When Heel pain is not in the Heel: Plantar fasciitis or Tarsal Tunnel?

The literature on heel pain consistently notes that about 85 percent of the cases will respond to conservative care. When it comes to unresponsive cases, one should consider the possibility of tarsal tunnel or the entrapment of one or more of the nerves in this region prior to proceeding with any more invasive therapies.

Baxter’s neuritis (or neuritis of the inferior calcaneal nerve ICN) typically occurs where the nerve takes a right angle turn from the medial aspect of the calcaneus. The nerve (ICN) travels between the abductor hallucis, quadratus plantae muscles and plantar fascia along the medial aspect of the calcaneus.

Chronic Plantar Fasciitis can cause thickening of this band creating significant pressure on the nerve (ICN) that can also present as heel pain.

Practitioners should consider this diagnosis when heel pain is not responding to standard conservative measures.

Specific symptoms for Baxter’s ICN neuritis include:

• No morning pain but pain towards the end of the day
• Paresthesia across the plantar aspect of the heel laterally
• Pain on palpation of the medial heel along the course of the nerve between the abductor hallucis and plantar fascia.

Treatment

The non-surgical approach to Baxter’s neuritis or tarsal tunnel is similar to that of plantar fasciitis. The difference is that often the non-surgical approach is not as predictable as that for plantar fasciitis. Due to the entrapment neuropathy associated with this condition, it is typically minimally responsive to conservative therapy.

The surgical approach for this condition can be complicated. For this reason, I have teamed up with Dr Eric Williams, a plastic surgeon specializing in peripheral nerve surgery. We utilize an approach of making an incision along the course of the nerve at the medial aspect of the heel extending to the plantar surface.

I proceed to perform a plantar fasciectomy, removing a section of plantar fascia without violating the lateral band of the plantar fascia in order to lessen lateral column pain due to pronatory changes.