KNEEtalk

The REHAB DEPARTMENT => Soft Tissue Healing Problems - Arthrofibrosis => Topic started by: Silkncardcrafts on November 29, 2011, 08:46:48 AM

Title: Anyone with fat pad impingement and maltracking problems ?
Post by: Silkncardcrafts on November 29, 2011, 08:46:48 AM
Hi there,

Just got my MRI results over the phone from my physio. Got fat pat impingement suggestive of maltracking.

I am currently on crutches and even painful with that.

What sort of treatment have you had with this condition ?

Seeing my surgeon next Monday.
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: Stasha83 on November 29, 2011, 09:03:33 AM
Hi

My knee nightmare began with my fat pad being trimmed (which was never the actual problem but hey ho!) and then being put in a brace for 6 weeks. Three surgeries later and a diagnosis of Arthrofibrosis I now have no fat pad at all as the remainder had to be removed in my last surgery.

The fat pad is highly innervated so if it is truly impinging or damaged this can cause extreme pain. Did you have an accident or trauma to the knee to cause this?

I think it's quite a tricky one to treat, my current OS says that he would never surgically touch a fat pad as in his experience, the knee doesn't respond too well. I am his exception to that rule though! On the other hand my original OS was obviously quite happy to fiddle with it so I guess it's down to the opinion of your OS and physio. I also think some OS's will inject the fat pad too as a first option.

My experience has not been a good one but hopefully you will hear from others that have had a better result than me. Good luck with your appointment next week.
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: Silkncardcrafts on November 29, 2011, 09:15:38 AM
Thanks for your input.

I am in extreme pain. Had a mishap at Pilates when I had a bad instructor a few months back and felt the knee twinge.

My surgeon will have to do something as I have been doing conservative treatment for over three months now.

Feel like my patella isn't tracking properly and my tibia is moving too.

Were you in hospital for long ?
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: Stasha83 on November 29, 2011, 10:23:19 AM
I think if you have tried the conservative approach for that long it's time to look at other options. Has your physio advised surgery would be a good option?

Have you had it injected? My physio told me about another patient who had an impingement and she recovered after having the fat pad injected and intensive physio to build up the muscle surrounding the knee.

After the first op (the fat pad trim) I woke up in agony and couldn't move, the pain was horrific. I later found out that I had very poor pain management in the hosiptal so I am sure this ould be addressed by a better OS. I was in hospital for 2 nights after that op. I had serious pain and swelling after and because of subsequent problems (AF) I will never fully recover and am in constant pain. But like I said before, my case is a particullarly bad one and i'm sure plenty of others have had good results.

I think as it is so full of nerves it just doesn't like being fiddled with, my OS told me about another OS who performed a scope on himself (for research or something) without any pain relief and he prodded the meniscus, ligaments, tendons etc but when he prodded the fat pad he passed out because of the pain. I think it is totally understandable why you are in so much pain!

Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: Driden on November 29, 2011, 01:39:53 PM
In addition to a steroid injection, ice, and oral or topical NSAIDs, you might google "McConnell patellofemoral taping unload fat pad" and buy on of those Luko(sp?) PF taping kits. The fat pad is likened to biting the inside of the cheek...it keeps getting nicked unless it calms down. So rest is also key. I have read that removal via surgery is often curative, and it sounds quite simple. Of course, it will not fix a root maltracking problem.
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: nwc07 on November 29, 2011, 02:35:35 PM
I've had 2 cortisone injections directly into my inflamed fat pad.  This has helped reduce the size and inflammation and lessen the impingement.  They can inject it with lidocaine so you dont feel it.  I think the worst I had was a dull ache the day after... 
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: nwc07 on November 29, 2011, 06:01:10 PM
I have read that removal via surgery is often curative, and it sounds quite simple.

I have read the same thing but when I questioned this I was told if you remove the fat pad that empty space will just fill up with more scar tissue?  Yet excision of the fat pad is frequently done in arthroplasty ...
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: Silkncardcrafts on November 29, 2011, 11:17:56 PM
Thanks for all your replies.

I have NEVER been in soooo much pain ! The pain is unrelenting.

Can't wait to see what my surgeon says on Monday.
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: Stasha83 on November 30, 2011, 09:01:17 AM
Having had my fat pad totally removed I too told was told that the 'empty' space will more likely than not fill with scar tissue. Given that I have AF, I think this is very probable indeed!

My problem was that the remainder (it was trimmed in June 2010) of my fat pad had become so scarred and hard it was causing constant pain and inflammation, which in turn, was producing even more scar tissue throughout the knee. It's too early to tell if the removal will help with my ongoing AF battle but in my case, it had to be removed as we had no other options.

Silkncardcrafts: Good luck with your appointment on Monday, I would be interested to hear how you get on.
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: Silkncardcrafts on November 30, 2011, 12:32:37 PM
Thanks for the good luck wishes.

Interesting to hear about your fat pad removal. I have a feeling they will need to remove some of mine.

My knee surgeon and sports physician aren't keen on me using cortisone plus I already take asthma relievers that have cortisone in them.

The worst part is that being on crutches it is putting other joints under pressure.

I see my sports physician in the morning. So, will be interesting see what he says.
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: Silkncardcrafts on December 05, 2011, 11:22:45 AM
Hi All,

Just wanted to update you on how I went with my knee surgeon tonight.

He doesn't want to do anything at the moment. My surgeon wants me to forget physio and clinical pilates but instead do exercise that I enjoy such as cycling, golf and walking.

The MRI shows minor bone edema, patella tendon issues, fat pad issues and grade 2-3 patellofemoral arthritis.

I will give things a few months and if nothing changes I will go back to see him again.

Finding it hard to take in all right now.
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: kapah on January 21, 2012, 02:29:19 PM
Hi,

I have been battling fat pad issues for almost 3 years now.  Started with a simple running twist at work which didnt flare up for 2 days, then it got worse and worse, especially as the first surgeon said it was a sprain.  Since then it has been 8 ortho surgeons, about 10 physios, 3 Exercise physiologists, a psychologist, a pain doctor, 1 x surgery (possibly another one soon), 2 bone scans, 3 MRIs and dont ask how many pain killers.

Cortisone injection did nothing but flare it up.

Some physio exercises worked to a degree, but only once the flare up had calmed down. I found surgery relieved my pain by 60% in the first day (yes, i was in less pain even immediately after the surgery).  I got back to almost new, and then when I threw myself completely back into full time active work, the pain started the cycle of the quads shutting down and thus muscle wastage and patella maltracking.

When the pain was at its worst........I was on 75mg of Endep per day (anti depressant) which helped calm the intense nerve pain that was mostly at night, and helped get me to sleep.  The only issue is that you become a bit zombie like, and it is hard to wean off as the pain smashed me when i tried getting off it 7 months after surgery....and within 4 days i had to go back on it to stop the pain. 

Currently I am seeing a Chiro/Kinesiologist who is brilliant and kept it going bloody well until the work issue re-irritated it, but he used Kinesio tape, which is so much more effective than the Jenny McConnell taping, and the Kinesio tape doesn't irritate your skin at all compared to the Elastoplast taping.

My advise......if physio and ice helps, then keep up the exercises to target VMO.  If you got as bad as me where laying in bed is impossible without a pillow under your knee, or having to walk the dog with a mobility scooter (I'm 32 and its not a good look), then ask your surgeon whether he has had much to to with fat pads....some dont even recognise it exists.  And above all, the pain is excruciating, and there is no logic to the pain.  You can rest it for 3 days and it will hurt worse, which makes no sense.  Do not let anyone tell you it is in your head.  My surgeon tried to tell me that I had a mental illness, and asked if I had seen a psychologist........I told him that I had been to one, and that it had been her that gave me his name.  That surgeon was shocked at how much improvement there was in 10 days, and finally stopped treating me like I was mad.
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: nwc07 on January 21, 2012, 03:53:54 PM
  That surgeon was shocked at how much improvement there was in 10 days, and finally stopped treating me like I was mad.

So your improvement came from Kinesio tape? 
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: PiotrS on January 21, 2012, 04:18:15 PM
I also had problems with fat pad impingement when I tripped and twisted my bad knee 2 months after ACLr surgery. Luckily my ACL held up, but I had problems with pain on extension for many weeks after. My muscle weakness following surgery was probably causing patella maltracking, and that was constantly aggravating the fat pad after the initial trip that must have caused it to swell in the first place.

We tried a number of approaches with my physio, but the best solution turned out to be kinesiotaping with a lot of quad strenghtening work to go with it. Before any serious exercise I was doing 100 step ups without full leg extension to get the VMOs to fire before doing any other exercise that could potentially aggravate the fat pad.

After two months of this regime, my patella tracking is now much better, and the problem with the fat pad has all but disappeared.

Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: cmoesle on January 24, 2012, 04:11:21 AM
Hi everyone,

First of all I am amazed to see that there are more people with the same problem that I am having. I felt as though no one understood what I was going through. I'm 19 years old and have currently redshirted my freshman year of college soccer due to the horrible knee problems I've been having. In the past year and a half I have had 2 scopes on my meniscus and have recently had fat pad resection. It's been 4 months and everything has gotten worse since this fat pad resection. Soccer seems completely out of the picture but more importantly I cannot live my day to day life being in this constant pain. I have a great  surgeon, the Indianapolis Colts doctor actually, and I trust that he is a very bright man but he cannot figure out what my next step should be.

Does anyone have any suggestions for me? Is a fat pad removal too drastic for someone my age?
In addition to the extreme pain I have right below my patellar tendon I continue to have the original pain (a stabbing pain between my femur and tibia) where the fat pad was supposedly being impinged.

If anyone had any insight I would be very thankful!
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: Stasha83 on January 24, 2012, 09:17:09 AM
Hi Cmoesle

You are certainly not alone with this problem!

I was 27 when I had the remainder of my fat pad removed. To be honest if I could turn back time I would never have had the first surgery where my fat pad was trimmed as all it has done is cause me more problems and constant severe pain. The area where the fat pad used to be is now highly sensitive and I get alot of pain in my patella tendon area, I guess because the fat pad is no longer there to do it's job.

Because I have had such a bad experience I think it's hard for me to give a balanced view, we could do with someone posting that has had a positive expereince really.

If I were you I would talk to your OS and physio and see what there opinion is and if possible even see another OS for a second opinion. The more opinions you get the better I think, especially as you're only 19 and want to get back to playing soccer.
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: cmoesle on January 25, 2012, 10:17:23 PM
Stasha,

I really appreciate your feedback. I agree that I wish I would never have gotten the fat pad resection. I really hope there is something they can do for both of us.....I can't picture myself living with this pain for much longer. I will be starting a new pill called Lyrica to help calm the nerves in the knee I guess? If that doesn't help then I will definitely be getting some other opinions.

Thank you again for your post and yes.......I hope we can hear from someone with some sort of solution to our problems!!!
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: joanfan123 on February 20, 2012, 08:00:10 PM
Silkncardcrafts- It sounds like you need a new OS. I had fat pad surgery in November, before that I was on crutches. I had been going to the OS for 2 years before switching (mostly waited because my mom didn't see how bad he was), but when I had been on crutches for a month due to a combination of pain and loss of ROM and he stilled did want to do anything for me I switch. My new OS is great he really listens to me and perform an arthroscope. He removed a part of my fat pad that had grown where it wasn't supposed to be. After not being able to straiten my knee since last February with the help of my PT I had full exstention about a month after surgery. I still had a lot of pain and a few other issues such as instability but I have full ROM and I am no longer on crutches. Also note that I was on crutches(or one crutch) for almost 6 weeks after a surgery some people walk out of the hospital after because my quad was so non-exsistant so don't wait. To answer your question about hospital stays I had to be at the hospital at 6:30am and was home by noon.

cmoesle- If it makes you feel better about your age I have fat pad issues and I am only 16 and have never been athletic and never had an injury.
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: nwc07 on March 03, 2012, 03:21:21 PM
cmoesle,

When you say you have had "fat pad resection" did they take out the entire fat pad or just remove scar from the fat pad?  I have been told to remove only what is damaged and leave the rest intact.  I have a similar problem but fortunately do not have any pain associated with this.  I believe most doctors are not familar with treating Hoffas disease. 
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: kapah on March 06, 2012, 01:38:00 PM
Hi Again,

I have further information since last time.

NWC07....sorry of the delay, yes the Kinesio tape helped keep the VMO active and I believe it helped reduce the general throb. 

Since my last post in January 2011, I have had a serious relapse when I went back to full time work.  I am a police officer and so you can imagine what a strain it puts on my knee both getting up and down constantly, and spending lots of time sitting in vehicles.  My knee consistently got better until the point that I was focussing so hard on staying 100% focussed on work, that my VMO started wasting as I was basically working, eating and sleeping, and no longer doing the things i enjoyed which maintained the strength such as horse riding.  I was being so careful to make sure I was fit for active duty that as the pain got worse, I rested it more, thus causing more wastage, thus causing more maltracking of the patella, thus causing more pain and ending up in that eternal cycle.

I thought this was just the normal transition pain going back into active duty, such as still feeling not 100% after having the flu and gradually getting better, however when I sought advise from a surgeon the MRI showed more scar tissue and it was very similar to the original MRI prior to the surgery.

Reading some peoples posts, I do recommend surgery as I had tried everything else.  I lived 10min from the famous Jenny McConnell and so had her personally taping my knee, and found that all it really did was increase my skin irritation to tape, and have her tell me it was only increasing core strength etc that would fix it.  Well I spent 18 months doing regular physio and became more and more crippled.  I rarely had swelling, often had searing heat in the knee and found the cortisone did nothing but irritate the fat pad (it was done via ultrasound guiding).

After the latest surgeon review I had to go back on the anti depressants as I found i was not longer able to lay in bed with my leg straight, and had to have a pillow under it.  I went onto 50mg Endep per night and it reduced the base level pain by about 60%, however I had not let it get nearly as bad as the first time round prior to surgery.  Endep is great, except you feel slow and tired during the day and Zombie like, where as soon as you stop thinking, your body goes into shut down mode.

After 3 months of intensive training on a very strict regiment consisting of only leg press, calf raises (to stop hyper extending) and nothing else (not ever bike) I had increased the VMO, but not enough to stop the maltracking....why, because I was still in pain.  I was constantly wearing Kinesio tape and being treated by my Chiro/Kinesiologist (who I believe is a god).  When I returned to my surgeon, he went to advise me that it was scar tissue and that if he surgically removed it, it would obviously just cause more scar tissue along the way.  I had seen an opinion offered on coolrunnings forum which indicated potentially cauterising the pad after shaving off the fly away areas of damage, and then being braced for 3 weeks to reduce the irritation and then build up the VMO again from there.  When I suggested this to my surgeon and said I couldnt keep living in so much pain, he suggested a Tibial Tubercle Transfer to stop the ongoing cause of the damage in the maltracking, The TTT means a fairly serious surgery and 6 weeks of being braced and I had this done 6 days ago.  It involved 2 nights in hospital and repositioning the angle / location of the knee cap and so far I am happy with the results.

http://www.sportsortho.co.uk/article.asp?article=118

6 days on, I am on the equivalent amount of pain meds that I was on normally, and previously I couldnt keep my leg at a straight angle for very long, now I am braced in the fully straight position and coping fine.  I know it will be a long road of intensive physio to regain my muscle, but hopefully now that the maltracking issue is resolved (fingers crossed) and the fat pad has been surgically corrected again, I am hoping to have the same success of becoming pain free, with less chance of re-damaging it.

For anyone that thinks this may relate, my patella sat very high (alta).  I will try and keep my progress updated so that it may help ease some of the suffering we are all experiencing.
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: nwc07 on March 06, 2012, 10:11:40 PM
Kapah,

How was your fat pad surgically corrected?  Did he remove a large portion of it?  Was the maltacking pinching the fat pad?

Hoping this is the final fix!!
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: kapah on March 07, 2012, 12:51:50 AM
Hi NWC07 -

I tried attaching a file, however the size was too big and it deleted the whole post.  If you would like to see the pictures from the arthroscope that I had from my first surgery I will be happy to send it to you.  email me on [email protected]

But to answer the question, the surgeon said he "shaved"the fat pad.  Which to me indicates that only the irritated and damaged areas were removed, leaving the majority of the fat pad intact.  At this time he said the chances of re-damaging it were minimal, but he obviously didnt take into consideration my knee caps that were high, my outer thigh muscles extremely strong (from my job and horseriding) and that my VMO was constantly wasting due to the pain.

What I believe is going on with the fat pad it this....it is like when you bite the inside of your cheek while eating, and you get an ulcer that all of a sudden you keep biting, and it gets bigger and bigger and you keep catching it.  The fat pad is like that, except because it is filled with nerve endings it is constantly sending pain signals.  Thus the VMO which shuts down as soon as there is a pain signal, starts wasting away, which caused the maltracking, as the outer thigh muscle stays as strong as it always was and pulls the knee cap to the outside.  Because my knee caps are unusually high, the maltracking caused more problems than would happen in normal people.
In my case, due to my job type and being restricted to sitting at a desk, this position is actually the worst thing for the knee as it pinches the fat pad, thus causing more pain, this continuing the cycle of VMO shutting down, pain and maltracking.  And of course with pain, your normal gate turns into a limp...and therefore the normal walking stride is also compromised, potentially causing more damage....so its not just one thing in the way.

I firmly believe that the inflammation of the fat pad in itself caused enough pain to do damage and start the maltracking, however the more serious pain comes when the inflamed areas get pinched, causing the fly away parts that then keep catching.  i think that is why some people get some pain but do not necessarily fit into a surgical option and can improve their pain by improving the VMO/Quads through physio.

Hoping that the surgery has fixed my bodies normal maltracking, and as the fat pad has been shaved again, that there will be no irritation once I start physio to build up my VMO again.  However I will definitely continue using the Kinesio tape once I'm out of the brace to try and keep the VMO switched on.

Hope this helps.....
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: Clarkey on March 10, 2012, 01:34:25 PM
Hi All,

I had my fat pad trimmed and medial plica removed in my right knee in November 2009 as I was getting pinching and sharp pain on the lateral side of my knee. After the surgery I no longer felt catching on the lateral side and not sure if it was caused by the inflammed fat pad or the medial plica!

The majorty of OS's do not want to trim the fat pad and will try all conservative methods 1st before doing a scope. I think soft tissue problems are hard to get right again and can be a very painful knee condition to have.

[email protected]
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: kapah on September 05, 2012, 12:28:43 PM
Just a quick post to update 6 months after TTT / LR and fat pad trim.  It is brilliant! I used to be reliant on pain killers and now haven't taken any since May and that was due to a dishwasher explosion that means hours of kneeling to mop up water. I did have a bad patch of Tendonitis that resolved within weeks of finally saying no to physiotherapy and resting it.
I can't tell you how much life has improved. It catches still a bit, but not on the fat pad and it is improving especially now that I'm amount up the walking. Today I caught myself jogging both up and down a set of stairs when I was in a hurry and didn't realize what I'd done as I had no pain.
My ability to sit at my desk at work is improving, and I can now feel when I haven't taken my Glucosamine tablets as I can feel it ache a bit.  Next step is working up to light jogging (I'm
a terrible runner anyway) and then hopefully this drama of 3.5 years will be behind me.
Please, don't let doctors tell you to deal with it, they don't understand how debilitating it is.  Research secondary issues ie fat pad and maltracking (patella alta). Without the second surgery I would never have maintained VMO strength, this continuing the fat pad issues.
Good luck all, will update at 12 months
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: Perrylock on August 02, 2016, 08:01:29 PM
To all fat pad irritation victims out there, there is a very easy way to get rid of this pain that worked for me. I began to experience the pain after an intense plyos workout and dealed with the pain for almost a year before i found a video online that showed friction massage on the fat pad. The video is youtube if you want to see how to do it, i did it at least once a day for 10mins on the affected knee. Good luck to all
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: Clarkey on August 03, 2016, 07:40:18 PM
To all fat pad irritation victims out there, there is a very easy way to get rid of this pain that worked for me. I began to experience the pain after an intense plyos workout and dealed with the pain for almost a year before i found a video online that showed friction massage on the fat pad. The video is youtube if you want to see how to do it, i did it at least once a day for 10mins on the affected knee. Good luck to all

Hi Perrylock, I am pleased it has helped you with your fat pad issue by doing friction massage therapy around the fat pad to break down the scar tissue. It does not work if you have already been through surgery trimming of the fat pad. I went through a 2nd surgery of AIR to remove the scar tissue that had built up from scope #1.

I am now having problems with patella tendonitis that has got to a stage where it stopping me from being able to run and take part in sporting activities. If PT does not solve or ease the tendonitis, I would go through a surgical procedure called 'patella decompression'.  The surgery exposes the patella tendon, removing any scar tissue that has built up.

[email protected]
Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: Aly0108 on August 24, 2016, 12:51:54 AM
Hi,

Last week, I did MRI and I am very sad. I have chondromalacia, patella tracking.

Finding:

Meniscus are intact, no demonstrable femorotibial chondral abnormality and no demonstrable patellofemoral abnormality. Patellar alignement are normal.

Only issue: Subtle edema superolaterally in Hoffa's fat pad raises the possibility of altered patellar tracking in both knees.

How Ihave to fix this problemes? One year I do exercises for fixing this miserable problem.

I dont find any solutions.
 
Walking is difficult for me because a pain in fat pad. I dont live with that issue.

Title: Re: Anyone with fat pad impingement and maltracking problems ?
Post by: Vickster on August 24, 2016, 07:32:31 AM
Have you asked the physio to tape the patella away from the fat pad? Does acupuncture help?
Are you working on all of your leg and hip muscles to address the balance. Is the maltracking solely due to muscles or is there a potential surgical fix? You should try to seek out a PF expert knee specialist and physiotherapist. Trimming the fat pad surgically might provide relief alongside targeted physio, but all surgery carries some risk. I had a fat pad trimmed, certainly relieved the issue in my knee (along with meniscus tidy)

Chondromalacia is a symptom, not a diagnosis per se, you need to address the cause with experts, it's a very common issue, and can be resolved with the right care and patience

Good luck