Management of foot drop is directed based on the cause.

If foot drop condition can not

be repaired with surgery then it is advisable to use ankle-foot orthosis (AFO)b. AFO can also be
used during neurological healing or healing after surgery. The use of AFO specifically aims to
provide dorsiflexion of the toes during the phase of leg swinging, lateral and medial stability
during the stasis phase, and if necessary can also help stimulate upward pushing during the final
phase of stasis.2 AFO is only effective when the foot can reach the plantigrade position when
standing. The success of using AFO as a walking aid will decrease if there is an equinus
contracture
The most commonly used AFO is made from polypropylene and is inserted into the
shoec. If AFO is made in such a way that it is in accordance with the part of the foot anteriorly to
maleoli, it will produce a rigid immobilization.3 Such adjustments are used when there are
problems with instability or ankle spasticity, for example in patients with upper motor neuron
lesions or stroke.3 AFO made in accordance with the posterior portion of the maleoli (posterior
type leaf-spring) allows movement of plantar flexion in the heel and the upward pushing
movement, returning the foot to neutral position for the next swinging phase. This tool helps the
movement of dorsiflexion at the drop foot with a mild equinovarus spastic deformity or flaccid.
There is also an orthosis that can be directly used on the heel of the shoe called shoe-clasp
orthosis.2
Peroneal nerve stimulation or also called Functional Electrical Stimulation (FES) can
be considered for the foot drop caused by hemiplegia. This type of stimulation was first
introduced in 1961.4 Nerve stimulation provides more effectiveness when used together with
AFO because nerve stimulation provides active gait correction and can be adjusted to each
patient individually. Peroneal nerve stimulation is performed by providing short duration
electrical stimulation to the peroneal nerve between the popliteal fossa and the fibular head. A
switch mounted on the heel of the foot that suffers from weakness will control the flow of
electrical stimulation.5 The stimulator will be activated when the foot is lifted and stops when the
foot touches the floor. Thus, dorsiflexion and eversion are achieved during the swinging phase of
gait.5,6
Nerve stimulators can be external stimulators, internal stimulators or stimulators with
radiofrequency activation.6 The use of electrical stimulation in stroke patients with spastic
hemiplegic is reported to be useful in 2% of cases. This method increases walking speed and
quality, and can contribute to motor relearning.6
Drop foot is a chronic condition that often results in psychological stress for the
sufferer, therefore the management of foot drop must pay attention to the psychological needs of
the sufferer.7 Paresthesia accompanied by chronic pain in patients with foot drop can be treated
with sympathetic nerve block or laparoscopic synovectomy.7,8 Other alternatives that can be
considered are amitriptyline, nortriptilin, pregabalin and gabapentin. Local anesthesia such as
transdermal capsaicin or diclofenac can reduce pain. The use of opioid drugs must be minimized
even in significant pain conditions. Foot drop management in patients with diabetes mellitus
must prioritize optimal glucose control and adding supplements of vitamins B1, B6 or B12 for
vitamin deficiency which can help reduce symptoms of chronic pain.8

Table. Ankle Foot Orthosis vs. Functional Electrical Stimulation

Ankle Foot Orthosis Functional Electrical Stimulation

Tools are big and heavy Tools are small and light
Must use special shoes tailored for AFO No need for special shoes
Passively correcting gait Involves active muscle contraction
Cannot reconstruct neuronal pathways Can reconstruct neuronal pathways
cosmetically can interfere with appearance ineffective used in foot drop due to peripheral
nerve damage
Fixate the foot at 90⁰ position to calf Gait looks normal
Cheaper than FES More expensive

Ankle foot orthosis

Ankle foot orthosis (AFO) is a therapeutic modality that is most often used for
unilateral foot drop. AFO is currently available in the market in a variety of materials, plastic,
metal and animal skin. AFO made of plastic is lighter than metal but only used for short periods.
Custom AFO models made of plastic (i.e according to the shape of individual feet) can be used
for a longer period of time because the risk of irritating the skin is smaller than the standard type.
AFO made of metal and animal skin is heavier than plastic AFO. Contact with the skin must be
minimal by using special socks. Metallic and animal skin AFO are good for patients who often
experience edema and fluctuations in the legs.10

Picture. AFO made from plastic6

Picture. AFO based on metal and leather6

 Picture. Shoes shaped AFO6

Operative
Acute nerve injury, including bruising, stretch injuries, lacerations, and crush injuries,
must be evaluated to determine the degree of functional damage and management. Injuries with
neurapraxia must be monitored because excellent results are obtained with non-operative
management. A more aggressive approach should be used for nerve injury of any severity
(including neurapraxia) that is present with complete loss of motor function or complete sensory
loss. Surgical exploration and decompression must be considered when the lesion worsen rapidly
or when there are no signs of improvement within 3 months. For open injuries with suspected
nerve lacerations, the nerves must be explored within less than 72 hours, if possible, and if
minimal gapping is found, repair must be done using epineurial or fascicular techniques. A
neural clinical study shows that no single technique is as good as epineurial or fascicular. In the
setting of contaminated wounds, local soft tissue debridement and suturing, and repair is carried
out in 2 to 7 days. If primary repair is not possible because of significant gapping or nerve
damage, nerve grafting is indicated. This can be done as a primary procedure but is more
commonly done as a procedure that can be postponed. Autologous grafting is the standard of
care, the most commonly used is sural nerve graft. An alternative nerve conduit, including veins,
bioabsorbable tubes and pseudosheaths, can be used. This channel has been shown to regenerate
nerves in short gaps (less than 3 cm), with reported results comparable to autografts. Although
the efficacy of nerve transfer remains unproven, this technique is an emerging option for
irreparable nerve injury, such as those with loss of segmental nerve or long regeneration. The
principle of nerve transfer is similar to tendon transfer; attempts are made to select the most
synergistic nerves, and in the case of irreparable CPN nerve injury, the most commonly used are
branches of the tibial nerve.6

Compressive Mass
When mass is found as the cause of compression, a thorough examination and evaluation must
be carried out before invasive treatment begins. Like tumors, doctors must assess the mass to
determine whether it is benign or malignant. Compressive mass excision is the same as mass
excision elsewhere in the body. If malignancy is suspected, it must be confirmed by frozen
section unless a biopsy has been performed. Extranural lesions, such as fibula osteochondromas,
vascular malformations, or extranural cysts, must be resected in a standard manner. Compression
of the peroneal nerve by extraneural benign mass is very rare but can still be included in the
differential diagnosis.

Tendon Transfer
Tendon transfer can also be used to restore function in refractory cases. This procedure
usually involves the transfer of the posterior tibialis tendon (PTT / posterior tibial tendon) to the
lateral cuneiform or cuboid, which means removing primary deformation forces to restore ankle
dorsiflexion. Goh et al compared two PTT methods: (1) subcutaneous transfer around the
medialtibia aspect and (2) transfer of tendons through the interosseous membrane to the dorsal
foot.
 Picture. Intraoperative ankle photos show posterior tibialis tendon
(PTT) transfer to the lateral cuneiform to restore ankle dorsiflexion. A,
an incision is made rather from the medial malleolus, extending about
5 cm to expose PTT, and the tendon is taken subperiosteally from
distal to proximal to the naviculocuneiform joint to ensure adequate
length of the tendon. B, the second incision is made about 15 cm
proximal to the medial end of the malleolus. C, PTT is given through
a proximal incision and is marked with sutures to facilitate transfer. D,
Skin is marked for a 5 cm incision along the anterior border of the
fibula. E, PTT is transferred from the proximal medial incision to the
lateral incision.8

Biomechanically, transinterosseous membrane techniques provide superior ankle

dorsiflexion with minimum pronation.7 Although there are many variations, techniques for
transferring PTT through the interosseous membrane usually take tendons in their insertions, slip
them through the proximal incision, pass through the interosseous membrane, and fix them to the
dorsal midfoot. The incision is made slightly far to the medial malleolus, extending about 5 cm
to expose PTT. The tendon is then taken subperiosteally from distal to proximal at the
naviculocuneiform joint to ensure adequate length of the tendon.
The second incision is made about 15 cm proximal to the medial end of the malleolus.
Dissection is done carefully. The saphenous vein and nerve are pulled anteriorly to expose the
fascia above the deep posterior compartment. The soleus muscle and flexor digitorum longus are
pulled back, showing PTT adjacent to the tibia and interosseous membrane. PTT is pulled
through a proximal incision and is marked by sutures. A 5 cm incision is made along the anterior
border of the fibula. The tip of the incision is identified by placing PTT above the anterolateral
aspect of the foot. After careful EDL dissection and retraction, about 4 cm of the interosseous
membrane is dissected from the fibula and cut to allow passage of PTT. PTT is transferred from
the proximal medial incision to the lateral incision. Care must be taken to pass directly to the
back of the tibia to prevent damage to the neurovascular bundle. The tendon is then passed
subcutaneously to the dorsal incision made above the lateral cuneiform. PTT then immersed into
the lateral cuneiform using interference screw fixation. One potential failure of this method is the
inadequate length of the tendon, which may require maximum ankle dorsiflexion or changing the
location of tendon placement to achieve a stable transfer. Tendon-to tendon sutures are an
alternative to this technique. However, direct suturing of the tendon-totendon often decreases the
strength of dorsiflexion due to the dispersion of the force supplied by PTT, and it can cause
unbalanced feet.

Picture. The illustration shows the anterior tibialis tendon transfer technique
described by Vigasio et al. A, the anterior tibial tendon (dashed line) is identified. B,
The tendon is extracted distally from the bottom of the retinaculum, as shown by the
arrow, and the borehole is made from medial to lateral cuneiform. C, the tendon is
passed to a new origin and is pulled proximally below the retinaculum, as shown by
the arrow, and reconnected to the posterior tibialis tendon transferred through the
interosseous membrane. 9

Vigasio et al described a technique in which PTT was transferred to the anterior tibialis
tendon (diverted through new insertions in the lateral cuneiform) and flexor digitorum longus
was transferred to EDL and the extensor hallucis longus tendon. This technique was carried out
in 16 patients with complete CPN palsy, and at a minimum follow-up of 24 months, the authors
recorded good to very good results in 80% of their patients.9 The authors conclude that this
method is a reliable way to get a balanced dorsiflexion in the feet and big toe, eliminating the
need for orthosis during ambulation.
The timing of the procedure is somewhat controversial. Previously, this procedure was
often delayed to await the possible return of nerve function. This often results in patients waiting
about 1 year after the initial injury or after the nerve repair to monitor neurological activity.
However, several studies have shown that tendon transfer must be considered as early as 3 to 4
months after the initial injury to prevent the development of significant equinus contracture and
ankle dorsiflexor atrophy. Tendon transfer also increases regeneration of nerve fibers when
tendon transfer is combined with the nerve repair and / or grafting procedure.6

Prognosis and Recovery

Recovery depends on the type of trauma (neuropraxia, axonotmesis or neurotmesis.
Signs of recovery will be seen or felt with increase muscle strength, especially in the proximal
muscle region. Recovery of sensation is preceded by deep sensations, then followed by pain and
position of sense. Regeneration of axons will be felt as a painful knock (tinel's sign).
Complications that occur are neuralgia, a burning sensation that is very disturbing to the patient
so that the action of sympathectomy in lower limbs needs to be done.

Case Report
Reporting the patient with initial “R”, 15-year-old, came with the chief complaint of
dropping right ankle (drop foot) and numbness. 1 year ago, when the patient ran in his school, he
fell with his right foot twisted. After the incident, the patient complained that his right foot drop
and could not be moved upward (drop foot). In addition, the patient also complained of swelling
and numbness in his right foot. Then he was brought to Mitra Kasih hospital and carried out
tendon transfer surgery and immobilization with casts above the knee a year ago. After the
surgery he routinely controls and goes to the Mitra Kasih hospital.
2 weeks after the surgery, the above knee cast is removed and the wound is treated.
During control, the patient still feels the right ankle still dropping and still feels numbness on his
right foot. Because his complaints has not improved, the patient was referred to Hasan Sadikin
Hospital and advised to do surgery at Hasan Sadikin Hospital.
From the physical examination, it is found that there is numbness on his right foot. The
patient also cannot move in the direction of dorsophlexion actively (drop foot). X-rays did not
reveal any abnormalities or discontinuities, but found 1 screw on the lateral side that penetrated
the cuboid os.

Picture. Patient with drop foot, and X-ray examination.

The patient is then operated with posterior tibialis tendon transfer surgery procedure
and immobilized with the Chilldress technique by using Schanz screw which is inserted from the
calcaneus (plantar side) to os talus, and os tibia.
 Picture. (A) Detachment from posterior tibialis tendon insertion. (B) Transfer of
tendons from the medial to the lateral side. (C) fixation with biological screw.

Picture. Immobilization with Chilldress procedure using Schanz screw

After that, the patient was treated for the wounds, and the Schanz screw was
maintained for 3 weeks. 2 weeks after the surgery, the surgical wound has dried and the sutures
is then removed. In addition, the ankle is still in the 90° dorsiflexion position which was
immobilized with Schanz screw.
 Picture. Control to Polyclinic 2 weeks after surgery.

3 weeks after surgery, the patient was operated on for an implant (Schanz screw)
removal, then the ankle joint was assessed and the patient's right ankle was found to be in a
dorsiflexion position. After that the patient was immobilized with a circular cast. And the patient
was advised to control the Orthopedic (Ankle and Foot) clinic in Hasan Sadikin Hospital.

Picture. 3 weeks after surgery, the Schanz screw removed and immobilized with a
circular cast.
Conclusion
Drop Foot is a significant weakness for dorsiflexion of the ankles and toes which can
cause deformity. This is a big problem for patients in their daily activities, especially walking.
Because patients tend to walk with excessive hip and knee flexibility to prevent the thumb.
Direct injury to the peroneal nerve and its branches should be explored and repaired or
transplanted as much as possible. As usual, the earlier the repairs, the better the results.

References

1. Katirji B: Peroneal neuropathy. Neurol Clin 1999;17(3):567-591.

2. Solmaz I, Cetinalp EN, Göçmez C, et al: Management outcome of peroneal nerve injury at
knee level: Experience of a single military institution. Neurol Neurochir Pol 2011;45(5):461-
466.
3. Stewart, J. D. (2008). Foot drop: where, why and what to do? Practical Neurology, 8(3), 158–
169
4. King J: Peroneal neuropathy, in Frontero J, Silver K, Rizzo T, eds: Essentials of Physical
Medicine and Rehabilitation, ed 2.
5. Flanigan RM, DiGiovanni BF: Peripheral nerve entrapments of the lower leg, ankle, and foot.
Foot Ankle Clin 2011;16(2): 255-274.
6. Poage, C., Roth, C., & Scott, B. (2016). Peroneal Nerve Palsy. Journal of the American
Academy of Orthopaedic Surgeons, 24(1), 1–10.
7. Goh JC, Lee PY, Lee EH, Bose K: Biomechanical study on tibialis posterior tendon transfers.
Clin Orthop Relat Res 1995;319:297-302.
8. Ho B, Khan Z, Switaj PJ, et al: Treatment of peroneal nerve injuries with simultaneous tendon
transfer and nerve exploration. J Orthop Surg Res 2014;9: 67-77.
9. Vigasio A, Marcoccio I, Patelli A, Mattiuzzo V, Prestini G: New tendon transfer for correction
of drop-foot in common peroneal nerve palsy. Clin Orthop Relat Res 2008;466(6):1454-1466.