Hoffa’s Fat Pad Syndrome

Hoffa’s Fat Pad Syndrome treatment and information

Hoffa’s fat pad impingement, also known as Hoffa’s syndrome, is one of the leading causes of pain at the front of the knee (anterior knee pain). Hoffa’s fat pad syndrome also known as infrapatellar fat pad syndrome is a condition that describes pain in the front of the knee and around the kneecap. The pain is usually exacerbated when the knee is in a “loading” position with muscle activation and forces applied around the joint and the fat pad (ie: walking up or down the stairs).

Pain is usually felt at the front of the knee, around the bottom of the patella. The pain may be worse when the leg is completely straight, when standing for a long time or when going up or down stairs. The area around the bottom of the kneecap may also feel very tender to the touch. There may also be some swelling present too.

• Symptoms usually include:
• Sharp pain located at the front of the knee
• Pain with prolonged periods of standing or sitting with crossed legs
• Pain with walking and squatting
• Pain during sport, in particular running and kicking activities
• Pain with wearing high heels
• Pain after periods of rest such as walking first thing in the morning or after sitting in

Infrapatellar fat pad syndrome can happen for a number of reasons. It can be caused by a sudden injury, such as a direct blow to your knee. More often though, it develops gradually over time if you repeatedly over-extend your knee. This is when your knee is forced past its fully straightened normal position. This is usually a very common injury mechanism, especially in a landing motion. Anterior Cruciate Ligament (ACL) injuries are also a potential cause of Hoffa’s syndrome, due to the resulting knee instability, making the fat pad more prone to being pinched.

The overload of the main knee extensor muscle (quadriceps) is very common in repetitive mechanisms, such as running or kicking the ball when playing football. Other common causes of the syndrome include other associated knee conditions such as: osteoarthritis, patellofemoral syndrome, or meniscal tear for example.

Hoffa’s fat pad syndrome can be partially diagnosed and clinically assessed based on the symptoms the patient is presenting. In a clinical environment, a test can be performed called Hoffa’s test, which involves moving the kneecap after the patient contracts the quadriceps muscles. However, Hoffa’s test is not very precise or specific, which makes it difficult to properly diagnose. Commonly patients can get misdiagnosed or even undiagnosed with a simple “diagnosis” of anterior knee pain, which doesn’t fully address the patient’s symptoms.
The confirmation necessary for a full medical diagnosis will come from an imaging procedure allowing the specialist to see the soft tissues, either an MRI or an ultrasound scan.

It is not necessary to visit your local hospital for a suspicion of Hoffa’s syndrome symptoms. Visiting your GP or a specialist consultant (physiotherapist or osteopath for example) can bring you clarity regarding your symptoms and offer an efficient guidance for the next steps to take in your management and treatment.

If hoffa’s fat pad syndrome has been present for six weeks or more, you will need some assistance. Some people give up their hobbies and past-times and it settles within a few months of rest, however it comes back when they return to their sports. It’s best to stop doing any activities that make the pain worse. This might mean not standing for too long, being aware not to overextend your knee, and taking a break from doing any sports that usually make your pain worse.

In the treatment of Hoffa’s syndrome, there are two phases: firstly, you need to calm the inflammation symptoms and pain; then you need to stop the cause of the inflammation, which is the pinching and compression of the fat pad.

The list belows offers options to help achieve both components of the rehabilitation process.

RICE – This simple home treatment can help with reducing pain and inflammation around the knee. RICE stands for rest, ice, compression and elevation.

Medication – your GP may suggest taking non-steroidal anti-inflammatory (NSAIDs) medication to help with reducing pain levels and inflammation. Examples of NSAIDs include ibuprofen. Sometimes an anti-inflammatory injection can be recommended by the GP, to be performed with imaging guidance.

Activity Change – refraining from doing the exercise that is aggravating your knee will help with reducing pain levels and recovery time. The most beneficial is to switch out high impact activities with low impact exercises such as swimming or the stationary bike. High impact exercises can then be slowly reintroduced as your knee pain improves.

Exercise prescription – A tailored program designed by a professional physiotherapist or osteopath can be used to help strengthen the muscles surrounding the knee joint and stabilise both the knee and foot of the affected side.

Osteopathy and Physiotherapy – Hands on physical therapy can be used to help assess and treat areas of weakness and instability within the knee joint complex. A treatment plan can then be put in place to help enhance and improve strength, mobility and function helping with pain reduction. Many different techniques may be used to do this, including: joint mobilisation and articulation, soft tissue release and guided exercise prescription.

Surgery is usually not recommended in this treatment process, as most if not all the inflammation can be addressed with conservative changes.

Because Hoffa’s fat pad inflammation isn’t always immediately caused as the result of a traumatic injury but tends to build up over time, it is important to understand how to prevent these symptoms from happening.

There is a group of predisposing factors leading to the occurrence of Hoffa’s syndrome. For example, suffering of or recovering from an ACL injury will lead to an instability of the knee, which will cause stress on Hoffa’s fat pad and inflammation.
Building strength in your muscles attaching to and surrounding your knee helps stabilize the kneecap (or patella) and avoids patellar maltracking. Reinforcing stability on your feet and ankles will also contribute to an overall balance and functional stability reducing the chances of occurrence of Hoffa’s syndrome.

The exercises* below are designed to help with the recovery from Hoffa’s syndrome. The aim of the exercises are to stabilise the affected knee, strengthen the muscles surrounding and stabilising the knee and help staying active even during the acute phase of the symptom presentation.

Here are 3 example of useful exercises:

Isometric wall sits: (this exercise can be done at any stage of the recovery), consisting of placing your back, straight, against a wall, with your knees and hips bent approximately around 120 degrees (mild flexion to avoid putting too much weight on the injured knee at a too early stage). Slowly raise the “healthy leg” off the floor to only have your injured side weight bearing, and hold the position for 10-15 seconds. This exercise can be repeated 3 times. The aim is to keep the whole foot on the ground at all times of the exercise and keep it stable. Early in the process of recovery, the leg can be found shaking: it is normal and will eventually stabilise over the weeks as the muscles get stronger.

Wobble board stability: basic exercise consisting of standing, one leg at a time, on a wobble board, with the knee of the leg on the board mildly bent (to unlock the knee joint and make the muscles work more efficiently). Ensure to find your stability, resisting the collapsing of the ankle inwards, or the body weight shift towards the outside, and keeping the big toe involved on the platform at all times. Can be done every 2 days, aiming to work on each leg for approximately 10 mins in total, with an extra 5 mins focus on the “weaker”, affected leg.

Hamstrings curl: lying on your stomach, with your legs fully extended flat on the floor. Bring your heel towards the buttocks, one foot at a time, while maintaining a flexion of your foot in order to only activate the hamstrings (position of dorsiflexion of the ankle). Slowly bring your leg down to the floor in a controlled manner. This exercise can be repeated 10 times for each side, for 2-3 sets. You can add more loading into the hamstrings by attaching an elastic band to your ankle creating a traction effect in the opposite direction of the movement you are performing. The aim of the exercise is to activate and strengthen the hamstrings to take away some of the potential imbalance in the leg muscles activation (quadriceps overdominant on the hamstrings, which means the movement of knee extension, prone to irritating the fat pad, will be dominating over the knee flexion).

*It is recommended to get the go ahead from your physical therapist or GP before carrying out any of these exercises.