Heel pain may be the most common foot complaint that a foot specialist sees. It is commonly thought that when you have pain in the bottom of your heel, it is due to plantar fasciitis. This is true for the majority of patients. However, there is another problem that is not as common called heel pad syndrome. In this blog, we will discuss the causes and treatment of heel fat pad syndrome. However, there is a possibility that you have been misdiagnosed and we will discuss a little-known diagnosis that may explain why your treatments are failing.
The Basics: Heel Anatomy
The foot is uniquely designed to absorb shock. As we walk or run, the foot will strike the ground with 3-4 times our body weight. To compensate for this, our heel is the softest bone in our body that will allow dissipation of that shock. Beneath the skin, we have a significant amount of fatty tissue distributed throughout the bottom of the foot.
This also allows for cushioning. Within the fat are tight connective tissues that serve as a net to support the structure of the fat pad. Also, on the bottom of the heel, if x-rays are taken there may be a heel spur noted. With the use of ultrasound technology, a podiatrist may also observe abnormality of the plantar fascia.
The plantar fascia originates in the ball of the foot and extends throughout the arch and inserts at the bottom of the heel. With every step that is taken, the arch flattens the fascia which is a tight connective tissue and is thought to pull on the heel.
Symptoms of Heel Pad Syndrome
When one is suffering from heel pad syndrome, the pain will be directly underneath the heel bone. Pain may be present first thing when you get up in the morning or when you walk throughout the day. The pain will not extend to the arch but is centered directly underneath the heel.
Causes of Heel Pad Syndrome
- Heredity – It is thought that some people may inherit a thinner fat pad.
- Cortisone Injections – Cortisone injection which may have been used to help plantar fasciitis may lead to heel pad syndrome and contribute to atrophy of the fat pad.
- Hard Surfaces –Walking or running barefoot and also doing activities on hard surfaces such as concrete or wooden floors can cause thinning of the fat pad.
- Biomechanics – Some foot structures may be more likely to cause atrophy of the fat pad.
- Excess Body Weight – People with more body weight may contribute to the development of heel pain. The added weight will create stress and displacement of the fat pad.
- Age – As we get older, it is thought thinning of the fat pad is part of the aging process.
- Metabolic Problems – Medical conditions such as type 2 diabetes, lupus, and rheumatoid arthritis may also increase the risk of developing heel pain.
How is Heel Pad Syndrome Diagnosed?
- Symptoms – The doctor will ask you about the symptoms, where they are, and when they occur.
- Examination – The doctor will examine the foot to see where the pain is located.
- Testing – X-rays may be taken to rule out any bony involvement.
- Diagnostic Ultrasound – Ultrasound can be used to measure the fat pad’s thickness and evaluate the plantar fascial tissue that inserts in this area.
- MRI Imaging – This may be ordered to evaluate the fascia and fat pad and, more importantly, rule out stress fracture to the heel.
Treatments may include the following:
- Shoe Gear – Shoe gear that may allow for more shoe cushioning may be helpful.
- Heel cups – Heel cups may help to center the fat more directly underneath the heel so that the fat is not displaced away from the middle of the heel when you’re bearing weight.
- Medication – Anti-inflammatories may be of some assistance to pain and inflammation.
- Icing – Icing may help alleviate the symptoms in mild cases of heel pad syndrome.
- Shoe inserts. Over-the-counter arch supports or custom-made orthotics.
Lifestyle change:
- Avoiding High-Impact Activities – Activities that cause heel pain such as basketball are high-impact activities. Jumping and landing on your foot should be avoided. These activities may cause wear and tear on the fat pad. Swimming and other low-impact activities with softer surfaces.
- Maintain a healthy weight – This will reduce impact and force on the feet, allowing for better distribution, and control.
Why the diagnosis of Heel Pad Syndrome should throw up a red flag in your mind?
Plantar Fasciitis. When we think about pain in the bottom of the heel, the most common diagnosis is plantar fasciitis. Patients with heel pain need to know that the best way to rule in or rule out plantar fasciitis is with a diagnostic ultrasound. With ultrasound, we can evaluate the appearance and thickness of the fascia to make the diagnosis. Without this test, the diagnosis cannot truly be confirmed.
Heel Spur. Heel Spur pain is a misconception. It used to be thought that if a heel spur was seen on an x-ray the spur was causing pain. With the advent of endoscopic surgery in the late 90s, pain from a heel spur became an antiquated idea. This endoscopic technique is highly successful at eliminating heel pain.
It allowed surgeons to make small incisions on both sides of the heel, visualize the fascia, and cut a portion of the fascia so it would stretch. Because the success of this technique did not allow the removal of heel spurs and many of the patients who had this procedure performed had a heel spur. This invalidated the concept of heel spur pain. In fact, in the 1930s as stated in medical literature the heel spur was a result of the fascia pulling from the heel but itself was not painful.
Your Fat Pad Syndrome Pain may truly be Nerve Pain. Are you misdiagnosed? Your Fat Pad Syndrome may be Nerve Pain.
The Medial Calcaneal Nerve Branch
The medial calcaneal nerve branch is a nerve that passes beneath the heel bone, and it is located precisely where the pain will be located. The origin of this nerve is from the posterior tibial nerve. The posterior tibial nerve is a nerve branch that travels on the inside of your ankle. This nerve has branches that supply the bottom of the foot much like the carpal tunnel area in the hand. Two branches in the tarsal tunnel area extend to the arch and ball of the foot to supply sensation to this area.
The third branch, the medial calcaneal nerve, goes down the inside of your heel and supplies the bottom of the heel bone. On its way to the bottom of the heel bone, it passes through a small tunnel on the inner side of the heel bone. This nerve tunnel composed of tightly connected tissue is thought to entrap (compress) this nerve. It is also thought that when the plantar fascia is thickened in patients with plantar fasciitis this nerve is also irritated. A patient can have both plantar fasciitis and nerve pain.
Diagnosis of Medial Calcaneal Nerve Branch Pain
- Clinically – The doctor can evaluate the heel. Usually there will be some discomfort on the inner side of your heel bone.
- Diagnostic Injections – An injection may be given at the entrapment site of the nerve at the inside of the heel before the nerve travels beneath the heel bone. Patients will respond favorably to these injections with a significant reduction of pain, and this confirms the diagnosis.
Treatment
- Cortisone Injections – Cortisone injections can help confirm the injection but a series of two or three injections can eliminate the pain.
- Radio Frequency Nerve Ablation Technique – This technique is used to block the pain signals in the nerve.
- Surgery – As a last result, surgery can be used to resect the nerve and bury it into muscle in the lower leg.
Have you been told you have heel pad syndrome and the attempts by your doctor have failed? Please consider the little-known diagnosis of medical calcaneal nerve branch entrapment. This may truly be what is slowing you down and causing your heel pain. This is why you should contact our certified foot doctors.
