Baxter's nerve/ tarsal tunnel

by Mike
(Georgetown TX)

70 yr old male, former runner, always active even when not able to run.

Heel pain (about 14mos.), which feels like contact pain (not PF) and worsens with activity, even slow walking. Without a Dr. consult, I would have said, running damaged my heel(fat pad?) and first tried heel cushions with no apparent help.

I have been through x-rays, ultra sounds, MRI,(even back), nerve response tests, steroids, fracture boot, and PT and several orthotic options. No help.
I recently received a Baxter's diagnosis, from described symptoms and MRI, and surgery recommendation. However, a second opinion, eliminated the Baxter's nerve diagnosis with a lidocaine injection under ultra sound, and now wants RSWT. Dr. #1, says there's no indication of abnormal PF, and I need surgery (baxter's and Tarsal relief) even though there's no confirmed diagnosis, and even admits only a 50% chance of cure.
Any thoughts or recommendations would be appreciated.
thanks,
Mike M

RESPONSE

Hi Mike,

Well....as a casual observer from the other side of the internet, it appears there is no definitive diagnosis being made and so surgical intervention at this juncture would not be my first recommendation. Given a 50 percent chance of success does not meet my risk/reward criteria, particularly with an elective procedure. Also, stop and consider that you could be worse after the surgery.

So making the assumption that your heel pain is a result of a tarsal tunnel or Baxter's nerve entrapment, which by the way are two completely different conditions, located in two different areas of the heel, I would suggest a different approach.

I would deal with the possibility of each with a more conservative approach in an attempt at the very least to see if the conservative treatments reduce the symptoms. Depending on which condition responds to more conservative care, not necessarily cure, I would be comfortable with a "final" diagnosis and then perhaps surgery, if conservative care did not remedy the problem.

In tarsal tunnel, most people are excessively pronated. It is this flattening out the foot that causes pressure against the nerve that passes down the leg through the inside of the ankle and into the foot. Typically tarsal tunnel will give give symptoms involving more then the heel, but it can be limited to the heel.

So my conservative therapy for this condition would be to get yourself into an orthotic that reduces pronation and thus reduces pressure against the nerve on the inside of the ankle and essentially wear the orthotics 24/7 for a period of four to six weeks. I am serious about the continual wear.

If you wear an orthotic for eight hours a day, then in the evening kick off your shoes and walk around barefoot for a couple of hours, you are negating all that was gained during the day, and you stand a more limited chance for success.

Additionally I would consider a cortisone shot or two into the tarsal tunnel canal if an effort to reduce the swelling and inflammation that may be pressing on the nerve. I will make the assumption that the MRI did not reveal any type of mass in the canal.

My conservative treatment for Baxter's nerve or heel neuroma would be a series of 4% denatured alcohol injections, upwards of seven or eight of them, at once a week intervals. This should be done by someone experienced with these types of injections as they are given somewhat different then a standard cortisone injection.

The purpose of these injections are to sclerose or deaden the affected nerve. If the injections work or at the very least reduce your symptoms by lets say 50 percent, then you know your problem is a Baxter's nerve entrapment and if push comes to shove you would be more comfortable consenting to surgery.

If you decide to try this experimentation to isolate which condition is causing your pain, it goes without saying you do not want to do both at the same time. Your symptoms may subside, but, you still won't know which condition is causing your pain.

Marc Mitnick DPM
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