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Infrapatella fat pad impingement, sometimes referred to as Hoffa Syndrome, is a common knee dysfunction condition that causes anterior knee discomfort. It can be the cause of pain in cases of knee osteoarthritis and pain in the anteromedial knee.
Due to its position within the knee, Infrapatella fat pad impingement is frequently misdiagnosed as patella tendinitis or patella femoral pain syndrome. However, there are a number of symptoms unique to Infrapatella fat pad impingement, which can help with accurate diagnosis of the condition.
Once diagnosed, the condition is usually quite easy to treat. However, to prevent reoccurrence, it is important that causal factors are also identified and managed. Effective treatment includes physiotherapy such as strengthening and local muscle flexibility exercises, local cryotherapy and taping. Symptoms can also be reduced with the correction of lower limb biomechanics.
Direct trauma or gradual wear and tear to the anterior knee can result in the fat pad becoming irritated. This can happen due to posterior tilting of the inferior patella pole and subsequent impingement of the fat pad. One of the most common causes of this is the combination of knee hyperextension and anterior hip rotation. Here the fat pad can become squashed between the quad tendon, patella, tibia and femur. Inflammation and swelling is the result of recurrent episodes, and a vicious cycle of impingement and irritation can begin.
Anyone can be affected by infrapatella impingement. However, people who take part in sports and other activities that put them at risk of a blow to the knee, such as hockey, football and rugby, are more likely to suffer kneecap pain as a result of the condition. Runners are also at an increased risk, especially those with excessive pronation.
The patient may present with restricted range of movement and sharp infrapatella pain that is either chronic or acute. They may also complain of pain during or following any activity involving full knee extension, such as walking, wearing high-heeled shoes and standing for any length of time. Pain may be intensified when climbing stairs or squatting.
Examination will reveal obvious puffiness and swelling of the infrapatella. The area is also likely to be tender to the touch.
Patients typically report reduced pain when the patella’s inferior pole is lifted up and separated from the fat pad by posteriorly manipulating the patella’s superior border. The resulting seesaw effect will minimise direct pressure on the fat pad and symptoms will be relieved.
The knee will be predisposed to Infrapatella fat pad impingement where there is excessive hyperextension. High heels can also cause an anterior pelvic tilt, which can shorten the quadriceps and push the knee into a hyperextended position. Tight quadriceps will move the patella superiorly, in turn posteriorly tilting the inferior pole. A taut patella tendon will increase any posterior displacement, especially if the patient has a pre-existing tendinopathy of the patella. In addition to anterior pelvic tilt and tight quadriceps, genu recurvatum can also create a predisposition for Infrapatella fat pad impingement.
Because of its location, Infrapatella fat pad impingement can often be mistaken for conditions such as patella tendinopathy. Perhaps one of the main differences is seen when a patella tendon band is worn. This will bring relief for those with patella tendinopathy but will actually increase the pain felt as a result of Infrapatella fat pad impingement.
A useful test for diagnosing Infrapatella fat pad impingement (Hoffa’s Test) involves palpation of the infrapatella alongside contraction of the quadriceps muscle. If irritation is present, pain may diminish as a result of the reduced access to the fat pad and patella tendinitis can be ruled out.
X-rays, MRI and tissue biopsies can also be used to assist diagnosis.
Treatment for Infrapatella fat pad impingement begins with addressing the inflammation and swelling. Rest is recommended initially, and applying ice to the area for between 15 and 20 minutes two to three times each day can help. This can be especially useful later in the day when kneecap pain and swelling will be at its worst. Bracing the knee to provide some support and keep it as rested as possible is often advised in the early stages. Over-the-counter anti-inflammatory pain medication may also be recommended. Some people benefit from a steroid injection to the swelling site.
Therapeutic ultrasound and iontophoresis with anti-inflammatory gel can also work to reduce swelling. As the swelling goes down, management of the condition becomes easier as the cycle of recurrent impingement is broken.
Impingement can be prevented through taping. The technique offloads the fat pad by lifting the inferior pole. The lateral and medial border of the patella is lifted up diagonally to support the patella superiorly. The inferior pole is then tilted away from the fat pad by taping horizontally across the superior border. The fat pad can then be given chance to heal. Taping of this nature should enable the patient to retain functional movement, but it will restrict the range of movement they are able to achieve. Rigid or the more elasticated Kinesio tapes may be used depending on the individual case.
Preventing excessive hyperextension with the use of tape can also be helpful to reduce symptoms, particularly during the acute phase.
Stretching exercises for the rectus femoris can work to counteract both knee hyperextension and pelvic tilt. In addition to these, myofascial release techniques can be used on the patella tendon and the quadriceps to offload the inferior pole and loosen some of the connective tissues that are not effectively released through stretching on its own.
It is important to then progressively strengthen the quadriceps, with particular focus on coordination and muscle control. This will reduce hyperextension and provide some mechanical support for the knee while helping with patella tracking.
Surgery may be an option for those with severe signs and symptoms who fail to respond to non-invasive treatments. This may involve removal or partial removal of the fat pad. This procedure is typically carried out using keyhole arthroscopy techniques. The surgeon will access the kneecap via two small holes on either side of it. They will use a keyhole camera to identify the problem, and using a miniature, motorised shaver can remove all or part of the impinged fat pad. Most patients recover within six weeks of the procedure.
Patients are advised to take a few preventive measures to avoid a relapse of the condition.
It is also important to address biomechanical factors alongside treating the inflammation and introducing techniques for patella realignment. Practitioners will usually recommend avoiding high heels as these encourage the knee hyperextension and anterior pelvic tilt.
Kneecap pain can alter the motor control of quadriceps when descending and ascending steps. This lack of stability will result in an increased load on the knee joint. Therefore, stability training should be included as part of quadriceps strength training with the aim of improving control and coordination.
Recovery time for infrapatella fat pad impingement can vary considerably from individual to individual. Recovery is dependent on a variety of factors and can take several months.
When medical advice is sought early, prognosis is generally very positive. When there has been an injury to the knee joint, intense physical activity should be avoided until a complete recovery has been made. Failure to seek proper treatment can lead to complications such as joint damage and prolonged pain.
The primary treatment of patella fat pad impingement predominantly revolves around allowing the fat pad to settle with local application of cold (ice packs etc). Physiotherapy can also be useful to help allow it to settle. It is possible to use a brace that reduces the likelihood of hyperextending the knee (the knee going backwards). It is advisable to have this done under the supervision of a Physio however.
It is important to be careful that you don’t compress the area too much as this could also potentially cause problems.