INTRODUCTION TO FOOT DROP

Any injury to the lower extremity where lateral popliteal nerve is affected results in a condition called as foot drop, in which the foot is dragged from mid swing to the phase of deceleration in the gait cycle, because of over acting of the plantar flxors as the dorsi flexors become weak or paralyzed resulting in high steppage gait.If not treated early it will lead to an obvious deformity. Depending on the severity of injury the, management can be medical or conservative management. What ever may be the line of management Physiotherapy is a major part of treatment. It is helpful in skin care, improving muscle tone to prevent atrophy and preventing contractures maintaining joint range to improve circulation. Physical therapy treatment consists of Exercise therapy, Wax therapy, Hydrotherapy, Electrical stimulations of muscles, Short wave diathermy, Ultrasound, Splinting: Ankle foot orthosis (AFO) is used to maintain the foot in normal range or in dorsiflexion. The components of functional electrical stimulation are, Electrostimulation device, electrodes, lead wires, control mechanism, sensors and microprocessor.The three systems of the functional electrical stimulaion are: surface electrode system, percutaneous electrode system, implanted electrode system.

ANATOMYLateral Popliteal Nerveo It is the smaller terminal branch of the sciatic nerve. o Root value:-L4, L5, S1, S2. Course:o It lies in the same plane of the tibial nerve. o It extends from the superior angle of the fossa to the lateral angle, along the medial border of the biceps femoris, continuing downwards and forwards, it winds around the posterio lateral aspect of the neck of the fibula, peirces the peroneous longus, and divides into the superficail and deep peroneal nerves. In the fossa, it gives: Two cutaneous branches:o The peroneal communicating. o The cutaneous nerve of the calf. Three genicular branches :o The superficial lateral. o The inferior lateral. o The recurrent genicular nerve. The common peroneal nerve can be palpated against the neck of fibula. The following are the two terminal branches of the common peroneal nerve. Superficial of musculo-skeletal branch. Deep peroneal nerve/ anterior tibial nerve. Superficail peroneal nerve divides into:- Medial digital branch.

The following are the two terminal branches of the common peroneal nerve. Superficial of musculo-skeletal branch. Deep peroneal nerve/ anterior tibial nerve. Superficail peroneal nerve divides into:o Medial digital branch. o Lateral digital branch. Deep peroneal nerve divides into:o Medial branch. o Lateral branch.

MUSCLES SUPPLIED BY LATERAL POPLITEAL NERVE

1) Tibilias anterior. 2) Extensor hallucis longus. 3) Extensor digitorium longus. 4) Peroneus tertius. 5) Extensor digitorium brevis. 6) Peroneus longus. 7) Peroneus brevis.

ANKLE JOINT Type of joint:

1) Ankle joint is the synovial joint of hinge variety. 2) Structurally the joint is very strong. 3) The stability is provided by the Close interlocking of the articular structures. 4) Strong collateral ligaments on the sides. 5) The tendons that cross the joint (4 in front & 5 behind). 6) The dynamic stability is provided by the muscles of the joint.

BIOMECHANICS The movements of the ankle joint are: Dorsi flexion. Plantar flexion.

In dorsi flexion the foot is raised. and the angle between the leg and dorsum of the foot is diminshed. In plantar flexion the fore foot is depressed, the angle between the dorsum of the foor and the leg is increased.

MUSCLES PRODUCING THE MOVEMENTS:Movement Principle Accessory

Dorsiflexion

Tibilias

1.Extensor digitorum longus. 2.Extensor hallucis longus. 3.Peroneus longus.

Plantar flexion

Gastrocnemius

1.Plantaris. 2.Tibilias posterior. 3.Flexor hallucis longus. 4.Flexor digitorium longus.

PHYSIOLOGYNERVE ACTION POTENTIAL:-

Nerve signalsare transmitted by action potentials, which are rapid changes in the membrane potentials that are spread rapidly along the nerve fibre membrane. Each action potentials begin with the sudden change from the normal resting negative membrane potential. To conduct a nerve signal action some changes that occur during action potential, with transfer of positive charges to the interior of the fibre as its onset and return of the positive charge at its end.

The successive stage of the action potential is as follows:

RESTING STAGE: This is the resting membrane before the action potential begins. The membrane said to be polarised during this stage because of the 90MV negative membrane potential that is present.

DEPOLARIZED STAGE:-

In this stage, the membrane suddenly becomes permeable to sodium ions allowing tremendous amount of positively charged sodium ions to follow to the interior of the axon. The normal polarized stage of 90 MV is immediatly neutralized by the following sodium ions. With the potential raising rapidly in the positive direction this is called depolarisation. In the large nerve fibres the membrane potential actually overshoots the zero level and becomes somewhat positive.

REPOLARIZATION STAGE:-

With in a few 10,000s of seconds after the membrane becomes higly permeable to sodium ions the sodium channels begin to close and the potassium channels open more than they normally do. The rapid diffusion of the potassium ions to the exterior re-establish the normal negative resting membrane potential, this is called repolarisation of the membrane.

VOLTAGE GATED SODIUM AND POTASSIUM CHANNELS:-

The necessary factor in causing both depolarisation and depolarisation of the nerve membrane in action potential is the voltage gated sodium channel. A voltage gated potassium channels plays a important role in increasing the rapi repolarisation of the membrane. These two voltage gated channels are in addition to the sodium potassium leak channels.

PATHOLOGY LEVELS OF LESIONS:High leson (above knee) both tibial nerve and common peroneal nerve are parlalysed. Low lesion (below knee) Spared: peroneus longus and brevis TYPES 1 LOST Tibialis anterior Extensor hallucis longus Extensor digitorum longus Peroneus brevis TYPE 2 LOST Peroneus longus

CLassification of Nerve injuries:Seddons classified three well defined varities Neuropraxia. Axonotomosis. Neurotomesis.

Neuropraxia In this case paralysis is incomplete as it is essentially a temporary intereference in function. Recovery is rapid and complete with no microscopic evidence of nerve damage. Symptoms and signs:1.Loss of function is predomintaly motor. 2.There is little wasting and the electrically reactions of the muscles persist unchanged. 3.Subjective sensory disturbance numbness, tingling and burning are common. 4.Objective disturbances are generally partial and often minimal as far as touch, pain and cold. 5.Loss of sweating is unusual. 6.Nerve conduction to the digital to the lesion is preserved. 7.Recovery is fairly rapid, usually beginning after a few days or weeks and complete within six or eight weeks. Axonotomosis Here, connective the axons are damaged remain but the surrounding segment

tissue

sheaths

intact.

Distal

undergoes Wallerian degeneration. Functional recovery fairly rapid and complete. Neurotomesis A complete section of the nerve truk. This results in a loss of the motor and sensory function till regeneration is complete.

functionally recovery is slow due to the loss of continuity of the nerve trunk.

Symptoms and signs:Complete division of the nerve causes motor, sensory, vasomotor, and tropic manifestations.

Sunderlands classified nerve injury into five degress based on histological features of nerve trunk. First degree injury: This basis of first degree injury, which correspondence to neuropraxia in sedans classifications is interruption at the site of the injury. Second degree injury: It corresponds to axonotomesis in seddons classification. Third degree injury: The essentail feature of this injurie is they are intrafascicular injuries that may be localised to as segment of the nerve. Fourth degree injury: Continuity of nerve trunk is preserved though the involved segment converted into a tangled mass of ruptured fasiculae, scar tissue, schwann cells and the regenerating axons that may form a neuroma. Fifth degree injury:

This is the one in which there is loss of continuity of the nerve trunk.

AETIOLOGYThe lateral popliteal nerve gets injured in the following conditions like Trauma: o Thermal trauma. o Chemical trauma. o Mechanical trauma. Metabolic Diseases. Collagen Diseases. Infection: o Leprosy or hansens diseases . Local causes: o Spina bifida. o Tumors. o Disc prolapse. o Posterior dislocation of hip. o Fracture around the hip. o Fracture acetabulum. o Deep intramuscular injection. o Fracture shaft of femur.

o Penetrating injury. o Gunshot injury.

CLINICAL FEATURESInjury to the lateral popliteal nerve can be suspected in accordance with level mainly based on the signs and symptoms. Motor signs: Active dorsiflexion of the ankel is lost as the tibialis anterior got paralyzed. Active extension of the great toe is lost as the exensor hallucis longus is paralyzed. Active extension of all the toe is lost as the long extensor digitorum longus and brevis are paralyzed. Active eversion of the foor is lost as the peroneal group of muscles are paralyzed. Sensory loss: Sensory loss is seen in the lateral aspect of the knee, proximal 1/3rd of the calf region, anterolateral and postero lateral regions of the calf, lateral malleolus, dorsum of the foot, lateral border of foot.Because of the loss of sensation of foot tropic ulcers are seen in case of leprosy or Hansens disease Atrophy of the Muscles: In the lateral popliteal nerve palsy the peroneal group of muscles undergo wasting. Tropic changes: Tropic ulcers are seen in case of leprosy or Hansens disease in

case of tropic ulcers MCR (Micro cellular rubber) chappals are used, skin care should be taken, antibiotics.

COMPLICATIONS Swelling and oedema: This may be increased as a result of co-existing. o Soft tissue injury. o Wound infections. o Bone fracture. While litigation of the major artery supplying the limb introduce an assitional completing factor. Exudates gravitate along muscles to their attachments in the vicinity of joint capsule ligaments. Deformity: The paralysis of some muslce and the unopposed action of contracting antagonists result in development of deformities in the early stages these are reducible. Either passively or by the contraction of unaffected muscle in time if neglected becomes fixed and irreducible. Joint stiffness and limitation of movements: These complications are due to fibrosis and adhesions that involve the capsule and ligaments of the joint and in this way restrict or prevent free movement. Joint dislocations:

Weakening of joint capsule and support structures predispose recurrent trauma to an intensive and insecure joint may finally lead to its collapse.

Contractures: This may develop in muscles paralysed due to prolonged un relieved immobilization the basic lesion in muslce fibre degeneration and its replacement by fibrous tissue. This is due to circulatory disturbances originating with an inactive paralyzed muscle. It ultimately results in the formation of contractures, with adhesions that attach them to surrounding structures there by reducing their mobility. These changes fix muscle in the position in which it has been immobilized or allowed to shorten in this way joint movement becomes restricted. Osteoporosis: It is the further result of the impaired circulation and is a conspicious feature of some irrigative lesions where pain causes immobilisation of the affected parts.

DIAGNOSIS

RADIOLOGICAL EXAMINATION This should be directed to a study of the displaced ends of a fractured bone. Callus formation. Dislocation. The presence of bony abnormalities and foreign bodies all with references to the possibility of their being responsibile. NERVE BLOCK: These are occassions when unusual motor and sensory functions confuse the diagnosis and raise the questions whether the parts normally served by injured are receiving an anatomous innervations from another source. This possibility can bedirected by blocking the nerve supplied of being the offender and this way releiving. MUSCLE BLOCK: This procedure has a limited use in the diagnosis of nerve injuries.

It should be reserved for the difficult and exceptional case when it is necessary to know nerve fibres are still present in muscle that has subjected to prolonged denervation. No recovery is to be expected when muscle tissue is no longer present.

Biopsy is rarely indicated. Within 1st yeare of denervated muscle have been subjected to appropriate therapy because with in this period theu retain the capacity to recover and function efficiently following satisfactory reinnervation. HISTOLOGICAL EXAMINATION OF THE BIOPSYSPECIMEN PROVIDES INFORMATION: The state of muscle fibre The nature and distribution of the intestinal connective tissue The state of the endoneural tubes: Empty endoneural tube indicates that regenerating axons are present in the muscle. DIAGNOSIS OF NERVE LESIONS: A complete diagnosis of traumatic nerve lesion should include the identification of the following. o Nerve or Nerves injured. o Anatomical level of the injury to the nerve.

o Pathological type of injury. o Associated bone, vascular and tendon injuries. o Secondary effects like deformities and contractures.

CLINICAL EXAMINATION In case of gun shot or major injuries and fracure neck of fibula, a detailed examination should be done only when patients general condition permits. MOTOR SIGNS: The muscle below the level of lesion are paralyzed and there is wasting of muscles. Motor power is to be addressed in terms of council grading, the re sponse could be 0 - Nil or no power at all. 1 - Only flickering of contraction of muscle. 2 - Active full range of motion in the gravity eliminated position. 3 - Active full range of motion against plane of gravity. 4 - Active full range of motion against plane of gravity with minimal resistance. 5 - Active full range of motion against plane of gravity with maximal

resistance.

SENSORY SIGNS: Subjective: Note the distribution of pain, tingling, or burning sensation Objective: Blunting or loss of sensation to pin prick, cotton wool touch and temperature. SUDOMOTOR SIGNS: Anhydrosis:-Note the area of dry skin due to absence of sweating. VASOMOTOR SIGNS: Warm phase in the first two weeks. Cold phase later. TROPIC CHANGES: Note the area of skin smoothness and shiny areas. Ulceration. Subcutaneous tissue atrophy. REFLEXES:

Loss of tendon reflexes. RECOVERY SIGN: Tinels sign.

SPECIAL TESTS

ELECTRO DIAGNOSTIC TEST:MUSCLE

o Electromyography o Strength duration curveNERVE

o Nerve conduction study o Conduction velocity SUDO MOTOR FUNCTIONING: This is done by sweat test using anizarine powder The iodized starch powder is dusted over the area, on inducing sweating, the powder remains grey in the denervated area but is turned purple in the normal areas, which sweat. ELECTRODIAGNOSTIC TEST:-

This is used for recognition of nerve injury for detecting the onset and for following its progress.

NERVE TRUNK STIMULATION The simplest form of electrodiagnosis is stimulation of the nerve trunk both above and below the site of the suspected lesion. It may be stimulated by needle electrodes or by direct stimulation above the lesion will indicate whether conduction is normal, completly or incompletly interrupted or impaired. Result The anamalous and supplementary innervations of muscle A nerve undergoing Wallerian degeneration will continue to respond ti electrical stimulatuion below the lesion for 3-4 days after the injury CHANGES IN MUSCLE RESPONSE TO ELECTRICAL STIMULATION: Muscle may be stimulated electrically either directly through the skin or indirectly by way of the motor nerve which innervates it. The stimulus may be of galvanic variety.

Following denervation the nerve fibres retain their excitability for about 3-4 days when fragmentation of the axons reaches a degree where continuity with the muscle is lost. Of the several electrodiagnostic methods based on the measurement of excitability of a muscle to electrical stimulation, the strength duration is the usual method.

THE STRENGTH DURATION CURVE OF A NORMAL MUSCLE Because nerve fibers respond ti current of much shorter duration than muscle fibers, the response of the muscle to stimulation is charancteristic of the nervefiber alone and S-D curve has the short time constantcharacteristic of nerve fiber The current strength required to elicit minimal contraction of the intact muscle remains same until the short pulse durations are reached when the current strength has to be increased. This gives a continuous, almost flat curve with an upward trend in voltage at the extremeleft of the curve, when short duration stimuli are used. The current intensity steeply rises with pulses between 0.1 to 0.01 milli seconds. THE STRENGTH DEGENERATION DURATION CURVE DURING FIBRE

As the nerve fibre gets degenerates the rapid nerve response declines and the slower muscle fiber response emerges and eventually predominance. This is reflected in the form of discontinuity or kinks that appear in the curve between the 3 and 10 millisecond pulse duration.

These kinks divide the curve into two parts, one a rapid component with a short timeconstant characteristic of the declining nerve fiber response and other with a long time constant. The appearance of kink or discontinuity in the curve is a relaible early sign of degeneration. THE STRENGTH DURATION CURVE OF DENERVATED MUSCLE In completely denervated muscle the strength duration curves response is only elicited with stimuli of long duration and the necessity to increase the current for stimulation occurs at about 10 milli second The normal duration curve in the form of horizontal line rising steeply with stimuli of short duration is there by converted into a distinctive steeply rising parabola which is displaced to the right, that is towards the long duration pulses. THE STRENGTH DURATION CURVE DURING RE-INNERVATION The first sign of recovery of a kink or discontinuity in the denervation strength curve, which is subdivided into two parts One has short time constant characteristic of an appearing nerve fibre response which depends on the presence of excitable nerve fibres in the muscle and other long time constant characteristic of the muscle fibre response. As recovery proceeds the more rapid component increases and eventually obscures the slower muscle fibre. ELECTROMYOGRAPHY Contractions in normal muscles include either directly by voluntary effort or indirectly by stimulating the nerve innervating the muscle action potential that can be placed up by surface or needle electrodes and recorded by electromyography It is of great value in detecting denervation relating to the condition of motor nerve fibres locating nerve lesions providing a sensitive index of reinnervation following the curve of motor recovery.

TREATMENT MEDICAL MANAGEMENT: The key objectives of treatment are the maintenance of dener denervated muscles Joints and particular structures and skin in an optimalcondition pending re innervatng and the preventing of deformities. TREATMENT OF DENERVATED MUSCLES Protectng the affected parts from exposure to cold,which aggrevates the degenerative changes in denervatd skin and muscle. Protecting paralised muscles from injury because denervating renders them particularly sensitive to trauma. Stimulating the arterial,venous and lymphatic circulation through the dennervated regions,this reduses the incidence of trophic changes,prevents oedema. maintaining paralised muscles at rest and protecting them from being over stretched as they result in lengthening of paralised muscles,shortening of antanogist muscles at joint deformity. TREATMENT OF THE JOINT AND PERIARTICULAR STRUCTURES Involvement of the joint capsule and ligaments in the pathological process introduced by the degenerative weakness joints and make them less resistance to deformity forces. In the chronic stages, they change forming ankylosis resulting joint stiffness. TREATMENT SHOULD BE DIRECTED TO Presere a free joint range of movement and free running tendons by maintaining the tendons and joints.

Supporting insensitive joints systems that have been weakend by softening of ligaments and the paralysis of muscles. Preventing the development of deformities of joint by a combination of splinting aimed at overcoming the action of unapposed antagonists and full range of movements-affected joints. CARE OF DENERVATED SKIN Insentive skin is particularly vulnerable to injury. Skin should be clean and protected. PATIENT SHOULD BE WARNED ABOUT THE DANGERS OF Insensitive from hot and sharp,cold objects. Even trivial injuries to leg and foot. In case of treatment of hansens disease,the care of limbs should be taken. Careless treatment of nails,which are common sites of tropic disrurbance. Incorectly applied splinting leads to pressure and friction. CONSERVATIVE MANAGEMENT In every case on nerve injury the limbs should be splinted in the position,that will completly relaxed the affected muscles. Example-footdrop splint for lateral popliteal nerve palsy. The patient walks with a high stepping gate to clear the foot from the floorand the unoposed calf muscles causes the foot to drop into equinovarus. This can be corrected by the use offoot drop splint and ankle foot orthosis.

A night splint should be made to support the foot at 90 degrees dorsiflexion and in the mid position between inversion and aversion. The splint should be extend for 2.5 cm distal to the toes to keep the weight of the bed clothes off the foot and should be lined carefully to avoid causing pressure sores. Recovery is watched in the affected muscles at peroidical intervals.

PHYSIOTHERAPY MANAGEMENT Physiotherapy management plays an important role in the functioning of the whole limb,given conservatively without involvement of operations.and also post operatively following

nerve sutures. PRINCIPLES OF PHYSIOTHERAPY MANAGEMENT FIRST 3 WEEKS The treatment programe is planed on an individual basis. Maintainence of range of motion to avoid contractures and deformities.a proper resting splint is to avoid undue sternuous movements. Control inflamation and swelling by gentle movements. Elevation of limb. Maintanance of muscle power,flexibility and endurence. Reduction of pian by using TENS. AFTER 3 WEEKS Electro diagnostic test is conducted to asses the degree of the nerve damage,by electrical reaction of degeneration test,to plan accurate regime of electrotherapy. Maintainence of soft tissue excurtoin by gentle stretching. Modifications in the splint for further improve the functional status. Motr re-education ;-correct methods of exercises to re educate muscle function are extremely important as soon as the recovery is indicated by diagnostic test. Sensory re-education ;-as the efficiency of the motor activity depends upon the sensory status.this should be given as soon as possible,as it plays an important role. As the voluntary movement returns the splint can be modified to provide resistive exercises.

Electrical stimulation plays an important role in preventing muscle fibrosis and atrophy. Electro diagnostic tests be repeated at regularly,to know the responce to trearment.if no recovery is seen even after 18 months to 2 years,surgery should be contruplated. After compelete assesment,the treatment measures are planed as per the requirements of the patients condition. During early stage During the stage of recovery Later stage DURING EARLY STAGE(FIRST 3 WEEK) This is the stage of paralysis and all the sympotms of early injury to the nerve are present,the treatment mesaures are;1;-REDUCTION OF INFLAMATION Reduce oedema by elevation of limb. Active and passive movements to improve circulation 2;-REDUCTION OF PAIN BY TENS TENS is effective in reducing pain.in sensory impared areas electrodes may be placed over the nearest area with intact sensation or over the nerve trunk. 3;-SPLINT It gives support to the area involved,its usuage and fitting is trained to the patient 4;-EXERCISES Active n resistive exercises to the muscles,which are un affected should be repeated as many as posible.

5;-RELAXED FULL RANGE PASSIVE MOVEMENTS It should be given to the unaffected joints,muscles imbalance due to paralysis of muscle sgroups,needs to be observed for the cause of tightness and contractures leading to deformity. 6;-ACESSORY PASSIVE MOVEMENTS It is also effective in preventing joint stiffness and should be included. DURING THE STAGE OF RECOVERY(3 WEEKS ONWORDS) Re-education of movements As there is recovery in the voluntary contraction of the paralysed muscles,it recovers initially begins as synergists,which should be followed as antagonists at a later stage. PNF techniques are extremely valluable at this stage. LATER STAGE When the changes of recovery are poor,surjery is indicated.physiotherapywill depend upon the type of surgical procedure. SURGICAL TREATMENT Normally nerve regeneration occurs at the rate of 1 mm a day or 25 mm a month,if there is no sign of motor or sensory,in the expected time of recovery,surjery is indicated. The appearence of palpable neuromas at the site of injury is another indication for surjery. Under general anasthesia and torniquet control,the nerve is explored by a long incision and the site of injury exposed. THE FOLLOWING PROCEDURES MAY BE REQUIRED

NEUROLYSIS NEURORAPHY NERVE GRAFTING;-autograft,homograft,heterograft. NEUROLYSIS;-external neurolysis, internal neurolysis FASICULOTOMY FASICULECTOMY TENDON TRANSFERS

This is a critical period described for every nerve after which no recovery is expected.this period varies with individual nerve,but

generally it is14-18 months after injury. Tendon transfers are indicated to improve the appearence or function of the foot. Lateral popliteal nerve palsy causes foot drop with loss of dorsi flexion at the ankle,loss of extension of toes,and loss of eversion. The transfered membrane. muscle is passed across an interosseous

Mobilisation should be sufficient to allow the muscle belly to pass through the membrane to reduce adhessions. Achillies tenton lengthening-in fixed equinus Sub talar stabilisation procedures-for fixed varus. Triple orthodesis-it is done in adults for a fixed varus at sub talar joints. The leg and the foot should be immobilised for 6 weeks and then the transfer is protected by foot drop splint for 3-6 weeks. PHYSIOTHERAPY FOLLOWING TENDON TRANSFERS The basic objective of the physiotherapy is to reduce the transfered tendon for its altered function. It is essential that muscle must be enough atleast grades 4,on the normal muscle testing scale,after transfer its power is ususlly reduced atlest by 1-2 grades.therefore if the power of the donar muscle is less than 3,then it shouldnot be taken for tendon transfer. PRE OPERATIVE ASSESMENT AND TRANING Donor muscle are out under vigorous sessions of isometric strengthening exercises to reach the requisite muscle power of grade 4.

The patient is educated on the new expected action of the muscle after transfer.tjis is done by demonstrating and practising. After surgical transfer,routine measures are taken to reduce the post surgical inflamation. As soon as thesoft tissue healing is adequate,the process of reeducation is started. Guide the patient initally by performing the relaxed passive range of movements Dynamic splint should be so fabricated that it offers adequate stabilisaton as well as assistance to the expected movements. Low faradic currents are given. EMG biofeed back techniqe is very effective in the re education of transplanted muscle. Active assisted effprts should be progresed to active movements. Functioning exercises promoting the accurate use of donod muscle are very usefull. Passive full range of motions are given. Hydrotherapy-very effective Deep friction massage or ultra sound are used Gradual weaning of splint as full function returns with in 8-12 weeks following surjery.

PHYSIOTHERAPY FOLLOWING SUTURE DURING IMMOBILISATION(1-3 WEEKS) IMMEDIATE FOLLOWING SURGERY

Limb elevation and measures to reduce inflamation. Diapulse can be given through immobilisation for early heling. Vigarous active movements to other non immobilised joints to improve circulation and to prevent contractures. MOBILISATION(3-6 WEEKS) Movements should be intensified and active movements to be progressed mild resistive exrecises and self developed tension exrecisess. Relaxed passive movements to be caried out motion. to full range of

Acessory movements can be added.sensory re education should be started. RESTORATION(6-8 WEEKS) The whole progamme of mobilisation and strengthening are made intensive by;Initating progressive resistance exercises. Functional activities should be made vigarous and vocational oriented. Deep friction massage to the surgical scar to avoid the adherence. Splint should be altered to offer exercises by 8-10 weeks adequate return of function should be achived. FREE EXERCISES FOR THE LATER STAGES Ankle dorsiflexion. Fore foot eversion and inversion. Toes flexion and extension.

Towel gripping exercises with all toes. Sand gripping exercises with all toes to strengthenthe flexors and extensors. Balance board can be used for effective stimulation of peroneal andanterior tibialis. Balance board helps in proprioception in lower limb. Facilitation techniques are used to support dorsi flexion of the foot at 90 degrees and in mid position between inversion and eversion. Active self stretching of dorsiflexors by using towel.

PASSIVE MOVEMENTS The patient in lying position,give passive dorsiflexions of ankle by putting some powder on couch to prevent friction. Te patient in spine lying, give passive movements of foot inversion and eversion. Give passive stretching of dorsiflexions of foot to prevent contractures of calf muscles. After gaining sensation the FES can be used. PLACEMENT OF ELECTRODES First the stimulus is felt as PINS & NEEDLES, most people become used to it but may find the sensation too uncomportable and may decide to stop using the stimulator, But using FES is uncomfortable but not dangerous. The active electrodes is placed on the nerve trunk, passive electrodes is placed on the motor points. Initially the Physiotherapists has to show the movement to get recognised by the patient as what action he is in need of (Dorsi flexion) Instructions are given as how to use the stimulator when needed Before going for FES observe for Muscle strength Response to the stimulation

Passive ankle dorsiflexion to atleast plantigrade 90 degrees

Role of Functional Electrical Stimulation Electrical stimulation in the form of functional electrical

stimulation can help facilitate and improve mobility along with other body functions lost due to injury by applying a controlled electrical stimulus to generate contractions and functional movements in the paralysed muscles Restoration of function through electrical stimulation Electrical stimulation can overcome the deficit produced by the lesion and maintain the integrity of various bodily functions through direct neuromuscular stimulation. FES (Functional Electrical Stimulation) is the technique of applying safe levels of electric current to activate the damaged or disabled neuromuscular system in a coordinated manner in order to achieve the lost function. Neuroprosthesis is a device that uses electrical stimulation to activate the nervous system. These intiate a physiology like system in the intact peripheral nerves, providing functional restoration of various body organs in the

neurologically impaired individuals. Functional applications The FES devices are initially designed in an attempt to provide assistance with standing or walking provided the paraplegic patient had adequate upper body motor control and strength. It is a Transcutaneous micro computerised Electrical stimulation system built into a small unit powered by batteries and is controlled by a fingure touch button located on a walkers hand bars for manual selection of stimulation menus. The system provides stimulaion out put to 12 surface electrodes that are attached to the skin at appropriate placements these stimulation pulses trigger action potential in the peripheral nerves to generate muscle contraction. It is the only system which is widely available and has been evaluated for its ambulation performance and medical or psychological effects. The use of these FES devices designed to permit or improve ambulation is not simple or not without risks. The amount of energy spent with FES walking is almost twice than that normal walking although the acheivable speed is slower than that of normal walking. In response to all these sensory inputs the FES system should be able to redefine the stimulation parameters according to the feed back it receives thus delevering more natural responses. These devices can help increase there level of independence by providing some assistance with standing whie transfering from Wheel chair to a Car, Climing a few steps of Reaching for a higher objects.The medical advantages of short distance ambulation include increased blood flow to lower limb muscle mass, reduced spasticity are acheived through FES assisted walking such as associated increase in self esteem and reduction in depression. Therapeutic application

Depending on the level of injury, unused paralysed muscles undergo disuse atropy with peripheral circulation and demineralisation in the bones leading to osteoporosis. The paralysis forces the patient towards a more sedentary life style.The autonomous nervous system impaired coupled with the lack of exercise and mobility leads to various cardiovascular problems thus increasing the morbidity. A significant improvement in rehabilitative application of FES is in improving muscle bulk and strength and prevention of denervation muscular atrophy. It also in facilitates peripheral cardiovascular circulation conditioning the use and of improvement through

stationary exercise devices like Treadmill. Axonal regeneration is the ability to extend the tip proximal portion of an amputated/ severed axon. This tip of the growing axon called the growth cone, has got the ability to sense cues from the environment and steer the axon to grow in one direction or another. For succcessful regeneration to happen a series of biological events is needed. The growing nerve fibre respond immediatly to the voltage gradient and tend to orient themselves parallely with the long axis of this gradient. Another important observed phenomenon was the directional response of the growing nerve fibres within the imposed electrical field. The position of the electrodes determine the direction of neurite growth. Neurites tend to grow three times faster towards the cathode electrode in DC field between 70 and 140mv/mm. However after a lag period of 30 min following the

exposure to voltage gradient, the neurites facing the anode start to regress as if being repelled by the anodal electrode. Further clarification on the response of applied DC voltages on single nerve fibres. The cathode directed reorientation was dependent on the strength of the electric fields, and the threshold level for this directional growth was 7mv/mm. The applied weak DC field was able to enhance the rate of regeneration in the severed axons towards th implanted cathode. These regenerated axons were also able to make functionsl synaptic connections with the caudal end of the injured. The placement of cathode rostral or caudal to the site of an determined direction regeneration. Proliferation and faster growth rate was seen towards the cathode. The axonal growth seen with the application of electrical field has been proposed to be mediated via membrane bound receptors and some secondary messengers like adenyl cyclase and interaction with other physiological neurotrophins present in the CNS. The cathode is believed to lead the reduction of cyto destructive effects in the degeneration of axonal growth tip facing the cathode. Other possible mechanisms include reduction in the number of astrocytes within the injury site and changes to post traumatic blood flow. Electrical stimulation has also shown to enhance the expression of regeneration associated and accelerates regeneration in peripheral nervous system.

ANKLE FOOT ORTHOSIS INDICATION Ankle foot orthosis is prescribed for Muscle weakness affecting the ankle and sub talar joint Prevention or correction of deformities of foot and ankle Reduction of in appropriate weight bearing forces. METAL ANKLE FOOT ORTHOSIS Proximal calf band with leather straps Madial and lateral bars articulating with lateral and medial ankle joints help in control of plantar and dorsiflexion.

Stirrups anchor the uprights to the shoes.

INDICATION FOR AFO IN DORSIFLEXORS ANKLE AIM;-To prevent contractures of achiles tendon prescribed a dorsiflexion assist plastic posterior leaf spring ankle foot orthosis that can be inserted into shoes. This facilitates the patient to wear different shoes The rationale for this option is that the spring prevents the foot from dragging during the swing phase and permits slight plantar flexion during early stages there by enabling the patient to achieve a flaat foot position without undue knee flexion. Tension of the achiles tendon counter cats any tendency to form contractures.

ASSESSMENT Name Age Sex Chief complaints History of History of present illness;-onset Duration Severity Side|site Past history;-etiology Medical history Family history

Personal history Socio economic history ON OBSERVATION Posture Gait Built Any external appliance Any splints ON EXAMINATION Skin colour Tone of the muscle Muscle girth Sensory examination Motor examination Range of motion Any tightnes Any tropic changes ON PALPATION Temperature Tenderness Tone VITAL SIGNS Respiratoty rate

Pulse Blood pressure Heart rate POSTURE GAIT Normal Abnormal TIGHTNESS / CONTRACTURES / DEFORMITY BOWEL AND BLADDER INVESTIGATIONS DIAGNOSIS TREATMENT Conservative Surgical Medical PHYSIOTHERAPY MANAGEMENT Problem list Short term goals Long term goals

CASE STUDY Name: xxx Age: 23 years Sex : Female Occupation: MBA student Address : Warangal Cheif complaints: unable to raise the right ankle and toes unable to walk properly History: History of present illness Onset : sudden Duration : One Week Mode of injury : RTA

Past History : nill significant Medical History: No medication On observation: Deformity : Foot drop (Right leg) Position of limb : Ankle plantar flexed, toe flexed, fore foot inverted External appliances : Foot drop splint Gait : High stepping gait On palpation: Wasting : Peroneal group of muscle and Tibialis Anterior Swelling : Absent Tenderness : Absent Tropical changes : In right lower leg region the skin is dry and scaly On examination: Sensory Examination: Loss in right lower leg and foot Motor Examination : Wasting and weekness of Tibialis anterior and peroneal group of muscles Tightness : Absent Muscle Testing: Muscles Tibialis anterior Extensor hallucis longus & brevis Peroneus longus Peronues tertius 2 3 Grade 2 2

Peroneus brevis Extensor digitorum Range of motion: Active ROM: Reduced Passive ROM : --

3 3

Ankle : Dorsi flexion - 15 degrees (0 to 20) ; Plantar flexion - 40 degrees ( 0 to 40) Sub talar: Inversion - 30 degrees ; Eversion - 10 degrees Toes- 1st Metacarpo phaleangeal joint flexion - 30 degrees; Extension- 30 degrees Interphaleangal joints : Flexion - 30 degrees Functional activities : Ambulation the gait is High steppage gait and walking with foot drop splint support Bed side activities are normal Communication normal Dressing independant Eating independant Toilet independant Investigations: X-ray;- normal S-D curve; The tested muscle is right tibialis anterior. The graphical representaiton was towards the right side (Denervation) and then after twenty days in follow up noticed the left side deviation of graphical representation ( innervation)

Provisional dagnosis; Right foot drop Physiotherapy management TENS & Ice packs : To reduce pain Electrical Stimulation : To prevent wasting of Muscle Strengthening: Passive movements, Stretching Positioning: Foot Drop Splint Sensory reducation Gait : Walking with Splint Feed back : Following the above protocol Individual muscle strength was observed FES is advised after gaining Muscle strength Home Programme:Counselling the Care taker and educating by showing the Passive movements and are advised for every one hour, Stretching, Active assisted with sound leg, and instructed the usage of FES

Literature review: - Electrical stimulation is the most frequently studied therapeutic method utilized in the treatment of Peripheral Nerve injury When adequately indicated and utilized, electrical

stimulation presented better results in reducing the severity as well as improving the motor function. - The several mechanisms of Peripheral Nerve damage can influence the therapeutic choice and FES effectivess, which showed to be the most promising therapy type. - It can be taken into account the fact that study has shown that Electrical stimulation is the best therapeutic resource.

CONCLUSION I Worked on project of functional electrical stimulation in foot drop,i observed that the usuage of functional electrical stimulation in few patients.have better effect on the treatment than other modalities in physiotherapy,as it helps in 1;-re-educating the muscle 2;-prevention of muscle atrophy 3;-re-education of gait 4;-early rehabilitation Therefore i here by conclude my project that incorporation of functional electrical stimulation along with the physiotherapy in the treatment of foot drop patients helps in acheiving the functional goals of the patient with in less span of time.

BIBILOGRAPHY 1.HUMAN NEURO ANATOMY; Inderbirsingh 2.HUMAN ANATOMY; B.D chausria 3.TEXT BOOK OF PHYSIOLOGY; guyton and hell 4.TEXT BOOK OF ORTHOPEDICS; natrajan 5.NERVE INJURIES AND THERE REPAIRS; Sunderland 6.ESSENTIAL OF ORTHOPEDICS; jayanth joshi and prakash kotwal 7.TIDYS PHYSIOTHERAPY; ann thomson 8.CASH NEUROLOGY; patrica a.downe 9.WEB SITES; e_medicine_footdrop article by james.w pritchett

Management of nerve injuries.htm Nerve repair.htm Salisburg university of foot drop.journals.