The following is not a real service. That is important to say upfront, because the uncomfortable truth is that it easily could be. If it were not so off-brand for MSKMag, you would be forgiven for assuming it was legit. And by legit, I mean real rather than credible, because this space is far from credible.

Across MSK, private healthcare, wellness, performance, diagnostics and so-called longevity medicine, we are seeing the ingredients of a new commercial model beginning to converge. Advanced screening. Wearables. ‘Optimised’ nutrition. Whole-body imaging. Regenerative injections. Manual therapy. Corrective exercise. Sleep tracking. Supplements. Aesthetic medicine. Concierge-style access. All wrapped in the language of prevention, personalisation and empowerment.

Many of these tools have legitimate value in the right context, for the right person, with the right clinical reasoning. That is not the concern. The concern is what happens when they are bundled together into a supposedly premium service for broadly healthy people, where the business model depends on finding things to monitor, treat, correct or optimise.

False positives, incidental findings, overdiagnosis, unnecessary treatment, health anxiety and the profitable cultivation of the ‘worried well’ are not fringe concerns. They are predictable consequences when reassurance is replaced by surveillance, and when uncertainty is converted into a monthly management plan. And I most feel for the victims of this fraud: the patients who perceive that they are taking their health seriously by delegating decisions to a combination of tech and supposed professionals.

So here is a spoof service brief. It is deliberately exaggerated, but only just. Please read it as satire, but don’t kid yourself that it’s fantasy.

Live Safer

Live Better

Live Longer

Introducing Live Health

The ultimate personalised care plan combining the latest in medical and therapy technologies to help you feel, look and be the healthiest you can be!

Our patented three-step process:

• The Screening

• The Treatment

• The Management

The Screening

Your dedicated longevity clinician will guide you through a tailored examination and diagnostic pathway that identifies specific issues pertinent to you right now, as well as indicators of which elements of your health require preventative attention. This will include, but not be limited to:

• Full genomic sequencing

• Full blood panel

• Whole-body MRI

• Postural screening

• Live glucose monitoring

• Biomechanical examination

• Sleep study

• Full orthopaedic testing

The Treatment

Optimising your health starts with a tailored report grounded in YOUR personal test data. Your screening results will identify areas that warrant treatment and establish their order of priority. Our precise testing sequence, which examines everything from your DNA to your movement patterns, informs stage two perfectly. Treatments include, but are not limited to:

• Personalised nutrition plan

• Timed eating schedule

• Tailored supplement regimen

• Meal prep

• Rehabilitation

• Cryotherapy

• Corrective exercises

• Posture restoration

• Sleep monitoring

• Manual therapies

• Massage

• Manipulation

• Acupuncture

• Orthotics

• Pillow, mattress and bed sheet design

• Injection therapies

• Stem cells

• Collagen

• PRP

• Botox

The Management

It is essential that the immediate gains achieved by stages 1 and 2 are maintained to ensure long-term health outcomes. Your dedicated longevity clinician will create a schedule of maintenance care that optimises your health and keeps you on track. Whilst everyone’s management plan will be unique, here is an example from our popular LiveToday tariff:

Throughout

• Sleep tracker

• Glucose monitoring

• Meal prep

Weekly

• Personal training

• Massage therapy

• Cryotherapy

Fortnightly

• Manipulation

• Acupuncture

Monthly

• Supplement adjustment

• Posture review

Quarterly

• Corrective exercise programme

• PRP, collagen and Botox top-ups

• Sleep device review

Annual

• Blood panel

• MRI scan

• Stem cell therapy

  

Some things to ponder…

What good is weight training if you are burning muscle and not fat due to poorly timed exercise and supplement schedules?

What good is cardio if you are further damaging a slipped disc?

What good is a monthly massage without a cryotherapy flush to release the scar toxins?

For too long, the healthcare of individuals has been based on data collected from groups. The most important person in your health is YOU. Take charge of your health today by instructing us to personalise your care.

Express your interest here to be the first to be contacted when appointments go live in our new Wimbledon, Kensington and Alderley Edge clinics.

The uncomfortable part of this spoof is not that any single component is necessarily absurd. Blood tests, imaging, exercise, nutrition, sleep work, rehabilitation, manual therapy and selected interventions can all be clinically useful when there is a clear indication. The problem is the logic of the package: screen first, find something, treat everything, then maintain indefinitely.

Each of these has evidence-based utility in specific circumstances, but not in combination and not regardless of demographic:

• Full genomic sequencing

• Full blood panel

• Whole-body MRI

• Postural screening

• Live glucose monitoring

• Biomechanical examination

• Full orthopaedic testing

The following ‘treatments’ do not specifically treat anything that the aforementioned screening tests would reveal. This is also not being suggested as a list of options from which one or two things will be selected. Instead, it is presented as ‘holistic’ care that includes each of these categories and implies that all can be meaningfully tailored.

• Personalised nutrition plan

• Timed eating schedule

• Tailored supplement regimen

• Meal prep

• Rehabilitation

• Cryotherapy

• Corrective exercises

• Posture restoration

• Sleep monitoring

• Manual therapies

• Massage

• Manipulation

• Acupuncture

• Orthotics

• Pillow, mattress and bed sheet design

• Injection therapies

• Stem cells

• Collagen

• PRP

• Botox

This example schedule is over-treatment on every level of analysis, with no basis in evidence. There is also emerging evidence that such close scrutiny may contribute to health anxiety. Interestingly, personal training, meal prep and sleep advice are likely to improve the health of many patients, with the risk that any progress would then be attributed to the numerous other interventions.

In that model, ‘personalised care’ can become a seductive justification for abandoning proportionality. Incidental findings become opportunities. Normal variation becomes pathology. Ageing becomes a defect. Prevention becomes provocation. The patient does not leave with a clearer sense of what matters; they leave with a longer list of vulnerabilities and a subscription to manage them.

This matters for MSK because our sector is especially vulnerable to this drift. We already work in a world where posture, movement, scans, asymmetries, degeneration and pain are too easily over-interpreted. Add longevity branding, consumer diagnostics and high-end concierge packaging, and the risk is obvious: we could end up selling certainty where none exists, treatment where none is needed, and dependency under the banner of optimisation.

The challenge is not to reject prevention, technology or personalised care. It is to ask harder questions before we package them. Who is this for? What problem are we solving? What is the likelihood of benefit? What is the risk of harm? What happens when we find something? And are we helping people live more freely, or teaching them to monitor themselves more fearfully?

Because the future of healthcare does not only depend on what we can measure. It depends on whether we have the restraint, composure and fundamental ethics not to treat every measurement as meaningful.

My interest in MSK healthcare grew out of my obsession with combat sports. In 2002 I was in the final stages of completing a maths PhD. In that same year, I became one of the first women in the UK to compete in Mixed Martial Arts (MMA) – which was at the time a small and niche sport often referred to as ‘cage fighting’.

One of the first things I learned about combat sports injuries is that it was almost impossible back then to get good advice on how to get back to fighting after an injury. When I mentioned my sport to a doctor or physiotherapist, they’d look at me like I’d grown another head and suggest it was a bad idea.

So, as with most things about MMA back in those days, we tried to figure it out for ourselves. As a result, my knowledge of combat sports rehab grew from an eclectic mix of things learned from books, the early internet, S&C coaches, a sports therapy course, and a lot of trial and error. A few years later I went back to university to study osteopathy, which added a more systematic understanding of clinical examination, anatomy and pathology, but I can still trace the foundations of what I do in clinic every day to those early years spent in the gym and on the mat.

Know your combat sports

Rehabilitation is about developing tolerance for the physical demands of an activity. For a sport like football, a lot of work has already been done to analyse these requirements. We know how to get people running, jumping or changing direction.

Combat sports, on the other hand, are full of weird movement patterns and unpredictable forces. There are a plethora of injury mechanisms that don’t exist in other sports. Athletes are not just facing the risk of accidental injury; they’re also up against an opponent intending to do them physical harm.

Structures ranging from the knee to the lower back find themselves loaded in positions rarely found outside of combat sports, or possibly a dungeon. And that’s before we talk about the risks associated with chokes, concussions and weight cutting induced dehydration.

This means that the threshold for getting fighters back to competition level following an injury is high. Too often I see athletes who have been given a generic rehab plan, and once the pain has settled, figured that they were good to go. Even those who undergo more specific rehabilitation are rarely progressed to the intensity needed for their sport. In my experience, the majority of rehabilitation failures with this patient group are related to underloading in crucial movement patterns.

The first step for any MSK practitioner wanting to treat fighters is to find out what is involved. Each discipline has its own individual set of demands. A detailed understanding of biomechanics isn’t required – but having watched a match or two, understanding some key movement patterns and being able to picture what they are doing in training goes a long way. Ask lots of questions! When it comes to getting a patient to buy into your rehab plan, demonstrating that you have an appreciation for where they need to get to is non-negotiable.

Key things to find out:

Read more

We’ll publish the answers in the MSKHub - make sure you’re a member (it’s free!) here!

Across

1 Right shoulder tip pain could be referred from this organ (11)

5 Rheumatoid finger deformity, buttonhole-style (11)

7 Claw hand nerve culprit (5)

8 Upper brachial plexus birth injury _____ palsy (4)

9 Muscle for shoulder adduction (10)

12 Horner’s, arm pain and wasting - not to be missed pathology (8)

14 Warmly dressed people prone to ulnar collateral ligament injury (6)

16 Nerve assessed in Phalen’s test (6)

18 Rich man’s disease (4)

21 Wrist drop caused by this nerve palsy (6)

22 White, blue or red fingers (8)

Down

2 Wrist bone prone to AVN (6)

3 Swollen and tender proximal interphalangeal (PIP) joints a common sign of this arthritide (10)

4 Nerve in Arcade of Frohse (3)

6 Vascular and brachial plexus squeeze (abbreviation) (3)

8 Abnormal fluid in joint (8)

10 Innervation for shoulder abduction (8)

11 Stenosing tenosynovitis of a finger flexor tendon (7)

13 Sound of impact, also a shoulder injury abbreviation (4)

15 Ulnar nerve’s tightest squeeze (7)

17 Short tendon in De Quervain’s (abbreviation) (3)

19 Location of Gottron papules (5)

20 Paediatric autoimmune joint disorder, briefly (3)

If you’ve ever caught yourself muttering “there has to be a better system than this“ mid-clinic, you’re not alone. For many MSK practice owners across the UK, the frustration with outdated practice management software has become background noise — something they’ve learned to live with rather than fix.

And the reason isn’t apathy. It’s fear. Fear that switching will mean weeks of disruption, lost patient records, a confused admin team, and a to-do list that somehow gets longer. The perceived pain of migrating to something new almost always feels bigger than the daily irritation of sticking with what you’ve got.

But is that fear well-founded? Or is it stopping you from making a change that would genuinely transform how your practice runs?

This is a guide to what switching practice management software actually involves - the real steps, the real risks, and the questions you should be asking any provider before you commit to anything.

Why MSK practices put off switching

The concerns are familiar: lost patient data, a team that can’t get to grips with something new, downtime you can’t afford, or the memory of a previous migration that went badly. All legitimate. All worth taking seriously.

But they are also problems that a well-designed migration process is specifically built to prevent. The question is whether the provider you’re considering has actually thought this through — or whether they’re just hoping you’ll figure it out.

What a good PMS migration actually looks like

Here’s the honest reality: switching your practice management software is not a weekend project. But it also doesn’t have to be a crisis. A well-run migration typically involves four stages.

Read more

Vascular claudication is angina in the legs: pain that starts when plaque narrows an artery enough that it cannot meet a working muscle’s demand for blood. One of the first English-language descriptions, from 1904, is still apt [1]:

“The patient while walking experiences paresthesia and pains in the feet; tension, pain or stiffness in the calves or even above... finally an increasing difficulty of locomotion that in increasingly shortening intervals causes the sufferer to stop completely and rest. After a short rest all of the symptoms disappear, and the subject is able to walk on as usual.”

Just as angina is a symptom of coronary artery disease, vascular claudication is a symptom of peripheral artery disease, or PAD. This symptom is not always present: PAD, like coronary artery disease, is often asymptomatic. But when claudication does appear, MSK clinicians are often the first to hear about it and the first to get a chance to raise the alarm. Vascular claudication points to PAD, which in turn points to systemic atherosclerotic disease. The claudication is ‘a warning sign to you and your patient’, as one professional group puts it. Within five years, 10 to 15% of people with PAD will die of plaque-related disease [2].

Where patients feel the pain depends on where the narrowing sits.

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AI in MSK is not about replacing physios; it is about removing friction, improving access, and helping clinicians and patients make better decisions with better data. The challenge is adopting it in ways that preserve clinical reasoning, data security, and the human side of rehab.

There is a certain kind of AI conversation in healthcare that feels like being cornered at a conference coffee stand by a man who has just discovered both automation and his own LinkedIn voice. He says ‘disruption’ a lot. He believes every complex human problem is one dashboard away from resolution. Somewhere nearby, a glowing slide deck promises transformation.

For those of us in MSK, it is hard not to meet some of this with a raised eyebrow.

Not because technology is irrelevant. Quite the opposite. AI is already becoming useful in healthcare. The issue is that its most valuable applications are often the least theatrical. There is no superhero landing. No machine taking over your clinic while you retreat into a life of strategic oversight and superior coffee. The real value is quieter than that. AI is most likely to help by removing friction around clinical work rather than replacing the clinician altogether. [1, 2]

And friction, if we are honest, is everywhere.

It lives in the note-writing, the dictation, the referral letters, the coding, the admin trail, the endless toggling between patient interaction and digital housekeeping. It is the fact that finishing a clinic is not the same as finishing work. It is opening the laptop again in the evening to clear a backlog of notes because the day was spent doing the actual job. Recent work on ambient AI scribes suggests these systems can reduce documentation burden, lower cognitive task load, and cut some after-hours work. [5][1]

That matters because cognitive load is not an abstract idea. It is what a day feels like.

It is the mental drag of listening, typing, remembering, filtering, deciding, and trying to stay on time without becoming robotic. It is the slow erosion caused by monotony. And monotony matters. Repetitive low-value work does not just waste time; it consumes attention. It narrows thought. It leaves less of you available for the parts of the consultation that actually require intelligence.

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Is it normal to assume that whenever someone cancels their appointment, despite explicitly thanking you and saying they’re feeling better, you’ve actually made their pain worse, ruined their life, and they’re simply too polite to tell you how terrible a clinician you are?

What about when someone cancels their 8.30am appointment late the night before because they have to see their workplace clinician instead and then never responds to your email reminding them of the late cancellation policy whereby there is a fee to pay?

Is it normal to assume they hate you and will be telling all their friends and colleagues to avoid?

Now imagine this clinician receiving an actual email that says ‘you did not meet my expectations and therefore I’d like to cancel my appointment’. It’s me; this is my inbox. A patient whom I’d seen once a few weeks ago was now detailing that they had expected hands-on treatment and advice to use TENS. When I looked back through the notes, I knew what my response had to be. I couldn’t apologise for the treatment offered because I’d still do the same thing today - there seemed no soft tissue that warranted hands on treatment - and TENS wouldn’t have been my go-to either.

I think a past iteration of me would have wanted to make things right straight away - ushering this patient back in for some poorly reasoned manual therapy; in fact, it’s on the house! Instead, I located the stomach that had dropped out of my backside on receiving essentially a rejection email, thanked the patient for their honest feedback and wished them well with their recovery.

For me this is the classic expectation mismatch that we’ve seen throughout MSK care - certainly since I’ve been qualified: the patient arrives with expectations of traditional (and sometimes outdated) treatments while we attempt to balance their preference with evolving evidence.

For years, MSK clinicians have grown comfortable challenging expectations around passive treatments. We’ve become better at explaining why imaging isn’t always necessary, why hands-on therapy may not be indicated, or why pain isn’t synonymous with damage. But the landscape is shifting again. Patients are no longer arriving armed only with outdated beliefs; increasingly they arrive influenced with information, wearable data, AI-generated advice and wellness narratives that often sound sophisticated, evidence-based and empowering.

So what about future treatments? What about now in 2026 when patients arrive with expectations of new interventions and technologies?

The challenge for modern clinicians is no longer simply rejecting outdated ideas. It’s learning how to critically appraise the endless stream of new ones.

Cue June’s MSKMag.

Up first, Jack Chew puts freshly hyped, package-style lifestyle medicine under the spotlight and explores where innovation risks becoming performance and packaging in ‘Beware Concierge Healthcare’.

Tim Colledge makes the case for being open to the friction smoothing and meaningful improvements to care that AI can bring to health professionals in ‘AI in MSK Care: Useful Tool or Clever Distraction?’

In her piece ‘Fighting Talk: Grappling with Combat Sports Rehab’, Rosi Sexton reminds us that unfamiliar sporting populations require genuine expertise, not generic rehab principles.

Staff writer Tom Jesson returns to bring us back to fundamental clinical awareness on the topic of Peripheral Artery Disease in his article ‘Notes on PAD’.

Finally, Natasha Miszewski of Splose shares her practical advice on changing your practice management software with behind the scenes expertise. Read about what questions you should be asking in ‘Switching MSK Practice Management Software: what it actually involves’.

The uncomfortable reality of modern MSK care is that sometimes good clinicians will disappoint patients, and sometimes convincing ideas will turn out not to be very good ones at all. But whether it’s AI, lifestyle medicine, unfamiliar sporting populations, overlooked pathology or the systems underpinning our clinics, the common thread throughout this month’s issue is adaptation. Not blind acceptance of the new, nor stubborn attachment to the old, but the ongoing challenge of deciding what genuinely deserves a place in MSK care.

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“All right, but what else could it be?”

Tracy sat there having just heard the news from me that she has a diagnosis of Fibromyalgia. As so often happens with persistent pain, she came into our service with pain in one area of her body that had then gradually become widespread over time. I’d been through an assessment with her, including the American College of Rheumatology (ACR) Fibromyalgia criteria [1] and gave her the news. Her question had caught me off guard and I replied tentatively.

“Well…errrm….in some people with widespread pain it can occur due to things like Rheumatoid Arthritis where they have too much inflammation because of their immune system, but thankfully you don’t have any symptoms like that, and you had some other blood tests which were ok.”

To my relief she accepted that explanation and the conversation moved on.

But what if it hadn’t?

If she’d have pressed me further the conversation may have got a lot more uncomfortable. She’d had some blood tests which were ‘normal’, but what were they testing for? Were they the right tests to be ordering? And did they cover all other conditions that could cause chronic widespread pain?

Here’s the dilemma. Since 2016, Fibromyalgia has been a diagnosis of inclusion, meaning you no longer need to rule out all other potential diagnoses before making the diagnosis. If someone fulfils the criteria then they have the condition. This means patients may get the diagnosis and therefore support quicker - but it comes with a big risk.

Because whether someone’s chronic widespread pain is indeed due to Fibromyalgia, a different rheumatological condition, or something else entirely is dependent on the clinical reasoning ability of the assessing clinician. That includes you reading this. Yet until very recently, there were no existing resources to support clinicians with this.

A few literature reviews exist on what other conditions can cause chronic widespread pain [2,3,4], but suggestions vary and aren’t always correct. The Royal College of Physicians in their guidance on diagnosing fibromyalgia [5] suggest some loose ideas on differential diagnosis and blood tests to order based on collective opinion, but don’t suggest what the results could mean or what to do with them.

Hence, to date, it has been down to individual clinicians and services to determine what other conditions to consider and what blood tests to order…resulting in potential under or over investigation for patients, missed diagnosis, and uncertainty for everyone.

So a gap existed, but what to do about it?

Thankfully around this time I needed a dissertation project for my MSc. I didn’t want to do just another systematic review or questionnaire study that highlights an issue but does nothing to resolve it. I wanted to create something that would make a difference, and that clinicians could use worldwide. It needed to be detailed enough to contain all appropriate differential diagnoses, but simple enough that clinicians could easily use it and integrate into existing electronic software.

And so began the long process of extensively going through the existing literature to see what conditions really did (or didn’t) lead to chronic widespread pain. Whilst some conditions were well known (think rheumatological conditions), other rarer conditions were quite a surprise (HIV, hepatitis).

After an initial list was created, I then took it to over twenty specialists from various fields to break it down even further. They added some conditions (Cushing’s) and removed others. There was however one key theme throughout: that this was a good idea.

But to make this clinically useful it needed to be more than just a list of differential conditions. It needed the combination of: what conditions to consider, what symptoms to look out for, what tests to arrange, and what to do with the results.

Interviewing the specialists helped clarify the answers to these, but the guide also needed to be simple enough to use that any clinician could pick it up and use it without any instruction. So along the way various edits were made to ensure this was not only clinically accurate, but user friendly.

Finally, after multiple versions and edits over the course of a year, the world’s first clinical resource guide for determining differential diagnosis for chronic widespread pain was announced and released into the world at the Advanced Practice Therapy Live event in March 2026. You can see it on the next page.

The process for using it is straightforward.

Fibromyalgia remains a diagnosis of inclusion. You complete your assessment as usual. If someone presents with chronic widespread pain and associated features such as fatigue and cognitive dysfunction, you can go through the ACR Fibromyalgia criteria with them and diagnose where appropriate. The next step is where the guide comes in.

There are some conditions, like osteomalacia and hypothyroidism that can cause chronic widespread pain that we cannot reliably differentiate subjectively; the only current way to be certain is through blood tests. Which ones to check are listed.

There is a reminder to ask the patient about any medication changes at the beginning of their pain. The classic culprit we often think of is statins, but many other drugs have the potential to contribute as well.

Finally, there are a collection of musculoskeletal and medical causes that can be subjectively differentiated to consider. It is not designed as a checklist, but to guide reasoning. If you are suspicious of an alternative diagnosis, apart from rheumatological ones, most would be initially further investigated and managed by the GP.

There is of course still work to be done and there may be smaller changes in the future as evidence changes and the guide goes through reliability and, if possible, validity testing. But the best way to know what does (and doesn’t) work is through feedback from people testing it in real life, which includes you reading this.

So here is a PDF version so you can download the guide yourself and use straight away in clinic. Try it out a few times and then let me know what you think - my social media handle is @BWhybrowPhysio.

Chronic Widespread Pain Guide

126KB ∙ PDF file

Download

Download

Back to Tracy.

Had I had this resource at the time I could have gone through it with her, which may have given her (and me) more confidence in her diagnosis and plan moving forwards. Since the creation of the guide, it has helped make a potentially uncomfortable part of the Fibromyalgia conversation much more manageable, I’d be keen to know how you find it.

For now, this is the biggest development in the diagnostic process for chronic widespread pain since the Fibromyalgia diagnostic criteria was overhauled in 2016. My hope is that one day they will be paired together and form a part of guidelines moving forwards. Not only could it help ensure a more accurate diagnosis but provide greater peace of mind for patients and clinicians alike.

Ben Whybrow is a Specialist Pain Physiotherapist in the NHS and Communication Skills Facilitator at Cambridge Medical School. You can find him on LinkedIn or across social media @BWhybrowPhysio

References

1. Wolfe, F., Clauw, D. J., Fitzcharles, M-A., Goldenberg, D. L., Haüser, W., Katz, R. L., Mease, P. J., Russell, A. S., Russell, I. J. & Walitt, B. (2016). 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Seminars In Arthritis And Rheumatism, 46(3), 319-329.

2. D’Amuri, A., Greco, S., Pagani, M., Presciuttini, B., Ciaffi, J. & Ursini, F. (2024). Common non-rheumatic medical conditions mimicking fibromyalgia: a simple framework for differential diagnosis. Diagnostics, 14(16), 1758. https://pmc.ncbi.nlm.nih.gov/articles/PMC11354086/pdf/diagnostics-14-01758.pdf

3. Haüser, W., Perrot, S., Sommer, C., Shir, Y. & Fitzcharles, M-A. (2017). Diagnostic confounders of chronic widespread pain: not always fibromyalgia. Pain Reports, 2(2017), e598. https://pmc.ncbi.nlm.nih.gov/articles/PMC5741304/pdf/painreports-2-e598.pdf

4. Krasin, E., Warschawski, Y. & Khoury, A (2022). The clinician’s guide to differential diagnosis of non-localized musculoskeletal pain a primer on musculoskeletal medicine. Bulletin Of The Hospital For Joint Diseases, 80(4), 236-245. https://journals.lww.com/bhjd/fulltext/2022/80040/the_clinician_s_guide_to_differential_diagnosis_of.7.aspx

5. Royal College of Physicians. (2022). The Diagnosis of Fibromyalgia Syndrome: UK Clinical Guidelines [Online]. London: Royal College of Physicians. [Accessed 25 March 2025]. Available From: https://www.rcp.ac.uk/media/udlhnt1b/the-diagnosis-of-fibromyalgia-syndrome-guidelines_1_2_0.pdf

Shockwave 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…

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Putting 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.”

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.

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If 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.

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The 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 bone

At 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.

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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 shit.

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

¡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.

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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 for

When 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 revenue

Ask 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 at

Every 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 matters

Not 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 preparation

There 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 first

Looking 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

Recently 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?

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Picture 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:

1. 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.

2. 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.

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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 Now

2014

Ann 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.

2026

Ann’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.

Conclusion

The 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’

2014

Ann 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.

2026

This 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 nuance

Recent 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].

Conclusion

Ann’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 Equity

2014

Ann 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.

2026

Subsequent 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].

Conclusion

Ann’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 Science

2014

Ann challenged researchers to produce rigorous trials comparing exercise interventions with other treatments and highlighted deficits in long-term follow-up.

2026

Over 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].

Conclusion

Exercise 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 Reflections

Looking 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

1. 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.

2. 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.

3. National Institute for Health and Care Excellence (NICE). Type 2 diabetes in adults: management (NG28). London: NICE; Updated 2026.

4. American Diabetes Association. Standards of Care in Diabetes—2026. Diabetes Care. 2026.

5. 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.

6. 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.

7. Look AHEAD Research Group. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med. 2013;369:145-154.

8. 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.

9. National Institute for Health and Care Excellence (NICE). Cancer rehabilitation and survivorship guidance. London: NICE.

10. 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.

11. 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.

12. Sallis R. Exercise is medicine and physicians need to prescribe it. Br J Sports Med. 2009;43:3-4.

13. World Health Organization. WHO Guidelines on Physical Activity and Sedentary Behaviour. Geneva: WHO; 2020.

14. NHS England. Physical Activity Vital Sign. NHS Data Dictionary. 2024.

15. 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.

16. 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.

17. National Institute for Health and Care Excellence (NICE). Behaviour change: individual approaches (PH49). London: NICE.

18. NHS England. Making Every Contact Count (MECC). London: NHS England.

19. World Health Organization. WHO guideline: recommendations on digital interventions for health system strengthening. Geneva: WHO.

20. 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.

21. Marteau TM, Hollands GJ, Fletcher PC. Changing human behaviour to prevent disease. BMJ. 2012;345:e6453.

22. NHS England. The NHS Long Term Plan. London: NHS England; 2019.

23. UK Chief Medical Officers. Physical Activity Guidelines. London: Department of Health; 2019.

24. NHS England. Social prescribing and community-based support: summary guide. London: NHS England.

25. Public Health England. Exercise Referral Schemes: A National Evaluation. London: PHE.

26. World Health Organization. Global Action Plan on Physical Activity 2018–2030. Geneva: WHO.

27. Sport England. Active Lives Survey. London: Sport England.

28. World Health Organization. Fair Play: Building a Strong Physical Activity System for More Active People. Geneva: WHO; 2024.

29. Sport England. This Girl Can campaign evaluation reports. London: Sport England.

30. World Health Organization. Guidelines on physical activity and sedentary behaviour. Geneva: WHO; 2020.

31. American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 11th ed. Philadelphia: Wolters Kluwer; 2021.

32. 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.

33. World Health Organization. Global Action Plan on Physical Activity 2018–2030: implementation framework. Geneva: WHO.

34. Look AHEAD Research Group. Eight-year weight losses with an intensive lifestyle intervention: the Look AHEAD study. Obesity. 2014.

35. Naci H, Ioannidis JPA. Comparative effectiveness research of exercise versus drug interventions: methodological perspectives. BMJ.

36. Sallis R, Pratt M. Physical activity as a global health priority: scaling Exercise is Medicine. Br J Sports Med.

Expertise 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?

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Dynamometry 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 Matters

Let’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 data

The Problem After Deciding to Measure

Once 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 Guidance

I’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:

1. Which device colleagues use

2. Which device is the cheapest

3. The device with the most impressive marketing

whichdynamometer.com is a completely free, unbiased online HHD comparison site - effectively a buyer’s guide and education hub for handheld dynamometry.

Note of Caution

I 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].

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