Baxter’s Nerve Entrapment

Apr 5

Heel pain is a common complaint encountered by chiropractors in clinical practice. While plantar fasciitis (PF) is often the primary diagnosis considered, it's essential to recognize other potential causes, such as Baxter's neuropathy. Baxter's neuropathy, also known as Baxter's nerve entrapment or compression, can mimic PF but requires a distinct approach for accurate diagnosis and management. In this blog, we'll delve into the nuances of Baxter's neuropathy, how it differs from PF, and essential considerations for chiropractors in evaluating and treating this condition.

88% of patients with heel pain also have degenerative findings in the lateral plantar nerve using nerve conduction velocity. (1)

An estimated 54% of patients with plantar foot pain have a neurologic etiology. (2)

Heel pain that is nocturnal or accompanies the first step in the morning may be of neural origin and is not pathognomonic with plantar fasciitis. (3)

Using this information will allow you to:

Accurately assess your patients using specific tests to rule in or out Baxter’s neuropathy.

Understand the signs and symptoms of Baxter’s neuropathy

Provide two manipulations and one in-office treatment to help alleviate symptoms associated with Baxter’s neuropathy.

Baxter’s Neuritis - Location

Nerve entrapments may result in either acute or chronic conditions affecting the heel. (4) A tibial, plantar, or calcaneal nerve lesion may result in plantar heel pain. (5) The first branch of the LATERAL PLANTAR NERVE (Baxter's Nerve) is the most common cause of heel pain of neural origin—Baxter's nerve courses between the abductor hallucis and the medial head of the quadratus plantae muscle.

Baxter’s Neuropathy - Key Symptom Differentiators from Plantar Fasciitis

Presence of Numbness, Tingling, or Pain: Unlike PF, Baxter's neuropathy presents with additional symptoms such as numbness and tingling along the course of the first branch of the lateral plantar nerve. Patients may describe a sensation of pins and needles or radiating pain into the foot's arch, indicating nerve involvement.

Location of Pain: While both conditions can cause heel pain, Baxter's neuropathy typically manifests with pain localized to the bottom and inside of the heel. The pain may worsen with weight-bearing activities and not improve with rest, distinguishing it from PF.

Duration of Symptoms: Plantar Fasciitis is quickly relieved upon the patient getting off their feet. Baxter’s neuropathy lingers for minutes to hours after increased activity on their feet.

Baxter’s Neuritis – Orthopedic Testing

Orthopedic evaluation allows us to exploit our knowledge of anatomy and physiology to assess this small nerve, which often causes significant problems.

1. Plantar Neurodynamic Testing

Begin by dorsiflexing and everting the supine patient’s foot. Then, passively dorsiflex the great toe, followed by a straight leg raise. Monitor for radicular symptoms as you progressively lift the patient’s straightened leg. Internal hip rotation is performed to increase neural tension upon reproducing radicular symptoms. Exacerbation of foot pain during hip internal rotation suggests foot pain of neurologic origin.

The test is positive if the patient experiences calf, plantar foot, or heel pain. (2) Reproduction of symptoms localized to the medial border of the calcaneus is positive for compression of the lateral plantar nerve, referred to as Baxter's neuritis.

2. Muscle Testing

Long-standing compression of any neural structure may result in loss of normal function of both the nerve and muscle it supplies. The lateral plantar nerve innervates the abductor digit minimi, which is responsible for the abduction of the 5th ray. Test the ability of your patient to abduct their 5th ray to assess the integrity of the lateral plantar nerve.

3. Tinel's Sign

Tapping or percussing along the course of the nerve can elicit pain, tingling, or a sensation of pins and needles, indicative of nerve irritation or compression.

MRI is vital in detecting tissue changes associated with Baxter's neuropathy. Acute and subacute changes, such as muscle edema, are best visualized on fluid-sensitive sequences, while chronic changes, including muscle atrophy and fatty infiltration, are identified using fat-sensitive sequences.

Baxter’s Neuropathy – Chiropractic Treatment Approaches

Treatment approaches to plantar fasciitis are straightforward and accessed within ChiroUp. However, management of Baxter's neuropathy involves a multidisciplinary approach, including chiropractic care, physical therapy, and possibly surgical intervention in severe cases. Treatment modalities may include:

1. Rest and Activity Modification: Avoid exacerbating activities and allow the affected nerve to heal. Healing of inflamed nerves is often longer than other MSK tissue.

2. Orthotic Devices: Orthotics may be used to increase the surface area of the plantar foot, contacting the ground and thereby redistributing the pressure, affecting the lateral plantar nerve. A less expensive option for your patients may be heel cups. Heel cups can help dissipate pressure via weight redistribution.

3. Manipulation of the Ankle and Foot:

4. Nerve Release - Posterior Tibial Nerve at the Ankle: Entrapment of the posterior tibial nerve may result in radiating pain or paresthesia into the medial ankle and medial plantar surface of the foot. Nerve release may help resolve adhesions and restore normal mechanical function. The patient should be supine with knee extension and ankle plantar flexion. Contact the site of adhesion and tension distally just below the medial malleolus while slowly moving the ankle into dorsiflexion and eversion. Mobilization should be done 4-5 times consecutively without eliciting lasting symptoms in the nerve distribution.

5. Surgical Intervention: Nerve decompression or ablation may reduce symptoms but will not restore function to chronically injured neve.

Baxter’s Neuropathy – Conclusion

In conclusion, Baxter's neuropathy presents a diagnostic challenge for chiropractors due to its overlapping symptoms with PF. Understanding the distinct clinical features and employing appropriate orthopedic tests and imaging modalities are essential for accurate diagnosis and effective management. By adopting a comprehensive approach encompassing conservative and surgical interventions, chiropractors can provide optimal care for patients with Baxter's neuropathy, improving outcomes and quality of life.

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1. Oztuna V, Ozge A, Eskandari MM, Colak M, Gölpinar A, Kuyurtar F. Nerve entrapment in painful heel syndrome. Foot Ankle Int 2002;23:208-11.
2. Shacklock M. Clinical Neurodynamics: A New System of Musculoskeletal Treatment. Edinburgh: Elsevier Butterworth-Heinemann; 2005. p. 137-8.
3. Thakar HD, Samson A, Palekar TJ. Prevalence for plantar fasciitis of neural origin in community-dwelling adults. (2022)
4. Alshami AM, Souvlis T, Coppieters MW. A review of plantar heel pain of neural origin: differential diagnosis and management. Man Ther. 2008 May;13(2):103-11. doi: 10.1016/j.math.2007.01.014. Epub 2007 Mar 30. PMID: 17400020
5. Goolsby MJ. Diagnosis and treatment of heel pain. Journal of the American Academy of Nurse Practitioners 2003;15(11):485–6.

Brandon Steele

Dr. Steele is currently in private practice at Premier Rehab in the greater St. Louis area. He began his career with a post-graduate residency at The Central Institute for Human Performance. During this unique opportunity, he was able to create and implement rehabilitation programs for members of the St. Louis Cardinals, Rams, and Blues. Dr. Steele currently lectures extensively on evidence-based treatment of musculoskeletal disorders for the University of Bridgeport’s diplomate in orthopedics program. He serves on the executive board of the Illinois Chiropractic Society. He is also a Diplomate and Fellow of the Academy of Chiropractic Orthopedists (FACO).