Fat Pad Syndrome: an underestimated cause of heel pain

The fat pad is located between the skin and the heel bone and acts as a natural shock absorber during standing and walking. This fat pad consists of a honeycomb structure with fibroelastic chambers filled with fat cells that contribute to pressure distribution and shock absorption. When this fat pad becomes thinner due to ageing or overuse, we see that the cushioning decreases. This makes the heel more sensitive to strain, resulting in pain and irritation.

Fat Pad Syndrome usually produces a dull, nagging pain located right under the heel. With plantar fasciitis, we see that pain mainly occurs during the first steps in the morning. In complaints due to fat pad syndrome, the symptoms actually increase during prolonged loading such as standing or walking. With direct pressure on the heel, the heel can then feel sensitive. Sometimes there is local swelling which makes wearing shoes uncomfortable.

A common complaint with fat pad complaints is irritation of the underlying bursa located between the fat pad and the heel bone. When this bursa becomes irritated, pain worsens and swelling sometimes occurs around the heel.

Fat pad syndrome usually results from repeated pressure on the heel. Factors contributing to this complaint include obesity, age (natural degeneration of the fat pad occurs from around 30 years of age), diabetes and conditions such as rheumatoid arthritis or arthritis psoriatica. Wearing inadequately supportive footwear, sudden ramping up of activities or low load capacity can also contribute to the onset of this complaint. Long-term use of corticosteroids is also a known risk factor because of its negative effect on tissue repair.

Because the symptoms of Fat pad syndrome are very similar to those of other heel complaints such as plantar fasciitis or heel spur, a thorough diagnostic process is necessary. Clinical examination combined with imaging offers a solution. Ultrasound is a valuable tool here. With ultrasound, the fat pad can be directly imaged and assessed for thickness, structure and deformability. The tendon plate and other structures around the heel can also be clearly seen, allowing differentiation between different causes of heel pain. 

Recovery from Fat pad syndrome takes time and a contribution from the patient. Treatment focuses on reducing strain and optimising shock absorption while walking. Practical measures include wearing footwear with a well-cushioned heel and firm support. Insoles can also be used, it is important not to walk barefoot or on hard surfaces for long periods of time.

Physiotherapy guidance plays an important role in the recovery process. Targeted exercise therapy can improve the load capacity of the heel region and foot. Exercises aimed at muscle strengthening and mobility, especially of the arch of the foot and the calf region, contribute to an increased load capacity of the heel during daily activities.

Preventing recurrent heel pain requires a broader view than just treating the pain. It is important to look not only at the complaint itself, but also at contributing factors. Consider, for example, wearing good footwear with sufficient cushioning and support, building up load in the right way and ensuring sufficient rest between activities. Being overweight can put extra pressure on the heel area and delay recovery, so it makes sense to include this aspect in the treatment plan as well. Muscle strength, mobility and gait also play a role. By identifying and targeting these factors, the chances of a structural decrease in symptoms are much higher.

Fat pad syndrome is a relatively unknown cause of heel pain. A timely and correct diagnosis is essential to avoid unnecessary treatments and wrong advice. Through a combination of load management, targeted exercise therapy and attention to lifestyle and shoe choice, most people with Fat pad syndrome can eventually regain symptom-free function. Good rapport and clear communication between healthcare provider and patient are key to successful recovery.