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At Zona Physical Therapy in Boise, Idaho, we commonly treat foot pain that has been misdiagnosed as plantar fasciitis. Sometimes, this “plantar fasciitis” pain right under the heel can be due to fat pad atrophy. Generally, fat pad atrophy will show in a form of heel pain that doesn’t get better with activity and is usually caused by landing on a sharp object while barefoot, prolonged steroid use, continuous heavy loading of the heel, and aging.

Anatomy of Heel Fat Pad

The anatomy of the fat pad on the heel allows the heel to accept large loads from running and walking. In the image below, you can see that the fat is gathered in U- shaped septa that are designed to accept compressive forces. Although created to withstand forces, these pads are vulnerable to degeneration and tend to break down in later years of life. The breakdown of septa can occur earlier with repetitive stress and other factors such as increasing weight or lack of cushion in high volume running. What can you do after some sort of pain from degeneration has started?

fat pad atrophy
Courtesy of https://doi.org/10.1016/S0958-2592(98)90026-8

There is currently a thought process that if you are experiencing fat pad atrophy and subsequent pain, you should get fat injected into the pad. Like a fat relocation process. I’ve had a patient ask if she could take some fat from her belly and inject it into her foot to fix her fat pad atrophy. Well……she could here at UPMC, but should she? Let’s take a look.

Fat Pad Injections

UPMC takes pride in solving pain for those who were experiencing fat pad injuries. They decided to perform a clinical trial and write a research article. Although UPMC has a link to this article on their site and promotes injection treatments, they disclosed that they do not have a financial interest to declare in their article. This is inherently flawed because they do have a monetary interest. Lots of it.

Moving on to the meat of the study, 31 adults who were experiencing fat pad atrophy were recruited to participate. 18 of the participants were given fat pad injections immediately. The other 13 were given “standard of care” for 12 months and then an injection. Both groups were followed for 24 months. Before I jump into the results, we need to look at the two treatments given.

The first, which is clear, is the injection. Subcutaneous fat was pulled from the body and injected into the foot. The second, which is not so clear, is the “standard of care” for heel pain. What is the standard of care? No one knows. It was never mentioned. “Standard of Care” could have been nothing, orthotics, physical therapy, steroid injections (please don’t do this for fat pad injuries!), or a myriad of other things. It will always be a mystery.

Fat Pad Injection Results

So how did the two groups compare? According to the pain and disability outcomes during the study, nothing. In the article, the authors wrote, “No significant difference was observed between group 1 and group 2 regarding all four categories of Manchester Foot and Disability Index scores at any time.”

Ouch. The group that waited one year for their injection had no significant improvement compared to the group that was injected immediately. In the last paragraph of the Results section, the authors conceded to note, “No change in work/leisure activities over time was observed in group 1 Although subjects in group 2 reported significant improvements in work/leisure activities at 1 and 2 months postoperatively improvements were not sustained through the 1-year of follow-up.”

Another ouch. Pain, functionality, appearance, and work leisure activity had some improvement, but the benefits did not last long term. So if injections don’t work, what’s to be done?

Our Current “Standard of Care”

While we may never know the standard of care in the reviewed research article, Dr. Hampton and I use a low-risk and more effective treatment. We use techniques to offload the fat until it desensitizes. One huge component we add to the home plan is adding a cushion under the heel at all times. We recommend Crocs or a soft cushioned slipper at home to keep the sensitive heel away from hard surfaces. The fat in the septa will not heal or “thicken,” but they will feel better if they’re offloaded enough and with the right techniques. If you’re experiencing heel pain, schedule a visit HERE to get an accurate diagnosis and get out of pain and back to your goals.

Check out our video about fat pad atrophy below-

Heel Pain? The fat pad could be to blame!

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