In the presence of widespread or multiple neurological involvement, particularly in brain and marrow diseases, it can be easily expected that the foot is affected.
In the neurological foot, paresthesias are common, which worsen at night, cramps that become actual electric discharges, and motor handicaps with partial palsy of a muscle or a group of them, that occur as lameness, steppage, or complete palsy.
The disorder is frequently complex, by way of example, a nerve usually innervates several muscles, and some muscles work associated with others against a single antagonist.
These peculiarities explain the frequency of rocker bottom foot in neuropathies, that is due to a spasticity of the triceps or a paralysis of the dorsal flexors often associated with that of the peroneuses.
The treatment is not only aimed at etiologic agent of the condition, chiropody is necessary given the trophic disorders in an hypo- or insensitive area, and kinesotherapy corrects the dysfunction of the injured muscles and helps to the flexibility of the joints, avoiding vicious positions.
Since there is no place for the correction of these structural disorders, the insoles should be palliative and capable of distributing the load efficiently, releasing the pressure areas from an excess weight transfer.
The surgical treatments can be established at any time of evolution of the disease, and range from neurolysis and nerve and tendon transplantation, to arthrodesis.
Neurological disorders of origin extrinsic to the foot
Hemiplegia: the foot is affected in half of the cases of hemiplegia, causing a non-functional hanging foot that will progress to spastic if it does not recover.
The surgery of digital claws enhances gait and driving, reducing the trophic disorders subsequently occurring and making even more difficult the use of the pedals.
This surgery involves two months far from driving, and requires car adaptations and steering wheel restrictions, based on the specialist’s report with the definitive sequels.
Poliomyelitis: the sequels of this disease are located mainly in the foot, and improve with footwear adaptations, external tutors and large arthrodesis.
Sometimes, modifications must be made for the driving position that are managed with the specialist’s report that specifies the sequels and functional limitations.
Paraplegia: this injury is frequent for the increased number of road accidents.
Spasticity occurs that enhances retractions, and it is advisable to suggest the patient to be alert about the skin trophic risks such as eschars, and bone risks such as fractures and deformation.
Charcot-Marie-Tooth: it causes pes cavus associated with bilateral steppage and amyotrophy of the tibial.
The external tutors help somewhat, and the surgeries associated with gait limitations range from digital alignments to triple arthrodesis.
Spina bifida: it is characterized by an evolved paralytic foot and the presence of club foot with or without equinism is frequent.
Sensitive deficiencies and injuries from the footwear and driving pedals on existing trophic disorders complicate the outcome.
Peripheral neuropathies: they always affect the feet, associated with motor and sensitive deficit that can be superficial and deep, by excess or defect, with abolition of tendinous reflexes, and often with trophic neurovegetative disorders.
Foot and sciatica: an intramuscular injection, a direct injury, a surgery of the hip or a compression, can affect the common trunk of the sciatic nerve.
The paralysis of the internal popliteal sciatic nerve affects the motility of the plantar flexors and of the posterior tibial, and also plantar sensitivity.
The paralysis of the external popliteal sciatic nerve is frequent in injuries of the neck of the fibula, with steppage and digital claws making gait difficult.
Driving should be advised against as long as the symptoms persist, up to complete resolution of the clinical condition.
- While the patient suffers pain, loss of force and functional limitation, preventing him from an adequate operation of the car pedals, he cannot drive.
- The loss of sensitivity in neurogenic disorders prevents from driving, and the patient should be adequately informed.
- Pain and limitations of movements will lead the physician to advise against driving.
- Patients with neurological foot benefit largely from adapted footwear and from external tutors to improve gait and, by extension, to controlling the extremity in the driving position at the adapted car.
- All these aids must be prescribed by the expert and evaluated facilitate driving.
- Nevertheless, the driver must be warned about the existing limitations, to help him to choose the type of driving where he can feel more comfortable.
- Every surgical technique has its own limitations in terms of driving, and two months are frequent for soft tissue surgeries and six or twelve for the most complex techniques.
- The specialist will indicate in his report the definitive sequels that permit adapting the car to be able to drive, if possible with the general disease of the patient.
Neurological disorders of origin intrinsic to the foot
Tarsal tunnel: it is a neuropathy by compression of the posterior tibial nerve or of its terminal branches, the medial calcaneal nerves and medial and lateral plantar nerves.
The presence of paresthesia or pain in the sole of the forefoot and toes increases at night, and when walking or with orthostatism.
Plantar nerves are totally affected and eventually cause paralysis of the intrinsic muscles.
Proximal irradiation of pain reaches the ankle and pain is usually dependent on the amount of load applied by the subject in his daily life.
Blockages with local anesthetics, followed by rest and exercises of ankle and foot flexibility, in addition to the insoles and antiinflammatory therapy relieve mild cases.
Surgical neurolysis followed by plaster immobilization for one month can be attempted.
Surgical release of the tarsal tunnel relieves the condition, and requires from two to three weeks of discharge. Normal activity is recovered in some weeks.
Morton neuroma: it is a frequent cause of metatarsalgia with pain in the third intermetatarsal space, that the patient reports as paroxysmal of nervous type and irradiates to proximal, increases with tight footwear, and worsens with progression.
It can interfere with driving when pressing the pedal, particularly in the right side.
The treatment is conservative with adequate footwear, local infiltrations, and insoles with metatarsal rising.
The surgical treatment involves removal of the medial plantar nerve when it passes through the intermetatarsal space, with recovery between the second and third weeks. Then the patient can drive.
- The interference with driving is variable, depending on the paresthesia and pain when pressing the pedals.
- The tarsal tunnel syndrome can cause loss of force in some foot movements necessary for driving, with the risk of accident if the pedals are not well pressed.
- All surgeries require a more or less prolonged period of functional recovery, during which the patient cannot drive, and the specialist will advise in this regard.