Baxter nerve pain

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Ginger Sellars, D. Entrapment Neuropathy. Pain on Bottom of the Foot. What could be my problem? What causes Entrapment Neuropathy? When the nerve becomes entrapped between two muscles, the abductor halluces and the quadratus plantar, located along the lower aspect of the inside medial-plantar of the heel.

When the nerve becomes compressed against the heel bone on the under plantar side of the foot. Heel Spurs calcaneal plantar enthesophyte and swelling of the plantar fascia may contribute to nerve entrapment at this location. What are my treatment options? The nerve then continues distally between the medial edge of the quadrutus plantae muscle and the lateral abductor fascia. At the lower border of the abductor hallucis muscle, it turns and moves laterally passing anterior to the medial calcaneal tuberosity and between the quadrutus plantae and the underlying flexor brevis - until it finally reaches the abductor digiti minimi The nerve has sensory fibres that innervate the calcaneal periosteum and long plantar ligament, and motor fibres for the quadrutus plantae, flexor digitorum brevis and ADMM 1,9.

Figure 1: Anatomy of the nerves in the foot Pathogenesis Initially described by Baxter and Thigpen in 11 , entrapment of the first branch of the lateral plantar nerve is a hard-to-diagnose condition that may mimic plantar fasciitis, and one that often co-exists with plantar fasciitis.

It is in fact one of the many causes of medial heel pain. Differential diagnoses of heel pain include 12 : Plantar fasciitis Entrapment of the first branch of the lateral plantar nerve Fat pad disorders Calcaneal body stress fractures Fatigue fractures of the medial calcaneal tuberosity Plantar aponeurosis rupture Tarsal tunnel syndrome Sciatica Painful piezogenic heel papules Glomus tumor of the heel pad There are a number of areas where the first branch of the lateral plantar nerve can become entrapped These include: Between the deep fascia of the abductor hallucis and the medial caudal margin of the medial head of the quadrutus plantae see figure 2 below.

Where the nerve passes through the deep fascia of the abductor hallucis. In the region of a co-exiting plantar spur figure 2 below. Where the nerve passes anterior to the medial calcaneal tuberosity. Between the flexor digitorum brevis muscle and the calcaneus 12, The resultant scar tissue may entrap the nerve. The pathomechanics that may predispose an athlete to this problem include: Posterior tibial tendon dysfunction, which results in excessive midfoot pronation and rearfoot valgus.

Co-existing achilles tendinopathy, which may limit dorsiflexion and result in a compensatory overpronation. Often, it may accompany chronic plantar fasciitis 8. This is due to focal oedema from the plantar fascia, which can lead to entrapment of the nerve. These include : Pain is usually more proximal and medial, usually just distal to the medial calcaneal tuberosity. Absence of early morning pain, instead tending to get worse as the day goes on, or pain appearing after prolonged activity.

A radiating pain may be present when the nerve is palpated. Pain is exacerbated by passive eversion and abduction of the foot. There is maximal tenderness at the medial border of the heel where the entrapment occurs - usually around the origin and deep to the abductor hallucis. This compresses the nerve due to narrowing of the porta pedis. There may be weak abduction of the fifth toe.

This is due to the ADMM. Paresthesias may be reproduced with tapping over the nerve beneath the abductor hallucis muscle. In chronic cases, patients may have diminished sensation in the lateral plantar foot. A diagnostic block at the site of the nerve may help confirm the diagnosis A potential physical test that the clinician can use is an adaptation of the tibial nerve test as described by Shacklock This test is performed in the following way: The patient lies supine.

The clinician holds the affected foot and pushes the foot into ankle dorsiflexion and notes symptoms. The clinician should then lift the leg into hip flexion, with the knee in extension and the foot maintained into dorsiflexion. Note any symptoms particularly medial heel pain.

To differentiate whether the issue is a nerve problem, a tendon issue or something else, a sensitiser is required that will change the nerve tension.

This is done by dropping the hip slowly out of flexion and noting if the symptoms change. If the medial heel pain improves with less hip flexion, then the tibial nerve and its branches are implicated.

Imaging Plain film X-rays can help to exclude bone pathology such as calcaneal spurs. MRI can determine the presence or absence of inflammation around the proximal fascia, as well as thickening of the fascia. Atrophy, increased water signal and fatty infiltration of the ADMM may indicate chronic nerve entrapment leading to atrophy of this muscle 5,18, Such findings are clearly depicted at T1-weighted images without fat suppression Typically, atrophy and fat infiltration occur homogeneously in the muscle belly.

The pathological state of the plantar fascia may potentially compress the nerve as it passes anterior to the medial calcaneal tuberosity. Stretching of the soleus and gastrocnemius muscles. Soft tissue therapy to the plantar fascia and foot intrinsic. Strengthening exercises for the foot intrinsics. This is diagnostic as well as therapeutic. If there is a relief of symptoms with the injection, this points to a nerve entrapment being the source of symptoms.

If not, then plantar fascia injury will be the most likely scenario. If a local steroid injection fails, a surgical intervention may be required. This may consist of decompression of the nerve by endoscopic approach, radiofrequency ablation techniques or open surgery 12, The recommended procedure is complete neurolysis by first releasing the proximal deep fascia of the abductor hallucis muscle.

Further surgical release is accomplished by following the nerve distally, and releasing it from any entrapment caused by the medial plantar fascia or the flexor digitorum brevis at their insertion to the calcaneus.

If there is an impinging bone spur in this area, a small portion may be removed if necessary, but removing the entire spur is not recommended because this action may lead to adverse outcomes 11, Summary Chronic medial heel pain is a common complaint in running-based athletes. In most cases, the source of pain is most likely plantar fasciitis. The major biomechanical factors relevant in this condition are similar to plantar fasciitis and these include rear foot valgus, over pronation of the midfoot and a lack of dorsiflexion.

The typical signs and symptoms may be similar to plantar fasciitis. However, a few distinct signs and symptoms may help the clinician differentiate this condition from plantar fasciitis. Treatment may initially involve conservative management; however, in recalcitrant problems, surgery may be required.

References Radiographics ; — Foot Ankle Int. Release of the nerve to the abductor digiti minimi. In: Kitaoka HB, ed. Master techniques in orthopaedic surgery of the foot and ankle. Foot Ankle. A new system of musculoskeletal treatment. Sydney Radiology ; P : Man Ther.

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