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Baltimore Peripheral Nerve Surgeon Dr. Eric H. Williams Shares How Nerve Compression Can Be Mistaken for Plantar Fasciitis

If you’ve been treated for plantar fasciitis for six months or more and are still struggling with chronic heel pain, it’s time to look for an alternative diagnosis. You may be suffering from Baxter’s nerve entrapment or tarsal tunnel syndrome. If so, Baltimore peripheral nerve surgeon Dr. Eric H. Williams can surgically decompress the pinched nerves in your foot to relieve your pain. 

How Nerve Compression Can Be Mistaken for Plantar Fasciitis 

Baxter’s nerve entrapment and tarsal tunnel syndrome are two types of compression neuropathy that share symptoms with plantar fasciitis. Understanding how these conditions differ is crucial to finding a solution for your chronic heel pain. 

Plantar fasciitis involves inflammation of the plantar fascia, a thick band of tissue that runs across the bottom of the foot and connects the heel bone to the toes. The primary symptom is pain in the heel, especially with your first steps in the morning or after you have been sitting for a long time. 

Baxter's nerve entrapment, also known as Baxter’s nerve compression, Baxter’s neuropathy, or inferior calcaneal nerve entrapment, involves the entrapment or compression of the first branch of the lateral plantar nerve (the inferior calcaneal nerve or Baxter's nerve). It can cause severe refractory heel pain similar to plantar fasciitis, but the pain is typically more localized around the inside of the heel and may involve numbness or tingling. In addition, if severe, the patient may notice that they can not spread or fan out their fifth toe.  

Tarsal tunnel syndrome occurs when the posterior tibial nerve and its branches become compressed or irritated. It is sometimes known as posterior tibial neuralgia or compression of the posterior tibial nerve. The pain associated with tarsal tunnel syndrome is typically located along the inside of the ankle and the bottom of the foot.  Because the tibial nerve is upstream of Baxter’s nerve, compression of the tibial nerve is likely to present with more symptoms than just the localized heel pain. It can affect all of the branches of the nerves that travel to the sole of the foot, not just the calcaneal nerves. This means that the medial plantar and lateral plantar nerves are often compressed, which is why tarsal tunnel syndrome most often causes numbness, tingling, buzzing, burning, and painful sensations to the sole of the foot from the arch to the toes. In some isolated cases, it may only affect the inside half of the sole of the foot or the outside half of the sole of the foot.   

Distinguishing between nerve compression and plantar fasciitis can be complicated due to the overlap in symptoms, so don’t be afraid to seek a second opinion if your plantar fasciitis treatment isn’t producing the desired result after six months. You may have been misdiagnosed or discover that you’re suffering from both plantar fasciitis and compression neuropathy. Because plantar fasciitis is so common, and most podiatrists and foot and ankle teams treat this so often, it is easy to fall through the cracks if your “heel pain” is not improving over time with treatment. Don’t be afraid to ask about these other possible diagnoses. 

Symptoms of a Pinched Nerve in the Foot

The symptoms of a pinched nerve in the foot can include: 

• Heel pain. The pain is often described as a sharp, shooting, or burning sensation.  
• Pain that worsens with activity. Pain from nerve compression typically increases with activities such as standing, walking, or running and may improve with rest. However, unlike plantar fasciitis, the pain may not be as severe in the morning or after long periods of inactivity.
• Tingling or numbness. There might be tingling, burning, or numbness in the area of the heel or along the path of the nerve.  It is very important to know that plantar fasciitis alone does not cause a change in sensation.  It is the nerve that is being pinched that causes the buzzing and tingling sensations.  
• Radiating pain. The pain might radiate from the heel into the arch of the foot or towards the toes, following the path of the compressed nerve.
• Weakness in the foot muscles. This is an important clue that your heel pain is NOT just plantar fasciitis. If you can not spread all of your toes apart on the foot that is hurting (especially your fifth toe), but you can on the normal foot – your heel pain almost for sure involves a nerve as well.  All of the muscle weakness in the bottom of the foot itself is innervated by the affected tibial nerve and its branches.  Patients with severe nerve compression may have atrophy or wasting away of these muscles that may also cause clawing of the toes.    

Checking for a Positive Tinel Sign to Determine if Nerve Compression Might Be the Cause of Your Heel Pain

If your plantar fasciitis treatment doesn’t seem to be working, one step in determining if nerve compression might be the culprit is to look for a positive Tinel sign. The Tinel sign is a clinical diagnostic technique used in the evaluation of peripheral nerve injuries and entrapment syndromes. The test is named after Jules Tinel, a French neurologist who first described it.

Here’s how to check for a positive Tinel sign from the comfort of your own home:

1. Get comfortable. Sit in a chair where you can easily reach your foot. Ensure your foot is relaxed and in a neutral position, resting on a stool or the floor.
2. Identify the area you want to test. Focus on the inside of your ankle and heel, just behind the ankle bone. This is where the nerve likely to be compressed is located within the tarsal tunnel.
3. Using the tip of your finger, gently tap over this area. The tapping should be firm but not too hard. Think of it as tapping on a door to get someone’s attention. (We are not talking about your teenage children or someone with headphones on here; we are talking about tapping enough force to make a light “thumping noise.”)
4. Pay attention to any sensations you feel as you tap. A positive Tinel sign is indicated by a tingling sensation or a feeling similar to a mild electric shock that radiates from the tapping site. This is often described as a "pins and needles" sensation or a sensation just like a “funny bone.”  The only problem is that it is rarely very funny.  Sometimes, it can be downright uncomfortable.   
5. Test both feet. It's a good idea to do this test on both feet, even if one foot is not bothering you. This can help you understand if the sensation is normal for you.
6. Note your findings. Was there tingling, numbness, or no reaction at all? Was there a difference between both feet? Was there significant pain and soreness but no tingling?  Did it feel “different” in any way from the other side? This information can help your doctor make an accurate diagnosis.

We also have a video on our website that demonstrates the steps to look for a Tinel sign. 

If you have a positive Tinel sign, this is a strong indication you may be suffering from nerve compression. However, if you can’t find a positive sign and you have symptoms that could indicate nerve compression, you should still schedule an appointment. Dr. Williams may be able to find a positive sign while performing the test in his office, as he has checked for this sign in many patients. Dr. Williams may also recommend additional diagnostic tests, including EMG nerve conduction studies or imaging tests like an MRI, to confirm the diagnosis and the exact location of the nerve entrapment.

How Nerve Decompression Surgery Can Put a Stop to Your Heel Pain

Nerve decompression surgery relieves the pressure or compression on a pinched nerve in your foot. Dr. Williams will make an incision near the heel, often on the side of the foot, to access the area where the affected nerve is located. Then, he’ll carefully release any structures compressing it. This may involve removing or cutting through tight ligaments or fibrous bands that are pressing on the nerve. After the nerve is decompressed, the incision is closed with sutures.

After surgery, you’ll need to limit your walking and weight bearing on the affected foot by using crutches. Physical therapy may be recommended to restore strength and flexibility, but many do not need extra therapy.  How much time you’ll need to take off work will depend on your specific work duties.

Individual results can vary, but you should see an immediate reduction in pain that continues as your body heals from the procedure. For example:

• Before seeing Dr. Williams, one patient had numbness, pain, and burning in her foot for more than one year. Three months out from a left-side tarsal tunnel release with decompression of the medial plantar, lateral plantar, and calcaneal nerves with a simultaneous plantar fascia release and lengthening of her gastrocnemius muscle, she reported a 90% to 95% decrease in pain. She was able to walk, stand, and exercise once more. 
• One patient suffered for more than 18 months with unsuccessful yet aggressive therapy for her suspected plantar fasciitis. Her referring podiatrist suspected tarsal tunnel syndrome with compression of the calcaneal nerve and plantar nerves. Six to seven weeks after nerve decompression surgery with Dr. Williams, she was completely pain-free.
• One patient had severe refractory heel pain and numbness in the foot accompanied by a loss of the ability to spread or fan out his toes. Treatment of the plantar fascia alone did not relieve his symptoms, but decompression of the tibial nerve, the lateral plantar, medial plantar, and calcaneal nerves resulted in complete resolution of the tingling, numbness, and burning pain in his foot, as well as the ability to once again move his toes.

If you are a candidate for nerve decompression surgery, Dr. Williams will answer any questions you have about the procedure and what to expect during the recovery process. You can learn more about the results he has been able to achieve with his patients on the testimonials section of our website.

Why does the tarsal tunnel syndrome cause so much pain?

Tarsal tunnel syndrome occurs when the tibial nerve and its branches of the medial plantar, lateral plantar, and calcaneal nerves get compressed or pinched.    Essentially the compression of nerve can occur from structural changes, trauma, extra muscles that you are born with, an enlarged nerve, and a variety of other cause.   Essentially there is just not enough room in a very tight space for the nerve to continue to function properly.   This leads to decreased blood flow or decreased ability for the nerve to get the appropriate nutrients and supplies it needs to function properly, and then it does the same thing that all nerves do when they stop working well…..  It talks to you!   Numbness, burning pain, tingling, buzzing, “creepy crawlies” can occur, or weakness, and muscle atrophy, loss of balance can also eventually set in.   Why some patients experience some of these symptoms while others do not is a bit of a mystery.

What is a typical recovery like after release of the tarsal tunnel and the medial plantar, lateral plantar, and calcaneal nerves?   

Most patients report that they actually do quite well after tarsal tunnel surgery, but some will struggle more than others. Because there is an incision on the inside of the ankle, and because the ankle does move, this is usually the source of most of the discomfort. Some physicians prefer to splint the foot after surgery to all the skin to rest and in an effort to improve the pain.   This is in general a good idea for orthopedic type procedures where the surgeon wants the foot to remain still so that bones heal, and that ligaments and tendons that were operated on or sutured together heal in with scar tissue like glue.  But when we consider nerve surgery we DON’T WANT SCAR TISSUE TO FORM AROUND NERVES, so it is very important to get the foot moving quickly.  Think of this as steel reinforced concrete.   The nerve is the rebar and the scar is the concrete.   We DON’T want steel reinforced concrete, we don’t want the nerve getting stuck in the scar tissue, so it won’t move or glide back and forth. We want to start making a tract for that nerve to move almost from the first day that we are done operating.  But we don’t want the skin to break down either.   So we have to play a delicate balancing act.   Ask the patient to move the ankle, but not use the ankle too much.  Ask the patient to move the foot, which may be uncomfortable, but allow the patient enough support, so they are not miserable.    We wrap the foot after tarsal tunnel release with a large cotton dressing that looks kind of like a giant cotton ball.   This bulky dressing is soft and moves with the patient but is sturdy enough not to fall apart.  It allows the patient to weight bear with some force, but it is annoying enough to keep them from running around the house.   It is soft enough that it won’t bother the person next to you in bed, but it is firm enough to be supportive and protect the incision.    

Will I need crutches after surgery? 

Yes. As we age, however, crutches can get a bit unwieldy, and so frequently, we will recommend a walker for those who have a bit more difficulty getting around.  Nearly all folks will need crutches at least until the dressing comes off after one week. Remember, we don’t want the patient to break the incision open because they are walking too much. About half the patients will no longer be using crutches at three weeks after the surgery when they come to have their incision evaluated and the sutures removed. A few stragglers will need crutches for about a month. If you need them longer than this, you are really struggling, and we will need to re-evaluate and make sure that everything is okay and determine if physical therapy would be beneficial for you.   

May I shower after surgery? 

I do expect patients to shower after surgery.  Patients will typically have to use a protective “cast bag” or large plastic bag around their leg to protect the giant water-absorptive cotton ball that is wrapped around their leg.  It is not fun when this gets wet – so don’t get it wet.  Have a plastic dressing placed over the incision that will allow them to shower.  But we do not allow patients to take a bath for about two weeks.

Can I wash my tarsal tunnel incision after my dressing comes off?  

Yes. You may wash the suture line with hibaclens soap (antibacterial soap) daily.  We then ask the patient to paint the incision with Betadine or Iodine to keep it clean and cover it with a large bandaid to protect it.  Putting an ace bandage on the foot at this time can also help keep the post-op swelling down. 

Do I need physical therapy after surgery after Tarsal tunnel release?  

This is a very personalized answer.  Some patients have had a wonderful experience with physical therapy while others have not.  Some patients will prefer to “do it on my own.”  While other patients will really like to have someone “helping them along.”  We are happy to recommend physical therapy when patients feel that this will be a major benefit for them.  I do think there is an advantage to this.  However, we also acknowledge that some patients will be able to control their own recovery well with a graded gentle return to activities.  We discourage any strenuous activities for about six weeks, but walking on even ground, walking on a treadmill, or elliptical trainer can be very helpful in increasing one’s activity AFTER the sutures have come out three weeks after surgery.   We generally will not start physical therapy until this time.    We strongly encourage walking on land and in a pool starting 3.5 weeks after surgery to help you recover well.  REMEMBER:  we don’t want patients busting open their incisions, so we ask patients to “walk for the needs, and not their wants” for the first three weeks.  

Can I drive after my tarsal tunnel release? 

Eventually you can return to driving.  But let’s use some common sense. 

1.  If we operate on the right foot and you have sutures in the ankle, then you are going to be moving that ankle a lot.   That is great for getting the nerve to move back and forth, but that is NOT great for the incision, which has sutures that can cut through the skin.  So if you have surgery on the RIGHT foot, it will be a bit longer before you can drive.  

2.  Common sense helps here as well.  If you are stoned on drugs – NO, you cannot drive.  3.  If your pain is more than you can tolerate and you are distracted by it – NO, you can not drive.  Most people who have their LEFT FOOT operated on can start to drive somewhere between 10-14 days after surgery. RIGHT FOOT is a bit longer.   BUT Everyone is different.  

The MOST IMPORTANT thing to remember is SAFETY!   Do not put yourself or others around you in danger.  Please use common sense.  If your spouse or family member won’t get in the car with you when you want to drive — then you should not be driving!   However, if they won’t ride with you PRIOR to surgery –  I can’t help you there…  You are on your own.      

When will I know if I am better after tarsal tunnel release?  

This is a complicated question. As one can imagine, there is NOT one correct answer here, and believe it or not – you will be telling your doctor when you are better!  However, in our experience, some patients will see relief from the minute they wake up. Others will get relief slowly over time.  Still, others may not get the relief that they were hoping for at all.   However, our experience is that most patients (85%) will eventually get improvements within weeks to months.   It is also common to continue to see improvements over time. We encourage patience, as those who have had symptoms for many years may take longer to improve.  We encourage patients to wait 6-12 months before trying to find and search out “other” causes for their pain because it can take time to see improvements, especially in particularly challenging situations.  

When can I return to work after tarsal tunnel release surgery? 

Again, this is a very individualized question.   If you are a sedentary worker and do mostly desk work, and you can work from home, then most patients may feel up to returning to work after about a week.   If the home option is not available, then it may take anywhere from 1-3 weeks.  If you have a heavy manual labor type position and are in significantly dangerous situations, then it may take up to 2-3 months.  If you have a position where you are expected to walk around for an extended period every day but are not in a particularly dangerous environment, you will probably be looking at about 3-4 weeks, but again everyone is different. The main point here is to make sure that you are SAFE to return to your work, and to be kind to yourself, while not taking advantage of your employer.    Your safety and your recovery are our priority, but we also want to be socially responsible as well.  

Will I be able to return to sports or activities like hiking, yoga, running, etc.?    

Well, it helps if you were active in these areas BEFORE the operation! But in general we do expect patients to get back to many if not all of the activities that they enjoyed prior to surgery. We strongly encourage walking on land and in a pool for several weeks after surgery to help you recover well.  It may take up to three months before you can be expected to have unrestricted activities.   

What kind of pain can I expect after a Tarsal Tunnel release surgery?

The pain after tarsal tunnel release seems to be very reasonable for nearly all patients. There are always the two ends of the spectrum. There are the patients that do have a very high pain threshold, as well as those with a very low pain threshold. But most patients do very well with a mixture of several medications. We encourage a cocktail of medications, both over the counter as well as prescription medications. We typically start with extra strength Tylenol and motrin alternating these throughout the day.  Then we add to this Gabapentin or lyrica for their treatment of nerve pain. We encourage ice on the surgical site intermittently, and then finally patients are given a prescription for a stronger narcotic medication that they may take if they are still experiencing pain that is not well controlled.  Some of our patients never take a pill of the narcotic, but most will take a few tablets. 

What will I need after my Tarsal Tunnel surgery?  

You will need crutches or a cane or walker for a few days to steady your gait. Some people who want to return to work early or who have long distances to walk may want to use a rolling scooter for some of the time they are up and about. You will need to pick up your medications for postop discomfort.  You will need a nice ice bag or two – (nothing wrong with a ziplock freezer bag.) You will need a protective cover to place over your dressing while you shower.  You will want to try to set up a place to recover that is on one floor if you can, but this is not required, but it is much easier. You will need someone to help drive and do many of your normal daily chores while you are recovering.  

When can I travel after my tarsal tunnel release?  

We do see many patients from out of town. If patients live less than two hours away from Baltimore, then they may go home after the procedure. They will need a ride as they will not be able to drive themselves. If they are driving distance, but further than two hours away, we typically ask them to spend the night in one of our local hotels. The reason we do this is in case of a complication such as bleeding, the patient can contact us and be seen quickly. Otherwise, they might be hours away and have a hard time trying to get into an emergency room with physicians that they do not know. If you are flying from out of town, we typically encourage patients not to make plans for a minimum of 24-36 hours. Again safety is our primary concern here. We want to make sure that there are no acute complications, that your pain is well controlled, and that you have plenty of time not to rush through the airport.