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Plantar heel fat-pad atrophy — MSRA MCQ

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HardAnkle and FootPlantar heel fat-pad atrophyMSRA

A 67-year-old woman presents with 4 months of left plantar heel pain. She has obesity and type 2 diabetes managed with metformin; monofilament testing, pedal pulses and capillary refill are normal. She works in a supermarket and stands for long periods. Eighteen months ago and again 9 months ago, she received corticosteroid injections for presumed plantar fasciitis, each giving brief relief. Her current pain is a deep, bruised sensation directly beneath the centre of the heel. It is worst when barefoot on hard floors and after prolonged standing. It is not particularly worse on taking the first steps after rest. Passive dorsiflexion of the toes does not reproduce the pain. Examination shows flattening of the central plantar heel pad and focal tenderness to direct pressure over its centre. There is no tenderness at the medial calcaneal tubercle, swelling, erythema, sensory loss or skin lesion. Calcaneal squeeze testing is negative. What is the most appropriate management today?

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Correct answer: C — Provide a cushioned heel pad, supportive footwear and load-modification advice, and avoid further corticosteroid injection

This is plantar heel fat-pad atrophy rather than recurrent plantar fasciopathy. The key discriminators are central, bruise-like heel pain that is provoked by barefoot loading on hard surfaces; a flattened heel pad with central direct-pressure tenderness; and absence of first-step pain, medial calcaneal tubercle tenderness or pain on toe dorsiflexion. Previous corticosteroid injections are a relevant contributor because fat-pad atrophy is a recognised potential harm. Management should therefore reduce local plantar impact: cushioned heel pads, supportive footwear and modification of prolonged standing/walking are appropriate. Further corticosteroid injection risks worsening the underlying pathology and is not a first- or second-line intervention in the NHS GGC plantar-heel pathway. A calcaneal stress fracture would be more concerning with focal bony tenderness and a positive calcaneal squeeze test; these are absent, so urgent MRI and non-weight-bearing are not indicated. Plantar fascia and Achilles stretching is appropriate first-line treatment for typical plantar fasciopathy, but does not address fat-pad insufficiency as the principal problem. Shock-wave therapy and surgery are escalation options after an appropriate conservative pathway or where diagnostic uncertainty persists. ([rightdecisions.scot.nhs.uk](https://www.rightdecisions.scot.nhs.uk/ggc-msk-foot-and-ankle/rearfoot/plantar-heel/?searchTerm=2024))

Reference: NHS Greater Glasgow and Clyde MSK Foot and Ankle: Plantar heel (Last reviewed 2 December 2025) — https://www.rightdecisions.scot.nhs.uk/ggc-msk-foot-and-ankle/rearfoot/plantar-heel/?searchTerm=2024 NHS: Plantar fasciitis (Last reviewed 14 February 2025) — https://www.nhs.uk/conditions/plantar-fasciitis/