Plantar fat pad syndrome: an often overlooked heel pain

Among the causes of chronic talalgia, atrophy of the plantar fat pad remains under-diagnosed. This essential anatomical structure plays a key biomechanical role in cushioning shocks to the calcaneus. Its degeneration or disorganization can lead to persistent, sometimes disabling pain, in both active and elderly patients.

The plantar fat pad is a fibro-fatty structure, compartmentalized by partitions of dense connective tissue, located beneath the calcaneus. It acts as a shock absorber, reducing the stress transmitted to the heel when walking, running or jumping.

Its effectiveness depends on the integrity of the fat lobules and surrounding septa. With age, repeated microtrauma or certain metabolic pathologies, these compartments can crack, collapse or atrophy, leading to a reduction in cushioning capacity.

Fat pad atrophy can result from :

• Natural aging: loss of elasticity and volume of fatty tissue.

• Repetitive strain injury: running on hard surfaces, prolonged standing, wearing unsuitable footwear.

• Metabolic disorders: diabetes, prolonged corticosteroid therapy.

• Iatrogenic factors: post-heel surgery, repeated local injections.

• Mechanical hyperpressure: overweight, hollow foot with posterior overload, length inequalities.

These factors alter the distribution of pressure under the heel, exposing the calcaneal periosteum to direct forces, a source of pain.

Patients generally describe localized pain in the center of the heel, aggravated by weight-bearing, particularly at the end of the day or after prolonged activity. It is often non-inflammatory, without redness or swelling, which distinguishes it from plantar fasciitis.

Clinical examination may reveal :

• Tenderness to palpation of the central calcaneus.

• A palpable reduction in the thickness of the fat pad.

• A painful loading test, accentuated by walking barefoot on hard ground.

• Absence of ascending radiation (unlike sciatica or plantar fascia syndrome).

• Musculoskeletal ultrasound: useful for measuring fat pad thickness (normally > 1.0 cm), looking for tissue disorganization.

• MRI: may show atrophy of fibrofatty tissue, underlying bone contusion or associated abnormalities (fasciitis, bursitis).

• Podography or pressure platform: to assess localized mechanical overload.

In the majority of cases, management is conservative, with a reduction in stress.

Reduced mechanical stress

• Orthopedic insoles with heel cushioning in silicone or memory foam.

• Wear shoes with good cushioning, soft heels, avoid walking barefoot.

Functional rehabilitation

• Progressive unloading work, stride correction.

• Strengthening the intrinsic muscles of the foot.

• Stretch the sural triceps (calf) to reduce posterior tension.

Manual therapies

• Gentle joint mobilization, tissue drainage if fibrosis.

• Proprioceptive work and postural reprogramming.

Medical treatments

• Local infiltration in case of associated inflammatory component (handle with caution).

• Background treatment if systemic pathology.

Advanced techniques (refractory and rare cases)

• Injections of PRP or autologous fat cells (under study).

• Reconstructive surgery is rare but can be envisaged in certain severe cases.

When a plantar pad atrophies, it's not just the heel that suffers: the whole body's mechanics can go haywire. This silent pain, often misidentified, can alter the pleasure of walking, running or simply standing.

Osteopathy offers a global, gentle and precise approach, which does not limit itself to the symptom. It aims to reduce mechanical stresses, rebalance supports and release accumulated tension, enabling the body to regain its harmony.

By working closely with the joints, fascias, posture and local circulation, the osteopath guides the patient towards better adaptation, lasting relief and a return to movement with confidence.

Because a well-harmonized, well-guided and well-trained body knows how to find its way back to comfort.