Every time you move, your heels endure pressure that exceeds twice your own weight. Unfortunately, nobody really considers the cushioning mechanism that protects your heel bones from that force. Underneath the skin of your heel is a specialized shock-absorbing system, a pack of fatty tissue arranged into tightly packed cells, optimally situated to provide cushioning.
Once this tissue thins out or wears away, it is called heel fat pad atrophy, and even something as simple as walking on a hard floor can cause moderate pain. This article discusses the causes, signs, symptoms, and differential diagnosis of this condition and explores the treatments currently available, from home remedies to new medical treatments.
What Is Heel Fat Pad Atrophy?
The heel fat pad is a tightly packed, fibrous, fatty structure under the calcaneus the main heel bone. It is made up of a complex arrangment of enclosed chambers that are separated by connective tissue septa which ensure that the fat remains enclosed and does not migrate under pressure. It is this physically complex nature that makes it such a good ‘shock absorber’.
How It Differs From Other Heel Conditions
Atrophy of the heel fat pad involves a loss of volume or structure of a normal tissue. The fat isn’t really disappearing; the chambers degrade and the tissue doesn’t seem able to absorb force. The difference from the other pathologies is significant though and explains why it is that plantar fasciitis, bursitis or a heel stress fracture may all sound similar and give sore feet, but involve totally different tissues.
Common Causes and Risk Factors
Numerous reasons can contribute to accelerated degeneration of the heel pad tissue. Age is the most broad and universal factor – taking into account all other potential influences, the fat pad begins thinning and loses its elasticity after approximately 40 years of age. However aging alone does not usually give the full answer as other influences interact.
How Everyday Habits Affect Your Heel Fat Pad
Staying on bare, cement, or tiled floors for extensive periods in ergonomic (or even inappropriately designed) shoes also administers repetitive, mechanical tolls to the heel pad with hardly a substantial period for rebounding. This affects workers across all of the above-mentioned fields almost equally, especially those of trades, healthcare, retail, and manufacturing. Shoes with relatively thin soles—for example, barefoot minimalist sneakers and even some dress shoes—grab hold of external padding and force its unaffected heel pad to support the entirety of the pound at every impact.
Continual, pounding repetition in hard running may do as much damage with or without bare feet.
Medical and Biomechanical Contributors
Specific conditions may accelerate the rate of fat pad degeneration. Rheumatoid arthritis can cause direct inflammation and thinning of the heel pad while Diabetes affects the overall quality of connective tissue and peripheral circulation resulting in increased susceptibility to breakdown. A pes cavus foot type results in increased pressure concentration through the heel as opposed to dispersion across the sole.
The administration of corticosteroid injections into the heel – used in the treatment of plantar fasciitis in the past – is a well documented cause of fat pad atrophy when used repeatedly or improperly.
Signs, Symptoms, and When to Seek Help
Characteristic is a deep, dull pain localized at the bottom of the heel- feels like walking on a bone. Pain unlike other foot conditions, isn’t better later in the day, and worse after spending long periods of time on your feet. Swelling of the heel isn’t typically seen, and pain won’t radiate up the leg or arch.
Heel Fat Pad Atrophy vs. Plantar Fasciitis
The two are often mixed up so some simple practical differences can differentiate them. The pain of plantar fasciitis is commonly worst on the first steps after arising in the morning that brief stabbing pain recedes after a few paces, while the fat pad atrophy pain tends to be more constant through activity and described as tender or bruised rather than sharp. The “painful spot” also tends to be located in different places: plantar fasciitis hurts nearer the inside of the heel where the fascia inserts, whereas fat pad pain is located more centrally, beneath the heel bone.
Pushing hard on the middle of your heel and comparing it to the inside edge can give an approximate self-diagnoisis although an accurate assessment from a professional is always preferable.
How Doctors Diagnose the Condition
A regular heel examination performed by a podiatrist or orthopedic physician always includes palpation of the heel. This allows the examiner to determine the tenderness, consistency of the tissues, and visibility of displacement of the fat pad. When necessary, ultrasound can be used in the diagnostic process – it can measure the thickness of the fat pad directly and detect structural abnormalities not visible on x-ray.
An MRI can also be requested in the cases where the diagnosis is unsure or other pathology needs to be eliminated. Your provider should also inquire about the your shoes history, previous heel problems, work needs, and any pertinent history in your medical history.
Heel Fat Pad Atrophy Treatment Options
For most patients conservative management substantially alleviates pain, leading to an enhancement in their daily function. The aim is to prevent further strain to the remaining fat pad tissue, whilst reducing the mechanical loading present.
Footwear, Insoles, and Heel Cushions
Changing your footwear is by far the best single change you can make. Choose shoes with high heel cushioning, a slight heel raise (about 10 to 15 millimeters) and a stiff midsole that doesn’t flatten flat under weight. Silicone heel cups are cheap and actually do a good job of taking the load off the middle heel.
Custom orthotics purchased through your podiatrist are more specific, particularly if you have problems with abnormal foot mechanics as well. Cushioned socks, with the extra padding in the heel area, are also worth using on hard floors.
Exercise, Weight Management, and Lifestyle Tips
Losing just a few pounds of body weight decreases the amount of load experienced by the heel pad with each step. Gentle stretching and strengthening exercises of the calf complex help decrease compensatory efforts within the foot. Gait retraining through the use of physical therapy can help patients alleviate more mass on other parts of the foot.
Switching to softer surfaces such as grass, rubberized tracks, and carpeted area provide rest to the tissue in the heels.
Advanced and Emerging Medical Treatments
When conservative care has not given relief over many months it is worth discussing medical intervention with a specialist.
Injectable Fillers and Fat Grafting
Autologous fat grafting, where the heel pad was re-sculpted with fat taken from elsewhere in the patient, is considered to be the anatomically most sound option, as by nature it replaces like with like. The outcomes are variable and some reabsorption of the fat graft takes place. Dermal fillers, such as hyaluronic acids, have been used off-label as a cheaper and minimally invasive procedure, with a short-lived effect requiring repeat treatment.
Allograft materials from donor tissue are still being studied, however long-term results are yet to be published.
Other Procedures and Future Directions
Attempts have been made to develop synthetic biomaterials that replicate the chamber structure of native heel fat pad tissue, but use of these products has not been adopted in the mainstream clinical setting. Although early studies have indicated some potential benefit for tissue healing, clinical results using platelet rich plasma injections are still in the preliminary stages. Surgery is infrequently performed solely for this diagnosis; patients are more often managed conservatively and with less invasive therapies first.
The advances in treatment are promising but unfortunately the patient must be cautious in regards to newer therapies, as honest patient/physician dialogue is essential when considering treatments other than conservative management. Heel fat pad atrophy produces profound heel pain and limits daily activity. Learn the causes, presenting features, diagnostic procedures and conservative as well as more advanced treatment options.