Look, the fat pad's full of nerve endings, which is why it's so sore. But that level of pain doesn't equate in any shape or form to harm.
SPEAKER_00:In a world where we're moving away from structured diagnosis, we chatted today about the Hoffer's fact add and how specific structures getting irritated can still be tested, but also the nuance around interviewing a patient and applying the cup analogy and really good interviewing and communication skills can be relevant. Well, today we spoke to Claire Robertson, otherwise known as Claire Patella. She's a wonderful person to talk to in this topic because she has many peer-reviewed articles on this. She also has a has a course on patellofemoral joint problems and you can check her out at Claire Patella for further resources and info. I hope you enjoyed this episode. My name is Michael Risk and this is Physio Explained. Hello Claire and thank you for joining us today.
SPEAKER_01:Hi, thank you very much for inviting me.
SPEAKER_00:We're going to talk about some knee pain, probably specifically Hoffa's fat pad. I thought I would start with how do we distinguish or how do you distinguish between a Hoffer's fat pad in the clinic and other common knee pathologies?
SPEAKER_01:I think it's a really good question. And I think there are some things that are real heads up that when you're listening to a patient, which of course is so important, you can really think, oh, hang on a minute. So what do I think? Well, the nature of the pain. This is... offer really nasty pain, really unpleasant. It's the condition that has people in tears in my clinic. And I don't usually make people cry. It's the thing that makes people very anxious, very fear avoidant. It's very nasty pain. It's the pain that people will often say, I can't work. They're really struggling with it. So severity of pain. Often use words like nipping, pinching and that is actually I think what is happening structurally as well when they report that phenomena so that's an interesting word to just listen out for as well and then the types of activities that aggravate this is probably the most effective way I think of differentiating between fat pad and patellofemoral pain because of course they both can be located in the same kind of area but they're very different in the key things that aggravate them so Think of it like this. The fat pad is a picture of extension problems. So therefore, prolonged standing and walking are often the two worst things. And yet in patellofemoral pain, for example, we're looking much for a problem with loaded flexions. So stairs, crouching, getting out of chairs. So look for that pattern of worsening extension problems. And then physically on assessment, you know, we're looking for edema in the fat pad, but we can't look for that exclusively because we do know that some patients have asymptomatic fat pad edema. But it's certainly, it's a useful thing to look at. And tenderness, you know, if someone has pain arising from their fat pad, they really, I find will be painful. There's no doubt about it when you palpate it. And so they're probably the biggest clues that you're looking at a fat pad problem, but obviously always remembering that because the causative factors are often the same for fat pads and patellofemoral pain, you can, of course, annoyingly, get a mixed picture where it's a bit of both. But those would be the hallmarks, I would say, of a fat pad problem.
SPEAKER_00:It probably speaks to clustering all those tests, the functional movements that are getting them, all their daily activities and plus your palpatients. Are there any tests on the bed that you would specifically do to differentiate?
SPEAKER_01:Yeah, I mean, I actually don't do... Hoffa's test, I don't actually find it that helpful. I prefer to build my picture from the sort of aforementioned points, using no one thing in isolation, just building that picture together and then saying, okay, this is sounding like Hoffa's fat palate. I don't think Hoffa's test is particularly useful. Personally, I know other people use it, but that's just what I find.
UNKNOWN:Yeah.
SPEAKER_00:I find a lot of false positives palpating around there. We treat a lot of recreational runners and most are just tender there.
SPEAKER_01:Exactly, exactly. So, you know, it's not particularly helpful.
SPEAKER_00:And what I find interesting, Claire, is that obviously a shift away from structural diagnosis in the more global narrative. How do you speak to something that is quite specific and structural with a Hoffer's Fat Pattern maybe using like a BPS approach or a cup analogy, we do need to speak to that structure because it is a specific structure. How do you tie that in with the more global factors?
SPEAKER_01:Yeah, it's a really good point. And I think, you know, I actually don't like being overly structuralist in my approach, but here I am talking about structure. So I think we have to factor in a few things. I think it's really important to help the patient understand it. So I do talk about structure for them to understand it. But what I bring it round to is I say, look, the fat pad's full of nerve endings, which is why it's so sore. But that level of pain doesn't equate in any shape or form to harm.
UNKNOWN:Hmm.
SPEAKER_01:And I go over that several ways and I might come at that from different angles. So it's that hurts doesn't equate to harm because when something is that painful, of course you're going to think that it's a damaged situation, it's a harm situation. And so that's a really important point to get across. And when I talk to patients about avoidance of aggravation, I'm quite careful to clarify that that's not because I'm worried that they're going to harm many long term. What I say is, look, we're trying to settle your knee. So doing things that wind the pain up are just going to go against what we're trying to achieve. But if you do do something and your pain is worse, it's okay. You know, you haven't changed the structure of your knee long term. It will calm down again. But where possible, whilst we're trying to settle it, let's try and do the right thing for it by not aggravating it. And certainly, it's very much a condition of inflammation. And again, this is a very big difference from patellofemoral pain, and perhaps I should have cited that before. So fat pad, it's often pain... during but very much after and very much the next day that can be really problematical and in fact sometimes it's only afterwards and of course that makes it really difficult to read sometimes as well when the pain is just latent but it's very much I'm looking at that picture of pain the next day which is so classic of inflammation whereas patellofemoral pain is very much a I do this, it hurts. I come out of that position, it stops hurting. So very much more mechanical. So also explain to patients about that cycle of inflammation. And again, I often say to them, look, the word inflammation comes from the Latin inflammation, which means fire. And it's like that. We've got this smoldering fire of inflammation. And if by accident you do something and you blow on the fire and it's really painful, it's It will calm down again, just like a fire will. But let's try and avoid that so we don't have that boom-bust cycle that can be so demoralizing and also just stop the treatment in its tracks. And also they can lose confidence in the whole process. So let's try where possible to have a graph that's just steady-eddy, not, as I say, high, big highs and lows.
SPEAKER_00:You're speaking to the real skill. In what we do now, it's difficult, isn't it? Because we want to nudge into the pain, but not blow on the fire, as you say. Do you have any other tips and tricks for how much will you push into that versus how much will you back off? And if someone does have a flare up, how do you keep them on track? I know you treat a lot of people who've had pain for more than three months.
SPEAKER_01:Yeah, I would push into pain more with the telephemeral pain. But even then, you know, with some sorts of rules, if you like. But I'm not keen on pushing into pain as a choice with fat pads. I don't think it's an effective thing to do. I really don't. So I actually aspire to be pain-free with the treatment of fat pads, which is different to how I would manage the patellofemoral pain because of the inflammatory nature. Otherwise, again, another analogy I say to the patients is if I have a bruise on my hand, And I just tap it nonstop. It's a micro trauma leading to a macro problem. And I've got to stop tapping it for it to just settle down. So I haven't structurally got a problem with my hand, but I've got something there that really needs to just be given half a chance. And I think often the patients that I see with fat pads have had failed physio. And often it's because the physio has perhaps been a little bit aggressive for a fat pad problem.
SPEAKER_00:Yeah. And do you have anything specifically, obviously case to case, super different. Do you have some go-to manual therapies, some go-to tapings or more just these are the movements we're going to avoid in the next few days? How does that look in your consults?
SPEAKER_01:Yeah. Yeah. I do have some go-to measures, definitely. So because it Then we know that the fat pad has such a problem in extension. And that's well evidenced, by the way. The anatomical studies show us that between 30 degrees and zero, the fat pad has to deform to cope with that movement. So if it's inflamed and big, that's the point where there's a real problem. So we know the further the knee goes back towards terminal extension, the more likely it is to get impinged if it's edematous. So one of the things that I'm really... Oh, wow. Oh, wow. I'm actually walking around on tiptoes. And I said, well, how about we make that a bit easier on your calves? And we just get you into like a wedge trainer. So I'm quite keen on, as long as they haven't got too much patella femoral pain going on, I'm quite keen on getting their heel elevated whilst you're trying to break the cycle. And as I say, for females, like a wedge trainer can be a really good option. Or even just something like an Asics where the profile of the sole is such that it's wider at the back than the front. That's going to be a much better profile than something, say, like a Converse. It's really flat. And it's really interesting. You know, there's been lockdown, lack of footwear phenomena. I've had... several patients who have set their fat pad off because they've been locked down at home. They have not been wearing their regular shoes because they've been working at home. They've been padding around barefoot and they've set off a fat pad problem. So I do think footwear makes a really big difference. So that's my number one go-to thing is to get that sorted. Number two is ice massage. They've often tried an ice pack, but I think an ice massage is just that bit more specific so some oil on the skin just to protect their skin and then some ice massage for two or three minutes moving it around just to really get that very strong vasoconstriction because ultimately inflammation of course is vasodilation and don't let them ice for too long if they ice for too long with a general ice pack then they'll get the opposite they'll get vasodilation and some of my patients have cited they've thought that ice had made them worse, but it's because they've conked it on at Sattler for 20, 30 minutes. So shoes, ice massage, and then I do tend to use tape with probably most of my fat pad patients to offload it because the margins are small. You know, I always think, and again, I laugh with some of the patients, I'll say, you know, I feel like it's a bit like a design flaw. The fat pad is a bit packed in. There's not much space. So the margins are really small here. So if we can just get another degree of tilt of the patella off the fat pad or one millimetre of elevation of the patella off the fat pad, we might just create that bit of space that's going to allow it to settle down. So I do tape and often the patients stand up and immediately go, oh, what a relief. And then you're like, yes, happy days.
SPEAKER_00:I think that speaks to a unique challenge. Off-air, you were saying how you do see a lot of people who have had it for a while. How do you take them to that first introduction of load and then maybe steering them away from those short-term things that have made them feel good? What's your first kind of loading mechanism?
SPEAKER_01:Yeah, it's a really good question. And we have to be really careful that they then don't become very sort of dependent. So I actually manage their expectation. And I say, we're going to have a two-week blitz on this. Choose ice massage tape. Because as soon as we start breaking that, we've seen that the edema is coming down. We've broken that cycle. There is no need, particularly for the tape and the ice. And then what I'll say to them is, look, let's have a period rather than going from 24-7 taping and icing, say, three times a day to nothing. Then what I might say is, they're your go-to measures whilst we're getting you back into a bit more exercise. So perhaps you might tape up to go to the gym. Or if you're going to go for a long walk, you might taper and you might ice afterwards. And then as we're building resilience, both physically and psychologically, then we will very actively look to remove those measures out of the equation. And I say to people, because let's face it, it's not normal to be icing your knee. You know, the whole world isn't walking around icing their knee wearing tape. So it's really important that we see that as a temporary, a specific period of time to be then moved away from
SPEAKER_02:And
SPEAKER_01:I'm quite keen that patients view their rehab, but it just morphs into wellbeing. So it moves away from the focal points of the knee itself into return to exercise, feeling good about themselves and whatever that may be for that patient. And ultimately, I'm not even talking about physio exercises. I'm talking about their forms of exercise, which is a really important difference.
SPEAKER_00:It's not so much, okay, two weeks of pain relief. Now we're going to start looking at squatting. It may just be that they are walking again and they can walk longer.
SPEAKER_01:Absolutely. Yeah, absolutely. And interestingly, though, over the walking, I also say to the patients, probably on their first consultation normally, just have the expectation that walking may be one of the very last things that normalizes. And I have actually got several patients that can run pain-free, but they can't go on a long walk pain-free. And it's because, particularly if you've got a forefoot runner with a short stride length, they're actually landing with a much more flexed knee than if you've got someone trying to stride out and heel strike walking.
SPEAKER_00:You often see that. Yeah, the slower pace walking, the heel strike versus running, they remain in that 10 to 15 degrees.
SPEAKER_01:Exactly. And so, and I've got one patient who just laughed about it. He says, I think my wife thinks I'm absolutely making this up because he says, I go in, I go for my run and I come in and then I say, so I can't stand and wash up because the running is just in that little bit more flexion. And again, I think it's demonstrative of how the angles are quite important. So very early on often, even before someone is comfortably walking at all, I might get them running on the spot because running on the spot is even less tibial swing through, obviously. You know, I find that that's something I can often do quite early on to the patient's complete amazement. And yet they might find it difficult to walk, you know, half a mile to their local shop. But again, it's all about education. And so they understand that and changing that perception. And I say, I know walking doesn't seem like that big a deal, but actually for the fat pad, it really is. So let's not get stressed out. If at a month walking is still difficult, that's okay. That's normal. And it will come.
SPEAKER_00:Now, I've been asking recent guests, how often would you see a patient that presents to you a new patient? There's been a varied response of, I'll see them in two weeks and keep regular contact, and others prefer to see them clinically more often. Do you have an approach that you found works for this?
SPEAKER_01:Well, it does depend slightly on my sense of how the level of buy-in is. which probably is more a reflection of me and my communication skills. But if I feel that I'm worried about that, then I would want to pull them back. I'm not going to be doing any manual therapy on them. I try and keep my exercises very straightforward. So I'm not pulling them back to do anything fancy with whistles and bells on. I can tell you it's more just to have another opportunity of face-to-face, get them on board, understanding the principles, understanding how to self-manage and Also, decrease anxiety and fear avoidance. Whereas other patients, you can see the light bulb goes on. Okay, they know what the plan is. And then I might say, right, I'll see you in a couple of weeks for a review. And then, you know, right from the outset, I'm keen on, I want to make you expert at managing this. And, you know, I'm just in the wings if you need me, but you're the one that's going to manage it.
SPEAKER_00:So you're getting a good read on probably their understanding and their buy-in to the condition.
SPEAKER_01:Absolutely. It's key. Absolutely key.
SPEAKER_00:Claire, you've covered everything from diagnosis to treatment and communication. Thank you so much. And where can people find out more?
SPEAKER_01:So, yes, if you're not bored of knees by now, which I hope you're not, then my website, which is www.claire.com. And there's resources for patients and there's resources for clinicians there as well. And I've just set up a fat pad forum for patients. So I'm just fine tuning it. But yes, so if anyone is mad about fat pads, that's where there's more information.
SPEAKER_00:Thank you so much for your time, particularly at night time in the UK there.
SPEAKER_01:Pleasure. It's all right.