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Tomasz Poboży

Kategoria: Patient Knowledge (EN)

Evidence-informed orthopaedic information for patients in English: symptoms, injuries, diagnostics, treatment, surgery and recovery.

  • Joint Aspiration — Why Is Synovial Fluid Collected?

    Joint aspiration, or arthrocentesis, is performed mainly to collect synovial fluid when the cause of an effusion needs to be clarified — particularly when infection, gout or another inflammatory process is suspected. Aspiration can also reduce pressure from a large effusion, but not every swollen joint needs to be drained. Ultrasound can confirm that fluid is present, identify the best pocket and help guide the needle safely, although it is not essential for every straightforward aspiration.

    Polish version: Punkcja stawu — po co pobiera się płyn?

    When is joint aspiration particularly important?

    The most urgent indication is suspected septic arthritis. A joint that becomes acutely very painful, swollen and hot requires prompt assessment, and infection remains possible even without a high fever. The SANJO guideline recommends aspiration as soon as septic arthritis is suspected because synovial-fluid analysis is central to confirming or excluding the diagnosis.

    Synovial fluid may also be collected when gout or calcium pyrophosphate crystal arthritis is suspected, when a large or atypical effusion appears after trauma, when the cause of an inflammatory effusion is unclear, or when fluid rapidly returns after previous aspiration.

    What is tested in synovial fluid?

    Depending on the clinical question, the sample may be assessed for the white-cell count and differential, crystals, Gram stain and bacterial culture. Additional microbiological or molecular testing can be selected when indicated.

    No single synovial-fluid white-cell threshold independently proves or excludes infection in every patient. Results must be interpreted together with symptoms, examination, blood tests, imaging when appropriate and the patient’s risk factors.

    Why is aspiration important when infection is suspected?

    Blood tests alone are not enough. A normal C-reactive protein concentration does not reliably exclude septic arthritis. In a clinically stable patient without sepsis, synovial fluid should generally be obtained for microbiology before antibiotics are started, because prior antibiotic treatment can reduce culture yield. This principle does not mean delaying urgent antimicrobial treatment in an unstable or septic patient.

    The presence of crystals does not automatically rule out a simultaneous bacterial infection. Gout or calcium pyrophosphate deposition and septic arthritis can coexist, so a crystal-positive sample still has to be interpreted in the full clinical context.

    Can the appearance of the fluid give the diagnosis?

    No. Cloudy, bloody or unusually coloured fluid may provide a clue, but visual appearance is not sufficiently reliable to establish the cause of an effusion. Laboratory analysis is needed when infection, crystal disease or another inflammatory process is a realistic possibility.

    What does ultrasound add?

    Ultrasound can confirm whether a collection is present and show where it is largest. It can help the operator avoid vessels, tendons and other sensitive structures, visualise the needle as it advances, and improve access when the effusion is small, deep or anatomically difficult. It can also be useful after a previous unsuccessful landmark-guided attempt.

    A systematic review of knee arthrocentesis found ultrasound guidance to be associated with greater procedural accuracy, less procedural pain and a larger volume of aspirated fluid compared with landmark-guided aspiration. A more recent meta-analysis in knee osteoarthritis also reported better accuracy. These findings do not mean that every uncomplicated knee aspiration requires ultrasound; the value of guidance depends on the joint, the amount and location of fluid, anatomy and operator experience.

    How is the procedure performed?

    The skin is prepared using strict aseptic technique and a needle is introduced into the joint through an appropriate route. When infection is suspected, meticulous asepsis is especially important. The needle should not be passed through an abscess and, where possible, should avoid inflamed or infected skin.

    Aspiration and injection are separate decisions. If joint infection is a realistic possibility, corticosteroid should not be injected before the situation has been clarified. Removing fluid may relieve pressure, but aspiration itself does not treat the underlying cause of the effusion.

    What about a painful joint replacement?

    A painful or swollen prosthetic joint requires a separate diagnostic pathway. Aspiration can be an important part of investigating periprosthetic joint infection, but interpretation follows dedicated criteria and should not be reduced to simply “draining fluid” from the joint.

    When does a swollen joint need urgent assessment?

    • acute severe joint pain with rapidly increasing swelling,
    • a red or hot joint, with or without fever or chills,
    • inability to bear weight or move the joint because of pain,
    • immunosuppression, diabetes, a recent procedure or another active infection together with a new effusion,
    • a prosthetic joint with sudden pain, fever, wound drainage or a marked loss of function.

    Septic arthritis can damage articular cartilage rapidly, so suspected infection should not be managed by simply waiting to see whether the swelling settles.

    Questions to discuss with an orthopaedic surgeon

    Does every knee effusion need aspiration?

    No. Aspiration is most useful when the result can clarify the diagnosis, when infection or crystal disease is suspected, or when a large effusion is causing significant symptoms. A small, clinically explainable effusion may not require aspiration.

    Does every aspiration need ultrasound?

    No. Ultrasound is especially useful when there is little fluid, anatomy is atypical, the joint is deep or access is difficult, or a previous attempt has failed. A straightforward aspiration of an obvious superficial effusion may be performed accurately without imaging by an experienced operator.

    Can the fluid be judged by colour alone?

    No. Appearance can suggest possibilities but cannot reliably distinguish infection, crystal disease and other inflammatory causes. Laboratory testing remains necessary when the diagnosis matters.

    References

    1. Ravn C, Neyt J, Benito N, et al.; SANJO guideline group. Guideline for management of septic arthritis in native joints (SANJO). J Bone Joint Infect. 2023;8:29–37. DOI: 10.5194/jbji-8-29-2023.
    2. Uson J, Rodriguez-García SC, Castellanos-Moreira R, et al. EULAR recommendations for intra-articular therapies. Ann Rheum Dis. 2021;80(10):1299–1305. DOI: 10.1136/annrheumdis-2021-220266.
    3. Wu T, Dong Y, Song HX, Fu Y, Li JH. Ultrasound-guided versus landmark in knee arthrocentesis: A systematic review. Semin Arthritis Rheum. 2016;45(5):627–632. DOI: 10.1016/j.semarthrit.2015.10.011.
    4. Deng X, Li D, Li Y. Ultrasound-guided versus blind arthrocentesis in knee osteoarthritis: A systematic review and meta-analysis. Medicine (Baltimore). 2025. DOI: 10.1097/MD.0000000000041389.

    ← Treatments and Procedures

    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.

  • 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.

  • Adult Hip Dysplasia — Symptoms, Diagnosis and Treatment

    Adult hip dysplasia means that the acetabulum provides insufficient coverage of the femoral head. It can cause groin pain, a sense of overload or instability and, over time, contribute to labral and cartilage damage. The diagnosis should not be made from a single X-ray angle alone: symptoms, clinical examination and appropriately performed imaging all matter.

    Polish version: Dysplazja biodra u dorosłych — objawy, diagnostyka i leczenie

    What is adult hip dysplasia?

    In a normally shaped hip, the acetabulum covers enough of the femoral head to distribute load across an adequate joint surface. In dysplasia, that coverage is reduced. This can increase stress at the acetabular rim, labrum and articular cartilage and may contribute to hip microinstability.

    Not every radiographic feature of undercoverage represents a symptomatic condition that requires treatment. Similar morphology can also be found in people without hip pain. Imaging therefore needs to be interpreted together with symptoms and the clinical examination.

    Which symptoms can suggest hip dysplasia?

    • groin pain, especially with prolonged walking, running or deep hip flexion,
    • a sense of fatigue or overload around the hip after activity,
    • pain on the lateral side of the hip or, less commonly, in the buttock,
    • a feeling of instability or that the hip is giving way,
    • catching, clicking or sharp pain during twisting movements, particularly when labral damage is also present.

    These symptoms are not specific to dysplasia. Similar pain can arise from femoroacetabular impingement, the labrum, tendons, the lumbar spine or other soft tissues around the hip. The source of pain therefore needs to be established rather than assumed from one imaging measurement.

    How does an orthopaedic surgeon diagnose hip dysplasia?

    Assessment starts with the history and clinical examination. The location of pain, range of motion, signs of instability or impingement, muscle strength and other potential sources of symptoms are considered. Properly performed radiographs of the pelvis and hip are the basic imaging tests.

    What does the Wiberg angle mean?

    One commonly used measurement is the lateral centre-edge angle, also known as the Wiberg angle or LCEA. An international 2026 consensus considered an LCEA below 20° typical of dysplasia, while values of 20–25° may raise suspicion of possible instability.

    This is not a rule in which “below 25° means surgery”. Pelvic positioning and radiographic technique can affect the measurement, and acetabular shape is three-dimensional. Other measurements, acetabular version, proximal femoral morphology and the condition of the cartilage may therefore also need to be considered.

    When are MRI or CT useful?

    MRI may be needed to assess the labrum, cartilage and other soft tissues, particularly when surgery is being considered or when symptoms are not adequately explained by radiographs. CT can be useful for a more detailed three-dimensional assessment of acetabular and femoral anatomy and orientation.

    Ultrasound is not the primary test for assessing femoral-head coverage in an adult. It can, however, be useful when tendons or other soft tissues around the hip need evaluation or when a diagnostic injection is to be performed accurately.

    Does hip dysplasia always require surgery?

    No. Management depends on the severity of symptoms, the degree of undercoverage, joint stability, the biological condition of the joint and the presence of osteoarthritis. For some patients, non-operative treatment is a reasonable first step.

    • modifying activities that clearly provoke pain without eliminating movement altogether,
    • exercises aimed at improving hip and trunk strength and control,
    • gradual adjustment of sporting and occupational loads,
    • pain-relieving or anti-inflammatory medication when appropriate and when there are no contraindications.

    In a review that included several non-arthritic causes of hip-related pain, including dysplasia, roughly half of patients achieved a satisfactory response to non-operative treatment. That figure should not be interpreted as the response rate for every form of dysplasia, because the included studies combined several different diagnoses.

    What is periacetabular osteotomy?

    In appropriately selected patients with symptomatic dysplasia and preserved cartilage, periacetabular osteotomy (PAO) may be considered. Controlled bone cuts allow the acetabulum to be mobilised and reoriented so that it provides better coverage of the femoral head. The aim is to improve joint mechanics while preserving the native hip.

    Long-term reviews report improvement in patient-reported outcomes after PAO, but most available evidence comes from observational studies of carefully selected patients. The presence of dysplasia on an X-ray is therefore not, by itself, an indication for osteotomy.

    What about hip arthroscopy?

    Hip arthroscopy can address labral damage or coexisting impingement, but it does not increase bony coverage of the femoral head. In true instability caused by dysplasia, repairing the labrum alone does not correct the underlying biomechanical problem. Borderline cases in particular require assessment of the hip’s overall geometry rather than one isolated measurement.

    When is joint replacement considered instead of joint-preserving surgery?

    If dysplasia is accompanied by advanced osteoarthritis and substantial cartilage damage, the potential benefit of a joint-preserving procedure may be limited. Depending on symptoms and function, total hip replacement may then be considered. More about this pathway: Hip Replacement.

    When does hip pain need more urgent assessment?

    • after an injury, you cannot bear weight or there is an obvious deformity,
    • the joint is very painful and hot, particularly with fever or systemic illness,
    • pain is rapidly increasing at rest or at night, especially with unexplained general symptoms,
    • there is sudden weakness, sensory loss or another new neurological symptom in the limb.

    Key point: treat the symptomatic hip, not an X-ray angle

    Hip dysplasia is a structural problem, but treatment decisions come from the combination of symptoms, examination, properly obtained radiographs and, when needed, MRI or CT. A single angle can support the diagnosis but cannot replace a complete assessment. Non-operative care is sufficient for some people, while selected patients with persistent symptoms and limited degenerative change may be candidates for surgery that preserves the native joint.

    References

    1. Leopold VJ, Rakhra K, Spiker AM, et al. Which Imaging Modalities, Parameters, and Diagnostic Thresholds Best Define Hip Instability? Consensus Statements From a Scoping Review and an International Multidisciplinary Delphi Study. Clinical Orthopaedics and Related Research. 2026;484(5):899–915. DOI: 10.1097/CORR.0000000000003905.
    2. MacLeod JS, Zhu JR, Lee MS, et al. Periacetabular Osteotomy Leads to Improved Long-term Patient-reported Outcomes: A Systematic Review. Orthopedics. 2025;48(3):e113–e123. DOI: 10.3928/01477447-20250409-03.
    3. O’Brien MJM, Semciw AI, Mechlenburg I, et al. Pain, function and quality of life are impaired in adults undergoing periacetabular osteotomy for hip dysplasia: a systematic review and meta-analysis. Hip International. 2024;34(1):96–114. DOI: 10.1177/11207000231179610.
    4. Probst DT, Sookochoff MF, Harris-Hayes M, et al. What is the Rate of Response to Nonoperative Treatment for Hip-Related Pain? A Systematic Review With Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. 2023;53(5):286–306. DOI: 10.2519/jospt.2023.11666.

    ← Hip 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.

  • 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.

  • 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.

  • 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.

  • Ulnar-Sided Wrist Pain — Could It Be the TFCC?

    Polish version

    Pain on the little-finger side of the wrist may come from the triangular fibrocartilage complex (TFCC), particularly when it begins after a fall onto the hand or a sudden twisting injury, or when it increases with forearm rotation and forceful gripping. TFCC injury is not the only possible cause. The extensor carpi ulnaris tendon, the distal radioulnar joint and other structures occupy the same region, so pain location alone is not enough to establish the diagnosis.

    What is the TFCC?

    The TFCC, or triangular fibrocartilage complex, is a group of fibrocartilaginous and ligamentous structures on the ulnar side of the wrist. It is an important stabiliser of the distal radioulnar joint, helps transmit load and acts as a cushion between the ulna and the carpal bones.

    TFCC damage may be traumatic or degenerative. Traumatic tears can follow a fall onto an outstretched hand, sudden wrist rotation, sport or work involving strong forearm rotation. Degenerative changes more often develop gradually, particularly when the ulnar side of the wrist is subjected to chronic overload.

    Which symptoms fit a TFCC injury?

    Typical pain is felt on the ulnar side of the wrist, between the ulnar head and the carpal bones. It may be provoked by opening a jar, using a screwdriver, turning a door handle, gripping firmly, pushing up from the hand or using the hands to rise from a chair.

    • pain with pronation and supination of the forearm,
    • tenderness in the ulnar fovea region,
    • clicking, catching or a sense that the wrist momentarily jams,
    • reduced grip strength,
    • a feeling of instability during forearm rotation.

    Not every click represents clinically important damage. TFCC abnormalities can also be visible on imaging in people without symptoms, so MRI findings must always be interpreted together with the clinical examination.

    What else can cause ulnar-sided wrist pain?

    This is one of the more demanding areas of wrist diagnosis. Similar symptoms may arise from irritation or instability of the extensor carpi ulnaris (ECU) tendon, distal radioulnar joint instability, ulnocarpal impaction, lunotriquetral ligament injury, fracture of the ulnar styloid or hook of the hamate, and sometimes a ganglion.

    How is TFCC injury diagnosed?

    Clinical examination

    The mechanism of injury and a careful examination are central. The clinician assesses the point of maximal tenderness, wrist motion, grip strength and distal radioulnar joint stability. Provocative tests that load the TFCC may also be used. No single manoeuvre is completely diagnostic, so findings must be considered together.

    X-ray

    After trauma, radiographs are often the first imaging test. They do not show the TFCC itself, but they can identify fractures, assess alignment and provide information such as ulnar variance, which can influence loading on the ulnar side of the wrist.

    Ultrasound

    Ultrasound can be valuable in the assessment of ulnar-sided wrist pain. It allows dynamic examination of the ECU tendon, parts of the TFCC and the distal radioulnar joint. It also has important limitations: a central TFCC disc tear cannot be reliably excluded with ultrasound. A normal scan therefore does not necessarily end the diagnostic process when symptoms continue to suggest an intra-articular lesion.

    MRI

    MRI provides detailed soft-tissue imaging and is commonly used when symptoms persist. It is not a perfect test. A diagnostic meta-analysis showed that conventional MRI can miss some TFCC tears and that accuracy varies with lesion location; peripheral tears can be particularly difficult to define unequivocally.

    MR arthrography or CT arthrography may be used in selected situations, but they are not required for every patient with ulnar-sided wrist pain.

    Arthroscopy

    Arthroscopy allows direct inspection of the TFCC and other structures inside the wrist. It is the most direct method of assessing the lesion itself, but because it is an operative procedure it is not a routine first-line diagnostic test. It is most relevant when symptoms are substantial, non-operative treatment has failed, or a lesion is suspected that can be treated during the same procedure.

    Does every TFCC tear require surgery?

    No. Stable traumatic TFCC tears without distal radioulnar joint instability can often be treated non-operatively first. A 2024 systematic review including 425 patients and 427 wrists found that appropriately selected non-operative management can produce good functional outcomes. Distal radioulnar joint instability or subluxation and complete foveal detachment were associated with a greater risk of failure of conservative treatment.

    The studies included in that review used different treatment protocols, so they do not support one universal immobilisation regimen. The type and duration of bracing should reflect the injury pattern and joint stability rather than the MRI report alone.

    What does non-operative treatment involve?

    Initially, activities that reproduce pain are usually reduced, particularly forceful gripping, rotation and weight bearing through the hand. Depending on the injury, temporary immobilisation or a brace may be used, followed by progressive restoration of movement and loading.

    Analgesic or anti-inflammatory medication can be used in selected patients when appropriate. Hand therapy may then help restore motion, strength and control without repeatedly overloading the injured region.

    An injection may occasionally be considered to reduce associated pain or inflammation, but an injection does not repair or “suture” a torn TFCC. When accurate needle placement matters, image guidance can be useful. See: Injection Treatments.

    When does an orthopaedic surgeon consider surgery?

    Surgery is considered more often when pain continues to limit function despite appropriate non-operative treatment or when clinically important distal radioulnar joint instability is present from the outset. The type and location of the lesion are important.

    Peripheral and foveal tears, particularly those associated with instability, may be suitable for repair. The central disc has a much poorer blood supply, so some symptomatic central tears are treated by arthroscopic debridement of unstable tissue rather than suturing. When ulnocarpal impaction is also present, treatment may need to address the underlying bony anatomy.

    Can the TFCC heal on its own?

    Healing potential depends partly on lesion location. The peripheral TFCC has a better blood supply than the central portion and therefore greater biological healing potential. Clinically, however, the more important question is whether the wrist regains stable, painless function rather than whether the structural tear disappears on imaging. Symptoms can improve without surgery even when structural changes remain visible.

    When should assessment not be delayed?

    Earlier assessment is required after a more substantial injury when there is deformity, rapidly increasing swelling, marked inability to rotate the forearm or move the wrist, major loss of strength or concern about a fracture. Urgent assessment is also needed if the hand becomes pale or cold, new sensory loss develops, there is an open wound, or signs of infection such as increasing redness, fever and marked warmth appear.

    For less acute symptoms, review is appropriate when ulnar-sided wrist pain persists despite reducing load, repeatedly returns during ordinary activities, or is accompanied by catching or a sense of instability.

    Key points

    Ulnar-sided wrist pain can result from a TFCC injury, but diagnosis requires the history, an assessment of wrist and distal radioulnar joint stability, and appropriately selected imaging. Ultrasound and MRI answer somewhat different questions, and neither replaces the clinical examination. Stable traumatic injuries can often be managed without surgery initially, whereas persistent pain combined with distal radioulnar joint instability requires more detailed assessment and more often leads to consideration of repair.

    Back to: Hand Surgery

    References

    1. Choi SI, Malik S, MacLean S. The Natural History of Non-operatively Treated Traumatic Triangular Fibrocartilage Complex Tears: A Systematic Review. J Wrist Surg. 2024;13(6):550-558. DOI: 10.1055/s-0044-1786164.
    2. Zhou JY, Tuyishime H, Yao J. Arthroscopic-Assisted Repair of the Triangular Fibrocartilage Complex. J Hand Surg Glob Online. 2024;6(4):445-457. DOI: 10.1016/j.jhsg.2024.03.011.
    3. Treiser MD, Crawford K, Iorio ML. TFCC Injuries: Meta-Analysis and Comparison of Diagnostic Imaging Modalities. J Wrist Surg. 2018;7(3):267-272. DOI: 10.1055/s-0038-1629911.
    4. Winnett M, et al. Sonographic Anatomy and Imaging of the Triangular Fibrocartilage Complex and the Distal Radio-Ulnar Joint. Australas J Ultrasound Med. 2025. DOI: 10.1002/ajum.70012.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Osteochondral Lesion of the Talus — Symptoms, Diagnosis and Treatment

    Polish version

    An osteochondral lesion of the talus is damage involving the articular cartilage and the bone immediately beneath it. It often becomes apparent after an ankle sprain as deep joint pain that does not settle within the expected time. Recurrent swelling, catching or locking may also occur. Standard X-rays can be normal, so persistent symptoms may require more detailed imaging—most often MRI and, in selected situations, CT.

    Not every osteochondral lesion requires surgery. Management depends on the size and depth of the defect, the condition of the subchondral bone, fragment stability, duration of symptoms, age and activity level, and whether ankle instability is also present.

    What does “osteochondral lesion” mean?

    The surface of the talus is covered by cartilage that forms a smooth part of the ankle joint. An injury can damage cartilage alone, cartilage together with the underlying bone, or create an osteochondral fragment. In some cases, a cyst develops in the bone beneath the lesion.

    These injuries are commonly abbreviated as OLT, for osteochondral lesion of the talus. Finding an OLT on imaging is not, by itself, enough to determine treatment. The key question is whether the lesion actually explains the patient’s symptoms.

    When should cartilage injury be suspected after an ankle sprain?

    A typical ankle sprain should gradually improve. If deep pain inside the joint persists despite appropriate treatment—particularly with weight bearing, running, descending stairs or twisting movements—it is worth considering causes other than ligament injury alone.

    Symptoms that may accompany an osteochondral lesion include:

    • persistent or recurrent ankle pain after injury,
    • pain felt deep within the joint rather than only around the lateral or medial malleolus,
    • swelling after greater activity,
    • catching, clicking or intermittent locking,
    • restricted motion,
    • difficulty returning to running or sport despite improvement in ligament stability.

    If the problem began with a recent sprain, the initial assessment still needs to address the ankle injury as a whole. See: Ankle Injuries.

    How is an osteochondral lesion of the talus diagnosed?

    Clinical examination

    The examination considers the location of pain, range of motion, swelling, ligament stability, foot and ankle alignment, and any mechanical symptoms. This matters because similar complaints can result from chronic instability after a sprain, syndesmotic injury, impingement, tendon disorders or degenerative joint disease.

    X-ray

    Radiographs are often the first imaging test, especially after injury. They may show a larger bony defect, a loose fragment, evidence of previous trauma or degenerative change. A normal X-ray does not exclude an osteochondral lesion, particularly when the defect is small or predominantly cartilaginous.

    MRI

    MRI provides useful information about cartilage, bone-marrow oedema, joint fluid, ligaments and other intra-articular structures. It is particularly helpful when pain persists despite normal radiographs or when associated injuries need to be assessed.

    CT

    CT depicts the bony architecture in detail, including the size of the osseous defect, cysts and fragment morphology. It may be useful before surgery or when the principal diagnostic question concerns the bony component of the lesion.

    Is ultrasound enough?

    Ultrasound is not the primary test for a complete assessment of cartilage over the talar dome because much of the articular surface lies deep within the joint and is obscured by bone. It can, however, help assess associated effusion, ligaments, tendons and other superficial structures. A normal ultrasound therefore does not exclude an OLT.

    Does every lesion need surgery?

    No. For a stable lesion without a loose fragment or another urgent indication, non-operative treatment is often a reasonable first step. This may include modifying activity and loading, temporary unloading or stabilisation in selected cases, and a progressive exercise programme to restore movement, strength and ankle control. Coexisting chronic instability should be addressed as part of the treatment plan.

    In a prospective study of 40 patients involving 42 ankles, clinically meaningful improvement in pain while walking was achieved by 38% of patients after one year of non-operative treatment. The mean improvement for the group as a whole remained below the threshold considered clinically important, but lesion size on imaging did not increase during the one-year follow-up. This illustrates two points: conservative management can be a sensible first option for appropriately selected patients, but it will not provide sufficient improvement for everyone.

    When does an orthopaedic surgeon consider surgery?

    Surgery is considered mainly when symptoms persist despite appropriately conducted non-operative treatment, when significant mechanical symptoms are present, when a fragment is unstable, or when the characteristics of the lesion favour repair from the outset.

    There is no single operation that suits every osteochondral lesion. Depending on the situation, options may include:

    • arthroscopic debridement with stimulation of subchondral healing for selected small lesions,
    • fixation of a preserved osteochondral fragment when its quality and morphology allow stable repair,
    • osteochondral grafting or other restorative techniques for larger, deeper or previously unsuccessfully treated lesions,
    • bone grafting when there is a substantial cyst or osseous defect.

    The latest international consensus on moderate-to-large lesions emphasises that the choice between reparative and restorative procedures still relies partly on expert judgement because high-quality head-to-head trials of many techniques are lacking. Lesion size matters, but it should not be the only criterion used to choose an operation.

    Can an osteochondral fragment be fixed rather than removed?

    In selected cases, yes. If there is a sufficiently large and viable osteochondral fragment, fixation may be considered to preserve the native joint surface. A systematic review of 10 studies involving 241 ankles reported high rates of union and clinical improvement after fixation, but most of the evidence came from non-comparative studies. These results therefore do not prove that fixation is superior to all other treatment options.

    What influences treatment selection?

    • lesion size and depth,
    • the presence of a subchondral cyst,
    • stability and quality of an osteochondral fragment,
    • lesion location,
    • time since injury and previous treatment,
    • age, activity level and patient expectations,
    • ankle instability, limb alignment and other associated pathology.

    For that reason, two patients with very similar MRI reports may require quite different management.

    When is urgent assessment needed?

    • the ankle is locked and cannot move freely after an injury,
    • the limb cannot be loaded after a recent injury or there is obvious deformity,
    • the foot becomes cold, pale or blue, or increasing numbness develops,
    • the joint becomes hot, markedly swollen and red, particularly with fever,
    • pain is rapidly worsening rather than gradually settling.

    Common questions

    Does an osteochondral lesion always occur after a sprain?

    No, although ankle trauma is common in the clinical history. The lesion may become apparent immediately, or only later when deep weight-bearing pain persists after an apparently healed sprain.

    Does a normal X-ray exclude cartilage damage?

    No. Small osteochondral lesions may not be visible on standard radiographs. If symptoms persist, MRI or CT may be requested depending on the specific diagnostic question.

    Is an MRI finding alone an indication for surgery?

    No. The decision should integrate symptoms, clinical examination and imaging characteristics. An asymptomatic or incidental lesion is not the same clinical problem as an unstable fragment causing pain and mechanical locking.

    Back to: Foot and Ankle Conditions

    References

    • Buck TMF, Steman JAH, Dahmen J, et al. Nonoperative Treatment for Osteochondral Lesions of the Talus Provides Clinical Improvement in the Minority of the Patients at Short-term Follow-up. Foot Ankle Int. 2025;46(7):699-706. DOI: 10.1177/10711007251330881.
    • van Bergen CJA, Baur OL, Murawski CD, et al. Diagnosis: History, Physical Examination, Imaging, and Arthroscopy: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle. Foot Ankle Int. 2018;39(1 Suppl):3S-8S. DOI: 10.1177/1071100718779393.
    • Rubin J, et al. Surgical Intervention for Moderate-To-Large Lesions (1-2.9 cm²): Proceedings of the International Consensus Meetings on Cartilage Repair of the Ankle. Foot Ankle Spec. 2026. DOI: 10.1177/19386400261456897.
    • Rikken QGH, Dahmen J, Stufkens SAS, Nakasa T, Kerkhoffs GMMJ. Fixation for osteochondral lesions of the talus leads to successful clinical outcomes in 9 out of 10 patients: A systematic review. J ISAKOS. 2025;11:100389. DOI: 10.1016/j.jisako.2025.100389.

    This material is educational. Investigation and treatment should be selected from the clinical examination and the individual characteristics of the lesion.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.