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Tomasz Poboży

Autor: Tomasz Poboży

  • Radial Tunnel Syndrome — Lateral Elbow Pain Without Numbness

    Polska wersja

    Radial tunnel syndrome can cause deep pain on the outer side of the elbow and upper forearm, usually without numbness in the fingers. The symptoms often resemble tennis elbow, but tenderness is typically located several centimetres below the lateral epicondyle. Diagnosis requires caution because no single test can confirm the syndrome on its own.

    Where is the nerve compressed?

    Around the elbow, the radial nerve divides into a superficial branch and a deep branch, which continues as the posterior interosseous nerve. The deep branch passes through a tunnel formed by muscles and fibrous bands in the proximal forearm. The region of the supinator muscle is one of the more common sites of compression.

    Pain is the dominant feature in radial tunnel syndrome. Clear finger drop or wrist drop suggests a more significant motor lesion of the posterior interosseous nerve or radial nerve and warrants more prompt investigation.

    Which symptoms can suggest radial tunnel syndrome?

    • deep, dull or burning pain on the lateral side of the elbow and upper forearm,
    • tenderness usually 3–5 cm below the lateral epicondyle of the humerus,
    • pain aggravated by forearm supination, gripping or repetitive hand work,
    • pain with resisted middle-finger extension or resisted supination,
    • usually no typical numbness of the skin of the hand or fingers.

    Radial tunnel syndrome or tennis elbow?

    In tennis elbow, maximal tenderness is usually directly over the lateral epicondyle at the origin of the wrist extensors. In radial tunnel syndrome, the most painful point is more often distal to the epicondyle, along the course of the nerve. The two problems can coexist, and a single provocative test does not settle the diagnosis.

    How is it diagnosed?

    Clinical examination

    The location of pain, muscle strength, sensation, range of motion of the neck and elbow, and reproduction of symptoms during specific resisted movements are all important. The differential diagnosis includes extensor tendinopathy, radiocapitellar joint disease, cervical radiculopathy and radial nerve compression at another level.

    EMG and nerve conduction studies

    Electrophysiological studies may be normal in a typical pain-dominant radial tunnel syndrome. They are more useful when there is objective weakness and the clinician needs to assess a motor nerve lesion or distinguish the problem from radiculopathy.

    Ultrasound and MRI

    Ultrasound can show the course of the nerve, changes in its calibre, compression by a cyst or another lesion, and can provide dynamic assessment. MRI can help identify a space-occupying lesion and signs of muscle denervation. Normal imaging, however, does not exclude a clinical pain syndrome.

    How does treatment begin?

    Management usually starts by reducing repetitive movements that provoke pain, particularly forceful gripping, forearm supination and work with the elbow extended. Ergonomic modification, graded exercise, soft-tissue treatment and work on mobility and strength may help, provided the programme does not continually provoke symptoms.

    Analgesic or anti-inflammatory medication can be used in appropriately selected patients. A targeted injection is sometimes used diagnostically or therapeutically, but evidence for durable benefit is limited. Ultrasound guidance improves control of needle placement, although technical accuracy alone does not confirm the diagnosis.

    When does an orthopaedic surgeon consider surgery?

    Surgical decompression may be considered in selected patients with well-documented, persistent pain despite appropriately conducted non-operative treatment, or when compression by a specific structure has been demonstrated. Outcomes are not uniformly predictable. A systematic review published in 2026 highlighted substantial variation in diagnostic criteria and surgical techniques, making it difficult to identify a single best operative approach.

    Red flags

    Prompt assessment is warranted for new finger or wrist drop, progressive grip weakness, sensory loss after injury, marked swelling or deformity of the elbow, worsening pain with fever and redness, or signs of impaired circulation in the hand. These findings should not be attributed simply to “overuse.”

    Back to: Peripheral Nerves

    See also: Elbow Conditions

    References

    • Wolf JM, Patel R, Ghosh K. Radial Tunnel Syndrome: Review and Best Evidence. J Am Acad Orthop Surg. 2023;31(15):e667–e674. DOI: 10.5435/JAAOS-D-23-00314.
    • Levina Y, Dantuluri PK. Radial Tunnel Syndrome. Curr Rev Musculoskelet Med. 2021;14:205–213. DOI: 10.1007/s12178-021-09703-w.
    • Raymond B, Cueto RJ, Mazudie Ndjonko LC, et al. Clinical Outcomes of Operative Management for Radial Tunnel Syndrome According to Surgical Approach: A Systematic Review. Hand (N Y). 2026;21(1):24–31. DOI: 10.1177/15589447251315761.

    This information is educational and does not replace an individual medical consultation.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Does Musculoskeletal Ultrasound Compare Both Sides?

    Polska wersja

    Comparing the painful side with the asymptomatic side can help distinguish an individual anatomical feature from a true abnormality. It is not, however, an automatic deciding test. The opposite limb may contain asymptomatic changes, and some disorders are bilateral.

    Each patient provides their own reference point

    Reference ranges for tendon thickness or nerve size are useful, but they do not capture the full range of biological variation. Comparing both sides can show whether a difference is pronounced in that particular patient. This is especially useful when the finding is subtle or lies close to the boundary of what is considered normal.

    What can an orthopaedic surgeon compare during ultrasound?

    • tendon thickness and internal structure,
    • nerve cross-sectional area and echogenicity,
    • the amount of fluid in a bursa or tendon sheath,
    • how a structure behaves during movement,
    • vascularity on Doppler imaging,
    • bony contours and anatomical relationships.

    Side-to-side comparison is most useful when the images are obtained in the same plane, with a similar limb position and identical machine settings. Otherwise, an apparent asymmetry may reflect technique rather than disease.

    Ultrasound is not only a static image

    One of the advantages of musculoskeletal ultrasound is the ability to observe tissues in real time. A tendon may snap only during a particular movement, a nerve may change position as a joint bends, and tissue impingement may appear only in a specific position. Comparing both sides during the same manoeuvre can therefore be more informative than comparing two isolated still images.

    Why is the other side not always a “healthy control”?

    Imaging abnormalities can occur without pain. This applies, among other things, to degenerative changes in tendons, entheses and menisci. Conversely, a disorder may affect both sides even when symptoms are present only on one side. A symmetrical appearance therefore does not exclude disease, and asymmetry by itself does not prove that the source of pain has been identified.

    The image must be matched to the exact site of symptoms

    The greatest value comes from combining three elements: the history, physical examination and ultrasound findings. If an abnormality is located where the patient hurts, changes during the movement that provokes symptoms and fits the clinical mechanism, it becomes more likely to be relevant. If it is incidental and does not correspond to the symptoms, it should not determine treatment on its own.

    This approach was also important in a study of 430 patients evaluating meniscal abnormalities with ultrasound, co-authored by Tomasz Poboży. Ultrasound was treated as one component of the clinical assessment, with attention to the type of symptoms and the limitations of the method.

    When can side-to-side comparison be misleading?

    • after a previous injury or operation on the currently asymptomatic side,
    • in bilateral or systemic disorders,
    • when the limb or transducer position is not equivalent on both sides,
    • when the difference lies within normal biological variation,
    • when the visible abnormality does not match the location of symptoms.

    Practical takeaway

    The opposite side is a valuable reference, but it does not replace knowledge of anatomy, diagnostic criteria or examination of the patient. Good ultrasound practice is not about finding any asymmetry. The question is whether the observed difference actually explains the symptoms and whether it should change further management.

    Back to: Diagnostic Tests

    More about: MSK Ultrasound and Ultrasound-Guided Procedures

    References

    • Poboży T, Konarski W, Janowski K, Michalak K, Poboży K, Domańska-Poboża J. Ultrasonographic Assessment of Meniscus Damage in the Context of Clinical Manifestations. Medicina. 2025;61(8):1339. DOI: 10.3390/medicina61081339.
    • European Society of Musculoskeletal Radiology. Musculoskeletal ultrasound technical guidelines. Current technical recommendations and regional scanning protocols.

    This material is educational and does not replace an individual medical consultation.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Reverse Shoulder Arthroplasty After Complex Proximal Humerus Fracture — An Advantage at 7 Years?

    Polish version · Trauma — Literature for Clinicians

    Key finding: at approximately 7.5 years, patients treated with reverse shoulder arthroplasty had a better Constant score than those treated nonoperatively. There was no advantage in pain or overall quality of life, however, and the long-term analysis included only 29 of the original 62 participants. This is an important clinical signal, but not a decisive argument for routine surgery.

    Why is this study interesting?

    In very elderly patients with displaced three- or four-part proximal humerus fractures, choosing between nonoperative treatment and reverse shoulder arthroplasty remains difficult. Early results do not necessarily reflect shoulder function several years later. The authors therefore returned to participants from a previous randomised trial and assessed them after a mean follow-up of more than seven years.

    Question and methods

    The original trial included 62 patients aged at least 80 years with displaced three- or four-part fractures. Reverse shoulder arthroplasty was compared with nonoperative treatment. Twenty-nine patients were available for long-term analysis: 17 after arthroplasty and 12 after nonoperative treatment. Mean follow-up was 7.6 and 7.4 years, respectively.

    Outcomes included the Constant score for shoulder function, DASH for upper-limb disability, pain on a visual analogue scale, SF-12 quality of life and radiographic findings. In the long-term subgroup, patients in the arthroplasty group were older on average: 92 versus 88 years.

    Results

    • The mean Constant score was 62 after reverse shoulder arthroplasty and 51 after nonoperative treatment; p=0.039.
    • DASH scores were 16 and 25, respectively; the difference did not reach statistical significance, p=0.069.
    • Pain was similar in the two groups: 1.5 versus 1.4 points.
    • No differences were found in either the physical or mental components of SF-12.
    • All fractures treated nonoperatively healed in malunion, but none of those patients later required reverse shoulder arthroplasty.
    • In the operative group, one patient required revision because of prosthetic dislocation.

    Clinical interpretation for an orthopaedic surgeon

    The advantage in Constant score suggests that in some relatively fit patients aged 80 years or older, reverse shoulder arthroplasty may preserve useful shoulder function better over the long term. At the same time, similar pain scores and the absence of a difference in SF-12 show that an improvement in a shoulder-specific measure does not necessarily translate into an equally large difference in overall wellbeing.

    Malunion after nonoperative treatment was not automatically equivalent to later surgical failure. In very elderly patients, the decision should still take into account pre-injury independence, functional expectations, deltoid function, perioperative risk, ability to participate in rehabilitation and patient preference.

    Limitations

    • Only 29 of the 62 originally enrolled patients remained in the long-term analysis. This substantial attrition can introduce survival and follow-up bias.
    • The small sample limits precision and the ability to assess uncommon complications.
    • After years of attrition, the original randomisation no longer fully protects against differences between the groups.
    • The groups differed in age at long-term follow-up.
    • A statistically significant difference was found in the Constant score, but not in DASH, pain or SF-12.
    • The findings should not be extrapolated to younger patients or to simpler fracture patterns.

    What might this change in practice?

    The study strengthens the case for discussing a possible long-term functional benefit of reverse shoulder arthroplasty with selected active patients of very advanced age rather than judging treatment only by the first few months. It does not justify automatic selection for surgery based on the fracture image alone.

    What does the study not prove?

    It does not prove that reverse shoulder arthroplasty is the best treatment for every patient over 80. It does not show an advantage in pain or overall quality of life, and the sample is too small for a precise comparison of complication risk. It also does not mean that every malunion after nonoperative care requires later reconstruction.

    Reference

    Lopiz Y, Alcobía-Díaz B, Coderch J, et al. Long-term outcomes of reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4-part proximal humerus fractures in elderly patients: results from a prior randomized clinical trial. Journal of Shoulder and Elbow Surgery. 2026;35(9S):S32–S38. DOI: 10.1016/j.jse.2026.05.029. PubMed.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Do Weight-Bearing X-Rays Show More?

    Polish version · Explore Diagnostic Tests

    A weight-bearing X-ray shows a joint under conditions that are closer to standing and walking than an image taken while lying down. Body weight may reveal joint-space narrowing, loss of alignment, collapse of the foot arch or instability that is less apparent on a non-weight-bearing image. This does not mean that every patient should have standing radiographs.

    The same knee can look different standing and lying down

    Articular cartilage is not directly visible on a standard X-ray. Its condition is assessed indirectly, among other features, by the width of the space between the bones. When a patient stands, load brings the joint surfaces together. If cartilage loss is uneven, narrowing may become more apparent in this position.

    It matters not only whether the joint space is narrower, but also where the narrowing occurs and how the limb axis behaves under load. Weight-bearing radiographs can therefore be important when assessing knee osteoarthritis and planning treatment. The image still needs to be interpreted alongside pain, range of motion, stability and everyday function.

    In the foot, loading can change the entire geometry

    The foot is a dynamic structure. When standing, the height of the arches, the position of the metatarsals and heel, and the relationships between joints all change. In hallux valgus, flatfoot, hindfoot deformity or suspected midfoot instability, a non-weight-bearing image may underestimate the true extent of the problem.

    This is one reason why properly performed standing foot radiographs are often the basis for measurements before planned treatment. MRI and ultrasound answer different questions: they can show selected soft tissues more clearly, but they do not replace assessment of bony alignment under load.

    Loading can reveal instability

    Some joints and ligament-related relationships may appear normal until force is applied. Selected midfoot injuries are an example: separation between bones can become visible only during a safely performed weight-bearing examination. Stress radiographs use a similar principle, although they have separate indications and techniques.

    When is a standing X-ray not a good idea?

    After a recent injury with suspected unstable fracture, severe pain or inability to bear weight safely, standing should not be forced simply to obtain a supposedly better image. Safety comes first. Depending on the clinical situation, standard projections, comparison views, CT or MRI may be more appropriate.

    Technique matters

    Radiographs can be compared meaningfully only when the limb position and projection are sufficiently similar. Knee rotation, different degrees of flexion or uneven weight distribution can alter measurements. The label “weight-bearing X-ray” is therefore not enough: the examination needs to be performed in a way that answers the clinical question.

    How an orthopaedic surgeon chooses the X-ray projection

    There is no single universal X-ray series for all of orthopaedics. Assessment of knee osteoarthritis requires different projections from assessment of hallux valgus or an acute injury. A useful imaging request should not simply name the body region. It should indicate what is being assessed and whether evaluation under load is needed.

    Practical conclusion

    A standing X-ray is not automatically more accurate than one taken while lying down. It shows a different aspect of the problem: how bones and joints behave under body weight. It is most useful when that information could change the diagnosis, measurement or treatment plan.

    References

    • Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® Chronic Knee Pain. Journal of the American College of Radiology. 2018;15(11S):S302–S312. DOI: 10.1016/j.jacr.2018.09.016.
    • Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® Acute Trauma to the Foot. Journal of the American College of Radiology. 2020;17(5S):S46–S55. DOI: 10.1016/j.jacr.2020.01.022.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Orthopaedic Surgical Wound Care — When Should You Change the Dressing?

    Polish version · Before and After Orthopaedic Surgery

    The most important rule is to keep an orthopaedic surgical dressing clean and dry and to follow the wound-care instructions given for the specific procedure. Not every wound needs to be uncovered or redressed every day. A small amount of staining can be normal, but increasing drainage, separation of the wound edges, spreading redness, fever or worsening pain should prompt contact with the treating team.

    Why are wound-care instructions different after different operations?

    A wound after arthroscopy, fracture fixation or joint replacement may be closed with different materials and protected by different dressings. Drains, negative-pressure wound therapy, coexisting medical conditions and medicines that affect clotting can also change the plan. For that reason, written discharge instructions take priority over general advice.

    When should the dressing be changed?

    If the dressing is dry, sealed and adheres well, it can often remain in place for the period recommended by the orthopaedic surgeon or the dressing manufacturer. It should be changed sooner if it becomes wet, soiled, loose or if drainage reaches the edge. Specialist dressings and negative-pressure systems should not be removed independently unless this has been specifically advised.

    How can a dressing be changed safely?

    • Wash and dry your hands thoroughly before touching the dressing and again after the change.
    • Prepare a clean surface and the materials recommended at discharge.
    • Do not touch the surface of the new dressing that will lie directly against the wound.
    • Remove the old dressing gently without pulling on sutures, skin-closure strips or tissue adhesive.
    • Do not apply creams, ointments, powders or topical antibiotics to the wound unless they have been specifically prescribed.
    • If the wound looks different from before, note the change and contact the treating team when appropriate.

    Can the wound be washed or soaked?

    NICE guidance indicates that showering is generally safe from 48 hours after surgery. This is not a universal instruction to wet every wound or dressing: the type of closure, a drain, a negative-pressure dressing or an individual instruction from the surgeon may require a different approach. After showering, the area should be dried gently without rubbing.

    Bathing, swimming, sauna use and prolonged soaking require more caution. They are usually postponed until the skin has fully closed and the wound has been reviewed. Prolonged water exposure can soften the wound edges and increase the risk of contamination.

    What can be normal during the first few days?

    • a small, non-increasing blood stain or a small amount of clear or lightly pink fluid on the dressing;
    • moderate tenderness that is not progressively worsening;
    • mild swelling and bruising around the operated area;
    • a pulling sensation in the skin during movement.

    The direction of change matters more than a single appearance. Over time, the wound should become calmer, while drainage and pain should gradually decrease.

    When does the wound need prompt review?

    • redness, warmth or swelling that is spreading around the incision;
    • pain that is increasing rather than decreasing, especially after an initial improvement;
    • cloudy, thick or unpleasant-smelling drainage;
    • a dressing that repeatedly becomes rapidly soaked with blood or fluid;
    • separation of the wound edges or a visible deeper defect;
    • fever, chills or a clear deterioration in general wellbeing;
    • new numbness, limb weakness, pallor or blue discolouration of the fingers or toes.

    After an operation involving an implant, even a small but persistent wound discharge should not simply be left until a distant routine follow-up. Early assessment can help distinguish superficial irritation from a problem that requires treatment.

    When are sutures or staples removed?

    The timing depends on the anatomical site, skin tension, closure method and healing rate. Sutures, staples, tissue adhesive and closure strips should not be removed independently. The wound should be reviewed at the time specified in the discharge instructions even when it appears normal from the outside.

    What increases the risk of wound-healing problems?

    Closer observation may be appropriate in people with diabetes, tobacco use, impaired circulation, anticoagulant treatment, reduced immunity, obesity or a previous history of wound-healing problems. These factors do not mean that a complication will occur, but they may justify earlier review.

    References

    • National Institute for Health and Care Excellence. Surgical site infections: prevention and treatment. NICE guideline NG125. Published 11 April 2019; updated 19 August 2020. Recommendations.
    • Centers for Disease Control and Prevention. Surgical Site Infection Basics. Updated 11 April 2024. CDC information.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Posterior Tibial Slope After Total Knee Arthroplasty — Does It Affect Outcomes?

    Polish version · Joint Replacement — Literature for Clinicians

    Changes in posterior tibial slope after total knee arthroplasty raise concern because they can influence flexion geometry and soft-tissue tension. A new analysis of 370 patients suggests, however, that in posterior-stabilised TKA, relatively small deviations within the range typically encountered in surgery do not translate into meaningfully worse functional outcomes.

    Why is this study interesting?

    Posterior tibial slope (PTS) is one parameter of tibial component alignment in the sagittal plane. Biomechanically, it can influence knee flexion, the flexion space and ligament behaviour. In practice, radiographic deviation from the planned slope is therefore sometimes treated as a possible explanation for a mediocre result after surgery. The authors examined whether this association could actually be detected in medium-term patient outcomes.

    Question and methods

    This was a single-centre retrospective cohort study of 370 patients who underwent primary cemented total knee arthroplasty using one posterior-stabilised implant design. Mean age was 71 years and mean follow-up was 64.6 months, with a minimum follow-up of 48 months.

    PTS was measured on standardised lateral radiographs before and after surgery. Two observers performed the measurements independently and were blinded to each other’s results. Change in slope was analysed by direction, magnitude (up to 3°, 4–9°, and at least 10°) and a 5.47° cut-off corresponding to the mean absolute change across the cohort. Outcomes included pain, WOMAC, Knee Society Score, Oxford Knee Score, Forgotten Joint Score-12 and range of motion. Multivariable analysis was also performed.

    Results

    • All patient-reported outcome measures improved significantly after surgery.
    • Neither the direction nor the magnitude of PTS change was associated with pain, function or overall clinical improvement; p was greater than 0.05 for all of these analyses.
    • A greater PTS was associated with statistically greater flexion: the coefficient was 0.53° of additional flexion for each 1° increase in PTS (p<0.001).
    • This difference in range of motion did not translate into better patient-reported outcomes.
    • Preoperative function remained the strongest predictor of postoperative outcome.

    Clinical interpretation for an orthopaedic surgeon

    The important distinction is between a measurable difference and one that matters to the patient. The association between PTS and flexion was statistically clear but small, and it was not reflected in any of the functional scores. The findings challenge the simple assumption that every few-degree sagittal-plane deviation must be the reason for a poor TKA result.

    The study supports a broader assessment of the dissatisfied patient. Baseline function, pain, stiffness, instability, alignment in other planes, component rotation, soft-tissue condition, infection and expectations all need to be considered. PTS measured on a lateral radiograph is rarely a complete explanation on its own.

    Limitations

    • The study was retrospective and single-centre, so it cannot establish causation.
    • It included only cemented TKA using one posterior-stabilised implant design; the findings should not automatically be extrapolated to cruciate-retaining, medially stabilised or other implant systems.
    • PTS was measured on conventional lateral radiographs, which do not fully represent three-dimensional component position and are sensitive to limb positioning.
    • The analysis does not answer questions about extreme malalignment, implant survivorship, aseptic loosening or outcomes beyond a decade.
    • Unmeasured confounding remains possible despite multivariable analysis.

    What might this change in practice — and what does it not prove?

    The findings may reduce the tendency to overinterpret a modest PTS deviation as the sole cause of an unsatisfactory result after posterior-stabilised TKA. They are not an argument for arbitrary tibial component positioning or for disregarding surgical planning. Nor do they prove equivalence between different PTS angles, because this was not a randomised study designed to demonstrate no difference.

    Reference

    Altun O, Ergişi Y, Özdemir E, Özihtiyar AA, Altıntaş M, Daşar U. The Effect of Posterior Tibial Slope Change on Functional Outcomes After Posterior-Stabilized Total Knee Arthroplasty: An Analysis of 370 Patients Who Had A Minimum 4-Year Follow-Up. Journal of Arthroplasty. Published online 9 September 2026. PMID 42716147. DOI: 10.1016/j.arth.2026.09.001. PubMed abstract.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Pain at the Front of the Shoulder — Could the Biceps Tendon Be the Cause?

    Polish version · Explore Shoulder Conditions

    Pain at the front of the shoulder can arise from the long head of the biceps tendon, but the source cannot be identified from pain location alone. Biceps tendon pathology often coexists with rotator cuff disease, labral lesions or injury to the structures that stabilise the tendon in the bicipital groove. Diagnosis therefore depends on combining symptoms, clinical examination and appropriately selected imaging.

    Where does the biceps tendon run in the shoulder?

    The biceps brachii has two proximal attachments around the shoulder. The long head originates near the superior glenoid and labrum, passes through the joint and then enters the bicipital groove of the humerus. Along this course it is stabilised by several structures, including fibres from the subscapularis and supraspinatus tendons and surrounding ligaments.

    This is why isolated “biceps tendinopathy” is not the only possible explanation. Pain may come from the tendon itself or its sheath, but also from a rotator cuff tear, a SLAP lesion, biceps tendon instability or another disorder within the shoulder joint.

    Which symptoms fit long-head biceps tendon pathology?

    • pain at the front of the shoulder, sometimes extending down the front of the upper arm;
    • pain that increases when raising the arm, working overhead, throwing or lifting an object;
    • pain when reaching behind the body, for example for a seat belt or while putting on a jacket;
    • tenderness over the bicipital groove;
    • sometimes painful snapping or clicking at the front of the shoulder.

    None of these findings is specific. Rotator cuff disease, frozen shoulder, acromioclavicular joint pathology and referred pain from the neck can produce a similar pattern. Speed’s test, Yergason’s test or tenderness over the groove may strengthen the suspicion, but a single positive test does not establish the diagnosis.

    A sudden pop and a bulge in the arm — could this be a rupture?

    An acute proximal biceps rupture may be accompanied by a pop, bruising and distal displacement of the muscle belly, producing a characteristic bulge lower in the upper arm. Pain can be substantial initially and then settle. Some patients are left with weakness during forearm supination, muscle cramping or a cosmetic concern.

    This appearance does not automatically mean surgery is required, particularly when the long head has ruptured and arm function remains good. The decision depends on age, activity level, the dominant arm, occupational demands and associated shoulder lesions.

    How is it assessed?

    Clinical examination

    The examination includes active and passive range of motion, rotator cuff strength, shoulder stability, the cervical spine, and sensation and strength throughout the limb. It is important to establish whether symptoms began after a single injury or developed with repetitive loading. Tendon snapping can suggest disruption of the structures that retain it in the groove, particularly near the subscapularis tendon.

    X-ray

    X-rays do not show the biceps tendon well, but they may reveal calcification, osteoarthritis, post-traumatic bony changes or another cause of shoulder pain. In an adult with persistent shoulder symptoms, radiographs are often a reasonable initial imaging study.

    Ultrasound

    Ultrasound can show the portion of the tendon within the groove, fluid around the tendon, thickening, partial or complete rupture and tendon displacement during movement. Dynamic scanning is useful when instability is suspected. The rotator cuff and subacromial-subdeltoid bursa can be assessed at the same examination.

    Ultrasound also has limitations. The intra-articular portion of the tendon and its attachment near the superior labrum are more difficult to assess completely. A normal appearance within the groove does not exclude pathology deeper inside the joint.

    MRI

    MRI can assess the biceps tendon together with the rotator cuff, cartilage, bone and other intra-articular structures. When a superior labral lesion is suspected, MR arthrography may be considered in selected cases. MRI is not necessary for every patient with anterior shoulder pain; it should answer a specific clinical question.

    How is biceps-related shoulder pain treated?

    Non-operative treatment

    Most overload-related symptoms are initially treated without surgery. This usually means temporarily reducing movements that clearly provoke pain rather than completely immobilising the shoulder, followed by a gradual return to loading. Rehabilitation may address range of motion, scapular control, rotator cuff exercises and progressive biceps strengthening.

    Analgesic or anti-inflammatory medication should be selected with other medical conditions and current medicines in mind. Cooling may reduce short-term symptoms after overload. If an injection is considered, it should follow a specific diagnosis. In selected situations medication can be placed into the tendon sheath under ultrasound guidance while avoiding injection into the tendon substance itself. Accurate needle placement does not by itself guarantee a durable clinical effect.

    When does an orthopaedic surgeon consider surgery?

    Surgery is considered mainly when appropriately conducted non-operative treatment does not restore acceptable function, when there is substantial tendon damage or instability, or when surgery is already planned for an associated rotator cuff or labral lesion. Common options include tenotomy, in which the damaged tendon is released, and tenodesis, in which it is detached from its intra-articular origin and fixed to the humerus. SLAP repair is reserved for appropriately selected patients.

    There is no single best procedure for everyone. Age, activity, cosmetic concerns, risk of cramping, occupational requirements and the other shoulder lesions all influence the choice.

    When is earlier assessment needed?

    • after an injury, the arm cannot be raised or there is clear new weakness;
    • the shoulder is deformed, markedly swollen or bruising is spreading quickly;
    • there is numbness, hand weakness, pallor or cooling of the limb;
    • pain is severe even at rest and is accompanied by fever, redness or deterioration in general condition;
    • shoulder pain occurs with shortness of breath, chest pressure or sudden general weakness.

    Key points

    Anterior shoulder pain can come from the long head of the biceps tendon, but associated pathology is common. Ultrasound is particularly useful for dynamic assessment of the tendon within the bicipital groove, whereas MRI better demonstrates intra-articular structures. For most patients, treatment begins with load modification and targeted rehabilitation; a decision about injection or surgery requires identification of the actual pain generator.

    References

    1. Poboży T et al. Clock-Face Sonography of the Glenoid Labrum: A Pictorial Technical Protocol for Patients Ineligible for MRI/MR Arthrography. Diagnostics. 2025;15(23):3031. DOI: 10.3390/diagnostics15233031. This publication includes assessment of the superior labrum and the region of the biceps attachment; it is not a treatment-effectiveness study for biceps tendinopathy.
    2. Lalehzarian SP, Agarwalla A, Liu JN. Management of proximal biceps tendon pathology. World Journal of Orthopedics. 2022;13(1):36–57. DOI: 10.5312/wjo.v13.i1.36. Full text.
    3. American Academy of Orthopaedic Surgeons. Biceps Tendinitis. Patient information prepared or reviewed by a member of the American Shoulder and Elbow Surgeons.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Active and Passive Range of Motion — Why Does an Orthopaedic Surgeon Check Both?

    Polish version · Explore Diagnostic Tests

    Comparing active and passive range of motion is one of the simplest ways to judge whether restricted movement is driven mainly by pain or weakness of a muscle or tendon, or by true joint stiffness. The number of degrees alone is not enough. It also matters who is producing the movement, where resistance is felt and whether the range can be increased safely.

    Two similar movements, two different pieces of information

    Active movement is produced by the patient using their own muscles. It therefore reflects not only the range available at the joint, but also muscle and tendon function, neural control, pain and confidence in the movement. Passive movement is produced by the examiner while the patient relaxes the limb as much as possible. It shows how much motion is available without requiring the patient to generate force.

    If a patient cannot lift the arm very far but the examiner can gently move it much further, that does not automatically mean the joint is normal. The discrepancy directs attention towards pain, rotator cuff weakness, tendon injury, altered scapular control or a neurological problem. If active and passive motion are restricted to a similar degree, capsular stiffness, an intra-articular disorder or a mechanical block becomes more likely.

    The shoulder shows why this comparison matters

    In frozen shoulder, both active and passive motion are usually restricted, particularly external rotation. With a large rotator cuff tear, active elevation may be markedly impaired even though passive motion is much better. In acute subacromial pain, the difference may reflect pain-related inhibition of muscle activity rather than a permanent structural failure.

    These patterns are not diagnoses by themselves. Severe pain can also limit passive movement, while a longstanding tendon lesion may eventually lead to secondary stiffness. The findings therefore need to be interpreted together with the history, strength testing, provocative tests and imaging when there is a clinical indication.

    The same principle applies to other joints

    Knee

    A patient may be unable to fully extend the knee actively because of pain, quadriceps weakness or injury to the extensor mechanism. If full extension is also missing passively, possibilities include contracture, a large effusion, a mechanical block or degenerative change. After surgery, the difference between active and passive motion can sometimes be more informative than a single isolated measurement.

    Ankle and foot

    Loss of active toe or foot movement with preserved passive motion may suggest a musculotendinous or neurological problem. Passive restriction more often points towards joint stiffness, swelling, contracture or a mechanical consequence of injury. The character of the end-feel also matters: whether resistance is elastic, hard, painful or appears abruptly.

    Why does the examination begin with observation?

    Before moving the limb, the examiner watches how the patient performs the movement independently. This can reveal the movement path, pain avoidance, trunk compensation, scapulohumeral rhythm, tremor or sudden giving way. Passive range and the quality of the end-feel can then be assessed.

    This is also a matter of safety. After a recent injury, particularly when a fracture or dislocation is suspected, motion should not be forced simply to obtain a complete measurement. Neurovascular assessment, appropriate immobilisation and imaging take priority in that situation.

    What does measuring the angle add?

    A goniometer can record the range in degrees and help track change over time. This is useful during rehabilitation, after surgery and when monitoring treatment. The result nevertheless depends on body position, anatomical landmarks, pain and measurement technique. A difference of a few degrees does not always represent a real clinical change.

    The most useful measurement is one that is repeated under similar conditions and interpreted alongside function: whether it has become easier to dress, climb stairs, straighten the knee during walking or lift an object. The aim is to treat a limitation that affects the patient’s life, not a number in isolation.

    What can active and passive motion not tell us?

    • they do not identify a single damaged structure on their own;
    • they do not reliably distinguish an acute injury from a chronic disorder;
    • they do not replace assessment of strength, stability, sensation and circulation;
    • they do not determine whether surgery is needed;
    • they do not remove the need for imaging when the injury mechanism or symptoms suggest a fracture, dislocation or another urgent diagnosis.

    Practical conclusion

    The difference between active and passive motion is a clue that guides the rest of the examination. A large discrepancy makes pain, weakness, tendon injury or a neurological problem more likely. Similar restriction of both ranges raises suspicion of joint stiffness or a mechanical block. The next step is chosen from the whole pattern, together with the history and the remaining examination findings.

    Reference

    Woodward TW, Best TM. The Painful Shoulder: Part I. Clinical Evaluation. American Family Physician. 2000;61(10):3079–3088.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • First-Time Patellar Dislocation — What Should You Do?

    Polish version · Explore Knee Conditions

    A first-time patellar dislocation requires assessment even if the patella has moved back into place on its own. It is important to exclude an osteochondral fragment, assess the structures that stabilise the patella and determine whether the anatomy of the knee increases the risk of another dislocation. Many patients begin with non-operative treatment, but not every first dislocation is the same.

    What happens during a patellar dislocation?

    The patella usually moves towards the outside of the knee. The injury may occur during a twist on a weight-bearing leg, a sudden change of direction or a direct blow. Sometimes the patella remains visibly out of its normal track, but it often reduces spontaneously as the knee straightens or before medical assessment.

    The medial soft tissues that stabilise the patella are commonly injured during the displacement, including the medial patellofemoral ligament (MPFL). Bone bruising, cartilage injury or detachment of an osteochondral fragment into the joint can also occur.

    What should you do immediately after the injury?

    If the patella is still visibly displaced, the knee is deformed or cannot be moved, urgent medical assessment is needed. Do not force the knee into flexion or repeatedly attempt to reduce the patella yourself. Support the limb in the least painful position.

    If the patella has reduced spontaneously, cooling through a cloth, reduced loading and crutches when walking is painful may help initially. Disappearance of the deformity does not exclude an injury inside the joint. A rapidly developing knee effusion can indicate bleeding or an osteochondral injury, among other causes.

    What symptoms are typical after a dislocation?

    • pain and tenderness along the medial side of the patella;
    • swelling or bruising around the knee;
    • a sense of instability or fear that the patella may “pop out” again;
    • pain during knee flexion and extension;
    • difficulty bearing weight;
    • locking or catching if a loose fragment is present in the joint.

    Anterior knee pain may persist after the acute phase. This does not automatically mean that another dislocation has occurred, but it may require assessment of patellar tracking, muscle strength and possible cartilage injury.

    How is a first-time patellar dislocation assessed?

    History and examination

    Age, the injury mechanism, previous episodes of the patella “giving way”, similar symptoms in the other knee and a family history of instability can all be relevant. The examination assesses effusion, tenderness, the ability to extend the knee, ligament stability and patellar position. In the acute phase, severe pain can limit the accuracy of some tests.

    X-ray

    Radiographs are obtained to confirm patellar alignment, exclude a fracture and look for a visible bony fragment. A normal X-ray does not exclude cartilage injury or a small osteochondral fragment.

    MRI

    The current ESSKA consensus recommends early MRI after a first-time dislocation, apart from the exceptional situation of an asymptomatic patient. MRI can identify cartilage injury, a loose fragment and MPFL injury, and it can demonstrate anatomical features associated with recurrence such as trochlear dysplasia and patella alta. The findings also help guide subsequent treatment.

    When is CT needed?

    CT is not required for every patient. It may be useful for more detailed assessment of a bony fragment, fracture or three-dimensional anatomy, particularly when surgery is being considered.

    Is a first dislocation usually treated without surgery?

    Often yes, but the decision should not be based simply on the number of previous dislocations. If there is no large osteochondral fragment, no clear injury requiring repair and no very high risk of recurrence, treatment usually includes a short period of knee protection, gradual restoration of movement and rehabilitation.

    A brace may improve confidence in the early period, but there is no strong evidence that prolonged bracing alone reduces recurrence risk. Excessive immobilisation can contribute to stiffness and quadriceps weakness.

    What does rehabilitation involve?

    The programme is adapted to pain, swelling and stability. The first goals are to restore safe extension and flexion and a normal gait. Rehabilitation then focuses on quadriceps and hip strength, control of lower-limb alignment and balance. Return to running, cutting movements and sport requires recovery of range of motion, strength and control comparable with the other leg — the passage of a few weeks alone is not enough.

    When is surgery considered after a first dislocation?

    • when a significant osteochondral fragment has detached and requires fixation or repair of the joint surface;
    • when a loose fragment inside the joint causes locking;
    • when the risk of another dislocation is high because of age, symptoms and anatomical abnormalities;
    • when clear instability persists despite appropriate treatment;
    • after recurrent dislocations.

    If surgery addresses the medial stabilising structures, current consensus favours MPFL reconstruction over simple ligament repair. In selected patients, an important bony risk factor may need to be corrected at the same time, but surgical thresholds are not identical for every patient and remain an area of discussion.

    How high is the risk of recurrence?

    The ESSKA consensus cites a recurrence rate of about 25% after a first-time dislocation. Risk is not the same for everyone. It is higher with younger age, skeletal immaturity, trochlear dysplasia, patella alta, previous symptoms of instability and the coexistence of several risk factors.

    Not having another complete dislocation does not always mean full recovery. Up to half of patients may report persistent pain, swelling, a sense of the knee giving way, functional limitations or fear of returning to sport. Treatment outcome therefore needs to be assessed more broadly than by recurrence alone.

    Warning signs

    • the patella remains out of position or the knee is visibly deformed;
    • the foot is pale, cold or numb, or cannot be moved normally;
    • the knee cannot be straightened or the straight leg cannot be lifted;
    • the knee rapidly fills with blood, locks or does not allow weight bearing;
    • pain and swelling are clearly increasing rather than gradually settling.

    Key points for an orthopaedic surgeon

    After a first-time patellar dislocation, assessment should consider not only whether the patella has returned to place, but also the cartilage, bone, MPFL and factors that increase recurrence risk. Most uncomplicated injuries can begin with non-operative treatment and targeted rehabilitation. An osteochondral fragment, locking or a high risk of another dislocation can, however, change management after the first episode.

    References

    1. Blønd L et al. Management of first-time patellar dislocation: The ESSKA 2024 formal consensus—Part 1. Knee Surgery, Sports Traumatology, Arthroscopy. 2025;33(5):1925–1932. DOI: 10.1002/ksa.12620. PubMed.
    2. Balcarek P et al. Management of first-time patellar dislocation: The ESSKA 2024 formal consensus—Part 2. Knee Surgery, Sports Traumatology, Arthroscopy. 2025;33(12):4197–4206. DOI: 10.1002/ksa.12637. PubMed.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Mechanism of Injury — Why Does It Matter?

    Polish version · Explore Injuries and Fractures

    Asking exactly how an injury happened is not a formality. The direction of force, the position of the limb and whether the foot or hand was fixed or supported can help identify which structures may have been injured and which investigation should come first. The mechanism narrows the differential diagnosis, but it never establishes a diagnosis on its own.

    “I twisted my knee” is not enough information

    When assessing a knee injury, it matters whether the foot was planted, whether the knee collapsed inward, whether there was contact with another player and whether the movement was accompanied by a pop. A twist on a weight-bearing leg may direct attention towards the ligaments, meniscus or patella, but each of these structures tends to produce a somewhat different clinical pattern.

    Likewise, saying “I fell on my hand” is too broad. It matters whether the elbow was straight, where the first pain appeared and whether the force was transmitted mainly to the wrist, elbow or shoulder. The same fall can result in a distal radius fracture, radial head fracture, shoulder injury or several injuries at the same time.

    Four elements of a useful injury description

    1. Limb position: was the joint flexed, extended, twisted or raised above the head?
    2. Direction of force: was there a blow from the side, a downward fall, or an inward or outward twist?
    3. Loading: was body weight on the limb, or did the movement occur without contact?
    4. Immediate response: was there a pop, deformity, rapid swelling, loss of strength, or an inability to keep walking or using the arm?

    You do not need to know anatomical terminology. A description such as “my foot stayed planted, my body turned to the left, my knee went inward and it became very swollen within an hour” is much more useful than the self-diagnosis “I tore a ligament”.

    How an orthopaedic surgeon uses the injury mechanism to select investigations

    After a high-energy injury, a direct blow, visible deformity or inability to bear weight, an X-ray often takes priority because it can quickly identify a fracture or dislocation. Ultrasound can show superficial tendons, muscles, selected ligaments, a haematoma and some forms of dynamic instability, but it does not replace radiography for assessing bone.

    MRI is useful when the clinical question concerns intra-articular structures, cartilage, bone marrow or a complex soft-tissue injury. It is not always the first test on the day of injury. Sometimes the first steps are to exclude a fracture, protect the limb and repeat the clinical examination after pain and swelling have settled.

    Examples that change the diagnostic reasoning

    Sudden acceleration or deceleration

    Sudden calf or posterior thigh pain during sprinting may suggest a musculotendinous injury. Useful details include whether the person felt as though they had been struck from behind, whether they could continue running and where bruising later appeared. A similar sensation around the heel may indicate an Achilles tendon injury and requires assessment of tendon continuity.

    Twisting on a weight-bearing leg

    Rapid joint swelling, a sense of instability and locking are important clues. Swelling that develops during the first few hours leads the diagnostic reasoning in a different direction from mild swelling that appears the following day. The patella, cruciate ligaments and meniscus can all be injured during events that sound superficially similar, so the mechanism alone cannot decide the diagnosis.

    Pain without one clear event

    The absence of a single injury event is also informative. Pain that gradually increases after a rise in running mileage, a new exercise programme or repetitive work more often suggests an overload problem. However, stress fractures and other conditions can occur without one clearly remembered moment of injury and must not be overlooked.

    Why can memory of the event be unreliable?

    An injury happens in a fraction of a second. Pain, stress and surprise mean that a patient may not remember the precise position of a joint. Video from a smartphone or sports camera can sometimes help, but it does not show everything either. A diagnosis therefore should not be forced to fit one detail of the story.

    The description of the event is considered together with the location of pain, swelling, range of motion, stability, strength, sensation and circulation. Agreement between several findings increases the probability of a particular injury.

    Mechanism must not delay urgent action

    Visible deformity, an open wound, an absent pulse, a pale or cold limb, increasing numbness, very severe pain out of proportion to the appearance of the injury, or inability to move the limb requires urgent assessment. In that situation, reconstructing the exact sequence of events is less important than protecting the limb and assessing its neurovascular status.

    Practical takeaway

    A clear description of the injury mechanism helps select the next step and reduces unnecessary “just in case” testing. The most useful information concerns limb position, direction of force, loading and the first symptoms. The mechanism is the starting point of diagnostic reasoning — its implications still need to agree with the clinical examination.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.