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Baxters Neuropathy

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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
    • Estimated that approximately 20% of cases of pain in the medial region of the heel are associated LPN neuropathy[2]
    • Up to 15% of athletes with chronic, unresolving heel pain may have FB-LPN entrapment[3]

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

Pathoanatomy

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

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
  • 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

References

  1. ↑ Baxter DE, Thigpen CM. Heel pain--operative results. (1984) Foot & ankle. 5 (1): 16-25.
  2. ↑ Oztuna V, Ozge A, Eskandari MM, et al. Nerve entrapment in painful heel syndrome. Foot Ankle Int. 2002;23:208–211.
  3. ↑ Schon L, Baxter D. Neuropathies of the foot and ankle in athletes. Clin Sports Med 1990;9:489–509.
  4. ↑ 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.
  5. ↑ David Del Toro, A. N. (2018). Guiding Treatment for Foot Pain. Physical Medicine and Rehabilitation Clinics of North America, 783-792
  6. ↑ Louisia S, Masquelet AC: The medial and the inferior calcaneal nerves: an anatomic study. Surg Radiol Anat, 1999; 21: 169–73
  7. ↑ 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
  8. ↑ 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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