Key Insights On Fat Grafting For Heel Fat Pad Atrophy

Emphasizing the potential benefits of autologous fat pad grafting in restoring the heel and improving function, these authors detail the treatment of a 64-year-old patient who had bilateral heel pain for five years despite conservative treatment.

The heel fat pad is a specialized adipose-based structure that protects the foot from stress generated during the gait cycle.¹ Researchers estimate that the heel fat pad absorbs 20 to 25 percent of the contact force at heel strike.² Studies have implicated heel fat pad atrophy in several pathologies and alteration in thickness is a determining factor for heel pain, which can cause total disability for the working population and athletes.^3,4 Patients with advanced age and obesity may be more prone to heel fat pad atrophy.^5-7 Traumatic events may also cause plantar fat pad destruction. These events include repetitive steroid injections, fractures, burns, iatrogenic surgical causes and prolonged activity on an orthopedically compromised foot.⁸

The heel pad is comprised of two types of adipose layers: a microchamber and a macrochamber. The microchamber is superficial and non-compressible. The macrochamber is the deeper chamber, which is compressible and largely responsible for shock absorption. The macrochamber is therefore our target zone for autologous fat pad augmentation.

Currently, the profession is addressing this problem through the use of extrinsic foot padding or orthotic management. We present a case report of a patient with fat pad atrophy who had autologous fat injections for heel restoration.

A Closer Look At The Patient Presentation

A 64-year-old female presented to our clinic with complaints of bilateral heel pain for five years in duration and progressively becoming worse. She soaks, wraps and pads her heels, but the heels continue to ache. She has a significant medical history for multiple sclerosis (MS) since 1994. In regard to her multiple sclerosis, the patient is taking the oral medications carisoprodol (Soma, Meda Pharmaceuticals) and dimethyl fumarate (Tecfidera, Biogen). She reports post-traumatic arthritis in her left shoulder. The patient takes oral calcium to help prevent osteoporosis and takes many vitamin supplements for health and wellness.

The patient has some concomitant plantar fasciitis in both heels, which she manages with supportive shoes and straps to her feet. However, the ache from her heel fat pad atrophy is unrelenting. She ambulated with a cane to her screening and reported using the cane more due to the heel discomfort than for lower extremity weakness from multiple sclerosis.

On the physical examination, the patient presented with palpable pedal pulses. She had some paresthesia and anesthesia in her feet secondary to the multiple sclerosis as well as some multiple sclerosis-related muscle weakness in her lower extremities and feet. The patient presented with a significant callus at the plantar central aspect of the left heel (see above photos). She has a flexible cavus foot and is pronated on ambulation. The patient had pain on direct palpation of the medial tuberosity of the calcanei and pain on lateral compression of her heels. She had some mild discomfort on palpation of the insertion of the plantar fascia at the plantar medial aspect of her heels. Her bilateral heels appeared deflated with significant wrinkling of the skin when pinched. We took ultrasound measurement at the plantar heel pad in line with the second ray (see below photos).

How The Fat Grafting And Post-Op Course Proceeded

The patient had autologous fat grafting to her left foot at the University of Pittsburgh Aesthetic Plastic Surgery Center. She received 10 mg of Valium 30 minutes prior to the procedure. We harvested fat from the bilateral outer thighs via tumescent liposuction and processed the fat using centrifugation. For the anesthetic, we utilized a local block of lidocaine and Marcaine around the heels. We injected each heel macrochamber with 6 cc of fat through two access sites, one on each side of the heel so fat could be distributed in a cross-hatch pattern. The heels felt full postoperatively and did not wrinkle on compression.

Postoperatively, we advised the patient to limit her ambulation for the first four weeks and she wore padded shoes. Ideally, we require Darco surgical shoes with heel cutouts but due to her balance issues and multiple sclerosis, she used supportive, cushioned laced shoes and ambulated only for necessity. The patient also wore removable straps to limit her plantar fascial traction and discomfort. We advised her to use padding in her shower and no barefoot walking. At two weeks post-op, she reported some bruising at her thighs and her left foot. The left foot was more tender postoperatively than her right foot. She did not need any pain management medications.

At her one-month post-op visit, all ecchymosis had resolved and her heel pain was significantly improved. She had no pain on direct palpation of bilateral central heel, on compression of the heels or at the plantar fascial insertion.

At her two-month visit, she reported being pain-free in her heels and was starting to increase her activity. She was also ambulating without her cane at her visit and reported minimal use of the cane at home. The left heel callus was present but improved.

At her six-month follow-up appointment, she continued to have no pain in her heels. Coincidentally, her plantar fasciitis pain completely resolved as well. She continues to use the cane minimally for balance but no longer uses it for heel pain. The left heel callus remained but was improved (see photo at left). We obtained a repeat ultrasound (see photo at right).

In Conclusion

Restoring the plantar fat pad with autologous fat grafting has the potential to improve foot function and decrease foot and bone pain. It also serves to increase shock absorption during gait and return people to their normal activities of daily living. By limiting an antalgic, compensatory gait, injury to the patient’s superstructure will be reduced. Hopefully, the decreased cane use will encourage her to maintain as much lower extremity muscle strength as possible.

Our case study demonstrates the unique collaboration of podiatry and plastic surgery, and the necessity of each specialist’s expertise. Together, we were able to provide greater comfort on ambulation for our patient with decreased dependence on her cane, which she could not accomplish solely with extrinsic padding and shoe gear modification. With this patient being involved in a larger two-year randomized crossover clinical trial, we intend to continue to follow her progress.

Beth Freeling Gusenoff, DPM is a board-certified podiatric surgeon and a Clinical Assistant Professor of Plastic Surgery in the Department of Plastic Surgery at the University of Pittsburgh.

Jeffrey Gusenoff, MD is an Associate Professor of Plastic Surgery in the Department of Plastic Surgery at the University of Pittsburgh.

References

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2. Morag E, Lemmon DR, Cavangh PR. What role does plantar soft tissue stiffness play in determining peak pressure under the heel? Gait Posture. 1997;5:164.

3. Baxter DE, Thigpen CM. Heel pain - operative results. Foot Ankle. 1984;5(1):16-25.

4. Ozdemir H, Söyüncü Y, Ozgörgen M, Dabak K. Effects of changes in heel fat pad thickness and elasticity on heel pain. J Am Podiatr Med Assoc. 2004; 94(1):47-52

5. Aldrigde T. Diagnosing heel pain in adults. Am Fam Phys. 2004; 70(2):332-8.

6. DeMaio M, Paine R, Mangine RE, Drez D Jr. Plantar fasciitis. Orthopedics. 1993; 16(10):1153-63.

7. Hill JJ, Cutting PJ. Heel pain and body weight. Foot Ankle. 1989;9(5):254-6.

8. Basadonna PT, Rucco V, Gasparini D, Onorato A. Plantar fat pad atrophy after corticosteroid injection for an interdigital neuroma; a case report. Am J Phys Med Rehabil. 1999;78 (3):283-5.