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An Approach to Foot Drop for Primary Care Physicians

What is foot drop?

Foot drop refers to weakness of the ankle dorsiflexors leading to an inability to lift the forefoot. This can lead to functional limitations with gait, mobility, and can be associated with chronic pain.

What are the causes of foot drop?

Most of the time, foot drop is the result of a neurological process, but a ruptured tendon involved in dorsiflexion can also be a cause. Neurological causes include the following:

  • Compression of the:
    • peroneal nerve near the fibular head (and less commonly in other locations)
    • L5 nerve root near the spine
  • Direct trauma of the peroneal nerve or its branches, especially those injuries that lead to fractures, dislocations, or deep lacerations.
  • Compartment syndrome in the leg leading to nerve ischemia
  • Neurological disorders such as Charcot-Marie-Tooth, amyotrophic lateral sclerosis, or multiple sclerosis
  • A systemic condition leading to nerve damage, such as diabetes or vasculitis

How do you evaluate a patient with foot drop?

History

  • The patient may complain of dragging their toes, problem walking or climbing stairs, or frequent tripping and falling.
  • There may be numbness in the anterolateral leg, dorsum of the foot, and/or first toe webspace.
  • Look for clues to the etiology:
    • Presence of trauma
    • Presence of back pain and/or sciatic symptoms
    • Factors that can lead peroneal nerve compression such as rapid weight loss, habitual leg crossing, and prolonged squatting.
    • Signs and symptoms of systemic conditions such as vasculitis or diabetes
    • Presence of other neurological symptoms not limited to the distribution of L5 or peroneal nerve

Physical exam

  • A thorough neurological exam of the lower extremity is required including an assessment of all dermatomes, myotomes, reflexes, and upper motor neuron signs.
  • Pay particular attention to peroneal nerve function:
    • Motor: assess for weakness in ankle dorsiflexion (deep branch), eversion, and plantarflexion (superficial branch)
    • Sensory: assess for decreased sensation of anterolateral leg, and dorsum of foot (superficial branch), as well as first webspace (deep branch)
  • The following chart of motor functions helps to differentiate between peroneal dysfunction and L5 radiculopathy:
WeakPeronealL5
Dorsiflexion (Deep peroneal)YesYes
Eversion (Superficial peroneal)YesYes
Inversion (Tibial)NoYes
Hip abduction (Gluteal)NoYes
Knee flexion (Sciatic)NoYes (medial hamstrings)

Investigations

  • Electromyography/Nerve Conduction Studies (EMG/NCS) should be ordered approximately three to four weeks after the onset of injury. If done too early, significant pathologies may be missed.
  • Imaging studies may be ordered to rule out a compressive lesion if:
    • an L5 lesion is suspected, a spine MRI should be ordered.
    • a peroneal lesion is suspected, an MRI of the leg (or an ultrasound if the suspected mass is superficial) should be obtained.
  • Serological lab tests should be ordered based on clinical suspicion of a systemic metabolic or autoimmune process.

How should you manage a patient with food drop?

  • Conservative therapy may be attempted in most patients as many cases will improve over time. These include:
    • Protect the peroneal nerve from further injury – padding around the fibular head, avoid leg crossing or prolonged squatting.
    • Physical therapy to maintain ankle and foot mobility and to prevent contractures
    • Electrostimulation of the affected muscles may help with recovery of function
    • Use of ankle foot orthosis to help with foot clearance during ambulation
  • Surgical referrals are indicated in the following situations:
    • If the foot drop developed acutely following a significant injury where a nerve transection is suspected, the patient should be referred urgently to a surgical center specializing in peripheral nerve injuries.
    • If there is evidence of severe nerve damage on EMG/NCS and/or lack of any functional recovery at three months, these patients should be referred to a surgical center specializing in peripheral nerve injuries within three to four months. They may be candidates for nerve transfer surgery if referred early.
    • If an obvious compressive mass is identified, it may be amenable to surgical excision
    • If patient continues to have functional deficits after conservative therapy, they may be referred for consideration of tendon transfer surgery (posterior tibial to lateral cuneiform or cuboid) to restore dorsiflexion

Summary: Foot drop refers to a weakness of the ankle dorsiflexors leading to an inability to lift the forefoot. The most common causes are injuries to the peroneal nerve or an L5 radiculopathy. The evaluation should focus on identifying which nerve structure is injured, the etiology of nerve injury, and to determine the extent of dysfunction. Most patients will improve with conservative therapy, but certain scenarios require timely surgical referral such as when a severe injury to the nerve is suspected.

Yuhao Shi, MD
Sports and Exercise Medicine Fellow, University of Ottawa
Advisor: Dr. Taryn Taylor, BKIN, MSc, MD, CCFP (SEM), Dip Sport Med

References:

  1. Elkwood, AI, Kaufman, MR, Abdollahi, H. Foot drop: Etiology, diagnosis, and treatment. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2021.
  2. Poage C, Roth C, Scott B. Peroneal Nerve Palsy. J Am Acad Orthop Surg. 2016 Jan 1;24(1):1–10.
  3. Nori SL, Stretanski MF. Foot Drop. StatPearls. StatPearls Publishing; 2020.

CME Opportunity for Primary Care Providers and Allied Health Professionals working in primary care

Update your knowledge on post-bariatric care and obesity management by attending this series of six ECHO Ontario Bariatric Network (OBN) sessions starting on June 3rd.  Register online at obn.echoontario.ca.  For more information contact ECHOobnadmin@stjosham.on.ca

Hold the date – Breast Imaging Update January 30, 2020

The Champlain Regional Cancer Program invites you to attend its’ annual Breast Imaging Update 2020, part of the Continuing Professional Development Series. Please find attached the poster prepared for this event and feel free to forward to your colleagues.

You can attend in person or by OTN.

Ontario Bariatric Network Offering New ECHO Training Series starting in January

Do you know how to work with your patients living with obesity who have received specialty care from the Bariatric Centre of Excellence at The Ottawa Hospital? 

A new series of 6 sessions focused on obesity management and post-bariatric care will be offered at no cost to primary care providers interested in building clinical expertise.  The sessions start on January 15, 2019, and are held bi-weekly from 12 – 1:30 pm.

Click to learn more: 2020 Curriculum ECHO Flyer The Ottawa Hospital

Project ECHO OBN is an innovative technology-enabled collaborative learning program where primary care providers and an interdisciplinary team of clinicians from the BCoE work together to discover new ways of providing care more effectively to patients with obesity.

Build clinical expertise by joining our six-week series to discuss patient cases from your practice and learn about leading surgical and medical treatment options for patients with obesity, strategies to identify and prevent potential post-operative complications after bariatric surgery as well as tools and resources to assist you to manage obesity-related issues seen in primary care.

CME Opportunity for Primary Care Providers: Cancer Update 2019

The Champlain Regional Cancer Program is pleased to invite you to Cancer Update 2019.

This annual event takes place on Friday,  December 6, 2019.

For details, please see the Cancer Update 2019 and feel free to share with others in your organization. 

Register online Now!

www.cancerprimarycare.eventbrite.ca

For more information contact Champlain Primary Care at 613-798-5555 x 15811 or cancerprimarycare@toh.on.ca

Post Bariatric Care and Obesity Management

Project ECHO® OBN
Update Your Knowledge on Post Bariatric Care and Obesity Management

The Ontario Bariatric Network (OBN) is launching an exciting new initiative Project ECHO™ OBN that partners primary care providers with a multi-disciplinary team of specialists from the Bariatric Centres of Excellence (BCOE) to share best practices on bariatric care and obesity management.

This series of 6 sessions hosted by The Ottawa Hospital begin on October 2, 2019 and is open to physicians, residents and medical students, nurse practitioners and allied health professionals working in primary care.  There is no cost to attend.

Learn about:

  • Changing practices in the surgical and medical management of patients with obesity
  • BCOE and primary care collaboration to implement the Shared Care Model
  • Obesity-related co-morbidities and treatment options
  • Evidence-based approaches to effectively manage patient complications

Managing the care of post-bariatric surgery patients can be complex.  Register soon to take advantage of this no-cost learning opportunity!

For more information on session dates, curriculum details and to register, please visit https://obn.echoontario.ca

Click to view PDF with details: ECHO Flyer with curriculum Aug 2019

 

 

Health Report Manager & EMR Practice Enhancement Program

Health Report Manager – Health Report Manager (HRM) is a digital health solution that enables clinicians using an OntarioMD-certified EMR to securely receive patient reports electronically from over 250 participating hospitals and specialty clinics, including over 30 in Champlain LHIN.

HRM electronically delivers text-based Medical Record reports, (e.g. Discharge Summary), and transcribed Diagnostic Imaging (excluding image) reports from sending facilities directly into patients’ chart, within your EMR. Once you are connected to HRM, you will also receive eNotifications, a useful digital health tool that lets you know sooner than the arrival of the discharge summaries that your patients were in the hospital.

Learn more about HRM. To sign up, please contact your local OntarioMD Practice Advisor or support@ontariomd.com.

 

EMR Practice Enhancement Program – The EMR Practice Enhancement Program (EPEP) is a complimentary provincial service designed to take an in-depth look at how you use your EMR to help you enhance your EMR skills and efficiency.

EPEP offers a current analysis of your EMR use, practice workflow and data quality to help you move beyond data capture and use information to improve patient care and practice efficiency. It provides hands-on support from Practice Advisors and Peer Leaders, who are expert EMR users, to create an enhancement plan that reflects your unique practice priorities, leading to improved workflow, efficiency and patient care.

 

Get started with EPEP today, or contact support@ontariomd.com to connect with a Practice Advisor.

OntarioMD Peer Leaders and Digital Health Events

OntarioMD Peer Leaders are a network of 60 physicians, nurses and clinic managers across the province who are expert users of OntarioMD-certified EMRs and are available to help you realize more clinical value from your EMR.

Peer Leaders understand the needs and challenges faced by busy community practices. They provide complimentary consulting services that can lead to more efficient EMR use and workflow, improved clinical decision support and much more. Peer Leaders can help you optimize your EMR’s functionality and show you how they use other features, including EMR-integrated provincial digital health tools.

Request a Peer Leader today, or contact support@ontariomd.com.

 

OntarioMD Quality Improvement Events

EMR: Every Step Conference:

    • Get more clinical value from your EMR. Learn how at the OntarioMD EMR: Every Step Conference! EMRs have become indispensable practice tools. Learn how you can take better advantage of your investment in your EMR by learning about more of its features and the latest digital health innovations integrated with it. There is so much more you can do for your patients and your practice. We’ll show you how.  This conference is for physicians, nurse practitioners, allied health professionals and administrative staff. EMR: Every Step Conference should be hyperlinked to https://www.ontariomd.ca/about-us/events/emr-every-step-conference/emr-every-step-conference-toronto-2019
      • Admission: $115.00 + HST (until August 31), $160.00 +HST (after August 31)

 

Project ECHO Ontario Skin and Wound

ECHO stands for Extensions for Community Healthcare Outcomes.

The ECHO model™ links specialist/ resource team (Hub) with primary care community-based partners (Spokes) to form the Hub and Spokesmodel.  It uses a combination of live online sessions and in-person skills training to build health care capacity. The online sessions are live 2 hours weekly and include a short educational lecture, followed by case-based learning from the participants’ own patients.

The resource team (Hub) puts together the content of the ECHO educational lectures. Participants present de-identified cases of their own patients during the live online sessions. Participants also contribute to case discussions and evaluation surveys. They also receive continuing education/ continuous professional development credits (CE/ CPD).

Through the ECHO model™, community providers and specialists learn from each other, acquire knowledge, skills, increase competency and build a strong community of practice. Participants become part of a supportive community of practice and an inter-professional team.

See: Q&A’s – ECHO Ontario Wound and Skin

We’re launching in May. Sign up below if you’re interested in no cost interprofessional skin and wound care learning surveymonkey.com/r/FM6T99B #onhealth #wounds #dermatology

What Is It?

  • FREE case-based learning on: wound bed preparation, pressure injuries (ulcers), diabetic foot ulcers, venous leg ulcers, interprofessional team building and other topics
  • No cost mentorship on skin and wound care best practices
  • Access to physicians, nurses and allied health providers who will offer you guidance on your patients with complex skin and wound care needs.

Who Should Join?

  • Health care providers based in Ontario who have an interest in skin and wound care, including nurses, physicians, and allied health providers.

Benefits for Participants

  • Enhanced care for patients with skin and wound care issues
  • Certificate of Attendance, if a regular participant
  • Continuing Medical Education (CME) Credits awarded by Queen’s University
    • Being part of an interprofessional community of practice

Details

  • Weekly 2-hour sessions: 15-minute didactic lecture, based on International Interprofessional Wound Care Course (IIWCC) curriculum, followed by a discussion of real clinical cases submitted by participants
  • Topics discussed: diabetic foot ulcers, leg ulcers, pressure injuries, wound bed prep, infection, malignant, post-surgical wounds, traumatic injuries, peristomal, lymphedema, acute infection and other wound and skin care issues
  • Hands-on learning at semi-annual boot camp sessions held across Ontario

Interested? Here’s What You’ll Need

  1. Internet connection and webcam-enabled device like a laptop or smartphone
  2. Minimum two hours per week of committed time
  3. Willingness to present your patient cases for group discussion

To Express Interest in Joining

Email:       info@echowoundskin.com

For More Information:

Visit:        https://www.echoontario.ca/Echo-Clinic/Wound.aspx

Follow on Twitter:    @ECHOWound

Integrated Cancer Screening and Prevention Program – events in your area

In the summer of 2018, the Integrated Cancer Screening and Prevention Program (ICS team) partnered with Cancer Care Ontario (CCO) to conduct a mapping exercise based on census data to identify areas where screening rates are low, for the following screening programs in the region:

  • Ontario Breast Screening Program (OBSP)
  • ColonCancerCheck (CCC)
  • Ontario Cervical Screening Program (OCSP)
  • Lung Cancer Screening Pilot for People at High Risk (HR LCSP) pilot

The ICS team also conducted an environmental scan focusing on primary care providers, cancer screening managers, and most importantly, patients, to identify and understand challenges to cancer screening. We are now reaching out to regional stakeholders in order to work together to develop improvement initiatives focused on increasing screening rates and facilitating healthier populations. For this reason, we would like to invite you to a series of information sessions being held in key areas including Hawkesbury, Cornwall, Petawawa, Pembroke and Renfrew.

To learn more about the impact you can have on the screening rates for the four cancer screening programs in the Champlain region, we invite you to register for an event in your area.

 

Area Date Time Location
Pembroke March 4, 2019 17:30 Carefor Health & Community Services: 700 MacKay St.
Renfrew March 18, 2019 17:30 GEM Hall: Groves Park Lodge,127 Raglan St. S
Cornwall March 19, 2019 17:30 The Cornwall Knights of Columbus Hall: 205 Amelia St.
Hawkesbury March 25, 2019 17:30 Stephanie’s Grill and Bar: 1680 Highway 34

To register for an event or for further information regarding the sessions, please call: 613-798-5555 ext. 15811 or email me: jdeloe@toh.ca.

We thank you for your support in working together to improve screening rates and promoting healthier populations in your area.

 

View the bilingual letter with the above information