‘Fat Pad’ Impingement (Hoffa’s Syndrome)

I write this piece from a personal viewpoint as unfortunately around where  live, it has come to my attention that there is simply not enough knowledge of this recognized problem.

My problems started a few months ago after completing the Berlin marathon. My IT Band went around the 19 mile mark and I only truly realised the full impact of this on my body some weeks later. Don’t get me wrong, as the pain and discomfort was obvious during the final miles of the race as I missed my goals, but it was only as I tried to step back into my training once again a couple of weeks later that I felt the need to see a physio for knee discomfort that was more than just delayed muscle onset.

I was diagnosed with IT Band syndrome and although my problems had stemmed from mechanical issues (typically weak glute not firing properly, pronating too much, weak hip, etc), the pain was very much in the knee. The IT Band had, over time, become inflamed, thickened, laid down scar tissue and continued to rub over the many bony points and bursars around my knee. This problem was perpetual as every time I tried to run, the scar tissue and tight IT Band around the knee would become thicker, laying down more scarring each time.

The physio and I threw everything at it, some serious downtime, regular ART to breakdown the scarring, dry needling to loosen the IT Band, regular massages, specific exercises to strengthen my root causes around glutes and hip. Everything, but still a nagging discomfort remained, which, in fact worsened around the ‘fat pad’ area just under and to the outside of the patella. We worked it to death with all the treatment and carefully considered everything for the inflammation (Ice, Ibruprofen, needles, rest, taping to lift the patella – usually received with good success, etc, etc), but still no real success.

Basically this ‘fat pad’ area becomes inflamed and thickened it can get ‘pinched’ between the end of the thighbone and the kneecap and is often a longstanding condition. http://bit.ly/gWYUq. Having thrown everything at it for weeks, it was decided by a few physio’s who had been heavily involved in studies in Australia that the best accepted and recognized step now would be to have a cortisone shot. It had been shown to work on many, many occasions with virtually no real risk at all (all injections / needles come with the inherent risk of infection being introduced to a site). In fact, had i been a professional athlete, this would probably have been given to me weeks and weeks ago!

Finally I went to see a doctor to try and obtain a cortisone shot to the ‘fat pad’. I was scorned away and told all about my mechanical imbalances and what was causing the knee discomfort and told to address these – I had been vigorously of course over the last several weeks and still am! I was, however sent for an X-ray which eventually showed up some small signs of the onset of arthritis, which is very normal in a gentleman of my age who has been very active over the last 10-15 years with my running, biking, soccer and skiing, etc. Still the Dr refused to give me this shot and advised me to consider another sport!

Time to look for a second opinion from a recognized sports medic in town. A little more sympathetic, but still wanted me to have an ultrasound first to better guage what was going on – although she did go on to say that she thought it may well be ‘fat pad’ impingement and when pressed, suggested that the treatment may well be a cortisone shot!!! Aaargh! Will no-one give me this shot! No, I have to wait several weeks for ultrasound before even getting there!! – Missing the Zurich marathon in April is becoming an increasing concern.

To be fair, medics are rightly concerned with cortisone shots that there is also a minimal risk that it could weaken any surrounding tendon, possibly leading to a tear or rupture, if injected into the wrong spot. However, the ‘fat pad’ area is directly under the skin and is fairly large, next to a thick tendon that is also fairly obvious – In other words ‘X’ really does mark the spot and it would be difficult for anyone to miss, with a needle or even a mallet!

It is so hard to have this malfunction diagnosed and of course, everyone has their own school of thoughts on how best to treat or tackle physical problems. However, from my experience, too many ‘experts’ are simply not skilled enough in specific knee disorders amongst athletes – bear in mind that general practitioners will have to cover an extremely wide range of medical complaints and problems and it is perhaps a little unfair to expect them to know everything, right?!

I guess time will tell if my problem has been accurately diagnosed by myself and my physio and if indeed, I can actually manage to get anyone to give me this shot. Perhaps it won’t prove to be the miracle cure I’m after, but in my case, it seems like it should at least be considered as the worst case scenario appears to be that nothing will improve.

As for our understanding and treatment of this ‘fat pad or Hoffa’s syndrome, well, it appears that some parts of the world are more dialled in and aggressive in their treatments than others.

Any feedback on this condition would be most welcome

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20 Comments

  1. ben

     /  August 29, 2011

    Have you had any success with the treatment of the fat pad? I have also been suffering from this condition and any advise would help.
    Thanks,
    Ben

    Reply
    • Hi Ben,

      Well, as you can imagine, I tried many things, ranging from ensuring a thorough treatment of my overly tight and scarred IT band initially, relieving the pressure on the pad through taping, regular accupuncture and paying stroing attention to strenghtening my glutes and core muscles to engage all correct muscle groups. I’ve also more rcently tried the slow transition into barfoot running with Vibram Five Fingers and basically ensuring I run more consistently on the ball of my foot and voiding heel strike.

      I’d say a mix of all of the above has worked for me to-date. I’m under no illusions that I need to maintain everything mechanically, but having removed the initial scarrng over the IT band at the knee, I think the key tool that perhaps helped made the real improvement was trough accupuncture. Really works for me everywhere. That said, I think you need to always look at the root of the issues, such as foot strike, mechanical imbalances and as i said, I can’t speak strongly enough for concentrating on developing your glutes and being able to enage them correctly (a good physio will help with this) along with your core muscles.

      Hope some of this helps. I was near to having a cortisone injection, but thankfully never came to this.

      Reply
  2. Peter

     /  November 16, 2011

    Hi ben and trav,

    I too have suffered from a fat pad impingement on my right knee for 12 months…even after an athroscope proved to bring me no relief I finally found a physio who was very switched on with this type of injury. Basically the path to success was fairly fast and I was completely cured in 3-4 weeks. Taping is a MASSIVE help when treating Hoffas pad impingements…taping should be applied when doing any physical activity, especially your exercises. Strengthening the glutes was a major factor also…including the VMO muscle….being sure to also increase the strength in the quads and hamstrings as well. A myofascial release on the ITB will be necessary also. If you would like a copy of a diagram for the specific taping method we used and some exercises to do I would be happy to email them to you. You need to do the exercises at least 3-4 times a week minimum…and with no pain! Cortisone injections are known to help in this instance however they are not always a sure fire fix by any stretch of the imagination and should be avoided where possible. Obviously a combination of the shot and what I have recommended above would be great. It’s a nagging injury and very frustrating, and many doctors, surgeons, physio’s fail to treat this very unique and stubborn injury…lucky for us some do!

    if you want a copy of the exercises and taping methods send me an email to:

    pete_gangies at hotmail dot com

    Cheers
    Pete (Sydney, NSW)

    Reply
  3. Hanne Karin

     /  February 10, 2012

    Hey!

    I have problems with my knee, and the doctor told me I have fat pad impingement, among other knee syndroms. I would really like you to send me a copy of the exercises and taping methods, if you could?! Then I might avoid operation.

    Thanks!
    From a sad cross country skiier:/

    Reply
    • For the best advice Hanne, I would go and see a good local sports physio. Some of the exercises they’ll provide, such as those to strengthen the weak areas like the glutes and core will show immense benefits in releasing much of the stress placed on other weaker muscles and tendons.

      Good luck with the recovery and avoid that surgery where possible

      Reply
    • Pete

       /  March 8, 2012

      send me an email and i’ll forward to the docs I have. Not many physio’s understand or know how to treat this condition unfortunately.

      Reply
      • Hanne Karin

         /  March 9, 2012

        Hey again and thanks for answer!

        I got the injury in mai 2011 after running, and have been to several therapists, chiropractors,sports physio and doctors. After several different threatments – cupuncture, massage, swiss dolarclast, vacuum-threatments, cortison, MR-test and so on..belived one doctor a have hoffas syndrome. I follow a program of some “knee training”, but it has no improvement. The next option is surgery. I hope I avoid this, but after 2 months using crutches, I do everything to be better.
        You can send me your docs, thanks!
        hannekarin_erixen@hotmail.com

        Hanne Karin

  4. Alyssa

     /  April 6, 2012

    Hello, I am an employee at a physical therapy clinic and I graduated with a BS in Kinesiology. I am an avid competitive volleyball player who dealt with fat pad impingement. I dealt with it for over 9 months before I got any relief. In the end it was arthroscopic removal of the fat pad which granted me about 90% relief from the problems I was having.

    I tried a month if physical therapy, was taking various NSAIDS almost around the clock, limited my activities for a period of time, tried cortisone injections, ice, McConnell taping you name it. Nothing gave me more than about 20% relief for a very short period of time.

    The orthopedic surgeon, PA, and physical therapist all thought it was simple chondromalacia at first. My main complaints were pain at rest (in both extension and flexion), pain with stairs, extreme pain with terminal knee extension, difficulty transferring from my car, pain with jumping and landing, and difficulty sleeping at night due to the pain waking me up. It even bothered me when walking at times. I was never inhibited from playing volleyball; I would just grit my teeth and play the game I loved.

    That being said, the arthroscopy was incredibly successful for me. I had almost immediate relief of the pain at rest and with rehab after the arthroscopic surgery I was back to playing sports within about 3 1/2 weeks. I experienced some similar pain due to some significant scar tissue but that resolved as the scar tissue broke up a little. I still have minimal problems with the anterior knee pain but overall I am very pleased with the outcome.

    Some things to note:
    I have several predispositions to fat pad impingement including patella alta, genu recurvatum, and some patellar instability.
    The main thing that separated my case from general chondromalacia was that I had pain with extension and had full flexion.
    I tried conservative measures first but they didn’t offer me any significant relief.

    I hope this can be of assistance to someone as none of the therapists at my clinic had ever dealt with fat pad impingement before and I found it hard to locate good information about the problem.

    Thank you.

    Reply
    • Hi Alyssa

      Many thanks for your comments and I’m sorry to hear of your troubles and suffering with this complaint.
      Good to hear you found a positve way forward

      Reply
    • Thanks for your info Alyssa! I have pretty much the same list of knee issues as you do and have just been scheduled for an arthroscopic surgery and fat pad clean up. My knee issues have been lifelong, so I am glad to hear a positive outcome for the last ditch treatment of surgery.

      Reply
  5. Samuli M.

     /  April 24, 2012

    Hey Pete, I wonder could you please send those docs for me also? My knee problems have been so significant that I need to use a wheelchair, almost 1,5 years now. It has been a tough road. Yeah. My e-mail address is satamoil@yahoo.com . Thank you!

    Reply
  6. Cassidy Terry

     /  July 29, 2012

    I was a competitive gymnast for 8 years and one day, after landing on straight knees while tumbling, I started feeling pain in my knees. That was 3 years ago. For 3 years straight I have been in pain while doing everything: walking, running, jumping, going up and down stairs, crawling, kneeling, and squatting. And the worst part is that I had to retire from gymnastics. I have had surgery on both of my knees to release the ligaments on the outside of both knees. Although the surgery was successful in fixing this problem, I am still in pain. The surgery was a year and a half ago. After trying all different kind of braces, physical therapy, and medicines my doctor thinks that this fat pad syndrome is the issue. Hopefully it is and we can finally get to fixing this problem once and for all but I’m just not sure. Although I have some of the symptoms, I have tried using braces that support my knees the way the taping methods do but this does not cure my pain. Does anyone else think that I might have fat pad syndrome or is there something else it could be? Is there a way to stop the pain that anyone knows of? I’m only 17 and I want to get this problem resolved as soon as I can so I can stop feeling like a 70 year old!

    Reply
  7. Melissa

     /  September 16, 2012

    I played every sport possible since I was young but basketball seemed to be my number one. In one game in last October, I went up for a shot and when I came down, I hyper extended my right knee. Stupid as I was, I went in the game a few minutes later. After seeing a doctor for the her extension, I took a month and a half off for all activities before starting up basketball again. I wore a very light brace from there on out. However, the pain seemed to never go away. Stupid as I was again, I played basketball six days a week, from November all the way to March. Basketball was the sport that kept my sane from everything, I couldn’t give up on it or my team, especially since we fell one game short from going to states. Anyway, after the season, I gave up playing in order to get my knee better. I saw another doctors who said that my high arches are causing the problem so just wear inserts and use the “playmaker” brace. I go back a couple months later and still no improvement. He suggests that I have patellar tendinitis. So, I got these injections called PRP, or platelet rich plasma. Here, the doctors draw your blood, spin it in a center fuse: which separates your blood, and finally he injects the plasma back into the patellar tendon. I received two of those which are $500 per injection. In addition to doing physical therapy, these injections were supposed to speed up the recovery process yet nothing changed. Then two months later I go back, and receive a steroid and anesthetic injection after another MRI. I go back a month later to the doctor with no change. I can’t sit for long periods of time, stand, run, walk, jump, climb stair, and basically can’t do anything without pain. I can’t even remember the last time I slept through a whole night; I was going to school on 2 hours of sleep. Not good. My doctor called me an anomaly. So, I am down to two options: surgery or live with it. This was a no brainer. I am 17 years old and my grandma has a better knee; she is 75. So I get my surgery on the 27th of this month. The doctor is going to remove the fat pad and any extra inflamed things in there. I just want to know that after the surgery the pain will be gone and my knee be fine. Does anyone who had the surgery feel any difference between your knee since there is no fat pad in one? That’s the only thing I am afraid about. It’s almost been a year of severe pain and I am done. I have been through three doctors, two physical therapists, four knee braces, two x-rays, two MRIs, three injections, and hopefully only one surgery. I am so sorry that everyone who has fat pad impingement has this horrid pain and that it is usually misdiagnosed at first. They promised me I’ll be back for my senior year of basketball in November. Let’s hope they’re right.

    Reply
  8. Peter

     /  September 18, 2012

    remove the fat pad? It serves a purpose you know….what does he propose to ‘replace’ the fat pad with?

    Reply
  9. Melissa

     /  September 19, 2012

    Yeah, apparently the fat pad only provides a little more cusion. He does not plan to replace it with anything. This is why I’m skeptical because won’t there be a difference between my knees having a fat pad in one and not having one in another?

    Reply
  10. Hi Melissa, I’ve also had almost a year of constant pain, thinking it’s improving only to get worse again, and have been to 2 doctors, 3 physios, had acupuncture and massage and a cortisone injection all with minimal improvement. I’m now booked to see a surgeon…in january next year! Let us know how your surgery went. I hope it was the cure to your pain! I’m hoping I won’t need to go down that road but I will do literally anything to be pain free and running again! Any further advice from other sufferers is very welcome, especially regarding transitioning to barefoot/minimalist shoe running 🙂

    Reply
  11. Melissa

     /  October 17, 2012

    Hey Kym, I had arthascopic surgery (I think that is how you spell it) about 3 weeks ago and I have never felt this good in a year. It was the best decision I made and I should of told the doctor to perform the surgery a while ago, but then again they thought the patellar tendonitis was my main problem instead of my impinges fat pad. I was in terrible pain after the surgeryy for a week but then slowly with the help of physical therapy, I can bend it more and I am able to walk on it a lot better. I still have about another month and a half before ibcan play sports again but the surgery is totally worth it. The great part is that I have three tiny scars from the probes. My orthopedic doctor did my surgery and it came out great. I can’t wait to get back to playing basketball as well as you can’t wait to run again! Hope this helps!

    Reply
  12. Lizzie

     /  November 26, 2012

    I am 18 years old and have been diagnosed with fat pad impingement by my physio (due to a hip rotation, and having one leg slightly longer than the other, the muscles work a lot harder in the shorter leg, causing my knee cap to move and grind against my fat pad) after one year of therapy, stretches, an insole in the shorter leg’s shoe, ice packs, ibulieve gel, acupuncture, rest from running, then working gradually back into it, i am still in agony after about 10 minutes of running. it now hurts every day even just walking and i have been having physio even more regularly, every week. what are everybody’s opinions/results from surgery and am i too young? i am desperate for this to go away, i love long distance running and really want to get back in to it.

    Reply
  13. kylie

     /  May 13, 2013

    Hi there, I’m 19.
    I have both Hoffa’s pad impingement and patellofemural syndrome. Have been having knee problems for close to nine years. I’m a culinary competitor, cook in an industrial kitchen, and a ballroom dancer. I have had the diagnosis diagnosis of Hoffa’s pad for over 14 months, due to a falling arch, and other syndromes.Have spent the last 14 months in physical therapy twice a week almost every week, have been given special braces to pull up the patella, special insoles to support my arch, as well as taping. And have received two cortisone shots. The shots only gave me temporary relief. I am now on the road to surgery, hoping it will be the missing piece of the puzzle. My case has been found extremely weird, by four of the five of orthos in the office. And puzzling due to the lack of progress throughout each treatment. All I can tell you is to try every option you can find before seeking surgery.
    How this helps you out.

    Reply
    • Hi Julie

      I realize it’s probably a little ignorant of me to jump straight in with this as I hope that your physios would have looked at this:
      Has anyone taken the time to look at how and if you manage to activate your glutes and if all the muscles are firing correctly – specifically the stabilizer muscles?

      I only ask as so many ‘knee issues’ and those around the ITB are radically aided when everything is firing and activating correctly.

      Thankfully I didn’t need surgery but part of my long process of recovery was to address this weakness.

      Hope you have it all resolved quickly

      Reply

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