Post-stroke spasticity significantly impairs upper limb function and quality of life. Ultrasound-guided botulinum toxin-A (BoNT-A) injections have become a cornerstone of management, enhancing precision and safety. This paper offers a comprehensive guide for clinicians on ultrasound-guided BoNT-A injections for distal upper limb muscles. Each muscle is detailed in terms of its role in spasticity management, ultrasound identification with key anatomical landmarks, clinical relevance, and injection strategies. Motor points, traditionally identified through anatomical studies or electromyography (EMG), are precisely localized using a musculoskeletal ultrasound by targeting the point of maximum muscle thickness, often corresponding to the motor point. The authors present their clinical method, developed at Elias University Hospital (EUH), to refine BoNT-A injection practices. This approach enhances efficacy, reduces dosage requirements, and improves patient outcomes. The paper also explores unique ultrasound characteristics of spastic muscles, such as their relationship with peripheral nerves, adjacent vascular and muscular structures, and intra- and intermuscular fascia, to guide clinicians in targeting functional muscle tissue. This guide is illustrated with representative ultrasound images and clinical diagrams and provides practical insights into anatomical relationships and injection techniques. Part I focuses on distal upper limb muscles, with Part II addressing proximal upper limb muscles.

Ultrasound-guided botulinum toxin type A (BoNT-A) injections have become an essential tool in the management of lower limb spasticity. Following our previous work, which focused on upper limb muscles, this third part provides a detailed visual guide to the identification and injection of proximal lower limb muscles frequently involved in spastic gait and posture disorders. This guide presents the ultrasound anatomy, clinical relevance, and injection strategies for eleven key muscles: gluteus maximus, piriformis, psoas major, rectus femoris, sartorius, gracilis, adductor longus, adductor magnus, semimembranosus, semitendinosus, and biceps femoris. For each muscle, the Elias University Hospital (EUH) model is applied, highlighting the zones of maximum thickness and motor point density to ensure precise and effective BoNT-A delivery. Enhanced with high-resolution ultrasound images and dynamic scanning techniques, this visual guide supports clinicians in performing safe, targeted injections. It serves as both an educational and practical reference for the ultrasound-guided treatment of spasticity in the proximal lower limb, completing the series and offering a standardized framework for comprehensive BoNT-A management. By promoting accurate toxin delivery, this approach is expected to improve functional mobility, reduce spasticity-related complications, and optimize patient-centered outcomes in rehabilitation settings.

Ultrasound-guided botulinum toxin type A (BoNT-A) injections play a critical role in the management of upper limb spasticity. This is the second part of ‘The Elias University Hospital Approach: A Visual Guide to Ultrasound-Guided Botulinum Toxin Injection in Spasticity’ and it focuses on the proximal upper limb muscles, complementing the first part, which addressed the distal upper limb muscles. This guide provides a detailed analysis of ultrasound anatomy, clinical relevance, and injection strategies for the latissimus dorsi, teres major, subscapularis, pectoralis major, pectoralis minor, deltoid, triceps brachii, biceps brachii, brachialis, and brachioradialis. Using the Elias University Hospital (EUH) model, it presents a structured approach to BoNT-A administration, ensuring precision, safety, and optimal outcomes in spasticity management. To enhance clinical application, this guide incorporates a wide array of high-quality ultrasound images and dynamic videos, offering a comprehensive and practical understanding of scanning techniques, anatomical structures, and injection procedures. This second part of the series serves as an essential reference for clinicians, aligning with the first installment to provide a complete and systematic approach to ultrasound-guided BoNT-A therapy for upper limb spasticity.

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—including equinus, varus, claw toe, and hallux deformities—and 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.

Background/Objectives: Persistent and recurrent symptoms after carpal tunnel release remain challenging, and non-surgical options for post-surgical carpal tunnel syndrome (CTS) are poorly defined. This study evaluated 6-month treatment success after ultrasound-guided 5% dextrose in water (D5W) hydrodissection in persistent or recurrent post-surgical CTS and compared outcomes between subgroups. Methods: In this prospective single-center interventional cohort study, 100 patients with post-surgical CTS were enrolled: 50 with persistent disease and 50 with recurrent disease. All underwent 1–4 treatments with ultrasound-guided D5W hydrodissection using a standardized protocol. Treatment success at 6 months was defined as Patient Global Impression of Change (PGIC) scores of 6–7 together with clinically meaningful improvement in at least two of three domains: ≥30% reduction in 0–10 VAS pain, ≥0.8-point reduction in BCTQ-SSS, and ≥0.5-point reduction in BCTQ-FSS. Secondary outcomes included 12-month durability; longitudinal clinical, ultrasonographic, and electrodiagnostic changes; predictors of treatment success; treatment exposure; and safety. Results: Treatment success at 6 months occurred in 58 of 100 patients (58.0%) and was more frequent in recurrent than persistent CTS (70.0% vs. 46.0%, p = 0.015). At 12 months, treatment success persisted in 52.0% of the cohort (64.0% vs. 40.0%, p = 0.017). Clinical and ultrasonographic outcomes improved significantly over time, with greater improvement in recurrent CTS. Electrodiagnostic improvement was more modest. Recurrent CTS independently predicted success (adjusted OR 2.58, 95% CI 1.10–6.03), whereas severe electrodiagnostic involvement and greater baseline median nerve cross-sectional area were associated with lower odds of success. No serious treatment-related adverse events occurred. Conclusions: Ultrasound-guided D5W hydrodissection was associated with meaningful improvement in post-surgical CTS, particularly recurrent disease.

Pelvic pain may persist despite guideline-concordant endometriosis care. Evidence for primary motor cortex repetitive transcranial magnetic stimulation (M1-rTMS) in this population is limited. We assessed daily pain and activity interference, treatment delivery and safety after clinically indicated M1-rTMS. A prospective, single-centre observational cohort enrolled women with confirmed endometriosis and chronic pelvic pain. Ten left M1-rTMS sessions were scheduled over two weeks (10 Hz, 80% resting motor threshold, 1500 pulses/session). Daily diaries recorded pelvic pain and activity interference during pre-treatment, treatment, and post-treatment days 1–28 and week 8. Changes were estimated using linear mixed-effects models. Forty-two participants were enrolled and 40 initiated treatment; analyses included 37 for pain and 35 for interference. Model-based marginal mean pain decreased from 5.69 to 4.69 (change, −1.00; 95% CI, −1.46 to −0.55; p < 0.001), and interference from 6.03 to 4.63 (change, −1.39; 95% CI, −1.84 to −0.95; p < 0.001). Both remained below pre-treatment at week 8. Ten of 34 evaluable participants achieved ≥30% pain reduction and three achieved ≥50%. Of the 400 planned sessions, 386 were delivered; a total of 33/40 participants attended all ten and 38/40 at least eight. Twenty-eight participants reported 47 treatment-emergent adverse events; one was severe, none was serious, and all were resolved. M1-rTMS was feasible to deliver with high protocol fidelity and acceptable tolerability. Modest reductions in pain and activity interference were observed, although clinically important pain relief occurred in a minority; without a sham, usual-care, or untreated comparator, these changes cannot be attributed causally to rTMS. Controlled trials are required to determine efficacy and optimal dosing.