Content uploaded by Adewumi Ojeniyi Durodola
Author content
All content in this area was uploaded by Adewumi Ojeniyi Durodola on Jan 20, 2020
Content may be subject to copyright.
_____________________________________________________________________________________________________
*Corresponding author: E-mail: isaac.amole@bowenuniversity.edu.ng, amoleio@yahoo.com;
Journal of Advances in Medical and Pharmaceutical
Sciences
21(4): 1-6, 2019; Article no.JAMPS.52673
ISSN: 2394-1111
Case Series: Management of Foot Drop
Isaac Olusayo Amole
1,2*
, Stephen Adesope Adesina
1,2
,
Adewumi Ojeniyi Durodola
1,2
and Samuel Uwale Eyesan
2,3
1
Department of Family Medicine, Bowen University Teaching Hospital, Ogbomosho, Oyo State,
Nigeria.
2
Bowen University, Iwo, Osun State, Nigeria.
3
Department of Surgery, Bowen University Teaching Hospital, Ogbomosho, Oyo State, Nigeria.
Authors’ contributions
This work was carried out in collaboration among all authors. Authors IOA and SAA designed the
study, wrote the protocol and wrote the first draft of the manuscript. Authors AOD and SUE managed
the literature searches. All authors read and approved the final manuscript.
Article Information
DOI: 10.9734/JAMPS/2019/v21i430143
Editor(s):
(1) Xiao-Xin Yan, Department of Anatomy and Neurobiology, Central South University Xiangya, School of Medicine (CSU-
XYSM), 172 TongziPo Road, Changsha, Hunan 410013, China.
Reviewers:
(1) Mariappan Natarajan, Sri Ramachandra Institute of Higher Education and Research, India.
(2)
D. Ramachandra Reddy, MGR Medical University, India.
Complete Peer review History:
http://www.sdiarticle4.com/review-history/52673
Received 17 September 2019
Accepted 22 November 2019
Published 18 December 2019
ABSTRACT
Aim:
To highlight the functional outcome of surgical management of foot drop in patients with
Hansen disease.
Case Presentation: We present three cases of foot drop following Hansen’s disease that were
managed surgically by Tibialis posterior transfer. The patients had preoperative physiotherapy for
ten days and postoperative physiotherapy for four weeks. Their post-operative periods were
uneventful and the corrections were satisfactory.
Discussion: Involvement of common peroneal nerve in Hansen’s disease usually results in
paralysis of the anterior tibial and/or peroneal muscles. Hansen’s disease patients with foot-drop
walk with a ‘high-stepping gait’, lifting the leg high as if climbing steps even while walking on
level ground. When the paralysis has been present for more than six months to one year
without recovery, the best option of treatment at this stage is corrective surgery and the main aim of
the corrective surgery is to restore active dorsiflexion of the foot so that the gait
becomes normal. This is achieved by re-routing the tendon of Tibialis posterior muscle, brings that
Case Report
Amole et al.; JAMPS, 21(4): 1-6, 2019; Article no.JAMPS.52673
2
tendon to lie in front of the ankle and is anchored distally. If the tendo-achillis tendon is
found to be tight, it should be lengthened as the first step of the Tibialis posterior transfer operation.
Conclusion: Surgical correction of foot drop usually leads to restoration of active dorsiflexion of the
foot thereby preventing development of secondary deformities and ulceration. Our patients were
able to dorsiflex their feet after the surgical correction.
Keywords: Hansen disease; foot drop; tibialis posterior; tendo-achillis.
1. INTRODUCTION
Hansen’s disease patients develop foot-drop
because of damage to the lateral popliteal (the
common peroneal) nerve. Leprosy caused the
Mycobacterium leprae is the most common
treatable cause of neuropathy. Foot drop is a
fairly common disability with an overall incidence
of 2.5 percent due to damage to the lateral
popliteal (the common peroneal) nerve and the
resultant paralysis of the muscles supplied by the
lateral popliteal nerve [1]. Hansen’s disease
patients with foot-drop walk with a ‘high-stepping
gait’, lifting the leg high as if climbing steps even
while walking on level ground. When these
patients sit on a high stool or couch with the
leg hanging down free, they will not be able to
lift the affected foot or toe [1,2]. If the foot drop is
left untreated it may result into
contracture formation and development of
secondary deformities and ulceration. Patient
may end up having below knee amputation
because of the secondary deformities and
recurrent ulceration if the foot drop is not
corrected on time [3,4].
When the paralysis has been present for more
than six months to one year without recovery and
when the paralysed anterior and lateral group of
leg muscles are severely atrophied, the paralysis
is taken as irreversible [1]. The best option of
treatment at this stage is corrective surgery [5].
The main aim of the corrective surgery is to
restore active dorsiflexion of the foot so that the
gait becomes normal. This is achieved by re-
routing the tendon of Tabialis posterior muscle to
run in front of the ankle with lengthening of
tendo-achillis. This muscle then functions as a
dorsiflexor of the foot. The procedure is
known as ‘Tibialis posterior transfer’ with
lengthening of tendo-achillis [3,6]. We present
three cases of foot drops who were managed
surgically. The patients had preoperative
physiotherapy for ten days and postoperative
physiotherapy for four weeks. Their post-
operative periods were uneventful and the
corrections were satisfactory.
1.1 Procedure
The operation is usually done under spinal or
general anaesthesia. A small incision is made
over the tuberosity of the navicular bone to
identify the tendon of tibialis posterior. The
tendon is then detached and withdrawn
proximally above the ankle through a 8 cm
curved incision on the medial side of the lower
leg. The lowest muscle fibres inserting into
tibialis posterior tendon are shaved off from the
tendon in order to get a better length of the
tendon. The tendon is then split longitudinally
into two “tails” up to the point where it will cross
the tibia proximally. A closed Z-plasty is then
done to increase the length of the achillis tendon.
Through a transverse incision on the dorsum of
the foot the extensor hallucis longus and
extensor digitorum longus is identified. A tendon
tunneller (Andersen’s tunneller) is passed from
the wounds in the dorsum to the wound in the
leg. Two separate subcutaneous tunnels are
made and the two “tails” of motor slips are pulled
through to run in front of the ankle. The motor
slips are pulled through. One is implanted in the
tendon of extensor hallucis longus and the other
in the tendons of extensor digitorum longus.
During this stage the knee is held in flexion of
about 30 degrees and the ankle in dorsiflexion of
at least 10 degrees. The motor tendons are kept
in moderate tension. After operation a below-
knee plaster is applied, with the foot further
dorsiflexed to release any tension on the tendon
sutures during healing. The plaster is bivalved
after four weeks, stitches are removed and re-
educative exercises are commenced [3,7].
2. CASE PRESENTATION
2.1 Case 1
A 10-year old girl presented with right foot drop
of 2-year duration. She was the second child of
her mother who also had Hansen’s disease. She
was separated from her mother when she was 2
years old and was living with one of her mother’s
relatives. She was returned back to her mother
when they noticed that she could no longer walk
properly. She stopped schooling on account of
this deformity. Her mother took her to a leprosy
center for medical care. She was examined at
the
center and found to have Hansen disease
with right foot drop. She was treated with MDT
for 1
year and was later referred to our centre for
correction of the foot drop. She had pre
physiotherapy for 10 days to strengthen the
Tibialis Posterior tendon [8]
. Transfer of Tibialis
Posterior with closed tenotomy was done and
short leg cast was applied for four weeks. The
cast was removed at the end of 4th week and
sutures were also removed. She had post
operative physiotherapy for another four weeks
aft
er which she regained the ability to dorsiflex
the right foot.
(a)
(b)
(c)
Amole et al.; JAMPS, 21(4): 1-6, 2019
; Article no.
3
properly. She stopped schooling on account of
this deformity. Her mother took her to a leprosy
center for medical care. She was examined at
center and found to have Hansen disease
with right foot drop. She was treated with MDT
year and was later referred to our centre for
correction of the foot drop. She had pre
-operative
physiotherapy for 10 days to strengthen the
. Transfer of Tibialis
Posterior with closed tenotomy was done and
short leg cast was applied for four weeks. The
cast was removed at the end of 4th week and
sutures were also removed. She had post
-
operative physiotherapy for another four weeks
er which she regained the ability to dorsiflex
(d)
Fig. 1. (a) Pre-
operative (Foot at rest); (b)
Post-
operative (Foot at rest); (c) Pre
(Dorsiflexion); (d) Post-
operative
(Dorsiflexion)
(a)
(b)
; Article no.
JAMPS.52673
operative (Foot at rest); (b)
operative (Foot at rest); (c) Pre
-operative
operative
(c)
(d)
Fig. 2. (a) Pre-
operative (Foor at rest); (b)
Post-
operative (Foot at rest); (c) Pre
(dorsiflexion); (d) Post-
operative
(Dorsiflexion)
2.2 Case 2
A 38-
year old Imam presented with 17
history of left foot drop. He noticed that his left
leg was becoming weak and sometimes slippers
fell off his foot without him knowing. He had
visited many hospitals without any significant
improvement in his condi
tion. His father
eventually took him to a leprosy center where
diagnosis of Hansen disease with left foot drop
was made and he was treated for a year with
Amole et al.; JAMPS, 21(4): 1-6, 2019
; Article no.
4
operative (Foor at rest); (b)
operative (Foot at rest); (c) Pre
-operative
operative
year old Imam presented with 17
-year
history of left foot drop. He noticed that his left
leg was becoming weak and sometimes slippers
fell off his foot without him knowing. He had
visited many hospitals without any significant
tion. His father
eventually took him to a leprosy center where
diagnosis of Hansen disease with left foot drop
was made and he was treated for a year with
MDT. He later discovered that his father had
similar illness and he was treated without the
knowledg
e of his family members. He had two
wives and five children and none of them has
Hansen disease. Whenever his friends asked
about the cause of his limping, he usually lied to
them that he was involved in road traffic
accident. He dropped out of school afte
secondary school and became an Imam because
of his health condition. He was referred to our
center for foot drop correction. He had pre
operative physiotherapy for 10 days to
strengthen the Tibialis Posterior tendon. Transfer
of Tibialis Posterior with c
losed tenotomy was
done and short leg cast was applied for four
weeks. The cast was removed at the end of 4
week and sutures were also removed. The post
operative period was uneventful and he had
post-
operative physiotherapy for another four
weeks after
which he regained the ability to
dorsiflex the left foot.
(a)
(b)
; Article no.
JAMPS.52673
MDT. He later discovered that his father had
similar illness and he was treated without the
e of his family members. He had two
wives and five children and none of them has
Hansen disease. Whenever his friends asked
about the cause of his limping, he usually lied to
them that he was involved in road traffic
accident. He dropped out of school afte
r
secondary school and became an Imam because
of his health condition. He was referred to our
center for foot drop correction. He had pre
-
operative physiotherapy for 10 days to
strengthen the Tibialis Posterior tendon. Transfer
losed tenotomy was
done and short leg cast was applied for four
weeks. The cast was removed at the end of 4
th
week and sutures were also removed. The post
-
operative period was uneventful and he had
operative physiotherapy for another four
which he regained the ability to
(c)
(d)
Fig. 3. (a) Pre-operative (
foot at rest
operative (foot at rest); (c) Pre
-
(dorsiflexion); (d) Post-
operative
(Dorsiflexion)
2.3 Case 3
A 38-
year old driver presented with history of
weakness of left foot of 2 year duration. He
claimed that he stepped on a charm at a motor
park two years earlier. He believed that the
weakness was as a result of the charm that he
stepped on. There was no hist
ory of Leprosy in
his family. He had not been able to continue with
his job because of this weakness. He was
advised by one of his friends who suspected that
what he had was leprosy to visit our center for
medical care. He was examined in our center
and he was found to have left foot
-
smear for M.
leprae was done and was positive.
He was treated with MDT for a year. After the
completion of the treatment, he had pre
operative physiotherapy for 10 days to
strengthen the Tibialis Posterior tendon. Transfer
of Tibialis Posterior with closed tenotomy was
done and short leg cast was applied for four
Amole et al.; JAMPS, 21(4): 1-6, 2019
; Article no.
5
foot at rest
); (b) Post-
-
operative
operative
year old driver presented with history of
weakness of left foot of 2 year duration. He
claimed that he stepped on a charm at a motor
park two years earlier. He believed that the
weakness was as a result of the charm that he
ory of Leprosy in
his family. He had not been able to continue with
his job because of this weakness. He was
advised by one of his friends who suspected that
what he had was leprosy to visit our center for
medical care. He was examined in our center
-
drop. Skin slit
leprae was done and was positive.
He was treated with MDT for a year. After the
completion of the treatment, he had pre
-
operative physiotherapy for 10 days to
strengthen the Tibialis Posterior tendon. Transfer
of Tibialis Posterior with closed tenotomy was
done and short leg cast was applied for four
weeks. The cast was removed at the end of 4
week and sutures were also removed. The post
operative period was uneventful and he had
post-
operative physiotherapy for another four
weeks after which he regained
dorsiflex the left foot.
3. DISCUSSION
Foot drop
is a sign of an underlying problem
rather than a condition itself.
Foot drop is caused
by nerve function impairment
(NFI) of the deep
branch of the lateral popliteal (common peroneal)
nerve. The tibialis anterior, extensor hallucis
longus, extensor digitorum longus, and peroneus
tertius muscles are Pa
ralysed. Superficial branch
involvement leads to paralysis of perone
longus and brevis, leading to loss of ankle
dorsiflexion, foot eversion, and toe extension.
Foot drop deformity is result of inability to
dorsiflex the foot [4,9].
The site where common peroneal nerve
involvement usually occur is at the head of the
fib
ula and it is at this site the common peroneal
nerve divides into its two branches. Depending
on the extent of damage therefore, the patient
may present with a complete foot drop in which
both branches are affected or an
incomplete/irregular footdrop, usua
the
anterior tibial muscles with sparing of the
evertors [1,10].
Initially, the paralysis is temporary and recovery
is possible if detected early and treated with
steroids, physiotherapy and electrical stimulation
of the muscles [
10]. If the muscles do not recover
by three months after initiation of steroid and
physiotherapy, it is quite likely that recovery may
not occur. All the three cases presented in our
series did not recover from the paralysis. All
patients whose muscles fai
led to recover will
benefit from surgical management. Review of
literature shows description of non
management that includes use of an ankle
orthosis. The outcome of this is less satisfactory
when compared with surgical management. It is
onl
y advocated where the patient or the foot is
not fit for surgery or where the surgical service is
not available [1].
Surgical correction of foot drop is relatively easy,
compared to tendon transfer surgery procedures
in the hand. Re-
education is also less
and chances for postoperative complications are
less. It is a procedure that is very rewarding and
it will help in reducing stress on the
anterior/lateral side of the foot, the site of the foot
; Article no.
JAMPS.52673
weeks. The cast was removed at the end of 4
th
week and sutures were also removed. The post
-
operative period was uneventful and he had
operative physiotherapy for another four
weeks after which he regained
the ability to
is a sign of an underlying problem
Foot drop is caused
(NFI) of the deep
branch of the lateral popliteal (common peroneal)
nerve. The tibialis anterior, extensor hallucis
longus, extensor digitorum longus, and peroneus
ralysed. Superficial branch
involvement leads to paralysis of perone
us
longus and brevis, leading to loss of ankle
dorsiflexion, foot eversion, and toe extension.
Foot drop deformity is result of inability to
The site where common peroneal nerve
involvement usually occur is at the head of the
ula and it is at this site the common peroneal
nerve divides into its two branches. Depending
on the extent of damage therefore, the patient
may present with a complete foot drop in which
both branches are affected or an
incomplete/irregular footdrop, usua
lly paralysis of
anterior tibial muscles with sparing of the
Initially, the paralysis is temporary and recovery
is possible if detected early and treated with
steroids, physiotherapy and electrical stimulation
10]. If the muscles do not recover
by three months after initiation of steroid and
physiotherapy, it is quite likely that recovery may
not occur. All the three cases presented in our
series did not recover from the paralysis. All
led to recover will
benefit from surgical management. Review of
literature shows description of non
-operative
management that includes use of an ankle
-foot
orthosis. The outcome of this is less satisfactory
when compared with surgical management. It is
y advocated where the patient or the foot is
not fit for surgery or where the surgical service is
Surgical correction of foot drop is relatively easy,
compared to tendon transfer surgery procedures
education is also less
demanding
and chances for postoperative complications are
less. It is a procedure that is very rewarding and
it will help in reducing stress on the
anterior/lateral side of the foot, the site of the foot
Amole et al.; JAMPS, 21(4): 1-6, 2019; Article no.JAMPS.52673
6
where patients are likely to develop ulcers if they
have concomitant paralysis of the posterior tibial
nerve [5,11]. The three patients had preoperative
physiotherapy for ten days and postoperative
physiotherapy for four weeks. Their post-
operative periods were uneventful and the
corrections were satisfactory.
4. CONCLUSION
Surgical correction of foot drop usually leads to
restoration of active dorsiflexion of the foot
thereby preventing development of secondary
deformities and ulceration. Patient may end up
having below knee amputation because of the
secondary deformities and recurrent ulceration if
the foot drop is not corrected on time [4].
CONSENT
We declare that ‘written informed consent was
obtained from the patients for publication of this
case series.
ETHICAL APPROVAL
We hereby declare that the study has been
examined and approved by the appropriate
ethics committee and have therefore been
performed in accordance with the
ethical standards laid down in the 1964
Declaration of Helsinki.
ACKNOWLEDGEMENT
We would like to appreciate Damien Foundation
Belgium for sponsoring the training of the doctor
and the physiotherapist and for the establishment
of the Reconstructive Center.
COMPETING INTERESTS
Authors have declared that no competing
interests exist.
REFERENCES
1. Srinivasan H, Palande DD. Essential
surgery in leprosy technique for district
hospitals. World Health Organization.
1997;68-78.
2. Aydin A, Topal M, Tuncer K, Canbek U,
Yildiz V, Kose M. Extramembranous
transfer of the tibialis posterior tendon for
the treatment of drop foot deformity in
children. Arch Iran Med. 2013;16(11):647–
651.
3. Schwarz R, Brandsma W. Surgical
reconstruction & rehabilitation in leprosy
and other neuropathies. Nepal. Ekta books
distribution pvt. Ltd. 2004;176-190.
4. Qian JG, Yan LB, Li WZ, Zhang GC.
Posterior tibialis transfer for foot-drop due
to leprosy: a case with 40 years follow up.
The British Association of Plastic Surgeon.
2004;57:450-2.
5. Hesham ES, Nabil A, Amr FK. Tendon
transfer for foot drop: A simple procedure
with effective outcome local experience.
Open Journal of Modern Neurosurgery.
2019;9:258-268.
6. Indrajeet K, Alok R, Laljee C.
Postoperative functional results of
posterior tibial tendon transfer for foot drop
as a consequence of nerve palsy in
leprosy. Annals of International Medical
and Dental Research. 2016; 2(3):118-202.
7. Srinivasan H, Mukherjee SM,
Subramaniam RR. Two-tailed transfer of
tibialis posterior for correction of drop-foot
in leprosy. The Journal of Bone and Joint
Surgery. 1968;50 (3):623–8.
8. Chaurasia RK. The role of tibialis posterior
tendon transfer in foot drop by circumtibial
route and evaluation of the results
according to criteria. Int Surg J. 2019;
6(8):2880-4.
9. Andersen JG. Foot drop in leprosy and its
surgical correction. ACTA Orthopaedica
Scandinavica, 1963;33:1-4:151-171.
DOI: 10.3109/17453676308999843
10. Sridhar K, Mohamed I. Tendon transfers in
foot drop. Indian J Plast Surg. 2019;52(1):
100–8.
11. Warren AG. The correction of foot drops in
leprosy. The Journal of Bone and Joint
Surgery. 1968;50(3):629-634.
_________________________________________________________________________________
© 2019 Amole et al.; This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
Peer-review history:
The peer review history for this paper can be accessed here:
http://www.sdiarticle4.com/review-history/52673
