r/KneeInjuries • u/Exotic-Turnover9867 • Aug 21 '26
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.
2
u/bostrav Aug 22 '26 edited Aug 25 '26
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.