Parkinsonism and Related Disorders 9 (2003) 355359

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Idiopathic foot dystonia treated with intramuscular phenol injection

Joong-Seok Kima, Kwang-Soo Leea,*, Young-Jin Kob, Seok-Beum Koa, Sung-Woo Chunga
a

Department of Neurology, The Catholic University of Korea, Kangnam St Mary Hospital, #505, Banpo-dong,
Seochu-gu, Seoul South Korea
b
Department of Rehabilitation Medicine, The Catholic University of Korea, Kangnam St. Mary Hospital, #505, Banpo-dong,
Seochu-gu, Seoul, South Korea
Received 4 July 2002; revised 18 November 2002; accepted 19 November 2002

Abstract
We describe a patient who developed involuntary, painless, dystonic contraction of the left foot on walking. The patient had been treated
with botulinum toxin A without benefit. Examination showed that walking brought on a spasmodic twisting of the left foot, with extension
and eversion of the ankle. The patient underwent an intramuscular phenol injection, which abolished the foot dystonia. This case suggests
that intramuscular phenol treatment may be an alternative for patients where botulinum toxin was unable to relieve the dystonias.
q 2003 Elsevier Science Ltd. All rights reserved.
Keywords: Foot dystonia; Phenol; Botulinum toxin

Botulinum toxin A has been known as the treatment of

choice for focal dystonia. However, some patients lose the
initial benefit (secondary non-responder) or never respond at
all (primary non-responder) [1]. For these patients, some
alternatives are still available, including several drugs
(anticholinergics, benzodiazepine, tetrabenazine), chemical
denervation (the use of other type botulinum serotypes or
phenol) and selective surgical denervation [2 5].
A recent report drew attention to intramuscular phenol
injection for cervical dystonia [6,7]. Intramuscular neurolysis with phenol has been used for several years in the
management of spasticity or contracture [8 10]. Phenol
produces a long-acting neuromuscular block as well as
neural destruction and muscle atrophy [11,12].
We describe a case of idiopathic foot dystonia, nonresponsive to botulinum toxin A, but successfully treated
with phenol.

1. Case report
A 46-year-old woman noticed an abnormal feeling in her
left leg and that she was beginning to limp. Since that time,
the left foot developed abnormal ankle twisting whenever
* Corresponding author. Tel.: 82-2-590-2720; fax: 82-2-599-9686.
E-mail address: ks1007@cmc.cuk.ac.kr (K.-S. Lee).

she walked. The abnormal movement was not painful, but it

prevented her from walking normally. She had no back pain
or weakness in the legs, and she had had no trauma to the leg
or back. There were no abnormal movements elsewhere. She
had never been on any neuroleptic or dopaminergic drugs and
there was no family history of neurological disease.
On examination, the cranial nerves and arms were
normal, and there was no evidence of an extrapyramidal or
pyramidal disturbance. An examination of the legs and feet
showed a normal appearance at rest and an upright position
with no wasting or fasciculation. The tone was normal, and
straight leg raising was full bilaterally. She had full power in
all muscle groups. There were no abnormal subjective or
objective sensory disturbances. The deep tendon reflexes in
both lower extremities were symmetric and normoactive
and both plantar were flexor.
An examination during gait (Fig. 1) showed spasmodic
twisting of the left foot, with a depression of the 1st ray and
an eversion of the ankle. These spasms occurred after
walking two or three paces. Each spasm would last for as
long as she continued walking and would normally be
relieved when she stopped walking. Certain movements
such as walking downstairs or upstairs were particularly
effective at bringing on the spasms, whereas these spasms
disappeared during movements such as walking backwards.
However, while walking, dystonic spasms were not noticed
in any part of the body or limbs other than in the left foot.

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J.-S. Kim et al. / Parkinsonism and Related Disorders 9 (2003) 355359

Fig. 1. This picture demonstrates the patient walking before intramuscular phenol injection. The dystonic contractions in the left foot begin after walking. The
main movement can be seen to include a spasmodic twisting of the left foot, with extension and eversion of the ankle.

The results of our routine investigations, including

hematological and biochemical screening, and measurements of the serum ceruloplasmin and copper levels, were
normal. MRI scans of the brain and lumbar spine as well as
electrophysiological studies of the left lower extremity were
also normal.

Some drugs such as levodopa, trihexiphenidyl and

baclofen were prescribed, but these drugs had little effect.
She had also been treated with botulinum toxin A without
any benefit.
The position of the foot during gait suggested a dynamic
hypertonicity of the peroneus muscle group. Phenol was

J.-S. Kim et al. / Parkinsonism and Related Disorders 9 (2003) 355359

injected into the left peroneus longus and brevis muscles in

order to aid in the diagnosis and possibly treat the foot
dystonia.
The procedure was performed with EMG localization in
the following manner. First, the motor points of each muscle
were identified with surface stimulation locating the area of

357

maximum muscle contraction with minimal stimulation

intensity. A hollow Teflon-coated monopolar needle was
inserted using a sterile technique. Again using EMG
guidance, a needle was repositioned in small increments
until the motor points were identified, displaying maximum
contraction with 1 3 mA stimulation. Five percent aqueous

Fig. 2. This picture was taken after intramuscular phenol injection. The patient is now free of abnormal movements of the left foot.

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J.-S. Kim et al. / Parkinsonism and Related Disorders 9 (2003) 355359

phenol was then slowly injected until no observable

contraction was seen with a similar stimulation intensity,
1.0 and 0.5 ml of phenol was injected into the peroneus
longus and brevis muscles, respectively. There were no
complications from the procedure. After this procedure, the
patient had an almost complete resolution of her dystonic
spasms during gait (Fig. 2). The patient has shown sustained
improvement in gait after a 1-year follow-up.

2. Discussion
The syndrome of painful legs and moving toes is a rare
condition in which lesions of the peripheral nerves, nerve
roots, cauda equina, and posterior root ganglion [13 15] are
associated with the onset of involuntary movement of a part
of a limb. In addition, isolated foot dystonia can occur in a
single muscle or a group of muscles [16]. Oral medications
such as baclofen, diazepam, and dantrolene have proven to
be unsatisfactory in providing complete symptomatic relief
[17]. Accordingly, botulinum toxin A has been presented as
the treatment of choice for these focal dystonias [16,18].
Our patient had an abnormal transient spasm of a single
group of muscles, and there was no evidence of visible
fasciculations or visible muscle contraction. Therefore, it is
likely that this patient had true dystonia, although a
definitive cause for the ankle twisting was not found.
Needle EMG localization of a group of peroneus muscles
prior to the phenol injection was important because it did
confirm the intrinsic overactivity of that muscle group. The
phenol was injected into two areas of the muscles displaying
the extremely high motor unit activity, which reduced the
overactive firing resulting in a correction of the abnormal
spasm during gait.
The neuromuscular blockade methods for treating focal
dystonia have previously been introduced using different
terminologies, i.e. intramuscular neurolysis, motor point
block, or muscle afferent block, according to the drug
mechanisms [8 12,19 21]. Neuromuscular blockade balances the agonist antagonist forces by diminishing the
stretch reflexes through neural destruction and the blocking
of neural transmission (4 6% phenol, alcohol, or local
anesthetics), by preventing or decreasing muscle fiber
contractions by muscle power destruction (alcohol or
phenol), or by blocking the neuromuscular junction activity
(botulinum toxin A). The net effect of a neuromuscular
blockade is complete or partial paralysis of the target
(agonist) muscles whilst leaving the antagonist muscles
unaffected.
The precise way in which phenol exerts its therapeutic
effect is still under study [8 12]. There are a number of
possible explanations to explain the mechanism. These
include neural destruction, intramuscular neurolysis, muscle
atrophy and muscle necrosis as ways of improving the
function of the limb by relieving the spasticity. The
temporal effect of a phenol injection appears to vary with

concentration and the duration of exposure. Recurrence in

the injected muscles is believed to be due to wallerian
degeneration and subsequent regeneration of the injured
motor nerves. The long-term effects may be secondary to
muscle necrosis and fibrosis, endoneural fibrosis, or local
vascular injury caused by non-specific protein denaturing
within the injection zone.
However, a number of precautions must be observed
when using this technique. Since phenol is a sclerosing
agent, it is a standard procedure to draw back on the syringe
to avoid an intravascular injection. The complications after
phenol use include skin slough, muscle necrosis, paresthesia, wound infections, and quite commonly, post-injection
pain. The latter may be the result of tissue necrosis and the
resultant inflammation, and these cases may require local or
systemic treatment [22].
In summary, a phenol injection was able to safely and
effectively relieve a focal dystonia of the peroneus muscles
in a patient who had functional impairment. It is believed
that an intramusclular phenol treatment may be an
alternative treatment for patients where botulinum toxin
was unable to relieve the dystonias.

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