Heel Pad Syndrome (HPS), also known as Heel Fat Pad Syndrome (HFPS), is an often-overlooked but significant cause of chronic heel pain. The fat pad beneath the heel bone acts as a natural shock absorber and pressure distributor during standing, walking, or running. When this cushion becomes thinned, inflamed, or displaced, it loses its ability to absorb impact, leading to pain and discomfort—especially when standing or walking on hard surfaces. While plantar fasciitis remains the most common cause of heel pain, HFPS is believed to be the second most frequent cause.
How Common It Is and Who Gets It? (Epidemiology)
Heel Pad Syndrome affects both active and sedentary populations but is most common in middle-aged and older adults. A U.S. study found a 4.2% prevalence of HFPS among older adults, compared to 6.9% for plantar fasciitis. In a South Korean study of patients with heel pain, 15% had HFPS and 53% had plantar fasciitis, confirming that HFPS is a major but underdiagnosed source of heel pain. It occurs equally in men and women but is slightly more common in those who spend long hours standing, have high body weight, or use inadequate footwear.
Why It Happens – Causes (Etiology and Pathophysiology)
The heel fat pad is composed of fibrous septa that compartmentalize fat cells into microchambers. This structure acts like a hydraulic cushion that absorbs up to 2.5 times body weight during running. When this tissue degenerates or becomes displaced, the heel loses its ability to absorb shock.
Common causes include:
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Aging: Natural thinning of the fat pad due to collagen and elastin loss.
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Overuse: Repetitive impact activities (running, jumping) or prolonged standing.
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Trauma: Hard landings on the heel or chronic microtrauma from poor biomechanics.
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Improper footwear: Shoes without adequate heel cushioning or support.
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Corticosteroid injections: Repeated injections for plantar fasciitis can weaken and thin the fat pad.
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Systemic conditions: Diabetes, rheumatoid arthritis, and connective tissue disorders can degrade the fat pad’s structure.
How the Body Part Normally Works? (Relevant Anatomy)
The heel fat pad lies beneath the calcaneus (heel bone) and is separated from the skin by connective tissue septa. It functions to absorb shock, distribute pressure, and protect the heel bone during standing and movement. The septa anchor the fat chambers to the underlying calcaneus, maintaining stability. When these septa stretch or rupture, the fat pad flattens and shifts, increasing direct stress on the heel bone and leading to inflammation and pain.
What You Might Feel – Symptoms (Clinical Presentation)
Patients with HFPS describe pain as deep, dull, or bruise-like, located in the center of the heel rather than the medial side (as seen in plantar fasciitis).
Key symptoms include:
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Pain worsens when walking barefoot or on hard surfaces.
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Pain may increase with prolonged standing.
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Discomfort may persist even at rest or at night.
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Lack of “first-step” morning pain (unlike plantar fasciitis).
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Occasionally bilateral pain (both heels).
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Sensation of “walking on a pebble.”
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis relies on a detailed history and physical examination.
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Clinical Exam: Localized tenderness in the middle of the heel pad rather than near the plantar fascia insertion. Pain often reproduces when pressing directly on the heel.
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Ultrasound: Measures heel pad thickness and elasticity. A thickness below 9 mm indicates atrophy or degeneration. It can also show septal rupture or loss of compressibility.
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MRI: Reveals fibrosis, edema, and septal ruptures, and differentiates HFPS from other causes like plantar fasciitis or bone stress injuries.
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Dynamic ultrasound: Evaluates fat pad mobility during heel loading, revealing abnormal displacement in some patients.
Classification
Heel Pad Syndrome may be categorized as:
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Primary (degenerative): Age-related thinning and wear of the heel pad.
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Secondary (traumatic or iatrogenic): From injury, repetitive impact, or corticosteroid injections.
Severity can also be classified as mild, moderate, or severe based on pain intensity and fat pad thinning on imaging.
Other Problems That Can Feel Similar (Differential Diagnosis)
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Plantar fasciitis (pain at medial heel, worse on first steps).
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Calcaneal stress fracture (localized tenderness, swelling, positive hop test).
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Heel bursitis (pain above or behind the heel).
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Tarsal tunnel syndrome (tingling or burning from nerve compression).
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Systemic conditions (gout, rheumatoid arthritis, or diabetic neuropathy).
Treatment Options
Non-Surgical Care
Most cases of HFPS improve with conservative measures that restore heel cushioning and reduce mechanical stress:
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Viscoelastic heel cups or gel inserts: Absorb shock and distribute weight evenly.
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Cushioned footwear: Shoes with thick midsoles and shock-absorbing materials help reduce heel pressure.
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Low-dye taping: Provides temporary support and stabilizes the heel pad to prevent displacement.
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Activity modification: Avoid prolonged standing, running, or walking on hard surfaces.
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Physical therapy: Focuses on calf stretching and foot mechanics correction.
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Weight management: Reducing excess body weight can lessen heel loading forces.
A quasi-experimental study found that low-dye taping reduced pain by up to 3 points on a 10-point scale and lowered plantar pressure during walking. Another case report documented improvement after 3 months of gel heel cup use, showing reduced fat pad stiffness and pain relief.
Surgical and Experimental Treatments
Surgery is rare and considered only in chronic, refractory cases. Options include:
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Fat pad reconstruction: Using autologous fat grafting or synthetic fillers to restore heel cushioning.
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Platelet-Rich Plasma (PRP) therapy: Promotes healing and regeneration of soft tissue.
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Stem cell injections: An emerging therapy aimed at restoring fat pad elasticity.
In one reported case, surgical repair following fat pad rupture allowed return to normal activity, though mild residual pain persisted.
Recovery and What to Expect After Treatment
With appropriate footwear and offloading strategies, most patients experience improvement within 6–8 weeks. Recovery may take several months for severe or chronic cases. Long-term adherence to cushioned footwear and orthotics is critical for sustained pain relief.
Possible Risks or Side Effects (Complications)
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Chronic pain from continued overloading.
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Permanent fat pad atrophy if untreated or worsened by corticosteroid injections.
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Altered gait mechanics and compensatory pain in knees or hips.
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Recurrent symptoms if inadequate footwear or improper activity modification.
Long-Term Outlook (Prognosis)
The prognosis for heel pad syndrome is favorable with early diagnosis and proper management. Conservative treatment is successful in most cases. However, untreated HFPS can become chronic, leading to persistent pain and disability.
Out-of-Pocket Costs
Medicare
CPT Code 15770 – Fat Pad Reconstruction/Augmentation (Graft; Dermal, Fat, and/or Fascia for Defect Repair): $157.77
CPT Code 27680 – Surgical Repair for Fat Pad Rupture (Excision of Lesion or Soft Tissue Repair of Leg/Ankle): $99.83
Medicare Part B covers 80% of the approved cost for these procedures once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield generally cover that remaining 20%, minimizing or eliminating out-of-pocket expenses for Medicare-approved procedures. These plans work with Medicare to close coverage gaps and reduce patient costs.
If you have Secondary Insurance such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it will act as a secondary payer. These plans usually cover any remaining balance, including coinsurance or small deductibles, which typically range from $100 to $300 depending on your plan and provider network.
Workers’ Compensation
If your heel pad injury or rupture is work-related, Workers’ Compensation will cover all medical expenses, including fat pad reconstruction, surgical repair, and rehabilitation. You will not have any out-of-pocket expenses, as the employer’s insurance carrier pays for all covered treatments directly.
No-Fault Insurance
If your heel pad syndrome or rupture occurred as a result of an automobile accident, No-Fault Insurance will generally cover the total cost of your treatment, including surgery and follow-up care. The only potential out-of-pocket cost may be a small deductible or co-payment depending on your policy.
Example
Jessica Allen suffered from heel pad syndrome and required fat pad reconstruction (CPT 15770) to restore cushioning under her heel. Her estimated Medicare out-of-pocket cost was $157.77. Since Jessica had supplemental insurance through Blue Cross Blue Shield, her remaining balance was fully covered, leaving her with no out-of-pocket expenses for the procedure.
Frequently Asked Questions (FAQ)
Q. What is heel pad syndrome?
A. Heel pad syndrome is a condition where the fat pad under the heel bone becomes thinned or damaged, leading to heel pain.
Q. What causes heel pad syndrome?
A. It is caused by the thinning, degeneration, or displacement of the natural fat pad that cushions the heel bone.
Q. What are the symptoms of heel pad syndrome?
A. Symptoms include deep, bruised-like pain in the center of the heel, especially during walking or standing for long periods.
Q. How is heel pad syndrome different from plantar fasciitis?
A. Heel pad syndrome causes pain in the center of the heel due to fat pad issues, while plantar fasciitis typically causes pain on the inner part of the heel due to inflammation of the plantar fascia.
Q. Who is at risk for developing heel pad syndrome?
A. Individuals who walk barefoot on hard surfaces, wear poorly cushioned shoes, or are overweight are at higher risk.
Q. How is heel pad syndrome diagnosed?
A. Diagnosis is typically made through clinical examination, patient history, and sometimes imaging like X-rays or MRI to rule out other causes.
Q. What conservative treatments are available for heel pad syndrome?
A. Conservative treatments include using cushioned heel pads, avoiding walking barefoot, wearing supportive shoes, and weight loss.
Q. Can heel pad syndrome be treated with physical therapy?
A. Yes, physical therapy may help reduce symptoms and improve foot mechanics.
Q. Is surgery required for heel pad syndrome?
A. Surgery is rarely needed; most cases respond well to non-surgical treatments.
Q. How long does it take to recover from heel pad syndrome?
A. Recovery time varies but most patients improve over weeks to months with proper treatment.
Q. Can imaging tests show damage to the heel pad?
A. Yes, MRI or ultrasound can show thinning or degeneration of the fat pad.
Q. What types of shoes are recommended for someone with heel pad syndrome?
A. Supportive shoes with good cushioning in the heel area are recommended to alleviate pressure and reduce pain.
Q. Can heel pad syndrome become a chronic condition?
A. Yes, if not properly managed, heel pad syndrome can become chronic and continue to cause pain over time.
Q. Is there a link between aging and heel pad syndrome?
A. Yes, the heel pad naturally thins with age, increasing the risk of developing the syndrome.
Summary and Takeaway
Heel Pad Syndrome (HFPS) is an underdiagnosed but common cause of chronic heel pain resulting from thinning or degeneration of the heel’s natural cushioning. Patients experience central, bruise-like pain that worsens with walking on hard surfaces or prolonged standing. Diagnosis is confirmed through clinical examination and imaging, particularly ultrasound. Most cases improve with conservative management such as cushioned footwear, heel cups, and activity modification. Surgery or regenerative therapy is reserved for persistent, severe cases.
Clinical Insight & Recent Findings
A recent study found that Heel Fat Pad Syndrome (HFPS) is likely the second most common cause of heel pain after plantar fasciitis, yet remains under-researched.
The review highlighted that HFPS causes deep, bruise-like heel pain that worsens when standing or walking on hard surfaces, differing from the morning “first-step” pain typical of plantar fasciitis. Ultrasound showing a thinned heel pad (under 9 mm) can help confirm the diagnosis.
While treatments like heel cups and taping are commonly recommended, their effectiveness has not yet been proven in large clinical trials. (“Recent study on heel fat pad syndrome – see PubMed.“)
Who Performs This Treatment? (Specialists and Team Involved)
HFPS is diagnosed and treated by orthopedic foot and ankle specialists, podiatrists, or sports medicine physicians. Physical therapists and orthotists assist in rehabilitation and orthotic design.
When to See a Specialist?
Seek evaluation if heel pain persists beyond 2–4 weeks despite rest, or if pain worsens while standing or walking barefoot on hard surfaces.
When to Go to the Emergency Room?
Emergency care is rarely needed unless heel pain follows acute trauma (fall or hard landing) or if infection, swelling, or redness develops.
What Recovery Really Looks Like?
Most patients recover with non-surgical care, requiring 6–8 weeks of consistent use of cushioned shoes or heel inserts. Severe or long-standing cases may take several months for full pain resolution.
What Happens If You Ignore It?
Untreated heel pad syndrome can lead to chronic pain, fat pad atrophy, and altered gait mechanics, which may cause secondary knee, hip, or back discomfort.
How to Prevent It?
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Wear cushioned, supportive footwear.
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Avoid walking barefoot on hard surfaces.
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Maintain a healthy body weight.
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Limit corticosteroid injections for heel pain.
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Strengthen lower-leg and foot muscles to support proper mechanics.
Nutrition and Bone or Joint Health
Adequate intake of vitamin D, calcium, and omega-3 fatty acids supports soft-tissue integrity and bone health. Hydration and a diet rich in collagen and antioxidants can aid recovery from tissue microtrauma.
Activity and Lifestyle Modifications
Avoid high-impact exercises during recovery. Engage in low-impact activities such as swimming or cycling. Gradually resume weight-bearing activities using orthotics and cushioned footwear to prevent recurrence.
Dr. Mo Athar
