Heel Fat Pad Syndrome

Original Editor - Puja Gaikwad

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Introduction[edit | edit source]

Heel fat pad syndrome

Heel Fat Pad Syndrome (HFPS) is a condition that happens as a result of changes in the elasticity and/or the thickness of the heel fat pad. This is often caused by wear and tear over time of the fatty tissues and muscle fibers that make up the heel pads leading to heel pain that could impact our daily routine and interfere with our regular activities. [1]Too much wear and tear can cause heel pads to shrink in size or lose their elasticity. When fat pad atrophy occurs, destruction of the fibrous membrane in the heel pad begins to occur, in addition to the loss of moister and soft tissue elasticity reduction leading to impaired shock absorption mechanism.[2] It is also termed Fat Pad Atrophy (FPA). It is considered to be the second leading cause (14.8%) of plantar heel pain after plantar fasciitis. It is commonly misdiagnosed as Plantar fasciitis, while both can be a source of heel pain but the risk factors, symptoms, and treatment vary for each condition.[3]

Anatomy[edit | edit source]

The heel fat pad is a specialized adipose structure overlying the calcaneum and proximal plantar fascia which are enclosed by ligamentous chambers that serve to cushion the impact of heel strike during locomotion. It also serves as a mechanical anchor that helps to disperse body weight appropriately without putting excessive pressure on the underlying tissues.[4] The heel can absorb 110% of the body’s weight during walking and 200% of the body’s weight during running; this excess mileage and chronic increase in pressure strike and load forces could lead to thinning of the heel fat pad, experiencing a common complaint of heel pain. A fat pad, known as the ‘corpus adiposum’ is usually about 1-2 cm in thickness with the average healthy calcaneal fat pad measuring approximately 18 mm thick.[5]

Risk Factors & Causes[edit | edit source]

It can occur because of overuse, injury, atrophy, or strain on the corpus adiposum. The alignment of the arch of the foot and the gait or biomechanics are the two most significant contributing factors responsible for heel fat pad syndrome. The function of the arch of the foot is to support the foot in a proper upright alignment. If the arch is injured or compromised, it places added pressure on the heel pad.

The following are some of the most prevalent causes of heel pad syndrome:

  1. Inflammation of the corpus adiposum: Inflammation of the fat pad can happen when it is continually placed under force or pressure repetitively, or for prolonged periods of time. This usually occurs in patients that are involved in activities that require a lot of jumping, such as basketball, volleyball, gymnastics, or athletics, etc.[6]
  2. Displacement or thinning of the corpus adiposum: In a few individuals, the fat pad in the heel becomes displaced or thinned. This is prevalent amongst elderly patients since the natural aging process results in a loss in elasticity of the soft tissue structures in the body.[7]
  3. Force: Walking or running barefoot, particularly on hard surfaces like concrete or tiles, puts undue force on the fat pad causing thinning and straining of the corpus adiposum and bruising of the calcaneus.[8]
  4. Gait imbalance: Patients with feet that point inwards or outwards can suffer from heel pad pain since their heel is striking the ground in a suboptimal way when they walk or run. The corpus adiposum frequently becomes thinned, worn, or inflamed in the areas where the heel is contacting the ground forcefully.
  5. Overweight and obesity: Patients that are overweight or obese are at higher risk of developing heel pad pain since their excess body weight puts additional pressure on the feet.
  6. Medical conditions causing fat pad atrophy: Though it is less common, it is thought that there are few medical conditions that contribute to atrophy of the heel fat pad. It is commonly seen in conditions like type 2 diabetes, lupus, and rheumatoid arthritis.[9]
  7. Plantar fasciitis: The corpus adiposum may become worn much quicker than it would be otherwise, in individuals suffering from plantar fasciitis. When the plantar fascia is injured or inflamed, it has a reduced ability to distribute the forces while walking or running which leads to extra pressure on the heel fat pad, and consequently, leads to quicker wearing.[10]

Signs & Symptoms[edit | edit source]

Symptoms of fat pad syndrome may include: [11]

  • Patients with heel pad syndrome present with deep, bruise-like pain, usually in the middle of the heel while walking, running, or standing for a long time.
  • It can be reproduced with firm palpation.
  • This pain increases in severity by prolonged walking or standing, especially when barefoot, walking on hard surfaces, or while performing any high-impact activities.
  • Mild cases of heel pad syndrome might be asymptomatic or felt occasionally when aggravated by pressing on it directly or came in contact with hard surfaces such as hardwood floors, concrete or ceramic tiles.
  • pain at night and resting pain.
  • Pain is typically experienced on one side (i.e. within one heel, not both).

Although similar in presentation, the pain from HFPS is felt in the middle of the heel, whereas in the case of Plantar Fasciitis the pain is located at the anteromedial aspect of the calcaneus.[4]

Diagnosis[edit | edit source]

A diagnosis of heel pad syndrome can be made based on the symptoms and physical examination. An X-ray or ultrasound study of the foot can be performed to diagnose fat pad atrophy or rule out other causes of heel pain. The thickness of the heel pad is measured on the imaging studies. Normal heel pads are 1-2 cm thick. A fat pad that measures <1 cm in thickness is considered atrophied. To assess elasticity, a therapist may compare the heel pad thickness in weight-bearing as well as non-weight-bearing positions.

Physiotherapy Management[edit | edit source]

  • Activity Modification: consider taking a break from intense athletic training, such as long-distance running, etc.
  • Mobilization: Mobilization and glides of portions of the foot and ankle, including the plantar fascia, rear-foot, and talocrural joint directed at increasing motion and restoring normal function.
  • Custom Insoles and Taping: Shoe inserts provide increased padding in symptomatic areas while taping procedures aim to correctly position the pad under the calcaneus in an anatomically correct form. Custom-molded shoes, heel cups, and cushioned socks with extra padding may support the feet and decrease the impact on the heels.[12]
  • Home Exercise Programs (HEP): Patient education to include discontinuation of symptom-aggravating activities (high impact exercises, etc.) and self-stretching and mobilization techniques. Stretching should focus on lengthening the gastrocnemius and soleus, while mobilizations should include ankle eversion and plantar fascia motions.
  • Improve foot, ankle, and lower leg muscle control: Start with foot stabilization exercises, weight-bearing strengthening exercises for the calf muscles. Address deficiencies that are likely causes of altered foot biomechanics.
  • Address biomechanics foot position and increase neuromuscular control: Look at muscular imbalances at the hip and knee to help align the lower limb. Work on balance, proprioception to improve better dynamic control around the foot and ankle.
  • Increase load on tissue, adding sport-specific/dynamic exercise: Prepare the foot and lower limb for more explosive movements to gradually progress back to full function. Also, include plyometric training- look at technique with jumping and landing (address alignment/technique during movements).[2]

Complications[edit | edit source]

Untreated heel pain can be disabling, making it difficult to walk, play sports, and be productive at work. Heel pain can also change the way individual walk, making susceptible to falls and injuries.

Prevention[edit | edit source]

As mentioned above, several factors could contribute to developing this condition, of which some of them cannot be avoided such as age or genetics, however, plenty of lifestyle and occupational causes could be prevented if the proper measures are being taken. These include:

  1. Ensuring proper footwear that is densely cushioned and provides enough support to the bottom of the feet at all times.
  2. Wearing athletic shoes when performing any high-impact activity.
  3. Restricting the intensity and duration of high-impact and weight-bearing activity, such as running or prolonged standing, etc. to ensure the heel fat pad’s ability to recover after these activities.
  4. Try to avoid wearing high heels, especially pointy heels, as high heels can poorly distribute the weight of the body, putting excessive pressure on one area of the foot.
  5. Avoid walking barefoot, particularly on hard or uneven surfaces.
  6. Inspect athletic shoes regularly and change them when observing a noticeable reduction in the cushioning.
  7. Maintain a healthy weight.

References[edit | edit source]

  1. Saad A, Kho J, Almeer G, Azzopardi C, Botchu R. Lesions of the heel fat pad. The British Journal of Radiology. 2021 Feb 1;94(1118):20200648.
  2. 2.0 2.1 Wearing SC, Smeathers JE. The heel fat pad: mechanical properties and clinical applications. Journal of Foot and Ankle Research. 2011 Dec;4(1):1-.
  3. Hossain M, Makwana N. “Not Plantar Fasciitis”: the differential diagnosis and management of heel pain syndrome. Orthopaedics and trauma. 2011 Jun 1;25(3):198-206.
  4. 4.0 4.1 Im Yi T, Lee GE, Seo IS, Huh WS, Yoon TH, Kim BR. Clinical characteristics of the causes of plantar heel pain. Annals of rehabilitation medicine. 2011 Aug;35(4):507.
  5. Özdemır H, Söyüncü Y, Özgörgen M, Dabak K. Effects of changes in heel fat pad thickness and elasticity on heel pain. Journal of the American Podiatric Medical Association. 2004 Jan 1;94(1):47-52.
  6. Tu P, Bytomski JR. Diagnosis of heel pain. American family physician. 2011 Oct 15;84(8):909-16.
  7. Taş S. Effect of gender on mechanical properties of the plantar fascia and heel fat pad. Foot & ankle specialist. 2018 Oct;11(5):403-9.
  8. Natali AN, Fontanella CG, Carniel EL. A numerical model for investigating the mechanics of calcaneal fat pad region. Journal of the Mechanical Behavior of Biomedical Materials. 2012 Jan 1;5(1):216-23.
  9. Falsetti P, Frediani B, Acciai C, Baldi F, Filippou G, Marcolongo R. Heel fat pad involvement in rheumatoid arthritis and in spondyloarthropathies: an ultrasonographic study. Scandinavian journal of rheumatology. 2004 Oct 1;33(5):327-31.
  10. Belhan O, Kaya M, Gurger M. The thickness of heel fat-pad in patients with plantar fasciitis. Acta orthopaedica et traumatologica turcica. 2019 Nov 1;53(6):463-7.
  11. Narváez JA, Narváez J, Ortega R, Aguilera C, Sánchez A, Andía E. Painful heel: MR imaging findings. Radiographics. 2000 Mar;20(2):333-52.
  12. Allam AE, Chang KV. Plantar Heel Pain. StatPearls [Internet]. 2020 Feb 6.
  13. Calcaneal fat pad atrophy-What is it and what does it look like? Available from: https://www.youtube.com/watch?v=UG-yQZaSkD8
  14. Your Heel Pain may NOT be Plantar Fasciitis: Fat Pad Syndrome Taping. Available from: https://www.youtube.com/watch?v=3QI6-wNO6XM