Ann Rehabil Med.  2015 Feb;39(1):32-38. 10.5535/arm.2015.39.1.32.

Determination of Injection Site in Flexor Digitorum Longus for Effective and Safe Botulinum Toxin Injection

  • 1Department of Rehabilitation Medicine, St. Paul's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea.


To determine the optimal injection site in the flexor digitorum longus (FDL) muscle for effective botulinum toxin injection.
Fourteen specimens from eight adult Korean cadavers were used in this study. The most proximal medial point of the tibia plateau was defined as the proximal reference point; the most distal tip of the medial malleolus was defined as the distal reference point. The distance of a line connecting the proximal and distal reference points was defined as the reference length. The X-coordinate was the distance from the proximal reference point to the intramuscular motor endpoint (IME), or motor entry point (MEP) on the reference line, and the Y-coordinate was the distance from the nearest point from MEP on the medial border of the tibia to the MEP. IME and MEP distances from the proximal reference point were evaluated using the raw value and the X-coordinate to reference length ratio was determined as a percentage.
The majority of IMEs were located within 30%-60% of the reference length from the proximal reference point. The majority of the MEPs were located within 40%-60% of the reference length from the proximal reference point.
We recommend the anatomical site for a botulinum toxin injection in the FDL to be within a region 30%-60% of the reference length from the proximal reference point.


Flexor digitorum longus; Botulinum toxins; Spasticity; Claw toes

MeSH Terms

Botulinum Toxins*
Hammer Toe Syndrome
Botulinum Toxins


  • Fig. 1 Photographs of the posteromedial aspect of the leg showing the motor entry point (arrowhead) and intramuscular motor endpoint (arrow).

  • Fig. 2 The X-coordinate was the distance from the proximal reference point (PRP) to the motor entry point (arrow) or intramuscular motor endpoint (rhombus) on the reference line, and the Y-coordinate was the distance from the medial border of the tibia to the motor entry point on a line perpendicular to the reference line. DRP, distal reference point.


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