Knee pain, hoffa's syndrome

Medical Q&A [Moderated]
1

Hey guys, I’ve been watching episode 19 and 20 of your podcasts now so I will try to give an accurate description of my problem and I hope you might be able to give me some tips to get back under the bar.

I’m 6’7’', 242 lbs and 28 years old, been strength training for almost 10 years, but only 3-4 of those have been doing squats, deadlifts etc.

Around spring this year I started getting some knee pain when running and squatting. I backed off from running a bit thinking there might be too much impact on my knee, but the pain didn’t really get much better and it hurt just about every time I squatted. At this point I was squatting twice a week.

Examination and working with a physical therapist, skip everything in itallic if it’s not relevant:
So I went to my physician and was referred to get an MRI scan which didn’t really show anything that would cause the pain in the area below the knee cap.
I was then referred to a specialist in physical medicine or something, at the national sports medical institute. He made me do some one legged squats, walk around a bit, did an ultrasound of my knee to look for any inflammed tendons, there were none.
He then went on to squeeze a bit and he found a really tender spot that hurt quite a bit when he applied pressure.
He concluded that I likely had hoffa’s syndrome, or fat pad impingement I guess is another name for it?
I was then referred to a physical therapist at the same institute.
First off I was told to stop squatting as that was making the pain worse.
She told me to do some balance exercises and some Jane Fonda type glute activation exercises as she said my glutes weren’t activating.
Later on I’ve done some bulgarian split squats which is nice as it’s atleast some strength training when I add weight, and some step ups which I find strangely hard when I take the back leg out of the movement.
Lastly I’ve been allowed to do banded squats with just the bar.
She also showed me a taping technique, not sure if it helps or not.

So my question is, do you think I should be adding any weight to my squats as long as it doesn’t cause pain? If so, at what rate would you add weight? Should I stop if it hurts?
Do you think light leg presses or knee extensions will help or should I keep focusing on glute exercises?
Do you think taping of the knee helps for recovery?
I see some articles talk about stretching the quads and flat footwear, do you think this will help/matters at all?

I am still deadlifting, if that matters.
English is not my first language so I hope I’m explaining everything well enough, sorry for the long post.

Hope you’re able to help me out!

2

So you had a normal MRI, and the entire diagnosis of fat pad impingement (Hoffa’s syndrome) was made by someone squeezing on your knee? Does it hurt to stand up when locking out a squat or deadlift? First, I’m wondering whether the current clinical diagnosis is accurate.

If you can add weight to the squats (2.5-5 lbs) pain-free then go for it.

I don’t think leg presses or knee extensions add anything unique in this situation.

I don’t think taping, any specific stretches, or footwear have much to do with this.

3

Thank you for the answer, really appreciate it.

Yes, he made me do some movements and then he applied pressure to different parts of the knee, it seemed to be the only thing left as my patella tendon looked fine.
I will try to translate my MRI results and the notes from the examination.
I was told there was nothing on the MRI that should contribute to the pain I had, but if you have any ideas for any alternate diagnoses that would be great.
And I forgot to say, right knee is the main problem.

MRI: “Right knee: cartilage alteration in trochlea upwards. Left knee: Alterations in medial meniscus posteromedial. Uneven surface of joint cartilage in trochlea upwards in the middle”

Examination: “Decent control during 1 legged squats. Walking bilateral normal. No pain during rotation of knees. Stable joints in general. No signs of quad. atrophy. Some tendernes over the patellofemoral joints. Moderat tendernes over Hoffa’s by external knee, mostly right side. Ultrasound show some hydrops (means fluid right?) in right knee. Patella and quad tendons in good condition.”

Deadlifts have never been painful.
During the squat the pain usually starts during the descent, halfway to parallel. There might also be some pain as i initiate the ascent from parallel, but not as bad.
I have to load a normal squat with at least 60-70 kgs to provoke any kind of pain, but it’s typically present almost immediately if I attempt to do it 1 legged.

Good to hear that all the weird stuff I’m reading in articles online is likely BS.
Do you think all the glute activation work and balance stuff is worth my time though?
Any suggestions in particular as to what I should do for rehab besides adding weight to pain free squats?

4

Based on the information you’ve provided here, I remain skeptical about the diagnosis of fat pad impingement syndrome. It sounds to me more like the nonspecific “patellofemoral pain syndrome”, which is a far more common clinical occurrence - I’d look it up and read more about it at PainScience.com.