625 - Botulinum Toxin: A Cure for Popliteal Artery Entrapment Syndrome?

40 yo male with left calf pain diagnosed with an anatomical variant with collateral circulation from peroneal artery distally.

Case Description:

A 40yo male presented for evaluation of popliteal artery entrapment syndrome (PAES) on left leg. He was referred to PM&R for conservative treatment of PAES. His cramping pain started two years ago while playing basketball. Pain was constant throughout the day but worse with exercise. We injected 100 units of botulinum toxin into the left gastrocnemius (75 units into medial and 25 units into lateral) with ultrasound guidance to visualize the popliteal artery. Within one month, he had greater than 75% relief in pain and was able to start running and playing basketball again.

 

Discussions:

Several case studies have shown that an injection of botulinum toxin provided 6-12 months and some over one year of symptom relief in patients with popliteal entrapment syndrome. It has been established in the literature as an alternative to surgery. However, botulinum toxin has not been established as a first line treatment and optimal treatment dosage or frequency has not been determined. Surgery is still reported as the main “curative” treatment. In this case report, we suggest that botulinum toxin should be considered as a first-tier treatment and hypothesize that 100U with a potential increased dosage of medial gastrocnemius from lateral gastrocnemius based on anatomy could be a starting dose.

Conclusions:

In this case report, we present a male patient with PAES that received substantial pain relief and functional improvement from botulinum toxin injections with ultrasound guidance in the gastrocnemius allowing him to go back to running and playing basketball after being unable for two years. It is important that we continue to add to the literature, so that a standard dosage and frequency is established for PAES and is accepted as a first line treatment.