Botox countering child gait disorder

When  small  children  unintentionally  walk  on  their  toes,  the  cause  may  be  a  gait  disorder called idiopathic toe-walking. If the disorder does not cease by itself or through physical therapy, Botox injections could bring improvement, according to a new study presented at the EFORT Congress in Istanbul.

Istanbul, 8 June 2013  – Botox injections in the calves can bring significant improvement to children suffering from idiopathic toe-walking (ITW), according to a new Italian study presented at the 14th Congress of the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) in Istanbul, where 7,500 experts are discussing current developments in their field.

Nine  children  suffering  from  idiopathic  toe-walking  were  included  in  the  pilot  study.  Their mean age was 7.6 years and they had not responded to other therapy attempts. Children with  neurological  disorders  were  excluded.  The  patients  received  injections  of  botulinum toxin A in the calf muscles. Ankle-foot orthoses and a program of stretching exercises were used in support of the drug therapy. The results were evaluated one and three months after the injection respectively. After three months, the children’s gait had improved significantly.

Manifold causes

The problem, addressed in an innovative way here, is not a rarity. “A little more than 2% of neurologically otherwise unremarkable five-year-olds walk with a toe gait,” said the study author, Prof Isabella Fusaro (Rizzoli Orthopaedics Institute, Bologna). The toe-walking is not without   consequences.   Foot   dysplasia,   back   pain,   spinal   problems   and   psychological difficulties lurk. A thorough diagnosis should precede therapy. When children increasingly burden their forefeet while walking, or actually tiptoe, the reasons for this can vary. Neurological diseases may be hiding behind the anomaly, or so too could idiopathic factors occurring  without  apparent  cause  but  in  which  a  significant  genetic  component  is observable.  In  the  context  of  such  latter  diagnosis,  certain  factors  should  be  initially excluded such as severe psychiatric disorders, cerebral diseases, orthopaedic as well as neuromuscular and neurodegenerative diseases. Even in cases of ITW, several types can be diagnostically distinguished. Among many of the affected, the problem takes care of itself within a relatively short time. There are many different approaches and relatively little evidence in regard to therapy. Prof Fusaro: “Treatment depends on age and characteristics of  the  gait  disorder.  Attempted  methods  include  physiotherapy,  plastering,  various orthopaedic shoes and insoles or, in severe cases, surgical extension of the Achilles tendon and, as the case may be, calf muscles.”

Surgical intervention should only be a last resort. A possible alternative is the temporary chemodenervation of the calf muscles through botulinum toxin. This leads to a forced relaxation of the gastrocnemius and the soleus muscles, and thus to an improvement in gait pattern. That’s the theory that has hitherto been confirmed by case reports but hardly by clinical trials. The new data provide additional evidence for treatment with Botulinum toxin.

Prof Fusaro: “For the first time, we now have trial data on the use of Botox in idiopathic toe walking. It was, nevertheless, only a small, non-controlled study. But based on the results, we  are  now  planning  a  randomized,  controlled  study  in  which  the  control  group  will  be treated with orthosis and exercise alone.”


The   European   Federation   of   National   Associations   of   Orthopaedics   and   Traumatology (EFORT) is the umbrella organisation linking Europe´s national orthopaedic societies. EFORT was founded in  1991 in  the Italian Marentino. Today it  has 42 national member societies from 43 member countries and six associate scientific members.

EFORT   is   a   non-profit   organisation.   The   participating   societies   aim   at   promoting   the exchange  of  scientific  knowledge  and  experience  in  the  prevention  and  treatment  of diseases and injuries of the musculoskeletal system. EFORT organises European congresses, seminars, courses, forums and conferences. It also initiates and supports basic and clinical research.

Source:  EFORT Abstract 3943: Clinical and instrumental evaluation of botulinum toxin effects on the “idiopathic toe walking”: a pilot study

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