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Treatment / Management

Nonoperative Management

Physical therapy is the mainstay of treatment for Hoffa pad impingement syndrome.[30] The goal of physical therapy is to restore the biomechanics of patellar tracking via vastus medialis obliquus strengthening, taping to offload the patella tendon and fat pad, stretching, and improving pelvic control with training focused on gluteal strengthening to optimize lower extremity mechanics.[31] The goal of taping is to tilt the inferior portion of the patella anteriorly to decrease impingement and subsequent inflammation of the IFP. This is accomplished by applying tape across the proximal half of the patella with the knee fully extended. Two strips are applied in a “V” formation, with the apex at the tibial tubercle. The first part of the V tape starts at the tibial tubercle and is applied over the medial epicondyle while the patella and surrounding soft tissue are pulled inferiorly. The second strip is similarly applied at the tibial tubercle and towards the lateral epicondyle. The tape is to remain in place every day until the patient is pain-free. Patients are also instructed to avoid hyperextension and rapid extension maneuvers to decrease impingement of the IFP.[31]

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Muscle training focuses on closed-chain exercises targeting the quadriceps, namely the vastus medialis obliquus, to improve patellar tracking.[32] Resistance training of the gluteus medius’s posterior fibers to decrease the hip’s internal rotation and the resultant valgus force at the knee can be implemented to align the patella within the trochlea better. The patient may stretch the anterior hip structures to increase available external rotation if the patient has marked femoral internal rotation. House and Connell reported an improved visual analog score after injecting a mean of 4 injections of alcohol and bupivacaine under ultrasound guidance.[33] IFP pain usually responds to 1 to 3 injections of 6 ccs of 2% lidocaine combined with 40 mg of methylprednisolone acetate or 50 mg of hydrocortisone at intervals of 4 to 6 weeks. Corticosteroid injections have also been used to treat Hoffa pad impingement syndrome and have demonstrated satisfactory results.[16]

Operative Management

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Operative intervention is indicated once the patient has exhausted conservative management. Arthroscopic resection of the posterior aspect of the IFP is the primary surgical treatment of the inflamed, symptomatic fat pad.[34] It has been recommended that a high anterolateral portal and a standard anteromedial working portal be used during arthroscopic resection. A high anteromedial portal is sometimes necessary to best visualize and access the lateral ala impingement. Symptomatic infrapatellar plica has been demonstrated to respond well to arthroscopic excision. The majority (86 to 91%) of patients with solitary infrapatellar plica release experienced few to no post-operative complaints. Regardless of the approach, hemostasis is precisely maintained.[35]

Patients with discomfort and swelling around the inferior pole of the patella may find relief with arthroscopic denervation of the nociceptive nerves innervating those areas. The inferior fat pad is often surgically removed from where it inserts on the inferior patellar pole using an electrothermal cautery method.[36] After arthroscopic excision, patients with significant impingement of the fat pad and no other concurrent disease may anticipate remission or long-term improvement in their symptoms and function.[34] Kim et al reported improved clinical results with either partial or subtotal arthroscopic excision of the impinged fat pad between the patella and femoral trochlea. Given that partial resection was just as successful as subtotal resection and kept more of the fat pad, it may thus be a suitable course of therapy.[37]

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