MSKMag OutLoud

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comShockwave therapy… I was surprised to hear it hadn’t been covered in MSKMag. So, when the opportunity came to write an article on it, I jumped at the chance.Those who know me will know I work for Physiquipe, a company who sells shockwave therapy devices. And for those who don’t know me, now you know I work for a company who sells shockwave devices!Despite my ‘commercial interest’, I’m an enthusiastic Sports Therapist who is passionate about shockwave therapy, but I am no evangelist (Jack Chew can verify). I truly believe it has its place, and if you’ve invested in this technology to better serve your patients, then kudos to you.I’ll assume most of you have encountered shockwave at some point, and you are aware of radial and focused shockwaves and their differences. If not, I implore you to have a read up as this article is not going to cover this, nor be the RCT regurgitation we see at every conference.I want to share something a little different: an honest look at what the shockwave world looks like from where I’m standing. And perhaps offer something useful for those still trying to make sense of it.There are many sides to this story, so let’s start with…

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comPutting the finishing touches to this article, I skim back over the Writer’s Guide. It encourages me to write boldly and to not be too afraid to offend because…“you’ll be surprised how polite professional challenges are in our industry.”We are a caring bunch…and this is exactly the problem.Three years into my Physiotherapy career I rotated onto an orthopaedic ward and attended the morning trauma round. It’s a cramped office in a quiet and worn out section of the hospital. X-ray after X-ray flashes up on a large projector at the front of the room and one-by-one the consultants discuss their patients and what intricate method of carpentry they will be using. It starts smoothly; there are not many questions and this silence appears to be taken as consent to continue by those presenting.But Case 5 is different. Heads look up, Candy Crush is paused and the temperature of the room heats up. Multiple consultants pile in, questioning and attacking the proposed management. The presenter fights back…“I’ve managed dozens like this non-operatively!”“Look at the posterior fragment!! If this was your ankle, you’d fix it.”“The displacement is minimal.”“That’s nonsense! If this displaces further, that’s on us.”“And if it gets infected, that’s also on us!”I catch the eye of an OT and we share a nervous wince. The ‘nonsense’ comment seemed to cross a line. However, a few minutes later the meeting ends and instead of any awkwardness or anger, the same consultants who were tearing chunks out of each other minutes before leave together, talking about the Six Nations score at the weekend.Not one hard feeling between them… and I thought it was brilliant.Only weeks before I had been on an MSK Outpatient rotation where one of our *cough* more experienced *cough* Band 8As had been training for a half marathon and developed some hamstring pain. They were complaining during team training about how they’d tried everything to resolve it without avail. ‘EVERYTHING’ seemed to be that they had been doing frictions on their hamstring… But instead of professional disagreement or debate, there was just meek silence from us all. Just a few quiet comments later in private. Some even played along at the time, humouring the outdated practice.We are a caring bunch… but we can be incredibly fragile.

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comIf you mention the words ‘elite performance’, most people will think of sport, but I think of the corporate sector. Both elite groups have talent, skill and can perform at maximum capacity. Both environments are highly competitive, deadline driven and with high stakes. But only the elite sportsperson works at the extreme of physical capability, developing problems when even their highly trained system cannot tolerate the physical demand placed upon it. Contrast this with the corporate athlete, whose mental load is so high it dramatically reduces their ability to tolerate minor or more moderate physical loads. Where these two groups experience their symptoms may be similar, and examination may come to the same diagnostic conclusion. But, given the differences in the reason for onset, their successful management, including return to activity and prevention of recurrence, will look very different.In the office the elite capability is mental and the load is continuous. To survive in this environment, you need to satisfy the demand for elite performance over long hours, day after day, month after month, year after year. Those who thrive enjoy the challenge and the competition, loving the work, the camaraderie, and of course their success. But many work at their limit of tolerance; constantly, and often unpredictably, permanently on call, and perilously close to burnout.Driven and academically gifted, these workers excel at school and elite universities. They are then thrown into the rigour of postgraduate training and onboarding programmes which instantly involve long hours, high stress, high accountability, tight deadlines and the constant, urgent need for accuracy. When junior, this group often fly the plane whilst building it, and when senior, manage a team and the clients’ expectations whilst managing caring responsibilities (in both directions) and experiencing an age- or menopause-related drop in physiological resilience. Everyone they work with (and compete with) was best in class too: they need to maximise their performance and keep it there to keep their job and stay in the game.They may work flat out for several months, only pausing for breath between cases, deals or deadlines. Many routinely work late into the evening, during the weekends and on holiday. They can be permanently on call. Additionally, with many companies going global, the traditional working day has been turned on its head: for some this can mean waking up for Asia, not logging off until America and working 80-120 hours per week. [1] For others the sheer volume of the work can result in their employer paying for ‘roundabout’ taxis: a ride home with the taxi waiting so they can shower and change and come straight back to the office. [2] Even away from these extremes, in these types of occupation a working week of 70-75 hours is very much the norm. [3,4]Welcome to my working world.

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comThe short answer is no - at least not in the way the term is typically applied in adult populations.Rotator cuff pathology is uncommon in paediatric shoulders, particularly in the absence of trauma [1]. While partial or full-thickness tears can occur, these are usually associated with acute injury, avulsion, or instability events. In contrast, the most frequent causes of shoulder pain in adolescents are physeal stress injuries and glenohumeral instability with associated labral pathology [1,2].These distinctions reflect fundamental differences between paediatric and adult shoulders in terms of anatomy, pathology, and clinical presentations. A failure to recognise these differences risks misdiagnosis and inappropriate management, potentially leading to long-term consequences for shoulder function and athletic development. Accurate clinical reasoning in this population therefore requires consideration of anatomical development, ossification timing, maturation status, and paediatric-specific pathology.From cartilage to boneAt birth, the skeleton is largely cartilaginous, enabling longitudinal growth. Through the process of ossification, cartilage is progressively replaced by bone, with skeletal maturity around the shoulder not reached until the mid-to-late twenties [3].Until then, shoulder injury is more likely to be to the immature bone, whereas in skeletally mature adults, the bone is stronger than the soft tissues, so injury is more likely to the tendon or ligamentous structures.The shoulder is particularly complex in its developmental anatomy. The humeral head initially forms from three secondary ossification centres, including the greater and lesser tuberosities, which unite around the age of 4-6 in boys, and up to two years earlier in girls. The diaphysis (humeral shaft) and the epiphysis (humeral head) are separated by the physis which is comprised of a series of layers packed with chondrocytes and osteoblasts to enable longitudinal growth. The humeral head does not ossify with the humeral shaft until around the age of 14-18 and until then the proximal humeral physis is vulnerable to injury.

I look around the waiting room. There’s an average BMI of about 40. I observe oedematous ankles and a variety of walking aids (some flowery so you know they’re not a temporary feature). I can almost smell the inflammatory soup. A young person sits glued to an iPad, headphones shielding them from the world. No doubt an ADHD diagnosis inbound.The health of the nation has changed, and not for the better.And I wonder, when did MSK care become less about sprained ankles and bad backs, and more about metabolic disease and mental health?But who is responsible for this decline?Scanning the room, my instinct is to lay responsibility at the door of the individual.The media will have us believe that our beloved health service is failing the nation but is it in fact the nation who is failing the health service?As someone who works hard to maintain a healthy, balanced lifestyle, I am of the belief that I need to be accountable for my own health. Not every condition is avoidable or preventable, but I feel that I need to at least do my bit. I’m no teetotal, clean-living vegan, but nor am I held together with statins and gabapentin.Don’t misunderstand me, as a healthcare professional, of course I believe that access to healthcare is important, but with such a high incidence of people living in poor health (89% of deaths in the UK are attributed to non-communicable diseases) surely, we all need to step up and do our bit?I am not, however, optimistic. ‘The Spectrum’, overwhelm, body positivity, and food noise are just some of the reasons one can choose to justify an external locus of control. But these are avoidance tactics. Avoidance of the difficult, the uncomfortable. Avoidance of Responsibility.I hear the food noise; I can hear the packet of biscuits seductively calling me but I’m not a labrador and am able to exercise a degree of self control. Is it always easy? No. The same way that curling up on the sofa might feel more appealing than heading out for a run. We all have choices, and we are all capable of autonomous thought (even if these days we seem not to exercise that particular skill).Before judgement completely takes over however, and I am able to reach the lofty heights of the moral high ground, I am pulled back by the sight of a physiotherapist escorting a patient with magnetic knees back to the waiting room (if you aren’t familiar with magnetic knees, they are the kind that due to years of deconditioning and lack of proper use, are drawn to each other as if the medial femoral condyles are polar opposites!). The patient has just undergone a steroid injection and the physio gives them some instructions about a couple of days rest, then hands them a sheet of exercises. Patient and physio part company like a couple of England football fans*; both hopeful for success, both expecting disappointment.And my judgement shifts, from the patient to the physio. Like a warning light on the dashboard of your car, the focus here seems to be on turning the light off, rather than addressing what triggered the alert in the first place. Corticosteroid and a few clam shells aren’t going to address years of deconditioning, poor diet and social isolation.And I ask myself again, who is responsible?While I still stand by the importance of taking care of our own health, we can only do so if we are educated - if we understand what is going on in our bodies and are aware of our choices. With so much access to information and misinformation it can be a minefield for an individual to navigate. But I see MSK services stuck in the past. Clinicians still treating knees and backs in isolation and failing to treat people. Failing to acknowledge the complexity, and failing to have honest, albeit difficult, conversations.And clinicians have their own set of excuses. Their own reasons for absolving responsibility. No time; out of scope; it only says ‘knee’ on the referral. The system is s**t.Now I do agree that time pressures in MSK services are a limiting factor, and services need a redesign, and I hear clinicians complain, but I don’t see them upskilling to meet this new demographic head on.If time is such a precious commodity, why are we wasting it trying to identify dysfunction rather than discussing dysregulation., Why are we not prioritising conversations about the impact of weight, stress, hormones and sleep on pain and MSK health?I see a dramatically changed patient population, but MSK clinicians failing to acknowledge or keep pace with these changes.Many pay lip service to a biopsychosocial model, remaining entrenched in a ‘lets fix it’ biomedical model, not because they are lazy or ignorant, but because they lack the skills to challenge the status quo in a meaningful way. Why should patients change, if clinicians are not prepared to do so?I do worry that if MSK professionals fail to upskill to meet the shifting demands of health, if they are not willing to take on the responsibility of helping patients to navigate these health challenges, they will become obsolete.But I digress, as this piece is about the responsibility of health and not a debate about the future of MSK services. That is perhaps for another day.I scan the room once again, and wonder if I am being unfair to my MSK colleagues. Why should they take on the nation’s ills, simply because pain is the thing that demands most attention?Shouldn’t the proverbial buck stop with primary care? As the first and most consistent point of healthcare for most patients, they are best placed to provide holistic, ongoing support.Patients might spend several years, sometimes a lifetime, with the same GP practice. Responsibility should surely start here as the best place to effect sustainable change??True that GP practices are under pressure, but maybe this is being perpetuated by referring away to specialist services with the promise of a solution, only to find patients boomerang back when the problem persists.There is some good news! There is a small, but growing number of GPs who are upskilling in the field of lifestyle medicine.Finally, some responsibility! But just as I begin to fantasise about a world in which all GPs are as skilled in promoting health as they are at treating illness, I look round the waiting room once more. Lifestyle medicine is still the exception, and far from the norm.Once again, I think about responsibility. What caused this epidemic in the first place?Several people sit scrolling on phones, someone opens a packet of crisps, another an energy drink…I’m not sure that the thumb movement involved in scrolling through Instagram requires that level of sugar and caffeine!My heart sinks with the realisation that what we are facing isn’t just about helping people make healthier choices. This is full scale addiction.Smart phones keep our sympathetic nervous system fired up, keeping us in fight or flight for sustained periods. And we now know these things aren’t addictive by default, they were designed that way. Add this to food-like substances, developed to leave you craving more, failing to nourish, creating inflammation and a heightened sense of threat in our nervous systems.The nation needs a detox!So, who is responsible now? The tech companies? Food conglomerates? The Government?Are we fighting a losing battle here, or does this bring us back to the beginning and individual responsibility?The addict can blame their dealer, but it’s supply and demand. We want life to be easy, convenient, and comfortable, but the easy choices in the short term don’t always serve us well in the long term. The important thing to realise is that there is choice.Clinicians can help a person on their health journey, but change will only happen off the back of individual effort. Health isn’t something that can be fixed, and recovery is hard. Our health is the most valuable and precious commodity we will ever possess; how can we not take responsibility for that?*Just to clarify, this is a reference to the men’s game This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe

This is a free preview of a paid episode. To hear more, visit mskmag.substack.com¡Buenos dias!I’ve been in Valencia for a few days to explore the city, get in some runs and fit in my obligatory new-city stadium tour. I heard all the best teams are 14th in their league this season so don’t even worry about it, Valencia C.F.This was a solo trip because every few years I like to push myself out of my comfort zone and also read the maximum possible amount of books. This one truly was a voyage of discovery because it involved my bank card being blocked and an Airbnb host with far too many boundaries for someone who shares her apartment with strangers on the regular.It was not relaxing - but I’ve realised that when I travel abroad, I’m never relaxed - and not for the obvious travel stress reasons.I’m never relaxed because it’s important for me to be the perfect tourist. Specifically the top British tourist of all time. I will need to develop eyes in the back and both sides of my head so that I do not hold up any cyclist or pedestrian whilst checking a map. I have practiced some local phrases and even if the only word I can recall is the one for ‘thank you’, you can bet your bottom euro that I’ll be using that liberally, whether the situation calls for it or not. I am a polite person but on holiday I am falling over myself to ensure locals for years to come will be saying “wow, we were so wrong about the English”.Did it work? Well just ask the restaurant owner who cleared up the glass of my upturned cerveza that I knocked over while having a diabetic hypo. Or the aforementioned Airbnb host in whose bathroom I used (and I pray you all won’t judge me for this incredible faux pas) THE INCORRECT HANDTOWEL. Or the fact that I feel like I need a holiday to recover from my holiday in which I was basically a main character on set the whole time.And of course I left the Airbnb host five stars - not because it was an entirely five-star experience but because it felt easier and I didn’t want to cause any issues…but mainly because I was a bit afraid of her. Which is where my being nice turns into conflict avoidance and people pleasing.And that leads me perfectly to this month’s MSKMag. James Horner is so spot on in his article ‘Physios are nice…and it’s killing our profession’ that I can’t believe it wasn’t written about me specifically.But it’s not all agreement and polite nodding. We’re also seeing a growing appetite for doing things differently; in this issue it’s shockwave therapy and where it fits in modern MSK care. Have a read of Dominic Smith’s article ‘Shockwave Therapy: A Love-Hate Story, and Everything In Between’.Elsewhere we have articles about those who naturally don’t fit the mould. Sue Julians has written about elite performance but she’s not talking about Olympians, more so ‘The Corporate Athlete’ who balances sport with their city job.And when you think shoulder pain you might well think rotator cuff…except if the patient in your clinic room is in their teens, warns Angela Jackson in her article ‘Do Adolescents Get Rotator Cuff Tendinopathy?’If there’s one area where trying to make people fit the mould has caused more harm than good, it’s in chronic pain. Offering a clearer framework and points not to miss, Ben Whybrow’s full Chronic Widespread Pain Diagnosis Guide is published this month alongside his article detailing the inspiration behind it and its scientific backing.So perhaps the goal this month isn’t to be the nicest physio in the staffroom or the tourist in the taverna who never gets it wrong. Maybe it’s less about being nice, and more about being genuine, kind and constructive - even when that feels way less comfortable in the moment.MSKMag this month though? No overthinking needed. That’s a genuine five stars from me.

I spent the better part of a decade buying MSK practices before I ever helped anyone sell one.I founded a physiotherapy clinic group in my twenties, growing it from a single site to 36 locations. Acquisitions were a significant part of how we scaled. I would sit opposite an owner, run the numbers, and work out what I was prepared to pay, doing this more times than I can count. Aged 30, I went through my own exit to a private equity firm.This experience and the lessons it taught me form the foundation of Verilo, the specialist brokerage firm I now run. Our team has advised on over 100 transactions representing more than £30 million in deal value. We work exclusively with health, medical and wellness business owners, sitting opposite buyers of every kind; from individual practitioners picking up their first clinic, to consolidators and private equity groups acquiring at scale.I explain this because this article’s themes are not theoretical; they are based on practice, where we observe the same patterns and mistakes being made. The reality of what makes an MSK practice more or less valuable to a buyer is often different to its owners’ assumptions. And that value is rarely based on the things people spend money on in the months before going to market.What a buyer is really paying forWhen I was acquiring clinics, I was not looking for the nicest waiting room or the fanciest website. I was looking for something that would hold together once I had taken over. The right foundations: a loyal patient base, a team that was not built around a single person, and a local reputation that had taken years to build and could not be replicated overnight.Those foundations pointed to something more important: a business that could run, retain patients, and generate revenue regardless of who was at the centre of it. Repeatable systems, consistent revenue, and a predictable diary. That kind of business takes years to build. When I found it, I found something genuinely worth paying for.The mistake I kept seeing was sellers spending money on the wrong things. A new waiting room, a rebrand, a website refresh – all fine, but none of them moved the dial for me as a buyer. If a business was performing well despite a dated website or an unloved interior, I saw that as upside. Mine to capture, once I took over. Far more appealing than paying a premium for improvements the seller had already funded.Not every buyer thinks like me, and investment is not always wasted. But the principle holds: cosmetics are easy to fix. The foundations of a business are not.What walks out the door with you?If I had to reduce everything about MSK practice saleability and valuation down to a single idea, it would be this: the more transferable a business is – and therefore the lower risk a buyer perceives – the higher its value and the more likely a sale. When you exit, how much of what you’ve built walks away with you? And how much stays?The lease is a good place to start. Most buyers want security of tenure above all else – confidence that the practice can continue trading where it is. Long-term certainty reads as an asset; the absence of it creates risk. A short, rolling or unrenewed lease may feel like flexibility to a seller, but a buyer sees it differently: a problem to be priced in or resolved before exchange. If you are approaching a sale with less than three years remaining, exploring renewal or extension options is almost always worth doing, even if your own timeline is uncertain.Brand identity follows a similar logic. A brand that patients associate with the practice rather than the person running it is transferable; one synonymous with the owner has an expiry date. Evolution should happen gradually and well in advance, creating time to establish patient associations a buyer can actually see and value.A well-maintained, GDPR-compliant client database is also crucial. It is a transferable asset in its own right – one that gives a buyer the ability to market to existing patients, re-engage lapsed ones, and model value from day one.Concentration risk: people and revenueAsk MSK practice owners what their biggest asset is, and the answer is usually people. The clinicians who have built patient relationships over years, the owner whose reputation draws referrals, the contract that keeps a reliable income stream flowing. These are what make a practice valuable, but they are also what make concentration risk one of the most significant devaluers we encounter. A buyer has to price what happens if any walk away.This concentration tends to show up in three ways: clinical team concentration, where patients follow one practitioner and leave with them; owner dependency, where the practice relies on the owner’s clinical output or reputation; and contract concentration, where a significant share of revenue ties to a single source. That last one is often the most overlooked. NHS contracts held in a rolling or holding-over position can be vulnerable to external factors, and a practice dependent on one such contract is a riskier proposition than one with a diversified private income base.When the concentration sits with the owner, an earn-out is a partial solution. If you are willing to stay with the business through a defined transition – usually six months to two years – you can protect some of the value. The buyer is paying for continuity you are providing, and it is worth considering seriously if you are the primary clinical draw.Where the concentration sits with an associate or employed clinician, the answer is harder. You cannot contractually guarantee a buyer your best physiotherapist will stay. The only real solution is taking time to build a team where no single departure would damage revenue.How are you finding new patients?For many owners, a full diary built entirely on word of mouth is a badge of honour – and, in one sense, rightly so. It speaks to clinical quality and the kind of patient trust that cannot be manufactured. But to a buyer, it raises a different question: if nothing is driving that growth deliberately, how confident can they be that it will continue?What a buyer actually wants to know is your strategy for getting new patients consistently. Can you demonstrate someone else could do it after sale? If the answer is yes, you become considerably more attractive.Well-documented marketing strategies, an updated Google profile, a referral partnership with a local GP, email automation for re-engaging lapsed patients, or proven paid advertising all tell a buyer growth is not accidental.Practices that can show a strong word-of-mouth reputation and a good grasp of patient acquisition are genuinely rare, and therefore worth a premium.The finances: what buyers actually look atEvery business is different, and value is often more art than science. It is ultimately determined by the market, by what a motivated buyer will pay. That said, we regularly see most experienced buyers follow a similar financial assessment process.Most buyers use a multiple of adjusted EBITDA, or earnings before interest, tax, depreciation and amortisation. In plain terms, it is the underlying profit the business generates, stripped of financing and accounting decisions: what the business actually earns before the owner decides how to structure it.Your EBITDA may be different from the profit figure on your tax return. Owners often pay themselves at non-market rates, and structure finances to minimise tax rather than demonstrate commercial value. Before a sale, these figures are normalised to reflect what a buyer would actually earn. What remains after those adjustments is your adjusted EBITDA – the number a buyer will base their offer on.In the MSK sector, multiples typically run between three and five times EBITDA, though we have seen transactions exceed that range. What pushes a multiple higher is the combination of factors covered in this article. Buyers are essentially pricing risk. The less risk they perceive, the more they are prepared to pay. Clean, well-maintained financial records support that process – they make it straightforward for a buyer to assess the business, build confidence in the numbers, and move quickly.Size mattersNot every practice will attract the same buyers, and turnover is one of the biggest factors in determining who comes to the table.At around £100,000 or below, the market is limited. These businesses are typically owner-operated, harder to model financially, and appeal mainly to individual practitioners or local competitors after a bolt-on. Valuations are variable and the likelihood of completing is lower.As turnover grows towards £250,000 to £500,000, the buyer pool widens: regional operators, multi-site acquirers, portfolio builders. Deals become more structured and valuations more predictable.Above £500,000, things change substantially. Consolidators, smaller private equity groups and family offices enter the picture. Buyers are no longer constrained to your postcode, competition between them increases, and that competition is one of the most reliable mechanisms for improving what a seller receives.Driving turnover is not just about building a bigger practice. It is about expanding the range of people who want to buy it.The process matters as much as the preparationThere is a point in every sale where preparation stops being the main variable and process takes over. How a business is presented to the market, and how that process is structured and managed, shapes a significant part of the final outcome.A well-run process creates competitive tension; with multiple credible buyers in conversation simultaneously and aware of each other, thinking tends to sharpen, conditions get clearer, and offers improve.The data on this is compelling. Based on a study published in The Quarterly Journal of Finance, represented sellers achieve between 6 and 25% higher purchase prices than those who go to market alone. [1] Unrepresented sales are also 60 to 70% less likely to complete at all.The reasons are fairly straightforward: fewer buyers in the room, higher emotion, avoidable problems surfacing too late, and the risk of getting too far down the road with the wrong buyer before realising it. If your primary deal falls through and there is no second or third option, you negotiate from a position of weakness. Time passes, momentum is lost, and the business often goes back to market at a discount.Having someone who understands the sector and knows the buyer landscape is not a luxury reserved for large transactions. For most practice owners, it is one of the most significant levers available once the preparation work is done.Build the better business firstLooking back across every transaction I have been part of – as buyer, seller, and now advisor – there is a clear pattern. The owners whose sales go well are almost always the ones who thought about transferability before it was urgent.A settled team, clean records, a secure lease, a respected brand, predictable client acquisition… None of these things require a sale to be on the horizon. They are just what a well-run practice looks like.Whether you plan to sell in two years or twenty, building something transferable is building something better. The exit is just one of the rewards, not the only one.References[1] Agrawal, A., Cooper, T., Lian, Q. and Wang, Q. (2023) ‘Does hiring M&A advisers matter for private sellers?’, The Quarterly Journal of Finance, 13(1). Available at: https://doi.org/10.1142/S2010139223500040 This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comRecently I found myself in two very different rooms: Laing Buisson’s Out of Hospital Healthcare Conference and HETT (Health Excellence Through Technology).Laing Buisson is a well-known health market intelligence organisation that convenes leaders from the independent and private healthcare sector, commissioners, insurers, investors and provider organisations. Conversations there tend to focus on contracts, investment, national footprint and insurer relationships.At HETT, by contrast, the focus is digital transformation across the NHS. The language was digital maturity, AI-supported triage, interoperability and dashboards. One room spoke about capital; the other about code. Yet the direction of travel was strikingly similar: scale, standardisation and measurable productivity.What struck me was not the difference between the two events, but the convergence in their thinking. Whether the conversation centred on investment models or digital architecture, the underlying assumptions about how healthcare should evolve were remarkably aligned. In both spaces the emphasis was on systems that could be replicated, measured and governed at scale.Listening to these conversations, I kept returning to a simple question: where is the patient in this?

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comPicture it. The next patient is walking through the door and you don’t have a f*****g clue what to do with them. You just hope they don’t ask too many questions.I know I’ve been there… have you?Thankfully, less so in recent years, although I certainly do still have those moments! I’m experienced enough now however to openly acknowledge this and save myself the later embarrassment showing that I was winging it. An embarrassment that I endured time and time again in my early years as a physiotherapist.“Patient’s had an ankle fusion? Hmm, not sure what that is and no real time to understand it or discuss it with my senior so to hell with it, I’ll just fall back onto pushing and rubbing it a bit.” This is the case that stands out to me when I reflect back. I cringe every time. Trying to restore movement in a joint that had been excised, packed with bone graft and held firmly together with a nail. What an idiot!This is an uncanny representation of that fateful day!Overconfidence in special tests, diagnosing everyone with complex biomechanical issues that existed purely in my own head and not having the foggiest idea of what would happen in the world of orthopaedics should my patient fail to improve. The list could go on.And the way I see it, there are two possibilities here:* I was in the bottom quartile when it came to knowledge after coming out of university and too arrogant to even think that this was a possibility.* I was simply not prepared in the right way to be as effective, accurate or aware of my own limitations as I needed to be in the complex world of MSK.Those who know me personally and read this will delight in telling me it’s number 1 and that they never experienced anything like what I’ve laid out above.And to them I say; it’s okay, they’re only my feelings you’ve hurt and I’m sure they’ll heal… and also you’re lying. Experiences just like mine are extremely common. Based on the conversations I have had, I would actually go as far as to say it is the normal experience for new graduates in MSK!But is it a sign of personal failure? Absolutely not.It’s actually a fairly predictable situation. Yet, we seem to be okay with it as a profession; regardless of the negative impact that it has on the clinician who might experience high levels of stress, the patient who has waited months or invested their own money to come and see a specialist, or the reputation of the profession when these two previous scenarios mix and leave a sour taste in everyone’s mouth.In this article, I want to challenge the status quo of MSK training and practice with a particular nod to the pre-registration degree, whether that be undergraduate or pre-registration masters. I will argue that it is no longer fit for purpose and can actually be counter-productive to producing good quality MSK clinicians.

In 2014, clinical pharmacist and exercise medicine champion Ann Gates spoke to Jack Chew on The Physio Matters Podcast about the need to reposition physical activity at the centre of healthcare. She described physical inactivity as a public health crisis, advocated for integrating exercise into every patient consultation, and encouraged us to view exercise as a therapeutic agent as legitimate as drugs or surgery.Nearly 12 years later, the evidence base for exercise medicine has grown substantially and many health systems are increasingly prioritising physical activity in policy and clinical practice. In our first Core Memories feature, we assess how Ann’s insights align with current evidence and thinking in 2026, exploring where her 2014 perspectives have been supported, updated, or reframed by the research.Exercise as Medicine: Then and Now2014Ann framed exercise as being akin to a pharmacological intervention; something that should be prescribed, monitored, and integrated into treatment regimens. She argued that exercise has cost-effectiveness comparable to many drugs and called for healthcare systems to see exercise as an equal partner to traditional medicine.2026Ann’s viewpoint has only strengthened with advancing research. Over the past decade, multiple large-scale meta-analyses and clinical guidelines have solidified what earlier researchers hinted at: exercise has measurable effects on morbidity and mortality across a range of chronic conditions.For example:Cardiometabolic disease: In secondary prevention and some high-risk groups, structured exercise interventions can achieve mortality outcomes comparable to drug therapy in the evidence base, and exercise-based programmes (e.g. cardiac rehabilitation) reduce cardiovascular mortality and recurrent events, though effects on all-cause mortality are more variable in contemporary trials [1,2].Type 2 diabetes: For type 2 diabetes, physical activity is firmly positioned as a foundational component of management rather than optional advice. Contemporary NICE and American Diabetes Association guidance places structured exercise alongside pharmacotherapy from diagnosis, recognising its role in improving insulin sensitivity, lowering HbA1c (a blood test that measures blood glucose levels over the past three months), and reducing cardiovascular risk [3,4]. Meta-analyses consistently show that aerobic, resistance and combined training meaningfully reduce glycaemic markers, with combined approaches often producing the greatest benefit [5,6]. While exercise does not replace medication for most patients, it can reduce medication burden in some cases and remains one of the most powerful long-term cardiometabolic interventions available [7].Cancer survivorship: Exercise is now embedded within survivorship care in many oncology pathways, with international guidelines recommending structured aerobic and resistance training following treatment [8,9]. Level-1 evidence, including large randomised trials such as the CHALLENGE study in colon cancer survivors, demonstrates reduced recurrence risk alongside improvements in quality of life and physical function [10]. Across tumour types, systematic reviews consistently confirm exercise as a safe, effective adjunct in post-treatment care [11].Health organisations and clinical initiatives (e.g. Exercise is Medicine/ACSM and NHS England-aligned programmes) increasingly treat physical activity as a “vital sign” assessed in routine consultations and linked to actionable goals [12–14]. Ann’s view that exercise should be monitored like a drug has gained traction in clinical pathways and electronic medical records, where best practice is for physical activity metrics to be charted alongside markers such as blood pressure and blood glucose, although adoption remains variable.ConclusionThe core premise of exercise medicine articulated in 2013 has been reinforced and operationalised. In 2026, it is not just progressive advocacy but a mainstream clinical priority in many healthcare systems.Brief Interventions and ‘Making Every Contact Count’2014Ann emphasised brief, teachable moments within consultations: short but confident advice linking exercise to measurable health outcomes. She cautioned against treating exercise advice as a quick fix and advocated for monitoring and follow-up analogous to pharmacotherapy.2026This approach aligns closely with contemporary behavioural science and implementation research. Brief physical activity interventions delivered in primary care have demonstrated modest but clinically meaningful increases in activity levels, particularly when combined with goal-setting and follow-up support [15,16]. Even very short conversations, often under two minutes, can prompt behaviour change when paired with structured referral pathways or digital reinforcement [16,17].Making Every Contact Count remains a valid and widely endorsed model within UK public health strategy [18], though modern implementation increasingly incorporates digital systems — including patient portals, remote monitoring, wearable data integration and automated messaging — to improve adherence and clinician follow-through [19].Importantly, systematic reviews confirm a point Ann anticipated: brief advice alone is usually insufficient unless embedded within wider behaviour-change systems that include ongoing support, environmental accessibility and tailored feedback [15,20].Current nuanceRecent work in behavioural medicine emphasises contextual tailoring; interventions are most effective when adapted to readiness to change, health literacy, socioeconomic context and cultural background [20,21].ConclusionAnn’s 2014 framing of brief, confident, monitored interventions anticipated current best practice. In 2026, the principle remains sound but effectiveness increasingly depends on structured follow-up and digitally enabled support systems.Healthcare Systems, Barriers, and Equity2014Ann argued that healthcare systems were poorly designed to promote exercise, stressing the need for community links, clinician empowerment, and breaking down barriers that prevent physical activity.2026Subsequent policy frameworks increasingly reflect this thinking. The last five years have seen:* Inclusion of physical activity targets within national strategies, including NHS Long Term Plan delivery updates and the UK Chief Medical Officers’ physical activity framework, which position prevention and activity promotion as core system priorities [22,23].* Growth of community-linked referral schemes, including social prescribing pathways and exercise referral programmes designed to connect patients with local activity providers through primary care networks [24,25].* Greater integration of social determinants of health into physical activity policy, with recognition that access to safe environments, green space, transport infrastructure and socioeconomic stability significantly influence participation [23,26].However, implementation remains uneven. Despite national ambition, regional variation in service availability and infrastructure persists, and disparities in access to community programmes continue to reflect the “postcode lottery” Ann described [24,27].A notable evolution over the past decade has been a sharper focus on health equity. Research consistently demonstrates disparities in physical activity participation by ethnicity, gender, age, disability and deprivation [26,28]. In response, targeted programmes — particularly those addressing adolescent girls, older adults and underserved communities — have demonstrated improved engagement and adherence when culturally and contextually tailored [28,29].ConclusionAnn’s 2014 critique of structural barriers remains valid. By 2026, however, policy frameworks are more explicitly equity-oriented and data-driven, even if delivery across systems remains inconsistent.Research Gaps and Implementation Science2014Ann challenged researchers to produce rigorous trials comparing exercise interventions with other treatments and highlighted deficits in long-term follow-up.2026Over the past decade, research quality in exercise medicine has improved substantially. Large pragmatic trials now more commonly incorporate structured, standardised exercise protocols aligned with public health guidance, including aerobic volumes consistent with 150+ minutes per week and inclusion of resistance training components [30,31].There has also been a marked rise in implementation science within physical activity research, focusing not only on efficacy but on scalability, system integration and real-world translation into primary and secondary care pathways [32,33]. Longer-term follow-up has become more common, with several contemporary trials and cohort extensions reporting outcomes beyond two to five years, addressing earlier concerns that exercise research relied too heavily on short-duration endpoints [34].That said, important gaps remain. Head-to-head comparative trials between structured exercise prescriptions and procedural or invasive interventions are still relatively uncommon outside selected cardiology and oncology contexts [35]. While funding streams and international collaborations in exercise oncology and cardiometabolic health are expanding, coordinated multi-site interdisciplinary exercise medicine research remains underdeveloped compared with pharmaceutical research infrastructures [32,36].ConclusionExercise medicine research is more rigorous and implementation-focused than it was in 2014. However, comparative trials and large-scale coordinated funding still trail behind other treatment areas. The evidence is stronger, but system-level integration remains incomplete.Final ReflectionsLooking back from 2026, many of Ann Gates’ perspectives from 2014 not only stood the test of time but anticipated future developments in clinical practice, research and health system design. Exercise medicine is now more embedded in routine care, brief interventions are backed by behavioural science and equity has become a central concern.We asked Ann for her thoughts on relistening to the podcast:“Revisiting that 2014 conversation on The Physio Matters Podcast, I’m struck by how consistent the core message remains: movement is powerful medicine. The evidence base has only strengthened over the past decade. What has evolved is our understanding of implementation and scale.Brief advice is well evidenced, and approaches such as Make Every Contact Count have rightly embedded physical activity within routine care. But advice achieves its greatest impact when the system around it supports and sustains behaviour change.Professional education, service design, leadership priorities and community environments determine whether movement becomes normalised or remains dependent on individual advocacy.The next critical step is strengthening our collective change agency — redesigning healthcare so prevention is structurally embedded, aligned with the systems approach set out in the World Health Organisation’s Global Action Plan on Physical Activity.Movement should be a mainstay in prevention, treatment and rehabilitation of ill health across the life course. The science is clear. The responsibility now is collective.”Our collective responsibility is clear. The vision of universally integrating exercise into every consultation, ensuring consistent access to supportive community resources and developing robust comparative evidence remains a work in progress. The conversation Ann started over a decade ago continues to shape how clinicians view physical activity — not as an optional extra, but as medicine with profound, evidence-based impact.References* Naci H, Ioannidis JPA. Comparative effectiveness of exercise and drug interventions on mortality outcomes: meta-epidemiological study. BMJ. 2013;347:f5577. doi:10.1136/bmj.f5577.* Dibben GO, Faulkner J, Oldridge N, Rees K, Thompson DR, Zwisler AD, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease: a meta-analysis. Eur Heart J. 2023;44(6):452-469. doi:10.1093/eurheartj/ehac747.* National Institute for Health and Care Excellence (NICE). Type 2 diabetes in adults: management (NG28). London: NICE; Updated 2026.* American Diabetes Association. Standards of Care in Diabetes—2026. Diabetes Care. 2026.* Pan B, Ge L, Xun YQ, et al. Exercise training modalities in patients with type 2 diabetes mellitus: a systematic review and network meta-analysis. Diabetes Care. 2018;41(12):2431-2439.* Umpierre D, Ribeiro PAB, Kramer CK, et al. Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: systematic review and meta-analysis. JAMA. 2011;305(17):1790-1799.* Look AHEAD Research Group. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med. 2013;369:145-154.* Campbell KL, Winters-Stone KM, Wiskemann J, et al. Exercise guidelines for cancer survivors: consensus statement from international multidisciplinary roundtable. Med Sci Sports Exerc. 2019;51(11):2375-2390.* National Institute for Health and Care Excellence (NICE). Cancer rehabilitation and survivorship guidance. London: NICE.* Courneya KS, Booth CM, Gill S, et al. Effects of a structured exercise program on disease-free survival in colon cancer survivors: the CHALLENGE randomized trial. N Engl J Med. 2024/2025.* Segal R, Zwaal C, Green E, et al. Exercise for people with cancer: systematic review and clinical practice guideline. Curr Oncol. 2017;24(1):40-46.* Sallis R. Exercise is medicine and physicians need to prescribe it. Br J Sports Med. 2009;43:3-4.* World Health Organization. WHO Guidelines on Physical Activity and Sedentary Behaviour. Geneva: WHO; 2020.* NHS England. Physical Activity Vital Sign. NHS Data Dictionary. 2024.* Orrow G, Kinmonth AL, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis. BMJ. 2012;344:e1389.* O’Brien N, McDonald S, Araujo-Soares V, et al. The effectiveness of physical activity interventions in primary care: systematic review. Br J Sports Med.* National Institute for Health and Care Excellence (NICE). Behaviour change: individual approaches (PH49). London: NICE.* NHS England. Making Every Contact Count (MECC). London: NHS England.* World Health Organization. WHO guideline: recommendations on digital interventions for health system strengthening. Geneva: WHO.* Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42.* Marteau TM, Hollands GJ, Fletcher PC. Changing human behaviour to prevent disease. BMJ. 2012;345:e6453.* NHS England. The NHS Long Term Plan. London: NHS England; 2019.* UK Chief Medical Officers. Physical Activity Guidelines. London: Department of Health; 2019.* NHS England. Social prescribing and community-based support: summary guide. London: NHS England.* Public Health England. Exercise Referral Schemes: A National Evaluation. London: PHE.* World Health Organization. Global Action Plan on Physical Activity 2018–2030. Geneva: WHO.* Sport England. Active Lives Survey. London: Sport England.* World Health Organization. Fair Play: Building a Strong Physical Activity System for More Active People. Geneva: WHO; 2024.* Sport England. This Girl Can campaign evaluation reports. London: Sport England.* World Health Organization. Guidelines on physical activity and sedentary behaviour. Geneva: WHO; 2020.* American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 11th ed. Philadelphia: Wolters Kluwer; 2021.* Glasgow RE, Harden SM, Gaglio B, et al. RE-AIM planning and evaluation framework: adapting to new science and practice with a 20-year review. Front Public Health. 2019.* World Health Organization. Global Action Plan on Physical Activity 2018–2030: implementation framework. Geneva: WHO.* Look AHEAD Research Group. Eight-year weight losses with an intensive lifestyle intervention: the Look AHEAD study. Obesity. 2014.* Naci H, Ioannidis JPA. Comparative effectiveness research of exercise versus drug interventions: methodological perspectives. BMJ.* Sallis R, Pratt M. Physical activity as a global health priority: scaling Exercise is Medicine. Br J Sports Med. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comExpertise is special skill or knowledge that is acquired by training, study, or practice.I follow an Orthopaedic surgeon from the US who is of a similar vintage and much of what he posts aligns with my current thinking. I like his posts because they ooze expertise. He is extremely considered when it comes to non-operative care and he himself states how much less he operates these days, as he has become more experienced.Yesterday, I met an extremely experienced health entrepreneur who’s worked on the business side of healthcare for decades. We were discussing how I am managing the latter part of a surgical career.I was explaining that I don’t learn a huge amount from additional surgical procedures these days but I still learn an immense amount from seeing my patients. Don’t get me wrong, I’m not giving up surgery at all. I still see patients regularly that really make me have to think hard. The harder I think, the less I operate. Why is it that the more expertise I have, the less I operate?It reminded me I had got thinking about expertise - there I go again – as far back as 2012. My question was, ‘can patient forums offer expertise?’ so I started looking at them online. I came across people with a condition who would have had plenty of experience or ‘practice’ in living with their condition. Many would have become very knowledgeable compared to the general population. There were, in addition, many who commented and gave advice that was way out of their lane of training. I don’t want to single out any allied health professionals but there were some who would have been trained for example in anatomy and manual therapies but virtually nothing to suggest they were people with the right expertise to advise on getting an MRI scan. The problem was that these two groups may have had huge experience of practice within MSK but that experience was not matched by training and study in the subject. Exposure without prior study, learning and reflection could not be called expertise.I started to think about where expertise sits in the treatment pathway. I followed what we all do from the moment we start seeing a patient. I came up with a progression from acquisition of many single points of data e.g. twisted knee, medial pain, medial tenderness, swelling. All those data points when put together assume a pattern leading to information e.g. MCL tear, meniscus tear, osteoarthritis. That list is unranked i.e. equal weight is given to all diagnoses. This is where it then starts to get interesting. When that data and information is viewed by someone with knowledge and expertise, they can start to rank them into a list that floats the most likely diagnosis to the top of the pile. The application of training, study and practice improves the ranking. They draw on prior knowledge and experience from exposure to start to see the patterns. Without this, treatment plans are like throwing spaghetti at the wall to see what sticks. In other words, a bit hit and miss. A bit like when we all did our first day at work and floundered to apply our study and training in a meaningful way. Those of you reading this who have qualified will remember how poorly equipped we all were on that very first day.So back to my original question: can patient forums offer expertise?

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comDynamometry and assessment of performance are hot topics right now and with the drive to provide data-driven decisions in clinical practice, you can see why rehab professionals are seeking tools to capture this information.A couple of years ago I had the pleasure of writing an article for MSK Mag [1], covering some of the fundamental aspects of dynamometry, assessment of performance and measurement error. We explored perhaps an uncomfortable truth:‘Just because you have a number doesn’t mean it represents reality’and a few ways to improve measurement accuracy. Hopefully readers were left with the take-home message that time is well invested into their measurement protocols to minimise measurement error, to generate useful data, and of course strategies on how to achieve this.In this article, we’re going to address the other important part of the equation - the measurement tool itself. I’ll provide a simple framework to help you identify the device that’s right for your setting, along with a completely free online comparison tool to scrutinise devices against the specifications that matter. More on that in a bit.Why Measurement MattersLet’s just roll back a bit first and revisit the question: is the measurement of muscle performance, such as strength and rate of force development (RFD), important? Clearly I think so but here are a few reasons why obtaining (accurate) objective measurements of parameters like muscle force can be useful:Table 1: The potential utility of objective dataThe Problem After Deciding to MeasureOnce you’ve rationalised your decision to test, honing your measurement skills addresses only part of the issue; the other part is the device itself and whether or not it’s fit for purpose. After reading this article, I want to leave you with a clear idea of some of the critical things to look for when selecting (or using) a dynamometer. For the purpose of this article we’re focusing on hand-held dynamometers (HHDs), but the considerations are applicable to most measurement devices.Given the considerable variation in technical specifications between devices, a resource that provides side-by-side comparisons would be super useful to help you make an informed choice on purchasing or to see how your device stacks up against these critical metrics. So I created one.The Need For A HHD Information Repository, With GuidanceI’ve interacted with thousands of therapists across the globe via my S&C teaching, and assessment of performance is an important part of this topic. Without fail, the most frequently asked question I receive is:“Which dynamometer should I buy?”Ten years ago the problem was lack of access to measurement tools. Now, the prolific rise in the number of HHDs and other devices makes “Which dynamometer should I buy?” a far more difficult question for the busy clinician to answer. Truth is, there is no single best dynamometer, nor is there a single unbiased and credible, centralised source of information on these measurement devices. So, I set out to create one - to arm clinicians with the critical information to help them navigate through the cacophony of information and marketing claims. In doing so, clinicians can identify the right dynamometer for their setting and avoid making decisions solely based on:* Which device colleagues use* Which device is the cheapest* The device with the most impressive marketingwhichdynamometer.com is a completely free, unbiased online HHD comparison site - effectively a buyer’s guide and education hub for handheld dynamometry.Note of CautionI realise that some discerning clinicians may diligently trawl the literature for publications on HHDs, in particular searching for reports on the reliability of devices. This is a commendable feat, however it may not deliver the answer as I highlight in my recent (open access) paper [2].

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comI took a phone call from a friend this month. She’s been called up for HCPC audit and we both run very similar sole practitioner clinics.A great deal of my replies to her questions about whether I had x, y or z policy in place were “erm… no?” Sure, I have consent forms for patients and a plan in place for the patient who comes in with unexplained bladder retention and bilateral leg pain… but you want to see my non-clinical policies? Written down? Give me 2–3 working days and I’ll, um, unearth them.My friend was dubious about this. For some reason - and perhaps it’s because we’re all encouraged to project this image - she presumed I was running the perfect clinic. Policy after policy filed alphabetically in a folder, always to hand. We have so much in common, but this folder - and my apparent drive to have created and maintained it - is our great divider.This folder does not exist.Somewhat related, I am currently reading a book called Doppelganger by Naomi Klein. Klein is a journalist and documentary-maker and also wrote the excellent Shock Doctrine about how governments use fear within populations. Klein is frequently confused online with another Naomi - Naomi Wolf - who has built a name and reputation as a conspiracy theorist and mass spreader of misinformation. It is - and I am merely paraphrasing Klein here - not ideal.In MSK, we all have our doppelgängers. Sometimes they look like us - only much, much better. And sometimes they’re just like us, only clearly getting it wrong. They rely too heavily on manual therapy, whereas we are, of course, more enlightened. Or perhaps they’re a totally hands-off maniac, while we sit comfortably in the skilled middle.Klein uses the example of her dog, Smoke, catching a glimpse of himself in a glass door and barking ferociously. ‘And this is the catch-22 of confronting your doppelganger’, writes Klein. ‘Bark all you want, but you inevitably end up confronting yourself’.This month’s MSKMag is full of these reflections: versions of us, past and present, held up for critique.Our new feature looks exactly like us…only from 2014. We hold The Physio Matters Podcast Episode 10 featuring Ann Gates speaking on exercise promotion to scrutiny to see if the messages still hold true. Check it out in Core Memories.If you’ve ever been on a ski forum online and thought wow, that sounds like Orthopaedic surgeon Jonathan Bell giving advice! It wasn’t his doppelganger, it was him. And he’s back to talk about expertise and why the more of it he gathers, the less he’s reaching for the scalpel. Read all about it in ‘What is Expertise?’If you can’t tell one dynamometer apart from the next, Claire Minshull’s piece ‘The Best Dynamometer for Clinical Practice’ and her associated new website is for you.If you’ve ever thought that physiotherapy graduates should look a little less identical and a whole lot more specialised from the off, Jeff Morton is putting forward his case for MSK to be a separate degree in ‘Trained to Struggle’.Katie Knapton has been to two conferences of late, covering digital transformation in the NHS and investment - but while the conference themes might have looked comparable, there was one vital thing missing. Find out what in ‘Industrialised Rehabilitation’.And if you’re envious of your doppelganger who just sold their clinic, check out our article by Verilo’s Joshua Catlett ‘How To Build Something Worth Selling’.Whether it’s our past ideas, our professional identity, or the clinics we build, we’re not really arguing with something new. Just a version of ourselves we’d rather not see too clearly.

Chewy and Jim are back and so is the theme tune. Now I am not usually one to call out Chewy’s mum for bias but apparently she is in a grump about the lyrics. Yes maybe we do omit ‘Chewy’s dashing looks’ but there is reference to his ‘gags’ which of course are absolutely dreadful and often unpublishable trash.Chewy and Jim is best watched in full via the video above (so you can check out Jim’s dashing looks) or you can listen on the usual podcast players.In this recording, Chewy and Jim cover a lot of ground relating to clinicians identity, conflicts of interest and the perils of social media.Are We Accidentally Creating a Two-Tier MSK System?Every few years, MSK seems to rediscover an old argument and insist it’s new. Hands-on versus hands-off. Manual therapy versus exercise. Biomedical versus biopsychosocial. Pick your side, sharpen your acupuncture needles, and head to social media.But while everyone is busy refighting those wars, a quieter shift appears to be happening under our noses. One that’s less about techniques and more about identity. Not how we treat, but what kind of clinician we are becoming.Not in the sense of ‘good’ and ‘bad’ clinicians, or evidence-based obsessives versus charlatans. But in the sense of two diverging professional trajectories: the interventionalist and the health-coach generalist.“I almost saw it as being those that were really trying to hark back to diagnostic specificity [that were getting more into interventions].” - ChewyJim asks Chewy this very interesting and insightful question: are we drifting towards a two-tier MSK system?“I think that there maybe are the crap ends of each of those spectrums.” - ChewyWhen we talk about conflicts of interest, we tend to think about obvious commercial ones: paid endorsements, sponsored products, affiliate links.But many of the most influential conflicts in MSK are reputational rather than obvious receipt of piles of cash.“Strength and conditioning I see a lot of people doubling down on because it’s grabbing attention.” - JimIs Two-Tier MSK Inevitable?Perhaps some degree of stratification is unavoidable. We do need interventionists. We do need clinicians with advanced technical skills. And we do need generalists who can guide patients through long-term behaviour change.“The multi-disciplinary clinics are doing very well because they can have some specific components to but also provide a more general service where you can cross refer.” - JimGood MSK care exhausts proportionate options before escalation. It recognises uncertainty. It manages expectations. It acknowledges bias. It remains flexible enough to change course without defending an identity.Of course clinical topics aren’t Jim’s only strengths; he can also make fantastic puns using Chewy’s name. Get involved in the features ‘Would Chew Rather?’ And ‘Who Are Chew?’Would Chew Rather see lots of complex patients every 30 minutes or just one person for a whole week? And who would Chew like to have dinner with? The answers will likely surprise you… Let us know yours.If you have any ‘Would Chew Rather?’ or ‘Who Are Chew?’ questions put them in the comments or email them to us [email protected] This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe

Over the past decade few developments have reshaped UK musculoskeletal (MSK) care as profoundly as the rise of First Contact Practitioners (FCPs) in primary care. What began as a pragmatic response to workforce pressure has quietly evolved into something far more significant: advanced-level clinical decision-making at the very forefront of the system.In many ways FCPs have changed the front door of the NHS.Patients now access specialist MSK expertise earlier. GPs are better supported. Pathways move faster. Risk is managed closer to the point of presentation. When the model works well, the whole system works smarter.But as the FCP role has expanded, it has become increasingly clear that the expectations placed on many FCPs now look very much like those of advanced practitioners, even though, formally, the role is rarely defined that way.For me, that creates a tension within the profession.Because the future of MSK care will not be shaped simply by how many FCPs we employ, but by how well we develop, support, and lead the clinicians working at the front line of primary care, and how well the rest of the system keeps pace with what that front line now requires.From workforce solution to advanced clinical realityThe FCP model was born out of necessity. General practice was under intense pressure. MSK presentations were consuming huge clinical capacity. Waiting lists were growing. Patients were often being referred into pathways that felt slow, fragmented, and overly medicalised.Putting experienced MSK clinicians at the point of first contact made sense, and in many places it has worked brilliantly.Today, FCPs are routinely:* Assessing undifferentiated presentations* Identifying serious pathology early* Making referral decisions* Managing clinical uncertainty in real time* Shaping patient beliefs at the very start of their journey* Influencing practice-wide MSK decision-making.This is not just triage or filtering demand. This is advanced-level practice in one of the most pressured environments in the NHS.MSK in primary care has become a setting where judgement matters as much as skill. Where pattern recognition, risk stratification, and professional confidence are tested daily. Where the first conversation often determines the entire trajectory of someone’s care.And yet despite this, we still tend to talk about FCPs as if they are primarily a service solution rather than a professional group operating at (or rapidly moving towards) advanced practice. That gap between what the role is called and what the role actually requires should not be ignored.What’s working wellAcross the UK, there are outstanding examples of FCP-led MSK services. Where advanced-level practice is properly supported in primary care, three things consistently stand out.1. Right expertise, right timeWhen skilled MSK clinicians see patients first, the impact is immediate. We see fewer unnecessary scans, more appropriate referrals, earlier reassurance, and high levels of patient satisfaction [1]. Having specialist MSK expertise at the front door reshapes what ‘good MSK care’ looks like.2. Stability in the grey zonesPrimary care is full of grey zones. MSK presentations are rarely neat. Pain is complex. Fear is common. Red flag pathologies are rare, but very much there.What experienced clinicians bring here is not certainty, but calm judgement. Confidence that comes from experience, pattern recognition, and knowing when not to act.That confidence reduces defensive referrals, unnecessary imaging, clinician anxiety, and patient fear. In this way, advanced MSK practice does more than assess and manage conditions. It helps to stabilise the system.3. FCPs as translators of MSK thinkingOne of the most underestimated contributions of FCPs is their educational influence.Every day, they reframe beliefs and myths. They support MDT colleagues with MSK reasoning. They influence how practices triage.They translate specialist MSK knowledge across primary care, and that influence reaches far beyond the clinic room.The tension we rarely nameHere is the issue we do not talk about openly enough.FCPs are not formally classed as advanced practitioners, yet many are expected to work at an advanced level.That matters.Because the responsibilities placed on FCPs increasingly include:* Holding undifferentiated clinical risk* Making decisions with downstream consequences* Acting as senior MSK decision-makers within practices* Influencing referral behaviour and shaping MSK pathways.These are not entry-level expectations. They are hallmarks of advanced practice.And yet, in many parts of the system, FCP roles are still viewed as sitting somewhere between senior clinician and advanced practitioner - without the clarity, structure, or investment that true advanced practice demands.The result is predictable.Some clinicians grow and excel through experience, self-directed learning, mentorship, and/or higher education. Others are placed into roles that quietly outpace their readiness.And that leads to another uncomfortable truth.Quality varies. A lot.Across the UK, the quality of FCP practice varies significantly.There are FCPs working at an exceptional level. Clinically confident, comfortable with risk, and deeply influential within their practices.And there are others, committed and capable clinicians, who have been placed into FCP roles before they were truly ready for the responsibility the role now carries [2]. This is not a criticism of individuals. It is a system design problem.The rapid growth of FCP services was driven by urgency. Access had to improve quickly. Roles expanded at pace. In many areas, this meant accelerated transitions, variable training standards, inconsistent supervision, and very different interpretations of what ‘FCP-ready’ actually means.The consequence is predictable: a wide spectrum of practice under a single job title.At one end, clinicians confidently manage complexity and shape MSK pathways. At the other, clinicians are still consolidating core reasoning while balancing advanced-level risk.Both are called FCPs. But they are not working at the same level of practice, and the system often behaves as if they are.Don’t get me wrong, variation exists in every profession. But in primary care, its impact is amplified. When FCP practice is done well, it reduces harm, cost, and fear. When it is done prematurely, it increases all three.But there is another layer to this that we do not talk about enough. Even when the FCP decision is clinically sound, the rest of the system does not always keep up.The rest of the MSK pathway is not up to speedLarge parts of the MSK system have not evolved at the same rate as FCP provision. Across the UK, outpatient physiotherapy services vary enormously in quality, resource, and capacity.In many settings, clinicians are working exceptionally hard within significant constraints. They are delivering care in overstretched services, under intense time pressure, and with limited access to facilities or follow-up [3].The issue is the system they are working within.In some areas, patients are seen quickly. They have access to proper gym equipment. They receive structured rehabilitation programmes. They are supported to progress, not just given advice and discharged.In others, waiting lists are long. Appointments are brief. Resources are minimal. Patients report being ‘handed a sheet of paper’ and told to get on with it.And then they come back to primary care saying they have ‘failed physiotherapy’.They say the exercises did not work.They say nothing changed.They ask, “What now?”They are often labelled as ‘non-responders’.But frequently, what has really failed is not physiotherapy itself. It is the quality, intensity, and individualisation of the rehabilitation they were given.This creates an unhelpful dynamic.The FCP makes a reasonable physiotherapy referral.The patient waits months.They receive minimal intervention.They return to primary care saying physio has not worked.And now the pressure to escalate, request imaging, inject, or refer increases.Not because the condition demands it. But because the rehabilitation pathway was not fit for purpose.This puts FCPs in an impossible position.They are working in a system where downstream services vary widely in quality, waiting lists undermine early intervention, rehabilitation standards are inconsistent, and patient expectations are shaped by poor prior experiences.That means FCPs are not just making clinical decisions. They are compensating for system weaknesses. They are trying to hold a line on conservative care in a system that does not always deliver conservative care properly.That is not a small thing.It requires judgement, resilience, and leadership. Advanced-level practice.What needs to change next?The uncomfortable reality is this.We have built advanced responsibilities at the front door, but not consistently built advanced pathways behind it. And we have built advanced expectations of FCPs without consistently building advanced support around them.That is not solved by telling FCPs to complete a postgraduate course alone.It is solved by designing better systems and providing appropriate, ongoing support and education.That means:* Clearer national expectations of what ‘FCP-ready’ actually means* Honest recognition that many FCP roles are, in practice, advanced practice roles* Protected time for development rather than pure service delivery* Formal mentorship and supervision as standard* More consistent standards for MSK rehabilitation downstream* Better communication between primary care, physiotherapy services, and interface clinics.Advanced practice should be earned through genuine development, not assumed through appointment or credentials alone.And advanced care should be delivered through proper systems, not heroic individual effort.A quiet signal of what’s coming next.There is a growing recognition that advanced MSK practice development needs regular support and learning opportunities:Exposure to complex cases and advanced clinical reasoning.Support with managing uncertainty.Leadership development grounded in real-world practice.Not just isolated training days, but ongoing programmes, regular CPD opportunities and resources and communities: spaces designed not simply to update skills, but to shape professional identity, leadership, and influence.Something is beginning to form in that space.Work is underway to create a platform specifically designed to support clinicians operating at, or working towards, advanced-level MSK practice. A platform that brings together monthly webinars, a substantial on-demand content library, courses, events, and a community focused on the realities of advanced practice.This work is being led by yours truly, not as someone standing outside the profession, but as a clinician working within it, facing the same uncertainty, responsibility, and complexity as others in these roles.The intention is simple: to help create the kind of space that many advanced practitioners wish had existed earlier in their careers, and one that remains relevant as practice continues to evolve.That work is taking shape as Physio Matters Advanced Practice (PMAP). Watch this space.References* Downie F, McRitchie C, Monteith W, Turner H. Physiotherapist as an alternative to a GP for musculoskeletal conditions: a 2-year service evaluation of UK primary care data. British Journal of General Practice [Internet]. 2019 Apr 8;69(682):e314–20. Available from: https://bjgp.org/content/69/682/e314* Hayward-Giles S. First contact physiotherapy: challenges and opportunities [Internet]. The Chartered Society of Physiotherapy. 2025. Available from: https://www.csp.org.uk/frontline/article/first-contact-physiotherapy-challenges-opportunities* NHS waiting lists rise demonstrates need for graduate physio job guarantee [Internet]. The Chartered Society of Physiotherapy. 2025. Available from: https://www.csp.org.uk/news/2025-08-14-nhs-waiting-lists-rise-demonstrates-need-graduate-physio-job-guarantee This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comUrinary incontinence is often seen as something that belongs firmly in the realms of pelvic health. When I worked solely in MSK, I rarely asked about it unless I was screening for cauda equina. If I am honest, I hoped for a straightforward “no”. If someone did say yes, I clarified that it was not new or acute, reassured myself it was not a red flag, and moved on. I am sure I was not alone in that approach.The reality is that urinary incontinence is very common.In the UK, around 14 million people live with some form of urinary incontinence. Roughly one in three women and up to one in ten men will experience it during their lifetime. In female athletes the numbers are higher still, particularly in impact sport. It is not rare or niche; it is present in many of the people we already treat.Broadly, we see two main patterns. Stress urinary incontinence occurs with effort such as coughing, jumping, lifting or sprinting. Urge urinary incontinence is leakage that follows a strong, sudden need to void that is difficult to delay. Many people experience a mix of both.Stress urinary incontinence is multifactorial. Pelvic floor muscle weakness is one contributor, but not the only one. Parity, hormonal changes, connective tissue laxity, hypermobility and altered neuromuscular timing all play a role. Oestrogen deficiency in the peri- and postmenopausal years can reduce urethral closure pressure and tissue integrity. In younger athletic populations, high training loads without adequate recovery may influence tissue resilience.So why does this matter in MSK?

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comI didn’t set out to write a book. I set out to understand people.Through founding and running Physiquipe, I’ve been incredibly fortunate. The business gave me a platform to step into elite sport environments, private clinics, NHS settings and boardrooms and, more importantly, to meet some amazing people along the way. Those relationships naturally led to conversations, and those conversations led to the Life Stories and Leading the Field podcasts.As those conversations grew, I found myself repeatedly asking the same questions of clinicians, leaders and business owners. What actually matters? What was harder than expected? And what would you do differently if you were starting again?Over time, the answers to those questions became my book, Real Growth. What started as curiosity quickly became something much deeper.I wasn’t trying to extract soundbites or clever business tips. I just wanted to understand people. How they got started. What they struggled with. What were their setbacks and failures. What actually mattered. Over time, patterns started to emerge. The same themes kept coming up, regardless of job title or level of success.After more than 200 podcast conversations, it felt wrong to keep those insights locked away in long-form audio and video. There was too much value there. Too much real insight. Too much learning. I realised I was learning as much from these people as anyone listening, and I wanted to bring it together in a way that was useful, practical, and human.That’s why I wrote this book.

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comImagine we can teleport to 2050 and witness a pain clinic visit. Before the patient enters the room, the clinician reviews a multimodal dashboard that has information from wearables, sleep tracking, movement, mood, and lifestyle pillars.An AI-generated risk profile with confidence intervals is generated along with psychosocial risk flags, so the clinician can be aware of the whole person components that may be worth exploring with the person in pain.The patient and clinician co-decide on possible neuromodulation techniques from a stimulation device or the desired mode of clinician-applied modulatory technique, while also identifying and responding to true tissue-based, mechanically sensitive pain behaviors when present. The AI clinical companion identifies specific psychological flexibility issues through its initial intake conversation and subsequent narrative check-ins with the patient during their course of care. This information, combined with ongoing assessment of load tolerance, movement sensitivity, and tissue recovery trajectories, along with options for graded exposure and an ACT-based pain curriculum, assists both the clinician and the patient in addressing and resolving issues as they emerge throughout the treatment process.The weirdest part of all this? Nothing here is science fiction. Everything in this scenario exists right now in 2026. We simply aren’t using it as we may in 2050.

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comWho was the first player you pictured when you read the title? I would bet for most of you it would have been someone famous. Perhaps Lionel Messi or Ronaldo (Brazilian version or Portuguese)? I would also bet that it would have been a male?I pictured European Champion, England Lioness and Chelsea forward Lauren James. Her brother Reece is also an England player. Talented family!Despite the social media noise, it’s not anterior cruciate ligament injuries that are the most common injury in professional women’s football. As with men’s football, it’s hamstring strains.The problemJust like their male counterparts, hamstring strains top the injury charts in the women’s game, accounting for 12% of all reported injuries in elite cohorts [1]. We talk a lot about ACLs, but hamstrings are the most common injury with fewer headlines.Most prevention models were designed from male data. That’s a bias baked into our protocols [2, 3]. We understand hamstring injury mechanisms reasonably well, but we haven’t fully adapted our strategies to the female athlete.EpidemiologyIn elite women’s football, epidemiological depth still lags behind the men’s game [1]. Physiology, biomechanics, and possible hormonal influences are underrepresented, which matters when you want targeted prevention and better return to play (RTP) decisions. The pattern is familiar by now: promising data, not enough of it in women, and too much extrapolation from men [2, 3].Anatomy that matters: the female pelvis and the hamstringsIncreased anterior pelvic tilt can leave hamstrings and gluteals chronically lengthened; increased femoral anteversion often rides alongside gluteus medius weakness; gluteus maximus weakness shows up again and again; pelvic width relative to femoral length changes alignment and loading; females typically have lower passive hamstring stiffness, higher joint laxity, and greater resistance to skeletal muscle fatigue [4].Clinically, that means we don’t always need to ‘stretch more’; we often need better pelvic control, stronger glutes (maximus and medius), and rehabilitation and prevention strategies that respect sex-specific stiffness profiles.At the muscle level, architecture matters: semitendinosus is especially sensitive to exercises involving large musculotendinous length changes; biceps femoris and semimembranosus have unipennate/bipennate arrangements with different functional and injury profiles [5]. That should inform assessment and exercise selection.Two injury archetypesThere are two distinct hamstring strain archetypes with different tissues and timelines [6]:1) Sprint type: high speed running, typically biceps femoris long head.2) Slow stretch type: extreme lengthening (high kick, slide, splits), often involving the free proximal tendon of semimembranosus.Slow stretch injuries often look less dramatic but take longer to return to play [6]. Label the mechanism early; it sets rehab pace and tissue focus. Also note that a shorter distance to the ischial tuberosity may be associated with longer RTP [8].Risk factors: what you can and can’t changeNon-modifiable predictors remain familiar: older age and previous hamstring injury carry the greatest risk, especially within the first year post-RTP. On the modifiable side, single metrics haven’t delivered reliable prediction: isolated strength deficits or imbalances can matter but don’t predict injury [9].The system is a riskA key insight from the UEFA Women’s Elite Club Injury Study is that extrinsic factors dominate the modifiable risk picture:

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comIf you’re a football fan, you’ll know the feeling of cup draw day. If you are not a football fan but live with one, you have no doubt endured this spectacle. The day a bag of small numbered balls are released into an empty goldfish bowl on live TV, agitated by a one-time footballing great, now retired player, and pulled out one by one - matching each team with another; one to play at home, the other away.Two weeks ago, the FA Cup fifth round draw was held and it resulted in the tie Newcastle United versus Manchester City.The reason this stands out is that my team, Newcastle United, have been pulled out of that bloody hat to face Manchester City no less than five times in the past six years across the two English cup competitions. Manchester City are - and allow me the greatest of understatements here - a pretty good team. A concerning opponent. Not my first choice team to face every single cup journey we embark on.In the event any of the current Newcastle United squad are reading this, I believe in you lads! You can do it! But get back to penalty practice.For the rest of you, let me tell you that drawing this tricky opposition team in the cup sparks some pretty major fear and frustration. Fear not so much of the unknown, rather what is absolutely known from one hundred million iterations of this game in the past six years (approximate values). Frustration that the situation we wanted on graduating from one stage of the cup to the next (drawing a team, for example, who has not won the entire league four times since 2020) has once more not transpired.March’s MSKMag is for the fearful and the frustrated.When you’ve taken up a new role as a First Contact Practitioner and soon realised there is a whole Advanced Practice component that you haven’t necessarily been trained in, read Matt Wedderburn’s article ‘Advanced Practice Without the Title. The Reality of the FCP Role’ and then check out Matt and Physio Matters’ latest project for Advanced Practitioners.When all the hamstring injury data is taken from male athletes but the injured hamstring in front of you belongs to a woman, read Carolyn Kent’s ‘Football has a Hamstring Problem’ and check out Carolyn’s Women’s Football Hub.When urinary continence comes up in clinic and you’ve established it’s not an emergency but have no clue how to continue the conversation, read Jenny Fielding’s ‘Continence Considerations’ to see if your assessment holds water.When you’re feeling stuck in your business development and could really do with the advice of hundreds of clinicians who came before you, turn to Andy Thomas’ article ‘The Business and Life Lessons Learned from MSK Industry Titans!’ which is based on Andy’s book.When you’re worried about a) the pain care of the future, or b) the prospect of AI having a negative impact on healthcare and our reasoning skills, read Mark Kargela’s ‘PAIn Care in 2050 - What Might it Look Like?’ for a time travelling exploration of both.See you in the next round.

How many shoulder classifications systems are enough?Or rather, how many shoulder classification systems are too many?Five sounds fair?Ten seems a little bit too much?and 18 would be… ridiculous right? RIGHT?!Well folks, hold onto your shoulders.In 2011 (15 years ago) a systematic review identified 18, yes EIGHTEEN, published classification systems in the existing literature, BEFORE they went on to develop their own. So 19 then. [1]Over the years that number has continued to rise. Has this abundance of classification systems helped to improve the lives of people with shoulder instability? No.Have the proposed rehabilitation regimes and treatment plans provided definitive answers on the best way to help all our patients? Not quite yet, more data needed.Do I have all the answers? No.Am I having a go? Definitely not.Shoulder instability is a small world. My experience so far in this space has been positive. This is because those who I’ve engaged with have been welcoming, receptive to new ideas, giving of their time and willing to engage in the conversations. (Thanks to all if I’ve not said so already!) They are often very experienced and knowledgeable clinicians all of whom are trying to do what’s best for people with shoulder instability.It’s important to remember that a lot of the concepts critiqued here came about as a result of trying to make sense of the chaos. They were the original ideas, innovations, fledgling hypotheses and the foundations from which other concepts could develop and compare themselves. Standing on the shoulders of giants and all that.History tells us that our initial ideas of how the world works aren’t always correct the first time around, (think flat earth theory, milk blood transfusions, and cocaine for hay fever [2]). We need to continually revisit our assumptions and understanding. It’s difficult to do this when there’s no new or reliable information.It seems like every time I get online, someone, somewhere has published a new shoulder instability classification system, rehabilitation plan or course.I’m not against that. This is a complicated area. Anything that brings about more clarity and certainty can only be a good thing. But we have to be honest about the state of our clinical practice, the evidence that drives it, and whether these growing contributions are actually helping or even making things worse. Is the information really ‘new’? Is it fit for purpose?To help answer this, in this article I want to put forward three main points:* Existing classification systems are conceptually useful but practically useless.* Research in this area is thin, not well joined up and does not follow the life of the patient.* We seem to be repeating the same mistakes and it’s time to try something different.Point 1 is the longest. If you make it through that, you’re on the home straight.Why is this important?There is a phenomenon in artificial intelligence (AI) known as iterative degradation or quality decay. You may have seen funny examples of it on the internet where ChatGPT is asked to create exact replicas of a picture over and over again. The final result ends up worse than the original (Figure 1). The cause of the problem comes from the fact that every time a ‘new updated version’ is fed back into the model, small errors and noisy data get larger.Figure 1. ChatGPT is asked to make exact replicas of a picture of Dwayne ‘The Rock’ Johnson 101 times. Source: https://www.reddit.com/r/ChatGPT/comments/1kbj71z/i_tried_the_create_the_exact_replica_of_this/Without new or accurate information to correct itself against, the system just gradually becomes a parody of its former self. Can you see where I am going with this?At the patient level, this potentially results in them not getting the best care. Misdiagnosis and wrongfully attributing things as the cause of their problems may result in delays or withholding of needed investigations or treatments. It may also result in unnecessary or ineffective treatments being used, all of which make the overall healthcare burden on people larger and longer.At the therapist level it makes entering the world of shoulder instability seem overly complex. As an exercise, I always ask myself, if I were a student trying to learn about this afresh, and all I had available to me was the published evidence, would I arrive at the same conclusions as someone else?Is the data or evidence clear enough?If I had to pick, which classification system or treatment plan would I use and why?How much of current practice is a product of tacit knowledge, departmental or institutional norms? More recently social media, course and masterclass conference presentations are playing a larger role and so we need to make sure we can help people discern the truth.So here’s my attempt at doing that.1. Existing classification systems are conceptually useful but practically useless.The purpose of classification is to identify distinct groups to which people or things can be assigned on the basis of some predetermined measures or characteristics. For example in Figure 2 you could classify Lego blocks by their colour or their shape.Figure 2. Lego blocks arranged by colourPhoto by Mourizal Zativa on UnsplashThese features (shape and colour) are practical, cheap and easy to observe (measure). You could argue that shape would be a more robust method for classifying Lego blocks. This is because misclassification may occur by people who are colour blind as in Figure 3. The main point here however, is that any object could be classified in multiple ways depending on the measure or feature, or combination of measures and features used.Figure 3. Examples of changes in colour depending on type of colour blindnessImage taken from https://midtownvision.com/blog-posts/types-color-blindnessClassification systems are therefore only as good as the measures on which they are based. If the measures or features aren’t reliable, are subject to interpretation or can’t be quantified, it may result in misclassification (like in the picture above).We also need to consider, did we make the classification systems and then assign measures we think should best go with them (top down)? Or, did we let the data and its features objectively (and without bias) tell us if there are actually distinct or overlapping groups (bottom up)? My feeling is that in healthcare we too often do the former.Another thing to consider is what purpose does the classification system we are using serve? Is it a conceptual and theoretical model to help us make sense of an incomplete understanding of physiological or biomechanical processes? Or, is it used as a definitive treatment algorithm based on objectively quantified measures or tests?Are we guilty of confusing the two?Do we erroneously give equal weight to both when we shouldn’t?So what is actually needed for a classification system to be any good?* The end treatment, investigation or management plan has to be different.* If all people irrespective of category get the same investigations or treatments, is the classification system serving a purpose?* It has to put people in distinct groups i.e. it has to be able to discriminate.* What if a person can simultaneously exist across all possible categories, each of which has a different investigation or treatment endpoint? Does the classification system have enough discriminatory ability to be considered suitable for practice?* It needs reliable and accurate measurements.* People need to agree on the way these measurements are used to combine or group people.So do existing shoulder instability clinical classification systems work? Not really, especially when compared against imaging or surgery which is usually considered the ‘gold standard’.Here are some quick stats:* Moroder et al, 2020 [3] reported that multidirectional instability was over diagnosed. 10 to 20% of patients had bony changes in their shoulder despite the cause of their shoulder problem being a ‘muscle co-ordination issue’.* Jaggi et al, 2023 [4] found that 10% of participants were later found to be unsuitable for the study after an arthroscopy showed no capsulolabral damage or a bony injury.* Clarke et al, 2024 [5] - summarised nicely by Adrian Davies [6] also shows an approximate error rate of 20% as well when it comes to confirming the direction of instability (in rugby players).Note: I have also purposefully mixed ‘traumatic and atraumatic’ instability and go interchangeably at times between them. The misclassification problem is a reason for this. When I refer to shoulder instability I am talking about the less obvious cases, although the concept could be extended to any subgroup.Now granted, there are some barn door obvious cases which arguably don’t need a classification system e.g. some traumatic dislocations accompanied by imaging. But as a clinician I’m usually more interested in the ones we don’t get right or are unclear, rather than the ones that are obvious. It appears we are getting it wrong for about 1 in every 10 (if you want to be optimistic) or 1 in 5 patients. Is that good enough?Why is this happening? What is it that existing classification systems aren’t telling us? To help illustrate some of the points I’m going to use the Stanmore Triangle.The Stanmore Triangle (reproduced below) frames shoulder instability as a dynamic or shifting condition, existing between 3 poles and 5 states (structural, non-structural, traumatic, atraumatic and muscle patterning - can you see why I said this may be overly complex?). The idea is that people can move along these poles and between states with varying levels of each state (basically along the lines of the triangle and across to other corners or poles).Reproduced from Lewis, A., Kitamura, T., & Bayley, J. I. L. (2004). (ii) The classification of shoulder instability: new light through old windows!. Current Orthopaedics, 18(2), 97-108. https://doi.org/10.1016/j.cuor.2004.04.002Seems like a handy framework right? But what happens when we get into the nuts and the bolts of it? Can it work practically? Does it do all of those things that are needed for a classification system to be any good? Does it put people in mutually exclusive categories? If the management options are different, but you can’t clearly identify who needs what accurately then what purpose does it serve?It took me a while to recognise where else I had seen this model before. It’s the same one used in theology to depict the Holy Trinity and it’s been keeping theologians busy for thousands of years as they depict (without committing heresy) an entity that is simultaneously all things at once and yet three distinctly different things at the same time. Somehow we’ve decided it’s a good model for shoulder instability. I’ve also seen people use triangle models to describe states of selective emotions e.g. excitement, nervousness and cynicism for an upcoming event. A triangle model in this case also makes sense. Having a combination of different emotions and transitioning between them regularly seems a conceptually helpful way to illustrate how someone feels.So it seems triangle models are helpful for concepts but not necessarily clinical decision making. At the end of the day we are therapists not theologians, practitioners not philosophers.There’s a few more things we need to consider. Irrespective of the shape (although I have seen someone propose the cube of shoulder instability to try to resolve this), the measures on which the classification is based are arguably the most important. For example, what does muscle patterning actually mean? Are we talking about a co-ordination issue? How would we detect this? What if the muscle patterning is a consequence of changes to the underlying structure rather than the cause. As things stand there’s not enough high quality evidence (based on state of the art 3D and surface electromyography measures) to differentiate between movement patterns that could be considered:* normal variation within a population* different but an adaptation for maintaining stability based on changes to the joint from instability and* different and is resulting / causing instability.If we can’t yet make this distinction with equipment that allows us to go back and look at the different joints and muscles at a pace we can comprehend and revisit, how then can we do this in real time, with our eyeballs during clinic?There are of course other classification systems available. The Frequency Etiology, Direction and Severity (FEDS) system is a helpful way of standardising the description of someone’s instability. Again, it seems pretty straightforward on the surface, however, when you look a bit more closely there are a lot of ways (30 different combinations) that people can be classified. It also doesn’t really tell us about the primary mechanism. Etiology is discussed in relation to being traumatic or atraumatic but with no reference to what role bony, muscular or soft tissue structures may play.A lot of the models also do not explicitly mention what role psychosocial factors play. As a result it seems people will borrow categories or attributes from other models creating a sort of Frankenstein’s monster classification system that may have negative downstream effects. For example, as a precursor to the Stanmore Triangle, in 1979 Rockwood identified that the presence of psychiatric problems was relevant for people who could voluntarily sublux their shoulder in type 3 instabilities. Whilst not explicitly stated in the Stanmore Triangle this historical association has continued to permeate into practice. The end result? Some of our research that used hypothetical patients to see how physiotherapists make decisions for shoulder instability patients identified that 1) female patients were more likely to have negative psychosocial factors attributed to them (despite having none stated in the cases) and 2) male participants were more likely to be offered investigations sooner [7].Stop here and consider the practicalities and real world implications of this.How can we practically and objectively identify people with genuine psychosocial and psychiatric factors that are contributing to their shoulder instability? I mean what does contributing in this sense even mean? What is the mechanism by which these will impact the stability of someone’s joint beyond the pre-existing constraints of their underlying bony morphology, soft tissue structures and muscle architecture? The risk here is guilt by association. The mere presence of non-traumatic instability makes you look for psychosocial factors more intentionally than you would in other forms of shoulder instability.If you were constantly worried about your shoulder coming out, or worse, it did keep coming out, your mood or mental health might be affected too. It’s also likely to be sore and limit what you can do which doesn’t help either. Next thing you know some therapist has decided the thing that’s most likely contributing to your shoulder instability is some form of life stress based on your gender although they don’t actually tell you this. We need to be careful about how and who we attach labels to, especially in the absence of any data we can point to and say “look here it is!” Classification systems that inform decision making are meant to provide objectivity in decision making by at least providing a check on our personal biases. They definitely aren’t meant to reinforce them.So what’s the summary of all this? It seems existing models are incomplete. They can’t seem to identify and describe in unambiguous terms all of the important information required to accurately describe and classify all forms of shoulder instability. This may not be such a big problem if we used shoulder instability classification systems conceptually rather than practically.But why are we in this cycle of inventing more and more classification systems? Well I’m glad you asked, the reason for this I believe is…2. Research in this area is thin, not well joined up and does not follow the life of the patient.Photo by engin akyurt on UnsplashSo what does the research tell us from a rehab perspective? Based on some (of the better) studies we know that:* In adults with atraumatic surgery there is not much difference in outcomes between diagnostic arthroscopy (placebo) or actual arthroscopic capsular shift surgery [4].* Existing uncertainties and a lack of robust evidence means that clinical recommendations were centred around expert opinion in arthroscopic shoulder stabilisation surgery for traumatic shoulder instability [8].* In adults (general public, typically non-athletic sample) with a first time traumatic dislocation, additional/multiple sessions of physiotherapy were not superior to a single session of advice, supporting materials and the option to self refer to physio - The ARTISAN trial [9].* High-load strengthening exercises are more effective than low-load strengthening in mainly adult females with hypermobile shoulders although results were variable [10].* In adults with multidirectional instability the Watson multidirectional instability programme seems to perform better then the Rockwood Instability Programme [11].* There is very little, if any, information available for young people with shoulder instability.* Even in the basic science/mechanism space, I was surprised when writing up our study [12] that all of the previous research on muscle activity and movement differences were predominantly adults with the odd young person. Our dataset is probably one of the youngest recorded.There are other studies that provide helpful information such as the Derby Instability Programme [13] and other similar single group, longitudinal studies. But remember when we want to know if something actually works or is better than something we are already doing, it’s usually well-designed and appropriately powered RCTs that are needed. Although there are other ways of evaluating effectiveness that I’ll discuss later.Consider then how does the existing evidence inform our decision on what to do with a young person who has multi-directional/atraumatic shoulder instability or an overlay of traumatic and atraumatic? Where are the RCTs for them to inform our decision making?The truth is getting funding in this area is difficult. Compared to other health conditions e.g. cancers, hypertension or heart attacks, shoulder instability as a proportion affects a small percentage of the population. It therefore doesn’t always tick the ‘value for money’ box funders are after. It also means getting enough people through the doors to answer the study question is more challenging.It’s also partly a hidden problem. Estimating the true incidences for some of the more complex shoulder instability subgroups is challenging due to a lack of robust evidence (a recurring theme in this field). No one really knows how big the problem is and the complications are often delayed. Funders also usually want to fund studies that answer a question in a reasonable amount of time.What’s not quantifiable in the data but very important to consider is that people with more mixed pictures/complex/multidirectional instability:* Usually present as children or adolescents. They may have several episodes of instability and do not present until it starts impacting on them and their parents’ or carers’ daily lives in a significant way.* Likely that the true size of the problem e.g. number of instability episodes and duration of problem is under reported.* May be reliant on their parents or carers for communicating this information given their age.* Their voice in the research agenda is therefore not prominent. They also likely have other life priorities or issues to sort out (remember how complex being a teenager was AND then your arm keeps popping out).* Can spend a long time in the healthcare system going between services, despite being a relatively small proportion of service users.* They can be complex cases for clinicians.* They may see multiple clinicians and be referred between multiple services (high healthcare burden for them and us) which,* may not result in joint up care. Throughout their life how many healthcare providers might someone with recurrent instability see (involves telling your story to lots of different people again and again)?* Overall a worse experience of healthcare (having to wait for formal diagnosis and feeling like you are being passed between services. Consider also the potential for being labelled as having ‘psychosocial’ problems).Unlike surgical interventions there’s not a culture / governance requirement to record and report outcomes. The end result is we can’t actually evaluate what we are doing to put a number to the problem.There’s also a funding gap which I find a bit mind-boggling. We know that shoulder arthritis is a big problem. We know that in traumatic shoulder instability you are between 10 to 19 times more likely to get shoulder arthritis later on.What we don’t know is how likely arthritis is to develop in someone with atraumatic shoulder instability who is experiencing multiple episodes of instability again and again.There are charities/funders set up to address arthritis.There are charities/funders set up to address health issues in children.Both are at opposite ends of the spectrum, meaning those with the more complex and under-researched shoulder instability presentations fall between this gap.If arthritis is such a big problem why aren’t we focusing on those most at risk to try and prevent it (if possible)? If funders are serious about addressing underserved groups or ensuring fairness though then surely this is one of the groups who should be considered?So in essence the reason there’s limited new and rigorous evidence is that it’s pretty hard to get the big definitive studies off the ground for the reasons stated. Often if there isn’t a clear pathway to a big clinical trial that answers a specific clinical question, it can make it a bit more challenging to get the initial funding that’s required to develop these projects. Research studies therefore tend to focus on small development or pilot work which doesn’t always progress on. The end result is lots of research, not all of which can be used to inform our decision making.Doing good research in this area is not impossible, just really really difficult. There’s also a circular logic problem. A lack of evidence makes getting funding to do more research difficult… which is needed to produce more evidence. The problem here seems to be…3. We seem to be repeating the same mistakes and it’s time to try something different.Photo by Collab Media on UnsplashAlbert Einstein is famous for saying “insanity is continuing to make shoulder instability classification systems and treatment plans in the absence of new data or RCTs” , or something like that.Given that we’ve gone beyond 19 instability classification systems and the rehab evidence base is likely less than 10 papers it’s probably time we did something different.The way I see it there are two possible options moving forward:* This blog inspires a drastic change in how shoulder instability work is funded leading to more definitive trials (I wish), or* We need to try something different, innovating and working within the systems we’ve got.I think a fundamental step in this is improving how we measure people with shoulder instability, for both diagnosis and over their lifespan. Whilst RCTs are an excellent methodology for demonstrating effectiveness, they aren’t always as well suited (practically) to less common conditions or subgroups.That doesn’t stop us from trying to answer some of our ongoing clinical questions using alternative methods, as long as we understand the implications of these. Remember in some cases we won’t be starting from a very high bar e.g. just expert opinion. There are some innovative studies going on in this space which provide hope:* Moroder et al, 2020 [3] used fluoroscopy to classify and confirm different types of shoulder instability. I agree we can’t use that on everyone but it’s a helpful starting point from which other technologies or solutions may develop.* In other rare diseases or complex movement disorders, things like 3D movement analysis and electromyography are used to help inform decision making. They also tend to have really good datasets that follow the patient throughout their life. Gillette Children’s Hospital is an excellent example of this.You might say the technology is not there and it’s too complicated for practice. The truth is the technology has been there for quite a long time and is already used for making decisions about rehab and surgery. These arguments were around in the early days of human movement analysis itself and likely CT (just run that past me again… you want me to buy a £100,000+ machine that emits ionising radiation whilst spinning at 120 to 240 revolutions per minute and you have to lie in the middle of it?). However, as we were able to demonstrate how improved diagnosis improved outcomes for people, these new ways of diagnosing people were introduced and made standard in clinical pathways.If we can improve our diagnosis alongside improved recording of outcomes that follow people throughout their life, we can then start to make positive steps to seeing not only how big the problem is, but what seems to change outcomes. This is always the starting point for further, well-designed definitive trials. In a world of digital health, secure data environments and AI, this should be easier than ever. However the risk is these just become really good systems that store and regurgitate really rubbish information. We need to try to avoid iterative degradation.So what needs to happen next? My hope is that if nothing else, we stop and take stock of where we are at. The answer to too much unusable research is not more unusable research. The answer to too much complexity is not more complexity. We need to go back to basics. If we are to continue to keep rising while standing on the shoulders of giants, it’s important the foundations are right.References[1] Kuhn, J. E., Helmer, T. T., & Dunn, W. R. (2011). Development and reliability testing of the frequency, etiology, direction, and severity (FEDS) system for classifying glenohumeral instability. Journal of shoulder and elbow surgery, 20(4), 548-556.[2] INGALS EF. COCAINE IN HAY FEVER. JAMA. 1886;VI(8):206. doi:10.1001/jama.1886.04250020066006[3] Moroder, P., Danzinger, V., Maziak, N., Plachel, F., Pauly, S., Scheibel, M., & Minkus, M. (2020). Characteristics of functional shoulder instability. Journal of shoulder and elbow surgery, 29(1), 68-78.[4] Jaggi, A., Herbert, R. D., Alexander, S., Majed, A., Butt, D., Higgs, D., ... & Ginn, K. A. (2023). Arthroscopic capsular shift surgery in patients with atraumatic shoulder joint instability: a randomised, placebo-controlled trial. British Journal of Sports Medicine, 57(23), 1484-1489.[5] Clarke CJ, Torrance E, Gibson J, Brownson P, Funk L. Diagnosing the direction of shoulder instability in rugby players. Shoulder Elbow. 2024 Feb;16(1):33-37. doi: 10.1177/17585732221092025. Epub 2022 Mar 31. PMID: 38435041; PMCID: PMC10902408.[6] Adrian Davies - Glenohumeral instability under the spotlight: Clinical findings vs. Intra-operative diagnosis, Adrians Shoulder Blog ttps://open.substack.com/pub/atdshoulder/p/glenohumeral-instability-under-the?r=37fnk4&utm_campaign=post&utm_medium=web[6] Philp, F., Faux-Nightingale, A., Woolley, S., de Quincey, E., & Pandyan, A. (2022). Evaluating the clinical decision making of physiotherapists in the assessment and management of paediatric shoulder instability. Physiotherapy, 115, 46-57.[7 Wong, C., Jaggi, A., Willmore, E., Maher, N., Bateman, M., O’Sullivan, J., ... & Chester, R. (2025). Critical evidence synthesis on rehabilitation following arthroscopic shoulder stabilisation surgery for traumatic anterior instability: consensus recommendations for clinical practice and research–commissioned by the British Elbow & Shoulder Society. British Journal of Sports Medicine.][8] Kearney, R. S., Ellard, D. R., Parsons, H., Haque, A., Mason, J., Nwankwo, H., ... & Underwood, M. (2024). Acute rehabilitation following traumatic anterior shoulder dislocation (ARTISAN): pragmatic, multicentre, randomised controlled trial. bmj, 384.[9] Liaghat, B., Skou, S. T., Søndergaard, J., Boyle, E., Søgaard, K., & Juul-Kristensen, B. (2022). Short-term effectiveness of high-load compared with low-load strengthening exercise on self-reported function in patients with hypermobile shoulders: a randomised controlled trial. British Journal of Sports Medicine, 56(22), 1269-1276.[10] Warby, S. A., Ford, J. J., Hahne, A. J., Watson, L., Balster, S., Lenssen, R., & Pizzari, T. (2018). Comparison of 2 exercise rehabilitation programs for multidirectional instability of the glenohumeral joint: a randomized controlled trial. The American journal of sports medicine, 46(1), 87-97.[11] Seyres M, Postans N, Freeman R, Pandyan A, Chadwick EK, Philp F. Children and adolescents with all forms of shoulder instability demonstrate differences in their movement and muscle activity patterns when compared to age- and sex-matched controls. J Shoulder Elbow Surg. 2024 Sep;33(9):e478-e491. doi: 10.1016/j.jse.2024.01.043. Epub 2024 Mar 10. PMID: 38467183.[13] Bateman, M., Osborne, S. E., & Smith, B. E. (2019). Physiotherapy treatment for atraumatic recurrent shoulder instability: updated results of the Derby Shoulder Instability Rehabilitation Programme. Journal of arthroscopy and joint surgery, 6(1), 35-41. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comThis summer, I was watching my two children running around the garden with their cousins. They don’t see each other very often so there was a lot of energy, a lot of noise, a lot of chaos, and a lot of joy. And as I watched them, it struck me that I could describe exactly the same scene in a few very different ways.I could say they were a group of children.Or a gaggle of mischief makers.Or a gang of youths.Nothing about the behaviour changes. But the words I choose tell you a lot about how I feel about what’s happening in my garden. And it’s exactly the same when we talk to patients about pain.The (Chronic Low) Back StoryChronic low back pain is associated with disability, work absence, unemployment, and high healthcare use. Quality of life is often dramatically reduced. In one study, people with chronic low back pain reported quality-of-life scores comparable to patients receiving palliative cancer care [1, 2]. Despite chronic low back pain being highly prevalent, it is still widely misunderstood. Large proportions of the general public believe back pain is caused by injury or damage, that bed rest is the best treatment, and that once you’ve ‘hurt your back’ it will never be the same again. What’s more concerning is that these beliefs are also common among healthcare professionals [3].And that matters because clinicians play a major role in shaping how patients understand their pain. We often talk about challenging patient beliefs so they can engage better with treatment. But inaccurate beliefs don’t just affect behaviour. Inaccurate pain beliefs can increase threat, and increased threat increases pain.Research shows that when clinicians deliver strongly biomedical messages, patients develop hypervigilance, more fear, and more disability. These patients often feel guilty if they can’t follow advice perfectly. And even when they do everything ‘right’, pain flares can feel baffling and demoralising. In contrast, when clinicians provide accurate reassurance and encourage movement and confidence, patients report higher self-efficacy, greater activity levels, and better engagement with life; not just exercise, but meaningful activities and social connection [4].Pitfalls in Pain ScienceMost clinicians can confidently define acute and chronic primary/secondary pain, or tell you the difference between pain aetiologies like nociceptive, neuropathic or nociplastic.But even with this clinical knowledge there are some common pitfalls that clinicians can fall into when forming their own beliefs about pain.Pitfall #1: Acute pain ‘goes chronic’ at 3 monthsAcute pain is defined as pain that’s been present for less than three months, and is more likely to be associated with nociception. Chronic pain is defined as pain that lasts longer than three months. Pain doesn’t magically change character at two months and twenty-nine days. What that timeframe reflects is two things: the time most tissues take to heal, and the point at which a number of neurological mechanisms that can maintain pain tend to become established. That three-month mark isn’t arbitrary, but it also isn’t a hard line.Not only that, but some chronic or persistent pain syndromes occur in the absence of an initial acute injury, and some are a result of ongoing nociception from a chronic disease.Pitfall #2: That some pains are biological and some are psychologicalWhen we talk about pain mechanisms, we usually describe three broad categories.

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comACL injury and patellofemoral pain (PFP) are rarely invited into the same conversation. One is acute, traumatic and unmistakable. The other is persistent, frustrating and often labelled ‘non-specific’. Yet when we step back from tissues and diagnoses and instead consider risk, these two conditions begin to overlap in important ways.Both are common. Both disrupt participation in sport and physical activity. And both emerge from a complex interaction between load, movement strategies, preparation, and behaviour. The difference is not how much we understand about risk — but how often that understanding meaningfully shapes what happens in practice.Different injuries, similar environmentsACL injuries remain most common in sports involving cutting, pivoting and jumping, with match play carrying a significantly higher risk than training [1]. PFP, meanwhile, continues to be one of the most frequent knee presentations across adolescents and adults and is a leading cause of reduced physical activity and sport participation [2].Despite obvious differences in presentation, both conditions tend to arise in similar environments: high training loads, repeated exposure to demanding tasks, limited recovery, and pressure to perform. From this perspective, ACL injury and PFP look less like unrelated problems and more like different outcomes within the same sporting and physical activity landscape.Risk factors: real, but rarely simpleIt is important to be clear about what we do not know. There is no single causal pathway for ACL injury. Rupture does not result from one faulty movement, one weak muscle, or one missed warm-up.

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comI think I know the MSKMag audience well enough to know that we’re a bunch that does love some evidence. We debate the nuances of treatment techniques, and we even (sometimes) read past the abstract of the RCTs we’re citing. We do this for a simple reason: we want to provide the best possible care based on what is actually happening on the ground rather than ‘gut feeling’ or outdated traditions.Yet, when we step out of the treatment room and into the ‘business’, that rigour often vanishes. We operate our clinics by feel, doing what we think is best without truly knowing. It’s not entirely our fault either; there actually isn’t that much data to guide us. What is it that makes a successful clinic owner successful? What are the most profitable clinics doing differently? No one really knows because nobody has ever asked. So we’re instead left with gurus to guide us on the ‘business’ – the exact thing we abhor.HMDG launched The Private Practice Barometer late last year with a simple aim: collect anonymous data from MSK clinic owners to finally answer some of those questions regarding the business side of the industry and the people that are running it. And despite the protestations from some who wrongly believed the intention for the survey was some secret other reason that they’d entirely made up in their heads - over 700 volunteered some data! And answers have been found! Huzzah!Now I can’t leak all of the results yet - that will come soon, I promise. But what I can do is hand-pick some of the points that I think are of particular interest.Clinic Ownership - Is it worth it?I’ll start with the question that I was most intrigued to see the answer to. What is the daily reality for most clinic owners? Are they happy? Are they stressed? Are they too busy counting their cash to care? There is an aspirational narrative often sold to clinicians about opening your own clinic: that it brings complete clinical freedom and WEALTH! Surely? Well, it turns out – maybe not quite.One uncomfortable truth staring out of the data is that the median MSK clinic owner earns around £48k annually - far below the compensation you would expect of any CEO. The reason I find it a particularly interesting data point is that the amount is also about the market rate of a senior clinician – in fact it’s less than a Band 7 salary in the NHS. And yet the responsibilities of running a clinic, along with the risk involved, comes with far more stress than simply managing a case-load provided for you.

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comFibromyalgia is a symptom-based disorder characterised by persistent widespread pain and accompanied by fatigue, poor and unrefreshing sleep, low mood or depression, and cognitive symptoms. The diagnosis is made using the 2016 American College of Rheumatology criteria [1] and, importantly, is not a diagnosis of exclusion, which has significant clinical implications for assessment and management. The diagnostic criteria assess both the extent and spread of pain, as well as the presence and severity of associated symptoms including fatigue, waking unrefreshed, and cognitive symptoms. In addition, symptoms must have been present for three months or longer. Recognised risk factors include female sex, older age, increased body mass index, the presence of medical co-morbidities, a history of poor sleep, and exposure to stressful life events or depression [2]. Fibromyalgia is estimated to affect 2–3% of the general population [3]. The condition has wide-ranging effects on people’s daily lives and often results in reduced ability to engage in occupational and leisure activities, social isolation, and disrupted relationships [4]. More generally, widespread pain is associated with high pain intensity, increased healthcare utilisation [5], and a history of poor outcomes following multiple interventions [6]

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comAt time of writing, I am on Day 1335 of learning French on Duolingo. I am very, very good at Duolingo. Unfortunately that doesn’t mean I’m very good at speaking French; in fact, put me in front of a French speaker and I’ll be asking them to slow down and perhaps even draw me a picture.If you’ve not used the app yourself, let me introduce you to Duo, an exceptionally needy, green owl character who will ruin your life with constant reminders to refresh your language skills daily to maintain your streak and not let your app friends down horribly.Any amount of your chosen language per day will keep Duo happy (though you will hurtle down the league tables if you don’t accumulate enough points that week).The modules do incorporate varied topics and test you on reading, speaking, listening and writing language skills…but unless you pay even more for premium premium plus Duolingo, you have to figure out grammatical errors yourself because it won’t tell you exactly why your incorrect answer was wrong.Sometimes I wonder if I’m learning French or just playing daily French-accented games as quickly as possible in order to win points, receive a pat on the back from a cartoon bird of prey and move on with my day, streak intact.This month, Duolingo introduced ‘pranks’, the absolute cherry on top of features that are non-conducive to learning. By ‘pranking’ another user, you can have your avatar’s head pop up on their screen for a few moments, blocking their access to the lesson and slowing their progress (seemingly so that you can nip up the league table at their expense in the meantime). I was about to write that there’s a reason no one has thought to barge into an in-service training session, flap around for a bit, then wonder why no one picked anything up but then I remembered that some of us have actually worked for NHS departments.I digress.The reason Duolingo comes to mind this month is because it mirrors something we can do remarkably well in MSK practice: staying active (maintaining our streak) without always building towards progress.This month’s Mag articles show us just how much work is being done to improve practice.Derek Griffin’s Unfogging Fibromyalgia tackles a condition that remains widely misunderstood; getting to the bottom of the science behind it. Similarly, Julia Gover’s The Back Story asks us to look not at what we know about chronic low back pain, but at how we explain it, and whether our narratives genuinely empower patients. Elsewhere, complexity itself comes under scrutiny. Fraser Philp’s Shoulder Instability: It’s All Getting a Bit Silly highlights how an ever-expanding array of classification systems prove that more structure doesn’t always mean more clarity. Tom Jacobs’ ACL and PFP: Related Risk Factors challenges us to think beyond neat diagnostic silos, showing how interconnected problems often share roots that are easy to miss. And then there’s Mark Reid’s The Private Practice Barometer, which shows us the data as to how we are actually working and the impact that is having on private clinicians - because learning doesn’t just happen in journals.Taken together, these articles represent what we have been doing well: questioning assumptions, revisiting explanations and trying to make sense of increasing complexity. But they also quietly expose where we could do better: by prioritising understanding over accumulation, coherence over completeness, and communication over mere correctness.Because, as with my French, it’s one thing to keep the streak alive. It’s another to be truly fluent.

Chiropractic manipulation has been around long enough to be both revered and misunderstood in equal measure. For some, it’s the magic button that fixes everything from a sore back to a bad mood. For others, it’s a mysterious cracking ritual that must be avoided at all costs. In truth, spinal and extremity manipulation is a highly skilled, evidence-informed tool, but like any powerful tool, it requires wisdom, restraint, and a healthy dose of common sense.Let’s start with a few common misconceptions. No, we don’t ‘put bones back in’. Your vertebra doesn’t go missing in action and need clicking back into place. And no, your spine is not now ‘aligned with the universe’. It’s a joint, not a solar system. And despite the internet’s enthusiasm, not every click, crack, or pop you see on social media is therapeutic; sometimes it’s just noise, clickbait, or a little harmless ASMR for the viewer and listener; best enjoyed with some doom-scrolling.One of the reasons manipulation attracts such polarised opinions is that it produces an immediate, tangible sensation. Patients feel something happen. Clinicians hear something happen. In a healthcare world increasingly driven by slow-burn outcomes and delayed gratification, that immediacy can be both its greatest strength and its biggest trap. Humans are wired to associate instant feedback with effectiveness, even when long-term outcomes may tell a more nuanced story. A click can feel convincing; a quiet improvement over six weeks of rehab, less so. This doesn’t make manipulation ineffective, far from it, but it does mean we must be careful not to confuse impact with importance.There’s also a performance element that’s hard to ignore. Manipulation looks confident. It looks decisive. It looks like you know what you’re doing, which is precisely why it should never be used to mask uncertainty. The real skill isn’t delivering a thrust; it’s being able to explain why you are or aren’t using one. Confidence built on clarity will always outlast confidence built on theatrics. Patients don’t need us to look impressive; they need us to be right often enough, honest always, and reflective when things don’t go to plan.I’ve built a career around this exceptional tool, where I know the hands-on skills I’ve delivered, with precision, intent, and certainty, have genuinely helped lead patients out of pain. The change can be immediate. Shoulders drop. Faces soften. Someone stands up straighter than they walked in. Painkillers stopped. In those moments, it’s tempting to believe you’ve found the answer. The only answer, one might think. And sometimes, that confidence becomes contagious, for not only for the patient, but also the practitioner.I’ve watched patients return with a familiar look: hopeful, expectant, already positioning themselves on the table before I’ve finished asking how they’ve been. “that crack was unreal!”, they’ll say. “That’s what fixed it last time.” Cue the affectionate but dangerous mythology, and the uphill task of convincing them to engage in load management, to change their habits, to take exercise snacks in the day, that will also help them.That’s when the line becomes blurred. Not because manipulation is ineffective - far from it - but because it worked so well that it risks becoming the whole story rather than part of it. When relief is rapid and repeatable, patients can start chasing the sensation rather than the outcome. And if we’re not careful, clinicians can start supplying it, mistaking patient satisfaction for patient progress.This is where certainty needs tempering with responsibility. The same confidence that makes manipulation powerful is the same confidence that can quietly undermine long-term resilience if it isn’t paired with education and restraint. Because our job isn’t to create repeat customers for a noise or a feeling, it’s to create people who don’t need us quite so much.Used well, manipulation can open a door. Used carelessly, it can become a revolving one.A chiropractor’s duty of care means knowing when not to adjust. That’s right - sometimes the best adjustment is no adjustment at all. Think of it like cooking: just because you own a spice rack doesn’t mean every dish needs a tablespoon of chilli powder. We’re responsible for screening, assessing, and deciding whether manipulation is appropriate, or whether other treatments (rehab, soft tissue therapy, education) might serve the patient better.Part of the confusion stems from terminology. In chiropractic circles you’ll hear ‘adjustment’, in physio circles ‘manipulation’, and in sports medicine ‘high-velocity low-amplitude thrust’ (HVLA), because nothing says fun like a name that sounds like a rocket launch. Ultimately, the principles are the same: skilled joint mobilisation to restore motion, reduce pain, and improve function. In musculoskeletal (MSK) practice and elite sports, it’s often used as part of a wider plan, not a solo act.Context matters enormously. In elite sport, for example, manipulation may be used to restore short-term range of motion or reduce protective tone or stimulate muscle proprioception before training or competition, in full knowledge that it’s a temporary window rather than a permanent fix. In primary care, the same technique might be used far more sparingly, prioritising reassurance, load management, and long-term self-efficacy instead. The technique hasn’t changed, the reason for using it has. This distinction is often lost in online debates, where manipulation is discussed as though it exists in a vacuum rather than within a broader clinical ecosystem.Equally important is recognising the difference between can and should. Many joints are manipulable; far fewer genuinely need it. Clinical maturity often shows itself not in how many techniques you’ve mastered, but in how many you consciously choose not to use. This restraint isn’t a loss of skill, it’s evidence of it.Now, let’s talk about the ‘gurus’. Many of us were taught that THE adjustment is the ultimate, all-powerful treatment. And yes, done well, it can be transformative. But as a wise man in red and blue Lycra once said: “With great power comes great responsibility.” Spiderman probably wasn’t talking about the lumbosacral junction, but the point stands. If all you have is an adjustment, every problem starts to look like a subluxation, or, as the saying goes, if you’re a hammer, everything is a nail.Growing up, I had a very simple engineering lesson passed down from my grandfather, Chuck. He worked out of a garage with a handwritten sign taped to the door: “Moving too much? Weld it. Not moving enough? WD-40. Otherwise, leave it alone.” Alongside it sat his personal motto: “If it ain’t broken, don’t fix it.” As crude as it sounds, that algorithm has served me surprisingly well in understanding when and why I use SMT. In my early chiropractic training, there were moments when the internal monologue behind an adjustment felt suspiciously like: “Why am I manipulating this part of the spine? Well… because chiropractic.” It wasn’t until I began applying my grandfather’s logic: intervention only when justified, that manipulation stopped being a default behaviour and started becoming a considered, rational clinical choice.As clinicians develop, there’s often a quiet shift from technique obsession to outcome obsession. Early on, it’s tempting to chase the perfect setup, the perfect contact, the perfect cavitation or click. Later, the questions change: Did this meaningfully alter the patient’s symptoms? Did it help them move, train, sleep, or cope better? Did it move the plan forward? If the answer is no, then the elegance of the thrust becomes largely irrelevant. Manipulation earns its place not by tradition or identity, but by utility.This is where reflective practice becomes essential. Reviewing outcomes, retesting, and being willing to say “that didn’t work as hoped” separates evidence-informed clinicians from ritual-based ones. Manipulation should survive scrutiny; if it doesn’t, it should be modified, replaced, or dropped altogether. Diagnostically the outcomes (or lack of) post-manipulation help to tell an important story of your patient.And that brings us neatly to the idea of ‘bang for buck’. In patient management, it’s about choosing interventions that deliver the greatest benefit relative to effort, risk, and cost. Just because a treatment exists or your own practitioner bias exists, it doesn’t mean it deserves top billing in every plan. Sometimes a well-placed adjustment will provide immediate relief and functional improvement, but other times targeted exercises, posture education, or soft tissue work will give more lasting results for less fuss. A savvy clinician weighs the options, considers the patient’s goals and context, and selects what truly gives the most value; not what simply makes the loudest crack. It’s a reminder that effectiveness is about outcomes, not theatrics - patients deserve more than just one cute thing.Let’s not leave patient safety out of this article either. A good chiropractor doesn’t just click and hope for the best, they continually evaluate its appropriateness. We explain what we’ve found, rule in or rule out manipulation as appropriate, and give patients clear advice on what to expect, including when to come back, and more importantly, provide the safety net of when to seek urgent medical help. Done properly, this process builds trust and ensures manipulation is used at the right time, for the right reason, in the right person. The wise words of my former boss, Ulrik Sandström, still resonate with me: “It works for some of the people, some of the time”, much like any other therapy, not just spinal manipulation.Perhaps the most underappreciated role of manipulation is its ability to open a conversation rather than bring it to a close. When used appropriately, it can help build trust, reduce fear, and give patients a sense of momentum early in their care. However, that moment should act as a doorway, not a destination. The real work often happens afterwards — in the exercises patients actually complete, the beliefs they quietly reframe, and the confidence they rebuild in their own bodies.Too often, this is undermined by what can only be described as a verbal chiropractic beat-down. Patients are told, “Your head is too far forward”, “Your hips are rotated inwards”, “You’ve got the flattest feet I’ve ever seen”, or “This muscle isn’t working — it’s very weak”. Faced with a list of perceived faults, it’s hardly surprising that the default conclusion becomes that spinal manipulation is the only solution. The problem isn’t the intervention itself, but the narrative built around it.I often say to students when teaching communication skills: if your patient wasn’t body-dysmorphic when they walked in, there’s a real risk they will be by the time they leave. This kind of fear-based messaging is rarely ill-intentioned, but it reinforces a passive model of care. It keeps patients dependent on being ‘fixed’, rather than empowering them through a more active, collaborative, and resilient approach to recovery.When framed this way, manipulation stops being the headline act and becomes what it arguably always should have been: a supporting character. Useful, sometimes impressive, occasionally indispensable, but never the entire story and a very essential working cog.In short: manipulation is neither mystical nor malevolent. It’s a tool - a powerful one at that - but not the only one in the box. Our job is to use it wisely, avoid overuse, and remember that sometimes the most heroic thing we can do for a patient is advise, reassure, educate, signpost…or just leave it be. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comNeurodiversity is estimated to affect 15% of the population [1], and despite a similar cause and a great deal of crossover, there are a variety of different diagnoses and expression of traits. Although many neurodiverse profiles are spiky by neurotypical standards, stigmatising terms implying severe disability such as ‘idiot savant’ have thankfully fallen out of use. A spiky profile means there are areas where ability is very high but others where natural ability is very low (when compared to a neurotypical normal range; an important caveat). Many neurodiverse individuals struggle with similar aspects of life because they are expected to conform to societal expectations and etiquette based on neurotypical norms, not neurodiverse ones: and the struggle to fit in whilst hiding your authentic self is exhausting and can lead to overwhelm and dysregulated behaviour. [2]With neurodiversity deriving from a difference in the detection and transmission of sensory input, it’s no surprise that there’s a large crossover with hypermobility. Less ascending information due to less resistant tissues means the gain is turned up to get enough information to coordinate and perform physical function. The brain will listen harder, gaining more information at greater volume but with less specificity than in neurotypicals. Other senses can be used to compensate (e.g. visual feedback for balance and auditory feedback from heel strike), but these make the performance of function much more concentrated and effortful. The hypermobile patient always walks on sand, never pavement. Also, the necessity of having much more input across the board, to get the information you need, means processing and reaction times can be slower as the system takes longer to filter out the relevant from the irrelevant. And with this increase in volume across the board, it’s no wonder the rates of chronic pain are so much higher. [3] If we expand this model of hypermobility to all mental and physical functions relying on sensory input and feedback, you start to get some idea of the day to day struggles neurodivergent people face.On the plus side, the sacrifice of speed for detail means neurodiverse individuals will often see the world differently and more completely, so it should be no surprise that a higher percentage of workers in innovation and the creative industries identify as neurodiverse. [4]

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comIn 2011 I took a year out to study for an MSc in Loughborough. At a crossroads in my career, I had become bored and a little disillusioned as a clinician and wanted to step into something new for a while.When I announced my plans to study for an MSc in Ergonomics, my physio colleagues were perplexed as to how studying someone’s desk set up could possibly be stretched out over the course of an academic year, never mind how it might result in being awarded a postgraduate degree!I wasn’t sure whether to be amused, insulted or frustrated.I was mildly amused that my colleagues genuinely thought that I was taking a year out to study this limited topic, a little insulted that they thought I really was that boring but perhaps more frustrated at the tendency of my profession to view things through a reductionist lens. But then again, Google seems to agree with my colleagues’ view, as a quick search of the term returns a plethora of information about the dangers of sitting, lifting or even sleeping in the ‘wrong’ posture.Ergonomics is in fact the science of designing things (jobs, products, systems and environments) to allow people to work safely, efficiently and comfortably. To reduce this whole discipline to ‘that’ diagram demonstrating the ‘correct’ way to sit and stare at a computer screen doesn’t merely oversimplify the field but is incorrect. Most ergonomists will tell you that as dynamic beings designed to move, the best posture is, in fact, the next posture!The truth is, those of us working within musculoskeletal pain can learn a great deal from Ergonomics, but it has nothing to do with posture or the correct way to lift a box. Far from studying one thing in detail, embarking on this MSc taught me about a range of topics, but more than that, it shifted my thinking and altered my career path. But more of that later.The course initially appealed to me because there was a module entitled ‘Product Design’ and I thought that it might allow me to combine my knowledge of human anatomy and function with an ambition to do something a little more creative. On that front, I was to be disappointed. Even though the course was based in the Design school, and Ergonomics certainly underpins the design and development of many products, development of which demands robust research processes, a grasp of statistics is perhaps more valuable than creative flair.But that’s not to say that my year at Loughborough was all data patterns and standard deviations. Before I get into the part of Ergonomics that I really fell in love with - the part that changed my thinking, and my career path as a physiotherapist - I would like to mention some of the great stuff that I did as part of my Masters year at Loughborough with the aim of giving some insight into such a varied and interesting speciality; one that is all around us, every day, without us often even knowing.Environmental Ergonomics gave me the opportunity to work on some fascinating projects spending time testing different objects in the wind tunnels in the labs at the university, as well as travelling to Portsmouth to assess sound levels at a rehearsal of the Band of the Royal Marines. Temperature, airflow, noise levels: those are all ergonomic factors.

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comWe’ve all heard the following words before and if we’re honest, probably even said them ourselves:“Don’t worry, I’ll do my exercises at home.”“I’ve got an incredible idea for a new venture.”“I really need to spend more time on the business, not just in it.”They’re statements of optimism and enthusiasm, small bursts of conviction that feel productive. But more often than not, they don’t lead to the outcomes we expect.We can all relate to the patients who fall behind on their rehab, leaders who struggle to make impact, or aspiring entrepreneurs with great ideas that stay on the shelf collecting dust.Why does this occur? Because of the intention–action gap. The space and disconnect between what people intend to do and what actually gets done.Good intentions are wonderful, but they don’t create results. And while this may sound painfully obvious, it’s one of the most overlooked truths in human performance and business alike. Simplicity is deceptive, especially when it challenges our human behaviour.In musculoskeletal rehab, leadership, and entrepreneurship, we consistently see people substitute the feeling of intention for the discipline of execution. ‘Busyness’ becomes the narrative, output masquerades as outcome, and genuine progress quietly slips out of reach.So, what’s the antidote to consider? Over the past year, I’ve continued to focus on a deceptively simple, three-part framework that has clarified how to bridge the gap between good intentions and real results:1. Clarity of outcomeBe explicit about where you want to end up. What specifically do you want to achieve and, just as importantly, how will you know when you’ve reached it?

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comMost of the time I talk about recognition of Rheumatological diseases that have developed and require onward referral; it has become my schtick. Reasonably many people ask me about people they work with who have already been diagnosed or don’t meet criteria for onward referral but have risk factor comorbidities.Here I will take you through these two scenarios and the adaptations and considerations we need to employ when we see people with existing autoinflammatory disorders.“This Isn’t A Problem” - You, The Reader“If the person doesn’t meet a threshold for onward referral to Rheumatology then there is no problem - they present with tendon-related issues and we manage them” is what someone would say if they were naive to the ways auto-inflammatory conditions, particularly spondyloarthritis, affect tendons.Let me spell out some problems:Spondyloarthritis (particularly peripheral or PSpA) can be triggered by tendon load spikes just like normal tendinopathy.Spondyloarthritis particularly affects high load tendon entheses such as the plantarfascia, Achilles, patella and lateral hip, just like normal tendinopathy. [1]PSpA affecting the entheses of the high load tendons presents clinically almost indistinguishably from normal tendinopathy.Tendon research almost exclusively removes people with spondyloarthritis from their cohorts to reduce confounding variables.I could actually go further but I think I risk losing some of you to boredom. The point is made and these issues aren’t the crucial component of what I want to write about in this particular piece.Managing Tendons On A Background Of Auto-Inflammatory PathologyThere are two main scenarios we need to consider and although they are similar in approach, the outcomes are slightly different so we will look at them in detail. These are:* Person with DIAGNOSED spondyloarthritis.* Person with inflammatory comorbidity that increases risk of DEVELOPING spondyloarthritis - namely psoriasis, ulcerative colitis, Crohn’s Disease, uveitis/iritis.

Hello! I’m Auntie Version and I am unbelievably excited to be MSKMag’s very own agony aunt. (We’re never going to be able to keep it secret so will immediately reveal that it’s me… Jo Turner 😉)Q: Dear Auntie VersionHow can I tell if I am suffering from imposter syndrome or if I am indeed not very good at something? Sometimes I worry that I’m failing at work when I don’t get good outcomes but then start going round in circles in my head. Could this just be imposter syndrome?Yours, Imposter?A: Dear Imposter?Such a good question. The difference between imposter syndrome and objectively not being very good at something is whether your feelings and internal narrative marry objective evidence.Imposter syndrome is classically characterised by feeling like a fraud (waiting to be found out) and not being able to accept praise, attributing any success either to luck, or the actions of others. This is despite evidence that you are in fact capable.If you are genuinely not good at something, then objective evidence or constructive feedback might support your opinion of yourself.You reference times when you don’t get good outcomes and it is probably tempting to conclude that this is supporting evidence for your internal feelings. Particularly in healthcare however, we need to give this context. Are you setting yourself a realistic bar for ‘good outcomes?’ Are you holding yourself to unachievable standards? How do your outcomes relate to those of direct peers, with similar levels of experience to you?The problem with imposter syndrome is that it feeds perfectionism - it has us overworking and overwhelmed as we strive to achieve the impossible. Yes, we need to be accountable and work to maintain good standards of care, but imposter syndrome and perfectionism are often evidence of the balance having tipped in an unhelpful direction.So when you look objectively at the evidence, does it genuinely support feelings that you are not good enough? If so, where can you seek good support to gain and improve your skills? If not, the support might be better directed towards helping you challenge those unhelpful thought patterns and behaviours.Q: Dear Auntie Version,How do I know how much I should specialise? I get bored being too general in my clinical work but worry that I will be less employable if I pick the wrong area!Yours, BoredA: Dear Bored,My immediate (and flippant) response is that if you’re bored, you’re already less employable than someone who loves their job. But I also hear your concern about becoming so specialist that employers may see that you will only be able to see a small percentage of their client base.There is a ‘Goldilocks’ option of specialising but retaining your generalist skills - I’ve heard this referred to as a ‘T’ shape career. You can treat most things that walk through the door, but you are the go-to person for your chosen specialism. That way, you get to spend a fair amount of time working on cases that really float your boat, but everyone knows you can treat other conditions.I would say that specialism often increases rather than diminishes employability, particularly if you can pick something that is future proof. Look at what is going on in the wider world of MSK and outside. If you can offer something that helps an employer offer up to date services that are in-line with emerging evidence and peoples’ needs in the modern world, you’re going to be very popular.And specialism needn’t be a trap. Nothing is forever. In a long career now, I’ve enjoyed many specialism chapters.Q: Dear Auntie Version,I see a lot of people talking about getting their health and fitness in order in the new year, but I feel like such a hypocrite. I’m not in a position to prioritise myself right now health-wise but still have to play the ‘Mr Motivator’ role. How can I walk the walk as well as talk the talk?Yours, Mr UnmotivatedA: Dear Mr Unmotivated,We all know that health and fitness regimes, even in someone with great insight and commitment, are subject to fluctuation or complete derailment - cos life happens. But we perhaps don’t talk about that enough as therapists. A colleague used a wonderful phrase on a clinic WhatsApp group recently. She said, “We all know each other, we know we are juggling and struggling at times but always have the best of intentions.” Admittedly this was clinician to clinician, but I think there is a level of being real we can find with our patients, without it being an overshare.I’m a big fan of James Clear’s book ‘Atomic Habits’ and often quote it to patients. Whilst James advocates consistency as the key factor in habit formation, he also allows for variation in output and acceptance of ‘missed days.’ His point is that habits are not broken on the first missed day. Instead of thinking we’ve failed and all is lost, much better to have compassion for ourselves and commit to trying again tomorrow, or maybe even next season.As for being Mr Motivator, fabulous though he was that was the 90s. Maybe Mr or Ms Relater is a more appropriate icon for our times.Q: Dear Auntie Version,I’m a physio working in an NHS clinic and the waiting times for appointments are getting me down. If I see someone today, I’m looking at 6 weeks before I can book them in for a follow-up appointment. It’s not working for them and it’s not working for me! How can I stay sane at work whilst doing my best for the patient?Yours, StrugglingA: Dear Struggling,I’m certainly not going to try and persuade you that having 6-weekly follow-ups as the only option for any condition counts as good care.Sadly, it’s a situation many readers will recognise all too well. We know the problem is systemic, and hopefully most clinicians are not blaming themselves for it, but that doesn’t make it any easier when you’re the one sitting in front of an understandably frustrated, frightened or desperate patient.So what can you do about it?Some people channel their own frustration into activism. Are there avenues or organisations you can use to advocate for patients and push for change? Even small actions may help you reclaim some sense of agency.Others decide to vote with their feet. If they can’t see any prospect of change, they choose to work in a different environment, maybe for an employer whose model better aligns with the care they want to provide, or they take the leap and set up their own service. Contrary to the belief of some, most people don’t go independent to chase a mythical high salary; they do it so they can practise in a way that feels fulfilling and sustainable.I’m not suggesting that leaving the NHS is the answer and I recognise that for some this is an ethical no-no. It’s a tough situation and I don’t believe there are any easy solutions right now. You’re doing your best in circumstances that would challenge anyone. And it’s more important than ever to hold on to the parts of your life that exist outside of your work; interests, relationships and activities that remind you of your identity beyond the therapist trying hard in a struggling system. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comGreetings and Happy New Year from my new role as Editor in Chief of MSKMag! Admittedly it looks a great deal like my previous role of Editor Adjacent to Chief of MSKMag, only with the added responsibility of penning this Editorial every month.Of course with such great power comes great editorial responsibility (to borrow and slightly tweak one of our titles this month), and so if you have any feedback about MSKMag, or things you’d like to see more of, please do get in touch on [email protected] predecessor Jack Chew gave me this advice for coming up with trending MSK issues for the Editorial: get LinkedIn. Now forgive me for writing this in December whilst clinging to my Christmas jumper and mulled wine and putting LinkedIn firmly in my January to-do list. Tis not the season. By the time you read this though, look me up! I’ll be the new person without any friends.The social media platform I’m found on mostly is Instagram and the trend stuck in my head and probably yours for the past several weeks comes with the soundtrack of Billy Joel’s lyrics from Piano Man ‘...and probably will be for life’ merging into a Fleetwood Mac song whilst a video montage plays, overlaid with the captions: ‘In your 20s…[a thing will present itself]. It is very important you [do/do not engage with/marry/get on board this thing]…’Now who doesn’t love a self-reflective social media trend this time of year? You’ll have to sing the backing music yourself (if you’ve heard it once, you’ve heard it a thousand times) but here’s MSKMag’s January issue version:In your early career, colleagues will tell you studying Ergonomics at Masters level will be boring. It is very important you do not listen to them. The result is Liz Prokopowicz’s article ‘The Human Factor’.In your life, you will tell yourself that you fully intend to do all of the things including the home exercise programme and that new business venture. It is very important that you do not believe yourself until you’ve set up a framework to success. You can read about that framework in Nicola Graham’s ‘The Road to Failure is Paved with Good Intentions’.In your clinic, you will see people with tendinopathy in whom you also really really suspect something else inflammatory is going on. It is very important you don’t ignore that instinct. Instead, read Jack March’s ‘Rheumatology and Tendons: Certainly No SpA Day’.In treating hypermobility in your patients, you will start to notice certain trends among some of those who are neurodiverse. It is very important you allow these patients to feel seen. You can learn to do the same in Sue Julian’s article ‘Should we treat neurodivergent patients differently’.In your practice you will be tempted to treat everyone you see using spinal manipulations ‘because chiropractic’. It is very important you listen to your grandad’s advice when this happens. Read about this advice and his own in Glenn Winslade’s ‘With Great Power Comes Great Chiropractic Responsibility’.And, in your reading of MSKMag, you’ll occasionally disagree, often learn something new, and hopefully feel part of a bigger conversation. It is very important you keep joining in. Largely because it’s far less fun if I’m talking to myself. Here’s to the conversations we’ll spark in 2026.Felicity ThowEditor in Chief

In the UK, more clinicians are taking the plunge into MSK Point of Care Ultrasound (POCUS). The buzz is real!Some are seeing it as the modern MSK clinic’s next essential tool, while others raise their eyebrows at how practical it truly is, asking whether it is just another expensive thing we can charge more for. Either way, it’s here, and growing FAST.Our social feeds are showing packed-out courses, there are countless ads for devices, and videos and images being shared with a story whilst we squint at these images pretending to know what they are looking at.So what is the real story? How do you learn POCUS? What should you keep your eye on?We are going to go on a journey and look at it through three lenses:* The beginner stepping into the unknown* The educator guiding new learners* And me, the industry insider who’s seen behind both the probe and the sales pitch.So why are we talking about POCUS?We can’t ignore it anymore. Diagnostic imaging, as a whole, is a staple part of our industry. Whether you are performing the scans or not, you will likely have referred someone for one at some point.The wonderful aspect of POCUS is that it gives you real-time, dynamic imaging and elevates your diagnostic confidence. Rob Beaven, a Chiropractor just starting out in ultrasound, puts it like this: “My interest in exploring POCUS stems from a desire to enhance diagnostic accuracy, clinical reasoning, and patient communication.”In a busy clinic, Rob sees how timely imaging can change the play: clarifying a working diagnosis, spotting red flags earlier, or simply helping patients visualise what we’re thinking. For him, ultrasound isn’t a replacement for skills, it’s a step up. “I see it as a way to strengthen my ability to form clear, evidence-based management plans and improve patient confidence in the process.”Mike Bryant, a Physiotherapist, Sonographer and experienced educator, has watched the landscape dramatically change. He describes ultrasound as “a technical skill of probe manipulation, anatomical knowledge and pattern recognition,” - a skill that you master by doing, not watching.From my standpoint in the industry, being a Sports Therapist BSc working within the device sales industry offers a rare insight into how both worlds operate. Understanding the clinical nuances of using diagnostic ultrasound, but also the business realities that clinics face when investing in new technology, helps me to separate the hype from the helpful.The sector is developing quickly, with more models and variations coming onto the market seemingly every week and it is hard to keep track and hard to know who to trust.The Reality CheckSpoiler alert: POCUS isn’t plug-and-play. I learned that very early on. Everything just looks the same at first. For beginners, the screen might as well be snow. Rob expects “a steep curve understanding anatomy from an ultrasound perspective,” and he knows his consultations might slow down while he gets comfortable.Mike agrees, “The biggest misconception is that it’s going to be an easy process and that they’ll be proficient after a couple of courses.” He warns, “it takes time and dedication to grasp the probe skills and the detailed anatomical knowledge.”His useful tip is simple: learn to scan normal anatomy before hunting for pathology.From the supplier’s side I see how technology creates the illusion of ease. Handheld devices have made ultrasound look easy. You plug it into a tablet, start scanning, and it seems simple, but that simplicity can be misleading.Back in January 2023 a UK qualitative study emphasised that POCUS implementation faces challenges including the need for proper training, education and quality assurance frameworks. [1]A proposed framework for MSK POCUS by physiotherapists highlights the importance of integrated scope of practice, education and governance solutions. [2]The takeaway: POCUS is a skill built with patience, repetition and humility. We all begin with fuzzy images; it’s the practice that sharpens the view.Mentorship, guidance and the art of feedbackHere’s what truly matters: the people you surround yourself with, not just a flash fancy machine. Rob values training where there’s “a supportive, structured training environment.” Small groups, experienced tutors and plenty of low-pressure scanning opportunities.Mike has seen and guided many clinicians through the educational pathway and has witnessed the evolution of courses. “Initially there were very few courses you could attend to get close supervision with experts,” he recalls. “Now, I try to keep sessions small and simple, with as much scanning time as possible.”He designs his courses accordingly. “Learning in small sessions and going back to the same area and scanning it again really helps,” he says. He’s a fan of the online, two-minute video demos that “you can pause, replay, and practice at your own pace.”But he also reminds learners not to get fixated on diagnosing the amazing tendon tear on day one. “The main challenge for most learners is getting regular supervision…and remembering to enjoy the process, not rushing to find pathology.”Most clinicians I speak to care more about training and educational support than features and benefits. For me, good suppliers aren’t just selling a system, they should help you on your journey and make sure you get the most out of your investment.In short: learning POCUS is like planting a garden. You need good soil, regular water and some time. The seeds don’t sprout overnight.The Technology – a blessing or distraction?Ultrasound tech has come a long way. What once filled a room now fits in a backpack, or even your back pocket! Mike observes that this shift has “enabled access to more MSK clinicians” and made the cost feasible for many more practices.But don’t be fooled! From where I sit, yes accessibility has exploded - which is great - but aggressive marketing can make POCUS appear deceptively simple to learn and lead you into a false sense of security.I’m asked all the time: “Do you have any demo units” or “What is your best price?” I appreciate some are on a budget, but if that is your main concern, hang fire on your POCUS journey. Your focus, above all else, should be on IMAGE QUALITY. If you’re new to POCUS, it’s safe to say you will be sh*t. Try and cut costs and you may get a sh*t machine. Meaning you will likely be double sh*t!Simply, if the image isn’t clear, everything else becomes harder and wayyyyy more expensive!But consider the other side, where Mike hits the nail on the head: “The best probe/device in the world cannot fix a bad operator. YOU must learn the craft before the tech.”I also stress the responsibility to suppliers in this equation. For me, we are just as responsible for offering good care and services to patients. Of course, we have sales targets to meet, but I have seen this blind the reps to just getting a sale done. This short sightedness risks compromising both clinician confidence and patient safety as clients may not be getting the appropriate system for their needs, or the necessary support and device training.So yes, join the tech revolution, but keep your brain switched on, this is not something to be rushed.Time, patience, and realismHere’s what I tell newcomers: the biggest investment isn’t money, it’s time. Rob gets this: “I know consistency will be key. Building a mental library of normal appearances takes scanning again and again.”Mike has seen the drop-off: “People come back after six months and realise they’ve forgotten half of it…Keep the probe in your hand. Even five minutes a day matters.”And from the business side: Clinicians are great at asking for training but considerably underestimate how much ongoing support they’ll need. Ultrasound is a long term investment. It isn’t like shockwave where you can just buy a machine and go, you are buying into a new, lifelong skill.In practice this may mean you have to squeeze in scanning sessions between patients or grabbing your wife, husband, brother or mother to scan them!Pro tip: if practicing on family members, keep them sweet and feed them with treats!Even years down the line, it is good practice to revisit the basics regularly and stay humble when the images are muddy.Ethics, confidence and the limits of POCUSThe governance and ethics side of things comes into focus with POCUS. Who can you scan? What can you scan? What can you say/not say? These are just some of the questions.Having more access means more responsibility. Rob is mindful of this: “It’s about integrating findings meaningfully, not scanning for scanning’s sake.” And Mike agrees: “Clinicians want to use it on every patient, but sometimes less is more.” Ultrasound is a supplement, not the main event. POCUS comes after a subjective and objective assessment not before: There’s a fine line between being enthusiastic and being over-confident.The technology is improving faster than the regulations, which means clinicians need to act responsibly. Governance will catch up for sure, but in the meantime, as mentioned earlier, surround yourself with good people to help guide you. And again, I stress the responsibility on those in the industry to know the regulations and not pass it off as the responsibility of the clinician. We are in this together.Yes, you can do more with POCUS. But you must also know when to stop, refer and seek a second opinion.Where POCUS is headingLooking ahead, I’m optimistic. POCUS use in the UK is growing fast, especially in private MSK practice. AI features are already creeping in to help with image interpretation and workflow. But beware, these fancy features can be a blessing and a curse!Remember Mike’s wise words: “You must learn the craft not the tech.”Mike has seen how the community is growing as well and how it is bringing people together and inspiring growth. “Courses, workshops, peer groups, it’s a community now. People learn faster when they share.”Rob describes his own path: “In the longer term, I see ultrasound becoming an integral part of my professional development and clinical identity… It allows me to offer more precise assessments and communicate findings visually with patients.”In short: if you start this journey now, you’re getting in early. This isn’t just a shiny gadget; you are investing in yourself and your patients and gearing up to become a key part of how MSK clinics operate.Key takeaways from the three of us* Prioritise the fundamentals: Probe handling, anatomy, pattern recognition.* Be kind to yourself: During the learning curve confidence will go up and down, and that’s ok.* Commit to time and practice: Regular scanning and regular workshops beat one big weekend course.* Have governance and a referral/second opinion pathway: POCUS doesn’t stand alone and you will need support.* Buy cheap, buy twice. If you must, wait and save. Image quality is paramount – skimp on the system you skimp on the image. Don’t be double sh*t!Final reflectionsPOCUS isn’t just about seeing what’s inside a joint or tendon. It’s about curiosity, patience and learning how to interpret shades of grey - both literally and figuratively. It’s a tool that rewards time and humility, where confidence grows quietly through repetition.The first scans are often frustrating. Anatomy will look alien, the image drifts and changes, even the simplest probe angle feels like a riddle. But as our three perspectives show: the beginner gains understanding, the teacher guides progress, and the industry insider brings perspective.At its best, POCUS doesn’t replace assessment or instinct, it sharpens them. It helps clinicians see what they’ve always known was there, only now with a bit more clarity, and a lot more grey.References* Akanuwe et al (2023), A UK qualitative study underscoring the need for proper POCUS training, supervision and governance frameworks pmc.ncbi.nlm.nih.gov.* Smith et al (2023), A framework paper for MSK POCUS highlighting integrated scope of practice, education, competency, and governance solutions theultrasoundjournal.springeropen.comtheultrasoundjournal.springeropen.com.Some quotes have been shortened or edited to fit the flow of this article. To see the full interview questions and answers, click here. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comBox 1. An acute non-specific LBP patient with no ‘red flags’A 28 year old woman has been suffering from her first episode of low back pain since lifting a 10kg box at work three weeks ago.She says that she has been unable to do her job managing a hospital cafeteria for this time, and has not worked since her symptoms began. While anxious to return to work, she feels immobilised by the pain. Her work duties are varied, but generally involve very few physical tasks. She works full-time during the day and has no dependents at home.In terms of activities, she says that she can sit for about 10 minutes and walk approximately 100 metres before she feels she has to stop due to her back pain. She reports that she is able to sleep through the night; however, her back is stiff in the morning and the stiffness lasts for about 10 minutes. There is no history of trauma or serious illness. The pain is limited to the low back area, without radiation.On physical examination, there is marked limitation of anterior flexion and tenderness in the left paraspinal region. The neurological examination is normal, and her pain does not worsen in response to straight leg raising beyond 90 degrees. All other case history and physical examination findings are unremarkable and she has not previously been seen by any healthcare practitioner since her symptoms began.Box 1 contains the text of a clinical scenario that was presented to physiotherapists, osteopaths, and chiropractors across the UK – first in 2003, and again in 2023 – as part of a study I recently published in BMC Musculoskeletal Disorders [1].Across the two surveys, more than 3000 eligible clinicians took part: 1758 in 2003 (834 physiotherapists; 592 osteopaths; and 332 chiropractors) and 1388 in 2023 (511 physiotherapists; 621 osteopaths; and 255 chiropractors). In short, this was a big study that took up many months of my time over the last 20+ years.Some background and insightThe 2003 survey was conducted as the baseline part of a randomised controlled trial that tested the effectiveness of mailed hard copies of a ‘LBP guideline awareness’ pamphlet package, designed by the late, great Gordon Waddell as part of a national media campaign in Scotland: printed clinical guidelines for LBP (RCGP 1999), along with nice glossy summary sheets for each back pain ‘stakeholder’ and a copy of the evidence-based booklet for patients, ‘The Back Book’ [2] (remember that?). This trial was the main study from my PhD at Keele University, supervised by Nadine Foster. The study was so big (and exhausting, given that I was doing the legwork on my own) that it added more than 2 years to my intended PhD completion time.Let me give you some insight as to what these numbers meant for me as a PhD student back in 2003. All envelopes had to be stuffed by hand, all questionnaires were photocopied and stapled, and all letters and address labels had to be individually printed (albeit using mail merge, which occasionally crashed). The hand-stuffed envelopes had to be manually taken to and posted out from the university’s mail room. The first ‘wave’ of invitations were sent out using lists in a database file, either manually downloaded from professional registers, or provided as a spreadsheet. We had to manually exclude any clinician in Scotland, because of the ongoing Working Backs Scotland campaign.We invited 3604 clinicians in that first wave of invitations. This meant that, for every single second spent preparing each posted envelope, on average, more than an hour of time was spent overall. Early envelopes were taking more than a minute to prepare; later ones around 30 seconds! Then, I had to track responses every day – and clear out the pigeon hole in the post room, which was usually overflowing – then for any clinician on our mailing list who didn’t respond within a fortnight, a second wave of invitations were sent in exactly the same way. Finally, for the 1758 baseline responders in 2003, half of these (allocated at random) were sent the pamphlet package by post, and then a further two waves of follow-up questionnaires were posted 6 months later. None of this included the time spent transferring the paper questionnaire data over to an electronic database, manually re-checking the accuracy of this transfer in 20% of all questionnaires from each stage, and then eventually analysing the data and writing it up.I’m amazed that my then-girlfriend eventually became my now-wife, given the several near-all-nighters that had to be pulled at the physio school at Keele, with her helping me stuff envelopes and deliver these to the post room at all hours. The 2-hour daily round trips up and down the M6 between Birmingham and Keele didn’t help either, especially the one when I pranged my parent’s estate car that was full of envelope-stuffing materials.Once my PhD was completed, I swore that I would never return to the topic again. I’d had enough; which partially explains why I didn’t write up and publish the inter-professional comparisons from 2003 alone (although I did present these at a few conferences). My research interests largely moved on to other aspects of pain science. Not to mention that posting questionnaires was expensive enough in 2003 (> £20,000 at the time) and has become more expensive since, not least due to exorbitant postage costs. However, by 2023, there were lots of options to send academic surveys by email, including my beloved REDCap – an excellent tool for researchers that I was already very familiar with – and during the COVID-19 lockdowns, I found myself unable to return to our university labs to collect in-person research data. Hence, the thought crossed my mind that an identical follow-up survey to the same three professional groups surveyed in 2003 might not only be valuable, but would also allow me to finally publish my now ‘out-of-date’ 2003 baseline data.

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comWork: the thing that you love or at least the thing that pays for the thing that you love.It would be great if return to work planning was a simple A–B journey. The person is signed off, nature takes its course, they go back to work, and everything is fine. However, we know it isn’t like that.The trouble is that most maps in musculoskeletal practice are drawn from a single source of information. We might be aware of the person’s job, but we don’t go very far into work-related outcomes in undergrad or post-grad training. What the person tells us is useful, yes. Complete, no.For people in physically demanding outdoor or manual roles, missing landmarks on the landscape of their recovery can be the difference between a smooth return and a turnstile experience of work: repeated flare ups and a recovery journey that keeps stalling [2]. That threatens their livelihood, their identity, and their confidence in work.Earlier this year I delivered a workshop at the ACPOHE (Association of Chartered Physiotherapists in Occupational Health and Ergonomics) study day in Cardiff: a sequential reveal of evidence bags I called Three Boxes. Wearing my dad’s old Ford Dagenham overalls and carrying a brick hod, I walked through three occupational health cases: Dave the digger, PC Peter Robson and ecologist Brooke Treadwell – with the aim of solving each return to work mystery.The three boxes are simple:* The story they tell us.* The work they actually do.* The bridge between them.Box One: The story they tell usThe subjective history is our starting point. It offers symptoms, timelines, aggravating and easing factors, and early clues about why the problem has happened. Very often it’s because demand has exceeded capacity. Around this point, a fit note appears: ‘not fit for work’ or ‘fit for work with adjustments’ [3].Critics of occupational health sometimes complain that the report ‘just parrots what the employee said’. People rarely describe the reality of their job in detail. It’s nearly always shorthand:“Lifting patients.”“Carrying kit.”“Climbing ladders.”“Working with machinery.”Each phrase compresses a complex movement landscape into something deceptively tidy. Rehabilitation based solely on that shorthand risks preparing people for a version of work that doesn’t exist outside the clinic. It can also keep people away from work that might actually help their recovery if the exposure is graded and dosed well.The aim of the Three Boxes workshop was to show the necessity of seeing the full picture. That means asking more questions, going to the workplace where possible, and being nosy about tasks. A tape measure, force gauge and heart rate monitor tell me more than any job title.Box Two: The work they actually doObserving real, contextual function changes everything.

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comThe Two Receptionist ProblemI was treating a private equity investor one afternoon when he asked, with genuine curiosity, why we employed two receptionists when technology could easily let us get by with one.Fair question. After all, this is a man whose job involves finding inefficiencies in businesses and eliminating them. He sees a line item that could be halved and naturally wonders: why the waste?I explained that we don’t want to sacrifice robustness for efficiency. We need contingency for when someone is ill, when the phones are running off the hook, or when a patient needs extra attention. If our focus is to provide an exceptional patient experience and a great place to work, then carrying a little fat is healthy. It’s what will ensure we’re still here in twenty years, still doing good work.Patients can feel the difference. They know when they’re in a place that isn’t stripped to its bones. They sense when the atmosphere is calm, welcoming, and unhurried. They notice when staff are cared for. That creates trust, and in healthcare, trust is everything.He nodded politely. I could see him thinking: soft. Sentimental. Inefficient.Perhaps. But I’ll try to explain why I think ownership matters in healthcare.Batting for both sides?I’ve been on both sides of this, having bought and sold clinics. I’ve sat in rooms with private equity-backed buyers who wanted to roll up a hundred physiotherapy practices into a portfolio. Smart people, impressive spreadsheets, beautifully polished pitch decks with stock photos of diverse patients looking happy.Not once - literally not one single time - did any of them articulate a guiding principle of providing excellent patient care for reasonable profit. The question was always: how do we maximise profit with an aim to exit in five years?

Definitions of Reasonable Adjustments (unofficial, but entirely reliable):* The Employee: “Anything that allows me to do my job while never being inconvenienced again, ever.”* The Manager: “Anything that doesn’t require rewriting the rota, or attending another meeting.”* The Colleagues: “Anything that doesn’t mean I pick up your shifts, your caseload, or your endless sighs.”* HR: “Anything we can paste into a policy document to demonstrate compliance without committing to action.”* Employee Health & Wellbeing: “Anything that can be delivered in the form of a mindfulness webinar at 2pm on a Tuesday right in the middle of a clinic.”Ah, ‘reasonable adjustments’. A phrase so slippery it could double as a banana skin on a corridor. The NHS loves it: simple enough to print on policy posters, vague enough to keep HR in full employment until the sun burns out (but not with enough staff to actually implement fair and reasonable adjustments).The word ‘reasonable’ itself is the first trap. Reasonable to whom? The Trust? The line manager? The staff member who insists their desk be precisely 87cm high lest their lumbar spine crumble like a dunked Rich Tea? Or the patient waiting 14 months for an appointment, wondering if the whole system could do with a slightly more urgent adjustment of its own?Let’s not forget the employee perspective. Many staff sincerely believe that their particular requirement - be it noise-cancelling headphones in a busy office or an emotional support cactus in the staff room - must surely outweigh such trivia as, say, seeing patients or the needs of their colleagues. After all, one can’t pour from an empty cup, and what better way to refill it than with a sit-stand desk, an additional tea break, and perhaps a personal Sherpa to carry the mug.Meanwhile, managers (often unsuspecting clinicians who thought they’d signed up to fix frozen shoulders, not frozen rotas) are left playing referee. They must weigh the noble aim of inclusivity against the practicalities of departments already held together with duct tape and existential dread. Should Jenny be allowed to work exclusively from home because she finds the lighting ‘oppressive’? Is it fair that Dave insists on a bespoke ergonomic chair that costs more than the annual physio budget, when the waiting room still has furniture held together by hope and infection control wipes?It’s not just about decisions, it’s also about secrecy. These managers are asked to adjust quietly, confidentially and compassionately the requirements of one employee’s wellbeing against the loud eye-rolling and unsolicited advice from the rest of the department. Like a clinician treating a patient with an OA knee who also has plantar fasciitis, every adjustment made in one area seems to flare up another. Add in the fact that the only training provided was a two-hour e-learning module written in 2009, and you have a recipe for managerial tendinopathy: chronic overload, no rest days, and very little prospect of healing.There’s the awkward truth that not all reasonable adjustments marry happily. One staff member’s ADHD means they thrive on chatter, spontaneity, and flexible timekeeping (“I’ll get there… eventually”), while their autistic colleague flourishes with quiet, structure, and their day nailed down to the minute. The result? An occupational oxymoron: one person’s reasonable adjustment is the other’s sensory nightmare. Managers are left playing mediator, trying to harmonise oil and water with nothing more than a policy and hope that the next time will be easier, when the staff member inevitably leaves as soon as they are competent.The cruel irony is that staff who genuinely need adjustments (the colleague with a progressive neurological condition, or the one recovering from surgery etc...) now find themselves queuing behind a mountain of dubious requests. Their legitimate needs risk being trivialised, dismissed, or endlessly delayed because the term ‘reasonable adjustments’ has been stretched further than an overzealous hamstring in a beginners Reformer Pilates class. For them, the process feels less like support and more like months of paperwork, inconsistent progress, and no guarantee of improvement.All of this is neatly reinforced by society’s current obsession with permanent happiness and total comfort. We live in an age where the faintest whiff of inconvenience is treated like a red flag for occupational health, and where negative emotions are seen less as a normal part of being human and more as a sign you need a bespoke wellbeing strategy. Resilience? Overrated. Tolerance? Obsolete. And personal responsibility for managing your own adjustments? Why bother, when someone else can rearrange your role, dim the lights, and deliver your high-protein snacks right to your ergonomic throne? The idea that work might occasionally feel like…work…now seems positively archaic, as though suggesting someone with a stiff neck try moving it a little.And patients? Ah yes, those mythical beings. One suspects they may not care whether their clinician uses a kneeling stool or a yoga ball, as long as someone actually shows up to see them before the NHS is no more...In the end, ‘reasonable adjustments’ are a bit like evidence-based medicine: everyone agrees in principle, no one agrees in practice, and someone always ends up with a flowchart. Perhaps the only truly reasonable adjustment is to accept that nothing is reasonable, everything is an adjustment and, particularly in the NHS, all of it will require another committee meeting, another e-learning module, and a small miracle - or at least a strongly brewed cup of tea.Now, I’ve spent far too long sitting on my bean bag writing this - I need a brew! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comIt remains to be seen if Wicked will dominate culture in the coming weeks as it did this time last year, but since you lot made the mistake of enjoying/tolerating my Defying Gravity musings back then, here I am once again with a witchifying editorial.I’m in a rather ponderous, reflective and mushy mood which usually needs no explanation but by the end of this you’ll understand that I have a decent reason for once. Said mood has me reminiscing about how incredibly fortunate I have been to work with the best and brightest in the industry. For them to have given their time to our shared cause and allow me to become the poor man’s Oprah Winfrey despite a criminal lack of specific expertise! More in-person events and meetings have led to more drinks and dinners which have led to more drunken reminiscing with colleagues who have become dear and loyal friends. 12 years is a while… I started Physio Matters in 2013 aged 25 but because it has flown by it is sometimes easy to forget what has changed/evolved/matured or deteriorated/lessened/regressed depending on who you ask. But regardless of how charitable the analysis is, one thing is for sure, the influence of people on me and my work has been profound.🎼 I’ve heard it said that people come into our lives for a reason. Bringing something we must learn and we are led to those who help us most to grow, if we let them. 🎶It would be ambitious to find specific reasons for the various crucial people who have entered my professional and personal life but there are some who so obviously provide calm, stability and assurance through reliability, loyalty and kindness. They’re often embodied in a different force to those who bring creative, exciting and fun energy but on occasion special people can be all of the above. Even rarer, some people provide a constant in your life as a friend, colleague and inspiration. One such person is MSKMag editor Felicity Thow who is approaching 20 years of toleration. If there is no further description of our relationship as ‘friendship’ in this piece it will be because it is disputed and she has edited it to describe us as ‘distant acquaintances’ and ‘colleagues’ to avoid over-association…Alongside many other influential contributors that I am delighted to call acquaintances, when it comes to Flic it’s impossible to objectively weigh up their contributions, but fortunately that’s not necessary. We’re all mosaics with elements of our character and behaviour coloured by experiences which are shaped by the people we encounter and form relationships with. When we analyse particular people, projects or careers it would be mad to not recognise both the nature and nurture that influenced the individuals. Crazier still would be to underestimate the contributions of individual talent and the culture in which that can flourish or be restricted. There are lots of inherent balancing acts here, including the recognition that we are often standing on the shoulders of the giants that came before us, without letting that fact minimise our own achievements. Taken too far, this recognition can humble us into thinking we’re ONLY lucky passengers without any semblance of agency.In this issue we celebrate two years of MSKMag which I am extremely proud of and know what it has taken to make it successful. But I assure you that it is not performative humility for me to recognise that it has been the contributions of many excellent people who have made it such a fun project and much-loved publication. To name a few, my wife Charlotte’s eye for detail, design and operational strategy means we’ve never missed the 1st of the month with a glossy mag, our staff writers Sue Julians, Tom Jesson, Claire Robertson, Jo Turner and Jonathan Bell have set the standard for the bravery and impact we wanted to achieve and our 100+ authors have proven that a monthly periodical can transcend professional boundaries - against the odds - in service of best MSK practice.Well this has ended up being far more Oscar-speechy than I intended but the news is that this will be my last issue as Editor in Chief and I will be handing over the baton to my good acquaintance Felicity in the new year! I’ll still be involved behind the scenes and helping to curate the content as Editorial Director. Rest assured, MSKMag will remain a crucial part of the Physio Matters media and education offering. It also means I can focus my attention on a number of game-changing innovations in the new year, including a huge return-to-form for my first born; The Physio Matters Podcast which Farouk and Fran have been doing brilliant work on.BUT FIRST this month’s MSKMag finishes the year and my tenure as Editor in Chief with a flourish! For me it’s an exciting combination of long time collaborators and new-found starlets! In the long-suffering acquaintance column we have the wonderful Karli Gibson with an excellent piece reflecting on the rehabilitation of REAL people in the harsh realities of REAL work. Giles Hazan also returns to discuss the diagnostic lookouts and management challenges in patients with neurodiversity and hypermobility. Cameron Tudor wrote a brilliant clinical piece on OA earlier in the year but is also a favourite thinker of mine when it comes to commercial factors affecting our industry; this month he explains how ownership matters. Now to the newcomers: David Evans is an osteopath and researcher who has been around long enough (whilst remaining wise enough) to repeat his ‘state of LBP care’ survey 20 years later! He pursues the question; ‘what has changed in 20 years’. And finally Dom Smith explains how the contentious subject of diagnostic ultrasound needn’t be contentious! PANIC NOT! I haven’t forgotten our longest serving staff writer Glen O’Humeral who once again seeks to get us cancelled with his/her take on ‘Unreasonable Adjustments’. I hope you enjoy this Mag and have enjoyed all 24 of our issues even half as much as I have enjoyed making them and thank you all so much for your feedback. You’re another group of people who I have the absolute privilege of working with and like all those aforementioned:🎼Who can say if I’ve been changed for the better? But because I knew you, I have been changed for good. 🎶

When was the last time you held a conversation with a colleague or patient about assisted dying? Never? You’re not alone — and that’s precisely why I’m writing this article. If a patient were to bring it up tomorrow, would you know how to respond, or even what the law currently says?As I write this, on 23rd September 2025, the Terminally Ill Adults (End of Life) Bill has just completed its second reading in the House of Lords. It is now one step closer to becoming law in England and Wales.If passed, this legislation would permit terminally ill adults — those with a prognosis of less than six months to live — to seek medical assistance to end their life.For many, this represents a compassionate choice and an act of autonomy at the end of life. For others, it is deeply troubling. One newspaper branded it a ‘licence to kill’. Another commentator countered, “Let’s be clear — people who choose assisted dying are not suicidal. They are dying, and they want to regain some control.”This isn’t an article for or against the Bill. Rather, it’s an invitation for MSK clinicians to understand what this legislation means, and why it might soon become part of the conversations we have with our patients.It’s also worth noting that assisted dying will only become law if both the House of Commons and the House of Lords agree on the final text. If that happens, the government will have four years to design and implement the service.What the Bill ProposesIn its current form, the Bill would allow adults aged 18 and over, who are mentally competent and terminally ill (with a life expectancy of six months or less), to request medical assistance to end their life.Built into the Bill are several safeguards:* Two independent doctors must confirm the person’s diagnosis, prognosis, and decision-making capacity.* The person must make two written declarations of intent, witnessed and signed.* A minimum reflection period (typically 14 days) must elapse between the declarations.* Healthcare professionals retain the right to conscientiously object.* All cases would be subject to oversight and review, ensuring decisions are free from coercion or abuse.At present, the Bill is at the discussion stage but its momentum in Parliament and the intensity of public debate make it something clinicians can’t ignore. [1,2]Why MSK Clinicians Should CareYou might be wondering why this has anything to do with musculoskeletal practice.After all, we don’t manage terminal diagnoses or prescribe medication. But our patients live within broader stories than the pain that brings them to us. Many will be living with, or alongside someone living with, terminal illness.Crucially, MSK clinicians often occupy a trusted space in a patient’s healthcare journey. People may disclose feelings or questions about assisted dying during treatment, perhaps before ever voicing them to their GP or palliative care team.Being able to listen without judgement, respond appropriately, and know where your professional boundaries lie will be vital if this Bill becomes law.Conversations You Don’t ExpectA patient raising assisted dying might catch you completely off guard. It’s not part of typical clinical education. But how you handle it matters.The correct response isn’t to advise or to share your personal view, it’s to acknowledge, listen, and signpost. Let the patient know you’ve heard them, avoid making assumptions, and refer back to their GP or specialist team who are equipped to explore such discussions safely and legally.You will have hopefully realised that this is not so different from our everyday person-centred care: recognising the person behind the condition, holding space for them to be heard, air their thoughts, and knowing when to seek support from others in the multidisciplinary team.Recognising VulnerabilityMuch of the opposition to the Bill revolves around coercion - the fear that vulnerable individuals might feel pressured into choosing assisted dying. As someone who specialises in supporting people with lifelong disabilities, this point has been high on people’s agenda.That pressure need not be overt, it can be subtle: a sense of being a burden, financial worry, or emotional exhaustion. Because MSK clinicians often see patients regularly, sometimes over months, we are well placed to notice changes in psychological state, behaviour, or motivation.If assisted dying becomes legal, these observations take on new significance. Recognising and acting on vulnerability will become even more central to safeguarding practice. [3]Understanding Your LimitsIt’s also crucial to be clear about what isn’t our role. The Bill hinges on a six-month prognosis, something notoriously hard to predict even for experienced physicians.MSK clinicians are not responsible for making or validating such judgements.Our remit remains focused on function, comfort, and communication, ensuring our interventions and observations support the broader healthcare picture while staying firmly within our scope of practice.If a patient raises assisted dying, record the interaction factually and without interpretation.Note what was said, how you responded, and what onward referrals or signposting were made. Avoid including your own opinions or assumptions.Clear documentation protects both the patient and you as a professional, and it provides continuity of care for other members of the healthcare team.The Ethical DivideThe arguments surrounding assisted dying are emotionally and ethically charged.Supporters view it as an issue of autonomy, a right to choose the timing and manner of one’s death, especially in cases of uncontrollable suffering. They argue it restores dignity, reduces prolonged distress, and provides clarity for families and clinicians.Some opponents are vehemently against assisted dying in all forms. Others worry about slippery slopes; that what begins as a choice for the terminally ill could expand to include those with chronic illness, disability, or psychological distress. Others highlight the difficulty of accurate prognoses and the potential emotional burden on healthcare professionals involved. [4–6]Neither stance is ours to champion as clinicians. But both shape the environment in which we practice, one where patients’ questions, fears, and choices may soon take new forms.Preparing for ChangeIf the Bill passes, change will come gradually but inevitably.While MSK clinicians are unlikely to play a direct role in assisted dying procedures, we will increasingly encounter patients and colleagues grappling with its ethical and emotional implications.Some ways to prepare include:* Keeping up to date with guidance from your professional body.* Reflecting on your own boundaries, beliefs, and comfort levels.* Building strong links with palliative care and primary care teams.* Seeking supervision or peer support when facing difficult conversations.This isn’t about advocacy; it’s about readiness. Our role, as ever, is to support patients with respect, clarity, and compassion, wherever their journey takes them.ConclusionAssisted dying is one of the most profound questions modern healthcare faces.As MSK clinicians, we may not sign the forms or certify the diagnoses, but we are part of the healthcare web that surrounds each individual confronting the end of life.Being informed and not indifferent is how we continue to uphold professional integrity, compassion, and patient trust in the years ahead.References* Parliament UK. Terminally Ill Adults (End of Life) Bill. Available at: https://bills.parliament.uk/bills/3774 (Accessed September 2025).* CMS LawNow. A licence to kill? The Assisted Dying Bill passes its second reading in the House of Lords. 2025.* Academic OUP. Safeguarding and Assisted Dying: Protecting Autonomy and Preventing Coercion. 2024.* Brabners. Legal Implications of the Assisted Dying Bill for Healthcare Professionals Explained. 2025.* British Medical Association. Physician Assisted Dying: Guidance for Clinicians. 2024. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comRecruitment, team journey and leadership are big topics that can often slip down the priority list in a busy private practice. How many therapists received formal training to manage a team before setting up their clinic? For some it might come naturally, but for most it’s a skill that can and must be developed.As the saying goes, ‘Culture eats strategy for breakfast every single day’. Strategy gives you direction. Culture gives you traction.No matter how meticulously you have planned your business strategy, if your culture is toxic or even just ‘vanilla’ it is going to be an uphill battle to run a successful business. I’m not saying strategy is not important because it is. Over the many years of working with private healthcare businesses, we have seen that those with a plan have generally had more success in achieving their goals than those who have just flown by the seat of their pants.Culture, however, is the glue that keeps the business together, giving it longevity and stability. It is what attracts great candidates to your business and retains them. Yes, you have to be able to be competitive and offer the right remuneration packages but ultimately if you get culture right you will create a business that is a pleasure to own, a pleasure to work in and painless to run.With the world of recruitment as it is today, it is so important to create an environment where your team members love coming to work, feel engaged and motivated. Belonging is one of the most fundamental human needs, it’s not a luxury. To help your team thrive, you need to intentionally cultivate that sense of belonging and trust.Living your WHY and your valuesHaving a clearly defined WHY (purpose) and outlined values are the building blocks of your culture. What is at the very heart of WHY your business is in existence and what are the non-negotiables of how your business comes across to your patients and team?

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comIn recent years there’s been increasing debate and discussion around ice therapy for injury recovery. While previously ice was always considered as the first-line approach for managing acute injuries, now the debate on its effectiveness has expanded and there are questions about the validity of ice therapy.Historical ViewIn 1978, a phrase that is synonymous with injury recovery was born: RICE. Discussed in The Sportsmedicine Book by author Dr Gabe Mirkin, it set the standard for injury treatment. Everyone is familiar with it and over the years many variations have morphed including RICER, POLICE, and PRICE. Generations of therapists and coaches embraced ice therapy as standard care for overtraining and injury. Even today, expert panels indicate that ice remains widely adopted. For example, a 2025 Delphi consensus of sports physiotherapists and athletic trainers reported that local cryotherapy is frequently considered for treating acute soft-tissue and muscle pain [1]. In both acute injury management and recovery after exercise, many professionals still include ice as a key tool for its pain-modulating and inflammation-limiting effects [2]. The theory was straightforward: ice lowered tissue temperature causing a vasoconstriction of blood vessels and leading to reduced blood flow to an area and therefore a reduction in local inflammation.The DebateHowever, many have questioned the validity of the RICE approach. And the first question we might ask is: does ice actually reduce inflammation? While there is little debate in research that ice is analgesic, there have been recent doubts whether using ice actually reduces inflammation.Secondly, does reducing inflammation slow down the healing process? If inflammation is a normal body response to injury, should we even be trying to slow down a normal part of the healing process?

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comThe Motivation ProblemAnyone who’s ever faced rehabilitation after an injury, surgery, or illness knows that recovery isn’t just about the body: it’s a mind game. The repetition, the discomfort, and the slow pace of progress can sap motivation. You may have heard the words before: “I’ll do it later”, “It’s boring”, “It’s repetitive” or “I can’t find the time”.And yet, consistency is everything in rehab. Missed sessions mean missed milestones.If you’ve ever heard me speak at a conference, a couple of my go-to phrases are “It’s not a knowledge deficit, it’s a behaviour deficit” and “It’s not that people don’t know better, they don’t do better”. Pretty much everyone has got the memo: rehab exercises are important, they know that eating more veggies is important, they know that going for a walk more often is important; but knowing doesn’t always translate to doing.But we’re evolutionarily hard wired to seek calorific food, conserve energy and avoid pain. If we’re going to overcome these physiological barriers to achieve both rehabilitation and public health goals, we’re going to need to pull on more motivational strings than just saying “it’s good for you” or “it’s important”. We’ve got to find a way to pull the levers that lead to endorphin pathways, and where we can leverage ‘fun’ and ‘social connections’, we may stand a chance of motivating society to actively engage in their rehab and treatment.Here’s where gamification, the use of game-like elements in non-game contexts, is stepping in to change the rules of recovery. What if your daily exercise routine could feel more like a challenge than a chore? What if your progress was visualised as levels completed, trophies unlocked, or goals achieved? For many people, that’s not just a fun idea, it’s the difference between giving up and getting better. Taking Serious Games SeriouslyIt’s just Super Mario and Minecraft right?

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comSo, you think you know what evidence-based practice (EBP) is? I’m glad you think you do.I’m not as certain as I was 10 years ago. With each passing year of clinical practice there seem to be increasing levels of complexity, treatment choice and demand falling at the feet of those delivering clinical services. This is particularly true for NHS colleagues, who are navigating in-person and digital care, aligning to the government’s ambition to move from ‘bricks to clicks’. Private practice is not without its own unique challenges in delivering EBP either.In the article that follows, I hope to provide an antidote to those that feel so assured of their opinions and are always keen to widely share these with the world on social media. Grab a cuppa and buckle in!What even is Evidence-Based Practice?If we start with ‘what is EBP’ and consider this at face value, a simple question soon unravels to become a behemoth of complexity – not dissimilar to navigating Spaghetti Junction without a satnav.I’m sure many of you will be familiar with my experience of (or old enough to share) meeting people’s expectations by treating patients with manual therapy, traction, electrotherapy or other (insert another modality which is no longer in vogue here), only for them to leave your clinic room with a spring in their step, seemingly cured (or were they?). Another satisfied patient!Is this evidence?

Welcome back to Chewy and Jim!The lads are joined in this recording by Rob Beaven who, amongst other things (like a chiro but we don’t hold that against him), is Partnerships Manager for Physio Matters. Jim and Rob didn’t want to involve Chewy but his name being in the theme tune kind of forced their hand.Chewy, Jim and Beav discuss clinical competency amongst MSK Therapists, using social media to ask for help, and the problems associated with just ‘having a go’ at treating stuff.So strap in, this is definitely best enjoyed in audio but here is a summary of the discussion if you don’t have any earphones in because not everyone wants to hear the theme tune for some reason…“If you see somebody with a stress fracture and you misdiagnose that as something else, you’re going to prolong their issues there. Or if you miss cancer, which everybody can, nobody is perfect… that’s the obvious safety component [concern].”Self-judged clinical competence is a tricky balance to strike, of course if you think you are incompetent at everything you will never see any patients and if you think you are amazing at everything you will equally cause some problems. This lends itself to some obvious safety concerns when missing red flag diagnoses.No one is perfect and diagnoses get missed or provided incorrectly; this happens and it’s part of the landscape of being ‘autonomous’. The real skill lies in knowing which scenarios are pushing YOUR limits or have a layer of complexity that require assistance from elsewhere.“Just imagine the perils of a new graduate physio in this climate. They’ve set up a neuro triage service or they fancy neuro rehab…the dangers of that if you’re the first contact professional for that person, who’s like, ‘oh, he’s got a bit wobbly on his feet, or should his face look like that?’ That is so dangerous.”Physios particularly are in demand, there are growing waiting lists and vacancies meaning patients are fighting at the door to be seen. Therapists are making their way into open posts sooner than they should and without appropriate support. Making all these dangers more likely.I don’t care what people say, patient mileage (how many different cases you have seen) is an experience that has to be earned through graft and your gut feelings need honing through the random weird s**t that comes through your door unexpectedly. Entering private practice without support or an FCP post where you are seeing unfiltered referrals a couple of years out of uni is a recipe for dumpster fire. No one here is saying clinicians who have been practicing longer are always better but boy-oh-boy it helps to have seen more presentations and individuals to understand the complex nuance of clinical practice.“I see enough social media posts that are like, ‘I have this patient coming in with this diagnosis that I’ve not treated before. What do people suggest?’ I just don’t think that’s an appropriate support mechanism.”The conversation discusses some logistical practicalities of individuals’ scope: worrying examples of this can be seen across social media regularly and are what prompted this discussion. It is clearly more challenging as a clinician who works on their own or is isolated to access support or mentoring for complex cases and there is a clear financial implication in the private sector of turning away patients. From a cynical point of view though, this can potentially increase the risk of ‘having a go’ - when seeing paying patients means keeping the lights on at home.Social media is not a good place to seek unfiltered advice because any weird, fringe or incompetent person could reply. We need robust support mechanisms in place that we trust BEFORE we need to seek their assistance.“Unfortunately we have a number of people that are [at] irritatingly far ends of a spectrum - self-flagellators who are over-reflective to the point of anxiety, and peacocks who are cavalier and just have a go. As an industry, we are not regulating that well amongst ourselves.”Chewy harks back to one of his editorials [1] where he posited that clinicians fit into two groups: those who are overly critical of their skills and those who are under critical, causing a double edged sword in this particular scenario, especially when consulting social media. Those who ask for help (self-flagellators) are likely to be helped by the peacocks which is probably not a desirable outcome. The peacocks don’t ask for help and barrel on treating anything and everything. Without proper regulation, we have no way of managing either side of the coin so the practices shall continue.Reference This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comI have a thing for counterintuitive things. It’s one of the reasons I consider myself so lucky to have gotten into the MSK game when I did. It’s counterintuitive that the extent of tissue damage doesn’t necessarily correlate with pain and that moving ‘badly’ doesn’t necessarily cause injuries or impair performance. If it was clear and obvious, I’d have been less interested and less interesting. The murkier the water, the more comfortable I am… unfortunately that also got me sacked from running Evian…As an inherent optimist and realist, I have benefitted from being able to present both hope and direction to patients engaging in rehab and colleagues keen to see our industry improve. Combining my optimism with my love of the counterintuitive is perhaps ambitious but I have in recent years found a way and it has helped my patients, colleagues and commercial partners in various ways. Let me introduce you to some examples of when we should wish things worse. The Region Beta Paradox [1] was described by psychologist Daniel Gilbert in 1998 when he and colleagues observed circumstances in which people recover quicker from a more intense negative experience. The general gist is that in situations of tolerable discomfort/frustration/unhappiness (Region Alpha), the threshold to take action isn’t met. Therefore the situation can go on for longer, become more integrated into your life and be negatively adapted to. So if the situation was worse - enough to inspire you to act (Region Beta) - you would at least have the chance to get over it quicker.The ultimate counterintuitive thing I’ve noticed when explaining this concept to patients, colleagues and commercial partners is that they are very often both delighted to know about it and wish I’d never introduced them to it. They recognise the ways in which they are sub-threshold but felt pleasantly ignorant to the fact that they should probably act on it.Clinically, the obvious examples are the annoying but not disabling conditions that people just live with, usually until they realise they are not able to function as well or as comfortably as they would like. The threshold is eventually met and they present for assessment but with a sometimes trickier presentation to treat. Might they have been better off if it had been worse? In such cases, I find it to be very important to unpack with the patient what has inspired action so that we don’t risk them judging our success purely on them hurting less. But that’s the low hanging fruit so here’s another way to apply the concept with patients: break their leg… We all know the patients with a condition which requires more relative rest than they’re willing and/or able to give it. In these cases, the pain and dysfunction is certainly beyond the threshold to seek help but not at the threshold for them to adjust their routine for a time to let things settle. Examples from my second opinion clinic this week; raging sub-acromial bursa in a mechanic; thick, angry achilles in a trail runner, and lumbar disc herniation in a Hyrox enthusiast. Especially having been mismanaged to date, I do understand why they were reluctant to make inconvenient adjustments. Self-employed mechanic ‘needs to get on with it’, trail runner ‘needs the hills to escape the kids’, and the Hyrox enthusiast ‘wouldn’t have anything to talk about’. So I push them over the threshold with a hypothetical, ‘I certainly hope you don’t but what if you walked out of here today and broke your leg?’. A conversation then ensues about the various awkward adaptations they would have to reluctantly make and then I make the case for us needing to dose what they’re doing in order to recover quicker.On a wider industry level, I do wonder whether many of us are sub-threshold in Region Alpha tolerating wide variations in standards, ineffective professional bodies, political insignificance, underfunding and disunity. I’ve found myself wondering if we should ‘wish things worse’ as that might invigorate change and disrupt what many are tolerating but not enjoying. Is there a unifying project that can take advantage of a societal moment that seems ready for rehabilitation and the positive effects of its proliferation?This month’s MSKMag is certainly not ambling along quietly and is full of spicy flavour. Celia Champion explains how to nurture good apples and identify bad ones, Ben Wilkins is back by popular demand discussing the gamification of rehab, Tim Allardyce ponders our ever evolving relationship with ice for acute injuries. Lewis Rawson made this editor sweat when I saw his title ‘Make MSK Great Again’ as he reflects on EBP in a red cap. Our weirdest feature Chewy & Jim is back and Rob Beaven gatecrashed our rant fest and finally, the inimitable Alistair Beverley, The LD Physio himself could have hung up on me when I asked him to write about an intensely delicate subject but instead stepped up and knocked it out of the park; ‘Beyond the ‘Licence to Kill’ Headlines: Assisted Dying and MSK Practice’ is our leading feature this month and is an absolute must read.It’s an excellent Mag with many excellent points made by excellent thinkers. But will it inspire change in you? Will it meet the threshold for you to act? Or should we wish things worse?Jack Chew

First up in this month’s MSKMag is a reprint of the wonderful Val Jones’ excellent article from earlier this year. We are re-publishing this as open access to bring further attention to her work and to help raise funds for an important campaign to get Val back home with her family.Val Jones is a Physiotherapist and educator specialising in elbow pain and pathology who we have had the pleasure of working with for many years. Unfortunately she was in a serious accident earlier this year which has resulted in her being paralysed due to a high spinal cord lesion. She is currently working on the ability to talk and eat again but will require full time ventilation in order to live at home with her family; which is her goal.Her family are raising money via the GoFundMe links below therefore please give generously to support one of our own who has been so generous to the MSK community for so long. For those who may not be aware of Val and her work, we have made a bundle of the podcasts, articles and webinars she has made with us over the years which we will make available to anyone who donates via the bundle link below. In our first round of this earlier in the month we were able to raise £3500 and I would love to make that £5000 through this push.Val’s influence on Physio Matters has been more profound than she would realise or admit. She has a rare talent for both academic writing and lay knowledge translation that helps bridge the gap between the sometimes jargon-laden world of empirical science and the practical realities of the clinical front line. On a personal level she has been a role model by charting a career in which she takes the subject matter seriously but retains humour and humility in not taking herself too seriously. Finally, alongside so many of our contributors and educators, she gives her time and energy so generously to our shared cause of raising MSK care standards for the patients we serve.Thank you Val and whilst it is the very least we can do, I hope this promotion of your work can attract the funds you so deserve for your ongoing care.Working in a Regional Trauma Centre, we’re used to seeing lots of soft tissue injuries on a regular basis. But the one that was considered more unusual when I first started working at the Shoulder & Elbow Unit in Sheffield over 20 years ago was the acute distal biceps rupture. Previous literature both on UK and US populations describe it as a rare injury, with an incidence of 1.2 to 2.6 per 100,000 person years [1,2]. This equated to seeing and operating upon between 10 and 12 patients per annum for the Sheffield population of approximately 750,000 during the first few years of the millennium.However, in the last decade there has been an explosion, quite literally, in the number of patients attending our unit with a distal biceps rupture. Our team now on average sees up to 40 cases per year - over a 300% increase - over a 20 year period. These figures made me question what was driving this increase and was this just a regional trend, or something that other orthopaedic units were seeing? Also, what are the implications for an already struggling healthcare system to cope with an increased demand for surgery, imaging, resources, and post-operative rehabilitation?Trawling through recent literature there is very little written on the incidence of these injuries, apart from one study looking at Swedish and Finnish registries [3], which found a 6- to 7-fold increase in this type of injury and a 28-fold increase in distal biceps repair surgery. Staggering numbers with a huge implication for resource allocation, with figures that echoed our own experience in Sheffield.In the general population, full thickness tears are most encountered in active middle-aged men between 40 and 60 years of age [1,2]. Often when questioned, these patients have had no warning signs before their tendon tear. The incidence in women is extremely low and clinically I’ve only met one female with this injury during my 23 year tenure in Sheffield. An evaluation of distal biceps tendon ruptures in women sees them describe a more gradual onset of symptoms and a higher incidence of partial tears[4], rather than full thickness ones.Other predisposing factors to injury may include an elevated body mass index (BMI), smoking and medication use [5]. Elevated BMI, possibly secondary to greater muscle mass, would increase the load on the tendon and may predispose to rupture. Furthermore, obesity has been shown to decrease immune responses to acute tendon injury [6]. Of patients with a distal biceps tendon rupture, 36–66% are reported to be obese [1,2], compared with the general UK population obesity rate which is approximately 30% [7].The exact incidence of smoking in patients with distal biceps tendon ruptures is unknown, but it is widely accepted that smoking is a predisposing factor in tendon injuries. One study quotes a 7-fold increase in distal biceps ruptures in smokers compared with non-smokers [1]. Smoking rates have increased in the adult population of those aged 45 and above [8], which is the peak age for these injuries to occur. A possible effect of smoking involves an increased zone of hypovascularity in the tendon between the proximal and distal blood supply [9]. Patients often ask if vaping carries the same risk as cigarette smoking but I have to be honest and tell patients that I just don’t have the answer currently. Maybe the correlation between musculoskeletal injury risk and vaping will become more evident over time…The image and performance enhancement drug (IPED) market, including anabolic steroids, has become increasingly accessible through online sellers [10], which has broadened their appeal to a wider market. Their usage has become semi-normalised and socially acceptable, coining the term ‘gym and tonic’. Weightlifters are the primary user group of IPEDs, with an increase in usage seen in both males and females.Anabolic steroid use combined with exercise may lead to dysplasia of collagen fibrils, which can decrease the tensile strength of the tendon, with an associated increase in muscle strength [11]. Changes in tendons’ crimp morphology have been shown to occur as well, which again may alter the tensile strength of the tendon [11]. Less commonly, tendon rupture can also be linked with statin and fluoroquinolone antibiotic use [12,13].High risk sports for distal biceps tendon ruptures are weightlifting, American football, judo and other contact sports [1,14] and usually occur when an eccentric force is applied to a flexed and supinated elbow [15] with most patients describing an audible ‘pop’, followed by pain and weakness. Not all are sporting injuries though. In Sheffield, we’ve seen it in patients who’ve tried to stop their dog running off by hanging onto their collar or by trying to catch a wardrobe falling down the stairs. That was never going to work out well.After discussion with the surgical team, most medically well patients opt for an acute repair. An acute repair is deemed less risky for patients with less chance of post-operative complications [16]. However, one note of caution is there is a lack of clinical consensus on the role of operative treatment, Support for surgery has largely been driven by biomechanical studies that report a reduction in supination and elbow flexion strength, as well as impaired endurance seen in injuries managed non-operatively [14,17]. There is a lack of robust evidence comparing non-operative versus operative treatment. Public perception towards surgical treatment is often positive, although the evidence of its superiority over other treatments is lacking. When considering surgery, there is often a disregard for the associated risks, with individuals often taking a ‘it will never happen to me’ stance. But distal biceps repairs carry a huge 25% complication rate, with 1 in 20 patients suffering a serious adverse event such as vascular or nerve injury, heterotopic ossification or re-rupture [16].Given the real risks involved with surgery, what’s driving the increase in this procedure? Firstly, the recognition of the injury and the accuracy of diagnosis by healthcare professionals may have improved. Physical examination techniques such as the commonly used Hook test [18], combined with a careful history, makes swifter diagnosis more likely. Historically, patients with a delayed presentation were often advised against surgery as delayed repairs are associated with higher complication rates. So faster diagnosis probably leads to an increase in surgical conversion rates.The availability of modern imaging technology, such as MRI and ultrasound scans, may have made confirming the diagnosis easier, and again will decrease any delay between injury and diagnosis, once again leading to an increased possibility of surgery.Other reasons may be that with increasing sporting participation and more active older populations, the incidence and age at presentation of this injury would be expected to rise. This group of patients may be more interested in full recovery and therefore surgical options are more likely to be explored, as patients are unwilling to live with a lifelong strength deficit and cosmetic deformity seen following conservative management.Recent advances in surgical techniques such as the use of ‘button’ techniques, allow for strong initial fixation which allows early active mobilisation [19]; music to most physios’ ears. There is little consensus on the optimal post-op rehabilitation programme but our own in-house experience of immediate active post-op mobilisation resulted in a faster return to function with less physiotherapy intervention, compared to delayed mobilisation. There was no increase in complication rates, such as re-rupture, following accelerated mobilisation. Loading above 10kg is avoided for 3 months post-op because of the pull-out strain of the button devices used, but otherwise there are no other restrictions placed on our patients.In conclusion, distal biceps ruptures are becoming increasingly prevalent for a variety of reasons. Healthcare practitioners should remain vigilant in diagnosing the injury, and swiftly refer on for an urgent surgical opinion. Despite the lack of robust evidence, surgery in the medically well is considered the current optimal treatment approach, with early mobilisation following surgery appearing to be beneficial, both in terms of speed of recovery and use of physiotherapy resources.References* Safran MR, Graham SM. Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clinical Orthopaedics and Related Research®. 2002 Nov 1;404:275-83.* Kelly MP, Perkinson SG, Ablove RH, Tueting JL. Distal biceps tendon ruptures: an epidemiological analysis using a large population database. The American journal of sports medicine. 2015 Aug;43(8):2012-7.* Launonen AP, Huttunen TT, Lepola V, Niemi ST, Kannus P, Felländer-Tsai L, Berg HE, Laitinen MK, Mattila VM. Distal biceps tendon rupture surgery: changing incidence in Finnish and Swedish men between 1997 and 2016. The Journal of hand surgery. 2020 Nov 1;45(11):1022-8.* Jockel CR, Mulieri PJ, Belsky MR, Leslie BM. Distal biceps tendon tears in women. Journal of shoulder and elbow surgery. 2010 Jul 1;19(5):645-50.* Caekebeke P, Duerinckx J, van Riet R. Acute complete and partial distal biceps tendon ruptures: what have we learned? A review. EFORT open reviews. 2021 Oct 19;6(10):956-65.* Del Buono A, Battery L, Denaro V, Maccauro G, Maffulli N. Tendinopathy and inflammation: some truths. International journal of immunopathology and pharmacology. 2011 Jan;24(1_suppl2):45-50.* Haase CL, Eriksen KT, Lopes S, Satylganova A, Schnecke V, McEwan P. Body mass index and risk of obesity‐related conditions in a cohort of 2.9 million people: Evidence from a UK primary care database. Obesity science & practice. 2021 Apr;7(2):137-47.* Tattan-Birch H, Brown J, Shahab L, Beard E, Jackson SE. Trends in vaping and smoking following the rise of disposable e-cigarettes: a repeat cross-sectional study in England between 2016 and 2023. The Lancet Regional Health–Europe. 2024 May 23.* Seiler III JG, Parker LM, Chamberland PD, Sherbourne GM, Carpenter WA. The distal biceps tendon: two potential mechanisms involved in its rupture: arterial supply and mechanical impingement. Journal of shoulder and elbow surgery. 1995 May 1;4(3):149-56.* Brennan R, Wells JS, Van Hout MC. The injecting use of image and performance‐enhancing drugs (IPED) in the general population: A systematic review. Health & social care in the community. 2017 Sep;25(5):1459-531.* Laseter JT, Russell JA. Anabolic steroid-induced tendon pathology: a review of the literature. Medicine and science in sports and exercise. 1991 Jan 1;23(1):1-3.* Deren ME, Klinge SA, Mukand NH, Mukand JA. Tendinopathy and tendon rupture associated with statins. JBJS reviews. 2016 May 3;4(5):e4.* Stephenson AL, Wu W, Cortes D, Rochon PA. Tendon injury and fluoroquinolone use: a systematic review. Drug safety. 2013 Sep;36:709-21.* Morrey BF, Askew LJ, An KN, Dobyns JH. Rupture of the distal tendon of the biceps brachii. A biomechanical study. JBJS. 1985 Mar 1;67(3):418-21.* Lappen S, Siebenlist S, Kadantsev P, Hinz M, Seilern und Aspang J, Lutz PM, Imhoff AB, Geyer S. Distal biceps tendon ruptures occur with the almost extended elbow and supinated forearm–an online video analytic study. BMC Musculoskeletal Disorders. 2022 Jun 22;23(1):599.* Amarasooriya M, Bain GI, Roper T, Bryant K, Iqbal K, Phadnis J. Complications after distal biceps tendon repair: a systematic review. The American journal of sports medicine. 2020 Oct;48(12):3103-11.* Freeman CR, McCormick KR, Mahoney D, Baratz M, Lubahn JD. Nonoperative treatment of distal biceps tendon ruptures compared with a historical control group. JBJS. 2009 Oct 1;91(10):2329-34.* O'Driscoll SW, Goncalves LB, Dietz P. The hook test for distal biceps tendon avulsion. The American journal of sports medicine. 2007 Nov;35(11):1865-9.* Barret H, Winter M, Gastaud O, Saliken DJ, Gauci MO, Bronsard N. Double incision repair technique with immediate mobilization for acute distal biceps tendon ruptures provides good results after 2 years in active patients. Orthopaedics & Traumatology: Surgery & Research. 2019 Apr 1;105(2):323-8. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comThe cells of a malignant tumour are restless. Every so often, one wriggles free and breaks off. It’s almost certainly doomed: if it’s not destroyed by immune cells, it will likely succumb to fluid shear stress as it’s dragged through narrow vessels, or just undergo programmed cell death [1].But some do make it to the spine and colonise it; we then call them metastases. Why so often the spine and not, say, the tibia or the deltoid?People often blame Batson’s plexus: blood draining back to the heart can be accidentally shunted into the venous plexus of the spine - Batson's plexus - because it lacks valves [2]. Those itinerant cancer cells can ride the shunt and make a home in the spine.That’s part of it, but the bigger reason is that the spine has something cancer cells want [3]. Stephen Paget suggested this first in 1889 [4], and he’s been proven mostly right [1]: “some bones suffer more than others; the disease has its seats of election... When a plant goes to seed its seeds are carried in all directions; but they can only live and grow if they fall on congenial soil.”

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comTherapists treating runners, cyclists, or triathletes can often feel frustrated when athletes keep breaking down despite everyone’s best efforts.I now work exclusively with endurance athletes and have spent recent years helping therapists understand how these people tick - and how we can help them more effectively.For decades, we were trained to think in terms of structure and mechanics: weak glutes, flat feet, overpronation, knee valgus, tight calves. The logic was simple: find the fault, fix it, prevent injury, boost performance.But if you’ve noticed that ‘fixing the fault’ doesn’t always stop injuries, you’re discovering a bigger truth: endurance athletes rarely get injured because of one (or many) mechanical flaws. More often, tissues simply weren’t ready for the training and competition load demanded of them.Biomechanics is always a hot topic and sometimes worth exploring, but it’s not what I see most therapists struggle with, other than trying to direct the athlete’s beliefs away from it. The real sticking point is how we talk with athletes about tissue and load tolerance - and how to use that in rehab and/or management of their ongoing training and racing.Many clinicians tell me, “I know biomechanics isn’t the whole story anymore, but I don’t know how to explain load and tissue tolerance to athletes or use it in rehab.”This article is for you. We’ll look at why biomechanics isn’t enough, what tissue tolerance really means, and how to guide endurance athletes with simple, effective load-based strategies.Why the Biomechanical Lens Falls ShortI remember the late ’90s and early 2000s: weekends spent on CPD courses, watching people walk across paper runways so I could hunt for ‘flaws’ and prescribe foam padding, orthoses, or elaborate corrective exercises for obscure muscles. I thought I was an expert. Sometimes patients improved, but often they didn’t.As my reasoning evolved, I questioned everything. If biomechanics didn’t consistently fix problems, why were some athletes improving while others weren’t?

This is a free preview of a paid episode. To hear more, visit mskmag.substack.comLast week, I spent three hours covering reception at our multidisciplinary clinic: a chiropractor answering the phones.In that short time, I broke the printer, deleted something important (still not sure what), and nearly undid a whole day’s worth of admin magic. In other words, I proved what our incredible front desk team already knows: I should never be left in charge without adult supervision.But between the chaos, I had four conversations that perfectly captured the public’s confusion around chiropractic and MSK healthcare in general. From behind the desk, I was uniquely placed to dig a little deeper into their thoughts and beliefs.For context, our clinic is a true MDT. We put clinical competency above professional titles. If you call with sciatica, you’ll be offered Laura, Rob, Alastair, or Sarah — not “the chiropractor today,” “the physio tomorrow,” or “the osteo on Thursday.” We’re always transparent about who you’re seeing, and anyone who requests a specific profession will get it. But in reality, fewer than 10% of people actually ask.When people do question it, our front desk uses a simple line: “All of our team are trained to examine, diagnose, and treat in a very similar manner.”* "I need a crack today."Caller one had acute back pain. Their regular chiropractor was away, and they urgently sought a ‘crack’ to ‘realign’ their back. They didn't want a physio as they believed that was “too focused on muscles not the alignment issue”.* "I’d rather see an osteopath."Caller two, in severe pain, palpably recoiled at my suggestion of chiropractic treatment assuming it would involve ‘all the cracking’. She instead requested osteopathy, perceiving it as gentler and more holistic, despite our clinic offering equally gentle chiropractic care.* "Please don't tell my GP."