Case Presentation

Diagnosis and Treatment of Abductor Hallucis

Focal Dystonia With Botulinum Toxin Injection:
A Case Presentation
Nathan S. Rosenberg, MD, Ib R. Odderson, MD, PhD

INTRODUCTION
Orthopedic foot deformities can result from neurologic conditions such as stroke, multiple
sclerosis, and cerebral palsy [1]. In such cases, imaging studies of the foot are often not
diagnostic of the underlying problem. Although it is not always considered, electro
diagnostic assessment can detect dystonia, spasticity, and neuropathy [2]. The information
gained from these electrodiagnostic studies can guide therapy, including medical and
surgical management. This case study describes the successful evaluation and treatment of
abducted hallux deformity by using electrodiagnostic testing and botulinum injection
treatment.
Focal dystonia is a rare neurologic condition that often limits function and is charac
terized by involuntary muscle contraction in a non velocity dependent manner. In the
majority of cases, an underlying cause remains unclear. The term describes a heterogenous
set of conditions that can affect almost any location in the body, including the cervical
musculature, oromandibular and laryngeal muscles, and the muscles of the extremities.
The incidence is estimated at 24 per million per year [3] and occurs most commonly in
men [4]. The incidence of upper extremity focal dystonia appears to be much higher in
professionals who perform skilled tasks with their hands, such as musicians, dentists,
surgeons, and watchmakers.

CASE PRESENTATION
An 81 year old man was referred to our rehabilitation clinic with a chief concern of severe
right hallux varus deformity and an associated abnormal gait pattern. He first noticed this
15 years before presentation and acknowledged its progression over time. He also had right
medial knee pain with ambulation. The patient had a pair of custom shoes with an
oversized medial aspect of the toe box to accommodate his toe deformity. Other than these
custom shoes, he had not undergone any other treatment. He denied any history of stroke
or upper motor neuron disorder. There was no history of traumatic foot or toe injury.
Medical and surgical histories were negative for foot trauma or surgery, contralateral joint
deformity, or movement disorder. Pertinent family history was a daughter with a similar
deformity.
Physical examination demonstrated a right hallux varus with an abduction angle of 58

when sitting (Figure 1) and firm muscular resistance appreciated with slow passive N.S.R. Department of Rehabilitation Medicine,
adduction of the great toe. This deformity was accentuated when standing, with a relative University of Washington, 1959 Pacific Ave,
Seattle, WA, 98115. Address correspondence
increase in abduction angle. There was no dystonia appreciated in the foot or the ankle.
to: N.S.R.; e mail: nsrosenberg@gmail.com
Neurologic examination was otherwise normal. Gait with a single point cane in the left Disclosure: nothing to disclose
hand was wide based, with pronounced external rotation of the right foot. A radiograph of I.R.O. Department of Rehabilitation Medicine,
the foot demonstrated medial subluxation of the first proximal phalanx with respect to the University of Washington, Seattle, WA
first metatarsal head. Given the physical examination finding of firm muscular resistance Disclosures outside this publication: board
membership, Merz advisory board; educational
with slow passive adduction, electromyography (EMG) assessment of the right abductor grants, Solstice Neurosciences and Merz Phar
hallucis was performed. The EMG demonstrated abnormal involuntary dystonic activity maceuticals; consultant and speaker, Allergan
(Figure 2). This was presumed to be the cause of the patient’s great toe deformity. Botu Submitted for publication September 21,
linum toxin injection is indicated to reduce dystonic activity at this muscle [5]. After 2012; accepted April 4, 2013.

PM&R ª 2013 by the American Academy of Physical Medicine and Rehabilitation

1934 1482/13/$36.00 Vol. 5, 726 728, August 2013
726
Printed in U.S.A. http://dx.doi.org/10.1016/j.pmrj.2013.04.003

Downloaded for Anonymous User (n/a) at Hualien Tzu Chi Medical Center from ClinicalKey.com by Elsevier on January 15, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
PM&R
Figure 1. Right hallux varus, which was present at rest and
pronounced with standing.
discussion of risks and benefits, the right abductor hallucis
muscle was subsequently injected under EMG guidance with
25 U onabotulinumtoxinA (100 U per 4 mL of preservative
free saline solution) in the mid belly of the muscle. The
patient tolerated the procedure well.
At a follow up appointment 2 months later, the patient
reported decreased medial knee pain. The hallux deviation
had decreased to 48
, with passive range of motion to 22
.
He obtained a new pair of shoes during this interval that
Figure 2. Electromyography at rest, demonstrating dystonic
activity.
Downloaded for Anonymous User (n/a) at Hualien Tzu Chi Medical Center from ClinicalKey.com by Elsevier on January 15, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
Vol. 5, Iss. 8, 2013 727
were not custom made and fit more comfortably. An EMG
assessment of the abductor hallucis at that time demon
strated reduced recruitment with 3þ fibrillations and 3þ
positive sharp waves consistent with previous chemo
denervation. Recommendations for a tenotomy procedure
were discussed with the patient given the focal nature of this
condition. He declined, stating that he was not interested in
a surgical procedure.
When he returned to the clinic 5 months after the che
modenervation, he indicated a return to baseline regarding
his right great toe deformity. The hallux abduction angle was
found to be 60
, with passive range of motion to 30
. An
EMG of the right abductor hallucis muscle now demon
strated dystonic activity without evidence of acute or chronic
denervation. Repeated chemodenervation with EMG guid
ance was performed at the right abductor hallucis with 25 U
onabotulinumtoxinA. The patient did not return to the clinic
for follow up for unknown reasons.
DISCUSSION
This case demonstrates a severe abductor hallucis varus
deformity that occurred without underlying bony or post
surgical abnormality. It underlines the importance of electro
diagnostic studies as a diagnostic tool in suspected underlying
focal dystonia. Intervention with chemodenervation was both
diagnostic and therapeutic because it led to a decrease in the
deformity and improvement in pain and impairment.
Focal dystonia of the hallux muscles has been reported,
although the majority of these cases involved dystonia of
the extensor hallucis longus muscle, which cause an
upgoing toe [5,6]. In addition, a set of focal foot dysto
nias has been described, which involved the foot and
ankle as well as the toes [7]. This appears to be the first
case report of focal dystonia of the abductor hallucis
muscle without radiologic abnormalities in the foot or
ankle. The onabotulinum toxin A dose of the 25 U was
judged to be adequate for the abductor hallucis brevis and
similar to the dose recommended for the flexor digitorum
brevis [8].
The most common cause of hallux varus deformity is
iatrogenic due to overcorrection of a hallux valgus deformity.
In addition, hallux varus can occur secondary to rheumatoid
arthritis, psoriatic arthritis, trauma, burn with secondary
contracture, peripheral neuropathy, paralysis, or poliomy
elitis [1]. Hallux varus deformity is often addressed with
surgery. Surgical planning for this condition takes into ac
count a number of factors, including the degree of flexibility
in the metatarsophalangeal and interphalangeal joints, the
underlying osseous anatomy and the degree of deformity.
Commonly performed procedures include ligamentoplasty,
arthrodesis, tendon transfer, and tenotomy [1].
Because the patient had limited interest in surgical
treatment and was satisfied with his current treatment
plan, further diagnostic workup, including more
728 Rosenberg and Odderson ABDUCTOR HALLUCIS FOCAL DYSTONIA WITH BOTULINUM TOXIN INJECTION

expansive electrodiagnostic studies, were not pursued. REFERENCES

These studies may have provided additional diagnostic
information because the positions of the other toes on his
right foot suggest that they may also be involved in this
process.
CONCLUSION
Electrodiagnostic studies can be helpful in determining the
underlying cause of hallux varus when focal dystonia is
suspected [2]. This condition should be considered in the
different diagnosis for foot deformities. Focal dystonia is
amenable to botulinum toxin injection to help improve the
deformity and decrease associated functional impairment
[5,6]. This finding suggests that patients may be able to
avoid surgical procedures and have improved functional
outcomes if this phenomenon is recognized and conservative
treatment options are offered.
1. Devos Bevernage B, Leemrijse T. Hallux varus: Classification and treat-
ment. Foot Ankle Clin 2009;14:51-65.
2. Yanagisawa N, Goto A. Dystonia musculorum deformans. Analysis with
electromyography. J Neurol Sci 1971;13:39-65.
3. Nutt JG, Muenter MD, Aronson A, Kurland LT, Melton LJ III. Epide-
miology of focal and generalized dystonia in Rochester, Minnesota. Mov
Disord 1988;3:188-194.
4. Bartolome FM, Fanjul S, Cantarero S, Hernandez J. Garcia Ruiz PJ.
Primary focal dystonia: Descriptive study of 205 patients. Neurologia
2003;18:59-65.
5. Giladi N, Meer J, Honigman S. The use of botulinum toxin to treat
“striatal” toes. J Neurol Neurosurg Psychiatry 1994;57:659.
6. Sherman AL, Willick SP, Cardenas DD. Management of focal dys-
tonia of the extensor hallucis longus muscle with botulinum toxin
injection: A case report. Arch Phys Med Rehabil 1998;79:1303-
1305.
7. Singer C, Papapetropoulos S. Adult-onset primary focal foot dystonia.
Parkinsonism Relat Disord 2006;12:57-60.
8. Odderson IR. Botulinum Toxin Injection Guide. New York, NY: Demos
Medical Publishing; 2008, 86.

Downloaded for Anonymous User (n/a) at Hualien Tzu Chi Medical Center from ClinicalKey.com by Elsevier on January 15, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.