When was the last time you held a conversation with a colleague or patient about assisted dying? Never? You’re not alone — and that’s precisely why I’m writing this article. If a patient were to bring it up tomorrow, would you know how to respond, or even what the law currently says?

As I write this, on 23rd September 2025, the Terminally Ill Adults (End of Life) Bill has just completed its second reading in the House of Lords. It is now one step closer to becoming law in England and Wales.

If passed, this legislation would permit terminally ill adults — those with a prognosis of less than six months to live — to seek medical assistance to end their life.

For many, this represents a compassionate choice and an act of autonomy at the end of life. For others, it is deeply troubling. One newspaper branded it a ‘licence to kill’. Another commentator countered, “Let’s be clear — people who choose assisted dying are not suicidal. They are dying, and they want to regain some control.”

This isn’t an article for or against the Bill. Rather, it’s an invitation for MSK clinicians to understand what this legislation means, and why it might soon become part of the conversations we have with our patients.

It’s also worth noting that assisted dying will only become law if both the House of Commons and the House of Lords agree on the final text. If that happens, the government will have four years to design and implement the service.

What the Bill Proposes

In its current form, the Bill would allow adults aged 18 and over, who are mentally competent and terminally ill (with a life expectancy of six months or less), to request medical assistance to end their life.

Built into the Bill are several safeguards:

* Two independent doctors must confirm the person’s diagnosis, prognosis, and decision-making capacity.

* The person must make two written declarations of intent, witnessed and signed.

* A minimum reflection period (typically 14 days) must elapse between the declarations.

* Healthcare professionals retain the right to conscientiously object.

* All cases would be subject to oversight and review, ensuring decisions are free from coercion or abuse.

At present, the Bill is at the discussion stage but its momentum in Parliament and the intensity of public debate make it something clinicians can’t ignore. [1,2]

Why MSK Clinicians Should Care

You might be wondering why this has anything to do with musculoskeletal practice.After all, we don’t manage terminal diagnoses or prescribe medication. But our patients live within broader stories than the pain that brings them to us. Many will be living with, or alongside someone living with, terminal illness.

Crucially, MSK clinicians often occupy a trusted space in a patient’s healthcare journey. People may disclose feelings or questions about assisted dying during treatment, perhaps before ever voicing them to their GP or palliative care team.

Being able to listen without judgement, respond appropriately, and know where your professional boundaries lie will be vital if this Bill becomes law.

Conversations You Don’t Expect

A patient raising assisted dying might catch you completely off guard. It’s not part of typical clinical education. But how you handle it matters.

The correct response isn’t to advise or to share your personal view, it’s to acknowledge, listen, and signpost. Let the patient know you’ve heard them, avoid making assumptions, and refer back to their GP or specialist team who are equipped to explore such discussions safely and legally.

You will have hopefully realised that this is not so different from our everyday person-centred care: recognising the person behind the condition, holding space for them to be heard, air their thoughts, and knowing when to seek support from others in the multidisciplinary team.

Recognising Vulnerability

Much of the opposition to the Bill revolves around coercion - the fear that vulnerable individuals might feel pressured into choosing assisted dying. As someone who specialises in supporting people with lifelong disabilities, this point has been high on people’s agenda.

That pressure need not be overt, it can be subtle: a sense of being a burden, financial worry, or emotional exhaustion. Because MSK clinicians often see patients regularly, sometimes over months, we are well placed to notice changes in psychological state, behaviour, or motivation.

If assisted dying becomes legal, these observations take on new significance. Recognising and acting on vulnerability will become even more central to safeguarding practice. [3]

Understanding Your Limits

It’s also crucial to be clear about what isn’t our role. The Bill hinges on a six-month prognosis, something notoriously hard to predict even for experienced physicians.MSK clinicians are not responsible for making or validating such judgements.

Our remit remains focused on function, comfort, and communication, ensuring our interventions and observations support the broader healthcare picture while staying firmly within our scope of practice.

If a patient raises assisted dying, record the interaction factually and without interpretation.Note what was said, how you responded, and what onward referrals or signposting were made. Avoid including your own opinions or assumptions.

Clear documentation protects both the patient and you as a professional, and it provides continuity of care for other members of the healthcare team.

The Ethical Divide

The arguments surrounding assisted dying are emotionally and ethically charged.

Supporters view it as an issue of autonomy, a right to choose the timing and manner of one’s death, especially in cases of uncontrollable suffering. They argue it restores dignity, reduces prolonged distress, and provides clarity for families and clinicians.

Some opponents are vehemently against assisted dying in all forms. Others worry about slippery slopes; that what begins as a choice for the terminally ill could expand to include those with chronic illness, disability, or psychological distress. Others highlight the difficulty of accurate prognoses and the potential emotional burden on healthcare professionals involved. [4–6]

Neither stance is ours to champion as clinicians. But both shape the environment in which we practice, one where patients’ questions, fears, and choices may soon take new forms.

Preparing for Change

If the Bill passes, change will come gradually but inevitably.While MSK clinicians are unlikely to play a direct role in assisted dying procedures, we will increasingly encounter patients and colleagues grappling with its ethical and emotional implications.

Some ways to prepare include:

* Keeping up to date with guidance from your professional body.

* Reflecting on your own boundaries, beliefs, and comfort levels.

* Building strong links with palliative care and primary care teams.

* Seeking supervision or peer support when facing difficult conversations.

This isn’t about advocacy; it’s about readiness. Our role, as ever, is to support patients with respect, clarity, and compassion, wherever their journey takes them.

Conclusion

Assisted dying is one of the most profound questions modern healthcare faces.As MSK clinicians, we may not sign the forms or certify the diagnoses, but we are part of the healthcare web that surrounds each individual confronting the end of life.

Being informed and not indifferent is how we continue to uphold professional integrity, compassion, and patient trust in the years ahead.

References

* Parliament UK. Terminally Ill Adults (End of Life) Bill. Available at: https://bills.parliament.uk/bills/3774 (Accessed September 2025).

* CMS LawNow. A licence to kill? The Assisted Dying Bill passes its second reading in the House of Lords. 2025.

* Academic OUP. Safeguarding and Assisted Dying: Protecting Autonomy and Preventing Coercion. 2024.

* Brabners. Legal Implications of the Assisted Dying Bill for Healthcare Professionals Explained. 2025.

* British Medical Association. Physician Assisted Dying: Guidance for Clinicians. 2024.

Recruitment, team journey and leadership are big topics that can often slip down the priority list in a busy private practice. How many therapists received formal training to manage a team before setting up their clinic? For some it might come naturally, but for most it’s a skill that can and must be developed.

As the saying goes, ‘Culture eats strategy for breakfast every single day’. Strategy gives you direction. Culture gives you traction.

No matter how meticulously you have planned your business strategy, if your culture is toxic or even just ‘vanilla’ it is going to be an uphill battle to run a successful business. I’m not saying strategy is not important because it is. Over the many years of working with private healthcare businesses, we have seen that those with a plan have generally had more success in achieving their goals than those who have just flown by the seat of their pants.

Culture, however, is the glue that keeps the business together, giving it longevity and stability. It is what attracts great candidates to your business and retains them. Yes, you have to be able to be competitive and offer the right remuneration packages but ultimately if you get culture right you will create a business that is a pleasure to own, a pleasure to work in and painless to run.

With the world of recruitment as it is today, it is so important to create an environment where your team members love coming to work, feel engaged and motivated. Belonging is one of the most fundamental human needs, it’s not a luxury. To help your team thrive, you need to intentionally cultivate that sense of belonging and trust.

Living your WHY and your values

Having a clearly defined WHY (purpose) and outlined values are the building blocks of your culture. What is at the very heart of WHY your business is in existence and what are the non-negotiables of how your business comes across to your patients and team?

In recent years there’s been increasing debate and discussion around ice therapy for injury recovery. While previously ice was always considered as the first-line approach for managing acute injuries, now the debate on its effectiveness has expanded and there are questions about the validity of ice therapy.

Historical View

In 1978, a phrase that is synonymous with injury recovery was born: RICE. Discussed in The Sportsmedicine Book by author Dr Gabe Mirkin, it set the standard for injury treatment. Everyone is familiar with it and over the years many variations have morphed including RICER, POLICE, and PRICE. Generations of therapists and coaches embraced ice therapy as standard care for overtraining and injury. Even today, expert panels indicate that ice remains widely adopted. For example, a 2025 Delphi consensus of sports physiotherapists and athletic trainers reported that local cryotherapy is frequently considered for treating acute soft-tissue and muscle pain [1]. In both acute injury management and recovery after exercise, many professionals still include ice as a key tool for its pain-modulating and inflammation-limiting effects [2]. The theory was straightforward: ice lowered tissue temperature causing a vasoconstriction of blood vessels and leading to reduced blood flow to an area and therefore a reduction in local inflammation.

The Debate

However, many have questioned the validity of the RICE approach. And the first question we might ask is: does ice actually reduce inflammation? While there is little debate in research that ice is analgesic, there have been recent doubts whether using ice actually reduces inflammation.

Secondly, does reducing inflammation slow down the healing process? If inflammation is a normal body response to injury, should we even be trying to slow down a normal part of the healing process?

The Motivation Problem

Anyone who’s ever faced rehabilitation after an injury, surgery, or illness knows that recovery isn’t just about the body: it’s a mind game. The repetition, the discomfort, and the slow pace of progress can sap motivation. You may have heard the words before: “I’ll do it later”, “It’s boring”, “It’s repetitive” or “I can’t find the time”.And yet, consistency is everything in rehab. Missed sessions mean missed milestones.

If you’ve ever heard me speak at a conference, a couple of my go-to phrases are “It’s not a knowledge deficit, it’s a behaviour deficit” and “It’s not that people don’t know better, they don’t do better”. Pretty much everyone has got the memo: rehab exercises are important, they know that eating more veggies is important, they know that going for a walk more often is important; but knowing doesn’t always translate to doing.

But we’re evolutionarily hard wired to seek calorific food, conserve energy and avoid pain. If we’re going to overcome these physiological barriers to achieve both rehabilitation and public health goals, we’re going to need to pull on more motivational strings than just saying “it’s good for you” or “it’s important”. We’ve got to find a way to pull the levers that lead to endorphin pathways, and where we can leverage ‘fun’ and ‘social connections’, we may stand a chance of motivating society to actively engage in their rehab and treatment.

Here’s where gamification, the use of game-like elements in non-game contexts, is stepping in to change the rules of recovery. What if your daily exercise routine could feel more like a challenge than a chore? What if your progress was visualised as levels completed, trophies unlocked, or goals achieved? For many people, that’s not just a fun idea, it’s the difference between giving up and getting better.

Taking Serious Games Seriously

It’s just Super Mario and Minecraft right?

So, you think you know what evidence-based practice (EBP) is? I’m glad you think you do.

I’m not as certain as I was 10 years ago. With each passing year of clinical practice there seem to be increasing levels of complexity, treatment choice and demand falling at the feet of those delivering clinical services. This is particularly true for NHS colleagues, who are navigating in-person and digital care, aligning to the government’s ambition to move from ‘bricks to clicks’. Private practice is not without its own unique challenges in delivering EBP either.

In the article that follows, I hope to provide an antidote to those that feel so assured of their opinions and are always keen to widely share these with the world on social media. Grab a cuppa and buckle in!

What even is Evidence-Based Practice?

If we start with ‘what is EBP’ and consider this at face value, a simple question soon unravels to become a behemoth of complexity – not dissimilar to navigating Spaghetti Junction without a satnav.

I’m sure many of you will be familiar with my experience of (or old enough to share) meeting people’s expectations by treating patients with manual therapy, traction, electrotherapy or other (insert another modality which is no longer in vogue here), only for them to leave your clinic room with a spring in their step, seemingly cured (or were they?). Another satisfied patient!

Is this evidence?

Welcome back to Chewy and Jim!

The lads are joined in this recording by Rob Beaven who, amongst other things (like a chiro but we don’t hold that against him), is Partnerships Manager for Physio Matters. Jim and Rob didn’t want to involve Chewy but his name being in the theme tune kind of forced their hand.

Chewy, Jim and Beav discuss clinical competency amongst MSK Therapists, using social media to ask for help, and the problems associated with just ‘having a go’ at treating stuff.

So strap in, this is definitely best enjoyed in audio but here is a summary of the discussion if you don’t have any earphones in because not everyone wants to hear the theme tune for some reason…

“If you see somebody with a stress fracture and you misdiagnose that as something else, you’re going to prolong their issues there. Or if you miss cancer, which everybody can, nobody is perfect… that’s the obvious safety component [concern].”

Self-judged clinical competence is a tricky balance to strike, of course if you think you are incompetent at everything you will never see any patients and if you think you are amazing at everything you will equally cause some problems. This lends itself to some obvious safety concerns when missing red flag diagnoses.

No one is perfect and diagnoses get missed or provided incorrectly; this happens and it’s part of the landscape of being ‘autonomous’. The real skill lies in knowing which scenarios are pushing YOUR limits or have a layer of complexity that require assistance from elsewhere.

“Just imagine the perils of a new graduate physio in this climate. They’ve set up a neuro triage service or they fancy neuro rehab…the dangers of that if you’re the first contact professional for that person, who’s like, ‘oh, he’s got a bit wobbly on his feet, or should his face look like that?’ That is so dangerous.”

Physios particularly are in demand, there are growing waiting lists and vacancies meaning patients are fighting at the door to be seen. Therapists are making their way into open posts sooner than they should and without appropriate support. Making all these dangers more likely.

I don’t care what people say, patient mileage (how many different cases you have seen) is an experience that has to be earned through graft and your gut feelings need honing through the random weird s**t that comes through your door unexpectedly. Entering private practice without support or an FCP post where you are seeing unfiltered referrals a couple of years out of uni is a recipe for dumpster fire. No one here is saying clinicians who have been practicing longer are always better but boy-oh-boy it helps to have seen more presentations and individuals to understand the complex nuance of clinical practice.

“I see enough social media posts that are like, ‘I have this patient coming in with this diagnosis that I’ve not treated before. What do people suggest?’ I just don’t think that’s an appropriate support mechanism.”

The conversation discusses some logistical practicalities of individuals’ scope: worrying examples of this can be seen across social media regularly and are what prompted this discussion. It is clearly more challenging as a clinician who works on their own or is isolated to access support or mentoring for complex cases and there is a clear financial implication in the private sector of turning away patients. From a cynical point of view though, this can potentially increase the risk of ‘having a go’ - when seeing paying patients means keeping the lights on at home.

Social media is not a good place to seek unfiltered advice because any weird, fringe or incompetent person could reply. We need robust support mechanisms in place that we trust BEFORE we need to seek their assistance.

“Unfortunately we have a number of people that are [at] irritatingly far ends of a spectrum - self-flagellators who are over-reflective to the point of anxiety, and peacocks who are cavalier and just have a go. As an industry, we are not regulating that well amongst ourselves.”

Chewy harks back to one of his editorials [1] where he posited that clinicians fit into two groups: those who are overly critical of their skills and those who are under critical, causing a double edged sword in this particular scenario, especially when consulting social media. Those who ask for help (self-flagellators) are likely to be helped by the peacocks which is probably not a desirable outcome. The peacocks don’t ask for help and barrel on treating anything and everything. Without proper regulation, we have no way of managing either side of the coin so the practices shall continue.

Reference

I have a thing for counterintuitive things. It’s one of the reasons I consider myself so lucky to have gotten into the MSK game when I did. It’s counterintuitive that the extent of tissue damage doesn’t necessarily correlate with pain and that moving ‘badly’ doesn’t necessarily cause injuries or impair performance. If it was clear and obvious, I’d have been less interested and less interesting. The murkier the water, the more comfortable I am… unfortunately that also got me sacked from running Evian…

As an inherent optimist and realist, I have benefitted from being able to present both hope and direction to patients engaging in rehab and colleagues keen to see our industry improve. Combining my optimism with my love of the counterintuitive is perhaps ambitious but I have in recent years found a way and it has helped my patients, colleagues and commercial partners in various ways. Let me introduce you to some examples of when we should wish things worse. The Region Beta Paradox [1] was described by psychologist Daniel Gilbert in 1998 when he and colleagues observed circumstances in which people recover quicker from a more intense negative experience. The general gist is that in situations of tolerable discomfort/frustration/unhappiness (Region Alpha), the threshold to take action isn’t met. Therefore the situation can go on for longer, become more integrated into your life and be negatively adapted to. So if the situation was worse - enough to inspire you to act (Region Beta) - you would at least have the chance to get over it quicker.

The ultimate counterintuitive thing I’ve noticed when explaining this concept to patients, colleagues and commercial partners is that they are very often both delighted to know about it and wish I’d never introduced them to it. They recognise the ways in which they are sub-threshold but felt pleasantly ignorant to the fact that they should probably act on it.

Clinically, the obvious examples are the annoying but not disabling conditions that people just live with, usually until they realise they are not able to function as well or as comfortably as they would like. The threshold is eventually met and they present for assessment but with a sometimes trickier presentation to treat. Might they have been better off if it had been worse? In such cases, I find it to be very important to unpack with the patient what has inspired action so that we don’t risk them judging our success purely on them hurting less. But that’s the low hanging fruit so here’s another way to apply the concept with patients: break their leg… We all know the patients with a condition which requires more relative rest than they’re willing and/or able to give it. In these cases, the pain and dysfunction is certainly beyond the threshold to seek help but not at the threshold for them to adjust their routine for a time to let things settle. Examples from my second opinion clinic this week; raging sub-acromial bursa in a mechanic; thick, angry achilles in a trail runner, and lumbar disc herniation in a Hyrox enthusiast. Especially having been mismanaged to date, I do understand why they were reluctant to make inconvenient adjustments. Self-employed mechanic ‘needs to get on with it’, trail runner ‘needs the hills to escape the kids’, and the Hyrox enthusiast ‘wouldn’t have anything to talk about’. So I push them over the threshold with a hypothetical, ‘I certainly hope you don’t but what if you walked out of here today and broke your leg?’. A conversation then ensues about the various awkward adaptations they would have to reluctantly make and then I make the case for us needing to dose what they’re doing in order to recover quicker.

On a wider industry level, I do wonder whether many of us are sub-threshold in Region Alpha tolerating wide variations in standards, ineffective professional bodies, political insignificance, underfunding and disunity. I’ve found myself wondering if we should ‘wish things worse’ as that might invigorate change and disrupt what many are tolerating but not enjoying. Is there a unifying project that can take advantage of a societal moment that seems ready for rehabilitation and the positive effects of its proliferation?

This month’s MSKMag is certainly not ambling along quietly and is full of spicy flavour. Celia Champion explains how to nurture good apples and identify bad ones, Ben Wilkins is back by popular demand discussing the gamification of rehab, Tim Allardyce ponders our ever evolving relationship with ice for acute injuries. Lewis Rawson made this editor sweat when I saw his title ‘Make MSK Great Again’ as he reflects on EBP in a red cap. Our weirdest feature Chewy & Jim is back and Rob Beaven gatecrashed our rant fest and finally, the inimitable Alistair Beverley, The LD Physio himself could have hung up on me when I asked him to write about an intensely delicate subject but instead stepped up and knocked it out of the park; ‘Beyond the ‘Licence to Kill’ Headlines: Assisted Dying and MSK Practice’ is our leading feature this month and is an absolute must read.

It’s an excellent Mag with many excellent points made by excellent thinkers. But will it inspire change in you? Will it meet the threshold for you to act? Or should we wish things worse?

Jack Chew

First up in this month’s MSKMag is a reprint of the wonderful Val Jones’ excellent article from earlier this year. We are re-publishing this as open access to bring further attention to her work and to help raise funds for an important campaign to get Val back home with her family.

Val Jones is a Physiotherapist and educator specialising in elbow pain and pathology who we have had the pleasure of working with for many years. Unfortunately she was in a serious accident earlier this year which has resulted in her being paralysed due to a high spinal cord lesion. She is currently working on the ability to talk and eat again but will require full time ventilation in order to live at home with her family; which is her goal.

Her family are raising money via the GoFundMe links below therefore please give generously to support one of our own who has been so generous to the MSK community for so long. For those who may not be aware of Val and her work, we have made a bundle of the podcasts, articles and webinars she has made with us over the years which we will make available to anyone who donates via the bundle link below. In our first round of this earlier in the month we were able to raise £3500 and I would love to make that £5000 through this push.

Val’s influence on Physio Matters has been more profound than she would realise or admit. She has a rare talent for both academic writing and lay knowledge translation that helps bridge the gap between the sometimes jargon-laden world of empirical science and the practical realities of the clinical front line. On a personal level she has been a role model by charting a career in which she takes the subject matter seriously but retains humour and humility in not taking herself too seriously. Finally, alongside so many of our contributors and educators, she gives her time and energy so generously to our shared cause of raising MSK care standards for the patients we serve.

Thank you Val and whilst it is the very least we can do, I hope this promotion of your work can attract the funds you so deserve for your ongoing care.

Working in a Regional Trauma Centre, we’re used to seeing lots of soft tissue injuries on a regular basis. But the one that was considered more unusual when I first started working at the Shoulder & Elbow Unit in Sheffield over 20 years ago was the acute distal biceps rupture. Previous literature both on UK and US populations describe it as a rare injury, with an incidence of 1.2 to 2.6 per 100,000 person years [1,2]. This equated to seeing and operating upon between 10 and 12 patients per annum for the Sheffield population of approximately 750,000 during the first few years of the millennium.

However, in the last decade there has been an explosion, quite literally, in the number of patients attending our unit with a distal biceps rupture. Our team now on average sees up to 40 cases per year - over a 300% increase - over a 20 year period. These figures made me question what was driving this increase and was this just a regional trend, or something that other orthopaedic units were seeing? Also, what are the implications for an already struggling healthcare system to cope with an increased demand for surgery, imaging, resources, and post-operative rehabilitation?

Trawling through recent literature there is very little written on the incidence of these injuries, apart from one study looking at Swedish and Finnish registries [3], which found a 6- to 7-fold increase in this type of injury and a 28-fold increase in distal biceps repair surgery. Staggering numbers with a huge implication for resource allocation, with figures that echoed our own experience in Sheffield.

In the general population, full thickness tears are most encountered in active middle-aged men between 40 and 60 years of age [1,2]. Often when questioned, these patients have had no warning signs before their tendon tear. The incidence in women is extremely low and clinically I’ve only met one female with this injury during my 23 year tenure in Sheffield. An evaluation of distal biceps tendon ruptures in women sees them describe a more gradual onset of symptoms and a higher incidence of partial tears[4], rather than full thickness ones.

Other predisposing factors to injury may include an elevated body mass index (BMI), smoking and medication use [5]. Elevated BMI, possibly secondary to greater muscle mass, would increase the load on the tendon and may predispose to rupture. Furthermore, obesity has been shown to decrease immune responses to acute tendon injury [6]. Of patients with a distal biceps tendon rupture, 36–66% are reported to be obese [1,2], compared with the general UK population obesity rate which is approximately 30% [7].

The exact incidence of smoking in patients with distal biceps tendon ruptures is unknown, but it is widely accepted that smoking is a predisposing factor in tendon injuries. One study quotes a 7-fold increase in distal biceps ruptures in smokers compared with non-smokers [1]. Smoking rates have increased in the adult population of those aged 45 and above [8], which is the peak age for these injuries to occur. A possible effect of smoking involves an increased zone of hypovascularity in the tendon between the proximal and distal blood supply [9]. Patients often ask if vaping carries the same risk as cigarette smoking but I have to be honest and tell patients that I just don’t have the answer currently. Maybe the correlation between musculoskeletal injury risk and vaping will become more evident over time…

The image and performance enhancement drug (IPED) market, including anabolic steroids, has become increasingly accessible through online sellers [10], which has broadened their appeal to a wider market. Their usage has become semi-normalised and socially acceptable, coining the term ‘gym and tonic’. Weightlifters are the primary user group of IPEDs, with an increase in usage seen in both males and females.

Anabolic steroid use combined with exercise may lead to dysplasia of collagen fibrils, which can decrease the tensile strength of the tendon, with an associated increase in muscle strength [11]. Changes in tendons’ crimp morphology have been shown to occur as well, which again may alter the tensile strength of the tendon [11]. Less commonly, tendon rupture can also be linked with statin and fluoroquinolone antibiotic use [12,13].

High risk sports for distal biceps tendon ruptures are weightlifting, American football, judo and other contact sports [1,14] and usually occur when an eccentric force is applied to a flexed and supinated elbow [15] with most patients describing an audible ‘pop’, followed by pain and weakness. Not all are sporting injuries though. In Sheffield, we’ve seen it in patients who’ve tried to stop their dog running off by hanging onto their collar or by trying to catch a wardrobe falling down the stairs. That was never going to work out well.

After discussion with the surgical team, most medically well patients opt for an acute repair. An acute repair is deemed less risky for patients with less chance of post-operative complications [16]. However, one note of caution is there is a lack of clinical consensus on the role of operative treatment, Support for surgery has largely been driven by biomechanical studies that report a reduction in supination and elbow flexion strength, as well as impaired endurance seen in injuries managed non-operatively [14,17]. There is a lack of robust evidence comparing non-operative versus operative treatment. Public perception towards surgical treatment is often positive, although the evidence of its superiority over other treatments is lacking. When considering surgery, there is often a disregard for the associated risks, with individuals often taking a ‘it will never happen to me’ stance. But distal biceps repairs carry a huge 25% complication rate, with 1 in 20 patients suffering a serious adverse event such as vascular or nerve injury, heterotopic ossification or re-rupture [16].

Given the real risks involved with surgery, what’s driving the increase in this procedure? Firstly, the recognition of the injury and the accuracy of diagnosis by healthcare professionals may have improved. Physical examination techniques such as the commonly used Hook test [18], combined with a careful history, makes swifter diagnosis more likely. Historically, patients with a delayed presentation were often advised against surgery as delayed repairs are associated with higher complication rates. So faster diagnosis probably leads to an increase in surgical conversion rates.

The availability of modern imaging technology, such as MRI and ultrasound scans, may have made confirming the diagnosis easier, and again will decrease any delay between injury and diagnosis, once again leading to an increased possibility of surgery.

Other reasons may be that with increasing sporting participation and more active older populations, the incidence and age at presentation of this injury would be expected to rise. This group of patients may be more interested in full recovery and therefore surgical options are more likely to be explored, as patients are unwilling to live with a lifelong strength deficit and cosmetic deformity seen following conservative management.

Recent advances in surgical techniques such as the use of ‘button’ techniques, allow for strong initial fixation which allows early active mobilisation [19]; music to most physios’ ears. There is little consensus on the optimal post-op rehabilitation programme but our own in-house experience of immediate active post-op mobilisation resulted in a faster return to function with less physiotherapy intervention, compared to delayed mobilisation. There was no increase in complication rates, such as re-rupture, following accelerated mobilisation. Loading above 10kg is avoided for 3 months post-op because of the pull-out strain of the button devices used, but otherwise there are no other restrictions placed on our patients.

In conclusion, distal biceps ruptures are becoming increasingly prevalent for a variety of reasons. Healthcare practitioners should remain vigilant in diagnosing the injury, and swiftly refer on for an urgent surgical opinion. Despite the lack of robust evidence, surgery in the medically well is considered the current optimal treatment approach, with early mobilisation following surgery appearing to be beneficial, both in terms of speed of recovery and use of physiotherapy resources.

References

* Safran MR, Graham SM. Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clinical Orthopaedics and Related Research®. 2002 Nov 1;404:275-83.

* Kelly MP, Perkinson SG, Ablove RH, Tueting JL. Distal biceps tendon ruptures: an epidemiological analysis using a large population database. The American journal of sports medicine. 2015 Aug;43(8):2012-7.

* Launonen AP, Huttunen TT, Lepola V, Niemi ST, Kannus P, Felländer-Tsai L, Berg HE, Laitinen MK, Mattila VM. Distal biceps tendon rupture surgery: changing incidence in Finnish and Swedish men between 1997 and 2016. The Journal of hand surgery. 2020 Nov 1;45(11):1022-8.

* Jockel CR, Mulieri PJ, Belsky MR, Leslie BM. Distal biceps tendon tears in women. Journal of shoulder and elbow surgery. 2010 Jul 1;19(5):645-50.

* Caekebeke P, Duerinckx J, van Riet R. Acute complete and partial distal biceps tendon ruptures: what have we learned? A review. EFORT open reviews. 2021 Oct 19;6(10):956-65.

* Del Buono A, Battery L, Denaro V, Maccauro G, Maffulli N. Tendinopathy and inflammation: some truths. International journal of immunopathology and pharmacology. 2011 Jan;24(1_suppl2):45-50.

* Haase CL, Eriksen KT, Lopes S, Satylganova A, Schnecke V, McEwan P. Body mass index and risk of obesity‐related conditions in a cohort of 2.9 million people: Evidence from a UK primary care database. Obesity science & practice. 2021 Apr;7(2):137-47.

* Tattan-Birch H, Brown J, Shahab L, Beard E, Jackson SE. Trends in vaping and smoking following the rise of disposable e-cigarettes: a repeat cross-sectional study in England between 2016 and 2023. The Lancet Regional Health–Europe. 2024 May 23.

* Seiler III JG, Parker LM, Chamberland PD, Sherbourne GM, Carpenter WA. The distal biceps tendon: two potential mechanisms involved in its rupture: arterial supply and mechanical impingement. Journal of shoulder and elbow surgery. 1995 May 1;4(3):149-56.

* Brennan R, Wells JS, Van Hout MC. The injecting use of image and performance‐enhancing drugs (IPED) in the general population: A systematic review. Health & social care in the community. 2017 Sep;25(5):1459-531.

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The cells of a malignant tumour are restless. Every so often, one wriggles free and breaks off. It’s almost certainly doomed: if it’s not destroyed by immune cells, it will likely succumb to fluid shear stress as it’s dragged through narrow vessels, or just undergo programmed cell death [1].

But some do make it to the spine and colonise it; we then call them metastases. Why so often the spine and not, say, the tibia or the deltoid?

People often blame Batson’s plexus: blood draining back to the heart can be accidentally shunted into the venous plexus of the spine - Batson's plexus - because it lacks valves [2]. Those itinerant cancer cells can ride the shunt and make a home in the spine.

That’s part of it, but the bigger reason is that the spine has something cancer cells want [3]. Stephen Paget suggested this first in 1889 [4], and he’s been proven mostly right [1]: “some bones suffer more than others; the disease has its seats of election... When a plant goes to seed its seeds are carried in all directions; but they can only live and grow if they fall on congenial soil.”

Therapists treating runners, cyclists, or triathletes can often feel frustrated when athletes keep breaking down despite everyone’s best efforts.

I now work exclusively with endurance athletes and have spent recent years helping therapists understand how these people tick - and how we can help them more effectively.

For decades, we were trained to think in terms of structure and mechanics: weak glutes, flat feet, overpronation, knee valgus, tight calves. The logic was simple: find the fault, fix it, prevent injury, boost performance.

But if you’ve noticed that ‘fixing the fault’ doesn’t always stop injuries, you’re discovering a bigger truth: endurance athletes rarely get injured because of one (or many) mechanical flaws. More often, tissues simply weren’t ready for the training and competition load demanded of them.

Biomechanics is always a hot topic and sometimes worth exploring, but it’s not what I see most therapists struggle with, other than trying to direct the athlete’s beliefs away from it. The real sticking point is how we talk with athletes about tissue and load tolerance - and how to use that in rehab and/or management of their ongoing training and racing.

Many clinicians tell me, “I know biomechanics isn’t the whole story anymore, but I don’t know how to explain load and tissue tolerance to athletes or use it in rehab.”

This article is for you. We’ll look at why biomechanics isn’t enough, what tissue tolerance really means, and how to guide endurance athletes with simple, effective load-based strategies.

Why the Biomechanical Lens Falls Short

I remember the late ’90s and early 2000s: weekends spent on CPD courses, watching people walk across paper runways so I could hunt for ‘flaws’ and prescribe foam padding, orthoses, or elaborate corrective exercises for obscure muscles. I thought I was an expert. Sometimes patients improved, but often they didn’t.

As my reasoning evolved, I questioned everything. If biomechanics didn’t consistently fix problems, why were some athletes improving while others weren’t?