What is the treatment for Baxter nerve compression?

Treatment for Baxter Nerve Compression

Begin with conservative management including physical therapy with neural gliding exercises and core strengthening, combined with NSAIDs as first-line pain therapy, reserving surgical decompression only for refractory cases after exhausting non-operative options. 1

Initial Conservative Management (First-Line Treatment)

Pharmacological Therapy

• NSAIDs serve as the primary pharmacological intervention for pain management in Baxter's neuropathy 1
• Local steroid injections can provide significant relief in chronic cases, with documented pain-free outcomes at 1-year follow-up 2

Physical Therapy Interventions

• Neural gliding exercises are essential to restore nerve mobility and reduce traction on the compressed nerve 1, 3
• Core strengthening exercises should be incorporated as part of the comprehensive physical therapy program 1
• The rationale for neural gliding is based on pathophysiology showing that compression neuropathy primarily affects the connective tissue "container" of the nerve (epineurium and perineurium), causing fibrosis that decreases nerve excursion and produces dynamic ischemia 3
• Physical therapy modalities that stretch nerves and restore neural gliding are frequently successful in relieving symptoms without surgical intervention 3

Duration of Conservative Treatment

• Continue conservative management for an adequate trial period before considering surgical options 1
• Most patients respond to conservative measures, as the majority present with symptoms related to connective tissue pathology rather than nerve fiber damage itself 3

Surgical Management (Reserved for Refractory Cases)

Indications for Surgery

• Failure of conservative management after appropriate trial period 4
• Persistent severe pain despite optimal non-operative treatment 4
• Progressive neurological symptoms 4

Surgical Technique

When surgery is indicated, the procedure involves:

• Medial incision of the plantar fascia (preserving the lateral portion) at its origin on the medial plantar calcaneus 4
• Decompression of Baxter's nerve by incising the superficial and deep fascia of the abductor hallucis muscle 4
• Resection of calcaneal spur if present 4
• In a series of 32 feet, postoperative MOXFQ scores improved from 52.5 to 31.3 at mean 25.6-month follow-up 4

Postoperative Protocol

• Two weeks of partial weight bearing (20 kg) in a healing shoe 4
• Progressive weight bearing using a stiff-soled shoe for an additional 4 weeks 4

Important Clinical Considerations

Diagnostic Confirmation

• MRI without IV contrast is the preferred imaging modality after negative or equivocal radiographs 1
• Key MRI finding: denervation changes in the abductor digiti minimi muscle, appearing as fatty atrophy with high signal on T1-weighted images and low signal on T2-weighted images 2, 5
• Selective fatty atrophy of the abductor digiti minimi muscle is the unique diagnostic sign of Baxter's neuropathy 5

Common Pitfalls to Avoid

• Do not overlook Baxter's neuropathy when evaluating heel pain, as it frequently accompanies plantar fasciitis and is often missed 2
• Recognize that patients may have significant symptoms even with minimal or normal electrodiagnostic findings, as symptoms often relate to connective tissue pathology rather than nerve fiber damage 3
• Avoid rushing to surgical decompression, as the evidence does not support nerve decompression procedures for prevention or routine treatment, given the inherent surgical risks and availability of effective conservative options 6

Surgical Complications

• Minor complications occur in approximately 25% of cases, including swelling, delayed wound healing, temporary hypoesthesia, or pain while walking 4
• Approximately 19% of patients may have same or worse pain at 6 weeks postoperatively 4