| Foot drop | |
|---|---|
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| Shown here, the right foot drops because of paralysis of the tibialis anterior muscle, while the left foot demonstrates normal lifting abilities. | |
| Specialty | Neurology  |
Foot drop is agait abnormality in which the dropping of the forefoot happens out of weakness, irritation or damage to thedeep fibular nerve (deep peroneal), including thesciatic nerve, or paralysis of the muscles in the anterior portion of the lower leg. It is usually a symptom of a greater problem, not a disease in itself. Foot drop is characterized by inability or impaired ability to raise the toes or raise the foot from the ankle (dorsiflexion). Foot drop may be temporary or permanent, depending on the extent of muscle weakness or paralysis, and it can occur in one or both feet. In walking, the raised leg is slightly bent at the knee to prevent the foot from dragging along the ground.
Foot drop can be caused by nerve damage alone or by muscle or spinal cord trauma, abnormal anatomy, toxins, or disease. Toxins include organophosphate compounds which have been used aspesticides and as chemical agents in warfare. The poison can lead to further damage to the body such as a neurodegenerative disorder calledorganophosphorus induced delayed polyneuropathy. This disorder causes loss of function of the motor and sensory neural pathways. In this case, foot drop could be the result of paralysis due to neurological dysfunction. Diseases that can cause foot drop include trauma to the posterolateral neck of fibula,stroke,[1][2][3][4]amyotrophic lateral sclerosis,muscular dystrophy,poliomyelitis,Charcot–Marie–Tooth disease,multiple sclerosis,cerebral palsy,hereditary spastic paraplegia,Guillain–Barré syndrome,Welander distal myopathy,Friedreich's ataxia, chroniccompartment syndrome, and severenerve entrapment. It may also occur as a result of hip replacement surgery or knee ligament reconstruction surgery.
Foot drop is characterized bysteppage gait.[5] While walking, people suffering the condition drag their toes along the ground or bend their knees to lift their foot higher than usual to avoid the dragging.[6] This serves to raise the foot high enough to prevent the toe from dragging and prevents the slapping.[7][8] To accommodate the toe drop, the patient may use a characteristic tiptoe walk on the opposite leg, raising thethigh excessively, as if walking upstairs, while letting the toe drop. Other gaits such as a wide outward leg swing (to avoid lifting the thigh excessively or to turn corners in the opposite direction of the affected limb) may also indicate foot drop.[9]
Patients with painful disorders of sensation (dysesthesia) of the soles of the feet may have a similar gait but do not have foot drop. Because of the extreme pain evoked by even the slightest pressure on the feet, the patient walks as if walking barefoot on hot sand.[citation needed]
The causes of foot drop, as for all causes of neurological lesions, should be approached using a localization-focused approach before etiologies are considered. Most of the time, foot drop is the result of neurological disorder; only rarely is the muscle diseased or nonfunctional. The source for the neurological impairment can be central (spinal cord or brain) or peripheral (nerves located connecting from the spinal cord to an end-site muscle or sensory receptor).[citation needed]
Foot drop is rarely the result of a pathology involving the muscles or bones that make up the lower leg. Theanterior tibialis is the muscle that picks up the foot. Although the anterior tibialis plays a major role in dorsiflexion, it is assisted by thefibularis tertius,extensor digitorum longus and theextensor hallucis longus. If the drop foot is caused by neurological disorder all of these muscles could be affected because they are all innervated by thedeep fibular (peroneal) nerve, which branches from thesciatic nerve. The sciatic nerve exits thelumbar plexus with its root arising from the fifth lumbar nerve space.[citation needed]
Occasionally, spasticity in the muscles opposite theanterior tibialis, the gastrocnemius and soleus, exists in the presence of foot drop, making the pathology much more complex than foot drop. Isolated foot drop is usually a flaccid condition. There are gradations of weakness that can be seen with foot drop, as follows according to MRC:[citation needed]
foot slap is a heel strike abnormality, which is the audible slapping of the foot to the floor with each step that occurs when the foot first hits the floor on each step. Sometimes it is not visible and the diagnosis is done by actually hearing the slap.
Treated systematically, possible lesion sites causing foot drop include (going from peripheral to central):
If the L5 nerve root is involved, the most common cause is aherniated disc. Other causes of foot drop are diabetes (due to generalizedperipheral neuropathy), trauma, motor neuron disease (MND), adverse reaction to a drug or alcohol, and multiple sclerosis.[citation needed]
Drop foot and foot drop are interchangeable terms that describe an abnormal neuromuscular disorder that affects the patient's ability to raise their foot at the ankle. Drop foot is further characterized by an inability to point the toes toward the body (dorsiflexion) or move the foot at the ankle inward or outward. Therefore, the normal gait cycle is affected by the drop foot syndrome.
The normal gait cycle is as follows:
The drop foot gait cycle requires more exaggerated phases.
Drop Foot is the inability to dorsiflex, evert, or invert the foot. So when looking at the Gait cycle, the part of the gait cycle that involves most dorsiflexion action would be Heel Contact of the foot at 10% of Gait Cycle, and the entire swing phase, or 60-100% of the Gait Cycle. This is also known as Gait Abnormalities.[citation needed]
Initial diagnosis often is made during routine physical examination. Such diagnosis can be confirmed by a medical professional such as aphysiatrist,neurologist,orthopedic surgeon orneurosurgeon. A person with foot drop will have difficulty walking on his or her heels because they will be unable to lift the front of the foot (balls and toes) off the ground. Therefore, a simple test of asking the patient to dorsiflex may determine diagnosis of the problem. This is measured on a 0-5 scale that observes mobility. The lowest point, 0, will determine complete paralysis and the highest point, 5, will determine complete mobility.[citation needed]
There are other tests that may help determine the underlying etiology for this diagnosis. Such tests may includeMRI,MRN, orEMG to assess the surrounding areas of damaged nerves and the damaged nerves themselves, respectively. The nerve that communicates to the muscles that lift the foot is theperoneal nerve. This nerve innervates the anterior muscles of the leg that are used during dorsiflexion of the ankle. The muscles that are used in plantar flexion are innervated by thetibial nerve and often develop tightness in the presence of foot drop. The muscles that keep the ankle from supination (as from an ankle sprain) are also innervated by the peroneal nerve, and it is not uncommon to find weakness in this area as well. Paraesthesia in the lower leg, particularly on the top of the foot and ankle, also can accompany foot drop, although it is not in all instances.
A commonyoga kneeling exercise, theVarjrasana has, under the name "yoga foot drop", been linked to foot drop.[10][11]
The underlying disorder must be treated. For example, if aspinal disc herniation in the low back is impinging on the nerve that goes to the leg and causing symptoms of foot drop, then the herniated disc should be treated. If the foot drop is the result of a peripheral nerve injury, a window for recovery of 18 months to 2 years is often advised. If it is apparent that no recovery of nerve function takes place, surgical intervention to repair or graft the nerve can be considered, although results from this type of intervention are mixed.[citation needed]
Non-surgical treatments forspinal stenosis include a suitable exercise program developed by a physical therapist, activity modification (avoiding activities that cause advanced symptoms of spinal stenosis), epidural injections, and anti-inflammatory medications like ibuprofen or aspirin. If necessary, a decompression surgery that is minimally destructive of normal structures may be used to treat spinal stenosis.[citation needed]
Non-surgical treatments for this condition are very similar to the non-surgical methods described above for spinal stenosis.Spinal fusion surgery may be required to treat this condition, with many patients improving their function and experiencing less pain.
Nearly half of all vertebral fractures occur without any significant back pain. If pain medication, progressive activity, or a brace or support does not help with the fracture, two minimally invasive procedures -vertebroplasty orkyphoplasty - may be options.
Ankles can be stabilized by lightweightorthoses, available in molded plastics as well as softer materials that use elastic properties to prevent foot drop. Additionally, shoes can be fitted with traditional spring-loaded braces to prevent foot drop while walking. Regular exercise is usually prescribed.[citation needed]
Functional electrical stimulation (FES) is a technique that uses electrical currents to activate nerves innervating extremities affected by paralysis resulting from spinal cord injury (SCI), head injury, stroke and other neurological disorders. FES is primarily used to restore function in people with disabilities. It is sometimes referred to as neuromuscular electrical stimulation (NMES)The latest treatments include stimulation of the peroneal nerve, which lifts the foot when you step. Many stroke and multiple sclerosis patients with foot drop have had success with it. Often, individuals with foot drop prefer to use a compensatory technique like steppage gait or hip hiking as opposed to a brace or splint.
FES is applied to lower extremities for improving functional walking in stroke patients; for the correction of foot drop. They have benefited patients by improving gait speed, muscle strength and other functions.[12]
Treatment for some can be as easy as an underside L-shaped foot-up ankle support (ankle-foot orthoses). Another method uses a cuff placed around the patient's ankle, and a topside spring and hook installed under the shoelaces. The hook connects to the ankle cuff and lifts the shoe up when the patient walks.
Both these techniques show significant improvement on usage.[12]
In December 2021, police in Toronto, Canada said they were looking for a person with a distinctive gait as a suspect in the murder ofBarry Sherman and Honey Sherman. Medical professionals quoted by theToronto Star said that the distinctive gait could be caused by foot drop.[13]