Wolfgang Jost

Pictorial Guide
to Botulinum
Toxin Injection
43940
Wolfgang Jost

Pictorial Guide
to Botulinum
Toxin Injection
Important note

As with every other science, medicine is subject to constant development. Research

and clinical experience widen our knowledge base, particularly with regard to treat-
ment modalities. If any dosages or methods of administration are mentioned in this
book, the reader may have confidence that the authors, editors and publishers have
taken great care to ensure that this information is in line with the latest knowledge
available at the time of publication.

However, the publisher cannot give guarantees for any information regarding tailor-
made peel formulae, dosing instructions and methods of administration. All users
are requested to take great care to check the package insert leaflets of the products
used and to consult the manufacturer/distributer, if necessary, to establish whether
the dosage recommendations or details of contraindications given therein differ in
any way from the information given in this book. This sort of check is particularly
important with rare indications, treatment areas, or with minimally used or recently
launched products. The use of any medication dose or method of administration
takes place at the user’s own risk. The authors and publisher appeal to all users to
inform them if they spot any obvious inaccuracies.

This book, including all its parts, is protected by copyright. Any use of this book
outside the narrow limits of copyright law, without permission from the publisher, is
prohibited and constitutes an offence. This applies in particular to duplication, trans-
lation, microfilming, and storage and processing in electronic systems.

Merz Pharmaceuticals GmbH, Germany © 2015

Preface

In the multimodal therapy of spasticity, botulinum neurotoxin has become indispens-

able. To inject the medication properly and optimally, good knowledge of anatomy
is required, which one always needs to refresh using anatomical atlases. This pocket
book is intended to support you in your daily work. Listed are all the major muscles
for this therapy, as well as the neighboring muscles. This booklet will also provide
important assistance in the use of additional techniques such as electromyography
and sonography. We would be delighted if you use this book regularly and also give
us feedback. With such collegial exchange, ambiguities and missing information can
be eliminated. Have fun working with this book.

The publication of this book could only be achieved with the dedication of many
colleagues and people involved in the project. I am grateful for their help and con-
tinuous constructive input. My special thanks go to Dr. Klaus-Peter Valerius, graphic
designer David Kühn for his expertise in creating the illustrations, and Dr. Susanne
Heitmann, Wiesbaden, who kindly supported me in providing the ultrasound images.

Printing and production of this pocket book have been supported with a financial
grant by Merz Pharmaceuticals GmbH.

Freiburg, April 2015

Prof. Dr. med. Wolfgang Jost
Contents

1 Overview of injection patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Table of clinical patterns, muscles, and botulinum neurotoxin dosages . . . . . . . 9

2 Upper limb muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Muscles of the pectoral girdle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Muscles of the shoulder joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Muscles of the elbow joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Muscles of the wrist joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Muscles of the finger joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

3 Lower limb muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Muscles of the hip joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Muscles of the knee joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Muscles of the ankle joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Muscles of the toe joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

4 Normal range of motion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

5 Additional therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

A multidisciplinary approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Additional therapy options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198

6 Principal scales used in rehabilitation . . . . . . . . . . . . . . . . . . 201

Disability evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Evaluation of the effect of a treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Global functional scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Lower limb functional scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Specific functional scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Upper limb functional scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Incapacity scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Muscle strength . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Quality of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Spasm scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Tone scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
1 Overview of
injection patterns

Pictorial Guide to Botulinum Toxin Injection 7

 Overview of injection patterns

Table of clinical patterns, muscles,

and botulinum neurotoxin dosages
Joint Pattern Active disability Passive disability

Upper Limb

Shoulder Adducted/ • Restricted ability to • Impairment of dressing,

internally reach targets in the envi- washing (risk of mac-
rotated ronment (e.g. pick up an eration in the axilla), and
1 object laterally placed), bathing
and on the body (e.g., to • Painful manipulation
2 comb one's hair) • Self-image consequences
• Walking and stand-up
3 imbalance

4
Elbow Flexed • Restricted ability to • Difficulties in pulling shirt
reach objects in space or jacket sleeve
5
• Walking and stand-up • Skin maceration in the
6 imbalance elbow pit
• Self-image consequences

Forearm Pronated • Impairment in the

ability to orient the hand

Wrist Flexed • Difficulties in pulling • Pain on passive move-

shirt or jacket sleeve or ment
gloves • Carpal tunnel symptoms
• Difficulties to grasp and
manipulate objects

8 Pictorial Guide to Botulinum Toxin Injection

 Table of clinical patterns, muscles, and botulinum neurotoxin dosages

Muscles Recommended Recommended Recommended total

­involved ­minimal dose (MU) ­maximal dose (MU) dose per pattern (MU)

Pectoralis Botox®/Xeomin®: 20 Botox®/Xeomin®: 100 Botox®/Xeomin®:

major* Dysport®: 80 Dysport®: 400 25–240
Dysport®: 100–950
Teres major* Botox®/Xeomin®: 10 Botox®/Xeomin®: 40
Dysport®: 40 Dysport®: 150

Latissimus Botox®/Xeomin®: 20 Botox®/Xeomin®: 100

dorsi Dysport®: 80 Dysport®: 400

Brachio­ Botox®/Xeomin®: 20 Botox®/Xeomin®: 100 Botox®/Xeomin®:

radialis* Dysport®: 50 Dysport®: 400 60–260
Dysport®:160–1000
Biceps brachii* Botox®/Xeomin®: 20 Botox®/Xeomin®: 100
Dysport®: 60 Dysport®: 400

Brachialis* Botox®/Xeomin®: 20 Botox®/Xeomin®: 60

Dysport®: 50 Dysport®: 200

Pronator Botox®/Xeomin®: 10 Botox®/Xeomin®: 30 Botox®/Xeomin®: 15–50

teres* Dysport®: 40 Dysport®: 100 Dysport®:60–180

Pronator Botox®/Xeomin®: 5 Botox®/Xeomin®: 20

quadratus* Dysport®: 20 Dysport®: 80

Flexor carpi Botox®/Xeomin®: 10 Botox®/Xeomin®: 60 Botox®/Xeomin®:

radialis* Dysport®: 40 Dysport®: 200 10–240
Dysport®: 40–800
Flexor carpi Botox®/Xeomin®: 10 Botox®/Xeomin®: 60
ulnaris* Dysport®: 40 Dysport®: 200

Flexor digito­ Botox®/Xeomin®: 20 Botox®/Xeomin®: 60

rum superficialis Dysport®: 60 Dysport®: 200

Flexor digito- Botox®/Xeomin®: 20 Botox®/Xeomin®: 60

rum profundus Dysport®: 60 Dysport®: 200

continued on next page 

The muscles marked * are usually the ones that have to be in­jected for the pattern mentioned.
Therefore, only their minimal dose is considered for the recommended minimal dose per pattern.

Pictorial Guide to Botulinum Toxin Injection 9

 Overview of injection patterns

Joint Pattern Active disability Passive disability

Fist Clenched • Increasing difficulties • Impairment of palm

to grasp and release access (washing, skin
objects maceration, nail cutting,
capillary glycaemia …)
• Pain on passive move-
ment

1
Thumb-In- Adduction + • Two or three-digit grasp • Pain
2 Palm Defor- Flexion impossible
mity
3
4
5
6
Lower Limb

Ankle Equinovarus • Walking discomfort via • Discomfort: lateral

the stance phase and pain of the foot, callus
foot drag formation, lateral skin
• Imbalance breakdown, floor
• Difficulty with limb • Difficulties with serial
advancement casting
• Ankle instability (risk of • Difficulties to put on
sprain) shoes

10 Pictorial Guide to Botulinum Toxin Injection

 Table of clinical patterns, muscles, and botulinum neurotoxin dosages

Muscles Recommended Recommended Recommended total

­involved ­minimal dose (MU) ­maximal dose (MU) dose per pattern (MU)

Flexor Botox®/Xeomin®: 20 Botox®/Xeomin®: 60 Botox®/Xeomin®:

digitorum Dysport®: 60 Dysport®: 200 40–120
superficialis* Dysport®: 120–400

Flexor Botox®/Xeomin®: 20 Botox®/Xeomin®: 60

digitorum Dysport®: 60 Dysport®: 200
profundus*

Adductor pol- Botox®/Xeomin®: 2.5 Botox®/Xeomin®: 10 Botox®/Xeomin®: 5–40

licis* Dysport®: 10 Dysport®: 40 Dysport®: 20–160

Opponens Botox®/Xeomin®: 2.5 Botox®/Xeomin®: 10

pollicis* Dysport®: 10 Dysport®: 40

Flexor pollicis Botox®/Xeomin®: 5 Botox®/Xeomin®: 20

longus Dysport®: 20 Dysport®: 80

Medial gast­ Botox®/Xeomin®: 20 Botox®/Xeomin®: 100 Botox®/Xeomin®:

rocnemius* Dysport®: 80 Dysport®: 300 80–480
(equinus) Dysport®: 320–1500

Lateral gast­ Botox®/Xeomin®: 20 Botox®/Xeomin®: 100

rocnemius* Dysport®: 80 Dysport®: 300
(equinus)

Soleus* Botox®/Xeomin®: 20 Botox®/Xeomin®: 100

(equinus) Dysport®: 80 Dysport®: 300

Tibialis poste- Botox®/Xeomin®: 20 Botox®/Xeomin®: 100

rior* (varus) Dysport®: 80 Dysport®: 300

Tibialis ante- Botox®/Xeomin®: 20 Botox®/Xeomin®: 80

rior (varus) Dysport®: 80 Dysport®: 250

continued on next page 

The muscles marked * are usually the ones that have to be in­jected for the pattern mentioned.
Therefore, only their minimal dose is considered for the recommended minimal dose per pattern.

Pictorial Guide to Botulinum Toxin Injection 11

 Overview of injection patterns

Joint Pattern Active disability Passive disability

Ankle Valgus • Imbalance • Pain over the median

• Ankle instability (risk of border of the foot
sprain)

1
2
3
4
5
6

Hallucis Extension • Increased varus pattern • Inability to wear a shoe

• Incomfort when wearing
shoes
• Pain at the tip of the toe

Toes Flexion • Imbalance • Discomfort

12 Pictorial Guide to Botulinum Toxin Injection

 Table of clinical patterns, muscles, and botulinum neurotoxin dosages

Muscles Recommended Recommended Recommended total

­involved ­minimal dose (MU) ­maximal dose (MU) dose per pattern (MU)

Peroneus Botox®/Xeomin®: 5 Botox®/Xeomin®: 40 Botox®/Xeomin®:

longus* Dysport®: 20 Dysport®: 140 60–400
Dysport®: 240–1500
Gastro­ Botox®/Xeomin®: 20 Botox®/Xeomin®: 100
cnemius* per head per head
Dysport®: 80 per head Dysport®: 300 per
head

Soleus* Botox®/Xeomin®: 20 Botox®/Xeomin®: 100

Dysport®: 80 Dysport®: 300

Tibialis Botox®/Xeomin®: 20 Botox®/Xeomin®: 80

­anterior Dysport®: 80 Dysport®: 250

Tibialis Botox®/Xeomin®: 20 Botox®/Xeomin®: 100

­posterior Dysport®: 80 Dysport®: 300

Flexor digito- Botox®/Xeomin®: 10 Botox®/Xeomin®: 40

rum longus Dysport®: 40 Dysport®: 140

Extensor hal- Botox®/Xeomin®: 20 Botox®/Xeomin®: 40 Botox®/Xeomin®: 20–40

lucis longus* Dysport®: 80 Dysport®: 140 Dysport®: 80–140

Flexor digito- Botox®/Xeomin®: 10 Botox®/Xeomin®: 40 Botox®/Xeomin®: 10–60

rum longus* Dysport®: 40 Dysport®: 140 Dysport®: 40–220

Quadratus Botox®/Xeomin®: 5 Botox®/Xeomin®: 20

plantae Dysport®: 20 Dysport®: 80

continued on next page 

The muscles marked * are usually the ones that have to be in­jected for the pattern mentioned.
Therefore, only their minimal dose is considered for the recommended minimal dose per pattern.

Pictorial Guide to Botulinum Toxin Injection 13

 Overview of injection patterns

Joint Pattern Active disability Passive disability

Knee Flexion • Imbalance • Impaired positionning

• Crouch gait pattern on bed
• Limitation of limb • Difficulties in pulling
advancement trousers

1
2
3
4
5
6

14 Pictorial Guide to Botulinum Toxin Injection

 Table of clinical patterns, muscles, and botulinum neurotoxin dosages

Muscles Recommended Recommended Recommended total

­involved ­minimal dose (MU) ­maximal dose (MU) dose per pattern (MU)

Biceps femo- Botox®/Xeomin®: 40 Botox®/Xeomin®: 140 Botox®/Xeomin®:

ris* (medial Dysport®: 100 Dysport®: 400 120–400
hamstrings) Dysport®: 400–1500

Semimembra- Botox®/Xeomin®: 20 Botox®/Xeomin®: 100

nosus* (lateral Dysport®: 80 Dysport®: 300
hamstrings)

Semitendino- Botox®/Xeomin®: 20 Botox®/Xeomin®: 80

sus* (lateral Dysport®: 60 Dysport®: 250
hamstrings)

Gastro­ Botox®/Xeomin®: 20 Botox®/Xeomin®: 100

cnemius* per head per head
Dysport®: 80 per head Dysport®: 300 per head

Rectus femoris Botox®/Xeomin®: 20 Botox®/Xeomin®: 100

(quadriceps Dysport®: 50 Dysport®: 300
femoris)

Vastus media- Botox®/Xeomin®: 20 Botox®/Xeomin®: 80

lis (quadriceps Dysport®: 50 Dysport®: 250
femoris)

Vastus Botox®/Xeomin®: 20 Botox®/Xeomin®: 80

intermedius Dysport®: 50 Dysport®: 250
(quadriceps
femoris)

Vastus lateralis Botox®/Xeomin®: 20 Botox®/Xeomin®: 80

(quadriceps Dysport®: 50 Dysport®: 250
femoris)

continued on next page 

The muscles marked * are usually the ones that have to be in­jected for the pattern mentioned.
Therefore, only their minimal dose is considered for the recommended minimal dose per pattern.

Pictorial Guide to Botulinum Toxin Injection 15

 Overview of injection patterns

Joint Pattern Active disability Passive disability

Knee Extension • Imbalance • Impaired positioning on

chair

1
2
3
4
5
6

16 Pictorial Guide to Botulinum Toxin Injection

 Table of clinical patterns, muscles, and botulinum neurotoxin dosages

Muscles Recommended Recommended Recommended total

­involved ­minimal dose (MU) ­maximal dose (MU) dose per pattern (MU)

Semimembra- Botox®/Xeomin®: 20 Botox®/Xeomin®: 100 Botox®/Xeomin®:

nosus* (lateral Dysport®: 80 Dysport®: 300 20–400
hamstrings) Dysport®: 80 –1000

Rectus Botox®/Xeomin®: 20 Botox®/Xeomin®: 80

femoris* Dysport®: 60 Dysport®: 250
(quadriceps
femoris)

Semitendi- Botox®/Xeomin®: 20 Botox®/Xeomin®: 100

nosus (lateral per head per head
hamstrings) Dysport®: 80 per head Dysport®: 300 per
head

Gastrocnemius Botox®/Xeomin®: 20 Botox®/Xeomin®: 100

Dysport®: 50 Dysport®: 300

Gluteus Botox®/Xeomin®: 40 Botox®/Xeomin®: 100

maximus Dysport®: 140 Dysport®: 300

Vastus media- Botox®/Xeomin®: 20 Botox®/Xeomin®: 80

lis (quadriceps Dysport®: 50 Dysport®: 250
femoris)

Vastus Botox®/Xeomin®: 20 Botox®/Xeomin®: 80

intermedius Dysport®: 50 Dysport®: 250
(quadriceps
femoris)

Vastus lateralis Botox®/Xeomin®: 20 Botox®/Xeomin®: 80

(quadriceps Dysport®: 50 Dysport®: 250
femoris)

Iliopsoas Botox®/Xeomin®: 25 Botox®/Xeomin®: 200

(psoas minor Dysport®: 100 Dysport®: 600
+ psoas major
+ iliacus)

continued on next page 

The muscles marked * are usually the ones that have to be in­jected for the pattern mentioned.
Therefore, only their minimal dose is considered for the recommended minimal dose per pattern.

Pictorial Guide to Botulinum Toxin Injection 17

 Overview of injection patterns

Joint Pattern Active disability Passive disability

Thighs Adducted • Scissoring walks: • Scissoring thighs:

­interfere with standing, interfere with perineal
and walking hygiene, dressing, sexual
• Imbalance intimacy, sitting, transfers

1
2
3
4
5
6

Hip Flexed • Interference with sexual • Interference with posi-

intimacy, and gait tioning, perineal care
• Urinary incontinence or
emergency via increase
intra-abdominal pressure

18 Pictorial Guide to Botulinum Toxin Injection

 Table of clinical patterns, muscles, and botulinum neurotoxin dosages

Muscles Recommended Recommended Recommended total

­involved ­minimal dose (MU) ­maximal dose (MU) dose per pattern (MU)

Adductor Botox®/Xeomin®: 20 Botox®/Xeomin®: 100 Botox®/Xeomin®:

longus* Dysport®: 50 Dysport®: 300 60–400
Dysport®: 180–1000
Adductor Botox®/Xeomin®: 30 Botox®/Xeomin®: 150
magnus* Dysport®: 100 Dysport®: 499

Adductor Botox®/Xeomin®: 20 Botox®/Xeomin®: 80

brevis* Dysport®: 50 Dysport®: 250

Gracilis* Botox®/Xeomin®: 20 Botox®/Xeomin®: 60

Dysport®: 50 Dysport®: 200

Iliopsoas Botox®/Xeomin®: 25 Botox®/Xeomin®: 200

(psoas minor Dysport®: 100 Dysport®: 600
+ psoas major
+ iliacus)

Pectineus Botox®/Xeomin®: 20 Botox®/Xeomin®: 50

Dysport®: 80 Dysport®: 180

Iliopsoas* Botox®/Xeomin®: 25 Botox®/Xeomin®: 200 Botox®/Xeomin®:

(psoas minor Dysport®: 100 Dysport®: 600 60–400
+ psoas major Dysport®: 180–1000
+ iliacus)

Pectineus* Botox®/Xeomin®: 20 Botox®/Xeomin®: 50

Dysport®: 80 Dysport®: 180

Rectus femoris Botox®/Xeomin®: 20 Botox®/Xeomin®: 100

(quadriceps Dysport®: 50 Dysport®: 300
femoris)

Adductor Botox®/Xeomin®: 20 Botox®/Xeomin®: 100

longus Dysport®: 50 Dysport®: 300

Adductor Botox®/Xeomin®: 20 Botox®/Xeomin®: 80

brevis Dysport®: 50 Dysport®: 250

Gluteus Botox®/Xeomin®: 40 Botox®/Xeomin®: 100

maximus Dysport®: 140 Dysport®: 300

The muscles marked * are usually the ones that have to be in­jected for the pattern mentioned.
Therefore, only their minimal dose is considered for the recommended minimal dose per pattern.

Pictorial Guide to Botulinum Toxin Injection 19

2 Upper limb muscles

Muscles of the pectoral girdle 22

Muscles of the shoulder joint 38

Muscles of the elbow joint 54

Muscles of the wrist joint 66

Muscles of the finger joints 76

Pictorial Guide to Botulinum Toxin Injection 21

 Upper limb muscles

Trapezius, lower (ascending) part

1
2
3
4
5
6

Nerve supply
Accessory nerve (XI).

Origin
Spinous processes of the 4th to 12th thoracic vertebrae.
Supraspinal ligament.

Insertion
Fibers end in an aponeurosis inserting onto the medial spine of the scapula.

Dosage/needle size
Xeomin®: 5–20 MU/injection site.
Botox®: 5–20 MU/injection site.
Dysport®: 20–80 MU/injection site.
Needle length: 20–40 mm.

22 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the pectoral girdle

Action
Lower fibers: pull down scapula.
Lower and upper fibers simultaneously: lateral rotation
of scapula (glenoid cavity points up and the inferior
angle to the side [elevation position]).

Injection protocol
Number of puncture sites: 2–4.

Topographical indication
Risk of latissimus dorsi injury if injected too low and
deep.
Risk of pneumothorax if injected extremely deeply and
vertically.

Injection technique
Site: lower fibers, at the height of the inferior angle of
scapula, ~ 3–4 cm lateral to the spine.
Direction: vertically or in the direction of the fibers.
Patient position: sitting or prone with arm flexed.

Clinical application
Cervical dystonia: frequent unilateral contracture of trapezius.
Pain therapy: palpated trigger points are injected directly.

Pictorial Guide to Botulinum Toxin Injection 23

 Upper limb muscles

Trapezius, middle (transverse) part

1
2
3
4
5
6

Nerve supply
Accessory nerve (XI).

Origin
Nuchal ligament.
Spinous processes of the 5th cervical and 3rd thoracic vertebrae.

Insertion
Spine of the scapula.
Acromion.

Dosage/needle size
Xeomin®: 5–20 MU/injection site.
Botox®: 5–20 MU/injection site.
Dysport®: 20–80 MU/injection site.
Needle length: 20–40 mm.

24 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the pectoral girdle

Action
Middle fibers: draw scapula toward midline, fixing it
on trunk.

Injection protocol
Number of puncture sites: 2–4.

Topographical indication
Risk of infiltrating rhomboid major if injected too
deeply.
Risk of pneumothorax if injected extremely deeply and
vertically.

Injection technique
Site: ~2 cm medial to the superior angle of scapula, on
a horizontal line between the spine of scapula and the
vertebral column.
Direction: vertically, or in the direction of the fibers.
Patient position: sitting or prone with arm abducted at
shoulder joint.

Clinical application
Cervical dystonia: frequent unilateral contracture of trapezius.
Pain therapy: palpated trigger points are injected directly.

Pictorial Guide to Botulinum Toxin Injection 25

 Upper limb muscles

Trapezius, upper (descending) part

1
2
3
4
5
6

Nerve supply
Accessory nerve (XI).
Ventral rami of C2–C4.

Origin
External occipital protuberance and medial third
of superior nuchal line, nuchal ligament.
Spinous processes of 1st to 4th cervical vertebrae.

Insertion
Lateral third of clavicle.
Acromion.

Dosage/needle size
Xeomin®: 5–20 MU/injection site.
Botox®: 5–20 MU/injection site.
Dysport®: 20–80 MU/injection site.
Needle length: 20–40 mm.

26 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the pectoral girdle

Action
Upper fibers: elevate scapula, and extend cervical spine
(tilt towards contracting side).
Upper and lower fibers simultaneously: lateral rotation
of scapula (glenoid cavity points up and the inferior
angle to the side [elevation position]).

Injection protocol
Number of puncture sites: 1 () or 2 ().

Topographical indication
Easily visible and palpable.
Risk of infiltrating levator scapulae if injected too deeply.
Risk of penetrating supraspinatus if injected too far
laterally.
Risk of pneumothorax if injected extremely deeply and
vertically.

Injection technique
Site: border of neck with shoulder.
Direction: vertically, or in the direction of the fibers.
Patient position: sitting or prone.
Cave: do not inject to deep.

Clinical application
Cervical dystonia (retrocollis, laterocollis and rotatory torticollis), and tension headache.
Pain therapy: palpated trigger points are injected directly.

Pictorial Guide to Botulinum Toxin Injection 27

 Upper limb muscles

Levator scapulae

1
2
3
4
5
6

Nerve supply
Dorsal scapular nerve, C3–C5.
Ventral rami of C3–C5.

Origin
Posterior tubercles of transverse processes of
1st to 4th cervical vertebrae.

Insertion
Superior angle of scapula and superior part of the
medial border of scapula.

Dosage/needle size
Xeomin®: 5–60 MU (rarely higher).
Botox®: 5–60 MU (rarely higher).
Dysport®: 20–200 MU (rarely higher).
Needle length: 40 mm.

28 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the pectoral girdle

Action
Depending on fixed point, elevates shoulder blade or
prevents pulling down; also medially rotates scapula.
Fixed shoulder: bilateral contraction flexes neck, unilat-
eral contraction tilts head.

Injection protocol
Number of puncture sites: 1–3.
1: preferred injection site in cervical dystonia.
2 3: especially in pain therapy.

Topographical indication
dorsal
Very superficial in front of trapezius or injection through
trapezius (1). Splenii capitis and cervicis lie medially,
1 1
and rhomboid slightly below.

ventral

Injection technique
Site 1: locate origin of levator scapulae, and inject be-
tween sternocleidomastoid and trapezius.
Site 2: best with ultrasound guidance.
Site 3: 3–4 cm above and 1–2 cm lateral to the insertion.
Patient position: sitting or prone. Incline head away
from injection site, slightly rotate inward and lift shoul-
der towards corresponding ear.

Clinical application
Cervical dystonia and tension headache.
Palpation should distinguish levator scapulae from upper trapezius.
Key muscle: involved in rotation, lateroflexion, head flexion (Antecollis), and shoulder
elevation.

Pictorial Guide to Botulinum Toxin Injection 29

 Upper limb muscles

Rhomboid major

1
2
3
4
5
6

Nerve supply
Dorsal scapular nerve, C4–C4.

Origin
Spinous processes of 1st to 5th thoracic vertebrae.

Insertion
Medial border and inferior angle of scapula.

Dosage/needle size
Xeomin®: 5–20 MU/injection site (rarely higher).
Botox®: 5–20 MU/injection site (rarely higher).
Dysport®: 20–80 MU/injection site (rarely higher).
Needle length: 20–40 mm.

30 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the pectoral girdle

Action
Rhomboids:
Elevate scapula and retract it towards spine.
Fix medial scapular border to thoracic wall (with ser-
ratus anterior).

Injection protocol
Number of puncture sites: 1 () or 2 ().

Topographical indication
Risk of pneumothorax if injected extremely deeply and
vertically.
Risk of reaching only trapezius if injected too superfi-
cially, and penetrating erector spinae if too deep.
Difficult to distinguish between major and minor rhom-
boid in cranial area.

Injection technique
Site: medial to scapula, in the middle of the inferior
angle and the spine of scapula.
Direction: vertically, or in the direction of the fibers; al-
ternatively also towards the scapular border.
Patient position: sitting or prone; shoulder blades re-
tracted.

Clinical application
Medial protrusion of scapula due to muscle paralysis.
Pain syndromes (rhomboid major).

Pictorial Guide to Botulinum Toxin Injection 31

 Upper limb muscles

Rhomboid minor

1
2
3
4
5
6

Nerve supply
Dorsal scapular nerve, C4.

Origin
Spinous processes of 6th and 7th cervical vertebrae.

Insertion
Medial border of scapula, near spine of scapula, superior to rhomboid major.

Dosage/needle size
Xeomin®: 5–20 MU/injection site (rarely higher).
Botox®: 5–20 MU/injection site (rarely higher).
Dysport®: 20–80 MU/injection site (rarely higher).
Needle length: 20–40 mm.

32 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the pectoral girdle

Action
Rhomboids:
Elevate scapula and retract it towards spine.
Fix medial scapular border to thoracic wall (with ser-
ratus anterior).

Injection protocol
Number of puncture sites: 1.

Topographical indication
Difficult to distinguish from middle part of trapezius.
Risk of reaching serratus anterior if injected too deeply.

Injection technique
Site: 1–2 cm medial and superior to medial border of
scapula.
Direction: vertically, or in the direction of the fibers;
alternatively also towards the scapular border.
Patient position: Sitting or prone; shoulder blades re-
tracted.

Clinical application
Pain syndromes. A muscle paralysis of this muscle can lead to a medical protrusion of the
scapula. The differentiation between rhomboid major and minor is artificial.

Pictorial Guide to Botulinum Toxin Injection 33

 Upper limb muscles

Serratus anterior

1
2
3
4
5
6

Nerve supply
Long thoracic nerve, C5–C7.

Origin
1st to 9th rib, forming an arch beginning below the armpit.

Insertion
Ventral aspect of the medial border of scapula between superior and inferior angles.

Dosage/needle size
Xeomin®: 5–10 MU/injection site (rarely higher).
Botox®: 5–10 MU/injection site (rarely higher).
Dysport®: 20–80 MU/injection site (rarely higher).
Needle length: 20–40 mm.

34 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the pectoral girdle

Action
Protracts scapula and (with trapezius) rotates it laterally
into elevated position.
Fixes medial scapular border to thoracic wall (with
rhomboid major).

Injection protocol
Number of puncture sites: multiple, usually 1–6 (in up
to 10 fleshy digitation-like attachments of the muscle).

Topographical indication
Risk of pneumothorax if injected extremely deeply and
vertically (especially between ribs).
Distal to the inferior angle of scapula, injecting too su-
perficially may reach latissimus dorsi; injecting too far
cranially may infiltrate teres major.

Injection technique
Site: palpate digitations of the muscle and inject be-
tween the middle and anterior axillary line.
Injection of one site (): distal to inferior angle of
scapula.
Patient position: sitting or prone with arm elevated.

Clinical application
Pain syndromes. A muscle paralysis of this muscle can lead to a medical protrusion of the
scapula (mainly of the inferior angle).

Pictorial Guide to Botulinum Toxin Injection 35

 Upper limb muscles

Pectoralis minor

1
2
3
4
5
6

Nerve supply
Medial and lateral pectoral nerves, C6–C8.

Origin
Upper border and ventral surface of 3rd to 5th ribs near costal cartilages, fascia of the respective
intercostals.

Insertion
Coracoid process of scapula.

Dosage/needle size
Xeomin®: 10–40 MU (rarely higher).
Botox®: 10–40 MU (rarely higher).
Dysport®: 40–200 MU (rarely higher).
Needle length: 40 mm.

36 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the pectoral girdle

Action
Fixes scapula to thoracic wall and prevents dorsal shift-
ing.
Draws shoulder blade inferiorly and medially.

Injection protocol
Number of puncture sites: 1.

Topographical indication
Risk of pneumothorax if injected extremely deeply.
Risk of puncturing pectoralis major if injected too su-
perficially.

Injection technique
Site: medioclavicular line at the height of the 3rd rib.
Direction: towards the rib.
Patient position: sitting or prone with arm abducted.

Clinical application
Pain therapy: muscle shortening can compress the brachial plexus or the axillary vessels in
the arm. Contracture leads to reduced arm anteversion.
Often difficult to distinguish from pectoralis major.

Pictorial Guide to Botulinum Toxin Injection 37

 Upper limb muscles

Deltoid

1
2
3
4
5
6

Nerve supply
Axillary nerve, C5–C6.

Origin
Anterior fibers: lateral third of clavicle.
Middle fibers: acromion.
Posterior fibers: lower lip of spine of scapula.

Insertion
Deltoid tuberosity of humerus.

Dosage/needle size
Xeomin®: 5–50 MU (rarely higher).
Botox®: 5–50 MU (rarely higher).
Dysport®: 20–200 MU (rarely higher).
Needle length: 20–40 mm.

38 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the shoulder joint

Action
Powerful abductor, also involved in ante- and retro-
version, and medial and lateral rotation.
Counteracts luxation of humerus.

Injection protocol
B A Number of puncture sites: 3 (1 per fiber group).
3/3
5 cm
Topographical indication
2/3 Injection into anterior fibers should not be too medial
or too deep (coracobrachialis); farther medial (pecto-
ralis major and the lateral cephalic vein).
1/3
Injection into posterior fibers should not be too medial
(teres minor) or too deep (long head of triceps brachii).

Injection technique
Site: middle fibers – below 1st third of the distance
between acromion and insertion of deltoid.
Direction: vertical to the skin.
Patient position: sitting or supine with arm resting
against the trunk.

Clinical application
Anterior parts: action sometimes not distinguishable from that of pectoralis major.
Anatomical variations: fibers may be absent or fuse with other muscles; occurence of
additional fiber groups.

Pictorial Guide to Botulinum Toxin Injection 39

 Upper limb muscles

Supraspinatus

1
2
3
4
5
6

Nerve supply
Suprascapular nerve, C4–C6.

Origin
Supraspinous fossa.
Supraspinous fascia.

Insertion
Superior facet of greater tubercle of humerus.

Dosage/needle size
Xeomin®: 5–20 MU (rarely higher).
Botox®: 5–20 MU (rarely higher).
Dysport®: 20–80 MU (rarely higher).
Needle length: 40 mm.

40 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the shoulder joint

Action
Abducts arm (with deltoid).
Stabilizes humerus in the glenoid fossa (in rotator cuff).

Injection protocol
Number of puncture sites: 1–2.

Topographical indication
Risk of pneumothorax if injected erroneously outside
supraspinous fossa.
Risk of reaching only trapezius if injected too super-
ficially.

Injection technique
Site: superior to the middle of the spine of scapula, into
the supraspinous fossa.
Direction: insert needle vertically to the osseous bottom
of the supraspinous fossa, then slightly retract needle
and inject.
Patient position: sitting, or prone (with arm abducted).

Clinical application
Difficult to differentiate from medial fibers of deltoid.
Impingement syndrome: chronic irritation of the supraspinatus tendon with strong pain,
leading to shrinkage of the joint capsule and impaired mobility in the shoulder joint.

Pictorial Guide to Botulinum Toxin Injection 41

 Upper limb muscles

Infraspinatus

1
2
3
4
5
6

Nerve supply
Suprascapular nerve, C5–C6.

Origin
Infraspinous fossa.
Inferior border of the spine of scapula.
Infraspinous fascia.

Insertion
Middle facet of greater tubercle of humerus.

Dosage/needle size
Xeomin®: 5–40 MU (rarely higher).
Botox®: 5–40 MU (rarely higher).
Dysport®: 20–150 MU (rarely higher).
Needle length: 40 mm.

42 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the shoulder joint

Action
Strong lateral rotator of the arm, especially during last
phase of abduction (laterally rotates greater tubercle of
humerus to avoid collision with arch of humerus).
Superior fibers abduct arm; inferior fibers adduct arm.

Injection protocol
Number of puncture sites: 1–3.

Topographical indication
Risk of pneumothorax is small.
Injecting too superficially risks puncturing trapezius.
Injecting too far inferiorly may pierce latissimus; too far
laterally may reach the posterior fibers of deltoid.

Injection technique
Site: middle of infraspinous fossa, in a triangle formed
by the shoulder blade (between acromion, superior and
inferior angles).
Direction: insert needle vertically to the osseous bottom
of the infraspinous fossa, then slightly retract needle
and inject.
Patient position: sitting, or prone (with arm abducted
or laterally rotated).

Clinical application
Difficult to distinguish from teres minor (sometimes fused), and deltoid posterior fibers.
Infraspinatus often fused with teres minor.
Part of rotator cuff.

Pictorial Guide to Botulinum Toxin Injection 43

 Upper limb muscles

Teres minor

1
2
3
4
5
6

Nerve supply
Axillary nerve, C5–C6.

Origin
Superior two thirds of the lateral border of scapula.
Fascia separating teres minor from teres major and infraspinatus.

Insertion
Inferior facet of greater tubercle of humerus, posterior to insertion of infraspinatus.

Dosage/needle size
Xeomin®: 5–20 MU (rarely higher).
Botox®: 5–20 MU (rarely higher).
Dysport®: 20–80 MU (rarely higher).
Needle length: 40 mm.

44 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the shoulder joint

Action
Rotates arm laterally – adducts it from the abduction
position.
Stabilizes humerus in glenoid fossa (in rotator cuff).

Injection protocol
Number of puncture sites: 1–2 (mostly 1).

Topographical indication
1/3
Injecting too far superiorly risks infiltrating infraspina-
tus; too far inferiorly may puncture teres major or the
2/3
long head of triceps.
If injection is not deep enough, deltoid may be infil-
3/3
trated laterally, and trapezius medially.

Injection technique
Site: between 1st and 2nd third of the muscle, along
‘line’ from lateral border of the acromion to the inferior
scapular angle.
Patient position: sitting or prone, with arm abducted
and laterally rotated.

Clinical application
Difficult to distinguish from infraspinatus (sometimes fused), and deltoid posterior fibers.
Part of rotator cuff.

Pictorial Guide to Botulinum Toxin Injection 45

 Upper limb muscles

Latissimus dorsi

1
2
3
4
5
6

Nerve supply
Thoracodorsal nerve, C6–C8.

Origin
Thoracolumbal fascia.
Supraspinous ligament.
Posterior part of the outer lip of iliac crest.
9th to 12th rib.
Inferior angle of scapula (small part).

Insertion
Intertubercular groove of the humerus.

Dosage/needle size
Xeomin®: 20–100 MU (rarely higher).
Botox®: 20–100 MU (rarely higher).
Dysport®: 80–400 MU (rarely higher).
Needle length: 20–40 mm.

46 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the shoulder joint

Action
Extends and adducts, and medially rotates humerus.
Retracts scapula indirectly (at pectoral joint) or directly
(pulling at inferior scapular angle).

Injection protocol
5 cm Number of puncture sites: 1–3 but mostly 1 (no cor-
5 cm relation with muscle size), into cranial part of muscle.
A 7–8 cm
Topographical indication
B Lies directly superior to latissimus dorsi in area of the
posterior axillary line.
Risk of pneumothorax if injected too close to scapula
border.
Risk of penetrating teres minor and major if injected
near the inferior angle of scapula.

Injection technique
Site: area of the posterior axillary line (dotted) 7–8 cm
below axillary fold.
Direction: vertical to the skin.
Patient position: sitting or prone, with arm flexed at
elbow joint.

Clinical application
Cases of impaired elevation of arm during flexion and abduction in the shoulder joint
(often in patients with scoliosis, kyphosis or excessive usage of crutches).
COPD (Chronic-Obstructive Pulmonary Disease) with hypertrophied border of latissimus:
muscle required for forced expiration or deep inspiration when arms are fixed.

Pictorial Guide to Botulinum Toxin Injection 47

 Upper limb muscles

Teres major

1
2
3
4
5
6

Nerve supply
Thoracodorsal nerve, C5–C7.

Origin
Posterior aspect of the inferior angle of scapula and adjacent part of the lateral scapular border.

Insertion
Crest of lesser tubercle of humerus and medial lips of the intertubercular groove of humerus.

Dosage/needle size
Xeomin®: 5–30 MU (rarely higher).
Botox®: 5–30 MU (rarely higher).
Dysport®: 20–100 MU (rarely higher).
Needle length: 40 mm.

48 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the shoulder joint

Action
Adducts and medially rotates humerus.
Retracts arm from anteversion position to neutral posi-
tion.

Injection protocol
Number of puncture sites: 1–2 (mostly 1).

Topographical indication
Hardly distinguishable from latissimus at inferior bor-
der; sometimes fused.
Injecting too far inferiorly may pierce serratus anterior.
Injecting too deeply risks injuring nerves and vessels,
3–5 cm
and causing pneumothorax.

Injection technique
Site: lateral border of scapula, 3–5 cm superior to the
inferior angle of scapula.
Direction: vertical, or in the direction of the fibers.
Patient position: sitting or prone, with arm extended
and medially rotated.

Clinical application
Similar to latissimus.
Palpation sometimes not possible due to overlying latissimus dorsi.

Pictorial Guide to Botulinum Toxin Injection 49

 Upper limb muscles

Pectoralis major

1
2
3
4
5
6

Nerve supply
Medial pectoral nerve, C8–T1.

Origin
Clavicular attachment: anterior surface of the medial half of clavicula.
Sternocostal attachment: anterior surface of sternum, cartilage of 6th to 7th ribs, aponeurosis of
the external oblique muscle of the abdomen.
Abdominal attachment: anterior lamina of the rectus sheath.

Insertion
Greater tubercle of humerus and lateral lip of intertubercular groove of humerus.

Dosage/needle size
Xeomin®: 20–100 MU (rarely higher).
Botox®: 20–100 MU (rarely higher).
Dysport®: 60–300 MU (rarely higher).
Needle length: 40 mm.

50 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the shoulder joint

Action
Inferior and middle parts (abdominal and sternocostal
attachments): adduct and medially rotate arm.
Isolated contraction of clavicular fibers: flexes at shoul-
der joint (anteversion).

Injection protocol
Number of puncture sites: 1–3.

Topographical indication
Injecting too deeply risks pneumothorax, and puncture
of coracobrachialis.
Injecting too deeply and superiorly risks damaging bra-
chial plexus and vessels in the axilla.
Injecting too far medially risks piercing biceps brachii.

Injection technique
Site: area of the anterior axillary fold.
Direction: medially, in the direction of the fibers.
Patient position: sitting or supine, with arm abducted
to ~45–90°.

Clinical application
Sternocostal fibers are important for walking on crutches.
Inspiration (accessory muscle).

Pictorial Guide to Botulinum Toxin Injection 51

 Upper limb muscles

Biceps brachii

1
2
3
4
5
6

Nerve supply
Musculocutaneous nerve, C5–C6.

Origin
Long head: supraglenoid tubercle of scapula.
Short head: coracoid process of scapula.

Insertion
Radial tuberosity and into the fascia of the forearm
via the bicipital aponeurosis.

Dosage/needle size
Xeomin®: 20–100 MU (rarely higher).
Botox®: 20–100 MU (rarely higher).
Dysport®: 60–300 MU (rarely higher).
Needle length: 40 mm.

52 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the shoulder joint

Action
Flexes and supinates forearm at elbow joint – most
powerful with elbow at 90°.
Flexes at shoulder joint; long head abducts shoulder
and stabilizes shoulder joint (with muscles of rotator
cuff).

Injection protocol
Number of puncture sites: 2–4 (mostly 2).

ventral Topographical indication

Easily palpable and distinguishable. Injecting too deeply
can pierce brachialis (1).

lateral medial

dorsal

Injection technique
Site: center of the muscle belly.
Direction and depth: vertically, or in the direction of the
fibers; depth dependent on muscle thickness.
Patient position: sitting or supine, with elbow flexed
and supinated.

Clinical application
Should always be considered in synergy with other flexors.
Injection into biceps always influences function of the other muscles of the arm. Injection
exclusively into biceps is rarely necessary.

Pictorial Guide to Botulinum Toxin Injection 53

 Upper limb muscles

Brachialis

1
2
3
4
5
6

Nerve supply
Musculocutaneous nerve, C5–C7.
Radial nerve, C5–C6.

Origin
Distal two thirds of the anterior shaft of humerus.
Intermuscular septum between brachialis and triceps
brachii.

Insertion
Ulnar tuberosity.
Coronoid process of ulna.

Dosage/needle size
Xeomin®: 20–60 MU (rarely higher).
Botox®: 20–60 MU (rarely higher).
Dysport®: 50–200 MU (rarely higher).
Needle length: 40 mm.

54 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the elbow joint

Action
Powerful flexor of elbow.
Uni-articulate (sole insertion onto ulna) – no influence
on radioulnar joint.

Injection protocol
Number of puncture sites: 1–2 (mostly 1).

ventral Topographical indication

3 Move injection medially to avoid piercing biceps brachii
1 (1); injecting too far posteriorly, and injection or drug
may reach triceps brachii (2).
Risk of injury to cephalic vein (3) – usually clearly visible
anterolaterally.

lateral
2 medial

dorsal

Injection technique
Site: 3–4 cm proximal to elbow fold, lateral to the ten-
don of the biceps.
Direction and depth: vertical, or in the direction of the
fibers; depth dependent on muscle thickness.
Patient position: sitting or supine, with elbow slightly
flexed.

Clinical application
Flexor spasticity (not only biceps brachii).
If secondary injection is too early while drug’s effect has not completely worn off, puncture
is difficult as muscle cannot be palpated. Ultrasound could be very useful.
Recommended dosage should not be exceeded, due to muscle stabilizing elbow. With
extreme flexor spasticity, recommended dosage is insufficient – total dosage must be
distributed between all elbow flexors.

Pictorial Guide to Botulinum Toxin Injection 55

 Upper limb muscles

Brachioradialis

1
2
3
4
5
6

Nerve supply
Radial nerve, C5–C6.

Origin
Lateral supracondylar ridge of humerus.
Lateral intermuscular brachial septum.

Insertion
Lateral aspect of radius, proximal to the base of
radial styloid process.

Dosage/needle size
Xeomin®: 20–100 MU (rarely higher).
Botox®: 20–100 MU (rarely higher).
Dysport®: 50–300 MU (rarely higher).
Needle length: 40 mm.

56 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the elbow joint

Action
Flexes elbow; returns forearm from extreme supination
or pronation to neutral position.

Injection protocol
Number of puncture sites: 1–3.

Topographical indication
palmar
Injecting too far radially risks piercing extensor carpi
radialis longus (1).
3 Injecting too deeply will puncture the supinator (2); in-
1 jecting too far to the ulnar side, will infiltrate the prona-
2
tor teres (3) with toxin.

radial ulnar
dorsal

Injection technique
Site: 2–3 cm distal to elbow fold.
Direction and depth: vertical, or in the direction of the
fibers; depth dependent on muscle thickness.
Patient position: sitting or supine, with elbow slightly
flexed and thumb pointing upwards.

Clinical application
All three flexors of elbow must be viewed in synergy, and dosage distributed according to
clinical picture.
Often easy to inject, but ultrasound could be very helpful. Dosage given is often too low.

Pictorial Guide to Botulinum Toxin Injection 57

 Upper limb muscles

Triceps brachii

1
2
3
4
5
6

Nerve supply
Radial nerve, C6–C8.

Origin
Long head: infraglenoid tubercle of scapula.
Lateral head: posterior shaft of humerus, lateral and superior to radial (spiral) groove.
Medial head: posterior distal shaft of humerus, medial and inferior to radial (spiral) groove.

Insertion
Olecranon.
Posterior wall of joint capsule.

Dosage/needle size
Xeomin®: 30–120 MU (rarely higher).
Botox®: 30–120 MU (rarely higher).
Dysport®: 80–350 MU (rarely higher).
Needle length: 40 mm.

58 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the elbow joint

Action
Powerful extensor of elbow.
Long head adducts at shoulder joint.

Injection protocol
Number of puncture sites: 3–4 (mostly 3).

ventral Topographical indication

Erroneous injection between the muscle heads could
occur.
Injecting too far ventrally or proximally may pierce the
deltoid.

medial lateral

dorsal

Injection technique
Site: center of muscle belly (for lateral head, muscle
must be distinguished from deltoid).
Direction and depth: vertical, or in the direction of the
fibers; depth dependent on muscle thickness.
Patient position: sitting or prone, with shoulder slightly
abducted.

Clinical application
Rarely treated, as flexor spasticity is more common.
Function of the flexors and muscles of the shoulder joint should be considered, with dos-
age regulated according to the other muscles being treated.

Pictorial Guide to Botulinum Toxin Injection 59

 Upper limb muscles

Supinator

1
2
3
4
5
6

Nerve supply
Radial nerve, posterior interosseous branch, C5–C6.

Origin
Lateral epicondyle of humerus.
Supinator crest of ulna.
Radial collateral and anular ligaments.

Insertion
Proximal third of radius (broad insertion).

Dosage/needle size
Xeomin®: 5–30 MU (rarely higher).
Botox®: 5–30 MU (rarely higher).
Dysport®: 20–100 MU (rarely higher).
Needle length: 20–40 mm.

60 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the elbow joint

Action
Supinates forearm, independent of elbow position (po-
sitions radius parallel to ulna).
Strong supinator of elbow when extended, otherwise
aided by biceps brachii.

Injection protocol
Number of puncture sites: 1–2 (mostly 1); ultrasound
or EMG control.

Topographical indication
volar Injection is through the more superficial muscles, and
is difficult.
2 Injecting from volar side of forearm can injure the radial
1
nerve and artery (1); injecting too far radially punctures
the brachioradialis (2).

radial ulnar
dorsal

Injection technique
Site: directly radial to distal insertion of the biceps (in
supination position), or from superior to distal between
extensor digitorum and other wrist extensors (in prona-
tion position).
Direction: vertical, or in the direction of the fibers.
Patient position: sitting or supine, with elbow slightly
flexed and supinated.

Clinical application
Dystonia or spasm, but injection rarely necessary – mostly only in combination with adja-
cent muscles.
Ventral part of muscle is very thin.

Pictorial Guide to Botulinum Toxin Injection 61

 Upper limb muscles

Pronator teres

1
2
3
4
5
6

Nerve supply
Median nerve, C6–C7.
Occasionally also musculocutaneous nerve.

Origin
Humeral head: medial epicondyle of humerus.
Ulnar head: coronoid process of ulna.

Insertion
Middle of lateral surface of radius, pronator
tuberosity.

Dosage/needle size
Xeomin®: 10–30 MU (rarely higher).
Botox®: 10–30 MU (rarely higher).
Dysport®: 30–80 MU (rarely higher).
Needle length: 20–40 mm.

62 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the elbow joint

Action
Pronates forearm.
Very weakly flexes forearm.

Injection protocol
1–2 cm Number of puncture sites: 1; ultrasound or EMG con-
trol.

cubital fold

Topographical indication
volar Index finger in elbow fold, middle finger on epicondyle
– muscle lies between the two fingers.
2
Injecting too deeply can infiltrate flexor digitorum su-
1 perficialis (1); injecting too far towards the ulna can
pierce flexor carpi radialis (2).

radial ulnar
dorsal

Injection technique
Site: 1–2 cm distal to elbow fold, medially (ulnar side)
of tendon of biceps.
Direction and depth: vertical, or in direction of fibers;
not too deeply.
Patient position: sitting or supine, with elbow slightly
flexed and supinated.

Clinical application
Pronator teres and quadratus functionally indistinguishable, thus most frequently, only the
pronator teres is injected.
Relevant for pronation, and for flexion at elbow joint.
Pronator teres syndrome: chronic compression of the median nerve between the two
muscle heads, e.g., in occupations involving frequent use of screwdrivers.

Pictorial Guide to Botulinum Toxin Injection 63

 Upper limb muscles

Pronator quadratus

1
2
3
4
5
6

Nerve supply
Anterior interosseous branch of median nerve, C6–T1.

Origin
Distal fourth of the anterior surface of ulna.

Insertion
Distal fourth of the anterior surface and lateral border of radius.

Dosage/needle size
Xeomin®: 5–20 MU (rarely higher).
Botox®: 5–20 MU (rarely higher).
Dysport®: 20–60 MU (rarely higher).
Needle length: 20 mm.

64 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the elbow joint

Action
Initiates pronation, and stabilizes wrist joint in synergy
with interosseous membrane (holding the forearm
bones together).

Injection protocol
Number of puncture sites: 1; EMG control or ultra-
sound (to avoid wrist vessels).

Topographical indication
Lies on distal fifth of anterior forearm. Radial nerve lies
laterally, median nerve in the middle, and ulnar nerve
and artery medially.
Injection is best from ulnar side, where muscle is
thicker; not from dorsal side.

Injection technique
Site: 5–6 cm distal to elbow fold, on anterior side of
forearm.
Direction: from medial (ulnar) side at 90° and slightly
higher than ulna.
Patient position: forearm supinated, hand slightly
opened and relaxed.

Clinical application
Works in synergy with pronator teres; in most cases only pronator teres is injected.
Cannot be palpated; therefore, ultrasound is very useful.

Pictorial Guide to Botulinum Toxin Injection 65

 Upper limb muscles

Extensor carpi radialis longus and brevis

1
2
3
Extensor carpi
4 radialis longus

5
6

Extensor carpi
radialis brevis

Nerve supply
Radial nerve, C6–C7.

Origin
Longus: lateral supracondylar ridge of humerus.
Brevis: lateral epicondyle of humerus.

Insertion
Longus: posterior surface of base of 2nd metacarpal.
Brevis: posterior surface of base of 3rd metacarpal.

Dosage/needle size
Xeomin®: 5–20 MU each (rarely higher).
Botox®: 5–20 MU each (rarely higher).
Dysport®: 20–80 MU each (rarely higher).
Needle length: 20–40 mm.

66 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the wrist joint

Action
Both muscles: extend wrist, and abduct hand (radial
deviation) with flexor carpi radialis.
Extensor carpi radialis longus: slight pronation of fore-
arm from supination position.

Injection protocol
Number of puncture sites: usually 2 per muscle.

x 4–5 cm

Topographical indication
volar Muscles are virtually indistinguishable – longus (1) lies
slightly nearer to radius.
2 Injecting too far radially can puncture brachioradialis
1 (2); too far to the ulnar side may pierce extensor digi-
torum (3).
3
radial ulnar
dorsal

Injection technique
Site: middle of muscle, 4–5 cm distal to lateral epicon-
dyle (x) – slightly proximal into longus and slightly distal
into brevis.
Direction and depth: vertical, or in the direction of the
fibers; not too deeply (both muscles are superficial).
Patient position: elbow flexed and pronated.

Clinical application
Dystonia and spasticity: dosage lower for dystonia than for spasticity.
Both muscles should be considered in synergy with other extensors of the wrist.

Pictorial Guide to Botulinum Toxin Injection 67

 Upper limb muscles

Extensor carpi ulnaris

1
2
3
4
5
6

Nerve supply
Radial nerve, C6–C8.

Origin
Humeral head: lateral epicondyle of humerus,
forearm fascia.
Ulnar head: posterior surface of ulna.

Insertion
Medial side of the base of 5th metacarpal.

Dosage/needle size
Xeomin®: 5–20 MU (rarely higher).
Botox®: 5–20 MU (rarely higher).
Dysport®: 20–80 MU (rarely higher).
Needle length: 20–40 mm.

68 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the wrist joint

Action
Extends wrist, and adducts hand (ulnar deviation) with
flexor carpi ulnaris.
Fixes wrist, conducting force from long finger flexors
to the finger joints.

Injection protocol
Number of puncture sites: 1–2 (mostly 1); ultrasound
or EMG control.

Topographical indication
volar
Injecting too far towards radius can puncture extensor
digiti minimi (1).
Injecting too deeply risks infiltrating other extensors
such as extensor pollicis longus (2).

2
1
radial ulnar
dorsal

Injection technique
Site: middle of ulna, just above osseous ridge.
Direction: towards hand.
Patient position: elbow flexed and pronated.

Clinical application
Dosage varies strongly depending on indication, e.g., very low dose for graphospasm
(writer’s cramp).

Pictorial Guide to Botulinum Toxin Injection 69

 Upper limb muscles

Flexor carpi radialis

1
2
3
4
5
6

Nerve supply
Median nerve, C6–C8.

Origin
Medial epicondyle of humerus.
Forearm fascia.

Insertion
Palmar surfaces of the bases of 2nd and 3rd meta-
carpals.

Dosage/needle size
Xeomin®: 5–60 MU (rarely higher).
Botox®: 5–60 MU (rarely higher).
Dysport®: 20–200 MU (rarely higher).
Needle length: 20–40 mm.

70 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the wrist joint

Action
Flexes wrist, and abducts hand (radial deviation) with
extensor carpi radialis.
Weak flexor and pronator at elbow.

Injection protocol
Number of puncture sites: 1–2; ultrasound or EMG
control.

6–8 cm

Topographical indication
volar
Injecting too deeply infiltrates flexor digitorum super-
2 ficialis (1).
1 Injecting too far towards ulna and elbow can puncture
pronator teres; too far towards ulna may pierce pal-
maris longus (2).

radial ulnar
dorsal

Injection technique
Site: 6–8 cm distal on a ‘line’ from the middle of the
elbow crease.
Direction and depth: vertically, in the direction of the
fibers; not too deep.
Patient position: elbow flexed and supinated.

Clinical application
Should always be considered in spasms of the wrist flexors.
Should always be considered in synergy with the other flexors.

Pictorial Guide to Botulinum Toxin Injection 71

 Upper limb muscles

Palmaris longus

1
2
3
4
5
6

Nerve supply
Median nerve, C7–T1.

Origin
Medial epicondyle of humerus.
Forearm fascia.

Insertion
Palmar aponeurosis.

Dosage/needle size
Xeomin®: 5–10 MU (rarely higher).
Botox®: 5–10 MU (rarely higher).
Dysport®: 20–40 MU (rarely higher).
Needle length: 20 mm.

72 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the wrist joint

Action
Weak flexor of wrist; negligibly weak flexor of elbow.
Tenses the palmar aponeurosis.

Injection protocol
Number of puncture sites: 1–2 (mostly 1).

3/3
2/3
1/3

Topographical indication
volar
Very thin muscle.
Injecting too deeply can infuse flexor digitorum superfi-
2
1 cialis (1); flexor carpi radialis (2) lies on radial side.

radial ulnar
dorsal

Injection technique
Site: border between the 1st and 2nd thirds of ‘line’
between medial epicondyle and the middle of the volar
wrist.
Direction and depth: vertical, or in the direction of the
fibers; not too deep.
Patient position: elbow flexed and supinated.

Clinical application
Limited action (absent in 14% of patients); injection rarely necessary.

Pictorial Guide to Botulinum Toxin Injection 73

 Upper limb muscles

Flexor carpi ulnaris

1
2
3
4
5
6

Nerve supply
Ulnar nerve, C7–T1.

Origin
Humeral head: medial epicondyle of humerus.
Ulnar head: olecranon, proximal shaft of ulna,
forearm fascia.

Insertion
Hamate, pisiform and 5th metacarpal.

Dosage/needle size
Xeomin®: 5–60 MU (rarely higher).
Botox®: 5–60 MU (rarely higher).
Dysport®: 20–200 MU (rarely higher).
Needle length: 20–40 mm.

74 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the wrist joint

Action
Flexes wrist and adducts hand (ulnar deviation) with
extensor carpi ulnaris.

Injection protocol
Number of puncture sites: 1–2; ultrasound control
helpful.
Sometimes it is helpful to inject the distal part additionally,
especially in severe ulnar deviation.
3/3
2/3
1/3

Topographical indication
volar
Injecting too deeply can pierce flexor digitorum super-
ficialis (1), or infiltrate flexor digitorum profundus (2)
1 where muscle becomes very thin near the wrist.
2

radial ulnar
dorsal

Injection technique
Site: border between 1st and 2nd thirds of ‘line’ be-
tween medial epicondyle and the styloid process of
ulna. Inject into the proximal third of muscle, which is
easily palpable.
Direction and depth: vertical, or in direction of the fi-
bers; not too deep.
Patient position: elbow flexed and supinated; wrist re-
laxed.

Clinical application
Spasticity or dystonia.
Spasticity of the flexors: carpi radialis and ulnaris are usually treated.
Should be viewed in synergy with the other flexors of the wrist.

Pictorial Guide to Botulinum Toxin Injection 75

 Upper limb muscles

Extensor digitorum

1
2
3
4
5
6

Nerve supply
Deep branch of radial nerve, C6–C8.

Origin
Lateral epicondyle of humerus, ulnar collateral ligament, forearm fascia.

Insertion
Lateral and dorsal surfaces of all phalanges of the four fingers.

Dosage/needle size
Xeomin®: 5–30 MU (rarely higher).
Botox®: 5–30 MU (rarely higher).
Dysport®: 20–100 MU (rarely higher).
Needle length: 20–40 mm.

76 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Extends wrist and all finger joints.
Negligibly involved in adduction of the hand.

Injection protocol
Number of puncture sites: 1–4 (mostly 1); ultrasound
or EMG control.

3/3

2/3

1/3

Topographical indication
volar
Injecting too near to elbow and too deeply can punc-
ture supinator.
Injecting too close to radius can infiltrate extensor car-
1 pis radialis longus and brevis (1, 2); injecting too close
2 to the ulna may pierce extensor digiti minimi (3) or ex-
tensor carpi ulnaris (4). Extensor tendons lie very close
4 3 to each other near the wrist.
ulnar radial
dorsal

Injection technique
Site: at border between 1st and 2nd thirds of forearm,
in the middle of the muscle
Depth: 10–15 mm, depending on muscle thickness.
Patient position: elbow flexed and pronated; fingers
comfortably extended.

Clinical application
Dystonia and spasticity: dosage is lower in dystonia than in spasticity.
Examined together with extensor digiti minimi and extensor indicis, as these muscles are
most powerful in synergy.

Pictorial Guide to Botulinum Toxin Injection 77

 Upper limb muscles

Extensor indicis

1
2
3
4
5
6

Nerve supply
Deep branch of radial nerve, C6–C8.

Origin
Distal half of posterior surface of ulna, interosseous membrane.

Insertion
Dorsal aponeurosis of index finger or so-called extensor expansion (also extensor hood).

Dosage/needle size
Xeomin®: 5–10 MU (rarely higher).
Botox®: 5–10 MU (rarely higher).
Dysport®: 20–40 MU (rarely higher).
Needle length: 20 mm.

78 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Extends index finger (acting alone or with extensor
digitorum).
Extends wrist.

Injection protocol
Number of puncture sites: 1; ultrasound or EMG con-
trol (with stimulation).

3–4 cm

Topographical indication
volar
Injecting too close to radial side may infiltrate exten-
sor pollicis brevis (1) or abductor pollicis longus (2); too
close to wrist could puncture extensor digitorum (3) or
extensor pollicis longus.

1 2
3
ulnar radial
dorsal

Injection technique
Site: 4–5 cm proximal to the styloid process of ulna
(with arm pronated), directly radial to ulna.
Depth: maximum 1 cm.
Patient position: elbow pronated; wrist and fingers
comfortably extended.

Clinical application
Cannot be palpated.
No other muscles in this region of postural surface of forearm.

Pictorial Guide to Botulinum Toxin Injection 79

 Upper limb muscles

Extensor digiti minimi

1
2
3
4
5
6

Nerve supply
Deep branch of radial nerve, C6–C8.

Origin
Lateral epicondyle of humerus.
Forearm fascia.

Insertion
Dorsal aponeurosis (extensor hood) of 5th finger.

Dosage/needle size
Xeomin®: 2.5–10 MU (rarely higher).
Botox®: 2.5–10 MU (rarely higher).
Dysport®: 10–40 MU (rarely higher).
Needle length: 20 mm.

80 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Extends 5th finger at all joints.
Extends wrist negligibly.

Injection protocol
Number of puncture sites: 1; ultrasound or EMG con-
trol.

7–9 cm

1.5–2 cm

Topographical indication
volar
Lies superficially and medially when forearm is pro-
nated – between extensor digitorum (1) and extensor
carpi ulnaris (2), and above the extensors pollicis brevis
(3) and longus (4).

3 4
1 2
radial ulnar
dorsal

Injection technique
Site: ~7–9 cm distal to the lateral epicondyle (with arm
pronated), ~1.5–2 cm towards the radial side.
Depth: maximal 1 cm.
Patient position: elbow pronated; wrist and fingers
comfortably extended.

Clinical application
Muscle is tested together with extensor digitorum and extensor indicis, as these muscles
are most powerful in synergy. Absent in some patients.
Wrist should be in a middle position between flexion and extension.

Pictorial Guide to Botulinum Toxin Injection 81

 Upper limb muscles

Extensor pollicis brevis

1
2
3
4
5
6

Nerve supply
Deep branch of radial nerve, C6–C8.

Origin
Posterior surface of distal radius, interosseous membrane.

Insertion
Posterior surface of the base of the proximal phalanx of the thumb.

Dosage/needle size
Xeomin®: 5–20 MU (rarely higher).
Botox®: 5–20 MU (rarely higher).
Dysport®: 20–60 MU (rarely higher).
Needle length: 20 mm.

82 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Extends proximal joints of the thumb (not the interpha-
langeal joint).

Injection protocol
Number of puncture sites: 1; ultrasound or EMG con-
trol.

7–9 cm

Topographical indication
volar
Muscle lies on ulnar side beneath extensor digitorum
(1) and extensor digiti minimi (2), bordered by extensor
pollicis longus (3) on the ulnar side and abductor pol-
licis longus (4) on the radial side. It lies on the interos-
seous membrane and radius.
4 3
1 2
radial ulnar
dorsal

Injection technique
Site: ~7–9 cm above the wrist (with arm pronated), di-
rectly at ulnar border with the radius.
Direction and depth: towards wrist; ~1 cm deep.
Patient position: elbow pronated; wrist and fingers
comfortably extended.

Clinical application
Difficult to distinguish from abductor pollicis longus – muscles extend thumb in synergy.
Treat with other muscles of the thumb to ensure success.

Pictorial Guide to Botulinum Toxin Injection 83

 Upper limb muscles

Extensor pollicis longus

1
2
3
4
5
6

Nerve supply
Deep branch of radial nerve, C6–C8.

Origin
Middle third of posterior surface of ulna, interosseous membrane.

Insertion
Posterior surface of the base of the distal phalanx of the thumb.

Dosage/needle size
Xeomin®: 5–20 MU (rarely higher).
Botox®: 5–20 MU (rarely higher).
Dysport®: 20–60 MU (rarely higher).
Needle length: 20–40 mm.

84 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Abducts thumb, and extends it at all joints.
Assists in extension and radial abduction of wrist; also
involved in supination.

Injection protocol
Number of puncture sites: 1–2; ultrasound or EMG
control.
1/3
2/3
3/3

Topographical indication
volar
Extensor digitorum needs to be penetrated.
Lies directly adjacent to extensor pollicis brevis (1), bor-
dered by extensor indicis on ulnar side and abductor
pollicis longus (2) on radial side.

2 1

radial ulnar
dorsal

Injection technique
Site: between radius and ulna (with arm pronated), on
the border with the 1st and 2nd thirds of forearm.
Direction and depth: towards the wrist; 1–2 cm deep.
Patient position: elbow pronated; wrist and fingers
comfortably extended.

Clinical application
Both extensors of the thumb (pollicis brevis and longus) examined together, as they act
synergistically to extend thumb.

Pictorial Guide to Botulinum Toxin Injection 85

 Upper limb muscles

Lumbricals 1–4

1
2
3
4
5
6

Nerve supply
Lumbricals 1 and 2: median nerve, C8–T1.
Lumbricals 3 and 4: deep branch of ulnar nerve, C8–T1.

Origin
Tendons of flexor digitorum profundus.

Insertion
Lateral (radial) side of corresponding tendon of extensor digitorum.

Dosage/needle size
Xeomin®: 2.5–5 MU/injection site (rarely higher).
Botox®: 2.5–5 MU/injection site (rarely higher).
Dysport®: 10–20 MU/injection site (rarely higher).
Needle length: 20 mm.

86 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Flex metacarpophalangeal joints II–V and extend re-
spective proximal interphalangeal joints.

Injection protocol
Number of puncture sites: 1 each.

Topographical indication
Muscles are on radial side of the respective flexor digi-
1
1 torum profundus tendons (1).
1 Injecting too deeply to treat the palmar interossei can
1 puncture the dorsal interossei.
1st lumbrical has to be distinguished from adductor
pollicis and the 1st dorsal interosseus.

Injection technique
Site: radial to each respective tendon, in the upper half
of the palm. Also possible from the dorsum of the hand.
1st lumbrical – directly above distal border of the meta-
carpal.
2nd–4th lumbricals – slightly distal and radial to the
head of the respective metacarpal.
Direction: towards the bone.
Patient position: elbow supinated; wrist and fingers
comfortably extended.

Clinical application
Spasticity: ‘lumbrical hand’ malposition is characteristic; injection from dorsal side.
Cannot be palpated; errors in injection, or diffusion of toxin into adjacent muscles, occur
easily.

Pictorial Guide to Botulinum Toxin Injection 87

 Upper limb muscles

Flexor digitorum superficialis

1
2
3
4
5
6

Nerve supply
Median nerve, C7–T1.

Origin
Humeroulnar head: medial epicondyle of humerus,
coronoid process of ulna.
Radial head: anterior surface of shaft of radius.

Insertion
Four tendons divide into two slips each, which insert
into the sides of the bases of the middle phalanges
of the four fingers. The tendons of flexor digitorum
profundus pierce the tendons of flexor digitorum superficialis and continue to the distal phalanx.

Dosage/needle size
Xeomin®: 20–60 MU (rarely higher).
Botox®: 20–60 MU (rarely higher).
Dysport®: 60–200 MU (rarely higher).
Needle length: 20–40 mm.

88 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Flexes metacarpophalangeal joints II–V and respective
proximal interphalangeal joints.
Most efficient when wrist is fixed by extensors; if not,
wrist also flexes.

Injection protocol
Number of puncture sites: 1–4; ultrasound or EMG
control.
radial side In case of multiple injections, both heads need to be
considered, thus injections near the elbow should be
given both on the ulnar and radial sides.

ulnar side

Topographical indication
volar
Injecting too far towards ulna can puncture flexor carpi
3 2 ulnaris (1); too far towards radius can puncture pal-
maris longus (2) or flexor carpi radialis (3).
1
5 Injecting too deeply can penetrate flexor digitorum
4
profundus (4).
Median nerve (5) runs beneath the fibrous arch be-
tween the two muscle heads.
radial ulnar
dorsal

Injection technique
Site: middle of ulnar side of the forearm, halfway be-
tween elbow and wrist, where muscle lies superficially.
For multiple injections, consider both heads, with injec-
tions near elbow given on both ulnar and radial sides.
Direction and depth: vertical; 1–2 cm deep.
Patient position: elbow supinated; wrist and fingers
comfortably extended.

Clinical application
Flexor spasticity: treated with other flexors (digitorum superficials and profundus act syner-
gistically to flex middle interphalangeal joints).
With ultrasound you may differentiate different fingers.

Pictorial Guide to Botulinum Toxin Injection 89

 Upper limb muscles

Flexor digitorum profundus

1
2
3
4
5
6

Nerve supply
Lateral half: anterior interosseous branch of median
nerve, C8–T1.
Medial half: ulnar nerve, C8–T1.

Origin
Proximal anterior shaft of ulna.
Forearm fascia.
Interosseous membrane.

Insertion
Four tendons pierce those of the flexor digitorum
superficialis and insert into the anterior surface of the base of the distal phalanges.

Dosage/needle size
Xeomin®: 20–60 MU (rarely higher).
Botox®: 20–60 MU (rarely higher).
Dysport®: 60–200 MU (rarely higher).
Needle length: 20–40 mm.

90 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Flexes metacarpophalangeal joints II–V and respective
proximal and distal interphalangeal joints (the only
flexor of these distal joints).
Most powerful when wrist is fixed by extensors; if not,
wrist also flexes.

Injection protocol
Number of puncture sites: 1–4 (mostly 1–2); ultrasound
control is very helpful.

3/3
2/3
1/3

Topographical indication
volar
Injection from anterior side of forearm is advisable to
avoid other muscles of the hand.
Inject between ulna (1) and flexor carpi ulnaris (2).
2

radial ulnar
dorsal

Injection technique
Site: with arm supinated, inject near border of the 1st
and 2nd thirds of the forearm.
Depth: 1–2 cm into lateral part; and 2–4 cm into me-
dial part.
Patient position: elbow supinated; wrist and fingers
comfortably extended.

Clinical application
Flexor spasticity: treated with other flexors (digitorum superficialis and profundus act
synergistically to flex middle interphalangeal joints).
Difficult to palpate.

Pictorial Guide to Botulinum Toxin Injection 91

 Upper limb muscles

Flexor digiti minimi brevis

1
2
3
4
5
6

Nerve supply
Deep branch of ulnar nerve, C8–T1.

Origin
Hamate.
Flexor retinaculum.

Insertion
Ulnar side of base of proximal phalanx of 5th finger.

Dosage/needle size
Xeomin®: 2.5–10 MU (rarely higher).
Botox®: 2.5–10 MU (rarely higher).
Dysport®: 10–40 MU (rarely higher).
Needle length: 20 mm.

92 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Flexes metacarpophalangeal joint V.
Action indistinguishable from flexor digitorum superfi-
cialis and profundus.

Injection protocol
Number of puncture sites: 1.

Topographical indication
Injection is not always possible – muscle is very small
and lies above opponens digiti minimi. Abductor digiti
minimi lies on its ulnar side.

1/2

Injection technique
Site: between carpal tunnel and ulnar border of the 5th
metacarpal.
Depth: maximum 1 cm.
Patient position: elbow supinated; wrist and fingers
comfortably extended.

Clinical application
Injection rarely necessary, and is difficult (muscle absent in some patients).

Pictorial Guide to Botulinum Toxin Injection 93

 Upper limb muscles

Flexor pollicis longus

1
2
3
4
5
6

Nerve supply
Anterior interosseous branch of median nerve,
C7–T1.

Origin
Middle of anterior shaft of radius.
Interosseous membrane.
Coronoid process of ulna.
Medial epicondyle of humerus.

Insertion
Palmar aspect of distal phalanx of the thumb.

Dosage/needle size
Xeomin®: 5–20 MU (rarely higher).
Botox®: 5–20 MU (rarely higher).
Dysport®: 20–60 MU (rarely higher).
Needle length: 20 mm.

94 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Flexes thumb at all joints (only flexor in interphalangeal
joint of the thumb).
Action is additive to those of other wrist flexors.

Injection protocol
Number of puncture sites: 1–2; ultrasound control (to
avoid radial artery).

1/2

Topographical indication
volar
Muscle lies beneath all other flexors directly on the ra-
dius (1). Flexor digitorum profundus (2) lies to the me-
3 4 dial (ulnar) side and the radial artery (3) to the radial
side.
2
1 Injecting too superficially can infiltrate flexor digitorum
superficialis (4).

radial ulnar
dorsal

Injection technique
Site: middle of forearm ( ); ultrasound control.
Direction and depth: towards the radius, close to radial
artery; 1–2 cm deep.
Patient position: elbow supinated; wrist and fingers
comfortably extended.

Clinical application
Flexion of interphalangeal joint.
Flexion of other joints of the thumb carried out synergistically with flexor pollicis brevis.
Ultrasound is nearly essential.

Pictorial Guide to Botulinum Toxin Injection 95

 Upper limb muscles

Abductor pollicis longus

1
2
3
4
5
6

Nerve supply
Deep branch of radial nerve, C6–C8.

Origin
Middle of posterior surfaces of ulna and radius.
Interosseous membrane.

Insertion
Radial side of base of 1st metacarpal.

Dosage/needle size
Xeomin®: 5–20 MU (rarely higher).
Botox®: 5–20 MU (rarely higher).
Dysport®: 20–60 MU (rarely higher).
Needle length: 20 mm.

96 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Extends, abducts and laterally rotates thumb.
Abducts (radial deviation) and slightly flexes wrist.

Injection protocol
Number of puncture sites: 1–2; ultrasound or EMG
control (with stimulation).

1/2

Topographical indication
volar
Injecting too far towards radius extensor may infiltrate
the extensor carpi radialis brevis (2); too far distally, the
extensor pollicis brevis (1); and too superficially, exten-
sor digitorum (3).

2
1
3
radial ulnar
dorsal

Injection technique
Site: middle of forearm, above the radius (in pronation
position). May inject to radius and then slightly retract
needle.
Direction and depth: towards wrist; 1–2 cm deep.
Patient position: elbow pronated; wrist and fingers
comfortably extended.

Clinical application
Abduction of carpometacarpal joint.
Hardly distinguishable from abductor pollicis brevis (1) – tendon partly fuses with that of
abductor pollicis brevis and extensor pollicis brevis.

Pictorial Guide to Botulinum Toxin Injection 97

 Upper limb muscles

Abductor pollicis brevis

1
2
3
4
5
6

Nerve supply
Median nerve, C7–T1.

Origin
Tubercle of scaphoid, tubercle of trapezium, flexor retinaculum.

Insertion
Base of proximal phalanx of the thumb.

Dosage/needle size
Xeomin®: 2.5–10 MU (rarely higher).
Botox®: 2.5–10 MU (rarely higher).
Dysport®: 10–40 MU (rarely higher).
Needle length: 20 mm.

98 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Abducts thumb and extends metacarpophalangeal
joint.
Extends interphalangeal joint of the thumb via insertion
into dorsal aponeurosis (extensor hood).

Injection protocol
1/2 Number of puncture sites: 1.

Topographical indication
Difficult to inject as embedded in the other thenar
muscles (opponens pollicis and flexor pollicis brevis).
Adductor pollicis lies deep and to the ulnar side.

Injection technique
Site: into palm in the middle of the 1st metacarpal.
Direction and depth: parallel to metacarpal, towards tip
of thumb; 0.5–1 cm deep.
Patient position: elbow supinated; thumb comfortably
extended and abducted.

Clinical application
Abduction of thumb with abductor pollicis longus; only abductor pollicis brevis acts on the
metacarpophalangeal joint.
Difficult to distinguish from the surrounding thenar muscles abducting thumb.
Injection often painful.

Pictorial Guide to Botulinum Toxin Injection 99

 Upper limb muscles

Abductor digiti minimi manus

1
2
3
4
5
6

Nerve supply
Deep branch of ulnar nerve, C8–T1.

Origin
Pisiform, flexor retinaculum, tendon of flexor carpi ulnaris.

Insertion
Medial (ulnar) aspect of base of proximal phalanx of 5th finger, inserting into the dorsal aponeu-
rosis (extensor expansion or hood) of the 5th finger.

Dosage/needle size
Xeomin®: 2.5–5 MU (rarely higher).
Botox®: 2.5–5 MU (rarely higher).
Dysport®: 10–20 MU (rarely higher).
Needle length: 20 mm.

100 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Abducts and flexes the 5th finger.

Injection protocol
Number of puncture sites: 1.

Topographical indication
Lies on the ulnar side of the hand.
Injecting too deeply can pierce flexor digiti minimi bre-
vis or opponens digiti minimi.

1/2

Injection technique
Site: ulnar border of the hand, in the middle of ‘line’
between pisiform and the 5th metacarpophalangeal
joint.
Depth: 0.5–1 cm.
Patient position: elbow supinated; wrist and fingers
comfortably extended.

Clinical application
Electroneurography of the ulnar nerve.
Easily palpated.

Pictorial Guide to Botulinum Toxin Injection 101

 Upper limb muscles

Dorsal interossei manus 1–4

1
2
3
4
5
6

Nerve supply
Deep branch of ulnar nerve, C8–T1.

Origin
Via two heads from adjacent sides of metacarpals.

Insertion
Lateral (radial) side of base of proximal phalanx of index finger.
Lateral (radial) and medial (ulnar) sides of base of proximal phalanx of middle finger.
Medial (ulnar) side of base of proximal phalanx of ring finger.
Dorsal aponeuroses (extensor expansion or hood) of 2nd to 4th finger.

Dosage/needle size
Xeomin®: 2.5–5 MU each (rarely higher).
Botox®: 2.5–5 MU each (rarely higher).
Dysport®: 10–20 MU each (rarely higher).
Needle length: 20 mm.

102 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Abduct fingers away from 3rd finger at metacarpo-
phalangeal joints; assist in flexion of these joints, and
extension of interphalangeal joints.

Injection protocol
Number of puncture sites: 1 each.

Topographical indication
Difficult to differentiate, partly lying on top of each other.
Injecting too deeply into 1st interosseus can puncture
adductor pollicis; injecting too deeply into the other in-
terossei can infiltrate aponeurosis and muscles of the
palm.

Injection technique
Site: easy to inject – intermediate tendons clearly visible.
1st dorsal interosseus – in 1st interosseous space to-
wards the 2nd metacarpal.
2nd–4th dorsal interossei – either halfway between the
metacarpals, or towards the respective metacarpal.
Depth: 0.5 –1 cm.
Patient position: elbow supinated; wrist in neutral posi-
tion; fingers extended and abducted.

Clinical application
Rarely injected.
Most important and most accessible is 1st dorsal interosseus.

Pictorial Guide to Botulinum Toxin Injection 103

 Upper limb muscles

Palmar interossei 1–4

1
2
3
4
5
6

Nerve supply
Deep branch of ulnar nerve, C8–T1.

Origin
1st palmar interosseus: medial (ulnar) side of base of 1st metacarpal (often absent).
2nd interosseous: medial (ulnar) side of index finger.
3rd and 4th palmar interossei: lateral (radial) sides of 4th and 5th metacarpals.

Insertion
Into the dorsal aponeuroses (extensor expansion or hood) of the respective proximal phalanges.

Dosage/needle size
Xeomin®: 2.5–5 MU each (rarely higher).
Botox®: 2.5–5 MU each (rarely higher).
Dysport®: 10–20 MU each (rarely higher).
Needle length: 20 mm.

104 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Adduct fingers towards 3rd finger at metacarpophalan-
geal joints; assist in flexion of these joints, and exten-
sion of interphalangeal joints.

Injection protocol
Number of puncture sites: 1 each.

Topographical indication
Lie at the 1st, 2nd (ulnar or medial side), 4th and 5th
(radial or lateral side) of the metacarpals. Difficult to
distinguish from dorsal interossei or lumbricals.

Injection technique
Site: middle of the respective metacarpal, possible from
palmar or dorsal side.
2nd palmar interosseus – middle of medial (ulnar side)
of 2nd metacarpal.
3rd palmar interosseus – middle of lateral (radial) side
of 4th metacarpal.
4th palmar interosseus – middle of lateral (radial) side
of 5th metacarpal.
Patient position: forearm supinated; wrist and fingers
comfortably extended.

Clinical application
Complex dystonias as well as spasticity: often overlooked during treatment.
1st palmar interosseus is often absent.

Pictorial Guide to Botulinum Toxin Injection 105

 Upper limb muscles

Adductor pollicis

1
2
3
4
5
6

Nerve supply
Deep branch of ulnar nerve, C8–T1.

Origin
Oblique head: anterior surfaces of 2nd and 3rd metacarpals, capitate, trapezium, intercarpal
ligaments.
Transverse head: proximal two thirds of palmar surface of 3rd metacarpal.

Insertion
Medial (ulnar) side of base of proximal phalanx of thumb, medial (ulnar) sesamoid.

Dosage/needle size
Xeomin®: 2.5–10 MU (rarely higher).
Botox®: 2.5–10 MU (rarely higher).
Dysport®: 10–40 MU (rarely higher).
Needle length: 20 mm.

106 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Adducts thumb; involved in opposition of thumb to
other fingers (pincer movements).

Injection protocol
Number of puncture sites: 1–2 (mostly 1).

Topographical indication
Can be injected from palm (favored, although can
pierce 1st dorsal interosseus) or back of the hand (eas-
ier in some cases, e.g., flexor spasticity).
Injection too deep and too lateral in the thenar emi-
nence can pierce opponens pollicis.

Injection technique
Site: skin fold between 1st metacarpal and 1st dorsal
interosseus, towards proximal base of 1st metacarpal.
Patient position: forearm supinated; wrist slightly ex-
tended and thumb abducted.

Clinical application
Adduction of thumb (works synergistically with 1st palmar interosseus, flexor pollicis brevis
and opponens pollicis – clinical differentiation is difficult).
Strong, two–headed muscle but false injection is still possible.

Pictorial Guide to Botulinum Toxin Injection 107

 Upper limb muscles

Opponens pollicis

1
2
3
4
5
6

Nerve supply
Median nerve, C7–T1.

Origin
Trapezium, flexor retinaculum.

Insertion
Lateral (radial) side of 1st metacarpal.

Dosage/needle size
Xeomin®: 2.5–10 MU (rarely higher).
Botox®: 2.5–10 MU (rarely higher).
Dysport®: 10–40 MU (rarely higher).
Needle length: 20 mm.

108 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Opposes thumb to other fingers – combining flexion,
abduction, rotation and adduction in the carpometa-
carpal joint of the thumb (all muscles of the thumb are
involved, apart from extensors).

Injection protocol
Number of puncture sites: 1.
1/2
Topographical indication
Lies laterally (to radial side) and below abductor pol-
licis brevis (which may be pierced by injecting too far
medially).
Injecting too deeply can reach adductor pollicis.

Injection technique
Site: middle of lateral (radial) border of 1st metacarpal,
between abductor pollicis brevis and metacarpals.
Depth: 1–2 cm.
Patient position: elbow supinated; wrist slightly ex-
tended, thumb relaxed.

Clinical application
Acts in synergy with adductor pollicis and flexor pollicis brevis.

Pictorial Guide to Botulinum Toxin Injection 109

 Upper limb muscles

Opponens digiti minimi

1
2
3
4
5
6

Nerve supply
Deep branch of ulnar nerve, C8–T1.

Origin
Hook of hamate, flexor retinaculum.

Insertion
Medial (ulnar) side of 5th metacarpal.

Dosage/needle size
Xeomin®: 2.5–5 MU (rarely higher).
Botox®: 2.5–5 MU (rarely higher).
Dysport®: 10–20 MU (rarely higher).
Needle length: 20 mm.

110 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Rotates, flexes and slightly adducts the 5th finger (can-
not perform a true opposition).

Injection protocol
Number of puncture sites: 1.

Topographical indication
Muscles of the hypothenar are difficult to differentiate:
flexor digiti minimi brevis lies on the volar side; abduc-
tor digiti minimi lies laterally (radial side) and above.
Injecting too deeply can pierce the 4th lumbrical.
1/2

Injection technique
Site: middle of ‘line’ between lateral (radial) border of
pisiform and head of metacarpal. Inject from volar to-
wards ulnar side.
Depth: 1–2 cm.
Patient position: elbow supinated; wrist slightly ex-
tended, fingers comfortably flexed.

Clinical application
Cannot be distinguished from other muscles of the hypothenar by palpation (or EMG in
some cases, e.g., malposition of the hand).

Pictorial Guide to Botulinum Toxin Injection 111

 Upper limb muscles

Palmaris brevis

1
2
3
4
5
6

Nerve supply
Superficial branch of ulnar nerve, C7–T1.

Origin
Palmar aponeurosis, flexor retinaculum.

Insertion
Skin of medial (ulnar side) of palm.

Dosage/needle size
Xeomin®: 2.5 MU/injection site (rarely higher).
Botox®: 2.5 MU/injection site (rarely higher).
Dysport®: 10 MU/injection site (rarely higher).
Needle length: 20 mm.

112 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the finger joints

Action
Tenses skin on the medial (ulnar) side of palm; involved
in hypertension of the palmar aponeurosis.

Injection protocol
Number of puncture sites: 1–3 (mostly 1).

Topographical indication
Has to be differentiated from flexor digiti minimi brevis
directly below and abductor digiti minimi to the ulnar
side. Cutaneous branch of ulnar nerve runs over the
palmaris brevis.

Injection technique
Site: medial (ulnar) side of palm to avoid ulnar nerve
and artery.
Depth: 0.5–1 cm (muscle is very superficial).
Patient position: elbow supinated; wrist and fingers
comfortably extended.

Clinical application
Relatively unimportant – primarily stabilizing; protective cover of ulnar nerve and vessels.

Pictorial Guide to Botulinum Toxin Injection 113

3 Lower limb muscles

Muscles of the hip joint 116

Muscles of the knee joint 138

Muscles of the ankle joints 152

Muscles of the toe joints 162

Pictorial Guide to Botulinum Toxin Injection 115

 Lower limb muscles

Gluteus maximus

1
2
3
4
5
6

Nerve supply
Inferior gluteal nerve, L5–S2.

Origin
Outer surface of ilium behind posterior gluteal line, adjacent posterior surface of sacrum and
coccyx, sacrotuberous ligament, aponeurosis of erector spinae.

Insertion
Cranial part: iliotibial tract of fascia lata.
Caudal part: gluteal tuberosity of femur.

Dosage/needle size
Xeomin®: 40–100 MU (rarely higher).
Botox®: 40–100 MU (rarely higher).
Dysport®: 120–300 MU (rarely higher).
Needle length: at least 40 mm.

116 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the hip joint

Action
Main: Brings trunk upright from flexed position; stabi­
lizes trunk, preventing forward tilt.
Others: flexes hip joint posteriorly and flattens lumbar
lordosis. Powerful supporter of extended knee (via ilio­
tibial tract).

Injection protocol
Number of puncture sites: 1–3.

Topographical indication
ventral
Sciatic nerve (1) runs medially and distal to injection
site – can be easily injured.

1
medial lateral
dorsal

Injection technique
Site: middle of ‘line’ between greater trochanter and
posterior superior iliac spine.
Depth: 2–8 cm; dependent on muscle thickness.
Patient position: prone or on the side.

Clinical application
Flex knee to optimally activate muscle, and deactivate hamstring muscles.

Pictorial Guide to Botulinum Toxin Injection 117

 Lower limb muscles

Iliopsoas

1
2
3
4
5
6

Nerve supply
Branches of the lumbar plexus.
Iliacus femoral nerve, L2–L3.
Psoas major ventral rami, L2–L4.
Origin
Iliacus: iliac fossa, anterior inferior iliac spine, iliolumbal
ligament, anterior sacroiliac ligament.
Psoas major vertebral bodies of 12th thoracic– 4th
lumbar vertebrae, intervertebral discs, costal processes
1st–5th lumbar vertebrae.
Insertion
Lesser trochanter.
Dosage/needle size
Xeomin®: 25–200 MU (rarely higher).
Botox®: 25–200 MU (rarely higher).
Dysport®: 100–600 MU (rarely higher).
Needle length: at least 40 mm.

118 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the hip joint

Action
Main: Balances hip on head of femur (especially when
flexed).
Others: flexes free leg at hip joint, and intensifies lum­
bar lordosis. One­sided contraction causes lateral flex­
ion of vertebral column.

Injection protocol
Number of puncture sites: 1–2 (1 psoas major; 2 ilia­
cus); ultrasound, CT or EMG control.

Topographical indication
ventral
Injecting distal to inguinal ligament, risks contact with
2
medially positioned femoral nerve, artery and vein.
1 Injecting too far laterally can impregnate sartorius.

lateral medial
dorsal

Injection technique
Site: 2 finger widths (3–4 cm) lateral to femoral artery;
1 finger width (1–2 cm) distal to inguinal ligament (1).
Depth: 2–4 cm; dependent on muscle thickness.
Patient position: supine, right leg slightly flexed.

Clinical application
Iliacus: transperitoneally from anterior (ultrasound control) or retroperitoneally (CT control);
distal injection under EMG control.
Psoas major: injection more effective from posterior (CT control).

Pictorial Guide to Botulinum Toxin Injection 119

 Lower limb muscles

Sartorius

1
2
3
4
5
6

Nerve supply
Femoral nerve, L2–L3.

Origin
Anterior superior iliac spine.

Insertion
Proximal and medial surface of tibia (common inser­
tion with semitendinosus and gracilis; so­called pes
anserinus).

Dosage/needle size
Xeomin®: 10–40 MU (rarely higher).
Botox®: 10–40 MU (rarely higher).
Dysport®: 40–140 MU (rarely higher).
Needle length: 20–40 mm.

120 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the hip joint

Action
Flexes, abducts and laterally rotates thigh at hip joint;
flexes leg at knee joint after flexion. Actions combine
when sitting cross­legged (tailor seat).

Injection protocol
5–10 cm
Number of puncture sites: 1–2 (1 femoral artery; 2 in­
guinal ligament). Ultrasound control is helpful.
2
1

Topographical indication
ventral 4
Slender muscle, difficult to inject.
3
2 1 Injecting too deeply impregnates rectus femoris (1);
medially can pierce the iliacus (2) or femoral nerve (3);
and laterally the tensor fasciae latae (4).

medial lateral
dorsal

Injection technique
Site: 5–10 cm distally along ‘line’ from anterior superior
iliac spine to medial epicondyle of the femur, lateral to
femoral artery.
Depth: 1–3 cm; dependent on muscle thickness.
Patient position: supine, with slight flexion of hip.

Clinical application
Only examined in combination with other hip flexors.

Pictorial Guide to Botulinum Toxin Injection 121

 Lower limb muscles

Gluteus medius

1
2
3
4
5
6

Nerve supply
Superior gluteal nerve, L4–S1.

Origin
Gluteal surface of ala of ilium (wing of ilium) between anterior and posterior gluteal lines.

Insertion
Greater trochanter.

Dosage/needle size
Xeomin®: 20–60 MU (rarely higher).
Botox®: 20–60 MU (rarely higher).
Dysport®: 70–200 MU (rarely higher).
Needle length: 20–40 mm.

122 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the hip joint

Action
Abducts femur at hip joint and rotates thigh medially.
Draws pelvis to weight­bearing leg during walking, al­
lowing opposite leg to swing freely.

Injection protocol
2–3 cm Number of puncture sites: 1–2 (usually on one side).

Topographical indication
ventral 2
Injecting too far medially (posteriorly) can pierce the
gluteus maximus (1); too far laterally (anteriorly) risks
injecting the tensor fasciae latae (2).

1
medial lateral
dorsal

Injection technique
Site: 2–3 cm distal to ‘line’ between greater trochanter
and summit of iliac crest.
Depth: 2–4 cm; dependent on thickness of muscle and
subcutaneous adipose tissue.
Patient position: prone or on the side.

Clinical application
Drop of pelvis to unaffected side (freely swinging side, Trendelenburg sign) if muscle is
weak or paralysed.
Cannot be isolated from gluteus minimus for purposes of examination.

Pictorial Guide to Botulinum Toxin Injection 123

 Lower limb muscles

Gluteus minimus

1
2
3
4
5
6

Nerve supply
Superior gluteal nerve, L4–S1.

Origin
Gluteal surface of ala of ilium (wing of ilium) between anterior and posterior gluteal lines.

Insertion
Greater trochanter.

Dosage/needle size
Xeomin®: 20–60 MU (rarely higher).
Botox®: 20–60 MU (rarely higher).
Dysport®: 70–200 MU (rarely higher).
Needle length: 20–40 mm.

124 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the hip joint

Action
Abducts at hip joint.
Draws pelvis to weight­bearing leg during walking, al­
lowing opposite leg to swing freely.

Injection protocol
Number of puncture sites: 1.

1/2

Topographical indication
ventral 2
Injecting should not be too superficial (gluteus medius)
(1); too anterior (tensor fasciae latae) (2); or too poste­
1
rior (gluteus maximus) (3).

3
medial lateral
dorsal

Injection technique
Site: midpoint of ‘line’ between top of iliac crest and
greater trochanter; puncture until wing of ilium is felt,
and retract slightly.
Depth: 2–5 cm; dependent on thickness of muscle and
subcutaneous adipose tissue.
Patient position: prone or on the side.

Clinical application
Cannot be isolated from gluteus medius for purposes of examination.

Pictorial Guide to Botulinum Toxin Injection 125

 Lower limb muscles

Tensor fasciae latae

1
2
3
4
5
6

Nerve supply
Superior gluteal nerve, L4–L5.

Origin
Outer edge of iliac crest near the anterior superior iliac spine.

Insertion
Iliotibial tract on upper part of thigh.

Dosage/needle size
Xeomin®: 20–60 MU (rarely higher).
Botox®: 20–60 MU (rarely higher).
Dysport®: 80–200 MU (rarely higher).
Needle length: 20–40 mm.

126 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the hip joint

Action
Flexes and abducts thigh at hip joint; important medial
rotator of hip, compensating for powerful lateral rota­
tion of gluteus maximus.
Strong extensor of knee (via iliotibial tract) – can par­
tially compensate for paralysis of quadriceps.
‘Sprinter muscle’ – works as tension band principle lat­
erally against forces on femur bone of weight­bearing
leg.

Injection protocol
5–10 cm Number of puncture sites: 1–3.

3–4 cm

Topographical indication
1 ventral
Injecting should not be too medial (sartorius [1] or rec­
2 tus femoris [2]); too lateral (gluteus medius [3]); too
3
posterior (vastus lateralis).

lateral medial
dorsal

Injection technique
Site: 3–4 cm (2 finger widths) anterior to greater tro­
chanter, 5–10 cm below anterior superior iliac spine.
Depth: 1–3 cm; dependent on thickness of muscle and
subcutaneous adipose tissue.
Patient position: supine or on the side.

Clinical application
Injection rarely needed (abduction also carried out by gluteus medius and minimus).
Sometimes important in pain syndromes.

Pictorial Guide to Botulinum Toxin Injection 127

 Lower limb muscles

Pectineus

1
2
3
4
5
6

Nerve supply
Femoral nerve, L2–L3.
Obturator nerve, anterior branch L3.

Origin
Pectineal line (pecten pubis) of pubis.

Insertion
From lesser trochanter to linea aspera of femur.

Dosage/needle size
Xeomin®: 20–50 MU (rarely higher).
Botox®: 20–50 MU (rarely higher).
Dysport®: 80–180 MU (rarely higher).
Needle length: 20–40 mm.

128 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the hip joint

Action
Thigh adductor in every hip joint position, flexor when
hip is extended; extensor when joint is strongly flexed
(e.g., when coming upright from deep sitting position),
with lateral rotating component.

Injection protocol
Number of puncture sites: 1.

Topographical indication
ventral
1 Injection should not be too medial (adductor longus [2]
or gracilis [3]); or too deep (obturatorius externus [4]).
2 Risk of puncturing femoral vein, artery, and nerve (1),
lateral to muscle.
4
3

lateral medial
dorsal

Injection technique
Site: 1–2 cm medial to pulse of femoral artery (A), pal­
pated in groin (or palpate pubic tubercle [B] and inject
1–2 cm laterally).
Depth: 1–3 cm; dependent on thickness of muscle.
Patient position: supine.

Pictorial Guide to Botulinum Toxin Injection 129

 Lower limb muscles

Adductor longus

1
2
3
4
5
6

Nerve supply
Obturator nerve, anterior branch, L2–L4.

Origin
Superior pubic ramus.

Insertion
Medial lip of linea aspera (middle third).

Dosage/needle size
Xeomin®: 20–100 MU (rarely higher).
Botox®: 20–100 MU (rarely higher).
Dysport®: 50–300 MU (rarely higher).
Needle length: at least 40 mm.

130 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the hip joint

Action
Guides leg to neutral position from a position of ex­
treme rotation involving flexed or strongly extended
hip joint.

Injection protocol
7–8 cm
Number of puncture sites: 1–3.

Topographical indication
ventral
Injection should not be too deep (adductor magnus
[1]); or too posterior (gracilis [2]).
3 Risk of puncturing femoral vein and artery, and saphe­
nus nerve (3).
2 1

medial lateral
dorsal

Injection technique
Site: palpate tendon at origin on pubic tubercle; inject
4 finger widths (7–8 cm) distally, in muscle belly.
Depth: 1–3 cm; dependent on thickness of muscle and
subcutaneous adipose tissue.
Patient position: supine; slightly flexed and abducted
hip; slight flexion of knee.

Clinical application
Adductor muscles are difficult to differentiate.
Dosage assumes that both sides and, e.g., adductor magnus, will also be injected. If
injected individually, higher dosage and several injection sites can be used.

Pictorial Guide to Botulinum Toxin Injection 131

 Lower limb muscles

Adductor brevis

1
2
3
4
5
6

Nerve supply
Obturator nerve, anterior branch, L2–L4.

Origin
Inferior ramus of pubis.

Insertion
Medial lip of linea aspera (proximal third).

Dosage/needle size
Xeomin®: 20–80 MU (rarely higher).
Botox®: 20–80 MU (rarely higher).
Dysport®: 50–300 MU (rarely higher).
Needle length: 40 mm.

132 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the hip joint

Action
Adducts thigh at hip joint.
Guides leg to neutral position from a position of ex­
treme rotation involving flexed or strongly extended
hip joint.

Injection protocol
7–8 cm
Number of puncture sites: 1–2 (usually 1).

Topographical indication
ventral
Lies beneath adductor longus (3), between pectineus
(1) and adductor magnus (2).
1 Injection should not be too superficial (adductor lon­
3 gus), or dorsomedial (gracilis [4]); too deep or too me­
4 2 dial (adductor magnus).

medial lateral
dorsal

Injection technique
Site: palpate tendon at origin on pubic tubercle; inject
4 finger widths (7–8 cm) distally from origin.
Depth: 3–5 cm through adductor longus; dependent
on thickness of muscle.
Patient position: supine; slightly flexed and abducted
hip; slight flexion of knee.

Clinical application
Palpation impossible.
Spasticity: dosage assumes other adductors are simultaneously treated. If treated individu­
ally, higher dosage is possible.
Also infiltrated with toxin by deeper injection into adductor longus.

Pictorial Guide to Botulinum Toxin Injection 133

 Lower limb muscles

Gracilis

1
2
3
4
5
6

Nerve supply
Obturator nerve, anterior branch, L2–L4.

Origin
Inferior ramus of pubis, medial border.

Insertion
Proximal end of tibia, medial to tibial tuberosity
(common insertion with the sartorius and semitendi­
nosus; so­called pes anserinus).

Dosage/needle size
Xeomin®: 20–60 MU (rarely higher).
Botox®: 20–60 MU (rarely higher).
Dysport®: 60–200 MU (rarely higher).
Needle length: 40 mm.

134 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the hip joint

Action
Flexes at both hip and knee joint, simultaneously acting
as adductor of thigh.
Assists in medial rotation of flexed knee.

Injection protocol
Number of puncture sites: 1–3.

1/2

1/3 1/3

Topographical indication
ventral
Injection should not be too deep (adductor magnus
[1]); or too lateral (adductor longus [2]).

2
1

medial lateral
dorsal

Injection technique
Site: middle (or if two injections, at each third) of ‘line’
between pubic tubercle and medial condyle.
Depth: 1–3 cm; dependent on thickness of muscle and
subcutaneous adipose tissue.
Patient position: supine, leg slightly abducted.

Clinical application
Rarely treated individually, but considered for spasm of the adductors.
Shares common insertion with sartorius, and semitendinosus beneath the medial condyle
of tibia.

Pictorial Guide to Botulinum Toxin Injection 135

 Lower limb muscles

Adductor magnus

1
2
3
4
5
6

Nerve supply
Obturator nerve L2–L4 anterior or linea aspera part of
adductor magnus.
Sciatic nerve L4–S1 posterior or adductor tubercle part
of adductor magnus.
Origin
Inferior ramus of pubis and ramus of ischium (medial
border) onto lower part of tuberosity of ischium.
Insertion
Anterior part: medial lip of linea aspera (proximal two­
thirds), gluteal tuberosity.
Posterior part: adductor tubercle of femur (adductor hiatus between both insertions).
Dosage/needle size
Xeomin®: 30–150 MU (rarely higher).
Botox®: 30–150 MU (rarely higher).
Dysport®: 100–500 MU (rarely higher).
Needle length: at least 40 mm.

136 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the hip joint

Action
Strong muscle that adducts free­swinging thigh.
Together with tensor fasciae latae, prevents femur
breaking under lateral body weight forces. Balances
pelvis on head of femur (with small gluteal muscles),
centering body weight forces on weight­bearing leg.
Guides leg to neutral position from extreme rotation
when hip joint is flexed or strongly extended.

Injection protocol
7–8 cm
Number of puncture sites: 1–3 (multiple injections
should not be given solely in the long axis of muscle,
but also into cross­section).
B A
1/2

ventral Topographical indication

Readily palpated. Avoid arched opening (adductor hia­
tus) in distal portion of muscle between the two areas
of insertion when injecting.
Injection should not be too medial (hamstrings); too
2
superficial (gracilis [1]); or too anterior (sartorius [2]).
1
medial lateral
dorsal

Injection technique
Site: (A) in the middle, and (B) 4 finger widths (7–8 cm)
above, midpoint of ‘line’ between medial condyle of
femur and pubic tubercle.
Depth: 10–13 mm; dependent on muscle thickness.
Patient position: supine; leg slightly flexed, abducted
and rotated laterally; knee slightly flexed.

Clinical application
Spasticity: dosage assumes other adductors are simultaneously treated. If treated individu­
ally, higher dosage is possible.

Pictorial Guide to Botulinum Toxin Injection 137

 Lower limb muscles

Quadriceps femoris: rectus femoris

1
2
3
4
5
6

Nerve supply
Femoral nerve, L2–L4.

Origin
Straight head (anterior head): anterior inferior iliac
spine.
Reflexed head (posterior head): superior border of
acetabulum.

Insertion
Patella; via patellar ligament to tibial tuberosity.

Dosage/needle size
Xeomin®: 20–100 MU (rarely higher).
Botox®: 20–100 MU (rarely higher).
Dysport®: 50–300 MU rarely higher).
Needle length: 40 mm.

138 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the knee joint

Action
Flexes hip; extends knee (with other quadriceps com­
ponents).
Used when thigh flexion and leg extension are needed
together; prevents knee from flexing during heel strike
in walking.

Injection protocol
Number of puncture sites: 1–3.

ventral Topographical indication

Distal part is easily differentiated from other quadri­
ceps.
2
1 3 Injection should not be too medial (vastus medialis [1])
and in middle of muscle belly, not too medial or too
deep (vastus intermedius [2]); too lateral (vastus late­
ralis [3]).
medial lateral
dorsal

Injection technique
Site: middle of muscle belly, on midpoint of ‘line’ be­
tween anterior superior iliac spine and cranial margin
of patella.
Depth: 15–30 mm; dependent on muscle thickness.
Patient position: supine.

Clinical application
Different components of quadriceps femoris must be viewed as a whole.
Spasticity: dosage assumes other portions of quadriceps are simultaneously treated. If
treated individually, higher dosage is appropriate.

Pictorial Guide to Botulinum Toxin Injection 139

 Lower limb muscles

Quadriceps femoris: vastus medialis

1
2
Vastus
medialis
3
4
5
6

Nerve supply
Femoral nerve, L2–L4.

Origin
Medial lips of linea aspera of femur, intertrochanteric
line, medial intermuscular septum, medial supracon­
dylar ridge.

Insertion
Patella; via patellar ligament to tibial tuberosity.
Medial condyle of tibia via patellar retinaculum.

Dosage/needle size
Xeomin®: 20–80 MU (rarely higher).
Botox®: 20–80 MU (rarely higher).
Dysport®: 50–300 MU (rarely higher).
Needle length: 40 mm.

140 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the knee joint

Action
Extends leg at knee joint (with other vasti), and pre­
vents patella luxation.
Medial rotation action (antagonist to vastus lateralis).

Injection protocol
Number of puncture sites: 1–3.

7–8 cm

ventral Topographical indication

Injection should not be too medial (sartorius [1], gracilis
4 [2], and adductor magnus [3]); too lateral (rectus femo­
ris [4]).
5 1 Femoral artery, vein and nerve (terminal branches), and
3 saphenous nerve (5) lie close by.
2

lateral medial
dorsal

Injection technique
Site: distal portion of muscle belly; 7–8 cm (4 finger
widths) proximal to ‘line’ from cranial, medial patellar
angle.
Depth: 15–30 mm; dependent on muscle thickness.
Patient position: supine.

Clinical application
Muscle can be very thin in debilitated patient – increase tension by rotating laterally.
Spasticity: dosage assumes other portions of quadriceps are simultaneously treated.

Pictorial Guide to Botulinum Toxin Injection 141

 Lower limb muscles

Quadriceps femoris: vastus intermedius

1
2
Vastus
3 intermedius

4
5
6

Nerve supply
Femoral nerve, L2–L4.

Origin
Intertrochanteric line, anterior and lateral surfaces of
upper two­thirds of femur.

Insertion
Patella; via patellar ligament to tibial tuberosity.

Dosage/needle size
Xeomin®: 20–80 MU (rarely higher).
Botox®: 20–80 MU (rarely higher).
Dysport®: 50–300 MU (rarely higher).
Needle length: 40 mm.

142 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the knee joint

Action
Extends leg at knee joint.

Injection protocol
Number of puncture sites: 1–2.

1/2

ventral Topographical indication

Must be injected through rectus femoris (1) – so avoid
1 injecting too superficially.
3 Injection should not be too lateral (vastus lateralis [2]);
2 too medial (vastus medialis [3]).

lateral medial
dorsal

Injection technique
Site: middle of ‘line’ between anterior superior iliac
spine and cranial surface in middle of patella. Insert
needle until it contacts bone, and retract slightly.
Depth: 3–5 cm; dependent on muscle thickness.
Patient position: supine.

Clinical application
Cannot be palpated.
Lies between vastus medialis and vastus lateralis, and beneath rectus femoris; difficult to
differentiate from vastus medialis (also functionally inseparable).

Pictorial Guide to Botulinum Toxin Injection 143

 Lower limb muscles

Quadriceps femoris: vastus lateralis

1
2
Vastus
3 lateralis

4
5
6

Nerve supply
Femoral nerve, L2–L4.

Origin
Intertrochanteric line, inferior border of greater tro­
chanter, gluteal tuberosity, lateral lip of linea aspera
of femur.

Insertion
Patella; via patellar ligament to tibial tuberosity.
Lateral condyle of tibia via patellar retinaculum.

Dosage/needle size
Xeomin®: 20–80 MU (rarely higher).
Botox®: 20–80 MU (rarely higher).
Dysport®: 50–300 MU (rarely higher).
Needle length: 40 mm.

144 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the knee joint

Action
Extends leg at knee joint (with other vasti).
Lateral rotation action (antagonist to vastus medialis).

Injection protocol
Number of puncture sites: 1–3 (usually 1–2).

B
A
10–11 cm

ventral Topographical indication

In distal portion of muscle, injection should not be too
2 posterior (biceps femoris [1]); or too anterior (rectus
femoris [2]).

1
1
lateral medial
dorsal

Injection technique
Site: middle and distal portion of muscle belly – (A)
middle of the thigh, anterior to furrow between bi­
ceps femoris and vastus lateralis; (B) 10–11 cm (hand’s
width) above patella.
Depth: 10–13 mm dependent on muscle thickness.
Patient position: supine.

Clinical application
Largest of the quadriceps components; easy to inject.
Tension increased by medial rotation in hip joint.
Spasticity: dosage assumes other portions of quadriceps are simultaneously treated.
If treated individually, higher dosage is appropriate.

Pictorial Guide to Botulinum Toxin Injection 145

 Lower limb muscles

Hamstrings: biceps femoris

1
2
3
4
5
6

Nerve supply
Long head: sciatic nerve, tibial part, L5–S2.
Short head: sciatic nerve, peroneal (fibular) part,
L5–S2.

Origin
Long head: ischial tuberosity, sacrotuberous ligament.
Short head: linea aspera, lateral intermuscular septum.

Insertion
Lateral side of the head of the fibula and lateral
condyle of tibia.

Dosage/needle size
Xeomin®: 40–140 MU (rarely higher).
Botox®: 40–140 MU (rarely higher).
Dysport®: 100–500 MU (rarely higher).
Needle length: 40 mm.

146 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the knee joint

Action
Extends hip joint and rotates thigh laterally.
Powerfully flexes extended knee; rotates flexed knee
laterally.
Brings trunk upright from forward flexed position, indi­
rectly flattening lumbar lordosis.

Injection protocol
Number of puncture sites: long head 1–3; short head 1.

1/2

ventral Topographical indication

Injection should not be too medial (semitendinosus [1]).
Before injecting the short head, the long head and
semimembranosus (2) on the medial side must be lo­
cated.

2 1
medial lateral
dorsal

Injection technique
Site: long head – middle of ‘line’ between head of
fibula and ischial tuberosity (slightly proximal from
middle); short head – above popliteal cavity, ~ 4 finger
widths above head of fibula, medial or lateral to ten­
don of long head.
Patient position: prone.

Clinical application
Inserting tendon forms lateral border of popliteal cavity; short head can be absent.
Failure of hamstring muscles has no serious effects on daily mobility, if gluteus maximus
compensates. There may be occasional over­extension at the knee.
Usually treated with other knee flexors; dosage refers to treatment of several muscles.

Pictorial Guide to Botulinum Toxin Injection 147

 Lower limb muscles

Hamstrings: semimembranosus

1
2
3
4
5
6

Nerve supply
Tibial portion of sciatic nerve, L5–S2.

Origin
Ischial tuberosity, proximal and lateral portion of the
common origin.

Insertion
Posterior and medial surface of medial condyle of
tibia.

Dosage/needle size
Xeomin®: 20–100 MU (rarely higher).
Botox®: 20–100 MU (rarely higher).
Dysport®: 80–300 MU (rarely higher).
Needle length: 40 mm.

148 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the knee joint

Action
Extends hip joint of weight­bearing leg, producing
propulsion during walking; flexes free­swinging leg at
knee joint.
Isolated contraction in flexed position medially rotates
leg at knee joint.

Injection protocol
Number of puncture sites: 1–3 (usually 1–2).

B A

ventral Topographical indication

Hamstring muscles are difficult to differentiate from
one another. Semimembranosus lies between semi­
tendinosus (1) and adductor magnus (2); short head of
biceps femoris and sciatic nerve (3) lie laterally. In mid­
3 2 thigh, semimembranosus lies beneath semitendinosus.
Injecting too far laterally can infiltrate semitendinosus.
1
lateral medial
dorsal

Injection technique
Site: (A) distal portion of muscle at lateral margin of
tendon of semitendinosus; (B) proximal portion of
muscle, at midpoint between head of semitendinosus
(medial border) and long head of biceps femoris (lateral
border).
Depth: 15–30 mm; dependent on muscle thickness.
Patient position: prone.

Clinical application
Can be absent or fused with semitendinosus; examined together with semitendinosus and
popliteus.
Failure of hamstring muscles has no serious effects on daily mobility, if gluteus maximus
compensates. There may be occasional over­extension at the knee.

Pictorial Guide to Botulinum Toxin Injection 149

 Lower limb muscles

Hamstrings: semitendinosus

1
2
3
4
5
6

Nerve supply
Tibial portion of sciatic nerve, L5–S2.

Origin
Ischial tuberosity together with the common tendon
of origin with the long head of biceps femoris.

Insertion
Tibial tuberosity (medial surface) (pes anserinus)
together with gracilis and sartorius.

Dosage/needle size
Xeomin®: 20–80 MU (occasionally higher).
Botox®: 20–80 MU (occasionally higher).
Dysport®: 60–300 MU (occasionally higher).
Needle length: 40 mm.

150 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the knee joint

Action
Extends hip joint of weight­bearing leg, producing pro­
pulsion during walking; decelerates forward motion of
tibia when free­swinging leg is extended, preventing
knee snapping into extension.
Control forward tilt of trunk, and helps to raise trunk
from flexed position.
Isolated action at flexed knee causes medial rotation of
leg at knee joint.

Injection protocol
Number of puncture sites: 1–3 (usually 1–2).

1/2

ventral Topographical indication

Hamstring muscles are difficult to differentiate from
one another – semitendinosus is the most superficial.
Injection should not be too lateral (long head of biceps
femoris [1]); too deep or too medial (semimembrano­
sus [2]).
1
2
lateral medial
dorsal

Injection technique
Site: middle of ‘line’ between ischial tuberosity and me­
dial epicondyle.
Depth: 15–30 mm; dependent on muscle thickness.
Patient position: prone.

Clinical application
Contraction indirectly affects lumbar lordosis working antagonistic to the iliopsoas. Flexes
free­swinging leg at knee joint.
Failure of hamstring muscles has no serious effects on daily mobility, if gluteus maximus
compensates. There may be occasional over­extension at the knee.

Pictorial Guide to Botulinum Toxin Injection 151

 Lower limb muscles

Gastrocnemius

1
2
3
4
5
6

Nerve supply
Tibial nerve, S1–S2.

Origin
Medial head: popliteal surface of femur; medial
condyle of femur.
Lateral head: popliteal surface of femur; lateral
condyle of femur.

Insertion
Calcaneal tuberosity via calcaneal tendon (Achilles
tendon).

Dosage/needle size
Xeomin®: 20–100 MU per head.
Botox®: 20–100 MU per head.
Dysport®: 80–300 MU per head.
Needle length: 40 mm.

152 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the ankle joints

Action
Powerful flexor at knee and ankle joints.
Produces propulsion during roll through and toe­off
phases of walking; supinates foot at talotarsal joint,
lifting medial side as it flexes in the ankle joint.

Injection protocol
Number of puncture sites: 1–3 per head (usually 2).
8–10 cm

dorsal Topographical indication

Injection should not be too deep (soleus [1]); too deep
into medial head (flexor digitorium longus [2], and
1 eventually hallucis longus or tibialis posterior [3]).
4
3 Tibial nerve, posterior tibial artery and vein (4) course
2
deeply to the triceps surae.
lateral medial

ventral

Injection technique
Site: in belly of both medial and lateral heads, ~ 4 finger
widths (8–10 cm) distal to crease at knee.
Depth: 2–4 cm; dependent on muscle thickness.
Patient position: prone, with feet over end of cot, or
supported with rolled cushion.
(Dosage depends whether patient presents with foot
drop or inverted position. For the latter, combined in­
jection of medial head with tibialis posterior is often
recommended.)

Clinical application
Together with soleus and plantaris forms the triceps surae – strongest supinator (inverted)
of the foot. Full power attained by a fully stretched leg at knee joint.

Pictorial Guide to Botulinum Toxin Injection 153

 Lower limb muscles

Soleus

1
2
3
4
5
6

Nerve supply
Tibial nerve, S1–S2.

Origin
Posterior surface of the tibia (soleal line), upper third
of posterior surface of fibula, fibrous arch between
tibia and fibula.

Insertion
Calcaneal tuberosity via calcaneal tendon (Achilles
tendon).

Dosage/needle size
Xeomin®: 20–80 MU (rarely higher).
Botox®: 20–80 MU (rarely higher).
Dysport®: 80–300 MU (rarely higher).
Needle length: 40 mm.

154 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the ankle joints

Action
Important flexor at ankle joint; supinates at talotarsal
joint.
Maintains upright position and resists collapse at ankle
joint due to force of body weight, thereby balancing
body over ankle joint.

Injection protocol
Achilles tendon
Number of puncture sites: 2–4 (usually 1–2).

dorsal Topographical indication

Injection should not be too superficial or proximal (gas­
1 trocnemius [1]); too deep for medial injection (flexor
digitorum longus [3], tibialis posterior [4]).
2
4 3 Tibial nerve, and posterior tibial artery and vein (2), run
beneath.
lateral medial

ventral

Injection technique
Site: below heads of gastrocnemius; lateral and medial
to calcaneal tendon.
Depth: 2–4 cm; dependent on muscle thickness.
Patient position: prone, with feet over end of cot, or
supported with rolled cushion.

Pictorial Guide to Botulinum Toxin Injection 155

 Lower limb muscles

Tibialis posterior

1
2
3
4
5
6

Nerve supply
Tibial nerve, L5–S1.

Origin
Lateral part of posterior surface of tibia, interosse­
ous membrane, proximal half of posterior surface of
fibula.

Insertion
Tuberosity of navicular bone, cuboid, cuneiforms,
2nd, 3rd and 4th metatarsal, sustentaculum tali of
calcaneus.

Dosage/needle size
Xeomin®: 20–100 MU (rarely higher).
Botox®: 20–100 MU (rarely higher).
Dysport®: 80–400 MU (rarely higher).
Needle length: 40 mm (eventually longer).

156 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the ankle joints

Action
Plantar flexes and supinates foot.
Tendon runs beneath sole, supporting foot arches (with
peroneus longus and tibialis anterior).

Injection protocol
Number of puncture sites: 1–3; ultrasound or EMG
control (with stimulation).

dorsal direction of Topographical indication

injection Injection should not be too superficial (soleus [1] or
flexor digitorum longus [2]); too deep (tibialis anterior
1 [3]).
4
Risk of damage to neighboring tibial nerve (4), and pos­
2
terior tibial artery and vein.
lateral 3 medial

ventral

Injection technique
Site: below medial head of gastrocnemius; posterior
to medial margin of tibia (needle punctures soleus and
flexor digitorum longus).
Depth: 2–4 cm; dependent on muscle thickness.
Patient position: prone; leg slightly rotated medially.

Clinical application
Relatively difficult to infiltrate due to deep position, very close to bone; approach through
tibialis anterior if injecting proximally is difficult (due to overlying gastrocnemius).
Function supported by gastrocnemius, flexor digitorum longus and flexor hallucis longus,
and by tibialis anterior when pes equinovarus is present.
Absent in some cases.

Pictorial Guide to Botulinum Toxin Injection 157

 Lower limb muscles

Tibialis anterior

1
2
3
4
5
6

Nerve supply
Deep peroneal (fibular) nerve, L4–L5.

Origin
Lateral condyle of tibia, upper half of lateral surface
of tibia, interosseous membrane superficial fascia.

Insertion
Medial side and plantar surface of medial cuneiform
bone and base of 1st metatarsal bone.

Dosage/needle size
Xeomin®: 20–80 MU (rarely higher).
Botox®: 20–80 MU (rarely higher).
Dysport®: 80–300 MU (rarely higher).
Needle length: 20–40 mm.

158 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the ankle joints

Action
Extends foot at ankle joint; supinates medial margin of
foot at talotarsal joint.
Raises front of foot when walking and running; bal­
ances leg over the trochlea of talus (with soleus, its
antagonist).

Injection protocol
Number of puncture sites: 1–3 (usually 1–2).

7–8 cm

dorsal Topographical indication

Injecting too far laterally can pierce extensor digitorum
longus (1).
Excessive injection volume with concomitant bleeding
can cause extreme pain, theoretically leading to an an­
terior compartment syndrome.
lateral 1 medial

ventral

Injection technique
Site: 7–8 cm below tibial tuberosity; 1 finger width lat­
eral to shaft of tibia.
Depth: 15–30 mm; dependent on muscle thickness.
Patient position: supine.

Clinical application
Injection rarely necessary, but should always be considered – e.g., in patients presenting
with pes equinovarus.
Muscle power should be tested with knee flexed (tonic contraction of calf muscles can in­
hibit contraction of tibialis anterior), and toes relaxed (to exclude involvement of extensor
digitorum and extensor hallucis longus).

Pictorial Guide to Botulinum Toxin Injection 159

 Lower limb muscles

Peroneus longus (fibularis longus)

1
2
3
4
5
6

Nerve supply
Superficial peroneal (fibular) nerve, L5–S1.

Origin
Head of fibula, upper two­thirds of lateral surface of
fibula.

Insertion
Lateral side of medial cuneiform, base of 1st meta­
tarsal.

Dosage/needle size
Xeomin®: 5–40 MU (rarely higher).
Botox®: 5–40 MU (rarely higher).
Dysport®: 20–140 MU (rarely higher).
Needle length: 20–40 mm.

160 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the ankle joints

Action
Everts and flexes the foot.
Runs beneath sole, actively supporting transverse arch
of foot (with tibialis posterior and tibialis anterior).
Helps maintain balance on weight­bearing foot (as an­
tagonist to the supinators).

Injection protocol
Number of puncture sites: 1–2.
5–6 cm

dorsal Topographical indication

Injection should not be too anterior (extensor digito­
rum longus [1]); or too posterior (soleus [2]).
2

lateral 1 medial

ventral

Injection technique
Site: 5–6 cm below head of fibula (readily palpated, at
right angles to muscle and slightly downward).
Depth: 15–30 mm; dependent on muscle thickness.
Patient position: supine; slightly flexed knee, with sup­
port if necessary.

Clinical application
Very long tendon, which runs (with peroneus brevis) under superior peroneal retinaculum
and distally under inferior peroneal retinaculum.

Pictorial Guide to Botulinum Toxin Injection 161

 Lower limb muscles

Extensor digitorum brevis and hallucis brevis

1
2
3
4
5
Extensor
6 digitorum brevis Extensor
hallucis brevis

Extensor digitorum brevis Extensor hallucis brevis

Nerve supply Nerve supply

Deep peroneal nerve. Deep peroneal nerve.

Origin Origin
Lateral surface of calcaneus. Dorsolateral surface of calcaneus.
Tarsal sinus.

Insertion Insertion
Extensor expansion of 2nd to 4th toes. Proximal phalanx of great toe.

Dosage/needle size
Xeomin®: 5–30 MU (rarely higher).
Botox®: 5–30 MU (rarely higher).
Dysport®: 20–100 MU (rarely higher).
Needle length: 20 mm.

162 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the toe joints

Action
Extends 2nd, 3rd and 4th toes, additive to action of
extensor digitorum longus.
Extends great toe.
: “Belly” of EDB.

Injection protocol
Number of puncture sites: 1 (for both muscles).

B Topographical indication
A Difficult to differentiate between different components
of the muscle.
4–5 cm

Injection technique
Site: (A) proximal third of lateral margin of sole of the
foot, ~ 2–3 finger widths (4–5 cm) distal to lateral mal­
leolus, directly into muscle belly; (B) medial from A.
Depth: 5–10 mm; dependent on muscle thickness.
Patient position: supine.

Clinical application
Extensor digitorum brevis frequently treated by antibody indication (EDB­test).
Injection made into main muscle mass (appears as single muscle).

Pictorial Guide to Botulinum Toxin Injection 163

 Lower limb muscles

Extensor hallucis longus

1
2
3
4
5
6

Nerve supply
Deep peroneal nerve, L5–S1.

Origin
Middle half of anterior surface of fibula and
interosseous membrane.

Insertion
Base of distal phalanx of great toe.

Dosage/needle size
Xeomin®: 20–40 MU (rarely higher).
Botox®: 20–40 MU (rarely higher).
Dysport®: 80–140 MU (rarely higher).
Needle length: 20–40 mm.

164 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the toe joints

Action
Only truly powerful muscle to stretch great toe; also
extends at ankle joint.
Corroborates action of tibialis anterior.

Injection protocol
Number of puncture sites: 1–2 (usually 1).
Ultrasound control is helpful.
2/3 3/3
1/3

dorsal Topographical indication

Injection should not be too lateral (peroneus tertius
or extensor digitorum longus [1]); too anterior (tibi­
alis anterior [2]) and theoretically, injecting too deeply
could pierce interosseous membrane and inject tibialis
3
posterior (3).
lateral 1 medial
2

ventral

Injection technique
Site: easy to inject – between the distal and middle
third of the leg into the lateral margin of the tibia.
Pulse of dorsalis pedis artery is felt in middle of dorsum
of the foot.
Depth: 5–15 mm; dependent on muscle thickness.
Patient position: supine.

Clinical application
Striatal toe in spasticity: to eliminate extension in great toe.
Tendon lies between tendons of tibialis anterior and extensor digitorum longus, beneath
superior and inferior extensor retinacula.

Pictorial Guide to Botulinum Toxin Injection 165

 Lower limb muscles

Extensor digitorum longus

1
2
3
4
5
6

Nerve supply
Deep peroneal nerve, L5–S1.

Origin
Upper two­thirds of anterior surface of fibula, interosseous membrane, lateral condyle of tibia,
muscle fascia.

Insertion
Via four tendons along dorsal surface of four lateral toes, and then to the bases of middle and
distal phalanges.

Dosage/needle size
Xeomin®: 5–40 MU (rarely higher).
Botox®: 5–40 MU (rarely higher).
Dysport®: 20–140 MU (rarely higher).
Needle length: 40 mm.

166 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the toe joints

Action
Extends at all toe joints, in metatarsophalangeal joint
and at ankle joint.

Injection protocol
Number of puncture sites: 1–2 (usually 1).
Ultrasound control is helpful.

1/3 2/3 3/3

dorsal Topographical indication

Difficult to inject – must be isolated from tibialis an­
terior (1), which lies anteriorly (injecting too far proxi­
mally requires penetration of tibialis anterior).
3 Injection should not be too deep (extensor hallucis
2 longus [2]); too lateral (peroneus longus [3]). Theo­
lateral 1 medial retically, injection can cause an anterior compartment
syndrome.

ventral

Injection technique
Site: middle third of lower leg, between tibia and fibula.
Depth: 5–10 mm; dependent on muscle thickness.
Patient position: supine.

Clinical application
Examined together with extensor digitorum brevis (both extend toes at all joints).
Supports action of tibialis anterior at ankle joint.

Pictorial Guide to Botulinum Toxin Injection 167

 Lower limb muscles

Flexor hallucis brevis

lateral head
1
2
3 medial head

4
5
6

Nerve supply
Medial head: medial plantar nerve, S1–S3.
Lateral head: lateral plantar nerve, S1–S3.

Origin
Common origin for both heads from planar surface of cuboid, cuneiform bones, long planar
ligament, calcaneocuboid ligament, tendon of tibialis posterior.

Insertion
Base of proximal phalanx of great toe; medial part to medial sesamoid bone, lateral part to
lateral sesamoid bone.

Dosage/needle size
Xeomin®: 5–30 MU (rarely higher).
Botox®: 5–30 MU (rarely higher).
Dysport®: 20­100 MU (rarely higher).
Needle length: 20–40 mm.

168 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the toe joints

Action
Actively supports medial longitudinal arch of foot.
Flexes proximal phalanx of great toe – powerfully flexes
and prevents medial tilting of foot during push­off
from ground. Steadies great toe during propulsion.

Injection protocol
Number of puncture sites: 1–2 (usually 1 at medial
head).

tendon of
flexor hallucis
longus

Topographical indication
medial Difficult to separate from neighboring muscles.
Injection should not be too medial (abductor hallucis
[1]); too lateral (adductor hallucis [2], or lumbricals).

2
1 lateral

Injection technique
Site: lateral to 1st metatarsal; use tendon of flexor hal­
lucis longus for orientation (runs over both heads) –
medial head is medial to tendon, lateral head is lateral
to tendon.
Depth: 5–10 mm; dependent on muscle thickness.
Patient position: supine.

Clinical application
Injection is sometimes painful.
Action cannot be differentiated from that of flexor hallucis longus.
Medial head is intertwined with abductor hallucis; lateral head with adductor hallucis.

Pictorial Guide to Botulinum Toxin Injection 169

 Lower limb muscles

Flexor hallucis longus

1
2
3
4
5
6

Nerve supply
Tibial nerve, L5–S2.

Origin
Distal two­thirds of posterior surface of fibula, interosseous membrane.

Insertion
Base of distal phalanx of great toe.

Dosage/needle size
Xeomin®: 10–40 MU (rarely higher).
Botox®: 10–40 MU (rarely higher).
Dysport®: 40–140 MU (rarely higher).
Needle length: 40 mm.

170 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the toe joints

Action
Flexes distal phalanx of great toe; assists in flexing foot
at the ankle and inverting foot.
Produces final thrust as foot lifts from ground during
locomotion.

Injection protocol
Number of puncture sites: 1–2 (usually 1).
10–11 cm

dorsal Topographical indication

Injection should not be too deep (tibialis posterior [1]);
too medial (flexor digitorum longus [2]); or too super­
3 ficial (soleus [3]).

1 2
lateral medial

ventral

Injection technique
Site: 10–11 cm proximal to calcaneal tuberosity, medial
to Achilles tendon.
Depth: 15–30 mm; dependent on muscle thickness.
Patient position: prone, with foot hanging over edge of
examination bed.

Clinical application
Only muscle flexing distal joint of great toe.
Tendon crosses that of the flexor digitorum longus (plantar chiasm); occasionally sends
tendons to 2nd and 3rd toes.

Pictorial Guide to Botulinum Toxin Injection 171

 Lower limb muscles

Flexor digitorum brevis

1
2
3
4
5
6

Nerve supply
Medial plantar nerve, S1–S2.

Origin
Plantar surface of calcaneal tuberosity, plantar aponeurosis.

Insertion
Middle phalanges of 2nd to 5th toes.

Dosage/needle size
Xeomin®: 10–80 MU.
Botox®: 10–80 MU.
Dysport®: 40–300 MU.
Needle length: 20–40 mm.

172 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the toe joints

Action
Flexes toes – supplements action of flexor digitorum
longus, allowing flexor longus to focus on flexion at
ankle and talotarsal joints.

Injection protocol
Number of puncture sites: 1–3.

1/2

Topographical indication
medial Injection should not be too lateral (abductor digiti min­
imi [1]); too medial (abductor hallucis [2]).

lateral

2 1

Injection technique
Site: into plantar aponeurosis in middle of foot arch;
midpoint of ‘line’ from head of 3rd metatarsal bone to
calcaneal tuberosity.
Depth: 5–15 mm; dependent on muscle thickness.
Patient position: supine.

Clinical application
Injection is often very painful; recommended to brace foot in a fixed position.
Thick skin of sole cannot be penetrated using a needle too thin (e.g., 30 G).

Pictorial Guide to Botulinum Toxin Injection 173

 Lower limb muscles

Flexor digitorum longus

1
2
3
4
5
6

Nerve supply
Tibial nerve, L5–S2.

Origin
Posterior surface of tibia.

Insertion
Bases of distal phalanges of 2nd to 5th toes.

Dosage/needle size
Xeomin®: 10–40 MU (rarely higher).
Botox®: 10–40 MU (rarely higher).
Dysport®: 40–140 MU (rarely higher).
Needle length: 40 mm.

174 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the toe joints

Action
Flexes toes and foot.
Important for push­off from ground when walking, and
for balance when standing.

Injection protocol
1/2
Number of puncture sites: 1–2 (usually 1).
Ultrasound control is helpful.

1–2 cm

dorsal Topographical indication

Anterior to posterior behind the medial malleolus:
tibialis posterior (3), flexor digitorum longus, and flexor
hallucis longus. Tibial artery, vein and nerve (1) also run
1 2
posteriorly.
3
Injecting too superficially will only penetrate soleus (2);
lateral medial injecting too far laterally will puncture tibialis posterior.

ventral

Injection technique
Site: middle of tibial shaft, 1–2 cm posterior to medial
margin.
Depth: 15–30 mm; dependent on muscle thickness.
Patient position: prone.

Clinical application
Spastic or dystonic flexor deformity (injection of short muscles of foot often insufficient).

Pictorial Guide to Botulinum Toxin Injection 175

 Lower limb muscles

Quadratus plantae (flexor accessories)

1
2
3
4
5
6

Nerve supply
Lateral plantar nerve, S2–S3.

Origin
Medial and lateral surfaces of calcaneus, long plantar ligament.

Insertion
Lateral margin of tendon of flexor digitorum longus before division into individual tendons.

Dosage/needle size
Xeomin®: 5–20 MU (rarely higher).
Botox®: 5–20 MU (rarely higher).
Dysport®: 20–80 MU (rarely higher).
Needle length: 20–40 mm.

176 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the toe joints

Action
Pulls tendons of flexor digitorum longus to create more
powerful flexion of toes towards heel – especially when
ankle is already flexed.

Injection protocol
Number of puncture sites: 1–2.

1/2

Injection technique
Site: midway on ‘line’ between calcaneal tuberosity and
head of 3rd metatarsal; inject until resistance of lateral
cuneiform can be felt, then retract needle slightly.
Depth: 10–25 mm.
Patient position: supine.

Clinical application
Cannot be palpated. Tested together with flexor digitorum longus.
Rarely indicated.

Pictorial Guide to Botulinum Toxin Injection 177

 Lower limb muscles

Flexor digiti minimi brevis

1
2
3
4
5
6

Nerve supply
Lateral plantar nerve, S2–S3.

Origin
Base of 5th metatarsal, sheath of peroneus longus tendon, long plantar ligament.

Insertion
Lateral side of base of proximal phalanx of 5th toe.

Dosage/needle size
Xeomin®: 5–20 MU.
Botox®: 5–20 MU.
Dysport®: 20–80 MU.
Needle length: 20 mm.

178 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the toe joints

Action
Flexes 5th toe and supports arch of foot.

Injection protocol
Number of puncture sites: 1.

2 cm

Topographical indication
medial Injection should not be too lateral (abductor digiti
minimi [1] or opponens digitii minimi [2]). Penetrate to
bone and retract slightly.

lateral

1 2

Injection technique
Site: 2 cm proximal to head of 5th metatarsal.
Depth: 5–10 mm; dependent on muscle thickness.
Patient position: prone.

Clinical application
Carries out flexion in metatarsophalangeal joint with digiti minimi brevis, flexor digitorum
longus and flexor digitorum brevis.

Pictorial Guide to Botulinum Toxin Injection 179

 Lower limb muscles

Dorsal interossei 1–4

1
2
3
4
5
6

Nerve supply
Lateral plantar nerve, S2–S3.

Origin
Adjacent sides of metatarsal bones.

Insertion
Bases of proximal phalanges.
1st: medial side of proximal phalanx of 2nd toe.
2nd, 3rd and 4th lateral sides of proximal phalanges of 2nd, 3rd and 4th toes.

Dosage/needle size
Xeomin®: 5–10 MU per muscle.
Botox®: 5–10 MU per muscle.
Dysport®: 20–40 MU per muscle.
Needle length: 20–40 mm.

180 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the toe joints

Action
Abduct toes; flex proximal phalanges.
Aid action of the extensors on interphalangeal and
ankle joints (with lumbricals and plantar interossei).

Injection protocol
Number of injection sites: 1–4 (1 per muscle).

Topographical indication
medial No relevant risks.
Injecting too deeply can penetrate transverse or oblique
head of adductor hallucis (1).

1
lateral

Injection technique
Site: spaces between metatarsals, 1–2 cm proximal to
metatarsophalangeal joints. For 1st dorsal intereosseus,
aim towards 2nd toe.
Patient position: supine.

Clinical application
Insert on bases of 2nd to 4th toes; movement oriented around 2nd toe.

Pictorial Guide to Botulinum Toxin Injection 181

 Lower limb muscles

Abductor hallucis

1
2
3
4
5
6

Nerve supply
Medial plantar nerve, S1–S2.

Origin
Tuberosity of calcaneus, plantar aponeurosis.

Insertion
Medial side of base of proximal phalanx of great toe.

Dosage/needle size
Xeomin®: 5–20 MU (rarely higher).
Botox®: 5–20 MU (rarely higher).
Dysport®: 20–80 MU (rarely higher).
Needle length: 20 mm.

182 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the toe joints

Action
Abducts great toe; flexes corresponding metatarsopha­
langeal joint.
Supports medial arch of foot, especially when pushing
off from the ground.

Injection protocol
1/2 Number of puncture sites: 1.

Topographical indication
medial Injection should not be too distal (flexor hallucis brevis
[1]); too deep (flexor digitorum brevis).

1
lateral

Injection technique
Site: middle of medial side of foot, 1 finger width be­
low navicularis.
Depth: 5–10 mm.
Patient position: supine, or on the side.

Clinical application
Can be difficult to tense muscle when great toe is in valgus position (hallux vagus causes
permanent adducted state, abductor hallucis tends to degenerate); great toe should be in
passive, middle position when testing.

Pictorial Guide to Botulinum Toxin Injection 183

 Lower limb muscles

Abductor digiti minimi

1
2
3
4
5
6

Nerve supply
Lateral plantar nerve, S2–S3.

Origin
Tuberosity of calcaneus, plantar aponeurosis.

Insertion
Lateral side of proximal phalanx of 5th toe.

Dosage/needle size
Xeomin®: 5–20 MU (rarely higher).
Botox®: 5–20 MU (rarely higher).
Dysport®: 20–80 MU (rarely higher).
Needle length: 20–40 mm.

184 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the toe joints

Action
Weakly abducts and flexes 5th toe.
Braces lateral longitudinal arch of foot.

Injection protocol
3–4 cm Number of puncture sites: 1.

Topographical indication
medial Injection should not be too anterior and deep (oppo­
nens [1]); too medial (flexor digiti minimi brevis [2]).
1

lateral

Injection technique
Site: lateral side of foot, 3–4 cm (2 finger widths) proxi­
mal to head of 5th metatarsal.
Depth: 5–10 mm.
Patient position: supine, or on the side.

Pictorial Guide to Botulinum Toxin Injection 185

 Lower limb muscles

Adductor hallucis

1
2
3
4
5
6

Nerve supply
Lateral plantar nerve, S2–S3.

Origin
Oblique head: cuboid, lateral cuneiform, plantar calcaneocuboid ligament, long plantar ligament.
Transverse head: capsules of 3rd and 4th metatarsophalangeal joints, deep transverse metatarsal
ligament.

Insertion
Lateral sesamoid bone, capsule of metatarsophalangeal joint of great toe, base of proximal
phalanx of great toe.

Dosage/needle size
Xeomin®: 5–20 MU per head (rarely higher).
Botox®: 5–20 MU per head (rarely higher).
Dysport®: 20–80 MU per head (rarely higher).
Needle length: 20–40 mm.

186 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the toe joints

Action
Adducts and slightly flexes great toe.
Braces transverse arch of foot.

Injection protocol
Number of puncture sites: 1–2 (usually 1).

Topographical indication
medial Lies deep to flexor digitorum brevis (1) and longus (2)
– injecting too superficially will infiltrate only the lum­
bricals.

lateral

1 2 1 2 1 2 1 2

Injection technique
Site:
Oblique head – proximal to head of 3rd metatarsal
bone. Inject until resistance of bone is felt, then retract
needle slightly.
Transverse head – 3–4 finger widths proximal to 2nd
and 3rd interdigital spaces 2 and 3 (not shown).
Depth: ~1 cm.
Patient position: prone.

Clinical application
Metatarsophalangeal joint of great toe is in permanently adducted state (hallux valgus) in
some patients.

Pictorial Guide to Botulinum Toxin Injection 187

 Lower limb muscles

Plantar interossei 1–3

1
2
3
4
5
6

Nerve supply
Lateral plantar nerve, S2–S3.

Origin
Bases and medial sides of 3rd, 4th and 5th metatarsal bones.

Insertion
Medial sides of bases of proximal phalanges of same toes.

Dosage/needle size
Xeomin®: 5–10 MU per head (rarely higher).
Botox®: 5–10 MU per head (rarely higher).
Dysport®: 20–40 MU per head (rarely higher).
Needle length: 40 mm.

188 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the toe joints

Action
Brings the 3rd, 4th and 5th toes towards 2nd toe.
Flexion of metatarsophalangeal joint leaves long exten­
sors to focus on corresponding interphalangeal joints
or ankle joint.

Injection protocol
Number of puncture sites: 1–3 (1 per muscle).

Topographical indication
medial Difficult to differentiate from other small muscles of the
sole of the foot. Flexor digiti minimi brevis lies laterally
(1); further laterally the abductor digiti minimi (2); me­
dially and superficially the lumbricals.

lateral

2 1

Injection technique
Injection site:
From dorsal – inject from medial to lateral, under cor­
responding metatarsal (3rd to 5th).
From plantar (not shown) – inject from medial to lat­
eral, on top of corresponding metatarsal (3rd to 5th);
after contact with bone, retract slightly.
Depth: 10–15 mm.
Patient position: supine or prone.

Pictorial Guide to Botulinum Toxin Injection 189

 Lower limb muscles

Lumbricals 1–4

1
2
3
4
5
6

Nerve supply
1st lumbricalis: medial plantar nerve, S1–S2.
2nd to 5th lumbricals: lateral plantar nerve, S2–S3.

Origin
Tendon of flexor digitorum longus.

Insertion
Dorsal surface of proximal phalanges.

Dosage/needle size
Xeomin®: 5–10 MU/injection site (rarely higher).
Botox®: 5–10 MU/injection site (rarely higher).
Dysport®: 20–40 MU/injection site (rarely higher).
Needle length: 20–40 mm.

190 Pictorial Guide to Botulinum Toxin Injection

 Muscles of the toe joints

Action
Flex toes at metatarsophalangeal joints, preventing hy­
perextension.
Weakly extend toes at interphalangeal joints.

tendons of Injection protocol

flexor digito- Number of puncture sites: 1 per muscle.
rum longus
Topographical indication
Difficult to differentiate the small muscles of the foot.
Injection should not be too far proximal (flexor digito­
rum brevis); too medial (flexor hallucis brevis).

Injection technique
Site: medial to tendon of flexor digitorum.
Depth: ~1 cm.
Patient position: prone.

Pictorial Guide to Botulinum Toxin Injection 191

4 Normal range of motion

Pictorial Guide to Botulinum Toxin Injection 193

 Normal range of motion

Normal range of motion

1
Joint Movement Range of motions in degree*
2
3 Shoulder External rotation 104 ± 8.5
in abduction
4
Internal rotation 69 ± 4.6
5 in abduction
6 Abduction 184 ± 7.0

Elevation 167 ± 4.7

Extension 62 ± 9.5

Elbow Flexion 141 ± 4.9

Extension 0.3 ± 2.0

Forearm Pronation 75 ± 5.3

rotation
Supination 81 ± 4.0

Wrist Extension 74 ± 6.6

Flexion 75 ± 6.6

Radial deviation 21 ± 4.0

Ulnar deviation 35 ± 3.8

* Adapted from Greene W.B. and Heckman J.D. The Clinical Measurement of Joint Motion (1994).

194 Pictorial Guide to Botulinum Toxin Injection

 Normal range of motion

Joint Movement Range of motions in degree*

Fingers Index Long Ring Little

Metacarpophalangeal 22 18 23 19
joint extension

Metacarpophalangeal 86 91 99 105
joint flexion

Proximal interphalan- 7 7 6 9
geal extension

Proximal interphalan- 102 105 108 106

geal flexion

Distal interphalangeal 8 8 8 8
extension

Distal interphalangeal 72 71 63 65
flexion

Hip External rotation 44 ± 4.8

(measured
Internal rotation 44 ± 4.3
in flexion)
Abduction 41 ± 6.0

Adduction 27 ± 3.6

Extension 12 ± 5.4

Flexion 121 ± 6.4

Knee Flexion 141 ± 5.3

Extension 2 ± 3.0

Ankle Dorsiflexion 13 ± 4.4

Plantar flexion 56 ± 6.1

Foot Eversion 21 ± 5.0

Inversion 37 ± 4.5

Pictorial Guide to Botulinum Toxin Injection 195

5 Additional therapies

Pictorial Guide to Botulinum Toxin Injection 197

 Additional therapies

Additional therapies
A multidisciplinary approach

Physical and rehabilitation therapies are a vital part of treatment for patients suffer-
ing from spasticity. They play key roles in acute/early treatment of the disorder, and in
maintaining and improving function in the longer term (White book, 2009).
1
A rehabilitation plan must be tailored to individual patient needs, and is likely to
2
involve medical intervention (e.g., botulinum toxin, pain medication), as well as mul-
3 tiple additional therapies – for example physical, occupational and psychological ap-

4 proaches (White book, 2009). Together, these therapies enable optimal management
of problems such as impaired mobility, strength, balance, and endurance, amongst
5 other spasticity-related issues.
6

Additional therapy options

Injection of botulinum toxin produces a quick reduction in local spasticity, and the
patient may present with a different clinical and functional picture post-injection
(Albany, 2002). For example a decrease in spasticity in one area may precipitate
functional changes in other areas, and some patients may become candidates for
therapeutic interventions not previously possible (Albany, 2002). In addition, injection
of spastic muscle with botulinum toxin should be defined depending on patient’s
goals and needs, leading to the necessity for a rehabilitation programme aimed at
reinforcing the expected effects of botulinum toxin.

Therefore, it is important that patients who are treated with botulinum toxin
undergo a thorough muscle evaluation to assess their functional capacity (and ad-
ditional therapy needs) both before and after the injection (Albany, 2002). Once this
evaluation is complete, additional therapies proposed for a patient with spasticity
may involve (Albany, 2002):
• Ambulation and gait training – exercise and coordination techniques, use of assis-
tive devices, and facilitation of arm swing. A key aim is to strengthen and facilitate
opposing and neighbouring muscles.

198 Pictorial Guide to Botulinum Toxin Injection

 Additional therapies

• Activities of daily living (ADLs, e.g., dressing, bathing, feeding and grooming) –
development of skills to overcome ADL barriers, and reassessment of adaptive
equipment.
• Modality use (e.g., heat, ice, electric stimulation) – as needed, for contracture,
pain management, etc. (should be avoided over injection area for 10 days post-
injection).
• Positioning – to optimise posture, function and movement; remove, add or modify
bracing, splinting, orthotics, casting, seating, etc., and re-educate regarding bal-
ance.
• Patient education – to help patient anticipate and cope with unaccustomed
changes in function, posture, etc., following injection.

These additional interventions are largely accepted as ‘standard practice’ for patients
with spasticity, and the effectiveness of botulinum toxin with/without these therapies
has not been widely compared (Olver et al., 2010; Sheean et al., 2010). The little
clinical evidence there is indicates that adjunct treatment with electrical muscle
stimulation may be more effective than botulinum toxin alone; that a stretching
programme post-injection may help reduce hypertonia in lower limbs (in that respect,
self stretching when possible should be recommended); and that taping or casting
may improve gains in the passive range of lower limb motion (Olver et al., 2010;
Sheean et al., 2010).

Importantly, there is an international consensus that the mainstay of spasticity man-

agement is a multidisciplinary approach (Olver et al., 2010; Sheean et al., 2010).

References

Albany K. Physical and occupational therapy considerations in adult patients receiving botulinum
toxin injections for spasticity. In: Mayer NH, Simpson DM (Eds.). Spasticity. Etiology, evaluation,
management and the role of botulinum toxin. Chapter 15. © WE MOVE™, August 2002.

Olver J, Esquenazi A, Fung VS, et al. Botulinum toxin assessment, intervention and aftercare for
lower limb disorders of movement and muscle tone in adults: international consensus statement.
Eur J Neurol 2010; 17 (Suppl 2): 57–73.

Pictorial Guide to Botulinum Toxin Injection 199

 Additional therapies

Sheean G, Lannin NA, Turner-Stokes L, et al. Botulinum toxin assessment, intervention and after-
care for upper limb hypertonicity in adults: international consensus statement. Eur J Neurol 2010;
17 (Suppl 2): 74–93.

Section of Physical and Rehabilitation Medicine Union Européenne des Médecins Spécialistes
(UEMS); European Board of Physical and Rehabilitation Medicine; Académie Européenne de
Médecine de Réadaptation; European Society for Physical and Rehabilitation Medicine. White
1 book on physical and rehabilitation medicine in Europe. Eur J Phys Rehabil Med 2009; 45 (Suppl
1 to No 3): 1–46.
2
3
4
5
6

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6 Principal scales used
in rehabilitation

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 Principal scales used in rehabilitation

Principal scales used in rehabilitation

Disability evaluation

Disability Assessment Scale

The Disability Assessment Scale (DAS) measures the impact of a spasticity on every-
day life using 4 domains. The sensitivity allows an assessment of changes after treat-
1 ment of spasticity. It can be used as well for other disabling conditions.

2
Domains
3 1. Hygiene

4 Extent of palm maceration, ulceration, and/or infection; palm cleanliness; ease of

cleaning and nail trimming; effect of hygiene-related disability in patient’s life
5 2. Dressing
6 Ability to put on clothing; effect of dressing-related disability due to upper limb
spasticity on patient’s life
3. Limb posture
Psychological and/or social interference that the limb’s posture has in the patient’s
life
4. Pain
Intensity of pain; discomfort and interference of upper-limb pain in patient’s life

Scoring for each domain:

0 No functional disability
1 Mild (noticeable, but does not interfere significantly with normal activities)
2 Moderate (normal activities require increased effort and/or assistance)
3 Severe (normal activities are limited)

Evaluation of the effect of a treatment

Global Assessment Scale

The GAS is a method of scoring the extent to which a subject’s individual goals are
achieved in the course of intervention. A realistic meaningful goal (or 2) should be
defined with the patient. Each goal is rated on a 5- or 6-point scale, with the degree
of attainment captured for each goal area:

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 Global functional scales

–2 A lot less than expected

–1 A little less than expected
0 Expected level of achievement
+1 A little better than expected
+2 A lot better than expected

Global functional scales

Fugl-Meyer Assessment
The Fugl-Meyer Assessment (FMA) is a stroke-specific, performance-based impair-
ment index. The FMA was designed for post-stroke hemiplegic patients of all ages.
The FMA measures and evaluates recovery of hemiplegic patients.

There are 5 domains which can also be assessed independently:

1. Motor functioning
2. Sensory functioning
3. Balance
4. Joint range of motion
5. Joint pain

It is applied clinically and in research to determine disease severity, describe motor

recovery, and to plan and assess treatment.

Scoring is based on direct observation of performance. Scale items are scored on the
basis of ability to complete the item using a 3-point ordinal scale where
0 Cannot perform
1 Performs partially and
2 Performs fully
The total possible scale score is 226.

Points are divided among the domains as follows:

• Motor score: ranges from 0 (hemiplegia) to 100 points (normal motor performance).
Divided into 66 points for upper extremity and 34 points for the lower extremity.
• Sensation: ranges from 0 to 24 points.
Divided into 8 points for light touch and 16 points for position sense.

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 Principal scales used in rehabilitation

• Balance: ranges from 0 to 14 points.

Divided into 6 points for sitting and 8 points for standing.
• Joint range of motion: ranges from 0 to 44 points.
• Joint pain: ranges from 0 to 44 points.

Rivermead Mobility Index

The Rivermead Mobility Index (RMI) assesses functional mobility following stroke
1 (e.g., gait, balance, and transfers).

2
The RMI includes fifteen mobility items: 14 self-reported and 1 direct observation
3 (standing unsupported). The 15 items are hierarchically arranged suggesting all items

4 are ordered according to ascending difficulty. Similarly, failure on an item suggests

the patient will be unable to complete the remaining more challenging items. Some
5 authors suggested caution in interpreting the RMI as a true hierarchical scale.
6
The RMI can be administered using self-report or proxy report. It consists of the fol-
lowing 15 questions:
1. Turning over in bed: Do you turn over from your back to your side without help?
2. Lying to sitting: From lying in bed, do you get up to sit on the edge of the bed
on your own?
3. Sitting balance: Do you sit on the edge of the bed without holding on for 10
seconds?
4. Sitting to standing: Do you stand up from any chair in less than 15 seconds and
stand there for 15 seconds, using hands and/or an aid, if necessary?
5. Standing unsupported: ask patient to stand without aid and observe standing
for 10 seconds without any aid.
6. Transfer: Do you manage to move from bed to chair and back without any help?
7. Walking inside (with an aid if necessary): Do you walk 10 meters, with an aid if
necessary, but with no standby help?
8. Stairs: Do you manage a flight of stairs without help?
9. Walking outside (even ground): Do you walk around outside, on pavements,
without help?
10. Walking inside, with no aid: Do you walk 10 meters inside, with no caliper,
splint, or other aid (including furniture or walls) without help?
11. Picking up off floor: Do you manage to walk five meters, pick something up
from the floor, and then walk back without help?

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12. Walking outside (uneven ground): Do you walk over uneven ground (grass,
gravel, snow, ice, etc.) without help?
13. Bathing: Do you get into/out of a bath or shower to wash yourself unsupervised
and without help?
14. Up and down four steps: Do you manage to go up and down four steps with
no rail, but using an aid if necessary?
15. Running: Do you run 10 meters without limping in four seconds (fast walk, not
limping, is acceptable)?

Scoring: Each item is coded 0 (= no) or 1 (= yes), depending on whether the patient
can complete the task according to specific instructions. A score of 0 = a ‘no’
response; a score of 1 = a ‘yes’ response. A total score is determined by summing
the points allocated for all items. A maximum score of 15 is possible: higher scores
indicate better mobility performance.

Rivermead Motor Assessment

The Rivermead Motor Assessment (RMA) assesses the motor performance of patients
with stroke and was developed for both clinical and research use.

The RMA consists of test items in three sections that are ordered hierarchically, that
is, the first items are easier and become increasingly more difficult toward the end of
the evaluation.

The three-sections test:

• Gross function (13 items)
e.g. walking with and without an aid, negotiating stairs with and without the rail,
walking, turning and retrieving an object, and running
• Leg and trunk movements (10 items)
e.g. standing on one leg and flexing the knee in a weight bearing position
• Arm movements (15 items)
e.g. control items such as pronating/supinating the forearm and bouncing a ball,
and functional items such as cutting putty, grasping and releasing objects, and
tying a bow

Scoring: The items are scored as pass (= 1) or fail (= 0). Traditionally, when three
consecutive attempts to complete an item are failed within a given subsection, the

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 Principal scales used in rehabilitation

test is stopped as it is assumed that all subsequent items in the subsection will also
be failed.

Lower limb functional scales

Six Minutes Walking Distance

1 The Six-Minute Walk Test (6MWT) is a functional walking test in which the distance
that a patient can walk within six minutes is evaluated. This test has been used to as-
2
sess individuals with stroke, head injury, and Parkinson’s disease as well as pulmonary
3 and cardiac diseases.

4
There are no actual items to the 6MWT.
5
6 The 6MWT is a simple test that requires a 100-ft, quiet, indoor, flat, straight rect-
angular hallway. The walking course must be 30 m in length. The length of the 30
m corridor must be marked by colored tape at every 3 m. The turnaround must be
marked with a cone.

Scoring:
• The lap counter or pen and paper should be used to note the number of laps that
the patient is able to walk during the 6MWT.
• Distance walked, and the number and duration of rests during the 6 minutes
should be measured.

Ten Meters Walking Time

The Walking Time Test assesses walking speed in meters per second over a short duration.

• The individual walks without assistance 10 meters (32.8 feet) and the time is
measured for the intermediate 6 meters (19.7 feet) to allow for acceleration and
deceleration.
• Various measures of gait speed use different distances (10 feet-14 meters),
although the 10MWT is the most common of these tests.
• Assistive devices can be used but should be kept consistent and documented from
test to test.
• If physical assistance is required to walk, this test should not be performed.

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• Test can be performed at preferred walking speed or fastest speed possible.

• Documentation should include the speed tested (preferred vs. fast).
• Collect three trials and calculate the average of the three trials.

Ambulation Index
The Ambulation Index (AI) is a rating scale developed to assess mobility by evaluat-
ing the time and degree of assistance required to walk 25 feet. Scores range from
0 (asymptomatic and fully active) to 10 (bedridden). The patient is asked to walk a
marked 25-foot course as quickly and safely as possible. The examiner records the
time and type of assistance (e.g., cane, walker, crutches) needed.

Scoring:
Although the patient’s walking is timed, the time is not used directly but is utilized in
conjunction with other factors to rate the patient on an ordinal scale with 11 grada-
tions, the Hauser Ambulation Index.

0 Asymptomatic; fully active

1 Walks normally, but reports fatigue that interferes with athletic or other demand-
ing activities
2 Abnormal gait or episodic imbalance; gait disorder is noticed by family and
friends; able to walk 25 feet (8 meters) in 10 seconds or less
3 Walks independently; able to walk 25 feet in 20 seconds or less
4 Requires unilateral support (cane or single crutch) to walk; walks 25 feet in 20
seconds or less
5 Requires bilateral support (canes, crutches, or walker) and walks 25 feet in 20
seconds or less; or requires unilateral support but needs more than 20 seconds
6 Requires bilateral support and more than 20 seconds to walk 25 feet; may use
wheelchair on occasion
7 Walking limited to several steps with bilateral support; unable to walk 25 feet;
may use wheelchair for most activities
8 Restricted to wheelchair; able to transfer self independently
9 Restricted to wheelchair; unable to transfer self independently

Functional Ambulation Categories

The Functional Ambulation Categories (FAC) is a functional walking test that evalu-
ates ambulation ability. This 6-point scale assesses ambulation status by determining

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 Principal scales used in rehabilitation

how much human support the patient requires when walking, regardless of whether
or not they use a personal assistive device. The FAC can be used with, but is not
limited to, patients with stroke or multiple sclerosis.

Scoring:
• A score of 0 indicates that the patient is a non-functional ambulator (cannot walk).
• A score of 1, 2 or 3 denotes a dependent ambulator who requires assistance
1 from another person in the form of continuous manual contact (1), continuous or
intermittent manual contact (2), or verbal supervision/guarding (3).
2
• A score of 4 or 5 describes an independent ambulator who can walk freely on:
3 level surfaces only (4) or any surface (5 = maximum score).

4
Timed Up and Go
5 The Timed Up and Go test (TUG) assesses mobility, balance, walking ability, and fall
6 risk in older adults:
• The patient sits in the chair with his/her back against the chair back.
• On the command “go”, the patient rises from the chair, walks 3 meters at a
comfortable and safe pace, turns, walks back to the chair and sits down.
• Timing begins at the instruction “go” and stops when the patient is seated.
• Scores range from 1 to 5 based on the observer’s perception of the patient’s risk
of falling.
• The patient should have one practice trial that is not included in the score.
• Patient must use the same assistive device each time he/she is tested to be able to
compare scores.

Scoring:
Performance of the TUG is rated on a scale from 1 to 5 where 1 indicates “normal
function” and 5 indicates “severely abnormal function” according to the observer’s
perception of the individual’s risk of falling. The score consists of the time taken to
complete the test activity, in seconds:

< 10 s Completely independent; with or without walking aid for ambulation and
transfers
< 20 s Independent for main transfers; with or without walking aid, independent for
basic tub or shower transfers and able to climb most stairs and go outside alone
> 30 s Requires assistance; dependent in most activities

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 Specific functional scales

Specific functional scales

ASIA Impairment Scale (AIS)

The ASIA (American Spinal Injury Association) Impairment Scale builds on the earlier
Frankel Scale, but includes a number of significant improvements.

Traumatic spinal cord injury is classified into five categories on the ASIA Impairment
Scale:
• AIS A (complete) classification is defined by the absence of motor and sensory
function in the sacral segments S4–S5. An AIS-A classification is made with a
single observation.
• The AIS B (sensory incomplete) classification is reserved for people with preserved
sensation below the neurological level of injury and at sacral segments S4–S5; and
no motor function preserved more than 3 levels below the motor level on either side.
• For AIS C and D (motor incomplete), the scale adds quantitative criteria for deter-
mining the appropriate diagnostic classification. For AISC or D must have either:
1) voluntary anal sphincter contraction OR 2) sacral sensory sparing with motor
sparing > 3 levels below the motor level for that side of the body.
– AIS C is assigned if half the key muscles below the neurological level of injury
are graded as less than 3/5.
– AIS D is assigned if half or more of the key muscles below the neurological level
of injury have a grade ≥ 3/5.
• Unlike the A, B, C and D classifications, an AIS E classification implies the presence
of a spinal cord injury but without detectable neurological deficits.

AIS classifications also differentiate incomplete SCI’s into one of five types:
1. A central cord syndrome diagnosis is associated with greater loss of upper versus
lower limb function.
2. A hemi-section lesion of the spinal cord is classified as Brown-Sequard syndrome.
3. An injury to the anterior spinal tracts is classified as anterior cord syndrome.
4. An injury to the conus is classified as conus medullaris syndrome.
5. An injury to the spinal roots is classified as cauda equina syndrome.

Berg Balance Scale

The Berg Balance Scale (BBS) is a 14-item objective measure designed to assess static
balance and fall risk in adult populations.

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 Principal scales used in rehabilitation

The items are:

• Sitting unsupported
• Change of position: sitting to standing
• Change of position: standing to sitting
• Transfers
• Standing unsupported
• Standing with eyes closed
1 • Standing with feet together
• Tandem standing
2
• Standing on one leg
3 • Turning trunk (feet fixed)

4 • Retrieving objects from floor

• Turning 360 degrees
5 • Stool stepping
6 • Reaching forward while standing

Scoring:
The rating is from 0 (inability to complete item) to 4 (completion of item) for each
item resulting in total scores from 0 to 56. The fall risk is evaluated as low (41–56),
medium (21–40) or high (0–20).

An alternative scale is the short form of the BBS (BBS-3P), which is composed of
7 items based on 3 levels.

The 7 items included in the BBS-3P are:

• Reaching forward with outstretched arm
• Standing with eyes closed
• Standing with one foot in front
• Turning to look behind
• Retrieving object from floor
• Standing on one foot
• Changing from a sitting to standing position

Scoring:
The rating is from 0 (inability to complete item) to 4 (completion of item) for each
item resulting in total scores from 0 (poor balance) to 28 (good balance).

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 Specific functional scales

Caregiver Burden Scale

The Caregiver Burden Scale assesses the burden of caregivers of impaired persons.
The questionnaire is a self-administered survey completed by a caregiver.

Questions:
• General feelings
1. Not enough time for self
2. Over-taxed with responsibilities
3. Lost control of life
• Feelings regarding caring for relative
1. Uncertain about what to do for relative
2. Feeling that he/she should do more for relative
3. Feeling that he/she could do a better job of caring
4. Overall level of burden
• Sense of responsibility
1. Excessive help requests
2. Level that impaired relative depends on caregiver
3. Sense that all responsibility falls on one caregiver
4. Fear of future regarding impaired relative
5. Fear of not enough money to care for relative
6. Fear of not being able to continue caring for relative
7. Wish to leave care of relative to someone else
• Feelings when with impaired relative
1. Sense of strain
2. Anger
3. Embarrassed
4. Uncomfortable about having friends over
• Relationship with relative negatively impacts
1. Social life
2. Other relationships with family and friends
3. Caregiver health
4. Privacy

Scoring:
Each question will be rated with a 5-point scale ranging from 0 (= Never) to 4
(= Nearly always).

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 Principal scales used in rehabilitation

Interpretation:
• No or minimal burden: 0 to 20
• Mild to moderate burden: 21 to 40
• Moderate to severe burden: 41 to 60
• Severe burden: 61 to 88

Modified Fatigue Impact Scale

1 The Modified Fatigue Impact Scale (MFIS) is a modified form of the Fatigue Impact
Scale based on items derived from interviews with Multiple Sclerosis patients
2
concerning how fatigue impacts their lives. This instrument provides an assessment
3 of the effects of fatigue in terms of physical, cognitive, and psychosocial functioning.

4
The full-length MFIS has 21 items. The MFIS is a 21-item shortened version of the
5 40-item Fatigue Impact Scale. It assesses the perceived impact of fatigue on the
6 subscales physical, cognitive and psychosocial functioning during the past 4 weeks.
An abbreviated version has 5 items only.

The subscales of the scale are:

• Physical subscale: range from 0–36
• Cognitive subscale: range from 0–40
• Psychosocial subscale: range from 0–8

Scoring is as follows:
5-point Likert Scale with a scale from 0 = ‘Never’ to 4 = ‘Almost always’ for each of
the 21 statements.
Total score (0–84) and subscales for physical (0–36), cognitive (0–40) and psychoso-
cial functioning (0–8). The 5-item version is scored (0–20). Higher numbers indicate
greater fatigue.

Upper limb functional scales

Nine Hole Peg Test

The Nine Hole Peg Test (NHPT) was developed to measure finger dexterity, also
known as fine manual dexterity. It can be used with a wide range of populations,
including patients with stroke. Additionally, the NHPT can be administered quickly.

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 Upper limb functional scales

The NHPT is composed of a square board with 9 pegs. At one end of the board are
holes for the pegs to fit in to, and at the other end is a shallow round dish to store
the pegs. The NHPT is administered by asking the patient to take the pegs from a
container, one by one, and placing them into the holes on the board, as quickly as
possible. Patients must then remove the pegs from the holes, one by one, and re-
place them back into the container. In order to practice and register baseline scores,
the test should begin with the unaffected upper limb. The board should be placed
at the patient’s midline, with the container holding the pegs oriented towards the
hand being tested. Only the hand being evaluated should perform the test. The hand
not being evaluated is permitted to hold the edge of the board in order to provide
stability.

Scoring:
Patients are scored based on the time taken to complete the test activity, recorded in
seconds. The stopwatch should be started from the moment the participant touches
the first peg until the moment the last peg hits the container. Maximum time to ac-
complish the task is 5 minutes.

Action Research Arm Test

The Action Research Arm Test (ARAT) is an evaluative measure to assess specific
changes in limb function among individuals who sustained cortical damage resulting
in hemiplegia. It assesses a patient’s ability to handle objects differing in size, weight
and shape and therefore can be considered to be an arm-specific measure of activity
limitation.

The ARAT consists of 19 items grouped into four subscales: grasp, grip, pinch, and
gross movement. Each subscale constitutes a hierarchical Guttman Scale, which
means that all items are ordered according to ascending difficulty. In the ARAT, if the
patient succeeds in completing the most difficult item in a subscale, this suggests he/
she will succeed in the easier items for that same subscale. Similarly, failure on an
item suggests the patient will be unable to complete the remaining more challenging
items in the subscale.

In the grasp and pinch subscales, testing materials are lifted 37 cm from the surface
of the table to the top of the shelf. In the grip subscale, testing materials are moved
from one side of the table to the other. Finally, in the gross movement subscale, the

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 Principal scales used in rehabilitation

patient is requested to place the hand being tested either behind his/her head, on
top of his/her head, or to his/her mouth. The proper sequence for testing is 1) grasp
subscale, 2) grip subscale, 3) pinch subscale, 4) gross movement subscale. The ARAT
comes with simple instructions to guide the evaluator on scoring and administering
the test.

Scoring:
1 The ARAT is scored on a four-level ordinal scale (0–3):
0 Cannot perform any part of the test
2
1 Performs the test partially
3 2 Completes the test, but takes abnormally long time

4 3 Performs the test normally

5 Box and Block Test

6 The Box and Block Test (BBT) assesses unilateral gross manual dexterity:
• Individuals are seated at a table, facing a rectangular box that is divided into two
square compartments of equal dimensions.
• One hundred and fifty, 2.5 cm, colored, wooden cubes or blocks are placed in one
compartment or the other.
• The individual is instructed to move as many blocks as possible, one at a time,
from one compartment to the other for a period of 60 seconds.
• To administer the test, the examiner is seated opposite the individual in order to
observe test performance.
• The BBT is scored by counting the number of blocks carried over the partition
from one compartment to the other during the one-minute trial period.
• Patient’s hand must cross over the partition in order for a point to be given, and
blocks that drop or bounce out of the second compartment onto the floor are still
rewarded with a point.
• Multiple blocks carried over at the same time count as a single point.
• Higher scores on the test indicate better gross manual dexterity.

Frenchay Arm Test

The Frenchay Arm Test (FAT) is a measure of upper extremity proximal motor control
and dexterity during ADL performance in patients with impairments resulting from
neurological conditions.

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 Upper limb functional scales

The items included move beyond the scope of ADL Scales, which tend to focus on
issues related to self-care and mobility. They can be separated into three factors:
1. Domestic chores
2. Leisure/work
3. Outdoor activities

The items of the FAT are:

• Preparing meals
• Washing dishes
• Washing clothes
• Dusting/vacuum cleaning
• Cleaning (heavy housework)
• Local shopping
• Social activities
• Walking outside > 15 min
• Hobby/sport
• Car/bus travel
• Outings
• Gardening
• Household/car maintenance
• Reading books
• Employment

Scoring:
• The frequency with which each item or activity is undertaken over the past 3 or 6
months (depending on the nature of the activity) is assigned a score of 1–4 where
a score of 1 is indicative of the lowest level of activity.
• The scale provides a summed score from 15–60.
• A modified 0–3 scoring system introduced in 1985 by Wade et al. yields a score of
0–45.

Motor Activity Log

The Motor Activity Log (MAL) is a scripted, structured interview to measure
real-world upper extremity function. It was developed to measure the effects of
constraint-induced movement therapy on the more impaired arm following stroke.

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 Principal scales used in rehabilitation

The original MAL consists of 14 activities of daily living (ADLs) such as using a towel,
brushing teeth, and picking up a glass. For a specified time period post-stroke, the
individual is asked about the extent of the activity performed and how well it was
performed by the more impaired arm.

Scoring:
The response scale ranges from 0 (never used) to 5 (same as pre-stroke).
1 The mean of the scores for frequency of the activity comprises the Amount Of Use
(AOU) Scale; the mean of the scores for how well the activity was performed com-
2
prises the Quality Of Movement (QOM) Scale. Ideally, ratings are obtained from the
3 individual with a stroke as well as a knowledgeable informant (caregiver).

4
Wolf Motor Function Test
5 The Wolf Motor Function Test (WMFT) quantifies upper extremity (UE) motor ability
6 through timed and functional tasks. The widely used version of the WMFT consists
of 17 items. The first 6 items involve timed functional tasks, items 7–14 are measures
of strength, and the remaining 9 items consist of analyzing movement quality when
completing various tasks. It has been initially developed to evaluate the effect of
constraint induced therapy but is used in various other situations.

The examiner should test the less affected upper extremity followed by the most
affected side. The following items should be performed as quickly as possible, trun-
cated at 120 seconds:
1. Forearm to table (side): patient attempts to place forearm on a table by abduct-
ing at the shoulder.
2. Forearm to box (side): patient attempts to place forearm on a box, 25.4 cm tall,
by abduction at the shoulder.
3. Extended elbow (side): patient attempts to reach across a table, 28 cm long, by
extending the elbow (to the side).
4. Extended elbow (to the side) with 1lb weight: patient attempts to push the
weight against outer wrist joint across the table by extending the elbow.
5. Hand to table (front): patient attempts to place involved hand on a table.
6. Hand to box (front): patient attempts to place hand on the box placed on the
tabletop.
7. Weight to box: patient attempts to place the heaviest possible weight on the
box placed on the tabletop.

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 Upper limb functional scales

8. Reach and retrieve (front): patient attempts to pull 1lb weight across the table
by using elbow flexion and cupped wrist.
9. Lift can (front): patient attempts to lift a can and bring it close to his/her lips
with a cylindrical grasp.
10. Lift pencil (front): patient attempts to pick up a pencil by using 3-jaw chuck
grasp.
11. Pick-up paper clip (front): patient attempts to pick up a paper clip by using a
pincer grasp.
12. Stack checkers (front): patient attempts to stack checkers onto the center
checker.
13. Flip 3 cards (front): using the pincer grasp, patient attempts to flip each card over.
14. Grip strength
15. Turning the key in lock (front): using pincer grasp, while maintaining contact,
patient turns key 180 degrees to the left and right.
16. Fold towel (front): patient grasps towel, folds it lengthwise, and then uses the
tested hand to fold the towel in half again.
17. Lift basket (standing): patient picks up a 3 lb basket from a chair, by grasping
the handles, and placing it on a bedside table.

Scoring:
The items are rated on a 6-point scale as outlined below:
1. “Does not attempt with UE being tested”.
2. “UE being tested does not participate functionally; however, an attempt is made
to use the UE. In unilateral tasks, the UE not being tested may be used to move
the UE being tested”.
3. “Does attempt, but requires assistance of the UE not being tested for minor read-
justments or change of position, or requires more than 2 attempts to complete, or
accomplishes very slowly. In bilateral tasks, the UE being tested may serve only as
a helper”.
4. “Does attempt, but movement is influenced to some degree by synergy or is
performed slowly or with effort”.
5. “Does attempt; movement is similar to the non-affected side but slightly slower;
may lack precision, fine coordination or fluidity”.
6. “Does attempt, movement appears to be normal”.

Lower scores are indicative of lower functioning levels.

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 Principal scales used in rehabilitation

Incapacity scales

Barthel Index
This index measures the extent to which somebody can function independently and
has mobility in their activities of daily living (ADL). The index also indicates the need
for assistance in care.

1 The items include:

• Feeding
2
• Bathing
3 • Grooming

4 • Dressing
• Bowel control
5 • Bladder control
6 • Toileting
• Chair transfer
• Ambulation
• Stair climbing

The scores are allotted in the following way:

• 0 or 5 points per item for bathing and grooming
• 0, 5, or 10 points per item for feeding, dressing, bowel control, bladder control,
toilet use, and stairs
• 0, 5, 10, or 15 points per item for transfers and mobility

The index yields a total score from 0 to 100 – the higher the score, the greater the
degree of functional independence.

A modified scoring system has been suggested using a 5-level ordinal scale for each
item to improve sensitivity to detecting change:
1 Unable to perform task
2 Attempts task but unsafe
3 Moderate help required
4 Minimal help required
5 Fully independent

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 Muscle strength

Functional Independence Measure

The Functional Independence Measure (FIM) was developed to address the issues
of sensitivity and comprehensiveness that were criticized as being problematic with
the Barthel Index (another measure of functional independence). The FIM was also
developed to offer a uniform system of measurement for disability based on the
International Classification of Impairment, Disabilities and Handicaps for use in the
medical system in the United States. The level of a patient’s disability indicates the
burden of caring for them and items are scored on the basis of how much assistance
is required for the individual to carry out activities of daily living.

The FIM assesses 6 areas of function:

Motor domain:
• Self-care (items: eating, grooming, bathing, dressing upper body, dressing lower
body, toileting)
• Sphincter control (item: bladder management, bowel management)
• Mobility (items: bed/chair/wheelchair, toilet, tub/shower)
• Locomotion (items: walk/wheelchair, stairs)
Cognitive domain:
• Communication (items: comprehension, expression)
• Social cognition (items: social interaction, problem solving, memory)

Scoring:
Each item on the FIM is scored on a 7-point Likert Scale, and the score indicates the
amount of assistance required to perform each item (1 = total assistance in all areas,
7 = total independence in all areas). The ratings are based on performance rather
than capacity.

Muscle strength

Medical Research Council Scale

The MRC Scale aims at evaluating the strength of a muscle or a group of muscles. As
much as possible, the action of each muscle should be observed separately:
0 No contraction
1 Flicker or trace of contraction
2 Active movement, with gravity eliminated

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 Principal scales used in rehabilitation

3 Active movement against gravity

4 Active movement against gravity and resistance
5 Normal power
(Note: Grades 4 –, 4 and 4 + may be used to indicate movement against slight, mod-
erate and strong resistance respectively)

1 Quality of Life
2
SF-36
3 The Medical Outcomes Study 36-item Short-Form Health Survey is a widely used, ge-

4 neric, patient-report measure created to assess health-related quality of life (HRQOL)

in the general population. It was developed as part of the Medical Outcomes Study
5 in patients with chronic conditions. The SF-36 has been revised several times to
6 overcome short-comings of the previous versions. Today, the SF-36 is one of the most
commonly used generic instrument for measuring quality of life.

Items of the SF-36 are divided into eight different domains:

• Physical component
– Physical functioning (10 items)
– Role limitations due to physical problems (4 items)
– Bodily pain (2 items)
– General health perceptions (5 items)
• Mental component
– Social functioning (2 items)
– General mental health (5 items)
– Role limitations due to emotional problems (3 items)
– Vitality (4 items)
• Other
– Health transition (2 questions): The respondent is asked to rate their current
health status compared to their health status one year ago.These two questions
remain separate from the 8 subscales and are not scored.

There are 11 questions in the SF-36, with 36 items in total. With the exception of the
general change in health status questions, subjects are asked to respond with refer-
ence to the past 4 weeks.

220 Pictorial Guide to Botulinum Toxin Injection

 Spasm scales

Scoring:
The SF-36 is not intended to generate an overall summary score. This is because
information within the individual responses is lost in the total scale score since the
total score can be achieved in a variety of ways from individual item responses. The
recommended scoring system for the SF-36 is a weighted Likert system for each
item. Items within subscales are totaled to provide a summed score for each subscale
or dimension. Each of the 8 summed scores is linearly transformed onto a scale from
0 (negative health) to 100 (positive health) to provide a score for each subscale.

Alternative modified questionnaires derived from the SF-36 questionnaire are:

• SF-12
The SF-12 was developed as an abbreviated version of the SF-36 for use in large
surveys of general and specific populations as well as large longitudinal studies of
health outcomes.
• SF-8
The SF-8, a new generic eight-item assessment, generates a health profile consist-
ing of eight scales and two summary measures describing HRQOL.
• SF-6D
The SF-6D is a preference-based scoring system that uses six subscales from the
SF-36, to allow for calculations of utilities from SF-36 and SF-36v2 responses.
The eight dimensions from SF-36 were reduced to six by omitting General Health
Perceptions and combining Role Limitations-Physical and Role Limitations-Emo-
tional.

The SF-36 should not be used to document individual patient change. The SF-36
should be used for large group comparisons only.

Spasm scales

Action Research Arm Test

The Action Research Arm Test (ARAT) is an evaluative measure to assess specific
changes in limb function among individuals who sustained cortical damage resulting
in hemiplegia. It assesses a patient’s ability to handle objects differing in size, weight
and shape and therefore can be considered to be an arm-specific measure of activity
limitation.

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 Principal scales used in rehabilitation

The ARAT consists of 19 items grouped into four subscales: grasp, grip, pinch, and
gross movement. Each subscale constitutes a hierarchical Guttman Scale, which
means that all items are ordered according to ascending difficulty. In the ARAT, if the
patient succeeds in completing the most difficult item in a subscale, this suggests he/
she will succeed in the easier items for that same subscale. Similarly, failure on an
item suggests the patient will be unable to complete the remaining more challenging
items in the subscale.
1
In the grasp and pinch subscales, testing materials are lifted 37 cm from the surface of
2
the table to the top of the shelf. In the grip subscale, testing materials are moved from
3 one side of the table to the other. Finally, in the gross movement subscale, the patient

4 is requested to place the hand being tested either behind his/her head, on top of his/
her head, or to his/her mouth. The proper sequence for testing is 1) grasp subscale, 2)
5 grip subscale, 3) pinch subscale, 4) gross movement subscale. The ARAT comes with
6 simple instructions to guide the evaluator on scoring and administering the test.

Scoring:
The ARAT is scored on a four-level ordinal scale (0–3):
0 Cannot perform any part of the test
1 Performs the test partially
2 Completes the test, but takes abnormally long time
3 Performs the test normally

Penn Spasm Frequency Score

The Penn Scale aims at evaluating the frequency and the severity of the spasms. It
is divided in 2 parts; the first is a self report measure with items on 5-point scales
developed to augment clinical ratings of spasticity and provides a more comprehen-
sive assessment of spasticity. The second component of the PSFS is a 3-point scale
assessing the severity of spasms.

Spasm frequency:
0 No spasm
1 Mild spasms induced by stimulation
2 Infrequent full spasms occurring less than once per hour
3 Spasms occurring more than once per hour
4 Spasms occurring more than 10 times per hour

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 Tone scales

Spasm severity:
1 Mild
2 Moderate
3 Severe

Spasm Frequency Score

This scale aims at evaluating the frequency of spasms the patient had in the last
24 hours in affected muscles or extremity.

Definitions of spasms:
0 No spasms
1 One spasm or fewer per day
2 Between one and five spasms per day
3 Between five and nine spasms per day
4 Ten or more spasms per day

Tone scales

Adductor Tone Rating

This scale aims at evaluating muscle hypertonia in proximal upper limb spasticity.
0 No increase in tone
1 Increased tone, hips easily abducted to 45º by one person
2 Hips abducted to 45º by one person with mild effort
3 Hips abducted to 45º by one person with moderate effort
4 Two people required to abduct the hips to 45º

Ashworth Scale
The way to evaluate the Ashworth Scale is the same as the Modified Ashworth Scale.
The difference is that here, there are only 4 levels:
0 No increase in tone
1 Slight increase in tone giving a catch when the limb was moved in flexion or
extension
2 More marked increase in tone but limb easily flexed
3 Considerable increase in tone – passive movement difficult
4 Limb rigid in flexion or extension

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 Principal scales used in rehabilitation

Modified Ashworth Scale

The MAS is the most frequently used scale. The most important characteristic is that
the patient should always be evaluated in the same position, and some time after a
physical therapy session and any stretching of the evaluated join.

Scoring:
0 No increase in muscle tone
1 1 Slight increase in muscle tone, manifested by a catch and release or by minimal
resistance at the end of the range of motion when the affected part(s) is moved
2
in flexion or extension
3 1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resis-

4 tance throughout the remainder (less than half) of the ROM

2 More marked increase in muscle tone through most of the ROM, but affected
5 part(s) easily moved
6 3 Considerable increase in muscle tone, passive movement difficult
4 Affected part(s) rigid in flexion or extension

REPAS Scale
The REPAS (REsistance to PASsive movement) Scale is a 26-item test for the assess-
ment of resistance to passive movement in all four limbs of the body in patients with
central paresis. The scale provides a global evaluation of spasticity status as well as
the status of spasticity per side of the body or per limb. It is indicated for a follow-up
of changes of spasticity treatment.

Items are evaluated as identical for both body sides. Sixteen items describe the condi-
tion of both upper limbs and 10 items the condition for lower limbs. Each item will
be rated using the Ashworh Scale (AS) ranging from 0 to 4 for each item for each
side of the body. Total score ranges from 0 (no resistance to passive movement for
any item) to 104 (limb rigidity to passive movement for all items).

The items rated using the AS are:

• Shoulder external rotation
• Shoulder flexion
• Shoulder abduction
• Elbow flexion
• Elbow extension

224 Pictorial Guide to Botulinum Toxin Injection

 Tone scales

• Forearm supination
• Wrist extension
• Finger extension
• Hip external rotation
• Knee flexion
• Knee extension
• Foot dorsiflexion
• Foot eversion/pronation

Scoring to rate items (Ashworth Scale):

0 No increase in muscle tone
1 Slight increase in muscle tone, manifested by a catch and release or by minimal
resistance at the end of the range of motion when the affected part(s) is moved in
flexion or extension
2 Marked increase in muscle tone, manifested by a catch in the middle range and
resistance throughout the remainder of the range of motion, but affected part(s)
easily moved
3 Considerable increase in muscle tone, passive movement difficult
4 Affected part(s) rigid in flexion or extension

Tardieu Scale / Modified Tardieu Scale

The Tardieu Scale allows direct measurement of spasticity. It allows a better identifica-
tion of the neural component of spasticity compared to other scales such as the
Modified Ashworth Scale.

Tardieu is a scale for measuring spasticity that takes into account resistance to pas-
sive movement at both slow and fast speed. The development of the scale originally
began in the 1950s and has gone through multiple revisions.

The most recent versions of the scale use the following criteria:

Individuals are positioned sitting to test the upper limbs and supine to test the lower
limbs.
• Two measurements:
– Quality of muscle reaction
– Angle of muscle reaction

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 Principal scales used in rehabilitation

• Three speed definitions:

– V1 is as slow as possible
– V2 speed of limb falling under gravity
– V3 moving as fast as possible

The resulting joint angles are defined as:

• R1 (the angle of catch following a fast velocity stretch – during either V2 or V3);
1 and
• R2 (passive range of motion following a slow velocity stretch – V1)
2
• V1 is used to measure the passive range of motion (PROM), only V2 and V3 are
3 used to rate spasticity.

4
Scoring of the quality of muscle reaction (scored 0–5):
5 0 No resistance throughout the course of the passive movement
6 1 Slight resistance throughout the course of the passive movement, with no clear
catch at a precise angle
2 Clear catch at a precise angle, interrupting the passive movement, followed by a
release
3 Fatigable clonus (< 10 seconds when maintaining pressure) occurring at a precise
angle
4 Infatigable clonus (>10 seconds when maintaining pressure) occurring at a precise
angle
5 Joint is immoveable

226 Pictorial Guide to Botulinum Toxin Injection