Keys To Detecting And Treating Entrapment Neuropathies

Start Page: 24
27
Author(s): 
Jodi Schoenhaus, DPM, and Jason Gold, DPM

   If you combine a Baxter’s nerve release with a tarsal tunnel release, the previously marked anatomy is the path of the incision. Employ the use of vessel loupes to facilitate the identification of nerve structures and careful dissection. Four critical sites of entrapment the surgeon can release include:

   • the tibial nerve under the flexor retinaculum;
   • the fascial septa between the medial and lateral plantar nerves at the porta pedis;
   • the medial calcaneal nerve; and
   • Baxter’s nerve.

   After performing these releases, proceed to perform superficial closure of the subcutaneous tissue and skin.6

   Apply a compression bandage and allow protective weightbearing in a walking boot. Remove the sutures after two weeks and have the patient initiate active range of motion. You can have the patient start weightbearing in a sneaker at four weeks. Anti-inflammatory medication or a steroid dose pack will help with postoperative edema and pain.

Final Notes

   In conclusion, physicians often overlook Baxter’s entrapment neuropathy or misdiagnose it as plantar fasciitis. Given the amount of overlap of symptoms between Baxter’s nerve entrapment and plantar fasciitis, the surgeon may combine the release of Baxter’s nerve with a partial plantar fasciotomy or heel spur resection. In some cases, one should also perform a complete tarsal tunnel release. A thorough preoperative clinical analysis will help identify and isolate these pathologies to allow for accurate surgical management.

Dr. Schoenhaus is in private practice in Boca Raton, Fla.

Dr. Gold is in private practice in Delray Beach, Fla.

Dr. Burks is a Fellow of the American College of Foot and Ankle Surgeons, and is board-certified in foot and ankle surgery. He is in private practice in Little Rock, Ark.

For further reading, see “How To Address Baxter’s Nerve Entrapment” in the November 2004 issue of Podiatry Today or “A Guide To The Differential Diagnosis Of Heel Pain” in the May 2009 issue.




References:

1. Sarrafian SK. Nerves. In: Anatomy of the Foot and Ankle. Sarrafian SK (ed). Lippincott, Williams and Wilkins, Philadelphia, pp 381, 1993.
2. Baxter DE. Release of the nerve to the abductor digiti minimi. In: Master Techniques in Orthopaedic Surgery of the Foot and Ankle. Kitaoka HB (ed). Lippincott, Williams and Wilkins, Philadelphia, pp 359, 2002.
3. Schon LC, Baxter DE. Heel pain syndrome and entrapment neuropathies about the foot and ankle. In: Operative Foot Surgery. Gould JS (ed). WB Saunders, Philadelphia, pp 192-208, 1994.
4. Recht MP, Grooff P, Ilaslan H, et al. Selective atrophy of the abductor digiti quinti: an MRI study. Am J Roentgenol 2007; 189(3):W123-7.
5. DiGiovnni B, Abuzzahab F, Gould J. Plantar fascia release with proximal and distal tarsal tunnel release: a surgical approach to chronic, disabling plantar fasciitis with associated nerve pain. Techniques Foot Ankle Surg 2003; 2(4):254-261.
6. Dellon L. Tarsal Tunnel Syndrome Release of the Four Medial Ankle Tunnels. DVD, 1998.




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