Halley,

Thanks so much for posting. I certainly appreciate the difficulty with regards to the differentials for this patient. Just a few thoughts:

– When you palpated her superior-medial patella (the area that was tender), did she identify this as HER pain, or distinct from her usual pain? Any sense of a taught band (e.g., thickened synovium)?

– Did you/could you perform the medio-patellar plica test? Certainly not one I am very familiar with, believe it only has limited research, however if positive would certainly point you in a certain direction.

– Hard to say if the fat pad itself is a pain generator for her (thanks for the updated article from McConnel also), however I certainly think that her landing/standing in full knee extension/hyperextension is not helping the cause. Eric has helped me to appreciate excessive knee hyperextension on a number of patients and the deleterious effects this has on the fat pad/other structures. I am sure that education and slight gait alteration will be nothing but helpful there.

– Pregnant patients have been difficult for me to manage at times; definitely not sure I have the answer, however (as in all patients really), I think that education and an encouraging outlook/positive prognosis is always helpful. “Pregnancy certainly has its challenges and there are real changes occurring in your body right now, however there is absolutely no reason to fear that this will be a linger condition. You certainly should be able to get back to your pre-activity levels.” Something like that perhaps.