Why won’t my plantar fasciitis go away?

Heel pain from nerve compression

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:

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.