Fat Pad Syndrome
Fat Pad Syndrome
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Fat pad syndrome is a condition that usually happens in the centre of the heel and is most often due to thinning and degeneration of the fat pad. Symptoms can appear very similar to those of plantar fasciopathy. However, fat pad syndrome differs slightly.
With initial first steps in the morning and after periods of rest, the discomfort is not as painful, the pain tends to build with increased weight bearing activity. The plantar fat pad is the soft tissue layer in between the skin and the heel bone.
It has a honeycombed structure with fibro-elastic chambers containing fat globules which helps with shock absorption and the spreading of pressure across the surface of your heel during activity. Foot with location of plantar fascia location
Reduced shock absorption will make the heel bone more vulnerable to repetitive micro-trauma.
This can lead to chronic inflammation, bruising, swelling and pain within the heel bone. Increased load can lead to irritation/ inflammation of the bursa which sits under the fat pad, also known as a fat pad contusion.
A bursa is a small fluid filled sack that is found between the heel bone and the soft tissue. The bursa helps with shock absorption and to reduce friction.
Patient Signs and Symptoms
Patient Signs and Symptoms
Deep generalised ache or bruised feeling on weight-bearing
Worse walking on hard ground, barefoot or thin-soled shoes
Pain central but diffuse in the heel
Significant Findings
Significant Findings
Flattened atrophied surface (less than 18mm)
Direct Central plantar heel palpation pain
Fat pad feels soft, malleable and easily displaced sideways
Easily palpated calcaneal plantar tubercle
Plantar heel oedema (more so if chronic > 6m)
Increased pain with lateral compression (also seen in osteoarthritis of the subtalar joint, stress fracture, calcaneal apophysitis)
Palpation pain improves with lateral pinching of fat pad which returns with direct palpation
More common in elderly/high BMI females
Occupations that involve standing on concrete floors
Higher prevalence with diabetes mellitus
Vascular disease
Gradual onset
Increasing age
Imaging
Imaging
Not indicated at initial assessment if Fat Pad Atrophy suspected but may be indicated for differential diagnosis if fails to settle. Diagnosis made by clinical signs as typically indicates accurate diagnosis.
Imaging maybe used at later date, can be discussed at our MSK Podiatry Virtual Escalation clinic as required on presentation.
Preferably weight bearing views in lateral, Dorsal/ Plantar and Oblique.
Findings suggestive of alternative diagnosis
Findings suggestive of alternative diagnosis
Abnormal neurology (radiating pain, power loss, paraesthesia/ Anaesthesia, reflex changes)
History of trauma and diffuse symptoms
History of inflammatory arthritis (significant joint swelling, morning stiffness widespread pain or history of inflammatory arthritis)
Posterior heel pain Ankle/ leg pain
Progressive change in foot posture
Prolonged rest pain
Calcaneal spurs do not correlate with symptoms
Differential Diagnosis
Differential Diagnosis
Posterior heel pain
Plantar Fasciopathy
Posterior Tibial Tendon dysfunction
Inflammatory (Rheumatoid Arthritis/ Gout/ Psoriatic Arthritis/ Juvenile Idiopathic Arthritis).
Bilateral heel pain may be suggestive of underlying Spondyloarthropathy. (Ask regards history of back pain, morning stiffness, joint pains, psoriasis may be present)
Calcaneal Apophysitits (6-14 year olds)
Referred from lower back (L5/S1 nerve pathology)
Local nerve entrapment (Paraesthesia, burning and tingling sensation, tenderness along the course of the nerve, positive neural provocation tests)
Trauma/ stress fracture (Diffuse heel pain, exacerbated by activity, swelling and redness of overlying skin, calcaneal tenderness)
Skin pathology (corn)
Rupture (sudden onset, tearing, or ripping pain in mid foot or hind-foot, bruising/ sub hematoma, activity can be intolerable)
Plantar fibromatosis
Critical limb ischaemia
Avascular necrosis
Infection (Fever, malaise, fatigue, weight loss)
Bone insufficiency (Osteoporosis/ long term steroid use)
Neoplasm/ space occupying lesion (deep bone pain, increased nocturnal pain)
Treatment not currently recommend based on evidence
Treatment not currently recommend based on evidence
Trigger point dry needling
Acupuncture
Therapeutic Ultrasound
Platelet Rich Plasma (PRP) injections
Low level laser
Steroid Injections
First line treatment options
First line treatment options
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