Botulinum toxin type A in the treatment of Idiopathic Toe Walking: a case series study

Introduction. Idiopathic Toe-Walking (ITW) is defined as persistent toe walking in a normal child in the absence of developmental, neurological or neuromuscular conditions. At the onset, there is full passive dorsiflexion but an equinus contracture can be developed over time1. The conservative treatment of ITW includes physical therapy, bracing, serial casting and off label Botulinum toxin type A (BTX-A) injection2. The primary outcome of our study is to evaluate the improvement of the ankle dorsiflexion after only one BTX-A injection in children with idiopathic toe walking. The secondary outcome is to see if there is a reduction of the percentage of time spent walking on toes. Materials and methods. From January 2011 and June 2012, we enrolled in our study six children with ITW. All the children were evaluated prior the BTXA injection (T0) and after 1 (T1), 3 (T2) and 6 (T3) months. The evaluation protocol consisted of the measurement of ankle dorsiflexion, both with knee flexed and extended, hip and knee range of motion (ROM), Selective Motor Control scale, Physician’s Rating Scale, perceived amount of time spent toe walking and satisfaction after the treatment, both rated by parents. All of the children underwent a BTX-A injection in the calf muscles with a total of 6 units/kg Botox ®. The parents were instructed to perform stretching exercises of the injected muscles and reinforcement exercises of antagonists for 45 minutes three times a week. The use of BTX-A was approved by the Medical Ethical Committee of the Second University of Naples. Moreover, the parents had to sign a detailed informed consent. Results. All of the children enrolled were males, with a mean age of 6.8 yr (range 4-9). Toe-walking occurred since the beginning of the ambulation. None of the children underwent a previous treatment for the toe walking. The improvement between T0 and T3 in the right ankle dorsiflexion, both with flexed knee and with extended knee, was statistically significant (p=0.0436, and p=0.0183 respectively), as well as in the left ankle dorsiflexion (p=0.0475, and p=0.0386 respectively). At the Selective Motor Control Scale, at T0, five children had F5 and only one had F4 while at T3 all of the children had F5. Taking in consideration the Physician Rating Scale, at the initial contact of the gait cycle, at T0 three children rested their feet to the ground on their toe and three their feet flat to the ground, at T3 all of the children rested their feet flat to the ground. Moreover, during the stance phase, at T0, three of them had an early lifting of the heel in the acceptance of load and three in mid-stance, while at T3 all of the patients had an early lifting of the heel during mid-stance. The mean percentage of time spent toe-walking, reported by parents, was 83.3% at T0 and 50% at T3 (p=0.0379). Only in one case parents were not very satisfied after the treatment. Conclusions. In our study the use of BTX-A resulted to be effective in improving the ankle dorsiflexion, the resting on the ground of the feet at the initial contact of the gait cycle and in reducing the percentage of time spent toe walking during the day with a good satisfaction expressed by parents. In addition, although none of our patients stopped toe walking completely, the use of BTX-A allowed us to avoid the development and the worsening of an equinus contracture so as to delay the lengthening of the Achilles tendon. Bibliography 1. Sobel E, Caselli MA, Velez Z.: Effect of persistent toe walking on ankle equinus. Analysis of 60 idiopathic toe walkers. J Am Podiatr Med Assoc. 1997;87:17-22. 2. Engstrom P., Gutierrez-Farewik E., Bartonek A., Tedroff K., Orefelt C., Haglund Y.: Does Botulinum Toxin A improve the walking pattern in children with idiopathic toe walking? J Child Orthop 2010; 4:301-308.