Fat Pad Syndrome

 

What is fat pad syndrome?

Fat pad syndrome is a condition that usually happens in the centre of your 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. 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.  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. 

 

Classic signs and symptoms: 
  • A gradual onset of a dull achy pain under the centre of the heel
  • Pain increases with activity during periods of standing or walking
  • Localised swelling that can cause discomfort when wearing footwear
  • Can feel tender or warm and is more painful when you press directly on it
What causes the problem?

In most cases, fat pad syndrome develops as a result of repeated overuse.

Other contributing factors
  • Being overweight
  • Age (from 30+ years) natural thinning of the fat pad
  • Wearing inappropriate unsupportive footwear
  • Spending long periods standing or walking, especially with a sudden increase in these activities
  • Diabetes
  • Inflammatory conditions i.e. rheumatoid arthritis, psoriatic arthritis etc.
  • Weakness in the muscles within your feet or leg
  • Tightness of the muscles in the backs of your legs
  • Not allowing adequate recovery time between activities
  • Prolonged use of oral corticosteroids
What can I do to help?

Unfortunately there is no quick or easy fix and your symptoms will not improve overnight. The advice below is focused on reducing your symptoms to help you get back to normal activity. Most peoples’ symptoms improve but it may take several months to get better.

It is important to note that if you have any of the above contributing factors you will need to consider making the necessary changes to your lifestyle to help aid your recovery.

The only person who can help you get better is you!

Weight management 

Increased weight will place extra stress through your heel and reduce the natural shock absorption in your feet. Losing even a small amount of weight can make a big difference.

If you need help with weight-control, you can find information, advice and groups you can join to help you manage your weight better. Follow this link to an NHS BMI Calculator (https://www.nhs.uk/live-well/healthy-weight/bmi-calculator/) to guide you on whether you should consider weight management.

Footwear  

With fat pad syndrome there will be some inflammation and swelling in the heel. It is advisable to avoid shoes that have thin, hard soles. This type of shoe will not provide enough cushioning or shock absorption for your foot. With the reduced ability of the heel to absorb shock, some people find benefit wearing a thicker soled shoe, like a trainer, that offers more shock absorption and cushioning. 

Pain Management

Pain medication can help reduce your symptoms, allowing you to move more comfortably which will aid your recovery. Your community Pharmacist can provide guidance on specific medication or other methods of pain relief (always read the label and manufacturer’s guidelines).

Injury Management 

The P.O.L.I.C.E guidelines describe what you should do for the first 24 to 48 hours after suffering a mild sprain, strain or sports injury.

Protection- Protect or support your injured body part for the first 24 to 48 hours after injury. Use a light bandage to support the injury.

Optimal Loading- Early activity encourages early recovery. The key of optimal loading is movement of the injured area within a pain-free range to help promote optimal healing.

Prolonged rest could lengthen your recovery period and it may impact on your health and wellbeing.

Ice- If you've had an injury or flare-up in the last two days:

• wrap crushed ice in a damp towel

• hold it for 20 minutes against the part of your body that hurts. Make sure you use a damp towel between the ice and the skin to avoid ice burn

Alternatively, you could try sports sprays and gel/cool packs, which do a similar job. You can do this every two to three hours.

Should I use a heat pad?

After two days, you may find that heat is more relaxing. You could use a heat pad or a hot water bottle with an insulated cover on it. Make sure this is not too hot and is not directly touching your skin. You should do this three to four times a day for 10 to 15 minutes.

Compression- Apply compression with a bandage or tubi-grip type of support until the swelling goes down. Wrap the bandage starting from the end furthest from your heart. Loosen the bandage if the pain increases or the area becomes numb.

Don't make the bandage too tight and do not wear tubi-grip or any compression bandage in bed at night.

Elevation- Elevate your foot / ankle above the level of your heart as much as possible during the first 24 to 48 hours, especially when sitting or lying down. Make sure you use pillows underneath your foot for support.

After 48 hours:

-Try to weight-bear more, loading with a limp is generally normal in this phase, exercise can help relieve pain

-Do whatever you normally would and remain at work, or return to work

-Avoid sports or heavy lifting until you have less discomfort and improved movement

It is normal to still be experiencing pain after 48 hours.   It is important to slowly begin weight-bearing through your painful foot as prolonged rest could lengthen your recovery period and may impact on your health and wellbeing.

If you are in pain,  do not try and do all your normal daily activities such as housework, at once. Break the harder jobs down into smaller jobs and do something gentler in between.

Extensive walking or standing should be avoided if it aggravates your pain. It is recommended to modify activities rather than to fully stop all forms of movement or exercise.  Swimming or cycling are an alternative to walking or running as these activities are non-weight bearing.

After periods of activity you may experience an increase in pain. Appling some ice can be useful in reducing some of the inflammation in your painful heel. This can be achieved by:

• Wrapping crushed ice in a damp towel. Using a damp towel between the ice and the skin will help to avoid an ice burn.  

• Hold it for 20 minutes against the painful heel. Alternatively, you could try sports sprays and gel/cool packs, which will do a similar job.

Stretching exercises 

Stretching exercises for the muscles in the back of the legs can improve the flexibility of your foot and ankle. This will allow your heel and foot to absorb shock more efficiently. Your podiatrist will advise you on which exercises are suitable for you.

Insoles

Buying a pair of soft gel heel cups or insoles that are cushioning and shock absorbing will very often help reduce your symptoms.  These can be found in most Pharmacies or bought online.

Strapping

Strapping/taping can be used to help maintain the position of the fat pad over the heel bone. This is a short term treatment and should be used until your symptoms improve. Your podiatrist will advise you on this.

Patience

Have patience. Your symptoms should start to improve within three months of following this advice.

What else can be done?

If your heel pain has not started to improve after a period of three  months of following the advice above, a self-referral can be made in person at your local Health Centre. 

Frequently Asked Questions 

The information below will answer many of the questions you may have in the early part of your treatment.  We aim to ensure your specific needs are considered throughout your treatment.     A shared decision making process is used by our teams.  This means you will be informed about the treatment options open to you the risks and benefits of each option.  You will be supported to make a choice about which treatment best meets your needs.

We hope the following questions that have been developed on the back of MSK focus groups, will provide you with some answers with provide you with key information around your condition.

• What is wrong? Why? What is the cause? Fat pad syndrome is a condition that usually happens in the centre of your heel and is most often due to thinning and degeneration of the fat pad. 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.

• What is the possible impact on my health and function? It can be very disabling, each step can become painful, which in turn can lead to strains elsewhere in the body.

• Will I get better or worse? The good news is that with appropriate advice and treatment this will resolve in the vast majority of cases.

• Is it curable? Unfortunately,  there is no quick or easy fix and your symptoms will not improve overnight. The advice below is focused on reducing your symptoms to help you get back to normal activity. Most peoples’ symptoms improve but it may take several months to get better.

• How long will it take to get better? Most people’s symptoms should start to improve within three months of following the self-help advice.  It can take several months to achieve a significant improvement.

• What are you (the health professional) able to do about my problem? By using our self-help tool, we would like to help you to better understand your condition and provide you with the tools which should help support your recovery.

• What is the treatment that is most appropriate for me? Treatment protocols for heel pain almost always start with basic principles and we would encourage you to consider trying some self-help treatment in the first instance before making a referral to your local Podiatry department.

• What can I do to help myself to alleviate it? We would encourage you to consider trying some self-help treatment in the first instance before making a referral to your local Podiatry department. Pain medication can help to reduce your pain and help you move more comfortably and help aid your recovery. Speaking to your community Pharmacist can provide guidance on specific medication or other methods of pain relief.

• How can I reduce or control my pain? Pain medication can help to reduce your pain and help you move more comfortably to help aid your recovery. Speaking to your community Pharmacist can provide guidance on specific medication or other methods of pain relief.

• How can I maintain my function and do the things I want to and need to do? If you are in pain do not try and do all your normal daily activities such as housework, at once. Break the harder jobs down into smaller jobs and do something gentler in between.

Extensive walking or standing should be avoided if it aggravates your pain. It is recommended to modify activities rather than to fully stop all forms of movement or exercise.  Swimming or cycling are an alternative to walking or running as these activities are non-weight bearing.

• What activities can I do and how should I adapt them (e.g. sports, work)? Avoid high impact activities like running or activities which involve long periods of standing which will significantly increase load through the plantar fascia, we would encourage you to participate in low impact activities like walking, swimming, cycling etc.

• Have I made an improvement? Most people’s symptoms should start to improve within three months of following the self-help advice, you should notice that although you may still have episodes of pain they will becoming less frequent and severe.

Why am I not improving? Where have I gone wrong? Am I doing the right things? There could be a number of reasons why your symptoms may not be improving within the three months of following the self-help advice.  We would advise you to make contact with one of our MSK Podiatry clinics for further advice/assessment. This can be done by either completing a self-referral form in person at your local Health Centre.