Drop Foot can be caused from many things ranging from a tumor in the brain or spinal cord, to something as simple as a bad ankle sprain. Fortunately, a drop foot is usually caused by an entrapment of the Common Peroneal Nerve knee the knee joint, which is relatively simple and straight forward to correct. If you develop a drop foot, you should seek attention immediately, and have a lower extremity peripheral nerve surgeon evaluate your condition if it has been ruled out that there is no “central” (stroke, brain injury, spinal injury, etc.) reason for this to occur. The longer one waits for treatment the more likely the outcome will NOT be a full recovery. We can usually restore almost complete function if the problem is addressed before 12 months after the injury.
This is a letter from one of my patients that I think will help those who have this condition to seek help early and gives a great illustration into how this problem can develop and what can be done:
When I was a young girl, around the age of twelve, I sustained a knee injury that would affect me for the rest of my life in ways that I never dreamed possible.
In 1978, I was cheerleading at a sporting event when I landed a jump a little off balance. This event tweaked my knee enough tear away my cartilage and dislodge my kneecap. I was carried away by wheel chair and found myself in surgery a few hours later with a four-inch zipper like incision constructed to remove all of my cartilage. My leg was casted several times over the next six months, leaving it skinny and weak. With no post injury physical therapy, my leg remained smaller than normal and my knee never completely healed thus leaving me with a slight limp.
Over the years, my knee ached and my low back (L5 – S1) began to nag at me to the point that required me to seek medical intervention. My family physician took x-rays of both my knee and back. He informed that my arthritic knee was causing me to limp and that my hip was showing slight arthritic changes due to over use. He referred me to an orthopedic specialist. After seeing this specialist, I was promptly scheduled for knee surgery to repair the damage created from years of bone on bone use. The surgery lasted only minutes. The surgeon said that he could not repair my knee and advised me to receive a total knee replacement at my earliest convenience.
Unable to come to grips with a prosthetic knee, due to my young age, I made the decision to wait.
Several years later, at the age of 45, I decided to seek a second opinion. I did my research and found what appeared to be on paper the best orthopedic surgeon for the job. I met with this doctor in 2009. His first impression of my limp was that I had a hip problem primarily and a knee problem secondarily. He took x-rays of both and informed me that my hip was a lot worse than my knee. He recommended a total hip arthroplasty (THA) stating that I would be as good as new in eight weeks at which time we would discuss the new total knee. He further explained that the hip would need to be done first to ensure the best possible outcome for the new knee.
I continued to live my normal life: teaching, swimming, hiking, waterskiing, and playing with my dog with constant pain for eleven more months at which time I decided to put my trust in this doctor to “fix” me because being restored to good as new sounded very suitable to me! My family and I took one last trip to the lake for the summer where I waterskied and hiked one week prior to the surgery.
During the summer of 2010 the THA was performed. My medical records state “the procedure went well without complications noted”. Upon being moved from the PACU to a room, the nurses applied antiembolism stockings and an abduction pillow. My husband reports that I was in pain all day complaining of pins and needles, with shooting and stabbing in my foot. Later that night when my doctor performed his “rounds”, he noted a partial motor palsy (peroneal) L. He gave me one round of Solumedrol x1 and promptly removed the abduction pillow strap from around my legs and detached the pillow. The next day my chart noted decreased sensation to the deep peroneal nerve and inability to dorsiflex the foot with an obvious partial motor palsy – a steroid bolus was given. During this stay other terms noted in my chart were: decreased sensation between the first and second toes, decreased eversion and long toe extension, EHL out, and foot is cold. Medications were given for muscle pain such as Oxycodone but nothing for nerve pain making my time at this hospital very painful.
I was released five days later with foot drop, an AFO, nerve pain and mental anguish. I couldn’t stand vertically because my foot was turned down and inward and it hurt. Laying in bed was painful because my foot flopped forward and down, causing tension on my tendons. I was in constant pain from the feeling of thousands of bees stinging my leg and foot plus the burning and pins and needles feeling. I encountered blood-circulating problems, which also made it difficult to stand. Life was looking grim for me.
I started calling my doctor’s office the day after I was released because of the pain. To no avail, he had left the country the night of my surgery and left his PA in charge of me. I began to tell my friends about my pain and one friend told me that it sounded like nerve pain. The PA called me two days later which felt like a year due to the pain and I asked her for nerve pain medicine. She prescribed if for me and it worked to take the edge off. It is hard for me to believe that my doctor, the nurses… did not prescribe this for me while I was admitted. They kept me for two extra days due to uncontrolled pain!
My first appointment with my doctor was at the four-week mark. I complained about the drop foot and asked for an EMG to find out if any nerves were damaged beyond repair. He told me that I had to wait eight weeks because these things happen and usually resolve themselves within eight weeks.
Four weeks later I visited with my doctor. I had not improved and requested an EMG. The EMG was performed by a Neurologist from the same group as my doctor. He reported my results as nerve death and told me that nothing can be done for me.
I met with my doctor several times over the next few months. He said that he stretched my sciatic nerve and that I am affected at the peroneal nerves. At six months post op, he recommended and performed a left sciatic, tibial, peroneal exploration and neurolysis at the level of the hip with intraoperative nerve conduction studies/EMG. He concluded that the peroneal nerve was functionally in continuity at this level.
One year later, I am no better and now the leg and foot has atrophied. I walk with an AFO, have nagging back pain, have physical therapy three times a week, take lyrica and Celebrex and try to improve my function. I have researched my issue and ask my doctor to refer me to a nerve specialist. He gives me the phone number to his friend at the Mayo Clinic. More EMG studies are taken and show that the nerve is not favorable for regeneration. After much discussion with the Mayo specialist, it is decided that I should have a left peroneal nerve neurolysis and decompression in the region of the fibular head. At sixteen months, my doctor performed the operation. The incision was made vertically, which obscured his vision resulting in a partial decompression. Upon waking up in the recovery room, I was able to move my foot to a neutral position. This surgery worked – a little due to not being done correctly.
I’m at the two year mark now post operatively. I meet with my doctor about every six weeks. Each time we meet, he tells me to give it three more months. My leg and foot look like they are wasting away, I can not walk with out an AFO, my short memory is shot due to the nerve medicine and I am frustrated, sad and desperate for a cure.
I ask my doctor one more time what happened to me in surgery? He said that he now believes that I incurred a double crush effect. He explains that he put a mild stretch on my sciatic nerve and when the nurse applied the abduction pillow, it put too much stress on my peroneal nerves which resulted in nerve death. He told me that the nerves regenerate about one mm per day, about an inch per month and that they must regenerate from my hip. I think my leg is a little more than three feet long meaning that I will heal in three years, right? Wrong.
I am at two and a half years post operatively when a friend of mine starts giving me a hard time about staying with a doctor who can’t help me. She proceeds to tell me about her daughter, a soccer player who injured her foot during a soccer game at the age of 23. Her daughter had drop foot and she took her to Dr. Barrett. Dr. Barrett did his magic and she was able to walk out of the recovery room. I have met the daughter so I know this to be true. My friend dials Dr. Barrett’s number, hands me the phone and says “make the appointment”. I did and that is how I began to finally make some progress.
Dr. Barrett assessed me and determined that I needed a peroneal decompression in three places. The procedure was performed successfully. Immediately my blood flow was restored and over time my ability to move my foot to the left (eversion) had completely returned. Unfortunately my anterior tibialis tendon was also pulled out, during the 2010 THA surgery. Dr. Barrett repaired it by braiding it back together. It has been eight months since the repair and as of this writing, I still unable to dorsiflex my foot.
In conclusion, my early knee surgery lead to a hip replacement later in life. The hip replacement did not go as planned leaving me with drop foot. My knee still needs to be replaced but has been put on indefinite hold due to my peroneal nerves being compromised. I have not been able to due many things that I love like: teach, hike or water ski in three years. If my doctor had taken me back to surgery that same day and decompressed my damaged nerve, I may be living my best life today.
- Effort must be taken to repair cartilage versus removing it.
- Physical therapy is a must after surgery, skipping this vital piece of rehabilitation can result in life long issues.
- If you as a doctor do not know how to help your patient, you must refer them to some one else – do not string them along until it is too late.
- As a patient, if your doctor does not have a plan to help you, MOVE ON!
The biggest mistake I made, besides having the surgery in the first place was staying with a doctor who could not help me. Please help me get the word out that in some cases drop foot can be fixed if dealt with in a timely manner.
- Orthopedic surgeons, if you stretch a patients nerve and they encounter drop foot, call Dr. Barrett ASAP and let him help your patient because he knows the technique needed to repair the damage. The window of opportunity is small please don’t wait.
Thank you for reading my story.