What is the management approach for foot palsy?

Management of Foot Palsy

The management of foot palsy requires a multidisciplinary approach with a team of specialists including neurologists, orthopedic surgeons, podiatrists, and physical therapists to optimize functional outcomes and prevent complications. 1

Initial Assessment and Diagnosis

• Perform a comprehensive foot examination including inspection of skin, assessment of foot deformities, neurological assessment using 10-g monofilament testing with at least one other assessment (pinprick, temperature, vibration), and vascular assessment including pulses in the legs and feet 2
• Test for loss of protective sensation (LOPS) using the 10-g Semmes-Weinstein monofilament at three sites on both feet, with the test considered positive if the patient correctly answers two out of three applications 2
• Use a 128 Hz tuning fork applied to the dorsal side of the distal phalanx of the first toe to assess vibration sensation, repeating proximally if the patient cannot sense vibrations at the toe 2
• Evaluate for peripheral arterial disease (PAD) through history of decreased walking speed, leg fatigue, claudication, and assessment of pedal pulses 2

Treatment Options

Non-surgical Management

• Provide appropriate orthotic devices based on severity of foot drop:

  • Ankle-foot orthoses (AFOs) for stabilization and improved gait 1
  • Well-fitted walking shoes or athletic shoes that cushion the feet and redistribute pressure for patients with neuropathy 2
  • Custom-molded shoes for patients with bony deformities who cannot be accommodated with commercial therapeutic footwear 2

• Implement physical rehabilitation:

  • Strengthening exercises for ankle dorsiflexors and functional task training for better long-term outcomes 1
  • Electrical stimulation to improve motor function in patients with chronic foot drop 1
  • Balance training to prevent falls and improve mobility 1

Surgical Management

• Consider surgical decompression for refractory cases, compressive masses, acute lacerations, or severe conduction changes 3
• Evaluate for tendon and nerve transfers in cases of failed decompression or poor prognosis for nerve recovery 3
• For foot deformities associated with foot palsy, surgical correction may be necessary when conservative measures fail 4, 5

Special Considerations for Diabetic Foot Palsy

• Optimize diabetes control with blood glucose <8 mmol/L or <140 mg/dL, using insulin if necessary 2
• Provide treatment for edema and malnutrition 2
• For diabetic foot ulcers:
  • Perform frequent wound inspection and debridement 2
  • Control exudate and maintain moist environment 2
  • Consider negative pressure therapy in post-operative wounds 2
  • For infection, cleanse and debride all necrotic tissue and start appropriate antibiotic therapy 2

Patient Education

• Instruct patients with LOPS on ways to substitute other sensory modalities (palpation or visual inspection using an unbreakable mirror) for surveillance of early foot problems 2
• Educate patients and relatives on appropriate self-care and how to recognize and report signs and symptoms of worsening infection (fever, changes in local wound conditions, hyperglycemia) 2
• Provide guidance on proper footwear selection and behaviors at home 2

Follow-up and Prevention of Recurrence

• Include patients in an integrated foot-care program with life-long observation, professional foot treatment, adequate footwear, and education once healing has occurred 2
• Schedule regular follow-up to monitor recovery and adjust treatment plans 1
• Ensure patients never return to the same shoe that caused an ulcer 2

Organization of Care

• Implement a three-level foot-care management system:

  • Level 1: General practitioner, podiatrist, and diabetic nurse
  • Level 2: Diabetologist, surgeon, vascular surgeon, podiatrist, and diabetic nurse, in collaboration with shoe-maker, orthotist, or prosthetist
  • Level 3: Specialized foot center with multiple experts from several disciplines 2

• Establish a multidisciplinary foot care team, which has been shown to reduce the number of diabetes-related lower extremity amputations 2

Common Pitfalls and Caveats

• Avoid footbaths as they induce maceration of the skin 2
• Be aware of the possible loss of buckling force of the monofilament if used for too long a period of time 2
• Do not allow the monofilament to slide across the skin or make repetitive contact at the test site during sensory examination 2
• Apply the monofilament along the perimeter of, not on, an ulcer site, callus, scar, or necrotic tissue 2
• Treatment approach should consider the mechanism of nerve injury, as functional outcomes vary significantly based on injury type 6