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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.

  • Active and Passive Range of Motion — Why Does an Orthopaedic Surgeon Check Both?

    Polish version · Explore Diagnostic Tests

    Comparing active and passive range of motion is one of the simplest ways to judge whether restricted movement is driven mainly by pain or weakness of a muscle or tendon, or by true joint stiffness. The number of degrees alone is not enough. It also matters who is producing the movement, where resistance is felt and whether the range can be increased safely.

    Two similar movements, two different pieces of information

    Active movement is produced by the patient using their own muscles. It therefore reflects not only the range available at the joint, but also muscle and tendon function, neural control, pain and confidence in the movement. Passive movement is produced by the examiner while the patient relaxes the limb as much as possible. It shows how much motion is available without requiring the patient to generate force.

    If a patient cannot lift the arm very far but the examiner can gently move it much further, that does not automatically mean the joint is normal. The discrepancy directs attention towards pain, rotator cuff weakness, tendon injury, altered scapular control or a neurological problem. If active and passive motion are restricted to a similar degree, capsular stiffness, an intra-articular disorder or a mechanical block becomes more likely.

    The shoulder shows why this comparison matters

    In frozen shoulder, both active and passive motion are usually restricted, particularly external rotation. With a large rotator cuff tear, active elevation may be markedly impaired even though passive motion is much better. In acute subacromial pain, the difference may reflect pain-related inhibition of muscle activity rather than a permanent structural failure.

    These patterns are not diagnoses by themselves. Severe pain can also limit passive movement, while a longstanding tendon lesion may eventually lead to secondary stiffness. The findings therefore need to be interpreted together with the history, strength testing, provocative tests and imaging when there is a clinical indication.

    The same principle applies to other joints

    Knee

    A patient may be unable to fully extend the knee actively because of pain, quadriceps weakness or injury to the extensor mechanism. If full extension is also missing passively, possibilities include contracture, a large effusion, a mechanical block or degenerative change. After surgery, the difference between active and passive motion can sometimes be more informative than a single isolated measurement.

    Ankle and foot

    Loss of active toe or foot movement with preserved passive motion may suggest a musculotendinous or neurological problem. Passive restriction more often points towards joint stiffness, swelling, contracture or a mechanical consequence of injury. The character of the end-feel also matters: whether resistance is elastic, hard, painful or appears abruptly.

    Why does the examination begin with observation?

    Before moving the limb, the examiner watches how the patient performs the movement independently. This can reveal the movement path, pain avoidance, trunk compensation, scapulohumeral rhythm, tremor or sudden giving way. Passive range and the quality of the end-feel can then be assessed.

    This is also a matter of safety. After a recent injury, particularly when a fracture or dislocation is suspected, motion should not be forced simply to obtain a complete measurement. Neurovascular assessment, appropriate immobilisation and imaging take priority in that situation.

    What does measuring the angle add?

    A goniometer can record the range in degrees and help track change over time. This is useful during rehabilitation, after surgery and when monitoring treatment. The result nevertheless depends on body position, anatomical landmarks, pain and measurement technique. A difference of a few degrees does not always represent a real clinical change.

    The most useful measurement is one that is repeated under similar conditions and interpreted alongside function: whether it has become easier to dress, climb stairs, straighten the knee during walking or lift an object. The aim is to treat a limitation that affects the patient’s life, not a number in isolation.

    What can active and passive motion not tell us?

    • they do not identify a single damaged structure on their own;
    • they do not reliably distinguish an acute injury from a chronic disorder;
    • they do not replace assessment of strength, stability, sensation and circulation;
    • they do not determine whether surgery is needed;
    • they do not remove the need for imaging when the injury mechanism or symptoms suggest a fracture, dislocation or another urgent diagnosis.

    Practical conclusion

    The difference between active and passive motion is a clue that guides the rest of the examination. A large discrepancy makes pain, weakness, tendon injury or a neurological problem more likely. Similar restriction of both ranges raises suspicion of joint stiffness or a mechanical block. The next step is chosen from the whole pattern, together with the history and the remaining examination findings.

    Reference

    Woodward TW, Best TM. The Painful Shoulder: Part I. Clinical Evaluation. American Family Physician. 2000;61(10):3079–3088.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

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

    Polish version · Explore Knee Conditions

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

    What happens during a patellar dislocation?

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

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

    What should you do immediately after the injury?

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

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

    What symptoms are typical after a dislocation?

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

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

    How is a first-time patellar dislocation assessed?

    History and examination

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

    X-ray

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

    MRI

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

    When is CT needed?

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

    Is a first dislocation usually treated without surgery?

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

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

    What does rehabilitation involve?

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

    When is surgery considered after a first dislocation?

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

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

    How high is the risk of recurrence?

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

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

    Warning signs

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

    Key points for an orthopaedic surgeon

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

    References

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

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Mechanism of Injury — Why Does It Matter?

    Polish version · Explore Injuries and Fractures

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

    “I twisted my knee” is not enough information

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

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

    Four elements of a useful injury description

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

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

    How an orthopaedic surgeon uses the injury mechanism to select investigations

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

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

    Examples that change the diagnostic reasoning

    Sudden acceleration or deceleration

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

    Twisting on a weight-bearing leg

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

    Pain without one clear event

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

    Why can memory of the event be unreliable?

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

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

    Mechanism must not delay urgent action

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

    Practical takeaway

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

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • What Does It Really Mean When Treatment Works?

    Polish version · For Patients

    Effective treatment does not always mean complete freedom from pain. In orthopaedics, success also includes restored function, the ability to perform activities that matter to the patient, durability of improvement, safety, and the burden or adverse effects required to achieve that benefit. A pain score is useful, but it is rarely enough on its own to judge an outcome fairly.

    Pain matters — but it is not the only outcome

    A reduction in pain from 8 to 4 may be transformative for one person if it allows them to sleep through the night and return to work. The same numerical change may be inadequate for someone who still cannot walk a few hundred metres or climb stairs safely. The number alone also says nothing about whether the improvement lasts an hour, a week or many months.

    It is therefore worth asking not only “how much does it hurt?”, but also “what does the pain stop you from doing?” and “what change would genuinely matter?”. That moves the discussion from an abstract scale to real-world function.

    Function shows whether improvement translates into daily life

    A meaningful result may be being able to put on socks, rise from a low chair, kneel, reach a shelf, return to walking or get through a working day comfortably. Two people with the same diagnosis can have very different goals, so there is no single universal test that captures every aspect of recovery.

    Assessing active and passive movement, strength, stability and gait helps determine whether limitation is driven mainly by pain, weakness, stiffness or a mechanical block. Related patient resources are collected in All Patient Resources.

    Imaging is not a stand-alone measure of success

    A tendon, cartilage surface or muscle may look different on ultrasound or MRI without changing at the same pace as symptoms. The reverse can also occur: pain improves even though follow-up imaging still describes an abnormality. If the aim of treatment is better function, treatment should not be labelled unsuccessful solely because the scan has not become “normal”.

    More information on choosing and interpreting investigations is available in the For Patients section.

    The cost of improvement matters too

    Two treatments may reduce pain to a similar degree but differ in complication risk, time away from work, medication requirements, rehabilitation burden and the likelihood of another procedure. The benefit therefore has to be weighed against the burden of treatment.

    The same principle applies to rapid improvement. A short-acting local anaesthetic can be useful diagnostically, but temporary pain relief is not proof of a lasting cure. Conversely, gradual progress without a dramatic day-to-day change may be valuable if it is stable and allows activity to increase safely.

    How can an orthopaedic surgeon and patient assess whether treatment is helping?

    • Before treatment begins, identify two or three activities that matter most to you.
    • Choose a simple measure: walking distance, sitting time, number of stairs, sleep quality or a specific movement.
    • Assess the result at an agreed time point rather than judging only the best or worst day.
    • Record adverse effects, medication use and any new limitations as well as improvement.
    • Do not increase load solely because a medication or injection has temporarily reduced pain.
    • If only one measurement improves, check whether that improvement produces a meaningful change in everyday function.

    A good decision starts with a good goal

    The most useful question is therefore not simply “has the pain gone?”, but “have we achieved a meaningful, durable and safe improvement?”. This framework makes it easier to compare rehabilitation, medication, injections and surgery, and helps avoid overvaluing a single test result or a short-lived effect.

    References

    1. World Health Organization. International Classification of Functioning, Disability and Health (ICF). WHO.
    2. Dworkin RH, Turk DC, Wyrwich KW, et al. Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. J Pain. 2008;9(2):105–121. DOI: 10.1016/j.jpain.2007.09.005. PubMed.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Deep Gluteal Syndrome — When Buttock Pain Mimics Sciatica

    Polish version · Explore Hip Conditions

    Deep gluteal syndrome can cause buttock pain that radiates into the back of the thigh, particularly when symptoms worsen with sitting. It refers to irritation or entrapment of the sciatic nerve outside the spine, within the deep tissues of the buttock. Not every case is “piriformis syndrome”, however, and diagnosis requires excluding more common causes arising from the lumbar spine, hip and pelvis.

    What is deep gluteal syndrome?

    The sciatic nerve leaves the pelvis and enters the lower limb through a space deep beneath the gluteal muscles. In this region it may be irritated by fibrous bands, abnormal muscle tension or anatomy, scar tissue after injury or surgery, a space-occupying lesion, or conflict between bony and soft-tissue structures.

    “Piriformis syndrome” describes only one possible mechanism. The broader term deep gluteal syndrome does not assume in advance which structure is responsible for the compression. This helps prevent the diagnostic process from being reduced to one muscle and one clinical test.

    What symptoms are typical?

    • deep, usually one-sided buttock pain;
    • radiation into the back of the thigh, sometimes farther down the leg;
    • worsening with prolonged sitting, especially on a hard surface;
    • pain during certain hip movements, running or walking uphill;
    • deep tenderness in the buttock;
    • sometimes tingling or altered sensation along the course of the sciatic nerve.

    In a systematic review of 14 studies involving 853 patients, recurring features included posterior hip pain, sciatica-like symptoms and difficulty sitting for about 30 minutes. None of these features, on its own, confirms the diagnosis.

    Could the symptoms be coming from the spine?

    The presentation can resemble lumbar radicular pain, so an important first step is to determine whether the sciatic nerve or its roots are being irritated by a disc lesion, spinal stenosis or another lumbar condition. Spinal causes are more often accompanied by low-back pain, radiation aggravated by coughing or sneezing, changes in reflexes, or weakness in specific muscle groups. These features are helpful, but none is an absolute rule.

    A similar pattern can also arise from the hip joint itself, the sacroiliac joint, the proximal hamstring origin, ischiofemoral impingement or other pelvic disorders. The overall pattern of symptoms and examination findings therefore matters more than any single test.

    More: hip conditions and causes of hip-region pain →

    How is deep gluteal syndrome diagnosed?

    History and clinical examination

    The examination considers where the pain is felt, its relationship to sitting and movement, hip range of motion, strength, sensation and reflexes. Provocative manoeuvres that tension or activate the deep hip rotators may be used, while the lumbar spine and other possible sources of pain are assessed as well. A positive provocative test can increase suspicion, but it should not determine the diagnosis by itself.

    X-ray, MRI and ultrasound

    X-rays can help assess the bones of the hip and pelvis. Lumbar MRI may be needed to look for disc disease or stenosis, while pelvic MRI can identify a lesion compressing the nerve, oedema, scar tissue or conflict within the deep gluteal space. A normal scan does not always exclude functional or intermittent nerve irritation.

    Ultrasound can show accessible portions of the sciatic nerve, selected muscles and fluid collections, and it allows side-to-side comparison. Its particular advantages are dynamic assessment and accurate guidance for a diagnostic injection. Depth of the structures and individual body habitus can limit the examination, however, so a normal ultrasound does not end the diagnostic process.

    EMG and diagnostic injection

    Nerve-conduction studies and electromyography can help distinguish a local problem from nerve-root injury or a more advanced neuropathy, but a normal result does not exclude local, position-dependent irritation. Temporary pain relief after a targeted image-guided injection can support a diagnostic hypothesis, but it does not replace a complete clinical assessment.

    How is deep gluteal syndrome treated?

    Treatment usually begins without surgery: reducing positions that reliably provoke symptoms, gradually adjusting load, physiotherapy directed at the hip, pelvis and spine, and appropriately selected neural-gliding exercises. Analgesic or anti-inflammatory medication should be matched to the patient’s health, risks and contraindications.

    An ultrasound-guided or otherwise image-guided injection may be considered when there is a specific anatomical hypothesis and the procedure is intended to answer a defined diagnostic or therapeutic question. It should not be performed blindly or repeated without assessing the response and reconsidering the diagnosis.

    More: injection treatments in orthopaedics →

    Surgery is rarely required. It may be considered when there is well-documented compression from a space-occupying lesion or persistent symptoms despite appropriately conducted non-operative treatment. A review of 13 studies involving 508 patients rated the overall quality of the evidence as low and did not show one conservative treatment to be clearly superior to the others.

    When is urgent assessment needed?

    Urgent medical assessment is needed for rapidly progressive leg weakness or foot drop, numbness in the saddle area, new bladder or bowel dysfunction, severe pain after injury with inability to bear weight, fever with worsening pain, or sudden signs of impaired circulation in the leg. These symptoms should not be attributed to the piriformis muscle without further assessment.

    Key point for an orthopaedic surgeon

    Deep gluteal syndrome is a possible, but not the most common, cause of buttock pain and sciatica-like symptoms. The diagnosis should emerge from agreement between the history, examination and appropriately selected investigations. Treatment usually begins conservatively, and a normal result from a single imaging study is not enough either to confirm or exclude the condition.

    References

    1. Kizaki K, Uchida S, Shanmugaraj A, et al. Deep gluteal syndrome is defined as a non-discogenic sciatic nerve disorder with entrapment in the deep gluteal space: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2020;28:3354–3364. DOI: 10.1007/s00167-020-05966-x. PubMed.
    2. Hopayian K, Mirzaei M, Shamsi MB, Arab-Zozani M. A systematic review of conservative and surgical treatments for deep gluteal syndrome. J Bodyw Mov Ther. 2023;36:244–250. DOI: 10.1016/j.jbmt.2022.12.003. PubMed.
    3. Park JW, Lee YK, Lee YJ, et al. Deep gluteal syndrome as a cause of posterior hip pain and sciatica-like pain. Bone Joint J. 2020;102-B:556–567. DOI: 10.1302/0301-620X.102B5.BJJ-2019-1212.R1. PubMed.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Stiff Elbow — Why Can’t It Fully Straighten?

    Loss of full elbow extension can result from pain and swelling after injury, capsular contracture, scar tissue, osteoarthritis, a loose body or a fracture that has healed in an abnormal position. If the restriction appears suddenly after trauma, the elbow should not be forcibly stretched before fracture, dislocation or a mechanical block has been excluded.

    What does a stiff elbow mean?

    The elbow allows the arm to bend and straighten and the forearm to rotate palm-up and palm-down. Even a relatively small loss of motion can interfere with eating, personal care, dressing, computer work or reaching the face. The functional effect therefore matters as much as the number of degrees lost.

    Some healthy people have a small, stable difference in extension between sides. New loss of motion, progressive restriction, pain, locking or functional decline is more concerning.

    Why might the elbow not fully straighten?

    Swelling and pain after a recent injury

    After a fall or direct blow, movement may be limited by a joint effusion, haematoma, bruising, fracture or dislocation. Inability to fully extend the elbow after trauma increases suspicion of an injury that may require imaging. The fact that the arm can still move does not exclude a fracture.

    Contracture after immobilisation or surgery

    The elbow is particularly prone to stiffness. After a fracture, dislocation or operation, the joint capsule may thicken and shorten and scar tissue may restrict tissue glide. Prolonged immobilisation increases the risk, although the timing of mobilisation must always respect the stability of repaired structures.

    A bony obstacle or loose fragment

    Osteophytes from osteoarthritis, malunited fracture, heterotopic ossification, a prominent implant or a loose body within the joint can create a mechanical block. A hard end point, intermittent locking or pain at the end of the range can be clues.

    Tendons, nerves and inflammation

    Pain at the back of the elbow may arise from the olecranon bursa or triceps tendon, while anterior symptoms may involve the biceps. Inflammatory disease or joint infection can also cause painful restriction. Ulnar-nerve irritation more often causes numbness in the little and ring fingers, but it may coexist with post-traumatic stiffness.

    How does an orthopaedic surgeon investigate the cause?

    The examination compares both sides, measures flexion and extension, assesses forearm rotation and determines whether active motion, passive motion or both are restricted. Stability, strength, sensation and hand circulation are also checked, together with the shoulder and wrist when appropriate.

    X-ray

    X-ray is usually the first imaging test after trauma and when a bony cause is suspected. It may show fracture, dislocation, osteoarthritis, heterotopic ossification, loose fragments or abnormal implant position.

    CT, MRI and ultrasound

    CT shows bony obstacles in greater detail and can be useful for operative planning. MRI is used selectively when cartilage, ligaments or other soft tissues are important. Ultrasound can assess selected tendons, bursae, fluid collections and nerves, but it does not replace X-ray or CT when the problem is an intra-articular bony block.

    How is loss of extension treated?

    Treatment depends on the cause and how long the restriction has been present. After a recent injury, the damaged structure is protected first. Once the joint is stable and there is no contraindication, appropriately timed controlled movement can help reduce the risk of contracture. Forceful self-stretching through severe pain or abrupt manipulation should be avoided.

    For chronic stiffness, physiotherapy and individually selected static-progressive or dynamic bracing may be used to increase motion gradually. A review in EFORT Open Reviews notes that improvement with bracing can continue over 6–12 months, so the absence of a rapid response does not automatically mean that surgery is required.

    Surgery may be considered when established stiffness clearly limits function despite appropriately conducted non-operative treatment, or when a mechanical obstacle is present. Release can be arthroscopic or open; the choice depends on the location of the contracture, bony changes, previous surgery and the course of nearby nerves. A difference of only a few degrees without meaningful symptoms is not in itself an indication for surgery.

    When is urgent assessment needed?

    • visible deformity after injury or sudden loss of motion;
    • severe pain with rapidly increasing swelling;
    • a hand that becomes cold, pale or blue;
    • increasing numbness or weakness;
    • a hot, red joint with fever;
    • a draining wound or possible open fracture;
    • true locking that prevents even gentle movement of the joint.

    The key point

    Loss of elbow extension is a symptom, not a single diagnosis. After a recent injury, fracture or dislocation must be excluded; in chronic stiffness, soft-tissue contracture must be distinguished from a mechanical block. Only then can exercises, bracing or operative treatment be selected rationally.

    More patient information: Orthopaedic Conditions and Symptoms and For Patients.

    References

    1. Siemensma MF, van der Windt AE, van Es EM, Colaris JW, Eygendaal D. Management of the stiff elbow: a literature review. EFORT Open Rev. 2023;8(5):351–360. DOI: 10.1530/EOR-23-0039. PubMed.
    2. American Academy of Orthopaedic Surgeons. Osteoarthritis of the Elbow. OrthoInfo.
    3. Fan M, Xu F, Fei C et al. Post-traumatic elbow stiffness: etiology, risk factors and current treatments. Front Surg. 2025;12:1643326. DOI: 10.3389/fsurg.2025.1643326.

    Polish version

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Does an Orthopaedic Examination Go Beyond the Painful Area?

    The place where pain is felt is not always where it originates. That is why a good orthopaedic examination may include an adjacent joint, the spine, the course of a nerve and the way the whole limb functions — even when the patient points to one very specific painful spot.

    Pain can be referred

    A hip problem may be felt mainly in the groin or even at the knee. A cervical-spine disorder can cause shoulder and arm pain, while irritation of a lumbar nerve root may be experienced in the buttock or leg. Pressing on the painful area therefore does not by itself identify the structure responsible for the symptoms.

    A nerve may need to be assessed along its course

    Hand numbness can result from nerve compression at the wrist, elbow or higher up. Similarly, radiating pain into the leg may originate in the spine, pelvis or deep tissues of the buttock. The site of the strongest tingling does not always correspond to the level of nerve compression.

    This is why the examination may include sensation, strength in selected muscle groups, reflexes and provocative tests at several levels. Ultrasound of one short segment of a nerve can be useful, but it does not replace a broader neurological examination of the limb.

    An adjacent joint can change loading elsewhere

    Restricted ankle motion can change how the knee works during a squat. Hip stiffness can alter knee loading, while limited shoulder motion may force compensation through the scapula and spine. In such cases, the painful area may be a genuine problem but not necessarily the only factor that needs to be addressed.

    After an injury, more than one point must be checked

    The force of an injury does not stop at the boundary of a single joint. With a fracture or dislocation, the examination may also include the skin, circulation, sensation, finger or toe movement and the joints above and below the injured area. This helps avoid missing a second injury, nerve compression or impaired blood supply.

    Why should imaging follow the clinical examination?

    If the source of pain is assumed too early, it is possible to perform a very detailed scan of the wrong region. A knee MRI will not identify referred pain arising from the hip, and a shoulder ultrasound will not answer a question about cervical nerve-root compression. The clinical question should come first; X-ray, ultrasound, MRI, CT or nerve-conduction testing can then be selected to answer it.

    For a broader explanation of how different investigations are selected, see Diagnostic Tests.

    What is useful to tell the orthopaedic surgeon?

    • where the pain starts and where it travels;
    • whether there is numbness, tingling or weakness;
    • which movement or position reproduces the symptoms;
    • whether the spine or a neighbouring joint also hurts;
    • how the injury happened;
    • whether symptoms change with coughing, sitting, walking or neck movement;
    • which everyday activities have become difficult or impossible.

    The key point

    Examining beyond the painful spot does not mean ignoring the main complaint. It is a way of determining whether that point is the true source of the problem, the site of referred pain or one part of a broader chain of dysfunction. That distinction often determines which test and which treatment actually make sense.

    More patient information: For Patients.

    Polish version

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Is Musculoskeletal Ultrasound Performed During Movement?

    One of the major advantages of musculoskeletal ultrasound is the ability to observe tissues while they move. A tendon, nerve or part of a joint may look normal at rest but move abnormally, impinge on a neighbouring structure or reproduce a characteristic snap only in a specific position.

    Polish version · For Patients

    A static image answers only part of the question

    MRI and CT provide extensive anatomical information, but they usually show the body in a fixed position. Ultrasound can be performed while the patient or examiner moves the joint. This means the examination can assess not only how a structure looks, but also how it behaves.

    The movement should not be arbitrary. It should be chosen from the history and clinical examination to reproduce the position in which pain, clicking, locking or snapping occurs. Dynamic imaging is most useful when it answers a specific clinical question.

    What can dynamic ultrasound reveal?

    Tendon movement

    During movement, ultrasound can assess structures such as the long head of the biceps tendon in the bicipital groove and the peroneal tendons behind the lateral malleolus. A brief subluxation may not be visible while the joint is held still.

    A snapping nerve

    The ulnar nerve may appear stable with the elbow extended but move over the medial epicondyle during flexion. Ultrasound can show the exact moment of displacement and help determine whether it corresponds to the patient’s snapping sensation. Movement alone is not necessarily abnormal; it has to be interpreted together with symptoms and the condition of the nerve.

    Impingement during a specific movement

    In selected situations, ultrasound can show the behaviour of tissues beneath the acromion, hand tendons, the iliotibial band or structures responsible for snapping around the hip. The image may help explain a mechanical phenomenon, but it should not be interpreted without considering pain and function.

    What does the dynamic part of the examination look like?

    The anatomy is first assessed at rest. The probe is then kept over the structure of interest while the patient performs a defined movement, sometimes slowly and sometimes against gentle resistance. The manoeuvre can be repeated from another angle or compared with the other side, remembering that asymmetry does not automatically mean pathology.

    Why is “it snapped on ultrasound” not enough?

    Some tendons and nerves move or sublux even in people without pain. Conversely, significant symptoms can arise from structures that ultrasound cannot assess sufficiently well. The finding therefore has to be integrated with the exact location of symptoms, injury mechanism, clinical tests and, when appropriate, X-ray, MRI or CT.

    Probe position, movement speed, muscle tension and examiner experience also affect the assessment. An overly forceful manoeuvre can unnecessarily increase pain, while the wrong movement may fail to reproduce the problem.

    When is dynamic assessment particularly useful?

    • when clicking or snapping occurs only in a specific position;
    • when intermittent tendon or nerve subluxation is suspected;
    • when symptoms change with muscle contraction;
    • when the aim is to distinguish smooth tissue gliding from mechanical conflict;
    • when a static image does not explain a reproducible symptom.

    Key point for an orthopaedic surgeon

    Dynamic ultrasound is not a separate “better test”. It is a way of using ultrasound to answer a question about tissue behaviour. Its greatest value comes when the movement is selected to reproduce the symptom and the observed mechanism fits the clinical examination.

    References

    1. American College of Radiology, American Institute of Ultrasound in Medicine and collaborating societies. Practice Parameter for the Performance of a Musculoskeletal Ultrasound Examination. ACR–AIUM practice parameter.
    2. Fodor D, et al. The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound – Part I: Extraarticular Pathologies. Ultraschall in der Medizin. 2022.
    3. Pan G, et al. Current status of dynamic musculoskeletal ultrasound for evaluation of extra-articular and intra-articular pathologies. 2024. Full text.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

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

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

    Polish version · For Patients

    Where is the scaphoid?

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

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

    Which symptoms raise suspicion?

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

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

    Why can the first X-ray be normal?

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

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

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

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

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

    How is a scaphoid fracture treated?

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

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

    What should be avoided while a fracture is still suspected?

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

    When is urgent assessment needed?

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

    Other causes of thumb-side wrist pain

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

    References

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

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Fifth Metatarsal Base Fracture — Avulsion or Jones Fracture?

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

    Polish version · For Patients

    Where is the fifth metatarsal?

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

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

    Zone 1: avulsion fracture

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

    Zone 2: Jones fracture

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

    Zone 3: stress fracture

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

    Which symptoms are important?

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

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

    How does an orthopaedic surgeon establish the diagnosis?

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

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

    Is surgery always required?

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

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

    Why does follow-up of union matter?

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

    When is urgent assessment needed?

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

    Sources

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

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

    Related postoperative rehabilitation protocol

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