68
Journal of The Association of Physicians of India ■ Vol. 63 ■ December 2015
Pictorial CME
Striatal Toe
Amandeep Raghuvanshi1, Jitender Sandhu2, Sujeet Raina3, Ashish Sharma4, Amit Bhardwaj4,
Rajesh Sharma 5
Fig. 1: Left side striatal toe
A
21 year old male who was taking
antipsychotic drugs from past 3
years presented with expressionless
face, slow initiation of movement and
abnormal upward posturing of the left
big toe for 6 months. This abnormal
posture of the left big toe was present
even during sleep and persisted during
walking. On examination left striatal
toe was noticed (Figure 1). Bradykinesia
and rigidity was present symmetrically,
but he had no tremors. Possibility of
drug-induced Parkinsonism was kept
and antipsychotics were withdrawn.
A striatal toe has been 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. 1
Striatal deformities of the hand and
foot are abnormal postures that are
common in patients with advanced
Parkinson’s disease (PD); they can
present in the early stages of PD and
in other parkinsonian disorders. 2 The
term striatal refers to the pathology
located in the neostriatum (caudate
and putamen). But it is inaccurate
because there is little evidence that a
striatal lesion is needed to produce
the posture. 2 Studies on striatal foot
have suggested an extrapyramidal
origin also.3 Striatal deformities
have been reported in 10% of patients
with untreated, advanced Parkinson’s
disease. 4
Misdiagnosis of the deformity
is common. Striatal toe must be
differentiated from dystonia, Babinski
sign and psychogenic toe.
Striatal toe deformity is fixed and is
present even during sleep but dystonia
commonly begins during activity and
can be associated with dystonic tremor.
Adult-onset primary dystonia rarely
affects legs and feet. 2 In Babinski sign
toe fanning and flexion synergy of other
muscles in the same leg is seen which
is absent in striatal toe. 1 In case of
striatal toe there is no pain or resistance
to passive plantar flexion and forced
dorsiflexion of second-fifth toes does
not alter the spontaneous toe extension
but in case of psychogenic toe passive
plantar flexion elicits pain and variable
resistance and forced dorsiflexion of the
second–fifth toes yields spontaneous
plantar flexion of the first toe. 5
References
1.
Winkler AS, Reuter I, Harwood G, Chaudhuri KR. The
frequency and significance of ‘striatal toe’ in parkinsonism.
Parkinsonism Relat Disord 2002; 9:97–101.
2.
Ashour R, Tintner R, Jankovic J. Striatal deformities of the
hand and foot in Parkinson’s disease. Lancet Neurol 2005;
4:423–31.
3.
Nausieda P, Weiner W, Klawans H. Dystonic foot response
of parkinsonism. Arch Neurol 1980; 37:132–36.
4.
Jankovic J, Tintner R. Dystonia and parkinsonism.
Parkinsonism Relat Disord 2001; 8:109–21.
5.
Espay AJ, Lang AE. The psychogenic toe signs. Neurology
2011; 77:508–9.
Registrar, 2PG Student, 3Assistant Professor, 5Associate Professor, Department of Medicine, 4Assistant Professor, Department of
Neurology, Dr. Rajendra Prasad Govt Medical College, Kangra, Himachal Pradesh
Received: 01.07.2014; Accepted: 09.07.2015
1