What treatment recommendations or referrals are suggested for a 26-year-old male with a history of left ankle/tibial surgery, follow-up electromyograms (EMGs) showing fibular nerve damage and transection of the nerve feeding the hallux, presenting with foot drop?

From the Guidelines

For a 26-year-old male with foot drop due to fibular nerve damage and hallux nerve transection following ankle/tibial surgery, I strongly recommend a comprehensive approach including both non-surgical and potential surgical interventions, prioritizing referral to a peripheral nerve specialist or neurosurgeon for evaluation of surgical options such as nerve transfer, nerve grafting, or tendon transfer procedures, as these are most effective when performed within 12-18 months of injury, as suggested by the most recent guidelines 1.

Initial Management

The patient should be fitted with an ankle-foot orthosis (AFO) to improve gait mechanics and prevent falls by maintaining the foot in a neutral position during walking, as supported by recent recommendations 1.

• Physical therapy focusing on strengthening the anterior compartment muscles, range of motion exercises, and gait training should be implemented 2-3 times weekly for at least 8-12 weeks.
• For nerve pain, if present, medications such as gabapentin (starting at 300mg daily and titrating up to 300mg three times daily as tolerated) or pregabalin (75mg twice daily) may be beneficial.

Specialist Referral

Referral to a peripheral nerve specialist or neurosurgeon experienced in nerve repair techniques is crucial for evaluating candidacy for surgical interventions, as emphasized by the need for timely intervention to maximize recovery potential 1.

• Consultation with a rehabilitation medicine specialist (physiatrist) would be valuable for comprehensive management, incorporating physical medicine evaluation and PT/OT rehabilitation/mobility specialty consultation as recommended 1.
• The patient's specific condition, including the transection of the nerve feeding the hallux, necessitates a tailored approach that may include functional electrical stimulation (FES) as an adjunct to traditional ankle-foot orthoses for managing foot drop, given their equal effectiveness as suggested by recent guidelines 1.

Ongoing Care

The multidisciplinary approach should address both functional limitations and potential nerve recovery, considering that peripheral nerves regenerate slowly at approximately 1mm per day, and complete spontaneous recovery may not occur with severe injuries like transection.

• Regular follow-up with the healthcare team is essential to monitor progress, adjust the treatment plan as necessary, and ensure the patient receives the most appropriate care for their evolving needs, incorporating the latest recommendations from stroke rehabilitation guidelines 1.

From the Research

Treatment Options for Foot Drop

• Ankle-foot orthoses (AFO) are a helpful device that enables patients to walk better and more safely 2, 3
• Surgical treatment options include neurolysis of the nerve, "end to end" repair, autogenous nerve graft procedures, nerve transfers, direct neuromuscular neurotization, and tendon transfers 3
• Nerve transfer to the deep peroneal nerve is a feasible and effective method of treating deep peroneal nerve injuries of less than 1-year duration 4
• Double nerve transfer from the tibial to the deep peroneal nerve is a novel technique for foot reanimation in patients with neurologic foot drop 5

Referral Recommendations

• Patients with foot drop should undergo a meticulous neurological evaluation to ascertain the site of the lesion 2
• Nerve conduction and electromyographic studies are useful adjuncts in localising the site of injury, establishing the degree of damage, and predicting the degree of recovery 2
• Imaging studies such as ultrasonography, CT, and MR imaging are important in establishing the cause of foot drop 2
• Referral to an orthopedic or neurologic specialist may be necessary for further evaluation and treatment 3, 6

Specific Considerations for the Patient

• The patient's history of L ankle/tibial surgery and follow-up EMGs showing nerve damage to the fibular nerve and transection of the nerve feeding the hallux should be taken into account when considering treatment options 2, 3
• The patient's foot drop is likely due to the nerve damage, and treatment options should be tailored to address this underlying cause 2, 3