Intra-articular botulinum toxin A as an adjunctive therapy for refractory joint pain in patients with rheumatoid arthritis receiving biologics: a report of two cases

Joint Bone Spine. 2009 Mar;76(2):190-4. doi: 10.1016/j.jbspin.2008.05.006. Epub 2008 Oct 25.


We report the use of intra-articular Botulinum toxin A in two RA patients with persistently painful monoarthritis in ankle/feet joints. Both patients had monarticular pain despite a good response of all other joints to a combination therapy that included anti-tumor necrosis factor therapy. Both patients had failed intra-articular corticosteroid injections and declined surgical options. After a single, "off-label", intra-articular injection of Botulinum toxin A into the right ankle (100 unit) and left first metatarsophalangeal joint (25 unit), respectively, pain and function improved significantly (> or =40%) in both patients. Durable response with improvement of pain and function lasting 15-18 months was noted (follow-up continuing). Ankle joint swelling resolved by 15 months and MTP joint swelling by one month. Intra-articular BoNT/A may be an additional therapeutic option in RA patients with persistent monoarthritis. A randomized study is underway to confirm these findings.

Publication types

  • Case Reports

MeSH terms

  • Adjuvants, Pharmaceutic
  • Ankle Joint / diagnostic imaging
  • Ankle Joint / physiopathology
  • Anti-Dyskinesia Agents / administration & dosage
  • Anti-Dyskinesia Agents / therapeutic use*
  • Arthritis, Rheumatoid / drug therapy*
  • Arthritis, Rheumatoid / physiopathology
  • Botulinum Toxins, Type A / administration & dosage
  • Botulinum Toxins, Type A / therapeutic use*
  • Health Status
  • Humans
  • Injections, Intra-Articular
  • Male
  • Metatarsophalangeal Joint / diagnostic imaging
  • Metatarsophalangeal Joint / physiopathology
  • Middle Aged
  • Pain / drug therapy*
  • Pain Measurement
  • Radiography
  • Surveys and Questionnaires
  • Treatment Outcome


  • Adjuvants, Pharmaceutic
  • Anti-Dyskinesia Agents
  • Botulinum Toxins, Type A