Clinical Orthopaedics and Related Research®

, Volume 471, Issue 7, pp 2327–2332 | Cite as

The Influence of Botulinum Toxin A Injections into the Calf Muscles on Genu Recurvatum in Children With Cerebral Palsy

  • Matthias C. M. Klotz
  • Sebastian I. Wolf
  • Daniel Heitzmann
  • Simone Gantz
  • Frank Braatz
  • Thomas Dreher
Clinical Research



With cerebral palsy (CP), an equinus deformity may lead to genu recurvatum. Botulinum toxin A (BtA) injection into the calf muscles is a well-accepted treatment for dynamic equinus deformity.


The purpose of this study was to determine whether BtA injections into the calf muscles to decrease equinus would decrease coexisting genu recurvatum in children with diplegic CP.


In a retrospective study, 13 children (mean age, 5 years) with spastic diplegic CP showing equinus and coexisting primary genu recurvatum, who were treated with BtA injections into the calf muscles, were included. Evaluations were done before and 6 and 18 weeks after intervention using three-dimensional gait analysis and clinical examinations according to a standardized protocol. Basic statistical analyses (power analysis, ANOVA) were performed to compare genu recurvatum before treatment and at 6 and 18 weeks after injection with BtA.


During stance phase, maximum ankle dorsiflexion was increased substantially from −3.0° ± 14.3° before to 6.2° ± 14.2° 6 weeks after the injections. Despite this, with the numbers available, the amount of recurvatum in stance did not improve with treatment at either 6 or 18 weeks. There was significant improvement of knee hyperextension during stance phase of 6.2° between baseline and 18 weeks after BtA injection, but a genu recurvatum was still present in most patients.


Despite improvement of ankle dorsiflexion after injection with BtA, genu recurvatum did not show relevant improvement at 6 or 18 weeks after injection with the numbers available. Because knee hyperextension remained in most patients, other factors leading to genu recurvatum should be taken into consideration. In addition, a botulinum toxin-induced weakness of the gastrocnemius may explain why recurvatum gait was not significantly reduced.

Level of Evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.


Cerebral Palsy Knee Extension Soleus Muscle Stance Phase Gait Analysis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We thank Simone Gantz for completing the statistics in this study, and the staff of Heidelberg’s motion laboratory for assistance in collecting the data.


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Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Matthias C. M. Klotz
    • 1
  • Sebastian I. Wolf
    • 1
  • Daniel Heitzmann
    • 1
  • Simone Gantz
    • 1
  • Frank Braatz
    • 1
  • Thomas Dreher
    • 1
  1. 1.Department of Orthopaedic and Trauma SurgeryHeidelberg University ClinicsHeidelbergGermany

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