Heel fat pad syndrome

What is heel fat pad syndrome, and how common is it?

Heel fat pad syndrome is when the fat pad (the cushioning layer between the skin and heel bone) thins and wears out, usually causing pain in the centre of your heel¹. The pad normally absorbs shock and spreads pressure across your heel². How common it is isn't clear: it may be the second most common cause of plantar heel pain, but that rests on very little³. Its presentation can closely resemble plantar fasciopathy, but a clinician can help differentiate the two¹.

What causes it, and who gets it?

It usually builds from repeated overuse¹. Several things can add to it: age from about 30, when the pad naturally thins; extra body weight; unsupportive footwear¹; long periods of standing or walking, especially after a sudden increase; tight or weak leg and foot muscles⁴; and too little recovery time between activities². Diabetes, inflammatory arthritis and long-term steroid tablets are also listed⁴, as are repeated steroid injections⁵. It's more common in older or overweight women, people who stand on concrete for long periods, and people with diabetes⁵.

What does it feel like, and how is it diagnosed?

It usually starts gradually as a dull, deep, bruise-like ache in the centre of the heel⁴⁵. The pain builds the more you stand or walk, and is worse barefoot on hard floors¹⁵. It's usually milder first thing in the morning, though morning pain doesn't rule it out, and both heels are often affected⁶¹. A doctor, physiotherapist or podiatrist can diagnose it from your story and an examination, and sometimes a scan⁷. Other causes are ruled out first⁵. Before you go, note when it started, where it hurts, what makes it worse, your footwear and surfaces, and any past steroid injections.

What can I do first?

Self-care comes first, and changing your habits is key¹.

• Wear cushioned, supportive shoes; consider insoles or heel pads¹.
• Stretch, do foot exercises and try low-impact exercise like swimming¹.
• Cut back long standing or walking; avoid high heels, flip-flops and barefoot walking on hard floors¹.
• Rest with your foot raised. Ice in a towel for up to 20 minutes every 2 to 3 hours, not on numb skin, open wounds or a foot with poor sensation or infection¹.
• If you're overweight, losing weight may help¹.

Heel cups and arch taping are often recommended but untested in trials for this condition³. In plantar heel pain, inserts may ease pain in the medium term, and ready-made and custom ones did about the same⁸.

What helps if that isn't enough?

If simple care hasn't helped, a podiatrist, physiotherapist or GP can review your diagnosis and options.

For a thinned pad, heel cushions, heel cups or low-dye taping may take pressure off the heel bone, with shockwave therapy for stubborn pain⁶. How well they work for this condition isn't clear yet.

A steroid injection isn't suggested early: it can thin the pad further and risk rupture of the plantar fascia⁶⁵. Ask about the benefits and risks before agreeing to any injection.

How long does it take, and how can I stop it coming back?

How long it takes to settle, and how often it comes back, isn't clear yet for this condition. Changing your habits and cutting back what aggravates your heel are described as key to recovery¹. Pacing can help: break tasks into parts, take regular breaks², and build standing and walking up gradually. Keep wearing supportive, cushioned shoes, and avoid walking barefoot on hard floors.

What can make it serious?

• You have new numbness, tingling, pins and needles or weakness in your foot that has come on gradually.
• Your pain is getting worse, or doesn't settle with rest, less activity or pain relief.
• You have lost weight without trying.
• You have had cancer before and notice a new lump, or pain that doesn't settle.
• You have a foot wound, ulcer or infection, or a red, hot, swollen foot, and also have a fever, chills, a fast heartbeat or feel unwell.
• Your foot, or a patch of skin on your foot or leg, becomes red, hot, swollen and painful.
• Your foot or ankle looks badly out of shape, or points at an odd angle, after an injury.
• You can't put weight on your foot or take four steps after an injury.
• You feel a sudden snap or pop at the back of your ankle or calf, as if you were kicked, and then find it hard to push off or stand on tiptoe.
• You have pain in a bone with a fever.