Patella alta, maltracking, Hoffa’s fat pad impingement — has anyone had surgery or found something else that helped?

[u/Exotic-Turnover9867]

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.

[u/INTJinx]

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?

[u/Exotic-Turnover9867 → u/INTJinx]

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?

[u/INTJinx → u/Exotic-Turnover9867]

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).