A bruise (‘contusion’) in the pillow of fat protecting the heel can result in pain, often worse when walking.

Symptoms

The pain of a fat pad injury is felt in the middle of the heel, where the foot strikes the ground. The signs and symptoms include:

Deep, bruise-like pain right under the heel
Pain that is worse on hard floors and when barefoot
Pain that comes on with walking or standing and eases with rest
Tenderness when the middle of the heel is pressed
A heel that feels as though the cushioning has gone

Fat pad pain is usually worst in the middle of the heel. Plantar fasciitis is usually worst at the front and inner edge of the heel, and is at its worst with the first steps in the morning.

Causes

The heel is protected by a thick pad of fat that spreads the load with every step. Pain occurs when this pad is bruised or when it thins with age.

A single heavy landing, such as jumping down or missing a step, can bruise the pad. Repeated pounding on hard surfaces can do the same over time. In older people, the pad naturally becomes thinner and less springy, so it protects the heel less well.

Risk Factors

Fat pad pain is more common in people who are on their feet on hard surfaces. Other factors that increase the risk include:

Older age, as the fat pad thins
Greater body weight, which loads the heel more
Running and jumping sport, especially on hard ground
Thin-soled or worn-out shoes, and going barefoot on hard floors
A previous heel injury
Steroid injections into the heel, which can thin the pad further

Investigations

Your doctor can usually make the diagnosis by examining the heel and finding the tender spot in the centre of the pad. Tests are not often needed, but may include:

X-ray, to rule out a fracture or other bone problem
Ultrasound or MRI, which can show the thickness of the pad and rule out other causes

Other causes of heel pain that may seem similar to bruising of the fat pad include:

Plantar fasciitis
Small hairline fractures in the heel bone (see calcaneus fracture)
Pain from the ankle or midfoot that seems to be present in the heel

Complications

Most fat pad pain settles, but where it does not it can lead to:

Heel pain that carries on for months
Reduced walking and standing, and the loss of fitness that follows
Changing the way you walk to protect the heel, causing pain elsewhere in the foot, knee or hip

Treatment

Treatment aims to protect and cushion the heel while the pad recovers:

Cushioned heel cups or gel pads inside the shoe
Well-cushioned shoes, and avoiding going barefoot on hard floors
Reducing running and jumping for a period
Ice and simple pain relief
Taping the heel, which supports the fat pad and holds it under the heel bone
Losing weight where this is contributing

Steroid injections are generally avoided, because they can thin the fat pad and make the problem worse. Surgery has no useful role.

Prevention

The risk of fat pad pain can be reduced by:

Wearing shoes with good heel cushioning, and replacing them when they flatten
Avoiding long periods barefoot on hard floors
Building up running and jumping gradually
Using a heel cup early if the heel starts to ache