Front horn

Treatment of a tear in the anterior horn of the medial (internal) meniscus

The medial meniscus differs from the lateral one in its larger circumference and greater distance between the horns (approximately two times). The anterior horn of the medial meniscus is attached in the area of ​​the anterior edge of the articular part of the tibia - in the so-called intercondylar fossa. The outer surface of the meniscus is tightly connected to the articular capsule, and the inner surface is tightly connected to the medial collateral ligament.

Normally, the anterior horn of the meniscus has a smooth surface and its edges are quite thin. The blood supply to the meniscus is mainly localized in the anterior and posterior horns, but the blood vessels extend only 5-7 mm from the edge of the meniscus.

Statistics

It is estimated that medial meniscus injuries account for 60 to 80 percent of all knee injuries. Rupture of the anterior horn of the medial meniscus ranks first in frequency of occurrence. Longitudinal and flap tears are more typical for this injury.

Reasons

The main reason for rupture or separation of the anterior horn of the meniscus is a significant load on the knee joint, combined with fixation of the foot and rotational movement of the knee. At risk are young people leading an active lifestyle, as well as older men. Statistically, rupture occurs more often in men than in women.

Symptoms

Damage to the anterior horn of the medial meniscus is often combined with displacement of the torn part and its blocking between the internal surfaces of the joint. When the anterior horn is torn off with entrapment, symptoms such as blockade of the knee joint, knee pain and the inability to move independently appear. After treatment, the joint block is eliminated. Also, with an injury to the anterior horn of the meniscus, the patient can often slightly bend the knee, after which a blockade occurs.

With an injury to the anterior horn of the medial meniscus, the following symptoms may also occur:

• Feeling of pain inside the joint,
• Increased pain when trying to bend the leg at the knee,
• Flabbiness of the thigh muscles,
• Sensation of “lumbago” when the knee joint is tense,
• Pain in the area where the meniscus and ligament attach.

Species

It is customary to distinguish three types of rupture:

• Rupture of the immediate anterior horn (complete or partial).
• A meniscal tear with degenerative changes.
• Rupture of the ligament that secures the meniscus.

Conservative treatment

For minor meniscus injuries, conservative treatment is sufficient. In the first stages, the injured limb is fixed using a splint. A puncture of the joint can also be performed to get rid of the blood accumulated in the cavity and remove the blockage of the joint. The patient is advised to rest and the load on the leg should be limited. Subsequently, a course of physiotherapy, physical therapy, massage sessions and electrical myostimulation is recommended.

Surgical treatment

If there is a complete rupture of the anterior horn of the internal meniscus, surgical treatment is recommended. A meniscectomy is performed, that is, an operation to remove the torn fragment. Today, open surgery is almost never performed, as is complete removal of the meniscus. Instead, stitching or fragmentary removal is performed using arthroscopy. Due to the low invasiveness of the arthroscopic method, trauma to the knee joint and the rehabilitation period are significantly reduced. Performing such a procedure allows you to preserve functionally significant elements of the meniscus, which prevents the development of arthrosis and osteoporosis and allows the patient to quickly return to normal life.

In young patients, it is possible to undergo arthroscopic suturing of the meniscus. In this case, a rupture of the anterior horn of the meniscus is an indication for such suturing, since the anterior horn has a good blood supply, and its restoration occurs faster and more fully.

Rehabilitation

Arthroscopy can significantly reduce recovery time after a meniscus injury. After just a few days, it becomes possible to put a load on the limb, develop the knee joint and return to the usual rhythm of life. The essence of rehabilitation is to get rid of pain and restore mobility to the knee joint.

The knee joint has a rather complex structure. It consists of the femur and tibia, the patella (kneecap), and a system of ligaments that provides stability to the bones of the joint. Another part of the knee joint is the meniscus - cartilage layers between the femur and tibia. When moving, a large load is placed on the knee, which leads to frequent injury to its elements. A tear of the posterior horn of the medial meniscus is one such injury.

Injuries to the knee joint are dangerous, painful and fraught with consequences. A rupture of the posterior horn of the meniscus, which can occur in almost any active person, is the most common and dangerous injury. It is dangerous primarily due to complications, and therefore requires timely detection and treatment.

What is meniscus

Menisci are very important structural units of the knee joint. They are curved strips of fibrous cartilage that sit between the bones of a joint. The shape resembles a crescent with elongated edges. It is customary to divide them into zones: the body of the meniscus (middle part); the elongated end parts are the posterior and anterior horns of the meniscus.

There are two menisci in the knee joint: medial (inner) and lateral (outer). Their ends are attached to the tibia. The medial one is located in the inner part of the knee and is connected to the internal collateral ligament. In addition, along the outer edge it is connected to the capsule of the knee joint, through which partial blood circulation is ensured.

The cartilaginous portion of the meniscus adjacent to the capsule contains a significant number of capillaries and is supplied with blood. This part of the medial meniscus is called the red zone. The middle region (intermediate zone) contains a small number of vessels and is very poorly supplied with blood. Finally, the inner region (white zone) has no circulatory system at all. The lateral meniscus is located on the outer area of ​​the knee. It is more mobile than the medial one, and its damage occurs much less frequently.

Menisci perform very important functions. First of all, they act as shock absorbers during joint movement. In addition, the menisci stabilize the position of the entire knee in space. Finally, they contain receptors that send operational information to the cerebral cortex about the behavior of the entire leg.

When the internal meniscus is removed, the contact area of ​​the knee bones is reduced by 50-70%, and the load on the ligaments increases by more than 100%. In the absence of an external meniscus, the contact area will decrease by 40-50%, but the load will increase by more than 200%.

Meniscus injuries

One of the characteristic injuries to the menisci is their rupture. Research shows that such injuries can occur not only in people involved in sports, dancing or heavy work, but also in accidental activities, as well as in older people. It has been found that meniscus tears occur in an average of 70 out of every 100,000 people. At a young age (up to 30 years), the damage is acute; With increasing age (over 40 years), the chronic form begins to predominate.

A torn meniscus can be caused by excessive lateral load combined with twisting of the tibia. Such loads are typical when performing certain movements (running over rough terrain, jumping on uneven surfaces, spinning on one leg, squatting for long periods of time). In addition, ruptures can be caused by joint diseases, tissue aging, or pathological abnormalities. The cause of injury can be a sharp, strong blow to the knee area or rapid extension of the leg. Based on the nature and location of the damage, several types of ruptures can be distinguished:

• longitudinal (vertical);
• oblique (patchwork);
• transverse (radial);
• horizontal;
• rupture of the anterior horn of the lateral or medial meniscus;
• rupture of the posterior horn of the meniscus;
• degenerative rupture.

Degenerative rupture is associated with changes in tissue due to disease or aging.

Symptoms of meniscus damage

When the meniscus of the knee joint is damaged, there are two characteristic periods - acute and chronic. The acute period lasts 4-5 weeks and is characterized by a number of painful symptoms. The moment of damage to the meniscus is usually determined by a sound resembling a cracking sound and sharp pain in the knee area. In the first period after injury, cracking and pain accompany a person during exercise (for example, walking up stairs). Swelling develops in the knee area. Often a meniscus tear is accompanied by hemorrhage into the joint.

During the acute period, movement of the leg in the knee joint in a person is limited or completely impossible. Due to the accumulation of fluid in the knee area, a “floating patella” effect can occur.

The chronic period of a meniscus tear is less painful. Attacks of pain occur only with sudden movements of the leg or increased stress. During this period, it is quite difficult to determine the fact of a meniscus tear. To diagnose injury, methods have been developed that rely on characteristic symptoms.

Read also: Benign formation: hemangioma of the spinal body

Baikov's symptom is based on identifying pain when pressing with fingers on the outer side of the knee while simultaneously extending the lower leg. Landa's symptom determines the injury by the degree of straightening of the leg at the knee joint when the leg lies freely on the surface (in case of injury, the palm of the hand is placed between the surface and the knee). Turner's symptom takes into account increased sensitivity of the skin on the inner surface of the knee joint and the upper part of the lower leg on the inside. The symptom of blockade is a gap in the jamming of the knee joint when a person moves up the stairs. This symptom is characteristic of a rupture of the posterior horn of the internal meniscus.

Characteristic symptoms of a medial meniscus tear

A tear of the medial meniscus of the knee joint has a number of characteristic symptoms. Injury to the internal posterior horn of the meniscus causes intense pain on the inside of the knee. When you press with your finger in the area where the horn of the meniscus attaches to the knee ligament, a sharp pain appears. A rupture of the posterior horn causes blockage of movement in the knee joint.

The gap can be determined by performing flexion movements. It manifests itself in the form of sharp pain when straightening the leg and turning the lower leg outward. Pain also occurs when the leg is strongly bent at the knee. According to the severity of damage to the meniscus of the knee joint, they are divided into minor, moderate and severe. Small tears (partial), including the horns of the meniscus, are characterized by pain and slight swelling in the knee area. Such signs of injury cease to appear after 3-4 weeks.

With moderate severity of injury, all the considered symptoms of the acute period appear, but they are limited in nature and appear during physical activity, such as jumping, moving up inclined planes, and squatting. Without treatment, this form of injury becomes chronic. This degree is typical for some tears of the anterior and posterior horn of the medial meniscus.

With severe injury, pain and swelling of the knee become obvious; hemorrhage occurs into the joint cavity. The horn is completely torn off from the meniscus, and its parts end up inside the joints, which causes a blockage of movements. Independent movement of a person becomes difficult. Severe injury requires surgery.

Read also: Proper rehabilitation for a fractured patella

Mechanism of posterior horn rupture

A very dangerous longitudinal tear (complete or partial), as a rule, begins to develop from the posterior horn of the medial meniscus. With a complete rupture, the separated part of the meniscal horn can migrate into the cavity between the joints and block their movement.

Oblique tears often develop at the border between the middle of the meniscus body and the beginning of the posterior horn of the internal meniscus. This is usually a partial tear, but the edge may be embedded between the joints. This produces a sound similar to a cracking sound and painful sensations (rolling pain).

Often, a rupture of the posterior horn of the internal meniscus is of a combined nature, combining different types of damage. Such ruptures develop simultaneously in several directions and planes. They are characteristic of a degenerative mechanism of injury.

A horizontal tear of the posterior horn of the medial meniscus originates from its inner surface and develops in the direction of the capsule. Such damage causes swelling in the area of ​​the joint space (the pathology is also characteristic of the anterior horn of the lateral meniscus).

Conservative treatment methods

Treatment for a tear of the posterior horn of the medial meniscus (similarly to the anterior horn of the medial meniscus) depends on the site of injury and its severity. Based on this, the method is determined - conservative or surgical treatment.

The conservative (therapeutic) method is applicable for small and moderate ruptures. This treatment is based on a number of therapeutic measures and is often effective.

The first step is to provide assistance in case of injury. To do this, it is necessary to provide the victim with peace; apply a cold compress to the inside of the knee; administer an anesthetic injection; apply a plaster bandage. If necessary, fluid should be punctured.

Typically, the conservative method involves long-term treatment for 6-12 months. First, the knee joint is reduced (repositioned) if there is a blockade. Manual methods can be used to remove the blockade. For the first 3 weeks, rest should be ensured, and the knee joint should be immobilized using a plaster splint.

When cartilage is damaged, it is necessary to restore and fuse it. For this purpose, a course of taking chondroprotectors and hyaluronic acid is prescribed. The use of drugs containing chondroitin and glucosamine is recommended as protectors. Painful symptoms and inflammatory processes must be eliminated by taking non-steroidal anti-inflammatory drugs (diclofenac, ibuprofen, indomethacin) and others.

To eliminate swelling and accelerate healing, external agents in the form of ointments (amzan, voltaren, dollit and others) are used. The treatment process includes a course of physiotherapy and special therapeutic exercises. Therapeutic massage gives a good effect.

Surgical treatment

In severe cases of damage, surgical intervention becomes necessary. In case of crushing of the cartilage, severe rupture and displacement of the meniscus, or complete rupture of the anterior or posterior horns of the meniscus, surgery is necessary. Surgical treatment is divided into several types: removal of the meniscus or torn horn; recovery; suturing the tear site; fastening detached horns using clamps; meniscus transplantation.

The knee is a complex structure, which includes the patella, femur and tibia, ligaments, menisci, etc.

The menisci are a layer of cartilage tissue that is located between two bones. When moving, the knee constantly withstands heavy loads, so most injuries occur in this joint. One such injury is a tear of the posterior horn of the medial meniscus.

Damage to the knee joint is painful and dangerous in its consequences.

A tear of the posterior horn of the meniscus can occur in any active person or athlete and can lead to severe damage later in life.

What is a meniscus

The meniscus is a part of the joint that is a curved strip of fibrous cartilage. They are shaped like a crescent with elongated edges. They are divided into several parts: the body, the posterior and anterior horns.

There are two menisci in the joint:

• lateral (outer);
• medial (internal).

Their ends are attached to the tibia.

The medial one is located on the inside of the knee and connects to the medial collateral ligament. Along its outer edge it is connected to the capsule of the knee joint, through which partial blood circulation passes.

Menisci perform important functions:

• cushion the joint during movement;
• stabilize the knee;
• contain receptors that control leg movement.

If this meniscus is removed, the area of ​​contact between the bones in the knee becomes 50-70% smaller, and the load on the ligaments becomes more than 100% greater.

Symptoms

There are two periods: chronic, acute.

The acute period lasts about a month and is characterized by a number of painful symptoms. When the injury itself occurs in the knee area, a person feels severe pain and a sound like a cracking sound. Swelling quickly appears on the knee. Bleeding into the joint also often occurs.

Joint movements are severely or partially limited.

Characteristic symptoms of a medial meniscus tear

This type of injury has a number of characteristic signs. When the posterior horn of the internal meniscus in the knee area is damaged, intense pain appears on the inside. On palpation, it intensifies in the area where the horn attaches to the knee ligament.

This injury also blocks the movement of the joint.

It is determined when trying to make flexion movements when turning the shin outward and straightening the leg, the pain becomes stronger and the knee cannot move normally.

In terms of severity, damage can be minor, medium or severe.

Types of rupture

Longitudinal complete or partial rupture of this part is considered very dangerous. It develops from the posterior horn. With a complete rupture, the part that has separated can move between the joints and block their further movement.

There may also be a gap between the beginning of the posterior horn and the middle of the meniscus body.

There are often cases when such an injury is of a combined nature and combines different types of damage. They are developing in several directions at once.

A horizontal tear of the posterior horn begins from its inner surface and develops towards the capsule. It causes severe swelling in the joint space.

Treatment

Treatment can be carried out using both conservative and surgical methods.

Conservative therapy is used for mild or moderate injuries.

The operation is performed for severe injuries that block the functioning of the joint and cause severe pain.

The most common knee injury is a meniscal injury. The meniscus can be damaged due to combined or indirect knee injury. Typically, a meniscus injury is accompanied by an outward rotation of the tibia (the internal meniscus suffers), a sharp extension of the bent joint, as well as a sharp change in the position (adduction or abduction) of the tibia. One of the most difficult knee injuries is a rupture of the posterior horn of the internal (medial) meniscus.

Between the tibia and femur in the knee joint there are crescent-shaped cartilaginous layers - menisci. They are designed to increase stability in the joint by increasing the contact area of ​​the bones. There is an internal (so-called medial) meniscus and an external (lateral) meniscus. Conventionally, they are divided into three parts: anterior, middle, posterior (anterior horn, body, posterior horn, respectively).

The back of the meniscus does not have its own blood supply; it is nourished by synovial fluid, which constantly circulates. Therefore, if a tear occurs, the back of the internal meniscus is not capable of healing on its own. Since this injury is very painful, it requires immediate treatment.

In order to correctly diagnose a meniscal tear, having previously accurately determined the severity and degree of complication, an MRI or X-ray examination of the knee with contrast is used.

Symptoms of a meniscus tear

Traumatic ruptures. After the rupture occurs, pain appears and the knee swells. If pain occurs when descending stairs, then most likely there is a tear in the back of the meniscus.

When the meniscus ruptures, part of it comes off, begins to dangle and interferes with movements in the knee joint. If the tears are small, they usually cause a feeling of difficulty moving or painful clicking. In the case of a large tear, the joint is often blocked. This occurs because the torn and loose portion of the meniscus, which is relatively large in size, moves toward the center of the joint and interferes with some movements. If the posterior horn of the meniscus is torn, knee flexion is usually limited.

When a meniscus ruptures, the pain can be so severe that a person cannot step on his leg, and sometimes the rupture only makes itself felt by pain during certain movements, for example, when climbing stairs. In this case, the descent may not cause pain at all.

If it happened sharp rupture with simultaneous damage to the ligament, the swelling usually develops faster and is more pronounced.

Degenerative (or chronic) tears usually occur in people after forty years of age. Increased pain and swelling cannot always be detected, since they develop gradually. It is not always possible to find evidence of injury in the health history, and sometimes a rupture may appear after simply getting up from a chair. Also at this moment, blockade of the joint may occur, but usually chronic ruptures manifest themselves only in the form of pain. It is worth noting that with such a rupture of the meniscus, the adjacent cartilage that covers the femur or tibia is often damaged.

Like acute tears, chronic tears can manifest themselves in completely different ways: sometimes the pain appears only with a certain movement, and sometimes the pain makes it impossible to even step on your foot.

Treatment of meniscus tears

If it is definitely established that a meniscus tear has occurred in the knee, then treatment for such an injury is carried out in a medical hospital. Treatment is prescribed by a doctor depending on the nature of the injury and its severity. If the meniscus is slightly damaged, then conservative treatment methods are usually used - physiotherapy or manual therapy, medications (painkillers and anti-inflammatory drugs).

If the rupture is severe, causes severe pain, or leads to joint blockage, then surgery is necessary to suture the meniscus (if serious irreversible damage has occurred) or remove it (meniscectomy). They try to perform surgical intervention using an arthroscope using a minimally invasive technique.

Pathology of the musculoskeletal system includes a rupture of the posterior horn of the medial meniscus. This injury is a consequence of indirect trauma to the lower limb. The human knee joint is very complex. Each of them contains 2 menisci. They are formed by cartilage tissue. They consist of a body, posterior and anterior horns. Menisci are essential for shock absorption, limiting range of motion, and matching bone surfaces.

Types of breaks

A tear of the posterior horn of the medial meniscus is a type of closed joint injury. This pathology is most often found in adults. This type of injury is rare in children. Women suffer from this disease 2 times more often than men. The gap is often combined with.

This is the most common joint injury. Complex rupture is diagnosed mainly in people from 18 to 40 years old. This is due to an active lifestyle. Sometimes combined damage to both menisci is observed.

The relevance of this problem is due to the fact that such an injury often requires surgical intervention and a long recovery period.

After surgical treatment, patients move on crutches. A distinction is made between complete and incomplete tissue rupture. The following options are known:

• longitudinal;
• vertical;
• patchwork bias;
• radial-transverse;
• horizontal;
• degenerative with tissue crushing;
• isolated;
• combined.

An isolated posterior rupture is diagnosed in 30% of all cases of this injury.

Causes of damage

The development of this pathology is based on strong extension of the lower leg or its sharp outward rotation. The longitudinal gap is due to several reasons. The main etiological factors are:

• falling onto a hard surface;
• bruises;
• traffic accidents;
• blows;
• degenerative processes against the background of gout and rheumatism;
• sprains;
• microtraumas.

A rupture of the posterior horn of the meniscus is most often caused by indirect and combined trauma. This usually happens in winter when there is ice. Failure to take precautions, haste, intoxication and fighting all contribute to injury. Often, rupture occurs when the joint is in fixed extension. Athletes face a similar problem. The risk group includes football players, figure skaters, gymnasts and hockey players.

Permanent damage causes meniscopathy. Subsequently, when making sharp turns, a rupture occurs. Degenerative damage is highlighted separately. It occurs mainly in elderly people with repeated microtraumas. The cause may be intense loads during training or careless work activities. Degenerative horizontal rupture of the posterior horn of the medial meniscus often occurs against the background of rheumatism.

It is facilitated by previously suffered tonsillitis and scarlet fever. Damage to the meniscus due to rheumatism is caused by impaired blood supply to tissues due to edema and other pathological changes. The fibers become less elastic and durable. They are not able to withstand heavy loads.

Less commonly, the cause of rupture is gout. Tissue injury occurs due to uric acid crystals. Collagen fibers become thinner and less durable.

How does a gap manifest itself?

If there is damage to the posterior horn of the medial meniscus, the following symptoms are possible:

• pain in the knee area;
• restriction of movements;
• cracking sound when walking.

In the acute period, reactive inflammation develops. The intensity of the pain syndrome is determined. If it is incomplete, then the symptoms are mild. Clinical signs persist for 2–4 weeks. A moderate flap rupture is characterized by acute pain and limited extension of the limb at the knee.

The sick person can walk. If proper treatment is not carried out, this pathology becomes chronic. Severe pain combined with tissue swelling is characteristic of a severe rupture. In such people, small blood vessels in the knee area may become damaged. Developing. Blood accumulates in the cavity of the knee joint.

It is difficult to support your leg. In severe cases, the local temperature rises. The skin takes on a bluish tint. The knee joint becomes spherical. After 2–3 weeks from the moment of injury, a subacute period develops. It is characterized by localized pain, effusion and blockages. Specific symptoms of Roche, Baykov and Shteiman-Bragard are typical. In the degenerative form of this meniscus pathology, complaints may appear only during work.

Patient examination plan

It is necessary to treat a linear break after clarifying the diagnosis. The following studies will be needed:

• general clinical tests;
• CT or MRI;
• radiography;
• arthroscopy.

Differential diagnosis is carried out in the following cases:

• arthritis of various etiologies;
• gonarthrosis;
• softening of cartilage tissue;

If the posterior horn of the meniscus is damaged, treatment begins after assessing the condition of the joint tissues. Magnetic resonance imaging is very informative. Its advantage is the absence of radiation exposure. Arthroscopy is performed according to indications. This is an endoscopic research method. A knee examination can be performed for both therapeutic and diagnostic purposes. Arthroscopy can be used to visually assess the condition of the knee joint. Before the procedure, you must undergo a series of tests. The study can be carried out on an outpatient basis.

Treatment tactics

Partial damage to the meniscus requires conservative therapy. The main aspects of treatment are:

• plaster application;
• use of painkillers;
• puncture of the knee joint;
• maintaining peace;
• applying cold compresses;
• massage;
• physiotherapy.

If the cause is degenerative-dystrophic processes, then chondroprotectors are prescribed. These are medications that strengthen the cartilage tissue of the joints. They contain chondroitin sulfate and glucosamine. Chondroprotectors include Arthra, Teraflex, Dona and. To eliminate pain, NSAIDs are prescribed (Ibuprofen, Movalis, Diclofenac Retard). These medications are taken orally and applied to the skin in the joint area.

External agents are used after the plaster is removed. Patients must maintain motor rest. To accelerate the healing of the medial meniscus, physiotherapy (electrophoresis, UHF therapy, exposure to magnetic fields) is performed. A puncture is often required. A needle is inserted into the joint. If there is a small amount of blood, the puncture is not performed.

Analgesics and anti-inflammatory drugs may be administered during the procedure. In severe cases, radical treatment is required. Indications for the operation are:

• separation of the horns and body of the medial meniscus;
• lack of effect from conservative therapy;
• displacement rupture;
• tissue crushing.

Reconstructive surgical interventions are most often performed. A complete meniscectomy is performed less frequently. This is due to the fact that removal of the medial meniscus in the future can lead to the development of deforming gonarthrosis. Special designs are used for tissue restoration. In the case of peripheral and vertical tears, the meniscus may be sutured.

Such an intervention is justified only if there are no degenerative changes in cartilage tissue. A complete meniscectomy can only be performed if there is a large tear and severe damage to the meniscus. Currently, arthroscopic operations are widely used. Their advantage is less trauma. After the operation, painkillers, physiotherapy and exercises are prescribed. Patients need to rest for up to a year.

Forecast and preventive measures

The prognosis for a rupture of the posterior horn of the internal meniscus of the knee is most often favorable. It worsens with severe hemarthrosis, combined lesions and untimely treatment. After therapy, pain disappears and range of motion is restored. In some cases, gait instability and discomfort while walking are observed.

The accumulation of large amounts of blood in the knee joint, without proper care, can cause arthrosis.

In old age, treatment can be difficult due to the impossibility of surgery. Rupture of the horns of the medial meniscus can be prevented. To do this, you need to adhere to the following recommendations:

• avoid sudden movements of the legs;
• observe safety precautions while working at work and at home;
• stop drinking alcohol;
• do not get into fights;
• wear knee pads when playing sports;
• give up traumatic activities;
• be careful during icy conditions;
• in winter weather, wear shoes with threads;
• give up extreme sports;
• promptly treat arthritis and arthrosis;
• diversify your diet;
• move more;
• take vitamins and mineral supplements;
• treat rheumatism in a timely manner and.

A meniscus tear is a very common pathology in adults and adolescents. In case of a fall or injury and pain, you should go to the emergency room.