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Foot drop: Where, why and what to do?
Abstract
Foot drop is a common and distressing problem that can lead to falls and injury. Although the most frequent cause is a (common) peroneal neuropathy at the neck of the fibula, other causes include anterior horn cell disease, lumbar plexopathies, L5 radiculopathy and partial sciatic neuropathy. And even when the nerve lesion is clearly at the fibular neck there are a variety of causes that may not be immediately obvious; habitual leg crossing may well be the most frequent cause and most patients improve when they stop this habit. A meticulous neurological evaluation goes a long way to ascertain the site of the lesion. Nerve conduction and electromyographic studies are useful adjuncts in localising the site of injury, establishing the degree of damage and predicting the degree of recovery. Imaging is important in establishing the cause of foot drop be it at the level of the spine, along the course of the sciatic nerve or in the popliteal fossa; ultrasonography, CT and MR imaging are all useful. For patients with a severe foot drop of any cause, an ankle foot orthosis is a helpful device that enables them to walk better and more safely.
... Peroneal nerve palsy is the most common cause of foot drop, with various mechanisms of injury having been identified, including direct trauma, tumor, infection and metabolic disorder 6,11,18) . Although less frequent, a foot drop can develop as a secondary outcome of a central lesion, such as anterior horn cell disease and/or lesion to the sciatic nerve, lumbar plexus, lumbo-sacral trunk and the axons of the L4 and L5 spinal nerves 15) . Although lower motor neuron and peripheral nerve lesions have commonly been described as causes of foot drop in clinical practice, a few studies have also reported lesions of the head and neck as possible causes of a foot drop, with stroke being a specific example of a central cause. ...
... A foot drop can be reflective of a number of myopathies and neuropathies, ranging from direct trauma to the peroneal nerve to myotonic dystrophy and other types of distal muscular dystrophies, such as Welander, Nonaka and Laing types of distal myopathies 6) . Although peripheral and lumbar spine lesions are the most common causes of foot drop 6,11,15,18) , lesions of the central nervous system and upper motor neurons can also result in a drop foot. ...
... The lateral trunk of Supplementary. Pre-operative dynamic cervical MRI extension showed more severe stenosis at C3-4, C4-5, C5-6 level the sciatic nerve becomes the common peroneal nerve, At this point, the common peroneal nerve divides into the superficial and deep peroneal nerves 15) . Because of its superficial position around the head and neck of the fibula, the peroneal nerve can easily be compressed by an external force, such as prolonged sitting with legs crossed. ...
... Foot drop is often encountered in clinical practice and is associated with significant morbidity. The etiology is broad, 1,2 with causes ranging from lesions affecting the peripheral nervous system (radiculopathies, common peroneal nerve palsies, trauma, double crush, Charcot-Marie-Tooth), [1][2][3][4][5] pathologies of the central nervous system (stroke, tumor, or cerebral palsy), or both (motor neuron disease). Clinical history, neurological examination, and imaging assist with identifying the site of the lesion. ...
... Clinical history, neurological examination, and imaging assist with identifying the site of the lesion. 2,5 Imaging is often confirmatory, with nerve-conduction studies particularly useful for patients with normal lumbar spine magnetic resonance imaging (MRI) findings. [6][7][8] Despite the available investigative options, diagnosing the cause of foot drop can be challenging, especially in patients with confounding lumbar spondylosis 1,2,5 Common causes of foot drop in neurosurgical practice are peroneal nerve injury, 2 L5 radiculopathy, sciatic neuropathies, and lumbosacral plexopathies. ...
... 2,5 Imaging is often confirmatory, with nerve-conduction studies particularly useful for patients with normal lumbar spine magnetic resonance imaging (MRI) findings. [6][7][8] Despite the available investigative options, diagnosing the cause of foot drop can be challenging, especially in patients with confounding lumbar spondylosis 1,2,5 Common causes of foot drop in neurosurgical practice are peroneal nerve injury, 2 L5 radiculopathy, sciatic neuropathies, and lumbosacral plexopathies. 2,5 Less common causes, such as mononeuritis multiplex or sciatic neuropathy, [9][10][11][12] can be diagnostically challenging, particularly when the cause is underreported in the literature, such as in isolated L5 neuritis. ...
BACKGROUND
New-onset adult foot drop is commonly encountered in neurosurgical practice and has a broad differential, including radiculopathy, peroneal nerve palsy, demyelinating diseases, and central causes. Etiology is commonly identified with comprehensive history, examination, imaging, and investigations. Despite familiarity with the management of lumbar spondylosis and peroneal nerve compression causes, rare or uncommon presentations of nonsurgical causes are important to consider in order to avoid nonbeneficial surgery.
OBSERVATIONS
The authors report a very uncommon cause of foot drop: new-onset isolated L5 mononeuritis in a 61-year-old nondiabetic male. They provide a review of the etiology and diagnosis of foot drop in neurosurgical practice and detail pitfalls during workup and the strategy for its nonsurgical management.
LESSONS
Uncommon, nonsurgical causes for foot drop, even in the setting of degenerative lumbar spondylosis, should be considered during workup to reduce the likelihood of unnecessary surgical intervention. The authors review strategies for investigation of new-onset adult foot drop and relate these to an uncommon cause, an isolated L5 mononeuritis, and detail its clinical course and response to treatment.
... Foot drop is caused by a weakness of dorsiflexion of the ankle and toes, leading to a lack of heel strike during ambulation [1,2]. It can be seen in isolation, and it can be unilateral or bilateral and temporary or permanent [2,3]. ...
... It can be seen in isolation, and it can be unilateral or bilateral and temporary or permanent [2,3]. The most common cause of foot drop is common peroneal neuropathy which can be due to external compression of the common peroneal nerve as it winds around the fibula head, direct trauma or traction injuries [1][2][3]. Other causes include lower motor neurone disorders such as L5 radiculopathy or lumbosacral plexopathies [1,2]. ...
... The most common cause of foot drop is common peroneal neuropathy which can be due to external compression of the common peroneal nerve as it winds around the fibula head, direct trauma or traction injuries [1][2][3]. Other causes include lower motor neurone disorders such as L5 radiculopathy or lumbosacral plexopathies [1,2]. Central causes, such as amyotrophic lateral sclerosis, are less common but must also be considered [1]. ...
Foot drop secondary to common peroneal neuropathy is frequently due to trauma or external compression. Ankle sprains are a rarer cause of this pathology and are extremely uncommon in the paediatric population. We present two cases of acute isolated unilateral foot drop in children, both following minimal trauma. Prompt investigation with magnetic resonance imaging (MRI), electromyography (EMG) and nerve conduction studies can assist in localising the level of the lesion and indicate prognosis. Both patients made a full recovery with the use of ankle-foot orthoses and physiotherapy. This case series highlights that although rare, common peroneal nerve palsy can occur in children following relatively minor trauma. Clinicians should identify this pathology early with a detailed clinical assessment and focussed investigations to increase the potential for a favourable recovery and avoid secondary problems.
... The distribution of weight-bearing in the lower limbs is considered to be an important factor affecting balance. Ideally, 50% of the body weight should be handled by each of the left and right lower limbs [19,20]. The ideal load-bearing distribution of each foot is generally considered to be 2/3 on the posterior foot [18,19,21]. ...
... Ideally, 50% of the body weight should be handled by each of the left and right lower limbs [19,20]. The ideal load-bearing distribution of each foot is generally considered to be 2/3 on the posterior foot [18,19,21]. Morasiewicz et al. evaluated the distribution of load on the lower limbs and balance before and after ankle arthrodesis with the Ilizarov method [22,23]. ...
... Sit-to-stand training with visual feedback may represent a useful means of reestablishing balance in such patients. [19,20,24] This study has following limitations. When the static balance and plantar load distribution were evaluated during the study, although we drew footprints on the floor to indicate how the participants should stand, in reality the feet of each of the participants may have been placed differently, to avoid pain in the affected foot. ...
Objective
Tibial cortex transverse distraction (TCTD) has been recently reported for the treatment of diabetic foot ulcers. Herein, we explored the characteristics of the impairments in static balance and plantar load distribution in patients.
Methods
We performed a retrospective study of 21 patients with diabetic foot ulcers who underwent TCTD, who were regularly followed up for > 1 year after surgery, and 20 healthy individuals (control group). A pressure platform was used to assess the standing balance functions of the lower extremities and the plantar load distribution.
Results
One patient underwent amputation because of severe infection. In patient group, center of pressure (COP) ellipse sway area, COP path length and angle θ were all larger, compared with those of control group (250.15 ± 98.36 mm² vs. 135.67 ± 53.21 mm², 145.15 ± 67.43 mm vs. 78.47 ± 34.15 mm, 39.75 ± 17.61° vs. 22.17 ± 14.15°), with statistically significant differences (P < 0.01). The average plantar load and backfoot load of the unaffected side was significantly larger than that of the affected side (58.4 ± 5.5% vs. 41.6 ± 5.5%, 45.3 ± 6.4% vs. 36.5 ± 5.6%), but they were similar for the two feet of members of the control group.
Conclusions
Although TCTD may represent an appropriate method for the treatment of diabetic foot ulcers, postoperative impairments in static balance and plantar load distribution remain in the long term. These potential long-term problems should be taken into account in further rehabilitation planning.
Type of study/level of evidence: Therapeutic III.
... Peroneal neuropathy is the most common mononeuropathy in the lower limb [1, 2] frequently causing foot drop, leading to gait difficulties and an increased risk of falling [3]. As the aetiology of peroneal neuropathy is broad and treatment strategies potentially differ accordingly, we previously proposed to classify peroneal neuropathies as idiopathic, idiopathic with established risk factors (e.g. ...
... The main objective is to assess whether foot drop, caused by peroneal nerve entrapment recovers better within 9 months after decompressive surgery compared to prolonged conservative treatment. This research question is highly relevant, since peroneal nerve entrapment is one of the most frequent causes of foot drop, causing gait difficulties and increased risk of falling [3,58]. In the absence of guidelines or high-quality literature, current management strategies range from early neurolysis to prolonged non-invasive care without surgery. ...
Background
High-quality evidence is lacking to support one treatment strategy over another in patients with foot drop due to peroneal nerve entrapment. This leads to strong variation in daily practice.
Methods/design
The FOOTDROP (Follow-up and Outcome of Operative Treatment with Decompressive Release Of The Peroneal nerve) trial is a randomized, multi-centre study in which patients with peroneal nerve entrapment and persistent foot drop, despite initial conservative treatment, will be randomized 10 (± 4) weeks after onset between non-invasive treatment and surgical decompression. The primary endpoint is the difference in distance covered during the 6-min walk test between randomization and 9 months later. Time to recovery is the key secondary endpoint. Other secondary outcome measures encompass ankle dorsiflexion strength (MRC score and isometric dynamometry), gait assessment (10-m walk test, functional ambulation categories, Stanmore questionnaire), patient-reported outcome measures (EQ5D-5L), surgical complications, neurological deficits (sensory changes, motor scores for ankle eversion and hallux extension), health economic assessment (WPAI) and electrodiagnostic assessment.
Discussion
The results of this randomized trial may elucidate the role of surgical decompression of the peroneal nerve and aid in clinical decision-making.
Trial registration
ClinicalTrials.gov NCT04695834. Registered on 4 January 2021.
... A wide differential diagnosis should be considered when evaluating a patient with foot drop, with consideration of uncommon pathologies such as lumbar plexopathy, radiculopathy, anterior horn cell disease, central causes, in addition to peroneal nerve compression and entrapment. 1 Additionally, tumors and masses are not uncommon along the course of the common peroneal nerve and its branches and should be considered in the differential diagnosis. Additionally, both benign and malignant lesions may present similarly, such as lipomas, benign and malignant nerve sheath tumors. 1 Imaging is a valuable tool for not only identifying lesions and avoiding misdiagnosis, but also differentiating between these pathologies for surgical planning and successful intervention. ...
... Additionally, both benign and malignant lesions may present similarly, such as lipomas, benign and malignant nerve sheath tumors. 1 Imaging is a valuable tool for not only identifying lesions and avoiding misdiagnosis, but also differentiating between these pathologies for surgical planning and successful intervention. ...
BACKGROUND
Foot drop is a common complaint with a broad differential diagnosis making imaging a key part of the diagnostic workup. The authors present a patient with an occult peroneal intraneural ganglion cyst who underwent imaging with high-frequency ultrasound (US) and high-resolution magnetic resonance imaging (MRI) to highlight the role of such techniques in cases of peroneal neuropathy.
OBSERVATIONS
Intraneural ganglion cysts are emerging as a common cause of common peroneal neuropathy. Imaging with US and MRI is a valuable tool used to illustrate the pertinent anatomy and identify the articular branch joint connection and cyst as part of the surgical planning and definitive management.
LESSONS
Intraneural ganglion cysts can be small or nearly invisible and failure to appreciate the intraneural cyst can lead to symptom or cyst persistence or recurrence. High-resolution modalities can be useful in the diagnosis and surgical planning of difficult cases.
... Consequently, it is more vulnerable to be compressed or injured in here. [4,5,8,9,12] Particularly, thin and slender people have thin subcutaneous tissue at the fibular neck that makes them more vulnerable to such injuries. [8,9] Aigner et al. [13] confirmed that the neck of the fibula had not been a safe area, concerning osteotomies or bone biopsies. ...
... [4,5,8,9,12] Particularly, thin and slender people have thin subcutaneous tissue at the fibular neck that makes them more vulnerable to such injuries. [8,9] Aigner et al. [13] confirmed that the neck of the fibula had not been a safe area, concerning osteotomies or bone biopsies. When the nerve is compressed, decrease in microvascular blood flow and axonal transport degradation can destroy the nerve structure and function within hours. ...
Objectives: Short leg casts are routine applications in orthopaedic practice. The aim of the study was to investigate the course of the common fibular nerve and its branches (deep and superficial fibular nerves) around the fibular neck in order to describe a convenient method for applying the lower extremity casts with low risk of fibular nerve entrapment. Methods: Fifty lower extremities of 26 cadavers were examined. The point where common fibular nerve itself or its branches (deep and superficial fibular nerves) crossed over the fibular neck were dissected. The points where the nerve or its branches have risk of compression between the fibula and the cast were investigated in relation to fibular length. Results: The average fibular length was 356.9±26.4 mm. The common fibular nerve did not pass over the fibular neck in any specimen, instead, its branches crossed over it. The average distance from the tip of the fibular head to deep fibular nerve and superficial fibular nerve were 42.9±6.5 mm and 52±6.3 mm, respectively. The mean ratio of fibular length to these distances were 8.5±1.2 and 7.0±0.8, respectively. Conclusion: As short knee casts is a frequent application in clinical practice, it is important to determine a safe upper border for the casts to protect common fibular nerve or its branches. We recommend that the upper border of short leg casts should not exceed the upper 1/7th of the fibular length of the patient in order to avoid fibular nerve palsy.
... Based on outcome predictions, gait training while wearing ankle-foot orthoses (AFO) was prescribed. As a result of the early and continuous intervention, this patient returned to work and recovered the same life as before the onset of his disease [4]. ...
... Peroneal palsy is a frequent cause of foot drop, and mostly due to the pressure on the fibular neck just below the knee. [1] Patients with unilateral peroneal nerve palsy are frequently encountered in clinical practice. However, peroneal nerve palsy is rarely bilateral. ...
... It is a consequence of impaired neural supply to the dorsiflexors of the ankle, namely tibialis anterior, extensor hallucis longus and extensor digitorum longus. This may be due to pathology arising from the superficial peroneal nerve, common peroneal nerve, sciatic nerve or L5 nerve root (however additional pathology in L4 and S1 may contribute) [1]. Pathology of the L5 nerve root can be attributed to degenerative disease of the spine such as disc herniation, degenerative spondylolisthesis and spinal stenosis [2]. ...
Purpose
Foot drop can uncommonly be a painless presenting symptom of degenerative spinal disorders. This systematic review aimed to summarise the literature on the management and outcomes of patients with a painless foot drop.
Methods
We performed a systematic review of PubMed, EMBASE and Medline according to PRISMA guidelines. All studies published after 1980 in English referring to adult patients with a painless foot drop were included. Exclusion criteria included opinion based reports, review articles and articles in which foot drop was not caused by degenerative pathology of the thoracolumbar spine.
Results
Of 62 included patients, 30 (48.4%) were male with an average age of 48.7 years (range 27–84). The mean duration of symptoms was 69.0 days (1–700). 98.8% were managed operatively. 46 (74.2%) patients had symptomatic improvement, with 41 (66.1%) having a post-intervention MRC power grading of 3 or above. Patients with a pre-procedure MRC 0 had a higher median increase in MRC post-procedure than those with MRC > 0. Of two studies comparing painful and painless symptoms, painless foot drop patients were less likely to recover to MRC equal to or over 3 than those with painful symptoms OR 0.31 (95% CI 0.04–2.65).
Conclusion
This systematic review and meta-analysis demonstrates a role for surgery in facilitating the neurological recovery of patients with a painless foot drop. Large randomised controlled studies are required to characterise the role of operative intervention in these patients and compare outcomes between patients with painless and painful foot drop.
... In certain circumstances, such as in elite athletes and those with significantly displaced fractures, surgical intervention may be required in order to minimise healing time [4]. Foot drop occurs when the dorsiflexors of the foot are not strong enough to lift the forefoot [9]. The dorsiflexors of the foot and ankle weaken, resulting in an equinovarus deformity. ...
The sacroiliac joint is frequently broken apart by high-energy trauma, which increases fatalities and complications from pelvic injuries. Ilium fractures are high-energy pelvic fractures that often progress from the iliac crest to the greater sciatic notch. Concomitant head injury exsanguinations and uncontrollable bleeding within the pelvis are considered important causes of mortality. In contrast, some assume that such extensive bleeding is extremely uncommon and that accompanying injuries could result in increased mortality. A shorter healing period and faster patient mobilization are possible with surgically treated Tile's type B and C fractures. Accident-related fractures can lead to decreased independence and functioning, restricted mobility, lowered self-confidence, and a worse quality of life; these fractures are caused by trauma, most frequently from minor falls and age-related osteopenia. By reducing discomfort, restoring range of motion and muscular strength, and assisting with early ambulation/loading of the fractured limb, early physical therapy intervention speeds up the clinical recovery of patients with fractures. When one cannot elevate the forefoot, it results in foot drop because of a lack of dorsiflexor strength in the foot. These may induce a risky antalgic gait, leading to falls-the diminished ability to lift the foot of the ankle or the toes (dorsiflexion). Injuries, including fractures, joint dislocations, or hip replacement surgery, can also result in a drop foot. The peroneal nerve, which innervates the tibialis anterior, is the muscle responsible for dorsiflexion, as it arises from the sciatic nerve's branch. Due to the foot drop, the anterior tibialis muscle will shorten and cause spasms in the calf muscle. After surgery, the patient was dependent and had difficulty going about his everyday life. However, the physiotherapy intervention improved the patient's pain and physical functionality. By lowering discomfort, restoring range of motion and muscular strength, and facilitating early ambulation/loading of the fractured limb, this study shows that combining definitive surgical methods with early physical therapy intervention speeds up the clinical recovery of patients with fractures.
... Consistent with the SL sign, the foot-drop due to DF weakness is a common clinical manifestation and may be the prominent feature of lower-limbs involvement in ALS . On the other hand, several disorders may produce a foot-drop, including peroneal neuropathy at the fibular-head, lumbar spondylosis disease, and peripheral neuropathies (Stewart, 2008;Hu et al., 2019). ...
Amyotrophic lateral sclerosis (ALS) is the most common motor neuron disease and has emerged among the disorders with the largest increasing incidence in Western countries. Although the diagnosis is based on clinical grounds, electromyography (EMG), and nerve conduction studies (NCS) play a crucial role to exclude other potential etiologies of lower motor neuron (LMN) dysfunction. Based on clinical grounds, a peculiar pattern of dissociated atrophy of the intrinsic hand and foot muscles, termed the “split-hand” (SH) and “split-leg” (SL) signs, has been described in a significant proportion of subjects with ALS, even at the early stages of the disease, when symptoms are focal. These signs are rare in neurological and non-neurological diseases other than ALS. In this review, we discussed current evidences concerning SH and SL signs, their pathogenetic hypotheses and neurophysiological findings. We also analyze whether SH and SL signs can be reliable markers in the differential diagnosis and in the prognosis of ALS.
... In addition to myogenic and neurogenic processes, lumbar spine disorders (e.g., lumbar degenerative disease, intervertebral disc herniation, and spinal stenosis) are common neurogenic causes of foot drop (Stewart, 2008). Foot drop resulting from lumbar spine disorder is a special presentation of a severe motor deficit (Iizuka et al., 2009;Wang and Nataraj, 2014). ...
Foot drop is a common clinical gait impairment characterized by the inability to raise the foot or toes during walking due to the weakness of the dorsiflexors of the foot. Lumbar spine disorders are common neurogenic causes of foot drop. The accurate prognosis and treatment protocols of foot drop are not well delineated in the scientific literature due to the heterogeneity of the underlying lumbar spine disorders, different severities, and distinct definitions of the disease. For translational purposes, the use of animal disease models could be the best way to investigate the pathogenesis of foot drop and help develop effective therapeutic strategies for foot drops. However, no relevant and reproducible foot drop animal models with a suitable gait analysis method were developed for the observation of foot drop symptoms. Therefore, the present study aimed to develop a ventral root avulsion (VRA)-induced foot drop rat model and record detailed time-course changes of gait pattern following L5, L6, or L5 + L6 VRA surgery. Our results suggested that L5 + L6 VRA rats exhibited changes in gait patterns, as compared to sham lesion rats, including a significant reduction of walking speed, step length, toe spread, and swing phase time, as well as an increased duration of the stance phase time. The ankle kinematic data exhibited that the ankle joint angle increased during the mid-swing stage, indicating a significant foot drop pattern during locomotion. Time-course observations displayed that these gait impairments occurred as early as the first-day post-lesion and gradually recovered 7–14 days post-injury. We conclude that the proposed foot drop rat model with a video-based gait analysis approach can precisely detect the foot drop pattern induced by VRA in rats, which can provide insight into the compensatory changes and recovery in gait patterns and might be useful for serving as a translational platform bridging human and animal studies for developing novel therapeutic strategies for foot drop.
... [4,5] This condition is related to the weakness or lack of voluntary control in ankle dorsiflexors and/or the increased spasticity of plantar flexor muscles. [6][7][8] Foot drop results in disruption of weight acceptance and weight transfer in the initial foot contact and stance phases and interferes with ankle dorsiflexion during the swing phase of the gait. [9] Thus, foot drop leads to an inefficient walking speed, reduces gait stability, [10] and increases the risk of falls. ...
Background:
Foot drop is a common complication in post-stroke. Patients with foot drop are at high risk for falls and fall-related injuries. Accordingly, it can reduce independence and quality of life in patients. Clinical studies have confirmed that acupuncture is effective in treating foot drop in post-stroke. However, there is a lack of systematic review exploring the efficacy and safety of acupuncture treatment. This study aims to assess the efficacy and safety of acupuncture in the treatment of foot drop in poststroke from the results of randomized controlled trials.
Methods:
We will search articles in 8 electronic databases including the Cochrane Central Register of Controlled Trials, the Web of Science, PubMed, Embase, the China National Knowledge Infrastructure, the Chinese Biomedical Literature Database, Wanfang Data Database, and the Chinese Scientific Journal Database for RCTs of acupuncture treated foot drop in post-stroke from their inception to 10 August 2022. We will analyze the data meeting the inclusion criteria with the RevMan V.5.4 software. Two authors will assess the quality of the study with the Cochrane collaborative risk bias tool. We will evaluate the certainty of the estimated evidence with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. Data analysis will be performed using STATA 16.0.
Results:
This study will review and evaluate the available evidence for the treatment of foot drop in post-stroke using acupuncture.
Conclusion subsections:
This study will determine the efficacy and safety of acupuncture applied to post-stroke individuals with foot drop.
... Foot drop is defined as weakness of ankle dorsiflexion with a Medical Research Council (MRC) grade of 3/5 or less. 1 The overall incidence of foot drop secondary to lumbar degenerative disease (LDD) is not widely reported in the literature but is said to be approximately 3-5%. 2 The proposed mechanism is due to compression of the L5 nerve root from disc herniation, facet cysts, ligament hypertrophy, osteophytes or a combination of these factors. [3][4][5][6][7][8] However, there is also evidence to suggest other nerve roots, such as L4 and S1, may contribute to the innervation of the anterior tibialis muscle which is responsible for the foot drop. [9][10] Foot drop often presents as weakness in the dorsiflexion of the foot or great toe associated with leg pain and/or sensory changes in the corresponding dermatomal supply. ...
Purpose:
There is considerable variation in the management of foot drop secondary to lumbar degenerative disease (LDD) that occurs between centres and surgeons (spinal surgeons and neurosurgeons). The lack of standardised practice reflects the paucity in evidence base for management of this condition. In this survey, we aimed to assess current practice in the UK and identify the areas of variation.
Methods:
A case-based survey was distributed to members of the Society of British Neurological Surgeons and British Association of Spine Surgeons through an online questionnaire. The survey consisted of 10 questions designed to determine the management of foot drop secondary to LDD.
Results:
A total of 163 responses were collected among UK neurosurgeons and spinal surgeons with good geographical representation. 92% were Consultants. 86% of the respondents would offer surgery. The indication for offering surgery varied but 54% of respondents would offer surgery to patients who present with a painful foot drop. There was a huge variation in offering surgery dependent on the grade of weakness. The strongest prognostic indicator predicted was duration of weakness (92%). The timing of intervention was wide-ranging in the responses received. Almost all responded that they would be willing to participate in a prospective study in the future to determine best practice.
Conclusions:
This survey highlights the significant variability in management of foot drop secondary to LDD amongst consultant surgeons within the UK. It is also suggestive of a weak evidence base and indicates an urgent need for a high quality national prospective study.
... It oftentimes presents with a steppage gait with an audible slap when the foot hits the ground due to weakness in the dorsiflexors of the foot [1,2]. The most common causes of this condition are L5 radiculopathies and peroneal peripheral neuropathy [3][4][5]. Other causes include anterior horn disease, spinal cord lesions, brain disorders, sciatic nerve compression, lumbar plexopathies, and radiculopathies secondary to herniated nucleus pulposus or foraminal stenosis [4][5][6][7][8]. ...
This case report presents a 63-year-old male patient with chronic left foot drop. The etiology for his condition most likely involved lateral lumbar stenosis and/or sacroiliac joint dysfunction resulting in radiculopathy and subsequent symptoms. The patient was previously recommended a surgical approach for his condition. After an extensive osteopathic examination and application of a high-amplitude low-velocity technique, the patient reported a significant improvement in his pain and resolution of his foot drop. To the best of the author's knowledge, this is the first reported case of the use of osteopathic medicine in the successful treatment and management of left foot drop most likely secondary lumbar stenosis and/or sacroiliac joint dysfunction. The aim of this case report is to discuss the possible mechanisms by which the condition may have been resolved and the role that osteopathic treatment played in it.
... In the previous literature, patients with foot drop mainly were induced by peroneal mono-neuropathy and lumbar radiculopathy by lumbar disc herniation [13]. The main treatment was surgery, but the result of which was far from satisfactory. ...
Background
Foot drop is a syndrome resulting from weakness or paralysis of the tibialis anterior muscle. Some patients with thoracic disc herniation seek medical help complain of foot drop as the initial symptom. The study investigated the clinical characteristics of these patients and clarified the clinical efficacy after treatment.
Methods
A total of 13 patients with foot drop as the initial symptom arising from thoracic disc herniation were collected from January 2015 to December 2020. The average follow-up period was 20.5 months. We recorded neurological functions, the tibialis anterior muscle strength, Japanese Orthopedic Association score (JOA), location of the lesion, and occupation rate of herniation in the spinal canal preoperatively and at the final follow-up.
Results
None pathological reflex was found in the patients. Surgical treatment was performed in 12 of the 13 patients, and tibialis anterior functional recovery was observed in 83.4% (10/12) of the cases, with an average recovery rate of 52.8 ± 18.5%. The mean JOA score increased from 6.8 ± 1.9 points preoperatively to 8.9 ± 1.3 points postoperatively (p < 0.05), achieving a mean recovery rate of 52.3 ± 13.1%. The MRI showed the conus medullaris was obviously compressed at the level of T11–L1, and the occupation rate of herniation was more than 40% in all patients, with an average of 65.4 ± 16.3%. CT indicated that 84.6% of the cases had calcification in intervertebral discs.
Conclusion
Foot drop can be the initial symptom caused by thoracic disc herniation at the T11–L1 level, especially for the calcified disc herniation. A satisfactory recovery rate can be achieved by surgical decompression with fixation.
... Foot drop is characterized by the inability to dorsiflex the ankle, which causes patients to drag their toes along the ground and compensate with a high step gait. 1 It is most commonly caused by common peroneal nerve injury, typically following trauma to the neck of fibular. 2 Given that foot drop is caused by paralysis of the muscles of the anterior compartment of the leg, loss of these muscles secondary to compartment syndrome, muscle necrosis, or oncological resection will also cause foot drop. ...
Foot drop is a debilitating condition, which causes physical disability and psychological challenges associated with difficulties walking. We report the indications, novel technique, and successful outcomes of two children (three limbs) who underwent free functional gracilis muscle transfers coaptated to the common peroneal nerve to reanimate active foot dorsiflexion and correct foot drop secondary to loss of the anterior compartment.
... Common peroneal nerve palsy and ankle-foot disabilities due to stroke (cerebrovascular accident) can cause foot drop, which disturbs gait and negatively affects activities of daily living [1,2]. Peroneal neuropathy at the neck of the fibula, anterior horn cell disease, lumbar plexopathies, L5 radiculopathy, and partial sciatic neuropathy can cause common peroneal nerve palsy, which leads to foot drop [3]. Conservative treatment strategies using orthotic and physical therapy are often the treatment of choice. ...
Foot and ankle disabilities (foot drop) due to common peroneal nerve palsy and stroke negatively affect patients’ ambulation and activities of daily living. We developed a novel robotics ankle hybrid assistive limb (HAL) for patients with foot drop due to common peroneal nerve palsy or stroke. The ankle HAL is a wearable exoskeleton-type robot that is used to train plantar and dorsiflexion and for voluntary assistive training of the ankle joint of patients with palsy using an actuator, which is placed on the lateral side of the ankle joint and detects bioelectrical signals from the tibialis anterior (TA) and gastrocnemius muscles. Voluntary ankle dorsiflexion training using the new ankle HAL was implemented in a patient with foot drop due to peroneal nerve palsy after lumbar surgery. The time required for ankle HAL training (from wearing to the end of training) was approximately 30 min per session. The muscle activities of the TA on the right were lower than those on the left before and after ankle HAL training. The electromyographic wave of muscle activities of the TA on the right was slightly clearer than that before ankle HAL training in the resting position immediately after ankle dorsiflexion. Voluntary ankle dorsiflexion training using the novel robotics ankle HAL was safe and had no adverse effect in a patient with foot drop due to peroneal nerve palsy.
... Neurological causes such as amyotrophic lateral sclerosis, cerebrovascular accident, Guillain-Barre syndrome, Charcot-Marie Tooth must also be considered. 1,2,3 Although drop foot from lumbar degenerative disease is rare, it can significantly add to the disability of patients suffering from spine disorders. [3][4][5][6][7] In the setting of lower back pain, radiculopathy, and/or incontinence, lumbosacral spine origin must be ruled out in patients presenting with drop foot. ...
Bilateral drop foot secondary to lumbar spinal disease is rarely reported in the literature. In this case report, a 60 year old male presented with acute on chronic weakness in ankle dorsiflexion and urinary/fecal incontinence. He was found to have L5-S1 severe disc degeneration and spinal stenosis. We report on the diagnosis of bilateral drop foot in the setting of lumbar spinal degenerative disease and the operative technique of the modified Bridle procedure.
... The neurological impairment causing the foot drop can be central or peripheral [1]. The central pathologies include motor neuron disease, parasagittal cortical or cerebral subcortical lesions [2]. The peripheral causes can be lumbar radiculopathy or mononeuropathies of sciatic, deep peroneal, or common peroneal nerves. ...
Lumbar intervertebral disc prolapse has been associated with radiculopathy and the sensory and motor changes that occur as the result of neural compression. The most important motor symptom is foot drop. Occurrence of foot drop in lumber protrusion of intervertebral disc prompts for the surgical treatment of the condition. Here, we report a case of a 32-year-male presented with unilateral foot drop, diagnosed as lumbar protrusion of intervertebral disc and recovered significantly without surgery. The good neurological outcome of the conservative management, in this case, puts the surgeon in a quandary whether to offer surgical management or not. A clinician should always remember this outcome before choosing the management plan for lumbar protrusion of intervertebral disc although rare.
... The most common cause of fibular neuropathy is external compression of the nerve at the fibular head (due to surgical complications, positional habits, tumors). Other causes are traumatic injuries, metabolic or vascular diseases, or excessive and rapid weight loss [1]. During the COVID-19 pandemic, most people were forced at home, often in smart working or in distance learning sitting for long time at the computer. ...
... Acute unilateral foot drop is a well-known condition, while there is a limited number of data regarding bilateral foot drop. [3] The most common etiology of unilateral foot drop is compression of the deep peroneal nerve, the common peroneal nerve, or the sciatic nerve. Neurological causes of the foot drop also include lumbosacral plexopathy and lumbar radiculopathy. ...
In these days of the pandemic, we have faced with the locomotor system problems following severe acute respiratory syndrome-coro- navirus 2 (SARS-CoV-2) infection. While some of these problems are related to the disease itself, some of them are associated with the prolonged immobilization during the infection. Long-term intensive care unit admissions of patients may also lead to various types of neuropathies, extending the recovery period. The real burden of the novel coronavirus-2019 (COVID-19) is still unclear. In particular, after a prolonged hospitalization period, the duration of rehabilitation may be longer to gain independence in daily living activities. In this report, we present a different aspect of the COVID-19 with bilateral foot drop in a 53-year-old female patient. To the best of our knowledge, this case is the first report of both peroneal and sciatic nerve damage following COVID-19.
... F OOT drop is a common and grievous disease that causes falls and other injures [1]. The leading cause of this disease is peroneal neuropathy at the neck of the fibula, and its rehabilitation requires a tremendous amount of time and effort [2]. The ankle flexion angle is a critical parameter in the foot drop rehabilitation both for the patient's rehabilitation progress evaluation and for the ankle foot orthosis control [3]. ...
Goal: In this paper, we introduced a novel ankle band with a vibrational sensor that can achieve low-cost ankle flexion angle estimation, which can be potentially used for automated ankle flexion angle estimation in home-based foot drop rehabilitation scenarios. Methods: Previous ankle flexion angle estimation methods require either professional knowledge or specific equipment and lab environment, which is not feasible for foot drop patients to achieve accurate measurement by themselves in a home-based scenario. To solve the above problems, a prototype was developed based on the assumption that the echo of a vibration signal on the tibialis anterior had different acoustic impedance distribution. By analyzing the frequency spectrum of the echo, the ankle flexion angle can be estimated. Therefore, a surface transducer was utilized to generate frequency-varying active vibration, and a contact microphone was utilized to capture the echo. A portable analog signal processing hub drove the transducer, and was used for echo signal collection from the microphone. Finally, a Random Forest regression model was applied to estimate the ankle flexion angle based on the spectrum amplitude of the echo. Results: Five healthy subjects were recruited in the experiment. The regression estimation error is 4.16 degrees, and the R is 0.81. Conclusions: These results demonstrate the feasibility of the proposed ankle band for accurate ankle flexion angle estimation.
... Peroneal neuropathy is the most common mononeuropathy in the lower limbs [1,2] and a very frequent cause of foot drop [3]. Foot drop causes gait difficulties, leading to an increased risk of falling [4]. ...
Background and purpose
Daily management of patients with foot drop due to peroneal nerve entrapment varies between a purely conservative treatment and early surgery, with no high-quality evidence to guide current practice. Electrodiagnostic (EDX) prognostic features and the value of imaging in establishing and supplementing the diagnosis have not been clearly established.
Methods
We performed a literature search in the online databases MEDLINE, Embase, and the Cochrane Library. Of the 42 unique articles meeting the eligibility criteria, 10 discussed diagnostic performance of imaging, 11 reported EDX limits for abnormal values and/or the value of EDX in prognostication, and 26 focused on treatment outcome.
Results
Studies report high sensitivity and specificity of both ultrasound (varying respectively from 47.1% to 91% and from 53% to 100%) and magnetic resonance imaging (MRI; varying respectively from 31% to 100% and from 73% to 100%). One comparative trial favoured ultrasound over MRI. Variable criteria for a conduction block (>20%–≥50) were reported. A motor conduction block and any baseline compound motor action potential response were identified as predictors of good outcome. Based predominantly on case series, the percentage of patients with good outcome ranged 0%–100% after conservative treatment and 40%−100% after neurolysis. No study compared both treatments.
Conclusions
Ultrasound and MRI have good accuracy, and introducing imaging in the standard diagnostic workup should be considered. Further research should focus on the role of EDX in prognostication. No recommendation on the optimal treatment strategy of peroneal nerve entrapment can be made, warranting future randomized controlled trials.
... Although the most frequent cause is peroneal neuropathy other cause includes anterior horn cell disease. 1 Contralateral hemiplegia is a result of damage to the motor cortex or corticospinal tract often with significant persistent distal weakness, that affects the swing phase in the gait which makes the patients unable to actively dorsiflex the foot during the swing phase of gait, which is referred to as drop foot. Due to motor impairment gait variations results in compensatory movement patterns, slowed gait velocity, limited functional mobility, and increased risk of falls. ...
Background: Foot drop is the result of sensory and motor impairment in the stroke patients. Treatment of foot drop patient is muscle stimulation along with exercise and gave beneficial result. PNF is also having evidences of improvement in sensory motor impairment. Combination of these two treatments gives remarkable result on patients.
... Furthermore, internal rotation of the foot in the transverse plane is also a usual compensatory mechanism [1,2]. This so called steppage gait impairs mobility and quality of life due to an increased risk of tripping and falling [1,3]. Several reasons like injuries, neuromuscular disorders or anatomical variations may lead to foot drop [1]. ...
Introduction
Foot drop is a disorder that impairs walking and leads to tripping and falling. Tendon transfer (e.g., tibialis posterior tendon) is a typical secondary procedure in foot drop treatment. The purpose of this systematic review was to identify the most common tendon transfer techniques for treating foot drop and to analyze the reported functional outcomes. Furthermore, it was of interest if the type of surgical technique affects the functional outcome.
Methods
A PubMed and MEDLINE literature search was performed according to PRISMA guidelines. The search terms used were (“tendon transfer” OR “tendon transposition”) AND (“foot drop” OR “peroneal neuropathies”). Any study published before January 2020 was considered for inclusion. No case reports or reviews were included. Common outcome measures (Stanmore score, AOFAS, FAAM, AFO use, patient satisfaction and active ankle dorsiflexion) were evaluated. The quality of the included studies was assessed using the Coleman Methodology Score.
Results
Of the 125 reviewed publications, 37 met the inclusion criteria. 42 cohorts were analyzed. The frequently reported tendon transfer technique was the tibialis posterior tendon transfer through the interosseus membrane. The most used fixation technique was tendon on tendon fixation; however in recent years, a tendon to bone fixation has gained popularity. There was an increase in Stanmore scores and AOFAS postoperatively and a decrease of AFO use postoperatively observed.
Conclusions
Due to various outcome measures and lack of preoperative assessment in the included studies, a meta-analysis of the pooled results was not possible. Nevertheless, the findings of this study show that tendon transfer increases mobility and self-independency leading to patient satisfaction. The choice of the surgical technique does not affect the outcome. A prospective collection of patient data and standardized outcome measures will be important to further analyze the efficacy of tendon transfer techniques.
... Aniansson et al. [12] reported a reduction of 25-35% in the muscle strength of the leg extensors in 70-80-year-old men. In addition, a peroneal nerve disfunction, that is a peripheral neuropathy commonly seen in the elderly, causes a lower activity or paralysis of the tibialis anterior (TA) muscle that in turn leads to foot drops (a gait abnormality where the forefoot drops when getting closer to the ground) [13]. ...
The loss of muscle mass with aging and consequent muscle weakness results in compensatory gait motions. Although these compensatory motions increase the cost of walking, they appear to be an attempt by the elderly to maintain safe ambulation. However, the relationship between the affected muscles and compensatory motions in the gait cycle is unclear. This study examined gait compensation in young subjects whose muscles were weakened with Muscle Activity Restriction Taping Technique, which restricts the muscle’s belly by tightening the lower limb(s). The study included different walking speeds (regular/slow) and restrictions (calf muscles/both calf and thigh muscles). It revealed that there was an active kinematic compensation chain, in which the non-restricted or less-restricted joints compensated for the affected joint to prevent foot drop, knee hyperextension in the terminal stance phase, and knee hyperflexion in the loading response phase, and to maintain the step length. Furthermore, joints could compensate for themselves when the muscles acting on the other joints were unable to assist, as observed on an ankle joint that compensated for itself to prevent foot drop when the knee and hip flexor muscles were restricted. Moreover, the observed compensation strategies agreed with a previously reported simulation on the gait compensations appearing along with muscle weakness. This study includes a comparison of these compensation strategies with those reported for the elderly. The results of this study provide an understanding of the mechanisms of gait compensation against limitations of gait ability.
... 85,86 However, in one series, as many as 18% of patients presenting with foot drop, have an intraneural ganglion of the fibular nerve identifiable with ultrasound. 87 Entrapment of the fibular nerve in the fibular tunnel is a rare cause of fibular neuropathy, 88 but this can be seen on ultrasound as a focal stricture of the nerve just prior to the fibular ( Figure 5). It is critical to image patients with fibular neuropathy to exclude entrapment and intraneural ganglion, as these patients require surgical decompression whereas non-operative management is indicated for other causes. ...
Andrew Hannaford,1 Steve Vucic,1 Matthew C Kiernan,2 Neil G Simon3 1Westmead Clinical School, Westmead Hospital, University of Sydney, Sydney, Australia; 2Brain and Mind Centre, University of Sydney, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia; 3Northern Beaches Clinical School, Macquarie University, Sydney, AustraliaCorrespondence: Neil G Simon Suite 6a, Northern Beaches Hospital, 105 Frenchs Forest Road W, Frenchs Forest, NSW, 2086, AustraliaTel +61 2 9982 2270Fax +61 2 9981 7880Email neil@nbneuro.com.auAbstract: Neuromuscular ultrasound is rapidly becoming incorporated into clinical practice as a standard tool in the assessment of peripheral nerve diseases. Ultrasound complements clinical phenotyping and electrodiagnostic evaluation, providing critical structural anatomical information to enhance diagnosis and identify structural pathology. This review article examines the evidence supporting neuromuscular ultrasound in the diagnosis of compressive mononeuropathies, traumatic nerve injury, generalised peripheral neuropathy and motor neuron disease. Extending the sonographic evaluation of nerves beyond simple morphological measurements has the potential to improve diagnostics in peripheral neuropathy, as well as advancing the understanding of pathological mechanisms, which in turn will promote precise therapies and improve therapeutic outcomes.Keywords: neuromuscular ultrasound, peripheral neuropathy, entrapment neuropathy, CIDP, hereditary neuropathy, amyotrophic lateral sclerosis
Objective:
To determine if MR neurography of the common peroneal nerve (CPN) predicts a residual motor deficit at 12-month clinical follow-up in patients presenting with foot drop.
Materials and methods:
A retrospective search for MR neurography cases evaluating the CPN at the knee was performed. Patients were included if they had electrodiagnostic testing (EDX) within 3 months of imaging, ankle and/or forefoot dorsiflexion weakness at presentation, and at least 12-month follow-up. Two radiologists individually evaluated nerve size (enlarged/normal), nerve signal (T2 hyperintense/normal), muscle signal (T2 hyperintense/normal), muscle bulk (normal/Goutallier 1/Goutallier > 1), and nerve and muscle enhancement. Discrepancies were resolved via consensus review. Multivariable logistical regression was used to evaluate for association between each imaging finding and a residual motor deficit at 12-month follow-up.
Results:
Twenty-three 3 T MRIs in 22 patients (1 bilateral, mean age 52 years, 16 male) met inclusion criteria. Eighteen cases demonstrated common peroneal neuropathy on EDX, and median duration of symptoms was 5 months. Six cases demonstrated a residual motor deficit at 12-month follow-up. Fourteen cases underwent CPN decompression (1 bilateral) within 1 year of presentation. Three cases demonstrated Goutallier > 1 anterior compartment muscle bulk. Multivariable logistical regression did not show a statistically significant association between any of the imaging findings and a residual motor deficit at 12-month follow-up.
Conclusion:
MR neurography did not predict a residual motor deficit at 12-month follow-up in patients presenting with foot drop, though few patients demonstrated muscle atrophy in this study.
A 76-year-old man who had undergone total bladder cancer resection one and a half year ago without recurrence or metastasis was presented. He started experiencing right lower limb pain two months prior accompanied by a right foot drop two weeks ago. On admission, severe right lower limb pain, weakness of the right anterior tibialis muscle, and toe dorsiflexion were noted. Routinely performed lumbar magnetic resonance imaging (MRI) revealed slight lumbar spinal stenosis at the L3/4 and L4/5 levels, which could not explain the exact mechanism of the patient's complaints and neurological deficits. Considering the severe leg pain and rapidly progressing foot drop, we suspected malignant lesions despite the former doctor's comments. Positron emission tomography scan was performed to rule out malignant disorders, which revealed a pelvic metastatic tumor in the right lumbosacral nerve trunk and plexus. The passage of the L5 and S1 nerves through the mass lesion at the lumbosacral plexus was clearly described by the MR neurography.
In this report, the authors gained vast knowledge about medical history taking, and meticulously performed neurological and image examination depending on the targeted lesion. The authors discussed lumbosacral plexus lesion as a cause of foot drop.
To control an actuated ankle–foot orthosis (AAFO) during walking, a selectively adaptive hybrid fuzzy control employing particle-swarm optimization was used in conjunction with a Lyapunov-theory-based adaptive fuzzy-logic control. Adaptation (a computationally expensive process) was performed only when the tracking error exceeded a certain half-Gaussian function. The stability of the overall closed-loop system was proved using Lyapunov theory. The proposed control strategy was verified both by simulations and by experiments with five healthy subjects. The proposed control strategy significantly reduced both tracking error and required control torque when compared to other competing control schemes.
Objectives:
The purpose of this study was to explore impairment and compensation characteristics of static balance and plantar load distribution in patients with chronic stroke.
Methods:
We recruited 68 patients who had chronic stroke who could stand independently (stroke group) and 30 healthy individuals (control group) with the Zebris FDM platform. Static balance parameters, including center of pressure (COP) ellipse sway area, COP path length, and angle-θ between y and major axis, were compared between 2 groups under standard standing posture. In the stroke group, balance parameters were re-tested under their preferring standing posture. Plantar load distribution was also assessed. Another 8 patients with chronic stroke who could not stand independently and had to rely on a crutch were enrolled to analyze the characteristics of balance compensation.
Results:
In the stroke group, the ellipse sway area, COP path length, and angle-θ were significantly larger than those of the control group. Sixty-one (89.7%) patients preferred standing with the affected foot outward-forward supporting, and their preferring standing balance was better than that of standard standing. All patients who could not stand independently tended to compensate for balance with a crutch supporting laterally and also preferred standing with a typical posture- the affected foot was outward-forward.
Conclusions:
In patients post stroke, static balance is impaired mainly at the lateral direction, and patients commonly locate the crutch laterally for compensation of lateral balance. Patients preferred standing with the affected foot outward-forward supporting, and their preferring standing balance was better than that of standard standing, which challenged the necessity of training standing symmetrically.
Introduction
Peroneal nerve entrapment is a frequent cause of foot drop. Despite being frequent, no guidelines exist to recommend surgical or non-invasive treatment, leading to important variations in daily practice.
Research question
To map variation in daily practice.
Materials and methods
An online Qualtrics survey was distributed among neurosurgeons, neurologists, orthopaedic surgeons and physical medicine and rehabilitation physicians through various national and international scientific organizations, mapping current treatment strategies. Descriptive statistics and non-parametric tests were used to analyse data with SPSS.
Results
Responses from 181 out of 221 participants from 35 countries were analysed. A large majority of participants agreed that good evidence supporting any treatment strategy is lacking (77.9%) and that daily practice is mostly guided by own beliefs and experience (84.0%). Both non-invasive treatment and neurolysis are well established treatment strategies (supported by respectively 92.3% and 93.4% of physicians). Timing of neurolysis and duration of non-invasive treatment varied considerably. Duration of non-invasive treatment was significantly shorter in the group of surgeons compared to non-surgeons (p = 0.033). Most physicians consider neurolysis a valid treatment option. However, significant more non-surgeons than surgeons were opposed to surgical treatment (p = 0.001).
Discussion and conclusion
Important differences in attitudes were observed not only between, but also within specialisms, regardless of physician experience. This survey highlights important variations in daily practice for foot drop due to peroneal entrapment and emphasizes the need for future controlled studies.
Foot drop is a common condition that may impact physical function and health-related quality of life. A detailed clinical history and physical examination are critical components of the initial evaluation of patients presenting with foot drop. Patients with refractory foot drop without spontaneous recovery of motor deficits, delayed presentation greater than 12 months from injury, or neural lesions that are not amenable to or have failed nerve reconstruction may be candidates for tendon transfers to restore active ankle dorsiflexion. The modified Bridle procedure is a dynamic tendon transfer that has demonstrated excellent functional outcomes in patients with refractory foot drop.
Foot drop is a common clinical condition which may substantially impact physical function and health-related quality of life. The etiologies of foot drop are diverse and a detailed history and physical examination are essential in understanding the underlying pathophysiology and capacity for spontaneous recovery. Patients presenting with acute foot drop or those without significant spontaneous recovery of motor deficits may be candidates for surgical intervention. The timing, mechanism, and severity of neural injury resulting in foot drop influence the selection of the most appropriate peripheral nerve surgery, which may include direct nerve repair, neurolysis, nerve grafting, or nerve transfer.
Acute correction of rigid drop foot deformity can be problematic due to the skin defect that may occur in the medial part of the ankle. The purpose of this study is to present an innovative solution for this problem. We hypothesized that acute correction for rigid ankle contractures without arthrosis might be possible if the medial skin defect could be closed. Therefore, we described a surgical technique for acute functional correction of rigid drop foot deformities. The closure of the medial defect was performed by applying a flap and partial-thickness skin graft. We have retrospectively evaluated the results of 18 patients who were treated between 2010-2016 with this technique. The mean age of the patients was 37±9.5 (22 to 56) years. Foot drop etiology was firearm-related nerve injury. Corrections were performed after 14.6±7.9 (8 to 38) months following the injury. At the end of an average follow-up period of 44.4 ± 6.2 (37 to 60) months, 14 of 18 patients (78%) recovered without complications, three patients experienced partial loss in the medial skin graft region, and one patient developed a superficial infection. None of the patients have developed pes planus. We observed that the ankle flexion contracture, which was 34°±9.2° (20° to 50°) preoperatively, could reach an average of 2.2°±2.5° (0° to 6°) dorsiflexion after surgery. We suggest that acute correction and tibialis posterior tendon transfer in the treatment of rigid foot drop deformity can be performed with an effective skin closure with low soft tissue complications.
Functional electrical stimulation (FES) is an effective method to induce muscle contraction and to improve movements in individuals with injured central nervous system. In order to develop the FES systems for an individual with gait impairment, an appropriate control strategy must be designed to accurate tracking performance. The goal of this study is to present a method for designing proportional-derivative (PD) and sliding mode controllers (SMC) for the FES applied to the musculoskeletal model of an ankle joint to track the desired movements obtained by experiments on two healthy individuals during the gait cycle. Simulation results of the developed controller on musculoskeletal model of the ankle joint illustrated that the SMC is able to track the desired movements more accurately than the PD controller and prevents oscillating patterns around the experimentally measured data. Therefore, the sliding mode as the nonlinear method is more robust in face to unmodeled dynamics and model errors and track the desired path smoothly. Also, the required control effort is smoother in SMC with respect to the PD controller because of the nonlinearity.
Objective:
Surgery for foot drop secondary to lumbar degenerative disease is not always associated with postoperative functional improvement. It is still unclear whether early decompression results in better functional recovery and how soon surgery should be performed. This study aimed to evaluate predicting factors that affect short- and long-term recovery outcomes and to explore the relationship between timing of lumbar decompression and recovery from foot drop in an attempt to identify a cutoff time from symptom onset until decompression for optimal functional improvement.
Methods:
The authors collected demographic, clinical, and radiographic data on patients who underwent surgery for foot drop due to lumbar degenerative disease. Clinical data included tibialis anterior muscle (TAM) strength before and after surgery, duration of preoperative motor weakness, and duration of radicular pain until surgery. TAM strength was recorded at the immediate postoperative period and 1 month after surgery while long-term follow-up on functional outcomes were obtained at ≥ 2 years postsurgery by telephone interview. Data including degree and duration of preoperative motor weakness as well as the occurrence of pain and its duration were collected to analyze their impact on short- and long-term outcomes.
Results:
The majority of patients (70%) showed functional improvement within 1 month postsurgery and 40% recovered to normal or near-normal strength. Univariate analysis revealed a trend toward lower improvement rates in patients with preoperative weakness of more than 3 weeks (33%) compared with patients who were operated on earlier (76.5%, p = 0.034). In a multivariate analysis, the only significant predictor for maximal strength recovery was TAM strength before surgery (OR 6.80, 95% CI 1.38-33.42, p = 0.018). Maximal recovery by 1 month after surgery was significantly associated with sustained long-term functional improvement (p = 0.006).
Conclusions:
Early surgery may improve the recovery rate in patients with foot drop caused by lumbar degenerative disease, yet the strongest predictor for the extent of recovery is the severity of preoperative TAM weakness. Maximal recovery in the short-term postoperative period is associated with sustained long-term functional improvement and independence.
Magnetic resonance (MR) images of 16 peripheral nerve tumors (14 patients) were correlated with histopathologic appearance. Thirteen patients had surgically proved neuro-fibromatosis. There were 10 neurofibromas, four schwannomas, and two neurofibrosarcomas. Seven of the 10 neurofibromas showed a target pattern of increased peripheral signal intensity and decreased central signal intensity on T2-weighted images. This pattern appeared to correspond to a distinctive zonal histologic appearance that was found only in the neurofibromas. This pattern was not seen on MR images of the other peripheral tumors.
Thirty-two patients with benign soft-tissue tumors of the extremities, causing nerve compression, exclusive of neurogenic tumors, have been seen at the Mayo Clinic. The peak incidence of these lesions was in the fifth decade, and the most frequent symptoms and signs were progressive weakness of parts of an extremity and a palpable mass. The average period between the onset of symptoms and treatment in this group was 13.6 months. Trauma was probably of significance in two cases of occult bursal enlargement at the elbow. The ulnar nerve was the nerve most commonly involved in the group. Roentgenographic examination revealed the radiolucent soft-tissue mass characteristic of a lipoma in ten patients. Lipomata accounted for approximately half of the tumors in our series. In ten patients, the extraneural tumor was not demonstrable prior to surgical exploration.
Treatment should consist in initial complete excision of the lesion with the double-tourniquet technique, with appropriate draping of the entire limb to allow for extra exposure of the nerve, if segmental resection and suture are necessary. A general anesthetic should be used, and the exploration should be performed by a team familiar with soft-tissue or neurogenic tumors. Neurolysis or translocation of the ulnar nerve may be required as well as simple excision of the tumor. Almost complete return of function should he achieved eventually provided that irreversible damage to the involved nerve has not been produced before operation. In the fourteen patients previously mentioned who noticed almost complete or complete return of function, the average duration for this return was three years with the extremes being three months and fourteen years.
Nature designed wisely when she protected important and slowly healing structures, such as nerves and blood vessels, by placing them in sheltered situations. A few of the major nerves, such as the facial, the ulnar, the radial and the peroneal, however, come close to the surface. To be sure, this exposure occurs only for short distances, but it explains in part the frequency with which these nerves are injured. In this paper I shall consider a possible and apparently neglected factor in the production of paralysis of the peroneal nerve.During the development of the hind limb, a rather extensive rotation carries the peroneal nerve laterad and ventrad, over the head of the fibula. In lower animals, it is still protected by the relative length of the tarsus and the usual position of flexion of the hind limbs.Observant clinicians have called attention to various forms of occupational palsies, but
Of the peripheral nerves closest to the surface, least protected and most vulnerable to both acute and chronic trauma, the common peroneal nerve ranks high. Thus, Wilson1 places it second only to the musculospiral and ulnar nerves for frequency of damage, while it stands first in Cassirer's2 series of over 1,000 cases. This nerve is particularly susceptible to injury not only where it runs its independent course but even as it runs side by side with the tibial nerve in the sciatic trunk. For example, among 71 cases of wounds of the sciatic nerves studied by Stewart and Evans (quoted by Wilson1), signs were restricted to the peroneal nerve in 33 cases and in only 3 to the tibial. Between 10 and 15 per cent of all injuries of the peripheral nerves, according to Clark,3 involve the common peroneal nerve.Because of its anatomic relationships, the
Peroneal-nerve paralysis following adduction injury to the knee or fracture of the proximal end of the fibula is well known. Less widely recognized is the impairment of nerve function that may follow an inversion sprain of the ankle. The present communication reports two additional cases of this syndrome and reviews the relevant literature.
BAKER'S cysts occur when the gastrocnemius-semimembranous bursa communicates with the knee joint and an effusion leads to a popliteal cyst. Rheumatoid synovitis may produce bursal swelling, distension, and eventually a Baker's cyst. If the cyst ruptures, this causes extravasation of the fluid into the compartments of the calf and produces symptoms and signs mimicking thrombophlebitis. On the other hand, if the cyst enlarges without rupturing, pressure may be exerted on branches of the low sciatic nerve and produce a neuropathy. I report the cases of five patients, each with an entrapment neuropathy secondary to Baker's cysts.Report of Cases
The five patients included three men and two women ranging in age from 51 to 66 years. Four patients had classical rheumatoid arthritis, while foot-drop developed in one man after trauma to the knee. In all five patients, a painful palpable enlargement in the popliteal area became most symptomatic with the
Seven cases of common peroneal nerve compression were seen among farm workers. The symptoms followed working in a sitting position with forward advancement, a position commonly adopted in India for harvesting a crop and hoeing. Motor and sensory impairment was seen in the distribution of the common peroneal nerve, more marked in the distribution of the deep peroneal branch. Motor conduction time, estimated in two cases, was delayed. At exploration, the cause of the compression was found to be a tendinous arch extending along the posterior border of the peroneus longus, and curving backwards and upwards along the lateral border of the soleus. Excision of this arch, with elimination of the origin of the upper part of the peroneus longus, led to disappearance of the neurological deficits.
Injuries to the lumbosacral plexus during labor and delivery have been reported in the literature for years, but have lacked electrophysiologic testing to substantiate the location of the nerve injury. We report 2 cases with comprehensive electrophysiologic testing which localizes the site of this obstetrical paralysis to the lumbosacral trunk (L4-5) and S-1 root where they join and pass over the pelvic rim. The paralysis may be mild or severe. Small maternal size, a large fetus, midforceps rotation, and fetal malposition may place the mother at risk for this nerve injury.
We performed a prospective clinical and electrophysiologic study of common peroneal (CP) neuropathy to evaluate the extent of involvement of the muscles and cutaneous areas supplied by this nerve. In 22 patients, seven had more weakness clinically in muscles innervated by the deep peroneal nerve than in those innervated by the superficial peroneal nerve; the reverse never occurred. Statistical paired comparisons confirmed the tendency in the entire group of patients for weakness to be greater in muscles supplied by the deep peroneal nerve. On EMG, denervation was more often present and of more marked degree in muscles supplied by the deep peroneal nerve. Motor nerve conduction studies indicated axonal damage and focal demyelination with similar frequency. Sensory deficits varied in the three areas supplied by the cutaneous branches of the CP nerve: five patients had involvement of all three areas, 11 of two areas, two of one area, and four had no sensory deficit. The most likely explanation for these findings is differing degrees of damage to individual fascicles within the CP nerve.
Common peroneal mononeuropathies, usually located at the fibular head, are one of the many causes of foot-drop, a condition often evaluated in the electromyography laboratory. If appropriate nerve conduction studies are performed and particular muscles studied on needle myography, a satisfactory diagnosis can almost always be provided for what may be a perplexing problem clinically. With all peroneal mononeuropathies, the compound muscle action potential amplitude of the peroneal motor tibialis anterior nerve conduction studies, stimulating distal to the fibular head, is a semi-quantitative measure of the number of viable fibers supplying the tibialis anterior and allows for accurate prognostication regarding the foot-drop.
Ninety-eight patients with chronic exercise-induced pain in the anterior compartment of the lower leg underwent extensive clinical and laboratory investigations to establish the diagnosis. They all were referred because of a putative chronic compartment syndrome (CCS). Intramuscular pressure was recorded bilaterally during exercise in the anterior tibial muscle in all of them. Conduction-velocity recordings of the deep and superficial peroneal nerves were performed in 29 patients. Other investigations included radiography, plethysmography, and scintigraphy. CCS was diagnosed in 26 of the 98 patients. Other diagnoses included periostitis in 41 patients, compression of the superficial peroneal nerve in 13, and miscellaneous other diagnoses in 18. CCS seems to be an uncommon reason for anterior pain in the lower legs.
Eight patients are reported who developed peripheral nerve injuries due to limb compression during unattended coma. In each patient, the site of the peripheral nerve lesion or the unique combination of peripheral nerve lesions and swollen limbs, pressure blisters, or myoglobinuria indicated that compartment syndromes caused the nerve injury. The peripheral nerve injuries were characterized by severe axonal loss with persistent and often disabling sequelae.
Twenty-three patients were seen with entrapment neuropathy in a two-and-a-half-year period. Symptoms consisted of pain, paresis, and paraesthesia in the distribution of the common peroneal nerve. Some degree of paresis was often present, which in five patients was severe enough to cause drop foot. In 20 patients decompression of the entrapped nerve at the neck of the fibula was quickly and completely successful. It is suggested that the ankle weakness which frequently follows sprains and other forced inversion injuries may often be at least partially due to entrapment of the common peroneal nerve.
The following case is presented to emphasize a relatively unrecognized cause of common peroneal nerve palsy1-4 and to stress that the condition may occur bilaterally.REPORT OF A CASE
A 22-year-old migrant worker was seen at the University of Oregon Health Sciences Center, Portland, with a threeday history of bilateral footdrop and numbness over the lateral aspect of his legs. He had worked the previous five days, seven hours a day, as a strawberry picker in a crouched position with periodic "duckwalking" forward movement. His health had been excellent, and results of his examination were normal exept for severe but incomplete footdrop. The gastrocnemius muscles, the inverters of the ankle, and the intrinsic foot muscles were of normal strength. The reflexes were symmetrically active. There was hypesthesia over the lateral legs on both sides. The common peroneal nerves were neither tender nor enlarged. Stimulation of the peroneal nerve proximal
Ten patients developed peripheral neuropathy while on a reducing diet. One of the patients sustained a severe polyneuropathy attributable to thiamine deficiency. Nine developed unilateral peroneal paralysis. Electromyography revealed bilateral abnormalities in three of these patients. The neuropathy could not be attributed to any factor other than weight reduction. In contrast to previous reports suggesting a compressive aetiology, the present observations indicate that metabolic disturbances are the cause of the disorder.
Compression neuropathies are a significant source of pain in the upper extremity. Although ulnar tunnel syndrome occurs much less frequently than cubital tunnel syndrome, compression of the nerve at this level is a readily treatable condition. Ulnar tunnel syndrome should be kept in the differential diagnosis when the patient complains of numbness of the ring and small fingers, hand weakness, and pain on the ulnar side of the wrist.
The objective of this pictorial essay is to illustrate the MR appearance of the common peroneal nerve and the appearance of masses that have been associated with peroneal nerve entrapment. Four human cadaveric knees underwent axial MRI utilizing a T1-weighted SE sequence. One knee was dissected by an orthopedic surgeon and three knees were transversely sectioned, and the gross morphology of the common peroneal nerve and the perineural structures was evaluated and correlated with the MR images.
A retrospective review of 20 patients with common peroneal nerve palsy treated with decompression between 1986 and 1997 was undertaken. Subjects were evaluated preoperatively and postoperatively by electromyography, nerve conduction, and clinical measures. The mean interval between the onset of symptoms to surgery (operative delay) was 15.9 months. The mean postoperative follow-up was 32.2 months with a minimum follow-up of 1 year. Decompression was performed at the level of the fibular neck and slightly distally at the tendinous origin of the peroneus longus using a standard approach to release tight fascial structures or scar tissue. External neurolysis was performed using the operating microscope in two cases for which scarring of the nerve was identified intraoperatively. Postoperatively, 19 of 20 patients showed improvement in ankle dorsiflexion as assessed by the Medical Research Council scale. Electromyographic examination was useful in the preoperative evaluation and selection of patients for decompression surgery. In conclusion, decompression even after a 1-year delay may offer benefit and suggest early intervention in patients with a severe lesion.
For many years the dangers of obesity have been extensively proclaimed in medical and lay publications. Current concepts regarding the role of fat metabolism in the etiology of cardiovascular disease underline the perils of excessive body weight. Accordingly, a reduction diet is often prescribed by the physician as part of the treatment of a wide range of ills, malnutrition excepted. The admonition—"lose 15 or 20 pounds"—reverberates in the ears of many a portly patient.
Moreover, the desirability of the "streamlined" appearance is insistently stressed by the dictators of high fashion and their talented hucksters. Modern supermarkets feature whole departments devoted to "dietary foods" on behalf of their calorieconscious consumers. It is readily apparent, in the face of this veritatble avalanche of propaganda, that many patients are struggling to reduce their body weight. A considerable proportion of these dieters, during a short-lived period of enthusiastic forbearance, may succeed in losing 15
In 10 consecutive patients with footdrop due to common peroneal neuropathy without an obvious cause, MRI of the knee showed pathology at the fibular head in 6, including 5 patients with clinically unsuspected cysts of the tibiofibular joint. All 6 of the patients improved with surgery.