Home The Book Dr Articles Products Message Boards Journal Articles Search Our Surveys Surgery ESWT Dr Messages Find Good Drs video

baxters nerve

Posted by Amy on 4/02/05 at 15:43 (172442)

hi -

I have been told from a second doc that my fhl tenosynovitis isn't causing my problems, it is actually compression of baxters nerve - he wants to go in and release it. He states there is no conservative treatment for it.

I assume this is different than 'traditional' tts - the nerve conduction test I had were normal (he is sending me for another set - to test more specific areas). My question is, is this surgery any more successful than a normal tarsal tunnel release? And, are there any conservative measures to try?

Thanks -
Amy

Re: baxters nerve

Dr. Z on 4/02/05 at 16:36 (172447)

Hi
Have you any local steriod injections about this nerve? I believe the doctor is ordering a sensory nerve conduction testing. Lets see what the results tell you.

Re: baxters nerve

Amy on 4/02/05 at 18:09 (172453)

I have not had injections into this area exactly - I have had three injections (1 in one foot, two in the other - this is bilateral) to deal with the FHL tenosynovitis which did nothing, which does lead me to believe the pain is probably from the nerve entrapment and not the FHL. Is it advisable to have injections into the feet again provided the location is different?

The sensory nerve test will test nerves that the other nerve conduction test did not, I assume.

FYI - I am an extremely healthy 34 year old, was previously very active (running, triathlon, etc) No systemic conditions, etc. Does this make me in any way a better candidate for surgery - if it comes to that?

I appreciate the time the doctors, including yourself, devote to this great website! (although I'd like to see a few more of the 'success stories' post here....I suppose there is no need to come back if you feel better)

Amy

Re: baxters nerve

Julie on 4/03/05 at 01:14 (172475)

Amy, you said 'I suppose there is no need to come back if you feel better'. That's probably true for many people, but not for all. There are quite a few of us here who no longer suffer from whatever condition that brought us here in the first place, but have stuck around to encourage others by offering our experience and accumulated expertise. Suzanne, Carole, and I have long since recovered from PF; Wendy's TTS no longer gives her serious trouble; John has had both and is greatly improved (he is the only one of those I've mentioned who has had surgery). Elliott is another long-standing poster who has had surgery; he has recently had further surgery and may stick around afterwards to tell the tale, whatever it is. And there are others: not everyone disappears when no longer in need themselves.

Join us! If you are a surgical 'success story' - and I certainly hope you will be, but even if you aren't - stay, and share whatever you learn with the new people who arrive almost daily for help and support.

I know this isn't a priority for you right now: your energies are focused on getting better and getting back to doing the things you love doing. But maybe you will think about it afterwards - and stick around.

I wish you all the best.
.

Re: baxters nerve

Amy on 4/03/05 at 10:42 (172483)

I've been lurking for quite a while and occasionally posting. I do realize there are some success stories out there and I am encouraged by those who do post. I do, however, become extremely distressed about my situation when I read of those who have had horrible experiences and are disabled by their surgeries. I seem to see these posts more often than the positive posts -

You and the others offer valuable advice to all of us and this site is a godsend -

Amy

Re: baxters nerve

Ed Davis. DPM on 4/03/05 at 11:02 (172486)

Amy:
The act of releasing Baxter's nerve is also a partial plantar fascial release so we are unsure if any beneficial effect from the surgery is derived from the release of the fascia or decompression of Baxter's nerve.
Ed

Re: baxters nerve

Julie on 4/03/05 at 11:53 (172492)

Amy, I don't think you, or anyone, should make their decisions on the basis of anyone else's experience. I'm sure you wouldn't do that - but it follows that perhaps we shouldn't be freaked out by all the horror stories. There are some constants, of course, but ultimately all surgeries are different, all doctors are different, every set of circumstances is different and all individuals are different. The important things are (a) to do your resarch, (b) to be sure you have an accurate diagnosis before deciding to have surgery, however long that takes and however many opinions are needed, and (c) to trust the doctor who is going to do the surgery.

Probably the successful surgeries are the ones performed for the right reason, on the right person, by the right doctor, at the right time.

If I understand you correctly, you've had two opinions and they disagree, so perhaps the next step is a third opinion.
.

Re: baxters nerve

Amy on 4/03/05 at 14:20 (172501)

Again, thank you for the insight.

However, I am looking for some input on one of my original questions if any of the Doctors could enlighten me.

'I have not had injections into this area exactly - I have had three injections (1 in one foot, two in the other - this is bilateral) to deal with the FHL tenosynovitis which did nothing, which does lead me to believe the pain is probably from the nerve entrapment and not the FHL. Is it advisable to have injections into the feet again provided the location is different?'

Thanks, Amy

Re: baxters nerve

Dr. Z on 4/03/05 at 14:56 (172505)

That is an option . I would have to know the exact location of the previous injections

Re: baxters nerve

Amy on 4/03/05 at 16:02 (172507)

In both feet he injected around the outer ankle, just below. In one foot he did an additional injection into the FHL tendon sheath about two inches down from the tip of my big toe. I would probably have to show you specifically, so I understand if you cannot give me a reply.

Re: baxters nerve

elliott on 4/03/05 at 17:46 (172510)

Amy,

I'm not sure I follow your story. Why did you get injected on the outer ankle for FHL? Doesn't the FHL run on the medial side as it comes down into the foot? Are you having any trouble lifting up your big toe? Also, are you having any nervy symptoms (and if so, what type, where and when), or just pain (where and when)? Maybe getting a few more opinions would help.

elliott

Re: baxters nerve

Amy on 4/03/05 at 20:31 (172518)

Yes Elliot, it was a little confusing to me at the time as well(as has been my entire journey with heel pain). He said sometimes the cortisone will make its way over to the vicinity of the FHL with a shot to the outer ankle - he gave it a 50% shot of working. He was hesitant to give the shot in the area of the tendon just in his office so this is what he could do at the time. Needless to say it gave no relief.

Regardless - I am beginning to realize my pain is probably not from the FHL as I do not have trouble lifting my big toe or any pain with resistance in that area. My pain is 'nervy' - burning in the arch -close to the insertion point of the plantar fascia. The pain is throughout the day - worse upon weight bearing - but it still burns lying in bed too.

If you do a search with my name you will see that I have sporadically posted since Nov. and you may have some more insight into my journey. In terms of opinions, I have one doc who wants to do a debridement of the tendon and another doc who wants to do the partial plantar fascia release with the decompression of Baxters neve. I would obviously like to resolve it conservatively - I have done my research and realize there are not alot of conservative options. I have tried acupuncture to no avail and am giving ART a try at the moment.

I am having a second nerve conduction test thursday and am hoping it can add some clarity as to what is going on with my feet -

My original questions in this post were:

'My question is, is this surgery (baxters nerve release) any more successful than a normal tarsal tunnel release? And, are there any more conservative measures to try?'

'FYI - I am an extremely healthy 34 year old, was previously very active (running, triathlon, etc) No systemic conditions, etc. Does this make me in any way a better candidate for surgery - if it comes to that?'

Thanks
Amy

Re: baxters nerve

Dr. Z on 4/03/05 at 20:46 (172520)

Hi
If this is a true nerve entrapement of the Medial Calcaneal nerve or a baxter's nerve ( they are two different nerve) it should be possible to inject the area with local plus steriod. If you get relief then you are closer to a correct diagnosis. Posertior nerve blocks can also be helpful.

Re: baxters nerve

elliott on 4/03/05 at 21:15 (172523)

Amy,

FWIW, I'll take a stab at answering your two questions:

'My question is, is this surgery (baxters nerve release) any more successful than a normal tarsal tunnel release? And, are there any more conservative measures to try?'

A: I think the more relevant question is, which surgery, if any, is appropriate? To that end, I think a few more opinions may help sway things. The TTS success rates aren't as bad as people here make out *if* you use someone good and really have what it is they're doing the surgery for (I was a serious runner and have had bilateral releases with a lot of relief). Baxters nerve release is often done for someone without nervy pain at all, under the assumption that that nerve is causing PF pain (not everyone buys into that theory, at least not on the scale Baxter envisioned). If you have TTS entrapment, you want a full nerve release. If it's more like PF with Baxter nerve entrapment, you want that one. If they're not sure but limit it to these two, doing both would not be unreasonable. Concerning conservative measures to try, there's always more, e.g., yet another orthotic. The question is, do you believe it's worth a try. Have you been following that cryo discussion? Given your hesitations about full-fledged surgery, maybe cryo would be appropriate here. Of course, it is rather new. Do get a few more opinions if you can; it often helps clear the air.

'FYI - I am an extremely healthy 34 year old, was previously very active (running, triathlon, etc) No systemic conditions, etc. Does this make me in any way a better candidate for surgery - if it comes to that?'

A: Better candidate for surgery in the sense that you're not an alcoholic, diabetic, smoker, obese, etc. having lower chances for success. You might also heal faster. Not sure it increase your odds beyond that.

Re: baxters nerve

Dr. Z on 4/03/05 at 21:31 (172525)

Elliott,
I agree that another opinion may be in order but there are I have a few comments I would like to see some research from you since you have no professional experience in these areas.
1. 'The results of TTS surgery aren't as bad as people make out'. Dellon who is considered one of the tops by most physicians gives somewhere between 60-63% success rate. Not really that good .
2. Baxters nerve release is often done for someone without nevy pain etc. There are specific signs and symtoms for a baxters nerve involvement completely separate frp, from involvement
3. Cyrotherapy could be the answer with a proper diagnosis . A local block with steriod is the standard I was taught to help determine if cyrotherapy is going to be useful



A: I think the more relevant question is, which surgery, if any, is appropriate? To that end, I think a few more opinions may help sway things. The TTS success rates aren't as bad as people here make out *if* you use someone good and really have what it is they're doing the surgery for (I was a serious runner and have had bilateral releases with a lot of relief). Baxters nerve release is often done for someone without nervy pain at all, under the assumption that that nerve is causing PF pain (not everyone buys into that theory, at least not on the scale Baxter envisioned). If you have TTS entrapment, you want a full nerve release. If it's more like PF with Baxter nerve entrapment, you want that one. If they're not sure but limit it to these two, doing both would not be unreasonable. Concerning conservative measures to try, there's always more, e.g., yet another orthotic. The question is, do you believe it's worth a try. Have you been following that cryo discussion? Given your hesitations about full-fledged surgery, maybe cryo would be appropriate here. Of course, it is rather new. Do get a few more opinions if you can; it often helps clear the air

Re: baxters nerve

elliott on 4/04/05 at 09:30 (172543)

Dr. Z,

First of all, I'm not trying to play doctor. I believe Amy was asking me for my answers since she repeated her questions for me at the end of her last post. At that time she had not yet received sufficient answers from the docs here.

You asked for research that TTS surgical results are more like 75% and higher, at least with careful patient selection and choice of surgeon. In fact, I just recently posted exactly that on Social:

bbv.cgi?n=172185

You've been repeating that 60-63% anecdote for some time now, but it may be time to ask him yourself. His own website, while a bit reluctant to be very explicit, claims more like upwards of 80%, even from a doctor trained by him:

http://www.dellonipns.com/treatment_of_decompression.htm

If Baxter's nerve involvement is so easy to figure out, how come Amy's docs haven't?

Agree, getting a nerve block in the appropriate area sounds like a good try.

Re: baxters nerve

Dr. Z on 4/04/05 at 10:08 (172546)

Interesting . I just spoke with one of Dellon's trained doctors last week and he gave me again the 60% percentage for decompression of the foot and lower leg for Diabetic neuropathy. Maybe this is a web site you need to take a look at again for truth What is told in the lecture halls is different that what is told he the literature

Re: baxters nerve

elliott on 4/04/05 at 10:51 (172549)

Dr. Z,

Regarding diabetic neuropathy (which one would think would have lower success rates than TTS), the site is also explicit regarding a Dellon-trained surgeon achieving a sucess rate of 80% or higher:

http://www.dellonipns.com/pioneering_pain_relief.htm

Does it make sense to you that the Dellon-trained surgeons achieve 80%+ and Dellon himself achieves 60-63%?

Ever notice how you often place the burden on me to produce literature backing up what I say, and then I often do? If you read my Social link and accept around 75% success for carefully selected patients and surgeon, then if Dellon's better than the rest, 80-85% is actually very believable.

You know me, I would never suspect any Dr.'s website as being anything but completely truthful.

Re: baxters nerve

Dr. Zuckerman on 4/04/05 at 11:46 (172557)

So if the field of doctors using this technique and my patients that I send to Dr. Dellon tell me that 63% is the success rate. Something strange is going on here . I do know that the upper extremity releease is around 85% sucessful
I think this is one that has you even beleiving such a high rate of sucess. Please TTS release has always had a fair outcome unless there were specific masses pressing on the nerve.

Re: baxters nerve

elliott on 4/04/05 at 12:39 (172563)

Dr. Z,

Please proofread a little more carefully before posting. Your last sentence, in addition to being garbled, may be saying exactly the opposite of what you want to say.

If by 'upper extremity release' you mean compression of the deep peroneal often called anterior tarsal tunnel syndrome, no one in his right mind would state success results for this type of problem generically as TTS success rates.

I gather from your words that you did not check out the TTS success links I provided. One was from the head pod at Temple:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8714673

Another was from a known nerve specialist and former past president of the orthopedic society:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12627619

Yet another is quoted in a chapter on nerve disorders in the current standard text on foot & ankle orthopedics:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9498577

My own surgeon, a renowned TTS specialist, gave 75%.

I believe these figures, so long as patient and doc are carefully selected.

Re: baxters nerve

JG on 4/04/05 at 13:05 (172564)

Elliott,
Thanks for providing the links. I found the Sammarco and Chang link, which states, 'Average time for return to usual activity was nine months,' very interesting. I was hopng for a speedier return to normal activity, but the way both my feet feel after TT surgery, I think that statement will unfortunately be correct for me.

Re: baxters nerve

Dr. Zuckerman on 4/04/05 at 16:46 (172569)

Upper extremity means arms Dellon does both
Lower extremity means foot and lower body below hip.

You read it correctly. It amazes me how you take these reports as fact and don't dissect the studies are you typically do. Trust me I see the results both on this board and in my practice and it ain't so successful as you would believe. I believe the 63% and not the 80%.
You can debate this but I see the clinical world. Be very careful when undergoing a TTS release, the results, complications and additional disablity are very real and very bad. If it were my TTS I would try everything and anything before the knife cut into the side of foot and ankle

Re: baxters nerve

Amy on 4/04/05 at 20:40 (172583)

I didn't realize I would spark a debate. I appreciate the links to the various studies, however I think the procedure my doc is proposing is different (it includes the partial plantar fascia release etc.) Anyway, there are so many variables involved it is hard to fathom -

Do you still run Elliot?

Amy

Re: baxters nerve

elliott on 4/04/05 at 21:33 (172587)

Dr. Z, if you look over the links to Dellon's site, it's clear they're talking about feet.

Re: baxters nerve

Dr. Z on 4/04/05 at 21:42 (172591)

I know. I just don't agree with the results that are stated. Come on you should know that the doctors do the surgery, do the study and now the results. Unlike FDA studies where they are multi- doctor, multi-center etc. I am just surprised that you just accept these results. which bring me to asking you again to talk about your decision to have extentive foot surgery after what I though you use to say was a failed TTS surgery or a screwed up TTS release that left you with a damage post tib tendon. Something did go wrong??? . What was it and please lets us understanding your bravery and thinking to have this fusion procedure with a major cutting of the heel bone ( dwyer).

Re: baxters nerve

elliott on 4/04/05 at 21:43 (172592)

Amy,

I gotta walk again before I can run. While the TTS in my right foot resolved with the surgery, that foot had other issues going on (which probably caused the TTS), and I just had major surgery to fix it (heel was sawed off and reattached more medially with a big screw, and my medial column was fused with a plate and screws). My right foot probably now weighs more than a quality bike frame. :-) The plate is titanium, though (not sure if it's 6/4 or 3/2.5 :-)). The doc thinks I have a chance of running again, although I sense, understandably, that Dr. Z has his doubts.

In short, all you have to know is, theoretically speaking, my TTS is not holding me back from running. :-)

Re: baxters nerve

Dr. Z on 4/04/05 at 21:48 (172594)

That what surprises me is you approach everything as not being truthful and then are now telling posters to believe the very high TTS success rates without applying the Elliott proof formula's . These rates are really just too high.

Re: baxters nerve

elliott on 4/04/05 at 22:21 (172597)

Dr. Z,

So are you questioning Dellon's and his disciples' figures as appears on the site? A Yes or No will suffice.

Regarding my own extensive foot surgery, no need to get in attack mode about it. That first ortho was not at all carefully selected, not a big-league doc, probably in over his head, hence not satisfying the criteria that the doc and patient be carefully selected. Those were back in the days when I was naive--I trusted a pod who recommended me to him; won't make that kind of mistake again. Regardless, he fixed the TTS problem completely. I had some unresolved pre-surgery heel pain which, at least in retrospect, clearly was structural and I think would have been picked up by a better doc, and also got some new instability in my first ray, in my mind likely a result of the posterior tibial tendon repair or the tight cast raising my first ray (the TTS release part does not dig in anywhere near so deep), but none of the opinions I got afterwards bought into this, instead fitting my symptoms in with a clear diagnosis. I'll still tell my story later.

Re: baxters nerve

Amy on 4/04/05 at 22:24 (172599)

Elliot, I hope you run again - sounds like you have been through a lot. My doc has a patient like me - bilateral - baxters nerve etc - and is up to 60 miles per week post surgery....I don't care a whole lot about running again (well..just a little) i would like to hike as i live in CO. Thanks for the insights of both yourself and Dr. Z -
Amy

Re: baxters nerve

Dr. Z on 4/04/05 at 22:29 (172601)

I do question the site. What have I been saying all this time.? I am surprised that you aren't questioning this either. I have been told my patients that I send to Dr. Dellon and some of his disciples that the sucess rate is what I have quoted around 63%.
I will still refer to Dr. Dellon, but my patients understand that this isn't a miracle procedure.

As for your foot problem. I guess anything is possible as to the cause. I have found that a logical approach still doesn't resolve foot/heel pain. The foot/heel is one tough problem at times.

Re: baxters nerve

Dr. Z on 4/04/05 at 22:34 (172604)

Amy,
There are patients that can and do recovery very well with a Baxter's opeation. I can't remember off the top of my head but there have been some Olympic runners who have done very well with a baxter's release. A TTS may be something completely different. I don't know of any high performance runners who have returned to running or even had the operation.
I also believe that Baxter's nerve entrapment is common with runners. There is an excellent issue in Podiatry Today which talks about Baxters nerve entrapment, treatments etc. You can get it online at podiatrytoday.com

Re: baxters nerve

Amy on 4/04/05 at 22:46 (172607)

This is the article I believe. I am hoping to get some answers on Wednesday - although I know the test won't necessarily show anything. If I commit to surgery, I think I may have a good doc - he has done a number of these and is with a highly respected clinic here. Let's hope it doesn't come to that.

I do know I can't live like this - no, i am not completely debilitated. I am in pain and my quality of life has diminished to the point I dread getting up in the morning. Not an option with a three year old and a ten month old.

Amy

http://www.podiatrytoday.com/podtd/displayArticleaa.cfm?articleID=article3160

Re: baxters nerve

elliott on 4/04/05 at 22:59 (172610)

But Dr. Z, he was your hero. Has he bit the dust in your eyes? Is there no web site left one can trust?

Speaking of web sites, I saw your revised one. Nice. And thanks for what's not there, if you know what I mean. (That chart does look a little lonely comparing the Dornier to itself, but that's OK.) Anyway, there still is some language perhaps inadvertently left in from the old site:

'The one year follow up FDA results showed a much higher patient satisfaction rate with the Dornier than the Ossatron.'

Could that also be removed or else further justified? Thanks for your consideration.

Re: baxters nerve

Dr. Z on 4/04/05 at 23:05 (172611)

When you pick up the phone and speak with Denise she would be glad to listen to anything you want to comment on . Excellence Shockwave Therapy 1-856-769-8270 Don't worry you don't need to use a pay phone.

Re: baxters nerve

elliott on 4/04/05 at 23:36 (172613)

Dr. Z, how do I know I don't need to use a pay phone? Imagine this paranoid scenario: Get my home phone number to appear on the caller ID to prove it's me, record the conversation, and then a clever lawyer goes over the transcript looking for something to nail me on; that could shut me up once and for all. You know, that preferably out-of-state phone booth is looking better and better. Even then, I must consider the possibility of voice analysis--anyone know where I can get a used scrambler? Not to mention gloves to avoid fingerprints on the phone handle, quick legs in case they put a tracer on the call (and I can't even walk without crutches)...

:-)

Re: baxters nerve

Dr. Zuckerman on 4/05/05 at 08:14 (172625)

Good luck and if there is anything else we can discuss to help you just letme know

Re: baxters nerve

Dr. Z on 4/05/05 at 17:37 (172664)

I will send the limo. We can have lunch. I know a great deli

Re: baxters nerve

elliott on 4/05/05 at 20:34 (172675)

Amy, thanks for posting that link to 'How To Address Baxter's Nerve Entrapment.' That article shows that such a diagnosis, often reached after a failed PF release, is far from clear.

Re: baxters nerve

Amy on 4/05/05 at 21:31 (172683)

I thought it was interesting, albeit a bit technical. I like the sound of this result: 'Henricson and Westlin reported 10 of 11 athletes with chronic heel pain with nerve entrapment symptoms were asymptomatic after decompression'

Amy

Re: baxters nerve

Dr. Z on 4/05/05 at 22:00 (172685)

Did you notice that there was absence of first step morning pain and the purpose of the local steriod injection. ( reading the article) A good clinician should be able to help you.

Re: baxters nerve

Amy on 4/05/05 at 22:05 (172686)

Yes I did - thank you.

Re: baxters nerve

elliott on 4/05/05 at 22:54 (172692)

Dr. Z, yes, the article offers useful tools to aid in the diagnosis, but I sense you take the diagnosis of Baxter's nerve to be relatively easy and definitive. I see that same article as suggesting it is difficult. You said, 'Did you notice that there was absence of first step morning pain and the purpose of the local steriod injection.' Actually, I didn't notice, because they put in several qualifiers: 'Patients with *classic* Baxter's nerve entrapment *often* will deny first step pain. And everyone knows a steroid shot does not always work as intended.

Re: baxters nerve

Amy on 4/05/05 at 22:57 (172693)

Since I have been to four orthopedics, a PT, a podiatrist, and an accupuncturist - and I still don't have a firm diagnosis - I can attest to the fact it is not easy to diagnose (if indeed this is what is going on with me....)

Re: baxters nerve

Dr. Zuckerman on 4/07/05 at 10:34 (172749)

It is easy when it is classic. The use of dignostic ultrasound is very helpful. It is the it is the response to the local injection at the time of the injection that is helpful. There is no question it is an art and you may need a few opinion or go to an experience heel pain doctor