Hoffa’s/Infrapatellar Fat Pad Impingement

Normal Anatomy Fibrous frame/scaffold packed with adipose tissue. Separates the anterior inferior synovial membrane from more anterior structures of the knee. Is intra articular but extra- synovial. Deformable space filler that adapts to changing contours of the knee during movement. Helps in the lubrication and distribution of synovial fluid.

Mechanism of Injury Traumatic – Direct compression to anterior aspect of the knee – Hyperextending the knee in kicking or kicking off the wall when turning in swimming – Damage following arthroscopic surgery Insidious – Excessive hyperextension – Anterior pelvic tilt – Posterior tilting of patella

Associated Pathologies Patella Mal-tracking Patellofemoral Pain Syndrome Patella Tendinopathy

Subjective Females more commonly than males Sharp or burning pain in the infra patella region Traumatic compression or biomechanical overload Pain on walking, prolonged standing or stairs Prolonged static flexion Wearing high heel shoes Activities involving hyperextension of the knee or increased anterior pelvic tilt

Objective Hyperextension in standing Anterior pelvic tilt Superior patella Posteriorly tilted patella Swelling around inferior pole Reduced and painful knee extension if acute Pain with quadriceps contraction Pain with force knee extension Any quads contraction in extension/hyper extension will exacerbate pain. Pain palpation infrapatella region and fat pad Anterior tilting of the inferior pole of patella will help relieve symptoms

Special Tests Hoffa’s Test Supine with the clients knee in flexion. Palpate under the patella either side of the patella tendon. Then ask the client to actively extend/straighten their knee. If pain Is reproduced or there is apprehension of movement then this is seen as a positive test of fat pad irritation.

Further Investigation MRI

Management Nearly always conservatively managed Chronic cases more difficult to manage Must correct underlying issue

Conservative - Management Rest from aggravating activities Correct biomechanical dysfunctions Stage 1 – Restore Normal Mobility – Anti- Inflammatory Modalities (Ice, NSAID’s, Massage) – Decrease tone of quadriceps/rectus femoris (Soft Tissue Techniques) – Encourage anterior tilt and global gliding of patella (Joint Mobilisations, Taping) Stage 2 – Restore Normal Motor Control and Strength – Quadriceps strengthening in a pain free range Avoid hyperextension or any positions that will irritate the fat pad Stage 3 – Dynamic Stability – Exercises to improve proprioception at the knee and entire kinetic chain Stage 4 – Return to Sport Rehabilitation

Plan B - Management Injection Local anaesthetic Corticosteroid Surgery Fat Pad Excision Debridement Anterior Interval Release Denervation of the Inferior Pole of the Patella