[Case Studies] Inside a complex hoffa’s fat pad case with Claire Robertson

In this episode with Claire Patella we explore an interesting case study on a real patient of hers - a patient who presents suffering with bilateral Hoffa’s Fat pain. We cover:

• Differential diagnosis of Hoffa’s Fat pad pain
• Role of the entire kinetic chain
• Key, expert tips for management of this condition
• Specific evidence-based exercises for treatment
• How to manage patient setbacks

This episode is closely tied to Claire’s case study she did with us. With case studies, you can see how top clinicians manage real-world cases and apply their strategies to get better results with your patients.

👉🏻 Watch Claire’s case study here with our 7-day free trial: https://physio.network/casestudy-robertson

Claire Robertson qualified in 1994 with a BSc(hons) Physiotherapy. She has since obtained her MSc Physiotherapy, in 2003, and PGCE in 2006. Claire has worked in the NHS, academia and private practice, and currently runs a specialist patellofemoral clinic at Fortius, London spending an hour per patient and liaising closely with their treating clinician. Claire has lectured internationally and has many research papers and editorials published in internationally peer-reviewed journals.  

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Our host is @James_Armstong from Physio Network

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Transcript

SPEAKER_01 0:02

Welcome back to Case Studies from Physio Network. In this episode, we're diving into a fascinating and very real clinical challenge: managing bilateral Hoffers fat pad inflammation. But what makes this conversation particularly valuable is that this case didn't follow a smooth or predictable path. Instead, it gives us an honest look at what happens when a patient gets worse before they get better, and how clinical reasoning, communication and adaptability become essential. Joining me is none other than Claire Robertson, a highly respected physiotherapist known internationally for her expertise in telephemoral pain and anterior knee disorders. Claire has spent decades working with complex knee presentations, combining strong biomechanical understanding with a deeply patient-centered approach. She's widely recognised for translating complex knee mechanics into clear, practical strategies that clinicians can apply in everyday practice. In this episode, Claire walks us through a real patient she treated, from initial assessment and treatment planning to the moments where progress stalled and symptoms flared. We explore how to respond when rehab doesn't go as expected, how to rethink loading and diagnosis, and what clinicians can learn from cases that challenge our assumptions. If you've ever had a patient whose symptoms escalated despite your best intentions, then this is an episode you do not want to miss. I'm James Armstrong and this is Case Studies. Claire, great to have you on Case Studies. Really looking forward to this episode. We've got a really good case to go through. It's great to have you back on.

SPEAKER_00 1:39

Thank you. Lovely to be here.

SPEAKER_01 1:41

So without further ado, we're going to get straight onto this. Hoffa's fat pad inflammation case study. I've given it away already. We're going to go through the history of the patient and the differential diagnosis, but we'll get through all of that in a second. Shall we kick start with the patient? Give us a bit of an overview of the presenting complaint and some of the history that you got from the patient.

SPEAKER_00 2:04

Yeah, sure. So 45-year-old lady, normally a non-exerciser, that was relevance the case, bilateral knee pain, reporting swelling, high pain scores, eight out of ten at worst, struggling with day-to-day life. And even on the first session, you're really quite anxious and tearful. And the history was that she normally had a fairly sedentary lifestyle for 5,000 steps, 1,000 steps a day, but no, never had any knee problems at all. Interestingly, she'd been to the GP who with a bit of hip pain previously had said, Oh, she has spotted arthritis, which had certainly lodged and created a bit of fear. And then she suddenly decided to get fit and put on a pair of basically kind of fashion trainers, went to the local park, went for a jog, no fall, no trauma at all. And then woke with severe pain, both knees, infraropatella, and she immediately decided to take some neurophan for five days, didn't do anything, and then she self-referred herself to me.

SPEAKER_01 3:10

There's some few bits there that listeners are probably straight away picking out that are quite pertinent. Let's go into some of the symptoms, Claire, that then start getting your ears thinking Hoffa's PatPad. So picking out those symptoms.

SPEAKER_00 3:24

So her her pain is infrapatella, but we can't presume by that it's Hoffers, because there's plenty of other things that can create pain there as well. It was the wording she used was quite interesting. Nipping, stabbing, and very much on attempts at extending her knee. Her gait wasn't really abnormal, walking with no heel strike whatsoever, on a very flat foot and flexed knee, standing really virtually impossible. She could manage a minute or two, wasn't sleeping well because of it. And visually, there was a lot of edema in the fat pads, both sides, centrally and medial and lateral, but no joint effusion. I think it's quite important to distinguish the difference between a joint effusion and edema in the fat pad, because they are most certainly not the same thing.

SPEAKER_01 4:11

While we're on that, in the case study, you do talk about that in terms of how you can maybe visualize that better. Any tips on when you're looking at that edematous fat pad, how might you see that?

SPEAKER_00 4:21

Yeah, well, sometimes I have a funny thing that I think it looks like frog's eyes under the patella because it's like a pair of bulging circles. So you're looking obviously at location of the edema, but be careful because with the fat pad, sometimes it can just be infralateral or inframedial. But then also you're looking for the absence of effusion. So you're looking for you can still see the dimples either side of the patella as you come down onto the joint line, and you might want to do a sweep test either side up besides the patella. And with the joint effusion, you'd be looking for that fluid to be seeping side to side, and you're not going to get that with a Hoffa's fat pad edema.

SPEAKER_01 4:59

Perfect. So we we've got a few things in the subjective there. Do you want to just pull out for those symptoms? What are the standout things that would differentiate this patient having a Hoffa's fat pad impingement or inflammation as opposed to say a patelephemoral pain?

SPEAKER_00 5:15

Yeah, because both of them could be atraumatic. I think the severity of the pain is more likely to be Hoffers, but you do get sometimes people with patelephemoral pain. But consistently, people with hoffers often talk about really awful pain. I think the nipping and catching is definitely something that you would see with hoffers, and that is as you get an impingement and the patello is literally catching and pinching the fat pad. And then it's very much a pattern of extension here. She's doesn't like standing, she doesn't like swinging through to a heel strike. Now, patellofemoral pain, you're going to be looking very much at a pattern of flexion, loading that is disliked. So getting out of a chair, going up the stairs, return from a crouch. Whereas fat pad is all the extension things, and they'll often choose to stand in knee flexion and they'll often walk in a bit like John Wayne with bent bent knees. And that's almost one of my biggest clues as they walk in from the waiting room, if they're walking in with that flex stance, a telephemoral pain sufferer would never choose to put themselves into that position.

SPEAKER_01 6:19

Excellent. Okay, lovely. And and in terms of other things we we might see, is there anything about heels, like wearing heels or footwear that someone might prefer or not like?

SPEAKER_00 6:29

So again, if you go up into a bit of uh an elevated heel, so essentially through the shoe, that's often very offloading for fat pad. So bizarrely, that you know, I've some of my patients have walked in almost in high heels with a raging fat pad problem because that's the only way they can offload them. I remember one lady had to be really high heel, and they often really dislike flats. And conversely, you know, you're never going to get someone with patella from all pain saying, Oh, I really like it when my heel is elevated because it's loading up that patellamore. So again, it's a really good way to differentiate.

SPEAKER_01 7:04

Some sort of clear patterns, they're almost opposites, aren't they? In some respects.

SPEAKER_00 7:08

Absolutely. They're really useful. I mean, obviously, some patients you have a bit of a mixture, but I I think they are really useful. I think the other thing actually is that with the walking, I always ask every patient, do you have pain walking on the flats? And if they say yes, it's highly unlikely to be patelephemoral pain. They might get walking down, pain walking downhill and sometimes uphill, but very unusual walking on a flat pavement, whereas the fat pads absolutely hate that.

SPEAKER_01 7:37

And I've other than found that actually people with telephemoral pain, you might even find that they can continue running. They've found ways that they can carry on, whereas you're not necessarily going to see that in someone with a with a fat pad irritation. Brilliant. Okay, so let's fly back to our case. So we we've assessed this, but you've assessed this patient. I'm putting myself in here now. You've assessed this patient. We've we've come to a pretty good conclusion that the fat pad is the origin of this poor person's pain. So now we're thinking, okay, right, what do we do? So what is some of the things that you your your go-to's in the initial stages of of helping someone in this situation?

SPEAKER_00 8:18

Yeah, so you can get pathology in fat pad, like ganglion, you can actually get tumours, but it's pretty unusual. So generally they fall into two counts, the fat pad patients. One is a trauma where they've had something like a blow to the front of the knee or a heavy fall onto the front of the knee. So very identifiable moment where it kicked it off with something that's come into contact with a fat pad, you know, and coffee tables, table legs, that sort of thing when people simply just whack the front of the knee. Then we got the case more like this one where there's no there's no trauma at all of any sort. And then you've got to ask, well, what are the drivers? So is there something biomechanically that is overloading the fat pad or encouraging it to get impinged? So we're really into a really solid biomechanical screen from the foot right up to the trunk.

SPEAKER_01 9:17

Yeah, really important to look at that whole kinetic chain.

SPEAKER_00 9:20

Yeah, absolutely.

SPEAKER_01 9:21

Okay. So then what's some of the most important bits that you would start with in terms of your treatment? How did you approach this patient?

SPEAKER_00 9:28

Yeah, so clearly she's got really quite aggressive inflammation, she's hugely anxious. The worst thing I can do is rev up that inflammation pain. Not only will it be really unpleasant for her, but she's gonna lose faith in me. So my starting point has got to be trying to reduce the inflammation because it's not just about symptom relief, but by reducing inflammation, I'm reducing the swelling, which means I'm reducing the size of the fat pad, which means I'm reducing the likelihood of it and pinging. So I'm helping to break that cycle that she's found herself in with this large fat pad. So my go-to measures here are an ice massage to oiled skin, two minutes to the fat pad. And look, I know there's a lot of controversy around ice at the moment, but just for the record, the controversy, if you really analyze it, is around healing, tissue healing, around subtissues, ligaments, tendons, muscle. We don't have a damaged structure to heal, to worry about the healing process here. We just have a fat pad that's in a state of inflammation. So I personally think that the ice massage is really, really useful. And it's been shown that they often have fat pads that are way too big, so really engorged with the blood. So the ice massage, I think taping is really useful as well with patients just to lift the patella, just a tiny bit, but it's often the margins are so small, it just breaks the cycle. Just a millimeter or two is enough to give the fat pad a bit more space and it it can calm down. And I'll also I'll often look to shoes, getting them into a trainer with a heel drop or putting a heel raise into their shoe as well. And just for a very short amount of time, not that this lady particularly needed persuading on it, having a uh keep the keep the step count low. And more often the conversation goes along the lines of look, I know you're not walking much at the moment because it's just you sore, but if you suddenly feel a lot better, don't suddenly go and do a lot of walking. Let's build that up incrementally. Otherwise, that lack of incremental reintroduction of walking, Stanley, will just set it off again.

SPEAKER_01 11:46

Ever wished you could see how experts treat real patients of theirs? With case studies by Physio Network, you can. Watch presentations where top clinicians break down real-life patient cases step by step, showing how they assess and treat even the trickiest of conditions. It's the best way to improve your clinical reasoning and build confidence in the clinic. Click the link in the show notes to start your free trial today. I remember we we had JFS Gullier, who was one of the lead authors of the peace and love paper, which talked about the removal of ice. But actually, interestingly though, Claire, I remember him talking about the fact that it was how deep down does that ice penetrate the tissue. And actually, we're talking about quite a super well, very superficial structure, aren't we?

SPEAKER_00 12:32

So you could argue skin, so it's really very good for ice massage.

SPEAKER_01 12:38

Absolutely. When we come on later on to one of the other measures that was used when this didn't go so well, another reason why having something that's quite subcutaneous or very low tight of skin, it can work. So really interesting. And and taping wise, a lot of people when we hear taping might often go to K-tape, so your stretchy kinesia tape. Actually, for this, I'm I believe you probably would recommend something a bit more rigid.

SPEAKER_00 13:02

Yeah, absolutely. Think zinc oxide is much more effective because you're just you are actually trying to get the mechanical effect of lifting and pulling that patella off the fat pad.

SPEAKER_01 13:10

Brilliant, brilliant. And then as physios, we usually want to give people something to do. And as you rightly said there, we we need to be careful to keep this patient bought into the process. How would you go about initially starting them out with some some strengthening and some some loading?

SPEAKER_00 13:30

Well, the good news is if you go for mid-range, so 30 to 60, we're really giving the fat a lot of space and often they can tolerate things really well in that space. This is also important, otherwise, the fear and ultimately then the kinesophobia can become really profound. So you do want them doing something. I mean, ideally, you want to do it for strength work in this case, but you also want to do it because you don't want them becoming incredibly fearful of their knee and moving. So I think again, isometric work is really useful, but in that range. So if we've got a really sore knee, am I going to move it around lots and rattle it around, or am I just going to put it in a position where I know the fat pad is likely to tolerate it and then get some loading off onto that muscle? So single stance at 30 degrees, moving the other leg around, or wall squats again at maybe 45, 50 degrees, working to just really try and get some activation so that we don't have then have a secondary risk factor of atrophy coming into play, which is just then something else you've got to deal with.

SPEAKER_01 14:36

Yeah. So you're almost managing the symptoms to settle, but keeping everything ticking over, maintain, maintaining, if you like, as at the same time. Yeah. Yeah.

SPEAKER_00 14:46

And above and below as well, hip and calf you can be doing in open chain, you could do side leg lifts, but again, bend the knee a bit. You could do seated calf raises with a weight on the lap. Ultimately, you're gonna have to choose how much in terms of volume of exercises. And this lady is a non-exerciser, she's not used to exercising, so I chose to keep it pretty slim in terms of the volume of exercises.

SPEAKER_01 15:11

Absolutely, yeah. No, any more than three exercises adherence drops, so not a not a bad shout. So I think from the case study, and and obviously, listeners, I really highly recommend you going into this case study because another thing I want to mention, Claire, you you go into much more detail about the space that the the fat pad occupies and and why some of those degrees of movement is quite important. So listeners can have a look at that in the case study. Another thing I'm going to highlight here before we go on to the the spin of this and and and the decline at one point is this patient, I believe, was had some significant things going on in terms of psychosocial elements to some isolation and things like that.

SPEAKER_00 15:49

This turned out to be an interesting element to it because she hadn't been in the UK very long and all her family were overseas. So she didn't have a she didn't have much of a support network, whether it was friends or family. She found the inability to walk without being in so much pain really rendered her housebound. And yes, on the one hand, it was good that she could work from home, but she really didn't go out for weeks and weeks and weeks. And she got into quite a sort of mindset of ruminating about her knees, poor sleep, feeling very helpless, and quite an obvious decline in her mood. She couldn't come to see me in person because it was too bad. So I was seeing her remotely, but I every time I saw her online, I was getting increasingly concerned about her state of mind.

SPEAKER_01 16:36

And so now we go on to the bit where it hasn't gone so well. So we had a bit of a setback. Talk us through the setback and then we're going to look at how you brought her out the other side.

SPEAKER_00 16:45

Yeah, just a little bit. So as I say, I had been observing and I was worried about her, but it's you know, like lots of our patients when they're in loss of pain, they have low mood. But she came on the call and she said it's changed. She said, My knees are on fire. I have to keep looking at them to see if they are actually on fire. Because I can't, I can't believe that they're not. The burning is so extreme. And she said they're red. And I said, Can I can I see over? Oh, it was remote, but can I see? And this is this is the picture that I was presented with. Very significant. I said, Have you just iced your knees? Well, coming on the call. I wanted to just check it wasn't because she just iced. No, she'd not ice. She was now saying that her pain was 10 out of 10, and that actually she couldn't go on like this. She had no one visiting her, she was on her own, the pain was unbearable, and that she had considered taking her own life.

SPEAKER_01 17:41

And that's quite a massive thing to hear, isn't it? Especially remotely, Claire, as well.

SPEAKER_00 17:47

It's very difficult. It's very, very difficult. And you know, you can't sit on that kind of information, you know. So I then felt compelled to involve her GP, made sure she had the number for the Samaritans. And I'm then thinking, okay, this isn't just her inability to cope. Something has actually genuinely physiologically changed because her knees were not bright red like this before, and she wasn't using the word burning, she was staying nipping, catching, much more mechanical. So I felt that we had entered a much more neuropathic presentation in order to confirm my thoughts. I scored her better and then for the S LAN using the SLAN score, which you know is in the case. It's really quick and easy, it's freely available online. And sometimes it also helps you persuade the patient about what you want to then go on and talk about. And she scored 24 out of 24. I mean, it was just as raging as it you could get. And so, for whatever reason, and I have my uh hypothesis on this, she had tipped into a very strong neuropathic scenario where it was no longer just mechanical knee pain, but the brain was perpetuating it and probably also perpetuating this very excessive blood flow through the area as well.

SPEAKER_01 19:04

Definitely. So, how do you switch approach then from a quite a mechanical picture to this the neuropathic driver? What was your your go-to then? How did you switch a thing up?

SPEAKER_00 19:16

You know, I didn't want to appear that I was gonna be, oh well, you know, I can't do it. So I'll send you to someone else. But I also absolutely needed someone else's help as well. So I um involved a consultant pain colleague. We worked together regarding this lady. So my treatments, physio, if you like, treatments, were that I gave her an upper body program because I wanted her to feel some element of control, something that she could do, and also for any kind of hormonal release from exercise, it's been shown to be so useful with neuropathic pain. I suggested the Curable app, which is written by a team of paying doctors, physios, neuroscientists, psychologists, for her to start working through. And I also recommended to her, which she did follow through on, that she had tried some acupuncture as well. Um and we managed to find someone really local to her, which was great. So one thing just to be aware of is knee extension is often considered quite an easy exercise, particularly if it's performed over a rolled-up towel or just over the edge of a bed. But don't be fooled. In this group, the fat pad patients, it's one of the most vicious things you can do. So I would steer away from that. I think there's a lot better things that you can choose that are lower risk.

SPEAKER_01 20:35

Definitely. And I think there's lots of ways to do this. Is the beauty of being a physio and having exercises? There's so many exercises that we could choose from, especially for the quads, that we we don't have to irritate something. We don't have to we don't need to. So moving finally on on Claire, what are some of the conclusions and and what was the final outcome with this patient?

SPEAKER_00 20:56

Yeah, so she did brilliantly in the end. She got back to a fully normal life, and I guess the silver lining, which was great, was that she enjoyed the exercise and the rehab so much. She ended up joining a gym, and I wrote her a whole body gym programme, which was great. So she ended up healthier, fitter, stronger than going into the problem. She also actually, we had quite a few discussions on sort of psychological resilience, and she'd been in a very dark place. So that was another silver lining for her. Ultimately, that she realized how psychologically strong she was as well. But I think the main things are I had to be very flexible and I had to do an absolute change of direction when things were changing, and I had to understand my own limitations and reach out for help. And I think that that's incredibly important. No one's ever going to criticize you for getting another pair of eyes and ears or just drawing in on some other profession's help. And I think just being consistent with the messaging as well, no matter how difficult it was, I needed to be calm because she was absolutely. I could see read constantly reading me. Has she given up on me? Does she think that I'm a lost cause? And it's that, no, this is difficult, but we can do this. We can do this. We can turn this around and being really consistent with the messaging. I wasn't as foolish to say a time frame, but just saying there is hope there, we have to keep hold of that. And I think that was really important, particularly when things were really difficult.

SPEAKER_01 22:25

Definitely, and that consistency, and rather than flip flopping between different things, and then the patient doesn't really know where they are, where they stand, and what what the outcome's like to be. Thank you very much, Claire. Thanks again.

SPEAKER_00 22:37

Pleasure. Thank you.