Hoffa’s Fat Pad Rehab: A Pro’s Approach

When we think of anterior knee pain, patellofemoral pain usually comes to mind. However, Hoffa’s fat pad inflammation is a less common but equally important cause to keep in mind. Highly innervated and easily irritated, the fat pad can cause severe, function-limiting pain that disrupts even simple daily activities.

In this blog, we jump into a real-world case of bilateral Hoffa’s fat pad inflammation, unpacking the clinical reasoning, management strategies, and challenges expert physio Claire “Patella” Robertson faced along the way.

If you want to see exactly how an expert physio assessed and managed a real patient with Hoffa’s fat pad inflammation, check out Claire’s full Case Study HERE. With Case Studies you can step inside the minds of experts and apply their strategies to get better results with your patients. Learn more here.

The case

This challenging case involved a 45-year-old woman who came to Claire’s clinic with significant bilateral infrapatellar pain that had not improved after five days of Non-Steroidal Anti-Inflammatories (NSAIDs). She had no prior history of knee pain, but symptoms began the day after completing a parkrun in flat-soled trainers.

She described the pain as nipping and stabbing, accompanied by self-reported swelling. The pain was aggravated by walking and standing with straight knees, it disrupted her sleep (both delaying her ability to fall asleep and waking her at night). Claire observed that the patient was anxious and teary in their first session – the patient’s main concern was osteoarthritis, as a past episode of hip pain (now resolved) had led her doctor to diagnose her with a “spot of osteoarthritis.”

On assessment, she was unable to walk with a normal gait or maintain a single-leg stance. Clinical findings included bilateral swelling of the fat pads without joint effusion. MRI confirmed bilateral fat pad inflammation.

Before we get into her management, watch Claire explain what Hoffa’s fat pad is in this clip from her Case Study:

Initial management

Claire’s first priority was to calm the pain and inflammation while reassuring the patient. Education played a central role, and key messages for this patient included:

1. There’s no structural damage: allaying the patient’s fears regarding osteoarthritis was the first step.
2. Why so painful? Validating the patient’s experience and explaining that fat pad inflammation can be extremely painful because of its rich nerve supply.
3. Treatment plan: Claire outlined her plan for rehab, and identified that recovery isn’t always linear, flare ups are common, but these don’t mean rehab isn’t working!

Since NSAIDs hadn’t helped (not uncommon with fat pad inflammation), Claire instead recommended running ice in a continual motion over the swollen fat pads.

Then, to offload the area, Claire used a simple taping technique that she taught the patient to self-apply. This gave her a practical tool she could also rely on during potential future flare ups. Watch Claire explain the taping technique in the below snippet from her Case Study:

Once pain and swelling had been addressed, Claire introduced gentle, confidence-building exercises: single-leg stance with variations (moving the opposite leg, closing eyes, tilting the head), and isometric quadriceps work such as wall sits at 50° of flexion. All exercises were performed pain-free and on alternate days.

Setbacks!

Setbacks happen to the best of physios, but how they’re handled can make all the difference.

Claire explains that Hoffa’s fat pad is highly irritable, so flare ups are common. The further along patients are in their rehab, the more distressing these flare ups can feel. In those moments, patients often look to their physio for reassurance and guidance. Claire’s usual approach is to normalise the experience, encourage a short period of self-taping, allow symptoms to settle, and then gradually return to the program.

While this is a typical challenge in fat pad rehab, this case threw up something more unusual. Claire had already identified that the patient was experiencing high levels of anxiety and fear around her knee pain, but after the initial management stage, the patient contacted Claire in crisis: her symptoms had escalated dramatically, with burning, redness and 10/10 pain. This was understandably accompanied by significant psychological distress. It was clear this was no longer just a mechanical, inflammatory issue, it was progressing into a neuropathic one.

Recognising the limits of her scope in this context, Claire referred the patient to a pain specialist. With this collaborative approach, the patient was able to regain control, reduce her symptoms and get back on track with her rehab plan. This case serves as a great example of how timely referral to other health professionals can help patients get better outcomes.

Wrapping up

Hoffa’s fat pad inflammation can be a challenging condition to manage, not just because of the irritability of the fat pad and risk of flare ups, but also due to the psychological distress that pain levels and impact on function can cause. This case highlights the importance of a multimodal approach: combining clear education and reassurance with practical strategies such as taping and load management, alongside graded rehabilitation and appropriate multidisciplinary referral, ultimately enabled the patient to achieve a good outcome.

It also reinforces a lesson: sometimes, physiotherapists need to recognise when a presentation is moving beyond a purely musculoskeletal problem. Claire’s timely referral to a pain specialist ensured the patient received appropriate support, allowing her to return to rehabilitation with confidence.

Curious to see how Claire progressed the rehab plan from here? Watch her full Case Study HERE.