Dr. Yi-Cheng Wu
中文

Heel Fat Pad Syndrome: The Heel Pain Often Misdiagnosed as Plantar Fasciitis

By Dr. Yi-Cheng Wu · Reviewed June 8, 2026

Heel fat pad syndrome is the second most common cause of heel pain and is often misdiagnosed as plantar fasciitis, although its risk factors, symptoms, and treatment differ.

Heel fat pad syndrome is a common cause of heel pain, second only to plantar fasciitis (accounting for about 14.8%), and is often misdiagnosed because the symptoms are similar. It is characterized by deep pain over the central weight-bearing part of the calcaneal tuberosity, typically worse with weight-bearing and relieved by rest, and it is not aggravated by dorsiflexion, which helps distinguish it from plantar fasciitis. Risk factors include older age, obesity, prolonged standing or walking on hard surfaces, and overuse in sport. Ultrasound can assess the thickness of the fat pad to aid diagnosis. Treatment focuses mainly on rest, weight control, load modification, orthotic insoles, and physical therapy, some of which have low-to-moderate evidence support.

Heel fat pad syndrome is the second most common cause of heel pain after plantar fasciitis (about 14.8%). It is usually misdiagnosed as plantar fasciitis, and although both can cause heel pain, the risk factors, symptoms, and treatment differ.

The heel fat pad is made up of fat tissue and separating fibrous tissue. It consists of columns (chambers) of fat, with fibrous septa running from the skin to the periosteum of the calcaneus. The fibrous partitions vary in structure and can run at vertical, spiral, or transverse angles, and these tissues absorb impact.

The heel pad sits directly beneath the calcaneus and acts as a shock-absorbing layer, allowing the heel to withstand repeated high loads for smooth walking. During walking the heel can absorb about 110% of body weight, and during running about 200%. The fat pad is usually about 1 to 2 cm thick, and an average healthy heel fat pad may be close to 18 mm thick.

Epidemiology

  • About 10% of people will experience heel pain at some point in their lives, with a peak age of 40 to 60. It is associated with increasing age, obesity, prolonged standing, hard floors, overuse, and diabetes.

  • With increasing age, fat tissue becomes less elastic and thinner. Injury and ongoing inflammation can also cause the fat tissue to degenerate, and the fibrous tissue may even rupture, leading to further tissue atrophy.

  • When the fat pad is repeatedly subjected to force or pressure, or is under pressure for long periods, inflammation of the fat pad may occur. This is also called fat pad inflammation, and it typically occurs in people who take part in activities requiring a lot of jumping, such as basketball, volleyball, gymnastics, or track and field.

Risk factors

  • Older age

  • Obesity

  • Prolonged standing, walking, and running on hard surfaces

  • Overuse in sport

  • Poorly constructed shoes and insoles: for example, avoid high heels, especially pointed high heels, because high heels can distribute body weight unevenly and place excessive pressure on a specific area of the foot, not necessarily the heel

  • Repeated corticosteroid injection

  • Related lower-limb biomechanical factors include: overpronation, insufficient ankle dorsiflexion range, reduced plantarflexion at the metatarsophalangeal joint, high-arched foot, and flat foot

  • Heel bone spurs are currently thought not to be related

Symptoms

  • Gradually developing heel pain, which may be unilateral or bilateral, and may include night pain

  • May extend to the midfoot arch or the medial heel

  • The pain is deep and easily confused with plantar fasciitis, and it is not aggravated by dorsiflexion

  • Pain occurs mainly with weight-bearing and eases with rest; walking barefoot or on hard surfaces worsens the symptoms

  • The pain is described as deep and non-radiating, mainly over the central weight-bearing part of the calcaneal tuberosity. It is often misdiagnosed as plantar fasciitis, but the symptoms of the two are in fact slightly different

Physical examination

  • A thorough examination of the lower limb is recommended, including a neuromuscular and skeletal examination

  • Observe the gait for signs of flat foot, high-arched foot, hindfoot deformity, and overpronation, and look for possible posterior tibial tendon dysfunction

  • Observe ankle range of motion (ROM), and confirm that passive movement of the ankle or toes does not reproduce the pain

  • Tenderness is directly over the central weight-bearing part of the calcaneal tuberosity, rather than over the distal tuberosity

  • In long-standing cases, marked atrophy of the fat pad may allow the underlying bone to be felt beneath the skin

Diagnostic tools

  • Diagnosis is difficult, so evaluation by an experienced sports medicine or rehabilitation physician or other qualified healthcare professional is recommended

  • X-ray to rule out bone problems: it may show a calcaneal spur or calcification, fracture, tumor, arthropathy, or other uncommon causes of heel pain. A heel spur is not necessarily related to the pain, and a lumbar spine X-ray can rule out a lower back problem

  • Ultrasound: the normal heel fat pad thickness is 1 to 2 cm. An uncompressed fat pad thickness under 10 to 12 mm can strongly raise suspicion (there is currently no agreed standard and variability is high, and some studies suggest under 7 to 9 mm). In addition, some studies use a ratio: a compressed HFP thickness divided by uncompressed HFP thickness under 0.45 or over 0.75 is considered abnormal

  • MRI: may be considered when there are other associated problems, such as edema of the abductor hallucis, quadratus plantae, or surrounding fascia

Differential diagnosis

  • Calcaneal fracture and stress fracture

  • Plantar fasciitis, plantar fascia rupture

  • Local inflammatory conditions: subcalcaneal bursitis, osteomyelitis, tendinitis/tenosynovitis

  • Systemic inflammatory diseases: enthesitis, ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, inflammatory bowel disease, gout, and pseudogout

  • Peripheral nerve entrapment: tarsal tunnel syndrome, medial calcaneal nerve, LPN/Baxter nerve

  • Lumbar nerve compression: S1 radiculopathy

  • Infectious diseases: osteomyelitis, tuberculosis

  • Benign tumors: heel pad glomus tumor, osteoid osteoma, intraosseous lipoma, giant cell tumor

  • Malignant tumors: osteosarcoma, chondrosarcoma, Ewing sarcoma, metastatic tumors

  • Neurological diseases: diabetes, alcoholism, sympathetic dystrophy

  • Metabolic causes: osteomalacia, Paget disease

Early treatment

  • Short-term medication with NSAIDs, and icing

  • Rest and modification of weight-bearing activity

  • Weight control

  • Shockwave therapy, low-level laser, dry needling, and taping can reduce pain, with low-to-moderate evidence support

Additional treatment

  • Orthotic insoles: arch support, heel cushioning material, a recess over the painful area beneath the heel, and slight medial elevation

  • Night splints

  • Increasing the flexibility of the Achilles tendon and plantar fascia, and strengthening the foot and ankle muscles

  • PRP injection: there are case reports, but the current level of evidence is low

  • Injection of filler materials (such as hyaluronic acid) to thicken the fat pad, or surgical fat grafting, although these may be time-limited and need to be topped up again after a period of time

References

Further reading

Frequently asked questions

Who needs to pay the most attention to this problem?

It is most common in people aged 40 to 60. Risk is higher in older adults, people with obesity, those who stand, walk, or run for long periods on hard surfaces, and those who overuse the foot in sport. Activities that involve a lot of jumping, such as basketball, volleyball, gymnastics, and track and field, can also inflame the fat pad.

What are the common treatments or management options?

Early management focuses on rest, load modification, weight control, short-term NSAIDs, and icing. Shockwave therapy, low-level laser, dry needling, and taping have low-to-moderate evidence for pain relief. Orthotic insoles, night splints, and foot and ankle strength and flexibility training may also be considered. Filler injections or PRP have lower-level evidence and should be assessed on an individual basis.

When should you seek medical evaluation?

Seek care if heel pain persists, if there is night pain, or if pain clearly worsens with weight-bearing. Because this condition is difficult to diagnose and easily confused with plantar fasciitis, it is best evaluated by an experienced sports medicine or rehabilitation physician, using X-ray, ultrasound, or MRI when needed to clarify the cause.

This article is also available in the original Chinese, with the full reference list.

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