Avoiding Crippling Cases Of Drop Foot With Early Diagnosis

Stephen Barrett DPM FACFAS

“Inspector,” I said, peering down at the drooping appendage, “who did this?”

The professorial detective looked up at me, shaking his head in utter disgust. Slowly turning away from the gory sight of the dangling drop foot, he cleared his throat with a loud, guttural noise. “You ask the wrong question, sir,” he snapped. “’Who’ is less important than ‘What’ in this case. Ignorance is to blame. Ignorance and its insidious cousin, Super Ego.”

I shook my head sadly because I too had seen that combination in an excessive number of cases and the almost certain damaging results. I lifted the yellow crime scene tape that surrounded the area and walked back to my clinic, reflecting on everything I just witnessed.

There are a lot of doctors who need to wake up and do it right now. The fact is that because these doctors are truly sleepwalking through every day in their clinics, many patients are now unable to walk normally. These patients are literally tripping with every step they take due to a drop foot condition, which in most cases could have received effective treatment with early diagnosis.

Many of these patients (victims) are incredibly impaired and have had their lives indelibly altered in such a negative way to the point where they are simply crippled. They are victims of a crime — not that they were stabbed or shot, or something heinous like that — but a crime nonetheless. They happened to be unfortunate enough to have gone to an ignorant physician and listened to him. In many cases, patients visited a whole cadre of imbeciles masquerading as doctors who took them down a treatment course that obviated definitive and simple and, most of the time, effective treatment. That is a crime, albeit one that is not on any state statute, but indeed a moral crime at the very least.

I suspect this crime goes unrecognized and unreported in many cases, and I want that to change. I see one or two of these “victims” monthly and just this week had a case that has me virtually to the point of going “postal.” (Going postal isn’t good — going Fed Ex would be better. That would be a real crime … I better just rant instead. By the way, is ranting still allowed in the United States?)

I will give a more detailed description of the crime “scene” but first I am going to do some perpetrator profiling. Yes, I used the “P” word: profiling. These criminals — excuse me, providers — come from all specialties, ranging from family practice to neurology and podiatry. You can throw orthopedics in there as well. As with all ill deeds of society, there is nothing black and white. Maybe there are 50 shades of gray as some of my female colleagues tell me? Certainly, one could almost excuse ignorance of this assault on the common fibularis nerve depending on the specialty. We cannot know everything about everything unless, of course, physicians refuse to refer. In these cases, Super Ego should do some hard time.

But I digress. The hematologist would get a pass and not have to go to jail for missing this, but the orthopedist who has a patient complaining of an inability to dorsiflex the foot after a total knee replacement and tells the patient that “nothing is wrong” or “that’s just something you will have to put up with” should do some real hard time, some bring-back-the-chain-gang hard time. This is egregious.

“You just stretched the hell out of this patient’s knee, jammed $30,000 worth of metal in there and you have no idea why she can’t raise her foot? Do you think you could have stretched the common fibularis nerve? Any possibility that could happen, doctor? Do you even know that nerve is there?”

True Story: When Hip Replacement Led To Drop Foot

Now let us move on to one of the crime scene reports. Sadly, there are many. This is the true story of one of my patients and illustrates my point completely.

When I was a young girl, 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 to tear away my cartilage and dislodge my kneecap. I was carried away by wheelchair 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 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 where it required me to seek medical intervention. My family physician took X-rays of both my knee and back. He informed me that my arthritic knee was causing me to limp and that my hip was showing slight arthritic changes due to overuse. He referred me to an orthopedic specialist. The orthopedic specialist advised surgery to repair the knee. Unfortunately, after the first surgery, that surgeon said he could not repair my knee and advised me to receive a total knee replacement at my earliest convenience.

I made the decision to wait.

Several years later, at the age of 45, I decided to seek a second opinion. 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, 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 arthroplasty would need to occur first to ensure the best possible outcome for the new knee.

During the summer of 2010, I underwent the total hip arthroplasty. My medical records state “The procedure went well without complications noted.” Upon being moved from the post-anesthesia care unit (PACU) to a room, the nurses applied anti-embolism stockings and an abduction pillow. I was in pain all day complaining of a pins and needles-like sensation with shooting and stabbing pain in my foot. Later that night, when my doctor performed his “rounds,” he noted a “partial motor palsy (peroneal) left.” He gave me methylprednisolone (Solu-Medrol, Pfizer), 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.”

I was released five days later with drop foot, an ankle foot orthotic (AFO), nerve pain and mental anguish. I couldn’t stand because my foot was turned down and inward, and it hurt. Lying 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.

At the four-week mark, my first post-op visit, I complained about the drop foot and asked for electromyography (EMG) to find out if any nerves were damaged beyond repair. My doctor told me I had to wait eight weeks because “these things happen” and “usually resolve themselves” within eight weeks.

Four weeks later, I had not improved and requested an EMG, which a neurologist performed. He reported my results as nerve death and told me that nothing could 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. Awkward but accurate 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 was no better and now the leg and foot had atrophied. I walked with an AFO, had nagging back pain, went to physical therapy three times a week, and took both pregabalin (Lyrica, Pfizer) and celecoxib (Celebrex, Pfizer) in an attempt to improve my function. I researched my issue and asked my doctor to refer me to a nerve specialist. More EMG studies showed that the nerve was not favorable for regeneration.

After much discussion with the specialist, we decided that I should have a left peroneal nerve neurolysis and decompression in the region of the fibular head. At 16 months, my doctor performed the operation. The incision was vertical, 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, but due to being done incompletely, I did not regain maximal function.

I am at two-and-a-half years postoperative 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 had nerve decompression and was able to walk out of the recovery room. I have met the daughter so I know this to be true.

I had successful nerve decompression. Immediately, my blood flow was restored and over time, my ability to move my foot to the left (eversion) had completely returned.

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. If my doctor had taken me back to surgery that same day and decompressed my damaged nerve, I might be living my best life today.

Keys To Properly Addressing Drop Foot

So what does this report tell us?

• If there is a drop foot present after any surgery, address it within three months with nerve decompression if there is not constant and consistent improvement.

• Do not rely on electrodiagnostic testing. You cannot hurt anyone with a properly performed neurolysis in this situation.

• Both the orthopedist and the neurologist dropped the proverbial ball several times.

The inspector came back later to my office to discuss the crime scene that had finally been closed and told me his conclusion. “Ignorance” is everywhere in every specialty and the only way to fight this ubiquitous criminal is to educate him incessantly.

With regard to the podiatric medical profession, I think ignorance is only part of the problem. The other side is fear. So I challenge you, colleagues: What are you afraid of?

Education and training would enable you to become a nerve superhero. Sadly, very, very few of you take advantage of these opportunities. You stick your head in the sand, basking in your own ignorance, or mumble something vaguely about “scope of practice” and scurry away. Or you commit the greatest sin of all: just continuing to do the same old, same old and hope one day that it actually works. Alternately, you could go to the Association of Extremity Nerve Surgeons national meeting in Houston this November.

Important Questions To Ask In The History Of Present Illness With Foot Drop

1. When did the symptoms first present?
A sudden onset in a young patient without trauma should be a warning sign for a central nervous system lesion.
2. Do you have a history of any trauma on the affected side?
Most unilateral entrapments are related to a past history of either severe or repeated ankle sprains.
3. Do you have any metabolic disease?
Diabetes, syndrome X (insulin resistance syndrome) and other metabolic diseases are commonly associated with any lower extremity peripheral nerve entrapment.
4. Do you notice any loss of strength or that your foot tends to slap the floor while walking?
This is a good indication that there is a high degree of peripheral nerve damage due to entrapment as the A-alpha (motor) fiber is the most robust when a focal entrapment exists.
5. Do you have any shooting pains, numbness or tingling that radiates down toward your toes?
These are classic descriptors or signs of peripheral nerve entrapment.
6. Do you or have you had a history of low back pain or sciatica?
A positive response to this question should make the provider more aware during the examination to rule out a spinal etiology for the pain, and also realize that there may be a double crush phenomenon, which is very common.
7. Has the patient had knee replacement or other knee or hip surgery on the affected leg?
It is common for the common peroneal nerve to be more susceptible to entrapment after these types of surgery as there is usually some degree of distraction required which can damage the nerve.

Comments

Dr. Barrett hits the point right on the head! Misdiagnosis by multiple physicians is a form of negligence and is seen constantly.

Take heel pain for example. I see Haglund's deformity patients who have had surgery by an orthopedist or podiatrist, and had continued pain in the heel. The returning patients are frustrated as they have put in months trying to get relief but their pain is actually worse. The role of posterior tibial nerve with sural nerve entrapment is a common cause for this location of pain. There are so many other situations where the overly qualified podiatrist is trying to do a 'big' procedure but forgets the basics in checking for peripheral nerve entrapment.

Well said Dr. Barrett.

Great article. I too have witnessed this firsthand with my mother and others.

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