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Tomasz Poboży

Autor: Tomasz Poboży

  • Tai Chi for Musculoskeletal Conditions — Where Is the Evidence Strong?

    Tai chi and other traditional Chinese exercise programmes have been studied across many musculoskeletal conditions, but a large number of publications does not automatically mean high-certainty evidence. A recent umbrella review brings together 92 meta-analyses and shows where the signal is relatively robust and where substantial uncertainty remains.

    Why is this study interesting?

    Research on tai chi, qigong, baduanjin and related exercise forms spans osteoarthritis, spinal pain, fibromyalgia, osteoporosis and other conditions. Individual meta-analyses often end on an optimistic note, but they vary in methodological quality, outcomes and comparators. An umbrella review takes a higher-level view by evaluating the existing meta-analyses rather than focusing on a single trial.

    The paper was published online on 17 August 2026 in the British Journal of Sports Medicine.

    Question and methods

    The authors asked how effective traditional Chinese exercise programmes are for musculoskeletal disorders and how certain the supporting evidence is. Databases were searched through 6 March 2026, and systematic reviews with meta-analyses of randomised trials were included.

    • 92 meta-analyses were included.
    • The review datasets collectively contained data from 1,744 randomised trials.
    • A total of 547 intervention-outcome associations were assessed.
    • Methodological quality of the reviews was assessed with AMSTAR 2, while certainty of evidence was graded using GRADE.

    The figure of 1,744 should not be interpreted as proof that all 1,744 trials were unique. In umbrella reviews, the same primary studies can appear in more than one meta-analysis, particularly when different outcomes or closely related interventions are assessed.

    Main results

    Sixty-five of the 92 meta-analyses, or 70.7%, were judged to have high methodological quality. The certainty of individual intervention-outcome associations was much more cautious:

    • high-certainty evidence was found for 23 of 547 associations, or 4.2%;
    • moderate-certainty evidence was found for 179 associations, or 32.7%;
    • the remaining findings were supported by low- or very-low-certainty evidence.

    Among the high-certainty findings was improvement in physical function in people with knee osteoarthritis. High-certainty evidence was also reported for selected mental-health outcomes in knee osteoarthritis and neck pain, and for sleep quality in fibromyalgia.

    This distinction matters. The review does not show that every traditional exercise programme improves every musculoskeletal symptom. It identifies a relatively small group of more reliable findings and a much larger body of evidence that still requires caution.

    Clinical interpretation for an orthopaedic surgeon

    The most practical finding concerns knee osteoarthritis. Tai chi can reasonably be considered one exercise option for patients who are comfortable with slower training involving weight transfer, postural control and coordination. It should not be presented as a separate treatment that “repairs cartilage”, but as one way of delivering exercise.

    Exercise selection should take into account safe standing ability, fall risk, comorbidities, pain severity and the likelihood of regular participation. For some patients, a simpler strengthening programme, lower-load exercise or individually supervised rehabilitation may be a better starting point.

    Limitations

    • An umbrella review inherits the limitations of the included meta-analyses and primary trials.
    • The interventions differed in style, intensity, duration, delivery and instructor experience.
    • Control groups ranged from no exercise to other active interventions, so effect sizes do not always answer the same clinical question.
    • Subjective outcomes are vulnerable to expectation effects, and full participant blinding is generally not feasible in exercise trials.
    • Overlap of primary studies across meta-analyses may make the apparent evidence base look larger than the number of unique trials.

    What might this change in practice?

    The review supports considering tai chi as a legitimate exercise option rather than dismissing it as an intervention without scientific support. The strongest practical argument concerns physical function in knee osteoarthritis. For other indications, patients should be told when certainty is only moderate, low or very low.

    What does the study not prove?

    • It does not prove that tai chi is superior to a well-designed strength, aerobic or neuromuscular programme.
    • It does not justify one universal exercise programme or dose for all conditions.
    • It does not show that every form of traditional exercise is effective for every type of musculoskeletal pain.
    • It does not replace assessment of red-flag symptoms or treatment that requires a different clinical approach.

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

    Source

    Chen WX et al. Efficacy and evidence certainty of traditional Chinese exercises for musculoskeletal disorders: an umbrella review of meta-analyses. Br J Sports Med. Published online 17 August 2026. DOI: 10.1136/bjsports-2026-111792. PubMed.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Does an Orthopaedic Surgeon Watch How You Walk?

    Walking is a brief functional test of the whole musculoskeletal system. In only a few steps, an examiner can see how pain, range of motion, muscle strength, balance and sensation work together under real load. That is why gait observation often begins before the formal examination on the couch.

    Gait shows function, not just the location of pain

    Examining one joint helps answer what is happening in a particular area. Watching someone walk shows how the body manages the entire task. A patient may have a good range of hip motion while lying down yet shorten the step, lean the trunk or avoid fully loading one leg while walking.

    Such adaptations may result from pain, weakness, stiffness, lack of confidence in the limb or a neurological problem. A gait pattern rarely establishes a diagnosis by itself, but it can direct the rest of the examination.

    What can be seen in a few steps?

    Protecting a painful limb

    When a leg hurts, people commonly spend less time standing on it. The steps become asymmetrical and the trunk may shift to reduce loading. This is an antalgic gait: it shows that the limb is being protected, but it does not identify the source of pain on its own.

    Restricted movement

    Stiffness of the hip, knee or ankle can alter step length and the way the foot moves through the gait cycle. The body may compensate through the pelvis, trunk or neighbouring joints. Sometimes the compensation itself contributes to pain elsewhere.

    Muscle weakness

    Weak hip abductors may appear as pelvic drop or a marked trunk lean. Weak ankle dorsiflexors may lead to exaggerated lifting of the knee so the toes clear the ground. These observations need confirmation with strength and neurological testing.

    Balance and control

    Straight-line walking is only one part of the assessment. Turning, stopping, stepping up and standing on one leg place different demands on the body. A problem may become evident only when direction changes or the base of support becomes smaller.

    Why does observation start before the examination couch?

    On the couch, body-weight loading largely disappears. That is useful for assessing movement, tenderness and stability in a controlled way, but it does not reproduce walking. The natural way a patient enters the room can provide information that is not always reproduced by asking someone to “walk normally” on command.

    Standing up from a chair, taking off a shoe or turning around can be equally informative. These are not hidden tests of the patient; they are ordinary tasks that show where a real functional difficulty appears.

    A gait pattern is not a diagnosis

    The same walking pattern can have different causes. Limping may occur with hip, knee or foot pain, after an injury, with a leg-length difference or in neurological disease. Conversely, some degenerative changes visible on imaging may have little effect on gait.

    Gait observation therefore needs to be combined with the history, joint examination, strength testing, sensation and reflexes and—when indicated—imaging. The most useful information comes from several findings pointing in the same direction, not from one striking sign.

    Do you need to prepare for gait assessment?

    Usually not. Comfortable clothing and the shoes you normally wear can be helpful. If the problem appears only in particular footwear, with an insole, after a longer distance or during running, mention it. A short video from the situation in which the symptom normally occurs can also be useful when the problem cannot be reproduced in the clinic.

    The key point

    Watching someone walk does not replace a full examination. It is, however, a quick way to see how the musculoskeletal system performs under load. It helps connect reported pain with real-world function and guides which areas should be examined more closely.

    Polish version · For Patients

    Source

    Pirker W, Katzenschlager R. Gait disorders in adults and the elderly: a clinical guide. Wien Klin Wochenschr. 2017;129:81–95. DOI: 10.1007/s00508-016-1096-4.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Bi-Unicompartmental Knee Arthroplasty — Do Patients Become More Active?

    Preserving both cruciate ligaments and more native bone did not translate into greater everyday physical activity after robotic bi-unicompartmental knee arthroplasty than after total knee arthroplasty. This secondary analysis of a randomised trial used accelerometers for up to two years. The result is clinically interesting, but the small sample does not establish equivalence between the procedures.

    Polish version · For Doctors and Physiotherapists

    Why is this study interesting?

    Bi-unicompartmental knee arthroplasty replaces the medial and lateral tibiofemoral compartments with two separate unicompartmental implants. It preserves the cruciate ligaments and more native structures than conventional total knee arthroplasty. Biomechanically, that is attractive, but the clinically relevant question is whether the patient actually walks more and becomes more active in everyday life.

    The study was published on 10 September 2026 in Bone & Joint Research.

    Question and methods

    This was an analysis of secondary outcomes from the TRUCK randomised trial. Patients were allocated to manual total knee arthroplasty or robotic arm-assisted bi-unicompartmental knee arthroplasty. Sixty-nine participants had usable accelerometer data for this analysis: 38 after total knee arthroplasty and 31 after bi-unicompartmental arthroplasty.

    A triaxial accelerometer was worn on the operated thigh for seven days, with at least three valid recording days required for analysis. Measurements were obtained before surgery and at one and two years.

    • total activity-related energy expenditure;
    • time spent in moderate-to-vigorous physical activity;
    • time spent in light activity;
    • sedentary time;
    • the relationship between objectively measured activity and patient-reported outcome measures.

    The trial involved a selected population with disease in the medial and lateral compartments, preserved cruciate and collateral ligaments, no major deformity and no advanced patellofemoral disease.

    Results

    No statistically significant between-group differences were found in any objectively measured activity parameter at either one or two years. This included total activity energy expenditure, moderate-to-vigorous activity, light activity and sedentary time.

    At one year, the bi-unicompartmental group showed numerically greater total activity and somewhat more moderate-to-vigorous movement, but the differences were not statistically significant and were not maintained at two years.

    Preoperative activity was a stronger predictor of postoperative activity. Higher baseline energy expenditure and more moderate-to-vigorous activity were associated with greater activity after surgery.

    Both groups improved similarly on clinical questionnaires. However, the association between patient-reported outcomes and objectively measured movement was weak and inconsistent. A patient may therefore report substantial improvement in pain and function without becoming more active in daily life.

    Clinical interpretation for an orthopaedic surgeon

    Tissue preservation and more physiological knee kinematics do not guarantee a change in real-world behaviour. Postoperative activity is also shaped by habits, preoperative activity, body mass, comorbidities, patient goals, environment and rehabilitation.

    The study also illustrates why questionnaires and accelerometry should not be treated as interchangeable outcomes. Questionnaires assess symptoms and perceived capability; accelerometers record how much movement the patient actually undertakes. These tools answer different questions.

    Limitations

    • Physical activity was a secondary outcome, and the trial was not powered specifically to detect differences in these measures.
    • The sample was small and the number of valid recordings declined over time. At two years, accelerometer data were available for 24 patients after total knee arthroplasty and 15 after bi-unicompartmental arthroplasty.
    • Three valid days of recording were sufficient for analysis and may not capture full week-to-week variability.
    • The comparison was robotic bi-unicompartmental arthroplasty versus manual total knee arthroplasty, so the effects of implant strategy and robotic technology cannot be separated.
    • The findings apply to carefully selected patients with preserved ligaments and a specific pattern of osteoarthritis.

    What might change in practice?

    When counselling patients, greater everyday activity should not be promised simply because a procedure preserves the cruciate ligaments and more native knee structures. It may be more useful to define realistic activity goals before surgery and to plan rehabilitation not only around regaining the ability to walk, but also around progressively changing physical-activity behaviour.

    The study also supports complementing conventional clinical outcomes with real-world activity measures in trials of techniques that are intended to improve higher-level function.

    What does the study not prove?

    • It does not establish equivalence between the two operations; absence of statistical significance in a small, underpowered analysis is not evidence of identical effects.
    • It does not exclude differences in maximal performance, kinematics, gait speed or other outcomes that this analysis was not designed to assess reliably.
    • It does not justify broadening indications for bi-unicompartmental arthroplasty beyond patients who meet the trial criteria.
    • It cannot separate the effect of robotic assistance from the effect of preserving ligaments and reducing the extent of bone resection.

    Source

    Kanakala S et al. Effect of robotic arm-assisted bi-unicompartmental knee arthroplasty versus total knee arthroplasty on objectively measured physical activity: secondary outcomes of a randomized controlled trial. Bone Joint Res. 2026;15(9):1136–1146. DOI: 10.1302/2046-3758.159.BJR-2026-0018.R1. PubMed.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Does an Orthopaedic Surgeon Ask Whether Pain Wakes You at Night?

    Night pain is clinically useful information, but it is not a diagnosis and it does not automatically indicate serious disease. What matters is whether pain appears only in a particular position, genuinely wakes the patient from sleep, improves after changing position or moving, and whether other symptoms are present.

    Polish version · For Patients

    “It hurts at night” can describe very different situations

    One person develops pain only when lying on the affected shoulder or hip. Another falls asleep normally but is woken several hours later by steadily increasing pain that is unrelated to position. A third sleeps poorly because each turn in bed provokes pain in a recently operated joint. These patterns are not equivalent.

    For that reason, asking about night pain is the beginning of the assessment rather than the end. It is useful to establish when the pain appears, whether it depends on position, how it responds to movement, and whether similar symptoms occur during the day.

    Position can increase pressure on sensitive tissues

    Side-lying may compress tissues over the lateral hip or a painful shoulder. Remaining in one position for a long time can also increase joint stiffness. If pain eases quickly after changing position, supporting the limb or briefly moving the joint, that is a useful mechanical clue.

    For example, shoulder pain at night is common in rotator cuff disorders, subacromial bursitis and frozen shoulder, but night pain alone does not distinguish among them.

    There are fewer competing stimuli at night

    During the day, attention is occupied by movement, work and the environment. In a quiet setting, bodily signals can become more noticeable. This does not make the pain “imaginary”; pain processing genuinely changes with sleep, stress and context.

    The relationship also works in the opposite direction. Pain disrupts sleep, while poor sleep can increase pain sensitivity the following day. This can create a self-reinforcing cycle that cannot be understood simply by treating an MRI finding.

    What details about night pain matter most?

    • whether pain occurs only in a specific position;
    • whether it wakes the patient despite a comfortable position;
    • whether it improves after moving, standing up or changing position;
    • whether it is progressively worsening from week to week;
    • whether fever, night sweats, weight loss or systemic illness are present;
    • whether there is swelling, redness, a new deformity, numbness or weakness;
    • whether there is a history of cancer, recent trauma, surgery or infection.

    When does night pain lower the threshold for further investigation?

    A new, persistent and progressive pain that is independent of position or movement, genuinely interrupts sleep and is accompanied by systemic symptoms, marked weakness or an abnormal clinical examination deserves particular attention. In that setting, the threshold for further investigation should be lower.

    By contrast, a painful shoulder that hurts when the patient lies directly on it is not the same clinical signal as rapidly worsening rest pain associated with fever. The meaning comes from the entire pattern.

    Is MRI needed straight away?

    Not always. The appropriate test depends on the anatomical region and the suspected cause. In some conditions the first investigation may be an X-ray; in others it may be ultrasound, blood tests or MRI. Imaging should answer a clinical question rather than replace the history and examination.

    How can a patient prepare this information for a consultation?

    For several days it can help to note the time at which pain appears, the sleeping position, how many times it causes waking, what relieves it and how the joint feels in the morning. This is often more useful than the general statement “it hurts at night”.

    Key point

    Asking about night pain helps distinguish position- and load-related symptoms from rest pain that may require broader assessment. It should never be interpreted in isolation. The pattern, progression and consistency with the clinical examination matter most.

    Reference

    Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain. 2013;14(12):1539–1552. DOI: 10.1016/j.jpain.2013.08.007.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Pain at the Back of the Knee — Could the Semimembranosus Tendon Be the Cause?

    Posteromedial knee pain can come from the distal semimembranosus tendon, but Baker’s cyst, meniscal disease, osteoarthritis and vascular problems can produce a similar pattern. Diagnosis depends on the exact location of pain, the clinical examination and, when appropriate, ultrasound or MRI.

    Polish version · For Patients

    Where is the semimembranosus tendon?

    The semimembranosus is one of the hamstring muscles. Its tendon runs along the posteromedial aspect of the knee and inserts on the upper tibia. It contributes to knee flexion and helps control the limb during walking, running, deceleration and movement on slopes.

    This area also contains bursae, the posterior horn of the medial meniscus, ligaments and vascular structures. For that reason, “pain behind the knee” is a symptom description rather than a diagnosis.

    What does semimembranosus tendinopathy usually feel like?

    • pain at the back and inner side of the knee that can often be localised with one finger;
    • tenderness along the distal tendon or near its tibial insertion;
    • worsening with running, uphill walking, acceleration or deep knee flexion;
    • pain with resisted hamstring contraction or loaded hamstring lengthening;
    • sometimes stiffness after rest that eases with movement but returns after heavier activity.

    Chronic tendinopathy usually develops gradually. A sudden pop, bruising and clear loss of strength are more suggestive of an acute muscle-tendon injury and require a different assessment.

    What else can cause pain behind the knee?

    Baker’s cyst

    A Baker’s cyst is a fluid-filled structure connected with the knee joint. It may cause pressure, tightness or a palpable swelling in the popliteal fossa. It is often a consequence of an intra-articular problem rather than a separate disease.

    Meniscus and cartilage

    A lesion of the posterior horn of the medial meniscus or degenerative joint disease can cause pain with deep squatting, twisting or rising from a chair. Locking, recurrent effusion or a clear loss of extension point the assessment towards intra-articular pathology.

    Other tendons and muscles

    Pain may arise from the gastrocnemius, popliteus or other hamstring structures, including after an acute injury. The clinical pattern and mechanism help separate these conditions from chronic semimembranosus tendinopathy.

    Deep vein thrombosis

    Unilateral calf swelling, warmth, pain or a sudden increase in calf circumference should not be attributed to a tendon problem without proper assessment. Suspected deep vein thrombosis requires urgent evaluation with an appropriate vascular pathway; this is not the same examination as routine musculoskeletal ultrasound.

    What does the clinical examination involve?

    The examination includes precise localisation of tenderness, range of motion, effusion, knee stability, meniscal testing and muscle strength. The clinician also checks whether symptoms can be reproduced with resisted knee flexion and other movements that load the hamstrings.

    In a real-world ultrasound study of 667 adults with lower-limb pain co-authored by Tomasz Poboży, abnormalities at the semimembranosus insertion were identified in 19 patients. This was not a population prevalence study—the participants had been referred for ultrasound—but it confirms that this structure is a genuine and visible potential pain source.

    When is ultrasound useful?

    Ultrasound can demonstrate tendon thickening, altered echotexture, insertional changes, fluid in a neighbouring bursa and a Baker’s cyst. It also allows the imaging finding to be matched to the exact site of symptoms and compared with the opposite side. As with all tendon imaging, structural change does not automatically mean that the abnormality is the cause of pain.

    Musculoskeletal ultrasound does not replace venous Doppler ultrasound when thrombosis is suspected, and it does not survey the intra-articular structures as comprehensively as MRI.

    When is MRI appropriate?

    MRI may be useful when the source of pain remains unclear, when a meniscal, cartilage, bone or deeper soft-tissue lesion is suspected, or when symptoms fail to improve despite appropriately managed treatment. MRI is not automatically the first investigation for every suspected tendinopathy.

    How is it treated?

    Treatment usually starts without surgery. The main task is to reduce the loading pattern that keeps provoking symptoms while progressively rebuilding the tendon’s capacity to tolerate work.

    • temporarily reduce the movements that most strongly provoke pain without stopping all activity;
    • progressively strengthen the hamstrings and the rest of the lower limb;
    • work on hip, knee and trunk control;
    • gradually reintroduce running, hills and changes of pace;
    • choose pain treatment in the context of comorbidities and current medication.

    Progress is judged by function and by the next-day response. Mild, short-lived discomfort during rehabilitation may be acceptable, whereas a clear increase in symptoms lasting into the next day usually means that the loading dose was too high.

    Are injections or surgery needed?

    Evidence for injections in this specific condition is limited. If the pain is shown to arise from an adjacent bursa rather than the tendon itself, a targeted ultrasound-guided procedure may be considered in selected cases. An intratendinous injection should not be performed simply because imaging describes tendon change.

    Surgery is rarely required and is generally reserved for persistent symptoms with a well-supported diagnosis after a substantial course of appropriate non-operative care. The surgical literature is based largely on small case series.

    Red flags

    • sudden calf swelling, warmth and pain, particularly after surgery, immobilisation or a long journey;
    • shortness of breath, chest pain or coughing up blood;
    • a sudden pop, major bruising and loss of strength after injury;
    • a hot, red knee with fever or systemic illness;
    • a locked knee or inability to regain extension;
    • a cold, pale or blue foot, progressive numbness or weakness.

    Key point for an orthopaedic surgeon

    The semimembranosus tendon is one possible cause of posterior knee pain, especially when tenderness is medial and symptoms increase with hamstring loading. The diagnosis should not be made from the location of pain alone. Intra-articular disease, Baker’s cyst and vascular causes must be considered when the clinical pattern suggests them.

    References

    • Poboży T, Janowski K, Domański P, Michalak K, Poboży K, Domańska-Poboża J, Konarski W, Chuść I, Kielar M. The Hidden Burden of Entheseal Pathology in Lower-Limb Pain: A Real-World Ultrasound Study of 667 Adults. Mayo Clin Proc Innov Qual Outcomes. 2026;10(4):100734. DOI: 10.1016/j.mayocpiqo.2026.100734.
    • Bylund WE, de Weber K. Semimembranosus tendinopathy: one cause of chronic posteromedial knee pain. Sports Health. 2010;2(5):380–384. DOI: 10.1177/1941738109357302.

    This material is educational. Identifying the cause of posterior knee pain requires the symptoms, clinical examination and appropriately selected imaging to be considered together.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • High-Intensity Laser Therapy for Knee Osteoarthritis — Large Effect, Important Caveats

    The trial is striking because of the size of the WOMAC difference, but it does not yet establish high-intensity laser therapy as standard treatment for knee osteoarthritis. The comparison was with therapeutic ultrasound, not with a sham procedure or exercise alone, which substantially limits what can be concluded.

    Why is this study interesting?

    Physical modalities are often added to exercise programmes for knee osteoarthritis even though the benefit of individual techniques remains uncertain. A randomised trial from Thailand, published on 8 September 2026, compared high-intensity laser therapy (HILT) with therapeutic ultrasound. The reported between-group difference was much larger than the authors’ prespecified estimate of a minimally important change, making the result clinically interesting—but also worth examining carefully in light of the study design.

    Question and methods

    The single-centre trial enrolled 66 adults with knee osteoarthritis. Participants were randomised 1:1 to HILT or therapeutic ultrasound. Both modalities were delivered as an adjunct to exercise twice weekly for six weeks. The outcome assessor was blinded to treatment allocation.

    The primary endpoint was change in the total WOMAC score 12 weeks after completion of treatment. The authors used 10 points as an approximate threshold for a minimally important change. Analysis followed the intention-to-treat principle. The trial was registered retrospectively, after recruitment had begun.

    Results

    Mean improvement in WOMAC was 40.0 points in the HILT group and 8.2 points in the therapeutic-ultrasound group. The adjusted between-group difference was −27.7 points (95% CI −39.0 to −16.5; p<0.001). Secondary analyses also favoured HILT for pain, function and quality of life, with the reported effect persisting up to 12 weeks after treatment ended.

    Clinical interpretation for an orthopaedic surgeon

    The magnitude of the difference is difficult to ignore, but the trial answers a narrower question than the headline might suggest: HILT plus exercise performed better than therapeutic ultrasound plus exercise. It does not show how much of the observed difference was due specifically to the laser, and how much may have reflected differences in expectations, treatment experience or a relatively weak response in the comparison group.

    It is also important that WOMAC and several other key outcomes were patient-reported. Blinding the outcome assessor does not remove the risk introduced when participants and therapists are likely to recognise which physical modality is being delivered.

    Limitations

    • small, single-centre sample;
    • short follow-up;
    • no sham-treatment group and no exercise-only group;
    • retrospective trial registration;
    • the minimally important change threshold was used as an approximation rather than a value validated specifically for this population and comparison;
    • secondary outcomes were exploratory;
    • a large effect from one centre requires independent replication.

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

    The study provides a credible preliminary signal that HILT may be a useful adjunct to exercise for some patients with knee osteoarthritis. It justifies a larger trial with sham treatment, longer follow-up and an economic evaluation. It does not prove superiority over exercise alone, a disease-modifying effect, or that routine funding of HILT is justified. It also does not identify which patients, if any, are most likely to benefit.

    Source

    Ninlerd C, Benjakulsap N, Amornsupak C, et al. Efficacy of high-intensity laser therapy versus ultrasound therapy in patients with knee osteoarthritis: a randomized controlled trial. Lasers Med Sci. 2026;41(1):219. DOI: 10.1007/s10103-026-05019-8. PubMed.

    Polish version · For Doctors and Physiotherapists

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Painful Surgical Scar — Could It Be a Neuroma?

    A sharply localised burning, stabbing or electric-shock-like pain in or next to a surgical scar can come from an irritated or trapped cutaneous nerve and, in some cases, from a painful neuroma. Not every tender scar is a neuroma, however. Normal healing, infection, implant-related problems, local tissue overload and complex regional pain syndrome must also be considered.

    What is a postoperative neuroma?

    When a nerve is cut or significantly injured, its fibres attempt to regenerate. If they cannot reconnect with the distal segment, a disorganised bulb of regenerating nerve tissue may form at the nerve end. This is a traumatic neuroma. Similar symptoms can also occur when a nerve remains anatomically continuous but becomes tethered in dense scar tissue or repeatedly irritated during movement.

    Which symptoms suggest neuropathic scar pain?

    • a very small, clearly defined point of maximal tenderness within or next to the scar;
    • burning, stabbing, shooting or electric-shock-like pain;
    • pain radiating along a nerve distribution when one specific point is pressed or tapped;
    • numbness, hypersensitivity or pain from light contact such as clothing;
    • symptoms aggravated by stretching the scar, moving the nearby joint, footwear or a brace pressing on the area.

    During the first weeks after surgery, local tenderness, a small patch of numb skin and altered sensation may improve gradually without additional treatment. A neuroma becomes more likely when the pain has a distinctly neuropathic quality, persists or worsens, and can be reproduced consistently by pressing one focal point.

    How is it investigated?

    What does an orthopaedic surgeon assess during examination?

    The scar itself is examined together with the distribution of sensory change, muscle strength and the expected course of the nerve. The clinician may also check whether tapping the painful point reproduces radiating symptoms. It is useful to know whether the nerve could have been cut, mobilised or placed at risk during the original operation.

    High-resolution nerve ultrasound

    High-resolution ultrasound can demonstrate focal nerve enlargement, loss of continuity, tethering to scar tissue and the relationship to tendons, implants or vessels. Dynamic examination may show whether movement stretches or displaces the symptomatic segment. A normal ultrasound does not completely exclude pain arising from a very small cutaneous nerve branch.

    Other tests

    MRI, including MR neurography in selected cases, may be helpful for deeper lesions. Nerve conduction studies and electromyography are more useful when pain is accompanied by muscle weakness or sensory loss in the territory of a larger peripheral nerve. A selective local anaesthetic injection can sometimes help test whether a particular nerve segment is generating the pain, but the result still needs to be interpreted in the context of the full examination.

    How are painful scars and neuromas treated?

    Treatment depends on the time since surgery, the severity of symptoms and whether the nerve is thought to be divided, tethered or temporarily irritated. Early management may include protecting the area from pressure, gradual desensitisation, scar mobility work and appropriate medical treatment for neuropathic pain. Aggressive massage directly over a very painful focal point before the diagnosis is clear can aggravate symptoms.

    Selected patients may benefit from diagnostic or therapeutic injections, sometimes performed under ultrasound guidance. Evidence for hydrodissection and other injection-based techniques remains limited, so these procedures should not replace an effort to identify the underlying pain mechanism.

    Surgery may be considered when pain is persistent, well localised, functionally important and has not improved with appropriate conservative treatment. Options include freeing a nerve from scar tissue, excising a neuroma and protecting or reconstructing the nerve end. The technique depends on the anatomy and on whether meaningful nerve continuity can be restored; no procedure guarantees complete relief.

    When is urgent assessment needed?

    Do not assume that worsening scar pain is a neuroma if the wound is hot, red or draining, if fever develops, swelling is increasing rapidly, or pain suddenly becomes much more severe. New or progressive muscle weakness, widespread numbness, a cold or pale limb, or severe pain associated with marked colour or temperature change and swelling of the whole region also require prompt assessment. Sudden neurological weakness should be investigated without delay.

    Key point

    A painful neuroma is one possible cause of persistent scar pain after surgery, but the diagnosis requires a consistent symptom pattern, clinical examination and—when appropriate—imaging or a diagnostic block. Treatment is most useful when it targets a specific mechanism rather than simply attempting to “break up” the scar.

    References

    1. Zhou L, Huo T, Zhang W, et al. New techniques and methods for prevention and treatment of symptomatic traumatic neuroma: a systematic review. Front Neurol. 2023;14:1086806. DOI: 10.3389/fneur.2023.1086806.
    2. Hendrickson NR, McDonald JR, Kennedy SA, et al. Treatment of Postsurgical Neuroma in Foot and Ankle Surgery. Foot Ankle Orthop. 2023;8(3). DOI: 10.1177/24730114231188125.
    3. Grimm A, Décard BF, Athanasopoulou I, et al. Nerve Ultrasound in Traumatic and Iatrogenic Peripheral Nerve Injury. Diagnostics. 2021;11(1):30. DOI: 10.3390/diagnostics11010030.

    Polish version · For Patients

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Does an Orthopaedic Examination Test Muscle Strength?

    Strength testing helps distinguish movement limited mainly by pain from weakness caused by tendon injury, nerve dysfunction or deconditioning after immobilisation. A single strength grade is not a diagnosis, but when it is interpreted together with range of motion, sensation and the pattern of symptoms, it can substantially narrow the differential diagnosis.

    It is not simply about how much weight you can lift

    During the examination, the clinician asks the patient to perform a specific movement and then gradually applies resistance. By positioning the limb carefully, selected muscle groups—and the tendons and nerves that support them—can be assessed. Failure to start a movement, normal movement without resistance, and a sudden painful “give-way” response all carry different clinical information.

    What can weakness mean?

    • Pain-inhibited movement: the muscle and nerve may be intact, but the patient cannot generate full effort because the movement hurts.
    • Tendon injury: the muscle contracts, but force is not transmitted normally to the bone.
    • Nerve injury or dysfunction: weakness often follows a recognisable anatomical pattern and may be accompanied by sensory change or altered reflexes.
    • Immobilisation and disuse: strength falls gradually when a limb has not been used normally, often without the sharp or electric quality of neuropathic pain.
    • A problem within the joint itself: pain and restricted motion can make a true strength assessment unreliable.

    For that reason, strength testing is interpreted alongside active and passive range of motion. If the examiner can move a joint farther than the patient can move it independently, the explanation may lie in pain, muscle function, tendon continuity or the nervous system rather than in fixed joint stiffness alone.

    Why does an orthopaedic surgeon compare both sides?

    “Normal” strength varies with age, body build, activity level, hand dominance and previous disease or surgery. The opposite limb therefore provides a useful practical reference, although it is not a perfect control because it may also be weak or previously injured. A consistent pattern across several movements is usually more informative than a small isolated side-to-side difference.

    The 0–5 scale and dynamometry

    In neurological examination, the Medical Research Council scale from 0 to 5 is commonly used, ranging from no visible muscle contraction to movement against substantial resistance. It is a practical ordinal scale rather than a precise force measurement. When subtle differences matter—for example during rehabilitation monitoring or athletic assessment—a handheld dynamometer may provide a more reproducible measurement, provided the testing position and method are standardised.

    Why does one weak test not establish the diagnosis?

    Strength testing is influenced by pain, fear of movement, fatigue, understanding of the instruction and the examiner’s own force. Manual testing is also less sensitive to small deficits in very strong patients. The result therefore needs to fit the history and the rest of the examination and, where appropriate, be supported by ultrasound, X-ray, MRI or nerve conduction studies.

    When does weakness need prompt assessment?

    Sudden loss of strength after an injury, inability to lift the foot or toes, a new wrist drop, rapidly progressive numbness, or weakness accompanied by a cold and pale limb requires prompt assessment. These patterns can indicate significant tendon, nerve or vascular injury and should not simply be observed for weeks without a diagnosis.

    References

    1. Medical Research Council. Aids to the Examination of the Peripheral Nervous System. Memorandum No. 45. London: Her Majesty’s Stationery Office; 1976.
    2. Bohannon RW. Manual muscle testing: does it meet the standards of an adequate screening test? Clin Rehabil. 2005;19(6):662–667. DOI: 10.1191/0269215505cr873oa.

    Polish version · For Patients

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Open Tibial Fracture — Two or Three Days of Antibiotics?

    Does a third day of prophylactic antibiotics reduce infection after severe open tibial fractures compared with two days? The PROACT trial did not show such a benefit. It also does not establish that the two regimens are equivalent, because the confidence intervals remain wide.

    Why is this study clinically interesting?

    The duration of antibiotic prophylaxis in open fractures remains debated. A regimen that is too short raises concern about infection, whereas unnecessary extension increases exposure to adverse effects and antimicrobial selection pressure. In Gustilo-Anderson IIIA and IIIB open tibial fractures, this question is particularly relevant because the soft-tissue injury is extensive and the baseline risk of infection is substantial.

    PROACT was a pragmatic randomised trial conducted in a centre with integrated orthopaedic and reconstructive care. It did not compare antibiotics with no antibiotics. Instead, it tested two closely related durations: 48 versus 72 hours.

    Question and methods

    Adults with Gustilo-Anderson type IIIA or IIIB open tibial fractures were eligible. Of 241 patients assessed for initial eligibility, 204 were randomised 1:1 to either two or three days of intravenous cefuroxime and amikacin prophylaxis. Metronidazole was added when contamination was related to agricultural exposure.

    The two-day group included 104 patients and the three-day group 100. All were analysed according to their original allocation. Outcome assessors were unaware of treatment allocation, whereas the nature of the intervention did not allow full blinding of the treating team. Orthoplastic care was standardised.

    The primary endpoint was surgical-site infection within 90 days. Secondary outcomes included unplanned reoperation within one year and secondary amputation.

    Results

    • Infection within 90 days occurred in 15 of 104 patients after the two-day regimen (14%) and in 18 of 100 after the three-day regimen (18%).
    • The risk difference was −3.6 percentage points, with a 95% confidence interval from −14.0 to 7.0 percentage points; p=0.60.
    • Time-to-infection analysis likewise showed no statistically significant difference: HR 1.22; 95% CI 0.60–2.46.
    • Unplanned reoperation within 12 months occurred in 24 of 104 patients in the two-day group (23%) and 19 of 100 in the three-day group (19%).
    • Each group had one secondary amputation because of failure of soft-tissue coverage.

    Clinical interpretation for an orthopaedic surgeon

    The most defensible conclusion is that in this centre, extending prophylaxis from two to three days was not shown to reduce infections. This is an important signal against routinely adding another day simply “to be safe”.

    However, a non-significant result must not be converted into proof of equivalence. The confidence interval remains compatible with clinically relevant effects in either direction. The trial also answers a narrow question: one additional day within a specific antibiotic protocol and within a well-organised orthoplastic pathway.

    Limitations

    • The study was single-centre and conducted in India, so care pathways, infection epidemiology and antimicrobial susceptibility may differ in other healthcare systems.
    • The sample was too small to exclude clinically important differences with high precision.
    • Only 48 and 72 hours of one antibiotic regimen were compared; the findings cannot be extrapolated to other agents or very short prophylaxis.
    • Only IIIA and IIIB fractures were included. The trial does not resolve management in IIIC injuries, other anatomical sites, delayed presentation or unusual contamination.
    • It does not replace decisions about rapid administration of the first antibiotic dose, radical debridement, fracture stabilisation and timely soft-tissue coverage.

    What could this change in practice?

    PROACT supports re-examining protocols in which a third day of prophylaxis is added automatically despite adequate debridement and standardised care. It does not justify independently shortening treatment outside local protocols. A larger multicentre trial, ideally designed to assess non-inferiority or equivalence of the shorter regimen, is still needed.

    The study does not show that antibiotics can compensate for inadequate surgical debridement, nor that prophylactic dosing is sufficient once infection has developed. It also does not answer whether an even shorter regimen would be safe.

    Source

    Devendra A, Imran A, Irfan Pc M, et al. Two-day versus three-day systemic antibiotic prophylaxis for Gustilo-Anderson type IIIA and IIIB open tibial fractures (PROACT): a randomised controlled trial. Lancet Regional Health – Southeast Asia. 2026;53:100830. DOI: 10.1016/j.lansea.2026.100830. PubMed.

    Polish version · More research updates for doctors

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Stairs After Surgery — How to Go Up and Down Safely

    After many lower-limb operations, stairs can be used, but the technique depends first of all on how much weight is allowed through the operated leg. Early on, patients usually use a step-to pattern while holding a handrail and a crutch. The safest approach is to practise the technique with a physiotherapist or ward staff before attempting stairs independently.

    First check the weight-bearing instructions from your orthopaedic surgeon

    “After surgery” covers very different situations. After some procedures, weight bearing as tolerated is permitted from the beginning. After others, only partial weight bearing is allowed, and sometimes the limb must remain non-weight-bearing for a period. The instruction depends on the operation, bone quality, stability of fixation and tissue healing.

    The key information in the discharge plan is therefore not simply how many days have passed since surgery, but the exact weight-bearing instruction. If this is unclear, do not guess and do not use pain alone as a guide. Little pain does not automatically mean the repaired or fixed structure is ready for full loading.

    How to go upstairs with a handrail and one crutch

    For a typical unilateral lower-limb operation, once this method has been approved:

    1. Stand close to the first step. Hold a secure handrail with one hand and the crutch with the other.
    2. Place the non-operated leg on the higher step.
    3. Bring the operated leg up to the same step.
    4. Bring the crutch up last.

    A simple way to remember the sequence is: the stronger leg leads going up. Take one step at a time initially rather than trying to use a normal alternating pattern straight away.

    How to go downstairs

    1. Stand close to the edge of the step and hold the handrail securely.
    2. Place the crutch on the lower step.
    3. Lower the operated leg.
    4. Bring the non-operated leg down last.

    The order is therefore reversed when descending: the support and operated leg go first, the stronger leg follows. Avoid leaning far forward and never place the crutch tip on the edge of the step.

    Two crutches, one crutch or a walker?

    Where a handrail is available, two crutches can sometimes be held together in one hand after proper instruction while the other hand uses the rail. Without a handrail, stair negotiation with two crutches is more difficult and requires good balance. Initial attempts should be supervised.

    A walking frame or walker provides useful stability on level ground, but it is not designed for climbing a full flight of stairs. If a walker is the only safe mobility aid, an alternative route, assistance from another person or temporary living on one level should be planned.

    When can alternating stair climbing return?

    There is no single universal date. In general, the following are needed:

    • permission for sufficient loading of the operated limb;
    • adequate pain control without dizziness or excessive medication-related drowsiness;
    • enough hip, knee and ankle range of motion;
    • sufficient strength to lift the body onto the step and control the descent;
    • no obvious knee buckling, loss of balance or progressively worsening limp.

    Alternating steps often return sooner when going up than when going down. Descent requires good eccentric muscle control — the ability to slow the body under load.

    Preparing stairs at home

    • Remove loose rugs, cables and objects from the stairs.
    • Ensure good lighting, including for night-time trips to the bathroom.
    • Check that the handrail is secure and easy to grip.
    • Wear closed, non-slip footwear. Avoid loose slippers and walking in socks.
    • Do not carry objects in your hands while using crutches. Small items can be carried in a light backpack.
    • If the stairs are winding, steep or lack a rail, arrange supervision and reduce the number of trips where possible.

    When should you stop?

    Stop the attempt if you lose balance, the leg suddenly gives way, pain rises sharply, or you develop dizziness or marked drowsiness. A fall, sudden pain with deformity, a snap followed by loss of function or a new inability to bear weight requires prompt assessment.

    Urgent review is also needed for increasing numbness, a cold or pale foot, rapidly worsening swelling, wound drainage, fever, a hot and markedly red operative area, or new calf pain and swelling — particularly if accompanied by shortness of breath.

    The most important rule

    The familiar rule “stronger leg up, operated leg down” is a useful memory aid, but it does not replace the instructions for a specific operation. Recovery after joint replacement, ligament reconstruction, fracture fixation or bilateral surgery may require different precautions.

    Sources

    Polish version · More on recovery after orthopaedic surgery

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.