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Baxter's Nerve Entrapment: Difference between revisions
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|image=Baxter nerve entrapment sites.png | |image=Baxter nerve entrapment sites.png | ||
|caption=The two common sites of entrapment between the abductor hallucis (AH) and quadratus plantae (QP), and along the medial calcaneal tuberosity under the flexor digitorum brevis (FDB) | |caption=The two common sites of entrapment between the abductor hallucis (AH) and quadratus plantae (QP), and along the medial calcaneal tuberosity under the flexor digitorum brevis (FDB) | ||
|pathophysiology=Compression of the [[Inferior Calcaneal Nerve (Baxter Nerve)]] | |||
|clinicalfeatures=Burning medial heel pain that worsens with standing and walking. | |||
|tests=MRI | |tests=MRI | ||
|treatment=Rest, NSAIDs, injections, orthotics, surgery. | |treatment=Rest, NSAIDs, injections, orthotics, surgery. | ||
}} | |||
Baxter's nerve entrapment, also known as Baxter neuropathy, and inferior calcaneal nerve entrapment, is plantar heel pain arising from compression of the [[Inferior Calcaneal Nerve (Baxter Nerve)|inferior calcaneal nerve (Baxter nerve)]]. Ā | Baxter's nerve entrapment, also known as Baxter neuropathy, and inferior calcaneal nerve entrapment, is plantar heel pain arising from compression of the [[Inferior Calcaneal Nerve (Baxter Nerve)|inferior calcaneal nerve (Baxter nerve)]]. Ā | ||
==Anatomy== | ==Anatomy== | ||
[[File:Baxter nerve.jpg|thumb|290x290px|Baxter nerve (Nerve to abductor digiti quinti).<ref name=":0">{{Cite journal|last=Baxter|first=D. E.|last2=Thigpen|first2=C. M.|date=1984-07|title=Heel pain--operative results|url=https://pubmed.ncbi.nlm.nih.gov/6479759|journal=Foot & Ankle|volume=5|issue=1|pages=16ā25|doi=10.1177/107110078400500103|issn=0198-0211|pmid=6479759}}</ref>]] | [[File:Baxter nerve.jpg|thumb|290x290px|Baxter nerve (Nerve to abductor digiti quinti).<ref name=":0">{{Cite journal|last=Baxter|first=D. E.|last2=Thigpen|first2=C. M.|date=1984-07|title=Heel pain--operative results|url=https://pubmed.ncbi.nlm.nih.gov/6479759|journal=Foot & Ankle|volume=5|issue=1|pages=16ā25|doi=10.1177/107110078400500103|issn=0198-0211|pmid=6479759}}</ref>]]{{Main|Inferior Calcaneal Nerve (Baxter Nerve)}} | ||
The [[Inferior Calcaneal Nerve (Baxter Nerve)|inferior calcaneal nerve (Baxter nerve)]] is the first branch of the [[Lateral Plantar Nerve|lateral plantar nerve]], which is itself a branch of the [[Tibial Nerve|tibial nerve]]. The nerve lies in between the abductor hallucis muscle and quadratus plantae. | The [[Inferior Calcaneal Nerve (Baxter Nerve)|inferior calcaneal nerve (Baxter nerve)]] is the first branch of the [[Lateral Plantar Nerve|lateral plantar nerve]], which is itself a branch of the [[Tibial Nerve|tibial nerve]]. The nerve lies in between the abductor hallucis muscle and quadratus plantae. | ||
The Gray's anatomy image and many other anatomy textbook images are incorrect. The Baxter nerve is quite posterior and lies very close to the calcaneus. It was named after Donald Baxter.<ref name=":0" /> | The Gray's anatomy image and many other anatomy textbook images are incorrect. The Baxter nerve is quite posterior and lies very close to the calcaneus. It was named after Donald Baxter.<ref name=":0" /> | ||
== Pathophysiology== | ==Pathophysiology== | ||
There are three entrapment points:<ref>{{Cite journal|last=Moroni|first=Simone|last2=Zwierzina|first2=Marit|last3=Starke|first3=Vasco|last4=Moriggl|first4=Bernhard|last5=Montesi|first5=Ferruccio|last6=Konschake|first6=Marko|date=2019-01|title=Clinical-anatomic mapping of the tarsal tunnel with regard to Baxter's neuropathy in recalcitrant heel pain syndrome: partĀ I|url=https://pubmed.ncbi.nlm.nih.gov/30368565|journal=Surgical and radiologic anatomy: SRA|volume=41|issue=1|pages=29ā41|doi=10.1007/s00276-018-2124-z|issn=1279-8517|pmc=6514163|pmid=30368565}}</ref> | There are three entrapment points:<ref>{{Cite journal|last=Moroni|first=Simone|last2=Zwierzina|first2=Marit|last3=Starke|first3=Vasco|last4=Moriggl|first4=Bernhard|last5=Montesi|first5=Ferruccio|last6=Konschake|first6=Marko|date=2019-01|title=Clinical-anatomic mapping of the tarsal tunnel with regard to Baxter's neuropathy in recalcitrant heel pain syndrome: partĀ I|url=https://pubmed.ncbi.nlm.nih.gov/30368565|journal=Surgical and radiologic anatomy: SRA|volume=41|issue=1|pages=29ā41|doi=10.1007/s00276-018-2124-z|issn=1279-8517|pmc=6514163|pmid=30368565}}</ref> | ||
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#More distally along the anterior aspect of the medial calcaneal tuberosity. A calcaneal plantar enthesophyte and/or soft tissue changes of plantar fasciitis may contribute to entrapment at this second location. | #More distally along the anterior aspect of the medial calcaneal tuberosity. A calcaneal plantar enthesophyte and/or soft tissue changes of plantar fasciitis may contribute to entrapment at this second location. | ||
== Aetiology == | ==Aetiology== | ||
The following are some causes of entrapment<ref name=":2">A.M. Trescot (ed.), Peripheral Nerve Entrapments: Clinical Diagnosis and Management, DOI 10.1007/978-3-319-27482-9_76</ref> | The following are some causes of entrapment<ref name=":2">A.M. Trescot (ed.), Peripheral Nerve Entrapments: Clinical Diagnosis and Management, DOI 10.1007/978-3-319-27482-9_76</ref> | ||
* Repetitive microtrauma. E.g. those with jobs requiring prolonged standing or walking, or avid runners. Plantar fasciitis. Fat pad atrophy. | *Repetitive microtrauma. E.g. those with jobs requiring prolonged standing or walking, or avid runners. Plantar fasciitis. Fat pad atrophy. | ||
* Acute trauma. direct trauma from a fall or stepping on a hard object, scar tissue after plantar fasciotomy. | *Acute trauma. direct trauma from a fall or stepping on a hard object, scar tissue after plantar fasciotomy. | ||
* Impingement from bony exostosis, calcaneal spur, neuroma, neurilemmoma | *Impingement from bony exostosis, calcaneal spur, neuroma, neurilemmoma | ||
* Stretch injury from a hypermobile pronating foot, abductor hallucis hypertrophy in runners | *Stretch injury from a hypermobile pronating foot, abductor hallucis hypertrophy in runners | ||
* Diabetic [[Peripheral Neuropathy and Polyneuropathy|peripheral neuropathy]]. | *Diabetic [[Peripheral Neuropathy and Polyneuropathy|peripheral neuropathy]]. | ||
==Epidemiology== | ==Epidemiology== | ||
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[[File:Medial calcaneal tubercle tenderness.jpg|thumb|Tenderness of the medial calcaneal tubercle (reproduced with permission by Dr A Trescot.)<ref name=":2" />]] | [[File:Medial calcaneal tubercle tenderness.jpg|thumb|Tenderness of the medial calcaneal tubercle (reproduced with permission by Dr A Trescot.)<ref name=":2" />]] | ||
=== History === | ===History=== | ||
The clinical features may be similar to or coexist with [[Plantar Fasciitis|plantar fasciitis]]. However there may be less morning pain, occasional altered sensation, and intrinsic muscle atrophy. The pain is felt in the medial heel and is often [[Neuropathic Pain|burning]]. It may worsen with prolonged standing and walking. It typically has a gradual onset. | The clinical features may be similar to or coexist with [[Plantar Fasciitis|plantar fasciitis]]. However there may be less morning pain, occasional altered sensation, and intrinsic muscle atrophy. The pain is felt in the medial heel and is often [[Neuropathic Pain|burning]]. It may worsen with prolonged standing and walking. It typically has a gradual onset. | ||
There are two groups of patients with this condition: keen runners and those involved in everyday living.<ref name=":0" /> | There are two groups of patients with this condition: keen runners and those involved in everyday living.<ref name=":0" /> | ||
=== Examination === | ===Examination=== | ||
On examination the patient may walk with exaggerated supination to avoid placing weight on the medial heel. They are tender over the medial calcaneal tubercle similar to the location for [[Plantar Fasciitis|plantar fasciitis]]. Ā | On examination the patient may walk with exaggerated supination to avoid placing weight on the medial heel. They are tender over the medial calcaneal tubercle similar to the location for [[Plantar Fasciitis|plantar fasciitis]]. Ā | ||
| Line 96: | Line 98: | ||
[[File:Baxter nerve entrapment MRI.jpeg|thumb|Coronal PD image showing fatty atrophy.<ref name=":1">Bauones, S., Feger, J. Baxter neuropathy. Reference article, Radiopaedia.org. (accessed on 15 Apr 2022) <nowiki>https://doi.org/10.53347/rID-25994</nowiki></ref>]] | [[File:Baxter nerve entrapment MRI.jpeg|thumb|Coronal PD image showing fatty atrophy.<ref name=":1">Bauones, S., Feger, J. Baxter neuropathy. Reference article, Radiopaedia.org. (accessed on 15 Apr 2022) <nowiki>https://doi.org/10.53347/rID-25994</nowiki></ref>]] | ||
=== Diagnostic Injection === | ===Diagnostic Injection=== | ||
Injecting the baxter nerve can't differentiate between plantar fasciitis and baxter nerve entrapment. | Injecting the baxter nerve can't differentiate between plantar fasciitis and baxter nerve entrapment. | ||
=== Imaging === | ===Imaging=== | ||
On MRI in the acute phase there is decreased T1 signal intensity and increased T2 signal intensity with fat saturation in the muscles innervated by the Baxter nerve. In the chronic phase there is fatty change of the [[Abductor Digiti Minimi|abductor digiti minimi]] muscle, and occasionally the [[Flexor Digitorum Brevis]] and [[Quadratus Plantae]]. | On MRI in the acute phase there is decreased T1 signal intensity and increased T2 signal intensity with fat saturation in the muscles innervated by the Baxter nerve. In the chronic phase there is fatty change of the [[Abductor Digiti Minimi|abductor digiti minimi]] muscle, and occasionally the [[Flexor Digitorum Brevis]] and [[Quadratus Plantae]]. | ||
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==References== | ==References== | ||
[[Category:Foot and Ankle Conditions]] | |||
[[Category:Peripheral Nerve Entrapments]] | |||
<references /> | |||
{{References}} | {{References}} | ||
{{Reliable sources}} | {{Reliable sources}} | ||
Revision as of 19:04, 16 April 2022
This article is still missing information.
| |
| Baxter's Nerve Entrapment | |
|---|---|
| Pathophysiology | Compression of the Inferior Calcaneal Nerve (Baxter Nerve) |
| Clinical Features | Burning medial heel pain that worsens with standing and walking. |
| Tests | MRI |
| Treatment | Rest, NSAIDs, injections, orthotics, surgery. |
Baxter's nerve entrapment, also known as Baxter neuropathy, and inferior calcaneal nerve entrapment, is plantar heel pain arising from compression of the inferior calcaneal nerve (Baxter nerve).
Anatomy
Baxter nerve (Nerve to abductor digiti quinti).[1]
- Main article: Inferior Calcaneal Nerve (Baxter Nerve)
The inferior calcaneal nerve (Baxter nerve) is the first branch of the lateral plantar nerve, which is itself a branch of the tibial nerve. The nerve lies in between the abductor hallucis muscle and quadratus plantae.
The Gray's anatomy image and many other anatomy textbook images are incorrect. The Baxter nerve is quite posterior and lies very close to the calcaneus. It was named after Donald Baxter.[1]
Pathophysiology
There are three entrapment points:[2]
- Where the nerve runs between the deep fascia of the abductor hallucis and medial plantar margin of the quadratus plantae
- More distally along the anterior aspect of the medial calcaneal tuberosity. A calcaneal plantar enthesophyte and/or soft tissue changes of plantar fasciitis may contribute to entrapment at this second location.
Aetiology
The following are some causes of entrapment[3]
- Repetitive microtrauma. E.g. those with jobs requiring prolonged standing or walking, or avid runners. Plantar fasciitis. Fat pad atrophy.
- Acute trauma. direct trauma from a fall or stepping on a hard object, scar tissue after plantar fasciotomy.
- Impingement from bony exostosis, calcaneal spur, neuroma, neurilemmoma
- Stretch injury from a hypermobile pronating foot, abductor hallucis hypertrophy in runners
- Diabetic peripheral neuropathy.
Epidemiology
It is estimated that up to 20% of patients with chronic heel pain may be due to Baxter nerve entrapment.[1]
Risk Factors
Obesity, age, diabetes, muscle hypertrophy, hyperpronated foot, pes planus, plantar calcaneal spur, plantar fasciitis, spondyloarthritis.
Clinical Features
Tenderness of the medial calcaneal tubercle (reproduced with permission by Dr A Trescot.)[3]
History
The clinical features may be similar to or coexist with plantar fasciitis. However there may be less morning pain, occasional altered sensation, and intrinsic muscle atrophy. The pain is felt in the medial heel and is often burning. It may worsen with prolonged standing and walking. It typically has a gradual onset.
There are two groups of patients with this condition: keen runners and those involved in everyday living.[1]
Examination
On examination the patient may walk with exaggerated supination to avoid placing weight on the medial heel. They are tender over the medial calcaneal tubercle similar to the location for plantar fasciitis.
Palpate the distal Achilles tendon and retrocalcaneal bursa looking for tenderness. Also squeeze the heel to detect a stress fracture.
Look at active motion of toe abduction and adduction and compare to the other side. Assess strength with resisted abduction and adduction.
Evaluate Tinel's sign by percussing the upper and lower tarsal tunnels, however this is often absent.
Differential Diagnosis
Differential Diagnosis of Heel Pain
- Plantar Fasciitis
- Fat Pad Contusion
- Calcaneal fractures (traumatic and stress)
- Inferior Calcaneal (Baxter) Nerve Entrapment
- Medial Calcaneal Nerve Entrapment
- Lateral Plantar Nerve Entrapment
- Medial Plantar Nerve Entrapment
- Tarsal Tunnel Syndrome
- Lumbar Radicular Pain
- Talar stress fracture
- Retrocalcaneal bursitis
- Spondyloarthritis
- Osteoid osteoma
- CRPS
Differentiation from plantar fasciitis is not always straight forward. MRI can be helpful.
| Feature | Baxter Nerve Entrapment | Plantar Fasciitis |
|---|---|---|
| Timing | Pain worse after activity and night | "First step" pain. Worse first thing in the morning and after a period of inactivity |
| Walking | Worse with walking | Better with walking |
| Pain type | Neuropathic pain | Nociceptive pain |
| Tenderness | Medial calcaneal tuberosity, radiates to medial ankles and/or lateral foot | Insertion of plantar fascia at medial calcaneal tuberosity and along the medial edge where the fascia may feel thickened. |
| Heel pad sensation | Equal to contralateral side | Equal to contralateral side |
| Modifed from Trescot et al.[3] | ||
If the patient has back pain then consider L5 or S1 radicular pain and examine for radiculopathy (See Lumbar Radicular Pain).
If the patient has bilateral heel pain then consider a rheumatologic origin.
Baxter nerve has no cutaneous sensation, and so if there is sensory change then medial calcaneal nerve entrapment is more likely.
In tarsal tunnel syndrome the entrapment and tenderness is more proximal.
Investigations
Coronal PD image showing fatty atrophy.[4]
Diagnostic Injection
Injecting the baxter nerve can't differentiate between plantar fasciitis and baxter nerve entrapment.
Imaging
On MRI in the acute phase there is decreased T1 signal intensity and increased T2 signal intensity with fat saturation in the muscles innervated by the Baxter nerve. In the chronic phase there is fatty change of the abductor digiti minimi muscle, and occasionally the Flexor Digitorum Brevis and Quadratus Plantae.
Ultrasound can show a thickened and hypoechoic plantar fascia. This doesn't rule out Baxter nerve entrapment because a thickened plantar fascia can entrap the nerve.
Treatment
The nerve can be injected with corticosteroid and/or hydrodissected under ultrasound guidance.
External Links
Baxter's Nerve (First Branch of the Lateral Plantar Nerve) Impingement - Radsource
Baxter nerve injection.[5]
References
- ā 1.0 1.1 1.2 1.3 Baxter, D. E.; Thigpen, C. M. (1984-07). "Heel pain--operative results". Foot & Ankle. 5 (1): 16ā25. doi:10.1177/107110078400500103. ISSN 0198-0211. PMID 6479759. Check date values in:
|date=(help) - ā Moroni, Simone; Zwierzina, Marit; Starke, Vasco; Moriggl, Bernhard; Montesi, Ferruccio; Konschake, Marko (2019-01). "Clinical-anatomic mapping of the tarsal tunnel with regard to Baxter's neuropathy in recalcitrant heel pain syndrome: part I". Surgical and radiologic anatomy: SRA. 41 (1): 29ā41. doi:10.1007/s00276-018-2124-z. ISSN 1279-8517. PMC 6514163. PMID 30368565. no-break space character in
|title=at position 123 (help); Check date values in:|date=(help) - ā 3.0 3.1 3.2 A.M. Trescot (ed.), Peripheral Nerve Entrapments: Clinical Diagnosis and Management, DOI 10.1007/978-3-319-27482-9_76
- ā Bauones, S., Feger, J. Baxter neuropathy. Reference article, Radiopaedia.org. (accessed on 15 Apr 2022) https://doi.org/10.53347/rID-25994
- ā Baxter's nerve Sd. Procedure: corticosteroid injection & orthotics. Good result. @Dr_Ramon_Balius #MSKUltrasound pic.twitter.com/ED9RcmqJnz
Literature Review
Literature Review
- Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf
- Articles from all years: PubMed search, Google Scholar search.
- TRIP Database: clinical publications about evidence-based medicine.
- Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,
