The frequency and significance of ‘striatal toe’ in parkinsonism
Introduction
Babinski, in 1896, first described a sign in which stimulation of the lateral aspect of the sole elicited the ‘phenomène des orteils’ (dorsiflexion of the great toe) and the ‘signe de l’éventail’ (fanning of toes), often regarded as part of the reflex [1], [2]. Extension of the big toe is part of a reflex response that involves not only the toes, but all muscles that shorten the leg. In the newborn the reaction to a stimulus applied to the sole of the foot is very brisk, involving all flexor muscles of the leg, including the toe ‘extensors’ which also shorten the leg (=withdrawal reflex). As the nervous system matures and the pyramidal tract gains more control over spinal motorneurones the withdrawal reflex becomes less brisk, and the toe ‘extensors’ are no longer part of it. With lesions of the pyramidal system the withdrawal reflex becomes disinhibited and the extensor plantar sign again becomes evident [3]. The extensor plantar was clearly regarded as pathognomonic of pyramidal dysfunction, and was evaluated in an extensive series of experiments at the beginning of the last century [4]. The pathognomonic significance of fanning of the toes is less clear as Babinski himself stated that it can appear in healthy subjects; however, when very marked it can point towards a lesion of the pyramidal tract even in the absence of an upgoing plantar [2].
The significance of the above described extensor plantar response in parkinsonism is not clear to date. Corkill and Chignell found an extensor plantar response on one or both sides in 15 out of 38 patients with widespread manifestations of Parkinson's disease [5]. The authors assumed that the extensor plantar response on Babinski manoeuvre represented involvement of the pyramidal tract in these patients [5]. A ‘pseudo-Babinski sign’ was reported by Ramsey–Hunt as early as 1917 in patients with severe juvenile onset of Parkinson's disease [6] and Davison likewise reported apparent bilateral extensor plantar responses in a similar group of patients [7]. A spontaneous extensor plantar was observed in some patients with Parkinson's disease and was mentioned by Charcot as early as the end of the 19th century in association with foot deformities [8]. The striatal foot was described in 1972 by Duvoisin et al. [9] who observed ‘extension of the great toe with flexion of the remaining toes, producing an effect reminiscent of the Babinski sign with the foot assuming an equinovarus position’ in patients with parkinsonism. The authors concluded this sign to be dystonic in nature and an intrinsic feature of Parkinson's disease, with the plantar response being truly flexor [9]. However, the phenomenon seems not to be restricted to Parkinson's disease as a similar foot posture with and without an extensor plantar was described in patients suffering from parkinsonism with dementia [10].
The phenomenon of a spontaneous extensor plantar or an extensor plantar response on Babinski manoeuvre in patients with parkinsonism is not entirely understood and has not been investigated systematically so far. We therefore designed the present study in order to determine the frequency and significance of an extensor plantar response in patients with parkinsonism.
Section snippets
Patients and methods
In a prospective, consecutive study 62 patients with parkinsonian syndromes were recruited from the regional Movement Disorders Clinic of King's College Hospital, London. Patients were examined according to a standardised protocol and patients with an apparent extensor plantar response were examined by two different observers (ASW, IR). The plantar response was elicited by three different methods, the Babinski, Oppenheim and Gordon manoeuvres. The Babinski manoeuvre was performed on a relaxed
Results
Seventeen out of 62 patients with parkinsonism demonstrated an extensor plantar response. This included 13 patients with plantar dorsiflexion in the absence of fanning of the toes and flexion synergy of the leg (striatal toe), either when elicited by the Babinski, Oppenheim and/or Gordon manoeuvres or spontaneously (two cases). Seven patients were suffering from IPD and six from ARS (MSA:PSP:DLB=3:2:1). Three patients had bilateral striatal toes. Four out of the 17 patients with an upgoing
Discussion
This study was designed to establish the frequency and significance of an upgoing hallux on plantar stimulation in patients with parkinsonism. The study protocol included only patients with an ARS and was not designed to compare the frequency of striatal toe in parkinsonian patients to that of patients with stroke and healthy individuals.
Approximately 27% of the patients examined in our study showed an upgoing plantar (unilateral or bilateral) either spontaneously or after performance of one or
Acknowledgements
We are indebted to Dr Chris Clough and Dr Steve Pollock for letting us study their patients and to Dr Sabine Landau for statistical advice.
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Cited by (22)
Principles and Practice of Movement Disorders
2021, Principles and Practice of Movement DisordersDystonia and Parkinson's disease: What is the relationship?
2019, Neurobiology of DiseaseCitation Excerpt :An isolated “striatal toe” is a subtype of striatal foot in the absence of the equinovarus foot. It needs to be differentiated from the Babinski sign which is usually associated with toe fanning and flexion synergy of other muscles in the same leg along with hallucal hyperextension (Winkler et al., 2002). Dystonia, rigidity (Kyriakides and Hewer, 1988) and inappropriate muscle contraction (Hu et al., 1999) may be responsible for the striatal foot.
Frequency and clinical correlates of postural and striatal deformities in Parkinson's disease
2016, Clinical Neurology and NeurosurgeryCitation Excerpt :Striatal toe is considered a type of striatal foot, but without the equinovarus foot. A striatal toe is defined as an apparent extensor plantar response, without fanning of the toes, in the absence of any other signs suggesting dysfunction of the cortico-spinal tract and has to be differentiated from the Babinski sign [20]. None of the patients had a postural and striatal deformity simultaneously; to our knowledge only one such case has been reported [21].
Lower limb post-immobilization dystonia in Parkinson's disease
2005, Journal of the Neurological SciencesStriatal deformities of the hand and foot in Parkinson's disease
2005, Lancet NeurologyCitation Excerpt :Pressure is increased over the lateral aspect of the foot and ankle instability occurs.29,31 Over the years, different terms have been used to describe the striatal foot deformity, including the dystonic foot response of parkinsonism,32 dystonic claudication,33 striatal toe,34,35 hitchhiker's great toe,29 pseudo-rheumatoid deformity,36 and pseudo-Babinski.35 The all-encompassing term foot dystonia is commonly used to describe dystonic posturing of the legs and feet that happens in various clinical settings including PD and other Parkinson-plus syndromes.19,33,37–43