Shemar Crawford, MD
Resident Physician
University of Miami
Miami, Florida, United States
Mark Joshua Williams, MD
Resident Physician
University of Miami / Jackson Health
MIAMI, Florida, United States
Andrew L. Sherman, MD
Professor
University of Miami Miller School of Medicine
Miami, Florida, United States
The patient is a 69-year-old gentleman with a chief complaint of lumbar pain x 10 years averaging 5/10, aching, and non-radiating. Lumbar MRI revealed mild multi-level facet arthropathy without stenosis. Notably, he exhibited significant hamstring tightness, with a maximum hip flexion angle of 30 degrees during straight leg raise testing. This maneuver also elicited considerable pain in the hamstrings when stretched. Given his hamstring dystonia, the decision was made to inject botulinum toxin (botox) into the bilateral hamstring muscles. 100 units of botox were injected divided into the left and right hamstrings. Additionally, the patient was prescribed a home exercise hamstring stretching program. On follow up four weeks later, the patient was noted to have increased hamstring flexibility, with hip flexion 0-55 degrees, with reduction in lumbar pain now rated at 3/10.
Discussions:
The role of hamstring flexibility in the generation of low back pain remains unclear currently, but some research points to increased hamstring flexibility leading to improvement in low back pain. In a recent meta-analysis, there was evidence that patients who participated in hamstring stretches regularly scored lower low back pain scores and showed improved function on a disability scale. However, there is a lack of research on the use of Botox for hamstring tightness in patients with low back pain, highlighting the need for further investigation. This would be the first published case demonstrating resolution of mid hamstring dystonia with low dose botox injection resulting in not only increased hamstring length but reduced chronic lumbar pain.
Conclusions:
Injection of low dose botox into extremely tight hamstrings such that dystonia is suspected and lumbar pain in this case resulted in both improved hamstring flexibility and reduced lumbar pain. More extensive studies with a large patient population and controls are warranted in our opinion.
