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Help with a case of drop foot

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Berms, Feb 7, 2006.

  1. Berms

    Berms Active Member


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    Help with a case of foot drop

    Hi,
    I am currently seeing a sixty four year old Lady with Parkinsons that was diagnosed six years ago. Her condition is relatively mild and she is able to move and ambulate well, with only the aid of a walking stick.
    She has foot drop on the right side, and complains of paraesthesia to the feet and toes at night and a feeling of numbness. Her Brief Vasc and Neuro tests were within normal limits at the time of consultation, and she currently wears a flexibple polypropylene AFO for the drop foot.
    Can anything else be done for this condition? Are there any exercises that can help restore muscle strength in cases of foot drop? :confused:

    Many thanks for any input,
    Adam
     
    Last edited: Feb 8, 2006
  2. Berms

    Berms Active Member

    Help with a case of foot drop

    Anyone?? :)
     
    Last edited: Feb 8, 2006
  3. Phil W

    Phil W Welcome New Poster

    Berm

    Maybe some reduction in the forces that increase 'footslap' at heel contact may help, depending on footwear used. By taking off a small amount of material from the posterior aspect of the heel of the shoe, a small amount of the GRF forces at heel contact can be 'reduced'. Has worked well for me in the past.
    BUT be aware that this change in force must go somewhere. If the patient is 'ponderous' on heel strike, the force of heel contact may be re-directed posterior to the COP (Center of Progression) and cause possible hyper extension at the knee or the patient may rock backwards in extreme cases.

    Phil
     
  4. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    You need to establish the *exact* cause of her footdrop.

    Is it the Parkinsons alone, or are other neurological issues at play?
    Which muscles are still working extrinsic and intrinsic to the foot?

    It is possible that if it is a non-progressive form of foot drop, then tendon transfer is probably the only viable alternative to an AFO. Discuss with your local pod surgeon I suggest.

    LL
     
  5. Unilateral foot drop is not uncommon in Parkinson's syndrome. I don't think that exercises will do much to help. Ankle-foot orthoses help prevent the plantarflexed ankle position during swing phase which, in turn, helps prevent tripping and stumbling and a steppage gait pattern. If it is severe and bracing is not an option for the patient, then an ankle arthrodesis would probably be the best surgical option for this progressive neurological condition. However, certainly an ankle arthrodesis should not be needed if you can find a skilled orthotist in your area.
     
  6. Berms

    Berms Active Member

    thanks Phil, Luckylisfranc and Kevin,

    The foot drop could be a result of a mild CVA she had 6 months ago rather than the parkinsons disease? I assume it is a progressive condition? (disuse = more muscle atrophy --> more muscle weakness).

    I have found a product on the market called Dictus Band - which is basically an ankle "cuff" with 2 large rubber bands attaching to the lacing system of the shoe with special hooks. This looks less cumbersome than the AFO, and would allow the pt to have a better fit into her shoes.

    Thanks for your input with this case, it has been helpful,
    Adam
     
  7. John Spina

    John Spina Active Member

    I have had patients with CVAs and resultant foot drop. An AFO is best for this condition.In fact,the most recent patient responded very well to an AFO.
    Unilateral drop foot is very common with CVA.When someone is complaining of this,or you see it in the way that they walk,ask about history of CVA.
     
  8. Tommy McDonough

    Tommy McDonough Welcome New Poster

    Hello Adam
    Obviously I have not seen the pt and do not no the idiosynchroses of her but here goes.
    I work in a stroke unit and regularly deal with drop foot. If the foot is hypotoned I find a Air Sports ankle Brace (ASAB) effective as it dorsiflexes the foot as part of the supinatory effect on the STJ. I would also treat this as a functional LLD and possibly raise the left side by as little as 8mm, this is often enough to bring the effected side through swing: you build your raise up so you are happy that you have not detrimentaly affected the gait pattern too much. In the 3 years I have been working here I have only recommended AFO less than 5 times. The ASAB is esy to fit, it does get as hot as the AFO in the summer and goes in most "normal " shoes. However the pt may need help with fitting. I personally do not like the way the AFO brings the ankle back to 90 degrees with little regard for the STJ and MTJ. I hope this helps. Tom
     
    Last edited: Feb 11, 2006
  9. posalafin

    posalafin Active Member

    Hi

    It would be appreciated if anybody can give some advice on the following case:

    25yo Asian male fit & healthy, denies any medical problems, current medication or allergies. Denies any recent illnesses or drug use other than occassional moderate alcohol consumption. Denies any family Hx of neurological diseases that he is aware of.

    Approx 3 weeks ago after long period of sitting cross legged on hard chair while playing computer games experienced immediate onset on numbness in anterior/lateral R) leg & dorsum of foot and noticed he had to consciously lift his R) leg higher when walking to prevent his foot 'getting caught on ground'.

    On examination he has 1/5 strength of R) dorsiflexors 3/5 strength of R) peroneals. L) side 5/5 all muscle groups. Ankle & knee tendon reflexes normal. Normal sensation to monofilament, light touch & sharp/blunt discrimination bi-laterally to the knees.

    I have diagnosed R) peroneal neuropathy secondary to prolonged compression from sitting croos legged for extended period of time. The advice I am seeking is:

    1) Would you refer to GP / neurologist for further testing given the clinical symptoms & Hx are highly suggestive of the cause?

    2) Is there any benefit of corticiosteroid injection for possible nerve swelling / compression? If so would any benefit likely be achieved after 3 weeks post onset of symptoms?

    3) Does physical therapy help?

    4) Are there any surgical options available?

    5) In your experience is this likely to improve with conservative care & over what time frame.

    My advice at time of consultation was to do some muscle strengthening exercises & discussed the possibility of an AFO(which he is not keen on) .

    Thanks

    David Kelly
     
  10. Griff

    Griff Moderator

    Sounds like a common peroneal nerve neuropraxia. My guess is that your chap will see a slow and gradual return to normal (eventually). I always refer these off to the Consultant Neurologist to be safe however.
     
  11. Perthpod

    Perthpod Active Member

    If anyone has had positive/negative experience with the 'Dictus Band - which is basically an ankle "cuff" with 2 large rubber bands attaching to the lacing system of the shoe with special hooks. ' mentioned above or similar eg http://www.ossur.com/?PageID=13530, please let me know.
    I had a female client who has had a stroke attend the clinic wearing one yesterday - it looks like a less irritating/cooler in summer/easier to use and prescribe than the custom/plastic AFO. Although Im sure not appropriate in more severe/advanced foot drop with lesions to accomodate etc, is this too good to be true for less severe cases?
     
  12. Peter

    Peter Well-Known Member

    ok for mild flaccid foot drop in a rather ambulant adult who can bend to apply it. Can only be really used with laced shoes, and although there is a shoeless version, it ain't great. It has a short lever arm as well, so many who don't tolerate it, progress onto an AFO
     
  13. David:

    Diagnosis: Peroneal nerve palsy secondary to external nerve compression

    Order the patient an AFO brace to help him avoid tripping, refer him to a neurologist to cover your behind and send him to physical therapy to help him try to regain some strength and help him with his gait. Like Ian noted, most of these gradually improve to near normal over time.

    Check out this cool article from 49 years ago which perfectly describes the condition.:drinks

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2022299/pdf/brmedj03474-0007.pdf
     
  14. timharmey

    timharmey Active Member

    Would one be totally passing the buck , to send him to a physio to have a spinal exam ?
     
  15. Boots n all

    Boots n all Well-Known Member

    Two PT on the one thread is going to make this messy.

    Footdrop.

    The biggest issue for most clients with foot drop is actually getting the toe to clear the ground during swing phase- the big trip!

    To get that toe clear at swing phase l would suggest you roll the toe of the sole off, a mild rocker toe, this means the end of the shoe could end up 10mm higher than what it was, giving better clearance for the swing phase.

    You may also consider most people put an AFO on a client and forget they just made that limb 4mm longer, making it just that little harder to clear the drop foot in the swing phase.

    In-fact for your client, l would make the left limb 4mm longer than the right through inlays to help the lesser right limb swing through easier.

    Whilst Phils idea to create a small rocker at the heel to reduce foot slap is good, it may also pay to make that a S.A.C.H. unit as that will reduce the speed of heel strike/impact further.
     
  16. RobinP

    RobinP Well-Known Member

    Hi Perthpod,

    I'm probably going to give you a complex answer to an, essentially, simple question.

    In neuro patients as you describe, the severity of the stroke in many cases is leess important than how the neuro deficit affects function. In short, Peter is right, the brace has its limitations but i would just add a couple of things.

    The Foot Up is very effective for flaccid foot drop as long as the coronal and sagittal plane deformity is minimal and there is a reasonable range of movement on the sagittal plane ie not too much equinous. Bear in mind that it is an elasticated tab holding the foot up with, as Peter pointed out, a very short lever arm.

    On the whole it is best to wear it with a lace up shoe but it is possible to wear it with a velcro fasten shoe if the velcro strap doubles back on itself and is approximately 12-15mm thick. The elastic tab has a loop that the velcro strap can go through. If your patient will let you, a slot can be made through the instep of a high fronted slip on loafer and the tab slotted through. Send it to a shoe adaptation company with the tab and they will cut the appropriate sized slot and stitch round to stop it from fraying.

    The biggest reaon that they are unsusscessful is if the patient cannot don it themselves. Fine if they have a willing partner/carer but if the patient has a hemiplegia, the tab may require two hands to click into the ankle wrap and if upper limb function is limited, it can make it a no go.

    If there is a fair amount of spasticity, and there is marked peroneal or tib post dominance(particularly tib post dominance as controlling excess supination moments is far more important as a very supnated foot can lead to ankle instability to the point where the patient cannot weight bear properly), there will be too much deformity to be controlled in anything other than a bespoke AFO

    I'm making some pretty mass generalisations here for the sake of simplicity otherwise I could be here all night

    An alternative to the foot up which is really a far more long term option due to cost is a SAFO(silicone AFO)

    It is a custom moulded silicone brace about the same size as a rocket sock but can be reasonably well skin matched. Again, it can only control mild amounts of coronal plane deformaity and requires 5 degrees of dorsiflexion at the ankle joint for the cast. The silicone is reinforced down the anterior aspect and limits plantarflexion. They can slightly reinforce medial and lateral aspects to control caoronal plane deformity.

    The best bit about the SAFO is the ability to have some sagittal plane control and the patient not be wearing footwear as, again, correctly pointed out by Peter the shoeless foot up is rubbish. It allows patients to wear sandals or go barefoot(BTW - I have no financial interest in Dorset Orthopaedic. They are a good company and in 8 years, i have only had one that needed remade.)

    In summary, the Foot up is a good short term option for foot drop with little spasticity and minimal coronal plane deformity. there are better but more expensive options and if you are trying to control more than just a flaccid foot drop, it is unsuitable...generally(obviously, there are always exeptions)

    Hope this helps

    Robin
     
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