Heel Pain: Neuritis of the Foot – Diagnosis and Treatments
Heel pain in the morning is odd and disturbing enough that patients bring the complaint to DeLoor Podiatry. No one wants to keep dealing with pain first thing in the morning.
“People ignore sprains especially when the pain seems to be ‘normal.’ You twist your ankle, it’s normal that it swells up and gives you grief,” says Dr. Jose Loor. “But your heel hurting in the morning, especially when it disrupts your preparations for the day– that’s not normal. Patients come to podiatrists for that sort of pain, especially when it keeps coming back.”
In fact, heel pain is the most common complaint patients bring to podiatrists.
The specialists of DeLoor Podiatry are gratified to publish this article on heel pain, because it can be tricky to diagnose.
Possible causes of heel pain in the morning, aside from fractures and tarsal tunnel syndrome, are plantar fasciitis or Baxter’s neuritis, or nerve entrapment, which can also be caused by chronic plantar fasciitis.
Physicians often overlook Baxter’s entrapment neuropathy or misdiagnose it as plantar fasciitis. This is understandable: the symptoms of plantar fasciitis and Baxter’s neuritis overlap.
What is Baxter’s neuritis?
Neuritis is a collective medical term for any damage pertaining to nerves, causing pain and loss of function. You might have heard of spinal neuritis, and neuritis in the wrist (carpal tunnel syndrome), elbow or shoulder.
Neuritis in the foot is quite common. The nerves can so easily be damaged when any other part of the foot suffers an injury. For example, in the case of plantar fasciitis and Baxter’s neuritis, small tears in the plantar fascia causes it to be inflamed and thickened. This pinches or “traps” the nerve running underneath the plantar fascia. This nerve is Baxter’s nerve.
It has two functions: sensory and motor.
Baxter’s nerve tells you when your heel is hot or cold, getting squashed in a tight shoe, or if someone is tickling you.
The motor function supplied by Baxter’s nerve goes to the muscle of your little toe (digiti minimi), enabling you to move your little toe away from your fourth toe. If you have Baxter’s neuritis, you have less and less sensation in your heel. Some people also lose the ability to move their little toe, but this test is not conclusive, because many people really don’t have that ability at all.
What is plantar fasciitis?
Plantar fascia is a set of strong connective tissues and ligaments that support your foot arch. The plantar fascia is a broad band of collagen fibers. When you walk, plantar fascia ligament absorbs gait-related shock. All that pounding as your heel slaps against the ground goes to the plantar fascia.
Not surprisingly, too much pounding and too little cushioning from good footwear causes damage to the plantar fascia. So does fallen arches or inborn flat feet that throws the biomechanical system of your foot out of balance. Avoid worse damage by going to specialists. DeLoor Podiatry has plenty of treatments for these conditions.
Without support from good shoes, normal arches, or corrective orthotics, the plantar fascia becomes inflamed. This results in a painful arch. Your feet hurt.
“Fasciitis is what we call the chronic heel pain from inflamed plantar fascia,” says Dr. Albana Thomaraj. “The inflammation happens when there’s tearing on the plantar fascia due to overuse. Think of your clothes, your shirts at the elbow, and your pants at the knee. If any of these spots are always strained, it tears. And one tear, even if repaired, can tear again. We often see fasciitis in athletes, and in older people who used their feet a lot in their careers. It’s a natural result of ageing.”
The causes of Baxter’s neuritis are still not determined, but it does share one aspect with plantar fasciitis. Fallen arches (pronation, or flat feet) puts too much pressure on the heel, and therefore inflames the plantar fascia and the heel muscles, canals and nerves, including Baxter’s nerve.
Plantar fasciitis and all that pressure on your heel also causes a growth on the heel bone called a heel spur. This spur is very painful– especially when it rubs on your Baxter’s nerve.
Why does my heel hurt in the morning?
“We call this ‘post-static dyskinesia,’ pain that’s worse and most noticeable after rest, or after getting out of bed, which is usually the morning,” says Dr. Audrey Abetmarco. “It’s common in those with neuritis in conjunction with plantar fasciitis.”
Also known as ‘first step pain,’ 10% of people in the United States experience it. The nerve beneath your heel gets pinched by the inflamed plantar fascia.
As already mentioned, your plantar fascia is a tough band of collagen, and during the day, it often adapts to the pounding it takes, making the pain gradually ease off. At DeLoor Podiatry, our patients notice that the pain goes away.
During sleep, your plantar fascia has enough time to get angry at all that pounding. Hence, the pain at your first step. It works itself out and might even be gone by the time you’re ready to go to work.
Pain that gets worse the longer I’m on my feet
If you have Baxter’s neuritis, or if your plantar fasciitis has progressed badly enough to inflame your Baxter’s nerve, you would soon notice that your heel gradually hurts worse and worse the longer you are on your feet.
Plantar fasciitis pain usually subsides when you sit down or rest. With Baxter’s neuritis, the pain persists even when you are off your feet. “Some patients describe it as a shooting pain that radiates from the heel to the middle of their foot. It’s a burning sensation with other patients,” says Dr. Audrey Abetmarco. “And for some, they can no longer stand on that foot for more than a minute.”
The pain may no longer stop even when you are on pain medications, which are usually effective for plantar fasciitis.
When conservative treatment does not offer relief, foot and ankle surgery is the solution.
Diagnosing Baxter’s neuritis
“We don’t make a diagnosis based on a physical exam,” says Dr. Loor. “If you’ve read about those ‘tests’ for Baxter’s neuritis, they’re not conclusive. Phalen’s maneuver (also done to diagnose carpal tunnel syndrome) and pressing on the inside of the heel can cause a shooting pain in the patient’s foot if he or she has Baxter’s neuritis, but that could also happen with other ankle issues. We would do differential diagnosis for other possible causes of your heel pain.”
Those possible causes are:
- Arthritis of the foot and ankle
- Calcaneal fracture
- Foreign body injury
- Heel spur
- Plantar fasciitis
- Plantar fat pad atrophy
- Tarsal tunnel syndrome
To make an accurate diagnosis, DeLoor Podiatry specialists use X-ray to rule out other injuries, and MRI or ultrasound to reveal the condition of the nerves. The Baxter’s nerve would appear pinched and inflamed: swollen and enlarged. Using diagnostic ultrasound as a guide, Dr. Loor can also numb the nerve. If the pain disappears, then it confirms Baxter’s neuritis.
Care should be taken that Baxter’s neuritis is accurately diagnosed, because the aggressive stretching regimen recommended to treat plantar fasciitis can worsen Baxter’s nerve entrapment.
New York and Brooklyn shockwave therapy for heel neuritis
Nerve entrapment needs nerve release. For Baxter’s neuritis, it’s called the Baxter’s procedure or neurolysis.
Neurolysis is a blanket term for “nerve release,” in which your surgeon desensitizes the affected nerve/s enough to remove your pain and suffering.
For Baxter’s neuritis, you have two neurolysis options: chemical and shockwave therapy.
Quick points about chemical neurolysis:
- Involves injection of the nerve with a chemical, often a solution of alcohol
- This desensitizes the nerve. But it doesn’t kill it.
- The nerve is a small target– DeLoor Podiatry specialists rely on their superb accuracy, and on imaging technology (diagnostic ultrasound) to perform this surgery.
- Because only a very small amount can be injected at each time, you would have 3 to 5 injections with an interval of two weeks between each treatment.
Nerves have different fibers that transmit sensations of touch/pressure, temperature and pain. The fibers for pain, unlike the ones for touch and temperature, are uninsulated, making it more sensitive. This saves our lives on a daily basis. If our pain nerve fibers are less sensitive, we’d be burning and slicing and poking ourselves to death.
But this lack of insulation also makes it easy to desensitize the pain fibers. This explains why some people can take a pounding on some of their scars because they don’t feel it any more. In the case of selective treatment, it’s the same. The injection of alcohol around the nerve easily treats the pain fibers.
Quick points about shockwave therapy for neuritis:
- Using ultrasound or arthroscopy, shockwave therapy for neuritis involves the insertion of a very thin probe near the area of the affected nerve.
- The nerve is stimulated with very mild current.
- The first two stimulations verify the accurate placement of the probe.
- The first stimulation recreates the symptoms of pain
- Through a lower frequency current, the second stimulation activates the motor branch of the Baxter’s nerve. Your little toe (the fifth toe) will flex a little.
- Finally, the shockwave therapy is started and heats the nerve to about 170F (around 80C).
- This lasts for a little over 60 seconds, enough to desensitize the pain fibers of the nerve.
- Only one treatment is enough. Pain relief is immediate.
After your surgery, you would have a bandage over the injection wound of the probe. That’s it. You may have to be non-weight bearing for 6 to 8 weeks, depending on your own personal recovery.
DeLoor Podiatry doesn’t recommend steroid injections. They do nothing for neuritis. Foot and ankle surgery in the form of shockwave therapy, also called radiofrequency ablation because it “removes” the pain sensors of the nerve, provides the best solution.
DeLoor Podiatry provides all-around podiatry services ranging from ankle and foot trauma, ingrown toenails, bunions and hammertoes, to advanced treatments like stem cell injections, arthroscopic reconstruction, bone stimulators and spider veins and varicose reduction. We serve patients across New York and New Jersey, including Gramercy, Flatiron, Murray Hill, Herald Square, Chinatown, Bay Ridge, Wall Street and Bensonhurst, Fair Lawn NJ. The specialists, led by Dr. Jose Loor.