The effect of electromyographic feedback functional electrical stimulation on the plantar pressure in stroke patients with foot drop

Purpose

The purpose of this study was to observe, using Footscan analysis, the effect of electromyographic feedback functional electrical stimulation (FES) on the changes in the plantar pressure of drop foot patients.

Methods

This case-control study enrolled 34 stroke patients with foot drop. There were 17 cases received FES for 20 min per day, 5 days per week for 4 weeks (the FES group) and the other 17 cases only received basic rehabilitations (the control group). Before and after 4 weeks, the walking speed, spatiotemporal parameters and plantar pressure were measured.

Results

After 4 weeks treatments, Both the FES and control groups had increased walking speed and single stance phase percentage, decreased step length symmetry index (SI), double stance phase percentage and start time of the heel after 4 weeks (p < 0.05). The increase in walking speed and decrease in step length SI in the FES group were more significant than the control group after 4 weeks (p < 0.05). The FES group had an increased initial contact phase, decreased SI of the maximal force (Max F) and impulse in the medial heel after 4 weeks (p < 0.05).

Conclusion

The advantages of FES were: the improvement of gait speed, step length SI, and the enhancement of propulsion force were more significant. The initial contact phase was closer to the normal range, which implies that the control of ankle dorsiflexion was improved. The plantar dynamic parameters between the two sides of the foot were more balanced than the control group. FES is more effective than basic rehabilitations for stroke patients with foot drop based on current spatiotemporal parameters and plantar pressure results.

Comparison of Staple, Anchor, and Tenodesis Screw for Posterior Tibialis Tendon Fixation: A Biomechanical Analysis

Various posterior tibialis tendon fixation techniques are described in literature. Suture anchor, staple and tenodesis screws are widely used for posterior tibialis tendon transfer, but their stiffness and the maximal ultimate failure load were not tested before. We aimed to compare the initial ultimate failure load and stiffnesses of suture anchor, staple and tenodesis screws on bovine tendon fixation to bovine metaphyseal bone. Thirty-five fresh bovine ankle joints and hooves were obtained from a local abattoir. Metatarsals bones with long extensor tendons were harvested. Staple group had 15, suture anchor group had 10, and tenodesis screw group had 10 samples. All fixations were tested with Instron® ElectroPuls® E10000 Test Instrument. Ultimate failure load and failure location were noted. Staple group's median ultimate failure load was 210.03 N (IQR: 133.43), suture anchor group's was 124.33 N (IQR: 63.67), and tenodesis screw group's was 394.46 N (IQR:115.09). Median stiffness of the staple group was 19.87 N/m (IQR: 15.29); the tenodesis screw group's was 20.28 N/m (IQR: 6.18), the anchor group's was 8.54 N/m (IQR: 4.35). Staples' failure occurred on tendon-staple interface, while suture anchors' occurred on anchor-suture interface and tenodesis screws' occurred on tendon-suture interface. Tenodesis screws' ultimate failure load was the highest (tenodesis vs anchor and staple p < .001 and p = .032, respectively). Staple fixation is less expensive than the other methods and can provide sufficient fixation strength but was weaker than the tenodesis screw fixation. Staples are still a good choice for tendon to bone fixation, whereas the suture anchors provide lower fixation strength at a higher cost.

Comprehensive Rehabilitation of a Patient With Foot Drop Secondary to Lumbar Canal Stenosis: A Case Report

One of the most prevalent degenerative musculoskeletal conditions is lumbar spinal canal stenosis (LSS), which is characterized by narrowing of the lumbar spinal canal that pressures the nerve roots and cauda equine. LSS, when treated surgically, usually presents with foot drop as its major complication. Foot drop is a common presentation of several clinical diseases, traditionally characterized as severe weakening of ankle and toe dorsiflexion. Foot drop has a great impact on patients' lives, lowering their quality of life and affecting their activities of daily living. Ankle dorsiflexion weakness leads to foot drop and a high-stepping gait, which can cause multiple falls and accidents. This case study aimed to assess the efficacy of a customized physiotherapy program in a 50-year-old woman with paraparesis along with left foot drop and post-surgery complications following lumbar decompression and spinal fusion at L3-S1 (lumbar-sacral) level after a jerk experienced by her while working out in the gym. The objective was to determine the impact of individualized exercises on the patient's strength, gait, balance, and pelvic floor function over a 12-week rehabilitation period. The interventions included lower limb exercises (stretching exercises, strengthening exercises, and weight-bearing exercises), pelvic floor exercises, and core stability training. The findings demonstrated significant improvements in the patient's functional outcomes, as evidenced by enhanced scores in the Berg Balance Scale, Manual Muscle Testing, Dynamic Gait Index, Barthel Index, and Stanmore Assessment Questionnaire. Notable progress was observed in the strength, balance, gait, and pelvic floor function, highlighting the positive influence of targeted physiotherapeutic interventions. This case underscores the importance of tailored exercise plans in addressing the complexities of post-surgery challenges, emphasizing the potential for comprehensive recovery and improved overall quality of life through personalized physiotherapy.

Physiotherapy Rehabilitation Towards Foot Drop in a Paediatric Case of Iatrogenic Sciatic Nerve Palsy: A Case Report

In this report, we are presenting a case of injection nerve palsy in a three-year-old child whose parents visited with the complaint of weakness of the left lower limb, inability to walk, and difficulty in performing lower limb movements after taking diphtheria-tetanus-pertussis (DPT) vaccination in the gluteal region by intramuscular route. The child exhibited a foot drop on his left leg and a high step gait when examined. Nerve conduction velocity was performed, which revealed pure motor axonal mononeuropathy involving the left sciatic nerve. She was diagnosed with a left sciatic nerve injury from a foot drop and was referred to physiotherapy. With the proper exercise protocol, physiotherapy rehabilitation began. We report that after rehabilitation, she showed improvement in the strength of the lower limb and gait pattern. As a result, physiotherapy is critical in improving a patient's gait pattern, ensuring early and rapid recovery, and treating the condition's clinical manifestations. This case study concludes that physiotherapy rehabilitation for injection palsy in a three-year-old female child with foot drop led to improved lower-limb strength, which assisted the patient in ambulation and prevented other deformities.

Rehabilitation of a Patient With D12 Wedge Compression Fracture and Bilateral Foot Drop With Spinal Fusion and Posterior Decompression: A Case Report

Vertebral fracture (VF) is one of the most common injuries seen in individuals with osteoporosis, especially in post-menopausal females. There is an increase in bone resorption rate, leading to the destruction of the microarchitecture of bone. A 67-year-old female patient diagnosed with wedge compression fracture of the D12 vertebra, mild compression of the spinal cord, and bilateral foot drop came to a tertiary care hospital, where she underwent spinal fusion at the D11-L1 level and posterior decompression, after which she was referred to physiotherapy, where a patient-tailored treatment protocol was made and implemented over three weeks. Outcome measures like the visual analog scale (VAS), functional independence measure (FIM), and Oswestry's low back disability questionnaire were recorded before and after rehabilitation, and improvement in pain and activities of daily living (ADL) was found. The patient needed mild assistance. There was also improvement in the range and strength of the lower limb muscles. This case report aims to provide a comprehensive treatment protocol for a post-operative spinal fusion and bilateral foot drop patient.

Novel Modular Walking Orthosis (MOWA) for Powerful Correction of Gait Deviations in Subjects with a Neurological Disease

This article introduces a novel concept where advanced technologies have been leveraged to produce a modular walking orthosis (MOWA) within a completely digital process chain. All processes of this new supply chain are described step-by-step. The prescription and treatment of lower leg orthoses for individuals with paralysis or muscle weakness, particularly cerebral palsy (CP), are complex. A single case study indicates successful treatment with this new orthosis (MOWA). From the authors' perspective, this innovative fitting concept is promising and will contribute to creating more efficient care within a multidisciplinary team.

Intraneural ganglion cyst of the peroneal nerve occurring after coronavirus disease-19 vaccination: A case report

Ganglion cysts are relatively common, but intraneural ganglion cysts (INGCs) within peripheral nerves are rare and poorly understood. We present the case of a 58-year-old woman who presented with acute right-foot drop. She experienced acute knee pain radiating from the lateral leg to the dorsal foot two days after the first coronavirus disease-19 (COVID-19) vaccination (BNT162b2, Pfizer-BioNTech). She had no history of trauma or medication use. Two weeks after the onset of symptoms, she developed a dorsiflexor weakness of the right foot (Medical Research Council grade, poor). The weakness worsened to a "trace" grade despite providing conservative management for one month. Ultrasonography revealed a fusiform echolucent structure within the course of the right common peroneal nerve around the fibular head. Magnetic resonance imaging revealed multiple intraneural cysts within the right common peroneal nerve. Nerve conduction and electromyographic studies revealed multiphasic motor unit action potentials accompanied by abnormal spontaneous activities in the innervated muscles, along with axonal degeneration of the deep peroneal nerves. Surgical removal of the cyst was performed, and the patient's symptoms gradually improved. Pathological examination revealed a cystic structure containing mucinous or gelatinous fluid and lined with flattened or cuboidal cells. The clinical course and sequential electromyographic findings relevant to this symptomatic cyst were temporally related to the vaccination date. The present case suggests that INGC-induced peroneal palsy is a possible complication after COVID-19 vaccination.

Characterizing peroneal nerve injury clinicoradiological patterns with MRI in patients with sciatic neuropathy and foot drop after total hip replacement

OBJECTIVE

Sciatic nerve injury following total hip arthroplasty (THA) predominantly affects the peroneal division of the sciatic nerve, often causing a foot drop. This can result from a focal etiology (hardware malposition, prominent screw, or postoperative hematoma) or nonfocal/traction injury. The objective of this study was to compare the clinicoradiological features and define the extent of nerve injury resulting from these two distinct mechanisms.

METHODS

Patients who developed a postoperative foot drop within 1 year after primary or revision THA with a confirmed proximal sciatic neuropathy based on MRI or electrodiagnostic studies were retrospectively reviewed. Patients were divided into two cohorts: group 1 (focal injury), including patients with an identifiable focal structural etiology, and group 2 (nonfocal injury), including patients with a presumed traction injury. Patient demographics, clinical examinations, subsequent surgeries, electrodiagnostic study results, and MRI abnormalities were noted. The Student t-test was used to compare time to onset of foot drop and time to secondary surgery.

RESULTS

Twenty-one patients, treated by one surgeon, met inclusion criteria (8 men and 13 women; 14 primary THAs and 7 revision THAs). Group 1 had a significantly longer time from THA to the onset of foot drop, with a mean of 2 months, compared with an immediate postoperative onset in group 2 (p = 0.02). Group 1 had a consistent pattern of localized focal nerve abnormality on imaging. In contrast, the majority of patients in group 2 (n = 11) had a long, continuous segment of abnormal size and signal intensity of the nerve, while the other 3 patients had a segment of less abnormal nerve in the midthigh on imaging. All patients with a long continuous lesion had Medical Research Council grade 0 dorsiflexion prior to secondary nerve surgeries compared with 1 of 3 patients with a more normal midsegment.

CONCLUSIONS

There are distinct clinicoradiological findings in patients with sciatic injuries resulting from a focal structural etiology versus a traction injury. While there are discrete localized changes in patients with a focal etiology, those with traction injuries demonstrate a diffuse zone of abnormality within the sciatic nerve. A proposed mechanism involves anatomical tether points of the nerve acting as points of origin and propagation for traction injuries, resulting in an immediate postoperative foot drop. In contrast, patients with a focal etiology have localized imaging findings but a highly variable time to the onset of foot drop.

Deep Learning-Based Knee MRI Classification for Common Peroneal Nerve Palsy with Foot Drop

Foot drop can have a variety of causes, including the common peroneal nerve (CPN) injuries, and is often difficult to diagnose. We aimed to develop a deep learning-based algorithm that can classify foot drop with CPN injury in patients with knee MRI axial images only. In this retrospective study, we included 945 MR image data from foot drop patients confirmed with CPN injury in electrophysiologic tests (n = 42), and 1341 MR image data with non-traumatic knee pain (n = 107). Data were split into training, validation, and test datasets using a 8:1:1 ratio. We used a convolution neural network-based algorithm (EfficientNet-B5, ResNet152, VGG19) for the classification between the CPN injury group and the others. Performance of each classification algorithm used the area under the receiver operating characteristic curve (AUC). In classifying CPN MR images and non-CPN MR images, EfficientNet-B5 had the highest performance (AUC = 0.946), followed by the ResNet152 and the VGG19 algorithms. On comparison of other performance metrics including precision, recall, accuracy, and F1 score, EfficientNet-B5 had the best performance of the three algorithms. In a saliency map, the EfficientNet-B5 algorithm focused on the nerve area to detect CPN injury. In conclusion, deep learning-based analysis of knee MR images can successfully differentiate CPN injury from other etiologies in patients with foot drop.

[Foot drop and cyclic sensory disturbance of the right lower limb due to endometriosis]

We report the case of a 40-year-old woman, with endometriosis, who presented with a history of foot drop and cyclic sensory disturbance of the right lower limb. She was initially diagnosed with lumbar disc herniation. Neurological examination revealed muscle weakness and sensory disturbance associated with the right sciatic nerve. Nerve conduction studies revealed a low amplitude sensory nerve action potential in the right superficial fibular and sural nerves. Pelvic magnetic resonance imaging revealed an endometriotic cyst in the right ovary, and an endometriotic lesion extending from the right ovary, pelvis, and the right sciatic nerve. Though her symptoms moderately improved with hormonal therapy, the foot drop remained. Our case and previous reports suggest that endometriosis with sciatic neuropathy shows cyclic neurological symptoms during menstruation, with a higher incidence on the right extremity. This case highlights that endometriosis should be considered as a potential differential diagnosis in women of reproductive age with sciatic nerve dysfunction. Its cyclic neurological manifestations should be investigated.

Common Peroneal Nerve Compression Neuropathy Due to a Large Synovial Cyst From the Proximal Tibiofibular Joint in a Teenager

Ganglion cysts are very rare in the lower limb and when present, ganglion cysts rarely cause compression neuropathy at any site. Peripheral nerve sheath tumors as a whole, are also very rare and mostly presented as a painful lump along the nerve path. Ganglion cysts are non-neoplastic gelatinous cysts, which lack true synovial lining. They can be divided into intraneural cysts which can be found within the epineurium of a peripheral nerve and lead to signs and symptoms of peripheral neuropathy or extraneural cysts which can develop from surrounding joints or tendon sheaths causing gradual nerve compression. Intraneural tumors of common peroneal nerve (CPN) are widely reported in the literature with varying degrees of symptoms; however, there are only a few case reports describing CPN palsy due to extraneural cysts. We are reporting a rare case of atraumatic CPN palsy, which resulted in irreversible foot drop in a teenage boy who presented with right leg radiating calf and foot pain. We recommend prompt investigation and excision of the cyst to decompress the nerve to increase the chances of early recovery and favorable outcomes.

Evaluation and Management of Idiopathic Unilateral Foot Drop

BACKGROUND

In this study, our purpose is to evaluate patients who were followed by acute developing single-sided foot drop and improving with conservative management or spontaneously.

METHODS

Between 2019 and 2020, 10 patients were evaluated for a unilateral weakness of the lower extremity in the form of absent dorsiflexion at the ankle joint and were given a diagnosis of foot drop without any etiological cause. Patients were followed for a period of 18 months. All patients were evaluated for acute foot drop of the affected extremity by utilizing the following diagnostic modalities, EMG, MRI lumbar spine, MRI knee, peripheral MRI neurography and non-contrast brain MRI. Each patient was evaluated for a history of Covid-19 infection over the past year. Patients with any identified cause were excluded.

RESULTS

Initial evaluation of muscle strength in all patients revealed 0/5 by the MRC muscle testing grading scale. (1) In 2 patients, the muscle strength was 3/5 at the 6th month, and in the other 8 patients 4/5 at the 6th month. The muscle strength of all patients improved as 5/5 in 1 year. Six of the patients were dispensed an AFO device and nine patient's performed physical therapy. Evaluation of EMG results identified significant neuropathy at the level of the common peroneal at the fibular head in all patients. In comparison with peroneal nerve stimulation below and above the fibular head in the lateral popliteal fossa; 50% reduction in sensory amplitude, and motor conduction slowing of >10 m/s was present. Evaluation of knee MRI revealed, no masses, edema, or anatomical variations at the level of the fibular head.

CONCLUSIONS

In patients diagnosed with unilateral acute foot drop without an etiological cause, one should keep in mind that spontaneous resolution of this condition can occur within one year period.

The Determination of Assistance-as-Needed Support by an Ankle-Foot Orthosis for Patients with Foot Drop

Patients who suffer from foot drop have impaired gait pattern functions and a higher risk of stumbling and falling. Therefore, they are usually treated with an assistive device, a so-called ankle-foot orthosis. The support of the orthosis should be in accordance with the motor requirements of the patient and should only be provided when needed, which is referred to as assistance-as-needed. Thus, in this publication, an approach is presented to determine the assistance-as-needed support using musculoskeletal human models. Based on motion capture recordings of multiple subjects performing gaits at different speeds, a parameter study varying the optimal force of a reserve actuator representing the ankle-foot orthosis added in the musculoskeletal simulation is conducted. The results show the dependency of the simulation results on the selected optimal force of the reserve actuator but with a possible identification of the assistance-as-needed support required from the ankle-foot orthosis. The required increase in support due to the increasing severity of foot drop is especially demonstrated with the approach. With this approach, information for the required support of individual subjects can be gathered, which can further be used to derive the design of an ankle-foot orthosis that optimally assists the subjects.

Assessment of Dorsiflexion Ability across Tasks in Persons with Subacute SCI after Combined Locomotor Training and Transcutaneous Spinal Stimulation

In people with spinal cord injury (SCI), transcutaneous spinal stimulation (TSS) has an immediate effect on the ability to dorsiflex the ankle, but persistent effects are not known. Furthermore, TSS has been associated with improved walking, increased volitional muscle activation, and decreased spasticity when combined with locomotor training (LT). In this study, the persistent impact of combined LT and TSS on dorsiflexion during the swing phase of walking and a volitional task in participants with SCI is determined. Ten participants with subacute motor-incomplete SCI received 2 weeks of LT alone (wash-in phase), followed by 2 weeks of either LT + TSS (TSS at 50 Hz) or LT + TSS_Sham (intervention phase). There was no persistent effect of TSS on dorsiflexion during walking and inconsistent effects on the volitional task. There was a strong positive correlation between the dorsiflexor ability for both tasks. There was a moderate effect of 4 weeks of LT on increased dorsiflexion during the task (d = 0.33) and walking (d = 0.34) and a small effect on spasticity (d = -0.2). Combined LT + TSS did not show persistent effects on dorsiflexion ability in people with SCI. Four weeks of locomotor training was associated with increased dorsiflexion across tasks. Improvements in walking observed with TSS may be due to factors other than improved ankle dorsiflexion.

Passive Articulated and Non-Articulated Ankle-Foot Orthoses for Gait Rehabilitation: A Narrative Review

The aim of this work was to study the different types of passive articulated and non-articulated ankle-foot orthoses for gait rehabilitation in terms of working principles, control mechanisms, features, and limitations, along with the recent clinical trials on AFOs. An additional aim was to categorize them to help engineers and orthotists to develop novel designs based on this research. Based on selected keywords and their composition, a search was performed on the ISI Web of Knowledge, Google Scholar, Scopus, and PubMed databases from 1990 to 2022. Forty-two studies met the eligibility criteria, which highlighted the commonly used types and recent development of passive articulated and non-articulated ankle-foot orthoses for foot drop. Orthotists and engineers may benefit from the information obtained from this review article by enhancing their understanding of the challenges in developing an AFO that meets all the requirements in terms of ease of use, freedom of movement, and high performance at a relatively low cost.

L5 mononeuritis, an uncommon cause of foot drop: illustrative case

BACKGROUND

New-onset adult foot drop is commonly encountered in neurosurgical practice and has a broad differential, including radiculopathy, peroneal nerve palsy, demyelinating diseases, and central causes. Etiology is commonly identified with comprehensive history, examination, imaging, and investigations. Despite familiarity with the management of lumbar spondylosis and peroneal nerve compression causes, rare or uncommon presentations of nonsurgical causes are important to consider in order to avoid nonbeneficial surgery.

OBSERVATIONS

The authors report a very uncommon cause of foot drop: new-onset isolated L5 mononeuritis in a 61-year-old nondiabetic male. They provide a review of the etiology and diagnosis of foot drop in neurosurgical practice and detail pitfalls during workup and the strategy for its nonsurgical management.

LESSONS

Uncommon, nonsurgical causes for foot drop, even in the setting of degenerative lumbar spondylosis, should be considered during workup to reduce the likelihood of unnecessary surgical intervention. The authors review strategies for investigation of new-onset adult foot drop and relate these to an uncommon cause, an isolated L5 mononeuritis, and detail its clinical course and response to treatment.

The treatment effect of posterior lumbar fusion surgery on patients suffering from lumbar disc herniation concurrent with peroneal nerve paralysis

Purpose

The purpose of this study is to investigate the clinical effect of posterior lumbar fusion surgery on patients who suffer from lumbar disc herniation concurrent with peroneal nerve paralysis.

Methods

The patients suffering from peroneal nerve paralysis and undergoing posterior lumbar fusion surgery between January 2012 and December 2019 were retrospectively reviewed. The data of the identified patients were then collected and processed. All patients were followed up post-operatively after discharge from the hospital. The data was analyzed in terms of Oswestry disability index (ODI), visual analogue scale (VAS) score, and relative lower-limb muscle strength.

Results

A total of 87 patients (52 males and 35 females) aged 54 ± 11 years met the inclusion criteria for this study. These patients stayed in hospital for 16 ± 6 days and were followed up for 81 ± 24 months. Data analysis showed that muscle strength of the tibialis anterior and extensor digitorum significantly recovered at the last follow-up with a grade of 3 (median), compared to grade 0 at admission (p < 0.001). Furthermore, the median VAS score decreased to 1 at the last follow-up from 6 at admission (p < 0.001), and the ODI greatly improved with 10% (median) at the last follow-up, while it was 58% at admission (p < 0.001). The ODI improvement rate was 60% on average at the last follow-up. Multivariate regression analysis regarding the ODI and muscle strength improvement rates showed that advanced age was a risk factor for postoperative recovery.

Conclusions

Most of the patients suffering from lumbar disc herniation concurrent with peroneal nerve paralysis can improve after undergoing posterior lumbar fusion surgery, but few can reach full recovery. Advanced age might be a risk factor that affects the prognosis of these patients after surgery.

Peroneal Nerve Repair with Cross-Bridge Ladder Technique: Parallel End-to-Side Neurorrhaphies

Background  Multiple nerve transfer techniques are used to treat patients with nerve injuries when a primary repair is not possible. These techniques are categorized to end-to-end, end-to-side, and side-to-side neurorrhaphy. Our study aims to explore the utility of the cross-bridge ladder technique (H-shaped), which has shown promising results in animal models and probably underutilized clinically. Methods  Four patients with significant loss of ankle dorsiflexion were seen in the clinic and underwent evaluation, including electrodiagnostic studies. A cross-bridge ladder repair technique was used between the tibial nerve as the donor and the common peroneal nerve as the recipient via one or two nerve grafts coapted in parallel with end-to-side neurorrhaphies. Dorsiflexion strength was measured preoperatively using the Medical Research Council (MRC) grading system and at each postoperative follow-up appointment. Results  All four patients had suffered persistent and severe foot drop (MRC of 0) following trauma that had occurred between 6 and 15 months preoperatively. Three of the four patients improved to an MRC of 2 several months postoperatively. The last patient had an immediate improvement to an MRC of 2 by his first month and had a complete recovery of ankle dorsiflexion within 4 months from surgery. Conclusion  We demonstrate the utility and clinical outcomes of the cross-bridge ladder technique in patients with persistent and prolonged foot drop following trauma. Both early and late recovery were seen while all patients regained motor function, with some patients continuing to improve up to the most recent follow-up. IRB Approval: Obtained 2013-1411-CP005.

Effect of Physiotherapeutic Rehabilitation on a Patient With an Iliac Fracture, and Superior and Inferior Pubic Rami Fracture With Foot Drop: A Case Report

The sacroiliac joint is frequently broken apart by high-energy trauma, which increases fatalities and complications from pelvic injuries. Ilium fractures are high-energy pelvic fractures that often progress from the iliac crest to the greater sciatic notch. Concomitant head injury exsanguinations and uncontrollable bleeding within the pelvis are considered important causes of mortality. In contrast, some assume that such extensive bleeding is extremely uncommon and that accompanying injuries could result in increased mortality. A shorter healing period and faster patient mobilization are possible with surgically treated Tile's type B and C fractures. Accident-related fractures can lead to decreased independence and functioning, restricted mobility, lowered self-confidence, and a worse quality of life; these fractures are caused by trauma, most frequently from minor falls and age-related osteopenia. By reducing discomfort, restoring range of motion and muscular strength, and assisting with early ambulation/loading of the fractured limb, early physical therapy intervention speeds up the clinical recovery of patients with fractures.  When one cannot elevate the forefoot, it results in foot drop because of a lack of dorsiflexor strength in the foot. These may induce a risky antalgic gait, leading to falls-the diminished ability to lift the foot of the ankle or the toes (dorsiflexion). Injuries, including fractures, joint dislocations, or hip replacement surgery, can also result in a drop foot. The peroneal nerve, which innervates the tibialis anterior, is the muscle responsible for dorsiflexion, as it arises from the sciatic nerve's branch. Due to the foot drop, the anterior tibialis muscle will shorten and cause spasms in the calf muscle. After surgery, the patient was dependent and had difficulty going about his everyday life. However, the physiotherapy intervention improved the patient's pain and physical functionality. By lowering discomfort, restoring range of motion and muscular strength, and facilitating early ambulation/loading of the fractured limb, this study shows that combining definitive surgical methods with early physical therapy intervention speeds up the clinical recovery of patients with fractures.

Ankle rehabilitation robot training for stroke patients with foot drop: Optimizing intensity and frequency

BACKGROUND

Robotic solutions for ankle joint physical therapy have extensively been researched. The optimal frequency and intensity of training for patients when using the ankle robot is not known which can affect rehabilitation outcome.

OBJECTIVE

To explore the optimal ankle robot training protocol on foot drop in stroke subjects.

METHODS

Subjects were randomly divided into four groups, with 9 in each group. The subjects received different intensities (low or high intensity) with frequencies (1 session/day or 2 sessions/day) of robot combination training. Each session lasted 20 minutes and all subjects were trained 5 days a week for 3 weeks.

RESULTS

After 3 weeks of treatment, all groups showed an improvement in passive and active ankle dorsiflexion range of motion (PROM and AROM) and Fugl-Meyer Assessment for lower extremity (FMA-LE) compared to pre-treatment. When training at the same level of intensity, patients who received 2 sessions/day of training had better improvement in ankle dorsiflexion PROM than those who received 1 session/day. In terms of the improvement in dorsiflexion AROM and FMA-LE, patients who received 2 sessions/day with high intensity training improved better than other protocols.

CONCLUSION

High frequency and high intensity robot training can be more effective in improving ankle dysfunction.

Time-course gait pattern analysis in a rat model of foot drop induced by ventral root avulsion injury

Foot drop is a common clinical gait impairment characterized by the inability to raise the foot or toes during walking due to the weakness of the dorsiflexors of the foot. Lumbar spine disorders are common neurogenic causes of foot drop. The accurate prognosis and treatment protocols of foot drop are not well delineated in the scientific literature due to the heterogeneity of the underlying lumbar spine disorders, different severities, and distinct definitions of the disease. For translational purposes, the use of animal disease models could be the best way to investigate the pathogenesis of foot drop and help develop effective therapeutic strategies for foot drops. However, no relevant and reproducible foot drop animal models with a suitable gait analysis method were developed for the observation of foot drop symptoms. Therefore, the present study aimed to develop a ventral root avulsion (VRA)-induced foot drop rat model and record detailed time-course changes of gait pattern following L5, L6, or L5 + L6 VRA surgery. Our results suggested that L5 + L6 VRA rats exhibited changes in gait patterns, as compared to sham lesion rats, including a significant reduction of walking speed, step length, toe spread, and swing phase time, as well as an increased duration of the stance phase time. The ankle kinematic data exhibited that the ankle joint angle increased during the mid-swing stage, indicating a significant foot drop pattern during locomotion. Time-course observations displayed that these gait impairments occurred as early as the first-day post-lesion and gradually recovered 7-14 days post-injury. We conclude that the proposed foot drop rat model with a video-based gait analysis approach can precisely detect the foot drop pattern induced by VRA in rats, which can provide insight into the compensatory changes and recovery in gait patterns and might be useful for serving as a translational platform bridging human and animal studies for developing novel therapeutic strategies for foot drop.

Atypical presentations of inclusion body myositis: Clinical characteristics and long-term outcomes

INTRODUCTIONS/AIMS

Inclusion body myositis (IBM) typically presents with progressive weakness preferentially involving finger flexors and quadriceps. Atypical presentations have been less commonly reported. Here, we aim to describe the clinical characteristics and long-term outcomes of IBM patients with atypical presentations.

METHODS

We retrospectively searched the Mayo Clinic medical records to identify IBM patients with atypical disease onset, seen between 2015 and 2020.

RESULTS

We identified 357 IBM patients, of whom 50 (14%) had an atypical presentation. Thirty-eight patients were diagnosed with IBM because they fulfilled one of the European Neuromuscular Center diagnostic categories at a later stage, 10 had all IBM histopathological features, and 2 were diagnosed on the basis of clinical and laboratory data. The most common presentation was dysphagia (50%), followed by asymptomatic hyperCKemia (24%; CK, creatine kinase), then foot drop (12%). 6% of patients presented with proximal arm weakness, 4% with axial weakness and 4% with facial diplegia. Median time from symptom onset to diagnosis was 9 y. Median age at diagnosis was 70.5 y. 16% of patients needed a walking aid. When tested, 86.5% of patients had impaired swallowing and 56% had elevated cytosolic nucleotidase-1A antibodies. Only 1/26 patients who received immunotherapy had minimal improvement. Upon follow-up, most patients had generalization of their weakness with a decline in their strength summated score of 0.082/mo.

DISCUSSION

A significant proportion of IBM patients may have an atypical presentation. Recognition of such heterogeneity could improve early diagnosis, prevent unnecessary immunotherapy, and provide insight for future diagnostic criteria development and clinical trials.

Evaluating Acute Bilateral Foot Drop: A Case Report

We illustrate the case of an 84-year-old Caucasian female who presented with complaints of bilateral lower extremity weakness and ambulation difficulties complicated by a unilateral deep venous thrombosis. Physical examination on hospital admission revealed an acute onset of bilateral foot drop with pes cavus deformity. Bilateral foot drop has been associated with a more chronic presentation due to metabolic, neurologic, and musculoskeletal etiologies. Acute onset of bilateral foot drop has been poorly defined in the literature and is considered a rare pathologic phenomenon, requiring additional investigation into the underlying cause of the presentation. We hypothesize that a spinal cord compression at the T12-L1 level resulted in L5 nerve root compression, resulting in our patient's presentation. Definitive treatment has not been established for this condition; however, studies have been completed to evaluate surgical versus conservative approaches to help restore patients' ambulatory function. Our aim is to incorporate this case report into the limited current literature on acute bilateral foot drop as well as outline possible treatment methods to restore impaired functionality.

Peroneal nerve palsy due to synovial cyst: An unusual cause of foot drop in a nine-year-old child

Foot drop is the inability to dorsiflex the foot, and peroneal nerve palsy, a common cause of foot drop, is a rare condition in pediatric patients. Herein, we present a nine-year-old patient with foot drop due to peroneal nerve palsy verified by electrophysiologic examination. A cystic mass was observed in ultrasonography and magnetic resonance imaging, and hyaluronic acid was detected in the cystic material by histopathological examination. The patient was referred to surgery, and one month after surgery, an increase in muscle strength was observed. It should be kept in mind that peroneal nerve palsy due to synovial cysts may cause foot drop in pediatric patients.

Early-Stage Physical Therapy for a Patient With Proximal Tibial Fracture With Acute Compartment Syndrome and Neurovascular Deficits Managed With External Fixation Complicated by Chronic Osteomyelitis: A Case Report

Tibial fractures occur following low-energy and high-energy trauma resulting from indirect and direct impacts, respectively. High-velocity trauma like road traffic accidents usually results in open fractures of the tibia associated with acute compartment syndrome, posing a serious threat. Thus, this injury requires prompt operative management with fasciotomy followed by fixating the fracture with an external fixator to avoid infection. Despite all the efforts, sometimes this condition may lead to osteomyelitis of the tibia requiring further care. Meanwhile, the patient has to be kept immobilized for a longer duration of time, which allows further complications to occur. Therefore, structured physiotherapeutic management of patients postoperatively is of immense necessity to prevent complications associated with prolonged immobility and achieve an optimal level of functional independence, thereby facilitating the patient to come back to near-normal life as soon as possible. Our case report provides a structured early-stage postoperative physical therapy treatment protocol for a patient with a proximal tibial fracture with acute compartment syndrome and neurovascular deficit managed with Ilizarov fixation.

Sudden bilateral foot drop due to dorsally unilateral migration of the herniated lumbar disc: A case report

BACKGROUND

Due to the anatomical characteristics of the anterior epidural space, dorsal migration of material from herniated lumbar disc is quite rare. Also, bilateral foot drop due to unilateral dorsal migration of disc herniation is extremely rare. This report presents a case of sudden bilateral foot drop caused by the unilateral dorsal migration of material from a herniated lumbar disc.

CASE DESCRIPTION

A 51-year-old male presented with sudden onset severe leg pain with bilateral foot drop. The patient was referred to our emergency department by a local clinic. Neurological examination showed bilateral ankle and big toe dorsiflexion weakness grade 1. There was no perianal anesthesia, anal sphincter weaknesses, or voiding difficulty. Apart from essential hypertension, this patient's medical history was unremarkable. Magnetic resonance imaging showed that intervertebral disc material in the dorsal extradural space at the L3-4 level had compressed the dural sac from the left side to the center. We performed an emergency operation. The pathologic result revealed fibrous cartilaginous materials. After the operation, the leg pain was markedly resolved. At postoperative three months, the patient showed improvement of foot drop.

CONCLUSION

We recommended emergent mass removal, which produced a favorable outcome.

Resection of Hibernoma of the Proximal Shin Followed by Foot Drop and Tendon Transfer: A Case Report

This is the description of the case of a 42-year-old male who presented with a growing, painless lump on his anterior leg. The diagnosis of a rare tumor called hibernoma was suspected after inspection of the radiologic findings. The unusual location of the tumor resulted in superficial peroneal nerve entrapment. The tumor was excised and the diagnosis of hibernoma was confirmed by histopathology. Surgery resulted in foot drop that was successfully treated with a tibialis posterior tendon transfer. Our case illustrates a rare tumor in an unusual location that can be challenging for clinicians to discern and to properly treat.

Biological Approach in the Treatment of External Popliteal Sciatic Nerve (Epsn) Neurological Injury: Review

The external popliteal sciatic nerve (EPSN) is the nerve of the lower extremity most frequently affected by compressive etiology. Its superficial and sinuous anatomical course is closely related to other rigid anatomical structures and has an important dynamic neural component. Therefore, this circumstance means that this nerve is exposed to multiple causes of compressive etiology. Despite this fact, there are few publications with extensive case studies dealing with treatment. In this review, we propose to carry out a narrative review of the neuropathy of the EPSN, including an anatomical reminder, its clinical presentation and diagnosis, as well as its surgical and biological approach. The most novel aspect we propose is the review of the possible role of biological factors in the reversal of this situation.

Functional electrical stimulation to aid walking in patients with adrenomyeloneuropathy: A case study and observational series

Adrenomyeloneuropathy (AMN) is a rare inherited condition where affected individuals develop slowly progressive spastic paraparesis with a gradual decline in walking ability. There is no cure for AMN and treatment focuses on supportive measures and aids. One treatment option is functional electrical stimulation (FES), a treatment, approved by The National Institute for Health and Care Excellence (NICE), for managing foot drop in upper motor neuron disorders. Limited evidence exists for its use in AMN patients. We describe the effects of FES in an individual case and more broadly within a cohort of 21 patients successfully treated with FES. Patients with AMN referred for FES typically report frequent falls (71%) and foot drop (57%) as the most common barriers to walking. When using FES, walking speed at baseline (0.70 m/s [SD = 0.2]) was maintained at the 2-year review (0.68 m/s [SD = 0.2]) with a persistent orthotic effect (improvement in walking speed when device on vs. off) seen from wearing FES over the same 2-year period (11%-19%). Patient walking satisfaction (visual analogue scale: 0 - very dissatisfied; 10 - very satisfied) was also greater when comparing no-FES versus FES over the same period (Year 1: 2.5 vs. 7.7; Year 2: 2.1 vs. 6.1). FES is not effective in all patients. Twelve patients referred found no benefit from the device; although there was no clear evidence, this was related to the degree of AMN associated peripheral neuropathy. However, FES is a safe, cost-effective treatment option and should be considered, along with assessment in a multidisciplinary clinic, for all AMN patients with walking difficulties.

The Effect of Implanted Functional Electrical Stimulation on Gait Performance in Stroke Survivors: A Systematic Review

The emerging literature suggests that implantable functional electrical stimulation may improve gait performance in stroke survivors. However, there is no review providing the possible therapeutic effects of implanted functional electrical stimulation on gait performance in stroke survivors. We performed a web-based, systematic paper search using PubMed, the Cochrane Library, and EMBASE. We limited the search results to human subjects and papers published in peer-reviewed journals in English. We did not restrict demographic or clinical characteristics. We included 10 papers in the current systematic review. Across all included studies, we found preliminary evidence of the potential therapeutic effects of functional electrical stimulation on walking endurance, walking speed, ankle mobility, and push-off force in stroke survivors. However, due to the heterogeneity between the included studies, small sample size, and lack of randomized controlled trials, more studies are critically needed to confirm whether implanted functional electrical stimulation can improve gait performance in stroke survivors.

Bilateral foot drop after COVID-19-related acute respiratory distress syndrome: A case report

In these days of the pandemic, we have faced with the locomotor system problems following severe acute respiratory syndrome-coro- navirus 2 (SARS-CoV-2) infection. While some of these problems are related to the disease itself, some of them are associated with the prolonged immobilization during the infection. Long-term intensive care unit admissions of patients may also lead to various types of neuropathies, extending the recovery period. The real burden of the novel coronavirus-2019 (COVID-19) is still unclear. In particular, after a prolonged hospitalization period, the duration of rehabilitation may be longer to gain independence in daily living activities. In this report, we present a different aspect of the COVID-19 with bilateral foot drop in a 53-year-old female patient. To the best of our knowledge, this case is the first report of both peroneal and sciatic nerve damage following COVID-19.

Pure Neuritic Leprosy with Bilateral Foot Drop and Central Nervous Involvement: A Clinical, Electrophysiological, and MR Correlation

Background

Central nervous system (CNS) involvement in leprosy is sparsely documented. Neurophysiological tests and magnetic resonance imaging (MRI) helps in demonstrating CNS involvement in the patient of pure neuritic leprosy.

Objectives

To demonstrate CNS involvement in pure neuritic leprosy.

Methods

Detailed clinical presentation and skin lesions were evaluated. Sural nerve biopsy, MRI diffusion tensor imaging of spinal cord and optic nerve were performed. Visual evoked potential and tibial somatosensory evoked potential were done. Their clinical, electrophysiological, and MRI were done at follow-up visits.

Results

We report three patients of pure neuritic leprosy with bilateral foot drop as the initial presentation. MRI T2W sequence of cervico dorsal cord showed dorsal column hyperintensity in two patients. Diffusion-weighted MR revealed decrease fractional anisotropy and an increase in the apparent diffusion coefficient. Similar findings were also noted in the optic nerves. The patients were managed with multidrug therapy multibacillary regimen and steroid in tapering dose. At follow-up, they showed clinical improvement in vision and power of ankle dorsiflexor.

Conclusions

Patients of pure neuritic leprosy may manifest with bilateral foot drop with the involvement of posterior column and cranial nerves.

Bilateral Well Leg Compartment Syndrome as a Complication of Prolonged Lithotomy Position in Abdominoperineal Resection Surgery

Patients undergoing prolonged surgery in a lithotomy position may develop acute lower limb compartment syndrome in the absence of trauma or pre-existing vascular disease, otherwise known as well-leg compartment syndrome (WLCS). Early recognition and management would prevent the potential, lethal complications associated with this condition. We present a case of a 55-year-old gentleman who developed bilateral WLCS after prolonged abdominoperineal resection of his pelvic liposarcoma.

Evidence in peroneal nerve entrapment: A scoping review

BACKGROUND AND PURPOSE

Daily management of patients with foot drop due to peroneal nerve entrapment varies between a purely conservative treatment and early surgery, with no high-quality evidence to guide current practice. Electrodiagnostic (EDX) prognostic features and the value of imaging in establishing and supplementing the diagnosis have not been clearly established.

METHODS

We performed a literature search in the online databases MEDLINE, Embase, and the Cochrane Library. Of the 42 unique articles meeting the eligibility criteria, 10 discussed diagnostic performance of imaging, 11 reported EDX limits for abnormal values and/or the value of EDX in prognostication, and 26 focused on treatment outcome.

RESULTS

Studies report high sensitivity and specificity of both ultrasound (varying respectively from 47.1% to 91% and from 53% to 100%) and magnetic resonance imaging (MRI; varying respectively from 31% to 100% and from 73% to 100%). One comparative trial favoured ultrasound over MRI. Variable criteria for a conduction block (>20%-≥50) were reported. A motor conduction block and any baseline compound motor action potential response were identified as predictors of good outcome. Based predominantly on case series, the percentage of patients with good outcome ranged 0%-100% after conservative treatment and 40%-100% after neurolysis. No study compared both treatments.

CONCLUSIONS

Ultrasound and MRI have good accuracy, and introducing imaging in the standard diagnostic workup should be considered. Further research should focus on the role of EDX in prognostication. No recommendation on the optimal treatment strategy of peroneal nerve entrapment can be made, warranting future randomized controlled trials.

Predictors of functional recovery following surgery for foot drop due to degenerative lumbar disease

OBJECTIVE

Surgery for foot drop secondary to lumbar degenerative disease is not always associated with postoperative functional improvement. It is still unclear whether early decompression results in better functional recovery and how soon surgery should be performed. This study aimed to evaluate predicting factors that affect short- and long-term recovery outcomes and to explore the relationship between timing of lumbar decompression and recovery from foot drop in an attempt to identify a cutoff time from symptom onset until decompression for optimal functional improvement.

METHODS

The authors collected demographic, clinical, and radiographic data on patients who underwent surgery for foot drop due to lumbar degenerative disease. Clinical data included tibialis anterior muscle (TAM) strength before and after surgery, duration of preoperative motor weakness, and duration of radicular pain until surgery. TAM strength was recorded at the immediate postoperative period and 1 month after surgery while long-term follow-up on functional outcomes were obtained at ≥ 2 years postsurgery by telephone interview. Data including degree and duration of preoperative motor weakness as well as the occurrence of pain and its duration were collected to analyze their impact on short- and long-term outcomes.

RESULTS

The majority of patients (70%) showed functional improvement within 1 month postsurgery and 40% recovered to normal or near-normal strength. Univariate analysis revealed a trend toward lower improvement rates in patients with preoperative weakness of more than 3 weeks (33%) compared with patients who were operated on earlier (76.5%, p = 0.034). In a multivariate analysis, the only significant predictor for maximal strength recovery was TAM strength before surgery (OR 6.80, 95% CI 1.38-33.42, p = 0.018). Maximal recovery by 1 month after surgery was significantly associated with sustained long-term functional improvement (p = 0.006).

CONCLUSIONS

Early surgery may improve the recovery rate in patients with foot drop caused by lumbar degenerative disease, yet the strongest predictor for the extent of recovery is the severity of preoperative TAM weakness. Maximal recovery in the short-term postoperative period is associated with sustained long-term functional improvement and independence.

Clinical Significance of Anatomic Peculiarities and Ultrasound-Guided Electromyography of the Posterior Tibial Muscle

The posterior tibial muscle (PTM) is a key muscle in diagnosing the level of the neurologic lesion that causes steppage gate that is a paralysis of nervous origin of the muscles ensuring the foot dorsiflexion. The aim of this manuscript is to illustrate the anatomical peculiarities of the PTM, the ultrasound (US) anatomy of the infero-posterior part of the leg, and the technique of US-guided electro-neuro-myography (ENMG) of the PTM, which is considered a key muscle in the diagnosis of the neurological lesion causing steppage gate. The US-guided ENMG of the PTM is technically easy and safe for young practitioners provided there is a good knowledge of US anatomy of the infero-posterior part of the leg.

Tibialis Posterior Transfer for Foot Drop: The Difference in Outcome for Two Different Attachment Sites

Introduction Common peroneal nerve injury leading to foot drop is of multifactorial etiology. The goal is to restore a normal toe-heel gait. Various static or dynamic surgical options are being performed. Among all, tendon transfer is the most commonly performed procedure with its different dorsal attachment sites on the foot i.e. tendon to bone or tendon to tendon transfer. The objective of our study was to evaluate the outcomes of two methods of transfer in terms of attachments sites on functional outcomes. Materials and methods In a retrospective study conducted at Liaquat National Hospital Karachi, a total of 38 patients were included. All of them were operated upon for foot drop from June 2015 to May 2018. A total of 32 patients showed up for the follow-up, 17 patients underwent tibialis posterior transfer with attachment on the second metatarsal and 15 on the tibialis anterior tendon. Functional outcome was assessed by grading of active foot dorsiflexion at six months and at the time of the study by and categorized as excellent, good, moderate, and poor. Results Most of the patients in both groups were male, and the mechanism of injury was penetrating trauma. At six months post-operatively, the majority of the patients in both groups showed excellent to good category of active dorsiflexion. At the time of the study (mean 34.4 months postoperatively) patients with insertion at second metatarsal were found to have active dorsiflexion as: excellent: 6 (35.3%), good: 8 (47.1%), moderate: 3 (17.6%), and for insertion at Tibialis Anterior tendon: excellent: 1 (6.7%), good: 6 (40.0%), moderate: 6 (40.0%) and poor: 2 (6.2%). These results were compared using the chi-square test and it was found to be statistically significant (p-value: 0.016). Conclusion Insertion at second metatarsal gives more favorable results as compared to insertion at tibialis anterior with balanced dorsiflexion.

Surgical outcomes with anatomic reduction of high-grade spondylolisthesis revisited: an analysis of 101 patients

OBJECTIVE

The ideal strategy for high-grade L5-S1 isthmic spondylolisthesis (HGS) remains controversial. Critical questions include the impact of reduction on clinical outcomes, rate of pseudarthrosis, and postoperative foot drop. The scope of this study was to delineate predictors of radiographic and clinical outcome factors after surgery for HGS and to identify risk factors of foot drop.

METHODS

This was a single-center analysis of patients who were admitted for HGS, defined as grade III or greater L5 translation according to the Meyerding (MD) classification. Complete postoperative reduction was defined as MD grade I or less and L5 slip < 20%. Forty-six patients completed health-related quality-of-life questionnaires (Oswestry Disability Index, Physical Component Summary of SF-36, and visual analog scale) and ≥ 2 years' follow-up (average 105 months). A 540° approach was used in 61 patients, a 360° approach was used in 40, and L5 corpectomy was used in 17. Radiographic analysis included measures of global spinopelvic balance (e.g., pelvic incidence [PI], lumbar lordosis) and measurement of lumbosacral kyphosis angle (LSA), L4 slope (L4S), L5 slip (%), and postoperative increase of L5-S1 height.

RESULTS

The authors included 101 patients with > 1 year of clinical and radiographic follow-up. The mean age was 26 years. Average preoperative MD grade was 3.8 and average L5 slip was 81%; complete reduction was achieved in 55 and 42 patients, respectively, according to these criteria. At follow-up, LSA correlated with all clinical outcomes (r ≥ 0.4, p < 0.05). Forty patients experienced a major complication. Risk was increased in patients with greater preoperative deformity (i.e., LSA) (p = 0.04) and those who underwent L5 corpectomy (p < 0.01) and correlated with greater deformity correction. Thirty-one patients needed revision surgery, including 17 for pseudarthrosis. Patients who needed revision surgery had greater preoperative deformity (i.e., MD grade and L5 slip) (p < 0.01), greater PI (p = 0.02), and greater postoperative L4S (p < 0.01) and were older (p = 0.02), and these patients more often underwent L5 corpectomy (p < 0.01). Complete reduction was associated with lower likelihood of pseudarthrosis (p = 0.08) and resulted in better lumbar lordosis correction (p = 0.03). Thirty patients had foot drop, and these patients had greater MD grade and L5 slip (p < 0.01) and greater preoperative LSA (p < 0.01). These patients with foot drop more often required L5 corpectomy (p < 0.01). Change in preoperative L4S (p = 0.02), LSA (p < 0.01), and L5-S1 height (p = 0.02) were significantly different between patients with foot drop and those without foot drop. A significant risk model was established that included L4S change and PI as independent variables and foot drop as a dependent variable (82% negative predictive value and 71% positive predictive value, p < 0.01).

CONCLUSIONS

Multivariable analysis identified factors associated with foot drop, major complications, and need for revision surgery, including degree of deformity (MD grade and L5 slip) and correction of LSA. Functional outcome correlated with LSA correction.

Foot Reanimation Using Double Nerve Transfer to Deep Peroneal Nerve: A Novel Technique for Treatment of Neurologic Foot Drop

BACKGROUND

Our primary objective was to assess the efficacy of a new technique for foot reanimation in patients with neurologic foot drop using double nerve transfer from the tibial to the deep peroneal nerve. Our secondary objective was to document the technical nuances of our technique.

METHODS

Thirty-one patients with common peroneal nerve injury between October 2015 and March 2019 were prospectively enrolled in the study. Patients underwent a transfer of the tibial nerve branches to flexor digitorum longus and lateral head of gastrocnemius to the deep peroneal nerve. Motor recovery, range of ankle dorsiflexion, pain, leg girth, and complications were examined as outcome measures. The modified Medical Research Council (MRC) scale was adopted to assess the motor power recovery. All patients were followed up for a minimum of 1 year.

RESULTS

Motor recovery of M3 or M4 grade of tibialis anterior, extensor hallucis longus, and extensor digitorum longus was achieved in 15 of 31, 13 of 31, and 12 of 31 patients, respectively. Those patients could discontinue use of orthosis. Most patients with high-energy traumas or knee-level injuries failed to recover antigravity function. Only 2 patients reported weak postoperative toe plantarflexion. Our patients achieved significant improvement of the pain perception and range of active ankle motion at the final follow-up.

CONCLUSION

The double nerve transfer technique represented a feasible and safe surgical option. It has been shown to improve function in some patients with neurologic foot drop resulting from a less than 12-month injury of the deep peroneal nerve.

LEVEL OF EVIDENCE

Level IV, therapeutic.

Amelioration of lower limb pain and foot drop with 10 kHz spinal cord stimulation: A case series

There are limited treatment options for patients with foot drop and associated lower back and/or leg pain. We present a case series of three patients who received permanent implantation of 10 kHz spinal cord stimulation (10 kHz SCS) devices. Following treatment, all patients reported sustained improvements in lower back and leg pain, foot mechanics and function which resulted in increased mobility and cessation of opioid use for pain management. Patients were followed up for approximately four years. Treatment with 10 kHz SCS may be a promising alternative to other interventional procedures commonly used for these patients.

Current Concepts Review: Common Peroneal Nerve Palsy After Knee Dislocations

Dislocation of the native knee represents a challenging injury, further complicated by the high rate of concurrent injury to the common peroneal nerve (CPN). Initial management of this injury requires a thorough neurovascular examination, given the prevalence of popliteal artery injury and limb-threatening ischemia. Further management of a knee dislocation with associated CPN palsy requires coordinated care involving the sports surgeon for ligamentous knee reconstruction and the peripheral nerve surgeon for staged or concurrent peroneal nerve decompression and/or reconstruction. Finally, the foot and ankle surgeon is often required to manage a foot drop with a distal tendon transfer to restore foot dorsiflexion. For instance, the Bridle Procedure-a modification of the anterior transfer of the posterior tibialis muscle, under the extensor retinaculum, with tri-tendon anastomosis to the anterior tibial and peroneus longus tendons at the anterior ankle-can successfully return patients to brace-free ambulation and athletic function following CPN palsy. Cross-discipline coordination and collaboration is essential to ensure appropriate timing of operative interventions and ensure maintenance of passive dorsiflexion prior to tendon transfer.

Smart Protocols for Physical Therapy of Foot Drop Based on Functional Electrical Stimulation: A Case Study

Functional electrical stimulation (FES) is used for treating foot drop by delivering electrical pulses to the anterior tibialis muscle during the swing phase of gait. This treatment requires that a patient can walk, which is mostly possible in the later phases of rehabilitation. In the early phase of recovery, the therapy conventionally consists of stretching exercises, and less commonly of FES delivered cyclically. Nevertheless, both approaches minimize patient engagement, which is inconsistent with recent findings that the full rehabilitation potential could be achieved by an active psycho-physical engagement of the patient during physical therapy. Following this notion, we proposed smart protocols whereby the patient sits and ankle movements are FES-induced by self-control. In six smart protocols, movements of the paretic ankle were governed by the non-paretic ankle with different control strategies, while in the seventh voluntary movements of the paretic ankle were used for stimulation triggering. One stroke survivor in the acute phase of recovery participated in the study. During the therapy, the patient’s voluntary ankle range of motion increased and reached the value of normal gait after 15 sessions. Statistical analysis did not reveal the differences between the protocols in FES-induced movements.

Recovery of foot drop in chronic inflammatory demyelinating polyneuropathy (CIDP)

INTRODUCTION/AIMS

Foot drop is common in chronic inflammatory demyelinating polyneuropathy (CIDP), but its prognosis is uncertain.

METHODS

CIDP patients with less than anti-gravity strength (<3/5 power) of ankle dorsiflexion (ADF) on Medical Research Council manual muscle testing on presentation at our center were identified by retrospective review. After initiation of standard treatment, ADF power was serially tabulated, and predictors of recovery were determined.

RESULTS

Of the 27 identified patients, ADF power at presentation was <3/5 in 48/54 legs. At 1 y after treatment, ADF power improved to >/= 3/5 in 17/27 patients in one (N = 6) or both (N = 11) legs. On multi-variate analysis, predictors of recovery of ADF power were tibialis anterior compound muscle action potential amplitude at presentation, shorter disease duration, and female gender.

DISCUSSION

Foot drop improves to anti-gravity power in most treated CIDP patients depending in part on the severity of fibular motor axon loss at onset of treatment.

COVID-19 Proned Ventilation and Its Possible Association With Foot Drop: A Case Series

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus causing the coronavirus disease 2019 (COVID-19) pandemic is known to lead to the complicated sequelae of severe acute respiratory distress syndrome. Proning has been used as an adjunctive treatment to improve oxygenation in both ventilated and non-ventilated patients. Although patients respond well to this strategy, complications from this arise as well. It is hypothesized that COVID-19 intensive care unit (ICU) proned ventilation is associated with new cases of foot drops or compressive unilateral ankle dorsiflexion weakness during the early 2020 COVID-19 pandemic. Five patients presented to an acute rehabilitation facility with unilateral ankle dorsiflexion weakness after ICU proned ventilation during the COVID-19 pandemic. Three patients were found to have primarily subacute left sensory-motor dysmyelinating common peroneal neuropathies located around the fibular head. Two patients were found to have primarily subacute sensory-motor dysmyelinating right-sided common peroneal neuropathies above the fibular head and distal to biceps femoris muscle. Compressive unilateral common peroneal neuropathies during the pandemic are possibly related to the impromptu, unconventional, and unfamiliar use of proned ventilation.

Ultrasound Imaging of the Deep Peroneal Nerve

Ultrasound is considered an excellent imaging modality to evaluate the nerves of the limbs. The deep peroneal nerve (DPN) is one of the terminal branches of the common peroneal nerve. The DPN may be affected by various disorders, which may be clinically challenging to show. This Pictorial Essay reviews the normal ultrasound anatomy of the DPN and presents disorders that may involve the nerve and its main branches along its course, from proximal to distal.

Bilateral Foot-Drop Secondary to Axonal Neuropathy in a Tuberculosis Patient With Co-Infection of COVID-19: A Case Report

Tuberculosis (TB) is a global pandemic and is one of the top 10 causes of death worldwide as well as the leading cause of death from a single infectious agent. It can cause a wide array of complications including peripheral neuropathy. In addition to TB pandemic the recent pandemic of coronavirus disease 2019 (COVID-19) has led to an increased interest in the co-infection of TB patients and COVID-19 and whether TB increases risk for COVID-19 and its role in causing severity of disease and vice-versa. This case report discusses about a young cachectic man who was found to have bilateral foot-drop under the setting of TB with co-infection of COVID-19 later confirmed to be axonal neuropathy on nerve conduction study. The report highlights the importance of differential diagnosis of TB in COVID-19 patients as well as the consideration of TB in a patient with peripheral neuropathy after nutritional causes have been ruled out.

Proximal fibular nerve conduction studies to tibialis anterior: Optimal E2 (reference electrode) placement

BACKGROUND

Several E2 (reference electrode) positions are described for fibular (peroneal) nerve conduction studies to tibialis anterior (TA).

METHODS

This study compared the contribution of different E2 sites to the TA motor response, using remote referential recordings and different bipolar montages.

RESULTS

The medial knee contributes minimal electrical activity to the bipolar TA recordings, whereas tibial, ankle, and toe references resulted in very similar, moderate amplitude contributions consistent with far field potentials. These observations were very similar in controls and in patients with lower leg symptoms and signs.

CONCLUSIONS

Standard montages using distal leg or foot E2 sites result in lower amplitudes with distortion arising from the E2 electrode, compared with the TA-Knee montage. Optimal measurement of the TA motor response is achieved using a medial knee reference, without compromising measures of fibular nerve conduction across the knee.

Early and consistent pattern of proximal weakness in GNE myopathy

BACKGROUND

GNE myopathy is widely regarded as a distal myopathy. Involvement of proximal musculature in this condition has not been systematically studied.

METHODS

The phenotype of genetically confirmed patients with GNE myopathy was analyzed. Fourteen groups of muscles were evaluated with Medical Research Council (MRC) grading and the average muscle scores (AMS:1-10) were calculated.

RESULTS

Fully documented AMS data was available in 31 of 65 patients. It showed a consistent pattern of severe weakness of hip adductors, hip flexors, knee flexors, and foot dorsiflexors, with milder weakness of the hip extensors and abductors. The knee extensors were largely unaffected. The proximal weakness appeared early in the course of the disease. Proximal muscle weakness was also present in the remaining 34 patients in whom the data were limited. A variant in exon 13 (c.2179G > A) was very common (81.5%).

CONCLUSIONS

The GNE phenotype in this Indian cohort exhibited mixed proximal and distal involvement. Weakness of adductors and flexors of the hip formed an integral part of the phenotype.

Acute foot drop secondary to lumbar disc prolapse after seizure

Generalised tonic-clonic seizures have been reported to cause musculoskeletal injuries including vertebral fractures usually without resultant neurological deficit. Lumbar disc prolapse resulting in neurological deficits following seizures has not been reported. We report a 43-year-old man who presented after a generalised seizure at which point he developed worsening of low back pain and left sciatica followed by an acute foot drop. His lumbo-sacral MRI demonstrated a diffuse disc bulge at L4-5 level and a large, caudally migrated, free disc fragment with resulting severe canal stenosis at L4/5 and left lateral recess stenosis at L5/S1. He underwent urgent left L4/5 and L5/S1 micro-discectomies with resolution of his symptoms. We illustrate a rare but important treatable complication of seizures. Detailed history and clinical examination in patients with post-ictal neurological deficit should be conducted to identify the specific cause. Appropriate imaging should be performed if there remains any doubt regarding diagnosis.