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Has anyone used Botox injections to reduce forefoot pressure in neuropathic patients with plantar ulcers? If so, what protocol have you used?

 

Rick How does an injection of Botox change the effects of pressure? I´m meaning that to change the pressure and the effects of GRF( Ground reaction force) wouldn´t you need to change the mechanics of the patient.

Pressure = Force/area so how does the botox injection change the force - I guess it might increase the area - is that the effect.I´m guessing it would be quite a small change. ?

 

I was referring to Botox injections being used to weaken the Triceps surae or Gastroc, as opposed to doing a TAL or Gastroc recession, not injection into the ulcers themselves. I've seen the articles on those surgical procedures working to reduce FF pressure and have seen it personally in several patients, but have not known anyone personally using Botox for the chemical analogue. Seeing a kid walk by with a scissor gait the other day reminded me of the use of Botox for muscle contracture and wonder about using it, both for neurotrophic ulcers and even in heel pain - where I did seen one of the recent posts in Podatry Forum that had pretty impressive results for heel pain.

 

Botox has been used in those diabetic foot ulcers injected into the calf musles: Botox for diabetic foot ulcers?. There is this clinical trial going on: Botulinum Toxin Effects on Plantar Ulcer Recurrence

Tendo-achilles lengthening has been shown to only result in a temporary decrease in forefoot plantar pressures, but an RCT combining tendon-achilles lengthening with TCC's shown a less recurrence in the ulcers in the tendo-achilles lengthening group.

There is some rationale for it. I can only seeing it helping if the tightness in the calf muscles are the reason for the increased plantar pressurs.

 

My experience is most people with forefoot ulcers, obviously, have some increased osseous pressure at a plantarflexed or long met head, etc., but almost uniformly, they also have an ankle equinus. If they are a poor candidate for a Total Contact Cast, say as a result of significant proproceptive loss secondary to the neuropathy or general proximal muscle weakness, then the reduction of pressure with the Botox might allow the ulcer sufficient reduction in pressure to heal and then perform a more definitive osseous procedure without the risk from having an open plantar lesion.

I have seen a few instances where even with osseous procedures, the plantar ulcer or keratosis, remained and only resolved post TAL.

I certainly don't think Botox is some panacea, but maybe another potentially helpful tool for a specific patient group that might not do well with a TCC. Some of my little old ladies and gentlemen, and even a lot of the middle age ones who such significant neuropathy would scare the used food out of me since they already have given me histories of unsteady gait and falls. And in the elderly, falls are a significant source of morbidity and mortality.

And that doesn't even scratch the surface of the problems those gait issues cause with depression, resulting noncompliance (bad enough in diabetics to start with), family conflict, and other things that are not in our area of therapy, but that certainly dramatically affect our patients, their families, and our results. But, that is a whole 'nother thread.