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Tomasz Poboży

Autor: Tomasz Poboży

  • Pertrochanteric Fracture — Intramedullary Nail or Primary Total Hip Arthroplasty?

    Polish version · Research Updates, Literature and Evidence-Based Medicine

    In older adults who had been mobile before injury, primary total hip arthroplasty did not accelerate functional recovery after a pertrochanteric fracture compared with a modern intramedullary nail. This was the finding of a small randomised trial published on 9 September 2026. Importantly, immediate full weight bearing was allowed in both groups.

    Why is this study interesting?

    Intramedullary nailing remains the standard treatment for pertrochanteric fractures. Advocates of primary arthroplasty have argued that, in an older patient, it may avoid the risk of fixation failure and facilitate early mobilisation. The trade-off is a more extensive operation, the need to reconstruct the trochanteric region and the risks inherent to joint replacement.

    French investigators compared these strategies in a group in whom the argument for arthroplasty might appear particularly persuasive: patients older than 70 years who had been able to walk outside the home before the fracture.

    Question and methods

    This was a prospective, single-centre, open-label randomised trial conducted from 2015 to 2017. Of 460 patients screened, 70 were randomly assigned to treatment and 69 were included in the analysis: 35 underwent intramedullary nailing and 34 underwent uncemented total hip arthroplasty with a dual-mobility cup and trochanteric stabilisation.

    The mean age was 84.7 years and 82.6% of participants were women. Eligibility required a pre-injury Parker Mobility Score of at least 5, indicating the ability to walk outside the home with or without assistance. Patients with dementia, severe cognitive impairment and pathological fractures were among those excluded. Immediate full weight bearing was permitted in both groups, and both groups followed the same rehabilitation programme.

    The primary endpoint was the Harris Hip Score at six months. The investigators also assessed function at six weeks and one year, pain, mobility, complications, operating time, mortality and subsequent reoperations. The analysis followed the original treatment allocation.

    Results

    • At six months, the mean Harris Hip Score was 85.7 after intramedullary nailing and 82.5 after arthroplasty; the difference was not statistically significant (p=0.291).
    • At six weeks, the scores were 70.4 and 69.7, respectively, and at 12 months 88.7 and 88.1, with no advantage for either strategy.
    • Pain, autonomy and the other functional measures were similar through one year. Function improved over time in both groups, but average mobility at one year had not fully returned to the pre-fracture level.
    • The median operating time was 30 minutes for nailing and 94 minutes for arthroplasty (p<0.001).
    • There was one early mechanical failure in the fixation group. In the arthroplasty group, one patient sustained both a dislocation and a deep infection requiring reoperation.
    • One-year mortality was 21.7% and did not differ between groups.
    • At a median follow-up of 4.1 years, 80% of the original cohort had died; there was no difference in survival. No patient underwent secondary conversion from fixation to arthroplasty.

    Clinical interpretation for an orthopaedic surgeon

    The study does not support the proposition that the additional burden of primary THA provides a functional advantage in an older person who had been mobile before injury. Particularly relevant is the fact that full weight bearing was also permitted after intramedullary nailing. In this protocol, the argument that arthroplasty is necessary mainly to allow immediate weight bearing was therefore not supported.

    The 3.2-point difference in Harris Hip Score at six months was not statistically significant and was also clearly below the closest available estimates of a minimal clinically important difference. Arthroplasty, meanwhile, required more than three times as long in the operating room.

    Limitations

    • The sample was small, and complete six-month functional data were available for 56 of 69 patients; missing results were mainly due to deaths.
    • The trial was not designed as a formal equivalence study. It shows no large clinical superiority of arthroplasty, but it does not prove that the two strategies are identical.
    • The population was highly selected: patients with dementia were excluded and pre-injury mobility had to be preserved. The result cannot be extrapolated to every patient with a hip fracture.
    • The fractures were AO/OTA A1–A2 patterns; the study does not settle management for every extremely unstable or unreconstructable fracture.
    • Uncemented femoral stems were used, reflecting the centre’s practice in 2015–2017. No cost analysis was performed.
    • Assessments were performed by treating clinicians, and surgeon experience differed between groups: arthroplasties were more often performed by more senior surgeons.
    • The long-term follow-up covered survival and major hip-related events, but not repeated functional measurements.

    What might this change in practice — and what does the study not show?

    The findings support retaining intramedullary nailing as a proportionate treatment for most pertrochanteric fractures in previously mobile older adults when stable fixation can be achieved and early weight bearing is possible. They do not provide a basis for routinely replacing nailing with primary THA solely because of age.

    The study does not show that arthroplasty has no role. A different strategy may be justified in unreconstructable destruction of the proximal femur, advanced pre-existing joint disease, a pathological fracture or as salvage after failed fixation — situations that this trial did not assess.

    Source

    Piercecchi A, Bordet A, Labattut L, Maczynski A, Baulot E, Martz P. Intramedullary nailing compared with primary total hip arthroplasty for pertrochanteric fractures in autonomous elderly patients: a prospective randomized study. Bone & Joint Open. 2026;7(9):1178–1186. Published 9 September 2026. DOI: 10.1302/2633-1462.79.BJO-2026-0142.R1. PubMed | open full text.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • What Does It Really Mean When Treatment Works?

    Polish version · For Patients

    Effective treatment does not always mean complete freedom from pain. In orthopaedics, success also includes restored function, the ability to perform activities that matter to the patient, durability of improvement, safety, and the burden or adverse effects required to achieve that benefit. A pain score is useful, but it is rarely enough on its own to judge an outcome fairly.

    Pain matters — but it is not the only outcome

    A reduction in pain from 8 to 4 may be transformative for one person if it allows them to sleep through the night and return to work. The same numerical change may be inadequate for someone who still cannot walk a few hundred metres or climb stairs safely. The number alone also says nothing about whether the improvement lasts an hour, a week or many months.

    It is therefore worth asking not only “how much does it hurt?”, but also “what does the pain stop you from doing?” and “what change would genuinely matter?”. That moves the discussion from an abstract scale to real-world function.

    Function shows whether improvement translates into daily life

    A meaningful result may be being able to put on socks, rise from a low chair, kneel, reach a shelf, return to walking or get through a working day comfortably. Two people with the same diagnosis can have very different goals, so there is no single universal test that captures every aspect of recovery.

    Assessing active and passive movement, strength, stability and gait helps determine whether limitation is driven mainly by pain, weakness, stiffness or a mechanical block. Related patient resources are collected in All Patient Resources.

    Imaging is not a stand-alone measure of success

    A tendon, cartilage surface or muscle may look different on ultrasound or MRI without changing at the same pace as symptoms. The reverse can also occur: pain improves even though follow-up imaging still describes an abnormality. If the aim of treatment is better function, treatment should not be labelled unsuccessful solely because the scan has not become “normal”.

    More information on choosing and interpreting investigations is available in the For Patients section.

    The cost of improvement matters too

    Two treatments may reduce pain to a similar degree but differ in complication risk, time away from work, medication requirements, rehabilitation burden and the likelihood of another procedure. The benefit therefore has to be weighed against the burden of treatment.

    The same principle applies to rapid improvement. A short-acting local anaesthetic can be useful diagnostically, but temporary pain relief is not proof of a lasting cure. Conversely, gradual progress without a dramatic day-to-day change may be valuable if it is stable and allows activity to increase safely.

    How can an orthopaedic surgeon and patient assess whether treatment is helping?

    • Before treatment begins, identify two or three activities that matter most to you.
    • Choose a simple measure: walking distance, sitting time, number of stairs, sleep quality or a specific movement.
    • Assess the result at an agreed time point rather than judging only the best or worst day.
    • Record adverse effects, medication use and any new limitations as well as improvement.
    • Do not increase load solely because a medication or injection has temporarily reduced pain.
    • If only one measurement improves, check whether that improvement produces a meaningful change in everyday function.

    A good decision starts with a good goal

    The most useful question is therefore not simply “has the pain gone?”, but “have we achieved a meaningful, durable and safe improvement?”. This framework makes it easier to compare rehabilitation, medication, injections and surgery, and helps avoid overvaluing a single test result or a short-lived effect.

    References

    1. World Health Organization. International Classification of Functioning, Disability and Health (ICF). WHO.
    2. Dworkin RH, Turk DC, Wyrwich KW, et al. Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. J Pain. 2008;9(2):105–121. DOI: 10.1016/j.jpain.2007.09.005. PubMed.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • SuperPATH Preserves the Quadratus Femoris — but Not One-Year Clinical Outcomes

    Polish version · Research Updates, Literature and Evidence-Based Medicine

    A randomized trial published online on 8 September 2026 found substantially less quadratus femoris damage on MRI after total hip arthroplasty performed through the SuperPATH approach than through a conventional posterolateral approach. At one year, however, this did not translate into superior pain or functional outcomes. The distinction matters: better preservation of soft tissue on imaging does not automatically mean a benefit that patients can feel.

    Why is this study interesting?

    Debate about whether a surgical approach is “minimally invasive” often centres on incision length, early postoperative pain or speed of mobilisation. The authors of this study in The Journal of Arthroplasty asked a more objective question: does SuperPATH actually preserve the muscles and tendons around the hip better when assessed by MRI 12 months after surgery?

    The study is particularly useful because it places an anatomical endpoint alongside clinical outcomes. That allows the MRI difference to be judged against what ultimately matters to the patient.

    Research question and methods

    Patients undergoing primary unilateral total hip arthroplasty were randomized to a SuperPATH approach — a superior capsular route with percutaneous introduction of part of the instrumentation — or to a posterolateral approach. The primary endpoint was the difference in quadratus femoris fatty infiltration on MRI at 12 months.

    The investigators also assessed atrophy and tendon continuity in other periarticular muscles, perioperative parameters, pain on a visual analogue scale and function using the Harris Hip Score. Eighty-two patients completed the full follow-up. The public abstract does not state how many patients were initially randomized or provide detailed information on the handling of missing data.

    Key results

    • At 12 months, there were no significant differences in fatty infiltration or atrophy of the piriformis, obturator internus or gluteus minimus.
    • Marked quadratus femoris fatty infiltration was reported in 7.3% of patients after SuperPATH versus 85.4% after the posterolateral approach; the difference was statistically significant.
    • SuperPATH was also associated with less quadratus femoris atrophy and more frequent preservation of tendon continuity: 100% versus 56.1%.
    • SuperPATH used a smaller incision but was associated with a longer operation and greater blood loss.
    • At one month, pain and functional scores favoured SuperPATH; by 12 months the groups no longer differed clinically.
    • Two early dislocations occurred in the posterolateral group.

    Clinical interpretation for an orthopaedic surgeon

    The trial provides a strong signal that the choice of approach can substantially affect the condition of a specific muscle as seen on MRI. At the same time, it demonstrates the limited value of a surrogate endpoint when considered in isolation: despite a striking imaging difference, patients had similar pain and function at one year.

    The better one-month results may matter for early recovery, but they do not show that SuperPATH produces a lasting functional advantage. The longer operating time and greater blood loss also illustrate why “minimally invasive” should not be interpreted as “better in every respect”.

    The two dislocations in one group are clinically relevant events, but this sample is far too small to establish a safety advantage. The trial was not presented as being powered to compare uncommon complications reliably.

    Limitations

    • The primary endpoint was an imaging outcome rather than an outcome directly experienced by the patient.
    • No clinical superiority was shown at one year, so the practical importance of the large MRI difference remains uncertain.
    • The public abstract does not provide the full participant flow, details of blinding for MRI assessment or the assumptions used for statistical power.
    • The study was conducted at a single hospital in China, limiting generalisability to other surgical teams and learning curves.
    • Twelve months is too short to assess the persistence of muscle differences, late dislocations, revision risk or implant survival.
    • The findings apply to the specific comparison of SuperPATH with a posterolateral approach, not to every tissue-sparing hip approach.

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

    The study supports more precise counselling about SuperPATH: there is evidence of better quadratus femoris preservation on MRI and a possible early recovery advantage. It does not justify describing SuperPATH as clinically superior at one year, nor does it support changing surgical technique independently of surgeon experience, patient anatomy and the wider perioperative pathway.

    Source

    Gan F, Zhang Q, Luo H, Li L, Zheng F, Lin X, Qin H. Magnetic Resonance Imaging Assessment of Muscle Damage After Postero-lateral Versus Supercapsular Percutaneously-Assisted Total Hip Approaches: A Randomized Controlled Trial. J Arthroplasty. Published online 8 September 2026. PMID: 42710744. DOI: 10.1016/j.arth.2026.08.056. PubMed record.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Deep Gluteal Syndrome — When Buttock Pain Mimics Sciatica

    Polish version · Explore Hip Conditions

    Deep gluteal syndrome can cause buttock pain that radiates into the back of the thigh, particularly when symptoms worsen with sitting. It refers to irritation or entrapment of the sciatic nerve outside the spine, within the deep tissues of the buttock. Not every case is “piriformis syndrome”, however, and diagnosis requires excluding more common causes arising from the lumbar spine, hip and pelvis.

    What is deep gluteal syndrome?

    The sciatic nerve leaves the pelvis and enters the lower limb through a space deep beneath the gluteal muscles. In this region it may be irritated by fibrous bands, abnormal muscle tension or anatomy, scar tissue after injury or surgery, a space-occupying lesion, or conflict between bony and soft-tissue structures.

    “Piriformis syndrome” describes only one possible mechanism. The broader term deep gluteal syndrome does not assume in advance which structure is responsible for the compression. This helps prevent the diagnostic process from being reduced to one muscle and one clinical test.

    What symptoms are typical?

    • deep, usually one-sided buttock pain;
    • radiation into the back of the thigh, sometimes farther down the leg;
    • worsening with prolonged sitting, especially on a hard surface;
    • pain during certain hip movements, running or walking uphill;
    • deep tenderness in the buttock;
    • sometimes tingling or altered sensation along the course of the sciatic nerve.

    In a systematic review of 14 studies involving 853 patients, recurring features included posterior hip pain, sciatica-like symptoms and difficulty sitting for about 30 minutes. None of these features, on its own, confirms the diagnosis.

    Could the symptoms be coming from the spine?

    The presentation can resemble lumbar radicular pain, so an important first step is to determine whether the sciatic nerve or its roots are being irritated by a disc lesion, spinal stenosis or another lumbar condition. Spinal causes are more often accompanied by low-back pain, radiation aggravated by coughing or sneezing, changes in reflexes, or weakness in specific muscle groups. These features are helpful, but none is an absolute rule.

    A similar pattern can also arise from the hip joint itself, the sacroiliac joint, the proximal hamstring origin, ischiofemoral impingement or other pelvic disorders. The overall pattern of symptoms and examination findings therefore matters more than any single test.

    More: hip conditions and causes of hip-region pain →

    How is deep gluteal syndrome diagnosed?

    History and clinical examination

    The examination considers where the pain is felt, its relationship to sitting and movement, hip range of motion, strength, sensation and reflexes. Provocative manoeuvres that tension or activate the deep hip rotators may be used, while the lumbar spine and other possible sources of pain are assessed as well. A positive provocative test can increase suspicion, but it should not determine the diagnosis by itself.

    X-ray, MRI and ultrasound

    X-rays can help assess the bones of the hip and pelvis. Lumbar MRI may be needed to look for disc disease or stenosis, while pelvic MRI can identify a lesion compressing the nerve, oedema, scar tissue or conflict within the deep gluteal space. A normal scan does not always exclude functional or intermittent nerve irritation.

    Ultrasound can show accessible portions of the sciatic nerve, selected muscles and fluid collections, and it allows side-to-side comparison. Its particular advantages are dynamic assessment and accurate guidance for a diagnostic injection. Depth of the structures and individual body habitus can limit the examination, however, so a normal ultrasound does not end the diagnostic process.

    EMG and diagnostic injection

    Nerve-conduction studies and electromyography can help distinguish a local problem from nerve-root injury or a more advanced neuropathy, but a normal result does not exclude local, position-dependent irritation. Temporary pain relief after a targeted image-guided injection can support a diagnostic hypothesis, but it does not replace a complete clinical assessment.

    How is deep gluteal syndrome treated?

    Treatment usually begins without surgery: reducing positions that reliably provoke symptoms, gradually adjusting load, physiotherapy directed at the hip, pelvis and spine, and appropriately selected neural-gliding exercises. Analgesic or anti-inflammatory medication should be matched to the patient’s health, risks and contraindications.

    An ultrasound-guided or otherwise image-guided injection may be considered when there is a specific anatomical hypothesis and the procedure is intended to answer a defined diagnostic or therapeutic question. It should not be performed blindly or repeated without assessing the response and reconsidering the diagnosis.

    More: injection treatments in orthopaedics →

    Surgery is rarely required. It may be considered when there is well-documented compression from a space-occupying lesion or persistent symptoms despite appropriately conducted non-operative treatment. A review of 13 studies involving 508 patients rated the overall quality of the evidence as low and did not show one conservative treatment to be clearly superior to the others.

    When is urgent assessment needed?

    Urgent medical assessment is needed for rapidly progressive leg weakness or foot drop, numbness in the saddle area, new bladder or bowel dysfunction, severe pain after injury with inability to bear weight, fever with worsening pain, or sudden signs of impaired circulation in the leg. These symptoms should not be attributed to the piriformis muscle without further assessment.

    Key point for an orthopaedic surgeon

    Deep gluteal syndrome is a possible, but not the most common, cause of buttock pain and sciatica-like symptoms. The diagnosis should emerge from agreement between the history, examination and appropriately selected investigations. Treatment usually begins conservatively, and a normal result from a single imaging study is not enough either to confirm or exclude the condition.

    References

    1. Kizaki K, Uchida S, Shanmugaraj A, et al. Deep gluteal syndrome is defined as a non-discogenic sciatic nerve disorder with entrapment in the deep gluteal space: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2020;28:3354–3364. DOI: 10.1007/s00167-020-05966-x. PubMed.
    2. Hopayian K, Mirzaei M, Shamsi MB, Arab-Zozani M. A systematic review of conservative and surgical treatments for deep gluteal syndrome. J Bodyw Mov Ther. 2023;36:244–250. DOI: 10.1016/j.jbmt.2022.12.003. PubMed.
    3. Park JW, Lee YK, Lee YJ, et al. Deep gluteal syndrome as a cause of posterior hip pain and sciatica-like pain. Bone Joint J. 2020;102-B:556–567. DOI: 10.1302/0301-620X.102B5.BJJ-2019-1212.R1. PubMed.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Stiff Elbow — Why Can’t It Fully Straighten?

    Loss of full elbow extension can result from pain and swelling after injury, capsular contracture, scar tissue, osteoarthritis, a loose body or a fracture that has healed in an abnormal position. If the restriction appears suddenly after trauma, the elbow should not be forcibly stretched before fracture, dislocation or a mechanical block has been excluded.

    What does a stiff elbow mean?

    The elbow allows the arm to bend and straighten and the forearm to rotate palm-up and palm-down. Even a relatively small loss of motion can interfere with eating, personal care, dressing, computer work or reaching the face. The functional effect therefore matters as much as the number of degrees lost.

    Some healthy people have a small, stable difference in extension between sides. New loss of motion, progressive restriction, pain, locking or functional decline is more concerning.

    Why might the elbow not fully straighten?

    Swelling and pain after a recent injury

    After a fall or direct blow, movement may be limited by a joint effusion, haematoma, bruising, fracture or dislocation. Inability to fully extend the elbow after trauma increases suspicion of an injury that may require imaging. The fact that the arm can still move does not exclude a fracture.

    Contracture after immobilisation or surgery

    The elbow is particularly prone to stiffness. After a fracture, dislocation or operation, the joint capsule may thicken and shorten and scar tissue may restrict tissue glide. Prolonged immobilisation increases the risk, although the timing of mobilisation must always respect the stability of repaired structures.

    A bony obstacle or loose fragment

    Osteophytes from osteoarthritis, malunited fracture, heterotopic ossification, a prominent implant or a loose body within the joint can create a mechanical block. A hard end point, intermittent locking or pain at the end of the range can be clues.

    Tendons, nerves and inflammation

    Pain at the back of the elbow may arise from the olecranon bursa or triceps tendon, while anterior symptoms may involve the biceps. Inflammatory disease or joint infection can also cause painful restriction. Ulnar-nerve irritation more often causes numbness in the little and ring fingers, but it may coexist with post-traumatic stiffness.

    How does an orthopaedic surgeon investigate the cause?

    The examination compares both sides, measures flexion and extension, assesses forearm rotation and determines whether active motion, passive motion or both are restricted. Stability, strength, sensation and hand circulation are also checked, together with the shoulder and wrist when appropriate.

    X-ray

    X-ray is usually the first imaging test after trauma and when a bony cause is suspected. It may show fracture, dislocation, osteoarthritis, heterotopic ossification, loose fragments or abnormal implant position.

    CT, MRI and ultrasound

    CT shows bony obstacles in greater detail and can be useful for operative planning. MRI is used selectively when cartilage, ligaments or other soft tissues are important. Ultrasound can assess selected tendons, bursae, fluid collections and nerves, but it does not replace X-ray or CT when the problem is an intra-articular bony block.

    How is loss of extension treated?

    Treatment depends on the cause and how long the restriction has been present. After a recent injury, the damaged structure is protected first. Once the joint is stable and there is no contraindication, appropriately timed controlled movement can help reduce the risk of contracture. Forceful self-stretching through severe pain or abrupt manipulation should be avoided.

    For chronic stiffness, physiotherapy and individually selected static-progressive or dynamic bracing may be used to increase motion gradually. A review in EFORT Open Reviews notes that improvement with bracing can continue over 6–12 months, so the absence of a rapid response does not automatically mean that surgery is required.

    Surgery may be considered when established stiffness clearly limits function despite appropriately conducted non-operative treatment, or when a mechanical obstacle is present. Release can be arthroscopic or open; the choice depends on the location of the contracture, bony changes, previous surgery and the course of nearby nerves. A difference of only a few degrees without meaningful symptoms is not in itself an indication for surgery.

    When is urgent assessment needed?

    • visible deformity after injury or sudden loss of motion;
    • severe pain with rapidly increasing swelling;
    • a hand that becomes cold, pale or blue;
    • increasing numbness or weakness;
    • a hot, red joint with fever;
    • a draining wound or possible open fracture;
    • true locking that prevents even gentle movement of the joint.

    The key point

    Loss of elbow extension is a symptom, not a single diagnosis. After a recent injury, fracture or dislocation must be excluded; in chronic stiffness, soft-tissue contracture must be distinguished from a mechanical block. Only then can exercises, bracing or operative treatment be selected rationally.

    More patient information: Orthopaedic Conditions and Symptoms and For Patients.

    References

    1. Siemensma MF, van der Windt AE, van Es EM, Colaris JW, Eygendaal D. Management of the stiff elbow: a literature review. EFORT Open Rev. 2023;8(5):351–360. DOI: 10.1530/EOR-23-0039. PubMed.
    2. American Academy of Orthopaedic Surgeons. Osteoarthritis of the Elbow. OrthoInfo.
    3. Fan M, Xu F, Fei C et al. Post-traumatic elbow stiffness: etiology, risk factors and current treatments. Front Surg. 2025;12:1643326. DOI: 10.3389/fsurg.2025.1643326.

    Polish version

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Does an Orthopaedic Examination Go Beyond the Painful Area?

    The place where pain is felt is not always where it originates. That is why a good orthopaedic examination may include an adjacent joint, the spine, the course of a nerve and the way the whole limb functions — even when the patient points to one very specific painful spot.

    Pain can be referred

    A hip problem may be felt mainly in the groin or even at the knee. A cervical-spine disorder can cause shoulder and arm pain, while irritation of a lumbar nerve root may be experienced in the buttock or leg. Pressing on the painful area therefore does not by itself identify the structure responsible for the symptoms.

    A nerve may need to be assessed along its course

    Hand numbness can result from nerve compression at the wrist, elbow or higher up. Similarly, radiating pain into the leg may originate in the spine, pelvis or deep tissues of the buttock. The site of the strongest tingling does not always correspond to the level of nerve compression.

    This is why the examination may include sensation, strength in selected muscle groups, reflexes and provocative tests at several levels. Ultrasound of one short segment of a nerve can be useful, but it does not replace a broader neurological examination of the limb.

    An adjacent joint can change loading elsewhere

    Restricted ankle motion can change how the knee works during a squat. Hip stiffness can alter knee loading, while limited shoulder motion may force compensation through the scapula and spine. In such cases, the painful area may be a genuine problem but not necessarily the only factor that needs to be addressed.

    After an injury, more than one point must be checked

    The force of an injury does not stop at the boundary of a single joint. With a fracture or dislocation, the examination may also include the skin, circulation, sensation, finger or toe movement and the joints above and below the injured area. This helps avoid missing a second injury, nerve compression or impaired blood supply.

    Why should imaging follow the clinical examination?

    If the source of pain is assumed too early, it is possible to perform a very detailed scan of the wrong region. A knee MRI will not identify referred pain arising from the hip, and a shoulder ultrasound will not answer a question about cervical nerve-root compression. The clinical question should come first; X-ray, ultrasound, MRI, CT or nerve-conduction testing can then be selected to answer it.

    For a broader explanation of how different investigations are selected, see Diagnostic Tests.

    What is useful to tell the orthopaedic surgeon?

    • where the pain starts and where it travels;
    • whether there is numbness, tingling or weakness;
    • which movement or position reproduces the symptoms;
    • whether the spine or a neighbouring joint also hurts;
    • how the injury happened;
    • whether symptoms change with coughing, sitting, walking or neck movement;
    • which everyday activities have become difficult or impossible.

    The key point

    Examining beyond the painful spot does not mean ignoring the main complaint. It is a way of determining whether that point is the true source of the problem, the site of referred pain or one part of a broader chain of dysfunction. That distinction often determines which test and which treatment actually make sense.

    More patient information: For Patients.

    Polish version

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Hop Tests After ACL Reconstruction — Not Enough to Predict Reinjury

    Hop tests after anterior cruciate ligament reconstruction can help describe functional readiness, but they should not be used on their own to decide whether an athlete is ready for a safe return to sport. A meta-analysis of 43 studies involving 17,350 participants found only modest associations between selected hop-test results and actual return to sport, with limited value for predicting reinjury.

    Why is this study important?

    Single-leg hop tests and the limb symmetry index (LSI) are widely used after ACL reconstruction. LSI expresses performance of the operated limb as a percentage of the opposite limb, and a threshold of 90% is often treated as an important marker of readiness. The problem is that symmetry does not necessarily mean full recovery: both limbs may be deconditioned, while jump distance alone says little about landing quality, fatigue, deceleration or performance in an unpredictable sporting situation.

    The meta-analysis, published on 1 September 2026 in the Journal of Sports Science and Medicine, examined whether hop-test performance is actually associated with return to sport and subsequent ACL injury.

    Question and methodology

    The authors searched PubMed, MEDLINE, SPORTDiscus and Web of Science. Eligible studies included patients after primary unilateral ACL reconstruction who had undergone hop testing and for whom return-to-sport or reinjury outcomes were reported. Risk of bias was assessed with a modified Newcastle–Ottawa Scale and certainty of evidence with a modified GRADE approach.

    Forty-three studies with 17,350 participants were included. Twenty-four analysed return to sport and 21 analysed reinjury; some studies reported both outcomes.

    Key findings

    • Achieving an LSI of at least 90% on the single-leg hop for distance was associated with a slightly greater likelihood of return to sport: OR 1.20; 95% CI 1.09–1.33.
    • For the triple crossover hop, the association with return to sport was similarly modest: OR 1.18; 95% CI 1.02–1.36.
    • For the triple hop for distance, an LSI of at least 90% was paradoxically associated with a slightly higher odds of reinjury: OR 1.05; 95% CI 1.01–1.09.
    • The association between the single-leg hop and return to sport was stronger in studies in which more than 90% of reconstructions used hamstring-tendon grafts and in patients without meniscal injury.
    • The overall certainty of evidence was rated as low.

    Clinical interpretation for an orthopaedic surgeon

    The main message is not that a 90% threshold has been validated as a universal cut-off, but that its limitations are substantial. Patients with good symmetry on selected hop tests were somewhat more likely to return to sport, but the effect was small. Returning to activity is also not the same as returning safely: the decision is influenced by the athlete’s goals, sport demands, access to training and advice from the treating team.

    The apparently paradoxical association between a good triple-hop result and slightly greater reinjury odds does not show that better-performing patients are rehabilitated poorly. A more plausible explanation is that those who perform better are more likely to return to sporting exposure, creating more opportunities for another injury. These observational associations cannot establish causation.

    Limitations

    • Studies differed in the timing of testing, definitions of return to sport, activity levels and methods used to define reinjury.
    • LSI compares the operated limb with the opposite leg, which may itself have become weaker after months of reduced activity.
    • Hop distance does not describe lower-limb alignment, trunk control, deceleration quality or performance under fatigue.
    • The analyses cannot separate physical readiness from the amount of subsequent exposure to training and competition.
    • Low certainty of evidence limits the ability to define a universal decision threshold.

    What could this change in practice?

    Hop tests remain useful, but they should form part of a broader return-to-sport assessment that includes strength, movement and landing quality, fatigue tolerance, stability, psychological readiness, time from surgery and the demands of the specific sport. It is also useful to examine the absolute performance of both limbs rather than symmetry alone.

    The study does not show that hop tests are unnecessary. It shows that passing a single threshold is not an insurance policy against reinjury and should not automatically trigger unrestricted training.

    Related resources

    Full rehabilitation protocol after primary, isolated ACL reconstruction →

    For broader clinical evidence appraisal and rehabilitation decision-making, see Research Updates, Literature and Evidence-Based Medicine.

    Source

    Liu Y, Sun Y, Cao M et al. Hop Test Performance is Associated with Return-to-Sport but Shows Limited Association with Reinjury after Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis. J Sports Sci Med. 2026;25(3):772–806. Published 1 September 2026. PMID: 42713242. DOI: 10.52082/jssm.2026.772. PubMed. Full text.

    Polish version

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Is Musculoskeletal Ultrasound Performed During Movement?

    One of the major advantages of musculoskeletal ultrasound is the ability to observe tissues while they move. A tendon, nerve or part of a joint may look normal at rest but move abnormally, impinge on a neighbouring structure or reproduce a characteristic snap only in a specific position.

    Polish version · For Patients

    A static image answers only part of the question

    MRI and CT provide extensive anatomical information, but they usually show the body in a fixed position. Ultrasound can be performed while the patient or examiner moves the joint. This means the examination can assess not only how a structure looks, but also how it behaves.

    The movement should not be arbitrary. It should be chosen from the history and clinical examination to reproduce the position in which pain, clicking, locking or snapping occurs. Dynamic imaging is most useful when it answers a specific clinical question.

    What can dynamic ultrasound reveal?

    Tendon movement

    During movement, ultrasound can assess structures such as the long head of the biceps tendon in the bicipital groove and the peroneal tendons behind the lateral malleolus. A brief subluxation may not be visible while the joint is held still.

    A snapping nerve

    The ulnar nerve may appear stable with the elbow extended but move over the medial epicondyle during flexion. Ultrasound can show the exact moment of displacement and help determine whether it corresponds to the patient’s snapping sensation. Movement alone is not necessarily abnormal; it has to be interpreted together with symptoms and the condition of the nerve.

    Impingement during a specific movement

    In selected situations, ultrasound can show the behaviour of tissues beneath the acromion, hand tendons, the iliotibial band or structures responsible for snapping around the hip. The image may help explain a mechanical phenomenon, but it should not be interpreted without considering pain and function.

    What does the dynamic part of the examination look like?

    The anatomy is first assessed at rest. The probe is then kept over the structure of interest while the patient performs a defined movement, sometimes slowly and sometimes against gentle resistance. The manoeuvre can be repeated from another angle or compared with the other side, remembering that asymmetry does not automatically mean pathology.

    Why is “it snapped on ultrasound” not enough?

    Some tendons and nerves move or sublux even in people without pain. Conversely, significant symptoms can arise from structures that ultrasound cannot assess sufficiently well. The finding therefore has to be integrated with the exact location of symptoms, injury mechanism, clinical tests and, when appropriate, X-ray, MRI or CT.

    Probe position, movement speed, muscle tension and examiner experience also affect the assessment. An overly forceful manoeuvre can unnecessarily increase pain, while the wrong movement may fail to reproduce the problem.

    When is dynamic assessment particularly useful?

    • when clicking or snapping occurs only in a specific position;
    • when intermittent tendon or nerve subluxation is suspected;
    • when symptoms change with muscle contraction;
    • when the aim is to distinguish smooth tissue gliding from mechanical conflict;
    • when a static image does not explain a reproducible symptom.

    Key point for an orthopaedic surgeon

    Dynamic ultrasound is not a separate “better test”. It is a way of using ultrasound to answer a question about tissue behaviour. Its greatest value comes when the movement is selected to reproduce the symptom and the observed mechanism fits the clinical examination.

    References

    1. American College of Radiology, American Institute of Ultrasound in Medicine and collaborating societies. Practice Parameter for the Performance of a Musculoskeletal Ultrasound Examination. ACR–AIUM practice parameter.
    2. Fodor D, et al. The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound – Part I: Extraarticular Pathologies. Ultraschall in der Medizin. 2022.
    3. Pan G, et al. Current status of dynamic musculoskeletal ultrasound for evaluation of extra-articular and intra-articular pathologies. 2024. Full text.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Ultrasound After Rotator Cuff Repair — Can It Guide Rehabilitation?

    Can ultrasound and elastography replace the calendar as the main guide for rehabilitation progression after rotator cuff repair? A recent systematic review found interesting associations between ultrasound-derived measures and tendon healing, function and return to activity. It also shows how far the field remains from validated decision thresholds that are ready for routine clinical use.

    Polish version · For Doctors and Physiotherapists

    Why is this study interesting?

    Rehabilitation after rotator cuff repair has to balance protection of the repair with gradual restoration of motion and strength. Protocols based only on time do not account for tendon quality, tear size or individual healing rates. Ultrasound is repeatable, dynamic and widely accessible, while shear-wave elastography can describe mechanical properties of tissue. The clinically relevant question is not simply whether an imaging measure correlates with outcome, but whether changing rehabilitation according to that measure improves patient outcomes.

    Question and methodology

    Shi, Bao and Li conducted a PRISMA-compliant systematic review with a protocol registered in PROSPERO. They searched PubMed and two Chinese databases, CNKI and Wanfang, for studies published from January 2020 through April 2026. Eligible studies involved patients after surgical rotator cuff repair and related grayscale ultrasound, Doppler or elastographic findings to rehabilitation decisions or functional outcomes.

    Eleven studies including 673 patients were synthesised: six prospective cohorts, three retrospective cohorts, one case series and one randomised trial. Individual studies included 39 to 95 patients. Nine of the eleven studies were therefore cohort studies, and most of the key inferences came from observed associations rather than direct comparisons of rehabilitation strategies.

    Main findings

    Shear-wave velocity in the tendon

    In normally healing supraspinatus tendons, shear-wave velocity, used as an indirect measure of stiffness, was approximately 6.2–6.3 m/s at one week, about 7.5 m/s at six months and 7.7–7.8 m/s at one year. This represented an increase of roughly 22–25% over 12 months.

    Higher early values were associated with a greater retear risk in one cohort. Tendon stiffness measured at 12 weeks was also correlated with later return to work or sport, with a reported correlation coefficient of 0.49. This is a moderate prognostic signal, not evidence that adjusting load according to that parameter improves outcomes.

    Muscle cross-sectional area and echogenicity

    Changes in muscle cross-sectional area and echogenicity were associated with shoulder function. In one study, correlations with the Constant score were 0.633 and 0.693 respectively. Confidence intervals were not reported, however, and these associations do not constitute validated criteria for starting active movement, increasing resistance or introducing electrical stimulation.

    Clinical interpretation for an orthopaedic surgeon

    The review supports the use of ultrasound as a tool for observing healing biology and for generating hypotheses about more individualised rehabilitation. It does not support a simple rule such as “the elastography value crossed a threshold, therefore loading can be increased”. The review itself acknowledges that quantitative thresholds remain limited and unvalidated.

    A value around 7.5 m/s at six months was presented as a potential reference point, but it depends on the ultrasound system, probe, measurement angle, tendon tension, limb position and protocol. It cannot be treated as a universal safety threshold.

    Limitations

    • only one of the 11 studies was randomised;
    • small samples, ranging from 39 to 95 patients, with 673 participants in total;
    • substantial heterogeneity in ultrasound techniques, time points and measured parameters;
    • no shared prospectively validated threshold for changing rehabilitation load;
    • some correlations were reported without confidence intervals;
    • the search was limited to three databases and English- and Chinese-language publications;
    • two reports by Maloof and colleagues each included 50 patients and may represent sequential analyses of the same or partly overlapping cohort;
    • the review did not directly compare imaging-guided rehabilitation with a well-conducted clinical rehabilitation protocol.

    What could change practice?

    At present, the most defensible use is systematic documentation of the repaired tendon and muscle parameters in centres with a reproducible protocol. An unusual appearance may prompt closer clinical review, reassessment of loading or additional imaging. It should not independently determine a return-to-sport date.

    A practice-changing study would need to randomise patients to a rehabilitation protocol modified according to standardised ultrasound measurements versus a protocol based on time, operative findings and functional assessment. Patient-important outcomes should include retear, pain, function, stiffness, return to work or sport and adverse events.

    What does the review not prove?

    It does not prove that elastography improves rehabilitation outcomes, that one shear-wave velocity is safe for every repaired tendon, or that a normal ultrasound can replace clinical examination. It also does not show that time-based protocols should be abandoned. The review is a useful map of a developing field, not a ready-made rehabilitation algorithm.

    Source

    Shi Y, Bao Y, Li C. Application of musculoskeletal ultrasound in postoperative rehabilitation assessment and monitoring after rotator cuff repair: a systematic review. PLoS One. 2026;21(9):e0357622. Published 8 September 2026. DOI: 10.1371/journal.pone.0357622. PubMed. Full text.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Scaphoid Fracture — Why Can the First X-Ray Be Normal?

    Thumb-side wrist pain after a fall can still represent a scaphoid fracture even when the first X-ray looks normal. If there is persistent tenderness in the anatomical snuffbox or over the scaphoid, the wrist should be protected and further imaging selected according to the clinical picture. Dismissing the injury too early as a simple bruise can delay treatment.

    Polish version · For Patients

    Where is the scaphoid?

    The scaphoid lies on the thumb side of the wrist and links the proximal and distal rows of carpal bones. It carries substantial load when the hand is used for support. The classic injury mechanism is a fall onto an outstretched hand, particularly with the wrist extended.

    Its blood supply is unusual: much of it enters distally and travels toward the proximal pole. Fractures closer to the forearm may therefore heal more slowly and carry a greater risk of nonunion or avascular necrosis than more distal fractures.

    Which symptoms raise suspicion?

    Typical features include pain and tenderness on the thumb side of the wrist, often worse with gripping, pushing through the hand or moving the wrist. Swelling may be modest and finger movement can remain normal. The absence of obvious deformity does not exclude a fracture.

    • pain in the anatomical snuffbox on the back of the wrist;
    • tenderness over the scaphoid tubercle on the palm side;
    • pain with axial loading of the thumb or strong gripping;
    • persistent symptoms after a fall despite an apparently normal first X-ray.

    Why can the first X-ray be normal?

    A fresh fracture line can be very fine, may run at an unfavourable angle to the X-ray beam or may be obscured by overlapping carpal bones. Dedicated scaphoid views improve detection, but even appropriate radiographs do not identify every acute fracture.

    If the examination still strongly suggests a scaphoid fracture, a normal radiology report should not automatically end the investigation. Immobilisation is often used while the diagnosis is clarified. Early MRI can reveal an occult fracture and other associated injuries, while CT is particularly good for defining the fracture line, displacement and subsequent union.

    How does an orthopaedic surgeon choose MRI, CT or repeat X-ray?

    MRI is highly sensitive for an acute occult scaphoid fracture and does not use ionising radiation. It can be especially useful when clear tenderness persists after injury but initial radiographs are normal.

    CT is particularly useful for fracture geometry. It can define displacement, instability and fragment position and is also useful when assessing union. Repeat radiographs after a period of immobilisation are still used in some pathways, but early MRI may confirm or exclude the injury sooner. The best test depends on availability, time since injury and the specific clinical question.

    How is a scaphoid fracture treated?

    Treatment depends on fracture location, displacement, stability, time since injury and the patient’s functional requirements. Stable, nondisplaced fractures of the distal scaphoid or waist can often be treated with immobilisation. Follow-up is still important because improvement in pain does not necessarily mean complete bony union.

    Surgery is considered more often for significant displacement, instability, proximal-pole fractures, delayed diagnosis, established nonunion or particular functional demands. Fixation commonly uses a compression screw. Surgery does not remove every healing risk and does not automatically allow an immediate return to sport or heavy manual work.

    What should be avoided while a fracture is still suspected?

    • do not repeatedly “test” the wrist with push-ups, weight-bearing or strong gripping;
    • do not remove prescribed immobilisation simply because the pain has improved;
    • do not treat a normal first X-ray as definitive exclusion of fracture when focal tenderness persists;
    • do not return to contact sport before safe healing has been confirmed.

    When is urgent assessment needed?

    Urgent assessment is needed for visible deformity, an open wound, rapidly increasing swelling, very severe pain, numbness or weakness of the fingers, or a hand that becomes pale, blue or cold. Increasing pain inside an immobilisation, a marked pressure sensation or worsening sensation also requires prompt review.

    Other causes of thumb-side wrist pain

    Pain in this area can also arise from ligament injury, a distal radius injury or tendon disorders. De Quervain tenosynovitis typically develops without a single acute fall and affects the first extensor compartment. Pain on the little-finger side of the wrist has a different differential diagnosis, including TFCC injury.

    References

    1. Clementson M, Björkman A, Thomsen NOB. Acute scaphoid fractures: guidelines for diagnosis and treatment. EFORT Open Reviews. 2020;5(2):96–103. DOI: 10.1302/2058-5241.5.190025.
    2. National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. NG38. Recommendations on imaging for suspected scaphoid fracture. NICE NG38.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.