CASE REPORT

Musculoskeletal Dysfunction and Drop Foot:

Diagnosis and Management Using Osteopathic Manipulative Medicine
John M. Lavelle, DO
Mark E. McKeigue, DO

Drop foot arises from dysfunction within the anatomic, mus- ground during heel strike. To avoid foot drag, an individual
cular, or neurologic aspects of the lower extremity. The with steppage gait will walk with exaggerated hip and knee
authors describe a patient with drop foot who had a com- flexion to clear his or her affected foot from the ground during
pressed common peroneal nerve caused by posterior fibular swing phase.4,5
head dysfunction. One 15-minute session of osteopathic As noted by Pritchett,6 “Peroneal neuropathy caused by
manipulative treatment resolved the patient’s symptoms. It compression at the fibular head is the most common com-
is important for physicians to use osteopathic manipulative pressive neuropathy in the lower extremity. Footdrop is its
medicine to diagnosis and manage this condition, particularly most notable symptom.” In the present report, we describe a
when it results from fibular head dysfunction. patient who developed drop foot secondary to posterior fibular
J Am Osteopath Assoc. 2009;109:648-650 head dysfunction. However, unlike many published reports of
drop foot,1,2,7 the condition was diagnosed and managed using
osteopathic manipulative medicine.

D rop foot can arise from various musculoskeletal or neu-

rologic etiologic processes. The condition involves the
muscles of foot dorsiflexion (tibialis anterior, extensor hallucis
Report of Case
A 47-year-old white man presented to the primary care office
longus, and extensor digitorum longus) and the nerves that noticeably dragging his left foot. He stated that he could not
supply them, primarily the common peroneal nerve. lift up his left foot. He had no trauma to his left leg. How-
Common causes of drop foot include compartment syn- ever, he had driven 5 straight hours in his automatic trans-
drome, diabetes, stroke, lumbar disc protrusions, muscu- mission car the night before and stated that his left leg was bent
loskeletal compression, myopathies, neuropathies, and periph- for most of the car ride. On exiting the car, he noticed some
eral nerve injuries.1-3 numbness and tingling in his left leg. When he awoke the
During the swing phase of heel-toe gait cycle, the muscles next morning, he was unable to raise his left foot.
of dorsiflexion work as agonists and allow the foot to clear the The patient denied having any similar episodes in the
ground. During heel strike of the stance phase, these muscles past and denied any pain. He had not taken any pain medi-
work as antagonists and control plantar flexion of the foot. cation for the numbness and tingling. Attempts at stretching
Injury to the muscles of dorsiflexion or their nervous supply his leg muscles gave no relief.
can cause drop foot and corresponding steppage gait—also The patient had no history of diabetes or muscular, neu-
known as drop-foot gait. In individuals with drop foot, the rologic, or vascular problems. His medical history included
plantar flexors have no resistance and cause the foot to remain hypertension and hypercholesterolemia, which were man-
in plantar flexion during swing phase, therefore not allowing aged with lisinopril and atorvastatin calcium, respectively.
the toes to clear the ground and causing them to slap to the The patient did not smoke tobacco and had no hypersensi-
tivities.
Physical examination revealed a physically fit man with
a pleasant disposition and stable vital signs (blood pressure,
From Boston University Medical Center in Massachusetts (Dr Lavelle) and 124/78 mm Hg; body temperature, 98.2⬚F; heart rate, 67 beats
from Midwestern University/Chicago College of Osteopathic Medicine in per min; respiratory rate, 14 breaths per min). He ambulated
Downers Grove, Illinois (Dr McKeigue). Dr Lavelle was an osteopathic med-
ical student at Midwestern University/Chicago College of Osteopathic Medicine with a steppage gait. Heart, lung, and abdomen examinations
at the time of manuscript submission. were unremarkable.
Financial Disclosures: None reported. On musculoskeletal examination of the extremities, the
Address correspondence to John M. Lavelle, DO, Boston University Med-
ical Center, Rehabilitation Medicine, Preston Family Building, 5th Floor, 732 patient had normal pulse on palpation (2+ pulses) bilaterally
Harrison Ave, Boston, MA 02118-2309. in the upper and lower extremities. Manual testing revealed
E-mail: [email protected] 5/5 muscle strength throughout the right lower extremity and
Submitted March 4, 2008; revision received August 4, 2009; accepted August 17, 1/5 muscle strength in the left lower extremity with ankle
2009. dorsiflexion and eversion. Sensation was absent to light touch

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 CASE REPORT

and two-point discrimination along the dorsum of the left Although the patient in the present report was not squatting
foot at the L5 and S1 dermatomes. Deep tendon reflexes were and denied leaning his left leg against the car door, we believe
1/4 at the Achilles and patellar tendons on the left lower that the prolonged bent position of his left leg may have caused
extremity and 2/4 on the right lower extremity. drop foot.
On osteopathic musculoskeletal examination, the patient The fibula has reciprocal movements of the fibular head
had left posterior fibular head dysfunction with tenderness proximally and the stylus of the fibula distally. When the
on palpation of the left common peroneal nerve. The patient fibular head translates posteriorly, the stylus of the fibula
had tight biceps femoris muscle with lateral hamstring Jones’ translates anteriorly. This motion occurs when the foot is in
tender points,8 bilaterally. The patient also had hypertonic plantar flexion. If the fibular head was maintained in a poste-
psoas major and minor muscles bilaterally. rior position, then the ankle would be restricted in dorsi-
The patient was diagnosed as having drop foot secondary flexion.12,13 As described in the present report, the patient was
to common peroneal nerve impingement from posterior fibular unable to dorsiflex his foot, providing evidence that he had a
head dysfunction. With the patient in a prone position, osteo- posterior fibular head dysfunction.
pathic manipulative treatment (OMT) was applied using The biceps femoris muscle has a long head, which origi-
muscle energy for the psoas and hamstring muscles and deep nates from the ischial tuberosity and sacrotuberous ligament,
articulation for the posterior fibular head. and a short head, which originates from the linea aspera and
While the fibular head was articulated, the patient noted the lateral supra condyle of the femur.14 Insertion of this muscle
discomfort but then stated that his foot was getting “warm is on the head of the fibula and the lateral condyle of the tibia.
and tingly.” Articulation was continued for about 1 minute. In normal functioning, the biceps femoris muscle provides
Total OMT lasted approximately 15 minutes. On re-evalua- flexion and lateral rotation of the leg at the knee.14 However,
tion, the patient had improved sensation along the dorsum of hypertonicity of this muscle could place a posterior draw on
his foot and demonstrated left foot dorsiflexion with 4/5 motor the fibular head, causing the common peroneal nerve to be
function. compressed,15 as described in our patient.
The patient was directed to use exercise band routines In the present report, muscle energy to the psoas and
to strengthen the dorsiflexors and evertors of his left ankle. He hamstring muscles and deep articulation to the fibular head
was able to walk out of the office without steppage gait. The resolved the patient’s symptoms. Therefore, the cause of this
next day, he telephoned the office and stated that he had com- patient’s symptoms was likely secondary to his tight bicep
plete range of motion, strength, and sensation in his left foot. femoris muscle, causing the fibular head to be pulled posteri-
orly. The posterior fibular head then caused compression of the
Comment common peroneal nerve, leading to drop foot.
Drop foot may occur with injury to the muscles of dorsiflexion
or along the nervous pathway of these muscles. The sciatic Conclusion
nerve develops at the lumbrosacral plexus and travels through In the present report, proper musculoskeletal examination
the greater sciatic foramen, located 80% of the time beneath the identified areas of dysfunction, therefore avoiding the use of
piriformis muscle, and continues along the posterior aspect of unnecessary diagnostic studies such as laboratory tests, radio-
the thigh. It divides to form the common peroneal and tibial graphy, magnetic resonance imaging, nerve conduction studies,
nerves above the popliteal fossa of the knee. and electrophysiologic tests.16 The patient had immediate
The common peroneal nerve travels laterally to wind relief of symptoms and normalization of his gait from a simple
over the posterior aspect of the fibular neck, dividing into the yet precise OMT technique without the need of more expen-
superficial and deep peroneal nerves. The superficial peroneal sive treatment modalities, such as ankle foot orthosis, medi-
nerve supplies the peroneus longus and brevis muscles and cations, or invasive treatments (eg, nerve root blocks, spinal
provides sensation to the anterolateral aspect of the leg and the decompression, tendon transposition).1,3 Osteopathic physicians
dorsum of foot.9 The deep peroneal nerve supplies the anterior with a strong knowledge of anatomy will be able to optimize
tibial, extensor digitorum longus, and extensor hallucis longus osteopathic diagnosis and OMT, which can provide cost-effec-
muscles and supplies sensation to the web space between the tive patient care.
first and second toes.10
The common peroneal nerve runs a superficial course, References
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compressed at the fibular neck after prolonged squatting.11 trophysiological review. J Neurol Neurosurg Psychiatry. 1976;39:1162-1171.

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JAOA Call for Case Reports

To advance the scholarly evolution of osteopathic medicine, JAOA—The Journal of the American
Osteopathic Association invites osteopathic physicians, researchers, and others in the healthcare pro-
fessions to submit case reports relevant to osteopathic medicine.
In preparing submissions, authors should adhere to the JAOA’s “Information for Contributors,”
which is available online at http://www.jaoa.org/misc/ifora.shtml.
Submissions should be e-mailed to [email protected] with the subject heading “JAOA Call
for Case Reports.”

650 • JAOA • Vol 109 • No 12 • December 2009 Lavelle and McKeigue • Case Report

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