Current Pedorthics | March-April 2013 | Vol. 45, Issue 2 | Page 19

or the patient is unable to actively abduct the fifth toe on the
involved side (Fig. 3).
In addition to standard therapies to lessen inflammation, an
alternate technique for treating Baxter’s neuropathy is to perform
nerve glides on the nerve to abductor digiti quinti. This is
accomplished by heating the involved region, lightly massaging
a 4-inch area directly over the site of entrapment (confirmed
with Tinel’s sign), and then performing a series of light stretches
in which the nerve is “flossed” back and forth in its tunnel
(Fig. 4). This technique has been proven to mobilize nerves
in the upper extremity (9), and is believed to loosen adhesions
responsible for maintaining the nerve in a fixed position.
If Baxter’s neuropathy is present, custom and prefabricated
orthotics are often helpful since they may lessen the “scissoring”
of the nerve between the long plantar ligaments and the plantar
fascia. The exception to this is if an orthotic is made in which
apex of the arch is placed beneath the sustentaculum tali. The
proximally positioned arch apex may damage not just Baxter’s
nerve, but also the medial and lateral plantar nerves. If an
orthotic is to be used in the treatment of Baxter’s neuropathy,
the laboratory must be instructed to place the apex of the arch
beneath the medial cuneiform.
It is also possible that chronic heel pain is the result of an
undiagnosed calcaneal stress fracture. A simple in-office test
to rule out calcaneal fracture is the medial/lateral squeeze
test. Because cortical bone in the calcaneus is so thin, medial
and lateral compression of the calcaneus between the thumb
and index finger produces significant discomfort when a stress
fracture is present. To ensure accuracy, sensitivity to pressure
should be compared bilaterally. If a calcaneal stress fracture does
occur, it is important to identify the cause, such as underlying
osteopenia/osteoporosis.
The final factor to consider in the differential diagnosis of
plantar fasciitis is the heel spur syndrome. The easiest way
to differentially diagnose these two conditions is to ask the
patient if they have increased pain while walking on the heel
or the forefoot. Because plantar fasciitis is a propulsive period
injury and heel spurs hurt during the contact period, patients
with plantar fasciitis have more pain while standing on their
toes, while patients with heel spur syndrome complain of pain
when striking the ground on the involved heel. In fact, heel
spur patients often make initial ground contact with the lateral
forefoot in an attempt to lessen pressure beneath the heel during
the contact period.
Because the treatment protocols for plantar fasciitis and heel
spur syndrome are different, it is important to diagnose these two
conditions correctly: plantar fasciitis is treated with orthotics,
stretches and exercises, while heel spur syndrome is treated
with pocket accommodations, heel cups and well-fitting heel
counters. Cortisone injections should be a last resort, especially
in individuals with heel spur syndrome, because it may result
in further degeneration of the calcaneal fat pad. As with the
majority of mechanical musculoskeletal conditions, treatment
interventions emphasizing manual therapy, orthotics, stretches,
and rehabilitative exercises almost always outperform popular
yet ineffective pharmacological interventions such as NSAIDs
and corticosteroid injections.
References:
1. Abreu M, Chung C, Mendes L, et al. Plantar calcaneal
enthesophytes: new observations regarding sites of origin based
on radiographic, MR imaging, anatomic, and paleopathologic
analysis. Skeletal Radiol. 2003 Jan;32:13-21.
2. Wearing S, Smeathers J, Yates B, et al. Sagittal movement of
the medial longitudinal arch is unchanged in plantar fasciitis.
Med Sci Sports Exerc. 2004;36:1761-1767.
3. Landorf K, Keenan AM, Herbert R. The effectiveness of foot
orthoses to treat plantar fasciitis: a randomized trial. Arch Intern
Med. 2006;166:1305-1310.
4. Kogler G, Solomonidis S, Paul J. Biomechanics of
longitudinal arch support mechanisms in foot orthoses and
their effect on plantar aponeurosis strain. Clin Biomech.
1996;11:243-252.
5. Kogler G, Veer F, Solomonidis S, Paul J. The influence of
medial and lateral placement of orthotic wedges on loading of
the plantar aponeurosis. J Bone Joint Surg Am. 1999;81:1403-
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6. DiGiovanni B, Nawoczenski D, Lintal M, et al. Tissue-
specific plantar fascia-stretching exercise enhances outcomes
in patients with chronic heel pain. A prospective, randomized
study. J Bone Joint Surg. 2003;85-A:1270–1277.
7. Harton F, Weiskopf S, Goecker R. Sectioning the plantar
fascia effect on first metatarsophalangeal joint motion. J Am
Podiatr Med Assoc. 2002;92 (10):532-536.
8. Renan-Ordine R, Alburquerque-Sendin F, Rodrigues De
Souza D, et al. Effectiveness of myofascial trigger point manual
therapy combined with a self-stretching protocol for the
management of plantar heel pain: a randomized controlled trial.
J Orthop Sports Phys Ther. 2011;41:43.
9. Coppieters M, Hough A, Dilley A. Different nerve-
gliding exercises induce different magnitudes of median
nerve longitudinal excursion: an in vivo study using dynamic
ultrasound imaging. J Orthop Sports Phys Ther. 2009;39:164.
© Previously published in Dynamic Chiropractic. Permission
for reprint by author.
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