Discussing Hoffa's Fat Pad with Claire Robertson | Physiotutors Podcast Ep. 003

Summary

In this insightful episode of the Physiotutors Podcast, Claire Robertson, an expert in patellofemoral complaints, delves into the intricacies of Hoffa's fat pad, a lesser-known but significant contributor to knee pain. Claire shares her extensive experience from both a clinical and research perspective, offering listeners a comprehensive understanding of the anatomy, diagnosis, and management of fat pad related issues. Through personal anecdotes and expert advice, she provides valuable guidance for physiotherapists in identifying and treating conditions related to this anatomical structure.

Highlights

• Claire Robertson shares her journey in specializing in patellofemoral complaints, highlighting her transition from clinician to researcher 👩‍⚕️🔬.
• Discussion on the anatomy of Hoffa's fat pad and its role within the knee joint, emphasizing its importance despite being intra-capsular 📚.
• Detailed exploration of common symptoms and typical patient presentations associated with fat pad inflammation 🤕.
• Claire's innovative use of tools like ice massage and taping provide significant relief for patients suffering from fat pad issues ❄️.
• The episode underscores the importance of understanding patient narratives to tailor physiotherapy interventions effectively 🗣️.

Key Takeaways

• Hoffa's fat pad, located below the patella, plays a crucial but often overlooked role in knee pain management 🦵.
• Claire Robertson’s journey from hesitant researcher to a specialist in patellofemoral complaints shows the unexpected paths of career development 🌟.
• Inflamed fat pads are likened to bathroom sponges, becoming engorged with fluid, causing significant pain and irritability 🔎.
• Education and personalized treatment plans are essential in managing patient anxiety associated with fat pad inflammation ❓.
• The necessity of moving away from one-size-fits-all treatment approaches to individualized care plans based on patient history and symptoms 🎯.

Overview

The discussion kicks off with Claire Robertson, a UK-based physiotherapist, who has carved a niche in treating patellofemoral and Hoffa's fat pad issues. Her journey from clinical practice to research has opened new avenues for understanding complex knee issues that often go unnoticed in standard physiotherapy training.

Claire explains the anatomy and common pathologies associated with Hoffa's fat pad. Using relatable analogies, she describes the fat pad as behaving like a bathroom sponge when inflamed, underscoring the significance of recognizing its impact on knee pain. The episode highlights the need for personalized care and the challenges posed by generic treatment protocols.

A sizeable portion of the podcast focuses on patient assessment and crafting unique treatment plans. Claire emphasizes the significance of individualized education for patients about their condition and treatment expectations, stressing the holistic approach needed in physiotherapy to address both physical and psychological aspects of rehabilitation.

Chapters

• 00:00 - 00:30: Introduction The chapter begins with a welcome to the audience and introduces Claire Robertson as the guest speaker. Claire is a physiotherapist, lecturer, and researcher from the UK, specializing in patellofemoral complaints. The discussion focuses on hoppers fat pad complaints.
• 00:30 - 03:00: Claire Robertson's Background Claire Robertson discusses her background and experience as a physiotherapist. She qualified in 1994 and spent her initial years working within the NHS. The chapter hints at a turning point that later defined her career path, although this specific turning point is not detailed in the transcript provided.
• 03:00 - 10:00: Anatomy and Physiology of Hoffa's Fat Pad The chapter titled 'Anatomy and Physiology of Hoffa's Fat Pad' discusses an individual's initial reluctance and eventual appreciation for research, particularly in the context of studying patellofemoral pain after hip replacements. The speaker describes their surprise at enjoying the research process and suggests that this experience serves as a lesson not to dismiss research opportunities before trying them.
• 10:00 - 18:00: Patient Characteristics and Diagnosis The chapter discusses the journey of the speaker, who continued to work part-time at a university and advance their research career, while also working in musculoskeletal outpatient care. During this time, the speaker became informally known for their interest and expertise in treating patellar problems, leading clinics and colleagues to frequently refer patients to them. This reflects the speaker's growing reputation and specialization in the field of musculoskeletal disorders.
• 18:00 - 31:00: Management and Treatment Approaches The chapter titled 'Management and Treatment Approaches' discusses the speaker's transition into a specialist patellofemoral service approximately 12 years ago. The speaker emphasizes a deep commitment to clinical practice, highlighting its importance in driving research efforts. This research is influenced by firsthand clinical experiences, aiming to address significant questions for fellow clinicians. The narrative underlines an ongoing engagement in both private clinical practice and research, illustrating a dedication to the medical community and patient care.
• 31:00 - 37:00: Research and Education The chapter 'Research and Education' discusses a medical practice primarily focused on providing second opinions for patients who have previously experienced unsuccessful treatments. The practitioner reviews each patient's case to diagnose underlying issues and determine if further imaging or investigation is necessary. Based on this analysis, they develop a customized treatment plan for the patient. The caseload described in this chapter mainly consists of cases related to patellofemoral fat pad and the iliotibial band (ITB). Additionally, the practitioner manages their practice independently, running their own business.
• 37:00 - 47:00: Challenges with Education and Research Impact The chapter titled 'Challenges with Education and Research Impact' explores the intersection between education and research in the field of health sciences, specifically focusing on patella femoral complaints. Claire Patella talks about her interest in education that covers both online and face-to-face formats. She shares her journey in becoming more interested in the fat pad and patella femoral complaints through her research work. For those unfamiliar with the topic, she provides an overview of the anatomy and physiology related to the fat pad in the knee, which is essential for understanding these complaints. The chapter aims to make complex medical topics more accessible and sheds light on the challenges of effectively communicating research impact within educational frameworks.
• 47:00 - 61:00: Future Directions in Research The chapter discusses the infrapatellar fat pad as described first by a researcher named Amiyo. It is located inferior to the patella and deep to the patellar tendon, highlighting the importance of understanding its intracapsular nature. This understanding is crucial because it impacts the way the fat pad performs and contributes to understanding its unique and complex functions.
• 61:00 - 77:00: Resources and Upcoming Events The chapter discusses the anatomical structure described by Lou Hoffa, emphasizing its significance and mystery in the past. Only recently, within the last five years, has there been an active effort to research it, measure its attributes, and determine its immunological role. Despite ongoing research, the full understanding of its role in health is still a work in progress. The chapter highlights the growing body of knowledge surrounding this structure and the journey towards unraveling its functions.
• 77:00 - 85:00: Conclusion and Acknowledgments This chapter discusses the changes observed in pathological knee conditions, particularly focusing on the characteristics of a fat pad issue in the knee. The conversation highlights the distinction between the pathology and inflammation of the fat pad, indicating that what is often referred to as pathology might more accurately be termed inflammation. The chapter concludes by considering typical patient characteristics and how these relate to knee pathologies.

Discussing Hoffa's Fat Pad with Claire Robertson | Physiotutors Podcast Ep. 003 Transcription

• 00:00 - 00:30 [Music] hey everybody and welcome back to another edition of the physios podcast today we have Claire Robertson with us as our guest speaker a physio a lecturer and researcher from the UK specializing in patella femoral complaints and today more specifically as we get into it we're going to be looking at hoppers fat pad complaints so Claire why don't you
• 00:30 - 01:00 start us off a little bit and tell us a bit more about yourself and how long you've been practicing and your background as a physiotherapist okay well thank you and so I qualified hit submit this 1994 I call physio and then fairly usual sort of a few years in the NHS and nothing particularly remarkable in terms of what I was doing at that point really I guess the turning point that started defining things was
• 01:00 - 01:30 my masters which I was absolutely dreading my research I was really anxious about it and then I looked at the presence of patellofemoral pain after hip replacements because I was interested in it and I'd seen it observed it quite a bit and I really enjoyed the research and it was completely surprised by that really and I think that's a lesson for everyone actually don't write off research before you've had a go at it and after that I
• 01:30 - 02:00 the universities asked me if I wants to carry on working at the University which I did part-time and carried on my career as a researcher and alongside that worked in musculoskeletal outpatients and at that point in time people would just sort of informally sending me all their patella from more patients because they said oh she likes that and then in the end women and clinics approached me and said well everyone's sending you
• 02:00 - 02:30 their patients anyway do you want to come and do a specialist patellofemoral service and that was about 12 years ago now so I've always practiced as a clinician and really dear to my heart and I don't think I would ever stop doing that and all my research really has been driven by things that I've seen in clinical practice and that is important to me as well to answer meaningful questions for clinicians and then so my private
• 02:30 - 03:00 practice is mostly second opinion so mostly patients who have had failed treatments so I look at them work out what I think is going wrong with they need further imaging or investigation and then I write a treatment plan for them in essence and that is all patellofemoral fat pad and a little bit of ITB that is my whole caseload and then my arm is my own business my own
• 03:00 - 03:30 education business Claire patella and that's all around education online and face-to-face yeah okay lovely so that covers also how you became more interested in the fat pad and patella femoral complaints through your research but for people that might not be so familiar with what's going on can you go over the anatomy physiology of the complaint with with the fat pad and the knee yes office fat sack offer was the
• 03:30 - 04:00 guy that first described in that amiyo the infrapatellar fat pad so it lies inferior to the patella deep to the patellar tendon and I guess the most important thing for people to realize because it impacts so much on how it performs is the fact that it's intra capsular and that is vital to the understanding of it's weird and wonderful things that it does to the
• 04:00 - 04:30 knee and and it's it really interesting Lou Hoffa described it as an anatomical structure a long long time ago really a very little has been known about and it's only in the last five years or so that people have been researching it's measuring it trying to ascertain its immunological role and it's a funny thing I mean it's exact role in the help scene is still not fully understood but we're starting to understand more and more about how it
• 04:30 - 05:00 changes in the pathological knee and the implications of that okay so what are the sort of typical patient characteristics then that you'd see with someone who is affected with pathological fat pad yeah so I think well and perhaps we need to be careful up there using the word pathological because that you can get a pathology in it like a nodule but most of the time it's an inflamed fat pad perhaps that's
• 05:00 - 05:30 the best way for us to think about it now the causes of the inflammation can be variable but if we think about it like an inflamed structure and I'd say the patients look it's a bit like a bathroom sponge and when it's inflamed it gets engorged with fluid and hence it gets big but the characteristics that I would typically identify are levels of pain you know this most people with patellofemoral pain with described as ache hurts a bit maybe younger stairs it's a nuisance the fat pads are the
• 05:30 - 06:00 ones that are unable to work it's just so painful they're the ones that have people in tears in my room incredibly irritable very very visible the slightest thing and it seems to really flare up again and I guess the biggest mechanical difference with patellofemoral pain is that the terrible pain tends to be problem in low deflection so getting out of a chair stairs squats where is fat pad it's very
• 06:00 - 06:30 much more a picture of near terminal extension so they don't like prolong standing where standing you wouldn't particularly expect it to be an issue for some with the telephone wall pain walking walking on the flats whereas walking on the flat again is not normally such an issue they're often better in a bit of a hill whereas obviously the patellofemoral pain patients often really dislike that so fat pad is much more picture of extension problems patella from was much
• 06:30 - 07:00 more picture of flexion okay so those are the sort of signs and symptoms that someone should look out for as a physio doing a patient history with someone saying yeah or extension pattern maybe think so how would you then go about assessing it because obviously that it's not always going to be a plus B is gonna equal C you will obviously have to assess a little bit more further into it but I
• 07:00 - 07:30 think the other thing in the history of taking this interesting is the history of what precipitated it so I mean quite a proportion of them are post arthroscopy because the portals go through the fat pad so that towards the fat pad there's certainly a group who've had a direct blow to the front of the knee they've fallen on it on my patients recently had two year-old had run in a tourney at speed
• 07:30 - 08:00 hyperextension inju injuries sort of foot goes into gets fixed and the knee and the body goes over the top of the leg so that sudden forced type of extension can sometimes create a fat pad problem it's not exclusively identifiable so you do get patients with insidious onset but often there is a clue in their background so that's worth having a bit of a dig as well and then in terms of physically I think it's
• 08:00 - 08:30 virtual heard of to have someone with pain from the fat pad without it being inflamed in terms of visually big so I would be very surprised if someone if I thought someone had sound like they had a fat pad problem in and they had no fat pad edema I would think oh okay that really isn't looking like a problem but conversely sorry because it's never straightforward is it an edema without
• 08:30 - 09:00 it being symptomatic and that has actually been evidenced that you can get patients on MRI who have an incidental edema in their fat pad but it's not symptomatic and generally I find if they're symptomatic from the fat pad tender on palpation there is a test hoppers test which I personally don't use I don't find it offers anything extra and if they've got a very is for me they don't thank you for squashing
• 09:00 - 09:30 the fat pad and but I certainly would palpate and I've observed on my course that people often don't palpates high enough superiorly enough for the fat pad so if we remember them Anatomy it attaches onto the joint line and the menisci and people often have it in their mind that it's this sort of inferior structure and in my experience it's often particularly the latter II the Supra the most superior part of the lateral aspects the fat pad that is
• 09:30 - 10:00 right up by the joint line that is the point that is tender and getting impinge so good palpation skills going right up to the joint line I think is important as well other things I'd look for would be paying response on passive hyperextension you wouldn't expect to see that in a telephone wall problem also often they really don't like active extension so that compression effect onto the fat pad I'm curious to know if
• 10:00 - 10:30 they've got a lot of extension hyperextension and if they have what is their control like so if they're up to it I might get them into single stance and get them it's very slowly extending seeing can they control out they flick into hyperextension so those would be my sort of I guess my main go-to things okay just to dig a little deeper with the the pain response I'm assuming than the pain that they'd feel if you asked
• 10:30 - 11:00 them to then locate that pain would also be on the front inferior to the patella or and most of the time but I am not exclusively the fat pad can refer retro patella it can refer around and about so what I would be looking for is that when I palpate the fat pad if it's other thing I will be saying is that your pain do you recognize that as your pain the pain that they have every time they have these familiar to them and then with the
• 11:00 - 11:30 patients who film might be capable of when you're asking them to do the single leg stance and go into the extension are you going to more so associated the patients with an issue as the ones who are able to hyperextend or the ones that are afraid of extending into it because of pain yeah I mean I'm interested in both of those groups so if it can't do it because of pain and that demonstrates to me the level of pain and that fits again with the fat pad problem and I would be
• 11:30 - 12:00 looking to work to they're comfortable maximum if they can do it I'm then looking at yeah the quality in the control of that movement yeah and awareness anywhere where zero is or has they've got that proprioceptive alteration women are actually really clear of where zero is so what sort of advice them would you give to other therapists if they were seeing patients like this obviously you've mentioned a few things to look out for in the history but what about in
• 12:00 - 12:30 terms of treating someone with this yeah it's it sounds a bit nerdy what I'm about to say now but I think he's taking applicable information comes from the latin name tamari which means fire and i think it's such a good analogy in this case and i think the point is that you can't push into pain with this at all not one choice because it's just like blowing on the fire and they just rage
• 12:30 - 13:00 and i just don't think you can work through it so I am looking to explain that's the patients particularly the patients that are perhaps so desperate to get it right they'll push through pain and perhaps they're overeager overzealous so often I view the treatment in two stages really the first stage is the settling process and I say some good we've got to get the inflammation ours because if we don't as soon as you start upping your functional levels the chances are it's going to
• 13:00 - 13:30 flare back up so it's no good just having glowing embers you've got to get the fire out so I have three go to measures that I sort of tend to try and pull on quite regularly with this day so one is an absolute complete ban on barefoot socks slippers because when they're in that position the fat pad is more likely to get impinged so I will get them to look at the pride get really
• 13:30 - 14:00 obsessed get all their shoes and look at the profiles so that I basically want the back of the shoe to be slightly deeper than the fronts and you know it's quite um you look at trainers some very much have that profile and some don't so it's really worth and you know so the worst kind of thing of very flat Valley puns flip-flops sort of a bit sort of super flat so and it's interesting often the patients say you know what I've already worked out but some shoes are
• 14:00 - 14:30 more comfortable than others so it's really important to have that and I always say look this is any temporary but it's an absolute rule you know even if you just got around the house no barefoot socks very flat shoes so that's my first thing the second thing is if they're irritable is walking is to make sure that they are minimizing really they're aggravating factors going back to this information concept so really
• 14:30 - 15:00 trying to only do what they need walk for what they need for need to do and any other things that they might have identified aggravating you know prolonged standing so for example I had a patient recently with the rage in fact I problem who works in a bookshop she was on her feet a lot so we really looked at her different duties and what and and then she spoke to the store management said I really need to try and minimize the amount of standing that I'm doing so that's it so really trying to
• 15:00 - 15:30 minimize those aggravating factors and then my two treatments to the needs transecting inflammation ah ice massage too oiled skin this is this is how I came about to invent the ice it away so I was recommending to patients that they used an ice cube and everyone was coming about saying the same thing it's really effective but it's really messy in my hand goes cold the problem to be solved so I design
• 15:30 - 16:00 it's funny little device that you can hold and then it's a sphere of ice that's really nice to massage read and I recommend they do that at least once a day ideally in the evening because the information tends to build up during the day and if they can manage it more times during the day just two or three minutes it's quite a small area and then my final go to measure is taping to offload and I use a rigid tape to do this so I pull the teller up and off the fat pad
• 16:00 - 16:30 and it's really interesting there's a significant group of patients to stand up and go that's better it's interesting it's a bit like you know having a bruise and you're constantly patting it and then the tape sort of stops that process and it can be really quite dramatic when someone's fat pad is very sore and very irritable and so that so the tape that ice massage the shoes and the removal of the aggravating things am I such a stage one if you like
• 16:30 - 17:00 and then really stage two varies hugely depending on what I feel is the driver sometimes actually if it's been a trauma like the arthroscopy portals or a direct blow once you've got over stage one it's just a question of reconditioning the limb and you actually often away but if there's no obvious trauma then you've got to sort of say well why did this come on in the first place and that could be the hyper extenders we talked
• 17:00 - 17:30 about but very often it can also be other things like they have a relatively unstable patella so I'm saying relatively so there might not be dislocating they might not perceive it to be an instability issue but I would view it an instability issue because the instability of the patella femoral joint is causing the patella to crash around and bang into the fat pad cause it to swell up and catch if that's the case and I'm going to be looking at things
• 17:30 - 18:00 like removing all unwanted movement from the limb whether it's from the foot up or the hip down or the trunk and then I'm going to want to offer up as much dynamic Stability from their quadricep strength as possible so that's your sort of instability group we've then got pate and those would probably present with the fat pad edema all the way around because the patella is crashing around medially laterally whereas there's another group which present with very
• 18:00 - 18:30 much almost looks like a bubble and that sort of lateral fat pad you know it's like a circle on that corner and then you've got to think along the lines of okay what's his pinching down what's him pinching down on that lateral fat pad and that can be the patella lateral izing so that could be for example through and tightness in a key element could be tightness in the proximal contractile origins the ITB or it could be either actually the femur is medial
• 18:30 - 19:00 izing which is still sort of crushing down that lateral corner so then it's a question of have you got an ant ability from your neck have they got excessive from rotation have they got poor control do they know that they're dropping in so a combination of dynamic control of femoral rotation with awareness movement awareness so it's really interesting and people say to me all the time how can you just do patellofemoral in fat pad
• 19:00 - 19:30 don't you get bored and I'm like Lou absolutely no it's like it's just so many different you know kind of subgroups and subcategories and I really enjoy the challenge of I'm breaking it down and I think that's why some of them don't respond to treatment because they get a broad sweep of give them a couple of stretches a bit of core strengthening maybe an orthotic you know and a bit of a catch-all and they vary so much they need this really and reasoned approach
• 19:30 - 20:00 yeah this keen eye for what it is there's the root cause the problem yeah oh you have this there are some exercises away you go yeah yeah exactly I think the last thing about the fat pad patients is that often it's very anxious I think the pain is so unpleasant you know the fat pad is the most innovative structure in the name I don't know quite how he got the ethics for hips I did this study where the people had all the anatomical structures and
• 20:00 - 20:30 pricked with a pin and we had to raise life they hope to rate it in terms of the pain and they all absolutely every single person said the fat pad was the most pain was the worst pain so these patients often you know in lots of trouble with it and and I think because it flares up so quickly it plays with your head a bit as well I think because often they've been doing really well oh yeah okay we're going along fine and then they do something that they consider really
• 20:30 - 21:00 quite innocuous maybe they stand to cook a Sunday lunch which then they stand a bit longer than I stood before and boom it's off again and then the next day they're really really saw and I think that level of irritability creates a cold creates a perfect environment if you like anxiety and of course we know that anxiety can bring about the avoidant behavior and it can also handling of pain so we need to be
• 21:00 - 21:30 mindful of managing that side of things as well I think so how would you go about coaching someone through that because that's not just looking at your specialism then of patellofemoral pain that's also going into yeah helping with fear avoidance yeah well I don't think you can remove you can separate the two and it's something I have people being my bonnet about because the field patellofemoral field the literature body
• 21:30 - 22:00 has been housed in very biomechanical quantitative literature for decades and that's fine and of course there's a huge place for it but there has been such a lack of qualitative literature I mean I did my qualitative work on practice and published that 2017-2018 Ben Smith did some great qualitative work and really apart from that there has just been just a void and a real lack of good quality
• 22:00 - 22:30 literature but it doesn't mean that it's not important and we know that the longer people have their symptoms the higher the chances are that they have central changes and so and you know most these patients come in they report long duration symptoms so I've never felt that it was anything other than a condition that involves a lot of understanding of pain you know it's very integral to the way that I work and as
• 22:30 - 23:00 part of that is education and it's really interesting if you look at the health beliefs literature it tells us that when someone has an accident say like an ACL rupture it's a very obvious cause and therefore sort of a linear course of action that needs to be taken through right need to prepare for surgery surgery we have six months whatever done but what's the health release literature shows and this isn't exclusive to paternal pain or even
• 23:00 - 23:30 musculoskeletal medicine he's like headaches it would score bowel syndrome people can't work out why it's there it's just crept on it Demming the literature tells us that there is worse engagement with treatment because and it's really interesting I say to my patients who've had failed physio which is most of them because I'm running a second opinion service and I say what was the gist of the physio you know I not expect them to say well in a range groups you know I think expecting
• 23:30 - 24:00 them to say just I want to get a bit stronger I'm like my pelvis or you know a bit stretcher in my car so I mean I'm looking for something like that and very few can tell me they just say oh I was given some exercises and then I said what do you think gold the exercises was oh yeah I suppose to get me a bit stronger I get things like that and people how can we expect someone who hasn't got an idea why their problems coming in the first place and they've been randomly given a few x-rays and they don't really know what they're
• 24:00 - 24:30 doing how can we expect people to adhere to that I think it's totally unrealistic so I spend a lot of time talking to my patients and it's something I feel really strongly about I get very irritable if someone goes off with the knee model because I use it all the time so explain how things are and I want it to be that when they leave my appointment they know why they've got their pain what's caused the
• 24:30 - 25:00 pain what the likely and prognosis is how long it's going to take what they need to do what the treatment should feel like should they push through pain should they push through practices you know I wanted to be really really informed and if they aren't I view that as a failing on my behalf that I haven't worked out their narrative what what is going to be important to them it's interesting you mentioned the new bottom side of it because I have the same problem as well sometimes someone runs
• 25:00 - 25:30 away with it and then I really have some patient busy well you say if you can help the patient visualize it and they'll understand the exercises better and if you ask them to do a certain number of reps and sets of an exercise and explain to them why when they can they can visualize the reasoning behind it and see what's going on in their own picture in their own head as best they can without being a physio or someone yeah some kind of person with anatomical
• 25:30 - 26:00 knowledge it it does help to the adherence as to why and what they're doing so I'm just really getting inside their narrative I mean I'm really interested in narrative medicine so basically looking at their story so trying to start as the commission from a point of sort of not knowing and listening really really well and asking questions but from a point of view just facilitating as opposed to you know
• 26:00 - 26:30 digging what for what you think you're going to hear I'll give you a really good example recently I had someone with patellofemoral and fat Pat it was a mixture of pain who was really quite distressed by the situation and when we explored it it wasn't the loss of the exercise that was the issue for her it was she got a real buzz I suppose is my sense you've got a real buzz from the music from the class that she went to so my number one
• 26:30 - 27:00 point on her treatment plan was email your big cars teacher and see if we can get a copy of the playlist because then you can do your rehab exercise to that and then you can feel good and we can start engaging with the feeling of well-being and happiness and I think you know as I say the field of patella from one fat pad has been so hard in biomechanics I think as much as we need to understand that we really need to engage with the patient's story and and
• 27:00 - 27:30 we need to see how we can really get them on board and work through with them as a partnership and I think that a lot of these patients do have significant chronic pain characteristics nice I like that kind of approach as well of really bringing it back down to to them that the whole idea of getting them to get the playlist for their rehab just provides a whole nother aspect that you probably may not get elsewhere
• 27:30 - 28:00 individualize everything for them it gives them that extra push I think that's right I think it's really really important and I don't sleep and you talk to people about time of day as well because patients often do their exercises and they get in in the evening and you know say you're trying to do something that's involved with motor recruitment and learning new patents and movement well hey guess what doing that when you're really tired essentially isn't the best time to do it so having those discussions I think can
• 28:00 - 28:30 make such a big difference as a package with someone and also you know it gives them the message that you're listening and that you really want to do very best for them and I think that therapists patients relationships so important just going back you mentioned you had a patient who had patella femoral and fat pads complaints now is it something that you see in combination quite often or
• 28:30 - 29:00 yeah yeah it is and it's of course you know we all you know particularly busy Kenny would like things to fit nicely into neat boxes but the reality is that particularly those insidious onset ones particularly might Smits with a rotational component that they are often high risk for both patellofemoral and fat pad and of course the minute the fat pad becomes the Demeter's it alters how
• 29:00 - 29:30 the patella moves so here's an example when we sit still our patella and should descend towards our foot because we're sitting in knee flexion but if you have a great big fat pad the patella can't descend so it's it's superior on the convexity of a femoral condyles and hence the retro patella pressure will be greater so cinema sign as it were is very common
• 29:30 - 30:00 in patellofemoral pain but that's often goes very much hand in hand with the inflamed fat pad so yes I'm afraid and they are the hard they are harder patients for that sounds because if you take them into too much flexion to avoid the fat pad the aggravates the patellofemoral pain and if you go to find some extension to avoid the patellofemoral pain you know what I tend to do is talk about the safe zone which
• 30:00 - 30:30 is often around twenty to forty degrees of knee flexion so the fat pads not impinged but we're not over fifty degrees of knee flexion the patella from forces go up very rapidly so if we stick between 20 and 40 degrees to do our early stages of our work whether it be glue to work or quadriceps then we're more likely to have a picture that is effective but not if not irritating okay and then using sort of in terms of the
• 30:30 - 31:00 exercises would you work in more high volume or isometric exercises or I yeah i quite like isometrics actually particularly for the patellofemoral pain because you know if you move them around like if they're seblak seem slightly if they're patellofemoral alignment isn't really good then the more chance of having a problem with that if they're moving around a lot so I think and the eyes metrics can be very very useful and often less painful and
• 31:00 - 31:30 again you know we've talked about irritation fat pad but also we know that pain disrupts the firing of the quads so I don't see any point in doing painful quads strength work you know maybe a little bit of fat grandson is fine but nothing significant and so isometric so really useful and then it really just depends what I found so it might be that for example on the stairs they are
• 31:30 - 32:00 dropping into excessive femoral internal rotation they don't realize they're doing it so I might have worked on pasti of fibers of gluteus medius and then I might I might have done that open chain then I might move them into standing to do that then I might move them into stride stunning then I might move them into step standing so getting close and closer to that functional movement that is causing them a problem yeah so yeah it depends what you feel is the driver but you you could do all of that without
• 32:00 - 32:30 a doubt with the knee between 20 and 40 degrees easily okay and then for myself and I think at least for many people that I've spoken to on this topic this isn't something that was covered too heavily in school in fact I think within school so much as the fat pad exists is probably as far as we got into talking on yeah exactly I mean what you mentioned that at the beginning of the podcast as well that it's probably only
• 32:30 - 33:00 in the last five years or so that it began to garner some attention what what do you think the reason is there doesn't get so much coverage within our education because I've CA it can play quite a big challenge in rehabilitation especially with yeah well I think it's in very recent years that actually people have realized that this is something that causes a significant number of people a significant level of problem so I just don't think it's been on people's radar really it was
• 33:00 - 33:30 described anatomically but why bother teaching about it unless you know you know you can see that it's an issue and the challenge actually now is whether we can get more education or I mean I'm also amazed and other structure the medial patellofemoral ligament isn't talked about now that is one of the primary restraints the patella yes structure that's not mentioned so I think changing practice mean well that's a whole nother podcast
• 33:30 - 34:00 you know that sir that is a perennial challenge but it's been really interesting for me seeing the interest in my webinar on the fat pad because people are great there's something to turn to to to get a few answers and then obviously it's it's something that's come up a lot and well that you've covered in in your own research how much do you you feel that your researchers impacted your clinical decisions and and
• 34:00 - 34:30 your clinical practice in general and the research that you've done through all of this yeah I mean my and I haven't done any research exclusively to the fat pad but I've done but as I said there's so much interplay between the patella femoral joint and the fat pad so my crepitus work was the idea was born from my clinical practice and it's informed my finger practice massively my anatomical work has on the VMO looking
• 34:30 - 35:00 at architecture change has definitely played into how I approach patients and select which pressure patients I might think that are going to benefit from quads work and I'm it's a writer for them at the moment but we've also been looking at the effects on the VL of Architecture from stretching and we've also looked at the effects on the bail architecture from foam rolling so we've looked at and its quality it's an
• 35:00 - 35:30 interesting collaboration you know I'm I do all this work with Phil ABS who is an anatomist and it's a really interesting and a good example of collaboration whereby he's very very a pure scientist really and he has a skill set that I I don't have you know he works in the dissection rooms at the University this fine anatomical knowledge is fabulous and I've very much coming from a clinical domain and we've been wanting
• 35:30 - 36:00 to go for over a decade now I'm researching and it's it's got to point he just sort of laughs and says what do you want to know now Claire I say what I want to know now is this it's always driven by my clinical practice and it's a great way to work because I couldn't do the research like him he couldn't do it without me it's a perfect collaboration and yeah it's and it's very much ongoing as well so we've been this last winter we've been looking at patellar tilt and how that changes with
• 36:00 - 36:30 hip adduction so we've been looking at measuring out tilts with ultrasound and that's borne out of observations that I've seen in clinical practice so yeah I hope there's constant interplay between practice and research which is something I feel really strongly about yeah absolutely I think so long as there's there's things there's always going to be something to research to look deeper into and you'll sound like you're very open to if you see something you want to
• 36:30 - 37:00 know more about what the deeper cause and deeper meaning I think that in line with that I think my next area that I'm really going to try and look at more is this role of Education because what I've observed is the kind of bio mechanist if you like are saying we must educate our patients as if it's something we do to them and for me that's like absolutely as I was saying before not how it works it's starting from that premise of not
• 37:00 - 37:30 knowing and there's quite a lot around in a psychiatric mixture actually around this this concept of not knowing starting from a blank canvas and I think what I want to demonstrate through court would have to be through qualitative research is is the breadth of issues that she's important to people so you know like my patient who actually when we dug and chatted through it was the me lost the music in the class you can't
• 37:30 - 38:00 predict that you can't ever predict something like that you know and for someone else it recently it was the fact that she had always wanted a dog she just got to the point where she thought she was gonna get a dog and I'm because I'm a fat pad and she couldn't walk she thought I'd better not get a dog and she'd start really depressed about that because it's something she'd really aspire to but she said I felt really silly about saying it because she said I know some people might think that's ridiculous and again you couldn't predict that and yet so the education for those two patients
• 38:00 - 38:30 have just given you examples so completely and utterly different you know it's not such a set rule eight point rules that we have to tell everyone with patellofemoral pain I am now educating you on these eight points it doesn't for me weren't like that nuts and I think for me aware I would like to take my research next okay that's gonna be quite some work especially I'm gonna keep you busy for quite some time I hope
• 38:30 - 39:00 you mentioned the way that you're currently I'm right up with the VL and the foam rolling and stretching and stuff is that something you can talk about at the moment yeah yeah so we we basically have been looking for last few years about the architecture of the VMO and how it changes with exercise strengthening exercise and we found consistently that the fiber angle relative to the femoral axis became bigger with exercise and so did the
• 39:00 - 39:30 insertion ratio the amount of muscle attached onto the patella and we found that really consistently and we've looked at different types of exercise for rid of muscle stem so what I then said was won't look when we treat patients with a bulky tight V L I sort of have a mental image of a cyclist in my head when I'm talking about it and you know we are we don't want that strong lateral izing force onto the patella so does it work the other way around when we stretch someone so we put people
• 39:30 - 40:00 on a stretching program and sure enough we found overarching knew that their architecture became more vertical which is what we want but not in everyone and what we found was the people with the very big angle to start with had the bigger change and for me really fitted intuitively with that patient that comes in they've got that hypertrophied type big ya that you intuitively want stretch and get your
• 40:00 - 40:30 hands and a release out that's I guess the patient that we identified with our research their architecture changes and we replicated the study with foam rolling I mean there is an absolutely total lack of good quality literature on foam rolling so we didn't set out to sort of give too much Susak logical argument Errani it was just simply what happens to the architecture when we've thrown rolled for six weeks and we found the same effect that in people with a
• 40:30 - 41:00 big VL to start with the angle became less so in other words more vertical less lateral icing so really interesting I am a bit biased I'll give you that wasn't even going through my head no no how would something like that play into a patient with fat pads or patella femoral complain how can you utilize the information on the VMO you research and
• 41:00 - 41:30 then the VR research as well well we at the clinic where I work we are measuring people's BMI architecture with ultrasound because we have ultrasound infinite so we because similar to the VR we identify the people with this fiber angle to start with so poor VMO bulk basically had the biggest change so if this doesn't it they have the sort of scope for more change if you like so we are using that as a predictor of who are
• 41:30 - 42:00 good candidates for quad strengthening I'm not going to call it V mo strengthening because we're not selectively activating the but when you train the quads you'll get this effect and in the VMO so we've using it as a predictor because quite frankly you know quad strength is for is relevance in a lot of patients but not all patients you know that patient that comes on the pain comes on a time and a training a lot and they're really strong you know you might all just tell them and find that they've got a really big VMO angle they've got great cause boat
• 42:00 - 42:30 that is not the driver of their problem so you know I don't just and I can really confirm that and the VL work we could don't just on it we haven't been but I think they're visually patients that you know you can see as I say so picture that cyclists that comes in with a big VL feels tie it's very active and could go back to the VMAs stuff I mean those patients you can visualize that
• 42:30 - 43:00 perhaps post surgical patients or post certification who've got a lot of atrophy they're almost hollow in that distal portion because the fibers have become more vertical and left this space where and there's a void if you like so you don't have to have ultrasound you know you can you can look just good observation skills marrying together with the history you know so this is a patient who's had a lot of pain and swelling they've had surgery right yeah okay I can see their VMO is really quite
• 43:00 - 43:30 wasted they're gonna have a really small insertion angle and conversely this person's been training are they've done lots of squats the cycling whatever it is they've got a massive tight active male the chances are that's going to be very lateral izing force on the patella you also mentioned earlier about patients who could potentially subluxated force in the lateral direction as well that's probably not going to be helping into their issues as well exactly and they might be the
• 43:30 - 44:00 person that's got that fat pad edema on the lateral side you know so if we see that picture lateral fat pad swelling big-time VL patella that sort of sub luxe on that lateral which of the trochlea that's called fitting for me so they might have patella from or and fat pad pain but the causative factors are probably the same okay lovely you've mentioned that you see a lot of overlap with the patella femoral patients as well when you're combining these approaches do you find a lot of
• 44:00 - 44:30 resistance from patients at all if if they have both of these problems you mentioned that sometimes you have in to work in these smaller ranges of motion but well I think it comes back down to education you know and and it's not that difficult to open a song because you know you can say look you know that when you stand for too long it hurts and I show them where the fat pad is and show them on me more than why that is and I was the saying you know when you go to you been like when you're going upstairs or try squat it's really sore so I said so what we're
• 44:30 - 45:00 going to do is think of your safe zone and pick that 20 to 40 degrees so I that isn't something I find if I've explained it like that I tend to think they're like okay yeah and I'll say from that we won't always be working in this range this now we can move further into bigger range but this is gonna be our starting point okay so how is it you think that we can bring the fat pad then into more light into the limelight so to speak
• 45:00 - 45:30 yeah well I mean I think it would be because people were as you say undergraduate level yeah you know I mean I really I've been trying to peddle Pantene so a couple of years now we do face face webinars obviously there's now this stuff thing you guys are doing for me on the fat pad and on my course I teach on it and the reason work coming through is increased interest around the role of osteoarthritis and the fat pad
• 45:30 - 46:00 and obesity in the fat pad and our areas of growth in terms of their funding and their research because all of a sudden people are going okay and it's not just about load when you've got a high BMI it's about you inflammatory profile as well and what we know is that if you're systemically inflamed because you've got a high BMI you will have more inflammation in your fat pad as well and you know and for me it explains why you can get to people
• 46:00 - 46:30 with an awful looking knee x-ray in terms of osteoarthritis but one will be the sort of wiry gentleman with very low BMI x-ray looks dreadful really not that much pain bit stiff may be functioning science yeah and then you get someone who might have slightly milder changes on there and x-ray but they've got a high BMI come in they've got an infused knee they've got a big fat pad and what I think we're starting to see from the literature and certainly this
• 46:30 - 47:00 fits with my experiences there the fat pad flips into a pro-inflammatory feeder if you like and merrily feeds things into the joint and so feeds Pro inflammatory cells Pro fibrotic cells and nitric oxide lots of things that encourage the inflammatory pathway and it's really interesting since looking at this work I've certainly treated started treating as patients completely differently I'm not thinking of as a sort of Oh a knee I'm thinking them as a
• 47:00 - 47:30 fat pie problem and I'm treating as a fat pad problem and I've had some great results with us and even also post total knee replacement no this is another interesting group some surgeons don't respect the fat pad and sometimes the fat pad can get and remain inflamed and I think can be a source of post total knee replacement ongoing pain and I had a lady recently who knee was just so warm and a bit of Fewster day year it
• 47:30 - 48:00 just hadn't settled down a fat pad was really angry and so I went for my measurement for ice tape you know people saying yeah but she's had a near-miss doesn't matter it's a fat pad problem I think the fat pad is driving this inflammatory profile so I went for the shoes taken ice and I'm completely changed it says if it would just switched it off and we stuck around to looking like how we were all expecting her to look like after knee replacements
• 48:00 - 48:30 so I think the fat pad and in the O a group is an area of interest and I know that there's some of the Australian researchers are looking at this and at the moment and I think there will be more emerging on this topic and in the next year or two I hope hopefully then the next time we we do something like this we can talk about more research than yeah and I'm definitely I think I'm
• 48:30 - 49:00 definitely going to start using the the rigid tape I do as well I mentioned to yourself when I de mailed you that I've got a bit of a problem with it myself hey I think I personally have with the rigid tape I think it's just gets a better offloading because I tried with the K tape and tried that a few times it's yeah a little bit but then it's yeah quite the relief that I'm sort of looking for expecting at the time so absolutely ah definitely be given that
• 49:00 - 49:30 again good thank you very much for your time and everything have you got any last little bits with bobs that you'd like to say to anyone out there listening you oh I'm wanting to be really keen and have a bit more info on the patellofemoral joint or the fat pad and really it's just my website www.levitt.com that's Claire with an iron Anthony and and it's there's a tab for patients as well so and I've got
• 49:30 - 50:00 quite a few case studies up there so it's quite a nice resource for patients to some different videos and my course is there up there so if anyone's to go super keen they can come and you know spend a day with me on my courses and then you're also on YouTube and on Twitter as well if people want to find you there so it's Claire patella is the YouTube channel and the same for Twitter as well says what it does on the tin perfect and have you got any upcoming
• 50:00 - 50:30 events or seminars that you cover in at the moment yes so pretty much all he's got and my day course in the diary in various locations so I've got in Yorkshire soon bath London and then I'm also speaking on the North East England musculoskeletal society study day in the autumn as well and so those events will be on my website as well all right lovely well thank you very much
• 50:30 - 51:00 it's a pleasure well ladies and gents thanks again for listening in and we'll catch you next time as always wherever you're listening to this we appreciate your time and if you have any comments or suggestions feel free to get in contact and let us know until next time [Music]