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Toxins 2017, 9(11), 375;

Ultrasonographic Evaluation of Botulinum Toxin Injection Site for the Medial Approach to Tibialis Posterior Muscle in Chronic Stroke Patients with Spastic Equinovarus Foot: An Observational Study

Neuromotor and Cognitive Rehabilitation Research Center, Department of Neurosciences, Biomedicineand Movement Sciences, University of Verona, Verona 37134, Italy
Health Sciences Department, Università del Piemonte Orientale, Novara 28100, Italy
Physical Medicine and Rehabilitation Section, “OORR Hospital”, University of Foggia, Foggia 71122, Italy
Author to whom correspondence should be addressed.
Academic Editors: Jennifer G. Goldman and Codrin Lungu
Received: 18 October 2017 / Revised: 15 November 2017 / Accepted: 16 November 2017 / Published: 18 November 2017
(This article belongs to the Special Issue Muscle Selection for BoNT)
PDF [239 KB, uploaded 22 November 2017]


The tibialis posterior muscle is a frequent target for injection of botulinum toxin during the management of spastic equinovarus foot in adults with post-stroke spasticity. Although it is deep-seated, the needle insertion into the tibialis posterior muscle is usually performed using anatomical landmarks and safety information obtained from healthy subjects and cadavers. Our aim was to evaluate the botulinum toxin injection site for the medial approach to the tibialis posterior muscle in chronic stroke patients with spastic equinovarus foot. Forty-six patients were evaluated at the affected middle lower leg medial surface with ultrasonography according to the following parameters: tibialis posterior muscle depth, thickness, and echo intensity. As to the spastic tibialis posterior, we found a mean muscle depth of 26.5 mm and a mean muscle thickness of 10.1 mm. Furthermore we observed a median tibialis posterior muscle echo intensity of 3.00 on the Heckmatt scale. The tibialis posterior muscle thickness was found to be inversely associated with its depth (p < 0.001) and echo intensity (p = 0.006). Furthermore, tibialis posterior muscle depth was found to be directly associated with its echo intensity (p = 0.004). Our findings may usefully inform manual needle placement into the tibialis posterior for the botulinum toxin treatment of spastic equinovarus foot in chronic stroke patients. View Full-Text
Keywords: muscle spasticity; rehabilitation; ultrasonography muscle spasticity; rehabilitation; ultrasonography
This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited (CC BY 4.0).

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Picelli, A.; Baricich, A.; Chemello, E.; Smania, N.; Cisari, C.; Gandolfi, M.; Cinone, N.; Ranieri, M.; Santamato, A. Ultrasonographic Evaluation of Botulinum Toxin Injection Site for the Medial Approach to Tibialis Posterior Muscle in Chronic Stroke Patients with Spastic Equinovarus Foot: An Observational Study. Toxins 2017, 9, 375.

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