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Tomasz Poboży

Kategoria: Blog (EN)

Practical expert commentary in English on orthopaedic diagnosis, MSK ultrasound, treatment, surgery and recovery.

  • Starting Pain — Why Do the First Steps After Rest Matter?

    Pain that is strongest during the first steps after getting out of bed or after sitting for a while is sometimes described as “starting pain”. It is a useful symptom pattern because it shows how symptoms respond to rest and renewed loading. It does not, however, point automatically to a single diagnosis.

    How does an orthopaedic surgeon interpret “first-step pain”?

    The pattern matters. Some people notice that the first several steps after sleep or a longer period of sitting are the most painful, that symptoms then ease partly with movement, and that pain may increase again after prolonged walking or exercise. Constant pain that worsens with every step is a different pattern, as is sudden pain after an injury.

    These differences can help organise the diagnostic process, but they do not replace an examination. The exact location of pain, duration of stiffness, swelling, strength, range of motion and response to increasing load all matter.

    When the pain is under the heel

    Pain with the first steps after rest is a typical feature of plantar heel pain associated with plantar fasciitis. It is usually felt on the plantar-medial side of the heel. The 2023 clinical practice guideline includes first-step pain after rest among the characteristic clinical features, while also stressing that other causes of heel pain need to be considered.

    Not every episode of morning heel pain has the same cause. Recent trauma, burning or numbness, more diffuse pain in the heel bone, or symptoms associated with inflammatory disease require a different assessment. See also: Foot and Ankle Conditions.

    When the Achilles tendon feels stiff

    Morning stiffness and pain after inactivity can also occur with midportion Achilles tendinopathy. Symptoms may change during walking or training, so the beginning of activity is only part of the picture; the response during loading and afterwards is important as well.

    A sudden snap, a marked loss of push-off strength or difficulty rising onto the toes does not fit the usual gradual pattern of tendinopathy and should prompt earlier assessment for a possible tendon rupture.

    Why the symptom name is not enough

    Pain that “warms up” with movement is not necessarily trivial, and pain after rest does not automatically mean there is damage that needs a procedure. Similar descriptions can come from different tissues and conditions. Imaging does not settle every case either: ultrasound, X-ray or MRI findings need to be interpreted alongside the site of pain and functional examination.

    Before a consultation, it can be useful to note how long a period of rest triggers the pain, how many steps or minutes it takes to ease, whether symptoms return after longer walking or exercise, where the most painful point is, whether there is swelling, warmth, numbness or weakness, and how the area feels the next day after greater loading.

    When is earlier assessment important?

    “Starting pain” should not be used to explain away a sudden loss of function after injury, inability to bear weight, visible deformity, rapidly increasing swelling, a hot red joint with fever, or new loss of sensation or strength. Persistent pain at rest or at night also deserves earlier assessment when it is worsening or does not follow the usual relationship with movement.

    The whole symptom pattern matters

    When pain appears is only one part of the history. Combined with its location, response to load and examination findings, it can help distinguish several possible sources and decide whether imaging is needed. First-step pain alone should not be used to self-diagnose a condition or choose insoles, an injection or a procedure.

    References

    1. Koc TA Jr, Bise CG, Neville C, Carreira D, Martin RL, McDonough CM. Heel Pain — Plantar Fasciitis: Revision 2023. J Orthop Sports Phys Ther. 2023;53(12):CPG1–CPG39. DOI: 10.2519/jospt.2023.0303.
    2. Chimenti RL, Neville C, Houck J, Cuddeford T, Carreira D, Martin RL. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision — 2024. J Orthop Sports Phys Ther. 2024;54(12):CPG1–CPG32. DOI: 10.2519/jospt.2024.0302.

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    Polish version: Ból startowy — dlaczego pierwsze kroki po odpoczynku są ważne?

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Worn Shoes Under the Microscope — A Clue, Not a Diagnosis

    Wear on a shoe sole can draw attention to asymmetry, the way the heel meets the ground or a difference between the right and left side. It can be a useful clue during a musculoskeletal examination, but it is not a diagnosis. The same wear pattern may result from several factors, including the design of the shoe, walking style, the surface used, mileage and repeated movement habits.

    What does an orthopaedic surgeon actually look at?

    The worn area of the outsole is only one part of the picture. It is useful to compare both shoes, see whether the upper leans or deforms, note where material is stretched and look for obvious pressure marks on the insole. The shoe itself also matters: sole height and stiffness, cushioning and fit can all influence how the limb is loaded.

    In a study that analysed 252 people, centro-lateral or lateral heel wear was far more common than medial wear. The investigators found associations between some gait features, knee alignment and shoe-wear patterns, but also identified effects of sex and body dimensions and limitations of visual assessment. These findings describe relationships within the study group; the appearance of a sole alone cannot diagnose valgus, varus or the cause of pain.

    Why can the same wear pattern have different causes?

    A shoe records the effect of thousands of steps, but it does not record the whole context. Running shoes used mainly on asphalt wear differently from work footwear or a pair worn mostly while driving. Sole materials also differ. Body weight, walking speed, surface, previous injuries and how long the shoes have been used can all contribute.

    Marked asymmetry is therefore the start of a question, not the answer. It should be considered together with symptoms, examination of the feet, knees and hips, limb alignment and gait observation. Sometimes pressure measurement, strength testing or movement recording adds useful information; sometimes the clinical examination is enough. Insoles or attempts to alter gait should not be prescribed from a photograph of the outsole alone.

    When is it worth bringing your shoes to an appointment?

    • when pain mainly appears during walking, running or work in particular footwear;
    • when one sole wears noticeably faster than the other;
    • when you use insoles, heel lifts or other shoe modifications;
    • when symptoms keep returning despite changing shoes;
    • when symptoms involve the foot, ankle, knee, hip or lower back.

    Bring the pair you use most often and, if symptoms are related to sport or work, the footwear used for that activity as well. An older pair may reveal more than a new one, but it helps to know how long it was worn and in what conditions. Bring any insoles you regularly use too.

    Shoes do not replace examination

    Outsole wear can help direct attention to a particular aspect of movement, but it cannot by itself explain the source of symptoms. A similar pattern may be present in someone without pain and in someone with a problem that requires treatment. The useful interpretation comes from combining the history, physical examination and observation of function, particularly when pain is worsening, limiting weight bearing or followed an injury.

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    References

    1. Soon J, Lee DW, Choi GR, Kim KJ, Bahn S. Identification of Gait and Personal Factors Associated with Shoe Abrasion Patterns. Int J Environ Res Public Health. 2022;19(19):12558. DOI: 10.3390/ijerph191912558.
    2. Finestone AS, Petrov K, Agar G, Honig A, Tamir E, Milgrom C. Pattern of outsole shoe heel wear in infantry recruits. J Foot Ankle Res. 2012;5:27. DOI: 10.1186/1757-1146-5-27.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Old Injury, New Pain — Why Does Previous Treatment Matter?

    New pain does not always start from a blank slate. An old injury, previous operation or prolonged period of immobilisation can change joint structure, the way a limb is loaded and the appearance of imaging studies, so an accurate history of earlier treatment can be important when assessing a new problem.

    An old injury can leave important context

    An intra-articular fracture or an injury to a ligament, meniscus or cartilage can affect stability, alignment and load distribution long after the initial healing period. In a meta-analysis of 131 studies, previous knee injury was associated with a higher risk of later radiographic knee osteoarthritis. That is useful information about risk, but it does not prove that every new pain appearing years later is caused by the old injury.

    The name of an operation is often not enough

    Saying that someone had “knee arthroscopy” or “shoulder surgery” does not tell us exactly what was done. A procedure may have involved repairing or partially removing a meniscus, repairing a tendon, stabilising a ligament, removing a loose body or combining several procedures. Those differences can affect how scars, range of motion, strength, stability and later imaging are interpreted.

    The type of implant, the position of anchors or screws, associated procedures and any complications may also matter after surgery. A discharge summary, operative report and implant card can therefore be more useful than the remembered name of the procedure alone.

    Old images can show what has changed over time

    Comparing a current X-ray, MRI or CT scan with an earlier study may show whether bone alignment, joint-space width, implant position or another feature has genuinely changed. Without previous images, a normal residual finding after an old injury or operation may look concerning, while slow progression can be harder to recognise.

    Not every old finding explains current symptoms

    This is just as important. A screw seen on an X-ray, scar tissue on MRI or an old calcification may have nothing to do with the new pain. The clinician compares the history with the exact location of symptoms, when they began, movement and functional examination and, when needed, new imaging. The aim is not to blame everything on an old operation, but to separate background findings from the most likely cause of the current problem.

    What information helps an orthopaedic surgeon assess an old injury?

    • the approximate date and mechanism of the previous injury;
    • the name and side of the area that was operated on;
    • the discharge summary, operative report and implant card, if available;
    • previous X-rays, MRI or CT images together with their reports;
    • information about infection, wound-healing problems, reinjury or additional procedures;
    • a short timeline of when the current symptoms appeared after any period of improvement.

    Missing some of the documentation does not prevent a useful consultation. It is better to say clearly what is unknown than to guess the name of a procedure. Practical information about preparation and documents is also available in Patient Questions.

    When should you not wait?

    More urgent assessment is warranted after a new injury with inability to bear weight, rapidly increasing swelling, a hot red joint, fever, discharge from an old scar, sudden weakness or new sensory disturbance. In these situations, previous documentation can be valuable, but obtaining it should not delay medical assessment.

    References

    1. Duong V, Abdel Shaheed C, Ferreira ML, et al. Risk factors for the development of knee osteoarthritis across the lifespan: A systematic review and meta-analysis. Osteoarthritis and Cartilage. 2025;33(10):1162–1179.
    2. Dilley JE, Bello MA, Roman N, McKinley T, Sankar U. Post-traumatic osteoarthritis: A review of pathogenic mechanisms and novel targets for mitigation. Bone Reports. 2023;18:101658.
    3. Washington University Orthopedics. Introduction to Orthopaedic Surgery: History, Physical Examination/Imaging.

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    Polish version

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

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • One Leg Feels Shorter — What Should Actually Be Measured?

    Feeling that one leg is shorter does not always mean that the bones are actually different in length. Pelvic position, a hip or knee contracture, scoliosis, foot deformity or the way a painful limb is loaded can produce a similar impression. Before using a shoe lift, it is therefore important to establish what is actually being measured.

    Two different situations: anatomical and functional discrepancy

    An anatomical leg-length discrepancy means that the bony segments of one limb are genuinely different in length. It may be developmental or follow a fracture, bone deformity or surgery. A functional discrepancy occurs when bone lengths are similar, but the position of the pelvis, spine or joints makes one leg behave as though it were shorter or longer.

    For example, a knee that cannot fully straighten effectively shortens the limb in standing. A hip contracture, pelvic tilt or collapse of the foot can also change functional limb height. This is why assessment should not begin and end with a tape measure between two points on the skin.

    What does the orthopaedic examination look for?

    The examination starts with standing and walking, pelvic and spinal alignment, and the position of the feet. Hip and knee extension are checked because a contracture can mimic shortening. It also matters whether both legs are loaded equally and whether the perceived asymmetry changes when the pelvis is levelled.

    One useful screening method is the block test: blocks of known height are placed progressively under the apparently shorter side until the pelvis is approximately level. A systematic review found this to be the most useful clinical method among those assessed, but it does not replace imaging when an exact measurement is needed for an important treatment decision.

    Gait adds another layer of information by showing whether the asymmetry actually affects function. More: Why Does an Orthopaedic Surgeon Watch How You Walk?

    Why can home measurements be misleading?

    Bony landmarks are covered by soft tissue, and even a small change in pelvic position or tape direction can alter the result. Measuring from the waistband, navel or floor does not show which segment of the limb is responsible for the asymmetry. Hip rotation, knee flexion and foot position can also change the measurement.

    A home observation can be a good reason to seek assessment, but it is not enough to justify a permanent lift. If the apparent discrepancy is caused by a contracture or pelvic tilt, mechanically “levelling” the height may not address the real problem.

    When is a standing full-length X-ray useful?

    If the exact size of the discrepancy could change treatment, a standing radiograph that includes the entire lower limbs may be useful. It allows the femur and tibia to be measured separately and shows alignment and joint position under load. In the systematic review by Alfuth and colleagues, full-length standing anteroposterior radiography appeared to be the most valid and reliable imaging method among those assessed for anatomical leg-length discrepancy.

    Not everyone needs this test. If a small asymmetry causes no symptoms and would not change management, additional imaging may add little. After a recent injury, standing should not be forced simply to obtain a measurement. More about imaging under body weight: Why Do Weight-Bearing X-Rays Show More?

    Does every discrepancy need to be corrected?

    No. The number of millimetres is only one part of the decision. The cause, symptoms, age, ability to compensate and effect on walking also matter. Reviews of treatment indications emphasise that evidence for rigid thresholds is limited and that management should not be based on a single measurement alone.

    A shoe lift can be helpful in a properly selected situation, but it is not a neutral experiment for everyone. Rapidly correcting the full measured difference in someone who has adapted to an asymmetry for years can itself provoke symptoms. The amount of correction should therefore follow the examination and the aim of treatment, not a home tape measurement.

    What if the sensation started after hip surgery?

    After hip replacement, a perceived leg-length difference has to be distinguished from an actual change in bony length. Previous contractures, pelvic position, gait and soft-tissue tension can influence the sensation, although a true anatomical difference is also possible. There is no single interpretation based only on the name of the operation: the actual procedure, the examination and, when relevant, appropriately performed imaging all matter.

    A sudden sense of shortening after an injury or operation together with severe pain, deformity or inability to bear weight requires urgent assessment. In other situations, the first step is to establish whether the problem is anatomical, functional or mixed before trying to correct it.

    The key point

    “One leg is shorter” is a description of a sensation or observation, not a diagnosis. The pelvis, spine, joint range of motion, feet and gait should be assessed before deciding whether precise imaging measurements are needed. Treatment makes sense when it addresses the real cause and a meaningful functional problem.

    References

    1. Alfuth M, Fichter P, Knicker A. Leg length discrepancy: A systematic review on the validity and reliability of clinical assessments and imaging diagnostics used in clinical practice. PLoS One. 2021;16(12):e0261457.
    2. Vogt B, Gosheger G, Wirth T, Horn J, Rödl R. Leg Length Discrepancy—Treatment Indications and Strategies. Deutsches Ärzteblatt International. 2020;117(24):405–411.

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    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Does an Orthopaedic Surgeon Ask About Blood-Thinning Medicines?

    Questions about anticoagulants and antiplatelet medicines are not a formality. The exact drug, dose and reason for taking it can affect how bruising or swelling after an injury is interpreted, how joint aspiration or an injection is planned, and how a possible operation is prepared. Stopping these medicines on your own can also increase the risk of thrombosis or stroke. The important point is therefore accurate information rather than simply saying that a medicine “thins the blood”.

    One everyday phrase, several different medicines

    Patients often use “blood thinners” for several different groups of medicines. Anticoagulants include vitamin K antagonists and direct oral anticoagulants, while antiplatelet medicines such as aspirin or clopidogrel work differently but also affect haemostasis. The dose, how regularly the medicine is taken, the time of the last dose, kidney function and the reason for treatment can all matter.

    For that reason, “I take something for my blood” is not precise enough. It is best to give the name from the package or medication list, the dose and dosing schedule. It also helps to explain whether the medicine was prescribed because of atrial fibrillation, thrombosis, pulmonary embolism, arterial disease, a coronary stent or another indication, because the reason for treatment affects the risk of any interruption.

    What changes after an injury?

    After a bruise or sprain, a person taking medication that affects clotting may develop more extensive bruising or a larger haematoma. The appearance of bruising alone does not show whether there is a fracture, tendon injury or ligament injury. The mechanism of injury, focal tenderness, ability to bear weight, range of motion, strength, sensation and circulation still matter.

    Rapidly increasing swelling, severe worsening pain, numbness, weakness, pallor or a cold limb need particular attention. A head injury in a person taking anticoagulants also warrants prompt medical assessment even when the initial symptoms seem minor. Antithrombotic treatment may help explain greater bleeding, but it should not distract from assessing the injury itself.

    Joint aspiration or injection does not automatically mean stopping treatment

    Bleeding risk depends on the procedure and the individual situation. EULAR recommendations state that intra-articular therapy is not automatically contraindicated in people taking antithrombotic medication unless the individual bleeding risk is high. This does not create one rule for every patient, every medicine or every procedure.

    Before a planned aspiration or injection, the clinician should know the exact medicine, dose, indication and other factors that may increase bleeding risk. Some procedures can be performed without changing treatment, while others require an agreed plan. The decision should not be based on independently skipping a tablet on the day of the appointment. More about the procedure: Joint Aspiration — Why Is Synovial Fluid Collected?

    Why is there no single rule before surgery?

    Planning has to balance the bleeding risk of the actual procedure against the thrombotic risk of interrupting treatment. Relevant factors include the type of medicine, kidney function, the indication for treatment, a recent thrombosis or stroke, the presence of a stent and the extent of the planned operation. The CHEST guideline emphasises an individual, patient-centred assessment of these competing risks.

    There is therefore no safe universal interval for stopping all “blood-thinning medicines”. Any specific instruction should come from the treating team and take account of both the actual procedure and the condition for which the medicine was prescribed. This article is not a perioperative medication protocol and does not replace individual instructions.

    What should you bring to the appointment?

    • the name and dose of every relevant medicine;
    • the time of the last dose if a procedure is planned;
    • the reason for taking the medicine and the clinician or clinic managing it;
    • information about previous thrombosis, pulmonary embolism, stroke, stents or significant bleeding;
    • any current test results that were specifically requested, without arranging extra tests on your own.

    The practical message is simple: do not hide treatment and do not stop it on your own. An accurate medication list makes it easier to assess an injury, plan an examination or procedure and, if treatment needs to be changed, coordinate that decision with the clinician responsible for the antithrombotic therapy.

    References

    1. Uson J, Rodriguez-García SC, Castellanos-Moreira R, et al. EULAR recommendations for intra-articular therapies. Annals of the Rheumatic Diseases. 2021;80:1299–1305.
    2. Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest. 2022;162(5):e207–e243. A corrigendum was published in Chest. 2023;164(1):267.

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    Polish version

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Clicking, Cracking, Popping — When Do Joint Sounds Matter?

    Clicking, cracking or popping by itself does not diagnose joint damage. The significance of a joint sound depends on when it started, whether it is accompanied by pain, swelling, locking or loss of function, and whether the same movement reliably reproduces it.

    The same description can mean different things

    People use similar words for very different sensations: a single pop, fine crackling with each bend, a tendon that can be felt snapping, or a sudden sound at the moment of injury. These do not all have the same mechanism. A sound can arise when joint surfaces separate rapidly and a gas cavity forms in synovial fluid, when a tendon or ligament moves over another structure, or when uneven or unstable structures move.

    Real-time MRI during finger-joint cracking showed that the characteristic single crack was associated with rapid cavity formation rather than bones simply rubbing together. That finding should not be generalised to every sound from a knee, shoulder or hip; its main value is to show that an audible crack can have a mechanism that is not tissue damage.

    Crepitus does not automatically mean damaged cartilage

    The knee is a useful example. A meta-analysis of 103 studies involving 36,439 people estimated knee crepitus in about 41% of the general population and about 36% of people without pain. Crepitus was also more common in osteoarthritis and with some structural changes seen on imaging. However, the certainty of these estimates was low or very low, so the sound cannot be used either to diagnose osteoarthritis or to prove that a joint is healthy.

    What matters more than how loud it is?

    • Onset: has the sound been present for years, or did it start at the exact moment of an injury?
    • Associated symptoms: is there pain, rapid swelling, loss of motion, instability or weakness?
    • Reproducibility: does the same movement cause it every time, or was it a one-off event?
    • Location: can you point to or feel the structure that is snapping?
    • Function: is the joint merely noisy, or does it truly lock and prevent the movement from being completed?

    It is worth describing “locking” precisely. Stopping a movement because of pain or apprehension is different from a mechanical block in which the joint cannot be freely straightened or bent. That distinction can change both the urgency and direction of assessment.

    When does a joint sound need faster assessment?

    A sudden pop during an injury deserves earlier assessment when it is accompanied by severe pain, rapidly increasing swelling, visible deformity, inability to bear weight, marked instability or persistent mechanical locking. New sensory loss, weakness, pallor or a cold limb also requires urgent assessment. By contrast, long-standing painless sounds without swelling or declining function can usually be assessed non-urgently.

    How an orthopaedic surgeon reproduces the symptom during examination

    During an examination, the important question is not only whether a sound can be heard, but which movement produces it and what happens to the joint, tendon or other structure at that moment. Comparing both sides and assessing active and passive movement can help. X-ray, ultrasound, MRI or CT should then be selected according to the suspected mechanism — not every click needs imaging, and no single scan explains every type of joint sound.

    See how diagnostic tests answer different orthopaedic questions →

    Sources

    1. Couch JL, King MG, De Oliveira Silva D, et al. Noisy knees – knee crepitus prevalence and association with structural pathology: a systematic review and meta-analysis. Br J Sports Med. 2025;59(2):126–132. DOI: 10.1136/bjsports-2024-108866. PMID: 39375004. This summary used the public abstract and bibliographic metadata for this paper.
    2. Kawchuk GN, Fryer J, Jaremko JL, et al. Real-Time Visualization of Joint Cavitation. PLoS One. 2015;10(4):e0119470. DOI: 10.1371/journal.pone.0119470. PMID: 25875374. Full text is open access.

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    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Does an Orthopaedic Surgeon Ask Which Hand You Write With?

    Asking which hand you write with is not just a formality. The dominant hand often performs more tasks that require precision, while the other hand may stabilise objects, carry loads or perform different movements. Knowing this helps interpret strength, range of motion and function — but it does not mean that the dominant side must always perform better.

    The dominant hand is not automatically the “stronger hand”

    In healthy groups, the dominant upper limb is stronger on average, but the difference depends on the movement tested, the joint, work demands, sport and individual habits. A meta-analysis of 87 studies found an average strength advantage of about 11.6% for the dominant upper limb, while differences across particular movements and regions ranged from about 2% to nearly 20%. This means that the familiar “10% rule” can be a useful group-level approximation, but it is not a fixed standard for every person or every test.

    Another study of 229 adults found that 32.3% recorded their greatest grip strength in the non-dominant hand. The sample was relatively small and 96.1% of participants were right-handed, so the result should not be applied rigidly to every patient. It does, however, show why a single measurement from one hand should not be interpreted according to a simple rule.

    What does this change during an examination?

    • Strength: a difference between sides may be normal, but it can also reflect pain, tendon injury, a nerve problem, a previous injury or reduced use of one hand.
    • Precision and speed: writing, fastening buttons or using a tool depends on more than maximum grip strength.
    • Range of motion: a small asymmetry may have existed before the current problem, especially with repetitive work or sport.
    • Functional importance: the same loss of function may have very different consequences for someone who writes, plays an instrument, works with tools or performs tasks with both hands.

    Why are both sides examined?

    The other hand is a useful reference point, but it is not a perfect copy of what the affected hand was like before an injury. It may have had its own previous injury, osteoarthritis, weakness or an unusual pattern of use. That is why side-to-side comparison is combined with the history, sensory examination, movement assessment and strength testing. See also: Why Does an Orthopaedic Examination Test Muscle Strength?

    What else is worth mentioning besides which hand you write with?

    It is useful to say which hand you use for work, sport and particular tasks, because dominance can depend on the activity. Mention previous injuries to either arm, operations, limitations that were already present before the current problem and whether symptoms affect one side or both. This context helps assess the function of the individual person rather than comparing them only with a simplified rule.

    Sources

    • Foley RCA, Callaghan DH, Forman GN, et al. A comprehensive scoping review and meta-analysis of upper limb strength asymmetry. Scientific Reports. 2025;15:4636. DOI: 10.1038/s41598-025-87413-w; PMID 39920213.
    • Cuyul-Vásquez I, Castillo-Vejar L, Garrido-Muñoz N, et al. One third of people exert greater handgrip strength with their non-dominant hand. Scientific Reports. 2026;16:1040. DOI: 10.1038/s41598-025-30659-1; PMID 41353458.

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    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Burning, Stabbing, Electric-Shock Pain — What Does Pain Quality Tell Us?

    The words used to describe pain are useful clues, but they are not diagnoses. Burning, stabbing, electric-shock sensations, pressure or a dull ache only become meaningful when they are considered together with where the pain starts, where it travels, what triggers it and what other symptoms accompany it.

    Why does the quality of pain matter?

    Pain is a personal experience, and the way it feels can help shape the first diagnostic hypotheses and guide the examination. Burning, shooting or electric-shock-like pain — especially when accompanied by tingling, numbness or unusual skin sensitivity — may direct attention towards the nervous system. A dull pain linked to movement or loading may lead to closer assessment of a joint, tendon, muscle or bone. None of these descriptions, however, is specific to a single structure or diagnosis.

    What does an orthopaedic surgeon combine with the pain description?

    • Starting point and direction: does the pain stay in one place or travel along the limb?
    • Triggers: movement, loading, a particular position, pressure, light touch, coughing or prolonged rest.
    • Timing: sudden or gradual onset, constant or episodic symptoms, and changes after injury or with activity.
    • Associated symptoms: altered sensation, weakness, swelling, redness, stiffness or restricted movement.
    • Effect on function: which specific activity can no longer be performed normally?

    That is why “my knee hurts” is the beginning of the history, not the end of it. It may matter just as much whether the pain appears while walking downstairs, twisting, sitting for a long time or after light contact with the skin.

    Why does “burning” not automatically mean “a nerve problem”?

    International criteria for neuropathic pain require more than characteristic words. The history should be compatible with a lesion or disease of the somatosensory nervous system, the distribution should be neuroanatomically plausible, and sensory findings on examination — and sometimes additional tests — help increase diagnostic certainty. Burning or stabbing pain can occur in other conditions as well. Conversely, nerve-related pain does not always feel “electric”, and more than one pain mechanism can coexist in the same person.

    How can you describe pain without finding the perfect word?

    You do not need medical terminology. A short description is often more useful: “the pain starts here, travels in this direction, appears with this activity and is accompanied by this symptom.” Give one typical example from everyday life and say whether the same movement reliably reproduces the problem. It can also help to show the movement that causes pain safely, provided that this does not require forcing an extreme position or pushing through severe pain.

    The description guides the assessment; the examination puts it in context

    A careful description helps select appropriate clinical tests and decide whether imaging, nerve assessment or another investigation is needed. It should not lead to self-diagnosis from a single adjective. The final interpretation comes from combining the history, examination and — when appropriate — targeted investigations. See also: Diagnostic Tests.

    Sources

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    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Does an Orthopaedic Surgeon Ask You to Show the Movement That Hurts?

    Being asked to show the movement that causes pain is not a fitness test or a test of pain tolerance. It is a controlled way to compare what you describe with how the limb actually works during a specific task. The clinician is interested not only in whether it hurts, but also in when the pain appears, where you feel it and how your body changes the movement to avoid it.

    Pain in the same area can have different causes

    Shoulder pain when reaching to a shelf may be related to restricted joint movement, the rotator cuff, the biceps tendon or symptoms referred from the neck. Knee pain while walking downstairs does not automatically mean a meniscal tear. The location of pain helps narrow the possibilities, but rarely identifies one structure with certainty.

    When you reproduce a familiar movement, the clinician can check whether it brings on the same symptom you know from daily life or only an unrelated discomfort. That distinction matters: pain that feels similar but occurs in a different place or at a different phase of movement may point towards a different diagnostic hypothesis.

    What is the orthopaedic surgeon looking for?

    • When the symptom appears: at the beginning, in the middle or only near the end of the movement.
    • Direction and load: whether pain occurs without weight, against resistance, during landing or with twisting.
    • Quality of movement: smoothness, shaking, giving way, clicking or a sudden stop.
    • Compensatory movements: leaning the trunk, hiking the shoulder, shortening the step or shifting weight to the other side.
    • Repeatability: whether the symptom appears each time and whether it changes after altering position or reducing the load.

    Musculoskeletal clinical practice guidelines emphasise repeatable measures of activity limitation and function. These measures can help direct the examination and later show whether treatment has improved a task that matters to the patient.

    From an everyday movement to a focused examination

    The examination often starts with a movement that resembles a real-life task: rising from a chair, stepping down, squatting, gripping, lifting the arm or turning the head. The task can then be broken into simpler components. The painful side may be compared with the other side, active movement with movement guided by the clinician, and strength and selected clinical tests can be assessed.

    This sequence helps answer practical questions. Is movement limited mainly by pain, weakness, stiffness, fear of loading or a mechanical block? Is the problem centred in one joint, or could an adjacent part of the limb or the spine also matter? For more context, see Why Does an Orthopaedic Examination Go Beyond the Painful Area?

    Reproducing pain is not a diagnosis

    Even a very characteristic response during one movement should not be interpreted separately from the history and the rest of the examination. Reviews of orthopaedic test accuracy show that many individual tests have limitations. They are usually more useful for strengthening or weakening an existing diagnostic hypothesis than for making a diagnosis on their own.

    The clinician may therefore repeat a similar movement with a different position, add light resistance or examine another region. Imaging is selected when it may resolve an important uncertainty or change management. A related explanation is available in What Does a Positive Orthopaedic Test Actually Mean?

    How can you prepare?

    It helps to describe briefly which task, speed and load bring on the problem. A recording made earlier under safe conditions can sometimes be useful, especially when the symptom occurs only during sport or work and is difficult to reproduce in the clinic. Do not deliberately provoke a sudden twist, fall, full sprint or heavy load simply to demonstrate the symptom.

    When should the painful movement not be provoked?

    After a recent injury with deformity or suspected fracture, sudden limb weakness, altered sensation or circulation, rapidly increasing swelling, or fever with a hot red joint, safety assessment comes first. In these situations, trying to “see whether you can still do it” may be unnecessary or harmful.

    The key point

    The movement that hurts is part of the medical history shown in action. It can connect a symptom with function and help focus the rest of the examination, but it does not replace a complete assessment. It is most informative when it can be reproduced safely and interpreted alongside the history, clinical examination and — when genuinely needed — imaging.

    Sources

    1. Blanpied PR, Gross AR, Elliott JM, et al. Neck Pain: Revision 2017. J Orthop Sports Phys Ther. 2017;47(7):A1–A83. doi:10.2519/jospt.2017.0302.
    2. Martin RL, Davenport TE, Fraser JJ, et al. Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021. J Orthop Sports Phys Ther. 2021;51(4):CPG1–CPG80. doi:10.2519/jospt.2021.0302.
    3. Schwieterman B, Haas D, Columber K, Knupp D, Cook C. Diagnostic accuracy of physical examination tests of the ankle/foot complex: a systematic review. Int J Sports Phys Ther. 2013;8(4):416–426. PubMed.

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    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Is Your Response to Exercise Assessed the Next Day?

    A well-chosen exercise dose is not judged only by what happens while you are moving. What happens several hours later and the following morning matters just as much: whether pain has returned to its previous level, stiffness lasts longer, swelling appears, and everyday activities feel easier or harder.

    Why is pain during exercise not enough?

    Pain during exercise is useful information, but it does not always tell you whether the load was safe and appropriately dosed. With chronic tendon problems, mild symptoms during training may be acceptable. After a recent injury, surgery or an unstable fracture, however, even an exercise that feels easy at the time may exceed the restrictions set for that stage of healing.

    The delayed response matters too. Tissues and the nervous system continue to respond for hours after exercise. If pain or stiffness is clearly worse the next day, swelling increases, or walking, gripping or climbing stairs becomes more difficult, the individual session may have been too demanding or the interval between sessions too short.

    What is worth comparing before exercise and the next morning?

    • Pain: not only its intensity, but also its location and character.
    • Stiffness: whether it lasts longer than usual and limits the first movements after rest.
    • Swelling: whether it is new or clearly greater than before.
    • Function: for example walking, stairs, squatting, raising the arm or grip strength.

    A simple, repeatable observation is often enough. Note these four elements before training, shortly afterwards and again the next morning. One worse day does not mean rehabilitation has failed, but a recurring pattern can help you adjust the programme more sensibly.

    The pain-monitoring model has limits

    The best-known pain-monitoring model was studied in people with Achilles tendinopathy. In a small randomised trial, 38 patients either continued running and jumping according to predefined symptom-monitoring rules or temporarily stopped those activities; both groups followed the same rehabilitation programme. Continuing activity within the pain-monitoring model did not worsen outcomes, but this study did not establish a universal rule for every tendon problem, injury or operation.

    Current guidance for midportion Achilles tendinopathy recommends tendon-loading exercise as first-line treatment, at a dose tolerated by the patient. That does not mean that one pain threshold or a single “24-hour rule” applies to every diagnosis. A programme after ligament reconstruction, fracture fixation or tendon repair must account for tissue healing and the specific restrictions given by the orthopaedic surgeon.

    How can the exercise dose be reduced safely?

    If the reaction after training is consistently excessive, it is usually more useful to change one variable than to stop moving altogether. You can reduce resistance, repetitions, range of motion, pace or session frequency. Changing one element at a time makes it easier to understand what is actually affecting symptoms. More on this approach: Conservative Treatment Is Not the Same as Waiting.

    It is also worth recording the sequence of events: what you did, when symptoms appeared and how long they lasted. This can make a consultation more informative and helps distinguish random fluctuation from a repeatable response to loading. See also: Symptom Timeline — Why Does the Order Matter?

    When should you not wait until the next day?

    Stop the exercise and seek prompt assessment if there is sudden severe pain, new marked weakness, loss of sensation, a pale or blue limb, rapidly increasing swelling, deformity, or fever with redness and warmth around the affected area. After surgery or a recent injury, individual restrictions on movement and weight bearing take priority over general exercise advice.

    The key point

    Rehabilitation is a process of dosing load, not a test of endurance. Symptoms during exercise, the response over the following hours and the next-morning baseline together give a more useful picture than a single pain score. Monitoring this pattern can help adjust a programme, but it does not replace a diagnosis or the instructions of the treating clinician or physiotherapist.

    References

    1. Chimenti RL, Neville C, Houck J, et al. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2024. J Orthop Sports Phys Ther. 2024;54(12):CPG1–CPG32. doi:10.2519/jospt.2024.0302.
    2. Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med. 2007;35(6):897–906. doi:10.1177/0363546506298279.
    3. Silbernagel KG, Hanlon S, Sprague A. Current Clinical Concepts: Conservative Management of Achilles Tendinopathy. J Athl Train. 2020;55(5):438–447. Full text.

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    Content prepared by: Tomasz Poboży - orthopaedic surgeon.