Search

The peripheral neuropathy of leprosy is classified as a multineuropathy. It starts as a demyelinating process and evolves to axonal damage. All three components of the peripheral nervous system are affected: sensory, motor, and autonomic. Sensory loss causes anesthesia, analgesia, and inability to discriminate hot and cold. Motor deficit causes muscle weakness, paralysis, and atrophy. Damage to autonomic nerve fibers impairs sweating and causes dry skin. Nerve damage is directly caused by leprosy and is called primary impairment. The complications that result from nerve damage, e.g., ulcers, contractures, bone destruction, and shortening of fingers and toes, are called secondary impairments and may lead to a variety of disabilities and handicaps. Accurate neurological examination includes testing for loss of sensation on skin lesions, palpation of the peripheral nerves of predilection, and evaluation of sensory function and muscular strength. In leprosy, virtually all peripheral nerves may be involved, but those that supply the face, eyes, hands, and feet need major attention and systematic evaluation.

In recent years various powered ankle foot orthoses (PAFO) have been developed to assist disabled persons during walking. Different actuation technologies have previously been used, each with their individual challenges (e.g. high weight). As a new actuation technique, we used shaft twisted string actuation (STSA). We tested the effect of the STSA-PAFO on the gait of five participants with a diagnosed foot-drop. For all participants the ankle dorsiflexion has increased at initial contact and during swing phase with the PAFO compared to no orthosis. Compared to the prescribed AFO, two participants showed an increase in total ROM during swing-phase with the STSA-PAFO. Further, the peak plantarflexion has increased in three participants at push-off with the STSA-PAFO. During user testing in laboratory setting the STSA-PAFO showed good function and is a promising approach for further development.

Functional electrical stimulation (FES) is a popular technique to treat foot drop, a common gait impairment caused by inadequate dorsiflexion of the ankle. Multi-field surface electrodes provide easier and faster electrode donning and doffing and higher selectivity of stimulation, solving the problems of traditional FES devices. It also allows an automatic configuration of the device. This pilot study analyses the effectivity of different postures for the automatic configuration of the Fesia Walk system, a commercial multifield technology-based FES device. 5 healthy subjects participated in the study, and 5 configurations where held at 3 body postures within 5 days. The analysis focused on the ability of the system to classify the movements (dorsiflexion, plantarflexion, eversion and inversion) of the ankle in the 3 configuration postures. Results show that sitting on top of a table with both knees extended and ankle and foot hanging freely is the most appropriate posture for configuration as it only presents limitations to generate inversion.

Functional electrical stimulation (FES) is an evidence-based technique for treating foot drop, the inability to lift the foot due to weak or absent ankle dorsiflexors. Surface multi-field electrodes have brought some advantages such as improved selectivity or possibility of performing automatic motor-search configurations. In fact, they provide new stimulation paradigms that should be tested. This pilot study analyses the movements created using different anode combinations and gel types with the Fesia Walk system, a commercial multi-field technology-based FES device for foot drop compensation. 8 different anode combinations and 2 gel types were tested in 4 healthy subjects. Results show that the most lateral anodes located on the shank produce predominantly ankle plantarflexion and eversion, while the ones located most medially produce more dorsiflexion and inversion. No significant effect was observed between both gel types. This study suggests that anode selection has an influence on the elicited ankle movements and therefore it should be taken into account in the configuration process.

Ankle Foot Orthosis (AFO) is a rehabilitation device which is used to assist patients with weakness over the ankle, foot and part of the leg especially when surgery is not warranted or during the recovery phase of the foot. In this research, the Pneumatic Artificial Muscle was used to develop and actuate the AFO to mimic the movement of the ankle, namely, plantarflexion, dorsiflexion and eversion. Gait pattern analysis was used to gauge the effectiveness of the AFO in human subjects. Two healthy subjects were recruited to simulate gait patterns. The gait analysis showed that the AFO actuated PAM was able to resist plantarflexion while assisting dorsiflexion. During the stance phase, the AFO were able to allow free ankle movement up to approximately 5° dorsiflexion. It also allowed approximately 9° eversion of the ankle from neutral position. Toe drag in the swing phase was avoided as the foot drop was prevented. In conclusion, the AFO performed well in providing support for a foot drop condition and this presents an opportunity for further testing in real patients with foot drop.

The free fibula flap is a workhorse flap for osseous free tissue transfer in extremity reconstruction. It is also the flap of choice for mandibular defects, but this is beyond the scope of this book. The fibula has several advantages that makes it an ideal choice when long bone defects reconstruction via osteogenesis is required: It is a long bone that can provide up to 25–30 cm of length when harvested; it is mainly comprised of cortical bone, making it ideal for rigid fixation; it is a straight bone that is triangular in cross section, providing adequate support after reconstruction; it can be shaped to fit the defect via multiple osteotomies without compromising its blood supply due to its segmental vascularization; once the anatomy is understood, the dissection is relatively fast and easy to perform; there is minimal donor site morbidity and finally the vascular pedicle is long and the diameter of the peroneal artery and veins are large making the anastomosis less challenging. An in-depth understanding of the anatomy of the lower leg, including the contents of all four compartments is of paramount importance to perform a safe dissection. The proximal and distal ends of the fibula need to be left in situ, to avoid destabilization of the leg. This is especially important in children, where destabilization can lead to a valgus deformity of the ankle. During dissection, care needs to be taken to identify the common peroneal nerve as it courses around the neck of the fibula. Inadvertent injury can result in loss of function of the muscles of the anterior compartment of the leg (foot drop) and loss of sensation along the course of the superficial peroneal nerve. The flexor hallucis longus (FHL) muscle is the most vulnerable muscle during dissection, and loss of its function may result from the harvest. Additionally, fibrosis of the tendon can lead to permanent flexion deformity of the great toe.The free fibula flap can be harvested as an osseous or osseoseptocutaneous flap with a skin paddle in the lateral aspect of the flap based off septocutaneous peroneal perforators. While sacrifice of the peroneal vessels usually does not result in distal foot ischemia, a preoperative angiogram may be of value in patients with significant peripheral arterial disease.

Focal weakness of the limbs can be organized by affected body region. Shoulder weakness is most commonly due to C5–6 radiculopathy or brachial plexopathy. Scapular winging is usually secondary to long thoracic or accessory neuropathy. Hand weakness is most commonly the result of ulnar neuropathy, C8–T1 radiculopathy, motor neuron disease, or cerebral processes. Wrist drop is a special kind of hand weakness. The two most common sources of wrist drop are radial neuropathy and stroke, and can be differentiated from each other with focused examination. Proximal leg weakness is usually the result of upper lumbar radiculopathy or lumbar plexopathy. Postpartum leg weakness has multiple potential causes that can be distinguished by careful examination. Foot drop may be due to lesions of the peroneal nerve, sciatic nerve, L5 nerve root, or central nervous system. Multifocal weakness is due to multifocal central or peripheral nervous system disease. Relevant peripheral nervous system causes of multifocal weakness include mononeuropathy multiplex, multifocal motor neuropathy with conduction block, and hereditary neuropathy with liability to pressure palsies.

The next day when the anesthesiologist visits the patient on post-delivery rounds (L-1), she complains of trouble with her right foot. Neurological examination reveals weakness in dorsiflexion of the foot (foot drop) and numbness in the great toe. The rest of her neurological exam is normal—specifically, she denies trouble with urination or defecation and any other numbness or weakness in the lower extremities. She is concerned that the epidural may have caused the problem and wants to know if it will get better (L-2).

The reported rate of peroneal nerve palsy (PNP) after total knee arthroplasty (TKA) ranges from 0.16% to 2.2%. Risk factors associated with PNP after TKA are preoperative valgus deformity ≥10°, total tourniquet time >120 min, diagnosis of a preexisting neuropathy, post-operative pathological complications and rheumatoid arthritis. Factors not associated with PNP after TKA are flexion contracture and the use of postoperative epidural analgesia. PNP is diagnosed by clinical tests (foot drop) and electrodiagnostic and diagnostic imaging procedures. It is important to differentiate between neurapraxia, axonotmesis and neurotmesis. The most important electrodiagnostic methods for evaluating peripheral nerve lesions are needle electromyography and nerve conduction studies. There is a general consensus that in nerve lesions belonging to the categories of neurapraxia and axonotmesis, early surgical exploration is not indicated due to the possibility of spontaneous recovery helped by rehabilitation and an anti-foot-drop orthesis. Neurapraxia and axonotmesis should be monitored for 6–12 months before recommending surgical exploration. In cases of neurotmesis, the repair time is more urgent (from 3 days to 3 weeks). Currently, the most common surgical techniques for the repair of nerve injuries are external and internal neurolysis, end-to-end suture and nerve grafting.

Functional Electrical Stimulation (FES) holds the premises to artificially control the musculoskeletal system aiming to improve quality of life in e.g. multiple sclerosis patients, or to provide targeted rehabilitation in e.g. stroke patients. Besides some neuromuscular stimulators which are widely used within FES clinics (e.g. Odstock Drop Foot Stimulator to correct foot drop in poststroke rehabilitation), some other FES-based control strategies e.g. to restore gait in paraplegia, are still under intensive research. The proposed chapter will shortly review the FES-based applications in neurorehabilitation and then will focus on current research that aims to artificially control the human body muscles by means of FES in order to, e.g. restore gait in paraplegia, improve neurorehabilitation in stroke patients, as well as the new trends to combine FES with hand and arm orthoses and Brain-Computer Interface (BCI).

In this paper is presented the manufacturing process of an Ankle-Foot Orthosis (AFO) model for the treatment of foot drop. To recreate the model were used three-dimensional (3D) printing, three-dimensional (3D) scanning techniques and a computer-aided design (CAD) software. The final result was a prototype Ankle-Foot Orthosis for foot drop patient.

Injection-induced injury during childhood is common. The usual clinical manifestations include (1) foot drop, (2) equinovarus, (3) buttock abscess, (4) gluteal fibrosis, and (5) quadriceps fibrosis. Injection injury is more likely in newborns and small babies where the skin and nerves are in closer proximity to each other than in older children. Many of the intramuscular injections given annually in developing countries are unnecessary yet are administered due to patient or family demand and caregiver overprescription. There is a prevalent belief in traditional settings that painful injections are more powerful and effective, even when adequate and recommended oral treatments are readily available. In many African languages, the words for “fever” and “malaria” are the same, and all fevers are treated as if they were malarial.

19-year-old man was admitted to hospital with left arm weakness and altered sensation as the main complaint lasting for 24 hours and a 5 day history of altered sensation in both feet and weakness in his legs. The day before admission he realised that he could not lift his left arm above his head. He also had pins and needles in his fingertips bilaterally. He denied any head injury or other trauma. He had no recent illness including diarrhoea and vomiting. He had felt fatigued and exhausted for last 4 weeks. On examination there was bilateral ankle weakness (4+/5) with foot drop, more prominent on the right (4/5). He was not able to lift his left arm over his head (2/5 proximally). He also had some difficulties lifting his right arm over his head (especially against resistance – 3/5). There was some ataxia and dysmetria (during finger/nose testing) but likely due to weakness. Reflexes were absent in all four extremities. Cranial nerves were normal. He was not breathless during physical activity. Bulbar functions were normal. There was rather distal light touch hypoasthesia but rest of the sensory functions were normal (vibration sense, pain). His complexion was slightly pale and yellowish. He had a temperature of 37.6 °C.

The optimal strategies to treat peroneal nerve injury of multiligament injured knee remain controversial. New surgical treatment strategies are being investigated focusing on nerve transfer techniques as opposed to nerve grafts, tendon transfers, direct nerve repair or neurolysis. The nerve transfer seeks to restore ankle dorsiflexion by transferring a fascicle of the tibial nerve to the motor nerve of the anterior tibialis muscle with minimal donor-site morbidity. Nerve transfer requires multidisciplinary cooperation with surgeons familiar with peripheral nerve reconstructive techniques. This chapter will focus on our approach to complete peroneal nerve injury in patients who sustained a knee dislocation. Particular attention will be placed on the mechanism of injury, imaging, surgical technique, and a review of currently available outcomes.

The deep peroneal nerve is a branch of the common peroneal nerve that innervates foot dorsiflexors in the anterior compartment and toe dorsiflexors in the foot. It provides sensory supply primarily to the interspace between phalanges 1–2, as well as some minor supply to the articulation of the ankle. It can be injured near its origin around the fibular head, leading to foot drop, or as it passes through the anterior tarsal tunnel, leading to Anterior Tarsal Tunnel Syndrome, which presents with dorsal foot pain radiating to the lateral tarsometaltarsal joints. Conservative management is first line therapy, with surgical intervention reserved for recalcitrant or complicated cases.

72-year-old gentleman, previously relatively fit, former soldier was admitted for 1 week history of poor balance, instability and gait difficulties. He also mentioned intermittent pins and needles in his legs. There was a past history of chronic lumbar spine issues (including surgery/laminectomy L4, L5 in the past) and longstanding foot drop on the left. He said that “his legs can not bear him” now. He was seen 6 weeks before current admission by psychiatrist with conclusion of mild cognitive decline, possibly related to early Alzheimer’s dementia and he was started on Donepezil. Psychiatrist requested CT scan of his brain which was reported normal (6 weeks before current admission).

Ruptures of the tibialis anterior tendon are uncommon but will typically present after an acute injury or as either an acute or chronic foot drop. In the setting of an acute injury, the injury mechanism is typically blunt tendon trauma or laceration. Acute ruptures of a healthy tendon are rare. Atraumatic ruptures tend to occur in older individuals with underlying chronic tendinopathy. Those patients with diabetes mellitus, inflammatory arthropathy, or gout, or who are undergoing treatment with corticosteroids, are at higher risk for spontaneous ruptures. A minor traumatic event may involve an eccentric load applied to a plantar-flexed ankle.

Most of hemiplegic subjects need foot drop correction in order to decrease the risk of falling during walking. Since compensatory movements such as circumduction and steppage gait are considered to be developed to achieve foot clearance in the swing phase, such movements might be improved if enough ankle dorsiflexion is developed in the swing phase. In this paper, hip joint and ankle joint angles of a hemiplegic subject were measured during walking with inertial sensors, when FES foot drop correction was applied. As the ankle dorsiflexion angle decreased by muscle fatigue, hip flexion angle begun to increase earlier and timings of the heel off and the toe off were detected earlier, which were similar to gait movement of the subject without FES foot drop correction. These changes were considered to be a preparatory movement for achieving foot clearance by increasing hip flexion. This result suggested that the compensatory movements by the hip joint could be improved by FES foot drop correction.

Motor rehabilitation and assistance post-stroke are becoming a major concern for healthcare services with an increasingly aging population. Wearable robots can be a technological solution to support gait rehabilitation and to provide assistance to enable users to carry out activities of daily living independently. To address the need for long-term assistance for stroke survivors suffering from drop foot, this paper proposes a low-cost, assistive ankle joint exoskeleton for gait assistance. The proposed exoskeleton is designed to provide ankle foot support thus enabling normal walking gait. Baseline gait reading was recorded from two force sensors attached to a custom-built shoe insole of the exoskeleton. From our experiments, the average maximum force during heel-strike (63.95 N) and toe-off (54.84 N) were found, in addition to the average period of a gait cycle (1.45 s). The timing and force data were used to control the actuation of tendons of the exoskeleton to prevent the foot from preemptively hitting the ground during swing phase.

Total knee arthroplasty has become a very common procedure over the last decade. Patients are being treated earlier, and the severe deformities seen in previous decade are encountered less frequently. Despite this, there are occasions where the patient presents with a significant fixed deformity. A stepwise approach is required to safely deal with these severe deformities. Failure to do so may lead to skin compromise and further complicate the surgery. Once the arthrotomy is performed, in a stepwise fashion, tight structures need to be released to enable good surgical exposure. Quadriceps snip and an early lateral release are two techniques that can improve exposure. The bone cuts are also important, and often additional distal bone is resected to allow for full extension. A post-capsule release is also often required to enable achievement of full extension. Caution is needed, and patients need to be counseled when there is a severe flexion contracture as well as valgus deformity, since this deformity can be associated with a postoperative foot drop.

A 32-year-old female presents with a 2-day history of exacerbation of her chronic low back pain, left leg numbness, and a foot drop. She had a previous lumbar discectomy at left L5-S1 11 years ago. No loss of bowel or bladder function. No history of trauma. She has smoked cigarettes half pack per day for 6 years.

Foot drop or dropped foot is a common gait problem in many people with an upper motor neuron lesion such as people after a stroke, people with Multiple Sclerosis and children and adults with Cerebral Palsy. This chapter explains the action of Functional Electrical Stimulation (FES) to the pre-tibial muscles in order to treat foot drop and how it can be adapted to the walking pattern of the individual patients by altering the stimulation patterns. The potential benefits of using FES to treat foot drop, the outcome measures used to assess these benefits and evidence for these benefits for three different clinical populations form the main part of this chapter. Finally, future directions of research into FES are summarised.

A 37-year-old male presents with an 8-month history of a left foot drop. This started immediately after an accident where a piece of glass lacerated the anterolateral aspect of the left upper leg. He was seen in a local emergency room, where the wound was washed out and the skin was closed, with a report of injured nerves and muscles, but no attempt was made to repair them. Since then he has had a left foot drop and 6/10 pain on the VAS. He underwent PT with no improvement. He is wearing a brace. PMH significant for hypertension, DVT, pulmonary embolism, and hernia repairs. FH positive for diabetes in the father and colon cancer in the mother. On examination, TA 0, EHL 0, extensor digitorum 0, eversion 0, the remaining muscle groups are 5/5. There is no sensation in the outer leg below the laceration or the dorsum of the foot. He has a Tinel’s sign over the previous scar.