UtilizationofBotulinumToxinforMusculoskeletalDisorders

Musculoskeletal pain and biomechanical dysfunction are common problems that can limit rehabilitation and recovery from injury. While traditional treatments include physical therapy, medications, and injections, there has been growing interest in using botulinum neurotoxin (BoNT) for painful musculoskeletal conditions. BoNT works by blocking nerve signals to muscles and also appears to affect pain pathways in sensory nerves. However, high-quality evidence for many of these off-label uses remains limited.

This review examines the current literature on BoNT use for several specific musculoskeletal conditions.

The authors conducted a narrative review of published literature on the use of botulinum toxin for five musculoskeletal conditions: chronic exertional compartment syndrome (CECS), plantar fasciopathy, osteoarthritis, lateral epicondylosis, and myofascial pain syndrome (MPS). They searched for and analyzed available studies including randomized controlled trials, case series, systematic reviews, and meta-analyses. For each condition, they described the proposed mechanism of BoNT action, summarized the existing evidence, and described their own clinical practice patterns for patient selection and injection techniques.

For CECS, a 2013 case series of 16 patients showed normalized intramuscular pressure in 87.5% (14/16) and eliminated exertional pain in 94% (15/16) of patients, with 11 patients experiencing transient dorsiflexion weakness. An unpublished retrospective review at their institution found 66% (19/29) of patients returned to desired activity levels. For plantar fasciopathy, a 2013 randomized trial of 40 patients found BoNT-A superior to dexamethasone at 2-6 months, and a 2016 meta-analysis of 22 RCTs found BoNT-A relieved pain in the first 6 months with no significant side effects. For knee osteoarthritis, a 2016 RCT of 44 patients showed VAS scores reduced from 5.05 ± 1.12 to 2.89 ± 1.04 at 1 week (P < 0.001).

For lateral epicondylosis, a 2018 RCT of 60 patients found 51.7% (15/29) of the BoNT-A group had greater than 50% decrease in pain compared with 25% (7/28) of placebo patients at 3 months. For MPS, a 2014 Cochrane review of 4 studies with 244 patients found inconclusive evidence for BoNT-A. A 2018 systematic review and meta-analysis of 33 studies found local anesthetic injections more effective than BoNT-A at reducing pain, with BoNT-A results described as inconsistent.

BoNT-A shows promise as an off-label treatment for several musculoskeletal conditions, particularly when conservative treatments have failed. The strongest emerging evidence appears to be for plantar fasciopathy and lateral epicondylosis, with moderate support for CECS and osteoarthritis. However, for myofascial pain syndrome specifically, the evidence does not support BoNT-A as superior to other injection therapies like local anesthetics. Clinicians should counsel patients about off-label use, set clear functional goals, and continue conservative management alongside BoNT treatment.

The authors emphasize that larger, higher-quality studies with longer follow-up periods are needed to establish definitive recommendations for dosing, injection sites, and long-term safety across all these conditions.