Transcript Surgical Foot Reconstruction for Posterior Tibial

TRAUMATIC DROP FOOT
By: Larissa Torres Nixon, SPT
Regis University
July 16, 2010
VIDEO
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http://www.youtube.com/watch?v=Q8KB2fhLDw
M&feature=related
PURPOSE:

Explain the importance of doing a thorough
examination on patients with traumatic drop foot
and the intervention options physical therapists
can offer these patients.
OBJECTIVES:
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Student will be able to describe the pathology for a
person with traumatic drop foot.
Student will be able to explain information obtained
during the examination and evaluation for this
patient.
Student will be able to discern a more thorough
evaluation process for this patient based on
evidentiary support.
Student will be able to develop an intervention
strategy using current literature evidence.
PATIENT CONSULTATION:
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Pt is a 25 y.o. male active
duty Army (ADA)
Dx: Pt is status post
multiple reconstruction
surgery due to blast
injury.
Rx: Please evaluate and
treat.
WHAT IS DROP FOOT?
Traumatic drop foot is
usually occupation or sport
related.7
 Caused by chronic
compression, traction or
transection of the common
peroneal or deep peroneal
nerve. 7
 Injury to the common
peroneal nerve results in
weakness of all muscles
innervated by the
superficial and deep
branches. 7

TRAUMATIC DROP FOOT: (CONT)
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Tibialis anterior muscle is the primary ankle DF.2
Tibialis anterior has the highest activity at heel
strike and after toe off during the swing phase. 2
Disruption leads to foot drop.
Common gait deviations include: flatfoot/forefoot
contact, decreased push off, and excessive hip and
knee flexion with ankle PF.
EXAMINATION:
Through patient history
 Systems Review
 Special tests
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Posture/Gait observation
MMT
ROM
Sensory/proprioceptive testing
Scar mobility
Outcome measure: LEFS
EMG and NCV studies can be used to determine
the degree of nerve damage and potential for
nerve recovery. However, are not necessary to
diagnose drop foot. 1
SUBJECTIVE HISTORY:
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Sx: c/o left drop foot, multiple trips/near falls over the
past 3 months. Pain with first few steps after getting
up.
Hx: MOS: 11B, was hit by an RPG August 30, 2009 on
left lower leg while deployed in Afghanistan. Was
MEDDVAC’d to Germany then transferred state side.
SUBJECTIVE HISTORY: (CONT)
He had a series of
10 limb salvation
surgeries from
September to
November 2009,
including an
external fixator
placed at Walter
Reed Army
Medical Center.
SUBJECTIVE HISTORY: (CONT)

November 2009:
Pt had muscle
flap of left
latisimus dorsi
transferred to
left calf and skin
graft from left
thigh placed over
site.
EXAMINATION FINDINGS:
Systems Review
 Cardiovascular: posterior
tibial and dorsal pedal pulses
present
 Neuromuscular: reflexes 3+ Lt
quad tendon, 2+ Rt quad
tendon/ bilat triceps surea
- Babinski bilat.
 Endocrine: No significant
findings
 Integumentary: 8 fully healed
screw wholes and fully healed
skin graft
 Musculoskeletal: also being
treated by physical therapy
for Lt shoulder injury that
occurred from the same
incident.
EXAMINATION FINDINGS: (CONT)
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Posture observation
 Assymetirical WBing to
Rt LE
 Excessive ER of Lt LE
Gait Observation
 Forefoot contact at heel
strike
 Excessive knee/hip
flexion with swing
phase
 Toe drop on Lt
throughout swing
phase
 Decreased stance time
on Lt

MMT
 Rt LE: 5/5 throughout
 Lt hip flex: 5/5
 Lt knee flex: 5/5
 Lt knee ext: 4+/5
 Lt ankle DF: 0/5
 Lt ankle PF: 1/5
 Lt ankle Inv: 1/5
 Lt ankle Ever: 0/5
 Great toe Ext: 0/5
 Minimal ability to
wiggle toes noted.
EXAMINATION FINDINGS: (CONT)
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PROM
Rt Ankle: 0 ̊ DF to 70 ̊ PF
 Lt Ankle: 10 ̊ PF to 35 ̊ PF
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Sensory/proprioceptive testing
Light tough: diminished L4, L5, S2 on Lt
 10/10 monofilament test on plantar surface of foot
 Balance: 30 seconds with EC on Rt, 7 seconds with eyes
open on Lt
 Proprioception: 4/10 correct on Lt ankle
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Scar mobility
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Poor scar mobility of 8 pin holes and lateral ankle incision.
Outcome measure: LEFS
38/80 (where 80/80 means no disability) 4
 MCID is 9 points
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EXAMINATION FINDINGS:
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NCV:
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Diminished NCV of Lt tibial nerve (35 ms), absent
on Lt peroneal nerve
EMG:
Intact Lt femoral nerve, sciatic nerve
 Diminished activity of the Lt tibial nerve with
maximum contaction
 No activity of Lt common peroneal nerve and it’s
branches.

DIAGNOSIS & PROGNOSIS:
Diagnosis:
 Left drop foot with complete neural loss of the
common peroneal nerve and it’s branches.
Prognosis:
 Poor
 If there are no signs for nerve recovery with EMG
after 6 months then there will likely be no
recovery of function.3
INTERVENTIONS & EVIDENCE:
 For
a patient with complete loss of muscle
innervation 2,7

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Maintain ankle ROM
Prevent PF contracture
Address gait impairments with AFO
 Long
term treatments may include 2,7
Talocrural and subtalar joint fusion
 Posterior tibialis tendon transfer
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No appropriate for this patient
BKA
ORTHOSES: DOES EVIDENCE MATCH MY
PATIENT?
Eberly et al. 6
ORTHOSES: DOES EVIDENCE MATCH MY
PATIENT?
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Patients with
common peroneal
nerve palsey require
a more solid, rigid
AFO than those with
only deep peroneal
nerve palsey. 8
He is still waiting to
receive his AFO.
TAKE AWAY:
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These returning injured soldiers will be PT
patients both acutely and later in our careers.
If you have a patient with a traumatic injury
always ask if the patient has pictures from the
initial injury or just prior to surgery.
EMG and NCV studies done in the physical
therapy clinic can provide helpful information for
diagnosis and prognosis of a patients injury.
CHECK FOR UNDERSTANDING:
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What are the causes of traumatic foot drop?
Which nerve(s) cause foot drop when they are
damaged?
What are 2 physical therapy interventions for a
patient with traumatic foot drop?
REFERENCES:
Images:
 Photos provided by the featured patient
 Family practice notebook.com http://www.fpnotebook.com/_media/AnkleAnatomyMuscleAP.gif
 Twin Oaks Orthotics & Prosthetics:
http://www.bing.com/images/search?q=AFO&FORM=BIFD#focal=57a9fe3e43ec50b4ffe5eef02b
ec67e6&furl=http%3A%2F%2Fwww.twincityop.com%2Fsitebuildercontent%2Fsitebuilderpict
ures%2FAFO_Family.jpg
Articles:
1.
Aminoff M. Electrophysiologic testing for the diagnosis of peripheral nerve injuries.
Anesthesiology [serial online]. May 2004;100(5):1298-1303.
2.
Baima J, Krivickas L. Evaluation and treatment of peroneal neuropathy. Current Reviews
In Musculoskeletal Medicine [serial online]. June 2008;1(2):147-153.
3.
Berry H, Richardson P. Common peroneal nerve palsy: a clinical and electrophysiological
review. Journal Of Neurology, Neurosurgery, And Psychiatry [serial online]. December
1976;39(12):1162-1171.
4.
Binkley J, Stratford P, Lott S, Riddle D. The Lower Extremity Functional Scale (LEFS):
scale development, measurement properties, and clinical application. Physical Therapy
[serial online]. April 1999;79(4):371-383.
5.
Chémali K, Tsao B. Electrodiagnostic testing of nerves and muscles: when, why, and how to
order. Cleveland Clinic Journal Of Medicine [serial online]. January 2005;72(1):37-48.
6.
Eberly V., Kubota K., Weiss W. To brace or not to brace: Making evidence-based decisions
with our clients with neurologic impairments. Paper presented at: Combined Sections
Meeting of the American Physical Therapy Association; February 1-5, 2006; San Diego, CA.
7.
Elman L, McCluskey L. Occupational and sport related traumatic neuropathy. The
Neurologist [serial online]. March 2004;10(2):82-96.
8.
Geboers J, Drost M, Spaans F, Kuipers H, Seelen H. Immediate and long-term effects of
ankle-foot orthosis on muscle activity during walking: a randomized study of patients with
unilateral foot drop. Archives of Physical Medicine & Rehabilitation [serial online].
February 2002;83(2):240-245.