Umów wizytę

Tomasz Poboży

Kategoria: Patient Knowledge (EN)

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

  • Why Does an Orthopaedic Examination Test Muscle Strength?

    Strength testing helps distinguish movement limited mainly by pain from weakness caused by tendon injury, nerve dysfunction or deconditioning after immobilisation. A single strength grade is not a diagnosis, but when it is interpreted together with range of motion, sensation and the pattern of symptoms, it can substantially narrow the differential diagnosis.

    It is not simply about how much weight you can lift

    During the examination, the clinician asks the patient to perform a specific movement and then gradually applies resistance. By positioning the limb carefully, selected muscle groups—and the tendons and nerves that support them—can be assessed. Failure to start a movement, normal movement without resistance, and a sudden painful “give-way” response all carry different clinical information.

    What can weakness mean?

    • Pain-inhibited movement: the muscle and nerve may be intact, but the patient cannot generate full effort because the movement hurts.
    • Tendon injury: the muscle contracts, but force is not transmitted normally to the bone.
    • Nerve injury or dysfunction: weakness often follows a recognisable anatomical pattern and may be accompanied by sensory change or altered reflexes.
    • Immobilisation and disuse: strength falls gradually when a limb has not been used normally, often without the sharp or electric quality of neuropathic pain.
    • A problem within the joint itself: pain and restricted motion can make a true strength assessment unreliable.

    For that reason, strength testing is interpreted alongside active and passive range of motion. If the examiner can move a joint farther than the patient can move it independently, the explanation may lie in pain, muscle function, tendon continuity or the nervous system rather than in fixed joint stiffness alone.

    Why does an orthopaedic surgeon compare both sides?

    “Normal” strength varies with age, body build, activity level, hand dominance and previous disease or surgery. The opposite limb therefore provides a useful practical reference, although it is not a perfect control because it may also be weak or previously injured. A consistent pattern across several movements is usually more informative than a small isolated side-to-side difference.

    The 0–5 scale and dynamometry

    In neurological examination, the Medical Research Council scale from 0 to 5 is commonly used, ranging from no visible muscle contraction to movement against substantial resistance. It is a practical ordinal scale rather than a precise force measurement. When subtle differences matter—for example during rehabilitation monitoring or athletic assessment—a handheld dynamometer may provide a more reproducible measurement, provided the testing position and method are standardised.

    Why does one weak test not establish the diagnosis?

    Strength testing is influenced by pain, fear of movement, fatigue, understanding of the instruction and the examiner’s own force. Manual testing is also less sensitive to small deficits in very strong patients. The result therefore needs to fit the history and the rest of the examination and, where appropriate, be supported by ultrasound, X-ray, MRI or nerve conduction studies.

    When does weakness need prompt assessment?

    Sudden loss of strength after an injury, inability to lift the foot or toes, a new wrist drop, rapidly progressive numbness, or weakness accompanied by a cold and pale limb requires prompt assessment. These patterns can indicate significant tendon, nerve or vascular injury and should not simply be observed for weeks without a diagnosis.

    References

    1. Medical Research Council. Aids to the Examination of the Peripheral Nervous System. Memorandum No. 45. London: Her Majesty’s Stationery Office; 1976.
    2. Bohannon RW. Manual muscle testing: does it meet the standards of an adequate screening test? Clin Rehabil. 2005;19(6):662–667. DOI: 10.1191/0269215505cr873oa.

    Polish version · For Patients

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Stairs After Surgery — How to Go Up and Down Safely

    After many lower-limb operations, stairs can be used, but the technique depends first of all on how much weight is allowed through the operated leg. Early on, patients usually use a step-to pattern while holding a handrail and a crutch. The safest approach is to practise the technique with a physiotherapist or ward staff before attempting stairs independently.

    First check the weight-bearing instructions from your orthopaedic surgeon

    “After surgery” covers very different situations. After some procedures, weight bearing as tolerated is permitted from the beginning. After others, only partial weight bearing is allowed, and sometimes the limb must remain non-weight-bearing for a period. The instruction depends on the operation, bone quality, stability of fixation and tissue healing.

    The key information in the discharge plan is therefore not simply how many days have passed since surgery, but the exact weight-bearing instruction. If this is unclear, do not guess and do not use pain alone as a guide. Little pain does not automatically mean the repaired or fixed structure is ready for full loading.

    How to go upstairs with a handrail and one crutch

    For a typical unilateral lower-limb operation, once this method has been approved:

    1. Stand close to the first step. Hold a secure handrail with one hand and the crutch with the other.
    2. Place the non-operated leg on the higher step.
    3. Bring the operated leg up to the same step.
    4. Bring the crutch up last.

    A simple way to remember the sequence is: the stronger leg leads going up. Take one step at a time initially rather than trying to use a normal alternating pattern straight away.

    How to go downstairs

    1. Stand close to the edge of the step and hold the handrail securely.
    2. Place the crutch on the lower step.
    3. Lower the operated leg.
    4. Bring the non-operated leg down last.

    The order is therefore reversed when descending: the support and operated leg go first, the stronger leg follows. Avoid leaning far forward and never place the crutch tip on the edge of the step.

    Two crutches, one crutch or a walker?

    Where a handrail is available, two crutches can sometimes be held together in one hand after proper instruction while the other hand uses the rail. Without a handrail, stair negotiation with two crutches is more difficult and requires good balance. Initial attempts should be supervised.

    A walking frame or walker provides useful stability on level ground, but it is not designed for climbing a full flight of stairs. If a walker is the only safe mobility aid, an alternative route, assistance from another person or temporary living on one level should be planned.

    When can alternating stair climbing return?

    There is no single universal date. In general, the following are needed:

    • permission for sufficient loading of the operated limb;
    • adequate pain control without dizziness or excessive medication-related drowsiness;
    • enough hip, knee and ankle range of motion;
    • sufficient strength to lift the body onto the step and control the descent;
    • no obvious knee buckling, loss of balance or progressively worsening limp.

    Alternating steps often return sooner when going up than when going down. Descent requires good eccentric muscle control — the ability to slow the body under load.

    Preparing stairs at home

    • Remove loose rugs, cables and objects from the stairs.
    • Ensure good lighting, including for night-time trips to the bathroom.
    • Check that the handrail is secure and easy to grip.
    • Wear closed, non-slip footwear. Avoid loose slippers and walking in socks.
    • Do not carry objects in your hands while using crutches. Small items can be carried in a light backpack.
    • If the stairs are winding, steep or lack a rail, arrange supervision and reduce the number of trips where possible.

    When should you stop?

    Stop the attempt if you lose balance, the leg suddenly gives way, pain rises sharply, or you develop dizziness or marked drowsiness. A fall, sudden pain with deformity, a snap followed by loss of function or a new inability to bear weight requires prompt assessment.

    Urgent review is also needed for increasing numbness, a cold or pale foot, rapidly worsening swelling, wound drainage, fever, a hot and markedly red operative area, or new calf pain and swelling — particularly if accompanied by shortness of breath.

    The most important rule

    The familiar rule “stronger leg up, operated leg down” is a useful memory aid, but it does not replace the instructions for a specific operation. Recovery after joint replacement, ligament reconstruction, fracture fixation or bilateral surgery may require different precautions.

    Sources

    Polish version · More on recovery after orthopaedic surgery

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • What Does a Positive Orthopaedic Test Actually Mean?

    A positive test during an orthopaedic examination is not a diagnosis by itself. It means that a particular movement, pressure or load produced the response the test was designed to provoke. Its real significance becomes clear only when it is interpreted alongside the history, the rest of the examination and, when appropriate, imaging.

    What is a provocative test?

    During an orthopaedic examination, the clinician deliberately positions a joint or loads a selected structure to see whether this reproduces familiar pain, instability, loss of motion or a neurological symptom. A test may be aimed at a tendon, ligament, meniscus, labrum, nerve or a particular direction of movement.

    The answer is not simply “painful” or “not painful”. The exact location and character of the symptom matter, as do side-to-side differences, end-feel, strength, range of motion and whether the manoeuvre reproduces the pain the patient actually recognises from everyday activities.

    Why can a test be positive without the suspected injury?

    A single movement often stresses several structures at the same time. A manoeuvre intended to assess a tendon may also tension the joint capsule, compress a bursa or provoke pain arising from a neighbouring area. A positive response can therefore come from a different source than the name of the test suggests.

    Tissue irritability, a recent injury, swelling, fear of movement and the way the test is performed can also affect the result. This is why a test is most useful when it answers a specific question generated by the history rather than when it is used as one item in a long, untargeted checklist.

    Sensitivity, specificity and pre-test probability

    Some tests are good at detecting a problem but also become positive in many people who do not have the condition. Others are more convincing when positive but can miss a proportion of genuine injuries. These characteristics are described, among other measures, by sensitivity and specificity.

    The same positive finding has a different meaning after a typical injury with characteristic symptoms than it does in a person with diffuse pain and no clear injury mechanism. The clinician first estimates how likely a diagnosis is from the history and then updates that probability using the examination findings. A test never exists independently of the person being examined and the clinical question being asked.

    Why does an orthopaedic surgeon often use several tests?

    Different manoeuvres may examine different aspects of the same structure or help distinguish between several similar causes of pain. A coherent pattern of findings is usually more informative than one isolated positive test. What the examination does not provoke may be just as important.

    For example, shoulder pain during arm elevation may arise from the rotator cuff, the long head of biceps tendon, the acromioclavicular joint, a stiff capsule or the cervical spine. Comparing active and passive movement, strength, tenderness and the response to several manoeuvres helps organise those findings into a clinically meaningful pattern.

    Does a positive test always mean an MRI is needed?

    No. Imaging is useful when it answers an unresolved question or may change management. Sometimes an X-ray is the right next step, sometimes ultrasound, sometimes MRI, and sometimes no immediate imaging is required. In selected situations, initial non-operative treatment and reassessment may be appropriate, particularly when there are no warning signs.

    Conversely, one negative test does not always exclude an injury. If the mechanism, loss of function or progressive symptoms remain concerning, further assessment may still be needed despite a negative manoeuvre.

    What can the patient contribute?

    It is helpful to say whether a test reproduced exactly the familiar symptom or merely caused pressure-related discomfort. It also helps to describe what happens afterwards: whether the pain resolves immediately, persists, radiates or is accompanied by numbness or weakness.

    An orthopaedic examination is a process of comparing pieces of information, not a search for one decisive “positive test”. The best interpretation comes from the pattern formed by history, examination and, when needed, targeted imaging.

    References

    • Bossuyt PM, Reitsma JB, Bruns DE, et al. STARD 2015: an updated list of essential items for reporting diagnostic accuracy studies. BMJ. 2015;351:h5527. DOI: 10.1136/bmj.h5527.
    • McGee S. Simplifying likelihood ratios. Journal of General Internal Medicine. 2002;17(8):646–649. PubMed.

    Polish version · More patient resources in English

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Diagnostic Injection — What Does Temporary Pain Relief Actually Tell Us?

    Temporary pain relief after a precisely placed local anaesthetic injection can suggest that the targeted structure contributes to the symptoms. It is not, however, a stand-alone diagnosis or a guarantee that surgery will succeed. A diagnostic injection is most useful when it answers a clearly defined clinical question and the response is assessed in a planned, reproducible way.

    A hypothesis test, not a “pain detector”

    Imaging often shows several abnormalities at the same time, and not all of them are symptomatic. If the history and examination point to a particular joint, bursa, tendon sheath or nerve region, temporary anaesthesia can help test whether reducing pain transmission from that site changes the patient’s typical symptoms.

    The most useful question is not simply “does it feel better after the injection?”, but rather “did the same pain decrease during the specific activity that reliably reproduced it beforehand?”. That activity may be climbing stairs, gripping, rotating the hip, moving the shoulder or applying pressure to a particular area.

    How does an orthopaedic surgeon assess the response?

    1. Before the procedure, identify the patient’s typical pain and reproduce it with a safe, repeatable task.
    2. After the injection, repeat the same task within the expected duration of action of the anaesthetic.
    3. Record the change in pain, function and sense of restriction rather than relying only on a general impression.
    4. Interpret the result together with the clinical examination and imaging before using it to influence treatment.

    Why can a positive response be misleading?

    Local anaesthetic may spread beyond the intended target and partially numb an adjacent structure. The procedure itself, post-procedure rest and expectation can also influence pain. If a corticosteroid is given at the same time, later improvement has a different meaning from the immediate anaesthetic response.

    A positive test increases the likelihood that the targeted region contributes to the symptoms, but it does not prove that it is the only pain generator. Hip pain, for example, may arise from both the joint and periarticular tissues; shoulder pain may involve the glenohumeral joint, tendons and the cervical spine at the same time.

    Why can a negative result also mislead?

    Lack of relief does not always exclude the suspected structure. The needle or medication may not reach the intended target precisely, the dose may be insufficient, or the provocative task may be poorly chosen. Persistent pain processing, multiple pain sources and testing at the wrong time can also produce a false-negative result.

    Ultrasound guidance or another suitable imaging method improves needle placement accuracy in many locations, but it does not eliminate all interpretive uncertainty. A technically precise injection can still produce an equivocal biological response.

    Diagnostic versus therapeutic injection

    In a diagnostic injection, the short-term response to local anaesthetic is the key observation. A therapeutic injection aims to provide longer-lasting symptom relief, for example with an anti-inflammatory medication in an appropriate indication. Combining both goals in one procedure can be practical, but it makes it harder to separate the immediate diagnostic signal from the delayed treatment effect.

    When does the test genuinely change a decision?

    The greatest value is when the result may direct management down two different paths: treating the joint rather than the spine, choosing between two neighbouring structures, or deciding against a procedure when the expected benefit is uncertain. If the treatment plan would be unchanged regardless of the result, the value of a diagnostic injection is lower.

    Safety and limitations

    Every injection requires a valid indication, review of anticoagulant medication, allergies and infection risk, and appropriate aseptic technique. Fever, rapidly increasing pain, marked redness or swelling, drainage, new weakness or persistent sensory disturbance after a procedure require prompt assessment.

    Practical take-home message

    A good diagnostic injection starts before the needle is inserted: define the clinical question, choose a reproducible provocative task and decide in advance what result would genuinely change management. Temporary relief is a clue to the source of pain — not a diagnostic label and not a promise that further treatment will work.

    References

    1. Davidson J, Jayaraman S. Guided interventions in musculoskeletal ultrasound: what’s the evidence? Clinical Radiology. 2011;66(2):140–152. DOI: 10.1016/j.crad.2010.06.006.
    2. Uson J, et al. EULAR recommendations for intra-articular therapies. Annals of the Rheumatic Diseases. 2021;80:1299–1305. DOI: 10.1136/annrheumdis-2021-220266.

    For Patients · Polish version

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Recurrent Shoulder Instability — Why Does the Shoulder Keep Giving Way?

    If the shoulder repeatedly dislocates, partially slips out, or gives a clear sensation of “giving way”, recurrent glenohumeral instability may be the cause. Not every click or snap represents instability. Diagnosis depends on the pattern of episodes, stability testing and appropriately selected imaging.

    What does it mean when the shoulder “comes out”?

    In a complete dislocation, the humeral head loses contact with the glenoid and usually requires reduction. A subluxation is a partial, often brief loss of joint congruity; the shoulder may return to position spontaneously. Patients may describe sudden slipping, apprehension in a particular arm position, or the need to stop the movement immediately.

    Painless clicking, scapular crepitus or tendon snapping do not necessarily indicate instability. More important are true loss of control, visible deformity, numbness, weakness or repeated episodes after a previous dislocation.

    Why does instability recur?

    A traumatic anterior dislocation may damage the anterior labrum and capsuloligamentous structures, classically producing a Bankart lesion. Recurrent episodes can increase bone loss from the glenoid or humeral head. Recurrence risk is higher in younger patients, particularly those involved in contact and overhead sports.

    A different mechanism is seen in generalized ligamentous laxity or multidirectional instability. In these patients the shoulder may be excessively mobile without a single major traumatic event. Rehabilitation and indications for surgery differ from those used after a typical traumatic anterior dislocation.

    How does an orthopaedic surgeon assess shoulder instability?

    The history is essential: the arm position during the first and subsequent episodes, whether reduction was required, the number of recurrences, the patient’s activity or sport, and any associated numbness or weakness. Examination includes range of motion, rotator cuff strength, scapular control, the direction of instability and generalized ligamentous laxity.

    X-ray, MRI, CT and ultrasound

    • X-ray assesses joint position, fractures and some osseous changes related to previous dislocations.
    • MRI or MR arthrography can assess the labrum, capsule, ligaments, cartilage and associated tendon injury.
    • CT is particularly useful when glenoid or humeral head bone loss must be quantified before surgery.
    • Ultrasound can add dynamic information and assess selected labral, tendon and nerve structures, but it does not replace MRI or CT when comprehensive surgical planning is required.

    Is surgery always necessary?

    No. In some forms of instability, the first-line approach is structured rehabilitation: improving scapular and humeral head control, strengthening the rotator cuff, gradually restoring confidence in movement, and modifying activities that provoke instability. Progress is assessed over months rather than after a few sessions.

    Surgery is considered particularly after recurrent dislocations, persistent giving-way despite appropriate rehabilitation, a high predicted recurrence risk, or clinically relevant labral and bone injury. The procedure depends on the direction of instability, tissue quality and the amount of bone loss. A “loose shoulder” alone does not determine one operation.

    Return to sport

    Return to sport should not be based only on the number of weeks since injury or surgery. Relevant criteria include pain-free range of motion, strength and endurance, shoulder control in sport-specific positions, absence of instability or apprehension, and tolerance of progressively increasing training loads.

    When is urgent assessment needed?

    A new visible deformity, inability to move the arm, severe pain, increasing numbness or weakness, or a pale or cold hand require urgent assessment. A suspected dislocation should not be reduced without appropriate training and assessment. Even when the shoulder appears to relocate spontaneously, neurovascular examination and usually an X-ray are still advisable.

    References

    1. Poboży T, et al. Clock-Face Sonography of the Glenoid Labrum: A Pictorial Technical Protocol for Patients Ineligible for MRI/MR Arthrography. Diagnostics. 2025;15(23):3031. DOI: 10.3390/diagnostics15233031.
    2. American Academy of Orthopaedic Surgeons. Chronic Shoulder Instability.
    3. Van Gastel ML, et al. Clinical practice on treatment of primary traumatic anterior shoulder dislocation: a multidisciplinary guideline. Acta Orthopaedica. 2026;97:531–537. DOI: 10.2340/17453674.2026.46434.

    For Patients · Polish version

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.