Heel Pain: Heel Fat Pad Syndrome, Lateral Plantar Nerve Entrapment

Ovid: 5-Minute Sports Medicine Consult, The

Heel Pain: Heel Fat Pad Syndrome, Lateral Plantar Nerve Entrapment
Reno Ravindran
Richard E. Rodenberg
Thomas L. Pommering
  • Heel fat pad syndrome:
    • The heel pad is composed of columns of adipose tissue separated by fibrous septae. It is located directly below the calcaneus and acts as a hydraulic shock-absorbing layer (1).
    • The encapsulated fat acts in a hydraulic fashion to absorb shock by resisting compressive loads.
    • Degeneration or trauma may cause local loss of the heel pad or rupture of the fibrous tissue septa, which may result in loss of the heel pad compressibility.
    • Cause is often multifactorial
    • The syndrome may result from a direct blow to the bottom of the heel, resulting in a bruise and loss of heel pad elasticity.
    • Displacement, loss, or atrophy of fat pads causes pain from excessive pressure.
  • Lateral plantar nerve entrapment:
    • Lateral plantar nerve (LPN) and the 1st branch of the LPN are branches of the tibial nerve, which supplies autonomic, sensory, and motor fibers to the plantar foot. The LPN is the most common cause of plantar heel pain of neural origin (2).
  • Synonym(s): Calcaneodynia; Heel pain syndrome; Calcaneal neuritis; Policeman's heel; Runner's heel; Tennis heel; Stone bruise; Tuber calcanei pain; Subcalcaneobursitis
  • 1 in 10 people develop heel pain in their lifetime.
  • Peak age 40–60 yrs (3)
  • 15% of all adults with foot problems are thought to be related to heel pain.
  • More common with increasing age, obesity, and diabetes
  • Relationship with athletic overuse injuries (stress-related pathogenesis)
  • More common with occupations requiring prolonged standing or walking on hard surfaces (4)
Risk Factors
  • Elderly, advancing age
  • Obesity, body mass index >30
  • Occupations requiring prolonged standing or walking
  • Repetitive trauma, such as in distance runners, hurdlers, long jumpers, triple jumpers, gymnasts, or dancers
  • Overuse in recreational or professional athletic activities (4)
LPN entrapment can occur at different sites:
  • Where the nerve passes at the sharp edge of the deep fascia of the abductor hallucis
  • Distal to the medial edge of the calcaneus
  • Between the abductor hallucis and the medial head of quadratus plantae muscle (2)
  • Gradual onset of plantar heel pain, which may be unilateral or bilateral
  • May have a history of local trauma
  • Pain may radiate into the arch or proximally to the medial heel area.
  • If pain is severe enough, a patient may walk on the ball or lateral aspect of the foot.
  • Heel fat pad syndrome:
    • Pain primarily with weight-bearing and relieved with rest
    • Pain is usually nonspecific and occurs diffusely over the heel pad.
    • Pain does not tend to radiate or increase with dorsiflexion (1).
  • LPN entrapment:
    • Burning, sharp, shooting, shocklike pain; localized to the medial inferior aspect of the heel and proximally into the medial ankle region. Pain may radiate across the plantar aspect of the heel to the lateral aspect of the foot.
    • Pain worse during or after weight-bearing activities and improves with rest, but can also occur at rest and in non-weight-bearing positions
    • Pain at night may be due to nerve compression as a result of venostasis and venous engorgement.
    • Post-static dyskinesia: Plantar heel pain when patient 1st stands after periods of rest. Can be typical in patients with heel pain of neural origin, but this can also occur in plantar fasciitis.
    • Sensory deficit may not be common, but occasionally can cause tingling and/or numbness in the heel or foot (2).
Physical Exam
  • Heel fat pad syndrome:
    • Thorough examination of the lower extremity, including neurovascular exam, is recommended.
    • Exam is facilitated by having the patient lie prone
    • Tenderness directly over the weight-bearing part of the calcaneus rather than on the distal tuberosity
    • May have palpable absence or diminution of a compressible pad
    • In prolonged cases, the underlying bone can be felt underneath the skin due to significant fat pad atrophy.
  • LPN entrapment:
    • Palpation over 1st branch of the LPN deep to the abductor hallucis muscle or medial calcaneal tuberosity with reproduction of pain/symptoms proximally and distally. Should have minimal tenderness over the plantar fascia origin.
    • Dorsiflexion with eversion of the ankle can reproduce symptoms. Although not specific, can help with diagnosis.
    • Plantar flexion-inversion may reproduce symptoms, although not specific
    • Negative Tinel's test (2)
Diagnostic Tests & Interpretation
  • Anteroposterior, lateral, and oblique plain radiographs. Radiographs may reveal calcaneal spurs or calcifications, fractures, tumors, arthrosis, or other unusual causes of heel pain.
  • High-resolution US or MRI to look for benign tumors or neuromas entrapping a nerve
  • Lumbar spine radiographs and MRI to rule out causes of lumbar radiculopathy
  • Consider bone scan or MRI to rule out suspected stress fracture.


Diagnostic Procedures/Surgery
  • Electromyography and nerve conduction studies can reveal abnormalities in LPN.
  • Quantitative sensory testing, also known as the pressure-specified sensory device, determines pain mechanisms by assessing function of large and small sensory nerve fibers.
  • If nerve entrapment is suggested by history and exam, a diagnostic injection with local anesthetic providing complete pain relief can help with diagnosis (2,5).
Differential Diagnosis
  • Calcaneal spurs
  • Local inflammatory conditions (plantar fasciitis, subcalcaneal bursitis, periostitis, tenosynovitis, blister)
  • Systemic inflammatory conditions (ankylosing spondylitis, Reiter's syndrome, psoriatic arthritis, rheumatoid arthritis, sarcoidosis, gout, and pseudogout)
  • Calcaneal fracture or stress fracture
  • Entrapment (tarsal tunnel syndrome, medial calcaneal nerve)
  • Infectious (osteomyelitis, tuberculosis)
  • Tumors (glomus tumor of heel pad, osteoid osteoma, osteoblastoma, chondromyxoid fibroma, chondrosarcoma, simple and aneurysmal cysts)
  • Neuropathy (diabetes mellitus, alcoholism, reflex sympathetic dystrophy)
  • Metabolic (osteomalacia, Paget disease)
  • Calcaneal apophysitis (4)
Ongoing Care
Follow-Up Recommendations
Heel fat pad syndrome responds very well to conservative treatment and is usually self-limited.
1. Aldridge T. Diagnosing heel pain in adults. Am Fam Physician. 2004;70:332–338.
2. Alshami AM, Souvlis T, Coppieters MW. A review of plantar heel pain of neural origin: Differential diagnosis and management. Man Ther. 2007.
3. Toomey EP. Plantar heel pain. Foot Ankle Clin. 2009;14:229–245.
4. Alvarez-Nemegyei J, Canoso JJ. Heel pain: diagnosis and treatment, step by step. Cleve Clin J Med. 2006;73:465–471.
5. Franson J, Baravarian B. Tarsal tunnel syndrome: a compression neuropathy involving four distinct tunnels. Clin Podiatr Med Surg. 2006;23:597–609.
6. Bateman JE. Disorders of the foot and ankle, medical and surgical management. Philadelphia: WB Saunders, 1991.
Additional Reading
Bordelon RL. Orthopedic sports medicine, principles and practice. Philadelphia: WB Saunders, 1994.
Cailliet R, ed. Foot and ankle pain. Philadelphia: FA Davis, 1997.
Karr SD. Subcalcaneal heel pain. Orthop Clin North Am. 1994;25:161–175.
Simons SM. Foot injuries of the recreational athlete. Phys Sports Med. 1999;27:57–70.
Turgut A, Gokturk E, Kose N, et al. The relationship of heel pad elasticity and plantar heel pain. Clin Orthop Rel Res. 1999;360:191–196.
355.6 Lesion of plantar nerve

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Accept Read More