Podcast #56: Patellofemoral Pain and Hoffa’s Fat Pad with Claire Robertson


Patellofemoral Pain

From sitting: “A tendon will classically feel stiff”. Patellofemoral won’t.

PFP and PT: “I think they do coexist because the risk factors are very similar (load, biomechanics, footwear, flexibility).”

The change in load that causes PFP: “Running is probably the number one thing.”

“The patellofemoral joint can refer to anywhere around the knee.”

“The younger they are, the less likely they are to have a degenerate tendon.”

PFP is “a pressure problem.”

“In patellofemoral pain, we can get slight alteration in load pattern on the back of the patella and on the trochlea and that overloads the subchondral bone… and that excess load and pressure can bring about pain.”

PFP: “It’s not a condition of structural damage, it’s a condition of load distribution.”

Major groups in PFP:

  • Hypermobile (e.g., excess valgus)
  • Excess muscular tightness
  • Change in load (sedentary to active)
  • Displasia (e.g. shallow trochlea, lateral tuberosity attachment)
    • “About 10% of the population has some dysplasia.”
    • “If their quads attachment is lateral, the last thing on earth they can afford is for their femur to medialize.”

“Very often, people are walking around with one or two risk factors for patellofemoral pain and getting away with it…. it’s when you get these collections of risk factors.”

“Most patellofemoral pain has just sort of crept on.”

“Insidious onset: headaches, irritable bowel syndrome, patellofemoral pain, people can’t make sense of it.”

“Running downhill… it’s pretty vicious on the patellofemoral joint.”

“You can’t jump and land well with a tight calf.”

“What we need to do is maximally load the muscle but minimally load the joint.”

“If the pain is going into the evening and into the next day, you’ve set off an inflammatory response and that’s not a clever thing to do.”

Stress on patellofemoral joint:

  • Closed chain (e.g. squat): “When you go beyond 50 degrees, it starts escalating really quickly.”
  • Open chain (e.g. leg extension): “Between 90 and 45, the load is not too bad. When you start pushing up from 45 up towards a straight knee, the load escalates.”

Blood flow restriction: “so that they fatigue more readily with less load put through the joint.”

“I’m not saying that they can’t ever do it but there’s a sequence of events… there’s no point doing that with an irritable patellofemoral joint. I can tell you, they’ll just get worse.”

“If you’re doing painful deep squats, I don’t think you’ll build up your VMO because it will be shut down by pain.”

Vastus Lateralis dominance:

  • “If the muscle is softer, it doesn’t brace out against the ITB so much.”
  • “The end of your gym session is probably the best time to be doing that stretch.”
  • “Am I doing adequate posterior chain, hamstring, glutes, or is it just quads, quads, quads?”

Hoffa’s Fat Pad

“Once you get between 30 degrees a 0… the fat has to deform quite a bit… if it’s inflamed, that is the problem angle (walking, standing).”

“The fat pad is more innervated, has more nerve endings, than any other structure in the knee… so it is capable of this really awful pain.”

“You cannot ever push through a fat pad problem. It will just get worse.”

“Barefoot would be the worse thing.”

Stage 1: Settle it off (ice, taping to offload, shoes with a slight heel, minimize the standing and walking)

Stage 2: Looking at drivers (arthroscopy, blow to the knee, hyperextenders, rotational control issues, people with incredibly tight quads)

“If your femur drops in, you will squish your lateral fat pad… it’s kind of like wringing out a towel and the fat pad is in the middle.”

“There’s no link between structural damage and crepitus.”

“People will package together noise and pain.”

Chondromalacia Patellae:

  • “The cartilage does not have any nerve endings, so it is not capable of producing pain.”
  • What is the cause of the pain? “It’s the pressure underneath.”
  • “It’s a really unhelpful diagnosis.”

Website: https://clairepatella.com

YouTube: https://www.youtube.com/channel/UChJdzm8jb1la496i2UjvYYg

Twitter: https://twitter.com/clairepatella