When Pain Has No Name
She was in her mid 40s. Fit, active, and not one to complain. But for nearly 10 months, pain had taken over her life in small but frustrating ways. It was right at the front of her knee, just beneath the kneecap. She’d feel it every time she walked, every time she went up or down the stairs, and especially when she squatted. Sometimes it was sharp, other times just a nagging ache, but it was always there.
She’d done what most people would do. She saw her GP. Had an X-ray. Her doctor said it looked fine and that it was nothing to worry about. She was then referred to an NHS physio who gave her some general exercises but they only made things worse, so she stopped. She was stuck in that all too familiar place of not being bad enough for urgent care, but not getting any better either.
But what stood out about her, and what ultimately made all the difference, was that she didn’t give up. She knew something wasn’t right, and she decided to look for answers elsewhere. And that’s when she found us.
Listening First, Then Looking Deeper
From the moment she walked in, her frustration was clear. Not just because of the pain, but because no one had taken the time to really dig into what was causing it.
We started from scratch. We listened to everything she’d been through and had a good look at how she moved. Where she was stiff. And what positions made the knee pain worse. And then I had her take her shoes off and walk.
That was when things got interesting.
Her knee wasn’t the problem. Not really. The real issue was how her body was moving, or more accurately, compensating. She had something called ankle equinus, which basically means a lack of dorsiflexion, the ability to bend the ankle upwards. That might not sound like a big deal, but it has a huge knock-on effect. When you can’t move well at the ankle, your body finds another way, often by over straightening the knee when walking. And that’s exactly what she was doing.
This over straightening was pinching a small but highly sensitive structure at the front of the knee called the fat pad.
Fat Pads: The Tiny Things That Hurt A Lot
Everyone has fat pads in their knees. They sit just under the kneecap, cushioning and supporting movement. They’re not big. They’re not flashy. And they’re certainly not something most people talk about. But when they get irritated or impinged, as in this case, they can cause a surprising amount of pain.
What makes fat pad impingement so tricky is that it doesn’t show up well on scans. It’s not arthritis. It’s not a torn ligament. But it can cause just as much discomfort and it’s often dismissed or missed entirely.
She was a textbook case. No obvious damage on the scans. No structural problem in the knee itself. But significant pain that made everyday things like walking, stairs, and squats a real challenge.
Even more telling, she’d already noticed that certain shoes made things worse. Flat soled shoes were a nightmare. But if she wore something with a little heel, her pain improved. She didn’t know why. But it did.
With limited ankle movement, a shoe with a slight heel lift actually helps reduce the strain at the front of the knee. It was the clue we needed.
The Right Plan Changes Everything
Once we had the diagnosis, everything else started to make sense. Our plan was simple but specific:
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Treat the fat pads directly: Gentle friction work and soft tissue therapy around the knee to calm the inflammation.
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Loosen the surrounding muscles: Especially the quads, which were working overtime.
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Strengthen the right areas: Hips, glutes, and core, to help her move more efficiently and take pressure off the knee.
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Correct the biomechanics: We prescribed her a custom orthotic with a heel lift to offload the ankle and stop the knee from overextending.
The results were almost immediate. Within two sessions, she was 70% better. And once her orthotics were fitted and she adjusted to them over about ten days, the knee pain vanished completely.
We saw her for just five sessions in total. That’s all it took.
Even more encouraging, the other aches and niggles she’d chalked up as unrelated, like tight calves and sore feet, also disappeared. Her body wasn’t just recovering. It was finally working how it was supposed to.
A Knee Problem That Wasn’t About the Knee
This case sticks with me not just because of how well she did, but because it’s such a perfect example of a common but overlooked problem.
Fat pad impingement is often missed because it doesn’t show up clearly on imaging. But it’s very real, very painful, and very treatable if you know what to look for.
There’s an old saying we use in clinic “The knee has two angry neighbours, the hip and the foot”. And if you’ve got knee pain, those are the first places you should check.
Her story is a reminder that pain doesn’t always come from where it hurts. Sometimes the problem starts somewhere else entirely. The knee was just the victim. The real culprit was her ankle and her movement pattern.
But most importantly, she didn’t settle. She trusted her instincts, asked better questions, and kept searching until she found someone who could listen and help.
And that made all the difference.
Joe Sharp
BSc (Hons) Physiotherapy
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