inversion interchangeably and pronation and eversion interchangeably. But, supination is actually a combination of inversion, plantarflexion and adduction. Pronation is a combination of eversion, dorsiflexion and abduction.

Supination: is a triplanar motion involving the foot moving down and towards the center of the body.

Pronation: is a triplanar motion of the subtalar joint involving the foot moving up and away from the center of the body.

To better understand supination, look at the right foot in the image below. The heel rotates towards the center of the body, the big toe moves towards the center of the body, the foot flexes down and the ankle rolls out.

To better understand pronation, look at the right foot in the image below. The heel rotates away the center of the body, the little toe moves away from the center of the body, the foot flexes up slightly and the ankle rolls in.

To understand these motions while standing, try this with your own feet. Stand with your feet parallel and facing foward. Rotate your body and look over your left shoulder, without moving your feet. Your left leg has rotated out (external leg rotation) and your weight will be on the outside of your left foot. Your left foot is supinated. Your right leg has rotated in (internal leg rotation) and your weight is on the inside of your right foot. Your right foot is pronated.

Gait Cycle

Contact/ Heel Strike: The beginning of the gait cycle is marked by the heel contacting the ground. This is called heel strike.

Forefoot contact: The forefoot contacts the ground, stabilizing the foot and the body.

Midstance: When the weight of the body is directly over the foot. The opposite foot is swinging from the rear of the body towards the front of the body.

Heel Off: When the heel starts to lift from the ground, the weight shifts to the front of the foot. The opposite foot has made contact with the ground.

Propulsion/ Push off: Also called toe off, this phase is the terminal stance phase of the gait cycle, which means that the foot is pushing off the ground and will be entering the swing phase (swinging from the rear of the body to the front of the body).

During the normal gait cycle (normal walking) the feet supinate and pronate. It’s important to understand that pronation is a normal motion when walking. When the feet pronate too much, this is when people experience problems like plantar fasciitis, tendonitis and painful arches. An abnormal amount of supination can cause also cause problems. When the foot supinates too much people may develop tendonitis and joint problems at the forefoot and big toe joint.

Definitions

  • Foot drop is an inability or difficulty in moving the ankle and toes upward (dorsiflexion). In walking, the leg must be lifted higher than usual to prevent the foot from dragging along the ground. …
  • a deficit in turning the ankle and toes upward. Conditions leading to foot drop may be neurologic, muscular or anatomic in origin, often with significant overlap. Foot drop is characterized by steppage gait. When the person with foot drop walks, the foot slaps down onto the floor. …
  • This describes the condition when a person cannot flex their ankle upwards towards the knee (opposite of pointing your toe). It may develop suddenly or slowly and may or may not be painful depending on the underlying condition.
  • Foot drop is not a disease, and depending on the cause, it may be either temporary or permanent. Foot drop is the symptom of an underlying problem, which is usually a neuromuscular disorder. According to spineuniverse.com, foot drop is most often caused by injury to the peroneal nerve. There are many different types of injuries that can occur to the peroneal nerve–the most common are: a disc herniation that causes nerve compression, a stroke, a tumor near the nerve or any type of crushing injury.

Foot Drop Causes, Symptoms

F oot drop, or drop foot as it may also be called, refers to a weakening of the muscles that allow one to flex the ankle and toes, causing the individual to drag the front of the foot while walking and to compensate for this scuffle by bending the knee to lift the foot higher than usual.

A quick way to test for foot drop is to try to walk on the heels. If this proves difficult, drop foot may be present.

In This Article:

While foot drop is a neuromuscular disorder that affects the nerves and muscles, it is not actually a disease in itself but rather a symptom of some other medical problem, possibly by a condition in the low back. The possibility that foot drop may be caused by a condition in the low back may be overlooked, but it is important to evaluate in order to pursue appropriate foot drop treatment.

Article continues below

Drop Foot Complications

Regardless of the foot drop cause for the specific patient, the fact remains that a dropped foot can produce many difficulties, including the inability to:

  • Point the toes upward at the body (this movement is known as dorsiflexion)
  • Walk normally in the heel-to-toe fashion.

Foot Dropped Considerations

Patients with dropped foot should be aware of the following:

Foot drop may be experienced in one oFoot Drop Symptoms, Steppage Gait & Other Warning Signs

Foot drop typically affects the muscles responsible for moving the ankle and foot upward, specifically the anterior tibialis, extensor hallucis longus and extensor digitorum longus.

With drop foot, these muscles are inhibited from performing several functions during a normal walking stride, including swinging the toes up from the ground at the start of a stride and controlling the foot after the heel is planted near the end of a stride. Consequently, the most recognized foot drop symptom occurs: high steppage gait.

In This Article:

High Steppage Gait from Drop Foot

The most common symptom of drop foot, a high steppage gait is often characterized by raising the thigh up in an exaggerated fashion while walking, as if climbing the stairs.

Article continues below

High steppage gait is associated with one of the following:

  • Dragging of the foot and toes
  • Scraping of the toes across the ground
  • Uncontrolled slapping of the toes against the ground.

The affected muscles are usually used to keep the foot off the ground during the swing-through portion of walking. When these are weak, they cannot keep the foot up and the foot will scrape across the ground if the foot is not picked up high.

Other Foot Drop Symptoms

Some other foot drop symptoms may include:

  • An exaggerated, swinging hip motion. With foot drop, the hip may swing out in an effort to counteract the toes from catching the ground.
  • Limp foot. Specifically, a foot that flops away from the body is another common drop foot symptom.
  • Tingling, numbness & slight pain in the foot. Ranging from a slight tingling sensation to a complete lack of feeling in the foot, these foot drop symptoms may make everyday activities like walking and driving a car very difficult. Such foot pain may specifically be linked to the lower back, specifically to a series of symptoms known as sciatica.

Difficulty with certain activities requiring the use of the front of the foot. As just one example, foot drop may make an activity like climbing the stairs especially difficult.

  • Muscle atrophy in the leg. Muscle atrophy refers to a muscle decreasing in mass and weakening. As the anterior tibialis, extensor hallucis longus and the extensor digitorum longus muscles are most affected by foot drop, atrophy may occur and make it much harder to exert force with the leg and the foot.

As there are various symptoms of foot drop, there are many different drop foot causes that merit understanding and evaluation when seeking treatment.

Foot drop can be diagnosed by a many types of physicians. If the lower back is suspected as a cause, a complete workup by a spine specialist, such as a physiatrist, orthopedic spine surgeon or neurosurgeon, may be advisable.

Once a cause is determined, various foot drop treatments may be implemented depending on the specific patient’s condition.

Articles Related to

“Foot Drop Diagnosis”

Spine-Health publishes original articles written for patients by over 100 physician authors and peer-reviewed by a 16 member Medical Advisory Board. This trusted, independent site is supported by hundreds of physician members and visited by millions of patients and their physicians.

The information in Spine-health.com is not intended as a substitute for medical professional help or advice but is to be used only as an aid in understanding back pain and neck pain.

Foot Drop Causes

When learning about drop foot, it should be reiterated that it is a symptom of an underlying condition. Generally speaking, foot drop causes may include:

  1. Muscle damage
  2. Skeletal or anatomical abnormalities affecting the foot
  3. Nerve damage.

Common Drop Foot Causes

Specific causes of foot drop that should be considered may include:

  • A lower back condition (see below for more detail)
  • A stroke or tumor
  • Parkinson’s disease
  • Diabetes
  • Motor Neuron disease
  • Multiple sclerosis
  • Adverse reactions to drugs or alcohol
  • An injury to the foot or lower leg.

This article focuses on the first cause, the specific lower back conditions that can cause foot drop.

Article continues below

How the Lower Back Causes Drop Foot

There are a number of conditions in the lower back that put pressure on the nerve that leads to the peroneal nerve in the lower leg, which innervates the muscles that allow the foot to flex up.

When compromised, peroneal nerve damage may occur and prompt foot drop as a result of the following lower back problems:

  • Lumbar herniated disc. While there are many causes of foot drop, one of the most common cause tends to be a herniated disc in the lower back (lumbar spine) that is putting pressure on the nerve that runs down the leg and into the foot. Putting pressure on the weakest spot of the disc (located right under the nerve root), a herniated disc may prompt pain to nerves beyond the sciatic nerve (including the peroneal nerve) that is referred to the leg and foot. More specifically, this pain will usually run below the knee and to the foot, with the foot pain accompanied with numbness.
  • Spinal stenosis. Occurring gradually over time and usually in elderly patients, spinal stenosis occurs when the spinal nerve roots are compressed and choked as a result of a number of potential factors, most commonly enlarged facet joints (e.g. from osteoarthritis). With lumbar spinal stenosis, nerve compression can produce symptoms of pain, especially with activities involving standing and walking, and possibly foot drop.
  • Spondylolisthesis. Prompting an unstable and compromised spine segment as a result of a vertebra slipping forward over a lower vertebra, spondylolisthesis may result in a pinched nerve in the lower back.
  • Bone fractures or lacerations. A fracture to a vertebra in the lower back, such as from osteoporosis, can cause stress and irritation to related nerves, leading to referred pain in the foot and possibly foot drop. For anyone with who is diagnosed with or at risk for osteoporosis, a vertebral fracture should be considered as a possible cause of foot drop.

It should be known that while some foot drop treatments may be directed at symptoms, determining the underlying cause of a dropped foot is often necessary in order to effectively treat it.

Articles Related to

“Foot Drop Causes “

Peroneal Nerve Symptoms

The peroneal nerve, which runs along the outside part of the lower knee, has an important when it comes to a person’s mobility. This nerve transmits impulses to and from three areas: the leg, the foot and the toes. If this nerve becomes damaged, the muscles in the lower leg and foot become weak. This causes a person to be unable to raise the foot upwards, a condition commonly known as foot drop.

Symptoms

1. The most common symptom of foot drop is the inability to raise the foot at the ankle. More specifically, a person with foot drop may be unable to point her toes toward her body, or in some more severe cases, she may not be able to move her foot at the ankle inward or outward. When this loss of function occurs, many times pain, weakness and numbness, as well as a tingling or prickling sensation, are noticed.

Since there is nerve damage, when a person with foot drop tries to walk, she may drag the affected foot or toes.

Causes

2. While damage to the peroneal nerve is the most common cause for foot drop, there are other causes as well. It can also be caused by injury to the sciatic nerve, which is the largest nerve in the body, originating in the network of nerves found in the lower back.
Foot drop is most commonly the symptom of a nerve problem; however, muscle damage, nerve and muscle disorders, some central nervous system disorders, and even a reaction to different drugs, such as chemotherapy drugs and certain drugs used to treat multiple sclerosis, may also be the cause, as they can have a severely toxic effect on the body, according to mayoclinic.com

3. If a person finds he cannot lift his foot or if he drags his foot when walking, it is time to seek medical advice. A doctor will give a complete physical exam as well as go over medical history thoroughly; she will also want to observe foot and leg movement to better determine the diagnosis. In some cases, a person who is thought to have foot drop may be referred to a neurologist for further testing. Treatment depends on how the injury was sustained as well as the severity of the injury. Some people with foot drop are fitted with a splint, an ankle foot orthotic or simply a brace that fits in the shoe and helps to stabilize the foot and ankle. Often physical therapy is also recommended.

In some cases, surgery is an option to correct the underlying problem, such as repairing a nerve that has been damaged, if possible; or if the cause is a herniated disc, the disc may be removed

Drop foot is a complex problem because there are so many variables as to cause. Therefore, the best first step in handling the condition is to speak to a medical

It descends obliquely along the lateral side of the popliteal fossa to the head of the fibula, close to the medial margin of the biceps femoris muscle. Where the common peroneal nerve winds round the head of the fibular, it is palpable<href=”#cite_note-LL-nerves-website-0″>[1].The common fibular nerve (common peroneal nerve; external popliteal nerve; peroneal nerve; lateral popliteal nerve), about one-half the size of the tibial nerve, is derived from the dorsal branches of the fourth and fifth lumbar and the first and second sacral nerves.

It lies between the tendon of the biceps femoris and lateral head of the gastrocnemius muscle, winds around the neck of the fibula, between the peronæus longus and the bone, and divides beneath the muscle into the superficial fibular nerve (superficial peroneal nerve) and deep fibular nerve (deep peroneal nerve).

It innervates the Peroneus longus and Peroneus brevis muscles.

Previous to its division it gives off articular and lateral sural cutaneous nerves.

§ The articular branches (rami articulares) are three in number:

§ Two of these accompany the superior and inferior lateral genicular arteries to the knee; the upper one occasionally arises from the trunk of the sciatic nerve.

§ The third (recurrent) articular nerve is given off at the point of division of the common fibular nerve; it ascends with the anterior recurrent tibial artery through the tibialis anterior to the front of the knee.

§ The lateral sural cutaneous nerve (n. cutaneus suræ lateralis; lateral cutaneous branch) supplies the skin on the posterior and lateral surfaces of the leg.

§ The motor branches:

§ As the common fibular nerve exits the popliteal fossa, it courses around the lateral aspect of the leg just below the head of the fibula. Here it is apposed with fibula and gives off two branches, the superficial fibular (peroneal) branch and deep fibular (peroneal) branch.

§ The superficial peroneal nerve supplies the muscles of the lateral compartment of the leg namely: peroneus longus and peroneus brevis. These two muscle help in eversion and plantar flexion of the foot.

§ The deep peroneal nerve innervates the muscles of the anterior compartment of the leg which are: tibialis anterior, extensor hallucis longus, extensor digitorum longus, and the fibularis (peroneus) tertius. Together these muscles are responsible for dorsiflexion of the foot and extension of the toes.

Clinical significance

Chronic peroneal neuropathy can result from, among other conditions, bed rest of long duration, hyperflexion of the knee, peripheral neuropathy, pressure in obstetric stirrups, and conditioning in ballet dancers. The most common cause is habitual leg crossing that compresses the common fibular nerve as it crosses around the head of fibula.<href=”#cite_note-1″>[2] Transient trauma to the nerve can result from peroneal strike.

Damage to this nerve typically results in foot drop, where dorsiflexion of the foot is compromised and the foot drags (the toe points) during walking; and in sensory loss to the dorsal surface of the foot and portions of the anterior, lower-lateral leg.

Surgical procedures

§ Peroneal nerve decompression:

§ In the surgical treatment of fibular nerve compression, an incision is made over the neck of the fibula. Fascia surrounding the nerves to the lateral side of the leg is released.<href=”#cite_note-dellonipns-2″>[3]

§ Deep peroneal nerve decompression:

§ In the surgical treatment of deep fibular nerve entrapment in the foot, a ligament from the extensor digitorum brevis muscle that crosses over the deep peroneal nerve, putting pressure on it and causing pain, is released.

Nervous system

Sacral plexus

Medical Therapy

Foot drop is very distressing, and attention to the patient’s psychological needs is very important. If painful paresthesias develop, they can sometimes be effectively managed with sympathetic blocks or laparoscopic synovectomy. Alternative treatments are amitriptyline, nortriptyline, pregabalin, and gabapentin. Local treatment with transdermal capsaicin or diclofenac can also reduce symptoms. Even if there is significant pain, narcotic medications should be kept to a minimum. Optimizing glucose control in diabetic patients and managing vitamin deficiencies with supplements of B-1, B-6, or B-12 can also be useful.

Erythropoietin is a naturally occurring hormone that is approved by the Food and Drug Administration for the treatment of anemia but also has neuroprotective and possibly neurotrophic properties. The proposed mechanism of action is anti-apoptotic and anti-inflammatory, promoting cell survival. Erythropoietin is given in 3 doses of 5000 U/kg over a week following nerve injury. It has a minimal side-effect profile. An animal study showed that erythropoietin treatment accelerated functional recovery after peripheral nerve injury.

Treatment of foot drop is directed to its etiology. If foot drop is not amenable to surgery, an ankle-foot orthosis (AFO) often is used. An AFO also is used during surgical or neurologic recovery. The specific purpose of an AFO is to provide toe dorsiflexion during the swing phase, medial and/or lateral stability at the ankle during stance, and, if necessary, push-off stimulation during the late stance phase. An AFO is helpful only if the foot can achieve plantigrade position when standing. Any equinus contracture prohibits its successful use.

The most commonly used AFO in foot drop is constructed of polypropylene and inserts into a shoe. If it is trimmed to fit anterior to the malleoli, it provides rigid immobilization. This is used when ankle instability or spasticity is problematic, such as in patients with upper motor neuron diseases or stroke. If the AFO fits posterior to the malleoli (posterior leaf spring type), plantar flexion at heel strike is allowed, and push-off returns the foot to neutral for the swing phase. This provides dorsiflexion assistance in instances of flaccid or mild spastic equinovarus deformity. A shoe-clasp orthosis that attaches directly to the heel counter of the shoe also may be used.

In patients in whom foot drop is due to hemiplegia, peroneal nerve stimulation can be considered. This type of stimulation was first applied in 1961. Nerve stimulation has advantages to the AFO, as it provides active gait correction and can be tailored to individual patients. In this system, a short burst of electrical stimulation is applied to the common peroneal nerve between the popliteal fossa and fibular head. A switch in the heel of the affected limb controls this burst. The stimulator is activated when the foot is lifted, and it is then stopped when the foot contacts the ground. This achieves dorsiflexion and eversion during the swing phase of gait.

In a study by Ring et al, the effects of a radiofrequency-controlled neuroprosthesis were compared with those of a standard ankle-foot orthosis (AFO) in 15 patients with foot drop caused by stroke or traumatic brain injury. The authors found that compared with AFO, the studied neuroprosthesis enhanced balance control during walking and, thus, more effectively managed foot drop.

Surgical Therapy

Foot drop due to direct trauma to the dorsiflexors generally requires surgical repair. When nerve insult is the cause of foot drop, treatment is directed at restoring nerve continuity, either by direct repair or by removal of the insult.

If foot drop is secondary to lumbar disc herniation (a finding in 1.2-4% of patients with this condition), consider discectomy. In the early phase of this condition, decreased blood flow due to compression is thought to lead to nerve root ischemia. The nerve root is more susceptible to compression injury than is the peripheral nerve because the vascular network of the nerve root is less developed, with no regional arteriolar blood supply. Foot drop due to nerve root injury may depend on the magnitude and duration of nerve root compression. Early decompression is recommended in cases accompanied by severe motor disturbance, especially in older patients.A Japanese study of 46 patients with degenerative lumbar disease who presented with drop foot noted that palsy duration and preoperative strength were the factors that most affected recovery after surgical intervention.

Foot drop following hip replacement can also be treated with sciatic nerve decompression, particularly if there is any concern about bleeding at the operative site. Shortening of the hip prosthesis may be helpful if the limb was lengthened during surgery.

A review of surgical management of peroneal nerve lesions demonstrated that neural repair is the first priority in selected patients with peroneal nerve palsy. This may be accomplished with nerve decompression (either central or peripheral) or nerve grafting or repair. For foot drop from deep peroneal nerve injuries of less than 1-year duration, one study has reported success with transfer of functional fascicles to deep peroneal-innervated muscle groups, using either the superficial peroneal or tibial nerve as a donor. Failing sufficient recovery with those measures, tendon transfer procedures may be considered. It has been suggested that a tendon transfer may be considered if there is no significant neural recovery at 1 year. If a foot drop is chronic and accompanied by contracture, Achilles tendon lengthening may be necessary to achieve adequate dorsiflexion.

In patients in whom foot drop is due to neurologic and anatomic factors (eg, polio, Charcot joint), arthrodesis may be the preferred option. The goal is to achieve a stable, well-aligned foot and ankle. This may be accomplished via ankle arthrodesis, Lisfranc arthrodesis, and triple or pantalar arthrodesis with or without Achilles tendon lengthening.

Functional electrical stimulation

Functional electrical stimulation (FES) is a technique that uses electrical currents to activate nerves innervating extremities affected by paralysis resulting from spinal cord injury (SCI), head injury, stroke and other neurological disorders. FES is primarily used to restore function in people with disabilities. It is sometimes referred to as Neuromuscular electrical stimulation (NMES)

FES was initially referred to as Functional Electrotherapy by Libersonand it wasn’t until 1967 that the term Functional Electrical Stimulation was coined by Moe and Post and used in a patent entitled, “Electrical stimulation of muscle deprived of nervous control with a view of providing muscular contraction and producing a functionally useful moment” Offner’s patent described a system used to treat foot drop.

The first commercially available FES devices treated foot drop by stimulating the peroneal nerve during gait. In this case, a switch, located in the heel end of a user’s shoe, would activate a stimulator worn by the user.

Common Applications

Spinal Cord Injury

Injuries to the spinal cord interfere with electrical signals between the brain and the muscles, resulting in paralysis below the level of injury. Restoration of limb function as well as regulation of organ function are the main application of FES, although FES is also used for treatment of pain, pressure, sore prevention, etc.

Some examples of FES applications involve the use of Neuroprostheses that allow people with paraplegia to walk, stand, restore hand grasp function in people with quadriplegia, or restore bowel and bladder function.

Stroke

FES is commonly used in foot drop neuroprosthetic devices.

Other

Electrical stimulation for the purpose of helping persons with paralysis of the arms or legs mainly focuses on the neuromuscular transmission peripherally. E-stim can also be used for central nervous system stimulation to hasten awakening from coma or the vegetative state. There is a long history of neurosurgeons who have implanted electrodes into the brain and spinal cord, especially in Japan, for increasing cerebral blood flow and certain neurotransmitters in persons in long term coma states.

Beginning in 1991 in Greenville, North Carolina (East Carolina University) and shortly after that in Ch

Disclaimer:

The information contains in this web-site is prepared for educational purpose. This site may be used by the students, faculties, independent learners and the learned advocates of all over the world. Researchers all over the world have the access to upload their writes up in this site. In consideration of the people’s participation in the Web Page, the individual, group, organization, business, spectator, or other, does hereby release and forever discharge the Lawyers & Jurists, and its officers, board, and employees, jointly and severally from any and all actions, causes of actions, claims and demands for, upon or by reason of any damage, loss or injury, which hereafter may be sustained by participating their work in the Web Page. This release extends and applies to, and also covers and includes, all unknown, unforeseen, unanticipated and unsuspected injuries, damages, loss and liability and the consequences thereof, as well as those now disclosed and known to exist.  The provisions of any state’s law providing substance that releases shall not extend to claims, demands, injuries, or damages which are known or unsuspected to exist at this time, to the person executing such release, are hereby expressly waived. However the Lawyers & Jurists makes no warranty expressed or implied or assumes any legal liability or responsibility for the accuracy, completeness or usefulness of any information, apparatus, product or process disclosed or represents that its use would not infringe privately owned rights. Reference herein to any specific commercial product process or service by trade name, trade mark, manufacturer or otherwise, does not necessarily constitute or imply its endorsement, recommendation or favouring by the Lawyers & Jurists. The views and opinions of the authors expressed in the Web site do not necessarily state or reflect those of the Lawyers & Jurists. Above all, if there is any complaint drop by any independent user to the admin for any contents of this site, the Lawyers & Jurists would remove this immediately from its site.