KNEEtalk

The WAITING ROOM => GENERAL KNEE QUESTIONS and comments (good for new threads) => Topic started by: Puffy the Knee Slayer on January 04, 2016, 11:46:59 AM

Title: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on January 04, 2016, 11:46:59 AM
Hello, wonder if anyone can help me. Sorry it’s a bit long.

I sprained my ankle badly in 2007 and have lost the arch in my foot as a result. 6 months later doing ankle stability exercises on a wobble board I fell onto my knee. Was dismissed with an X-ray which didn’t show anything. Eventually got an MRI which showed fat pad oedema. Did extensive physio which didn’t resolve the problem.

Then in 2012 twisted the knee, had an MRI which showed a medial meniscal tear of the posterior third. Again had extensive physio which hasn’t resolved things.

During this time I had a useless muscular skeletal consultant who would come up with such gems as “well we all get aches and pains sometimes”; “you don’t have Hoffa’s syndrome” and “you were probably born that way” (regarding my collapsed arch). I stuck with her because my physio was helpful.

I now have a decent pair of orthotics which are helping but still having knee pain.

Have finally been referred to orthopaedics instead. Further MRI has shown I don’t have a meniscal tear, but do have Pes Anserine Bursitis and Superolateral Fat Pad Impingement. In addition I was told I have Patellar-Femoral Osteoarthritis.

So far they’ve given me 2 sets of injections – 1st was subcutaneous cortisone; 2nd duralane and cortisone into the joint. Neither helped.

They are now saying they want to discharge me as the injections haven’t helped!!!

I reminded them I have chronic fat pad impingement so now they’re offering me an injection into the fat pad. I was previously told this wasn’t done due to the risk of fat pad atrophy?

I’ve also never been offered ultrasound and asked my GP about it – he told me it isn’t available on the NHS?

To me it makes no sense for them to discharge me as surely the PF OA will get worse if the FPI isn’t treated. They haven’t offered any advice on how to manage the pain (I can’t take NSAIDs) or how to stop things getting worse.

Current symptoms include random pinching, random sharp pains on medial side of knee; inability to squat, bend or kneel; unable to increase resistance on any machine without pain, even after 3 years extensive physio; anterior toothache like knee pain radiating into hip; pain going up stairs, severe flare ups after physical examination of knee and can’t do any impact exercise; popping on flexion/extension; patellar maltracking.

I’ve tried taping and saw a private sports podiatrist who recommended trying to draw out the fluid with soda crystals, but that didn’t work either as the fluid keeps re-accumulating.

My osteopath read my MRI report and said I also have subchrondral cysts, degeneration of cartilage and the patella groove, and ITB band inflammation.  She said orthopaedics probably see the fat pad impingement as a result of the overall degeneration of the knee rather than the cause thus won’t do anything.

Does anyone have any advice for me, please?  I have an orthopaedic appointment mid- January and would like to know what to say.

Is an injection into the actual fat pad a good idea?

Is Ultrasound available on the NHS and has it helped anyone?

Should I push for an arthroscopy or will this make things worse?

Thank you!
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Clarkey on January 04, 2016, 04:37:00 PM
Hi There,

I can only give your information from my own personal experiences after having had an inflamed fat pad myself back in 2009. My fat pad showed fluid (effusion) on my MRI scan rather than bruising (oedema) that came up on your MRI scan.

My OS tried all the conservative methods of treatment before finally doing a diagnostic arthroscopy. Once he scoped my knee he not only trimmed my fat pad that was giving me a catching sensation similar to a cartilage tear on the medial side! My medial plica was removed that was enlarged, this was also the contributing to the sharp pain and catching sensation.   

Conservative treatments pre-op were physiotherapy, ultrasound, orthotics and a cortisone injection near to the fat pad effusion. The surgery was a slow recovery of 18 months with another cortisone injection before I was able to return back to full fitness. I like to go for long distance runs that I was able to do at a competitive time of 1 mile in an average time of 6 minutes 50 seconds at my peak before my right knee problem flared up again 3 years ago this month in January 2013! I have not been able to run again since.   

I had another MRI scan and it showed medial femoral condyle bone oedema which could represents cartilage degeneration? It turned out to be excessive scar tissue from my previous scope. In July 2014 I had an arthroscopy done with a possibility of a microfracture ending up with 'anterior release surgery' (AIR) to reduce the scarring inside the knee.

Post op since scope#2 I have had a total of 3 cortisone injections in 2015 and PT that have not been helpful in any way. I am still not able to walk well and running looks unlikely to happen again!   

Judging from your MRI scan report there is a lot of issue going on with your knee right now to warrant at least a diagnostic arthroscopy at this stage of treatment. Ultrasound is available on the NHS as I have had previous injections using US guided injections confirming that your GP is incorrect.

It is a very poor attitude to have to say they will discharge you if the injections do not prove helpful, I know my OS would do all he can to rectify my right knee problems. It should be the opposite if the injections has worked and benefited you then it would be ok to discharge you.

Where in the UK do you live as I could then give you further advice of which NHS hospitals go for and the that you should be see. I live in the Midlands region so lucky to have a good selection of top Knee OS’s based at 'The Birmingham Royal Orthopaedic Hospital' that also worked private clinics. South East and London also have a good selection of top UK Knee specialists.

If you are interested you can read parts of my post-op diary of two previous right knee surgeries.

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=43471.1380

Good luck and Happy New Year.

[email protected]

Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on January 04, 2016, 08:48:25 PM
Thank you for your response, I am sorry to hear surgery has not been successful for you and that you are unable to run.

I'm in SW London, not sure I should say which hospital I am at though due to privacy issues? The surgeon I am currently under is I believe a specialist of menisectomies, since this is what they originally thought I had. It seems hard to find someone who knows about the fat pad. If you know anyone good that would be really helpful.

My cortisone injections were ultrasound guided, but I meant the type of ultrasound that is meant to break up scar tissue.

Happy New Year to you too. I will take a look at your thread, cheers.
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Vickster on January 04, 2016, 08:58:05 PM
I'm also in SW London and had a lateral fat pad excision and lateral meniscus trim last February which seem to have helped with the knee pain. I ended up with some PFS as I went back to cycling too quickly. I have other pain in that leg but that's not related to the knee.  I have weak glutes and really tight calves, can't squat either

You seem to have other things going on, notably the ITB (do you foam roll?) and also the arthritis, which could also be the cause of the pain

My surgeon is great, he's been treating my raggedy knees for over 6 years now (I see him privately but he has a solid NHS practice too)
If being treated locally, presumably you are at Kingston, St George's or Epsom & St Helier?
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on January 05, 2016, 09:48:54 AM
Hi, thanks for your reply.

I don't foam roll but do various exercises for ITB band, hip flexor, glutes, quads etc

The ITB inflammation I understood to be linked to the fat pad pinching. When the fat pad pops, the ITB pain goes. It also disappears after manipulation from the sports podiatrist. What sort of foam rolling is helpful? Sorry bit ignorant about it.

I do calf stretches on an incline board and calf raises but my inner calf on bad leg is still really slack even after years of physio - was told by private sports podiatrist it's due to the calf not pumping properly because of my biomechanical issues.

My osteopath said the only thing she could suggest was to focus on my hamstrings as I'm hypermobile and this could be affecting the fat pad. Since I can't do open chain exercises she told me to go backwards on the cross trainer.

The arthritis came on after years of the FPI so not sure it is the primary source of the pain.

I'm a bit further in than Kingston - Chelsea & Westminster.
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Vickster on January 05, 2016, 10:26:25 AM
Ah ok, they have good knee docs there

Hope you get some relief. Hyper mobility can certainly complicate things. Have you seen a rheumatologist with msk expertise, there's a renowned guy locally but think he's private only (Parkside Wimbledon) . Might be worth exploring if surgery isn't an option

Good luck
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Clarkey on January 05, 2016, 05:16:41 PM
You are living in area of the UK that has a good selections of top OS's that specialise in knee problems at your doorstep. I also had problems with my ITB with pain and tightness pre-op to scope #2 I was given a US guided Botox injection above my right groin into the tensor fascia lata muscle! It did not really help which is why surgery was scheduled for surgery.

I had ultrasound post-op after scope#1 both on the NHS and Private PT using gel and the machine to massage around all the portals as well as friction massage therapy to beak up the scar tissue! I saw a sports physician as well as a physiotherapist after scope #1 that may be beneficial to you to have an initial assessment done.

Good Luck.

[email protected]
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on January 22, 2016, 10:47:59 AM
Thanks.

So, I saw the senior registrar this week, who said he’d looked at my MRI scan and that my kneecap is the wrong shape for the groove and sitting in the wrong place. I was probably born with it but injury has aggravated it.

He says this is the cause of the fat pad impingement and PF osteoarthritis and recommended a Tibial Tubercle Transfer. His thoughts were that I could have it now or in 5 years but that things would not improve without it and likely deteriorate.

I’ve since looked this up and understand it is a major operation and not like an arthroscopy. He told me they don’t trim fat pads as the fat pad will just grow back and pinch again, and also denied a pinching fat pad could become fibrosed and lead to osteoarthritis – which is not what I’ve read before??

But he did say that the TTT would resolve the pain at the front of the knee and ITB band and that I should be able to get back to running one year post op, and that 8 out of 10 patients are happy with the outcome.

I am not sure what to do.

Am tempted by the potential resolution of symptoms and getting back to running but confused as to why minor operations like fat pad resection or lateral release have not been offered first, and have trepidation about having a major op with a long rehab period.

Any thoughts please?
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Vickster on January 22, 2016, 11:21:31 AM
Can you get a second opinion from a patella specialist assuming the reg and his consultant aren't? There are some suggestions in the learning hub I think

TTT is an open op with bone work, there's also info in the learning hub
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on January 23, 2016, 09:48:16 AM
Thank you yes, I will try and get a second opinion. I guess I will have to do this privately as it took long enough to get a 1st opinion on the NHS. But the info does not say if they are specifially patella specialists?

I have no idea if the current reg and consultant are specialists as the previous consultant has left the Trust and the new one is so new there is no info on either the hospital website or the net apart from a Linkedin profile which doesn't say much.

Am a bit confused by the changeover from "the injections didn't work so we want to discharge you" to "we want to perform major surgery".

Also everything I have read would suggest the fat pad swelling and impingement is causing the kneecap to be in the wrong place, not vice versa. So really don't understand why they are not trying ultrasound, trimming the fat pad etc first to see if that helps.

Have never heard of the fat pad regrowing either - I thought the whole point of them being careful how much they trim is because it doesn't regrow!
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Vickster on January 23, 2016, 09:53:18 AM
I had quite a lot of fat pad removed a year ago. My surgeon told me that some of the void left would be filled by scar tissue so maybe that's what they meant?
Maybe you are thinking of the meniscus which is where they are careful?

Have you had a scan done since you saw the dr before? Also, approaches are subjective varying from case to case and surgeon to surgeon so it's possible that is what is going on. The simple hasn't worked so now they are looking at the more complex.
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on January 23, 2016, 10:02:16 AM
The MRI I had was in January 2015. It showed Superolateral Fat Pad Impingement, Pes Anserine Bursitis and inflammation of the ITB band as well as subchondral cysts...I have a copy of the report, it says something about chondral degeneration of the trochlear groove cartilege, and the tibial tuberosity trochlear groove distance being 12mm.

From what the registrar said, the cut off point is normally 15mm which is maybe why the previous doctor did not suggest TTT.

He did not mention scar tissue just said fat pad trim is a temporary solution as the fat pad regrows. Also peturbed that he said there is no evidence that a chronically impinged fat pad can lead to oa, though the impinged bit and the oa are in the same area?
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Vickster on January 23, 2016, 11:57:54 AM
I'm assuming the poorly tracking patella is causing the trochlea damage and the fat pad impingement. Fixing that is more of a longer term solution
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on January 23, 2016, 12:59:01 PM
I thought it was the other way round, ie patella maltracking due to swollen fat pad pushing it in wrong direction, but you may well be right, thanks.
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Clarkey on January 23, 2016, 03:24:17 PM
Your continuing knee problems sounds similar to my right knee problems past and present. Mine starting around the same time as yours October 2007 after a heavy fall onto my right knee while I was running. Sounds like you having maltracking problems and patella femoral syndrome (PFS) as well as soft tissue injury problems to be dealing with.

TTT surgery is usually done if your kneecap dislocates regularly and have subluxation problems. Lateral release is a less invasive surgery than having what is called an ‘osteotomy’ involving the reposition of the kneecap or knee realignment surgery.

Have you had a CT scan done as this will help your OS get an idea the positioning of your kneecap and if you would require surgery such as an osteotomy to realign the kneecap in the correct position that is should be in.

Pre-op to my last surgery I had bone edema around the trochlear groove that looked as if it was osteoporosis with a possible mircofracture surgery to regenerate new cartilage growth. I had AIR surgery to remove excessive scar tissue behind the patella tendon. I am now 18 months post-op worse off, I have had 3 cortisone injection last year that have not be of any benefit.

[email protected]
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Vickster on January 23, 2016, 06:05:09 PM
Maybe not if your kneecap is malaligned especially as you've had the issues for a number of years. As Nick says, a CT scan is the best way for the surgeon to assess the true location of the different bony bits

There's info here which may answer some questions http://www.kneeguru.co.uk/KNEEnotes/primers/patella-primer

And if you choose to go the second opinion route, there might be some names here to start you off

http://www.kneeguru.co.uk/KNEEnotes/whos-who-knee-surgery/whos-who-patellofemoral-surgery
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on January 24, 2016, 09:19:48 AM
yeah this is what I don't get, I don't have dislocation, though the kneecap does move to the wrong place, ie lateral side, I can sort of push it back into position using a technique a sports podiatrist taught me but it doesn't last, in spite of endless quad/VMO exercises - which I thought was because of the swollen fat pad preventing it from sitting correctly.

They told me 8 out of 10 people are happy with the outcome of surgery - but I assume those will be people who have dislocation, not just maltracking!

I don't get why they are not suggesting lateral release instead, I will have to ask them next time. Also would prefer they trimmed the fat pad first, though I gather from yours and other people's experiences this is no guarantee either. But if they don't do something, the osteoarthritis will get worse!

I haven't had a CT scan only X-ray and MRI.

Been reading your post-op diary, sounds like you have been through the mill, I'm really sorry you're still suffering so much after all this time :(
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on January 24, 2016, 09:23:33 AM
Thanks Vickster for the info
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Vickster on January 24, 2016, 10:05:41 AM
Is it possible that your trochlea right grove is too narrow, the wrong shape or similar? Hence why the kneecap doesn't sit properly. A CT scan would give more detail, an MRI doesn't necessarily

There's quite a lot on this board about lateral eleven, my understanding is its indicated where the kneecap is stable but tilted with no cartilage damage. There's a link to the right >>> as well as further info in tne learning hub. I know after I had my scope to trim fat pad, meniscus and tidy my tatty patella, my physio said she was very glad the surgeon hadn't done a lateral release as they often cause more issues than they solve (not that he had ever mentioned the possibility)

That said I'm not sure my pain at that time was solely due to these issues in the knee, as I still have leg pain which the surgeon now thinks is down to a 9mm bone spur on my fibula irritating everything around it. Looks quite impressive (and ouchy)on my recent CT!

Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on January 24, 2016, 10:26:40 AM
Thanks Vickster that is helpful. Next time I go I will ask for a CT scan. Have been reading the patella primer and it does say lateral release is not for people with a mishapen patella so maybe that's why they haven't suggested it.

MRI says trochlear groove appears subjectively shallow and with chondral degeneration of the trochleal groove cartilege.

It must be difficult for them to know what is causing what since it has all gone on for so long and things have developed since the initial injury.

Ooh bone spur sounds really painful, can they do anything about that?
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Vickster on January 24, 2016, 10:34:26 AM
The bone spur can be removed, but it's in a tricky position as there's a big nerve in tne way, so there are risks. I need to have a shoulder op in mid March so tne leg is taking a back seat. I'm not keen (risky and a biggish incision needed) and I'm not sure the surgeon is either, although it's been paining me for over a year (mostly when I'm not doing anything) so if it doesn't settle, I may not have a choice. It's uncomfortable rather than downright painful, achy and burny. Tramadol takes the edge off at night, paracetamol and ibuprofen don't do a lot

It does sound like your groove and patella are the issue, which is scraping at the trochlea. Problem is deepening the groove is a big and painful op by all accounts and few surgeons do the op. Jonathan Eldridge in Bristol is a name that comes up on these boards. Not local to London obviously but might be worth seeking his opinion privately even if that's all you do. At least you'll have the opinion of an expert

CT scan is normally only done to inform the best course surgically so I'm not sure the NHS will fund if there isn't a surgical plan in place. That's the reason I had one done, so the surgeon knows the detaild situatiin before going in
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Clarkey on January 25, 2016, 03:54:58 PM
Lateral release surgery can go either way it usually a surgery that can make the knee problem even worse rather than better. Plica excision is also a hit and miss surgery! It can work out ok for some patients with success stories that have been posted by members of the bulletin board. I also read unsuccessful plica, fat pad trimming and LR surgery.

I am just unlucky that I am more prone to excessive scarring or bleeding inside the knee straight after surgery plus maltracking problems and PFS. Not being able to run is not just physically demanding it also get to you mentally if you suddenly are not able to run anymore at a young age.

Worst case scenario would be an open surgery to sort out the shallow trochlear groove that sounds similar to patella realignment surgery or 'Osteotomy' that can be a great success despite it being a major knee surgery!

Link to a post-op diary success story proving that the surgery can be a great success.

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=49136.0

My long on-going knee problem is also proving difficult to get it right again for the orthopaedic team at the hospital I had both scopes and various other types of treatments.

[email protected]
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on January 27, 2016, 09:26:24 AM
Good luck with your shoulder op Vickster, sounds like you have a lot going on. It's difficult to weigh up the costs and benefits, sometimes I wonder if the current pain is better than the risk of things getting worse. Chronic pain must be very difficult though, I think tramadol is quite heavy duty so sounds like the pain is bad. I can't take ibuprofen myself which probably hasn't helped things.

Thanks for the info regarding Jonathan Eldridge, I will have to email about the costs.

Clarkey, thanks for the link to a success story, I have been freaking out a bit at all the potential complications - read that I could end up with bone fractures, am likely to have neuropathy in the shin, a bit of bone that hurts on kneeling etc.

The registrar did not mention deepening the trochlear groove, only moving the kneecap. In fact he did not mention the bone work I only found that's part of TTT when I looked online.

Will have to ask how experienced this surgeon is - impossible to find out anything online as there is no info about him, I think he has only recently reached Consultant status.
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Aly0108 on January 28, 2016, 12:35:41 AM
Anybody cured Fat pad impingement with PRP, Stem Cell, Ozone, Prolo, etc.
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Clarkey on January 31, 2016, 03:20:46 PM
Good luck Vicky with your shoulder surgery in mid March, its at the same time when I will have another consultation what to do next with my right knee! I am now such a regular patient that I have a hot beverages hospital loyalty at the café.

I have been searching and also like to ask the same question? Would a PRP injection be beneficial for fat pad inflammation and chronic patella tendonitis! I remember Vicky in my post-op diary mentioned trying PRP injection.

http://www.prptreatments.org/sports-medicine/patellar-tendonitis-tendinosis/prp-treatment-for-patellar-tendnosis/

Does the NHS provide PRP injection, would I be eligible as I have had 3 cortisone injection last year without feeling any benefits. I hope if I print out the above link to show my OS that he would be ok about me suggesting it.

It makes sense at this stage of my hard to fix inflamed patella tendon problems to try out PRP injections, this would be better than having another cortisone injection. It is not really benefitting my right knee problems ending up making my knee worse having too many cortisone shots in a short space of time.

Is PRP injections less risky that does not weaken the articulate cartilage!

[email protected]
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Vickster on January 31, 2016, 04:54:53 PM
I think you'll struggle to get PRP in the NHS but you can but ask. I am not aware of specific risks as its derived from your own blood (plasma, so minus the red cells)

Multiple shots of Cortisone is are to be avoided if possible, they can be effective and are cheap. The equipment for PRP is expensive on the other hand. You may also need multiple injections

Your surgeon cites PRP as an area of research interest on his website bio so I'm sure he'll be willing to discuss even if he can't offer it to you on the NHS

http://www.sportinjuriesclinic.co.uk/surgeon/
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on February 18, 2016, 09:44:06 AM
Hi, so before I have even got a second opinion regarding the TTT, received the letter to my GP from orthopaedics.

Seems they have now changed their minds and letter states I am not a candidate for TTT as "TT-TG is 12mm and this distance is still within normal limits - up to 15mm for females".

Instead they say they may offer me "arthroscopic debridement of patellar femoral joint to stop further fissuring and slow down progression of degenerative changes".

So a complete u-turn, no idea why, probably funding.

They are now claiming my anterior knee pain is most likely due to degenerative changes....errr...no I had this pain since I fell in 08 and injured the fat pad!!!

Am fed up with the whole thing. What is the point of them going in and cleaning up the joint if they are not going to do anything about the fat pad???!!!! It will still be pinching aftewards!!

Am considering going to see John Hardy. I've read a lot of his posts on Runners World and he seems to have a good understanding of FPI and the relationship between FPI and PF OA.

Just totally fed up with NHS, if they had done their job properly in 2008 (they did x-ray not MRI) I might not have OA now.  >:(
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Vickster on February 18, 2016, 10:38:04 AM
My cycling Physio recommended I see a consultant Physio at Parkside in Wimbledon, Claire Robertson, who is expert in PFS

Link here. Not cheap if self paying but might be of value.

 http://www.wimbledonclinics.co.uk/consultants/ms-claire-robertson/

Not heard of John Hardy so can't comment

Good luck
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on February 20, 2016, 09:24:29 AM
Thanks for the info Vickster. The fee is OUCH! :o

Well I might pay her a visit as well.

Have been recommended Mark Bender as a physio by the podiatry clinic, will probably see him first (he's a tad less expensive) and then if that doesn't help maybe I will try Claire. Seeing as they are not offering me an op I guess I have the rest of my life to try out different specialists eh!  ::)
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Vickster on February 20, 2016, 09:30:13 AM
The fee is less than seeing an ortho privately. I guess if you get some answers it helps lessen the blow. I'm very glad I have Bupa, costs me a lot a month (about the same as a consultant Physio appointment) but I get my money's worth! My shoulder op in March would be well over 4K self funded

Never heard of Mark Bender. Physio recommended Claire to me as a PFS specialist
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on March 11, 2016, 09:10:07 PM
I am due my steroid injection for the pes anseurine bursitis only next week, after it has settled I will try and arrange to see Mark Bender, then if after a while that doesn't help I'll try and see Claire.

Though reading Clarkey's post op diary I am wondering if I am better off trying to live with the fat pad impingement rather than get it excised :-\
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Clarkey on March 14, 2016, 04:16:49 PM
I am sorry if my post-op diary is making you reconsider having fat pad excision! I had medial plica excision in November 2009 and had my fat pad trimmed down caused catching, it was not excised. The plica excision surgery that might be the cause of having to go through AIR surgery in July 2014 to remove excessive scar tissue from scope#1! #

I am more prone to excessive scarring after surgery, I have had PFS since childhood feeling anterior knee pain after running and cycling. I think the fat pad acts like a shock absorber for the knee that can cause problems if it gets trimmed or removed. I might be wrong thinking in this way,  think I read up about it somewhere online.

See Claire 1st before considering any form of surgery, she can advise what would be the best course of action for your Fat Pad Impingement problems. Good luck.

[email protected]
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on March 14, 2016, 05:16:30 PM
hi

I had my injection into the pes anseuerinus today, spoke to the doctor giving the injection about the fat pad.

He said if the fat pad impingement occurs on its own, then a steroid injection into the fat pad is likely to help, but if it is caused by patella maltracking then it is less likely

The problem is chicken and egg though. I knocked the fat pad first, I am not sure if the quad exercises would lead to the patella tracking normally if the fat pad were not swollen, or if the fat pad were trimmed the pinching/catching would reoccur as the patella would still be maltracking.

Sorry you are still having so many problems with your knee Clarkey it seems a nightmare.

Anyway at this stage I have not been offered a fat pad trim, seems the only thing OS are willing to do is clean out the patella.

I'm going to try Mark Bender first as he was recommended to me by a podiatrist I know, and is also nearer to me and cheaper, but if I really don't make progress there then will definitely look into seeing Claire before agreeing to any surgery, whether fat pad trim, patella debridement or if the TTT offer is back on the table. 

I don't think I would want the fat pad removed altogether  :o though doctor today said some people do have it removed and are fine after...hmmm..
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Clarkey on March 15, 2016, 05:36:07 PM
Sorry you are not yet seeing any further improvements, know what you are going through. I also had a cortisone injection directly into the fat pad with my previous OS pre-op to scope#1. I did not feel any great benefits apart from numbing the pain slightly. The pain and catching was still there which is why my fat pad was trimmed and medial plica removal.

One becomes more knowledgeable about knee problems when one has a never ending knee problems. It is nice to know that my post-op dairy has a lot of impact on members with similar problems that they know they are not alone with soft tissue injury problems

It might be a nightmare at this present time, one has to remain positive that we can get through it ok in the hope of returning to long distance running again for me personally that I miss greatly. My family and friends think I am bonkers that I wish to return to long distance running if it is still possible and could still happen.

I totally agree with you that that to trim the fat pad is bad enough, to remove it totally is completely bonkers! It makes my ambition more normal and less insane, to hopefully go back to long distance running once again.

You doing the right things right now seeing the UK’s top PT’s and can get the last decision from Claire a PFS specialist, that Vicky has already suggested. Think my right knee problem is no chronic rather than an acute.

Thanks for the good luck message on your other topic, tomorrow will be a big pressure release for me finally I hope?

[email protected]
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on March 19, 2016, 11:28:36 AM
I understand how frustrated you must be, I don't think you are insane to want to return to long distance running, I just want to be able to run for a bus and be able to walk up stairs, I used to do kick boxing somehow I don't think that will be on the cards in the near future, not that I was very good at it anyway haha.

I can relate to your frustration after seeing your consultant, I hope the second opinion works out better for you, sounds like you have selected a good one.

Have still not made appointment with Bender yet due to upcoming commitments and uncertainty re: work but hope to get an appointment soon before he starts touring with Andy Murray again!

Have had 5 days of no physio/gym to give the steroid a time to work, this co-incided with my having a cold which is probably just as well or the lack of exercise might have driven me up the wall.

Am so fed up of reading in the press that osteoarthritis is caused by being overweight and lack of exercise, I am neither and I would do more exercise if they would fix my fat pad!

Oh also I notice I am developing saddlebags in my old age, I have never had these before, i looked this up and it's caused by weakness in the lateral hip muscles - guess what all the suggested exercises are - deadlifts, squats, lunges, step ups. I can do none of these so I must just wobble about!
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: iwillwalkagain on April 11, 2016, 08:36:31 PM
Do quad sets and SLRs make your fat pad more inflamed?  This was the case for me.  I had PT for over a year making me do these exercises contributing to chronic inflammation. 
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Hipop on April 14, 2016, 01:38:25 PM
Hi, You mentioned that you are hypermobile. Do your knees hyperextend ? If so, do you weight bear to any extent with them hyperextended ?
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Clarkey on April 14, 2016, 03:12:35 PM
It's hard to say with my right knee problems if it the fat pad causing the problems on top of the inflammation of my patella tendon and possible excessive scarring of the right knee! One leg squats can inflame my knee, also struggle going up and down stairs and steep gradients. Straight away I get anterior knee pain around the tibia region of my right knee.

I do not think I am hypermobile, you will find each person knee problems will be different to the next person’s, one can never really compare with one another. I know how you feel going up the stairs at a slow pace and not being able to run for a bus or train and then end up missing it and having to wait for over 1 hour for the next bus or train. 

Hope you are all able to make progress with your fat pad impingement inflammation, it can be hard to get right again through my own personal experiences know the frustration and stress is causes on your daily lifestyle. Good luck in what ever treatment options you decide to take.

[email protected]
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Hipop on April 14, 2016, 05:51:21 PM
Hi clarky,  I was referring to puffyknee who stated that her osteopath thought the problem might be related to her hypermobility. She (he?) also mentioned doing calf stretches on an incline . I caused pain/?damage to my anterior  medial knee by doing calf stretches and leg extensions with a hyperextended knee . This is why I was querying if she has/used a hyperextended knee with weight.
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on April 30, 2016, 06:34:28 PM
Hi Hipop

I no longer do leg extensions, have not done them for years, though for a while a physio had told me to do them with a theraband

calf stretches on the incline board was meant to increase dorsiflex in my ankles which podiatry said were contributing to my fibula related equinus

i use the leg press, fairly light weight but i make sure i don't hyperextend when i do it

physio had me doing single leg squats and step downs for a time but i had to stop as it made the tugging pain much worse

Hi Clarkey i have yet to see Mark Bender as first when i rang they said they didn't know when he would be there and tried to get me to see one of his colleagues, then said he'd be back end of April possibly, then when I rang later in the month he was fully booked up!

Have orthopaedic appointment next week and still haven't had second opinion from either physio or another ortho
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Vickster on April 30, 2016, 07:18:06 PM
Could you not see the lady at parkside?

Good luck with your OS appointment
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on April 30, 2016, 08:22:32 PM
Hi Vickster

thanks

I could see her but wanted to get this guy's opinion first, and now i have left it a bit late for either, due to other committments am probably going to have to see either of them after the ortho

though since they seem to have withdrawn the TTT offer that may not matter as much.

How is your shoulder?
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Vickster on April 30, 2016, 09:01:39 PM
Pretty sore shoulder, well more arm. Had to go back to work after 2.5 weeks (contractor, needed to get back), physio reckons I went back too soon (although 2 weeks was the surgeons recommendation). Pain is the price I'm paying but on the upside my ROM is very good for 6 weeks! Physio for 6 weeks then follow up,with the surgeon. Can drive from week 8 but can't see it happening, at least not any sort of distance. Will take physio advice.
Knees a little grumbly but better than when I'm cycling! ;D

Is this an OS you saw before? I didn't think they were offering much as you say?  I'd go the specialist physio route if there isn't a sensible surgical one
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on May 03, 2016, 11:32:31 AM
ooh, sorry your shoulder is sore and you had to go back to work even with it hurting. It's difficult isn't it if you can't get the leave. Hope it continues to improve and you'll soon be doing pull ups and TRX, heheh. Hope you have good transport where you are, if you're not able to drive, and are not getting the shoulder squashed on the commute.

The OS, it's the same clinic but the previous consultant has left. They did offer me TTT at the last appt but then the GP letter said I didn't meet the criteria, so I need to check what they are planning now.

Specialist physio, yep am planning to do that anyway before resorting to the knife. Have just been really disorganised with other stuff going on, and Mark Bender not being available, will give it another shot but if he still isn't around (doesn't look likely now with tennis season starting as he's Andy Murray's physio) I will go with Claire at Parkside.
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on May 11, 2016, 07:31:43 AM
Hi all,

So have had further consultation with OS.

It transpires TTT is still a viable option but perhaps not currently the recommended one. I asked about the success rate of TTT for people with maltracking as opposed to patella dislocation and was told it's pretty much 50/50 (as opposed to 80% success for people with dislocation) so to me the odds are not that good for such a drastic op at this stage.

Also was told TTT is purely for pain relief and does not prevent the need for TKR in later life.

I think it was Vickster who mentioned deepening of the patella groove - I asked about this and they said they don't do it, and it isn't done in UK as far as they know.

They also never perform lateral release at this hospital which given what I've read about it is probably just as well.

I have had some improvement with the pes anserine bursitis from the steroid though perhaps not as much as I said in my appointment (was asked percentage wise and as on the spot came out with 50%) but still getting sharp pains on inside of knee, worse in work shoes.

The hospital I am at does not do fat pad trimming because in their opinion this exposes nerve endings and is likely to make things worse. Instead they said apart from TTT the other option is repeated steroids. The OS said eventually the fat pad will give up sending pain signals to the brain, however this would not necessarily mean the fat pad was better!!

The other option they have given me is a relatively new treatment involving injecting botox into the hip muscle. I am undecided on this, there is some info here:

http://www3.imperial.ac.uk/newsandeventspggrp/imperialcollege/newssummary/news_22-2-2016-15-14-26 (http://www3.imperial.ac.uk/newsandeventspggrp/imperialcollege/newssummary/news_22-2-2016-15-14-26)

and here

https://www.fortiusclinic.com/sam-church-lateral-patellar-overload-syndrome (https://www.fortiusclinic.com/sam-church-lateral-patellar-overload-syndrome)

sample size was fairly small but what he says makes sense.

What do people think?

In meantime have opted for another go with steroid into fat pad and will try and see a specialist physio before next OS appointment.

Current OS still opines that it is the maltracking that has led to chronic FPI not other way round, he says without the maltracking the fat pad would have resolved ages ago.

Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on June 22, 2016, 10:16:41 PM
Have had the steroid injection directly into the fat pad. I don't think the doctor could find the precise spot and just put it in generally on the lateral side.

The knee does not like it much. Was told to rest if for 4 days, just tried doing physio today and already my quads have vanished, wtf. Also was getting pain on the medial side directly after injection, think gait altered and putting pressure elsewhere

I think the injection is about 8 years too late anyway.

Have not made the appointment with the Parkside physio yet, i keep meaning to do it then not doing it.

I think I am going to go with the botox.  Can't see what else will help. The injection is supposed to be at its optimum in a couple of weeks but somehow i am not hopeful it is going to work, especially as i cant seem to keep the patella off it even with mconnell tilt glide and rotation taping
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Clarkey on June 23, 2016, 03:28:15 PM
Hi Puffy the Knee Slayer,

As you may already know I have also had a steroid injection directly into my fat pad in 2008. It did not really make any difference. I had medical plica excision and fat pad trimming done in November 2010. Do you feeling any catching on the lateral side of your kneecap? I had this problem pre-op to scope #, I thought it might be loose cartilage.

I have also had botox injection into the top of my right thigh muscle to release tightness around the hip. It was contributing to the knee pain pre-op to scope #2 of anterior interval release in September 2013, followed by surgery in July 2014.   

TTT surgery is a big surgery to be going through, it is usually done for patients with regular patella dislocations. For maltracking problems an osteotomy is performed to realign the kneecap into the correct position. 

The patella groove has been mentioned in my right knee OS reports saying the following in one of the paragraphs.

The MRI showed change of signal of the fat pad underneath the patella. Otherwise there were no pathological findings on it. On further evaluation of the MRI one may appreciate a slightly bigger distal pole of the patella with a bone spur which may be affecting the fat pad; however the signal of the tendon is normal. In addition Professor Snow was a little concerned about developing of patella Baja after surgery.

The fat pad can cause other problems, one needs to be careful and cautious about how to go about treating problems with the fat pad! It is a part of the knee that is not very well known by many. They have all heard about cartilage tears and ruptured tendons. I hope you are able to sort it out sooner rather than later, the longer it takes the more paranoid and anxious one becomes.

[email protected]
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on June 25, 2016, 12:48:56 PM
I do feel catching and pinching yes, also pain up the ITB band into the hip. My kneecap is in the wrong position tilted towards the lateral side and the tip is straight instead of towards the hip.

Did the botox help you?

I think the steroid has just aggravated the fat pad, I wish I had not had it and just gone for the botox first  :'(

i don't think it is going to be sorted any time soon, it has been over 8 years already

when i die i will leave my fat pad to medical science :(((((
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Clarkey on June 27, 2016, 04:10:36 PM
Hi Puffy the Knee Slayer,

It's is often the case that a cortisone injection can make the knee problems even worse rather than better. The botox injection was to release the tension of the tightened muscles and ITB band, that was contributing to the hip and knee pain. For me it did not really help as I already had scarring inside my right knee that was confirmed in my MRI scan back in March 2014. The botox injection was done in September 2013, followed by AIR surgery in July 2014.

The fat pad is often not really considered to be too much of a concern and problem by many OS's! It can often lead to deterioration of the knee once it has been shaved or removed. 8 years is a long time to be dealing with an on-going knee problems, have you seen another OS for to see what he/she says?

A detailed gait analysis can also be benefit ITB hip pain, a sports PT are better than standard PT's. I did use to see a sports PT until he left the UK to the Middle East. Since he has left have found it hard to find a half descent PT. The one's I have seen made my right knee injury worse rather than better.   

Good luck in trying to sort out your fat pad problems.

[email protected]
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on July 09, 2016, 10:56:37 PM
Hi Clarkey,

The pain from the injection has died down now and just gone back to the normal pain. I am still eating like a pig though and gaining weight so not happy, I didn't think this would happen with an injection, is this normal?? Do steroid injections into the joint increase appetite?? So now I have gained weight feel too embarassed to go and see the sports physio in case she decides my weight has caused my knee problems  :'(

No I haven't seen another OS as only got referred to this one recently and havent gone through all the options. For years I had a very useless muscular skeletal consultant who denied I even had fat pad syndrome and dismissed my medial knee pain as an ache and pain we all get sometimes.

Sorry the botox did not work for you. I don't think I have scarring so maybe it will help me.

I will try and make an appointment for the physio when my distended stomach has gone down :(
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Vickster on July 09, 2016, 11:39:21 PM
Why do you need to wait to see the Physio?
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Clarkey on July 11, 2016, 06:56:05 PM
Hi Puffy the Knee Slayer,

Cortisone/steroid injections did not give me any negative side effects and certainly never increased my appetite. Anxiety and stress levels will affect each individual in different ways. We can over indulge by comfort eating or not eat enough during the day. It is very challenging to keep your weight at a healthy level if your cannot do any physical activities on a daily basis.

Swimming is not in the same league as long distance running for me personally, I miss my running as it was not just good for my physical health but also good for me socially. When I was a active member at my local running club I was starting to make new friends, staying for a drink after a run or attended social evenings.

Due to my Asperger's I find it harder to interact and socialise, at the running club I found it a lot easier to chat and get to know other members. Who knows if I was able to run I might have found a potential girlfriend or future wife. This is why I am so determined and eager to try and get my right knee sorted our asap. January 2013 was the last time I was able to run and missing it greatly.

It will not do any harm trying out botox, it can help give some pain relief that is always beneficial if you are able to reduce some of the knee pain and discomfort.

Vicky is right that you should be able to see an NHS PT at fairly swiftly usually within 2 to 3 weeks. I had to wait 8 weeks to see the Head PT at the Hospital as my PT regime is specialised in chronic patella tendonitis, followed by ESWT sessions.

Never give up hope, one day both of us will be physically active once again, need to convince an OS that willing to happy to take a risk doing procedures that are not often used in the operating theatre. Patella decompression surgery is not done very often, if you can find the right OS for your specific knee problem he/she should be able to sort it out with a successful surgery and recovery programme.

[email protected]
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on July 16, 2016, 10:40:23 AM
Why do you need to wait to see the Physio?

because i have gained a lot of weight in a short space of time and currently resemble Jabba the Hut  :'(. Going on diet in time for OS appt in August.

Not an NHS physio, have given up with them, i meant the private one.
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Vickster on July 16, 2016, 01:59:26 PM
I can't see why it matters? I'm overweight/now obese following a lack of exercise and too much eating post shoulder surgery (probably gained 10 kilos this year).  I've been like this for years, no medical professional has ever judged me. The only time I discussed it with my knee surgeon was because I brought it up to get his opinion

Obviously being a good weight is better for knees, but I certainly wouldn't delay treatment due to it!
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on September 03, 2016, 06:23:44 PM
Hi Vickster, I'm not overweight I just gained weight recently.

I've now been back to the OS and agreed to have the botox injection into the hip muscle, but am freaking out a bit after reading that people can have health issues later on due to botulism. The OS said they've not seen any negative effects, though sometimes the injection does not work.

Anyway this is the last ditch NHS attempt as after this my only NHS options are a clean-up arthroscopy or TTT! They don't do fat pad trims or trochleaplasty and I really don't think repeated steroid injections are going to do owt.

Am holding off seeing the Parkside private physio for now as I will get an NHS physio to assess me before the botox and give me exercises to do after, it's a 3 month treatment period. If it fails then I will see the private one as there is not much else left for me on the NHS.

I have had to stop the fat pad unloading and patella tilt/glide taping as due to the hot weather my skin was reacting badly to the tape. I noticed the muscles were quite weak after I removed it so maybe it's better to keep it off for a while. Havent noticed much difference in pain without it, except it feels like my kneecap is sometimes digging into or tugging on something, not sure if that's the fat pad or the patella tendon.

Anyway am due to see the NHS physio at the end of the month for pre-botox assessment so will discuss with him.
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Clarkey on September 13, 2016, 03:20:52 PM
Hi Puffy the Knee Slayer,

I am not overweight and have a slim build, I still had problems with my fat pad! I went through a botox injection 3 years ago in September 2013 that did not make much difference. July 2014 I had scope#2 of RK AIR. As you already fully aware reading through my never ending post op diary it has made the right knee worse than it was pre-op to scope#1 and #2. Three cortisone injections last year works for some patients but not for me and many others.

I feel that with all the NHS cutbacks and a limited budget, high demand plus the junior doctor's strikes that unless your knee is completely warn out or have a large meniscus tear they will try ways to try and make you change your mind about considering gambling with a diagnostic arthroscopy. Saying the worst case scenarios that are unlikely to happen, to cover themselves in case the worse did happen.

The NHS PT'S I have seen so far all reassure me that there nothing to worry about as the knee looks ok, ending up with 2 scopes. Private PT's think in a similar way; I would advise you to go on what your knee is telling you with the pain, discomfort and limitations it is having on your daily life.

I am really missing not being able to do any long distance running since January 2013, I know that you also feel the same as I do with your knee injury.

[email protected]
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on September 28, 2016, 05:10:43 PM
Hi Clarkey,

Yes I think you may be right about the cuts influencing their treatment decisions. A previous MRI had shown a meniscus tear but the last MRI didn't show it so they said I don't have one.

I've now been seen by the NHS physio and am due for the botox next week. I've been given a few extra exercises including foam rolling the ITB which is OUCH! and he says because the ITB is so tight the botox has a good chance of success. He mentioned ITB lengthening op if necessary.

He does not seem to think my fat pad is the problem but rather my tilted kneecap. I don't really agree with this but for now am going along with it.

Anyway I will see how it goes, maybe it will help. If they have nothing more to offer I may try a second opinion on the NHS as maybe elsewhere does different ops other than just TTT.

Yes they have warned me that a lot of people feel after an arthroscopy that their knee never felt the same again...but as they don't do fat pad trims or MPFL anyway, probably not much point in having one.

Of course I know they say not much is wrong, and it is still affecting our daily life, pain and discomfort and limitation of activities daily, but then they act like we are making a fuss about nothing. They seem to be taking me seriously for now, will just have to see what happens.

Did you mean I ought to push for a diagnostic scope?
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: naedoc94 on September 29, 2016, 12:29:04 AM
Puffy you are like a butterfly that I have seen outside my house in the garden. I hope you have better conditions with your knee so you can have butterflies in your garden too.
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on October 02, 2016, 08:00:57 PM
Puffy you are like a butterfly that I have seen outside my house in the garden. I hope you have better conditions with your knee so you can have butterflies in your garden too.

Thanks for your kind words
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Clarkey on October 03, 2016, 04:46:48 PM
Hi Puffy,

If you feel that having a diagnostic arthroscopy would be a risk worth taking then you have the rights to go head. The OS will tell you it extremely risky and may end up with your knee becoming worse rather than improving.

You are the one giving your consent, no one else that you are willing to take a risk and gamble by going ahead with surgery. If you are in pain and discomfort and not able to take part in sporting activities that been going on for a while then you have the rights to ask for a diagnostic arthroscopy.

When I had scope #1 my OS did pre-warn me that he may not find any problems once he looked inside my right knee. The fat pad was inflamed and my medial plica was removed as it was restricting movement in my right knee. Scope #2 was lucky that I had a positive MRI scan showing unusual bone bruising that looked like wear and tear! Turned out to be excessive scar tissue.

Despite what many OS say that MRI scans are very accurate, I think they are not that great if you have soft tissue injuries or scarring inside the knee! This will give a false MRI scan reading making out that the knee is perfectly ok when it is not. I often read on KG bulletin board that large cartilage tears have been missed out on the MRI scan.

The best and most accurate way to diagnoses a long term knee problem is a diagnostic arthroscopy under the expert eyes of the OS. Think they are just being super paranoid and cautious in case they get sued if the patient knee ends up a lot worse than it was pre-op.

Good luck in getting the right sort of care and treatment that you deserve.

[email protected]
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on October 04, 2016, 12:17:05 PM
Thanks Nick, I will think about it. It may come to that as all the conservative treatment doesn't seem to be doing much and if I leave out straight leg raises for a few days my quads start to disappear. Am I going to be doing SLRs forever!!

It's true I do wonder how the MRI in 2012 showed a meniscal tear and the one last year didn't show it, as these tears do not heal in the posterior third and after a certain age I wonder if they missed it second time round or think I am too old to bother operating on!

I have had my botox injection into the TFL this morning as well as a steriod into the lateral femoral condule.

I have to wait 5 days before doing any physio exercises.

Have tried the foam rollering the week before - it's a bitch. It really really hurts but must mean I am tight and it needs doing.

Will let people know how I get on with it
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on October 05, 2016, 08:14:27 AM
Local anaesthetic wore off mid-afternoon yesterday and have been in terrible pain since, around the site of the steriod injection -  first knee itself and fat pad, and now around the joint where it bends on the outside, and down the outer calf, very stiff and painful.

am hobbling around with a hiking stick, taking paracetamol (i can't take NSAIDs) and sleeping with a hot water bottle under the joint.

The botox site is fine!

I think I am not going to agree to further steroid injections as all they seem to do is cause flare ups and not help. I wish I had just had the botox by itself as if this pain continues it is going to impare my ability to do the physio.

Thought I might at least be able to go to the gym and do upper body work while I wait 5 days to start physio, but can hardly walk without pain and was whimpering like a puppy last night.

Hopefully it will wear off in a few days!!
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on October 06, 2016, 07:06:40 PM
Some of the pain and stiffness has worn off but am getting random shooting pains up the outside of my calf beneath the lateral femoral condyle injection!

It feels like they left the needle in (I know they didn't) and when I move the leg it shoots up it.

I have not had this with any of the previous steroid injections!

What did she dooooooooooooooooooooo? :o

If anyone has had this injection and can let me know if this is normal and how long it takes to pass that would be good, thank you!
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Vickster on October 06, 2016, 07:17:24 PM
It's probably taken me a good 48 hours to get over the steroid flare and then maybe another week for the discomfort from having a big needle stuck in the knee!

You say you can't get the fat pad trimmed? Is that just your hospital/surgeon or the NHS generally (mine was done 18 months ago in SW London, albeit privately, along with a lateral meniscus trim)
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on October 06, 2016, 07:25:13 PM
Hi Vickster,

Thanks for your reassurance, I have had post steroid flare before but not as bad as this, hopefull the shooting pains will recede in a week or so then  :)

The NHS hospital I am at does not do fat pad trims. They also do not do lateral release, MPFL tightening or trochleaplasty. Apparently new research is showing that fad pad trims do not resolve the problem and by opening up nerve endings it can make things worse??

I do not know whether this is the case for all NHS hospitals. I thought once I have completed physio regarding the botox into the hip, if they have nothing left to offer me apart from TTT, I might ask my GP to refer me to a different NHS hospital for a second opinion. I don't have insurance and couldn't afford a private op.

My options currently at the hospital I am at are: repeated botox or possible ITB operation, or a TTT or an arthroscopic clean up of the joint, that is it.

Whenever I mention the fat pad they say that if that was the primary problem it would have cleared up with a steroid injection. Well maybe but not after 8 years! They insist the maltracking is causing the problem, all I know is that my MRI initially after injury showed fat pad oedema and my kneecap was normal, now it is tilted several years of impingement later.
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Daniellezana on October 18, 2016, 07:39:18 PM
Hello all,

Am new to the thread but sadly not to knee problems.

My issues started about 3.5 years ago now after a long tennis match aged 23, my knee feeling very strange after like it was sinking and generally uncomfortable particularly when straightening my leg. Also much more conscious of the issue when wearing jeans.

I've seen loads of Physios, Osteopaths, Consultants and never got a firm diagnosis. I had 3 MRIs and a CT on the a knee. They would say I do have a slight tracking problem but my symptoms were not typical. I also had scans of my hip, back etc. I got orthotics and used to tape it but got stress fracture in my navicular and so have also had times of complete rest.

Anyway I had an exploratory arthroscopy three weeks ago and was told that they have resected the fat pad and the plica. I'm trying to remain positive but it's still swollen and feels fairly similar at the moment. I'm slightly terrified I may never get rid of this. I'm taking anti inflammatories, icing etc am not in loads of pain but very uncomfortable walking so pretty much all sport is out currently. I used to play sport nationally so really hoping I can find a way through. I delayed moving out of home to sort thing out with Physios and really I'd like an active job so I feel a bit on hold. I know pain can be slightly mental in the end but visibly seeing the shape of my knee at the moment I know that something is wrong. Does anyone have any experience of fat pad /plica resection and time it took to rehabilitate? Appreciate individuals probably vary but if you have any tips that would be great. Pretty much willing to try anything.

Also someone on here posted about TTT. I actually spoke about this to my consultant as I am on the borderline at 18mm. I was basically told by my surgeon that he would never recommend this to someone who wants to be active/ continue to engage in sport as the outcomes are too unpredictable. Have you tried a Kneehab garment along with quads training?

Thanks for your help x
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Clarkey on October 19, 2016, 06:01:10 PM
Hi Daniel,

I have so far had 2 scopes on my right knee, scope #1 was also an exploratory arthroscopy and had my fat pad trimmed and medial plica removed that were both causing restriction in the knee as could fee catching and sharp pain pre-op to scope #1.

I also have maltracking in both kneecaps; this a common problem for many individuals that will also have an impact on their other joints. Orthotics work if you have flat feet and did have some made that did not really make any difference. Three weeks post-op is still early days and had to wait 18 months until I was back to long distance running again only to slip on ice! Since the fall in January 2013 I am no longer able to run and had had to go through scope #2 that turned out to be scar tissue from scope #2. 

I have a long post op-diary of both surgeries and can take a look at parts that might be beneficial to you to know more about the surgery of medial plica excision and fat pad trim. Scope #2 AIR surgery Anterior Interval Release, basically it is surgery to remove excessive scar tissue from scope #1.

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=43471.0

I was competitive in long distance running averaging under 6 minutes & 40 seconds mile with a best time of under 6 minutes a mile. I see that you were at play sports at a national level until your knee problems started. I did running long distances as a hobby as I enjoyed it immensely as you did with the sports that you are gifted in to a very high level until your own knee problems started.

My best running session a few days before fall in black ice while walking link below! Gutted as I was going to take part in my local town half marathon and had no option and pulled out as I was not able to run.

https://www.runtastic.com/en/users/nick-clarke-3/sport-sessions/38296072

Never give up hope, need to remain strong & optimistic.

[email protected]
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Daniellezana on October 19, 2016, 06:32:27 PM
Thanks Nick. Will have a browse through? Dd you find anything effective in bringing down the swelling other than the RICE routine?

It's definitely a tough thing all this. Not sure I can bear the thought of 18 months. I'm seeing the surgeon again next week so will be sure to go with my question list. Actually the lack of diagnosis and different opinions has been the most difficult as my MRI scans showed little I was investigated for referred pain and to pain management. So I hope even if its a while that we have a diagnosis. It's also a shame as I think I would have been managed much better conservatively if I'd known about the culprit.

Orthotics I've tried. Actually when I first started with all this I paid a couple of hundred for custom made orthotics and continued to play sport and tape my knee- shortly a navicular stress fracture followed. I was told that also I am very marginally osteopenic that this was biomechanical, but was put on alendronic acid. Then I developed oesophagal ulcers which was particularly unpleasant!

Anyway I really hope your knee improves soon. If there is one thing I've learnt it's to find consultants and Physios that you trust and won't give up on you when it gets tough and confusing. As not to see too many people either however desperate you are to find an answer as you can get lost in the noise!!
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Clarkey on October 20, 2016, 03:04:04 PM
Hi Daniel,

I did not have too much swelling pre-op to both scopes and soon went down post-op by icing and taking anti-inflammatories. I will always have some swelling around the portals that also scar tissue that can be reduced by doing friction massage therapy and having ultrasound with gel around the incisions. It took me longer to recover than expected due to the scar tissue build up! What did seem to help at the time was going through IMS sessions, intramuscular stimulations a form of dry needling. Basically it is the medical version of acupuncture into the quadriceps and thigh muscles. My muscles were super tight and the IMS session loosened the muscles, I was able to run again until I had my fall.

Hopefully your recovery will go quicker with a successful outcome and can compete again at National level, orthotics will help balance your knee alignment. I did not really feel the benefits myself as I am only slightly flat footed; my OS said that I should not waste my money buying custom made orthotics. 

It's true if you can find a good medical team to help and support you it helps to ease the nerves doing all they can to get your physically active again.

[email protected]
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on October 27, 2016, 08:10:58 PM
Hi Danielle,

I hope your knee is feeling better soon. I had a rubbish pair of "chairside orthotics" for years that did nothing and contributed to what they thought was a medial meniscal tear, but I have a decent pair now that have helped to an extent but not corrected the problem entirely. I have one foot with a collapsed arch following an ankle sprain and the biomechanics of the leg is all wrong.

Re: TTT, I was offered this for the fat pad impingement and maltracking but having researched it decided 50% success rate was not high enough to risk as it is pretty major surgery.

_____________________________________________________

RE: CURRENT TREATMENT FOLLOWING BOTOX

Currently I am having physio following a botox injection (Dysport) into the tensor fascia latae and a steroid injection into the lateral femoral condyle.

After the post steroid flare up wore off I looked up side effects from botox and found a botox support forum which freaked me out as it was full of people who have had terrible long term effects from botox!! I think I will not look there again, I feel fine apart from some headache and flu-like symptoms for a week or two after the injection.

The knee itself still hurts at the front but is not pulling on the laterals as before.

I am definitely noticing a difference when doing the straight leg raises, as the lateral muscles are temporarily switched off, leg raises are really really hard and can feel the inner quads activating.

I used to do 2 sets of 15 finishing with one set of 20, am now doing 3 sets of 10 but sometimes failing on 8, as it is so much harder.

Am hoping this means it is going to work, though it is early days yet, kneecap still clicking and popping and still tilted. 

Foam rollering has left me with bruising down the outside of my thigh. Hmm, not sure that is meant to happen.

I see the physio next week for a follow up, hope the bruising is gone by then.

Some people have more than one botox treatment, I am hoping I will not need another and that this will work, but another 2 months to go.
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Clarkey on November 01, 2016, 05:02:03 PM
Hi Puffy,

How frustrating that the botox injection into the tensor fascia latae and the steroid injection into the lateral femoral condyle had increased your problems even more. When I had botox injection in September 2013 it was a comical experience ended up at the wrong end of the hospital and was wheeled into the wrong ward after the injection as a precaution.

What was also odd and daunting was having an anaesthetist and anaesthetic machine on standby. Did this happen to you? It could well have been a mix up with another procedure that requires a full anaesthetic.

We all know how frustrating it is not making any progress as you cannot turn back time to pre-op to our Fat Pad Impingement that has made our knee problems worse rather than better.

[email protected]
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on November 02, 2016, 08:09:59 AM
Hi Nick,

I wouldn't say the botox has made things worse, it has increased the difficulty of the SLRs but that means the inner quads are getting stronger by themselves without also strengthening the laterals.

The steroid I did not like and would not have again, on occasion having pain at the joint, lateral side, and strange sensation of the lower half of leg moving when I do quad stretches.

Am due to see the physio this week for a review, it's only been a month since the injections and 3 weeks since doing the exercises so early days yet.

Wow so when they were doing yours they had anaesthesia ready? wtf. I had a local for it, but I know someone who gets injections for rheumatoid arthritis and he says they don't give him a local when they do it - ouch!!!

Were you on a ward then after your injection? I had mine done in ultrasound and walked home after, felt fine until the local wore off then OWWWWW

Yes I dearly wish I could turn the clock back, its hard to remember life before my knee problems, but what can I do just have to get on with things best I can.
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Puffy the Knee Slayer on December 17, 2016, 11:33:32 AM
So to update on this, have had my final physio review before going back to the OS clinic in the new year.

As I have said in my other thread, the new pain lateral side is still ongoing

 http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=67511.0

With regards to the fat pad, the botox does seem to have helped to an extent although it hasn't got rid of the pain altogether, it seems less frequent and less severe.

However I am still very much reliant on taping, both fat pad unloading and patella taping - without the tape I do get much more pain. Also more pain if not in stability trainers the whole time, even with the orthotics.

The pes anserine bursitis pain has gone altogether but I now have this new lateral side pain which prevents me from doing the upright bike or the cross trainer.

Physio has said in the run up to my OS appointment in the new year I must now try out things I was not doing before the botox treatment to see if things have improved - ie running!!!

So far I have tried this, one minute on and one minute walking, did not manage very long, not because of knee pain but because I am so unfit from years of not running!

It did not hurt at the time, in fact the other knee which compensates was more painful immediately afterwards, but then later and next day the fat pad started.

I am not convinced that running is a good option currently. Although the maltracking seems to have improved a bit, the fat pad is still swollen and I wonder if it is pinching between the knee bones as it is hurting below the kneecap.

In short even if there is not much pain I may be causing damage by running on it. But it is only for a few weeks so they can assess whether the treatment has worked.

Physio has promised me the fat pad will go down eventually. I really want to believe him.

He's said even if the fibrosed portion of fat pad does not go back to normal, if I'm asymptomatic it's not a problem as there are probably people out there with fat pad inflammation who are asymptomatic and don't know they have it. Is this even possible, the fat pad is highly innervated!

But it is about weighing up potential damage to knee and balancing that with trying to get back to normal activities.

Anyway, something to review/discuss when I see the OS next year.

Festive wishes and thanks to all the good people on knee geeks who have supported me through this injury and treatment. xx


Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: plant on September 09, 2019, 12:10:04 PM
Hi, I know this post is from years ago but I've also been struggling with fat pad impingement for years. Probably due to hypermobility - I've done intensive physio for almost a year now, have had 2 injections but still can't walk without pain/catching sensation and progressive swelling.
Am now keen to try surgery, I'm based in London - Vickster do you have any recommendations for the area? Agree that surgeons who specialise in this are hard to come by.
Thanks for the help.
Title: Re: Fat Pad Impingement 8 years and counting – advice please!
Post by: Vickster on September 09, 2019, 01:24:01 PM
NHS or private?
I’d go to Claire Robertson at Parkside Wimbledon in the first instance. About £200. She’s expert in PF issues.
 Get her advice on surgery (she’s generally for conservative management but does work closely with a team of (mostly private only) surgeons 

https://www.wimbledonclinics.co.uk/consultants

There’s a surgeon who’s who in the learning portfolio under primers, small list of PF specs

Are you under a hypermobility spec? Can they suggest and refer?