Usually, initial treatment involves use of an off-the-shelf or custom brace called an AFO (ankle foot orthosis), which helps to improve the position of the foot while a person is walking. When this brace is no longer helpful, surgery can be considered.
You should discuss your options with your foot and ankle orthopaedic surgeon before proceeding with surgery.
The surgical procedure for a foot drop is called a tendon transfer. In general, a tendon transfer is a procedure in which a tendon (and attached muscle) that is still working is taken from one part of the foot and moved to another part of the foot to
try to replace the missing muscle function. The most common tendon transferred is the posterior tibial tendon.
If a Bridle procedure is performed, a second tendon, the peroneus longus, is cut above the level of the ankle on the outer side of the leg. This tendon is then routed to the front of the ankle and the free end is attached to the posterior tibial tendon
and the anterior tibial tendon in a bridle configuration. With this construct the posterior tibial muscle pulls on all three tendons to pull the foot up. The posterior tibial tendon is routed to the top of the foot as described above.
Occasionally, the ankle can be very stiff from long-standing weakness. If it is not possible to pull the ankle up for attachment of the tendon transfer, the Achilles tendon is lengthened to help bring the foot and ankle up. This is done either through
an incision on the calf or an incision right over the Achilles tendon. The location of the incision is based on which portion of the Achilles is too tight.
The ankle is placed in a splint in the operating room to hold the position of the foot and ankle and protect the newly transferred tendon(s). Strict elevation and non-weightbearing are enforced over the first 10 to 14 days. Stitches are removed in about
two weeks, after which the foot will be in a cast for about six weeks. The patient usually is non-weightbearing during this time.
Once the cast is removed, the patient will be allowed to walk in a special boot. Physical therapy to retrain the tendon(s) in its new position continues for 8-12 weeks. A night splint is worn for three months after surgery to prevent premature stretching
of the tendon transfer.
As swelling improves a custom-molded brace can be worn in an athletic shoe and the walker boot is discontinued. Once the patient’s strength and motion are improved with physical therapy, the brace may be discontinued. The goal of the surgery is
for the patient to walk in a regular shoe without the need for a brace.
Risks and Complications
Potential complications of this treatment can include wound infection, deep infection that can compromise the tendon transfer, and failure of the tendon or tearing of the repair.
Will I have "normal" ankle movement after this procedure?
A foot drop procedure changes the function of the ankle and allows a patient to walk without a brace. However, it is not possible to restore normal strength and full range
of motion with this procedure.
Will I be able to pull up my toes?
Often a nerve injury that causes a foot drop also limits the ability to pull up the toes. The tendon transfer will not restore this function. If this is a concern, make sure that you mention it
to your doctor.
Will I be able to walk without a brace?
The purpose of the procedure is to try to improve function of the ankle so that a patient can walk without a brace. However, with severe nerve injury it is not always possible to guarantee
that a patient will be brace-free all the time.
Can foot drop surgery be performed if I have no working muscles at all?
The foot drop tendon transfer surgery only works if some of the muscles around the ankle are still working.
Is there a "best time" to have the procedure after a foot drop occurs? Is sooner better than later?
Nerve injuries can improve very slowly over time. At the initial time of injury, it is possible that over months to a year, the foot
drop will actually improve and strength will return. By about one year, if no function has returned, a foot drop procedure is reasonable to consider.
For a long-standing foot drop (that is, the injury happened many years ago) a foot drop procedure can still work if the other muscles around the ankle are still working. So no matter how long ago it happened, it is reasonable to seek the opinion of a
foot and ankle orthopaedic surgeon to see if you are a candidate
for this procedure.
Will I need physical therapy?
It is helpful to have formal physical therapy to help retrain the muscle for its new function. Therapy continues until progress is made in both strength and motion and you are able to transition out
of the boot or brace.
Original article by Sandra Klein, MD
Contributors/Reviewers: Patrick Maloney, MD; Selene Parekh, MD
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