Botulinum Toxin Therapy (BOTOX)

[In Him]

Following a surgical procedure (Modified Kidner) that required the use of a Cadaver Achilles Allograft to reattach the Posterior Tib Tendon - I was left with continual spasms in my 5th toe (it has been loosely called dystonia, but I've also been told there is no formal Dx thus no ICD 9 code or Dx Name is available). I was also left with other nerve issues/problems following this procedure. This has been going on for aproximately 1 year. It is evident that the Abductor Digiti Minimi is also involved. I've seen 8 doctors to date (DPMs, Orthopedic Foot & Ankle Specialists, Neurologists and Pain Management physicians). Everyone has stated they have never seen this in a patient. Thus, there is no formal diagnosis... Subsequently, no formal treatment plan has been set in place.

Most recently it has been suggested to use Botox to paralyze the muscle to stop the spasms for aproximately 3 months.

Does anyone have knowledge or possible diagnosis for this type of spasm in the 5th toe? Has anyone heard of Botox being utilized for this type of issue?

Personally, I'm very leery of Botox. I feel it is just a bandaide and not a solution to the problem.

[DrJim]

Botox maybe a viable option as it stops the contraction of the muscle. If this is the cause of your pain in the 5th toe, this theoretically would help your condition. I say theoretically because if the condition is not due to the spasm of the muscle and rather due to an impingement of nerve(s), then likely this would not help. You may want to consider having a procedure done to possibly free up any entrapted nerves which may have happened since the previous surgery or may be occuring in the 5th toe region.

[In Him]

Dr. Jim,
Thank you for your reply. I had an EMG done since my post and I was told that the Abductor Digiti Minimi is 100% involved. My Pain Management physician has never seen this type of reading by this muscle. At this point most of my pain is still medially. He wants to try to locate the lateral plantar nerve to try doing a regional block. If he is able to find the nerve and is successful in blocking it he states it should stop the spasms. Is that correct?

The 5th toe is annoying, achey and cramps up. But the pain medially is awful. I had a Tarsal Tunnel Release of the Posterior Tib Nerve, but the doctor didn't go low enough to release the medial or lateral plantar nerves. I've also been diagnosed with RSD / CRPS. I've now undergone 4 lumbar sympathetic blocks. I had a good response through my 3rd block. Then I took a month off and the pain substantially increased again. I just had my 4th block this week. I've has some relief.

With the Dx of RSD / CRPS - what can be done with the lateral plantar nerve? Is it adviseable to try alcohol injections if they can identify the nerve?

[DrJim]

I agree completely with your pain management doctor, if you have been diagnosed with RSD, you want to stop that cycle as soon as possible. Gold standard is a regional block once the nerve is identified. Sometimes it does take multiple injections. You also may need to have the tarsal tunnel release surgery repeated if the post. tib. nerve is identified as still being entrapted and the injections do not resolve the pain long term. If the nerve is still impinged upon by either soft tissue or osseous structures, likely, these other injections may help, however, they are not curring the actual condition, compression of the tib. nerve and the pain will likely keep returning.

[In Him]

Thank you again for your input. I had my 4th sympathetic block on Tuesday. We had some issues with sedation, but I've been assured by my Pain Management doctor that he'll be increasing the medication used. My 5th sympathetic block is Tues., April 29th. I'm hoping for a good outcome.

Nov. 12th, 2007 I had an Ortho Foot & Ankle specialist go in and reconstruct my PTT by harvesting my FHL. So I'm now over 4 months out and I'm still having significant pain in that general area too. I have 2 anchors that were used in the navicular to reattach the reconstructed PTT in the Navicular. In the last set of X-Rays taken one of the anchors is out. I've been told that my Ortho doesn't want to go back in unless he absolutely has to, so he is wanting to wait 3 months to see if the pain resolves. I'm continuing with Physical Therapy 3x/week to work on desensitizing, ROM and strengthening of the PTT. Any exercises in PT that signal out the PTT are painful. This is not nerve pain. It is tendon pain and runs in the exact path of the PTT.

As you can see I have several different things that I'm dealing with. A reconstruction of the PTT that is suspect at this time, a loose anchor, possible impengement of the lateral plantar nerve and then early stages or RSD / CRPS. Is it possible that the PTT, loose anchor and impengement of the lateral plantar nerve could be habituating the medial pain and RSD / CRPS?

Is there any diagnostic test that could be done to check the PTT to ensure it is still intact since one of the anchors is out? Is there any was to verify the possible impengement of the lateral plantar nerve?

I think we've decided to wait on any possible Botox. I would prefer to find the real problem and fix it... rather than just putting a temporary bandaide on it.

Thank you sooo much for your input.

[DrJim]

It is very possible the PTT, loose anchor, and impingement of the lateral plantar nerve could be habituating the medial pain and RSD. Any irritation of this region can result in this condition.

To check the PTT status, normally a MRI is done. However, if the surgeon used metallic anchors (newer ones are biosynthetic), then you could not have a MRI. A CT scan could be ordered, not as helpful as MRI to show up soft tissue pathologies, however, it would show up edema and to a certain extent abnormalities of the tendon itself.

To diagnose impingement of the lateral plantar nerve, a test called "nerve conduction velocity test" could be done. This is where probes are used at each end of the nerve, an electrical impluse is applied to the proximal nerve and a receptor probe is used at the distal end. Time it takes the impulse to reach the receptor probe is measured. If the time is increased over the normal parameters, then there is some nerve pathology, either nerve impingement or nerve damage/abnormalty.

Hope these posts help. Sounds like you are in good hands with the care you are receiving.

[ssn679]

Unfortunately nothing to do with the fifth toe. I had moderate success with Botox A for several years with minimal sides. Condition Benign essential blepharospasms. Rash on arms and chest no where neer injection site. Besides being painful and given with little or no care as to the discomfort of the shots not bad until Botox B or Myoblock came into the picture. The dug dispensed with little regard for the correct usage. As in should not be given at same dose as Botox A, given sooner than the recommended waiting period 2 months instead of 4 months. The side effects worse than the cure. it seems botox b migrates and can cause serious sides three or four weeks after the injections. Be Leary. I have contacted the FDA and manufacturer of the medicine and gotten a tremendous amount of information. After experiencing dysphagia trouble speaking, extreme dry eyes, weakness and numbness in both arms and severe pain in the left arm. i decided against the next round of shots again not given at the prescribed interval. Shots given AT Va hospital here quality of care from mediocre to excellent . You being a physician i would imagine you would get the latter. I know i ramble, seriously read up on the sides. Be wary of the doc's giving the injections. Check out a website called WeMove.org . Don't let people board certified or otherwise touch you unless they are willing to explain all the possible sides before hand. then deny you had any of them after you have serious effects and then try to calm you down using bad jokes and clearly they were concerned that the information had not been dispensed. The pharmacist at VA says residents do not take the patient data sheets even though they come with the medication. i experienced these sides out of the blue and since i had minimal effects with botox a assumed b to be similar or the same. I had volunteered for a study but was turned down because of the proximity of a botox a injection (too soon) now the VA just gives the shots wily nilly no regard for the patient. They promised a myectomy nearly a year ago and threatened that I not tell anyone about my experience. I believe the VA is doing a study on the Botox B to see if it works in these cases . bottom line yes it gives some relief. your toe is spasming I don't know what type of pain you are experiencing. How does it affect your day to day life. Botox is a deadly poison. What I am getting at are there any alternatives?