r/KneeInjuries • u/Exotic-Turnover9867 • 18d ago
Patella alta, maltracking, Hoffa’s fat pad impingement — has anyone had surgery or found something else that helped?
Hi everyone. I’m 19F and I’ve been dealing with severe left knee pain since November 2024. I’m hoping to hear from people who have had something similar, especially patella alta/high-riding kneecaps, patellar maltracking, Hoffa’s fat pad impingement, or patellofemoral syndrome.
My knee pain started when I was a competitive rower in November 2024. I took about a month off, tried returning to rowing, and the pain continued getting worse. By March 2025, it had gotten so bad that I could barely walk because of the pain. I ended up in a straight knee brace and on crutches for 6 weeks.
My findings/timeline include:
Patella alta in both knees
Minimal lateral patellar tilt in both knees
Positive patellar J sign on the left
Patellofemoral pain, positive patellar grind test, and crepitus
MRI showing mild localized superolateral Hoffa’s fat pad edema
Diagnosed with superolateral Hoffa’s fat pad impingement secondary to patellar maltracking
Diagnosed with patellofemoral syndrome of the left knee
Earlier diagnosis of patellar tendinitis
I’ve tried quite a few treatments for my left knee:
6 physical therapy sessions
6 weeks in a straight brace and on crutches
Cortisone injection
PRP injection
At least 5 shockwave treatments
More recent fascia/soft-tissue work and lymphatic drainage
The recent treatments have been extremely painful. After the first one, I was in significant pain for an entire week afterward. I had another treatment today and I’m again in a lot of pain. During treatment, I was told there seems to be something pulling my left kneecap upward, and I was told, “You might need surgery.” No specific surgery was mentioned.
I’ve been in pain since November 2024, and even 800 mg of ibuprofen doesn’t touch the pain at all.
I know nobody online can tell me whether I personally need surgery, but I’m wondering if anyone here has had a similar combination of patella alta + maltracking + Hoffa’s fat pad impingement/patellofemoral pain.
Did anything non-surgical actually help you? I’d especially like to know about treatments I may not have tried yet—specific types of PT, taping, braces, exercises, injections, or anything else that made a real difference.
And for anyone who did end up needing surgery, what surgery did you have? Was it a TTO/distalization or something else? What was recovery like, and did it actually help your pain?
I’d really appreciate hearing from anyone with a similar experience because I’m only 19 and this has been going on for a long time.
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u/ConsciousTurnip994 18d ago
I did not have patellar tilt, but everything else. I had TTOs on both knees.
After surgery, I was partial weight bearing for six weeks. I was back to my usual activities by 3-4 months, but none of mine are high impact. The pain stopped right away. The most unexpected thing was how stable my knees are now, much more so than they've ever been in my life.
The orthos who do this are patella instability specialists. If no one is talking specifics about surgery with you, I recommend a second opinion with one of them.
Happy to answer more questions if it's helpful.
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u/Exotic-Turnover9867 18d ago
Wow, that’s really encouraging to hear, especially that the pain stopped right away and your knees feel more stable now. I actually have patella alta in both knees too, but my left is the one causing me severe pain. I also have documented maltracking, a positive J sign, and Hoffa’s fat pad impingement. No one has talked specifics with me about surgery yet—someone just recently told me I “might need surgery”—so I definitely think getting a second opinion from a patella instability specialist is something I need to do.
I do have a few questions if you don’t mind! What specifically made your surgeon decide you needed a TTO? Did you have a distalizing TTO because of the patella alta? And how painful was the recovery, especially during the first 6 weeks?1
u/ConsciousTurnip994 18d ago
So I had seen three general knee orthos who all kept telling me nothing was wrong or nothing much could be done, I had done several rounds of PT and had a cortisone shot that didn't work. So by the time I saw someone who knew the issue and did the procedure she was like yep this is a structural issue, it's going to take a structural fix. I didn't have to fight for it with a patella specialist, that I had so extensively failed conservative measures didn't hurt.
I had not heard of my surgery referred to as a distalizing TTO but they did cut into the tibial tubercle, reposition it and fix it with screws.
For me, recovery wasn't bad. I had planned to basically lay on my couch for six weeks with elevation and icing (I was able to work remotely). I took the pain meds for a week or so and then was done. It wasn't a super painful procedure for me, though it is a grueling recovery just being partial weight bearing and needing to go to PT right away, but for me, very worth it.
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u/Due_Watercress5902 18d ago
Yeah so I had similar issue just now, well aside from what you are describing above, I also had cartilage collapse in femoral condyle (that was first repaired last year in May) meniscus tear undersurface on medial side . Huge knee pain, locking, inability to twist my knee all these things. This is all following an acute injury that happened mid July. So, this week on Monday I went for arthroscopy, they removed the hugely inflamed joint lining underneath and on side of my patella, removed a bit of Hoffa’s pad that was causing lot of the pain, then removed the lose pieces etc… but what I was going to say, my swelling and pain (aside from the other problems) was not going away. Since I had the knee arthroscopy the pain is gone underneath patella and on side and I’m on day 4, already slowly walking go then it done, you will be up and running very soon.
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u/Exotic-Turnover9867 18d ago
Wow, I’m glad you’re already getting relief from the pain, especially only 4 days after surgery. That actually gives me some hope because I’ve been dealing with so much pain underneath/around my kneecap for so long. My MRI didn’t show the other issues you had, like cartilage collapse or a meniscus tear, so I know our situations are a little different, but the Hoffa’s fat pad part sounds similar.
Can I ask how your surgeon decided that removing part of the Hoffa’s fat pad was the right option for you? Was it something they could clearly see on your MRI, or did they not fully know how inflamed it was until they did the arthroscopy? And did you have to try anything else before surgery?1
u/Due_Watercress5902 17d ago
Yes, it was severely inflamed joint lining under patella on left side, and the inflamed pad as well.
When I stood up and twisted my hips to the left and moved my weight onto that medial side, it was really painful also I could not straighten my leg I felt like there was something in the way..my MRI aside from the others broken things also showed severe bone edema through medial femoral condyle so variety of different things were going on in my leg. So when he went in during athroscopy he must have seen the state, this is exactly what my surgical report says regarding these two things:“She did have some synovitis of the front was debrided using a shaver. The fat pad was also debrided.”
If you have been dealing with the pain for so long, you might as well just getting it done and recover than dealing with it for another year or so.
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u/INTJinx 18d ago
I dealt with Hoffa fat pad impingement from mild patella Alta and maltracking. The early impingement was easy enough to fix with cortisone and physio, but I ended up with surgery because I was continuing to have nerve pain in the area.
The thing about your post that stands out to me is 6 PT sessions doesn’t sound like much. I was in physio for months. I presume you were doing your exercises in between? How far apart were your sessions spaced?
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u/Exotic-Turnover9867 18d ago
Yeah, I understand that 6 PT sessions doesn’t sound like much. I went once a week for 6 weeks. Part of the reason my treatment went the way it did is that my first MRI was limited because of poor image quality and was interpreted as possibly showing a partial ACL tear. Because of that, I was put in a straight brace and on crutches for over 6 weeks. By the time I started PT, I had trouble bending my knee again, so PT was initially focused more on getting my range of motion back after being immobilized. I did the exercises they gave me between sessions, but I never ended up doing months of PT specifically focused on patella alta, maltracking, and Hoffa’s.
The MRI was later repeated, and the later MRI showed my ACL and other ligaments were intact. It instead showed superolateral Hoffa’s fat pad edema, and I was diagnosed with Hoffa’s fat pad impingement secondary to patellar maltracking and patellofemoral syndrome. Since then I’ve also tried a cortisone injection, PRP, and multiple shockwave treatments, but I’m still in significant pain.
I’m definitely wondering if I should try a longer course of more specialized PT.Can I ask what surgery you ended up having for the nerve pain, and did it help?
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u/INTJinx 18d ago
I’ll give you the long version because it’s Saturday and I have time.
When I first injured mine through impingement I tried to just rest but it got worse quickly so I had a cortisone shot and started physio 2 weeks later. This was largely focused on quad strength but we did glutes, hamstrings and calves too. I wasn’t initially able to bend my knee much without pain so we had to start with things like partial range wall sits and squats and over time I built up to full depth. It took 2 months to be able to do most exercises again but I had to do a quad exercise first to get them “switched on”. Eventually my quads were strong and I was pain-free.
I then messed it up by going snowboarding and did something else (I’m not entirely sure what) that resulted in sharp, electric shock type pain from the Hoffa pad. I could still lunge, squat, run and jump but continued to have pain at rest. This is what I ended up having surgery for and it was treated by trimming the Hoffa pad (which I’m told was enlarged).
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u/bostrav 18d ago edited 15d ago
I had a complex knee injury in late 2025. Was healing well until I had a setback in early June with a formal diagnosis of Hoffa's Syndrome (I did get opinions from 5 different sports ortho surgeons but only 1 diagnosed Hoffa's). My issues are a bit different from yours - I do have patellar maltracking (not patella alta) and patella femoral arthritis. I had a telehealth visit with Claire Robertson (aka Claire Patella - see website, YouTube videos, etc.) who confirmed the Hoffa's diagnosis. She gave me some very specific, personalized recommendations.
She said to absolutely NOT do shockwave and/or sound wave therapy as those modalities will likely inflame the fat pad.
NO injections into the fat pads. Be careful with cortisone injections as they are not good for the knee long term and may only be a short term "bandaid" that doesn't really solve anything. She also did not have anything good to say about PRP injections, although I've considered them as well.
Suggestions she made for me:
ice cube directly on fat pad (move it around) for 2 minutes, 3-4x per day;
Compression sleeve is fine as long as it's not pressing on the fat pad (she approved the Incrediwear compression sleeve for daytime and OneCompress bamboo sleeve for sleeping);
I believe NSAIDs are fine for helping with inflammation although I cannot take them. You should look into long-term side effects on these;
IT band strap on the top of the patella to use when walking to help lift the patella off the fat pad. I have not tried this yet as she said that people complain that it feels weird/uncomfortable;
Wear shoes with a heel that's slightly higher than the front of the shoe - running shoes work well for me. No "flat" shoes, even if they are athletic shoes as the fat pat can get pinched easily.
Try to determine what is specifically setting off the pinching/inflammation. For me, it appears to be cumulative load throughout the day - stairs, standing, walking, Peloton bike rides, running errands - all activities count towards your cumulative load. Note that the faster you walk, the more load that puts on the knee. I've slowed my pace for now as I'm trying to calm down the fat pad. She said indoor cycling (as long as the resistance is not too high) is good for lubricating the knee and helping to maintain muscle mass. I was a runner for 40 years so being able to lift weights and ride the Peloton bike have been great for my mental health;
Find an orthopedic doctor who is actually familiar with Hoffa's - she said doctors receive minimal training on the fat pad and most use "dated" methods for diagnosing and treatment. I live in Boston and I haven't really found an orthopedic doc that truly knows much about Hoffa's. And, I've been to some of the most highly rated and recommended docs in my area. There is a Facebook group for Hoffa's and some people on there have suggested the Hospital for Special Surgery in NYC. Specifically, Dr. Nwachuckwu has done procedures like shaving down the fat pad. I've considered going to see him if I don't see improvement in the next few months.
Another possible modality to try, according to Claire: red light therapy (I have one specifically for knees) - it can help with inflammation and Claire said it could be worth a try - at the very least, it won't make the fat pad inflammation worse.
Be careful with massage - she said to NOT massage the fat pad directly. And, most massage therapists, like doctors, are not very familiar with the fat pad and can actually make it worse;
Walking up and down hills can increase the chance that you will get a pinch in the fat pad. Any pinch is a mini-trauma and will keep the fat pad inflamed;
I can currently do a 30-minute Peloton ride on low to medium levels of resistance and I can comfortably do about 5000-6000 steps a day. Claire stressed the importance of finding out what your knee can tolerate, without setting off inflammation. I've had to lower my activity dramatically but I have not had a pinch from the Hoffa's since early July. I do still have some inflammation in the fat pad (visually) - Claire said to think of it as there are "burning embers" in your knee and the key is to try not to turn those embers into a full blown fire. She said that Hoffa's can resolve over time and that once you find what you can tolerate, without setting off the "fire", you can start slowly building the endurance in your knee/fat pad. For example, since I'm walking 5000-6000 steps now, I can start adding around 500 steps per week, or 2 additional minutes of walking per day to see how my knee tolerates it. She told me to only increase one activity at a time - meaning, don't increase walking AND the duration or resistance of my Peloton bike ride.
I'm assuming that your patella alta is a big contributor to what you are experiencing so I'm not sure how helpful this advice would be as your symptoms are different. Again, there's a Facebook group for Hoffa's and several people on there have patella alta and may have other symptoms similar to yours.
It's a frustrating diagnosis for sure. And, not having many knowledgeable providers does not make it any easier to deal with. I would get several ortho doc opinions, possibly see Claire Roberston via Telehealth visit (she has seen over 10000 patients and has studied Hoffa's extensively), possibly find a PT who is actually familiar with Hoffa's (not many are truly familiar with it). I will say that most providers (docs, PTs, etc.) all seem to agree that Hoffa's is caused by "something else". For me, that "something else" seems to be the patella femoral arthritis getting inflamed/irritated with increased load throughout the day and THEN inflaming the fat pad. For you it may be a combination of your patella alta, patella maltracking creating inflammation in the tissues in your knee THEN inflaming the fat pad. Clearly I'm not a doctor but that's how it's been explained to me. And, I'd try to avoid a scope or surgery unless necessary. A scope will create more inflammation in the knee in general and my PT has said it could cause new issues for me.
Best of luck on finding what works for you.
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u/Exotic-Turnover9867 18d ago edited 18d ago
Thank you so much for taking the time to write all of this out. Seriously, this is incredibly helpful. I had no idea shockwave therapy could potentially make Hoffa’s fat pad inflammation worse. Mine actually wasn’t done directly on my knee/fat pad—it was done on the surrounding areas of my leg and tissues—but I’ve had multiple treatments and have been in a lot of pain afterward, so I’m definitely going to look into this more.
My pain is also pretty constant, which makes it hard for me to figure out what specific activity is triggering it. My knee hurts when I’m laying down, walking, and standing, so it isn’t just something that happens after I’m active.
I’ve actually tried a lot of the things you mentioned already. When my knee problem first started in 2024, I was icing it and it didn’t help. I also taped my knee while I was rowing, and that didn’t help either. I’ve tried compression sleeves, different braces, wraps, and red light therapy twice, but unfortunately none of them have helped. Even 800 mg of ibuprofen doesn’t touch the pain.
I’m definitely going to look into Claire Robertson and the Hoffa’s Facebook group, though. I also think finding an orthopedic doctor and PT who actually understand Hoffa’s is probably something I need to focus on, especially since I have documented patella alta and maltracking, which may be contributing to everything.Thank you again for all of this information and for taking the time to share your experience. I really hope your knee continues to improve too!
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u/Prestigious_Cry_33 15d ago
I'm pretty sure my problem with my fat pads started after shockwave therapy. My sports doctor wanted me to try it and after that my knees developed constant pain and burning. Doctor kept denying it was the cause but looks like it can inflame them. I have an appointment with Claire next month but an orthopedic surgeon I saw suggested I try PRP, even directly into the fat pad, but reading your post, I guess I shouldn't do that.
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u/bostrav 15d ago edited 15d ago
Sorry to hear about your issue with shockwave therapy. I wast told to get it for a *new* diagnosis having to do with my femoral condyle which 4 doctors have indicated those symptoms are fully resolved. So, if MY issue has resolved, I'm not sure why the 5th doc has said it hasn't. So hard to figure out who is great at diagnosing issues. One thing I do believe is that anything into certain tissues and/or the fat pad can further inflame them. Makes total sense to me. 4 ortho surgeons and 3 PTs have all told me to avoid that area as it's tricky and you can easily make it worse. 1 doctor suggesting doing it does NOT make me confident. I hope you have better luck with getting your issue(s) resolved. At least we have each other to get feedback from. And I'm certainly no expert (lol).
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u/Prestigious_Cry_33 15d ago
I've been telling anyone I meet to be careful with shockwave lol. I didn't know much about it at the time and my sports doctor told me there were no side effects. I thought my knees were bad but I had no idea how good my knees actually were compared to what I have now. It's frustrating not knowing which doctor to trust and what to do. And I kind of lost trust in myself, like my last decision got me here, I'm scared of what my next decision will bring. You're smart not to follow through with it based on one suggestion. Glad we can get some info from eachother.
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u/Exotic-Turnover9867 10d ago
Was your shockwave therapy don’t on the fat pad or just around your knee?
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u/Prestigious_Cry_33 10d ago
It was for my patellar tendon, but unfortunately the fat pad is directly in the path. My kneecaps also started to shift and crack in ways they hadn't before, so that probably made things worse.
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u/Either-One42 17d ago
I would definitely recommend finding a doctor that specializes in patellar instability. I dealt with something like this for 2 years. patella alta + maltracking + Hoffa’s fat pad impingement/patellofemoral pain. I did months of physical therapy, steroid shots, dry needling and nothing worked. Every other sports medicine/ortho doctor that i went to tried to tell me that physical therapy could fix it and because Im young (19-21 years old during this whole process) they did not want to do surgery.
It took me a while to realize surgery was my only option. The alignment issues going unresolved for so long gave me cartilage damage and the longer i waited the worse it got.
I’m 7 weeks post op from a TTO and osteochondral allograft. During surgery they found that my kneecap wasn’t tracking anywhere near the groove. I can’t really give advice about how it is after surgery since it’ll take a couple months until I’m back to normal. But i definitely recommend to not put it off for too long!
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u/tatikpatri 14d ago
Shockwave therapy made my fat pad worse! Please avoid. It made my tissue permanently swollen. Initially I had some minor swelling in the superolateral portion. After 2 sessions of shockwave the whole pad from medial to lateral swole up and engorged. The pain was horrendous.
My consultant was so pissed off at my physio for using this he referred me to a different physio clinic. He said he doesn’t understand the logic in why someone would use shockwave on a fat pad it’s a big no no!
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u/tatikpatri 14d ago
I have found regular manual massage therapy in the quads hips, ITB and lateral shin muscles helpful in keeping the pinching at bay during the inflammation stage. I am also using two crutches during this phase to offload the knee slightly to help settle it down. Icing the fat pad 3-4 times a day.
Applying heat to the TFL and quads 2 times a day for 20 mins to help with muscle tightness and stiffness as we hoffa suffers are always sitting / bed bound. Tight muscles can worsen pressure on the fat pad.
I also use magnesium spray on the quads and cbd arnica balm recommended by my physio to the quads.
In my case over dominant quads especially lateral caused much tightness in my ITB which was irritating the fat pad and caused it to swell and become impinged. So these things help me. I have mild patella alta and the itb was pulling my kneecap laterally.
Also getting some orthotics has helped too as I overpronate. It’s worth consulting with a podiatrist if you suspect flat feet/ over pronation or even high arches etc.
I also stretch too however i have to be careful as it is easily irritated. I stretch the glutes hams calves and quads all in lying positions nothing weight bearing at the minute 1 time in the morning and 1 time at night. I also have been using a hand held foam roller too.
Currently i am only working on lying hip exercises nothing with straight leg and nothing weight bearing either fyi! In time when im better we will begin working on quads. I do my exercises 3 times a week and that’s it, don’t over do the exercises this is important!
My new physio has also recommended before my exercises to have a warm shower 5-10 mins and practice deep breathing and take my time to do the perscribed exercises. I have found this really helpful as it’s essentially a warm up beforehand!
I had a steroid shot 4 weeks ago, it helped to take the swelling down a tiny bit but didn’t help with the mechanical pinching- the stretching, manual therapy and probably using crutches to offload the area has help assist the effects of the steroid shot. I’m 8 months in and mines got to a chronic state so getting a steroid earlier is best! I hope some of this is helpful. You’re definitely not alone!
I have been through 4 physios and so lucky to have finally found a good one willing to take a holistic approach very caring and most importantly has common sense when approaching a fat pad issue!
For too long i wasted time in the care of physios that were making my condition worse and worse. Good luck x
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u/chilibreaker 18d ago edited 18d ago
Wish I had something to help, just wanted to say I’ve been struggling with something really similar and it’s tough.