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Author Topic: Fat Pad Impingment and PFPS  (Read 201 times)

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Offline Strongknees

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Fat Pad Impingment and PFPS
« on: October 10, 2018, 01:12:27 pm »
Hi all,

I have posted questions here and there but I thought it's a good idea to consolidate my case in a single thread.
I am 35yo male living in the UK.

History of my injury

April 2017
Anterior Knee Pain after football game. I had to limp for a few days.

May 2017 - July 2017
Stopped playing football. Pain went away. Tried running once but there was some pain so I stopped after 5 minutes

August 2017
Played sports at the beach (big mistake). Pain increased a lot. Unable to do stairs for couple of weeks.

September 2017
Started Physio. At this point I felt a lot of stiffness in my joint. Pain while sitting at my desk as well. Diagnosed with PFPS.
Exercises did not help

November 2017
MRI is negative
Doctor says I should push more with the exercises - I am being too conservative in his opinion. I don't trust this and planned to see another PT

January 2018
New PT asks me to do cycling on stationary bike with no resistance every day for 15mins. I don't have much pain doing that (but not painless) but the right quad doesn't really fire. At this point i started developing pinching on the lateral side of my patella (fat pad??), probably because the bike seat was too high?

March 2018
Still see no benefit, so stop PT

June 2018
Start a more aggressive PT rehab plan but although my strength improves, the symptoms don't. I start realizing that standing has become painful and start developing similar but milder symptoms on the left leg

August 2018
The impingement becomes more obvious and I go and see Claire Robertson in London. She asks me to ice it and do gentle exercise for my VMO. A flight to Canada exacerbate the symptoms (airport, stairs, sitting etc..).

September 2018
Started Laser therapy.
Started gentle PT focusing on core, hamstrings and hips.



Where I am now

I have started to tape my knee with alternate results, probably not doing it right all the time. Or maybe it doesn't work. I have read a lot of people saying that taping is key for fat pad impingement.
I limp a bit. My walking is not natural at all and every now and then i get the painful pinch on the lateral side. I also have some pain right underneath the kneecap.
The left knee is better but is not without symptom.
I keep icing the knee and also started laser therapy, but these do not offset the damage caused by the commute to work (especially the standing and walking on uneven surfaces!). I would say I keep managing it but it is less than ideal and cannot continue like this. I can't really walk for long.

I am not sure what to do. I don't think I am improving. I think over the past year It has actually gotten gradually worse.


Possible strategies from now

1. Finding a proper taping technique that works for me so that I can walk without the pinching. Avoiding all aggravating activities (take cab to work). Gentle PT regime to focus on core, hamstrings, gluteus to start with. Potentially also see a Podiatrist for an expert assessment of my walking.

2. Adopting Dr. Dye regime.. (how are you doing with this?). Is this too extreme for my current symptoms? Is it worth having a consultation with him? I have read all your experiences and I know what he is going to tell me... I have a decent (but less than healthy) amount of muscles - I am scared to lose it all! @BusterCatLegs? is this regime working for you? I feel we have similar symptoms?

3. Any other suggestion? Something in between 1 and 2?

Thanks a lot to you all.

Offline adamas

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Re: Fat Pad Impingment and PFPS
« Reply #1 on: October 10, 2018, 03:05:40 pm »
 How was the fat pad impingement diagnosed? Is the fat pad swollen or tender? Where exactly is your pain located? Do you still have stiffness in the joint?

If the fat pad is the culprit, some doctors suggest a steroid shot into the fat pad itself. Has Claire recommended that?

Offline Strongknees

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Re: Fat Pad Impingment and PFPS
« Reply #2 on: October 10, 2018, 03:38:19 pm »
Hi adamas,

Thanks.

Claire diagnosed it. There is a bulge to the lateral side of the patella. I also tested positive to Hoffa test (ie it hurts when you press there!).

She hasn't suggested a shot yet, but has it ever worked for anyone?

Also the fat pad impingement is a consequence of the patella not tracking properly. So Solving the fat pad on its own won't probably solve the issue. What do you think?

Offline adamas

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Re: Fat Pad Impingment and PFPS
« Reply #3 on: October 10, 2018, 04:01:37 pm »
Hi adamas,

Thanks.

Claire diagnosed it. There is a bulge to the lateral side of the patella. I also tested positive to Hoffa test (ie it hurts when you press there!).

She hasn't suggested a shot yet, but has it ever worked for anyone?

Also the fat pad impingement is a consequence of the patella not tracking properly. So Solving the fat pad on its own won't probably solve the issue. What do you think?

I haven't had a fat pad shot myself, so cannot speak for that. Do you think that you had fat pad impingement since your first injury in 2017 or that it developed later?
According to the literature, fat pad impingement often starts if you have a blow to the patella or if your knee hyperextends, which may happen when you play football.

So, is your pain mostly on the lateral side where the bulge is? Or is it more widespread? Is your knee stiff when you stand or walk? Or does the pain increase?

I guess that Claire suggested VMO exercises because of the patella not tracking properly then.

I had a consultation with Dr. Dye myself, and his approach is almost the opposite of what any PT would say. Basically, whether the source of the pain is the fat pad or another structure, he recommends avoiding any stress to the knee as much as possible, and for a long time, but unfortunately this amount of resting often conflicts with a normal working life. Besides, even though some people improve with this approach, where is the scientific, and not just anecdotical, evidence that it works?

Offline Strongknees

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Re: Fat Pad Impingment and PFPS
« Reply #4 on: October 10, 2018, 05:18:41 pm »
Hi adamas,

Thanks.

Claire diagnosed it. There is a bulge to the lateral side of the patella. I also tested positive to Hoffa test (ie it hurts when you press there!).

She hasn't suggested a shot yet, but has it ever worked for anyone?

Also the fat pad impingement is a consequence of the patella not tracking properly. So Solving the fat pad on its own won't probably solve the issue. What do you think?

I haven't had a fat pad shot myself, so cannot speak for that. Do you think that you had fat pad impingement since your first injury in 2017 or that it developed later?
According to the literature, fat pad impingement often starts if you have a blow to the patella or if your knee hyperextends, which may happen when you play football.

So, is your pain mostly on the lateral side where the bulge is? Or is it more widespread? Is your knee stiff when you stand or walk? Or does the pain increase?

I guess that Claire suggested VMO exercises because of the patella not tracking properly then.

I had a consultation with Dr. Dye myself, and his approach is almost the opposite of what any PT would say. Basically, whether the source of the pain is the fat pad or another structure, he recommends avoiding any stress to the knee as much as possible, and for a long time, but unfortunately this amount of resting often conflicts with a normal working life. Besides, even though some people improve with this approach, where is the scientific, and not just anecdotical, evidence that it works?



The most annoying pain is lateral, where the bulge is. The pain is not constant but happens occasionally when I walk. However I do limp a bit, it's like I have forgotten how to walk properly. There is also more widespread pain underneath the kneecap.
There is stiffness in both knees, although it decreases with rest.
The pain in both knees increases rapidly with standing, whereas I can tolerate walking a bit longer.

Offline Vickster

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Re: Fat Pad Impingment and PFPS
« Reply #5 on: October 10, 2018, 05:32:53 pm »
Have you tried daily ice massage on the pump, plus perhaps a higher strength topical NSAID like Voltaren emugel...my rheumatologist recommends for localised inflammation, I also take a systemic anti inflammatory (with a PPI)
Came off bike onto concrete 9/9/09
LK arthroscopy 8/2/10
2nd scope on 16/12/10
RK arthroscopy on 5/2/15
Lateral meniscus trim, excision of hoffa's fat pad, chondral stabilisation
More tears and wear, scope planned in Jan 2019 to tidy up

Offline Strongknees

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Re: Fat Pad Impingment and PFPS
« Reply #6 on: October 10, 2018, 07:34:06 pm »
Have you tried daily ice massage on the pump, plus perhaps a higher strength topical NSAID like Voltaren emugel...my rheumatologist recommends for localised inflammation, I also take a systemic anti inflammatory (with a PPI)

I do ice massage daily. I struggle to be consistent with Voltaren - i guess i canít see any immediate effect. How long should I use it for?

Offline Vickster

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Re: Fat Pad Impingment and PFPS
« Reply #7 on: October 10, 2018, 08:19:58 pm »
I was told twice a day
Came off bike onto concrete 9/9/09
LK arthroscopy 8/2/10
2nd scope on 16/12/10
RK arthroscopy on 5/2/15
Lateral meniscus trim, excision of hoffa's fat pad, chondral stabilisation
More tears and wear, scope planned in Jan 2019 to tidy up

Offline Strongknees

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Re: Fat Pad Impingment and PFPS
« Reply #8 on: October 11, 2018, 03:41:56 pm »
I was told twice a day

yes, I ice it at least twice a day. More often at weekends.

Offline Vickster

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Re: Fat Pad Impingment and PFPS
« Reply #9 on: October 11, 2018, 05:09:26 pm »
Ah no, she said to ice massage at the end of the day, or after activity

The rheumatologist recommended the voltaren twice a day  :)

Follow the instructions given to you however  :)
Came off bike onto concrete 9/9/09
LK arthroscopy 8/2/10
2nd scope on 16/12/10
RK arthroscopy on 5/2/15
Lateral meniscus trim, excision of hoffa's fat pad, chondral stabilisation
More tears and wear, scope planned in Jan 2019 to tidy up

Offline Strongknees

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Re: Fat Pad Impingment and PFPS
« Reply #10 on: October 12, 2018, 08:27:01 pm »
I just donít believe voltaren does anything good? Or does it?

Offline Vickster

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Re: Fat Pad Impingment and PFPS
« Reply #11 on: October 12, 2018, 09:55:58 pm »
I do find it helps for localised acute soreness. Rheum recommends the double strength 2.32% which my GP prescribes (can get otc).  Not effective for my more achy inflammatory arthritis pain obviously (I take systemic NSAID for that).
Came off bike onto concrete 9/9/09
LK arthroscopy 8/2/10
2nd scope on 16/12/10
RK arthroscopy on 5/2/15
Lateral meniscus trim, excision of hoffa's fat pad, chondral stabilisation
More tears and wear, scope planned in Jan 2019 to tidy up