Chiropractic Evaluation of Neurologic Heel Pain
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Did you know:
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)
Misdiagnosis of heel pain as Plantar Fasciitis (PF) is common. Frequently, heel pain may actually be neurologic in etiology. Chiropractic evaluation of heel pain must test for nerve entrapment of the posterior tibial nerve as it enters the foot to make this differentiation. Fortunately, the Plantar Neurodynamic Test will help you differentiate between neurologic and other musculoskeletal causes of heel pain.
Where Is The Most Common Site Of Nerve Compression Resulting In Heel Pain?
Nerve entrapments may result in either acute or chronic conditions affecting the heel. (4) A lesion within the tibial, plantar, or calcaneal nerve 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.
Orthopedic evaluation allows us to exploit our knowledge of anatomy and physiology to assess this small nerve, often causing significant problems.
How Can I Diagnose Neurologic Heel Pain?
The Plantar Neurodynamic Test applies direct tension to all the divisions of the tibial nerve. Positive testing results in the patient experiencing 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.
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. As you progressively lift the patient’s straightened leg, monitor for radicular symptoms. Upon reproducing radicular symptoms, perform internal rotation of the hip to increase neural tension. Exacerbation of foot pain during hip internal rotation suggests foot pain of neurologic origin.
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.
If you want to take a deep dive into other causes of heel pain, check out this recent blog by Dr. Bertelsman.
Suppose your patient does have plantar fasciitis. Be sure to reference ChiroUp. We have the most up-to-date information for both you and your patient to resolve these stubborn cases successfully. Don't just prescribe exercises, instead perform a comprehensive evaluation, prescribe the most efficient rehabilitation program, and provide patient education that matters! All with ChiroUp. Get started with your 14-day FREE trial today!
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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.
