Umów wizytę

Tomasz Poboży

Kategoria: Patient Knowledge (EN)

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

  • Why Are Sensation and Pulses Checked After an Injury?

    After a limb injury, assessment should not stop at the painful bone or joint: circulation and nerve function below the injury also need to be checked. A fracture, dislocation, large haematoma or overly tight immobilisation can compress a blood vessel or nerve. Detecting that problem early may be more urgent than assigning a precise fracture label.

    Polish version · For Patients

    What does an orthopaedic surgeon check during the examination?

    A neurovascular examination combines several observations. The clinician compares colour and temperature between limbs, checks capillary refill after pressure on a nail bed, feels for pulses at appropriate sites, tests sensation in the territories of individual nerves and asks the patient to perform selected movements of the fingers, toes, hand or foot.

    Each part answers a different question. A palpable pulse is reassuring, but it does not exclude every clinically important circulatory problem. Likewise, normal skin colour does not rule out injury to a specific nerve. The overall pattern and comparison with the opposite side matter.

    Why is the examination repeated?

    The condition of a limb can change after reduction of a fracture or dislocation, application of a cast, increasing swelling or secondary displacement. Neurovascular findings should therefore be documented before an intervention and checked again afterwards. This helps establish whether an abnormality was present from the outset or developed later.

    This is also why patients are told to watch their fingers or toes after immobilisation. Swelling often increases during the first few days and a cast or splint that was initially comfortable may become too tight.

    What can an abnormal finding mean?

    • a cold, pale or blue limb may indicate impaired blood flow;
    • delayed capillary refill has to be interpreted together with temperature and pulses;
    • new numbness may reflect nerve compression or injury;
    • inability to perform a movement can result from pain, tendon or muscle injury, or nerve dysfunction;
    • pain that seems disproportionate to the injury and worsens with passive movement of the digits can be one warning sign of acute compartment syndrome.

    Why is an X-ray not enough?

    X-rays show bone position well, but they do not directly assess nerve function or blood flow. Good fracture alignment therefore does not automatically mean that all soft tissues are safe. Conversely, numbness does not necessarily mean that a nerve has been divided; swelling or pressure can cause temporary symptoms. Distribution, progression and the complete examination determine how concerning a finding is.

    Which symptoms after injury or casting need urgent reassessment?

    • increasing numbness or reduced ability to move the fingers or toes;
    • digits that become clearly colder, pale or blue;
    • severe and increasing pain despite elevation and prescribed analgesia;
    • a rapidly increasing sense of pressure or tightness under a cast;
    • marked swelling that makes finger or toe movement difficult.

    In that situation, do not cut or alter the immobilisation yourself. Prompt reassessment is needed. Trying to check a pulse at home is not an adequate substitute: it may be difficult to locate reliably, and the presence of a pulse does not rule out every complication.

    Sources

    1. National Institute for Health and Care Excellence. Fractures (complex): assessment and management. NICE guideline NG37.
    2. National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. NICE guideline NG38.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Retained Foreign Body in the Hand or Foot — When Is Ultrasound Useful?

    After a puncture, cut or stepping on a sharp object, ultrasound can help locate retained glass, wood, metal or plastic in the hand or foot—especially when the fragment is not visible on an X-ray. A normal ultrasound does not exclude every retained foreign body, and the decision to remove a fragment depends on its material, depth, symptoms and proximity to nerves, vessels, tendons or a joint.

    When should a retained foreign body be suspected?

    Common examples include a splinter, thorn, piece of glass, metal or plastic after an injury to the hand or foot. Suspicion is higher when the patient remembers the object entering the skin, the wound was deep, or part of the object broke during an attempt to remove it.

    Possible clues include focal tenderness, a sharp sensation during movement or weight bearing, a palpable lump, recurrent redness, drainage from the wound or difficulty fully bending a finger. Symptoms may develop only after several days or weeks. Pain alone, however, does not prove that a foreign body remains: a haematoma, tendon or nerve injury, fracture and infection can produce similar symptoms.

    X-ray or ultrasound—which is more useful?

    X-rays show some materials well

    Plain radiographs are usually the first test when glass, metal or another radiopaque material is possible. They can also reveal a fracture. Wood, thorns and some plastics are much less visible. A very small fragment, or one projected over bone, may also be difficult to identify.

    Ultrasound shows soft tissues and anatomical relationships

    Ultrasound can show the foreign body itself and the tissue reaction around it. It can help determine the fragment’s depth and its relationship to a tendon, tendon sheath, nerve, blood vessel or joint. For superficial foreign bodies, the skin can be marked before a procedure and, in selected cases, removal can be guided in real time.

    Ultrasound also has limitations. Detection depends on the fragment’s size, material and location, the time since injury and the examiner’s experience. Air in a fresh wound, proximity to bone and deep location can make assessment more difficult. In a meta-analysis of 17 studies, pooled ultrasound sensitivity was 72% and specificity 92%. A positive result can therefore be very helpful, but a normal result does not completely exclude a retained foreign body when clinical suspicion remains high.

    When are CT or MRI needed?

    CT may be useful for deeply located foreign bodies, complex anatomy or an equivocal radiograph. MRI is used selectively, particularly when soft-tissue complications need to be assessed. If a metallic fragment is possible, MRI should not be ordered blindly; the type and location of the material should first be established.

    Does every foreign body need to be removed?

    No. Removal is more often indicated when the fragment causes pain, infection, restricted movement or compression of a nerve, vessel or tendon. Organic material such as wood or a thorn is more likely to provoke inflammation and infection. Foreign bodies close to a joint, tendon sheath or neurovascular structures deserve prompt assessment.

    A small, deeply located, inert and asymptomatic fragment can sometimes be left in place when retrieval would cause more tissue damage than benefit. The decision should balance the expected benefit of removal against the procedural risk. Tetanus protection should also be reviewed according to the wound and vaccination history.

    What does ultrasound-guided removal involve?

    The fragment is first located and the safest access route is planned. In an appropriate superficial location, a small incision can be made and the instrument followed under real-time ultrasound, potentially reducing unnecessary tissue dissection. Not every case is suitable for this approach.

    Operating-room conditions may be required when the object is deep, brittle, large, fragmented, close to a nerve or vessel, has penetrated a tendon, or lies within a joint. Blind attempts to dig out an unseen fragment with a needle or tweezers can push it deeper, break it into smaller pieces and increase the risk of infection.

    What should you do after a fresh injury?

    • Do not probe a deep wound with household instruments.
    • If an object remains deeply embedded, do not force it out.
    • Cover the wound with a clean dressing and reduce loading of the painful hand or foot.
    • Note what material caused the injury and when it occurred.
    • For a deep, contaminated or puncture wound, seek advice about cleaning, antibiotics when indicated and tetanus prophylaxis.

    Warning signs

    Urgent assessment is needed for increasing pain and swelling, rapidly spreading redness, pus, fever, red streaking along the limb, numbness or weakness of finger or toe movement, a pale or cold hand or foot, severe pain when moving a finger, or a wound that may have penetrated a joint. A high-pressure injection injury requires immediate medical attention even when the skin opening looks minor.

    Key points for an orthopaedic surgeon

    Ultrasound is especially valuable when a retained fragment is not visible on X-ray or when its relationship to soft tissues needs to be mapped. It is not a perfect test. When the history and symptoms still strongly suggest a retained foreign body, one normal imaging result should not automatically end the diagnostic process.

    Sources

    1. Davis J, et al. Diagnostic Accuracy of Ultrasonography in Retained Soft Tissue Foreign Bodies: A Systematic Review and Meta-analysis. Acad Emerg Med. 2015;22(7):777–787. DOI: 10.1111/acem.12714. PubMed.
    2. Rupert J, Honeycutt JD, Odom MR. Foreign Bodies in the Skin: Evaluation and Management. Am Fam Physician. 2020;101(12):740–747. Full text.

    Polish version · Diagnostic Tests · For Patients

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Does an Injury Sometimes Need to Be Re-Examined?

    A repeat examination a few days after an injury does not necessarily mean that the first assessment was wrong. Early pain, swelling and protective muscle guarding can obscure important findings, while some injuries become easier to identify only as symptoms evolve or swelling settles.

    The first examination answers different questions

    Immediately after an injury, the priority is to identify problems that require urgent treatment: an open fracture, dislocation, impaired circulation, nerve injury, compartment syndrome or an infected wound. The assessment focuses on the mechanism of injury, deformity, tenderness, ability to bear weight, sensation, movement and the peripheral pulse.

    Why can the early examination be difficult?

    Severe pain may make almost every movement seem impossible. Swelling can blur normal anatomical landmarks. Reflex muscle guarding can make joint-stability testing unreliable, and diffuse bruising may hide the focal tenderness that points toward a particular bone or ligament.

    This can occur after wrist, ankle, knee and shoulder injuries. Some fractures are also occult on the first radiographs. A classic example is a suspected scaphoid fracture: initial X-rays may be normal despite a genuine fracture, so immobilisation, repeat clinical assessment and appropriately selected MRI or CT may be needed.

    What can an orthopaedic surgeon learn from a follow-up examination?

    • It can localise the most tender area more precisely.
    • It allows a more reliable assessment of movement and stability after pain settles.
    • It shows whether swelling, bruising and function are changing as expected.
    • It may reveal tendon or nerve dysfunction that was initially unclear.
    • It helps decide whether different imaging or a change in treatment is needed.

    When does repeating an X-ray make sense?

    That depends on the suspected injury. In some cases, a later radiograph can show fracture signs that were not visible initially. In others, early MRI or CT is more useful than simply waiting for another X-ray. For example, when a scaphoid fracture is clinically suspected despite negative initial radiographs, expert guidance supports MRI, or CT when appropriate, within the following few days.

    Imaging should not be repeated merely because a certain amount of time has passed. There should be a specific question: are we looking for an occult fracture, checking fracture alignment, assessing healing, or investigating persistent symptoms?

    When should you not wait for a routine follow-up?

    Urgent reassessment is appropriate for rapidly increasing pain or swelling, new numbness, worsening weakness, a pale or cold limb, increasing pressure or severe pain under a cast, fever, pus, spreading redness, a new deformity or inability to bear weight after an injury. In those situations, waiting several days for a scheduled review is not the right plan.

    The key principle

    Trauma diagnosis is a process, not a single image or test. The first visit is designed to identify urgent threats and establish safe initial management. Follow-up checks whether the clinical course supports the initial diagnosis and whether new findings justify more targeted imaging or a different treatment strategy.

    Sources

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

    Polish version · For Patients

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Dental Treatment After Joint Replacement — Is Antibiotic Prophylaxis Needed?

    Having a hip or knee replacement does not usually mean that antibiotics are required before every dental procedure. Current guidance does not support routine prophylaxis for all patients. The type of dental treatment, timing in relation to arthroplasty, active oral infection and individual risk factors all matter.

    Why was dental treatment considered a risk after joint replacement?

    Some dental procedures can cause transient bacteraemia. This led to concern that bacteria might seed the surface of a joint implant and cause periprosthetic joint infection. Such infection is a serious complication, but biological plausibility alone does not prove that a preventive antibiotic dose before dental care effectively reduces that risk.

    Bacteraemia also occurs during everyday activities such as brushing, flossing and chewing, particularly when gum health is poor. Over the long term, regular dental care and good oral hygiene are therefore more important than an occasional antibiotic dose before every procedure.

    Is an antibiotic needed before dental treatment?

    According to the AAOS and AAHKS guideline published on 18 November 2024, routine systemic antibiotic prophylaxis before dental procedures in patients with a hip or knee replacement may not reduce the risk of subsequent periprosthetic joint infection. The evidence quality was rated low, so this is a limited-strength option rather than an absolute rule for every patient.

    The American Dental Association likewise states that prophylactic antibiotics are generally not recommended for every patient with a prosthetic joint. Uncommon exceptions should be considered individually, particularly in people with previous complications related to the joint replacement and when the planned procedure involves gingival manipulation or incision of oral mucosa.

    Leftover antibiotics should not be taken without a specific recommendation. Unnecessary treatment can cause allergic reactions, diarrhoea, Clostridioides difficile infection and contributes to antimicrobial resistance.

    A joint replacement is not the same as a prosthetic heart valve

    Antibiotic prophylaxis for infective endocarditis is a separate issue. Some people with specific cardiac conditions may require antibiotics before procedures involving gingival manipulation or oral mucosa. In those situations, the indication may be cardiac rather than orthopaedic. Patients should tell their dentist about all implants and relevant medical conditions, but the two indications should not be conflated.

    When should dental infection be treated before arthroplasty?

    Before elective joint replacement, active sources of oral infection should be treated. Tooth pain, an abscess, facial swelling, fever or active periodontal infection require dental care, and elective arthroplasty is generally postponed until treatment is completed and healing is confirmed.

    The AAOS/AAHKS guidance suggests that planned dental extractions and oral surgical procedures should be completed at least three weeks before arthroplasty to allow mucosal healing. A routine dental examination without probing, dental radiographs or denture adjustment does not require the same interval.

    When can dental treatment be performed after surgery?

    An urgent dental infection should not be left untreated simply because a joint replacement was recent. It requires prompt dental care, with the dentist informed about the recent operation and management coordinated with the orthopaedic team when appropriate.

    For planned procedures that manipulate the gingiva or require oral surgery, the guideline suggests considering a delay of up to three months after joint replacement. This is a consensus recommendation based on indirect evidence; it does not mean that every earlier dental procedure causes an implant infection. Non-invasive assessment and dental imaging may be performed sooner when clinically needed.

    How should a patient prepare for a dental visit?

    • Tell the dentist which joint was replaced and when.
    • Report any previous joint replacement infection or other implant-related complication.
    • List diseases and medications that affect immunity, clotting or healing.
    • Ask whether the planned procedure involves the gingiva, bone or oral mucosa.
    • Do not stop anticoagulants or start antibiotics without a specific instruction.

    When is urgent assessment needed?

    Increasing tooth pain, an abscess, swelling of the face or neck, difficulty swallowing, trismus and fever require prompt dental assessment. In a person with a joint replacement, new severe pain in the operated joint, swelling, marked warmth, fever or drainage from the surgical scar also requires rapid orthopaedic evaluation.

    Key points for an orthopaedic surgeon

    A joint replacement is not an automatic indication for antibiotics before every dental visit. Good oral health, timely treatment of active infection and sensible scheduling of dental procedures around arthroplasty are more important. If prophylaxis is considered in an unusual high-risk situation, it should be based on an individual decision involving the dentist, orthopaedic team and patient.

    Sources

    1. American Academy of Orthopaedic Surgeons; American Association of Hip and Knee Surgeons. Prevention of Total Hip and Knee Arthroplasty Periprosthetic Joint Infection in Patients Undergoing Dental Procedures. Guideline published 18 November 2024. Full guideline.
    2. American Dental Association. Antibiotic Prophylaxis Prior to Dental Procedures. ADA guidance.

    Polish version · Before and After Orthopaedic Surgery

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Conservative Treatment Is Not the Same as Waiting

    Conservative treatment should not mean passively waiting for a problem to disappear. It is a structured process with a working diagnosis, specific interventions, a measurable goal and a planned review point. Without those elements, it is difficult to know whether treatment was actually carried out or why it failed.

    What makes a good plan?

    The first step is to identify the likely source of symptoms and rule out conditions that need urgent treatment. Management of tendon overload is different from care after an unstable injury, and both differ from management of advanced osteoarthritis. The same exercise, brace or medication is not a universal answer to every musculoskeletal pain problem.

    The plan should also define the outcome that matters to the patient: sleeping through the night, climbing stairs, returning to work, restoring a particular range of motion or returning gradually to sport. A change on an imaging report is rarely the main goal by itself.

    What can conservative treatment include?

    Depending on the diagnosis, treatment may include load modification, exercise, physiotherapy, analgesic treatment, temporary use of a brace or crutches, changes in work tasks, weight reduction or an injection. The aim is not to collect as many treatments as possible, but to select those that fit the specific problem.

    Activity modification does not mean complete rest

    Temporarily reducing a movement that reliably provokes pain may be appropriate, but prolonged avoidance of all activity often leads to weakness, loss of fitness and greater fear of movement. In many situations it is better to identify a tolerable level of loading and increase it gradually rather than wait for perfect symptom-free status.

    Exercise has a dose

    Just as medication has a dose and frequency, an exercise programme should specify the movement, number of repetitions, resistance, frequency and progression. “Do some exercises” is not a complete plan. There should also be criteria for reducing load when the tissue response is excessive.

    How long should treatment be tried?

    There is no single mandatory duration of conservative treatment for every condition. Some acute problems change over days, tendon and muscle adaptation usually takes weeks or months, and osteoarthritis management is long term. The review interval should reflect biology and risk rather than an administrative rule.

    A review does not always mean waiting until the full programme is finished. Earlier adjustment is appropriate when symptoms worsen, new weakness appears, the recommended load is not tolerated or the working diagnosis no longer matches the clinical course.

    How do we know whether treatment is working?

    • Pain is less intense or settles more quickly after activity.
    • The patient can do more daily activities.
    • Strength, range of motion, stability or exercise tolerance improves.
    • There is less need for medication or mobility aids.
    • A previously agreed goal that matters to the patient is being reached.

    Complete absence of pain is not always necessary. A clinically meaningful and durable gain in function may matter more.

    When has a trial genuinely failed?

    Lack of improvement becomes informative only when the diagnosis was reasonable, the intervention was appropriate, the dose was sufficient and the patient could realistically carry out the plan. If exercises were random, inconsistent or repeatedly exceeded tissue tolerance, it may be unclear whether the method failed or the programme was not delivered effectively.

    After a properly conducted trial, the next decision may be to modify treatment, revisit the diagnosis, obtain targeted imaging or discuss a procedure. Surgery is not a “punishment” for unsuccessful rehabilitation, and conservative treatment is not a ritual that must precede every operation. The decision depends on expected benefit, risk and the patient’s goals.

    When should we not wait for months?

    More urgent management may be needed for an open or displaced fracture, dislocation, threatened skin, compromised circulation, progressive nerve injury, infection, a locked joint or rapidly increasing weakness. In these situations, a routine “rehabilitation first for several months” approach may be inappropriate.

    Key point for an orthopaedic surgeon

    Good conservative treatment has a structure: diagnosis, goal, selected intervention, appropriate dose, monitoring and a decision point. That structure makes it possible to adjust treatment intelligently and, when necessary, decide about surgery on the basis of the actual treatment course rather than the passage of time alone.

    Sources

    1. American Academy of Orthopaedic Surgeons. Management of Osteoarthritis of the Knee (Non-Arthroplasty). Evidence-Based Clinical Practice Guideline. 2021. Full guideline.
    2. National Institute for Health and Care Excellence. Osteoarthritis in over 16s: diagnosis and management. NICE guideline NG226. 2022. Guideline.

    Polish version · Treatments and Procedures

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Return to Sport After an Ankle Sprain — When Is It Safe?

    Return to sport after an ankle sprain is safest when the joint tolerates loading, has sufficient range of motion, strength and balance, and the athlete can perform sport-specific movements without substantial pain, giving way or a clear increase in symptoms the following day. The number of days since injury—or the disappearance of swelling alone—is not enough.

    Progression should be gradual: from normal walking and simple exercises to running, changes of direction and finally full training. A more severe injury, suspected syndesmotic injury, fracture or osteochondral lesion requires a different plan.

    First establish what was injured

    A typical lateral ankle sprain involves the ligaments on the outer side of the ankle. Similar symptoms, however, can occur with a fracture, syndesmotic injury, peroneal tendon injury or an osteochondral lesion. If the diagnosis is uncertain, an early return to sport can delay appropriate treatment.

    Imaging should be selected to answer a clinical question rather than ordered automatically. See the English overview of diagnostic tests for the roles of X-ray, ultrasound, MRI and CT.

    There is no single safe number of days

    Two injuries both described as an “ankle sprain” can differ greatly in severity, stability and sporting demands. A runner returning after a minor sprain faces different requirements from a footballer, basketball player or tennis player who needs to brake, land and change direction rapidly.

    The calendar is therefore only one part of the decision. More important is how the ankle responds to progressively harder loading and how it feels over the following 24 hours.

    Five areas an orthopaedic surgeon and physiotherapist assess

    The international PAASS consensus organises return-to-sport assessment into five domains. It is not a single test or an automatic clearance certificate, but a practical framework that helps ensure important elements are not overlooked.

    1. Pain

    Pain should be assessed during sport and over the previous 24 hours. Mild discomfort does not always mean activity must stop, but pain that increases during training, changes movement technique or is clearly worse the next day suggests that the load was too high.

    2. Range of motion, strength and power

    The ankle should regain the range of motion required for the sport. Strength of the peroneal muscles and calf matters, but so do endurance and the ability to produce force quickly. Calf raises, single-leg squats and side-to-side comparison tasks can be useful in practice.

    3. Confidence and perceived stability

    The athlete should trust the ankle during landing, cutting and contact. Fear of movement can alter loading even when simple tests look satisfactory. A persistent feeling that the ankle “gives way” deserves reassessment.

    4. Balance and neuromuscular control

    The ankle must respond to loss of balance and uneven ground. Single-leg stance and dynamic tasks help assess limb control. It is useful to observe not only time or distance but also landing quality, knee and trunk position, and the number of errors.

    5. Sport-specific tasks and full training

    Jumping, landing, acceleration, deceleration, cutting and ball drills should reflect the demands of the individual sport. One of the most useful tests is the ability to complete a full training session without loss of control and without a meaningful increase in symptoms afterwards.

    How should return be progressed?

    1. Daily loading: walking without a marked limp, stairs and basic exercises.
    2. Straight-line movement: brisk walking, jogging and easy running.
    3. Dynamic loading: hops, landings and acceleration.
    4. Change of direction: cutting, braking and tasks on less predictable surfaces.
    5. Sport training: controlled drills first, followed by full training.
    6. Competition: only after the athlete tolerates the full demands of training.

    Each stage should be performed with good movement quality. If pain, swelling or a sense of instability clearly increases during activity or the next day, the load should be reduced and the situation reassessed.

    What should rehabilitation include?

    Current guidance supports progressive restoration of weight-bearing, range of motion, strength and neuromuscular control. Rehabilitation commonly includes mobility work, strengthening, balance training, single-leg tasks and gradual progression toward sport-specific movement.

    Prolonged complete immobilisation is not standard for every ankle sprain. A short period of immobilisation can be appropriate after a severe injury, but subsequent care should usually include early, safe mobilisation. The details depend on ankle stability and associated injuries.

    Can a brace or taping reduce the risk of another sprain?

    For athletes returning after a sprain, bracing or taping can be one component of recurrence-risk reduction, particularly in sports involving jumps and rapid changes of direction. They do not replace rehabilitation. External support by itself does not restore strength, balance or confidence in movement.

    When do symptoms not fit a simple ankle sprain?

    Reassessment is appropriate when pain is higher above the ankle, deep within the joint, accompanied by locking, tendon snapping, repeated giving way or a lack of expected improvement. Pain behind the lateral malleolus may also arise from the peroneal tendons rather than from the ankle ligaments themselves.

    Warning signs

    • visible deformity or suspected dislocation;
    • inability to bear weight with marked focal bony tenderness;
    • a cold, pale or blue foot, increasing numbness or weakness;
    • very severe or rapidly increasing pain;
    • an open wound;
    • increasing calf swelling, shortness of breath or chest pain;
    • lack of expected improvement or deterioration after initial improvement.

    The key point

    Safe return to sport after an ankle sprain is a function-based decision. Pain, movement, strength, balance, confidence in the joint and sport-specific performance all matter. Completing full training without a subsequent symptom flare is a much more useful test than the date of injury alone.

    Polish version · Sports Medicine and Reconstructive Surgery

    References

    • Smith MD et al. Return to sport decisions after an acute lateral ankle sprain injury: introducing the PAASS framework—an international multidisciplinary consensus. Br J Sports Med. 2021;55:1270–1276. DOI: 10.1136/bjsports-2021-104087.
    • Martin RL et al. Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021. J Orthop Sports Phys Ther. 2021;51(4):CPG1–CPG80. DOI: 10.2519/jospt.2021.0302.

    This material is educational. Rehabilitation pace and return-to-sport decisions should be tailored to the injury, clinical examination and demands of the sport.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Does an Orthopaedic Surgeon Watch How You Walk?

    Walking is a brief functional test of the whole musculoskeletal system. In only a few steps, an examiner can see how pain, range of motion, muscle strength, balance and sensation work together under real load. That is why gait observation often begins before the formal examination on the couch.

    Gait shows function, not just the location of pain

    Examining one joint helps answer what is happening in a particular area. Watching someone walk shows how the body manages the entire task. A patient may have a good range of hip motion while lying down yet shorten the step, lean the trunk or avoid fully loading one leg while walking.

    Such adaptations may result from pain, weakness, stiffness, lack of confidence in the limb or a neurological problem. A gait pattern rarely establishes a diagnosis by itself, but it can direct the rest of the examination.

    What can be seen in a few steps?

    Protecting a painful limb

    When a leg hurts, people commonly spend less time standing on it. The steps become asymmetrical and the trunk may shift to reduce loading. This is an antalgic gait: it shows that the limb is being protected, but it does not identify the source of pain on its own.

    Restricted movement

    Stiffness of the hip, knee or ankle can alter step length and the way the foot moves through the gait cycle. The body may compensate through the pelvis, trunk or neighbouring joints. Sometimes the compensation itself contributes to pain elsewhere.

    Muscle weakness

    Weak hip abductors may appear as pelvic drop or a marked trunk lean. Weak ankle dorsiflexors may lead to exaggerated lifting of the knee so the toes clear the ground. These observations need confirmation with strength and neurological testing.

    Balance and control

    Straight-line walking is only one part of the assessment. Turning, stopping, stepping up and standing on one leg place different demands on the body. A problem may become evident only when direction changes or the base of support becomes smaller.

    Why does observation start before the examination couch?

    On the couch, body-weight loading largely disappears. That is useful for assessing movement, tenderness and stability in a controlled way, but it does not reproduce walking. The natural way a patient enters the room can provide information that is not always reproduced by asking someone to “walk normally” on command.

    Standing up from a chair, taking off a shoe or turning around can be equally informative. These are not hidden tests of the patient; they are ordinary tasks that show where a real functional difficulty appears.

    A gait pattern is not a diagnosis

    The same walking pattern can have different causes. Limping may occur with hip, knee or foot pain, after an injury, with a leg-length difference or in neurological disease. Conversely, some degenerative changes visible on imaging may have little effect on gait.

    Gait observation therefore needs to be combined with the history, joint examination, strength testing, sensation and reflexes and—when indicated—imaging. The most useful information comes from several findings pointing in the same direction, not from one striking sign.

    Do you need to prepare for gait assessment?

    Usually not. Comfortable clothing and the shoes you normally wear can be helpful. If the problem appears only in particular footwear, with an insole, after a longer distance or during running, mention it. A short video from the situation in which the symptom normally occurs can also be useful when the problem cannot be reproduced in the clinic.

    The key point

    Watching someone walk does not replace a full examination. It is, however, a quick way to see how the musculoskeletal system performs under load. It helps connect reported pain with real-world function and guides which areas should be examined more closely.

    Polish version · For Patients

    Source

    Pirker W, Katzenschlager R. Gait disorders in adults and the elderly: a clinical guide. Wien Klin Wochenschr. 2017;129:81–95. DOI: 10.1007/s00508-016-1096-4.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Does an Orthopaedic Surgeon Ask Whether Pain Wakes You at Night?

    Night pain is clinically useful information, but it is not a diagnosis and it does not automatically indicate serious disease. What matters is whether pain appears only in a particular position, genuinely wakes the patient from sleep, improves after changing position or moving, and whether other symptoms are present.

    Polish version · For Patients

    “It hurts at night” can describe very different situations

    One person develops pain only when lying on the affected shoulder or hip. Another falls asleep normally but is woken several hours later by steadily increasing pain that is unrelated to position. A third sleeps poorly because each turn in bed provokes pain in a recently operated joint. These patterns are not equivalent.

    For that reason, asking about night pain is the beginning of the assessment rather than the end. It is useful to establish when the pain appears, whether it depends on position, how it responds to movement, and whether similar symptoms occur during the day.

    Position can increase pressure on sensitive tissues

    Side-lying may compress tissues over the lateral hip or a painful shoulder. Remaining in one position for a long time can also increase joint stiffness. If pain eases quickly after changing position, supporting the limb or briefly moving the joint, that is a useful mechanical clue.

    For example, shoulder pain at night is common in rotator cuff disorders, subacromial bursitis and frozen shoulder, but night pain alone does not distinguish among them.

    There are fewer competing stimuli at night

    During the day, attention is occupied by movement, work and the environment. In a quiet setting, bodily signals can become more noticeable. This does not make the pain “imaginary”; pain processing genuinely changes with sleep, stress and context.

    The relationship also works in the opposite direction. Pain disrupts sleep, while poor sleep can increase pain sensitivity the following day. This can create a self-reinforcing cycle that cannot be understood simply by treating an MRI finding.

    What details about night pain matter most?

    • whether pain occurs only in a specific position;
    • whether it wakes the patient despite a comfortable position;
    • whether it improves after moving, standing up or changing position;
    • whether it is progressively worsening from week to week;
    • whether fever, night sweats, weight loss or systemic illness are present;
    • whether there is swelling, redness, a new deformity, numbness or weakness;
    • whether there is a history of cancer, recent trauma, surgery or infection.

    When does night pain lower the threshold for further investigation?

    A new, persistent and progressive pain that is independent of position or movement, genuinely interrupts sleep and is accompanied by systemic symptoms, marked weakness or an abnormal clinical examination deserves particular attention. In that setting, the threshold for further investigation should be lower.

    By contrast, a painful shoulder that hurts when the patient lies directly on it is not the same clinical signal as rapidly worsening rest pain associated with fever. The meaning comes from the entire pattern.

    Is MRI needed straight away?

    Not always. The appropriate test depends on the anatomical region and the suspected cause. In some conditions the first investigation may be an X-ray; in others it may be ultrasound, blood tests or MRI. Imaging should answer a clinical question rather than replace the history and examination.

    How can a patient prepare this information for a consultation?

    For several days it can help to note the time at which pain appears, the sleeping position, how many times it causes waking, what relieves it and how the joint feels in the morning. This is often more useful than the general statement “it hurts at night”.

    Key point

    Asking about night pain helps distinguish position- and load-related symptoms from rest pain that may require broader assessment. It should never be interpreted in isolation. The pattern, progression and consistency with the clinical examination matter most.

    Reference

    Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain. 2013;14(12):1539–1552. DOI: 10.1016/j.jpain.2013.08.007.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

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

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

    Polish version · For Patients

    Where is the semimembranosus tendon?

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

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

    What does semimembranosus tendinopathy usually feel like?

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

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

    What else can cause pain behind the knee?

    Baker’s cyst

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

    Meniscus and cartilage

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

    Other tendons and muscles

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

    Deep vein thrombosis

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

    What does the clinical examination involve?

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

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

    When is ultrasound useful?

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

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

    When is MRI appropriate?

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

    How is it treated?

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

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

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

    Are injections or surgery needed?

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

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

    Red flags

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

    Key point for an orthopaedic surgeon

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

    References

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

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

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Painful Surgical Scar — Could It Be a Neuroma?

    A sharply localised burning, stabbing or electric-shock-like pain in or next to a surgical scar can come from an irritated or trapped cutaneous nerve and, in some cases, from a painful neuroma. Not every tender scar is a neuroma, however. Normal healing, infection, implant-related problems, local tissue overload and complex regional pain syndrome must also be considered.

    What is a postoperative neuroma?

    When a nerve is cut or significantly injured, its fibres attempt to regenerate. If they cannot reconnect with the distal segment, a disorganised bulb of regenerating nerve tissue may form at the nerve end. This is a traumatic neuroma. Similar symptoms can also occur when a nerve remains anatomically continuous but becomes tethered in dense scar tissue or repeatedly irritated during movement.

    Which symptoms suggest neuropathic scar pain?

    • a very small, clearly defined point of maximal tenderness within or next to the scar;
    • burning, stabbing, shooting or electric-shock-like pain;
    • pain radiating along a nerve distribution when one specific point is pressed or tapped;
    • numbness, hypersensitivity or pain from light contact such as clothing;
    • symptoms aggravated by stretching the scar, moving the nearby joint, footwear or a brace pressing on the area.

    During the first weeks after surgery, local tenderness, a small patch of numb skin and altered sensation may improve gradually without additional treatment. A neuroma becomes more likely when the pain has a distinctly neuropathic quality, persists or worsens, and can be reproduced consistently by pressing one focal point.

    How is it investigated?

    What does an orthopaedic surgeon assess during examination?

    The scar itself is examined together with the distribution of sensory change, muscle strength and the expected course of the nerve. The clinician may also check whether tapping the painful point reproduces radiating symptoms. It is useful to know whether the nerve could have been cut, mobilised or placed at risk during the original operation.

    High-resolution nerve ultrasound

    High-resolution ultrasound can demonstrate focal nerve enlargement, loss of continuity, tethering to scar tissue and the relationship to tendons, implants or vessels. Dynamic examination may show whether movement stretches or displaces the symptomatic segment. A normal ultrasound does not completely exclude pain arising from a very small cutaneous nerve branch.

    Other tests

    MRI, including MR neurography in selected cases, may be helpful for deeper lesions. Nerve conduction studies and electromyography are more useful when pain is accompanied by muscle weakness or sensory loss in the territory of a larger peripheral nerve. A selective local anaesthetic injection can sometimes help test whether a particular nerve segment is generating the pain, but the result still needs to be interpreted in the context of the full examination.

    How are painful scars and neuromas treated?

    Treatment depends on the time since surgery, the severity of symptoms and whether the nerve is thought to be divided, tethered or temporarily irritated. Early management may include protecting the area from pressure, gradual desensitisation, scar mobility work and appropriate medical treatment for neuropathic pain. Aggressive massage directly over a very painful focal point before the diagnosis is clear can aggravate symptoms.

    Selected patients may benefit from diagnostic or therapeutic injections, sometimes performed under ultrasound guidance. Evidence for hydrodissection and other injection-based techniques remains limited, so these procedures should not replace an effort to identify the underlying pain mechanism.

    Surgery may be considered when pain is persistent, well localised, functionally important and has not improved with appropriate conservative treatment. Options include freeing a nerve from scar tissue, excising a neuroma and protecting or reconstructing the nerve end. The technique depends on the anatomy and on whether meaningful nerve continuity can be restored; no procedure guarantees complete relief.

    When is urgent assessment needed?

    Do not assume that worsening scar pain is a neuroma if the wound is hot, red or draining, if fever develops, swelling is increasing rapidly, or pain suddenly becomes much more severe. New or progressive muscle weakness, widespread numbness, a cold or pale limb, or severe pain associated with marked colour or temperature change and swelling of the whole region also require prompt assessment. Sudden neurological weakness should be investigated without delay.

    Key point

    A painful neuroma is one possible cause of persistent scar pain after surgery, but the diagnosis requires a consistent symptom pattern, clinical examination and—when appropriate—imaging or a diagnostic block. Treatment is most useful when it targets a specific mechanism rather than simply attempting to “break up” the scar.

    References

    1. Zhou L, Huo T, Zhang W, et al. New techniques and methods for prevention and treatment of symptomatic traumatic neuroma: a systematic review. Front Neurol. 2023;14:1086806. DOI: 10.3389/fneur.2023.1086806.
    2. Hendrickson NR, McDonald JR, Kennedy SA, et al. Treatment of Postsurgical Neuroma in Foot and Ankle Surgery. Foot Ankle Orthop. 2023;8(3). DOI: 10.1177/24730114231188125.
    3. Grimm A, Décard BF, Athanasopoulou I, et al. Nerve Ultrasound in Traumatic and Iatrogenic Peripheral Nerve Injury. Diagnostics. 2021;11(1):30. DOI: 10.3390/diagnostics11010030.

    Polish version · For Patients

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.