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Tomasz Poboży

Kategoria: Knee (EN)

English-language patient articles about knee pain, instability, menisci, ligaments and joint replacement.

  • 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.

  • Pes Anserine Pain — A Cause of Medial Knee Pain

    Pain several centimetres below the medial knee joint line, aggravated by stairs, rising from a chair or prolonged activity, can come from the pes anserine region. Not every case of medial knee pain is caused by the pes anserinus, however: a meniscal problem, medial collateral ligament injury or knee osteoarthritis can produce similar symptoms.

    Polish version: Gęsia stopka — ból po wewnętrznej stronie kolana

    What is the pes anserinus?

    The pes anserinus is the combined insertional region of three tendons on the medial side of the proximal tibia: sartorius, gracilis and semitendinosus. A bursa lies between these tendons and the deeper tissues. Symptoms may reflect tendon overload, irritation of the bursa or a combination of both, so the label “pes anserine bursitis” does not always describe the full clinical picture.

    How does pes anserine pain usually present?

    • pain is usually located on the medial side of the tibia, approximately 4–5 cm below the knee joint line,
    • there may be focal tenderness when the area is pressed with one finger,
    • stairs, rising from a chair, longer walks, running or kneeling can aggravate symptoms,
    • the pain may coexist with knee osteoarthritis, so there can be more than one source of symptoms.

    If the most painful point is directly at the joint line, there is true mechanical locking, or symptoms began after a twisting injury, a meniscal lesion should also be considered.

    How does an orthopaedic surgeon assess a pes anserine problem?

    The history and a careful examination of the knee are the foundation of diagnosis. Pain location is particularly useful because symptoms from the pes anserine region can resemble pain arising from the medial meniscus. The examination also assesses range of motion, ligament stability, limb alignment, muscle strength and other possible sources of pain.

    Is ultrasound necessary?

    Not always. A typical clinical presentation may be recognised without additional imaging. Ultrasound can be useful when the tendons, bursa and neighbouring tissues need to be assessed, when a fluid-containing lesion needs to be distinguished from other structures, or when a precise injection is being planned. The absence of obvious bursal fluid does not exclude symptoms from this region, and an abnormal ultrasound finding alone does not prove that it is the only source of pain.

    When are X-ray or MRI more useful?

    Plain radiographs are often more important than ultrasound when osteoarthritis or another bony or joint-related cause is suspected. MRI may be considered when symptoms suggest an intra-articular problem, meniscal injury or ligament damage and the clinical examination together with simpler imaging does not provide a satisfactory answer.

    How is it treated?

    Treatment usually starts non-operatively. The aim is not to rest the leg completely for many weeks, but to reduce and restructure loading so that the tissues can gradually regain tolerance to activity.

    • activities that clearly provoke pain can be reduced temporarily,
    • strength and movement-control exercises can then be progressed gradually,
    • when knee osteoarthritis coexists, treatment should also address the joint itself,
    • pain-relieving or anti-inflammatory medication should be used only with appropriate attention to contraindications and the patient’s other medical conditions.

    Can an injection help?

    For some people with persistent symptoms, an injection into the painful region or bursa may be considered. Randomized studies have reported short-term improvement after corticosteroid injection, and a trial comparing ultrasound-guided with landmark-based injection found a greater reduction in pain in the ultrasound-guided group. These are relatively small studies, however, and they do not mean that injection should be the first-line treatment for every patient.

    When an injection is considered, accurate needle placement is only one part of the decision. The procedure still needs to be matched to a plausible pain source and a clear clinical indication.

    What about PRP, shockwave therapy and other methods?

    PRP, shockwave therapy, dextrose and other injection-based approaches have also been studied. Results from individual trials are heterogeneous, protocols differ and follow-up is often short. The available evidence therefore does not establish one of these methods as universally superior. Correctly identifying the source of pain and addressing coexisting knee pathology remain more important than choosing a treatment solely because it is technically available.

    When does medial knee pain require urgent assessment?

    • the knee is rapidly swelling, clearly hot and red, particularly with fever,
    • after an injury, weight bearing is impossible or there is a deformity,
    • the knee is truly locked and cannot be fully extended,
    • there is increasing one-sided calf swelling, especially with shortness of breath or chest pain,
    • pain is severe, continuously worsening or accompanied by systemic symptoms.

    Key point: pain location is not yet a diagnosis

    The pes anserine region is one possible extra-articular source of medial knee pain, but symptoms may coexist with osteoarthritis, a meniscal problem or another condition. Treatment should therefore follow the clinical assessment, with ultrasound, X-ray or MRI selected to answer a specific diagnostic question rather than used automatically.

    References

    1. Poboży T, Janowski K, Domański P, Michalak K, Poboży K, Domańska-Poboża J, Konarski W, Chuść I, Kielar M. The Hidden Burden of Entheseal Pathology in Lower-Limb Pain: A Real-World Ultrasound Study of 667 Adults. Mayo Clinic Proceedings: Innovations, Quality & Outcomes. 2026;10(4):100734. DOI: 10.1016/j.mayocpiqo.2026.100734. This study concerned a broader group of lower-limb enthesopathies and tendinopathies, not pes anserine pathology alone.
    2. Hasan M, Berkovich Y, Khatib M, et al. Knee Bursae: A Comprehensive Review of Clinical Evaluation, Imaging Differentiation, and the Expanding Role of Biologic Therapies. Cartilage. 2025. DOI: 10.1177/19476035251362434.
    3. Zavarei S, Khalifeh Soltani S, Raissi G, et al. Efficacy of ultrasonography-guided compared to surface landmark-based corticosteroid injection for people with chronic pes anserine tendinitis or bursitis: a randomised controlled trial. International Journal of Therapy and Rehabilitation. 2023;30(4):1–10. DOI: 10.12968/ijtr.2021.0140.
    4. Babaei-Ghazani A, Eftekharsadat B, Soleymanzadeh H, ZoghAli M. Ultrasound-Guided Pes Anserine Bursitis Injection Choices: Prolotherapy or Oxygen-Ozone or Corticosteroid: A Randomized Multicenter Clinical Trial. American Journal of Physical Medicine & Rehabilitation. 2024;103(4):310–317. PMID: 37752656.

    ← Knee Conditions

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Sport After Hip or Knee Replacement — What Can You Do and When?

    Polish version

    After an uncomplicated hip or knee replacement, most patients can gradually return to low-impact activity such as walking, cycling and swimming once the wound has fully healed. There is no single date when every sport becomes safe. Running, jumping, contact sports and activities involving sudden changes of direction require much more cautious assessment because higher loads also increase the consequences of a fall or injury.

    The important question is not only how many weeks have passed since surgery. Healing, muscle strength, balance, range of motion, gait stability, the joint’s response to exercise, the type of replacement and the patient’s previous experience in the sport all matter.

    Do you have to give up sport after joint replacement?

    No. The purpose of joint replacement is to improve function and quality of life, and regular physical activity is an important part of maintaining overall fitness. Current evidence shows that a large proportion of patients return to recreational activity after surgery, particularly low-impact sports.

    In a meta-analysis of knee arthroplasty including 45 studies and 14,498 knees, approximately 85% of patients returned to physical activity or sport, with a median return time of 4.1 months. The authors emphasised, however, that certainty of evidence for the analysed outcomes was very low. These figures describe a population; they are not an individual clearance date for sport.

    A similar pattern is seen after total hip arthroplasty. In a review of 57 studies, the pooled return-to-sport rate was about 85%, with a mean time of approximately 16 weeks. Return to low-intensity activity was much more common than return to high-impact sport.

    Which activities are usually easiest to resume?

    Return is most predictable for activities with lower joint loading and a lower risk of falling. These commonly include:

    • walking and brisk walking;
    • stationary cycling, followed later by outdoor cycling in safe conditions;
    • swimming once the wound is fully healed;
    • water-based exercise;
    • golf;
    • controlled strength training appropriate to the stage of recovery.

    This does not mean that every activity can be restarted immediately. Entering a swimming pool before the wound has fully healed can create wound problems, while cycling in traffic requires substantially more balance and reaction speed than exercising on a stationary bike.

    What about running, tennis, skiing and contact sports?

    The greater the impact, jumping, cutting and risk of falling, the less useful a simple rule such as “you can return after this many weeks” becomes. High-intensity sports are resumed much less often after joint replacement than low-impact activities.

    This is particularly relevant to regular running, contact sports, games with frequent changes of direction, intensive tennis, combat sports and activities with a substantial risk of falling. The issues are not limited to implant wear: dislocation, periprosthetic fracture and an injury requiring another operation also need to be considered.

    This does not amount to an automatic ban on every demanding sport. A patient who has skied recreationally for years and regains full control of the limb after surgery is different from someone planning to start a high-fall-risk sport only after joint replacement. The decision should be individual.

    Is return to sport the same after hip and knee replacement?

    Not entirely. After hip replacement, early limitations may relate to tissue healing, muscle weakness, pelvic control and fall risk. After knee replacement, swelling, limited flexion, stiffness and quadriceps weakness often remain relevant for longer.

    After unicompartmental knee arthroplasty, some patients return to activity more readily than after total knee arthroplasty. In the recent meta-analysis, the probability of returning to physical activity or sport was higher after unicompartmental replacement, but the certainty of this finding was rated very low. It should not be treated as a guarantee of faster return for an individual patient.

    How does an orthopaedic surgeon assess readiness to increase the load?

    Before moving to more demanding activity, function is more useful than the calendar. Favourable conditions for increasing load generally include:

    • a fully healed wound;
    • no increasing pain at rest;
    • stable walking without a pronounced limp;
    • enough range of motion for the planned activity;
    • adequate strength in the operated limb;
    • good balance and movement control;
    • no marked increase in swelling after the current level of exercise.

    If a higher load produces a clear increase in pain or swelling that does not return to the previous level, progression may have been too rapid.

    How should return to sport be progressed in practice?

    A staged return is the safest approach. First rebuild basic function: walking, range of motion, strength and balance. Then increase exercise duration and intensity. More complex sport-specific movements should be introduced later.

    Avoid increasing duration, intensity and technical difficulty all at once. For sports requiring rapid reactions, it is useful to regain movement control first in a safer environment. Patients returning to more demanding disciplines may benefit from physiotherapy assessment and an agreed plan with the operating surgeon.

    When should activity be stopped and medically reviewed?

    New severe pain after a fall, sudden inability to bear weight, obvious deformity, a sensation that the joint has moved out of position or a sudden loss of function requires urgent assessment. Fever, increasing redness, warmth or wound drainage also warrants prompt review.

    New calf pain and swelling may require assessment for deep-vein thrombosis. Shortness of breath, chest pain, coughing up blood or fainting requires immediate medical attention.

    The key principle

    Returning to activity after joint replacement is desirable, but the type of sport should match the stage of healing, current function and the risk of injury. Average time points from studies are useful for planning recovery, but they do not replace assessment of the individual patient.

    In a publication by Tomasz Poboży and Maciej Kielar on selection of hip prostheses, everyday activity and the patient’s future plans were highlighted as relevant elements in treatment planning. That paper does not define the timing of return to sport, but it illustrates why activity level should already be considered when planning surgery and selecting an implant strategy.

    Back to: Before and After Orthopaedic Surgery

    References

    1. Poboży T, Kielar M. The use of various types of hip prostheses depending on the patient’s age and level of everyday activity. Medical Studies/Studia Medyczne. 2015;31(3):213–222. DOI: 10.5114/ms.2015.54763.
    2. Braz R, Gomes E, Valente C, et al. High rate of return to low-impact physical activity or sports after total and unicompartmental knee arthroplasty: A systematic review with meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2026;34(9):3415–3428. DOI: 10.1002/ksa.70267. PMID: 41527885.
    3. Pasqualini I, Emara AK, Rullan PJ, et al. Return to Sports and Return to Work After Total Hip Arthroplasty: A Systematic Review and Meta-analysis. JBJS Rev. 2023;11(8). DOI: 10.2106/JBJS.RVW.22.00249. PMID: 37549241.
    4. Pasqualini I, Emara AK, Rullan PJ, et al. Return to Sports and Return to Work After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. JBJS Rev. 2023;11(7). PMID: 37499045.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • When Can You Stop Using Crutches After Hip or Knee Replacement?

    Polish version

    After an uncomplicated hip or knee replacement, the decision to stop using crutches should not be based on the number of days since surgery alone. What matters most is whether you can walk safely, without a clear limp or giving way of the operated leg, with adequate balance and muscle control. Many patients begin weight-bearing very early, often as tolerated, but progression from two crutches to one and then to unaided walking should reflect the operation performed and the individual postoperative instructions.

    Can you put weight on the operated leg immediately after joint replacement?

    After a typical, stable primary hip or knee replacement, contemporary recovery programmes favour early mobilisation and getting out of bed as soon as practical. ERAS recommendations for hip and knee replacement support early mobilisation, while current physical therapy guidance after total knee arthroplasty emphasises early recovery of walking, balance and efficient movement patterns.

    For uncemented total hip arthroplasty, a meta-analysis of 17 studies found no evidence that immediate unrestricted weight-bearing increased excessive stem micromotion, failure of bone integration or revision risk compared with partial weight-bearing. This does not mean, however, that every patient after every operation may load the leg without restriction.

    When may the instructions be different?

    Temporary weight-bearing restrictions may be needed after revision surgery, an intraoperative or periprosthetic fracture, bone grafting, an osteotomy, repair of additional soft-tissue structures, or whenever the reconstruction needs protection while healing. For that reason, the operating surgeon’s discharge instructions take priority over any general rehabilitation timetable.

    How do patients usually progress from two crutches to one?

    A common sequence is a walking frame or two crutches, followed by one crutch or a walking stick, and finally unaided walking. There is no requirement for every patient to move through each stage at the same time.

    • Two crutches or a walking frame are useful while gait remains uncertain, the leg is weak, pain limits loading or there is a meaningful risk of losing balance.
    • One crutch or a walking stick may be the next step when the patient can safely transfer weight onto the operated leg without clearly increasing the limp.
    • Unaided walking is best introduced when removing support does not worsen gait quality.

    When one crutch or a walking stick is used after hip or knee surgery, it is usually held on the side opposite the operated leg. This reduces the demand on the muscles that stabilise the pelvis and can help maintain a better gait pattern.

    How can you tell when it is reasonable to try walking without crutches?

    Functional criteria are more useful than a fixed date. Reducing support is reasonable when:

    • you can walk on a level surface without a pronounced limp;
    • the operated leg does not feel as though it is giving way or suddenly buckling;
    • your balance allows you to turn, stop and rise from a chair safely;
    • pain and swelling remain controlled after increasing your step count;
    • after knee replacement, quadriceps control is sufficient to keep the knee stable during weight-bearing;
    • after hip replacement, pelvic control is sufficient and walking without a crutch does not produce marked trunk leaning;
    • the orthopaedic surgeon has not prescribed a temporary weight-bearing restriction.

    Is it better to keep one crutch for longer or stop using it as soon as possible?

    If walking without the crutch produces a clear limp, shorter steps, trunk leaning or reluctance to load the operated leg, it is usually more sensible to continue using support for a while and work on strength and gait quality. The goal is not to “get rid of the crutches” as quickly as possible, but to regain safe and reasonably symmetrical walking.

    Conversely, there is no benefit in continuing with two crutches purely out of habit when there are no loading restrictions, walking is stable and the patient can reduce support without deteriorating gait. Current guidance after knee replacement emphasises functional training, balance and gait retraining rather than the passage of time alone.

    What if pain or swelling increases after reducing support?

    A temporary increase in muscle fatigue after greater activity can occur. If changing the way you walk clearly increases pain, swelling or limping, reduce the load and briefly return to the previous level of support. Symptoms that worsen from day to day should prompt assessment of the cause rather than continued attempts to push through them.

    When should you seek urgent assessment rather than wait for a routine review?

    Urgent assessment is particularly important if there is:

    • sudden shortness of breath, chest pain or fainting;
    • markedly increasing one-sided calf swelling with pain or tenderness;
    • fever accompanied by increasing redness, warmth or wound drainage;
    • sudden severe pain after a fall or twisting injury;
    • a new deformity, obvious limb shortening or inability to bear weight after previously making progress;
    • a sudden substantial loss of function instead of gradual improvement.

    Stopping crutches is only one stage of recovery

    Independent walking does not mean rehabilitation is complete. Strength, balance and tolerance of longer periods of activity continue to improve. Readiness for driving, returning to work and returning to sport should be assessed separately rather than inferred simply from the ability to walk without a crutch.

    Back to: Before and After Orthopaedic Surgery

    References

    1. Bove AM, Carroll LA, Cone S, et al. Clinical practice guideline for physical therapist management of total knee arthroplasty: revision 2026. Physical Therapy. 2026;106(7). DOI: 10.1093/ptj/pzag058.
    2. Huang L, Han W, Qi W, et al. Early unrestricted vs. partial weight bearing after uncemented total hip arthroplasty: a systematic review and meta-analysis. Front Surg. 2023;10:1225649. DOI: 10.3389/fsurg.2023.1225649.
    3. Wainwright TW, Gill M, McDonald DA, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. Acta Orthop. 2020;91(1):3–19. DOI: 10.1080/17453674.2019.1683790.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Can You Kneel After Total Knee Replacement?

    Polish version

    Yes. Once a total knee replacement has healed properly, kneeling is generally not considered harmful to the implant. For many patients it is still uncomfortable or difficult because of scar tenderness, numb skin, pressure sensitivity, stiffness or fear of putting weight through the operated knee. Kneeling should not be attempted on a fresh or incompletely healed wound, and the timing of return should reflect wound healing and the individual postoperative plan.

    Can kneeling damage a knee replacement?

    A common concern is whether direct pressure through the knee can loosen or damage the prosthesis. Available evidence does not indicate that kneeling, once healing is complete, is harmful to a normally functioning total knee replacement. The American Academy of Orthopaedic Surgeons likewise notes that kneeling may be uncomfortable after total knee arthroplasty but is not considered damaging to the implant.

    That does not mean every patient will kneel easily. A review of function after total knee replacement found that 60–80% of patients reported some difficulty with kneeling or avoided it. Importantly, the perception that “I cannot kneel” does not always match the person’s actual ability to perform the task when it is assessed directly.

    Why can kneeling remain difficult after surgery?

    • Scar tenderness — direct pressure on the front of the knee may remain uncomfortable for a long time.
    • Skin numbness — small cutaneous sensory branches can be divided during the surgical approach, leaving an area of reduced sensation, often lateral to the scar. This commonly becomes less troublesome with time but may not disappear completely.
    • Pressure pain — even a well-functioning knee can remain sensitive on a hard surface.
    • Limited range of motion — deeper kneeling requires sufficient flexion, although range of motion does not explain all of the difference between people who kneel and those who avoid it.
    • Fear of damaging the implant — some patients never try because they believe kneeling is prohibited.
    • Other musculoskeletal limitations — the opposite knee, hip, spine, muscle weakness or difficulty getting back up from the floor may be more limiting than the replaced knee itself.

    When can you start trying?

    There is no single date that is appropriate for everyone. The key prerequisite is complete wound healing. Do not put direct pressure on a fresh scar, a wound that is still draining, an area with a scab, increasing redness or marked tenderness. Some centres advise waiting several months, while others allow gentle attempts earlier once the wound is fully healed. Differences reflect surgical technique, the course of healing and the rehabilitation plan.

    Function and safety are more useful than the calendar alone. Before kneeling, the patient should have stable walking, adequate strength and the ability to lower themselves toward the floor and get up again safely.

    How can kneeling be reintroduced safely?

    First attempts are best made in a controlled setting with a stable support for the hands. A soft mat, thick pad or cushion can reduce focal pressure on the front of the knee. There is no need to move immediately into a deep kneeling position or stay on the knees for a prolonged period.

    A sensible progression is to begin with brief contact on a soft surface, then gradually increase time and load as long as pain and swelling are not increasing. When the main difficulty is getting down to the floor and standing up again rather than kneeling itself, practising those transitions with a physiotherapist can be useful. Studies suggest that instruction and task-specific practice can improve actual kneeling ability.

    Is a large amount of knee flexion required?

    Greater flexion makes some kneeling positions easier, but it is not the only requirement. Some patients with good range of motion still avoid kneeling because of tenderness or fear, while others can achieve a functional kneel despite only moderate flexion. The flexion angle alone therefore does not predict whether kneeling will be comfortable.

    Does the type of implant or surgery matter?

    The influence of incision type, implant design and patellar resurfacing has been studied, but the findings do not provide a simple way to predict kneeling ability. A meta-analysis of 36 studies found some associations between surgical technique and kneeling, while also emphasising the need for better randomised evidence. There is no good basis for selecting an implant solely to optimise this one activity.

    If regular kneeling is essential for work, gardening, a hobby or religious practice, it is worth discussing this before surgery. It should form part of the conversation about realistic functional goals after knee replacement.

    What about kneeling after partial knee replacement?

    Kneeling can also be difficult after unicompartmental knee replacement, although available evidence suggests that appropriate instruction may improve the ability to perform the task. Those findings should not be transferred automatically to every total knee replacement because the extent of surgery and biomechanics differ.

    When should kneeling be avoided and the knee assessed?

    Kneeling should be postponed when the wound has not fully healed or when symptoms suggest a postoperative complication. Earlier assessment is particularly important for:

    • drainage from or separation of the wound,
    • increasing redness and marked warmth around the operated knee,
    • fever together with worsening knee symptoms,
    • sudden or rapidly increasing pain and swelling,
    • new instability or a clear deterioration in function,
    • calf pain and swelling, especially if accompanied by shortness of breath or chest pain, which requires urgent medical assessment.

    Kneeling is only one part of returning to function

    Patients after knee replacement also ask about driving, work and sport. Each activity requires a different combination of strength, control and tolerance. Someone who can walk several kilometres comfortably may still dislike pressure on the scar while kneeling. Conversely, difficulty kneeling does not by itself mean that the knee replacement is functioning poorly.

    Key points for an orthopaedic surgeon

    After a well-healed total knee replacement, kneeling itself is not generally considered harmful to the implant. The more common barriers are scar tenderness, numbness, pressure pain, stiffness and fear of damaging the prosthesis. Return should be gradual, initially on a soft surface, and only once the wound has healed. Increasing pain, swelling, wound problems or other warning signs should be assessed before kneeling is resumed.

    Back to: Before and After Orthopaedic Surgery

    References

    • Wylde V, Artz N, Howells N, Blom AW. Kneeling ability after total knee replacement. EFORT Open Rev. 2019;4(7):460–467. DOI: 10.1302/2058-5241.4.180085.
    • Nadeem S, Mundi R, Chaudhry H. Surgery-related predictors of kneeling ability following total knee arthroplasty: a systematic review and meta-analysis. Knee Surg Relat Res. 2021;33:36. DOI: 10.1186/s43019-021-00117-z.
    • Wallace SJS, Berger RA. Most Patients Can Kneel After Total Knee Arthroplasty. J Arthroplasty. 2019;34(5):898–900. DOI: 10.1016/j.arth.2019.01.047.
    • American Academy of Orthopaedic Surgeons. Total Knee Replacement. OrthoInfo. Accessed 10 September 2026.

    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.

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

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

    Polish version · For Patients

    Where is the semimembranosus tendon?

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

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

    What does semimembranosus tendinopathy usually feel like?

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

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

    What else can cause pain behind the knee?

    Baker’s cyst

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

    Meniscus and cartilage

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

    Other tendons and muscles

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

    Deep vein thrombosis

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

    What does the clinical examination involve?

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

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

    When is ultrasound useful?

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

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

    When is MRI appropriate?

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

    How is it treated?

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

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

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

    Are injections or surgery needed?

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

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

    Red flags

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

    Key point for an orthopaedic surgeon

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

    References

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

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

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.