Umów wizytę

Tomasz Poboży

Kategoria: Tendons and Enthesopathies (EN)

English-language patient information about tendinopathy, tendon pain, enthesopathies, imaging and rehabilitation.

  • Starting Pain — Why Do the First Steps After Rest Matter?

    Pain that is strongest during the first steps after getting out of bed or after sitting for a while is sometimes described as “starting pain”. It is a useful symptom pattern because it shows how symptoms respond to rest and renewed loading. It does not, however, point automatically to a single diagnosis.

    How does an orthopaedic surgeon interpret “first-step pain”?

    The pattern matters. Some people notice that the first several steps after sleep or a longer period of sitting are the most painful, that symptoms then ease partly with movement, and that pain may increase again after prolonged walking or exercise. Constant pain that worsens with every step is a different pattern, as is sudden pain after an injury.

    These differences can help organise the diagnostic process, but they do not replace an examination. The exact location of pain, duration of stiffness, swelling, strength, range of motion and response to increasing load all matter.

    When the pain is under the heel

    Pain with the first steps after rest is a typical feature of plantar heel pain associated with plantar fasciitis. It is usually felt on the plantar-medial side of the heel. The 2023 clinical practice guideline includes first-step pain after rest among the characteristic clinical features, while also stressing that other causes of heel pain need to be considered.

    Not every episode of morning heel pain has the same cause. Recent trauma, burning or numbness, more diffuse pain in the heel bone, or symptoms associated with inflammatory disease require a different assessment. See also: Foot and Ankle Conditions.

    When the Achilles tendon feels stiff

    Morning stiffness and pain after inactivity can also occur with midportion Achilles tendinopathy. Symptoms may change during walking or training, so the beginning of activity is only part of the picture; the response during loading and afterwards is important as well.

    A sudden snap, a marked loss of push-off strength or difficulty rising onto the toes does not fit the usual gradual pattern of tendinopathy and should prompt earlier assessment for a possible tendon rupture.

    Why the symptom name is not enough

    Pain that “warms up” with movement is not necessarily trivial, and pain after rest does not automatically mean there is damage that needs a procedure. Similar descriptions can come from different tissues and conditions. Imaging does not settle every case either: ultrasound, X-ray or MRI findings need to be interpreted alongside the site of pain and functional examination.

    Before a consultation, it can be useful to note how long a period of rest triggers the pain, how many steps or minutes it takes to ease, whether symptoms return after longer walking or exercise, where the most painful point is, whether there is swelling, warmth, numbness or weakness, and how the area feels the next day after greater loading.

    When is earlier assessment important?

    “Starting pain” should not be used to explain away a sudden loss of function after injury, inability to bear weight, visible deformity, rapidly increasing swelling, a hot red joint with fever, or new loss of sensation or strength. Persistent pain at rest or at night also deserves earlier assessment when it is worsening or does not follow the usual relationship with movement.

    The whole symptom pattern matters

    When pain appears is only one part of the history. Combined with its location, response to load and examination findings, it can help distinguish several possible sources and decide whether imaging is needed. First-step pain alone should not be used to self-diagnose a condition or choose insoles, an injection or a procedure.

    References

    1. Koc TA Jr, Bise CG, Neville C, Carreira D, Martin RL, McDonough CM. Heel Pain — Plantar Fasciitis: Revision 2023. J Orthop Sports Phys Ther. 2023;53(12):CPG1–CPG39. DOI: 10.2519/jospt.2023.0303.
    2. Chimenti RL, Neville C, Houck J, Cuddeford T, Carreira D, Martin RL. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision — 2024. J Orthop Sports Phys Ther. 2024;54(12):CPG1–CPG32. DOI: 10.2519/jospt.2024.0302.

    ← Back to Patient Blog

    Polish version: Ból startowy — dlaczego pierwsze kroki po odpoczynku są ważne?

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Lateral Knee Pain in Runners — Could It Be Iliotibial Band Syndrome?

    Pain on the outer side of the knee that appears during running and builds as the distance increases may be caused by iliotibial band syndrome. Not every case of lateral knee pain has this explanation, however. Diagnosis is based mainly on the history and clinical examination; ultrasound or MRI are generally reserved for atypical symptoms, persistent problems despite treatment, or situations in which another condition needs to be excluded.

    Polish version: Ból po bocznej stronie kolana u biegacza — czy to pasmo biodrowo-piszczelowe?

    What does iliotibial band syndrome usually feel like?

    The pain is typically quite well localised on the lateral side of the knee, near the lateral femoral epicondyle. Early on, it may appear only after a certain amount of running and settle quickly when exercise stops. With greater overload, symptoms may begin earlier and may also occur while walking downstairs or during longer walks.

    A large knee effusion, a feeling of “fluid in the knee” or true mechanical locking are not typical. When those features dominate, another source of symptoms should be considered.

    Does the iliotibial band really “rub” over the bone?

    The condition was traditionally called iliotibial band friction syndrome. Contemporary reviews emphasise that the mechanism is more complex, and the simple concept of the band sliding back and forth and rubbing over the lateral femoral epicondyle has been questioned.

    Overload of tissues on the lateral side of the knee, control of the limb during running, hip muscle strength and coordination, and sudden changes in training load may all contribute. For that reason, simply “stretching the band” should not be regarded as a complete treatment strategy.

    What else can cause lateral knee pain?

    Similar symptoms may arise from the lateral meniscus, patellofemoral joint, lateral collateral ligament, biceps femoris tendon, proximal tibiofibular joint or bone. After trauma, ligament and intra-articular injuries also need to be considered.

    How is iliotibial band syndrome diagnosed?

    The key elements are the pain pattern, its precise location, its relationship to running and a careful examination of the limb. Assessment should not be limited to the knee: hip function, range of motion, muscle strength, lower-limb control under load and signs of another injury may all be relevant.

    There is no single test that independently confirms the diagnosis in every patient. When the clinical picture is typical, additional imaging is not always necessary.

    When can ultrasound help?

    Ultrasound can be useful when symptoms persist or recur, or when superficial structures on the lateral side of the knee need to be assessed. Reported findings may include soft-tissue oedema or fluid deep to the iliotibial band near the lateral femoral epicondyle. Thickening of the band itself is neither constant nor sufficiently specific to establish the diagnosis on its own.

    When is MRI useful?

    MRI is not routinely required for a typical presentation. It becomes more useful when the diagnosis is uncertain, intra-articular symptoms are present, pain persists despite appropriate management, or a meniscal, cartilage, bone or other structural problem needs to be excluded.

    How is it treated?

    The usual starting point is a temporary reduction in the load that provokes pain, followed by a gradual return to running. This does not normally mean several weeks of complete rest. The aim is to identify an activity level that does not perpetuate symptoms while addressing factors that may be contributing to overload.

    Exercise

    A 2024 systematic review of 13 studies involving 201 runners found that hip abductor strengthening was the most common component of rehabilitation programmes. The individual studies were highly heterogeneous and a reliable meta-analysis could not be performed. Exercise is therefore an important part of management, but there is no single proven programme that is appropriate for every runner.

    A rehabilitation plan may include strengthening of the hip and trunk muscles, improved control during single-leg loading, and progressive functional exercises that reflect the demands of running.

    Training load and running technique

    Recent changes in weekly distance, pace, hill running, downhill running and training frequency are worth reviewing. Selected changes in running mechanics may help some runners, but there is no basis for prescribing the same stride or cadence modification to everyone.

    Medication, shockwave therapy and injections

    Anti-inflammatory medication may be used briefly in selected patients when there are no contraindications, but it does not correct the cause of overload. Shockwave therapy has also been described in the literature.

    A corticosteroid injection is not a routine first-line treatment for every runner. It may be considered in selected persistent cases after the pain source has been identified. If an injection is performed, ultrasound guidance allows the needle and injectate to be placed in the intended location.

    When can you return to running?

    The decision should not be based only on the number of days since symptoms began. Return should be progressive and guided by tolerance of everyday walking and basic exercises, followed by a short easy run that does not cause escalating pain during activity or a clear deterioration the next day.

    A common mistake is to return immediately to the previous mileage, pace and downhill workload. It is safer to increase load step by step and monitor how the knee responds.

    When does lateral knee pain need earlier assessment?

    • pain began after a clear injury and makes weight bearing difficult,
    • the knee becomes rapidly and markedly swollen,
    • the joint is hot or red, particularly with fever,
    • the knee truly locks or clearly gives way,
    • there is very focal bone tenderness and pain with weight bearing, especially after a sudden increase in training,
    • pain becomes constant, occurs at night or progresses despite reducing activity.

    Key point for an orthopaedic surgeon

    Iliotibial band syndrome is a common cause of lateral knee pain in runners, but the diagnosis should come from the whole clinical picture. Typical cases are usually managed without surgery through load adjustment, exercise and a gradual return to running. Ultrasound and MRI are supporting tools, especially when the presentation is atypical or progress is not as expected.

    References

    1. Sanchez-Alvarado A, Bokil C, Cassel M, Engel T. Effects of conservative treatment strategies for iliotibial band syndrome on pain and function in runners: a systematic review. Front Sports Act Living. 2024;6:1386456. DOI: 10.3389/fspor.2024.1386456.
    2. Bonoan M, Morales M, Liu XW, Oyeniran O, Zheng K, Palatulan E. Iliotibial Band Syndrome Current Evidence. Curr Phys Med Rehabil Rep. 2024;12:193-199. DOI: 10.1007/s40141-024-00442-w.
    3. Jiménez Díaz F, Gitto S, Sconfienza LM, Draghi F. Ultrasound of iliotibial band syndrome. J Ultrasound. 2020;23(3):379-385. DOI: 10.1007/s40477-020-00478-3.

    ← Knee Conditions

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Pes Anserine Pain — A Cause of Medial Knee Pain

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

    Polish version: Gęsia stopka — ból po wewnętrznej stronie kolana

    What is the pes anserinus?

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

    How does pes anserine pain usually present?

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

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

    How does an orthopaedic surgeon assess a pes anserine problem?

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

    Is ultrasound necessary?

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

    When are X-ray or MRI more useful?

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

    How is it treated?

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

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

    Can an injection help?

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

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

    What about PRP, shockwave therapy and other methods?

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

    When does medial knee pain require urgent assessment?

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

    Key point: pain location is not yet a diagnosis

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

    References

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

    ← Knee Conditions

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Lateral Ankle Pain — Could It Be the Peroneal Tendons?

    Polish version

    Pain on the outer side of the ankle, particularly behind or just below the lateral malleolus, may come from the peroneal tendons. It often becomes more noticeable when walking on uneven ground, running, rising onto the toes or after an ankle sprain. Similar symptoms can also arise from ligaments, joint cartilage, bone or the sural nerve, so pain location alone is not a diagnosis.

    What are the peroneal tendons?

    The peroneus longus and peroneus brevis tendons run together behind the lateral malleolus. They help stabilise the foot and ankle, especially during weight bearing on uneven surfaces, and are held within their groove by the retinaculum. Problems can include tendinopathy, longitudinal splitting or tearing, tenosynovitis, or instability in which the tendons snap or move out of their normal position.

    Which symptoms are typical?

    • pain and tenderness behind the lateral malleolus or along the outer border of the foot,
    • pain that increases on uneven ground, during running or with resisted eversion of the foot,
    • swelling along the course of the tendons,
    • a snapping sensation or audible click behind the ankle,
    • recurrent feelings of instability after previous ankle sprains.

    A sudden snap after injury can indicate retinacular damage with tendon subluxation. By contrast, persistent lateral ankle pain without one clear injury is more often associated with overload, foot alignment, recurrent sprains or chronic tendon damage.

    What else can cause pain in the same area?

    The differential diagnosis includes lateral ligament injury after a sprain, fracture of the ankle or the base of the fifth metatarsal, an osteochondral lesion of the talus, ankle impingement, sural nerve irritation and pain arising from more distal joints of the foot. After an acute injury, this is why an X-ray is often the first imaging test rather than ultrasound.

    See also: Ankle Injuries.

    How is the problem assessed?

    Clinical examination

    The exact site of tenderness, muscle strength, ankle stability, foot alignment and reproduction of pain with resisted movement all matter. When tendon snapping is suspected, the tendons should also be assessed while the ankle is moving.

    X-ray

    After a recent injury, radiographs help exclude a fracture. They may also show bony anatomy that contributes to impingement or chronic overload, but they do not usually assess the tendons themselves adequately.

    Ultrasound

    Ultrasound can show tendon continuity and structure, fluid within the tendon sheath and tendon behaviour during movement. Dynamic assessment is especially useful when snapping or subluxation behind the lateral malleolus is suspected. A normal ultrasound, however, does not exclude every subtle abnormality.

    MRI

    MRI can help define the extent of tendon injury while also assessing cartilage, ligaments, bone marrow and other deeper structures. The choice between ultrasound and MRI depends on the clinical question; the two tests can be complementary.

    How are peroneal tendon problems treated?

    Overuse-related symptoms and stable partial injuries are usually treated non-operatively first. Management may include temporarily reducing activities that provoke pain, progressive strengthening and ankle-control exercises, footwear modification and, in selected cases, an orthotic or a short period of immobilisation. Return to running should depend on strength, stability and the tendon’s response to loading rather than simply on the number of days that have passed.

    Analgesic or anti-inflammatory medication may be appropriate for selected patients, but it does not repair a damaged tendon. Tendon-sheath injections are considered selectively; image guidance is advisable, and steroid should not be injected into the tendon itself. Evidence for injections in this region remains limited.

    More about image-guided procedures: Injection Treatments.

    When does an orthopaedic surgeon consider surgery?

    Surgery is considered mainly for complete or extensive tendon tears, recurrent subluxation, persistent weakness or pain that continues despite appropriate non-operative treatment. The procedure depends on whether the main problem lies in the tendon itself, the retinaculum, the groove behind the lateral malleolus or associated ankle instability.

    Warning signs

    Earlier assessment is needed after an injury if the foot cannot be loaded, there is an obvious deformity, swelling is increasing rapidly, sensation or circulation is impaired, there is an open wound, fever develops with marked local redness, or a sudden snap is followed by clear weakness of the foot. The ability to take a few steps does not by itself rule out a significant injury.

    Back to: Foot and Ankle Conditions

    More about: Tendons and Enthesopathies

    References

    • van Dijk PAD, Miller D, Calder J, et al. The ESSKA-AFAS international consensus statement on peroneal tendon pathologies. Knee Surg Sports Traumatol Arthrosc. 2018;26(10):3096–3107. DOI: 10.1007/s00167-018-4971-x.
    • Ghandour S, Mercer RW, Strahan JA, et al. Diagnostic accuracy of MRI and US for peroneal tendon tears: a systematic review and meta-analysis. Eur Radiol. 2025. DOI: 10.1007/s00330-025-11472-w. PubMed.
    • Dombek MF, Lamm BM, Saltrick K, Mendicino RW, Catanzariti AR. Peroneal tendon tears: a retrospective review. J Foot Ankle Surg. 2003;42(5):250–258.

    This material is educational and does not replace an individual medical consultation.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Pain at the Front of the Shoulder — Could the Biceps Tendon Be the Cause?

    Polish version · Explore Shoulder Conditions

    Pain at the front of the shoulder can arise from the long head of the biceps tendon, but the source cannot be identified from pain location alone. Biceps tendon pathology often coexists with rotator cuff disease, labral lesions or injury to the structures that stabilise the tendon in the bicipital groove. Diagnosis therefore depends on combining symptoms, clinical examination and appropriately selected imaging.

    Where does the biceps tendon run in the shoulder?

    The biceps brachii has two proximal attachments around the shoulder. The long head originates near the superior glenoid and labrum, passes through the joint and then enters the bicipital groove of the humerus. Along this course it is stabilised by several structures, including fibres from the subscapularis and supraspinatus tendons and surrounding ligaments.

    This is why isolated “biceps tendinopathy” is not the only possible explanation. Pain may come from the tendon itself or its sheath, but also from a rotator cuff tear, a SLAP lesion, biceps tendon instability or another disorder within the shoulder joint.

    Which symptoms fit long-head biceps tendon pathology?

    • pain at the front of the shoulder, sometimes extending down the front of the upper arm;
    • pain that increases when raising the arm, working overhead, throwing or lifting an object;
    • pain when reaching behind the body, for example for a seat belt or while putting on a jacket;
    • tenderness over the bicipital groove;
    • sometimes painful snapping or clicking at the front of the shoulder.

    None of these findings is specific. Rotator cuff disease, frozen shoulder, acromioclavicular joint pathology and referred pain from the neck can produce a similar pattern. Speed’s test, Yergason’s test or tenderness over the groove may strengthen the suspicion, but a single positive test does not establish the diagnosis.

    A sudden pop and a bulge in the arm — could this be a rupture?

    An acute proximal biceps rupture may be accompanied by a pop, bruising and distal displacement of the muscle belly, producing a characteristic bulge lower in the upper arm. Pain can be substantial initially and then settle. Some patients are left with weakness during forearm supination, muscle cramping or a cosmetic concern.

    This appearance does not automatically mean surgery is required, particularly when the long head has ruptured and arm function remains good. The decision depends on age, activity level, the dominant arm, occupational demands and associated shoulder lesions.

    How is it assessed?

    Clinical examination

    The examination includes active and passive range of motion, rotator cuff strength, shoulder stability, the cervical spine, and sensation and strength throughout the limb. It is important to establish whether symptoms began after a single injury or developed with repetitive loading. Tendon snapping can suggest disruption of the structures that retain it in the groove, particularly near the subscapularis tendon.

    X-ray

    X-rays do not show the biceps tendon well, but they may reveal calcification, osteoarthritis, post-traumatic bony changes or another cause of shoulder pain. In an adult with persistent shoulder symptoms, radiographs are often a reasonable initial imaging study.

    Ultrasound

    Ultrasound can show the portion of the tendon within the groove, fluid around the tendon, thickening, partial or complete rupture and tendon displacement during movement. Dynamic scanning is useful when instability is suspected. The rotator cuff and subacromial-subdeltoid bursa can be assessed at the same examination.

    Ultrasound also has limitations. The intra-articular portion of the tendon and its attachment near the superior labrum are more difficult to assess completely. A normal appearance within the groove does not exclude pathology deeper inside the joint.

    MRI

    MRI can assess the biceps tendon together with the rotator cuff, cartilage, bone and other intra-articular structures. When a superior labral lesion is suspected, MR arthrography may be considered in selected cases. MRI is not necessary for every patient with anterior shoulder pain; it should answer a specific clinical question.

    How is biceps-related shoulder pain treated?

    Non-operative treatment

    Most overload-related symptoms are initially treated without surgery. This usually means temporarily reducing movements that clearly provoke pain rather than completely immobilising the shoulder, followed by a gradual return to loading. Rehabilitation may address range of motion, scapular control, rotator cuff exercises and progressive biceps strengthening.

    Analgesic or anti-inflammatory medication should be selected with other medical conditions and current medicines in mind. Cooling may reduce short-term symptoms after overload. If an injection is considered, it should follow a specific diagnosis. In selected situations medication can be placed into the tendon sheath under ultrasound guidance while avoiding injection into the tendon substance itself. Accurate needle placement does not by itself guarantee a durable clinical effect.

    When does an orthopaedic surgeon consider surgery?

    Surgery is considered mainly when appropriately conducted non-operative treatment does not restore acceptable function, when there is substantial tendon damage or instability, or when surgery is already planned for an associated rotator cuff or labral lesion. Common options include tenotomy, in which the damaged tendon is released, and tenodesis, in which it is detached from its intra-articular origin and fixed to the humerus. SLAP repair is reserved for appropriately selected patients.

    There is no single best procedure for everyone. Age, activity, cosmetic concerns, risk of cramping, occupational requirements and the other shoulder lesions all influence the choice.

    When is earlier assessment needed?

    • after an injury, the arm cannot be raised or there is clear new weakness;
    • the shoulder is deformed, markedly swollen or bruising is spreading quickly;
    • there is numbness, hand weakness, pallor or cooling of the limb;
    • pain is severe even at rest and is accompanied by fever, redness or deterioration in general condition;
    • shoulder pain occurs with shortness of breath, chest pressure or sudden general weakness.

    Key points

    Anterior shoulder pain can come from the long head of the biceps tendon, but associated pathology is common. Ultrasound is particularly useful for dynamic assessment of the tendon within the bicipital groove, whereas MRI better demonstrates intra-articular structures. For most patients, treatment begins with load modification and targeted rehabilitation; a decision about injection or surgery requires identification of the actual pain generator.

    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. This publication includes assessment of the superior labrum and the region of the biceps attachment; it is not a treatment-effectiveness study for biceps tendinopathy.
    2. Lalehzarian SP, Agarwalla A, Liu JN. Management of proximal biceps tendon pathology. World Journal of Orthopedics. 2022;13(1):36–57. DOI: 10.5312/wjo.v13.i1.36. Full text.
    3. American Academy of Orthopaedic Surgeons. Biceps Tendinitis. Patient information prepared or reviewed by a member of the American Shoulder and Elbow Surgeons.

    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.