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Hoffa’s Fat Pad/Infrapatella Fat Pad
Normal Anatomy
 Fibrous scaffold packed with adipose tissue
 Intra articular but extra synovial
 Separates the anterior inferior synovial membrane from more anterior
structures of the knee.
 Attaches to proximal patellar tendon, inferior pole of the patella,
transverse meniscal ligament, medial and lateral meniscal horns and
retinaculum
 Helps in lubrication and distribution of synovial fluid. Especially at end
range flexion and extension.
Pathology
 Inflammation or impingement of the infrapatella fat pad
Mechanism of injury
Traumatic
 Direct compaction injury
 Excessive hyper extension e.g Kicking a ball or kicking off the wall when
tumbling in swimming
 Damage following arthroscopic surgery
Non Traumatic
 Excessive hyper extension of the knee causing excessive posterior tilting
of the patella impinging on the infra patella fat pad
 Excessive anterior pelvic tilt forces knee into hyperextension, shortening
quads/rectus femoris. This pulls patella superior causing posterior tilt of
the inferior pole of the patella increasing compression into infrapatella
fat pad
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Associated Pathologies
Patella mal-tracking
 Altered patella kinematics can cause excessive pressure of the
infrapatella fat pad
Patellofemoral Pain Syndrome
 Acute infrapatella fat pad symptoms are commonly found with other
painful structures as a source of pain in PFPS
Patella Tendinopathy
 Biomechanical changes alter patella position and stress through the
tendon. Therefore fat pad irritation can occur in combination with
patella tendinopathy
Differential Diagnosis
 To differentiate with patella tendinopathy palpate the patella tendon in
knee flexion. This should reproduce pain in tendinopathy as palpating
the fat pad in this position is difficult
Examination
Subjective
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Females more commonly than males
Sharp or burning pain in the infra patella region
Traumatic compression or biomechanical overload
Pain on walking, prolonged standing or stairs
Prolonged static flexion
Wearing high heel shoes
Activities involving hyperextension of the knee or increased anterior
pelvic tilt
Objective
 Hyperextension in standing
 Anterior pelvic tilt
 Superior patella
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Posteriorly tilted patella
Swelling around inferior pole
Reduced and painful knee extension if acute
Pain with quadriceps contraction
Pain with force knee extension
Any quads contraction in extension/hyper extension will exacerbate
pain.
 Pain palpation infrapatella region and fat pad
 Anterior tilting of the inferior pole of patella will help relieve symptoms
Special Tests
1. Hoffa’s Test
Further investigation
 MRI
Management
Conservative
 Rest from aggravating activities
 Correct biomechanical dysfunctions
 Stage 1 – Restore Normal Mobility
o Anti- Inflammatory Modalities (Ice, NSAID’s, Massage)
o Decrease tone of quadriceps/rectus femoris (Soft Tissue
Techniques)
o Encourage anterior tilt and global gliding of patella (Joint
Mobilisations, Taping)
 Stage 2 – Restore Normal Motor Control and Strength
o Quadriceps strengthening in a pain free range
 Avoid hyperextension or any positions that will irritate the
fat pad
 Stage 3 – Dynamic Stability
o Exercises to improve proprioception at the knee and entire kinetic
chain
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 Stage 4 – Return to Sport Rehabilitation
Plan B
Injection
 Local anaesthetic
 Corticosteroid
Surgery
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Fat Pad Excision
Debridement
Anterior Interval Release
Denervation of the Inferior Pole of the Patella
References
(Bisicchia & Savarese, 2012; Borja et al., 2013; Doner & Noyes, 2014; Dragoo et al., 2012; McConnell,
2013; Subhawong et al., 2010)
Bisicchia S, Savarese E. Infra-patellar fat pad cysts: a case report and review of the literature.
Muscles Ligaments Tendons J 2012; 2(4): 305-8.
Borja MJ, Jose J, Vecchione D, Clifford PD, Lesniak BP. Prefemoral fat pad impingement syndrome:
identification and diagnosis. Am J Orthop (Belle Mead NJ) 2013; 42(1): E9-11.
Doner GP, Noyes FR. Arthroscopic resection of fat pad lesions and infrapatellar contractures.
Arthrosc Tech 2014; 3(3): e413-6.
Dragoo JL, Johnson C, McConnell J. Evaluation and treatment of disorders of the infrapatellar fat
pad. Sports Med 2012; 42(1): 51-67.
McConnell J. Management of a difficult knee problem. Man Ther 2013; 18(3): 258-63.
Swan A. Anatomy of the Infrapatellar Fat Pad. New Zealand Journal of Physiotherapy 2005; 33(1):
19-22
Subhawong TK, Eng J, Carrino JA, Chhabra A. Superolateral Hoffa's fat pad edema: association with
patellofemoral maltracking and impingement. AJR Am J Roentgenol 2010; 195(6): 1367-73.
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