What is the initial treatment for plantar fat pad herniation on the heel?

Initial Treatment for Plantar Fat Pad Herniation on the Heel

The initial treatment for plantar fat pad herniation on the heel should include properly fitting footwear with cushioning, orthotic devices with heel cups, and activity modification to reduce pressure on the affected area.

Understanding Plantar Fat Pad Herniation

Plantar fat pad herniation is a condition where the specialized adipose tissue that normally provides cushioning under the heel becomes displaced or damaged, resulting in:

• Loss of natural shock absorption
• Pain during weight-bearing activities
• Discomfort that worsens with prolonged standing or walking

Diagnostic Considerations

Before initiating treatment, confirm the diagnosis by:

• Examining for tenderness directly under the heel rather than at the medial plantar calcaneal region (which would suggest plantar fasciitis)
• Assessing for pain that increases with direct pressure on the heel pad
• Considering ultrasonography to evaluate fat pad thickness and structural integrity 1

Treatment Algorithm

First-Line Interventions

1. Footwear Modifications

   • Recommend open-backed shoes with adequate cushioning 2
   • Avoid barefoot walking, thin-soled slippers, or flat shoes 2
   • Consider heel lifts to reduce pressure on the affected area 2

2. Orthotic Devices

   • Prescribe accommodative padding or heel cups to redistribute pressure 2
   • Consider custom-made insoles for cases with significant discomfort 2
   • Felted foam in combination with appropriate footwear can provide additional cushioning 2

3. Activity Modification

   • Limit prolonged standing and walking 2
   • Recommend weight loss if the patient is overweight 2
   • Advise use of assistive devices (canes or crutches) if necessary to reduce weight-bearing 2

Second-Line Interventions (if no improvement after 6-8 weeks)

1. Physical Therapy

   • Stretching exercises for calf muscles and plantar fascia 2
   • Foot-ankle exercise program for 8-12 weeks 2

2. Advanced Offloading

   • Consider removable ankle-high offloading devices for severe cases 2
   • Padding techniques to redistribute pressure away from the affected area 2

3. Pain Management

   • NSAIDs for pain and inflammation control 2
   • Ice massage to reduce inflammation 3

Special Considerations

Cautions

• Avoid corticosteroid injections in the heel fat pad area as they can cause further fat pad atrophy and worsen the condition 4
• Differentiate from plantar fasciitis, which presents with pain at the medial plantar calcaneal region rather than directly under the heel 3, 1
• Monitor for signs of skin breakdown in patients with diabetes or peripheral neuropathy 2

Emerging Treatments

• Platelet-rich plasma (PRP) injections have been proposed as a potential treatment option for heel fat pad syndrome, though evidence is currently limited to case reports 5

When to Consider Referral

• If no improvement occurs after 6-8 weeks of conservative treatment 2
• For custom orthotic fabrication if prefabricated devices are ineffective
• For consideration of advanced imaging or specialized interventions in recalcitrant cases 2

By following this treatment approach, most patients with plantar fat pad herniation can achieve significant symptom relief without requiring invasive interventions.