Hoffa’s Syndrome | Fat Pad Impingement Syndrome – A Cause of Anterior Knee Pain


What is Fat Pad Impingement?

Sometimes after a forceful direct impact to the kneecap, the fat pad can become impinged (pinched) between the distal thigh bone ( femoral condyle) and the kneecap (patella).

As the fat pad is one of the most sensitive structures in the knee, this condition is known to be extremely painful. The knee pain is  situated anteriorly on either side of the lower kneecap and is worsened by straightening (extension) of the knee joint. Hence the fat pad comes under constant irritation and may become significantly inflamed.

It is also termed Hoffa’s Syndrome.

Where is the Fat Pad in the Knee?

Fat Pad of the Knee Joint

What Are the Symptoms of Fat Pad Impingement?

  • Pain and/or swelling around the bottom and under the kneecap
  • Patients may have a history of knee hyper-extension (called genu recurvatum)
  • Positive Hoffa’s test (with the patient in lying with their knee bent, the examiner presses both thumbs along either side of the patellar tendon, just below the patella. The patient is then asked to straighten their leg. Pain and/or apprehension of the patient is considered a positive sign for fat pad impingement)

Treatment of Fat Pad Impingement

Treatment of this condition is normally by conservative methods such as:

  • Rest and avoiding aggravating activities – stop running.
  • Ice or cryotherapy to reduce pain and inflammation.
  • Physiotherapy modalities such as ultrasound and TENS.
  • Muscle strengthening exercises to maintain the strength and fitness of the surrounding muscle groups
  • Taping the patella may help. One method involves taping the upper surface of the patella to allow more space for the structures beneath the lower surfaces i.e. the fat pad.  This leads to less stress and impingement on the fat pad.

If conservative treatment does not work then surgery may be advised. This may involve the complete or partial removal of the fat pad itself.

Surgery for Fat Pad Impingment

This is done using key-hole arthroscopy surgery.

Two tiny holes on either side of the lower part of the kneecap allows the surgeon to visualise the problem using a camera system and a small motorised shaver to remove the impinging fat pad.

This is an example of a patient whom I treated recently.  He experienced pain in the front of the knee for the past 3 to 4 months. The pain was brought on after running for about 10 minutes. He was able to complete his 1 hour run but would have pain and mild limp over the next 1 to 2 days.  The problem worsened and he could no longer run for more than 10 minutes.

Clinical examination showed pain in the front of the knee at the level below and adjacent to the kneecap.  The pain was made worse by straightening his knee.

Fat Pad Impingement or Hoffa's Syndrome

The pain went away immediately after the surgery.

For more information on Hoffa’s syndrome, please contact us at 65-683 666 36 or email us at hcchang@ortho.com.sg

You may wish to visit our website at http://www.ortho,com.sg

Comments
257 Responses to “Hoffa’s Syndrome | Fat Pad Impingement Syndrome – A Cause of Anterior Knee Pain”
  1. Elliot Wilson says:

    Hi there. I am a doctor with this syndrome. What are the possible risks to the knee post-excision of the fat pad? ie can the function well without it or does the fat re-accumulate with time?
    Thanks for your post – very informative

    Elliot wilson

    • Hi Elliot, excision of impinging fat pad is a very safe procedure. The surgeon will attempt to remove the impinging portion of the fat pad only. The rest of the fat pad behind the patellar tendon should not be excised.

      • Nikki Patterson says:

        I am 27 and have had a knee arthroscopy surgery on Octobrer 7 2011. Doc shaved some tissue in there. I am now been experecing a swallen knee by the fat pads. I can not bent the full length or straighten fully. It does hurt when I try to do eighter. Doc now recommended a 2nd surgery. I am worried this isnt going to work. ANd what is going happen to my knee after?

      • I would consider physical therapy and perhaps a cortisone injection to the painful fat pad areas first before rushing into another surgery. The physiotherapist has to help you mobilize the patella (kneecap) and this may help.

    • Ned says:

      Try a steroid injection first

  2. Katie says:

    I have this but not as a result of a sports injury. Could you please explain?

    • It can happen after trauma e.g. falling onto the kneecap or even after excessive walking up and down the stairs. Anything that potentially can inflame the fat pad can make this painful. A mal-aligned kneecap can also contribute to this problem.

  3. Ana Reichenbach says:

    My 14 year old son has just been diagnosed with Osgood Schlatter’s Disease and Hoffa’s Syndrome. He’s very active in sports. He is giving up the second half of his basketball season, in hopes of avoiding future knee surgery. Would you recommend cortisone injections for someone his age, or would physical therapy be a better option for him?

  4. AKDixit says:

    My son Vibhu Dixit is 19 and Student of army course. He has undergone arthroscopic surgery for removal of fat pad. How much rest is required for complete recovery. Thanks.

    • Recovery is generally fast.
      The surgical wounds heal in 10 days.
      The knee swelling will reduce over 3 weeks.
      The quadriceps muscle will need to build up again over time.
      Most patients return to work within a week of the surgery.

  5. S Bourgeois says:

    I am 38 and an active runner. I have been dealing with Hoffas Syndrom for close to a year. Did the PT, cort shots, ultrasound gel massages, and exhausted all running, with no relief and now my Doc and I are discussing surgery. If I have the surgery, will I be able to still run and how soon after would it be reasonable to start doing so again, obviously in small amounts initually?

    • It is important during surgery to remove just the right amount of impinging fat tissues and not remove too much. If done properly, you should be able to go back to some running at 2 to 3 months after the surgery.

      Excessive removal of the fat pad can cause scarring of the front of the knee giving rise to pain in the front of the knee whenever you start to run. This pain usually goes off after a while but the knee may feel swollen and uncomfortable subsequently.

      All the best!

  6. Zoe O'Leary says:

    HI, I am 19 and have this. I experienced pain while playing sport and continued to play for a little while through the pain. After having MRI and I went to see an orthapedic surgeon who specialises in knee sporting injuries. By the time I had my appointment, in the meantime i was resting and not doing any sport or any other strenuous activity, the pain had subsided in which the Dr said it should have. After slowly going back into normal things e.g. work, horseriding and a little sport the pain has come back – as bad as it was. It has been 2 months since the pain had subsided and have only been back into full action for about a month. Even now i am not playing hardly any sport but am working more which means i am on my feet and walking around for 8 hour shifts with very little break, although this is not hard work.
    I am also taking iibuprofen which is not being very effective. What should my next step be. I want to be able to go back into full sporting form as i was when playing full time and training. Which has been about 1.5 yrs due to other injuries!!
    Thanks

  7. Susan Ferrari says:

    Dr. Chang,
    I had an MRI done and it says I have a cyst on my hoffa fat pad. I have had serious pain in my knee for 3 months and it travels down my shin into my ankle. I limp when I walk and its not getting any better. I was told to get physical therapy. Is this going to help? I cant run, step or do leg extensions. Im very active and this is really putting a dent in my wrokouts. What can I do?

  8. Charlotte says:

    I had scar tissue removal from my Hoffa Fat pad. Scar tissue has returned and my fat pad is hard as a rock. Massage, cortisone and ultrasound have helped some but it is still hardened and gets stuck under my patellar tendon when I bend my knee. Can the entire fat pad be removed and what are the consequences of this? How do I stop the car tissue from returning?

    • This is really tough. Further surgery may make the stiffness and anterior knee tightness worse. I would not recommend excessive removal of the fat pad.
      When I do fat pad surgery, it is just to remove the parts that are hypertrophied and impinging. It is not a good idea to remove excessive amounts as it can lead to scarring and fibrosis. Patients starts to have problems with knee bending as well as pain when running.

  9. Charlotte says:

    Can fat pad scarring cause a thickening of the patellar tendon–or are these unrelated conditions? How does one treat a thickened patellar tendon? Surgey? PT has shown only minimal improvement.

  10. Charlotte says:

    When a fat pad is “hypertrophied” does it change in color as well as size? How does one know the correct amount to remove without being excessive?

  11. Dyfan says:

    Hi there,

    Following a successful medial meniscus repair on my right knee over two years ago l am experiencing lateral anterior pain that occurs while cycling (l am a keen, competitive racer). I have seen my surgeon and he has suggested a partial fat pad excision in order to relieve the symptoms. He thinks the pad may have some scar tissue. In addition to this, my knee has never regained its full range of extension following the first operation (both my knees used to slightly hyperextend). Just to complicate things further(!), my level of pain has dropped slightly following a cortisone shot. Do you think l should try another shot, or do you think excising the pad may be the best long term option? Also, can you tell me what kind of recovery to expect, and also whether you think the fat pad may be preventing the knee from extending?

    Many thanks,

    Dyfan

    • Hi Dyfan,

      I would be very cautious in going into this knee to remove scar tissues. It may cause more scar tissues to form after the surgery and this may make things worse.
      I usually give cortisone injection (once or twice) to the portal areas to help reduce the pain. Most of the time it should settle down.

      I recently saw a patient who had arthroscopy done elswwhere and there was a lot of scar tissues over the portal areas. He has pain in the front of his knee during running. I did not offer him surgery as I did not believe I can make him better. I advised him to go for scar tissue massage by the therapist.

      Regards,

      HC

      • Dyfan says:

        Hi Dr Chang,

        Thanks for your reply. Things have moved on slightly since l last wrote to you, and l was wondering if you could offer me some advice? I received around 6 weeks of physiotherapy involving ultrasound and taping to relieve the pressure on the fat pad. This seems to work to a degree when the tape is in place, however my skin has had an allergic reaction to the tape, and so for the past week l have been unable to use it. The tape allowed me to get on my bike fairly regularly, however since not using it, the symptoms are beginning to return.

        The pain is a dull aching sensation both to the lateral aspect and underneath the patella tendon, with occasional sharp pain. The hoffa’s test is negative, and it is not painful to touch neither does it feel like there is anything lumpy or hard under the skin, so l’m guessing that if there is scarring, there isn’t much of it?

        I am contemplating surgery as this has gone on for over 6 months, however l would like to know what you would suggest in this situation? My surgeon has given me a cortisone shot, which definetely helped, but will not give me another.

        Many thanks.

  12. Denise says:

    I had an MRI back in October of 2011. I kept complaining to my doctor that the pain in my knee was in the knee cap area. The MRI came back showing bursitis, small joint effusion, and posterior medial corner strains and sprains. The radiologist went on to further say that my meniscus was not torn. My doctor reviewed the MRI and said my meniscus was torn and I needed to have surgery. I had surgery and come to find out my meniscus was NOT torn. So I recovered from that surgery, but only to continue with the pain in my knee cap. Tried physical therapy, cortisone shots, medications, topical pain creams…nothing is helping. Had another MRI yesterday which showed:

    (1) development of signal and fluid along the posterior aspect of the Hoffa’s fat pad and apex, suspicious for Hoffa’s fat pad impingement, (2) small knee joint effusion, (3) progressive superficial infrapatellar bursitis at the level of the tibial tubercle, (4) borderline patella alta and (5) mild posterior medial corner strains and sprains.

    Not sure what all that means and I don’t see doctor until Monday morning. I just want to know what is wrong with my knee.

    • The MRI findings of possible fat pad impingement is most likely post arthroscopy changes. I would avoid any further surgery. The safest thing to do is avoid activities that make your knee pain worse and get a really experienced physiotherapist to get you going.

  13. Kev says:

    Hi Doctor,

    Approximately 1.5 years ago, I injured my knee from repetitive squatting and twisting. While having bad pain and problems walking, bicycling and my knee being swollen, I tried all options to eliminate my knee pain and stiffness but had no luck in doing so. Although I have more movement and less pain than pre surgery (Fat Pad removal), I continuously have bad pain along the left, middle and right side of my knee joint. While on my feet for a while or trying to run or take quick cuts, I am in horrible pain for days or even a whole week and with a strong limp. I am only 36 and a very active Athlete, which is frustrating. My Surgeon recommended seeing if I was a Synvisc candidate. Is there a way to completely eliminate this pain so I can be active again? What do you suggest this knee problem may be and what I may look into doing to correct? And, will I be able to play any sports again?

    Thank you very much Doc!

    Kev

    • There may be some scar tissues that will form in the area of the fat pad after surgery. Scar tissues can be painful when suddenly stretched. The patient may experience discomfort or overt pain when starting to run. Once the knee is warmed up, the pain may become less and the runner feels better. But the pain may bother him later after the run due to the irritated and inflamed scar tissues. This can result in limping for a day or so. There is no good solution. Synvisc is unlikely to help.

  14. India says:

    Dr Chang Haw Chong

    I have been having problems for a couple of years now. I was being treated for patella tendonopathy. Finally after having an MRI it showed my fat pad is hypertrophic. I have been advised to have surgery on this I now cannot run at all due to severe pain. The MRI also showed medial meniscus tears on both knees. I am not symptomatic of the menscal tears, so should I have these polished on the knee that has the fat pad hyper trophy? I have had physio and a steroid injection into the fat pad with only temporary improvement. After working for 8hrs on my feet all day my knee is painful. The only thing that I have not tried is the taping. Is it wise to have the surgery and afterwards how long will it be before I can swim, run and cycle as I want to get back to triathlon. Would very much appreciate your advise.

    • The treatment must be based on the actual cause of your knee pain. This can only be done by understanding where your pain is and what is found during physical examination.

      A hypertrophied fat pad may not be the cause of your knee pain if the examination does not correlate with this diagnosis.

      Hence any surgery should only be done if the cause of your knee pain is certain.

      Meniscal tears are more likely to give you knee pain then the fat pad.

      If the pain is definitely from the fat pad, removal of the impinging portion will usually solve the pain. Recovery to return to sports is about 6 weeks to 3 months.

  15. Nicola says:

    Hi, I had a full fat pad removal 4 weeks ago. I am still unable to walk without the use of a crutch and am not able to fully straighten my leg or bend it back more than about 45 degrees without severe pain and a feeling of splitting at the bottom of the knee.
    I have had 2 physio sessions so far in which I was told my quadriceps are now not working correctly – I’m assuming this is due to lack of use. I’m on strong painkillers in order to do physio exercises and am due to go back to my consultant in 4 weeks.
    My discharge notes came through today and they say that they also found slight lateralisation of the patella – what does this mean? Would this be a reson for my pain and lack of mobility?

    Regards
    Nicola

    • I remove the impinging part of the fat pad during surgery. I avoid removing the entire fat pad as it may lead to more problems of pain, stiffness and slow recovery. I believe your surgeon did not remove the whole fat pad.

      The patella can be lateralised in some patients and that can result in mal tracking during knee movements. This can be a cause of anterior knee pain.

      I suggest you speak with your surgeon to clarify your doubts and ask if a good knee guard may be useful in the interim period before your knee becomes stronger. A Baurfeind Genutrain P3 knee brace can sometimes be quite useful.

      I hope you get well soon!

      • Nicola says:

        Thanks for your reply Dr Chong.
        My discharge notes have a brief detail of surgery which say; Slight lateralization of patella. SOC fat pad apporas to be encroaching into joint. ACL intact.
        I’m unsure if these are the correct words as the handwriting is barely legible.

        It states that the operation involved; Left knee arthroscopy and excision of Hoffa’s fat pad and after speaking to the nurse after the procedure she said that it was a full excision.

        In your opinion should I now have recovered if only the impinging part has been removed?

        I will be seeing my surgeon at the end of April so I still have what feels like a long wait to get answers to my concerns.

        Thanks again for your reply
        Nicola

  16. THilton says:

    Dr Chong,

    It seems that fat pad surgey isnt always successsful. Can one “exercise” the scarring of the Hoffa Pad away using eliptical trainer, bike and strengthening via leg extensions and leg press?

    • Dear THilton,

      I would try oral anti-inflammatory medications as well as a good course of knee physiotherapy.
      As to which form of exercise is good, you need to talk to the therapist.
      Do note that when the fat pad is acutely swollen and inflamed, you are unlikely to be able to do much anyway due to the pain.

      Regards,

      HC Chang

      • THilton says:

        Thank you for your response. Unfortunately, based on my experience in the U.S., this condition frequently goes unrecognized and untreated.

  17. Tricia says:

    my 15 year old daughter has been complaning on severe knee pain for 2 weeks after a xray and mri Dr told us today she had Hoffa’s? She is taking a steriod by mouth and has for 3 days now. Still severe pain. Today he suggested no theropy at all and just wanted to wait and see her again in 2 weeks! She is just in so much pain all the time it seems like something needs to be done. I think we need a second Dr to look at it. But don’t want to rush into surgery but he said there was nothing to do by wait?? told her she could even still run! but she can hardly walk?

    • Dear Tricia,

      It will be painful when the fat pad is inflamed and impinged. The fat pad is very well innervated and hence a rich source of pain.
      I tend to agree with your doctor that she should rest, ice the knee and take anti-inflammatory medications. Such simple measures should bring about some results in 1 to 2 weeks’ time.
      Try to avoid surgery and see if conservative treatment works.
      Surgery should only be done if a trial of non-surgical treatment has been attempted and failed.

      Regards,

      HC Chang

  18. M.C. says:

    Can I exericise fat pad scar tissue away and avoid further surgery as that only seems to produce more scar tissue. Also over time (possibly years) will fat pad scar tissue get reabsorbed into the body?

    • Dear MC,

      Yes, I would certainly try to avoid more surgery. The best way to go is to get a good physiotherapist to massage the painful scar tissue and get it more pliable.

      All the best!

      HC Chang

  19. Alyssa says:

    Hello, I have found your thread to be very helpful. Thank you for posting! About 2.5 months ago I had arthroscopic removal of the impinging portion of my fat pad which provided tremendous relief from the knee pain I had been experiencing. I’m pleased with the results, but I do have a question for you…
    Is it normal to have some rather severe sensitivity to my kneecap still? Even bumping it on a desk and making contact just below the patella (where my pain originally was) almost makes me go through the roof. What might be the cause of that? It is not usually painful once I’m warmed up but definitely hurts when there is direct contact with the inferior pole of the patella.
    Thank you for any advice!

    • Dear Alyssa,

      Thank you for your comment.

      As for your sensitive kneecap, it may be related to some scar tissues forming at the areas of the surgery as well as a certain degree of infrapatellar contracture post-surgery. Hence it is better once you are warmed up as scar tissues become more compliant after warming up.

      I suggest working with a good physiotherapist to massage the painful areas to loosen up the scar as well as try taping techniques (a bit of trial and error here) to see if it helps.

      Good luck!

      HC Chang

  20. Denise says:

    Appearance Catches The Eye, Personality Captures The Heart
    sure if actually related. I had another MRI in March. My doctors says it does not show anything. Says I have bursitis and may have to remove my bursa. However radiologist suspects a fat pad impingement. My doctor says nothing about that. My symptoms are burning sensation in knee cap and there is an indention in my knee cap. I have trouble squatting and when I do it hurts and it pops. I am seeing another doctor next week for another opinion.

    • Denise says:

      the first part of my message is gone.

      Here it is again

      I had arthroscopic knee surgery in November of last year. I had an MRI and the radiologist said my meniscus was not torn. My doctor felt otherwise and said I needed surgery. Surgery was about 10 minutes and my meniscus was not torn. I am still having problems to this day. I did fall on my knee about two years ago and just started having symptoms last year. I am not sure if actually related.

      I had another MRI in March. My doctors says it does not show anything. Says I have bursitis and may have to remove my bursa. However radiologist suspects a fat pad impingement. My doctor says nothing about that. My symptoms are burning sensation in knee cap and there is an indention in my knee cap. I have trouble squatting and when I do it hurts and it pops. I am seeing another doctor next week for another opinion.

    • THilton says:

      DENISE,
      I have nearly identical symptoms. When I squat the kneecap gets “hung up” on something and I must push thru the “pop.” Also my kneecap looks like it is indented. The only thing that has helped is strengthening the leg muscles and targeted deep tissue massage to the area that “pops”. Most doctors are not familar with injury to the Hoffa pad.

  21. Dean says:

    Dear Dr. Chang,
    I’ve had knee pain for several years. MRI findings were normal with the exception of a big effusion in the left anterior knee below the patella. Is this common with Hoffa’s Syndrome? Is this fluid detrimental? And if so, should it be drained? I would appreciated any input you have. Thank you.

    • Dear Dean,

      The knee swelling (effusion) can be due to various causes and may not be due to Hoffa’s. It is not normal to have a lot of swelling in the knee. The knee swelling points to some underlying inflammation of that knee. The cause could be due to meniscus tear, cartilage tear or other pathologies. The fluid can be drained for comfort but it will re-accumulate if the underlying cause is not treated.

  22. Tina says:

    Hi Dr. Chong,
    I am a 55 yr. old female which has exhausted all avenues in diagnosising my knee pain. The pain starts just above my knees (femur) to my feet. I is a throbbing pain that feels imflamed which affects walking, bending, stairs and daily activities. The pain worsens at night to the extent that I cannot sleep. I manage to sleep 3-4 hours with the help of Lyrica and 2 over the counter pm pain pills. I have had the knee pain since I was a child which is worsening as I grow older. It is so painful that I am afraid I am going to end-up in a wheel chair. Could the pain be a result of my knees being turned in when I was born to which they still bend inward? We were poor so the only therapy I had as a child was my mother rubbing/turning in my knees while in warm water.

    One Orthopaedic Dr. recommended arthroscopy surgery in one knee but not the other (diag. in both knees were small knee joint effusion, subtle prepatellar bursal inflammation) so I took the MRI results to another Orthopaedic Dr. to which he said I did not need the surgery but yet had no explanation of the pain. According to the MRI results my patellar tendon, and intrapatellar Hoffa’s fat pad is normal but yet I have the pain you describe. I have since been treated by a Chiropractic Dr. via physical therapy, water therapy and accupuncture with no success. I then went to a

    Nerologist, and a Rumatologist which diag. me with fibromyalgia which I totally disagree with and just recently went to a Vascular Dr. to which they all state my knees are fine. All of this has
    been within a 5 year time frame as I trying to find out the exact diagdosis so I can get the appropriate treatment. I am in desperate need of advise…please help! (sorry for being so long)

    Thank You Tina
    P.S. I have also been treated by pain management for Bursitis in my right hip which will not heal as well.

  23. Chris says:

    I have just been diagnosed with this condition after 4 1/2 years of knee pain brought about by running. The pain is worse when the leg is bent, and is alleviated when straightened. Two or three 4 mile runs a week for two weeks and i normally have to give up altogether because it is not worth the discomfort/pain. My question Dr: What is the success rate of this kind of surgery? And since my knee is not 100 percent broke (the pain largely disappears if I don’t run), should I attempt to fix it?

    • Dear Chris,

      Fat pad impingement pain tends to occur on knee extension and not with knee flexion. Hence I would be cautious to diagnose you with this problem.
      Surgery may not be the answer until an accurate diagnosis is obtained.

  24. S Bourgeois says:

    Hi Doc,

    I wrote you back in January. I had my surgery on March 7th, so today will mark 2 months out. Doc removed 50% of my fat pad, and GOUT that has crystalized, from what he suspects to be caused by the injury. Anyhow, knee feels fine unless I have it straight out extended. Then the patella tendon hurts like heck! Just had blood drawn and it appears my uric acid levels are in the norm,so I don’t fear any reoccurance of GOUT. PT therapist says my quad muscles are very weak, and I am currently focusing on re-educating the quad muscles and strengthing the quad. PT thinks once the quad is back strong, the patella pain will calm. My question is, can the patella tendon pain be caused by anything else, besides what I explained? Thanks S. Bourgeois

  25. Michael Armitage says:

    Dr Chang Haw Chong
    An MRI showed I have scarring of the lateral fat pad and I am unable to walk 400m with out it feeling very inflamed in the fat pad area of the knee. I also am unable to perform any quad / knee strengthening exercises as this also makes my knee feel very inflamed. Is it likely that excising some of the fat pad and debridement will help me do you think? – is the scar tissue likely to come back if I did this?
    Many Thanks Michael

    • Dear Michael,

      It is a difficult situation. The fat pad is usually scarred due to previous surgery to the knee. Further surgery to the fat pad may cause more scarring and pain. The fat pad surgery is useful only if it is hypertrophied and is causing pain due to impingement. Otherwise I will not recommend surgery.

      • Michael says:

        Thanks Dr Chang. I scarred the fat pad by falling off my mountain bike and hitting my knee on a rock. My OS said my fat pad is slightly hypertrophied and impinging, however the pain I feel is not sharp pain, but a strong dull inflamed pain and doing any strength exercises aggravates the pain and makes me limp. I’m having an Ultrasound scan to see how much scar tissue there is. But I have been told that surgery results are “mixed” and so I’m not sure what to do?
        many thanks Michael

      • If there is impinging fat pad causing pain and the fat pad impingement test is positive, careful resection of the impinging area will give good results. Avoid excessive resection which will cause a lot of scarring.

        Best of luck to you!

  26. Jacqueline says:

    Hi Dr Chang,

    I’ve knee pain in both knees and fat pad pain in my left medial knee. I’ve been through 3 months of PT to strengthen my leg muscles and regular stretching. While my knees have no major pain right now, my fat pad still gets irritated from time to time, even when I gently use my hand to brush and touch it. My PT noticed I’ve slightly mis-aligned kneecaps, with my left kneecap facing out. I’ve flat feet too.

    What would you advise me to do?

    Many thanks!

    • Dear Jacqueline,

      It appears you have lateral patellar tilt with anterior knee pain. The flat feet will aggravate the situation.
      My suggestions:

      1. Obtain flat feet insoles.
      2. Loosen the lateral aspect of your thighs and knees. It involved a lot of stretching and deep tissue massages.
      3. Strengthen the vastus medialis obliquus of your knee. This is the quadriceps muscle on the superomedial aspect of your knee.
      4. Avoid stairs, squats and up-hill/down-hill activities.

      All the best!

  27. Tristan says:

    I’ve recently had an MRI scan because I am suffering with pain on my tibial tubercle. The results show an abnormailty with my fat pad under the knee. My knee makes a lot of crunching sounds when I bend/squat my knee. I am a serious competing runner (33 yeras of age) but havent been able to run since January mainly due to the TT pain. Do you think the fat pad problem can cause pain in the TT? I also pronate a lot on my right foot and have suffered a hip impingement and also had an ankle debridement last year. I just want to get back to running but feel like im falling apart, please help! Tristan

    • Dear Tristan,

      I would be hesitant to attribute the pain at the TT to fat pad. The fat pad pain is usually at the side of the patellar tendon and worse on pressing or on knee extension when walking.

      • Tristan says:

        Thanks Dr Chang. Do you have any idea what could be causing the problem with my TT. There is raised soft tissue on the TT which makes it looks like Osgoods and I can feel a small bump on the bone. Specialist wants to excise the entire fat pad but seems a bit extreme when that could be a red herring! Would like to know if there is anything else that could be causing the TT pain i.e. poor foot flexion?

      • Tricky says:

        Hi Dr Chang

        I am having surgery on my fat pad this week in an attempt to remove some cyst formations that have appeared (on the fat pad). My surgeon is keen to remove the entire fat pad but I am concerned about fibrosis/scar tissue. My main source of pain is located on the insertion pont of my tibial tuberosity. Do you think having some of the fat pad removed may help with the pain located on the tibial tuberosity? I am concerned that he may be taking the wrong course of action?

        Regards
        Tristan

      • Hi Tristan,
        I have not encountered a patient with cyst in the fat pad presenting with pain in the tibial tuberosity. This is very peculiar. I always try to avoid removing the entire fat pad as it can cause more problems – persistent pain, stiffness etc.
        Please discuss with your doctor.

        Regards,
        hc

      • Tricky says:

        Yes the pain in the tibial tuberosity is most odd. Perhaps it is a seperate issue with some damage to the bone at the point of insertion? However the ultrasound didnt show up anything. I cant find anything on the internet regarding this condition other than osgoods and its obviously not that as I am 33! There is a definite raised bump and pain directly on top of it when I press down with my thumb. If you have any idea what else could be causing it I would be very pleased to find out! Many thanks for yout time.

      • There may be a loose ossicle at the tibial tuberosity from previous OSD. However, the ultrasound should have picked that up. I do not think surgery will be useful honestly.

  28. susan brooks says:

    I had an excision of my fat pad back in february, it was that badly damaged i had the entire fat pad removed from my left knee. 4 and a half months on i am still suffering with moderate/severe pain below and above my knee. I have severe swelling above my knee also. I have had 22 sessions on hour long physio and am only able to get a bed which awake of 121degrees. i had a manipulation carried out may 8th and also has cortisone injections and local anaesthetic. Neither of these have reduced the swelling or the pain.
    One physio is wondering if there could be fluid being held in the sac above my knee causing the excruciating pain, i asked my consultant this and he has said there is no chance without really investigating the cause o my pain and discomfort.

    Do you have any suggestions as to what could be causing me such pain?

    thanks

    • Dear Susan,

      It is not good to remove the entire fat pad as it will be filled by scar tissue thereafter. Scar tissues are painful when stretched or when the knee is moved after a period of inactivity.

      It is very difficult to get rid of your knee pain at this point in time.

      • susan brooks says:

        Thanks for this, do you have any thoughts on what could be causing the swelling above my knee now? It’s severely painful if touched and moved too far. There is a very large amount of swelling. It looks very much like I have half a tennis ball above my knee when standing up straight.
        Could it be possible what my physio thought? That it is a sac above my knee filled with fluid causing the excrutiating pain? How long could it take for this to occur if it is a possibility?

        Thanks doc :-)

  29. Dear Nicola,

    I usually avoid removing the entire fat pad as the area where it used to be will be filled by scar tissues that are painful when stretched or when moved after a period of inactivity.

    During surgery, I usually remove the impinging part of the fat pad only.

  30. susan brooks says:

    susan brooks says:
    June 29, 2012 at 1:17 am

    Thanks for this, do you have any thoughts on what could be causing the swelling above my knee now? It’s severely painful if touched and moved too far. There is a very large amount of swelling. It looks very much like I have half a tennis ball above my knee when standing up straight.
    Could it be possible what my physio thought? That it is a sac above my knee filled with fluid causing the excrutiating pain? How long could it take for this to occur if it is a possibility?

    My Consultant has now discharged me from his care because he is not willing to investigate the tennis ball sized swelling above my knee cap and is just saying it is due to muscle deterioration which i do not believe to be correct.

    I have had 22 sessions of physio and am still relying on using one crutch to help me get around.

    Neither ice, rest, physio or cortisone injections or anti-inflammatories have even started to reduce the swelling it is slowly increasing in size and the pain is too increasing.

    Thanks doc

  31. Justin says:

    Hi,

    I had an MRI which showed a mild tear to the meniscus and fat pad syndrome on my left knee. I have done 2 months of therapy and continue to do strength exercises daily. I would like to start mountaining biking, nothing hardcore but do not want to cause any further damage. Is cycling recommended after this type of injury. I am active but can not run as this causes pain.
    thanks

    • Hi Justin,

      You need to ask your treating doctor this question as I have no idea what you mean by “mild tear to the meniscus”. I would be hesitant to start my patient on any repetitive loading activities to the knee with a meniscus tear that was not treated. As for the Hoffa’s, it is more of a clinical diagnosis rather than an MRI diagnosis. Cycling should not worsen it too much as the fat pad usually gets impinged during terminal knee extension rather than flexion like in cycling.

      Please consult your treating doc :)

      hc

  32. Tomas Gomez says:

    Hey Doctor,

    I am a soccer player who plays year round. Im 19 and recently went in to see the doctor about my knee. The pain is more annoying instead of a pain that actually hurts. I received an MRI and it came back negative. The doctor believes it is an inflamed fat pad. I had the same issue last fall but during the spring it seemed to go away. I am faced with the option of getting a cortisone shot or getting scope done. I was wondering what you believe would be the best option. I start preseason in a month so I need to make a decision quick. Thanks

    Tomas Gomez

    • Hi Tomas,

      I strongly suggest conservative treatment with ice, cortisone injection and knee strengthening. Surgery should be considered only after you have failed conservative treatments.

      Cheers!

      hc

  33. Mike M says:

    Hi Dr. At 16 i tore my fat pad, and broke my ankle. I was not weight bearing and in a cast so i didnt notice the knee pain until about 2 months later. This was in the year 2000 or so. The surgeon completely opened up my knee (4 inch incision on the outside) and removed a good portion of the fat pad. About a year later the impingement was back. I couldnt take another surgery and still have lingering doubts as to how the first one was handled. Basically, i’ve been living with this for 12 + years and very active(ice, stretching, isometrics, stretching, orthodics, knee braces, ive tried just about everything).

    I still have trouble fully extending my knee, its still painful and still gets swollen. What would you suggest i do?

  34. crxhearts says:

    Hi Dr Chang, my sports doctor diagnosed me with chronic swelling of my fat pad. He is putting me through physio and says that the fat pad swelling will slowly subside if I stop aggravating it. Is this true?

    Thanks!

    • Hi,

      He is not wrong. Rest, avoidance of aggravating activities e.g. squatting, running, sports, can allow the inflamed fat pad to quieten down with resolution of pain. U can also try icing the knee and do some physiotherapy. Surgery is not considered until you have exhausted these avenues.

      Cheers!

      hc

  35. steve says:

    Hi Dr Chang,
    I had ACL reconstruction 1.5 years ago using hamstring graft. I had quite severe swelling of my knee which took almost 3-4 months to subsided. I noted I had markedly reduced patellofemoral joint mobility with very sharp anterior knee pain with my patella tendon and quadricep tendon much thickened and tightened. I tried very hard to stretch and massage the tendon and now the patella mobilisation nearly back to normal. I had another MRI of my knee with my graft ACL intact but showing some signal change at my infrapatella fat pad but no definite impingement. I now still suffered from anterior knee pain but it appears to decrease with improving patellofemoral mobility. I tried NSAID and the pain reduced. My question is, if my anterior knee pain is related to inflammation of my infrapatella fat pad. Is it because of my previous maltracking of patella leading to the constant irritation of it ? So now my maltracking probelm is solved(just solved in these weeks), is it possible for my fat pad to “cool down” and I can fully return to my sports activities?

    • Dear Steve,

      You have infrapatellar contracture post-arthroscopic surgery. This increases the compressive loading to your knee’s patellofemoral joint. It is not likely to be due to fat pad impingement. The treatment is stretching. It’s a difficult problem to solve as the tissues over the front of your knee and around the kneecap are stiffer than usual. Most people with similar problems report having anterior knee pain during the start of the sporting activity and the pain may improve once the knee is “warmed up”. However, the pain may come later and persists for the next day in some sufferers. Do you have similar issues?

      Regards,
      hc

      • steve says:

        Dear Dr Chang,
        Yeah. The pain is worse in the morning and improve when my knee is warmed up and then usually reappears again the next morning and lasts for a few days . It hurts particularly in the morning. In fact, I notice there is some swelling below my knee cap with mild increased temperature whenever I have pain.
        I have to say that my maltracking was very severe before, I noticed my knee cap was tilted upward and lateral to the usual position with “clicking” of my patella over a half a year ago. Since then, I stretched my quadricep everyday and use the foam roller to help release my tight tendon. It actually works and even the physiotherapist was surprised to see my “tight like a rope” tendon to come loose.
        Yesterday morning ( one day after exercise), my patella tendon area was tendon. In fact, I am not sure whether it’s my patella tendon pain or just the tissues underneath my tendon causing me pain. This is quite distressing to me as I used to be a very active lesiure soccer player.
        Another question is , is further strengthening of my quadricep would help share the loading ? So should I still continue gym training or I should rest my knee?

        Best regards,
        Steve

  36. steve says:

    spelling mistake->tendon was tender

    • steve says:

      Hi Dr Chang,

      Another important question is, why I only experience pain when my knee is in full extension, particularly when I stand with my knee totally straight.
      Thanks.

      Best regards,
      Steve

      • When the pain is at full extension, it implies something in the front is being caught or impinged. It could be the fat pad. As you have surgery before, it is difficult to ascertain what exactly is happening. MRI scan may help. I still think it is post-surgical constracture in the front of the knee causing your symptoms.

        Regards,

        hc

  37. John says:

    Could you advise how long after a fat pad impingement scope I can start to cycle again?

    Thanks

  38. B. Smith says:

    Dr Chang,
    I had a “simple” arthroscopy of my knee and ended up with fat pad syndrome. Why are the arthroscopic incisions made into this sensitive fat pad/patellar tendon area if it is known to be prone to scarring? I now have a problem that I didnt have prior to my surgery and am far worse than before. If fat pad is fibrotic what can be done other than removal and once it is fibrotic will it never return to “normal” tissue? Thank you for your time and consideration on this topic.

    • The portals are usually made close to the centre of the knee where the fat pad is as it allows the surgeon to do more things without damaging the articular cartilage of the knee joint. Sometimes a small portion of the fat pad is removed to allow better visualisation. This can potentially lead to scarring and chronic pain.

  39. Allison says:

    With the announcement today that tennis champion Rafael Nadal has been diagnosed with Hoffa’s…in the general sense, as a professional athlete, could he get back to playing how he was playing BEFORE the impingement? Say, if surgery were necessary, could he get back to “normal” or would he have to change the way he trains/competes so the Hoffa’s wouldn’t occur again?

  40. Meika says:

    About 4 years ago I had the key hole surgery on my knee, the surgeon that perfomed said he had to remove the entire fat behind from behind my knee because it had been shreeded. Four years on I am now currently expericing weakness in the knee giving way, I am a fairly active person. Is the removal of the fat pad a huge issue???

  41. Kylie Gottsche says:

    Hi I just wanted to get your thoughts after my recent consult with a orthopeditic surgeon and he has recommened to me that I should get my fat pad taken out. As he has said that the fat is causing my knee cap to mis-track and hence my knee to dislocate. Can you function “normally” without a fat pad? Thanks Kylie

    • Dear Kylie,

      I have not examined your knee nor seen your scans. Hence it is tough to comment too much. However, kneecap maltracking or dislocation is not treated through surgery to the fat pad. The fat pad should only be operated on if it is causing pain. I think you might have misunderstood what your surgeon was trying to convey to you.

      Cheers!

      hc

  42. chanda says:

    Hi, I just had surgery 4 days ago for what the doctor and physical therapist thought was a plica band but after the surgery they informed me they removed the fat pad and there was no plica band. My knee is still very swollen and painful but the thing that is bothering me the most is that when I bend my knee there is a squishing noise in my knee and it feels like it wants to lock up on me. I have been using ice, ice and more ice and elevating my toes above my nose like I have been told also I have been taking anti-inflamatory meds, a baby asprin a day to avoid blood clots and narcotic pain medicine prescribed bu the doctor. None of this seems to be helping the pain or the swelling. I am on crutches and am told to put a little weight on my leg but the pain is horrible. Is there anything that you can suggest or that I should not be doing that is making it worse?

    • Hi, please do not panic as yet. It’s early days since your surgery.
      The squishing sound in the knee is typical after knee scope as fluid was placed inside the knee joint during surgery. This residual fluid is mixed with some air bubbles and blood from post-surgery bleeding inside the knee joint to cause this sound. It is harmless.

      You feel unwell as it the operated knee tends to be inflamed and swollen at 3 to 4 days after a knee arthroscopy. I typically warn my patients about this prior to surgery and they cope with it much better.

      I also bring my patients back to my clinic at 3 to 4 days after the knee scope surgery to drain out excessive blood in the knee joint. This helps to relieve the tension in the knee and they can walk much better.

      Speak to your surgeon. Communication is key.

      • Kylie Gottsche says:

        Just one other thing can you function without a fat pad?

        Thankyou Kylie Gottsche

        Sent from my iPad

      • Yes, it is commonly removed during a knee replacement surgery. These patients tend to do well without the fat pad. However, younger and more active people may complain of pain in the front of the knee from stiffness especially with activities such as running.

  43. Tricky says:

    Dear Dr Chang

    Following an MRI scan I have been diagnosed as having cysts on my Hoffa fat pad. The reason i went for the MRI scan is because I have had (for over 6 months), an ongoing pain and lump located on my tibial tuberosity (at the insetrtion point). My surgeon wanted to excise the entire fat pad but I have asked him to only take out the impinging or cysted areas and leave the rest of the fat pad alone. He is not sure whether this will cure the problem with the tibial tuberosity. My hope is that the patella will function a bit better (with rehab) and the alignment improve with the tibial tendon thus reducing strain on tibial tuberosity insertion. Do you think I am taking the correct course of action?

    Many thanks.

  44. Aaron Hartle says:

    I just had surgery yesterday for a plica syndrome which actually was OK, however the surgeon found fat pad impingement which he shaved down. I know it has only been a day since surgery, but the knee feels quite good and I have only taken a couple of advil here and there. How long untill I should start physical therapy, biking, swimming, knee strengthing exercises, etc?

    • Swimming by about 14 days after surgery.
      Biking by about the 3rd week onwards.
      Knee strengthening exercises can commence soon.

      Cheers!

      • Aaron Hartle says:

        Thank you Dr. Chong. My doctor wants me up on a stationary bike immediately. What are your thoughts on early biking. I have reached 110 degrees flexion, but it is still a bit tender. By the way, can I just say how nice it is to be able to ask you about these questions. Thank you for your service.

      • Hi,

        I usually advise my patients not to overdo things during the initial period after surgery. Surgery causes trauma to the knee joint and the knee usually responds by becoming swollen and inflamed. We should try to calm it down before subjecting it to exercises prematurely. All the best to you!

        hc

  45. Aaron Hughes says:

    Hi. I’m 19 and just got my MRI results for the pain and swelling around my knee which I had over the summer. The Doc sais I’ve got a fat pad impingement. She said I could get round it first I have to try Physio to strenghten the muscles around my hip and knee. I asked her If I could get back into sports after the physio and she said she couldn’t see no reason why I couldn’t. Is 19 an age where I can reverse this and go back to playing sports ?

    • Yes, with adequate rest, use of oral anti-inflammatory medication and a good course of physiotherapy, your symptoms should settle down and you can gradually resume your sporting activities.

      • Aaron Hughes says:

        Hi thanks for the reply
        Im currently in a waiting list for physiotherapy and I dont know when i’ll be called up and i’m worried it could get much worse over time if it isnt treated. Do you have any suggestions as to how I can treat until I get physiotherapy ?

  46. Liam Patrick says:

    Hi guys.
    I currently play AFL and at the start of this year after a long pre season started getting pain under my knee. i worked with my physio for roughly 8 weeks with massage, icing, antiinflams, taping and no sport. My knee felt great and went back to training. sure enough 15min into this my knee became a little sore until at one point during a kicking motion i felt the worst pain i had ever experienced. i could hardly put weight on my leg.
    A few weeks later i starting seeing a sports doctor who specialises in knees. He straight away confirmed it was the fat pad inpeingement and proceeded to give me a cortizone injection. This helped hugely and two weeks later was back playing sport only to have the exact same thing happen.
    i have now had an MRI and am about to book in for surgery. My concern is that it has been sex months since i have played any sport, or required to hyper extend my leg therefore am an sure if the fat pad is still inflamed? Does this mean it will not be visible to cut away?

    Thanks

    • Hi,

      I suppose your surgeon is worried that you will have the same problem of fat pad impingement pain when you restart your training. Hence he felt that it was better to trim part of the fat pad. I think this course of treatment is reasonable. Do talk to your surgeon about your concern before embarking on the surgery. All the best and speedy recovery!

      hc

  47. Krisztina says:

    Hi Dr Chong,

    I would be greatly appreciated if I could get your advice on my situation below:

    I had an MRI the other day as I have been experiencing pain in my left knee over the last 8 months.
    As it seemed to be improving up until the last 3 weeks, I was doing regular exercise (stepper machine, elliptical machine, lunges, dead lift…) I was mainly feeling dull pain in the knee during the day (sitting job) and exercising seemed to helped for a while.
    However in the last few week the pain doesn’t go away, there i a constant tingling, pulsing and I have difficulties in walking. The pain often spreads to the surrounding muscles.

    The MRI shows the following:
    ‘Best appreciated on axial PD FS image, focal oedematous changes are noted involving the superomedial aspect of the infrapatellar fat pad, this are of fat may impinge between the medial patella and the medial femoral condyle.
    ‘Small area of focal oedema is noted within the superomedial aspect of the infrapatellar fat pad, this may explain symptoms. ‘

    The GP wasn’t able to advise if physio therapy or surgery is the better option to resolve the problem.

    As I am unable to make the decision because of the limited knowledge on this area, I would be grateful if you could advise your opinion on the above?

    Thanks in advance and I look forward hearing from you.
    Regards,
    K

    • Dear K,

      MRI shows likely fat pad impingement. However, the diagnosis is still best made after a careful clinical examination.
      I suggest you avoid excessive stairs, squatting, and physical exercises e.g. running to allow the fat pad inflammation to settle.
      Consider taking some oral anti-inflammatory medications from your GP.
      Icing the painful area of the knee can help.

      It is not wrong to try physiotherapy first.

      Surgery should not be your 1st choice until conservative management has failed.

      Do see an Orthopaedic Surgeon for an expert opinion.

      Regards,

      Dr Chang

  48. Wendy says:

    I am going in on the 31st of October for fat pad trimming. I am worried about the pain being worse or chronic after surgery. I haven’t seen a lot of information on successful post surgery stories. My question I guess is, is it mostly scar tissue that is the biggest post surgery side effect to having your fat pad trimmed? How do you proactively prevent the build up of scar tissue?
    Thank you!

    • Dear Wendy,

      I usually only remove as little of the fat pad as possible and I give a steroid injection to the knee at about 3 to 5 days post-surgery to avoid excessive scarring.
      Hope this answers your question.

  49. sam says:

    i work with care of the elderly and have just been diagnosed with hoffa’s syndrone is it visable to work as i am in constant pain nd i fear that i my rick the health of others

  50. I think I have this my knee started hurting during a run at 3 mile point i was able to continue but after couldnt walk this was 3 months ago i’m still in pain been having physical therapy for past two months after rest & ice for first month. Its still painful sometimes at rest my muscles are often going into spasm around my knee every time i think it improves it gets worse again, I have not been able to do any CV exercise at all can’t even tap my foot without being reminded of severe pain. What can I do, shall I ask for surgery or will the vicious circle i’m in resolve eventually?

  51. Dr Chang

    I am hoping you may be able to provide some advice on my current situation:

    I have been in chronic pain for two years with hoffas syndrome/fat pad impingement in both knees, I tried conservative methods such as physiotherapy, cortisone injections, medication and accupuncture none of which worked. Six weeks ago I had arthroscopic surgery on both knees to remove the apex of the fat pad and medial plica. I was told that this was the only option and would relieve my symptoms and pain to get me back to physical activity. I am now six weeks post surgery and still in pain. Physiotherapy seemed to be helping the right knee however the left felt as though it was getting worse, so I am now doing hydrotherapy instead. I hit the physio, walking and weightbearing quite hard soon after surgery and fear that I may have done more damage and fear that I will not heal at all. I am told that because I am hypermobile and have ‘chronic sensitivity to pain’ i will take longer to heal than others but I am not seeing any improvement as of yet. My physiotherapists tell me that I need to get my knee moving, and into full extension, that the knee feels more swollen to me than it actually is and that i’m not doing any more damage. however the surgeon tells me to be gentle and rest. I am very confused as to what I should do now. The physio does seem to help as I walk away much better after my sessions, but my extension and the swelling (under my patella and to the outer side) does not seem to be going down and my surgical scars are extremely pink. Should I try a cortisone injection? will this heal with time? I am fearing that i will be left in chronic pain once again. any advice you have to offer would be greatly appreciated.

    Thanks

    K

    • Hi K,

      The pain from fat pad impingement usually goes away almost immediately after surgery. Your situation of persistent pain post-surgery is not usual. One needs to consider other possibilities such as patellofemoral pain syndrome from lateral patellar tilt or subluxation. I would consider a steroid injection as your mentioned. But please consult your surgeon.

      All the best!

      hc

  52. Arthur says:

    I was diagnosed with tendinopathy and fat pad impingement in both knees 2 years ago following an MRI. After 2 years of physiotherapy, rest, return to exercise (football) and return of symptoms. I recently had steroid injections, these seemed to not have worked and now I am considering surgery, presuming the problem is fat pad impingement, is this sensible. I am a very fit 23 year olds.

  53. sage says:

    Hello Dr. Chang,
    Thank you very much for your informative thread! I am a fit and active 42 year old woman. In April 2012 I severed my ACL. Prior to the ACL injury, I had never had any knee pain or problems at all. On June 29. 2012 I had ACL Alograft replacement surgery. Recovery started well and by month 2.5 seemed on a good track, being dedicated to PT.. however slowly by month 3 knee pain turned and began getting worse and worse. Now at month 4, I can’t climb stairs, straighten knee without sharp pain and popping, and stiffness with walking is also getting worse.

    I got an MRI this week and the results read:
    “Mild to moderate synovitis. Inflammatory change and scarring in the Hoffa’s fat” (intact ACL, no cyclops lesion, no meniscal tear)

    My surgeon seems keen to “go in and cut out the scar tissue” however I would prefer non-invasive options if they have good results. It has been 6 months since I can move and I just want to fix this- in fina-l as fast as possible. I should also mention that I have Keloid and am concerned that scar tissue would keep building up (?? is that common??) Your thoughts and recommendations are greatly appreciated!

    Sage

    • Hi,

      It is common to have a bit of scarring at the fat pad after knee scope surgery. You knee pain appears to be due to synovitis and inflammation rather than Hoffa’s.
      I will caution going in to do another surgery at this point in time. I would consider oral anti-inflammatory medications, ice therapy and go slower on the physiotherapy.

      All the best!

      hc

  54. Gareth Richards says:

    Hello Dr Chang, first let me say I really appreciate you taking the time to answer people’s questions here.
    My right knee has a greatly enlarged fat pad confirmed by MRI. There are no mensical tears but there is thinning of the meniscus. I am in no pain at all when walking or other daily activities. However, I am not able to do any kind of repetitive motion exercise (biking, elliptical, swimming) for more than about 15 minutes, because the area around the pad in front of the knee becomes extremely swollen. I have not attempted to run for nearly 2 years because of concern that the root cause is not diagnosed. I do not have a local pain in one specific area but rather a soreness and throbbing due to the swelling. So I am not able to do any kind of cardio exercise, My doctor is recommending partial removal of the fat pad to correct the problem, but he cautions that in about 10% of cases there are undesirable after effects such as scarring etc. So I am weighing the benefit of the surgery with the risk of creating a problem in daily life that I do not have today. What is your experience in such cases? Is there a risk of creating harm via such a procedure and is the 10% consistent with the rate in the literature etc.? Regards.

    • Hi,
      I would assess your patellar tracking carefully. The pain can be due to fat pad impingement or it can be due to patellofemoral overload. Some patients have kneecaps which track laterally. It is also prudent to examine for any flat feet in your case. Flat feet can make the kneecap pain worse. Simple insoles for flat feet can sometimes do wonders to the knee pain.

      The key hole surgery to remove impinging fat pad can be very good if the cause of the pain is indeed from Hoffa’s syndrome.

      Regards,

      hc

      • Nicola Jones says:

        Hi Mr Chang, I hae written to you before about the removal of my fat pad. I had most of the fat pad removed in Feb this year and have since gotten less able to bend the leg and walk up and down stairs, stepping over things mostly always causes my knee to lock and I’m then stuck with a locked knee until it decides to release itself. I have been back to my consultant and had intense physio but this hasn’t worked so I had another mri which showed that the remaining fat pad is now inpinged. My consultant wanted to do another arthroscopy but after getting a 2nd opinion now has arranged a course if extracorporeal shockwave treatment and so I’m wondering what your opinion is to this new treatment. Many thanks Nicola

      • Dear Nicola,

        I have no experience in using ESWT for fat pad pain or post-surgery scar pain. I only use EWST for plantar fasciitis or Achilles tendon pains.
        How did your treatment go?

        Regards,

        HC

      • Dale Kinder says:

        Hi Doctor Chang, I just had Surgery in my knee due to My hoffa fat pad being enlarged twice what it is suppose to be, It is now 2 week after surgery. I am still in pain and when getting up from a sitting position my knee throbs. The swelling has not gone done much and I think there is alot of fluid inside my knee. Is this normal and what usally is the recovery time. I can walk on it but it hurts when I do. I am in the navy and injured myself with a direct blow to my knee. Right below my knee cap is where most of my pain is. I look forward to your response. Thank you very much,

      • Dear Dale,

        It is normal for the knee to swell up after arthroscopy. It will usually subside over a period of 2 to 3 weeks. In my practice, I usually bring the patient back to the office at the 3rd or 4th day after the surgery to remove the blood from the operated knee using a needle and syringe. The aspiration of the accumulated blood in the knee helps the patient to have less pain and earlier return to quadriceps function and control of the knee joint. Perhaps you may like to speak to your surgeon if aspiration of the blood in your knee may be helpful.

        Regards.

        HC

  55. Bryant says:

    A year ago I was told I have this syndrome. I started therapy and taping the knee. I’ve noted that icy hots work the best for me. I also have noticed that the pain is only bad in the winter. Why would this be true?

  56. Carmina says:

    Dr. Chaw Haw Chong,

    Hello, I recently had an MRI and it revealed that I have cysts on the Hoffa fat pad.
    My daily activities do not aggravate; however, whenever I play soccer…the pain is quite substantial. I can live with the pain as I love playing that much. My question is am I doing more harm than good by being active?

    Thx for your help,

    CS

    • Carmina says:

      Forgot to mention ….pain occurs after I play, during I’m fine.

    • Dear Carmina,

      If the pain in the knee worsens, or if the knee swells up after sports, then it is probably not good for you to continue playing. These cysts can sometimes be removed arthroscopically or aspirated percutaneously using ultrasound guidance.

      Regards,

      hc

  57. mark d says:

    Hello Dr. CHC,

    I had patellar debridement 18 months ago for a 3+ year condition that did not respond to any of the conservative treatments I tried. The patellar tendon feels good but I’m left with pain behind the knee cap. A Synvisc-one injection gave me a lot of relief for just over 6 months but the pain is now back.

    I saw a new surgeon today and got a new MRI. He believes the first arthroscopic surgery removed too much of the Hoffa fat pad (looked to me like the upper/superior 50% was removed, so no direct padding behind the patellar tendon.) and scarring behind tendon and slightly behind patella is the source of my continued pain. He said the tissue tends to be very sensitive and that it could go down over time but he thinks it is unlikely. He suggests a second surgery to trim out scar tissue.

    My question for you is this…Would vigorous massage of the scar tissue tend to help soften/break it up or would I just end up with newly irritated tissue (repeatedly)?

    Thank you for your time. This Q and A thread has been informative!

    Mark

    • mark d says:

      Forgot to add that the MRI show a very healthy knee in ALL other categories. I am a 45 year old man that has been running and cycling for 20+ years. I can still ride but I dream of being able to run again….Thanks.

    • Dear Mark,

      If your pain is due to scar tissue formation, then additional surgery to trim the scar may result in more scar tissue formation. I will be very hesitant to offer surgery. I feel that stretching, massaging the scar tissue, ultrasound treatments with the physiotherapy may be safer and potentially useful.

      Regards,

      HC

  58. Andrea Tsurutis says:

    Hi,
    I had a minor left knee injury when running on Nov 4th 2012 that has progressed. I am an athlete, and have not been able to exercise since the day of injury. I initially did not have any edema. It was painful with walking (the worst pain to walk down stairs) and I felt minimal relief unless I was completely non-weight bearing. The pain I feel is to my anterior, lower knee area and across my lower patella. There is also radiation of the pain down my lateral anterior shin. Initially, I used ice, rest, a knee brace, and NSAIDs without relief.

    I had an MRI that showed Hoffa’s and IT Band Syndrome. My Ortho doctor gave me a cortisone injection to the fat pad area about 3 weeks ago. I also was on 10 days of Naproxen. The pain was relieved in about 4 days, but I was experiencing a moderate amount of swelling, tightness, and a feeling of exhaustion in the knee area.

    Since then, the tightness and exhaustion is gone. The knee remains edematous (about 1 cm larger than the right knee). I also do not have full extension or flexion to the knee. The moderate-severe pain has also returned. I have stopped the NSAIDs due to a family history of GI bleeds. I have just been icing as much as possible.

    What do you think of subsequent cortisone injections? What about an oral steroid burst?

    What would your next steps be?

    Thank you in advance,
    Andrea

    • Yes, a 2nd cortisone injection may be useful. You should also ice the knee frequently, avoid sports, squatting and stairs.
      A course of physiotherapy to the affected knee may be useful.
      If all else fails, arthroscopic surgery to remove the impinging fat pad may be useful. The non impinging fat pad should not be removed.

      Regards,

      HC

      • Dale Kinder says:

        Dr Chang, thanks for your quick reply, What I meant was is it normal to have pain around or on the hoffa fat pad after Surgery. I had a good portion of my hoffa fat pad removed due to it getting impinged.

      • Hi Dale,

        In my experience, the pre-operative pain goes away quite fast, usually within a few days of the surgery.

        Regards,

        hc

  59. Dale says:

    Well thank you for taking the time to reply. I see my ortho tommorrow. The swelling has not gone down, I have been on Oxycodone for pain, as well as Toradol for inflammation and it still has not gone down in swelling. The front of my knee is very hot to the touch. I am going to suggest to my DR, to drain my knee to see if that would alleviate the swelling, The oxycodone does not work that well and neither does the Toradol, I have even went as far as taking Ibuprofen and icing it but it does not help. Will let you know what my DR says. Thank you!

  60. Mike S says:

    Dear Dr. Chang,
    A few years ago I started exhibiting pain in the front of the knee below the knee cap. The first Ortho that I went to suggested that it may be fat pad syndrome but he wanted to make sure that there is nothing else going on – so I did an MRI. The MRI showed a meniscus tear on the SIDE of the knee (specifically, the inside of the knee). Since the pain was in the front and the tear was on the side, they didn’t think the tear was the cause of the pain so they had me do Physical Therapy to see if it would help. It did not. I then switched ortho (my insurance changed) and the new ortho suggested that there may be a pain transference going on and that we should go ahead with fixing the documented problem (i.e. the tear). So I did the surgery but it did not help. The new ortho never mentioned the possibility of fat pad syndrome and , in fact, he mentioned that during the surgery he was able to observe that structurally, other than the fixed tear, my knee looked great. To address the pain, he had me do several other things over the years: additional Physical Therapy, switching between, anti inflammatory meds (which reduced the pain a bit but didn’t address the core problem), wear a strap under the knee cap, and finally a cortisone shot which didn’t help. After all of this he suggested that this is just something that I’m going to have to live with.

    Over the years I’ve consulted with a podiatrist, acupuncturist, a rheumatologist and another ortho. This ortho said that the pain I’m experiencing could benefit from a year long intense physical therapy (he thought that my previous PT wasn’t long enough) which would include injections to numb the pain – and then MAYBE I’ll see a difference – I passed.

    After researching the symptoms on your site and the internet, it does sound like the original ortho was correct. If I go on the elliptical machine at the gym for more than 15-20 minutes, I will be in pain for the following 1-3 days. And, standing still is unbearable after 10 minutes or so – waiting in line at the airport is the worse.

    I recently made another appointment with the ortho that did my surgery and asked him about fat pad syndrome. He mentioned that it is very difficult to diagnose since this syndrome cannot be visually observed or documented. For this reason, he is hesitant to do this type of procedure.

    Any suggestions would be much appreciated.

    Thank you very much for your site.

  61. Jay says:

    Doctor, I appreciate the information provided. It has been difficult finding a Physician with experience treating this disease. I have bi lateral fat pad inflammation and pain. During Physio for an unrelated ankle surgery, I was advised to perform a terminal knee extension exercise with a resistance band to activate my VMO. While doing the aforementioned exercise I believe I hyper extended my knees and aggravated the fat pads.

    Currently, I have received four months of Physio treatment, ice, rest, Voltaren, hyperbaric chamber treatment and a single cortisone injection. All have failed in treating the enlarged medial fat pads. It is difficult to walk, stand, and squat. I am an athlete and have a very active/physical career. I am considering surgery.

    How successful is the arthroscopic resection? How long is the recovery time? Do you recommend any Los Angeles based surgeons?

    • Mak says:

      Hi doctor, i had an soccer injury about 4 years ago by twisting the right side of my knee. All scans done and no ligaments damaged how ever pain persists when jump and run for a long time and also upstairs. All doctors i have seen give different views. Physiotherapy does not work cus i can’t do some of the lifts and squats. Recent doctor i saw told me might be the fat under my knee causing problem. Only one side of the knee near the knee cap hurts and some times after exercise i may have to rest the knee to bring down the pain. By removing the fat pad will i be able to go to my activities like before i am 27yrs.

  62. Casey says:

    Dear Dr. Chang,
    I went in for surgery 2 weeks ago for a suspected Medial Plica. During surgery Doctor found Hypertrophied Fat pad, not plica. He removed the entire Hoffas Pad. I have good range of motion, but stiff and still swollen. My question though is in regards to a very sharp, painful sensation I get on the medial aspect of my patella when I turn or twist or lift my foot during turning motions. The Physical Therapist says its scar tissue and wants to painfully massage it away…making it worse. The orthopaedic surgeon says its just trying to heal and shouldn’t be massaged. Can you please tell me if this is normal, and if it is just part of the healing process, as I’m worried that my knee will not function normally without the fat pad. I would like to return to cycling and running one day, but now just hope to walk without these sharp pains.
    Thank You very much for your wonderful responses and explanations to all our questions,
    Casey

    • hi Casey,

      i usually only remove the impinging parts of the fat pad and not the entire fat pad. the fat pad is a very sensitive structure and removing the entire fat pad will cause a lot of pain and swelling during the immediate post-op period. i tend to ask my patient to massage the tender areas as well. but different surgeons have different preferences.

      cheers!

      hc

  63. sitoshna says:

    hello doctor,
    2 months back i had done a long run after a really long break, then i had terrible pain in my knee,i went to the physio and ortho ,they said my fat pad had undergone impingement,i was given TENS,physio and the ortho gave me some meds and advised 2 weeks rest ,after that the pain wasn;t there,.. but now i am enrolled for police training in which i will have to run a lot of long distance, is it going to relapse.. or its going to be fine..help? if there is any way it can be stopped from relapsing during the training?

  64. Kylie Gottsche says:

    Hi Dr Chang , I would like to seek your advice on my fat pad. I have had several MRI and they have all come back with a inflamed fat pad. I have seen 3-4 orthopedist about it and 2 of them have said that it is one of the biggest fat pad they have seen and constantly getting inflamed and pinched. Their advice was to completely remove the fat pad as I have already had stem cell injection and that really didn’t make a difference. Thanks Kylie Gottsche

    • Hi,
      I would caution against excising the entire fat pad as it may result in formation of scar tissues and this can lead to problems.
      It is better to remove the parts of the fat pad that is swollen and impinging. In this way, your pain will resolve and the recovery will be faster.

      Regards,

      hc

      • Kylie Gottsche says:

        Hi dr Chang I was wondering if you could help me. I am finding it hard to find a doctor that is willing to perform the fat pad impinchment. The only response I have had so far is to remove the entire fat pad. I was wondering if you have any recommendations in Sydney Australia? Thanks.

        Sent from my iPad

      • hi Kylie, I am not too familiar with the doctors in Australia. I know of a Dr John Bartlett from Melbourne. He is an experenced knee surgeon and might be able to advise you on how to proceed further. He might be able to recommend a surgeon in Sydney for you as well.

        http://www.ogl.net.au/vic/bartlett_vic.html

        Regards,

        hc

  65. Fredy says:

    Hi Dr.
    I was diagnosed with this syndrome in both knees, I was a dancer, I’m working actualmete which requires a lot of physical strength, lifting pipes and other heavy objects for the oil industry in Mexico, I have injected with cortisone and have taken other drugs (25 mg. indomethacin, 0.75 mg . betamethasone, 215 mg. methocarbamol) for 20 days, but continuous pain in the knee, do you think I need to perform an operation? or do I have to wait a little longer and hope the injections work? What is your recommendation for pain relief? Ice or hot compresses? If I operate on how long I can go back to my heavy work without making some kind of problem?
    Thank you very much, very complete article.
    Regards

    • Dear Fredy,

      I prefer icing the knee. it helps to reduce pain and swelling. most of my patients who need to go for this surgery can walk immediately after the surgery without crutches. they can get back to running in about 4 to 6 weeks. for heavy work, i suggest 2 months. It is difficult for me to advise if surgery is needed in your case as I have not examined you.

      Regards,

      hc

  66. erik says:

    Hi Dr. Chang. I recently talked to a orthopaedic surgeon, but I would like to get another opinion. I have had a knee problem for the past 2-3 years, swelling up here and there randomly. Whether it was after an exercise or just walking on it for 8 hours a day at work. I was told that I have a cyst that is 1.5cm by 1.6cmm within my patellar fatpad, which is also causing a tendon bursa on the back right of my right knee. I’ve tried taking thinks such as naproxin, icing my leg on both sides(back and front). I recently had 2 cortisone injections, the first one helped, but the second injection was a much deeper injection into the knee, which cause a reaction(knee swelled up like a balloon) and was extremely painful to walk on, after a about a week the swelling went down and got a lot better. I still feel a click from the front of my knee up to my hip, and still get a burning sensation in the back of my knee. I was wondering whether or not I should do the surgery, or just wait it out a little bit longer with anti-inflammatory medication and ice.

    • Hi Erik,
      The decision whether to proceed with arthroscopic surgery to remove the cyst is best discussed with your surgeon as he has examined your knee and seen the MRI scans. It is difficult for me to comment.
      All the best!

      Regards,

      hc

  67. Maura says:

    Good morning Dr. Chang,
    My 18-year-old son joined his college crew team 6 months ago. As part of his training he must row 1 1/2 hours daily on an erg machine or out on the actual boat. He has been experiencing pain with his knee. The team doctors have done tests and therapies and we were told that the pain stems from the fat pad of the knee.
    My question to you is that even with treatment of cortisone or shaving the fat pad should be continue a sport like rowing where you repetitively move your knee/leg to a locked and unlocked position? Could continuing with rowing do further damage?
    Thank you very much for any input that you may have.
    Maura S

  68. Chris Rapp says:

    Hey Dr. Chang! I just had a “ton of fat” removed in my knee cap 3 days ago… I was just wondering when can I walk on it? Iv’e tried but have been in a lot of pain. My knee is swelled up like a ballon and my foot is feeling cold, numb, and is tingling. Is this normal? And when do you think I will be able to return to basketball?

    Thank you,
    Chris

    • Hi Chris,
      The initial swelling should subside within 2 to 3 weeks. I tend to aspirate the knee to remove the blood at the 3rd day after surgery. This helps with the pain and allows the patient to walk better. It may take 3 months to return to basketball.
      Regards,
      hc

  69. Denise says:

    My daughter injured her knee during a track practice/meet and has had pain now for 2 months. We had an MRI because all the doctors thought it was a tear in the meniscus, however it only showed alot of fluid on her knee and alot of inflamation to the fat pad under her knee. The doctor is now recomending surgery (which he says will heal very fast) to remove part of the fat pad and fluid. Is this the right choice? How long should she expect to not be able to run?

    • Hi Denise,
      It is probably better to try non-surgical treatments initially. These include icing the knee, rest from sports. oral anti-inflammatory medication, physiotherapy and steroid injection. If these fails, surgical excision of the impinging part of the fat pad can be very effective. Most patients should be able to get back to running within 3 months of the surgery.
      Cheers,
      hc

  70. JOse Florez says:

    Dear Dr. Chang
    i was diagnosed a cyst on my right knee, after 3 month pain. Doctors said a punktion and drainage of the cyst shoudl do the trick, but it was extremly painfull which is unusual for cysts and they were unable to extract any fluid….
    do you have any ideas what it could be or waht could have happened at the punktion….
    they want to excise te cyst but i am kind of skeptical!
    thank you very much for your time!
    J

    • Hi Jose,
      The MRI scan of your knee should be able to allow the doctor to come to an accurate diagnosis. It may be a meniscal cyst. The treatment would be arthroscopic treatment of the lesion. If it is a solid tumour, then the MRI should have given an indication of what it could be.

      hc

      • JOse Florez says:

        Dear DR Chang
        thank you for your quick response.
        Doctors ruled out arthroscopy since the cyst is outside the articulation, between pattella and tendon. As well i think they missed to see if the tumor was solid or not…
        any suggestions?

        Many thanks
        jose

  71. Ryan Michael says:

    Hi Doctor,

    I am an avid runner who was experiencing some knee pain. An MRI showed a subacute subchondral stress fracture of the lateral tibial plateau along with slight edema in the Hoffa’s pad. I tried returning to running after a period of weeks but now feel a burning pain near the stress fracture and around both sides my patella tendon/tibial tuberosity, which seems consistent for fat pad impingement (I’ve also had this knee scoped before for plica). My question is, could the swelling from the fracture be irritating the fat pad? If so, should the fat pad irritation go away when the fracture is healed? (I’m going to swim for 6 weeks and slowly try running again). Thank you for your time.

    -Ryan

    • Dear Ryan,

      The stress fracture is the most likely source of your problem. The pain from the stress fracture will affect the way you walk, stand, run and climb stairs. This can lead to secondary inflammation of the fat pad. My suggestion is to treat the stress fracture with rest and the fat pad irritation should go away.

      Regards,

      hc

  72. jen decasas says:

    Hi Dr. Chong,

    I hurt my knee 7 months ago taking a step wrong and felt instant pain and crunching/grinding in my right knee and meniscus area. Bring us to present day with a MRI findings of patellafemoral syndrome with inflammation/edema within the superior and lateral aspect of Hoffa’s fat pad; Iliotibial band syndrome; patella is relatively immobile and not tracking well; medial compartmental arthrosis and then throw Fibromyalgia into the mix also .

    I had a second opinion this past Friday (when I also got a cortisone injection for the IT syndrome) and it was the first sign of hope that this can be fixed surgically. I have been doing the stretches/strengthening, icing my knee, injections, pain pills, 5 knee braces, blah blah with NO real results. Pretty much like bandaid.

    So I had my consult with the ortho surgeon today and left in tears telling me to keep doing what I’m doing…ice, rest, rehab, knee brace, pills, injections. I have a 6 year old that I can’t play with and a job I had to leave (I am a chef).

    Is surgery an option in your opinion? At this point I want surgery if it’ll remedy the pain and swelling. I want my life back and me back

    • Dear Jen,

      Surgery will only help if the source of the pain is correctly identified ie it is coming from the fat pad impingement as well as tight lateral retinaculum. An arthroscopic excision of the impinging portion of the fat pad together with a lateral release may help you. Please consult your doctor.

      Regards,

      hc

  73. Karen says:

    Dear Dr Chang-I had meniscal tear, debridement and fat pad shaving done in Jan. Did pt as ordered and was having trouble with pain in kneecap, flexion. Sent to pt…build up quads, ion treatment, tens, ultrasound, pt continued. no improvement. Feels like huge knee, severe pain, can’t bend knee well or get up and down without using furniture to help boost me up. Went back to surgeon, ordered mri…said I had so much fat pad edema and impingement. Put on 40 mg prednisone, complete rest for 2 wks, ice 4 times daily. Finishing up prednisone and still absolutely no better. Throbs, keeps me awake at night, unable to work (house cleaning business) can’t stand long. Surgeon said he had never seen so much inflammation without injury since I had just had surgery 3 months ago. I stuck very strictly to guidelines following surgery as I am a runner and wanted to absolutely do nothing to slow my complete recovery. I am so frustrated and wondering what is my next step. thanks for your input.

    • Dear Karen,
      I am sorry to hear about your painful knee. I usually avoid removing excessive amounts of the fat pad. The fat pad is a normal structure and is very well innervated. If surgery is done for Hoffa’s syndrome, I only remove the areas that appear to impinge during knee movements. I do not remove the entire fat pad. If excessive fat pad is removed, it may cause a lot of pain, swelling and difficulty with walking. Most of my cases walk well within a few days of the surgery because I am very careful not to remove excessive amounts of this structure. The other issue is post-surgery fat pad scarring can be a cause of knee pain and stiffness. In your case, I would consider an intra-articular injection of cortisone (steroid) and ice the knee frequently and continue working with the physiotherapist.
      I hope you get better soon.

      Regards,

      HC

      • Karen says:

        Thank you for your help. I will continue on with pt and currently he’s taping my knee to see if that helps. I just want to run again. Again thanks for your input. I appreciate what you do for all of us out here with this problem and all the insight you give. It is a blessing to us looking for answers

  74. Chris says:

    I am currently a professional football player. I had ACL reconstruction back in August 2012. The ligament is completely healed and the surrounding muscles are developing back to the strength they had before the injury. I have this pain under/beneath my patella when I completely straighten my leg and when my quad is flexed. It is difficult to completely flex my quad because I feel more and more pain in my knee. For the past couple of months I have been doing many treatments, as far as MOBS, TENS, using Ultrasound, extensive dry needling in the surrounding muscles thinking tight muscles are causing this pain. I have done some research and Hoffa’s Syndrome seems to be the issue at hand. How long would recovery be from an arthroscopic surgery procedure to get back to running and doing football activities? I lost some significant strength in my leg after my ACL surgery, so I was curious if the same or something close would happen with this surgery?

    • Hi Chris,

      Have your surgeon tried injecting some steroids to the area of the pain? It may solve your problem instead of another surgery. Sometimes the pain is not so much due to Hoffa’s syndrome but due to post-arthroscopy fat pad scarring. I have had great results with just localised steroid injections to the portal areas and into the areas around the fat pad.

      Regards,

      hc

  75. Angel says:

    Weeks following ACL surgery I developed fat pad impingement. One year later had some of my fat pad surgically removed. After this fat pad surgery my knee aches constantly. Just received an Orthovisc for the arthritis in this knee and believe the needle may have inflamed my fat pad once again. In lots of pain. Taking Motrin and Tramadol together throughout the day just to get by. Haven’t played sports or run in 8 months. Extremely upset and tired of the pain and achiness. Have done physical therapy, injections, taping, almost everything. Any suggestions for relieving my fat pad pain, it’s been two years and very miserable? Thank you!

    Angela

    • Dear Angel,

      It is a difficult situation. The ACL surgery probably caused some scarring along the infrapatellar fat pad which resulted in your knee aches and pains. This is a bit different from fat pad impingement or Hoffa’s syndrome. I suggest you massage the infrapatellar portal scar areas frequently and warm up the knee with a hot pack before attempting exercises or sports. It may help. You will then need to ice the knee after these activities. I hope this may bring you some relief.

      Regards,

      hc

      • Angel says:

        Trying to determine if what aches and pain I have is from scar tissue or fat pad impingement or both. Would fat pad impingement give me aches and pains constantly, day in, day out? Got my MRI results yesterday which show nothing on the fat pad. But yet my knee pinches in that ACL portal area throughout the day. This is so difficult for me and appreciate your help!

  76. Dale J says:

    Dr. Chang.,

    I had a Fat Pad Impengement surgery done Last year Dec 12. Its been almost 5 months. The surgeon had shaved down most of my Fat pad. Now I am in more pain when I walk than I was before the surgery. Sometimes my knee feels limp like its going to give out. Ive had 12 weeks of PT. I am in the navy and this was done at a military Hospital. I have tried steroid injections before the surgery. I have asked the surgeon for another MRI to take a look inside and he doesnt see it to be necessary. I also asked about another surgery to clean up any more scar tissue. He said no to that as well because he things it will create even more scar tissue. I am about to get kicked out of the military due to a medical discharge. The surgeon told me he cant do anything more for me and said hes done all he could. However he has refereed me to someone else in this big clinic who has more EXP than him. What would be some things to bring up to this new surgeon that could help him fix my knee. I am willing to do anything. Do you think Another surgery would be nessacry or another MRI to see how the knee has healed? Your thoughts please..? Thank you.

    • Dear Dale,

      No. I do not think further surgery will be of any further benefit to you. The role of surgery for Hoffa’s syndrome is to remove the offending portion of the fat pad and the idea is to preserve and leave alone as much of this structure as possible. If most of the fat pad has been removed, there will be a lot of scarring and it can cause pain when running or during cold or rainy weather. There is no good solution after that.

      Regards,

      hc

      • Dale J says:

        Is this pain that I will have to live with for the rest of my life?

      • Dear Dale,

        I do see patients with similar problems as you. I really have no good solution for them. Activity modification and judicious use of pain medications may be the way to go. You might benefit from a consultation with a chronic pain management doctor.

        hc

  77. Dale J says:

    Thanks for your opinion. This is something I am going to keep pressing on about.

  78. Brendan says:

    Dear Dr. Chang,

    In January 2012 I had an arthroscopic lateral retinacular release for chronic knee pain. I’m 30 yrs old and have been an avid cyclist and mountain biker for the last 10 yrs. Before the surgery I had tried long breaks from riding, PT-recommended stretching & exercise regimen, patellar taping, electric stim, ultrasonic stim, many oral NSAIDs, joint fluid injections. Nothing worked. I lost patience and asked my OS to do something. He suggested LRR as his best guess, said it didn’t have a high success rate but was low risk for making things worse.

    ~3 weeks after surgery I fell down stairs and had a loud ‘pop’ from my post-op knee, followed by immense pain and stiffness. An MRI showed no torn tendons. The pain & swelling from the fall subsided after a few weeks, but 6 months after surgery I was no where near recovered. My original OS said I must be patient, but I was not improving.

    I saw a new OS in June, who looked at the MRI from February (as well as an MRI pre-op) and noticed an inflamed infrapatellar fat pad post-op. He injected cortisone into the fat pad, and I noticed a big improvement in acute pain over the next week. Some of this effect wore off, but I was still significantly better than before the injection. I had much less acute pain but still chronic pain, made worse by hard efforts on the bike. A second injection in the fat pad in October did not improve my condition.

    I tried a second course of joint fluid injections (Orthovisc) in December, and immediately the acute infrapatellar pain that I had before my 1st cortisone shot reappeared. I also started to notice a dull pain on the posterior of my knee capsule around this time. I had another MRI in January ’13. It showed some slight fat pad inflammation (not nearly as bad as Feb ’12) and significant scar tissue on the lateral retinaculum. (my symptoms were not too bad on the day of the MRI). My new OS has suggested another athroscopy to excise the inflamed fat pad tissue and clean up the retinacular scar tissue, but said it’s not a clear-cut solution and is not guaranteed to fix me. He doesn’t want to give me more Cortisone.

    I’ve been trying to improve my quad & glute strength and medicating with ice and NSAIDs for the last 4 months, but I’m not seeing any improvement, losing patience again and seriously considering the 2nd operation. But it sounds like the original Hoffa’s syndrome could have been caused by the LRR, so could another arthroscopy to excise the inflamed tissue just cause more irritation and inflammation? And, is it possible that the pain in the posterior of my knee is related to the fat pad, or is this more likely a separate pathology?

    Sorry for the long message and thanks in advance,
    Brendan

    • Dear Brendan,

      It is common to see fat pad inflammation post-arthroscopy even in the absence of further trauma to the knee as in your case.
      Your doctor did the right thing to give the cortisone injection.

      As for the pain in the back of the knee, you should actively look out for any cyst in the popliteal fossa, or any meniscus tear involving the posterior 1/3 or posterior horn. The pop that you experienced in your 2nd fall can sometimes be from acute knee flexion resulting in an avulsion of the posterior root of the medial meniscus. Go back to your MRI scan and look at it again carefully.

      Regards,

      hc

  79. Brynn Gardner says:

    Dr. Chang,

    I have been suffering from Hoffa’s Syndrome for about 1 year now, due to a direct blow to the front of my right knee. I have constant pain and swelling in addition to a sharp pinching with terminal extension, squatting, and stairs.
    My diagnosis was confirmed with novacaine that was injected with cortisone directly ino the fat pad. This completely relieved my pain until a few hours later when the novacaine wore off. The cortisone shot itself didn’t cause any noticeable improvement. I have also tried R.I.C.E., 8 months of physical therapy, an intrarticular cortisone shot, NSAIDs, and a 2 month course of prednisone with no success.
    My current doctor wants to do an arthroscopy involving 2 portals below the kneecap and 2 above (4 total) to look at the fat pad. Have you ever heard of the surgery being done this way?
    Also, he says that he only wants to remove part of the fat pad if it is shown to be impinging, which I agree with. However, I am concerned that this impingement may not be visible during arthroscopy since I only get the pinching when doing aggravating activities while weight-bearing (ie. squatting, stairs) and during active extension of my right leg. While sitting or lying down, I can bend and straighten my leg passively with my hands without experiencing the pinching sensation.
    Will the doctor still be able to see which part of the fat pad is impinging under these circumstances? If not, will the doctor be able to tell which part of the fat pad has been impinging based on scar tissue or fibrosis of the affected portion?
    I would greatly appreciate any insight into this issue that you may have. Thank you very much.

    Brynn

    • Dear Brynn,

      I usually perform this surgery using just 2 portals. I place the portals further away from the patellar tendon than what I usually do for other knee cases. This allows me to have a better view of the fat pad. The impinged portion of the fat pad can be seen when the surgeon straightens out the knee during surgery. The tissues are usually inflamed (reddish) and hypertrophied.

      Regards,

      hc

  80. Madeleine says:

    Hi,
    I have had severe knee pain since March this year. This pain has got progressively worse, to the point where I am on crutches to walk and have been unable to work. I had an MRI scan last week which revealed I have fat pad impingement, patella alta and patello-femoral chondromalacia. My physio is reluctant to work on my knee until the pain is under control. My questions are, is it possible to make a full recovery from fat pad impingement causing severe pain without surgery? Should I completely rest my knee to get the pain under control? Many thanks.

  81. Jason says:

    Hello all,
    I recently had a medial meniscus arthroscopy done of Feb 22, 2013 and since then I had a rough recovery. I’m a few months out from surgery and have been diagnosed with patellar maltracking and Hoffas Pad Syndrome along with new edema developments in the lower portion of the knee as well as under the knee cap. I have been doing therapy twice a week and they have been working on the tracking issues and removing scar tissue around the knee. And also working on the IT band and taping the knee however the tracking issues have been an issue since therapy started a week after surgery. I injured the knee on 10-24-12 at work and had a pipe slam into the front of my knee while I was carrying 550 of tools on my right shoulder. My knee hyperextended and I felt a “pop” in the knee. I had to continue to work under intense physical strain at work for 7 more weeks constantly kneeling on the knee, carrying between 200-800 pounds of tools up and down stairs as well as not having time off or any rest of my knee. During this time the knee continued to lock up and buckle on me and I fell routinely on me knee when this happened. I’ve had sharp pains behind the knee cap and tracking issues since the injury and couldn’t walk up or down stairs or squat or do much without the sharp shooting pains behind my knee cap. I started cortisone shots last week and the usual soreness has gone down a bit however I’m still experiencing the sharp pains behind the knee cap. I had to wait almost 4 months since the injury until workers comp agreed to cover the surgery. Could I have developed any arthritis issues or any other issues due to the long period of wait I had to go through since the injury. And I’m concerned that I can’t carry weight on my right knee or squat my own body weight or go up or down stairs without sharp shooting pain behind my knee cap. At this point what should I expect or what could be an issue that is causing this?

  82. Kathleen says:

    Dr Chang, If a large portion of the fat pad is removed, will the resulting empty space automatically fill with scar tissue? How does one break the cycle of repeat scarring with this syndrome?

    • Dear Kathleen,

      Yes, excessive resection of the fat pad will lead to scarring. Even simple arthroscopy done for other reasons can result in fat pad scarring. The important thing is to remove only the impinging and inflamed part of the fat pad and leave the rest alone.

      Regards,

      hc

      • Kathleen says:

        Thanks . Is an inflamed fat pad obvious visually to the surgeon? Is it a different color than healthy fat pad?

  83. Midou says:

    Hello dr chang,
    I have an hoffite left knee, I made ice for 20 minutes / 3 times- day and followed with a physiotherapist, I recommended to make a splint Knee is it good ?
    I stopped jogging for 6 months, even Bike .. I keep small pain but not much since I stop effort on my legs… Do you think I can heal and inflammation disappears little by little ?
    Thanks

  84. tony says:

    Good day Dr. I had a biking accident and landed on my knees about 1.5 years ago. After several months they felt normal again for the most part. I knelt down on my right knee and felt a pinch. I went to a sports orthopedist and he took xrays and said that my knees seemed fine but he believe I have Hoffa’s Syndrome. He suggested anti-inflamatories and limit the range of motion of my right knee. He also said that he would next suggest cortisol injections, and then surgery. If feels like it gets better, but when my son pitches to me and I catch, I seem to be re-inflaming it. Should I consider cortisol, or just use anti-inflamatories as needed and not hyperextend the knee, or just go for the cortisol shot?

    Thanks,
    Tony

    • Dear Tony,

      It all depends on how bothersome is your knee pain from the Hoffa’s syndrome. If it causes pain often enough, then the 1st thing to try is the cortisone injection. It usually works quite well.

      Surgery should not be done unless the pain becomes significant and affects your daily activities. The 1st course of action is always activity modification, oral anti-inflammatory medications, physiotherapy and then cortisone injection.

      Good luck!

      Regards,

      hc

      • tony says:

        Thanks you very much for your time. I truly appreciate it. When it is uncomfortable it feels like there is a sock, or balloon in my knee. Then over time, with over the counter anti- inflamatories it tends to pop like there are air bubbles in it. I think that I will try to give it a little more time then go for the shot. Thank you again.

        Regards,
        Tony

  85. Toni Blake says:

    Hello Dr. Chang – I had surgery on June 28th where Hoffa’s was discovered Dr. said otherwise I had a “beautiful” knee. After 10 days at my appt. she said I was one of the 20 percent who did not absorb the fluid they injected so she drained it. Now a week after that I have begun physical therapy. I know the fluid is called synovial fluid but my question is – did this happen because of excessive removal? Or was it that the saline was not injected slowly and the synovial capsule got ruptured? I want to know if this will create a problem for recovery or make the recovery longer. Of course I swell after doing the physical therapy exercises at home and am concerned the swelling will never go away.

    Thank you –

    Toni

    • Hi Toni,

      What you have is post-arthroscopy knee swelling. It is usually blood in the initial week and synovial fluid thereafter.
      This happens to almost all patients.
      This accumulation of blood or fluid in the operated knee usually resolves by itself over a few weeks.
      I routinely aspirate it out for my patients at the 3rd day post-surgery.
      Nothing to worry about.

      Regards,

      hc

  86. Mary says:

    Hi Doctor Chang,

    I am a long distance runner and was recently diagnosed (via MRI) of having Hoffa’s pad inflammation after 8 months of left knee pain. In your experience, how likely is it that I will return to running following RICE, and quad strenghthening exercises with a PT? Or is surgery the only way I will be able to return to running? In other words, which method has proven to be most effective for runners wishing to return to their previous level of activity?

    Thanks!

  87. Tracey says:

    Hi Dr, I am 31 years old and have been experiencing pain in both knees for just over 10 years now. My condition was undiagnosed for many years as my GP never took my pain seriously however after eventually having an mri scan earlier this year I have been told that I have fat pad inpingement. I have been having physio for around 3 months and as it has been discovered that I hyperextend my knees the treatment has mainly been on trying to correct this and to build up supporting muscles. I have been told that the consultant that I am under doesn’t like giving injections for pain relief and surgery causes scarring of the tissue and therefore isn’t always successful. As I have had this condition for so long do you think it is worth me pushing for surgery or is the damage likely to be irreparable?

  88. katie says:

    I’ve had this for 4 years and I am very into soccer, I’ve done the resting and the icing and the physical therapy twice and it goes away when I’m in off season, but the moment I start to run I’m in pain. I’m now a junior in high school and ay the moment not playing soccer isn’t option. I’ve tried braces and tapping and nothing has worked. What do you suggest as the next step.

  89. Katiekre says:

    Hi Dr. , Katie again, just wondering is there anything to relieve any pain? Because at this moment we don’t really want surgery, I know when I’m a little older that I will have to have it!

    • Hi Katie,

      Non surgical treatments include:

      1. Physiotherapy.
      2. Ice
      3. Reduce running.
      4. Localised steroid injections to the painful areas of the fat pad.
      5. Some patients report less symptoms with knee brace.

      Regards,

      hc

  90. Ryan says:

    Dr Chong,

    I am 27 years old, I have been in the military almost 7 years and am very active. I had knee pain on the front of my knee for over 2 years and after physical therapy I had an MRI. The MRI showed that I had a fat pad impingement. I had surgery a little over a month ago and the surgeon removed the entire fat pad. Every since I came off crutches I still felt the same pain I had from before the surgery and the swelling is still very bad. I am not sure if it is normal for after the surgery but I still do not have full activation of my entire quad and have some stability issues.

    • Hi Ryan,

      I usually try to remove as little of the fat pad as possible. The impinged areas are usually obvious and at the sides of the actual fat pad. Removal of the entire fat pad can cause problems such as prolonged swelling, pain and subsequently anterior knee pain from scar formation. The knee cap tends to be pulled downwards (patellar baja).

      Most of my patients who do this surgery do not need crutches and they get back to cycling and running within 6 weeks of surgery.

      Regards,

      hc

  91. James Casey says:

    Hello Doctor,
    My wife had a knee replacement 2 years ago and has had constant pain ever since. X-rays proved negative so she had an MRI on Aug.23 and it reported postsurgical changes noted within Hoffa’s fat, within the subcutaneous fat overlying the patella and patellar tendon, and within the lateral patellar retinaculum. There is no disproportionate fatty atrophy of the musculature. My question is could the knee replacement be causing an impingement and, since you reported the fat is commonly removed in this operation, could removing it stop the pain?
    Thank you for your valuable time and insight.
    Jim

    • Dear James,

      The fat pad is usually removed at the time of a knee replacement surgery.
      It is very unlikely to be the cause of her knee pain.
      Was her kneecap (patella) replaced as well? Some surgeons prefer to leave the patella un-resurfaced and it can lead to anterior knee pain in some patients.

      Regards,

      hc

      • caseman@nyc.rr.com says:

        Dear Doctor,

        I think the kneecap was replaced but will ask. The procedure was a left knee arthroplasty.
        If, after the MRI, postsurgical changes were noted within the Hoffa’s fat, wouldn’t that suggest that the fat pad is still in place?
        Additionally, a large Bakers cyst, measuring 3.4x5x7.8cm was found and drained, allowing her more flexibility but hardly any pain relief.

        All the best,

        JC

  92. diane says:

    Hi Dr,
    do you know of any surgeons in the Toronto, Canada area that specialize in this surgery?. i saw a couple of well know sport knee surgeons and they both said they don’t like and have very little experience scoping under the knee cap. I also have a fat pad impingement, very painful and cannot straighten my leg. tried cortisone, and few other types of injections that did not work so looks like surgery is going to be my next option (been dealing with this for over a year)

    thanks
    D

    • Hi Diane,

      You can try:

      Richard Holtby
      43 Wellesley Street, East
      Suite 634
      Toronto
      Ontario, M4Y 1H1
      Phone: 4169624906
      Fax: 4169678704
      Email: richard.holtby@sunnybrook.ca

      Please ask him if he can help you.

      Regards,

      hc

      • Dale says:

        Hi Dr Chang,

        A year ago I had surgery for a fat pad impingement. The surgeon went in with a scope and shaved down the fat pad. Now a year later Im in even more pain so I got refereed to another surgeon and they did another MRI and this is what is said. Edema of the Hoffas fat pad with a 5mm Ossified body, and something about Patella tracking. What does this mean exactly and what is the best course of action for this? I dont understand these terms. Please help.

  93. Dale says:

    Hi Dr Chang,

    A year ago I had surgery for a fat pad impingement. The surgeon went in with a scope and shaved down the fat pad. Now a year later Im in even more pain so I got refereed to another surgeon and they did another MRI and this is what is said. Edema of the Hoffas fat pad with a 5mm Ossified body, and something about Patella tracking. What does this mean exactly and what is the best course of action for this? I dont understand these terms. Please help.

  94. Ariana says:

    Dr Chang,
    I have fat pad scarring from arthroscopy. I have also developed Patella Baja due to this scarring. What if anything can be done at this point ?

    • Dear Ariana,

      Are you having a lot of knee pain from this problem?
      I posed your question to a panel of international experts at our singapore orthopaedic association scientific meeting last week and there was no solution offered.
      It is a difficult problem.
      Hc

      • Ariana says:

        No I do not have alot of pain but the knee is tight in front making walking difficult. I also have clicking/clunking. Would a procedure to change forces on the kneecap be recommended ?

  95. Chris M. says:

    Hello,
    Very insightful thread here! I had arthroscopic surgery on my right knee on 9/27/12 to remove a floating body and to clean up the meniscus, 2 weeks later and I was working again. Then, in December 2012, I started having anterior pain in my left knee, just to the side of the patellar tendon. The pain was felt upon standing up from a squat and during dynamic exercises. Had an MRI and the diagnosis was patellar tracking issues and possible fat pad impingement. After physical therapy, massages for scar tissue and ice, and complete rest nothing was working.

    Orthopedic surgeon recommended a lateral release, and was completed on 4/18/13. About 2 weeks after the procedure my knee had no swelling, full range of motion, and no pain, a very speedy recovery. The very next day a staph infection formed in the joint and my knee swelled to the size of two fists. Had an emergency Incision and Drainage (5/2/12), and was sent home with an external vacuum drain for 1 week. Swelling was still abnormal and my quad began to atrophy dramatically and rapidly. On 5/22 another incision and drainage was performed because of another version of staph (skin infection maybe) was in the joint, possibly from the external drain. 5 months after the initial surgery, I am still having complications. The knee sustained a lot of surgical trauma because of the short time span in which the surgeries took place, resulting in a weakened joint. In addition, the leg muscle atrophied and most of the strength was lost, as was most of the stability of the muscles, slowing recovery. Knee pain is still felt, however it is under the kneecap, and feels like a bruise when the knee bends. It is not sensitive to the touch. However, when I activate the quads with Electrical stimulation, or many, many repetitions of quad sets, the pain is dramatically increased. Do you think the pain under the patella is a combination of weakness in the quads (unable to support the joint) and scar tissue from the 3 arthroscopic entries? I feel zero pain when I try to hyper extend the knee so I”m not too confident in the Hoffas diagnosis.

    It is my thinking that as of right now, the quads are still semi “asleep” and do not activate during normal movements. I spent a lot of time favoring my right side as well, before the LR. It is only when I achieve deep muscle contraction that the pain is almost zero, except for some popping and clicking. This is from a small meniscus tear sustained a few weeks ago during rehab. Again, I point to instability. Any and all questions, comments, or views on this is greatly appreciated. I would very much love to return to my athletic career.

    • Dear Chris,

      I am so sorry to hear about your knee infection post-surgery. A septic arthritis of the knee can result in a lot of quads weakness and intra-articular scarring.

      Do you have any stiffness in your affected knee? I expect you to have some stiffness in that knee. The stiffness in your knee will manifest as pain if you try to push it over the stiff range.

      The 1st thing to do is to make sure that the infection is eradicated. Thereafter, you need to maximize your quads recovery with a good physiotherapist. Sometimes, it may be necessary to do a debridement of the knee arthroscopically to increase the volume in the knee. It involves resecting scar tissues around the gutters of the knee joint as well as the suprapatellar pouch.

      It is quite difficult to comment on your condition without examining you.

      I wish you speedy recovery.

      Regards,

      hc

      • Chris M. says:

        The infection has been cleared out since early June. There is a lot of weakness still in the quads, but it is coming along. I plan to strengthen the quads and surrounding musculature until March of next year before I consider another arthroscopic procedure, giving the joint time to heal as well. I have full range of motion and stiffness is minimal. I expect some amount of scar tissue is present, combined with the strength inadequacy of the quads and the slight meniscus tear may explain the lingering pain. However, as I feel the quads getting stronger, pain is becoming less sharp and more of a deep soreness. I expect that this recovery will take some time. All of the work is being done through a sports medicine clinic and have been with me every step of the way. Your inout is very much appreciated. Thank you.

        Regards,

        Chris.

  96. Tony I says:

    Dear Dr Chang Haw Chong,

    I haven’t seen a sports medicine doctor yet and was wondering what you thought of my prognosis and how long the recovery time would be.

    The MRI reads : Extensor mechanism: Very mildly increased signal is seen in the patellar attachment of the patellar tendon with small amount of edema extending along the posterior surface of the tendon and into the adjacent Hoffa’s fat pad suggestive of grade 1-2 sprain. The quadriceps tendon, extensor retinacula, patellofemoral ligaments and iliotibial band are normal.”

    First off, What does that mean? That’s very confusing and my doctor didn’t explain that very well.
    Secondly, i play basketball in college, will this injury linger?

    Thanks for taking the time to read my comment and get back to me!

    You’re awesome

    -Tony

    • Hi Tony,

      Your MRI report referred to “increased signal” in the patella tendon at the insertion to the lower pole of the kneecap. This is usually due to “patellar tendinosis”.
      The pain is usually at the front of the kneecap and at the patellar tendon insertion to the kneecap.
      It is common in people who play sports that require a lot of jumping e.g. basketball and central defenders in soccer.
      Your MRI also talked about “sprain” of the fat pad. This means your fat pad is a bit flared up and causing anterior knee pain.
      You need to get some oral anti-inflammatory medications, ice your knee, rest from sports for a couple of weeks and see a physical therapist.
      I think you will recover quite nicely.

      All the best,

      hc

  97. Dear Dr. Chang Haw Chong,

    Hello. Recently I had a MRI on my knee to rule out a meniscus tear due to medial knee pain with locking or sticking of the knee causing it to feel as if it was going out or stuck again all medial side. The MRI results came back with meniscus and ligaments intact but revealed Hoffa’s syndrome with synovitis and minimal fluid. From what I have read on Hoffa’s it is described as anterior knee pain, mine is medial why? Why does it lock? Over long periods of time yes pain does go anterior and inferior of the patella but the chronic pain now is all medial. I do have patellar tendonitis and have had problems with the knee for over ten years mainly because of sports. (Running, swimming, basketball cheerleading, etc..) and being horribly pigioned toed when I was younger. I also recieved a cortisone injection(about a week ago) which the knee feels worse than before the injection again all medial. Walking causes the pain and I can’t really stop that but have been taking breaks in between. Bracing has not helped it still locks and theraputic modalities have been with negative results. Surgery has been discussed to resection, should I pursue or should I try anything else?

    Melanie

  98. Sarah says:

    Hello Dr. Chang Haw Chong,

    I am a medical student and am fairly certain that I developed this syndrome after ACL reconstruction. I have anterior knee pain that is worse on extension and my MRI shows chronic inflammatory changes to the fat pad. However, my surgeon wasn’t concerned about the fat pad and thought I might benefit from another arthroscopy to remove some scar tissue, which ended up worsening my problem.
    I’d like to try a cortisone injection but have read that the injection points need to be quite precise; is that the case? Do you recommend I try to find a physician who is experienced with these injections? Any advice with regards to the injection process would be much appreciated.

    Thank you,
    Sarah

    • Hi Sarah,

      What you have is fat pad scarring post-arthroscopy.
      A cortisone injection may help. It is quite easy to inject. The sheer volume (usually 3 to 5cc) of the medication will usually ensure that the area of treatment will be reached.

      Good luck!

      Regards,

      hc

  99. Haleigh says:

    Hi I have recently been told I hoffas fat pad in both my knees currently going to physio but the pain is horrible it’s going to down to my ankles I’m limping and I’m scared of the long term affects this will have on my body wat is the best solution is surgery the best way to go and is it expensive can I go back to training or will this be an ongoing issue for me now :( thanks

  100. tasos says:

    i had hyaluronic acid injections in my knees 2 months ago and my right knee hurts big time.canot bend neither extend and doctors told me i have hoffa syndrome. is that possible to happen fron an injection? my mri are clear by the way, but the pain i cant decribe.. ive tried strong med and physio for 2 months but nothing… what to you suggest to be my next step? cortisone injection or surgery?

  101. tasos says:

    i didnt have any pain before the injections, i just put them precusiously cause i have weak knees. they crack all the time. but no pain. no pain until i took these injections hyaluronic acid

    • Dear Tasos,

      The hyaluronic acid injection should go into the knee joint space. If injected into the fat pad, it can cause intense inflammation, thickening of the fat pad with resultant scarring. This may lead to fat pad impingement.

      Regards,

      hc

  102. Angela says:

    Had surgery for fat pad impingement two yrs ago on left knee. It seems every time I try to jog or play tennis (any activity that pounds on my knee) it seems to inflame for 2 weeks after intense activity, needing ice, rest, and pain medicine everyday for the two weeks. Could it be the fat pad inflamed like that? PT seems to think its tendonitis, never mentioned fat pad. But pain and inflammation seems to be on the outer side of knee where fat pad is. Does the fat pad get inflamed like that from over use after surgery? Thank you!

    • Hi Angela,

      It is unlikely to be fat pad impingement as you have already undergone surgery to remove part of the fat pad. The more likely reason is post-surgery fat pad scarring. This scar tissue is sensitive to stretch and “pounding” sporting activities. It can cause pain.

      Regards,

      hc

  103. Dr Freud says:

    Dr Chang

    Thank you for this very informative forum. I have been recently diagnosed with fat pad impingement but have not found a surgeon that seems sufficiently experienced to entrust him with the arthroscopy. Do you have someone to recommend in the US?

  104. Toni Blake says:

    Dr. Chang – I wrote to you on July 17th. It has been over 9 months since the fat pad surgery last June. I am in more pain than I was before the surgery. I am limited in what I can do some days and icing several times a day. It always hurts = some days worse than others particularly the day after I run errands or go to the gym. I do not do any weigh machines on my legs but fast walk on the treadmill. I obviously have not been able to return to my pre op exercise routine and def not to my pre injury routine of now 1.5 year ago! So the “weeks” promise made to me after surgery from the Dr., physical therapist and it appears you concur – never arrived. I was told by an Ortho Dr. after I moved to another state that surgery is rarely done for this and that I should have been given an injection which probably would have healed it. And that the surgery may have given me arthritis now because of the synovial fluid’s attack on the cartilage. I don’t know what to do. I am scheduled to try an injection this week but tried an Chiro last week and it felt some better after that. I am wondering if I should just stay with that a while and avoid the injection since I have heard that has risks and I certainly don’t need more problems. Any advice would be most appreciated. This has gone on too long and there has to be something I can do to help what should have been an 8-9 week at the most recovery. Wish I never did it.

  105. Angela says:

    I have the same exact thing as you. Had my fat pad trimmed twice. Still not better after three yrs of going through this awful ordeal. Can no longer run or play soccer. Down to the elliptical and a fast walk although that still gives me that achy feeling all day, everyday. Last month my doc gave me a cortisone shot in the fat pad and it only inflamed it more leaving me in even more pain. I don’t recommend that for you. I think I have tried everything and nothing works other than taping and ice for temp relief. You said you tried Chrio? Could you tell me what that is? Thanks so much.

  106. Scott says:

    How long does it take fat pad inflammation to calm down? How many weeks, months? Mine feels constantly inflamed from just the elliptical 3 days a week for 25 minutes and walking the track during my kids soccer practice. Thank you!

  107. sandersjm15 says:

    I had fat pad surgery a year ago that removed part of my fat pad. I still experience some pain and swelling, especially after activities such as playing soccer, rucking with a heavy pack for the army etc. Is there anything I can do to help with this?

    • Hi,
      Generally a properly performed surgery for fat pad impingement should result in significant resolution of the pain symptoms. There can be some “stiffness” or “pulling discomfort” at the front of the knee at the level of the surgical portal scars due to soft tissue healing with scar formation. Gentle massage to these areas can help to soften the scar. A local cortisone injection to the scar area can sometimes result in good relief of the residual discomfort.

      Regards,

      hc

  108. Carrie says:

    Hi there – this is a great thread and I’ve read through it with real interest. I have what I suspect is fat pad syndrome and I’ve had it for about 6 years. I (was) a runner and cyclist and the pain / swelling started about 6 years ago when I was doing sustained interval training – pouding on a treadmill with additional leg weights. I have seen physios and had all physio treatments, I’ve seen doctors and been to my local hospital;. I can’t walk more thean 10 mins without having to aply ice to my knees, I can’t run at all and I can do limited cycling only if I have my knees taped. They are taped all day every day and I am in various degrees of pain (and they are slightly swollen) most of the time.. I have to manage pretty much every physical activity I do. The pain is markedly worse if I am going down inclines and sometimes I have difficulty straightening my legs / standing straight. I stand with slightly bended knees. The pain in a sort of low, throbbing, tweeked almost pinched like pain and when it’s at its worst it is pretty excrutiating. The doctor at my local hospital said he had never heard of fat pad syndrome / impairment even though my physio has said all along that’s what it likely is. Finally I have seen a sports injury / knee surgeon and he’s advised that I undergo keyhole surgery to investigate further then have part of the pad removed if necessary. Whilst I am desperate to try and sort this out surgery does worry me a little after reading comments on peoples’ experiences. Can I ask (1) will the surgeon be able to ascertain if it is fat pad impingement when he goes into my knees to investigate (sometimes they are more puffed up than at other times and (2) what are the risks of success with surgery and what’s the chances of my condition actually being made worse if things don’t work out? Any advice would be hugely appreciated. Many thanks

  109. DV says:

    Hi,

    I have been dealing with a severe fat pad impingement for 2 years, i could not straighten my leg without extreme pain. All my MRI’s (i had 3) kept showing nothing to cause this except for cartilage loss/damage under the patella. I tried all conservative treatments (physio, cortisone, PRP, hyaluronic acid injections) with no improvements. I have been following this post for some time and wanted to give your readers an update.

    After seeing about 3-4 surgeons, I finally found one who was comfortable using scope surgery to determine what was going on and who actually believed that it wasn’t just a “patellar tracking issue” . During my surgery they found a hypertrophic fat pad, a very large medial plica, a torn meniscus, cartilage damage under the patella, and patellar tendinitis. They removed the fat pad, plica, trimmed the meniscus, and cleaned up the cartilage. (the fat pad was getting impinged on the plica and bones) Funny, the meniscus actually had no symptoms because i could not straighten my leg far enough for it to cause a locking.

    Its been 5 weeks from my surgery and I am doing very well. I can straighten my leg with out pain and am already biking and swimming. I am just working on my range of motion especially knee extension since its been so long. Surgery ended up being the best option for me. I wanted to share this with you because the MRI’s missed so much. I hope this info can shed some light on your situation

  110. Rebecca says:

    Hi there,

    When I was 15 I hyperextended my right knee quite badly playing football when a goalkeeper fell on my straightened leg. It was awful but healed on its own. A few months ago (im now 25),i hyperextended the same knee, no impact this time, just the combination of my ankle rolling and speed and momentum taking me forward, the pain was awful. I couldnt walk after the injury as everytime my knee went back into the leg straight position the pinch and pain was sickening. I saw a physio and she was great, she used new fangled devices and technology to get the swelling/fluid down and an ultrasound to show that i had impinged my fat pad. Other tests she did indicated no ligament damage which i was relieved with. I had a electrotherapy to build my quad around my knee back up to strength and everything was fine.

    She then sort of said brilliant, see how you go, and that was that. Before I had done any sort of exercises, movement or anything. Since then i’ve been apprehensive about working out because I have a history of injuries recurring and I really dont want this to happen again.However I now really want to get back in the gym and start playing again, but my knee still doesn’t feel right.It feels weird, and its crackily (only way i can describe it) and not on the same level as my left knee, i dont feel confident with it. When resting my leg, i tense my quad to straighten my leg i get a small click, at the top of my patella on slightly right of centre as it goes down. Like its having to slot into place. It doesnt hurt but it feels odd and doesn’t help my confidence of the security of the joint. Occasionally it gets achey too.

    Is this all normal? I know it sounds like i’m making a big fuss over nothing, but even though it rarely bothers me on a day to day casual basis, i’m still too scared to go running, or go football training. Any sort of advice would be great.

    • Hi,
      A careful examination of your knee may help to define your problem better. An MRI may also be needed. I guess you should go back to your physiotherapist to see if she can help you further or see an Orthopaedic specialist for an opinion. A hyperextension injury can potentially result in one of the following:

      1. Posterior cruciate ligament injury.
      2. Posterolateral corner of the knee injury.
      3. Anterior horn of meniscus tear.
      4. Fat pad impingement – usually anterolateral.

      I hope this helps.

      Regards.

      hc

  111. Jon M says:

    Doctor I just today had this agitated plica surgery while I expected some soreness of course I’m also having what appears to be air bubbles on both sides of the patella if I push one side or the other it it makes (sorry to sound childish) almost like a fart noise and making the other side swell up slightly until I push on that side repeating the process to the other side I’ve been told it’s normal but just wanted to check to see if this is normal. I train and kind of teach ju jitsu which requires movement of every body part often and was wondering when it’s possible that I could resume training pain free I have to have the stitches removed on the 9th of next month and am 25 years old sorry if my comment is a little sloppy I am currently still feeling the effects of the anisthesia I was given during surgery.

    • Hi,

      The squishing sound from your operated knee is normal. Arthroscopic surgery is done by placing fluid into the knee joint to push away the joint capsule and to improve visibility. The sound is due to water mixed with some air. It will go away after a few days. As for return to ju jitsu, you need to discuss with your surgeon. I believe it may be between 4 to 6 weeks from surgery.

      Regards,

      hc

  112. Andrea Toppin says:

    Is started with a tight hamstring in my left knee & then moved it’s way down to straining my poppliteus muscle…then I felt pain in my knee. My PT said my fat pads were inflamed because it wasn’t patellar tendintis due to the fact my patellar tendon wasn’t tender to touch. Running (I am a collegiate runner) would be a bother but I would have to ease into it (it would warm up after the 1st mile or so. One day though it felt awful as the run went on. So I took 5 days of active rest ( pool running, biking, and elliptical). My knee started to feel great..not painful to walk on anymore or bend & straighten! Then I did a test run on it yesterday…it worsened throughout my run & I barely made it 2 miles. Now when sitting for awhile & I get up…walking feels awful again. The pain is felt when straightening knee & when I walk or run…impact on the heel strike. Is my fat pad bad now? Or does it just need a couple weeks to calm down? And how long until I could say run/train competitively again without screwing it back up? Thanks! Sorry this is a long message.

  113. Jo Yirrell says:

    Hi. I have been diagnosed with an inflamed Hoffa Pad after my twisting my when exercising. It started to reduce in pain but then I tricked and is bad. I cannot walk without a crutch! I am icing it and attempting to rest, however my knee is more painful in bed and it hurts a lot being elevated ( I have a pillow under my knee and between my knee at night) do you have any other suggestions for getting comfortable pleas.

    Jo

  114. bri says:

    Hi Doctor,

    I am booked in to have partial or full removal of my fat pad in my left knee in a weeks time. I originally had the lateral meniscus trimmed after a tear 15 months ago. Since then I have had trouble locking/straightening my knee, cortisone injections, physio weekly all of which have helped slightly but I am still in pain and it feels like there is bit enough room in my knee (best way to describe it). I train 7 x a week from running, functional full body training, swimming and cycling and can complete all exercises but not without pain so I just bear it.
    I have had MRI’s, bone scans, blood tests and X-rays which all showed up fine but as I would describe my pain now 7/10 on a bad day the surgeons “guess” is that the fat pad is still aggregated from the initial surgery so if they remove or partial remove it I should feel better right away.

    Do you agree with this resolution given the history with fat pad (before the cortisone injections) and the pain I am experiencing? It doesn’t hurt every day but when it does it is painful for a number of days and this happens weekly.

    Any insight would be great.

    Thank you.
    Bri

    • Hi Bri,

      I suspect you have fat pad scarring from previous arthroscopic surgery. Just think of it as the fat pad in the front of your knee is no longer soft and pliable but scarred and tight. This will lead to some anterior knee discomfort or pain when starting physical activities involving running and jumping. It usually settles down once the scarred fat pad is warmed up.

      If this is the case, then further surgery to this fat pad may potentially cause more scarring and pain.

      I have seen patients with such problems and it is very difficult to treat.

      I have not examined you nor seen your MRI scans. The best person to advise you is still your doctor who is treating you.

      Regards,

      hc

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