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Fat Pad Impingement (knee)


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#1 cjr

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Posted 21 November 2008 - 08:32 AM

After years of "runners knee" type mild knee pain (enough to severely limit my running, but not to stop) and on and off physio I finally bit the bullet and decided to see a sports doctor, who suspected patella tendonosis and sent me for an MRI.

The MRI found everythign was fine, except that my Hoffa's fat pad was enlarged with "an increased bulk of fat extendin into the intercondylar notch....which may be causing impingement syndrome". I also have some joint effusion, which may be a result of this

I have basically been given 4 options

1. Keep going with physio, which "may" help
2. A cortisone injection into the fat pad
3. A routine arthroscopy to "clean it all up"  
4. Do nothing and stop running

I am interested to hear from anyone else who has been diagnosed with this, and what you did

Thanks

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#2 Steve 'The Footman'

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Posted 21 November 2008 - 09:49 AM

You need to make a decision on the likely risks and benefits as well as the cost and rehab time.  You really need to take the advice of the sports physician in that regard.  

There is usually a ladder of treatment options that you take.  The least invasive is the Physio treatment but seeing that you have done that for years and it has not resolved the problem then that is likely to continue to be the case.  The fat pad itself responds well to anti-inflammatory treatment.  You might try topical voltaren gel and icing for a few weeks and see if that helps with symptoms.  The end stage of that option is a corticosteroid injection.  Considering the duration of the problem this should be a serious consideration before trying surgery.  If you do eventuually go the surgery route then you need to grill the surgeon on:
1.  What technique he will use.
2.  The likely prognosis afterwards
3.  How many of these operations he has done
4.  What is his success rate.

The final option of course (not running) is not an option.

#3 cjr

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Posted 21 November 2008 - 03:49 PM

Thanks for the reply, Steve

The initial results were given over the phone - I have a proper consult next week so will hopefully have some more discussion of the options. I am not at all keen on the surgery since a friend had a "routine procedure" and 6  months later is still limping after being told he would be fine 6 weeks after the op.

Edited by cjr, 21 November 2008 - 03:52 PM.


#4 tank girl

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Posted 25 November 2008 - 12:56 PM

I had a fat pad impingement late last year. After ramping up my training for Western States, I had slight discomfort, but then I trained and raced while still recovering from the flu and it flared up badly.  (I put this down to a combination of immune issues and fatigue-induced poor technique).  I took a little bit of time off and used voltaren but when I started up again so did the problem, which made me cancel some planned summer events.  I had a forced break from running early this year after I broke my foot; since my return to running (around September), I haven't had a recurrence.  Although the option of not running is not an option (to paraphrase Steve), sometimes it's worth considering.  I'll always sacrifice a few months of running now to ensure I will still be running well into my 90s ;)

#5 Quinkin

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Posted 25 November 2008 - 08:12 PM

I have had a maltracking patella for three years. I have found McConnel taping (with fat pad unloading) + exercises glute/quad exercises have helped. At times in this injury the fat pad was quite puffy.

I have had several physios and one chiroprator suggest I need surgery. I think these people where just out of ideas.

What I did was shop around for a sports physician and physio who knew knees.

Fortunately the sports physician and physio who cautioned surgery as a last resort are the ones who have helped my condition.

This physio has been so helpful that I have been able to run for the first time in 22 years. It's a shame it took me so long to get physio that really worked. I might've had a longer running career.

I have found the hard way that there is effective and ineffective physio for knee problems. My knee was so stuffed by the ineffective physio that it has taken nearly two years to rebulid my wasted VMO.

Surgery or not you need to fix any biomechanical issues with PT.

Edited by Quinkin, 25 November 2008 - 08:25 PM.


#6 kskillern

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Posted 27 July 2009 - 09:13 AM

I see this posting was a while back, so if there's anyone out there listening/reading, can you help?

Has anyone been diagnosed with chronic Hoffa's Disease/fat pad impingement??  I have had this chronically for 15 years, with a major flare-up when it first started 15 years ago, and then now again recently.  To top it off, I live in the U.S. and it is almost impossible to find anyone here that recognizes it as a legitimate condition.  They just basically deny that the fat pads can be a true source of pain.

Long story short, I've tried everything and am now getting ready to try a treatment that I discovered online, used in London.  This treatment is ultrasound-guided alcohol ablation directly into the fat pads.  I have not yet tried cortisone injections into the fat pads, but my guess is that this is only a temporary fix.  I think my last option of surgery to remove or trim the fat pads.

Is there anyone out there who has had any good, permanent results from any kinds of treatment???
Help!!!!

#7 cjr

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Posted 27 July 2009 - 09:35 AM

View Postkskillern, on Jul 27 2009, 09:13 AM, said:

I see this posting was a while back, so if there's anyone out there listening/reading, can you help?

Has anyone been diagnosed with chronic Hoffa's Disease/fat pad impingement??  I have had this chronically for 15 years, with a major flare-up when it first started 15 years ago, and then now again recently.  To top it off, I live in the U.S. and it is almost impossible to find anyone here that recognizes it as a legitimate condition.  They just basically deny that the fat pads can be a true source of pain.

Long story short, I've tried everything and am now getting ready to try a treatment that I discovered online, used in London.  This treatment is ultrasound-guided alcohol ablation directly into the fat pads.  I have not yet tried cortisone injections into the fat pads, but my guess is that this is only a temporary fix.  I think my last option of surgery to remove or trim the fat pads.

Is there anyone out there who has had any good, permanent results from any kinds of treatment???
Help!!!!

After starting this thread I got a cortisone injection into the fat pad. It was really sore for the next few weeks but then made a dramatic improvement. I kept running and was waitign for the Cortisone to wear off, but it didn't and I ran the Great Ocean Road marathon in May. The knee is now not quite 100% but is pretty close and heaps better than ever before - the cortsone shot was a definite turning point. I am planning on running another marathon this year

So I can say that the cortisone really made a long term difference to me. When I was deciding whether to have it everyone I asked said pretty much the same thing - for $100 you have nothing to lose. At worst it will do nothing - at best it will help, so may as well try.

Mine was not nearly as bad as yours sounds though. Good luck!

#8 kskillern

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Posted 30 July 2009 - 03:08 AM

View Postcjr, on Jul 26 2009, 04:35 PM, said:

After starting this thread I got a cortisone injection into the fat pad. It was really sore for the next few weeks but then made a dramatic improvement. I kept running and was waitign for the Cortisone to wear off, but it didn't and I ran the Great Ocean Road marathon in May. The knee is now not quite 100% but is pretty close and heaps better than ever before - the cortsone shot was a definite turning point. I am planning on running another marathon this year

So I can say that the cortisone really made a long term difference to me. When I was deciding whether to have it everyone I asked said pretty much the same thing - for $100 you have nothing to lose. At worst it will do nothing - at best it will help, so may as well try.

Mine was not nearly as bad as yours sounds though. Good luck!



Dear CJR,

Thank you so much for responding!!!  I can't tell you what a relief it is to me to converse with someone else who has this condition.  It is so much more recognized and treated in the U.K. than the U.S.  I don't know why that is.  Tomorrow I see the interventional radiologist at the local pain center/clinic.  He has been looking into this alcohol ablation that is used at the London Pain Center.  I will know a lot more after tomorrow.  You mentioned your cortisone injections went into the fat pads.  Was this ultrasound-guided???  I am going to ask him tomorrow if I should try the cortisone first before the alcohol ablation.  I also want to find out if the ablation actually gets rid of or shrinks the fat pads, or just kills the nerve endings.  This is still the treatment that is used for this condition at London Pain Center.  This condition has just put the kibosh on so many athletic activities for me for the last 15 years.  I used to be involved in all kinds of athletics, not anything serious, but jogging, tennis, aerobics, skiing, etc.  I would love to be out of pain for good.  Acupuncture is what finally helped me after the first flare-up 15 years ago.  They had tried everything, McConnell taping, physiotherapy, orthotics, finally arthroscopic surgery to take a look around.  The orthopedic surgeon found nothing, but he was not looking at the fat pads at all, and never considered them to be the source of my pain, even though I asked him whether the fact that I had stood very hyperextended all my life, and this was now causing the pain.  My fat pads were also bulging, which could not be more obvious to me than 1 + 1 = 2.  When he finally sent me to P.T. they are the ones who produced an article for me on fat pad irritation, that described me to a "T".  Then I finally got in to see another knee specialist who completely ignored this article that I brought with me.  He suggested I go to acupuncture, which I did because I was at wits end.  That brought my pain from 8/10 pain scale, to a livable 2/10, that I've lived with for 15 years.  Anyway, this is my long story.  I will let you know what I find out tomorrow.  If you have any more to add, please let me know.  In the mean time, you can definitely use the rigid tape to pull your patella (kneecap) up and away from the fat pad at least while you run.  Have you tried this?  It will remove the pain immediately, and keep you from irritating the pads further in activities that irritate, such as maybe running, etc.

Karen

#9 cjr

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Posted 04 August 2009 - 02:24 PM

Hi Karen

It sounds like my experiences are a fraction of yours. I would never even have regarded it as pain, only really discomfort and only after a long run. If I stopped running for a few months it would go away. Of course the easy solution would have been to stop running, but that was never really an option for me and I just put up with it for years - as long as I onlt ran a couple of times a week and not more than 10kms I could live with it. I had seen the odd physio over the years, and it has always been diagnosed as runners knee and I had been given the usual strengthening and stretching exercises, which never really seemed to help.
This year I decied to run another marathon and as part of the process decided to invest some money and have a last real effort at gettign it sorted and went to see another physio who was highly recommended (and expensive!). After several more months of exercises etc with no real results she recommended seeing a good sports doctor, and teh first thing he did was send me for an MRI. Even then, the fat pad diagnosis was not conclusive as I don't think it was too severe. He suggested the cortosone as he said if it was the fad pad one or 2 injections would shrink it permanently. He just did it with me sitting in the chair in his office, although he poked around quite a bit with the needle under my kneecap.

As I said above, it got a lot worse before it started feeling better, and is still not 100%, but pretty close and I am able to run 40kms a week now without major discomfort.

I don't even really know if it was the cortosone that made the difference as I have also made several other changes around the same time, incl different shoes, takling high dose of glucosamine and also changing my running style.

So I don't know if this is going to be of any help to you. As I said above, everyone I consulted re the cortosone said that I had nothing to lose so it was worth a shot.

Best of luck

#10 kskillern

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Posted 04 August 2009 - 03:24 PM

Hi CJR,

Thanks for the response.  I am trying very hard to make an educated decision.  My absolute only problem with my knee (now both knees), is the enlarged inflamed fat pads.  I surely don't want to complicate this, and as I read about so many post-surgery stories, that definitely concerns me.  

I have attached for you the full article on this alcohol ablation for the fat pads.  Please let me know what you think.

My pain doctor, an interventional radiologist at the local pain center here, thinks it sounds really good, and he's ready, willing and able to give it a go.  I was also, a few weeks back, when I was in excruciating pain after my first real flare-up in 15 years.  But I have been going for acupuncture, and now taping it up, and starting to do my own phys therapy as I do know what to do after living with it for so long.  And so now, my pain is not too bad, my VMO is building up again and so.... after the wisdom of many counselors I think I may really try the conservative route first.

I have never had an injection of cortisone directly into the fat pad.  I think I may try that first, and maybe a few PT sessions, just to see if they can offer any more advice than what I've already obtained.

Then if that all doesn't bring my pain down to a good tolerable level, I may just go ahead and try this alcohol ablation.  I did speak to them at the London Pain Center, and they told me they are still using this treatment for fat pad impingement/irritation, but they don't see it that often.  I definitely have a true, classic case of chronic irritation (not from trauma).

What concerns me about this ablation is that it definitely does shrink the tissue down, which is a great thing, but it will be replaced with a fibrous scar-like tissue.  And fibrous tissue in the knee is usually not a good thing - a common cause of pain.  But I guess that since the alcohol kills the nerves as well, you just don't feel any pain.  So fat pads smaller, nerves killed, that all sounds like 1+1=2.  What do you think?  I wonder if there is anyone out there who's had it and will read these blogs and give us their long-term results.  That would be incredibly awesome!

Karen

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#11 Em00

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Posted 04 August 2009 - 04:53 PM

I'm reading this thread with great interest- I've had fat pad impingement in my right knee for about 3 months now. It was first misdiagnosed as an inflammed bursa by both my physio and then sports doctor. I had 3 cortison injections which did not seem to help. I then had an MRI to get an accurate diagnoses of the problem. I am not running at the moment, I'm finding that I can walk and hike all day with little problem, although I am in a small amount of discomfort almost all of the time, but as soon as I start to run it is very painful. I really want to get back into running but certainly don't want to make it worse.
I'm interesting to know if anyone has found that taping works and what type of taping?
Goodluck with your decision Karen.
Em.

#12 kskillern

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Posted 05 August 2009 - 04:27 AM

Hi Em,

I can very much relate.  I've lived with this condition chronically for 15 years, say 2/10 on a pain scale.  When it flares up, which really has happened only once recently aside from when it started 15 years ago, my pain is about 8/10.  Very painful.

I can testify that the taping is a lifesaver with this condition.  It really is the ONLY way to get rid of inflammation when it comes to treating this conservatively.  If you don't tape while in an inflammatory flare-up, you just keep irritating it and causing more inflammation, especially with prolonged standing (not moving).  

Here's what I can offer for the taping that works best for me.  Others may give you different advice, and you'll eventually find what works best for you:

I purchase this rigid tape at the local sporting goods store.  There is also more breathable tape (Hypafix is one you can find online), to put under the rigid tape to protect your skin.  I am just using the rigid and my skin is getting used to it.  It's kind of a hassle, that's why I just use the one.

Anyway, you can go to a physical therapist to show you some ways but ultimately you can play with it yourself and see what feels best.  The tape must relieve the pain and not cause any other kneecap pain when it's applied right. If you walk and feel any pain, you have to retape.  You will know when it's taped right for your pain location.  You will immediately feel that you will be able to contract your VMO (innermost) quad muscle which is very painful to engage with this condition.  I've found for me that it's best to apply while standing up.  

I tape starting at the top of my kneecap, and in the middle, and then I yank it way over to the inside underside of my thigh, bunching up the skin underneath.  What this is doing is pulling the kneecap up and away from the lateral outside portion of the fat pad, because for me that's where my pain is.  This gets the kneecap mostly off of the fat pad, and gives it a chance for the inflammation to go away.  

Also, at the end of the day, it's best to prop your legs up (above the level of your heart), and put ice on them.  Then I think if you tape everyday from the time you get up till you go to bed for maybe a few weeks, you should start to see some great relief.  It's just a really long process for the inflammation to go down with this condition, I think because just weight-bearing continues to inflame.

Then once the inflammation (pain) is mostly gone, you should then try to start building up your VMO and gluts.  I've found you have to get the inlammation down before starting any kind of rehab or tweaking of the way you walk and stand (this is definitely a biomechanical problem in the absence of any trauma).

Long story, huh?  But I hope this helps you.  I know it is an extremely painful, frustrating condition.  I can completely relate to your pain.  You probably should be taking ibuprofen (at least 600 mg. around 3 times per day with food to protect your stomach) while in an inflammatory flare-up.

I don't know what to do about the chronic pain.  I have just learned to live with that.  I've had to reduce my exercise to mainly walking and I'm going to schedule a visit for PT to find out what kind of weight training I can do with my quads because I love it and it keeps me toned up.  Swimming is also good I've found.  The pain center told me definitely do not run on a treadmill as this is the worst.  They said first dirt/grass, then gravel, then blacktop, then the worst is treadmill.

I think I'm going to try the cortisone injection directly into the fat pad.  I've only had one corisone injection 15 years ago, but it went into the joint capsule, not into the fat pad.  I am so curious and intrigued by this alcohol ablation (did you read the attachement above?), but I am going to wait on that and keep trying more conservative methods.  I think I would definitely try it before surgery, though.  Don't like the idea of that at all - very much last final resort.

Please let me know how it goes for you.  My prayers are with you!

Blessings,
Karen

#13 Em00

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Posted 05 August 2009 - 10:02 PM

Thanks for your informative reply Karen!
I will give the taping a go as you suggested and I plan to see my physio in the next few weeks to see if I'm doing it correctly.
My sports doctor has had me on a few different anti-inflammatories over the last few months but I've stopped taking them now as I don't really like the idea of taking them for so long and they didn't seem to be doing anything (that I could tell anyway). I also ice my knee religiously everyday. My doctor suggested that if it's no good in a couple of months that we look at surgery but I would rather not go down that path if I can help it.
I did read the attachment on the Alcohol Ablation, it certainly sounds interesting.
Thanks again for your advice and I hope that things start to look up for you as well.  
Let me know how things go and if you decide to try the Alcohol Ablation.
Cheers,
Em.

#14 DPT

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Posted 05 August 2009 - 10:09 PM

Hi Em,

Was having a quick look at the site and saw your post, so had to sign up and respond.

Firstly, fat pad impingement/Hoffa's syndrome can sometimes be difficult to diagnose without imaging.  Occasionally it's blatantly obvious (if you're looking out for it), but other times it can closely mimic patellar tendinopathy or patellofemoral pain syndrome.

Once diagnosed, we usually manage it using a stepwise approach:

1) Physio (the problem here is that there are Physios and there are Physios) - hope I don't get in trouble for saying that.  I still get patients coming to me who have been seriously mismanaged with aggressive and incorrect exercises such as leg extensions or straight-leg raises.  Our data suggests that 4 out of 5 patients will return to previous levels of function with sound conservative treatment (and perseverance.)

     - most fat pad impingements are largely biomechanical in either "origin" or "propagation", so they respond well to a good assessment and correction of any contributing biomechanical factors.  Things like internal rotation of your femur, poor buttock control, inside quadricep timing dysfunction, and a tendency to hyperextend the knee in weight-bearing.  On this point, you should definitely have your running mechanics analysed, as you may be able to make some simple changes to your style that decrease the degree of impingement.

     - unloading is very important, and is usually achieved quite effectively with taping that includes a fat pad "lift" component.  

     - a fairly aggressive avoidance of the activities that cause pain is also important.  Because the fat pad has a lot of blood vessels supplying it, ongoing impingement will cause it to "puff up" and pinch some more.  Ultimately, if this continues for long enough, the fat pad tissue changes and becomes scarred and fibrous.  This is generally not a great scenario, and makes things difficult for the physio, the sports doc, the orthopaedic surgeon, and most of all, the poor patient.  


2) Cortisone injection

     - cortisone is catabolic, so it breaks down or shrinks the tissue it comes in contact with.  It can be quite useful for a true fat pad impingement that is not responding to good physio treatment.  There are few potential side effects when performed by a good sports doctor, however, one that the docs frequently forget to mention is that it can cause a slight discolouration of the skin around the injection site.  As most patients with fat pad impingement are female (not saying that guys don't care what their legs look like!), this can be an important consideration.


3) Partial fat pad excision

     - pretty much an absolute last resort.  That being said, a study presented in the journal Arthroscopy a couple of years ago suggests about 90% of patients with isolated fat pad impingement (i.e. no other issues), will have a good to excellent result.  I'd read that number with caution though, as many of their patients were quite acute and probably would have responded to good conservative management also.  There was no control in the study.


Anyway, I hope that helps in some strange way...

Generally, we do very well with conservative management, so find a good physio (if you haven't already) and hang in there!

All the best.

#15 kskillern

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Posted 06 August 2009 - 08:11 AM

Dear DPT,

Thank you so much!  That was the most advice I've EVER heard on this apparently rare, or should I say rarely diagnosed correctly, condition!  In other words, your advice is GOLD!

Can you tell us more?  For instance,

1.  How long can we expect to be in pain once a flare-up starts? (i.e. weeks, months, etc.)

2.  Are there any machines we can use to help build up the quads, as you mentioned no leg extensions?  How about leg press, just to the point of not straightening to take care not to hyperextend?

3.  What happens if you end up with fibrous scar tissue in the pads?  

I know that I have it as my MRI revealed fibrous scar tissue and edema in the Hoffa pad.  I've been living with this condition at a pain level of say chronic 1/10 pain scale for 15 years.  Only one knee.  But I recently started a 12-week fitness challenge (with a lot of fairly heavy leg extensions which I thought would benefit me), and have had a flare-up in both knees now.  I'm hoping the other knee does not end up with scar tissue.

4.  Do you recommend cortisone injections then?  I have never had one directly into the fat pad.

5.  Do the corisone injections actually shrink the fat pads permanently?  I could care less about skin discoloration - wouldn't care if it stayed bright purple - just get me out of this pain!

6.  If they do cortisone injection, does it hurt to use fluoroscopy-guided, or should they just use ultrasound-guided?  Everything I've read said just ultrasound-guided, but my local pain center said they also like to use fluoroscopy.  Do you think the dye could further injure the fatty tissue??

7.  Did you by any chance read the journal article on alcohol ablation of the fat pads being used in London on my email above (see attachment under my name)?  What are your thoughts on that?
I called the London Pain Center and they told me it is still the treatment they use when they see this condition, but that they don't see it too often.  But it says a lot that that is still their treatment of choice with fat pad impingement.

I was all set to try the alcohol ablation, but I thought I'd try the corisone first.  I do have an appointment with a ortho specialist at the University of Washington who specializes in non-surgical treatment on Aug. 21.  I did email him the article on alcohol ablation so he could take a look at it before I see him.  I hope that he recognizes this condition and that I won't be wasting my time, and getting my hopes up...

8.  I know my condition is of biomechanical origin.  Fifteen years ago when it started I'd always stood very hyperextended and my knee was sort of locking in hyperextension, and I started having a lot of pain.  I ran at the time, too.  My ortho doc then said the way I stood had nothing to do with my pain, although he shook his head after trying everything he knew, and told me he couldn't figure it out.  But he continued to tell me that the way I stood had nothing to do with it.  It wasn't until he sent me to PT that they produced an article on fat pad irritation that described me to a "T".  I am the classic case of Hoffa's Disease.  

My question is that I haven't stood that way, don't anymore, but after my latest fitness challenge they've flared up.   Do you think it was from the approx. 70-lb. leg extensions I was doing????  I was also doing squats and lunges, and a tiny bit of jogging on the treadmill.

9.  Do you think my pain will go away with conservative treatment??

I don't know if it's kosher on this website to call (I'm new), but is it possible to call you?  I just have so many questions.  Everything I've learned, I've learned from hours and hours and hours of searching online everything I could find, which really isn't a lot.  ...

Your expert advice and knowlege of this rare (?) painful condition is soooooooooooo appreciated!!!

Thank you in advance,
Karen

#16 tank girl

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Posted 06 August 2009 - 10:18 PM

Hi Karen, I avoid leg extensions unless I'm trying to balance out a very specific problem. I don't think it's beneficial for runners to attempt to strengthen the quads by straightening the knee in this position, because it's very different to the position we use in running. I think that step-up, squat and lunge  exercises are much more useful. I don't know if it would have caused the problem, though. I can't figure out what caused my fat pad impingement, but I suspect it was related to other activities I did, not just running.

#17 Em00

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Posted 07 August 2009 - 07:02 PM

DPT, thank you for your input.
I agree that it is difficult to diagnose, mine was misdiagnosed up until I had the MRI.
My knees hyperextend quite a lot so I do wonder if this plays a large part in my problems.
I found it interesting that you mentioned that cortisone can discolour the skin.. I didn't know that. I've had 3 injections into my knee for this problem, doesn't seem to have discoloured the skin although I do already have slightly scared skin over the area anyway due to a fall on my knee about 6 months ago! Not that I care what colour the skin is- I'm with you Karen, discoloured skin over knee problems any day.
Any further advice or instructions on taping? I can't get into see my physio for 2 weeks. I've been playing around with taping but really have no idea if I'm doing it correctly.
Cheers everyone for your info and advice.
Em.

#18 kskillern

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Posted 07 August 2009 - 07:31 PM

Hi Em,

I was wondering.  You said you had 3 cortisone injections when they thought it was your bursa sac, and then you were finally diagnosed properly after your MRI.  Did they inject the cortisone using imaging guidance (i.e. ultrasound, fluoroscopy, etc.) directly into the fat pad where it was inflamed?  It seems like this would make a big difference in the success of your cortisone injection treatment.

I hope DPT can respond back to you about the taping.  My method works for me, but you do have to be careful and not rub your kneecap wrong.  I've been taping heavily for a few weeks now, and now all of a sudden my patella tendons are sore.  I wonder if it's from my taping method.

You can't seem to win with this condition.  It's so hard to get rid of the inflammation.  Maybe if you stayed off your feet, kept them elevated and iced for a few weeks straight.  But who can realistically do that?

I am waiting on two expert opinions on the alcohol ablation.  I will inform you all what I hear back.  I want to be so careful not to complicate my seemingly simple injury.  I am horrified by the stories I read on this and the Kneeguru website from poor people who have been through so many surgeries to fix complications from what seemed like a fairly simple problem to begin with on the knee.  So scary to me.

Blessings to you,
Karen

#19 Em00

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Posted 07 August 2009 - 08:20 PM

Hi Karen,
Yes you are right- I did have the 3 cortisone injections before it was correctly diagnosed and therefore was injected for treatment of the bursa and with no imaging guidance. So I guess it would make sense that this may be a big reason that the injections were not helpful.
I'm going to do a long hike tomorrow and will try and tape it as you suggested for now and see how it goes.
To be honest apart from stopping running and other high impact activities I am still very active and do quite long and fast walks most days and long hikes normally once a week. I can't bare to not do any activity, I find it hard enough as it is not being able to run at the moment. I probably should have a break from all activity as I think I'm pretty much pushing my knee as far as I can without getting serious pain again, however I really can't see myself doing that though  :)
I'll be interested to hear the feedback you get on the alcohol ablation.
Cheers,
Em.

#20 kskillern

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Posted 08 August 2009 - 04:23 AM

Hi Em,

I've located some good articles on taping and fat pad unloading for you, including McConnell methods.  You'll have a pretty good understanding after reading them.  First one's long, so just copy and paste, but it's a great excerpt from a PT manual.

http://books.google....l...lt&resnum=1

http://www.clinicals...hapters/24e.htm

http://quinkin.wordp...cconell-taping/


Hope it helps and won't confuse you.

Blessings,
Karen

#21 kskillern

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Posted 08 August 2009 - 04:30 AM

Em,

On the first link, go to start at p. 194, but the actual picture of the taping is on p. 200.

On the last link, if you click on the picture of the taping at the bottom of the text, it will enlarge and you will get a good observation.

Karen

#22 Em00

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Posted 09 August 2009 - 04:23 PM

Karen,
Thank you for those links for the taping, it's much appreciated!
Em
:)

#23 kskillern

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Posted 11 August 2009 - 08:35 AM

Hi Em,

Definitely try the "V" McConnell method.  I went back to using it (haven't had to do it in 15 years!), and I am getting great relief!  

Karen

#24 era5678

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Posted 21 October 2009 - 08:40 AM

I know that these are older postings, but it has taken me this long to find this much information on fat pad impingement!  I am not a runner!  This is for my 15 year old daughter who is a softball pitcher and has been having issues with this since around August.  Her original injury was jumper's knee, which the doctor thinks was the cause of this fat pad issue.  She is terrified of getting a cortisone injection and pt has not helped at all.  Of course being 15, doing her PT is few and far between.  If anyone can tell me anything about cortisone injections, alcohol ablation(which they haven't hear of here in the US) or any other treatment.  Taping no longer works for her and she is doing PT for hip strengthening.  I hope I haven't hopped on here too late and I hope someone responds!

Thank you!!!

Charlene

#25 cjr

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Posted 21 October 2009 - 09:14 AM

As the original poster, I guess it is time for another update...

I ran the Melbourne Marathon last week, my second marathon of the year, and I guess I can now say (although I am probaly cursing myself by saying this) thay my knee is pretty much 100% now.
This time last year I thought I would never be able to run more than 5kms again after suffering worsening "runners knee" for many years.

I have changed a lot, including
-  changed to neutral shoe
- change running style and concentrate on good form (heelstrike to midfoot strike, although I think I have a way to go still)
- take glucosamine every day
- foam roller on ITB (altough I don't do that much now)
- quality rather than quantity in training (only run 3 times  a week, stick to 10% rule)

The turning point though was definitely the cortisone into the fat pad, although I am sure some or all of the above factors helped

#26 era5678

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Posted 21 October 2009 - 10:55 AM

View Postcjr, on Oct 21 2009, 07:59 AM, said:

As the original poster, I guess it is time for another update...

I ran the Melbourne Marathon last week, my second marathon of the year, and I guess I can now say (although I am probaly cursing myself by saying this) thay my knee is pretty much 100% now.
This time last year I thought I would never be able to run more than 5kms again after suffering worsening "runners knee" for many years.

I have changed a lot, including
-  changed to neutral shoe
- change running style and concentrate on good form (heelstrike to midfoot strike, although I think I have a way to go still)
- take glucosamine every day
- foam roller on ITB (altough I don't do that much now)
- quality rather than quantity in training (only run 3 times  a week, stick to 10% rule)

The turning point though was definitely the cortisone into the fat pad, although I am sure some or all of the above factors helped

Thank you for your update cjr!  I will let my daughter read your results.  She is very depressed about this whole situation and is freaking out about this injection if that's the way we decide to go.  How was your experience with the injection?  Was it painful or did they numb the area?  Even though she's not a runner, good form is so important to a pitcher also and as I said, she is doing hip strengtheneing exersices.  Any type of information you can give that would enable me to calm her down would be greatly appreciated.  She is talking about quitting softball and she is too good to give up that easily.

Thank you again for not only your response, but also for starting this thread!

Charlene

#27 cjr

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Posted 21 October 2009 - 01:17 PM

The injection was really not a big deal at all. The guy did it in sitting in a chair in his office The cortisone was mixed with a little local anasthetic, needle in below the kneecap, prodded around a bit, a few squirts in diferent places and finished. The whole thing took about a minute and was about as scary and painful as giving a blood sample. The knee ached for a week or two and then started getting better
Of course you need to have a doctor that knows what they are doing and can get it in the right place - I have heard it is better if done with an ultrasound machine to guide it, but I imagine that would cost a bit more. The guy who did mine was very experienced and said it was not necessary
The advice I had before from several sources was that there is nothinfg to lose by having one cortisone injection -  at best it would fix it , at worst it would do nothing and you would be $100 poorer.

#28 Em00

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Posted 21 October 2009 - 07:45 PM

CJR- It is fantatic to hear that you're doing well!
Things are also looking positive for me so I thought I would share what I believe has helped. My knee is definitely not 100% but it is much better. I was able to run an ultra marathon a few weeks ago with only little discomfort.
Things that I have tried and may have helped are:
-Glucosamine and fish oil daily (I really believe this was a main contributor, when I started with the Glucosamine is when I start to see improvements)
-A few months of walking only and still only mixing between walking and running at this stage
-Icing
-Stretching
-Massage around knee and legs and rolling ITB
-Anti Inflammatories- tablets and cream (Not sure of how effective these were)
-I had 3 cortisone injections but did not see any improvements after these

#29 kskillern

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Posted 31 October 2009 - 06:31 AM

Dear DPT,

Thank you again for your post.  It has been quite helpful for me.  

I just got through 6 weeks of physical therapy.  He mainly worked on strengthening the hip and gluteus medius, and I was really taking it easy and the only exercise I did was at PT each week.  I also worked on proprioception and hip stability.  I did leg presses and some balancing and squats on a squishy half-sphere.  For about 2 weeks toward the end I was having very minimal "fat pad pain".  It felt amazing since I've lived with fat pad pain for a very long time.  Then the last time he bumped it up quite a bit and I did leg presses, squats, and step-up/downs on a little step.  Then the next day I was in pain again, and then into another flare-up.  I was sooooo discouraged, and so was my PT.

So yesterday I went back to my orthopedic specialist at the University in Seattle, WA.  He gave me an injection of cortisone (ultrasound-guided), my first one.  He was very hesitant as he said that his biggest concern was rupturing the patellar tendon.

But what do you think?  Do you think if I have possibly another one or two cortisone injections, making sure to stay well away from the tendon by ultrasound, that this might actually shrink the fat pad?  

I am trying everything to avoid surgery.  Do you have any advice?  I would so appreciate it.

#30 snowshells

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Posted 19 March 2010 - 08:21 AM

This is an old thread… I'm hoping someone with fat pad issues is still around. It would be a huge relief to talk to other people with the same problem, it seems to be such a rare injury that I have had a hard time getting answers. Even the sports doctors have hardly ever seen it.

I've had this nasty problem for 2 years now. It started out with awful, red hot painful puffy knees, I could hardly walk more than 15min. Standing was extremely painful too. Now I'm infinitely better, and I'm quite functional, I can ride my bike hard, and xcountry ski etc. But I'm still not out of the woods, as they get flared up easily if I do a new activity, or if I do anything weight baring.  Running is still out of the question, that makes it flare up instantly. I take Advil to keep them under control, but I don't like having to do that as it is hard on the stomach.

I have a few questions if any of you are still out there?

  • I'm wondering if anyone has had surgery for this problem? I saw my knee surgeon a month ago, and he said Hoffa's Fat disease is very rare, and he's never had to do surgery for someone with the condition. Consequently he couldn't give me much idea as to the rate of success. Has anyone been cured by having part of their fat pad snipped away?
  • I'd also love any stories of hope. Has anyone fixed a chronic fat pad problem through muscle strengthening, and by correcting muscle imbalances? (without cortisone injections or surgery)
  • Has anyone found a good way to strengthen the VMO without aggravating this condition?
  • I've seen a number of posts on Taping. Did you leave your tape on all the time or just while trying to exercise or walk around?  I did try taping, but it seemed to just be another aggravator. It's hard to get the patella in the right place to accommodate a variety of activities.
Hoffa's fat pad  I find the stronger I get the better my knees get. Although it's tricky … You need to strengthen but not aggravate and that's very difficult sometimes.  Advil and Fish oil seems to help, as does sleeping with a pillow tucked behind my knees to keep them bent.  

Anybody still out there…?

#31 kskillern

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Posted 19 March 2010 - 02:25 PM

Yes, I'm still out here.  As a matter of fact, I just had surgery and am on week 8 of recovery.  I definitely had end-stage Hoffa's disease.  My surgeon removed almost the entire fat pad which had turned into total scar tissue and was impinged between the bones.  I also had a sheet of scar tissue around the area of the fat pad that was removed.  So he basically said it was an arthrofibrotic knee, meaning I had a lot of scar tissue (including the fat pad).  He said he'd never seen a situation like this that began from a fat pad irritation.  He's seen arthrofibrotic conditions like this on a small percentage of patients who've had ACL repairs.  And he's a great surgeon with many years' experience.  He took my word for it when he went into surgery, because I was convinced this was my problem.

Have you had an MRI?  This is the only conclusive test.  It will show scar tissue and inflammation in the infrapatellar fat pad if this is what you have.

I have had success with ultrasound, and have actually now purchased my own home portable one for a little more than $100.  I was going into physical therapy and only having this done when I was in a painful flareup.  No use using a PT session just for that when you can do it at home yourself.  I also have had success with acupuncture in the past, and now after surgery.  Before surgery, even the taping didn't help me.

Cortisone was a disaster for me.  The needle was jabbed around in the fat pad and I was in excruciating pain for weeks after.  Though I have to say my cortisone shots were done at a pain clinic and the doctor was not familiar with this condition.  He did use ultrasound to guide the needles.

It's a really tough call.  I'd say to get the MRI and see how the fat pad looks.  I had no choice.  I had to have surgery.  I was in so much pain I could barely walk.  And I had tried everything known to help.  The recovery from surgery is long.  At least 6 to 8 weeks.  Fortunately I was able to stay off my feet as much as possible as I didn't want to develop more scar tissue, so I followed a postop arthrofibrosis prevention protocol that I found online.  Basically, you have to just do nothing but range of motion and some straight-leg quad raises only until all inflammation and pain are gone.  You do nothing that causes irritation (and that for me was just weight-baring).  Then when it's healed, you can start some strength training and more quad strengthening.  I'm just now starting that.

I agree, the most frustrating part is the lack of knowlege out there.  The really good physical therapists are usually the ones who know the most about it.  You may call around and interview some.  Most of the orthopedic surgeons I saw denied the condition even exists.  Although I hear from my physical therapist that studies are showing that it is commonly misdiagnosed, and maybe the orthopedic surgeon community will catch up soon, I hope.

Update us on your condition.  You're not alone!

#32 rinny

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Posted 19 March 2010 - 03:36 PM

I have been reading everything there is to be said on Fat Pads......

My story began almost 12 months ago now while running at work.....2 days later i got shooting pains through my knee.  I have now had 3 ortho surgeons, 2 physions and numerous other meaningless amounts of input as to my problem including a psychologist as one doc thought it was all in my head.

I have also been seeing Jenny McConnell and found her to be wonderful, but the taping not so effective as it has for some people I have heard from.  Today I got back my second MRI scan results that show the Fat Pad Inflammation.  Jenny is now discussing the steroid injection.  Fingers crossed that it works, but after almost a year of being on serious restrictions due to excessive pain I am hoping to have some light shed on how long it will take to return to normal?

My job relies on me being fit and at full capacity, and at the current time I cannot manage to even sit at desk comfortably.

I am on anti inflammatories, anti depressants (for the nerve pains) and strong pain killers as my average level of pain is 7 /10.  I want my life back.  Does anyone else have any words of wisdom....bearing in mind I am under the constraints of workers comp

Also to anyone that has had the surgery...where is the point of demanding surgery ....after all it has taken me 11 months to get to more than one person agreeing on a diagnosis?

help!

#33 snowshells

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Posted 20 March 2010 - 05:59 AM

Thanks for writing back, it's good to hear from other people that have fad pad issues and that share similar frustrations…
(Although I wish none of us had to deal with this.)

Oh my gosh kskillern… that sounds like an absolute nightmare!  I'm so sorry.... No wonder you were in so much pain! I read some of your earlier posts and it sounded like had success with physio at one point…   You mentioned in one of your posts you had had low grade fat pad issues for 15 years? Were you still running during that time? I really hope you get better soon.. If you are 8 weeks in to recovery, is sounds like you might be getting to the fun part of trying some strengthening.  I look forward to hearing about you being pain free and mobile.

rinny, do the anti-depressants help the nerve pain? I feel for you if you have an active job! I'm lucky I have a computer job, I just sit all day if I want to. I actually find activities where you're standing, but fairly static to be very hard on the knees… even cooking and cleaning. In fact cooking seems almost more "dangerous" than going for a little walk to me...

My MRI did indicate a number of issues, it said that the fat pad has "stranding" but it doesn't indicate any horrific enlargement or anything. In my case the plica is also inflamed, which may connected somehow I suppose?  Maybe because my patella is not tracking properly (the initial problem), it's causing irritation and inflammation underneath the knee cap and causing problems with both the fad pad and plica (I'm making my own uneducated assumptions on that).  I'm not aware of any plica problems even though it shows up on the MRI, no clicking or giving way, for me it is the knee inflammation that is the pain, which results from weight bearing activities.

Thankfully I did find a really good physio and he does take it seriously and has helped a lot. He used to work in a knee clinic so he's seen several cases. He said it normally goes away without having surgery… mine knee seems stubborn though.

I have lots of stories to tell but I'll try and do this in order….

I had patellofemoral syndrome off and on for 2 years, following that in April 2008 I started having the fat pad issue.  At first I thought it was patellofemoral again, and tried to strengthen my legs by walking backwards on the treadmill (the exercise I did for the VMO), which made them 10x worse..  Then my physio diagnosed the fat pad problem, and told me I had to rest. I did that…. There were a couple of physio exercises for me to do including single leg squads on a wobble board, and another one where you pull an elastic back behind you until you almost straighten your knee, you stop just before it's straight. (That's to train your brain to not let your leg hyperextend) That helped a little. Because the pain was so bad I did a lot of icing, for months. I did too much icing for too long in fact, as I damaged the skin around my knee.  I used to go in the pool to swim a bit (without kicking), and when I'd get out my knees were all blue looking and horrible.  I tried ultrasound too.  At first it seemed to help, but after I damaged the skin around my knee the ultrasound seemed to cause problems as well.

I had the MRI in January 2009, and the MRI didn't show anything wrong, although the radiologist wasn't looking for specific structures. Based on the diagnosis of a simple patellofemoral problem, I started on a strengthening program with weights in March 2009. To my surprise it really helped. I had struggled to walk and stand, and then doing the leg press helped, I was amazed. Maybe after nearly a year of resting I was better able to handle the strengthening than I initially would have been. I never got to the point of being able to "jump"  or anything too crazy. The strengthening, along with about 5 Advil a day got me to a point where I could start to do short bike rides. That was a big step, before that I couldn't bend my knee enough to rotate the pedals. The biking sometimes causes irritation, but it has also helped a lot because it has strengthened my quads. It also provides enormous stress relief. I always find being anxious and acutely unhappy makes the injury even worse... It's hard for me to stop obsessing about it, and it's also hard for me to not test some new way of fixing it, and it's hard to sleep peacefully when you're not able to exercise.. . I am almost glad that the 1st MRI came out that way, because the whole resting thing was just not fixing it…. my muscles got so atrophied it seemed to get worse!

I had a 2nd MRI in December 2009 at which point I was actually feeling much better, and this time the radiologist was told to look specifically at the plica and fat pad. This time the radiologist actually commented on both the plica and fat pad in my left knee:
In the left knee the MRI indicated:

Mildly increased signal involving the biceps femoris tendon near its insertion on the fibular tip, suggestive of strain injury. No other abnormalities of the soft tissues otherwise.
Medial patellar plica with minimal inflammation in the adjacent adipose tissue, and a small joint effusion, could reflect low-grade medial patellar plica syndrome, even though the medial plica is not significantly thickened.
Trace stranding within Hoffa's fat pad.
Small joint effusion. Trace Baker's cyst. Low grade biceps femoris tendon strain.


Now I'm at a point where I can ride my bike on some pretty serious rides, although it still hurts sometimes and gets swollen. I'd say I always see some swelling in the area, but most of the time it's about a 1 on the pain scale of 10, especially compared to what it was like before (probably an 8 in late 2008). Recently when it gets irritated it's about a 3 or 4 on the scale. I haven't been trying to do much weight bearing activity on it, it seems better to just stick to a couple of safe activities for now.  I tried a few steps of jogging last summer and I had instant flare up… The surgeon said that it seemed to be better to stay on the current course of action for a while, and to arrange for surgery if I wanted him to cut out part of the fat pad and plica.  He also said that I'm not hurting my knee by doing what I'm doing… it's just causing inflammation.  Waiting seemed a good idea to me, especially since I had no indication of how successful the surgery might be! I'm 38, I'm a bit concerned about doing anything too radical in there.

I think for the next 6 months I'll continue to really try and strengthen my legs (without pushing it too much or letting the inflammation get out of hand). Cycling does seem to strengthen the VMO, although it's a slow process. I'm really hoping that when my muscles are more balanced, that these issues will go away completely and that I'll be able to walk further and maybe even try a bit of running.  If it's still not better after that, I'll know I've tried what I can… and then I'll try something more drastic.

My deepest most sincere wishes for recovery for you all…
Keep us posted on your progress!

Edited by snowshells, 20 March 2010 - 06:00 AM.


#34 kskillern

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Posted 20 March 2010 - 12:15 PM

To Snowflakes and Rinny,

All I can tell you both is that my MRI only showed minor inflammation and some scar tissue, and before surgery, the surgeon told me it looked so minor compared to some fat pad pathologies he's seen when there has been an acute hyperextension injury.  So prior to surgery he was somewhat reluctant to agree with me that this was my problem.  But it was a different story when he went in there.  The pad was hypertrophied, impinging between bones, and was just plain scar tissue.  

He also told me prior to surgery that he didn't think it would harm me to just leave it and not have surgery.  But this is also wrong.  If you read some of the articles on end-stage Hoffa's disease, you'll find that the standing inflammation causes joint degeneration.  

The fat pad is highly innervated (lots of nerve endings), lots of substance-P pain sensors and also highly vascular (a lot of blood vessels).  These equate to lots of pain and inflammation.  So once the pads become hypertrophied, hard, and scarred, it is near to impossible to turn back.  And the inflammation causes degeneration.  The surgeon told me after my surgery that there was nothing I was going to do that would have helped me.

So from everything I read, you try the step-up approach.  You try the different modalities to heal and strengthen, and then you decide if you want surgery.  You have to listen to your body.  The orthopedic surgeons, since at this point in history are not conclusive or taught about fat pad pathology, can't really help you make your decision.  Mine was great, though, in that he at least accepted my conviction that this was my problem, and told me that my decision should be based on my level of pain.  He said that if it were him and his pain level was at a 1 or 2 as mine had been for years, that he would not have the surgery (based on the length of recovery time).  But if the pain were 7 or 8 for a length of time, he would have the surgery.  This helped me make my decision.  

As well, when mine first flared up again in June of 2009, I had sent my MRI to Dr. Frank Noyes (probably the top knee doctor in the U.S.) and his research assistant.  They both reviewed my MRI and history, and told me I needed to have it removed.  I suppose I just needed to try all the conservative methods under the sun to feel comfortable with my decision.  This just took a long, long time because each thing takes a while to try and see if it's going to help.  

This is a long story to tell you in short that there doesn't have to be a lot of inflammation on the MRI in the fat pad for there to be a pathology, a diseased fat pad.  

And I completely agree that it is something you obsess over - first because it's so darn painful, and second because it is so commonly misdiagnosed.  I also totally agree that just plain standing in place for even a short amount of time (unloading dishwasher, cooking dinner, standing in the shower, waiting in a line), is so much worse than moving, going for a walk.  It was the standing still that would totally worsen my irritation and then inflammation.  

If you can get rid of the inflammation, you can get rid of the most horrible, high pain scale pain.  So flare-ups of inflammation cause the increased terrible pain.  Then when the inflammation goes down, if you have a hypertrophied (enlarged) and scarred fat pad (which you will after a long-standing disease process), you are then left with the lower pain scale pain.   It's a horrible, painful condition and only one who has experienced it can truly understand.  

If the fat pad irritation is caused from an acute injury (blow to the front of the knee, or a hyperextension injury) it is formally classified as Hoffa's Syndrome.  But if it is from a biomechanical injury that occurs slowly over time with repeated microtrauma to the pad, it is classified as Hoffa's Disease.  But both I believe will cause this horrible pain.  I described mine as it feeling like someone took a 2' x 4' and whacked me in the knee.  It was excruciating mostly on weight-baring and prolonged standing.  Walking did not bother me.  

Let us know how you do.  I can completely relate and again, you are absolutely not alone.  And yes, in week 7 I started my exercises to strengthen quads and I am excited to feel those muscles kick in again.  My VMO was wasted, too, because I had so much knee pain I couldn't strengthen it.  I still have tape on when I'm out and about so as not to irritate the healing tissue.  But now the tape gets rid of all the pain, whereas prior to surgery, it wasn't working anymore.  I hope to be off the tape in a few months when my quads are built back up.  But I do not have that excruciating, "whacked in the knee" pain anymore, and for that I am so thankful.  Blessings to you both.

#35 snowshells

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Posted 21 March 2010 - 08:58 AM

Thank you Kskillern, you're been a huge source of information!

It sounds like this is something that I really have to get to settle down completely... or it will continue to cause more damage.

I look forward to hearing how you make out in your recovery!

All the best!
sf

#36 rinny

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Posted 30 March 2010 - 11:42 AM

Hi again,

Snowshells you asked about the anti depressants and whether they work, well the immediate answer was yes.  Within days of taking them I found that the general ache and the shooting nerve pains were generally reduced by about 40%.  At the time I was doing the equivalent of a happy dance on one leg.....I found that they increased my ability to sleep through the pains, and basically due to not waking up hurting, everything seemed better.  That is not to say that I could overload it without pain.  Just like everything with this condition I still needed to pace myself, and consider every movement.  I increased the dosage from 20mg of Endep daily up to 50mg daily and was going pretty good for about 2.5months and was increasing my work hours and starting back at the gym.  Then, out of the blue (maybe from a session with a personal trainer) it all went bad. Now I still take them, but they mainly assist with being able to sleep at night.  But be aware, they are designed to give your body a more restful time.  that means unless you keep yourself busy during the day all you want to do is sleep.

My MRI showed Hoffa's Fat Pad hypertensity at the inferiorlateral patella as well as maltracking.  The surgeon has referred me to have a steroid injection by way of ultrasound guiding, but stated that surgery would be the next step. However the person I need to see isn't available for another 3 weeks.....so more pain.

If anyone has had the injection which didn't work and had to move onto surgery I'd love to hear more specifics.

Thanks

#37 snowshells

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Posted 11 April 2010 - 08:08 AM

View Postrinny, on Mar 29 2010, 07:42 PM, said:

Hi again,

Snowshells you asked about the anti depressants and whether they work, well the immediate answer was yes.  Within days of taking them I found that the general ache and the shooting nerve pains were generally reduced by about 40%.  At the time I was doing the equivalent of a happy dance on one leg.....I found that they increased my ability to sleep through the pains, and basically due to not waking up hurting, everything seemed better.  That is not to say that I could overload it without pain.  Just like everything with this condition I still needed to pace myself, and consider every movement.  I increased the dosage from 20mg of Endep daily up to 50mg daily and was going pretty good for about 2.5months and was increasing my work hours and starting back at the gym.  Then, out of the blue (maybe from a session with a personal trainer) it all went bad. Now I still take them, but they mainly assist with being able to sleep at night.  But be aware, they are designed to give your body a more restful time.  that means unless you keep yourself busy during the day all you want to do is sleep.

My MRI showed Hoffa's Fat Pad hypertensity at the inferiorlateral patella as well as maltracking.  The surgeon has referred me to have a steroid injection by way of ultrasound guiding, but stated that surgery would be the next step. However the person I need to see isn't available for another 3 weeks.....so more pain.

If anyone has had the injection which didn't work and had to move onto surgery I'd love to hear more specifics.

Thanks


#38 snowshells

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Posted 11 April 2010 - 08:11 AM

hi Rinny
Thanks for the info. I guess it's another option to consider...

I feel for you that you have a standing up job.. I would have been off work for ages if I didn't get to sit all day.
Hope the injection goes well and that it helps!

ss

#39 gmbrunnergirl

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Posted 18 May 2010 - 10:57 AM

I am so excited to have found this!  I have been suffering from (apparantly) fat pad impingement for about 5 years.  After my initial flare up it took a couple of years to increase my running to 25-30 miles a week, and I've recently had another flare up.  I've seen numerous dr's and today my orthopedist told me this is what he thinks it is.  Finally, an answer that makes sense!

Question about taping--Are those who are taping--taping all the time during a flare up, or just when you exercise?

I started using a Mueller brace--Attached File  knee_strap.jpg   41.05K   13 downloads
and it appears to mimic the tapic method that was linked in above.  I am wearing it while running, and was able to run 6 miles yesterday with no pain--only 2 weeks since my major flare up.  I'm wondering if I should be wearing it all the time?

I had a cortisone shot today and I'm really hopeful that I will be able to run pain free in the Adventure Relay that I'm signed up for in two weeks.  I will be running about 14 miles over 24 hours.

Thanks!

#40 drobinson

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Posted 28 May 2010 - 01:04 PM

I saw your post re: fat pad impingement and your mention of Dr Noyes.  I looked him up and found he is in Cincinnati Oh, a little over an hr from my home in Columbus Ohio USA.  I saw him in early May.

Did he perform your fat pad surgery?

I originally twisted my knee nearly 5 yrs ago and had pain/discomfort only when stressing my knee (ie exercise).  Multiple MRIs, xrays (MRIs showed no problems according to several drs until my visit to Dr Noyes where he noticed an inflamed/enlarged fat pad), PT sessions of all modalities, antiinflammatory meds, massage etc etc have not helped.  Now the pain has, after nearly 5 yrs, escalated to to almost intolerable levels.  

I am having extreme pain below the knee cap and as you did, I think, I have significant pain when standing.  I also have developed pain in the lateral side of my knee around the IT band and tightness in the back of my knee.  Also, severe "nervy" feelings in my foot at times when my knee have been stressed (pins and needles type feeling).  I can no longer run, bike or virtually anything else in terms of exercise.  As I said, standing is extremely uncomfortable even for just a couple of minutes.  

Dr Noyes gave me a novacane injection into the fat pad then had me run on a treadmill to see if the pain was any better.  It was.  He thinks removing part of the fat pad would help.  He thinks he may need to take out up to 75% of the fat pad.  How much of yours did the OS take out?  

I appreciate any detailed feedback you could provide re: your symptoms and the surgery and how long your recovery was, and what helped and what to expect.  I am at my wits end with this.  My 5 yr old daughter is learning to ride a bike and I can barely run along side her to help her.  It is very frustrating.  I am  a 47 yr old male in pretty good health other than this very life altering problem.  

Thanks.  

Dave

Edited by drobinson, 28 May 2010 - 01:25 PM.


#41 holly14

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Posted 19 June 2010 - 03:47 PM

Hello all,
I was really hoping that some one could help me. I am 19 and have always been a very active person, but have always had problems with my knee since about 14. the problems have varied in pain but recently have been diagnosed with fat pad inpingment. I am and have been living on anti inflamatories for the past 3 months or so and am worried that just physio isnt doing enough for me. i am in almost constant pain (even whilst taking up to 6 anti inflam a day) even doing every day activities, but am worried that surgery will stop me from doing the sports and physical activities i love.
If anyone could tell me their experiences and/or how long recovery was i would REALLY apreciate it. I just had to take two weeks off all physical activity and that nearly killed me. stopping all togeather is not really an option

#42 kskillern

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Posted 20 June 2010 - 04:02 AM

Hi Holly,

I can very much relate to your condition and your pain.  I've lived with a fat pad impingement for many years and just had surgery to have it removed.  It's such a long story and way too much for me to type.  Would you like to contact me?  My email is kskillern@comcast.net.  Maybe we can exchange phone numbers.  I just had a long conversation on the phone with another person who has the same thing, and is getting ready for surgery as well.  I can share with you all that I have learned, and some things that might be of help to you.  It's a rather complicated, commonly misdiagnosed, and severely painful condition that affects all areas of your life.

Look forward to hearing from you.

Blessings,
Karen

#43 Em00

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Posted 19 August 2010 - 11:49 AM

It has been a while since I have posted on here. I have had fat pad impingement of my knee for a year and a half now. After initialling taking a few months off of running about a year ago, having coritison etc etc etc I have spent the last year running and putting up with the pain, managaing my injury with icing and taping. It is contant pain when running to some degree, sometimes bad sometimes not so bad.
I was told earlier this year that my knee will never get better without surgery so my plan has been to have surgery late October this year after I had done a few big events which I plan to do. Now it's come to crunch time to decide what I am doing and book in for surgery and I'm trying to decide whether to do it or wait another year, I've been told the sooner the better but that I probably have a year or so up my sleave if I do want to wait but it is not ideal as it may make it worse.. SO.. my questions are (mainly to you kskillern seeing as you have had surgery):
What is the recovery time? - how long until you can run?
What activities can you do in the meantime during recovery?
Kskillern - How affective was your surgery? Has it worked for you??
Thank you,
Em.

#44 kskillern

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Posted 19 August 2010 - 05:13 PM

Hi Em,

I had surgery in January 2010, and had the majority of the fat pad removed.  But what happens when you have had a longterm fat pad impingement like I did, the fat pad turns from a nice soft fatty tissue to a hard, dense fibrous scar tissue.  So really in essence, it is a scar tissue "issue".  My mistake in January was that I did not go to an orthopedic surgeon that specializes in scar tissue in the joints, also called arthofibrosis.  I had done so much research on the Kneeguru website (have you checked that web out?  A lot of good advice and recommendations), and really knew in my gut that I should have travelled out of state to one of the arthofibrosis specialists listed on that site.  But I listened to very good intentioned family and friends who felt I did not need to travel out of state, that there were so many "good" orthopedic surgeons in my area.

So, now here I am going for surgery once again next week, as the scar tissue has grown back already.  But this time I'm going to see an arthrofibrosis specialist, and I hope that through his techniques for removing the tissue, as well as very specific postoperative protocol for preventing it from coming back, that this will be my last surgery on this knee.  There are many arthrofibrosis success stories on the Kneeguru website, and you will see that they all recommend that to stop the surgery cycle, you need to see an arthrofibrosis specialist.  

I know from my experience that there were certain things done in surgery, in physical therapy and in my own actions for lack of restrictions after surgery, that have contributed to more scar tissue in the space that once was the fat pad, all at the bottom of the kneecap, running under the tendon.  It's all in the "infrapatellar" region, meaning below the kneecap.

Here is a list of specialists from the Kneeguru website for scar tissue:
Dr. Colin Eakin, Palo Alto Medical Foundation, California
Dr. Steadman, Steadman-Hawkins Clinic, Vail, Colorado  
Dr. Peter Millet, Steadman Hawkins, Vail (as of 10/1/05)
Dr. Lonnie Paulos, Texas
Dr. Frank Noyes, Cincinnati Sports Clinic, Ohio
Dr. Wojitys, Ann Arbor, Michigan
Dr. Folk in South Carolina
Dr. Mike Terry, University of Chicago
Dr. Shelbourne, Indianapolis, IN
Dr. Flandry, Hughston Clinic, Columbus, Georgia

If you ask me for my honest opinion, I'd say to find one of these somewhat close to you, and do all you can to see one of them.  I don't mean to scare you, but only to help prevent multiple surgeries.  Some of them may allow you to send them your X-rays/MRI and give you an opinion long distance.  I'd definitely start there.  

My surgeon did not cauterize the area after removing the scar tissued fat pad, I should've been non-weightbearing on crutches for weeks after but was not, my physical therapists did some deep cross-friction rubbing on the two arthroscopic portals, and too aggressive therapy are some of the things that have contributed to more scar tissue forming.  With this surgery, and especially the postop protocol, you have to be very careful after to do NOTHING that causes irritation/pain.  That irritation can lead to more scarring.  It's not a common surgery, and from what one of the specialists said, most orthopedic surgeons only see 1 fat pad every 10 years.  Most I'm sure will tell you, "Hey, no problem, I can do that."  But be certain, you want to be very choosy.

Also, from what I understand, with a successful surgery you would be able to run, but running is not really recommended, if you don't absolutely have to.  I don't want to be the bearer of bad news, but I'm presenting to you what I've found across the board on the Kneeguru website.  But I believe that would be your choice, obviously, and you would also have other exercise options.  I know that's not easy to accept if you're a runner...

I hope this helps you.  I know it doesn't paint a rosy picture, but there is hope - you just have to be careful how you go about the surgery, and the postop protocol.  It's been a long, painful learning experience for me.  I am not looking forward to surgery again, but I am hopeful, and prayerful, that finding the right doctor, and doing things a lot differently postoperatively will keep the scar tissue from coming back.  Looking on the bright side, I am looking forward to seeing Vail, Colorado!

Keep us posted, and blessings to you,
Karen

#45 Em00

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Posted 19 August 2010 - 05:27 PM

Hi Karen,
Thanks for your reply. I am in Australia so won't be visiting any of those specialists anytime soon  :D but thank you anyway!
I am booked in for an appointment with my sports doc next week and have decided that if I can get booked in for surgery in the time frame I am hoping for then I will do it this year and if not then I will wait until next year. I figure that if it's got to be done then I might as well do it sooner rather than later instead of putting it off.
I am sorry to hear that you are about to have more surgery, I really hope that it goes well for you. All the best with it and I look forward to hearing how it goes.
Take care,
Em.


View Postkskillern, on Aug 19 2010, 04:43 PM, said:

Hi Em,

I had surgery in January 2010, and had the majority of the fat pad removed.  But what happens when you have had a longterm fat pad impingement like I did, the fat pad turns from a nice soft fatty tissue to a hard, dense fibrous scar tissue.  So really in essence, it is a scar tissue "issue".  My mistake in January was that I did not go to an orthopedic surgeon that specializes in scar tissue in the joints, also called arthofibrosis.  I had done so much research on the Kneeguru website (have you checked that web out?  A lot of good advice and recommendations), and really knew in my gut that I should have travelled out of state to one of the arthofibrosis specialists listed on that site.  But I listened to very good intentioned family and friends who felt I did not need to travel out of state, that there were so many "good" orthopedic surgeons in my area.

So, now here I am going for surgery once again next week, as the scar tissue has grown back already.  But this time I'm going to see an arthrofibrosis specialist, and I hope that through his techniques for removing the tissue, as well as very specific postoperative protocol for preventing it from coming back, that this will be my last surgery on this knee.  There are many arthrofibrosis success stories on the Kneeguru website, and you will see that they all recommend that to stop the surgery cycle, you need to see an arthrofibrosis specialist.  

I know from my experience that there were certain things done in surgery, in physical therapy and in my own actions for lack of restrictions after surgery, that have contributed to more scar tissue in the space that once was the fat pad, all at the bottom of the kneecap, running under the tendon.  It's all in the "infrapatellar" region, meaning below the kneecap.

Here is a list of specialists from the Kneeguru website for scar tissue:
Dr. Colin Eakin, Palo Alto Medical Foundation, California
Dr. Steadman, Steadman-Hawkins Clinic, Vail, Colorado  
Dr. Peter Millet, Steadman Hawkins, Vail (as of 10/1/05)
Dr. Lonnie Paulos, Texas
Dr. Frank Noyes, Cincinnati Sports Clinic, Ohio
Dr. Wojitys, Ann Arbor, Michigan
Dr. Folk in South Carolina
Dr. Mike Terry, University of Chicago
Dr. Shelbourne, Indianapolis, IN
Dr. Flandry, Hughston Clinic, Columbus, Georgia

If you ask me for my honest opinion, I'd say to find one of these somewhat close to you, and do all you can to see one of them.  I don't mean to scare you, but only to help prevent multiple surgeries.  Some of them may allow you to send them your X-rays/MRI and give you an opinion long distance.  I'd definitely start there.  

My surgeon did not cauterize the area after removing the scar tissued fat pad, I should've been non-weightbearing on crutches for weeks after but was not, my physical therapists did some deep cross-friction rubbing on the two arthroscopic portals, and too aggressive therapy are some of the things that have contributed to more scar tissue forming.  With this surgery, and especially the postop protocol, you have to be very careful after to do NOTHING that causes irritation/pain.  That irritation can lead to more scarring.  It's not a common surgery, and from what one of the specialists said, most orthopedic surgeons only see 1 fat pad every 10 years.  Most I'm sure will tell you, "Hey, no problem, I can do that."  But be certain, you want to be very choosy.

Also, from what I understand, with a successful surgery you would be able to run, but running is not really recommended, if you don't absolutely have to.  I don't want to be the bearer of bad news, but I'm presenting to you what I've found across the board on the Kneeguru website.  But I believe that would be your choice, obviously, and you would also have other exercise options.  I know that's not easy to accept if you're a runner...

I hope this helps you.  I know it doesn't paint a rosy picture, but there is hope - you just have to be careful how you go about the surgery, and the postop protocol.  It's been a long, painful learning experience for me.  I am not looking forward to surgery again, but I am hopeful, and prayerful, that finding the right doctor, and doing things a lot differently postoperatively will keep the scar tissue from coming back.  Looking on the bright side, I am looking forward to seeing Vail, Colorado!

Keep us posted, and blessings to you,
Karen


#46 kskillern

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Posted 21 August 2010 - 01:30 PM

Hi Em,

I found this on the Kneeguru website.  There is a Dr. Cross in Sydney at the North Sydney Orthopaedic and Sports Medicine Centre who is an arthrofibrosis specialist.  Are you near there?

Karen

#47 rinny

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Posted 01 October 2010 - 11:33 PM

View Postkskillern, on Aug 21 2010, 02:30 PM, said:

Hi Em,

I found this on the Kneeguru website.  There is a Dr. Cross in Sydney at the North Sydney Orthopaedic and Sports Medicine Centre who is an arthrofibrosis specialist.  Are you near there?

Karen


Hi all,   An update from Fat Pad hell in Sydney.  4 weeks ago I had surgery which they shaved off some of the Fat Pad.  The surgeon who I will not name (but is a knee specialist) was quite frankly one of the biggest wankers I had ever met.  Each time I left his office I was in tears as he made me feel like my pain was "in my head".  In fact I had been dealing with this for so long that I even considered that option myself as it hurt no matter what I did.  The funny thing is that the psychologist I went to see realised I was just in a load of pain and referred me to this surgeon.
Having never had surgery previously, I'm now finding it hard to work out what is "old" pain and what is surgery pain.  My average pain now a month on is about 60% better than what it was at the worst over the 18 months.  As mine was a workers comp issue I had to battle the insurance company who refused to pay surgery as their Professor wanted conservative management, involving intensive physio 3 times a week for 3 months.  I had seen Jenny McConnell the knee guru, and saw no improvement.  I was using the McConnell taping method, which I became so expert at doing myself even her physios thought she had taped me.  I began seeing another physio as Jenny unfortunately would never have complied with physio 3 times per week, and Workers Comp would not have covered the almost double fee of normal physios.
The physio I went to was fabulous.  He didnt claim to be the smartest or the best, but he paid attention and would listen, watch and discuss.  He saw how much my knee could flare up from day to day with no reason, and actively worked on my VMO, icing, taping etc.
After 3 months even workers comp could not refuse to take a more aggressive approach.  During this time I was on Glucosamine / Chrondotin, Fish Oil, Endep 75mg per day (reduced the nerve pain) and Endone (pain killers).
I ended up being off work for 7 months as I was unable to even sit at a desk job for more than a couple of hours without high levels of pain relief.  A simple task such as going to the grocerie store was often greeted by people stopping me to ask me if I was ok.  I had even an 80 year old man stop to offer me assistance as I looked so bad......and that was on a reasonably good day.
So anyway, after 18 months, 1 month post surgery I am alot happier.  I am back to work for a few hours a day, there is still stiffness in the knee, however I am hopeful.  I will also mention that the horrible surgeon almost wet his pants when I told him how much it had improved.  Hopefully this will make him treat new patients with this problem with a bit of respect.  This week, starting back and work, and actively attempting to organise my wedding which is 5 weeks away, I am now overjoyed to be pain killer free for 2 days.  This is a great achievement considering the additional stress involved that would normally have set the nerves alight.

My advise so far to sufferers is - don't give up
- don't let anyone treat you like it is in your head
- try the Endep
- Cortisone Injection did not help me whatsoever
- be prepared to give physio a good go
- find a physio who will listen to your ideas / pain etc

For me now, I am starting a physio / personal training program next week with an exercise physiologist and hope to regain full flexibility in the knee, and be able to enjoy walking down the aisle pain free and enjoy a honeymoon.
So any Sydney sufferers please feel free to send your details if you want specific names / details etc.

#48 kskillern

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Posted 02 October 2010 - 04:02 AM

Hi Em,

That is so great to hear that your surgery is behind and healing is in front of you!!!!  Fat pad problems can be such a long road because there are sooooo many orthopedic surgeons who just plain don't believe the fat pads can be a source of the problem.  But from what I am hearing and reading from the physical therapy community and studies, etc., it is finally becoming more recognized.  Shall we start the Fat Pad Society to increase awareness????  Funny, but I wish someone would.

It is one of the most, if not the most, sensitive structures in the knee along with the synovial lining of the knee joint.  And because of that the pain is so debilitating.  And then when it's mostly not being recognized, it is the worst struggle.

When it has become diseased beyond conservative methods, you need to have it taken care of surgically.

My suggestion to you would be to take your rehab really, really, really slow as you can reform scar tissue if your knee gets irritated.  The key is to keep the swelling down and the heat out, through elevating, icing, ibuprofen, and wait for a long time for sports.  Let all the surgical healing take place (6 to 8 weeks at least) before the physios let you start any strength training.

This is just my advice, but it's what I've been instructed to do from one of the top scar tissue (including fat pad issues) specialists, Dr. Steadman.  I am following their protocol to the "T".  It takes a long time, but you have to be patient.

I hope you have continued steady recovery, and a pain-free knee in the not too distant future!!!

Blessings,
Karen

#49 rinny

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Posted 12 October 2010 - 09:56 PM

View Postkskillern, on Oct 2 2010, 05:02 AM, said:

Hi Em,

That is so great to hear that your surgery is behind and healing is in front of you!!!!  Fat pad problems can be such a long road because there are sooooo many orthopedic surgeons who just plain don't believe the fat pads can be a source of the problem.  But from what I am hearing and reading from the physical therapy community and studies, etc., it is finally becoming more recognized.  Shall we start the Fat Pad Society to increase awareness????  Funny, but I wish someone would.

It is one of the most, if not the most, sensitive structures in the knee along with the synovial lining of the knee joint.  And because of that the pain is so debilitating.  And then when it's mostly not being recognized, it is the worst struggle.

When it has become diseased beyond conservative methods, you need to have it taken care of surgically.

My suggestion to you would be to take your rehab really, really, really slow as you can reform scar tissue if your knee gets irritated.  The key is to keep the swelling down and the heat out, through elevating, icing, ibuprofen, and wait for a long time for sports.  Let all the surgical healing take place (6 to 8 weeks at least) before the physios let you start any strength training.

This is just my advice, but it's what I've been instructed to do from one of the top scar tissue (including fat pad issues) specialists, Dr. Steadman.  I am following their protocol to the "T".  It takes a long time, but you have to be patient.

I hope you have continued steady recovery, and a pain-free knee in the not too distant future!!!

Blessings,
Karen

Just in response to Karen, I would make a minor suggestion to the 6-8 week recovery.  My idiot surgeon suggested that as I knew all the physio exercises as I had been doing them for 18 months that I go it alone.  Now 9 weeks after surgery I have 2-3 cm muscle wastage in my VMO, and so now have been advised that I am not at a level to take part in a structured rehab program.  So back to physio for me.  This is despite doing the exercises suggested by the surgeon, and actively increasing walking, getting back to work on restricted duties and limping around trying to organise my wedding.

I was referred to a knee guru called Lance Morton who runs Peak Training in Sydney.  While he is not actively treating patients, I would suggest that his knowledge of the Fat pad may infact be more impressive than Jenny McConnell.  I know that seems like a big call, but maybe it was more that he was willing to talk to me, and explain each symptom and reaction with diagrams, displays and even drawing every which way on my knees.
I left Lance feeling a bit disheartened by the bad news of the needing critical physio treatment, but strengthened by the fact that he provided more information and confirmed just about everything each different Surgeon, pain doctor, physio etc has told me in dribs and drabs over 19 months.

I am now not reliant on pain killers to get through the day, and did weight bearing physio yesterday without the typical flare up, and with minimal night pain.  So fingers crossed for me to be able to wear high heels and walk down the aisle in 25 days without pain!

Good luck all

Rinny

#50 Quinkin

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Posted 27 October 2010 - 07:59 AM

Knee injuries are HARD to overcome. Too right they are a long road, and there is often no guarantee of success.

I had a maltracking patella, with wasted quads. This is a common knee injury and one of the most easily treated knee problems with conservative treatment apparenlty.

Still, it took me three years to beat this common knee injury. Three years to rebuild my knee, with daily exercises, taping, stretches, and self massage. Three years of hell, where my life was diminished in so many ways. My knee pain never took a holiday, so I never took a holiday from trying to beat it. I tried everyhting at least twice. It was like climbing a mountain, all hard work without any guarantee of success. I don't know why I kept fighting, I never believed I would be pain free, let alone run again.  

I've since run in 7 Half Marathons, 2 City to Surfs, and many many fun runs. My return to running feels nothing short of a miracle.

I saw Dr. Ken Crichton and Brad McIntosh. I actually only had consultations with Dr. Crichton twice, and Brad McIntosh four times. All the rest of the physio I did at home.