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Figure A is a dissection of the medial aspect of the left ankle and foot. Which of the following nerves indicated in Figure A is most commonly implicated in nerve entrapments in the running athlete?
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Point A demonstrates the first branch of the lateral plantar nerve (Baxter's nerve). Baxter's nerve innervates the abductor digiti quinti, flexor digitorum brevis, and quadratus plantae. It traverses just superior to the insertion of the plantar fascia on the medial calcaneal tuberosity. Compression of this nerve causes maximal pain over the plantar medial aspect of the foot, and can be difficult to distinguish from plantar fasciitis. Baxter's nerve compression is a common pattern of entrapment found in the running athlete.
Illustration A depicts the sensory distribution of the tibial nerve. Illustration B shows the dissection with the other responses labeled; Point B are the medial calcaneal nerve branches, Point C is the tibial nerve, Point D is the lateral plantar nerve and Point E is the medial plantar nerve.
The review article by Neufeld and Cerrato discusses plantar fasciitis and its differential diagnoses including Baxter's nerve compression, calcaneal stress fracture, lumbar radiculopathy, and plantar fibromatosis.
Neufeld SK, Cerrato R.
J Am Acad Orthop Surg. 2008 Jun;16(6):338-46. PMID: 18524985 (Link to Abstract)
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A 40-year-old runner complains of heel pain for 4 months. He reports tenderness over the abductor hallucis origin with a positive Tinel's sign radiating to the lateral foot. The pain worsens with prolonged activity. What is the most likely diagnosis?
heel fat pad fat atrophy
compression of the first branch of the lateral plantar nerve (Baxter's nerve)
tarsal tunnel syndrome
Patients with distal entrapment of the lateral plantar nerve or its branches usually present with chronic heel pain that has been present for 9-12 months. Many of their symptoms are similar to plantar fasciitis, especially the location of their pain and their startup pain. In addition to the mechanical symptoms of plantar fasciitis, they present with neuritic pain that is unrelated to weight bearing or loading of the foot. Baxter and Thigpen described a biomechanical basis for the entrapment of the first branch of the lateral plantar nerve in the athlete. They proposed that entrapment results from the stretching and tethering of the plantar nerves, which are encased in the abductor hallucis deep fascial leashes, and from the hypertrophy of the small foot muscles, as well as from the increased forces in the hindfoot in the running athlete that create additional microtrauma to the runner's medial heel structures. They also noted that most of their patients with sports-related injuries had a normally arched or cavus-type foot.
Baxter DE, Thigpen CM.
Foot Ankle. 1984 Jul-Aug;5(1):16-25. PMID: 6479759 (Link to Abstract)
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A competitive marathoner reports 6 months of pain over the lateral distal leg and dysesthesia over the dorsum of the foot. There is a tender fullness over the distal lateral fibula with a positive Tinel's sign. There is normal motor strength, but pain with passive plantar flexion and inversion of the ankle. The most appropriate surgical treatment is:
Repair muscle herniation and closure of the fascial defect
Fascial release and superficial peroneal neurolysis
Fascial release of all four compartments
Superficial peroneal neurectomy
This is a case of superficial peroneal nerve entrapment by the fascial opening in the distal leg. It is classically exacerbated by plantar flexion and inversion of the foot. Treatment involves release of the fascial opening to reduce this traction phenomenon.
Sridhara et al reported on 2 cases that were successfully treated by surgical decompression of the nerve at the bulge by fasciotomy. They described the following findings: 1) a decrease in sensation on the foot dorsum over the cutaneous distribution of the nerve with sparing of the first web space; 2) a soft tissue bulge over the anterolateral leg 10 cm above the lateral malleolus; 3) a Tinel sign over the bulge; 4) an increase in the size of the bulge either with resisted ankle dorsiflexion or weight bearing; and 5) tenderness over the bulge or distally over the terminal sensory branches of the superficial peroneal nerve.
Styf et al published a more recent series of 17 patients (19 legs) with entrapment of the superficial peroneal nerve. We performed decompression of the superficial peroneal tunnel in 14 patients and local fasciectomy in three. Fourteen patients (80%) were free from symptoms or satisfied with the result.
Sridhara CR, Izzo KL.
Arch Phys Med Rehabil. 1985 Nov;66(11):789-91. PMID: 4062533 (Link to Abstract)
Styf J, Morberg P.
J Bone Joint Surg Br. 1997 Sep;79(5):801-3. PMID: 9331039 (Link to Abstract)
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Which nerve innervates the abductor digiti quinti and can be compressed as it travels under the fascia of the abductor hallucis muscle leading to symptoms of plantar heel pain?
First branch of the lateral plantar nerve
Most of the plantar aspect of the foot is derives its sensory innervation from the plantar nerves, which are the terminal sensory branches of the tibial nerve. The lateral plantar nerve innervates the abductor digiti quinti and travels across the heel, just anterior to the medial tuberosity of the calcaneus.
The first branch of the lateral plantar nerve passes between the deep taut fascia of the abductor hallucis muscle and the medial caudal margin of the medial head of the quadratus plantae muscle. The superfical branch of the peroneal nerve supplies the dorsum of the foot except the first web space (deep branch). The sural nerve supplies that lateral aspect of the foot and not the plantar surface.
Baxter et al showed good to excellent results in 89% of patients where they decompressed the first branch of the lateral plantar nerve for medial heel pain.
Baxter DE, Pfeffer GB.
Clin Orthop Relat Res. 1992 Jun;(279):229-36. PMID: 1600660 (Link to Abstract)
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