DROP FOOT

Background
Foot drop is a deceptively simple name for a potentially complex problem. It can be defined as a significant
weakness of ankle and toe dorsiflexion. The foot and ankle dorsiflexors include the tibialis anterior, the
extensor hallucis longus, and the extensor digitorum longus. These muscles help the body clear the foot
during swing phase and control plantar flexion of the foot on heel strike.
Weakness in this group of muscles results in an equinovarus deformity. This is sometimes referred to as
steppage gait, because the patient tends to walk with an exaggerated flexion of the hip and knee to prevent
the toes from catching on the ground during swing phase. During gait, the force of heel strike exceeds body
weight, and the direction of the ground reaction vector passes behind the ankle and knee center (see the
image below).

Foot drop is caused by weakness or paralysis of the muscles that lift the front part of the
foot

Diagram of ground reaction vector during heel strike.

This causes the foot to plantar-flex and, if uncontrolled, to slap the ground. Ordinarily, eccentric lengthening
of the tibialis anterior, which controls plantar flexion, absorbs the shock of heel strike. Foot drop can result if
there is injury to the dorsiflexors or to any point along the neural pathways that supply them.
Foot drop can be associated with a variety of conditions, including dorsiflexor injuries, peripheral nerve
injuries, stroke, neuropathies, drug toxicities, or diabetes. The causes of foot drop may be divided into 3
general categories: neurologic, muscular, and anatomic. These causes may overlap. Treatment is variable
and is directed at the specific cause (see Treatment).

Epidemiology
Peroneal neuropathy caused by compression at the fibular head is the most common compressive
neuropathy in the lower extremity. Foot drop is its most notable symptom. All age groups are affected
equally, but the condition is more common in males (male-to-female ratio, 2.8:1). About 90% of peroneal
lesions are unilateral, and they can affect the right or the left side with equal frequency.
A foot drop of particular concern to orthopedic surgeons is the peroneal nerve palsy seen after total knee
arthroplasty (TKA; 0.3-4% of cases) or proximal tibial osteotomy (3-13% of cases). Ischemia, mechanical
irritation, traction, crush injury, and laceration can cause intraoperative injury to the peroneal nerve. It has
also been suggested that correction of a severe valgus or flexion deformity can stretch the peroneal nerve
and lead to palsy. Postoperative causes of peroneal nerve palsy include hematomas and constrictive
dressings.
In a study by Cohen et al, the relative risk of palsy was 2.8 times higher with epidural anesthesia for TKA
than with general or spinal anesthesia. [2] Epidural anesthesia probably decreased proprioception and
sensation (intraoperatively and to some extent postoperatively), allowing the limb to rest in an unprotected

state susceptible to local compression. In addition, intraoperative neurologic damage may not have been
readily apparent in the immediate postoperative period because of ongoing effects of epidural anesthesia.
In the same study, the relative risk of palsy was 6.5 times greater in patients who had a prior lumbar
laminectomy.[2]
A series of patients who developed foot drop after primary hip arthroplasty were carefully examined and
found to have spinal stenosis.[3] As many as 70% of patients undergoing hip arthroplasty have
electromyographic (EMG) evidence of nerve injury, but they rarely have clinical symptoms. [4] Patients with
preexisting spinal stenosis are believed to be at increased risk for foot drop after hip arthroplasty because
of this proximal compromise; this is the double-crush phenomenon.

Prognosis
Prognosis and outcome vary according to the cause of the foot drop. In a peripheral compressive
neuropathy, recovery can be expected in up to 3 months, provided that further compression is avoided. A
partial peroneal nerve palsy after total knee replacement has a uniformly good prognosis. [5] A variable
amount of recovery is seen with a complete postoperative palsy. Follow-up EMG and nerve conduction
studies may be useful for assessing recovery.
A partial palsy recovers faster because of local sprouting. With complete axonal loss, reinnervation is
achieved solely through proximal-to-distal axonal growth, which usually proceeds at a rate of 1 mm/day.
Thus, injuries of a nerve close to its target muscle also have a more favorable outcome. In a nerve root
compressive neuropathy, one study concluded that severe motor weakness lasting longer than 6 months, a
negative straight leg-raising test, and old age were poor prognostic factors for recovery of dorsiflexion. [6]
When there is direct injury to the peroneal nerve, the outcome is more favorable for penetrating trauma
than for blunt trauma; a traction or stretch injury to the nerve has an intermediate outcome. When nerve
grafting is performed, functional recovery depends on the severity of injury and thus on the length of the
graft used. With grafts longer than 12 cm, good functional recovery is rare.
Wound infection may occur after surgical treatment, as may nerve graft failure. In tendon transfer
procedures, recurrent deformity has been reported. In arthrodeses or fusion procedures, pseudoarthrosis,
delayed union, or nonunion may be noted.

Claw foot
Claw foot is a deformity of the foot. The toe joint nearest the ankle is bent upward and the other toe
joints are bent downward. The toe looks like a claw.
Considerations
Claw toes present at birth (congenital). The condition can also can develop later in life because of
other disorders (acquired). Claw toes may be caused by a nerve problem in the legs or a spinal cord
problem. The cause is unknown in many cases.
Claw toes are not usually harmful in themselves. They may be the first sign of a more serious disease
of the nervous system.
Claw toes may cause pain and lead to calluses on the top of the toe over the first joint, but may also
be painless. The condition may create problems wearing shoes.
Causes

Ankle fractures or surgery

Cerebral palsy

Charcot-Marie-Tooth disease

Other brain and nervous system disorders

Rheumatoid arthritis