Why Fat Pad Impingement Hurts so Damn Much

Understanding Fat Pad Impingement

The infrapatellar fat pad is a sensitive mass of tissue that lies behind the patella tendon and on the front side of the knee joint.  With it being located below and behind the distal end of the patella or kneecap, it’s quite vulnerable to trauma and is an obvious source of pain.

It is not the most common of knee injuries but it may be one of the most difficult ailments to eliminate.  The main function of the fat pad, or Hoffa’s pad, is to provide a protective padding to the knee’s condyles located at the distal end of the femur or thighbone.  Many knee injuries involve a blow to the front of the knee and the fat pad is an effective structure to buffer the forces on the vulnerable articular surfaces of the distal femur.

The two most common mechanisms of injury for fat pad impingement is a direct blow to the patella and front of the knee and hyperextension of the knee joint itself.  Both mechanisms create a pinching of the fat pad resulting in swelling of the pad and surrounding tissue.

With this type of a knee injury, the fat pad becomes very painful and slow to heal. Due to the location of the fat pad behind the patella tendon and the high forces associated with the patella itself, an enlargement of the fat pad can significantly impair the overall function of the knee and quickly limit the athlete’s leg strength.

Signs & Symptoms of an Impingement of a Fat Pad

  • Palpable swelling below and to both sides of the patella tendon.
  • Pain below and to the sides of the patella tendon with squatting.
  • Pain below and to the sides of the patella tendon with leg extension along with noticeable bulges to the sides of the patella tendon when the knee reaches full extension.
  • Increased warmth and a sense of fullness in front of the knee below the patella.
  • The inability to actively extend the knee to full extension due to pain when pressure is applied to both sides of the patella tendon.  This is referred to as a Hoffa’s Test.

Professional Treatment for Fat Pad Impingement

  • Resting the knee while avoiding all activities that apply pressure to the anterior knee and/or increase symptoms.
  • Ice, ice and more ice.
  • The necessary modalities and therapy devices to reduce swelling, decrease pain and restore normal knee mechanics.
  • The use of a roller and massage therapy for the hip flexors, quadriceps, ITB, hamstrings and calves to increase tissue mobility and reduce patella compressive forces.
  • Painfree flexibility activities for the hip flexors, quadriceps, ITB, hamstrings and calves to improve lower extremity range of motion.
  • Implement a quad-strengthening program that is painfree while being performed in a range of motion between 90 degrees of flexion and 20 degrees from full extension.
  • Patellofemoral taping can be an effective treatment for sub-acute and chronic knee injuries that involve the patella and the patella tendon.
  • Knee sleeves that provide stability and motion control to the patella may be helpful if additional pressure is not applied to the infrapatella area.

Asking the Questions a Pro Athlete Would Ask

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Are you certain of the diagnosis (Dx) of fat pad impingement and does this Dx match my mechanism of injury (MOI)?
  2. Are there any additional complications to this injury that I need to be made aware of?
  3. I’m concerned about losing my quad strength so what can I do to help me maintain my lower extremity strength?
  4. Do I show any signs of a mechanical abnormality such as a leg length discrepancy or chondromalacia that needs to be addressed in addition to my fat pad injury?
  5. What type of progression do I need to follow when I return to my sport?

Elite Sports Medicine Tips from Mike Ryan

  • Start Treatment ASAP – You don’t want a chronically inflamed fat pad.  Treat it the right way now and be done with it.  If you wait expecting it to “just go away”, you may be sorry that you did.
  • No Go 2 Stop & Go – Stop & go sports such as tennis and basketball are no friend to a painful fat pad.  Don’t be in a rush to return to such sports until the swelling is minimal, the quad strength is at least 90% and the pain is mild.
  • Pray for Help – Kneeling on the knee, as in the praying position, will increase the symptoms of an inflamed fat pad.  I’m not suggesting that you stop praying but a simple pillow under your knee will help make your religious duties much more comfortable.
  • Looking Elsewhere – If your fat pad is painful yet the mechanism of injury just does match up, the problem may be from somewhere else.  Chronic foot pain, tight hips, a symptomatic plica and Jumpers Knee are just a few examples of injuries that can indirectly inflame a fat pad.
  • Avoid the Knife – I have seen very few fat pads that required surgery.  I strongly suggest that you avoid getting surgery on this issue until you have exhausted all of your conservative options and been diligent with your rehabilitation.

Author: Mike Ryan

After 26 seasons as a full-time certified athletic trainer and registered physical therapist in the National Football League, Mike Ryan has outstanding first-hand experience. His unique professional and athletic background has sharpened his skills in the arts of sports injury management, elite rehabilitation, performance enhancement and injury prevention. Mike is now taking his experience to mainstream America. His mission is simple: Sports Medicine advice that is easy to use and brings fast results. Learn more about Mike Ryan

142 thoughts on “Why Fat Pad Impingement Hurts so Damn Much”

  1. Mike! Great information, with rest and ice, conservative strength training of the hamstrings and quads, how long for this injury to heal? Thanks

    1. The sooner your treat it and eliminate the stress on the tissue, the sooner it heals. A chronically swollen fat pad is a nightmare.

  2. Hi mike..
    I had acl reconstruction in september 2015..since then i have suffered chronic pain in my leg knee down and total numbness..my surgeon says it has absolutely nothing to do with my knee and that it could likely be sciatica..lastweek i made him send me off for an MRI due to being annoyed at his responses that the symptoms im feeling are irrelecant to my knee..ive just received my results and its saying i have slight impingement to the ligament..is this rectifiable without going under the knife again and do i need a new surgeon..please email reply..thanks mike

    1. Hi Jenene, I’m sorry to hear of your condition and complications from your ACLR. Your issue can be resolved often with non-surgical treatment if a physical therapist can regain your range of motion (ROM). The leg numbness does sound like it’s more back than knee related. Not surprising if you’re walking alignment is off and you’re compensating for your knee.
      To Do: Find others (friends, FB posts, phone calls to rehab clinics,…etc.) with knee injuries who “love” their knee physical therapists. You need to get that PT(s) to treat you.
      1. Restore full knee extension and 90% of knee flexion.
      2. Restore at least 85% of quad strength of involved (not “bad”!!) knee.
      3. Balance out walking patterns = each side of your body (knee band, foot position, arm swing, trunk rotation, foot placement,..etc.) is doing the exact same thing as the other side.

      Start there and you will: Be so much happier and/or know if surgery is the only realistic option.

      I wish you a fast recovery. Keep me posted Janene.

  3. Hi Mike
    I have anterior knee pain and an US showed impingement of my superior-lateral fat pad between my patella tendon and a thickened ITB. I also had an MRI but there wasn’t much to see. My fat pad looked normal. I have had the pain on and off for a couple of months now as I have been training for a marathon. I fear whatever is being impinged is now chronic. Ice helps. Taping my patella to move it medially does too but it just won’t get better. Any other suggestions? Apart from stop running. Is there any benefit to an Ultrasound guided cortisone injection?

    1. Hi Ruth,
      What you describe if often referred to as patella femoral pain syndrome (PFPS) and it’s not an easy injury to manage as a runner…..but I’ve suffered from the same injury and I have some tricks to help you. Get to a runner-friendly physical therapist or athletic trainer to help you. There’s a reason why this keeps coming around and the major factors are often above and/or below the knee itself.

      Here’s what you need to LOOK AT:
      Leg length – Don’t be shocked if 1 leg is 1/2+ inch longer than the other.
      Knee flexion (bending) – It’s very common that a painful PFPS knee has very tight quad muscles.
      Quad strength – Do the mirror check: is that quad smaller and weaker?

      Here’s what you need to DO:
      Roller – Get aggressive with a hard roller on your quad and ITB for both knees at least 2 times per day.
      Stretch – The looser your hamstrings are, the less compressive forces on your patella (kneecap)
      Cross train – Add swimming, biking and elliptical trainer to improve your fitness and to balance your leg muscle conditioning.
      Ice – As you have done, continue to do it early and often.

      You have some work ahead of you, Ruth, but this is a manageable injury. It’s time to get busy and keep me posted.

      Happy Miles, MDR

  4. I have been diagnosed with an enlarged fat pad and have been scheduled in for surgery. I have had no other treatment and the injury occurred over a year ago in the gym through an over extension of my leg on a spinning bike. I am really unsure wether to go ahead with the surgery and would really appreciate some advice. Is physical therapy the best route and does surgery cure it. The knee gives way coming down the stairs regularly and exercise is sore on the joint so I have not done any for several months.

    1. I strongly suggest a solid 4-6 weeks of physical therapy before going he way of surgery. Regaining normal ankle, knee and hip biomechanics and strength is so important for you because this injury is a year old. I’m sure you’re compensating for this injury with your entire lower extremity and restoring it to it’s pain-free state is so crucial with a fat pad injury. Example: Both a $300,000 car and a $200 car will have problems throughout the entire car if it has poor wheel alignment. Getting your biomechanics “right” may help you avoid surgery or if you eventually do need surgery, your recovery will be less then 1/2 the required time.

  5. Hi mike, I have a long standing fat pad impingement that has not been resolved with PT, cortisone shot and most recently working with a chiro. My quad muscles are gone and I have been trying to build them but everything is so painful-should I just push through the pain or can you suggest anything else I should try?

    1. Hi Di, to answer your question is NO, don’t just push thru the pain. Quad strength is so important to both improve your pain and to help you prevent it from returning. Based on your comments, this will be a struggle for you. Here’s your key tip: ISOMETRIC QUAD STRENGTHENING. After a thorough warmup with rollers, patella mobs and stretching, find a position to isometrically isolate the quads. Your focus: Find a position with a knee angle/foot position which creates quad fatigue with MINIMAL knee pain.
      Examples: Isometric Wall sits, isometric sitting knee extensions, quad sets.
      Start slow. Concentrate on getting your quad to respond quickly then focus on the strength of the contraction. Gaining a responsive quad (“wake up the quad”) without knee pain is the initial goal then build on that.
      Because this is such a chronic injury, the improvements will be small so look for them, celebrate them and build on them.
      Keep me posted on your upcoming amazing recovery, Di!

  6. “You don’t want a chronically inflamed fat pad. Treat it the right way now and be done with it. If you wait expecting it to “just go away”, you may be sorry that you did.” Unfortunately, I was foolish enough to believe that it would go away on its own and now I’m definitely regretting it. I was diagnosed with the injury last year. I attempted physical therapy last month but it didn’t help much at all. I read an article that stated cortisone shots are very effective for fat pad impingement. Is this true? I am a 20 year old male if that has anything to do with how quickly a fat pad hardens/how likely it is to heal. Thank you for the information. I only wish I had taken the initiative to treat my injury and find this page sooner.

    1. Your dilemma is too common, Victor. Injections are not always the answer and should not be done until you’ve tried other conservative options. Get back with PT with new vigor to get your swelling down and your quad strength up. Aggressive home treatment is a must so let your PT direct you for what to do and what NOT to do. Mechanically, something is “off” and finding the source of that factor(s) such as a leg length imbalance, stiff ankle, hyper-mobile kneecap,..etc. is the key to a quicker recovery with a knee fat pad injury.

  7. Helpful read, thanks! My 11yo just got her MRI back and it showed inflammation and infringement of the fat pad. She is highly competitive in karate and hurt it landing a jump where she must have hyperextended her knee 1 month ago. She was on full rest for two weeks because they thought she fractured her growth plate but that was ruled out. She’s seeing a pediatric physical therapist next week. Is there a general timeframe when competitive athletes can get back to form? She’s still in a good bit of pain just walking with full pressure but is hoping to make the National Championships in a month…realistic? Thanks again for the info, I had never even heard of a fat pad before today!

    1. Thanks for your email, Danielle, and sorry to hear of your daughter’s knee fat pad injury. Fat pads tend to have a “mind of their own”, therefore, there is no set timeframe with this injury. My advice to you: Use pain, swelling and function as your guide. If she’s still sore walking, she should limit the weight on her leg with crutches if she has any chance to compete in Nationals in 1 month. In addition, pain-free quad strengthening, deep-pool running, massage/flexibility and ankle mobilizations should be part of her rehab plan with her physical therapist. Don’t be surprised if they need to repeat her MRI if symptoms persist. I wish her a quick recovery.

  8. I have had chronic knee pain for the better part of six years that all started by my right knee giving out rounding third base in softball. It didn’t hurt or swell right away, it wasn’t until the next morning when I went to walk on it the next day that I knew something was wrong. I went to the university doctors office and was given a “sprained MCL” diagnosis. It got “better” but since have experienced chronic pain. I have had a couple issues with it giving out and instability. Most recently it gave out on a simple fadeaway jumper. My doctor thinks it could be a fat pad inpingement, but having an MRI done in a few days to access. If it is indeed fat pad infringement, what kind of recovery am I looking at, epecially since the injury is old and has been chronic?

    1. Hi Kenny, the MRI will give you valuable advice. Don’t be surprised if the MRI reading of the fat pad is inconclusive. With a chronic issue like this, assuming it’s not a laxity issue based on complaints of more pain than consistent buckling of the knee, I suggest you get with a physical therapist to develop a PAIN-FREE quad strengthening and patella mobilization plan. If the fat pad is impinged and enlarged, those 2 PT plans becomes very important.
      Minimizing anything that’s inflaming your knee (kneeling, deep knee bends, squats, minimalist shoes,..etc.) will help. Doing everything you can to quiet your knee like icing, aggressive rollers, quad strengthening, core exercises and hamstring stretching will certainly help.
      This is your knee and it’s time for you to take control of it’s function and pain, Kenny! I can help you do that starting today.

  9. Dear Mr Ryan,

    Thank you for this informative post. I just had a few queries. In April 2016, I injured my knee by kicking a ball ( I feel it was hyper extension). I did not think much of the injury to begin with ( bad, bad mistake) and continued to play sport and run athletics for 5 more days until I realized it was not getting better. I got a x-ray done on the knee in early May and a MRI done on the 22nd May; however, both suggest that my knee is fine. I have been to a physiotherapist for around 4 weeks but I felt that they did little to improve my condition. I have also been foam rolling my IT band every night. With my conventional options exhausted, I went to a specialist doctor last week, where he told me that it might be a “fat pad impingement” and that I might need to get a “keyhole surgery” to shave off the fat.

    I am quite hesitant about getting surgery so I just wanted your opinion on my symptoms and whether it matches that of a “fat pad impingement”. When my knee is bent, I feel virtually nothing; however, when standing up and keeping my knee very straight, I feel TIGHTNESS and DISCOMFORT in the knee, in an area which I feel is hard to localize. Also, when kicking a ball, I feel a shape pain in my knee as well.

    If you feel it is indeed a “fat pad impingement”, what can I do to help my condition without getting surgery? I have read multiple website including yours and I have started to ice my leg for 10 minutes every hour. Is there anything else I should do to accelerate my healing process (e.g. quad stretches) or do you think surgery is the only way right now.

  10. Hey Mike,
    I have a 16 y/o who competes at high level volleyball. In April she hurt her knee with a hyperextension movement. She was immediately diagnosed with plica and inflamed fat pad via MRI from an awsome OS. He gave her the options and we decided to proceed conservatively. She was nwb for a few weeks and has been doing PT and no sports since with no significant improvement. Her pain level is constant 3-4/10. She recently had a cortisone inj. into the fat pad and after a short duration of increased pain it has returned to the prior 3-4/10. Her season is beginning again the end of July and she wants to get back desperately and is entertaining the scope removal. My concerns are:
    Will the cortisone cont to work and break down the fat pad and inflamation improving her pain level in the next 2 weeks?
    Recovery time to play post scope?
    Future complications of scope? Adhesions? Trauma to knee structures without the pad after diving and jumping?
    With all of these factors, what is your opinion.
    I would hate to continue to treat it conservatively and have to scope in the end where she would miss all this time.

    Ugh! Desperate to make the correct decision

    1. It sounds very similar to fat pad impingement Rona. I hope she had a full exam to rule-out other sources of pain in that area like bone bruise and meniscal tear? Don’t rush into the surgery but if it’s needed to SEE the entire knee, compared to reading an IMAGE from the MRI, and to remove a now chronically-inflamed fat pad, is not a bad option. Regaining her quad strength is very important for jumping athlete like her.

  11. Thanks so much for all of the information! I was diagnosed with fat pad impingement just over a year ago. There was no initial injury or hyperextension that caused it, just lots of running. Running is the only time the pain is sharp. After stopping almost all exercise and doing physical therapy for a few months, I tried to ease back into running but the pain came right back. I then had a cortisone shot, more months of rest and physical therapy and a second MRI and second opinion confirming the diagnosis. I was able to start easing back into running again and had no pain and minimal swelling for 3-4 months. Now the pain and swelling are back. I will definitely try focusing more on stretching and foam rolling my hamstrings, quads and IT bands after reading this. What activities can I do to stay in shape that will still allow the fat pad to heal? Biking, swimming, weights – squats, lunges? None of these cause sharp pain but do sometimes cause swelling and/or dull, mild aching.

    1. Hey Sarah, It’s not surprising that running causes fat pad impingement but it is interesting that lunges and squats don’t do the same. You need to change the angle of your knee when you run. “What??” Let me explain: You can apparently load your kneecap and go thru a big range of motion (ROM) without angering your fat pad yet the very angle that you run in, which is typically very limited in 40-60 degree of motion, directly catches your fat pad. It’s like biting your cheek and swollen cheek flat gets bigger and it gets in the way more often.
      Your success will come down to your ability to progress your running on a combo of inclines, softer surfaces, shortened stride length, more stable running shoes, calf/Achilles stretches (say after me: “I love downdogs and I’ll do that 2-3x/day”), quad/ITB rolling on a HARD roller, ITB stretching and a full body flexibility program.
      As a PT who also loves running to watch how you run and see what needs to change. Sway low back? Toe runner? Over-strider? There’s something there that needs to change.
      Also (my mind loves to race with cool injury puzzles like your’s!), get your PT to do lots of patella mobilizations. Normalizing the movement patterns of your kneecap is crucial for fat pat impingement patients.
      Keep me posted Sarah. I wish you well.

  12. My knee has a strange problem, which looks like a severe nerve irritation from the joint. The electric shocking pain comes from the area under/near patella tendon. The pain feels deep and explosive. Most of time it seems spontaneous and I can also sometimes trigger the pain by stepping on the leg during walking. When I stepped on it, the pain spreads horizontally and feels like a chain.

    A lot of things have been tried and MRI/Xray only shows mild lateral subluxation of the patella with intact medial retinaculum/cartilage, and small effusion. No doctors think the joint should be so irritated.

    A few things lead me thinking of fat pad irritation:

    1. I had a direct injury on that location which also created a one time shocking pain at the time.
    2. Push knee cap towards foot can sometimes trigger the pain.
    3. Injured tendon area is sometimes 2-3F warmer.
    4. Tendon band triggers more pain when wearing it
    5. Straighten leg on bed for a second can sometimes trigger a delay episode

    The pain has been going for half year now. I would like to hear your opinion on fat pad issue. Thank you so much.

    1. Hi Hans,
      I’m sorry that you’re dealing with this knee injury. I agree with your thoughts on the fat pad. Your mechanism of injury, location of pain and characteristics of the pain all align with a fat pad injury.
      Are you getting physical therapy for this? I’d be curious to see how it responded to controlled range quad strength work. The key step, as you’ll see in my article on this much under-appreciated injury, is to quiet it down with ice, eliminating activities that increase symptoms and possibly anti-inflammatory meds. I’m not a big fan of any medicine so this might be one of those times to ask you doctor about them.
      Sometimes it comes down to two simple questions to get you on the right track after your 6 month battle:
      What makes it better?
      What makes it worse?
      Start there, with your ice, get a great PT to work with you and keep me posted. Best to you Hans.

      1. Thank you Mike.

        One great news is that nerve block on saphenous nerve reduced the nerve inflammation and now the spontaneous day/night endless pain stopped. Remained is activities triggered pain.

        My PT doesn’t feel fat pad is very irritated. It is not clearly swollen. However, the massage on tendon reveals a few tender points, one is particular painful. I can never feel those tender points by myself and I don’t recall any Dr tried that before. For some reason, I always feel great after massage on tendon with a cold hand.

        I was told my muscle is weak and needs to get stronger.

        I will keep work on that direction to strength the quad muscle, ice cube massage, TENS stimulation VMO and NSAID.

  13. Dr Ryan,

    Could you please describe details of the worst fat pad irritation you have ever seen?


    1. I’ve seen knee fat pads that were huge, painful and blocked complete knee extension. Most of them were secondary to violent trauma to the front of the knee. #NotGood

  14. Dr. Ryan,

    Thank you for all your helpful comments. I’ve been suffering from bilateral fat pad impingement/ scarring for over 8-9 months now. It comes and goes, and make quad strengthening extremely difficult (I’ve been suffering from mild chondromalacia in my knees for a while now). I just had a PRP injection for my left knee cartilage last week, and the fat pad has flared up again since the needle was inserted in my knee through there. I’m afraid I have more hypertrophy now of the fat pad than I did pre-injection. Once the fat pad hypertrophies, is surgery the only way to fix symptoms?


  15. Hi Dr. Ryan!
    6/11/16 14yo son ran his 2nd 5k. did fine. no problems. not much of athlete, so no history of sports injuries.
    6/15/16 twisted/cracked/popped knee in basketball game. went back in limping, hobbled about that evening with friends. didn’t seem like a big injury. moderate swelling, pain, so iced TID and ibuprofened for many days. tried walking normally on it after a week of limping and babying it, resulting in audible “pop” sound along with increased pain. used crutches a bit when had to be up for long. may have over done it with a vacation to float the river…
    6/28/16 PCP (who happens to have played college baseball so very familiar with sports injuries): ‘osgood-schlatter’ but could have a broken bone in there so yes, keep that appt with ortho in 2wk to get an xray. wear this brace for now…
    7/5/16 ENDOCRINOLOGIST check up for HGH treatment: no worries in regard to this treatment and this injury, stay on program as usual growth rate 5.2 over past 3mon. fastest ever since starting HGH 3.5 yrs ago.
    7/11/16 ORTHO: hmm significant swelling and pain for it to be one month post injury… ACL feels loose..get MRI
    7/ 14/16 MRI results: 1. changes are most consistent with bursitis of the deep infrapatellar tendon, but there is also suggestion of Hoffa’s impingement syndrome. 2. otherwise unremarkable

    we have 5 more days until the ORTHO can see us to go over these results and tell us what to do 🙁 kiddo missing out on all kinds of summer fun while we we fear doing anything wrong to cause further damage. we need him on the mend asap (the weed eating really needs to get done!) any thoughts would be much appreciated!
    Stagnating here in East Texas

  16. Thanks so much for all of the information! I was diagnosed with fat pad impingement just over a year ago. There was no initial injury or hyperextension that caused it, just lots of running. Running is the only time the pain is sharp. After stopping almost all exercise and doing physical therapy for a few months, I tried to ease back into running but the pain came right back. I then had a cortisone shot, more months of rest and physical therapy and a second MRI and second opinion confirming the diagnosis. I was able to start easing back into running again and had no pain and minimal swelling for 3-4 months. Now the pain and swelling are back. I will definitely try focusing more on stretching and foam rolling my hamstrings, quads and IT bands after reading this. What activities can I do to stay in shape that will still allow the fat pad to heal? Biking, swimming, walking, yoga, weights – squats, lunges (these keep my strength up but cause muscle tightness)? None of these cause sharp pain but do sometimes cause swelling and/or dull, mild aching.

  17. Hi Dr. Ryan,

    I was seen by my family physician for knee pain and referred to physical therapy. The physician did a few tests on my leg (moving it around, watching me move it), and determined that my knee seemed in tact. The physical therapist also did similar external tests, and diagnosed me with fat pad impingement. My question is, is it odd that I haven’t gotten any imaging, no X-ray or MRI? I agree the diagnosis seems to make sense based on what I’m experiencing, and I did take a direct blow to the knee cap during a fall about 6 weeks ago. But it seems like some imaging would tell us for sure whether there is anything else going on. Would you suggest asking for imaging, or does this seem pretty standard to you?

    Thanks so much for this blog! I didn’t even know impingement was a word when the pt said it, so I was glad to find this information. 🙂

  18. I have been having pain for a couple years now in my left knee have had 2 mris done in the past 3 months in campe up showing that I have high t2 intensity signal where my fat pad is. Can someone explain what this means.

  19. Hi Dr Ryan . Last year I had an injury on both my knees my doc said only physical therapy is needed. While i was doing pt this year I got injured again in my right knee the pain was so strong that I only could walk with crunches and a brace. My results of the recent MRI said “Persistent edema in the lateral aspect of Hoffa’s fat pad most likely related to chronic patellofemoral impingement” my doc said that I might need surgery will that help ? Thanx

  20. Hi Mike, I have recently had surgery on the fat pad and also a stimulation of the patella as there is some bone growth there. There is not much swelling, however the pain is quite high at times, is that normal? Also, I do not seem to have much movement and cannot tense my leg muscles at this stage. I heard it can be a long recovery from this surgery, what do you recommend? I walked about 200m yesterday, which was slow and more than enough. I know I need to weight bear, just not sure how much I should be doing? Many thanks

    1. Hi Nigel,
      Thanks for your questions and I’m concerned about your injury. I’m not sure what you mean by “stimulation of the patella” and what was actually done during your surgery of your fat pad? I’m also concerned that you’re unable to contract you quad muscles and your weight bearing protocol is not in writing and in your hands. I’m sorry to sound like “Mr Negative Ned”.
      Based on your comments, here is my advice:
      1. Make an appointment with your surgeon and take notes with his explanation of what he did during your surgery.
      2. Get a written rehab protocol from your surgeon.
      3. Make an appointment with a registered physical therapist WHO SPECIALIZES IN KNEE INJURIES to rehabilitate you and to monitor your aggressive home exercise program.
      4. Work hard with your exercises, roller, stretching, icing and conditioning based on exactly what your doctor and PT prescribe for you to do.
      Get healthy fast and be a great patient.

  21. Hi Mike my name is Dan. I have had hoof syndrome most of my adult life and have done everything bar go under the knife to fix it. I get good and bad days with it, but sometimes it can effect my work and I’m getting fed up of it. I really want to avoid the knife but I really don’t know any over options. I can be fine one day, climbing a mountain in the Lakes and then be bed ridden the next. I was on crutches with this pain for 6 months of last year and it has been a hindrance on my adult life. I have seen so many Doctors ect.. and just do not want to get an operation. the only thing that seems to stop the pain when I’m trying to sleep at night is to put a pillow under my knee (but I have been told this is a bad thing to do) I keep taking pain killers but it’s not solving the problem. I would appreciate any advice.

    1. I feel for you, Dan. Sorry to hear of your struggles with your fat pad impingement. It sounds like you have run the conservative/non-surgery plan for a long time and now surgery is your best option. I don’t say that too often, as a physical therapist, but if long-term pain medicine and serious chronic pain in the outcome as-is, it’s time to change that plan.
      The other big benefit of a surgery is the doctor’s ability to completely evaluate your knee. There may be other factors that have been contributing to your pain.
      I wish you well, Dan.

  22. After medial meniscus repair surgery nearly 3 ago I have been left with severely swollen fat pads and inability to fully straighten my knee. Suffering daily knee pain. I had a bad fall tearing meniscus, mcg and small tear in acl. Spent many sessions at physio, icing and anti inflammatories with no result. Seen another physio who suggested I go back to surgeon. Any suggestions ??

    1. Hi Raelene, You need to restore your knee range of motion and quad strength. There are many ways to do that while the fat pad impingement improves. I worry that you may be waiting on the swollen fat pad and the remainder of the knee is suffering. If that’s the case, get back to the doctor to get you in the hands of a new physio (PT in the states) to get you back on track to rehab your entire knee. I wish you well and a fast knee recovery!

  23. I have recently Ben diagnosed with Hoffa Syndrome. My doctor placed me in a locked knee brace. However I seem to have more pain while normal bending of the knee to get into bed and other activities. Should I look to more of a compression sleeve?

    1. Ana, Hoffa Syndrome or Fat Pad Impingement requires the front of the knee and the inflamed fat pad to both quiet down. Wearing a brace locked in complete extension is one way to do it but it’s not the only way.
      I suggest you call your doctor to explain your symptoms and how some “slow and limited motion” of the knee makes you knee feel better. I think he will trust you and your physical therapist to slowly progress with limited motion as long as he can trust that you will avoid deep knee bending and all trauma to the front of the knee which would increase the swelling in your knee fat pad.

      1. Thanks Mike, I talked to my doctor and he changed the brace to an unlock giving more motion and has me doing walks in the evening which has lessened my pain when I try to bend!! I still have a long way to go but eventually I hope to get back into the elliptical Thank you

  24. Hello! I am from Russia. I am Sorry for my English! 2 question. Does fat pad grows after resection surgery? Do I have limits in sports activity after surgery? Thank you Mike.

    1. Thanks Valery. Your English is fine and I like how you get direct with your questions about fat pad impingement! No wasted words. LOL
      To answer your questions:
      1. Some of the resected fat pad does grow back. Hopefully by that time, the knee mechanics and patella tracking patterns have been corrected. Therefore the likelihood the fat pad would be impinged is minimal.
      2. Yes, you will have some early knee limitations after fat pad impingement surgery while you regain the key factors associated with your entire knee such as quad strength, patella mobility, leg length difference, ankle range of motion (ROM), quad flexibility and activity modification. With proper knee rehab, those functional limitations are short-term.
      I wish you well.

  25. HI Mike! Appreciate all the advice and information you have provided. I had a medial meniscus repair 8 months ago, struggled significantly with fat pad issues as well as irritation from the sutures/anchors. The fat pad calmed down (with the exact advice you had recommended!!) but the suture and anchor kept bothering me so it was taken out recently (meniscus healed down). I felt great for the first few weeks (though still very swollen), then was walking at the stores and on my feet for nearly 2 hours when all of a sudden I found it difficult to bend my knee out of full knee extension. Every step is super slow because I can’t bend my knee. I get really concerned it can be something inside the joint (intra-articular) but I think it sounds more fat pad as all my symptoms match up with the findings . Interestingly backwards walking doesn’t cause any restrictions. I’m working on painfree range quad strengthening, working on flexibility and any soft tissue restrictions. The problem is my job requires me being on my feet most the day:( Do my symptoms seem to match up with fat pad ? The locking really freaks me out:( It’s with 90% of my steps, and always if I try to walk with normal velocity gait. But again, it doesn’t happen when I backwards walk! Appreciate any tips! This has been one tough year:(

    1. Tough year for you, Emma. But your “I’m going to get thru this” attitude will reward you! My thoughts: You problem does sound intra-articular (inside the joint) like a swelling or meniscus issue. Not reporting any “catching” or locking” is great and it tells me the meniscus is not the main culprit. Backwards walking isolated the hamstrings to quickly bend your knee and that is why you can do it easier than actively unloading the leg, relaxing the quads then initiate your hamstrings.
      Must Do’s:
      1. Control your swelling – ice, compression, anti-inflammatories and comfortable/stable shoes.
      2. Get on the roller to regain mobility of your quads, ITB, upper calves and hamstrings.
      3. Consistent motion without the weight bearing loads. (bike, pool running, swimming, AlterG)
      4. Patella mobs and massage. Get that kneecap moving and moving well. Research Patella Baja…you DON’T want this so make sure this is not happening.
      5. Regain quad strength but only in a comfortable range for the kneecap.
      6. Ice, ice baby! Try doing it in a 45-90 degrees of flexion to see it is allows for more motion when it thaws out.

      Keep me posted Emma.

  26. Hi mike

    I found out earlier this year that I have an injury behind my kneecap above the fat pad and it’s not an impingement. Ive been having severe knee pain since febuary and got it checked in April. The advice of my knee specialist was to strengthen the muscles around the knee but I have limitations of what I’m able to do.

    Ive been doing exercises such as leg extension, leg curl and leg press. I use both ice and heat treatment as well as massage around my knee to help. Nothing is helping. My doctor said that having surgery or steriod injections would cause more complications for me, due to the position of the injury. Have you got any advice that I can do or try to reduce the pain?

    1. Hi Natasha, Your doctor is correct but your exercises need more direction. You do need to strengthen your quads (muscles on front of thigh) but only in a very limited range of motion (ROM). Doing leg extensions and leg presses in full range like you’re doing will only irritate the damage behind your kneecap.
      Find the range for both of those exercises where you have NO pain and MINIMAL grinding. Note that those range will probably vary with both of this exercises. Now only do those exercises in a slow and controlled manner within those ranges.
      Get busy using a hard roller on the front and sides of your thighs 2-5x/day. It will keep your muscles limber and greatly reduce the compression on the back of your kneecap.
      Forget the heat. Go with lots of ice after your workouts and at night before you go to bed.
      Keep me posted and feel better soon.

  27. Hey Mike.

    I’m two months into debilitating pain in both knees, and MRIs say “bilateral edema throughout the suprapatellar fat pad.” I’ve been in PT for over a month with zero improvement. I saw a specialist today but her speciality was in trauma, and didn’t have any advice. At this point, I can barely walk for more than a half hour or so a day. Should I consider using crutches for awhile? Or take a couple straight days in bed? Both knees are killing me. It even hurts when I sit. Totally lost.

    1. Hi Jacob, Yes, you need to completely rest your knees in a position of about 30 degrees of flexion with pillows behind the knees. Ice every hour, do easy knee bend/straighten in a PAINFREE range of motion, stretch your hamstrings consistently, use a medium/hard roller on the front and sides of the thigh, stretch your calves with downward dog stretches and focus on increasing your comfort level when walking. The next step is improving your quad strength but quieting your kneecaps is your top priority for now. I wish you well Jacob.

  28. Mike,
    What does fat pad impingement feel like? Is it possible a patient only occasionally triggers the sharp impingement pain near lower pole of patella during walking?
    Thanks, Han

    1. Yes. It’s like when you bite the inside of your cheek. The more you do it the more swollen the inflamed “flap” on your inner cheek and the more likely you bite it again. An inflamed knee fat pad becomes larger and it is more likely to be pinched under your kneecap and become painful.

      1. Thank you Mike for this information. It was never mentioned on other web articles on fat pad syndrome.

        Is this occasional pinched sensation unique to fat pad impingement, or it could apply to other issues like plica and synovitis?

        1. Great question. It can apply to a plica, meniscus tear or loose body. The key factors which differentiate between all of these “something just gets caught in my knee!” injuries are:
          1. Location of the pain – Exact location where it catches.
          2. What is it catching under – Fat pad >> under kneecap, Plica >> upper/inside knee cap, Meniscus >> Between thigh bone and shin bone.
          3. Mechanism of injury – Contusion (plica) vs twist (meniscus) vs over-use (fat pad)
          4. The Unknown – Knees are vulnerable. The comments above are “typical”. As we know in sports medicine, it is NOT an exact science so we can always find outliers with any injury. 🙂

  29. I injured my knee about 9 years ago in dance and noticed the swelling and pain ever since. It feels like if I could just lift my kneecap, I would gain some relief. Finally decided to have it checked since now I’m standing for at least 6 hours at a time at work, and it’s become more painful. I was referred to physical therapy that hasn’t helped at all so I had an MRI, and was told I don’t have enough fat tissue and have Hoffas disease. Now looking at going to an orthopedic Dr and possible a scope. Any advice? Am I at the chronic stage now that I’ve waited too long?

    1. I hear your type of story often Marie. Yes it’s chronic and seeing an orthopedic doctor is a smart move. An injection might be an option. Did your PT have you using a hard thigh roller? Patella mobilizations? Both are vital treatments I’d recommend to include for you.
      Another thing: Stand in front of a full mirror with your short-shorts on. Is that quad skinner? Is the muscle round muscle at your distal INNER quad just above your kneecap flatter and softer than the other side? If so, you need to do more PAINFREE quad strength work.

  30. Mike,

    Why cortisone shot into joint through bursa won’t do much good for fat pad impingement? Is fat pad isolated from the joint?


    1. Yes, the fat pad is separate from the joint capsule. They are 2 different “bags of fluid” although they are both in the same neighborhood. 🙂

  31. Hi Mike,
    So glad I found your page. I slipped and landed on both my knees, my left knee taking the most damage. After painful visits to my doctor and physio I went for a MRI scan which diagnosed I have a damaged fat pad. I have had months of physio and I’ve been exercising lightly but the pain is always there and seems to be going worse. I’m also getting pain in the back of my knee cap, I have to keep my leg straight whilst sitting down. Just don’t know what to do next…my doctor says that it will go in 6-9 months its been 6 !months up to now.

    1. The mechanism you suffered – trauma to the front of your knees – is the most common way to inflame your knee fat pads. Seeing it has been 6 months, it is officially “chronic” so you need to at all your options. Here are what I suggest you focus on:
      1. Loosening up your fascia from your hips to your arches. Get with the best physical therapist who can treat your fascia. It’s not just a fancy name for a “massage.”
      2. Patella mobilizations – regaining normal motion of your kneecaps is key.
      3. Pain-free quad strength work. You need strong quads that are balanced = all 4 quad muscles for each quad. Limited arc knee extensions will do it as long as that arc is pain-free.
      4. Very flexible quads, hamstrings and calves will decrease the compression on your fat pads AND normalize the way you move. Your fat pads will thank you.

  32. I wish this article was out sooner! A few years ago I had been kicked at work and also slipped on ice the same day while running. It took over a year to get a diagnosis of Fat Pad impingement syndrome because the symptoms are very similar to IT band syndrome or classic runners knee. I had massage 3x per week for several months, acupuncture, Graston, PT for a solid year, (three different PT’s and a lot of money) I saw osteopaths, Active release therapist. I want to a pool therapist so I could keep my strength up when I couldn’t even walk pain free. I had cold laser therapy, I did it ALLLL… End result was surgery. Before I could even feel my leg fully again I knew I was cured. I’ve been running again since and have PRed in the marathon, but the recovery from surgery is still on going. Very hard to rebuild and MAINTAIN inner quad strength. I have constant over rotation from being so imbalanced and now I suffer from super bad sciatica…. Better than the knee, but this injury just plain SUCKS! My sports medicine doctor let me be awake for surgery because I wanted to see the issue myself just to be sure I didn’t make it up (which was what many PT’s started thinking…) Hopefully I make a full recovery ffrom surgery, but I think I’ll always have PT to do to maintain balance.

    1. Wow, what a story and a true tribute to your determination, Cait. I’m so happy to hear about your successful outcome regarding your knee. Stay on top of your inner quad strength work. Have your loyal PT(s) evaluate you for a leg length difference and be aggressive with your core flexibility and strengthening to resolve your back pain.

    2. Hi Cait,

      Your story sounds very similar to mine, only it took me 2 years to get a diagnosis. All conservative treatment methods have failed, and I want to take the next step in getting the fat pad trim surgery. Can I ask how you found a surgeon to help you with this condition, or who you actually saw?


      1. Also, if a specific surgeons name cannot be mentioned here, please email me at amanda.papili@ymail.com. I desperately need help with this. I cannot even perform basic household tasks or walk much anymore, let alone the running, snowboarding, and other athletic activities I used to do. I really appreciate any help..

  33. Hi Mike

    I am a doctor myself who is suffering from bilateral chronically enlarged and inflamed fat pads for 1yr now. One off event where hyperextention the cause. PT has helped but 3/10 burning pain starts after a short while when legs in extended.

    Can I just add your advice at the top of this page is one of the most useful I have seen on the net. I have researched this topic a lot and completely agree with you.

    My question is, once the fat pad becomes a chronic injury and remodels it can of course start to effect the patello femoral joint dynamics as a result. In situations like this where it is felt clinically there are no major maltracking issues otherwise, is surgery the way foreword ? Or have you indeed seen good PT actually reduce a chronically inflamed fat pad which is much tougher in consistency.


    1. Jay, If the fat pad is inflamed for that long, PT can help but I’m not convinced the infrapatella fat pad will return to the pre-injury size. If you go the way of surgery as you’ve read in the dozens of my followers, only use a surgeon who has surgically treated 30+ of these chronic injuries and a physical therapist who has rehabbed 50+ surgical and non-surgery Hoffa fat pad injuries.
      Make sense?

  34. Hi, my wife had some of her fat pat shaved as it was trapped behind the knee this was on Jan 9th 2017. She can’t FWB she is still on crutches is this normal procedure? She was due to start a new job 4 weeks ago as she got adviced crutches for 2 days then start to FWB. Any help ,advice, exercises would be very much appreciated.

    1. Is she seeing a physical therapist or certified athletic trainer? Her pain should be much better by now. For example, if she’s not full weight bearing (FWB) she needs to be working on her quad strength and knee range of motion to prepare her entire leg to be ready for the rigors of walking. It’s not a rest, rest, rest then be FWB plan for a post-operative knee.

  35. Found this article so helpful thank you!! I have been struggling with fat pad impingement (+ patella maltracking) for 10 months now, when it first happened it started off with sore arches, tight calves as well as painful knee, I tried walking down a slope and it felt like someone had whacked my knee with a hammer, from that point I could barely walk and was stuck in doors for weeks, forcing me to leave my job as I was on my feet all day.
    I have always had achey knees and found I had to stop squats and leg lunges from the age of 28 as it was too painful but stupidly chose to ignore it and carried on running with out getting them checked out. Never long distance as knees wouldn’t let me.
    I have tried everything I can think of the last 10 months, I have had 3 physiotherapists, (although first one we didn’t know that it was fat pad impingement at that time) 2 cortisone shots which didn’t help me much and acupuncture. I take turmeric, and flax seed oil to help with inflammation and ice is definitely my best friend. I have been to see and Orthopedic Surgeon, mainly for an opinion and advice rather than surgery, but he does think I am better off having the surgery. I know no one wants to have surgery but I would much rather heal this knee if its possible without going down that road. But I am now getting to that point where I’m sick of the pain and restricted to do things that I’m seriously starting to consider it. I had left my recent physio has he made me do squats which i was nervous about doing and of course felt the pinch almost fell over and my knee flared up again, he now says i should consider surgery, safe to say i lost my confidence in him. Unsure whether I should persevere, start physio with someone else and give it one last shot. Or would surgery be my better option now? just worried it may cause further problems afterwards.

    1. Hi Maria, I know this injury must be very frustrating for you. Everyone with this injury feels that b/c few medial specialists appreciate the limitations and pain associated with fat pad impingement. Therefore, you are not alone. Read the others who have echoed your same thoughts on my website. 🙁
      Here’s the key points to think about before you look at more rehab, another injection and/or surgery: You need to restore your knee range of motion (ROM), mechanics and strength. The squats are not the answer as you wisely noted. Very limited, painfree ROM strength work is needed. Even if it’s isometrics, that is fine. Increase increase the QUAD straight WITHOUT increasing fat pad pain. Sounds easy, huh?
      I’m biased, I admit. Go with a smart physical therapist who listens to you and keeps your rehab simple and effective. Keep you rehab plan focussed on the 3 key objectives above. (restore your knee range of motion (ROM), mechanics and strength.)
      Stay with me, Stay positive, ice allot, listen to your body, keep me in the loop and I want to make you one of the dozens of SUCCESSFUL fat pad athletes. Sound good?
      Go get to work.

  36. Cyclist. Nonpast problems. Hard ride has equalled me being out for 6 weeks so far. Had two physics and been icing, resting, rebuilding with no change at all. Serious frustration with the lack of progress after such a long time. The minute I try to increase or do a little more it just flares up again. So many cycling events in Europe planned and paid for and I can’t even walk day after day without pain or feelings. Losing patience!!!

    1. I’m sorry to hear this Craig. I hate to sound like a broken record but read what I just wrote to Steve about his daughter with this injury. But it sounds like you HAVE been aggressively treating this…aka, no being passive. Correct? If so, too aggressive?Looking back at what started the knee pain, were you pushing too big of a gear or recently make a big bike fit change with seat or handlebar drops?

  37. Hi Mike
    thanks for the great info here. I couldn’t find much info about fat pad impingement elsewhere. We will get on with the exercises you suggest ASAP.

    I have a question for you:

    My 14 yr old field hockey mad daughter hurt her knee is august last year. After no progress and continual pain, we got an MRI last month which showed an acute fat pad impingement.

    She has stopped all sports but still walks to school each day and by the time she gets home she is in significant pain most days. Is this making the problem worse? I could drive her and could get her crutches. do you think that would be a good idea to help her rehab?

    thanks for your help!


    1. Hi Steve, If prolong walking it making your daughter’s knee fat pad painful, yes it is making her knee worse. She need to see her ORTHOPEDIC doctor and physical therapist to get inflamed tissue treated. Based on the 6 month timeframe she’s been dealing with this injury, it is “chronic” and now more difficult to treat. Lots of ice, stop all activities which increase her pain, keep her in a stable shoe and keep the fat pad painfree as you regain her knee range of motion (ROM) and strength.

  38. Hello. I have just been in for an operation. They have apparently removed the fat pad and a large Plica (On my piece of paper).
    They didn’t know the cause so I asked/ gave permission for them to take a look.
    I am a little lost as to what to do next. It has been four days and I can stand on my leg and hobble along. However I cannot bend the leg (heel to bum) much at all.
    All I was told, was what they had done and given some pain relief and physio exercises to do. But I’m left questioning how well I should be doing with these?
    I have no need for pain killers as it doesn’t hurt to just be around the house. Changed my bandages after 48 hours. Rested up for 3 days mainly in bed.Went for a walk with crutches to shop and back.
    So the specialist appointment is in 6 weeks. What should I be expecting roughly and what should I be doing? Any help is appreciated!
    Kind regards Colin (a self-employed outdoor instructor)

    1. Hi Colin, I don’t want to complicate what your knee surgeon has done with your surgery….therefore it’s VERY important for you to contact your doctors to:
      1. Get SPECIFICS of what you should do and should not do for the next 6 weeks.
      2. DEMAND to start physical therapy for your knee fat pad asap. You want a local PT to examine you and manage your rehab NOW, not 6 weeks from now.

      Here are my general thoughts:
      – Your patella (kneecap) femoral joint and knee joint (separate joints) both need to be mobilized and their range of motion increased. A still knee is not kind to your fat pad or to your knee plica.
      – Quad strength is important but how you do it and the range of motion used for those exercises should be done under the watchful eyes of a certified athletic trainer or physical therapist.
      – Your knee plica is a seam in your knee capsule. When the doctor cut your knee plica, it will scar down quickly. Patella mobilizations and massage are needed asap to keep the knee plica from scarring down just as tight as it was before the surgery.
      The bottom line is you need help now to ensure you benefit from the surgery. If you don’t think it’s important, simply read the dozens of comments on my website regarding my followers who are limping in pain because of a fat pad injury which was NOT treated properly. Learn from them.
      Remember: Your doctors and rehab specialist work for you, not the other way around.

  39. Hello Mike. Thank you for the advice and reply so quickly!
    Yes to your suggestions. I will try and demand. I’m quite annoyed I’m in the dark and having to read up and frankly ask you. It affects my life, happieness and work massively and was not an easy choice to have surgery knowing there would need to be time off work and potential risks that could leave me without the same life or career. I am keen to recover and get back my leg strength and mobility that has not been 100% for 5 years now.
    I really appreciate your time and advice and understand your position of knowing very little but wanting the best for me. Best wishes, Colin

  40. Hi Ryan! The information you provide is so incredibly informative. I and the hundreds of others who are frustrated or feel lost are very appreciative! I actually have a few questions about long term outcomes (if you happen to know). I had two scopes (most recent one 8 months ago), both which pissed off the fat pad. On the second one, prolonged sitting and walking 2 weeks after surgery caused something to get pinched, the fat pad became very big and mechanically limiting. Had a cortisone shot which helped, had two wonderful PTs who I worked with. My rom is symmetrical, medial patella tilt is still limited from the tight lateral structures. It I find this is improving. Quad strengthening closed chain 90-50 degrees is doable. I had recent MRI which shows a continued inflamed and scarred fat pad. I also continue to have small amount of knee joint effusion. It continually becomes trapped inferior and lateral patella when coming out of extension open chain. The only thing that limits this is loosening up all the lateral structures/fascia/muscle, but it doesn’t last more than a few steps. My options are wait, PRP injection, surgery to trim. I’ve been patient with this for over a year now, and I can continue to be …. I want to avoid surgery if possible, as after each surgery my knee has ended up in worse condition. Any suggestions? And have you seen these improve over time like I am describing? I used to be a competitive runner and now I have been struggling to walk for the past year. Really appreciate any info on your experience!

    1. Your symptoms and struggles are common for your fat pad pain. As you know all too well, the solution is not simple and a bit cloudy. What you need to do at this point, based on what you told me, is regain your knee ROM and to decrease your fat pad swelling. Ask yourself: “What are you doing which is increasing the stress on my knee fat pad?” It can be simple things or your workouts. You know you will feel better if you:
      1. Increase your knee ROM
      2. Decrease your fat pad swelling.
      3. Increase your quad strength.
      I hope this helps.

  41. Hi Mike, I’ve been dealing with knee pain for 5 years now and I’ve never injured the leg. Its been diagnosed as a Plica and PatellaFemoral Pain Syndrome. After PT and a Cortisone shot did nothing and the pain got worse I had Orthoscopic surgery. Even after Surgery there was no relief. After that I went through more PT, a Chrio, and had another cortisone shot which gave complete relief for about 2 days. Eventually I had another surgery that was effective. I’ve been doing PT since then and the pain is returning. I’ve been told I need to accept that the knee is not normal and I may not be able to do things like Run. I’m currently trying to build my Quad because it is noticeably smaller than my good leg. Taping also provides some relief. I’m only 31, is pain going to be my new reality?

  42. Hello Mike!
    Thank you for all the info, it’s an incredible insight after hearing so many people ask me what a fat pad is…
    At this point, seeing as when I initially injured myself I waited for it to go away…. Only seeking medical help 6 months later. After wrong diagnostics and an MRI, the fat pas impingement is now clear….. Bringing me to the chronically inflammed part of it all. Walking is painful, so actual workouts are out of the question.

    When it comes to Chronic inflamation ofnthe fat pad… What’s next? Ive spent all of a month on crutches and there’s no improvement, my PT is suggesting full stop (stay home, keep minimal movement and ice) and going under the knife aounds like a bad idea? Will this ever end?

    1. I feel badly for your struggle Maria.
      I don’t agree that you shut everything down. It’s a balance of QUIETING DOWN your inflamed knee, REGAINING your knee range of motion (ROM) and INCREASING your quad strength. Orchestrating those three (3) knee factors for a chronic knee fat pad impingement is not easy and a challenge for you and your physical therapist.
      Things you can do to help your Hoffa fat pad injury:
      1. Aggressive knee icing – Throw away the frozen peas…ice with an ice cup massage or a slush-ice in a zip lock bag with the knee in 30 degrees of bend.
      2. Quad roller on front and side of thigh – Reducing the tension on the top of the patella (kneecap) will reduce the compression of the knee fat pad.
      3. Painfree Stretching – Stretch above and below the infrapatella fat pad. Hamstrings, calf muscles, hip flexors, ITB and Quads. Initially your flexibility of the quad muscles will be significantly limited. That will improve.
      “Ice, Motion and Ice” is your new plan.
      Keep me posted. Feel better soon. Your improvement will be baby steps so be consistent and avoid drastic changes in your knee activity.

  43. Hello I’m 26years old and I have been told I have inflammation in Both of my knee joint fat pads :(. However should this also cause my knee’s to cluck/pop when moving. It feels like someone is trying to rench off my knee caps. is this also a common issue with inflammation of the fat pads?

    1. Hi Kim, Yes it can be a result of an inflamed knee fat pad. The reason for the pops and kneecap pain is the enlarged knee fat pad changed the mechanics of your kneecap. The fat pad pushed on the backside of the patella tendon and your knee doesn’t like that. Look at your quads in the mirror with short-shorts on. You’ll notice that side quad is smaller and softer. You need to change that with pain-free quad extensions to increase the strength. Lots of ice on the knee to control the swelling of both the fat pad and the knee joint.

  44. Dear Mike Ryan.
    I am a 39 year old nurse writing you from Denmark.
    I Hurt my knee running in august 2015. I had alot of pain and tried to get back to Running, but couldn’t. MR last year showed inflammation and small edema in the knee. Was sent to PT. Had a hard time not overdoing it at the gym, but didn’t run. In march 2017 I went to the hospital (sports clinic). They gave me a steroid shot in the knee. It crystallized and made the inflammation flare Up. I can hardly walk Now. Now 6 Weeks later I am still in so much pain. A new MR showed corpus Hoffa syndrome – looked the same as a year ago.
    Is there hope for me? They told me PT and taping. But it Hurts so much. Could the shot really cause permanent Damage? Waiting for the shot to wear off but can’t Work right Now. Really desperate and scared – any advice?

    1. Hi Maria,
      I’m so sorry to hear about your pain and limitation after having your knee injected. I don’t do injections, I don’t like injections and I don’t claim to know when an injection is merited. I can tell you from a physical therapist perspective, you need to decrease your fat pad and knee swelling.
      Are you seeing a physical therapist in Denmark?
      I strong suggest you do. Getting the scar tissue from both the needle puncture hole and the initial injury loose and limber is so important. With the extra swelling in the fat pad, the patella and tendon can’t move properly. Get the best knee physical therapist in town to help you restore knee mechanics while decreasing the fat pad swelling.
      You WILL get over this injury, Maria, but it won’t happen with a passive plan. It will take work and a solid rehab team around you.
      Keep me posted on your plan and your upcoming success.
      Mike Ryan

  45. Hi, I am scheduled to have surgery on my knee for fat pad impingement and also just to see if anything else is going on in my knee. I was just wondering if I will be in a brace or anything after surgery and for how long? I have been dealing with this for a while and we have tried everything from physical therapy, immobilizing my knee and even a steroid shot into the knee. None of these worked so next step is surgery, he already told me I will be on crutches for 2-3 days but didn’t say anything about a brace, so is a brace something they make you wear after surgery for fat pads?

    1. You most likely will not be in a brace. Restoring knee range of motion and strength are important after this surgery. Make sure you have your physical therapy scheduled before your surgery so you don’t waste time during your recovery.

  46. Hi Mike,

    I fainted in my kitchen over the weekend, breaking my coffee pot and ended up with a shard of glass in my knee. Went to the ER and x-rays findings indicate “a small intra-articular joint effusion and gas seen in Hoffa’s fat pad.” I am definitely experiencing the pain associated with this injury as everyone else has mentioned, but it has progressively been getting better with Advil and time. Since this injury was caused by an acute trauma vs sports, what would you recommend for my treatment plan? Should I consult PT or is rest/ice/time best for my situation?

    1. Hi Laila, Sorry to hear about your injury. I think it will do well with a physical therapist monitoring your healing. The chronic Hoffa Syndrome or fat pad impingements are much harder to treat compared to an acute trauma related injury like yours.
      My suggested plan:
      1. Control your fat pad swelling with ice, no kneeling or hyper-bending, supportive shoes and limited ballistic quad loading.
      2. Anti-inflammatory meds – My many followers are going to be shock with this comment b/c I rarely like to involve medicine with my treatments. I’m a strong believer in elite sports medicine techniques instead of medicine. In this case you need to control your swelling asap. If you wonder why that is important, just read previous comments on this article to see the horror stories of the pain and long-term limitations this injury can result in.
      4. Easy motion via bike or heel slides.
      Keep me posted and fast healing. MDR

  47. Hi Dr Ryan,

    I started to have a knee inflammation 7 months ago and managed to calm down the inflammation after a couple of months.

    Then did an MRI and been diagnoctised with patello femoral pain syndrom + hoffa’s fat pad impingement + low grade patella tendinopathy.

    I went to a physio who helped by taping my knee and giving me exercises to recover step my step. I’ve seen some improvements after a month, not massive but a bit. Inflammation was still down.

    Meanwhile i was too impatient as my physio went on holiday and been to a practicioner doing chinese medicine / acupuncture. He said the best way to fight against hoffa’s fat pad issues was to break the tissues and therefore “worked” on it by putting high pressure on my fat pad area. Result: inflammation is back and knee in very inflammed, and now the area under the knee is becoming harder and harder!

    Why did the area under the knee became harder and how to make it softer? Should i keep putting ice on it? Also what do you think about the chinese technic, would you avoid it?

    Thanks in advance!

    1. I’m obvious bias being a physical therapist but why would you seek aggressive treatment when they talk about “break the tissue”? It’s not a sidewalk or an old patio, it’s your knee.
      What you need to do now it to reduce the knee inflammation involving your fat pad. Secondly, regaining your knee range of motion (ROM) without increasing your fat pad swelling is your next step.
      How do you do these two key steps?
      1. Ice massage
      2. Easy bike
      3. Roller on quads and lateral thigh
      4. Moderate massage of distal quad, back of knee and around the kneecap WITHOUT IRRITATING KNEE FAT PAD.
      5. Quad sets – Contracting the quads with the knee in full extension as long as it is comfortable below the kneecap.
      6. Ice massage
      Hoffa’s syndrome is a chronic injury that can be slow to heal. Be smart with your exercise and get back with your physio to treat this properly.
      Thanks for sharing my website with your friends and family to help to help others with FREE sports medicine advice.
      Mike Ryan, PT,ATC

  48. Hi Mike!

    I’ve read through most your responses listed above. I’ve been dealing with fat pad impingement/scarring for nearly a year now (following 2 arthroscopies). Things have improved moderately, but the pinching and catching I have continues to be 99.5% constant with every step (though it is 75% less overall). And I always have 1+ effusion by the end of the day. Things that have helped me the most is releasing anything that forms into the lateral retinaculum and anything that decreases compression on the knee cap.. I find after I foam roller, stretch or ice… I can have a few steps without any symptoms. It never last though. My ROM is symmetrical bilaterally, quad strength is also symmetrical (had this tested with BET), hamstring strength is still very weak however. I have been seeing wonderful PT’s whom I wouldn’t have gotten this far without! I still have some tightness on the lateral retinaculum (slight decreased medial tilt compared to my noninvolved side) and I think that tightness and lack of patella mobility is what got the fat pad pinched in the first place! I definitely can’t continue with my knee the way it is now, but I am afraid of surgery which could potential make things worse. Have you seen cases like mine which improve, even after it has been 1 year? I can palpate the area that gets pinched and stuck and it feels so small (like pea sized), but it causes me so much mechanical symptoms. I was a very competitive runner prior to this and now I can barely tolerate standing on my feet for longer than 10mins at a time and still can’t do stairs without irritating my knee.

    Any advice would be helpful! I am unsure if I should continue being patient that things will improve, or if surgery might be the route I need to go. I really appreciate your insight on this matter! Thanks

    1. Hi Leslie, You are a real trooper with your fat pad knee pain and recovery from Hoffa pad impingement. Yes it can turn around and I have seen a few, yet clearly not a majority, of the chronic fat pad impingement injuries. I worry, as do you, about how limited and painful your injury is to project how much improvement you will gain in the next 3-6 months. As you read from the dozens of patients who have emailed me about this injury each month, this injury is stubborn and slow to heal.
      I love to hear you have a great physical therapist in your corner. That is so important. Work closely with your physical therapist. Ice it multiple times per day and work on decreasing the Hoffa pad swelling while increasing your quad strength.
      Is surgery the answer? No one really knows because the surgery is more of a salvage/cleanout technique compared to a well-defined repair like an ACL or meniscus trimming. Ask you surgeon “how many of these specific surgeries have you done in the last 6 months?” You may be shocked with the low # he/she gives you. You want the most experienced doctor behind that knife.
      Keep me posted. Keep working hard. I wish you a full recovery. Mike

  49. Hello, I’ve recently undergone surgery for the pad and had some removed due to the extensive damage. I could not straighten my leg for 6 months. Since surgery I have gained full extension with post op physio. However now 2 months on I really struggle to bend the knee from a lying position as it feels it will ‘lock’. Is this normal?


    1. Hi Clare,
      Your tightness with bending of you knee is not unusual but it’s something your physical therapist or physio needs to address with your rehab. Scar tissue and adhesions are making your remaining fat pad firm which is creating the sensation of “locking” below your kneecap. You need a mobile and pliable fat pad for it to protect the backside of your patella tendon when bending the knee.
      What can you do to help?
      1. Roller – do it daily on your quads and ITB to lower the stress on the top part of your kneecap.
      2. Ice often – swelling is your enemy.
      3. Treatment – Work with a good physio who knows knees very well and communicates well with you.
      4. Be Your Boss – You need a healthy knee so be the boss of your knee to ensure you’re doing your part, your doctors are THOROUGHLY evaluating you and your physio is treating you with personalized and caring skills.
      Keep me posted and I wish you a full recovery.

      1. Hi Mike

        Thanks for your answer!

        And for quadriceps tendinopathy? Is swimming good too?

        I have both 🙁



        1. Yes – swimming is great for it. It’s also a perfect place to do my new favorite exercise as I rehab myself following hernia surgery: Deep water running.
          Tuck a floaty or noodle under each arm and start running in the deep end of the pool. It awesome….and it will kick your a*s! Get busy….

  50. Hi Mike!

    Thank again for your reply!

    In which fase is better to do this kind of rehab? Because I have tried it when the quadriceps were swollen and it got worse… Do tou think I should wait a better moment? Which would it be?

    Thank you!


    PS: Sorry for my English. I am brazilian.

    1. Regaining painfree range of motion of your knee is more important at this phase of your rehab. Key tip for Fat Pad Rehab: Do not recreate the pain. Deep water is perfect for you to do.

  51. Mike, Chris here from the UK- Excellent page and advice. Im a Kickboxer who has just been diagnosed with Fat Pad Impingment after some kind of Injury in April this year. I have not being given much advice other than ice, ice and more ice and get the quad super strong. Unfortunately my physio has not been very helpful with a specific plan.

    Im thinking of say doing the usually quad strenght execerises mini squats, quad sets with just body weight for say 1 month, then increase reps and weight over the coming months till pain is gone. My next step would be to begin a jogging program then if ok get back to kickboxing.

    Does that seem about right? I totally agree with you about the surgery iv heard once your cut its never right again.

    Also also any tips to avoid flare up in the future? Im thinking of just avoiding knee strikes on hard surfaces as I think thats what did my knee.

    1. Hi Christopher, I like your plan while I suggest a couple of additional tips:
      1. Don’t recreate the pain – For example, if simple body squats hurt, stop doing them.
      2. Restore normal knee mechanics – Regaining more painfree range of motion (ROM) is more important than big quads at this point in your recovery.
      3. Get a PT who knows this injury very well – This is a tough rehab to do on your own. Get with a rock-solid PT who can help with little things like patella mobilizations, proximal fibular mobs, soft-tisse release of your patellofemoral ligaments,..etc.
      4. Work above and below – This is no longer a knee recovery plan. Improving mobility of your ankles, hip flexors, calves, hip rotators,..etc. should be part of your plan.
      I wish you well and a fast recovery. MDR

  52. Hello Mike, Can fat pad injuries cause hypersensitivity and hyperalgesia over the knee. I’ve had two surgeries now to remove plical folds that the surgeon told me were irritating the fat pad. Actually the injury started out with the main issue being a feeling of fullness and finding wearing trousers/leggings/ tights unbearable?

    1. Your case sounds different and I wonder if the fat pad is the main source of your symptoms instead of the plica? With the hypersensitivity and hyperalgesia around your knee, I suggest you get a second opinion to get a new set of eyes on your now-complicated knee condition.

  53. Hi Mike,
    I had a plica removal surgery 9 weeks ago. The post op period seems fine but I still have pain in the same place as pre surgery, not as much as before but it still exists. My PT and surgeon think that the plica stump is infalmmed from the abut injury i,e surgery, and the MRI images show that the plica is fully excised and all other tissues are normal. I feel a tightness at the end range of knee flexion and also pain in the area of plica when my leg is suspended and flexed. I just hope I don’t have to go into surgery again, but does it take 9 or more weeks for an excised plica (stump) to heal? I’ve been following PT instructions regarding exercising and icing.
    Thanks you!

    1. Hi Varun, If your post-op treatment included patella mobilizations and massage to increase the mobility of the surgical area involving the plica, no it should not take this long to feel significant improvement.
      I suggest you have a group evaluation with both the doctor and your PT to determine:
      1. The source of your pain.
      2. The reason why your ROM is limited.
      3. The exact WRITTEN rehab protocol to increase your knee function and strength b/c obviously your present plan is not producing the results of your liking.
      I wish you well.

      1. Thanks very much Mike. I have been doing some patella mobilization over the past few weeks. I’ll check on the group evaluation.

  54. Hi Mike
    I had an arthroscopy 8 weeks ago to repair torn meniscus. I was doing really well then started to get pain that took me back 6 weeks. The surgeon thought my physio had pushed me too hard on rehab and recommended stopping all the squats and steps and reverting to isometric quad exercises. That was starting to help when I had a sudden pain as I went up the front door step. The physio thinks the fat pad is inflamed which certainly fits the symptoms. I am doing isometric exercises and regular ice massage. Should I lay off the squats for now? And am I OK walking? I’m due to go on holiday in 3 weeks time and really need to be able to walk (gently) for an hour or so at a time. I can walk with just mild discomfort right now. I am sometimes OK on the stairs, other times it hurts.

    1. Yes, stop doing squats. Ice > Motion > Ice should be your plan. Increasing your pain-free range of motion is very important for you as you plan for holiday and avoiding chronic knee fat pad pain.

  55. Hi Mike,
    Thank you for all of the informative responses you have given other peoples questions, but I have a few unique ones of my own.
    To give you a bit of a back-story I am also dealing with a fat pad impingement in my right knee (MRI has confirmed this) and have been dealing with this for 4 months now. The doctor had prescribed me with two different types of oral anti-inflammatory medications as well as a cortisone injection in my knee (none of which have worked). My PT has me doing hip and thigh related exercises 3 times per day and I have been on this program for about two months and not seen results yet. My range of motion is very limited and I can only bend my leg up to 90 degrees (on a good day) and cannot bend it straight, so my leg is stuck in that 20-90 degree ROM which has me walking with a very noticeable limp. I have also had two x-rays and the latest one I had last week shows the bone behind my kneecap deteriorating due in large part from not being able to weight bare with a bent leg. My questions are:
    1. My PT has be doing squats now which are extremely painful once my leg reaches a certain point and she says I must fight thru the pain. Is this normal? Should I continue with these type exercises?
    2. PT also has me trying to regain my ROM by extending my leg straight and bending it to where the pain starts. Isn’t this pinching the fat pad and causing more harm than good?
    3. Do you recommend and other types of exercises based on my limited ROM?
    4. What is the time-frame for this type of injury? The doctor says she hasn’t seen a case as bad as mine.

    I am feeling quite hopeless at this point by not seeing any results or relief from these exercises.


    1. Hi Jeff, I’m not too excited about your PT just pushing through painful ranges with you on squats and leg extensions. It sounds to me that this plan is increasing your pain and that is a clear sign that you need a PLAN B REHAB PROTOCOL to follow.
      Here’s what you need to do:
      1. Read the many comments my follows have shared with me on this injury. BEWARE: It will scare you but it will empower you to ensure your knee is treated properly.
      2. Write out what you want from your rehab plan and your desired goals and athletic ambitions.
      3. Make an appointment with your doctor to discuss your condition and dissatisfaction with your knee. Show him/her your goals and athletic ambitions.
      4. Request the best knee PT’s in your area to rehab your knee…without injections.
      5. Compare the list of PT’s with the local running clubs, track teams, high-level fitness clubs,…etc. See what those top athletes go to when they have knee pain.
      Do you see where I’m going with this?
      It’s time to take control over your knee care, Jeff. You only get one shot to get your knees right or you will pay the price with pain and a very limited lifestyle for the next 50+ years.
      Keep me posted on your progress and plan Jeff. MDR

  56. I was having issues with my Achilles’ tendon and was diagnosed tendinitis back in September. My tendon was tight and to relax it properly they put me in a cast. I was in a walking cast for about a month and a half until the pain was gone. As soon as they took that cast off, my knee started to swell and I could barely bend my knee without pain. I immediately started to ice and elevate until I could be seen. I had been on strong anti inflammatories so they gave me an injection and it’s been HELL. My kneecap is unrecognizable and the swelling is much worse. I do have to walk to places to get around and I’m up and down the stairs in my apartment. They wanted me to do physical therapy but I’ve been so sore—now it seems nearly impossible to do anything. I do as much leg strengthening exercises in my bed as I can. Is there anything else I can do? Should I ask for an mri? My knee is lost is a sea of swelling I can’t seem to get down and I’m starting to get extremely concerned.

    1. That is a sad story Jackie and I’m sorry to hear it. My advice: Yes, get the MRI. Something is seriously wrong in that knee and you need to know why you have so much swelling. I’m obviously a big fan of physical therapy so I think you need to get that knee in the hands of a skilled PT. Ice is your friend to help control the swelling and restoring the mechanics of your knee and kneecap is a very high priority.

  57. My 17 year old daughter dealt with two years of knee pain after a dance and then cheerleading injuries. She had cortisone knee injections and countless rounds of physical therapy with no relief. She eventually had fat pad impingement surgery which provided relief for only a few weeks. The pain came back and she struggled to lead a normal teenage life. We found an MD that told her to take turmeric capsules 500mg twice a day and fish oil capsules 1200mg also twice a day. He asked her to give it 4 months. After 2.5 months, she had less pain and after 4 months, she is pain free and can lead a normal life. She dealt with 8 doctors and countless rounds of physical therapy before we found a wonderful doctor who understood that fat pad impingement is about inflammation and turmeric reduces inflammation.

    1. That’s a great story, Beth. Thanks for sharing. So many of the fat pad impingement injury stories have painful outcomes.

    2. mike what’s your thoughts on the turmeric thing posted by Beth, iv been struggling with this injury for 8 months and am willing to try anything to avoid surgery and start kickboxing again, thanks chris

      1. I like Beth’s comments about Turmeric to help her daughter’s symptoms. Turmeric has been long known as an anti-inflammatory spice. It’s a much healthier option, along with strong physical therapy and ice, compared to popping a pill.

  58. Hi,
    My ortho told me that I had fat pad syndrome and avoid all expenses exercises..is walking exercise also should be avoided.. Normally I walk for 30 minutes daily.. Now I fear to walk also after the diagnosis.. I don’t have any pain while walking.. I have pain only when my knee touches the floor..

    1. That’s a great Q to ask your doctor. Personally, I think walking is fine but keeping to the plan set forth by your doctor will help you avoid many of the nightmare fat pad issues you can read about under previous comments for this post.

  59. Help Please, I was diagnosed with Hoffas syndrome in my right knee which I was advised that the inflammation is on the lower right side if im looking down. However I went to the doctor for the pain being above my knee cap on the left side. Though the MRI showed no problems in that area and only in the lower right area. Maybe I have been mistaking my pain in that general area as I don’t believe there are as many pain receptors in that area. I have been to my pcp and a chiropractor. One of them has never heard of Hoffas syndrome and the other has only seen it twice so Im slightly concerned on the diagnosis, unfortunately I don’t have that many sports type doctors in my area.

    Does this still sound like Hoffas syndrome? If so should I commence taping techniques, voodoo flossing the area, or wearing neoprene knee sleeves? Any help is appreciated.

    1. Hi Richard, Please don’t take a passive approach to managing your knee injury. An inflamed knee fat pad is no joke and getting healed quickly is important. All you have to do is read about some of my other followers with this injury and their nightmare recoveries. Manage it well asap.
      If you can’t find a doctor in your area who is not strong with knee injuries, find a well qualified physical therapist or athletic trainer. Look for a local college or sports team to help you.
      Your priorities need to be: 1. Reducing the fat pad swelling. 2. Regain your knee pain-free range of motion. 3. Eliminate any activities you do which increase your knee symptoms. 4. Increase your quad strength WITHOUT increasing your knee symptoms.
      Ice it 3-5x/day. Avoid any knee sleeve. Keep your hamstrings and ankles very flexible.
      Keep me posted. Mike

  60. Hey Mike,

    It seems like most of the talk about fat pad impingement revolves around pinching between the patella and the femur. Looking at its position in the knee, it seems there’s potential for pinching between the femur and tibia as well. Would the cause and treatment be different depending on what is pinching it?

    For anyone reading, the biggest help I’ve found trying to fix this issue is focusing on alignment of the pelvis. When I square up my pelvis (no anterior tilt, level height and making sure one side doesn’t stick out forward farther than the other) and stand up tall, stacking my joints, I have zero to very little discomfort with standing and walking.

    If only I could get the swelling to go away…

    1. You’re a smart man, Jake. Looking at your entire body as it has an impact on your knee is wise and the reason why your knee fat pad pain is better so quickly. Keep avoiding activities which pinch your fat pad, patella mobilizations to regain normal forces on your patella tendons and restore knee ROM as long as it doesn’t increase your symptoms.

  61. Hi Mike,
    I’ve read this article many times. I was diagnosed with fat pad impingement in August of 2017… I am a group fitness instructor and stubborn. I continued to teach and would have good days and bad days until I was in so much pain I couldn’t walk. I then started PT and they did some hip strengthening exercises along with hamstrings (my hamstrings are extremely flexible and not strong). However, in my stubbornness I didn’t rest- I was still teaching spin, doing squats and lunges and high impact classes. I finally decided in late Nov I would do total rest which was disastrous! I lost my ROM and had trouble walking- my mother is a PT professor at our local medical school- her colleague looked at me and started me with McKenzie stretches to regain ROM- I did really well for about 4-6 weeks…. and when I started trying to do longer walking and some jumping I went right back to inflammation. I am now with a PT who is trained in postural alignment- I am working on my left hip which is internally rotated which he believes is causing knee pain… but right now I still have issues with walking, standing too long, knees bent too long etc. I can’t seem to nail down what’s causing it to get aggravated. Question- I haven’t tried a steroid. Should I? Also, do I go back to total rest? What exercises should I avoid in your opinion? I cannot take antiimflammatories. I am worried I am chronic and the fat pad is permanently huge! I’ve had an MRI (September) which just showed slight inflammation behind my knee cap which the dr. wasn’t concerned about at all… he said my fat pad looked okay at the time. I’m at a loss and very frustrated/sad. Thanks!

    1. Dear Kate, I’m saddened to read your heartfelt dilemma with your fat pad injury. I’m not a fan of putting a needle into an injury but I think it might be well merited for your chronic injury with a long record of rehab and many factors which increase your symptoms. Example: Simple standing or prolonged sitting is returning you to a painful knee. I suggest you find an orthopedic doctor who works with lots of runner and who knows this injury VERY well. Getting a steroid injection followed by simple treatment to regain knee ROM and patella mobility is a top priority. > NO ballistic jumps, deep squats or kneeling should be part of your routine for the next 6 months.
      > Get busy with lots of ice, pain-free quad, ITB, hamstring and calf stretching, thigh roller and patella taping.
      Please keep posted on your amazing recovery to follow, Kate.

  62. Hi Mike, I’m a 32 yo soldier and was highly active before this surgery. 1 year ago I had surgery for mild anterior knee pain. I foolishly listened to the surgeon who said he thought he could fix it by trimming the plica. While in there he also trimmed the Hoffas fat pad and did a microfracture on my patella.
    12 months later it’s constantly aching and far worse than pre surgery. I’ve since had another MRI which showed scaring and swelling. My quad has all but disappeared. My OS advised me to just push through the pain and the quad will grow but this hasn’t worked. I’m now following a far more conservative PT program with the use of an e stims machine on the vmo. And totally avoiding anything that causes pain.
    I’m taking celecoxib and icing twice a day. Really don’t want more surgery. Going to see a Dr Scott Dye who specialises in pf pain and arthrofibrosis next month.
    Is there anything else you can recommend other than stretching, strengthening, and foam rolling?
    Can the scar tissue cause damage in my knee?

    1. James, your story and struggles makes my heart ache b/c I hear stories like this way too often, as you’ve probably read from the dozens of comments on my fat pad article. As a soldier who works hard to protect this country and knows how to rehab aggressively, your story is even more frustrating hear how much extra stress your surgeon put on your knee joint. Your OS’s advice to just work harder is not wise when it comes to a scarred down pat fad following a microfracture surgery.
      I have lots of advice which will help you. I’ll email you directly to setup a phone chat. Your appt with Dr Dye is a smart move. We will talk soon and I’d be happy to help you turn the corner. Mike

    2. Hello Mike and James

      Sadly this is the same exact issue as me, I am at 18 months and my job as an outdoor instructor is severely suffering as I have gone from active to just getting by! My legs look like Jekyll and Hyde, Chicken and Bull. I have only now started to feel the effects in my lower back and in bruising of the inner thigh and ankle when I really push and try to do a mountain day. I’ve had to resort to only taking paddlesports days and things I can do.Not to mention my own self esteem and confidence has disappeared and I no longer go out with friends as I can’t keep up!
      My two post op MRIs have shown a small meniscus tear but apparently it wasn’t there before and is not of any significance.I’ve stopped physio as they just got more and more frustrated with me rather than understanding that “just push through the pain”! was impossible unless I’d gone in full of pain killing drugs.Example: 120kg leg extension right (non dominant) leg and 1 yes 1 Kg leg extension possible on the left but cannot retract it without the other leg to help it back down due to some catching and agony!
      Specialist sent me to head physio as second opinion as he couldn’t understand without going back in, head physio just said push through and attend gym every day for 6 months until strong again…..
      Help from either and sharing info we both get James would be amazing
      I work for the British Military so feel your pain both ways!

      Best wishes and thank you for the great website and information Dr Ryan

      1. Colin, I’m sorry to hear about your pain and lack of progress. I just emailed you. Let’s coordinate a time when we can Skype. I do it often to provide a visual exam and to share with you personalized rehab techniques.
        Mike Ryan, PT,ATC

  63. Hi Mike
    I injured both of my knees about six years ago. I fell to my knees onto a concrete floor. It didn’t really start hurting until a few days later. I just disregarded the pain, figuring it would heal in a few days–to a week. Now six years later, the pain has gotten steadily worse. I’ve had X-rays and an MRI that showed a fat pad impingement in my left knee. Now my primary has sent me to a Orthopedic Surgeon. A couple of questions: it’s been six years, with no treatment is it to late? And after six years should surgery be the first option? Im also disabled and have seizures and don’t drive, therefore I walk everywhere or take the local bus. So (resting) my knee is going to be very hard to do. I truly appreciate any help.

    1. Lorraine, you’re a trooper, I can tell! 6 yrs after your injury is a long time so I’m sure you have been compensating for the pain and limited range of motion of your knee. I do not think surgery should be your first option. I suggest physical therapy to increase the mobility of your kneecaps, improving your pain-free quad strength and enhancing your flexibility. Seeing how much you walk I suggest you get your feet evaluated to see if your alignment needs to improve via orthotics or foot strengthening.
      I wish you well.

  64. Hi Mike,
    I am a certified personal trainer and I have a client who has been diagnosed with fat pad impingement in one knee. This client is an avid tennis player and will not stop playing — uses a brace during play to prevent the leg collapsing – and she does not want surgery. Doctor’s have said lay off of tennis, add icing and leg strengthening/flexibility until pain is gone.

    I have incorporated stretching and strengthening – wall sits, wall squats (limited ROM), static lunge (limited ROM) – and a flexibility program into the weekly workout schedule. I only see the client twice a week and they have promised to do the strengthening and stretching exercises another day on their own.

    After reading some of your responses, I will incorporate a rolling program as well.

    My question is this: since my client will not stop playing tennis, what can I do as her personal trainer to help with the healing process and ensure I do not cause any further irritation of the issue?

    I appreciate whatever guidance you can give!


    1. Great question and reasoning for your role with your client, Lucinda.
      Based on the factors you explained, here are my suggestions:
      1. Roller, pain-free quad stretching and ice immediately after playing tennis.
      2. Warmup thoroughly before playing tennis.
      3. Rate the pain – have her rate her pain (1 to 10) daily. If it’s not getting better, she needs to agree that she needs to reduce her time on the court.
      4. Dry Needling – around the knee and patella tendon should help the pain.
      5. Pain-free patella mobs and stretching above and below the knee: Achilles, hip flexors.

  65. Hi Nat, Your troubles are concerning but not unusual for this type of difficult surgery and recovery. To answer your question, YES a full recovery is possible! Your physio (physical therapist) is your savior. Find the best knee physio in your area. The two of you need to work together reduce the swelling within the knee, increase the range of motion and restore quad strength. Tips to help: Use a hard roller daily, get daily patella mobilizations and stretch your ITB. I wish you a fast recovery.

    1. Hi Mike

      thanks for the pearls on this page, it is one of the few sources of information on the entire Web about fat pad.
      I have been having anterior knee pain on both knees for more than a year now. Since then, I stopped running, cycling and hiking. I had X-ray, MRIs and a bone scan. The MRIs show mild chondromalacia patellae and the bone scan shows increased uptake in both patellae.
      I have had PRP, hyaluronic acid injections to no avail. I have done PT, focused on quads and hips strengthening, and that helped only partially, but since 3 months the pain is getting worse and the PT can’t figure out why.

      The PT I saw mentioned fat pad impingement, but the fat pad doesn’t look swollen, warm or tender, and the Hoffa’s sign is negative. Still though I can feel some discomfort below the patella, but not like catching or anything similar.

      I am feeling really hopeless and lost, and don’t know what to do, (complete rest on crutches or PT etc.) since it’s hard to find a PT knowledgeable with knees in my rural area.

      What are your thoughts about these symptoms? Is there hope to recover?


      1. Hi Michele, Your complaint is common with pain in the front of your knee and below the kneecap. The fat pad is an obvious source of your pain but it’s not the only option for your pain.
        Get back with your physical therapist and ask them to THOROUGHLY evaluate your kneecap, patella tendon and knee cartilage. Make sure you have very flexible quads on both legs, mobile kneecaps and you use a roller 2x/day. That helps restore normal motion of your knees to maximize the opportunity to put normal stress on the tissue around the knee.
        After doing so, it makes the evaluation of your knee fat pad easier.

    1. For a localized injury like an inflamed fat pad, ice massage is the best method. The thermal impact is deeper with ice massage and the max time of the treatment is 10 Minutes. Fast & effective = ⬇️ downtime.

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