{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T05:14:50Z","timestamp":1787030090188,"version":"build-2736575974"},"reference-count":50,"publisher":"MDPI AG","issue":"10","license":[{"start":{"date-parts":[[2025,10,16]],"date-time":"2025-10-16T00:00:00Z","timestamp":1760572800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Toxins"],"abstract":"<jats:p>Spasticity of the distal lower limb substantially impairs stance, gait, and quality of life in patients with upper motor neuron lesions. Although ultrasound-guided botulinum toxin A (BoNT-A) injections are increasingly employed, structured, muscle-specific visual guidance for the distal lower limb remains limited. This study provides a comprehensive guide for ultrasound-guided BoNT-A injections across ten key distal lower limb muscles: gastrocnemius, soleus, tibialis posterior, flexor hallucis longus, flexor digitorum longus, tibialis anterior, extensor hallucis longus, flexor digitorum brevis, flexor hallucis brevis, and extensor digitorum longus. For each muscle, we present (1) Anatomical positioning relative to osseous landmarks; (2) Sonographic identification cues and dynamic features; (3) Zones of intramuscular neural arborization optimal for injection; (4) Practical injection protocols derived from literature and clinical experience. High-resolution ultrasound images and dynamic videos illustrate real-life muscle behavior and guide injection site selection. This guide facilitates precise targeting by correlating sonographic signs with optimal injection zones, addresses common spastic patterns\u2014including equinus, varus, claw toe, and hallux deformities\u2014and integrates fascial anatomy with motor-point mapping. This article completes the Elias University Hospital visual series, providing clinicians with a unified framework for effective spasticity management to improve gait, posture, and patient autonomy.<\/jats:p>","DOI":"10.3390\/toxins17100508","type":"journal-article","created":{"date-parts":[[2025,10,17]],"date-time":"2025-10-17T07:33:50Z","timestamp":1760686430000},"page":"508","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["The Elias University Hospital Approach: A Visual Guide to Ultrasound-Guided Botulinum Toxin Injection in Spasticity, Part IV\u2014Distal Lower Limb Muscles"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9043-7585","authenticated-orcid":false,"given":"Marius Nicolae","family":"Popescu","sequence":"first","affiliation":[{"name":"Department of Physical and Rehabilitation Medicine, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania"},{"name":"Clinic of Physical and Rehabilitation Medicine, Elias Emergency University Hospital, 011461 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-0891-4775","authenticated-orcid":false,"given":"Claudiu","family":"C\u0103pe\u021b","sequence":"additional","affiliation":[{"name":"Clinic of Physical and Rehabilitation Medicine, Elias Emergency University Hospital, 011461 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4632-576X","authenticated-orcid":false,"given":"Cristina","family":"Popescu","sequence":"additional","affiliation":[{"name":"Department of Oncologic Dermatology, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9379-4580","authenticated-orcid":false,"given":"Mihai","family":"Berteanu","sequence":"additional","affiliation":[{"name":"Department of Physical and Rehabilitation Medicine, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania"},{"name":"Clinic of Physical and Rehabilitation Medicine, Elias Emergency University Hospital, 011461 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,10,16]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Zeng, H., Chen, J., Guo, Y., and Tan, S. 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