This is a reasonably common foot pain complaint that brings patients into the office. They are concerned about the “lumps" that are occurring on either or both heels.
They are a pressure induced herniation of the subcutaneous fat through the fascial lining of the heel. Fascia is a covering over soft tissue, underneath the skin, similar in appearance to saran wrap. What happens is that the fat herniates or protrudes through small tears in the fascial lining resulting in nodules or lumps that are seen in the heel area. Diagnosis is made solely on physical examination; there is no lab work or imaging studies that will diagnose piezogenic papules.
These are benign lesions (non-malignant). The image below is a typical presentation of piezogenic papules.
Off weight bearing they can be difficult to see but on weight bearing they become pronounced but rarely painful. Defects in the fascial lining allow the fat to protrude through and press against the skin creating the lumps. These lumps can be seen on the medial (inside), lateral (outside) and posterior aspect of the heel and can occur on either heel or both heels. They have also been diagnosed on the wrist.
The tendency for this condition is more common in young and athletic people. There is no racial or hereditary predisposition. They are seen slightly more in women then men. In the small percent of patients who experience pain from these herniations the patients tend to be obese or those prone to long periods of standing.
TREATMENT OF PIEZOGENIC PAPULES
The first treatment is reassurance that these “growths" are harmless.
Plastic heel cups- In those individuals where there is some degree of pain or discomfort, plastic heel cups can be very helpful. These are plastic egg shell shaped devices that are placed around the heel. What they basically do is push the fat back into the fascial defect.
4% denatured alcohol injections- Many foot specialist may also recommend one or more injections of 4% denatured alcohol. This is particularly effective if there is a burning component to the pain as the injections sclerose or deaden the nerves that end at the level of the papules. This is the same injection that we use for Morton's neuroma.
Surgical excision- On very rare occasions they have to be excised. This is generally limited to instances where there is nerve tissue embedded in the fat that is protruding through the fascial defect.