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Baxters Neuropathy
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Contents
Other Names
- Compressive neuropathy of the first branch of the lateral plantar nerve
- Entrapment of the first branch of the lateral plantar nerve
- Inferior Calcaneal Nerve Entrapment
- First Branch- Lateral Plantar Nerve Entrapment (FB-LPN)
Background
- This page refers to neuropraxia of the Lateral Plantar Nerve (LPN), commonly termed 'Baxter's Neuropathy' (BN)
History
- Named after orthopedic surgeon Donald Baxter[1]
Epidemiology
- Demographics
- One study found average age 38, 88% male (need citation)
- Prevalence
Pathophysiology
- General
- Rare disease, not well described in the literature
- Entrapment of the first branch of the LPN, the inferior calcaneal nerve
- Hard to distinguish from other causes of heel pain such as plantar fasciitis
Etiology
- Compression can occur in several places
- Deep to or adjacent to the fascial edge of a hypertrophied abductor hallucis muscle
- Along the medial edge of the quadratus plantae muscle
- Adjacent to the medial calcaneal tuberosity
Associated Conditions
- Plantar Fasciitis
- At least one case study reporting plantar fasciitis as the etiology[4]
Pathoanatomy
- Lateral Plantar Nerve
- Terminal branch of the Posterior Tibial Nerve[5]
- Motor: Quadratus Plantae, Abductor Digiti Minimi
- Sensory: Anterior thir0ds of the lateral sole of the foot, plantar surfaces for the 5th and half of the 4th toe
- Inferior calcaneal nerve[6]
- First branch of the lateral plantar nerve (FB-LPN)
- Courses in a medial to lateral direction between the abductor hallucis muscle and the medial calcaneal tuberosity.
- Motor: Flexor Digitorum Brevis, Quadratus Plantae
Risk Factors
- Sports
- Runners
- Joggers
- Systemic
- Obesity
- Seronegative Spondyloarthropathies
- Biomechanical disorders
- Pes Cavus
- Pes Planus
- Hyperpronated Foot
- Direct compression
- Plantar fasciitis
- Masses
- Plantar calcaneal osteophytes/ spurring[7]
- Hypertrophied abductor hallucis
Differential Diagnosis
- Fractures & Osseous Disease
- Traumatic/ Acute
- Stress Fractures
- Other Osseous
- Dislocations & Subluxations
- Muscle and Tendon Injuries
- Ligament Injuries
- Plantar Fasciopathy (Plantar Fasciitis)
- Turf Toe
- Plantar Plate Tear
- Spring Ligament Injury
- Neuropathies
- Mortons Neuroma
- Tarsal Tunnel Syndrome
- Joggers Foot (Medial Plantar Nerve)
- Baxters Neuropathy (Lateral Plantar Nerve)
- Arthropathies
- Hallux Rigidus (1st MTPJ OA)
- Gout
- Toenail
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Freibergs Disease (Avascular Necrosis of the Metatarsal Head)
Clinical Features
- History
- The patient often describes paresthesias or tingling in the medial portion of the foot
- There is no cutaneous sensory deficit
- Patient may have a history of plantar fasciitis, diagnosed incorrectly
- Symptoms are precipitated by sports in 50% of cases
- About 1/4 athletes have morning pain due to venous engorgement, night pain is uncommon
- Physical Exam: Physical Exam Foot
- They may feel pain while pressuring the course of the nerve
- Location medial heel, superior to the plantar fascia origin, along a line drawn parallel to the posterior tibia
- In chronic cases, 5th digit abduction may be limited and lateral foot muscles may be atrophied
- They may feel pain while pressuring the course of the nerve
- Special Tests
Evaluation
- The diagnosis is primarily clinical
Radiographs
- Standard Radiographs Foot
- Initial imaging modality of choice
- Findings
- Typically normal
- Calcaneal enthesophyte on plantar surface has been implicated, but are commonly seen in asymptomatic patients
MRI
- Imaging study of choice in BN
- Acute phase
- Decreased signal intensity on T1
- Increased signal intensity on T2 with fat-saturation
- Due to increased extracellular water content and decreased muscle fiber volumes
- Chronic Findings
- Pathognomonic feature: Isolated atrophy of the abductor digiti minimi[8]
- Less commonly of the flexor digitorum brevis and the quadratus plantae muscles.
Classification
- Not applicable
Management
Nonoperative
- Indications
- Most cases
- Activity modification
- Physical Therapy
- Stretching exercises for the Achilles tendon and plantar fascia
- Emphasis on muscle rebalancing about the ankle-foot and entire lower limb kinetic chain
- Orthotics
- Biomechanical management for pronation control
- Heel cups with or without a lift
- Foot strappings
- Flexible or rigid foot orthoses
- Padding
- Soft-soled shoes
- Corticosteroid Injection
- Hydrodissection
- Consider neuropathic pain medications
Operative
- Indications
- Failure of conservative treatment, typically at least 6-12 months
- Technique
- Surgical release
Rehab and Return to Play
Rehabilitation
- Recovery typically takes 3 to 6 months
- May be longer if small toe abduction is weak preoperatively
Return to Play/ Work
Complications and Prognosis
Prognosis
- Among athletes, good or excellent results may be seen in approximately 85% of patients (need citation)
Complications
- Needs to be updated
See Also
- Internal
- External
- Sports Medicine Review Foot Pain: https://www.sportsmedreview.com/by-joint/foot/
References
- ↑ Baxter DE, Thigpen CM. Heel pain--operative results. (1984) Foot & ankle. 5 (1): 16-25.
- ↑ Oztuna V, Ozge A, Eskandari MM, et al. Nerve entrapment in painful heel syndrome. Foot Ankle Int. 2002;23:208–211.
- ↑ Schon L, Baxter D. Neuropathies of the foot and ankle in athletes. Clin Sports Med 1990;9:489–509.
- ↑ Dirim, Berna, Donald Resnick, and Nesibe Kurt Ozenler. "Bilateral Baxter's neuropathy secondary to plantar fasciitis." Medical Science Monitor: International Medical Journal of Experimental and Clinical Research 16.4 (2010): CS50-53.
- ↑ David Del Toro, A. N. (2018). Guiding Treatment for Foot Pain. Physical Medicine and Rehabilitation Clinics of North America, 783-792
- ↑ Louisia S, Masquelet AC: The medial and the inferior calcaneal nerves: an anatomic study. Surg Radiol Anat, 1999; 21: 169–73
- ↑ Chundru U, Liebeskind A, Seidelmann F et al: Plantar fasciitis and calcaneal spur formation are associated with abductor digiti minimi atrophy on MRI of the foot. Skeletal Radiol, 2008; 37: 505–10
- ↑ Delfaut EM, Demondion X, Bieganski A et al: Imaging of foot and ankle nerve entrapment syndromes: from well-demonstrated to unfamiliar sites. Radiographics, 2003; 23: 613–23
Created by:
John Kiel on 7 July 2019 08:08:21
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Last edited:
4 October 2022 12:42:06
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