Do Botulinum Injections Help Or Hinder The Effect Of Serial Casting?

Ron Raducanu DPM FACFAS

I am a forum junkie. If there is a forum about something I am interested in, then I am there. I participate in forums for my remote-controlled vehicle addiction, for my new cycling addiction, for the eagerly anticipated massively multi-player online role-playing game (MMORPG) “The Old Republic” and, of course, for various topics in podiatry. I am more of a spectator with professional forums. I prefer to read and learn from others rather than participate in these forums.

Recently though, I felt obliged to partake in a professional forum that discussed a topic that hit close to home. Last year, my aunt had a massive stroke. Thankfully, she rehabilitated very well and is lucky to be alive. She has intermittent issues with spasticity in her affected limb. Some of her doctors thought serial botulinum toxin (Botox, Allergan) injections might help with this.

My aunt did not like the idea of doctors sticking her with needles simply to test a hypothesis. I explained that it might help her deal with the uncomfortable intermittent spasticity but ultimately her doctors decided against it.

Shortly after this, I came across a discussion on an international podiatry forum about cerebral palsy. The forum discussed how casting is the order of the day for long-term cerebral palsy management. Someone on the forum suggested using serial botulinum toxin injections to potentiate the effect of the casting in reducing deformity. This sparked a conversation about the frequency of injections, the amount to be injected and finally the efficacy of the injections themselves.

This got me thinking of the simple serial casting procedures I have performed in the past. Many of these not only did not respond well to the serial casting but eventually reverted back to their pre-casting spasticity and progressed in deformity. I may be behind the times but I had never considered trying serial botulinum toxin injections to potentiate the serial casting.

I started doing some of my own research and found a study by Kay and colleagues, which someone later cited in the thread on the podiatry forum.1 Interestingly, there is research available that suggests using botulinum toxin for spasticity in kids with cerebral palsy. However, this article concluded that botulinum may actually counteract the effect that one is trying to stimulate with the serial casting. Maybe I was not so behind the times after all. It is possible that my aunt’s doctors read this article and decided against the protocol they initially recommended.

One theme that does emerge with this topic is the long-term data available as to the efficacy of serial casting, serial casting and botulinum, or even surgical intervention for this and whether there is a permanent “fix” for these patients. I can tell you that more often than not, when conservative care fails or patients regress, they end up in the OR for a Murphy procedure (a type of tendo-Achilles advancement) with gastroc recessions.

If anyone has experience with this topic or has ever encountered some anecdotal evidence, I would love to hear from you. Any input would be great.


1. Kay RM, Rethlefsen SA, Fern-Buneo A, Wren TA, Skaggs DL. Botulinum toxin as an adjunct to serial casting in children with cerebral palsy. J Bone Joint Surg Am. 2004; 86-A(11):2377-84.

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