The Interdisciplinary Management of Foot Drop

Abstract

Background: Foot drop can be caused by a variety of diseases and injuries. Although it is a common condition, its overall incidence has not been reported to date. Foot drop markedly restricts the everyday activities of persons suffering from it. There is, therefore, a need for an optimized strategy for its diagnosis and treatment that would be standardized across the medical specialties encountering patients with this problem.

Methods: This article consists of a review on the basis of pertinent publications re- trieved by a search in the Pubmed/MEDLINE and Cochrane databases, as well as a description of the authors' proposed strategy for the diagnosis and treatment of foot drop.

Results: Foot drop can be due to a disturbance at any central or peripheral location along the motor neural pathway that terminates in the dorsiflexor muscles of the foot, or at multiple locations in series. Optimal localization of the lesion(s) is a pre- requisite for appropriate treatment and a successful outcome. The most common causes are L5 radiculopathy and peroneal nerve injury. An operation by a neuro- surgeon or spinal surgeon is a reasonable option whenever there is a realistic chance that the nerve will recover. In our opinion, any patient with a subjectively disturbing foot drop and a clinically suspected compressive neuropathy of the peroneal nerve should be informed about the option of surgical decompression of the nerve at the fibular head, which can be performed with little risk. In case of a permanent foot drop, some patients can benefit from muscle-transfer surgery. For spastic foot drop, the option of botulinum toxin injections should be evaluated.

Conclusion: The care of patients with foot drop could be optimized by interdisciplin- ary foot-drop clinics involving all of the relevant specialists. The goals of treatment should always be improved mobility in everyday life and the prevention of falls, pain, and abnormal postures.

Figure 1

Innervation pathway of the foot dorsiflexors

Figure 2

Peroneal nerve lesions a) Compression of the common peroneal nerve on entry into the muscle compartment – split fascia (arrow) b) Injury to the superficial branch (arrow) c) Intraneural ganglion cyst – magnetic resonance imaging of the left upper/lower leg (arrow) d) and e) intraneural ganglion cyst – intraoperative finding

Figure 3

Diagnosis and treatment algorithm for foot drop DH, disc herniation; T-spine, thoracic spine; EMG, electromyography; C-spine, cervical spine; L-spine, lumbar spine; mNCV, motor nerve conduction velocity; MRI, magnetic resonance imaging; SOL, space-occupying lesion; SCS, spinal canal stenosis; TENS, transcutaneous electrical nerve stimulation

Figure 4

Tibialis-posterior transfer a) Transferred tendon on target location on cuneiform bone b) MRI cross-section with anchor (arrow)