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Author Topic: Fat Pad Impingement 8 years and counting – advice please!  (Read 9533 times)

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Offline Puffy the Knee Slayer

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Fat Pad Impingement 8 years and counting – advice please!
« 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!
06/07 ankle sprain - collapsed arch
01/08 fall doing physio
06/09 MRI fat pad impingement
01/13 MRI medial meniscal tear
03/15 - decent orthotics
01/15 MRI - pes anseurine bursitis, SPL fat pad impingement, PFMaltracking
Cortisone 04/15; 03/16; 06/16; 08/15 Cortisone+Duralane; 10/16 Cortisone+Botox

Offline Clarkey

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Re: Fat Pad Impingement 8 years and counting – advice please!
« Reply #1 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]

RK: PFPS, Arthrofibrosis, Tendinopathy, Five cortisone injections
16/01/18 Anterior interval release, distal patella excision, lateral meniscal repair
18/07/14 Anterior interval release  
16/11/09 Medial plica excision, fat pad trimming

Offline Puffy the Knee Slayer

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Re: Fat Pad Impingement 8 years and counting – advice please!
« Reply #2 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.
06/07 ankle sprain - collapsed arch
01/08 fall doing physio
06/09 MRI fat pad impingement
01/13 MRI medial meniscal tear
03/15 - decent orthotics
01/15 MRI - pes anseurine bursitis, SPL fat pad impingement, PFMaltracking
Cortisone 04/15; 03/16; 06/16; 08/15 Cortisone+Duralane; 10/16 Cortisone+Botox

Online Vickster

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Re: Fat Pad Impingement 8 years and counting – advice please!
« Reply #3 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?
« Last Edit: January 04, 2016, 09:04:54 PM by Vickster »
Came off bike onto concrete 9/9/09
LK arthroscopy 8/2/10
2nd scope on 16/12/10
RK arthroscopy on 5/2/15
Lateral meniscus trim, excision of hoffa's fat pad, chondral stabilisation
LK scope 10.1.19 medial menisectomy, trochlea microfracture, general tidy up

Offline Puffy the Knee Slayer

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Re: Fat Pad Impingement 8 years and counting – advice please!
« Reply #4 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.
06/07 ankle sprain - collapsed arch
01/08 fall doing physio
06/09 MRI fat pad impingement
01/13 MRI medial meniscal tear
03/15 - decent orthotics
01/15 MRI - pes anseurine bursitis, SPL fat pad impingement, PFMaltracking
Cortisone 04/15; 03/16; 06/16; 08/15 Cortisone+Duralane; 10/16 Cortisone+Botox

Online Vickster

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Re: Fat Pad Impingement 8 years and counting – advice please!
« Reply #5 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
Came off bike onto concrete 9/9/09
LK arthroscopy 8/2/10
2nd scope on 16/12/10
RK arthroscopy on 5/2/15
Lateral meniscus trim, excision of hoffa's fat pad, chondral stabilisation
LK scope 10.1.19 medial menisectomy, trochlea microfracture, general tidy up

Offline Clarkey

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Re: Fat Pad Impingement 8 years and counting – advice please!
« Reply #6 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]
RK: PFPS, Arthrofibrosis, Tendinopathy, Five cortisone injections
16/01/18 Anterior interval release, distal patella excision, lateral meniscal repair
18/07/14 Anterior interval release  
16/11/09 Medial plica excision, fat pad trimming

Offline Puffy the Knee Slayer

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Re: Fat Pad Impingement 8 years and counting – advice please!
« Reply #7 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?
06/07 ankle sprain - collapsed arch
01/08 fall doing physio
06/09 MRI fat pad impingement
01/13 MRI medial meniscal tear
03/15 - decent orthotics
01/15 MRI - pes anseurine bursitis, SPL fat pad impingement, PFMaltracking
Cortisone 04/15; 03/16; 06/16; 08/15 Cortisone+Duralane; 10/16 Cortisone+Botox

Online Vickster

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Re: Fat Pad Impingement 8 years and counting – advice please!
« Reply #8 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
Came off bike onto concrete 9/9/09
LK arthroscopy 8/2/10
2nd scope on 16/12/10
RK arthroscopy on 5/2/15
Lateral meniscus trim, excision of hoffa's fat pad, chondral stabilisation
LK scope 10.1.19 medial menisectomy, trochlea microfracture, general tidy up

Offline Puffy the Knee Slayer

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Re: Fat Pad Impingement 8 years and counting – advice please!
« Reply #9 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!
06/07 ankle sprain - collapsed arch
01/08 fall doing physio
06/09 MRI fat pad impingement
01/13 MRI medial meniscal tear
03/15 - decent orthotics
01/15 MRI - pes anseurine bursitis, SPL fat pad impingement, PFMaltracking
Cortisone 04/15; 03/16; 06/16; 08/15 Cortisone+Duralane; 10/16 Cortisone+Botox

Online Vickster

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Re: Fat Pad Impingement 8 years and counting – advice please!
« Reply #10 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.
Came off bike onto concrete 9/9/09
LK arthroscopy 8/2/10
2nd scope on 16/12/10
RK arthroscopy on 5/2/15
Lateral meniscus trim, excision of hoffa's fat pad, chondral stabilisation
LK scope 10.1.19 medial menisectomy, trochlea microfracture, general tidy up

Offline Puffy the Knee Slayer

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Re: Fat Pad Impingement 8 years and counting – advice please!
« Reply #11 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?
06/07 ankle sprain - collapsed arch
01/08 fall doing physio
06/09 MRI fat pad impingement
01/13 MRI medial meniscal tear
03/15 - decent orthotics
01/15 MRI - pes anseurine bursitis, SPL fat pad impingement, PFMaltracking
Cortisone 04/15; 03/16; 06/16; 08/15 Cortisone+Duralane; 10/16 Cortisone+Botox

Online Vickster

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Re: Fat Pad Impingement 8 years and counting – advice please!
« Reply #12 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
Came off bike onto concrete 9/9/09
LK arthroscopy 8/2/10
2nd scope on 16/12/10
RK arthroscopy on 5/2/15
Lateral meniscus trim, excision of hoffa's fat pad, chondral stabilisation
LK scope 10.1.19 medial menisectomy, trochlea microfracture, general tidy up

Offline Puffy the Knee Slayer

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Re: Fat Pad Impingement 8 years and counting – advice please!
« Reply #13 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.
06/07 ankle sprain - collapsed arch
01/08 fall doing physio
06/09 MRI fat pad impingement
01/13 MRI medial meniscal tear
03/15 - decent orthotics
01/15 MRI - pes anseurine bursitis, SPL fat pad impingement, PFMaltracking
Cortisone 04/15; 03/16; 06/16; 08/15 Cortisone+Duralane; 10/16 Cortisone+Botox

Offline Clarkey

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  • Neil TheElephant knee packed up carrying his trunk
Re: Fat Pad Impingement 8 years and counting – advice please!
« Reply #14 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]
RK: PFPS, Arthrofibrosis, Tendinopathy, Five cortisone injections
16/01/18 Anterior interval release, distal patella excision, lateral meniscal repair
18/07/14 Anterior interval release  
16/11/09 Medial plica excision, fat pad trimming