Posted in Case Studies

42 year old female, right inferopatellar pain

Female, 42, describing intense pain sometimes burning, inferopatellar, worse laterally. Area swells up locally. Complains of intermittent giving-way associated with sharp pain. No locking.

Thoughts: Typical of inferopatellar fat pad but can’t discount patella tendinopathy or referral from PFJ. Giving way probably pain induced quads inhibition but can’t yet disqualify possibility of intra-articular pathology. Swelling sounds local to fat pad and not an effusion.

 

Agg. prolonged standing, kneeling.

Thoughts: Prolonged standing typical of fat pad-need to ascertain if type of shoe alters this. Kneeling could be fat pad/ PFJ or tendon.

 

Shoes. Worst in bare foot or very flat. Better in a slight heel.

Thoughts: Best clue so far that this is probably a fat pad problem. Unlikely to like a heel if PFJ or tendon.

 

Ease. Standing with knee flexed. Avoidance of kneeling.

Thoughts: Very unlikely to be PFJ if likes standing in flexion. Offloading her fat pad with this stance.

 

HPC. 4 months ago her 2 year old ran into her knee at speed and hit inferopatellar area. Very sore and swollen initially. Settled 70% over first 2 weeks but no further improvement. Anxious about her knee as she wants to try and get pregnant again but doesn’t know if that is a bad idea with her knee as it is. She comments she is very aware of her age and her declining fertility. Moving house out of area and very stressed about house hunting/ not knowing people/ moving away from family.

Thoughts: This lady has a lot on! She doesn’t know the meaning of her pain and how this should impact on her decision re getting pregnant. She sees this as a potential threat to something very important to her. Stress of moving and all associated with it has the potential to decrease her ability to cope with this current pain.

The blow to the front must also be considered for a potential PCL rupture as this can present as PFP as the PFJ gets overloaded by the posterior sag of the tibia.

 

PMH. Nil of note. Obese.

Thoughts: Obesity will increase the likelihood for catastrophic handling of her pain. The high BMI also increases her systemic inflammatory state as well as her inflammatory sate of her fat pad.

SH. Full time stay at home mum with one two year old. Spends a lot of the time on the floor playing with daughter and does not wear shoes at home.

Thoughts: A lot of kneeling going on here plus time bare foot, both of which are likely to stop an inflamed fat pad from settling.

 

O/E.

Obs: Stands with knees in hyperextension. Fat pad oedematous compared to the other side.

 

Thoughts. Constant position of hyperextension creating impingement of patella on fat pad. Need to feel passive hyperextension to check posterior capsule not been overstretched by blow from the front.

 

ROM. R=L. 30 degrees hyperextension. Right painful on passive hyperextension.

Thoughts. Capsule normal but fat pad painful when compressed.

 

Ligament testing: ACL & PCL normal.

 

Palpation: Patella tendon soft and non tendon. Fat pad just lateral to the tendon very tender.

 

Quads: Some subtle atrophy. In single stance unable to control 30 to zero degrees and snaps back into hyperextension.

Thoughts. Poor terminal extension control means that she is likely to accelerate into hyperextension which creates a microtrauma to the fat pad.

 

Other: Excessive pronation of foot visible by abduction of forefoot and rearfoot valgus. Correction in weight bearing visibly makes the lateral fat pad appear less impinged by the patella.

Thoughts: This foot posture closes down the space for the lateral fat pad.

 

Impression.

 

Inferopatellar fat pad inflammation initially started by a direct blow form toddler. A number of factors have meant that the fat pad is struggling to settle. These are:

  • Tendency to hyperextend.
  • Volume of kneeling.
  • Foot posture exacerbated by volume of time bare foot.

There is also a concern here that there is a real risk of catastrophising as the knee problem is perceived as a threat to her future pregnancy, happily moving house and coping with her daughter with reduced family support.

 

Plan.

 

  1. Reassure re the pain. Nothing serious and should be viewed as a nuisance but not a worry. She should not be considering delaying a second pregnancy because of this. Absolutely no need for surgery whatsoever.
  2. Calm the fat pad itself. Ice massage to oiled skin at end of day,(the ice-it-away is fantastic for this), fat pad tape offload and tape in the popliteal fossa to help educate re hyperextension.
  3. Indoor trainer with chunky rear foot sole to provide better foot position and help avoid hyperextension.
  4. One exercise only, (more may become a stressor in itself) to practice 30 to zero degrees in front of a mirror slowly, initially little and often. This must be done pain free,
  5. Avoidance of kneeling as a temporary measure. Sitting on her bottom not kneeling, and bathing daughter with a rolled up towel under knees on tiled floor.
  6. Gentle conversation re BMI stressing it should be viewed as a long-term plan and that she should turn her attention to it when the time is right for her, (ready for change).

 

 

 

 

 

 

 

Daniel 03-08-2016

Great case study! just wondering what you are getting the patient to do with the single leg standing test, you mentioned that she lacked control 0-30deg and tended to hyperextend. Was this performing a movement e.g. small SL squat or purely just standing on one leg and observing the way she was standing? Also is the exercise you prescribed just practicing moving the knee from 0-30deg and back without hyperextending? Thanks :)

Claire 14-08-2016

I'm so glad you liked this. The assessment and treatment are both particularly looking at motor control moving between 30and zero, observing quality, speed, and an awareness of where zero is.The exercise is exactly as you describe, perfored ideally initially with a mirror, and ultimately with eyes shut. I hope that helps!?

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