Recently one of my neighbors developed foot drop; I saw her using a walker and she couldn’t walk her dog without someone with her. Of course, I volunteered. I couldn’t help asking her what happened.
She explained the foot drop came on suddenly. Her doctor told her it was slimmer’s palsy. (I’m thinking, what’s that?) She said he told her it probably would resolve on its own and if not, she might need surgery. She asked if chiropractic might help. Of course, I said yes, but I must admit I was a bit peeved with myself because I had not heard of this term.
There are many causes for foot drop; I’ve personally treated patients with foot drop with positive results, but not a patient with a diagnosis of slimmer’s palsy. So, I did some research on this term and now I am sharing it with you.
Slimmer’s Palsy
Slimmer’s palsy is a term used when there is entrapment of the common peroneal nerve at the neck of the fibula and is associated with rapid weight loss. It can be exacerbated by leg crossing or prolonged squatting. Carpet layers, plumbers and farmworkers are also at risk for common peroneal nerve entrapment. Most improve when they stop the activity. Frequent breaks and knee pads can help.
Even when the nerve lesion is clearly at the fibular neck, there are a variety of causes that may not be immediately obvious.1-2 I was not aware of weight loss being associated with peroneal nerve entrapment. This is a diagnosis of elimination along with the associated history.
Symptoms & Diagnosis
Foot drop symptoms require a meticulous neurological evaluation to ascertain the site of the lesion. There are many causes of acute-onset foot drop, ranging from deep fibular nerve or sciatic nerve injury caused by trauma or a compressive mass such as a neuroma, to spinal cord disorders like disc herniation causing L4-5 radiculopathy. Even brain disorders like MS, stroke or ALS can result in foot drop, including various muscular dystrophies affecting the tibialis anterior muscle.
Foot drop causes significant disability and markedly restricts everyday activities, which is distressing because it can cause falls, resulting in other injuries.
Nerve conduction and electromyographic studies are useful adjuncts in localizing the site of injury, establishing the degree of damage, and predicting the degree of recovery. 3 Imaging, MR or ultrasonography, is important in establishing the cause of foot drop, be it at the level of the spine, along the course of the sciatic nerve or in the popliteal fossa.4-5
It is not always easy to clearly determine the cause. The main challenge is to differentiate between radiculopathy and peripheral nerve injury or a neurological systemic disease.
Treatment
Chiropractic practitioners are underutilized in the conservative management of this disorder. Unfortunately, there is still controversy over treatment and little data available on the conservative management of this problem, so it is often not being addressed appropriately.7
“There are a range of treatment options, some are causal and others symptomatic in nature. Typically, these treatments cannot be provided by one specialty alone.” – Anne Elisabeth Carolus8
I found only one ongoing clinical trial on the efficacy of conservative vs surgical treatment to determine which patients with foot drop caused by peroneal nerve root entrapment need operative intervention or conservative management (ClinicalTrials.gov: NCT04695834). The trial will not be completed until 2027.
So, what was causing of my neighbor’s foot drop? No diagnostic studies had been performed to confirm there wasn’t any other condition causing this acute onset. The only recommendation was to stop crossing her legs and use the walker until it resolved.
She did receive a referral for physical therapy, but no appointments were available for over two months, at least under her insurance plan (thanks to our crazy health care system).
The Cause?
Initially, she didn’t mention that she had lost 25 lbs. over a two-month period by taking Ozempic. (I think she was a little embarrassed.) As with many patients, history is key. With that information, I understand how she got that diagnosis; but without some sort of diagnostic testing, how could one be certain?
Ozempic is prescribed for diabetics. However, semaglutide, the active ingredient in Ozempic and Wegozy, are not only prescribed for overweight diabetics. It has become popular with patients who want to lose weight quickly.
My neighbor wanted to lose weight quickly for a family wedding. I didn’t think she was that “overweight”; maybe 10 or 15 pounds. Who knew she might develop foot drop? She ended up going to the event with her walker, but in the pictures she looked slimmer. (A win/lose situation?)
I reviewed all the side effects reported by the pharmaceutical companies that make Ozempic and Wegozy.9 Foot drop / slimmer’s palsy is not mentioned. Apparently, this problem can happen with any dramatic weight loss over a short period of time. It is not associated directly with semaglutide.
The present theory is that rapid weight loss leads to the depletion of adipose tissue. When the peroneal nerve is not protected by the normal fat pad as it courses adjacent to the fibular head on the medial side, and by the peroneus longus tendon on the lateral side, entrapment can occur. It can be aggravated mechanically by long periods of crossing the legs and/or squatting.10-11
Regarding my neighbor, she was able to receive treatment from a team of practitioners at a multidisciplinary sports medicine clinic. She received intense physical therapy from a team chiropractor with a specialty in sports injuries (DACBSP) and one minor intervention of hydrodissection from a sports team physician.12-13 (Just south of San Diego, there is an Olympic training center in Chula Vista; hence a plethora of sports and musculoskeletal specialists.)
This patient was practical, lucky and had resources; she didn’t wait around to get her PT appointment, which her insurance would cover. Timely care is important, especially with nerve regeneration, which might not have been possible without surgical intervention. Patients need to be involved in their own care, especially now with all the problems with our health care system.
Chiropractic Relevance
We chiropractors need to keep in mind that the cause of foot drop could be rapid weight loss. We need to ask the right questions; especially when the weight loss exceeds 5 kg a month and is prolonged over several months. Further care should be taken if the patient has known conditions predisposing them to neurological issues.14-16
Given the growing popularity of weight-reducing medications, I would anticipate this not-so-common disorder will increase in prevalence in the near future. Chiropractors can certainly manage slimmer’s palsy with conservative treatment, which should be the first option.
References
When sports chiropractors first appeared at the Olympic Games in the 1980s, it was alongside individual athletes who had experienced the benefits of chiropractic care in their training and recovery processes at home. Fast forward to Paris 2024, where chiropractic care was available in the polyclinic for all athletes, and the attitude has now evolved to recognize that “every athlete deserves access to sports chiropractic."
It is estimated that 61% of patients with CTS avoid taking surgical options due to postoperative complications and costly surgical procedures. Chiropractic care offers a comprehensive and effective treatment for carpal tunnel syndrome, addressing the condition from multiple angles. Recent studies also have unveiled a game-changing adjunct to chiropractic treatments for CTS: nerve flossing.
Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
