What Is Heel Fat Pad Syndrome and How to Treat It?

What Is Heel Fat Pad Syndrome?

Heel fat pad syndrome is a painful condition in which the layer of fatty tissue just underneath your heel wears away, becoming thin. It is the cushion of specialized fat tissue that is located between the heel bone (calcaneus) and the external skin. As a shock absorber for your foot, when this pad becomes less thick and less spongy it is no longer as efficient at its task. This can lead to a deep bruised-type of pain when putting weight on the foot. Heel fat pad syndrome is the second most common cause of heel pain, after plantar fasciitis. It is often overlooked and misdiagnosed as plantar fasciitis. The easiest way to separate these two conditions is to understand that in plantar fasciitis, the plantar fascia ligament is inflamed. In fat pad syndrome, the problem lies within the pad itself.

Anatomy of the Heel Pad

The heel pad is a thick and springy structure that can tolerate extreme pressure and is broken down into dense pockets of fat separated by fibrous chambers. The heel pad has an average thickness of 1–2 cm and is found in healthy adults. The primary function of the midfoot is to dissipate forces across the foot to reduce the stress on bones, nerves, and blood vessels in the foot’s deeper tissues. Biomechanical factors, including the structure of the foot arch, will influence how these forces are buffered. The fat pad is the most important part of the heel bone; it acts as a sponge-like shock absorber under load. However, the fat pad becomes thinner as we age and loses its mechanical benefit, leaving behind a paper-thin padding that can no longer support the body enough to remove the pressure from the joints.

The decreased ability to cushion this region is the main cause of plantar fat pad syndrome.

How Common Is Heel Fat Pad Syndrome?

Mistaken for plantar fasciitis and almost as standard, heel fat pad syndrome frequently causes severe pain under the heel. They often have the highest reporting rate due to the prevalence of misdiagnoses. The two illnesses have such similar symptoms that, without a full workup, they can be easily confused with each other even earlier. As you get older, you become more prone to heel fat pad syndrome, predominantly because the fatty tissue becomes thinner over time. Gait imbalances causing unequal heel pressure and systemic diseases, including but not limited to type 2 diabetes, rheumatoid arthritis, and lupus, also increase the risk of calcaneal bursitis.

What Are The Symptoms Of Heel Pad Syndrome?

Common symptoms of heel fat pad syndrome include severe, sharp pain—usually described as a deep, bruising type of pain in the middle portion of your heel. Furthermore, this discomfort is heightened during weight-bearing activities, for instance, prolonged standing or walking on a supporting surface, and is excruciating when barefoot. The pain experienced from plantar fasciitis and fat pad syndrome are different. Pain due to plantar fasciitis is present with the first step after a period of rest, such as sleep or sitting. The pain is present for a few minutes then it decreases as the fascia stretches only to return later in the day. On the contrary, heel fat pad syndrome pain is present after a few minutes of standing and gradually gets worse throughout the day. Typically, pain from fat pad syndrome does not dissipate.  Cushioned shoes can protect the heel pad and reduce pressure, resulting in a decrease in symptoms.

What Causes Heel Pad Syndrome?

Fat pad syndrome of the heel is most commonly a breakdown of the heel’s protective fat pad caused by long-term mechanical or general wear and tear. In many cases, age is the culprit, most commonly after the age of 30-40 years, which thins and dehydrates the heel pad. You may also be suffering from shin pain due to your low ankle/foot mobility. As we know, constant pressure on our feet from being overweight or participating in any high-impact sport only exacerbates the condition. This will cause stress to pile up in previous foot injuries and uneven weight distribution. Genetic issues like connective tissue disorder & hypermobility also increase susceptibility as these may make your heel pad predisposed to injury in many cases.

How Is Heel Fat Pad Syndrome Diagnosed?

Diagnosis is made by exclusion as there are mild and nonspecific symptoms when presenting with this syndrome, which makes diagnosis challenging. Accurate diagnosis is vital as treatment is based on cushioning and minimizing movement.

Clinical examination is the first and most important step. After visual inspection and palpation, the physician can determine where the pain is coming from. However, the most obvious sign of fat pad syndrome is that pressure on the middle of the heel pad will cause pain. In plantar fasciitis, the lateral or front side of the heel where the plantar fascia connects will be painful. A physician may also check the thickness and architecture of the fat pad in bearing and non-bearing weight. A medical history can provide additional clues. A physician can take a history about trauma, increased activities, or repetitive injury to the heel.

Imaging is only done following clinical exams and history, taken to confirm the findings and rule out any other possible causes of pain. The most common test is scintigraphy, which measures normal bone material and calcium uptake of the skeleton when ruling out infection. The study is useful for identifying injuries but cannot always differentiate between the causes of lamp pain. The imaging that may follow after scintigraphy can be X-rays, ultrasounds, or MRI scans. X-rays will show increased bony uptake and spurs, but they do not show the syndrome.

MRI should be done in unclear cases to allow for detailed soft-tissue imaging. To differentiate fat pad syndrome from other diseases, plantar fasciitis is the sudden onset of severe pain that usually begins in the arch and on the front part of the heel. Stress fractures in the calcaneus are associated with a recent increase in activity and present with consistent recognition.

How Is Heel Pad Syndrome Treated?

There is no actual cure for heel fat pad syndrome. The objective is to alleviate discomfort, restore well-being, and prevent additional harm to your natural lower heel cushioning. Treatments are personalized for the individual and based on conservative options that likely begin with exercises before more aggressive treatments if required.

Conservative Treatments

They are your first line of defense to help you decrease pressure and inflammation on the heel pad. Most of these strategies can be done at home, but the help from a specialist is indispensable for both a correct diagnosis and even indication.

• Rest: The first thing you can do is to rest the foot and avoid doing things that aggravate the pain. That way, your heel pad has time to come back from being under constant stress.
• Ice: Applying ice to the area for 15-20 minutes, several times a day, can help reduce inflammation and numb pain. An ice pack or a polar environment therapy slipper could be used to ease back pain.
• Pain Relievers: Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin IB, and others), can help reduce pain and inflammation.
• Supportive Footwear: A thick, cushioned sole with good arch support can help absorb the shock and reduce stress on your heel. Always avoid walking barefoot on a hard floor, especially in the house.
• Orthotics: Custom or commercially available orthotic shoe inserts are very effective. They can be crafted to offload heel forces and contribute essential cushioning. General guidelines may include soft orthotic heel cups or heel pads made to cushion the heel and absorb shock.
• Taping: Taping is a great short-term solution, as you are compressing down the heel pad, and lots of supportive tape helps to do its job! Possible methods are low-dye taping or a figure-8 taping pattern.
• Physical Therapy: A physical therapist can provide a tailored plan. These involve stretches for the calf muscles and Achilles tendon, which can ultimately reduce stress on the foot. This needs to be used by those with gait imbalances. Manual therapy and massage can also help relax painful muscle spasms.
• Shockwave Therapy: A non-invasive treatment that sends high-energy sound waves to the area of your pain and stimulates tissue repair, which can help to speed up healing time and decrease discomfort. It is usually considered after other conservative treatments have failed.

Advanced Treatments

Aggressive treatments may be considered for a reasonable option if nonsurgical measures fail to control symptoms.

• Platelet-Rich Plasma (PRP) Injections: This treatment contains a concentration of the patient’s own platelets and growth factors that are used to promote tissue repair.
• Fat Grafting/Autologous Fat Transplantation: It carries the risk of rejection, as fat is being harvested from another part of the body, like the abdomen or buttocks, and injected into the heel pad. This would be used to fill and also give a new, more regular cushion. Without heavy weight-bearing, recovery is usually speedy (2–6 weeks).
• Injectable Fillers (Dermal Fillers): To give the atrophied heel pad more volume, dermal fillers can be injected, much like fat grafting. Materials include hyaluronic acid and poly-L-lactic acid. It is less intrusive than fat grafting, but the effects are short-lived, lasting anywhere from a few months to a year.
• Allografting: If necessary, the doctor may use donor fat obtained from a tissue bank for rebuilding the heel pad. This obviates the need for a harvesting procedure while having consequences for tissue compatibility.
• Surgery: Surgery is considered a last resort and is rarely needed to treat the heel fat pad syndrome itself. However, the underlying foot or leg deformity is what causes or aggravates the condition. In that case, surgery must be performed to eliminate this direct cause of mechanical stress on her heel.

What Are The Complications Of Untreated Heel Fat Pad Syndrome?

If heel pad fat syndrome is not treated, then it can cause a lot of complications that significantly affect a person’s life. The persistent, stabbing heel pain will force you to alter your gait, making you at risk for other health issues affecting various parts of the body.

• Chronic Pain and Reduced Mobility: This is the main side effect, which can dramatically downgrade your lifestyle. This can make walking, standing for long periods, and even basic household chores painful, creating a downward spiral affecting your mobility.
• Altered Gait and Secondary Issues: To prevent discomfort, you may unwittingly change your gait. This abnormal gait may put excess pressure on other joints, leading to secondary musculoskeletal issues in the knees, hips, and lower back. A modified reel pulls your balance and firmness outside, making you more vulnerable to falls.
• Reduced Activity Capacity: As pain becomes a factor, you are not able to perform in sports or activities that you used to do. That in turn results in living a more sedentary lifestyle, which is detrimental to your long-term health.

Risk Factors and Causes

The leading cause of heel fat pad syndrome is that the heel impacts the ground over time, but several triggers make you more susceptible to this injury.

• Foot Structure: Your foot structure could be the it factor. In a cavus foot (high arch), the biomechanics may affect how weight is distributed on the heel pad, leading to increased pressure.
• Direct Trauma/Injury: By far the most common cause is a direct blow to the heel from an accident or a hard landing, resulting in injury/damage to the fat pad, leading to atrophy.
• Family History/Genetics: If you have a family history of the disease, there is a probability that it can be passed down to you.
• Medical Conditions: Some systemic diseases, such as rheumatoid arthritis, lupus, and type 2 diabetes, may cause connective tissue to thin out as you age or increase in thickness with age.
• Heel Spurs: A heel spur is a bony outgrowth on the heel bone. This in itself does not cause this initial condition, but secondarily, it may traumatize the fat pad, altering the mechanics of that walker’s shoe and causing friction on it.
• Previous Corticosteroid Injections: Although injections are sometimes used for pain relief, repeated steroid injections in the heel can weaken and accelerate the atrophy of the fat pad tissue, worsening the condition over time.

Prognosis and Recurrence

Heel fat pad syndrome usually heals through proper management within a few weeks to months. It does not cure the condition itself but effectively manages symptoms so that one can live a pain-free life. Left untreated, it will likely evolve into a long-term pain condition that gets worse over time.

What is alarming is that the rate of recurrence remains high, as the fundamental causes are not addressed. To lessen the risk, one needs to wear supportive shoes, be at a healthy weight, and follow the prescribed exercises. The effect of heel pain on walking and its secondary problems is the result of the body trying to circumvent this heel pain. This compensatory action may result in some of your joints having excessive wear and tear, leading to chronic pain elsewhere, and an increased risk of falling due to decreased stability.

Can Heel Fat Pad Syndrome Be Prevented?

Yes, you cannot do anything about aging and genetics, for example; however, there are a few things that you can do to prevent heel fat pad syndrome from becoming too bad. Reduce mechanical stress on the heels by kicking back or using foot care.

Pain Activity Ladder

This is a straightforward guide to orient your pain and activity. You should slow down or even refrain from any activity that increases your pain. The goal is to discover an activity level that doesn’t cause symptoms and to gradually increase the amount of activity over time.

Ankle, Foot, and Toe Exercises

To improve your foot’s stability and function, it is essential to strengthen the muscles in your feet using exercises for your ankles and toes. Toe curls, marble pickups, and calf stretches are among the many exercises that can help to bolster your foot’s natural structure so it distributes pressure throughout in an even manner.

Weight Reduction

Some of the most effective ways to reduce pressure on your heels are maintaining a healthy weight. Excess body weight puts considerable strain on the feet, leading to premature wear and tear of the footpads.

Appropriate Footwear

Shoes are of paramount importance. Choose shoes with cushioning and arch support. Try to avoid wearing high heels (they will stretch your muscles in all the wrong ways, especially pointy toes) for long periods. Without proper cushioning and support, shoes can damage the feet and contribute to many ailments. Wear good athletic shoes when you are involved in high-impact activities.

Modification of High-Impact Activities

Activities like running and jumping are high-impact and place a significant amount of force on heel pads. Limit these activities and alternate with lower impact activities (such as swimming, biking, or yoga) to avoid damage. This will allow the heel pad to rest and not become overstressed.

How Does It Differ From Other Heel Conditions?

Heel fat pad syndrome is a common reason for heel pain and can be misdiagnosed as other conditions. Heel pain is also much more likely to be related to plantar fasciitis, which is an inflammatory condition involving the fibrous tissue on the underside of the foot. A calcaneal stress fracture is a microfracture (tiny crack) in the heel bone, usually from repetitive stress. Bursitis (an inflammatory condition of a fluid-filled sac on the heel) or nerve entrapment are other possibilities that can present as plantar fasciitis. A correct diagnosis is key to effective treatment.

Moving Forward With Heel Fat Pad Syndrome Treatment

Heel fat pad syndrome can be frustrating to treat, but with the right diagnosis and treatment plan, it can be managed. Home remedies are a great initial way to treat this condition, but it is also important to know when to reach out to a professional. If heel pain becomes chronic, severe, or starts to impact your life and it does not seem to get better on its own after a few weeks of home treatment (rest, ice, over-the-counter pain medications), it is time to get evaluated by a professional. Advanced care goes beyond self-management strategies. Using a clinical exam and imaging studies, a podiatrist or orthopedic specialist can make a definitive diagnosis.

Treatments can include the recommendation of physical therapy or custom orthotics (made-to-order for the perfect foot support) to advanced biologic treatments such as PRP injections or fat grafting. Dr. Jodi Schoenhaus has over ten years of experience in the diagnosis and treatment of heel fat pad syndrome and knows all the signs and symptoms of this often misdiagnosed injury. Early action is key. The sooner you know what you have and begin treatment, the more likely the pain will be managed and the condition will not progress. Early treatment will decrease your chance of developing long-term consequences, including chronic pain and changes in gait.

Don’t let your heel pain become a chronic issue. Contact the Foot, Ankle & Leg Vein Center to make an appointment with Dr. Schoenhaus and schedule today!

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