Foot Drop: Trends in assessment and treatment

by Nina Silberstein
Foot drop is the inability to actively dorsiflex the ankle during the swing phase of gait. It's a
clinical sign that occurs in a variety of conditions such as cerebral vascular accident (CVA), spinal
cord injury, multiple sclerosis (MS), traumatic brain injury, cerebral palsy, or other central nervous
system (CNS) diseases. In this article, we will discuss causes, symptoms, diagnosis/assessment,
therapy, and trends in treatment, as well as current clinical studies.

CAUSES
"The loss of dorsiflexion can be due to flaccid paralysis or low muscle tone, as well as high
gastroc-soleus muscle tone or equinovarus posturing at the ankle," explains Helen Rogers, PT, PhD,
director of clinical support for Innovative Neurotronics Inc, Austin, Tex. Rogers has 25 years of
experience in neurological physical therapy with both children and adults. She had taught courses in
neurological patient care at the University of Texas Medical Branch MPT program for 12 years before
joining Innovative Neurotronics, where she is responsible for education and training in the use of the
WalkAide™ system. She also coordinates clinical research trials on the use of functional electrical
stimulation (FES) with individuals who have suffered a CVA.
"Foot drop is a clinical sign seen with CNS dysfunction," she adds. "It is usually a diagnosis in and of
itself; a finding attributed to the primary diagnosis, for example, CVA."
OTHER CAUSES INCLUDE:
• Neurodegenerative disorders of the brain that cause muscular problems, such as multiple
sclerosis, stroke, and cerebral palsy;
• Motor neuron disorders, such as polio;
• Some forms of spinal muscular atrophy and amyotrophic lateral sclerosis;
• Injury to the nerve roots, as in spinal stenosis;
• Peripheral nerve disorders like Charcot-Marie-Tooth disease or acquired peripheral neuropathy;
• Local compression or damage to the peroneal nerve as it passes across the fibular bone below
the knee; or
• Muscle disorders such as muscular dystrophy or myositis.

SYMPTOMS
Patients will have an inability to raise the front part of the foot due to weakness or paralysis of
the muscles that lift the foot. As a result, they will scuff their toes along the ground or bend their knees
to lift their foot higher than usual to avoid the scuffing, which causes a steppage gait. Foot drop can be
unilateral or bilateral. It affects both males and females. However, it is more common in males.
"Many times, patients come in and we look at how they walk and if they are dragging their feet," says
Jessica K. To-Alemanji, PT, DPT, owner of Body Kinetics Rehab Physical Therapy in Annandale, Va.
"It's a good indication that something's going on with their muscles in terms of being weak. To-
Alemanji dedicates her practice exclusively to the neurologically involved patient and speaks to
physicians, case managers, and community support groups about the value of physical therapy clinics
that focus on treating patients with these conditions.

ASSESSMENT
Although foot drop is usually diagnosed through a physical exam, magnetic resonance imaging
can be used to create cross-sectional images in the diagnosis phases along with electromyography and
nerve-conduction studies that help measure electrical activity in the muscles and nerves.
"Most clients come to me with the diagnosis of foot drop," says Kim Kobata, a PT at the
Swedish Medical Center in Seattle. "I assess it by asking clients to lift their toes up. Usually I ask them
to point their toes down and then pick them up. That way I can see if there is any active movement."
Kobata also has them relax and move their ankle back and forth to see what range of motion (ROM)
exists. She can then test how strong of resistance they can hold. If there is active ROM, she looks at the
foot drop while the patient is walking to note if they can pick up their toes without fatigue after a few
steps.
"A thorough physical therapy evaluation must be done, consisting of a complete patient history
and an assessment of range of motion, strength, sensation, spasticity, reflexes, and mobility," add Tami
Phillips, PT, DPT, MBA, physical therapy supervisor, and Laura Zajac-Cox, PT, NCS, physical
therapy clinical coordinator, Emory Center for Rehabilitation Medicine in Atlanta. The center provides
inpatient and outpatient rehabilitative care for patients suffering from neurological damage,
musculoskeletal problems, pain, amputations, and chronic diseases. The medical team uses evidence-
based medicine, novel assistive technology, and community integration to improve each patient's
quality of care and life.
At first observation, To-Alemanji says, they see how the patients move around and how they
walk into the clinic. Then, once they get them into the treatment room, they look at more elements and
do a manual muscle test. If patients cannot pick up their feet on their own, is it because they have
limited ROM and they cannot do it or is it just because they are purely weak? "We want to make sure
that we're really looking at true foot drop versus something else that is causing their foot to drop. Some
[people] can be very tight in their calf muscle (contracted) and can't pick up their foot because it's so
tight and stuck," she adds.
To-Alemanji also says they look at musculoskeletal and bone issues. "Is a bony structure
blocking us because this person is so contracted?" An x-ray might help determine if they can
physically get this ankle to bend or if it is just impossible because there's a bony structure problem. A
nerve-conduction test is sometimes warranted to find out what's going on in the muscles and if FES or
other devices will help re-educate the muscles. "Is that device going to be effective or not? If they don't
have signals coming down, there's nothing we can do to get that muscle back," she states.

TREATMENT
"Traditional treatment varies depending upon the cause and presentation of the foot drop,"
Phillips and Zajac-Cox note. "These treatments can include therapeutic exercise (ROM, stretching,
and/or strengthening), electrical stimulation, gait training, and/or use of an ankle foot orthotic (AFO)."
"Each patient is unique, so we utilize all different types of AFOs, depending on the client's need," the
therapists note. "The four most common types we use are solid ankle, articulated ankle, posterior leaf
spring, and the [Allard] ToeOff®." The rehab center is beginning to use neuroprostheses such as the
Bioness® L-300 and the WalkAide as well.
The typical AFO is custom made of polypropylene. A solid ankle AFO is rigid and more
appropriate if the ankle and/or knee is unstable or in the case of severe spasticity. An articulated ankle
allows for some ankle motion, dorsiflexion assist, and partial push-off during gait. "A consideration is
that these two types of AFOs often require wearers to get a larger shoe [due] to their size," Phillips and
Zajac-Cox explain. "A posterior leaf spring is not articulated, is less rigid, and can provide a small
amount of dynamic response during push-off as well as dorsiflexion assist during swing phase."
"FES has been shown to improve functional outcomes such as gait speed, muscle strength, and
voluntary muscle control, as well as improve motor learning, facilitate the return of normal movement
patterns, and assist in the management of high tone and spasticity," Rogers notes.
Surgery that fuses the foot and ankle joint or that transfers tendons from stronger leg muscles is
occasionally performed.

TRENDS IN TREATMENT
The WalkAide that Rogers previously mentioned restores lost functionality to people with foot
drop. It is a FES system and is programmed to stimulate the peroneal nerve and cause a contraction of
the anterior tibialis and peroneus longus muscles to assist with or create dorsiflexion during the swing
phase of gait. "The electrical stimulation of the muscle from the WalkAide is generated at the proper
time based on tibial position during the step and timed to match the patient's gait speed," Rogers says.
It has an accelerometer and inclinometer built into the device that allows for real-time adjustment to
changes in the patient's step length and gait velocity. "This flexibility allows individuals to vary the
size and speed of their steps to accommodate for architectural barriers or environmental tasks, such as
crossing the street before the street light changes. It is intended to be a replacement for the
conventional treatment of bracing with an AFO."
The WalkAide is contraindicated for conditions involving peripheral nerve or lower motor
neuron damage or disease. Patients with any serious comorbidity such as heart disease or seizure
disorder should receive their physician's approval before using FES.
The Bioness NESS L-300 Foot Drop System has been used as an alternative to bracing. "It
allows a flexible ankle during gait to obtain a more normal walking pattern, and the ankle does not feel
as restricted on stairs," Kobata says. It could assist with increased walking velocity, improved balance,
and ability to walk on uneven surfaces. "A nice bonus is that it allows them to wear a variety of
footwear," Kobata adds, noting that the best case she has had is someone who used it soon after a
CVA. It helped to stimulate the patient's nerve/muscle so that after a month he no longer needed to
wear it. "I have also heard that it increased [his] overall energy because it took so much effort to clear
his toes when walking that he was too tired to go to the store. Now he has no difficulty walking in the
community and working."
To-Alemanji says the Bioness product is very effective. "It's a great tool because it really
educates the muscle. Any functional FES is great when the muscle is intact." She's talking about
patients with CNS problems like stroke or MS. "Those types of patients tend to respond very well
because there's nothing that has been interrupted. If your spinal cord is interrupted in any way, if it's
severed or cut, the chances of retraining the muscles are very difficult." To-Alemanji also likes the heel
sensor feature, noting that it eliminates error in terms of the fact that the machine comes on every time
patients lift their foot.
"It, however, does not completely replace a brace," Kobata explains. "It is not recommended in
certain situations or may not work if there is too much LE edema or cognitive need to be able to
operate the control unit, take care of the electrode pads, and apply the brace." There are other situations
where she does not recommend it. For example, if someone hyperextends the knee standing on it, the
L-300 does not support the knee while an orthosis (brace) could if fit appropriately. Another situation
would be if a patient's ankle is not stable in stance, it would not provide the support of a brace. Kobata
has used it predominately in gait training. It allows her to look at muscles more proximally than in the
ankle when walking. Patients are then not so worried about picking up their foot.
To-Alemanji would not recommend it for somebody who does not have a caregiver to help
maintain it and monitor it with them; or for somebody who does not understand how it works, how to
check their skin, or how to use the device and controllers. "It's not appropriate for patients if they're not
getting any muscle activity and the EMG result showed that no signals were coming down from their
muscles"; if the muscles are never going to "wake up" (patients with peripheral nervous system
conditions).
The braces from Allard USA are made of a carbon composite that absorbs energy at heel strike
and returns it a toe-off. "They are lighter, allow some movement at the calcaneus in response to the
ground, and they allow a more normal gait pattern for wearers," Phillips and Zajac-Cox say. The
therapists use the ToeOff most often with their neurologic patients who have mild to moderate ankle
instability and anywhere from mild to severe foot drop. It is intended to be worn with a shoe insert or
foot orthotic over the footplate but is not effective for clients where moderate to severe hyperextension
of the knee accompanies foot drop. "The body of the ToeOff is anterior over the tibia, so the client can
put the brace into their shoe and then slide their foot in normally. Conversely, the body of a typical
AFO sits over the calf, requiring [patients] to slide their foot down in-between the brace and the shoe,"
according to Phillips and Zajac-Cox.

CLINICAL STUDIES
The National Institute of Neurological Disorders and Stroke conducts research related to the
neurological conditions that cause foot drop in its laboratories at the National Institutes of Health, and
also supports additional research through grants to major medical institutions across the country. Much
of this research focuses on finding better ways to prevent, treat, and, ultimately, cure the kinds of
neurological disorders that cause foot drop. Other studies of note:
Currently, there's a study sponsored by the Institute of Child Health and Human Development
to determine if electrical stimulation can improve strength and coordination of the lower limb muscles
and the walking ability of stroke survivors. "The knowledge gained from this study may lead to
enhancements in the quality of life of stroke survivors by improving their neurological recovery and
mobility. The results may lead to substantial changes in the standard of care for the treatment of lower
limb hemiparesis after stroke," as per the purpose outlined in the study. Additionally, there is a
research investigation/randomized crossover study comparing the effect of the WalkAide (drop foot
stimulator) to a traditional plastic ankle foot orthotic for walking performance and quality of life in
adults with hemiplegia secondary to stroke. "The primary outcome variables are walking speed,
physiological cost index, and quality of life," explains an article by rehabtrials.org (February 2008).
This research is funded by Innovative Neurotronics Inc with the support of Hanger Orthopedic Group
Inc.