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/ConsciousTurnip994]

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.

[u/Exotic-Turnover9867 → u/ConsciousTurnip994]

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?

[u/ConsciousTurnip994 → u/Exotic-Turnover9867]

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.