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reliability of the first-few-steps-in-the-morning test

Posted by elliott on 7/18/01 at 09:09 (053568)

Hi, everyone! I hang out in the TTS forum; this is my first post here.

I had a TTS release on my right foot two years ago, but, among other problems, still have heel pain that sounds like PF (feeling of stone bruise at tip of heel, something pulling at heel, discomfort more on the medial side, a cushioned shoe feels better than a hard one, etc.) and which may have contributed to the TTS. However, it is not necessarily the worst the first few steps in the morning. I'd say I feel it more 5 minutes after walking around, as well as after prolonged standing or walking. A cushioned shoe feels better than a hard one. I understand it should be worse first thing in the morning because the plantar fascia gets strained too suddenly and reinjured to some extent. Does this mean what I have is definitely not PF, or is that morning thing more a general PF rule that doesn't always hold? Thanks so much for your insights.

Re: reliability of the first-few-steps-in-the-morning test

Steve P on 7/18/01 at 15:02 (053596)

Hi Elliott --- I understand that the classic 'first steps in the morning' symptom is typical of PF but not universal, i.e. you can still have PF without having that particular symptom.

Better see your doc to be sure if you have PF.

Best...........Steve

Re: and how does the doc know for sure? (nm)

elliott on 7/18/01 at 15:05 (053597)

.

Re: and how does the doc know for sure? (nm)

nancy s. on 7/18/01 at 16:19 (053601)

hi elliott,
most likely, the doc will press hard on your heel at the exact plantar fascia insertion point (often referred to around here as 'The Spot') -- they know just where it is -- and if that sends you through the ceiling, you have pf.
nancy

Re: reliability of the first-few-steps-in-the-morning test

Carmen H on 7/18/01 at 16:32 (053605)

I don't have the pain until about 4-5 minutes after walking around either.
However this morning it took longer to have the pain....after the stretching exercises. I think they really made a difference in the morning. I don't getout of bed without doing them and in order to avoid 'middle of the night' trips I stopped drinking sooo much water before bed.

Re: reliability of the first-few-steps-in-the-morning test

Paula G. on 7/18/01 at 17:31 (053610)

I would say that there is no 100% symptom. Definitely get to a doctor. I had x-ray that proved I have heel spurs, but the PF was more or less diagnosed by what I complained my symptoms were. Like what you said about prolonged standing. That is the worst. I also had an MRI that showed 'normal'...but I knew I did not FEEL normal and am not normal.
Gut feeling and symptoms are the true tests sometimes

Re: reliability of the first-few-steps-in-the-morning test

Jeff on 7/18/01 at hrmin (053616)

Paula, you're right. There's no 100% rule.
You know, some times medical terminology seems cumbersome and other times it's helpful. Post static dyskinesia. I think it's a medical term that hits the bulls eye in this case. Break it up and it means that you hurt when you first try to stand or walk. Could we call it PSD for short?
PSD is pretty common in PF when getting out of bed. But on ther other hand, some folks with PF exhibit PSD only as the day goes on. For instance, after a break at work or after sitting down for lunch.
The other consideration, Elliot, is a selective entrapement of the branch of the posterior tibial nerve that supplies the plantar aspect of the heel. It's not all that uncommon to see selective entrapements.
Jeff

Re: reliability of the first-few-steps-in-the-morning test

Julie on 7/19/01 at 02:23 (053664)

Hi Carmen

The reason the first-step pain is so painful (for those who have it) is that the feet have been relaxed and plantarflexed (pointed forwards) all night, so the calf muscles and Achilles Tendon have been contracted. When your feet hit the floor and you stand up, they're suddenly stretching out and exerting a tremendous pull on the fascia. That pain means that the fascia is being re-injured, and that's why it's important to do simple foot exercises before getting out of bed: you're helping to avoid re-injury as well as sparing yourself that intense pain.

I'm glad the exercises are helping you. Try doing them frequently, whenever you think of it, throughout the day, and especially after periods of sitting - from which getting up is the same scenario (though not quite as bad because the contraction hasn't been going on for so long).

Re: and does everyone's "Spot" go through the ceiling? (nm)

elliott on 7/19/01 at 09:40 (053703)

.

Re: any way to tell for sure?

elliott on 7/19/01 at 09:44 (053704)

that is, whether it's 1) PF, 2) medial calcaneal nerve entrapment, or 3) both? Thanks (you and everyone else).

Re: and does everyone's "Spot" go through the ceiling? (nm)

nancy s. on 7/19/01 at 10:16 (053711)

hi elliott,
my understanding from the several doctors i went to until i found a good one for me was that if you don't have pf, pressing on that spot will not hurt at all. if it DOES hurt (usually a lot), you do have pf. however, if it doesn't hurt, it doesn't necessarily mean that you don't have pf -- but i believe it does hurt for the majority of pf'ers. sorry if i wasn't clearer about this in my too-short earlier post!
nancy

Re: and does everyone's "Spot" go through the ceiling? (nm)

john h on 7/20/01 at 11:00 (053819)

i can on occasion find a spot that is very sensitive but at other times i cannot. the doctor is better at finding it since he can dorsifex your foot and get better leverage to press. i also on occasion can feel a small nodule in this area but not always.

Re: "Spot" through the ceiling?

Glenn X on 7/20/01 at hrmin (053827)

This is really curious: I've had PF 3-plus years and have never been able to find a 'sore spot' where, pushing or poking at the bottom of my foot, I feel pain. Doctors haven't, even a massage therapist, who knows how to dig in there, hasn't. My PF right foot is no more tender to the touch or prod than my non-PF left. Yet when I stand and try to walk unaided across a room, I can't make it. I feel a distinct and painful 'pull' right where the classic PF sweet spot is.

Re: any way to tell for sure?

Jeff on 7/20/01 at hrmin (053843)

Elliot,
You know, I guess if you look at medicine as an art, there's some Picassos and there's a bunch of regular Joes out there. What I mean to say is that no, there is no way to tell for sure other than clinical interpretation of your symptoms and that's where the art comes into play. Once you start to treat the symptoms, you'll see a response. From there you learn what helps, and what doesn't, right?
There is one recent advance though. Recently, I traveled to Johns Hopkins to evaluate a new tool called quantitative sensory testing(QST). QST was developed by Lee Dellon, MD in the Baltimore area. Lee's a plastic surgeon with a sub-specialty of peripheral nerve surgery. Here's what QST is all about.
Neural sensation travels in three major spinal tracts, temperature/pain, vibration and soft touch. Each of these tracts are lost at varying rates with diferent types of nerve damage, meaning to say that diabetic neuropathy will be diferent from compression neuropathy such as TTS. That's why diabetics loose a sense of touch but can still feel pain. Dellon noted that with compression neuropathy, such as TTS, the first sensation to be lost is light touch. So, he developed a QST device that can be very helpful in differentiating between PF and TTS.
QST is very new and very costly. It's significantly more accurate than EMG or NCV studies.
I tried their web site at http://www.sensorymanagement.com but it wasn't active today for some reason. You might try later if your're interested in contacting them.
Jeff

Re: QST significantly more accurate? Beg to differ.

elliott on 7/22/01 at 11:48 (053965)

Many months after getting a positive TTS reading on my left foot on the standard NCV/EMG, I got tested by QST, and the results were completely negative (i.e. suggesting normality). A TTS giant who ended up operating on my left foot found the largest vein pressing on my nerve he had ever seen in his career in connection with TTS. So the TTS diagnosis was confirmed surgically, and QST missed it, despite NCV/EMG detecting it much earlier. And I think I know why. QST detects self-perceived sensory loss. But if your condition is such that at the time of testing, the symptoms of sensory loss on your outer skin (e.g. numbness, burning tingling, etc.) have calmed down (as is common for a runner with a long injury layoff; just about any runner who has had TTS knows that), QST might very well test normal, as it did for me, whereas the standard NCV can still detect entrapment because it is still detecting the slowed nerve conduction.

Sure, QST has some uses, e.g. NCV is not really able to reliably test for entrapment in the medial calcaneal nerve, whereas QST can, and QST is painless to boot, but my feeling, along with much of the medical community, is that QST is still somewhat experimental, has the added potential for error due to being patient-driven, and, at least based on my experience, is not exactly near the 100% accuracy in avoiding false negatives as the research articles of its proponents suggest.

Re: QST significantly more accurate? Beg to differ.

Donna SL on 7/22/01 at 17:14 (053980)

Hi Elliott,

I'm just curious. Did you also have an MRI, in addition to the standard NVC/EMG? If so, I'm assuming it was a varicose vein, and was wondering if it showed up on the MRI, or was it not found until you had the surgery? If you didn't have an MRI did your doctor say it would have shown up on a MRI?

I had a positive NCV/EMG, in the lateral plantar nerve, and one of the branches (baxters nerve, or also called the inferior calcaneal nerve). The medial plantar nerves appeared normal on the motor part of the test, but had no repsonse along with the lateral nerves on the mixed sensory potentials. This was in both feet, but the MRI was normal. I was then diagnosed with TTS. I had further testing on my back, and some disc problems were found, but I was told the positive EMG/NCV in my feet is probably a seperate problem directly related to foot trauma. They never mentioned the possibility of a vein pressing on the area, and I was wondering if surgery is the only way to find that out?

I've had a huge reduction in symptoms from conservative treatments (close to 90% at times), but don't feel totally cured yet. From what I've read if you have something like a vein occupying the TT area, vs some type of scar tissue from injury, surgery if definitly needed.

Donna

Re: "Spot" through the ceiling?

john h on 7/23/01 at 09:22 (054010)

glenn: i have always been curious as to why one can have difficulty finding a painful 'spot' from a disease than create havoc with your feet when standing. this would clearly lead you to believe that the pressure created by standing is not causing pressure on a nerve. it would not rule out a blood vessel enlarging as blood flows to the feet thereby causing pressure on a nerve. it would not rule out stretching/tension on the fascia caused by standing and thereby causing pain. i think most of us find relief when not standing although some do report pain when laying down. this could of course be pain caused by excessive stressing of the fascia with the resulting residual pain when off your feet. i am starting to think that repetitive tearing of the fascia over a long period of time makes if difficult if not near impossible for the fascia to heal. the resulting weak fascia will always be subject to tearing. sort of like a surgically repaired back or knee it is never as good as it was and as in surgery sometimes worse.

Re: Fascia Pain

Glenn X on 7/23/01 at hrmin (054036)

John: I'm with you. My pain happens when up on my feet. Not when resting, not when poking. I'm almost certain it comes from longitudinal tightness in the fascia. My fascia is no longer strong enough to contain the tension. Equally important, my other foot parts, particularly foot muscles, are now so weakened from lack of use, they can't help.

My rudimentary plan at this point is to obsessively rest the fascia, let it heal AGAIN, eliminate factors that might place undue stress on the fascia when I start testing it in a few weeks or months (flexibility, tape, and arch support), and strengthen my foot, toe and lower leg muscles as best I can so they can reinforce the work of the fascia. All the while continuing my research.

Plan feels good, and was enabled by this website and all it's many contributing experts. What good fortune stumbling on this place was.

I think too that more recovery is possible than my current circumstances seem to suggest. Even broken bones continue healing and strengthening for a year or more after we regain their use ... provided we allow them to.

I'm not expecting to play volleyball again, but I am expecting to be able to participate in active life activities. It just may take a couple of years to get there.

Re: Fascia Pain

john h on 7/23/01 at 14:24 (054038)

glenn: i have been trying to rest my fascia but i guess mowing the yard this week would not qualify as resting the fascia. i am to hyperactive and my life has been about sports all my life including compulsive running. iguess it pays not to put all your life in one basket.

as to rest, without confining yourself to bed if you have bi-laterial pf, how do you really rest your fascia without becoming an invalid? it would appear that the simple process of just standing on your feet would put tension on damaged fascia thereby causing repetative damage. how much rest would one need for the damaged fascia to allow routine standing and movement without redamaging the fascia? i see post of many people who wore a cast for months only to be worse when they got out of the cast. Barb has been on crutches for sometime so her foot must be getting some rest and if the fascia is her problem it should be healing. sometimes i think i understand PF and then someone post something that refutes all my high powered thinking. some people who seemed to have a bad case of PF have disappeared from the board and seem to be cured or at least back to a normal life. Yoko comes to mind. the last time i communicated with her some months ago whe was back to running. my current routine is (1) taping with two strips of leuko tape (2) ice 2 or 3 times a day (3) wear birk sandals or New Balance 853 x-trainers with a semi flex orthotic (4) ride a stationary bike and do some light weights and non weight bearing stretching primarly for my back and legs (5) take a pain pill ever once in a while but they really do not help. I think i should take up yoga and have made a visit to some yoga classes but have not yet made the necessary commitment. when i depart this life i plan to leave my feet to one the doctors on this board in hopes that they can take a look at my fascia and see what in the devil is wrong with it! you would think under a microscope a pathologist should be able to see what the problem is. why has this not been done and why are there no medical publications on such findings?

Re: details

elliott on 7/23/01 at 16:23 (054047)

Yes, I had an MRI, no it didn't pick up any abnormalities, and I strongly doubt a varicose vein (which it was) would be detected as an abnormality. I think my vein is visible from the outside, epsecially when I stand with one foot on a chair and with the barefooted TTS foot to be observed on the ground. The vein is visible just under the ankle, intersecting with the course of the medial plantar nerve just forward of the ankle. If you suspect a varicose vein, you may want to try this look test, FWIW (of course, I didn't do so before my own surgery, but didn't know to). If you've reduced symptoms by a whopping 90%, I'd think twice or many more times about the need for surgery, regardless of culprit, especially after what you've read on these forums. As my surgical results were not perfect, I am currently trying a prescription compression sock to see if that helps with the vein as it relates to the nerve. If it does, I'll post about it later.

I too ended up with disc problems (bulging L4-L5), giving me sciatica running down one leg (the other leg, that is; I had TTS in both feet, and it's a long story) Exactly when I first got that is unclear. Neurosurgeon thinks it's unrelated to TTS. But if there is a common connection, I'd like to know more about that. My theory was that walking unevenly due to TTS pain or even more likely the post-surgical pain and weakness led to the bulging disc, but who knows? Not we're not talking about the case where a patient describes the pain in his foot which is radiating from the back but fails to mention to the doc that it's coming from the back and doc performs unnecessary TTS release. I can clearly distinguish between the localized, peripheral TTS problem and that originating from the back. If you find out anything more about the relationship between TTS and discs other than the case of mistaken identity, please let me know.

Re: Resting the Fascia

Glenn X on 7/23/01 at hrmin (054060)

John: Not sure what bi-lateral PF is. One of the most encouraging messages I read on this site was from Scott in his book. Rest finally got him back on track. And it sounded like he was eventually relentless about it.

I'm on crutches not just to rest my fascia but because I can't walk across a room without them. But what I haven't done so far is wait beyond the point where I can venture a few steps without them. I've always been too impatient. I need to crutch well past the time I can take steps and keep resting it . . . and strengthen the foot muscles.

I like your plan. I'll stick mine on the site tomorrow. I've been giving it some thought, particularly as it fits into a 'strategy.'

I too get no benefit from pain pills.

If it ain't the fascia, what might it be?

Re: Healing the torn fascia

Julie on 7/24/01 at 01:15 (054079)

I agree with your analysis, John, and this is precisely why, and how, taping helps: by preventing all that re-tearing. What leapt out at me when I first read the heel pain book was Scott's explanation of taping as RESTING. If rest is what the injured fascia needs, and if taping really does rest the fascia, then, if I taped, I could continue walking when I had to and still be resting and still be healing. The logic of it seemed beautiful to me, and that's how I became a devotee of taping. I'm quite sure that it was the crucial factor for me, and it worked.

So I'm glad that after all your years of pain you're giving it a go, and I hope it works for you too.

And Glenn - I'm glad for you too! I feel sure you're on the right track. Yes: it IS important to maintain and improve strength throughout the musculature of the feet. I think you said you were trying the toe, foot and ankle exercises I described in my post to Rudy. (See my later post to Carmen with the entire series of exercises that work on all the joints: you'll be able to do all of them sitting down.)

Your good attitude is an inspiration to everyone here. Please keep posting!

Re: Healing the torn fascia

Julie on 7/24/01 at 02:42 (054086)

PS - Glenn, I know you use crutches. I think the exercises for the fingers and wrists may be particularly helpful to you.

Re: Resting the Fascia

john h on 7/24/01 at 08:52 (054105)

glenn: bi-laterial pf is pf in both feet. crutches no help here! interesting how many people develop bi-laterial pf? i cannot remember exactly when i developed pf in 2nd foot. it may have been months apart or weeks apart. if i were to guess how many hours i am actually on my feet each day doing something i would guess 5-6 hours. if scott reads this i wonder how much time he was on his feet each day when he was in his rest mode? i do remember when i had surgery on my left foot and was on crutches for about 2 weeks that the first few days off the crutches my foot felt great. about 3-4 days later back to pre op conditions.

Re: Butting in....

Carmen H on 7/24/01 at 11:25 (054127)

Hi John and Glenn.....May I butt in? I too am wondering HOW MUCH REST is required for the Fascia to heal? And what could it be if it's not that? I work at a desk all day and only walk tothe mail box and to take the dog out. Other then that....not a wholelot of activity. BUT my feet feel no different AT ALL. In other words I feel like I am getting plenty of rest for both Fascia but nothing seems to get better. The minute I stand up it take about 2 minutes and i am hurting again. I also tried to do upper body work (without doing free weights b/c that requires carrying or holding weight and that hurts feet) but find I am in worse pain after. Even though most of my work is sitting....if not laying. I have read a lot of statements about further damaging the feet if putin a cast. That this is not good for the muscles. So all of this information is overwhelming me as well. I go to a foot specialist August 1st. i am taking my notes and my journal and actually getting the time with him I pay for if it kills me!

Re: any way to tell for sure?

footpro on 8/04/01 at 00:05 (055401)

Actually, it's not an entrapment of the medial calcaneal nerve. The nerve affected is the 1st branch of the lateral plantar nerve (Baxter's Nerve). There is a test for this and it is accomplished by squeezing both sides of the heel. Pain will be elicited on the medial aspect of the heel (inside portion of the heel). Also, pain with Baxter's neuritis is more typically pronounced after standing or walking. In addition, there can be a component of plantar fasciitis involved as well. There is an excellent article on this by Alan Banks in the Journal of the American Podiatric Medical Association. I have cut and pasted the article in its entirety with exception of the figures (pictures).

Analysis of Release of the First Branch of the
Lateral Plantar Nerve

JAPMA VOLUME 90 / NUMBER 6 / JUNE 2000

Robert M. Goecker, DPM*
Alan S. Banks, DPM†

*Submitted during third-year residency, Northlake Regional Medical Center, Tucker, GA. Mailing address:1961 Floyd St, Ste C, Sarasota, FL 34239.

† Member, The Podiatry Institute, Tucker, GA; Director of Residency Training, Northlake Regional Medical Center, Tucker, GA.

--------------------------------------------------------------------------------

The authors conducted a retrospective study of the release of the first branch of the lateral plantar nerve in the treatment of chronic heel pain unrelieved by conservative treatment modalities. A total of 17 patients (18 feet) were evaluated following external neurolysis for heel pain caused by entrapment of the first branch of the lateral plantar nerve. The average postoperative follow-up time was 32.8 months, with a range of 10 to 72 months. Every patient deemed the surgery successful. At the time of follow-up examination, nine feet were asymptomatic and nine feet experienced mild pain after extended activity. There was one postoperative complication, medial calcaneal nerve entrapment; it was successfully treated with neurectomy. (J Am Podiatr Med Assoc 90(6): 281-286, 2000)

--------------------------------------------------------------------------------

Plantar heel pain is usually attributed to plantar fasciitis or heel spur syndrome. In certain individuals, however, a different entity can produce similar pain and symptoms. Several authors have described a neurogenic source of heel pain: entrapment of the first branch of the lateral plantar nerve.1-12

The first branch of the lateral plantar nerve is a mixed nerve with both motor and sensory fibers. Muscles supplied by this nerve include the abductor digiti minimi, flexor digitorum brevis, and quadratus plantae. Sensory fibers supply the calcaneal periosteum, the long plantar ligament, and the skin at the plantar lateral aspect of the foot. This branch originates from the lateral plantar nerve proximal to the abductor hallucis and then dives through the fascia at the superior margin of the abductor. The nerve courses distally between the abductor hallucis muscle and the medial edge of the quadratus plantae until it reaches the inferior margin of the abductor fascia. There it turns laterally between the flexor digitorum brevis and the quadratus plantae.1 The nerve at this point lies adjacent to the calcaneus approximately 0.5 cm distal to the medial tubercle of the calcaneus.2, 3 Failure of traditional heel spur surgery may be due to damage and subsequent entrapment of the first branch of the lateral plantar nerve or an inadequate release of a primary neurogenic source of heel pain. Obviously, the nerve is not released through the traditional open heel spur surgical approach. This nerve branch should not be confused with the medial calcaneal nerve, a purely sensory nerve that lies in the superficial fascia of the heel.4, 5

In 1963, Tanz6 proposed the first branch of the lateral plantar nerve as an overlooked source of plantar heel pain, and he demonstrated the nerve's anatomy from cadaveric dissection. However, it was not until 1981 that Przylucki and Jones3 correlated actual patient symptoms with this structure. Their surgical treatment for this condition consisted of excision of the nerve. Subsequently, other authors reported successful treatment of this type of chronic heel pain with external neurolysis rather than nerve excision.1, 4, 5, 7, 8, 10-12

Baxter and Thigpen7 in 1984 described two possible sites of entrapment. The first is the sharp fascial edge of the abductor hallucis muscle where the nerve changes course and turns laterally. Another possible site is the medial ridge of the calcaneus where the nerve passes beneath the tuberosity and origin of the flexor digitorum brevis and the plantar fascia. Therefore, nerve impingement may be caused by an increase in mass, such as a calcaneal spur, within the flexor digitorum brevis. Rondhuis and Huson13 concluded that the exact site of the entrapment is where the nerve passes between the taut deep fascia of the abductor hallucis muscle and the medial caudal margin of the medial head of the quadratus plantae muscle (Fig. 1). Pronation, muscle hypertrophy, or other sources of irritation have been cited as instigating events that may irritate the nerve as it passes through the fascial port of the abductor hallucis.

Patients with heel pain secondary to nerve entrapment may present with slightly different symptoms than individuals suffering from plantar fasciitis. In the former condition, the pain is usually not as great in the morning or after periods of rest, but seems to be more pronounced after activity. Przylucki and Jones3 noted that compression of the first branch of the lateral plantar nerve may occur by physiologic motion secondary to pronatory forces. As the foot is pronating, the tension of the fascial structures increases, resulting in compression of the nerve. This suggests that the nerve compression may be not only static (constant) but also dynamic and can worsen with pathologic gait patterns.

However, in some patients a history more similar to that associated with plantar fasciitis may be described. Chronic inflammation of the plantar fascia may coexist with, and possibly predispose to, entrapment of the first branch of the lateral plantar nerve.4, 5 Therefore, the patient may initially have some component of plantar medial heel pain as well. In such cases, the plantar fascial symptoms will tend to respond to the conservative modalities, but the symptoms related to the nerve entrapment may tend to persist. In some instances, the patient may complain of pain radiating toward the lateral aspect of the heel following the normal anatomical course of the nerve. There may be associated motor weakness of the abductor digiti minimi indicated by the patient's inability to abduct the fifth toe (Fig. 2). Abduction of the fifth toe may be a difficult task for many people to perform, but in some individuals with this entrapment, a difference may be observed between the symptomatic and asymptomatic sides.

Regardless of the history, the diagnosis of entrapment of the first branch of the lateral plantar nerve may be made during the clinical examination. The exact source of the patient's symptoms may be determined by careful palpation of the plantar aspect of the heel. Clinically, the pathognomonic sign of this entity is greater pain with compression over the medial aspect of the heel than plantarly (Fig. 3). Hendrix et al8 labeled this test the nerve compression test. Palpation in this region pinches the nerve between the deep fascia of the abductor hallucis and medial caudal margin of the quadratus plantae, resulting in pain and possible paresthesia.1 Hendrix et al8 have also found that plantarflexion and inversion of the foot (Phalen's maneuver) may be helpful in diagnosing entrapment of the terminal branches of the tarsal tunnel, including the first branch of the lateral plantar nerve. This movement reduces the width of the porta pedis and causes the superior margin of the abductor hallucis to compress the nerve, producing nerve impingement signs and symptoms. The nerve is also felt to be compressed at the exit site of the fascia between the abductor and flexor brevis.4, 5

The role of other diagnostic tests, such as electromyography and nerve conduction velocities, has been described by Schon et al.9 They found electrophysiologic abnormalities in 23 of 38 symptomatic heels, although careful review reveals that abnormalities in the lateral plantar nerve were found in only 7 patients (16%). It is also worth noting that the first branch of the lateral plantar nerve is technically difficult to isolate. It must therefore be emphasized that diagnostic tests are not a substitute for good clinical evaluation. If one does not trust a clinical diagnosis of nerve entrapment, technetium bone scans and magnetic resonance imaging (MRI) evaluations can be used to rule out an inflammatory source of heel pain. In the first few cases evaluated by the authors, patients underwent technetium bone scans and MRI evaluations, both of which failed to demonstrate inflammatory change in the heel area. This suggests that in these patients the pain is more consistent with nerve entrapment. Therefore, simple release of the plantar fascia will have limited effects on the symptoms.

The purpose of this article is to report on the success and long-term efficacy of release of the first branch of the lateral plantar nerve in those patients who failed to respond to conservative treatment modalities.

Materials and Methods

A total of 17 patients (18 feet) with painful medial heel pain were first treated with conservative modalities, such as padding, strapping, orthoses, various forms of immobilization, cortisone injections, and diagnostic nerve blocks. All patients had received extensive conservative treatment. Some of the patients had received conservative care by other physicians prior to surgical intervention by the authors. Anyone with prior heel surgery was excluded from the study. In each of these cases, the diagnosis of nerve entrapment was based on a positive clinical history and physical diagnostic findings consistent with entrapment of the first branch of the lateral plantar nerve. No other diagnostic modalities are necessary or routinely used by the authors for this condition. Surgery was elected in recalcitrant cases. The surgeries included in the study were performed over a 5-year period. All patients' charts were reviewed, and each patient was evaluated by means of a follow-up examination or a telephone interview. The outcome of the procedures was assessed by means of a questionnaire (Fig. 4).

The surgical technique that was used consists of an oblique incision made over the medial aspect of the heel overlying the course of the first branch of the lateral plantar nerve. The distal extent of the incision ends just beyond the junction of the calcaneal tuber and the plantar fascia. When the incision is oriented in this manner, it remains relatively parallel to the branches of the medial calcaneal nerve; this creates less potential for postoperative entrapment of these structures (Fig. 5).

Dissection is carried through the subcutaneous tissue until the deep fascia over the abductor hallucis can be identified. The superficial fascia is then bluntly separated anteriorly and posteriorly so that the abductor fascia may be clearly visualized. A carefully controlled inverted T-incision is then made, with the horizontal component of the T beginning at the inferior margin of the deep fascia overlying the abductor hallucis muscle. The vertical incision is then made extending proximally from the middle of the horizontal arm to the superior aspect of the abductor hallucis muscle belly. The muscle belly of the abductor is freed from the fascia at the superior margin and retracted inferiorly, exposing the fascia separating the abductor hallucis from the quadratus plantae. A vertical incision is then made through this deeper fascial layer, and a segment of tissue is removed. This should eliminate any constriction of the first branch of the lateral plantar nerve. As the nerve may also be compressed at the inferior edge of the abductor muscle, this fascia deep to the abductor hallucis muscle belly is vertically sectioned as far inferiorly as possible. The abductor muscle is retracted superiorly, and any remaining intermuscular fascia between the abductor and flexor digitorum brevis is sectioned. This circumferentially releases the fascia around the abductor hallucis muscle belly.

Next, a small portion (approximately one-quarter) of the medial aspect of the plantar fascia is sectioned to completely free the abductor hallucis and eliminate any potential irritation at this level. However, the windlass effect of the plantar fascia is maintained. Sometimes, if it is deemed necessary, an inferior calcaneal spur is gently removed with hand instruments. A Freer elevator is usually placed over the spur to prevent damage to the soft tissues and nerve at this level.

Following surgery, the patient is kept nonweightbearing for 3 weeks. A cast or posterior splint, as opposed to a soft bandage alone, has worked well. It is felt that maintaining the foot in a neutral position prevents coaptation of the incised fascial tissues.

Orthotic support is reinstituted following surgery, especially in patients in whom the plantar fascia is partially sectioned. The loss of support of the plantar fascia results in greater weightbearing forces in the midfoot and the lateral column. Pain or discomfort in this region was noted postoperatively, despite significant improvement in the heel. This generalized cramping, achiness, and midfoot pain tends to resolve over time and is effectively treated with biomechanical support.

Results

Seventeen patients (18 feet) who had undergone release of the first branch of the lateral plantar nerve using the previously described technique were available for follow-up clinical or telephone evaluation. The average duration of heel pain prior to surgery was 21.2 months, with a range of 6 to 120 months. The time elapsed since surgery ranged from 10 to 72 months, with an average postoperative follow-up time of 32.8 months. Every patient deemed the surgery successful. On a pain scale of 0 to 4, all patients were asked to rate their pain both preoperatively and postoperatively (Table 1). At the time of follow-up examination, nine feet were asymptomatic and nine feet experienced mild pain after extended activity.

Re: Thanks footpro Re: any way to tell for sure?

Donna SL on 8/04/01 at 10:48 (055438)

Footpro,

Thanks so much for taking the time to reproduce that article, and also mentioning the on-line version of JAPMA. I didn't know it existed. I appreciate any info on this subject. There seems to be lot of other good foot articles also in JAPMA.

I went un-diagnosed with lateral plantar nerve entrapment, and also the first branch (aka the inferior calcaneal nerve, or Baxter's nerve) in both feet for over a 1 1/2 years. Finally after a third opinion where one podiatrist performed the proper manual exam, and listened to my symptoms diagnosed the entrapments. This was then further confirmed with a follow-up nerve conduction test. The confirming doctor still referred to it as TTS.

So far, most of the time I've had close to 80%-90% relief of symptoms from conservative treatments (ART, acupunture, meds, etc.) which I'm still receiving. There's also an article in Podiatry today that talks about Baxter's neuritis, how to identify it, and various methods of treatments.

http://www.podiatrytoday.com/archive/pod_200010/pod_200010f1.htm

I won't know for a while if the entrapment is totally gone, because the nerves were at the stage of demylination by the time this was discovered. Until the nerves heal completly I won't be able to measure complete success with a NCV test. I can move all my toes now, which were totally paralyzed at one time. I'm keeping my fingers crossed the conservative methods are permanent, because I don't want to have surgery.

I thought I had read in the past that Baxter himself, and his associate only claimed around a 44% success rate with surgery in this area, unless they are now using a newer method.

It's just so unfortunate that this gets mis-diagnosed so often. I had tremendous pain, yet several doctors never bothered to do the squeeze test, and only tapped the tarsal tunnel area higher up on the ankle. They kept saying since I don't have a positive tinnel sign in that area that the source of the pain, burning, etc. in my feet, and heels wasn't related to any nerve problems. My only diagnosis was PF. I even brought the Podiatry Today article to the doctor treating me at the time to show him how to examine me for this, because I started to suspect nerve involvement, and he just brushed the article aside.

Donna

Re: Thanks footpro Re: any way to tell for sure?

john h on 8/04/01 at 11:42 (055450)

i had my surgery performed by a surgeon who trained under dr. baxter. the Baxter surgical procedure for PF is not the same procedure used by most Podiatrist and Most Orthopedic Surgeons. The Baxter procedure removes a half moon shaped piece of the fascia approximately 1/2' in width where the fascia attaches to the heel on the inside portion of the foot. This does remove some of the tension on the fascia but you do not have nearly as many problems with people being worse after than before surgery. Dr. Baxter suggest the section of fascia he removes (which is over the Baxter nerve) takes pressure off of the nerve. I do not remember for sure but i think he claims a success rate exceeding 70%. I do know he performed the procedure on Carl Lewis the olympic sprinter and Mr. Lewis returned to his world class running. I had a TTS release at the same time and the surgeon said there was a large vericose vein against the nerve but he did not know if moving it/removing it (cannnot remember) was the problem. I have always assumed that Baxter's Neuritis was an inflamation of this nerve where it runs under the fascia? it has been 2 + years since my surgery and i may be a little better but still running at a pain level of 1-3 depending on how much i do. the reason i chose this procedure is that was significantly less chance of having worse pain after than before surgery. we have two doctors in our city who trained under dr baxter in Houston.

Re: reliability of the first-few-steps-in-the-morning test

Steve P on 7/18/01 at 15:02 (053596)

Hi Elliott --- I understand that the classic 'first steps in the morning' symptom is typical of PF but not universal, i.e. you can still have PF without having that particular symptom.

Better see your doc to be sure if you have PF.

Best...........Steve

Re: and how does the doc know for sure? (nm)

elliott on 7/18/01 at 15:05 (053597)

.

Re: and how does the doc know for sure? (nm)

nancy s. on 7/18/01 at 16:19 (053601)

hi elliott,
most likely, the doc will press hard on your heel at the exact plantar fascia insertion point (often referred to around here as 'The Spot') -- they know just where it is -- and if that sends you through the ceiling, you have pf.
nancy

Re: reliability of the first-few-steps-in-the-morning test

Carmen H on 7/18/01 at 16:32 (053605)

I don't have the pain until about 4-5 minutes after walking around either.
However this morning it took longer to have the pain....after the stretching exercises. I think they really made a difference in the morning. I don't getout of bed without doing them and in order to avoid 'middle of the night' trips I stopped drinking sooo much water before bed.

Re: reliability of the first-few-steps-in-the-morning test

Paula G. on 7/18/01 at 17:31 (053610)

I would say that there is no 100% symptom. Definitely get to a doctor. I had x-ray that proved I have heel spurs, but the PF was more or less diagnosed by what I complained my symptoms were. Like what you said about prolonged standing. That is the worst. I also had an MRI that showed 'normal'...but I knew I did not FEEL normal and am not normal.
Gut feeling and symptoms are the true tests sometimes

Re: reliability of the first-few-steps-in-the-morning test

Jeff on 7/18/01 at hrmin (053616)

Paula, you're right. There's no 100% rule.
You know, some times medical terminology seems cumbersome and other times it's helpful. Post static dyskinesia. I think it's a medical term that hits the bulls eye in this case. Break it up and it means that you hurt when you first try to stand or walk. Could we call it PSD for short?
PSD is pretty common in PF when getting out of bed. But on ther other hand, some folks with PF exhibit PSD only as the day goes on. For instance, after a break at work or after sitting down for lunch.
The other consideration, Elliot, is a selective entrapement of the branch of the posterior tibial nerve that supplies the plantar aspect of the heel. It's not all that uncommon to see selective entrapements.
Jeff

Re: reliability of the first-few-steps-in-the-morning test

Julie on 7/19/01 at 02:23 (053664)

Hi Carmen

The reason the first-step pain is so painful (for those who have it) is that the feet have been relaxed and plantarflexed (pointed forwards) all night, so the calf muscles and Achilles Tendon have been contracted. When your feet hit the floor and you stand up, they're suddenly stretching out and exerting a tremendous pull on the fascia. That pain means that the fascia is being re-injured, and that's why it's important to do simple foot exercises before getting out of bed: you're helping to avoid re-injury as well as sparing yourself that intense pain.

I'm glad the exercises are helping you. Try doing them frequently, whenever you think of it, throughout the day, and especially after periods of sitting - from which getting up is the same scenario (though not quite as bad because the contraction hasn't been going on for so long).

Re: and does everyone's "Spot" go through the ceiling? (nm)

elliott on 7/19/01 at 09:40 (053703)

.

Re: any way to tell for sure?

elliott on 7/19/01 at 09:44 (053704)

that is, whether it's 1) PF, 2) medial calcaneal nerve entrapment, or 3) both? Thanks (you and everyone else).

Re: and does everyone's "Spot" go through the ceiling? (nm)

nancy s. on 7/19/01 at 10:16 (053711)

hi elliott,
my understanding from the several doctors i went to until i found a good one for me was that if you don't have pf, pressing on that spot will not hurt at all. if it DOES hurt (usually a lot), you do have pf. however, if it doesn't hurt, it doesn't necessarily mean that you don't have pf -- but i believe it does hurt for the majority of pf'ers. sorry if i wasn't clearer about this in my too-short earlier post!
nancy

Re: and does everyone's "Spot" go through the ceiling? (nm)

john h on 7/20/01 at 11:00 (053819)

i can on occasion find a spot that is very sensitive but at other times i cannot. the doctor is better at finding it since he can dorsifex your foot and get better leverage to press. i also on occasion can feel a small nodule in this area but not always.

Re: "Spot" through the ceiling?

Glenn X on 7/20/01 at hrmin (053827)

This is really curious: I've had PF 3-plus years and have never been able to find a 'sore spot' where, pushing or poking at the bottom of my foot, I feel pain. Doctors haven't, even a massage therapist, who knows how to dig in there, hasn't. My PF right foot is no more tender to the touch or prod than my non-PF left. Yet when I stand and try to walk unaided across a room, I can't make it. I feel a distinct and painful 'pull' right where the classic PF sweet spot is.

Re: any way to tell for sure?

Jeff on 7/20/01 at hrmin (053843)

Elliot,
You know, I guess if you look at medicine as an art, there's some Picassos and there's a bunch of regular Joes out there. What I mean to say is that no, there is no way to tell for sure other than clinical interpretation of your symptoms and that's where the art comes into play. Once you start to treat the symptoms, you'll see a response. From there you learn what helps, and what doesn't, right?
There is one recent advance though. Recently, I traveled to Johns Hopkins to evaluate a new tool called quantitative sensory testing(QST). QST was developed by Lee Dellon, MD in the Baltimore area. Lee's a plastic surgeon with a sub-specialty of peripheral nerve surgery. Here's what QST is all about.
Neural sensation travels in three major spinal tracts, temperature/pain, vibration and soft touch. Each of these tracts are lost at varying rates with diferent types of nerve damage, meaning to say that diabetic neuropathy will be diferent from compression neuropathy such as TTS. That's why diabetics loose a sense of touch but can still feel pain. Dellon noted that with compression neuropathy, such as TTS, the first sensation to be lost is light touch. So, he developed a QST device that can be very helpful in differentiating between PF and TTS.
QST is very new and very costly. It's significantly more accurate than EMG or NCV studies.
I tried their web site at http://www.sensorymanagement.com but it wasn't active today for some reason. You might try later if your're interested in contacting them.
Jeff

Re: QST significantly more accurate? Beg to differ.

elliott on 7/22/01 at 11:48 (053965)

Many months after getting a positive TTS reading on my left foot on the standard NCV/EMG, I got tested by QST, and the results were completely negative (i.e. suggesting normality). A TTS giant who ended up operating on my left foot found the largest vein pressing on my nerve he had ever seen in his career in connection with TTS. So the TTS diagnosis was confirmed surgically, and QST missed it, despite NCV/EMG detecting it much earlier. And I think I know why. QST detects self-perceived sensory loss. But if your condition is such that at the time of testing, the symptoms of sensory loss on your outer skin (e.g. numbness, burning tingling, etc.) have calmed down (as is common for a runner with a long injury layoff; just about any runner who has had TTS knows that), QST might very well test normal, as it did for me, whereas the standard NCV can still detect entrapment because it is still detecting the slowed nerve conduction.

Sure, QST has some uses, e.g. NCV is not really able to reliably test for entrapment in the medial calcaneal nerve, whereas QST can, and QST is painless to boot, but my feeling, along with much of the medical community, is that QST is still somewhat experimental, has the added potential for error due to being patient-driven, and, at least based on my experience, is not exactly near the 100% accuracy in avoiding false negatives as the research articles of its proponents suggest.

Re: QST significantly more accurate? Beg to differ.

Donna SL on 7/22/01 at 17:14 (053980)

Hi Elliott,

I'm just curious. Did you also have an MRI, in addition to the standard NVC/EMG? If so, I'm assuming it was a varicose vein, and was wondering if it showed up on the MRI, or was it not found until you had the surgery? If you didn't have an MRI did your doctor say it would have shown up on a MRI?

I had a positive NCV/EMG, in the lateral plantar nerve, and one of the branches (baxters nerve, or also called the inferior calcaneal nerve). The medial plantar nerves appeared normal on the motor part of the test, but had no repsonse along with the lateral nerves on the mixed sensory potentials. This was in both feet, but the MRI was normal. I was then diagnosed with TTS. I had further testing on my back, and some disc problems were found, but I was told the positive EMG/NCV in my feet is probably a seperate problem directly related to foot trauma. They never mentioned the possibility of a vein pressing on the area, and I was wondering if surgery is the only way to find that out?

I've had a huge reduction in symptoms from conservative treatments (close to 90% at times), but don't feel totally cured yet. From what I've read if you have something like a vein occupying the TT area, vs some type of scar tissue from injury, surgery if definitly needed.

Donna

Re: "Spot" through the ceiling?

john h on 7/23/01 at 09:22 (054010)

glenn: i have always been curious as to why one can have difficulty finding a painful 'spot' from a disease than create havoc with your feet when standing. this would clearly lead you to believe that the pressure created by standing is not causing pressure on a nerve. it would not rule out a blood vessel enlarging as blood flows to the feet thereby causing pressure on a nerve. it would not rule out stretching/tension on the fascia caused by standing and thereby causing pain. i think most of us find relief when not standing although some do report pain when laying down. this could of course be pain caused by excessive stressing of the fascia with the resulting residual pain when off your feet. i am starting to think that repetitive tearing of the fascia over a long period of time makes if difficult if not near impossible for the fascia to heal. the resulting weak fascia will always be subject to tearing. sort of like a surgically repaired back or knee it is never as good as it was and as in surgery sometimes worse.

Re: Fascia Pain

Glenn X on 7/23/01 at hrmin (054036)

John: I'm with you. My pain happens when up on my feet. Not when resting, not when poking. I'm almost certain it comes from longitudinal tightness in the fascia. My fascia is no longer strong enough to contain the tension. Equally important, my other foot parts, particularly foot muscles, are now so weakened from lack of use, they can't help.

My rudimentary plan at this point is to obsessively rest the fascia, let it heal AGAIN, eliminate factors that might place undue stress on the fascia when I start testing it in a few weeks or months (flexibility, tape, and arch support), and strengthen my foot, toe and lower leg muscles as best I can so they can reinforce the work of the fascia. All the while continuing my research.

Plan feels good, and was enabled by this website and all it's many contributing experts. What good fortune stumbling on this place was.

I think too that more recovery is possible than my current circumstances seem to suggest. Even broken bones continue healing and strengthening for a year or more after we regain their use ... provided we allow them to.

I'm not expecting to play volleyball again, but I am expecting to be able to participate in active life activities. It just may take a couple of years to get there.

Re: Fascia Pain

john h on 7/23/01 at 14:24 (054038)

glenn: i have been trying to rest my fascia but i guess mowing the yard this week would not qualify as resting the fascia. i am to hyperactive and my life has been about sports all my life including compulsive running. iguess it pays not to put all your life in one basket.

as to rest, without confining yourself to bed if you have bi-laterial pf, how do you really rest your fascia without becoming an invalid? it would appear that the simple process of just standing on your feet would put tension on damaged fascia thereby causing repetative damage. how much rest would one need for the damaged fascia to allow routine standing and movement without redamaging the fascia? i see post of many people who wore a cast for months only to be worse when they got out of the cast. Barb has been on crutches for sometime so her foot must be getting some rest and if the fascia is her problem it should be healing. sometimes i think i understand PF and then someone post something that refutes all my high powered thinking. some people who seemed to have a bad case of PF have disappeared from the board and seem to be cured or at least back to a normal life. Yoko comes to mind. the last time i communicated with her some months ago whe was back to running. my current routine is (1) taping with two strips of leuko tape (2) ice 2 or 3 times a day (3) wear birk sandals or New Balance 853 x-trainers with a semi flex orthotic (4) ride a stationary bike and do some light weights and non weight bearing stretching primarly for my back and legs (5) take a pain pill ever once in a while but they really do not help. I think i should take up yoga and have made a visit to some yoga classes but have not yet made the necessary commitment. when i depart this life i plan to leave my feet to one the doctors on this board in hopes that they can take a look at my fascia and see what in the devil is wrong with it! you would think under a microscope a pathologist should be able to see what the problem is. why has this not been done and why are there no medical publications on such findings?

Re: details

elliott on 7/23/01 at 16:23 (054047)

Yes, I had an MRI, no it didn't pick up any abnormalities, and I strongly doubt a varicose vein (which it was) would be detected as an abnormality. I think my vein is visible from the outside, epsecially when I stand with one foot on a chair and with the barefooted TTS foot to be observed on the ground. The vein is visible just under the ankle, intersecting with the course of the medial plantar nerve just forward of the ankle. If you suspect a varicose vein, you may want to try this look test, FWIW (of course, I didn't do so before my own surgery, but didn't know to). If you've reduced symptoms by a whopping 90%, I'd think twice or many more times about the need for surgery, regardless of culprit, especially after what you've read on these forums. As my surgical results were not perfect, I am currently trying a prescription compression sock to see if that helps with the vein as it relates to the nerve. If it does, I'll post about it later.

I too ended up with disc problems (bulging L4-L5), giving me sciatica running down one leg (the other leg, that is; I had TTS in both feet, and it's a long story) Exactly when I first got that is unclear. Neurosurgeon thinks it's unrelated to TTS. But if there is a common connection, I'd like to know more about that. My theory was that walking unevenly due to TTS pain or even more likely the post-surgical pain and weakness led to the bulging disc, but who knows? Not we're not talking about the case where a patient describes the pain in his foot which is radiating from the back but fails to mention to the doc that it's coming from the back and doc performs unnecessary TTS release. I can clearly distinguish between the localized, peripheral TTS problem and that originating from the back. If you find out anything more about the relationship between TTS and discs other than the case of mistaken identity, please let me know.

Re: Resting the Fascia

Glenn X on 7/23/01 at hrmin (054060)

John: Not sure what bi-lateral PF is. One of the most encouraging messages I read on this site was from Scott in his book. Rest finally got him back on track. And it sounded like he was eventually relentless about it.

I'm on crutches not just to rest my fascia but because I can't walk across a room without them. But what I haven't done so far is wait beyond the point where I can venture a few steps without them. I've always been too impatient. I need to crutch well past the time I can take steps and keep resting it . . . and strengthen the foot muscles.

I like your plan. I'll stick mine on the site tomorrow. I've been giving it some thought, particularly as it fits into a 'strategy.'

I too get no benefit from pain pills.

If it ain't the fascia, what might it be?

Re: Healing the torn fascia

Julie on 7/24/01 at 01:15 (054079)

I agree with your analysis, John, and this is precisely why, and how, taping helps: by preventing all that re-tearing. What leapt out at me when I first read the heel pain book was Scott's explanation of taping as RESTING. If rest is what the injured fascia needs, and if taping really does rest the fascia, then, if I taped, I could continue walking when I had to and still be resting and still be healing. The logic of it seemed beautiful to me, and that's how I became a devotee of taping. I'm quite sure that it was the crucial factor for me, and it worked.

So I'm glad that after all your years of pain you're giving it a go, and I hope it works for you too.

And Glenn - I'm glad for you too! I feel sure you're on the right track. Yes: it IS important to maintain and improve strength throughout the musculature of the feet. I think you said you were trying the toe, foot and ankle exercises I described in my post to Rudy. (See my later post to Carmen with the entire series of exercises that work on all the joints: you'll be able to do all of them sitting down.)

Your good attitude is an inspiration to everyone here. Please keep posting!

Re: Healing the torn fascia

Julie on 7/24/01 at 02:42 (054086)

PS - Glenn, I know you use crutches. I think the exercises for the fingers and wrists may be particularly helpful to you.

Re: Resting the Fascia

john h on 7/24/01 at 08:52 (054105)

glenn: bi-laterial pf is pf in both feet. crutches no help here! interesting how many people develop bi-laterial pf? i cannot remember exactly when i developed pf in 2nd foot. it may have been months apart or weeks apart. if i were to guess how many hours i am actually on my feet each day doing something i would guess 5-6 hours. if scott reads this i wonder how much time he was on his feet each day when he was in his rest mode? i do remember when i had surgery on my left foot and was on crutches for about 2 weeks that the first few days off the crutches my foot felt great. about 3-4 days later back to pre op conditions.

Re: Butting in....

Carmen H on 7/24/01 at 11:25 (054127)

Hi John and Glenn.....May I butt in? I too am wondering HOW MUCH REST is required for the Fascia to heal? And what could it be if it's not that? I work at a desk all day and only walk tothe mail box and to take the dog out. Other then that....not a wholelot of activity. BUT my feet feel no different AT ALL. In other words I feel like I am getting plenty of rest for both Fascia but nothing seems to get better. The minute I stand up it take about 2 minutes and i am hurting again. I also tried to do upper body work (without doing free weights b/c that requires carrying or holding weight and that hurts feet) but find I am in worse pain after. Even though most of my work is sitting....if not laying. I have read a lot of statements about further damaging the feet if putin a cast. That this is not good for the muscles. So all of this information is overwhelming me as well. I go to a foot specialist August 1st. i am taking my notes and my journal and actually getting the time with him I pay for if it kills me!

Re: any way to tell for sure?

footpro on 8/04/01 at 00:05 (055401)

Actually, it's not an entrapment of the medial calcaneal nerve. The nerve affected is the 1st branch of the lateral plantar nerve (Baxter's Nerve). There is a test for this and it is accomplished by squeezing both sides of the heel. Pain will be elicited on the medial aspect of the heel (inside portion of the heel). Also, pain with Baxter's neuritis is more typically pronounced after standing or walking. In addition, there can be a component of plantar fasciitis involved as well. There is an excellent article on this by Alan Banks in the Journal of the American Podiatric Medical Association. I have cut and pasted the article in its entirety with exception of the figures (pictures).

Analysis of Release of the First Branch of the
Lateral Plantar Nerve

JAPMA VOLUME 90 / NUMBER 6 / JUNE 2000

Robert M. Goecker, DPM*
Alan S. Banks, DPM†

*Submitted during third-year residency, Northlake Regional Medical Center, Tucker, GA. Mailing address:1961 Floyd St, Ste C, Sarasota, FL 34239.

† Member, The Podiatry Institute, Tucker, GA; Director of Residency Training, Northlake Regional Medical Center, Tucker, GA.

--------------------------------------------------------------------------------

The authors conducted a retrospective study of the release of the first branch of the lateral plantar nerve in the treatment of chronic heel pain unrelieved by conservative treatment modalities. A total of 17 patients (18 feet) were evaluated following external neurolysis for heel pain caused by entrapment of the first branch of the lateral plantar nerve. The average postoperative follow-up time was 32.8 months, with a range of 10 to 72 months. Every patient deemed the surgery successful. At the time of follow-up examination, nine feet were asymptomatic and nine feet experienced mild pain after extended activity. There was one postoperative complication, medial calcaneal nerve entrapment; it was successfully treated with neurectomy. (J Am Podiatr Med Assoc 90(6): 281-286, 2000)

--------------------------------------------------------------------------------

Plantar heel pain is usually attributed to plantar fasciitis or heel spur syndrome. In certain individuals, however, a different entity can produce similar pain and symptoms. Several authors have described a neurogenic source of heel pain: entrapment of the first branch of the lateral plantar nerve.1-12

The first branch of the lateral plantar nerve is a mixed nerve with both motor and sensory fibers. Muscles supplied by this nerve include the abductor digiti minimi, flexor digitorum brevis, and quadratus plantae. Sensory fibers supply the calcaneal periosteum, the long plantar ligament, and the skin at the plantar lateral aspect of the foot. This branch originates from the lateral plantar nerve proximal to the abductor hallucis and then dives through the fascia at the superior margin of the abductor. The nerve courses distally between the abductor hallucis muscle and the medial edge of the quadratus plantae until it reaches the inferior margin of the abductor fascia. There it turns laterally between the flexor digitorum brevis and the quadratus plantae.1 The nerve at this point lies adjacent to the calcaneus approximately 0.5 cm distal to the medial tubercle of the calcaneus.2, 3 Failure of traditional heel spur surgery may be due to damage and subsequent entrapment of the first branch of the lateral plantar nerve or an inadequate release of a primary neurogenic source of heel pain. Obviously, the nerve is not released through the traditional open heel spur surgical approach. This nerve branch should not be confused with the medial calcaneal nerve, a purely sensory nerve that lies in the superficial fascia of the heel.4, 5

In 1963, Tanz6 proposed the first branch of the lateral plantar nerve as an overlooked source of plantar heel pain, and he demonstrated the nerve's anatomy from cadaveric dissection. However, it was not until 1981 that Przylucki and Jones3 correlated actual patient symptoms with this structure. Their surgical treatment for this condition consisted of excision of the nerve. Subsequently, other authors reported successful treatment of this type of chronic heel pain with external neurolysis rather than nerve excision.1, 4, 5, 7, 8, 10-12

Baxter and Thigpen7 in 1984 described two possible sites of entrapment. The first is the sharp fascial edge of the abductor hallucis muscle where the nerve changes course and turns laterally. Another possible site is the medial ridge of the calcaneus where the nerve passes beneath the tuberosity and origin of the flexor digitorum brevis and the plantar fascia. Therefore, nerve impingement may be caused by an increase in mass, such as a calcaneal spur, within the flexor digitorum brevis. Rondhuis and Huson13 concluded that the exact site of the entrapment is where the nerve passes between the taut deep fascia of the abductor hallucis muscle and the medial caudal margin of the medial head of the quadratus plantae muscle (Fig. 1). Pronation, muscle hypertrophy, or other sources of irritation have been cited as instigating events that may irritate the nerve as it passes through the fascial port of the abductor hallucis.

Patients with heel pain secondary to nerve entrapment may present with slightly different symptoms than individuals suffering from plantar fasciitis. In the former condition, the pain is usually not as great in the morning or after periods of rest, but seems to be more pronounced after activity. Przylucki and Jones3 noted that compression of the first branch of the lateral plantar nerve may occur by physiologic motion secondary to pronatory forces. As the foot is pronating, the tension of the fascial structures increases, resulting in compression of the nerve. This suggests that the nerve compression may be not only static (constant) but also dynamic and can worsen with pathologic gait patterns.

However, in some patients a history more similar to that associated with plantar fasciitis may be described. Chronic inflammation of the plantar fascia may coexist with, and possibly predispose to, entrapment of the first branch of the lateral plantar nerve.4, 5 Therefore, the patient may initially have some component of plantar medial heel pain as well. In such cases, the plantar fascial symptoms will tend to respond to the conservative modalities, but the symptoms related to the nerve entrapment may tend to persist. In some instances, the patient may complain of pain radiating toward the lateral aspect of the heel following the normal anatomical course of the nerve. There may be associated motor weakness of the abductor digiti minimi indicated by the patient's inability to abduct the fifth toe (Fig. 2). Abduction of the fifth toe may be a difficult task for many people to perform, but in some individuals with this entrapment, a difference may be observed between the symptomatic and asymptomatic sides.

Regardless of the history, the diagnosis of entrapment of the first branch of the lateral plantar nerve may be made during the clinical examination. The exact source of the patient's symptoms may be determined by careful palpation of the plantar aspect of the heel. Clinically, the pathognomonic sign of this entity is greater pain with compression over the medial aspect of the heel than plantarly (Fig. 3). Hendrix et al8 labeled this test the nerve compression test. Palpation in this region pinches the nerve between the deep fascia of the abductor hallucis and medial caudal margin of the quadratus plantae, resulting in pain and possible paresthesia.1 Hendrix et al8 have also found that plantarflexion and inversion of the foot (Phalen's maneuver) may be helpful in diagnosing entrapment of the terminal branches of the tarsal tunnel, including the first branch of the lateral plantar nerve. This movement reduces the width of the porta pedis and causes the superior margin of the abductor hallucis to compress the nerve, producing nerve impingement signs and symptoms. The nerve is also felt to be compressed at the exit site of the fascia between the abductor and flexor brevis.4, 5

The role of other diagnostic tests, such as electromyography and nerve conduction velocities, has been described by Schon et al.9 They found electrophysiologic abnormalities in 23 of 38 symptomatic heels, although careful review reveals that abnormalities in the lateral plantar nerve were found in only 7 patients (16%). It is also worth noting that the first branch of the lateral plantar nerve is technically difficult to isolate. It must therefore be emphasized that diagnostic tests are not a substitute for good clinical evaluation. If one does not trust a clinical diagnosis of nerve entrapment, technetium bone scans and magnetic resonance imaging (MRI) evaluations can be used to rule out an inflammatory source of heel pain. In the first few cases evaluated by the authors, patients underwent technetium bone scans and MRI evaluations, both of which failed to demonstrate inflammatory change in the heel area. This suggests that in these patients the pain is more consistent with nerve entrapment. Therefore, simple release of the plantar fascia will have limited effects on the symptoms.

The purpose of this article is to report on the success and long-term efficacy of release of the first branch of the lateral plantar nerve in those patients who failed to respond to conservative treatment modalities.

Materials and Methods

A total of 17 patients (18 feet) with painful medial heel pain were first treated with conservative modalities, such as padding, strapping, orthoses, various forms of immobilization, cortisone injections, and diagnostic nerve blocks. All patients had received extensive conservative treatment. Some of the patients had received conservative care by other physicians prior to surgical intervention by the authors. Anyone with prior heel surgery was excluded from the study. In each of these cases, the diagnosis of nerve entrapment was based on a positive clinical history and physical diagnostic findings consistent with entrapment of the first branch of the lateral plantar nerve. No other diagnostic modalities are necessary or routinely used by the authors for this condition. Surgery was elected in recalcitrant cases. The surgeries included in the study were performed over a 5-year period. All patients' charts were reviewed, and each patient was evaluated by means of a follow-up examination or a telephone interview. The outcome of the procedures was assessed by means of a questionnaire (Fig. 4).

The surgical technique that was used consists of an oblique incision made over the medial aspect of the heel overlying the course of the first branch of the lateral plantar nerve. The distal extent of the incision ends just beyond the junction of the calcaneal tuber and the plantar fascia. When the incision is oriented in this manner, it remains relatively parallel to the branches of the medial calcaneal nerve; this creates less potential for postoperative entrapment of these structures (Fig. 5).

Dissection is carried through the subcutaneous tissue until the deep fascia over the abductor hallucis can be identified. The superficial fascia is then bluntly separated anteriorly and posteriorly so that the abductor fascia may be clearly visualized. A carefully controlled inverted T-incision is then made, with the horizontal component of the T beginning at the inferior margin of the deep fascia overlying the abductor hallucis muscle. The vertical incision is then made extending proximally from the middle of the horizontal arm to the superior aspect of the abductor hallucis muscle belly. The muscle belly of the abductor is freed from the fascia at the superior margin and retracted inferiorly, exposing the fascia separating the abductor hallucis from the quadratus plantae. A vertical incision is then made through this deeper fascial layer, and a segment of tissue is removed. This should eliminate any constriction of the first branch of the lateral plantar nerve. As the nerve may also be compressed at the inferior edge of the abductor muscle, this fascia deep to the abductor hallucis muscle belly is vertically sectioned as far inferiorly as possible. The abductor muscle is retracted superiorly, and any remaining intermuscular fascia between the abductor and flexor digitorum brevis is sectioned. This circumferentially releases the fascia around the abductor hallucis muscle belly.

Next, a small portion (approximately one-quarter) of the medial aspect of the plantar fascia is sectioned to completely free the abductor hallucis and eliminate any potential irritation at this level. However, the windlass effect of the plantar fascia is maintained. Sometimes, if it is deemed necessary, an inferior calcaneal spur is gently removed with hand instruments. A Freer elevator is usually placed over the spur to prevent damage to the soft tissues and nerve at this level.

Following surgery, the patient is kept nonweightbearing for 3 weeks. A cast or posterior splint, as opposed to a soft bandage alone, has worked well. It is felt that maintaining the foot in a neutral position prevents coaptation of the incised fascial tissues.

Orthotic support is reinstituted following surgery, especially in patients in whom the plantar fascia is partially sectioned. The loss of support of the plantar fascia results in greater weightbearing forces in the midfoot and the lateral column. Pain or discomfort in this region was noted postoperatively, despite significant improvement in the heel. This generalized cramping, achiness, and midfoot pain tends to resolve over time and is effectively treated with biomechanical support.

Results

Seventeen patients (18 feet) who had undergone release of the first branch of the lateral plantar nerve using the previously described technique were available for follow-up clinical or telephone evaluation. The average duration of heel pain prior to surgery was 21.2 months, with a range of 6 to 120 months. The time elapsed since surgery ranged from 10 to 72 months, with an average postoperative follow-up time of 32.8 months. Every patient deemed the surgery successful. On a pain scale of 0 to 4, all patients were asked to rate their pain both preoperatively and postoperatively (Table 1). At the time of follow-up examination, nine feet were asymptomatic and nine feet experienced mild pain after extended activity.

Re: Thanks footpro Re: any way to tell for sure?

Donna SL on 8/04/01 at 10:48 (055438)

Footpro,

Thanks so much for taking the time to reproduce that article, and also mentioning the on-line version of JAPMA. I didn't know it existed. I appreciate any info on this subject. There seems to be lot of other good foot articles also in JAPMA.

I went un-diagnosed with lateral plantar nerve entrapment, and also the first branch (aka the inferior calcaneal nerve, or Baxter's nerve) in both feet for over a 1 1/2 years. Finally after a third opinion where one podiatrist performed the proper manual exam, and listened to my symptoms diagnosed the entrapments. This was then further confirmed with a follow-up nerve conduction test. The confirming doctor still referred to it as TTS.

So far, most of the time I've had close to 80%-90% relief of symptoms from conservative treatments (ART, acupunture, meds, etc.) which I'm still receiving. There's also an article in Podiatry today that talks about Baxter's neuritis, how to identify it, and various methods of treatments.

http://www.podiatrytoday.com/archive/pod_200010/pod_200010f1.htm

I won't know for a while if the entrapment is totally gone, because the nerves were at the stage of demylination by the time this was discovered. Until the nerves heal completly I won't be able to measure complete success with a NCV test. I can move all my toes now, which were totally paralyzed at one time. I'm keeping my fingers crossed the conservative methods are permanent, because I don't want to have surgery.

I thought I had read in the past that Baxter himself, and his associate only claimed around a 44% success rate with surgery in this area, unless they are now using a newer method.

It's just so unfortunate that this gets mis-diagnosed so often. I had tremendous pain, yet several doctors never bothered to do the squeeze test, and only tapped the tarsal tunnel area higher up on the ankle. They kept saying since I don't have a positive tinnel sign in that area that the source of the pain, burning, etc. in my feet, and heels wasn't related to any nerve problems. My only diagnosis was PF. I even brought the Podiatry Today article to the doctor treating me at the time to show him how to examine me for this, because I started to suspect nerve involvement, and he just brushed the article aside.

Donna

Re: Thanks footpro Re: any way to tell for sure?

john h on 8/04/01 at 11:42 (055450)

i had my surgery performed by a surgeon who trained under dr. baxter. the Baxter surgical procedure for PF is not the same procedure used by most Podiatrist and Most Orthopedic Surgeons. The Baxter procedure removes a half moon shaped piece of the fascia approximately 1/2' in width where the fascia attaches to the heel on the inside portion of the foot. This does remove some of the tension on the fascia but you do not have nearly as many problems with people being worse after than before surgery. Dr. Baxter suggest the section of fascia he removes (which is over the Baxter nerve) takes pressure off of the nerve. I do not remember for sure but i think he claims a success rate exceeding 70%. I do know he performed the procedure on Carl Lewis the olympic sprinter and Mr. Lewis returned to his world class running. I had a TTS release at the same time and the surgeon said there was a large vericose vein against the nerve but he did not know if moving it/removing it (cannnot remember) was the problem. I have always assumed that Baxter's Neuritis was an inflamation of this nerve where it runs under the fascia? it has been 2 + years since my surgery and i may be a little better but still running at a pain level of 1-3 depending on how much i do. the reason i chose this procedure is that was significantly less chance of having worse pain after than before surgery. we have two doctors in our city who trained under dr baxter in Houston.