DROPFOOT
(sometimes also called FootDrop)
Dr. David Gitlin has significant interest in the treatment of footdrop (or dropfoot if you prefer to spell it that way). We realize that this is a very difficult condition to live with since it severely alters a persons walk and we also understand that the braces commonly prescribed do not do a very comfortable job correcting the foot.
We specialize in a particular procedure called the ‘tendon transfer’. This procedure also happens to be the most powerful and predictable surgical procedures to correct dropfoot. Unfortunately though it is very rarely taught anymore to new doctors and is becoming a lost art. The procedure consists of taking a tendon and muscle that does one job and moving it over to a new position to enable it to do a different job, in the case of dropfoot the new position of the muscle must dorsiflex the ankle ( bring the toes up to the nose).
Generally in the ankle and foot, for every muscle we have to pull our foot up there is one that pulls our foot down. So everything is balanced normally. When one muscle is damaged for whatever reason there is an imbalance and one tendon pulls unopposed and causes what we call a contracture and over time it can be referred to as a deformity (we don’t like to use that term). In this arm picture of a stroke patient you can see how the arm and hand contract when one muscle is damaged by a stroke in the brain. Similar situation happens in the ankle.
Foot drop describes the inability to raise the front part of the foot due to weakness or paralysis of the muscles that lift the foot. As a result, individuals with foot drop scuff their toes along the ground or bend their knees to lift their foot higher than usual to avoid the scuffing, which causes what is called a “steppage” gait. You can see an example of that in the video here. Foot drop can be unilateral (affecting one foot) or bilateral (affecting both feet). Foot drop is a symptom of an underlying problem and is either temporary or permanent, depending on the cause.
Important note - not every perceived dropfoot is necessarily a dropfoot, we see many cases where a weakness of a muscle and a tightening of other muscle restricts motion and this condition which might look like a dropfoot can be corrected with even a simpler surgical solution.
Over the past 10 years Dr. Gitlin has transferred every muscle in the lower leg and ankle to correct this condition. Why 'every muscle'? Because every case is unique, depending on the cause of the dropfoot, different muscles may be injured and nonfunctional so using different muscles and tendons may be necessary. If you search and read online you will find the posterior tibial tendon transfer is probably the most common procedure used- but many times other tendons must be either lengthened or shifted at the same time. Every patient is assessed in a very particular way to find which muscles- if any are functional and movable and where they should be moved to for the best possible outcome.
We have two publications submitted for research journals with two new tendon transfer techniques never performed before. At Mount Sinai Beth Israel we are also conducting a landmark study using EMG muscle testing and EEG brain wave monitoring to help assess pre op surgical planning and post op muscle training, this study to be completed and submitted for review and publication in orthopedic journal later this year..
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 (commonly known as Lou Gehrig’s disease); injury to the nerve roots, such as in spinal stenosis; peripheral nerve disorders such as 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; and muscle disorders, such as muscular dystrophy or myositis.
At our office we utilize the most current invasive and conservative techniques for dropfoot correction. To date we have performed all combinations of tendon transfer, joint fusion, and bone osteotomy to allow the patient to ambulate as normal as possible. Most times postoperatively no one can tell the patient ever had a dropfoot condition at all. We also understand that surgery is not for everyone and use nerve stimulation, physical therapy, and bracing as well to manage the dropfoot. We work closely with our orthopedic colleagues to address and other joint contractures and pathology such as knee procurvatum, knee recurvatum, developmental hip conditions, and arthritic conditions.
See the video attached below that one of our patients made, try to see the before and dramatic after videos, we are so proud of her case - it makes all the long hours of study worthwhile.
PEOPLE ALSO ASK :
Is Foot Drop a red flag?
It can be - sudden onset foot drop from either an acute injury needs to be immediatly addressed. The nerve that gives power to the muscles that pull up the foot (dorsiflex) is called the peroneal nerve. Of of the most easily injured nerved happens to be this common peroneal nerve. It is located on the outside of the knee just past the knee joint and in that area if does not have good protection and lives pretty much right under the skin. Our body like to protect major nerves deeper inside, or between muscles of padded by layers of fat. Unfortunately not in this case which makes the common peroneal nerve one of the most commonly injured nerves in the body. There are other red flag issues for a foot drop that are no related to a local injury to the nerve. After knee replacement surgery, hip replacement surgery or certain spine procedures an acute drop foot may develop. This can be from a direct injury to the nerve since that nerve to the dorsiflexion muscle starts in the lower spine. Also there are cases where certain neuromuscular diseases or medications may cause a relatively acute onset of dropfoot. All of these need to be addresses and investigated as an emergency! In some cases there may be a way to correct the problem and prevent progression to a permement condition. Also even if there is no surgery involved a new injury of the lower back can easily puch on the spinal nerves in a way to cause new onset paralysis and dropfoot. This is an emergency and must be addressed immediately.
Is dropfoot a nerve injury to L4 or L5 ?
One of the most common injuries to this area of the lower back/spine is disk herniation. Disks in the spinal column cushion the vertebra and allow motion between them as well. If the disk herniates or bulges in a certian direction it can pinch the spinal cord which is protected by the spine bones. This can lead to a new acute onset drop foot and othe lower leg weakness as well, in the upper leg and thigh. This should be addressed in an emergent treatment to prevent permamant nerve injury. The longer a nerve in pinched or compressed the more chance for permanent injury occurs. In the diagram her eyou can see the arrow pointing to a disk bulging into the spinal cord which is the main trunk of the nerve from the brain.
What is mistaken for foot drop?
There are occasions where weakness of the muscles pulling the foot up (dorsiflexion) can look like a dropfoot. Even though a true dropfoot is usually because of complete paralysis of the dorsiflexion muscles this can give the appearance of a dropfoot at first glance. The muscles pulling the foot down ( plantar flexion) have to just be slightly weaker than those mucles that pull the foot up. For example here is a short video of a patient with this situation where a surgical procedure really changed her life altogether- not a dropfoot though everyone else though it was. The biggest problem is these weaknesses , if not taken care of can result in a contraction of the muscles that are strong, this will then altogether prevent the dorsiflexion muscles - whom are already weak- from ever being able to pull the foot up properly again. There is another condition although rare called Foot Dystonia. In this condition there is also a relative weakness of the muscles that pull the foot up thus creating a ‘pseudo’ dropfoot. This can most often be found in patients with parkinsons disease and also leads to the particular gait that is linked to those patients.
When is it too late to fix foot drop?
It is never too late to have it fixed if the condition changes a patients activities of daily living. As laid out above in the surgery explanation there are a number of different procedures we do for foot drop. If there is simply a muscle power imbalance then we can do procedures to lengthen certain tendons and muscles that are restricting motion. If there is a true paralysis of a muscle, we can find another muscle to transfer - called a tendon transfer. This is our preferred method since in many cases we can restore close to normal function. In other more rare cases we do need to do fusions of joints, usually the ankle joint because there are no functional muscles so it’s almost as if we are “placing an internal ankle brace”. Of course we only leave this arthrodesis fusion procedure for cases where there is no other option; but it works well to stabilize the foot and allow the patient to walk without a brace and in a normal shoe in most cases.
How long before a foot drop is permanent?
This is very difficult to answer since there are so many possible causes and degree of cause. For example a patient with a gunshot wound that injures the nerve may have no ability to recover since the nerve may be significantly damaged. there are progressive neurological diseases that can cause a dropfoot. In many cases it gets worse over a period of time , such as we see in multiple sclerosis (MS), Charcot - Marie-Tooth, spinal muscular atrophy, parkinson’s disease , muscular dystrophy and other diseases of the peripheral nerves. these situations of foot drop can be nonreversible. On the other hand there are cases of simple direct nerve injury without severe nerve damage, or postoperative swelling near a nerve after a spine or knee or hip surgery - these may be cases where time may bring back some or all of the function. These cases need to be carefully followed by the overseeing doctor. In cases where a nerve is compressed but another structure in the body; causing dropfoot- there is a short timeline for how long a nerve can survive until there is permanent damage
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