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MRI vs EMG for Baxter's nerve

by Bessie
(Florida)

Baxter's nerve

Baxter's nerve

After xray and 8 weeks PT my podiatrist ordered an MRI for entrapped Baxter nerve diagnosis. PT said to have my neurologist do nerve test. He ordered an EMG for tarsal tunnel syndrome diagnosis. My podiatrist says the MRI is all I need.


I am scared of surgery and husband said we will get different docs diagnosis until someone says no surgery.

Having MRI next week and insurance won't cover EMG but will have it if it is needed eventually when I can afford it.

Is this something I should discuss with both my doctors?

Thank you

Bessie

RESPONSE

Hi Bessie,

Let me start off by saying that certainly you should discuss your treatment options with your any doctor involved in this particular problem as they are the most familiar with your situation.

Having said that I do have a few concerns based on your narrative and I would like to address them.

According to you, it seems like all you had so far was an x-ray and some physical therapy; hardly what I would call any real treatment for a possible Baxter's nerve.

Baxter's nerve is an irritation of one of the branches coming off the medial plantar nerve. (the red arrow is pointing to Baxter's nerve on the bottom of the heel).

It is a diagnosis that is generally not too difficult to make just by examination. In most cases there will be pain when the doctor presses on the inside of the heel, even though your actual pain may be on the bottom of the heel when you walk. This same pain is usually not evident on pressing in the same spot on the other foot.

Additionally, there may be some degree of numbness on the bottom of the affected heel compared to the other heel. This can be identified by using a dull pin and pressing against the bottom of each heel, the affected heel will be duller than the other heel.

In most cases of a heel neuroma (Baxter's nerve) the heel will become more painful, the more you walk. This is in contrast to plantarfasciitis which is most painful on initial ambulation and then eases up as you walk.

The reason a heel neuroma will worsen as you walk is because the pounding of the heel during ambulation will aggravate the nerve and make it worse.

In my mind at least making the diagnosis of Baxter's nerve is not that difficult. I have found it rare in my practice that people just have Baxter's nerve issues; I tend to find that they run concurrent with plantarfasciitis.

Plantarfasciitis tends to be easier to treat and when patients end up having prolonged pain that does not respond to the usual therapies for plantarfasciitis, it is usually due to a heel neuroma or even a heel bursitis.

Moving along, one of the problems with a heel neuroma is that it may actually be a
tarsal tunnel (the foot equivalent of carpal tunnel seen in the hand), where the nerve further up the foot at the level of the ankle becomes entrapped and can give symptoms such as heel pain as well as more diffuse pain in the foot.

Now, you podiatrist wants to do an MRI and states that is all you need. The problem with an MRI is that I have found them to be poor prognosticators of neuromas.

In theory they should be able to identify enlarged nerves but in my experience they tend to give too many false negatives, meaning they do not find neuromas when one actually exists.

I can tell you of multiple instances over my career where I have had an MRI that came back negative for a Morton's neuroma, which is a neuroma in the forefoot, only to go in surgically and actually remove a neuroma.

In theory, an MRI should be able to reveal nerve entrapment found in tarsal tunnel, but an EMG, at least in my opinion would be the better test.

Having said all that, if you were my patient, at this point I would not be ordering any tests without actually have given you some specific treatment, besides physical therapy.

One of my favorite treatments for heel neuromas is the use of 4% percent denatured alcohol injections given weekly for upwards of seven weeks. What this injection does is sclerose or deaden the nerve and in doing so, reduces or eliminates the heel pain of a heel neuroma.

There are additional treatments that are mildly invasive that can be done for your heel pain such as injected CO2 which essentially freezes the nerve to keep it from hurting.

The amount of fat that you have on the bottom of your heel may also be a factor is heel neuroma. I do not know how old you are but as we age the one area where we lose fat is on the bottom of the foot. Some younger individuals also exhibit very little heel fat.

The problem here is that without much fat to cushion the area, Baxter's nerve is constantly being irritated by walking. Thus, in many instances adding a heel cushion to deaden the impact of heel strike when walking may go a long way in reducing symptoms.

At this point in time I do not think you are a candidate for surgery, certainly not without having tried some less invasive therapies. It may turn out that even after some of these treatments, if you are still in enough pain, then a surgical procedure may be indicated.

In closing, discuss all this with your doctor(s). You should always be part of the decision making process since it is your foot. If you find that you end up being at odds with what your doctor recommends, then seek out a second opinion with a doctor in your area.

Marc Mitnick DPM
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Nov 08, 2017
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Next step after Cortisone injections
by: Hurt foot:(

Hi I have a right foot nerve injury and had 2 X-rays that were negative to bone fracture and several cortisone shots. It was getting so much better no swelling and very little pain. Doc said I could walk normally so I wore heels. Now it hurts and is numb like Before and I am back to putting ice on it every night and trying to walk less due to the pain. Do you recommend more shots, Emg or Mri? It’s been 4 months since nerve injury. When will this pain go away and what can I do as a home remedy or are there pills to help heal nerves faster? Thanks. :(
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The rule of thumb for cortisone injections is three in the same location in a 12 month period, so if you have already had three, I would hold off on more.
An emg will maybe only confirm what you already know, an mri may be more helpful in determining if there is an additional issue going on.

Marc Mitnick DPM

Apr 13, 2015
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EMG AGAIN!
by: Bessie Mae

Had another painful EMG Nerve test today which nerves and muscles are working fine. No tarsal tunnel either. This doc specializes in these and gives you the results right away. Unlike the last one, he also did the bottom of my feet and my lower back. This time I did not bleed either. Still quite painful in the calves and thought my leg was gonna jump off the table when the electrode hit. He said my pain is orthopedic. Looks like I am back to the starting gate. One and a half years, creams, injections, various prescriptions, 40 weeks of therapy, wearing a boot, compression stockings and still wearing shoe inserts for plantar faciitis. Got a feeling this pain is simply something I am gonna have to learn to live with. Arthritis on left side of spine and bulging disks on right side. Rheumatologist is talking spinal injections and we are hopeful it will at least get me moving more.

Aug 27, 2014
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Therapy
by: Bessie Mae

After only one PT session with electrical stimulation, ultrasound, contrast bath, slant board, and soft tissue massage my left foot responded 90% and right foot 75%. Less pain during todays session and almost no grinding feelings in left foot at all. I still don't understand why the other PT did none of these for the 8 weeks I went, but I am too grateful to complain (today). The Orthopedist gave me a softer orthotic for my right foot and tomorrow I iron clothes for hours which is a true test. Thanks again doc for having this website and we STILL need qualified Podiatrists in beautiful sunny Tampa Bay (Bradenton) Florida.


Thank you and good luck.
Marc Mitnick DPM

Aug 26, 2014
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New Diagnosis
by: Bessie Mae

Went to a doc who is not in my insurance network, meaning it's gonna cost me more. My husband used him in the past and PT there for years (seemed like it). We trusted him enough with our daughter so kiddos said I can spend their inheritance on my feet. Plantarfaciitis. The PT said my symptoms for this would not always be the same as my husbands since he is flat footed and I have very high arches. Their goal is to teach me how to walk properly so I don't wobble as much and they think the extreme pain I had on my fifth toe is actually a fracture caused by the way I put all my weight on the outside of my foot so the arches don't hurt. He put the orthotics inside my shoe while I was there and said I am not to remove them. Worth a go since the other doc wanted an MRI of the wrong foot.

Jul 05, 2014
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PF
by: Bessie Mae

New doc messed up on MRI order so went to Good Feet. May as will give more inserts a try. PF according to them. Did I mention the great weather in Florida doc? Barefeet on beach needs reliable podiatrist.

Jun 18, 2014
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Results
by: Bessie Mae

Results from Nerve Test and EMG came back normal. Neurologist explained my pain as neuropathy even though results said no. I am more confused now than before. He said the results are like listening to a trio singing. A big loud voice which is heard, a middle size medium which is heard less but still heard, and a small quieter voice drowned out by the other two so the test could not hear it. Like I said, I am now more confused.

Jun 03, 2014
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EMG
by: Bessie Mae

EMG results is no tarsal tunnel. I don't remember what he thought the problem is. He says I should see a podiatrust as he does not see how an orthopedist could help. Test was painful and I am very sore now but at least I know what IT isn't. Next step is finding a new doc. Weather is Florida is great Dr. Marc.
I will continue my search but if all else fails, OTC meds aplenty.

May 28, 2014
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MRI vs EMG
by: Bessie Mae

Insurance denied MRI again. Doc forgot to tell them I had an xray of left foot, injection in left foot, prescription compounding cream for both feet 3 times daily for 2 months so far, and 5 weeks PT for both. I cancelled EMG until someone else can drive since it is for my rigt foot. I also have concern with a Chiropractor doing the EMG when a radiology lab can do the same thing. The pain has now progressed to include my heels. Hoping it is a mental thing on that one since everything I read includes heel pain. After a short camping vacation trip where all we do is walk I will be heading back into fixing my feet.
Lesson to readers, if you fall, don't assume if you can still move it you don't need to have a medical professional look at it. I regret not going to my primary doctor for referrals, at least that way maybe the insurance company would treat this as one injury and PT could have been done immediately.

Hi Bessie,
Your last paragraph is great advice to people visiting this site. In general, if an injury does not show substantial improvement within lets say 3-5 days, then in most cases it could be a sign of a more serious injury. The earlier an injury is treated, the better the outcome. Hoping an injury gets better on its own is not a sound medical strategy.
If you are going to have an EMG, a neurologist is the one to do it. Just so I do not get nasty comments from chiropractors, I do doppler studies in my office for circulation issues, but they are more of a "screening test". Ultimately, if I suspect poor circulation, I send my patients to a vascular specialist for follow up and confirmation.
Good luck to you.
Marc Mitnick DPM
ps: have your doctor call the insurance company again and mention all the previous treatments you have had; in most cases that should be enough to approve an MRI.

May 22, 2014
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Thank You
by: Bessie

Thank you so much for your response. Indeed my pain is not in my heel and since both doctors have negative opinions of each other's diagnosis it is time to seek out an unbiased party. I forgot to mention I did have one injection in my left foot and my podiatrist did not do an xray of the right foot which is a different and more pronounced pain.
Tank you again.

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