Assessment of Inflammation of Infrapatellar Fat Pad and its Contribution to Anterior Knee Pain Severity and Severity of Knee Osteoarthritis

Assessment of Inflammation of Infrapatellar Fat Pad and its Contribution to Anterior Knee Pain Severity and Severity of Knee Osteoarthritis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessment of Inflammation of Infrapatellar Fat Pad and its Contribution to Anterior Knee Pain Severity and Severity of Knee Osteoarthritis Amira Abd Allah, Nadia Salah, Mohammed Ali, Soha Eldessouki This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7272743/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: Osteoarthritis is the most common arthritic disease worldwide, characterized by debilitating pain and joint tissue damage. While the exact cause of knee osteoarthritis pain remains unclear, evidence suggests that inflammation plays a role in both disease progression and pain. Early detection and treatment of inflammation may improve outcomes. This study aims to assess infrapatellar fat pad (IPFP) inflammation using Doppler ultrasound in patients with knee osteoarthritis and in those with anterior knee pain without osteoarthritis, and to evaluate its impact on pain severity, and response to treatment (conservative therapy vs. Ultrasound-guided steroid injection). Methodology: This case-control study involved 60 patients with anterior knee pain (30 with knee osteoarthritis and 30 without). Each group was split into two subgroups of 15 patients: one received conservative treatment, and the other received ultrasound-guided injections of methylprednisolone into the infrapatellar fat pad. Clinical and ultrasound assessments were conducted at the start and after 6 months. Pain was evaluated using the Visual Analog Scale (VAS) and the Western Ontario and McMaster universities(WOMAC) index. Results: At baseline, Ultrasound showed IPFP inflammation in both groups, more commonly in osteoarthritis knees. After 6 months, steroid injection groups showed significantly better pain relief and functional improvement than conservatively treated groups (p < 0.05). The best outcomes were seen in non- osteoarthritis patients receiving injections (WOMAC ↓52%, VAS ↓61%). Ultrasound also showed reduced IPFP thickness and vascularity in injected knees, especially non- osteoarthritis ones, with minimal changes in the conservative groups. Conclusion: Infrapatellar fat pad inflammation contributes to anterior knee pain in both osteoarthritis and non- osteoarthritis patients. Doppler ultrasound helps in early detection. Ultrasound guided steroid injections were more effective than conservative treatment, supporting targeted fat pad therapy for better pain control and potential osteoarthritis progression delay. Infrapatellar fat pad Anterior knee pain Knee osteoarthritis Ultrasound Corticosteroid injection INTRODUCTION Osteoarthritis (OA) of the knee is among the most prevalent and disabling joint disorders worldwide ( Zhang et al., 2020 ). A significant decline in quality of life is a common result, along with functional impairment and persistent discomfort ( Al-Hourani et al., 2022 ). As the world's population ages and obesity rates rise, more and more people, including those who are physically active, are experiencing knee osteoarthritis ( Glyn-Jones et al., 2015 ). Knee OA pain is often debilitating and is the hallmark symptom of the disease ( Neogi, 2013 ), but its exact etiology is multifactorial and not fully understood. Knee OA was formerly thought to as a bone and cartilage degeneration disease; however, new research shows that inflammation of different joint tissues is a major contributor to the disease's structural advancement and pain production ( Scanzello & Goldring, 2012 ). Nociceptive pathways can be sensitised and chronic pain can be developed and maintained by pro-inflammatory cytokines within the joint ( Schaible et al., 2014 ). Specifically, OA-related synovitis and periarticular structural inflammation have been associated with worsening knee pain and impairment. In the front of the knee, right below the patella, there is a collection of fat called the infrapatellar fat pad (IPFP), which is also called Hoffa's fat pad. This mass of fat is located intracapsularly but extrasynovially ( Mace et al., 2016 ). Patellar tendon, femoral condyles, tibial plateau, and IPFP are all closely related; the IPFP cushions the knee as it moves forward and fills the anterior compartment ( Stephen et al., 2018 ). Adipocytes, macrophages, and other immune cells that can produce inflammatory mediators are found within its well-innervated and vascularised interior. The inflammatory processes in the IPFP in knee OA have been demonstrated in multiple investigations. The fat pad produces cytokines and adipokines, which can add to the joint inflammatory environment ( Wang et al., 2024 ). The IPFP is a significant source of interleukin-6 in knee OA, according to Distel et al. (2009). A decrease in the threshold of nociceptive nerve fibres within the fat pad can be caused by these inflammatory cytokines, leading to the induction and intensification of pain ( Schaible et al., 2014 ). Indeed, severe inflammation of the IPFP has been associated with higher pain scores and greater disability in knee OA patients ( Satake et al., 2023 ). The IPFP may be involved in the pathogenesis of knee OA, according to new findings. When looking at the IPFP of individuals with knee osteoarthritis, histopathologists have found fibrosis, inflammatory cell infiltration, and neoangiogenesis ( Belluzzi et al., 2019 ). Articular cartilage, synovium, and subchondral bone are all sites that the IPFP can interact with; inflammatory mediators produced by the IPFP have the ability to hasten degenerative changes in these tissues ( Jiang et al., 2019 ). On imaging, signal alterations in the IPFP on magnetic resonance imaging (MRI) have been correlated with knee pain severity and can even predict progression to knee replacement within a few years ( Wang et al., 2018 ). The IPFP's function is multifaceted, while some evidence suggests that an enlarged or hypertrophic IPFP may provide mechanical protection for the joint through stress absorption. For instance, one study followed individuals over time and discovered that those with larger IPFP areas had less cartilage degradation and less knee problems ( Pan et al., 2015 ), hinting at a possible protective effect in certain contexts. A clinical observation that emphasises the importance of conserving the IPFP is that surgical excision of the fat pad, which is commonly done during total knee arthroplasty to get access to the joint, may increase the risk of postoperative anterior knee discomfort ( Sun et al., 2020 ). This suggests that the IPFP is not merely a vestigial structure but rather can influence knee pain and outcomes. Musculoskeletal ultrasound (US) has emerged as a valuable tool to assess the IPFP in vivo. Ultrasound can readily detect features of IPFP pathology, including effusions around the fat pad, changes in echogenicity (a normal IPFP is uniformly hyperechoic, whereas inflammation makes it appear hypoechoic), increased thickness, and hypervascularity on power Doppler. Compared to MRI, ultrasound is more accessible, noninvasive, and cost-effective, and it offers higher spatial resolution for superficial soft-tissue structures along with the ability to perform dynamic, real-time examinations ( Lake Zurich Open MRI, 2024 ). Thus, US is well suited for both diagnosing IPFP inflammation and guiding targeted interventions such as injections. Despite these insights, relatively few studies have focused on the IPFP as a therapeutic target for knee pain. It remains unclear to what extent inflammation of the IPFP contributes specifically to anterior knee pain in patients without radiographic OA, and whether treating this inflammation can improve clinical outcomes. We hypothesized that IPFP inflammation is an important contributor to knee pain severity and that ultrasound-guided targeting of the IPFP would alleviate pain and improve function. In light of this, the current study set out to use musculoskeletal ultrasound to measure infrapatellar fat pad inflammation in patients suffering from knee osteoarthritis and those suffering from chronic anterior knee pain who did not have osteoarthritis. The secondary objective was to determine whether there was a correlation between the degree of inflammation and the severity of pain in these groups. Furthermore, we evaluated the clinical results and ultrasound findings of two treatment modalities in comparison to one another: conservative therapy and US-guided IPFP corticosteroid injection. AIM OF THE WORK The purpose of this study is to examine the relationship between IPFP inflammation, the intensity of anterior knee pain, and various treatment modalities in patients with knee osteoarthritis (KOA) using musculoskeletal Doppler ultrasound. PATIENTS AND METHODS Study Design and Patients This study was designed as a prospective case-control trial involving 60 patients with anterior knee pain, recruited from those attending outpatient clinic of physical Medicine, Rheumatology and Rehabilitation Department at 2 years, divided into two equal groups. Group 1 consisted of 30 patients with knee osteoarthritis (OA group), and Group 2 consisted of 30 patients with anterior knee pain without OA (non-OA group). The diagnosis of knee OA was established according to the American College of Rheumatology (ACR) clinical and radiographic criteria for knee OA ( Altman et al., 1986 ), which require characteristic knee pain along with radiographic evidence of osteophytes and specific clinical features. Patients in the non-OA group had chronic anterior knee pain (duration ≥ 3 months) with no evidence of knee OA on clinical examination or X-ray (Kellgren–Lawrence grade 0) ( Kellgren and Lawrence, 1957 ). Inclusion and Exclusion Criteria Only persons (defined as 18 years or older) suffering from anterior knee pain for a minimum of three months were considered for the study. Exclusion criteria encompassed the following: a history of major knee trauma or surgery; a knee internal derangement (such as symptomatic meniscal tears or ligament injuries); intra-articular metallic implants (which could interfere with imaging); and pregnancy or lactation. Other forms of inflammatory or metabolic arthritis, such as rheumatoid arthritis or gout, were also considered. We also did not include patients whose damaged knees had an intra-articular injection in the previous six months. Ethical Approval The study protocol was approved by the Faculty of Medicine Research Ethics Committee (Approval No. MD 189/2018, dated 22 July 2018), and all participants provided written informed consent for participation before enrollment, in accordance with the Declaration of Helsinki. Interventions Each group of patients (OA and non-OA) was further subdivided into two subgroups (A and B) of 15 patients each, based on the treatment received. Subgroup A patients underwent conservative management, while subgroup B patients received local IPFP injections. Thus, group 1A refers to OA patients treated conservatively, Group 1B to OA patients receiving injections, Group 2A to non-OA patients treated conservatively, and Group 2B to non-OA patients receiving injections. – Conservative Treatment (Subgroup A) : Patients managed conservatively received a standard regimen consisting of patient education, lifestyle and activity modification (including weight reduction when applicable), a course of nonsteroidal anti-inflammatory drugs (NSAIDs) for 2 weeks, and a focused physiotherapy program. The physiotherapy included therapeutic ultrasound diathermy, transcutaneous electrical nerve stimulation (TENS), and strengthening exercises for the quadriceps muscle around the affected knee. These modalities were administered over a 6-week period with regular supervised sessions aimed at reducing pain and improving knee function ( Alghadir et al., 2019 ). – Ultrasound-Guided IPFP Injection (Subgroup B) : Patients in the injection subgroups underwent ultrasound-guided infiltrations of the infrapatellar fat pad with corticosteroid and local anesthetic. The injection technique was performed under strict sterile conditions. With the patient supine and the knee extended and supported, the most tender area of the IPFP (typically at the inferolateral patellar region) was identified. A high-frequency (13 MHz) linear ultrasound probe (LOGIQ P5, GE Healthcare, Milwaukee, WI, USA) was placed longitudinally over the patellar tendon to visualize the IPFP. Using an out-of-plane lateral approach, a 22-gauge needle was inserted horizontally at the lateral edge of the patellar tendon, just inferior to the patella, targeting the IPFP deep to the tendon. Proper needle placement within the fat pad was confirmed on the ultrasound image, and lack of resistance to injection was ensured. Then, 2 mL of solution containing 40 mg of methylprednisolone acetate and 1.8 mL of 3% mepivacaine HCl was injected into the IPFP as a bolus. This procedure was adapted from standard musculoskeletal injection techniques ( Saunders & Longworth, 2018 ). Each patient in subgroup B was allowed up to a maximum of three IPFP injections at 4-week intervals (one injection per month) if pain persisted or recurred; otherwise, no repeat injection was given. All injections were performed by an experienced physician under ultrasound guidance to ensure accuracy and safety. Baseline Evaluation All patients were evaluated thoroughly at the beginning of the study. The patient's complete medical history was documented, which included vital signs such as age, sex, weight, height, and BMI. Any pertinent comorbidities and medications were also noted. A comprehensive evaluation of the injured knee was carried out. We looked for abnormalities in the animal's gait and limb alignment as well as signs of joint oedema or effusion and quadriceps muscle atrophy throughout our examination. The knee's passive ROM was assessed by utilising a goniometer to quantify the degree of flexion and extension. Using the patellar tap and bulge tests, palpation was used to confirm the presence of an effusion and to detect discomfort along the joint lines. Traditional examinations for ligamentous stability were used to evaluate the knee. By applying deep thumb pressure on each side of the patellar tendon (directly over the IPFP) while the knee was bent at a 30-60° angle, the examiner may clinically assess IPFP inflammation using the Hoffa's test. If there was greater discomfort upon palpation in this area, it was deemed a positive finding. Fat pad pathology indicated by Hoffa's sign ( Schaible et al., 2014 ). Clinical Outcome Measures Two standardized outcome measures were used to evaluate the degree of pain and the function of the knee. A knee osteoarthritis index developed by Western Ontario and McMaster Universities (WOMAC) was the initial one. Osteoarthritis of the knee and hip can be assessed with the help of the WOMAC, a self-administered questionnaire that has been validated. There are a total of 24 items on the scale, with 5 questions covering pain in different situations (e.g., while walking, climbing stairs, in bed, sitting/lying, or standing), 2 questions covering stiffness upon waking up and throughout the day, and 17 questions covering physical function (e.g., difficulty with using stairs, standing, bending, walking, getting in and out of a car, shopping, putting on socks, getting out of bed, etc.). The Likert scale ranges from 0 (not at all) to 4 (very intense) for each item. Higher WOMAC scores indicate worse pain, stiffness, and functional limitations; subscale values vary from 0 to 20 for pain, 0 to 8 for stiffness, and 0-68 for function. The overall WOMAC score can be anywhere from 0 to 96. It was common practice to convert the overall WOMAC score to a percentage scale from 0 to 100, with 100 indicating the most severe symptoms, in order to facilitate interpretation. ( Howard Head Sports Medicine, 2020 ). Follow-up At the 6-month follow-up appointment, patients underwent a musculoskeletal ultrasound (US) of the afflicted knee joint in addition to the Visual Analogue Scale (VAS) for knee pain, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and other diagnostic tools ( Wang et al., 2023 ). Statistical Analysis Software developed by IBM®, Chicago, IL, USA, known as SPSS v27, was used to conduct the statistical study. The Shapiro-Wilks test and histograms were used to assess the data's normality. When presenting quantitative parametric data, we used standard deviation (SD) and analysis of variance (ANOVA) with a post hoc Tukey test for comparisons. With the use of the Kruskal-Wallis test and the Mann Whitney U-test for pairwise comparisons, non-parametric quantitative data were displayed as median and interquartile range (IQR). To analyse qualitative variables, the Chi-square test was used, and the results were shown as percentages and frequencies. For statistical purposes, a two-tailed P value less than 0.05 was deemed significant ( Kruskal & Wallis, 1952 ). RESULTS Table 1: Knee Range of Motion (ROM) of the studied groups. Group 1A (n=15) Group 1B (n=15) Group 2A (n=15) Group 2B (n=15) P value Flexion ROM (◦) Before Mean ± SD 125.4 ± 10.05 132.8 ± 11.12 143.3 ± 5.01 144.1 ± 4.43 <0.001* Range 110 - 148 115 – 150 132 - 150 135 – 149 P1 0.076 <0.001* <0.001* P2 0.005* 0.002* P3 0.993 After Mean ± SD 126.1 ± 9.25 135.3 ± 8.25 143.3 ± 5.01 145.4 ± 2.77 <0.001* Range 115 - 148 125 – 150 132 - 150 139 – 149 P1 0.003* <0.001* <0.001* P2 0.012* <0.001* P3 0.827 Extension ROM (◦) Before Mean ± SD 7.3 ± 1.83 8.6 ± 1.55 10 ± 0 10 ± 0 <0.001* Range 5 - 10 5 – 10 10 – 10 10 – 10 P1 0.092 <0.001* <0.001* P2 0.003* 0.003* P3 1 After Mean ± SD 7.9 ± 1.6 9 ± 1.25 10 ± 0 10 ± 0 <0.001* Range 6 - 10 7 – 10 10 – 10 10 – 10 P1 0.018* <0.001* <0.001* P2 0.044* 0.044* P3 1 *: Data presented in the form of mean±SD . Significantly different as Pvalue≤0.05 .ROM: range of motion The ROM of the knees for each group is displayed in Table 1 . Group 2 had larger ranges of motion (ROM) values compared to Group 1 (p < 0.05), indicating a statistically significant difference in flexion and extension ROM between the two groups. Neither Group 2B nor Group 2A differed from Group 1A in terms of flexion or extension ROM before nor after therapy. Nevertheless, according to Table 1 , Group 2B had significantly larger ranges of motion (ROM) for flexion and extension following treatment compared to Group 1B, Group 2A to Group 1A, and Group 1B to Group 2A (p < 0.05) ( Table 1) . Table 2: Echogenicity of Hoffa’s Fat Pad Before and After Treatment Group 1A (n=15) Group 1B (n=15) Group 2A (n=15) Group 2B (n=15) P value Before Hypoechoic 8 (53.33%) 7 (46.67%) 15 (100%) 15 (100%) 0.002* Echoic 7 (46.67%) 8 (53.33%) 0 (0%) 0 (0%) After Hypoechoic 4 (26.67%) 2 (13.33%) 15 (100%) 15 (100%) < 0.001* Echoic 11 (73.33%) 13 (86.67%) 0 (0%) 0 (0%) *: significantly different as Pvalue≤0.05. Table 2 displays the echogenicity of the Hoffa’s fat pad in the studied groups. Echogenicity of the IPFP before and after treatment was significantly different among the groups (p = 0.002 and p < 0.001, respectively). Before treatment, both Group 2A and 2B (patients without OA) showed 100% hypoechoic fat pads, whereas Group 1 had a mix of hypoechoic and echoic pads. After treatment, hypo-echogenicity markedly decreased in Group 1B and 1A (with more fat pads becoming echoic), whereas Group 2 remained 100% hypoechoic ( Table 2 ). Table 3: Hoffa’s Fat Pad Width (mm) Before and After Treatment Group 1A (n=15) Group 1B (n=15) Group 2A (n=15) Group 2B (n=15) P value Hoffa fat pad width (Before) Mean ± SD 14.1 ± 1.18 13.6 ± 1.45 13.9 ± 1.33 13.3 ± 1.46 0.370 Range 11.7 – 16 11.5 - 15.7 11.4 – 16 11.1 - 15.5 Hoffa fat pad width (After) Mean ± SD 9.8 ± 2.25 6.7 ± 0.35 8.3 ± 1.94 5.3 ± 0.14 <0.001* Range 7 – 13 6.2 - 7.2 5.8 - 12.2 5.1 - 5.7 P1 <0.001* 0.041* <0.001* P2 0.032* 0.048* P3 <0.001* *: Data presented in the form of mean±SD . significantly different as Pvalue≤0.05. Table 3 shows the Hoffa’s fat pad width measurements. Hoffa’s fat pad width before treatment did not differ significantly among the four groups. After treatment, however, there was a significant difference (p < 0.001). Specifically, the Hoffa’s fat pad width was significantly lower in Group 2B than 1B, in Group 1B than 2A, and in Group 2A than 1A (p < 0.05) (Table 3 ). Table 4: Largest Fat Lobule Width Before and After Treatment Group 1A (n=15) Group 1B (n=15) Group 2A (n=15) Group 2B (n=15) P value Largest fat lobule (Before) Mean ± SD 4.9 ± 1.17 4.8 ± 0.81 5.2 ± 0.14 5.4 ± 0.16 0.076 Range 3 - 6.4 3.5 - 6.1 5 - 5.4 5.1 - 5.6 Largest fat lobule (After) Mean ± SD 2.1 ± 0.11 2.6 ± 0.17 2.4 ± 0.18 2.8 ± 0.18 <0.001* Range 2 - 2.3 2.2 - 2.8 2.1 - 2.6 2.5 - 3 P1 <0.001* <0.001* <0.001* P2 0.001* 0.018* P3 <0.001* *: Data presented in the form of mean±SD . significantly different as Pvalue≤0.05 Table 4 shows the largest fat lobule width in the IPFP. Before treatment, the largest fat lobule width was similar in all groups (no significant difference). After treatment, the largest fat lobule width differed significantly among groups (p < 0.001). It was significantly higher in Group 2B than 1B, in Group 1B than 2A, and in Group 2A than 1A (p < 0.05) ( Table 4) . Table 5: WOMAC Index Scores Before and After Treatment Group 1A (n=15) Group 1B (n=15) Group 2A (n=15) Group 2B (n=15) P value WOMAC index (Before) Mean ± SD 47.8 ± 1.86 41.7 ± 6.17 46 ± 3.44 38.5 ± 4.94 <0.001* Range 45 – 50 30 - 50 40 – 50 30 - 47 P1 0.002* 0.68 <0.001* P2 0.045* 0.205 P3 <0.001* WOMAC index (After) Mean ± SD 25.7 ± 3.74 20.1 ± 1.94 22.4 ± 1.55 17.8 ± 1.32 <0.001* Range 20 – 30 18 - 25 20 – 24 16 - 20 P1 <0.001* 0.002* <0.001* P2 0.041* 0.049* P3 <0.001* *: Data presented in the form of mean±SD . significantly different as Pvalue≤0.05. Table 5 presents the WOMAC index scores of the studied groups. The WOMAC index before treatment was not significantly different between Group 1A and 2A, nor between Group 1B and 2B. However, it was significantly lower in Group 2B and Group 1B than in Group 1A, and also lower in Group 1B and 2B than in Group 2A (p < 0.05). After treatment, the WOMAC index differed significantly among all groups (p < 0.001). Specifically, WOMAC scores were significantly lower in Group 2B than 1B, in Group 1B than 2A, and in Group 2A than 1A (p < 0.05) ( Table 5) . Table 6: VAS Pain Scale Scores Before and After Treatment Group 1A (n=15) Group 1B (n=15) Group 2A (n=15) Group 2B (n=15) P value VAS scale (Before) Median 8 8 8 8 0.054 IQR 7.5 – 9 7 - 8 7 – 8 7 - 8 VAS scale (After) Median 4 3 4 2 <0.001* IQR 4 – 5 2.5 - 4 3 – 5 2 - 3 P1 <0.001* <0.001* <0.001* P2 <0.001* <0.001* P3 <0.001* *: Data presented in the form of Median (IQR) . significantly different as P value≤0.05. Table 6 shows the VAS pain scale scores of the studied groups. The VAS score before treatment was similar (median ~8) in all groups (no significant difference). After treatment, there was a significant difference (p < 0.001): the median VAS was lowest in Group 2B (median 2) and highest in Group 1A (median 4), indicating better pain improvement in the non-OA injection group. Post hoc analysis showed VAS after treatment was significantly lower in Group 2B than 1B, and in Group 1B than 2A, and in Group 2A than 1A (p < 0.05) (Table 10). The VAS scale before treatment was not significantly different among the groups, whereas after treatment it showed significant differences as noted above ( Table 6) . DISCUSSION We aimed to determine whether inflammation of the infrapatellar fat pad was a factor in anterior knee discomfort in individuals with and without knee osteoarthritis, and if so, how effective was it to treat this inflammation with ultrasound-guided injections. Our results show that both groups experience IPFP inflammation, and that injecting corticosteroids into the IPFP dramatically improves function and significantly decreases pain. The key novel insight is that ultrasound-detected IPFP abnormalities (effusion, hypo-echogenicity, increased thickness) correlate with pain severity, and alleviating these abnormalities through injection yields superior outcomes compared to conservative management. Notably, the benefits of IPFP-directed therapy were most pronounced in patients with anterior knee pain but no radiographic OA – these patients often achieved near-complete pain relief – whereas patients with established knee OA also improved but to a lesser extent, likely because their pain arises from multiple sources in addition to the fat pad. Overall, our results support the hypothesis that IPFP inflammation is an important driver of anterior knee pain and demonstrate that it is a modifiable source of pain and disability. Our data align with and extend previous research on knee OA and pain. We observed that, at baseline, the OA patients had more restricted knee range of motion and more frequent effusions than the non-OA patients, despite similar pain scores. This is consistent with the understanding that knee OA is typically accompanied by joint stiffness and intermittent synovitis ( Scanzello & Goldring, 2012 ). After treatment, improvements in knee ROM were greatest in the injection groups, particularly in non-OA patients. Improved ROM is an important outcome, as restricted knee motion due to pain and effusion can significantly impair gait and function in these patients ( Rutherford et al., 2012 ). Knee OA often forces patients to adopt slower or abnormal gait patterns to minimize pain ( Brandes et al., 2008 ). Patients probably had increased range of motion (ROM) and, maybe, a more normal gait after receiving IPFP injections, which successfully reduced inflammation and pain in the fat pad. This is supported by Debi et al. (2011), who found that knee OA patients with better functional status (lower WOMAC scores) had gait parameters closer to normal, such as longer single-limb support time during walking ( Debi et al., 2011 ). Thus, the ROM gains and pain relief from IPFP injections in our study may translate to improved biomechanics during ambulation. In general, interventions that restore knee motion and stability can break the cycle of disuse and weakness. Our research shows that reducing discomfort in the fat pad and other intra-articular areas can significantly enhance mobility, an essential component of knee health and well-being. Curiously, there was no difference in baseline levels of systemic inflammation markers (ESR, CRP) between the OA and non-OA groups, and no elevation in our patients, suggesting that the inflammation was mostly localized. This contrasts with the findings of Hanada et al. (2015), who reported that elevated ESR and high-sensitivity CRP correlated with more severe radiographic knee OA ( Hanada et al., 2015 ). In our study, even the OA patients mostly had normal ESR/CRP, perhaps because many had moderate OA limited to the knees. The non-OA patients, despite having chronic knee pain (often due to conditions like patellofemoral pain syndrome), also did not show systemic inflammation. These observations suggest that IPFP-driven knee pain can occur with normal systemic inflammatory markers, highlighting the importance of local evaluation (e.g., via imaging) in such cases. The discrepancy with Hanada’s results may be due to differences in patient selection (their cohort included more advanced OA or inflammatory features) or sample size. It reinforces that biomarkers like ESR/CRP are not sensitive for detecting the kind of low-grade, localized inflammation present in the IPFP. Our ultrasound findings shed light on the local inflammatory environment of the knee. We noted that baseline effusions (particularly in the lateral recess) were common in OA knees and significantly less so in non-OA knees, reflecting a higher degree of synovitis in OA. After treatment, the resolution of effusions in the injected groups (especially OA injection subgroup) was striking – the difference between OA and non-OA in effusion presence disappeared. This suggests that the corticosteroid injections effectively reduced synovial inflammation and fluid production in the knee ( McAlindon et al., 2017 ). Effusion can be both a marker and contributor of joint inflammation. Therefore, eliminating the effusion, as we achieved in many injected patients, might not only relieve pain but could also potentially slow disease progression. Although our study’s follow-up was too short to assess long-term structural outcomes, it is encouraging that the intervention reduced effusions; in theory, less synovial fluid and inflammation might mean less cartilage breakdown over time. Another interesting finding was that the presence of medial osteophytes did not differ significantly among groups or change over time. By definition, our non-OA patients should have no (or only minimal) osteophytes, whereas OA patients have them; however, the statistical analysis did not show a clear separation, likely because a few “non-OA” patients had small osteophytes (K/L grade 1 changes) without meeting full OA criteria. It is also possible that our sample size limited the power to detect differences in this categorical variable. Clinically, the lack of correlation between osteophytes and pain is well documented ( Markhardt et al., 2018 ). Markhardt et al. (2018) noted that osteophytes in certain compartments (e.g., the patellofemoral joint) can exist even when cartilage is relatively normal and may or may not cause symptoms ( Markhardt et al., 2018 ). They suggested that osteophytes in the patellofemoral compartment should be considered separately from tibiofemoral OA when evaluating pain. In our study, some patients in the non-OA group might have had isolated patellofemoral osteophytes (related to anterior knee pain) that did not qualify as OA under K/L criteria. This underscores the point made by Markhardt and colleagues that osteophytes alone are not a reliable indicator of pain severity or overall OA status. Our results align with this view: improvements in pain were driven by treating the fat pad inflammation, not by any change in osteophyte status. In essence, our interventions addressed the “active” inflammatory pain generators rather than the static bony changes. The infrapatellar fat pad itself appears to be a key active tissue in knee pain. We found that reducing IPFP inflammation via injection led to significant clinical gains. Conversely, in the conservatively treated patients, the IPFP remained hypoechoic and thickened (indicating ongoing inflammation) and these patients continued to experience more pain. Liu et al. (2023) conducted a cross-sectional study using MRI and observed that IPFP signal intensity alterations correlated with knee OA status ( Liu et al., 2023 ). They also reported, interestingly, that pain scores did not differ significantly between their early OA patients and controls without OA ( Liu et al., 2023 ), which they attributed to sample characteristics. In our study, baseline pain levels were indeed similar between OA and non-OA patients (since all had anterior knee pain to begin with), but it was the response to treatment that differentiated them. The non-OA patients (whose pain was presumably driven largely by the fat pad and related soft tissues) responded dramatically to fat pad injection, whereas OA patients had a more moderate response, likely because their pain had additional sources (cartilage degradation, subchondral bone changes, etc.). The difference between our findings and Liu’s highlights that in a population specifically selected for anterior knee pain, IPFP inflammation plays a dominant role, whereas in unselected early OA vs. controls, pain levels might not differ if early OA is asymptomatic. Our results demonstrate that when anterior knee pain is present, treating local inflammation (IPFP) can yield substantial pain reduction, supporting the idea that the IPFP is a meaningful pain generator even if systemic inflammation is absent. This concept is supported by fundamental research on pain mechanisms: Schaible et al. (2010) showed that proinflammatory cytokines within a joint can produce pain hypersensitivity without systemic involvement ( Schaible et al., 2010 ). In our patients, the local production of such cytokines in the fat pad (as suggested by other studies ( Morel et al., 2011 )) was likely contributing to pain, and the steroid injection curtailed that local cytokine activity, leading to pain relief. Our study also provides insight into the duration of steroid injection benefits, especially in comparison to other studies. We observed that at 6 months, OA patients who received injections had some return of pain (their WOMAC and VAS at 6 months were not as low as at 1 or 3 months, based on interim evaluations), but they still fared better than those without injections. Non-OA injected patients maintained very low pain levels through 6 months. This pattern is consistent with the known temporizing effect of intra-articular steroids in OA – typically providing significant relief for a few weeks to a few months ( McAlindon et al., 2017 ). For instance, Jones and Doherty (1996) demonstrated that intra-articular corticosteroids are effective for short-term pain relief in knee OA, although predicting the duration of response is difficult ( Jones and Doherty, 1996 ). In our case, the use of up to three injections might have extended the relief in the OA group somewhat. Büyük et al. (2017) reported that knee OA patients who received a corticosteroid injection had a large improvement in WOMAC scores at 2 weeks (from a baseline score of ~68 down to ~32) and that some of this benefit persisted at 6 months (WOMAC around 61, still better than baseline) ( Büyük et al., 2017 ). Our OA injection subgroup showed a very similar trend: a major drop in WOMAC after injection and some gradual increase by 6 months, but remaining improved compared to baseline and compared to controls. On the other hand, Kikkuri et al. (2021) observed an even more dramatic early response in WOMAC (improvement from ~48 to ~93 on a 0–100 scale at 3 weeks) that then diminished to ~55 by 6 months ( Kikkuri et al., 2021 ). The differences in magnitude and trajectory of WOMAC improvement across studies could be due to patient factors (e.g., Kikkuri’s patients might have had less baseline disability or a differently scaled WOMAC) or injection protocols. Importantly, Chansoria et al. (2016), who studied ozone vs. steroid injections, found that VAS pain in the steroid group dropped from 8.9 (baseline) to 2.8 at 1 month, then gradually rose to 5.1 by 6 months ( Chansoria et al., 2016 ) – a pattern very much in line with our OA injection results (initial drastic pain reduction with some recurrence by 6 months). In contrast, our non-OA patients had almost no pain at 6 months after injections, suggesting that when the primary pain generator (the fat pad) is effectively treated and there is no ongoing joint degeneration, pain relief can be more durable. This difference emphasizes that in OA, continuous or repeated interventions may be required to maintain improvement, as the disease process is chronic. Furthermore, our results emphasize that conservative therapy, while beneficial to some extent, was not as effective in reducing IPFP inflammation or improving outcomes. Conventional measures like NSAIDs and physiotherapy can help symptoms, but in our study many patients on conservative treatment still had persistent IPFP inflammation on ultrasound and significant pain (particularly the OA patients). This suggests that the IPFP can be a therapeutic target not adequately addressed by standard OA management. The marked success of the injections in the non-OA group also indicates that some cases of anterior knee pain (often labeled as idiopathic or “patellofemoral pain syndrome”) might actually have an inflammatory fat pad component (sometimes termed Hoffa’s disease or fat pad syndrome) that responds extremely well to steroid injection. Clinicians should be aware of this, as patients with refractory anterior knee pain but normal radiographs might benefit from an ultrasound evaluation of the fat pad and a targeted injection if inflammation is present. Limitations: The sample size was small (n=60), limiting statistical power and generalizability. The follow-up period was short (6 months), which may not capture long-term outcomes or side effects. The study was not blinded, increasing the risk of bias from participants and investigators. There was no placebo control group, making it difficult to rule out placebo effects. Pain assessments were subjective, using tools like VAS and WOMAC that may be influenced by patient perception. Variability in conservative treatments (e.g., differences in physiotherapy adherence) may have affected results. Adverse effects of corticosteroid injections were not thoroughly evaluated or reported. CONCLUSION Anterior knee pain, with or without osteoarthritis, is often linked to inflammation of the infrapatellar fat pad (IPFP). This study shows that musculoskeletal ultrasound can detect IPFP inflammation early and guide targeted therapy. In non-OA patients, ultrasound-guided corticosteroid injections provided near-complete symptom relief, while OA patients improved more than with conservative care alone. IPFP is a modifiable pain source, and its ultrasound-guided treatment can reduce pain, improve mobility, and enhance outcomes in knee OA and related conditions . Recommendations: Larger multicenter studies with extended follow-up are needed to validate findings. Routine musculoskeletal ultrasound (US) should be used for early detection of IPFP inflammation. Targeted ultrasound-guided corticosteroid injections for IPFP inflammation may improve pain and function in knee OA patients. IPFP-directed therapy should be considered in non-OA patients with anterior knee pain. Monitor long-term outcomes of IPFP injections to assess sustained pain relief and functional improvement. Integrate ultrasound assessment of the IPFP into standard knee pain evaluation. Abbreviations AUC Area under the curve BMI Body mass index CRP C-Reactive Protein CSA Cross sectional area ESR Erythrocyte sedimentation rate IA Intra-articular IL Interleukin IPFP Infrapatellar fat pad IQR Interquartile range K/L Kellgren-Lawrence KOA Knee osteoarthritis KOOS Osteoarthritis outcome score MRI Magnetic resonance imaging NSAID Non-Steroidal Anti Inflammatory drug OA Osteoarthritis QOL Quality of life ROC Receiver Operating Characteristics SD Standard deviation TENS Trans cutaneous electrical nerve stimulation Us Ultra sound VAS Visual analogue scale WOMAC Western Ontario and McMaster universities Declarations Funding Disclosure: The authors declare that they did not receive any financial support or funding for the conduct of this study or the preparation of this manuscript . Consent to participate: Written informed consent was obtained from all participants prior to their inclusion in the study, in accordance with the Declaration of Helsinki Consent for publication: Not applicable. Ethical approval number: The study protocol was approved by the Faculty of Medicine Research Ethics Committee (Approval No. MD 189/2018, dated 22 July 2018). Data availability : All data and materials used for this study are available upon request. References Alghadir AH, Anwer S, Sarkar B, Paul AK, Anwar D (2019) Effect of 6-week retro or forward walking program on pain, functional disability, quadriceps muscle strength, and performance in individuals with knee osteoarthritis: A randomized controlled trial. BMC Musculoskelet Disord 20:159 Al-Hourani M, Al-Hourani A, Al-Hourani M (2022) The impact of pain on quality of life in patients with osteoarthritis. 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Acta Ortopédica Brasileira 25(4):153–157 Chansoria M, Upadhyay A, Jain A (2016) Comparative efficacy of intraarticular injection of combination of ozone and steroid and ozone alone in patients with primary knee osteoarthritis: A prospective and randomized clinical analysis. J Orthop Allied Sci 4(2):65–70 Debi, R., Mor, A., Segal, G., Segal, O., Agar, G., Debbi, E., … Elbaz, A. (2011).Correlation between single limb support phase and self-evaluation questionnaires in knee osteoarthritis populations. Disability and Rehabilitation, 33(13–14), 1103–1109. Distel E, Cadoudal T, Durant S, Poignard A, Chevalier X, Benelli C (2009) The infrapatellar fat pad in knee osteoarthritis: An important source of interleukin-6 and its soluble receptor. Arthr Rhuem 60(11):3374–3377 Glyn-Jones S, Palmer AJR, Agricola R, Price AJ, Vincent TL, Weinans H, Carr AJ (2015) Osteoarthritis. 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J Am Stat Assoc 47(260):583–621 Lake Zurich Open MRI (2024) Ultrasound vs. MRI for Diagnosis: A Comprehensive Comparison . Retrieved from https://lakezurichopenmri.com/ultrasound-vs-mri-for-diagnosis/ Liu, Z., Wu, J., Xiang, W., Wu, J., Huang, S., Zhou, Y., … Liu, B. (2023). Correlation between the Signal Intensity Alteration of Infrapatellar Fat Pad and Knee Osteoarthritis:A Retrospective, Cross-Sectional Study. Journal of Clinical Medicine, 12(4), 1331. Mace J, Bhatti W, Anand S (2016) Infrapatellar fat pad syndrome: A review of anatomy, function, treatment and dynamics. Acta Orthop Belg 82(1):94–101 Markhardt BK, Block WF, De Smet AA (2018) MRI-detected osteophytes of the knee: Natural history and structural correlates of change. Arthritis Res Therapy 20(1):1–9 McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M, Ward RJ (2017) Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: A randomized clinical trial. JAMA 317(19):1967–1975 Morel M, Berenbaum F, Cohen-Solal M (2011) The infrapatellar fat pad should be considered as an osteoarthritic joint tissue capable of modulating inflammatory and destructive responses in knee osteoarthritis. Osteoarthr Cartil 19(1):21–27 Neogi T (2013) The epidemiology and impact of pain in osteoarthritis. Osteoarthr Cartil 21(9):1145–1153 Pan, F., Han, W., Wang, X., Liu, Z., Jin, X., Antony, B., … Ding, C. (2015). A longitudinal study of the association between infrapatellar fat pad maximal area and changes in knee symptoms and structure in older adults. Annals of the Rheumatic Diseases, 74(10), 1818–1824. Rutherford DJ, Hubley-Kozey CL, Stanish WD (2012) Knee effusion affects knee mechanics and muscle activity during gait in individuals with knee osteoarthritis. Osteoarthr Cartil 20(9):974–981 Satake Y, Izumi M, Aso K, Ikeuchi M (2023) Association between infrapatellar fat pad ultrasound elasticity and anterior knee pain in patients with knee osteoarthritis. Sci Rep 13:20103 Saunders S, Longworth S (2018) Injection Techniques in Musculoskeletal Medicine: A Practical Manual for Clinicians in Primary and Secondary Care, 4th edn. Elsevier Health Sciences Scanzello CR, Goldring SR (2012) The role of synovitis in osteoarthritis pathogenesis. Bone 51(2):249–257 Schaible H-G (2014) Nociceptive neurons detect cytokines in arthritis. Arthritis Res Therapy 16:470 Schaible, H.-G., von Banchet, G. S., Boettger, M. K., Bräuer, R., Gajda, M., Richter,F., … Natura, G. (2010). The role of proinflammatory cytokines in the generation and maintenance of joint pain. Annals of the New York Academy of Sciences, 1193, 60–69. Stephen JM, Sopher R, Tullie S, Amis AA, Ball S, Williams A (2018) Anatomy of the infrapatellar fat pad of the knee and its deformation during knee motion. Knee Surg Sports Traumatol Arthrosc 26(11):3515–3524 Sun C, Zhang X, Lee WG, Tu Y, Li H, Cai X, Yang H (2020) Infrapatellar fat pad resection or preservation during total knee arthroplasty: A meta-analysis of randomized controlled trials. J Orthop Surg Res 15:297 Wang C-C, Hu T-M, Chen C-L, Hong C-C, Chang Y-H, Kao C-L (2023) Concurrent imaging and clinical study of the efficacy of hyaluronic acid injection for knee osteoarthritis: A synovial membrane investigation with ultrasound imaging. Pharmaceuticals 16(8):1186 Wang K, Ding C, Hannon MJ, Chen Z, Kwoh CK, Lynch J, Hunter DJ (2018) Signal intensity alteration within infrapatellar fat pad predicts knee replacement within 5 years: Data from the Osteoarthritis Initiative. Osteoarthr Cartil 26(10):1345–1350 Wang MG, Seale P, Furman D (2024) The infrapatellar fat pad in inflammaging, knee joint health, and osteoarthritis. NPJ Aging, 10 (1), Article 159. Zhang Y, Jordan JM, Hunter DJ (2020) Global, regional prevalence, incidence and risk factors of knee osteoarthritis in population-based studies. Lancet Rheumatol 2(9):e557–e567 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7272743","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":512433552,"identity":"10e714bd-3d71-4678-b5a7-5fae09a39f63","order_by":0,"name":"Amira Abd Allah","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIie3PIQvCQBTA8Xc8mEW36mHwK2zForKvckMwXRD8AoPBTGLdkl/BNOtEWJpm4UBM5s0gggbv7G6zGe4fXnjw4/EAdLp/LFXDBrCsIPssjFZTQqNsCsAkwUZEqZQPPgTqiClScjvNzn3q5/dL+Uj6JgIpSv6d0CPDHrfnzgqXWydiwgkRkMbJd2LnAJIwEvuHpNdmgkhiYKea4FMSd5PyqyJuE2KoK54khiJeLaE5CYeSTOIoG9BoKiYhkqDyFzPHveAvNl5ZwbVbjMR4vQh2RVlBAIhfv9HpdDrdj70BWkpO2WTWvzYAAAAASUVORK5CYII=","orcid":"","institution":"Ain Shams University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Amira","middleName":"Abd","lastName":"Allah","suffix":""},{"id":512433553,"identity":"48122d43-adba-43a5-a852-7b90d340abc9","order_by":1,"name":"Nadia Salah","email":"","orcid":"","institution":"Ain Shams University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nadia","middleName":"","lastName":"Salah","suffix":""},{"id":512433554,"identity":"80787c93-8803-438d-9688-83bdf748ff9a","order_by":2,"name":"Mohammed Ali","email":"","orcid":"","institution":"Ain Shams University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"","lastName":"Ali","suffix":""},{"id":512433555,"identity":"bfefa351-1e70-488f-9e7c-37b5a0d21b41","order_by":3,"name":"Soha Eldessouki","email":"","orcid":"","institution":"Ain Shams University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Soha","middleName":"","lastName":"Eldessouki","suffix":""}],"badges":[],"createdAt":"2025-08-01 15:38:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7272743/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7272743/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90958433,"identity":"3987b4c9-3ea1-494a-a579-97ab0d49713d","added_by":"auto","created_at":"2025-09-10 03:51:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1567854,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7272743/v1/c2080711-117b-43b3-b5a9-6a27291d9458.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of Inflammation of Infrapatellar Fat Pad and its Contribution to Anterior Knee Pain Severity and Severity of Knee Osteoarthritis","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eOsteoarthritis (OA) of the knee is among the most prevalent and disabling joint disorders worldwide (\u003cstrong\u003e\u003cem\u003eZhang et al., 2020\u003c/em\u003e\u003c/strong\u003e). A significant decline in quality of life is a common result, along with functional impairment and persistent discomfort (\u003cstrong\u003e\u003cem\u003eAl-Hourani et al., 2022\u003c/em\u003e\u003c/strong\u003e). As the world\u0026apos;s population ages and obesity rates rise, more and more people, including those who are physically active, are experiencing knee osteoarthritis (\u003cstrong\u003e\u003cem\u003eGlyn-Jones et al., 2015\u003c/em\u003e\u003c/strong\u003e). Knee OA pain is often debilitating and is the hallmark symptom of the disease (\u003cstrong\u003e\u003cem\u003eNeogi, 2013\u003c/em\u003e\u003c/strong\u003e), but its exact etiology is multifactorial and not fully understood. Knee OA was formerly thought to as a bone and cartilage degeneration disease; however, new research shows that inflammation of different joint tissues is a major contributor to the disease\u0026apos;s structural advancement and pain production (\u003cstrong\u003e\u003cem\u003eScanzello \u0026amp; Goldring, 2012\u003c/em\u003e\u003c/strong\u003e). Nociceptive pathways can be sensitised and chronic pain can be developed and maintained by pro-inflammatory cytokines within the joint (\u003cstrong\u003e\u003cem\u003eSchaible et al., 2014\u003c/em\u003e\u003c/strong\u003e). Specifically, OA-related synovitis and periarticular structural inflammation have been associated with worsening knee pain and impairment. In the front of the knee, right below the patella, there is a collection of fat called the infrapatellar fat pad (IPFP), which is also called Hoffa\u0026apos;s fat pad. This mass of fat is located intracapsularly but extrasynovially (\u003cstrong\u003e\u003cem\u003eMace et al., 2016\u003c/em\u003e\u003c/strong\u003e). Patellar tendon, femoral condyles, tibial plateau, and IPFP are all closely related; the IPFP cushions the knee as it moves forward and fills the anterior compartment (\u003cstrong\u003e\u003cem\u003eStephen et al., 2018\u003c/em\u003e\u003c/strong\u003e). Adipocytes, macrophages, and other immune cells that can produce inflammatory mediators are found within its well-innervated and vascularised interior. The inflammatory processes in the IPFP in knee OA have been demonstrated in multiple investigations. The fat pad produces cytokines and adipokines, which can add to the joint inflammatory environment (\u003cstrong\u003e\u003cem\u003eWang et al., 2024\u003c/em\u003e\u003c/strong\u003e). The IPFP is a significant source of interleukin-6 in knee OA, according to \u003cstrong\u003eDistel et al. (2009).\u003c/strong\u003e A decrease in the threshold of nociceptive nerve fibres within the fat pad can be caused by these inflammatory cytokines, leading to the induction and intensification of pain (\u003cstrong\u003e\u003cem\u003eSchaible et al., 2014\u003c/em\u003e\u003c/strong\u003e). Indeed, severe inflammation of the IPFP has been associated with higher pain scores and greater disability in knee OA patients (\u003cstrong\u003e\u003cem\u003eSatake et al., 2023\u003c/em\u003e\u003c/strong\u003e). The IPFP may be involved in the pathogenesis of knee OA, according to new findings. When looking at the IPFP of individuals with knee osteoarthritis, histopathologists have found fibrosis, inflammatory cell infiltration, and neoangiogenesis (\u003cstrong\u003e\u003cem\u003eBelluzzi et al., 2019\u003c/em\u003e\u003c/strong\u003e). Articular cartilage, synovium, and subchondral bone are all sites that the IPFP can interact with; inflammatory mediators produced by the IPFP have the ability to hasten degenerative changes in these tissues (\u003cstrong\u003e\u003cem\u003eJiang et al., 2019\u003c/em\u003e\u003c/strong\u003e). On imaging, signal alterations in the IPFP on magnetic resonance imaging (MRI) have been correlated with knee pain severity and can even predict progression to knee replacement within a few years (\u003cstrong\u003e\u003cem\u003eWang et al., 2018\u003c/em\u003e\u003c/strong\u003e). The IPFP\u0026apos;s function is multifaceted, while some evidence suggests that an enlarged or hypertrophic IPFP may provide mechanical protection for the joint through stress absorption. For instance, one study followed individuals over time and discovered that those with larger IPFP areas had less cartilage degradation and less knee problems (\u003cstrong\u003e\u003cem\u003ePan et al., 2015\u003c/em\u003e\u003c/strong\u003e), hinting at a possible protective effect in certain contexts. A clinical observation that emphasises the importance of conserving the IPFP is that surgical excision of the fat pad, which is commonly done during total knee arthroplasty to get access to the joint, may increase the risk of postoperative anterior knee discomfort (\u003cstrong\u003e\u003cem\u003eSun et al., 2020\u003c/em\u003e\u003c/strong\u003e). This suggests that the IPFP is not merely a vestigial structure but rather can influence knee pain and outcomes. Musculoskeletal ultrasound (US) has emerged as a valuable tool to assess the IPFP in vivo. Ultrasound can readily detect features of IPFP pathology, including effusions around the fat pad, changes in echogenicity (a normal IPFP is uniformly hyperechoic, whereas inflammation makes it appear hypoechoic), increased thickness, and hypervascularity on power Doppler. Compared to MRI, ultrasound is more accessible, noninvasive, and cost-effective, and it offers higher spatial resolution for superficial soft-tissue structures along with the ability to perform dynamic, real-time examinations (\u003cstrong\u003e\u003cem\u003eLake Zurich Open MRI, 2024\u003c/em\u003e\u003c/strong\u003e). Thus, US is well suited for both diagnosing IPFP inflammation and guiding targeted interventions such as injections. Despite these insights, relatively few studies have focused on the IPFP as a therapeutic target for knee pain. It remains unclear to what extent inflammation of the IPFP contributes specifically to anterior knee pain in patients without radiographic OA, and whether treating this inflammation can improve clinical outcomes. We hypothesized that IPFP inflammation is an important contributor to knee pain severity and that ultrasound-guided targeting of the IPFP would alleviate pain and improve function. In light of this, the current study set out to use musculoskeletal ultrasound to measure infrapatellar fat pad inflammation in patients suffering from knee osteoarthritis and those suffering from chronic anterior knee pain who did not have osteoarthritis. The secondary objective was to determine whether there was a correlation between the degree of inflammation and the severity of pain in these groups. Furthermore, we evaluated the clinical results and ultrasound findings of two treatment modalities in comparison to one another: conservative therapy and US-guided IPFP corticosteroid injection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAIM OF THE WORK\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe purpose of this study is to examine the relationship between IPFP inflammation, the intensity of anterior knee pain, and various treatment modalities in patients with knee osteoarthritis (KOA) using musculoskeletal Doppler ultrasound.\u003c/p\u003e"},{"header":"PATIENTS AND METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was designed as a prospective case-control trial involving 60 patients with anterior knee pain, recruited from those attending outpatient clinic of physical Medicine, Rheumatology and Rehabilitation Department at 2 years, divided into two equal groups. Group 1 consisted of 30 patients with knee osteoarthritis (OA group), and Group 2 consisted of 30 patients with anterior knee pain without OA (non-OA group). The diagnosis of knee OA was established according to the American College of Rheumatology (ACR) clinical and radiographic criteria for knee OA (\u003cstrong\u003e\u003cem\u003eAltman et al., 1986\u003c/em\u003e\u003c/strong\u003e),\u0026nbsp;which require characteristic knee pain along with radiographic evidence of osteophytes and specific clinical features. Patients in the non-OA group had chronic anterior knee pain (duration \u0026ge; 3 months) with no evidence of knee OA on clinical examination or X-ray (Kellgren\u0026ndash;Lawrence grade 0)\u0026nbsp;(\u003cstrong\u003e\u003cem\u003eKellgren and Lawrence, 1957\u003c/em\u003e\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion and Exclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnly persons (defined as 18 years or older) suffering from anterior knee pain for a minimum of three months were considered for the study. Exclusion criteria encompassed the following: a history of major knee trauma or surgery; a knee internal derangement (such as symptomatic meniscal tears or ligament injuries); intra-articular metallic implants (which could interfere with imaging); and pregnancy or lactation. Other forms of inflammatory or metabolic arthritis, such as rheumatoid arthritis or gout, were also considered. We also did not include patients whose damaged knees had an intra-articular injection in the previous six months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Faculty of Medicine Research Ethics Committee (Approval No. MD 189/2018, dated 22 July 2018), and all participants provided written informed consent for participation \u0026nbsp;before enrollment, in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterventions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach group of patients (OA and non-OA) was further subdivided into two subgroups (A and B) of 15 patients each, based on the treatment received. Subgroup A patients underwent conservative management, while subgroup B patients received local IPFP injections. Thus, group 1A refers to OA patients treated conservatively, Group 1B to OA patients receiving injections, Group 2A to non-OA patients treated conservatively, and Group 2B to non-OA patients receiving injections.\u003c/p\u003e\n\u003cp\u003e\u0026ndash; \u003cstrong\u003eConservative Treatment (Subgroup A)\u003c/strong\u003e: Patients managed conservatively received a standard regimen consisting of patient education, lifestyle and activity modification (including weight reduction when applicable), a course of nonsteroidal anti-inflammatory drugs (NSAIDs) for 2 weeks, and a focused physiotherapy program. The physiotherapy included therapeutic ultrasound diathermy, transcutaneous electrical nerve stimulation (TENS), and strengthening exercises for the quadriceps muscle around the affected knee. These modalities were administered over a 6-week period with regular supervised sessions aimed at reducing pain and improving knee function (\u003cstrong\u003e\u003cem\u003eAlghadir et al., 2019\u003c/em\u003e\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u0026ndash; \u003cstrong\u003eUltrasound-Guided IPFP Injection (Subgroup B)\u003c/strong\u003e: Patients in the injection subgroups underwent ultrasound-guided infiltrations of the infrapatellar fat pad with corticosteroid and local anesthetic. The injection technique was performed under strict sterile conditions. With the patient supine and the knee extended and supported, the most tender area of the IPFP (typically at the inferolateral patellar region) was identified. A high-frequency (13 MHz) linear ultrasound probe (LOGIQ P5, GE Healthcare, Milwaukee, WI, USA) was placed longitudinally over the patellar tendon to visualize the IPFP. Using an out-of-plane lateral approach, a 22-gauge needle was inserted horizontally at the lateral edge of the patellar tendon, just inferior to the patella, targeting the IPFP deep to the tendon. Proper needle placement within the fat pad was confirmed on the ultrasound image, and lack of resistance to injection was ensured. Then, 2 mL of solution containing 40 mg of methylprednisolone acetate and 1.8 mL of 3% mepivacaine HCl was injected into the IPFP as a bolus. This procedure was adapted from standard musculoskeletal injection techniques (\u003cstrong\u003e\u003cem\u003eSaunders \u0026amp; Longworth, 2018\u003c/em\u003e\u003c/strong\u003e). Each patient in subgroup B was allowed up to a maximum of three IPFP injections at 4-week intervals (one injection per month) if pain persisted or recurred; otherwise, no repeat injection was given. All injections were performed by an experienced physician under ultrasound guidance to ensure accuracy and safety.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBaseline Evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients were evaluated thoroughly at the beginning of the study. The patient\u0026apos;s complete medical history was documented, which included vital signs such as age, sex, weight, height, and BMI. Any pertinent comorbidities and medications were also noted. A comprehensive evaluation of the injured knee was carried out. We looked for abnormalities in the animal\u0026apos;s gait and limb alignment as well as signs of joint oedema or effusion and quadriceps muscle atrophy throughout our examination. The knee\u0026apos;s passive ROM was assessed by utilising a goniometer to quantify the degree of flexion and extension. Using the patellar tap and bulge tests, palpation was used to confirm the presence of an effusion and to detect discomfort along the joint lines. Traditional examinations for ligamentous stability were used to evaluate the knee. By applying deep thumb pressure on each side of the patellar tendon (directly over the IPFP) while the knee was bent at a 30-60\u0026deg; angle, the examiner may clinically assess IPFP inflammation using the Hoffa\u0026apos;s test. If there was greater discomfort upon palpation in this area, it was deemed a positive finding. Fat pad pathology indicated by Hoffa\u0026apos;s sign (\u003cstrong\u003e\u003cem\u003eSchaible et al., 2014\u003c/em\u003e\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Outcome Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo standardized outcome measures were used to evaluate the degree of pain and the function of the knee. A knee osteoarthritis index developed by Western Ontario and McMaster Universities (WOMAC) was the initial one. Osteoarthritis of the knee and hip can be assessed with the help of the WOMAC, a self-administered questionnaire that has been validated. There are a total of 24 items on the scale, with 5 questions covering pain in different situations (e.g., while walking, climbing stairs, in bed, sitting/lying, or standing), 2 questions covering stiffness upon waking up and throughout the day, and 17 questions covering physical function (e.g., difficulty with using stairs, standing, bending, walking, getting in and out of a car, shopping, putting on socks, getting out of bed, etc.). The Likert scale ranges from 0 (not at all) to 4 (very intense) for each item. Higher WOMAC scores indicate worse pain, stiffness, and functional limitations; subscale values vary from 0 to 20 for pain, 0 to 8 for stiffness, and 0-68 for function. The overall WOMAC score can be anywhere from 0 to 96. It was common practice to convert the overall WOMAC score to a percentage scale from 0 to 100, with 100 indicating the most severe symptoms, in order to facilitate interpretation. (\u003cstrong\u003e\u003cem\u003eHoward Head Sports Medicine, 2020\u003c/em\u003e\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFollow-up\u003c/strong\u003e\u003cbr\u003eAt the 6-month follow-up appointment, patients underwent a musculoskeletal ultrasound (US) of the afflicted knee joint in addition to the Visual Analogue Scale (VAS) for knee pain, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and other diagnostic tools (\u003cstrong\u003e\u003cem\u003eWang et al., 2023\u003c/em\u003e\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003cbr\u003eSoftware developed by IBM\u0026reg;, Chicago, IL, USA, known as SPSS v27, was used to conduct the statistical study. The Shapiro-Wilks test and histograms were used to assess the data\u0026apos;s normality. When presenting quantitative parametric data, we used standard deviation (SD) and analysis of variance (ANOVA) with a post hoc Tukey test for comparisons. With the use of the Kruskal-Wallis test and the Mann Whitney U-test for pairwise comparisons, non-parametric quantitative data were displayed as median and interquartile range (IQR). To analyse qualitative variables, the Chi-square test was used, and the results were shown as percentages and frequencies. For statistical purposes, a two-tailed P value less than 0.05 was deemed significant (\u003cstrong\u003e\u003cem\u003eKruskal \u0026amp; Wallis, 1952\u003c/em\u003e\u003c/strong\u003e).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eTable 1:\u0026nbsp;\u003c/strong\u003eKnee Range of Motion (ROM) of the studied groups.\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 36px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1A\u003cbr\u003e\u0026nbsp; (n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1B\u003cbr\u003e\u0026nbsp; (n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2A\u003cbr\u003e\u0026nbsp; (n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2B\u003cbr\u003e\u0026nbsp;(n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"10\" style=\"width: 16px;\"\u003e\n \u003cp\u003eFlexion ROM (◦)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e125.4 \u0026plusmn; 10.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e132.8 \u0026plusmn; 11.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e143.3 \u0026plusmn; 5.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e144.1 \u0026plusmn; 4.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e110 - 148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e115 \u0026ndash; 150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e132 - 150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e135 \u0026ndash; 149\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.076\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.005*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0.993\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAfter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e126.1 \u0026plusmn; 9.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e135.3 \u0026plusmn; 8.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e143.3 \u0026plusmn; 5.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e145.4 \u0026plusmn; 2.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e115 - 148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e125 \u0026ndash; 150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e132 - 150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e139 \u0026ndash; 149\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.012*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0.827\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"10\" style=\"width: 16px;\"\u003e\n \u003cp\u003eExtension ROM\u003c/p\u003e\n \u003cp\u003e(◦)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e7.3 \u0026plusmn; 1.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e8.6 \u0026plusmn; 1.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e10 \u0026plusmn; 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e10 \u0026plusmn; 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e5 - 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e5 \u0026ndash; 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e10 \u0026ndash; 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e10 \u0026ndash; 10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.092\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAfter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e7.9 \u0026plusmn; 1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e9 \u0026plusmn; 1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e10 \u0026plusmn; 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e10 \u0026plusmn; 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e6 - 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e7 \u0026ndash; 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e10 \u0026ndash; 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e10 \u0026ndash; 10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.018*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.044*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.044*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003e*: Data presented in the form of \u003cstrong\u003emean\u0026plusmn;SD\u003c/strong\u003e. Significantly different as Pvalue\u0026le;0.05\u0026nbsp;\u003c/em\u003e\u003cem\u003e.ROM: range of motion\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe ROM of the knees for each group is displayed in \u003cstrong\u003eTable 1\u003c/strong\u003e. Group 2 had larger ranges of motion (ROM) values compared to Group 1 (p \u0026lt; 0.05), indicating a statistically significant difference in flexion and extension ROM between the two groups. Neither Group 2B nor Group 2A differed from Group 1A in terms of flexion or extension ROM before nor after therapy. Nevertheless, according to \u003cstrong\u003eTable 1\u003c/strong\u003e, Group 2B had significantly larger ranges of motion (ROM) for flexion and extension following treatment compared to Group 1B, Group 2A to Group 1A, and Group 1B to Group 2A (p \u0026lt; 0.05) (\u003cstrong\u003eTable 1)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u0026nbsp;\u003c/strong\u003eEchogenicity of Hoffa\u0026rsquo;s Fat Pad Before and After Treatment\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1A\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1B\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2A\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2B\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 10px;\"\u003e\n \u003cp\u003eBefore\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypoechoic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e8 (53.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e7 (46.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e15 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e15 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEchoic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e7 (46.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e8 (53.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 10px;\"\u003e\n \u003cp\u003eAfter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypoechoic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e4 (26.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e2 (13.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e15 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e15 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEchoic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e11 (73.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e13 (86.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*: \u003cem\u003esignificantly different as Pvalue\u0026le;0.05.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003edisplays the echogenicity of the Hoffa\u0026rsquo;s fat pad in the studied groups. Echogenicity of the IPFP before and after treatment was significantly different among the groups (p = 0.002 and p \u0026lt; 0.001, respectively). Before treatment, both Group 2A and 2B (patients without OA) showed 100% hypoechoic fat pads, whereas Group 1 had a mix of hypoechoic and echoic pads. After treatment, hypo-echogenicity markedly decreased in Group 1B and 1A (with more fat pads becoming echoic), whereas Group 2 remained 100% hypoechoic (\u003cstrong\u003eTable 2\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u0026nbsp;\u003c/strong\u003eHoffa\u0026rsquo;s Fat Pad Width (mm) Before and After Treatment\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 38px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1A\u003cbr\u003e\u0026nbsp; (n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1B\u003c/strong\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;(n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2A\u003cbr\u003e\u0026nbsp; (n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2B\u003cbr\u003e\u0026nbsp;(n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 26px;\"\u003e\n \u003cp\u003eHoffa fat pad\u0026nbsp;\u003cbr\u003e\u0026nbsp;width (Before)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e14.1 \u0026plusmn; 1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e13.6 \u0026plusmn; 1.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e13.9 \u0026plusmn; 1.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e13.3 \u0026plusmn; 1.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.370\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e11.7 \u0026ndash; 16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e11.5 - 15.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e11.4 \u0026ndash; 16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e11.1 - 15.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 26px;\"\u003e\n \u003cp\u003eHoffa fat pad\u0026nbsp;\u003cbr\u003e\u0026nbsp;width (After)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e9.8 \u0026plusmn; 2.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e6.7 \u0026plusmn; 0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e8.3 \u0026plusmn; 1.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e5.3 \u0026plusmn; 0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e7 \u0026ndash; 13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e6.2 - 7.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e5.8 - 12.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e5.1 - 5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.041*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.032*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.048*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003e*: Data presented in the form of \u003cstrong\u003emean\u0026plusmn;SD\u003c/strong\u003e. \u0026nbsp;significantly different as Pvalue\u0026le;0.05.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003eshows the Hoffa\u0026rsquo;s fat pad width measurements. Hoffa\u0026rsquo;s fat pad width before treatment did not differ significantly among the four groups. After treatment, however, there was a significant difference (p \u0026lt; 0.001). Specifically, the Hoffa\u0026rsquo;s fat pad width was significantly lower in Group 2B than 1B, in Group 1B than 2A, and in Group 2A than 1A (p \u0026lt; 0.05) \u003cstrong\u003e(Table 3\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4:\u0026nbsp;\u003c/strong\u003eLargest Fat Lobule Width Before and After Treatment\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 37px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1A\u003cbr\u003e\u0026nbsp; (n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1B\u003cbr\u003e\u0026nbsp; (n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2A\u003cbr\u003e\u0026nbsp; (n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2B\u003cbr\u003e\u0026nbsp;(n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 24px;\"\u003e\n \u003cp\u003eLargest fat lobule (Before)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e4.9 \u0026plusmn; 1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e4.8 \u0026plusmn; 0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e5.2 \u0026plusmn; 0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e5.4 \u0026plusmn; 0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.076\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e3 - 6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e3.5 - 6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e5 - 5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e5.1 - 5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 24px;\"\u003e\n \u003cp\u003eLargest fat lobule (After)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e2.1 \u0026plusmn; 0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2.6 \u0026plusmn; 0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2.4 \u0026plusmn; 0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2.8 \u0026plusmn; 0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e2 - 2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2.2 - 2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2.1 - 2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2.5 - 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.018*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*: \u003cem\u003eData presented in the form of \u003cstrong\u003emean\u0026plusmn;SD\u003c/strong\u003e. significantly different as Pvalue\u0026le;0.05\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u0026nbsp;\u003c/strong\u003eshows the largest fat lobule width in the IPFP. Before treatment, the largest fat lobule width was similar in all groups (no significant difference). After treatment, the largest fat lobule width differed significantly among groups (p \u0026lt; 0.001). It was significantly higher in Group 2B than 1B, in Group 1B than 2A, and in Group 2A than 1A (p \u0026lt; 0.05) (\u003cstrong\u003eTable 4)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5:\u003c/strong\u003e WOMAC Index Scores Before and After Treatment\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 40px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1A\u003cbr\u003e\u0026nbsp; (n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1B\u003cbr\u003e\u0026nbsp; (n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2A\u003cbr\u003e\u0026nbsp; (n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2B\u003cbr\u003e\u0026nbsp;(n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 27px;\"\u003e\n \u003cp\u003eWOMAC index (Before)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e47.8 \u0026plusmn; 1.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e41.7 \u0026plusmn; 6.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e46 \u0026plusmn; 3.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e38.5 \u0026plusmn; 4.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e45 \u0026ndash; 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e30 - 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e40 \u0026ndash; 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e30 - 47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.045*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0.205\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 27px;\"\u003e\n \u003cp\u003eWOMAC index (After)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e25.7 \u0026plusmn; 3.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e20.1 \u0026plusmn; 1.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e22.4 \u0026plusmn; 1.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e17.8 \u0026plusmn; 1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e20 \u0026ndash; 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e18 - 25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e20 \u0026ndash; 24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e16 - 20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.041*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.049*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*: \u003cem\u003eData presented in the form of \u003cstrong\u003emean\u0026plusmn;SD\u003c/strong\u003e. significantly different as Pvalue\u0026le;0.05.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5\u0026nbsp;\u003c/strong\u003epresents the WOMAC index scores of the studied groups. The WOMAC index before treatment was not significantly different between Group 1A and 2A, nor between Group 1B and 2B. However, it was significantly lower in Group 2B and Group 1B than in Group 1A, and also lower in Group 1B and 2B than in Group 2A (p \u0026lt; 0.05). After treatment, the WOMAC index differed significantly among all groups (p \u0026lt; 0.001). Specifically, WOMAC scores were significantly lower in Group 2B than 1B, in Group 1B than 2A, and in Group 2A than 1A (p \u0026lt; 0.05) (\u003cstrong\u003eTable 5)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6:\u003c/strong\u003e VAS Pain Scale Scores Before and After Treatment\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 33px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003eGroup 1A\u003cbr\u003e\u0026nbsp; (n=15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003eGroup 1B\u003cbr\u003e\u0026nbsp; (n=15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003eGroup 2A\u003cbr\u003e\u0026nbsp; (n=15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003eGroup 2B\u003cbr\u003e\u0026nbsp;(n=15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 22px;\"\u003e\n \u003cp\u003eVAS scale (Before)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIQR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e7.5 \u0026ndash; 9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e7 - 8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e7 \u0026ndash; 8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e7 - 8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 22px;\"\u003e\n \u003cp\u003eVAS scale (After)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIQR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e4 \u0026ndash; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2.5 - 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e3 \u0026ndash; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2 - 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*: \u003cem\u003eData presented in the form of \u003cstrong\u003eMedian (IQR)\u003c/strong\u003e.\u0026nbsp;\u003c/em\u003esignificantly different as P value\u0026le;0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6\u003c/strong\u003e shows the VAS pain scale scores of the studied groups. The VAS score before treatment was similar (median ~8) in all groups (no significant difference). After treatment, there was a significant difference (p \u0026lt; 0.001): the median VAS was lowest in Group 2B (median 2) and highest in Group 1A (median 4), indicating better pain improvement in the non-OA injection group. Post hoc analysis showed VAS after treatment was significantly lower in Group 2B than 1B, and in Group 1B than 2A, and in Group 2A than 1A (p \u0026lt; 0.05) (Table 10). The VAS scale before treatment was not significantly different among the groups, whereas after treatment it showed significant differences as noted above (\u003cstrong\u003eTable 6)\u003c/strong\u003e.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eWe aimed to determine whether inflammation of the infrapatellar fat pad was a factor in anterior knee discomfort in individuals with and without knee osteoarthritis, and if so, how effective was it to treat this inflammation with ultrasound-guided injections. Our results show that both groups experience IPFP inflammation, and that injecting corticosteroids into the IPFP dramatically improves function and significantly decreases pain. The key novel insight is that ultrasound-detected IPFP abnormalities (effusion, hypo-echogenicity, increased thickness) correlate with pain severity, and alleviating these abnormalities through injection yields superior outcomes compared to conservative management. Notably, the benefits of IPFP-directed therapy were most pronounced in patients with anterior knee pain but no radiographic OA \u0026ndash; these patients often achieved near-complete pain relief \u0026ndash; whereas patients with established knee OA also improved but to a lesser extent, likely because their pain arises from multiple sources in addition to the fat pad. Overall, our results support the hypothesis that IPFP inflammation is an important driver of anterior knee pain and demonstrate that it is a modifiable source of pain and disability. Our data align with and extend previous research on knee OA and pain. We observed that, at baseline, the OA patients had more restricted knee range of motion and more frequent effusions than the non-OA patients, despite similar pain scores. This is consistent with the understanding that knee OA is typically accompanied by joint stiffness and intermittent synovitis (\u003cstrong\u003e\u003cem\u003eScanzello \u0026amp; Goldring, 2012\u003c/em\u003e\u003c/strong\u003e). After treatment, improvements in knee ROM were greatest in the injection groups, particularly in non-OA patients. Improved ROM is an important outcome, as restricted knee motion due to pain and effusion can significantly impair gait and function in these patients (\u003cstrong\u003e\u003cem\u003eRutherford et al., 2012\u003c/em\u003e\u003c/strong\u003e). Knee OA often forces patients to adopt slower or abnormal gait patterns to minimize pain (\u003cstrong\u003e\u003cem\u003eBrandes et al., 2008\u003c/em\u003e\u003c/strong\u003e). Patients probably had increased range of motion (ROM) and, maybe, a more normal gait after receiving IPFP injections, which successfully reduced inflammation and pain in the fat pad. This is supported by Debi et al. (2011), who found that knee OA patients with better functional status (lower WOMAC scores) had gait parameters closer to normal, such as longer single-limb support time during walking (\u003cstrong\u003e\u003cem\u003eDebi et al., 2011\u003c/em\u003e\u003c/strong\u003e). Thus, the ROM gains and pain relief from IPFP injections in our study may translate to improved biomechanics during ambulation. In general, interventions that restore knee motion and stability can break the cycle of disuse and weakness. Our research shows that reducing discomfort in the fat pad and other intra-articular areas can significantly enhance mobility, an essential component of knee health and well-being. Curiously, there was no difference in baseline levels of systemic inflammation markers (ESR, CRP) between the OA and non-OA groups, and no elevation in our patients, suggesting that the inflammation was mostly localized. This contrasts with the findings of Hanada et al. (2015), who reported that elevated ESR and high-sensitivity CRP correlated with more severe radiographic knee OA (\u003cstrong\u003e\u003cem\u003eHanada et al., 2015\u003c/em\u003e\u003c/strong\u003e). In our study, even the OA patients mostly had normal ESR/CRP, perhaps because many had moderate OA limited to the knees. The non-OA patients, despite having chronic knee pain (often due to conditions like patellofemoral pain syndrome), also did not show systemic inflammation. These observations suggest that IPFP-driven knee pain can occur with normal systemic inflammatory markers, highlighting the importance of local evaluation (e.g., via imaging) in such cases. The discrepancy with Hanada\u0026rsquo;s results may be due to differences in patient selection (their cohort included more advanced OA or inflammatory features) or sample size. It reinforces that biomarkers like ESR/CRP are not sensitive for detecting the kind of low-grade, localized inflammation present in the IPFP. Our ultrasound findings shed light on the local inflammatory environment of the knee. We noted that baseline effusions (particularly in the lateral recess) were common in OA knees and significantly less so in non-OA knees, reflecting a higher degree of synovitis in OA. After treatment, the resolution of effusions in the injected groups (especially OA injection subgroup) was striking \u0026ndash; the difference between OA and non-OA in effusion presence disappeared. This suggests that the corticosteroid injections effectively reduced synovial inflammation and fluid production in the knee (\u003cstrong\u003e\u003cem\u003eMcAlindon et al., 2017\u003c/em\u003e\u003c/strong\u003e). Effusion can be both a marker and contributor of joint inflammation. Therefore, eliminating the effusion, as we achieved in many injected patients, might not only relieve pain but could also potentially slow disease progression. Although our study\u0026rsquo;s follow-up was too short to assess long-term structural outcomes, it is encouraging that the intervention reduced effusions; in theory, less synovial fluid and inflammation might mean less cartilage breakdown over time. Another interesting finding was that the presence of medial osteophytes did not differ significantly among groups or change over time. By definition, our non-OA patients should have no (or only minimal) osteophytes, whereas OA patients have them; however, the statistical analysis did not show a clear separation, likely because a few \u0026ldquo;non-OA\u0026rdquo; patients had small osteophytes (K/L grade 1 changes) without meeting full OA criteria. It is also possible that our sample size limited the power to detect differences in this categorical variable. Clinically, the lack of correlation between osteophytes and pain is well documented (\u003cstrong\u003e\u003cem\u003eMarkhardt et al., 2018\u003c/em\u003e\u003c/strong\u003e). Markhardt et al. (2018) noted that osteophytes in certain compartments (e.g., the patellofemoral joint) can exist even when cartilage is relatively normal and may or may not cause symptoms (\u003cstrong\u003e\u003cem\u003eMarkhardt et al., 2018\u003c/em\u003e\u003c/strong\u003e). They suggested that osteophytes in the patellofemoral compartment should be considered separately from tibiofemoral OA when evaluating pain. In our study, some patients in the non-OA group might have had isolated patellofemoral osteophytes (related to anterior knee pain) that did not qualify as OA under K/L criteria. This underscores the point made by Markhardt and colleagues that osteophytes alone are not a reliable indicator of pain severity or overall OA status. Our results align with this view: improvements in pain were driven by treating the fat pad inflammation, not by any change in osteophyte status. In essence, our interventions addressed the \u0026ldquo;active\u0026rdquo; inflammatory pain generators rather than the static bony changes. The infrapatellar fat pad itself appears to be a key active tissue in knee pain. We found that reducing IPFP inflammation via injection led to significant clinical gains. Conversely, in the conservatively treated patients, the IPFP remained hypoechoic and thickened (indicating ongoing inflammation) and these patients continued to experience more pain. Liu et al. (2023) conducted a cross-sectional study using MRI and observed that IPFP signal intensity alterations correlated with knee OA status (\u003cstrong\u003e\u003cem\u003eLiu et al., 2023\u003c/em\u003e\u003c/strong\u003e). They also reported, interestingly, that pain scores did not differ significantly between their early OA patients and controls without OA (\u003cstrong\u003e\u003cem\u003eLiu et al., 2023\u003c/em\u003e\u003c/strong\u003e), which they attributed to sample characteristics. In our study, baseline pain levels were indeed similar between OA and non-OA patients (since all had anterior knee pain to begin with), but it was the response to treatment that differentiated them. The non-OA patients (whose pain was presumably driven largely by the fat pad and related soft tissues) responded dramatically to fat pad injection, whereas OA patients had a more moderate response, likely because their pain had additional sources (cartilage degradation, subchondral bone changes, etc.). The difference between our findings and Liu\u0026rsquo;s highlights that in a population specifically selected for anterior knee pain, IPFP inflammation plays a dominant role, whereas in unselected early OA vs. controls, pain levels might not differ if early OA is asymptomatic. Our results demonstrate that when anterior knee pain is present, treating local inflammation (IPFP) can yield substantial pain reduction, supporting the idea that the IPFP is a meaningful pain generator even if systemic inflammation is absent. This concept is supported by fundamental research on pain mechanisms: Schaible et al. (2010) showed that proinflammatory cytokines within a joint can produce pain hypersensitivity without systemic involvement (\u003cstrong\u003e\u003cem\u003eSchaible et al., 2010\u003c/em\u003e\u003c/strong\u003e). In our patients, the local production of such cytokines in the fat pad (as suggested by other studies (\u003cstrong\u003e\u003cem\u003eMorel et al., 2011\u003c/em\u003e\u003c/strong\u003e)) was likely contributing to pain, and the steroid injection curtailed that local cytokine activity, leading to pain relief. Our study also provides insight into the duration of steroid injection benefits, especially in comparison to other studies. We observed that at 6 months, OA patients who received injections had some return of pain (their WOMAC and VAS at 6 months were not as low as at 1 or 3 months, based on interim evaluations), but they still fared better than those without injections. Non-OA injected patients maintained very low pain levels through 6 months. This pattern is consistent with the known temporizing effect of intra-articular steroids in OA \u0026ndash; typically providing significant relief for a few weeks to a few months (\u003cstrong\u003e\u003cem\u003eMcAlindon et al., 2017\u003c/em\u003e\u003c/strong\u003e). For instance, Jones and Doherty (1996) demonstrated that intra-articular corticosteroids are effective for short-term pain relief in knee OA, although predicting the duration of response is difficult (\u003cstrong\u003e\u003cem\u003eJones and Doherty, 1996\u003c/em\u003e\u003c/strong\u003e). In our case, the use of up to three injections might have extended the relief in the OA group somewhat. B\u0026uuml;y\u0026uuml;k et al. (2017) reported that knee OA patients who received a corticosteroid injection had a large improvement in WOMAC scores at 2 weeks (from a baseline score of ~68 down to ~32) and that some of this benefit persisted at 6 months (WOMAC around 61, still better than baseline) (\u003cstrong\u003e\u003cem\u003eB\u0026uuml;y\u0026uuml;k et al., 2017\u003c/em\u003e\u003c/strong\u003e). Our OA injection subgroup showed a very similar trend: a major drop in WOMAC after injection and some gradual increase by 6 months, but remaining improved compared to baseline and compared to controls. On the other hand, Kikkuri et al. (2021) observed an even more dramatic early response in WOMAC (improvement from ~48 to ~93 on a 0\u0026ndash;100 scale at 3 weeks) that then diminished to ~55 by 6 months (\u003cstrong\u003e\u003cem\u003eKikkuri et al., 2021\u003c/em\u003e\u003c/strong\u003e). The differences in magnitude and trajectory of WOMAC improvement across studies could be due to patient factors (e.g., Kikkuri\u0026rsquo;s patients might have had less baseline disability or a differently scaled WOMAC) or injection protocols. Importantly, Chansoria et al. (2016), who studied ozone vs. steroid injections, found that VAS pain in the steroid group dropped from 8.9 (baseline) to 2.8 at 1 month, then gradually rose to 5.1 by 6 months (\u003cstrong\u003e\u003cem\u003eChansoria et al., 2016\u003c/em\u003e\u003c/strong\u003e) \u0026ndash; a pattern very much in line with our OA injection results (initial drastic pain reduction with some recurrence by 6 months). In contrast, our non-OA patients had almost no pain at 6 months after injections, suggesting that when the primary pain generator (the fat pad) is effectively treated and there is no ongoing joint degeneration, pain relief can be more durable. This difference emphasizes that in OA, continuous or repeated interventions may be required to maintain improvement, as the disease process is chronic. Furthermore, our results emphasize that conservative therapy, while beneficial to some extent, was not as effective in reducing IPFP inflammation or improving outcomes. Conventional measures like NSAIDs and physiotherapy can help symptoms, but in our study many patients on conservative treatment still had persistent IPFP inflammation on ultrasound and significant pain (particularly the OA patients). This suggests that the IPFP can be a therapeutic target not adequately addressed by standard OA management. The marked success of the injections in the non-OA group also indicates that some cases of anterior knee pain (often labeled as idiopathic or \u0026ldquo;patellofemoral pain syndrome\u0026rdquo;) might actually have an inflammatory fat pad component (sometimes termed Hoffa\u0026rsquo;s disease or fat pad syndrome) that responds extremely well to steroid injection. Clinicians should be aware of this, as patients with refractory anterior knee pain but normal radiographs might benefit from an ultrasound evaluation of the fat pad and a targeted injection if inflammation is present.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe sample size was small (n=60), limiting statistical power and generalizability.\u003c/li\u003e\n \u003cli\u003eThe follow-up period was short (6 months), which may not capture long-term outcomes or side\u0026nbsp;effects.\u003c/li\u003e\n \u003cli\u003eThe study was not blinded, increasing the risk of bias from participants and investigators.\u003c/li\u003e\n \u003cli\u003eThere was no placebo control group, making it difficult to rule out placebo effects.\u003c/li\u003e\n \u003cli\u003ePain assessments were subjective, using tools like VAS and WOMAC that may be influenced by patient perception.\u003c/li\u003e\n \u003cli\u003eVariability in conservative treatments (e.g., differences in physiotherapy adherence) may have affected results.\u003c/li\u003e\n \u003cli\u003eAdverse effects of corticosteroid injections were not thoroughly evaluated or reported.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eAnterior knee pain, with or without osteoarthritis, is often linked to inflammation of the infrapatellar fat pad (IPFP). This study shows that musculoskeletal ultrasound can detect IPFP inflammation early and guide targeted therapy. In non-OA patients, ultrasound-guided corticosteroid injections provided near-complete symptom relief, while OA patients improved more than with conservative care alone. IPFP is a modifiable pain source, and its ultrasound-guided treatment can reduce pain, improve mobility, and enhance outcomes in knee OA and related conditions\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eLarger multicenter studies with extended follow-up are needed to validate findings.\u003c/li\u003e\n \u003cli\u003eRoutine musculoskeletal ultrasound (US) should be used for early detection of IPFP inflammation.\u003c/li\u003e\n \u003cli\u003eTargeted ultrasound-guided corticosteroid injections for IPFP inflammation may improve pain and function in knee OA patients.\u003c/li\u003e\n \u003cli\u003eIPFP-directed therapy should be considered in non-OA patients with anterior knee pain.\u003c/li\u003e\n \u003cli\u003eMonitor long-term outcomes of IPFP injections to assess sustained pain relief and functional improvement.\u003c/li\u003e\n \u003cli\u003eIntegrate ultrasound assessment of the IPFP into standard knee pain evaluation.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAUC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eArea under the curve\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBody mass index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCRP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eC-Reactive Protein\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCSA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCross sectional area\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eESR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eErythrocyte sedimentation rate\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntra-articular\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInterleukin\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIPFP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInfrapatellar fat pad\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInterquartile range\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eK/L\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKellgren-Lawrence\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKOA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKnee osteoarthritis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKOOS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOsteoarthritis outcome score\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMagnetic resonance imaging\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNSAID\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNon-Steroidal Anti Inflammatory drug\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOsteoarthritis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eQOL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eQuality of life\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eROC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eReceiver Operating Characteristics\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStandard deviation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTENS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTrans cutaneous electrical nerve stimulation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUltra sound\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVisual analogue scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWOMAC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWestern Ontario and McMaster universities\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Disclosure:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they did not receive any financial support or funding for the conduct of this study or the preparation of this manuscript\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from all participants prior to their inclusion in the study, in accordance with the Declaration of Helsinki\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval number:\u0026nbsp;\u003c/strong\u003eThe study protocol was approved by the Faculty of Medicine Research Ethics Committee (Approval No. MD 189/2018, dated 22 July 2018).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e: All data and materials used for this study are available upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlghadir AH, Anwer S, Sarkar B, Paul AK, Anwar D (2019) Effect of 6-week retro or forward walking program on pain, functional disability, quadriceps muscle strength, and performance in individuals with knee osteoarthritis: A randomized controlled trial. BMC Musculoskelet Disord 20:159\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAl-Hourani M, Al-Hourani A, Al-Hourani M (2022) The impact of pain on quality of life in patients with osteoarthritis. BMC Musculoskelet Disord 23:112\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAltman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, Wolfe F (1986) Development of criteria for the classification and reporting of osteoarthritis: Classification of osteoarthritis of the knee. Arthr Rhuem 29(8):1039\u0026ndash;1049\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBelluzzi E, Stocco E, Pozzuoli A et al (2019) Contribution of infrapatellar fat pad and synovial membrane to knee osteoarthritis pain. \u003cem\u003eBioMed Research International, 2019\u003c/em\u003e, Article ID 6390182\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrandes M, M\u0026uuml;ller G, Heeg E, Rosenbaum D (2008) Gait pattern analysis in patients with osteoarthritis of the knee. Clin Biomech Elsevier Ltd 23(3):342\u0026ndash;348\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eB\u0026uuml;y\u0026uuml;k AF, Yıldız N, Topuz O (2017) Compared efficacy of intra-articular injection of methylprednisolone acetate and triamcinolone hexacetonide in bilateral and symmetrical knee osteoarthritis. 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Lancet Rheumatol 2(9):e557\u0026ndash;e567\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"egyptian-rheumatology-and-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"","snPcode":"43166","submissionUrl":"https://submission.springernature.com/new-submission/43166/3","title":"Egyptian Rheumatology and Rehabilitation","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Infrapatellar fat pad, Anterior knee pain, Knee osteoarthritis, Ultrasound, Corticosteroid injection","lastPublishedDoi":"10.21203/rs.3.rs-7272743/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7272743/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOsteoarthritis is the most common arthritic disease worldwide, characterized by debilitating pain and joint tissue damage. While the exact cause of knee osteoarthritis pain remains unclear, evidence suggests that inflammation plays a role in both disease progression and pain. Early detection and treatment of inflammation may improve outcomes. This study aims to assess infrapatellar fat pad (IPFP) inflammation using Doppler ultrasound in patients with knee osteoarthritis and in those with anterior knee pain without osteoarthritis, and to evaluate its impact on pain severity, and response to treatment (conservative therapy vs. Ultrasound-guided steroid injection).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case-control study involved 60 patients with anterior knee pain (30 with knee osteoarthritis and 30 without). Each group was split into two subgroups of 15 patients: one received conservative treatment, and the other received ultrasound-guided injections of methylprednisolone into the infrapatellar fat pad. Clinical and ultrasound assessments were conducted at the start and after 6 months. Pain was evaluated using the Visual Analog Scale (VAS) and the Western Ontario and McMaster universities(WOMAC) index.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt baseline, Ultrasound showed IPFP inflammation in both groups, more commonly in osteoarthritis knees. After 6 months, steroid injection groups showed significantly better pain relief and functional improvement than conservatively treated groups (p \u0026lt; 0.05). The best outcomes were seen in non- osteoarthritis patients receiving injections (WOMAC ↓52%, VAS ↓61%). Ultrasound also showed reduced IPFP thickness and vascularity in injected knees, especially non- osteoarthritis ones, with minimal changes in the conservative groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInfrapatellar fat pad inflammation contributes to anterior knee pain in both osteoarthritis and non- osteoarthritis patients. Doppler ultrasound helps in early detection. Ultrasound guided steroid injections were more effective than conservative treatment, supporting targeted fat pad therapy for better pain control and potential osteoarthritis progression delay.\u003c/p\u003e","manuscriptTitle":"Assessment of Inflammation of Infrapatellar Fat Pad and its Contribution to Anterior Knee Pain Severity and Severity of Knee Osteoarthritis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-10 03:35:18","doi":"10.21203/rs.3.rs-7272743/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-25T08:30:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-23T10:32:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9889287959782923957948026120632520065","date":"2025-10-10T09:02:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-09T10:13:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"264139712317852255523681160329832798815","date":"2025-09-07T00:46:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"308503811405686167452179243535736242069","date":"2025-09-05T09:49:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-04T08:53:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-31T09:27:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-18T10:27:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"Egyptian Rheumatology and Rehabilitation","date":"2025-08-17T17:47:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"egyptian-rheumatology-and-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"","snPcode":"43166","submissionUrl":"https://submission.springernature.com/new-submission/43166/3","title":"Egyptian Rheumatology and Rehabilitation","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ca27d689-f105-480a-99e0-e011f4e73e6c","owner":[],"postedDate":"September 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-03T17:25:06+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-10 03:35:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7272743","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7272743","identity":"rs-7272743","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}