A Guide for Patients with a Fluid-Filled Lump Behind the Knee

What causes a Baker's cyst, how it is diagnosed and how it is treated

Lafi S. Khalil, MD, FAANA

Understanding a Baker's Cyst

A Baker's cyst, also called a popliteal cyst, is a soft, fluid-filled swelling behind the knee. It is named after Dr. William Baker, who described it in the 1800s. Behind the knee is a small fluid sac (bursa) that is often connected to the knee joint through a small opening. When the knee makes extra fluid, that fluid can flow into the sac but has trouble flowing back, so the sac fills and bulges like a balloon.

The cyst itself is rarely the real problem. In adults it is almost always a sign of something else irritating the knee, so treatment focuses on that underlying cause.

Common causes

• Arthritis (osteoarthritis or rheumatoid arthritis)
• A meniscus (cartilage) tear or ligament injury
• Gout or other inflammation of the knee lining

Symptoms

• A lump or fullness behind the knee, often more noticeable when standing
• Tightness or stiffness, especially when fully bending or straightening the knee
• Knee pain, often from the underlying cause rather than the cyst
• Swelling that gets worse with activity

How the Diagnosis Is Made

• History and exam. We ask about prior injuries and arthritis and examine the back of the knee.
• Ultrasound is a quick, painless test that shows whether the lump is filled with fluid and can rule out a blood clot.
• X-rays do not show the cyst but show arthritis, a common cause.
• MRI shows the cyst and what is causing it, such as a meniscus tear.

Treatment

Many cysts shrink or go away when the underlying knee problem is treated. Treatment usually starts without surgery.

Home care

• Rest from activities that make the knee swell, such as running and jumping.
• Ice for 15 to 20 minutes at a time, with a cloth between the ice and your skin.
• Compression with an elastic sleeve or wrap, snug but not tight.
• Elevation of the leg above heart level when resting.
• Anti-inflammatory medicine such as ibuprofen or naproxen, as directed on the label, if it is safe for you.
• Maintaining a healthy weight to reduce stress on the knee, and using a cane if walking is painful.

Treatments in the office

• Physical therapy to restore motion and strength.
• Cortisone injection into the knee joint to calm inflammation, which can also shrink the cyst.
• Ultrasound-guided aspiration: draining the cyst with a needle, often with a cortisone injection. The cyst can refill if the cause is not treated.

Surgery

Surgery is rarely needed for the cyst itself. When it is, it usually targets the cause, such as knee arthroscopy for a torn meniscus, sometimes combined with treating the connection between the joint and the cyst.

What the research says: A review of 30 studies found that injecting cortisone into the cyst, with or without draining it, is an effective nonsurgical treatment. Arthroscopic surgery that treats problems inside the knee and widens the opening between the joint and the cyst had the best-studied surgical results (Van Nest 2020).

Follow-Up

Please keep your scheduled follow-up appointments so we can check your progress and adjust your plan as needed.

Learn More

• OrthoInfo (AAOS): Baker's Cyst (Popliteal Cyst): https://orthoinfo.aaos.org/en/diseases--conditions/bakers-cyst-popliteal-cyst/

Clinical Sources

• Van Nest DS, Tjoumakaris FP, Smith BJ, Beatty TM, Freedman KB. Popliteal cysts: a systematic review of nonoperative and operative treatment. JBJS Rev. 2020;8(3):e0139.
• Fritschy D, Fasel J, Imbert JC, et al. The popliteal cyst. Knee Surg Sports Traumatol Arthrosc. 2006;14(7):623-628.
• American Academy of Orthopaedic Surgeons. Baker's Cyst (Popliteal Cyst). OrthoInfo.

A Guide for Patients with Pain Around the Kneecap ("Runner's Knee")

Why the front of the knee hurts, what helps, and a home exercise program

Lafi S. Khalil, MD, FAANA

Understanding Patellofemoral Pain

Patellofemoral pain syndrome (PFPS), often called runner's knee, is pain under or around the kneecap (patella), where it glides in a groove on the end of the thighbone. It can affect one or both knees, in children and adults. It is one of the most common causes of knee pain in active people, especially females and athletes in running, jumping and squatting sports.

What contributes to it

• Overuse, or increasing training too quickly
• Weak thigh (quadriceps) and hip muscles, which let the kneecap track poorly
• Tight hamstrings, calf or outer thigh muscles
• Kneecap alignment or anatomy, and foot mechanics
• Changes in footwear, equipment, technique or playing surface

Symptoms

• A dull ache around or behind the kneecap, usually starting gradually
• Pain with squatting, kneeling, running, jumping or going up and down stairs
• Pain after sitting for a long time with the knees bent ("moviegoer's knee")
• Grinding or popping under the kneecap, which on its own is usually harmless

Diagnosis

The diagnosis is usually made from your history and a physical exam. X-rays may be used to rule out other problems. An MRI is only needed if symptoms do not improve or another problem is suspected.

Treatment

Most people improve without surgery. Exercise is the most important treatment.

• Modify activity, don't stop it. Cut back on the activities that hurt (deep squats, stairs, hills, jumping) while staying active with less painful exercise such as cycling or swimming.
• Exercise therapy. Strengthening the hip and thigh muscles, combined with stretching, is the best-supported treatment.
• Ice for 15 to 20 minutes after activity, with a cloth between the ice and your skin.
• Anti-inflammatory medicine for short periods, as directed on the label, if it is safe for you.
• Foot orthotics (shoe inserts) can help some people, especially in the short term.
• Taping or bracing helps some people; evidence is mixed.
• Surgery is rarely needed and is reserved for specific structural problems found on further testing.

What the research says: An international expert consensus recommends exercise therapy, especially combining hip-focused and knee-focused exercises, as the core treatment for patellofemoral pain. Foot orthoses and combined treatments can also help; passive treatments alone, such as knee mobilization or electrical stimulation, are not recommended (Collins 2018).

Home Exercise Program

Mild discomfort (up to 3 out of 10) during exercise is acceptable if it settles by the next day. Stop and let us know if an exercise causes sharp pain or makes your knee worse the next day.

Stretches

Strengthening

Prevention

• Increase training intensity and mileage gradually
• Warm up and stretch before activity
• Wear supportive shoes suited to your sport, and replace them when worn
• Keep up your strengthening program, and maintain a healthy weight

Follow-Up

Please keep your scheduled follow-up appointments so we can check your progress and adjust your plan as needed.

Learn More

• OrthoInfo (AAOS): Patellofemoral Pain Syndrome: https://orthoinfo.aaos.org/en/diseases--conditions/patellofemoral-pain-syndrome
• OrthoInfo (AAOS): Adolescent Anterior Knee Pain: https://orthoinfo.aaos.org/en/diseases--conditions/adolescent-anterior-knee-pain

Clinical Sources

• Collins NJ, Barton CJ, van Middelkoop M, et al. 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017. Br J Sports Med. 2018;52(18):1170-1178.
• American Academy of Orthopaedic Surgeons. Patellofemoral Pain Syndrome. OrthoInfo.

A Guide for Patients Whose Kneecap Has Dislocated or Feels Unstable

Why the kneecap slips out of its groove, what raises the risk, and how it is treated

Lafi S. Khalil, MD, FAANA

Understanding Your Kneecap

The kneecap (patella) connects the thigh muscles to the shinbone. As you bend and straighten your leg, it glides up and down in a V-shaped groove at the end of the thighbone called the trochlea. When the kneecap stays in its groove, you can walk, run, sit and stand easily. When it slips out of the groove, usually toward the outside of the knee, it can dislocate partially (subluxation) or completely.

Several structures hold the kneecap in place: the medial patellofemoral ligament (MPFL) on the inner side of the knee, the thigh muscles, and the shape of the groove and bones. The MPFL is almost always torn when the kneecap dislocates.

What Raises the Risk?

Some people are born with anatomy that makes the kneecap more likely to slip. More than 80% of people with patellar instability have at least one of these risk factors, and they raise the chance of dislocating again after the first time:

Treatment

Right after a dislocation

If the kneecap does not go back into place on its own, it is gently pushed back into the groove (reduction). We will check x-rays or an MRI for damage, because a dislocation can chip cartilage or bone from the underside of the kneecap or the end of the thighbone.

Nonsurgical treatment

For a first-time dislocation without a loose fragment, treatment usually starts with a short period of protection in a brace, followed by physical therapy to restore motion and strengthen the thigh, hip and core muscles. Cycling is often part of rehab, and a stabilizing brace may be used for sport. Most patients return to normal activities within 1 to 3 months.

Surgical treatment

Surgery is usually recommended if the kneecap keeps dislocating, if a loose piece of cartilage or bone needs to be fixed, or when high-risk anatomy is present. Procedures are tailored to your anatomy and may include:

• MPFL reconstruction: rebuilding the torn inner ligament with a tendon graft. This is the most common procedure.
• Tibial tubercle osteotomy: moving the bony attachment of the kneecap tendon to correct alignment or a high-riding kneecap.
• Trochleoplasty: deepening a very shallow groove (performed only in selected cases).

What the research says: In a review of randomized trials of first-time dislocations, the kneecap dislocated again in about 30% of patients treated without surgery compared with about 11% after surgery, although knee function scores were similar (Patel 2026). MPFL reconstruction had the lowest re-dislocation rate of the options studied (Hurley 2022). Dr. Khalil has published his individualized approach to combining these procedures based on each patient's anatomy (Khalil 2025).

Repeated dislocations can damage the cartilage under the kneecap, which is another reason surgery may be recommended for recurrent instability.

Follow-Up

Please keep your scheduled follow-up appointments so we can check your progress and adjust your plan as needed.

Learn More

• OrthoInfo (AAOS): Unstable Kneecap (Patellar Instability): https://orthoinfo.aaos.org/en/diseases--conditions/unstable-kneecap
• OrthoInfo (AAOS): Knee Dislocation and Instability in Children: https://orthoinfo.aaos.org/en/diseases--conditions/patellar-dislocation-and-instability-in-children-unstable-kneecap/
• Arthroscopy: Anatomic Risk Factors for Lateral Patellar Instability: https://www.arthroscopyjournal.org/article/S0749-8063(24)00577-2/fulltext

Clinical Sources

• Only AJ, Arendt EA, Hinckel BB. Anatomic risk factors for lateral patellar instability. Arthroscopy. 2024;40(11):2642-2644.
• Patel S, Anaspure OS, Baumann AN, Manz TM, Mistovich RJ. Operative versus nonoperative treatment of medial patellofemoral ligament injuries: a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis. Am J Sports Med. 2026;54(2):475-484.
• Hurley ET, Colasanti CA, Anil U, et al. Management of patellar instability: a network meta-analysis of randomized control trials. Am J Sports Med. 2022;50(9):2561-2567.
• Khalil LS, Cominos ND, Terrian L, Driessche AM, Pantuso A, Farrow LD. Surgical techniques to address patellofemoral instability: an individualized approach. Arthrosc Tech. 2025;14(10):103804.
• American Academy of Orthopaedic Surgeons. Unstable Kneecap (Patellar Instability). OrthoInfo.

A Guide for Patients with Hip Impingement

What FAI is, how it damages the hip, how it is treated and a home conditioning program

Lafi S. Khalil, MD, FAANA

Understanding FAI

Femoroacetabular impingement (FAI) is a condition in which the bones of the hip are shaped abnormally, so they do not fit together perfectly. With certain motions, the bones rub or pinch against each other and can damage the joint.

The parts of the hip

• The hip is a ball-and-socket joint. The ball is the head of the thighbone (femur), and the socket is the acetabulum, part of the pelvis.
• Both are covered with smooth, slippery articular cartilage that lets the bones glide easily.
• The socket is ringed by the labrum, a strong rim of cartilage that seals the joint like a gasket and helps keep it stable.

How FAI damages the hip

In FAI, extra bone (bone spurs) forms on the ball, along the rim of the socket, or both. Instead of moving smoothly, the ball bumps against the labrum and cartilage at the rim and pinches them. Over time this can tear the labrum and wear away the cartilage, leading to arthritis.

Who gets FAI, and does it get worse?

No one knows for certain whether FAI is present from birth or develops during growth; it is likely a mix of genetics and environment. Heavy athletic activity before the bones finish growing may raise the risk. Contact sports such as football and hockey, and male sex, are linked to cam impingement, while pincer impingement may be more common in women. Exercise does not cause FAI, but active people may notice symptoms earlier.

Many people live long, active lives with FAI and never have problems. Once symptoms start, they usually mean the cartilage or labrum is damaged, and the condition is likely to progress.

Symptoms

Most people feel deep pain in the groin, sometimes toward the outside of the hip. It may be sharp and stabbing with turning, twisting or squatting, or a dull ache. Getting up from a chair often makes it worse. Stiffness and limping can also occur.

Treatment

First steps

• Find and change the trigger. Identify the activity that brings on pain, modify it and let the hip rest.
• Anti-inflammatory medicines such as ibuprofen or naproxen may help, if they are safe for you.
• Physical therapy and home exercise to improve motion and strengthen the muscles that support the hip (program below).
• Injection. A numbing and cortisone injection into the hip can relieve pain and help confirm the joint is the source.

If symptoms continue, come back to see us. The longer painful FAI goes untreated, the more damage it can cause.

Surgery

When pain persists despite these steps and testing shows joint damage, hip arthroscopy can repair or clean the labrum and cartilage and reshape the bone to remove the impingement. Surgery can successfully reduce symptoms and help prevent further damage, but not all damage can be fully repaired, especially if treatment was delayed.

What the research says: In a large randomized trial, both hip arthroscopy and a personalized physical therapy program improved hip-related quality of life in patients with FAI, but arthroscopy produced a greater, clinically meaningful improvement at 1 year (Griffin 2018).

Our research

Patient-reported outcomes are a major focus of Dr. Khalil's research. You may be asked to complete short questionnaires at your visits, which helps us continue to improve care for patients with FAI.

Home Hip Conditioning Program

A well-structured conditioning program strengthens the muscles that support the hip and helps keep the joint stable. Continue it for 4 to 6 weeks unless your doctor or physical therapist says otherwise. Afterward, doing the exercises 2 to 3 days a week maintains your strength and motion and protects your hips over the long term.

Getting started

• Warm up. Walk or ride a stationary bike for 5 to 10 minutes of easy, low-impact activity first.
• Order. Do the stretches first, then the strengthening exercises, then repeat the stretches to finish.
• Do not ignore pain. You should not feel pain during an exercise. Talk to your doctor or therapist if you do.
• Ask questions. If you are unsure how to do an exercise or how often, ask your doctor or physical therapist.

Stretching exercises

Strengthening exercises

For the hip abduction, adduction and extension exercises, begin with a weight that allows 8 repetitions and work up to 12. When that becomes easy, add ankle weight in 1-pound steps and start again at 8.

Follow-Up

Please keep your scheduled follow-up appointments so we can check your progress and adjust your plan as needed.

Learn More

• OrthoInfo (AAOS): Femoroacetabular Impingement: https://orthoinfo.aaos.org/en/diseases--conditions/femoroacetabular-impingement/
• OrthoInfo (AAOS): Hip Arthroscopy: https://orthoinfo.aaos.org/en/treatment/hip-arthroscopy/
• OrthoInfo (AAOS): Hip Conditioning Program: https://orthoinfo.aaos.org/en/recovery/hip-conditioning-program/

Clinical Sources

• Griffin DR, Dickenson EJ, Wall PDH, et al. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. Lancet. 2018;391(10136):2225-2235.
• American Academy of Orthopaedic Surgeons. Femoroacetabular Impingement. OrthoInfo.
• American Academy of Orthopaedic Surgeons. Hip Conditioning Program (exercise handout), 2026. OrthoInfo.

A Guide for Patients with Pincer-Type Impingement from a Backward-Tilted Socket

Understanding your diagnosis, how it is confirmed, your treatment options and a home conditioning program

Lafi S. Khalil, MD, FAANA

Understanding Your Hip

The hip is a ball-and-socket joint. The socket (acetabulum) is part of the pelvis, and the ball (femoral head) is the top of the thighbone. Both are covered with smooth cartilage, and a ring of tough tissue called the labrum rims the socket like a gasket.

Femoroacetabular impingement (FAI) means the ball and socket are not shaped to fit together perfectly, so the bones rub or pinch as the hip moves. Over time that can tear the labrum and wear away cartilage. There are three types: pincer (extra bone along the rim of the socket), cam (a bump on the ball) and combined (both).

What Is Acetabular Retroversion?

In most people the socket faces slightly forward. In acetabular retroversion the socket is tilted backward, so its front edge overhangs the ball. When you bend the hip or turn it inward, such as when you squat, pivot or pull your knee to your chest, the thighbone runs into that overhanging rim and pinches the labrum. This is a form of pincer impingement.

Retroversion is linked to hip pain, FAI and early arthritis in young adults, and it often goes along with less inward rotation and less hip bending. In one study of 538 painful hips at a hip-preservation center, about 1 in 8 had true, whole-socket retroversion.

Why it develops

• FAI develops when the hip bones form abnormally during childhood growth; little can be done to prevent it.
• Exercise does not cause FAI, but active people may notice symptoms earlier because they work the hip harder.
• Some people with FAI never have problems. Once symptoms begin, it usually means the labrum or cartilage is damaged.

Symptoms

• Pain, most often in the groin, sometimes toward the outside of the hip; a dull ache or sharp, stabbing pain.
• Sharp pain with turning, twisting or squatting.
• Stiffness and sometimes a limp.

How the Diagnosis Is Made

We will review your symptoms and examine your hip. In the impingement test, we bring your knee toward your chest and rotate it inward. If this recreates your pain, the test is positive.

• X-rays show bone shape and arthritis. Retroversion is first suspected on a standard pelvis x-ray.
• CT scan measures exactly how the socket is tilted (acetabular version). Normal is roughly 10° to 25°; less than about 10° is retroversion.
• MRI shows the labrum and cartilage; contrast dye in the joint can make damage clearer.
• Diagnostic injection of numbing medicine into the hip can confirm the joint is the source of pain.

Why careful x-ray reading matters

What the research says: In a study of 538 painful hips, the crossover sign alone overcalled retroversion. Using all three signs plus a retroversion index above 30% raised diagnostic accuracy from 31% to 68%, and when that pattern was absent, whole-socket retroversion could be ruled out 94% of the time (Lerch 2022). This matters because over-calling retroversion can lead to trimming too much of the socket rim, which can make the hip unstable.

Treatment Options

Nonsurgical treatment (first step)

• Activity changes. Deep squatting, twisting, pivoting and long periods of deep sitting are common triggers. Modify or avoid them and let the hip settle.
• Anti-inflammatory medicines can relieve pain and inflammation, if they are safe for you.
• Physical therapy improves hip motion and strengthens the muscles that support the joint. The home program in this handout is a starting point.

Surgical treatment

• Hip arthroscopy. Through small incisions, the labrum and cartilage are repaired or cleaned and the impingement is corrected by carefully trimming the rim and any bump on the ball.
• Retroversion specifically. Treatment is individualized. Both arthroscopic and open approaches have satisfactory results. When the whole socket is tilted backward, some surgeons consider an anteverting periacetabular osteotomy, an open operation that re-aims the socket.
• Long-term outlook. Surgery can reduce symptoms and prevent further damage, but it cannot always undo damage that has already occurred.

What the research says: In a large randomized trial of patients with FAI, both hip arthroscopy and a personalized physical therapy program improved hip-related quality of life, but arthroscopy led to a greater, clinically meaningful improvement at 1 year (Griffin 2018).

Home Hip Conditioning Program

A well-structured conditioning program strengthens the muscles that support the hip and helps keep the joint stable. Continue it for 4 to 6 weeks unless your doctor or physical therapist says otherwise. Afterward, doing the exercises 2 to 3 days a week maintains your strength and motion and protects your hips over the long term.

Getting started

• Warm up. Walk or ride a stationary bike for 5 to 10 minutes of easy, low-impact activity first.
• Order. Do the stretches first, then the strengthening exercises, then repeat the stretches to finish.
• Do not ignore pain. You should not feel pain during an exercise. Talk to your doctor or therapist if you do.
• Ask questions. If you are unsure how to do an exercise or how often, ask your doctor or physical therapist.

Stretching exercises

Strengthening exercises

For the hip abduction, adduction and extension exercises, begin with a weight that allows 8 repetitions and work up to 12. When that becomes easy, add ankle weight in 1-pound steps and start again at 8.

Follow-Up

Please keep your follow-up appointments so we can reassess your motion and strength and decide whether further testing or surgery should be discussed.

Learn More

• OrthoInfo (AAOS): Femoroacetabular Impingement: https://orthoinfo.aaos.org/en/diseases--conditions/femoroacetabular-impingement/
• OrthoInfo (AAOS): Hip Conditioning Program: https://orthoinfo.aaos.org/en/recovery/hip-conditioning-program/

Clinical Sources

• Lerch TD, Meier MK, Boschung A, et al. Diagnosis of acetabular retroversion: three signs positive and increased retroversion index have higher specificity and higher diagnostic accuracy compared to isolated positive cross over sign. Eur J Radiol Open. 2022;9:100407.
• Griffin DR, Dickenson EJ, Wall PDH, et al. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. Lancet. 2018;391(10136):2225-2235.
• American Academy of Orthopaedic Surgeons. Femoroacetabular Impingement. OrthoInfo.
• American Academy of Orthopaedic Surgeons. Hip Conditioning Program (exercise handout), 2026. OrthoInfo.

A Guide for Patients with a Shallow Hip Socket

Understanding your diagnosis, how it is confirmed, your treatment options and a home conditioning program

Lafi S. Khalil, MD, FAANA

Understanding Your Hip

The hip is a ball-and-socket joint. The socket is the acetabulum, part of the pelvis, and the ball is the femoral head, the top of the thighbone. Both are lined with smooth cartilage, and a ring of strong tissue called the labrum rims the socket like a gasket, sealing the joint and helping keep it stable.

What Is Hip Dysplasia?

In hip dysplasia the socket is too shallow to fully cover and support the ball. Because the ball is under-covered, body weight and activity are concentrated on a smaller area of cartilage and on the labrum. Over time this can cause labral tears, fraying of the cartilage and early arthritis. Severity ranges from a hip that is slightly loose in the socket to one that is completely unstable.

Borderline dysplasia

Socket coverage is measured on an x-ray with the lateral center-edge angle (LCEA). An angle of 25° or more is generally normal, and less than 20° is classic dysplasia. Hips between 20° and 25° are called borderline dysplasia. These hips may look nearly normal on x-ray, yet they can still behave like unstable hips. Borderline dysplasia is common in patients seen at hip-preservation centers and is more often seen in dancers and hockey goalies.

Why it develops

• Most often the socket did not form fully in infancy and childhood (developmental dysplasia of the hip), sometimes without being recognized early in life.
• It runs in families and is more common in girls, firstborn children and babies born breech.
• General joint looseness (ligament laxity) can add to the problem.

Symptoms

• Pain in the groin, sometimes toward the outside of the hip or the buttock. It is often mild and occasional at first, then more frequent, usually worse with activity or at the end of the day.
• Pain after standing or walking for a long time, or tiredness in the muscles on the outside of the hip.
• Catching, locking, popping or grinding, or a sense that the hip is unstable.
• Pain with twisting and getting in and out of a car.

How the Diagnosis Is Made

We will review your history and examine your hip, including how much it moves and whether stressing it reproduces a feeling of instability. We also check for joint looseness elsewhere in the body.

• X-rays are the first test. The LCEA and other measurements show how well the socket covers the ball and whether arthritis is present.
• CT scan shows the three-dimensional shape of the socket and thighbone, including the twist (version) of the bones.
• MRI shows the labrum, cartilage and soft tissues.

Instability or impingement?

Hips with borderline dysplasia can hurt because of instability, because of impingement (bones pinching), or both. Telling these apart guides treatment.

Treatment Options

Nonsurgical treatment (first step)

• Activity changes. Avoid activities that bring on pain. Weight loss can reduce load on the hip.
• Physical therapy. Strengthening the muscles around the hip and core helps support the joint. The home program in this handout is a starting point.
• Anti-inflammatory medicines such as ibuprofen or naproxen can ease pain, if they are safe for you.
• Injection. A cortisone injection into the hip can give temporary relief and help show whether the joint is the source of pain.
• Observation. For mild dysplasia without labral or cartilage damage, we may simply follow you with visits every 6 to 12 months.

Surgical treatment

• Periacetabular osteotomy (PAO). The pelvis is cut around the socket, which is rotated to cover the ball better and fixed with screws. It usually takes 2 to 3 hours with a 2- to 4-day hospital stay, and aims to relieve pain and delay or prevent hip replacement. Risks include infection, blood clots, nerve or blood vessel injury, ongoing pain and the bone not healing.
• Hip arthroscopy. Small incisions and a camera are used to repair the labrum and treat cartilage. In borderline dysplasia it is mostly considered when impingement is the main problem; the labrum is preserved and repaired, the socket rim is not trimmed, and the joint capsule may be tightened.
• Hip replacement is used for severe arthritis when the joint cannot be preserved.

What the research says: In a combined analysis of 989 hips, including 315 borderline-dysplastic hips, patients with borderline dysplasia did as well after arthroscopy as patients with normal coverage at about 3 years (Krivicich 2023). Still, up to 40% of borderline hips may have a less-than-ideal result after either arthroscopy or PAO, so a careful, individualized decision is important (Nepple 2021).

Home Hip Conditioning Program

A well-structured conditioning program strengthens the muscles that support the hip and helps keep the joint stable. Continue it for 4 to 6 weeks unless your doctor or physical therapist says otherwise. Afterward, doing the exercises 2 to 3 days a week maintains your strength and motion and protects your hips over the long term.

Getting started

• Warm up. Walk or ride a stationary bike for 5 to 10 minutes of easy, low-impact activity first.
• Order. Do the stretches first, then the strengthening exercises, then repeat the stretches to finish.
• Do not ignore pain. You should not feel pain during an exercise. Talk to your doctor or therapist if you do.
• Ask questions. If you are unsure how to do an exercise or how often, ask your doctor or physical therapist.

Stretching exercises

Strengthening exercises

For the hip abduction, adduction and extension exercises, begin with a weight that allows 8 repetitions and work up to 12. When that becomes easy, add ankle weight in 1-pound steps and start again at 8.

Follow-Up

Please keep your follow-up appointments so we can check your progress and decide whether further testing or surgery should be discussed.

Learn More

• OrthoInfo (AAOS): Adolescent Hip Dysplasia: https://orthoinfo.aaos.org/en/diseases--conditions/adolescent-hip-dysplasia/
• OrthoInfo (AAOS): Hip Conditioning Program: https://orthoinfo.aaos.org/en/recovery/hip-conditioning-program/
• Ohio State Wexner Medical Center: Hip Dysplasia in Adults: https://wexnermedical.osu.edu/orthopedics/hip/hip-dysplasia

Clinical Sources

• Krivicich LM, Rice M, Sivasundaram L, Nho SJ. Borderline dysplastic hips undergoing hip arthroscopy achieve equivalent patient-reported outcomes when compared with hips with normal acetabular coverage: a systematic review and meta-analysis. J Am Acad Orthop Surg. 2023;31(6):e336-e346.
• Nepple JJ, Fowler LM, Larson CM. Decision-making in the borderline hip. Sports Med Arthrosc Rev. 2021;29(1):15-21.
• American Academy of Orthopaedic Surgeons. Adolescent Hip Dysplasia. OrthoInfo.
• American Academy of Orthopaedic Surgeons. Hip Conditioning Program (exercise handout), 2026. OrthoInfo.

A Home Exercise Program for Hip Strength and Flexibility

Stretching and strengthening exercises to support the hip after an injury or as part of your treatment plan

Lafi S. Khalil, MD, FAANA

Purpose of the Program

After an injury, or as part of treating a hip condition, a structured conditioning program helps you return to daily activities, sports and recreation.

• Strength. Strong muscles around the hip keep the joint stable, relieve pain and help prevent further injury.
• Flexibility. Stretching the muscles you strengthen restores range of motion, reduces soreness and helps prevent injury.
• Target muscles: gluteus maximus and medius (buttocks), hamstrings (back of thigh), piriformis (deep buttock), adductors (inner thigh), and abductors and tensor fascia (outer thigh).
• Length. Continue for 4 to 6 weeks unless told otherwise, then 2 to 3 days a week as lifelong maintenance.

The Exercises

Do the program as described below. Your doctor or physical therapist may add, remove or modify exercises to fit your hip and your goals.

Getting started

• Warm up. Walk or ride a stationary bike for 5 to 10 minutes of easy, low-impact activity first.
• Order. Do the stretches first, then the strengthening exercises, then repeat the stretches to finish.
• Do not ignore pain. You should not feel pain during an exercise. Talk to your doctor or therapist if you do.
• Ask questions. If you are unsure how to do an exercise or how often, ask your doctor or physical therapist.

Stretching exercises

Strengthening exercises

For the hip abduction, adduction and extension exercises, begin with a weight that allows 8 repetitions and work up to 12. When that becomes easy, add ankle weight in 1-pound steps and start again at 8.

Follow-Up

Please keep your scheduled follow-up appointments so we can check your progress and adjust your plan as needed.

Learn More

• OrthoInfo (AAOS): Hip Conditioning Program: https://orthoinfo.aaos.org/en/recovery/hip-conditioning-program/
• OrthoInfo (AAOS): printable Hip Conditioning Program (PDF): https://www.orthoinfo.org/globalassets/pdfs/hip-conditioning-program-2026.pdf

Clinical Sources

• American Academy of Orthopaedic Surgeons. Hip Conditioning Program (exercise handout), 2026. OrthoInfo.

Adhesive Capsulitis: Home Care and Recovery

A step-by-step guide to understanding and treating frozen shoulder at home

Lafi S. Khalil, MD, FAANA

What Is Frozen Shoulder?

Frozen shoulder, also called adhesive capsulitis, causes shoulder pain and stiffness that gradually get worse. The shoulder joint is surrounded by a capsule of tissue that normally allows a wide range of motion. In frozen shoulder, the capsule becomes inflamed, thickened and tight, and bands of scar-like tissue (adhesions) form. The shoulder becomes hard to move, both when you try to move it and when someone else moves it for you.

It most often affects people between 40 and 60 and is more common in women. Diabetes and thyroid disease raise the risk, and it can follow an injury, surgery or any time the shoulder was kept still. Often no clear cause is found.

The Three Stages

Full recovery commonly takes 1 to 3 years. This is frustrating, but most people improve substantially with time and consistent home exercise, without surgery.

How Frozen Shoulder Is Treated

Treatment is stepped: we start with the simplest options and add more only if needed.

• Pain relief. Over-the-counter anti-inflammatory medicines (ibuprofen, naproxen) or acetaminophen, as directed on the label, can make stretching more tolerable.
• Physical therapy and home exercise. The most important treatment. Consistent, gentle daily stretching is what restores motion.
• Cortisone injection into the joint. It works best earlier in the course and may shorten how long symptoms last.
• Hydrodilatation ("brisement"). If pain and stiffness persist, an image-guided injection of a larger volume of fluid with cortisone and numbing medicine gently stretches the capsule from the inside, usually followed right away by physical therapy.
• Surgery (rarely needed). If there is no meaningful improvement after about 9 to 12 months, options include manipulation under anesthesia or arthroscopic capsular release. Physical therapy afterward is essential.

What the research says: Most patients recover with nonsurgical care, and an early cortisone injection appears to shorten the overall course (Redler 2019). A review of hydrodilatation found it gave greater short-term improvements in disability and outward rotation than a standard cortisone injection, and intensive therapy afterward is a promising addition (Poku 2023).

If you have diabetes, keeping your blood sugar well controlled can help recovery. Note that a cortisone injection can raise blood sugar for several days.

Home Exercise Program

Warm the shoulder first with a warm shower or heating pad for 10 to 15 minutes. Mild to moderate discomfort (about 4 to 5 out of 10) is expected. Sharp or worsening pain means you are pushing too hard: ease off and try again next session. Frequent, gentle sessions work better than occasional aggressive ones.

Stretches (all stages)

Start these as soon as you are diagnosed, keeping them gentle in the painful "freezing" stage and progressing as pain allows.

Your therapist may add cane stretches, holding a cane or broomstick in both hands to guide the affected arm overhead, out to the side and into outward rotation. Each is usually held about 10 seconds, 10 reps, 2 to 3 times a day.

Strengthening (once motion starts to improve)

Add shoulder-blade squeezes, shrugs and gentle isometric pushes into a wall (forward, back, out and in, holding 5 seconds, 10 reps) as motion returns.

When to Consider More Treatment

• Pain or stiffness has not started improving after 2 to 3 months of consistent home exercise.
• Pain is severe enough that you cannot stretch, even with over-the-counter medicine.
• You are approaching 9 to 12 months without meaningful improvement; this is when we discuss hydrodilatation, manipulation or capsular release.

Follow-Up

Please keep your scheduled follow-up appointments so we can check your progress and adjust your plan as needed.

Learn More

• OrthoInfo (AAOS): Frozen Shoulder: https://orthoinfo.aaos.org/en/diseases--conditions/frozen-shoulder/
• OrthoInfo (AAOS): printable Frozen Shoulder overview (PDF): https://www.orthoinfo.org/globalassets/pdfs/frozen-shoulder.pdf

Clinical Sources

• Redler LH, Dennis ER. Treatment of adhesive capsulitis of the shoulder. J Am Acad Orthop Surg. 2019;27(12):e544-e554.
• Poku D, Hassan R, Migliorini F, Maffulli N. Efficacy of hydrodilatation in frozen shoulder: a systematic review and meta-analysis. Br Med Bull. 2023;147(1):121-147.
• American Academy of Orthopaedic Surgeons. Frozen Shoulder. OrthoInfo.

A Guide for Young, Active Patients and Athletes with Loose Joints

Understanding, treating and managing a shoulder that slips in more than one direction

Lafi S. Khalil, MD, FAANA

Understanding Your Shoulder Instability

The shoulder is the most mobile joint in the body. It trades a shallow socket for a huge range of motion and relies on the ligaments, capsule and muscles around it to stay centered. Multidirectional instability (MDI) means the shoulder partially slips (subluxates) or dislocates in more than one direction, usually some combination of forward, backward and downward.

Laxity is a shoulder that moves more than average without causing symptoms. Instability is when that extra movement causes pain, a slipping or "dead arm" feeling, apprehension or actual dislocation. Many people have loose shoulders and never have a problem; MDI is diagnosed only when the looseness causes symptoms.

MDI is most common in the teens and twenties and in people with generally loose joints. It is also seen in athletes who repeat overhead motions thousands of times a season, such as swimmers, gymnasts, volleyball and baseball players, and weightlifters.

Why it happens

In some people the capsule and ligaments are naturally stretchy. This can run in families, appear with looseness in other joints (elbows, knees, thumbs, fingers), or develop from years of overhead sport. Because the socket is shallow, stability depends on the rotator cuff and shoulder-blade muscles keeping the ball centered. In MDI these muscles often are not firing in the right sequence, which is exactly what a structured exercise program retrains.

How We Treat MDI: Rehabilitation Comes First

For most patients, especially when there was no major injury, a dedicated exercise program is the right first treatment. It needs a real trial: at least 3 to 6 months of consistent, well-done therapy. Patients who are going to improve usually show it within the first 3 months.

What the research says: In a classic study of a structured strengthening program, 80% of shoulders with atraumatic instability had good or excellent results (Burkhead 1992). A review of 861 shoulders found that only about 1 in 5 patients (21%) treated with physiotherapy went on to need surgery (Longo 2015). High-quality trials are still lacking, so the exact benefit of exercise remains uncertain (Karasuyama 2026), but it remains the recommended first step.

If a real trial of therapy does not control your symptoms, arthroscopic capsular plication, a keyhole procedure that takes up slack in the stretched capsule, is the modern surgical option, with results comparable to older open surgery.

Activity Guidance

• Early on, avoid positions that provoke symptoms: hanging or pull-ups, forceful overhead lifting, reaching behind your back while lifting and sleeping with the arm overhead.
• Treat pain, a feeling of looseness or apprehension as cues to modify a movement, not to push through.
• You can usually continue sport as tolerated; let your coach, athletic trainer or therapist know about pain or apprehension so technique or load can be adjusted.
• Keep your shoulder blades gently back and down through the day rather than letting your shoulders round forward.
• Therapy does not "tighten" ligaments. It builds the muscle control that keeps the looseness from causing symptoms.
• Expect good days and bad days, especially early in therapy and during growth spurts.

Home Exercise Program

Focus on quality of movement over resistance. Muscle fatigue is expected; sharp pain, a slipping feeling or symptoms lasting more than a couple of hours are not. Unlike a stiff shoulder, more flexibility is not the goal: these exercises avoid stretching into the loose directions.

Physical Therapy

Retraining the timing of the shoulder-blade and rotator cuff muscles usually needs more than a home program, so we typically refer patients with MDI to formal physical therapy early. Your therapist will add scapular stabilization, progressive rotator cuff strengthening, body-awareness drills and a gradual, sport-specific return. Plan on at least 3 to 6 months.

Long-Term Outlook

• MDI often improves over time as tissues stiffen somewhat with age.
• Return to sport is guided by little or no pain or apprehension and strength close to the other side, not by a calendar date.
• If you also bruise easily, have unusually stretchy skin or pain in several joints, tell us; an evaluation for a connective tissue condition such as Ehlers-Danlos syndrome may be worthwhile.
• Surgery remains an option later if a sustained course of therapy does not control your symptoms; most patients who need it still do well.

Follow-Up

Please keep your scheduled follow-up appointments so we can check your progress and adjust your plan as needed.

Learn More

• OrthoInfo (AAOS): Chronic Shoulder Instability and Dislocation: https://orthoinfo.aaos.org/en/diseases--conditions/chronic-shoulder-instability/

Clinical Sources

• Longo UG, Rizzello G, Loppini M, et al. Multidirectional instability of the shoulder: a systematic review. Arthroscopy. 2015;31(12):2431-2443.
• Burkhead WZ Jr, Rockwood CA Jr. Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am. 1992;74(6):890-896.
• Warby SA, Pizzari T, Ford JJ, Hahne AJ, Watson L. Exercise-based management versus surgery for multidirectional instability of the glenohumeral joint: a systematic review. Br J Sports Med. 2016;50(18):1115-1123.
• Karasuyama M, Imai T, Gotoh M, et al. Exercise for multidirectional instability of the shoulder. Cochrane Database Syst Rev. 2026;2:CD015450.
• Hippensteel KJ, Uppstrom TJ, Rodeo SA, Warren RF. Comprehensive review of multidirectional instability of the shoulder. J Am Acad Orthop Surg. 2023;31(16):871-880.
• Best MJ, Tanaka MJ. Multidirectional instability of the shoulder: treatment options and considerations. Sports Med Arthrosc Rev. 2018;26(3):113-119.
• Gaskill TR, Taylor DC, Millett PJ. Management of multidirectional instability of the shoulder. J Am Acad Orthop Surg. 2011;19(12):758-767.
• Ruiz Ibán MA, Díaz Heredia J, García Navlet M, Serrano F, Santos Oliete M. Multidirectional shoulder instability: treatment. Open Orthop J. 2017;11:812-825.

A Guide for Overhead Athletes and Baseball Pitchers

Understanding, correcting and monitoring loss of throwing-shoulder internal rotation, with a full home exercise program

Lafi S. Khalil, MD, FAANA

What Is GIRD?

Glenohumeral internal rotation deficit (GIRD) is a loss of internal rotation (rolling the arm inward) in the throwing shoulder compared with the other shoulder. It is measured lying on your back with the shoulder out to the side at 90° and the elbow bent to 90°. GIRD is generally defined as a loss of 20° or more compared with the non-throwing side.

Repeated throwing, especially the extreme cocked-back position of a pitch, gradually stretches the front of the shoulder capsule. In response, the back of the capsule and the rotator cuff tighten, and the arm bone itself can remodel. Together these shift the arc of motion backward: more external rotation, less internal rotation.

Not all GIRD is a problem. Total rotational motion (external plus internal rotation) often matters more than internal rotation alone. When total motion in the throwing shoulder is within about 5° of the other side, the shift is usually a normal adaptation to throwing. "Pathologic" GIRD is a true loss of total motion, and that pattern is most associated with problems.

Why It Matters

Pathologic GIRD has been associated with:

• Tears of the labrum at the top and back of the socket, including SLAP tears
• Partial tears of the underside of the rotator cuff, from the cuff pinching between the ball and socket rim during the cocking phase ("internal impingement")
• Deep, aching pain in the back of the shoulder, a longer warm-up, and loss of velocity or command ("dead arm")

What the research says: A meta-analysis of more than 2,000 overhead athletes found a trend toward more arm injuries with GIRD, less total motion and larger external-rotation gains, but none of these reached statistical significance (Keller 2018). Tracking total motion is at least as important as the internal rotation number, and correcting back-of-shoulder tightness remains standard care for any thrower with symptoms.

How GIRD Is Treated

The mainstay of treatment is consistent stretching of the back of the shoulder, combined with shoulder-blade and rotator cuff strengthening and attention to posture. This is almost always successful without surgery (Rose 2018).

• Stretching works. In a randomized trial of overhead athletes with GIRD and shoulder pain, both the sleeper stretch and the cross-body stretch, done 3 times a week for 4 weeks, reduced pain and improved internal rotation by about 15°, with no clear advantage of one over the other (de Araújo 2026).
• The evidence holds up. A meta-analysis of 6 randomized trials (255 athletes) found sleeper stretching, alone or with cross-body stretching, improved internal rotation by about 7° and cross-body motion by about 6° compared with no stretching (Iida 2026).
• Consistency beats intensity. Gentle, frequent stretching works better than occasional aggressive stretching. Keep it going through the season as a maintenance habit.
• Surgery is rarely needed. A release of the tight back of the capsule is reserved for the few throwers who do not respond to a sustained, well-done program.

Home Exercise Program

Some tension is expected during stretches: aim for mild discomfort, never sharp or lasting pain. Stop and let us know if an exercise consistently increases your pain.

Posture (all day)

Posterior shoulder stretches

Shoulder blade and rotator cuff strengthening

A tight back of the shoulder and a weak shoulder blade and rotator cuff tend to go together in throwers.

Round out your program with core and hip strength and a review of throwing mechanics, which are just as important to the throwing chain as the shoulder itself.

Monitoring and Prevention

• Have your internal and external rotation checked by your athletic trainer, physical therapist or physician before the season and whenever you notice stiffness or a drop in performance.
• Follow pitch count and rest guidelines for your age, such as MLB Pitch Smart.
• Keep up your stretching and shoulder-blade program even when you feel good.
• Avoid year-round throwing and single-sport specialization when possible; take time off between seasons.

Follow-Up

Please keep your follow-up appointments so we can re-check your motion, track your progress and adjust your program.

Learn More

• OrthoInfo (AAOS): Shoulder Injuries in the Throwing Athlete: https://orthoinfo.aaos.org/en/diseases--conditions/shoulder-injuries-in-the-throwing-athlete
• OrthoInfo (AAOS): Baseball & Softball Injury Prevention: https://orthoinfo.aaos.org/en/staying-healthy/baseball-injury-prevention/
• MLB Pitch Smart: Pitching Guidelines: https://www.mlb.com/pitch-smart/pitching-guidelines

Clinical Sources

• Rose MB, Noonan T. Glenohumeral internal rotation deficit in throwing athletes: current perspectives. Open Access J Sports Med. 2018;9:69-78.
• de Araújo JN, Oliveira ABA, de Araújo DLF, et al. The effects of sleeper stretch vs. crossbody stretch in overhead athletes with shoulder pain and glenohumeral internal rotation deficit: a randomized controlled trial. J Shoulder Elbow Surg. 2026;35(7):1832-1840.
• Iida N, Velasquez Garcia A, Kuroiwa T, Hsu KL, Selim OA. Role of stretching interventions in enhancing the shoulder range of motion in overhead athletes with glenohumeral internal rotation deficit: a systematic review and meta-analysis. PM R. 2026;18(2):200-209.
• Keller RA, De Giacomo AF, Neumann JA, Limpisvasti O, Tibone JE. Glenohumeral internal rotation deficit and risk of upper extremity injury in overhead athletes: a meta-analysis and systematic review. Sports Health. 2018;10(2):125-132.

A Guide for Young Throwing Athletes, Parents and Coaches

Why growing arms get hurt, why rest and a slow, step-by-step return matter, and what the road back looks like

Lafi S. Khalil, MD, FAANA

What Are Little League Shoulder and Elbow?

Children and teens are still growing. At the ends of their bones are soft areas of growing cartilage called growth plates. Growth plates are the weakest link in a young arm, weaker than nearby tendons and ligaments. When a young athlete throws over and over, small amounts of damage can add up in a growth plate faster than the body can repair it. That overuse injury is "Little League" shoulder or elbow.

Despite the name, these injuries are not limited to Little League or baseball. They affect softball players, quarterbacks, tennis and cricket players, and any growing athlete who throws or serves overhead many times.

Why This Happens

• Immature anatomy. Throwing twists the upper arm bone and pulls hard on the inside of the elbow; growth cartilage cannot tolerate as much force as adult bone.
• Developing mechanics. Young pitchers often rotate the trunk too early, leaving the arm behind and increasing strain.
• Too much, too often, too tired. Year-round play, multiple teams, showcases and no off-season all add up. Throwing with a tired arm and single-sport specialization are strong risk factors.
• A tight back of the shoulder (GIRD). In one study, youth pitchers with elbow pain had an average internal-rotation loss of about 33°, compared with about 15° in pitchers without pain (Rosen 2022).

The Danger of Not Resting, or Coming Back Too Fast

Pain is the arm's warning light. Pushing through it, returning early or jumping straight back to full-speed pitching can turn a treatable overuse injury into a lasting one.

• Shoulder: the growth plate can stay widened or widen further. Rarely, it can close early or change the twist of the arm bone.
• Elbow: repeated pulling can progress to a pulled-off piece of bone; fragments displaced more than about 5 mm are often treated with surgery. Ligament (UCL) injuries and cartilage injuries on the outer elbow can also develop.

What happened to young players 5 years later: In 61 youth players treated without surgery, more than 80% returned to competition, but up to 40% changed positions. Symptoms came back in more than 1 in 5, on average about 9 months after diagnosis, and fewer than half were still playing baseball 5 years later; players whose symptoms returned were less likely to still be playing and had worse arm function (Jensen 2024). A review of Little League shoulder found that about 94% returned to sport after rest (Bednar 2021).

The takeaway: most young throwers do well and surgery is uncommon, but the first months after diagnosis are the highest-risk window for pain to return. Respecting the rest period and progressing slowly gives the best chance of still playing years later.

How We Treat It

• Rest from throwing until the growth plate has healed and pain is gone. Most athletes can keep working their legs and core and play non-throwing sports if pain-free and cleared.
• Comfort and protection. Ice for soreness; a short period in a cast or splint only if the elbow bone is fragmented.
• Rehabilitation. Shoulder-blade control, rotator cuff and forearm strength, core and leg strength, balance, and back-of-shoulder stretching if internal rotation is tight, plus a review of throwing mechanics.
• Graded return to throwing with a written, step-by-step interval throwing program.
• Position changes. Many centers advise avoiding pitching and catching for up to 12 months after diagnosis.
• Surgery is rarely needed, mainly for a displaced elbow bone fragment.

Protocol at a Glance

This is a general framework. Your timeline depends on age, symptoms, imaging and exam. Skipping a step is a common reason pain comes back.

Pitch Smart: Daily Limits and Required Rest

Major League Baseball's Pitch Smart guidelines set the maximum pitches per day and the days of rest needed afterward. They apply to game pitches and do not replace rest after a diagnosis. Parents should track pitches too.

Read across: the number of pitches thrown that day determines the days of rest needed. Check the current guidelines at mlb.com/pitch-smart.

Tips for Parents and Coaches

• Treat arm pain as a stop sign. Pain, a tired arm or a drop in velocity or accuracy means stop and tell an adult.
• Count pitches and track rest days across all teams, practices and showcases.
• Take a true off-season from overhead throwing (2–3 months; 4 is ideal) and let kids play other sports.
• Do not let a player "test it out" on game day. Restart throwing only through the written program.
• Invest in sound mechanics and a year-round strength and mobility routine.

Follow-Up

Please keep all follow-up visits. We will re-examine the arm, repeat x-rays if needed and clear each stage before you move on.

Learn More

• MLB Pitch Smart: Pitching Guidelines: https://www.mlb.com/pitch-smart/pitching-guidelines
• American Sports Medicine Institute: Position Statement for Adolescent Baseball Pitchers: https://asmi.org/position-statement-for-adolescent-baseball-pitchers/
• OrthoInfo (AAOS): Throwing Injuries in the Elbow in Children: https://orthoinfo.aaos.org/en/diseases--conditions/throwing-injuries-in-the-elbow-in-children/

Clinical Sources

• Jensen EJ, Pennock AT, Hulbert MA, Tadlock JC, Paranjape CS, Bryan TP. What happens to youth baseball players diagnosed with Little League shoulder and Little League elbow syndrome? J Pediatr Orthop. 2024;44(8):e722-e726.
• Ina J, Soma D, Camp C, Pulos N. Treatment and prevention of injuries in skeletally immature throwing athletes. J Am Acad Orthop Surg. 2026;34(2):e151-e160.
• Bednar ED, Kay J, Memon M, et al. Diagnosis and management of Little League shoulder: a systematic review. Orthop J Sports Med. 2021;9(7):23259671211017563.
• Rosen M, Meijer K, Tucker S, et al. Shoulder range of motion deficits in youth throwers presenting with elbow pain. Sports Health. 2022;14(4):478-482.

A Guide for Patients with a Fracture at the Top of the Arm Bone

How these fractures heal, how to care for your arm at home, and when to start moving

Lafi S. Khalil, MD, FAANA

Understanding Your Fracture

The humerus is the upper arm bone, running from the shoulder to the elbow. A proximal humerus fracture is a break near the top of the bone, just below the ball of the shoulder joint. It usually happens from a fall onto the arm or shoulder and is especially common in older adults with thinner bones.

Fractures range from a hairline crack to a bone broken into several pieces. Most of these fractures are treated without surgery. The goal is for the bone to heal while restoring as much shoulder motion and function as possible, which requires a balance of rest and early, gentle motion.

What the research says: In a large randomized trial of adults with displaced fractures involving the neck of the humerus, patients treated with a sling did as well at 2 years as those treated with surgery (Rangan 2015), and a Cochrane review found that surgery did not improve outcomes for most of these fractures but did increase the chance of another operation (Handoll 2015). Starting gentle motion within about 1 week of injury is safe and may speed early recovery (Challoumas 2025).

What to Expect

• Most people begin to feel better within 3 to 4 weeks.
• Most return to most activities by 3 to 4 months, but full recovery can take 6 to 12 months.
• Bruising often spreads down the arm toward the elbow and even the chest over the first week or two. This is normal.
• Some stiffness is common; your exercises are the best way to limit it.

Caring for Your Arm at Home

• Ice the shoulder for 10 to 20 minutes every 1 to 2 hours while awake for the first 3 days, with a thin cloth between the ice and your skin.
• Sling for comfort. The sling is not required for healing. You may remove it for bathing, sleeping or whenever you are comfortable without it, unless we tell you otherwise.
• Sleeping is often easier sitting up on several pillows or in a recliner.
• Pain medicine. Take prescription medicine exactly as directed. If you are not taking a prescription, ask us before using an over-the-counter medicine.
• Keep the hand, wrist and elbow moving. Wiggle your fingers and bend and straighten the wrist and elbow several times a day to reduce swelling and stiffness.

Early Motion Exercises

Begin shoulder motion as pain allows. It may be too uncomfortable for the first 7 to 10 days; that is okay. Gentle motion should not cause sharp pain.

We will add more shoulder exercises and, when the bone is healing, physical therapy to restore motion and strength.

Protecting your bones

A fracture from a simple fall can be a sign of thinning bones (osteoporosis). Ask us or your primary care doctor whether you should have a bone density test, and see our Vitamin D and Calcium handout.

Follow-Up

Follow-up visits and x-rays are an important part of your care. They let us confirm the fracture is healing in good position and advance your exercises.

Learn More

• OrthoInfo (AAOS): Shoulder Trauma (Fractures and Dislocations): https://orthoinfo.aaos.org/en/diseases--conditions/shoulder-trauma-fractures-and-dislocations/
• OrthoInfo (AAOS): Fragility Fractures: Frequently Asked Questions: https://www.orthoinfo.org/diseases--conditions/fragility-fractures-frequently-asked-questions/

Clinical Sources

• Rangan A, Handoll H, Brealey S, et al. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015;313(10):1037-1047.
• Handoll HH, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2015;(11):CD000434.
• Challoumas D, Minhas H, Bagni S, Millar N. Early versus delayed mobilisation for non-surgically treated proximal humerus fractures: a systematic review and meta-analysis of randomised trials. BMC Musculoskelet Disord. 2025;26(1):203.
• American Academy of Orthopaedic Surgeons. Shoulder Trauma (Fractures and Dislocations). OrthoInfo.

A Guide for Patients with Pain at the Back of the Heel

Also called insertional Achilles tendinopathy, retrocalcaneal bursitis or Haglund's deformity

Lafi S. Khalil, MD, FAANA

Understanding the Condition

The Achilles tendon connects the calf muscles to the heel bone. Insertional Achilles tendinitis is irritation and wear of the tendon right where it attaches to the heel. It often comes with a bony bump on the back of the heel (Haglund's deformity), bone spurs within the tendon, and an inflamed fluid sac (bursa) between the tendon and the bone.

Symptoms

• Pain and swelling at the back of the heel where the tendon attaches
• "Start-up" pain that is worse when you first stand after sitting or in the morning
• A tender, sometimes visible bump at the back of the heel, often rubbed by shoes
• Symptoms that come on gradually, sometimes flaring with a jump in activity

It is most common in middle age and is associated with a tight calf and higher body weight.

Diagnosis

The diagnosis is made by examining the heel. X-rays show the heel bump and any spurs in the tendon. An MRI is usually not needed but can show tendon damage and fluid in the bursa.

Treatment

Nonsurgical treatment controls symptoms for most people. It usually happens in three overlapping phases: settle the pain, gradually increase activity, then keep symptoms under control.

• Heel lift or a shoe with a modest heel to take tension off the tendon. Choose shoes with a soft or open back that do not press on the bump.
• Activity modification. Cut back on running, hills and jumping; cycling and swimming are good alternatives.
• Exercise and physical therapy, especially calf strengthening (see below).
• Ice for 15 to 20 minutes after activity, and weight loss if needed.
• Shockwave therapy (ESWT) is a helpful option if symptoms persist.
• Cortisone is generally avoided in or near the Achilles tendon because it can weaken it.

What the research says: Reviews of the research found that calf-strengthening exercises and low-energy shockwave therapy have the best evidence as first treatments for insertional Achilles tendinopathy, and that shockwave combined with exercise may work best (Jarin 2021; Zhi 2021).

Home Exercise Program

Mild discomfort (up to 3 to 4 out of 10) is acceptable if it settles by the next morning. With insertional tendinitis, do these on a flat floor, not off the edge of a step, because dropping the heel below the step can pinch the tendon against the heel bone.

Surgery

Surgery is reserved for severe symptoms that do not improve after several months of well-done nonsurgical treatment. Recovery is long, often 6 to 12 months. Surgery may include removing the heel bump (Haglund's deformity) and bone spurs, removing damaged tendon and the inflamed bursa, reattaching the tendon to the heel bone, and sometimes transferring a nearby tendon (the tendon that bends the big toe) to reinforce the Achilles.

Follow-Up

Please keep your scheduled follow-up appointments so we can check your progress and adjust your plan as needed.

Learn More

• OrthoInfo (AAOS): Achilles Tendinitis: https://orthoinfo.aaos.org/en/diseases--conditions/achilles-tendinitis/

Clinical Sources

• Jarin IJ, Bäcker HC, Vosseller JT. Functional outcomes of insertional Achilles tendinopathy treatment: a systematic review. JBJS Rev. 2021;9(6):e20.00110.
• Zhi X, Liu X, Han J, et al. Nonoperative treatment of insertional Achilles tendinopathy: a systematic review. J Orthop Surg Res. 2021;16(1):233.
• American Academy of Orthopaedic Surgeons. Achilles Tendinitis. OrthoInfo.

Image-Guided Cortisone and Numbing Injection into the Hip

What is in the injection, what to expect afterward, and a pain diary to bring to your next visit

Lafi S. Khalil, MD, FAANA

About Your Injection

A hip joint injection places medicine directly into the hip joint using x-ray or ultrasound guidance, because the hip lies deep and cannot be felt from the skin. You will receive instructions on how to schedule it.

Why the first hours matter

Because the numbing medicine works right away, how your hip feels in the first several hours helps show whether the joint itself is the source of your pain. That is why we ask you to keep the pain diary on the last page and bring it to your next visit.

What the research says: In patients with hip impingement, a hip injection relieved pain for about 4 in 5 patients. Patients who got little or no relief were less likely to improve after hip arthroscopy, which is why your response helps guide treatment decisions (Ayeni 2014; Lynch 2016).

After Your Injection

• Take it easy for 3 to 5 days. Avoid exercise and heavy use of the hip so the medicine can work.
• Normal, temporary reactions (not everyone has them): facial flushing or warmth for a day or two, and mild to moderate soreness or swelling at the injection site for about 24 hours.
• Possible skin changes (uncommon): lightening of the skin color at the site, more noticeable with darker skin, or a small dimple from thinning of the fat under the skin.

If the site is sore

• Apply ice or a cold pack for 20 minutes on, then at least 40 minutes off, with a cloth between the ice and your skin. Never leave it on longer than 20 minutes at a time.
• Acetaminophen (Tylenol) as directed on the label, unless you are allergic to it, for up to 48 hours.
• Ibuprofen (Advil, Motrin) or naproxen (Aleve) as directed on the label for up to 48 hours, unless you are allergic to anti-inflammatory medicines or have kidney or stomach problems.

Follow-Up

Please bring your completed pain diary to your next visit so we can review your response and plan next steps.

Hip Injection Pain Diary

For the 12 hours after your injection, describe your pain. Write down what you were doing, the type of pain (aching, burning, throbbing or sharp), where it is (groin, side of the hip, buttock) and rate it from 1 (minimal) to 10 (worst imaginable).

Learn More

• OrthoInfo (AAOS): Cortisone Shot (Steroid Injection): https://orthoinfo.aaos.org/en/treatment/cortisone-shot-steroid-injection/
• OrthoInfo (AAOS): Hip Osteoarthritis: https://orthoinfo.aaos.org/en/diseases--conditions/osteoarthritis-of-the-hip

Clinical Sources

• Ayeni OR, Farrokhyar F, Crouch S, et al. Pre-operative intra-articular hip injection as a predictor of short-term outcome following arthroscopic management of femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc. 2014;22(4):801-805.
• Lynch TS, Steinhaus ME, Popkin CA, Ahmad CS, Rosneck J. Outcomes after diagnostic hip injection. Arthroscopy. 2016;32(8):1702-1711.
• American Academy of Orthopaedic Surgeons. Cortisone Shot (Steroid Injection). OrthoInfo.

What PRP Is, What It Can Treat and What to Expect

A guide to preparing for and recovering from a PRP injection

Lafi S. Khalil, MD, FAANA

What Is PRP?

Blood is mostly liquid (plasma) plus red cells, white cells and platelets. Platelets are best known for clotting, but they also carry hundreds of proteins called growth factors that signal the body to repair tissue and calm inflammation. Platelet-rich plasma (PRP) is your own blood, spun in a machine (centrifuge) so it contains several times more platelets than normal.

Blood is drawn from your arm, processed in the office, and the PRP is injected into the injured area, often with ultrasound guidance. The visit takes about 30 to 60 minutes.

PRP is not a cure and does not regrow a worn-out joint. The goal is to reduce pain, improve function and help you stay active, as one part of a plan that includes exercise or physical therapy.

What Can PRP Treat?

Who May Not Be a Good Candidate

• An infection in the area or elsewhere, or a fever
• Active cancer, especially blood cancers, or recent cancer treatment
• A low platelet count or bleeding disorder
• Pregnancy
• Severe ("bone-on-bone") arthritis, where PRP is less likely to help

Before Your Injection

• Stop anti-inflammatory medicines for 1 week before, such as ibuprofen (Advil, Motrin), naproxen (Aleve), meloxicam, diclofenac and celecoxib (Celebrex). They may weaken the effect of the platelets.
• Do not stop a prescribed blood thinner or daily heart aspirin without talking with the doctor who prescribed it.
• Drink plenty of water and eat a normal meal; this makes the blood draw easier.
• Wear loose clothing that lets us reach the area.

After Your Injection

• A flare of pain and swelling for 2 to 5 days is common, and after a tendon injection it can last 1 to 2 weeks. This is expected and does not mean the treatment failed.
• Ice for 15 to 20 minutes at a time, with a cloth between the ice and your skin. Acetaminophen (Tylenol) is fine as directed on the label.
• Avoid anti-inflammatory medicines for 2 weeks after the injection.

When to expect results: PRP works slowly. Most people notice improvement in 6 to 12 weeks, and the full benefit can take 3 to 6 months. Some people do not improve.

Cost and Insurance

PRP is usually not covered by insurance, including Medicare and workers' compensation. We will give you the cost before you schedule, and you will sign a consent form. Cortisone injections, physical therapy and bracing remain covered options we are happy to discuss.

Risks

Because PRP comes from your own blood, the risk of allergic reaction is very low. Possible side effects include a temporary pain flare, swelling, stiffness and bruising. Infection, bleeding and nerve injury are rare.

Follow-Up

Please keep your scheduled follow-up appointments so we can check your progress and adjust your plan as needed.

Learn More

• OrthoInfo (AAOS): Platelet-Rich Plasma (PRP): https://orthoinfo.aaos.org/en/treatment/platelet-rich-plasma-prp/
• OrthoInfo (AAOS): Orthobiologics (Regenerative Medicine) FAQ: https://orthoinfo.aaos.org/en/treatment/orthobiologics-faq

Clinical Sources

• Belk JW, Kraeutler MJ, Houck DA, et al. Platelet-rich plasma versus hyaluronic acid for knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. Am J Sports Med. 2021;49(1):249-260.
• Fitzpatrick J, Bulsara MK, O'Donnell J, Zheng MH. Leucocyte-rich platelet-rich plasma treatment of gluteus medius and minimus tendinopathy: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med. 2019;47(5):1130-1137.
• Mishra AK, Skrepnik NV, Edwards SG, et al. Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients. Am J Sports Med. 2014;42(2):463-471.
• Kearney RS, Ji C, Warwick J, et al. Effect of platelet-rich plasma injection vs sham injection on tendon dysfunction in patients with chronic midportion Achilles tendinopathy: a randomized clinical trial. JAMA. 2021;326(2):137-144.
• American Academy of Orthopaedic Surgeons. Platelet-Rich Plasma (PRP). OrthoInfo.

Platelet-Rich Plasma (PRP), Bone Marrow Aspirate Concentrate (BMAC) and Hyaluronic Acid (HA): what they are, what they can treat and what to expect

Lafi S. Khalil, MD, FAANA

Understanding Orthobiologics

Orthobiologics are treatments made from natural substances, most often taken from your own body, that are used to calm pain and support healing in joints, tendons, ligaments, muscles and bone. You may also hear them called "regenerative medicine." They are given as an injection, usually in the office, and often with ultrasound to guide the needle to the exact spot.

Orthobiologics are not a cure, and they do not regrow a worn-out joint. The goal is to reduce pain, improve function and help you stay active, and in some cases to delay the need for surgery. They work best as one part of a plan that also includes exercise or physical therapy, activity changes and, when needed, weight management.

What the research says: In a review of 18 high-quality studies of knee arthritis, PRP improved pain and function scores by about 45%, compared with about 13% for hyaluronic acid (Belk 2021). For outer hip (gluteal) tendon pain, one PRP injection worked better than cortisone at 6 months, and the benefit lasted at least 2 years (Fitzpatrick 2019). For other conditions, such as Achilles and patellar tendon pain, well-designed studies have not shown a clear benefit. How well these treatments work depends on the condition, how severe it is, how the injection is prepared and your overall health.

The Three Main Types

Platelet-poor plasma (PPP) is the clear part of the blood left over after the platelets are removed. It is sometimes used for muscle strains.

Where Orthobiologics Are Used

Evidence key:Stronger = several good studies show benefit. Moderate = some benefit, or results vary. Limited = early, mixed or no clear benefit so far.

Who May Not Be a Good Candidate

• An infection in the area or elsewhere in the body, or a fever
• Active cancer, especially blood cancers, or a recent cancer treatment
• A low platelet count or a bleeding disorder
• Pregnancy
• Severe ("bone-on-bone") arthritis, where these treatments are less likely to help
• Hyaluronic acid only: an allergy to eggs, feathers or bird products (some brands are made from rooster combs)

Tell us if you take a blood thinner, or if you have had a cortisone injection in this area recently.

Before Your Injection

• Stop anti-inflammatory medicines for 1 week before PRP or BMAC. These include ibuprofen (Advil, Motrin), naproxen (Aleve), meloxicam, diclofenac and celecoxib (Celebrex). They may weaken the effect of the platelets. This is not needed for HA.
• Do not stop a prescribed blood thinner or daily heart aspirin without first talking with the doctor who prescribed it.
• Drink plenty of water the day before and the day of your injection, and eat a normal meal. This makes the blood draw easier.
• Wear loose, comfortable clothing that lets us reach the area.
• BMAC: if you are given medicine to help you relax, you will need someone to drive you home.

After Your Injection

What is normal

• A flare of pain and swelling for 2–5 days is common, and with tendon injections it can last 1–2 weeks. This is an expected reaction and does not mean the treatment failed.
• Bruising at the blood draw site or, for BMAC, soreness and bruising in the lower back or buttock for several days.

Pain control

• Ice the area for 15–20 minutes at a time, several times a day, with a cloth between the ice and your skin.
• Acetaminophen (Tylenol) is safe to use as directed on the label.
• Avoid anti-inflammatory medicines for 2 weeks after PRP or BMAC. They are fine after HA.

Activity

After HA: avoid strenuous activity for 48 hours, then return to normal activity as comfortable.

BMAC harvest site care

• Keep the bandage on for 24 hours. You may shower after that.
• Do not soak in a bath, pool or hot tub until the site has healed, usually 3–5 days.

When to expect results

Orthobiologics work slowly. Most people notice improvement in 6–12 weeks, and the full benefit can take 3–6 months. Some people do not improve. If you respond well, the injection can often be repeated in the future.

Cost and Insurance

• PRP and BMAC are usually not covered by insurance, including Medicare and workers' compensation, and most plans consider them investigational. We will give you the cost before you schedule, and you will sign a consent form before treatment.
• Your office visit, and an ultrasound when one is needed, may still be billed to your insurance.
• HA is often covered for knee arthritis, though some plans require prior approval or that other treatments be tried first.
• Cortisone injections, physical therapy and bracing remain covered options. We are happy to discuss them.

Risks and Safety

• Because PRP and BMAC come from your own body, the risk of an allergic reaction or rejection is very low.
• Possible side effects include a temporary pain flare, swelling, stiffness and bruising. Infection, bleeding and nerve or blood vessel injury are rare.
• Be cautious of clinics advertising "stem cell" cures or regrown cartilage. The FDA has not approved any stem cell product for orthopaedic conditions. Same-day treatments using your own tissue, like the ones we offer, are different from lab-grown cell products.

Follow-Up

Learn More

• OrthoInfo (AAOS): Orthobiologics (Regenerative Medicine) FAQ: https://www.orthoinfo.org/treatment/orthobiologics-faq/
• OrthoInfo: Platelet-Rich Plasma (PRP): https://www.orthoinfo.org/treatment/platelet-rich-plasma-prp/
• OrthoInfo: Viscosupplementation Treatment for Knee Arthritis: https://www.orthoinfo.org/treatment/viscosupplementation-treatment-for-knee-arthritis/
• OrthoInfo: Arthritis of the Knee: https://www.orthoinfo.org/diseases--conditions/arthritis-of-the-knee/
• OrthoInfo: Tennis Elbow: https://www.orthoinfo.org/diseases--conditions/tennis-elbow-lateral-epicondylitis/
• U.S. FDA: Important Patient and Consumer Information About Regenerative Medicine Therapies: https://www.fda.gov/vaccines-blood-biologics/consumers-biologics/important-patient-and-consumer-information-about-regenerative-medicine-therapies

Clinical Sources

1. Belk JW, et al. Platelet-rich plasma versus hyaluronic acid for knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. Am J Sports Med. 2021;49(1):249-260.
2. Dhillon J, Parry D, Kraeutler MJ. Current perspectives on platelet-rich plasma injections for knee osteoarthritis: how to optimize clinical outcomes. Open Access J Sports Med. 2025:179-186.
3. Corsini A, et al. Re-evaluating platelet-rich plasma dosing strategies in sports medicine: the role of the "10 billion platelet dose" in optimizing therapeutic outcomes. A narrative review. J Clin Med. 2025;14(8):2714.
4. Hernigou P, et al. Subchondral bone or intra-articular injection of bone marrow concentrate mesenchymal stem cells in bilateral knee osteoarthritis: what better postpone knee arthroplasty at fifteen years? A randomized study. Int Orthop. 2021;45(2):391-399.
5. Kon E, et al. Combined subchondral and intra-articular injections of bone marrow aspirate concentrate provide stable results up to 24 months. Knee Surg Sports Traumatol Arthrosc. 2023;31(6):2511-2517.
6. Park D, Koh HS, Choi YH, Park I. Bone marrow aspirate concentrate (BMAC) for knee osteoarthritis: a narrative review of clinical efficacy and future directions. Medicina (Kaunas). 2025;61(5):853.
7. Fitzpatrick J, et al. Leucocyte-rich platelet-rich plasma treatment of gluteus medius and minimus tendinopathy: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med. 2019;47(5):1130-1137.
8. Mishra AK, et al. Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients. Am J Sports Med. 2014;42(2):463-471.
9. Peng Y, et al. Comparison of the effects of platelet-rich plasma and corticosteroid injection in rotator cuff disease treatment: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2023. doi:10.1016/j.jse.2023.01.037
10. Scott A, et al. Platelet-rich plasma for patellar tendinopathy: a randomized controlled trial of leukocyte-rich PRP or leukocyte-poor PRP versus saline. Am J Sports Med. 2019;47(7):1654-1661.
11. Kearney RS, et al. Effect of platelet-rich plasma injection vs sham injection on tendon dysfunction in patients with chronic midportion Achilles tendinopathy: a randomized clinical trial. JAMA. 2021;326(2):137-144.
12. Chauhan A, et al. Nonoperative treatment of elbow ulnar collateral ligament injuries with and without platelet-rich plasma in professional baseball players: a comparative and matched cohort analysis. Am J Sports Med. 2019;47(13):3107-3119.
13. Kruse RC, et al. Platelet-poor versus platelet-rich plasma for the treatment of acute thigh muscle injuries. Am J Phys Med Rehabil. 2025;104(3):250-256.

Hyaluronic Acid ("Gel") Injections for Knee Arthritis

What gel injections are, what to expect, and how to care for your knee afterward

Lafi S. Khalil, MD, FAANA

What Is Viscosupplementation?

Healthy joint fluid contains hyaluronic acid (HA), a slippery substance that cushions and lubricates the joint. In arthritis, this fluid becomes thinner. Viscosupplementation injects a lab-made form of HA (sodium hyaluronate) into the knee to help lubricate it and ease pain. It is sometimes called a "gel" or "rooster comb" injection.

Common brands include Durolane, Euflexxa, Gel-One, GelSyn-3, Hyalgan, Monovisc, Orthovisc, Supartz and TriVisc. Depending on the brand, treatment is 1 to 5 injections, usually 1 week apart.

What to expect

• It is used for knee osteoarthritis when exercise, weight management and medicines have not given enough relief, or when cortisone is not a good option.
• Relief, if it occurs, usually builds over several weeks and may last several months.
• It does not rebuild cartilage or reverse arthritis.
• It is often covered by insurance for knee arthritis, though some plans require prior approval.

What the research says: Results vary from person to person. Some patients get meaningful relief, but a large review of placebo-controlled trials found that, on average, the improvement over a placebo injection was small (Pereira 2022), and expert guidelines rate HA as an option of uncertain benefit for specific patients (McAlindon 2014). PRP has outperformed HA in head-to-head trials (Belk 2021). We will help you decide whether it is a good choice for you.

Before Your Injection: Tell Us If You Have

• An allergy to eggs, feathers, poultry or bird products (some brands are made from rooster combs), or to any medicine, dye or preservative
• An infection in or around the knee, or a skin condition or infection at the injection site
• A bleeding disorder, or if you take a blood thinner
• Pregnancy, plans to become pregnant, or breastfeeding

After Your Injection

• Avoid strenuous activity for 48 hours, such as jogging, tennis, heavy lifting or standing for more than an hour at a time. Then return to normal activity as comfortable.
• Ice for 15 to 20 minutes at a time for any soreness, with a cloth between the ice and your skin.
• Acetaminophen (Tylenol) or anti-inflammatory medicines are fine after HA, as directed on the label.

Common, mild side effects

These usually go away within a few days: knee pain, stiffness, warmth or swelling; bruising, redness or soreness where the needle went in; headache or muscle aches. Let us know if they continue or bother you.

Follow-Up

Please keep your scheduled follow-up appointments so we can check your progress and adjust your plan as needed.

Learn More

• OrthoInfo (AAOS): Viscosupplementation for Knee Arthritis: https://orthoinfo.aaos.org/en/treatment/viscosupplementation-treatment-for-knee-arthritis/
• OrthoInfo (AAOS): Arthritis of the Knee: https://orthoinfo.org/en/diseases--conditions/arthritis-of-the-knee

Clinical Sources

• Pereira TV, Jüni P, Saadat P, et al. Viscosupplementation for knee osteoarthritis: systematic review and meta-analysis. BMJ. 2022;378:e069722.
• McAlindon TE, Bannuru RR, Sullivan MC, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014;22(3):363-388.
• Belk JW, Kraeutler MJ, Houck DA, et al. Platelet-rich plasma versus hyaluronic acid for knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. Am J Sports Med. 2021;49(1):249-260.
• American Academy of Orthopaedic Surgeons. Viscosupplementation for Knee Arthritis. OrthoInfo.

Glucosamine, Chondroitin and Turmeric for Arthritis Pain

How to take them, what to expect and who should avoid them

Lafi S. Khalil, MD, FAANA

About These Supplements

Some patients with arthritis find that certain supplements help with joint pain. They are not a substitute for exercise, weight management and the other treatments we discuss, and they do not rebuild cartilage. Supplements are not regulated like medicines, so choose a reputable brand, ideally with a third-party quality seal (such as USP or NSF).

Glucosamine and Chondroitin

What the research says: Results are mixed. In a large trial, glucosamine and chondroitin did not reduce knee pain more than placebo overall, but the combination helped in patients with moderate-to-severe pain (Clegg 2006; that study used 1,500 mg glucosamine and 1,200 mg chondroitin daily). A broader review found small benefits of unclear importance (Liu 2018). Side effects are uncommon, so a 3-month trial is reasonable.

Turmeric (Curcumin)

Turmeric can be taken in addition to glucosamine and chondroitin and may help knee arthritis pain.

• Dose: 500 mg, 4 times a day.
• It may cause stomach upset or diarrhea in a small number of people. If this happens, simply stop taking it.
• Do not take turmeric if you take a blood thinner (such as warfarin, apixaban/Eliquis, rivaroxaban/Xarelto or clopidogrel/Plavix), and stop it a week before any surgery. Check with us or your doctor if you have gallbladder disease or kidney stones.

What the research says: A review of 16 randomized trials in more than 1,800 adults found turmeric extracts reduced knee arthritis pain and improved function compared with placebo, with similar effects to anti-inflammatory medicines and fewer side effects, although the studies were short and varied in quality (Wang 2021).

Follow-Up

Please keep your scheduled follow-up appointments so we can check your progress and adjust your plan as needed.

Learn More

• OrthoInfo (AAOS): Arthritis of the Knee: https://orthoinfo.org/en/diseases--conditions/arthritis-of-the-knee
• OrthoInfo (AAOS): Osteoarthritis: https://orthoinfo.aaos.org/en/diseases--conditions/osteoarthritis

Clinical Sources

• Clegg DO, Reda DJ, Harris CL, et al. Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med. 2006;354(8):795-808.
• Liu X, Machado GC, Eyles JP, Ravi V, Hunter DJ. Dietary supplements for treating osteoarthritis: a systematic review and meta-analysis. Br J Sports Med. 2018;52(3):167-175.
• Wang Z, Singh A, Jones G, et al. Efficacy and safety of turmeric extracts for the treatment of knee osteoarthritis: a systematic review and meta-analysis of randomised controlled trials. Curr Rheumatol Rep. 2021;23(2):11.

Supplement Recommendations for Stress Fractures, Low Bone Density and Osteoporosis

How much to take, how to take it, and other ways to keep your bones strong

Lafi S. Khalil, MD, FAANA

Why They Matter

Calcium is the main building block of bone, and vitamin D helps your body absorb it. Getting enough of both is essential for bone healing, bone strength and muscle function. Follow these recommendations unless your provider gives you different instructions.

What the research says: In a randomized trial of more than 5,000 female Navy recruits, daily calcium (2,000 mg) and vitamin D (800 IU) during basic training lowered the rate of stress fractures by about 20% (Lappe 2008).

1. Vitamin D (Vitamin D3, Cholecalciferol)

For comparison, the general recommended daily amount for healthy adults is 600 IU (800 IU after age 70). Higher amounts are recommended here because of your bone condition.

• Vitamin D3 is preferred over D2.
• Take it with a meal that contains some fat for best absorption.
• Take it every day; consistency matters.
• Signs of low vitamin D can include fatigue, muscle aches, bone pain, stress fractures or slow healing.

2. Calcium

• Get as much as you can from food first. If you fall short, take a supplement to make up the difference, usually 500 mg once or twice a day.
• Your body absorbs calcium best in doses of 500 mg or less at a time, so split larger amounts.
• More is not better: total calcium above 2,000–2,500 mg a day can cause kidney stones and other problems.

Calcium-rich foods: milk, yogurt and cheese; leafy green vegetables; almonds; canned salmon or sardines with bones; and calcium-fortified orange juice, cereals and plant milks.

3. Other Ways to Protect Your Bones

• Do not smoke, and limit alcohol; both weaken bone.
• Eat enough protein to support healing and bone formation.
• Do weight-bearing and strengthening exercise as permitted by your provider.
• Prevent falls with good footwear, lighting and home safety measures.
• Your provider may recommend repeat vitamin D blood work or a bone density (DEXA) scan.

Follow-Up

Please keep your scheduled follow-up appointments so we can check your progress and adjust your plan as needed.

Learn More

• OrthoInfo (AAOS): Vitamin D for Good Bone Health: https://orthoinfo.aaos.org/en/staying-healthy/vitamin-d-for-good-bone-health/
• NIH Office of Dietary Supplements: Vitamin D: https://ods.od.nih.gov/factsheets/VitaminD-Consumer/
• NIH Office of Dietary Supplements: Calcium: https://ods.od.nih.gov/factsheets/Calcium-Consumer/
• Bone Health & Osteoporosis Foundation: Nutrition for Bone Health: https://www.bonehealthandosteoporosis.org/patients/treatment/nutrition/

Clinical Sources

• Lappe J, Cullen D, Haynatzki G, et al. Calcium and vitamin D supplementation decreases incidence of stress fractures in female navy recruits. J Bone Miner Res. 2008;23(5):741-749.
• Demay MB, Pittas AG, Bikle DD, et al. Vitamin D for the prevention of disease: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2024;109(8):1907-1947.
• National Institutes of Health, Office of Dietary Supplements. Vitamin D Fact Sheet for Consumers.
• National Institutes of Health, Office of Dietary Supplements. Calcium Fact Sheet for Consumers.