Published online: 2019-05-24

THIEME
100 Review Article

Tendon Transfers in Foot Drop

Sridhar Krishnamurthy1  Mohamed Ibrahim1

1 Institute for Craniofacial Aesthetic and Plastic Surgery, SRM Address for correspondence Sridhar Krishnamurthy, MS, MCH,
Institute for Medical Sciences, Chennai, Tamil Nadu, India Institute for Craniofacial Aesthetic and Plastic Surgery, SRM Institute
for medical sciences, No.1 Jawaharlal Nehru road, Vadapalani,
Chennai 600026, Tamil Nadu, India (e-mail: srid.subha@gmail.com).

Indian J Plast Surg 2019;52:100–108

Abstract The common peroneal nerve is the most commonly injured nerve in the lower extremity.
Peroneal nerve pathology results in loss of dorsiflexion at the tibiotalar joint, loss of ever-
Keywords sion at the subtalar joint, and loss of extension of toes resulting in foot drop. The varied
►►foot drop etiology of the problem is discussed. The various treatment modalities like conservative
►►tibialis posterior management, steroid therapy, nerve decompression, nerve repair, or reconstruction are
transfer described, but due to uncertain outcomes after primary nerve p ­ rocedures, secondary
►►tendon transfer for procedures like tendon transfers often end up as definitive treatment. The rationale and
foot drop technique of tibialis posterior transfer is discussed in detail.

Common peroneal nerve is the most commonly injured callosity and ulceration developing on the lateral aspect of the
nerve in the lower limb1 and commonly manifests with foot foot as inversion is maintained by the tibialis posterior muscle.
drop. Peroneal nerve pathology results in loss of dorsiflexion In partial lesions, the superficial branch is commonly spared
at the tibiotalar joint, loss of ankle eversion at the subtalar and hence eversion of the foot is preserved. The decision to
joint, and loss of extension of toes which is much more com- perform tendon transfer depends on whether only the anteri-
plicated than what the term “foot drop” conveys. or group is involved or if both the anterior and lateral groups
During normal walking, heel strike and swing phase are are involved.
two important phases. When the heel strikes the ground,
the ankle is kept in either neutral position or in minimal
Etiological Factors
extension. Then, during swing phase the toes must clear the
ground, which requires active extension of the toes and the Both neurological and muscular involvement can produce
ankle to be held in neutral position. In patients with peroneal foot drop. Among the neurological factors, common peroneal
nerve palsy, these motors are absent and the patient slaps nerve neuropathy (of idiopathic etiology), diabetic neuropathy,
the foot on ground in heel strike and drags the toe along the ­compression at the level of the neck of the fibula, lumbar disc
ground in swing phase. To avoid this, the patient flexes the prolapse, and nerve injury form the bulk of neurologic etiologies.
hip more than normal to lift the entire foot and toe off the In leprosy, the nerve gets compressed at the site where it winds
ground as if he is walking up the stairs (high stepping gait).2 around the fibular neck. At this place the nerve is also suscepti-
ble to injury as it lies comparatively superficially. Tumors of the
nerve or fibula, cerebral palsy, p
­ oliomyelitis, multiple sclerosis,
The Anatomical Basis
Charcot–Marie–Tooth disease, stroke, and spinal cord lesions are
The common peroneal nerve winds around the neck of the some of the other causes. Muscle i­njury, rupture of the tibialis
­fibula and divides into superficial and deep branches (►Fig. 1). anterior tendon, compartment syndrome, muscular dystrophy,
The superficial peroneal nerve supplies the ­peroneus longus and amyotrophic lateral s­ clerosis are some of the muscular caus-
and brevis muscles and continues as sensory branch. Hence, it es. In a multi centric study done in Italy, the aetiology and pre-
is also called as the musculocutaneous nerve. The deep branch disposing factors of common peroneal nerve mono-neuropathy
supplies the tibialis anterior, extensor d
­ igitorum, extensor hal- were studied. It was found that in 16% of patients, the cause
lucis, and peroneus tertius muscles. Consequently, in lesions of peroneal mono-neuropathy was idiopathic, 20.3% patients
of the common peroneal nerve there is also loss of eversion of had developed neuropathy after surgery around the knee and
foot. In long-standing cases, especially in leprosy, we can see trauma was the cause in 11.6% patients, surprisingly weight

published online DOI https://doi.org/ ©2019 Association of Plastic

May 24, 2019 10.1055/s-0039-1688105 Surgeons of India
ISSN 0970-0358.
 Tendon Transfers in Foot Drop  Krishnamurthy, Ibrahim 101

and to examine the efficacy and safety of adjuvant or new

t­ herapies for treating nerve damage in leprosy.11

Nerve Surgery
Primary nerve surgery for patients with foot drop includes
neurolysis or decompression, primary repair, nerve
­grafting, or nerve transfer. Nerve decompression aims to
relieve m ­ echanical compression due to edema secondary
to neuritis. Surgical decompression is indicated in lepro-
sy patients with obvious evidence of nerve compression,
nerve abscess, nerve pain, or nerve function impairment
that is r­ efractory to ­medical treatment.7,12,13 Outcomes fol-
lowing nerve decompression are highly varied with good
outcomes reported by Chaise and Roger.14 However, Boucher
et al in a moderate size RCT stated that combined treatment
with s­ teroids and decompression showed an improvement
Fig. 1  Common peroneal nerve course and muscles supplied.
in sensory and motor d ­ eficits but statistically significant
results were observed only in patients with incomplete
loss contributed to peroneal mono-neuropathy in 14.5% in paralysis and patients with n ­ euritic pain alone.15 In patients
their series.3 In 1959 working in Polambakkam leprosy center with p ­ eroneal nerve neuropathy due to other causes, neu-
in India, Hemerijckx4 reported an incidence of 3 bilateral and rolysis is indicated in patients with intact nerve action
59 unilateral foot drop deformity in 2,337 leprosy patients with potentials. Kim et al reported good outcomes in 88% of
overall incidence of 2.5% in the 8 associated leprosy centers cov- such patients.16 As per a Japanese study, early decompres-
ered by the Belgian leprosy center in India. sion is r­ ecommended in patients with foot drop caused by
lumbar degenerative ­disease accompanied by severe motor
disturbance, ­especially in older patients.17 In patients with
Management
peroneal nerve c­ompression secondary to nerve tumors
­
Conservative Management especially schwannomas, excision of tumor while preserv-
Conservative management is indicated for patients with ing nerve ­continuity is possible with intraoperative mon-
foot drop secondary to leprosy of less than 12 months’ itoring of nerve action potentials. Kim and Kline reported
duration because 50% of these patients recover sponta- 80% of patients with nerve tumors had excision of nerve
neously during the first 12 months.5 Fritschi and Brand tumors with complete preservation of function.16
working in the Karigiri leprosy unit have recorded that Nerve repair or grafting is indicated in patients in whom
they would wait for up to a year before considering sur- nerve continuity is not preserved following tumor excision
gery.6 In idiopathic conditions too, waiting for a year after or when the nerve is transected. Primary nerve repair with
the onset is recommended. epineural stitches under magnification is ideal but a nerve
All patients with foot drop of more than 12 months dura- gap of more than 3 cm will require nerve grafting. Kim and
tion will ultimately require surgery to prevent contractures Kline analyzing 318 patients with peroneal nerve pathology
and foot ulceration.7 The aim of c­ onservative management of ­varied etiology concluded that timely surgical exploration
is to prevent development of contractures and foot ulcers and nerve repair or grafting achieved good results; however,
while the involved nerve is allowed to spontaneously recover. in their series the wait for spontaneous recovery in trauma
­Conservative management involves placing the patient under was only 4 months which we feel is inadequate.16 In their
a closely supervised program of physiotherapy and splinting. series, patients who had nerve grafts less than 6 cm had better
The foot is splinted in a foot and ankle orthosis to prevent outcomes when compared with patients with longer grafts.
stretching of the paralyzed anterior group of muscles and to Nerve transfers are indicated in patients with foot drop of
prevent contracture of the tendo Achilles.7,8 Role of steroids less than 1 year duration. This involves transfer of f­ unctional
in patients with foot drop in leprosy is still controversial. A fascicles of either the superficial peroneal nerve or of the
multicenter, randomized, double-blind, placebo-controlled tibial nerve to the deep peroneal nerve or motor branch of
trial conducted in Nepal and Bangladesh did not reveal any tibialis anterior muscle. Nath and colleagues reported success
differences between the treatment and placebo groups; how- using this technique with 11 out of 14 patients recovering
ever, there was reduced deterioration of nerve function in the grade 3+ or more muscle power.18,19
prednisolone group.5 The efficacy of steroid therapy seems
to depend upon the duration of nerve involvement and the Secondary Procedures
degree of impairment. The earlier corticosteroids were given When direct surgical repair is not possible and conservative
after the onset of nerve damage, it was likelier to prevent per- management or nerve surgeries have failed, then second-
manent nerve function impairment.9,10 A Cochrane Review in ary procedures are required. The primary aim of the surgery
2016 stated that further randomized controlled trials (RCTs) is restoring active dorsiflexion of the foot and correcting the
are needed to establish optimal corticosteroid regimens inversion deformity when the peronei are also paralyzed along

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102 Tendon Transfers in Foot Drop  Krishnamurthy, Ibrahim

with the anterior group. This is achieved using t­endon trans- Before proceeding with tendon transfer surgery, it must
fers, and when tendon transfer is not feasible or has failed, be ascertained that there is no contracture of tendo Achilles.
then bony procedures like triple arthrodesis with tenodesis or If contracture is present, it needs to be stretched or released
ankle arthrodesis may have to be considered to achieve a sta- before the actual transfer is performed. Tendo Achilles release
ble foot. Due to uncertain outcomes after primary nerve pro- and t­ endon transfer can be performed in the same sitting. In
cedures, secondary procedures like tendon transfers often end leprosy, ulcers in foot are common and they must be healed
up as the definitive treatment in these patients.7 before taking up for transfers.
Disorganization of the tarsal bones is often seen in
Tendon Transfer patients with foot drop secondary to leprosy and in diabe-
Preoperative Assessment: Preoperative evaluation of the tes as involvement of the tibial nerve is also present in most
involved muscles and potential donor muscles play a major of the patients leading to neuropathic bone disintegration.7
role in determining the choice of procedure. The muscles of Radiological imaging of the foot is required to determine
the anterior and lateral compartment are evaluated in terms whether there are any disorganization of the tarsal bones.
of muscle power. Tibialis anterior is tested by keeping the Radiological evidence of disorganization is a relative contra-
patient in sitting position and asking the patient to dorsiflex indication for tendon transfer. When the disorganization is
the ankle and invert the foot without extending the toes. significant to the extent that the passive range of movement
The extensor hallucis longus (EHL) and extensor digitorum of the ankle is less than 10 degrees or with the presence of
longus (EDL) are tested by asking the patient to extend the instability, it may be worthwhile to opt for bony procedures
great toe and 2nd to 5th toes, respectively, at the metatarso- rather than tendon transfer. X-rays of the foot, with the foot
phalangeal joint.20 It is essential to assess the strength of the in full forced varus and valgus will help determine whether
peroneal muscles before contemplating tendon transfer. The the instability is principally in the subtalar or ankle joint. If
correct way of testing the peroneus longus and brevis is to the instability is in the ankle joint, or if the tibialis ­posterior
make the patient sit, place the affected limb over the oppo- muscle is not acting, then the patient will be required to
site knee with the hip internally rotated and knee flexed, and undergo ankle arthrodesis or pantalar fusion.7
have the patient lift the foot (evert) (►Fig. 2). The patient will We can analyze the tendon transfer procedures under
not be able to do so if the peronei are paralyzed. If this is ­various components, viz. choice of motor, the route it takes
the case, tibialis posterior is the ideal choice as motor for the to reach its site of insert, and various insertions.
transfer. Once tibialis posterior is chosen as the motor, preop-
erative training of tibialis posterior is to be started by making Motor
the patient sit, place the affected foot over the opposite knee As discussed earlier when both the anterior and lateral groups
with the hip externally rotated, knee flexed, and have the of muscle are involved, the choice of motor is the ­tibialis pos-
patient lift the foot (invert). This is continued for few weeks terior muscle. This not only removes the unopposed inversion
and strengthening of the tibialis is achieved by suspending a force but also helps to restore dorsiflexion when it is inserted
sand bag over the foot while performing the same maneuver. on to the dorsum of the foot. Tibialis posterior transfer for
foot drop in leprosy is credited to Paul Brand who worked
in CMC Vellore in the year 1955.21 Other choices for motor
are flexor digitorum longus (FDL) used along with the tibi-
alis posterior to power the extensor digitorum and hallucis
tendons as a double transfer.22 Leclère et al reported anterior
transposition of the lateral gastrocnemius muscle along with
neurotization of the peroneal nerve.23
In patients with isolated deep peroneal nerve involve-
ment, where the peroneus longus and brevis are spared then
it is better not to transfer the tibialis posterior.24 Removal of
the tibialis posterior will eliminate the balancing inversion
force against the peroneal evertors of the foot which are not
paralyzed. Rerouting the peroneus longus is a better proce-
dure in such conditions.

Route
Since the peroneus longus lies adjacent to the anterior group
of muscles separated only by a septum, it can be shifted
anteriorly without difficulty from the lateral side. Tibialis
­posterior on the other hand lies posterior to the bones and
interosseous membrane, and requires taking a different route
to reach the anterior compartment.
The two commonly followed routes are the interosseous
Fig. 2  Testing the peroneus longus and brevis. route and circumtibial route (►Fig. 3). As reported by ­Watkins

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 Tendon Transfers in Foot Drop  Krishnamurthy, Ibrahim 103

his two-tail procedure of tibialis posterior transfer which is

being followed by many treating leprosy patients worldwide.
He inserts the split tibialis posterior tendon brought circum-
tibially and sutures one slip to the EHL and the other to the EDL
and peroneus tertius tendons.35 In his series of 39 c­ ases, 34
cases had 90 degrees or more of dorsiflexion. Out of these 34
patients, 30 had range of movement of more than 15 degrees.35
We prefer to include the tibialis anterior along with the EHL in
one slip and the other to the EDL. Insertion into the EHL, EDL,
and peroneus tertius balances the foot well and produces good
range of movement.

Procedure
Fig. 3 Tibialis posterior transfer—routes of tendon transfer
(­Courtesy: Srinivasan H. Atlas of corrective surgical procedures Tibialis Posterior Transfer
­commonly used in leprosy). The two-tail tibialis posterior procedure is given below.36
Either general anesthesia or spinal/epidural anesthesia
et al,25 Codivilla26 and Putti27are considered the pioneers of is given. A pneumatic tourniquet is applied. The tendon of
the anterior transposition of the tibialis posterior tendon to the tibialis posterior at its insertion is identified through
the dorsum of the foot through the interosseous membrane. an oblique incision made over the tuberosity of the navic-
Gunn and Molesworth28 reported 56 cases of drop foot (54 of ular bone along one of the creases (►Figs. 4–6). A suture is
them caused by leprosy) in which the tibialis posterior ten- applied to the tendon close to its insertion and left long. This
don was inserted into the tarsus after being brought forward suture steadies the tendon and helps to retrieve it back if it
through the interosseous membrane of the leg. gets stuck while delivering it into the leg. The tendon is then
In circumtibial route described by Ober,29 the posterior detached from its insertion and its synovial attachments
tibial ­tendon is brought around the medial aspect of the tibia. are divided. Sometimes if the end looks bulbus it must be
The d ­ ifference in functional outcome between the two routes trimmed (►Fig.  7). A 5-cm curvilinear incision is made in
is ­negligible with marginal increase in range of movement of the lower part of the leg close to the medial border of the
ankle in the ­circumtibial route30 but there is also a likelihood tibia, about 10 cm above the medial malleolus. The tendon
of more inversion deformity than in the interosseous route.31 of the tibialis posterior is identified and pulled out (►Fig. 8).
The lowest muscle fibers inserting into the tibialis posterior
The Insert tendon may have to be shaved off from the tendon if it comes
Fixation of tendon can be done to bone, periosteum or ten- in the way of smooth gliding. The tendon is split into two
dons on the dorsum of foot. tails up to where it will cross the tibia proximally (►Fig. 9).
Barr originally inserted the tendon to the intermediate or By keeping the split tendon over the skin circumtibially, we
lateral cuneiform bone or base of the second or third metatar- can assess where exactly the tendons will reach ultimately
sal bone bringing the tendon through the interosseous route.32 when tunneled. At this place, two transverse incisions are
Modification of Barr’s procedure, fixing the tendon to the made on the dorsum of the foot, one over the EHL tendon
cuboid bone, according to Salihagić et al produced much better and the other over the tendons of the EDL (►Figs. 10 and 11).
result than the classic Barr’s procedure.33 Ober fixed the tendon Through these incisions, the tendons of the EHL and the EDL
to the base of the third metatarsal bringing it circumtibially.29 and peroneus tertius are identified and isolated. A tendon
Stable fixation to the bone requires pull-out wire sutures, sta- tunneler is passed from each of these wounds in the dor-
ples, or bone anchor. Many of us feel that fixing the transferred sum of the foot to the wound in the leg making two separate
tendon to the tendons on the dorsum of the foot is easy and tunnels for each slip. The tunnels are made subcutaneously
the balancing of forces can be achieved to correct both inver- (►Fig. 12). The motor slips are pulled through. The recipient
sion and plantar flexion deformity. Combining a bony anchor- tendon of the EHL is lifted with a hook and pulled proximally
age with tendon suturing was ­suggested by Vigasio et al.22 The to keep it taut. A slit is made in it and the slip of the tibialis
tibialis anterior tendon was divided proximally and the distal posterior tendon is passed through it. Another slit is made
tendon was r­ erouted ­tunneling through the cuneiform bones distally in another plane and again it is passed through it
and sutured to the tibialis posterior tendon brought through (►Figs.  13–15). The tendon is fixed with three or four 2/0
the interosseous route, along with FDL tendon motorizing nonabsorbable suture material. The next slip is passed
the EHL and EDL tendons. Classical Bridle insert34 is to the similarly through the EDL and peroneus tertius keeping
tendons of the tibialis anterior and peroneus longus balanc- the tension to balance the foot in neutral position without
ing the inversion and eversion of the foot. In 1966, Thangaraj inversion or eversion. During this stage, the knee is held in
reported over 50 operations in which the tibialis posterior flexion of approximately 30 degrees and the ankle in dorsi-
tendon, brought anteriorly through the interosseous mem- flexion beyond 90 degrees to the maximum possible extent
brane, was inserted into the tendons of the EDL and EHL in the (►Fig. 16). We can use a tension adjustment splint as shown
anterior compartment of the leg.30 Srinivasan et al described or held in place by placing towels as shown (►Fig. 17). The

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104 Tendon Transfers in Foot Drop  Krishnamurthy, Ibrahim

Fig. 4  Tibialis posterior transfer: exposure and division of the tibialis posterior in the foot (Courtesy: Srinivasan H. Atlas of corrective surgical
procedures commonly used in leprosy).

Fig. 6  Identification and isolating the tibialis posterior tendon.

Fig. 5  Incision over the tuberosity of navicular to expose the tibialis

posterior tendon insertion.

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 Tendon Transfers in Foot Drop  Krishnamurthy, Ibrahim 105

Fig. 9  Tibialis posterior transfer—exposure in leg, retrieval of the

tendon, and division into two slips (Courtesy: Srinivasan H. Atlas of
corrective surgical procedures commonly used in leprosy).

Fig. 7  Division of the tibialis posterior tendon and synovium (note

the bulbous distal end of the tendon).

Fig. 10  Tibialis posterior transfer—incision in foot and exposure of

the recipient tendons (Courtesy: Srinivasan H. Atlas of corrective sur-
gical procedures commonly used in leprosy).

Fig. 8  Retrieval of the tibialis posterior tendon into the leg wound.

motor tendons are kept in moderate tension. The final posi-

tion is as shown in ►Fig. 18.

Peroneus Longus Transfer

An oblique incision is made over the lateral aspect of the
foot from base of the fifth metatarsal to approximately 1
cm below the lateral malleolus to expose the insertion of
the peroneus longus and brevis. Srinivasan divides the bre-
vis tendon distally and longus more distally and sutures the
proximal brevis tendon to the distal longus tendon making
the brevis act as a longus. Many do not use this step. The lon-
gus which is divided distally is delivered in the leg through Fig. 11  Division of the tibialis posterior tendon into two slips, which
a 5-cm-long incision made anterolaterally approximately 5 is placed over the lower 3rd of the leg to assess their reach. It is also
cm above the lateral malleolus. The tendon is then split as used to determine the orientation of the subcutaneous tunnels.

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106 Tendon Transfers in Foot Drop  Krishnamurthy, Ibrahim

Fig. 12  Tibialis posterior transfer—tunneling of tendon slips (Cour-

tesy: Srinivasan H. Atlas of corrective surgical procedures commonly
used in leprosy). Fig. 14  Passing and suturing of the slip of the tibialis posterior ten-
don through slits made in the extensor hallucis longus tendon.

Fig. 15  Passing and suturing of the slip of the tibialis posterior
­tendon through slits made in the extensor digitorum longus tendon
and peroneus tertius tendons.

to contract the tibialis muscle. After 4 week, the patient is

Fig. 13  Tibialis posterior transfer—suturing of slips (Courtesy: made to stand with support. Between periods of exercise, the
­S rinivasan H. Atlas of corrective surgical procedures commonly used
leg and foot are kept in the plaster slab. After 6 weeks, the
in leprosy).
patient is allowed to walk between parallel bars with mini-
mal weight bearing. From 8 weeks onwards, full weight bear-
in tibialis posterior transfer. Like the tibialis posterior pro-
ing is allowed.
cedure, tunnels are made and suturing done as before. The
only difference being the tendon slips reach the foot from the Complications
lateral side instead of the medial side in the tibialis posterior The reported complications following tendon transfers of the
transfer. foot and ankle include persistent deformity, pain and rigidi-
ty, wound infections and abscesses, tarsal tunnel syndrome,
Postoperative Period sural nerve injuries, and other causes of paresthesias, and
A below-knee plaster is applied. The plaster is bi-valved neuropathic pain.37 Postoperative surgical site infections are
after 3 weeks. Physiotherapy is started with reeducation rare. Adhesions giving rise to reduced range of movements are
as discussed earlier. Initially after 3 weeks, training is done noticed especially in interosseous route transfers which can

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 Tendon Transfers in Foot Drop  Krishnamurthy, Ibrahim 107

Fig. 16  The position to be maintained during tenorrhaphy, knee in

flexion and the ankle in maximum dorsiflexion (beyond 90 degrees).

be avoided if the window in the interosseous membrane is

large enough. Insufficient tension gives rise to reduced dorsi-
flexion or persistent equinus deformity. In circumtibial trans-
fers excessive inversion may be noticed. This can be avoided Fig. 18  The final resting tension after completion of the transfer.

Fig. 17  Tibialis posterior transfer—tension adjustment splint (Courtesy: Srinivasan H. Atlas of corrective surgical procedures commonly used
in leprosy).

by tunneling first vertically from the EHL site proximally and involved, it may be worthwhile arthrodesing the ankle and
then curving it around the tibia facilitating vertical pull. Inter- subtalar joints.
osseous route transfers do not produce this. Similarly, eversion In conclusion, when there is no recovery after primary
can occur if excess tension is given while the EDL slip is tight- procedures for foot drop, in leprosy and other causes of
ened more. Rarely in leprosy the tibialis posterior may become peroneal neuropathy, dynamic transfers yield very good
paralyzed later and may not work. Dehiscence is rare. results. There is not much difference between circumtibial
and interosseous routes. Tendon fixations are much easier
Arthrodesis to perform than bony fixation and can give excellent results.
As discussed earlier, if there is disorganization of the t­ arsal In our experience, two-tail tibialis posterior procedure gives
bones and in cases where the tibialis posterior is also good results.

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108 Tendon Transfers in Foot Drop  Krishnamurthy, Ibrahim

Conflict of Interest 17 Matsui H, Kanamori M, Kawaguchi Y, Kitagawa H, Nakamura H,

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Indian Journal of Plastic Surgery  Vol. 52  No. 1/2019