Choosing Shoes for Heel Fat Pad Syndrome and Plantar Fasciitis
If you're dealing with heel fat pad irritation or plantar fasciitis, the shoe that feels best in the store is often not the one that helps most. Here is how I manage the acute phase, what I look for in a shoe once symptoms settle, and a few road and trail options worth trying.
Acute phase first: offload, then change the shoe
Heel fat pad syndrome can get very tender, so I calm the tissue down before making shoe changes. For acute management I often give silicone or neoprene heel cushion inserts, such as a Dr. Scholl's silicone heel cushion, to offload the fat pad and let it heal. We usually take them out once symptoms settle to about 1 to 2 out of 10. If symptoms are spiking, above 3 out of 10 and into the yellow or red zone of the pain traffic light, we use heel cup cushioning support for a short time before introducing a denser shoe. Check that your heel still feels locked in with the insert in place.
Cushion has its place
Soft cushioning is the right tool for an injury flare and for the late miles of an ultra. Around mile 70 or 100, your feet start to crave the relief of a plush landing, and that's fine for getting to the finish line. I just don't recommend training in plush shoes, for the reasons below.
What doesn't help
Corticosteroid injections are at the top of my list. A steroid shot may take the edge off for a few weeks, but it can thin the very tissue we're trying to protect. Repeated corticosteroid injections can accelerate fat pad breakdown [1], and a Cochrane review of steroid injections for plantar heel pain found benefit only up to about a month, with rare but serious complications such as plantar fascia rupture [2]. If your heel pad is already thin, an injection can make things worse.
Also avoid walking barefoot on hard surfaces like tile, concrete or hardwood; thin, flat or worn-out shoes with no heel cushioning; high-impact activity such as hard-surface running or jumping during a flare; and high heels [1]. Jumping straight to a firm shoe before symptoms settle is a mistake too, which is why the acute phase comes first.
When to get it checked
Deep, central heel pain that worsens with prolonged standing is typical of heel fat pad syndrome. But heel pain can also come from a stress fracture of the heel bone, which needs imaging to confirm [1], from plantar fasciitis (the two often overlap), or from a pinched nerve. Pain at night or at rest, swelling, numbness or tingling, or being unable to bear weight needs a proper evaluation.
What to look for in a shoe
Start with the heel. The heel counter and heel cup are the most important stability part of the shoe. It should be firm and deep, and your heel should not slide or shift in any direction. Heel stability sets the stage for the rest of the foot and for the whole gait cycle from heel strike to toe-off. If your heel feels like it's moving around, the shoe isn't right, no matter how comfortable it is otherwise.
Then let the forefoot move. The forefoot should give your toes and arch room to splay and pronate freely. A locked-down heel with a roomy forefoot is the combination I want.
The thumb test. Press your thumb into the midsole on the side of the heel and compare it to your current shoe. If you're coming from a very soft, maximum-cushion shoe like a Hoka or an Altra, the new shoe should feel much denser, ideally at least twice as firm. If it feels about the same, it's too soft for this purpose.
Heel strike, midfoot and forefoot
Most runners are heel strikers [3], and heel striking is efficient, especially for the calves. Some runners land on the midfoot or forefoot at slow speeds, and that's fine. I would never push a heel striker to become a forefoot striker. I would encourage a forefoot striker to try heel striking if they're dealing with calf or Achilles problems, because forefoot striking generally loads the calf and Achilles more [4]. The calf works to lower the heel after landing and then works again to push off, while a heel strike starts on the outer heel and mostly asks the calf to work at toe-off.
As speed increases, many runners shift toward the midfoot so they can reach further and push the ground behind them. In my experience that shift happens around 6 to 7 minutes per mile, though it varies from person to person, and plenty of fast runners still heel strike. Most marathoners at the 2017 World Championships were rearfoot strikers [5]. At slow, easy paces in Zone 1 and Zone 2, heel striking should be encouraged. It's where most people land naturally.
Why I lean firmer
For everyday running and walking, I prefer a more responsive surface. Very plush shoes exaggerate whatever your foot strike is and can raise ground reaction forces, especially at faster speeds. My working theory is that your foot and nervous system tune muscle activity to the impact they expect. When the surface is very soft, the feedback gets muddied. The intrinsic foot muscles may not fire as well, and the heel, metatarsals and Achilles can take more of the load.
The research is partial but points the same way. One lab study of heel-strike runners compared a maximum-cushion Hoka to a conventional Brooks. At faster speeds, impact peak and loading rate were about 11 and 12 percent higher in the max-cushion shoe, and the authors suggested runners stiffen their legs when the shoe is very soft, which cancels out the extra padding [6]. Other lab work has also reported higher vertical impact forces with softer midsole shoes [7]. Still, these are small studies, so I treat them as a reason to try firmer shoes, not a universal rule. Injury data is mixed. One large randomized trial found that the effect of shoe cushioning on injury risk depended on the runner's body mass [8].
The goal is a middle ground
Picture running barefoot on concrete. You'd tiptoe across it, afraid to drop your heel. That's too responsive. Now picture a very plush shoe where your heel sinks in and bottoms out, and you lose energy. That's too soft. What we want is close to running on grass. You can feel the ground, the shoe protects your foot, and you're not afraid to land on your heel.
Options to try
Mount to Coast R1 (road): dual-density foam with urethane reinforcement, 35 mm heel and 27 mm forefoot stack, 8 mm drop.
Brooks Adrenaline GTS 25 (road): stability shoe with GuideRails support.
Topo Athletic Traverse (trail): roomy forefoot with a snug midfoot and secure heel, 5 mm drop, rock plate, Vibram outsole. This is the best choice if you also need a wider toe box.
Hoka Speedgoat 7 (trail): a Hoka, but a trail model with a Vibram Megagrip outsole and a more responsive ride than their max-cushion road shoes.
Once your symptoms have settled, try them on, do the thumb test, and make sure your heel feels locked in and your toes can spread. Feel free to reach out with questions.
References
Kulmala JP, Kosonen J, Nurminen J, Avela J. Running in highly cushioned shoes increases leg stiffness and amplifies impact loading. Sci Rep. 2018;8:17496. doi:10.1038/s41598-018-35980-6
Malisoux L, Delattre N, Urhausen A, Theisen D. Shoe cushioning influences the running injury risk according to body mass: a randomized controlled trial involving 848 recreational runners. Am J Sports Med. 2020;48(2):473-480. doi:10.1177/0363546519892578
Baltich J, Maurer C, Nigg BM. Increased vertical impact forces and altered running mechanics with softer midsole shoes. PLoS One. 2015;10(4):e0125196. doi:10.1371/journal.pone.0125196
Most marathon runners at the 2017 IAAF World Championships were rearfoot strikers, and most did not change footstrike pattern. J Biomech. 2019. https://www.sciencedirect.com/science/article/abs/pii/S0021929019303562
Rice H, Patel M. Manipulation of foot strike and footwear increases Achilles tendon loading during running. Am J Sports Med. 2017;45(10):2411-2417. doi:10.1177/0363546517704429
