AI scribes have become remarkably good at solving that problem. They listen to our consultations, turn conversations into structured notes and draft letters before we’ve finished our coffee.

But after more than a decade treating patients and running clinics, I’ve come to think we’ve aimed AI at the easiest part of the problem. Whilst notes are frustrating, the bigger admin problem is everything required to deliver good care between appointments.

The invisible workload of good care

Think about what happens after a fairly normal MSK consultation. You might need to update the patient’s exercise program, film a new exercise, find the right video, and write down the sets, reps and loading parameters.

You might want to send the patient a summary of what you think is going on, remind them of their goals and explain what progress should look like over the next few weeks.

Perhaps there’s an insurer form that needs completing before another block of treatment is approved. Then there’s the patient you haven’t seen for three weeks, who you were supposed to book again in seven days.

Should you message them? Has reception already tried? What were their goals again? Did they stop coming because they were better? Because they weren’t improving? Because life got busy? Or because they forgot why the next appointment mattered?

None of these jobs are particularly difficult, but multiply them by twelve patients a day, five days a week, and suddenly ‘good patient care’ has generated a second job. That’s the opportunity in AI that interests me most. Not simply making the documentation of care faster, but making the delivery of good care easier.

We started with clinician-centred AI

The first wave of healthcare AI has understandably been clinician-centred. Documentation is repetitive, expensive and unpopular. So we built machines that could do more of it for us. Whilst that’s a win, faster notes don’t necessarily mean better care.

If an AI scribe saves me 30 minutes at the end of the day, I’ve improved my working life. If AI helps my patient understand their diagnosis, remember their exercises, see their progress and stay engaged with their rehabilitation, we may have also improved their life too.

All practitioners want to deliver optimal patient care, but we’re often limited in what’s achievable by the number of hours in the day. This is where AI for physiotherapy starts to become much more interesting.

Exercise adherence in MSK care is hardly a solved problem. Recent reviews continue to describe uptake and adherence to exercise-based rehabilitation as suboptimal [1]. We also know that adherence isn’t simply a matter of telling someone to ‘do their exercises’. Self-efficacy, social support, goal setting, instruction and demonstration are all relevant [2].

Digital interventions aren’t a magic wand either. A systematic review and meta-analysis found that digital rehabilitation improved therapeutic exercise adherence at intermediate follow-up, but not consistently at short- or long-term follow-up [3].

So the lesson clearly isn’t to throw more technology at patients, but rather to make the care we’re already trying to provide more individualised, consistent and easier to act on.

The gap between knowing and doing

Most clinicians already know what good care looks like. We know patients need clarity about their condition, we understand the importance of regular goal setting, and we know progress should be measured and visible.

We’re also clear on the benefits of inter-appointment check-ins and the importance of following up with patients who have dropped out of care prematurely.

But there is often a gap between knowledge and execution. A busy clinician can genuinely believe in all of those things and still finish a Tuesday afternoon with three exercise programs to update, two insurer forms to complete and a patient from last week they meant to follow up.

What does patient-centred AI actually look like?

Imagine finishing a consultation and, before your patient has walked out of the clinic, they receive a message with an up-to-date treatment plan.

Not a generic post-appointment email, but their plan in a living portal. It explains the working diagnosis in understandable language. Their goals and objective measures are there. Progress since their initial assessment is visible. Their exercise program reflects what you discussed five minutes earlier and their recommended appointment schedule is clear.

Then you see them again next week and rather than recreating the document, the new consultation updates it.

Their shoulder flexion has moved from 120 to 150 degrees? Progress measure automatically updates. They’re back to swimming twice a week? The goal updates.

You’ve progressed their external rotation exercise? The rehab program automatically progresses with their newly prescribed exercise.

The treatment plan becomes a living representation of their rehabilitation rather than a PDF that was accurate for approximately seven minutes after their initial assessment.

Another example is exercise prescription. Historically, creating a genuinely individualised program has been surprisingly fiddly. Search a library, find something close enough, add instructions, change dosage and maybe even film the patient on their phone if you can’t find what you’re looking for (with no record of the video for the practitioner).

Now imagine the exercise content being created from what the practitioner actually says during the appointment. A suitable video can be automatically matched. An AI-generated image can demonstrate an unusual exercise that doesn’t exist in the library. Or, better still, you can film the patient performing their own exercise correctly and add it to their program in real time.

The clinician still makes the clinical decisions, but AI removes the effort required to turn that decision into something useful and accessible for the patient.

What about when the patient disappears?

This might be the part I’m most interested in and excited by. We talk a lot about exercise adherence in physiotherapy, but we talk less about treatment-plan adherence.

Imagine a patient presents with a problem that we reasonably expect will require a period of rehabilitation. Together we establish some goals and start treatment.

Then, somewhere between ‘feeling a bit better’ and actually rebuilding the capacity required for their goal, they disappear. Historically, our systems haven’t been particularly sophisticated at handling this. Maybe reception runs a recall list, or the practitioner notices an empty space in the diary and remembers them. Maybe nobody does.

What if the software already understood the plan?

It knows the patient was recommended to return in seven days and it knows they haven’t booked. It knows their goal was to get back to running 10 kilometres, but only progressed to three kilometres at their last review.

That creates the possibility of a very different automated message to patients:

Not, “Hi John, you’re due for an appointment.“

But something closer to, “Hi John. At your last appointment you’d built your running back to 3km and we’re working towards your goal of 10km. Your next review was planned for this week so we can reassess your progress and adjust your loading. Tom has a free spot tomorrow at 3pm, would you like to book that?“

Add a one-click booking option based on their usual clinic, practitioner and appointment preferences, and suddenly following up patients doesn’t require the clinician to spend their lunch break trawling through a recall list.

And importantly, the purpose isn’t to squeeze another appointment out of someone who doesn’t need one. If the patient has reached their goal, brilliant. The purpose is to reduce the number who accidentally fall off a plan they haven’t finished.

Horizontal AI versus vertical AI

This is where I believe healthcare AI will increasingly diverge. A general medical scribe has an extraordinarily broad job, such as understanding conversations across different professions, specialties, conditions and workflows.

But an MSK clinician doesn’t just need software that understands general medicine. We need software that specifically understands MSK care, both in terms of content and practitioner workflow.

That’s the difference between horizontal and vertical AI. A horizontal AI system might understand that I said “three sets of eight split squats” and document it correctly. Whereas AI built for the vertical of physiotherapy would automatically convert that into rehab videos or images and deliver it to a patient’s phone and track daily progress.

It would understand that today’s objective measures may represent progress against measures taken four weeks ago, and track those improvements over time in a way that’s visible for both the practitioner and the patient.

And it understands that the patient’s goals, treatment plan, exercises, outcome measures, appointment recommendations and clinical record are a continuum or relevant context across appointments rather than six unrelated pieces of information.

This has been a major lesson for me while building Preve. Full disclosure: my interest in this isn’t entirely academic. I’m a physiotherapist and clinic owner, and these frustrations were a large part of why we built Preve in the first place.

From day one, it was about building a tool that was centred around better patient care, whilst also doing the heavy lifting for the practitioner.

What happens in the real world?

We’re now starting to see what happens when AI is applied to the patient journey rather than just the clinical record.

In an internal study, across hundreds of practitioners using Preve, we’ve seen uplifts of more than 95% in patient visitation rates due to those patients having an updated treatment plan.

That’s obviously not the same as evidence from a randomised controlled trial, and visitation shouldn’t be treated as a clinical outcome in itself, but it is exciting. Particularly because adherence to physiotherapy and exercise remains challenging, and interventions including goal setting, written instructions, feedback and communication have all been investigated as ways of improving engagement [2,4].

We’ve also seen clinics report around a 50% increase in monthly five-star Google reviews after implementing AI that focuses on a more patient-centric model of care. Again, Google reviews aren’t an outcome measure, but they are a useful window into something we probably don’t measure enough: the patient’s perception of the care surrounding the treatment.

Do they understand what’s happening? Can they see their progress? Do they know what they’re working towards? Do they feel looked after during the other 167 hours of the week when they’re not standing in our treatment room?

And then there’s the clinician. In our clinic data, practitioners using this broader workflow are saving around an additional hour per day of administration compared with practitioners already using an AI scribe for notes and letters. The additional saving comes from the other work: plans, exercises, forms, communication and follow-up. The stuff surrounding good care.

Perhaps we asked AI the wrong question

The conversation around AI in healthcare has understandably started with, ‘How much time can this save the clinician?’ It’s a good question, because clinician burnout and administrative burden matter. Nobody benefits when skilled healthcare professionals spend their evenings writing notes.

But perhaps there’s a better question: ‘What could I do for every patient if time was no longer the constraint?’ Could every patient leave with a clear plan? Could every exercise program actually reflect what happened in the room? Could progress always be visible? Could insurer paperwork be completed before it delays care?

Could every patient who unexpectedly drops off receive a personalised message reminding them what they’re working towards? Could we provide a level of communication and continuity that currently requires an impossibly organised clinician with unlimited time?

That’s where AI gets exciting for me. Not because I want less clinician involvement, but because I want the clinician’s limited time spent on the things that actually require a clinician. Things like listening, reasoning, reassuring, educating, motivating, connecting and using their physical skills.

The first generation of clinical AI gave many practitioners some hours of their evenings back, but the next generation has a bigger opportunity. Perhaps the best measure of AI in physiotherapy won’t be how many minutes it saves us after an appointment, but rather how much better we become at looking after the patient before the next one.

References

[1] Ingram R, et al. (2025) ‘Barriers and facilitators to exercise-based rehabilitation in people with musculoskeletal conditions: A systematic review’ - https://pubmed.ncbi.nlm.nih.gov/40088807/

[2] Willett M, Duda J, Gautrey C, Fenton S, Greig C, Rushton A. (2019) ‘Effectiveness of behavioural change techniques in physiotherapy interventions to promote physical activity adherence in patients with hip and knee osteoarthritis: a systematic review’ - https://pubmed.ncbi.nlm.nih.gov/29911311/

[3] Zhang ZY, Tian L, He K, Xu L, Wang XQ, Huang L, Yi J, Liu ZL. (2022) ‘Digital Rehabilitation Programs Improve Therapeutic Exercise Adherence for Patients With Musculoskeletal Conditions: A Systematic Review With Meta-Analysis’ - https://pubmed.ncbi.nlm.nih.gov/35960507/

[4] Peek K, Sanson-Fisher R, Mackenzie L, Carey M. (2016) ‘Interventions to aid patient adherence to physiotherapist prescribed self-management strategies: a systematic review’ - https://pubmed.ncbi.nlm.nih.gov/26821954/

In case you haven’t heard of Neko Health, let me enlighten you.

Neko Health is the brainchild of Spotify founder Daniel Ek and Swedish Engineer Hjalmar Nilsonne, whose stated goal is to move healthcare from the reactive (treating illness) to the proactive / preventative (early detection). Their website describes the Neko scan as ‘a completely new healthcare experience, engineered from the ground up. Data captured across your skin, heart, blood, and metabolic health. Then a clinician to help you understand what it all means – and what to do next. All in one hour.’

Reaction to Neko Health has - to put it mildly - been mixed. Some have been concerned about the increasing health anxiety of our metric-obsessed age. Some have been concerned by the creeping medicalisation and Americanisation of the UK health space leading to overtreatment (there’s a pill for that!). Others still have been concerned that anomalous findings will result in increased pressure on the NHS, as overworked GPs swamped with already ill patients struggle to meet the demands of the worried well. On the other side there have been many gushing editorials in glossy and business magazines, lauding the founders of Neko as visionaries and this type of screening as the healthcare of the future.

I was inclined to dislike it. I’m generally of the view that genuinely well individuals adopt healthy behaviours to be able to enjoy their lives to the full, not to improve markers that apparently dictate their biological age, whatever that is. I am also of the opinion that prevention of illness is best achieved by living as healthy a life as possible, and medical interventions in those without symptoms should only be undertaken if there is known high risk.

That said, when you meet the sniper alley of your 40s and 50s, screening regularly identifies issues before they become symptomatic and develop into serious, life limiting illness. I am regularly invited to participate in NHS screening programmes (now I’m in my mid 50s) because my risks of the most commonly occurring serious illnesses are much higher. On balance I am for screening, but only when there is a common increased risk.

My prediction was that certain aspects could be helpful but other markers may send people anxiously down a cascade of unnecessary interventions to satisfy arbitrary findings, with iatrogenic harms and no net benefit. I wondered whether the veneer of respectability of standard tests (bloods, ECG, mole mapping) would be outweighed by the AI interpretation of information gleaned by more innovative (AKA untested and unproven) sensors.

At least I would have a comparator. Whilst I was honest on my pre-scan questionnaire, Neko didn’t know I’d seen a cardiologist and had a battery of cardiovascular tests (due to high cholesterol and a strong family history of cardiovascular disease). Would their results be the same? I was interested to find out.

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Rewards for quality, consequences for a lack of. It’s not a big ask, is it?!

Yet to my eye we have neither and it risks stagnating the MSK industry. In any healthy environment the incentives are well balanced. An excess of rewards, especially for those undeserving when it comes to effort and ability, creates a cringeworthy, self-important and sycophantic atmosphere [1]. The technical literature in this direction names it ‘Distributive Injustice’. As a deeply untechnical person I’m going with ‘too many carrots’. Disproportionate consequences decrease healthy risk taking, innovation and creativity whilst inadvertently promoting deception at best and bullying at worst [2]. The modern lingo refers to ‘Psychological Safety’ and its absence. Again, I am reaching for the accessible term ‘too many sticks’.

The Missing Town Square

The reason I’ve immediately gone to describe an excess of both is because I think by temperament, we clinicians tend towards carrots and have a healthy concern for sticks. We witness the upside of positively praising a patient’s participation in their rehab and recognise the difficulty recovering a relationship when a patient feels dismissed or threatened. But we are in the behaviour change business. We need to balance incentives and recognise that good rapport gives you scope to discuss both the positive outcomes of treatment AND the negative consequences of functional disability. But we’re nice [3]. It’s a care thing. It’s a therapist thing. It’s the selection pressures that make certain people work in pain and injury rather than civil engineering and finance. But I think that this disposition leaves us ill-equipped when it comes to the necessary work we need to do to improve industry standards, practices and policies. It feels uncomfortable for some to even witness someone asking “Why do you do it like that?” or “Might there be a better way of doing this?”; especially if said challenge is across a perceived authority line! This discomfort made the professional debates on podcasts such as Physio Matters, and public social media such as Twitter, a surprising and rare phenomenon. We listened and watched because some of the friction sparked positive engines of change. We listened and watched because some of the friction sparked destructive wildfires of shame. Between 2013 and 2023, Twitter was the MSK town square and while Facebook, Instagram and LinkedIn had their artisanal monthly craft markets, Twitter was always open and had stalls for all arguments. A crucial difference between Twitter and the other platforms was that you couldn’t delete other people’s replies when they were inconvenient. Now I don’t want to romanticise this time and I’ll absolutely be coming back to the ample issues of it, but when I look out over the current MSK landscape, I am very concerned that we are missing a town square. Very rarely is the answer to an imperfect forum to instead not have any at all. We’ve regressed into siloed, closed shops where special interests, style specific and professionally exclusive clinical discussions are left under-scrutinised and under-exposed. We lack sticks, have forgotten how to make them and I fear that our next generation have developed the stick allergy of the 1990s and 2000s.

Bring back the square, not the stocks

Public MSK debate back then was a bit aggro. The injustices in how patients were being mismanaged and how authorities and institutions were gatekeeping knowledge were so obvious and blatant that tensions ran high much of the time. It disrupted stale and lazy thinking but also disrupted a polite agreeableness that was seen as the ‘professionalism’ of the time. To my taste, it was often overstated how hostile the atmosphere was and the vast majority of the time, people shared opinions and literature in defence of their styles of practice. But any opposition to the norms of the time felt uncomfortable in the same way that democracy is uncomfortable. That said, the fact that Twitter and iTunes were public, unconstrained platforms, where snippets of text and long form podcasts were on show for our patients as well as our colleagues, should have been accounted for more carefully. We were discussing professional matters in a public forum and whilst I’m relieved that we don’t have much evidence of such debates escaping very far into the public consciousness, the inherent vulnerability to such an open platform is clear to me now. There were moments where debates became fights and the town square was used to host floggings. Those more averse to confrontation lurked rather than engaged for fear of being put into the digital stocks.

Sounds icky… Do we have to?

So to my taste we need some delicious carrots to reward our finest clinicians, projects and services whilst wielding some sticks of consequence that are appropriate and proportional when clinicians, projects and services fall below par. Easier said than done of course but I’m certainly more comfortable with a world in which we’re trying to refine our incentive structures than one in which we give up on them. I’m well aware that some of you will bristle at the thought of ANY metaphorical stick-wielding in our industry, since it is famous for its lack of credible, authoritative organisations. But my plea is not to let the fear of imprecision cloud the fact that you probably agree with the principle.

Should quality care be rewarded, celebrated, championed and elevated in order to further the chance of it being replicated across sectors, postcodes and borders?

Should poor quality care be scrutinised, questioned, challenged and refined in order to lessen the chance of it being replicated across sectors, postcodes and borders?

I’m perhaps now being too generous handing you the strongest arguments against me but for thoroughness: OF COURSE the key issue is WHO gets to define what is considered ‘quality’ to be lauded and ‘poor quality’ to be poked at? An absolutely fair challenge that I admit has a deeply unsatisfying answer. We do. The community of practice made up of those of us who work in the pain and injury field we broadly call MSK. It would be lovely if we had a central authority and a mechanism of democratic accountability but believe me, that dream is for the birds and I can tell you no one is working on that because I’ve been asking [4]. So instead we must create fresh channels, bravely air fresh arguments, persuade fresh audiences and farm fresh carrots… aaand there’s the upper limit to my metaphor for this piece… I knew it was coming.

The New Solutions

Even I’m not arrogant enough to pitch you a comprehensive solution. I grew out of that in 2020. A rare side effect of Covid [4]. But I do have some suggestions and, as remains my instinct, I’ve built some things that I think will help. Much like in clinical practice, if my diagnosis is off, then my treatments will fail. But if I’m even in the right ballpark then maybe we can come together and positively redefine the MSK incentive structures.

The MSK Awards is the ultimate celebration of excellence in our industry with the inaugural event on the 27th November 2026 at the incredible Sky Gallery in Birmingham [5]. Henceforth to be known as MSK Carrot Fest after the inevitable viral success of this article’s metaphor.

Then on the 23rd and 24th April 2027, Therapy Live is back as a hybrid event. An event where we will grapple with the key MSK issues of our time and define the direction of travel for the industry together. With Therapy Live, we are deliberately creating a forum in which contested ideas are exposed to scrutiny rather than merely presented from a stage. Ideas supported by evidence and open to challenge, rather than thinly developed abstracts from Masters’ theses with an N of 8. More on this next month!

Most importantly for now, nominate the colleagues, projects and services who deserve recognition, knowing that it’s those humble giants who are so unlikely to nominate themselves or their own work! [6] Then get your tickets whilst you still can for the first annual MSK Awards Ceremony, the ultimate networking opportunity and perhaps the coolest place ever to have your work Christmas do. Huge thanks to Physio Matters’ co-hosts Physio First for being brave and recognising that organisations need to step up and do more for the industry at this time of flux. What an incredible opportunity we have to centre MSK rehabilitation and its multiple overlapping fields in UK healthcare.

References

[1] Colquitt, JA et al (2001) Justice at the millennium: a meta-analytic review of 25 years of organisational justice research. J Appl Psychol.

[2] Mehraein, V et al (2023) The dark side of leadership: a systematic review and meta-analysis of destructive leadership research. Int J Manag Rev.

[3] Horner, J (2026) Physios are nice. And it’s killing our profession. MSKMag.

[4] Thow, F (2024) The rise and fall of MSKReform. MSKMag.

[5] The MSK Awards website (2026) MSKAwards.com

[6] TMA Nomination Process (2026) https://zealous.co/mskawards/creative-opportunities/

He presented for physiotherapy assessment. A story like this in a growing child should set alarm bells ringing. A normal X-ray does not mean ‘nothing to worry about’. Unless you know your paediatric anatomy and pathology, you may not appreciate that the tissue that fails under load depends entirely on skeletal maturity.

Why adult reasoning isn’t enough here

Adult MSK expertise remains highly relevant to paediatric practice; clinical reasoning, exercise prescription, and progressive loading principles still apply. But applying adult diagnoses and management without considering paediatric skeletal anatomy, growth, and pathology can lead to incorrect diagnosis and inappropriate loading. Same location, same mechanism, same sporting load - but a growing skeleton can fail completely differently to a mature one.

The growing knee isn’t just a scaled-down adult knee

It’s tempting to think of paediatric anatomy as ‘adult anatomy, scaled down’. It isn’t. A growing knee has structural features not present in the adult, and each changes how load, injury, and imaging must be interpreted. Every bone has its own ossification timeline, opening a ‘window’ for paediatric-specific pathologies that varies by site, sex, and individual.

Depending on his maturation status, our athlete likely has a partially cartilaginous, still-ossifying patella with an active distal patella apophysis. In an adult, the patellar tendon attaches directly to cortical bone; in a child, it attaches to the apophysis which is structurally weaker than mature bone, and most vulnerable during rapid growth [1]. The patella and its distal apophysis don’t fully fuse until late adolescence. Once the physis closes, injury patterns revert to adult ones. Knowing where a child sits on this timeline is central to getting the diagnosis right.

Are all 12-year-olds the same?

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In 2014, Dr Ian Horsley joined Jack Chew on the Physio Matters Podcast to discuss the ‘rugby shoulder’, challenging prevailing orthopaedic thinking and advocating for a more functional, systems-based approach to shoulder rehabilitation. His perspectives, shaped by elite sport and emerging research, questioned diagnostic certainty, emphasised movement quality, and highlighted the role of proprioception, load, and the wider kinetic chain.

Over a decade later, the shoulder literature has evolved significantly. Concepts such as regional interdependence, load management, and uncertainty in structural diagnosis are now more prominent within contemporary musculoskeletal and sports rehabilitation literature, although debate remains around their interpretation and application. In this month’s Core Memories feature, we revisit Ian’s key themes and explore how they align with current evidence and contemporary rehabilitation frameworks in 2026 [10,11,12].

Diagnosis, Uncertainty, and the Limits of Orthopaedic Testing

2014

Ian was openly critical of orthopaedic shoulder testing, noting the sheer number of available tests (over 100) and their limited diagnostic utility. He argued that:

• Test accuracy is heavily clinician-dependent

• Diagnostic accuracy is generally low to moderate and highly variable across tests and pathologies

• Most athletes present with multiple coexisting pathologies, reducing test validity

• Clinicians should move away from rigid diagnostic labels toward clinical reasoning and response to treatment

2026

This position is broadly supported - and expanded - by contemporary research.

Systematic reviews continue to demonstrate limited standalone diagnostic accuracy for most orthopaedic shoulder tests, particularly for labral pathology and instability [1,2]. Clusters of tests may improve diagnostic confidence, but overall certainty remains limited.

Importantly, inter-rater reliability remains inconsistent, reinforcing Ian’s point that test performance is clinician-dependent [1].

More broadly, some contemporary shoulder rehabilitation frameworks emphasise clinical reasoning, symptom behaviour, irritability, and functional limitation alongside structural considerations, particularly in non-traumatic shoulder pain [10,11,12]. Contemporary clinical frameworks increasingly prioritise:

• Symptom behaviour

• Load tolerance

• Movement quality

• Functional limitation

rather than strict structural identification.

In elite sport, however, tension remains. As Ian described, coaches and stakeholders still seek clear timelines and labels, especially in high-performance environments. While shared decision-making models have improved communication, the demand for certainty has not disappeared.

Current nuance

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Tendons are frequently discussed as though loading is either therapeutic or harmful. That distinction is too simple. Mechanical loading is essential for tendon homeostasis, adaptation and performance, yet the same load may be tolerated by one athlete and provocative for another. The relevant question is therefore not whether a tendon should be loaded, but whether the magnitude, rate, volume and frequency of loading are appropriate for its present capacity and are followed by sufficient recovery.

This distinction is particularly important for the Achilles tendon. During locomotion, the Achilles transmits force from the gastrocnemius–soleus complex and stores and returns elastic energy. Running, jumping, accelerating and changing direction expose it to substantial forces delivered over short time periods.[1,2] Long-term preparation must develop the capacity to tolerate these demands. Acute preparation immediately before activity has a different purpose: it progressively exposes the muscle–tendon unit to force, rehearses relevant movement strategies and provides a practical check of readiness. It cannot produce structural adaptation within minutes, nor should it be presented as an isolated method of preventing injury.

Tendon structure, function and adaptation

Tendon is a hierarchical, collagen-rich tissue rather than an inert cable. Collagen molecules form fibrils, fibres and fascicles, while the interfascicular matrix permits relative movement between these structures. Tenocytes and tendon-derived cells respond to mechanical deformation through mechanotransduction: mechanical signals are converted into cellular responses influencing collagen synthesis, extracellular-matrix turnover and tendon mechanical properties.[3,4] Adaptation is therefore load-dependent, but it is not determined by external weight alone. Joint position, muscle recruitment, moment arm, contraction type, movement velocity and individual anatomy all influence the force and strain experienced by the tendon.

The Achilles is an energy-storing tendon. Its length and compliance allow energy to be stored during loading and returned during propulsion, enabling the calf complex’s muscle fibres to operate over smaller length changes and at slower shortening velocities.[1] This contributes to economic locomotion and repeated force production. Consequently, Achilles capacity cannot be described by calf strength alone. The athlete not only requires sufficient plantar flexion force but also, sufficient rate of force development, tendon stiffness, elastic energy storage and tolerance of repeated contacts.

The foot beneath the Achilles is part of the same energy-storing system and deserves attention in its own right. The foot core model reframes the small intrinsic muscles of the plantar arch as active local stabilisers, comparable to the deep stabilisers of the trunk, yet they are still frequently neglected in lower limb rehabilitation.[20] These muscles do more than hold up a static arch. During locomotion the foot behaves as a spring that stores and returns elastic energy across the stretch-shortening cycle, and the intrinsic muscles actively assist this process. Contraction of muscles such as flexor digitorum brevis facilitates tendon stretch and recoil within the arch, contributing to energy storage and return rather than merely supporting a fixed structure.[21]

Their more decisive contribution appears to be in stiffening the forefoot into an effective lever for propulsion. When the intrinsic muscles are experimentally inhibited via a tibial nerve block, the positive, propulsive work generated falls substantially at the foot and, importantly, also at the ankle, even though passive structures continue to support the arch itself.[22] The clinical inference is reasonable, although not yet proven. A foot that cannot adequately stiffen and return energy offers a less effective lever and spring, so a greater share of the propulsive work is likely transferred proximally to the triceps surae and the Achilles, which must then generate more force and elastic work at push-off. To my knowledge, no study has yet shown that intrinsic foot weakness causes Achilles tendinopathy, and the chain should be presented as mechanistically coherent rather than directly established. Even so, it provides a defensible rationale for treating the foot as part of the kinetic picture in the reactive, spring-reliant athlete, and for introducing low-level stretch-shortening tasks, including dedicated foot and ankle work, within both preparation and rehabilitation.

Tendons adapt to resistance exercise, with systematic reviews demonstrating increases in stiffness, elastic modulus and, in some programmes, cross-sectional area.[3,5] Higher loading intensities generally appear to produce greater adaptation than low-intensity loading in healthy tendons. However, findings from healthy participants cannot be transferred uncritically to symptomatic tendons. Frequently cited strain ranges, such as 4.5–6.5%, are not universal clinical thresholds, and a percentage of maximal voluntary contraction is not a reliable substitute for measuring local tendon strain. Individual tendon geometry, neuromuscular strategy and pain can all alter the internal dose.[4]

Adaptation must also be considered across the entire muscle–tendon unit. Strength and hypertrophy can develop more rapidly than tendon material properties, particularly following a rapid increase in resistance training. The athlete may consequently become capable of producing forces that the tendon has not yet been conditioned to transmit repeatedly. This does not mean that muscular strength is undesirable; it means that progression should allow the tendon sufficient time and should eventually include the rates and movement patterns through which that force will be expressed. Conversely, a tendon may possess adequate structural stiffness while the plantarflexors remain weak or poorly coordinated. Assessment should therefore combine symptoms with measures of force, endurance, heel-raise quality and, where appropriate, hopping or running performance rather than relying on a single structural or strength measure.

Tendinopathy: capacity, symptoms and pathology

Tendinopathy is characterised clinically by localised, load-related pain and impaired function. Structural abnormalities may be present on ultrasound or magnetic resonance imaging, but imaging and symptoms are incompletely coupled. Abnormal morphology can exist without pain, while substantial symptoms may occur without a proportionate change on imaging.[6] Pain should therefore not be treated as a direct readout of tissue damage.

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Happy New Football Season to all who celebrate!

And godspeed to all my fellow Newcastle United fans. For those of you fortunate enough to not have endured the comings and goings and goings and goings of the Newcastle squad this summer, let me give you a brief overview.

Following a few seasons of success featuring our first domestic trophy since 1955 and two qualifications to the Champions’ League, we had a pretty terrible season ending in May 2026. I’m not even going to relive it; just know that sleep, points and a certain amount of pride were lost.

With the appointment of a new manager, a handful of new players and the designation of a new captain, this has been a summer described by many as one of transition. Let me report to you live from deep inside the cocoon on the eve of the Premier League season that it feels more like a summer of metamorphosis. We just don’t know if what will emerge is a stunning butterfly or a terrifying, lopsided moth, destined to fly in chaotic circles until it dies.

My fear as a Newcastle fan of 25 years is not that we will be bad this season. Even last season pales into insignificance when compared to the time I moved back to the city from university only to find us relegated, or the time I got up in the middle of the night in New Zealand to watch games a few years later, only to watch us be relegated again. My dad will tell you these in turn are small fry compared to the torrid pre-Keegan years.

Time, anxiety disorders and Newcastle United have each taught me a great deal about accepting the things I cannot control, and the performance of eleven men and the decisions made about those eleven men by other men in a boardroom fall firmly in that camp. No, what worries me is that my fellow Toon fans and I, fuelled by bruised egos, clickbait, and the usual culprits, sorry, pundits, judge this season based on past successes. What might be even more important than points this season, is resetting our expectations for a new team, not the old one, and to recalibrate our brains to hold not just what’s happening on the pitch in front of us, but the bigger picture too.

Our authors are showing us the bigger picture and reaching for new scales in this month’s MSKMag.

First up, our latest staff writer Angie Jackson cautions against using the embedded reasoning we use for adult patients when it comes to paediatric cases in her article ‘Children Are Not Mini Adults: Rethinking Sudden Anterior Knee Pain in the Skeletally Immature Athlete’.

Caelum Trott of Preve shares his experience creating better AI solutions in healthcare, widening the net from just note-writing to ways in which it can improve both the clinician and patient experience in ‘AI Solved Our Notes - But Can it Improve Care?’

Is your slow, heavy loading getting your tendons to nowhere but a plateau? Daniel Morgan will stretch your thinking more effectively than collagen in ‘Tendons: What’s Load Got to Do With It?’

Sue Julians has been in the field on investigative journalism duty, putting her biases and cardiovascular system to the test as she checks out a private preventative medicine screening clinic in ‘MSKMag goes to... Neko Health’.

And Jack Chew wants to readdress how we reward good practice and how we manage consequences for bad in ‘MSK’s Lost Carrots & Sticks’, which features less donkeys than you are picturing right now.

We’ve also stepped back in time in this month’s Core Memories feature to see how well Ian Horsley’s 2014 podcast episode on the Rugby Shoulder holds up against contemporary evidence.

So as we - clinicians and football fans alike - head into a new season of the unknown, September’s MSKMag encourages us to treat what’s in front of us, rather than measuring it against past iterations of the same line up.

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A rugby player lands heavily on the point of his shoulder. He’s ‘done’ his AC joint. Strap it up. Add some padding. Get him through the season. If the x-ray says it is a Grade V, perhaps he gets referred to a surgeon. Everyone else carries on, often wearing their new bump like a badge of honour around the changing room. After all, it’s only a little joint at the top of the shoulder, right? Sound familiar?

I’ve been there and done that. It was last century, but I’m not sure our thinking has evolved as much as it should have. Did it work? Sometimes. It often got the player back onto the field. But what happened to those people several years later?

I now work as a Specialist Shoulder Physiotherapist, and chronic AC joint instability is one of the more common conditions I see. These injuries may continue to grumble or become more troublesome years later, affecting heavy work, gym training, sport and sustained use of the arm. Many have already completed several rounds of typical shoulder rehabilitation (rotator cuff exercises, low rows, push-up plus etc) without much success. Often, the problem is not the AC joint itself, but the ongoing secondary scapular dysfunction caused by the original injury.

The unstable scapula: a clinical re-frame

Part of the problem is that we continue to view these injuries as a localised joint disruption. We call them AC joint injuries. We grade them according to an x-ray of the AC joint. We then tend to direct our treatment towards the painful area at the top of the shoulder. Guilty (there may even have been an ultrasound unit involved many years ago).

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“Children aren’t mini adults” is a phrase we hear a lot to highlight the differences in Paediatric physiotherapy to remind clinicians that children and young people have different needs and require different care. Yet Paediatric musculoskeletal (MSK) services around the country continue to be left in the shadows of adult MSK. Despite 1 in 3 adolescents experiencing MSK pain [2] and 1 in 10 seeking healthcare annually for MSK symptoms [6], Paediatric physiotherapy services remain significantly under-resourced. Unlike in adult MSK services, those who work in paediatric clinics are often expected to see patients with not only musculoskeletal complaints but also stay skilled in neurological and developmental assessments. Most Paediatric physiotherapy teams do not have their own department but share spaces with adult teams which can be unsuitable for a younger population. Teams can also sit under many care groups in NHS services such as family health or adult physiotherapy, showing inconsistency between services.

I am a Paediatric physiotherapist in the North East of England and remember starting my exciting new career path with limited knowledge and awareness of Paediatric MSK. With no teaching provided at university and just a 5-week placement to go on, I took the plunge into Paeds. What I didn’t expect to find was a love and passion for MSK and Orthopaedic Paediatric care. And what I really didn’t expect was being one of only three clinicians who saw MSK patients in a team that covered a large geographical area. Other staff members could cover here and there as required but not by choice. They felt they lacked confidence in MSK caseloads and their area of interest lay more with the neurodisability caseload. As time has passed, and the more opportunities that have come up to network with neighbouring teams, I have found this is a very common theme and is impacting children’s services around the country.

Many Paediatric physiotherapists are comfortable treating neurodisability and developmental caseloads but can lack the confidence to see MSK caseloads. Sometimes this may be due to personal interest but otherwise can be down to lack of training and opportunities to work with these patients. Within Paediatric physiotherapy teams you may have a staff member working with a neurodevelopmental caseload one day and an MSK caseload the next. Would we see this happening in adult physio? Would you ask your Stroke Rehab colleague to cover your MSK clinic if you were short staffed?

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Oh the arrogance in my assumption that I have any wisdom to impart about your life, and the irony that much of my advice will implore you to resist that clinician’s urge to fix and advise! Nevertheless, I do hope you’ll find this column informative, thought-provoking, occasionally amusing and that you’ll find some helpful tips amongst my best guesses and opinions.

Dear Auntie Version,

It’s bloody hot!! Where I work, in a clinic in southern England, it has been sweltering this past week. Other than the odd minute to stand in front of a fan between patients, there is not much relief. My employer seems to be of the opinion that as there is no legal temperature limit when it comes to safe working, that we need to just get on with it. Is there anything I can do??

Sweaty Betty

Hi Sweaty Betty,

Whilst I’m no expert, a quick search on gov.uk confirms there is no guidance for a maximum temperature limit, just the following (not very helpful) statement:

'During working hours, the temperature in all indoor workplaces must be reasonable.’

It’s fair to say that last week’s heatwave was especially challenging with the added effect of extreme humidity – to me it felt like a reality check.

You say your employer seems to be of the opinion that, as there is no legal temperature limit, ‘we need to just get on with it’. Giving them the benefit of the doubt, I think a lot of businesses felt caught out last week. Many came to the realisation that this is no longer a once-in-a-summer event to just get through, but something we are going to have to find longer term solutions for. Without knowing your boss (in which case feel free to disregard), is it possible they are not yet sure of the correct course of action and it’s making them a bit defensive?

I wonder if it would be helpful for you and your colleagues to sit down and chat through with them what constitutes a reasonable level of comfort and what the options might be to achieve that. We’re all in new territory here - I’m not sure anyone has the answers yet. Surely the more ideas that can be brought into the mix, the better.

Auntie Version

Dear Auntie Version,

I’m a sole practitioner in my own physio clinic and getting very tired of working for underpaying private insurance providers. However, I’m finding it hard to bite the bullet and quit them as surely a filled slot is better than nothing right??

To Leave or Not to Leave?

Dear TLONTL,

Sounds like the real question isn’t the one in your sign off, but whether or not a filled slot is better than nothing. There are different factors at play here. From a purely financial perspective, it’s true that a smaller amount of money coming in from an insurance company is more than no money. That presumes however that you’re not currently at capacity and that if you didn’t take that insurance patient, you’d be sitting twiddling your thumbs.

You could argue that the insurance patient is blocking a space that could be taken by a higher paying independent client. Could you use the marketing for more of your ideal clients? Or developing a new service? Or maybe an exciting new side hustle?

It also depends on how you feel about working for a lower fee than your advertised rates. It might not bother you at all, money is money after all. But it might feel like it’s trampling on a boundary around what constitutes fair pay for your work. It might feel like you’re working for an organisation who doesn’t value your skills or profession. There are no right answers to these questions, but they will probably inform your decision.

Auntie Version

Dear Auntie Version,

I started up a World Cup sweepstake at the start of the tournament for my team where everyone predicts results and you get points for predicting the right outcome and more points for guessing the exact score. Top 3 win a cash prize.

The only problem is, I’m faring miserably and my reactions to my colleagues’ success suggest I may have become over invested in the competition.

Said colleagues include one who knows nothing about football and just inserted a random allocation of 0s and 1s as scorelines, one who stopped participating at the end of the group stage, and, most annoyingly, Jack March.

How can I claw back some pride??

Jack Chew

Anon

Hello Anon.

Firstly, commiserations on your miserable performance.

You’re clearly a dedicated fan and I can hear how annoying it is that your colleagues seem to be doing so much better, despite being completely uninformed about the sport you hold dear.

Or are they? (uninformed)

Perhaps this is a clear sign of the random nature of human beings playing sport, with all their nerves, their overconfidence, unfamiliar environments and climates, not to mention bodies trying to perform within ridiculously tiny tolerances.

I don’t think you’re over-invested. I just think you’re a fairly typical physio – whilst not wanting to generalise, we’re a competitive bunch, aren’t we? (ask any member of our admin team who’s attended a clinic quiz night, or anything involving sport!)

Enjoy the game, enjoy some pantomime disdain for your colleague’s undeserved success – and then maybe you can be happy for them.

I am reminded of something a friend once said “If you’re not feeling like you can be overjoyed for your friend who is enjoying a wonderful sunny two-week holiday, then maybe stay off Facebook today!”

Auntie Version

Observing clinicians across the landscape of musculoskeletal care, I see the relentless effort poured into every consultation. Everyone is doing their best in the healthcare system, be that public or private, but as we know, the workload and complexity have increased. The total number of people living with an MSK disorder globally sits at approximately 1.68 billion representing a 95% increase in total cases since 1990 [1] and are on a trajectory to expand by more than half by 2050 [2]. While physiotherapists have significantly increased their scope of practice over the last 40 years, in particular into areas of practice that were historically occupied by medicine, how are we managing this continuing and increasingly challenging future? Recent research suggests that physiotherapists in the UK are struggling with burnout [3–6], work related stress [7] impacting on wellbeing resulting in moral distress and injury [8,9]. It appears that the profession is stretched holding the professional duties, roles, responsibilities and obligations in one hand and trying to adapt to growing and multiple patient, societal and system related influences in the other. This can make clinicians feel trapped, stagnant, and stuck in a healthcare system that itself is struggling to adapt.

In a way, we feel like we are on a treadmill, walking, running, even sprinting, but never getting anywhere.

Dave Nicholls captured our current predicament beautifully in his 2024 IFOMPT presentation in Basel, titled ‘The post-professional futures for the physical therapies’ [10]. He articulated the profound global and specific challenges facing our profession, pointing to three forces that are actively accelerating them: late-stage capitalism, the unbundling of expertise, and digital disruption. Dave asked penetrating questions about what comes next, concluding that we must uncover what truly lies beneath the surface of physical therapy. Only by doing so can we open up opportunities to adapt to this rapidly unravelling landscape.

Before we attempt to answer this question let’s briefly take a history of the present of MSK physiotherapy.

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She was 25 and needed a hip replacement — how can we stop this happening?

Not the start to the week that I wanted.

One of my patients on Monday morning was just 25 years old. Chronic hip pain for over four years. Seen by multiple clinicians. Not picked up.

Hip dysplasia. Missed. Now progressed to severe osteoarthritis.

She’s missed the window for periacetabular osteotomy (PAO) surgery. Now she’s waiting for a hip replacement.

Twenty-five.

This case isn’t unique. And that’s precisely the problem. Kennedy et al. [1] found that the mean time from a patient presenting to their GP to finally being seen at a specialist young adult hip clinic was over 40 months. Those with delayed referrals had worse functional scores, higher radiological osteoarthritis grades, and were significantly more likely to require total hip arthroplasty rather than the joint-preserving periacetabular osteotomy that could have changed the trajectory of their condition entirely.

Gambling and Long [2] explored the psychosocial impact of this diagnostic delay in a study of 97 young adults with hip dysplasia. Seventy-five of them experienced a delayed diagnosis, with an average delay of eight years. Eight years of being told it’s muscular, it’s postural, it’ll settle with exercises. These patients became progressively more debilitated, experienced chronic pain, and reported a profound impact on their quality of life and psychological wellbeing.

As frontline MSK clinicians, we are often the first point of contact for these patients. We have the opportunity to change this. But only if we know what we’re looking for.

Here are five clinical pointers that should raise your index of suspicion for hip dysplasia, and the reasoning behind each one.

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A community pilot reduced musculoskeletal waiting lists by 20%, and its reward was a national budget smaller than the pilot itself. The announcement, stripped of its press-release gloss, identifies an initiative that reduced community musculoskeletal waiting lists by a fifth that is now going national. The reward for that success is a grand total of £3.225m, which I had to read twice as I was expecting more zeros [1]. The pilot that proved the model in the first place cost £3.5m [2], so the reward it has earned, namely the budget to do exactly the same across every health system in England, is somehow smaller than the pilot that produced it.

A bit of backdrop before we get to the outrage - because the scale of it really does matter. Ill health now costs the UK economy somewhere in the region of £212bn a year, a figure published in last autumn’s Keep Britain Working Review and worth roughly seven per cent of GDP [3], and my dear old friend MSK sits second only to mental health among the drivers of that bill. MSKMag readers will know that musculoskeletal conditions affect nearly 18 million people in England [4] and account for somewhere between a fifth and a third of GP appointments, depending on whose figures you happen to trust [5]. They also make up the third largest area of NHS spend at around £5bn a year [6], so when you set the national rollout against that £212bn you land at roughly 0.0015 per cent of the problem, which is a rounding error for the Treasury.

Let’s be clear, none of this is a criticism of the work itself, which is genuinely very good. GIRFT’s MSK Community Delivery Programme cut eighteen-week community waits by twenty per cent across seventeen integrated care boards between December 2024 and March 2025 [7]. It did so with deeply unglamorous ingredients, namely community clinics, local clinical leadership and one-stop appointment days that bundle assessment, treatment, mental health support and physical activity into a single visit rather than scattering them across four separate letters and four separate days off. There is no miracle buried in any of this, just a sensible, joined up pathway run by the right people, close to where patients actually live.

I have a bit of skin in this game because I spent years involved in one-stop initiatives in orthopaedics and rheumatology, the very kind that GIRFT now references. Their simplicity was a key ingredient in why they worked, with patients seen, assessed, imaged and started on a plan inside a day instead of bouncing around the system for the better part of a year. The point worth holding onto is that the model is genuinely repeatable and translatable, which is to say it is not a clever local fluke that happened to work because of one brilliant clinical lead, it is a method and methods can be copied and scaled.

Which is exactly where it grates, because the seventeen-area pilot cost £3.5m and a second cohort of six more areas took another £2.2m [1]. In effect, the model has now been proved twice, across twenty-three systems and rewarded with a national budget of £3.225m to cover the entire country. England has forty-two Integrated Care Boards (ICBs) where the pilot areas received up to £300,000 each. The national rollout funding works out closer to £77,000 per area, which is roughly a third of what the trailblazers got to do precisely the same job [1]. The unspoken brief reads something like, “erm guys, can you do the same again, at scale, for less money than you spent the first time?” Anyone who has ever run a service will recognise both the request and the quiet despair this ignorance tends to produce.

The deeper problem sits underneath the budget line; in the workforce, and I talk about this a lot on my various channels because the gap is real and it is widening. Becoming a physiotherapist today means obtaining near-perfect grades, no meaningful tuition concession of the sort we used to offer, a brutal job market the moment you qualify and a salary that flattens inside a decade. Being good is no longer enough and there is constant pressure to specialise, or to extend scope, simply to stay relevant and employable. We have quietly turned (in my opinion) the single most cost-effective profession in healthcare into one of the least attractive to enter and then we act faintly surprised when the workforce pipeline starts to thin.

The opportunity here is enormous and it is worth being specific about why. The twenty per cent reduction was on the community list - the smaller and earlier queue, which is precisely what makes it exciting rather than marginal. Treat and mobilise people earlier in the community and you take pressure off the trauma and orthopaedics list further downstream, which remains the single largest elective queue in the country [8]. Keeping patients moving, at work, and off surgical waiting lists will reduce expensive problems in years to come. And those who do still need surgery will arrive in better physical and mental shape, which is a precursor for faster recovery, less time spent in hospital, and less cost to the system on the way through.

The model also does something rather neat which deserves more credit. By pulling movement and mental health into the same visit, it chips away at the two biggest contributors to that £212bn bill at the same time and movement (psst, it is rather good for the brain as well as the body). The link has been known for years but we simply do not commission or broadcast it as though we believe it.

If the system were serious - and by system I mean something rather more durable than a revolving door of health secretaries - it would do four fairly obvious things:

1. It would fund the workforce in the tens of millions rather than the low single figures

2. It would treat compliant hybrid digital MSK pathways as a genuine clinical priority, where the whole population can access at the front door.

3. It would build in-house rather than reflexively buying off-the-shelf products to fill the gap. This is not complex tech and return on investment multiples when there are no licence fees going to external developers.

4. It would actually scrutinise what it has already bought, because a surprising amount of tech has never been shown, independently, to do very much at all. Don’t get me started on a medical device’s defined intended use versus how it is being deployed in the system.

So here is where I keep landing as this issue travels a long way beyond MSK. We consistently mistake cost and complexity for value. The expensive, complicated, heavily branded intervention feels serious, so it gets the money and the contract. Meanwhile the cheap, simple, effective solutions are overlooked as if it cannot possibly be the answer. Pilots happen, credit ensues, yet the budget to achieve impact at scale never materialises. For me simple, good physiotherapy is affordable, effective and scalable. Its only real crime is that it is not shiny.

So I will leave you with the same question I opened with, because I’m yet to see a satisfying answer - if a pilot scheme can knock a fifth off the waiting list on a shoestring and proven its effectiveness across twenty-three areas, why on earth are we not throwing cash at it?

References

1. GIRFT (2026) National rollout of GIRFT’s musculoskeletal (MSK) Community Delivery Programme, thanks to £3.2m government funding. gettingitrightfirsttime.co.uk

2. GIRFT (2025) GIRFT starts work on £3.5m government programme to reduce waiting times for elective community MSK services. gettingitrightfirsttime.co.uk

3. Keep Britain Working Review (2025) summary of the £212bn annual cost of ill-health economic inactivity, approximately 7% of GDP. economicsbydesign.com

4. GOV.UK (2026) MSK patients to get faster care and help returning to work (MSK affects nearly 18 million people in England). gov.uk

5. NHS England Musculoskeletal health (over 20 million people in the UK; up to 30% of GP consultations; over 30 million working days lost annually). england.nhs.uk

6. Hansard, UK Parliament (2024), citing the Office for Health Improvement and Disparities: MSK conditions are the third largest area of NHS spend at around £5bn a year. hansard.parliament.uk

7. GIRFT (2026) Evaluation shows MSK waiting lists reduced by 20% during GIRFT pilot. gettingitrightfirsttime.co.uk

8. The King’s Fund (2025) Waiting Times for Elective (Non-Urgent) Treatment: Referral to Treatment (RTT) (trauma and orthopaedics has the largest specialty waiting list). kingsfund.org.uk

When was the last time you ate something without some input from a medical device? For me it was 2010. I was diagnosed with Type 1 diabetes aged 22 whilst seeing the GP for a UTI - which is quite undramatic as Type 1 diagnoses go. Since then, every meal starts with either a blood test or a look at the app screen of my continuous glucose monitor (CGM) and an injection of insulin. It is very easy to get this dose wrong given that some of the factors that can affect your blood glucose other than what you’ve just eaten include: stress, the temperature, illness, alcohol, certain medications, the stage of my menstrual cycle, and exercise. This doesn’t even come close to being an exhaustive list.

And so that is why one day, over a year ago, I inputted the word ‘FURY’ to my CGM after it alarmed on and off for a few hours whilst I tried to work, and a few weeks after that my consultant said “regular states of fury do suggest this might be impacting your mental health”, and a few months after that I ended up being approved for an insulin pump, for which I attended an education evening this week.

There are two means of delivering insulin to a Type 1 diabetic: multiple daily injections via a pen, or by an electrical device that attaches either directly to your skin or via a tube and cannula. The pump more accurately mimics the pancreas by drip feeding the dose of insulin over a period of hours. Cleverly, pumps now also communicate with CGMs and can (alongside occasional human input) use a rising or falling blood glucose reading to help keep you in range.

One does not simply get an insulin pump. Some Type 1s prefer the idea of pens to being stuck to another medical device. Others have to meet the eligibility criteria for funding. The criteria where I live involves a specific HbA1C blood test reading that suggests your blood glucose control could be better (which I don’t meet), considering pregnancy (nope), or that regular hypos are impacting your mental health. Well just ask 7 out of 10 of my post-prandial patients about that while I shove precisely eight Haribo Goldbears down my neck. I qualify.

What that criteria doesn’t take into account though is what I was seeing in my own diabetes management. The slow creep upwards of my HbA1C alongside a level of burnout that’s impossible to quantify on a blood test but is directly related to sixteen years of mental arithmetic and option weighing before and after every meal, sleep and bout of exercise. I’m not in crisis, I’m just tired, and unspectacularly getting worse at this full time job of sixteen years. And yet the thing that might help is not widely available.

Which is, funnily enough, a theme running through this month’s MSKMag. In his article The Biggest Wins in the NHS are Cheap, Luke Kellaway explores why lower cost, efficiency-boosting programmes get reduced funding versus costly, complex interventions. Just as prevention and glucose management doesn’t shout the way a crisis does, neither does a smoothly running MSK pilot that reduces waiting times.

Meanwhile, Chloe Wearmouth issues a plea for more thought to be given to Paediatric services where all manner of presentations and specialties are shoehorned into one catch-all Paeds department in The Forgotten Child of MSK.

Benoy Mathew shares insight of a presentation that can drastically change a patient’s outcome if we sit on it too long. Read The Diagnosis that Keeps Getting Missed: Adult Hip Dysplasia and avoid hip replacements in the young.

In her article Beyond the Bump: Reframing High-Grade AC Joint Injury, Angela Cadogan highlights the value of looking beyond simply strapping up the ACJ and getting on with it in her advice-packed piece covering ACJ rehab.

And finally, a philosophical viewpoint from Matthew Low in Off the Treadmill, Into the Field, which asks us to stop thinking about the body as a fixed thing that occasionally breaks, and start thinking about it as a process that never stops moving. Matthew suggests that a patient isn’t a stable object briefly interrupted by injury, but a flow of circulation, metabolism and circadian rhythm that clinicians step into and move alongside for a while.

Folks, I have been living this for sixteen years: I just didn’t have the word for it. My blood glucose is not a problem I fixed in 2010 and have been managing ever since. It is a flow that moves with every meal, every goal Newcastle United score or miss, and sometimes for no apparent reason at all. It never pauses to let me get it right and then leaves me alone. There is no version of me that is ‘fixed’. There is only a version of me that is in closer or looser conversation with it, hour to hour, and a pump is simply a slightly better way of me getting a word in edgeways.

Which perhaps is the real case for funding the insulin pump, the pilot scheme, the paediatric service or the properly rehabbed AC joint before crisis point: not because it fixes anything once and for all, but because bodies, like health systems, don’t hold still long enough to be solved. They only ever get better tended, or worse neglected.

Consider this issue your own insulin pump education evening without the need to self-cannulate: five articles on the difference between fixing and tending, between waiting for crisis and listening for the creep. I hope by the end that you’ll feel just a little more in-range.

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As testosterone injections become normalised for strength, physique and recovery, emerging research is raising uncomfortable questions about injuries to ligaments, tendons and surgical repairs.

Testosterone has had a rebrand.

For many people, it no longer seems to sit in the same mental category as ‘performance-enhancing drug’ or ‘anabolic steroid’. It has become wellness-adjacent. Gym-adjacent. Recovery-adjacent.

More muscle. Better physique. Faster recovery. More confidence. Back in the gym sooner.

Sounds neat.

Until the ACL goes.

Or the Achilles. Or the biceps tendon. Or the rotator cuff.

This is the bit of the testosterone conversation that feels strangely quiet. The online discussion often starts and ends with body composition, energy, libido and performance. But for those of us working in musculoskeletal practice, there is another question worth asking.

What is happening to the tissues that have to tolerate all this extra force?

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The Market Read is a snapshot of the UK MSK market, bringing patient demand, search behaviour and the wider economy together in one place. It is prepared by HMDG every month for MSKMag readers.

In May 2026, the British Medical Association, the largest doctors’ union in the UK, published the findings of a survey of over 5,000 doctors on the role of Advanced Practitioners (APs), with 81% saying that the way APs currently work poses a risk to patient safety. This was reflected in a new position statement from the Royal College of Physicians, suggesting that replacing doctors with other roles created ‘a real risk of fragmented care and harm to patient safety’.

To understand the degree of antipathy against APs, we must go back to the beginning (This is where, in a film, the swirly spiral denotes we are going back in time (you can hum the atmospheric tune yourselves…)).

The Origin Story

It’s the millennium, and there is a steady but unmistakable shift from a model of care that was in place from the inception of the NHS in the 1940s to when I qualified in the early 2000s. The 1-in-2 on-call rotas are rapidly becoming a thing of the past as Modernising Medical Careers and the European Working Time Directive from 2004 onwards reduced the average number of hours worked by doctors and the old ‘firm’ structures (Consultant, Registrar, SHO, HO etc) made way for newer ways of working.

Whilst the number of hours doctors worked decreased, the population continued to age and grow, creating a tidal wave of increasing complexity and acuity, placing services under unprecedented demand. The number of patients registered with NHS GPs in England grew significantly, from roughly 50 million in 2020 to just under 64 million by 2025.

To meet this growing demand, the Health Foundation suggests that a further 3,500 GPs will be needed by 2031. But it takes a long time to train a doctor; 10+ years as a minimum for GPs, and the number of full-time equivalent GPs has dropped by 458 since 2015.

Step into the breach: non-doctor roles. By the time of the NHS long-term plan in 2019, early pilots of first-contact physiotherapists had shown they could be useful members of the primary care team. In 2020, the National Evaluation of the First Contact Practitioner (FCP) model of primary care evaluated 240 FCPs from 40 services in England and found that FCPs were acceptable to patients, produced positive outcomes, and reduced GP workload [1].

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Are physiotherapy graduates ready for practice? If you’ve ever asked this question, you’re not alone.

The quick answer? No. But they’re not meant to be.

The longer answer? Well that starts in 1894…

The Start of Physiotherapy Education

[Image 1: Almeric Paget Military Massage Corps [8]]

Four women drew a line. Stories in the national press were warning the public about ‘unscrupulous’ people offering massage as cover for something else entirely. They set up the Society of Trained Masseuses because the work deserved better. They established a curriculum and examinations. Standards mattered from the very beginning.

What followed was a profession that proved itself through necessity. When World War I broke out in 1914, physiotherapists were quickly deployed to military hospitals. They went where the need was greatest.

This community instinct, going where people are and working in the places where health matters, was not a policy position. It was simply what the profession did.

Recognition followed practice: it always has.

So, what does ‘being ready’ really mean for a profession that has always gone where people needed it, and found a different answer every time?

Ownership

In its earliest years, the physiotherapy classroom and clinic were never far apart. Learning happened close to the work, even without a formal structure.

By 1955 that structure arrived in the form of a national syllabus for physiotherapy [1]. Every UK student physiotherapist followed this one pathway - a three-year curriculum taking place in schools attached to a hospital. After an initial six months of training, they spent 1,500 hours or more treating patients under the supervision of qualified physiotherapists, accounting for 10-30 contact hours a week. The final exams were entirely practical, and they assessed and treated patients in the hospital. Assessment papers were sent directly to the professional body to be moderated against a national standard.

There was no gap between education and practice because the two had never been separated, everything taking place under one roof.

[Image 2: 1955 CSP Syllabus [1]]

Interestingly, the syllabus described the preparation of students as “a graduated process of education leading to admission to membership.“ Not admission to a qualification, but admission to a community. To qualify was to join. The professional body set the standards, ran the examinations, and held the membership. Regulation and professional identity were, in practice, the same thing.

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