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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.
... Posture-induced compression, such as habitual leg crossing, sitting cross-legged, prolonged squatting, and kneeling stand, are common reasons. [1][2][3][4][5] Foot drop due to weakness of the dorsiflexor muscles of the foot is the most common clinical presentation in PN. Diagnosis is made by anamnesis, neurological examination, and electrodiagnostic evaluation. ...
... Further evaluation and imaging methods for differential diagnosis should be planned when necessary. [2,6] Posture-related compressive PN (CPN) is mostly unilateral, has been documented in adults, and is rarely seen in childhood. This article aimed to review the clinical presentation, risk factors, diagnosis, treatment options, and prognosis of four patients of different age groups, including adolescents and adults, who developed unilateral/bilateral CPN secondary to prolonged squatting during the same harvest season. ...
... However, a careful diagnostic approach is required as there are many other possible causes. [2] Detailed anamnesis and physical examination is the first step of the evaluation method in diagnosis and differential diagnosis. Although posture-induced CPN is a well-known clinical entity, there are very few individual reports on bilateral posture-induced CPN. ...
Posture-induced compressive peroneal neuropathy usually occurs after maintaining certain positions, such as prolonged squatting or habitual leg crossing. Peroneal neuropathy mainly presents with unilateral foot drop and variable sensory deficit. In this article, a case series of unilateral/bilateral peroneal nerve palsy secondary to prolonged squatting during peanut harvesting was reported. The four patients presented were aged between 12 and 21 years. All patients showed signs of peroneal nerve palsy in the electrophysiological examination. The present article also reviewed the clinical evaluation, rehabilitation approaches, and prognosis of posture-induced peroneal neuropathy in light of the current literature.
... Foot drop, prevalent in various neurological disorders, significantly heightens the risk of falls and diminishes individuals' physical independence [1][2][3][4]. This condition, marked by a decreased capacity to dorsiflex the foot during walking, results in a dragging or slapping motion of the foot against the ground. ...
... Foot drop is typically attributed to weakness in ankle dorsiflexors or over-activation in ankle plantar flexors [3]. Consequently, individuals affected by foot drop often exhibit slower walking speeds and encounter challenges navigating uneven terrain like stairs [2][3][4]. Compensatory mechanisms, such as hyper-flexion of the knee and hip joints (e.g., "steppage gait" and "hip hiking"), can lead to improper skeletal loading and injury over time [5,6]. Furthermore, a foot drop may restrict activities of daily living, contributing to a decline in functional independence and overall quality of life [1]. ...
... Common treatment options include nerve decompression surgery, ankle-foot orthoses, and functional electrical stimulation [2][3][4]. Surgical interventions are invasive and primarily target peripheral causes like peroneal nerve compression or direct trauma (e.g., fracture, dislocation, etc.) [2]. While ankle-foot orthoses effectively enhance ambulatory function, they may limit ankle mobility, potentially causing discomfort and muscle contracture over time [9,10]. ...
Previous research has shown that exercise interventions requiring increased activation of the tibialis anterior (TA), the primary ankle dorsiflexor, can improve walking performance in individuals with foot drop. Correspondingly, heightened drag forces experienced during walking performed in water may augment TA activation during the swing phase of gait, potentially leading to improved walking gait on land. Therefore, this study aimed to compare surface electromyographic (sEMG) activation in the TA and medial gastrocnemius (GM) during gait performed in water versus on land. Thirty-eight healthy, recreationally active young adults, comprising 18 females and 20 males, participated in the study. Each participant completed 2 min walking trials under five conditions: land 2.5 mph, land 3.5 mph, water 2.5 mph, water 3.5 mph, and water 3.5 mph with added jet resistance. Stride kinematics were collected using 2-dimensional underwater motion capture. TA and GM, muscle activation magnitudes, were quantified using sEMG root-mean-square (RMS) amplitudes for both the swing and stance phases of walking. Additionally, TA and GM co-activation (Co-A) indices were estimated. Two-way within-subjects repeated measures analyses of variance were used to evaluate the main effects of and interactions between the environment and walking speed. Additionally, paired sample t-tests were conducted as a secondary analysis to investigate differences between walking in water at 3.5 mph with and without added jet resistance. Main effects and interactions were observed across various stride kinematics and sEMG measures. Notably, TA sEMG RMS during the swing phase of walking gait performed at 2.5 mph was 15% greater in water than on land (p < 0.001). This effect increased when walking gait was performed at 3.5 mph (94%; p < 0.001) and when jet resistance was added to the 3.5 mph condition (52%; p < 0.001). Furthermore, TA Co-A was increased during the stance phase of gait in water compared to on land (p < 0.001), while GM Co-A was reduced during the swing phase (p < 0.001). The findings of this study offer compelling evidence supporting the efficacy of aquatic treadmill walking as a potential treatment for individuals suffering from foot drop. However, further research is needed to evaluate whether a causal relationship exists between heightened TA activation observed during aquatic treadmill walking and improvements in voluntary dorsiflexion during gait.
... Foot drop is a symptom of the weakness of the dorsiflexor of the ankle, and caused by entrapment, compression, or injuries of the central and peripheral nerve distributing ankle flexor muscles [1]. Because it is a quite common condition with various etiologies, precise localization or optimal diagnosis of foot drop is a prerequisite to planning treatment and rehabilitation strategies [2]. ...
... Because it is a quite common condition with various etiologies, precise localization or optimal diagnosis of foot drop is a prerequisite to planning treatment and rehabilitation strategies [2]. The most common causes of foot drop are common peroneal nerve (CPN) injury, followed by lower lumbar radiculopathy, and sciatic nerve lesion [1,3]. In order to confirm foot drop due to CPN injury, abnormality in a nerve conduction study should be confirmed through electrophysiologic studies [4]. ...
... However, since these electrophysiological abnormalities usually occur 1-2 weeks after the onset of symptoms, these studies may not be appropriate as a highly sensitive test for early diagnosis of CPN injury [5]. Clinical evaluation alone may miss foot drop due to cerebral infarction or lumbosacral radiculopathy, so clinical suspicion and accurate localization via electrophysiologic studies are necessary for the differentiation of foot drop [1]. In 1992, an MR neurography technique called the T2+fat suppression sequence was introduced for the diagnosis of peripheral neuropathy [6]. ...
Foot drop can have a variety of causes, including the common peroneal nerve (CPN) injuries, and is often difficult to diagnose. We aimed to develop a deep learning-based algorithm that can classify foot drop with CPN injury in patients with knee MRI axial images only. In this retrospective study, we included 945 MR image data from foot drop patients confirmed with CPN injury in electrophysiologic tests (n = 42), and 1341 MR image data with non-traumatic knee pain (n = 107). Data were split into training, validation, and test datasets using a 8:1:1 ratio. We used a convolution neural network-based algorithm (EfficientNet-B5, ResNet152, VGG19) for the classification between the CPN injury group and the others. Performance of each classification algorithm used the area under the receiver operating characteristic curve (AUC). In classifying CPN MR images and non-CPN MR images, EfficientNet-B5 had the highest performance (AUC = 0.946), followed by the ResNet152 and the VGG19 algorithms. On comparison of other performance metrics including precision, recall, accuracy, and F1 score, EfficientNet-B5 had the best performance of the three algorithms. In a saliency map, the EfficientNet-B5 algorithm focused on the nerve area to detect CPN injury. In conclusion, deep learning-based analysis of knee MR images can successfully differentiate CPN injury from other etiologies in patients with foot drop.
... 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 refers to the condition of diminished strength in the dorsiflexor muscles of the foot, most caused by a lesion of the common peroneal nerve [1]. The nerve is susceptible to compression and injury in the area where it encircles the fibular neck. ...
... The causes of foot drop are diverse and can stem from neurological, muscular, spinal, autoimmune, and neural injuries, which can originate anywhere along the neuromuscular pathway [1][2][3][4]. Iatrogenic injury often occurs during procedures like osteosynthetic or arthroscopic surgery [5]. Peroneal nerve injuries following vascular procedures have been documented in multiple cases [6][7][8]. ...
Introduction
Foot drop is a disorder characterized by weakness in the dorsiflexor muscles of the foot, caused by various pathologies, including neurological, muscular, spinal, and autoimmune conditions. Sometimes, it can be iatrogenic due to direct nerve compression, traction, or ischemia. The occurrence and underlying mechanism of foot drop following aortobifemoral bypass surgery are not well-documented in literature.
Case presentation
A 40-year-old male, with short distance claudication secondary to multi-level lower limb arterial occlusions, mainly, external iliac arteries and superficial femoral arteries. The patient underwent an uneventful aortobifemoral bypass. Post-operatively, the patient developed left sided foot drop with no clear etiology. With intensive physiotherapy, the patient improved and eventually recovered.
Discussion
After excluding other causes of the manifestation, this case could potentially give an insight to a rare postoperative complication following aortobifemoral bypass surgery. Despite a smooth intraoperative course, the patient developed foot drop, a rarely reported complication, suggesting a potential link between the procedure and foot drop.
Conclusion
This case report highlights a rare postoperative complication after aortobifemoral bypass surgery, emphasizing the need for further research to elucidate the direct mechanisms behind this rare occurrence.
... Bilateral and symmetric deficits of the muscles of the anterolateral compartment of the legs are caused by polyneuropathies and myopathies. This syndrome is mimicked by central palsies caused by lesions in the brain or spinal cord, which are typically accompanied by other symptoms including spasticity [1,2]. Individuals diagnosed with a traumatic brain injury (ABI) may experience peripheral FDS because of extended bed rest, the use of leg braces or casts, or improper leg placement that compresses the nerve at the fibula's neck [3,4]. ...
... Concomitant mononeuropathy, polyneuropathy or myopathy in patients with ABI are relevant comorbidities; nevertheless, often in rehabilitation settings, weakness, and atrophy of the dorsiflexion muscles of the feet are often undiagnosed, underestimating its potential to interfere with functional outcome [1][2][3]. The current study used a simplified electrophysiological screening technique to investigate the prevalence of PN or CIPNM in patients with ABI. ...
Background: Foot drop syndrome (FDS), characterized by severe weakness and atrophy of the dorsiflexion muscles of the feet, is commonly found in patients with severe acquired brain injury (ABI). If the syndrome is unilateral, the cause is often a peroneal neuropathy (PN), due to compression of the nervous trunk on the neck of the fibula at the knee level; less frequently, the cause is a previous or concomitant lumbar radiculopathy. Bilateral syndromes are caused by polyneuropathies and myopathies. Central causes, due to brain or spinal injury, mimic this syndrome but are usually accompanied by other symptoms, such as spasticity. Critical illness polyneuropathy (CIP) and myopathy (CIM), isolated or in combination (critical illness polyneuromyopathy, CIPNM), have been shown to constitute an important cause of FDS in patients with ABI. Assessing the causes of FDS in the intensive rehabilitation unit (IRU) has several limitations, which include the complexity of the electrophysiological tests, limited availability of neurophysiology consultants, and the severe disturbance in consciousness and lack of cooperation from patients. Objectives: We sought to propose a simplified electrophysiological screening that identifies FDS causes, particularly PN and CIPNM, to help clinicians to recognize the significant clinical predictors of poor outcomes in severe ABI at admission to IRU. Methods: This prospective, single-center study included 20 severe ABI patients with FDS (11 females/9 males, mean age 55.10 + 16.26; CRS-R= 11.90 + 6.32; LCF: 3.30 + 1.30; DRS: 21.45 + 3.33), with prolonged rehabilitation treatment (≥2 months). We applied direct tibialis anterior muscle stimulation (DMS) associated with peroneal nerve motor conduction evaluation, across the fibular head (NCS), to identify CIP and/or CIM and to exclude demyelinating or compressive unilateral PN. Results: At admission to IRU, simplified electrophysiological screening reported four unilateral PN, four CIP and six CIM with a CIPNM overall prevalence estimate of about 50%. After 2 months, the CIPNM group showed significantly poorer outcomes compared to other ABI patients without CIPNM, as demonstrated by the lower probability of achieving endotracheal-tube weaning (20% versus 90%) and lower CRS-R and DRS scores. Due to the subacute rehabilitation setting of our study, it was not possible to evaluate the motor results of recovery of the standing position, functional walking and balance, impaired by the presence of unilateral PN. Conclusions: The implementation of the proposed simplified electrophysiological screening may enable the early identification of unilateral PN or CIPNM in severe ABI patients, thereby contributing to better functional prognosis in rehabilitative settings.
... Foot drop is a physiological dysfunction affecting the lower leg muscles surrounding the ankle joint [1,2], possibly being caused by multiple diseases like stroke [3], multiple sclerosis [4], cerebral palsy [5] or Charcot-Marie-Tooth disease [6]. The outcome is an influence on the lower leg muscle functions, which can either result in a complete loss of function (paralysis) or in a partial loss of function (paresis) of the individual muscle [7]. ...
... These muscles are affected to an individual extent, ranging from no implication over paretic influence to paralysis of the muscles. In any case, these muscle deficiencies cause the patient to have a foot drop expressed in the inability to lift the toes and having them just hanging towards the ground [2,8]. The patients' issues with foot drop are especially manifested during gait. ...
Patients who suffer from foot drop have impaired gait pattern functions and a higher risk of stumbling and falling. Therefore, they are usually treated with an assistive device, a so-called ankle–foot orthosis. The support of the orthosis should be in accordance with the motor requirements of the patient and should only be provided when needed, which is referred to as assistance-as-needed. Thus, in this publication, an approach is presented to determine the assistance-as-needed support using musculoskeletal human models. Based on motion capture recordings of multiple subjects performing gaits at different speeds, a parameter study varying the optimal force of a reserve actuator representing the ankle–foot orthosis added in the musculoskeletal simulation is conducted. The results show the dependency of the simulation results on the selected optimal force of the reserve actuator but with a possible identification of the assistance-as-needed support required from the ankle–foot orthosis. The required increase in support due to the increasing severity of foot drop is especially demonstrated with the approach. With this approach, information for the required support of individual subjects can be gathered, which can further be used to derive the design of an ankle–foot orthosis that optimally assists the subjects.
... Although anterior horn cell disease, L5 radiculopathy, or partial sciatic neuropathy might be a cause of foot drop, peroneal neuropathy due to external pressure is considered to be the most frequent reason for this condition. This type of neuropathy may result from the seemingly blissful pressure from the habitual crossing of the legs, prolonged squatting, or even positioning during surgery or prolonged bed rest (1). Peroneal neuropathy might also be one of the forms of diabetic neuropathy, but it is very rarely reported as the first sign of diabetes. ...
... The possible causes of peroneal neuropathy in patients with diabetes are susceptibility to external pressure or ischemic alterations (1,6). As a result of altered glucose metabolism, nerves show both functional impairment and structural changes, mainly swelling, which makes them more prone to entrapment neuropathies (6). ...
The etiology of foot drop is diverse from various diseases to mechanic injuries and includes neuropathy of the peroneal nerve. Peroneal neuropathy might also be one of the forms of diabetic neuropathy, very rarely reported as the first sign of diabetes. We describe three cases of children with newly diagnosed type 1 diabetes (TID) who developed unilateral peroneal nerve palsies and tibial nerve palsies, presenting clinically as a foot drop. In two of our cases, the symptoms of foot drop occurred shortly after starting treatment for severe diabetes ketoacidosis. In the third patient, food drop was a reason for the initial medical consultation, but eventually, TID was diagnosed. The presented cases highlight that neuropathy can be observed not only as a chronic complication of T1D, but it can also appear at the time of disease manifestation. The incorrect position of the lower limb during a keto coma may contribute to the development of neuropathy.
Learning points:
Neuropathy can be observed not only as a chronic complication of type 1 diabetes (T1D), but it can also appear at the time of disease manifestation. The incorrect position of the lower limb causing external pressure during a keto coma may contribute to the development of neuropathy. It is important to examine the glycemia in patients with acute peroneal neuropathy, as this kind of peripheral neuropathy can be associated with newly diagnosed T1D. Normalization of glycemia might lead to rapid neuronal recovery.
... Foot drop (FD) is a clinical impairment characterized by an inability to lift the foot against gravity because of a dorsiflexor muscle weakness [1]. Patients affected by foot drop show a typical abnormal gait pattern with compensatory hyperflexion of the hip and knee joints associated with internal rotation of the foot in the transverse plane [2], which could be responsible for further injuries or falls [3]. FD can be unilateral or bilateral in relation to the causes that may concern central or peripheral nervous systems or the dorsiflexor muscle directly [1], for example, patients with multiple sclerosis, cerebral palsy, cerebrovascular disease, plexopathy, L5 radiculopathy or sciatic neuropathy [4]. ...
... Various studies support this theory, also demonstrating how a rigorous diagnostic and therapeutic protocol with adequate characterization of the cyst or the presence of an articular peduncle plays a decisive role [20]; our patient, in particular, had significant distension of the superior tibiofibular recess on MRI, supporting Spinner's theory. The symptoms associated with IG include sensory deficits with paresthesia affecting the lateral surface of the leg and the back of the foot, painful symptoms mainly localized at the head of the fibula, positive Tinel test and motor deficits of the muscles of the anterior region of the leg up to stepping during walking, sometimes characterized by repeated falls [3]. The tendon reflexes, as in the case of our patient, should be normal. ...
Background:
Foot drop (FD) is characterized by an inability to lift the foot against gravity because of dorsiflexor muscle weakness. The aim of the present study is to report a clinical case of acute non-traumatic FD in patients with peroneal intraneural ganglion, after performing a scoping review on the methodological management of this disease.
Methods:
We performed a review of the literature and reported the case of a 49-year-old man with acute FD caused by an intraneural ganglion cyst of the peroneal nerve.
Results:
Out of a total of 201 articles, 3 were suitable for our review beyond our case report. The acute FD caused by peroneal intraneural ganglion can be managed by a careful clinical-instrumental differential diagnosis. A targeted surgery with subsequent rehabilitation produced a satisfactory motor recovery.
Conclusions:
Acute FD requires an appropriate diagnostic-therapeutic framework to identify and effectively treat the causes in order to promote complete recovery.
... The plantarflexors on the other hand are active in the stance phase until the foot is lifted from the ground to push off and accelerate the body forward (Neptune et al., 2001). If the nerve (Ischias) that is responsible for the regulation of the lower leg muscles is damaged, a motor disorder known as foot drop can be the result (Stewart, 2008). Patients suffering from this disease show a pathological gait pattern, slower gait speed and a higher risk of stumbling and falling (Stewart, 2008;Kluding et al., 2013). ...
... If the nerve (Ischias) that is responsible for the regulation of the lower leg muscles is damaged, a motor disorder known as foot drop can be the result (Stewart, 2008). Patients suffering from this disease show a pathological gait pattern, slower gait speed and a higher risk of stumbling and falling (Stewart, 2008;Kluding et al., 2013). This is mainly caused by paralysis or paresis of the dorsiflexors making it impossible for the patients to lift their toes during walking. ...
Motor disorders are diseases affecting the muscle function of the human body. A frequently occurring motor disorder affects the lower leg muscles resulting in a pathological gait called foot drop. Patients have a higher risk of stumbling and falling. The most common treatment is the use of a passive ankle-foot-orthosis (AFO). However, the compensation of foot drop is only limited due to the non possible support of all rotational directions of the ankle joint. Therefore, a newly developed concept for a passive AFO is currently in work. To ensure a best possible treatment of the patient, the provided support by the AFO and required support by the patient have to be in accordance. Thus, in this contribution a method is presented that integrates model order reduced finite element analysis for computing the provided support of the AFO and musculoskeletal human models for representing the patients' gait behaviour. With the method, the design of the force generating structures of the AFO can be realized regarding the patients' requirements. The presented method is further evaluated with a specific use case. The main focus lies here in the principal functionality of the method and the provision of valid results.
... 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.
... Bu olguların %63 ünde sensorimotor polinöropati saptandı. Diffüz polinöropati veya miyopatide, dorsifleksiyon güçsüzlüğü plantar fleksiyon güçsüzlüğünden daha belirgin olabilir ve bilateral düşük ayak nedenleri arasında bu nedenler de akla gelmelidir (24 (26). Bu olgularda nörolojik muayene yol göstericidir ve tipik olarak olgularda etkilenen ekstremitede artmış kas tonusu, hiperrefleksi, ayak bileği klonusu ve Babinski pozitifliği saptanır (26,27,28). ...
Amaç: Bu çalışmamızda düşük ayak ön tanısı düşünülerek nörofizyoloji laboratuvarına yönlendirilen olguların etiyolojik ve elektrofizyolojik özelliklerini ortaya koymayı amaçladık. Gereç ve Yöntem: Ocak 2019 - Eylül 2022 arasında düşük ayak kliniği nedeniyle elektromiyografi (EMG) laboratuvarına yönlendirilen 127 olgunun klinik ve elektrofizyolojik bulguları retrospektif olarak değerlendirildi. Bulgular: Çalışmaya dahil edilen 114 olgunun yaşları 18-85 (ort. 49,6) aralığında değişmekteydi. Olguların %31 i kadın, %69 u erkekti. 79 olgu dahili, 35 olgu ise cerrahi branşlardan yönlendirilmişti. Düşük ayak etiyolojisi olarak en sık fibuler sinir hasarı (%44.7) saptanmakla birlikte, sıklık sırasına göre radikülopati %21.9, siyatik sinir hasarı %16.7, polinöropati %10.5, lumbosakral pleksopati %4.4, ön boynuz motor nöron hastalığı %1,8 oranında saptanan diğer etiyolojilerdi. Olguların %83 ünde tek taraflı, %17 sinde bilateral düşük ayak mevcuttu. Bilateral düşük ayak saptanan 19 olgunun 12 sinde polinöropati, 3’ünde radikülopati (L4-5, S1 kök), 2’sinde fibula başı nöropatisi, 1’inde lumbosakral pleksopati, 1’inde ön boynuz motor nöron hastalığı mevcuttu. Elektrofizyolojik bulgular, olguların %85’inde aksonal, %11’inde demiyelinizan özellik göstermekteyken, %4 olguda demyelinizan veya aksonal hasar ayırdedilemedi. Fibular sinir hasarı dahili ve cerrahi branşlardan yönlendirilen olgularda en sık etiyolojik etken olmakla birlikte, dahili branşlarda polinöropati cerrahi branşlara göre daha sık saptandı. Tüm olgularda klinik olarak etkilenen bölge ile patolojik elektrofizyolojik bulguların elde edildiği bölge birbiri ile uyumluydu. Sonuç: Düşük ayak kliniği ile yönlendirilen hastalarda etiyolojide fibular sinir nöropatisi sık olsa da, farklı etiyolojiler saptanabilir Elektrofizyolojik testler bu olgularda periferik patolojinin belirlenmesinde yol göstericidir. Bu nedenle düşük ayak kliniği olan olgularda lezyon lokalizasyonunun belirlenmesinde, etiyolojiye yönelik yapılması gereken tetkiklerin planlanmasında, nörolojik muayene ile birlikte elde edilen elektrofizyolojik bulgular mutlaka göz önünde bulundurulmalıdır. Not: Bu çalışma 38.Ulusal Klinik Nörofizyoloji EEG-EMG Kongresi’nde (26-30 Ekim 2022) sözel bildiri şeklinde sunulmuştur.
... Foot drop is a common medical term used by physical medicine clinicians to describe gait deviations due to neurologically induced weakness of muscle dorsiflexors [1]. This condition is often caused by peripheral peroneal neuropathies or disorders of the central nervous system such as stroke, multiple sclerosis, or cerebral palsy [2]. ...
The purpose of this quasiexperimental study was to test the effects of wearing the NewGait rehabilitative device on walking abilities in individuals with foot drop. The study involved 16 participants with foot drops caused by stroke (11 participants), multiple sclerosis (one participant), and peripheral neuropathies (four individuals). During a single testing session, participants walked 12 m at their self-selected speed in four experimental conditions: walking without any orthotic device; walking while wearing a regular plastic posterior leaf ankle foot orthosis (AFO); walking with the NewGait device assisting ankle dorsiflexion only; and walking with the NewGait device assisting the hip, knee, and ankle joint motions. Body motions during walking were recorded using a 3D system for motion analysis and analyzed with a set of spatiotemporal and kinematic parameters and a gait decomposition index. The gait decomposition index indicated sagittal interjoint coordination in the three joint pairs (hip–knee, knee–ankle, and hip–ankle) of the paretic (foot drop) leg during walking and was validated in a previous study. Overall, wearing all three orthotic devices improved the gait velocity, ankle dorsiflexion, and foot clearance compared to gait trials in which no assistive devices were used. However, wearing the AFO significantly restricted the plantarflexion range of motion and decreased interjoint coordination as measured by joint decomposition. In contrast, the NewGait device altered the ankle plantarflexion motions but also increased coordinated movement (reduced the decomposition) in most lower-extremity joint pairs and conditions. Therefore, the NewGait rehabilitative device can be considered superior to a regular AFO in correcting gait deviations caused by foot drop.
... For the split-elbow sign, Khalaf et al. (2019) reported relative sparing of the triceps brachii compared to the biceps brachii [67] whereas Liu et al. (2021) found the opposite -that the elbow flexors are less affected than the elbow extensors [71]. For the split-leg sign, Simon et al. (2015) reported relative sparing of the ankle dorsiflexors compared to the ankle plantarflexors [68] but this was not consistent with the indication of more strongly afflicted ankle dorsiflexors in other studies, more consistent with foot drop syndrome in ALS patients [71][72][73][74]. One possible explanation for these discrepancies is that the nature of the preferential wasting might vary depending on the cohort of patients recruited for each study. ...
Background: Amyotrophic lateral sclerosis (ALS) is a fatal and incurable neurodegenerative condition. In ALS, wasting of skeletal muscle causes weakness, paralysis and ultimately, death due to respiratory failure. Diagnosis of ALS is a long process and delays in diagnosis are common, which impedes rapid provision of patient care and treatment. Additional tools or methodologies that improve early detection might help overcome the diagnostic delays and enhance survival and quality of life for people with ALS. In this study, we used a transgenic mouse model to create a detailed catalogue of skeletal muscle wasting with the goal of finding muscles that can be examined to enhance early diagnosis of ALS.
Methods: Cortical pathology was induced by crossing CaMKIIa-tTA and tetO-hTDP-43ΔNLS transgenic mice (ΔNLS). Transgenic expression was induced at 30-days postnatal via removal of doxycycline diet. Mice were aged to 15-, 20-, 30- and 45-days post transgene induction. Microdissection was applied to isolate 22 individual hindlimb muscles for measurement of weight. Both males and females were used at all timepoints.
Results: We found that male and female ΔNLS mice exhibited hindlimb skeletal muscle atrophy relative to controls. Multiply innervated muscles, also known as series-fibered muscles, were especially vulnerable to atrophy. The strongest predictor of the atrophic response across all hindlimb muscles was the extent to which any individual muscle was larger in males than females, known also as sexual dimorphism. In males, muscles that are usually larger in males compared to females experienced the most atrophy. Conversely, in females, muscles that are usually of similar size between males and females experienced the most atrophy. Segregating muscles based on whether they were more affected in males or females revealed that hip extensors, knee flexors, knee extensors, ankle dorsiflexors and ankle evertors were more affected in males. Hip adductors, hip rotators, hip flexors and ankle plantarflexors were more affected in females.
Conclusions: Our results demonstrate that the difference in the size of skeletal muscles in males compared to females is the most powerful predictor of muscle atrophy in response to dying forward pathology. This indicates that sex is a strong determinant of skeletal muscle vulnerability in ALS. Our results provide new insights into determinants of skeletal muscle atrophy and may help inform selection of muscles for diagnostic testing of ALS patients.
... Verschiedene Krankheiten, wie Schlaganfälle, Tumoren oder Multiple Sklerose, können zu einer paralysierten oder paresierten Unterschenkelmuskulatur führen, was zu einem gestörten pathologischen Gangverhalten der Patienten führt [17]. Zur Behandlung von Patienten mit einer entsprechenden Fußheberschwäche werden zumeist Sprunggelenksorthesen verwendet, die individuell angefertigt werden [8,14]. ...
Computational research methods, such as finite element analysis (FEA) and musculoskeletal multi-body simulation (MBS), are important in musculoskeletal biomechanics because they enable a better understanding of the mechanics of the musculoskeletal system, as well as the development and evaluation of orthopaedic implants. These methods are used to analyze clinically relevant issues in various anatomical regions, such as the hip, knee, shoulder joints and spine. Preoperative simulation can improve surgical planning in orthopaedics and predict individual results.
In this article, the methods of FE analysis and MBS are explained using two practical examples, and the activities of the “Numerical Simulation” cluster of the “Musculoskeletal Biomechanics Research Network (MSB-NET)” are presented in more detail. An outlook classifies numerical simulation in the age of artificial intelligence and draws attention to the relevance of simulation in the (re)approval of implants.
... 7 First described by Winters et al, 8 drop foot is best characterized by increased plantar flexion (PF) in swing phase due to paralysis or weakness of the dorsiflexor muscles relative to the overactivity of the plantar flexors. 8,9 Excessive plantar flexion at initial contact will result in a foot flat, forefoot, or low heel contact, affecting stability during stance. Furthermore, weak or paralyzed dorsiflexors result in a dynamic equinus at the ankle joint, inhibiting toe clearance during swing. ...
Background
In children with unilateral spastic cerebral palsy (USCP), ankle-foot orthoses (AFOs) are widely used to correct common gait deviations such as a drop-foot pattern. Most studies on this topic have investigated specific time points while omitting other parts of the gait cycle.
Objectives
This study investigated the separate effects of prefabricated carbon fiber AFOs and custom-made hinged AFOs compared with barefoot walking in children with USCP with a drop-foot gait pattern using statistical parametric mapping.
Study design
Retrospective, cross-sectional, repeated measures study.
Methods
Twenty ambulatory children (9.9 ± 2.5 years) with USCP and a drop-foot gait pattern were included. Kinematics, kinetics, and spatiotemporal parameters assessed during 3-dimensional gait analysis were compared between barefoot and AFO walking. Statistical parametric mapping was used to compare joint angles and moment waveforms. Kinematics, kinetics and spatiotemporal parameters assessed during 3-dimensional gait analysis were compared between barefoot and AFO walking for each AFO type but not between the 2 AFO types.
Results
Compared with barefoot walking, there was a steeper sole angle at initial contact, corresponding to a heel strike pattern, and an increased ankle dorsiflexion in swing with the use of both AFOs. The ankle plantar flexion moment during loading response increased. Ankle power generation during pre-swing decreased in the carbon fiber AFO group when walking with AFOs.
Conclusions
Both AFOs were beneficial for improving a drop-foot gait pattern in these small patient groups and can, therefore, be recommended to treat this gait deviation in patients with unilateral cerebral palsy. However, the reduction in ankle power generation during push-off and additional goals targeted by AFOs, such as correction of structural or flexible foot deformities, should be considered for prescription.
... The gait altering condition known as "foot-drop" consists of the foot slapping down on the floor with each step and is generally caused by weakness of the foot and ankle dorsiflexor muscles. Foot-drop can cause falls and injuries [1], and its solutions can be conservative or nonconservative (surgical), which are generally avoided unless the gait impairment is severe [2]. A conservative solution that is very commonly used is an ankle-foot orthosis (AFO) [3] . ...
There are many current active orthosis designs to assist with disabilities related to foot-drop, with most of them intervening during the whole gait cycle. We propose that, for the treatment of foot-drop, it is possible to design an ankle–foot device that will assist a walking user only during the dorsiflexion stages of the gait, avoiding interference with other stages, by using a single actuator with a simple transmission and a suspension block. This design can be improved by the use of multi-objective optimization to obtain a static set of parameters that are applicable to varying initial conditions. We present a computer simulation study of an active ankle–foot orthosis design, based on the interaction of a cam and lever with a suspension block, with the objective of assisting only with dorsiflexion during the gait cycle, leaving the rest of the movements unimpeded while reducing the complexity and weight of the device. This design is validated using a full simulation environment that includes the movements of the lower leg and foot, as they interact with our device and a ground element. As part of the design and validation, we found sets of mechanical and control parameters that provoke adequate output behavior of the orthosis to help the wearer perform a moderate-speed, normal gait. To optimize the design, we proposed three objectives to warrant ankle angle accuracy, minimal oscillations, and low energy consumption. A set of solutions was obtained with multi-objective optimization algorithms NSGA-II and RVEA to tune the parameters of the active orthosis. The solutions set from RVEA resulted in lower mean and standard deviation values for the oscillations and energy objectives in comparison to the solutions from NSGA-II, while for the MSE objective, NSGA-II obtained lower mean and standard deviation; for the energy consumption objective, the mean score using RVEA is 17% less than with NSGA-II. The orthosis is shown to be robust to differences in initial ankle angles. We observed that it is possible to obtain a broad set of solutions with a good performance during the gait cycle in controlled spaces and that in this application, the RVEA algorithm results in a better option for optimization to balance the objectives.
... Motor impairment frequently persists in chronic post-stroke individuals, interfere in functional mobility, and causes long-term disability [1]. these individuals usually present foot drop, reduced motor control, muscle weakness, and increased spasticity [2,3]. the recovery of motor function in chronic post-stroke individuals can be modest [4]. ...
Background:
Transcranial direct current stimulation (tDCS) and foot drop stimulators (FDS) are widely used for stroke rehabilitation. However, no study has investigated if tDCS could boost the effects of FDS and gait training in improving clinical parameters and neuroplasticity biomarkers of chronic post-stroke subjects.
Objective:
To investigate the effects of combining tDCS and FDS on motor impairment, functional mobility, and brain-derived neurotrophic factor (BDNF) serum levels. Also, to evaluate the effects of this protocol on the insulin-like growth factor-1 (IGF-1), insulin growth factor-binding proteins-3 (IGFBP-3), interleukin (IL) 6 and 10, and tumor necrosis factor-α (TNF-α) levels.
Methods:
Thirty-two chronic post-stroke individuals were randomized to tDCS plus FDS or sham tDCS plus FDS groups. Both groups underwent ten gait training sessions for two weeks using a FDS device and real or sham tDCS. Blood samples and clinical data were acquired before and after the intervention. Motor impairment was assessed by the Fugl-Meyer Assessment and functional mobility using the Timed up and Go test.
Results:
Both groups improved the motor impairment and functional mobility and increased the BDNF levels. Both groups also increased the IL-10 and decreased the cortisol, IL-6, and TNF-α levels. No difference was observed between groups.
Conclusion:
tDCS did not add effect to FDS and gait training in improving clinical parameters and neuroplasticity biomarkers in chronic post-stroke individuals. Only FDS and gait training might be enough for people with chronic stroke to modify some clinical parameters and neuroplasticity biomarkers.
... Introduction: Within musculoskeletal modelling, a paradigm shift from making generic models to person-specific has occurred over the last decade using, e.g., medical imaging. Meanwhile, developing ways to incorporate person-specific muscle properties has not undergone the same development [1]. This lack of development is problematic since muscle properties impacts internal joint loading [2], e.g., muscles in the knee are accountable for more than two-thirds of the resultant knee forces during walking [3]. ...
... Foot drop is presented as a reduction in dorsiflexion during heel strike and the swing phase of walking, resulting in poor Original Article foot clearance, increasing the risks of trips and falls. 1 Foot drop is a frequently occurring problem in stroke, spinal cord injury, and peripheral nerve injury. An ankle-foot orthosis (AFO) is commonly used to treat foot drop. ...
... The associated findings include a small ankle dorsiflexion range at heel strike, reduced plantar flexion at the terminal stance, and foot drop in the swing phase. These are primarily caused by weakness of dorsiflexor muscles and spasticity of plantar flexors, whenever present (Dreher et al., 2014;Stewart, 2008). As a result, there is no heel strike at the first contact with the ground in the AL, and the forefoot takes over the load . ...
Background:
Peripheral nerve injury caused by leprosy can lead to foot drop, resulting in an altered gait pattern that has not been previously described using 3D gait analysis.
Methods:
Gait kinematics and dynamics were analyzed in 12 patients with unilateral foot drop caused by leprosy and in 15 healthy controls. Biomechanical data from patients' affected and unaffected limbs were compared with controls using inferential statistics and a standard distance, based on principal components analysis (PCA).
Findings:
Patients walked slower than controls (0.8 ± 0.2 vs. 1.1 ± 0.2 m/s, p = 0.003), with a reduced stance and increased swing percentage. The affected limb increased (p < 0.05) plantar flexion at the initial contact (-16.8o ± 8.3), terminal stance (-29.1o ± 11.5), and swing (-12.4o ± 6.2) in the affected limb compared to unaffected (-6.6o ± 10.3; -14.6o ± 11.6; 2.4o ± 7.6) and controls (-5.4o ± 2.5; -18.8o ± 5.8; -1.4o ± 3.9). Increased pelvic tilt and knee adduction/abduction range, with lower hip adduction, were observed. The second peak of ground reaction force (98.6 ± 5.2 %BW), ankle torque (0.99 ± 0.33 Nm/kg), and net ankle work in stance (-0.03 ± 5.4 J/Kg) decreased in the affected limb compared to controls (104.1 ± 5.5 %BW; 1.24 ± 0.4 Nm/kg; -4.58 ± 5.19 J/kg; p < 0.05). There were decreasing multivariate standard distances in the affected limb compared with the unaffected and controls. PCA loading factors highlighted the major differences between groups.
Interpretation:
Leprosy patients with foot drop presented altered gait patterns in affected and unaffected limbs. There were remarkable differences in ankle kinematics and dynamics. Rehabilitation devices, such as ankle foot orthosis or tendon transfer surgeries to increase ankle dorsiflexion, could benefit these patients and reduce deviations from normal gait.
... 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]. ...
Coronavirus disease 2019 (COVID-19) is associated with muscle and nerve injuries as a consequence of prolonged critical illness. We report here a case of intensive care unit-acquired weakness (ICU-AW) with bilateral peroneal nerve palsy after COVID-19. A 54-year-old male with COVID-19 was transferred to our hospital. He was treated by mechanical ventilation and veno-venous extracorporeal membrane oxygenation (VV-ECMO), from which he was successfully weaned. However, by day 32 of ICU admission, he had developed generalized muscle weakness with bilateral foot drop and was diagnosed with intensive care unit-acquired weakness complicated with bilateral peroneal nerve palsy. Electrophysiological examination showed a denervation pattern in the tibialis anterior muscles, indicating that the foot drop was unlikely to recover immediately. Gait training with customized ankle-foot orthoses (AFO) and muscle-strengthening exercises were started as part of a regimen that included a stay in a convalescent rehabilitation facility and outpatient rehabilitation. Seven months after onset, he returned to work, and 18 months after onset, he had improved to the same level of activities of daily living (ADLs) as before onset. Outcome prediction by electrophysiological examination, appropriate prescription of orthoses, and continuous rehabilitative treatment that focused on locomotion contributed to the successful outcome in this case.
... 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. ...
... A common impairment of patients with upper motor neuron syndrome is a foot drop. It often causes instability and an increased risk of toe dragging and falling [1]. Besides the standard of ankle-foot orthoses, functional electrical stimulation (FES) of the ankle dorsiflexors is used as an alternative treatment for patients with mild impairments. ...
... 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.
Background:
Compressive neuropathy of the common fibular nerve (CFN) is increasingly recognized as an etiology for foot drop and falls. Electrodiagnostic (EDX) studies are widely used to evaluate this condition, but such tests are invasive and costly. As with carpal and cubital tunnel syndromes, there may be patients with characteristic symptoms of CFN compressive neuropathy but normal EDX studies in which ultrasound may aid in decision-making.
Purpose:
We sought to examine the association between ultrasound and nerve conduction studies (NCS) and electromyography (EMG) in the diagnosis of compressive neuropathy of the CFN.
Methods:
We performed a retrospective review identifying 104 patients who underwent CFN decompression from January 1, 2015, to June 30, 2023. Patients were included if they had both ultrasound and NCS/EMG prior to CFN decompression for compressive neuropathy and if they were older than 18 years at time of surgery. Patients were excluded if they had entrapment secondary to trauma, iatrogenic injury, or if they had had superficial fibular decompression alone without CFN decompression. After applying exclusion criteria, 17 patients remained in the cohort.
Results:
Mean ultrasound cross-sectional area and side-to-side (STS) ratios were significantly higher in those with abnormal compound muscle action potential (CMAP) amplitudes versus those with normal CMAP amplitudes. The probability of having an abnormal CMAP amplitude when STS ratio was abnormal was 18 times greater compared with those with normal STS ratio. With each unit increase in STS ratio, CMAP amplitude was reduced by 2.79 mV.
Conclusions:
This retrospective review found that ultrasound may provide complementary diagnostic information to EMG/NCS for compressive neuropathy of the CFN. Further study is needed to examine the relationship between ultrasound findings for CFN compressive neuropathy and results of surgical decompression.
This paper illustrates the development and validation of a passive ankle-foot orthosis (AFO) for walking propulsion and drop-foot prevention of individuals with a drop-foot gait. First, the biomechanics of a human ankle joint during walking and the energy flow analysis between the AFO and human body are introduced. Next, the hardware design of the AFO is presented. The AFO is primarily composed of a propulsion module, a drop-foot prevention module, and a support module. The propulsion module and drop-foot prevention module are mainly responsible for controlling the storage and release of the energy required for walking propulsion and drop-foot prevention, respectively. The propulsion module can detect the wearer?s gait stages, and it can control the energy storage and release of an energy storage spring-A by switching the state of a clutch-A mechanism with the ground reaction force. The drop-foot prevention module is designed to correct the abnormal gait of individuals with a drop-foot gait during the swing phase. Additionally, the modeling of the human-AFO system is proposed. Finally, experiments are conducted to evaluate the performance of the developed AFO. The experimental results demonstrate that the AFO has the potential to provide plantarflexion assistance and dorsiflexion assistance for the wearers during the late stance phase and swing phase, respectively. During a gait cycle, reductions of 7.74%, 6.72%, and 16.36% of the average muscle activities of the gastrocnemius, soleus, and tibialis anterior are observed, respectively.
Amaç: Ayak bileği dorsifleksiyon güçlüğü nörolojik yolaklarda çeşitli seviyelerdeki hasar sonucu ortaya çıkabilir. Düşük ayak kliniğinin cinsiyet ve yaşa göre de farklı etiyolojik nedenleri olduğu bilinmektedir. Ancak epidemiyolojik veriler sınırlıdır. Bu çalışmada düşük ayak kliniği ile başvuran ve tanısı elektrofizyolojik olarak doğrulanan hastaların demografik, klinik etiyolojik ve elektrofizyolojik özelliklerinin araştırılması amaçlanmıştır. Materyal ve Metod: Nörofizyoloji laboratuvarına düşük ayak ön tanısı ile yönlendirilen ve elektromiyografi (EMG) ile tanısı doğrulanan hastaların verileri retrospektif olarak incelendi. Demografik bilgileri, motor ve duyusal semptomları, nörolojik muayene bulguları, elektrofizyolojik incelemeleri ve semptom başlangıcından EMG yapılana kadar geçen süre açısından değerlendirildi. Hastalar öykülerinde yer alan etiyolojik faktörlere göre sınıflandırıldı. Elektrofizyolojik incelemelerine göre etkilenen sinir ve taraf bilgileri kaydedildi. Bulgular: Çalışmaya 55’i (%44) kadın, 107’si (%66) erkek olmak üzere 162 hasta dahil edildi. Hastaların yaş ortalaması 39,86±20,55 (5-85 yaş)’ydı. Hastalar semptom başlangıcından ortalama 9,80±17,09 ay sonra EMG laboratuvarına başvurdu. Elektrofizyolojik olarak en çok etkilenen sinir peroneal+tibial (%37, n=60) sinirdi. Bunu izole peroneal sinir (%27.8, n=45) takip ediyordu. Etiyolojide ise en sık travmaya (%37, n=61) bağlı düşük ayak geliştiği görüldü. Erkek hastalarda travmaya bağlı düşük ayak kliniği anlamlı olarak (p=0,037) daha sık saptanmışken, kadın hastalarda cerrahi komplikasyonlara bağlı düşük ayak kliniği anlamlı olarak (p=0,005) daha sıktı. Yaş ile etiyolojik nedenler arasında ise anlamlı farklılık yoktu (p=0,306). Sonuç: Düşük ayak kliniği günlük yaşamda çeşitli derecelerde özürlülüğe sebep olması nedeni ile önemlidir. Mevcut veriler retrospektif çalışmalara dayanmaktadır. Nöromusküler yolaktaki herhangi bir yaralanma bu kliniğe neden olabileceğinden bu hastalarda kapsamlı bir araştırma yapılması gerekmektedir.
Foot drop is a condition characterized by the inability to lift the foot upwards towards the shin bone. This condition may affect a proportion of critically ill patients, impacting on their recovery after the acute phase of the illness. The occurrence of foot drop in critical care patients may result from various underlying causes, including neurological injuries, muscular dysfunction, nerve compression, or vascular compromise. Understanding the etiology and assessing the severity of foot drop in these patients is essential for implementing appropriate management strategies and ensuring better patient outcomes. In this comprehensive review, we explore the complexities of foot drop in critically ill patients. We search for the potential risk factors that contribute to its development during critical illness, the impact it has on patients' functional abilities, and the various diagnostic techniques adopted to evaluate its severity. Additionally, we discuss current treatment approaches, rehabilitation strategies, and preventive measures to mitigate the adverse effects of foot drop in the critical care setting. Furthermore, we explore the roles of critical care physical therapists, neurologists, and other healthcare professionals in the comprehensive care of patients with foot drop syndrome and in such highlighting the importance of a multidisciplinary approach.
Purpose
Foot drop still occurs in clinical practice, including in our case. Treatments for foot drop vary based on its etiology and severity of symptoms. Hence, in intractable foot drop cases, an invasive surgical intervention is needed. Here, we introduce a special noninvasive technique to treat our patient's foot drop. In this approach, we applied STIMPOD NMS460 neuromuscular stimulator device (STIMPOD NMS460), which is a low-frequency (10 Hz or less) transcutaneous electrical nerve stimulation (TENS) device with a pulsed radiofrequency (PRF) component. We are eager to know how effective the device is in treating foot drop, and we compared it with two kinds of surgical interventions.
Materials and methods
The device settings are 5 Hz in frequency and 30mA in current amplitude. The device was applied on her left side at the L4 and L5 regions and at the fibular head. Each therapy session consists of individual 15-min treatments on these two body areas, and it only takes a total of 30 minutes. We recorded the change in ankle dorsiflexion degrees and muscle strength of our patient.
Results and Conclusions
To our surprise, our patient's actual treatment status through STIMPOD NMS460 showed more effective recovery and no specific side effects than surgical interventions in similar conditions. Besides, after a three-month intervention, her affected ankle dorsiflexion recovered to almost her usual status. The reason why this device has such an effect may be that it has the benefits of TENS and PRF. Besides, some studies have revealed the nerve-repair effect of TENS and PRF. In conclusion, we believe that this device is fairly promising and may be qualified to be used in other patients with foot drop.
The use of compression therapy is known to be effective in the management of patients with venous leg ulceration and is commonly recommended as a first-line treatment. A rare but known complication of compression therapy is pressure damage to the limb, also referred to as bandage damage, which should be categorised as a medical device-related pressure injury. Patients should receive a comprehensive, holistic assessment before any compression therapy is applied. Risk factors for compression therapy injury include peripheral arterial disease, older age, fragile skin, pronounced bony prominences or tendons, calf atrophy, foot drop, neuropathy/absent sensation, limited movement, cognitive impairment and receiving end of life care. Risks can be mitigated through a variety of approaches, and practitioners should be aware that these can change depending on the patient's condition. A community improvement initiative, illustrated with a case study, introduced a clinical pathway that can facilitate the identification and management of patients who are at risk of developing pressure injuries as a result of compression therapy.
Ankle–foot orthoses (AFOs) assist patients with gait impairment by correcting ankle and foot deformities, restoring mobility, reducing pain, and providing protection and immobilization. AFOs can effectively manage various types of gait pathologies, including foot drop, crouch gait, equinus gait, and stiff knee gait. AFOs are available in prefabricated or custom‐made forms in various designs. The selection criteria for the fabrication of an AFO are the duration of usage, the amount of applied force, the degree of axial loading, the patient's skin condition, and the cost. The accessibility of diverse materials in the last century has significantly improved orthoses. Ideal orthotic materials must be light, stiff, and strong, and can be made of plastics, metals, polymer‐based composites, leather, or a hybrid of different materials. A deeper understanding of the materials employed in the fabrication of AFOs holds the potential for more advanced and efficient orthoses, which can improve patients’ ability to ambulate in the real world. The present review provides insight into the various materials utilized for the fabrication of AFOs and describes the benefits and challenges associated with the materials. An attempt has also been made to highlight typical gait pathologies and design concepts in response to them.
Introdução. A síndrome do pé caído é conhecida como um distúrbio que dificulta ou gera uma incapacidade na movimentação da articulação do tornozelo e nos dedos dos pés. Uma vez instalada esta dificuldade na realização de dorsiflexão nos músculos do pé afetado, caracteriza-se por ser um sinal de dano neuromuscular com manifestação clínica permanente ou transitória. Objetivo. Descrever e revisar os aspectos etiológicos da síndrome do pé caído. Método. Revisão narrativa, baseada nas bases de dados PUBMED/MEDLINE, LILACS e Scielo. Resultados. Foi confeccionado um referencial teórico sobre as principais doenças que desencadeiam a síndrome do pé caído, de acordo com o neurônio motor lesionado, apontando a fisiopatologia da síndrome do pé caído envolvida em cada etiologia descrita. Conclusão. Ressalta-se a importância do entendimento clínico sobre as patologias que podem desencadear a síndrome do pé caído e as alterações funcionais decorrentes deste processo, visto que o embasamento sobre as taxas de prevalência e incidências também ressaltam a importância inclusive da assistência em pacientes que desenvolvem pé caído. As discussões sobre o tema necessitam de pesquisas mais robustas em busca de evidências que permitam embasar e ressaltar as alterações funcionais mediante a evolução desta patologia.
Age-related skeletal muscle atrophy appears to be a muscle group-specific process, yet only a few specific muscles have been investigated and our understanding in this area is limited. This review provides a comprehensive summary of the available information on age-related skeletal muscle atrophy in a muscle-specific manner, nearly half of which comes from the quadriceps. Decline in muscle-specific size over ~50yr of aging was determined from 47 cross-sectional studies of 982 young (~25yr) and 1,003 old (~75yr) individuals and nine muscle groups: elbow extensors (-20%, -0.39%/yr), elbow flexors (-19%, -0.38%/yr), paraspinals (-24%, -0.47%/yr), psoas (-29%, -0.58%/yr), hip adductors (-13%, -0.27%/yr), hamstrings (-19%, -0.39%/yr), quadriceps (-27%, -0.53%/yr), dorsiflexors (-9%, -0.19%/yr), and triceps surae (-14%, -0.28%/yr). Muscle-specific atrophy rate was also determined for each of the subcomponent muscles in the hamstrings, quadriceps, and triceps surae. Of all the muscles included in this review, there was more than a 5-fold difference between the least (-6%, -0.13%/yr, soleus) to the most (-33%, -0.66%/yr, rectus femoris) atrophying muscles. Muscle activity level, muscle fiber type, sex, and timeline of the aging process all appeared to have some influence on muscle-specific atrophy. Given the large range of muscle-specific atrophy and the large number of muscles that have not been investigated, more muscle-specific information could expand our understanding of functional deficits that develop with aging and help guide muscle-specific interventions to improve the quality of life of aging women and men.
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.
1. Thirteen cases are reported of nerve compression by a ganglion. At operation a connection between the ganglion and the neighbouring joint was established in many instances.
2. It is suggested that so-called ganglia of the nerve sheath and simple ganglia are anatomical varieties of the same entity.
3. The treatment of choice is excision of the ganglion. If this procedure is technically difficult, puncture is advisable.
4. Recovery of sensibility after operation was good. Motor recovery was poor when damage to motor fibres occurred during excision of the ganglion or when paralysis had been present for more than eighteen months.
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
In a series of 70 patients (75 cases of common peroneal nerve palsy) the common causes were trauma about the knee or about the hip, compression, and underlying neuropathy. A few palsies occurred spontaneously for no apparent reason. The prognosis was uniformly good in the compression group; recovery was delayed but usually satisfactory in patients who had suffered stretch injuries. In the acute stage, when clinical paralysis appears to be complete, electrophysiological studies are a useful guide to prognosis. They may also indicate an underlying neuropathy and they detect early evidence of recovery. The anatomical peculiarities of the common peroneal nerve are noted and aspects of the clinical picture, management, and prognosis of palsy are discussed.
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.
The authors examined the American Society of Anesthesiologists Closed Claims Study database to define the role of nerve damage in the overall spectrum of anesthesia-related injury that leads to litigation. Of 1,541 claims reviewed, 227 (15%) were for anesthesia-related nerve injury. Ulnar neuropathy represented one-third of all nerve injuries and was the most frequent nerve injury. Less-frequent sites of nerve injury were the brachial plexus (23%) and the lumbosacral nerve roots (16%). In a large proportion of cases, the exact mechanism of injury was unclear despite evidence of intensive investigation in the claim files. Median payment for nerve damage claims involving disabling injury was 225,000 median payment for claims for disabling injury not involving nerve damage (P less than 0.01). The closed claims reviewers judged that the standard of care had been met significantly more often in claims involving nerve damage than in claims not involving nerve damage. The authors conclude that nerve damage is a significant source of anesthesia-related claims but that the exact mechanism of nerve injury is often unclear. In particular, ulnar nerve injuries seemed to occur without identifiable mechanism.
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 results of a prospective study of 34 Nigerian women with obstetric neuropraxia (puerperal paresis of the lower limbs) seen at the University College Hospital, Ibadan, are presented. The height of 29 (84%) was under 62 in (1.58 m). All were younger than 45, and 41% (14) were primiparous. Lumbosacral plexus injury with a foot-drop was the most frequent presenting feature (88%), bilateral involvement was observed in 13 patients (38%), femoral neuropathy was observed in nine (26%) and the ankle tendon jerks were absent in 35%. Spastic paraparesis was not uncommon (15%). Results of electromyographic examination and determinations of conduction velocities were consistent with proximal neuropraxia of the lumbasacral trunk in many of them (88%). The presentation of the fetus was cephalic in 97% of the women. The major predisposing factor was prolonged labor. Among the complications associated with the neuropraxia were hydroureters above the pelvic brim and vesico- and rectovaginal fistulae. Perinatal mortality was high particularly with labor of more than 18 hours. Recovery from the neuropraxia was complete for 76% of the patients. It is concluded that direct pressure on the lumbosacral plexus and nerve trunks by the presenting fetal part is the major factor in the pathogenesis of obstetric neuropraxia encountered in Nigerians.
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
Among 421 patients undergoing coronary artery bypass graft surgery, 55 (13%) developed 63 new peripheral nervous system (PNS) complications postoperatively. Most common was a brachial radiculoplexopathy, which occurred in 23 patients. Of these, 21 involved lower trunk or medial cord fibers. In 17 there was a correlation between the site of jugular vein cannulation and the side affected, suggesting that needle trauma played a role. Stretching from chest wall retraction may have caused some cases. Other deficits included 13 saphenous, 8 common peroneal, and 5 ulnar mononeuropathies. Six patients had persistent singultus, suggesting phrenic nerve involvement. Unilateral vocal cord paralysis was found in 5. An isolated partial Horner syndrome and a facial neuropathy were also identified. Males were more likely to develop PNS complications. Hypothermia during surgery was associated with increased risk. Most PNS deficits were transient, and lasting disability was rare.
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.
A retrospective analysis of clinical results in a relatively large series of peroneal nerve lesion is presented. Historically, such lesions have been difficult to manage successfully.
Between 1967 and 1991, 302 patients with either injury or tumor of the peroneal nerve at the knee were evaluated at Louisiana State University Medical Center. Mechanisms of injury included stretch injury with or without fracture, "sharp" or "blunt" laceration, gunshot wound, compression, entrapment, and iatrogenic injury. Surgery was performed on 183 of 276 patients (66%). If spontaneous recovery had not occurred 4 to 6 months after injury, patients were operated on and lesions in continuity were usually evaluated using nerve action potential recordings.
Eighty-six patients required interfascicular grafts. Graft lengths varied from 4 to 20 cm (average, 10 cm). Grafts measured < 5.5 cm in some patients with blunt laceration, gunshot wound, or iatrogenic injury. Eighteen of 24 of those patients (75%) recovered peroneal function to Grade 3 or better, and a kickup foot brace was no longer needed to walk with a reasonable gait. Fourteen of 40 patients (35%) with graft lengths of 6 to 12 cm and only 3 of 22 patients (14%) with graft lengths of 13 to 20 cm recovered function to Grade 3 or better. Seventeen patients received end-to-end suture repair, and 14 (82%) recovered to Grade 3 or better by 24 months. After neurolysis, 71 of 80 patients (89%) with transmittable nerve action potentials across lesions in continuity recovered useful function despite severe preoperative functional loss in most cases. In addition, 24 tumors intrinsic to the peroneal nerve and two lesions caused by hypertrophic neuropathy were resected.
Neural repair is the first priority in selected patients with peroneal nerve palsy. As with other nerve lesions, a timely operation and thorough intraoperative evaluation are necessary for optimal results.
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.
The objectives of this study were to evaluate the clinical and electrophysiological findings in peroneal mononeuropathies following a weight-reduction diet. Thirty patients with acute peroneal palsy and weight loss were studied. Complete nerve conduction studies (NCS) were performed in upper and lower limbs. NCS showed conduction block (CB) of the peroneal nerve at the fibular head that recovered in 29 patients within 3 weeks to 3 months. Severity of CB was correlated with clinical weakness. Three patients had abnormalities consistent with polyneuropathy (PNP). NCS in asymptomatic relatives confirmed familial neuropathy. Nerve biopsy and molecular study were consistent with hereditary neuropathy with liability to pressure palsies (HNPP). One of these peroneal palsies (6 months) recovered after neurolysis. Weight loss might be a risk factor in peroneal mononeuropathies. NCS is a tool in the diagnosis of the site and severity of the nerve injury. Testing should be considered for relatives of patients with PNP because peroneal mononeuropathies may be the first expression of HNPP.
The goal of this project was to study the frequency and natural history of perioperative lower extremity neuropathies.
A prospective evaluation of lower extremity neuropathies in 991 adult patients undergoing general anesthetics and surgical procedures while positioned in lithotomy was performed. Patients were assessed with use of a standard questionnaire and neurologic examination before surgery, daily during hospital stay in the first week after surgery, and by phone if discharged before 1 postoperative week. Patients in whom lower extremity neuropathies developed were observed for 6 months.
Lower extremity neuropathies developed in 15 patients (1.5%; 95% confidence interval, 0.8-2.5%). Unilateral or bilateral nerves were affected in patients as follows: obturator (five patients), lateral femoral cutaneous (four patients), sciatic (three patients), and peroneal (three patients). Paresthesia occurred in 14 of 15 patients, and 4 patients had burning or aching pain. No patient had weakness. Symptoms were noted within 4 h of completion of the anesthetic in all 15 patients. These symptoms resolved within 6 months in 14 of 15 patients. Prolonged positioning in a lithotomy position, especially for more than 2 h, was a major risk factor for this complication (P = 0.006).
In this surgical population, lower extremity neuropathies were infrequent complications that were noted very soon after surgery and anesthesia. None resulted in prolonged disability. The longer patients were positioned in lithotomy positions, the greater the chance of development of a neuropathy. These findings suggest that a reduction of duration of time in lithotomy positions may reduce the risk of lower extremity neuropathies.
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.
We performed sonographic examination of the common peroneal nerve in 41 consecutive patients with a footdrop to determine whether there was a structural lesion of the peroneal nerve. Five of the 28 patients (18%) with an isolated peroneal mononeuropathy had an intraneural ganglion of the peroneal nerve confirmed by histology. High-resolution sonography should be considered in patients with nontraumatic peroneal palsy.
Fibular tunnel syndrome.
- Maudsley
The two of us: my life with John Thaw
- S Hancock
Neurology and pregnancy
- J O Donaldson