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Tomasz Poboży

Kategoria: Injuries and Sports Medicine (EN)

English-language patient information about orthopaedic injuries, sports medicine, rehabilitation and safe return to activity.

  • 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.

    ← More patient blog articles

    Polish version

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

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Distal Biceps Tendon Rupture at the Elbow — When Is Surgery Needed?

    Polish version: Zerwanie ścięgna bicepsa przy łokciu — kiedy potrzebna jest operacja?

    Sudden pain at the front of the elbow after a forceful pull or while lifting, a noticeable “pop,” rapidly developing bruising and a clear loss of strength when turning the palm upward may indicate a distal biceps tendon rupture. A complete rupture in an active person is often treated surgically, but not every injury requires an operation. The extent of the tear, age, activity level, functional demands and coexisting medical conditions all matter.

    What actually tears?

    The biceps brachii ends near the elbow in a strong tendon that attaches to the radius. This tendon contributes not only to elbow flexion but especially to forearm supination—the movement that turns the palm upward.

    Rupture most often occurs when a large sudden load is applied to an extended or extending elbow, for example while trying to catch or hold a falling weight. The injury may be complete or partial.

    What symptoms are typical?

    • sudden pain at the front of the elbow, often during heavy loading,
    • a popping sensation or sound,
    • swelling and bruising in the elbow crease or forearm,
    • a change in the contour of the biceps, with the muscle belly sometimes retracting slightly upward,
    • reduced elbow-flexion strength,
    • particularly noticeable weakness when turning the forearm palm-up, such as when using a screwdriver or loosening a tightly fastened object.

    Pain may improve considerably after several days, but less pain does not mean that the tendon has reattached. With a complete rupture, a persistent loss of strength—especially in supination—may remain.

    Does every rupture look dramatic?

    No. A partial tear may present mainly as pain at the front of the elbow during exertion, without extensive bruising or an obvious change in muscle contour. Persistent pain in this area should therefore not automatically be labelled as tennis elbow or golfer’s elbow.

    Tennis elbow usually causes pain on the lateral side of the elbow, while golfer’s elbow is typically medial. Pain directly at the back of the elbow has a different differential diagnosis again. The location and mechanism of symptoms are therefore important.

    How is a distal biceps tendon rupture diagnosed?

    The starting point is the history and clinical examination. The clinician assesses the contour of the muscle, bruising, elbow-flexion and supination strength, and uses tests aimed at tendon continuity, including the Hook test.

    Ultrasound

    Ultrasound can rapidly assess tendon continuity, the site of injury, retraction of the torn end and some partial tears. The distal biceps tendon is technically demanding to examine because of its deep position and twisted course, so operator experience matters.

    MRI

    MRI is particularly useful when the clinical picture or ultrasound findings are inconclusive, when a partial tear is suspected, or when the degree of retraction and other structures around the elbow need more detailed assessment. A patient with a clinically typical complete rupture does not necessarily need MRI as the first diagnostic test.

    When can non-operative treatment be reasonable?

    Non-operative treatment can be appropriate for some partial tears, for people with relatively low strength demands, or when the risks of surgery are greater than the expected benefit. Initial management includes reducing load and controlling pain, followed by gradual restoration of movement and strengthening.

    The possibility of persistent weakness should be understood. Meta-analyses of complete ruptures have found that operative treatment provides greater average flexion strength and, in particular, greater supination strength than non-operative care. Most of this evidence is observational, however, and the non-operative groups were much smaller, so the decision should not be reduced to a single percentage from a pooled analysis.

    When does an orthopaedic surgeon consider surgery?

    Tendon repair is most often considered for a complete rupture in an active patient who wants to recover as much elbow-flexion and forearm-supination strength as possible. This is especially relevant for people who perform physical work, strength training or sports that place substantial demands on the upper limb.

    Assessment should not be postponed for many weeks simply because the pain has improved. Over time, the torn tendon may retract and scar, making primary repair more difficult. Chronic cases may occasionally require a more complex reconstruction using a graft.

    Surgery also carries risks, including temporary sensory disturbance from irritation of cutaneous nerves and, less commonly, motor nerve injury, heterotopic ossification or loss of motion. The expected gain in strength therefore needs to be weighed against the risks of the procedure.

    What does return to activity look like?

    After tendon repair, the reattachment is initially protected while movement is restored gradually. Strengthening is introduced later according to the surgeon’s protocol and progress of healing. Return to heavy loading is usually measured in months rather than weeks.

    In a systematic review of 42 studies involving more than 1,000 patients after surgical repair, about 91% returned to sport, with a mean time to return of approximately 6 months. These are pooled figures from very different patient groups and should not be treated as a fixed deadline for an individual patient.

    When is urgent assessment needed?

    After a recent injury suspicious for tendon rupture, orthopaedic assessment should be arranged without unnecessary delay, particularly after a characteristic pop, extensive bruising or a clear loss of strength. More urgent medical attention is warranted if there is increasing numbness or weakness of the hand, a cold or pale hand, abnormal pulses, very rapid severe swelling, an open wound, or an injury in which a fracture is also suspected.

    Key takeaways

    A distal biceps tendon rupture is different from the common overuse disorders that cause elbow pain. In an active patient with a complete rupture, surgery often offers a better chance of restoring strength, especially forearm supination. Non-operative treatment remains a reasonable option in selected cases. The key is to identify the type of injury promptly and match treatment to the patient’s actual functional needs.

    References

    1. Looney AM, Day J, Bodendorfer BM, et al. Operative vs. nonoperative treatment of distal biceps ruptures: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2022;31(4):e169–e189. DOI: 10.1016/j.jse.2021.12.001.
    2. Deschrijver M, Hautekiet A, Steyaert A, De Muynck M, Luypaert E. Distal biceps tendon ruptures: more efficient diagnostics for a better outcome. Acta Orthop Belg. 2022;88(1):160–167. DOI: 10.52628/88.1.20.
    3. Cuzzolin M, Secco D, Guerra E, et al. Operative Versus Nonoperative Management for Distal Biceps Brachii Tendon Lesions: A Systematic Review and Meta-analysis. Orthop J Sports Med. 2021;9(10):23259671211037311. DOI: 10.1177/23259671211037311.
    4. Boufadel P, Daher M, Lopez R, et al. Return to Sport After Distal Biceps Tendon Repair: A Systematic Review. Am J Sports Med. 2025;53(7):1769–1778. DOI: 10.1177/03635465241295618.

    ← Injuries and fractures: patient guide

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Lateral Knee Pain in Runners — Could It Be Iliotibial Band Syndrome?

    Pain on the outer side of the knee that appears during running and builds as the distance increases may be caused by iliotibial band syndrome. Not every case of lateral knee pain has this explanation, however. Diagnosis is based mainly on the history and clinical examination; ultrasound or MRI are generally reserved for atypical symptoms, persistent problems despite treatment, or situations in which another condition needs to be excluded.

    Polish version: Ból po bocznej stronie kolana u biegacza — czy to pasmo biodrowo-piszczelowe?

    What does iliotibial band syndrome usually feel like?

    The pain is typically quite well localised on the lateral side of the knee, near the lateral femoral epicondyle. Early on, it may appear only after a certain amount of running and settle quickly when exercise stops. With greater overload, symptoms may begin earlier and may also occur while walking downstairs or during longer walks.

    A large knee effusion, a feeling of “fluid in the knee” or true mechanical locking are not typical. When those features dominate, another source of symptoms should be considered.

    Does the iliotibial band really “rub” over the bone?

    The condition was traditionally called iliotibial band friction syndrome. Contemporary reviews emphasise that the mechanism is more complex, and the simple concept of the band sliding back and forth and rubbing over the lateral femoral epicondyle has been questioned.

    Overload of tissues on the lateral side of the knee, control of the limb during running, hip muscle strength and coordination, and sudden changes in training load may all contribute. For that reason, simply “stretching the band” should not be regarded as a complete treatment strategy.

    What else can cause lateral knee pain?

    Similar symptoms may arise from the lateral meniscus, patellofemoral joint, lateral collateral ligament, biceps femoris tendon, proximal tibiofibular joint or bone. After trauma, ligament and intra-articular injuries also need to be considered.

    How is iliotibial band syndrome diagnosed?

    The key elements are the pain pattern, its precise location, its relationship to running and a careful examination of the limb. Assessment should not be limited to the knee: hip function, range of motion, muscle strength, lower-limb control under load and signs of another injury may all be relevant.

    There is no single test that independently confirms the diagnosis in every patient. When the clinical picture is typical, additional imaging is not always necessary.

    When can ultrasound help?

    Ultrasound can be useful when symptoms persist or recur, or when superficial structures on the lateral side of the knee need to be assessed. Reported findings may include soft-tissue oedema or fluid deep to the iliotibial band near the lateral femoral epicondyle. Thickening of the band itself is neither constant nor sufficiently specific to establish the diagnosis on its own.

    When is MRI useful?

    MRI is not routinely required for a typical presentation. It becomes more useful when the diagnosis is uncertain, intra-articular symptoms are present, pain persists despite appropriate management, or a meniscal, cartilage, bone or other structural problem needs to be excluded.

    How is it treated?

    The usual starting point is a temporary reduction in the load that provokes pain, followed by a gradual return to running. This does not normally mean several weeks of complete rest. The aim is to identify an activity level that does not perpetuate symptoms while addressing factors that may be contributing to overload.

    Exercise

    A 2024 systematic review of 13 studies involving 201 runners found that hip abductor strengthening was the most common component of rehabilitation programmes. The individual studies were highly heterogeneous and a reliable meta-analysis could not be performed. Exercise is therefore an important part of management, but there is no single proven programme that is appropriate for every runner.

    A rehabilitation plan may include strengthening of the hip and trunk muscles, improved control during single-leg loading, and progressive functional exercises that reflect the demands of running.

    Training load and running technique

    Recent changes in weekly distance, pace, hill running, downhill running and training frequency are worth reviewing. Selected changes in running mechanics may help some runners, but there is no basis for prescribing the same stride or cadence modification to everyone.

    Medication, shockwave therapy and injections

    Anti-inflammatory medication may be used briefly in selected patients when there are no contraindications, but it does not correct the cause of overload. Shockwave therapy has also been described in the literature.

    A corticosteroid injection is not a routine first-line treatment for every runner. It may be considered in selected persistent cases after the pain source has been identified. If an injection is performed, ultrasound guidance allows the needle and injectate to be placed in the intended location.

    When can you return to running?

    The decision should not be based only on the number of days since symptoms began. Return should be progressive and guided by tolerance of everyday walking and basic exercises, followed by a short easy run that does not cause escalating pain during activity or a clear deterioration the next day.

    A common mistake is to return immediately to the previous mileage, pace and downhill workload. It is safer to increase load step by step and monitor how the knee responds.

    When does lateral knee pain need earlier assessment?

    • pain began after a clear injury and makes weight bearing difficult,
    • the knee becomes rapidly and markedly swollen,
    • the joint is hot or red, particularly with fever,
    • the knee truly locks or clearly gives way,
    • there is very focal bone tenderness and pain with weight bearing, especially after a sudden increase in training,
    • pain becomes constant, occurs at night or progresses despite reducing activity.

    Key point for an orthopaedic surgeon

    Iliotibial band syndrome is a common cause of lateral knee pain in runners, but the diagnosis should come from the whole clinical picture. Typical cases are usually managed without surgery through load adjustment, exercise and a gradual return to running. Ultrasound and MRI are supporting tools, especially when the presentation is atypical or progress is not as expected.

    References

    1. Sanchez-Alvarado A, Bokil C, Cassel M, Engel T. Effects of conservative treatment strategies for iliotibial band syndrome on pain and function in runners: a systematic review. Front Sports Act Living. 2024;6:1386456. DOI: 10.3389/fspor.2024.1386456.
    2. Bonoan M, Morales M, Liu XW, Oyeniran O, Zheng K, Palatulan E. Iliotibial Band Syndrome Current Evidence. Curr Phys Med Rehabil Rep. 2024;12:193-199. DOI: 10.1007/s40141-024-00442-w.
    3. Jiménez Díaz F, Gitto S, Sconfienza LM, Draghi F. Ultrasound of iliotibial band syndrome. J Ultrasound. 2020;23(3):379-385. DOI: 10.1007/s40477-020-00478-3.

    ← Knee Conditions

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Radial Head Fracture — When Is Surgery Needed?

    Most isolated, nondisplaced or only mildly displaced radial head fractures can be treated without surgery. Management usually involves brief support for comfort followed by controlled restoration of motion as early as the injury safely allows. Fragment displacement of more than 2 mm is not, by itself, an automatic indication for an operation. Mechanical blockage of forearm rotation, comminution, elbow instability and associated injuries are more important.

    Polish version: Złamanie głowy kości promieniowej — kiedy potrzebna jest operacja?

    How does a radial head fracture occur?

    The usual mechanism is a fall onto an outstretched hand. Force travels through the wrist and radius to the elbow, where the radial head impacts the distal humerus. The injury may be a small fracture line, a displaced fragment, or — in more severe trauma — a comminuted radial head fracture.

    The radial head is not simply a piece of bone that needs to unite. It contributes to elbow stability. In complex injuries, treatment therefore depends not only on the fracture itself but also on the ligaments, the other bony structures around the elbow and the stability of the joint as a whole.

    Typical symptoms

    • pain on the lateral side of the elbow, particularly after a fall onto the hand,
    • swelling and tenderness over the radial head,
    • pain or restriction when turning the palm up or down,
    • difficulty fully bending or straightening the elbow,
    • pain with tasks such as turning a key, a door handle or opening a bottle.

    Similar post-traumatic pain can also come from ligaments, cartilage or other elbow structures, so the diagnosis should not be based on pain location alone.

    How is the fracture diagnosed?

    Assessment should include the whole upper limb rather than only the most painful point. Elbow motion — especially pronation and supination — joint stability, circulation and sensation are checked. The forearm and wrist also deserve examination because some radial head fractures are accompanied by injuries farther from the elbow.

    Plain radiographs are the basic imaging test. CT can be helpful in more complex or comminuted fractures when the number and position of fragments need to be defined more precisely or when surgery is being planned. Ultrasound does not replace radiographs for diagnosing an acute adult fracture, although it can complement soft-tissue or effusion assessment in selected situations.

    What does the Mason classification mean?

    In simplified terms, Mason type I describes a fracture without substantial displacement, type II a displaced fragment involving part of the radial head, and type III a comminuted fracture. In the Johnston modification, type IV refers to a radial head fracture associated with elbow dislocation.

    The classification is useful for describing the injury, but it does not choose the treatment by itself. Two fractures within the same category may differ in stability, available motion and associated damage.

    When can treatment be non-operative?

    Non-operative management is appropriate mainly for nondisplaced and minimally displaced fractures when the elbow is stable and there is no mechanical block to motion. This is typical for Mason type I fractures and also applies to many carefully selected isolated Mason type II injuries.

    A key goal is to avoid unnecessary elbow stiffness. If fracture and joint stability permit, controlled range-of-motion exercises are introduced after a short period of protection. The exact timing and progression of loading depend on the injury pattern rather than a single fixed timetable for every patient.

    A randomized trial of 45 adults with isolated Mason type II fractures found no significant one-year functional advantage of screw fixation over non-operative treatment. A 2026 meta-analysis involving 181 patients likewise found no clear operative advantage in function or range of motion. The evidence remains limited, however: the meta-analysis included only four studies, just one of which was randomized, and some analyses were heterogeneous.

    Does displacement of more than 2 mm mean surgery?

    No. A review in EFORT Open Reviews emphasizes that displacement beyond 2 mm, in the absence of a mechanical block to pronation or supination, is not by itself an unequivocal indication for surgery.

    What matters is the overall pattern: fragment size and position, remaining bony contact, comminution, unrestricted motion, joint stability and associated injuries. Treatment should therefore not be decided from a millimetre measurement in a radiology report alone.

    When is surgery more likely to be needed?

    • A true mechanical block to forearm rotation — a bony fragment prevents pronation or supination rather than motion being limited only by pain.
    • Marked comminution of the radial head, particularly when reliable reconstruction is difficult or impossible.
    • Loss of elbow stability or an associated dislocation, ligament injury or additional fracture.
    • Major displacement with loss of fragment contact, especially when other features of a complex injury are present.
    • A situation in which acceptable elbow anatomy and function cannot be restored with non-operative treatment.

    In a complex injury, preserving or reconstructing the radial head may be important for joint stability. Simply removing an inconvenient fragment is therefore not a universal solution.

    What does surgery involve?

    If the fracture can be anatomically reconstructed, open reduction and internal fixation is commonly performed with screws and, in some patterns, a plate. If a severely comminuted fracture cannot be reconstructed reliably and the radial head is needed for elbow stability, radial head replacement may be considered.

    The choice of procedure depends on the entire injury pattern. There is no single operation that is appropriate for every radial head fracture.

    Return to function

    Loss of motion is one of the main problems after elbow injury. When the fracture and the joint are stable, the aim is therefore to begin controlled movement as early as safely possible. Heavier loading, lifting and return to sport require adequate healing progress and restoration of function.

    Recovery speed depends on the fracture pattern, associated injuries, treatment method and individual response. The absence of pain at rest does not by itself mean that the bone is fully healed or ready for high loads.

    When is urgent assessment needed?

    • the elbow is visibly deformed or dislocation is suspected,
    • there is an open wound or exposed bone,
    • the hand becomes pale, blue or clearly colder than the other hand,
    • numbness, finger weakness or other neurological symptoms are increasing,
    • pain and swelling are rapidly worsening despite protection and analgesia,
    • forearm rotation is essentially impossible or there is a clear mechanical block,
    • the forearm or wrist also hurts, suggesting that more than one structure may be injured.

    Key point for an orthopaedic surgeon

    A radial head fracture does not automatically require surgery. Stable, isolated fractures without a mechanical block often do well with non-operative treatment and early controlled motion. Mechanical blockage, comminution, instability and associated injuries are usually more important than a single displacement measurement. The whole elbow and upper limb therefore need to be assessed, not just one fragment on an image.

    References

    1. van der Windt AE, Langenberg LC, Colaris JW, Eygendaal D. Which radial head fractures are best treated surgically? EFORT Open Reviews. 2024;9(5):413–421. DOI: 10.1530/EOR-24-0035.
    2. Goy C, van de Wall BJM, Beeres FJP, et al. Operative vs. nonoperative treatment in Mason type II fractures: a meta-analysis. JSES Reviews, Reports, and Techniques. 2026;6(3):100773. DOI: 10.1016/j.xrrt.2026.100773.
    3. Mulders MAM, Schep NWL, de Muinck Keizer RJO, et al. Operative vs. nonoperative treatment for Mason type 2 radial head fractures: a randomized controlled trial. Journal of Shoulder and Elbow Surgery. 2021;30(7):1670–1678. DOI: 10.1016/j.jse.2021.02.025.

    ← Elbow conditions

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Clavicle Fracture — When Is Surgery Needed?

    Polish version

    A clavicle fracture does not automatically mean surgery. Many fractures can be treated successfully without an operation, usually with a sling. The choice depends on the location of the fracture, the degree of displacement and comminution, the condition of the skin, shoulder-girdle stability, neurovascular findings, and the patient’s age and functional needs. In selected displaced fractures, surgery reduces the risk of nonunion, but it does not give every patient a better long-term functional result.

    How does a clavicle fracture happen?

    The most common mechanism is a direct fall onto the shoulder, for example while cycling, skiing or taking part in contact sport. A clavicle fracture can also occur in a road-traffic injury or after a fall onto an outstretched arm.

    The location matters as much as the fact that the bone is broken. Midshaft fractures behave differently from lateral fractures near the acromioclavicular joint, while medial fractures near the sternum are less common and raise a different set of anatomical concerns.

    What symptoms are typical?

    • pain over the clavicle that increases with arm movement;
    • swelling and bruising;
    • a palpable step, irregularity or deformity;
    • difficulty lifting the arm;
    • sometimes a clearly prominent bone fragment beneath the skin.

    The appearance of the shoulder alone cannot determine whether surgery is required. Clinical examination and X-rays are central to the decision.

    How is a clavicle fracture diagnosed?

    Plain X-rays are the first-line imaging test. They usually show the fracture location, displacement and comminution well enough to guide initial management. CT can be useful in selected fractures with more complex anatomy, particularly when standard radiographs do not answer the relevant clinical questions.

    Ultrasound does not replace X-ray for routine diagnosis of a clavicle fracture. It may, however, help assess selected associated soft-tissue problems around the shoulder.

    When does a clavicle fracture need urgent assessment?

    Many isolated clavicle fractures can be reviewed in an urgent or planned orthopaedic pathway depending on the injury. Some findings should not wait.

    • An open wound over the fracture or visible bone may indicate an open fracture.
    • Marked skin tenting, blanching or skin damage over a sharp fragment can mean that the fragment is threatening to break through the skin.
    • Numbness, weakness of the hand, a cold or pale limb, or abnormal pulses require assessment for nerve or vascular injury.
    • Shortness of breath, chest pain or a high-energy mechanism requires assessment for chest injury and other associated trauma.
    • Major shoulder-girdle deformity or suspicion of an associated scapular fracture may indicate a more unstable injury pattern.

    When can treatment be non-operative?

    Non-operative treatment is often appropriate when displacement is limited or the overall alignment is acceptable, the skin is not threatened and there is no neurovascular injury.

    In the acute phase, a sling is usually used. The American Academy of Orthopaedic Surgeons guideline favours a sling over a figure-of-eight brace for most acute clavicle fractures. The main purpose is pain relief and protection during the early phase of healing.

    This does not mean complete immobility for many weeks. Movement of the elbow, wrist and fingers is usually maintained from the outset, while shoulder movement is gradually increased according to pain, fracture stability and the treating clinician’s instructions.

    When is surgery more likely to be considered?

    Absolute or very strong indications for urgent operative treatment include open fractures, threatened skin, significant neurovascular injury and selected unstable injuries of the shoulder girdle.

    Outside those situations, the decision is more individual. Surgery is considered more often in adults with markedly displaced, shortened or comminuted midshaft fractures and in selected unstable fractures of the lateral end. Occupation, sport, arm dominance, patient expectations and the estimated risk of nonunion also matter.

    No single X-ray measurement determines the need for surgery on its own. Shortening and displacement are part of the assessment, but they need to be interpreted in the full clinical context.

    Does surgery give a better result?

    The best available evidence is more nuanced than simply saying that surgery is better. Meta-analyses of randomised trials in displaced midshaft clavicle fractures show that operative treatment reduces the risk of nonunion. It may also provide faster functional improvement during the first weeks.

    That functional advantage becomes much smaller over time. A meta-analysis of 10 randomised trials including 1,333 patients found a DASH difference of about 9.4 points at 6 weeks in favour of surgery, but the differences at 3 and 6 months were smaller and no longer clinically meaningful.

    A 2026 systematic review of 18 randomised trials including 1,201 adults treated non-operatively for displaced midshaft clavicle fractures found that function generally improved substantially during the first months. Nonunion occurred in about 14%, while approximately 13% later underwent surgery.

    The practical conclusion is that surgery can reduce the risk of union-related problems in appropriately selected patients, but it is not necessary for every adult with a displaced fracture.

    What are the disadvantages of surgery?

    Plate fixation or another form of internal fixation carries the usual operative risks, including infection, wound problems, nerve injury, implant-related symptoms and the possibility of another procedure, for example to remove symptomatic hardware. The benefit of reducing nonunion risk therefore has to be weighed against the risks and burden of surgery itself.

    How long does a clavicle fracture take to heal?

    Healing takes weeks and varies between patients. Pain often improves before full bony union is achieved, so feeling better does not mean the clavicle is ready for heavy loading or contact sport.

    Return to heavy work, strength training or sport with a meaningful risk of falling should be based on several factors together: pain resolution, recovery of movement and strength, and adequate fracture healing. Lighter daily activity is often possible earlier, but progression should remain individual.

    When should you seek reassessment during non-operative treatment?

    • pain is clearly increasing rather than gradually improving;
    • a new deformity appears or the fragments seem to be moving;
    • the skin over a fragment becomes increasingly tense or red;
    • numbness, weakness, or a change in the colour or temperature of the hand develops;
    • marked tenderness and lack of healing progress persist after many weeks;
    • general symptoms or wound problems develop after operative treatment.

    Key points for an orthopaedic surgeon

    • Many clavicle fractures can be treated without surgery.
    • X-ray is the main imaging test.
    • When non-operative care is chosen, a sling is generally preferred to a figure-of-eight brace.
    • Surgery is considered more strongly for open fractures, threatened skin, neurovascular injury, instability and selected markedly displaced fractures.
    • In adults with displaced midshaft fractures, surgery reduces nonunion risk, but long-term functional results often converge with non-operative treatment.
    • The decision should not be based on one radiographic measurement alone.

    Back to: Injuries and Fractures

    References

    1. American Academy of Orthopaedic Surgeons. Treatment of Clavicle Fractures: Evidence-Based Clinical Practice Guideline. Published December 2, 2022. Full AAOS guideline.
    2. Vaajala M, Tarkiainen J, Liukkonen R, Launonen AP, Mattila VM. Non-surgical treatment for displaced midshaft clavicle fractures: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-10208-1.
    3. Qvist AH, Jensen SL. Minimal early functional gains after operative treatment of midshaft clavicular fractures: a meta-analysis of 10 randomized controlled trials including 1333 patients. JSES International. 2024;8(3):400–406. DOI: 10.1016/j.jseint.2023.12.011.

    This material is educational and does not replace individual medical assessment of a fracture.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Ultrasound After a Muscle Injury — When Is It Worth Doing?

    Polish version

    Ultrasound is most useful after a muscle injury when the result may change management: for example when pain is severe, there is a substantial haematoma or weakness, a larger tear is suspected, or the clinician needs to determine whether the injury extends into the aponeurosis or tendon. Imaging is often unnecessary after a mild, typical strain. Ultrasound is particularly good for superficial muscles and dynamic assessment, whereas MRI may be more informative for deep injuries, tendon-origin injuries or marked loss of function.

    What can ultrasound show after a muscle injury?

    Normal muscle has an organised fibre pattern and visible connective-tissue septa on ultrasound. Injury can disrupt this architecture and produce focal fibre discontinuity, swelling, a haematoma or a change in muscle contour. In larger tears, ultrasound may also help define the extent of the defect and the relationship between the injured tissue ends.

    The exact location of the injury matters. Prognosis and treatment can differ between damage confined to muscle fibres and injury involving the myotendinous junction, aponeurosis or tendon. Modern sports-medicine classifications therefore pay attention to connective-tissue involvement rather than describing an injury only as a “small” or “large” tear.

    Does ultrasound need to be performed immediately?

    There is no single ideal hour or day for every muscle injury. A very early scan may underestimate a small lesion because haematoma and other tissue changes evolve over time. Conversely, prompt assessment can be important after a major injury, pronounced weakness or suspected tendon rupture because the result may affect the next step in treatment.

    In practice, ultrasound is often performed during the first few days when there is a specific clinical question. If symptoms and the initial scan do not agree, or the clinical picture changes, the examination can be repeated. This is one of ultrasound’s practical advantages: the same structure can be reassessed during healing without radiation exposure.

    When is ultrasound particularly useful?

    • after sudden pain during sprinting, jumping, kicking or forceful muscle lengthening;
    • when bruising, a palpable lump or a palpable defect develops after injury;
    • when there is clear weakness compared with the opposite side;
    • when muscle injury needs to be distinguished from tendon injury or another superficial soft-tissue problem;
    • when symptoms persist despite appropriately conducted treatment;
    • for follow-up of a larger haematoma, healing process or selected post-traumatic complications.

    How does an orthopaedic surgeon choose between ultrasound and MRI?

    These tests are not simply competitors; they often answer different questions. Ultrasound provides high-resolution imaging of superficial tissues, allows side-to-side comparison, can assess a muscle during movement and compression, and is convenient for serial follow-up. Its performance is more operator-dependent, however, and deep structures can be difficult to evaluate.

    MRI covers a larger anatomical field and depicts deep tissues more comprehensively. It is particularly useful when a substantial injury is suspected, when the proximal tendon origin may be involved, when there may be tendon avulsion from bone, when the clinical picture is unclear, or when detailed anatomy is required for operative planning. In severe hamstring injuries, MRI is especially valuable when proximal tendon-origin injury is suspected.

    Can ultrasound tell exactly when it is safe to return to sport?

    No. Imaging is only one part of the decision. Even when ultrasound shows healing, return to running, strength training or multidirectional sport should also reflect pain, range of motion, strength, tolerance of progressively increasing load and the demands of the specific activity.

    Research links some imaging features with time away from sport, but an image alone cannot reliably identify one exact day on which return becomes safe. A follow-up scan should therefore not replace functional assessment.

    How are muscle tears usually treated?

    Most partial muscle injuries are treated without surgery. Early management aims to control pain and excessive tissue bleeding, followed by a progressive return of movement, strength and load tolerance. Prolonged complete immobilisation is usually not beneficial; the loading programme should match the location and severity of the injury.

    Surgery is considered mainly for selected complete ruptures, tendon injuries with clinically important displacement, or other situations in which the injury anatomy makes a satisfactory result with non-operative treatment less likely.

    When does a muscle injury need urgent assessment?

    Urgent assessment is warranted when pain is very severe or rapidly worsening, swelling is large and increasing quickly, there is pronounced loss of strength, visible deformity, numbness, pallor or coolness of the limb. A large haematoma deserves particular caution in someone taking anticoagulant medication. Increasing pain that is disproportionate to the injury together with tense swelling can indicate compartment syndrome and requires immediate evaluation.

    The key point: imaging must fit the symptoms

    Musculoskeletal ultrasound is most useful when it follows from the history and clinical examination rather than being ordered “just in case”. It can answer many focused questions about muscle injury quickly, but not every episode of pain after exercise represents a tear and not every injury requires imaging.

    Back to: Muscle and Tendon Injuries

    See also: Diagnostic Tests

    References

    1. Palermi S, Scavone A, Anzà M, et al. Diagnostic ultrasound of muscle injuries: what the sports medicine clinician should know. British Journal of Sports Medicine. 2025;59(24):1759–1770. DOI: 10.1136/bjsports-2025-110255.
    2. Marrero AM, Mazza LA, Cedola N, et al. MRI and US in Hamstring Sports Injury Assessment: Anatomy, Imaging Findings, and Mechanisms of Injury. RadioGraphics. 2025;45(5). DOI: 10.1148/rg.240061.
    3. Martin RL, Cibulka MT, Bolgla LA, et al. Hamstring Strain Injury in Athletes. J Orthop Sports Phys Ther. 2022;52(3):CPG1–CPG44. DOI: 10.2519/jospt.2022.0301.

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

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

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

    Polish version · Explore Knee Conditions

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

    What happens during a patellar dislocation?

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

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

    What should you do immediately after the injury?

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

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

    What symptoms are typical after a dislocation?

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

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

    How is a first-time patellar dislocation assessed?

    History and examination

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

    X-ray

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

    MRI

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

    When is CT needed?

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

    Is a first dislocation usually treated without surgery?

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

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

    What does rehabilitation involve?

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

    When is surgery considered after a first dislocation?

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

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

    How high is the risk of recurrence?

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

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

    Warning signs

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

    Key points for an orthopaedic surgeon

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

    References

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

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Mechanism of Injury — Why Does It Matter?

    Polish version · Explore Injuries and Fractures

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

    “I twisted my knee” is not enough information

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

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

    Four elements of a useful injury description

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

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

    How an orthopaedic surgeon uses the injury mechanism to select investigations

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

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

    Examples that change the diagnostic reasoning

    Sudden acceleration or deceleration

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

    Twisting on a weight-bearing leg

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

    Pain without one clear event

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

    Why can memory of the event be unreliable?

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

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

    Mechanism must not delay urgent action

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

    Practical takeaway

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

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

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

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

    Polish version · For Patients

    Where is the scaphoid?

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

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

    Which symptoms raise suspicion?

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

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

    Why can the first X-ray be normal?

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

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

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

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

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

    How is a scaphoid fracture treated?

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

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

    What should be avoided while a fracture is still suspected?

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

    When is urgent assessment needed?

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

    Other causes of thumb-side wrist pain

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

    References

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

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Fifth Metatarsal Base Fracture — Avulsion or Jones Fracture?

    Not every fracture at the base of the fifth metatarsal is a Jones fracture. An avulsion fracture lies closer to the tip of the bone and usually heals more readily. A Jones fracture is slightly more distal, in an area with less favourable blood supply, so it more often requires prolonged protection from loading, closer follow-up and, in selected patients, surgery.

    Polish version · For Patients

    Where is the fifth metatarsal?

    The fifth metatarsal runs along the outer side of the foot and connects with the little toe. Its proximal end forms the bony prominence that can be felt along the lateral border of the foot. Several different injuries can occur in this small region, with different prognoses, so the phrase “fracture of the fifth metatarsal base” is not always specific enough to plan treatment.

    Avulsion, Jones and stress fractures — what is the difference?

    Zone 1: avulsion fracture

    A fragment is pulled away from the tuberosity at the base of the bone. This injury often accompanies an inversion-type ankle or foot injury and may initially resemble a simple ankle sprain. Most small, stable fractures in this zone are treated without surgery.

    Zone 2: Jones fracture

    The fracture line lies at the metaphyseal-diaphyseal junction, typically near the articulation between the fourth and fifth metatarsals. Blood supply is less favourable here, increasing the risk of delayed union or nonunion. The term “Jones fracture” should not be used for every fracture along the lateral border of the foot.

    Zone 3: stress fracture

    This occurs farther distally toward the shaft, often after repetitive loading. Pain may build gradually without a single clear injury. It has to be distinguished from other metatarsal stress fractures.

    Which symptoms are important?

    • pain along the outer border of the foot, worse with walking;
    • focal tenderness over the base or proximal fifth metatarsal;
    • swelling and bruising along the lateral foot;
    • difficulty bearing weight;
    • pain that increases with running or jumping even without a single acute injury.

    Similar symptoms can come from an ankle sprain, injury around the cubometatarsal joint or peroneal tendon pathology. The point of maximal tenderness and the injury mechanism are therefore more useful than the general label “sprained foot”.

    How does an orthopaedic surgeon establish the diagnosis?

    After an acute injury, standard foot radiographs in appropriate views are the first-line investigation. They help define the fracture zone, displacement and any articular involvement. In a stress-type presentation, early X-rays can still be normal; further imaging should then be selected according to the clinical examination.

    CT can be useful when union is difficult to assess, the fracture pattern is complex or surgery is being planned. MRI is particularly useful for a suspected early stress fracture when radiographs remain normal. Ultrasound may show some cortical abnormalities or associated soft-tissue injuries, but it does not replace standard imaging of the entire fracture.

    Is surgery always required?

    No. Stable avulsion fractures are most often treated functionally in a walking boot or stiff-soled shoe, with weight bearing adjusted to pain and the treatment plan. Follow-up is used to confirm satisfactory healing.

    For an acute Jones fracture, non-operative treatment usually requires more careful protection and a period of restricted weight bearing. Surgery is considered more often when there is displacement, failure of healing to progress, a stress fracture, refracture, or in athletes for whom a predictable return to high loads is particularly important. Activity level alone does not replace assessment of the fracture pattern and a discussion of surgical risk.

    Why does follow-up of union matter?

    Pain can improve before the bone has regained full strength. Returning too early to running, jumping or cutting sports increases the risk of refracture. Progression of loading should be based on symptoms, examination, fracture type and evidence of healing rather than simply the number of weeks since injury.

    When is urgent assessment needed?

    • the foot is visibly deformed or a wound exposes bone;
    • the toes become cold, pale or blue;
    • numbness is increasing or the toes cannot be moved normally;
    • pain and swelling increase rapidly despite elevation;
    • it is impossible to take a few steps after the injury;
    • persistent lateral foot pain remains after an earlier diagnosis of a “sprain”.

    Sources

    1. Chloros GD, Kakos CD, Tastsidis IK, Giannoudis VP, Panteli M, Giannoudis PV. Fifth metatarsal fractures: an update on management, complications, and outcomes. EFORT Open Reviews. 2022;7(1):13–25. DOI: 10.1530/EOR-21-0025.
    2. Attia AK, Taha T, Kong G, Alhammoud A, Mahmoud K, Myerson M. Return to Play and Fracture Union After the Surgical Management of Jones Fractures in Athletes: A Systematic Review and Meta-analysis. American Journal of Sports Medicine. 2021;49(12):3422–3436. DOI: 10.1177/0363546521990020.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

    Related postoperative rehabilitation protocol

    Fifth metatarsal fracture — postoperative rehabilitation. The rehabilitation pathway depends on the procedure performed.