Specific Pilates exercises like the Pilates tower, horse, reformer exercises, etc., can significantly target and heal diseases and conditions. Today we will talk about Hoffa’s disease and how exercises like the Pilates tower, reformer exercises, and other types can help manage these conditions.

Albert Hoffa initially described Hoffa’s disease (or infrapatellar fat impact syndrome) in 1904. It is characterized by developing chronic inflammatory changes associated with the incarceration of hypertrophied infrapatellar fat in the femorotibial and femoro-patellar spaces.

Hoffa syndrome can be defined as acute or chronic, persistent, deep, sudden, and throbbing pain.

It is often associated with trauma or high-stress activities for the patellofemoral joint, such as going up and downstairs, bending, jumping, and running resulting from physical or biomechanical disturbances.

It is an inflammation of Hoffa’s pouch, and irritation caused due to compression of this “cushion” of infrapatellar fat. Inflammation occurs due to micro-injuries in adipose tissue caused by improper movements.

On the track, Hoffa’s fat is injured when the athlete exhibits excessive hyperextension of the knee, exaggerated rotational movements, and improper contraction of the anterior thigh muscle (quadriceps).

The process can begin after major acute trauma (direct or indirect) or chronic repetitive microtrauma, causing hemorrhage and edema in the infrapatellar fat.

The resulting volumetric increase predisposes the entrapment and impact on the infrapatellar fat, leading to the accentuation of the local inflammatory changes, hypertrophy of the fatty pad, and feedback of the process.

The main clinical manifestations of Hoffa syndrome are pain, loss, or limitation of the affected knee movement.

Orthopedic alterations of the knee can occur, such as hyperextension knee and rotational instability. In the knees that present some ligament slack, allowing more significant rotation during physical exercises, they are described as the leading causes of the syndrome by Hoffa.

On clinical examination, hypertrophy of the adipose tissue is characterized, which is hardened and painful, finding the “Hoffa signal” being typical.

The most common signs and symptoms are:

  • Acute or chronic pain associated with swelling around or deep in the patellar ligament
  • Pain during walking or wearing high heels
  • Limitation of maximum knee extension

With the positive Hoffa test (the patient is supine with the knee bent), the examiner presses with both thumbs along the sides of the patellar tendon while the patient extends the leg. If the patient feels pain, it is a positive sign for inflammation of the Hoffa fat.

Over the knee

The knee is possibly the joint that suffers the most in the locomotor system. This joint is made of the femur’s distal end, the tibia’s proximal end, and the patella (or kneecap).

It has ligaments that stabilize this joint, and it has menisci that cushion impacts on cartilage.

The patellofemoral joint includes a wide variety of tissues, cartilage, subchondral bone, synovium, infrapatellar fat pad, retinaculum, capsule, and tendons in combination and synergistically.

Being a complex synovial joint, it has two separate joints:

The femoro-patellar joint consists of the patella, a sesamoid bone that resides within the tendon of the anterior thigh muscle (quadriceps femoris muscle), and on the patellar surface in front of the femur, on which it glides, and the femoral joint – tibial links the femur (thigh bone) to the tibia, the prominent bone of the leg.

A viscous fluid bathes this joint, and this fluid is contained within the synovium. In the stability of this joint, there are two main subdivisions:

  • Static Stability – mainly given by the ligaments

  • Dynamic Stability – given by the muscles

The menisci are cartilages present in the knee joint, between the femur’s condyles and the tibia. They have the function of reducing the impact and promoting adaptation between the femur’s articular faces and the tibia.

There are two menisci, one medial and the other lateral, both located above the tibia. They have a half-moon shape, with a division into the anterior horn, body, and posterior horn.

Mechanics of the Muscles Involved

There is a muscular weakness of the quadriceps muscle (vastus medialis oblique, vastus intermedius, vastus lateralis, and rectus femoris). In this way, the vast medialis oblique allows a lateral deviation of the patella, with adverse effects on the patellofemoral mechanism.

Weakness or strain of the hip muscles (adductors, abductors, and external rotators) may occur. The vast medialis oblique originates from the adductor Magnus tendon, a premise on which the recommendation to reinforce the adductor (gluteus medius) is based on stabilizing the pelvis.

The tension of the iliotibial bands can lead to the patella’s excessive lateral stability by causing an excessive lateral force on it, being also capable of externally rotating the tibia and, in this way, altering the balance of the patella-femoral mechanism.

The hamstrings’ tension leads to greater posterior force on the knee, causing increased pressure between the patella and the femur, the hind leg muscles (the soleus muscle and gastrocnemius), leading to compensatory pronation and cause increased posterior knee strength.

Some studies correlate a delay in activating the vastus medialis muscle to patellar instability; however, it is not sure whether this imbalance between the vast medialis and the extensive lateral forces is the primary cause of instability.

Therapeutic Approach

The initial therapeutic approach should be clinical treatment. In refractory cases, a surgical approach is indicated for resection of the lesion.

This topic becomes one of the most controversial topics, and both surgical treatment and non-surgical treatment can be used.

However, the non-surgical treatment approach has priority, since this treatment is low cost, easily accessible and in most cases results in an improvement of the symptomatic picture.

Non-surgical treatment is aimed at reducing pain and edema, correcting biomechanical deficiencies, increasing strength and endurance, restoring movement and function.

The physiotherapeutic approach in turn involves analgesia conditions such as:

  • Cryotherapy – to reduce pain and edema

  • Thermotherapy (with ultrasound, hot wet compresses or hot hydromassage) – for local vasodilation and consequent pain reduction

  • Phonophoresis Iontophoresis – to reduce inflammation and pain

  • Transcutaneous Electrical Nerve Stimulation – to decrease pain

Some doctors indicate the complete rest of the patient as a form of conservative treatment, but at present there is evidence that physical therapy under the supervision of a qualified professional, becomes more effective in the treatment of Hoffa syndrome.

However, this theory of rest is relative, but during the acute phase of this inflammation, the activity of the knee must be decreased, since this pathology occurs due to overload.

The objective of physical exercise in this rehabilitation is neuromuscular deficits: muscles that present poorly such as quadriceps, vastus medialis oblique, tension of molar tissues or dynamic alignment abnormalities.

This type of treatment includes various combinations and variations of open kinetic chain and closed kinetic chain exercises, selective or non-selective muscle recruitment exercises, and stretching.

Patients with Hoffa syndrome tolerate closed kinetic chain exercises better, although both have beneficial results for rehabilitation.


In this way, combined treatments can be used, initially with closed kinetic chain exercises, which allow better control of movement, and later with open kinetic chain exercises.

Pilates and Hoffa Syndrome 

Exercises for joint stability, proprioceptive training, increased range of motion, muscle strengthening, maintenance of physical conditioning, muscle stretching and even postural correction are part of the rehabilitation .

Intervention with supervised physical activity reduces pain symptoms and improves the strength and function of this joint. Strengthening the hip musculature is extremely important as the gluteus medius contributes to knee alignment.

Strengthening the hip muscles begins with isometry exercises for the gluteus medius muscle. Consequently, we strengthen the lateral rotator muscles and the abductors and work the knee extension in order to increase resistance.

Proprioception work in recovery is extremely necessary, since proprioceptive deficiency facilitates joint injury.

Exercises Indicated for Hoffa Syndrome 

  • Front Stretch

This exercise aims to stretch the hamstring muscles.

The patient must stand on the barrel, with unipodal support, maintaining axial growth.

One of the lower limbs should be placed on the barrel, and the trunk should be flexed if possible (always respecting the patient’s limit) on the limb, moving vertebra by vertebra.

Be careful not to tilt the pelvis due to possible shortening.

  • Bidding the reformer

This exercise aims to strengthen the hamstrings, gluteus, gastrocnemius, quadriceps and abdomen.

With the patient lying in supine position, the foot should be supported on the foot bar, flex the hips and knees.

Here the exercise can be performed with a load for strengthening or without a load for mobilization, it will depend on the stage in which the patient is.

  • Horse

This exercise aims to strengthen the pectineus, gracilis, adductor longus, adductor short, adductor magnus, and the inferior and mediais fibers of the gluteus maximus.

Ask the patient to sit on the barrel with the lower limbs abducted, when performing the adduction force against the barrel it should form a “tunnel” under the pelvic region.

Caution not to perform hyperlordosis through compensation.

  • Pilates Tower

The pilates tower exercise aims to strengthen the gluteus medius, gluteus minimus, gluteus maximus, rectus abdominis, oblique muscles, stretching the posterior muscles and mobilizing the spine.

With the patient supine, have the patient position the hip at 90 ° and rest the foot on the tower bar.

He must perform the hip lift by pushing the tower bar up.