T RAUMATIC D ROP F OOT
By: Larissa Torres Nixon, SPT
Regis University
July 16, 2010

V IDEO
 http://www.youtube.com/watch?v=Q8KB2fhLDw
M&feature=related

P URPOSE :
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Explain the importance of doing a thorough examination on patients with traumatic drop foot and the intervention options physical therapists can offer these patients.

O BJECTIVES :
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Student will be able to describe the pathology for a person with traumatic drop foot.
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Student will be able to explain information obtained during the examination and evaluation for this patient.
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Student will be able to discern a more thorough evaluation process for this patient based on evidentiary support.
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Student will be able to develop an intervention strategy using current literature evidence.

P ATIENT CONSULTATION :
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Pt is a 25 y.o. male active duty Army (ADA)
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Dx: Pt is status post multiple reconstruction surgery due to blast injury.
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Rx: Please evaluate and treat.

W HAT IS D ROP F OOT ?
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Traumatic drop foot is usually occupation or sport related.
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Caused by chronic compression, traction or transection of the common peroneal or deep peroneal nerve.
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Injury to the common peroneal nerve results in weakness of all muscles innervated by the superficial and deep branches.
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T RAUMATIC D ROP F OOT : ( CONT )
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Tibialis anterior muscle is the primary ankle DF.
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Tibialis anterior has the highest activity at heel strike and after toe off during the swing phase.
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Disruption leads to foot drop.
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Common gait deviations include: flatfoot/forefoot contact, decreased push off, and excessive hip and knee flexion with ankle PF.

E XAMINATION :
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Through patient history
Systems Review
Special tests
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Posture/Gait observation
MMT
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ROM
Sensory/proprioceptive testing
Scar mobility
Outcome measure: LEFS
EMG and NCV studies can be used to determine the degree of nerve damage and potential for nerve recovery. However, are not necessary to diagnose drop foot. 1

S UBJECTIVE H ISTORY :
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Sx: c/o left drop foot, multiple trips/near falls over the past 3 months. Pain with first few steps after getting up.
Hx: MOS: 11B, was hit by an RPG August 30, 2009 on left lower leg while deployed in Afghanistan. Was
MEDDVAC’d to Germany then transferred state side.

S UBJECTIVE H ISTORY : ( CONT )
He had a series of
10 limb salvation surgeries from
September to
November 2009, including an external fixator placed at Walter
Reed Army
Medical Center.

S UBJECTIVE H ISTORY : ( CONT )

November 2009:
Pt had muscle flap of left latisimus dorsi transferred to left calf and skin graft from left thigh placed over site.

E XAMINATION F INDINGS :
Systems Review
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Cardiovascular: posterior tibial and dorsal pedal pulses present
Neuromuscular: reflexes 3+ Lt quad tendon, 2+ Rt quad tendon/ bilat triceps surea
- Babinski bilat.
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Endocrine: No significant findings
Integumentary: 8 fully healed screw wholes and fully healed skin graft
Musculoskeletal: also being treated by physical therapy for Lt shoulder injury that occurred from the same incident.

E XAMINATION F INDINGS : ( CONT )
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Posture observation
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Assymetirical WBing to
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Rt LE
Excessive ER of Lt LE
Gait Observation
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Forefoot contact at heel
 strike
Excessive knee/hip flexion with swing phase
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Toe drop on Lt throughout swing phase
Decreased stance time on Lt
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MMT
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Rt LE: 5/5 throughout
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Lt hip flex: 5/5
Lt knee flex: 5/5
Lt knee ext: 4+/5
Lt ankle DF: 0/5
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Lt ankle PF: 1/5
Lt ankle Inv: 1/5
Lt ankle Ever: 0/5
Great toe Ext: 0/5
Minimal ability to wiggle toes noted.

E XAMINATION F INDINGS : ( CONT )
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PROM
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Rt Ankle: 0 ̊ DF to 70 ̊ PF
Lt Ankle:
10 ̊ PF to 35 ̊ PF
Sensory/proprioceptive testing
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Light tough: diminished L4, L5, S2 on Lt
10/10 monofilament test on plantar surface of foot
Balance: 30 seconds with EC on Rt, 7 seconds with eyes open on Lt
Proprioception: 4/10 correct on Lt ankle
Scar mobility
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Poor scar mobility of 8 pin holes and lateral ankle incision.
Outcome measure: LEFS
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38/80 (where 80/80 means no disability) 4
MCID is 9 points

E XAMINATION F INDINGS :
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NCV:
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Diminished NCV of Lt tibial nerve (35 ms), absent on Lt peroneal nerve
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EMG:
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Intact Lt femoral nerve, sciatic nerve
Diminished activity of the Lt tibial nerve with maximum contaction
No activity of Lt common peroneal nerve and it’s branches.

D IAGNOSIS & P ROGNOSIS :
Diagnosis:
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Left drop foot with complete neural loss of the common peroneal nerve and it’s branches.
Prognosis:
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Poor
If there are no signs for nerve recovery with EMG after 6 months then there will likely be no recovery of function.
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I NTERVENTIONS & E VIDENCE :
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Maintain ankle ROM
Prevent PF contracture
Address gait impairments with AFO
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2,7
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Talocrural and subtalar joint fusion
Posterior tibialis tendon transfer
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No appropriate for this patient
BKA

O RTHOSES : D OES E VIDENCE MATCH MY
PATIENT ?
Eberly et al. 6

O RTHOSES : D OES E VIDENCE MATCH MY
PATIENT ?
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Patients with common peroneal nerve palsey require a more solid, rigid
AFO than those with only deep peroneal nerve palsey.
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
He is still waiting to receive his AFO.

T AKE AWAY:
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These returning injured soldiers will be PT patients both acutely and later in our careers.
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If you have a patient with a traumatic injury always ask if the patient has pictures from the initial injury or just prior to surgery.
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EMG and NCV studies done in the physical therapy clinic can provide helpful information for diagnosis and prognosis of a patients injury.

C HECK FOR UNDERSTANDING :
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What are the causes of traumatic foot drop?
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Which nerve(s) cause foot drop when they are damaged?
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What are 2 physical therapy interventions for a patient with traumatic foot drop?

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R EFERENCES :
Images:
Photos provided by the featured patient
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Family practice notebook.com http://www.fpnotebook.com/_media/AnkleAnatomyMuscleAP.gif
Twin Oaks Orthotics & Prosthetics: http://www.bing.com/images/search?q=AFO&FORM=BIFD#focal=57a9fe3e43ec50b4ffe5eef02b ec67e6&furl=http%3A%2F%2Fwww.twincityop.com%2Fsitebuildercontent%2Fsitebuilderpict ures%2FAFO_Family.jpg
Articles:
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Aminoff M. Electrophysiologic testing for the diagnosis of peripheral nerve injuries.
Anesthesiology [serial online]. May 2004;100(5):1298-1303.
Baima J, Krivickas L. Evaluation and treatment of peroneal neuropathy. Current Reviews
In Musculoskeletal Medicine [serial online]. June 2008;1(2):147-153.
Berry H, Richardson P. Common peroneal nerve palsy: a clinical and electrophysiological review. Journal Of Neurology, Neurosurgery, And Psychiatry [serial online]. December
1976;39(12):1162-1171.
Binkley J, Stratford P, Lott S, Riddle D. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. Physical Therapy
[serial online]. April 1999;79(4):371-383.
Chémali K, Tsao B. Electrodiagnostic testing of nerves and muscles: when, why, and how to order. Cleveland Clinic Journal Of Medicine [serial online]. January 2005;72(1):37-48.
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Eberly V., Kubota K., Weiss W. To brace or not to brace: Making evidence-based decisions with our clients with neurologic impairments. Paper presented at: Combined Sections
Meeting of the American Physical Therapy Association; February 1-5, 2006; San Diego, CA.
Elman L, McCluskey L. Occupational and sport related traumatic neuropathy. The
Neurologist [serial online]. March 2004;10(2):82-96.
Geboers J, Drost M, Spaans F, Kuipers H, Seelen H. Immediate and long-term effects of ankle-foot orthosis on muscle activity during walking: a randomized study of patients with unilateral foot drop. Archives of Physical Medicine & Rehabilitation [serial online].
February 2002;83(2):240-245.