What is the treatment for heel pad syndrome?

Treatment for Heel Pad Syndrome

The treatment of heel pad syndrome should focus on cushioning and supporting the heel through heel pads, orthotics, and activity modification, with NSAIDs for pain management and weight loss if indicated. 1

Diagnosis and Clinical Features

Heel pad syndrome is characterized by:

• Pain in the central heel area (rather than at the plantar fascia insertion)
• Pain that worsens with walking on hard surfaces
• Tenderness with direct compression of the heel pad
• Thinning or damage to the fat pad structure (visible on ultrasound)

Treatment Algorithm

First-Line Treatment

1. Cushioning and Support

   • Customized heel pads with shock-absorbing materials 2
   • Soft molded orthotics with medial arch support 2
   • Open-backed shoes to reduce pressure on the heel area 1

2. Activity Modification

   • Decreased weight-bearing activities 1
   • Avoidance of walking barefoot, especially on hard surfaces 1
   • Rest during acute pain episodes

3. Pain Management

   • NSAIDs for pain and inflammation 1
   • Ice application after activity

4. Weight Management

   • Weight loss if the patient is overweight/obese 1, 3

If No Improvement After 6-8 Weeks

1. Advanced Interventions

   • Immobilization with cast or fixed-ankle walker-type device 1
   • Referral to podiatric foot and ankle surgeon 1
   • Consider corticosteroid injection (used cautiously to avoid further fat pad atrophy) 3

2. Emerging Treatments

   • Platelet-rich plasma (PRP) injections may be considered for refractory cases 4

Evidence-Based Efficacy

A study evaluating customized heel pads and soft orthotics showed significant pain reduction after 5 weeks of use (P≤0.0001) 2. These interventions are considered effective first-line treatments for heel pain and associated functional limitations.

Important Clinical Considerations

• Differential Diagnosis: Heel pad syndrome must be differentiated from plantar fasciitis, which typically causes pain at the medial calcaneal tubercle rather than centrally in the heel 5

• Risk of Misdiagnosis: In adolescents, heel pain may be due to Sever's disease (calcaneal apophysitis) rather than heel pad syndrome 6

• Common Pitfalls:

  1. Failing to address footwear issues
  2. Not providing adequate cushioning
  3. Overuse of corticosteroid injections, which can further atrophy the fat pad
  4. Neglecting weight management in obese patients

• Monitoring: Patients should be reassessed every 4-6 weeks to evaluate treatment response and adjust interventions accordingly

The evidence strongly supports that most patients with heel pad syndrome will respond to conservative measures, particularly customized heel pads and orthotics that provide proper cushioning and support to the damaged fat pad structure.