Orthopaedic Surgery - Biceps Tendon Rupture

Basics

The biceps tendon may rupture either proximally near the shoulder or distally near the elbow.

Most biceps tendon ruptures occur proximally.

At the shoulder, the long head of the biceps contributes to stabilization and depression of the humeral head. Distally, the biceps is the principal supinator of the forearm and also contributes significantly to elbow flexion.

Epidemiology

Biceps tendon rupture occurs most commonly in men between 40 and 60 years of age.

The dominant upper extremity is affected more frequently.

Although the condition is classically seen in middle-aged adults, rupture can also occur in younger athletes. In younger individuals, a history of anabolic steroid use should be considered because steroid exposure may weaken tendon structure.

Risk Factors

Important risk factors include male sex, age between 40 and 60 years, tendon degeneration, and anabolic steroid use.

For proximal ruptures, associated rotator cuff impingement or rotator cuff disease increases the risk of tendon failure.

For distal ruptures, chronic degenerative changes within the tendon predispose it to avulsion during a sudden high-load eccentric contraction.

Pathophysiology

Most biceps tendon ruptures occur through a background of degenerative tendon change.

This degeneration may be symptomatic or may remain clinically silent until rupture occurs.

In the proximal tendon, degeneration may result from reduced vascularity or chronic mechanical impingement beneath the coracoacromial arch.

Distal Tendon Pathophysiology

The distal biceps tendon commonly fails near its attachment to the radial tuberosity.

A degenerated tendon may avulse when subjected to a sudden and powerful eccentric force, particularly when the elbow is flexed and the muscle is attempting to contract against resistance.

This mechanism is often seen when a person suddenly tries to hold or lower a heavy object.

Associated Conditions

Biceps tendon rupture is commonly associated with rotator cuff disease, particularly when the rupture is proximal.

The presence of associated shoulder pathology should therefore be assessed during evaluation.

Diagnosis

Signs and Symptoms

Symptoms depend on whether the rupture is proximal or distal.

A sudden tearing sensation may be followed by pain, bruising, swelling, weakness, and visible change in the contour of the biceps muscle.

History in Proximal Rupture

Patients with a proximal biceps tendon rupture may complain of pain in the anterior shoulder, upper arm, or antecubital region.

Pain may be acute initially but can improve relatively quickly.

Some patients primarily notice a change in arm appearance rather than major functional loss.

History in Distal Rupture

Patients with a distal rupture commonly report antecubital pain together with weakness during forearm supination or elbow flexion.

The injury often follows a clear history of a sudden heavy eccentric load applied to a contracting biceps muscle.

Patients may describe a pop or tearing sensation at the time of injury.

Physical Examination

Proximal Rupture

Proximal tears may produce bruising and swelling around the shoulder, arm, or antecubital fossa.

The biceps muscle belly may retract distally, creating an abnormal contour of the arm.

This can produce the characteristic “Popeye” deformity.

Distal Rupture

With a distal tendon rupture, the biceps muscle belly retracts proximally toward the shoulder.

The normal tendon may no longer be palpable in the antecubital fossa.

A clearly absent distal tendon strongly suggests a complete distal rupture.

Strength Testing

Weakness may be present with both elbow flexion and forearm supination.

The loss of strength is usually more clinically significant after a distal rupture because the distal biceps plays a major role in supination.

Pain during resisted flexion or supination may occur in partial tears.

Popeye Sign

The Popeye sign describes visible bunching or distortion of the biceps muscle belly after tendon rupture.

It is more classically associated with proximal long-head biceps rupture, although changes in muscle contour may also occur with distal injury.

The location of muscle retraction helps distinguish proximal from distal rupture.

Imaging

MRI

MRI is the most useful imaging study when the diagnosis is uncertain or when the extent of injury must be defined.

It can identify complete or partial tendon disruption, tendon retraction, associated rotator cuff pathology, and surrounding soft-tissue injury.

MRI is particularly useful for planning surgery in distal ruptures or symptomatic partial tears.

Differential Diagnosis

Important differential diagnoses include rotator cuff impingement and rotator cuff tear.

Other causes of shoulder or antecubital pain should also be considered when the examination does not clearly demonstrate tendon rupture.

Treatment

General Principles

Management depends primarily on whether the rupture is proximal or distal, as well as the patient’s age, activity level, functional demands, cosmetic concerns, and associated pathology.

Proximal ruptures are often successfully treated nonoperatively.

Distal ruptures are more commonly treated surgically because untreated injury can result in meaningful loss of strength.

Proximal Biceps Tendon Rupture

Initial treatment of an isolated proximal rupture is usually nonoperative.

Many affected patients are older than 40 years and experience only modest weakness or functional limitation.

Pain often settles with conservative care, and many patients adapt well to the cosmetic deformity.

Candidates for Surgery After Proximal Rupture

Surgical treatment may be considered in patients who are younger, highly active, athletic, concerned about the appearance of the arm, or seeking maximal restoration of function.

Persistent cramping or pain may also support operative treatment.

Distal Biceps Tendon Rupture

For complete distal ruptures, surgical repair generally provides the best functional outcome, particularly in active patients.

Because the distal biceps is an important supinator, nonoperative treatment can result in persistent weakness, especially during activities requiring forceful supination.

Partial Distal Rupture

Partial distal biceps tears may initially be treated nonoperatively when symptoms are mild.

However, persistent pain or weakness despite conservative management may require surgical treatment.

Operative management may involve completing the partial release and then repairing the tendon back to the radial tuberosity.

Nonoperative Management

Conservative treatment includes rest, activity modification, analgesia, and gradual rehabilitation.

During the acute phase, the arm should be rested until pain and swelling decrease.

Gentle range-of-motion exercises can then begin.

Activity is gradually advanced as tolerated.

Physical Therapy

Physical therapy focuses initially on maintaining comfortable shoulder, elbow, and forearm motion.

As pain improves, strengthening can be introduced progressively.

In nonoperatively treated patients, rehabilitation aims to maximize the function of remaining muscles and compensate for any persistent weakness.

Medication

NSAIDs and acetaminophen may be used during the acute phase for pain relief.

Medication should be combined with rest and gradual restoration of function.

Surgical Management of Proximal Rupture

For selected proximal ruptures, the biceps tendon may be treated with tenodesis.

In this procedure, the tendon is fixed to the humerus to restore a more normal muscle contour and reduce cramping or discomfort.

Tenodesis is often performed mainly for functional or cosmetic reasons.

Proximal Rupture With Rotator Cuff Disease

When a proximal biceps rupture occurs together with significant rotator cuff or impingement pathology, surgery may address both conditions.

Procedures may include biceps tenodesis together with treatment of rotator cuff disease, and in selected cases acromioplasty may also be performed.

Surgical Management of Distal Rupture

Distal biceps repair involves reattaching the tendon to the radial tuberosity.

This can be performed through a single anterior incision or through a two-incision muscle-splitting approach.

The objective is to restore the normal insertion and regain elbow flexion and forearm supination strength.

Surgery for Symptomatic Partial Tears

A symptomatic partial distal tear may be treated surgically when pain or weakness persists.

The damaged tendon may be released and then formally reattached to the radial tuberosity.

This can improve both pain and function in appropriately selected patients.

Follow-Up

Follow-up should assess pain, swelling, range of motion, strength, and restoration of functional use of the arm.

Patients treated surgically require progressive rehabilitation according to tendon healing and the repair technique used.

Strengthening should be advanced carefully to protect the repair.

Prognosis

Patients undergoing successful surgical repair of a distal biceps rupture can generally expect a near-complete return of flexion and supination strength.

Outcome is typically best when repair is performed before substantial chronic retraction or scarring develops.

Prognosis After Proximal Tenodesis

Patients undergoing tenodesis for a proximal rupture can generally expect good pain relief and improvement in arm contour.

The procedure also helps reduce the prominence of the Popeye deformity.

Complications of Nonoperative Treatment

Without surgery, some patients may continue to experience activity-related pain, cramping, or weakness.

This is usually more clinically important after distal rupture than proximal rupture.

Loss of Supination Strength

The most important functional deficit after an untreated distal biceps rupture is reduced forearm supination strength.

Patients may notice difficulty with activities such as turning a screwdriver, opening a jar, using tools, or performing repetitive lifting with the palm facing upward.

Elbow flexion strength may also decrease, but the loss is generally less pronounced because other muscles can assist with flexion.

Patient Monitoring

Patients should be monitored for recovery of pain-free motion, strength, and functional use of the extremity.

Persistent weakness, ongoing pain, or difficulty with supination should prompt reassessment, particularly in patients with suspected distal rupture or symptomatic partial tendon injury.

Orthopaedic Surgery - Back Pain in Children

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Basics

Pediatric back pain is less common than back pain in adults but becomes increasingly frequent with age.

The estimated prevalence is approximately 6% among children aged 7–10 years and approximately 18% among adolescents aged 14–16 years.

Participation in competitive sports has been associated with a higher risk of pediatric back pain. Behavioral, emotional, and psychological difficulties may also be associated with a greater frequency of symptoms.

Although most pediatric back pain is musculoskeletal and self-limiting, persistent or severe symptoms require careful evaluation because infection, tumor, structural abnormalities, and neurologic disorders may also present with back pain.

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Etiology

The differential diagnosis of pediatric back pain is broad.

Important causes include spondylolysis, spondylolisthesis, tethered cord syndrome, neoplasms, spondyloarthropathies, Bertolotti syndrome, discitis, pyogenic sacroiliitis, Scheuermann disease, lumbar disc herniation, and musculoskeletal strain.

Age, pain characteristics, neurologic findings, systemic symptoms, and activity history help distinguish among these conditions.

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Spondylolysis

Spondylolysis is a defect or stress fracture involving the pars interarticularis, the portion of the vertebral arch located between the superior and inferior facet joints.

It usually develops as a fatigue injury caused by repeated lumbar extension and rotational movements.

Sports involving repetitive hyperextension, such as gymnastics and certain throwing or kicking activities, can increase mechanical stress on the pars.

The estimated prevalence in children is approximately 4.4%.

The fifth lumbar vertebra (L5) is affected most commonly.

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Spondylolisthesis

Spondylolisthesis refers to anterior displacement of one vertebral body relative to the vertebra beneath it.

In children and adolescents, it frequently occurs in association with a pars defect or spondylolysis.

Its estimated prevalence is approximately 0.9%.

Low back pain is the most common clinical manifestation, although some patients may also develop radicular pain or neurologic symptoms if neural structures are affected.

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Primary Tethered Cord Syndrome

Primary tethered cord syndrome is caused by abnormal fixation of the lower spinal cord to surrounding tissues.

This abnormal attachment restricts normal movement of the cord during growth and may progressively impair the lumbosacral nerve roots.

The estimated prevalence is approximately 0.1%.

Tethered cord syndrome may occur together with other congenital spinal abnormalities, including spina bifida.

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Clinical Features of Tethered Cord Syndrome

Symptoms may include low back pain, lower-extremity muscle wasting, clubfoot deformity, leg-length discrepancy, scoliosis, weakness, and sensory loss.

Bladder or bowel dysfunction may also occur in clinically significant cases.

Progressive neurologic abnormalities should prompt further spinal cord evaluation.

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Neoplastic Causes

Tumors are a rare cause of pediatric back pain, accounting for approximately 0.1% of cases.

Both benign and malignant bone or spinal cord tumors may present with back pain.

Pain that is persistent, occurs at night, is associated with systemic symptoms, or is accompanied by neurologic abnormalities warrants further investigation.

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Osteoid Osteoma

An osteoid osteoma is a benign primary bone tumor that may involve the spine.

Up to approximately 20% of osteoid osteomas can occur in spinal locations.

A characteristic clinical feature is back or neck pain that is worse at night and responds markedly to NSAIDs.

The lesion may also cause painful scoliosis when located asymmetrically in the posterior spinal elements.

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Ewing Sarcoma

Ewing sarcoma is an important malignant bone tumor occurring in children and adolescents.

It may present with localized pain together with systemic or constitutional symptoms such as fever, fatigue, and weight loss.

Persistent unexplained back pain associated with constitutional symptoms should therefore raise concern for malignancy.

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Spinal Cord Tumors

Spinal cord tumors may be benign or malignant.

Clinical manifestations depend on the location and extent of the lesion.

Children may develop back pain, progressive motor weakness, sensory abnormalities, gait disturbance, or bowel and bladder dysfunction.

Neurologic deterioration requires prompt imaging.

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Spondyloarthropathies

Pediatric spondyloarthropathies include ankylosing spondylitis, psoriatic arthritis, enthesitis-related arthritis, reactive arthritis, and arthritis associated with inflammatory bowel disease.

Their estimated prevalence is approximately 0.2%.

Common manifestations include inflammatory back pain, sacroiliitis, enthesitis, and dactylitis.

Many affected children are HLA-B27 positive, although HLA-B27 positivity alone does not establish the diagnosis.

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Associated Features of Spondyloarthropathies

Reactive arthritis may occur in association with urethritis and conjunctivitis.

Psoriatic arthritis may be associated with cutaneous or nail manifestations of psoriasis.

Enteropathic arthritis occurs in association with inflammatory bowel disease.

Recognition of these associated features can help identify an inflammatory cause of back pain.

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Bertolotti Syndrome

Bertolotti syndrome occurs when a lumbosacral transitional vertebra becomes symptomatic.

A lumbosacral transitional vertebra is an anatomical variant in which the lowest lumbar vertebra has an enlarged transverse process that partially or completely articulates or fuses with the sacrum.

The estimated prevalence of this anatomical variant is approximately 4–10%.

When the abnormal articulation is responsible for low back pain, the condition is termed Bertolotti syndrome.

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Clinical Features of Bertolotti Syndrome

Pain is commonly mechanical and may worsen during lumbar extension.

Some patients also develop radicular symptoms caused by altered lumbosacral mechanics or nerve compression.

Radiographs may demonstrate an enlarged transverse process articulating with the sacrum.

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Discitis

Discitis is an inflammatory or infectious disorder of the intervertebral disc space and is seen most commonly in children younger than approximately 5 years.

Young children may present with back pain, irritability, refusal to walk, or reluctance to sit or bend.

Many affected children remain afebrile, and the peripheral white blood cell count may be normal.

The erythrocyte sedimentation rate (ESR) is elevated in many cases and can support the diagnosis.

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Pyogenic Sacroiliitis

Pyogenic sacroiliitis is a bacterial infection involving the sacroiliac joint.

Patients may complain of pain in the lower back, buttock, hip, or abdomen.

The ESR is often elevated, although the white blood cell count may remain normal.

Because symptoms may be poorly localized, diagnosis can be delayed without a high index of suspicion.

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Scheuermann Disease

Scheuermann disease is a developmental disorder involving the thoracic or thoracolumbar vertebrae.

Its estimated prevalence is approximately 0.2%.

The classic radiographic criterion is anterior wedging greater than 5° in at least three consecutive vertebral bodies.

The precise cause is uncertain, although a hereditary component with autosomal dominant inheritance and incomplete penetrance has been proposed.

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Clinical Features of Scheuermann Disease

Patients commonly present during adolescence with back pain and a rigid focal kyphotic deformity.

Pain may worsen with prolonged sitting, standing, or activity.

Unlike postural kyphosis, the deformity is relatively rigid and does not fully correct with voluntary posture.

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Herniated Nucleus Pulposus

Lumbar disc herniation is uncommon in younger children but may occur in adolescents, sometimes after trauma.

The lumbar spine is affected most frequently.

Symptoms often include low back pain radiating into one or both lower extremities, depending on the nerve root involved.

Neurologic deficits may develop when compression is substantial.

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Musculoskeletal Back Pain

Muscular strain and ligamentous sprain are the most common causes of pediatric back pain.

Symptoms are generally related to activity and improve with rest.

Musculoskeletal back pain is typically self-limiting.

When the history and examination are reassuring and no red-flag features are present, additional imaging may not be necessary.

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Diagnosis

History

History should focus on defining the location, quality, severity, duration, and pattern of pain.

The clinician should ask about trauma, sports participation, repetitive activities, aggravating movements, and previous episodes.

Particular attention should be paid to features that suggest more serious pathology.

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Concerning Symptoms

Red-flag symptoms include motor or sensory deficits, persistent nocturnal pain, bowel or bladder dysfunction, progressive weakness, and gait disturbance.

Constitutional symptoms such as fever, unexplained weight loss, and fatigue may suggest infectious, inflammatory, or neoplastic disease.

These findings usually warrant further investigation.

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Psychological Assessment

Mental and emotional well-being should also be considered.

Anxiety, depression, behavioral problems, and emotional distress have been associated with a higher prevalence of pediatric back pain.

These factors should be evaluated without assuming that the pain is purely psychological.

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Physical Examination

A complete examination should include inspection, palpation, provocative maneuvers, lumbar range of motion, gait assessment, and a detailed neurologic examination.

The findings should be interpreted together with the history.

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Inspection

The child’s posture should be evaluated in both the coronal and sagittal planes.

The examiner should look for scoliosis, excessive kyphosis, abnormal lordosis, pelvic asymmetry, or other deformity.

Skin findings such as dimples, hairy patches, masses, or other congenital markers over the spine may suggest occult spinal dysraphism.

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Gait Assessment

Gait should be observed for abnormalities such as Trendelenburg gait, limping, weakness, or ataxia.

An abnormal gait may indicate hip pathology, neurologic dysfunction, pain, or muscular weakness.

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Palpation

The spinal column, paraspinal muscles, and sacroiliac joints should be palpated.

Midline spinal tenderness raises concern for fracture, infection, or other structural pathology.

Paraspinal tenderness is more commonly associated with muscular strain.

The examiner should also assess for swelling, edema, or a palpable mass.

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Straight Leg Raise Test

The straight leg raise test helps assess possible lumbar disc herniation with nerve root irritation.

With the patient lying supine, the examiner passively raises the leg while maintaining the knee in extension.

Reproduction of radicular pain when the hip is flexed approximately 30–70° supports irritation of the lumbosacral nerve roots and raises suspicion for disc herniation.

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FABER Test

The FABER test evaluates pathology involving the sacroiliac joint or hip.

With the patient supine, the tested hip is flexed, abducted, and externally rotated so that the ankle rests over the opposite thigh.

Downward pressure is then applied to the flexed knee while the contralateral pelvis is stabilized.

Pain around the sacroiliac region may suggest SI joint pathology, including sacroiliitis.

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Lumbar Range of Motion

Lumbar range of motion does not always identify the specific cause of pain, but it can help assess functional limitation and disease progression.

Average pediatric lumbar flexion is approximately 52°, with extension around 19°.

Average axial rotation is approximately 33° to the left and 32° to the right.

Average lateral flexion is approximately 30° to the left and 31° to the right.

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Neurologic Examination

A detailed bilateral neurologic examination should assess motor strength, sensation, and reflexes.

Neurologic abnormalities may help localize a disc herniation or identify spinal cord or nerve root pathology.

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Disc Herniation Findings

An L4–L5 disc herniation may cause weakness involving ankle or great-toe dorsiflexion, depending on the affected nerve root.

An L5–S1 disc herniation may produce a diminished or absent Achilles tendon reflex.

Sensory changes should also be mapped according to the involved dermatome.

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Neurologic Red Flags

Progressive weakness, abnormal reflexes, sensory loss, gait disturbance, or bowel and bladder dysfunction should raise concern for significant neurologic compression or a spinal cord lesion.

Neoplastic and congenital neurologic disorders must also be considered.

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Imaging

The three principal imaging modalities are plain radiographs, CT, and MRI.

The decision to image should be based on the patient’s symptoms and examination while considering radiation exposure and the possible need for sedation in younger children.

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When Imaging Is Not Required

When the neurologic examination is normal and there are no concerning features such as fever, weight loss, persistent night pain, or neurologic changes, immediate imaging is often unnecessary.

Children with uncomplicated musculoskeletal pain may be managed initially with observation and conservative care.

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Plain Radiographs

Plain radiographs are often the initial imaging study when structural pathology is suspected.

They are useful for evaluating vertebral alignment, deformity, spondylolysis, spondylolisthesis, transitional vertebrae, Scheuermann disease, and some tumors.

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CT

CT provides excellent visualization of bone detail.

It can help define pars defects, fractures, congenital abnormalities, and other osseous lesions.

Three-dimensional reconstructions can be useful when detailed anatomical assessment is required.

Because CT exposes children to ionizing radiation, its use should be selective.

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MRI

MRI provides detailed visualization of the spinal cord, nerve roots, intervertebral discs, bone marrow, ligaments, and soft tissues.

It is particularly useful for evaluating infection, tumors, tethered cord, disc herniation, sacroiliitis, and neurologic abnormalities.

MRI avoids ionizing radiation but may require sedation in some young children.

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Imaging in Spondylolysis

Plain radiographs may demonstrate a radiolucent defect through the pars interarticularis.

When radiographs are normal but clinical suspicion remains high, advanced imaging may be considered.

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Imaging in Spondylolisthesis

Radiographs demonstrate anterior displacement of one vertebral body relative to the vertebra below.

Standing lateral radiographs are particularly useful for assessing the degree of slip.

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Imaging in Tethered Cord Syndrome

MRI is the preferred study.

Findings may include abnormalities of the filum terminale, a low-lying cord, or dorsal adherence of the spinal cord.

Associated congenital abnormalities may also be identified.

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Imaging in Osteoid Osteoma

Radiographs or CT may demonstrate a small focal lesion, often with surrounding sclerosis.

CT is particularly useful for identifying the central nidus when osteoid osteoma is suspected.

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Imaging in Ewing Sarcoma

Radiographs may show a destructive bone lesion with a mixture of lytic and sclerotic features.

MRI is useful for defining marrow involvement and soft-tissue extension.

Further oncologic imaging is required if malignancy is suspected.

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Imaging of Spinal Cord Tumors

MRI is the investigation of choice for suspected spinal cord tumors.

Lesions may demonstrate abnormal signal intensity, often appearing hyperintense on T2-weighted imaging, depending on tumor type.

MRI also demonstrates the degree of cord or nerve compression.

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Imaging in Bertolotti Syndrome

Radiographs may reveal an enlarged transverse process of the lowest lumbar vertebra contacting or articulating with the sacrum.

The imaging abnormality must correlate with the patient’s symptoms before it is considered the source of pain.

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Imaging in Discitis

Plain radiographs may eventually demonstrate narrowing of the intervertebral disc space, although early studies can be normal.

MRI is more sensitive for early infection and for evaluating adjacent vertebral and soft-tissue involvement.

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Imaging in Pyogenic Sacroiliitis

MRI may demonstrate inflammation, edema, or fluid around the sacroiliac joint.

It is useful for identifying associated abscess formation or surrounding bone involvement.

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Imaging in Scheuermann Disease

The radiographic diagnosis requires anterior wedging of more than 5° in at least three consecutive vertebrae.

Other findings may include irregular endplates and Schmorl nodes.

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Imaging in Disc Herniation

MRI may demonstrate disc bulging, protrusion, extrusion, reduced disc height, or nerve root compression.

It is the preferred imaging modality when neurologic symptoms suggest clinically important disc disease.

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Imaging in Musculoskeletal Pain

Imaging is usually normal in uncomplicated muscular or ligamentous back pain.

When the history and examination are reassuring, normal imaging is not required to establish a clinical diagnosis of musculoskeletal strain.

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Treatment

Treatment depends on identifying the underlying cause.

Management options include activity modification, rest, physical therapy, medication, and surgery.

Most uncomplicated musculoskeletal causes can be treated conservatively.

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Rest and Activity Modification

Rest from the provoking activity is often the first step in treating spondylolysis and low-grade spondylolisthesis.

Repetitive extension, rotation, and impact activities may need to be temporarily avoided.

Activity is gradually resumed after pain improves and strength and flexibility have been restored.

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Physical Therapy

Physical therapy is beneficial for many causes of pediatric back pain.

Treatment may focus on core strengthening, flexibility, hamstring stretching, posture, spinal stabilization, and correction of biomechanical abnormalities.

The program should be tailored to the child’s diagnosis and activity demands.

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Medication

NSAIDs and acetaminophen can be used for symptomatic treatment of many conditions, including musculoskeletal pain, Bertolotti syndrome, and disc herniation.

Medication should be combined with treatment of the underlying cause rather than used as the sole therapy.

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Spondyloarthropathy Treatment

NSAIDs are commonly used as initial treatment for inflammatory spondyloarthropathies.

Patients with persistent active inflammatory disease may require biologic therapy, including tumor necrosis factor inhibitors, under specialist rheumatologic care.

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Osteoid Osteoma Treatment

Pain from osteoid osteoma often responds markedly to NSAIDs.

Definitive treatment may be considered when symptoms persist or medication is undesirable for long-term use.

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Treatment of Discitis

Discitis is generally treated with appropriate antimicrobial therapy when bacterial infection is suspected or confirmed.

Empiric therapy commonly includes coverage against Staphylococcus aureus, with subsequent adjustment according to cultures and clinical response.

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Treatment of Pyogenic Sacroiliitis

Pyogenic sacroiliitis also requires antibiotic therapy directed toward the causative organism.

Staphylococcus aureus is an important pathogen to cover initially when bacterial infection is suspected.

Drainage may be required if an abscess or persistent collection is present.

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Treatment of Neoplasms

Tumors require treatment according to their histologic diagnosis and stage.

Malignant conditions such as Ewing sarcoma may require systemic chemotherapy together with local control by surgery and/or radiotherapy.

Spinal cord tumors require specialist oncologic and neurosurgical evaluation.

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Surgical Management of Spondylolysis

Most cases of spondylolysis are treated nonoperatively.

Persistent symptomatic lesions that fail conservative treatment may occasionally require direct repair of the pars defect using internal fixation and bone grafting.

Fusion may be considered in selected patients with associated instability or advanced spondylolisthesis.

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Surgery for Spondylolisthesis

Progressive or high-grade spondylolisthesis may require spinal fusion, particularly when there is persistent pain, progression of the slip, deformity, or neurologic compromise.

The exact procedure depends on the severity and level of the deformity.

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Surgery for Bertolotti Syndrome

Most patients with Bertolotti syndrome are initially treated conservatively.

Persistent symptoms attributable to the transitional articulation may occasionally require resection or fusion, depending on the anatomical abnormality and pain generator.

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Surgery for Tethered Cord Syndrome

Symptomatic tethered cord syndrome may require surgical detethering.

The goal is to release abnormal attachments and prevent further neurologic deterioration.

Surgery is particularly considered when progressive weakness, sensory loss, deformity, or bladder dysfunction is present.

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Surgery for Disc Herniation

Most pediatric disc herniations are initially managed nonoperatively when neurologic function is preserved.

Persistent radicular pain, progressive neurologic deficit, or significant neural compression may require discectomy, sometimes combined with limited decompression such as laminotomy or laminectomy.

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Follow-Up

Follow-up should be individualized according to the underlying diagnosis.

Children with uncomplicated musculoskeletal pain should demonstrate progressive improvement with activity modification and rehabilitation.

Persistent pain, worsening deformity, new neurologic abnormalities, or constitutional symptoms require reassessment.

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Prognosis

The prognosis is generally favorable for uncomplicated musculoskeletal causes of pediatric back pain.

Many stress-related and mechanical conditions improve with appropriate activity modification and physical therapy.

Prognosis for infection, tumors, neurologic disorders, and structural deformities depends on the underlying condition and how early treatment is initiated.

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Red Flags Requiring Further Evaluation

Features that should prompt more urgent investigation include night pain, persistent or progressive pain, fever, weight loss, fatigue, neurologic deficit, gait disturbance, bowel or bladder dysfunction, and significant spinal tenderness.

Back pain in very young children also deserves a lower threshold for further investigation.

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Patient Monitoring

Children should be monitored for improvement in pain, spinal motion, posture, gait, muscle strength, and neurologic function.

Return to sport should occur gradually after pain has resolved and normal strength, flexibility, and movement have been restored.

Failure to improve as expected should prompt reconsideration of the diagnosis and possible further imaging or specialist referral.

Orthopaedic Surgery - Back Pain

Basics

Low back pain (LBP) is one of the most common musculoskeletal complaints and is a major cause of disability. It accounts for a substantial number of years lived with disability and is responsible for a very large amount of lost work productivity.

An estimated 149 million workdays per year are lost because of low back pain, and approximately 70–80% of adults experience a significant episode of back pain at some point during their lives.

Back pain may involve the bones, joints, ligaments, discs, or muscles of the spine. It occurs most frequently in middle-aged adults but may also affect children and adolescents.

Classification

Back pain can be broadly classified as traumatic or atraumatic.

Pathologic pain may originate directly from the spine, including spondylogenic or neurogenic causes, or may arise from structures outside the spine, including visceral, vascular, or psychogenic sources.

Because low back pain is a symptom rather than a single disease, careful clinical assessment is necessary to determine its underlying cause.

Synonyms

Common terms include backache and low back pain (LBP).

Epidemiology

Low back pain is extremely common in adults.

It is less common in children, and significant back pain in a child should prompt careful investigation.

Children or adolescents with scoliosis may report mild discomfort, but severe or persistent pain should raise concern for conditions such as infection, tumor, fracture, or another structural abnormality.

Age Considerations

The prevalence of chronic low back pain increases with age and is highest during approximately the fifth and sixth decades of life.

Most surgical procedures performed for low back pain occur in patients between approximately 35 and 55 years of age.

Sex Distribution

Back pain has historically been reported more frequently in males, partly because of greater exposure to manual labor, motor vehicle trauma, and industrial accidents.

However, low back pain affects both sexes and is common across the general population.

Incidence

Approximately 25% of adults in the United States report experiencing low back pain over a given period.

The burden of disease is substantial because symptoms may interfere with work, exercise, mobility, sleep, and activities of daily living.

Prevalence

The point prevalence of chronic low back pain among adults aged approximately 20–69 years has been reported at around 13%.

The likelihood of chronic symptoms rises with age.

Risk Factors

Important risk factors include obesity, cigarette smoking, manual labor, and traumatic accidents.

Repeated heavy lifting, prolonged mechanical loading, poor physical conditioning, and certain occupational exposures may also contribute.

Genetics

There is no single established genetic predisposition that explains most cases of nonspecific low back pain.

However, inherited factors may contribute indirectly to certain disorders, such as degenerative disc disease or inflammatory spondyloarthritis.

Pathophysiology

There is no single pathologic process responsible for all forms of back pain.

The mechanism depends on the underlying disorder and may involve mechanical strain, disc degeneration, nerve compression, inflammation, fracture, infection, neoplasm, or referred pain from other structures.

Etiology

Traumatic Causes

Traumatic causes include vertebral fractures or microfractures, fracture-dislocations, intervertebral disc herniation, and ligamentous injuries.

Fractures and major structural injuries usually produce sudden and often severe pain following trauma.

Atraumatic Causes

Atraumatic causes include degenerative disc disease, degenerative spinal stenosis, inflammatory arthritis, osteoporosis, spondylolysis, spondylolisthesis, infection, and neoplasms.

Tumors may be primary bone lesions or metastatic disease.

Associated Conditions

Low back pain may occur in association with ankylosing spondylitis, rheumatoid arthritis, sciatica, and cauda equina syndrome.

Neurologic symptoms accompanying back pain require particular attention because they may indicate nerve root or spinal canal compromise.

Diagnosis

Signs and Symptoms

Common symptoms include low back pain, stiffness, and numbness.

Patients may also experience radiating pain into the buttocks or lower extremities when nerve roots are involved.

Neurologic Signs

Potential examination findings include paravertebral muscle spasm, motor weakness, loss of deep tendon reflexes, sensory loss, clonus, and a positive Babinski sign.

The presence of upper motor neuron findings or significant neurologic deficits should prompt further investigation.

History

A detailed history is essential because routine diagnostic studies are often unnecessary in uncomplicated low back pain.

The clinician should determine the onset, location, severity, duration, and character of pain, together with aggravating and relieving factors.

A history of trauma, systemic illness, malignancy, infection risk, osteoporosis, or neurologic symptoms is particularly important.

Pain Mapping

Rather than relying only on verbal descriptions, asking the patient to identify or map the exact distribution of pain can improve localization.

The pattern may help distinguish localized mechanical pain from radicular, referred, or systemic causes.

Red Flag History

Important concerning features include night pain, unexplained weight loss, fever, recent serious trauma, history of malignancy, immunosuppression, intravenous drug use, progressive neurologic deficit, or bowel and bladder dysfunction.

These findings may indicate serious structural disease and require urgent investigation.

Physical Examination

Examination begins with inspection of the spine and overall posture.

The clinician should assess for asymmetry of the ribs, flanks, pelvis, or shoulders, and should observe the normal sagittal spinal curves.

Deformities such as scoliosis, excessive kyphosis, or abnormal lumbar lordosis should be documented.

Range of Motion

Lumbar motion should be assessed in flexion, extension, lateral bending, and rotation.

Pain suddenly reproduced during a specific movement may suggest a mechanical abnormality.

Restriction of motion may occur because of pain, muscle spasm, degenerative disease, inflammation, or structural deformity.

Palpation

The lumbar spine and surrounding muscles should be palpated for tenderness.

Paravertebral muscle spasm may be present in acute mechanical pain.

Percussion tenderness over the spine may raise concern for fracture, infection, or other osseous pathology.

Neurologic Examination

The neurologic examination is a crucial component of assessment.

It should include motor strength, sensory testing, deep tendon reflexes, and gait evaluation.

The distribution of weakness or sensory loss may help identify the involved nerve root.

Motor Testing

Major muscle groups of the lower extremities should be examined systematically.

Weakness may indicate nerve root compression, spinal cord involvement, severe pain inhibition, or another neurologic disorder.

Reflexes

Deep tendon reflexes should be assessed and compared bilaterally.

Abnormal or absent reflexes may indicate nerve root involvement, whereas hyperreflexia, clonus, or a positive Babinski response may suggest spinal cord pathology.

Gait Examination

The patient’s gait should be observed for antalgia, weakness, foot drop, imbalance, or other neurologic abnormalities.

Difficulty with heel or toe walking may provide additional information regarding specific nerve root or muscle dysfunction.

Laboratory Tests

There are no routine laboratory tests required for uncomplicated mechanical low back pain.

Investigations should be guided by clinical suspicion.

Evaluation for Infection

When infection is suspected, a complete blood count and erythrocyte sedimentation rate (ESR) may be obtained.

Inflammatory markers are commonly elevated in spinal infection, with ESR often being particularly useful.

C-reactive protein may also assist in assessing inflammatory activity.

Evaluation for Multiple Myeloma

In older patients, particularly those over approximately 50 years of age with unexplained persistent back pain, laboratory investigations may be used to screen for disorders such as multiple myeloma when clinically indicated.

HLA-B27 Testing

In younger patients with marked spinal stiffness and symptoms suggestive of inflammatory back pain, testing for HLA-B27 may support evaluation for ankylosing spondylitis.

It should not be used as a stand-alone diagnostic test.

Imaging

Plain Radiographs

Routine radiographs are not necessary for every first episode of uncomplicated low back pain, particularly when symptoms follow a minor mechanical event such as lifting and there are no concerning findings.

Imaging should be considered when history or examination suggests a significant structural abnormality.

Indications for Imaging

Radiographs may be appropriate when there is suspicion of fracture, ankylosing spondylitis, severe deformity, malignancy, infection, or another important structural disorder.

The decision to image should be based on clinical findings rather than pain alone.

CT

Computed tomography is particularly useful for evaluating bony abnormalities.

It can provide detailed assessment of fractures, pars defects, osteoid osteoma, and other osseous lesions.

CT is also helpful when complex anatomy must be defined before surgery.

MRI

MRI provides excellent visualization of bone marrow, discs, ligaments, neural structures, and surrounding soft tissues.

It is particularly useful for detecting disc herniation, spinal stenosis, infection, metastatic disease, marrow abnormalities, and nerve compression.

MRI is generally the preferred advanced imaging modality when neurologic symptoms or serious spinal pathology are suspected.

Bone Scintigraphy

Technetium bone scanning can help detect areas of increased skeletal activity.

It may be useful for identifying early bone infection, stress injury, occult fracture, or metastatic lesions.

Its use has decreased in many situations because MRI often provides more detailed anatomic information.

Differential Diagnosis in Adults

Traumatic Causes

Important traumatic causes include herniated disc, compression fracture, fracture-dislocation, and traumatic spondylolysis.

A clear traumatic history increases suspicion for these conditions.

Atraumatic Causes in Adults

Atraumatic causes include degenerative disc disease, spinal stenosis, inflammatory arthritis, spondylolysis, spondylolisthesis, ligamentous or muscular strain, and neoplasm.

Malignant causes include metastatic bone disease and multiple myeloma.

Differential Diagnosis in Children

Back pain in children deserves careful attention because serious causes are relatively more important.

Traumatic causes include fracture and disc herniation.

Atraumatic causes include scoliosis, disc-space infection, vertebral osteomyelitis, and tumors.

Persistent severe pain should not automatically be attributed to muscular strain.

Treatment

General Measures

Most patients with uncomplicated low back pain can be managed nonoperatively.

Treatment may include short-term rest, appropriate analgesia, NSAIDs when indicated, activity modification, and physical therapy.

The overall aim is to restore mobility and prevent deconditioning.

Bed Rest

Prolonged bed rest is generally not beneficial.

In patients with severe acute spasm or pain, a very short period of rest—often no more than 2–3 days—may be reasonable.

During the first several days, activity may be temporarily restricted, but progressive mobilization should begin as symptoms improve.

Early Mobilization

If no serious structural abnormality is identified, patients should gradually resume activity.

Early mobilization helps prevent muscle weakness, stiffness, loss of cardiovascular fitness, and prolonged disability.

Physical Therapy

Physical therapy and structured exercise can improve back strength, flexibility, range of motion, posture, and general fitness.

Therapy should be tailored to the underlying diagnosis and the patient’s functional limitations.

Exercise Programs

Traditional exercise approaches include the Williams flexion program and McKenzie extension-based exercises.

No single exercise method is appropriate for every patient.

Programs emphasizing coordination, stabilization, strength, and resistance training are particularly useful in chronic low back pain.

Core and Stabilization Training

Exercises targeting the abdominal, paraspinal, pelvic, and hip muscles can improve spinal stability.

Motor-control and stabilization programs may reduce recurrent symptoms and improve function in patients with chronic mechanical low back pain.

Activity Modification

Patients should be educated regarding safe lifting techniques, posture, gradual return to activity, and strategies for preventing recurrent injury.

Temporary modification of work or sporting activity may be required during painful episodes.

Work-Hardening Programs

Patients injured at work may benefit from a structured work-hardening program.

These programs progressively reproduce occupational tasks in a controlled setting and help restore strength, endurance, and confidence before return to full duty.

Passive Therapies

Massage, acupuncture, electrical stimulation, and other passive modalities may provide temporary symptom relief.

However, they generally provide less durable benefit than active exercise and strengthening programs.

They should therefore be considered adjuncts rather than the primary long-term treatment.

Medication

NSAIDs

Nonsteroidal anti-inflammatory drugs are commonly used for short-term symptomatic relief.

They may reduce pain and inflammation sufficiently to allow earlier mobilization and participation in rehabilitation.

Treatment should be individualized according to gastrointestinal, renal, cardiovascular, and other patient-specific risks.

Duration of Medication

NSAIDs may be prescribed for several weeks when necessary, but treatment should be reassessed regularly.

Once symptoms improve, medication can usually be reduced or discontinued.

Muscle Relaxants

Muscle relaxants have a limited role in routine management.

They may be useful for short-term relief in patients with severe muscle spasm, especially during an acute episode.

They are generally not recommended for prolonged use.

Treatment of Spinal Infection

When infection is present, treatment requires appropriate antimicrobial therapy and management of the infected spinal segment.

Intravenous antibiotics are commonly required initially.

Inflammatory markers such as ESR and CRP may be followed to assess response to treatment.

Surgical Management

Only a minority of patients with low back pain require surgery.

Approximately 1–5% may ultimately become candidates for operative treatment, depending on the underlying pathology.

Surgery is generally reserved for clearly defined structural problems that fail to respond to appropriate conservative care or threaten neurologic function.

Surgical Principles

The principal surgical goals include decompression of compressed nerve roots or the spinal cord, stabilization of an unstable spine, and correction of significant deformity.

The exact procedure depends on the diagnosis.

Decompression

Nerve root or spinal cord compression may require surgical decompression.

Examples include significant disc herniation, spinal stenosis, tumor, infection, or traumatic compression associated with neurologic deficits.

Spinal Fusion

Fusion may be used when instability is present or when decompression would otherwise leave the spine unstable.

It can also be considered for selected cases of deformity, spondylolisthesis, or severe degenerative disease.

Fusion solely for nonspecific low back pain is relatively uncommon.

Deformity Correction

Patients with significant spinal deformities such as scoliosis or spondylolisthesis may require realignment combined with fusion.

Correction is generally considered when deformity is progressive, symptomatic, unstable, or neurologically compromising.

Instrumentation

Modern spinal fusion may use a variety of fixation systems.

Examples include pedicle screws, rods, plates, and interbody devices.

Instrumentation provides mechanical stability and increases the likelihood of obtaining a solid fusion.

Lumbar Disc Arthroplasty

Lumbar disc replacement has been developed as an alternative to fusion for selected patients with persistent discogenic low back pain.

The objective is to remove the painful disc while preserving motion at the involved spinal level.

Short-term outcomes have been encouraging in appropriately selected patients.

Limitations of Disc Arthroplasty

Longer-term studies have demonstrated that prosthetic disc motion may gradually decrease over time.

Because of concerns regarding durability, patient selection, adjacent-segment effects, and revision surgery, lumbar disc arthroplasty remains controversial in some settings.

Follow-Up

Patients with uncomplicated low back pain should be reviewed according to symptom severity and functional limitation.

Follow-up at approximately 4–6-week intervals may be appropriate until substantial improvement occurs.

Persistent or worsening symptoms should prompt reconsideration of the diagnosis.

Prognosis

The prognosis is generally good in patients without major structural abnormalities.

Many episodes improve with activity modification, appropriate medication, exercise, and rehabilitation.

However, recurrent or chronic symptoms are common in some patients.

Prognosis After Fusion

Patients who undergo major spinal fusion can often return to many routine activities.

However, heavy manual work and repeated high-load activities may remain difficult because spinal motion is reduced and adjacent segments experience greater mechanical demand.

Complications

Potential complications of spinal disease and its treatment include infection, neurologic injury, surgical failure, pseudarthrosis, loss of fixation, and persistent unexplained pain.

Complication risk varies according to the underlying disorder and surgical procedure.

Pseudarthrosis

Pseudarthrosis refers to failure of a planned spinal fusion to unite.

It may result in persistent pain, hardware failure, deformity, or instability and may occasionally require revision surgery.

Cauda Equina Syndrome

Cauda equina syndrome is a neurologic emergency caused by severe compression of the cauda equina nerve roots.

It may result from a large disc herniation, tumor, infection, fracture, or other space-occupying lesion.

Signs of Cauda Equina Syndrome

Concerning findings include progressive bilateral leg weakness, saddle anesthesia, urinary retention or incontinence, bowel dysfunction, and severe neurologic loss.

Untreated compression can result in permanent paralysis and irreversible loss of bladder and bowel function.

Urgent imaging and surgical evaluation are required.

Patient Monitoring

Patients should demonstrate gradual improvement with rest, activity modification, appropriate medication, and rehabilitation.

Range of motion, strength, gait, neurologic function, and ability to perform daily activities should be monitored.

If pain fails to improve as expected or new neurologic or systemic symptoms develop, a significant structural or systemic cause should be reconsidered.

Orthopaedic Surgery - Atypical Stress Fractures

Basics

Atypical stress fractures most commonly involve the subtrochanteric region or femoral shaft and are strongly associated with prolonged bisphosphonate therapy.

These fractures occur distal to the lesser trochanter and proximal to the supracondylar region of the femur.

They generally result from a low-energy mechanism, such as a fall from standing height, and some patients report no preceding traumatic event at all.

A characteristic radiographic feature is localized thickening or beaking of the lateral femoral cortex.

The fracture is usually transverse or short oblique, is generally noncomminuted, and may occasionally demonstrate a medial cortical spike.

Epidemiology

The reported incidence of atypical femoral fractures is approximately 50–130 cases per 100,000 patient-years.

The true incidence may be lower because epidemiologic studies sometimes have difficulty consistently identifying fractures that meet formal atypical femoral fracture criteria.

These fractures remain substantially less common than typical osteoporotic hip fractures.

They appear to occur more frequently in women and individuals of Asian ethnicity.

Risk Factors

The most important risk factor is long-term bisphosphonate use.

The risk increases with longer duration of treatment and becomes more significant after approximately 4 years of continuous therapy, although atypical fractures have been reported after as little as 1.5 years of treatment.

Other recognized risk factors include Asian ethnicity, prolonged glucocorticoid therapy, autoimmune disease, obesity with a BMI greater than 30 kg/m², age younger than approximately 70 years, and earlier menopause.

Etiology and Pathophysiology

The principal proposed mechanism is prolonged suppression of normal bone remodeling caused by bisphosphonates.

The femur is exposed to repetitive mechanical loading during everyday activities. This produces microscopic damage, particularly along the lateral cortex, which normally undergoes continuous remodeling and repair.

Bisphosphonate therapy can markedly reduce bone turnover. When remodeling is excessively suppressed, microdamage may accumulate rather than being repaired.

Over time, small cortical cracks may propagate and eventually develop into an incomplete or complete atypical fracture.

Mechanical Factors

The lateral femoral cortex experiences considerable tensile stress during weight-bearing.

Certain anatomical characteristics can increase these stresses, including lateral femoral bowing and varus alignment of the proximal femur.

These mechanical factors may concentrate forces along the lateral cortex and increase susceptibility to fracture.

Genetic Factors

A genetic predisposition has also been reported in some patients.

The precise genetic contribution remains incompletely understood, but inherited differences in bone remodeling or femoral geometry may influence susceptibility.

Associated Conditions

Atypical femoral fractures are frequently encountered in patients with osteoporosis receiving prolonged bisphosphonate treatment.

They may also occur in individuals with autoimmune disorders who have required prolonged glucocorticoid therapy, which can adversely affect bone quality and healing.

Diagnosis

Signs and Symptoms

Some patients are completely asymptomatic before sustaining a complete fracture.

Others experience characteristic prodromal pain for weeks or months before the fracture becomes complete.

The pain is often described as a dull or aching discomfort involving the groin or thigh, particularly during weight-bearing.

Symptoms may be vague or sharply localized.

History

The clinical history should specifically assess the duration of bisphosphonate use.

Although the greatest concern traditionally involves treatment extending beyond 4–5 years, atypical fractures can occur earlier.

A history of long-term glucocorticoid use should also be documented.

Patients should be questioned about preceding thigh or groin pain and whether symptoms worsen with walking or prolonged standing.

Physical Examination

Patients with an incomplete fracture may have localized tenderness along the thigh and pain during weight-bearing.

Hip range of motion may reproduce discomfort, particularly internal rotation.

A complete displaced fracture usually results in inability to bear weight.

Visible deformity and shortening of the affected limb may also be present.

Imaging

Plain Radiographs

Initial evaluation should include an anteroposterior radiograph of the pelvis together with AP and lateral views of the hip, entire femur, and knee.

It is important to image the entire femur because the lesion may occur anywhere from the subtrochanteric region to the distal shaft.

Early Radiographic Findings

Before a complete fracture develops, radiographs may show focal periosteal reaction, cortical thickening, or beaking along the lateral femoral cortex.

These changes may represent an impending atypical fracture.

A transverse radiolucent line extending inward from the lateral cortex may indicate an incomplete fracture.

Complete Fracture Pattern

Complete atypical femoral fractures are typically transverse or short oblique.

The fracture pattern is usually simple and demonstrates little or no comminution.

A characteristic medial cortical spike may occasionally be present.

These features help distinguish atypical fractures from typical high-energy femoral shaft fractures.

Contralateral Femur Imaging

Atypical femoral fractures are frequently bilateral or sequential.

Therefore, radiographs of the contralateral femur should routinely be obtained when an atypical fracture is identified.

The opposite femur should be examined for cortical thickening, beaking, periosteal reaction, or a transverse radiolucent line.

MRI

MRI is generally unnecessary when a complete fracture is clearly visible on radiographs.

However, it is the preferred imaging study for detecting an occult or incomplete atypical fracture when plain radiographs are normal or equivocal but clinical suspicion remains high.

Typical findings include bone marrow edema and a linear low-signal fracture line.

MRI is particularly useful in patients receiving long-term bisphosphonates who present with unexplained thigh or groin pain.

Bone Scintigraphy

Bone scintigraphy may detect increased metabolic activity at an impending fracture site.

However, it is less specific than MRI and is not generally required when a complete fracture is already visible radiographically.

It may be useful when MRI cannot be performed.

CT

CT is also usually unnecessary for complete atypical fractures.

It has lower sensitivity than MRI for detecting early stress reactions and incomplete fractures.

Its use is therefore generally reserved for selected cases in which detailed cortical anatomy is required.

Dual-Energy X-Ray Absorptiometry

Dual-energy X-ray absorptiometry may occasionally identify cortical abnormalities such as periosteal reaction or lateral cortical beaking during monitoring of patients receiving prolonged bisphosphonate therapy.

Its primary purpose remains assessment of bone mineral density rather than diagnosis of atypical fracture.

Differential Diagnosis

The differential diagnosis includes insufficiency fracture, intertrochanteric or peritrochanteric fracture, typical osteoporotic hip fracture, and femoral neck stress fracture.

Musculoskeletal conditions such as overuse tendinopathy may also produce thigh or groin pain and can mimic prodromal symptoms.

Treatment

General Measures

Long-term bisphosphonate therapy should be reassessed in patients at increased risk of atypical femoral fracture.

A drug holiday may be considered in appropriate patients after balancing the risk of atypical fracture against the continuing risk of osteoporotic fragility fracture.

Patients receiving bisphosphonates for approximately 3–5 years or longer should be monitored for symptoms suggestive of an atypical femoral fracture.

Monitoring for Prodromal Symptoms

Patients on prolonged bisphosphonate treatment should be questioned about new groin or thigh pain, particularly pain occurring during weight-bearing.

When such symptoms develop, imaging should be obtained promptly.

Early identification of an incomplete lesion may allow prophylactic treatment before displacement occurs.

Laboratory Evaluation

Bone turnover markers may occasionally be assessed when excessive suppression of remodeling is suspected.

Potential investigations include serum or urine N-telopeptide or C-telopeptide levels and bone-specific alkaline phosphatase.

These tests may provide information about bone turnover but do not establish the diagnosis of an atypical fracture.

Weight-Bearing Restrictions

Patients with prodromal pain and radiographic or imaging evidence of an incomplete fracture should reduce loading of the affected limb.

Partial or non-weight-bearing may be recommended while definitive treatment is arranged.

The objective is to reduce the risk of progression to a complete displaced fracture.

Surgical Management

Intramedullary Nailing

Intramedullary nailing is the preferred treatment for most complete atypical femoral fractures.

It is also commonly recommended for incomplete fractures that are painful or demonstrate features indicating a high risk of progression.

The intramedullary device provides load-sharing fixation along the length of the femur and allows early mobilization.

Incomplete Fractures

Incomplete atypical fractures have a substantial risk of progressing to complete displaced fractures.

This risk is particularly high when a visible radiolucent fracture line, lateral cortical beaking, and persistent prodromal pain are present.

Observation alone may therefore be inappropriate in high-risk lesions.

Prophylactic Intramedullary Nailing

Prophylactic intramedullary fixation may be recommended for patients with an incomplete atypical lesion before a displaced fracture occurs.

Important indications include lateral cortical beaking combined with persistent thigh or groin pain.

Preventive fixation can reduce the likelihood of sudden complete fracture and may allow a more predictable recovery.

Plate Fixation

Intramedullary nailing may be technically difficult in patients with substantial femoral bowing.

In such situations, lateral plate fixation may be considered.

The choice of fixation should take femoral geometry, fracture location, and surgeon experience into account.

Contralateral Femur Management

Management of the opposite femur is controversial.

Routine prophylactic fixation of an asymptomatic contralateral femur is not recommended for every patient.

However, prophylactic intramedullary nailing may be considered when multiple high-risk features are present.

High-Risk Contralateral Features

Factors that may support prophylactic fixation of the opposite femur include Asian ethnicity, prodromal thigh pain, varus proximal femoral geometry, marked femoral bowing, and radiographic abnormalities such as cortical beaking or a transverse radiolucent line.

The decision should be individualized according to overall fracture risk and symptoms.

Follow-Up

Patients require close follow-up after both operative and nonoperative management.

Serial radiographs are used to assess healing, implant position, and possible progression of incomplete lesions.

The contralateral femur should also be monitored because a second atypical fracture may develop later.

Prognosis

Intramedullary fixation generally permits relatively early or immediate protected weight-bearing and facilitates return to function.

However, atypical femoral fractures often heal more slowly than typical traumatic femoral fractures.

They have a higher incidence of delayed union, nonunion, and revision surgery compared with more typical hip or femoral fractures.

Delayed Healing

Suppressed bone remodeling and the chronic stress-fracture nature of the injury may contribute to prolonged healing.

Radiographic union can therefore take considerable time even after technically successful fixation.

Patients should be counseled that recovery may be slower than after a conventional femoral fracture.

Complications

An incomplete atypical fracture may progress to a complete displaced fracture, particularly if weight-bearing continues despite prodromal symptoms.

Other important complications include delayed union, nonunion, implant-related problems, and the development of an atypical fracture in the contralateral femur.

Contralateral Fracture

Patients who sustain one atypical femoral fracture have an increased risk of developing a similar lesion on the opposite side.

Persistent or new contralateral thigh pain should therefore be investigated promptly.

Long-term surveillance of both femora may be appropriate in high-risk individuals.

Patient Teaching

Patients receiving long-term bisphosphonate therapy should understand that atypical femoral fractures are uncommon but recognized complications of prolonged treatment.

They should be advised to report new groin or thigh pain during weight-bearing, even if there has been no trauma.

Early Warning Signs

Patients should understand that an atypical fracture may initially produce no symptoms.

When symptoms do occur, vague aching pain in the thigh or groin may precede complete fracture by weeks or months.

Radiographs may show lateral cortical thickening or beaking before the fracture becomes complete.

Importance of Early Evaluation

Early recognition of an impending atypical femoral fracture can prevent progression to a displaced injury.

Patients with significant prodromal symptoms, radiographic abnormalities, or other high-risk findings should undergo prompt orthopedic evaluation.

Patients with a complete atypical fracture, or those with an incomplete lesion at high risk of progression, commonly require surgical stabilization.

Orthopaedic Surgery - Arthroscopy

Basics

Arthroscopy is a minimally invasive surgical technique that allows direct visualization and treatment of structures within a joint through small portal incisions.

The procedure should be performed only after a complete clinical history, thorough physical examination, and appropriate imaging studies have been obtained.

Most arthroscopic procedures can be performed on an outpatient basis, although the postoperative course depends on the joint involved and the complexity of the procedure.

General Principles

Arthroscopy uses a small camera, or arthroscope, inserted through one portal while surgical instruments are introduced through one or more additional portals.

The technique allows the surgeon to inspect articular cartilage, ligaments, tendons, menisci, labral structures, synovium, and other intra-articular tissues.

In addition to diagnostic evaluation, many abnormalities can be treated during the same procedure.

Knee Arthroscopy

Indications

Common indications for knee arthroscopy include meniscal repair or debridement, treatment of meniscal cysts, management of osteochondral lesions, and reconstruction or debridement of anterior or posterior cruciate ligament injuries.

It may also be performed for synovial biopsy, synovectomy, evaluation of unexplained knee pain or instability, and selected cases of degenerative joint disease requiring debridement.

Procedure

Knee arthroscopy is usually performed through two or more small portal incisions, each measuring approximately 0.5 cm.

One portal is used for the arthroscope, while the remaining portals permit insertion of surgical instruments.

The technique allows systematic visualization of all three major compartments of the knee: the patellofemoral, medial, and lateral compartments.

Articular Cartilage Assessment

The articular cartilage of the femur, tibia, and patella can be directly inspected.

The surgeon can evaluate cartilage for degeneration, fissuring, osteochondral defects, loose fragments, or traumatic injury.

Selected cartilage lesions may be treated arthroscopically during the same procedure.

Meniscal Assessment

Both the medial and lateral menisci can be visualized and probed.

Probing helps determine the location, configuration, stability, and extent of a meniscal tear.

Depending on the tear pattern and vascularity, treatment may involve meniscal repair or selective debridement.

Cruciate Ligament Assessment

The anterior cruciate ligament and posterior cruciate ligament can also be visualized and probed arthroscopically.

Their integrity, tension, attachment sites, and associated injuries can be assessed.

ACL and PCL reconstruction can be performed with arthroscopic assistance.

Postoperative Weight-Bearing

After uncomplicated knee arthroscopy, many patients can begin partial or full weight-bearing with crutch assistance soon after surgery.

The exact amount of permitted weight-bearing depends on the procedure performed.

For example, rehabilitation after simple debridement may progress more rapidly than after meniscal repair, cartilage restoration, or ligament reconstruction.

Rehabilitation After Knee Arthroscopy

The duration of rehabilitation varies according to the underlying injury and surgical procedure.

Physical therapy commonly focuses on restoring range of motion, gait, core stability, quadriceps strength, and hamstring strength.

The rehabilitation protocol should be individualized rather than based solely on the fact that arthroscopy was performed.

Shoulder Arthroscopy

Indications

Shoulder arthroscopy may be performed for a wide variety of conditions.

Common indications include shoulder instability, synovial or tissue biopsy, removal of loose bodies, subacromial impingement, rotator cuff tears, and superior labral anterior-posterior (SLAP) lesions.

It can provide both diagnostic assessment and definitive surgical treatment.

Procedure

Shoulder arthroscopy typically requires two or more portals, generally measuring approximately 0.8 cm.

The arthroscope is introduced into the glenohumeral joint to inspect the articular surfaces and surrounding soft tissues.

Additional portals provide access for probing, debridement, repair, and fixation.

Articular Cartilage Assessment

The articular surfaces of the glenoid and humeral head can be inspected directly.

Arthroscopy may identify abnormalities such as osteoarthritis, cartilage defects, osteochondral fragments, or loose bodies.

The severity and distribution of cartilage damage can therefore be assessed accurately.

Glenohumeral Ligament Assessment

The major soft-tissue stabilizers of the shoulder can be examined arthroscopically.

These include the inferior, middle, and superior glenohumeral ligament complexes.

Their integrity is particularly important when evaluating recurrent instability or previous dislocation.

Labral Assessment

The glenoid labrum can be inspected throughout its circumference.

Arthroscopy can identify Bankart lesions, SLAP tears, degenerative labral changes, and other labral injuries.

The stability of the labrum can also be assessed with a probe.

Subacromial Assessment

When rotator cuff or impingement symptoms are present, arthroscopy can be extended into the subacromial space.

The rotator cuff, bursa, undersurface of the acromion, and surrounding structures are examined for causes of mechanical impingement or tendon injury.

Arthroscopic Stabilization

Recurrent shoulder instability can often be treated arthroscopically.

Procedures may include Bankart repair or capsulolabral stabilization, in which the detached labrum and capsule are restored to the glenoid rim.

These procedures aim to restore stability while preserving shoulder motion.

Acromioplasty

Arthroscopic acromioplasty may be performed in selected cases of mechanical subacromial impingement.

The procedure involves reshaping part of the acromion and removing impinging tissue to increase the available space for the rotator cuff.

Rotator Cuff Repair

Many rotator cuff tears can be repaired arthroscopically.

The torn tendon is mobilized and reattached to its insertion on the greater tuberosity, commonly using suture anchors.

Arthroscopic repair allows treatment through small portals while minimizing disruption of the surrounding deltoid muscle.

SLAP Lesions

SLAP lesions may be treated with arthroscopic repair or debridement, depending on the tear pattern, patient age, activity level, and associated pathology.

Direct visualization allows accurate evaluation of the superior labrum and biceps anchor.

Rehabilitation After Shoulder Arthroscopy

Physical therapy is an essential component of recovery after shoulder arthroscopy.

Early rehabilitation usually emphasizes restoring appropriate motion while protecting repaired tissues.

Later stages focus on strengthening the rotator cuff, scapular stabilizers, and other dynamic stabilizers of the shoulder.

The duration and progression of rehabilitation depend on the operation performed.

Hip Arthroscopy

Indications

Hip arthroscopy may be used for synovial biopsy, synovectomy, removal of loose bodies, and treatment of labral tears.

Because the hip is a deep, constrained joint, specialized traction and instrumentation are generally required.

Labral Treatment

Hip arthroscopy allows direct inspection of the acetabular labrum.

Symptomatic labral tears may be treated with repair, selective debridement, or other arthroscopic techniques, depending on the pattern and quality of the tissue.

Loose-Body Removal

Intra-articular loose bodies can produce pain, locking, catching, and restricted motion.

Arthroscopy permits their removal without requiring a large open surgical exposure.

Ankle Arthroscopy

Indications

Ankle arthroscopy may be performed for synovial biopsy or synovectomy, removal of loose bodies, excision of bone spurs, and treatment of osteochondral lesions.

It is particularly useful for disorders causing mechanical impingement, locking, or persistent intra-articular pain.

Osteochondral Lesions

Osteochondral lesions of the talus can be evaluated directly during ankle arthroscopy.

Depending on the size and characteristics of the lesion, treatment may include debridement, stabilization of unstable cartilage, or marrow-stimulation techniques.

Bone-Spur Removal

Anterior or posterior ankle osteophytes can produce painful impingement during motion.

Arthroscopic excision of selected osteophytes can improve movement and relieve mechanical symptoms.

Elbow Arthroscopy

Indications

Elbow arthroscopy may be used for synovial biopsy, synovectomy, loose-body removal, and debridement of cartilage lesions or osteophytes.

It can be especially useful in patients with mechanical locking, restricted motion, or symptomatic intra-articular pathology.

Cartilage and Osteophyte Debridement

Degenerative cartilage fragments and osteophytes may restrict elbow motion and cause pain.

Arthroscopic debridement can remove these structures while minimizing soft-tissue disruption compared with some open procedures.

Wrist Arthroscopy

Indications

Wrist arthroscopy may be performed for synovial biopsy, synovectomy, removal of loose bodies, and diagnosis or treatment of triangular fibrocartilage complex (TFCC) injuries.

It provides detailed visualization of small intra-articular structures that may be difficult to assess using imaging alone.

TFCC Assessment

The triangular fibrocartilage complex can be directly inspected and probed arthroscopically.

Tears may be assessed according to their location, stability, and tissue quality.

Depending on the lesion, treatment may involve debridement or repair.

Advantages of Arthroscopy

Arthroscopy generally requires smaller incisions than traditional open surgery.

Potential benefits include less disruption of surrounding soft tissues, improved visualization of intra-articular structures, and the ability to diagnose and treat several abnormalities during the same procedure.

Many procedures can also be performed without overnight hospitalization.

Limitations

Arthroscopy is not appropriate for every joint disorder.

The decision to operate should be based on the patient’s symptoms, physical examination, imaging, functional impairment, and likelihood that the identified pathology is responsible for the symptoms.

Abnormal imaging alone does not necessarily justify arthroscopic surgery.

Postoperative Rehabilitation

Rehabilitation should always be tailored to the specific procedure performed.

Simple diagnostic arthroscopy or debridement may allow rapid progression of activity.

Procedures involving meniscal repair, ligament reconstruction, labral repair, rotator cuff repair, or cartilage treatment generally require more prolonged protection and structured rehabilitation.

Patient Monitoring

Postoperative follow-up should assess wound healing, pain, swelling, joint range of motion, strength, and functional recovery.

Patients should also be monitored for complications such as infection, stiffness, neurovascular symptoms, or persistent mechanical complaints.

Progression of weight-bearing, strengthening, and return to sport should follow the requirements of the specific arthroscopic procedure rather than a single universal protocol.

Orthopaedic Surgery - Arthrocentesis

Basics

Arthrocentesis is a procedure in which synovial fluid is aspirated from a joint using a needle.

It may be performed for either diagnostic or therapeutic purposes.

Diagnostic aspiration allows examination of synovial fluid for infection, crystals, blood, and inflammatory changes, while therapeutic aspiration can reduce pressure, pain, and restricted movement caused by a large joint effusion.

Causes of Joint Effusion

A joint effusion may develop from many different conditions.

Important causes include infection, crystal arthropathies, hemophilia, autoimmune inflammatory disorders, trauma, and pigmented villonodular synovitis (PVNS).

The appearance and composition of the aspirated fluid can provide valuable information regarding the underlying diagnosis.

Indications

Synovial joints may be aspirated for several reasons.

One of the most important indications is to exclude septic arthritis, particularly when a joint is acutely painful, swollen, and warm.

Arthrocentesis is also useful for diagnosing gout, pseudogout, inflammatory arthritis, hemarthrosis, and other arthropathies.

Therapeutically, aspiration can reduce pain and improve movement by decreasing pressure within a tense joint effusion.

Signs and Symptoms

A joint containing sufficient fluid for aspiration usually has a clinically detectable effusion.

Patients may complain of pain, swelling, stiffness, and difficulty moving the affected joint.

Infectious, inflammatory, and crystalline arthropathies commonly produce a joint that is warm and tender.

Erythema may be present over the joint, although surrounding cellulitis must be distinguished carefully because it affects the safe approach for aspiration.

Physical Examination

The affected joint should be inspected and palpated for swelling, warmth, tenderness, erythema, and the presence of an effusion.

Range of motion should be assessed when tolerated.

Patients with septic arthritis, crystal arthropathy, or acute traumatic injury may have substantial restriction of both active and passive movement.

The surrounding skin should also be examined for abrasions, wounds, cellulitis, bruising, or other evidence of trauma or infection.

Common Sites for Joint Aspiration

The optimal needle entry site depends on the joint involved.

The elbow is commonly approached posterolaterally.

The shoulder can be aspirated anteriorly, although ultrasound, CT, or fluoroscopic guidance may improve accuracy.

The hip can be approached anteriorly or laterally and generally benefits from imaging guidance because of its depth and proximity to major neurovascular structures.

The knee is commonly aspirated from either the medial or lateral side through the suprapatellar pouch.

The ankle is often approached from the anterolateral aspect.

Synovial Fluid Assessment

Synovial fluid should be assessed according to its appearance, white blood cell count, proportion of polymorphonuclear leukocytes, crystal content, Gram stain, and culture.

Additional biochemical or molecular testing may be performed depending on the suspected diagnosis.

The overall pattern is interpreted together with the clinical presentation rather than relying on a single laboratory value.

Noninflammatory Synovial Fluid

Noninflammatory fluid is generally clear or straw-colored.

The white blood cell count is usually relatively low, and the proportion of polymorphonuclear cells is limited.

This type of fluid may be seen in conditions dominated by degenerative rather than active inflammatory changes.

Inflammatory Synovial Fluid

Inflammatory fluid is commonly cloudy or yellow and contains an increased number of white blood cells.

Inflammatory arthropathies, including rheumatoid disease and crystal deposition disorders, can produce markedly elevated synovial leukocyte counts.

Because substantial overlap exists between inflammatory and infectious processes, synovial fluid analysis must be interpreted carefully.

Septic Synovial Fluid

Fluid from an infected joint may appear purulent, opaque, or markedly cloudy.

The white blood cell count is frequently very high, with a predominance of polymorphonuclear leukocytes.

Gram stain may identify organisms directly, while culture provides definitive microbiological identification in many cases.

A high cell count strongly raises suspicion for infection but is not completely specific because severe inflammatory and crystalline arthropathies can occasionally produce similarly elevated counts.

Traumatic Effusion

Traumatic joint aspiration may produce bloody synovial fluid or frank hemarthrosis.

This may occur after ligament injury, intra-articular fracture, cartilage injury, or other traumatic damage.

If the aspirated blood separates into a fat-fluid level after standing, an intra-articular fracture should be suspected because marrow fat may have entered the joint.

Imaging

Plain Radiographs

Radiographs are frequently useful when evaluating a joint effusion.

They can identify fractures, degenerative changes, erosions, osteophytes, joint-space narrowing, or other osseous abnormalities.

Imaging is particularly important when trauma is suspected or when the cause of the effusion is uncertain.

Crystal Analysis

Synovial fluid should be examined using polarized light microscopy when a crystal arthropathy is suspected.

Identification of characteristic crystals can distinguish gout from calcium pyrophosphate deposition disease.

Gout

Gout is caused by deposition of monosodium urate crystals within the joint.

Under standard microscopy, the crystals are typically needle-shaped.

With compensated polarized light microscopy, they demonstrate strong negative birefringence.

Identification of intracellular or extracellular urate crystals strongly supports the diagnosis of gout.

Pseudogout

Pseudogout, or calcium pyrophosphate deposition disease, is associated with calcium pyrophosphate crystals.

These crystals are generally shorter and more blunt or rhomboid in shape than monosodium urate crystals.

They characteristically demonstrate weak positive birefringence under compensated polarized light.

Septic Arthritis Findings

Synovial fluid from septic arthritis often contains a very high leukocyte count, frequently exceeding 50,000–100,000 cells/mm³, with a high percentage of polymorphonuclear leukocytes.

Gram staining may demonstrate the causative organism, although a negative Gram stain does not exclude infection.

Synovial fluid should therefore be sent for culture, particularly when clinical suspicion for infection is significant.

Overlap Between Infection and Inflammation

Synovial white cell counts should not be interpreted in isolation.

Severe inflammatory conditions, particularly gout and other crystalline arthropathies, may produce counts within ranges commonly associated with septic arthritis.

Conversely, infection may occasionally occur with lower cell counts, particularly in immunocompromised patients or during early disease.

Clinical findings, cultures, and other investigations remain essential.

Lyme Disease

In selected patients, molecular testing such as polymerase chain reaction or appropriate serologic testing may assist in evaluating suspected Lyme arthritis.

Testing should be guided by the clinical presentation and exposure history.

Differential Diagnosis

The major differential diagnoses for an acute joint effusion include septic arthritis, gout, pseudogout, autoimmune inflammatory disease, trauma, and hemophilia.

Autoimmune causes include conditions such as rheumatoid arthritis and systemic lupus erythematosus.

Clinical history and synovial fluid analysis help distinguish these conditions.

Treatment

General Measures

Treatment is directed toward the underlying cause of the effusion.

Arthrocentesis itself may provide immediate symptomatic benefit by reducing joint pressure and pain.

It may also improve the accuracy of the physical examination by allowing the joint to move more freely after a large effusion has been decompressed.

Traumatic Effusions

Patients with traumatic effusions should be treated according to the underlying injury.

Aspiration may provide pain relief when a large hemarthrosis is present.

The joint should subsequently be assessed for ligamentous injury, fracture, cartilage damage, or other structural abnormalities.

Septic Arthritis

Septic arthritis requires urgent treatment because infection can rapidly destroy articular cartilage.

Synovial fluid and blood cultures should be obtained before antibiotics whenever this can be done without causing harmful delay.

Treatment generally includes appropriate intravenous antibiotics together with adequate joint drainage.

Joint Irrigation and Debridement

Many cases of septic arthritis require operative irrigation and debridement.

The exact method depends on the joint involved, the severity of infection, the causative organism, and the patient’s clinical condition.

Drainage may be performed arthroscopically or through an open approach when necessary.

Inflammatory and Crystal Arthropathies

Patients with inflammatory or crystal-induced arthritis often improve with anti-inflammatory treatment after septic arthritis has been excluded.

Depending on the diagnosis, therapy may include NSAIDs, colchicine, corticosteroids, or disease-specific rheumatologic medications.

Referral to a rheumatologist may be appropriate for recurrent or systemic inflammatory disease.

Arthrocentesis Technique

A strict sterile skin preparation is essential before inserting the aspiration needle.

The joint and surrounding skin should be cleansed thoroughly, and sterile technique should be maintained throughout the procedure.

This is particularly important when aspirating a joint in which infection is already being considered.

Local Anesthesia

A small-gauge needle may be used to infiltrate local anesthetic into the skin and superficial tissues before aspiration.

This can reduce procedural discomfort, especially when a large aspiration needle is required or when more than one attempt may be necessary.

Needle Selection

Synovial fluid can be relatively viscous, particularly in certain inflammatory conditions.

A sufficiently large needle is therefore required for effective aspiration.

An 18-gauge needle or larger is commonly used for large joints such as the knee, although needle size should be adapted to the joint and clinical situation.

Knee Arthrocentesis

The knee is one of the easiest joints to aspirate because large effusions commonly distend the suprapatellar pouch.

A common approach is from the lateral side beneath or adjacent to the patella, directing the needle into the joint space.

A medial approach may also be used depending on clinician preference and the location of the effusion.

Image-Guided Arthrocentesis

Imaging guidance can improve accuracy for deeper or anatomically difficult joints.

Ultrasound is particularly useful because it allows real-time visualization of the effusion, needle, and surrounding structures.

Fluoroscopy or CT guidance may be useful for joints such as the hip or shoulder in selected circumstances.

Follow-Up

After aspiration, the patient should be reassessed for improvement in pain and range of motion.

The puncture site should be observed for bleeding, persistent drainage, or signs of infection.

Laboratory and culture results should be reviewed promptly, particularly when infection was part of the differential diagnosis.

Complications

The most important potential complication is iatrogenic infection of the joint.

Strict sterile technique is therefore mandatory.

Other potential complications include bleeding, pain, damage to nearby tendons or neurovascular structures, and failure to obtain adequate fluid.

Aspiration Through Cellulitis

Whenever possible, a joint should not be aspirated through an area of overlying cellulitis or infected skin.

Passing the needle through infected tissue may introduce bacteria into a previously sterile joint.

An alternative approach through uninvolved skin should be selected when feasible.

Special Consideration in Suspected Septic Arthritis

A potentially infected joint requires particularly careful technique.

Aspiration is nevertheless essential when septic arthritis is suspected because synovial fluid analysis and culture are often central to diagnosis.

The benefit of obtaining diagnostic fluid must therefore be balanced with meticulous sterile preparation and selection of a safe needle path.

Patient Monitoring

Patients should be monitored according to the underlying diagnosis rather than the aspiration alone.

Those with suspected infection require particularly close follow-up until cultures are finalized and clinical improvement is documented.

Patients with recurrent inflammatory or crystal arthropathies may require longer-term rheumatologic management, whereas traumatic effusions should be followed until the associated injury has healed.

Orthopaedic Surgery - Anterior Cruciate Ligament Injury

Basics

The anterior cruciate ligament (ACL) is essential for maintaining knee stability, particularly during athletic activities that involve running, cutting, pivoting, jumping, landing, and kicking.

The ACL originates from the posteromedial aspect of the lateral femoral condyle and inserts on the anterior portion of the tibial plateau between the intercondylar eminences.

It consists of two principal functional bundles: the anteromedial bundle and the posterolateral bundle.

The ACL is the primary restraint to anterior translation of the tibia relative to the femur and also acts as an important secondary restraint to excessive internal rotation of the tibia.

Injury Pattern by Age

The pattern of ACL injury differs between skeletally immature and mature patients.

In children and adolescents with open growth plates, the ligament itself may remain intact while the injury occurs at the bone-ligament interface. This can produce an avulsion fracture of the tibial spine, where the ACL attachment is pulled away with a fragment of bone.

In skeletally mature adults, injury more commonly produces a midsubstance rupture of the ACL.

Epidemiology

ACL injuries are strongly associated with sports that involve rapid changes in direction, deceleration, jumping, landing, or direct contact.

Commonly associated activities include football, hockey, basketball, lacrosse, gymnastics, wrestling, and volleyball.

ACL injuries occur in both contact and noncontact situations, although many occur without direct impact to the knee.

Risk Factors

Female athletes participating in comparable competitive sports have an ACL injury rate approximately 4–6 times higher than male athletes.

The difference is likely multifactorial and may involve anatomical, hormonal, biomechanical, and neuromuscular factors.

Etiology

Several anatomical features have been associated with increased susceptibility to ACL injury.

These include an increased Q angle, narrowing of the femoral intercondylar notch, and a relatively narrow ACL.

Neuromuscular factors are also important. Landing with inadequate knee flexion together with excessive dynamic knee valgus can substantially increase strain on the ACL.

Noncontact Mechanism

Many ACL tears occur through a noncontact mechanism.

A typical injury occurs when an athlete rapidly decelerates, plants the foot, changes direction, pivots, or lands from a jump.

The foot remains fixed while abnormal rotational and translational forces are transmitted across the knee, producing ACL failure.

Contact Mechanism

ACL rupture may also result from direct trauma.

A classic contact mechanism involves a valgus force applied to the knee combined with external rotation of the tibia, such as a clipping injury during contact sport.

This mechanism may also damage other structures, particularly the medial collateral ligament.

Associated Bone Bruising

Bone bruises or trabecular microfractures occur in more than half of acute ACL injuries.

They are typically found on the posterior aspect of the lateral tibial plateau and near the sulcus terminalis of the lateral femoral condyle.

These opposing contusions are sometimes described as a “kissing contusion” pattern.

They are believed to occur when the posterolateral tibial plateau impacts against the lateral femoral condyle during the injury mechanism that ruptures the ACL.

Meniscal Injuries

Meniscal tears accompany more than half of ACL injuries.

During the acute injury, lateral meniscal tears are generally more common than medial meniscal tears.

In a chronically ACL-deficient knee, repeated episodes of instability place greater stress on the medial meniscus. Consequently, medial meniscal tears become more common in chronic ACL deficiency.

Other Associated Injuries

ACL rupture may occur together with other ligamentous injuries.

The medial collateral ligament (MCL) is more frequently injured than the lateral collateral ligament.

Articular cartilage damage may also occur either at the time of the original injury or later as a consequence of recurrent instability.

Diagnosis

Signs and Symptoms

Patients commonly describe immediate knee pain at the time of injury.

Many report hearing or feeling an audible “pop” within the knee.

Rapid swelling usually develops within several hours because of acute hemarthrosis.

The patient often feels that the knee is unstable and may be unable to continue participating in the activity.

Weight-bearing may initially be painful or difficult.

History

The mechanism of injury should be carefully established.

Important historical features include sudden deceleration, pivoting, landing from a jump, a contact valgus injury, or twisting of the knee while the foot was planted.

The presence of a pop, rapid swelling, immediate instability, and inability to continue sporting activity strongly raises suspicion for ACL rupture.

Physical Examination

A careful physical examination can diagnose the majority of ACL injuries.

Findings in the injured knee should always be compared with those of the contralateral normal knee because baseline ligamentous laxity varies between individuals.

Knee Effusion

Inspection commonly reveals a moderate or large knee effusion.

Effusion can be assessed by compressing fluid from the suprapatellar pouch toward the joint while palpating for increased fluid pressure around the knee.

Patellar ballottement may also help identify a significant intra-articular effusion.

Range of Motion

Full knee extension is commonly limited during the acute stage.

This may result from pain, joint effusion, protective hamstring spasm, or mechanical impingement from the torn ACL stump.

Flexion may also be restricted because of swelling and discomfort.

Restoring full extension is particularly important during rehabilitation.

Posterior Sag Consideration

When assessing anterior tibial translation, the examiner should first ensure that the tibia is not sitting abnormally posteriorly because of an associated posterior cruciate ligament injury.

If posterior sag is present, anterior translation during testing may simply return the tibia to a neutral position and falsely suggest excessive anterior laxity.

Lachman Test

The Lachman test is the most sensitive clinical examination for diagnosing an acute ACL tear.

The knee is positioned in approximately 30° of flexion.

The examiner stabilizes the distal femur and applies an anteriorly directed force to the proximal tibia or calf.

The amount of anterior translation and the quality of the endpoint are assessed.

Lachman Test Interpretation

An intact ACL normally produces a firm endpoint.

An ACL-deficient knee generally demonstrates increased anterior tibial translation together with a soft or poorly defined endpoint.

The difference between the injured and uninjured knees is clinically important.

Guarding During Lachman Testing

The Lachman test can be difficult to perform in the acute setting because pain and anxiety may cause involuntary hamstring contraction.

The examiner should support the leg fully, minimize discomfort, and encourage the patient to relax.

Reducing muscle spasm improves the accuracy of the examination.

Pivot Shift Test

The pivot shift test assesses dynamic anterolateral rotational instability of the ACL-deficient knee.

It evaluates anterior subluxation of the lateral tibial plateau relative to the lateral femoral condyle.

The test can be difficult to perform reliably in an awake patient with an acutely painful knee because guarding interferes with the maneuver.

It is often more informative when performed under anesthesia.

Pivot Shift Technique

The patient lies supine with the knee initially extended.

The tibia is placed in internal rotation while the examiner applies a valgus force to the knee as it is slowly flexed.

In an ACL-deficient knee, the lateral tibial plateau begins in an anteriorly subluxated position.

At approximately 20–40° of knee flexion, the iliotibial band causes sudden reduction of the tibia.

A palpable or visible jerk during this reduction constitutes a positive pivot shift.

Anterior Drawer Test

The anterior drawer test is less reliable than the Lachman test for diagnosing an acute ACL injury.

The patient is positioned with the hip flexed to approximately 45° and the knee flexed to 90°.

The examiner grasps the proximal tibia and applies an anteriorly directed force.

The amount of anterior translation and the firmness of the endpoint are assessed and compared with the opposite knee.

Instrumented Laxity Testing

Objective knee laxity can be measured with devices such as the KT-1000 arthrometer.

These devices quantify anterior tibial translation and are useful in research, postoperative assessment, or when objective documentation is required.

They are not necessary for routine diagnosis in most patients.

A side-to-side difference of more than approximately 3 mm in anterior tibial translation is considered abnormal.

Imaging

Plain Radiographs

Initial radiographic evaluation generally includes anteroposterior, lateral, and tunnel views of the knee.

Plain radiographs do not directly demonstrate the ACL but may reveal associated osseous abnormalities that strongly suggest ACL injury.

Tibial Spine Avulsion

A tibial spine avulsion fracture may be seen in skeletally immature patients.

This represents avulsion of the ACL attachment from the tibial eminence rather than midsubstance rupture of the ligament.

The amount of displacement is important in determining treatment.

Segond Fracture

A Segond fracture is a small avulsion fracture involving the lateral aspect of the proximal tibia.

It is strongly associated with ACL rupture and represents injury around the anterolateral capsular or ligamentous structures.

Identification of a Segond fracture should prompt careful evaluation for an ACL injury.

Other Radiographic Findings

Additional radiographic findings suggestive of ACL injury include avulsion involving the anterolateral ligament and deepening of the lateral femoral sulcus or sulcus terminalis.

These findings reflect the mechanism of impaction and rotational instability associated with ACL rupture.

MRI

MRI is the imaging modality of choice for evaluating the ACL and associated intra-articular injuries.

It can demonstrate the ligament directly and assess accompanying bone bruises, meniscal tears, collateral ligament injuries, cartilage damage, and occult fractures.

MRI has an overall diagnostic accuracy of approximately 95% for ACL injury.

MRI in Children

MRI is also highly effective in pediatric patients.

Reported sensitivity is approximately 96%, with specificity around 97% for diagnosing ACL injuries in children.

It is particularly useful for distinguishing a midsubstance ACL injury from tibial spine avulsion or associated meniscal pathology.

MRI Appearance of ACL Tear

On sagittal MRI, an intact ACL normally appears as a continuous low-signal structure extending from the femur to the tibia.

A tear may appear as discontinuity, abnormal orientation, waviness, or increased signal within the ligament.

Associated bone marrow edema often provides additional evidence of the injury mechanism.

Differential Diagnosis

Important differential diagnoses include osteochondral fracture, osteochondritis dissecans, tibial plateau fracture, meniscal injury, and articular cartilage injury.

Other ligamentous injuries that may mimic or accompany ACL rupture include injuries of the MCL, LCL, and PCL.

Initial Stabilization

During the acute period, the injured knee may be supported temporarily with a splint or knee immobilizer.

Crutches can be used for comfort and to reduce painful weight-bearing.

Prolonged immobilization should generally be avoided because early restoration of motion is important.

The primary early rehabilitation goal is to regain full knee range of motion, particularly full extension.

Acute Symptom Control

Ice and elevation help reduce swelling.

Simple analgesics or anti-inflammatory medication may be used for pain control.

Once tolerated, early active knee motion should be encouraged to prevent stiffness.

General Treatment Principles

Treatment decisions are individualized according to several factors.

Important considerations include patient age, activity level, occupational demands, sporting participation, degree of instability, skeletal maturity, and associated meniscal or cartilage pathology.

Activities involving cutting, pivoting, jumping, and rapid directional change place particularly high demands on ACL stability.

Treatment in Skeletally Mature Patients

Treatment options include structured nonoperative rehabilitation or ACL reconstruction.

Nonoperative treatment may be appropriate for older individuals, relatively sedentary patients, or those who can modify their activities and do not experience significant instability.

Reconstruction is more commonly considered in young or active patients who wish to return to pivoting or cutting sports.

Treatment in Skeletally Immature Patients

Management of ACL tears in children requires consideration of the open growth plates.

Historically, some children were treated nonoperatively until skeletal maturity.

However, prolonged instability may contribute to progressive meniscal and articular cartilage injury.

As a result, contemporary treatment increasingly favors carefully selected surgical reconstruction using techniques designed to minimize damage to the physes.

Tibial Spine Avulsion Treatment

Nondisplaced or minimally displaced tibial spine avulsion fractures in skeletally immature patients can often be managed with closed reduction and immobilization with the knee in extension.

More significantly displaced fractures may require operative reduction and fixation to restore ACL tension and joint congruity.

Activity Modification

Patients should be counseled regarding activities that place high rotational loads on the knee.

Sports requiring cutting, pivoting, sudden deceleration, jumping, and landing are particularly likely to produce recurrent instability in an ACL-deficient knee.

Activity modification may be sufficient for some patients treated nonoperatively.

Functional Bracing

The benefit of routine functional knee bracing after ACL injury or reconstruction remains controversial.

Braces may improve confidence in selected patients but do not reliably substitute for normal ligament function, neuromuscular control, or rehabilitation.

Physical Therapy

Rehabilitation is important whether the ACL injury is treated nonoperatively or surgically.

The program should emphasize early restoration of range of motion, particularly full extension, together with early appropriate weight-bearing.

Progressive strengthening is then introduced.

Strengthening

Closed-chain, weight-bearing exercises are commonly used to strengthen the quadriceps and hamstrings while limiting excessive anterior shear across the knee.

The goal is to restore quadriceps and hamstring function to at least approximately 90% of the strength of the opposite limb before unrestricted return to high-level activity.

Preoperative Rehabilitation

Patients selected for ACL reconstruction should ideally regain full knee range of motion and substantially reduce swelling before surgery.

Operating on a stiff, swollen knee increases the risk of postoperative stiffness and arthrofibrosis.

Reconstruction outcomes are generally better when full or near-full motion has been restored before surgery.

Postoperative Rehabilitation

After reconstruction, rehabilitation focuses on restoring motion, strength, proprioception, balance, and neuromuscular control.

Agility and progressive strengthening exercises are commonly introduced around 6 weeks after surgery, although exact timing depends on the reconstruction technique and rehabilitation protocol.

Later stages include running, jumping, cutting, and sport-specific drills.

Medication

During the acute period, pain may be treated with NSAIDs or acetaminophen.

Routine opioid analgesics are generally avoided when symptoms can be adequately controlled with simpler medications.

Surgical Indications

ACL reconstruction is commonly recommended for active individuals who experience functional instability after an acute tear.

It is also indicated in patients with chronic ACL deficiency when recurrent instability threatens the menisci and articular cartilage.

Associated repairable meniscal injury may strengthen the indication for stabilization.

ACL Reconstruction

Modern ACL surgery usually involves intra-articular ligament reconstruction rather than primary repair of a midsubstance tear.

The torn ACL is replaced with a tendon graft positioned to reproduce the function of the native ligament.

Reconstruction may be performed arthroscopically or with combined open techniques when required.

Graft Selection

Graft choice depends on patient age, activity demands, anatomy, surgeon experience, and individual preference.

Both autografts and allografts can be used.

Autograft Options

Common autograft choices include bone-patellar tendon-bone graft, four-strand hamstring tendon graft, and quadriceps tendon graft.

Each has specific advantages and potential donor-site complications.

Autografts are frequently preferred in young and highly active patients.

Allograft Options

Allograft tissue may be obtained from structures including the Achilles tendon, quadriceps tendon, patellar tendon, hamstring tendons, anterior or posterior tibialis tendons, and fascia lata.

An advantage is avoidance of autograft harvest and therefore less donor-site morbidity.

Historically, concerns have included disease transmission and altered graft incorporation, although tissue-processing techniques have greatly reduced transmission risk.

Graft Choice in Young Patients

In children, adolescents, and young active adults, current practice generally favors autograft reconstruction.

Allograft reconstruction in younger patients has been associated with a higher risk of graft failure compared with autograft.

Primary ACL Repair

Primary repair is not generally recommended for a typical adult midsubstance ACL rupture.

However, operative reduction and repair or fixation may be appropriate for a displaced tibial spine avulsion fracture because the ligament itself may remain structurally intact.

Reconstruction in Skeletally Immature Patients

The operative technique in children depends on skeletal maturity.

The goal is to restore knee stability while minimizing the risk of growth-plate injury.

Tanner Stage 1

Patients at Tanner stage 1 have substantial growth remaining.

Physeal-sparing reconstruction techniques are generally preferred to avoid crossing the open growth plates.

Tanner Stage 2

Patients at Tanner stage 2 may be treated with selected partial transphyseal techniques depending on skeletal maturity, growth remaining, and surgeon preference.

Care is taken to minimize the amount of physeal injury.

Tanner Stage 3 and Above

Patients approaching skeletal maturity, typically Tanner stage 3 or higher, may undergo more conventional complete transphyseal ACL reconstruction.

The potential risk to the growth plates becomes lower as skeletal maturity approaches.

Follow-Up

Patients should be followed regularly during rehabilitation to assess swelling, range of motion, knee stability, quadriceps and hamstring strength, and progression of functional activity.

Follow-up is particularly important during the early rehabilitation period to identify patients developing stiffness or muscle weakness.

Prognosis

The prognosis after appropriately selected and well-performed ACL reconstruction is generally excellent.

Most patients regain good stability and are able to return to a high level of function.

However, return to sport depends on successful rehabilitation, restoration of strength and neuromuscular control, associated injuries, and psychological readiness.

Consequences of Chronic ACL Deficiency

An untreated ACL-deficient knee may experience repeated episodes of instability.

Over time, this can increase the risk of meniscal tears and articular cartilage damage.

Development of later symptomatic osteoarthritis may also occur, although the relationship between ACL reconstruction and prevention of osteoarthritis remains complex.

Contralateral ACL Injury

Patients who have sustained one ACL tear have an increased risk of subsequently tearing the ACL in the opposite knee.

This risk is particularly important in younger and highly active athletes.

Neuromuscular training and appropriate return-to-sport criteria are therefore important for both knees.

Recurrent ACL Tear

Graft rupture or recurrent ACL injury can occur after reconstruction.

Higher reinjury rates have been reported among athletes involved in high-demand pivoting sports, including football, gymnastics, and soccer.

Young athletes returning to sport at a high competitive level are particularly vulnerable.

Complications of Nonoperative Treatment

Chronic ACL deficiency is associated with an increased risk of complex meniscal injury.

Repeated instability can progressively damage both the menisci and articular cartilage.

There may also be an increased risk of later osteoarthritis, although the degree to which reconstruction prevents this remains controversial.

Surgical Complications

Potential complications after ACL reconstruction include graft failure, graft impingement, quadriceps weakness, patellofemoral pain, infection, and arthrofibrosis.

Rare complications include deep vein thrombosis, nerve injury, vascular injury, compartment syndrome related to arthroscopic fluid extravasation, and complex regional pain syndrome.

Arthrofibrosis

Arthrofibrosis can produce substantial postoperative stiffness, particularly loss of knee extension.

The risk is increased when surgery is performed on a knee that remains swollen and stiff.

Preoperative restoration of motion and careful postoperative rehabilitation are therefore important preventive measures.

Bone-Patellar Tendon-Bone Graft Complications

Harvesting a bone-patellar tendon-bone autograft may result in anterior knee pain or discomfort while kneeling.

Rare complications include patellar fracture and patellar tendon rupture.

Graft selection should therefore consider the patient’s sporting, occupational, and kneeling requirements.

Patient Monitoring

Patients should generally be reassessed at approximately 4–6-week intervals during important phases of recovery.

Monitoring should focus on restoration of knee extension and flexion, quadriceps and hamstring strength, swelling, stability, gait, and functional progression.

Patients who fall behind expected milestones may require more intensive physical therapy to prevent persistent weakness or stiffness.

Orthopaedic Surgery - Ankylosing Spondylitis

Basics

Ankylosing spondylitis (AS) is a seronegative spondyloarthritis characterized by chronic inflammation affecting the axial skeleton and, to a lesser extent, peripheral joints.

The disease primarily involves the spine and sacroiliac (SI) joints, although the hips and shoulders may also be affected. Any level of the spine can become involved as the disease progresses.

AS affects both synovial and fibrous joints. Persistent inflammation can produce chronic synovitis, erosions, sclerosis, fibrosis, and ultimately ankylosis, resulting in progressive loss of joint and spinal mobility.

Extra-articular manifestations may involve the eyes, cardiovascular system, lungs, skin, and mucous membranes.

Epidemiology

Ankylosing spondylitis most commonly becomes symptomatic in young adults, particularly during the third and fourth decades of life.

The disease has traditionally been recognized more frequently and often more severely in males, although both males and females can be affected.

Initial manifestations developing after the age of approximately 40 years are relatively uncommon.

The precise cause remains unknown, but there is a strong association with genes of the major histocompatibility complex, particularly HLA-B27.

Incidence

The reported frequency of ankylosing spondylitis in North America is approximately 0.1–0.3% of the population.

The likelihood of disease is substantially increased among individuals carrying the HLA-B27 gene.

However, genetic susceptibility alone is insufficient to cause disease, and the majority of HLA-B27-positive individuals never develop ankylosing spondylitis.

First-degree relatives of affected patients also have a significantly increased risk compared with the general population.

Prevalence and HLA-B27

Although ankylosing spondylitis is strongly associated with HLA-B27, fewer than approximately 5% of individuals carrying the gene ultimately develop the disease.

Therefore, the presence of HLA-B27 supports the diagnosis in the appropriate clinical setting but does not by itself establish the diagnosis.

Risk Factors

The principal recognized risk factors are HLA-B27 positivity and a positive family history of ankylosing spondylitis or related spondyloarthritis.

An earlier age of onset is often associated with a more severe disease course.

Genetics

Ankylosing spondylitis has a strong hereditary component.

The concordance rate is substantially higher in identical twins than in fraternal twins, supporting an important genetic contribution.

The strongest association is with HLA-B27, although other major histocompatibility complex genes, including HLA-DRB1 and HLA-B60, have also been implicated.

Additional genetic associations have been reported involving genes such as CYP2D6 and IL-1B.

Despite this strong genetic contribution, environmental and immune factors are also believed to influence whether disease develops.

Pathophysiology

Ankylosing spondylitis is a chronic inflammatory arthropathy that characteristically involves the sacroiliac joints, often bilaterally.

Both synovial and fibrous joints of the axial and peripheral skeleton may become inflamed.

Inflammation can also occur at the sites where tendons and ligaments attach to bone, known as entheses.

Persistent inflammation leads to erosion and structural damage, followed by fibrosis and new bone formation. Over time, this may result in progressive ankylosis of the affected joints and spine.

Disease Course

The onset is usually gradual and insidious.

Patients commonly experience periods of worsening symptoms followed by partial improvement or remission.

Although both sexes are affected, disease has historically been observed to be more severe in males.

Earlier onset is also associated with a greater likelihood of significant structural and functional impairment.

Etiology

The exact cause of ankylosing spondylitis remains unknown.

Genetic susceptibility appears to interact with immune and environmental factors.

Various infectious triggers have been investigated. Klebsiella species have been proposed as a possible contributor, although studies have not established a definitive causal relationship.

There is also evidence of an association between ankylosing spondylitis and inflammation of the small intestine, supporting a possible relationship between intestinal immune responses and axial inflammation.

Associated Conditions

Enthesopathy is common and may present as plantar fasciitis or Achilles tendinitis.

Extra-articular manifestations include acute anterior uveitis and cardiovascular abnormalities such as aortic insufficiency, cardiomegaly, and cardiac conduction disturbances.

Pulmonary abnormalities may develop in advanced disease.

Diagnosis

Signs and Symptoms

Diagnosis is based on the combination of clinical features and imaging findings.

Typical symptoms usually persist for at least 3 months and are characteristic of inflammatory rather than mechanical back pain.

Pain and stiffness generally improve with exercise and do not improve significantly with rest.

Morning stiffness is common and may be prolonged.

Common Clinical Features

Patients may develop progressive restriction of spinal movement, fatigue, and reduced chest expansion.

Weight loss can occur in patients with active systemic inflammation.

Inflammation of the costosternal or costovertebral joints may cause chest discomfort.

Progressive disease can lead to thoracic kyphosis and loss of the normal lumbar lordosis.

Upper-extremity peripheral joint involvement is less common than involvement of the hips and lower limbs.

Pulmonary Manifestations

Advanced disease may be associated with apical pulmonary fibrosis.

Restricted mobility of the costovertebral and costosternal joints can also reduce chest expansion and contribute to restrictive respiratory mechanics.

History

The history often reveals a gradual onset of discomfort involving the lumbosacral spine, buttocks, or hips.

Symptoms commonly begin before the age of 40 years and persist for longer than three months.

A characteristic feature is morning stiffness that improves with physical activity.

Pain frequently improves during exercise but returns after prolonged inactivity.

Physical Examination

Patients may have relatively few abnormal findings early in the disease.

A comprehensive examination should include the musculoskeletal, neurologic, pulmonary, and ocular systems.

Careful assessment of spinal posture and mobility is essential.

Lumbar Spine Examination

Reduced lumbar flexion and extension are common as the disease progresses.

Loss of normal lumbar movement may be subtle initially but becomes more evident with increasing structural involvement.

Spinal stiffness should be compared with age-appropriate expectations.

Sacroiliac Joint Examination

Tenderness may be present over the SI joints.

Provocative maneuvers that stress the sacroiliac region may reproduce the patient’s typical buttock or low-back pain.

However, physical examination alone is not sufficiently specific to confirm sacroiliitis.

Chest Expansion

Chest expansion should be assessed because involvement of the costovertebral and costosternal joints may progressively restrict thoracic excursion.

Decreased expansion can contribute to reduced pulmonary function in advanced disease.

Neurologic Examination

A complete neurologic examination is important, particularly in patients with advanced spinal deformity or suspected fracture.

Any new weakness, numbness, gait disturbance, or bowel or bladder abnormality requires urgent evaluation.

Ocular Examination

Patients should be questioned about eye pain, redness, photophobia, and visual disturbance because these symptoms may indicate acute anterior uveitis.

Recurrent uveitis is a well-recognized extra-articular manifestation of ankylosing spondylitis.

Laboratory Tests

HLA-B27

Testing for HLA-B27 can support the diagnosis in a patient with compatible clinical findings.

However, because many healthy individuals carry the gene without developing disease, it should not be interpreted in isolation.

Inflammatory Markers

The erythrocyte sedimentation rate (ESR) may be elevated and can reflect inflammatory activity.

Other inflammatory markers such as C-reactive protein may also be elevated.

However, normal inflammatory markers do not exclude ankylosing spondylitis.

Rheumatoid and Antinuclear Antibodies

Rheumatoid factor and antinuclear antibodies are generally not useful for diagnosing ankylosing spondylitis.

The condition is classified as a seronegative spondyloarthritis, meaning rheumatoid factor is typically absent.

Imaging

Plain Radiographs

Radiographs may remain normal during the early stages of disease.

As ankylosing spondylitis progresses, characteristic abnormalities develop, particularly around the sacroiliac joints.

Sacroiliac Joint Findings

Radiographic changes of the SI joints are central to the diagnosis of established ankylosing spondylitis.

Changes are typically bilateral and relatively symmetric.

Early abnormalities include erosions and subchondral sclerosis, producing irregular or poorly defined joint margins.

Apparent widening of the SI joint may occur because erosions create a pseudo-widened appearance.

Late Sacroiliac Changes

With progression, fibrosis and new bone formation lead to narrowing and eventually complete osseous bridging or ankylosis of the SI joints.

These findings indicate advanced structural disease.

Spinal Radiographic Findings

Inflammation at the vertebral margins and outer annulus fibrosus leads to erosive changes followed by new bone formation.

Bridging syndesmophytes may progressively connect adjacent vertebral bodies.

When extensive, this produces the characteristic radiographic appearance known as a “bamboo spine.”

Bamboo Spine

The bamboo-spine appearance results from progressive ossification and syndesmophyte formation across multiple vertebral levels.

The spine becomes increasingly rigid and behaves biomechanically more like a long bone than a flexible segmented column.

This rigidity substantially increases the risk of unstable spinal fractures.

Imaging for Suspected Fracture

Fractures in ankylosed spines can be difficult to identify on standard radiographs.

Anteroposterior, lateral, and appropriate additional views should be examined carefully.

When fracture is suspected, CT with multiplanar or 3D reconstruction is highly useful because it is more sensitive for detecting fracture lines and defining their extent.

MRI

MRI is particularly valuable when neurologic symptoms are present or when an occult fracture or soft-tissue complication is suspected.

It can identify epidural hematoma, spinal cord compression, ligamentous injury, and other neural abnormalities.

MRI is also useful for detecting active inflammatory sacroiliitis before structural radiographic changes become obvious.

Differential Diagnosis

The differential diagnosis includes other seronegative spondyloarthropathies.

Important conditions include reactive arthritis, psoriatic arthritis, and inflammatory bowel disease-associated arthritis related to Crohn disease or ulcerative colitis.

Additional Differential Diagnoses

Other conditions that may resemble ankylosing spondylitis include septic sacroiliitis, osteoarthritis, rheumatoid arthritis, and lumbar disc herniation.

Clinical history, imaging findings, laboratory studies, and the distribution of joint involvement help distinguish these disorders.

Treatment

Initial Management

The foundation of treatment is regular exercise and maintenance of spinal mobility.

Back exercises and flexibility training help reduce pain, maintain function, and limit progressive loss of motion.

Exercise should begin early and continue throughout the course of the disease.

General Measures

Patients should be encouraged to maintain an active and healthy lifestyle whenever possible.

Regular recreational activity helps preserve cardiovascular fitness, muscle strength, posture, and spinal mobility.

Prolonged inactivity should be avoided because stiffness often worsens when movement is reduced.

Posture

Postural training is important because progressive ankylosis may fix the spine in a kyphotic position.

Patients should be encouraged to maintain an upright posture during daily activities and sleep.

Appropriate exercises can help preserve extension and limit progressive flexion deformity.

Physical Therapy

Physical therapy is a central component of management.

Programs should focus on spinal flexibility, posture, chest expansion, strengthening, and maintenance of functional mobility.

Hyperextension exercises may help reduce the tendency toward progressive thoracic kyphosis.

Flexibility Training

Regular stretching and mobility exercises can decrease stiffness and improve functional ability.

Consistent flexibility training may also improve quality of life by helping patients maintain independence and activity.

Medication

First-Line Therapy

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used as first-line pharmacologic treatment.

They can reduce pain and stiffness and improve function.

Selection is largely based on patient response and tolerance because no single NSAID, including selective COX-2 inhibitors, has consistently demonstrated clear superiority.

Additional Medical Therapy

Other medications may be considered when symptoms remain inadequately controlled.

Historically, agents such as corticosteroids and sulfasalazine have been used in selected cases, particularly when peripheral joint disease is present.

Systemic corticosteroids are generally not preferred for routine long-term axial disease because of their adverse-effect profile.

Biologic Therapy

Biologic agents that inhibit tumor necrosis factor-alpha (TNF-α) can substantially reduce disease activity in patients with persistent active disease despite conventional treatment.

These medications have become an important treatment option for moderate-to-severe ankylosing spondylitis.

Other targeted biologic therapies may also be used depending on disease characteristics and response.

Other Therapies

A variety of additional agents, including older treatments such as pamidronate and thalidomide, have been investigated.

These are not generally considered routine first-line therapies.

Antibiotics are not routinely indicated because no infectious organism has been established as the direct cause of ankylosing spondylitis.

Surgical Management

Surgery does not treat the underlying inflammatory disease itself.

Instead, surgery is used primarily to manage structural complications that develop as a consequence of long-standing disease.

Total Hip Arthroplasty

Severe hip involvement may lead to painful stiffness and major functional impairment.

Total hip arthroplasty is one of the most commonly performed orthopedic procedures in patients with advanced ankylosing spondylitis.

It can significantly improve pain, mobility, and quality of life.

Spinal Fracture Stabilization

Fractures of an ankylosed spine are often highly unstable.

Because the rigid spine behaves like a long lever arm, even apparently minor fractures may extend through all spinal columns.

Operative stabilization is frequently required to prevent displacement and neurologic deterioration.

Corrective Spinal Osteotomy

Advanced ankylosing spondylitis may produce severe fixed kyphotic deformity.

When deformity markedly limits forward vision, standing balance, or daily function, a corrective spinal osteotomy may be considered.

These procedures are complex and require careful preoperative planning.

Follow-Up

Patients require regular long-term follow-up to assess disease activity, posture, spinal mobility, neurologic function, and extra-articular complications.

Ongoing review also provides an opportunity to reinforce exercise and postural programs and adjust pain medication.

Prognosis

The disease course varies considerably among patients.

Individuals with early-onset disease and prominent peripheral joint inflammation may experience a more severe clinical course.

There is no definitive cure, but modern medical treatment, exercise, and prevention of complications can substantially reduce disability.

Spinal Fracture Risk

One of the most serious complications is spinal fracture after relatively minor trauma.

The ankylosed spine is rigid and brittle and cannot absorb energy in the same way as a normal flexible spine.

As a result, fractures may occur after falls or trauma that would otherwise be considered minor.

Neurologic Complications

Spinal fractures may displace and injure the spinal cord or nerve roots.

Delayed neurologic deterioration can occur if an initially unrecognized fracture subsequently shifts.

Any suspected fracture should therefore be treated as potentially unstable until adequately evaluated.

Epidural Hematoma

Cervical spinal fractures may be associated with an epidural hematoma.

The hematoma can compress the spinal cord and produce rapidly progressive neurologic impairment.

MRI is particularly useful for identifying this complication.

Failure to recognize spinal cord compression may result in permanent paralysis.

Management of Spinal Fractures

Spinal fractures in ankylosing spondylitis require urgent stabilization.

Treatment may involve external immobilization or internal fixation depending on fracture configuration, alignment, neurologic status, and patient factors.

Because these fractures are frequently unstable, surgical fixation is often required.

Uveitis

Acute anterior uveitis develops in a significant proportion of patients, historically reported in approximately 25%.

Symptoms include painful red eye, photophobia, and visual disturbance.

Prompt ophthalmologic assessment is important, and treatment may include topical corticosteroids and other ophthalmic therapies.

Cardiovascular Complications

Potential cardiovascular manifestations include aortic regurgitation, cardiac enlargement, and abnormalities of the cardiac conduction system.

Patients with suggestive symptoms should undergo appropriate cardiovascular evaluation.

Pulmonary Complications

Restrictive respiratory impairment may develop because of reduced chest wall mobility.

Rarely, advanced disease may be associated with upper-lobe pulmonary fibrosis.

Respiratory symptoms should therefore be assessed during long-term follow-up.

Patient Monitoring

Patients should undergo regular review, commonly around every 6 months, although the interval should be individualized according to disease activity.

Monitoring should include posture, spinal mobility, exercise adherence, pain control, and neurologic function.

Patients should also be assessed for extra-articular complications, particularly uveitis and cardiovascular or pulmonary abnormalities.

Early recognition and treatment of complications can substantially reduce long-term morbidity.

Orthopaedic Surgery - Ankle Sprain

Basics

An acute lateral ankle sprain is one of the most common injuries in sport and is also frequently encountered in the general population.

The injury usually involves the lateral ligament complex of the ankle. The anterior talofibular ligament (ATFL) is affected most often, either as a partial tear or complete rupture. More severe injuries may additionally involve the calcaneofibular ligament (CFL).

Most lateral ankle sprains occur through an inversion mechanism, often while the ankle is plantarflexed.

Classification

Lateral ankle sprains are commonly classified according to the degree of ligament injury.

Grade I injuries involve a partial tear or stretching of the lateral ligaments without major mechanical instability.

Grade II injuries involve a partial or complete tear of the ATFL together with partial injury of the CFL.

Grade III injuries represent complete rupture of both the ATFL and CFL and are generally associated with greater swelling, bruising, pain, and instability.

Sequence of Ligament Injury

As the severity of an inversion injury increases, the lateral stabilizing structures tend to fail in sequence.

The anterolateral joint capsule is generally injured first, followed by the ATFL.

With greater force, the injury may progress to involve the CFL.

This sequence explains why isolated ATFL injuries are more common than combined ATFL and CFL tears.

Anterior Talofibular Ligament

The ATFL is the most frequently injured ligament of the ankle.

It is the principal restraint to inversion when the ankle is in a plantarflexed position.

The ligament is particularly vulnerable when the foot is subjected to a combination of inversion, plantarflexion, and internal rotation.

Because many ankle sprains occur in this position, ATFL injury is extremely common.

Calcaneofibular Ligament

The CFL contributes to stability of both the ankle and subtalar joints.

It becomes particularly important in resisting inversion when the ankle is in a neutral or dorsiflexed position.

CFL injury therefore tends to occur when inversion forces are applied while the ankle is less plantarflexed.

Involvement of the CFL usually indicates a more severe sprain.

Dynamic Stabilizers

The peroneal muscles and tendons are the primary dynamic stabilizers resisting ankle inversion.

Rapid contraction of the peroneal muscles can help prevent excessive inversion and protect the lateral ligament complex.

Weakness, fatigue, or delayed neuromuscular response of the peroneals may increase the risk of recurrent sprains.

Epidemiology

Ankle sprains are among the most common musculoskeletal injuries.

In the United States, approximately 27,000 ankle sprains occur each day.

They are considered the most frequent athletic injury and occur particularly often in activities involving running, jumping, landing, and rapid changes in direction.

Risk Factors

Athletes are at increased risk because of repetitive loading and frequent changes in direction.

Dancers are also vulnerable because of repeated extreme ankle positions and balance demands.

Structural abnormalities such as congenital tarsal coalition may alter hindfoot mechanics and predispose to recurrent sprains.

A varus hindfoot alignment also increases the tendency for the ankle to invert and may contribute to repeated injury.

Etiology

The usual mechanism is inversion of the foot while body weight is transmitted through the ankle.

The degree of plantarflexion at the time of injury influences which ligament is most likely to be damaged.

Inversion in plantarflexion primarily stresses the ATFL, whereas inversion with the ankle closer to neutral or dorsiflexion places greater stress on the CFL.

Diagnosis

Signs and Symptoms

Patients commonly present with pain, tenderness, and swelling over the lateral aspect of the ankle.

Bruising may develop over the lateral malleolus and surrounding soft tissues.

Weight-bearing may be painful, and patients with more severe sprains may initially have considerable difficulty walking.

History

The mechanism of injury should be carefully established.

An inversion injury occurring with the ankle in plantarflexion is more suggestive of ATFL injury.

Inversion occurring with the ankle in dorsiflexion or near-neutral position places greater stress on the CFL.

The history should also determine whether the patient heard or felt a pop, was able to continue activity, and has sustained previous ankle sprains.

Physical Examination

Tenderness and swelling are usually localized to the lateral aspect of the ankle, particularly anterior and inferior to the tip of the lateral malleolus.

The degree of swelling and bruising should be documented.

The entire ankle and foot should be examined to ensure that an associated fracture or other injury is not overlooked.

Muscle Strength

Manual strength testing should include the major muscle groups acting across the ankle.

Particular attention should be given to the peroneal muscles and tendons, because they provide important dynamic resistance to inversion.

Pain, weakness, or loss of function may indicate associated tendon injury.

Neurovascular Examination

A complete neurovascular examination should be performed.

The superficial peroneal nerve can occasionally sustain a traction or stretching injury during an inversion sprain.

Sensation over the dorsum of the foot, motor function, pulses, and capillary refill should therefore be assessed.

Assessment of Ligament Stability

Mechanical stability should be evaluated once pain and swelling permit.

The injured ankle should always be compared with the contralateral side because a certain degree of physiologic laxity may be normal.

The main clinical tests are the anterior drawer test and inversion or talar tilt test.

Anterior Drawer Test

The anterior drawer test primarily assesses the ATFL.

The distal tibia is stabilized firmly with one hand while the other hand grasps the heel.

With the ankle in a neutral or slightly plantarflexed position, the heel and hindfoot are drawn anteriorly relative to the tibia.

Excessive anterior translation compared with the opposite side suggests ATFL insufficiency.

Inversion Tilt Test

The inversion tilt test primarily evaluates the CFL.

The ankle is positioned in neutral dorsiflexion.

The examiner stabilizes the distal tibia with one hand and applies an inversion force to the hindfoot with the other.

Excessive talar tilt or inversion compared with the uninjured ankle suggests CFL disruption.

Imaging

Plain Radiographs

When imaging is clinically indicated, standard ankle radiographs include anteroposterior, lateral, and mortise views.

Radiographs are primarily used to exclude associated fractures.

They may also demonstrate an osteochondral lesion of the talus, pre-existing arthritis, or another bony abnormality.

CT

Computed tomography is not routinely required for a straightforward ankle sprain.

CT may be useful when an occult fracture is suspected despite normal plain radiographs.

It may also assist in the assessment of a suspected tarsal coalition or other complex bony abnormality.

MRI

MRI is rarely necessary for an uncomplicated acute ankle sprain.

It may be appropriate when symptoms are unusually severe or persistent, or when an associated tendon tear, osteochondral injury, or other soft-tissue abnormality is suspected.

MRI provides detailed visualization of the ligaments, tendons, cartilage, and bone marrow.

Differential Diagnosis

Important differential diagnoses include a distal fibular fracture, osteochondral fracture of the talar dome, peroneal tendon subluxation, congenital tarsal coalition, talar fracture, and calcaneal fracture.

Persistent or atypical pain after an apparent ankle sprain should prompt reconsideration of these alternative diagnoses.

Treatment

General Measures

Most acute ankle sprains are treated nonoperatively.

Initial treatment commonly follows the RICE protocol: rest, ice, compression, and elevation.

These measures help reduce pain and swelling during the acute phase.

Prolonged complete immobilization is generally avoided when the injury is stable because early protected movement helps restore function.

Weight-Bearing

Weight-bearing can usually be advanced gradually as pain permits.

An ankle brace may provide support and allow earlier ambulation while limiting excessive inversion.

Patients with mild injuries can often progress rapidly, whereas more severe sprains may require a longer period of protected weight-bearing.

Ankle Bracing

A functional ankle brace can reduce painful motion while allowing controlled mobility.

Bracing is particularly useful during the early return to walking and athletic activity.

Continued brace use during high-risk sports may also reduce the likelihood of recurrent injury.

Range of Motion

Gentle active ankle movement should begin as tolerated.

Early range-of-motion exercises help reduce stiffness and improve circulation.

Patients may perform simple exercises such as drawing the alphabet with the great toe to encourage controlled multidirectional ankle movement.

Proprioceptive Training

For mild sprains, a home-based proprioceptive program may be sufficient.

Exercises may include single-leg balance activities, controlled ankle movements, and progressive balance challenges.

Proprioceptive retraining is important because ankle sprains can impair joint-position awareness and neuromuscular control.

Severe Sprains

More severe injuries may benefit from a formal physical therapy program.

Treatment should address swelling, mobility, muscle strength, endurance, balance, and proprioception.

The rehabilitation program should progress gradually toward running, jumping, cutting, and other sport-specific activities.

Activity Modification

Sporting activity should be restricted until pain and swelling have improved and ankle function has recovered.

Return to sport should not be based solely on the passage of time.

The patient should regain adequate strength, range of motion, balance, and confidence before resuming unrestricted activity.

Physical Therapy

Physical therapy should emphasize range of motion, strengthening, and proprioceptive retraining.

Both concentric and eccentric strengthening may be used, with particular attention to the peroneal muscles.

Balance-board exercises and single-leg activities can improve neuromuscular control and reduce the risk of recurrent sprains.

Medication

NSAIDs and simple analgesics may be used when pain is significant.

However, medication is often unnecessary for mild sprains.

Pain control should complement, rather than replace, functional rehabilitation.

Surgical Management

Surgical repair of an acute lateral ankle ligament tear is rarely necessary.

Most even high-grade sprains heal satisfactorily with appropriate nonoperative treatment and rehabilitation.

Primary repair of the ATFL and CFL may be considered only in selected acute situations.

Surgery for Recurrent Instability

Surgery may become appropriate when repeated sprains lead to chronic mechanical instability despite adequate rehabilitation and bracing.

Operative treatment may involve direct repair of the lateral ankle ligaments.

Reconstruction using tendon tissue, including part of the peroneus brevis tendon, has historically been used when direct repair is not feasible.

Follow-Up

Patients should be reviewed according to the severity of the injury and their functional demands.

Recovery should be assessed by evaluating pain, swelling, range of motion, strength, balance, and stability.

Persistent symptoms should prompt reassessment for an associated osteochondral, tendon, or bony injury.

Prognosis

The prognosis is excellent for most patients.

Recovery time varies according to the severity of the ligament injury.

Grade I sprains generally improve relatively quickly, whereas grade II and III injuries may require a longer period of rehabilitation before full athletic function returns.

Complications

Possible complications include an osteochondral lesion of the talus, recurrent ankle sprains, chronic instability, and ankle impingement.

Inadequate rehabilitation is an important contributor to recurrent symptoms.

Repeated sprains may eventually produce chronic ligamentous laxity, cartilage injury, and degenerative change.

Recurrent Sprains

A previous ankle sprain substantially increases the risk of another injury.

Residual weakness, impaired proprioception, ligamentous laxity, and premature return to sports all contribute to recurrence.

Structured rehabilitation and preventive bracing are therefore important after the initial injury.

Ankle Impingement

Repetitive injury may lead to scar formation, synovitis, osteophytes, or other tissue changes around the ankle.

These abnormalities can produce painful mechanical impingement during ankle movement.

Persistent pain or restricted motion after apparently successful treatment should therefore be investigated further.

Patient Monitoring

Patients should regain full or near-full strength and range of motion before returning to unrestricted sports.

They should also be able to perform functional activities such as running, jumping, cutting, and single-leg balance without pain or instability.

Functional bracing or taping during the return to athletics may help reduce the risk of recurrence, particularly in patients with a history of previous ankle sprains.

Orthopaedic Surgery - Ankle Pain

Basics

Ankle pain is an extremely common clinical complaint with a broad range of possible causes. It may result from traumatic injury, degenerative or inflammatory arthritis, sports-related conditions, overuse, infection, systemic disease, or neoplastic processes.

Successful treatment depends on accurately identifying the underlying pathology. A detailed knowledge of ankle anatomy, careful history-taking, and a systematic physical examination are therefore essential for developing an appropriate differential diagnosis.

Ankle Anatomy

The ankle joint is formed by the talus, distal tibia, and distal fibula.

The lateral ligament complex consists of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL).

The distal tibiofibular syndesmosis is supported primarily by the anterior inferior tibiofibular ligament and posterior inferior tibiofibular ligament.

Medial ankle stability is provided by the superficial and deep components of the deltoid ligament complex.

Epidemiology

Ankle pain is extremely common and may affect individuals of all ages.

Its prevalence generally increases with age because degenerative joint disease, chronic tendinopathy, and systemic inflammatory conditions become more frequent in older individuals.

Etiology

Potential causes include acute trauma, degenerative arthritis, inflammatory arthritis, stress fractures, repetitive overuse, osteochondral lesions of the talus, tendinitis, tendon tears, acute ligament sprains, and chronic ankle instability.

Infectious conditions such as septic arthritis and osteomyelitis can also produce ankle pain.

Less commonly, pain may result from a bone or soft-tissue neoplasm.

Traumatic Causes

Pain developing immediately after a traumatic episode may result from an ankle sprain, fracture, tendon strain or rupture, osteochondral injury, or dislocation.

The mechanism of injury, location of tenderness, ability to bear weight, swelling, and presence of deformity help determine the likely diagnosis.

Arthritis

Ankle arthritis may be either degenerative or inflammatory.

Degenerative arthritis commonly produces activity-related pain, progressive stiffness, swelling, and reduced range of motion.

Inflammatory arthritis may produce prolonged morning stiffness, warmth, swelling, and involvement of multiple joints.

Stress and Overuse Injuries

Repetitive loading can result in stress fractures, tendinitis, chronic tendinosis, and osteochondral lesions.

Symptoms commonly develop gradually and worsen with activity.

Pain may initially resolve with rest but can become persistent if repetitive loading continues.

Infection

Acutely severe ankle pain associated with warmth, erythema, swelling, and marked pain during passive movement should raise concern for septic arthritis.

Osteomyelitis should be considered when pain is associated with chronic wounds, previous surgery, systemic infection, or persistent unexplained symptoms.

Prompt recognition is essential because untreated infection may rapidly damage bone and articular cartilage.

Geriatric Considerations

In older individuals, common causes of ankle pain include degenerative arthritis, inflammatory arthritis, posterior tibial tendon dysfunction, chronic tendinosis, and gout.

Reduced bone quality, muscle weakness, altered balance, and age-related changes in tendons and cartilage may also contribute.

Pediatric Considerations

In children and adolescents, ankle pain frequently follows trauma.

Other important causes include an occult tarsal coalition and bone or soft-tissue tumors.

Persistent unexplained pain, particularly when accompanied by night symptoms, swelling, or a mass, requires further investigation.

Pregnancy Considerations

During pregnancy, transient ankle pain may occur because of lower-extremity edema and altered biomechanics.

Increased body weight, changes in posture, ligamentous laxity, and altered gait can increase mechanical loading around the ankle.

However, other common adult causes should still be considered when symptoms are significant or persistent.

Associated Conditions

Systemic disorders associated with ankle pain include rheumatoid arthritis, other inflammatory arthropathies, gout, and Lyme disease.

Structural disorders such as tarsal coalition may also cause chronic pain, stiffness, and recurrent ankle symptoms.

Diagnosis

Signs and Symptoms

Well-localized pain after an acute traumatic event may represent an ankle sprain, fracture, or tendon injury.

Severe pain without trauma, together with substantial swelling, warmth, erythema, and marked pain during passive range of motion, should raise suspicion for septic arthritis or an acute gout attack.

Chronic activity-related ankle pain in adults commonly suggests degenerative arthritis, whereas prolonged morning stiffness may suggest an inflammatory disorder.

Ankle pain and swelling accompanied by a skin rash following a tick bite may indicate Lyme disease.

History

A detailed history should identify the onset, duration, location, and character of the pain.

The clinician should ask about previous trauma, activities that reproduce symptoms, sporting participation, occupational demands, and previous ankle disorders.

The relationship of symptoms to activity and rest can provide important diagnostic information.

Important Historical Features

The presence of morning pain or stiffness may indicate inflammatory disease.

A history of gout, particularly previous involvement of the great toe, should be documented.

Constitutional symptoms such as fever, night sweats, unexplained weight loss, night pain, or rest pain may suggest infection, inflammatory disease, or neoplasm.

A history of tick exposure should also be obtained when clinically relevant.

Physical Examination

Physical examination should begin by identifying the exact site of pain and tenderness.

The medial and lateral malleoli, hindfoot, and proximal fifth metatarsal should be palpated, particularly after trauma.

The tendons, ligaments, and joint line should then be examined systematically.

Tendon Examination

The posterior tibial tendon, peroneal tendons, Achilles tendon, and extensor tendons should be palpated.

Pain, swelling, crepitus, weakness, or tenderness may indicate tendinitis, tendinosis, or tearing.

Resisted muscle testing can help determine whether a particular tendon is contributing to symptoms.

Ligament Examination

The medial deltoid ligament, lateral ligament complex, and distal tibiofibular syndesmotic ligaments should be examined for tenderness and instability.

Provocative testing may help identify acute or chronic ligamentous injury.

Findings should be compared with the opposite ankle whenever possible.

Joint-Line Examination

The anterior ankle joint line and capsule should be palpated for tenderness or swelling.

Joint-line pain and effusion may occur with arthritis, synovitis, osteochondral injury, or infection.

Range of Motion

Both active and passive ankle motion should be assessed and compared with the unaffected side.

Restricted motion may occur with arthritis, post-traumatic stiffness, joint effusion, tarsal coalition, or infection.

Severe pain during passive movement should increase concern for significant intra-articular pathology.

Stability and Strength

Ligamentous stability should be assessed with appropriate stress testing.

Manual muscle strength should also be evaluated.

Weakness may result from tendon injury, neurologic dysfunction, chronic instability, or inhibition caused by pain.

Skin Examination

The skin around the ankle should be assessed for bruising, erythema, wounds, scars, rash, swelling, and increased warmth.

The presence of a joint effusion should also be noted.

Skin findings may provide useful clues to traumatic, infectious, inflammatory, or systemic causes.

Neurovascular Examination

A complete neurovascular assessment of the foot and ankle should be performed.

Motor function, sensation, pulses, and capillary refill should be documented.

Neurologic abnormalities may indicate peripheral nerve injury or another neurologic condition contributing to the pain.

Gait Assessment

The patient’s gait should be observed whenever possible.

An antalgic gait may indicate pain with weight-bearing.

Other abnormalities, such as altered foot progression, inability to perform heel rise, or reduced ankle motion, may suggest tendon dysfunction, arthritis, instability, or structural deformity.

Laboratory Tests

Laboratory investigations are selected according to the suspected diagnosis rather than ordered routinely.

When septic arthritis is suspected, investigations commonly include a complete blood count with differential, erythrocyte sedimentation rate, and C-reactive protein.

Inflammatory Arthritis Investigations

Patients suspected of having rheumatoid or another inflammatory arthritis may undergo appropriate rheumatologic testing.

Investigations may include rheumatoid factor, inflammatory markers, antinuclear antibodies, and other disease-specific serologic tests.

Laboratory findings should be interpreted in conjunction with the patient’s clinical presentation.

Gout Investigations

A serum uric acid level may support the assessment of suspected gout.

However, uric acid may be normal during an acute attack, and a normal result does not exclude the diagnosis.

Joint aspiration and crystal analysis provide greater diagnostic certainty.

Lyme Disease Investigations

When the clinical presentation and exposure history suggest Lyme disease, Lyme antibody testing may be appropriate.

Testing should be guided by geographical exposure, tick history, rash, and associated systemic manifestations.

Imaging

Plain Radiographs

Initial imaging commonly consists of standing anteroposterior, lateral, and mortise radiographs of the ankle.

These views help identify fractures, alignment abnormalities, arthritis, osteophytes, joint-space narrowing, and other bony abnormalities.

Foot Radiographs

An oblique radiograph of the foot may be obtained when calcaneonavicular coalition is suspected.

Additional specialized views may be selected according to the location and suspected cause of symptoms.

MRI

MRI is valuable for detecting occult conditions that may not be visible on plain radiographs.

It may identify stress fractures, osteochondral lesions, occult fractures, tendon abnormalities, tendon tears, ligamentous injuries, bone marrow abnormalities, and neoplasms.

MRI also provides detailed information regarding cartilage and other soft-tissue structures.

CT

CT provides detailed assessment of bony anatomy.

It can define fracture fragments, articular involvement, and complex fracture patterns.

CT may also help identify tarsal coalition, bone cysts, osteoid osteoma, and other osseous lesions.

Arthrocentesis

Joint aspiration is particularly useful when septic arthritis, gout, or pseudogout is suspected.

Synovial fluid can be analyzed for cell count, Gram stain, bacterial culture, and crystals.

Septic Arthritis Findings

Synovial fluid from a septic joint may demonstrate a positive Gram stain or bacterial culture.

Staphylococcus aureus is among the most common organisms responsible for septic arthritis.

Because infection can rapidly destroy the joint surface, investigation and treatment should proceed urgently when suspicion is high.

Crystal Arthropathy

In gout, synovial fluid contains monosodium urate crystals.

Pseudogout is characterized by calcium pyrophosphate crystals.

Crystal analysis helps distinguish these conditions from septic arthritis and other inflammatory disorders.

Differential Diagnosis

The differential diagnosis includes ankle sprain, ankle fracture, tendon strain or rupture, stress fracture, tendinitis, chronic tendinosis, and degenerative osteoarthritis.

Other possibilities include rheumatoid or inflammatory arthritis, septic arthritis, Lyme disease, acute gout, and osteochondral lesions of the talar dome.

Additional Differential Diagnoses

Less common but important causes include bone tumors, soft-tissue neoplasms, and tarsal coalition.

The patient’s age, history of trauma, duration of symptoms, examination findings, and imaging results help narrow the diagnosis.

Treatment

General Measures

Treatment should be directed at the underlying cause.

Minor ankle sprains and low-grade traumatic injuries may initially be treated with rest, ice, compression, and elevation (RICE).

Weight-bearing can then be gradually increased as pain and swelling improve.

Management of Ankle Fractures

Patients with ankle fractures should be appropriately splinted.

They should generally remain non-weight-bearing until the fracture has been fully evaluated for stability.

Displaced or unstable fractures require prompt orthopedic assessment and may require surgical fixation.

Hot and Swollen Ankle

A hot, erythematous, swollen ankle requires careful evaluation.

Arthrocentesis may be necessary to distinguish septic arthritis from gout or another inflammatory process.

This distinction is particularly important because septic arthritis requires urgent treatment.

Activity

Patients with minor sprains or low-grade trauma may begin progressive weight-bearing as tolerated.

Activity should be increased according to pain, swelling, stability, and recovery of function.

Non-Weight-Bearing

Patients with unstable ankle fractures should remain non-weight-bearing while awaiting definitive orthopedic management.

Crutches, a walker, or another assistive device may be required.

Protected Weight-Bearing

Protected weight-bearing in a cast, boot, or brace can be useful for tendon strains, tendinitis, chronic tendinosis, stress fractures, osteochondral lesions of the talus, and symptomatic tarsal coalition.

The duration of protection depends on the specific diagnosis and severity.

Physical Therapy

Physical therapy is useful in many cases after the diagnosis has been established and appropriate initial treatment completed.

Rehabilitation may include range-of-motion exercises, strengthening, proprioceptive training, balance exercises, gait retraining, and gradual return to sport or work.

The treatment program should be tailored to the underlying disorder.

Medication

First-Line Therapy

Nonsteroidal anti-inflammatory drugs may be used for ankle sprains, tendon injuries, stress-related disorders, and arthritis.

Analgesic treatment should be individualized according to symptom severity and patient comorbidities.

Fracture Pain

Severe fracture pain may occasionally require stronger analgesic medication.

Medication should be used as part of a broader treatment strategy that includes immobilization and definitive management of the fracture.

Gout Treatment

Acute gout may be treated with NSAIDs, colchicine, or other anti-inflammatory medications.

Patients with recurrent attacks may require long-term urate-lowering therapy such as allopurinol after appropriate assessment.

Septic Arthritis Treatment

Septic arthritis requires prompt antibiotic treatment and drainage of the infected joint.

Drainage may be achieved by aspiration or surgical irrigation and debridement depending on the clinical circumstances.

Corticosteroid Injection

Corticosteroid injection may provide symptomatic relief for selected forms of ankle arthritis.

Infection must be excluded before any intra-articular corticosteroid injection is performed.

Surgical Management

Surgery may be required for several underlying causes of ankle pain.

Unstable fractures commonly require reduction and internal fixation.

Chronic ligament instability, significant tendon tears, or symptomatic osteochondral lesions may also eventually require operative treatment.

Surgery for Septic Arthritis

Surgical irrigation and debridement may be preferred for chronic infections, infections caused by difficult organisms, or cases that fail to respond to aspiration and antibiotics.

Operative treatment may also be favored in immunocompromised patients or when substantial purulent material is present.

Surgery for Ankle Arthritis

Severe arthritis that remains painful despite appropriate nonsurgical treatment may require ankle arthrodesis or total ankle arthroplasty.

The choice depends on patient age, activity level, alignment, bone quality, severity of degeneration, and condition of adjacent joints.

Management of Neoplasms

A suspected bone or soft-tissue tumor requires appropriate staging and biopsy before definitive treatment.

Benign lesions may require procedures such as curettage and bone grafting.

Malignant lesions may require wide surgical excision, limb-sparing reconstruction, systemic treatment, or, in selected advanced cases, amputation.

Referral

Acute fractures requiring definitive stabilization should be referred to an orthopaedic surgeon.

Chronic ankle pain that does not improve despite rest, activity modification, medication, rehabilitation, or immobilization should also prompt specialist referral.

Musculoskeletal Oncology Referral

A suspected bone or soft-tissue neoplasm should be referred to a musculoskeletal oncologist for proper staging and biopsy planning.

Biopsy should ideally be coordinated with the specialist responsible for definitive tumor treatment because poorly planned biopsy placement may complicate later surgery.

Prognosis

The prognosis depends on the underlying cause.

Minor sprains, tendon irritation, and many overuse conditions usually respond well to appropriate treatment.

More serious disorders, including advanced arthritis, infection, unstable fractures, and neoplasms, may require prolonged treatment and can produce significant long-term disability.

Complications

Many causes of ankle pain can lead to progressive pain, stiffness, weakness, instability, and loss of range of motion.

Untreated traumatic or degenerative disease may progress to chronic arthritis.

Infection can cause rapid destruction of cartilage and bone, while tumors may progressively damage surrounding structures.

Patient Monitoring

Careful short-term follow-up is important to monitor pain, swelling, gait, and recovery of ankle motion.

Range of motion should be maintained whenever clinically safe to reduce the risk of stiffness and contracture.

Patients should be reassessed promptly if there is increasing pain, swelling, fever, inability to bear weight, progressive deformity, neurologic symptoms, or other concerning clinical changes.