Banner - Hide this banner





Author Topic: Immobile fat pad and unable to walk. What do I do next?  (Read 1268 times)

0 Members and 1 Guest are viewing this topic.

Offline CaliCoast

  • MICROgeek (<20 posts)
  • *
  • Posts: 11
  • Liked: 0
Immobile fat pad and unable to walk. What do I do next?
« on: February 02, 2022, 10:12:33 PM »
Hi, I had a meniscectomy and fat pad resizing surgery in April 2021 and 10 months later am still unable to stand. Post-surgery, I lost the ability in my left knee to hit full 0% extension (I can get to about 20%) and am only able to limp for 30 seconds at a time. I'm desperate to figure out a strategy to walk again, and wanted to share my story. I’ve tried to take an investigative approach towards treatment and hoped this forum could help. My current challenge is diagnosing the primary cause of my limited ROM post-surgery—is it arthrofibrosis, reactive arthritis, or impingement alone?—so I can build a treatment plan.

It started in 2018 when I noticed dull joint pain while standing for long periods. This got progressively worse after runs in the following years, particularly my anterior knee discomfort in my left knee. In April 2020, I went surfing and twisted my left knee. The next day I woke unable to walk on my left knee due to swelling and anterior knee discomfort.  I saw three separate orthopedic surgeons to get a broad opinion. They ran an MRI and found a small tear on my lateral interior discoid meniscus. Two of the surgeons claimed the tear was too small to create such a challenge to stand and walk, and attributed it to patellar tracking dysfunction or general over-use. The third surgeon thought the small tear was causing inflammation in my knee capsule and was the root cause of my issue. She recommended a meniscectomy.

I took a year to try physical therapy and had limited success. My knee improved greatly by August of 2021 and I was walking several hours a day. Yet, I inflamed the knee after a long day of use in October that took me back to the start. I poured myself into PT the second half of 2021--probably over doing it--yet was never able to get back to where I was. The PT itself seemed to aggravate my knee. I resigned to trying the surgery in April 2021 without any other foreseeable options.

I was able to stand and walk again for the first week after surgery, and had great optimism for recovery. Yet,  started to slowly lose my ability to fully extend by the end of the first month. It started to become clear that the meniscus tear wasn't causing my knee issue, and the surgery had drastically made my knee worse. Before the surgery, I could fully extend to zero, walk for 15 minutes with discomfort, yet post surgery, I'm no longer able to stand or extend to zero.

I started to look into other causes such as rheumatoid arthritis or severe hoffa's syndrome. I tested negative for RhA but my doctor said that my joints showed inflammation in my hands and feet. She diagnosed me with reactive arthritis in July 2021 (although this is a best guess catch-all diagnosis since there are no conclusive tests for this). I was really hopeful this was the cause since I do have tendon and joint issues beyond my knee. I’ve since been on multiple medications for reactive arthritis (Humira, etc.) yet none have worked, and had to stop them due to side-effects, bringing me back to square one again.

My overall theory of my condition is such: I likely had systematic inflammation—caused by an immune disorder or food sensitivity—over the last 10 years that localized in my left knee fat pad (among other places). This lead to fat pad swelling that then lead to mechanical impingement and then more swelling in a vicious cycle. I made the mistake to get meniscus and fat pad resizing, which dramatically worsened my hoffa’s syndrome and removed my ability to stand in extension.

Now I’m stuck at a crossroads. Knee extension is limited by a swollen and immobile fat pad but I don’t know the cause or interplay of causes. Is the cause (1) excessive scarring (arthrofibrosis) that will remain irrespective of stretching, diet, or exercise where only viable option is surgical scar removal (2) systematic inflammation preventing the healing of my fat pad post-surgery that if I address then I will heal overtime or (3) mechanical impingement is the primary issue for my swollen fat pad, and I’ll need to continue to wait overtime for reducing the fat pad size through limited exercise. I realize that all three issues likely appear together, but identifying the keystone here will help me determine if surgery is my only option.

I’m not sure how I can determine or differentiate what is limiting my knee extension and causing my fat pad inflammation and mobility. Has anyone had any experiences like mine? How did you identify the cause? Did you find any strategies to regain mobility or was your new disability permanent?

Thank you so much for your help and reading my post!

Offline DogfacedGirl

  • Forum Faithful
  • ****
  • Posts: 166
  • Liked: 19
Re: Immobile fat pad and unable to walk. What do I do next?
« Reply #1 on: February 03, 2022, 08:03:19 AM »
Hi,
I'm really sorry about your knee, you're between a rock and a hard place, with really bad AF.

I have a few suggestions, but as you know, nobody can promise a cure and managing symptoms may be the best outcome. You're clearly well informed so this won't be news to you.

Regarding your question, is it mostly excessive scarring, systematic inflammation or mechanical impingement of the Hoffa's fat pad, you're probably correct in thinking it is all three, and because the body's systems are tightly connected and they can't be put into separate boxes. You will almost certainly have excessive scar tissue and the myofibroblast cells that make it. Myofibroblasts pump out inflammatory cytokines and sooner or later the scar tissue will impinge into the joint.

You can read more about the Hoffa's fat pad the points I'll summarise below at https://arthrofibrosis.info
 
Here are some suggestions, you have no doubt thought of many of these and had them done.
1. An MRI that specifically requests a comment on the condition of the Hoffas. Unless radiologists are directed to this they usually won't comment, even if there is a problem.
2. Test for infection in the joint using an aspirated sample of synovial fluid. This is best performed by somebody experience in this procedure (not a general practitioner) and the fluid should have a PCR test in addition to a culture test. Culture on it's own is not adequate.
3. See a rheumatologist and test for a range of autoimmune conditions, especially connective tissue disorders. Test the systemic levels of inflammatory cytokines, especially TNF-α, IL-1 and IL-6. If TNF-α is elevated, which is likely, you may want to try Simponi or one of the alternative TNF-α antibody treatments other than Humira. Some people have found Simponi helpful to give them more pain-free leg time.
4. Blood tests for essential nutrients including iron, vit D, magnesium and a urine test for iodine. Supplement any of these nutrients if needed, your immune system can't operate properly if levels are low.
5. Get some sunshine without burning. This may be difficult in your winter, in which case a near infrared lamp may help. Recent research shows that Near Infrared Radiation is necessary for cells to make anti-oxidants. It can penetrate lightweight clothing and sunblock.
6. If your medical condition permits take omega 3 fatty acids and low dose aspirin (get off any other NSAIDS). Look after your diet and limit processed carbohydrates such as cakes, soft drinks, bread etc. You may want to consider intermittent fasting to get the benefit of ketone bodies and reduced inflammation.
7. Try to get good sleep. If your medical condition permits take melatonin if needed.
8. Limit exercise. Unfortunately, you found out the hard way that this is essential.
9. More surgery is an unknown risk for everybody, and there is always the risk of more fibrosis including nerve fibrosis and neuropathy, which is where you may already be at.
10. Consider using a CPM to gain ROM safely. See more on this on the website in the text above.

All the best,
Kay
1999 Osteoarthritis both knees, chondroplasty
2004 MACI graft L knee
2005 MACI graft both knees
2007 MACI graft R knee
2007 Patella baja
2011 TKR both knees
2011 arthrofibrosis

Offline CaliCoast

  • MICROgeek (<20 posts)
  • *
  • Posts: 11
  • Liked: 0
Re: Immobile fat pad and unable to walk. What do I do next?
« Reply #2 on: February 04, 2022, 06:07:37 PM »
Thank you, Kay! Very helpful, and agree that it's hard to pull my three causes apart. So in other words -- can the body reduce scarring and fibrosity over time if the patient can remove inflammation (medication and diet) and impingement (crutches for x months)? The site you supplied me (very helpful!) seemed to say that this is indeed possible, but varies greatly upon the individual, timing, and effort? (And yes, no guarantees for sure.)

Also, have you ever heard of anyone using ultrasound (or other methods) to assess the severity of impingement and immobility of the fat pad? Using ultrasound on the right (full ROM) and left knee (no extension) to compare? I've gotten an MRI and it showed scar tissue in the fat pad, but the static cross-sections don't allow understanding of fluid mechanics and how far away it is from clearing any impingement.

I'm curious about this since the severity of symptoms and my ROM fluctuate rapidly within a day. Randomly, I'll have hours in the afternoon where I can reach close to 5% extension, and then later that night it will "tighten" and I can only do 20%. Have you heard of this happening among others?

Offline DogfacedGirl

  • Forum Faithful
  • ****
  • Posts: 166
  • Liked: 19
Re: Immobile fat pad and unable to walk. What do I do next?
« Reply #3 on: February 05, 2022, 12:46:56 PM »
Hi CaliCoast,

Thanks for the feedback, I'm glad the website was helpful. Yes, the body will break down scar tissue over time in the absence of inflammation, and it seems that it can sometimes do this even for cross-linked collagen. However, as you know, removing inflammation is extremely difficult and some people have an innate tendency towards chronic low-grade inflammation.

And yes, using elbow crutches (not under-arm) for around 6 weeks should give your Hoffas fat pad a rest from constant aggravation and a chance to resolve. You'll lose muscle in that leg, but can re-build afterwards, and you can exercise other parts of the body.

Yes, ultrasound can be used to image the deep parts of the Hoffas in the right hands, but due to the bones, they can't perform cross-section imaging so seeing the impingement is tricky and perhaps won't show. It's performed through the front of the Hoffas and will show the scar tissue.

It's normal to wake up in the morning feeling stiff, as the body contracts overnight. This is when CPM will help to relax the tissues and stretch them before micro-tears and strains occur. For example, if you suffer from plantar fasciitis, which is scarring of the plantar fascia in the feet, gently stretching the soles of the feet before any weight bearing will frequently keep the symptoms under control.

Over the course of the day activities stretch tissues out so you may experience more ROM. By the evening you may be getting more inflammation due to being on your feet or exercise, and this will cause tissue contraction and reduce ROM.

Feel free to ask more questions, and it will be helpful to hear how you go.

Kay
1999 Osteoarthritis both knees, chondroplasty
2004 MACI graft L knee
2005 MACI graft both knees
2007 MACI graft R knee
2007 Patella baja
2011 TKR both knees
2011 arthrofibrosis

Offline CaliCoast

  • MICROgeek (<20 posts)
  • *
  • Posts: 11
  • Liked: 0
Re: Immobile fat pad and unable to walk. What do I do next?
« Reply #4 on: February 23, 2022, 10:18:50 PM »
Hi Kay, I had a couple of follow-up questions.

I recently talked with a Physical Therapy clinic (Shelbourne Knee Center) that has seen many arthrofibrosis cases. They instructed that stretching your knee into extension, with a tool like "Ideal Knee Stretch", is key to rebuilding extension. It seems sensible but I've found that my knee becomes more aggravated the following day after I do passive extension stretching. (E.G. I'm using a CPM machine set to the edge of my discomfort, or I'll sit on the ground and slowly let gravity full extend my knee through slight discomfort.) The next day, my ROM slightly decreases as my knee feels more sticky and "full", so this advice at least feels a bit counter to my personal experience. I know many experts advise against full extension when you suffer from a swollen fat pad -- since it can exacerbate it -- so figured that may be at play here beyond AF?

Should I keep a daily practice of putting my knee into zero degrees extension to regain extension? Do I just need to increase the frequency of this practice for my knee to adapt? Or is the opposite true, and need to avoid full extension at all costs so I don't create further trauma/swelling?

PS: You mentioned elbow crutches in your last reply. Wouldn't underarm crutches work just as well or am I missing something?


Offline DogfacedGirl

  • Forum Faithful
  • ****
  • Posts: 166
  • Liked: 19
Re: Immobile fat pad and unable to walk. What do I do next?
« Reply #5 on: February 24, 2022, 02:45:55 AM »
Hi CaliCoast,

I think that the Hoffa's fat pad is the most under-appreciated organ in it's role in the health and disease of the knee. Yours is clearly a very unhappy and scarred fat pad, and the literature suggests that fibrosis of the fat pad can drive AF on its own. You can get fibrosis in any of the soft tissue structures of the knee, and arthrofibrosis can result from many of these, but an unhappy Hoffas seems to be a key part of the picture.

Therefore, keeping the fat pad as happy as possible is probably the best approach, but this has not been tested scientifically. Stretching exercises are indeed key to maintaining and regaining ROM, however, I believe that stretching should always be done in the pain-free zone. If the degree of stretch causes problems afterwards this indicates, as you suggest, that the Hoffas is being pinched and it's getting more inflamed (and/or another structure is getting inflamed) as a consequence. This is not helpful for overcoming AF.

I don't think that buying another stretching tool is the answer, and even although you're being careful I feel that you should probably stop the stretches at a lesser amount of extension - that is, not push it to get to zero. You'll need to see what degree of extension is safe for you, and only increase that when it's safe to do so. One advantage of the CPM is the precise read-out of the degrees of stretch, so you can set it within your safe zone. Be patient, and do the stretches at least twice a day. It will take time, most likely months, but the Hoffas may settle down and allow more extension.

Regarding the crutches, the under-arm type can cause nerve damage since your body weight is hanging from a delicate area not designed for this. The elbow type are safe, and allow more dexterity, but remember to always put them aside before you sit down or stand up, or they can slip out and damage you.

Kay


1999 Osteoarthritis both knees, chondroplasty
2004 MACI graft L knee
2005 MACI graft both knees
2007 MACI graft R knee
2007 Patella baja
2011 TKR both knees
2011 arthrofibrosis

Offline CaliCoast

  • MICROgeek (<20 posts)
  • *
  • Posts: 11
  • Liked: 0
Re: Immobile fat pad and unable to walk. What do I do next?
« Reply #6 on: February 24, 2022, 04:36:55 AM »
Thanks, Kay. Your advice matches my experience with this issue, so will try and be more patient and give my knee more time to mend. Will keep you posted.

Offline amy

  • MINIgeek (20-50 posts)
  • **
  • Posts: 20
  • Liked: 0
Re: Immobile fat pad and unable to walk. What do I do next?
« Reply #7 on: March 30, 2022, 05:14:55 PM »
Hi Calicoast ands Kay

I just wondered how you are getting on Calicoast with you fat pad problem and AF and if resting and using crutches is working?
I have been suffering with a fat pad problem for 15months, kicked off by surgery for a small lateral meniscal tear last Jan. I was recovering but no where back to normal and then stupidly crouched down in the shower and really did aggravated the fat pad. I was given a steroid injection into it 12days later that made it a lot worse and have pretty much been immobile since. I has a few weeks of improvement in Aug last year through doing hydrotherapy and then a change in exercises from my Physio put me back to square one. I've been unable to stand for even a few seconds comfortably since Aug last year and use crutches to get around the house for essentials like to the loo! Im also 32 weeks pregnant so can't get another MRI yet (last one in July last year showed oedema in the Apex of the fat pad)
I also get a constant burning pain on the outside of the knee now that started in Oct 6 months ago- it can just com eon a rest and often comes on very intensely when i get into bed. Its constant and sometimes lasts days. I'm wondering if its an irritated nerve as its not like any other pain i've ever experienced.
Life is a struggle, ive lost huge amounts of muscle now from being immobile for the past 15months. My Envelope of function and tolerability seems to be regressing despite me being more and more careful. At the beginning of Jan I was taking myself to a pool a few times a week to walk up and down- that was my only walking for the day, and a few mins on a static reclining bike. I'm  not able to tolerate any of that apart from my hydrotherapy session one a week in deeper warmer water so not really weight bearing.

I can totally sympathise with your situation - being in constant pain and disabled is not fun. I'm so lucky my partner looks after me and cooks/cleans/walks the dogs. I was a professional horse rider and still have   a yard at  home but have had to sell most of my horses as I cant even walk the 100 steps out to the yard let alone ride. Its soul destroying. Really hope you have some good news and you are improving a little?

Sorry for the long post. I welcome anyone's help and knowledge!

Offline DogfacedGirl

  • Forum Faithful
  • ****
  • Posts: 166
  • Liked: 19
Re: Immobile fat pad and unable to walk. What do I do next?
« Reply #8 on: April 01, 2022, 02:18:22 PM »
Hi Amy,

You may have some nerve fibrosis happening, this can occur inside the fat pad and the inflammation could cause nerve fibrosis further along the nerve outside the fat pad. It's very painful. The fat pad is packed with nerves, and all soft tissues can becomes fibrotic.

I don't know if this will work but you could try putting 5 % lidocaine (also called lignocaine eg Xylocaine) cream on the area that burns on the outside of your knee and also on the fat pad area. Lidocaine is an anaesthetic that dentists and surgeons use to make an area numb and it's very effective. Make sure you wash any fingers that get it on or your fingertip will go numb. Check with the pharmacist or your doctor to make sure it's OK to use it when pregnant.

Try to avoid the patella tendon, go either side of it just under the knee cap - you can probably feel the Hoffas if you push there. However, the nerves in the fat pad are possibly too deep inside the knee for the cream to work well there, and you may have more success with the other area. The cream may need to be replaced when it wears off after several hours. There are also lidocaine patches that you can buy and these stay on for a day, but I've heard that they're expensive.

It's possible to have anaesthetic injected into the fat pad and on the side of the knee, but this doesn't last more than a day. You may want to see a pain specialist to see if they can help with pain medications, but be careful of invasive procedures since they can cause more harm than good, as you've unfortunately found out.

If the lidocaine works it will help to reduce inflammation in the fat pad because upset nerves cause inflammation.

All the best,

Kay

1999 Osteoarthritis both knees, chondroplasty
2004 MACI graft L knee
2005 MACI graft both knees
2007 MACI graft R knee
2007 Patella baja
2011 TKR both knees
2011 arthrofibrosis

Offline amy

  • MINIgeek (20-50 posts)
  • **
  • Posts: 20
  • Liked: 0
Re: Immobile fat pad and unable to walk. What do I do next?
« Reply #9 on: April 01, 2022, 02:42:34 PM »
Hi Kay

Thanks for getting back to me :-) Everyone on here seems to be so supportive of each other.

I was using the 5% lidocaine patches last year (prescribed by a pain specialist) before I fell pregnant and they definitely helped, but unfortunately they cross the placenta so I had to stop! I've not tried the cream and hadn't heard of it so thank you- it may also cross the placenta but worth finding out and good to know for when the baby has arrived. Its interesting you saying about the lidocaine helping to reduce the inflammation as well so that's a real plus if they work, which they did last year and I did see some improvements in August so maybe it was the patches helping to reduce the inflam by interrupting the nerve signal.

I had heard of fibrosis on the fat pad but not nerve fibrosis that spread radiating from the fat pad but it totally makes sense now you've said it. Do you know if this is reversible?

I did have a fat pad injection given my my OS back in April last year along with steroid (depomedrone) and it made the knee pain go away for the afternoon (at that point i didn't have any of the constant nerve pain on the outside of knee) But it then subsequently flared by knee up a lot worse over the following week since the anaesthetic worse off :-(

I have also been told I could have a Genicular nerve block/ablation if pain doesn't improve- which in turn should allow me to do some physio. I've been doing hydrotherapy since May last year but the short term improvement I had in August last year seems impossible to get to again- but the movement in the water in at least keeping my back and hips moving a bit as I sit all day pretty much apart from hobbling on crutches to the loo and up to bed...

Also been advised to try Gabapentin after the baby is born, do you know much about this drug and if it can get rid of the nerve pain for good or at least improve it ?! I'm very very weary about having a fat pad trim or any further surgery...

Sorry for so many questions, iv'e been lurking on this forum for a while and finally plucked up the courage to post that post the other day!

Thanks again
Amy

Offline DogfacedGirl

  • Forum Faithful
  • ****
  • Posts: 166
  • Liked: 19
Re: Immobile fat pad and unable to walk. What do I do next?
« Reply #10 on: April 03, 2022, 09:21:25 AM »
Hi Amy,

Yes, I've always found KneeGuru to be a supportive community.

Ah, that's a shame you can't use the lidocaine patches at the moment, and I'm guessing the cream will be the same story.

Nerve fibrosis is sometimes reversible if it's successfully treated early on. The problem is that the different forms of fibrosis aren't labelled as "fibrosis" in the same way that different forms of cancer are labelled - for example, "breast cancer". Because of this there is less understanding of the pathology of fibrosis and less sharing of therapies between the specialities. And many clinicians may not even be aware that fibrosis is the root issue in nerves.

The anaesthetic injection in your Hoffas did at least demonstrate that your pain originates from the nerves there, so it was some use. My guess is that the steroid caused the increased pain afterwards.

I think a fat pad trim would be extremely unwise in your situation. Gabapentin was one of the pain meds I was thinking of, it's probably the main "go-to" med used for neuralgia. It downregulates the release of Substance P (P for pain) which not only reduces pain but also reduces inflammation. It's certainly worth a try after you've had your baby.

I'm glad that you plucked up the courage to post, everybody learns from reading posts from other people  :) Feel free to a ask more questions.

Kay


1999 Osteoarthritis both knees, chondroplasty
2004 MACI graft L knee
2005 MACI graft both knees
2007 MACI graft R knee
2007 Patella baja
2011 TKR both knees
2011 arthrofibrosis

Offline DogfacedGirl

  • Forum Faithful
  • ****
  • Posts: 166
  • Liked: 19
Re: Immobile fat pad and unable to walk. What do I do next?
« Reply #11 on: April 03, 2022, 09:27:46 AM »
I forgot to mention magnesium supplements, check with your doctor that it's OK for you to take first in case it interferes with a med you're taking. Magnesium is essential for many body processes and low magnesium causes inflammation and fibrosis and is common in cases of chronic inflammation.

Check what form it is in and avoid magnesium oxide, this form is poorly absorbed by the body and as a result can cause diarrhoea. Magnesium citrate is one form that is absorbed fairly well, however, the oxide form is cheaper to make and more commonly sold.

Kay
1999 Osteoarthritis both knees, chondroplasty
2004 MACI graft L knee
2005 MACI graft both knees
2007 MACI graft R knee
2007 Patella baja
2011 TKR both knees
2011 arthrofibrosis

Offline amy

  • MINIgeek (20-50 posts)
  • **
  • Posts: 20
  • Liked: 0
Re: Immobile fat pad and unable to walk. What do I do next?
« Reply #12 on: April 03, 2022, 02:54:18 PM »
Thank you- I will get some magnesium ordered!

What would be the best way to get a diagnosis of the nerve fibrosis or any other fat pad fibrosis? Do I go back to my GP and push for MRI/MRN /bone scan/ US/ XRAY? The MRI last year in July showed oedema in the apex of the fat pad and local friction to the patella tendon. But the pain has become more constant since and the knee less and less tolerable/constant pain at rest. I had an EMG test and nerve conduction study done last June that gave all normal results- but the nerve pain wasn't as bad then and my muscles weren't yet as atrophied as they are now, as had only been immobile for a few months.

Do you know how quickly fibrosis starts to happen? It's been 15months since my meniscectomy, 12 months since I then really worsened things by crouching down in the shower, and a good 6-7 months since I started to get this burning constant 'nerve' pain as I call it on the outside of the knee. Although its all very 'nervy' type pain from the fat pad!  I'm wondering if I should consider being induced so I can get the pain management things under control sooner as I'm really struggling to get through the days and nights...

I know a few have had some success with deep friction massage into the fat pad- do you have any experience with this? Generally any pressing on the fat pad flares it up but occasionally I have massaged it a bit deeper in a warm bath and haven't flared it up too much.

Will definitely being trying the Gabapentin and lidocaine patches as soon as safe to do so. Are there any other known treatments for reversing this nerve pain/ fibrosis? Laser/Cryotherapy? 

I would be happy with just small progress to be able to walk in house without crutches and do the recumbent  bike again for 10 mins a day to build strength, but my new Physio has said to avoid bike as too repetitive whilst the fat pad is still so painful. He has given me some non weightbearing quad exercises to do that stay out of full extension. Any standing even for 30 seconds aggravates it!

It feels almost impossible to rebuild muscle as the knee is so painful. I am frightened i'm going to be stuck like this forever and never recover or worse case get even worse. Its as much a mental challenge as a physical one and I do struggle to cope with the disability. I'm lucky my partner does everything in the house, I would be stuck if I was on my own so am eternally grateful for that.

Thank you again, and sorry for so many questions. Its nice to finally be chatting to someone who understands where im coming from. What position are you in with your knee/s at the moment?

Amy :-)



Offline DogfacedGirl

  • Forum Faithful
  • ****
  • Posts: 166
  • Liked: 19
Re: Immobile fat pad and unable to walk. What do I do next?
« Reply #13 on: April 04, 2022, 02:23:40 PM »
Hi Amy,

You could have another MRI to get a diagnosis for the fat pad and patellar tendon fibrosis (make sure this is specifically requested on the referral), the problem then is, how to treat it. In my opinion the effects of the anaesthetic into the fat pad is diagnostic of fibrosis there and for the nerves on the outside of the knee.

Fibrosis can happen very quickly with a severe insult such as surgery or injury, or more gradually with a low grade chronic insult, as often happens with frozen shoulder. You're likely correct that crouching in the shower scissored the Hoffas between the bones of the knee and damaged it, creating more inflammation and fibrosis, especially as these were already present to some degree.

Regarding deep massage, my "rule of thumb" is that if the knee feels worse in the aftermath, then whatever it was that you did (massage, exercise, etc) was too much, and you need to back off. It's possible to cause bruising (bleeding) if the massage is too vigorous or if your tissues are especially delicate, and bleeding is very detrimental in the setting of fibrosis. It is true that massage can help to remove cell debris and increase blood flow, and people can be helped by this, but be very careful with it and if there is pain then back off.

I don't know if you have restricted ROM, but in any case, you need to keep that leg moving as much as possible to maintain blood flow and keep the tissues functional, but in a way that is not painful. This can be achieved with careful CPM performed several times a day in the pain-free zone. I can refer you to a website that explains how to go about this if you're interested, you may have come across it already.

I don't think lasers are the answer because they create damage (burns), same with many forms of cryotherapy. There are no available therapies that specifically target fibrosis unfortunately, although there are some in trials. The best that can be done is to target inflammation, but even here it's difficult. If you're taking NSAIDS long term this is actually detrimental.

You've likely seen my earlier posts about low dose aspirin and high dose omega 3 fatty acids. These induce the production of resolvins, compounds that the body makes to help resolve inflammation. With all of these things I suggest, check with your doctor before taking them.

I also suggest a blood test for essential minerals and vitamins, particularly Vit D, iron, potassium, and a urine test for iodine. I expect you may have already had this done, they are essential for proper functioning of the body. Iodine is often not tested but is frequently low in people on a Western diet, and it's essential for immune function.

These suggestions are not a cure, but everything helps. Other things include a diet low in sugar and processed carbohydrates and high in fibre because gut bugs have a major impact on inflammation. Lots of plant based food provides fibre and the anti-inflammatory benefits of a range of plant compounds, the more colourful you plate is the healthier it is. Probiotics also help.

There is a product that has been developed from the compounds found in cabbages and broccoli that is strongly anti-inflammatory. The best of these products that is available has been used in many scientific studies on cancer etc and extensively independently tested, so we know it contains what it claims to, and doesn't have added nasties. This is called Avmacol. However, it is a powerful compound and it can affect how other medications are metabolised, so again, check with your doctor, especially while pregnant.

Regarding the bike, in my opinion repetitive is not the problem, pedalling can help maintain ROM and blood flow. However, pain afterwards certainly is a problem. If you're able to pedal without any resistance for even 5 minutes twice a day, this would help to keep the leg mobile as well as maintain some muscle, but as always, if it hurts afterwards then back off. That also applies to non weightbearing quad exercises!

Full extension while standing and exercising will pinch the puffy inflamed fat pad, that is why it hurts so much.

I do understand, and I'm sorry that you're having to consider being induced.

Thanks for asking about my knee, I'm doing OK  :)

Kay




1999 Osteoarthritis both knees, chondroplasty
2004 MACI graft L knee
2005 MACI graft both knees
2007 MACI graft R knee
2007 Patella baja
2011 TKR both knees
2011 arthrofibrosis

Offline amy

  • MINIgeek (20-50 posts)
  • **
  • Posts: 20
  • Liked: 0
Re: Immobile fat pad and unable to walk. What do I do next?
« Reply #14 on: April 05, 2022, 09:58:54 AM »
Hi Kay

Thanks again for all the useful advice. Magnesium should be arriving today...

My ROM is not too bad I don't think- I can put the leg into full extension when sat up in bed but its uncomfortable and if I do it for too long it flares my pain up worse. I can bend the knee reasonably far back when doing heel slides, its not very comfortable the more bend it gets and again if I do it too many times it flares the pain a lot worse. I don't have to 'click' it into full extension or anything- i just feels like the hoffas is being squeezed more in it and same for the more flexed position. It doesn't even really like me laying down with my knees bent a bit on the bed. I also try and get in a pool twice a week for gentle walking and to move my hips and back- once with a hydro person and once on my own with my mum to help me. I use the crutches until I get pool side. Happy to look into the CPM machine if it can help but also happy to try reclining bike again for 5mins am and pm or just once am on days I get in the water. I very gently roll my foot on a soft football when sat in a chair for 2 sets of 2 most days but not every day depending on how extreme pain is but avoid complete extension and flexion.

The problem really is that there is pain  in the knee all of the time, just sometimes its more bearable and sometimes so intense,  burning and like electricity thronging in my lateral knee and a bit down my leg- constant once it kicks off sometimes even for days. I have quite  bit of noisy crepitus I can hear and feel in the bad knee under the knee cap, assuming this is the inflammation in the fat pad, esp noticeable when squeezing quads. But the constant full on irritation makes me wonder if there is a bit of a compressed /irritated nerve somewhere as well as the fat pad issue? Or if this truly is just radiating nerve pain from the unhappy lateral hoffas  to the peroneal nerve on the outside... any thoughts on this? I cant lie on it anymore in bed- I try to but within a minute it sends the pain rocketing so I turn over again. It never used to be quite this intense and irritable a few months ago :-(

I have heard about  low dose of aspirin helping inflammation but not sure what dose to take? I also might need to wait until after the baby is born unless its only a really low dose. The tablets I have are 300mg but can easily be split in half. I've also been taking Omega 3 1000mg daily since I fell pregnant since around Sept as also good for baby's development and we eat fish a few times week. Also take a probiotic daily as well. Will make an effort to cut out more sugar from now on... The Avmacol supplement looks interesting but will check with GP.

Haven't had any of those blood tests done so this is something I could do- I'm guessing I will have to go privately for this if I cant persuade my GP to do them!!

The other thing I am yet to explore are a PRP injection/s, not sure if these go into fat pad or joint. I know its less damaging than a steroid, but wondering if needle itself would upset fat pad/knee even more. I'm starting to wonder if the injection into the side of my knee joint in Oct started to kick off this extreme constant nerve pain I get on the outside of knee.. maybe it caught a nerve and its since got more and more inflamed?

Finally wondered if you know of anyone who has had success with breaking down inflammation with shockwave therapy or daily gentle ultra sound? One suggestion my OS gave me was to go straight to having a genicular nerve block- but again weary as its another 'procedure.' So maybe I should try the lidocaine patches and then gabapentin first for a few months as soon as safe to do so.

Glad your knee is doing well. I was considering starting a new thread and posting about my situation- one thing I am keen to do is find an OS that has experience with fat pad issues. Do you know any that have a particularly good reputation?
 I have seen Claire Robertson PFS physio at Wimbledon clinics last year once in May and have stayed in touch with her via zoom sessions but as I cant really do any physio she has said I need pain management once the baby is here. 


Amy :-)