Bilateral Shoe Deterioration as a Result of Complex Motor Tics in Tourette Syndrome

Background: Tourette syndrome (TS) is a neurodevelopmental condition characterized by motor and phonic tics, commonly presenting with comorbid behavioral problems. We report the case of a patient with TS who presented with salient complex motor symptoms, namely treatment-refractory kicking resulting in bilateral shoe deterioration. Case History: “A.B.” was referred to our specialist clinic for adults with TS at the age of 18, following an 11-year history of tics, which started with mouth opening. He subsequently developed more complex motor tics and phonic tics, as well as echolalia, echopraxia, palipraxia, coprolalia, and copropraxia. He scored 65% on the YGTSS, indicating marked tic severity, and had a concomitant diagnosis of obsessive-compulsive disorder, experiencing obsessional thoughts and performing counting rituals. As part of his tic repertoire, this patient presented with repetitive, bilateral kicking, which was associated with arithmomania. The repetitive movement was most apparent when walking, and caused marked shoe damage, particularly at the tip. The frequency and severity of this repetitive movement resulted in this patient’s requiring new pairs of shoes almost every week. This symptom also caused hip and toe pain, and at one time led to dislocation of the knee joint. Interestingly, the kicking tic did not respond to antidopaminergic medication, unlike the other motor and vocal symptoms, which showed marked improvement on aripiprazole. Conclusions: The repetitive and stereotypical nature of complex motor tics in the context of TS can result in self-injurious movements. The compulsive nature of these symptoms can contribute to their refractoriness to conventional antidopaminergic treatment.