spasticity is a frequent consequence of stroke1 , 
 2 . in the lower leg ,
this malposition or 
 malalignment causes mechanical stress to foot joints in the lateral forefoot area , and 
 joints under this stress are likely to be inflamed and painful4 .
foot pain causes difficulty in standing and walking , and thus 
 limits daily living activities .
the malposition or malalignment of the foot can be managed by the 
 control of spasticity .
it was proposed that correcting the malposition or malalignment can 
 reduce abnormal mechanical pressure in specific areas of the foot , which leads to a 
 reduction in foot pain . of the several options available for the management of spasticity
, 
 the clinical usefulness of nerve and motor point blocks with alcohol has been well 
 demonstrated5,6,7 . in the current study , whether a reduction of ankle spasticity using nerve and motor point 
 blocks with 20% ethyl alcohol can manage foot pain was examined .
a 58-year - old woman visited the rehabilitation department of a university hospital due to 
 piercing pain ( numeric rating scale [ nrs ] : 8) in the left fifth metatarsal head for two 
 years .
erythema and edema were present on the lateral aspect of the head of the fifth 
 metatarsal bone ( fig .
1.(a ) an image of the patient s left foot shows erythema and edema 
 in the fifth metatarsal head area .
( b ) the left foot x - ray showed that the fourth and 
 fifth intermetatarsal angle was 7.7 ) . the patient provided informed signed consent 
 for participation in the study .
the study was approved by the research ethics committee of 
 yeungnam university hospital ( yuh-16 - 0425-d7 ) . on the foot x - ray ,
the fourth and fifth 
 intermetatarsal angle of the left foot was 7.7 ( fig . 

she had a history of intracerebral 
 hemorrhage on the right basal ganglia about five years previously .
the degree of her spasticity was a modified 
 ashworth scale ( mas)8 of 1 + .
additionally , slight motor weakness ( medical 
 research council9 : 4 + ) in the left upper 
 and lower extremities was shown .
other neurological symptoms , including sensory and 
 cognitive deficits , were not present . at first , 0.5  ml of 2% lidocaine with 10  mg 
 triamcinolone acetonide was injected into the tender point of the left fifth metatarsal head 
 area .
( a ) an image of the patient s left foot shows erythema and edema 
 in the fifth metatarsal head area .
( b ) the left foot x - ray showed that the fourth and 
 fifth intermetatarsal angle was 7.7 it was proposed that the ankle spasticity in the patient caused repetitive pressure and 
 shearing between the soft tissue and head of the fifth metatarsal bone .
thus , we considered 
 the possibility that controlling spasticity might be helpful in the management of pain from 
 the tailor s bunion , and decided to control spasticity in this patient using a nerve or 
 motor point block with 20% ethyl alcohol . to reduce the spasticity of the left ankle plantar 
 flexor , the medial and lateral motor branches to the gastrocnemius muscle of the left tibial 
 nerve
the block of nerve branches 
 was performed based on the method described by jang et al5 . to manage spasticity in the left ankle supinator
a motor point 
 block was performed in the left tibialis posterior muscle with 5  ml of 20% ethyl alcohol . 

both nerve and motor points were 
 located using the nerve stimulator at the popliteal area and at the mid - calf level , 
 respectively .
the cathode stimulating needle ( teflon - coated , 23-gauge needle ) was slowly 
 advanced in the direction of the nerve and posterior tibialis muscle .
the needle hub was 
 connected to injection tubing that bore the syringe containing the 20% ethyl alcohol . 

contractions were seen and palpated as the tip came close to the nerve or motor point of the 
 tibialis posterior . at this stage ,
the intensity of the current was between 3 ma and 5 ma . 
 after the needle was placed close to the targeted nerve or motor point ,
the tip is assumed to be in contact with the nerve or motor 
 point when maximum contraction is obtained with minimum current .
the needle was finally 
 positioned at a current of 1 ma with nerve block and 3.5 ma with motor point block . 

additionally , the patient underwent the stretching exercises for the left ankle plantar 
 flexors and ankle supinators for 2 weeks after the alcohol block ( monday through friday : 15 
 mins  1 time / day ) . to evaluate dynamic foot pressure , the foot pressure measurement system ( fpms ) ( tpscan ; 
 biomechanics , goyang , korea ) was used10 . 

dynamic foot contact pressure data during gait were recorded on the fpms floor mat ( 40.5  
 40.5  cm ) at the middle of the gait test .
the foot pressure was presented as a 
 color : red is the highest pressure followed by orange , yellow , green , and blue .
foot contact 
 pressure was evaluated twice before and one- month after the nerve and motor point block 
 procedure . before the procedure
, contact pressure was highly distributed to the lateral 
 forefoot , however , reduced distribution was observed in the medial forefoot and hindfoot 
 ( fig .
2.foot 
 pressure measurement imagethe foot pressure image of a normal foot and the 
 images of the patient s foot pressure showing alterations pre - alcohol block and 
 post - alcohol block . ) . 

after the procedure , the distribution of foot contract pressure was found to be similar to 
 that of a normal control ( 56-year - old female individual ) .
foot 
 pressure measurement image the foot pressure image of a normal foot and the 
 images of the patient s foot pressure showing alterations pre - alcohol block and 
 post - alcohol block .
at the follow - up evaluation , two weeks after the alcohol block , the spasticity in the left 
 ankle plantar flexor and supinator had disappeared ( mas : 0 ) .
in addition , ankle clonus was 
 not present . moreover , the pain in the left fifth metatarsal head was significantly reduced 
 from nrs 8 to nrs 1 . at one , two , and three
months after the alcohol block the effects on 
 ankle spasticity and foot pain were sustained .
in the present study , foot pain related to tailor s bunion was reduced after spasticity 
 treatment using nerve and motor point block with 20% ethyl alcohol .
although the incidence of foot pain in patients with stroke has not been investigated , 
 patients with stroke are prone to have foot pain due to deteriorated musculoskeletal 
 position or alignment induced by spasticity or motor weakness .
the tailor s bunion or 
 bunionette , which was first described by davies in 194911 , is a painful bony prominence on the lateral , dorsolateral , or 
 plantar aspect of the head of the fifth metatarsal bone12 .
the conflict between the fifth metatarsal head and footwear has 
 been reported to be the cause of tailor s bunions12 . in the patient ,
the spasticity in the ankle plantar flexor and 
 supinator appeared to cause repeated mechanical stress and chronic irritation in the fifth 
 metatarsal head area , which is thought to induce a tailor s bunion . for the management of foot pain due to tailor s bunion , corticosteroids were injected into 
 the tender point of the fifth metatarsal head area ; however , the patient s pain was 
 unresponsive to this injection .
it was considered that non - controlled spasticity can lead to 
 continuous mechanical stress or irritation and repeated occurrence of inflammation in the 
 fifth metatarsal head area .
therefore , the spasticity was controlled using a block with 20% 
 ethyl alcohol on the motor branches to the gastrocnemius muscle of the tibial nerve and the 
 motor points of the posterior tibialis muscle .
after the block with ethyl alcohol , spasticity in this 
 patient had almost disappeared ( from mas 1 + to mas 0 ) .
also , the patient received the 
 stretching exercises for the ankle plantar flexors and the ankle supinators .
the stretching 
 exercise is known to effectively reduce spasticity13 , 
 14 by increasing tissue 
 extensibility15 .
it was thought that 
 the reduced spasticity in the patient was attributed , at least in part , to the stretching 
 exercises .
it is thought that the mechanical stress and irritation in the fifth metatarsal 
 head area during walking were significantly reduced with the disappearance of spasticity in 
 this patient .
when the stress and irritation were reduced after the management of 
 spasticity , the pain due to tailor s bunion appeared to be significantly reduced .
in addition , the fpms was used for detailed evaluation of the effect of the 20% ethyl 
 alcohol block . before the alcohol block ,
after the control of spasticity with the alcohol 
 block , increased contract foot pressure in the hindfoot and medial forefoot were observed . 

this change in pressure distribution is concurrent with the results of several previous 
 studies10 , 16 , 17 . using fpms ,
it was 
 confirmed that mechanical stress abnormally concentrated on the fifth metatarsal head area 
 was corrected to near normal following the alcohol blocks on the tibial nerve branches and 
 the motor point of the tibialis posterior muscle .
the correction of foot contact pressure 
 distribution appears to have contributed to the pain reduction in the fifth metatarsal head 
 area . in conclusion ,
the case of a patient with chronic hemiparetic stroke whose pain due to 
 tailor s bunion showed relief following the control of spasticity using nerve and motor 
 point blocks with 20% ethyl alcohol was reported .
this study showed that deteriorated foot 
 position or alignment induced by spasticity and malposition / malalignment - related foot pain 
 can be successfully managed by nerve and motor point blocks with 20% ethyl alcohol . on the 
 basis of the clinical experience in this study ,
when clinicians treat foot pain in patients 
 with stroke , they should consider the possibility that spasticity can contribute to the 
 development of foot pain .
this is first study to show that management of spasticity can 
 reduce foot pain in a patient with hemiparetic stroke . however , since this study reports a 
 single case , further studies involving a larger number of patients are necessary .
 [ purpose ] this study report a case of a patient with hemiparetic stroke who showed 
 significantly reduced foot pain when ankle spasticity was reduced using nerve and motor 
 point blocks with 20% ethyl alcohol . 
 [ subject and methods ] a 58-year - old woman with left 
 hemiparesis following intracranial hemorrhage five years previously presented with pain in 
 the left fifth metatarsal head for two years ( numeric rating scale[nrs ] : 8) . 
 erythema and 
 edema were observed on the lateral aspect of the head of the fifth metatarsal bone . 
 she 
 was diagnosed with a tailor s bunion . 
 spasticity was observed in the left ankle plantar 
 flexor and ankle supinator ( modified ashworth scale : 1 + ) . using 20% ethyl alcohol , a block 
 in the medial and lateral motor branches to the gastrocnemius muscle of the left tibial 
 nerve and the motor point of the left posterior tibialis muscle was performed . 
 [ results ] 
 after the alcohol block , spasticity had almost disappeared and foot pain was significantly 
 reduced ( nrs : 1 ) . 
 results from the foot pressure measurement system test showed foot 
 contact pressure was highly distributed to the lateral forefoot pre - block . 
 after the 
 block , the distribution of foot contract pressure was similar to normal distribution . 
 
 [ conclusion ] clinicians should consider the possibility that spasticity can contribute to 
 foot pain . 